Previous studies regarding CD:

A study conducted by (Colman et al., 2009) entitled “Outcomes of conduct problems in adolescence: 40 year follow-up of national cohort”. They aimed to find out the long term outcomes regarding adolescents diagnosed with conduct disorder by the teacher. The study was a longitudinal study from 13-53year, and the sample comprised the Medical Research

Council National Survey of Health and Development in Britain. Participants were 3652 members. Results showed that 348(9.5%) of the participants (adolescents) were diagnosed with conduct disorder, 1051 of participants(28.8%) was found to have mild externalising behaviour( mild conduct symptoms), and 2253 of participants (62%) with no externalising behaviour. Outcomes were measured in adulthood and were found to be negative for those with severe and mild conduct symptoms in adolescence. For example: 65.2% of severe conduct symptoms in adolescence were likely to leave school without any qualifications, while for those with mild conduct symptoms the percentage was 52.2% and for those with no conduct symptoms it was 30.8%. Mental health, family life and relationships, and education and economic problems were measured as a composite measure of global adversity. The result showed that those with severe conduct symptoms scored 40.1% in top quarter, and those with mild conduct symptoms scored 28.3%, and those with no conduct symptoms scored 17.0%. This proved the assumption that adolescents with severe conduct symptoms will experience multiple social and health impairments which will in turn affect them adversely, their families, and the society through their adulthood life.

A study conducted by (Kramer et al.2009) entitled “Childhood Conduct Problems and Other Early Risk Factors in Rural Adult Stimulant Users”. The aim was to understand the risk factors in childhood that have association with the substance use and legal problems in adulthood which are important for treatment and prevention strategies.

They examined the relationship between substance use, conduct problems before the age of 15 and the history of the family on the adult outcomes in the use of stimulants in rural areas. The participants were 544 who were Adult cocaine and methamphetamine users from Arkansas and Kentucky. They were interviewed and the data were analysed using the multiple logistic regression and the log-linear regression and the bivariate analyses. The dependent variables were if there are any substance abuse/dependence, stimulant abuse/dependence, total number of days incarcerated and total number of arrests since age 18. Results showed that one-third of participant had three or more conduct disorder symptoms before age 15, half of participants had substance initiation, excluding alcohol, before age15; and 60% had family history of substance problems. It was found that the three variables were associated with substance abuse or dependence, but only the last two were associated with stimulant abuse or dependency.

A study conducted by (Gelhorn et al., 2007) entitled “ DSM-IV Conduct disorder criteria as predictors of antisocial personality disorder”. Their main aim of the study was to figure out the association between conduct disorder and a predicted antisocial personality disorder. The sample consisted of 41,571 individual recruited from the civilian non- institutionalized population in the United States aged 18 years and over. The diagnosing was done based on reported criteria from the NIAAA Alcohol Use Disorder for Conduct Disorder and Associated Disabilities Interview Schedule-DSMIV Version (AUDADIS-IV) for Antisocial personality disorder. Results showed that in males 6.7% of participant had a CD diagnosing and 79% of them had antisocial personality disorder. In females 2.6% had CD diagnosing and 75% of them had antisocial personality disorder diagnosing.

A study conducted by (Nock et al.,2006) entitled “Prevalence, Subtypes, and Correlates of DSM-IV Conduct Disorder in the National Comorbidity Survey Replication” . They aimed to find out the prevalence of conduct disorder , its subtypes and other comorbid disorder through a retrospective assessment using a fully structured diagnostic interview among 3199 participants from the U.S from the National Comorbidity Survey Replication. Results showed 9.5% was the prevalence of CD and median age of onset is 11.6 years( 12% among male participant and 7.1 among females). They found five CD subtypes :(1) rule violations.(2) deceit/theft.(3)aggression.(4)severe covert behaviour. (5) pervasive CD symptoms. A high relationship was noticed between the severity of CD and other subsequent disorders which often occurred after anxiety and impulse control disorders. A study conducted by (Sarkhel et al., 2006) entitled “Prevalence of conduct disorder in schoolchildren of Kanke”. The study was conducted in Kanke. The sample was recruited from four schools, chosen by simple random sampling, aged 10-15. Number of participants were 240 students, 132 boys and 108 girls. Participants were interviewed and the CD screening section of Schedule for affective Disorders and Schizophrenia for School-Age Children and Lifetime Version was applied. Participants who cross the cut off score were applied to assessment for CD and ADHD. Then , the student and their parents were interviewed separately. An overall impression was done depending on the DSM IV diagnosis of CD, and comorbid ADHD. Results showed that prevalence of conduct disorder was 4.58%. the disorder was more common in males than girls by the ratio 4.5:1. The onset of the disorder was 73% in childhood and 27% in adolescents. Participants with comorbid CD and ADHD were 36%.

2. 13.4 Conclusion:

According to the researcher knowledge, the studies that wereconducted in Palestine including Gaza strip regarding prevalence of ADHD, were very few. For comorbidity between ADHD and any other disorders, the researcher found only one study conducted in Gaza strip regarding ADHD and comorbid PTSD . In Bethlehem governorate a study was conducted by Rezqalla regarding quality of life among ADHD children. It was obvious that the studies in the Arab world in general were also few compared to those conducted in the west. All studies in the Arab world recommended further researches to be done on ADHD prevalence and more in depth studies regarding treatment, interventions, comorbidity and risk factors. In addition, several studies indicated the importance of early detection of ADHD due to the worse outcome of this disorder if completed to be in adulthood without treatment.

These studies showed different prevalence rates that ranged from 2.21 in Germany to 15% in Stip town, and up to 29.5% and 33% in North Florida and Brazil respectively, in the years 2005 to 2011. Most of them were cross sectional study from the community, public schools or from clinics. There were researchers who studied associated factors such as gender, socio-economic and socio-demographic status, health conditions, nutrition, outcome and co-morbidities to ADHD.

Various methods and instruments were used in the researches which may have affected the variance in the results. As for the instruments used, some had used the Conners scale, the DSM-IV check list, the SNAP questionnaire, or the clinical investigation. Some were dependent on the teachers view, parents view or both. Some results showed an agreement between teachers and parents while others did not.

The sample age taken in most of the studies mostly ranged from 4 to 18, only one took range up to 29 and another to 82. Some find gender differences regarding prevalence and noticed that males cases exceed females with a ratio of 2.28: 1. On the other hand Iranian researchers find that hyperactivity decreases by age where inattention increases by age. Most studies done regarding prevalence of conduct disorder and prevalence of ADHD comorbid with conduct disorder were western studies.

from 13% in a British study up to 36% in a study done in Kanke. The studies varied in their aims, some were longitudinal and aimed to find out the adulthood outcome of childhood CD or ADHD comorbid with CD, some had proved a future association with antisocial personality disorder(79% ), other proved association with substance abuse, adverse effect on the family, society, school-leaving without achievement( 65%) and high risk of future delinquency.

There is an important need for further studies to be done in the Arab world especially in Palestine. Many western researches studied conduct disorder, oppositional defiant disorder, poor academic performance, depression, anxiety and obsessive compulsive disorder as a probability to be associated with adult ADHD. In the Arab world the studies among ADHD are very restricted and on comorbidities are much restricted.

This study is characterised by studying the prevalence of ADHD among a restricted age period (fifth grade), and by studying the comorbidity with conduct behaviour in Bethlehem schools from the mothers’ perspective among fifth grade children and will bring out some recommendations that will assist in developing the quality of programs done regarding the educational knowledge of the disorder and its comorbid behaviour among the family, schools and all the professionals who are interested to work with people diagnosed with the disorder and their families. On the other hand, recommendations will be directed to school headmasters to help in assisting these children and improving their quality of life at school as well as their academic intake. In addition it will reveal the importance of detecting comorbid disorders that might be associated with ADHD which will also have a great impact on the person, the family and society if left undiagnosed and untreated.