A Joint Masters Degree Program Between University of Gondar & Amanuel Mental Specialized Hospital in Integrated Clinical and Community Mental Health

A JOINT MASTERS DEGREE PROGRAM BETWEEN UNIVERSITY OF GONDAR & AMANUEL MENTAL SPECIALIZED HOSPITAL IN INTEGRATED CLINICAL AND COMMUNITY MENTAL HEALTH

PREVALENCE AND ASSOCIATED FACTORS OF ATTENTION DEFICIT HYPERACTIVITY DISORDER (ADHD) AMONG CHILDREN AGE 6 TO 17 YEARS OLD LIVING IN RURAL AREA OF GIRJA DISTRICT, GUJI ZONE, SOUTHERN OROMIA REGIONAL STATE, ETHIOPIA.

BY: HIRBAYE MOKONA LOLA (BSc)

ADVISORS: ABEBAW GEBEYEHU (PhD)

AEMRO ZERIHUN (MSc)

THESIS TO BE SUBMITTED TO UNIVERSITY OF GONDAR, COLLEGE OF MEDICINE AND HEALTH SCIENCE, DEPARTMENT OF PSYCHIATRY AND AMANUEL MENTAL SPECIALIZED HOSPITAL FOR PARTIAL FULFILLMENT OF MASTERS DEGREE IN INTEGRATED CLINICAL AND COMMUNITY MENTAL HEALTH.

August, 2015

ADDIS ABABA, ETHIOPIA Approved By Examining Board

As members of examining boards of the final MSc thesis defense, we certify that we have read and evaluated the thesis prepared by: Hirbaye Mokona

Prevalence and associated factors of attention deficit hyperactivity disorders (ADHD) among children age 6 to 17 years old living in rural area of Girja district, Guji zone, Southern Oromia regional state, Ethiopia

We recommended that it was accepted as fulfilling the thesis requirement for MSc degree of integrated clinical and community mental health

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Chairman, department graduate committee Signature Date

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Name of advisors Signature Date

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Name of internal examiner Signature Date

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Name of external examiner Signature Date

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I hereby certify that I had read this thesis prepared under my guidance and recommended that it was accepted as fulfilling the thesis requirement.

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Name of advisor Signature Date Acknowledgement First of all I would like to extend my special gratitude to my God for His great help during day and night from start to completion of my thesis.

Secondly, I would like to extend my deep gratitude to my advisors Abebaw Gebeyehu (PhD), University of Gondar, and Aemro zerihun (MSc), AMSH, for their supportive and constructive comments from beginning to completion of my thesis.

I would like to extend my warm gratitude to University of Gondar and Amanuel Mental Specialized Hospital for giving me this chance and financial support.

I would like to thank Amanuel Mental Specialized Hospital Library for internet access and librarians for giving me necessary information.

Also my deepest gratitude goes to Girja district health office for their cooperation, support and time devoted during data collection period. I would like to extend huge and warm thanks to supervisors and data collectors for their good job during data collection and the study participants for their valuable participation.

Last but not the least my acknowledgement goes for those people who helped me directly or indirectly to achieve this thesis.

Acronyms

ADDES Attention Deficit Disorder Evaluation Scale

ADHD Attention Deficit Hyperactivity Disorder

ADHD-I Attention deficit hyperactivity disorder inattentive

ADHD-HI Attention deficit hyperactivity disorder hyperactive/impulsive

ADHD-C Attention deficit hyperactivity disorder combined

AMSH Amanuel Mental Specialized Hospital

AOR Adjusted Odds Ratio

APA American Psychiatric Association

CD Conduct Disorder

CDC Center of Disease Control

CI Confidence Interval

COR Crude Odds Ratio

DBD Disruptive Behavioral Disorder

DICA Diagnostic Instrument for Child & Adolescent

DSM-IV Diagnostic & statistical manual of mental disorder forth edition

FMOH Federal Ministry of Health

ICCMH Integrated Clinical and Community Mental Health

NSCH National Survey of children’s Health

ODD Oppositional Defiant Disorder

OR Odds Ratio

SD Standard Deviation

SPSS Statistical Package for the Social Sciences

WHO World Health Organization

Table of content

Contents page

Acknowledgement ...... I

Acronyms ...... I

Table of content ...... II

List of Tables ...... IV

List of Figures ...... V

Abstract ...... VI

1. Introduction ...... 1

1.1. Statement of the Problem ...... 1

1.2. Literature review ...... 3

1.2.1. Prevalence of ADHD among children ...... 3

1.2.2. Factors Associated with childhood ADHD...... 5

1.3. Justification of the study ...... 8

2. Objectives ...... 9

2.1. General objective ...... 9

2.2 .Specific Objectives ...... 9

3. Methodology ...... 10

3.1. Study design and period ...... 10

3.2. Study Area ...... 10

3.3. Source population ...... 12

3.4. Study population ...... 12

3.5. Inclusion and exclusion criteria ...... 12

3.5.1. Inclusion criteria ...... 12

3.5.2. Exclusion criteria ...... 12

3.6. Sample Size determination and Sampling techniques ...... 12

3.6.1 Sample size determination ...... 12

3.6.2 Sampling techniques/procedures ...... 13

3.7. Study variables ...... 15

3.7.1. Dependent variable ...... 15

3.7.2. Independent variables ...... 15

3.7.3. Operational definition ...... 16

3.8. Data collection procedure ...... 16

3.9. Data quality assurance...... 17

3.10. Data processing and analysis ...... 17

3.11. Ethical consideration ...... 18

4. Results ...... 19

5. Discussions ...... 32

6. Limitations of the study ...... 36

7. Conclusion ...... 37

8. Recommendation ...... 38

9. References ...... 39

10. ANNEXES ...... 44

III

List of Tables Table 1 Socio-demographic characteristics of children age 6 to 17 years old living in rural area of Girja district, Guji zone, southern Oromia regional state, Ethiopia, 2015. . 20 Table 2 Socio-demographic characteristics of children’s family living in rural area of Girja district, Guji zone, southern Oromia regional state, Ethiopia, 2015...... 22 Table 3 Clinical/biological factors of children and their mothers living in rural area of Girja district, Guji zone, southern Oromia regional state, Ethiopia, 2015...... 23 Table 4 Distribution of studied children according to maternal factors those living in rural area of Girja district, Guji zone, southern Oromia regional state, Ethiopia, 2015...... 24 Table 5 Prevalence distribution of ADHD subtypes by sex in children age 6 to 17 years old living in rural area of Girja district, Guji zone, southern Oromia regional state, Ethiopia, 2015...... 26 Table 6 Prevalence distribution of ADHD subtypes by age group in children age 6 to 17 years old living in rural area of Girja district, Guji zone, southern Oromia regional state, Ethiopia, 2015...... 27 Table 7 Socio-demographic Factors associated with ADHD among children age 6 to 17 years old living in rural area of Girja district, southern Oromia regional state, Ethiopia, 2015 (bivariate &multivariate logistic regression)...... 29 Table 8 Clinical factors associated with ADHD among children age 6 to 17 years old living in rural area of Girja district, southern Oromia regional state, Ethiopia, 2015 (bivariate &multivariate logistic regression)...... 30 Table 9 Maternal factors associated with ADHD among children age 6 to 17 years old living in rural area of Girja district, southern Oromia regional state, Ethiopia, 2015 (bivariate &multivariate logistic regression)...... 31

List of Figures Figure (1) Conceptual framework showing relationship between childhood ADHD and associated factors of ADHD ...... 7 Figure (2) Map of the Girja district showing, the study area...... 11 Figure (3) Schematic presentation of sampling procedures ...... 14 Figure (4) Prevalence of ADHD among children age 6 to 17 years in Girja district, Southern Oromia regional state, Ethiopia, 2015...... 25 Figure (5) Distribution of ADHD subtypes by sex among children age 6 to 17 years in Girja district, Southern Oromia regional state, Ethiopia, 2015...... 26 Figure (6) Distribution of ADHD subtypes by age groups among children age 6 to 17 years in Girja district, Southern Oromia regional state, Ethiopia, 2015...... 27

Abstract Introduction: Attention deficit hyperactivity disorder (ADHD) is the most common neurodevelopmental disorder in childhood with long-term consequences. Although ADHD is the most extensively studied mental disorders of childhood in developed countries very few studies have been conducted in African countries, particularly in Ethiopia on this important disabling mental disorder of childhood.

Objective: To assess the prevalence and associated factors of ADHD among children age 6 to 17 years old living in rural area of Girja district, Guji zone, Southern Oromia regional state, Ethiopia, 2015.

Method: A community based cross-sectional study was conducted from May 09 to June 02, 2015 among children age 6 to 17 years living in rural area of Girja district. Multi-stage cluster sampling technique was used to select 1302 study subjects. 18 items Disruptive Behavior Disorder (DBD) rating scale based on DSM-IV and semi-structured questionnaire was used to collect data. Data was coded and entered into EpiData version 3.1; cleaned and analyzed by SPSS version 20. Binary logistic regression was used to identify the association of dependent and independent variables. Variables which show significant association on multivariate logistic regression analysis were reported using adjusted odds ratio (AOR) with their 95% CI.

Results: The overall prevalence of ADHD among children age 6 to 17 years in this study was 7.3% (95%CI: 5.8%-8.8%), from which 63.3% (n=57), 24.4% (n=22) and 12.3% (n=11) were predominantly inattentive, hyperactive/impulsive and combined subtypes respectively. Being male [AOR=1.81, 95%CI: (1.13, 2.91)], child living circumstance (living with single parent) [AOR=5.0, 95%CI: (2.35, 10.65)], child birth order/rank [AOR=2.35, 95%CI: (1.30, 4.25)], low family socio-economic status (low SES) [AOR= 2.43, 95%CI: (1.29, 4.59)], maternal alcohol/khat use during pregnancy [AOR=3.14, 95%CI: (1.37, 7.37)] and complication at delivery [AOR=3.56, 95%CI: (1.19, 10.64)] were more likely to develop ADHD when compared with their counterparts.

Conclusion: The prevalence of ADHD in children in the present study was similar with that of other African countries and worldwide prevalence of ADHD in children. So, prevention, early detection and management of its modifiable risk factors should be undertaken alongside increasing community awareness.

Keywords: ADHD, prevalence, children, associated factors

1. Introduction

1.1. Statement of the Problem Attention Deficit Hyperactivity Disorder (ADHD) is one of the most common neurodevelopmental disorder with childhood onset(1). It is characterized by pervasive and impairing symptoms of inattention, hyperactivity, and impulsivity that occur before 7 years of age that cause clinically significant impairments in social, academic or occupational functioning. According to the Diagnostic and Statistical manual of mental disorder fourth edition (DSM-IV) it has three subtypes: predominantly inattentive, hyperactive/impulsive and combined type ADHD (2).

The exact cause of ADHD is not known. It is a very complex neurobiological disorder that is associated with many regions of the brain and neurotransmitters(3). Current models of ADHD suggest that it is associated with functional impairments in some of the brain’s neurotransmitter systems, particularly those involving dopamine and norepinephrine. The dopamine and norepinephrine pathways that originate in the ventral tegmental area and locus ceruleus project to diverse regions of the brain and govern a variety of cognitive processes. The dopamine pathways and norepinephrine pathways which project to the prefrontal cortex and striatum (particularly, the nucleus accumbens) are directly responsible for modulating executive function (cognitive control of behavior), motivation, and reward perception. These pathways are known to play a central role in the pathophysiology of ADHD (4-7). Medications used to treat ADHD such as methylphenidate, amphetamine, and atomoxetine indicate a dopamine/norepinephrine deficit as the neurochemical basis of ADHD, but the etiology is more complex(8).

The worldwide-pooled prevalence of ADHD for persons age 18 and under was 7.2%, based on a systematic literature review and meta-analysis of 175 studies from all world regions(9). According to studies done in Egypt, Nigeria and Kenya, the prevalence of ADHD were 6.9%, 23.15% and 6.3% respectively and it is one of the most prevalent behavioral and mental disorders in childhood (10-12). The prevalence of ADHD in Africa based on studies coming from the continent ranges between 5.4% and 8.7%, amongst

1 school children, 1.5% amongst children from the general population and 45.5% to 100.0% amongst special populations of children with possible organic brain pathology (13).

A community based study done in Butajira, Southern part of Ethiopia, on topic of prevalence of mental and behavioral disorder amongst children from the general population showed prevalence of ADHD 1.5% (14). According to unpublished study conducted among 1112 children age 8 to 17 years in Estie town, south Gondar, Ethiopia, reported prevalence of ADHD was 6.6%(15).

ADHD has negative consequences on the individual at home, school or other settings from childhood to adulthood if not diagnosed early and managed appropriately (16). Although ADHD usually first presents during childhood and its diagnosis is most often made in school-aged children , many children with the disorder continue to experience symptoms as they enter adolescence (60-85%) and adult life (40%) (17).

Children with ADHD are at increased risk of dropping out of school, teenage pregnancy and criminal behavior and untreated ADHD increases the risk for future complications such as poor academic performance and learning delay, low self-esteem, poor social skills and physical injury in childhood(16). Children with ADHD are also significantly at increased risk for a wide range of psychiatric disorders like; oppositional defiant disorder, conduct disorder, mood disorders, anxiety disorders, tic disorders, personality disorders and early onset substance-related disorders(18).

Generally, as a result of lack of awareness in the community, children with ADHD due to their impairing symptoms of inattention and hyperactivity/impulsivity are ignored and actively rejected by their peers, siblings, parents, teachers and others and treated in negative ways.

Even though a lot of studies have been conducted on the prevalence and risk factors of childhood ADHD in western(developed) countries, very limited studies have been conducted in African countries specially in Ethiopia and per my knowledge, there was no study conducted on prevalence and associated factors of childhood ADHD in rural area of Girja district. In addition to limited number of study, the previous study done in

Estie town, South Gondar, was on children living in urban area. Therefore, the present study will estimate the prevalence and associated factors of ADHD among children living in rural area of Girja district, Southern Oromia regional state.

1.2. Literature review

1.2.1. Prevalence of ADHD among children Based on a systematic literature review and meta-analysis of 175 studies from all world regions, the worldwide-pooled prevalence of ADHD for persons age 18 and under was 7.2% (95% confidence interval: 6.7% to 7.8%)(9). Another more recent updated Systematic review and meta-regression Analysis comprising of 135 studies concluded that there was no evidence to suggest an increase in the number of children in the community who meet criteria for ADHD when standardized diagnostic procedures are followed(19). According other systematic literature review and meta-analysis of 86 studies of children and adolescents comprising of 163,688 individuals and 11 studies of adults comprising of 14,112 individuals based on DSM-IV, the reported pooled prevalence of ADHD among children and adolescent was(5.9 - 7.1%) and 5% among adults (20).

A recent report from the US Centers for Disease Control and prevention (CDC),based on parent• report data, suggests that the prevalence of ADHD diagnosis among US children age 3-17 year olds is approximately 6.8% and that ADHD diagnosis in the US increased by 21.8% between 2003---2007 (21). Based on National survey of children’s health (NSCH) among US children and adolescent aged 4 to 17 years old, the estimated prevalence of parent-reported ADHD was 11%(6.4 million children) and according to this survey a parent-reported prevalence of ADHD was increased by 42% from 2003 to 2011(22). Another National Survey For Children’s Health(NSCH) among samples of 64076 US children ages 6 to 17 years old, parent reported prevalence of ADHD was 8.2% (95% confidence interval: 7.7%-8.7%) (23).

According to the systematic review and meta-analysis of fourteen cross-sectional, observational epidemiological studies among 13,026 children age 6 to 17 years in Spain, the pooled prevalence of ADHD was 6.8% representing 361,580 children and adolescents in the community(24). Based on the other systematic literature review of

3 seven studies in Brazil, the estimated prevalence of ADHD was 5.8% using DSM-IV criteria and 1.5% using ICD-10 (25).

According to institutional based cross-sectional study conducted among 1535 Venezuela children age 4 to 12 years old by using Conner’s parent and teacher rating scale, the estimated prevalence of ADHD was 10.03%(26). Similar study conducted in Saudi Arabia among 1287 male students age 6 to 13 years old by using ADDES school version and parent’s questionnaire, prevalence of ADHD by subtypes were 16.4% for combined ADHD (ADHD-C), 16.3% for inattention subtype ADHD(ADHD-I) and 12.4% for hyperactive/impulsive ADHD (ADHD-HI) (27).

According to study conducted in Jeddah, kingdom of Saudi Arabia, among 2770 primary school children age 6 to 12 years by using Attention deficit hyperactivity disorder scale (based on DSM-IV), the estimated prevalence of ADHD was 11.6% of which 6.3% had the Inattention subtype, 2.2% had the hyperactive/impulsive subtype and 3.1% had the combined ADHD subtype(28). According to another institutional based study conducted among 1403 preschool-aged Iranian children age 3 to 6 years by using 19-item observer-rating scale questionnaire by parents and teachers evaluation independently, the prevalence of ADHD according to their parent’s evaluation was 25.8% (23.6-28.1%) and according to their teacher’s evaluation was 17% (14.1-20.4%) (29).

Based on literature review of 9 studies from African countries on childhood ADHD, its prevalence ranges between 5.4% and 8.7%, amongst school children, 1.5% amongst children from the general population and 45.5% to 100.0% amongst special populations of children with possible organic brain pathology(13). Some studies in African countries estimated the prevalence of childhood ADHD, for example the prevalence of ADHD in Egypt was 6.9%(21) , in Nigeria 3.2%-23.15% (11, 30), in Kenya 6.3% (12) and in Democratic republic of Congo 6% (31). According to hospital based cross-sectional study conducted among 600 children age 5 to 12 years attending the general pediatric outpatient clinic of Minoufia University hospital, Egypt, both from rural and urban regions by using ADHD rating scale, the reported prevalence of ADHD was 19.7% (32).

A study conducted in Butajira, Southern Ethiopia, on topic of mental and behavioral disorder among 1477 children age 5 to 14 years by using Diagnostic instrument for children and adolescent (DICA) which was not specifically on topic of ADHD like that of other African countries, the estimated prevalence of ADHD was 1.5%(14).

1.2.2. Factors Associated with childhood ADHD ADHD is thought to be the result of complex interactions between genetic, environmental, and neurological factors and it is attributed to genetic factors in about 80%(33).

Basic information about how the prevalence of ADHD varies by race/ethnicity, sex, age, socioeconomic status (SES), maternal factors, clinical factors and substance factors were remains poorly described. According to the systematic review conducted in the world, the main factors associated in the variation for the prevalence of ADHD across the world were diagnostic criteria, source of information, presence or absence of impairment criteria for diagnosis and geographic origin of the studies(34). In a study conducted in Saudi Arabia among primary school male children age 6 to 13 years parents’ low level of education, mother’s occupation, and low socioeconomic status were significantly associated with ADHD(27). According to a cross-sectional study conducted in Iran among children age 3 to 6 years Gender(male gender), child rank(birth order), mother education level, living with single parent and interest in aggressive television program were significantly associated with development of ADHD(29).

A study conducted among children aged 6 to 12 years presenting at the child psychiatry clinic of the Aminu Kano teaching hospital in Kano, Northern Nigeria showed that living with single/divorced parents (p=0.001), mother smoking (p=0.004) and drinking (p=0.005) while pregnant, modes of delivery other than vaginal delivery (p=0.018) and starting school at the age of 5 years (p=0.029) have significant correlates with ADHD(35). Based on a cross-sectional study conducted among 68,634 US children, 5– 17 years old, from the National Survey of Children’s Health (NSCH) watching television/playing video games, participation in sports, two-parent family structure, and family members’ smoking status were significantly associated with ADHD (36).

A case-control study conducted among 404 children (208 cases and 196 controls) age 4 to 11 years in Iran revealed that parental psychiatric disorders, previous abortion, unwanted pregnancy, history of trauma and accident to abdomen during pregnancy, cesarean delivery, maternal alcohol and tobacco exposure during pregnancy, head trauma and epilepsy were significantly more among children with ADHD than control group (37). According to other case-control study conducted among children and adolescents age 6 to 12 years (164 cases and 166 controls) attending the child and adolescent psychiatric clinic of Tabriz University of medical sciences, Iran demonstrated that gender (male gender) and maternal employment (those children with working mothers suffered more from ADHD) were more among children with ADHD than control group (38). According to hospital based cross-sectional study conducted among 600 children age 5 to 12 years attending the general pediatric outpatient clinic of Minoufia University hospital, Egypt, both from rural and urban regions by using ADHD rating scale, male sex, living in urban areas, low socioeconomic families, large family size, living with a single parent, family history of ADHD, preterm children, low birth weight and bottle fed children were significantly associated with high prevalence of ADHD(32).

 Socio-demographic Family factors factors  Birth rank/order  Age  Family size  Sex  Child living  Ethnicity circumstance  Religion  Family educational  Household level assets  Family marital status

Childhood

ADHD

Clinical factors

 Maternal health status Maternal factors during pregnancy  Child health status  Duration of  Maternal history of pregnancy substance use during  Complication at prenancy delivery

 Family history of mental  Type of infant feeding illness  History of head trauma

Figure 1 Conceptual framework showing relationship between childhood ADHD and associated factors of ADHD (independent variables).

1.3. Justification of the study Attention deficit hyperactivity disorder is serious public health problem affecting millions of children throughout the world.

Children with ADHD are at increased risk of problems with interpersonal relationship with family and peers, dropping out of school, teenage pregnancy and criminal behavior. If left untreated, childhood ADHD increases the risk for future complications such as poor academic performance (academic underachievement) and learning delay, low self-esteem, poor social skills and physical injury in childhood.

Children with ADHD are also significantly at increased risk for a wide range of psychiatric disorders like; oppositional defiant disorder, conduct disorder, mood disorders, anxiety disorders, tic disorders, personality disorders and early onset substance-related disorders. As a result of lack of awareness in the community, children with ADHD due to their impairing symptoms of inattention and hyperactivity/impulsivity are ignored and actively rejected by their peers, siblings, parents, teachers and others and treated in negative ways.

In short, it has been associated with a broad range of negative outcomes in affected subjects with a serious burden to families and society, which characterizes it as a major public health problem.

Despite the negative consequences of ADHD on the individual’s future life, the family and community as whole, very little attention has been given to this important disabling behavioral and neurodevelopmental disorder of childhood in our country, Ethiopia.

Even though ADHD is the most extensively studied mental disorders of childhood, very few studies have been conducted regarding this topic in our country, Ethiopia, and per my knowledge no study has been conducted on prevalence and associated factors of ADHD among children living in rural area of Girja district, Southern Oromia regional state.

Therefore, the present study will estimate the prevalence and associated factors of ADHD among children 6-17 years old living in rural area of Girja district.

So, an understanding of epidemiological aspect of ADHD may provide insight into its distribution and associated factors as well as information for planning the allocation of budget for mental health services in the area.

2. Objectives

2.1. General objective  To assess the prevalence and associated factors of ADHD among children living in rural area of Girja district, Guji zone, Southern Oromia regional state, Ethiopia, 2015.

2.2 .Specific Objectives  To determine the prevalence of ADHD among children living in rural area of Girja district, Guji zone, Southern Oromia regional state, Ethiopia.  To identify factors associated with ADHD among children living in rural area of Girja district, Guji zone, Southern Oromia regional state, Ethiopia.

3. Methodology

3.1. Study design and period Community based cross-sectional study design was conducted to assess the prevalence and associated factors of ADHD among children age 6 to 17 years old living in rural area of Girja district, Guji zone, Oromia regional state, Ethiopia, from May 09 to June 02, 2015.

3.2. Study Area The study was conducted in Girja district, which is found in Guji zone, Oromia regional state. It is located in the southern part of Ethiopia as well as Oromia regional state at a distance of 559 kilometer from the capital city of Ethiopia, Addis Ababa and 207 kilometer from Negele, the capital of Guji zone. It has a total population of 62083 (31289 males and 30793 females), 19357 children age from 5 to 15 years, 20 kebeles, 12934 households ,45 governmental schools, 4 governmental health centers, 3 private clinics . There is no hospital and mental health clinic in the district [report from Girja district health office].

Figure 2 Map of the Girja district showing, the study area (Boundaries of Girja district, North- Sidama zone of SNNPR, Northwest-west Arsi zone, West- Adola Rede district of Guji zone by Genale river, East- Mada walabu district of Bale zone, South- Goro Dola district of Guji zone).

3.3. Source population All children age 6 to 17 years old living in rural area of Girja district were source population for this study.

3.4. Study population All children age from 6 to 17 years living in rural area of Girja district in the selected kebeles and those who have informants during the study period were study population.

3.5. Inclusion and exclusion criteria

3.5.1. Inclusion criteria Children of age from 6 to 17 years old, both sexes, with a permanent residence in Girja district were included in this study.

3.5.2. Exclusion criteria Children who have hearing problems and children without informants were not included in this study.

3.6. Sample Size determination and Sampling techniques

3.6.1 Sample size determination In this study, Single population proportion formula was used to calculate the sample size by taking the assumption of 95% confidence interval (CI), precision 2% and the prevalence of childhood ADHD of unpublished study reported from Estie town, South Gondar, Ethiopia, which was 6.6 %( 0.066) was used (15). Thus a minimum number of 592 children age 6 to 17 years old were the required number in the study. To compensate for some non-response rate, the study added 10% of the sample size. So as to increase sample size and to minimize variability, design effect 2 was used. The formula to determine the sample size is as below.

= 592

Non-response rate = 592x10% = 592x0.1 ≈59

Total sample size was = n+59 = 592+59 =651 and multiply by design effect 2, then the total sample size was 1302 study subjects.

Where, n = minimum sample size required for the study

Zα/2 = value of the standard normal distribution corresponding to a significant

Level of alpha (α) 0.05 which is 1.96 p = prevalence of ADHD among children in Ethiopia was 6.6% d = the margin of error between the sample and the population (2%).

3.6.2 Sampling techniques/procedures

Multi-stage cluster sampling technique was employed. The twenty kebeles in the district are classified as cluster. Out of twenty kebeles, five kebeles were selected by simple random sampling. A total of 5351children age from 5 to 15 years old were living within 3573 households in the five selected kebeles. From each kebeles, two Gotts were selected by simple random sampling. Then we selected children age 6 to 17 years old from each household which had eligible child until the sample size was accomplished. When more than one eligible child is available in the household, lottery method was used to select one child.

Girja district (19357 children age 5 to 15 years)

N= 12934 household

Clustered by kebele

Girja district, 20 kebeles

Simple random sampling

Kebele 1 Kebele 2 Kebele 3 Kebele 4 Kebele 5

HH=666 HH=537 HH=901 HH=649 HH=820

G1&G2* G1&G2 G1&G2 G1&G2 G1&G2

HH=303 HH=298 HH=405 HH=300 HH=320

One child per household was selected

n= 1302

G*=Gott

Figure 3 Schematic presentation of sampling procedure on prevalence and associated factors of childhood ADHD among children age 6 to 17 years living in Girja district, Guji zone, Oromia regional state, Ethiopia, 2015.

3.7. Study variables

3.7.1. Dependent variable  Childhood Attention deficit hyperactivity disorder (ADHD) (yes/no)

3.7.2. Independent variables  Socio-demographic factors  Age  Sex  Ethnicity  Religion  Family factors  Birth rank/order  Family size  Child living circumstance  Family educational level  Family marital status  Wealth index  Clinical factors  Maternal health status during pregnancy  Child health status  Maternal history of substance use during pregnancy  Family history of mental illness  History of head trauma  Maternal factors  Duration of pregnancy  Complication at delivery  Type of infant feeding

3.7.3. Operational definition ADHD Predominantly Inattentive(ADHD-IN) type; from DBD rating scale items 1-9 of inattention symptoms 6 or more items must be endorsed as “pretty much” or “very much”.

ADHD Predominantly Hyperactive-Impulsive (ADHD-HI) type; from DBD rating scale items 10-18 of hyperactive/impulsive symptoms 6 or more items must be endorsed as “pretty much” or “very much”.

ADHD Combined (ADHD-C) type; if 6 or more items are endorsed as “pretty much” or “very much” from inattentive and hyperactive/impulsive DBD rating scale item separately.

Poor maternal health during pregnancy; The mother who had acute severe illness history and /or chronic illness when she was pregnant for the child that was selected for this study.

Complication at delivery: the mother who had history of prolonged labor, instrumental delivery and Cesarean section delivery for the child that was selected for this study.

3.8. Data collection procedure The semi-structured questionnaire was used to identify the socio-demographic characteristic of parents and children, clinical factors and maternal factors which are associated factors of ADHD. DBD rating scale based on the DSM-IV criteria, which is used to investigate the presence of ADHD symptoms. The scale consists of 45 items representing symptoms of Disruptive Behavior Disorders which are oppositional defiant disorder (ODD), ADHD and conduct disorder (CD). Out of the 45 items, 18 items are DSM-IV ADHD symptoms assessment criteria. Therefore, only these 18 items were used in present study. Each symptoms was rated on a 4-point scale indicating the occurrence and the severity of symptoms: 0(not at all), 1(just a little), 2(pretty much) or 3(very much) (39). DBD rating scale had internal consistency with cronbach’s alpha of 0.96 in the present study.

Two BSc nurses for supervision and five diploma clinical nurses for data collection were recruited and trained by principal investigator.

Data was collected from parents or caretakers by face to face interview technique using Disruptive Behavior Disorder (DBD) rating scale item and semi-structured questionnaire after translated into Afan Oromo.

3.9. Data quality assurance Data collectors and supervisors were trained for two consecutive days on data collection procedures and supervision techniques. Maximum effort was applied to minimize bias and error during data collection by using the following strategies: using standard DBD rating scale items which was translated into Afan Oromo by senior psychiatrists, appropriate and representative study participants were identified, Supervision was conducted strictly and frequently and at the end of the day all the collected data were checked for completeness by the principal investigator and supervisor. In addition, the data collection instrument was pre-tested on 5% of the actual sample size in Haranfama Debisa kebele with similar characteristics of the study unit that was not included in the main study. Finally, after checked completeness of the required type of data by principal investigator and supervisor the completed data were coded.

3.10. Data processing and analysis First the data was checked for completeness and consistency. Then it was coded, entered and cleaned before and during data processing by using EpiData version 3.1 and exported to statistical package for social sciences (SPSS) version 20 for analysis. Association between the dependent and independent variables was assessed using binary logistic regression. Variables which have p-value less than 0.2 during bivariate analysis were taken to multivariable logistic regression for further analysis. The strength of the association was presented by crude odds ratio and adjusted odds ratio with their 95% C.I. Variables that have P-values less than 0.05 were considered as statistically significant. Data was described by using frequencies, tables and figures. Descriptive statistic was used to explain the study participants in relation to study variables.

3.11. Ethical consideration The study was conducted after getting ethical clearance from the Institutional Review Board (IRB) of University of Gondar, college of medicine and health sciences, and Amanuel Mental Specialized Hospital. All study subjects were informed about the purpose of the study, the importance of their participation and Privacy and confidentiality of information given by each respondent was kept properly. All procedures were explained to the study participants in the local language and written or thumb-printed informed consent was obtained from each parent or caretaker and older children age 12 to 17 years old were assented to all relevant study procedures, which was approved by the IRB. Parents or caretakers who have had positive child for ADHD were advised to be linked to psychiatry clinic of Adola Woyu district Hospital.

4. Results 4.1. Socio-demographic characteristics of children

Of the 1302 proposed participants a total number of 1238 children were participated in the present study with the response rate of 95.1%. There were a total of 640 males (51.7%) and 598 females (48.3%). The mean age of children participated in this study was 10.87 years with standard deviation of ±2.2 years. Eight hundred and ninety four (72.2%) of the children were between the age group of 6 to 12 years. Majority of the children, 1208 (97.6%) were Oromo in ethnicity and 1003 (81%) were protestant in religion. About 85% (n =1052) of children were primary school students in their educational status. Majority of children, 1195 (96.5%) were living with both parents followed by 43 (3.5%) with single parent (Table1).

Table 1 Socio-demographic characteristics of children age 6 to 17 years old living in rural area of Girja district, Guji zone, southern Oromia regional state, Ethiopia, 2015.

Socio-demographic characteristics of the children Frequency Percent (%)

Sex Male 640 51.7 Female 598 48.3 Age groups in years 6-12 894 72.2 (Mean age 10.87 ± 2.2 years) 13-17 344 27.8

Ethnicity Oromo 1208 97.6 Others** 30 2.4

Religion Protestant 1003 81 Orthodox 167 13.5 Muslim 68 5.5 Child education level 0-4 grade 1052 85 5-8 grade 186 15 Living circumstance of the child Living with both parents 1195 96.5 Living with single parent 43 3.5

**= Amhara, Wolaita and Sidama

4.2. Socio-demographic characteristics of family

Majority of parents, 1202 (97.1%) were married followed by divorced/widowed 36(2.9%). From the total mothers those who are alive, 716 (58.5%) were unable to read and write. Regarding family size, 68.3% (n= 845) families had >4 children in the house. Of the children participated in the study, 685 (55.3%) were first child in birth order/rank (Table 2).

Table 2: Socio-demographic characteristics of children’s family living in rural area of Girja district, Guji zone, southern Oromia regional state, Ethiopia, 2015.

Socio-demographic characteristics of the family Frequency Percent (n= 1238) (%)

Family marital status Married 1202 97.1 Divorced/ Widowed 36 2.9 Child’s mother alive Yes 1224 98.9 No 14 1.1 Mother’s educational level Unable to read & write 716 58.5 Primary school¹ 455 37.2 secondary & above² 53 4.3 Father’s educational level Unable to read & write 265 21.4 Primary school¹ 678 54.8 secondary & above² 295 23.8 Child birth rank/order First child 553 44.7 Second child & above 685 55.3 Family size >4 children 845 68.3 1-4 children 393 31.7 Socio-economic status of the Lowest 416 33.6 family Middle 413 33.4 (By Wealth Index) Highest 409 33.0

¹= Grade one to grade eight ²= Grade nine and above

Table 3: Clinical/biological factors of children and their mothers living in rural area of Girja district, Guji zone, southern Oromia regional state, Ethiopia, 2015.

Clinical factors Frequency Percent (%)

Maternal health status during pregnancy Sick 30 2.4

Healthy 1208 97.6

Child health status before 6 years of age Sick 26 2.1

Healthy 1212 97.9

Maternal history of substance use during Alcohol/khat 45 3.6 pregnancy None 1193 96.4

Yes 37 3 Family history of mental illness

No 1201 97

Yes 22 1.8 History of head trauma No 1216 98.2

Table 4: Distribution of studied children according to maternal factors those living in rural area of Girja district, Guji zone, southern Oromia regional state, Ethiopia, 2015.

Maternal factors Frequency Percent (%)

Pre-term 20 1.6

Duration of pregnancy Full-term 1218 98.4

Complication at delivery Yes 22 1.8

No 1216 98.2

Child feeding style during the first six Bottle feeding 40 3.2 month Breast feeding 1198 96.8

4.3. Prevalence of ADHD among children age 6 to 17 years

Among the total children participated in this study, 90 (7.3%; 95% CI: 5.8%, 8.8%) of children had ADHD. From the total ADHD, 57 (63.3%) were ADHD-IN subtype, 22 (24.5%) were ADHD-HI subtype and 11(12.2%) were ADHD-C subtype (figure 4).

12.20%

24.50% ADHD-IN 63.30% ADHD-HI ADHD-C

Figure 4: Prevalence of ADHD among children age 6 to 17 years living in rural area of Girja district, Guji zone, Southern Oromia regional state, Ethiopia, 2015.

Table 5: Prevalence distribution of ADHD subtypes by sex in children age 6 to 17 years old living in rural area of Girja district, Guji zone, southern Oromia regional state, Ethiopia, 2015.

ADHD Subtypes Sex ADHD-IN ADHD-HI ADHD-C no % no % No % Male 34 59.6 17 77.2 8 72.7 Female 23 40.4 5 22.8 3 27.3 Total 57 100 22 100 11 100

90.00% 77.20% 80.00% 72.70% 70.00% 59.60% 60.00%

50.00% Male 40.00% Female 30.00%

20.00%

10.00%

0.00% ADHD-I ADHD-HI ADHD-C

Figure 5: Distribution of ADHD subtypes by sex among children age 6 to 17 years living in rural area of Girja district, Guji zone, Southern Oromia regional state, Ethiopia, 2015.

Table 6: Prevalence distribution of ADHD subtypes by age group in children age 6 to 17 years old living in rural area of Girja district, Guji zone, southern Oromia regional state, Ethiopia, 2015.

ADHD Subtypes Age Group in years ADHD-IN ADHD-HI ADHD-C no % no % no % 6-12 39 68.4 20 90.9 9 81.8 13-17 18 31.6 2 9.1 2 18.2 total 57 100 22 100 11 100

100.00% 90.90% 90.00% 81.80% 80.00% 68.40% 70.00% 6-12 years 60.00% 13-17 years 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% ADHD-IN ADHD-HI ADHD-C Figure 6: Distribution of ADHD subtypes by age groups among children age 6 to 17 years in Girja district, Southern Oromia regional state, Ethiopia, 2015.

4.4. Factors associated with ADHD among children age 6 to 17 years old living in rural area of Girja district, Guji zone, Southern Oromia regional state, Ethiopia, 2015.

Bivariate analysis

From the bivariate analyses of ADHD in relation to each explanatory variable like sex, family marital status, living circumstances of the child, child birth order/rank, family size, socio- economic status of the family(by wealth index), maternal health status during pregnancy, maternal history of substance use during pregnancy, duration of pregnancy, complication at delivery and child feeding style during the first six months of life were variables that fulfilled the minimum requirement (0.2 level of significance in this study) for further analysis and entered into multivariate regression analysis. On the other hand, child age, child health status before six years of age, mother’s educational status, father’s educational status, family history of mental illness and history of head trauma were variables not significant at 0.2 level of significance and were excluded from further analysis.

Multivariate logistic analysis

Assessment was done and it revealed that the model adequately fits the data for ADHD as p-value from Hosmer and Lemeshow test was 0.798. During the multivariate analysis of ADHD in relation to all explanatory variables; being male [AOR=1.81, 95%CI: (1.13, 2.91)], child living circumstance (living with single parent) [AOR=5.00, 95%CI: (2.35, 10.65)], child birth order/rank [AOR=2.40, 95%CI: (1.30, 4.25)], family socio-economic status (low SES) (AOR= 2.43, 95%CI: 1.30, 4.60), maternal alcohol/khat use during pregnancy [AOR=3.14, 95%CI: (1.34, 7.37)] and complication at delivery [AOR=3.60, 95%CI: (1.19, 10.64)] were statistically significant with ADHD, while there was no statistical difference between children with ADHD and those without ADHD, with respect to family marital status, family size, maternal health status during pregnancy and child feeding style for the first six months of life(Table 7).

Table 7: Socio-demographic factors associated with ADHD among children age 6 to 17 years old living in rural area of Girja district, southern Oromia regional state, Ethiopia, 2015 (bivariate &multivariate logistic regression).

With ADHD Without Explanatory variables ADHD COR(95%CI) AOR(95%CI) (Socio-demographic factors) No % No % Sex Male 59 9.2 581 90.8 1.9(1.18-2.91) 1.81(1.13-2.91)* Female 31 5.2 567 94.8 1 1 P-value 0.007 0.014 Family marital status Divorced/widowed 12 33.3 24 66.7 7.21(3.47- 0.8(0.1-5.14) Married 78 6.5 1124 93.5 14.95) 1 1 P-value <0.001 0.8 Living circumstances of child Living with single parent 14 32.6 29 67.4 7.11(3.6-14) 5.0(2.35-10.65)* Living with both parents 76 6.4 1119 93.6 1 1 P-value <0.001 <0.001 Child birth order/rank First child 20 3.6 533 96.4 3(1.82-5.05) 2.4(1.30-4.25)* Second child & above 70 10.2 615 89.8 1 1 P-value <0.001 0.005 Family size >4 children 67 8.1 764 91.9 1.5(0.9-2.4) 0.99(0.5-1.8) 1-4 children 23 5.7 384 94.3 P-value 0.127 0.97 SES(By Wealth Index) Lowest 49 11.8 367 88.2 3.5(1.9-6.4) 2.43(1.28-4.58)* Middle 26 6.3 387 93.7 1.8(0.9-3.4) 1.4(0.7-2.8) Highest 15 3.7 394 96.3 1 1 P-value <0.001 0.006

* = statistically significant (p-value <0.05) 1= Reference variable

Table 8: Clinical factors associated with ADHD among children age 6 to 17 years old living in rural area of Girja district, southern Oromia regional state, Ethiopia, 2015 (bivariate &multivariate logistic regression).

Explanatory variables With ADHD Without ADHD COR(95%CI) AOR(95%CI) (Clinical factors) No % No % Maternal health status during pregnancy Sick 4 22.2 14 77.8 3.8(1.21-11.7) 2.4(0.7-8.8) Healthy 86 7 1134 93 1 1

P-value 0.022 0.16 Child health status before 6 years of age Sick 3 11.5 23 88.5 1.7(0.5-5.7) Healthy 87 7.2 1125 92.8 1 P-value 0.4 Maternal history of substance use during pregnancy Alcohol/khat 7 18.9 30 81.1 3.37(1.42-8.46) 3.14(1.37-7.37)* None 83 6.9 1118 93.1 1 1 P-value 0.008 0.009 Family history of mental illness Yes 4 10.8 33 89.2 1.6(0.54-4.54) No 86 7.2 1115 92.8 1 P-value 0.4 History of head trauma Yes 2 9.1 20 90.9 1.3(0.3-5.6) No 88 7.2 1128 92.8 1 P-value 0.7

* = statistically significant (p-value <0.05)

1= Reference variable

Table 9: Maternal factors associated with ADHD among children age 6 to 17 years old living in rural area of Girja district, southern Oromia regional state, Ethiopia, 2015 (bivariate &multivariate logistic regression).

Explanatory variables With ADHD Without (Maternal factors) ADHD COR(95%CI) AOR((95%CI) No % No % Duration of pregnancy

Pre-term 4 20 16 80 3.3(1.1-10.1) 3(0.9-10.7) Full-term 86 7.1 1132 92.9 1 1 P-value 0.037 0.07 Complication at delivery

Yes 5 22.7 17 77.3 3.91(1.41-10.9) 3.6(1.19-10.64)* No 85 7 1131 93 1 1 P-value 0.009 0.023 Child feeding style during the first six month of life Bottle feeding 5 12.5 35 87.5 1.9(0.7-4.9) 2(0.7-5.7) Breast feeding 85 7.1 1113 92.9 1 1 P-value 0.2 0.18

* = statistically significant (p-value <0.05)

1= Reference variable

5. Discussions 5.1. Prevalence of Attention Deficit Hyperactivity Disorder (ADHD)

A community based cross-sectional study was conducted to assess prevalence and associated factors of ADHD among children age 6 to 17 years by using DBD rating scale, which is based on DSM-IV criteria, and semi-structured questionnaires for assessing risk factors. The overall prevalence of ADHD in this study was 7.3% (95%CI: 5.8%-8.8%) from which ADHD predominantly inattentive type (n= 57, 63.3%) was the most prevalent type followed by ADHD predominantly hyperactive/impulsive type (n=22, 24.4%) and lastly ADHD predominantly combined type (n=11, 12.3%).

The present study finding was consistent with the study done in Estie town, south Gondar, Ethiopia, which was 6.6%(15). The present study’s finding was also in line with other studies carried out in Egypt 6.9%(21), in Kenya 6.3%(12), in Democratic Republic of Congo 6% (31), in Spain 6.8%(24) and in USA 8.2% (23). And also in the current study finding, the prevalence of ADHD was consistent with worldwide-pooled prevalence of ADHD for children age 18 years and under which was 7.2% (95%CI: 6.7% to 7.8%) (9) and with systematic literature review and meta-analysis of 86 studies conducted in different parts of the world comprising of 163,688 children based on DSM- IV criteria to estimate prevalence of ADHD which was 5.9%-7.1%(20).

However, the prevalence of ADHD in the present study was higher than the study done in Butajira, southern Ethiopia 1.5%(14) and Nigeria 3.2%(11). The variation might be due to socio-cultural difference, difference in sample size which was only 282 participants in Nigeria (11) and difference in data collection tool which was Diagnostic Instrument for Children and Adolescent (DICA) in Ethiopia(14).

On the other hand, the finding of the present study was lower than the finding of study done in Venezuela 10.03%(26), in Saudi Arabia by subtypes; 16.4%ADHD-C, 16.3%

ADHD-IN &12.4% ADHD-HI (27) and in Jeddah, kingdom of Saudi Arabia, 11.6%(28), in Iran 17%-25.8% (29), in Nigeria 23.15%(40) and in Egypt, 19.7%(32). The variation might be due to; 1) socio-cultural difference, 2) data collection to which was Conner’s parent and teacher rating scale in Venezuela, ADHDES in Saudi Arabia and 19-item observer-rating scale in Iran, 3) age difference: because of the fact that for children under 6 years of age, a stage when child development is rapid, it is difficult to distinguish ADHD symptoms from normal developmental variation in impulsivity and attention which may lead to over diagnosis.

5.2. Factors associated with Attention Deficit Hyperactivity Disorder

With respect to gender, being male was 1.8 times more likely to have ADHD than female, which was in agreement with several other studies(21, 32, 40). The explanation of difference of ADHD prevalence among males and females was so difficult because most of the etiopathogenesis and acquired risk factors reported in the prenatal, perinatal and postnatal periods (first two years) cannot differ as regard sex. However, we can explain that according to the study that reported the slightly larger heads of males might have put males more susceptible to pressure and head injury at birth(41). Also, the skeletal immaturity of boys relative to girls, which may render boys more vulnerable to damage and that will lead to minimal brain damage which may predispose later on to develop ADHD among those children(42). Other study also reported that gender difference might be due to referral bias as males are more likely to present with more externalizing symptoms such as hyperactivity or impulsivity and physical aggression than females and females are more likely to present with more internalizing symptoms like being withdrawn, low self-esteem and anxiety than males(43).

In the current study, children living with single parents were 5 times more likely to have ADHD when compared to those children living with both parents. This result was in agreement with some other studies (32, 44, 45) that reported, the separation of the child from one or both parents early in life was associated with increased prevalence of ADHD in accordance with the current study. Parental separation had been shown to have negative effects on the child’s behavior due to inconsistent parenting, more punishment, violence and criticism(45).

In our study, we found that being first birth child was 2.4 times more likely to develop ADHD than second and above birth order, which was similar with the study conducted in Assiut city-Egypt (44) that reported more ADHD symptoms among first birth. The reason why ADHD symptoms are more among first birth order might be explained by; a) Deficiency in experiences of mothers in dealing with their first baby. b) The first birth child has a special position in some families that may act as one of the risk factors for ADHD (e.g. over protection and spoiling). The first birth child may also be liable to some troubles during pregnancy and labor such as lack of prenatal care and narrow pelvis in primigravida that may lead to difficult labor or labor complication. Again also, the reason why ADHD symptoms are more among last birth order might be explained by; a) the last birth in some families may be spoiled. b) The last birth may come from large family size in which it had many troubles between brothers and sisters regarding hyperactivity and impulsivity. c) In some last birth mothers may be old with decreased interest in rearing their last child. d) The old age of some mothers led to some medical complications especially chromosomal aberrations of the last birth child with associated abnormal behaviors. This was also in agreement with study that reported child who has special position in the family as over protection and spoiling is more liable to develop ADHD than other children(46).

This study showed that being child of family with low level socio-economic status was 2.4 times more likely to develop ADHD when compared to child of family with high level socio-economic status. This result was similar with several other studies (27, 32, 47). This could be explained by the fact that children belonging to a lower social class are at an increased risk of having various psychiatric problems including ADHD because factors such as complicated pregnancy and malnutrition are commonly associated with poor socio-economic status.

The result of this study showed no significant association between parents’ education and prevalence of ADHD. This result was in line with some other studies(27) (32).However, it was in disagreement with other study (48) that reported high prevalence of ADHD in children of parents with low level of education which could be explained by; 1) parents with low level of education had poor knowledge of how to deal

34 with children having ADHD and frequently lack several important parenting skills. 2) Parents with low level of education might be treating children having ADHD violently and aggressively, which may reflect negatively on them and lead to increased symptoms of ADHD. On the other hand, high level of parents’ education especially mothers’ education were found to reflect positively on better physical and psychological health of their children(49).

In the present study, mothers who have used alcohol/khat during pregnancy were 3.14 times more likely to have a child with ADHD when compared to mothers who haven’t used alcohol/khat during pregnancy, which was consistent with the results of other studies (50-52).

With respect to history of complication at delivery, mothers who had history of complications at delivery (perinatal complications) were 3.6 times more likely to have a child with ADHD as compared to mothers who haven’t had history of perinatal complication, which was in agreement with the result of one case-control study (70 cases and 50 controls) reported from outpatient program of the Child Psychiatry department, Douglas Hospital, Montreal(53).

Finally, in our discussion, some studies have variation with the present study which could be due to use of different tool, diagnostic criteria (either DSM-IV or ICD-10), study setting (community based or institutional based) and source of information (parents, teachers or self-report by children).

6. Limitations of the study Difficulty in recalling history of child health status before six years of age, child feeding style in the first six month of life, maternal health status during pregnancy and complication at delivery (perinatal complication) by some illiterate mothers during data collection.

It was also difficult to establish temporal cause and effect relationship between ADHD and its associated factors by cross-sectional study.

7. Conclusion The prevalence of ADHD in the present study in Girja district among children age 6 to 17 years was similar with that of other African countries and worldwide prevalence of ADHD. ADHD is associated with many risk factors both modifiable and non-modifiable such as sex, living with single parents, child birth order/rank, low socio-economic status of the family, maternal alcohol/khat use during pregnancy and complication at delivery. So, prevention, early detection and management of its modifiable risk factors should be undertaken alongside increasing community awareness.

8. Recommendation To Oromia regional state Health Bureau

 It is better if several approaches implemented to reduce the prevalence and associated factors of ADHD which should be directed to the child, family, primary health care services, the school and community by integrating mental health service within primary health care services.

To Girja district Health Office

 It is better if Psychiatry clinic established as one unit in Girja district health centers.

To health professionals

 Early identification and management of children with ADHD have great value for children, family and community as whole.  At maternal and child health care service, mothers should be aware about relationship of substance use during pregnancy and complication at delivery (e.g. prolonged labor) which may later on predispose the child for ADHD.  Health information regarding associated factors and symptoms of ADHD should be given for parents, teachers and community.

To researchers

 Prospective study should be considered to investigate the cause-effect relationship between ADHD and its associated factors.

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33.Mick E, Faraone SV. Genetics of attention deficit hyperactivity disorder. Child and adolescent psychiatric clinics of North America. 2008;17(2):261-84. 34.Polanczyk G, de Lima MS, Horta BL, Biederman J, Rohde LA. The worldwide prevalence of ADHD: a systematic review and metaregression analysis. Am J Psychiatry. 2007;164(6):942-8. 35.Sale S. Correlates of Attention Deficit/Hyperactivity Disorder (ADHD) among children in a clinical psychiatric center in Northern Nigeria. 2011. 36.Lingineni RK, Biswas S, Ahmad N, Jackson BE, Bae S, Singh KP. Factors associated with attention deficit/hyperactivity disorder among US children: results from a national survey. BMC Pediatr. 2012;12. 37.Golmirzaei J, Namazi S, Amiri S, Zare S, Rastikerdar N, Hesam AA, et al. Evaluation of Attention-Deficit Hyperactivity Disorder Risk Factors. International Journal of Pediatrics. 2013;2013. 38.Malek A, Amiri S, Sadegfard M, Abdi S, Amini S. Associated factors with attention deficit hyperactivity disorder (ADHD): a case-control study. Arch Iran Med. 2012;15(9):560-3. 39.Pelham WE, Gnagy EM, Greenslade KE, Milich R. Teacher Ratings of DSM-III-R Symptoms for the Disruptive Behavior Disorders. Journal of the American Academy of Child & Adolescent Psychiatry. 1992;31(2):210-8. 40.Egbochuku EO, Abikwi MI. The prevalence of attention deficit/hyperactivity disorder (ADHD) among primary school pupils of Benin metropolis, Nigeria. Journal of Human Ecology. 2007;22(4):317-22. 41.Ingram CP, Kvaraceus WC. Selected References from the Literature on Exceptional Children. The Elementary school journal. 1953:462-76. 42.Johnston FE. Individual variation in the rate of skeletal maturation between five and eighteen years. Child development. 1964:75-80. 43.Hoseini BL, Abbasi MA, Moghaddam HT, Khademi G, Saeidi M. Attention Deficit Hyperactivity Disorder (ADHD) in Children: A Short Review and Literature. International Journal of Pediatrics. 2014;2(12).

44.El-Tallawy HN, Hassan WA, El-Behary AA, Shehata GA. Prevalence of attention deficit hyperactivity disorder among elementary schools children in Assiut City-Egypt. Egyptian Journal of Neurology, Psychiatry and Neurosurgery. 2005;42(2):517-26. 45.Counts CA, Nigg JT, Stawicki JA, Rappley MD, Von Eye A. Family adversity in DSM- IV ADHD combined and inattentive subtypes and associated disruptive behavior problems. Journal of the American Academy of Child & Adolescent Psychiatry. 2005;44(7):690-8. 46.Frey C, Wyss-Senn K, Bossi E. [Subjective evaluation by parents and objective findings in former perinatal risk children]. Zeitschrift fur Kinder-und Jugendpsychiatrie. 1995;23(2):84-94. 47.Pineda DA, Lopera F, Palacio JD, Ramirez D, Henao GC. Prevalence estimations of attention-deficit/hyperactivity disorder: differential diagnoses and comorbidities in a Colombian sample. International Journal of Neuroscience. 2003;113(1):49-71. 48.Sauver JLS, Barbaresi WJ, Katusic SK, Colligan RC, Weaver AL, Jacobsen SJ, editors. Early life risk factors for attention-deficit/hyperactivity disorder: a population- based cohort study. 2004 2004: Elsevier. 49.Pelham, Jr., Fabiano GA, Massetti GM. Evidence-based assessment of attention deficit hyperactivity disorder in children and adolescents. Journal of Clinical Child and Adolescent Psychology. 2005;34(3):449-76. 50.Golmirzaei J, Namazi S, Amiri S, Zare S, Rastikerdar N, Hesam AA, et al. Evaluation of Attention-Deficit Hyperactivity Disorder Risk Factors. International Journal of Pediatrics. 2013;2013:e953103. 51.Banerjee TD, Middleton F, Faraone SV. Environmental risk factors for attention‐ deficit hyperactivity disorder. Acta paediatrica. 2007;96(9):1269-74. 52.Button TMM, Maughan B, McGuffin P. The relationship of maternal smoking to psychological problems in the offspring. Early human development. 2007;83(11):727- 32. 53.Amor LB, Grizenko N, Schwartz G, Lageix P, Baron C, Ter-Stepanian M, et al. Perinatal complications in children with attention-deficit hyperactivity disorder and their unaffected siblings. Journal of Psychiatry and Neuroscience. 2005;30(2):120.

10. ANNEXES

ANNEX I: participant information sheet, Consent form and questionnaire

Part I: Participant Information sheet Code No: ______

Dear Participants!

My name is ------I am here on behalf of Hirbaye Mokona. He is a final year student undertaking a Master degree in Mental Health, a joint program between University of Gondar and Amanuel Mental Specialized Hospital. One of the requirements for the degree is to conduct a research project. This letter serves to ask consent from you to take part in this research.

Title: prevalence and associated factors of ADHD among children age 6 to 17 years living in rural area of Girja district, Southern Oromia regional state, Ethiopia.

Objective: The purpose of this research is to assess the Prevalence and associated factors of Attention Deficit Hyperactivity Disorder among children age 6 to 17 years living in rural area of Girja district, Southern Oromia regional state, Ethiopia.

Introduction: Studies in other countries show that childhood ADHD is one of the most common mental disorder that cause clinically significant impairments in social, academic or occupational functioning in children. This study will be critical input for policy makers and organizations involved on care and support for children with ADHD.

Risk: There is no risk in participating in this research project. Your participation in this research is voluntary. If you decide not to participate there will be no negative consequences on your life.

Benefit: If you do decide to participate in this research project, there may be no direct benefits for you. However, your participation on this study is very important for achievement of the study and for paving the way for the integration of mental health service in the care of children with ADHD thereby increasing the quality of care for these children.

Procedure: The study subject will be child’s parent or caretaker. Data will be collected by interviewer administer questionnaire and it will be taken 25 minutes to answer the questionnaire.

Confidentiality: Study subjects will not be subjected to any harm and confidentiality will be kept as much as possible. You are not expected to give your name or phone number. Without permission from you, any part of this study will not be disclosed to third person. You have full right to refuse and withdrawal to participate in this study if you don’t wish at any time. Your participation in this study is very important for achievement of the present study and baseline for the purpose. This research project will be reviewed and approved by the ethical committee of the University of Gondar and Amanuel Mental Specialized Hospital. If you are willing to participate in this study, you need to understand and sign the agreement form. If you have any questions and /or complaints you can contact us by the following addresses.

Addresses: Principal investigator: -Hirbaye Mokona

- Mobile: +251922470503

- Email:- [email protected]

Advisors: -Abebaw Gebeyehu (PhD)

-Aimiro Zerihun (Bsc, MSc)

Are you voluntary to participate in the interview? Agree Disagree

Part II: Consent form I hereby confirm that I understand the contents of this information and the nature of research project, and I consent for participating voluntarily in the research project. I also understand that I have right to withdraw from the interview at any time.

Participant signature ______date ______

Data collector name and signature ______date______

Date of questionnaire filled ______time started _____ time completed ______

Supervisor name and signature ______date ______

Result of interview:

1. completed 2.partially completed 3.refused 4.respondent not available

Assent Form for children age 12 t0 17 years

I hereby confirm that I understand the contents of this information and the nature of research project, and I assent for participating voluntarily in the research project.

Signature of the child ______date ______

Data collector name and signature ______date______

Supervisor name and signature ______date ______

Part II: list of questionnaire 1. Socio-demographic variables S.No Questions Choice of answer Remark

101 What is the age of child?

102 What is the sex of child? 1.Male 2.Female

103 What is religion of the child? 1.Protestant 2.Orthodox 3.Muslim 4.Others 104 What is ethnicity of the child? 1.Oromo 2.Amhara 3.Sidama 4.Others 105 What is the family marital status? 1.married 2.single 3.separated 4.divorced 5.widowed 106 If answer for S.No 1.5 is different ______form choice 1&2, at what child age that happened? 107 With whom the child lives? 1.father & mother 2.mother 3.father 4.specify others ______108 If answer for S.No 107 is different ______from choice 1, at what child age that happened? 109 What is educational level of the ______child? 110 Is there repeating class at one 1.yes 2.no grade? 111 If answer is yes at what class? ______

112 For how many times repeat class? ______

200 Family factors

201 Is child’s mother alive? 1.yes 2.no

202 If yes what is her educational 1.unable to read& write level? 2.Able to read & write

3.1-5 grade

4.6-10 grade

5.Secondary/university

203 What is father’s educational level? 1.unable to read& write 2.Able to read & write 3.1-5 grade 4.6-10 grade 5.Secondary/university 204 How many people live in the family? 205 What is the rank/order of this child in the family? 300 Household assets/wealth index

301 Housing ownership 1.Their own 2.Rental 302 Roofing materials of the house 1.Thatch 2.Iron sheet(tin) 303 Flooring materials 1.Mud/dung 2.Cement 304 Household effects

Availability of radio 1.yes 2.no Availability of television 1.yes 2.no

Availability of mobile phone 1.yes 2.no

Availability of refrigerator 1.yes 2.no

305 Number of sleeping rooms for the 1.one family 2.two & above

306 Access to electricity 1.yes 2.no

307 Ownership of agricultural land 1.yes 2.no

308 Ownership of bank or saving 1.yes 2.no account 309 Ownership of farm animals

Availability of 1.yes 2.no cow milk Availability of oxen or bull 1.yes 2.no

Availability of donkeys 1.yes 2.no

Availability of mules 1.yes 2.no

Availability of goats 1.yes 2.no

Availability of sheep 1.yes 2.no

310 Source of River/lake 1.yes 2.no drinking water Communal tap 1.yes 2.no water

4.Clinical factors

401 Maternal health status during 1.chronically sick pregnancy of this child 2.acutely sick 3.well 402 Substance taken by mother during 1.alcohol pregnancy of this child 2.khat 3.others 4.none 403 Family history of mental illness 1.yes 2.no

404 History of head trauma 1.yes 2.no 3.if yes at what age?______405 Was there time child severely ill 1.yes ,specify______before 6 years old? 2.no

406 If yes for how long? ______

407 At what age that happened? ______

408 What was the management of this 1.Inpatient child illness at that time? 2.outpatient 3.herbal medicine 4.no treatment 5.Maternal factors

501 Duration of pregnancy 1.full-term 2.pre-term 502 Was there any complication at 1.yes 2.no delivery? 503 What was the child feeding style 1. Breast feeding during the first six month? 2. Bottle feeding

6. ADHD Symptom assessment questionnaire (18 items DBD rating scale)

Key:- 0=Not at all 1=Just a little 2= Pretty much 3=Very much

For each item, select the box that best describes this child. Put only one item 0 1 2 3

601 Often fails to give close attention to details or makes careless mistakes in 0 1 2 3 schoolwork, work, or other activities

602 Often has difficulty sustaining attention in tasks or play activities 0 1 2 3

603 Often does not seem to listen when spoken to directly 0 1 2 3

604 Often does not follow through on instructions and fails to finish schoolwork, 0 1 2 3 chores, or duties

605 Often has difficulty organizing tasks and activities 0 1 2 3

606 Often avoids, dislikes, or is reluctant to engage in tasks that require 0 1 2 3 sustained mental effort (such as school work or homework)

607 Often loses things necessary for tasks or activities (e.g., toys, school 0 1 2 3 assignments, pencils, books, or tools)

608 Is often easily distracted by extraneous stimuli 0 1 2 3

609 Is often forgetful in daily activities 0 1 2 3

610 Often fidgets with hands or feet or squirms in seat 0 1 2 3

611 Often leaves seat in classroom or in other situations in which remaining 0 1 2 3 seated is expected

612 Often runs about or climbs excessively in situations in which it is 0 1 2 3 inappropriate

613 Often has difficulty playing or engaging in leisure activities quietly 0 1 2 3

614 Is often "on the go" or often acts as if "driven by a motor" 0 1 2 3

615 Often talks excessively 0 1 2 3

616 Often blurts out answers before questions have been completed 0 1 2 3

617 Often has difficulty awaiting turn 0 1 2 3

618 Often interrupts or intrudes on others (e.g. butts into conversations or 0 1 2 3 games)

7. Questions for those participants who answer 6 or more items from part 6 questionnaire which scored 2 or 3.

7.1. At what age of your child these symptoms occurred for the first time?

7.2. When the child showed these symptoms for the last time?

7.3. At which setting these problems observed (home, school or other setting)?

Anneksii II: Guca odeeffannoo, waliigaltee fi gaaffii hirmaattotaa (Afan Oromo version)

1. Guca odeeffannoo Koodii______

Jaalatamtoota hirmaattotaa!

Maqaan kiyya ______yemmuu ta’u as kan dhufe obbo Hirbaayyee Mokkonnaa bakka bu’eeti. Obbo Hirbaayyee Mokkonnaa yuuniversiitii Goondarii fi Hoospitaala Ispeeshaala wal’aansa dhibee sammuu, Amaanu’elitti fayyaa sammuutiin barataa digrii 2ffaa woggaa xumuraati. Ulaagaale digrii 2ffaa xumuruuf barbaachisan keessaa tokko qorannoo fi qo’annoo geggeessuudha. Kanaafuu, xalayaan tun qorannoo fi qo’annoo isaan geggeessan kana irratti akka hirmaattan waliigaltee keessan gaafachuuf gargaarti.

Mata-duree qorannoo fi qo’annoo: tatamsa’inaa fi sababoota dhibee hanqina xiyyeeffannoo fi jarjartii (Attention Deficit Hyperactivity Disorder, ADHD) ijoollee woggaa 6 hanga 17 irratti mul’atu qorachuu

Kaayyoo: Aanaa Girjaatti tatamsa’inaa fi sababoota dhibee hanqina xiyyeeffannoo fi jarjartii (ADHD) ijoollee woggaa 6 hanga 17 irratti mul’atu qorachuudha.

Seensa: Akka ragaan qorannoo fi qo’annoo biyyoota adda addaa mul’isutti dhibeen hanqina xiyyeeffannoo fi jarjarsuu(ADHD), dhibee amalaa fi guddina sammuu daa’imman irratti beekamoo ta’an keessaa tokko yemmuu ta’u dhiibbaan inni gama hawaasummaatiin, barnootaa fi walumaagalatti jireenya daa’immanii gara fuul-duraa irratti qabu daraan cimaa dha. Qorannoo fi qo’annoon kun namoota poolisii barnootaas ta’ee kan fayyaa tumaniif akkasumas dhaabbilee yaalaa fi deeggarsa daa’imman dhibee kana qaban irratti hirmaataniif bu’uura ta’a jedhamee yaadama.

Miidhaa: Qorannoo fi qo’annoo kana irratti hirmaachuu keessaniin miidhaan isinirra gahu tokkollee hin jiru. Hirmaannaan isin qorannoo fi qo’annnoo kanarratti gootan fedhii keessaniin ta’a. Yoo hirmaacuu hi barbaannes ta’e dhiibbaan isinirratti raawwatamu hin jiru.

Bu’aa: qorannoo fi qo’annoo kana irratti hirmaachuu keessaniin onnachiiftuun ykn kaffaltiin kallattiin isinii kaffalamu hin jiru. Haata’uu malee, hirmaannaan keessan galma ga’iinsa qorannoo fi qo’annoo kanaatiif akkasumas tajaajila ittisaa fi wal’aansa dhibee sammuu daa’immanii karoorsuuf baay’ee barbaachisaadha.

Adeemsa qorannoo: Qorannoo fi qo’annoon kun kan adeemsifamu maatii ykn guddistoota daa’immanii gaaffilee gaafachuun yemmuu ta’u, daqiiqaa 25 fudhata jedhamee tilmaamama.

Icciitii hirmaattotaa: Qorannoo fi qo’annoo kana irratti hirmaachuu keessaniin miidhaan isinirra gahu hin jiru akkasumas icciitiin isin qabdan hundi ni eeggama. Maqaa fi lakkoofsa bilbilaa keessan kennuun isinirraa hin eeggamu. Eeyyama keessaniin alatti, namni biraa odeeffannoo isinirraa fuudhatame kana baruu hin danda’u. Yeroo kamiiyyuu qorannoo fi qo’annoo kana irratti hirmaachuu diduu fi addaan kutuuf mirga guutuu qabdu. Qorannoo fi qo’annoo kana irratti hirmaachuuf guca waliigaltee hubachuu fi mallatteessuun barbaachisaa ta’a. Gaaffii ykn komii yoo qabaattan teessoo armaan gadiitiin nu qunnamaa.

Maqaa qorataa: Hirbaayyee Mokkonnaa

Lakk.bilb_ +251922470503

Email:[email protected]

Maqaa gorsitootaa

1. Abebaw Gebeyehu(PhD)

Lakk.bilb.+251920314519

2. Aimiro Zerihun (MSc)

Lakk.bilb.+251912137853

Fedhiidhaan hirmaachuu ni barbaadduu? Eeyyee Miti

II. Guca waliigaltee maatii daa’immanii

Akkaataa odeeffannoo armaan olitti naaf kennameen qabiyyee qorannoo fi qo’annoo kanaa hubadhee fedhii kiyyaan irratti hirmaachuuf waliigaluu kiyya akka armaan gadiitti mirkaneessa. Akkasumas yeroo barbaadetti addaan kutee bahuuf mirga guutuu qabaachuu kiyya hubadheera.

Mallattoo hirmaataa______guyyaa______

Maqaa fi mallattoo nama odeeffannoo fuudhuu______guyyaa______

Guyyaa gaaffiin guutame______sa’aatii itti jalqabe______sa’aatii itti xumurame______

Maqaa fi mallattoo to’ataa______guyyaa______

Bu’aa gaaffii:

1.Guutumatti xumurame 2.Walakkaan xumurame 3.Didameera

4.Deebii-kennaan hin jiru

Guca walligaltee ijoollee waggaa 12 hanga 17

Akkaataa odeeffannoo armaan olitti naaf kennameen qabiyyee qorannoo fi qo’annoo kanaa hubadhee fedhii kiyyaan irratti hirmaachuuf waliigaluu kiyya akka armaan gadiitti mirkaneessa

Mallattoo daa’imaa ______guyyaa ______

Maqaa fi mallattoo nama odeeffannoo fuudhuu ______guyaa______

Maqaa fi mallattoo to’ataa ______guyyaa ______

III: Gaaffii Afaan Oromoo (Questionnaire Afan Oromo version)

1.Odeeffannoo haala jireenya hawaasummaa

Lakk. Gaaffilee Filannoo deebii Yaada

101 Umriin daa’imaa meeqa? ______

102 Koorniyaan daa’imaa maali? 1.dhiira 2.dubara

103 Amantaan daa’imaa maali? 1.Prootestaantii 2.Ortoodoksii 3.Musliima 4.kan biro 104 Sabni daa’imaa maali? 1.Oromoo 2.Amaara 3.Tigree 4.kan biro 105 Haalli fuudhaa fi heeruma maatii maali? 1.kan wal fuudhan 2.kan wal hin fuudhin

3.kan adda bahan 4.kan wal hiikan 5.kan irraa du’e/duute 106 Deebiin gaaffii lakk 105 yoo filannoo 1ffaa fi ______2ffaa irraa adda ta’e, yeroo daa’imni woggaa meeqaatti raawwate? 107 Daa’imn eenyu waliin jiraata? 1.Abbaa fi Haadha 2.Haadha 3.Abbaa 4.kanneen biroo ______108 Deebiin gaaffii lakk 1.7 yoo filannoo 1ffaa ______irraa adda ta’e,yeroo umriin daa’imni woggaa meeqaatti jalqabe? 109 Sadarkaan barnoota daa’imaa kutaa ______meeqa? 110 Kutaa tokko irraa gara kutaa biraatti darbuu 1.eeyyee 2.miti dadhabuun irra ni deddeebi’aa? 111 Deebiin gaaffii lakk 1.10 eeyyee yoo ta’e, ______kutaa meeqatti? 112 Si’a meeqaaf irra deddeebi’e/kufe? ______

200.Sababoota haala jireenya maatiitiin wal qabata

201 Haati daa’imaa lubbuudhaan ni jirtii? 1.eeyyee 2.miti

202 Deebiin gaaffii lakk 201 eeyyee yoo ta’e, 1.barreessuu fi dubbisuu hin sadarkaan barnoota ishii meeqa? dandeessu 2. barreessuu fi dubbisuu ni dandeessi 3.kutaa 1-5 4.kutaa 6-10

5.sadarkaa 2ffaa/yuuniversiti 203 Sadarkaan barnoota abbaa daa’imaa 1.barreessuu fi dubbisuu hin meeqa? danda’u 2. barreessuu fi dubbisuu ni danda’a 3.kutaa 1-5 4.kutaa 6-10 5.sadarkaa 2ffaa/yuuniversiti 204 Baay’inni ijoollee maatii kanaa meeqa ta’a? ______

205 Maatiif daa’imni kun/tun meeqaffaadha? ______

300.Agarsiiftuuwwan Qabeenya maatii (wealth index) 301 Mana jireenyaa 1.Kan dhuunfaa isaanii 2.Kan kiraa 302 Akaakuu mana Mana citaa 1.eeyyee 2.miti jireenyaa Mana qorqorroo 1.eeyyee 2.miti

303 Wanta dhaabni Dhoqqee 1.eeyyee 2.miti manaa irraa Simmintoo 1.eeyyee 2.miti tolfame 304 Qabeenya mana Raadiyoo 1.eeyyee 2.miti keessaa Televizhiinii 1.eeyyee 2.miti

Bilbila moobayilii 1.eeyyee 2.miti

Firiijii 1.eeyyee 2.miti

305 Baay’ina kutaa ciisicha maatii 1.tokko 2.lama 3.sadi

306 Ibsaa elektirikii ni qabuu? 1.eeyyee 2.miti

307 Lafa qonnaa ni qabuu? 1.eeyyee 2.miti

308 Beeyilada ni Sa’a aannanii 1.eeyyee 2.miti qabuu? Qotiyyoo 1.eeyyee 2.miti

Harree 1.eeyyee 2.miti

Gaangee 1.eeyyee 2.miti

Re’ee 1.eeyyee 2.miti

Hoolaa 1.eeyyee 2.miti

309 Burqaa bishaan Bishaan lagaa/haroo 1.eeyyee 2.miti dhugaatii Bishaan ujjummoo 1.eeyyee 2.miti kan ummataa

400. sababoota fayyaan walqabatan

401 Yeroo ulfa daa’ima kanaatti/tanaattii 1.yeroo dheeraaf fayyaan haadhaa akkam ture? dhukkubsatte 2.yeroo gabaabaaf baay’ee dhukkubsatte 3.guutumaan guututti fayyaa turte 402 Wantoota yeroo ulfa daa’ima 1.dhugaatii alkoolii kanaatti/tanaatti haati fayyadamaa turte 2.caatii 3.tamboo xuuxuu 4.hin jiru

403 Maatii keessa namni dhibee sammuu qabu 1.eeyyee 2.miti ni jiraa? 404 Mataa daa’imaa irra miidhaan gahee 1.eeyyee 2.miti 3.eeyyee beekaa? yoo ta’e yeroo daa’imni waggaa meeqaati?______405 Woggaa 6ffaa isaatiin ykn isheetiin dura 1.eeyyee 2.miti yeroon daa’imni kun/tun baay’ee itti 3.yoo eeyyee ta’e, dhukkubsate/tte ni jiraa? maali?______

406 Deebiin gaaffii lakk 405 eeyyee yoo ta’e, ______yeroo hammamiitiif dhukkubsate/tte? 407 Yeroo dhukkubsatu/ttu san umriin isaa ykn ______ishee meeqa ta’a? 408 Yeroo sanitti yaaliin ykn gargaarsi 1.ciibsanii yaaluu godhameef maal ture? 2.deddeebisanii yaaluu 3.qoricha mukaa 4.yaaliin hin godhamneef 5.Sababoota haadhaan walqabatan

501 Daa’imni kun/tun ji’a meeqatti dhalate/tte? 1.ji’a sagalitti 2.ji’a sagal dura (sadheessa) 502 Yeroo da’umsaatti rakkinni haadha mudate 1.eeyyee 2.miti ni jiraa? 503 Ji’oota jahan jalqabaatiif haalli soorannaa 1.harma haadhaa qofa daa’imaa akkam ture? 2.xuuxxoon kennamaafii ture

6. Gaaffilee mallattoo dhibee ADHD ittiin qorannu (18 items DBD rating scale)

Furtuu-0=hin jiru 1=darbee darbee ni jira 2= yeroo tokko tokko sirritti jira 3=yeroo hundumaa ni jira

Tokko tokkoo qabxiilee armaan gadiitiif deebii tokkoo ol kennuun hin danda’amu. 0 1 2 3 Qabxii daa’ima kana/tana sirritti ibsu tokko qofa filuun itti marsaa 601 Daa’imni keessan yeroo baay’ee wantoota xiyyeeffannaa barbaadan irratti 0 1 2 3 xiyyeeffannaa kennuu dadhabuu akkasumas barnootaa fi hojiilee biro irratti dogoggora salphaa uumuu.

602 Daa’imni keessan yaada isaa/ishee walitti sassaabuun hojii tokko ykn tapha 0 1 2 3 irra turuuf yeroo baay’ee ni rakkataa/ttii? 603 Yeroo baay’ee osoo kallattiin itti dubbattanii waan qalbiin isin dhageeffanne 0 1 2 3 isinitti fakkaatee beekaa? 604 Daa’imni keessan yeroo baay’ee qajeelfama hordofuu dadhabuu akkasumas 0 1 2 3 hojii barnootaa fi waan ajajame xumuruu dadhabuun irratti ni mul’ataa?

605 Yeroo baay’ee waan hojjatamuu qabu eega itti himamee booda, waan 0 1 2 3 dalagamu qindeessuun wal-duraa duubaan kaa’uuf ni rakkataa/ttii? 606 Daa’imni keessan yeroo baay’ee hojiilee xiinxala sammuu barbaadan 0 1 2 3 kanneen akka hojii barnoota (fkn hojii manaa hojjachuu) ni jibbaa/tii?

607 Daa’imni keessan yeroo baay’ee meeshaalee dalagaaf ykn barnootaaf 0 1 2 3 barbaachisan kanneen akka kitaabaa,dabtaraa,qalama/kobbee fi kkf ni gataa/ttii?

608 Yeroo baay’ee salphumaan ta’ii naannoo isaa/isheetti ta’uun yaadni 0 1 2 3 isaa/ishee ni bittinnaa’aa? 609 Daa’imni keessan yeroo baay’ee dalagaalee guyyaa guyyaan raawwataman 0 1 2 3 ni irraanfataa/ttii? 610 Daa’imni keessan yeroo baay’ee bakkuma taa’utti harkaa fi miilaan ni 0 1 2 3 socho’aa ykn ni wixxisaa? 611 Daa’imni keessan yeroo baay’ee daree barnootaa ykn iddoo taa’ee turuun 0 1 2 3 irraa eegamutti tasgabbaa’ee teessumarra taa’ee turuuf ni rakkataa/ttii?

612 Daa’imni keessan yeroo baay’ee haala hin barbaachifneen asii fi achi fiiguu 0 1 2 3 ykn wantoota irratti rarra’uu fi yaabuudhaan isin rakkisaa/stii?

613 Daa’imni keessan yeroo baay’ee kohaa isaas ta’ee hiriyoota isaa waliin 0 1 2 3 tasgabbaa’ee taphachuuf ni rakkataa/ttii? 614 Daa’ima keessan yeroo baay’ee gochi sochiin itti baay’ate irratti ni mul’ataa? 0 1 2 3

615 Daa’imni keessan yeroo baay’ee haasawa ni baay’isaa? Ykn haasawa 0 1 2 3 jalqbee addaan kutuuf ni rakkataa/ttii? 616 Daa’imni keessan yeroo baay’ee osoo gaaffiin gaafatamee hin xumuramin 0 1 2 3 akkasumas osoo itti hin yaadin deebii deebisuuf ni ariifataa/ttii?

617 Daa’imni keessan yeroo baay’ee yeroo kanneen biro waliin taphatu ykn 0 1 2 3 wanta dabaree eegachuun barbaachisu dabaree eegatee godhuuf ni rakkataa/ttii? 618 Daa’imni keessan yeroo baay’ee wayita namootni biraa haasawa godhan 0 1 2 3 akkasumas wayita daa’’imman biraa taphatan gidduu galuudhaan ni jeeqaa?

7. Gaaffilee hirmaattotni qabxiilee lakkoofsa 6ffaa jala jiran 6 fi isaa ol deebisan(gulantaalee 0-3 keessaa 2 ykn 3 kan galmeessan) gaafataman

7.1. Mallattooleen amma natti himtan kunneen yeroo jalqabaatiif wayita mul’atan umriin daa’ima keessanii woggaa meeqa ta’a?

7.2. daa’imni keessan yeroo dhumaatiif mallattoolee kanneen kan agarsiise yoomi?

7.3. Mallattooleen kunneen yeroo baay’ee daa’ima keessan irratti kan mul’atan iddoowwan akkamiitti (manatti, mana barnootaatti)?

Declaration

I, the undersigned, MSc student declare that this thesis is my original work in partial fulfillment of the requirement for Master of Science degree in ICCMH.

Name of the student: Hirbaye Mokona signature______date ______

Place of submission: Amanuel Mental Specialized Hospital, Addis Ababa

Date of submission: ______

This thesis work has been submitted for examination with my/our approval as Gondar University advisor (s).

Approval of the advisor (s)

Advisors’ name signature date

1. Abeba Gebeyehu (PhD) ______2 .Aemro Zerihun (MSc) ______