Children who experience family and environmental stressors, and traumatic experiences, such as poverty,  mental illness and exposure to violence, are more likely to be diagnosed with Attention Deficit/Hyperactivity Disorder (ADHD), according to new research by investigators at the Children’s Hospital at Montefiore (CHAM), titled “Associations Between Adverse Childhood Experiences and ADHD Diagnosis and Severity,” published in Academic Pediatrics.

ADHD is the most common neurobehavioral disorder of childhood. There has been a significant increase in parent-reported ADHD prevalence over the last decade, and there has also been an associated rise in stimulant medication use. Current ADHD clinical practice guidelines recommend evaluating for other conditions that have similar symptoms to ADHD, such as disruptive behaviors, impulsivity, and issues with memory, organization and problem-solving, but few pediatricians routinely ask about psychosocial factors that could be effecting a child’s health during ADHD assessment.

Exposure to Adverse Childhood Experiences (ACEs), commonly referred to as family or environmental stressors, such as divorce and familial incarceration, is one way that behaviors similar to those exhibited by children with ADHD, can be triggered. Research has shown that this is because ACEs may increase a child’s risk for toxic levels of stress, which in turn may impair brain development, behavior, and overall physical and mental health.

“If clinicians aren’t routinely discussing exposure to traumatic experiences and identifying ACEs, particularly among children with behavioral concerns such as ADHD, there may be a heightened risk of missing an underlying trauma history or misattributing some of the symptoms of traumatic stress as solely those of ADHD,” said lead author Nicole M. Brown, M.D., M.P.H., M.H.S., attending pediatrician, Division of Academic General Pediatrics, CHAM, and assistant professor of Pediatrics, Albert Einstein College of Medicine. “We sought to examine the link between ADHD and ACEs in an effort to improve ADHD assessment and management.”

Dr. Brown and co-investigators at CHAM used a nationally representative sample of 76,227 children from the 2011-2012 National Survey of Children’s Health, to identify children 4 -17 years old whose parents reported both the presence and severity of ADHD and their child’s exposure to nine ACEs – socioeconomic hardship, divorce, death, domestic violence, neighborhood violence, substance abuse, incarceration, mental illness in the family, and discrimination.

The analysis found that children with parent-reported ADHD were more likely to have two or more ACEs exposures, compared to children without parent-reported ADHD. Most significantly, children with socioeconomic hardship, parent/guardian divorce, familial mental illness, neighborhood violence, and familial incarceration were more likely to have an ADHD diagnosis, and those with socioeconomic hardship and familial mental illness were more likely to have moderate to severe ADHD, according to parental reports.

Children with parent-reported ADHD represented 8.8 percent of the 76,227 children, and were more likely to be male, aged 12 – 17 and non-Hispanic white.

“Our research shows there are significant associations between ACE exposures and having an ADHD diagnosis, and we encourage pediatric providers to more frequently evaluate for ACEs as part of ADHD assessments,” said Dr. Brown. “Ultimately, this may lead to more trauma-informed approaches to care, particularly for children whose response to stimulant medications or targeted behavioral therapies are poor.”