Disorder (ADHD) has proved to be the most common disorder during childhood among the disruptive behaviour disorders.1
The diagnostic criteria for ADHD in the Diagnostic and Statistical Manual of Mental Disorders, 4th
edition, Text Revision (DSM-IV-TR), is based on the identification of symptoms and level of impairment. The factors significantly associated with impairment, as measured by clinicians, were the severity of ADHD symptoms, peer relationship problems and comorbidity with conduct disorders.3
Symptomatology and impairment are moderately related but not identical; they are likely to have distinct correlations and importance in the diagnosis and assessment of ADHD.4
In addition, impairment may be more of a universal notion, as opposed to the potentially culturally biased measurement of symptomatology.7
The measurement of functional impairment, in addition to symptomatology, is the focus of recent child psychiatric epidemiological studies. The findings of these studies add emphasis to impairment, measured using a multidimensional approach, in the daily activities essential to success in school and interpersonal relationships.8
Such interest has contributed to the identification of a true prevalence rate by reducing the number of false positive cases and determining community needs. Impairment can be measured either by a diagnostic interview linked to individual symptoms, case vignettes
, or by global ratings.2
Global ratings have many advantages over other methods, as it is time-efficient, links impairment to clinical judgment, and forecasts service utilisation and community needs. The disadvantages of a global ratings system lie in its lack of specificity in linking impairment with individual symptoms.4
Global rating scales, such as the Child and Adolescent Psychiatric Assessment (CAPA), Children’s Global Assessment Scale (C-GAS), Global Assessment of Function (GAF) and Children’s Problems Checklist (CPC), were used in several studies to assess the severity of functional impairment in preschool and school-aged children.9
Both GAF and C-GAS rate the severity of impairment on a scale of 1–100, where lower scores indicate greater impairment. The prevalence rate of ADHD, using the C-GAS score of <61, varied in different studies. In the USA, figures were low (1.85%), medium (6%) or high (10%).2
In Europe, the rate of ADHD using the same global rating scale was 7.9%; in the Netherlands, it was 5.6% and in the UK, 11.1%.15
Data on the rate of ADHD in Bahrain are not available; however, it is estimated that in 2011, 66 out of 348 new referrals received a diagnosis of ADHD at the Child and Adolescent Psychiatric Unit (CAPU) of the Bahrain Psychiatric Hospital. The CAPU is the main facility for children with psychological and behavioural problems in Bahrain. It has a busy outpatient clinic as well as an inpatient/day-care programme for 12 children. The unit programme utilises structured behavioural modification principles with a reward system within a token economy system. It provides a living and learning environment in which staff present the opportunity for modelling behaviour and counselling the family.
Global rating scales are not used routinely in clinical practice; the clinician comes to a clinical judgment by assessing the degree of impairment. This study aimed to examine the use of C-GAS in measuring initial functionality and treatment outcomes.