Ecological model of school engagement and attention-deficit/hyperactivity disorder in school-aged children

School engagement protects against negative mental health outcomes; however, few studies examined the relationship between school engagement and attention-deficit hyperactivity disorder (ADHD) using an ecological framework. The aims were to examine: (1) whether school engagement has an independent protective association against the risk of ADHD in children, and (2) whether environmental factors have an association with ADHD either directly or indirectly via their association with school engagement. This cross-sectional study used data from the 2011-2012 National Survey of Children's Health, which collected information about children's mental health, family life, school, and community. The sample contained 65,680 children aged 6-17years. Structural equation modeling was used to estimate the direct association of school engagement and ADHD and indirect associations of latent environmental variables (e.g., family socioeconomic status (SES), adverse childhood experiences (ACEs), environmental safety, and neighborhood amenities) and ADHD. School engagement had a direct and inverse relationship with ADHD (=-0.35, p<0.001) such that an increase in school engagement corresponds with a decrease in ADHD diagnosis. In addition, family SES (=-0.03, p=0.002), ACEs (=0.10, p<0.001), environment safety (=-0.10, p<0.001), and neighborhood amenities (=-0.01, p=0.025) all had an indirect association with ADHD via school engagement. In conclusion,schoolengagement had a direct association with ADHD. Furthermore, environmental correlates showed indirect associations with ADHD via school engagement. School programs targeted at reducing ADHD should consider family and community factors in their interventions.