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Adverse Childhood Experiences and ADHD

Diagnosis and Severity: An UpdateRunning title:
ACEs and ADHD

Elizabeth Crouch, Emma Boswell

PII: S1876-2859(24)00014-7
DOI: https://doi.org/10.1016/j.acap.2024.01.014
Reference: ACAP2445

To appear in: Academic Pediatrics

Received date: 5 January 2024
Accepted date: 20 January 2024
Please cite this article as: Elizabeth Crouch and Emma Boswell, Adverse
Childhood Experiences and ADHD Diagnosis and Severity: An UpdateRunning
title: ACEs and ADHD, Academic Pediatrics, (2024)
doi:https://doi.org/10.1016/j.acap.2024.01.014
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 Adverse Childhood Experiences and ADHD Diagnosis and Severity: An Update

Running title: ACEs and ADHD

Elizabeth Crouch, PhDa*, Emma Boswell, MPHa

a
Rural and Minority Health Research Center, Arnold School of Public Health, University of

South Carolina, 220 Stoneridge Drive, Suite 204, Columbia, SC, 29210, USA.

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Author email addresses:
Elizabeth Crouch: [email protected]

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Emma Boswell: [email protected]

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* Corresponding Author: Elizabeth Crouch, [email protected], Rural and Minority

Health Research Center, Arnold School of Public Health, University of South Carolina, 220
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Stoneridge Drive, Suite 204, Columbia, SC, 29210
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Keywords:
adverse childhood experiences; attention-deficit hyperactivity disorder; child development and behavior
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What’s New: Children with exposure to childhood trauma are at increased risk of diagnosis and
higher severity of ADHD than children without trauma exposure. New research updates our
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original findings, highlighting the need for further studies on ADHD and positive childhood
experiences.
Abbreviations:

ACE: adverse childhood experiences (ACEs); ADHD: attention deficit-hyperactivity disorder

(ADHD); NSCH: National Survey of Children’s Health

In “Examining the Relationship Between Adverse Childhood Experiences and ADHD Diagnosis

and Severity”, we found that children exposed to a high count of adverse childhood experiences
(ACEs), which includes exposure to abuse, neglect, and household dysfunction before the age of

18, had a much higher likelihood of being diagnosed with attention deficit-hyperactivity disorder

(ADHD), a neurobehavioral disorder diagnosed in childhood and characterized by impulsivity,

hyperactivity, and inattention.1 We found that children exposed to four or more ACEs had a

higher odds of ADHD and moderate to severe ADHD, than children who had been exposed to

less than four ACEs. We also found that public insurance, a proxy measure for poverty, was

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associated with caregiver reported moderate to severe ADHD.1 Our study findings highlighted

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the association of ACEs and both ADHD diagnosis and severity, including household

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characteristics which may be important moderating effects for this relationship.1 Since first

submitting this manuscript for publication in October 2020, other researchers have updated both
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prevalence estimates of ADHD and the relationship between ACEs and ADHD diagnosis and
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severity. The purpose of this progress report is to describe new and expanding research from our

prior study.
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Association of ACEs with ADHD diagnosis

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There is continued evidence that exposure to both psychosocial, environmental, and social
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stressors, such as ACEs, may impact brain development.2 Therefore, increasing attention needs
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to be placed on examining the relationship between ACEs and neurobehavioral disorders, such as

ADHD. Since our original study publication, two studies have confirmed our findings of a

significant relationship between exposure to ACEs and ADHD diagnosis.

Walker et al. confirmed our findings, also using the 2017-2018 NSCH to find that an increasing

count of ACEs among children and adolescents in a national sample was associated with an

increase in the odds of an ADHD diagnosis. This study also found that type of ACE mattered,

with the ACEs most strongly associated with ADHD being residing with someone with mental
illness and caregiver incarceration.3 Song et al. expanded on our prior study by using a latent

class approach with the 2018 National Survey of Children’s Health (NSCH), characterizing

ACEs as low-risk, moderate-risk, high discrimination and neighborhood violence, and high-risk,

to examine patterns of ACEs associated with psychological and behavioral disorders among

adolescents with ADHD. Song et al. found that high-risk ACEs and high discrimination and

neighborhood violence were strongly associated with behavioral challenges among children and

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adolescents with ADHD.4 Yet, neither Walker nor Song examined the relationship between ACEs

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and severity of ADHD.

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Association of ACEs with ADHD severity
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Understanding the association between ACEs and ADHD severity is essential to ensuring that

children are receiving the resources and interventions that they need. Expanding upon our
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findings of a relationship between ACEs and ADHD severity, Alfonso et al., using a sample of

adults referred for neuropsychological evaluations, found that those with higher counts of self-
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reported ACEs also had higher rates of childhood and cognitive ADHD symptoms. 5 Alfonso
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also found that adults with higher counts of ACEs reported higher rates of impulsivity,
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inattention, and hyperactivity, suggesting that chronic stress may increase the risk of higher
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severity of ADHD symptoms.5 Recent research in Brazil, among a birth cohort study of children

between the age of six and eleven, found that children with traumatic experiences had not only

an increased risk of ADHD and hyperactivity disorders, but also an increased risk of multiple

psychiatric disorders and higher severity disorders. 6 The findings of ACEs associated with

increased ADHD severity highlight the need for interventions that may create resilience to

decrease the impact of ACEs on children and adolescents. 7

ACEs, ADHD, and Resilience

Therefore, while the relationship between ACEs and ADHD, as well as ACEs and ADHD

severity, have been documented, there has been minimal attention paid to the relationship

between resilience and ADHD. Okwori et al. used the 2018 NSCH to examine ACEs, resilience,

and various mental health outcomes, including ADHD.8 The findings from the Okwori et al.

study demonstrated that children and adolescents who had been reported as having individual

resilience, as well as resilience metrics (ex. of these metrics) measured, lowered the likelihood of

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being diagnosed with ADHD and other behavioral disorders. 8 Adarlegbe et al. did a scoping

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review examining ACEs, ADHD, and resilience, noting the importance for healthcare providers

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and educators in the early identification and detection of ACEs among individuals diagnosed

with ADHD. 9 e-
Future Work
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As chronic stress may increase the risk of ADHD severity, future research should examine

positive childhood experiences, which are known to promote resilience, and ADHD diagnosis
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and severity, as these “counter ACEs” may reduce the effects of trauma and stress in children and
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adolescents. 7 The findings from these studies illustrate the need for pediatricians to consider
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ACEs when diagnosing and treating ADHD among children and adolescents. The American
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Academy of Pediatrics (AAP) ADHD Clinical Practice Guidelines recommend physicians rule

out alternative causes of symptoms when determining a diagnosis of ADHD. Children

experiencing hyperactivity and inattention may be having a reaction to traumatic stress rather

than ADHD and would be better served by addressing the traumatic stress instead of the

hyperactivity.10 Therefore, clinicians should assess ACEs during the diagnosis of ADHD, as

findings from our original study and subsequent literature demonstrate strong associations

between ACE count, ACE type, patterns of ACEs, and ADHD diagnosis and severity.
References
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severity. Academic pediatrics, 21(8), 1388-1394.
2. Bhutta, Z. A., Bhavnani, S., Betancourt, T. S., Tomlinson, M., & Patel, V. (2023). Adverse
childhood experiences and lifelong health. Nature Medicine, 29(7), 1639-1648. Song, J.
(2023). Patterns of Adverse Childhood Experiences and Psychiatric Disorders Among
Adolescents with ADHD: A Latent Class Analysis. Child Psychiatry & Human

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Development, 1-12.
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Declaration of Competing Interest

none

Acknowledgements

The authors declare that they have no conflict of interest. This research did not receive any specific grant
from funding agencies in the public, commercial, or not-for-profit sectors.

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