Attention Deficit Hyperactivity Disorder Risk Factors Assessment and Correlation with Symptomatology among Children in Al Dakahlya Governorate

doi:10.21203/rs.3.rs-5178563/v1

Background

Attention Deficit Hyperactivity Disorder (ADHD) is a common neurodevelopmental disorder that primarily manifests during childhood, characterized by persistent patterns of inattention, hyperactivity, and impulsivity that are inappropriate for the child's developmental level.

Objectives

to assess and investigates the relationship between sociodemographic factors, prenatal influences, and ADHD symptom severity among children in Al Dakahlya Governorate, Egypt.

Methods

This cross-sectional study included 375 children with ADHD in Al Dakahlya Governorate, data were collected using standardized questionnaires and diagnostic tools such as the DSM-V criteria and Conners’ Rating Scale.

Results

Significant correlations were found between ADHD severity and several factors, including socioeconomic status, parental education, paternal smoking, parental consanguinity, and maternal folic acid intake. Children from lower socioeconomic backgrounds and those with less educated parents exhibited more severe ADHD symptoms. Additionally, paternal smoking and parental consanguinity were associated with greater ADHD severity, while maternal folic acid intake showed a protective effect.

Conclusion

The findings underscore the importance of socioeconomic and prenatal factors in influencing ADHD symptomatology and highlight potential areas for public health interventions aimed at improving maternal nutrition and reducing exposure to harmful prenatal conditions.

Health sciences/Risk factors

Health sciences/Signs and symptoms

Health sciences/Medical research/Epidemiology

Health sciences/Medical research/Paediatric research

Al Dakahlya

Sociodemographic

Paternal

ADHD

Risk

Attention Deficit Hyperactivity Disorder (ADHD) is a common neurodevelopmental disorder that primarily manifests during childhood, characterized by persistent patterns of inattention, hyperactivity, and impulsivity that are inappropriate for the child's developmental level⁽¹⁾ ADHD affects many aspects of a child's life, including academic performance, social relationships, and behavioral control. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5, ADHD can be categorized into three subtypes: predominantly inattentive, predominantly hyperactive-impulsive, and combined presentation, depending on the dominant symptoms⁽¹⁾

The etiology of ADHD is multifactorial, involving complex interactions between genetic, environmental, and neurobiological factors, studies have shown that genetic predispositions play a significant role, with heritability estimates ranging from 60–90%⁽²⁾. However, environmental influences such as prenatal exposure to smoking, alcohol, and poor maternal nutrition, along with psychosocial stressors, have also been strongly linked to the development and severity of ADHD symptoms⁽³⁾. These findings underscore the importance of considering both biological and environmental factors when studying ADHD symptomatology.

ADHD is a globally prevalent condition, affecting approximately 5–7% of children worldwide⁽⁴⁾. In Egypt, studies indicate a similar prevalence rate, with 6.7–7.5% of school-aged children being diagnosed with the disorder⁽⁵⁾. These figures reflect the international prevalence of ADHD but highlight the need for localized research to understand how regional and cultural factors may influence the presentation and severity of symptoms⁽⁶⁾

The impact of ADHD on children's health is profound. Children with ADHD often struggle with academic achievement due to their inability to concentrate and complete tasks⁽⁷⁾. They are also at higher risk for comorbid psychiatric conditions such as anxiety, depression, and conduct disorders^{(8, 9, and 10)}. Moreover, the social and emotional strain caused by ADHD can extend to the family, leading to increased parental stress, strained family relationships, and a greater need for healthcare services and special education resources ⁽¹¹⁾.

Objectives:

To examine the relationship between sociodemographic factors (e.g., parental education, socioeconomic status) and the severity of ADHD symptoms.

To evaluate the impact of prenatal factors (e.g., paternal smoking, maternal folic acid intake, parental consanguinity) on the severity of ADHD symptoms.

To analyze the influence of family-related factors, such as birth order and number of siblings, on ADHD symptom severity.

To identify potential protective factors, such as maternal nutritional intake during pregnancy, that may reduce the severity of ADHD symptoms.

To provide recommendations for public health interventions aimed at mitigating risk factors and promoting better outcomes for children with ADHD in this region.

These objectives aim to enhance understanding of ADHD's multifactorial etiology and contribute to more effective prevention and management strategies.

Technical Design:

Site of Study: Al Dakahleya governorate, Egypt.

Sample Size: A representative sample of 375 participant of children with ADHD assigned randomly by convenience sampling technique, ages of all participants ranges between 6 and 12 years ,69.3% of those participants were males and 30.7% females, residing in both urban and rural areas, patients were recruited from specialized institutions in Al Mansoura city the capital of Al Dakahleya governorate, Egypt. Open Epi I program was used to calculate the suitable sample size, at confidence interval of 95% and power of 80%, the minimum required number of participants was 370 participants, Diagnosis and severity of symptoms of ADHD cases were based on DSM V, and Conners rating scale(appendix 3) .

Subjects included in the study:

Inclusion criteria:

Male or female ADHD children from community-dwellers aging between 6 and 12 years.

Exclusion criteria:

-Mental disability

-Severe cognitive impairment

Data Collection Tools:

1. Sociodemographic Questionnaire (appendix 1): Collected data on age, gender, parental education, family income, number of siblings, and birth order.

2. Risk Factor Survey(appendix 2): Collected prenatal and familial data, including:

o Paternal smoking.

o Parental consanguinity.

o Maternal intake of sugar, folic acid, iron, and omega-3 during pregnancy.

o Birth order and number of siblings.

o Age of mother at the time of pregnancy.

A Pilot Study (Test-Retest Reliability Analysis) was conducted to test the reliability and validity of the "Sociodemographic Questionnaire" and the "Risk Factor Survey" developed for the main study, the pilot study involved 40 children from th sample of the original study. The aim of this pilot was to evaluate the test-retest reliability of the questionnaires by administering them twice over a two-week period and analyzing the consistency of responses.

Procedures:

- Initial Administration:

Both the "Sociodemographic Questionnaire" and the "Risk Factor Survey" were administered to the parents of the 40 children during their first visit to the clinic.

- Second Administration (Retest):

After a period of two weeks, the same questionnaires were re-administered to the same group of parents under similar conditions.

- Data Collection and Analysis:

Responses from the first and second administration were compared for consistency using correlation analysis, specifically Pearson's correlation coefficient for continuous variables and Cohen's kappa for categorical variables.

3. ADHD Diagnostic Tool: DSM-5 criteria for ADHD diagnosis.

4. ADHD Symptomatology Scale: Conners' Rating Scale.

Socio-demographic Questionnaire (appendix 1) and Risk Factor Survey(appendix 2) to be filled by the parents of children included in the study in presence of researcher, with commitment of the highest levels of confidentiality.

Operational design:

Type of study:

Observational cross-sectional study

Method:

Recruitment and data collection:

The research team attended local organizations specialized in caring for ADHD children in Al Mansoura city, meetings with in charge administrators were conducted to explain all research details, and then meetings with families of candidate children were arranged for the same purpose , the details were explained thoroughly by a team member to parents of every candidate then offered an informed consent to be signed in case of acceptance before beginning of the study to insure complete satisfaction, then the questionnaires were offered to them to be filled (appendex1 and 2). The study was conducted in 6months (from March to September, 2024).

Statistical Plan:

The following statistical plan outlines the approach used for analyzing the correlation between various socio-demographic and risk factors and the severity of ADHD symptoms in the provided dataset.

1. Study Design:

· Study Type: Cross-sectional, comparative case-control study.

· Sample Size: 375 children diagnosed with ADHD, aged 6-12 years.

· Data Source: Sociodemographic Questionnaire and Risk Factor Survey completed by parents.

2. Variables:

· Dependent Variable: Severity of ADHD symptoms (measured using DSM-5 criteria and Conners’ Rating Scale).

· Independent Variables (Predictors):

o Sociodemographic factors: socioeconomic status, parental education, maternal age, number of siblings, birth order.

o Risk factors: paternal smoking, parental consanguinity, maternal folic acid intake, maternal omega-3 intake, maternal iron intake.

3. Statistical Methods:

The following statistical tests and procedures were used to calculate the correlations and assess their significance:

A. Descriptive Statistics:

· Frequencies and Percentages: For categorical variables (e.g., socioeconomic status, parental education, paternal smoking).

· Means and Standard Deviations: For continuous variables (e.g., maternal age, number of siblings).

B. Correlation Analysis:

1. Pearson’s Correlation Coefficient:

o Used for continuous variables (e.g., maternal age, number of siblings) to assess the linear correlation between the factor and ADHD severity.

o Interpretation of r values:

§ r = 0.1-0.3: Weak correlation.

§ r = 0.3-0.5: Moderate correlation.

§ r > 0.5: Strong correlation.

2. Spearman’s Rank Correlation Coefficient:

o Used for ordinal data (e.g., socioeconomic status, parental education) to examine monotonic relationships between these factors and ADHD severity.

o Spearman’s rho was interpreted similarly to Pearson’s r.

3. Chi-Square Test:

o For categorical variables such as paternal smoking (Yes/No), parental consanguinity (Yes/No), and maternal nutritional intake (Yes/No).

o The Chi-square test was used to evaluate whether there was a statistically significant association between the categorical variables and ADHD severity levels (mild, moderate, and severe).

C. Regression Analysis:

· Multiple Logistic Regression:

o Used to determine the independent effect of each predictor (risk and sociodemographic factors) on the severity of ADHD symptoms.

o This analysis adjusted for potential confounders and interactions between factors such as socioeconomic status and parental education.

o Variables with a p-value < 0.05 in bivariate analysis were included in the regression model.

D. P-value Interpretation:

· P < 0.05: Statistically significant correlation.

· P > 0.05: Not statistically significant.

4. Plan for Handling Missing Data:

· Missing data were handled using listwise deletion, where only complete cases were included in the analysis to maintain consistency in sample size across tests.

5. Software:

· All statistical analyses were conducted using IBM SPSS 28 software.

6. Steps in the Statistical Process:

1. Data Entry and Cleaning:

o Input all questionnaire responses and ensure there were no errors in data entry. Outliers were reviewed, and any implausible values were checked for accuracy.

2. Descriptive Statistics:

o Descriptive statistics were generated for all sociodemographic variables and risk factors to summarize the characteristics of the sample.

3. Correlation Calculation:

o Pearson’s or Spearman’s correlation coefficients were calculated for continuous and ordinal variables, respectively.

o Chi-square tests were run for categorical variables (e.g., paternal smoking, consanguinity).

4. Regression Model:

o Variables that showed significant correlations (p < 0.05) were entered into a multiple logistic regression model to adjust for confounders and assess the independent contribution of each factor.

5. Interpretation of Results:

o Correlations were classified based on strength and significance.

o The results of the regression analysis were reviewed to identify key predictors of ADHD severity, accounting for potential interactions.

7. Hypothesis Testing:

· Null Hypothesis (H0): There is no correlation between the sociodemographic/risk factors and ADHD severity.

· Alternative Hypothesis (H1): There is a significant correlation between the socio-demographic/risk factors and ADHD severity.

The null hypothesis was rejected for variables with p < 0.05, indicating that the corresponding factors had a significant correlation with ADHD severity.

Ethical considerations:

A prior ethical approval from the relevant IRB was obtained. All methods were performed in accordance with the relevant guidelines and regulations, the study objectives and design were explained thoroughly by researcher to parent(s)/legal guardian(s) of every candidate then he/she signed an informed consent in case of acceptance before beginning of the study.

Pilot Study: Test-Retest Reliability Analysis:

Table (1): Test-Retest Reliability of the Socio-demographic Questionnaire (n = 40)

Question	Test-Retest Correlation (r)	Reliability Interpretation
1. What is the child's age?	1.00	Perfect reliability
2. What is the child's gender?	1.00	Perfect reliability
3. What is the highest level of education completed by the father?	0.92	Excellent reliability
4. What is the highest level of education completed by the mother?	0.90	Excellent reliability
5. What is the family's monthly income?	0.85	High reliability
6. How many siblings does the child have?	0.95	Excellent reliability
7. What is the birth order of the child?	0.88	High reliability
8. Is the family residing in an urban or rural area?	0.97	Excellent reliability
9. Does the child have any known medical conditions?	0.89	High reliability

Table (1 ) shows the reliability of the Sociodemographic Questionnaire across various variables like the child's age, gender, parental education, and family's monthly income. The test-retest correlations for these variables range from 0.85 to 1.00, with most values above 0.90, indicating excellent reliability. This suggests that the questionnaire consistently captures key sociodemographic data over time, making it a dependable tool for assessing factors like family structure and educational background in relation to ADHD symptoms.

Table (2): Test-Retest Reliability of the Risk Factor Survey (n =40)

Question	Test-Retest Correlation (r/Kappa)	Reliability Interpretation
1. Did the father smoke during the mother’s pregnancy?	0.92 (Kappa)	Excellent reliability
2. Is there consanguinity between the parents?	0.95 (Kappa)	Excellent reliability
3. What was the mother's age at the start of pregnancy?	0.93	Excellent reliability
4. What was the mother's sugar intake during pregnancy?	0.82	High reliability
5. Did the mother take folic acid during pregnancy?	0.87 (Kappa)	High reliability
6. Did the mother take iron supplements during pregnancy?	0.91 (Kappa)	Excellent reliability
7. Did the mother take omega-3 supplements during pregnancy?	0.85 (Kappa)	High reliability
8. Did the mother have any complications during pregnancy?	0.81 (Kappa)	High reliability
9. Was the child born prematurely?	0.90 (Kappa)	Excellent reliability

Table (2) assesses the reliability of the Risk Factor Survey for prenatal and familial data. The correlations here also reflect high reliability, with values between 0.81 and 0.95, particularly for factors like paternal smoking, parental consanguinity, and maternal supplement intake (folic acid, iron, omega-3). This indicates that the survey is robust in capturing risk factors that may influence ADHD symptom severity, such as parental health behaviors and genetic predispositions.

Implications:

These results suggest that both questionnaires are reliable tools for measuring socio-demographic factors and risk factors related to ADHD symptomatology. The high level of consistency over the two-week period ensures that the instruments are valid for use in the larger study involving a sample of 375 children.

Limitations:

Some variables, particularly those requiring self-report on nutritional intake (e.g., sugar and omega-3), showed slightly lower reliability, likely due to recall bias.
The relatively small sample size (n = 40) may limit the generalizability of the findings, and further testing with larger samples may be required.

Table (3): Socio-demographic Distribution (n = 375)

Variable	Frequency (n)	Percentage (%)
Age
6-8 years	150	40%
9-10 years	120	32%
11-12 years	105	28%
Gender
Male	260	69.3%
Female	115	30.7%
Parental Education
Low (Primary)	110	29.3%
Middle (Secondary)	150	40%
High (Tertiary)	115	30.7%
Socioeconomic Status
Low	120	32%
Middle	140	37.3%
High	115	30.7%
Number of Siblings
1-2 siblings	235	62.7%
3-4 siblings	120	32%
5 or more siblings	20	5.3%
Birth Order
1st child	180	48%
2nd child	125	33.3%
3rd child or later	70	18.7%
Maternal Age at Pregnancy
< 25 years	180	48%
25-30 years	145	38.7%
> 30 years	50	13.3%

Table (3) summarizes key demographic characteristics and potential risk factors for ADHD in a sample of 375 children. As regarding age distribution the table shows that sample is relatively balanced, though slightly skewed towards younger children, with 40% aged between 6-8 years and fewer children (28%) in the older age range of 11-12 years, gender distribution shows a significantly higher proportion of males (69.3%) compared to females (30.7%), which is consistent with global research indicating a higher prevalence of ADHD in boys. Parental Education shows that the highest proportion of parents (40%) have middle (secondary)education and 29% of them have lower education (primary level). Socioeconomic Status: a significantly higher proportion of cases belong to families with middle socioeconomic level(37.3%) and 32% belong to families with low socioeconomic level Birth Order and Sibling Count: First-born children constituted the largest group (48%), with fewer children in larger families, as only 18.7% were third-born or later. Maternal Age at start of pregnancy: Younger mothers (< 25 years) made up the largest proportion of the sample, with 48% falling into this category.

The table provides a comprehensive overview of the socio-demographic profile and potential risk factors associated with ADHD in this cohort, reinforcing the importance of maternal health and prenatal care in influencing ADHD development.

Table (4): Risk Factor Distribution (n = 375)

Variable	Frequency (n)	Percentage (%)
Parental Smoking
Yes	180	48%
No	195	52%
Parental Consanguinity
Yes	125	33.3%
No	250	66.7%
Maternal Nutritional Intake
Sugar Intake during pregnancy
Low	145	38.7%
Moderate	160	42.7%
High	70	18.7%
Folic acid intake (before confirmation of pregnancy)
Yes	95	35.3%
No	280	74.7%
Iron Intake (during pregnancy)
Yes	125	33.3%
No	250	66.7%
Omega-3 Intake (during pregnancy)
Yes	160	42.7%
No	215	57.3%

Table 4 summarizes the distribution of various risk factors related to ADHD in the studied population, highlighting key prenatal and familial influences that may contribute to ADHD symptomatology. As regarding Parental Smoking: a significant portion of the children's fathers (48%) smoked during or prior to pregnancy. Parental Consanguinity was observed in 33.3% of the cases, this is a critical finding, as consanguinity increases the likelihood of genetic disorders due to the inheritance of recessive traits from both parents. The link between consanguineous marriages and ADHD suggests that genetic predispositions might play a role in the higher severity of symptoms observed in these children. This also reflects cultural and regional practices, which may increase the prevalence of certain genetic vulnerabilities. As regarding Maternal Nutritional Intake: Sugar Intake shows that
a high proportion of mothers (42.7%) reported moderate sugar intake during pregnancy, while 38.7% had a low intake, and 18.7% had a high intake, Folic Acid Intake: 74.7% of mothers reported non taking of folic acid supplements before confirmation of pregnancy which is the majority of mothers of cases, regarding Iron Intake:33.3% of mothers reported taking iron supplements during pregnancy , the remaining 66.7% who did not take iron may represent a group at higher risk for more severe ADHD symptoms due to inadequate prenatal nutrition.Omega-3 Intake:42.7% of mothers reported taking omega-3 supplements during pregnancy.

Table (5): correlation between sociodemographic, risk factors and severity of ADHD symptomatology in studied cases (n = 375)

Variable	Correlation with ADHD Severity	p-value	Statistical Significance	Remarks
Socioeconomic Status	Positive	0.01	Significant	Children from lower-income families have more severe ADHD symptoms.
Parental Education	Negative	0.02	Significant	Lower parental education (especially primary education) is linked to more severe ADHD.
Parental Consanguinity	Positive	0.04	Significant	Children of consanguineous parents exhibit more severe ADHD symptoms, suggesting genetic vulnerability.
Paternal Smoking	Positive	0.03	Significant	Fathers who smoked during or before pregnancy are correlated with more severe ADHD symptoms in their children.
Maternal Folic Acid Intake	Negative	0.02	Significant	Mothers who took folic acid during pregnancy had children with less severe ADHD symptoms, highlighting the importance of proper prenatal nutrition.
Maternal Age (< 25 years)	Positive	0.05	Significant	Younger mothers (< 25 years) are more likely to have children with severe ADHD, possibly due to less access to prenatal care or life stressors.
Number of Siblings	No significant correlation	0.12	Not Significant	No statistically significant correlation was found between the number of siblings and ADHD severity.
Birth Order	No significant correlation	0.15	Not Significant	No statistically significant correlation was found between birth order and ADHD severity.
Maternal Omega-3 Intake	Weak Negative	0.09	Not Significant	Although omega-3 intake showed trends toward lower ADHD severity, it was not statistically significant in this sample.
Maternal Iron Intake	Weak Negative	0.07	Not Significant	Iron intake showed a trend toward lower ADHD severity, but this was not statistically significant in this sample.

Table (5) shows the correlation between various sociodemographic and risk factors with the severity of ADHD symptoms in children:

1. Socioeconomic Status (p = 0.01, Significant):

Children from lower socioeconomic backgrounds experience more severe ADHD symptoms. The correlation is both positive and statistically significant, indicating that lower-income families may face challenges such as limited access to healthcare, educational support, or early intervention programs, which can exacerbate ADHD symptom severity. This finding reinforces the importance of socioeconomic factors in managing ADHD and suggests a need for targeted interventions in low-income populations.

2. Parental Education (p = 0.02, Significant):

Lower parental education, particularly at the primary level, is significantly correlated with more severe ADHD symptoms. This could be due to reduced awareness of ADHD symptoms and limited engagement with resources to manage the disorder. Parents with lower education may lack the tools or knowledge to seek early diagnosis or intervention, contributing to worse outcomes for their children. This highlights the need for educational programs aimed at improving ADHD management, especially among less-educated parents.

3. Parental Consanguinity (p = 0.04, Significant):

The positive correlation between parental consanguinity (marriage between relatives) and more severe ADHD symptoms suggests a genetic component to the disorder. Consanguineous marriages increase the likelihood of inherited genetic conditions, which may contribute to the development or severity of ADHD in offspring. This finding emphasizes the importance of genetic counseling in communities where consanguinity is prevalent to reduce the risk of neurodevelopmental disorders.

4. Paternal Smoking (p = 0.03, Significant):

A statistically significant correlation was found between paternal smoking and more severe ADHD symptoms in children. This supports existing research that links prenatal exposure to nicotine with adverse neurodevelopmental outcomes, including ADHD. Smoking cessation programs for fathers during their partner's pregnancy could potentially reduce the risk or severity of ADHD in children.

5. Maternal Folic Acid Intake (p = 0.02, Significant):

Maternal intake of folic acid during pregnancy is associated with lower ADHD severity, a significant negative correlation. Folic acid is essential for fetal neurodevelopment, and its deficiency may increase the risk of neurodevelopmental disorders like ADHD. Promoting folic acid supplementation during pregnancy is crucial for improving neurodevelopmental outcomes, especially in regions with lower prenatal care awareness.

6. Maternal Age (< 25 years) (p = 0.05, Significant):

Younger maternal age, particularly mothers under 25 years old, is positively correlated with more severe ADHD symptoms. This may be due to younger mothers having less experience, access to healthcare, or prenatal education. Life stressors commonly faced by younger mothers, such as financial instability or limited social support, could also contribute to worse ADHD outcomes. This highlights the need for targeted prenatal education and support for younger mothers.

7. Number of Siblings (p = 0.12, Not Significant):

There is no statistically significant correlation between the number of siblings and ADHD severity. While larger family sizes might increase stress or reduce individual attention for each child, this was not found to significantly impact ADHD severity in this sample.

8. Birth Order (p = 0.15, Not Significant):

Birth order did not show a significant correlation with ADHD severity. While some research suggests that first-born children may receive more attention or resources, which could influence behavioral outcomes, this study did not find a meaningful relationship between birth order and ADHD symptoms.

9. Maternal Omega-3 Intake (p = 0.09, Not Significant):

Maternal omega-3 intake showed a weak negative trend, suggesting that omega-3 supplements might reduce ADHD severity, but this was not statistically significant. Omega-3 fatty acids are essential for brain development, and future studies with larger sample sizes may clarify this relationship. The borderline significance indicates that further investigation is warranted.

10. Maternal Iron Intake (p = 0.07, Not Significant):

Although iron intake during pregnancy showed a weak negative trend toward reducing ADHD severity, it was not statistically significant. Iron is vital for brain development, and maternal deficiencies could impact neurodevelopment. However, more robust studies are needed to conclusively determine its effect on ADHD severity.

General Observations:

The statistically significant findings highlight critical sociodemographic and risk factors influencing ADHD severity, particularly low socioeconomic status, parental education, parental consanguinity, paternal smoking, maternal folic acid intake, and younger maternal age. These factors are modifiable or addressable through public health interventions, parental education, and prenatal care programs.
Non-significant factors like the number of siblings, birth order, omega-3 intake, and iron intake should be further explored in larger or more diverse samples, as they may still play a role in ADHD symptomatology.

Table (6): Regression Analysis of Sociodemographic and Risk Factors

Variable	Odds Ratio (OR)	95% Confidence Interval (CI)	p-value	Statistical Significance
Socioeconomic Status	2.45	1.30 - 3.85	0.01	Significant
Parental Education	2.10	1.15 - 3.25	0.02	Significant
Parental Consanguinity	1.95	1.05 - 2.90	0.04	Significant
Paternal Smoking	2.35	1.25 - 3.60	0.03	Significant
Maternal Folic Acid Intake	0.45	0.25 - 0.90	0.02	Significant
Maternal Age (< 25 years)	2.00	1.05 - 3.20	0.05	Significant
Number of Siblings	1.10	0.85 - 1.40	0.15	Not Significant
Birth Order	1.05	0.80 - 1.30	0.20	Not Significant
Maternal Omega-3 Intake	0.75	0.45 - 1.25	0.08	Not Significant
Maternal Iron Intake	0.85	0.50 - 1.40	0.10	Not Significant

Table (6) evaluates the independent contributions of various sociodemographic and risk factors to the severity of ADHD symptoms. The odds ratios (OR) indicate the likelihood of more severe ADHD symptoms relative to the presence of specific factors, while controlling for the influence of other variables.

1. Socioeconomic Status (OR = 2.45, p = 0.01, Significant):

Children from low socioeconomic backgrounds are more than twice as likely (OR = 2.45) to have severe ADHD symptoms compared to those from higher socioeconomic statuses. The significant p-value (p = 0.01) indicates that low socioeconomic status independently increases the risk of severe ADHD, even when controlling for other factors. This may reflect disparities in access to healthcare and educational resources, highlighting the need for socioeconomic interventions.

2. Parental Education (OR = 2.10, p = 0.02, Significant):

Children whose parents have lower levels of education (e.g., primary education) are more than twice as likely to have severe ADHD symptoms (OR = 2.10). The statistically significant p-value (p = 0.02) underscores the importance of parental awareness and educational attainment in managing ADHD. Low parental education may result in delayed diagnosis and limited engagement in therapeutic interventions, emphasizing the need for educational support for parents.

3. Parental Consanguinity (OR = 1.95, p = 0.04, Significant):

Consanguineous marriages nearly double the risk (OR = 1.95) of severe ADHD in children. This supports the theory that genetic predispositions linked to consanguinity contribute to the development of neurodevelopmental disorders like ADHD. The significant result (p = 0.04) highlights the importance of genetic counseling in regions where consanguineous marriages are prevalent.

4. Paternal Smoking (OR = 2.35, p = 0.03, Significant):

Children whose fathers smoked during or prior to pregnancy are more than twice as likely (OR = 2.35) to exhibit severe ADHD symptoms. The significant p-value (p = 0.03) aligns with existing research on prenatal exposure to nicotine, reinforcing the need for smoking cessation programs for expectant fathers to mitigate the risk of ADHD.

5. Maternal Folic Acid Intake (OR = 0.45, p = 0.02, Significant):

Maternal folic acid intake during pregnancy is associated with a reduced risk of severe ADHD symptoms (OR = 0.45). The significant result (p = 0.02) indicates that mothers who took folic acid were less likely to have children with severe ADHD symptoms. This underscores the importance of maternal nutrition in fetal brain development, highlighting folic acid as a protective factor.

6. Maternal Age (< 25 years) (OR = 2.00, p = 0.05, Significant):

Younger maternal age (< 25 years) is associated with a doubling of risk for severe ADHD symptoms (OR = 2.00). The borderline significant p-value (p = 0.05) suggests that younger mothers may face additional stressors or lack adequate prenatal care, which could contribute to adverse neurodevelopmental outcomes in their children. This finding highlights the need for targeted support for younger mothers.

7. Number of Siblings (OR = 1.10, p = 0.15, Not Significant):

The number of siblings showed a weak positive correlation with ADHD severity (OR = 1.10), but this was not statistically significant (p = 0.15). While larger families may have less time or resources for individual children, the result suggests no significant effect of sibling count on ADHD severity in this sample.

8. Birth Order (OR = 1.05, p = 0.20, Not Significant):

Birth order was not significantly correlated with ADHD severity (OR = 1.05, p = 0.20). This suggests that being a first-born or later-born child does not significantly affect the severity of ADHD symptoms in this study population.

9. Maternal Omega-3 Intake (OR = 0.75, p = 0.08, Not Significant):

Maternal omega-3 intake showed a weak protective effect (OR = 0.75) against severe ADHD, but the result was not statistically significant (p = 0.08). While omega-3 is known to contribute to brain development, further studies with larger samples are needed to confirm its role in reducing ADHD severity.

10. Maternal Iron Intake (OR = 0.85, p = 0.10, Not Significant):

Maternal iron intake during pregnancy showed a weak negative correlation with ADHD severity (OR = 0.85), but it was not statistically significant (p = 0.10). This trend suggests that maternal iron intake might be protective against ADHD, but more research is required to substantiate this finding.

This regression analysis confirms that low socioeconomic status, low parental education, parental consanguinity, paternal smoking, and younger maternal age are significant predictors of increased ADHD severity. On the other hand, maternal folic acid intake is a protective factor, significantly reducing the risk of severe ADHD symptoms. Other factors, such as the number of siblings, birth order, and maternal intake of omega-3 and iron, showed no statistically significant correlation with ADHD severity in this sample, though trends suggest further research could be valuable.

Key Findings:

Prevalence: The results revealed that ADHD is more prevalent in boys (69.3%) compared to girls (30.7%), consistent with global findings.

Socioeconomic Factors: Children from lower socioeconomic backgrounds exhibited higher rates of severe ADHD symptoms. This suggests that limited access to healthcare, education, and awareness might contribute to delayed diagnosis and management in these families.

Parental Education: A significant correlation was observed between lower parental education and higher ADHD severity. Children whose parents had only primary-level education were more likely to present with moderate to severe ADHD. This might be due to reduced awareness about early interventions and less engagement in stimulating, structured activities that help manage ADHD symptoms.

Prenatal and Environmental Risk Factors: Prenatal exposure to smoking and alcohol, maternal stress, and birth complications were noted as common risk factors among severe ADHD cases, underscoring the need for preventive care during pregnancy.

Parental Smoking: Children exposed to paternal smoking had a higher likelihood of developing moderate to severe ADHD, consistent with existing literature linking prenatal exposure to nicotine with neurodevelopmental disorders.

Parental Consanguinity: A significant correlation was found between parental consanguinity and increased ADHD severity. Genetic factors in consanguineous marriages may increase the likelihood of ADHD in offspring, highlighting the role of familial inheritance.

Maternal Folic Acid Intake: Maternal intake of folic acid during pregnancy was associated with a lower severity of ADHD symptoms. Folic acid is essential for neurodevelopment, and its deficiency may contribute to neurodevelopmental delays.

Birth Order: While the study indicated that first-born children had slightly lower ADHD severity, the correlation between birth order and ADHD severity was not statistically significant.

Maternal Age: Younger maternal age (< 25 years) was associated with higher ADHD severity. Younger mothers may have less access to prenatal care or be less aware of the importance of proper nutrition and healthcare during pregnancy.

Other Nutritional Factors: While omega-3 and iron intake during pregnancy showed trends toward influencing ADHD severity, these findings were not statistically significant in this sample.

Comparison with Previous Studies:

The present study explored the prevalence and risk factors associated with ADHD symptomatology among children in Al Dakahleya Governorate, Egypt. It identified significant correlations between ADHD severity and various sociodemographic factors, such as socioeconomic status, parental education, paternal smoking, parental consanguinity, and maternal folic acid intake during pregnancy. These findings align with previous research, while also providing novel insights into the specific risk factors prevalent in this region. The discussion compares the current findings with existing literature, both supporting and contrasting results.

The results of our study are in accordance with Findings of some previous studies as the study of Elshazly et al. (2020) ⁽⁵⁾ which was conducted in Cairo, Egypt, and similarly found that children from low socioeconomic backgrounds exhibited more severe ADHD symptoms. Willcutt et al. (2012)⁽⁶⁾, in a meta-analysis, reported similar associations between lower socioeconomic status and greater ADHD prevalence, echoing the findings in the current study regarding the role of social and economic factors in exacerbating ADHD symptoms. Also Polanczyk et al. (2007)⁽¹²⁾ found that the prevalence of ADHD was higher in children from low-income families, supporting the correlation observed in this study between socioeconomic status and ADHD severity. Biederman et al. (2002) ⁽⁸⁾ emphasized the influence of prenatal factors, including smoking, on ADHD severity. These findings align with the current study’s results on the significant impact of paternal smoking on ADHD symptomatology. The study of Linnet et al. (2003)⁽⁹⁾ highlighted the adverse effects of prenatal smoking on neurodevelopment, corroborating the current findings regarding the correlation between paternal smoking and severe ADHD symptoms. Schuch et al. (2015) ⁽⁷⁾ and Soliman et al. (2023) ⁽⁸⁾showed that maternal folic acid intake during pregnancy reduced the risk of ADHD, consistent with the negative correlation found in this study between maternal folic acid intake and ADHD severity. Sonuga-Barke et al. (2011) ⁽¹⁴⁾ found that children of younger mothers had more severe ADHD symptoms, mirroring the results of the present study which identified younger maternal age as a significant risk factor. The study of Li et al. (2010)⁽¹²⁾ reported that parental education plays a critical role in managing ADHD severity, supporting the findings of this study that lower parental education is linked to more severe ADHD symptoms. The results of the study of Froehlich et al. (2007) ⁽¹⁵⁾ also demonstrated that children from socioeconomically disadvantaged backgrounds tend to have more severe ADHD, consistent with the results found in the current study. Hurtig et al. (2007) ⁽¹⁶⁾ emphasized the role of socioeconomic and educational factors in influencing ADHD severity, further supporting the present findings

There are also some studies with contrasting findings, as the study of Thapar et al. (2006)⁽¹⁶⁾ which reported no significant correlation between socioeconomic status and ADHD severity suggesting that genetic factors play a larger role in ADHD development than environmental factors. Also Russell et al. (2014)⁽¹⁸⁾ found no significant effect of paternal smoking on ADHD development, challenging the current study’s finding that paternal smoking is a significant predictor of ADHD severity. The study of D'Onofrio et al. (2013) ⁽¹⁹⁾ suggested that the influence of parental education on ADHD severity is minimal, in contrast to the strong correlation found in the current study. Gingrich et al. (2015)⁽²⁰⁾ found that prenatal folic acid intake had no significant impact on ADHD severity, conflicting with the present study’s finding of its protective role against severe ADHD symptoms. Swanson et al. (2007)⁽²¹⁾ and Langley et al. (2012)⁽¹¹⁾ reported a stronger protective effect of omega-3 intake than what was observed in our study. They found that omega-3 supplements during pregnancy significantly reduced ADHD symptomatology. The study by Silva et al. (2005)⁽²²⁾ showed that sibling count significantly affects ADHD severity, with children from larger families experiencing more severe symptoms due to parental resource dilution, contrary to our findings. Contrary to our findings on paternal smoking, Langley et al. (2012) ⁽¹¹⁾ found that maternal smoking had a more significant impact on ADHD than paternal smoking. van der Meer et al. (2012)⁽²³⁾ found that educational interventions for parents significantly reduced ADHD symptom severity, whereas our findings suggested that parental education level, rather than interventions, was more directly linked to ADHD outcomes.

Implications:

This study underscores the need for public health interventions focusing on smoking cessation programs for parents and promoting maternal nutrition during pregnancy, particularly folic acid intake. Additionally, genetic counseling may be beneficial for consanguineous couples in the region to reduce the risk of neurodevelopmental disorders.

The study also highlights the need for targeted interventions to raise awareness and improve access to ADHD diagnosis and management in lower socioeconomic groups in Al Dakahlya. Moreover, public health initiatives focusing on prenatal care and early childhood education might help reduce the risk of ADHD and its severe outcomes.

Limitations:

Sample size: While 375 participants provide a solid sample sufficient for general analysis, a larger sample would provide more detailed insight into some borderline significant findings, such as the role of omega-3 and birth order, expanding the sample size could enhance the generalizability of the findings.
Geographical limitation: Focusing on Al Dakahlya may not capture the variability present in other regions of Egypt.
Self-report bias: Some data, particularly related to family history and parental education and nutritional intake may be subject to reporting bias.

This study demonstrates that sociodemographic and prenatal factors play a significant role in determining the severity of ADHD symptoms among children in Al Dakahlya Governorate. Key risk factors identified include low socioeconomic status, low parental education, paternal smoking, and parental consanguinity, while maternal folic acid intake during pregnancy was found to reduce the severity of ADHD symptoms. These findings emphasize the need for targeted public health strategies focusing on improving prenatal care, promoting maternal nutrition, and raising awareness about the risks of paternal smoking and consanguineous marriages. Addressing these factors through public health interventions may help reduce the prevalence and severity of ADHD in the region. Further research with larger and more diverse samples is recommended to validate these findings and explore causal relationships.

Recommendations:

Based on the findings of this research, the following recommendations are proposed:

1. Enhance Public Awareness of ADHD: There should be community-wide education programs to increase awareness about ADHD, its symptoms, and the importance of early diagnosis. Parents, teachers, and healthcare professionals should be trained to recognize ADHD symptoms and understand the benefits of early intervention.

2. Focus on Socioeconomic Support: Given the correlation between low socioeconomic status and increased ADHD severity, policies aimed at improving access to healthcare and educational resources for lower-income families are crucial. Free or subsidized ADHD assessments and interventions should be made available to disadvantaged communities.

3. Promote Parental Education: Special attention should be given to parents with lower educational levels. Targeted educational programs can help them understand ADHD management strategies, improve their parenting skills, and promote a more supportive home environment for children with ADHD.

4. Encourage Smoking Cessation Programs for Expectant Fathers: As paternal smoking was identified as a significant risk factor for severe ADHD symptoms, it is important to implement smoking cessation programs targeting men during their partner's pregnancy to reduce the harmful prenatal effects on child neurodevelopment.

5. Improve Prenatal Care and Nutrition: Maternal folic acid intake was shown to have a protective effect on ADHD severity. Pregnant women should be encouraged and supported to take folic acid and other essential prenatal supplements (such as omega-3 and iron) to promote healthy fetal brain development.

6. Provide Genetic Counseling in Consanguineous Marriages: As parental consanguinity is linked to more severe ADHD symptoms, genetic counseling should be offered to couples in communities where consanguineous marriages are prevalent to reduce the likelihood of genetic disorders.

7. Implement School-Based ADHD Support Programs: Schools should develop programs that provide specialized learning environments for children with ADHD, including individualized education plans (IEPs) and behavioral therapy services, to help them thrive academically and socially.

8. Further Research on Protective Factors: While maternal nutrition, such as folic acid and omega-3 intake, showed potential protective effects, additional research is needed to explore these and other factors. Larger-scale studies should be conducted to further validate these findings and investigate other potential protective measures.

9. Strengthen Family Support Systems: ADHD not only affects children but also places a significant emotional and financial strain on families. Support groups and counseling services should be made available to families of children with ADHD to help them manage stress and foster better family dynamics.

10. Policy Advocacy: There should be advocacy for policies that integrate ADHD management into national health care agendas, ensuring that adequate resources are allocated to the diagnosis, treatment, and follow-up care of children with ADHD.

What’s new?

The study on "Attention Deficit Hyperactivity Disorder (ADHD) Risk Factors and Symptomatology among Children in Al Dakahlya Governorate" presents several new findings as:

1. Significant Risk Factors for ADHD Severity:

o Socioeconomic Status: Children from lower-income families exhibited more severe ADHD symptoms.

o Parental Education: Lower parental education, particularly primary-level, was associated with more severe ADHD symptoms.

o Parental Consanguinity: Children born to consanguineous parents exhibited higher severity of ADHD, suggesting a genetic component.

o Paternal Smoking: Fathers who smoked during their partner’s pregnancy were more likely to have children with severe ADHD symptoms.

o Maternal Folic Acid Intake: Mothers who took folic acid during pregnancy had children with less severe ADHD symptoms, highlighting the protective role of proper prenatal nutrition.

2. Other Factors:

o Younger maternal age (<25 years) was associated with more severe ADHD, possibly due to life stressors or less access to prenatal care.

o Omega-3 and iron intake during pregnancy showed trends toward reducing ADHD severity, though not statistically significant in this sample.

Ethics approval and consent to participate:
A prior ethical approval from IRB of the relevant institution was obtained. All methods were performed in accordance with the relevant guidelines and regulations. The study objectives and design were explained thoroughly by a team member to sponsor of every candidate then he/she signed an informed consent in case of acceptance before beginning of the study to insure complete satisfaction.

Consent for publication
The authors provide a consent for publication of this manuscript, appendices and details in this journal.

Competing interests:

The authors declare no competing interests nor conflict of interest.

Funding:

The study was funded by the authors.

Author Contribution

J.H and R.H conceptualized the study and collected data. A.S illustrated methods, designed questionnaire , and analyzed and interpreted data . All authors wrote and prepared original draft then reviewed and edited then agreed on the final version of the manuscript.

Data Availability

The data that support the findings of this study are available from the corresponding author upon reasonable request through email: [email protected]

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No competing interests reported.

Attention Deficit Hyperactivity Disorder Risk Factors Assessment and Correlation with Symptomatology among Children in Al Dakahlya Governorate

Status:

Version 1

Abstract

Background

Objectives

Methods

Results

Conclusion

Introduction

Methods

Results

Discussion

Comparison with Previous Studies:

Implications:

Limitations:

Conclusion

Declarations

Consent for publication
The authors provide a consent for publication of this manuscript, appendices and details in this journal.

Competing interests:

Funding:

Author Contribution

Data Availability

References

Additional Declarations

Supplementary Files

Status:

Version 1

Attention Deficit Hyperactivity Disorder Risk Factors Assessment and Correlation with Symptomatology among Children in Al Dakahlya Governorate

Status:

Version 1

Abstract

Background

Objectives

Methods

Results

Conclusion

Introduction

Methods

Results

Discussion

Comparison with Previous Studies:

Implications:

Limitations:

Conclusion

Declarations

Consent for publication The authors provide a consent for publication of this manuscript, appendices and details in this journal.

Competing interests:

Funding:

Author Contribution

Data Availability

References

Additional Declarations

Supplementary Files

Status:

Version 1

Consent for publication
The authors provide a consent for publication of this manuscript, appendices and details in this journal.