Hayek et al. Archives of Psychology, vol.

3, issue 7, August 2019 Page 1 of 23

RESEARCH ARTICLE

Adult ADHD in the Arab World: A review

Ghinwa El Hayek1, Dahlia Saab1, Claudia Farhat1, Zaher Krayem1,2,3, Elie
Karam1,2,3*
Authors’ affiliations:
1
Institute for Development, Research, Advocacy and Applied Care (IDRAAC), Beirut,
Lebanon.
2
Department of Psychiatry and Clinical Psychology, University of Balamand, Faculty of
Medicine, Beirut, Lebanon.
3
Department of Psychiatry and Clinical Psychology, St George Hospital University Medical
Center, Beirut, Lebanon.

*Corresponding author: Elie G. Karam, M.D.

Department of Psychiatry and Clinical Psychology,
University of Balamand Faculty of Medicine, St George University Medical Center,
Institute for Development, Research, Advocacy and Applied Care (IDRAAC)
Email: egkaram@idraac.org
Tel: +961 1 583583
Beirut, Lebanon

ABSTRACT

Introduction: Attention Deficit Hyperactivity Disorder (ADHD) has been mainly studied in
children, even though it persists into adulthood; only recently has adult ADHD received the
required attention. ADHD research in Arab speaking countries is relatively scarce.

Objectives: This scoping review has as objectives to provide a comprehensive overview of adult
ADHD research in the 22 Arab countries, to identify gaps in the literature and inform future
research.

Methods: The scoping review is underpinned by the five-stage framework of Arksey and
O'Malley. Eight electronics databases were searched for published and unpublished literature as
well as conference proceedings from conception date of databases until February 2018.

Results: The literature search yielded 2,792 citations after removal of duplicates, out of which
11 articles and conference proceedings were included. Publications were concentrated in the
21st century. ADHD diagnosis and sample differed between each study, where a variety of
screening and diagnostic tools were used among clinical and community samples. National
prevalence of adult ADHD only exists for Lebanon and Iraq as they are part of the World Mental
Health (WMH) Surveys initiative. Also, adult ADHD is highly comorbid with bipolar and

Copyright © 2019, Archives of Psychology. All rights reserved. http://www.archivesofpsychology.org

 Hayek et al. Archives of Psychology, vol. 3, issue 7, August 2019 Page 2 of 23

substance use disorder and related entities.

Conclusions: This is the first methodologically rigorous scoping review focusing solely on adult
ADHD in the Arab region. We found that adult ADHD is quite prevalent in the Arab World
where studied, linked to serious impairment, and is highly comorbid, yet it is under-researched
and undertreated across the Middle East and North Africa.

Keywords: Attention, hyperactivity, Comorbidities, mental health, Middle East

1. Introduction: (NCSR) reported that 36.3% of adults (aged

1.1 Overview of Adult ADHD: Attention
Deficit Hyperactivity Disorder (ADHD) is a
disorder of inattention, hyperactivity, and
impulsivity, affecting 5.3% of children
(Polanczyk, Willcutt, Salum, Kieling, &
Rohde, 2014). ADHD has been extensively
studied over the past four decades, especially
in the United States (US), Canada, Europe,
and Australia and more recently Eastern
Asia (Hodgkins et al., 2012; Polanczyk et al.,
2014; Thomas, Sanders, Doust, Beller, &
Glasziou, 2015). Scientific research on
ADHD in the Middle East, and particularly
Arab countries is relatively limited
(Alhraiwil, Ali, Househ, Al-Shehri, & El-
Metwally, 2015; Alkhateeb & Alhadidi,
2016; Farah et al., 2009).
While it is known that ADHD often persists
into adulthood (Goodman, 2007; Mannuzza,
Klein, Bessler, Malloy, & LaPadula, 1993;
Weiss & Hechtman, 1993; Wilens, Faraone,
& Biederman, 2004) only recently has it
been considered seriously in adults,
becoming the focus of clinical and
epidemiological studies (Pary et al., 2002;
Wilens, Biederman, & Spencer, 2002;
Wilens & Dodson, 2004). In fact, the
National Comorbidity Survey Replication
18–44 years) with a retrospective diagnosis
of childhood ADHD met DSM-IV criteria
for adult ADHD in the US (Kessler, Adler,
Barkley, et al., 2005). Recently, the World
Mental Health (WMH). Surveys concluded
that 2.8 % of adults across 20 countries
(including Lebanon and Iraq from the
Middle East) suffered from ADHD (Fayyad
et al., 2017).
ADHD in adults often goes unnoticed and
untreated, as the majority of adults are not
aware of it, leading to poor social,
emotional, behavioral and functional
outcomes (Ginsberg, Quintero, Anand,
Casillas, & Upadhyaya, 2014). Indeed,
clinical research suggests that adult ADHD
patients are more prone to unemployment
(Kessler, Adler, Ames, Barkley, et al., 2005;
Mannuzza, Klein, Bessler, Malloy, &
Hynes, 1997; K. Murphy & Barkley, 1996).
Moreover, distinguishing ADHD from other
comorbid psychiatric conditions that are
more common in the clinical adult
population is a challenge. As a matter of fact,
as many as 80% of adult ADHD patients are
estimated to meet criteria for at least one
other mental health disorder (anxiety
disorder, substance use disorder (SUD),

Copyright © 2019, Archives of Psychology. All rights reserved. http://www.archivesofpsychology.org

 Hayek et al. Archives of Psychology, vol. 3, issue 7, August 2019 Page 3 of 23

Bipolar Disorder (BD), major depressive 47%, regardless of whether comorbidity is

disorder…etc) (Barkley, Murphy, & Fischer, assessed in ADHD or BD populations
2008; Newcorn, Weiss, & Stein, 2007). (Wingo & Ghaemi, 2007).
Consequently, patients are most likely
1.2 ADHD research in the Arab World:
treated for the comorbid disorder (Fayyad et
Literature on ADHD in Arab countries is
al., 2007). The reported rates of ADHD
relatively sparse, with the latest review of
comorbidities vary in the literature, further
literature conducted by Alkhateeb and
complicating matters. The discrepancy in the
Alhaidi (2016) finding 58 articles conducted
rates varies according to the type of
in fourteen out of twenty-two Arab
population studied (community or clinical,
countries. Most of the studies included were
etc.), and type of diagnostic measures
done in the last decade and did not use
(Composite International Diagnostic
specific DSM criteria, only 9 (15%) reported
Interview (CIDI), Structured Clinical
doing so while the others reported relying on
Interview for DSM (SCID), the Mini
screening tests, and rating scales. The
International Neuropsychiatric Interview
prevalence of ADHD in children and youth
(MINI), clinical diagnosis, etc.…) (Kessler
ranged from 1.3% (Alyahri & Goodman,
et al., 2006; Park et al., 2011). For instance,
2008) to 34.5% (Khamis, 2006). Another
when looking at rates of anxiety disorders,
review conducted by Alhraiwil and
some studies found a higher prevalence of
colleagues (2015) included 22 articles,
panic disorder, posttraumatic stress disorder,
reporting a prevalence range between 0.5%
social phobia, and other anxiety disorders in
and 19.6%. The first review about ADHD in
individuals with ADHD (Biederman,
Arab countries by Farah and colleagues
Faraone, Monuteaux, Bober, & Cadogen,
(2009), reported the ADHD prevalence
2004; Gorlin, Dalrymple, Chelminski, &
among children and adolescents to be 0.9%
Zimmerman, 2016; Kessler et al., 2006;
in the community and 0.5% in school. Only
Miller, Nigg, & Faraone, 2007) and other
one article in the three reviews addressed
studies observed no such differences
adult ADHD, noting that this article was not
(Murphy & Barkley, 1996; Murphy,
the same in the three reviews (Abdelkarim,
Barkley, & Bush, 2002; Schubiner et al.,
Salama, Ibrahim, & El Magd, 2015;
2000). Nevertheless, findings related to
Alhraiwil et al., 2015; Alkhateeb &
elevated rates of SUD and antisocial
Alhadidi, 2016; Ashor, 2012; Farah et al.,
personality disorders among adult ADHD
2009; Fayyad et al., 2007).
groups (versus adults without ADHD) were
more consistent (Biederman et al., 1993; The scarcity of adult ADHD research in the
Gorlin et al., 2016; Miller et al., 2007; K. Arab region, and the fact that none of the
Murphy & Barkley, 1996; Park et al., 2011; previous reviews followed a systematic
Schubiner et al., 2000). In addition, adult approach, prompts for mapping the literature
ADHD is reported to co-occur with BD to disseminate any findings regarding adult
(Kessler et al., 2006). Meta-analysis ADHD, identifying the gaps, and making
examining comorbidity of ADHD and BD in recommendations for future research.
adults identified rates ranging from 5% to Subsequently, a scoping review is a suitable

Copyright © 2019, Archives of Psychology. All rights reserved. http://www.archivesofpsychology.org

 Hayek et al. Archives of Psychology, vol. 3, issue 7, August 2019 Page 4 of 23

methodology, as according to Arksey and publications/mental-health-research-in-the-

O’Malley’s (2005) it will examine the extent
and nature of research activity, identify if a
further systematic review is necessary,
summarize research findings and report
potential research gaps. The aim of this
paper is to draw conclusions on any relevant
literature related to adult ADHD in the Arab
region. The five specific objectives of this
scoping review are: 1) conduct a systematic
search of the published and gray literature
for adult ADHD in the Arab world 2) Map
out the different methodologies used to
assess adult ADHD in the different papers 3)
Extrapolate findings related to prevalence of
ADHD and its comorbidities, as well as any
additional information 4) examine any
challenges and limitations 5) propose
recommendations for advancing adult
ADHD research in the Arab region.
2. Methods
2.1 Protocol: The protocol of this scoping
review was developed following the
methodological framework of Arksey and
O’Malley and more recently the Joanna
Briggs Institute (Arksey & O'Malley, 2005;
Peters et al., 2015). The research question
was: “What is the research available on adult
ADHD in the Arab Region?”
2.2 Study Selection: The following search
engines: Medline, PubMed, Embase,
Scopus, CINAHL, in addition to IDRAAC’s
search engine
(http://www.idraac.org/home/research-and-
Table 1: Inclusion criteria for the literature search
Term Include
Study Population Men and women above 18 years old with ADHD
Study Type Original research articles
Geography Middle East and North Africa (Arab Speaking countries)
Language of articles English, French, Arabic
arab-world), Google scholar and Google
were used to look for articles, conference
abstracts, presentations and reports in
English, French and Arabic pertaining to the
objective of this review. Furthermore, the
authors contacted key ADHD stakeholders
in the region for unpublished and un-indexed
reports and research papers. The timing of
the search spread from the conception date
of databases until February 2018. The search
strategy was developed by the authors and a
medical librarian. The key words used for
ADHD were “attention deficit disorder”,
“ADD”, “ADHD”, “ADDH”,
“Hyperactivity”, and “Hyperkinetic
Syndrome”. The context of the study was
limited to the Arab Region. Accordingly, the
Arab Countries chosen were: Algeria,
Bahrain, Comoros, Djibouti, Egypt, Gaza,
Iraq, Jordan, Kuwait, Libya, Lebanon,
Mauritania, Morocco, Oman, Qatar, Saudi
Arabia, South Sudan, Sudan, Syria, Tunisia,
United Arab Emirates, West Bank, and
Yemen.
Studies were screened by one of the authors,
at first by title and abstract following the
inclusion criteria (Table 1). Once selected
the articles were agreed on by all authors of
the manuscripts. Additionally, the reference
list of the included articles and their citations
were screened for additional manuscripts.

Copyright © 2019, Archives of Psychology. All rights reserved. http://www.archivesofpsychology.org

 Hayek et al. Archives of Psychology, vol. 3, issue 7, August 2019 Page 5 of 23

3. Results abstracts or posters. Subsequently, 57 full

text articles were reviewed, including a
3.1 Literature Search: The literature search
conference presentation of a yet to be
yielded 2,792 citations after removal of
published study by two of the authors of this
duplicates (Figure 1). The records screened
manuscript from the IDRAAC search
for their abstract were only 244, as the others
engine. Only 11 articles were selected to be
were removed for either not fitting under the
discussed in details in this scoping review as
research question and for being conference
per the inclusion criteria in Table 1.
Figure 1: Flow Diagram of the different phases of the study, mapping the numbers of records
identified, reviewed, included, and excluded with reasons

3.2 Study Characteristics: The first was
published in 1997 and the last one in 2017.
Egypt and Lebanon had the highest number
of original research on adult ADHD with 4
articles each, Saudi Arabia followed with
two, and Iraq with one. Of the four articles
that included data from, Lebanon, three were
part of the WMH Surveys, as well as one
article that includes Iraq (Table 2). The
fourth source of data from Lebanon, is a

Copyright © 2019, Archives of Psychology. All rights reserved. http://www.archivesofpsychology.org

 Hayek et al. Archives of Psychology, vol. 3, issue 7, August 2019 Page 6 of 23

presentation conducted by two of the authors
of this manuscript during the “ADHD across
the Lifespan” Conference in April 2017 in
Beirut, Lebanon, and currently under final
preparation for publication. The samples of
participants recruited in all these 11 articles
were equally diverse, as 54.54% (n=6) were
clinical samples from either mental health
inpatients or outpatient facilities and the
remaining were epidemiological samples
from household surveys, or university
students. All studies defined used the
terminology ADHD, except one study that
used the term “Behavioral Disorder-
Hyperactive”.

Table 2: Characteristics of included studies

Authors (Year), Sample Type/Selection Sample Instrument(s) used to diagnose

Location criteria Size/Age range condition
Al-Sulaiman Clinical: patients in N=608 No instrument: Screened and
(1997), rehabilitation centers in N= 244: below examined by a team of either a
Saudi Arabia the eastern province: The 13 years old pediatrician and nurse or neurologist
Vocational Rehabilitation N= 321: 14-65 and nurse.
Center, the years old
Comprehensive N=43: above
Rehabilitation Center, both 65 years old
in Dammam, the Welfare
Society and Rehabilitation
Institute in Sehat, and the
Rehabilitation center for
severely handicapped in
Hofuf.
Fayyad et al. Epidemiological: Stratified Total ADHD: Version 3.0 of the WHO
(2007), multistage clustered area N=11,422 with Composite International Diagnostic
World Mental probability sample of ADHD: 18-44 Interview (CIDI 3.0), based on
Health Survey household residents. years old questions originally developed in the
including Lebanon Diagnostic Interview Schedule for
Lebanon N=595 with DSM-IV.
ADHD Adult ADHD: Respondents classified
retrospectively as having met full
ADHD criteria in childhood were
then asked a single question about
whether they continued to have any
current problems with attention or
hyperactivity–impulsivity.
De Graaf et al. Epidemiological: Stratified Total ADHD: Version 3.0 of the WHO
(2008), World multistage clustered area N=11,422 with Composite International Diagnostic
Mental Health probability sample of ADHD: 18-44 Interview (CIDI 3.0), based on
Survey household residents. years old questions originally developed in the
including Lebanon Diagnostic Interview Schedule for
Lebanon N=595 with DSM-IV.
ADHD Adult ADHD: Respondents classified
retrospectively as having met full
ADHD criteria in childhood were

Copyright © 2019, Archives of Psychology. All rights reserved. http://www.archivesofpsychology.org

 Hayek et al. Archives of Psychology, vol. 3, issue 7, August 2019 Page 7 of 23

then asked a single question about

whether they continued to have any
current problems with attention or
hyperactivity–impulsivity.
El-Hay and El Epidemiological: College N= 2000: ADHD: Screening using the short
Sawy (2011), Students in Tanta above 18 years version of Adult ADHD Self-Report
Egypt University attending old, surveyed Scale, Version1.1. (ASRS-V1.1)
classes on Saturday, with the Diagnosis: Individual assessment
Monday, and Wednesday screener using the 18-question form of the
during the academic year ASRS-V1.1 ASRS-V1.1e, the Barkley Childhood
2009–2010. N=39 with ADHD Symptom Scale, and the
Then selected a sample ADHD: 19.2 to ADHD Current Symptom Scale.
with ADHD, was 21.9 years old, Other psychiatric disorders: The Mini
compared with a sample matched by age International Neuropsychiatric
without ADHD and gender to Interview.
N=39 without Functional Impairment: The Global
ADHD: 19.2 to Assessment of Functioning (GAF)
21.9 years old Scale.
Ashor (2012), Epidemiological: Medical N=361: 18-25 ADHD: ASRS-screener
Iraq students in their 1st to 6th years old Nicotine Dependence: The
years attending the Fagerstrom Test for Nicotine
Department of Dependence (FTND). An FTND
Pharmacology, University score ≥6 signifies heavy smokers, and
of Al-Mustansiriya in an FTND score ≤5 signifies light
Baghdad. smokers.
Abdelkarim Clinical: Substance use N= 102: aged ADHD: Arabic validated version of
(2015), inpatients the Addiction between 18 and Adult ADHD Self-Report Scale
Egypt Treatment Center at El 60 years old (ASRS-v1.1) and a Symptom
Maamoura psychiatric N=36 with Checklist
Hospital. ADHD: 25-53 Childhood ADHD: Arabic validated
years old version of Wender Utah Rating Scale
N=66 without (WURS)
ADHD: 19-42 Psychiatric Interview with DSM-IV-
years old TR
Physical and neurological
examinations
Salama et al. Clinical: Male inpatients N=102: 19-53 ADHD: Arabic validated version of
(2015), from the Addiction years old Adult ADHD Self-Report Scale
Egypt Treatment Center at El N=36 with (ASRS-v1.1) and a Symptom
Maamoura Psychiatric ADHD Checklist
Hospital N=66 without Childhood ADHD: Arabic validated
ADHD version of Wender Utah Rating Scale
N=28 with (WURS)
childhood Psychiatric Interview with DSM-IV-
ADHD TR
Physical and neurological
examinations

Copyright © 2019, Archives of Psychology. All rights reserved. http://www.archivesofpsychology.org

 Hayek et al. Archives of Psychology, vol. 3, issue 7, August 2019 Page 8 of 23

Khalil et al. Clinical: inpatients and N=97: 18-65 ADHD Screening: Arabic validated
(2016), outpatients screened years old, mean version of Adult ADHD Self-Report
Egypt positive for Alcohol, average=40.9 ± Scale (ASRS-v1.1) and a Symptom
Opioids, Amphetamine or 5.8 years old Checklist.
Cannabis, at the N=27 with ADHD Diagnosis: Patients who
Psychiatric Department of ADHD: mean answered positive for four or more
Mansoura University. average=34.2± questions were further interviewed
5.8 years old using Diagnostic Interview of Adult
N=70 without ADHD (DIVA)
ADHD: mean Substance use: Alcohol: Enzymatic
average=38.1± method by oxidation to acetaldehyde
5.8 years old with NADH+. Opiates, amphetamines
and cocaine: Immunoassay screening
for urine and gas chromatography-
mass spectroscopy.
Alosaimi et al. Clinical: Patients seeking N= 1,205 ADHD: Routine clinical interviews
(2017), psychiatric help at six patients: above using DSMIV-TR criteria
Saudi Arabia major Hospitals in Saudi 18 years old,
Arabia: King Khalid total mean
University Hospital in average=
Riyadh and Zulfi General 38.1±13.0
Hospital (central region), years old
Jeddah Mental Health N=443
Hospital (western region), inpatients:
Al Amal Complex for mean
Mental Health in average=8.4±1
Dammam (eastern region), 3.6 years old
Aljouf Mental Health N=762
Hospital (northern region), outpatients:
and Abha Mental Health mean
Hospital (southern region). average=37.4±
King Khalid University 12.0 years old
Hospital is a university-
affiliated governmental
hospital whereas the other
hospitals are government-
funded service hospitals
under the authority of the
Ministry of Health.
Fayyad et al. Epidemiological: Stratified Total ADHD: Version 3.0 of the WHO
(2017), multistage clustered area N=26,744 with Composite International Diagnostic
World Mental probability sample of ADHD: 18-44 Interview (CIDI 3.0), based on
Health Survey household residents. years old questions originally developed in the
including Iraq Lebanon Diagnostic Interview Schedule for
and Lebanon N=595 with DSM-IV.
ADHD Adult ADHD: Respondents classified
Iraq N=3227 retrospectively as having met full
ADHD criteria in childhood were
then asked a single question about
whether they continued to have any
current problems with attention or
hyperactivity–impulsivity.

Copyright © 2019, Archives of Psychology. All rights reserved. http://www.archivesofpsychology.org

 Hayek et al. Archives of Psychology, vol. 3, issue 7, August 2019
Karam et al. Clinical: first time patients
(2017), presenting for a
Lebanon consultation at MIND
Clinics in Saint Georges
Hospital University
Medical Center in Beirut,
Lebanon, between January
2014 and December 2016.
3.3 Methods of assessing adults ADHD:
Different methods were used to assess
ADHD in the selected studies. Three studies
used medical diagnosis (a medical and
clinical team diagnosed them based on
medical definitions rather than using self-
administered questionnaires, or structured
interviews such as the CIDI) in order to
classify patients as ADHD: one failed to
mention the exact method used, yet patients
were already in a rehabilitation center (Al-
Sulaiman, 1997), while in another study
psychiatric residents and staff were
responsible for the chart review that had
psychiatric diagnosis based on DSMIV-TR
criteria (Alosaimi et al., 2017). The study
done by the authors of this paper, diagnosed
patients rigorously based on the DSM
system of diagnosis, but not following the
checklist systematically. The patients were
diagnosed by both the physician’s assistant
and the psychiatrist. Patients with past or
present ADHD or ADD diagnosis were
classified according to levels: Definite,
Probable and Possible (Karam, El Hayek, &
Farhat, 2017). Five papers used a self-rated
screening test such as the short screening
version of the adult ADHD Self-Report
Scale (ASRS). The Arabic version of the
ASRS V1.1 Screener (WHO, 2014) was
Copyright © 2019, Archives of Psychology. All rights reserved.
Page 9 of 23
Total N= 1,305 Adult ADHD: Physician assistant and
N= 236 with Psychiatrist diagnosed patients
ADHD rigorously based on the DSM-IV
N=136 with criteria, but not following the
ADHD and checklist systematically. Patients
Bipolar classified as ADHD are patients with
Disorder either past or present ADHD or ADD
N=100 with diagnosis and classified according to
ADHD and levels: Definite, Probable and
non-Bipolar Possible
Disorder
used in three studies in Egypt (Abdelkarim
et al., 2015; Khalil et al., 2016; Salama,
Ibrahim, El Magd, & Kerim, 2015), the other
two studies (El Hay and Sawy (2011), and
Ashor (2012)) failed to mention if they used
the Arabic or English version. The ASRS
was developed in conjunction with the
revision of the CIDI, its 18 items are based
on the 18 DSM-IV criteria and symptoms of
ADHD. They are measured on a 5-point
scale (0=never to 4=very often), yielding a
possible score of 0 to 72. Items 1-9 cover the
symptoms of inattention; and items 10-18
covers the symptoms of hyperactivity and
impulsivity (Adler, Kessler, & Spencer,
2003; Kessler et al., 2005). The ASRS is
standardized and validated in individuals
above 18 years old (Kessler, Adler, Ames,
Demler, et al., 2005; Kessler, Adler,
Barkley, et al., 2005; Kessler et al., 2007), in
different languages (Evren et al., 2016; Kim,
Lee, & Joung, 2013; Morin, Tran, & Caci,
2016; Ramos-Quiroga et al., 2009) and
among patients with other comorbid
disorders (Carlucci, Ivanova, Bissada, &
Tasca, 2017; Chiasson et al., 2012; C. Daigre
et al., 2009; Constanza Daigre et al., 2015;
Reyes et al., 2016; Van de Glind et al.,
2013). The ASRS V1.1 Screener used in the
three Egyptian studies is a subset of the
http://www.archivesofpsychology.org
 Hayek et al. Archives of Psychology, vol. 3, issue 7, August 2019
WHO’s 18 question ASRS, which measures
the presence and frequency of current
ADHD symptoms (WHO, 2003, 2014). It
has 6 items rated on a 5-item Likert scale
(scale 0-4), asking about the frequency of the
symptoms of ADHD during adulthood.
There are four questions pertaining to the
theme of inattention and two questions
related to hyperactivity, when four or more
marks appear in darkly shaded boxes, then
there is suspicion of adult ADHD, prompting
for further tests, and diagnosis (WHO,
2003). Abdelkarim et al., (2015) and Salama
et al., (2015) used in addition to the ASRS
V1.1, the Arabic version, the Wender Utah
Rating Scale for the retrospective
assessment of childhood ADHD with a cut
off of 46 (Wender, 1998). To verify the
results of the ASRS V1.1 and make a final
diagnosis, patients in one study were
subjected to the Diagnostic Interview for
ADHD in Adults (DIVA 2.0) (Khalil et al.,
2016). This structured interview is divided
into three parts that are each applied to both
childhood and adulthood, the criteria for
attention deficit, the criteria for
hyperactivity-impulsivity, the age of onset
and impairment accounted for by ADHD
symptoms. The patients are diagnosed as
having adult ADHD if they scored six or
more for each of the symptom domains of
attention deficit and hyperactivity-
impulsivity in childhood and during adult
life with evidence of life-long persistent
course with impairment in at least two
situations and these symptoms not explained
by another psychiatric disorder (Kooij et al.,
2005; Sandra Kooij et al., 2008). In another
study in Egypt as well, students above the
age of 18 years with positive screening of
ADHD were assessed individually by both
Copyright © 2019, Archives of Psychology. All rights reserved.
Page 10 of 23
investigators of the study at the same time,
for the core symptoms of ADHD (El-Hay &
El Sawy, 2011). This time the complete
version of the ASRS V1.1 was used, along
with Barkley childhood ADHD symptom
scale, and the ADHD current Symptom
Scale (Barkley & Murphy, 1998; WHO,
2003). While the Barkley childhood ADHD
symptom scale focuses on the retrospective
assessment of the 18 DSM-IV criteria, the
adult scale looks at the patients’ behavior
during the past 6 months only. It is
composed of questions corresponding to the
nine symptoms of inattention and the nine
symptoms of hyperactivity/impulsivity
according to the DSM-IV, using a scale from
0-3 (with 0=never/rarely, 1= sometimes,
2=often and 3=very often) ( Barkley &
Murphy, 1998). The WMH surveys
evaluated retrospectively childhood ADHD
with Version 3.0 of the WHO CIDI as a part
of the assessment of different mental health
disorders (de Graaf et al., 2008; Fayyad et
al., 2007; Fayyad et al., 2017; Kessler &
Üstün, 2004). The module that assessed
ADHD was originally developed from the
Diagnostic Interview Schedule for DSM-IV
(DIS) (Robins, Cottler, Bucholz, &
Compton, 1995). When respondents meet
the full childhood ADHD criteria, they are
asked a single question whether they
continued to have any current problems with
attention or hyperactivity-impulsivity.
Based on a pilot clinical reappraisal
interview done in the US, a transformation
rule was developed to convert responses to
the CIDI ADHD symptom-recency
questions into a predicted probability of
adult ADHD for each respondent in the
larger samples (Fayyad et al., 2007; Kessler
et al., 2006).
http://www.archivesofpsychology.org
 Hayek et al. Archives of Psychology, vol. 3, issue 7, August 2019
3.4 Prevalence of adult ADHD:
3.4.1 The World Mental Health Cross-
National Studies: In 2007, the first cross
national prevalence of ADHD was published
as part of WMH surveys, and among the
different countries taken into consideration
Lebanon was then the only Arab country.
The estimated prevalence of DSM-IV and
CIDI adult ADHD in Lebanon was 1.8%
(n=595), based on nationally representative
data collected in 2002-2003 through
multistage clustered households stratified by
area probability (Fayyad et al., 2007). In the
updated publication of WMH about DSM-
IV adult ADHD, Iraq completed its survey
in 2006-2007 and as such the prevalence in
Iraq was 0.6% in its nationally representative
sample. Results showed that the percentage
of adult ADHD cases who were childhood
ADHD cases was 52.4% for the Lebanese
and 77.0% for the Iraqis. Additionally,
29.9% of adult Lebanese with ADHD and
47.9% of adult Iraqis with ADHD reported
sub-threshold childhood ADHD. Sub-
threshold childhood ADHD was defined by
having 4 to 5 symptoms of inattention,
hyperactivity and impulsivity. One notable
result this analysis was that the estimated
prevalence of adult ADHD was higher than
that of childhood ADHD. This was deemed
true because a substantial proportion of adult
threshold cases were sub-threshold
childhood cases according to retrospective
reports. The presence of so many sub-
threshold childhood cases that converted
into full adult cases, explained their findings
(Fayyad et al., 2017). The WMH surveys
series, went on and estimated the prevalence
of ADHD among workers (employed/self-
employed). In Lebanon 0.9% (n=305) of
Copyright © 2019, Archives of Psychology. All rights reserved.
Page 11 of 23
workers were diagnosed as ADHD,
compared to 2.8% (n=290) among other
respondents (de Graaf et al., 2008).
3.4.2 University Studies: Two studies
focused on university students. The first,
conducted in Egypt on students with a mean
age of 20.5 years, found a total prevalence of
ADHD of 2.7% (N=39); whereby 69.2%
(n=27) had a predominantly inattentive type
and 30.8% (n=12) had a predominantly
combined type. The ratio of men to women
with ADHD was 1.4:1 (El-Hay & El Sawy,
2011). The second was a cross sectional
study involving 361 medical students in Iraq.
The prevalence of ADHD was 16.6%, with
male medical students having borderline
significant higher ADHD symptoms relative
to their female counterparts with 19.8% and
12.1% respectively (Ashor, 2012).
3.4.3 Clinical Population Studies: The
oldest study selected in this review is from
1997. It reported signs of hyperactivity
rather than ADHD and found a prevalence of
24% among 608 residents of rehabilitation
centers aged from ≥13 years old to ≤ 65
years old (Al-Sulaiman, 1997). One study
reported on prevalence of ADHD among
1,205 inpatients (n=443) and outpatients
(n=762) attending 6 hospitals in Saudi
Arabia. The total prevalence of ADHD was
0.3% (n=4), representing 0.2% (n=1) for
inpatients and 0.4% (n=3) for outpatients
(Alosaimi et al., 2017). In the conference
presentation, two of the authors of this
present publication, studied various
psychiatric disorders among 1,305 adults
visiting for the first time an outpatient clinic
(MIND) in Lebanon, between January 2014
and December 2016. This study looked at
ADHD diagnosis in the total clinical sample,
http://www.archivesofpsychology.org
 Hayek et al. Archives of Psychology, vol. 3, issue 7, August 2019 Page 12 of 23

whereby 18.1% (n=236) had ADHD. A 3.5 ADHD and comorbidities:

closer analysis, which will be developed
3.5.1 The World Mental Health Cross-
further in a future publication, found that
National Studies: The studies derived from
adult Bipolar patients were more likely to
the WMH surveys discussed ADHD
receive also the diagnosis of ADHD: 27.5 %
comorbidities, as one general sample not by
(n=136) out of the Bipolar (N=495) patients,
country (Fayyad et al., 2007; Fayyad et al.,
versus 12.4% (n=100) out of the non-bipolar
2017). Odds Ratios (OR) were in the range
patients (n=810) (Karam et al., 2017).
between 2.5 (major depressive disorder) and
Three studies conducted in Egypt by two 15.0 (oppositional defiant disorder). Bipolar
different research groups checked had a significant OR of 5.4 (95% CI: 4.0,
specifically on prevalence of ADHD among 7.2), Panic disorder had an OR of 4.5 (95%
SUD patients. One was at the psychiatric CI: 3.0, 6.6), and Social Phobia an OR of 3.9
department of Mansoura University, looking (95 CI: 2.9, 5.1) (Fayyad et al., 2017).
at a sample of inpatients and outpatient
3.5.2 University Studies: Among university
screening positive for SUD based on DMS-
students in Egypt, El-Hay and El Sawy
IV-TR. The number of recruited SUD
(2011), diagnosed 39 students with ADHD,
participants was 97 (90 males and 7
and chose 39 students without ADHD as a
females), out of which 27.8% (n=27) had
control group, to compare the psychiatric
ADHD, divided as follow 24 males and 3
comorbidities of both groups. Lifetime
females (Khalil et al., 2016). The other two
psychiatric comorbidity in the ADHD group
studies were at the addiction treatment
was found to be 66.7% (n=26), compared
center of El Maamoura psychiatric hospital.
with 25.6% (n=10) of the control group.
The cross sectional studies enrolled 102
Compared to students without ADHD,
male inpatients. These patients were
students with ADHD were more depressed
classified as follows: 63.7% (n=64) had a
(20.5%, n=8 versus 2.6%, n=1), anxious
positive history of childhood ADHD
(20.5%, n=8 versus 2.6%, n=1), smoked
according to the WURS, and 43.1% (n=44)
more cigarettes (48.7%, n=19 versus 23.1%,
were positive for adult ADHD as per the
n=9), and abused more substances (30.8%,
ASRS-v1.1. Following a semi-structured
n=12 versus 10.3%, n=4) (El-Hay & El
interview only 35.3% (n=36) were
Sawy, 2011). Nevertheless, there was no
diagnosed as having ADHD, out of which 16
significant differences reported for BD and
met criteria for ADHD inattentive type, 2
Obsessive Compulsive Disorder (OCD) (El-
met criteria for ADHD hyperactive-
Hay & El Sawy, 2011). In Iraq, Ashor (2012)
impulsive type and 18 met criteria for the
showed that medical students with ADHD
combined type (Abdelkarim et al., 2015;
symptoms smoked at higher rate with 45%
Salama et al., 2015). The mean age of
versus 11.6% for non-ADHD. Additionally
ADHD patients was 30.2±4.9, while it was
about half of them (51.8%) were heavy
32.8±7.3 for non-ADHD patients.
smokers, and started smoking at a younger
(Abdelkarim et al., 2015).
with 17.2±2.3 years old versus 18.5±2.1
years old for non-ADHD (Ashor, 2012). In

Copyright © 2019, Archives of Psychology. All rights reserved. http://www.archivesofpsychology.org

 Hayek et al. Archives of Psychology, vol. 3, issue 7, August 2019
the second part of this study, there was a
comparison among different types of
smokers such as non-smokers, light
smokers, and heavy smokers assessed using
the Fagerström Test for Nicotine
Dependence (FTND). Therefore, two third
(66.7%) of heavy smokers reported
symptoms of ADHD in comparison with
31.7% of light smokers, and 11% of non-
smokers. Also, heavy smoking was
associated with significant deterioration in
the inattentive and total ASRS scores in
comparison with none and light smokers.
The hyperactivity symptoms scores
significantly differed between nonsmokers
in comparison with light and heavy smokers.
A correlation was established between
ASRS and FTND scores, showing that
students with a high FTND score tend to start
smoking earlier (r=-0.432, p=0.001), and to
have higher inattentive (r=0.391, p=0.001),
and total ASRS scores (r=0.330, p=0.004)
(Ashor, 2012).
3.5.3 Clinical Population Studies: Two
studies conducted in the Addiction Center of
Al Maamoura psychiatric Hospital,
investigated patterns of substance use and
ADHD. The first study observed that mean
age of substance use was lower in the ADHD
group with 13.2±2.6 years compared to
15.6±3.8 years in the non ADHD group.
Also, comorbid ADHD and SUD led to
double the number of hospital admissions
with 6.8±8.1 times compared to 3.4±4.0
times or the non ADHD and SUD group. The
latter was able to have a longer period of
abstinence with 209.8±282.0 compared to
124.5±171.9 days for SUD patients with
ADHD (Abdelkarim et al., 2015). The
comorbidity of ADHD and SUD might be a
Copyright © 2019, Archives of Psychology. All rights reserved.
Page 13 of 23
source of legal problems for 38.9% of this
sample (Salama et al., 2015). In view of
substances consumption, the ADHD group
had a higher cocaine use with 11.1% (n=4)
compared to 0% among non-ADHD. The
multivariate regression pointed out that
ADHD and SUD patients prefer 2.6 times to
sniff heroin more than only SUD patients.
They are also, admitted to the hospital 1.13
times more than their non ADHD
counterparts. They start SUD use at earlier
with a ratio of 0.9. When comparing SUD
patients with a history of childhood ADHD
and SUD patients with adult ADHD, the
latter consumed substances at an earlier age
(13.2±2.6 versus 14.9±2.9), had more
exposure to legal problems (38.9%, n=14
versus 14.3%, n=4), and a shorter duration of
abstinence (124.5±171.9 versus
271.5±363.9). Nevertheless both groups had
a similar mean average for the number of
times to be admitted to the hospital (6.8±8.1
and 4.2±4.9) (Salama et al., 2015).
Similarly, a study conducted among
inpatients and outpatients at the psychiatric
department of Mansoura University
explored ADHD among SUD patients. The
SUD with ADHD group had an earlier age
of onset with 20.2±2.1 years when compared
to SUD without ADHD who had a mean age
of onset of 32.8±6.2 years. Besides, they had
a longer period of substance use (12.4±6.1
years versus 4.3±4.1 years). The study
indicated that they relapsed about three
times more than SUD patients without
ADHD (3.9±1.4 versus 1.1±1.2), yet this
finding was borderline significant with a p-
value of 0.056 (Khalil et al., 2016). In the
study conducted in Lebanon in MIND
clinics referred to above, ADHD patients
(n=236) had higher rates of Bipolar disorder,
http://www.archivesofpsychology.org
 Hayek et al. Archives of Psychology, vol. 3, issue 7, August 2019
and SUD compared to non-ADHD patients
(n=1,069) with 57.6% (n=136) versus 33.6%
(n=359) and 28.4% (n=67) versus 13.8%
(n=147) respectively (Karam et al., 2017).
Adjusting for age and gender bipolar and
SUD patients were 2.3 (95% CI= 1.5, 3.6)
and 1.8 (95% CI= 1.1, 2.8) times more likely
to have ADHD. More analysis is underway
at present in a larger sample.
3.6 ADHD and work performance: De
Graaf et al. (2008) described the loss of role
performance among workers as part of the
WMH surveys. On an individual level,
compared to subjects without ADHD,
adjusting for age, gender, education and
occupation, employed/self-employed
patients with ADHD, were out of role for
19.4 days, yet this was not statistically
significant. On a national level (in millions
of days), the overall days out of role was 0.3
(de Graaf et al., 2008). This article also
stated that socio-demographics among
Lebanese could predict total role
performance for ADHD workers (p-
value=0.044), yet the effect size was not
presented, as the table showed associations
for the total sample of 10 countries (de Graaf
et al., 2008). In Egypt, university students
with ADHD, scored lower on the Global
Assessment of Functioning (GAF) a scale
that evaluates their overall functioning. The
mean average was 56.7 compared to 86.0 for
the control group (El-Hay & El Sawy, 2011).
3.7 ADHD treatment: Patterns of treatment
for mental health disorders were computed
in the WMH surveys: as such 1.1% and 0.7%
of ADHD patients received any professional
help during the last 12 –months in Lebanon
and Iraq respectively (Fayyad et al., 2007;
Fayyad et al., 2017). However, none of the
Copyright © 2019, Archives of Psychology. All rights reserved.
Page 14 of 23
adults with ADHD received any treatment
specifically for ADHD, but 0.8% in Lebanon
(and none in Iraq) received mental health
treatment for other mental disorders (Fayyad
et al., 2007; Fayyad et al., 2017).
3.8 ADHD and family history of
Psychiatric disorders: Only one article
examined the consequences of the presence
of a family history of psychiatric disorders
and ADHD among the offspring (El-Hay &
El Sawy, 2011). As it turns out, family
history of psychiatric disorders was more
common among students with ADHD
(59.0%) compared to students without
ADHD (28.2%). In particular, a family
history of ADHD, and Major Depression
Disorder were more prevalent among
students with ADHD with 28.2% and 23.1%
respectively, compared to 5.1% for both
disorders in the control group (El-Hay & El
Sawy, 2011).
4. Discussion: To the extent of our
knowledge this is the first scoping review
that specifically discusses adult ADHD in
the Arab region. In this review we managed
to map out the different methodologies used
to assess adult ADHD in the different papers
and extrapolate findings related to the
prevalence of ADHD and its comorbidities.
This review have several strengths: its
protocol was developed following the
methodological framework of Arksey and
O’Malley and more recently the Joanna
Briggs Institute (Arksey & O'Malley, 2005;
Peters et al., 2015). Various search engines:
Medline, PubMed, Embase, Scopus,
CINAHL, in addition to IDRAAC’s search
engine, Google scholar and Google were
used to look for articles, conference
abstracts, presentations and reports in
http://www.archivesofpsychology.org
 Hayek et al. Archives of Psychology, vol. 3, issue 7, August 2019
English, French and Arabic; pertaining to the
objective of this review. In addition, the
authors contacted key ADHD stakeholders
in the region for unpublished and un-indexed
reports and research papers.
This review yielded significant findings. The
results of the WMH surveys demonstrated
that not only childhood but also adult ADHD
is quite prevalent (1.8% in Lebanon and
0.6% in Iraq) (Fayyad et al., 2007; Fayyad et
al., 2017), seriously impairing, and highly
comorbid but greatly under-recognized and
undertreated across countries and cultures.
Most importantly, it proved that adult
ADHD is possibly more prevalent than
childhood ADHD probably due to
conversion of sub-threshold cases of
childhood ADHD, as the data from WMH
surveys across 20 countries showed (in
addition to non-childhood onset of ADHD)
(Fayyad et al., 2017). De Graaf et al. (2008),
showed higher rates of absenteeism and
lower productivity amongst ADHD workers
pointing to the importance of providing
assistance and accommodations to workers
struggling with ADHD. Further WMH
surveys are on the way in the Arab region,
rendering nationally representative data on
mental health disorders available soon.
Indeed, the survey in Saudi Arabia has just
been completed (Hyder et al., 2017; Shahab
et al., 2017), yet the results are not out at the
time of writing of this manuscript.
Furthermore, Qatar will be implementing its
own survey soon.
Various studies pointed to the co-occurrence
of ADHD with other mental disorders.
Although the WMH surveys did not discuss
comorbidities by country but rather as one
general sample, it is important to note their
Copyright © 2019, Archives of Psychology. All rights reserved.
Page 15 of 23
significant findings. Twelve-month adult
ADHD was significantly and positively
comorbid with 12-month prevalence of other
DSM-IV/CIDI disorders considered in the
WMH surveys (Fayyad et al., 2017).
University students with ADHD were found
to have more lifetime psychiatric
comorbidities, notably depression and
anxiety (El-Hay & El Sawy, 2011), whereas
outpatients showed a higher rate of BD
(Karam et al., 2017).
Quite significantly, adult ADHD seems to be
highly comorbid with SUDs in the Arab
region. In Lebanon, ADHD patients had
higher rates of SUD (Karam et al., 2017). In
the other clinical studies an earlier age of
onset of substance used was noticed
(Abdelkarim et al., 2015; Khalil et al., 2016;
Salama et al., 2015), as well as higher rates
of cocaine use and preference for heroin
(Salama et al., 2015). Additionally, more
than one study (Ashor, 2012; El-Hay & El
Sawy, 2011), found that university students
who had ADHD consumed more cigarettes
and abused more substances. Furthermore,
comorbid adult ADHD in SUD patients
prolonged the course of SUD and
contributed to higher relapse rates in these
groups of patients (Ashor, 2012; Khalil et
al., 2016).
These findings point to the need for
providing clinical scrutiny in adults who
suffer from ADHD in general but also those
suffering from other mental disorders
(including substance use disorders) who
might as well have comorbid ADHD. In
addition, adult ADHD may be frequently not
diagnosed by clinicians because of the false
impression that ADHD occurs only in
childhood and adolescence.
http://www.archivesofpsychology.org
 Hayek et al. Archives of Psychology, vol. 3, issue 7, August 2019
4.1 Limitations: Limitations of this review
were due to those of the existing literature
and included lack of standardization of
assessment tools and difficulties with
random sampling. This limited our ability to
compare cross-national results.
4.1.1 Limitations of the World Mental
Health Cross-National Studies: In the
well-known international WMH surveys
which has comprised so far 31 countries
used DSM-IV criteria for ADHD that were
developed for children, and offered limited
guidance regarding adult diagnosis,
childhood ADHD was assessed
retrospectively, leaving room for recall bias
as per the authors of those studies (de Graaf
et al., 2008; Fayyad et al., 2007; Fayyad et
al., 2017). Furthermore, adult ADHD was
diagnosed based entirely on adult respondent
self-report which typically leads to
inaccuracies. In addition, adult ADHD was
estimated from an imputation model carried
in the US only, rather than directly (de Graaf
et al., 2008; Fayyad et al., 2007; Fayyad et
al., 2017).
4.1.2 Limitations of University Studies:
University studies such as El-Hay and El
Sawy (2011), noticed that unlike childhood
ADHD studies, no gender differences were
seen in the adult population, proposing that
the standard Hyperactivity/Impulsive
diagnostic criteria might not be suitable for
the adult population. In addition these
findings might not apply to all college
students, and the theoretical possibility that
the use of screening tools not necessarily
standardized for the Egyptian culture (El-
Hay & El Sawy, 2011) In addition, Ashor
(2012) themselves highlighted that small
sample size, students belonging to only one
Copyright © 2019, Archives of Psychology. All rights reserved.
Page 16 of 23
university, and relying on clinical interviews
to diagnose ADHD were significant
limitations to their study.
4.1.3 Limitations of Clinical Population
Studies: In clinical population studies,
limitations were small sample size (Ashor,
2012; Khalil et al., 2016), patients belonging
to one institution or a clinical facility (Ashor,
2012; Karam et al., 2017), absence of female
patients (Abdelkarim et al., 2015; Salama et
al., 2015), and the use of different diagnostic
tools that are not the Structured Clinical
Interview for DSM-IV (SCID) (Alosaimi et
al., 2017; Ashor, 2012), or not following
strictly the SCID interview format (Karam et
al., 2017). The cross-sectional design of the
studies selected prevents from making any
causal inferences on the association of
ADHD with demographics, other psychiatric
disorders, family history of psychiatric
disorders, work performance, and treatment.
Nevertheless, only two studies
acknowledged this (Alosaimi et al., 2017;
Khalil et al., 2016). Additionally, one
clinical study acknowledged not looking at
Oppositional Defiance Disorder, and anti-
social personality disorder (Karam et al.,
2017).
Furthermore, all the clinical and university
studies used convenient sampling, when
compared to the WMH national surveys,
resulting in the non-generalizability of the
results.
Despite the limitations of the studies
involved, there are various implications for
future research and clinical practices. The
presence of only one study (El-Hay & El
Sawy, 2011), examining family history of
psychiatric disorders and ADHD among the
http://www.archivesofpsychology.org
 Hayek et al. Archives of Psychology, vol. 3, issue 7, August 2019
offspring highlights the importance of
further research in that realm in the Arab
World. Furthermore, due to the lack of
awareness around distinguishing ADHD
symptoms it is important to provide public
and professional trainings on how to
diagnose adult ADHD (Fayyad et al., 2017).
Distinguishing between symptoms of
ADHD and other comorbid disorders can be
very complicated. This becomes especially
important if ADHD first started in adulthood
and was not present in childhood in a sub-
threshold form (Sibley et al., 2017);
experienced clinicians should look at the
first time ever adult onset ADHD to tease
apart nuanced differences from, or overlap
with other disorders (Sibley, Arnold,
Swanson, Kennedy, et al., 2018). For
example, differentiating the causal roles of
substance use and other mental disorders is
very necessary (Sibley, Arnold, Swanson,
Hechtman, et al., 2018). This could explain
some false positive so-called late onset
ADHD. Hence the importance of carefully
assessing impairment, psychiatric history,
and substance use before diagnosing late
onset ADHD. In addition, there are many
other sources of cognitive dysfunction that
might lead to false positive symptom
endorsement on an ADHD checklist. A few
examples are, unhealthy lifestyles; (sleep,
diet, and physical activity), extremely taxing
environmental demands such as working
multiple jobs and experiencing high stress
(Sibley, Arnold, Swanson, Kennedy, et al.,
2018). Also Chamberlain and Muller (2018),
argued that some ADHD like symptoms may
be caused by non-psychiatric pathologies
such as traumatic brain injury, or thyroid
disease.
Copyright © 2019, Archives of Psychology. All rights reserved.
Page 17 of 23
Based on the evidence and research on
ADHD in the Arab World, there is a great
need for larger scale studies including bigger
sample sizes in order to produce more
conclusive results. This also requires the use
of random sampling and diverse
representative samples (female patients as
well) to reflect the populations that are being
studied, reducing sampling bias, and
increasing generalizability. This will be
available soon as stated above with the
addition of Saudi Arabia and Qatar to the
already existing Iraq and Lebanon WMH
surveys. Furthermore, longitudinal studies
which are more demanding than cross-
sectional studies can be helpful in
monitoring ADHD symptoms and
psychiatric histories across time, and in
determining causality (Alosaimi et al., 2017;
Khalil et al., 2016). This may improve the
understanding of adult ADHD and the
impact it has at both personal and societal
levels. Greater in depth research may shed
the light on how to work with adults with
ADHD to better understand the everyday
challenges that result from the disorder. It
would also be useful to have a practical
ADHD screening scale that is validated
across many countries rather than relying on
imputation in future studies (Fayyad et al.,
2017). This standardization of tools across
epidemiological studies will lead to an
improved ability to compare cross-national
results.
Moreover, increasing awareness around
ADHD could be beneficial in providing the
needed support for adults who struggle with
it. This may take the shape of supporting
adults with ADHD in the workplace by
providing targeted workplace screenings and
http://www.archivesofpsychology.org
 Hayek et al. Archives of Psychology, vol. 3, issue 7, August 2019
treatment programs (De Graaf et al., 2008).
Consequently, a better integration of adults
with ADHD in society in the Arab world, a
reduction in unemployment, and higher rates
of treatment seeking could be achieved.
Meanwhile, more clinical studies that look at
ADHD might be easier to do than larger
epidemiologic and longitudinal studies and
those can be relatively easy to integrate in
the practice of most mental health
professionals in the Arab region and
elsewhere. This could answer several
important questions; such as how do adult
patients differ from others with respect to
major mental health disorders such as mood,
anxiety disorders, temperament and
substance use disorders? How does ADHD
influence the treatment of these
comorbidities and vice versa? In fact, Ekinci
et al. (2013) examined the links between
affective disorders, temperament, and
ADHD. Their findings showed significant
links between affective disorders,
temperament and ADHD (Ekinci et al.,
2013). These convenient clinical studies, in
addition to the larger more expensive
epidemiologic and longitudinal studies,
could fill in gaps that cannot be grasped
easily and may very well be influenced by
regional or cultural variables. They could
also be a place to start for the remaining
Arab countries.
Acknowledgment
Acknowledgements: Ms. Aida Farha for
helping in developing the search strategy.
Copyright © 2019, Archives of Psychology. All rights reserved.
Page 18 of 23
References:
1. Abdelkarim, A., Salama, H., Ibrahim, S.,
& El Magd, O. A. (2015). The
prevalence and characteristics of
attention-deficit hyperactivity disorder
among a sample of Egyptian substance-
dependent inpatients. Egyptian Journal
of Psychiatry, 36(1), 9.
2. Adler, L., Kessler, R., & Spencer, T.
(2003). Adult ADHD Self-Report Scale
(ASRS-v1.1) Symptom Checklist
Instructions. Retrieved from
https://add.org/wp-
content/uploads/2015/03/adhd-
questionnaire-ASRS111.pdf`:
3. Al-Sulaiman, A. A. (1997). Neurological
disorders in institutionalized patients in
the Eastern Province of Saudi Arabia.
Saudi medical journal, 18(4), 387-389.
4. Alhraiwil, N. J., Ali, A., Househ, M. S.,
Al-Shehri, A. M., & El-Metwally, A. A.
(2015). Systematic review of the
epidemiology of attention deficit
hyperactivity disorder in Arab countries.
Neurosciences, 20(2), 137.
5. Alkhateeb, J. M., & Alhadidi, M. S.
(2016). ADHD Research in Arab
countries: A systematic review of
literature. Journal of Attention
Disorders, 1087054715623047.
6. Alosaimi, F. D., Alzain, N., Asiri, S.,
Fallata, E., Abalhassan, M., Qrmli, A., &
Alhabbad, A. (2017). Patterns of
psychiatric diagnoses in inpatient and
outpatient psychiatric settings in Saudi
Arabia. Archives of Clinical Psychiatry
(São Paulo), 44(3), 77-83.
7. Alyahri, A., & Goodman, R. (2008). The
prevalence of DSM-IV psychiatric
disorders among 7–10 year old Yemeni
schoolchildren. Social Psychiatry and
http://www.archivesofpsychology.org
 Hayek et al. Archives of Psychology, vol. 3, issue 7, August 2019
Psychiatric Epidemiology, 43(3), 224-
230.
8. Arksey, H., & O'Malley, L. (2005).
Scoping studies: towards a
methodological framework.
International journal of social research
methodology, 8(1), 19-32.
9. Ashor, A. W. (2012). Variable influence
of the degree of smoking dependence on
adult attention deficit/hyperactivity
disorder in Iraqi medical students.
Neurosciences, 17(3), 241-247.
10. Barkley, R., Murphy, K., & Fischer, M.
(2008). Adult ADHD: What the science
says. New York: Guilford.
11. Barkley, R. A., & Murphy, K. R. (1998).
Attention-deficit hyperactivity disorder:
A clinical workbook: Guilford Press.
12. Biederman, J., Faraone, S. V.,
Monuteaux, M. C., Bober, M., &
Cadogen, E. (2004). Gender effects on
attention-deficit/hyperactivity disorder
in adults, revisited. Biol Psychiatry,
55(7), 692-700.
doi:10.1016/j.biopsych.2003.12.003
13. Biederman, J., Faraone, S. V., Spencer,
T., Wilens, T., Norman, D., Lapey, K.
A., . . . Doyle, A. (1993). Patterns of
psychiatric comorbidity, cognition, and
psychosocial functioning in adults with
attention deficit hyperactivity disorder.
Am J Psychiatry, 150(12), 1792-1798.
doi:10.1176/ajp.150.12.1792
14. Carlucci, S., Ivanova, I., Bissada, H., &
Tasca, G. A. (2017). Validity and
reliability of the attention deficit
hyperactivity disorder self-report scale
(ASRS-v1. 1) in a clinical sample with
eating disorders. Eating behaviors, 26,
148-154.
15. Chamberlain, S. R., & Müller, U. (2018).
Comment on Late-Onset ADHD
Copyright © 2019, Archives of Psychology. All rights reserved.
Page 19 of 23
Reconsidered With Comprehensive
Repeated Assessments Between Ages 10
and 25. American Journal of psychiatry,
175(5), 480-480.
16. Chiasson, J.-P., Stavro, K., Rizkallah, É.,
Lapierre, L., Dussault, M., Legault, L., &
Potvin, S. (2012). Questioning the
specificity of ASRS-v1. 1 to accurately
detect ADHD in substance abusing
populations. Journal of Attention
Disorders, 16(8), 661-663.
17. Daigre, C., Ramos-Quiroga, J. A.,
Valero, S., Bosch, R., Roncero, C.,
Gonzalvo, B., . . . Casas, M. (2009).
Adult ADHD Self-Report Scale (ASRS-
v1. 1) symptom checklist in patients with
substance use disorders. Actas Esp
Psiquiatr, 37(6), 299-305.
18. Daigre, C., Roncero, C., Rodríguez-
Cintas, L., Ortega, L., Lligoña, A.,
Fuentes, S., . . . Casas, M. (2015). Adult
ADHD Screening in alcohol-dependent
patients using the Wender–Utah rating
scale and the adult ADHD self-report
scale. Journal of Attention Disorders,
19(4), 328-334.
19. de Graaf, R., Kessler, R. C., Fayyad, J.,
ten Have, M., Alonso, J., Angermeyer,
M., . . . de Girolamo, G. (2008). The
prevalence and effects of adult attention-
deficit/hyperactivity disorder (ADHD)
on the performance of workers: results
from the WHO World Mental Health
Survey Initiative. Occupational and
environmental medicine, 65(12), 835-
842.
20. El-Hay, M. A., & El Sawy, H. (2011).
Attention deficit hyperactivity disorder
among a sample of students from Tanta
University. Middle East Current
Psychiatry, 18(3), 138-143.
21. Ekinci, S., Özdel, K., Öncü, B., Çolak,
B., Kandemir, H., & Canat, S. (2013).
http://www.archivesofpsychology.org
 Hayek et al. Archives of Psychology, vol. 3, issue 7, August 2019
Temperamental characteristics in adults
with attention-deficit hyperactivity
disorder: a comparison with bipolar
disorder and healthy control groups.
Psychiatry investigation, 10(2), 137-
142.
22. Evren, C., Umut, G., Bozkurt, M.,
Teksin-Unal, G., Agachanli, R., &
Evren, B. (2016). Psychometric
Properties of the Turkish Version of the
Adult ADHD Self-Report Scale (ASRS-
v1. 1) in a Sample of Inpatients with
Alcohol Use Disorder. Dusunen Adam:
Journal of Psychiatry & Neurological
Sciences, 29(2).
23. Farah, L. G., Fayyad, J. A., Eapen, V.,
Cassir, Y., Salamoun, M. M., Tabet, C.
C., . . . Karam, E. G. (2009). ADHD in
the Arab world: a review of
epidemiologic studies. Journal of
Attention Disorders, 13(3), 211-222.
24. Fayyad, J., De Graaf, R., Kessler, R.,
Alonso, J., Angermeyer, M.,
Demyttenaere, K., . . . Lara, C. (2007).
Cross-national prevalence and correlates
of adult attention-deficit hyperactivity
disorder. The British Journal of
Psychiatry, 190(5), 402-409.
25. Fayyad, J., Sampson, N. A., Hwang, I.,
Adamowski, T., Aguilar-Gaxiola, S., Al-
Hamzawi, A., . . . Florescu, S. (2017).
The descriptive epidemiology of DSM-
IV Adult ADHD in the World Health
Organization World Mental Health
Surveys. ADHD Attention Deficit and
Hyperactivity Disorders, 9(1), 47-65.
26. Ginsberg, Y., Quintero, J., Anand, E.,
Casillas, M., & Upadhyaya, H. P. (2014).
Underdiagnosis of attention-
deficit/hyperactivity disorder in adult
patients: a review of the literature. The
primary care companion for CNS
disorders, 16(3).
Copyright © 2019, Archives of Psychology. All rights reserved.
Page 20 of 23
27. Goodman, D. W. (2007). The
consequences of attention-
deficit/hyperactivity disorder in adults.
Journal of Psychiatric Practice®, 13(5),
318-327.
28. Gorlin, E. I., Dalrymple, K., Chelminski,
I., & Zimmerman, M. (2016). Diagnostic
profiles of adult psychiatric outpatients
with and without attention deficit
hyperactivity disorder. Comprehensive
psychiatry, 70, 90-97.
29. Hodgkins, P., Arnold, L. E., Shaw, M.,
Caci, H., Kahle, J., Woods, A. G., &
Young, S. (2012). A systematic review
of global publication trends regarding
long-term outcomes of ADHD.
Frontiers in psychiatry, 2, 84.
30. Hyder, S., Bilal, L., Akkad, L., Lin, Y.-
c., Al-Habeeb, A., Al-Subaie, A., . . .
Kattan, N. (2017). Evidence-based
guideline implementation of quality
assurance and quality control procedures
in the Saudi National Mental Health
Survey. International journal of mental
health systems, 11(1), 60.
31. Karam, E., El Hayek, G., & Farhat, C.
(2017). ADHD/ADD in an outpatient
clinic. Paper presented at the ADHD
Across the Lifespan, Beirut, Lebanon.
32. Kessler, R. C., Adler, L., Ames, M.,
Barkley, R. A., Birnbaum, H.,
Greenberg, P., . . . Üstün, T. B. (2005).
The prevalence and effects of adult
attention deficit/hyperactivity disorder
on work performance in a nationally
representative sample of workers.
Journal of Occupational and
Environmental Medicine, 47(6), 565-
572.
33. Kessler, R. C., Adler, L., Ames, M.,
Demler, O., Faraone, S., Hiripi, E., . . .
Spencer, T. (2005). The World Health
Organization Adult ADHD Self-Report
http://www.archivesofpsychology.org
 Hayek et al. Archives of Psychology, vol. 3, issue 7, August 2019
Scale (ASRS): a short screening scale for
use in the general population.
Psychological medicine, 35(2), 245-256.
34. Kessler, R. C., Adler, L., Barkley, R.,
Biederman, J., Conners, C. K., Demler,
O., . . . Secnik, K. (2006). The prevalence
and correlates of adult ADHD in the
United States: results from the National
Comorbidity Survey Replication.
American Journal of psychiatry, 163(4),
716-723.
35. Kessler, R. C., Adler, L. A., Barkley, R.,
Biederman, J., Conners, C. K., Faraone,
S. V., . . . Spencer, T. (2005). Patterns
and predictors of attention-
deficit/hyperactivity disorder persistence
into adulthood: results from the national
comorbidity survey replication.
Biological psychiatry, 57(11), 1442-
1451.
36. Kessler, R. C., Adler, L. A., Gruber, M.
J., Sarawate, C. A., Spencer, T., & Van
Brunt, D. L. (2007). Validity of the
World Health Organization Adult
ADHD Self‐Report Scale (ASRS)
Screener in a representative sample of
health plan members. International
journal of methods in psychiatric
research, 16(2), 52-65.
37. Kessler, R. C., & Üstün, T. B. (2004).
The world mental health (WMH) survey
initiative version of the world health
organization (WHO) composite
international diagnostic interview
(CIDI). International journal of methods
in psychiatric research, 13(2), 93-121.
38. Khalil, D. M., Sherra, K. S., Abuhegazy,
H. M., El Masry, N. M., Kamel, A.,
Azim, K. A. A., . . . El Melegy, A. M.
(2016). A study of prevalence and other
characteristics of adult ADHD in
substance use disorder patients: a cross
sectional study.
Copyright © 2019, Archives of Psychology. All rights reserved.
Page 21 of 23
39. Khamis, V. (2006). Family environment
and parenting as predictors of attention-
deficit and hyperactivity among
Palestinian children. Journal of Social
Service Research, 32(4), 99-116.
40. Kim, J.-H., Lee, E.-H., & Joung, Y.-S.
(2013). The WHO Adult ADHD Self-
Report Scale: reliability and validity of
the Korean version. Psychiatry
investigation, 10(1), 41-46.
41. Kooij, J. S., Buitelaar, J. K., Van Den
Oord, E. J., Furer, J. W., Rjinders, C. A.
T., & Hodiamont, P. P. (2005). Internal
and external validity of attention-deficit
hyperactivity disorder in a population-
based sample of adults. Psychological
medicine, 35(6), 817-827.
42. Mannuzza, S., Klein, R. G., Bessler, A.,
Malloy, P., & Hynes, M. E. (1997).
Educational and occupational outcome
of hyperactive boys grown up. Journal of
the American Academy of Child &
Adolescent Psychiatry, 36(9), 1222-
1227.
43. Mannuzza, S., Klein, R. G., Bessler, A.,
Malloy, P., & LaPadula, M. (1993).
Adult outcome of hyperactive boys:
Educational achievement, occupational
rank, and psychiatric status. Archives of
general psychiatry, 50(7), 565-576.
44. Miller, T. W., Nigg, J. T., & Faraone, S.
V. (2007). Axis I and II comorbidity in
adults with ADHD. J Abnorm Psychol,
116(3), 519-528. doi:10.1037/0021-
843x.116.3.519
45. Morin, A. J., Tran, A., & Caci, H. (2016).
Factorial validity of the ADHD Adult
Symptom Rating Scale in a French
community sample: results from the
ChiP-ARD study. Journal of Attention
Disorders, 20(6), 530-541.
46. Murphy, K., & Barkley, R. A. (1996).
Attention deficit hyperactivity disorder
http://www.archivesofpsychology.org
 Hayek et al. Archives of Psychology, vol. 3, issue 7, August 2019
adults: comorbidities and adaptive
impairments. Comprehensive
psychiatry, 37(6), 393-401.
47. Murphy, K. R., Barkley, R. A., & Bush,
T. (2002). Young adults with attention
deficit hyperactivity disorder: subtype
differences in comorbidity, educational,
and clinical history. The Journal of
nervous and mental disease, 190(3),
147-157.
48. Newcorn, J. H., Weiss, M., & Stein, M.
A. (2007). The complexity of ADHD:
diagnosis and treatment of the adult
patient with comorbidities. CNS
spectrums, 12(S12), 1-16.
49. Park, S., Cho, M. J., Chang, S. M., Jeon,
H. J., Cho, S.-J., Kim, B.-S., . . . Hong, J.
P. (2011). Prevalence, correlates, and
comorbidities of adult ADHD symptoms
in Korea: results of the Korean
epidemiologic catchment area study.
Psychiatry research, 186(2), 378-383.
50. Pary, R., Lewis, S., Matuschka, P. R.,
Rudzinskiy, P., Safi, M., & Lippmann, S.
(2002). Attention deficit disorder in
adults. Ann Clin Psychiatry, 14(2), 105-
111.
51. Peters, M. D., Godfrey, C. M., Khalil,
H., McInerney, P., Parker, D., & Soares,
C. B. (2015). Guidance for conducting
systematic scoping reviews.
International journal of evidence-based
healthcare, 13(3), 141-146.
52. Polanczyk, G. V., Willcutt, E. G., Salum,
G. A., Kieling, C., & Rohde, L. A.
(2014). ADHD prevalence estimates
across three decades: an updated
systematic review and meta-regression
analysis. International journal of
epidemiology, 43(2), 434-442.
53. Ramos-Quiroga, J., Daigre, C., Valero,
S., Bosch, R., Gómez-Barros, N.,
Nogueira, M., . . . Casas, M. (2009).
Copyright © 2019, Archives of Psychology. All rights reserved.
Page 22 of 23
Validation of the Spanish version of the
attention deficit hyperactivity disorder
adult screening scale (ASRS v. 1.1): a
novel scoring strategy. Revista de
neurologia, 48(9), 449-452.
54. Reyes, M. M., Schneekloth, T. D.,
Hitschfeld, M. J., Geske, J. R., Atkinson,
D. L., & Karpyak, V. M. (2016). The
clinical utility of ASRS-v1. 1 for
identifying ADHD in alcoholics using
PRISM as the reference standard.
Journal of Attention Disorders,
1087054716646450.
55. Robins, L., Cottler, L., Bucholz, K., &
Compton, W. (1995). Diagnostic
interview schedule for dsm-iv (dis-iv).
56. Salama, H., Ibrahim, S., El Magd, O. A.,
& Kerim, A. A. (2015). The impact of
attention-deficit hyperactivity disorder
across the lifespan on substance use
disorders. Egyptian Journal of
Psychiatry, 36(2), 66.
57. Sandra Kooij, J., Marije Boonstra, A.,
Swinkels, S., Bekker, E. M., de Noord,
I., & Buitelaar, J. K. (2008). Reliability,
validity, and utility of instruments for
self-report and informant report
concerning symptoms of ADHD in adult
patients. Journal of Attention Disorders,
11(4), 445-458.
58. Sibley, M. H., Arnold, L. E., Swanson, J.
M., Hechtman, L. T., Mitchell, J. T.,
Molina, B. S., . . . Roy, A. (2018). The
Importance of Scrutinizing Emergent
ADHD Symptoms in Adults: Response
to Chamberlain and Müller. American
Journal of psychiatry, 175(5), 480-481.
59. Sibley, M. H., Arnold, L. E., Swanson, J.
M., Kennedy, T. M., Molina, B. S.,
Hechtman, L. T., . . . Mitchell, J. T.
(2018). Addressing Incomplete
Psychiatric Histories in Adult ADHD:
Response to Agnew-Blais and
http://www.archivesofpsychology.org
 Hayek et al. Archives of Psychology, vol. 3, issue 7, August 2019
Arseneault. American Journal of
psychiatry, 175(5), 482-483.
60. Sibley, M. H., Rohde, L. A., Swanson, J.
M., Hechtman, L. T., Molina, B. S.,
Mitchell, J. T., . . . Roy, A. (2017). Late-
onset ADHD reconsidered with
comprehensive repeated assessments
between ages 10 and 25. American
Journal of psychiatry, 175(2), 140-149.
61. Shahab, M., Al‐Tuwaijri, F., Bilal, L.,
Hyder, S., Al‐Habeeb, A. A., Al‐Subaie,
A., . . . Kessler, R. C. (2017). The Saudi
national mental health survey:
methodological and logistical challenges
from the pilot study. International
journal of methods in psychiatric
research, 26(3), e1565.
62. Schubiner, H., Tzelepis, A., Milberger,
S., Lockhart, N., Kruger, M., &
Schoener, E. P. (2000). Prevalence of
attention-deficit/hyperactivity disorder
and conduct disorder among substance
abusers. The Journal of clinical
psychiatry, 61(4), 244-251.
63. Thomas, R., Sanders, S., Doust, J.,
Beller, E., & Glasziou, P. (2015).
Prevalence of attention-
deficit/hyperactivity disorder: a Jama, 292(5), 619-623.
systematic review and meta-analysis.
Pediatrics, 135(4), e994-e1001.
64. Van de Glind, G., van den Brink, W.,
Koeter, M. W., Carpentier, P.-J., van
Emmerik-van Oortmerssen, K., Kaye,
S., . . . Konstenius, M. (2013). Validity
of the Adult ADHD Self-Report Scale
(ASRS) as a screener for adult ADHD in
treatment seeking substance use disorder
patients. Drug and alcohol dependence,
132(3), 587-596.
65. Weiss, G., & Hechtman, L. T. (1993).
Hyperactive children grown up: ADHD
in children, adolescents, and adults:
Guilford Press.
Copyright © 2019, Archives of Psychology. All rights reserved.
Page 23 of 23
66. Wender, P. H. (1998). Attention-deficit
hyperactivity disorder in adults.
Psychiatric Clinics, 21(4), 761-774.
67. WHO. (2003). Adult self-report scale,
ASRS-V1. 1 screener. Retrieved from
https://www.hcp.med.harvard.edu/ncs/ft
pdir/adhd/6Q_ASRS_English.pdf:
68. WHO. (2014). Adult ADHD Self-Report
Scale-V1.1 (ASRS-V1.1) Screener from
WHO Composite International
Diagnostic Interview. Retrieved from
https://www.hcp.med.harvard.edu/ncs/ft
pdir/adhd/6Q_Arabic_final.pdf
69. Wilens, T. E., Biederman, J., & Spencer,
T. J. (2002). Attention
deficit/hyperactivity disorder across the
lifespan. Annual review of medicine,
53(1), 113-131.
70. Wilens, T. E., & Dodson, W. (2004). A
clinical perspective of attention-
deficit/hyperactivity disorder into
adulthood. The Journal of clinical
psychiatry.
71. Wilens, T. E., Faraone, S. V., &
Biederman, J. (2004). Attention-
deficit/hyperactivity disorder in adults.
72. Wingo, A. P., & Ghaemi, S. N. (2007).
A systematic review of rates and
diagnostic validity of comorbid adult
attention-deficit/hyperactivity disorder
and bipolar disorder. The Journal of
clinical psychiatry.
http://www.archivesofpsychology.org