658123

research-article2016
JADXXX10.1177/1087054716658123Journal of Attention DisordersGul and Gurkan

Article
Journal of Attention Disorders

Child Maltreatment and Associated

1­–11
© The Author(s) 2016
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DOI: 10.1177/1087054716658123

With ADHD: A Comparative Study jad.sagepub.com

Hesna Gul1,2 and Cihat Kagan Gurkan1

Abstract
Objective: This study investigated the role of child and parental factors in maltreatment of children with ADHD compared
with a healthy control group. Method: We examined the rates and correlations of child maltreatment by parents in a
sample of children with ADHD (n = 100) and a matched comparison sample of children without ADHD (n = 100), all
aged 6 to 11 years. Parent and child ratings evaluated demographic characteristics, severity of ADHD symptoms, and
childhood trauma exposure. Results: According to regression analysis, maternal hyperactivity/impulsivity and male gender
of the child increase the emotional abuse; whereas maternal history of emotional abuse and physical neglect and paternal
attention deficit increase sexual abuse, and higher maternal hyperactivity/impulsivity increases emotional neglect of ADHD
children. Conclusion: The study’s findings provide strong evidence that the maltreatment of children with ADHD is more
associated with parental factors than with the symptoms of ADHD in children. (J. of Att. Dis. XXXX; XX(X) XX-XX)

Keywords
ADHD, child abuse, child neglect, parental factors, trauma

Introduction abuse, sexual abuse, witnessing parental domestic violence,

ADHD is one of the most common early-onset neurobe-
havioral disorders, affecting 1% to 20% of school-age chil-
dren (Polanczyk, de Lima, Horta, Biederman, & Rohde,
2007) and 4.4% of adults (Kessler et al., 2006; Willcutt,
2012). There is a strong association between the diagnosis
of ADHD and a variety of adverse health, educational,
and social outcomes including child maltreatment (Ryan-
Krause, 2010).The frequency of ADHD among abused
children is reported as 14% to 46% (Briscoe-Smith &
Hinshaw, 2006; Endo, Sugiyama, & Someya, 2006), and
ADHD may be implicated as an early risk factor in child
maltreatment. Conversely, early child maltreatment may
affect the emergence of ADHD symptoms.
Current etiological models have tended to focus largely
on biological, psychological, and social conditions that can
act individually or together to increase the risk of ADHD
(Schachar & Tannock, 2002). Among the neurobiological
risk factors of ADHD, genetic heritability (Morrell &
Murray, 2003), prematurity, low birth weight, pregnancy,
and/or birth complications and the mother’s use of alcohol
or tobacco during pregnancy (Linnet et al., 2006; Mattson
& Riley, 1998; Mick, Biederman, Faraone, Sayer, &
Kleinman, 2002; Richards, 2012) seem to be significant.
From a psychosocial perspective, ADHD has been shown to
be a consequence of inadequate and/or adverse environ-
ment and adverse childhood experiences including physical
and childhood neglect (Fuller-Thomson & Lewis, 2015;
Roy, Rutter, & Pickles, 2000; Kreppner, O’Connor, Rutter,
& The English and Romanian Adoptees [ERA] Study Team,
2001). Although the mechanisms underlying the relation-
ship between childhood adverse experiences, child mal-
treatment, and ADHD have not been clearly elucidated yet,
three pathways dominate according to the studies. The first
pathway is linked to changes in brain functioning because
of stress resulting from exposure to childhood maltreatment
(Anda et al., 2006). According to this pathway, severity or
scope of the experiences over time may be more important
than the types of maltreatment (McLaughlin et al., 2014).
The second pathway suggests that distinct types of learned
experiences of threat or deprivation may affect neural
development, resulting in distinct alterations in brain
structures consistent with ADHD (McLaughlin et al., 2014).
The third pathway is related to difficulties inherent in par-
enting a child with ADHD, which may increase physical
punishment by parents, causing a vicious cycle where
1
Ankara University, School of Medicine, Turkey
2
Necip Fazil State Hospital, Kahramanmaras, Turkey
Corresponding Author:
Hesna Gul, Department of Child and Adolescent Psychiatry, Necip Fazil
State Hospital, Mimarsinan Quarter, Aladdin Özdenören Street, MA
46050 Kahramanmaras, Turkey.
Email: drhesnagul@gmail.com
2 Journal of Attention Disorders 
physical abuse increases the ADHD symptoms (Becker &
McCloskey, 2002).
In exploring the relationship between child maltreatment
and ADHD, there is some justification for analyzing the data
separately for parental and child risk factors. Generally,
among the parental factors of child maltreatment, low
parental education, low income, young parental age, being a
mother in adolescence, and parental psychiatric disorders
seem to be significant predictors (De Paul & Domenech,
2000; Dubowitz et al., 2011; Gillham et al., 1998; Margolin
& Larson, 1988; Wolfe, Edwards, Manion, & Koverola,
1988). Characteristics of children leading to higher vulnera-
bility of being abused are male gender, young age, and hav-
ing difficult temperament, behavioral problems, and mental
or physical disorders (Berger, 2005; Malekpour, 2004; Ross,
1996). Some common features of ADHD and child maltreat-
ment such as socioeconomic status (SES), parental psycho-
pathologies, and parenting styles of parents are considered
the cause of co-occurrence. The parents of children with
ADHD are likely to show more impulse control and more
attention problems themselves, and as a result of adult
ADHD, they also have low SES, low social support, and a
high amount of aggressive behavior (Chase-Lansdale &
Pittman, 2002; Evinç et al., 2014; Rutter & Quinton, 1977).
From the perspective of abusive discipline attitudes with
their children and corporal punishment used more signifi-
cantly than among parents of non-ADHD children, Alizadeh
and Evinc reported that parents of children with ADHD
have lower self-confidence, less warmth, and less involve-
ment (Alizadeh, Applequist, & Coolidge, 2007; Evinç et al.,
2014). The association between ADHD and child maltreat-
ment is complex and few studies have been conducted in
this field. Conducted studies mostly focus on one side of the
problem, investigating either just one of the parents or the
child. However, there might be an interaction between
the characteristics of the child and the parents. Therefore,
exploring all sides together, both characteristics of children
and of the parents, in the same study may be beneficial. The
aim of this study was to investigate the frequency of child
maltreatment and its association with parental characteris-
tics of children with ADHD. Possible relationships between
the severity of parental ADHD symptoms and child maltreat-
ment, and various other maternal and paternal characteris-
tics (i.e., age, educational level, SES, parents’ trauma history,
and type of abuse) were also explored.
Method
Participants and Procedure
In this study, we used a case control design and we included
two groups of age- and gender-matched children; the study
group consisted of 100 children with ADHD and the control
group consisted of 100 schoolchildren. The research proto-
col was approved by the Research Ethics Board of Ankara
University School of Medicine. Participants in the study
group were recruited from newly diagnosed children with
ADHD and their parents, who were referred to Ankara
University Department of Child and Adolescent Psychiatry.
The aim and procedure of the study were explained to all
parents and children and written informed consent was
obtained from parents and assent was obtained from chil-
dren. Children were aged 6 to 11 years (M = 8.4 years,
SD = 0.88 years), and 73% of the sample were males. The
mean Hollingshead–Redich Scale score was 3.46 ±  1.22.
Mothers were aged 23 to 49 (M = 35.8 years, SD = 5.56
years) and fathers were aged 28 to 56 years (M = 39.7 years,
SD = 5.64 years). Fifty-five percent of mothers of ADHD
participants completed eighth grade or less, 34% completed
high school, and 11% completed a 2-year or longer college
degree. Forty-five percent of ADHD group participants’
fathers completed eighth grade or less, 37% completed high
school, and 18% completed a 2-year or longer college
degree. The majority of parents were married (96%).
The age- and gender-matched control group was recruited
from an elementary school in Ankara. The teachers and par-
ents were asked to complete the Conners’ Scales. Children
with an ADHD diagnosis according to the Schedule for
Affective Disorders and Schizophrenia for School Age
Children–Present and Lifetime version (K-SADS-PL) were
excluded. Children in the control group were aged 6 to 11
years (M = 8.4 years, SD = 1.69 years) and 71% of the partici-
pants were male. The mean Hollingshead–Redich Scale
score was 3.68 ± 1.12. Mothers were aged 27 to 53 years
(M = 35.8 years, SD = 5.04 years) and fathers were aged 31
to 62 years (M = 39.6 years, SD = 5.91 years). Of mothers of
control group participants, 63% completed eighth grade or
less, 28% completed some high school, and 9% completed a
2-year or longer college degree. Of fathers of control group
participants, 51% completed eighth grade or less, 35% com-
pleted some high school, and 14% completed a 2-year or
longer college degree. All parents were married in this group.
According to Hollingshead–Redich Scale, SES scores of
the groups were similar (see details in Table 1).
All referred children with a diagnosis of ADHD, who
were aged between 6 and 11 years, were consecutively
included in the study. Children with a diagnosis of a neuro-
logical/physical disorder or mental retardation, and families
who did not want to participate were excluded. The pres-
ence of psychiatric comorbidity in children was not accepted
as an exclusion criterion, except for posttraumatic stress
disorder.
Measurements
Demographic information form. This form consisted of
questions that were prepared by the authors to obtain infor-
mation about demographic characteristics (age, school,
parental age and education, monthly household income,
marital status of parents) of the participants.
Gul and Gurkan 3
Table 1.  Demographic Characteristics of Parents and Children.
Characteristics ADHD group
N 100
 Male 73
 Female 27
Age (years)
  M ± SD 8.48 ± 1.70
 (range) (6-11)
Maternal age (years)
  M ± SD 35.81 ± 5.56
 (range) (23-49)
Paternal age (years)
  M ± SD 39.74 ± 5.64
 (range) (28-56)
Hollingshead–Redich Scale (M ± SD) 3.46 ± 1.22
Note. There were no significant differences between the groups at p < .05. Unpaired t test and Mann–Whitney U test.
K-SADS-PL.  The K-SADS-PL was originally developed by
Kaufman (Kaufman et al., 1997) and the validity and reli-
ability study of Turkish version was conducted by Gökler
(Gökler et al., 2004). It is a semi-structured instrument that
aims to diagnose psychiatric disorders in children.
Adult ADD/ADHD Diagnostic and Statistical Manual of Mental
Disorders (DSM-IV–Based Diagnostic Screening and Rating
Scale). This rating scale assesses ADHD symptoms in
adults. It was developed by Turgay in 1998 (Turgay, 1998)
and was adapted to Turkish by Günay (Günay, Savran, &
Aksoy, 2005). This scale is completed using a three-point
Likert-type rating and consists of three sections: the first
section is composed of nine items that are defined as the
symptoms of attention deficit in Diagnostic and Statistical
Manual of Mental Disorders (4th ed.; DSM-IV; American
Psychiatric Association, 1994). Total scores between 0 and
3.00 were interpreted as mild, 3.01 and 10.99 as moderate,
and 11.00 or higher scores as severe attention deficit. The
second section is composed of nine items about hyperactiv-
ity/impulsivity that conform to those in DSM-IV. The total
scores between 0 and 3.00 were interpreted as mild, 3.01
and 10.99 as moderate, and 11.00 or higher scores as severe
hyperactivity/impulsivity.
The third section consists of 30 questions prepared to
obtain information about the features and issues related to
ADHD (feeling of failure, difficulty in starting work, deal-
ing with many jobs at the same time and so having difficul-
ties in tracking jobs, verbal aggression, physical aggression,
alcohol abuse, substance abuse, legal challenges and diffi-
culties, depression, self-mutilative behaviors, anxiety, disap-
pointment, discouragement, etc.). The total scores between
0.00 and 12.99 were interpreted as mild, 13.00 and 34.99 as
moderate, and 35.00 or higher scores as severe features
related to ADHD. Günay demonstrated that the Turkish ver-
sion of Adult ADHD Rating Scale is transliterally equiva-
lent, valid, and reliable (Günay et al., 2005).
Control group p value
100  
71  
29  
8.47 ± 1.69 .971
(6-11)  
35.86 ± 5.04 .712
(27-53)  
39.65 ± 5.91 .791
(31-62)  
3.68 ± 1.12 .188
Abuse and Neglect Assessment Questionnaire for Children. This
questionnaire was developed by Irmak (2008) consisting of
21 items, which aimed to identify physical, emotional, and
sexual abuse and neglect of children by their parents, except
sexual abuse category. Sexual abuse was documented by
asking questions about five different groups of potential
abusers (parents, siblings, friends, relatives, and strangers).
This tool is applied to children by an interviewer.
In the physical abuse category (eight questions), hair
and ear pulling; pinching; throwing things; pushing and
detraction; connecting with a rope or locking in a room;
hitting with a stick or a ruler; burning part of the body with
cigarettes, iron, or another hot object; putting hot pepper
into the mouth; and hurting or threatening were queried.
In the sexual abuse category (two questions), behaviors
involving sexuality and showing pornographic films or
photos were questioned. In the emotional abuse category
(four questions), telling the child that he or she should not
have been born, threatening the child with abandonment,
swearing, and insulting or contempt were queried. In the
physical neglect category (four questions), lack of nutri-
tional, medical, educational, and other types of caregiving
were questioned. In the emotional abuse category (one
question), children’s feelings of not being loved and
accepted enough were investigated. Children who reported
at least one positive answer in a category were accepted as
the abused/neglected group. The test–retest reliabilities for
physical and emotional abuse subgroups were high, r = .80
and r = .78, respectively.
Conners’ Rating Scales (CRS). The Conners’ Parental and
Teachers Rating Scales are popular research and clinical
tools to determine childhood behavior problems (Conners,
Sitarenios, Parker, & Epstein, 1998). Conners’ Parents Rat-
ing Scale (CPRS) was designed for use by parents to assess
ADHD symptoms in children aged 3 to 17 years. It has
48 items that are coded on a four-point Likert-type scale.
4 Journal of Attention Disorders 
Table 2.  Group Differences in Child Abuse and Neglect Types.
ADHD group
Characteristics of child maltreatment (%; n = 100)
Physical abuse 95
Emotional abuse 90
Sexual abuse 13
Physical neglect 17
Emotional neglect 71
Note. There were no significant differences between the groups at p < .05.
Pearson χ2.
Conners’ Teacher Rating Scale (CTRS) consists of 28
items that assess the symptoms of ADHD observed in the
classroom.
Childhood Trauma Questionnaire (CTQ).  The CTQ is a 28-item
self-report instrument developed by Bernstein that evalu-
ates emotional, physical, and sexual abuse and physical and
emotional neglect during childhood (Bernstein & Fink,
1998). It was translated into Turkish by Sar, and previous
studies in Turkey have supported the validity of this instru-
ment (Sar, Ozturk, & İkikardeş, 2012).
Statistical Analysis
Demographic variables; rates of physical, emotional, and
sexual abuse; neglect types in children and childhood
trauma; and adult ADHD symptoms in parents were com-
pared with the control group using t tests, Pearson chi-
square, Fisher exact test, and Contingency Table analyses as
appropriate, using SPSS 18 for Windows. The associations
of different variables of maltreated children with ADHD
were calculated by univariate analysis. The variables for
which the unadjusted p value was <.10 in logistic regression
analysis were identified as potential risk markers and were
included in the full multivariate model. Backward elimina-
tion multivariate logistic regression analyses using likelihood
ratio tests to eliminate variables were utilized. Hosmer-
Lemeshow goodness-of-fit statistics were used to assess fit.
A 5% Type-1 error level was used to infer statistical signifi-
cance. A p value <.05 was considered significant.
Results
In the study group, 5% of (n = 5) children with ADHD
were predominantly inattentive type, and 95% (n = 95) of
children were combined type. In children with ADHD 87%
had at least one comorbid disorder. These comorbid disor-
ders were mood disorders (n = 10, 10%), anxiety disorders
(n = 26, 26%), oppositional defiant disorder (n = 53, 53%),
and conduct disorder (n = 6, 6%).
As predicted, participants in the control group had
significantly lower exposure scores on physical (95% vs.
Control group
(%; n = 100) Test statistics and p value
75 χ2 = 20.4, df = 1, p < .001
30 χ2 = 72.2, df = 1, p < .001
3 χ2 = 6.68, df = 1, p = .016
3 χ2 = 10.8, df = 1, p = .002
25 χ2 = 42.3, df = 1, p < .001
75%, p < .001), emotional (90% vs. 30%, p < .001), sexual
abuse (13% vs. 3%, p = .01), physical neglect (17% vs. 3%,
p = .002), and emotional neglect (71% vs. 25%, p < .001;
see Table 2).
In Table 3, the means and SD of attention deficit, hyper-
activity/impulsivity, and features associated with ADHD
and childhood trauma statements for two groups of parents
are presented. Parents of children with ADHD had signifi-
cantly higher scores on adult ADHD symptoms (in all sub-
groups p < .001). According to childhood trauma history of
parents, in all categories except for sexual and emotional
abuse, significant differences were found between parents
of children with ADHD and parents of control children.
Parents of children with ADHD have significantly more
exposure to these types of childhood traumas. In sexual
abuse category, the differences were significant for mothers
but not for fathers (p = .04, p = .770, respectively); and, in
the emotional abuse category, differences were significant
for fathers but not for mothers (p = .04, p = .296, respec-
tively). Results are given in detail in Table 3. When we con-
ducted linear regression analyses to predict the associations
between ADHD symptoms and childhood trauma in par-
ents, we found that physical neglect was associated with
attention deficit (b = 0.21, t = 2.70, p = .008), physical abuse
was associated with hyperactivity/impulsivity (b = 0.20,
t = 2.39, p = .01), and physical abuse, physical neglect, and
emotional neglect were associated with features linked with
ADHD in mothers (b = 0.19, t = 2.54, p = 0.01; b = 0.17,
t = 2.31, p = .02; b = 0.20, t = 2.57, p = .01, respectively).
We did not find any significant associations between child-
hood traumas and ADHD symptoms in fathers.
Then, we compared maltreated and non-maltreated
subgroups of children with ADHD. We explored the dif-
ferences in demographic variables, child characteristics,
parental ADHD symptoms, and childhood trauma history in
maltreated/non-maltreated subgroups of children with
ADHD. As summarized in Table 4, according to univariate
analysis, significant differences at p < .1 were found
between some child maltreatment types and maternal edu-
cation level, maternal history of emotional abuse, maternal
alcohol abuse, paternal substance abuse, parental ADHD
symptoms, child comorbid oppositional defiant disorder,
Gul and Gurkan 5

Table 3.  Group Differences in Childhood Traumas and ADHD Scores of Parents.

ADHD group Control group

Characteristics of parents (%; n = 100) (%; n = 100) Test statistics and p value
Maternal childhood trauma
  Physical abuse 37 11 χ2 = 18.5, df = 1, p < .001a
  Physical neglect 46 31 χ2 = 4.75, df = 1, p = .04a
  Emotional abuse 38 30 χ2 = 1.42, df = 1, p = .296a
  Emotional neglect 37 13 χ2 = 15.7, df = 1, p < .001a
  Sexual abuse 13 4 χ2 = 5.20, df = 1, p = .04a
Maternal ADHD scores (M ± SD)
  Attention deficit 8.51 ± 6.47 4.25 ± 3.46 p < .001b
 Hyperactivity/impulsivity 7.07 ± 5.92 3.02 ± 3.10 p < .001b
  Features associated with ADHD 22.62 ± 13.86 10.21 ± 8.56 p < .001b
Paternal childhood trauma
  Physical abuse 28 14 χ2 = 7.69, df = 1, p = .008a
  Physical neglect 50 29 χ2 = 13.2, df = 1, p < .001a
  Emotional abuse 28 17 χ2 = 4.91, df = 1, p = .04a
  Emotional neglect 36 17 χ2 = 12.3, df = 1, p = .001a
  Sexual abuse 5 7 χ2 = .19, df = 1, p = .770a
Paternal ADHD scores (M ± SD)
  Attention deficit 7.58 ± 5.93 3.76 ± 3.50 p < .001b
 Hyperactivity/impulsivity 7.61 ± 6.28 3.06 ± 3.84 p < .001b
  Features associated with ADHD 23.63 ± 15.33 9.33 ± 8.60 p < .001b

Note. There were no significant differences between the groups at p < .05. Unpaired t test and Mann–Whitney U test.
a
Pearson χ2.
b
Mann–Whitney U test.

child male gender, and child ADHD symptoms. Lower Discussion

maternal education, paternal substance abuse, and maternal
depression were significantly higher among physically
abused children with ADHD. Boys had more emotional
abuse exposure and maternal hyperactivity/impulsivity
level and maternal history of physical neglect was signifi-
cantly higher in this group. ADHD levels and comorbid
conduct disorder diagnosis were higher in sexually abused
children than others according to CTRS and K-SADS semi-
structured interviews. In sexually abused ADHD children,
maternal history of emotional abuse, both maternal and
paternal history of physical neglect, and paternal ADHD
scores were significantly higher too. Lower education level
of mothers, maternal attention deficit, and maternal depres-
sion were higher in physically neglected ADHD children,
whereas maternal alcohol abuse, parental hyperactivity/
impulsivity, and child attention deficit level were higher in
emotionally neglected children.
A logistic regression model was used to identify inde-
pendent predictors of child maltreatment types for the study
group. Logistic regression analysis revealed that maternal
hyperactivity/impulsivity and male gender of child increase
emotional abuse, maternal history of emotional abuse and
physical neglect and paternal attention deficit increase sex-
ual abuse, and higher maternal hyperactivity/impulsivity
increases the emotional neglect in ADHD children. Results
are given in detail in Table 5.
Purpose of this article was to determine the risk factors of
children and parents for child maltreatment of children with
ADHD. In this study, we showed that a group of clinically
referred children with ADHD have higher rates of maltreat-
ment compared with an age- and gender-matched group of
schoolchildren. It appears that child maltreatment was asso-
ciated with some parental characteristics and ADHD symp-
toms, rather than severity of children’s ADHD symptoms.
To our knowledge, this study is the first to focus on both
paternal and maternal characteristics in this field, including
childhood trauma statements, demographic variables, and
ADHD symptoms in children with and without ADHD.
Results from the study showed associations between
parental characteristics associated with ADHD and child-
hood traumas and increased incidence of child maltreatment
in children diagnosed with ADHD. Also, results showed that
abused or neglected ADHD children were distinct from non-
abused/neglected ADHD counterparts in terms of their own
characteristics (gender, comorbid disorders, ADHD symp-
tom severity), levels of parental ADHD scores, and child-
hood trauma exposure of parents. We found associations
between adverse childhood experiences and ADHD symp-
toms in parents of two groups. Using regression analyses,
we found that male gender and maternal hyperactivity and
impulsivity are independent predictors for emotional abuse,
6 Journal of Attention Disorders 

Table 4.  Effects of Various Variables on Maltreatment Types of Children With ADHD in Univariate Logistic Regression Analyses.
Maternal Physical abuse Emotional abuse Sexual abuse Physical neglect Emotional neglect
characteristics of
children with ADHD OR (CI 95%) p OR (CI 95%) p OR (CI 95%) p OR (CI 95%) p OR (CI 95%) p

 Age 0.89 [0.69, 1.16] .41 1.09 [0.96, 1.22] .15 0.95 [0.86, 1.06] .43 1.07 [0.97, 1.17] .16 1.02 [0.94, 1.10] .59
  Education level 0.54 [0.27, 1.08] .08 0.87 [0.71, 1.06] .17 0.93 [0.77, 1.13] .48 0.79 [0.65, 0.96] .02 0.95 [0.83, 1.09] .46
  History of physical 5.29 [0.00] .99 0.98 [0.77, 1.24] .88 0.64 [0.19, 2.09] .46 0.60 [0.21, 1.73] .34 0.55 [0.21, 1.41] .21
abuse
  History of 1.31 [0.56, 3.04] .52 0.92 [0.25, 3.39] .90 0.22 [0.06, 0.78] .01 0.85 [0.29, 2.46] .76 0.99 [0.40, 2.43] .99
emotional abuse
  History of physical 0.99 [0.61, 1.61] .98 3.57 [0.89, 14.39] .07 3.25 [0.83, 12.6] .08 0.95 [0.33, 2.70] .92 0.51 [0.20, 1.25] .14
neglect
  History of 1.39 [0.79, 2.42] .24 1.48 [0.42, 5.25] .54 0.64 [0.19, 2.09] .46 1.17 [0.40, 3.40] .76 0.55 [0.21, 1.41] .21
emotional
neglect
  History of sexual 5.26 [0.00] .99 0.00 .99 0.79 [0.15, 4.07] .78 1.14 [0.23, 5.71] .86 0.17 [0.02, 1.41 [ .10
abuse
  Attention deficit 1.13 [0.82, 1.56] .44 1.02 [0.92, 1.14] .60 1.01 [0.92, 1.10] .76 1.06 [0.98, 1.14] .09 1.05 [0.97, 1.13] .17
 Hyperactivity/ 1.11 [0.78, 1.57] .54 1.61 [1.14, 2.27] .006 1.07 [0.98, 1.17] .10 1.05 [0.97, 1.14] .20 1.18 [1.05, 1.33] .004
impulsivity
  Maternal alcohol 3.43 [0.00] .99 0.00 .99 0.00 .99 0.00 .99 0.12 [0.01, 1.24 [ .07
abuse
 Maternal 2.07 [0.00] .99 1.24 [0.00] .99 0.00 .99 3.52 [0.00] .99 1.77 [0.25, 12.6] .56
substance abuse
 Maternal 0.28 [0.07, 1.07] .06 0.63 [0.30, 1.33] .23 0.62 [0.21, 1.82] .39 7.71 [0.97, 61.24] .053 0.93 [0.51, 1.70] .82
depression
Paternal characteristics of children with ADHD
 Age 0.87 [0.69, 1.09] .24 1.04 [0.92, 1.18] .49 0.90 [0.79, 1.02] .11 1.02 [0.93, 1.11] .65 0.99 [0.91, 1.08] .92
  Education level 0.64 [0.35, 1.19] .16 0.94 [0.76, 1.16] .60 1.04 [0.86, 1.26] .63 0.93 [0.79, 1.10] .42 0.99 [0.86, 1.14] .97
  History of physical 2.63 [0.15, 43.5] .50 0.53 [0.10, 2.66] .44 0.85 [0.24, 3.04] .81 0.66 [0.21, 2.00] .46 0.43 [0.14, 1.28] .13
abuse
  History of 2.63 [0.15, 43.5] .50 2.39 [0.66, 8.58] .18 0.85 [0.24, 3.04] .81 0.92 [0.29, 2.90] .88 0.58 [0.20, 1.62] .30
emotional abuse
  History of physical 0.73 [0.00] .99 1.22 [0.34, 4.3] .75 3.91 [1.008, .049 0.65 [0.22, 1.87] .42 0.50 [0.20, 1.21] .12
neglect 15.22]
  History of 1.8 [0.10, 29.6] .68 1.01 [0.27, 3.74] .97 0.88 [0.26, 2.94] .84 0.76 [0.26, 2.22] .62 0.91 [0.36, 2.25] .84
emotional
neglect
  History of sexual 0.00 .99 2.12 [0.21, 20.9] .51 0.57 [0.06, 5.61] .63 3.52 [0.00] .99 0.59 [0.06, 5.59] .65
abuse
  Attention deficit 1.37 [0.78, 2.40] .27 1.07 [0.94, 1.22] .29 1.23 [1.09, 1.39] .001 1.03 [0.94, 1.13] .44 1.03 [0.95, 1.11] .46
 Hyperactivity/ 1.60 [0.70, 3.64] .26 1.18 [0.95, 1.22] .24 1.16 [1.05, 1.28] .003 1.01 [0.92, 1.10] .79 1.10 [1.008, 1.21] .03
impulsivity
  Paternal alcohol 0.54 [0.11, 2.54] .44 1.02 [0.31, 3.29] .97 0.86 [0.26, 2.84] .812 0.00 .99 0.67 [0.32, 1.43] .31
abuse
  Paternal substance 0.02 [0.001, 0.18] .016 0.24 [0.02, 2.90] .26 0.00 .99 0.00 .99 0.20 [0.01, 2.35] .20
abuse
 Paternal 0.46 [0.14, 1.48] .19 0.63 [0.31, 1.29] .21 0.00 .99 1.15 [0.57, 2.32] .68 0.94 [0.51, 1.75] .86
depression
Child characteristics
  Male gender 0.36 [0.02, 5.98] .47 0.25 [0.07, 0.92] .03 0.19 [0.02, 1.58] .12 0.80 [0.23, 2.71] .72 2.15 [0.72, 6.39] .16
  Conduct disorder 0.00 .99 0.00 .99 0.12 [0.01, 1.01] .052 3.47 [0.00] .99 0.00 .99
 Oppositional 1.88 [0.11, 31.04] .65 3.29 [0.00] .99 3.36 [0.70, 16.1] .13 0.98 [0.33, 2.93] .97 0.96 [0.39, 2.40] .94
defiant disorder
  Anxiety disorders 3.08 [0.18, 51.2] .47 0.34 [0.09, 1.26] .10 1.12 [0.28, 4.47] .86 0.76 [0.23, 2.42] .64 1.54 [0.59, 4.05] .37
  Major mood 0.000 2.02 [0.24, 17.0] .51 0.58 [0.14, 2.41] .46 0.86 [0.21, 3.44] .83 0.51 [0.13, 1.96] .33
disorders
  Attention deficit 1.06 [0.87, 1.29] .52 0.95 [0.87, 1.04] .28 1.13 [1.02, 1.25] .01 0.99 [0.92, 1.07] .95 1.06 [0.99, 1.12] .06
 Hyperactivity/ 1.01 [0.85, 1.20] .86 0.99 [0.92, 1.07] .98 1.07 [1.008, 1.15] .04 1.02 [0.96, 1.09] .36 1.04 [0.98, 1.09] .15
impulsivity

Note. OR = odds ratio; CI = confidence interval. Boldface values are p < 0.1.

maternal history of emotional abuse and physical neglect
were predictors for sexual abuse, and maternal hyperactivity
and impulsivity were predictors for emotional neglect.
According to the framework presented earlier in the arti-
cle, ADHD and child maltreatment have some common
etiological risk factors including genetic (biological) and
environmental (psychosocial) variables. The hypothesis
about the interplay between genetics and environment is
that families with manifestations of ADHD through several
generations may also have impulsivity and behavioral
Gul and Gurkan 7

Table 5.  Effects of Various Variables on Maltreatment Types of Children With ADHD in Multivariate Logistic Regression Analyses.

Variables Adjusted OR 95% CI p value

a
Physical abuse
  Maternal educational level 0.73 [0.35, 1.54] .41
  Maternal depression 0.22 [0.02, 1.81] .16
  Paternal substance abuse 0.006 [0.00, 1.88] .058
Emotional abuseb
  Maternal history of physical neglect 5.04 [0.98, 25.89] .053
  Maternal hyperactivity/impulsivity 2.00 [1.22, 3.30] .006
  Male gender 0.10 [0.02, 0.62] .01
Sexual abusec
  Maternal history of emotional abuse 0.06 [0.005, 0.82] .03
  Maternal history of physical neglect 63.8 [1.90, 2136.2] .02
  Paternal history of physical neglect 0.25 [0.02, 3.13] .28
  Paternal attention deficit 1.42 [1.002, 2.03] .049
  Paternal hyperactivity/impulsivity 1.15 [0.85, 1.57] .34
  Child comorbid conduct disorder 524.5 [3.0, 91740] .01
  Child attention deficit 1.06 [0.88, 1.28] .49
  Child hyperactivity/impulsivity 1.20 [0.97, 1.48] .09
Physical neglectd
  Maternal educational level 0.83 [0.68, 1.02] .08
  Maternal attention deficit 1.03 [0.96, 1.12] .34
  Maternal depression 0.63 [0.21, 1.91] .42
Emotional neglecte
  Maternal hyperactivity/impulsivity 1.19 [1.04, 1.37] .01
  Maternal alcohol abuse 0.06 [0.003, 1.17] .06
  Paternal hyperactivity/impulsivity 1.07 [0.95, 1.19] .23
  Child’s attention deficit 1.06 [0.98, 1.14] .10

Note. OR = odds ratio; CI = confidence interval.

a
Adjusted for maternal educational level, maternal depression, paternal substance abuse.
b
Adjusted for maternal history of physical neglect, maternal hyperactivity/impulsivity, child’s male gender.
c
Adjusted for maternal history of emotional abuse, maternal history of physical neglect, paternal history of physical neglect, paternal attention deficit,
paternal hyperactivity/impulsivity, child comorbid conduct disorder, child attention deficit, child hyperactivity/impulsivity.
d
Adjusted for maternal educational level, maternal attention deficit, maternal depression.
e
Adjusted for maternal hyperactivity/impulsivity, maternal alcohol abuse, paternal hyperactivity/impulsivity, child’s attention deficit.
Boldface values are p < 0.05.

dysfunction, and membership in such a family might
increase the risk of child’s exposure to episodes of
violent impulsivity or possibly abusive behavior (Cuffe,
McCullough, & Pumariega, 1994; McLeer, Callaghan,
Henry, & Wallen, 1994; Richards, 2012). In other words,
primary ADHD may often be a consequence of maltreat-
ment, vulnerable parenting, and predisposition to other cog-
nitive and mental health problems (Bayer et al., 2011; Klein,
Damiani-Taraba, Koster, Campbell, & Scholz, 2015;
McDonald Culp, 2010). Consistent with the hypothesis, in
a study, Ford and colleagues assessed the associations
between consecutive child psychiatric outpatient admis-
sions with disruptive behavior or adjustment disorders and
maltreatment types. They found that ODD and ADHD were
associated with a history of physical or sexual maltreatment
(Ford et al., 2000). On the other hand, ADHD symptoms
can be a risk factor for potential maltreatment. Studies
investigating the role of ADHD diagnosis on parents’
abusive manner recommended that a child with ADHD is
more prone to parental and environmental maltreatment,
including physical, emotional. and sexual types (Briscoe-
Smith & Hinshaw, 2006; Endo et al., 2006). Ouyang and
colleagues reported that physical and sexual abuse and neg-
ligence practiced by parents to their children were related to
increased prevalence of children’s ADHD (Ouyang, Fang,
Mercy, Perou, & Grosse, 2008). MacKenzie furthermore
suggests that difficult temperament in children, such as
hyperactivity and oppositional behaviors, increases parental
distress; also, mothers of hyperactive children exhibited
more physical discipline (MacKenzie, Nicklas, Brooks-
Gunn, & Waldfogel, 2011) and parents of these children
were found to have lower self-confidence, less warmth, and
involvement with their children (Alizadeh et al., 2007). In
another study that compared the mothers of children diag-
nosed with ADHD and the mothers of children with no psy-
chiatric diagnosis with respect to abusive discipline attitudes
8 Journal of Attention Disorders 
and ADHD symptoms, they found that ADHD symptoms
increased the risk of parental verbal and physically abusive
discipline (Evinç et al., 2014). According to the results
of the present study, there was a significant association
between male gender in children with ADHD and emotional
abuse. Although child attention deficits were higher in
ADHD and the emotional neglect subgroup, both child
attention deficit and hyperactivity/impulsivity were higher
in the sexual abuse subgroup; according to regression anal-
yses, these predictors were not independently associated
with the mentioned maltreatment types. Our results may be
partially considered as consistent with the literature in
showing that ADHD symptoms were linked to a higher
prevalence of parental abusive manner (Evinç et al., 2014;
Ford et al., 2000). Although it is not possible to evaluate
causality in a cross-sectional study such as the present one,
it can be speculated that ADHD boys might have higher risk
of emotional abuse, the level of child attention deficit in
ADHD children might be associated with emergence of
emotional neglect and/or sexual abuse, and severe hyperac-
tivity/impulsivity could be a major risk factor for sexual
abuse in children with ADHD.
It is also important to remember that parental psychopa-
thologies, including depression and alcohol or substance
abuse, are recognized risk factors for ADHD and child
maltreatment. There is considerable research indicating
the association between maternal depression and ADHD
symptoms and/or comorbid conduct disorder in children
(Cunningham, Benness, & Siegel, 1988; McCormick, 1995;
Shaw, Lacourse, & Nagin, 2005). Hibbs predicted that
depression may result in mothers being less emotionally
available or more critical and negative about their children
(Hibbs et al., 1991). In a study that addressed maternal–child
interactions in 7- to 10-year-old boys with ADHD, maternal
responsiveness was found to be negatively correlated to
child conduct problems and maternal depressive symptoms
(Johnston, Murray, Hinshaw, Pelham, & Hoza, 2002). It was
hypothesized that child conduct problems, maternal depres-
sive symptoms, and maternal responsiveness were compo-
nents that influenced the development of each other over
time (Johnston et al., 2002; Richards, 2012). In this approach,
caring for a child with problematic behavior can lead to,
or exacerbate, maternal depression (Richards, 2012), and
maternal depression can be a risk factor for emotional abuse
and neglect in children with ADHD. By contrast, we did
not find any association between maternal and/or paternal
depression and maltreatment types in children with ADHD.
The impacts of parental alcohol and/or substance abuse
seem to be risk factors for child abuse and neglect, and chil-
dren living in such families are at greater risk of trauma,
whether to themselves or in witnessing interparental vio-
lence (Duncan, Reder, Reder, McClure, & Jolley, 2000;
Manning, Best, Faulkner, & Titherington, 2009; Neger &
Prinz, 2015; Richards, 2012). However, we could not find
any significant association between parental alcohol or
substance abuse and maltreatment types in children with
ADHD using regression analyses. This may be a result of
recall bias by parents and also underestimation given the
sensitive nature of the topic.
Another goal of the current study was to investigate
the gender-specific associations between parental adverse
childhood experiences, adult ADHD symptoms, and child
maltreatment types in children with ADHD. In a recent
study that investigated the relationship between early adver-
sities and adult ADHD symptoms for both men and women,
childhood physical and sexual abuse were found to be asso-
ciated with significantly higher odds of ADHD symptoms
(Fuller-Thomson & Lewis, 2015). Emotional abuse and
neglect were also common among adult ADHD men and
women (Rucklidge, Brown, Crawford, & Kaplan, 2006;
Sugaya et al., 2012). Our findings are consistent with previ-
ous research for women (mothers) but not for men (fathers);
we found physical neglect was associated with attention
deficit, physical abuse was associated with hyperactivity/
impulsivity, and physical abuse, physical neglect, and
emotional neglect were associated with features linked
to ADHD in mothers (Briscoe-Smith & Hinshaw, 2006;
Fuller-Thomson & Lewis, 2015; Ouyang et al., 2008).
Maternal hyperactivity/impulsivity increases the rate of
emotional abuse and emotional neglect, and paternal atten-
tion deficit was higher in sexually abused children with
ADHD. Maternal history of emotional abuse and physical
neglect were also risk factors for sexual abuse in ADHD
children. It is possible that childhood traumas and adult
ADHD symptoms may lead to long-term consequences that
result in becoming an abusive and/or unprotective parent.
Our study has several limitations. First, we used the
Abuse and Neglect Questionnaire for Children to define
the abuse categories and according to this scale, a child
needed to have only one item endorsed in each category
to be defined categorically as having abuse. When we
divided the children as abused and non-abused within the
ADHD group, the number of the children in some sub-
groups was low and this limits the ability to find relation-
ships with some factors. The degree of association would
be stronger with larger samples of participants. Another
limitation was the negligence of assessing other parental
psychiatric disorders (e.g., personality disorders) that
may cause child abuse and neglect. Finally, assessment of
maltreatment was just based on a questionnaire, which
is dependent on the patient’s report of past or ongoing
maltreatment. This might have caused underestimation of
rates of maltreatment.
This study confirms that rates of maltreatment are higher
in children with ADHD compared with control group and
underlines the effects of both paternal and maternal past
experiences and adult ADHD symptoms on child maltreat-
ment in children with ADHD. In future studies, it will be
Gul and Gurkan 9
important to measure parental factors at more than one time
point, before and after the treatment of child ADHD and
parental psychopathology, to examine whether perspectives
on maltreatment shift with changes in parental characteris-
tics or child symptoms.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
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