Associations Between Adverse Childhood Experiences and ADHD Diagnosis and Severity Nicole M. Brown, MD, MPH, MHS; Suzette N. Brown, MD, MPH; Rahil D. Briggs, PsyD; Miguelina Germ  an, PhD; Peter F. Belamarich, MD; Suzette O. Oyeku, MD, MPH From the Department of Pediatrics, Albert Einstein College of Medicine and Children’s Hospital at Montefiore, Bronx, NY (Drs N. Brown, Briggs, German, Belamarich, and Oyeku); and Department of Pediatrics, Maimonides Infants and Children’s Hospital of Brooklyn (Dr S. Brown), NY The authors have no conflicts of interest to disclose. This work was presented as a platform presentation at the Pediatric Academic Societies Meeting in Vancouver, British Columbia, Canada, May 6, 2014. Address correspondence to Nicole M. Brown, MD, MPH, MHS, Department of Pediatrics, Albert Einstein College of Medicine, Children’s Hospital at Montefiore, 3444 Kossuth Ave, Bronx, NY 10467 (e-mail: nicolebr@montefiore.org). Received for publication February 25, 2016; accepted August 29, 2016. ABSTRACT OBJECTIVE: Although identifying adverse childhood experi- ences (ACEs) among children with behavioral disorders is an important step in providing targeted therapy and support, little is known about the burden of ACEs among children with atten- tion deficit–hyperactivity disorder (ADHD). We described the prevalence of ACEs in children with and without ADHD, and examined associations between ACE type, ACE score, and ADHD diagnosis and severity. METHODS: Using the 2011 to 2012 National Survey of Chil- dren’s Health, we identified children aged 4 to 17 years whose parents indicated presence and severity of ADHD, and their child’s exposure to 9 ACEs. Multivariate logistic regression was used to estimate associations between ACEs, ACE score, and parent-reported ADHD and ADHD severity, adjusted for sociodemographic characteristics. RESULTS: In our sample (N ¼ 76,227, representing 58,029,495 children), children with ADHD had a higher prevalence of each ACE compared with children without ADHD. Children who experienced socioeconomic hardship (adjusted odds ratio [aOR], 1.39; 95% confidence interval [CI], 1.21–1.59), divorce (aOR, 1.34; 95% CI, 1.16–1.55), familial mental illness (aOR, 1.55; 95% CI, 1.26–1.90), neighborhood violence (aOR, 1.47; 95% CI, 1.23–1.75), and incarceration (aOR, 1.39; 95% CI, 1.12–1.72) were more likely to have ADHD. A graded relation- ship was observed between ACE score and ADHD. Children with ACE scores of 2, 3, and $4 were significantly more likely to have moderate to severe ADHD. CONCLUSIONS: Children with ADHD have higher ACE expo- sure compared with children without ADHD. There was a signif- icant association between ACE score, ADHD, and moderate to severe ADHD. Efforts to improve ADHD assessment and man- agement should consider routinely evaluating for ACEs. KEYWORDS: adverse childhood experiences; adverse childhood experiences score; attention deficit–hyperactivity disorder ACADEMIC PEDIATRICS 2016;-:1–7 WHAT’S NEW Children with attention deficit–hyperactivity disorder (ADHD) have a greater prevalence of adverse child- hood experiences compared with children without ADHD. There is a significant association between adverse childhood experience score, having an ADHD diagnosis, and moderate to severe ADHD. A TTENTION DEFICIT–HYPERACTIVITY DISORDER (ADHD) is the most common neurobehavioral disorder of childhood, and there has been a significant increase in parent-reported ADHD prevalence over the past decade. 1 There has also been a concomitant increase in stimulant medication use—expenditures on prescription medications for ADHD exceeded 2 billion dollars in 2007, accounting for more than 8% of all treatment expenditures for children ages 5 to 17 years. 2 Optimizing evaluation methods to improve diagnostic accuracy and management of ADHD is a central part of ef- forts to enhance the quality of ADHD care delivered in pe- diatric primary care settings and reduce related expenditures. Current ADHD clinical practice guidelines and the Diagnostic and Statistical Manual of Mental Disor- ders (Fifth Edition) recommend evaluating for and/or excluding other potential conditions with manifestations similar to those of ADHD, such as exposure to psychoso- cial or environmental stressors. 3,4 There is growing evidence showing that repeated or sustained exposure to adverse childhood experiences (ACEs)—defined as traumatic occurrences before the age of 18 years that are experienced as physically or emotionally harmful or threatening—increases a child’s risk for toxic levels of stress, which in turn might impair neurodevelopment, behavior, and overall physical and mental health. 5–7 Studies have shown associations between parental psychopathology, 8,9 marital discord, 10 low socioeconomic status, 11,12 and presence and severity of ADHD. Although it has been shown that children exposed to ACEs can manifest many of the disruptive behaviors, impulsivity, ACADEMIC PEDIATRICS Copyright ª 2016 by Academic Pediatric Association 1 Volume -, Number - -–- 2016