- Email: [email protected]
hyperactivity disorder in children
International Journal of Pediatric Otorhinolaryngology 77 (2013) 1291–1294
Contents lists available at SciVerse ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
Association between the self-insertion of nasal and aural foreign bodies and attention-deficit/hyperactivity disorder in children Fatih Celenk a,*, Cem Gokcen b, Nazli Celenk c, Elif Baysal a, Cengiz Durucu a, Muzaffer Kanlikama a a
Department of Otorhinolaryngology, Gaziantep University Faculty of Medicine, Turkey Department of Child and Adolescent Psychiatry, Gaziantep University Faculty of Medicine, Turkey c Department of Child and Adolescent Psychiatry, Mersin University Faculty of Medicine, Turkey b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 13 March 2013 Received in revised form 10 May 2013 Accepted 11 May 2013 Available online 14 June 2013
Objective: To investigate whether the prevalence of attention-deficit/hyperactivity disorder (ADHD) is higher in children presenting with nasal and aural foreign bodies than in the control group. Methods: The present study was conducted between April 2012 and December 2012 and included 60 pediatric patients presenting with self-inserted nasal and aural foreign bodies and 50 healthy controls aged between 3 and 9 years. The Conner Parent Rating Scale (CPRS) and Turgay’s DSM-IV based ADHD and disruptive behavior disorders screening scale (T-DSM-IV-Scale) were used to investigate ADHD. Results: The difference between the patient group and the control group was significant with respect to the abnormal scores obtained from all the subscales (p < 0.05). In children between 5 and 9 years of age, the abnormal scores were significantly higher in the patients than the controls for all the subscales (p < 0.05). However, in children between 3 and 4 years of age, there were no significant differences between the patients and the controls for the scores obtained from all the subscales (p > 0.05). No statistically significant difference was found between the patients with a previous history of selfinserted foreign bodies and those without any history of foreign body insertion (p > 0.05). Conclusions: The findings of our study demonstrated a possible association between the self-insertion of nasal and aural foreign bodies and ADHD. Clinicians should be aware of the possible presence of ADHD in children, especially in those patients between 5 and 9 years of age who present with self-inserted nasal and aural foreign bodies. ß 2013 Elsevier Ireland Ltd. All rights reserved.
Keywords: Attention-deficit/hyperactivity disorder Foreign body Nasal Aural
1. Introduction Attention-deficit/hyperactivity disorder (ADHD) is one of the most common childhood psychiatric disorders [1]. In a recent meta-analysis, the estimated prevalence of ADHD in childhood and adolescence was reported to be between 5.9% and 7.1% [2]. The characteristic features of ADHD are inattentiveness, hyperactivity and impulsivity [3,4]. Children with ADHD are at higher risk for unintentional injuries than unaffected children [5–7]. The causes of increased risk for injuries among children with ADHD have not been clarified. Impulsiveness, hyperactivity, inattentiveness and aggressive or risk-taking behaviors in children with ADHD may make them more prone to unintentional injuries [6,8]. These behaviors may result in the inability of children with ADHD to comprehend the consequences of certain activities [9].
* Corresponding author at: Department of Otorhinolaryngology, Gaziantep University Faculty of Medicine, Gaziantep, Turkey. Tel.: +90 505 3912781. E-mail address: [email protected] (F. Celenk). 0165-5876/$ – see front matter ß 2013 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijporl.2013.05.012
Nasal and aural foreign bodies are commonly encountered in the pediatric population. Foreign body insertion comprises approximately 11% of all otorhinolaryngological emergency cases [10,11]. Although foreign-body insertion appears to be a simple problem, it can have several important consequences. Nasal foreign bodies may cause epistaxis, infection, tissue necrosis, septal perforation, bronchopulmonary aspiration and even death if the objects pass through the lower airways [12]. Insertion of the aural foreign body or manipulating it in the external ear canal may result in tympanic membrane perforation, canal laceration, otitis externa, hematoma and hearing loss due to ossicular chain damage [13]. Complications related to foreign bodies may occur in 22% of these patients [10]. The self-insertion of a foreign body into the nose or external ear canal may be considered an unintentional injury [9]. Although otorhinolaryngeal foreign bodies are quite common and have the potential to cause significant morbidity and even mortality, the association between ADHD and foreign-body insertion has not been extensively studied. Only one published investigation has examined the prevalence of ADHD among children with
1292
F. Celenk et al. / International Journal of Pediatric Otorhinolaryngology 77 (2013) 1291–1294
self-inserted foreign bodies. To the best of our knowledge, no controlled study exists that addresses this issue. Therefore, the aim of the present study was to investigate whether the prevalence of ADHD is higher in children presenting with nasal or aural foreign bodies than in the corresponding control group. 2. Materials and methods This prospective study was conducted between April 2012 and December 2012 and included children between 3 and 9 years of age who presented to the emergency department or the ear, nose and throat (ENT) outpatient clinic with self-inserted nasal and aural foreign bodies. The initial evaluation and management of the patients were performed by an ENT surgeon. A detailed medical history was obtained, and a thorough head and neck examination was performed on all of the patients. Each patient’s age and gender, type of object and site of the foreign-body insertion were noted. In addition to a careful otoscopic examination for aural foreign bodies, an anterior rhinoscopic examination was performed, employing a nasal speculum and headlight to search for nasal foreign bodies. Foreign bodies in the ear were removed using an angled ear curette and/or a Hartmann micro-ear forceps under an otoscopic or microscopic view. Angled curettes, bayonet forceps or a punch forceps were used to remove anteriorly located nasal foreign bodies, as facilitated by anterior rhinoscopy. A 2.7-mm rigid endoscope or flexible fiberoptic endoscope was used for posteriorly located nasal foreign bodies. Removal of the foreign body was performed under general anesthesia in uncooperative children. After the appropriate intervention for the removal of the foreign body, the parents were informed about the study. If the parents agreed to participate in the study, they filled out a form that included questions regarding the patient’s age and gender, previous accidental injuries, previous foreign-body insertion, type of object and site of the foreign-body insertion. Children with motor and mental retardation or pervasive developmental disorders, foreign-body cases in which the object was inserted by another person, were excluded from the study. The control group was composed of healthy children who were matched to the patient group with respect to age and gender. The patients and controls were divided into 2 groups according to their age. Group 1 consisted of patients and controls who were between 3 and 4 years of age, and group 2 consisted of patients and controls who were between 5 and 9 years of age. The Conner Parent Rating Scale (CPRS) and Turgay’s DSM-IVbased ADHD and disruptive behavior disorders screening scale (TADHD) were used to assess the behavioral characteristics of ADHD and to determine the severity of the symptoms. CPRS is one of the popular rating scales for ADHD evaluations [14], and the Turkish adapted and validated form of this scale is available [15]. The inattention and hyperactivity subscales of the Turkish form of the CPRS were utilized in this study. The parents responded to each item on a 4-point Likert scale (0 = never, 1 = rarely, 2 = often, and 3 = always). A score of at least 5 points on the inattention subscale (CPRS-IA) and 6 points on the hyperactivity-impulsivity subscale (CPRS-HA) were considered to be abnormal for inattentiveness and hyperactivity, respectively. The T-ADHD scale consists of DSM-IV criteria for destructive behavioral disorders, and this scale was validated and adapted for the Turkish language [16,17]. This scale was used for screening of ADHD (inattentiveness and hyperactivity), oppositional defiant disorder and conduct disorder; each symptom was rated on a 4-point Likert scale (0 = never, 1 = occasionally, 2 = often, and 3 = very often). Two ADHD subscales were utilized in this study. A score of 2 or 3 on at least six of the hyperactivity (T-ADHD-HA) and inattention items (T-ADHDIA) was used as the criterion for hyperactivity-impulsivity and
inattentiveness. The scales were completed by the parents and evaluated by a child psychiatrist. The study protocol was reviewed and approved by the institutional ethics committee. Informed consent was obtained from all the parents. Student’s t-test, Chi-square test and Fisher’s Exact Test were used to analyze variables. Continuous variables were compared with Student’s t-test and categorical variables were compared with Chi-square test and Fisher’s Exact Test. The difference between the two groups was considered to be statistically significant when p < 0.05. 3. Results Sixty children who presented with self-insertion of nasal or aural foreign bodies met the inclusion criteria, including 30 (50%) male and 30 (50%) female patients. The age of the patients ranged between 3 and 9 years, with a mean of 4.43 1.5 years. The control group consisted of 50 healthy children, namely, 23 (46%) male and 27 (54%) female participants. The age of the control subjects ranged between 3 years and 8 years, with a mean age of 4.76 1.4 years. No statistically significant differences in age or gender existed between the patients and the controls (p = 0.676). Group 1 consisted of 38 patients and 22 controls between 3 and 4 years of age, and group 2 consisted of 22 patients and 28 controls between 5 and 9 years of age. There were 35 (58.3%) aural and 25 (41.7%) nasal foreign bodies. The most common foreign bodies were beads (n = 34, 56.7%), followed by seeds (n = 5, 8.3%), nutshells (n = 3, 5%), metal fragments (n = 3, 5%), pen-nibs (n = 3, 5%), batteries (n = 2, 3.3%), eraser fragments (n = 2, 3.3%), small stones (n = 2, 3.3%), paper (n = 2, 3.3%), food items (n = 2, 3.3%), pills (n = 1, 1.6%) and buttons (n = 1, 1.6%). General anesthesia was required to removal the foreign body in 8 (13.3%) patients. Twenty patients with a self-inserted foreign body (33.3%) and 4 controls (8%) had abnormal scores on the CPRS-IA. Twenty-two patients (36.7%) and 6 controls (12%) had abnormal scores on the CPRS-HA. Seven patients (11.7%) and 1 control (2%) had abnormal scores on the T-ADHD-IA. Twenty patients (33.3%) and 7 controls (14%) had abnormal scores on the T-ADHD-HA. The difference between the patient group and the control group was significant with respect to abnormal scores on all 4 subscales (p < 0.05). The abnormal scores of the patients and controls on all 4 subscales are summarized in Table 1. In group 1, no significant differences were determined between the patients and the controls for the scores obtained from all 4 subscales (p > 0.05). However, within group 2, the abnormal scores were significantly higher in the patients compared with the controls for all the subscales (p < 0.05). The distribution of abnormal scores for the patients and controls within each age group for the 4 subscales, as well as the corresponding p values, are presented in Table 2. Within the patient group, there was no statistically significant gender-related difference in the scores on all the subscales (p > 0.05). Thirteen (21.7%) patients had histories of a self-inserted foreign body. Three children had experienced multiple past episodes of self-insertion of a foreign body, and all of these subjects had abnormal scores on at least 3 of 4 subscales. Seven (11.7%) patients had a history of previous injuries, such as burns, head trauma or extremity fractures. No statistically significant difference was found between the patients with a previous history Table 1 Comparison of the abnormal scores of the patients and controls. Measure
Patients (n = 60)
Controls (n = 50)
p
CPRS-IA CPRS-HA T-ADHD-IA T-ADHD-HA
20 22 8 20
4 6 1 7
0.001 0.003 0.031 0.019
(33.3%) (36.7%) (13.3%) (33.3%)
(8%) (12%) (2%) (14%)
F. Celenk et al. / International Journal of Pediatric Otorhinolaryngology 77 (2013) 1291–1294
1293
Table 2 Distribution of abnormal scores based on age. Measure
CPRS-IA CPRS-HA T-ADHD-IA T-ADHD-HA
Group 1 (3–4 years, n = 60)
Group 2 (5–9 years, n = 50)
Patients (n = 38)
Controls (n = 22)
p
Patients (n = 22)
Controls (n = 28)
p
8 12 2 10
2 3 1 4
0.299 0.122 1.000 0.473
12 10 6 10
2 3 0 3
0.000 0.005 0.005 0.005
(21.1%) (31.6%) (5.2%) (26.3%)
(9.1%) (13.6%) (4.5%) (18.1%)
of self-inserted foreign bodies and those without any history of foreign-body insertion (p > 0.05). 4. Discussion In the present study, we found that children with self-inserted foreign bodies had significantly higher rates of abnormal scores on all of the subscales compared with the control participants. The rate of abnormal inattention scores was 4-times higher with the CPRS-IA and 6-times higher with the T-ADHD-IA in the patients compared with the controls. The rate of abnormal hyperactivity scores was approximately three-times higher in the patients than in the controls. To the best of our knowledge, only one published study exists that evaluates the relationship between ADHD and self-inserted foreign bodies [9]. Those authors used two scales for the assessment of ADHD in 34 children presenting with selfinserted foreign bodies, compared their findings with the prevalence rate that was previously reported (5.1%) and found that their measured hyperactivity rates were higher. Our findings were consistent with that report by Perera et al. [9]. Impulsiveness, hyperactivity, inattentiveness, aggressiveness and risk-taking behavior exhibited by children with ADHD are suggested to be associated with increased risk of injuries [6,8]. These behaviors may cause lack of awareness of danger and an inability to comprehend the consequences of an activity [9]. Based on this point of view, foreign-body insertion may be categorized as an injury because the affected children insert foreign objects into their body cavities without considering the possible magnitude of the consequences. Nasal and aural foreign-body injuries are potentially serious and are frequently encountered childhood emergencies [10]. Particularly, nasal foreign-body insertion may become a life-threatening condition due to the risk of airway blockage. Therefore, the possible etiological and predisposing factors for foreign-body insertion should be elucidated to prevent injuries and recurrent self-insertion of the foreign bodies. The mean age of the patients was approximately 4 years, and patients between 3 and 4 years of age were predominant in our study. Several publications have addressed the sociodemographic risk factors related to otorhinolaryngological foreign bodies. Rybojad et al. [18] investigated the sociodemographic risk factors involved in 1011 otolaryngological foreign-body cases and reported that male patients between 1 and 3 years of age constitute the largest population. In a series of 353 foreign-body cases, children between 4 and 8 years of age comprised the largest group [19]. We found a significant difference between the patients and the controls with respect to abnormal scores in children between 5 and 9 years of age. The CPRS-IA scores were abnormal in approximately one-half of the patients, and the abnormal scores were 7-times higher in the patients compared with the controls in this age group. The abnormal scores on the other subscales were also higher within the patient group within this age range. We found no statistically significant association with respect to the inattention and hyperactivity subscale scores in children between 3 and 4 years of age. In accordance with our findings, Perera et al. [9] determined abnormal hyperactivity scores in 17.6% of the patients
(54.5%) (45.4%) (27.3%) (45.4%)
(7.1%) (10.7%) (0%) (10.7%)
over 5 years of age and in 2.9% of the patients between 3 and 4 years of age. These age-related findings in both studies can be explained by the difficulty in diagnosing ADHD in younger children. The diagnosis of ADHD in younger children is challenging because individuals in this age group usually exhibit behavioral characteristics of ADHD, including high activity levels, impulsivity, and short attention spans [20]. Perera et al. [9] found that 20% of the children reported previous episodes of self-insertion and that 17.1% of the children had previously suffered from other unintentional injuries requiring hospitalization. Although we also found that the rates of patients with previous self-insertion (21.7%) and accidentalinjury histories (11.7%) were higher than the estimated prevalence of ADHD (5.1%), there was no significant difference compared to those subjects without past episodes of selfinsertion or accidental injuries. However, all of the patients with multiple past episodes of foreign-body insertion had abnormal scores on at least 3 of 4 subscales, suggesting that children with multiple past episodes of foreign body insertions are more likely to be diagnosed with ADHD. Additional large controlled studies are necessary to address these issues. 5. Conclusions The findings of our study demonstrated the possible association between the self-insertion of nasal or aural foreign bodies and ADHD. Clinicians should be aware of the possible presence of ADHD in children, especially in those patients between 5 and 9 years of age who present with self-inserted nasal or aural foreign bodies. Screening, diagnosis and treatment of ADHD in children with self-inserted foreign bodies may prevent not only subsequent foreign-body insertions but also unintentional injuries. References [1] G. Polanczyk, L.A. Rohde, Epidemiology of attention-deficit/hyperactivity disorder across the lifespan, Curr. Opin. Psychiatry 20 (2007) 386–392. [2] E.G. Willcutt, The prevalence of DSM-IV attention-deficit/hyperactivity disorder: a meta-analytic review, Neurotherapeutics 9 (2012) 490–499. [3] M.D. Rappley, Clinical practice. Attention deficit-hyperactivity disorder, N. Engl. J. Med. 352 (2005) 165–173. [4] G. Polanczyk, M.S. de Lima, B.L. Horta, J. Biederman, L.A. Rohde, The worldwide prevalence of ADHD: a systematic review and metaregression analysis, Am. J. Psychiatry 164 (2007) 942–948. [5] K.M. Fritz, C. Butz, Attention deficit/hyperactivity disorder and pediatric burn injury: important considerations regarding premorbid risk, Curr. Opin. Pediatr. 19 (2007) 565–569. [6] Y. Shilon, Y. Pollak, A. Aran, S. Shaked, V. Gross-Tsur, Accidental injuries are more common in children with attention deficit hyperactivity disorder compared with their non-affected siblings, Child Care Health Dev. 38 (2012) 366–370. [7] C. DiScala, I. Lescohier, M. Barthel, G. Li, Injuries to children with attention deficit hyperactivity disorder, Pediatrics 102 (1998) 1415–1421. [8] P.N. Pastor, C.A. Reuben, Identified attention-deficit/hyperactivity disorder and medically attended, nonfatal injuries: US school-age children, 1997–2002, Ambul. Pediatr. 6 (2006) 38–44. [9] H. Perera, S.M. Fernando, A.D. Yasawardena, I. Karunaratne, Prevalence of attention deficit hyperactivity disorder (ADHD) in children presenting with selfinserted nasal and aural foreign bodies, Int. J. Pediatr. Otorhinolaryngol. 73 (2009) 1362–1364. [10] R.R. Figueiredo, A.A. Azevedo, A.O. Ko´s, S. Tomita, Complications of ENT foreign bodies: a retrospective study, Braz. J. Otorhinolaryngol. 74 (2008) 7–15.
1294
F. Celenk et al. / International Journal of Pediatric Otorhinolaryngology 77 (2013) 1291–1294
[11] A. Mukherjee, D. Haldar, S. Dutta, M. Dutta, J. Saha, R. Sinha, Ear, nose and throat foreign bodies in children: a search for socio-demographic correlates, Int. J. Pediatr. Otorhinolaryngol. 75 (2011) 510–512. [12] P.M. Patil, R. Anand, Nasal foreign bodies: a review of management strategies and a clinical scenario presentation, Craniomaxillofac. Trauma Reconstr. 4 (2011) 53–58. [13] G.B. Singh, T.S. Sidhu, A. Sharma, R. Dhawan, S.K. Jha, N. Singh, Management of aural foreign body: an evaluative study in 738 consecutive cases, Am. J. Otolaryngol. 28 (2007) 87–90. [14] C.K. Conners, Conners’ Rating Scales-Revised, Multi-Health Systems Publishing, North Tonawada, NY, 1997. [15] C. Dereboy, S. Senol, S. Sener, F. Dereboy, Adaptation of Conners’ parent rating scale in Turkish, in: Proceedings 10th National Congress of Psychology, Ankara, 1998.
[16] E.S. Ercan, S. Amado, O. Somer, S. Cıkoglu, Dikkat Eksikligi hiperaktivite Bozuklugu ve Yikici Davranis Bozukluklari icin bir test bataryasi gelistirme calismasi, J. Child Adolesc. Mental Health 8 (2001) 132–144. [17] A. Turgay, Turgay’s DSM-IV based ADHD and Disruptive Behaviour Disorders Screening Scale, Integrative Therapy Institute Publication, Toronto-Ontario, Canada, 1997. [18] B. Rybojad, A. Niedzielski, G. Niedzielska, P. Rybojad, Risk factors for otolaryngological foreign bodies in Eastern Poland, Otolaryngol. Head Neck Surg. 147 (2012) 889–893. [19] A. Ngo, K.C. Ng, T.P. Sim, Otorhinolaryngeal foreign bodies in children presenting to the emergency department, Singapore Med. J. 46 (2005) 172–178. [20] J.A. Blackman, Attention-deficit/hyperactivity disorder in preschoolers. Does it exist and should we treat it? Pediatr. Clin. North Am. 46 (1999) 1011–1025.
Contents lists available at SciVerse ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
Association between the self-insertion of nasal and aural foreign bodies and attention-deficit/hyperactivity disorder in children Fatih Celenk a,*, Cem Gokcen b, Nazli Celenk c, Elif Baysal a, Cengiz Durucu a, Muzaffer Kanlikama a a
Department of Otorhinolaryngology, Gaziantep University Faculty of Medicine, Turkey Department of Child and Adolescent Psychiatry, Gaziantep University Faculty of Medicine, Turkey c Department of Child and Adolescent Psychiatry, Mersin University Faculty of Medicine, Turkey b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 13 March 2013 Received in revised form 10 May 2013 Accepted 11 May 2013 Available online 14 June 2013
Objective: To investigate whether the prevalence of attention-deficit/hyperactivity disorder (ADHD) is higher in children presenting with nasal and aural foreign bodies than in the control group. Methods: The present study was conducted between April 2012 and December 2012 and included 60 pediatric patients presenting with self-inserted nasal and aural foreign bodies and 50 healthy controls aged between 3 and 9 years. The Conner Parent Rating Scale (CPRS) and Turgay’s DSM-IV based ADHD and disruptive behavior disorders screening scale (T-DSM-IV-Scale) were used to investigate ADHD. Results: The difference between the patient group and the control group was significant with respect to the abnormal scores obtained from all the subscales (p < 0.05). In children between 5 and 9 years of age, the abnormal scores were significantly higher in the patients than the controls for all the subscales (p < 0.05). However, in children between 3 and 4 years of age, there were no significant differences between the patients and the controls for the scores obtained from all the subscales (p > 0.05). No statistically significant difference was found between the patients with a previous history of selfinserted foreign bodies and those without any history of foreign body insertion (p > 0.05). Conclusions: The findings of our study demonstrated a possible association between the self-insertion of nasal and aural foreign bodies and ADHD. Clinicians should be aware of the possible presence of ADHD in children, especially in those patients between 5 and 9 years of age who present with self-inserted nasal and aural foreign bodies. ß 2013 Elsevier Ireland Ltd. All rights reserved.
Keywords: Attention-deficit/hyperactivity disorder Foreign body Nasal Aural
1. Introduction Attention-deficit/hyperactivity disorder (ADHD) is one of the most common childhood psychiatric disorders [1]. In a recent meta-analysis, the estimated prevalence of ADHD in childhood and adolescence was reported to be between 5.9% and 7.1% [2]. The characteristic features of ADHD are inattentiveness, hyperactivity and impulsivity [3,4]. Children with ADHD are at higher risk for unintentional injuries than unaffected children [5–7]. The causes of increased risk for injuries among children with ADHD have not been clarified. Impulsiveness, hyperactivity, inattentiveness and aggressive or risk-taking behaviors in children with ADHD may make them more prone to unintentional injuries [6,8]. These behaviors may result in the inability of children with ADHD to comprehend the consequences of certain activities [9].
* Corresponding author at: Department of Otorhinolaryngology, Gaziantep University Faculty of Medicine, Gaziantep, Turkey. Tel.: +90 505 3912781. E-mail address: [email protected] (F. Celenk). 0165-5876/$ – see front matter ß 2013 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijporl.2013.05.012
Nasal and aural foreign bodies are commonly encountered in the pediatric population. Foreign body insertion comprises approximately 11% of all otorhinolaryngological emergency cases [10,11]. Although foreign-body insertion appears to be a simple problem, it can have several important consequences. Nasal foreign bodies may cause epistaxis, infection, tissue necrosis, septal perforation, bronchopulmonary aspiration and even death if the objects pass through the lower airways [12]. Insertion of the aural foreign body or manipulating it in the external ear canal may result in tympanic membrane perforation, canal laceration, otitis externa, hematoma and hearing loss due to ossicular chain damage [13]. Complications related to foreign bodies may occur in 22% of these patients [10]. The self-insertion of a foreign body into the nose or external ear canal may be considered an unintentional injury [9]. Although otorhinolaryngeal foreign bodies are quite common and have the potential to cause significant morbidity and even mortality, the association between ADHD and foreign-body insertion has not been extensively studied. Only one published investigation has examined the prevalence of ADHD among children with
1292
F. Celenk et al. / International Journal of Pediatric Otorhinolaryngology 77 (2013) 1291–1294
self-inserted foreign bodies. To the best of our knowledge, no controlled study exists that addresses this issue. Therefore, the aim of the present study was to investigate whether the prevalence of ADHD is higher in children presenting with nasal or aural foreign bodies than in the corresponding control group. 2. Materials and methods This prospective study was conducted between April 2012 and December 2012 and included children between 3 and 9 years of age who presented to the emergency department or the ear, nose and throat (ENT) outpatient clinic with self-inserted nasal and aural foreign bodies. The initial evaluation and management of the patients were performed by an ENT surgeon. A detailed medical history was obtained, and a thorough head and neck examination was performed on all of the patients. Each patient’s age and gender, type of object and site of the foreign-body insertion were noted. In addition to a careful otoscopic examination for aural foreign bodies, an anterior rhinoscopic examination was performed, employing a nasal speculum and headlight to search for nasal foreign bodies. Foreign bodies in the ear were removed using an angled ear curette and/or a Hartmann micro-ear forceps under an otoscopic or microscopic view. Angled curettes, bayonet forceps or a punch forceps were used to remove anteriorly located nasal foreign bodies, as facilitated by anterior rhinoscopy. A 2.7-mm rigid endoscope or flexible fiberoptic endoscope was used for posteriorly located nasal foreign bodies. Removal of the foreign body was performed under general anesthesia in uncooperative children. After the appropriate intervention for the removal of the foreign body, the parents were informed about the study. If the parents agreed to participate in the study, they filled out a form that included questions regarding the patient’s age and gender, previous accidental injuries, previous foreign-body insertion, type of object and site of the foreign-body insertion. Children with motor and mental retardation or pervasive developmental disorders, foreign-body cases in which the object was inserted by another person, were excluded from the study. The control group was composed of healthy children who were matched to the patient group with respect to age and gender. The patients and controls were divided into 2 groups according to their age. Group 1 consisted of patients and controls who were between 3 and 4 years of age, and group 2 consisted of patients and controls who were between 5 and 9 years of age. The Conner Parent Rating Scale (CPRS) and Turgay’s DSM-IVbased ADHD and disruptive behavior disorders screening scale (TADHD) were used to assess the behavioral characteristics of ADHD and to determine the severity of the symptoms. CPRS is one of the popular rating scales for ADHD evaluations [14], and the Turkish adapted and validated form of this scale is available [15]. The inattention and hyperactivity subscales of the Turkish form of the CPRS were utilized in this study. The parents responded to each item on a 4-point Likert scale (0 = never, 1 = rarely, 2 = often, and 3 = always). A score of at least 5 points on the inattention subscale (CPRS-IA) and 6 points on the hyperactivity-impulsivity subscale (CPRS-HA) were considered to be abnormal for inattentiveness and hyperactivity, respectively. The T-ADHD scale consists of DSM-IV criteria for destructive behavioral disorders, and this scale was validated and adapted for the Turkish language [16,17]. This scale was used for screening of ADHD (inattentiveness and hyperactivity), oppositional defiant disorder and conduct disorder; each symptom was rated on a 4-point Likert scale (0 = never, 1 = occasionally, 2 = often, and 3 = very often). Two ADHD subscales were utilized in this study. A score of 2 or 3 on at least six of the hyperactivity (T-ADHD-HA) and inattention items (T-ADHDIA) was used as the criterion for hyperactivity-impulsivity and
inattentiveness. The scales were completed by the parents and evaluated by a child psychiatrist. The study protocol was reviewed and approved by the institutional ethics committee. Informed consent was obtained from all the parents. Student’s t-test, Chi-square test and Fisher’s Exact Test were used to analyze variables. Continuous variables were compared with Student’s t-test and categorical variables were compared with Chi-square test and Fisher’s Exact Test. The difference between the two groups was considered to be statistically significant when p < 0.05. 3. Results Sixty children who presented with self-insertion of nasal or aural foreign bodies met the inclusion criteria, including 30 (50%) male and 30 (50%) female patients. The age of the patients ranged between 3 and 9 years, with a mean of 4.43 1.5 years. The control group consisted of 50 healthy children, namely, 23 (46%) male and 27 (54%) female participants. The age of the control subjects ranged between 3 years and 8 years, with a mean age of 4.76 1.4 years. No statistically significant differences in age or gender existed between the patients and the controls (p = 0.676). Group 1 consisted of 38 patients and 22 controls between 3 and 4 years of age, and group 2 consisted of 22 patients and 28 controls between 5 and 9 years of age. There were 35 (58.3%) aural and 25 (41.7%) nasal foreign bodies. The most common foreign bodies were beads (n = 34, 56.7%), followed by seeds (n = 5, 8.3%), nutshells (n = 3, 5%), metal fragments (n = 3, 5%), pen-nibs (n = 3, 5%), batteries (n = 2, 3.3%), eraser fragments (n = 2, 3.3%), small stones (n = 2, 3.3%), paper (n = 2, 3.3%), food items (n = 2, 3.3%), pills (n = 1, 1.6%) and buttons (n = 1, 1.6%). General anesthesia was required to removal the foreign body in 8 (13.3%) patients. Twenty patients with a self-inserted foreign body (33.3%) and 4 controls (8%) had abnormal scores on the CPRS-IA. Twenty-two patients (36.7%) and 6 controls (12%) had abnormal scores on the CPRS-HA. Seven patients (11.7%) and 1 control (2%) had abnormal scores on the T-ADHD-IA. Twenty patients (33.3%) and 7 controls (14%) had abnormal scores on the T-ADHD-HA. The difference between the patient group and the control group was significant with respect to abnormal scores on all 4 subscales (p < 0.05). The abnormal scores of the patients and controls on all 4 subscales are summarized in Table 1. In group 1, no significant differences were determined between the patients and the controls for the scores obtained from all 4 subscales (p > 0.05). However, within group 2, the abnormal scores were significantly higher in the patients compared with the controls for all the subscales (p < 0.05). The distribution of abnormal scores for the patients and controls within each age group for the 4 subscales, as well as the corresponding p values, are presented in Table 2. Within the patient group, there was no statistically significant gender-related difference in the scores on all the subscales (p > 0.05). Thirteen (21.7%) patients had histories of a self-inserted foreign body. Three children had experienced multiple past episodes of self-insertion of a foreign body, and all of these subjects had abnormal scores on at least 3 of 4 subscales. Seven (11.7%) patients had a history of previous injuries, such as burns, head trauma or extremity fractures. No statistically significant difference was found between the patients with a previous history Table 1 Comparison of the abnormal scores of the patients and controls. Measure
Patients (n = 60)
Controls (n = 50)
p
CPRS-IA CPRS-HA T-ADHD-IA T-ADHD-HA
20 22 8 20
4 6 1 7
0.001 0.003 0.031 0.019
(33.3%) (36.7%) (13.3%) (33.3%)
(8%) (12%) (2%) (14%)
F. Celenk et al. / International Journal of Pediatric Otorhinolaryngology 77 (2013) 1291–1294
1293
Table 2 Distribution of abnormal scores based on age. Measure
CPRS-IA CPRS-HA T-ADHD-IA T-ADHD-HA
Group 1 (3–4 years, n = 60)
Group 2 (5–9 years, n = 50)
Patients (n = 38)
Controls (n = 22)
p
Patients (n = 22)
Controls (n = 28)
p
8 12 2 10
2 3 1 4
0.299 0.122 1.000 0.473
12 10 6 10
2 3 0 3
0.000 0.005 0.005 0.005
(21.1%) (31.6%) (5.2%) (26.3%)
(9.1%) (13.6%) (4.5%) (18.1%)
of self-inserted foreign bodies and those without any history of foreign-body insertion (p > 0.05). 4. Discussion In the present study, we found that children with self-inserted foreign bodies had significantly higher rates of abnormal scores on all of the subscales compared with the control participants. The rate of abnormal inattention scores was 4-times higher with the CPRS-IA and 6-times higher with the T-ADHD-IA in the patients compared with the controls. The rate of abnormal hyperactivity scores was approximately three-times higher in the patients than in the controls. To the best of our knowledge, only one published study exists that evaluates the relationship between ADHD and self-inserted foreign bodies [9]. Those authors used two scales for the assessment of ADHD in 34 children presenting with selfinserted foreign bodies, compared their findings with the prevalence rate that was previously reported (5.1%) and found that their measured hyperactivity rates were higher. Our findings were consistent with that report by Perera et al. [9]. Impulsiveness, hyperactivity, inattentiveness, aggressiveness and risk-taking behavior exhibited by children with ADHD are suggested to be associated with increased risk of injuries [6,8]. These behaviors may cause lack of awareness of danger and an inability to comprehend the consequences of an activity [9]. Based on this point of view, foreign-body insertion may be categorized as an injury because the affected children insert foreign objects into their body cavities without considering the possible magnitude of the consequences. Nasal and aural foreign-body injuries are potentially serious and are frequently encountered childhood emergencies [10]. Particularly, nasal foreign-body insertion may become a life-threatening condition due to the risk of airway blockage. Therefore, the possible etiological and predisposing factors for foreign-body insertion should be elucidated to prevent injuries and recurrent self-insertion of the foreign bodies. The mean age of the patients was approximately 4 years, and patients between 3 and 4 years of age were predominant in our study. Several publications have addressed the sociodemographic risk factors related to otorhinolaryngological foreign bodies. Rybojad et al. [18] investigated the sociodemographic risk factors involved in 1011 otolaryngological foreign-body cases and reported that male patients between 1 and 3 years of age constitute the largest population. In a series of 353 foreign-body cases, children between 4 and 8 years of age comprised the largest group [19]. We found a significant difference between the patients and the controls with respect to abnormal scores in children between 5 and 9 years of age. The CPRS-IA scores were abnormal in approximately one-half of the patients, and the abnormal scores were 7-times higher in the patients compared with the controls in this age group. The abnormal scores on the other subscales were also higher within the patient group within this age range. We found no statistically significant association with respect to the inattention and hyperactivity subscale scores in children between 3 and 4 years of age. In accordance with our findings, Perera et al. [9] determined abnormal hyperactivity scores in 17.6% of the patients
(54.5%) (45.4%) (27.3%) (45.4%)
(7.1%) (10.7%) (0%) (10.7%)
over 5 years of age and in 2.9% of the patients between 3 and 4 years of age. These age-related findings in both studies can be explained by the difficulty in diagnosing ADHD in younger children. The diagnosis of ADHD in younger children is challenging because individuals in this age group usually exhibit behavioral characteristics of ADHD, including high activity levels, impulsivity, and short attention spans [20]. Perera et al. [9] found that 20% of the children reported previous episodes of self-insertion and that 17.1% of the children had previously suffered from other unintentional injuries requiring hospitalization. Although we also found that the rates of patients with previous self-insertion (21.7%) and accidentalinjury histories (11.7%) were higher than the estimated prevalence of ADHD (5.1%), there was no significant difference compared to those subjects without past episodes of selfinsertion or accidental injuries. However, all of the patients with multiple past episodes of foreign-body insertion had abnormal scores on at least 3 of 4 subscales, suggesting that children with multiple past episodes of foreign body insertions are more likely to be diagnosed with ADHD. Additional large controlled studies are necessary to address these issues. 5. Conclusions The findings of our study demonstrated the possible association between the self-insertion of nasal or aural foreign bodies and ADHD. Clinicians should be aware of the possible presence of ADHD in children, especially in those patients between 5 and 9 years of age who present with self-inserted nasal or aural foreign bodies. Screening, diagnosis and treatment of ADHD in children with self-inserted foreign bodies may prevent not only subsequent foreign-body insertions but also unintentional injuries. References [1] G. Polanczyk, L.A. Rohde, Epidemiology of attention-deficit/hyperactivity disorder across the lifespan, Curr. Opin. Psychiatry 20 (2007) 386–392. [2] E.G. Willcutt, The prevalence of DSM-IV attention-deficit/hyperactivity disorder: a meta-analytic review, Neurotherapeutics 9 (2012) 490–499. [3] M.D. Rappley, Clinical practice. Attention deficit-hyperactivity disorder, N. Engl. J. Med. 352 (2005) 165–173. [4] G. Polanczyk, M.S. de Lima, B.L. Horta, J. Biederman, L.A. Rohde, The worldwide prevalence of ADHD: a systematic review and metaregression analysis, Am. J. Psychiatry 164 (2007) 942–948. [5] K.M. Fritz, C. Butz, Attention deficit/hyperactivity disorder and pediatric burn injury: important considerations regarding premorbid risk, Curr. Opin. Pediatr. 19 (2007) 565–569. [6] Y. Shilon, Y. Pollak, A. Aran, S. Shaked, V. Gross-Tsur, Accidental injuries are more common in children with attention deficit hyperactivity disorder compared with their non-affected siblings, Child Care Health Dev. 38 (2012) 366–370. [7] C. DiScala, I. Lescohier, M. Barthel, G. Li, Injuries to children with attention deficit hyperactivity disorder, Pediatrics 102 (1998) 1415–1421. [8] P.N. Pastor, C.A. Reuben, Identified attention-deficit/hyperactivity disorder and medically attended, nonfatal injuries: US school-age children, 1997–2002, Ambul. Pediatr. 6 (2006) 38–44. [9] H. Perera, S.M. Fernando, A.D. Yasawardena, I. Karunaratne, Prevalence of attention deficit hyperactivity disorder (ADHD) in children presenting with selfinserted nasal and aural foreign bodies, Int. J. Pediatr. Otorhinolaryngol. 73 (2009) 1362–1364. [10] R.R. Figueiredo, A.A. Azevedo, A.O. Ko´s, S. Tomita, Complications of ENT foreign bodies: a retrospective study, Braz. J. Otorhinolaryngol. 74 (2008) 7–15.
1294
F. Celenk et al. / International Journal of Pediatric Otorhinolaryngology 77 (2013) 1291–1294
[11] A. Mukherjee, D. Haldar, S. Dutta, M. Dutta, J. Saha, R. Sinha, Ear, nose and throat foreign bodies in children: a search for socio-demographic correlates, Int. J. Pediatr. Otorhinolaryngol. 75 (2011) 510–512. [12] P.M. Patil, R. Anand, Nasal foreign bodies: a review of management strategies and a clinical scenario presentation, Craniomaxillofac. Trauma Reconstr. 4 (2011) 53–58. [13] G.B. Singh, T.S. Sidhu, A. Sharma, R. Dhawan, S.K. Jha, N. Singh, Management of aural foreign body: an evaluative study in 738 consecutive cases, Am. J. Otolaryngol. 28 (2007) 87–90. [14] C.K. Conners, Conners’ Rating Scales-Revised, Multi-Health Systems Publishing, North Tonawada, NY, 1997. [15] C. Dereboy, S. Senol, S. Sener, F. Dereboy, Adaptation of Conners’ parent rating scale in Turkish, in: Proceedings 10th National Congress of Psychology, Ankara, 1998.
[16] E.S. Ercan, S. Amado, O. Somer, S. Cıkoglu, Dikkat Eksikligi hiperaktivite Bozuklugu ve Yikici Davranis Bozukluklari icin bir test bataryasi gelistirme calismasi, J. Child Adolesc. Mental Health 8 (2001) 132–144. [17] A. Turgay, Turgay’s DSM-IV based ADHD and Disruptive Behaviour Disorders Screening Scale, Integrative Therapy Institute Publication, Toronto-Ontario, Canada, 1997. [18] B. Rybojad, A. Niedzielski, G. Niedzielska, P. Rybojad, Risk factors for otolaryngological foreign bodies in Eastern Poland, Otolaryngol. Head Neck Surg. 147 (2012) 889–893. [19] A. Ngo, K.C. Ng, T.P. Sim, Otorhinolaryngeal foreign bodies in children presenting to the emergency department, Singapore Med. J. 46 (2005) 172–178. [20] J.A. Blackman, Attention-deficit/hyperactivity disorder in preschoolers. Does it exist and should we treat it? Pediatr. Clin. North Am. 46 (1999) 1011–1025.