Main focus of parents of children with attention deficit hyperactivity disorder and the effectiveness of early clinical screening

Abstract

BACKGROUND

Attention deficit hyperactivity disorder (ADHD) is a common mental and behavioral disorder among children.

AIM

To explore the focus of attention deficit hyperactivity disorder parents and the effectiveness of early clinical screening

METHODS

This study found that the main directions of parents seeking medical help were short attention time for children under 7 years old (16.6%) and poor academic performance for children over 7 years old (12.1%). We employed a two-stage experiment to diagnose ADHD. Among the 5683 children evaluated from 2018 to 2021, 360 met the DSM-5 criteria. Those diagnosed with ADHD underwent assessments for letter, number, and figure attention. Following the exclusion of ADHD-H diagnoses, the detection rate rose to 96.0%, with 310 out of 323 cases identified.

RESULTS

This study yielded insights into the primary concerns of parents regarding their children's symptoms and validated the efficacy of a straightforward diagnostic test, offering valuable guidance for directing ADHD treatment, facilitating early detection, and enabling timely intervention. Our research delved into the predominant worries of parents across various age groups. Furthermore, we showcased the precision of the simple exclusion experiment in discerning between ADHD-I and ADHD-C in children.

CONCLUSION

Our study will help diagnose and guide future treatment directions for ADHD.

Key Words: Attention deficit hyperactivity disorder; Children; Parents; Direction of attention; Simple test

Core Tip: Attention deficit hyperactivity disorder (ADHD) is a common mental and behavioral disorder among children. In order to explore the concerns of parents with attention deficit hyperactivity disorder and the effectiveness of early clinical screening, we conducted relevant surveys and studies. Our findings unveiled the primary worries of parents across various age brackets. Additionally, we illustrated the precision of a straightforward exclusion experiment in distinguishing between ADHD-I and ADHD-C in children.

INTRODUCTION

Attention deficit hyperactivity disorder (ADHD) is one of the most common neurodevelopmental disorders in children, and according to the DSM-5 criteria, ADHD can be divided into three subtypes: Major inattention (ADHD-I), hyperactive impulsivity (ADHD-H), and combined (ADHD-C)[1]. This disease can lead to different degrees of neurological dysfunction in children, which brings a huge burden to society due to psychological dysfunction, family pressure and socio-economic costs[2]. According to one study, medical expenditures for ADHD in the United States totaled $23 billion in 2013[3,4], and the annual social costs associated with ADHD in the United States alone exceeded $143 billion[5]. Therefore, early diagnosis and intervention of attention deficit hyperactivity disorder is urgent and necessary. Many studies have reported the prevalence of ADHD as a guideline for assessment and treatment[6]. According to a 2016 study, the overall prevalence of ADHD in children and adolescents worldwide is 5.9%-7.1%[7]. The National Survey of Children's Health reports that an estimated 6.1 million American children ages 2-17 (9.4%) have ever been diagnosed with ADHD[8]. In China, the overall prevalence of children with ADHD can reach 6.26%, among which ADHD-I has the highest prevalence, followed by ADHD-HI and ADHD-C[9]. Relevant studies have pointed out that parents' attention, children's family and community environment are closely related to the occurrence and development of ADHD[10]. 50%-75% of children with ADHD may exhibit mood disorder symptoms, such as irritability, anger, low tolerance for frustration, or sometimes excessive expression of positive emotions[11,12], and the presence of these symptoms increases the risk of other psychiatric comorbidities in children with ADHD, such as opposition-related disorders and anxiety[13]. At the same time, the existence of these comorbidities often leads to the deterioration of the mental health status of children with ADHD, which further increases the burden of family and society. The pathogenesis of attention deficit hyperactivity disorder is still unclear, and clinical diagnosis depends to a certain extent on the experience of professional doctors, which may lead to missed diagnosis and misdiagnosis. Simple and convenient screening tests are of great significance in clinical auxiliary diagnosis[14-17]. The direction of attention of families of children with ADHD affects the occurrence and development of ADHD to a certain extent, and has guiding significance for the evaluation criteria of children's recovery. Therefore, through this study, we tried to analyze the most concerned directions of parents of children with ADHD and test the effectiveness of simple screening tests, hoping to contribute to the clinical treatment of ADHD, help early diagnosis and timely intervention.

In this study, we wanted to identify parents' primary concerns for children with ADHD, tested the screening efficiency of conners' 10-item scale and exclusion experiments, and analyzed the comorbidities of ADHD in addition to psychiatric disorders. We hope to help with a simple tool to diagnose ADHD in a timely manner and guide future treatment directions.

MATERIALS AND METHODS

Selection of participants

The study was conducted from January 2018 to December 2021 at two hospitals, the First Affiliated Hospital of Ningbo University (Bund District) and the First Affiliated Hospital of Bengbu Medical University. Families who come to the hospital for ADHD-related medical help are considered potential participants. Eligible families were invited to participate in the study based on the following criteria: (1) Children aged 6 to 16 years; (2) Parents or guardians agree to attend; and (3) First visit to a clinic for medical assistance. Exclusion criteria include: (1) Failure to obtain informed concern; and (2) the child was previously diagnosed with ADHD or another psychiatric disorder.

The study protocol was approved by the Ethics Committee of Ningbo University Medical School and the First Affiliated Hospital of Ningbo University. Parents of all eligible potential participants signed written informed consent and provided written permission to share the results of this study.

Research process first

Firstly, potential participants were invited to select eligible families according to the inclusion and exclusion criteria. In order to understand what parents are most concerned about when seeking medical help for their children, we first designed a scale by ourselves, including the following items: (1) Basic information of children; and (2) main symptoms that parents observe or are concerned about in their child (selected or specified in existing programs). Potentially eligible families are invited to complete the scale and enter the diagnostic phase.

For the diagnosis of ADHD, we went through a two-stage procedure. In the first phase, eligible parents were asked to complete a Chinese version of the Connors 10-item scale, and eligible children were asked to complete an exclusion experiment. Connors' 10-item scale consists of 10 statements that parents rate their children's behavior based on frequency, on a scale of 0 to 3. It distinguishes well between children with and without ADHD and is therefore used as an effective screening tool to identify ADHD. In the second phase, children who were suspected of having ADHD, based on Conners’ 10-item scale score, were interviewed by two psychiatrists from the research team, in the presence of their parents, to be diagnosed with or without ADHD according to DSM-5 criteria. Ten percent of children who scored negative on Conners' 10-item scale also had a diagnosis based on DSM-5 criteria. If both doctors agree, a final diagnosis is made, otherwise, the diagnosis is submitted to the chief psychiatrist (CX) for a final conclusion. According to the DSM-IV-TR, children who are diagnosed will be divided into different subtypes.

Relevant experimental materials

Connors' 10-item Scale is a simple list of questions used to assess children's behavior in areas such as sleep, temper, and peer relationships[16,17]. Parents rated each question on a scale of 4 (0, 1, 2, 3); The behaviors were categorized into six factors: behavioral problems, learning problems, psychosomatic, impulsive hyperactivity, anxiety, and hyperactivity index. A higher score indicates a more serious problem. In this study, a tipping point of 15 was set for parents. Children with scores ≥ 15 on the Conners10-item scale were considered positive and included in the stage 2 diagnosis.

Exclusion experiments

Exclusion experiments were performed in children diagnosed with ADHD. The children were provided with a piece of paper with 625 letters (numbers or patterns) on it. The diagnostic doctor selected a letter at random and told the children to remove the letter in each line as correctly as possible within five minutes. Count the number of missed exclusion alphabets (M). Use the formula to calculate the score: Score = 100 × [(625-m)/625]. Children with a score below 95 are considered positive.

Data analysis

SPSS version 18 was used for data analysis. The Chi-square test was used to compare the rates of suspected ADHD in children identified by Conners' 10-item scale and exclusion experiments, to compare the prevalence of ADHD diagnosed by different age groups and different age groups in the DSM-5, and to compare the rates of each ADHD subtype as defined by the DSM-IV-TR. When P value < 0.05, the difference was significant.

RESULTS

The number of children with potential disease increased year by year

Between 2018 and 2021, 5683 children participated in the study. Parents first fill in the questionnaire designed by themselves, including the parents' basic information about their children and the main issues of concern. The number of children with potential ADHD has gradually increased from 1103 in 2018-1880 in 2021 (Table 1).

Table 1 The number of children with potential attention deficit hyperactivity disorder between 2018 and 2021.

Year	Boys	Girls	Total
2018	78	320	1103
2019	658	370	1028
2020	1021	651	1672
2021	997	883	1880
Total	3459	2224	5683

Parents' main concerns about seeking medical help for children with potential ADHD

From the results in Figure 1 and Table 2, we can see that compared to the control group (< 7-year-old), Chinese parents are generally concerned about their children's shorter attention span. Among children over the age of 7, parents are concerned about the gap in their children's academic performance. This focus accounts for 13.7% of the total sample. Therefore, in the entire analysis sample, children's short attention time was the main problem, accounting for 23.1% of the total sample. So, in China, once a child enters primary school (around 7-year-old), the quality of academic performance becomes the main concern of parents. Secondly, for children aged 7-12, parents are primarily concerned about poor academic performance, and for children aged 12 and above, parents are also concerned about this issue.

Figure 1  Parents' concerns about children with attention deficit hyperactivity disorder in different age groups.

Table 2 Parents' concerns about children with attention deficit hyperactivity disorder.

Year	Concerns
	Poor academic performance	Poor friend relationship	Poor sleep quality	Making careless mistakes	Taking to himself	Hitting people nearby	Short attention time	Disobedient	Emotional	Restles	Others
< 7	56	9	72	46	66	242	962	521	465	508	8
7-12	452	76	4	185	22	35	220	210	45	59	7
> 12	120	15	18	35	7	19	35	68	26	20	4

Diagnosis of ADHD with CONnerS10-item scale and DSM-5

A total of 5683 potentially eligible children completed Connors' 10-item scale. Of these, 17 had no scale or were invalid. A total of 5666 scales were analyzed. We found that 1019 (18.0%) children (703 boys, 316 girls) received high scores (> 15), according to the DSM-5. Invited for a final diagnosis, 360 children met the DSM-5 criteria for ADHD and were diagnosed with ADHD, 210 children were diagnosed with ADHD-I, 37 children were diagnosed with ADHD-H, and 113 children were diagnosed with ADHD-C. As for gender differences, 282 boys and 78 girls were diagnosed with ADHD. We observed that boys had significantly higher rates of ADHD than girls. The diagnostic flow chart of ADHD is shown in Figure 2.

Figure 2 The diagnostic flow chart of attention deficit hyperactivity disorder. ADHD: Attention deficit hyperactivity disorder.

Help diagnose ADHD by analyzing exclusion experiments

From the results in Figure 3, we can see that a total of 1019 children scored higher on the 10 scales that parents were previously concerned about. Among them, 360 children were diagnosed with ADHD, while 659 (64.7%) children were non-ADHD patients. Therefore, we selected 360 (35.3%) children diagnosed with ADHD to conduct exclusion experiments. This study conducted a ranking analysis of children with ADHD based on their gender.

Figure 3  Exclusion test scores for children of different genders.

In this experiment, we found that 255 boys and 62 girls were positive and 27 boys and 16 girls were negative. The detection rate of ADHD was about 88.0% (317). There was no significant difference in the detection rate between girls and boys. Considering that the exclusion experiment was primarily related to attention, we analyzed the data to exclude ADHD-H children throughout the experiment. We found that the detection rate increased to 96.0% (310/323), indicating that the exclusion test could effectively distinguish ADHD-I associated (ADHD-I and ADHD-C) children.

DISCUSSION

ADHD in children is commonly referred to as attention deficit hyperactivity disorder or mild brain dysfunction syndrome in clinical practice[18-20]. ADHD is a common behavioral problem in childhood. There is currently no unified conclusion on the pathological basis of ADHD. Among them, most clinical doctors and scholars believe that ADHD is caused by a combination of multiple factors. Among them, a syndrome caused solely or in combination by biological, psychological, and social factors is mainly prevalent in adolescents, children, and premature infants. At present, the prevalence of ADHD in Chinese children is 1%-10%, and male children are significantly more common than female children. 65%-70% of symptoms persist into adolescence, and 32%-50% persist into adulthood[21-23]. Children with ADHD mainly exhibit two main symptoms in clinical practice, namely attention deficit and hyperactivity, which can be accompanied by behavioral impulses and learning difficulties. Attention Deficit Hyperactivity Disorder in children usually occurs before the age of 6, and there are obvious symptoms during school age. The symptoms gradually improve with age, and some cases can continue into adulthood. 29%-60% of children with ADHD are accompanied by adversarial disorders, 15%-32% are accompanied by conduct disorders, 21%-33% are accompanied by anxiety disorders, and 19%-58% are accompanied by school skills disorders[24,25]. Related clinical research results show that 65% of children with ADHD still experience symptoms during adolescence, and 4% of ADHD children experience symptoms that persist for a lifetime[26,27]. When children are found to have symptoms such as lack of concentration, short attention time, excessive activity, and impulsiveness, accompanied by learning difficulties, conduct disorders, and maladaptation, they should promptly seek medical attention from a child's psychology or psychiatric department, and be diagnosed through psychological assessment and laboratory assisted examinations. When treating children with ADHD, comprehensive interventions such as medication therapy, psychological and behavioral therapy, or personalized education programs are often used according to the needs of the condition to improve its symptoms and social function. Children with ADHD have significantly lower social adaptability compared to normal children due to difficulty concentrating and impulsive behavior. Therefore, early detection and intervention are extremely important for reducing symptoms and improving social function in children with ADHD.

Children with ADHD typically exhibit complex physiological and psychological behaviors. Children with this disease are easily distracted by the external environment, so their attention often shifts from one object to another frequently during play or class. At the same time, a small number of children may exhibit staring at one place in a daze, and those with mild attention deficit may be interested in their own activities. For example, people with severe attention deficit may have difficulty concentrating on any activity, such as watching TV or listening to stories. Children with ADHD usually enjoy provoking others, deliberately making noise to attract attention, playing pranks, and overreacting to unpleasant stimuli. They often do not obey their parents and teachers, and are prone to fighting, lying, abusing others and small animals, interfering with group activities. Some children also exhibit aggressive behavior. For example, behaviors such as hitting people, damaging objects, skipping school and running away, and stealing. Therefore, children with ADHD have diverse physiological and psychological behaviors, and often differ due to differences in age, environment, and attitudes towards others around them.

ADHD belongs to chronic neurodevelopmental disorders[28,29]. There are many comorbidities of this disease, and children may co suffer from oppositional defiance disorder, tic disorder, anxiety disorder, depression disorder, or autism spectrum disorder[30-32]. If parents find that their children are already accompanied by serious emotional or behavioral problems, such as obvious emotional instability or anxiety and depression, obvious disobedience towards parents or teachers, parents should pay enough attention.

The intervention and treatment of ADHD is a comprehensive treatment process, which includes drug therapy, psychological and behavioral therapy, family education, etc[33-35]. Drug therapy can be administered under the guidance of a doctor to treat ADHD, improve a child's brain dysfunction, reduce excessive activity and impulsivity, and improve their attention. Cognitive behavioral therapy focuses on a series of problems in children with ADHD, such as poor time management, emotional instability, social difficulties, etc. Based on the specific symptoms of children with ADHD, professionals will use a series of specific behavioral therapy methods to improve their symptoms and problems[36,37]. During the treatment process, it requires the joint efforts of parents and children. Executive function training can improve executive dysfunction associated with ADHD, enhance working memory and inhibitory control abilities[38]. Aerobic exercise can improve attention and working memory in children with ADHD, reduce hyperactivity, and effectively improve their emotional and sleep problems, relieving stress[39,40]. At the same time, parents should also receive health education and behavioral management training, follow the advice of clinical doctors and teachers, and learn certain behavioral management skills, using the correct educational methods to educate children in the family.

In this study, we first explored the main directions of parents' attention to their children in ADHD clinics. In addition, we used Conners' 10-item scale and the DSM-5 gold standard to diagnose ADHD. The subtypes of ADHD were distinguished. In addition, we hope to test the accuracy of simple exclusion experiments, which may contribute to a simple and effective diagnosis of ADHD. The comorbidities of ADHD were analyzed and the prognosis of ADHD was evaluated by medical techniques.

Interestingly, we found that parents' primary concerns change as their children get older. When children are under 7 years old, short attention spans are a common concern for parents. Poor academic achievement in children over the age of seven was a major concern for parents of children aged 7-12 and older than 12. When children start school, parents care more about academic performance than anything else. This result may guide pediatricians to consider improved academic performance as the primary prognosis for children with ADHD.

The number of children with ADHD presenting to the hospital is increasing year by year, which may be due to the increased prevalence of ADHD or the increased awareness of ADHD among parents. The study also suggests that the lower early prevalence is largely due to missed diagnosis. Different studies have different prevalence rates, which may be related to sample size, region or diagnostic criteria. The increasing incidence of attention deficit hyperactivity disorder makes early diagnosis and intervention important and urgent. In our study, 282 of 3459 boys and 78 of 2224 girls were diagnosed with ADHD. Boys are more likely to have ADHD than girls, which is consistent with previous results.

In an exclusion experiment for diagnosed ADHD, we found that the detection rate was about 88.0%, slightly lower than expected. Considering that the exclusion experiment was primarily related to attention in children, we excluded children diagnosed with ADHD-H. After re-analyzing the data, we found that the detection rate improved to 96.0% (310/323), which makes the exclusion test an effective tool to help diagnose ADHD (ADHD-I or ADHD-C). Since the ADHD-I and ADHD-C subtypes are the majority, accounting for 89.7 percent in our study and about 92 percent in other studies, exclusion tests can be used as an initial screening tool. However, one should keep in mind that exclusion experiments are difficult to detect subtypes of ADHD, and other complementary scales or methods need to be applied together.

CONCLUSION

In summary, we show the main concerns of parents of children of different ages. In addition, we demonstrated the accuracy of the simple exclusion experiment in children with ADHD-I and ADHD-C. Our study may help diagnose and guide future treatment directions for ADHD.