BEI-PSY is the first study to investigate the prevalence of psychiatric disorders among adolescents residing in Beirut, and its findings highlight a high prevalence of ADHD among adolescents residing in that area. Compared to healthy controls, adolescents with ADHD were more likely to be associated with a family history of psychiatric illness, a personal history of chronic medical illness, alcohol use, bullying and being bullied, as well as a lower school performance and an increased reliance on home tutoring. A diagnosis of ADHD was highly comorbid with emotional disorders, and ODD or CD. Parents of adolescents with ADHD reported a significantly higher impact of the illness compared to parents of adolescents in the other two groups. However, attitudes towards treatment seeking were similar regardless of the psychiatric diagnosis and only a minority of parents ever sought mental health services.
The prevalence of ADHD in this study is 10.2% and is relatively high compared to prevalence estimates reported in other parts of the Arab world  and in an earlier Lebanese study  which found a prevalence of 3.2% among school-aged children using a teacher rating scale. Our high prevalence could be explained by a difference in methodology as our study used a structured diagnostic tool to interview both adolescents and their parents in order to make a diagnosis based on DSM-IV criteria, whereas most other regional studies were conducted in school samples, surveyed pre-adolescent children, and relied on self-questionnaires or teachers’ rating scales [19, 20]. Furthermore, although our sample was socioeconomically diverse, our sampling area was uniformly urban, and studies conducted in urban environments have been associated with increased parental reporting of ADHD . The DAWBA has been shown to be highly accurate and reliable in detecting childhood psychiatric disorders, including ADHD [14, 22] and our prevalence and male-to-female ratio are similar to the numbers found in the 2011 USA National Survey of Children’s Health for children aged between 11 and 17 years .
Adolescents diagnosed with ADHD had distinct characteristics when compared to healthy adolescents and adolescents with other psychiatric diagnoses. Previous studies in the Arab region found that being raised by a single parent , having polygamous parents , having a parent with history of ADHD  and having a low socioeconomic level  were associated with being diagnosed with ADHD. In our study, we found that ADHD was associated with a positive family psychiatric history as reported by the parents who were interviewed; however, we did not find an association between having ADHD and the parents’ marriage status and socioeconomic level. It has been consistently reported in the literature that parents of children with ADHD are more likely to have psychiatric illnesses such as ADHD, mood and anxiety disorders, personality disorders and substance use [28, 29]. Contrary to our psychiatric controls subgroup, our ADHD subgroup had a significantly poorer academic performance (higher propensity to repeat grades and to need home tutoring) compared to the healthy subgroup, a finding that has been well-documented in the international literature. A recent meta-analysis found that poor attention and hyperactivity are strong predictors of academic problems such as repeating grades and using special education services even after adjusting for IQ, socioeconomic status and comorbidities . Added to the academic difficulties, the ADHD and the psychiatric controls subgroups experienced more peer-relation difficulties than the healthy subgroup, as evidenced by a higher propensity to bully others and to be bullied. Indeed, it has been shown that school children who have any type of mental health issues (including ADHD) were more likely to be involved in bullying as perpetrators and/or victims than healthy school children [31, 32].
Similar to international literature, adolescents in our ADHD subgroup had significantly more psychiatric comorbidities such as emotional disorders and ODD [33, 34], and more alcohol use  as compared to those who do not have ADHD. The loss of other significant associations (e.g., with CD, chronic medical conditions, and cigarette smoking) might be due to the small numbers as evidenced by the large confidence intervals of the odds ratios.
Although all psychiatric illnesses require in their diagnostic criteria impairment in functioning, our study showed a significantly higher burden of disease for ADHD on the adolescent and his/her surroundings as measured by the total impact score on the SDQ, compared to other psychiatric illnesses. However, there seems to be a discrepancy between the parents’ and the adolescents’ perceptions of burden of ADHD: parents found it to be significantly burdensome as evidenced by an average total impact score above 2, whereas affected adolescents had an average score of 0.67, reflecting a perception of a lack of impairment . Our results are in line with previous reports highlighting the clinical importance of parent-reported impact of illness: it was found to be predictive of new-onset seeking of mental health services and new-onset of self-harm, whereas self-reported impact was not . In our study, the higher burden of disease in ADHD was indeed associated with a better awareness to consider seeking help from a mental health professional; however, only a negligible proportion of those actually sought it. A similar reluctance to seek psychiatric treatment has been reported in Lebanese adults (only 10.9% of diagnosed adults obtained treatment) and has been explained by the preponderance of barriers to treatment in Lebanese society, including financial constraints and a lack of mental health awareness . The international literature has consistently reported that ADHD is undertreated [39, 40] and a recent meta-analysis identified the following main barriers to seeking treatment for ADHD: child characteristics (sex, age, ethnicity, comorbidities), family’s socioeconomic status, structural barriers (financial costs, healthcare system), parents’ perception of ADHD and of its treatment and fear of stigma . Further research exploring Lebanese-specific barriers to seeking mental health services in general and ADHD treatment in particular is timely.
Limitations and offsetting strengths
The findings of this study must be interpreted with some limitations in mind. Our findings may not be generalizable to the entire population of Lebanon since our sampling was strictly limited to Beirut, given the lack of an updated official population census (last one conducted in 1932). Our sample, however, reliably reflected the diversity of the socioeconomic strata of the Lebanese society as a whole . In addition, we administered the SDQ to the adolescent and one parent/legal guardian but not to a teacher, which might have underestimated the impact of the illnesses surveyed.
Despite these limitations, this study is the first to investigate ADHD in adolescents in Lebanon and the first in the Arab region to uncover the significant medical, academic and functional burden as well as important correlates. Our findings highlight the need for relevant governmental authorities and mental health advocates to further develop public awareness about the symptoms of ADHD and the functional impact of the illness and the availability of resources for treatment. These efforts should specifically focus on schools as teachers and counselors can be educated to detect possible symptoms and discuss with the parents referrals for an assessment. Finally, mental health specialists should be sensitized to extensively discuss treatment options and their benefits and risks not just with the parents, but also with the affected adolescent.