Environmental Risk Factors Associated with Behavioral Problems among Children with Attention Deficit Hyperactivity Disorder:  Maternal Perceptions

Chutinart Sakarinkhul; Soontaree  Srikosai

Authors

Chutinart Sakarinkhul Rajanagarindra Institute of Child Development, Thailand https://orcid.org/0009-0003-5522-2751
Soontaree Srikosai Rajanagarindra Institute of Child Development, Thailand

Keywords:

ADHD, risk factors, behavioral problems, maternal percep- tions

Abstract

Objective This study aims to identify environmental risk factors associated with behavioral problems in children and adolescents with attention deficit hyperactivity disorder (ADHD).

Methods A case-control study was conducted in children aged 4-15 years comprising 92 children diagnosed with ADHD and 92 controls without ADHD. Stratified sampling was used to select 184 participants residing in Chiang Mai and Lamphun provinces, Thailand. Data were collected from the mothers of the participants using a self-report questionnaire between May and August 2022. The questionnaire consisted of three parts: child characteristics (gender, age, underlying diseases, past illness history), mother’s characteristics (age, income, occupational status, history of cigarette smoking and alcohol drinking), and maternal perceptions about caring for the child and the child’s behavioral problems (exposure to chemicals/toxicants, frequent punishment, excessive use of digital media and games). Data were analyzed using descriptive statistics, chi-squared test, odds ratio (OR) and logistic regression using SPSS version 21.

Results Most of participants were males (86.96%) while 13.04% were females. The results showed that the ADHD cases were significantly more likely than the controls to have underlying diseases such as G6PD, allergy, and asthma (p = 0.006). There was also a statistically significant correlation with smoking history in the mothers of ADHD cases (OR = 2.64; 95% CI: 1.36-5.13 p = 0.004). In terms of maternal perceptions, the mothers of ADHD children were significantly more likely than the controls to have frequently punished the child (OR = 6.26; 95% CI: 3.24-12.07; p < 0.001), to have children who were exposed to chemicals (pesticides and fertilizer) or toxicants (passive smoking) (OR = 4.14; 95%CI: 1.76-9.73; p = 0.001), and to have allowed their child to use digital media and play video games excessively (OR = 2.82; 95% CI: 1.55-5.16; p = 0.001). After adjustment for other environmental risk factors, frequent child punishment (ORadj = 4.32; 95% CI: 2.13-8.78; p < 0.001) and exposure of the child to chemicals/toxicants (ORadj = 2.66; 95% CI: 1.00-7.02; p = 0.049) were found to be significantly related with ADHD.

Conclusions Frequent child punishment was the most significant environmental risk factor related to behavioral problems among children with ADHD. This indicates the importance of healthcare providers developing strategies and/or interventions to enhance knowledge and awareness in mothers of ADHD which can improve treatment outcomes.

References

Cabral MD, Liu S, Soares N. Attention-deficit/hyperactivity disorder: diagnostic criteria, epidemiology, risk factors and evaluation in youth. Transl Pediatr. 2020;9(Supplement_1):S104-13.

Faraone S, Rostain A, Blader J, Busch B, Childress A, Connor D, et al. Practitioner review: emotional dysregu-lation in attention-deficit/hyperactivity disorder - implications for clinical recognition and intervention. J Child Psychol Psychiatry. 2019;60:133–50.

American Psychiatric Association (APA). Diagnostic and statistical manual of mental disorders: DSM-5TM. 5th ed. Arlington, VA, US: American Psychiatric Publishing; 2013. p. 947

Thomas R, Sanders S, Doust J, Beller E, Glasziou P. Prevalence of attention-deficit/hyperactivity disorder: a systematic review and meta-analysis. Pediatrics. 2015;135:e994-1001. PubMed PMID: 25733754

Danielson ML, Bitsko RH, Ghandour RM, Holbrook JR, Kogan MD, Blumberg SJ. Prevalence of parent-reported ADHD diagnosis and associated treatment among U.S. children and adolescents, 2016. J Clin Child Adolesc Psychol. 2018;47:199–212.

Visanuyothin T, Pavasuthipaisit C, Wachiradilok P, Arunruang P, Buranasuksakul T. The prevalence of attention deficit/hyperactivity disorder in Thailand. Journal of Mental Health of Thailand. 2013;21:66–75.

Srikosai S, Thakham A, Somchai C, Sakarinkhul C, Momwong W, Pitakham D. The link between alcohol, tobacco, and substance use during pregnancy and children’s autism spectrum disorder and attention- deficit/hyperactivity disorder. J Ment Health Thai. 2023; 31:37–51.

Linnet K, Dalsgaard S, Obel C, Wisborg K, Henriksen T, Rodriguez A, et al. Maternal lifestyle factors in pregnancy risk of attention deficit hyperactivity disorder and associated behaviors: review of the current evidence. Am J Psychiatry. 2003;160:1028–40.

Chatterji P, Markowitz S. The impact of maternal alcohol and illicit drug use on children’s behavior problems: evidence from the children of the national longitudinal survey of youth. J Health Econ. 2001;20:703–31.

Froehlich T, Anixt J, Loe I, Chirdkiatgumchai V, Kuan L, Gilman R. Update on environmental risk factors for attention-deficit/hyperactivity disorder. Curr Psychiatry Rep. 2011;13:333–44.

Claussen A, Holbrook J, Hutchins H, Robinson L, Bloomfield J, Meng L, et al. All in the Family? A systematic review and meta-analysis of parenting and family environment as risk factors for attention-deficit/hyperactivity disorder (ADHD) in Children. Prev Sci. 2022;1–23. PubMed PMID: 35438451

Miller M, Arnett A, Shephard E, Charman T, Gustafsson H, Joseph H, et al. Delineating early developmental pathways to ADHD: Setting an international research agenda. JCPP Advances. 2023;3:e12144. PubMed PMID: 37753147

Polańska K, Jurewicz J, Hanke W. Exposure to environmental and lifestyle factors and attention-deficit / hyperactivity disorder in children - a review of epidemiological studies. Int J Occup Med Environ Health. 2012;25:330–55.

Thangnak P. Factors associated with attention deficit hyperactivity disorder among children aged 3-12 years who were admitted in Benjalak Hospital Commemorating His Majesty the King’s 80th Birthday Anniversary, Sisaket Province [Internet]. 2023 [cited 2023 Dec 25]. Available from: https://healthregion10.moph.go.th/

Phongsathirat P, Wachiradilok P. Factors associated with attention deficit/hyperactivity disorders in school-age children. The Journal of Psychiatric Nursing and Mental Health. 2013;27:108–20.

Saksritavee B, Chanwanpen E, Phenwan T. Factors associated with attention deficit/hyperactivity disorders in school aged children of Sichon Hospital in crossectional study. Region 11 Medical Journal. 2019; 33:327–38.

Wiener J, Biondic D, Grimbos T, Herbert M. Parenting stress of parents of adolescents with attention-deficit hyperactivity disorder. J Abnorm Child Psychol. 2016;44:561–74.

Fletcher K, Fischer M, Barkley R, Smallish L. A sequential analysis of the mother-adolescent interactions of ADHD, ADHD/ODD, and normal teenagers during neutral and conflict discussions. J Abnorm Child Psychol. 1996;24:271–97.

Faul F, Erdfelder E, Buchner A, Lang A. Statistical power analyses using G*Power 3.1: Tests for correlation and regression analyses. Behavior Research Methods. 2009; 41:1149–60.

Cohen J. Statistical power analysis for the behavioral sciences, Rev. editor. Hillsdale, NJ, US: Lawrence Erlbaum Associates; 1977. p. 474.

Schlesselman J. Sample size requirements in cohort and case-control studies of disease. Am J Epidemiol. 1974;99:381–4.

Andrade C. Understanding relative risk, odds ratio, and related terms: as simple as it can get. J Clin Psychiatry. 2015;76:e857-61. PubMed PMID: 26231012

Alizadeh H, Applequist K, Coolidge F. Parental self- confidence, parenting styles, and corporal punish-ment in families of ADHD children in Iran. Child Abuse Negl. 2007;31:567–72.

Błachno M, Szamańska U, Kołakowski A, Pisula A. Parental corporal punishment in children with attention-deficit hyperactivity syndrome. Psychiatr Pol. 2006;40:43–55.

Faraone S, Rostain A, Blader J, Busch B, Childress AC, Connor DF, et al. Practitioner review: emotional dysregulation in attention-deficit/hyperactivity disorder – implications for clinical recognition and intervention. J Child Psychol Psychiatry. 2019;60:133–50.

Steinberg E, Drabick D. A developmental psychopathology perspective on ADHD and comorbid conditions: The role of emotion regulation. Child Psychiatry Hum Dev. 2015;46:951–66.

Saez M, Barceló M, Farrerons M, López-Casasnovas G. The association between exposure to environmental factors and the occurrence of attention-deficit/hyperactivity disorder (ADHD). A population-based retrospective cohort study. Environ Res. 2018;166:205–14.

Akmatov M, Ermakova T, Bätzing J. Psychiatric and nonpsychiatric comorbidities among children with ADHD: an exploratory analysis of nationwide claims data in germany. J Atten Disord. 2021;25:874–84.

Roberts J, Dawley E, Reigart J. Children’s low-level pesticide exposure and associations with autism and ADHD: a review. Pediatr Res. 2019;85:234-41.