Attention-Deficit / Hyperactivity Disorder (ADHD) and Adverse Childhood Experiences

“Inattentive, hyperactive, and impulsive behaviour may mirror the effects of adversity, and many doctors don’t know how—or don’t have time—to tell the difference.” [1]

​​People with ADHD may have trouble paying attention, controlling impulsive behaviours (may act without thinking about what the result will be), or be overly active. Although ADHD can’t be cured, it can be successfully managed, and some symptoms may improve as the child ages [2].  The CDC website highlights two treatments for ADHD (a) behaviour therapy, including training for parents, and (b) medications.

The prevalence of ADHD is shows high variations worldwide, ranging from as low as 1% to as high as nearly 20%, depending on the diagnostic criteria and the assessment tools used.  With an estimated worldwide-pooled prevalence of 5.3%, ADHD is the most prevalent mental disorder in children. In India, the prevalence of ADHD has been reported to be 1.6–17.9%[3].

ADHD symptoms or outcomes (Source: CDC website)

Figure 1: ADHD symptoms or outcomes (Source: CDC website)

While ADHD is a neurological condition diagnosed with behavioural factors, it is linked to adverse childhood experiences that the child goes through such as abuse, neglect or household challenges.  While it is not a simple correlation, as highlighted by recent research, the link needs careful integration with the mainstream identification and treatment of ADHD. Key research findings are highlighted below:

  • The children with ADHD have higher ACE exposure compared with children without ADHD. Moreover, there is sufficient evidence linking increased ACE scores with increased ADHD symptoms[4].
  • In a study of >1500 urban children, ACEs occurring before age nine were associated with ADHD diagnosis at 9. This study highlighted that intervention in childhood is essential. Even after adjusting for early childhood ACEs and ADHD at age 5, there was a strong association between ADHD and ACEs in middle childhood[5].
  • ADHD predicts subsequent risk for ACEs, and the inattentive presentation may confer the most trouble[6].
  • The above ideas are validated when we review the prevalence of ADHD among individuals with PTSD (Post Traumatic Stress Disorder)[7]. For example, individuals with PTSD and ADHD have increased psychiatric comorbidity and point to the possible role of family environment and the experiences. A study amongst college students also identified an overlap between attention problems, PTSD symptoms and trauma experiences. The research also encouraged those being assessed for ADHD to be counselled to explore trauma history and PTSD symptoms[8].

So what?

The above evidence only highlights the need to focus on the causes and potential risks of ADHD.  The common thread is ACE or trauma, and this is where we provide help in addressing the implications of the trauma.  While it is not easy (it takes time, courage and follow-through), we can help the individuals deal with their ACEs first.

ACEs and ADHD may form part of a cycle that perpetuates hardship and adversity. It is critical to developing interventions that halt this cycle and steer children out of negative developmental trajectories[9]. Figure 2 provides a visual perspective showing % of individuals who have ADHD and are facing other issues.

 

Figure 2: Percentage of ADHD children with some additional/other disorder (Source: CDC website)Figure 2: Percentage of ADHD children with some additional/other disorder (Source: CDC website)

 

The reasons to believe:

We measure adverse childhood experiences (ACE) in the form of an ACE score.  Higher the ACE score, the higher the likelihood of emotional health challenges (the long term challenges faced by individuals with higher ACE go beyond just emotional health).  There is a dose-response relationship between ACE score and the extent of challenges an individual faces.

Our data provides beneficial and actionable insights.  Figure 3 shows anxiety data for individuals with different levels of ACE exposure.  Those with ACE scores of 6 and above present with much higher anxiety levels (14.6, i.e. severe) compared to those with an ACE score between 0 and 2 (anxiety level is 12.3, i.e. moderate). After four sessions, all the groups showed a reduction in anxiety to an acceptable level (though the ACE >=6 group still had an anxiety level of 8.1, though much below the expected cut-off of 10). There is a similar reduction in depression levels (now captured here) and improvement in sleep and psychological well-being.

 

Changes in anxiety levels for groups with different ACE levels

Figure 3 – Changes in anxiety levels for groups with different ACE levels (Source: Wellness Space data)

 Summary:

The ADHD condition is linked with more adverse childhood experiences, and it also increases the risk of facing more adverse childhood experiences.  Our work focuses on the emotional health parameters (anxiety, depression, well-being, sleep quality and PTSD or Post Traumatic Stress Disorder) and provides significant improvement in all the parameters. For fellow therapists or parents who are dealing with ADHD conditions, few suggestions are highlighted below:

  1. Identify anxiety, depression levels and sleep quality for the individuals. Address them first.
  2. Understand if the individual (whether adult or child) has gone through some form of traumatic or adverse experiences as a child (before the age of 18). Measure or assess for PTSD (Post Traumatic Stress Disorder) and address it.
  3. Recognize that any childhood conditioning that has caused trauma creates an unconscious response through implicit memory. The triggers to any similar schema could result in a fight or flight response and reduce the individual’s ability to focus.
  4. Finally, help the individual feel “Safe”, address emotional imbalances such as anxiety, depression and deal with the trauma.

Gunjan Y Trivedi

[email protected]

 

References:

[1] How Childhood Trauma Could Be Mistaken for ADHD, Rebecca Ruiz, https://www.theatlantic.com/health/archive/2014/07/how-childhood-trauma-could-be-mistaken-for-adhd/373328/

https://www.theatlantic.com/health/archive/2014/07/how-childhood-trauma-could-be-mistaken-for-adhd/373328/

[2] Center for Disease Control website https://www.cdc.gov/ncbddd/adhd/index.html (The figures 1 and 2 are used based on CDC approval)

[3] Sharma P, Gupta RK, Banal R, Majeed M, Kumari R, Langer B, Akhter N, Gupta C, Raina SK. Prevalence and correlates of Attention Deficit Hyperactive Disorder (ADHD) risk factors among school children in a rural area of North India. J Family Med Prim Care [serial online] 2020 [cited 2021 Oct 11];9:115-8. Available from: https://www.jfmpc.com/text.asp?2020/9/1/115/276748

[4] Brown, N. M., Brown, S. N., Briggs, R. D., Germán, M., Belamarich, P. F., & Oyeku, S. O. (2017). Associations between adverse childhood experiences and ADHD diagnosis and severity. Academic pediatrics, 17(4), 349-355.

[5] Jimenez, M. E., Wade, R., Jr, Schwartz-Soicher, O., Lin, Y., & Reichman, N. E. (2017). Adverse Childhood Experiences and ADHD Diagnosis at Age 9 Years in a National Urban Sample. Academic pediatrics, 17(4), 356–361. https://doi.org/10.1016/j.acap.2016.12.009

[6] Lugo-Candelas, C., Corbeil, T., Wall, M., Posner, J., Bird, H., Canino, G., Fisher, P. W., Suglia, S. F., & Duarte, C. S. (2021). ADHD and risk for subsequent adverse childhood experiences: understanding the cycle of adversity. Journal of child psychology and psychiatry, and allied disciplines, 62(8), 971–978. https://doi.org/10.1111/jcpp.13352

[7] Antshel, K. M., Kaul, P., Biederman, J., Spencer, T. J., Hier, B. O., Hendricks, K., & Faraone, S. V. (2013). Posttraumatic stress disorder in adult attention-deficit/hyperactivity disorder: clinical features and familial transmission. The Journal of clinical psychiatry, 74(3), e197–e204. https://doi.org/10.4088/JCP.12m07698

[8] Miodus, S., Allwood, M. A., & Amoh, N. (2021). Childhood ADHD Symptoms in Relation to Trauma Exposure and PTSD Symptoms Among College Students: Attending to and Accommodating Trauma. Journal of Emotional and Behavioral Disorders, 29(3), 187–196. https://doi.org/10.1177/1063426620982624

 [9] Lugo-Candelas, C., Corbeil, T., Wall, M., Posner, J., Bird, H., Canino, G., Fisher, P. W., Suglia, S. F., & Duarte, C. S. (2021). ADHD and risk for subsequent adverse childhood experiences: understanding the cycle of adversity. Journal of child psychology and psychiatry, and allied disciplines, 62(8), 971–978. https://doi.org/10.1111/jcpp.13352