The influence of nutritional status, the home environment, and schooling on behavioral outcomes of hyperactivity and inattention among grade-school children in rural Nepal

Attention-deficit/hyperactivity disorder (ADHD) in children is characterized by frequent inattention and/or hyperactivity that can affect child development, including learning, social adaptation, and mental health. Despite the impact of these behaviors, data on the prevalence and risk factors of child behavioral and neurodevelopmental disorders in low- and middle-income countries are limited. This paper aims to identify maternal, child and environmental risk factors associated with ADHD-related behaviors (hyperactivity/ oppositionality, and inattention) in a cohort of 7- to 9-year-old children born between 1999-2001 (n = 1,927), whose mothers participated in a cluster randomized trial of prenatal micronutrient supplementation, and who were subsequently enrolled in a preschool micronutrient supplementation trial. Behaviors were assessed using the Conners' Parent and Teacher Rating Scales-Revised (CPRS-R, CTRS-R). T-scores are reported and dichotomized at the upper tertile, defining the presence of behavioral difficulties. Multivariable logistic regression models were conducted to assess the association between behavioral outcomes and maternal characteristics (anemia, education, and intelligence using the Raven's Coloured Progressive Matrices), child nutritional status (anemia, height-for age, body mass index z-scores (HAZ, BMIZ)), child schooling history and the home environment, using the Middle Childhood Home Observation Measurement of the Environment (MC-HOME). Boys (50.2%) and girls (49.8%) were evenly distributed, with a mean age of 8.38 (SD 0.66) years and parent and teacher behavioral assessments were available for 1,808 and 1,374 children, respectively. Mean t-scores for parent-reported inattention and hyperactivity/oppositionality and teacher-reported inattention and hyperactivity were 62.9 (SD 6.29), 62.1 (SD 5.84), 62.2 (SD 8.07) and 62.2 (SD 8.43), respectively. In adjusted logistic regression models, a higher HOME score was associated with a reduced risk of parent-reported inattention (RR 0.97, 95% CI 0.96, 0.99), whereas higher maternal Raven's score (RR 0.99, 95% CI 0.97, 1.00), a higher HOME score (RR 0.98, 95% CI 0.97, 1.00) and child pre-primary, late and continuous schooling compared to no schooling (RR 0.75, 95% CI 0.57, 0.98; RR 0.66, 95% CI 0.52, 0.85; RR 0.68, 95% CI 0.48, 0.98) were associated with a reduced risk of parent-reported hyperactivity/oppositionality. Higher child HAZ was associated with a reduced risk of teacher-reported hyperactivity (RR 0.87, 95% CI 0.80, 0.96) after adjustment. The home psychosocial environment, and child schooling and height were the strongest predictors of inattention and hyperactivity/oppositionality in school-age children in rural Nepal.