NORDIC JOURNAL OF PSYCHIATRY

2022, VOL. 76, NO. 4, 272–279

https://doi.org/10.1080/08039488.2021.1962973

ARTICLE

Childhood trauma in adults with ADHD is associated with comorbid anxiety

disorders and functional impairment
Dawn E. Peleikisa , Mats Fredriksenb and Stephen V. Faraonec,d
a
Division of Mental Health and Addiction, Vestre Viken Hospital Trust, Asker DPS, Drammen, Norway; bDivision of Mental Health and
Addiction, Vestfold Hospital Trust, Tønsberg, Norway; cDepartment of Psychiatry, SUNY Upstate Medical University, Syracuse, NY, USA;
d
Department of Neuroscience and Physiology, SUNY Upstate Medical University, Syracuse, NY, USA

ABSTRACT ARTICLE HISTORY

Background: Child and adolescent psychological trauma exposure is associated with psychopathology Received 18 June 2021
in the adult population in general, but literature on childhood trauma (CT) in adults with ADHD Accepted 19 July 2021
is scarce.
KEYWORDS
Aims: To determine the prevalence of CT among adult patients with ADHD, and whether a history of
ADHD; childhood trauma;
CT implies different adult outcomes of psychiatric comorbidities, and functional impairment comorbidity; PTSD;
than without. anxiety disorders
Method: Previously unmedicated adult outpatients with ADHD (n ¼ 250, median age 32 years) entered
the study. Participants were diagnosed with ADHD using the Diagnostic Interview for ADHD in Adults,
second edition (DIVA 2.0), and were assessed by historical data, validated questionnaires, and struc-
tured clinical interviews for CT and mental disorders including post-traumatic stress disorder (PTSD)
and functional impairment. Analyses compared ADHD patients with and without CT.
Results: Prevalence of CT was 44%. Of those with PTSD (n ¼ 21), many had CT (85%, p < 0.001). In bin-
ary logistic regression analyses, CT was linked to an increased likelihood of concomitant panic disorder
(unadjusted odds ratio, OR ¼ 3.0, p < 0.001, and adjusted OR ¼ 2.7, p < 0.01) and any anxiety disor-
ders and two or more comorbid psychiatric disorders (adjusted OR ¼ 1.9, p < 0.05 and OR ¼ 1.7,
p < 0.05, respectively), and was associated with significant functional impairment.
Conclusions: These findings suggest that awareness of child and adolescent trauma is clinically rele-
vant among young to middle-aged adult ADHD patients, and implications for earlier detection of CT
and treatment warrant further studies.

Introduction Adult retrospective research indicates that childhood

psychological trauma is a significant risk factor for the devel-
Attention-deficit hyperactivity disorder (ADHD) is the most
opment of general psychological distress, anxiety, and
prevalent childhood neuropsychiatric disorder worldwide and
depressive disorders in adulthood in general [13–18].
is accompanied by prevalent persistence and functional
Reaction to psychological trauma may sometimes result in
impairments in adulthood [1,2]. The estimated prevalence of
ADHD in adults is around 3–5% [3–5]. Studies show high her- symptoms that are similar to ADHD in children, and some
itability (70–80%) for ADHD [6,7]. It is related to severe con- overlapping symptoms as inattention, disorganization, rest-
sequences as increased mortality [8], and functional lessness, emotional dysregulation, or sleep disturbances may
disabilities in several domains of life including education, complicate diagnostic assessments in children and adoles-
occupation, family, and social life [9]. Frequently, ADHD is cents [19].
associated with psychiatric co-morbidity including anxiety Based on extensive research, ADHD is known with high
and depressive disorders [5,10–12]. In a large survey of psy- heritability and as a neurodevelopmental disorder [6,20]. On
chiatric disorders in adult patients with ADHD in the USA, the other hand, trauma-related psychiatric disorders typically
70–80% met diagnostic criteria for a comorbid psychiatric occurring after exposure to psychological very stressful
disorder [5]. They reported high percentages of anxiety disor- events in the environment or about other persons, should
ders (47%), mood disorders (38%), and post-traumatic stress therefore basically be thought of as different disorders than
disorder (PTSD) (12%). Correspondingly, a large Norwegian ADHD both in childhood and adulthood [21]. However,
register-based study [10] found co-morbidities between anx- recent research literature indicates a bidirectional association
iety or mood disorders with ADHD varying with a 3- to 5- between ADHD and trauma-related disorders in childhood,
fold factor compared to controls without ADHD. the one condition at all ages being associated with

CONTACT Dawn E. Peleikis [email protected], [email protected] Division of Mental Health and Addiction, Department of
Psychiatry, Vestre Viken Hospital Trust, Asker DPS, Postbox 800, 3004, Drammen, Norway
Supplemental data for this article can be accessed online at https://doi.org/10.1080/08039488.2021.1962973.
ß 2021 The Nordic Psychiatric Association
 NORDIC JOURNAL OF PSYCHIATRY 273

increasing the prevalence of the other and vice versa [22]. In childhood criteria of ADHD based on collateral historical
a study in pre-pubertal children with ADHD (n ¼ 179) and information by parents, school or other sources, and adult
controls (n ¼ 212), about 27% had a history of CT vs. 16% of criteria of persistent ADHD symptoms. To be diagnosed with
the controls [23]. ADHD, participants must meet at least 6 out of 9 DSM-IV
Regarding current PTSD at adult age, two cross-sectional symptoms of the domains of inattention and/or hyperactiv-
studies indicate a relationship between ADHD and PTSD. ity/impulsivity in childhood, with some symptoms present
One study comparing male military veterans with PTSD and before age of 7 years, and currently have at least 6 out of
male veterans with panic disorder without PTSD, found a sig- 9 DSM-IV symptoms of inattention and/or hyperactivity/
nificant association of PTSD with ADHD and suggested that impulsivity for the last 6 months. In addition, we included
having ADHD entailed an increased risk of developing PTSD patients with 5 or more out of 9 symptom criteria of one or
[24]. Another study of military veterans [25] reported that both symptom domains in adulthood, and symptoms caused
55% in the sample met criteria for current PTSD and that an significant impairment in social, academic, or occupational
increased proportion of them (12%) met criteria for adult functioning. Patients meeting this lower diagnostic threshold
ADHD, as well. Both trauma exposure and ADHD severity would be diagnosed as ADHD NOS in DSM-IV (314.9), but are
were associated with greater severity of the current PTSD. diagnosed with full threshold ADHD in DSM-5 [28]. Exclusion
Summing up, research literature brings evidence for a higher criteria were (1) ADHD symptomatology better explained by
prevalence of associated comorbid mental disorders, and another axis-I mental disorder according to DSM-IV criteria,
more severe symptoms and impairments related to child- and any clinical unstable psychiatric condition which
hood and adolescent trauma exposure both for children and required another treatment with higher priority. (2) Patients
adults in general, and which is found evident in children with previous stimulant medication as adults (above 18 years
with ADHD as well. In adults with ADHD, the literature indi- age), (3) Learning disability and mental retardation with IQ-
cates the increased prevalence of comorbidity between score under 70 based on the Wechsler Adult Intelligence
ADHD and current PTSD. However, the impact of childhood Scale-IV (WAIS-IV) [29].
or adolescent trauma needs to be further investigated, and
whether a history of CT is related to different adult outcomes
may contribute significantly to the understanding of these Diagnostic assessments
complex conditions and their treatment. The initial assessment included a complete clinical history
The main aim of this study was to examine the preva- obtained by both structured and unstructured clinical inter-
lence of childhood psychological trauma among adult ADHD views collecting demographic information and lifetime his-
patients, and whether a history of CT is related to the differ- tory of psychiatric symptoms. Two board-certified
ent adult outcomes of comorbid psychiatric disorders. psychiatrists assessed the ADHD diagnosis according to DSM-
Another aim was to assess the association between CT and
IV TR criteria by a multisource procedure using the
functional outcomes. We hypothesized that a history of
Diagnostic Interview for ADHD in Adults, second edition
childhood trauma implied different adult outcomes of
(DIVA 2.0) [30]. Supplemental information on childhood
psychiatric comorbidities and functional impairment
symptoms was collected from school records, parents, and
than without.
any close relatives. Other data from this clinical sample are
previously published [26,31], and the study protocol is there-
Method fore described in brief here.
Outcomes of comorbid mental disorders were examined
Participants by the MINI International Neuropsychiatric Interview Plus
This study included baseline data from participants in an (M.I.N.I.-Plus) for DSM-IV Axis I disorders [32]. In a pilot,
observational study on medical treatment of adults with before this study, the two psychiatrists independently exam-
ADHD without previous stimulant treatment recruited from ined 21 patients. For the diagnosis of ADHD Cohen’s kappa
August 2009 to December 2010 [26]. Subjects included were was 0.77, and for comorbid mental disorders, the kappa
of age between 18 and 60 years, and with disabling symp- was 0.79.
toms of ADHD. They were recruited from consecutive refer-
rals to the specialist outpatient clinic at Vestfold Hospital Retrospective assessments of childhood trauma
Trust, in Norway. We obtained written informed consent exposures and ADHD symptoms
from all participants after they had received a detailed
description of the study. The study was designed by the eth- History of traumatic life events in childhood before 15 years
ical standards laid down in the Declaration of Helsinki and of age was assessed in retrospect by the board-certified psy-
was approved by the Regional Committee of Medical Health chiatrists. They used the structured interview M.I.N.I.-Plus to
Research Ethics (REC South-East Norway; 2009/S-07339a assess DSM-IV qualifying trauma during childhood and for
[2.2007.2008]) and the Norwegian Social Science Data the diagnose of current PTSD during the last month and sup-
Services (NSD; 2009/20597/2/IB). plied with data from the PTSD symptom scale-interview ver-
Inclusion required a diagnosis of ADHD according to the sion (PSS-I), a widely used and validated instrument for the
Diagnostic and Statistical Manual of Mental Disorders 4th assessment of traumatic events [33]. A childhood trauma (CT)
edition, text revision (DSM-IV TR) criteria [27], meeting was validated by confirming questions of exposure to any
274 D. E. PELEIKIS ET AL.

traumatic events including actual or threatened death, ser- (the NoCT group). The data were initially analyzed by
ious injury or physical maltreatment, sexual or physical descriptive methods. We analyzed categorical variables using
assault in either directly experiencing the traumatic event, or the chi-square test or Fisher’s exact test. We used the
witnessing in person the traumatic event. In addition, retro- Student’s t-test to evaluate differences of continuous varia-
spectively reported events of childhood caregivers’ physical bles between two independent groups and after assessment
or emotional neglect were recorded. for normality. We kept using the t-test for some continuous
Information of ADHD symptoms and DSM-IV subtype in variables showing light skewed distributions considering the
childhood were derived from the diagnostic assessments sample size and findings of similar skewness and variance
outlined above. Further, to characterize childhood ADHD between the compared groups [43]. We present results with
symptoms, we used the Wender Utah rating scale (WURS), p-values as-is due to many measures are correlated and the
and its short form (25 items, WURS-25) more specifically for associations studied were a restricted number of preplanned
ADHD symptoms [34,35]. A cutoff score of 46 or higher is comparisons [44].
reported to correctly identify 86% of adults with ADHD [36]. To examine the relationship between our outcome varia-
bles of comorbidity and functional impairment, and the
potential predictive variables, we applied logistic regression
Assessments of functional impairment and adult analysis. We entered the independent variables found to be
ADHD symptoms associated with the outcome variables using the chi-square
Evaluation of functional impairment was performed by the test, into a binary logistic regression model, initially one at a
two psychiatrists using the Global Assessment of Functioning time (unadjusted). Confounding effects were finally adjusted
(GAF) Scale (range 0–100) [37,38]. We applied the split ver- by entering age, sex, and the measure of childhood ADHD
sion for the functioning (GAF-F) to improve reliability and WURS-25 category together into the equation, probability for
focus on impairment [39,40]. The intra-class correlation coef- stepwise entry p ¼ 0.05 and removal p ¼ 0.10. Odds ratios
(ORs) and 95% confidence intervals (CI) were estimated as a
ficient assessing inter-rater reliability was 0.79 for the GAF-F.
measure of the strength of association. All tests were two-
Adult ADHD symptoms present for the last six months
tailed and were considered significant if p < 0.05. Analyses
were dimensionally rated by the 18 item Adult ADHD Self
were conducted using the software package IBM SPSS
Report Scale version 1.1 (ASRSv.1.1) [41,42] with the nine
Statistics (Version 23).
inattentive criteria and nine hyperactive-impulsive criteria
according to DSM-IV. To quantify outcome we used the con-
tinuous scoring method of frequency of ADHD symptoms, Results
self-rated on a 5-point scale, sum scores range 0–72 points
for the total symptom load. Cronbach’s alpha for the total Sociodemographic and clinical characteristics
scale was 0.86. Of the 250 patients with adult ADHD included, 109 (44%)
participants had experienced childhood trauma (CT)
(Table 1). Childhood traumatic experiences were of different
Analytic strategy and statistical methods
events (Table 2), and several participants had been victi-
In a retrospective design, we compared participants with mized by multiple events. Significantly more women
ADHD from two groups i.e. cases with a childhood history of reported CT (50% women and 37% men, p ¼ 0.048). The
trauma exposure (the CT group) and the controls without median age by inclusion was 32 years, 75-percentile of

Table 1. Demographic and clinical characteristics by childhood trauma exposure.

Group statistics
All ADHD patients No childhood trauma Childhood trauma
n ¼ 250 n ¼ 141 n ¼ 109 p-Valuea v2/t
Age (years), mean (SD) 32.4 (9.8) 31.0 (10.0) 34.1 (9.4) 0.057b t ¼ 1.91b
Sex, n (%)
Female 129 (51.6) 65 (46.1) 64 (58.7) 0.048 v2 ¼ 3.92
Male 121 (48.4) 76 (53.9) 45 (41.4) –
Living and marital status, n (% within group)
Married/cohabiting partnership 107 (42.8) 63 (44.7) 44 (40.4) 0.494 v2 ¼ 0.47
DSM-IV symptoms of childhood ADHDc
n (% within group)
ADHD-inattentive 6 criteria vs. not 219 (87.6) 125 (88.7) 94 (86.2) 0.566 v2 ¼ 0.33
ADHD-hyperactive-impulsive 6 criteria vs. not 143 (57.2) 75 (53.2) 68 (62.4) 0.145 v2 ¼ 2.12
Wender Utah Rating Scale (25 items version)d
WURS 25 < 46 71 (28.4) 51 (36.2) 20 (18.3) 0.002 v2 ¼ 9.60
WURS 25  46 179 (71.6) 90 (63.8) 89 (81.7) –
Values presented in means and standard deviations (SD) or frequencies n and percentages (%) within column. Characteristics shown by groups of patients
reporting childhood trauma before 15 years of age or not assessed by interview.
a
From Pearson chi-square, sig. two-sided test.
b
Independent t-test, sig. two-sided.
c
DSM-IV core symptoms of childhood ADHD assessed by DIVA 2.0 (Diagnostic Interview of Adult ADHD version 2.0).
d
Level of childhood ADHD-symptoms by the Wender Utah Rating Scale 25 items version, categorical variable defined by the cut-off score 46, displayed n (%
within group).
 NORDIC JOURNAL OF PSYCHIATRY 275

40 years, and with a range of 17–58 years. There were no sig- Adult psychiatric comorbidity
nificant differences between the CT and the no-trauma
A larger proportion with CT had two or more comorbid dis-
group (NoCT) for age, marital or occupational status. No dif-
ferences were seen between the CT and NoCT patients orders (57 vs. 39%, p ¼ 0.030) (Table 3). Panic disorder, agora-
regarding parents’ nor patients’ level of education phobia, and post-traumatic stress disorder (PTSD) were
(Supplemental Table). There were no significant differences altogether significantly more prevalent in the CT group com-
in the ADHD subtype presentations by clinicians’ assessment pared to the NoCT group (Table 3). Twenty participants (8%)
either. However, more patients in the CT group reported a (nine men and 11 women) met DSM-IV criteria for current
higher load of childhood ADHD symptoms by the WURS 25 PTSD, and more of them had childhood trauma (before the
(score 46) than the NoCT (82 vs. 64%, p ¼ 0.002) (Table 1). age of 15 years) than later in life (17 patients vs. three
About half of those with CT (16 men and 34 women) patients, p < 0.001).
reported exposure to any physical or sexual victimization;
including 36 participants exposed to any sexual abuse, and
Adult ADHD symptoms and functional impairment
with trice more women than men (n ¼ 27 vs. n ¼ 9, p ¼ 0.015,
chi-square 5.9). Fourteen individuals reported exposure to Patients’ self-rating of current ADHD symptoms on the 18
physical maltreatment without sexual abuse (seven women). item versions of the Adult ADHD Self-Report Scale (version
The other half with CT (n ¼ 59), who reported no sexual or 1.1) demonstrated slightly more affected outcomes among
physical abuse, had exposure to one or more psychological patients in the CT group than the NoCT (Table 4). Comparing
or social trauma, such as caregiver’s neglect (n ¼ 24), being the measure of global functioning and impairment, the GAF-
witness to distressing incidents of assault or harassment of a F in adulthood, we found a corresponding difference. The
close family member (n ¼ 27) and/or distressing event by NoCT group had significantly higher function by GAF-F
substance abuse among parents (n ¼ 25) (not in the tables). scores compared to the CT group.

Likelihood of the adult outcomes

Table 2. Childhood experience of traumatic events.
Trauma n (%) To examine the likelihood of comorbidities in adulthood
Any sexual victimization 36 (33.0) associated with CT and load of childhood ADHD symptoms
Any violent physical maltreatment 26 (23.9) by the WURS-25 category, we performed logistic regression
Caregiver’s neglect 38 (34.9)
Witness distressing incidents of assault or harassment of a close 52 (47.7)
analysis (Table 5). Entering the unrelated covariates of age
family member and sex one at a time in the model, none of them had a sig-
Reported distressing event by parent’s substance abuse 51 (46.8) nificantly higher likelihood of any comorbidity outcomes.
Participant reported traumatic events in childhood (up to age of 15 years) in However, having CT increased the likelihood of all the
this sample of adults with ADHD reporting childhood trauma (n ¼ 109).
Several participants had multiple trauma. studied adult outcomes of comorbidity. This was evident
even when adjusting for age, sex, and a load of ADHD

Table 3. Adult comorbid psychiatric disorders.

Group statistics
All ADHD patients No childhood trauma Childhood trauma
n ¼ 250 n ¼ 141 n ¼ 109 p-Valueb v2
Co-morbid psychiatric diagnoses , n (%)
a

No known co-morbid disorder 60 (24.0) 40 (28.4) 20 (18.3) 0.030 8.96

One co-morbid disorder 73 (29.2) 46 (32.6) 27 (24.8) – –
Two co-morbid disorder 67 (26.8) 34 (24.1) 33 (30.3) – –
Three or more disorder 50 (20.0) 21 (14.9) 29 (26.6) – –
Psychiatric diagnosesa, n (%)
Major depressive disorder 52 (20.8) 28 (19.9) 24 (22.0) 0.676 0.17
Recurrent depressive episode 31 (12.4) 18 (12.8) 13 (11.9) 0.842 0.04
Dysthymia 47 (18.8) 28 (19.9) 19 (17.4) 0.626 0.24
Bipolar disorder 39 (15.6) 22 (15.6) 17 (15.6) 0.999 0.00
Panic disorder 61 (24.4) 22 (15.6) 39 (35.8) <0.001 13.57
Agoraphobia 55 (22.0) 24 (17.0) 31 (28.4) 0.031 4.67
Social phobia 43 (17.2) 23 (16.3) 20 (18.3) 0.672 0.18
Obsessive-compulsive disorder (OCD) 25 (10.0) 15 (10.6) 10 (9.2) 0.702 0.15
Post-traumatic stress disorder (PTSD) 20 (8.0) 3 (2.1) 17 (15.6) <0.001c 15.15
Generalized anxiety disorder 11 (4.4) 4 (2.8) 7 (6.4) 0.171c 1.88
Alcohol abuse or dependenced 27 (10.8) 15 (10.6) 12 (11.0) 0.925 0.01
Drug abuse or dependenced 16 (6.4) 8 (5.7) 8 (7.3) 0.594 0.29
Any anxiety disorder (incl. PTSD and OCD) 136 (54.4) 65 (46.1) 71 (65.1) 0.003 8.98
Values presented in frequencies n and percentages within column. Psychiatric comorbidity displayed by groups of patients reporting childhood trauma before
15 years of age or not. Group statistics compared by Pearson chi-square, sig. two-sided test.
a
Co-morbid psychiatric diagnoses were assessed by the Mini International Neuropsychiatric Interview (M.I.N.I.) version 5.0.0 for DSM-IV (American Psychiatric
Association’s Diagnostic and Statistical Manual, 4th ed.) axis I disorder, met criteria lifetime if not otherwise specified.
b
From Pearson chi-square, if not otherwise specified.
c
Fisher’s exact test, sig. two-sided test.
d
Abuse or dependence within last 12 month.
276 D. E. PELEIKIS ET AL.

Table 4. ADHD symptoms and impairment in adults with ADHD by childhood trauma exposure.
All ADHD patients No childhood trauma Childhood trauma Group statistics
(n ¼ 250) (n ¼ 141) (n ¼ 109)
Mean (SD) Mean (SD) Mean (SD) p-Valuea ta
b
ADHD symptoms (ASRSv1.1) scale sum 18 items version 50.40 (10.18) 48.95 (10.89) 52.27 (8.89) 0.010 2.58
Global Assessment of Functioningc (GAF-F) 51.22 (8.06) 52.13 (7.56) 50.06 (8.55) 0.045 2.02
Values presented in means and standard deviations (SD).
a
Independent samples t-test comparing the trauma status group means, sig. two-sided.
b
Adult ADHD Self Report Scale, version 1.1 (ASRSv1.1), developed by the WHO Workgroup on Adult ADHD. Scale sum 18 items version, range 0–72 points.
c
Global Assessment of Functioning (GAF), functioning subscale (GAF-F), clinician-rated, score ranked 0–100.

symptoms in childhood (WURS-25  46 vs. reference <46); Our finding of higher scores on measures of ADHD symp-
for panic disorder with adjusted OR 2.7 (p < 0.01), any anxiety toms in childhood (the WURS-25) among those exposed to
disorder with adjusted OR 1.9 (p < 0.05), two or more psychi- CT, corresponds to findings of more externalizing problems
atric disorders with adjusted OR 1.7 (p < 0.05). In addition, a and greater parent-reported ADHD severity in trauma-
higher load of ADHD symptoms in childhood (WURS-25  46) exposed children compared to non-exposed children with
was associated with two or more psychiatric disorders in ADHD in the above-cited child study [23]. In our study,
adulthood even when CT was included in the regression patients with CT showed a significantly lower score on global
model (adjusted OR 2.1, p < 0.05). The likelihood of global assessment of functioning (by the GAF-F) than the NoCT.
functioning impairment by the GAF-F measure demonstrated Correspondingly, patients with CT scored higher on self-rated
a corresponding independent association with CT and the current ADHD symptoms (by the ASRSv1.1) compared with
WURS category, adjusted OR 1.70 (p ¼ 0.048) and 1.95 the NoCT patients. These findings are in accordance with
(p ¼ 0.030), respectively. studies on children reporting higher symptom severity of
ADHD, and more neurological soft signs of hyperactivity
related to trauma or PTSD in children [23,47].
Discussion A larger proportion of ADHD patients with CT had two or
more comorbid disorders compared with the no-traumatized
To our knowledge, this is the first study on the prevalence
ones. The most common comorbidities were panic disorder
and relationship between childhood trauma and psychiatric
and agoraphobia. A recent study found that current anxiety
co-morbidities and impairment in medication naïve adult
modulated the relation between ADHD severity and working
ADHD patients. The main findings were a high frequency of
memory-related brain activity in adolescents and young
childhood trauma among all the participants, and this was
adults [48]. Such a relationship may contribute to explain
more prevalent in women than among men. ADHD patients
functional impairment associated with comorbid anxiety in
with childhood trauma had more psychiatric comorbidities
our sample too. Similar to what we found, a study of ADHD
including panic disorder, agoraphobia, and PTSD in adult-
youth reported that being traumatized, indicated by PTSD,
hood than those without. Among participants with current
was significantly associated with a higher risk of poorer
PTSD, the clear majority had suffered from traumas in child-
social functioning and a higher prevalence of anxiety disor-
hood. Patients with childhood trauma had more ADHD ders [49].
symptoms, and functional impairment compared to Comparing to the literature, the prevalence of current
those without. PTSD in our sample (8%), lies close to that found in another
In our sample, many participants (44%) had experienced study of a clinical population of adults with ADHD (10%)
childhood traumatization. This prevalence is larger than the [50], and in-between the prevalence of PTSD found in a large
27% reported in a study of children up to 8 years of age [23], American comorbidity survey including both ADHD and non-
but at the same level as a recent study among help-seeking ADHD individuals (12 vs. 3%) [5]. In our study, most of the
youth in a US community non-psychiatric population were PTSD patients reported any childhood trauma (85%), and
about forty percent reported exposure to one or more trau- conversely, a larger proportion of those with PTSD, was
matic events [45]. found among ADHD patients with a childhood trauma vs.
In our study, the inclusion of childhood trauma for a those with no childhood trauma (16 vs. 2%). These findings
wider age range up to 15 years, may partly explain this dif- are in line with results from a review of studies on trauma-
ference. In our sample, there was no significant difference exposed children and adolescents that reported the preva-
between the childhood traumatized and no-traumatized lence of current PTSD to be 15.9% for individuals exposed to
ADHD patients regarding age, patients’ or parents’ educa- interpersonal trauma, and girls at highest risk [51]. In our
tional level, or current employment, respectively. Such factors study, most patients reported exposure to childhood trauma
were thus less likely to explain differences between the CT in the context of interpersonal relations; only two patients
and NoCT group. We found that three times as many women reported car accidents and natural disasters, and those
than men reported sexual abuse, which fits well with the occurred after 15 years of age.
previous finding of ratio in a questionnaire-based prevalence Belonging to any ADHD subtype did not differ between
study on 17-year-old boys and girls in a Swedish study our trauma status groups (CT group vs. NoCT). Of those with
between girls (11.2%) and boys (3.1%) [46]. CT, about half reported having been exposed to sexual
 NORDIC JOURNAL OF PSYCHIATRY 277

victimization and violence or physical maltreatment without

1.70 (1.004–2.89)

Binary logistic regression models estimating the likelihood of the adult outcomes, crude Odds Ratio (OR) with 95% confidence interval (CI) by entering independent factors one at a time in the equation. Adjusted values
OR for age, sex and Wender Utah Rating Scale 25 items version (WURS-25) covariates. Probability for stepwise entry 0.05, and removal 0.10. Global functioning impairment is defined by a Global Assessment of
1.95 (1.07–3.55)
1.02 (0.99–1.05)

1.10 (0.47–1.47)
Adjusted OR
sexual abuse. These types of trauma, particularly sexual
Global functioning impairment

abuse and violence are previously found to be associated

Ref.

Ref.

Ref.
with later PTSD in samples of children and adolescents with-
out ADHD [51,52]. In our study, comparing a load of child-
n ¼ 112

hood ADHD symptoms by the WURS subscales between the

NoCT group and the CT group, childhood traumatization was
1.96 (1.18–3.26)

2.06 (1.16–3.68)
1.02 (0.99–1.05)

1.01 (0.62–1.67)

linked to significantly higher mean scores of ADHD symp-

Crude OR

Ref.

Ref.

Ref.
toms. These findings may suggest that childhood traumatiza-
tion moderates by increasing the symptom load already
evident in childhood both for ADHD severity and for other
psychopathology, even for cases where PTSD does
1.71 (1.01–2.90)

2.09 (1.15–3.80)

not develop.
1.01 (0.99–1.04)

1.08 (0.64–1.83)
Adjusted OR
Two or more psychiatric disorders

Interestingly, we found that the likelihood of the adult

Ref.

Ref.

Ref.

outcome of panic disorder, any anxiety disorder, or multiple

psychiatric comorbidities, were unrelated to age and sexes.
However, having CT increased the likelihood of all these
n ¼ 116
Table 5. Estimated likelihood of adult outcome of panic disorder, any anxiety disorder, multiple psychiatric comorbidities or global functioning impairment.

adult outcomes. Adjusted for age, sex, and childhood ADHD

1.99 (1.20–3.30)

2.26 (1.27–4.02)
1.01 (0.99–1.02)

1.15 (0.70–1.89)

symptoms, the increased risk was evident for all outcomes of

Crude OR

comorbid anxiety, and with an almost tripled odds ratio for

Ref.

Ref.

Ref.

panic disorder. I addition, a higher load of self-reported

ADHD symptoms in childhood (WURS) was independent of
having CT, associated with adult outcomes of two or more
psychiatric disorders, indicating an independent impact of
1.87 (1.10–3.18)

Level of childhood ADHD-symptoms by the Wender Utah Rating Scale 25 items version: WURS-25 score <46, i.e. reference (ref.).
1.01 (0.99–1.04)

1.45 (0.86–2.45)

1.72 (0.96–3.07)

severity of childhood ADHD symptoms as well. The adult glo-

Adjusted OR

Childhood psychological traumatization (CT) vs. no CT retrospectively assessed by clinician administered structural interview.

bal functioning impairment by the GAF-F measure demon-

Ref.

Ref.

Ref.

strated a corresponding association both with CT and ADHD

Any anxiety disorder

symptomatology by the WURS category, indicating these fac-

n ¼ 136

tors are independently linked with the outcome of impair-

ment in adulthood. These associations found may fit with a
2.19 (1.31–3.67)

1.83 (1.05–3.19)
1.02 (0.99–1.05)

1.56 (0.94–2.57)

theoretical approach for a vulnerability-stress model.

Crude OR

Theoretically, individuals with ADHD may have several vul-

Ref.

Ref.

Ref.

nerabilities with respect to traumatization. Individual varia-

tions of combined inherent neurocognitive and brain arousal
regulation deficits [53], and difficulties with interpersonal
functional skills, may converge into impaired comprehension
2.69 (1.45–4.99)**
Adjusted OR (CI)
1.00 (0.97–1.03)

1.79 (0.84–3.79)
1.41(0.76–2.62)

and coping with situations and execution, and lead to

increased risk for and worsening of psychosocial outcome
Ref.

Ref.

Ref.

after exposure to psychological trauma.

Panic disorder

Functioning (GAF) split functioning scale, score below 50 (range 0–100).

n ¼ 61

Limitations
3.01 (1.65–5.50)

2.11 (1.03–4.35)
1.01 (0.98–1.03)

1.49 (0.83–2.67)
Crude OR (CI)

The participants comprised medication naïve, adult ADHD

Ref.

Ref.

Ref.

patients and represented a naturalistic clinical sample includ-

ing a wide age span of both genders and comorbid condi-
p < 0.05, p < 0.01, p < 0.001, sig. two-tailed.

tions. Data collection also included historical data from

school and consultations with former health care services
journals, and all patients in the present study were examined
Childhood ADHD by WURS-25 categoryb

with structured diagnostic interviews by two board-certified

Childhood trauma (CT) (n ¼ 109)
No childhood trauma (n ¼ 141)

and experienced clinicians.

There are however several limitations in the present study.
Childhood traumatizationa

Investigators were not blind to the participants’ diagnostic

High (46) (n ¼ 179)
Low (<46) (n ¼ 71)

status, which could have influenced their assessments.

Female (n ¼ 129)
Variables (n ¼ 250)

Retrospective data are possibly distorted by current symp-

Male (n ¼ 121)

toms that may bias estimates of associations. Given our

Age (years)

partly cross-sectional and retrospective design, we cannot

claim inference of causal relationships between traumatiza-
Sexes

tion, PTSD, ADHD, and functional measures. Although a

b
a
278 D. E. PELEIKIS ET AL.

historical timeline may be indicated by the childhood data. Funding

Further, the limitations of self-report or symptom checklists
D.E.P and M.F. have received no funding for this study. S.V.F. has
for several measures may be considered. received funding from the European Union’s Horizon 2020 Research and
Heterogeneity within the trauma group, absence of com- Innovation Programme grant agreement No 667302.
plete information about trauma severity or duration, may
also limit the interpretation of our results. Some evidence
suggests that certain types of the complexity of trauma, dif-
ORCID
ferentially contribute to symptoms and functional impair-
ment and that the age at which the traumatic event took Dawn E. Peleikis http://orcid.org/0000-0001-6922-1547
place may influence the impact of trauma [54]. Mats Fredriksen http://orcid.org/0000-0002-8392-3366

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