Child Abuse & Neglect 62 (2016) 1–9

Contents lists available at ScienceDirect

Child Abuse & Neglect

Effects of attention-deficit/hyperactivity disorder on child

abuse and neglect
Emel Sari Gokten a,∗ , Nagihan Saday Duman b , Nusret Soylu c ,
Mehmet Erdem Uzun a
a
Yuksek Ihtisas Training ve Research Hospital, Bursa, Child and Adolescent Psychiatry, Turkey
b
Afyon Public Hospital, Afyon, Child and Adolescent Psychiatry, Turkey
c
Inonu University School of Medicine, Malatya, Child and Adolescent Psychiatry, Turkey

a r t i c l e i n f o a b s t r a c t

Article history: It is known that children with mental and developmental problems are at risk of abuse and
Received 24 June 2016 neglect. Attention-deficit/hyperactivity disorder is one of the most frequent neurodevel-
Received in revised form 4 October 2016 opmental disorders in children and adolescents. The purpose of this study is to examine
Accepted 8 October 2016
whether children diagnosed with ADHD are under more risk in terms of child abuse and
Available online 19 October 2016
neglect compared to controls. In this case-control study, 104 children, who applied to Child
and Adolescent Psychiatry Unit of Bursa Yuksek Ihtisas Training and Research Hospital
Keywords:
between January and June 2015, were diagnosed with ADHD, and had no other psychi-
Emotional abuse
atric comorbidity except for disruptive behavior disorders, and 104 healthy children were
Sexual abuse
Violence compared. Abuse Assessment Questionnaire was applied to children after approval of the
Child abuse (neglect) families was received. It was determined that the children diagnosed with ADHD were
exposed to more physical (96.2%) and emotional abuse (87.5%) in a statistically significant
way compared to controls (46.2%; 34.6%), they were exposed to physical and emotional
neglect (5.8%) at a lower rate compared to healthy children (24.0%), and there was no dif-
ference between them and healthy children in terms of witnessing family violence (56.7%;
47.1%) and being exposed to sexual abuse (5.8%; 1.9%). The children diagnosed with ADHD
were exposed to physical and emotional abuse at a higher rate; further studies should
emphasize the role of parents in this topic and how parental education and treatment
programs change the results.
© 2016 Elsevier Ltd. All rights reserved.

Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterized with inattention, hyper-

activity, and impulsivity inappropriate to age and development level (American Psychiatric Association, 2000). ADHD is one
of the most frequent psychiatric disorders in children and adolescents and its prevalence worldwide was reported as 5.29%
in a meta-analysis study (Polanczyk, de Lima, Horta, Biederman, & Rohde, 2007). Its prevalence in boys is reported to be
higher than in girls, and this rate varies between 2 and 9:1 depending on sampling sources (Rucklidge, 2010).
ADHD-associated symptoms pave the way for numerous problems, such as low academic success, learning disabilities,
lower occupational status, difficulties in social relationships, increased risk for substance use, frequent accidents, behav-
ioral problems, anxiety, and mood disorders through the lifespan (Barkley, 2002; Biederman, 2005). Comorbid psychiatric

∗ Corresponding author.
E-mail address: esgokten@hotmail.com (E. Sari Gokten).

http://dx.doi.org/10.1016/j.chiabu.2016.10.007
0145-2134/© 2016 Elsevier Ltd. All rights reserved.
2 E. Sari Gokten et al. / Child Abuse & Neglect 62 (2016) 1–9

disorders are commonly seen in children diagnosed with ADHD. The most frequently encountered comorbid diseases are
disruptive behavior disorders and anxiety disorders (Biederman, 2005; Hergüner & Hergüner, 2012; Taurines et al., 2010).
Child abuse is a common problem in the world. According to data from National Youth Center, approximately 3 million
children were abused in the United States of America in 1993. Almost half of these children were exposed to moderate or
serious injury due to abuse (Snyder & Sickmund, 2006).
Child abuse occurs in several different ways. The National Society for the Prevention of Cruelty to Children (NSPCC)
describes types of child abuse as follows: a) Physical abuse: refers to every action causing injury to the child. b) Emotional
abuse: refers to every type of action damaging self-respect of the child. c) Neglect: refers to disregard of basic needs of child
(physical or emotional) (NSPCC, 2010). There is evidence that children having mental and developmental problems are at
risk of physical abuse and neglect (Sullivan & Knutson, 2000). For example, reports state that 18.5% of children with autism
were physically abused, and 14.3% of girls diagnosed with ADHD were abused (Mandella, Walrathc, & Manteuffeld, et al.,
2005).
In a cross-sectional study, researchers found that emotional abuse and neglect were more common than other types of
abuse among children, and children diagnosed with ADHD were exposed to more physical and emotional abuse and neglect
than were non-ADHD children (Hadianfard, 2014). Similarly, Ford et al. (2000) reported that rates of physical and sexual
abuse were higher in children diagnosed with ADHD, oppositional defiant disorder, and especially comorbid ADHD and
oppositional defiant disorder. In a study comparing a group of abused children diagnosed with ADHD with a group of non-
abused children diagnosed only with ADHD in terms of symptoms and course; it was found that abused children diagnosed
with ADHD had higher inattention and impulsivity scores while hyperactivity symptoms were similar. In the group diagnosed
only with ADHD, boys experienced onset at a younger age than girls did; however, there was no difference between boys
and girls in terms of age at onset in the abused group with ADHD (Becker-Blease & Freyd, 2008). Population-based studies
questioning adult subjects retrospectively, in terms of ADHD symptoms and child abuse, indicated that childhood ADHD
symptoms were correlated with self-reported child abuse (Fuller-Thomson, Mehta, & Valeo, 2014; Fuller-Thomson & Lewis,
2015; Ouyang, Fang, Mercy, Perou, & Grosse, 2008).
Children diagnosed with ADHD continuously and recurrently demonstrate social behavior problems such as tantrums,
verbal and physical aggression, hostility, disturbance, and extroverted behaviors. Those behaviors produce/increase per-
vasive conflicts with teachers, peers classmates, and parents (Barkley, 2002). Children diagnosed with ADHD often do not
follow the rules and limitations established by adults; therefore, parents, teachers, or other students feel desperate and
exhausted in their relationships with these children (Aro, Imasiku, Haihambod, & Ahonen, 2011). In addition, numerous
teachers are not adequately equipped to work with children with special needs (Mapsea, 2006). Deficiencies of teachers and
parents in evaluating ADHD as a real disease also leads them to consider these children lazy or untalented (Olaniyan et al.,
2007).
Genetic research indicates that ADHD is mainly an inherited disorder (Biederman, 2005). This means that many children
diagnosed with ADHD have parents diagnosed with adult ADHD. Children having parents diagnosed with psychiatric dis-
orders receive inadequate parental care (Mooney, Oliver, & Smith, 2009). Studies show that adults diagnosed with ADHD
have difficulties in parenting skills. For example, these parents experience more stress, feel deterred more easily, have more
discussions with family members, and have lower self-confidence (Yousefia, Soltani, & Abdolahia, 2011; Harvey, Danforth,
McKee, Ulaszek, & Friedman, 2003). Previous related studies revealed that parents diagnosed with ADHD had more marital
problems (Murphy & Barkley, 1996), had difficulties working at their jobs regularly (Murphy & Barkley, 1996), and had
financial problems (Stavro, Ettenhofer, & Nigg, 2007). Poverty is an independent risk factor for child abuse (Drake & Pandey,
1996). Furthermore, parents with ADHD have difficulty being patient and experience outbursts of anger, and this situation
establishes a risk for abuse because the parents have higher impulsivity and lower emotion regulatory skills (Surman et al.,
2011).
Previous studies on the correlation between ADHD and child abuse were mostly population-based and cross-sectional
studies in which adult subjects were retrospectively questioned in terms of ADHD diagnosis and abuse (Fuller-Thomson
& Lewis, 2015; Fuller-Thomson et al., 2014; Ouyang et al., 2008). On this point, an important difference of our study
from others was that it was conducted on subjects in child and adolescent age groups, and diagnosis of ADHD was con-
firmed and established by a child and adolescent psychiatrist based on DSM-V criteria via semi-structured interview
(e.g. K-SADS-PL). Also, in previous studies, evaluations were carried out in terms of primarily physical and sexual abuse,
and enough information was not provided in terms of emotional abuse and neglect (Mulsow, O’Neal, & Murry, 2001;
Ford et al., 2000; Fuller-Thomson et al., 2014). In several studies examining emotional abuse and neglect, the small
size of sample groups is remarkable (Becker-Blease & Freyd, 2008; Hadianfard, 2014). All subtypes of abuse (physical,
emotional abuse, neglect, family violence, and sexual abuse) were questioned in interviews regarding present sub-
jects.
The present study involved ADHD-diagnosed children applying to the Child and Adolescent Psychiatry Outpatient Clinic
in order to receive treatment. And aimed to compare children diagnosed with ADHD with age/gender matched in terms of
subtypes of child abuse. Hypotheses of the study were (1) Children diagnosed with ADHD would be exposed to all types
of abuse at higher rates than controls, (2) ADHD subtypes would differ in terms of being exposed to abuse, and lastly
(3) The rate of the children’s exposure to abuse would increase with ADHD and disruptive behavior disorders comorbid-
ity.
 E. Sari Gokten et al. / Child Abuse & Neglect 62 (2016) 1–9 3

1. Materials and methods

1.1. Sample

The methodology applied in the present research is a case-control one with two groups of ADHD and controls. The sample
of study consisted of children between 6 and 12 years old who applied to the Child and Adolescent Psychiatry Outpatient
Clinic of Bursa Yuksek Ihtisas Training and Research Hospital between January and June 2015, and were diagnosed with
ADHD by a child and adolescent psychiatrist according to DSM-V diagnostic criteria. All subjects meeting the inclusion and
exclusion criteria were included in the study. The inclusion criteria of the study were determined as follows: 1) being in the
age group of 6–12 years, 2) having social and mental functioning to participate in an interview, and 3) having a diagnosis of
ADHD according to DSM-V diagnostic criteria. Exclusion criteria were determined as follows: 1) having a disorder impairing
cognitive condition such as intellectual disability, specific learning disability, psychotic disorder, orpervasive developmental
disorder, 2) having a diagnosed genetic, neurologic, and/or metabolic disorder to explain psychiatric symptoms, 3) having
psychiatric treatment previously, and 4) having another psychiatric disorder in addition to ADHD, except for oppositional
defiant disorder and behavioral disorder (e.g., anxiety disorder, elimination disorder). According to these criteria, the follow-
ing numbers of subjects were excluded: 44 subjects due to comorbid anxiety disorder, 2 subjects due to comorbid obsessive
compulsive disorder, 3 subjects due to comorbid depression, 11 subjects due to comorbid adjustment disorder, 25 subjects
due to comorbid elimination disorder, and 9 subjects due to comorbid tic disorders. No subjects refused to participate in the
study.
Healthy children aged 6–12 years old who applied to the outpatient clinic of Pediatric Surgery Department of the same
hospital between the same dates because of reasons such as circumcision, acute appendicitis or inguinal hernia, and who were
evaluated by a child and adolescent psychiatrist, were included in the control group. The exclusion criteria for the control
group were that they did not meet the diagnostic criteria of ADHD, oppositional defiant disorder, and conduct disorders
in addition to criteria of the children with ADHD. As a result of the semi-structured interviews (Kiddie-Sads) applied, the
following subjects were excluded: 22 subjects due to anxiety disorder, 15 subjects due to elimination disorder, 5 subjects
due to tic disorder, and 9 subjects due to ADHD.
A priori power analysis to determine a difference with moderate effect size (Cohen’d d = 0.3) at 80.0% power with an alpha
level of 0.05 via chi square tests at 5 ◦ of freedom revealed that a sample of 143 children would achieve the required power
(Faul, Erdfelder, Lang, & Buchner, 2007). Within the specified time period 208 children (from ADHD and control groups)
could be enrolled leading to a power of 94.0% (Faul et al., 2007).

1.2. Administration

Out of 756 subjects who applied to the outpatient clinic of Child and Adolescent Psychiatry Unit of Bursa Yuksek Ihti-
sas Training and Research Hospital between January and June 2015, 198 were diagnosed with ADHD according to DSM-V
diagnostic criteria. A group of 104 children meeting inclusion and exclusion criteria, who agreed (with their mother and/or
father) to participate in the study, constituted the sample group. All subjects and their parents in the sample group were
informed about the aim of the study, and provided their consents. The study was approved by Ethics Committee of Bursa
Yuksek IhtisasTraining and Research Hospital. After ADHD was diagnosed, socio-demographic data forms, which were pre-
pared by the researchers was filled by the parents first. Then, psychiatric assessment was carried out by using Schedule for
Affective Disorders and Schizophrenia for School Age Children-Present and Lifetime Version (Kiddie-SADS-PL). Afterwards,
the Abuse Assessment Questionnaire was administered to the children by a child and adolescent psychiatrist who asked the
children questions one by one in a room without their parents.
The 104 healthy children who were patients in the outpatient clinic of Pediatric Surgery Department of the same hospital,
and who wereevaluated to have no cognitive, psychiatric, or social disorder, were included in the study for a control group.
After families consented to participation in the study, parents filled out a socio-demographic questionnaire, and psychiatric
assessment was carried out by administrating theSchedule for Affective Disorders and Schizophrenia for School Age Children-
Present and Lifetime Version (Kiddie-Sads) to the children through semi-structured interviews. Lastly, the Abuse Assessment
Questionnaire was administered to the children by a child and adolescent psychiatrist.

1.3. Screening procedures

The data form was filled according to data obtained from parents about the children’s age, gender, educational background,
family structure, and alsothe age and educational background of parents.
In addition,the Schedule for Affective Disorders and Schizophrenia for School Age Children-Present and Lifetime Version-
Turkish Version (K-SADS-PL-T) is a semi-structured interview form developed by Kaufman et al. (1997), in order to determine
psychopathologies of children and adolescents in the past and now (Kaufman et al., 1997). K-SADS-PL-T is administered
through an interview conducted with mother-father and child, and evaluated in accordance with information acquired from
all sources (i.e., mother-father, child, school). If there was a nonconformity between information obtained from different
sources, the clinician uses his or her own judgment. The reliability and validity study of the Schedule-Turkish adaptation
was carried out by Gökler et al. (2004).
4 E. Sari Gokten et al. / Child Abuse & Neglect 62 (2016) 1–9

Table 1
Socio-demographic characteristics of cases.

Socio-demographic characteristics ADHD Control x2* p**

n (%) n (%)

Gender Boy 83 (79.8%) 83 (79.8%) NA NA

Girl 21 (20.2%) 21 (20.2%)
Whom they lived with Living together with both parents 100 (96.2%) 101 (97.1%) 0.148 0.701
Separated from one or both of parents 4 (3.8%) 3 (2.9%)
Monthly income of family Minimum wage or lower 13 (12.5%) 31 (29.8%) 9.339 0.002
Higher than minimum wage 91 (87.5%) 73 (70.2%)
Grade retention Yes 2 (1.9%) 2 (1.9%) NA NA
No 102 (98.1%) 102 (98.1%)
Disciplinary action Yes 8 (7.7%) 2(1.9%) 3.782 0.052
No 96 (92.3%) 102 (98.1%)

OD ± SD OD ± SD t** p**

Age 9.51 ± 1.71 9.12 ± 1.89 1.554 0.122

Mother’s education period (year) 8.37 ± 3.56 6.84 ± 3.07 3.337 0.001
Father’s education period (year) 8.83 ± 3.50 7.60 ± 3.53 2.527 0.012

x2 * Chi-Square test x2 value, p* Chi-Square test p value,

t** Students t-test t value, p** Students t-test p value.

Finally, the Abuse Assessment Questionnaire in Children and Adolescents is a form with 21 questions (Yılmaz Irmak, 2008).
In this form, there are nine questions regarding physical abuse and 12 regarding emotional abuse, neglect, witnessing family
violence, and sexual abuse. There are two questions evaluating sexual abuse, two questions evaluating witnessing violence,
four questions evaluating emotional abuse, and four questions evaluating neglect. In the present study, this questionnaire
was administered to children participating in the study with semi-structured interviews, and the types of neglect and abuse
to which children were exposed were recorded with the information of the person who committed the abuse. The cronbach
alpha value reported previously for this scale varied between 0.78 and 0.80 (Yılmaz Irmak, 2008). For the present study
Cronbach alpha was found to be 0.63.

1.4. Data analysis

SPSS for Windows 22.0 was used for analysis. In the study, continuous variables were present with mean and standard
deviation values. Because continuous variables displayed normal distribution, comparisons between the two groups utilized
independent samples to test amongparametrical tests. Pearson’s Chi-square test and Fisher’s exact Chi-square test were used
for comparison of variables having categorical values with groups. ADHD-related independent variables were examined by
using multiple logistic regression analysis. Significance level of 95% (P < 0.05) was accepted in the study.

2. Results

2.1. Socio-demographic results

The study included 104 subjects each of both ADHD and control groups (20.2% girls (n = 21), and 79.8% boys (n = 83)).
No difference was determined between the two groups in terms of gender (p > 0.05). While average age of the ADHD group
was determined as 9.51 ± 1.71 (min:6, max:12), average age of control group was 9.12 ± 1.89 (min:6, max:12). A statistically
significant difference was not found between average ages of the two groups (p = 0.122). All subjects in both the ADHD and
control groups were attending primary school.
Table 1 illustrates the comparison of the two groups in terms of socio-demographic characteristics. The table shows
the educational period of both mother and father in the ADHD group was higher compared to the control group (p < 0.05).
The percentage of families with monthly income at minimum wage or lower was higher in the control group (p = 0.002).
A statistically significant difference was not determined between the two groups in terms of other socio-demographic
characteristics (p > 0.05).

2.2. Results regarding physical abuse

Table 2 shows the comparison of abuse and neglect assessment forms with Chi-square test in terms of the first nine items
evaluating physical abuse in children and adolescents in both the ADHD and the control groups. In the evaluation, Behaviors
such as hair tearing, ear pulling or nipping; Throwing slippers or any objects; Behaviors such as pushing, pulling, biting or
scragging; Behaviors such as smacking, beating or kicking; Striking with tools like belt, stick, ruler; Burning with cigarette,
iron, fire or hot water etc., or have hot pepper eaten; and Threatening with giving damage or killing were determined to be
higher in the ADHD group at a statistically significant level compared to the control group in the study (p < 0.05). The rate of
 E. Sari Gokten et al. / Child Abuse & Neglect 62 (2016) 1–9 5

Table 2
Comparison of ADHD and control groups in terms of abuse and neglect results.

ADHD CONTROL x2* p*

n (%) n (%)

Physical Abuse (Exposure to any) Yes 100 (96.2%) 48 (46.2%) 63.34 <0.001
1. Behaviors such as hair tearing, ear pulling or nipping Yes 72 (69.2%) 23 (22.1%) 46.52 <0.001
2. Throwing slippers or any objects Yes 55 (52.9%) 20 (19.2%) 25.54 <0.001
3. Behaviors such as pushing, pulling, biting or scragging Yes 43 (41.3%) 9 (8.7%) 40.48 <0.001
4. Behaviors such as tying up them to somewhere or locking them in a dark Yes 15 (14.4%) 8 (7.7%) 2.39 0.122
environment
5. Behaviors such as smacking, beating or kicking Yes 73 (70.2%) 20 (19.2%) 54.63 <0.001
6. Striking with tools like belt, stick, ruler Yes 31 (29.8%) 4 (3.8%) 25.04 <0.001
7. Burning with cigarette, iron, fire or hot water etc., or have hot pepper eaten Yes 20 (19.2%) 1 (1.0%) 19.12 <0.001
8. Willing to injure you via a knife or other ways Yes 4 (3.8%) 2 (1.0%) 1.84 0.174
9. Threatening to injure or kill (with knife or other tools) Yes 9 (8.7%) 3 (2.9%) 3.18 0.074
Emotional Abuse (Exposure to any) Yes 91 (87.5%) 36 (34.6%) 61.16 <0.001
1. Wishing you had not been born or threatening to leave Yes 29 (27.9%) 3 (2.9%) 29.97 <0.001
2. Swearing or insulting Yes 52 (50%) 12 (11.5%) 36.11 <0.001
3. Mocking, humiliation, nick naming Yes 57 (54.8%) 13 (12.5%) 41.67 <0.001
4. Thinking about not to be loved enough Yes 36 (34.6%) 24 (23.1) 3.37 0.066
Neglect (Exposure to any) Yes 6 (5.8%) 25 (24.0%) 13.68 <0.001
1. Not providing food requirement despite having enough money Yes 1 (1.0%) 11 (10.6%) 8.84 0.003
2. Not providing some needs like clothing, books despite having enough money Yes 0 (0.0%) 8 (7.7%) 8.32 0.004
3. Not taking to see a doctor or not giving medication Yes 1 (1.0%) 4 (3.8%) 1.84 0.174
4. Thinking about not to be cared enough Yes 5 (4.8%) 14 (13.5%) 4.69 0.3
Witnessing Family Violence (Exposure to any) Yes 59 (56.7%) 49 (47.1% 1.93 0.165
1. Witnessing two adults having loud argument Yes 59 (56.7%) 48 (46.2%) 2.33 0.127
2. Seeing two adults having fistfight or other ways Yes 10 (9.6%) 10 (9.6%) NA NA
Sexual Abuse (Exposure to any) Yes 6 (5.8%) 2 (1.9%) 2.08 0.149
1. Being exposed to behaviors including sexuality (like kissing, fondling, Yes 3 (2.9%) 2 (1.9%) 0.2 0.651
touching) despite they did not want
2. Behaviors like showing photographs or make them watched movie Yes 3 (2.9%) 1 (1.9%) 1.02 0.313
containing sexuality despite they did not want

x2 * Chi-Square test x2 value, p* Chi-Square test p value.

Table 3
Physical abuse by whom.

ADHD CONTROL x2* p*

n (%) n (%)

By mother Yes 62 (59.6%) 40 (38.5%) 9.31 0.002

By father Yes 39 (37.5%) 15 (14.4%) 14.41 <0.001
By siblings Yes 17 (16.3%) 3 (2.9%) 10.84 0.001
By someone out of family Yes 15 (14.4%) 5 (4.8%) 5.53 0.019

being exposed to physical abuse with any of these behaviors was also higher in the ADHD group at a statistically significant
level (p < 0.05).
Table 3 shows the comparison of the subjects in terms of the physical abuser. The rates of being exposed to physical
abuse by mother, father, siblings, and someone outside the family were found to be higher in the ADHD group (p < 0.05).

2.3. Results regarding emotional abuse

Table 2 illustrates the comparison of abuse and neglect assessment forms with Chi-square test in terms of four items
evaluating emotional abuse in children and adolescents. As shown in the table, Wishing you had not been born or threatening
to leave; Swearing or insulting and Mocking, humiliation, nick naming items in ADHD subjects were determined to be at
higher rates than control group (p < 0.05). The rate of being exposed to any of the emotionally abusive behaviors was also
found to be higher in the ADHD group (p < 0.05).

2.4. Results regarding neglect

Table 2 illustrates the comparison of subjects in terms of four examples of abuse and neglect in the assessment form
evaluating neglect in children and adolescents. The items Not providing food requirement despite having enough money
and Not providing some needs like clothing, books despite having enough money occurred at higher rates in the control
group compared to the ADHD group. The rate of being exposed to any kind of neglect was also found to be higher in the
control group (p < 0.05).
6 E. Sari Gokten et al. / Child Abuse & Neglect 62 (2016) 1–9

Table 4
Multiple Logistic Regression Analysis.

VARIABLES ␤ S.E. p OR 95.0% C.I. for OR

Lower Upper

Behaviors such as hair tearing, ear pulling or nipping 1.906 0.471 <0.001 6.728 2.672 16.941
Behaviors such as smacking, beating or kicking 1.989 0.470 <0.001 7.306 2.907 18.363
Striking to you with tools like belt, stick, ruler 1.940 0.818 0.018 6.956 1.399 34.584
Wishing you had not been born or threatening to leave 2.854 0.834 0.001 17.362 3.383 89.090
Mocking, humiliation, nick naming 2.751 0.558 <0.001 15.665 5.244 46.794
Not providing food requirement despite having enough money −2.780 1.254 0.027 0.062 0.005 0.725
Thinking about not to be cared enough −2.684 0.936 0.004 0.068 0.011 0.427
Witnessing two adults having loud argument −0.945 0.478 0.048 0.389 0.152 0.992

2.5. Results regarding witnessing violence

ADHD and control groups were compared with Chi-square test in terms of two items evaluating witnessing of violence
by children and adolescents in the abuse and neglect assessment form (Table 2). As a result of evaluation, a statistically
significant difference was not determined between ADHD and control groups in terms of witnessing violence (p > 0.05).

2.6. Results regarding sexual abuse

Table 2 shows the comparison of subjects in terms of items evaluating sexual abuse in children and adolescents on the
abuse and neglect assessment form. A statistically significant difference was not determined between the two groups in
terms of being exposed to sexual abuse (p > 0.05).

2.7. Multiple logistic regression analysis

Table 4 illustrates the ADHD-related independent factors in multiple logistic regression analysis including socio-economic
status, age, and educational periods of mother and father. According to this, Behaviors such as hair tearing, ear pulling or
nipping; Behaviors such as smacking, beating or kicking; Striking with tools like belt, stick, ruler; Wishing you had not been
born or threatening to leave; Mocking, humiliation, nick naming; Not providing food requirement despite having enough
money; Thinking about not to be cared enough; Witnessing two adults having loud argument at home were found to be
ADHD-related independent factors (p < 0.05).
Significance of the obtained model was determined by using Hosmer and Lemeshow test (Chi-square = 5.25; df = 7;
p = 0.63). When coefficients of the multiple logistic regression model which were estimated were controlled by using the
omnibus test, they were observed to be significant (Chi-square = 149.479; df = 7, p < 0.001).

2.8. Correlation of ADHD subtypes with neglect and abuse

It was observed that 83.7% (n = 87) of ADHD subjects were mixed type, 12.5% (n = 13) were attention-deficit dominant,
and 3.8% (n = 4) were hyperactivity-dominant type. A significant difference between ADHD subtypes was not determined
in terms of being exposed to physical abuse (x2 = 0.72, p = 0.699), emotional abuse (x2 = 0.75, p = 0.687), neglect (x2 = 1.24,
p = 0.537), witnessing family violence (x2 = 1.63, p = 0.442), or sexual abuse (x2 = 1.24, p = 0.537) (p > 0.05).

2.9. Correlation of comorbidity of disruptive behavior disorders with neglect and abuse

Finally, as to comorbidity of disruptive behavior disorders, 24.0% (n = 25) of ADHD subjects had ODD and 7.7% (n = 8) had
CD. Table 5 illustrates the comparison of 33 subjects having comorbidity of disruptive behavior disordersand 71 subjects
not having comorbidity of disruptive behavior disorders in terms of exposure to neglect and abuse. A statistically significant
difference was not determined between the two groups in terms of neglect and abuse (p > 0.05).

3. Discussion

In this study, 104 children diagnosed with ADHD and not having any comorbidity except for disruptive behavior disorders
with a semi-structured psychiatric interview schedule were compared to 104 healthy children diagnosed with no psychiatric
diagnosis with a semi-structured psychiatric interview schedule in terms of being exposed to abuse and neglect. Out of the
104 children constituting ADHD group, 20.2% (n = 21) were girls and 79.8% were boys (n = 83) in the present study. This
situation is compatible with previous literature determining the girl/boy ratio as 2/1 and 9/1 (Rucklidge, 2010).
Each of nine different items evaluating physical abuse in the present study was determined to be more frequent in the
ADHD group compared to control group. In particular, three of the nine items Behaviors such as hair tearing, ear pulling or
nipping; Behaviors such as smacking, beating or kicking and Striking with tools like belt, stick, ruler were seen as independent
 E. Sari Gokten et al. / Child Abuse & Neglect 62 (2016) 1–9 7

Table 5
Comparison of cases with and without comorbidity of Disruptive Behavior Disorder among ones with ADHD in terms of abuse and neglect results.

DISRUPTIVE BEHAVIOR DISORDER x2* p*

YES (n=33) NO (n=71)

n (%) n (%)

Being exposed to any of Physical Abuse types Yes 32 (97.0%) 68 (95.8%) 0.09 0.768
No 1 (3.0%) 3 (4.2%)
Being exposed to any of Emotional Abuse types Yes 30 (90.9%) 61 (85.9%) 0.51 0.474
No 3 (9.1%) 10 (14.1%)
Being exposed to any of Neglect types Yes 1 (3.0%) 5 (7.0%) 0.67 0.414
No 32 (97.0%) 66 (93.0%)
Being exposed to any of Witnessing Family Violence types Yes 20 (60.6%) 39 (54.9%) 0.3 0.587
No 13 (39.4%) 32 (45.1%)
Being exposed to any of Sexual Abuse types Yes 4 (12.1%) 2 (2.8%) 3.59 0.058
No 29 (87.9%) 69 (97.2%)

x2 * Chi-Square test x2 value, p* Chi-Square test p value.

variables associated with ADHD. In previous studies conducted with both population-based and clinical samples, diagnosis
of ADHD correlated with physical abuse (Ford et al., 2000; Fuller-Thomson & Lewis, 2015; Hadianfard, 2014; Ouyang et al.,
2008). The present study contributed to literature in what ways children were exposed to physical abuse and which items
were ADHD-related independent risk factors.
Each of the four items evaluating emotional abuse was determined to more frequent in the ADHD group compared to the
control group. From these four items, Wishing you had not been born or threatening to leave and Mocking, humiliation, nick
naming items were observed to be related to ADHD diagnosis. Even though several studies examining correlation of ADHD
and abuse have not focused on emotional abuse, a few small-scaled studies (Becker-Blease & Freyd, 2008; Cornellà & Juárez,
2014; Hadianfard, 2014) revealed that emotional abuse in the ADHD group was more frequent compared to the controls.
The most important difference of the present study compared to others was that diagnosis of ADHD and comorbidities were
established and confirmed by a child and adolescent psychiatrist based on DSM-V criteria via semi-structured interview
(e.g. K-SADS-PL). Because all comorbidities except for Disruptive Behavior Disorders were extracted from ADHD group, the
association of ADHD on child abuse and neglect was well determined.
Each of four items evaluating neglect in the present study was more frequent in the control group. Those without
psychiatric disorders, among children applying to Pediatric Surgery Department of the same hospital due to reasons like cir-
cumcision, acute appendicitis, and inguinal hernia, were included in the control group of our study. A significant difference in
favor of ADHD existed between socioeconomic levels of subjects applying to different two units of the same hospital. It was
approved that neglect was seen more in control group as a result of logistic regression analysis applied in order to eliminate
the effect of this difference. Two items of neglect, such as Not providing food requirement despite having enough money
and Thinking about not to be cared enough were determined as independent variables. Numerous studies in the literature
report that those diagnosed with ADHD are exposed to neglect more often. While some studies reaching this result are case-
control studies including small sample groups (Hadianfard, 2014), some are retrospective studies examining adult subjects
(Rucklidge, Brown, Crawford, & Kaplan, 2006). Ouyang et al. (2008) reported that hyperactivity-dominant ADHD subjects
were not significantly subjected to physical neglect. In the present study, the children diagnosed with ADHD independently
from socioeconomic status were determined to have less exposure to physical and emotional neglect. This situation can be
thought to be associated with children diagnosed with ADHD being more demanding and persistent. Compared to parents
of subjects applying to pediatric surgery, parents of subjects applying to child psychiatry with ADHD symptoms, which
influence functioning relatively less, were more interested.
Though witnessing family violence in ADHD group was higher than control group in the present study, this difference was
not statistically significant. Biederman et al. (1995) reported that diagnosis of ADHD was a risk factor in terms of difficulties
experienced in the family. It was determined in another study that family violence was significantly high only among girls
diagnosed with ADHD, but such significant difference was not found among boys (Fuller-Thomson & Lewis, 2015). Most
children diagnosed with ADHD have parents diagnosed with adult ADHD (Biederman, 2005). A significant correlation was
reported between diagnosis of ADHD and violence in partners (Fang, Massetti, Ouyang, Grosse, & Mercy, 2010).
A statistically significant difference was not determined between ADHD and control groups in the present study in terms
of being sexually abused. Subjects that had photographs with pornographic content watched by friends or peers, or were
exposed to sexual behaviors included five subjects in ADHD group and two subjects in control group. In some of population-
based studies (Fuller-Thompson & Lewis, 2015),there are results indicating that children with ADHD are sexually abused
more frequently; on the other hand, a significant correlation was not determined between ADHD and sexual abuse in another
population-based study (Ouyang et al., 2008). Because the present study was smaller-scaled and consisted of only subjects
applying to clinic, it is reasonable to obtain results different from population-based studies. In addition, in the present study,
two different questions were asked of children for evaluating sexual abuse, and assessment was carried out according to
information from children. In population-based studies, in which adult subjects were asked to evaluate retrospectively,
subjects were asked the following questions for this assessment: How many times did an adult touch your body though you
8 E. Sari Gokten et al. / Child Abuse & Neglect 62 (2016) 1–9

did not wish? How many times did an adult attempt sexual activity by threatening or forcing you? These differences applied
in the method could have led to different results.
When subjects in the present study were evaluated in terms of subtypes of ADHD, abuse and neglect rates did not
change according to subtypes. In a population-based study in which subjects were investigated retrospectively in terms
of ADHD symptoms and child abuse and neglect, physical and supervision neglect and physical and sexual abuse were
seen significantly more in attention-deficit-dominant subjects, and hyperactivity-dominant subjects had more supervision
neglect and physical abuse at lesser significance (Ouyang et al., 2008). In the present study, 83.7% (n = 87) of ADHD subjects
were mixed type, 12.5% (n = 13) were attention-deficit-dominant type, and 3.8% (n = 4) were hyperactivity-dominant type.
Except for the mixed type, inadequate number of subjects in other types could have led artifact in results.
When subjects with and without comorbidity of disruptive behavior disordersin addition to ADHD diagnosis were com-
pared, there was no significant difference between them in terms of being exposed to abuse and neglect. Some studies in the
literature reported that subjects with oppositional defiant disorder were more physically and sexually abused compared to
subjects diagnosed only with ADHD (Ford et al., 1999; Ford et al., 2000). In another study, ADHD-diagnosed girls showing
disruptive behavior disorders were more often physically and sexually abused (Briscoe-Smitha & Hinshaw, 2006). The fact
that subjects showing disruptive behavior disorders were subjected to abuse and neglect at the same rate with children only
diagnosed with ADHD in the present study could be associated with the fact that subjects with comorbidity were fewer in
number than other groups.
The most important limitation of the present study was that parents of subjects could not be evaluated with regards
to their adult ADHDs and parenting styles. Another limitation was that items related to abuse and neglect were limited to
only questions asked to children; parents did not fill out a scale about this subject. In addition, our study offers valuable
information regarding ADHD and child abuse and neglect to literature because it included an adequate number of subjects,
and the diagnoses were established on clinical interviews based on the DSM-V and the semi-structured interview like
Kiddie-Sads, also the items related to abuse and neglect were marked by the interviewer explaining them to children one
by one.

4. Conclusions

Findings in the present study have important implications for intervention and prevention. One finding is that children
diagnosed with ADHD expose physical and emotional abuse more frequently than healthy children whereas healthy children
expose neglect more. The other finding is that there is no difference to expose witnessing family violence and sexual abuse.
Also ADHD is associated with child abuse and neglect independently from comorbid disruptive behavior disorders or effects
of subtypes. Therefore, social support and education programs have an important place in protection and treatment of
subjects applying to clinic for therapy, or subjects in the community that have never applied. Further studies should include
assessments of parents of ADHD-diagnosed children in terms of adult ADHD, and examination of both ADHD treatment of
these adults and the role of their education about parental skills in decreasing child abuse and neglect.

Conflict of interest

The authors declare that they have no conflict of interest.

Human and animal rights

All IRB procedures were followed and full approval was obtained. No animals were used in this research.

Informed consent

Informed consent was obtained from parents of all individual participants included in the study.

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