ArticlePDF Available

Abstract and Figures

Objective: We examined the association of neighborhood social and physical characteristics with ADHD, accounting for individual and family factors. Method: The 2007 National Survey of Child Health, a nationally representative data set, was used (N = 64,076). Three neighborhood scales were generated: social support, amenities, and disorder. Logistic and ordinal logistic regressions were conducted to examine the association of these scales with ADHD diagnosis and severity while adjusting for individual and family characteristics. Results: Eight percent had a child with ADHD: 47% described as mild, 40% moderate, and 13% severe. In adjusted models, lower neighborhood support was associated with increased ADHD diagnosis (odds ratio [OR] = 1.66 [1.05, 2.63]) and severity (OR = 3.74 [1.71, 8.15]); neighborhood amenities or disorder were not significantly associated. Poor parental mental health was associated with ADHD prevalence and severity. Conclusion: Neighborhood social support is a potential area of intervention for children with ADHD and their caregivers. Research challenges and opportunities are discussed.
Content may be subject to copyright.
Journal of Attention Disorders
The online version of this article can be found at:
DOI: 10.1177/1087054714542002
published online 15 July 2014Journal of Attention Disorders
Nooshin Razani, Joan F. Hilton, Bonnie L. Halpern-Felsher, Megumi J. Okumura, Holly E. Morrell and Irene H. Yen
Neighborhood Characteristics and ADHD: Results of a National Study
Published by:
can be found at:Journal of Attention DisordersAdditional services and information for Alerts:
What is This?
- Jul 15, 2014OnlineFirst Version of Record >>
at LOMA LINDA UNIV LIBRARY on July 17, 2014jad.sagepub.comDownloaded from at LOMA LINDA UNIV LIBRARY on July 17, 2014jad.sagepub.comDownloaded from
Journal of Attention Disorders
1 –10
© 2014 SAGE Publications
Reprints and permissions:
DOI: 10.1177/1087054714542002
ADHD is the most commonly diagnosed psychiatric condi-
tion in childhood: National estimates of prevalence range
from 8% to 10% of U.S. children (Bloom, Cohen, &
Freeman, 2011; Centers for Disease Control and Prevention
[CDC], 2010). ADHD is a highly heritable condition
(Faraone et al., 2005). Nongenetic factors such as preterm
birth, low birth weight, prenatal tobacco exposure, and
socioeconomic status have also been associated with ADHD
(Nigg, Nikolas, & Burt, 2010; Russell, Ford, Rosenberg, &
Kelly, 2014). We are interested in whether neighborhood, in
other words, the social and physical environment where
young people spend their time, is associated with ADHD.
Previous research suggests that children with ADHD are
sensitive to place. A series of cross-sectional and interven-
tional studies show that natural settings are associated with
better impulse control and attention span in children with
ADHD (Kuo & Taylor, 2004; Taylor, 2001; Taylor & Kuo,
2009). Geographic variation has been shown in the preva-
lence of ADHD, and interestingly, correlated with sun expo-
sure (Arns, van der Heijden, Arnold, & Kenemans, 2013).
Children with ADHD may also benefit from living in
neighborhoods that promote physical activity. Physical
activity has been associated with improved cognition and
behavior in the general population (Archer & Kostrzewa,
2012; Gapin, Labban, & Etnier, 2011) and improved
symptoms in children with ADHD (Medina et al., 2010).
Neighborhood amenities that increase physical activity
include the presence of recreation centers, sidewalks, mixed
land use providing a variety of walking destinations (such
as a library), and nearby parks and playgrounds (Ding,
Sallis, Kerr, Lee, & Rosenberg, 2011; Mota, Almeida,
Santos, & Ribeiro, 2005; Veitch et al., 2012). Other neigh-
borhood factors such as a lack of safety, or neighborhood
disorder in the form of vandalism and graffiti detract from
physical activity.
A neighborhoods’ social environment, the presence of
social networks, trust, cooperation, and sense of safety
among neighbors has been protective for a variety of
health outcomes including other mental health conditions
(Chung & Docherty, 2011; Evans, 2003; Leventhal &
Brooks-Gunn, 2000). There is reason to believe that these
associations would apply to ADHD as well. Improved
support for mothers of children with ADHD has been
shown to improve psychological measures such as per-
ceived stress, anxiety, and depression (Lovell, Moss, &
542002JADXXX10.1177/1087054714542002Journal of Attention DisordersRazani et al.
1University of California at San Francisco, USA
Corresponding Author:
Nooshin Razani, UCSF Benioff Children’s Hospital Oakland, 5220
Claremont Ave., Oakland, CA 94609, USA.
Neighborhood Characteristics and ADHD:
Results of a National Study
Nooshin Razani1, Joan F. Hilton1, Bonnie L. Halpern-Felsher1,
Megumi J. Okumura1, Holly E. Morrell1, and Irene H. Yen1
Objective: We examined the association of neighborhood social and physical characteristics with ADHD, accounting
for individual and family factors. Method: The 2007 National Survey of Child Health, a nationally representative data set,
was used (N = 64,076). Three neighborhood scales were generated: social support, amenities, and disorder. Logistic and
ordinal logistic regressions were conducted to examine the association of these scales with ADHD diagnosis and severity
while adjusting for individual and family characteristics. Results: Eight percent had a child with ADHD: 47% described
as mild, 40% moderate, and 13% severe. In adjusted models, lower neighborhood support was associated with increased
ADHD diagnosis (odds ratio [OR] = 1.66 [1.05, 2.63]) and severity (OR = 3.74 [1.71, 8.15]); neighborhood amenities
or disorder were not significantly associated. Poor parental mental health was associated with ADHD prevalence and
severity. Conclusion: Neighborhood social support is a potential area of intervention for children with ADHD and their
caregivers. Research challenges and opportunities are discussed. (J. of Att. Dis. XXXX; XX(X) XX-XX)
ADD/ADHD, childhood, parks, physical activity, neighborhood characteristics, parental functioning
at LOMA LINDA UNIV LIBRARY on July 17, 2014jad.sagepub.comDownloaded from
2 Journal of Attention Disorders
Wetherell, 2012). Is it possible that improved social sup-
port at the neighborhood level will buffer the stresses
associated with ADHD?
Curtis et al. (2013) create a conceptual framework link-
ing neighborhood conditions to mental health. This frame-
work shows interplay between neighborhood physical
characteristics and social factors that influence causal path-
ways in mental health. These neighborhood or community-
level factors interact with individual and family attributes
that may put the person at risk of mental health
While there is a theoretic association of ADHD and
neighborhood physical and social characteristics suggested
by these studies, we are not aware at studies looking at the
potential and compared relationship. Using a nationally
representative survey of children in the United States, we
examine the relationship between neighborhood character-
istics and ADHD, while accounting for individual and fam-
ily level factors. The aims of the present study were to
determine whether:
1. Neighborhood social characteristics such as trust
among neighbors and perceived safety (social sup-
port), plus physical characteristics such as side-
walks, libraries, recreation centers, parks, and
disorder, are associated with ADHD prevalence.
2. These neighborhood social characteristics and phys-
ical characteristics are associated with ADHD
3. These findings hold true after controlling for indi-
vidual and family characteristics.
We hypothesized that greater neighborhood social sup-
port and amenities, and that less neighborhood disorder
would be associated with lower ADHD prevalence and
Data Set
This is a secondary data analysis of the 2007 National
Survey of Children’s Health (NSCH). This telephone sur-
vey was conducted as part of the State and Local Area
Integrated Telephone Survey Program (http://www.cdc.
gov/nchs/slaits/nsch.htm#2007nsch) by the National Center
for Health Statistics with funding from the Maternal Child
Health Bureau and CDC. Telephone interviews were con-
ducted in English, Spanish, Mandarin, Cantonese,
Vietnamese, or Korean. Sampling weights were provided
by the NSCH to represent the entire noninstitutionalized
child population in the United States. Further description of
the sampling methodology is described elsewhere
(Blumberg et al., 2012).
The study participant was the adult in eligible families who
knew the most about the sample child’s health. (In 94% of
cases, this was the mother or father; hence, we will refer to
the respondent as the parent.) We limited the sample to chil-
dren of age 6 and above, which was the age range specified
by the Diagnostic and Statistical Manual of Mental
Disorders (4th ed.; DSM-IV; American Psychiatric
Association, 1994) definition of ADHD in place when the
data were collected (N = 64,076, 70% of 91,642 total
ADHD prevalence and severity. Children were identified as
having ADHD if the parent answered yes to both of the fol-
lowing questions: “Has a doctor or health care provider ever
told you that [sample child] has ADHD or ADD?” followed
by, “Does [sample child] currently have [ADHD or ADD]?”
Parents were asked, “Would you describe [sample child’s]
illness as mild, moderate, or severe?” For analysis, severity
was limited to children with ADHD and scored as: mild (1),
moderate (2), and severe (3).
Family characteristics. Characteristics of the family environ-
ment were chosen based on previously recognized associa-
tions with ADHD, including race/ethnicity (non-Hispanic
White, Hispanic, non-Hispanic Black, and Other; Merikan-
gas et al., 2010), income as percentage of federal poverty
level (greater than 400% federal poverty level, 200%-400%
federal poverty level, and less than 200% federal poverty
level), family structure (two biological or adoptive parents,
two parents with at least one step-parent, one parent house-
hold, and other family structures), maternal education
(greater than high school, high school, less than high
school), and self-reported maternal mental health (excel-
lent/very good, good, or fair/poor; Blackwell, 2010; John-
ston & Mash, 2001; Nigg et al., 2010).
Neighborhood characteristics. Twelve questions survey
neighborhood social and physical characteristics. Initial
analysis was run using each variable independently. As sev-
eral of the variables were correlated, the analysis was
repeated using a collapsed set of categories.
To create categories, principal components analysis was
conducted using a polychoric correlation matrix to account
for the combination of ordinal and binary variables
(Kolenikov & Angeles, 2004). Three unique components
were chosen based on the results of a parallel analysis
(Hayton, Allen, & Scarpello, 2004). The component-based
scales described below were created by using variables with
loading scores greater than 0.3. Internal consistency of
these scales was confirmed using Cronbach’s alpha. These
at LOMA LINDA UNIV LIBRARY on July 17, 2014jad.sagepub.comDownloaded from
Razani et al. 3
categories are also consistent with scales of support, ameni-
ties, and disorder used by others (Ding et al., 2011; Grootaert
& van Bastelaer, 2001; Sampson & Raudenbush, 1999).
The first scale, “Neighborhood Support,” comprised five
questions (Figure 1), with four-point Likert-type scale
responses. The nonmissing values for each respondent were
averaged to generate a four-point scale. We converted the
resulting scale, ranging from 1 to 4, to a categorical scale, with
“low” (1.0-1.9), “medium” (2.0-3.9), and “high” (4) levels of
support. After generating the scale, 3% had a missing value.
The second scale, “Neighborhood Amenities,” com-
prised four questions (Figure 1), with yes (1) or no (0)
answers each. Nonmissing responses were summed to gen-
erate a scale that ranges from 0 to 4. The data are presented
as “none” (zero amenities), “some” (1-3 amenities), and
“all” (4 amenities). After generating the scale, 2% had a
missing value because one or more questions were
The final scale, “Neighborhood Disorder,” comprised
three questions (Figure 1) with yes/no answers. Nonmissing
responses were summed to create a scale that ranged from 0
to 3. We present the data in three categories: “none” (zero
markers for disorder), “some” (1-2 markers of disorder),
and “all” (3 markers of disorder). After the scales were gen-
erated, 1% had a missing value because one or more ques-
tions were missing.
Statistical Analysis
We present the overall distributions of each of the neighbor-
hood and family characteristics, as well as the distributions
of the family characteristics within each of the neighbor-
hood characteristics (Table 1). We performed descriptive
statistics on family characteristics and neighborhood char-
acteristics using the Cochran–Mantel–Haenszel chi-square
We conducted a series of unadjusted logistic regression
analyses predicting odds of reported ADHD diagnosis with
individual, family, and neighborhood characteristics, a mul-
tivariate logistic regression analysis predicting odds of
ADHD prevalence with neighborhood characteristics after
controlling for individual and family—covariates, and an
analogous set of unadjusted and multivariate ordinal logis-
tic regression analyses to examine the influence of family—
and neighborhood characteristics on three levels of ADHD
severity. Given that a child’s age and sex are recognized
covariates of ADHD prevalence, we controlled for them in
the final multivariable models (Mick, Faraone, &
Biederman, 2004; Rucklidge, 2010). All analyses were con-
ducted using Stata 11 (College Station, TX), accounting for
the complex sampling design.
Sample Characteristics
Most respondents reported medium to high Neighborhood
Support, medium to high Neighborhood Amenities, and low
Neighborhood Disorder. Four percent of parents reported
feeling low Support, 5% reported having no Amenities, and
4% reported having all three markers of Neighborhood
Neighborhood Support
How much do you agree or disagree with each of these statements about your neighborhood or community:
“People in this neighborhood help each other out”
“We watch out for each other’s children in this neighborhood”
“There are people I can count on in this neighborhood”
“If my child were outside playing and got hurt or scared, there are adults nearby who I trust to help my child”
How often do you feel your child is safe in your neighborhood?
Neighborhood Amenities
Which of the following are available in your neighborhood, even if your child does not use them?
A park or playground area
Sidewalks or walking paths
A library or bookmobile
A recreation center, community center, boys’ or girls’ club
Neighborhood Disorder
Which of the following exist in your neighborhood?
Litter or garbage on the street or sidewalks
Poorly kept or delapidated housing
Vandalism such as broken windows or graffiti.
Figure 1. 2007 National Survey of Child Health Neighborhood Scales.
at LOMA LINDA UNIV LIBRARY on July 17, 2014jad.sagepub.comDownloaded from
4 Journal of Attention Disorders
Neighborhood characteristics varied by socioeconomic
status (Table 1). A higher proportion of White respondents
reported higher Neighborhood Support (69%) than the pro-
portion of Hispanic (13%) or African American (10%)
respondents. Higher income, maternal education, parental
mental health levels, and two parent (biological or adoptive)
households are represented at higher proportions in the
higher Neighborhood Support categories, as well as with
more Amenities and less Disorder. Of note, only 4% of care-
givers who stated they had high Neighborhood Support
reported poor mental health, whereas 26% of those with low
Neighborhood Support reported poor mental health. Each of
these associations was statistically significant at p < .01.
ADHD Diagnosis, Controlling for Neighborhood,
and Family Factors
Eight percent of participants reported having a child with
ADHD. ADHD prevalence among children with low
Neighborhood Support was 15%, as compared with 7% to
8% in those with more Social Support (Table 2). The
prevalence of ADHD was also higher among individuals
reporting high Neighborhood Disorder, low incomes,
lower maternal mental health, and households not headed
by two biological or adoptive parents. Low Neighborhood
Support remained associated with higher ADHD preva-
lence after adjusting for child, family, and other neighbor-
hood variables (odds ratio [OR] = 1.66; 95% confidence
intervals [CI] = [1.05, 2.63]). Neighborhood Disorder and
Amenities were not associated with higher ADHD preva-
lence. Lower levels of reported maternal mental health
were associated with higher ADHD prevalence with an
odds ratio of 3.03 (95% CI = [2.35, 3.91]), family struc-
tures other than two biological or adoptive parents were
also associated with higher ADHD, while non-White
race/ethnicity and lower maternal education had lower
ADHD Severity, Controlling for Neighborhood,
and Family Factors
Of those with ADHD, 47% have mild symptoms, 40% mod-
erate symptoms, and 13% were described as severe. Lower
Neighborhood Support was associated with higher ADHD
Table 1. U.S. NSCH 2007 Results: Distributions of Family Characteristics, Overall and Within Level of Neighborhood
Neighborhood characteristics
Support (%) Amenities (%) Disorder (%)
Family characteristics Full sample N = 64,076 (%) Low Medium High None Some All None Some All
White 57 29 56 69 64 60 55 61 50 34
Hispanic 19 33 20 13 18 19 18 18 23 24
Black 15 31 16 10 12 13 17 13 17 32
Other 8 7 9 8 6 7 10 8 10 9
Income as percentage of federal poverty level
Greater than 400 30 8 29 40 18 28 34 35 18 10
200-400 33 19 33 34 33 33 32 33 32 25
Less than 200 37 74 38 26 49 39 33 31 50 66
Maternal education
Greater than high school 62 35 62 68 49 59 67 66 54 40
High school or equivalent 26 39 26 23 34 27 25 24 31 38
Less than high school 12 26 12 9 17 14 9 10 15 23
Maternal mental health
Very good/excellent 71 43 69 82 62 69 74 74 64 54
Good 21 27 22 15 27 22 19 20 24 27
Poor/fair 8 29 8 4 11 9 7 6 12 19
Family structure
Two parent, biological or adoptive 63 37 62 71 62 63 62 66 57 42
One parent 20 44 20 14 18 20 20 18 24 36
Two parent, at least one step 10 11 10 10 10 10 10 10 11 14
All others 7 8 7 6 10 7 7 7 7 8
Note. NSCH = National Survey of Children’s Health.
at LOMA LINDA UNIV LIBRARY on July 17, 2014jad.sagepub.comDownloaded from
Razani et al. 5
severity, after controlling for age, sex, other family and
neighborhood factors (Table 3; OR = 3.74; 95% CI = [1.71,
8.15]). The presence of Neighborhood Amenities was not
significantly associated with decreased reported ADHD
severity (OR = 1.56; 95% CI = [0.91, 2.68]), although the
increasing odds with decreasing amenities score suggests a
potential relationship. Reported poor parental mental health
and lower income were associated with increased ADHD
In this nationally representative sample of U.S. children, we
found that lower neighborhood social support was associ-
ated with higher odds of ADHD diagnosis and higher
ADHD severity, even after taking into consideration age,
sex, family, income, and other neighborhood characteris-
tics. Neighborhood amenities and disorder were not statisti-
cally associated with ADHD prevalence or severity.
Table 2. U.S. NSCH 2007 Results: Neighborhood and Family Level Associations With Odds of ADHD Diagnosis (n = 52,084).
OR of ADHD (95% CI)
% ADHD prevalence Unadjusted Adjusted
Full sample 8
Neighborhood characteristics
Neighborhood support
High 7 Ref Ref
Medium 8 1.21 [1.03, 1.43] 1.13 [0.94, 1.37]
Low 15 2.28 [1.50, 3.48] 1.66 [1.05, 2.63]
Neighborhood amenities
All (4 of 4) 8 Ref Ref
Some (1-3 of 4) 9 1.13 [0.98, 1.38] 1.12 [0.96, 1.30]
None (zero of 4) 8 1.06 [0.83, 1.36] 0.90 [0.66, 1.24]
Neighborhood disorder
None (zero of 3) 8 Ref Ref
Some (1-2 of 3) 9 1.12 [0.95, 1.30] 0.96 [0.81, 1.14]
All (3 of 3) 13 1.78 [1.29, 2.47] 1.43 [0.96, 2.15]
Family characteristics
White (non-Hispanic) 9 Ref Ref
Hispanic 5 0.51 [0.39, 0.67] 0.44 [0.30, 0.65]
Black (non-Hispanic) 9 1.00 [0.82, 1.21] 0.62 [0.48, 0.80]
Other (non-Hispanic) 8 0.88 [0.69, 1.12] 0.81 [0.62, 1.07]
Income as percentage of federal poverty level
Greater than 400 7 Ref Ref
200-400 8 1.01 [0.84, 1.21] 0.89 [0.73, 1.09]
Less than 200 10 1.36 [1.13, 1.63] 1.09 [0.87, 1.38]
Maternal education
Greater than high school 8 Ref Ref
High school or equivalent 9 1.15 [0.98, 1.36] 0.96 [0.80, 1.15]
Less than high school 7 0.91 [0.70, 1.16] 0.69 [0.51, 0.93]
Maternal mental health
Very good/excellent 6 Ref Ref
Good 10 1.59 [1.34, 1.87] 1.61 [1.34, 1.93]
Poor/fair 19 3.42 [2.69, 4.35] 3.03 [2.35, 3.91]
Family structure
Two parent, biological/
6 Ref Ref
One parent 11 2.29 [1.93, 2.71] 1.93 [1.58, 2.36]
Two parents, step-parent 13 1.99 [1.63, 2.43] 1.76 [1.42, 2.17]
All other family structures 12 2.15 [1.72, 2.68] 2.31 [1.34, 3.99]
Note. Adjusted model included age and sex. NSCH = National Survey of Children’s Health; OR = odds ratio; CI = confidence interval.
at LOMA LINDA UNIV LIBRARY on July 17, 2014jad.sagepub.comDownloaded from
6 Journal of Attention Disorders
Individuals with ADHD have elevated stress levels and
poorer recovery from stress than control groups
(Lackschewitz, Huther, & Kroner-Herwig, 2008). Families
living with ADHD have been shown to have increased
stresses such conflict compared with controls (Russell et
al., 2014). One explanation for our findings is that neigh-
borhood social support serves as buffer for these stressors, a
potential added factor in creating resiliency, and that its
absence exacerbates ADHD in those at genetic risk
(Modesto-Lowe, Yelunina, & Hanjan, 2011). For children
with ADHD, who often have social dysfunction because of
inattention, hyperactivity, and impulsivity (Nijmeijer et al.,
2008), a neighborhood with social support may provide
added opportunity to create social bonds beyond those from
school or home environments.
Neighborhood social conditions have been associated
with other mental health conditions. Perceived or actual
poor neighborhood safety increases the risk of externalizing
problems such as generalized misconduct, delinquency,
hostility, and violent behaviors as well as greater risk of
internalizing problems such as depression, distress, and
anxiety (Curtis et al., 2013). Social capital, defined as trust,
community participation, and community/individual net-
works have been associated with mood disorders, such that
Table 3. U.S. NSCH 2007 Results: ADHD Severity and Neighborhood, Family Characteristics (n = 4,290).
Odds for increased ADHD severity OR (95% CI)
Unadjusted Adjusted
Neighborhood characteristics
Neighborhood support
High Ref Ref
Medium 1.37 [1.03, 1.83] 1.22 [0.89, 1.66]
Low 4.60 [2.76, 7.66] 3.74 [1.71, 8.15]
Neighborhood amenities
All (4 of 4) Ref Ref
Some (1-3 of 4) 1.73 [1.23, 2.45] 1.27 [0.94, 1.70]
None (0 of 4) 1.39 [1.07, 1.80] 1.56 [0.91, 2.68]
Neighborhood disorder
None (zero of 3) Ref Ref
Some (1-2 of 3) 1.38 [1.02, 1.86] 1.05 [0.75, 1.48]
All (3 of 3) 1.56 [0.81, 3.01] 0.84 [0.42, 1.68]
Family characteristics
White (non-Hispanic) Ref Ref
Hispanic 0.69 [0.40, 1.18] 0.60 [0.34, 1.05]
Black (non-Hispanic) 1.12 [0.77, 1.65] 0.74 [0.46, 1.18]
Other (non-Hispanic) 1.40 [1.00, 1.94] 1.67 [0.96, 2.90]
Income as percentage of federal poverty level
Greater than 400 Ref Ref
200-400 1.77 [1.27, 2.47] 1.77 [1.26, 2.49]
Less than 200 2.44 [1.74, 3.43] 1.81 [1.15, 2.83]
Maternal education
Greater than high school Ref Ref
High school or equivalent 1.48 [1.12, 1.97] 0.99 [0.71, 1.38]
Less than high school 1.31 [0.75, 2.28] 0.79 [0.42, 1.50]
Maternal mental health
Very good/excellent Ref Ref
Good 1.66 [1.24, 2.24] 1.33 [0.95, 1.87]
Poor/fair 2.91 [1.90, 4.48] 2.04 [1.22, 3.42]
Family structure
Two parent, biological/adoptive Ref Ref
One parent 1.69 [1.25, 2.29] 1.14 [0.77, 1.69]
Two parents, step-parent 1.34 [0.91, 1.97] 0.95 [0.62, 1.45]
All other family structures 1.13 [0.75, 1.68] 1.35 [0.50, 3.64]
Note. Adjusted model included age and sex. NSCH = National Survey of Children’s Health; OR = odds ratio; CI = confidence interval.
at LOMA LINDA UNIV LIBRARY on July 17, 2014jad.sagepub.comDownloaded from
Razani et al. 7
low social capital is associated with depression, anxiety,
and schizophrenia (Whitley & McKenzie, 2005).
The associations between neighborhood social condi-
tions and mental health may be applied to ADHD. In the
presence of externalizing or internalizing comorbidities
(such as anxiety or depression), having poor neighborhood
conditions may lead to increased diagnosis, or reported
severity of ADHD. While we did not adjust for comorbidi-
ties in this study, future research should investigate how
depression, anxiety, and misconduct may mediate the rela-
tionship between neighborhood and ADHD.
Modesto-Lowe et al. (2011) present a resilience frame-
work to explain the variability in the clinical, academic, and
social course of ADHD: In teen studies, 20% do well, 20%
do poorly, and 60% are somewhere in between. A resilient
life trajectory is one where individuals have tools to adapt
to adversity throughout their life span. In Modesto-Lowe’s
review they find that the best predictor of success with
ADHD (defined as being an adapted adult) is not IQ, aca-
demic achievement, or classroom behavior, but peer rela-
tionships. Modesto-Lowe et al. (2011) argue that there is a
need to find strategies for social competence in children
with ADHD. We propose that interventions at the neighbor-
hood level, which create opportunities to socialize, and a
feeling of support and trust at home, may be helpful for
families with ADHD.
Secure attachment, experiencing positive emotions, and
having a purpose in life are three important aspects of resil-
ience in mental health in general. For families with a child
with ADHD, social support at the neighborhood level may
improve parental mental health and therefore opportunities
for secure attachment for children. As reviewed above, fam-
ilies dealing with ADHD may need even more support than
other families. Parents may feel overwhelmed, depressed,
or in need of support. Neighborhood social support may
also help resilience in that a decrease in the child’s ADHD
may improve the child’s behavior, and therefore parental
mental health. Neighborhood support as we defined it—
perceived neighborhood trust and perceived safety—has
been associated with parents’ willingness to allow their
children to play in outdoor public places and to use avail-
able amenities (Evans, 2006; Rosenberg et al., 2009). In
supportive settings even where there are amenities such as
parks, children may be able to experience neighborhood
nature or to be physical active.
An important area of future research is how neighbor-
hood characteristics may be associated with mental health
outcomes for caregivers of children with ADHD. The
respondents in our study with low neighborhood support,
low amenities, and high disorder reported poor mental
health in the parent. In addition, poor maternal mental
health remained associated with ADHD in the final model.
Prior research has attributed poor mental health among par-
ents of children with ADHD with behavior problems or
oppositional behavior that can accompany ADHD
(Pimentel, Vieira-Santos, Santos, & Vale, 2011). It is easy to
imagine that these issues may be exacerbated in families
with ADHD where there is low neighborhood support, low
amenities, and high disorder. In Bartlett’s qualitative study
of families living in high-rises located in a neighborhood
with low perceived trust and safety, he describes how chil-
dren are kept indoors for much of the day, and mothers and
children had fewer opportunities to be outdoors to meet and
create social networks with neighbors. In the cases he fol-
lows, the missed opportunities for creating a safety net
among neighbors and restlessness among children kept
indoors all day contributed to family conflict and stress
(Bartlett, 1998). Cooper-Marcus’s observation of public
housing showed that the arrangement of public spaces is
related to when and how tenants have the opportunity to
socialize with each other, and how supported parents felt in
child care and in allowing their children to play outdoors
(Marcus, 2001; Marcus & Francis, 1998).
We did not find significant associations with neighbor-
hood physical characteristics as surveyed in the NSCH.
This finding dovetails with a variety of other work showing
more pronounced effect for neighborhood social than phys-
ical characteristics for mental health (Gidlow, Cochrane,
Davey, Smith, & Fairburn, 2010). Given the evidence that
children with ADHD benefit from time in nature, sunshine,
and from physical activity, it will be important to create
valid measures of neighborhood exposure before discount-
ing the importance of physical characteristics in the neigh-
borhood. The NSCH survey used in this study assessed for
the presence of a variety of neighborhood amenities and
detractors, but does not establish how often children were
exposed to amenities such as parks, and how often they
were outside in their neighborhood. In our case, it is of note
that the linear relationship between neighborhood amenities
and ADHD suggests that there may be a potential
There are several limitations to this study. Relying on
parental report to measure ADHD severity in a child may
introduce measurement bias. The total prevalence of ADHD
in this sample may be overreported as the survey methodol-
ogy did not ask parents to distinguish whether ADHD diag-
noses were made by primary care providers or psychiatrists.
Inattentive children with mood disorders, anxiety disorders,
learning disabilities, or even autism may be misdiagnosed
as having ADHD. These misdiagnoses may have increased
the number of children who were diagnosed as having
ADHD or having “severe ADHD” as maternal depression,
mood disorders, and anxiety can show up in children whose
parents have mood and anxiety disorders. In future research
looking at ADHD and neighborhood conditions, parental
report should be corroborated by psychiatrist or develop-
mental pediatrician evaluation.
Future investigations are needed to determine how par-
ent, child, and investigator report of ADHD symptoms in a
range of neighborhood environments would be useful in
at LOMA LINDA UNIV LIBRARY on July 17, 2014jad.sagepub.comDownloaded from
8 Journal of Attention Disorders
assessing potential bias. Future analysis should look at the
potential role for mental health comorbidities which may be
on the causal pathway between neighborhood support and
ADHD. As this is a cross-sectional study, longitudinal
research will be necessary to tease out the potential causal
relationship between neighborhood social support and
ADHD. How the social and physical characteristics of a
neighborhood may interact in the context of ADHD is an
important area or further research.
Despite these limitations, the strengths of this study
include a large sample size and random survey sampling
design that create a unique opportunity to study ADHD in
the context of neighborhood characteristics across a repre-
sentative sample of noninstitutionalized children in the
United States. This is the first nationally representative
study of ADHD and neighborhood, family, and sociodemo-
graphic associations. Although ADHD is known to have a
strong genetic component, national studies such as this one
remind us of the importance of applying a public health per-
spective to ADHD, as finding neighborhood level correlates
implies there are multiple levels of opportunity for inter-
vention. Our study suggests that increasing neighborhood
social support—in the form of trust among neighbors, and
perceived safety—could positively affect the prevalence
and severity of ADHD.
We would like to thank Dr. Michael Cabana, Dr. Mark Miller, and
Rebecca Scherzer for their assistance in preparing this
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
American Psychiatric Association. (1994). Diagnostic and statis-
tical manual of mental disorders (4th ed.). Washington, DC:
Archer, T., & Kostrzewa, R. M. (2012). Physical exercise alle-
viates ADHD symptoms: Regional deficits and development
trajectory. Neurotoxicity Research, 21, 195-209. doi:10.1007/
Arns, M., van der Heijden, K. B., Arnold, L. E., & Kenemans,
J. L. (2013). Geographic variation in the prevalence of
attention-deficit/hyperactivity disorder: The sunny perspec-
tive. Biological Psychiatry, 74, 585-590. doi:10.1016/
Bartlett, S. (1998). Does inadequate housing perpetuate children’s
poverty? Childhood, 5, 403-420.
Blackwell, D. L. (2010). Family structure and children’s health
in the United States: Findings from the National Health
Interview Survey, 2001-2007 (Vital and Health Statistics,
Series 10, No. 246, pp. 1-166). Retrieved from http://www.
Bloom, B., Cohen, R. A., & Freeman, G. (2011). Summary
health statistics for U.S. children: National Health Interview
Survey, 2010 (Vital and Health Statistics, Series 10, No.
250, pp. 1-80). Retrieved from
Blumberg, S. J., Foster, E. B., Frasier, A. M., Satorius, J., Skalland,
B. J., Nysse-Carris, K. L., . . .O’Connor, K. S. (2012). Design
and operation of the National Survey of Children’s Health,
2007 (Vital and Health Statistics, Series 1, No. 55, pp. 1-149).
Retrieved from
Centers for Disease Control and Prevention. (2010). Increasing
prevalence of parent-reported attention-deficit/hyperac-
tivity disorder among children—United States, 2003 and
2007. Morbidity and Mortality Weekly Report, 59, 1439-
1443. Retrieved from
Chung, H. L., & Docherty, M. (2011). The protective function of
neighborhood social ties on psychological health. American
Journal of Health Behavior, 35, 785-796.
Curtis, S., Pain, R., Fuller, S., Khatib, Y., Rothon, C., Stansfeld, S.
A., & Daya, S. (2013). Neighbourhood risk factors for com-
mon mental disorders among young people aged 10-20 years:
A structured review of quantitative research. Health Place,
20, 81-90. doi:10.1016/j.healthplace.2012.10.010
Ding, D., Sallis, J. F., Kerr, J., Lee, S., & Rosenberg, D. E. (2011).
Neighborhood environment and physical activity among
youth a review. American Journal of Preventive Medicine,
41, 442-455. doi:10.1016/j.amepre.2011.06.036
Evans, G. W. (2003). The built environment and mental health.
Journal of Urban Health, 80, 536-555. doi:10.1093/jurban/
Evans, G. W. (2006). Child development and the physical envi-
ronment. Annual Review of Psychology, 57, 423-451.
Faraone, S. V., Perlis, R. H., Doyle, A. E., Smoller, J. W.,
Goralnick, J. J., Holmgren, M. A., & Sklar, P. (2005).
Molecular genetics of attention-deficit/hyperactivity disor-
der. Biological Psychiatry, 57, 1313-1323. doi:10.1016/
Gapin, J. I., Labban, J. D., & Etnier, J. L. (2011). The effects of
physical activity on attention deficit hyperactivity disorder
symptoms: The evidence. Preventive Medicine, 52(Suppl. 1),
S70-S74. doi:10.1016/j.ypmed.2011.01.022
Gidlow, C., Cochrane, T., Davey, R. C., Smith, G., & Fairburn,
J. (2010). Relative importance of physical and social aspects
of perceived neighbourhood environment for self-reported
health. Preventive Medicine, 51, 157-163. doi:10.1016/j.
Grootaert, C., & van Bastelaer, T. (Eds.). (2001). Understanding
and measuring social capital: A synthesis of findings and
at LOMA LINDA UNIV LIBRARY on July 17, 2014jad.sagepub.comDownloaded from
Razani et al. 9
recommendation for the social capital initiative. Washington,
DC: The World Bank.
Hayton, J. C., Allen, D. G., & Scarpello, V. (2004). Factor reten-
tion decisions in exploratory factor analysis: A tutorial on par-
allel analysis. Organizational Research Methods, 7, 191-205.
Johnston, C., & Mash, E. J. (2001). Families of children with
attention-deficit/hyperactivity disorder: Review and recom-
mendations for future research. Clinical Child and Family
Psychology Review, 4, 183-207.
Kolenikov, S., & Angeles, G. (2004). The use of discrete data in
PCA: Theory, simulations, and applications to socioeconomic
indices. Retrieved from
Kuo, F. E., & Taylor, A. F. (2004). A potential natural treatment
for attention-deficit/hyperactivity disorder: Evidence from
a national study. American Journal of Public Health, 94,
Lackschewitz, H., Huther, G., & Kroner-Herwig, B. (2008).
Physiological and psychological stress responses in adults
with attention-deficit/hyperactivity disorder (ADHD).
Psychoneuroendocrinology, 33, 612-624. doi:10.1016/j.psy-
Leventhal, T., & Brooks-Gunn, J. (2000). The neighborhoods they
live in: The effects of neighborhood residence on child and
adolescent outcomes. Psychological Bulletin, 126, 309-337.
Lovell, B., Moss, M., & Wetherell, M. A. (2012). With a little help
from my friends: Psychological, endocrine and health corol-
laries of social support in parental caregivers of children with
autism or ADHD. Research in Developmental Disabilities,
33, 682-687. doi:10.1016/j.ridd.2011.11.014
Marcus, C. C. (2001, March). The neighborhood approach to
building community: Different perspectives on smart growth.
Western City Magazine.
Marcus, C. C., & Francis, C. (1998). People places: Design guide-
lines for Urban Open Spaces (2nd ed.). Danvers, MA: John
Medina, J. A., Netto, T. L., Muszkat, M., Medina, A. C., Botter,
D., Orbetelli, R., . . .Miranda, M. C. (2010). Exercise impact
on sustained attention of ADHD children, methylphenidate
effects. Attention Deficit and Hyperactivity Disorders, 2, 49-
58. doi:10.1007/s12402-009-0018-y
Merikangas, K. R., He, J. P., Brody, D., Fisher, P. W., Bourdon,
K., & Koretz, D. S. (2010). Prevalence and treatment of men-
tal disorders among US children in the 2001-2004 NHANES.
Pediatrics, 125, 75-81. doi:10.1542/peds.2008-2598
Mick, E., Faraone, S. V., & Biederman, J. (2004). Age-dependent
expression of attention-deficit/hyperactivity disorder symp-
toms. Psychiatric Clinics of North America, 27, 215-224.
Modesto-Lowe, V., Yelunina, L., & Hanjan, K. (2011).
Attention-deficit/hyperactivity disorder: A shift
toward resilience? Clinical Pediatrics, 50, 518-524.
Mota, J., Almeida, M., Santos, P., & Ribeiro, J. C. (2005).
Perceived neighborhood environments and physical activity in
adolescents. Preventive Medicine, 41, 834-836. doi:10.1016/j.
Nigg, J., Nikolas, M., & Burt, S. A. (2010). Measured gene-
by-environment interaction in relation to attention-deficit/
hyperactivity disorder. Journal of the American Academy of
Child & Adolescent Psychiatry, 49, 863-873. doi:10.1016/j.
Nijmeijer, J. S., Minderaa, R. B., Buitelaar, J. K., Mulligan,
A., Hartman, C. A., & Hoekstra, P. J. (2008). Attention-
deficit/hyperactivity disorder and social dysfunctioning.
Clinical Psychology Review, 28, 692-708. doi:10.1016/j.
Pimentel, M. J., Vieira-Santos, S., Santos, V., & Vale, M. C.
(2011). Mothers of children with attention deficit/hyperac-
tivity disorder: Relationship among parenting stress, paren-
tal practices and child behaviour. Attention Deficit and
Hyperactivity Disorders, 3, 61-68. doi:10.1007/s12402-011-
Rosenberg, D., Ding, D., Sallis, J. F., Kerr, J., Norman, G.
J., Durant, N., . . .Saelens, B. E. (2009). Neighborhood
Environment Walkability Scale for Youth (NEWS-Y):
Reliability and relationship with physical activity. Preventive
Medicine, 49, 213-218. doi:10.1016/j.ypmed.2009.07.011
Rucklidge, J. J. (2010). Gender differences in attention-deficit/
hyperactivity disorder. Psychiatric Clinics of North America,
33, 357-373. doi:10.1016/j.psc.2010.01.006
Russell, G., Ford, T., Rosenberg, R., & Kelly, S. (2014). The
association of attention deficit hyperactivity disorder with
socioeconomic disadvantage: Alternative explanations and
evidence. Journal of Child Psychology and Psychiatry, 55,
436-445. doi:10.1111/jcpp.12170
Sampson, R. J., & Raudenbush, S. W. (1999). Systematic social
observation of public spaces: A new look at disorder in urban
neighborhoods. American Journal of Sociology, 105, 603-
651. doi:10.1086/210356
Taylor, A. F. (2001). Coping with ADD: The surprising connec-
tion to green play settings. Environment & Behavior, 33,
Taylor, A. F., & Kuo, F. E. (2009). Children with attention deficits
concentrate better after walk in the park. Journal of Attention
Disorders, 12, 402-409. doi:10.1177/108705-4708323000
Veitch, J., van Stralen, M. M., Chinapaw, M. J., te Velde, S. J.,
Crawford, D., Salmon, J., & Timperio, A. (2012). The neigh-
borhood social environment and body mass index among
youth: A mediation analysis. The International Journal of
Behavioral Nutrition and Physical Activity, 9, Article 31.
Whitley, R., & McKenzie, K. (2005). Social capital and psychia-
try: Review of the literature. Harvard Review of Psychiatry,
13, 71-84. doi:10.1080/10673220590956474
Author Biographies
Nooshin Razani, MD MPH, is a pediatrician practicing at
UCSF Benioff Children’s Hospital Oakland. She currently
serves as senior health fellow for the Institute at the Golden
Gate, a program of the Golden Gate National Parks
Conservancy in partnership with the National Park Service.
She completed this study while a general pediatrics fellow at
at LOMA LINDA UNIV LIBRARY on July 17, 2014jad.sagepub.comDownloaded from
10 Journal of Attention Disorders
Joan F. Hilton, ScD, MPH, is a biostatistician and professor in the
Department of Epidemiology and Biostatistics at UCSF. Professor
Hilton researches methods for exact inference, teaches clinical
trial methods, and collaborates on a wide range of biomedical
Bonnie L. Halpern-Felsher is a developmental psychologist and
is currently a professor in adolescent medicine in the Department
of Pediatrics at Stanford University. Her research interests include
child, adolescent, and emerging adult development, as well as ado-
lescent and young adult health, risk behavior, risk perceptions,
decision making, and risk communication.
Holly E. Morrell, PhD, is a clinical psychologist and is cur-
rently an assistant professor in School of Behavioral Health,
Department of Psychology at Loma Linda University. Her inter-
ests are in health psychology and advanced statistics and
Megumi J. Okumura, MD, is a combined internal medicine and
pediatrics physician, and assistant professor of pediatrics at UCSF.
Her research interests include children with special health care
needs, health care transitions from pediatrics to adult health care,
and chronic illness management.
Irene H. Yen, PhD MPH, is a social epidemiologist and associate
professor in the Department of Medicine at UCSF. Her research
expertise is in survey design and research methods. Her research
interests include social determinants of health, and neighborhood
influences on health behaviors and health status.
at LOMA LINDA UNIV LIBRARY on July 17, 2014jad.sagepub.comDownloaded from
... SD L = 8.2, M C = 37.8, SD C = 10.0, p < .001). In a US sample, Razani et al. (2015) found no statistically significant differences in the severity of ADHD symptomatology between children and adolescents with Black, Hispanic, or White ethnicity. Only those children and adolescents with an ancestry other than White, Black, or Hispanic showed a slightly increased risk of more severe ADHD (OR = 1.4, ...
... Growing up with a single parent was associated with more severe ADHD symptoms in children. It should be noted that only one of the four studies included in the meta-analysis revealed a significant association (Razani et al., 2015). A possible explanation for the inconsistent findings may be that studies included in the metaanalysis failed to differentiate between biological, adoptive, foster and stepparents. ...
... SD = 14.2, p = .02). However, Razani et al. (2015) did not find increased Total stress score minus the subscale scores for "distractibility/hyperactivity," "demandingness," "mood," and "parent health"; c ...
Objective Both genetic and environmental factors contribute to the development of ADHD, but associations between risk factors and ADHD symptom severity in affected children remain unclear. This systematic review and meta-analysis synthesizes evidence on the association between familial factors and symptom severity in children with ADHD (PROSPERO CRD42020076440). Method PubMed and PsycINFO were searched for eligible studies. Results Forty-three studies ( N = 11,123 participants) were meta-analyzed. Five additional studies ( N = 2,643 participants) were considered in the supplemental review. Parenting stress ( r = .25), negative parenting practices ( r = .19), broken parental partnership ( r = .19), critical life events ( r = .17), parental psychopathologies ( r = .14–.16), socioeconomic status ( r = −.10), and single-parent family ( r = .10) were significantly associated with ADHD symptom severity. Conclusion These results suggest that psychosocial familial factors show small but significant associations with symptom severity in children with ADHD. Implications are discussed.
... Neighborhoods may affect children's development through a variety of causal mechanisms operating either through social, institutional or biological processes; for extended discussions see Sampson, Morenoff and Gannon-Rowley [12] and Galster [11]. The potential neighborhood social mechanisms relevant for neurodevelopmental outcomes include: neighborhood deprivation [13,14]; social cohesion and control [15]; ethnic mix [16]; violence and social disorder [17]; institutional resources [18]; physical surroundings [19,20]; and exposure to environmental pollutants [6,9,[21][22][23]. These mechanisms may affect health outcomes via biological responses and/or alterations in health and risk behaviors and usage of health facilities. ...
... Another substantial body of research has identified associations between children's poorer cognitive outcomes and the low socioeconomic position of their neighborhoods [14,38,[43][44][45][46][47][48][49][50][51]. For instance, studies have linked higher numbers of caregiver-reported physical neighborhood hazards [52] and lower levels of neighborhood social support [15] with greater incidence of attention deficit hyperactivity disorder. In a European sample, neighborhood-level socioeconomic deprivation was associated with higher prevalence of autism spectrum disorders with co-occurring intellectual disability [53]. ...
... While the literature has discussed links between the residential stability of the child and these disorders, there has been little discussion about the role that resident churn might play in delaying such diagnoses. Perhaps this reflects a decrease in connections to neighborhood information networks, weakened norms and social ties to neighbors-connections which might facilitate knowledge about and help-seeking for such disorders, as well as provide social support to affected children and their families [15]. ...
Full-text available
Nearly three out of ten neurodevelopmental disabilities in the United States have been linked to environmental conditions, prompting emerging lines of research examining the role of the neighborhood on children’s developmental outcomes. Utilizing data from a natural experiment in Denver, this study quantifies the impact of exposure to varied neighborhood contexts on the diagnosis of neurodevelopmental disorders over the course of childhood. Our analysis is based upon retrospective child, caregiver, household and neighborhood data derived from the Denver Child Study for a sample of approximately 590 Latino and African American children and youth whose families were quasi-randomly assigned to subsidized housing operated by the Denver (CO) Housing Authority during part of their childhood. We employed binary response models with endogenous explanatory variables, estimated using instrumental variables (IV) probit and average marginal effects to identify predictors of a neurodevelopmental disorder diagnosis during childhood. We found that multiple dimensions of neighborhood context—especially neighborhood socioeconomic status, older housing stock, residential instability and prevalence of neurological hazards in the ambient air—strongly and robustly predicted the diagnosis of a neurodevelopmental disorder during childhood.
... are strongly associated with ADHD diagnosis in children 65,66 . Nationally, indicators of urbanicity, including living in a core-based statistical area (CBSA), metropolitan statistical area, or metropolitan principal city, are positively correlated with a lack of ADHD diagnosis, which is expected since urban areas have greater access to resources 57 . ...
... Nationally, indicators of urbanicity, including living in a core-based statistical area (CBSA), metropolitan statistical area, or metropolitan principal city, are positively correlated with a lack of ADHD diagnosis, which is expected since urban areas have greater access to resources 57 . Neighborhood amenities, including the presence of parks, sidewalks, and recreation centers, promote physical activity which is associated with improved cognition and behavior and could benefit childhood ADHD outcomes 65,[67][68][69][70] . Lack of neighborhood amenities is strongly associated with ADHD diagnosis (Fig. 4a) and vice versa, while both LA and NV show a distinct pattern of neighborhood maintenance, including rundown housing, litter, and vandalism, more strongly associated with ADHD diagnosis (Fig. 4b,c). ...
Full-text available
Attention-deficit/hyperactivity disorder (ADHD), the most diagnosed emerging neurodevelopmental disorder in children, is a growing health crisis in the United States. Due to the potential increase in ADHD severity during and post the COVID-19 pandemic, we analyzed recent national and two state-specific ADHD data distribution among U.S. children and adolescents by investigating a broad range of socioeconomic status (SES) factors. Child and adolescent ADHD diagnosis and treatment data were parent-reported via National Survey of Children’s Health (NSCH). The nationwide childhood prevalence of ADHD is 8.7%, and 62.1% of diagnosed children are taking medication. Louisiana (15.7%) has the highest percentage of children diagnosed with ADHD and California (5.6%) has the lowest, followed by Nevada (5.9%). Multiple correspondence analysis (MCA, n = 51,939) examining 30 factors highlights four areas of interest at the national and state level: race/ethnicity, financial status, family structure, and neighborhood characteristics. Positive correlations between ADHD diagnosis and unsafe school, unsafe neighborhood, and economic hardship are evident nationally and statewide, while the association between a lack of ADHD diagnosis and higher urban neighborhood amenities are evident nationally, but not in two opposing outlier states—Louisiana or Nevada. National and state-specific hierarchical analyses demonstrate significant correlations between the various SES factors and ADHD outcomes. Since the national analysis does not account for the demographic heterogeneity within regions or individual states, the U.S. should rely on comprehensive, county-specific, near real-time data reporting to effectively model and mitigate the ADHD epidemic and similar national health crises.
... A paper based on the Quebec Longitudinal Study of Kindergarten Children (QLSKC) [45] reported an association of household income with ADHD measured when the child was 6 years old consistent with our findings from the QLSCD; however, in contrast to QLSCD findings of no association with ICESD level of maternal education measured when the child was 6 months of age, they reported an association with parental education based on whether or not the parent had a high school diploma by the age of 30. A 2007 cross-sectional study based on a nationally representative sample of the US child population, reported no association of ADHD with low maternal education, but a clear association with low income consistent with the US NLSY cohort findings, although reporting a higher prevalence rate of 8% [46]. A Dutch case-control study, nested within a cohort study, found no association of ADHD for low parental education during early childhood [47]. ...
Full-text available
Objective This study aimed to examine social gradients in ADHD during late childhood (age 9–11 years) using absolute and relative relationships with socioeconomic status exposure (household income, maternal education) during early childhood (<5 years) in seven cohorts from six industrialised countries (UK, Australia, Canada, The Netherlands, USA, Sweden). Methods Secondary analyses were conducted for each birth cohort. Risk ratios, pooled risk estimates, and absolute inequality, measured by the Slope Index of Inequality (SII), were estimated to quantify social gradients in ADHD during late childhood by household income and maternal education measured during early childhood. Estimates were adjusted for child sex, mother age at birth, mother ethnicity, and multiple births. Findings All cohorts demonstrated social gradients by household income and maternal education in early childhood, except for maternal education in Quebec. Pooled risk estimates, relating to 44,925 children, yielded expected gradients (income: low 1.83(CI 1.38,2.41), middle 1.42(1.13,1.79), high (reference); maternal education: low 2.13(1.39,3.25), middle 1.42(1.13,1.79)). Estimates of absolute inequality using SII showed that the largest differences in ADHD prevalence between the highest and lowest levels of maternal education were observed in Australia (4% lower) and Sweden (3% lower); for household income, the largest differences were observed in Quebec (6% lower) and Canada (all provinces: 5% lower). Conclusion Findings indicate that children in families with high household income or maternal education are less likely to have ADHD at age 9–11. Absolute inequality, in combination with relative inequality, provides a more complete account of the socioeconomic status and ADHD relationship in different high-income countries. While the study design precludes causal inference, the linear relation between early childhood social circumstances and later ADHD suggests a potential role for policies that promote high levels of education, especially among women, and adequate levels of household income over children’s early years in reducing risk of later ADHD.
... This may be explained by contextual factors in lower socioeconomic neighborhoods and proximal context in young adult lives (e.g. schooling, peer groups and family) given that these are strong correlates of substance use (Cambron et al., 2020) and the development of ADHD (Razani et al., 2015). Low socioeconomic status is also associated with other risk factors for SUDs, including poor physical and mental health and childhood adversities (Fedele et al., 2012;Laskey et al., 2012;Schreier and Chen, 2013). ...
Aim (a) To document the prevalence and odds of (i) alcohol use disorders, (ii) cannabis use disorders, (iii) other drug use disorders and (iv) any substance use disorder (SUD), among young adults with and without ADHD, and (b) to investigate the degree to which the association between ADHD and SUDs is attenuated by socio-demographics, early adversities and mental health. Method Secondary analysis of the nationally representative Canadian Community Health Survey-Mental Health (CCHS-MH). The sample included 6872 respondents aged 20–39, of whom 270 had ADHD. The survey response rate was 68.9%. Measurements Substance Use Disorder: World Health Organization’s Composite International Diagnostic Interview criteria, SUDs, were derived from lifetime algorithms for alcohol, cannabis and other substance abuse or dependence. ADHD was based on self-report of a health professional’s diagnosis. Findings One in three young adults with ADHD had a lifetime alcohol use disorder (36%) compared to 19% of those without ADHD (P < 0.001). After adjusting for all control variables, those with ADHD had higher odds of developing alcohol use disorders (OR = 1.38, 95% CI: 1.05, 1.81), cannabis use disorders (OR = 1.46, 95% CI: 1.06, 2.00), other drug use disorders (OR = 2.07, 95% CI: 1.46, 2.95) and any SUD (OR = 1.69, 95% CI: 1.28, 2.23). History of depression and anxiety led to the largest attenuation of the ADHD-SUD relationship, followed by childhood adversities and socioeconomic status. Conclusions Young adults with ADHD have a high prevalence of alcohol and other SUDs. Targeted outreach and interventions for this extremely vulnerable population are warranted.
... We found no association of ND with children's ability to inhibit behaviors, hyperactive behaviors, ADHD index, or BRIEF sub-scales comprising the measure of metacognition. While some studies demonstrated associations between ND and child ADHD symptoms (Edwards and Bromfield, 2010;Sharp et al., 2019), others reported null findings (Nfonoyim et al., 2020;Ford et al., 2004;Razani et al., 2015), suggesting more research is need on ND and ADHD. To our knowledge, we are the first study to examine the effect of ND on childhood metacognition, defined as the "monitoring and control of thought" (Martinez, 2006); consisting of school-success related skills or abilities like working memory, planning and organizing, organization of materials, and self-monitoring. ...
Background Neighborhood disadvantage (ND) is a risk factor for child behavior problems (CBPs), but is understudied outside the United States and Europe. Our mixed methods study aims to (1) create a culturally meaningful measure of ND, (2) test cross-sectional associations between ND and CBPs and (3) qualitatively explore life in the neighborhoods of families participating in the Salud Ambiental Montevideo (SAM) study. Methods The quantitative study (Study 1) comprised 272, ~7-year-old children with geolocation and complete data on twelve behavioral outcomes (Conner's Teachers Rating Scale – Revised Short Form: CTRS-R:S and Behavioral Rating Inventory of Executive Functioning: BRIEF). A ND factor was created at the census segment level (1,055 segments) with 19 potential indicators of ND downloaded from the Municipality of Montevideo Geographic Services. Children were assigned ND scores based on the location of their household within a census segment. Multilevel models tested associations between ND and all CBP scales, controlling for confounders at the individual level. The qualitative study (Study 2) comprised 10 SAM caregivers. Photovoice alongside semi-structured interviews in Spanish were used to foster conversations about neighborhood quality, activities, and raising children. Thematic analysis with inductive coding was used to summarize qualitative study findings. Results The ND factor consisted of 12 census-based indicators related to education, employment, ethnicity, housing quality, and age characteristics, but unrelated to home ownership and some ethnicity variables. In multivariable models, ND was associated with greater conduct problems (β = 1.37, p < .05), poor shifting (β = 1.56, p < .01) and emotional control problems (β = 2.36, p < .001). Photovoice and semi-structured interviews yielded four themes: physical disorder, recreation, safety and crime, and community resources. Residents discussed improving waste management and transportation, updating playgrounds, and ensuring neighborhood safety. Conclusions ND in Montevideo comprised a unique set of census indicators. ND was primarily related to behavioral regulation problems. Hypothesized pathways whereby ND affects CBPs are discussed.
... In smaller geographic areas, it may be less likely that there are providers of similar racial/ethnic backgrounds and the perceived stigma may be greater especially if they lack sufficient social support. 28,29 ...
Background: Kentucky has among the highest rate of attention deficit/hyperactivity disorder (ADHD) and stimulant use in the United States. Little is known about this use by race/ethnicity and geography. This article describes patterns of diagnosis of ADHD and receipt of stimulants and psychosocial interventions for children aged 6-17 years receiving Kentucky Medicaid in 2017 and identifies factors associated with diagnosis and treatment. Methods: Using Medicaid claims, children with and without ADHD (ICD-10 codes F90.0, F90.1, F90.2, F90.8, and F90.9) were compared and predictors of diagnosis and treatment type were examined. Psychosocial interventions were defined as having at least one relevant CPT code. Chi-squared tests and logistic regression models were used for univariate and multivariable analysis, respectively. Results: The rates of ADHD, stimulant use, and psychosocial interventions in our study population exceeded the national average (14% vs 9%; 75% vs 65.5%; and 51% vs 46.5%, respectively). The distributions varied by sex, race/ethnicity, sex among race/ethnicities, and population density. In general, race/ethnicity predicted ADHD diagnosis, stimulant use, and receipt of psychosocial interventions with non-Hispanic White children being more likely to receive diagnosis and medication, but less likely to receive psychosocial therapy than other children. Differences were also shown for rural compared with urban residence, sex, and sex within racial/ethnic groups. Conclusions: Diagnosis and treatment modalities differed for children by race/ethnicity, population density, and sex. More data are needed to better understand whether differences are due to provider bias, child characteristics, or cultural variations impacting the utilization of different treatment options.
Background: Caregivers of children with autism spectrum disorder (ASD) has been shown to have unique mental health vulnerabilities that community support may buffer. Positive caregiver mental health can stimulate family resilience behaviors, such as strong communication and problem-solving. Further, community support has been found to be related to caregiver mental health, as well as improved child functioning. The current study aimed to investigate caregiver mental health as a mediator between community support and family resilience in families of a child with an autism spectrum disorder. Methods: Data obtained from caregivers of 654 children with a reported diagnosis of ASD were utilized from the 2016 National Survey of Children's Health (NSCH) public database. Results: Community support was positively correlated with family resilience and caregiver mental health. Bivariate correlations indicated significant positive associations between community support and family resilience. Caregiver mental health significantly partially mediated the relationship between community support and family resilience. Conclusions: The present study provided important insight into fostering caregiver health as a strategy to promote family resilience behaviors. Interventions designed to address family resilience behaviors among families of children with ASD should focus on ways in which to positively impact caregiver mental health.
We systematically reviewed the existing evidence (until end of November 2021) on the association between long-term exposure to greenspace and behavioral problems in children according to the PRISMA 2020. The review finally reached 29 relevant studies of which, 17 were cross-sectional, 11 were cohort, and one was a case-control. Most of the studies were conducted in Europe (n = 14), followed by the USA (n = 8), and mainly (n = 21) from 2015 onwards. The overall quality of the studies in terms of risk of bias was “fair” (mean quality score = 5.4 out of 9) according to the Newcastle–Ottawa Scale. Thirteen studies (45%) had good or very good quality in terms of risk of bias. The strength and difficulty questionnaire was the most common outcome assessment instrument. Exposure to the greenspace in the reviewed studies was characterized based on different indices (availability, accessibility, and quality), mostly at residential address locations. Association of exposure to different types of greenspace were reported for nine different behavioral outcomes including total behavioral difficulties (n = 16), attention deficit hyperactivity disorder (ADHD) symptoms and severity (n = 15), ADHD diagnosis (n = 10), conduct problems (n = 10), prosocial behavior (n = 10), emotional symptoms (n = 8), peer-relationship problems (n = 8), externalizing disorders (n = 6), and internalizing disorders (n = 5). Most of the reported associations (except for conduct problems) were suggestive of beneficial association of greenspace exposure with children's behaviors; however, the studies were heterogeneous in terms of their exposure indicators, study design, and the outcome definition.
Full-text available
Poor adherence is a major concern in the treatment of attention-deficit/hyperactivity disorder (ADHD). The objective of this study was to evaluate factors linked to early interruption of and low adherence to treatment with osmotic-release oral system methylphenidate hydrochloride (OROS-MPH) in pediatric patients with ADHD. A total of 1353 young people (age 6–17 years) with a diagnosis of ADHD who newly started OROS-MPH were extracted from the pharmacoepidemiological data of 3 million people in Japan. The cohort was retrospectively surveyed every month for 12 months. Ten possible risk factors were extracted from the data and analyzed by multivariable logistic regression. Sensitivity analysis was conducted to ensure the robustness of the analysis. The results revealed that treatment adherence was generally poor, with a tendency for discontinuation in the early stage. Multivariable logistic regression results showed that adherence is reduced by female sex, lower starting dose, and concomitant atomoxetine or hypnotics. These findings may help clinicians to predict the risk of poor adherence in the early stage of treatment and improve not only patients’ symptoms, but also their quality of life.
Full-text available
The aim of this study was to investigate the relationship between characteristics of neighborhood context and the practice of physical activity in adults through a systematic review. The Scopus, Web of Science and Pubmed database, were accessed in February 2013. We’re used the syntax (“Residence Characteristics”[Mesh] OR Neighborhood [all field]) AND (“Sedentary Lifestyle”[Mesh] OR Physical activity [all fields] OR Motor activity [Mesh]) in Pubmed database and a correspondent syntax in the others. The initial search found 5779 (2257 being duplicates). After analysis and application of inclusion criteria 19 articles were included in the review. The main instrument used for measuring physical activity was the IPAQ (16 articles). Regarding questionnaires to measure perceived neighborhood, 5 different instruments were identified. The analysis of the association between physical activity and context characteristics pointed out several inconsistencies, regardless of the instrument used to analyze, not indicating a strong relationship between neighborhood characteristics and physical activitypractice. The diversity of populations and methodologies to measure neighborhood characteristics may be one of the reasons for the differences noted. This study highlights an important gap in studies of association between physical activity and characteristics of the neighborhood context. No use of multilevel analyzes in the analyzed studies can be seen as a reason for no significant associations or inconsistencies found between studies.
Full-text available
Studies throughout Northern Europe, the United States and Australia have found an association between childhood attention deficit hyperactivity disorder (ADHD) and family socioeconomic disadvantage. We report further evidence for the association and review potential causal pathways that might explain the link. Secondary analysis of a UK birth cohort (the Millennium Cohort Study, N = 19,519) was used to model the association of ADHD with socioeconomic disadvantage and assess evidence for several potential explanatory pathways. The case definition of ADHD was a parent-report of whether ADHD had been identified by a medical doctor or health professional when children were 7 years old. ADHD was associated with a range of indicators of social and economic disadvantage including poverty, housing tenure, maternal education, income, lone parenthood and younger motherhood. There was no evidence to suggest childhood ADHD was a causal factor of socioeconomic disadvantage: income did not decrease for parents of children with ADHD compared to controls over the 7-year study period. No clinical bias towards labelling ADHD in low SES groups was detected. There was evidence to suggest that parent attachment/family conflict mediated the relationship between ADHD and SES. Although genetic and neurological determinants may be the primary predictors of difficulties with activity level and attention, aetiology appears to be influenced by socioeconomic situation.
Full-text available
Attention Restoration Theory suggests that contact with nature supports attentional functioning, and a number of studies have found contact with everyday nature to be related to attention in adults. Is contact with everyday nature also related to the attentional functioning of children? This question was addressed through a study focusing on children with Attention Deficit Disorder (ADD). This study examined the relationship between children’s nature exposure through leisure activities and their attentional functioning using both within and between-subjects comparisons. Parents were surveyed regarding their child’s attentional functioning after activities in several settings. Results indicate that children function better than usual after activities in green settings and that the “greener” a child’s play area, the less severe his or her attention deficit symptoms. Thus, contact with nature may support attentional functioning in a population of children who desperately need attentional support.
Full-text available
Increasing numbers of children in the United States live in housing that is considered substandard. However, there is little understanding of the long-term impact of such housing for children. Using a framework provided by prospective studies of resilience, this article draws on ethnographic research to speculate on the significance of unsuitable housing for the long-term capacity of children to break out of poverty. Events and circumstances in the household lives of three young children are examined closely in order to clarify the connections between specific dimensions of housing, parental behavior and the children's sense of identity, trust, autonomy, competence and general development. Evidence gathered through both interviews and observation suggests that inadequate housing contributes, along with other factors, to patterns of behavior and perception that can undermine positive development and perpetuate disadvantage. The implications for policy and practice are discussed.
Full-text available
Background: Attention-deficit/hyperactivity disorder (ADHD) is the most common psychiatric disorder of childhood, with average worldwide prevalence of 5.3%, varying by region. Methods: We assessed the relationship between the prevalence of ADHD and solar intensity (SI) (kilowatt hours/square meters/day) on the basis of multinational and cross-state studies. Prevalence data for the U.S. were based on self-report of professional diagnoses; prevalence data for the other countries were based on diagnostic assessment. The SI data were obtained from national institutes. Results: In three datasets (across 49 U.S. states for 2003 and 2007, and across 9 non-U.S. countries) a relationship between SI and the prevalence of ADHD was found, explaining 34%-57% of the variance in ADHD prevalence, with high SI having an apparent preventative effect. Controlling for low birth weight, infant mortality, average income (socioeconomic status), latitude, and other relevant factors did not change these findings. Furthermore, these findings were specific to ADHD, not found for the prevalence of autism spectrum disorders or major depressive disorder. Conclusions: In this study we found a lower prevalence of ADHD in areas with high SI for both U.S. and non-U.S. data. This association has not been reported before in the literature. The preventative effect of high SI might be related to an improvement of circadian clock disturbances, which have recently been associated with ADHD. These findings likely apply to a substantial subgroup of ADHD patients and have major implications in our understanding of the etiology and possibly prevention of ADHD by medical professionals, schools, parents, and manufacturers of mobile devices.
Full-text available
The decision of how many factors to retain is a critical component of exploratory factor analysis. Evidence is presented that parallel analysis is one of the most accurate factor retention methods while also being one of the most underutilized in management and organizational research. Therefore, a step-by-step guide to performing parallel analysis is described, and an example is provided using data from the Minnesota Satisfaction Questionnaire. Recommendations for making factor retention decisions are discussed.
We present a critical review of research concerning the vulnerability of mental health of young people in the 10-20 year age range to neighbourhood factors that are theoretically associated with increased risk of Common Mental Disorders (CMDs). We interpreted 'neighbourhood factors' as attributes and processes in the local social and physical environment that young people inhabit, beyond the immediate household. We conducted an extensive search, and a structured method of assessment of the research papers that met our search criteria. We draw conclusions about the research evidence on this topic and identify issues needing further discussion and investigation. We focus particularly on quantitative research that aims to measure these relationships. We note that parallel to this research, a significant body of qualitative research on the geographical experiences of young people (though not specifically on their mental health) offers a rich source of background information to illuminate the statistical findings. We conclude with some reflections on the future challenges for research in this field.
This review integrates and critically evaluates what is known about family characteristics associated with childhood Attention-Deficit/Hyperactivity Disorder (ADHD). Evidence suggests that the presence of ADHD in children is associated to varying degrees with disturbances in family and marital functioning, disrupted parent–child relationships, specific patterns of parental cognitions about child behavior and reduced parenting self-efficacy, and increased levels of parenting stress and parental psychopathology, particularly when ADHD is comorbid with conduct problems. However, the review reveals that little is known about the developmental mechanisms that underlie these associations, or the pathways through which child and family characteristics transact to exert their influences over time. In addition, the influence of factors such as gender, culture, and ADHD subtype on the association between ADHD and family factors remains largely unknown. We conclude with recommendations regarding the necessity for research that will inform a developmental psychopathology perspective of ADHD.
To examine relations between neighborhood characteristics and psychological health, specifically whether neighborhood trust and cooperation buffers the effects of neighborhood disorder on depression and aggressive behavior. The sample was composed of 127 urban, African American young adults from Trenton, NJ. The protective function of neighborhood social interactions depended on the outcome, such that trust and cooperation among neighbors moderated the effect of neighborhood disorder on aggression but not depression. Results confirm the importance of taking an ecological approach to study and promote the emotional and behavioral health of young adults living in urban communities.