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. 2024 Jul 18;19(7):e0307173. doi: 10.1371/journal.pone.0307173

The pooled prevalence of attention-deficit/hyperactivity disorder among children and adolescents in Ethiopia: A systematic review and meta-analysis

Desalegn Girma 1,*, Zinie Abita 2, Amanuel Adugna 1, Melsew Setegn Alie 2, Nigusie Shifera 2, Gossa Fetene Abebe 1
Editor: Simone Varrasi3
PMCID: PMC11257254  PMID: 39024258

Abstract

Background

Attention-deficit/hyperactivity disorder is one of the most common childhood neurobehavioral disorders, which has a serious negative effect on educational achievement, peer relationships, social functioning, behavior, and self-esteem of children. However, the pooled prevalence of attention-deficit/hyperactivity disorder is not well known in Ethiopia. Therefore, the main objective of this systematic review and meta-analysis is to estimate the pooled prevalence of attention-deficit/hyperactivity disorder among children and adolescents in Ethiopia.

Methods

PubMed, HINARI, Science Direct, Psych INFO, Google Scholar, African Journals Online, and cross-referenced were searched to identify relevant articles. Quality appraisal was done using the Joanna Briggs Institute checklist. Heterogeneity was tested using the I-square statistics. Publication bias was tested using a funnel plot visual inspection. Further, trim and fill analysis was done to correct publication bias.Forest plots and tables were used to present results. The random effect model was used to compute the pooled prevalence of attention-deficit/hyperactivity disorder among children and adolescents.

Results

The overall pooled prevalence of attention-deficit/hyperactivity disorder among children and adolescents in Ethiopia was 14.2% (95% CI: 8.48, 22.83). Being male (OR: 2.19, 95% CI: 1.54; 3.12), being aged 6–11 years (OR: 3.67, 95% CI: 1.98; 6.83), low family socioeconomic status (OR: 3.45 95% CI: 2.17; 5.47), maternal complication during pregnancy (OR: 3.29, 95% CI: 1.97; 5.51) and family history of mental illness (OR: 3.83, 95% CI:2.17; 6.77) were factors associated with a higher odds of attention-deficit/hyperactivity disorder among children and adolescents.

Conclusions

The overall pooled prevalence of attention-deficit/hyperactivity disorder among children and adolescents is high in Ethiopia as compared to previous literature. To reduce the prevalence of attention-deficit/hyperactivity disorder among children and adolescents, emphasis has to be given to prevention, early detection, and management of pregnancy-related complications. Moreover, parents with mental illness should be supported and properly treated to reduce the impact of hostile parenting on their child’s health.

Trial registration

Registered in PROSPERO with ID: CRD42024536334.

Introductions

Attention-Deficit/Hyperactivity Disorder(ADHD) is one of the most common neurodevelopmental disorders in children [1]. ADHD is usually first identified in school-aged children when it leads to distraction in class [2]. Children with ADHD have trouble focusing, being fidgety, controlling impulsive behaviors [3]. ADHD has three main subtypes: attention deficit, hyperactive-impulsive, and combined types [1, 4]. Children with attention deficit subtype have difficulties paying attention, organizing, or completing tasks [2].On the other hand, children with hyperactive-impulsive subtypes are characterized by high levels of activity, fidgety and difficulty sitting or quiet, waiting their turn, and having trouble with impulsivity [1, 2, 4]. Lastly, children with combined subtypes manifest both attention deficit and hyperactive-impulsive class symptoms [4].

The exact cause of ADHD remains unknown. However, genetic predisposition and environmental factors have been considered as potential risk factors [5–8]. Moreover, other factors such as parent psychopathology also attributed to offspring ADHD. Previous studies reported that the likelihood of ADHD was higher among children whose parents were diagnosed with psychiatric disorders [9, 10], which further reduces the neurocognitive performance of children with ADHD [11]. This implies that children whose parents with psychopathological symptoms should be screened for ADHD and incorporated into treatment programs.

ADHD affects the life of children in many aspects. Such as education is one of the major affected areas; different studies reported that children with ADHD have lower academic achievement than children without ADHD [5, 12–18]. Additionally, Children with ADHD have difficulties in peer relationships, social functioning, and behaving with others [9, 19–26]. Furthermore, studies found that children with ADHD are at higher risk of unintentional accidents [27–33]. Lastly, ADHD can lead children to anxiety and depression [34–36] and poor self-esteem if not appropriately treated [37, 38]. Previous literature reported that ADHD can persist into adulthood [39, 40]. During adulthood, it impairs occupational function and work productivity [41–44], academic achievements [44], family and interpersonal relationships [45] and increases the risk of substance abuse [46]. Moreover, ADHD also increases economic burden on families and society [47, 48].

Globally, the prevalence of ADHD among children and adolescents raged from 5.29% to 8.0% [8, 49–51]. Moreover, according to the systematic review and meta-analysis conducted in the different parts of the continents, the prevalence of ADHD among children and adolescents was found to be 2.9% in Europe [52], 10.90% in America [44], 5.9% in Arab Gulf [53], 10.3% in the Middle East and North Africa [54] and 5.4% to 8.7% in Africa [55, 56]. This shows that a large number of children and adolescents remain affected by ADHD and are facing difficulties associated with the disorder.

According to studies conducted in different parts of Ethiopia, the prevalence of ADHD among children and adolescents varied across the regions, ranging from the lowest (7.3%) in the Oromia region [57] to the highest (44.2%) in the Amahara region [58]. Moreover, other primary studies have also reported disequilibrium findings regarding the prevalence of ADHD among children and adolescents across regions in Ethiopia, and different factors were identified [59–63]. With this discrepancy, the pooled prevalence of ADHD among children and adolescents has not been estimated in Ethiopia. Therefore, the main purpose of this systematic review and meta-analysis is to estimate the aggregated prevalence of ADHD among children and adolescents and identify its associated factors. The finding of this study could help the policymakers, researchers, program implementers, and other responsible bodies by disclosing the pooled prevalence of ADHD among children and adolescents and identifying its associated factors.

Methods

Search strategy

The Preferred Reporting Items for Systematic Review and Meta-Analysis Statement (PRISMA-2020) guideline was used to report the results [64]. International databases such as PubMed, HINARI, Science Direct, Psych INFO, and other sources such as Google Scholar, African Journals Online, and cross reference were searched on March 12, 2024 to obtain relevant studies. The following terms and phrases such as “prevalence”, “magnitude”, “epidemiology”, “attention deficit hyperactivity disorder”, “ADHD”, “ADDH”, “behavioral disorder”, “neurodevelopmental disorder” “pediatrics”, “children” “under-five children”, “adolescents” and “Ethiopia” were used to search articles. The Boolean search operators such as “AND” and “OR” were used separately and in combination during database searching (S1 Table).

Eligibility criteria

The inclusion criteria were: 1) original studies that report the prevalence of ADHD among children and adolescents in Ethiopia and/or associated factors, 2) longitudinal studies (using a cross-sectional or case-control design), 3) studies published in English languages and 4) studies available at the electronic source up to March 12, 2024 were incorporated in the study. On the other hand, studies that didn’t report the event (i.e. the number of ADHD) or factors, citations without abstract and/or full-text, anonymous reports, editorial reports, and qualitative studies were excluded from the analysis.

Data extraction

After searching the databases, all the studies were exported to EndnoteX7 to identify and remove duplication. The data was independently extracted using a standardized extraction form by three authors (GF, ZA, and MS). From each study, the author’s name, publication year, the number of ADHD, study region, and the predictor of ADHD with odd ratios were extracted.

Quality assessment/critical appraisal

The Joanna Briggs Institute (JBI) Critical Appraisal Checklist for cross-sectional study design was used to assess the quality of the study [65]. The qualities of the primary studies were independently assessed by two authors (AA and NS). Any discrepancy between the two authors was handled by taking the mean score of the two authors. The tool has Yes, No, Unclear, and Not Applicable options: “1” is given for “Yes” and “0” is given for other options. The scores were summed and changed to percentages. Finally, 7 studies that received a quality score of >50% were included in this meta-analysis (S2 Table).

Outcome measurement

The prevalence of ADHD among children and adolescents in Ethiopia was the first outcome of this systematic review and meta-analysis. The factors associated with ADHD among children and adolescents were the second outcome of this study. Accordingly, the odd ratio of factors associated with ADHD with its 95% confidence intervals (CI) was extracted from the original studies to compute the pooled odd ratio.

Statistical analysis

Data entry was done using Microsoft Excel 2013 and then imported into R software version 4.1.3 for further analysis. Data analysis was done using meta-package. Heterogeneity was checked using the I-square test [66]. Heterogeneity was declared as low, medium, and high if the I2 value was 25%, 50%, and 75%, respectively [67]. Subgroup analysis was done using the study region and sex of children and adolescents. To identify the possible source of heterogeneity meta-regression analysis was done using sample size and the publication years. Sensitivity analysis was done by omitting individual studies to detect the contribution of each study to the final pooled prevalence of ADHD. Funnel plot visual inspection was done to identify publication bias. Further, the trim-and-fill imputation was done to correct the publication bias. The forest plot was used to present the prevalence of ADHD with its 95% confidence interval. Tables were also used to present data.The random effect model was used to compute the pooled prevalence of ADHD.

Results

Characteristics of included studies

A total of 1,612 studies were searched from PubMed, HINARI, Science Direct, and Psych INFO and other sources such as Google Scholar, African Journals Online, and cross-reference. Among these, 441 studies were from PubMed, 42 studies were from HINARI, 189 studies were from Science Direct, 823 studies were from Psych INFO and the rest 117 studies were searched from other sources. From these studies, 639 studies were excluded due to duplication. From the remaining 973 studies, 955 studies were excluded as not being relevant to the study after reviewing the title and abstract. From the rest 18 studies, the full text of the two studies was not retrieved and removed from the analysis. The rest 16 studies were assessed by reviewing the full text. Finally, a total of 7 studies were eligible and incorporated in the final systematic review and meta-analysis [57–63] (Fig 1). All of the studies were conducted using the cross-sectional study design. These studies were done from different parts of Ethiopia (Tigray region, Amhara region, and Oromia region (Table 1).

Fig 1. PRISMA flow chart describing screening protocols of studies for meta-analysis.

Fig 1

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Table 1. Characteristics of studies included in the systematic review and meta-analysis, 2024.

Author Publication year Regions Sample size Number of ADHD Prevalence (%)
Lola, et al (2019) [57] 2019 Oromia 1238 90 7.3
Benti, et al (2021) [59] 2021 Oromia 407 34 8.4
Mulat, et al(2021) [58] 2021 Amhara 260 115 44.2
Aliye, et al (2023) [60] 2023 Oromia 504 50 9.9
Kassa, et al (2018) [61] 2018 Tigray 541 100 18.5
Tiruneh, et al (2015) [62] 2015 Oromia 387 53 13.7
Mulu, et al (2021) [63] 2021 Amhara 355 46 13
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The pooled prevalence of ADHD among children and adolescents in Ethiopia

A total of seven studies were used to compute the pooled prevalence of ADHD among children and adolescents [57–63]. Accordingly, the pooled prevalence of ADHD among children and adolescents was found to be 14.2% (95% CI: 8.48, 22.83) using the random effect model (Fig 2). Heterogeneity (I2 = 97%, p-value <0.01) was identified between included studies. Hence, Subgroup analysis was done based on the study regions and sex of children and adolescents. Accordingly, the pooled prevalence of ADHD among males was 9.45% (95% CI: 4.48; 18.85) whereas among females was 4.57% (95% CI: 2.53; 8.14) (Table 2). Sensitivity analysis was done to determine the contribution of each study in the final pooled estimate of ADHD. Accordingly, except for one study [58], nearly all studies have equal contributions in the final pooled estimate(Fig 3).

Fig 2. The forest plots show the pooled prevalence of attention-deficit/hyperactivity disorder among children and adolescents in Ethiopia, 2024.

Fig 2

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Table 2. Sub-group analysis of ADHD among children and adolescents in Ethiopia, 2024.

Variables Characteristics Estimated ADHD (95%CI) I2 tests with p-value
Sex Male 0.0945 (0.0448; 0.1885) I2 = 97.7%, P-value <0.001
Female 0.0457 (0.0253; 0.0814) I2 = 90.5%%, P-value <0.001
Regions Tigray 0.1848 [0.1543; 0.2198] -----
Amhara 0.2563 [0.0627; 0.6397] I2 = 98.6%,P-value <0.001
Oromia 0.0952 [0.0719; 0.1250] I2 = 80.5%,P-value = 0.001
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Fig 3. Sensitivity analysis for pooled prevalence of attention-deficit/hyperactivity disorder among children and adolescents in Ethiopia, 2024.

Fig 3

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Meta-regression

Meta-regression was conducted to identify the possible source heterogeneity of ADHD among children and adolescents using the publication years and sample size. Of these factors, none of them were statistically significant (Table 3).

Table 3. Meta-regression analysis using publication years and sample sizes for the possible source of heterogeneity of pooled prevalence of ADHD, Ethiopia, 2024.

Variables Coefficients P-value
Publication years -0.0405 (-0.1412, 0.0603) 0.99
Sample size 0.0002 (-0.0019,0.0024) 0.14
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Publication bias

Asymmetric distribution was detected in the funnel plot visual inspection (Fig 4). Accordingly, further trim and fill analysis was done to correct publication bias. Accordingly, after adding two studies, the pooled prevalence of ADHD became 18.44% (95% CI: 11.03; 29.19) using the random effect model.

Fig 4. Funnel plot showing publication bias among studies used to compute the pooled prevalence of attention-deficit/hyperactivity disorder among children and adolescents in Ethiopia, 2024.

Fig 4

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Factors associated with ADHD among children and adolescents

Seven studies were used to estimate the pooled odd ratio of factors associated with ADHD among children and adolescents [57–63]. Accordingly, the odds of ADHD were 2.19 times (OR: 2.19, 95%CI: 1.54; 3.12) higher among male children and adolescents as compared to female children and adolescents [57–59]. The likelihood of ADHD was 3.67 times (OR: 3.67, 95% CI: 1.98; 6.83) higher among children and adolescents whose ages are 6–11 years as compared to children and adolescents whose ages are greater than 11 years [59, 60]. The odds of having ADHD were 3.45 times (OR: 3.45, 2.17; 5.47) higher among children and adolescents who are from low socio-economic status family members as compared to their counterparts [57, 59, 61]. The odds of having ADHD were 3.29 times (OR: 3.29: 95% CI: 1.97; 5.51) higher among children and adolescents who had maternal complications during pregnancy as compared to their counterparts [59–61]. The likelihood of having ADHD was 3.83 times (OR:3.83, 95% CI: 2.17; 6.77) higher among children and adolescents who have a family history of mental illness as compared with those who didn’t have a family history of mental illness[58, 59] (Table 4).

Table 4. Factors associated with ADHD among children and adolescents, Ethiopia, 2024.

Variables Included studies OR (95% CI) Pooled OR (95% CI) Heterogeneity
Male sex Lola, et al (2019 1.81 (1.13; 2.91) 2.19(1.54; 3.12) I2 = 0%, p-value = 0.47
Benti, et al (2021) 3.07 (1.16; 9.39)
Mulat, et al(2021) 2.70 (1.46; 4.97)
Age 6–11 years Benti, et al (2021) 3.38 (1.22; 9.39) 3.67(1.98; 6.83) I2 = 0%, p-value = 0.83
Aliye, et al (2023) 3.86 (1.7700; 8.43)
low family socioeconomic status Lola, et al (2019) 2.43 (1.28; 4.58) 3.45 (2.17; 5.47) I2 = 38.9%, p-value = 0.19
Benti, et al (2021) 3.47 (1.25; 10.1)
Kassa, et al (2018) 6.55 (2.76; 15.57)
Maternal complications during pregnancy Benti, et al (2021) 3.05 (1.10; 8.48) 3.29 (1.97; 5.51) I2 = 0%, p-value = 0.97
Aliye, et al (2023) 3.56 (1.44, 8.79)
Kassa, et al (2018) 3.26 (1.49; 7.15)
Family history of mental illness Benti, et al (2021) 3.60 (1.78; 8.21) 3.83 (2.17; 6.77) I2 = 0%, p-value = 0.81
Mulat, et al(2021) 4.14(1.76; 9.68)
Preterm Kassa, et al (2018 1.87 (1.01 3.49) 4.17(0.7454; 23.35) I2 = 84.5%,p-value = 0.01
Tiruneh, et al (2015) 10.92(3.253;36.67)
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OR: odds ratio. CI: confidence interval.

Discussion

To the best of the author’s knowledge, there is no pooled estimate of ADHD among children and adolescents in Ethiopia. Therefore, this systematic review and meta-analysis provide the pooled prevalence of ADHD among children and adolescents. Accordingly, the overall pooled prevalence of ADHD among children and adolescents was found to be 14.2% (95% CI: 8.48, 22.83) using the random effect model. The finding is higher than the systematic review and meta-analysis studies conducted elsewhere [8, 43, 49–55]. The possible elucidation for the discrepancy might be the difference in culture and socioeconomic characteristics of study participants that are consistently associated with increased rates of ADHD in children and adolescents [68, 69]

In this systematic review and meta-analysis, the odds of having ADHD are higher among males than females. The finding is synonymous with studies conducted elsewhere [39, 70, 71]. The possible clarification might be due to differences in the expression of the disorder between males and females [72]. Most of the time females present with internalized symptoms (such as anxiety, depression, and low self-esteem) and missed from diagnosis [73, 74]. Whereas males with ADHD externalize the symptoms (such as hyperactive or impulsive and aggressive behavior) than females and can be easily diagnosed [75]. This may make the difference between male and female.

In this systematic review and meta-analysis, the likelihood of having ADHD is higher among children and adolescents whose ages are 6–11 years as compared to children and adolescents whose ages are greater than 12 years. The finding is in agreement with the study conducted elsewhere [39]. The possible justification might be due to the reduction in hyperactive-impulsive symptoms, and stability of inattentive symptoms as age increased.

The other observed finding of this study is that the odds of having ADHD are higher among children and adolescents who are from low socio-economic status family members as compared to their counterparts. The finding is supported by the study conducted elsewhere [69, 76, 77]. The possible elucidation might be family with low socioeconomic status may not meet the needs of their children such as school choice and others. This can change the behavior of children and adolescents. Moreover, low socioeconomic status increases the risk of pregnancy-related complications, which is the known risk factor for ADHD [39, 78].

The odds of having ADHD are higher among children and adolescents who have maternal complications during pregnancy as compared to their counterparts. The finding is supported by studies conducted elsewhere [39, 78, 79]. The possible explanation might be maternal complications during pregnancy might cause multi-organ damage including the central nervous system, which can affect fetal neurodevelopment and may predispose to ADHD [80, 81].

This systematic review and meta-analysis revealed that the odds of having ADHD are higher among children and adolescents who have a family history of mental illness than those who don’t have a family history of mental illness. The finding is consistent with studies conducted elsewhere [70, 82–85]. This is the fact that genetic predisposition contributes to offspring ADHD [86, 87]. Moreover, this is the fact that hostile parent interaction can affect their child’s behaviors and increase the risk of being diagnosed with ADHD [88]. Generally, more emphasis has to be given to the prevention and treatment of children and adolescents with ADHD. Moreover, researchers, program implementers, and policymakers should consider the aforementioned factors in their strategic plans.

Limitations

This systematic review and meta-analysis has the following limitations: In this analysis, articles published only in English were included, only three regions were included in the analysis which some regions may not be represented in the study and some factors associated with ADHD were excluded from the analysis because of there were reported only in one primary article and/or classified as different way from the included articles. Moreover, though we rigorously searched for studies conducted on treatment modalities of ADHD among children and adolescents in Ethiopia, we can’t access any published study on treatment modalities of ADHD in Ethiopia. Such that, we can’t review the primary treatment modalities of ADHD among children and adolescents in Ethiopia.

Conclusions

The overall pooled prevalence of ADHD among children and adolescents is high in Ethiopia as compared to previous literature. Being male, having low family socioeconomic status, being aged 6–11 years, having maternal complications during pregnancy, and family history of mental illness are factors associated with higher odds of ADHD among children and adolescents. To reduce the prevalence of ADHD among children, emphasis has to be given to prevention, early detection, and management of pregnancy-related complications. Moreover, parents with mental illness should be supported and properly treated to reduce the impact of hostile parenting on their child’s health. Furthermore, in Ethiopia, further studies on the treatment modality of ADHD and its effects have to be done to enhance the quality of life of children and adolescents with ADHD.

Supporting information

S1 Checklist. PRISMA 2020 checklist.

(DOCX)

pone.0307173.s001.docx (35.8KB, docx)
S1 Table. Search terms summary for the pooled prevalence of attention-deficit/hyperactivity among children and adolescents, Ethiopia, 2024.

(DOCX)

pone.0307173.s002.docx (13.8KB, docx)
S2 Table. Critical appraisal of studies included in the systematic review and meta-analysis for pooled prevalence of attention-deficit/hyperactivity disorder among children and adolescents in Ethiopia, 2024.

(DOCX)

pone.0307173.s003.docx (16.6KB, docx)

Abbreviations

ADHD

Attention-Deficit/Hyperactivity Disorder

JBI

The Joanna Briggs Institute Critical Appraisal Checklist

PRISMA

Preferred Reporting Items for Systematic Review and Meta-Analysis Statement

OR

odds ratio

CI

confidence interval

Data Availability

The data used for this study was deposited at Harvard Dataverse repository URL: https://doi.org/10.7910/DVN/4FYYGN.

Funding Statement

The author(s) received no specific funding for this work.

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Decision Letter 0

Simone Varrasi

22 May 2024

PONE-D-24-12742The pooled prevalence of attention-deficit/hyperactivity disorder among children and adolescents in Ethiopia: A Systematic Review and Meta-Analysis.PLOS ONE

Dear Dr. Girma,

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Reviewer #1: Dear authors,

your systematic review and meta-analysis is interesting dealing with gathering evidence on ADHD in Ethiopia.

Some amendments are necessary in order to improve the overall quality of the manuscript:

1. Into the introduction, some information about ADHD in adulthood are interesting to take into account. For this reason, you could take some information by https://doi.org/10.3390/educsci13010037;

2.The manuscript demonstrates strong writing and methodological validity, although it's worth noting that the meta-analysis was based on only 7 studies, which may be seen as a limitation. Additionally, the evidence presented suggests no significant variations in ADHD prevalence between the Ethiopian population and global trends, particularly in terms of gender disparities or exacerbating factors. Consequently, the study doesn't significantly contribute to the existing scientific discourse.

To enhance the originality of the study, one suggestion is to incorporate a section that systematically reviews or narratively explores the primary treatment modalities available for Ethiopian children and adolescents with ADHD. This addition could introduce a novel perspective and broaden the scope of the research, potentially offering valuable insights into diverse cultural contexts and treatment approaches.

Reviewer #2: Dear authors,

thank you for submitting your work to the journal PLOS ONE and for focusing your study on the topic of ADHD, which is increasingly relevant and at the center of scientific debate. The work sheds important light on the prevalence and associated factors of ADHD among children and adolescents in Ethiopia.

Thank you for your contribution to this essential field of research.

However, some of the steps described within this project need further clarification.

In particular, the following observations could go a long way towards clarifying certain aspects that need to be revised and reformulated.

1. The references section should be formatted according to the PLOS ONE guidelines, please refer to https://journals.plos.org/plosone/s/submission-guidelines .

2. The denomination and description of the table should be placed below it, according to the guidelines.

3. Given the lack of information due to various reasons in Ethiopia and the need to demonstrate to policymakers, researchers, program implementers, and other responsible bodies the importance of understanding the pooled prevalence of ADHD among children and adolescents and identifying its associated factors, it is crucial to highlight the future perspectives for these children as they transition into adulthood, in order to remark the impact of this clinical condition. For more detailed insights, please refer to https://doi.org/10.3390/educsci13010037.

4. I would also suggest including within the introductory section the issue regarding parents with psychopathology in a more cohesive manner, as this topic is mentioned only in the abstract and conclusions without being well integrated into the context with specific references (e.g. 46-47; 268-269).

**********

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Reviewer #1: No

Reviewer #2: No

**********

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PLoS One. 2024 Jul 18;19(7):e0307173. doi: 10.1371/journal.pone.0307173.r002

Author response to Decision Letter 0

23 Jun 2024

Reviewer #1 comments and an author response

Your systematic review and meta-analysis is interesting dealing with gathering evidence on ADHD in Ethiopia

Authors: I would like to express my heart-felt thanks for your devoted time to review our manuscript

Reviewer comment #1: Into the introduction, some information about ADHD in adulthood are interesting to take into account. For this reason, you could take some information by https://doi.org/10.3390/educsci13010037;:

Authors Response: dear reviewer, we thank you heartily for your constructive comments. As per your suggestion we incorporated in the revised manuscript, please, look on page 5 from lines numbers 86-89

Comment #1: The manuscript demonstrates strong writing and methodological validity, although it's worth noting that the meta-analysis was based on only 7 studies, which may be seen as a limitation. Additionally, the evidence presented suggests no significant variations in ADHD prevalence between the Ethiopian population and global trends, particularly in terms of gender disparities or exacerbating factors. Consequently, the study doesn't significantly contribute to the existing scientific discourse.

To enhance the originality of the study, one suggestion is to incorporate a section that systematically reviews or narratively explores the primary treatment modalities available for Ethiopian children and adolescents with ADHD. This addition could introduce a novel perspective and broaden the scope of the research, potentially offering valuable insights into diverse cultural contexts and treatment approaches.

Authors Response: Thanks very much for your comments and concerns. We accepted your comments. Dear, reviewer, we searched as much as our best for studies conducted on treatment modalities of ADHD among children and adolescents in Ethiopia, however, we can’t access any published study or literature on treatment modalities of ADHD in Ethiopia. Such that, we can’t review the primary treatment modalities of ADHD among children and adolescents in Ethiopia. Dear reviewer, in this regard, we considered your comments as a major limitation of our study and we incorporated under our limitation (please look on page from lines numbers 290-293). Moreover, we recommended further studies on the treatment modality of ADHD and its effects among children and adolescents with ADHD (please look, on page 15 from lines numbers 302-303).

Dear reviewer, this indicates that ADHD is negated in Ethiopia. Dear reviewer, in our study, at least, we disclosed the burden of ADHD among children in Ethiopia, which can alarm the governments and urge the policymaker to endorse strategies or programs, and treatment guidelines related to ADHD to improve the quality of children with ADHD and to prevent the Lifespan impact of ADHD. In this regard, this study may have importance in a country, which has limited evidence regarding ADHD.

Dear reviewer, having this, we are ready to consider your further recommendation for any reservation do you have.

Response to Reviewer #2:

Reviewer: thank you for submitting your work to the journal PLOS ONE and for focusing your study on the topic of ADHD, which is increasingly relevant and at the center of scientific debate. The work sheds important light on the prevalence and associated factors of ADHD among children and adolescents in Ethiopia.

Thank you for your contribution to this essential field of research.

However, some of the steps described within this project need further clarification.

In particular, the following observations could go a long way towards clarifying certain aspects that need to be revised and reformulated.

Authors: I would like to express my heart-felt thanks for your devoted time to review our manuscript

Comment 1: The references section should be formatted according to the PLOS ONE guidelines, please refer to https://journals.plos.org/plosone/s/submission-guidelines .

Authors Response: Thanks very much, for your concern and comments, dear reviewer, amendment was done based on the submission-guidelines on reference No.1 and 2

2. The denomination and description of the table should be placed below it, according to the guidelines.

Authors Response: Thanks very much, for your concern and comments. Dear reviewer, descriptions were incorporated in the revised manuscript for supplemental tables and figures, which are not uploaded as supplemental material or uploaded separately as figures.

Comment 2: Given the lack of information due to various reasons in Ethiopia and the need to demonstrate to policymakers, researchers, program implementers, and other responsible bodies the importance of understanding the pooled prevalence of ADHD among children and adolescents and identifying its associated factors, it is crucial to highlight the future perspectives for these children as they transition into adulthood, in order to remark the impact of this clinical condition. For more detailed insights, please refer to https://doi.org/10.3390/educsci13010037.

Authors Response: dear reviewer, we thank you heartily for your constructive comments. As per your suggestion, we incorporated it in the revised manuscript, please, look on page 5 from lines numbers 86-89

Comment 3: I would also suggest including within the introductory section the issue regarding parents with psychopathology in a more cohesive manner, as this topic is mentioned only in the abstract and conclusions without being well integrated into the context with specific references (e.g. 46-47; 268-269).

Authors Response: dear reviewer, we thank you heartily for your constructive comments. As per your suggestion, we incorporated it in the revised manuscript, please, look on page 4 from lines numbers 73-79

Attachment

Submitted filename: Response to reviewers final.docx

pone.0307173.s004.docx (20.8KB, docx)

Decision Letter 1

Simone Varrasi

24 Jun 2024

PONE-D-24-12742R1The pooled prevalence of attention-deficit/hyperactivity disorder among children and adolescents in Ethiopia: A Systematic Review and Meta-Analysis.PLOS ONE

Dear Dr. Girma,

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Kind regards,

Simone Varrasi

Academic Editor

PLOS ONE

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Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: (No Response)

Reviewer #2: (No Response)

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2. Is the manuscript technically sound, and do the data support the conclusions?

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Reviewer #1: Yes

Reviewer #2: Yes

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: N/A

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Reviewer #1: No

Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: Dear authors,

thank you for the revisions made. However, please review the form of the references, as it may not be correct for the journal. It is suggested to use reference software (e.g. Zotero, Mendeley).

Reviewer #2: Thank you for reviewing your work.

In my opinion, the manuscript aligns with the journal's standards.

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Reviewer #1: No

Reviewer #2: No

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PLoS One. 2024 Jul 18;19(7):e0307173. doi: 10.1371/journal.pone.0307173.r004

Author response to Decision Letter 1

26 Jun 2024

Reviewer #1: Dear authors,

thank you for the revisions made. However, please review the form of the references, as it may not be correct for the journal. It is suggested to use reference software (e.g. Zotero, Mendeley).

Authors response: Dear reviewer thank you for comments and concern, we used EndNote software which is one of the popular citation manager as like Zotero, Mendeley. We have no experience on Zotero, Mendeley. Dear reviewer, we have article that published in Plos One and other journal which was cited using EndNote as like as our current manuscript.

Reviewer #2: Thank you for reviewing your work.

In my opinion, the manuscript aligns with the journal's standards.

Authors response: Dear reviewer thank you very much for your devoted time to review our manuscript.

Attachment

Submitted filename: Response to reviewers final1.docx

pone.0307173.s005.docx (18KB, docx)

Decision Letter 2

Simone Varrasi

2 Jul 2024

The pooled prevalence of attention-deficit/hyperactivity disorder among children and adolescents in Ethiopia: A Systematic Review and Meta-Analysis.

PONE-D-24-12742R2

Dear Dr. Girma,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Simone Varrasi

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Acceptance letter

Simone Varrasi

8 Jul 2024

PONE-D-24-12742R2

PLOS ONE

Dear Dr. Girma,

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now being handed over to our production team.

At this stage, our production department will prepare your paper for publication. This includes ensuring the following:

* All references, tables, and figures are properly cited

* All relevant supporting information is included in the manuscript submission,

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Lastly, if your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

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Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Simone Varrasi

Academic Editor

PLOS ONE

Associated Data

    This section collects any data citations, data availability statements, or supplementary materials included in this article.

    Supplementary Materials

    S1 Checklist. PRISMA 2020 checklist.

    (DOCX)

    pone.0307173.s001.docx (35.8KB, docx)
    S1 Table. Search terms summary for the pooled prevalence of attention-deficit/hyperactivity among children and adolescents, Ethiopia, 2024.

    (DOCX)

    pone.0307173.s002.docx (13.8KB, docx)
    S2 Table. Critical appraisal of studies included in the systematic review and meta-analysis for pooled prevalence of attention-deficit/hyperactivity disorder among children and adolescents in Ethiopia, 2024.

    (DOCX)

    pone.0307173.s003.docx (16.6KB, docx)
    Attachment

    Submitted filename: Response to reviewers final.docx

    pone.0307173.s004.docx (20.8KB, docx)
    Attachment

    Submitted filename: Response to reviewers final1.docx

    pone.0307173.s005.docx (18KB, docx)

    Data Availability Statement

    The data used for this study was deposited at Harvard Dataverse repository URL: https://doi.org/10.7910/DVN/4FYYGN.

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