See

discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/232234434

Prevalence of attention deficit hyperactivity

disorder among children and adolescents in
Spain: A systematic review and m....

Article in BMC Psychiatry · October 2012

DOI: 10.1186/1471-244X-12-168 · Source: PubMed

CITATIONS READS

71 189

6 authors, including:

Ferrán Catalá-López Salvador Peiro

University of Valencia FISABIO|SALUDPÚBLICA
255 PUBLICATIONS 10,538 CITATIONS 559 PUBLICATIONS 4,522 CITATIONS

SEE PROFILE SEE PROFILE

Gabriel Sanfélix-Gimeno Ricard Gènova-Maleras

Center for Public Health Research (CSISP-FISA… Regional Health Council, Madrid
110 PUBLICATIONS 744 CITATIONS 86 PUBLICATIONS 696 CITATIONS

SEE PROFILE SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Evaluación económica de la hospitalización para intervención de cataratas View project

Public healthcare data warehouse View project

All content following this page was uploaded by Salvador Peiro on 15 May 2014.

The user has requested enhancement of the downloaded file.

Dear Author
Here are the proofs of your article.

·You can submit your corrections online, or via e-mail.

· For online submission please insert your corrections in the online correction form. Always indicate
the line number to which the correction refers.
· You can also insert your corrections in the proof PDF and email the annotated PDF.
· Remember to note the journal title, manuscript number, and your name when sending your
response via e-mail.
· Check any questions that have arisen during copy editing or typesetting and insert your
answers/corrections.
·Check that the text is complete and that all figures, tables and their legends are included. Also check
the accuracy of special characters, equations, and additional files if applicable. Substantial changes in
content, e.g., new results, corrected values, title and authorship are not allowed without the approval of
the responsible editor. In such a case, please contact us for futher advice.
· If we do not receive your corrections within 48 hours, we will send you a reminder.
· The final versions of your article will be published around one week after receipt of your corrected
proofs.
 Catalá-López et al. BMC Psychiatry 2012, 12:168
http://www.biomedcentral.com/1471-244X/12/168

1 RESEARCH ARTICLE Open Access

2 Prevalence of attention deficit hyperactivity

3 disorder among children and adolescents in
4 Spain: a systematic review and meta-analysis
5 of epidemiological studies
6 Ferrán Catalá-López1,2*, Salvador Peiró1,2, Manuel Ridao1,3, Gabriel Sanfélix-Gimeno1, Ricard Gènova-Maleras4
7 and Miguel A Catalá5

8 Abstract
9 Background: Attention deficit hyperactivity disorder (ADHD) is a commonly diagnosed neuropsychiatric disorder in
10 childhood, but the frequency of the condition is not well established in many countries. The aim of the present
11 study was to quantify the overall prevalence of ADHD among children and adolescents in Spain by means of a
12 systematic review and meta-analysis.
13 Methods: PubMed/MEDLINE, IME, IBECS and TESEO were comprehensively searched. Original reports were selected
14 if they provided data on prevalence estimates of ADHD among people under 18 years old in Spain and were cross-
15 sectional, observational epidemiological studies. Information from included studies was systematically extracted and
16 evaluated. Overall pooled-prevalence estimates of ADHD were calculated using random-effects models. Sources of
17 heterogeneity were explored by means sub-groups analyses and univariate meta-regressions.
18 Results: Fourteen epidemiological studies (13,026 subjects) were selected. The overall pooled-prevalence of ADHD
19 was estimated at 6.8% [95% confidence interval (CI) 4.9 – 8.8%] representing 361,580 (95% CI 260,550 – 467,927)
20 children and adolescents in the community. There was significant heterogeneity (P < 0.001), which was
21 incompletely explained by subgroup analyses and meta-regressions.
22 Conclusions: Our findings suggest that the prevalence of ADHD among children and adolescents in Spain is
23 consistent with previous studies conducted in other countries and regions. This study represents a first step in
24 estimating the national burden of ADHD that will be essential to building evidence-based programs and services.

25 Background family stress, academic and vocational adversity and a 35

26 Attention deficit hyperactivity disorder (ADHD) can be clear negative effect on the self-esteem of the subject 36
27 defined as a condition starting in childhood, that com- affected [1]. 37
28 prises a persistent pattern of symptoms of hyperactivity, Currently, there exist two diagnostic criteria in regular 38
29 impulsiveness and/or lack of attention, more frequent use to diagnose ADHD in children and adolescents, DSM- 39
30 and severe than usual for that age, and causing a signifi- IV and ICD-10. Both classifications utilise lists of beha- 40
31 cant impairment in school or work performance and in viours to consider in the process of diagnosing hyperactive 41
32 the activities of daily life. ADHD is a common neuro- conditions. The main differences between DSM-IV and 42
33 psychiatric disorder, with a high impact on the health ICD-10 pertain to the concomitance of the three domains 43
34 system and the community in terms of economic costs, (inattention, hyperactivity and impulsivity), the exclusion 44
of comorbidity and the degree of pervasiveness. The ICD- 45
10 criteria require a full set of symptoms in all three 46
* Correspondence: ferran_catala@hotmail.com
1
Centro Superior de Investigación en Salud Pública (CSISP), Valencia, Spain
domains, whereas the DSM-IV recognizes three subtypes 47
2
Fundación Instituto de Investigación en Servicios de Salud, Valencia, Spain of the disorder – the predominantly inattentive type, the 48
Full list of author information is available at the end of the article

© 2012 Catalá-López et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the
Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use,
distribution, and reproduction in any medium, provided the original work is properly cited.
 Catalá-López et al. BMC Psychiatry 2012, 12:168 Page 2 of 13
http://www.biomedcentral.com/1471-244X/12/168

49 predominantly hyperactive-impulsive type and the com- 2. Índice Médico Español (IME) and Índice Bibliográfico 101
50 bined type. Español en Ciencias de la Salud (IBECS): The 102
51 Despite its relevance in terms of public health, the fre- preferred terms “TDAH”, “trastorno por déficit de 103
52 quency of the disorder is not well established in many atención”, “hiperactividad”, and “hipercinético” were 104
53 countries, including Spain. This information may be ne- used. 105
54 cessary to improve the design of future studies on 3. TESEO database (database of Spanish PhD theses): 106
55 aetiological factors and disease distribution in the popu- The preferred terms “TDAH”, “trastorno por déficit 107
56 lation, evaluate the effectiveness and cost-effectiveness de atención”, “hiperactividad”, and “trastorno 108
57 of various interventions or programmes and provide hipercinético” were used as descriptors. 109
58 representative reference values for evidence-based health
59 services planning. In recent decades, several observational The full list of terms used is shown in the additional 110
60 studies have been performed in different population file 1: "Search Terms Used in the Bibliographic Review". 111
61 groups and geographic areas. Epidemiological studies in Furthermore, complementary hand-searches reviewing 112
62 several countries have used questionnaires and scales the literature of extracted articles were carried out. 113
63 based on symptoms as a criterion for ADHD. According
64 to previous studies, in Spain the prevalence of ADHD Selection of studies 114
65 would be 3-14% in children aged 8-15 years in Valencia The primary end-point was the prevalence of ADHD 115
66 [2,3], 4-6% in children aged 6-15 years in Seville [4] and among children and adolescents. By design, we used the 116
67 1% in children aged 6-8 years in Navarre [5]. Therefore, it investigator-reported definitions of ADHD patients pro- 117
68 would be relevant that the data provided in the scientific vided in each single study. Of the references resulting after 118
69 literature were analysed through integrated approaches the bibliographic review, those referring to original publi- 119
70 which allow for establishing the extent of ADHD and its cations of epidemiological observational studies meeting 120
71 epidemiological characteristics for the whole children and the following criteria were selected: cross-sectional design 121
72 adolescent population. and studies reporting data for current (point/past month) 122
73 In this context, the objective of this study was to per- or period prevalence of ADHD among people under 18 123
74 form a systematic review of the studies performed in years old in Spain. For the purpose of the primary ana- 124
75 Spain on the prevalence of ADHD in children and ado- lyses, studies with any of the following criteria were 125
76 lescents and combine its results in an overall estimation excluded: studies with samples selected in a clinical set- 126
77 through meta-analysis techniques. ting, studies on adult population, lack of information on 127
relevant study issues (not specifying sample size, number 128
78 Methods of cases, or the reference population), editorials and re- 129
79 Literature search view articles. No date (year of publication) or language 130
80 A systematic review was performed to document the restrictions were established. 131
81 availability of prevalence data for ADHD among children
82 and adolescents in Spain. Methods were consistent with Data extraction 132
83 those recommended by the Meta-analysis of Observa- Information about design and participants were extracted 133
84 tional Studies in Epidemiology (MOOSE) group [6]. A as recommended by PRISMA (Preferred Reporting Items 134
85 broad comprehensive search for original studies (pub- for Systematic Reviews and Meta-Analyses) guidelines [8]. 135
86 lished between January 1980 and August 2011) was con- The PRISMA and MOOSE checklists are provided in the 136
87 ducted in the following electronic databases: Web Appendix (additional file 2: “PRISMA and MOOSE 137
checklists). Data extraction from source documents was 138
88 1. PubMed/MEDLINE (via the U.S. National Library of done independently by two investigators (one psychiatrist 139
89 Medicine): The following terms or keywords were and one epidemiologist) and verified. Disagreements were 140
90 used: "attention deficit disorder with hyperactivity" resolved by consensus. The investigators used a specific 141
91 [MeSH Terms], ("attention" [All Fields] AND "deficit" form specifically designed to extract data of methodo- 142
92 [All Fields] AND "disorder" [All Fields] AND logical and scientific quality. The following variables were 143
93 "hyperactivity" [All Fields]), "attention deficit disorder collected: author and year of publication, author affiliation 144
94 with hyperactivity" [All Fields], "adhd" [All Fields], (e.g. university, primary care, or hospital), journal title, 145
95 "hyperkinesis" [MeSH Terms], combining them with characteristics of the population (including sample size 146
96 "epidemiologic studies" [MeSH], "prevalence" [MeSH and age), geographic area, origin of the sample (e.g. school 147
97 Terms] and with the geographic filtre proposed by or population-based), some methodological issues (e.g. 148
98 Valderas et al. [7] for identifying studies performed in diagnostic criteria, assessment tools and number of stages 149
99 the Spanish population and minimizing bias of evaluation, clinical interview, impairment criterion 150
100 regarding the indexing of geographical items. and source of information) and the main results. The 151
 Catalá-López et al. BMC Psychiatry 2012, 12:168 Page 3 of 13
http://www.biomedcentral.com/1471-244X/12/168

152 prevalence rate data (e.g. defined as the percentage of explore investigator-reported definitions of ADHD across 184
153 subjects with ADHD) were obtained from the selected the studies, we conducted sensitivity analyses to determine 185
154 studies. If these results were not directly provided and the robustness of effect size by excluding studies on the 186
155 it was feasible, they were calculated from the case and basis of the clinical ascertainment (e.g. consideration 187
156 population data provided in each single study. only of those studies including cases clinically con- 188
firmed which applied DSM criteria and/or those studies 189
157 Data analysis scoring above 1.5 standard deviation on different spe- 190
158 The overall pooled-prevalence was estimated by random- cific questionnaires). 191
159 effects meta-analysis using the inverse variance method We assessed publication bias using the funnel plot 192
160 [9,10]. Heterogeneity was evaluated using the Cochran’s method. 193
161 chi-squared test (Cochran’s Q) and the I2 statistics [11,12]. All the analyses were performed using STATA 11 194
162 Cochran's Q is the sum of the squared differences between (StataCorp, College Station, TX, USA). 195
163 each study's effect estimate and the overall effect estimate,
164 weighted for the information provided by the particular Results 196
165 study. I2 is the proportion of total variation observed Identification and selection of articles 197
166 between the studies attributable to differences between Our initial searches yielded 345 literature references. 198
167 studies rather than sampling error. To investigate sources After screening titles and abstracts, 48 articles were po- 199
168 of heterogeneity, subgroups (from the characteristics of tentially eligible and were retrieved in full text. After a 200
169 the population and study design) and univariate meta- careful reading of these articles, 11 studies were found 201
170 regression analyses were defined. Particularly, because the to meet the inclusion criteria. Complementary hand 202
171 large time span of the eligible studies, we explored trends searches allowed for identifying 3 additional studies. 203
172 over time using random-effects meta-regression with the Therefore, a total of 14 studies were included [2-5,13-24]. 204
173 year of publication as the explanatory variable. Similarly, We excluded 35 reports (the reasons for exclusion are 205
174 we explored trends of prevalence variation with gender given in additional file 3: “List of Excluded References 206
175 in terms of the male-to-female ratio. Because only a few and Reasons for Exclusion”). Figure 1 shows a flow dia- 207 F1
176 covariates were individually significant, multivariate meta- gram for the selection process of studies included in 208
177 regression or hierarchical models were not developed. the systematic review. 209
178 A sensitivity analysis was also conducted to examine
179 the possible influence of single studies by excluding Characteristics of the studies 210
180 possible outlier (extreme) observations. The identifica- The 14 studies included in the systematic review and in 211
181 tion of a study as an outlier was not based on an a the meta-analysis included a total of 13,026 children and 212
182 priori statistical criterion, but rather on visual evaluation adolescents. Table 1 shows the summary characteristics 213 T1
183 of forrest plost with all selected studies. Furthermore, to of the studies selected. The first author of most studies 214

345 articles retrieved from bibliographic search

297 excluded unlikely to be relevant

based on title and abstract

48 full-text articles retrieved for detailed evaluation

35 articles excluded not meeting

one or more inclusion criteria

13 articles (11 studies) eligible for final inclusion

3 additional articles identified from

reference lists and/or hand searching

16 articles (14 studies) included in systematic review

Figure 1 Flow diagram showing selection process of articles included in the systematic review.
 Catalá-López et al. BMC Psychiatry 2012, 12:168 Page 4 of 13
http://www.biomedcentral.com/1471-244X/12/168

t1:1 Table 1 Summary characteristics of the 14 studies Table 1 Summary characteristics of the 14 studies
t1:2 included in the systematic review included in the systematic review (Continued)
t1:3 Characteristic Number (%) Source of information t1:47
t1:4 Year of publication Parents and teachers 9 (64.3) t1:48
t1:5 1980-1989 2 (14.3) Parents and subjects 2 (14.3) t1:49
t1:6 1990-1999 7 (50.0) Teachers 2 (14.3) t1:50
t1:7 2000-2011 5 (35.7) Parents, teachers and subjects 1 (7.1) t1:51
t1:8 Journal title (abbreviated)
t1:9 Rev Neurol 3 (21.4) worked in an academic setting. With regard to the year 215
t1:10 Acta Psychiatr Scand 1 (7.1) of publication, half of the studies were published in the 216
t1:11 Soc Psychiatry Psychiatr Epidemiol 1 (7.1) 90s [2-4,13-15,22,23]. Only three of the studies were per- 217
formed in the general population [2,3,15,23] while in the 218
t1:12 Rev Psiquiat y Psicol Med 1 (7.1)
rest the sample of children and adolescents was obtained 219
t1:13 An Psiquiatr 1 (7.1)
from the school population [4,13,14,16-21]. Half of 220
t1:14 Actas Luso Esp Neurol Psiquiatr Cienc Afines 1 (7.1) the studies were described through a two-stage design 221
t1:15 Acta Pediatr Esp 1 (7.1) [2-4,15,16,18,20,22]: first, a psychometric screening 222
t1:16 Rev Pediatr Aten Primaria 1 (7.1) that evaluated the presence of ADHD symptoms in 223
t1:17 Arch Pediatr 1 (7.1) children and adolescents; and second a clinical con- 224
firmation using standardised diagnostic criteria. The 225
t1:18 Pediatr Catalana 1 (7.1)
specfic characteristics in each study included in the 226
t1:19 None/unpublished (e.g. PhD thesis) 3 (21.4)
systematic review are given in Table 2. Most of the 227 T2
t1:20 Peer reviewed journal studies using diagnostic criteria [2-4,13-16,20-23] ap- 228
t1:21 Yes 10 (71.4) plied the DSM-III-R and/or DSM-IV criteria of the 229
t1:22 No 4 (28.6) American Psychiatric Association. In twelve studies 230
t1:23 Author affiliation [2-5,13,16,18-21,23] the prevalence of ADHD was cal- 231
culated with information from at least 2 informers (in 232
t1:24 University 7 (50.0)
nine of them from parents and teachers), while in two 233
t1:25 Primary care 3 (21.4)
studies [14,17] there was a single informer (the tea- 234
t1:26 Hospital 2 (14.3) chers) to assess the presence of the disorder. The 235
t1:27 Other/non explicit 2 (14.3) fourteen studies provided the exact number of ADHD 236
t1:28 Population age cases in the study population and the relevant prevalence 237
t1:29 Children and adolescents (under 17 years) 6 (42.9) rates, with values ranging from 1% to 14% [2,5,14]. Ten 238
studies reported the male-to-female ratio [3,13-17,19-24] 239
t1:30 Children (under 12 years) 8 (57.1)
and the prevalence of ADHD was generally higher in 240
t1:31 Origin of sample
men than in women, with a 4:1 ratio in four studies 241
t1:32 School 11 (78.6) [14,17,22,24] and 2:1 in three studies [3,13,20]. 242
t1:33 General population 3 (21.4)
t1:34 Reference to a diagnostic criterion
t1:35 DSM-III-R 6 (42.9)
Overall meta-analysis and publication bias 243
The forest plot in Figure 2 shows the data from the single 244 F2
t1:36 DSM-IV 4 (28.6)
studies and on the overall pooled-prevalence of ADHD 245
t1:37 Other/non explicit 4 (28.6) from the baseline meta-analysis. Using the random effect 246
t1:38 Impairment criterion model, an overall pooled-prevalence of ADHD of 6.8% 247
t1:39 Yes 7 (50.0) (95% CI 4.9 – 8.8%) was obtained for children and ado- 248
t1:40 No 7 (50.0) lescents with substantial between-study heterogeneity 249

t1:41 Number of stages of evaluation (I2 = 95.9%; Q statistic P < 0.001). From the projections 250
of the current population [25] and the results of the 251
t1:42 One 7 (50.0)
baseline meta-analysis, it was estimated that in Spain 252
t1:43 Two 7 (50.0) ADHD would currently affect around 361,580 (95% CI 253
t1:44 Inclusion of clinical interview 260,550 – 467,927) children and adolescents in the 254
t1:45 Yes 8 (57.1) community. 255
t1:46 No 6 (42.9) Visual inspection of the funnel plot denoted no evi- 256
dence of publication bias (Figure 3). 257 F3
 http://www.biomedcentral.com/1471-244X/12/168
Catalá-López et al. BMC Psychiatry 2012, 12:168
t2:1 Table 2 Characteristics of the studies included in the systematic review on knowledge on ADHD prevalence among children and adolescents in Spain
t2:2 Author, year Region or Study Age Origin of sample Assessment tools Clinical Source of Reference Impairment Prevalence
t2:3 of county population (in (size) interview information to a criterion estimate
t2:4 publication years) diagnostic (%)
criterion
t2:5
t2:6 Geographic Response rate (%) Male-to-
t2:7 location female
ratio
t2:8 Guimón et al, Biscay Children 5-11.5 School Hyperkinesia scales, perinatal history, neurological No Parents and None or Yes 8.0%
t2:9 1980* ( N= 140 ) examination and Bender-Gestalt test, CAT, Corman test, teachers non explicit
t2:10 North
PFT, intelligence scales (WISC, Terman-Merrill), academic
4:1
performance
t2:11 Non explicit
t2:12 Farré and Navarre Children 6-8 School Conner’s scales, Raven's Colored Progressive Matrices, No Parents and None or No 1.0%
t2:13 Narbona, (only boys) ( N= 561 ) academic performance teachers non explicit
t2:15
t2:14 1989*
Northeast - t2:16
t2:17 93%
t2:18 Gutiérrez Asturias Children 6-11 School Conner’s scales, CBCL Yes Parents and DSM-III-R No 4.5%
t2:19 Bengoechea, ( N= 1,048 ) teachers
t2:21
t2:22
t2:20 1992
North >90% 4:1

t2:23 Benjumea Seville Children 6-15 School Conner’s scales, PACS Yes Parents and DSM-III-R No 4.0%-6.0%
t2:24 and Mojarro, and ( N= 1,791 ) teachers
t2:27
t2:28
t2:25 1993* South adolescents >60% - t2:26
t2:29 Verdeguer, Castellon Children 10 General population Conner’s scales, Werry-Weiss-Peters activity rating scale, Yes Parents and DSM-III-R Yes 7.1%
t2:30 1994 ( N= 325 ) K-SADS-E, Raven's Colored Progressive Matrices, GAF teachers
t2:31 East
scale, ADHD rating scale
10:1 t2:32
t2:33 93%
t2:34 Gómez- Valencia Children 8, 11 General population CBCL, K-SADS-E, Raven's Colored Progressive Matrices, Yes Parents and DSM-III-R Yes 14.4%, 5.3%,
t2:35 Beneyto et and and ( N = 1,127 ) GAF scale subjects 3.0%
t2:37
t2:36 al, 1994*
East
adolescents 15
t2:39 94% 1.2-1.7:1 t2:38
t2:40 Andrés- Valencia Children 10 General population K-SADS-E, Raven's Colored Progressive Matrices, Yes Parents and DSM-III-R Yes 8.0%
t2:41 Carrasco et ( N = 387 ) GAF scale subjects
t2:44
t2:42 al, 1995 and
East 2:1
t2:45
t2:43 1999* 98%

t2:46 Eddy, 1997* Barcelona Children 7 and School Conner’s scales No Parents and DSM-III-R No 5.7%-9.8%
8 ( N= 263 ) teachers
t2:47
t2:48 Northeast Non explicit 2:1
t2:49 Ruiz et al, Barcelona Children 6-10 School SNAP modified, VADTRS No Teachers DSM-IV Yes 14.0%
t2:50 1999 ( N = 1,433 )
t2:52 Northeast 98% 4:1 t2:51
t2:53 García- Navarre Children 6-12 School Conner’s scales, Conner’s modified, ADHD rating scale Yes Parents, DSM-IV Yes 9.0%
t2:54 Jiménez et and ( N= 222 ) teachers
t2:56
t2:57
t2:55 al, 2005*
Northeast
adolescents
82%
and subjects
5.6:1

Page 5 of 13
t2:58 Blázquez Barcelona Children 6-13 School Conner’s modified, ADHD rating scale No Teachers None or No 12.2%
t2:59 Almeria et al, and ( N = 2,401 ) non explicit
t2:61
t2:62
t2:60 2005*
Northeast
adolescents
Non explicit 4:1
 http://www.biomedcentral.com/1471-244X/12/168
Catalá-López et al. BMC Psychiatry 2012, 12:168
Table 2 Characteristics of the studies included in the systematic review on knowledge on ADHD prevalence among children and adolescents in Spain
(Continued)
t2:63 Rodríguez Canary Children 7-10 School SDQ No Parents and None or No 3.9%
t2:64 Hernández, Islands ( N= 595 ) teachers non explicit
t2:66
t2:65 2006 89% -
t2:67 South
t2:68 Rodríguez Castile- Leon Children 6-16 School ADHD rating scale, Vanderbilt ADHD assessment scale, Yes Parents and DSM-IV Yes 6.7%
t2:69 Molinero et and ( N= 1,095 ) CSI teachers
t2:72
t2:70 al, 2009*
North
adolescents
2.3:1 t2:71
t2:73 Non explicit
t2:74 Cardo et al, Majorca Children 6-12 School ADHD rating scale No Parents and DSM-IV No 1.2%-4.6%
t2:75 2007 and and ( N= 1,509 ) teachers
t2:78
t2:79
t2:76 2011*
East
adolescents
Non explicit 1:1.5 t2:77
t2:80 CAT: Children's Apperception Test; CBCL: Child Behavior Checklist; CSI: Child Symptom Inventory; GAF: Global Assessment of Functioning; K-SADS-E: Kiddy Schedule for affective diseases and Schizophrenia
t2:81 (epidemiological version); PACS: Parenteral account of children's symptoms; PFT: Rosenzweig Picture Frustration Test; SDQ: Strengths and Difficulties Questionnaires; SNAP-IV: Swanson, Nolan y Pelham, 4th Edition;
t2:82 VADTRS: Vanderbilt ADHD Teacher Rating Scale.; WISC: Wechsler Intelligence Scale for Children.
t2:83 *Published in a peer-reviewed journal.

Page 6 of 13
Catalá-López et al. BMC Psychiatry 2012, 12:168 Page 7 of 13
http://www.biomedcentral.com/1471-244X/12/168

Author, year Prevalence (95% CI) Weight (%)

Guimón et al, 1980 8.0 (3.4–12.3) 5.0

Farré and Narbona, 1989 1.0 (0.01–1.7) 6.8
Gutiérrez-Bengoechea, 1992 4.5 (3.2–5.7) 6.7
Benjumea and Mojarro, 1993 5.0 (4.1-6.0) 6.7
Verdeguer, 1994 7.1 (4.3 -10.0) 6.0
Gómez- Beneyto et al, 1994 (8 years) 14.4 (10.6 -18.2) 5.4
Gómez- Beneyto et al, 1994 (11 years) 5.3 (3.0-7.4) 6.3
Gómez- Beneyto et al, 1994 (15 years) 3.0 (1.3- 4.5) 6.5

Andrés- Carrasco et al, 1995 and 1999 8.0 (5.3-10.7) 6.0

Eddy, 1997 5.7 (2.9-8.5) 6.0
Ruíz et al, 1999 14.0 (12.2-15.9) 6.5

García - Jiménez et al, 2005 9.0 (5.2-12.8) 5.5

Blázquez-Almeria et al, 2005 12.2 (10.8 -13.4) 6.6
Rodríguez-Hernández et al, 2006 3.9 (2.3- 5.4) 6.6
Rodríguez-Molinero et al, 2009 6.7 (5.2-8.1) 6.6
Cardo et al, 2007 and 2011 4.6 (3.5-5.6) 6.7

Prevalence (overall) 6.8 (4.9-8.8) 100.0

0 5.0 10.0 15.0

Figure 2 Prevalence of ADHD among children and adolescents in Spain: meta-analysis. Note: Random effects model.
Cochran’s Q: χ2 = 367.8 (d.f. = 15), p < 0.001; I 2= 95.9%.

10
Log (Prevalence)

- 10

- 20

-6 -4 -2 0
SE Log (Prevalence)

Figure 3 Publication bias: funnel plot.

 Catalá-López et al. BMC Psychiatry 2012, 12:168 Page 8 of 13
http://www.biomedcentral.com/1471-244X/12/168

t3:1 Table 3 Prevalence of ADHD among children and adolescents in Spain: subgroup meta-analysis and heterogeneity
analysis
t3:2 Characteristics Observations* (N) Prevalence (%) 95% CI I2 P value
t3:3 Origin of sample
t3:4 School 11 6.7 4.2-9.1 97.0% < 0.001
t3:5 General population 5 7.2 4.0-10.5 88.8% < 0.001
t3:6 Geographic location
t3:7 North/Northeast 8 7.6 3.8-11.4 97.9% < 0.001
t3:8 South 2 4.6 3.5-5.7 38.4% 0.203
t3:9 East 6 6.6 4.3-8.9 86.7% < 0.001
t3:10 Sample size
t3:11 < 600 subjects 9 6.1 3.7-8.4 91.9% < 0.001
t3:12 > 600 subjects 7 7.7 5.0-10.4 96.4% < 0.001
t3:13 Population age
t3:14 Children (under 12 years) 10 7.0 4.1-9.9 96.0% < 0.001
t3:15 Children and adolescent (under 17 years) 6 6.6 3.9-9.3 95.6% < 0.001
t3:16 Peer reviewed journal
t3:17 Yes 12 6.7 4.4-8.9 95.9% < 0.001
t3:18 No 4 7.3 2.7-12.0 96.9% < 0.001
t3:19 Reference to a diagnostic criterion
t3:20 DSM-III-R 8 6.1 4.5-7.7 81.4% < 0.001
t3:21 DSM-IV 3 9.9 4.6-15.2 94.8% < 0.001
t3:22 None or not explicit 5 5.8 1.5-10.0 98.1% < 0.001
t3:23 Impairment criterion
t3:24 Yes 9 8.3 5.5-11.0 92.0% < 0.001
t3:25 No 7 5.2 2.5-7.9 97.2% < 0.001
t3:26 Clinical interview
t3:27 Yes 9 6.4 4.9-7.9 82.2% < 0.001
t3:28 No 7 7.0 3.0-10.9 98.1% < 0.001
t3:29 Number of stages of evaluation
t3:30 One 7 7.5 3.3-11.7 98.1% < 0.001
t3:31 Two 9 6.0 4.6-7.4 82.8% < 0.001
t3:32 Number of informants
t3:33 One 2 13.0 11.1-14.9 65.0% 0.091
t3:34 Two 13 5.5 4.1-6.9 90.7% < 0.001
t3:35 Three 1 9.0 5.2-12.8 - -
t3:36 Children are among the informants
t3:37 Yes 5 7.6 4.1-11.2 89.4% < 0.001
t3:38 No 11 6.5 4.1-8.9 97.0% < 0.001
t3:39 Teachers are the sole informants
t3:40 Yes 2 13.0 11.1-14.9 65.0% 0.091
t3:41 No 14 5.7 4.3-7.1 90.4% < 0.001
t3:42 *Note: Data set correspond to individual observations (n=16) because the study by Gómez-Beneyto contributed to analyses with three estimates (for people of 8,
t3:43 11 and 15 year-old each).
 Catalá-López et al. BMC Psychiatry 2012, 12:168 Page 9 of 13
http://www.biomedcentral.com/1471-244X/12/168

258 Subgroup and univariate meta-regression analyses prevalence of ADHD was 5.3% (95% CI 4.5 – 6.2%), with 286
259 It must be noted that there was a high degree of hetero- moderate between-study heterogeneity (I2 = 60.8%; Q 287
260 geneity between the studies included in the review in statistic P = 0.003). Complementary sensitivity analyses 288
261 terms of the prevalence calculated (Q = 367.8; P < 0.001). based on the clinical ascertainment (e.g. consideration 289
262 Therefore, it was considered important to investigate and only studies including cases clinically confirmed by DSM 290
263 try to explain the possible sources of heterogeneity that criteria) and the choice of the statistical model did not 291
264 could be present in the studies included in the review. For make any noticeable difference for the above analyses 292
265 this, subgroup analyses and univariate meta-regression (please see webappendix, additional file 4). Particularly, 293
T3 266 analyses were performed. Table 3 shows the results of the in 7 out of 14 studies (6,175 children and adolescents) 294
267 meta-analysis by subgroups with the I2 indices. The with clinically confirmed ADHD cases, the pooled- 295
268 variables “geographic area” and “among informers only prevalence was 6.4% (95% CI 4.9 – 7.9%) with substan- 296
269 teachers are included” would allow for explaining very tial between-study heterogeneity (I2 = 82.2%; Q statistic 297
270 partially part of the heterogeneity found. The results of P < 0.001). 298
271 random-effects meta-regression analyses that assessed
272 the relationship between selected covariates and the Discussion 299
273 observed prevalences in each single study is presented This study reviewed 14 epidemiological observational 300
F5 F4 274 in Figures 4 and 5. There was a non statistically signifi- studies that analyse the prevalence of ADHD in children 301
275 cant linear trend to explain effect size variation by year and adolescents in Spain, over more than 13,000 people. 302
276 of publication (P = 0.537). Similarly, there was a non The main result was the identification of the epidemio- 303
277 statistically significant linear trend to explain effect size logical information for providing an estimation of the 304
278 variation by gender in terms of the male-to-female ratio overall prevalence of disorder in the country. It also 305
279 (P = 0.557). provides a greater precision than that resulting of the 306
studies individually considered. Specifically, the results 307
280 Sensitivity analyses of the meta-analysis show a pooled-prevalence of ADHD 308
281 The results of the sensitivity analysis are provided in of 6.8% in children and adolescents. These values would 309
282 additional file 4: “Uncertainty and sensitivity analyses”). be generally consistent with those found in the European 310
283 The prevalence estimate after excluding the four estima- Union [26,27]. Wittchen et al. [27] recently estimated that 311
284 tions with extreme outliers [2,5,15,23] was consistent 3.3 million children and adolescents aged 6-17 years have 312
285 with other previous studies [26]. The overall pooled- ADHD in the European Union, with a prevalence of 5%. 313
15.0
10.0
Prevalence (%)
5.0
0.0

1980 1990 2000 2010

Year of publication

Figure 4 Relationship between year of publication and the prevalences of ADHD among children and adolescents in Spain. Meta-
regression analysis. Note: The size of the bubble is inversely related to the variance of the study. The solid line represents the linear regression
(year of publication as the meta-independent variable). The shaded area corresponds to the confidence intervals of the prediction.
 Catalá-López et al. BMC Psychiatry 2012, 12:168 Page 10 of 13
http://www.biomedcentral.com/1471-244X/12/168

20.0
15.0
Prevalence (%)
10.0
5.0
0.0

0 2 4 6 8 10
Male -to- female ratio

Figure 5 Relationship between male-to-female ratio and the prevalences of ADHD among children and adolescents in Spain. Meta-
regression analysis. Note: The size of the bubble is inversely related to the variance of the study. The solid line represents the linear regression
(male-to-female ratio as the meta-independent variable). The shaded area corresponds to the confidence intervals of the prediction.

314 The results of the meta-analysis by Polanczyk et al. [26] characteristics and heterogeneity is measured, it must 343
315 yielded a world prevalence equivalent to 5.3%, with similar be always considered that the meta-analysis is a com- 344
316 values for developed regions. bination of sometimes disagreeing results. With this 345
317 ADHD is a major cause of personal impairment to regard, the prevalence of ADHD ranged from 1% to 346
318 patients and their families and place a substantial burden 14% in the studies reviewed. Specifically, the study by 347
319 on the healthcare services [1]. Given the large amount of Farré and Narbona [5] reported the lowest frequencies 348
320 literature on ADHD in recent years, healthcare profes- (1%). These values are probably influenced by the defin- 349
321 sionals and decision-makers must have up-to-date epi- ition of a high critical score as hyperactivity index (> 18 350
322 demiological information gathering the best scientific of 30 points in the hyperactivity index of the Conners’ 351
323 evidence that is useful for service planning and public scales). In the same study, the authors recognised that, 352
324 health policy. Particularly, this information may be ne- considering subjects with a critical score in at least one 353
325 cessary to improve the design of future nationwide of the two questionnaires, the prevalence of ADHD was 354
326 epidemiological studies, evaluate the impact of inter- 6.4% (2.1% in parents, 3.4% in teachers and 0.8% both). 355
327 ventions or programmes on ADHD. With this regard, Furthermore, in two studies [14,17] using a single in- 356
328 the prevalence measures provided can be used to fur- former (the teacher) the prevalence rates were higher 357
329 ther assess the non-fatal consequences of ADHD inte- (12-14%). This is consistent with the information from 358
330 grating this information in summary measures of other authors reporting that using two informers in- 359
331 population health, such as disability-adjusted life years stead of one usually provides a lower prevalence [26]. 360
332 [28]. Furthermore, where scientific evidence exists on Along this, previous studies [29,30] found that teacher 361
333 the (cost-) effectiveness of particular health services and and parents agreement on questionnaires is often low, 362
334 treatments, our results can also provide data inputs neces- with teachers reporting more symptoms than parents. 363
335 sary for models of health impact assessments considering Both the DSM-IV [31] and the ICD-10 criteria [32] re- 364
336 the implementation of alternative interventions. quire that the main symptoms (attention deficit, hyper- 365
337 This study has some limitations that must be consid- activity and impulsiveness) occur in more than one 366
338 ered. On the one hand, it shows the generic limitations setting (e.g., home and school). For example, Rojo et al. 367
339 of any systematic review and meta-analysis, particularly [33] analyzed the risk of ADHD characteristics among 368
340 that its quality depends on the studies included and that, obese adolescents using a self-administered report of 369
341 although the variability is controlled statistically by the Strengths and Difficulties Questionnaire (SDQ). As 370
342 random effect models, strata are weighed by their they mentioned, the sensitivity for predicting ADHD 371
 Catalá-López et al. BMC Psychiatry 2012, 12:168 Page 11 of 13
http://www.biomedcentral.com/1471-244X/12/168

372 conditions was reported to be very low because they quality of selected studies was insufficient to allow a 426
373 were based only on data from one informant (adoles- detailed analysis of their quality. 427
374 cents) and a clinical evaluation of the probable cases The diagnosis of ADHD is complex and should be 428
375 was not conducted. Although the aim of that study was based on the clinical assessment confirmed by an expert 429
376 not to establish prevalence estimates of ADHD, the on the recognition and treatment of it. In epidemio- 430
377 authors provided a proportion of ADHD characteristics logical studies there is no agreement about the instru- 431
378 equals to 21.4% of adolescents aged 13-15 years. It is ments to be used for evaluating children with potential 432
379 noteworthy that these results diverge somewhat from ADHD; there is also some controversy about the criteria 433
380 those obtained by Rodríguez-Hernández [18] and included to be used for defining a so-called “case”. These difficul- 434
381 in our meta-analysis (3.9% of children aged 7-10 years ties in the detection, diagnostic process and methods 435
382 using parents/teachers’ SDQ). affect the epidemiological studies performed, originating 436
383 As with other systematic reviews and meta-analyses changes that can lead to under- or over-diagnosing 437
384 [26,34] a significant heterogeneity was found in the ADHD. In our meta-analysis, although based on a small 438
385 prevalence measures, that were explained incompletely subgroup of studies, the inclusion of those epidemiological 439
386 by analysis of subgroups and univariate meta-regressions. studies that were restricted to clinically confirmed ADHD 440
387 In our study, the variables “geographic area” (e.g. South cases (e.g. DSM diagnostic criteria) led to a reduction of 441
388 region), “among informers only teachers are included” the pooled-prevalence from 6.8% (95% CI 4.9 – 8.8%) to 442
389 and/or “one informant” would allow for explaining very 6.4% (95% CI 4.9 – 7.9%), which is even more consistent 443
390 partially part of the heterogeneity found. Meta-regression with the prevalence rates worldwide [26]. Similarly, people 444
391 on all epidemiological studies showed only a non statisti- who screen negative do not undergo the clinical ascertain- 445
392 cally linear trend to explain effect variation by year of pub- ment by the specialists, therefore false negatives might 446
393 lication and male-to-female ratio, perhaps because of the have occurred in some epidemiological studies. In this 447
394 limited power of our analysis (e.g. number of observa- revision, a number of studies did not mention any 448
395 tions). These findings also suggest that other unknown reference diagnostic criterion [5,17,18,24]. In addition, 449
396 factors could be important in accounting for between- some used only screening scales with a low sensitivity 450
397 study variations. For example, it is noteworthy that none and specificity and that are not valid as a single meas- 451
398 of the studies included in our systematic review has stud- urement for the diagnosis. Actually, DSM-IV and ICD- 452
399 ied the overall prevalence within the national population. 10 are the diagnostic criteria most commonly used. 453
400 The lack of whole population studies has been criticised Both classifications describe the clinical condition of 454
401 in the past because selected populations (e.g. subnational/ hyperactive children (ADHD/Hyperkinetic disorder) and 455
402 local different samples) and settings (e.g. population-based use similar operative criteria for diagnosing it. However, as 456
403 versus school-based studies) might introduce bias and the ICD-10 diagnostic criteria are more restrictive, the 457
404 some degree of uncertainty to the estimates. Previously, diagnoses according to this classification will correspond 458
405 the revision by Skounti et al. [34] suggested that the to the most severe cases of ADHD according to DSM-IV 459
406 characteristics of the population, the study methods criteria. Therefore, the prevalence studies taking ICD-10 460
407 and the diagnostic criterion differences could explain as reference will probably yield lower rates than those 461
408 part of the changes in the ADHD prevalence rates. using DSM-IV. ICD-10 and DSM-IV are also different 462
409 The existence of nonindexed epidemiological studies when considering the subtypes of disorder. 463
410 in the databases consulted may have involved the loss of The disagreement between the different studies in 464
411 some locally relevant studies despite the extensive terms of case definition criteria involves the need for 465
412 data searches we made (e.g. PubMed/MEDLINE, IME, performing separate analyses for each criteria used for 466
413 IBECS and TESEO). Although an attempt was made the diagnosis of ADHD. In our revision, no study 467
414 to minimize this possible screening bias with specific reported expressly ICD-10 reference diagnoses. There 468
415 searches in national databases and thesis dissertations, exist evidences [35-37] that the prevalence of ADHD as 469
416 there may be other studies which have not been iden- defined in the DSM-IV can be somewhat higher than 470
417 tified. However, publication bias is not anticipated (as when defined according to DSM-III-R criteria, due to 471
418 denoted by funnel plot) because of we obtained a sub- the inclusion of the types “with hyperactive-impulsive 472
419 stantial proportion of data from unpublished studies. predominance” and “with attention deficit predomin- 473
420 We also conducted subgroup and sensitivity analyses ance” (that had been diagnosed as ADHD not specified 474
421 to assess uncertainty assumptions on the pooled in the DSM-III-R) [38]. For the diagnosis of ADHD, the 475
422 ADHD-prevalence for study characteristics. Such an DSM-III-R requires the presence of at least 8 symptoms 476
423 approach is important in assessing the validity of the of a total of 14; it does not include the requirement that 477
424 assumptions made for the statistical calculations in meta- they must occur in at least two settings and does not 478
425 analyses. Unfortunately information on methodological give a division into subtypes, and the severity criterion is 479
 Catalá-López et al. BMC Psychiatry 2012, 12:168 Page 12 of 13
http://www.biomedcentral.com/1471-244X/12/168

480 based on the number of symptoms. In our subgroup Author details 531
1
481 meta-analysis, we confirmed that the use of DSM-IV vs Centro Superior de Investigación en Salud Pública (CSISP), Valencia, Spain. 532
2
Fundación Instituto de Investigación en Servicios de Salud, Valencia, Spain. 533
482 DSM-III-R increases the prevalence rate. However, it is 3
Instituto Aragonés de Ciencias de la Salud (I+CS), Zaragoza, Spain. 4Primary 534
483 note worthy that the analyses of subgroups involve a loss Care General Directorate, Regional Health Council, Madrid, Spain. 5University 535
484 of statistical power and, therefore, of precision and the of Valencia, Valencia, Spain. 536
485 unfeasibility to analyse population subgroups that would Received: 6 November 2011 Accepted: 10 October 2012 537
486 have been interesting (e.g. analysis by age or social class). Published: 12 October 2012 538
487 As with other revisions [26,34] in virtually all the studies
488 reviewed, regardless of the methods used, the prevalence
References 539
489 rates of ADHD were significantly higher in men than in 1. Matza LS, Paramore C, Prasad M: A review of the economic burden of 540
490 women. On the contrary, in the study by Cardo et al. ADHD. Cost Eff Resour Alloc 2005, 3:5. 541
491 [19] ADHD prevalence rates were slightly higher among 2. Gómez-Beneyto M, Bonet A, Catalá MA, Puche E, Vila V: Prevalence of 542
mental disorders among children in Valencia, Spain. Acta Psychiatr Scand 543
492 women. This could be due to the fact that retained stu- 1994, 89:352–357. 544
493 dents, children with special educational needs and those 3. Andrés Carrasco MA, Catalá MA, Gómez-Beneyto M: Study of the 545
494 with some known psychopathological diagnosis were prevalence of the attention deficit hyperactivity disorder in ten-year-old 546
children living in the Valencia metropolitan area. Actas Luso Esp Neurol 547
495 excluded from the study, which would have underesti- Psiquiatr Cienc Afines 1995, 23:184–188. 548
496 mated prevalence in males. 4. Benjumea P, Mojarro MA: Trastornos hipercinéticos: estudio 549
epidemiológico en doble fase de una población sevillana. An Psiquiatr 550
1993, 9:306–311. 551
497 Conclusion 5. Farré M, Narbona J: Índice de hiperkinesia y rendimiento escolar: 552
validación del cuestionario de Conners en nuestro medio. Acta Pediatr 553
498 The prevalence of ADHD based on evidence synthesis Esp 1989, 47:103–109. 554
499 techniques (systematic reviews and metanalysis) are 6. Stroup DF, Berlin JA, Morton SC, Olkin I, Williamson GD, Rennie D, Moher D, 555
500 readily calculated and useful for measuring the fre- Becker BJ, Sipe TA, Thacker SB: Meta-analysis of observational studies in 556
epidemiology: a proposal for reporting. Meta-analysis of observational 557
501 quency of the disorder for a specific country. Particu- studies in epidemiology (MOOSE) group. JAMA 2000, 283:2008–2012. 558
502 larly, our findings suggest that the prevalence of ADHD 7. Valderas JM, Mendivil J, Parada A, Losada-Yáñez M, Alonso J: Development 559
503 among children and adolescents is considerable in Spain. of a geographic filter for PubMed to identify studies performed in Spain. 560
Rev Esp Cardiol 2006, 59:1244–1251. 561
504 Our estimates are consistent with those previously 8. Moher D, Liberati A, Tetzlaff J, Altman DG, PRISMA Group: Preferred 562
505 reported in other countries and regions. Finally, this reporting items for systematic reviews and meta-analyses: the PRISMA 563
506 study also represents a first step in estimating the na- statement. PLoS Med 2009, 6:e1000097. 564
9. Cochran WG: Problems arising in the analysis of a series of similar 565
507 tional burden of ADHD that will be essential to building experiments. J Royal Stat Soc 1932, 4:102–118. 566
508 evidence-based programs and services. 10. DerSimonian R, Laird N: Meta-analysis in clinical trials. Controlled Clin Trials 567
1986, 7:177–188. 568
11. Cochran WG: The combination of estimates from diffetent experiments. 569
509 Additional files Biometrics 1954, 10:101–129. 570
12. Higgins J, Thompson SG, Deeks JJ, Altman DG: Measuring inconsistency in 571
510
meta-analyses. BMJ 2003, 327:557–560. 572
512 Additional file 1: “Search Terms Used In The Bibliographic Review” 13. Eddy LS: Estudio del trastorno por déficit de atención con hiperactividad. 573
513 Additional file 2: PRISMA Checklist. MOOSE Checklist. Prevalencia, factores de riesgo y factores asociados. Arch Pediatr 1997, 574
514 Additional file 3: “List Of Excluded References And Reasons for 48:37–48. 575
Exclusion” 14. Ruiz S, Ferrer J, García Tornel S: Prevalencia del trastorno de 576
hiperactividad con déficit de atención en escolares de Barcelona. Pediatr 577
515 Additional file 4: “Uncertainty And Sensitivity Analyses” Catalana 1999, 59:236–242. 578
15. Andrés MA, Catalá MA, Gómez-Beneyto M: Prevalence, comorbidity, risk 579
factors and service utilisation of disruptive behaviour disorders in a 580
516 Competing interests community sample of children in Valencia (Spain). Soc Psychiatry Psychiatr 581
517 The authors declare that they have no competing interests. Epidemiol 1999, 34:175–179. 582
16. García-Jiménez MC, López-Pisón J, Blasco-Arellano MM: The primary care 583
518 Authors’ contributions
paediatrician in attention deficit hyperactivity disorder. An approach 584
519 FCL conceived the study aims and design, and developed the study in
involving a population study. Rev Neurol 2005, 41:75–80. 585
520 discussions with MAC, SP, MR, GSG and RGM. FCL performed the analysis 17. Blázquez-Almería G, Joseph-Munné D, Burón-Masó E, Carrillo-González C, 586
521 and drafted the initial manuscript. All authors contributed to interpretation Joseph-Munné M, Cuyàs-Reguera M, Freile-Sánchez R: Results of screening 587
522 of results, revised and commented on the manuscript for important for symptoms of attention deficit disorder with or without hyperactivity 588
523 intellectual content. All authors read and approved the final manuscript. FCL in schools by means of the ADHS scale. Rev Neurol 2005, 41:586–590. 589
524 is guarantor of the manuscript. 18. Rodríguez Hernández PJ: Estudio de la prevalencia de los trastornos mentales 590
infantiles en la comunidad autónoma canaria. University of La Laguna 591
(Tenerife); 2006. PhD thesis. 592
525 Acknowledgements 19. Cardo E, Servera M, Llobera J: Estimation of the prevalence of attention 593
526 We would like to acknowledge the editors and the peer reviewers, Maite deficit hyperactivity disorder among the standard population on the 594
527 Ferrin and Anna Van Meter, for their helpful comments on our submitted island of Majorca. Rev Neurol 2007, 44:10–14. 595
528 manuscript. The views expressed are those of the authors and should not be 20. Rodríguez Molinero L, López Villalobos JA, Garrido Redondo M, Sacristán 596
529 understood or quoted as being made on behalf of or reflecting the position Martín AM, Martínez Rivera MT, Ruiz S: Estudio psicométrico-clínico de 597
530 of any institution. prevalencia y comorbilidad del trastorno por déficit de atención con 598
 Catalá-López et al. BMC Psychiatry 2012, 12:168 Page 13 of 13
http://www.biomedcentral.com/1471-244X/12/168

599 hiperactividad en Castilla y León (España). Rev Pediatr Aten Primaria 2009,
600 11:251–270.
601 21. Cardo E, Servera M, Vidal C, de Azua B, Redondo M, Riutort L: The influence
602 of different diagnostic criteria and the culture on the prevalence of
603 attention deficit hyperactivity disorder. Rev Neurol 2011, 52:S109–S117.
604 22. Gutiérrez Bengoechea M: Hiperactividad infantil, una aproximación a su
605 epidemiología en el área sanitaria VII de Asturias. University of Oviedo;1992.
606 PhD thesis.
607 23. Verdeguer Dumont M: Estudio de la prevalencia de trastorno por déficit de
608 atención con hiperactividad (TDAH) en niños de 10 años de la Vall d’Uixó.
609 University of Valencia;1994. PhD thesis.
610 24. Guimón J, Luna D, Gutiérrez M, Ozamiz A: Elementos clínicos sobre el
611 síndrome hipercinético infantil. Rev Psiquiat y Psicol Med 1980, 14:9–22.
612 25. Instituto Nacional de Estadística (INE): Projections of the current population
613 for the year 2011, Spain. Madrid: INE; 2011.
614 26. Polanczyk G, de Lima MS, Horta BL, Biederman J, Rohde LA: The worldwide
615 prevalence of ADHD: a systematic review and metaregression analysis.
616 Am J Psychiatry 2007, 164:942–948.
617 27. Wittchen HU, Jacobi F, Rehm J, Gustavsson A, Svensson M, Jönsson B,
618 Olesen J, Allgulander C, Alonso J, Faravelli C, Fratiglioni L, Jennum P, Lieb R,
619 Maercker A, van Os J, Preisig M, Salvador-Carulla L, Simon R, Steinhausen
620 HC: The size and burden of mental disorders and other disorders of the
621 brain in Europe 2010. Eur Neuropsychopharmacol 2011, 21:655–679.
622 28. World Health Organization: In Summary measures of population health:
623 Concepts, ethics, measurement and applications. Edited by Murray CJL,
624 Salomon JA, Mathers CD, Lopez AD. Geneva: World Health Organization;
625 2002.
626 29. Amador-Campos JA, Forns-Santacana M, Guàrdia-Olmos J, Peró C: DSM-IV
627 attention deficit hyperactivity disorder symptoms: agreement between
628 informants in prevalence and factor structure at different ages.
629 J Psychopathol Behav Assess 2006, 28:21–32.
630 30. Wolraich ML, Lambert EW, Bickman L, Simmons T, Doffing MA, Worley KA:
631 Assessing the impact of parent and teacher agreement on diagnosing
632 attention-deficit hyperactivity disorder. J Dev Behav Pediatr 2004,
633 25:41–47.
634 31. American Psychiatric Association: The diagnostic and statistical manual of
635 mental disorders. 4th edition. Washington D.C: American Psychiatric
636 Association; 1994.
637 32. World Health Organization: The ICD-10 classification of mental and
638 behavioural disorders. Clinical descriptions and diagnostic guidelines. Geneva:
639 World Health Organization; 1992.
640 33. Rojo L, Ruiz E, Domínguez JA, Calaf M, Livianos L: Comorbidity between
641 obesity and attention deficit/hyperactivity disorder: population study
642 with 13-15-year-olds. Int J Eat Disord 2006, 39:519–522.
643 34. Skounti M, Philalithis A, Galanakis E: Variations in prevalence of attention
644 deficit hyperactivity disorder worldwide. Eur J Pediatr 2007, 166:117–123.
645 35. Baumgaertel A, Wolraich ML, Dietrich M: Comparison of diagnostic criteria
646 for attention deficit disorders in a German elementary school sample.
647 J Am Acad Child Adolesc Psychiatry 1995, 34:629–638.
648 36. Wolraich ML, Hannah JN, Pinnock TY, Baumgaertel A, Brown J: Comparison
649 of diagnostic criteria for attention-deficit hyperactivity disorder in a
650 county-wide sample. J Am Acad Child Adolesc Psychiatry 1996, 35:319–324.
651 37. Faraone SV, Sergeant J, Gillberg C, Biederman J: The worldwide prevalence
652 of ADHD: is it an American condition? World Psychiatry. 2003, 2:104–113.
653 38. American Psychiatric Association: The diagnostic and statistical manual of
654 mental disorders: DSM-IV-TR. Washington D.C: American Psychiatric
655 Association; 2000.
Submit your next manuscript to BioMed Central
656 doi:10.1186/1471-244X-12-168
657 Cite this article as: Catalá-López et al.: Prevalence of attention deficit and take full advantage of:
658 hyperactivity disorder among children and adolescents in Spain: a
659 systematic review and meta-analysis of epidemiological studies. BMC • Convenient online submission
660 Psychiatry 2012 12:168.
• Thorough peer review
• No space constraints or color figure charges
• Immediate publication on acceptance
• Inclusion in PubMed, CAS, Scopus and Google Scholar
• Research which is freely available for redistribution

Submit your manuscript at

www.biomedcentral.com/submit

View publication stats