About the study
The study measured exposure to adverse childhood experiences:
- Socioeconomic hardship
- Divorce
- Familial substance abuse
- Familial mental illness
- Neighborhood violence
- Incarceration of a parent or guardian
- Death of parent or guardian
- Domestic violence
- Racial or ethnic discrimination
Nicole Brown vividly recalls the 9-year-old boy brought to her during her residency at Johns Hopkins Medical Center in Baltimore.
"His great grandmother was his primary caregiver," Brown says. "The words she used were that he was 'off the chain.' He was really hard to manage at home, and he was having a lot of difficulty at school."
The boy, already diagnosed with attention-deficit/hyperactivity disorder (ADHD), had been exhibiting increasingly severe behavioral issues and was not responding to medications. As Brown, M.D., M.P.H., M.H.S., now an attending physician in the division of general pediatrics at The Children's Hospital at Montefiore, dug deeper, she discovered a history of family trauma—including years of physical and sexual abuse by a relative.
"The more I learned, the more I started to wonder how the trauma played into his behavior," Brown says. "I began to question whether or not I could just attribute it to ADHD, or if some of it could be attributed to the trauma to which he'd been exposed."
Significant association
The experience led Brown to further investigate the role childhood trauma plays in ADHD, culminating in research published in Academic Pediatrics. In it, Brown says she and her colleagues were able to draw a significant association between adverse childhood experiences (ACEs) and ADHD.
Sampling nearly 80,000 children ages 4 to 17 from the 2011-2012 National Survey of Children's Health, the researchers measured the presence of nine ACEs, including socioeconomic hardship, divorce and familial substance abuse, among others.
The study revealed children with parent-reported ADHD had a higher incidence of exposure to ACEs than the children without ADHD. For some ACEs, ADHD occurrence was as much as 55 percent higher. Further, the research showed children with two or more ACEs were much more likely to have moderate-to-severe ADHD than their peers with one or no ACEs.
More information needed
Though previous studies have looked at this correlation, Brown says there is not much research available on the subject. As a result, pediatricians often don't inquire about ACEs when treating their ADHD patients. In fact, Brown cites research showing only 2 percent of doctors regularly use an ACE screening tool.
"Time is a big constraint when it comes to digging deeper and asking more sensitive questions," Brown says. "The other thing is that a lot of pediatricians—even if they do ask—aren't always sure what to do with that information."
Treatment solutions
Brown says understanding the association between ACEs and ADHD could lead to treatments that address the underlying trauma. She points to an early-childhood development program at Montefiore, Healthy Steps, which provides families with access to a child psychologist and resources for parents. From there, patients may be referred to mental health providers or social workers within the community to help remedy any environmental factors that could be contributing to the condition.
Brown acknowledges that much more work lies ahead to more effectively treat ADHD, from additional research on the causes of the disorder to wider implementation of the ACE screening. But she remains motivated by that young patient she first met so many years ago. "There was a lot of adversity that he was experiencing and had experienced," Brown says. "He has really inspired this work."
Read the full study: "Associations between Adverse Childhood Experiences and ADHD Diagnosis and Severity."