Essay: Adopted children diagnosis with ADHD

Evidence suggests adopted children are more likely to be diagnosed with Attention deficit hyperactivity disorder (ADHD) compared to non-adopted children. This difference exists for a number of reasons.
The first concerns the risky sexual behaviour displayed by young adults with ADHD. This risky sexual behaviour may lead to unwanted pregnancies, ending with termination or adoption. Due to the highly heritable nature of the disorder, this leads to adopted children who have inherited their ADHD from their biological parents.
In addition, mothers who have their children adopted may have a host of problems during pregnancy, which leads to the development of ADHD in their children. For example, the ingestion of prenatal teratogens such as alcohol and nicotine, and the heightened maternal stress, have an effect on the development of the disorder.
In addition, there is evidence to suggest psychosocial factors impact the development of ADHD. Children who are placed into adopted families may have histories of abuse or neglect, which then leads to a diagnosis later on in their childhood. In spite of this, we must consider the potential referral biases of adopted children, and the often hypervigilant nature of their adoptive parents, which leads to an overrepresentation of adopted children with ADHD. It is also the case that children are almost always better off having been adopted, rather than being left in often undesirable or harmful situations.
Furthermore, ADHD can be characterised as a long-term disorder with symptoms of either inattention and/or hyperactivity-impulsivity. These symptoms must arise before the age of 12 and must be present for at least 6 months. Inattention symptoms include being easily distracted, forgetfulness, making careless mistakes and an inability to follow instructions. In contrast, hyperactivity includes fidgeting, excessive talking and restlessness, or an inability to sit still. Children with ADHD may also be impulsive, which can result in an inability to wait ones turn and saying things aloud which are inappropriate to the situation. The disorder is diagnosed primarily through parental, teacher and self-report techniques, alongside tasks such as the Wisconsin card sort task and the stroop test. The nature of the diagnosis may produce problems surrounding misdiagnosis, or may lead to a child going undiagnosed altogether.
Subsequently, children who are adopted are more likely to be diagnosed with the ADHD. Banerjee et al (2007) cites 5-10% of children are diagnosed with ADHD. However, Simmel et al (2010) looked at parental reports of 808 adopted children and found 21% of these children met the symptomology for ADHD. This suggests adopted children are much more likely to be diagnosed with the disorder.
The first reason for this concerns the biological parents of adopted children having ADHD themselves, which is inherited by the child. ADHD is highly heritable. For example, Faraone et al (2005), in a meta-analysis of 20 twin studies, found a heritability rate estimated at 76%. Similarly, Nikolas (2011) concluded that both the inattention and hyperactivity characteristics of the disorder, were highly heritable. They found ‘genetic factors accounted for 71% and 73% of the variance’ in the dimensions of inattention and hyperactivity (Nikolas, 2011, p.1). They also concluded that environmental factors in the development of ADHD are moderate at best (Nikolas, 2011).
Evidence to suggest those with ADHD have more teenage pregnancies comes from Ostergaard et al (2017). This historical prospective cohort study looked at 2,698,052 individuals and the association between parenthood and ADHD. The results found those with ADHD were significantly more likely to have a child from the ages 12-16, with an incidence rate ratio (IRR) of 3.62 for females, and 2.3 for males (Ostergaard et al, 2017). Teenagers often terminate their pregnancies or go on to have their children adopted. If teenagers with ADHD are more likely to find themselves pregnant, due to their risky sexual behaviour, this may explain the high number of adopted children going on to be diagnosed.
In addition, mothers who go on to have their child adopted may have a host of other psychological or physical problems during pregnancy. Research looking at the effects of prenatal toxins on the foetus show how compromising the prenatal environment might affect chances of later clinical diagnosis for the child. In relation to the development of ADHD, Mick et al (2002), in a case-control study, found nicotine and alcohol are positively associated with an ADHD diagnosis. Through comparing 280 children with ADHD and 242 without, Mick et al (2002) found a two-fold increased risk for ADHD if the mother smoked at least a pack of cigarettes a day, for at least three months during the pregnancy.
In addition, there was a 2.5 fold increased risk if the mother had drunk alcohol every day or had gone on binges (Mick et al, 2002). In addition, Millberg et al (1997), who looked at maternal smoking during pregnancy (MSDP) and ADHD, found a significant association. Through looking at boys from the ages of 6-17 years, they identified those with ADHD and those without. They found that children with a history of MSDP were 22% more likely to have been diagnosed with ADHD, compared to 8% of those without ADHD (Millberg et al, 1997). This remained the case even after adjusting for parental ADHD. This is considerable evidence for why adopted children are more likely to have a diagnosis. This is because biological mothers of adopted children may be more likely to smoke or drink during pregnancy, or may continue to smoke around the child once they are born.
In addition, people with ADHD are more likely to smoke, and become highly dependent quickly, compared to those without ADHD (Rhodes, 2017). Therefore, if an adopted child’s biological mother has ADHD, and smoked during pregnancy, this combination of genetic influence and prenatal toxins, further increases their risk of developing the disorder.
Further evidence for the positive association between alcohol and ADHD comes from studies looking at foetal alcohol syndrome (FAS). Children born with foetal alcohol syndrome have abnormalities of the brain, and specifically abnormalities to the corpus callosum. Riley et al (1995) found four of the five regions of the corpus callosum are smaller in children exposed to high levels of alcohol prenatally. In addition, Riley et al (1995) cite that this reduction in size of the corpus callosum is also seen in those with ADHD. Symptoms of FAS and ADHD also converge, with Banerjee et al (2007) finding children with FAS are likely ‘hyperactive, disrupted, delinquent or impulsive’ (Banerjee et al, 2007, p. 1270). Mothers who have addictions to alcohol often go on to have their children adopted, which then leads to many adopted children whose early development was compromised. This may then lead to the development of ADHD.
In addition to teratogens, mothers who go on to have their children adopted may experience heightened prenatal stress, compared to those who keep their children. This prenatal stress has been shown to be positively associated with the development of disorders such as ADHD. For example, Mick et al (2002) found a 1.8 fold increased risk of ADHD if the mother suffered from depression during pregnancy. Furthermore, Ronald (2011), in a longitudinal cohort study, found prenatal maternal stress (PNMS) was independently associated with ADHD behaviours in 2 year olds. The process of adoption is psychologically distressing for the biological mother, and this may be further heightened if they do not want to give their child up, but feel they have to in order to provide the child with a better life. Finley (1999) argues ‘potential birthmothers likely are under substantial stress, experiencing intensely conflicting decision making, and perhaps lacking adequate nutrition and prenatal medical care’ (Finley, 1999, p. 363). Evidence suggests all of these factors help to explain the high levels of ADHD in adopted children.
Furthermore, once a child is born, psychosocial adversity, abuse and neglect, can all effect their chances of developing a disorder. Although most adoptive parents aim to adopt children soon after birth, from April 2016 to March 2017, 72% of children waiting to be adopted were over 2 years old (Adoption Match, 2016/17). Some of these children may have been placed into government care due to inadequate or neglectful parenting by their biological parents. Therefore, children adopted at later stages may have histories of trauma, abuse or neglect. Szymanski et al (2011) cite evidence to suggest that children who have been through trauma or have been maltreated develop an inability to regulate their affect, which leads to ‘a particular vulnerability for disruptive behaviours of an ADHD diagnosis’ (Szymanski et al, 2011, p. 54). The child will try to cope with past trauma through efforts not to think about the trauma which leads to ‘high distractibility and forgetfulness’ and ‘hypervigilance, irritability and an exaggerated startle response’ (Szymanski et al, 2011, p. 54). This mirrors the inattention and hyperactivity seen in those with ADHD, making these children more likely to go on to develop the disorder. In addition, ‘feelings of anxiety that characterise PTSD can mirror the impulsivity cluster of ADHD’ (Szymanski et al, 2011, p. 54). However, care must be made during the diagnosis, as there may be a child who is diagnosed with ADHD who is in fact suffering from PTSD, which goes undiagnosed (Szymanski et al, 2011). Further to this, a misdiagnosis may be detrimental to the child, as a missed case of trauma can lead to further psychiatric difficulties in the future (Hanbury, 2017). An ADHD diagnosis will not help the child with the trauma they are experiencing as they will not be receiving the tailored support that is necessary. Therefore, much caution should be taken when diagnosing an adopted child with ADHD, as although the symptoms might suggest the disorder, the child could instead be suffering with PTSD.
However, there is evidence to suggest there is an overrepresentation of adopted children with ADHD. This is not because they are more likely to have the disorder, but they are more readily diagnosed. Haugaard et al (1998) claims adopted children have more clinical diagnoses due to referral biases and the stigma surrounding the process of adoption. Haugaard (1998) argues there is a lower symptom threshold for adopted adolescents, and adoptive parents are more inclined to seek treatment if they notice apparent issues within their child. There is also the stigma that adopted children might carry more risk of having clinical problems, either due to teratogens or malnutrition during pregnancy, or due to the child’s treatment after birth. This then leads to adoptive parents seeking medical advice because of their hypervigilance and anxiety surrounding their child’s wellbeing. Adoptive parents are also more likely to be overly cautious as they have often tried other methods of conception, such as IVF, before deciding to adopt. The process of adoption is stressful and can, and often does, go wrong. Therefore, once the adoption process is over, great importance is placed on the child. This leads to their often over-protective nature. In addition, whilst adoptive parents might see their child’s behaviour as abnormal, some parents may see the behaviour of their children as a phase, or simply may not place much importance on the behaviour.
Although the above evidence suggests adopted children are more likely to be diagnosed with ADHD, alongside a host of other problems, this should not deflect from the benefits of adoption. For example, compelling support for the power of adoption comes from evidence to suggest adopted children, overall, are not hindered by their adopted status. For example, Brand & Brinich (1999) found differences between adopted and non-adopted children at age 11 were insignificant, and the majority of adopted children will not require differential treatment. This was the case once the researchers had removed cases of severe mental difficulties which had caused such a large difference. Once these abnormalities were removed, they found small to insignificant differences between adoptees and non-adoptees. In addition, adoptive families usually have a higher socio-economic status (SES), which means the child will go on to receive better education, leading to more opportunities. Evidence suggests adopted children fare better than those in institutions, foster care, or in disadvantaged single parent families. In the case of a child with ADHD, they may have greater access to behavioural support and medication they may need, if placed in a family with more resources and greater concern. It is also important to consider the circumstances a child may be in if they were left with their biological parents. It is often the case that a child’s situation before adoption is undesirable, whether this be through neglect or abuse. Through the adoption process, a child is less likely to suffer further psychological or physical harm.
In conclusion, there are a number of reasons as to why adoptees are more likely to have an ADHD diagnosis. The first concerns the number of biological parents with ADHD who display risky sexual behaviour in their youth, resulting in the termination or adoption of a child. This parental ADHD is then passed on to the child and presents itself in later childhood. In addition, the prenatal environment of an adoptee is often compromised through teratogens or heightened maternal stress. These factors are positively associated with the development of ADHD. Subsequently, for those adopted later in childhood, these children often have histories of abuse or neglect. Although these factors can later lead to an ADHD diagnosis, extra caution must be taken in misdiagnosing a child with ADHD when they are instead suffering with PTSD. In the same strain, evidence suggests adoptees are more likely to be diagnosed with ADHD, and other disorders, due to the adoptive parent’s hypervigilance. In addition, clinicians may be more likely to diagnose a child with ADHD if they know that this child was adopted, due to the stigma surrounding adoptees and the prevalence of disorders and mental health concerns. This evidence suggests we need to be cautious of the potential for adoptees to develop ADHD, however, we must be sure to not misdiagnose. In addition, adoptive parents must be informed of the potential risks of their child having ADHD, but must not assume their child has the disorder.