Childhood ADHD, Conduct Disorder Linked to Intimate Partner Violence

Deborah Brauser

November 11, 2010

November 11, 2010 — Adolescents with conduct disorder (CD), alone or with attention-deficit/hyperactivity disorder (ADHD), may be at increased risk for perpetrating intimate partner violence (IPV) with and without injury as young adults, new research suggests.

In addition, childhood ADHD without CD was found to be a significant predictor of later IPV resulting in injury.

"One of the novel aspects of our study was understanding that ADHD did seem to have a unique relationship with [IPV]," study investigator Greta Massetti, PhD, lead behavioral scientist in the Division of Violence Prevention at the Centers for Disease Control and Prevention Injury Center in Atlanta, Georgia, told Medscape Medical News.

Dr. Greta Massetti

She noted that it was also interesting that the adolescents with both ADHD and CD "were at the very highest risk" for IPV.

Looking specifically at ADHD, the researchers also found that retrospectively reported symptoms of inattention (IA) were found to contribute to IPV without injury, whereas hyperactivity/impulsivity (HI) symptoms significantly predicted IPV resulting in injury.

"These findings indicate that impulse control problems constitute a higher risk for perpetration of serious violence," the researchers write.

However, "future studies are needed to examine the specific phenomena (verbal impulsivity, relationship conflict, impulsive aggression) underlying the associations between IA, HI, and IPV of differing severity," they add.

Clinicians should be aware that as kids with psychiatric disorders grow older and develop intimate relationships, it is important to provide a strong foundation for them to understand how to resolve conflict, to develop strong coping skills, and to be aware of the risks for having difficulties.

"One of the important take-home messages is that clinicians should be aware that as kids with psychiatric disorders grow older and develop intimate relationships, it is important to provide a strong foundation for them to understand how to resolve conflict, to develop strong coping skills, and to be aware of the risks for having difficulties," said Dr. Massetti.

The study is published in the November issue of the Archives of General Psychiatry.

Few Studies

IPV, which is defined as "physical, sexual, or psychological harm by a current or former partner or spouse," causes almost 2 million injuries and 1500 deaths in the United States each year, write the study authors.

Although past studies have looked at identifying risk factors for adult IPV perpetration, the presence of childhood ADHD symptoms "has received little research attention."

Dr. Massetti noted that several past trials have shown that CD is a key factor for IPV and that ADHD has a strong relationship with ADHD. "What we don't know very well is the extent to which ADHD is also associated with IPV."

For this trial, the investigators evaluated data on 11,238 participants (50.4% girls) in the National Longitudinal Study of Adolescent Health (known as Add Health), all of whom were in grades 7 through 12 during the 1994 to 1995 school year (mean age, 15.7 years).

After baseline interviews, participants were followed-up between April and August 1996 (mean age, 16.2 years) and between August 2001 and April 2002 (mean age, 22.0 years).

During wave 3 interviews, all participants were asked detailed questions about sexual and/or romantic relationships in the past 6 years, including IPV perpetration. At that time, they also gave retrospective self-reports of any ADHD symptoms experienced between the ages of 5 and 12 years.

Self-reports of CD symptoms were given during the wave 1/baseline data collection.

"This longitudinal, nationally representative sample allowed us to generalize the findings to broader populations," explained Dr. Massetti.

Significant Predictors

Results showed that 8.4% of the participants reported ADHD symptoms and 12.4% reported CD symptoms. A total of 27.1% reported perpetrating IPV.

In unadjusted analysis, the odds ratio (OR) for predicting IPV conduct resulting in injury was 1.75 for ADHD and 2.82 for CD (both, P < .01). For IPV without injury, the unadjusted ORs were lower but still significant (1.19 [P < .05] and 1.49 [P < .01], respectively).

Although HI symptoms were found to significantly predict future IPV perpetration without injury (P < .01), this association was no longer significant when IA and CD symptoms were controlled. However, HI predicted IPV conduct resulting in injury (unadjusted, P < .01; adjusted, P < .05).

Even after controlling for CD and HI symptoms, IA symptoms predicted perpetrating IPV without injury (P < .05) but did not predict it with injury.

When controlling for HI and IA, CD symptoms significantly predicted IPV with and without injury (both P < .01).

In categorical analyses that adjusted for sociodemographic factors, ADHD was not associated with carrying out IPV without injury. CD, however, "significantly increased the risk of IPV perpetration without injury by 95% when controlling for ADHD," write the researchers.

For perpetration resulting in injury, ADHD was a significant predictor (OR, 1.71) and remained so even when controlling for CD (OR, 1.53), whereas CD "tripled the odds" when controlling for ADHD (OR, 3.20).

Finally, the investigators compared the 4 subgroups: those with ADHD only (6.4% of sample), those with CD only (10.5%), those with ADHD plus CD (1.9%), and those with neither ADHD nor CD (81.2%).

They found that for perpetration without injury, ADHD only was not a significant predictor, but both CD only (OR, 1.96) and ADHD plus CD (OR, 2.10) were.

For violence resulting in injury, ADHD only (OR, 1.81), CD only (OR, 3.49), and ADHD plus CD (OR, 3.75) were all significant predictors of future risk.

Overall, the results "suggest the need for services and treatment strategies that specifically address the risks for violence and promote healthy intimate relationships for youths with CD and ADHD," the study authors write.

Questionable Findings?

"The sample is large and representative of the United States, so it has advantages there. [However,] ADHD symptoms during childhood were reported retrospectively by adults," Benjamin B. Lahey, PhD, professor of epidemiology, psychiatry, and behavioral neuroscience in the Department of Health Studies at the University of Chicago, in Illinois, told Medscape Medical News.

"Regrettably, we know that such retrospective reporting is highly inaccurate and there are no data showing that the specific retrospective measure of childhood ADHD symptoms used in this study is valid. As a result, these findings regarding ADHD just cannot be taken seriously," said Dr. Lahey, who was not involved with this study.

He noted that although he could not tell how the investigators measured childhood CD, "it seems to be at least partially based on reports of adolescent conduct problems that were actually measured during adolescence. So, it is possible that CD predicted interpersonal violence and ADHD did not because CD was measured better than ADHD.

"That said, other better studies have actually reached the same conclusions as this study," added Dr. Lahey. "Some antisocial children (but certainly not all) grow up to be antisocial adults, and sadly, [IPV] is one of the antisocial things that they do."

Most of the antisocial children who grow up to be antisocial adults do have ADHD as children, but childhood ADHD in the absence of childhood CD does not predict this outcome.

"Most of the antisocial children who grow up to be antisocial adults do have ADHD as children, but childhood ADHD in the absence of childhood CD does not predict this outcome," he concluded.

The original Add Health study was supported in part by a grant from the Eunice Kennedy Shriver National Institute of Child Health and Human Development, "with cooperative funding from 17 other agencies." The study authors and Dr. Lahey have disclosed no relevant financial relationships.

Arch Gen Psychiatry. 2010;67:1179-1186. Abstract

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