الفهرس 
1.INTRODUCTIOOnly 14 pages are availabe for public view
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Abstract
ADHD affects many children worldwide and continues into adulthood. ADHD is a persistent condition of inattention and/or hyperactivity-impulsivity that interferes with functioning or development of the children. It should persist for at least 6 months to a degree that negatively impacts directly on social and academic activities of the children. ADHD is more common among boys than girls, male to female ratio ranges from 1:1 to 3:1.
ADHD is a complex disorder and factors contributing to its etiology are still under investigation. There are growing evidences for the involvement of environmental factors during pregnancy or early childhood.
This study is trying to assess the association between some environmental risk factors and ADHD among children in Alexandria and to compare manganese and lead levels in the hair of children with ADHD and normal children.
The study is a case-control one and was conducted in outpatient clinics of El Shatby Pediatric University Hospital, Alexandria University. A sample of two hundred fifty two children was involved in this study, 126 cases and 126 controls. Hair samples from these children were collected for lead and manganese level using Atomic Absorption Spectrophotometer. As well as a pre-designed and pre-coded structured interviewing questionnaire was applied to each parents and care-givers, from the cases and controls to collect data. These data included personal and socio-demographic data, parents occupation and medical and pregnancy history of the mother. Life style and, residential and indoor and outdoor environmental risk factors were ascertained. As well as, life style and dietary habits of the children were studied. Appropriate statistical procedures were applied and the following results were obtained:
1- As regards socio- demographic data, significant differences were detected between cases and controls in relation to education, crowding index, mothers age at her first pregnancy and the presence of kinship between parents . Cases were more disadvantaged than controls.
2- Occupational exposure to chemical compounds, specially petroleum products during father work (worker in oil station, toktok driver and taxi driver) or exposure to paints and its solvents which yielded higher odd ratio (OR= 26.091, 95%CI: 7.858–86.625) in relation to ADHD children.
3- Low mean of birth interval (11.41 ± 15.84 months) and noncompliance of mothers for their vitamins intake during pregnancy period (calcium, folic acid and iron intake) (OR= 7.2 , 95%CI: 2.097–25.282) were related with ADHD in children. Despite history of health problems encountered during mother pregnancy was not associated statistically to ADHD but a higher percentage of mothers (39%) suffering from hypertension was found in the case group .
4- Low birth weight of the children, less than 2500 gram (OR= 2.72 , 95%CI: 1.59–4.68), children born with high level of jaundice (OR= 7.438, 95%CI: 3.536–15.64) and with asthma (OR= 21.25, 95%CI :2.62–171.75) were defined as risk factors for ADHD. While breast feeding for more than 6 months was found to have a protective effect (OR= 0.2 , 95%CI :0.071–1.003).
5- Regarding mother smoking during pregnancy or postnatal (OR= 2.2, 95%CI :1.209–4.198) and a frequent use of pesticides at home, more than 3 times per week (OR= 10.8, 95%CI :2.110–56.188), a strong association with ADHD was found.
6- Exposure to some indoor environmental risk factor, from old paints (OR= 7.30, 95% CI : 2.950–18.3) and old pipes (OR= 2.7, 95 %CI: 1.609–4.63), and the use of newspaper (OR= 61 , 95%CI: 14.37–262.69 ) and unpackaged flour (OR= 45, 95 %CI: 13.679–154.4) in food preparation can present a source of lead at home. As well as, water supply from non -treated underground water (OR= 6.8, 95 %CI: 1.499–31.29) can be a source of manganese that was found to present a risk factor for ADHD. These factors have proved detrimental on ADHD in children.
7- Residence of mother during her pregnancy and/or the child in his early life in the proximity of high way (OR= 41, 95 %CI: 12.382–135.76), near high traffic (OR= 1.9, 95%CI 1.17-3.28 ), petrol station (OR= 25, 95 %CI: 10.2453–61.003), industrial zone (OR= 2.3, 95%CI: 1.0012–5.322) and agricultural fields (OR= 46.6, 95 %CI: 11.007–196.44) where pesticides were applied, were found to be risk factors for ADHD.
Regarding children life style, exposure to pesticides at home, watching TV more than 5 hours per day (OR= 32, 95%CI: 3.222–327.774) using mobile phone screens more than two hours (OR= 2.6, 95 %CI: 1.312 – 5.193) and to computers more than two hours per day (OR= 2.1, 95 %CI: 1.160 – 4.04) were more liable to have ADHD. In addition, children eating potatoes crisps (2-5 times weekly )(OR: 27.08, 95 %CI: 1 12.300–59.62), Commercial packed noodles daily (OR: 39.4, 95 %CI: 8.491–183.23) , drinking soft drinks (OR: 3.89, 95 %CI: 1.937–7.812) and with a higher consumption of sugars daily (OR: 4 95 %95CI: 753–9.12) and children who did not drink milk or only once weekly (OR: 21.875, 95 %95CI: 6.78–70.48 and OR= 9.77, 95% CI: 4.14-23) were more likely to have ADHD . On the other hand, eating fruits and vegetable daily have proved to have a protective effect.
8- The results of lead and manganese level analysis in hair show significant elevated concentrations in cases compared to controls (OR= 1.4, 95% CI: 1.16-1.7) and (OR= 2.25 , 95% CI: 1.689–3.016). Lead is a potent neurotoxicant and can interfere with neurotransmitters altering dopaminergic systems. Also, Manganese affects dopaminergic system and its transmissions accordingly they are involved in ADHD etiology.
9- A cut off point for hair lead level in children, below 2.8 unit and reading manganese level, less than 2 unit, was found in the studied groups.
In light of the findings of the present study, many recommendation can be suggested :
• Campaigns to raise awareness regarding ADHD symptoms early diagnosis and risk factors involved in its development
• Exposure of the children at early stage in their life to any screen, before 3 years old : TV, computer, mobile phone is not recommended and for older children should not exceed two hours per day maximum.
• Early screening of the children in primary schools and playschool for an early diagnosis of the ADHD children.
• Improved epidemiologic studies that explore the prevalence of the disease in Egypt as well as the association between environmental exposure to indoor and outdoor risk factors.
In conclusion, ADHD is a neurodevelopmental disorder and its prevalence is increasing globally. Several environmental risk factors are involved in its development. Efforts should be made to decrease the incidence of ADHD and further research is needed to determine the best preventive strategy in Egypt.
Conclusion
ADHD is a complex disease and Factors contributing to its etiology are still under investigation. There is a growing body of evidence for the involvement of environmental factors during pregnancy or early childhood. This case control study is shedding light on the most important risk factors related to ADHD.
Children from mothers and fathers with low level of education were found in higher frequency than the control group and in case of consanguinity between the parents. Poor living conditions with a high crowding index is also a risk factor for ADHD .
In addition exposure to petroleum products during father work (worker in oil station, toktok driver and taxi driver) or from paints and its solvents is yielding higher odd ration regarding ADHD.
Regarding the different maternal variables, hypertensive mothers and non compliance of the mothers to their vitamins intake and a short birth interval between pregnancies were among risk factors for ADHD.
Children born less than 2500 grams of weight, or with respiratory problems or suffering from long jaundice were at higher risk of developing ADHD. While breast feeding for a period more than 6 months showed a protective effect.
The investigation of some indoor environmental risk factors confirmed the effects of second hand smoking, especially among mothers, frequent usage of pesticides more than three times per week, household water supply from non treated ground water that can be a source of manganese, water from old pipes and painted surfaces with old paint on the development of ADHD in children. Regarding food preparation using newspapers, aluminum pots in cooking and unpacked flour proved detrimental on ADHD.
Studying various residential risk factors demonstrated higher risks of ADHD when mothers or children living in the vicinity of gasoline station, high way roads, landfill, industrial emissions from nearby factory areas, agricultural fields utilizing pesticides. Good aeration and sun exposure of the children demonstrated a protective effect from ADHD
Regarding children household exposure to pesticide at home, those who watching TV or computers fir more than two hours , are more liable to have ADHD. In addition, children eating potatoes crisps, commercial packed noodles, drinking soft drinks and with a higher consumption of sugars daily were more likely to have ADHD. On the other hand, eating fruits and vegetables and daily drinking of milk proved a protective effect.
The study also reveals the elevated concentration of lead and manganese in the hair of ADHD children than in the controls. Lead is a potent neurotoxicant and can interfere with neurotransmitters altering dopaminergic systems. As well as, Manganese affects dopaminergic system and its transmissions accordingly they are involved in ADHD etiology.
It is evident that ADHD is multi-factorial in nature , where many environmental risk factors and life style of the mother and the children interact and contribute for its development. This emphasizes the urgent need for interventions to raise awareness regarding exposure of the mother and the children to second hand smoking, household pesticides and the hour of exposure of the children to electronic screens.
Recommendations
In the light of the findings of the present study, many recommendations can be suggested as follows:
For Parents:
1-Parents should be aware that inattention and/or hyperactivity of their children can be diagnosed as a disease and it needs to be followed by a psychiatrists for diagnosis then a psychologist for follow up. School teachers in kindergarten and primary schools should be close with children parents for any abnormal persistent inattention or hyperactivity .
Early diagnosis of the disease can lead to a better prognosis of the cognitive skills of the children.
2-Children with familial history of ADHD can be identified as high risk group and they should be diagnosed for any persistent pattern of inattention and/or hyperactivity more than six months.
3-Parents of young children, who are exposed during their work to chemicals and organic solvents such as benzene or paints or exposed to lead , should wear masks and clean their hands , clothes and shoes before leaving their work.
4-Exposure of the children at early stage in their life to any screen before 2 years old: TV, computer, mobile phone is not recommended and for older children , should not exceed two hours per day.
5- Children should practice physical activities and should be exposed to open view, green areas and sun.
6- Children learn from interaction with other people consequently parents should be advised to share activities with their young children: reading books , talking with them and doing activities in open areas.
7- Smoking mothers should be advised to quit smoking at least during their pregnancy period as their offsprings will be at high risk to develop ADHD.
For Community Organizations, NGOs and Mass media
It is of utmost important to develop health education programs of parents, especially young mothers, to raise their knowledge and awareness regarding some indoor environmental risks of ADHD:
Examples :
1.Dangerous effects of tobacco smoke during antenatal period or post- natal.
2.Healthy life style during pregnancy and the intake of vitamins (folic acid, calcuim and iron supplements ).
3. Avoid frequent use of household pesticides when the children are at home.
4.Good aeration of the house and exposure of the children to sun.
5.Risks of using newspapers, unpacked flour and aluminum pots in food preparation.
For Health Care Providers And Psychologists
Physicians and nurses in primary health care should be aware for the signs and symptoms of ADHD.
1- Early screening of the children in playschool and primary schools and for an early diagnosis of the ADHD children.
2- Good communication with children’s parents to ensure a better understanding of the disease in order to provide a healthy life style and dietary habits of the child
Recommendations for Future Research:
1-Improving epidemiologic studies that detect the prevalence of the disease in Egypt as well as the association between environmental exposure in houses and play schools and ADHD.
2-Early screening of the children in playschool and primary schools for an early diagnosis of the ADHD children.
3-Follow up studies in the levels of manganese in different sources of drinking water with suggested intervention for its reduction.
4-Regular monitoring of levels of lead in the air, particularly in heavy traffic areas to avoid exceeding the permissible limits.