Prenatal Cocaine Exposure, Perinatal Risks, and Mediators to Preadolescent Attention Deficit Hyperactivity Disorder (ADHD)

Highlights: What are the main findings? Prenatal cocaine exposure increases the risk of ADHD in preadolescence, with effects largely mediated through attention problems and impulsivity at 4–5 years of age. Male sex is an independent risk factor with a direct path to the ADHD diagnosis. What is the implication of the main finding? Screening for behavioral problems before 4 years of age in prenatal cocaine exposure would make possible early intervention to mitigate later diagnosis or severity of ADHD. Attention-deficit/hyperactivity disorder (ADHD) is the most common behavioral problem in children. Multiple risk factors, including prenatal substance exposure, have been associated with this disorder. Objectives: We determined (1) the rate of ADHD in children with prenatal cocaine exposure (PCE) as compared to those non-exposed, (2) the association of ADHD with the infant’s sex, race, and birth weight, maternal age and education, and other known risk factors, and factors that may mediate the relationship between these risk factors and ADHD. Methods: This was a secondary analysis of data from the Maternal Lifestyle Study for a long-term follow-up. ADHD was defined as any diagnosis of attention deficit, hyperactivity disorder, or the combination, from the National Institute of Mental Health Diagnostic Interview Schedule for Children (NIMH DISC) administered to children, ages 11 or 14 years. The main exposure variable was PCE. Independent variables included infant and maternal characteristics, caretaker psychopathology, and maternal–child conflict. Mediators evaluated were the child’s impulsivity at 4 years of age and attention problems at 5 years from the Child Behavior Checklist. Results: Path analysis revealed that the effects of risk variables, including PCE, were mediated through the child’s attention problems at age 5 years. Child’s impulsivity, which was significantly associated with attention problems, was also a mediator between PCE and ADHD. Male sex had a direct path to ADHD. Conclusions: Our findings lend support to early screening before 4 years of age in children with PCE or other risk factors for ADHD. Behavioral interventions provided during early childhood may mitigate the later diagnosis or severity of ADHD.