OriginalEditorial OrgOdRe Article Socioeconomic status and its impact on the prevalence of severe ADHD in the Maltese Islands Christopher Rolé, Nigel Camilleri, Rachel Taylor-East, Neville Calleja Abstract The main aim of this study was to assess Attention deficit hyperactivity disorder whether higher prevalence rates of ADHD were (ADHD) is a common disorder which presents in present in the districts, which are classically childhood. The core symptoms include; associated with a low socioeconomic status. All hyperactivity, impulsivity and reduced attention. If persons aged 0 to 18 years attending the left untreated this may possibly lead to various governmental clinics, having a documented impairments of function in other areas of one’s life, diagnosis of severe ADHD and therefore being such as lack of educational attainment, increased prescribed pharmacotherapy were identified and risk of accident-prone behaviour, substance misuse included in this study. Nine young people were and antisocial behaviours. Although the exact living in institutional care and were therefore aetiology is still not fully understood, various excluded from statistical analysis since this would studies have demonstrated the presence of both a skew that data in this study. A significant difference genetic and an environmental component. ADHD is (p<0.0001) in the point prevalence of ADHD highly hereditable, demonstrating a strong genetic between the six Malta districts was found, with component (0.75). Furthermore, increased rates of higher rates of ADHD occurring in the harbour ADHD have been linked with a low socioeconomic districts. Though not statistically significant, a status. positive correlation was demonstrated between the The islands of Malta have traditionally been ADHD prevalence and a number of socioeconomic divided for statistical purposes into 6 districts, with variables, these included; the rate of smoking certain districts more often being associated with (p=0.111), number of people classified as at-risk-of- low socioeconomic demographics. poverty per district (p=0.397), and number of people with no schooling per district (p=0.156). The overall point prevalence for ADHD in Malta obtained was 0.85, a value which is less than the average prevalence noted worldwide. The authors believe this value is an underestimation since the data collection in this study did not include ADHD Christopher Rolé M.D., M.Sc.* cases off pharmacological treatment and any Mount Carmel Hospital Attard , Malta ADHD cases assessed and treated in the private [email protected] sector. Nigel Camilleri M.D., MD Keywords Mount Carmel Hospital ADHD, prevalence, Malta, low socioeconomic Attard, Malta status c Rachel Taylor-East M.D., MSc Mount Carmel Hospital Introduction Attard , Malta Attention deficit hyperactivity disorder (ADHD) is the commonest childhood-onset mental Neville Calleja M.D., Ph.D. Directorate for Health information and Research disorder which manifests itself with symptoms of Pieta, Malta inattention, hyperactivity and impulsivity, with males being affected more than females.1 This *Corresponding author condition can have serious effects on the overall Malta Medical School Gazette Volume 03 Issue 03 2019 16 OriginalEditorial OrgOdRe Article functioning of a child, since it can influence the c. employment child’s education attainment together with his/her d. population density behaviour.2 ADHD symptoms can persist in e. being classified at risk of poverty adulthood with prevalence rates as high as 4.4% in f. being reared by a single mother the community.3 Evidence suggests that this g. number of nights spent abroad as a measure condition is highly heritable 4, several studies in of affluence different countries have demonstrated that ADHD is more prevalent in socioeconomically disadvantaged Methodology groups.5 Ethical approval and data collection The Maltese archipelago consists of 3 main A retrospective study was designed with the islands: Malta, Gozo and Comino. It is traditionally aim of calculating the point prevalence of severe divided for statistical purposes into six districts, ADHD in every district in Malta respectively. namely the Southern Harbour area, Northern Ethical approval was obtained from the Ethics Harbour area, the South-Eastern region, Western board of the University of Malta and permission for region, Northern region, and the 2 smaller islands data handling was obtained from the Data Gozo & Comino being considered as one district. Protection Office for Mental Health Services of The harbour regions, are considered less affluent Malta, located at Mount Carmel Hospital. areas with greater social deprivation and poverty.6 This project did not involve any direct contact In published literature it was reported that people with patients, their carers nor their attending living in the harbour areas have higher rates of physicians. Data accessed throughout this project psychosis.7 involved a retrospective case note review of the The Government of Malta has set up two patents clinical files as well as clinic databases clinics that assess and treat children and adolescent (where available). This demographic data collected, with mental disorders. These are the Child and included; the name and identification number, age Young People’s services (CYPS) located at St of the patient and address as well as diagnosis and Luke’s Hospital, Malta and the Gozo Psychiatry treatment modality being used as per February outpatient’s clinic. A number of independent 2017. All data were stored on a password protected psychiatry clinics are also found throughout the private computer with confidential access Maltese islands. Government based child and throughout the whole project as per data protection adolescent clinics accept referrals for youngsters law of the laws of Malta (DPA chapter 440). aged 0 till 18. Patients may be referred by any Records of all patients under 18 years of age, doctor working both in the private and government who ever attended these clinics (included sector, including general practitioners, psychiatrists discharged patients), were studied. All patients who and paediatricians. After the age of 18, patients received a diagnosis of ADHD by a psychiatrist followed at these clinics are referred to mainstream were highlighted for further analysis. Although adult psychiatry services. these clinics do not have established written The aims of this study included: protocols for the diagnosis of ADHD, literature 1. to retrospectively estimate the point prevalence suggests that treatment should only be initiated in of severe ADHD in children aged 0 to 18 years severe cases.8 Hence, in order to aim for high on treatment attending governmental clinics as specificity, only patients receiving treatment were per February, 2017, both in general and at selected implying the presence of severity of district level ADHD. Cases where a diagnosis of ADHD was 2. to assess whether a significant difference exists done but was not sufficient enough to warrant a in the point prevalence of severe ADHD pharmacological intervention were excluded. between the six districts in Malta. All data were imputed in a confidential 3. to assess whether a correlation exists between Microsoft Excel® file, containing demographic data rates of severe ADHD in those ages 0 to 18 as well as diagnosis and treatment modality. In years per district and a number of order to protect identification of patients all socioeconomic variables, including: patients’ names and identification numbers were a. smoking converted to a generated personalised identification b. education system, which was subsequently used throughout Malta Medical School Gazette Volume 03 Issue 03 2019 17 OriginalEditorial OrgOdRe Article the whole project. Patients’ addresses were people considered below the poverty line is double examined and every patent was allocated to one of the amount of people considered at or above the the six districts, as per Census of Populations and poverty line.15 Hence smoking can be considered a Housing of 2011.9 factor associated with low socio-economic status. Patients living in institutional care were excluded from the study in view of their current Demographic data of the Maltese islands living address being unreflective of the original Information related to the demographic data of demographic address. It was acknowledged that a the Maltese islands was obtained from the last number of families do move home and change their National census carried out in 2011 with results address. However, following discussions with the published preliminarily in 2012 and with the final medical statistician, in view that the number of official report published in 2014.9 These inter-district translocations tends to be mutual and publications can be accessed freely on the internet random it was deemed unnecessary to exclude from the National Statistics Office as well as patients whose family changed address before purchased from the above-mentioned office itself. February 2017. Data collected from the census included, total It was also acknowledged that a small number population according to the Maltese districts, of children are reared in foster families. However, including population per age group, population following discussions with the medical statistician density per district, level of education and since the number of fostered children in Malta and employment for individuals aged 15+. Further Gozo is very low, it was considered too small as to information was obtained about the lifestyle