Attention Deficit Hyperactivity Disorder: The Role of Maternal Health

Introduction

Impulsivity, hyperactivity, and inattention are hallmarks of attention-deficit/hyperactivity disorder (ADHD), a neurodevelopmental disease that often persists throughout adolescence and adulthood. Estimates of the prevalence of ADHD have been rising consistently, with estimates putting it between 5 and 7% of children globally.¹ To satisfy the DSM-5 and ICD-10 criteria, the prevalence of excessive impulsivity, hyperactivity, and inattention must be disproportionate to the develop-mental level. Three typical forms of ADHD are listed in the DSM-5: mixed, inattentive, and hyperactive/ impulsive. The symptom load is used to differentiate between these presentations. For a formal diagnosis, the symptoms must manifest in many environments before age twelve and last for at least six months (DSM-5) or six (ICD-10).^2,3 Even though it is still uncertain what causes ADHD, numerous risk factors have been found via study, such as genetic predispositions, environmental variables, and changes in the structure and function of the brain.

Methods

A comprehensive and methodical search technique was utilized in the methodology to locate pertinent studies across multiple databases. A systematic search was conducted utilizing combinations of keywords such as "ADHD," "Attention-Deficit/Hyperactivity Disorder," "maternal health," "prenatal factors," "prevention," and related terms to access PubMed/MEDLINE, Scopus, Web of Science, and other credible academic databases.

Criteria for Inclusion and Exclusion

• English-language research on the connection between a mother's health during pregnancy and the onset or avoidance of ADHD in children met the inclusion criteria. Research on dietary effects, mental health issues, substance abuse, environmental pollutants, maternal health concerns, prenatal risk factors, and preventive strategies were taken into consideration.

• Papers published in languages other than English, duplicates, reviews without primary data, and research not pertinent to the particular issue were among the exclusion criteria.

Factors that may lead to ADHD

Maternal health has become one of the most important areas of research among the many variables impacting ADHD. There are several reasons why children may exhibit symptoms of ADHD, including mother’s age, moms with a history of ADHD, and the prenatal and postnatal environments, which have a substantial impact on a child's neurodevelopment.

The etiology of ADHD is complex because the disorder has been attributed to both environmental and inherited causes.⁴ Some factors have been linked to higher levels of Copy Number Variation (CNV), preterm birth, a relative with ADHD, and maltreatment.⁵ Furthermore, several research investigations have found a negative association between ADHD and unfavorable outcomes (such as an increased divorce rate, an increased incidence of an elevated mortality rate, and drug addiction issues in adulthood). Additionally, the prognosis for ADHD is worse when there is comorbidity.^6,7 It has been demonstrated that there is a strong link between ADHD in both parents and children and behavioral issues.

Maternal history of ADHD

However, given the incomplete understanding of aspects associated with both the long-term prognosis and the evolution of ADHD, more attention needs to be focused on the developmental course of the disorder.⁸ Research indicates that there is a high probability that children will inherit parental psychopathology. However, little is known about how mothers' resilience, attachment style, signs of hyperactivity, and attention deficit (ADHD) function in how well their children respond to treatment once they are diagnosed with the disorder. ADHD development in offspring may be predisposed by the ADHD of the mother.^9,10 Furthermore, according to a new study, children with ADHD are more likely to have parents with mental health issues; the mother’s diagnosis was found to have more significant associations with ADHD in children than the father’s diagnosis.¹¹ Research has indicated a clear relationship between parental ADHD and the level of chaos in the home as measured by self-reports and parenting styles.¹² However, no study has looked at the relationship between the treatment outcome for their offspring and the symptomatology of the mother's ADHD.

Not only might mothers' symptoms of ADHD raise their children's risk of developing ADHD, but the depth of the mother- child bond has also been questioned. It has been proposed that risk factors for attachment disorders include ADHD.¹³ After examining the relevant literature, we found a substantial link between insecure attachment and ADHD. When one disease was present, the other's chances increased. This highlights the potential that there is a reciprocal risk between ADHD and unstable relationships.¹⁴ Secure adult attachment was consistently associated with better parenting. In comparison, insecure attachment was associated with more negative parenting, according to a recent thorough analysis of parental self-reported attachment type and caregiving.¹⁵

Maternal age

The age of the mother when she gave birth is known as her maternal age at childbirth. In general, a mother is regarded as young at childbirth if she is 19 years of age or younger, and she is considered to be advanced if she is at least 35 years old.¹⁶ Both young and older maternal ages at childbirth may affect the health of mothers and their offspring. Preterm delivery, low birth weight, neonatal mortality, and maternal cardiovascular disease have all been linked to early maternal age at childbirth. Mother cancer risk, stillbirth, cerebral palsy, neuro-cognitive difficulties, mental disorders, and other adverse health outcomes are all associated with advanced mother age during delivery.^{17,18,19,20,21} However, according to certain studies, there is no connection between an older mother and her children's long-term morbidity.²²

Aspects both genetic and epigenetic: ADHD risk may be affected by both genetic predisposition and epigenetic modifications that occur during pregnancy. The child's susceptibility to ADHD may be influenced by maternal genetic variables and epigenetic changes.²³

Prenatal Factors and Maternal Health

• Maternal Nutrition: The development of the fetal brain is significantly influenced by the mother's diet throughout pregnancy. It has been found that a deficiency in specific nutrients, such as iron, zinc, folate, and omega-3 fatty acids, increases the likelihood of ADHD in offspring. This section looks at the effects of supplements, maternal dietary habits, and certain nutrients on the risk of ADHD.²⁴
• Balanced Diet: To ensure that the mother and developing fetus obtain the vital nutrients, a well-balanced and diverse consumption of whole grains, fruits, and vegetables, lean proteins, and healthy fats is necessary.²⁵
• Processed Foods and Sugars: Although more research is required to demonstrate conclusive causation, a higher risk of ADHD symptoms in offspring has been suggested by heavy consumption of processed foods, sweetened beverages, and diets high in refined sugars during pregnancy.²⁶
• Function of Supplements: When taken according to medical professionals' recommendations, prenatal vitamins and supplements can help guarantee proper nutrient intake during pregnancy. For example, folic acid supplementation is essential for avoiding neural tube abnormalities but has not consistently demonstrated an association with the risk of ADHD.²⁷

Maternal Obesity and Malnutrition

• Obesity: A higher risk of Children with ADHD has been shown to be associated with maternal obesity both before and during pregnancy. It might affect inflammatory markers, change the availability of nutrients, and impair fetal growth.²⁸
• Malnutrition: Although specific correlations to ADHD require more research, severe maternal malnutrition, as observed in some cases of eating disorders or excessive dietary restrictions, can severely affect fetal brain development and raise the risk of neurodevelopmental problems.²⁹
• Mother Stress and Mental Health: Due to abnormal fetal neurodevelopment, children of pregnant mothers who suffer from stress, anxiety, or depression are more likely to acquire ADHD. Examining the molecular processes behind stress-related pathways and their effects on the developing brain will help us understand the connection between maternal stress and ADHD.³⁰
• Anxiety, depression, and stress all of which are frequently linked to symptoms of ADHD may also raise the chance of less favorable fetal and child developmental outcomes during pregnancy^.31 According to earlier studies, these variables may influence fetal development through such as increased glucocorticoid exposure, which could change the methylation status of genomic areas crucial for maintaining the hypothalamic-pituitary (HPA) axis in children in all its aspects.³² Long-term consequences of prenatal stress exposure have been linked to children's emotional and behavioral problems as well as reduced intellectual performance.³³ Furthermore, the foetus’s growth and the kid may be impacted by the psychological and behavioural signs of maternal anxiety, such as a decreased ability for the mother to form healthy relationships with her foetus and to make wise decisions.³⁴
• Drug Use and Exposure to Environment: ADHD growth in kids has been linked to maternal exposure to substances like alcohol, tobacco, and specific environmental contaminants during pregnancy. To address preventive strategies, it is imperative to comprehend the impact of these exposures on neurodevelopment and their contribution to vulnerability to ADHD.³⁵

Postnatal Influences and Maternal Health

• Nursing and Early Nutrition: Research continues to show how nursing and early nutrition can reduce the risk of ADHD. We will look into studies examining the length of nursing, nutritional components, and their impacts on neurocognitive development and outcomes related to ADHD.³⁶
• Parenting Practices and Mother Engagement: A child's behavioral and cognitive development is altered by many postnatal circumstances, such as parental techniques, mother engagement, and the home environment. Gaining knowledge about the connection between these elements and symptoms of ADHD could help develop intervention and support plans.³⁷
• Postpartum Maternal Mental Health: The postpartum phase is essential to the health of the mother and the child. Maternal mental health issues such as postpartum depression should be checked and corelated with the factors affecting child behaviour, parenting, and the progression of ADHD.³⁸

Biological Mechanisms and Pathways

It is crucial to investigate a number of possibilities, such as alterations in neurodevelopmental processes, neurotransmitter systems, and epigenetic modifications, in order to understand the molecular underpinnings that link the development of ADHD in mothers.

These mechanisms should be checked to understand the complex ways in which neurodevelopmental pathways linked to ADHD are influenced by maternal factors.³⁹

Implications for Management and Treatment

An important topic of research is how maternal health affects the way ADHD is managed and how well treatments work. We will talk about things like moms' participation in treatment plans, their commitment to interventions, and how their mental health affects how well ADHD treatments work.

• Prenatal Care: Frequent prenatal exams and consultations with medical professionals can aid in managing maternal health issues and offer direction on dietary and lifestyle choices that will promote a healthy pregnancy.
• Healthy Lifestyle: Reducing exposure to environmental contaminants, avoiding smoking, drinking, and illicit substances, maintaining a balanced diet high in vital nutrients, and engaging in physical activity as directed by healthcare professionals can all help lower the risk of ADHD in children.
• Stress Management: Pregnancy-related stress in mothers can be effectively managed by practicing stress-reduction techniques like mindfulness and relaxation techniques and asking for help from support groups or medical professionals.
• Early Intervention: There is a chance to lower the likelihood of ADHD in progeny by recognizing risk factors early in pregnancy and pursuing appro-priate therapies or treatments for mental health disorders, substance use disorders, or maternal health conditions.^{40, 41}

Review of literature

Attention-deficit/hyperactivity disorder (ADHD) is characterized by impulsivity, hyperactivity, and inattention. It is frequently identified in children. New research emphasizes the important role that a mother's health during pregnancy plays in determining her child's chance of developing ADHD, as well as possible preventive measures. In order to clarify the complex relationship between maternal health, the development of ADHD, and preventive strategies, this review compiles the most recent research.

The health of the mother greatly influences fetal neurodevelopment, and a variety of prenatal factors are linked to an increased risk of ADHD. Children's ADHD has been linked to maternal health issues such as infections, high blood pressure, and gestational diabetes.⁴² Furthermore, the intricate interactions impacting the neurodevelopment of the child are influenced by insufficient prenatal nutrition, maternal stress, mental health issues, substance abuse, and exposure to environmental contaminants.⁴³

The development of preventative measures is made possible by an understanding of these prenatal risk factors. Comprehensive prenatal care is essential, focusing on nutritional assistance and mental health monitoring for the mother. The goal of strategies includes early interventions for maternal health issues, stress management approaches, and healthy lifestyle promotion to reduce the rate of ADHD.⁴¹

A comprehensive approach to prenatal care and therapies is necessary since maternal health has a major impact on the risk of ADHD in offspring. By incorporating study findings into clinical practice, the burden of ADHD can be eventually decreased by providing possibilities for early identification, individualized therapies, and preventive measures.

Discussion

The correlation between mental health issues and ADHD symptoms during pregnancy and physical health may also be related to problems with interpersonal relationships.⁴³ Pregnant women with ADHD symptoms will probably have a harder time depending on their partners for help, as evidenced by the correlation between ADHD symptoms and increasing the possibility of divorce, deteriorating the quality of intimate partner relationships, and being the victim or perpetrator of intimate partner violence.³⁸ ADHD symptoms have also been linked to worse friendship quality in adulthood, so pregnant women with these symptoms may not have as much access to greater social support.⁴⁰ There is some conflicting empirical evidence regarding the claims that pregnancy-related partner and social support may help lessen the consequences of stress and mental health problems.^25,27 Therefore, it's possible that pregnant women who experience symptoms of ADHD are missing a crucial protective component for both their health and the health of the developing foetus. Another study examined the link between a mother's smoking throughout her pregnancy and her child's chance of developing ADHD. It made clear that mother smoking increases the likelihood that children may have ADHD and related behaviours, possibly as a result of nicotine's effects on fetal brain development.⁴¹

Additional studies looked into the connection between obesity in the mother before pregnancy and ADHD symptoms in her children. They discovered a connection between greater maternal obesity and elevated signs of ADHD in children, suggesting a potential link between the incidence of ADHD and prenatal nutrition relationship between pregnant stress and the risk of psychopathology in the child including ADHD.²⁸ It was made evident that the stress levels of a pregnant mother can increase the likelihood that her unborn child will experience ADHD and other mental health issues later in life.³⁰ The relationship between a mother's smoking during pregnancy and the likelihood that her unborn child will have ADHD was examined in another systematic review and meta-analysis. It compiled research results from several studies, indicating a persistent association between maternal smoking and a higher incidence of ADHD in offspring.³⁷

The correlations between stress and depressive sym-ptoms align with earlier studies indicating that internalizing issues like anxiety and depression, including pregnancy and ADHD symptoms, frequently co-occur.⁸ These connections most likely stem from a variety of factors, such as the impact of experiencing difficulties in interpersonal and occupational functioning linked to symptoms of ADHD, as well as the challenges with emotional dysregulation that are a prevalent hallmark of ADHD.¹⁶ Pregnancy adds responsibilities that could make these issues worse.

Considering the links between stress and depression, it may be advantageous for women receiving prenatal care who have identifiable symptoms of ADHD to have internalizing symptoms screened earlier and more frequently to reduce the burden on mother and child and provide prompt management. Many women may not have received a diagnosis at all since they are more prone than males to have their ADHD symptoms ignored.¹⁰

Additionally, albeit not with unintended pregnancies, our study suggested a possible link between signs of ADHD and unplanned pregnancies. The correlation with an undesired pregnancy is in line with earlier research showing that ADHD symptoms are linked to an increased likelihood of unplanned pregnancies. Previous research has suggested a potential link between higher sexual risk-taking and symptoms of ADHD, which could explain the link with unintended pregnancies.⁴⁰ On the other hand, there is evidence linking symptoms of ADHD to an increased risk of being involved in relationships where intimate partner abuse occurs.⁴⁴ Consequently, it's also probable that women who suffer from ADHD symptoms are more likely to be sexually coerced into becoming pregnant against their will. Furthermore, a link has been found between decreased social support from friends, family, and significant others and symptoms of ADHD during pregnancy. This is in line with earlier research showing that social and romantic interactions provide challenges for persons with ADHD symptoms. A recent study found that relationship impairment was predicted throughout this period by indications of impulsivity and inattention but not hyperactivity.⁴⁵

Conclusion

A multitude of genetic, environmental, and physiological factors can impact the complex neurodevelopmental conditions known as ADHD. Prenatal and postnatal factors related to maternal health are important in determining how a kid develops neurodevelopmental and whether or not they become susceptible to ADHD. Gaining knowledge about the complex interplay between ADHD and maternal health can help in developing preventive, intervention, and treatment plans. To improve outcomes for those with ADHD, more study into the mechanisms behind this connection is necessary in order to develop focused interventions and support networks.

Contributorship Statement

All authors have done the Conception and design of the study, Acquisition and analysis of data, drafting or revising of the manuscript, and Approval of the final version of the manuscript.

Conflict of interest

None