Data collection
Study was carried out using a two-stage ascertainment procedure. Children were evaluated for eligibility after registration at the reception between 9 am to 8 pm during week days. A maximum of 10 participants were recruited on any given day to minimize burden in the department and to hopefully capture a wider spectrum of medical conditions. Details about the study were explained to the parents by the principal investigator or the research assistant after patients had been seen by the clinician for the presenting problem. Information necessary for DSM-IV classification was obtained from parents who also completed VAS form.
Vanderbilt diagnostic parent rating scale has 55 questions divided into two sections comprising of symptoms and performance. The symptoms section contains 47 questions that are divided into various sub-sections as follows: questions 1-18 covers symptoms of ADHD, questions 19-26 oppositional defiant disorder symptoms, questions 27-40 conduct disorders and 41-47 anxiety and depression. Performance section has eight questions that indicate the level of impairment under questions 48-55. School performance, relationships with family and peers and participation in organized activities are considered under this section [18]. Hence, the tool evaluates the core symptoms of ADHD, rates the impairment ADHD may have on academic work and behavioural performance under different social settings [19].
Directions for filling out the form require parents to think about the child’s behaviour over a six month period. Additionally, the form has questions on whether patient is on medications. Symptoms scales are rated: never = 0, occasionally = 1, often = 2, very often = 3. Parent is also instructed to circle only one of the numbers on the scale. Similarly, performance scales are rated as: excellent = 1, above average = 2, average = 3, somewhat of a problem = 4, problematic = 5. The parent form contains 55 items that take approximately 10 minutes to complete [18].
Numbers for each section were tallied to meet DSM-IV criteria for diagnosis. For the predominantly inattentive subtype of ADHD, the patient was expected to score either a 2 or 3 in six out of nine questions under 1-9 and score 4 or 5 on the performance questions 48-55. To be categorized under predominantly hyperactive/impulsive subtype of ADHD, the score had to be either a 2 or 3 in six out of nine on questions 10-18 and 4 or 5 on the performance questions 48-55. ADHD combined inattention/hyperactivity required the above criteria on both inattention and hyperactivity [18].
ADHD co-morbid conditions on the form were: ODD had to score a 2 or 3 in four out of eight on questions 19-26 and score 4 or 5 on the performance questions 48-55. Conduct disorder score was 3 out of 14 on questions 27-40 and score 4 or 5 on performance questions 48-55. Anxiety/depression had to obtain 2 or 3 on three out of seven in questions 41-47 and score of 4 or 5 on performance questions 48-55 [18].
The first author (SW) or a pre-trained research assistant explained to parents how to fill out a questionnaire adapted from American Psychiatric Association, Diagnostic and statistical manual of mental disorders [16], 4th ed. Washington, D.C., 1994. SW had previously undergone training with study psychiatrist (FN) on use of the tool and subsequently trained the research assistant on its application. The following questions were inquired: (i) If their child had any of the listed symptoms of inattention that have persisted for at least six months, symptoms of hyperactivity-impulsivity that had persisted for at least six months to a degree that was inconsistent with their developmental level. The hyperactive-impulsive or inattentive symptoms that caused impairment had to have been present before age seven years. There also had to have been impairment from the symptoms in two or more settings like at school or home. Clear evidence of clinically significant impairment in social and academic functioning also had to be demonstrable [18].
Care providers of study children were requested to complete the risk assessment form with assistance provided as needed. It contained questions about school performance such as repetition of class and average end of term marks which was categorized as; below 25%, 25-50%, 50-75% or above 75%. A grade above 50% was considered as acceptable performance. Only injuries for which medical treatment was sought were considered for inclusion and categorized into burns, fractures and open wounds. Information on causes of injuries was classified under falls, fight, car accident and others. Completion of an assessment form took approximately 15 minutes after which questionnaire was scored and tabulated before providing feedback to parents. A neuro-developmental history was taken from guardians of children who screened positive for ADHD symptoms followed by a comprehensive physical examination. Visual acuity test was done using a Snellen chart and bed side testing for hearing performed using a 512 Hz tuning fork. After addressing any concerns raised by guardians, children who screened positive for ADHD were referred to a psychiatrist for re-assessment and appropriate management at a pre-negotiated subsidized cost.
The first author or research assistant explained to parents the importance of getting input from the child’s teacher. Parents were asked to consent and sign a release of information form that was then to be passed on to teachers responsible for documenting school performance feedback. Parents were asked to forward pre-stamped, self-addressed envelopes containing the DSM-IV and Vanderbilt Teacher Assessment (VTA) forms to the class teachers for completion. They were also requested to mail back completed forms to the investigator. A cover note explaining the study to teachers and instructions on how to fill the form, including a completed sample form, was enclosed in the package. The note stated that that the child would be evaluated for an undisclosed medical condition and that teachers were to complete a form on behavioural rating without specifying the actual behavioural condition. Further, they were to sign a confidentiality agreement in order to protect the privacy of the patient. Where responses delayed beyond two weeks, a telephone reminder was sent through the parents.