It is well established in the research literature that individuals with ADHD have difficulty with “executive functioning” – the processes that reside in the frontal lobes. They enable recall of tasks that need accomplishing, organization to accomplish these tasks, assessment of consequences of actions, prioritization of thoughts and actions, keeping track of time, awareness of interactions with surroundings, the ability to focus despite competing stimuli, and adaptation to changing situations.
Research has identified alterations in the dopaminergic and adrenergic pathways of individuals with ADHD. In particular, areas of the prefrontal cortex appear to be the most affected. Dopamine and norepinephrine are neurotransmitters playing an important role in brain function. The uptake transporters for dopamine and norepinephrine are overly active and clear these neurotransmitters from the synapse faster than in normal individuals. This is thought to increase processing latency and salience, and diminished working memory.
Anger and Antisocial Behavior
Impulsive behavior is a common effect of ADHD. One example of that is anger. People with ADHD have difficulty controlling their emotions, so they may display violent or hostile behavior that is excessive. In addition, many with ADHD are driven to danger by impulsivity or hyperactivity — hallmark symptoms of ADHD — combined with a high need for stimulation and a diminished ability to grasp consequences.
Studies in children with ADHD document strong associations with both antisocial behavior and frontal lobe dysfunction (Moffitt, 1993a, 1993b, Pennington & Ozonoff, 1996).
In her book, The Biology of Violence, Dr. Debra Niehoff notes; “ADHD is not simple misbehavior; it’s no more willful than the insensibility of a horse enduring a first-time rider. Attention fails when there’s too much to attend to, when the needle of the signal is lost in the haystack a perceptual noise. And overwhelmed brain has no priorities, and without priorities, responsible actions are impossible.
ADHD troubles parents, educators, and child psychiatrists because about half of children who can’t pay attention are also behind the door when the rules of conduct are handed out. In the subgroup, inattention festers into an oppositional, hostile defiance that may net them a trip to the nearest mental health professional. If they’re not careful, it may land them in the nearest juvenile detention facility. According to Tony Rostain, of the Philadelphia Child Guidance Center, ‘It’s the kids with the oppositional form of ADHD who develop a real problem with aggression. If you look at kids who present for treatment here in the clinic, probably more than three quarters fall into this category. Inattentive or hyperactive kids who are pleasant socially and get along with others can be managed. The aggressive kids are harder to manage.’
Long-term follow-up suggests that the concerns parents and physicians have about hyperactivity is not unfounded. Oppositional ADHD in children can be a prelude to worse behavior in adolescence and adulthood. At least 20 reports linking early hyperactivity and attention deficits to later antisocial or violent behavior have appeared in the clinical literature. Other studies have documented an increased risk for substance abuse and suicide. . . Some children with the aggressive form of ADHD are hostile and impulsive. ‘These kids are hypervigilant to the extreme,’ explains Rostain. ‘They can’t calm down enough to pay attention. They’re easily frustrated, on a hair trigger.’ Niehoff, D. (1999). The biology of violence. The Free Press, p.201-202.
In their book, Assessing and Managing Violence Risk in Juveniles, Borum and Verhaagen note; “Hyperactivity is shown a strong and consistent relationship to violent behavior. Current research shows that hyperactive children demonstrate high rates of antisocial behavior and conduct problems in adolescence. . . Hyperactive boys have even been shown to be significantly more violent than their non-hyperactive male siblings. . . Associations have also been found between measures of restlessness and fidgetiness and subsequent violence in males. . .
Manuzza et al. (1989) studied 103 hyperactive males and 100 non-hyperactive controls between 16 and 23 years of age. Hyperactive males were significantly more likely than controls to be arrested for any offense (39% versus 20%) or for a felony (25% versus 7%). A very similar pattern was found in a controlled study, where hyperactive kids had significantly higher rates of arrest (46% hyperactive versus 11% control) and incarceration (22% versus 1%). Hyperactive subjects also had a higher rate of arrest specifically for violent crimes (34% versus 9%). . . Overall, then, ADHD appears to be a significant risk factor for the development and acceleration of violent behavior throughout childhood and adolescence and even into adulthood.” Borum, R., Verhaagen, D. (2006). Assessing and managing violence risk in juveniles. Guilford Press, p.37-38.
Risky Behaviors
As a result, they may begin courting problems early. Teens with ADHD get three times as many speeding tickets and are involved in nearly four times as many car accidents as peers without the disorder. In one study of adolescents, more than 50% of teens diagnosed with ADHD contracted a sexually transmitted disease. Risk taking then extends into adulthood in the form of substance abuse, physical fights, habitual gambling, jumping headlong into online relationships with strangers, and other perilous or even life-threatening actions.
George Keepers, MD, is chair of psychiatry at Oregon Health and Science University and director of the OHSU Adult Attention Deficit Disorder Clinic. He notes, “How might ADHD be at fault? The disorder impairs the brain’s executive functions. Where we form judgments, where we predict the future, where we try to conform our actions to tasks that will lead us to success, rather than to failure.” There is hope, but that is dependent on early medical treatment. “Their likelihood of avoiding risky behaviors is very much related to whether they’re treated,” Keepers says.
Need for Intense Stimulation
Why do some people with ADHD have a “hunger for intense stimulation,” as psychiatrist Edward M. Hallowell, MD, describes in his book Driven to Distraction? Thrill or danger may focus the distracted or inattentive mind in a way similar to that of ADHD stimulant medications: by enhancing the release of adrenaline, Hallowell writes. “Hence, such behavior may constitute a form of self-medication.”
References
Moffit, T. E. (1993a). Adolescence-limited and life-course-persistent antisocial behavior: A developmental taxonomy. Psychological Review, 100, 674-701.
Moffit, T.E., (1993b). The neuropsychology of conduct disorder. Development and Psychopathology, 5, 135-152.
Moffitt, T. E., Caspi, A., Harrington, Hl, and Milne, B. J. (2002). Males on the life-course-persistent and adolescence-limitited antisocial pathways: Follow-up at age 26 years. Development and Psychopathology, 14, 179-207.
Pennington, B. F., & Ozonoff, S. (1996). Executive functions and developmental psychopathology. Journal of Child Psychology and Psychiatry, 37, 51-87.
Research Abstracts regarding ADHD and Violence
Impulsive, but violent? Are components of the attention deficit-hyperactivity syndrome associated with aggression in relationships?
Theriault, Stephen W. and Holmberg, Diane
Violence Against Women, Vol 7(12), Dec, 2001. pp. 1464-1489.
Abstract:
Links between attention deficit hyperactivity disorder (ADHD) and relationship aggression were explored in 157 adults aged 17–46 yrs. The role of disorders comorbid with ADHD, such as conduct disorder (CD), and the role of pragmatic language difficulties also were examined. ADHD and comorbid disorders (CD) were small but significant predictors of both physical and sexual aggression in relationships. Regarding pragmatic language difficulties, verbal impulsivity—a tendency to blurt out thoughts and interrupt others—predicted relationship aggression. Once verbal impulsivity had been accounted for, ADHD and CD symptoms were no longer significant predictors, suggesting that verbal impulsivity and an inability to successfully negotiate relationship difficulties might account for the ADHD-relationship aggression link.
Attention-deficit/hyperactivity disorder, conduct disorder, and young adult intimate partner violence.
Fang, Xiangming, et.al.
Archives of General Psychiatry, Vol 67(11), Nov, 2010. pp. 1179-1186.
Abstract:
Context: Studies based on clinical samples suggest a connection between childhood attention-deficit/ hyperactivity disorder (ADHD) and later intimate partner violence (IPV) perpetration.
Objective: To examine the association between retrospectively reported childhood ADHD and conduct disorder (CD) symptoms and the perpetration of physical IPV in a population-based sample of young adults.
Design, Setting, and Participants: The study population consisted of 11238 participants (mean [SD] age, 22.0 [1.7] years) in the National Longitudinal Study of Adolescent Health. Multinomial logistic regressions and propensity score matching were used to analyze the relationships of IPV with symptoms of ADHD domains (hyperactive/ impulsive and inattentive) and symptoms of CD as well as with ADHD and CD dichotomized on the basis of symptom criteria.
Main Outcome Measures: Respondents’ answers to the 2 questions in the wave III survey reflecting perpetration of physical violence toward a partner were used to define IPV perpetration. Intimate partner violence perpetration resulting in injury or not was assessed with a follow-up question.
Results: Conduct disorder significantly predicted IPV perpetration both with and without injury. Controlling for CD and hyperactivity/impulsivity, inattention independently predicted young adult IPV perpetration without injury. Controlling for inattention and CD, no significant relationship between hyperactivity/impulsivity and IPV perpetration without injury was found. Results were different regarding IPV perpetration resulting in injury. Hyperactivity/impulsivity, but not inattention, independently predicted IPV perpetration resulting in injury. In categorical analyses, CD predicted both types of IPV, and ADHD significantly predicted IPV perpetration resulting in injury but did not significantly predict IPV perpetration without injury.
Conclusions: Conduct disorder is consistently associated with violence in intimate relationships. Controlling for CD, there is also an association between ADHD and IPV. Results suggest the need for services and treatment strategies that specifically address the risks for violence and promote healthy intimate relationships for youths with CD and ADHD.
Impulsivity in the general population: A national study.
Chamorro, Jaime, et.al.
Journal of Psychiatric Research, Vol 46(8), Aug, 2012. pp. 994-1001.
Abstract:
Objective: The construct of impulsivity is an important determinant of personality differences, psychiatric disorders, and associated risk-taking behaviors. Most existing knowledge about impulsivity comes from clinical samples. To date, no study has estimated the prevalence of impulsivity and examined its correlates in the general population.
Method: We analyzed data from a large national sample of the United States population. Face-to-face surveys of 34 653 adults aged 18 years and older residing in households were conducted during the 2004-2005 period. Diagnoses of mood, anxiety, and drug disorders as well as personality disorders were based on the Alcohol Use Disorder and Associated Disabilities Interview Schedule—DSM-IV Version.
Results: Impulsivity was common (17% of the sample), particularly among males and younger individuals, and associated with a broad range of axis I and II disorders, particularly drug dependence, cluster B, dependent and schizotypal personality disorders, bipolar disorder and ADHD. It was associated with behavioral disinhibition, attention deficits, and lack of planning. Individuals with impulsivity were more likely to engage in behaviors that could be dangerous to themselves or others, including driving recklessly, starting fights, shoplifting, perpetrating domestic violence and trying to hurt or kill themselves. They were exposed to higher risk of lifetime trauma and to substantial physical and psychosocial impairment.
Conclusion: Given the association of impulsivity with psychiatric disorders and multiple adverse events, there is a need to target impulsivity in prevention and treatment efforts.
A Systematic Review of Risk Factors for Intimate Partner Violence
Capaldi, Deborah M., et.al.
Partner Abuse. 2012 April ; 3(2): 231–280.
Abstract:
A systematic review of risk factors for intimate partner violence was conducted. Inclusion criteria included publication in a peer-reviewed journal, a representative community sample or a clinical sample with a control-group comparison, a response rate of at least 50%, use of a physical or sexual violence outcome measure, and control of confounding factors in the analyses. A total of 228 articles were included (170 articles with adult and 58 with adolescent samples). Organized by levels of a dynamic developmental systems perspective, risk factors included: (a) contextual characteristics of partners (demographic, neighborhood, community and school factors), (b) developmental characteristics and behaviors of the partners (e.g., family, peer, psychological/ behavioral, and cognitive factors), and (c) relationship influences and interactional patterns. Comparisons to a prior review highlight developments in the field in the past 10 years. Recommendations for intervention and policy along with future directions for intimate partner violence (IPV) risk factor research are presented.
Axis I psychopathology and the perpetration of intimate partner violence.
Crane, Cory A., et.al.
J Clin Psychol. 2014 Mar; 70(3): 238–247.
Abstract:
Objectives: Initial evidence suggests that individuals with specific psychiatric conditions may perpetrate intimate partner violence (IPV) at greater frequency than nondiagnosed comparison samples. The present investigation examined the relationship between IPV and specific clinical diagnoses.
Method: The current investigation utilized data provided by 190 (34% female) adult offenders during court-mandated substance use evaluations to investigate the incidence of past-year IPV among samples of dually diagnosed (bipolar, posttraumatic stress disorder [PTSD], and attention deficit-hyperactivity disorder [ADHD]) clients relative to 3 comparison samples matched on substance use and sociodemographic variables.
Results: Bipolar and PTSD diagnosed participants were more likely to perpetrate IPV than matched comparison and ADHD participants. Bipolar and PTSD diagnosed participants were equally likely to perpetrate IPV, as were ADHD and matched comparison samples.
Conclusions: The frequency of IPV perpetration among bipolar and PTSD diagnosed clients may complicate interpersonal and relationship functioning. The development of integrated treatments for IPV and underlying psychopathology is recommended.
Psychiatric disorders prior to dating initiation and physical dating violence before age 21: Findings from the National Comorbidity Survey Replication (NCS-R).
McCauley, Heather L., et.al.
Soc Psychiatry Psychiatr Epidemiol. 2015 Sep; 50(9): 1357–1365.
Abstract:
Purpose: Poor mental health is associated with teen dating violence (TDV), but whether there are specific types of psychiatric disorders that could be targeted with intervention to reduce TDV remains unknown.
Methods: Multivariable logistic regression models were used to assess the associations of psychiatric disorders that emerged prior to dating initiation with subsequent physical dating violence in a nationally representative sample from the National Comorbidity Survey Replication, adjusting statistically for adverse childhood experiences.
Results: In adjusted models, internalizing disorders (AOR 1.14, 95 % CI 1.04,1.25; no sex differences noted) and externalizing disorders (males: AOR 1.28, 95 % CI 1.10, 1.49; females: AOR 1.85, 95 % CI 1.55, 2.21) were associated with subsequent involvement in any physical dating violence victimization or perpetration before the age of 21. Those at greatest risk included girls with ADHD and a substance use disorder, in particular.
Conclusions: The range of psychiatric disorders associated with TDV is broader than has generally been recognized for both boys and girls. Clinical and public health prevention programs should incorporate strategies for addressing multiple pathways through which poor mental health may put adolescents at risk for TDV.
ADHD symptoms as risk factors for intimate partner violence perpetration and victimization.
Wymbs, Brian T., et.al.
Journal of Interpersonal Violence, Vol 32(5), Mar, 2017. pp. 659-681.
Abstract:
Preliminary evidence underscores links between attention-deficit hyperactivity disorder (ADHD) symptoms and intimate partner violence (IPV) perpetration and victimization. However, little is known about whether ADHD symptoms are uniquely associated with IPV perpetration and victimization beyond well-established risk factors of IPV commonly associated with the disorder. In a cross-sectional design, 433 college students rated their ADHD symptoms as well as frequencies of psychological and physical IPV perpetration and victimization. Additional risk factors of IPV included childhood maltreatment, primary psychopathy, alcohol abuse, and illicit drug use. Correlational analyses indicated that students with greater ADHD symptom severity reported higher rates of psychological and physical IPV perpetration, and higher rates of psychological IPV victimization. Regression analyses indicated that ADHD symptoms were not additive risk factors of psychological IPV perpetration and victimization. Students reporting any alcohol abuse or illicit drug use endorsed high rates of psychological IPV perpetration and victimization, regardless of their level of ADHD symptoms. However, students who reported no alcohol abuse or drug use, but did report greater ADHD symptom severity—particularly inattention, indicated higher rates of psychological IPV perpetration and victimization than those reporting no alcohol abuse or drug use and low ADHD symptoms. These findings extend prior research by indicating that alcohol abuse and illicit drug use moderate associations between ADHD symptoms and psychological IPV perpetration and victimization. Investigations are needed to identify mechanisms of the association between ADHD symptoms and IPV perpetration and victimization, particularly those abusing alcohol and drugs, for appropriate prevention and intervention efforts to be developed.
Childhood ADHD potentiates the association between problematic drinking and intimate partner violence.
Wymbs, Brian T., et.al.
Journal of Attention Disorders, Vol 21(12), Oct, 2017. pp. 997-1008.
Abstract:
Objective: Excessive alcohol consumption increases risk of perpetrating intimate partner violence (IPV). ADHD is associated with problematic drinking and IPV, but it is unclear whether problem drinkers with ADHD are more likely than those without ADHD to perpetrate IPV.
Method: We compared the strength of association between problem drinking trajectories and IPV perpetration among 19- to 24-year-old men with (n = 241) and without (n = 180) childhood ADHD.
Results: Men with ADHD who reported higher heavy episodic drinking or alcohol use problems at age 19, and slower decreases in alcohol use problems from age 19 to 24, were more likely to perpetrate IPV than problem drinkers without ADHD, among whom the same associations were non-significant. Associations between problem drinking and IPV were not attenuated in adults with ADHD upon controlling for antisocial personality disorder.
Conclusion: Study findings highlight the heightened risk of problem drinkers with ADHD perpetrating IPV.
The importance of impulsivity and attention switching deficits in perpetrators convicted for intimate partner violence.
Romero‐Martínez, Ángel, et.al.
Aggressive Behavior, Vol 45(2), Mar-Apr, 2019. pp. 129-138.
Abstract:
It has been stated that Attention deficit hyperactivity disorder (ADHD) increases the likelihood of risky behavior such as intimate partner violence (IPV), but the cognitive mechanisms that facilitate or underlie these types of behavior remain unexplained. In this regard, several authors have established that impulsivity and inattentive symptoms might affect basic processes such as emotional decoding and set‐shifting abilities, which are important processes for emotional and behavioral regulation. Hence, these symptoms entail a reduction in sensitivity to key contextual stimuli. Accordingly, the main aim of this study was to examine the involvement of impulsivity (assessed by self‐reports) and attention switching impairments (assessed with the Attention Switching Task; AST), as well as the associations between these cognitive processes in facial emotion decoding (assessed by the eyes test) and cognitive flexibility impairments (measured by the Wisconsin Card Sorting Test, WCST) in a sample of IPV perpetrators (n = 89; mean age = 40) and a control group matched on socio‐demographic characteristics (n = 39; mean age = 41). IPV perpetrators had higher trait impulsivity and greater attention switching costs than controls. Moreover, differences were also found between groups in facial expression decoding and WCST performance, with IPV perpetrators showing lower Eyes Test and WCST scores. Mainly, we observed that the ability to recognize facial expressions was poorer when individuals showed high impulsivity in both groups, but this association was only explained by deficits in attention switching in IPV perpetrators. Our research reinforces the importance of impulsivity and inattentive symptoms as targets for specific cognitive rehabilitation interventions designed to prevent the long‐term IPV risk of recidivism.
Rates of intimate partner violence perpetration and victimization among adults with ADHD.
Wymbs, Brian T., et.al.
Journal of Attention Disorders, Vol 23(9), Jul, 2019. pp. 949-958.
Abstract:
Objective: Research has demonstrated an association between ADHD and intimate partner violence (IPV).However, it is unclear whether adults with ADHD persisting from childhood are especially at risk, and whether ADHD is a unique risk factor beyond well-established predictors of IPV.
Method: Adults with (n = 95) and without childhood histories of ADHD (n = 121) who were recruited from Amazon’s Mechanical Turk reported their levels of IPV perpetration and victimization, and provided data on additional risk factors of IPV (e.g., childhood maltreatment, alcohol abuse).
Results: While controlling for additional risk factors, adults diagnosed with ADHD as children, particularly those with elevated current ADHD symptoms (ADHD-Persist), reported higher rates of IPV perpetration and victimization than adults with ADHD histories but low current symptoms (ADHD-Desist) and adults who were never diagnosed with ADHD (control).
Conclusion: Adults with ADHD histories and elevated current symptoms are most likely to report IPV perpetration and victimization.
Childhood social functioning and young adult intimate partner violence in girls with and without ADHD: Response inhibition as a moderator.
Youn, Cherry, et.al.
Journal of Attention Disorders, Vol 23(12), Oct, 2019. pp. 1486-1496.
Abstract:
Objective: Examine the moderating effects of response inhibition on the longitudinal association between social preference/relational aggression measured in childhood, and intimate partner violence (IPV) measured in young adulthood, among women with (n = 140) and without (n = 88) histories of childhood ADHD.
Method: During childhood, social preference was measured through confidential peer sociometric nominations, yielding negative and positive peer regard; relational aggression was assessed via staff behavioral observations; and response inhibition was assessed using commission errors from the continuous performance task. During young adulthood, IPV was ascertained via a clinician-administered, semistructured interview.
Results: Social preference and relational aggression independently predicted IPV; this prospective link was moderated by response inhibition.
Conclusion: In combination with low social preference or high relational aggression in childhood, poor response inhibition predicted the highest levels of young-adult IPV. Given the developmental significance of peer relationships, additional research on the causes of and treatments for poor social functioning in ADHD is warranted.
Type and severity of intimate partner violence in offenders with and without ADHD.
Buitelaar, Nannet, et.al.
The International Journal of Forensic Mental Health, Vol 19(2), 2020. pp. 142-151.
Abstract:
Intimate partner violence (IPV) offenders were clinically assessed for ADHD, other psychiatric diagnoses, and frequency of different types of IPV. Of the 347 participants (16.4% women), n = 210 (61%) were clinically diagnosed with ADHD. The ADHD group showed a higher frequency of psychological, minor physical and clinician rated IPV, and also higher rates of comorbid anxiety or mood disorder, substance use disorder, and borderline and antisocial personality disorders. Hierarchical multiple regression analyses revealed that ADHD accounted for significant change of variance in frequency of psychological and clinician rated IPV above the effects of age, gender, and comorbid disorders.