Combined association of BTEX and material hardship on ADHD-suggestive behaviours among a nationally representative sample of US children

Background Previous research shows that environmental and social factors contribute to the development of attention-deficit/hyperactivity disorder (ADHD). Objective To determine the relationship between early-life exposure to common ambient air pollutants (benzene, toluene, ethylbenzene, and xylene, also known as BTEX), household material hardship (a measure of socio-economic status), and ADHD-suggestive behaviours in kindergarten-age children. Methods Pollutant exposure estimated from the 2002 National Air Toxics Assessment at each child's residential ZIP code at enrolment was linked to the Early Childhood Longitudinal Study Birth Cohort (n = 4650). Material hardship was assigned as a composite score of access to food, health care, and housing. Kindergarten teachers rated children's behaviours and activity in the classroom using a five-point Likert scale. Children with summary scores in the bottom decile were classified as displaying ADHD-suggestive behaviours. Logistic regression models were constructed to estimate the association between both BTEX exposure and material hardship on ADHD-suggestive behaviours. Results The odds of displaying ADHD-suggestive behaviours were greater in children with combined high-level exposure to BTEX and in those experiencing material hardship (odds ratio 1.54, 95% confidence interval [CI] 1.12, 2.11, and OR 2.12, 95% CI 1.25, 3.59, respectively), adjusting for covariates. These associations were stronger when restricting the study population to urban areas. There was no evidence of interaction between early life BTEX exposure and material hardship, although the effects of BTEX exposure were slightly greater in magnitude among those with higher material hardship scores. Conclusions Children exposed to air toxics, material hardship, or both early in life are more likely to display signs of ADHD-suggestive behaviours as assessed by their kindergarten teachers. The associations between exposures to air pollution and to socio-economic hardship were observed in all children but were particularly strong in those living in urban areas.