March 9, 2022
Previous meta-analyses have found an association between cesarean delivery (CD) and subsequent ADHD in children delivered in that manner. Some have theorized that by bypassing the birth canal, children delivered via CD may acquire their first microbiota from the hospital environment rather than from their mothers, which could disturb the normal development of the nervous system, including the brain.
Nevertheless, earlier studies have not fully explored the role of confounding factors.
A team of Swedish researchers availed themselves of the country's all-encompassing system of national population and health care registers to examine a cohort of over a 1.1 million single births from 1990 through 2003 and followed up through 2013.
They distinguished between planned CD and intrapartum (i.e., during the act of birth) CD. The latter is performed in response to complications with childbirth. This distinction could matter both because of different levels of exposure to the maternal gut microbiota, and because "intrapartum CD is often the result of complications during pregnancy (e.g., preeclampsia) or delivery (e.g., fetal distress), which could affect brain development."
Of 1,179,341 individuals, 1,048,838 were delivered vaginally, 59,514 were delivered by planned CD, and 70,989 were delivered by intrapartum CD.
After adjusting for the child's year of birth, gestational age, age of mother and father at birth, parity, mother's highest education level at birth, maternal smoking during pregnancy, maternal and paternal history of psychiatric disorders, maternal hypertension, maternal diabetes, maternal infections during pregnancy, fetal MAL presentation, large for gestational age, polyhydramnios, oligohydramnios, preeclampsia, and pelvic disproportion, children born by planned CD were 17% more likely to have ADHD.
After adjusting for all previously listed variables plus placenta disorders, dystocia failed induction, and fetal distress, children born by intrapartum CD were 10% more likely to have ADHD.
So far, the analysis confirmed results from previous meta-analyses.
But by exploring such a large cohort, it also became possible to compare ADHD prevalence, not only among unrelated individuals, but also among siblings and cousins, and thereby assess the role of confounders arising from genetics or shared environment.
Whether between full siblings or full maternal cousins, the associations between both types of CD and subsequent ADHD became weak and statistically non-significant.
The authors concluded, "The findings of this study suggest that the association between CD and increased risk of neurodevelopmental disorders in the children was most likely explained by unmeasured familial confounding."
Tianyang Zhang, Gustaf Brander, Ängla Mantel, RalfKuja-Halkola, Olof Stephansson, Zheng Chang, Henrik Larsson, David Mataix-Cols, Lorena Fernández de la Cruz, "Assessment of Cesarean Delivery and neurodevelopmental and Psychiatric Disorders in the Children of population-Based Swedish Birth Cohort,". JAMA Network Open(2020)4(3):e210837,https://doi:10.1001/jamanetworkopen.2021.0837.
Given the persistence of ADHD and its adverse effects on children and adolescents, one might expect caregivers to face greater parenting challenges, with potential effects on their own mental health.
To what extent do parenting stress, depression, and – at the extreme – even suicidal ideation manifest themselves among caregivers of ADHD patients as opposed to caregivers of children and adolescents without ADHD?
A pair of Korean researchers made use of their country’s single-payer health insurance system, which maintains records on virtually the entire population, to perform a nationwide population study. They used data from the Korean National Health and Nutrition Examination Surveys (KNHANES) covering the decade from 2011 to 2020. KNHANES is an annual survey using a sophisticated sampling design conducted by the Korean Ministry of Health and Welfare to represent the entire population of South Korea.
The analysis included 14,428 individuals who had children younger than 19 at the time of participation. All were asked whether their child had ever been diagnosed with ADHD by a physician. The mental health problems of the parents were assessed in terms of perceived stress, depressive symptoms, and suicidality.
Of the 14,428 participants, 8,298 (57.5 %) were mothers and 6,130 (42.5 %) were fathers. Of the mothers, 116 (1.4 %) had a child with ADHD, and of the fathers, 86 (1.4 %) had a child with ADHD.
The researchers adjusted for the following confounders: age of caregiver, education level, household income, area of residence, employment status, alcohol consumption, smoking status, cohabitation status, number of children, and child’s age.
After adjustment, mothers of ADHD patients fared significantly worse than mothers of typically developing children on all three categories of mental health problems. They were 67% more likely to report higher stress, three times as likely to report symptoms of depression, and 2.5 times more likely to report suicidal ideation.
Yet that pattern did not carry over to fathers, where there was no significant difference in mental health indicators between fathers of children with ADHD and fathers of children without ADHD.
The authors concluded, “Parents of children with ADHD, especially mothers, need community support and public health attention to help alleviate their mental health problems.”
Background:
ADHD is commonly accompanied by psychiatric comorbidities that complicate its diagnosis and treatment. Roughly two out of three affected children and adolescents have one or more comorbid psychiatric disorder.
Because the peak age of ADHD onset is typically a decade or more earlier than those for schizophrenia, depressive disorder, or bipolar disorder, it is essential to explore these comorbidities over an extended period. Populations studies help researchers identify broader patterns and trends within an entire population and includes adults as well as children. This type of study provides unique insights into the population at large, rather than a sample group.
In earlier studies the maximum follow-up period was twelve years, insufficient in view of the roughly ten years between onset of ADHD and onset of major psychiatric disorders. Also, previous nationwide population studies have included less than 150,000 participants.
This study, relying on data from South Korea’s universal single-payer health insurance system, included over one and a half million individuals. Persons previously diagnosed with depression, bipolar disorder, tic disorder, or schizophrenia were excluded.
382,434 individuals had been diagnosed with ADHD, while 1,169,279 were without an ADHD diagnosis.
Propensity score matching ensured that potential confounders, both sociodemographic and clinical, were equalized for the ADHD and control groups. After matching, there were 353,898 individuals in each group.
After these adjustments, individuals in the ADHD group were at least an order of magnitude more likely to subsequently be diagnosed with psychiatric disorders than their peers without an ADHD diagnosis:
Conclusion:
The Korean study team concluded, “Overall, our findings suggest that upon prolonged examination, the risk of subsequent diagnoses of other psychiatric disorders in individuals with ADHD appears to be higher than that reported previously. … Therefore, patients with ADHD should be carefully screened for the presence of other psychiatric symptoms on a regular basis from an earlier age … It is advisable to have a follow-up period extending beyond 10 years to sufficiently identify the occurrence of comorbid disorders in patients with ADHD.”
Children with ADHD often face challenges in social interactions, leading to long-term consequences if not properly addressed. While various interventions exist, many fail to consider the broader social context in which these children interact. A recent study conducted in Bergen, Norway, explored how primary school teachers perceive their role in supporting children with ADHD who struggle socially and the strategies they use to assist them.
Researchers conducted semi-structured interviews with five focus groups of primary school teachers. Using reflexive thematic analysis, they identified two major themes:
Rather than relying on standardized interventions, teachers tailored their strategies to foster an inclusive and supportive social environment. Their methods included both active participation in social situations and behind-the-scenes efforts to encourage peer inclusion and understanding.
This study underscores the need to move beyond labels and recognize children with ADHD as individuals with distinct social needs. Teachers play a crucial role in shaping these children’s experiences, using flexible and personalized approaches to promote positive social interactions. By integrating social context and individualized support, educators can help children with ADHD build meaningful connections and navigate their social world more effectively.
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