Poverty, Maltreatment and ADHD
Poverty, Maltreatment and ADHD
ADHD is a common condition, affecting between 3% and 5% of children, with important consequences for adverse long-term outcomes in health and education and welfare; as such it is an important public health problem. It is also a significant problem among children affected by violence. Clinicians working in this area face difficult clinical and ethical dilemmas, which might be less challenging if our understanding of the population expressing this behavioural phenotype was better. We need research to robustly test the ADHD-phenocopy hypothesis, including genetic studies that incorporate, or control, epigenetic phenomena. Current whole population cohort studies are problematical because they rely on current diagnostic approaches. In addition, they often fail to adequately record exposure to violence, including to domestic abuse which, as is pointed out above, is itself associated with other confounding risk factors for ADHD, such as prematurity, maternal alcohol abuse, and maternal smoking; for example, domestic abuse is identified in the ALSPAC cohort by the parental question 'Has anyone been cruel to you', a question that renders this cohort unsuitable for any study investigating the impact of domestic abuse on children as it is likely to be very insensitive. Longitudinal family studies using cohorts from genetic studies may help, but they need to include qualitative as well as quantitative approaches, and include children's experiences of school as well as at home. We need in addition to investigate whether children with ADHD who have a history of child maltreatment, including domestic abuse, respond differently to medication to children without a history of maltreatment and violence, and to review the effectiveness of drug treatments and other therapeutic approaches in these different groups.
This hypothesis has wider implications for the nature, implications and limitations of other diagnoses, which are based on symptoms alone, without biological markers, with the possibility of overlooked heterogeneity. A greater knowledge of epigenetics, which can be anticipated in the coming years, has huge potential to improve our understanding of the determinants of health and illness in children, and the interaction of social and biological drivers of diseases and disorders in childhood.
Conclusions
ADHD is a common condition, affecting between 3% and 5% of children, with important consequences for adverse long-term outcomes in health and education and welfare; as such it is an important public health problem. It is also a significant problem among children affected by violence. Clinicians working in this area face difficult clinical and ethical dilemmas, which might be less challenging if our understanding of the population expressing this behavioural phenotype was better. We need research to robustly test the ADHD-phenocopy hypothesis, including genetic studies that incorporate, or control, epigenetic phenomena. Current whole population cohort studies are problematical because they rely on current diagnostic approaches. In addition, they often fail to adequately record exposure to violence, including to domestic abuse which, as is pointed out above, is itself associated with other confounding risk factors for ADHD, such as prematurity, maternal alcohol abuse, and maternal smoking; for example, domestic abuse is identified in the ALSPAC cohort by the parental question 'Has anyone been cruel to you', a question that renders this cohort unsuitable for any study investigating the impact of domestic abuse on children as it is likely to be very insensitive. Longitudinal family studies using cohorts from genetic studies may help, but they need to include qualitative as well as quantitative approaches, and include children's experiences of school as well as at home. We need in addition to investigate whether children with ADHD who have a history of child maltreatment, including domestic abuse, respond differently to medication to children without a history of maltreatment and violence, and to review the effectiveness of drug treatments and other therapeutic approaches in these different groups.
This hypothesis has wider implications for the nature, implications and limitations of other diagnoses, which are based on symptoms alone, without biological markers, with the possibility of overlooked heterogeneity. A greater knowledge of epigenetics, which can be anticipated in the coming years, has huge potential to improve our understanding of the determinants of health and illness in children, and the interaction of social and biological drivers of diseases and disorders in childhood.
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