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Review Article
care, health and development
doi:10.1111/cch.12168

Diagnosing attention-deficit hyperactivity disorder


(ADHD) in children involved with child protection
services: are current diagnostic guidelines
acceptable for vulnerable populations?
B. Klein,*† G. Damiani-Taraba,‡§ A. Koster,‡ J. Cambpell¶ and C. Scholz‡
*Landsdowne Children’s Centre, Brantford, ON, Canada
†McMaster University, Hamilton, ON, Canada
‡Brant Family and Children’s Services (CAS), Brantford, ON, Canada
§Oxford Children’s Aid (CAS), Oxford, ON, Canada, and
¶University of Western Ontario, London, ON, Canada

Accepted for publication 18 May 2014

Abstract
Children involved with child protection services (CPS) are diagnosed and treated for
attention-deficit hyperactivity disorder (ADHD) at higher rates than the general population.
Children with maltreatment histories are much more likely to have other factors contributing to
behavioural and attentional regulation difficulties that may overlap with or mimic ADHD-like
symptoms, including language and learning problems, post-traumatic stress disorder, attachment
difficulties, mood disorders and anxiety disorders. A higher number of children in the child welfare
Keywords
ADHD diagnosis, child system are diagnosed with ADHD and provided with psychotropic medications under a group care
protection services, setting compared with family-based, foster care and kinship care settings. However, children’s
multidisciplinary
practices, overmedicated
behavioural trajectories change over time while in care. A reassessment in the approach to
ADHD-like symptoms in children exposed to confirmed (or suspected) maltreatment (e.g. neglect,
Correspondence: abuse) is required. Diagnosis should be conducted within a multidisciplinary team and practice
Gissele Damiani-Taraba,
guidelines regarding ADHD diagnostic and management practices for children in CPS care are
Brant Family and
Children’s Services, 70 warranted both in the USA and in Canada. Increased education for caregivers, teachers and child
Chatham St., Brantford, welfare staff on the effects of maltreatment and often perplexing relationship with ADHD-like
ON, Canada N3T 5R7
E-mail:
symptoms and co-morbid disorders is also necessary. Increased partnerships are needed to ensure
gissele.taraba@brantfacs.ca the mental well-being of children with child protection involvement.

interrupting conversations, intruding on personal space, and


Introduction
not following social cues or rules (Kaiser et al. 2011). Untreated
Attention-deficit hyperactivity disorder (ADHD) is character- ADHD is associated with academic underachievement in
ized by impairments in attention, hyperactivity and impulsivity. school, compromised family relationships, increased rates of
It is considered a lifelong, potentially debilitating disorder asso- criminality and accidents; and mental health disorders
ciated with academic problems, social skill difficulties (Harpin (McCarthy et al. 2012). ADHD usually continues to manifest
2005) and substance abuse (Wilens et al. 2011). Children itself into adulthood. Polanczyk and colleagues (2007) found
with ADHD face peer rejection because of difficulties with worldwide-pooled population prevalence of 5.29% for ADHD

© 2014 John Wiley & Sons Ltd 1


2 B. Klein et al.

in a systematic review and metaregression analysis. The US 2007 investigations were conducted across Canada during 2008,
National Survey of Children’s Health estimated based on in which 85 440 maltreatment cases were substantiated. Of
survey data that nationwide 6.4% of children 2–17 had a substantiated cases, ADHD was reported in an estimated 11%
diagnosis of ADHD (http://childhealthdata.org/browse/survey/ (Trocmé et al. 2010). It should be noted that children involved
results?q=724&r=1, accessed 10 November 2012), and 4.2% in unsubstantiated cases are considered to be at high risk for
were diagnosed with ADHD and took medication for ADHD poor psychosocial outcomes as well (Campbell et al. 2012;
(http://childhealthdata.org/browse/survey/results?q=241&r=1, Fallon et al. 2011). Burge (2007) found a 20.7% rate of ADHD
accessed 10 November 2012). According to a longitudinal study among a sample of 429 children 0–18 years old with crown ward
conducted on Ontario’s children (Ontario Child Health Study), status in Ontario, Canada. Similarly, the Ontario Looking After
the prevalence of ADHD ranges between 3% and 9% (Szatmari Children Survey (ONLAC); a CPS survey of the health and
et al. 1989). Despite the vast research being conducted on development of children in care; found caregiver reported rates
ADHD in the general population, relatively little is known of ADHD of 27% for children 5–9 years, 39% for 10–15 years of
about ADHD in children involved with child protection age and 29% for children 16 and over (Miller & Flynn 2011).
services (CPS). More importantly, there also seems to be a lack These findings are supported by the modelling work conducted
of understanding about whether current diagnostic guidelines on the MedicAid data of children in foster care by Rubin et al.,
and interventions are acceptable for this population. Thus a which found that from 2005 to 2007, ADHD was the most
preliminary literature view was conducted in order to examine common diagnoses among 3- to 11-year-olds and had the
the rates of ADHD in children with CPS involvement and largest absolute increase compared with other diagnoses over
the adequacy of current diagnostic guidelines for this vulner- the study period (Rubin et al. 2012). Furthermore a review of
able group. health insurance expenditures from one Southern Ontario child
welfare agency suggests that ADHD medications (e.g. Strattera,
Concerta) were the treatments most commonly dispensed
Methodology
to children in care. Fifty-one per cent of health care expen-
The authors conducted an extensive literature review using ditures for children in care were for pharmacotherapy
PUBMED, Psychinfo, EBSCO, ERIC and Google Scholar to (Monreau-Shepell 2011). Clearly, an examination of diagnostic
find peer reviewed articles using the following keywords: issues is needed to understand incidence of ADHD and medi-
ADHD and children in (foster) care, ADHD and children in cation usage in CPS involved children.
CPS, psychotropic medication and children in care, inatten-
tion and children in (foster) care, hyperactivity and children in
Diagnosis of ADHD in maltreated children
(foster) care. Searchers were repeated to include children
‘looked after’ to include international articles. The Cochrane The diagnosis of ADHD is subjective and the nature of impair-
and Campbell collaboration searches did not yield any ment criteria are context-bound (Hjern et al. 2010). The diag-
articles although this was not searched in depth. When these nosis itself is descriptive and does not imply causal factors.
searches did not yield a high number of articles, the search There is no proven pathological mechanism but rather the diag-
was increased to examine articles on behaviours of children in nosis is based on clinical assessment with added rigour from
care, and the mental health of children in care. Inclusion standardized questionnaires that are prone to subjectivity. Dif-
criteria included only articles that discussed attention/ ficulties with behavioural regulation may be multifactorial, and
hyperactivity or co-morbid factors and being involved with in practice it can difficult to parse out relative effects of
CPS. The authors also include a review of grey literature which ‘primary’ ADHD from anxiety, language difficulties, tempera-
included reports from the USA and Canada, and internal mental differences, learning disabilities, etc.
Ontario-based child welfare reports. Even more nebulous in the evaluation of ADHD-like symp-
toms are possible contributions of early experiences, particu-
larly parenting differences. In a population-based study using
Rates of ADHD in children involved with child
data from the National Longitudinal Survey of Children and
protection (CPS)
Youth, Romano and colleagues (2006) found high and persis-
Children with CPS involvement are known to have high rates of tent hyperactivity was predicted by maternal prenatal smoking,
ADHD diagnosis and medication usage compared with the child male gender, maternal depression and hostile parenting.
general population. An estimated 235 842 maltreatment-related ADHD, parenting and social developmental difficulties indeed

© 2014 John Wiley & Sons Ltd, Child: care, health and development
ADHD and child protection 3

share a complex relationship. Parenting and ADHD severity occupational impairment in multiple settings. They also
have been found to be independently associated with child suggest assessment of coexisting conditions and assessment
social skill and aggressive behaviour, with parenting as a pos- of environmental factors such as the parents/foster parents’
sible mediator between ADHD severity and child outcomes mental health. For preschool and school age children, the first
(Kaiser et al. 2011). In a Swedish population-based study by line of management is psychosocial intervention for families
Caspi et al. education, lone parenthood and reception of social and children; pharmacotherapy is indicated if ADHD is
welfare are associated with medicated ADHD (Caspi et al. considered ‘severe’. Pharmacotherapy is always part of a
2002). comprehensive treatment plan which includes psychological,
According to the 2010 Canadian ADHD Practice Guidelines education and behavioural interventions for parents and
(CADDRA 2010) the diagnosis of ADHD is usually conducted teachers.
by a paediatrician or a family physician (GP) although referrals Perhaps the most problematic aspect in diagnosing ADHD in
usually come from a variety of sources such as teachers, parents children who have experienced maltreatment is the overlapping
or family members. Once ADHD is diagnosed, the first line of nature of symptoms experienced such as aggression, external-
treatment is pharmacotherapy while psychoeducational inter- izing behaviours and school difficulties (Briscoe-Smith &
ventions are encouraged, but not required. The CADDRA Hinshaw 2006; Alavi & Calleja 2012). Both ADHD and conse-
guidelines are for ‘uncomplicated’ ADHD, ‘ADHD subtypes quences of abuse are strongly linked to issues of self-regulation
and associated co-morbid disorders change over time and by (Pears et al. 2010). Canadian ADHD Practice Guidelines
developmental age’ (CADDRA 2010) and therefore require (CADDRA 2010) reported that as many as 33% of children with
more tailored approaches. In the USA, the American Academy ADHD have co-morbid anxiety. Post-traumatic stress disorder
of Pediatrics Guidelines (American Academy of Pediatrics (PTSD) may be difficult to distinguish from ADHD as symp-
2001) suggest multidisciplinary approaches to diagnosis and toms for both include physiological reactivity to external cues,
treatment decisions for ADHD. The guidelines suggest that a increased arousal, difficulty concentrating, hypervigilance and
team comprised of psychologists, psychiatrists, neurologists irritability and anger (Weinstein et al. 2000). Similarly, the
and other specialists along with the patients make decisions disinhibited subtype of Reactive Attachment Disorder consists
about the likelihood of an ADHD diagnosis. These guidelines, of social impulsivity and intrusiveness, indiscriminate overtures
like the CADDRA, are only intended for ADHD without major towards unfamiliar adults, lack of checking in with a caregiver
coexisting conditions. The concern of appropriateness of the before acting, including asking overly personal questions, vio-
ADHD guidelines for maltreated children has been noted in lating personal space and excessive physical contact (Zeanah
the literature (Weinstein et al. 2000; Briscoe-Smith & Hinshaw et al. 2011). Thus, it is imperative to further examine co-morbid
2006). conditions associated with maltreatment in order to understand
European guidelines for diagnosis and management of the possible contributing factors of ADHD-like symptoms in
ADHD further address issues with more complex children. CPS involved children.
According to the NHS-NICE Clinical guidelines [National
Institute for Health and Clinical Excellence (NHS) 2008],
because ADHD symptoms can overlap with other disorders,
Co-morbidities and contributing factors
it cannot be considered a categorical diagnosis. The NHS
suggests in order for ADHD to be diagnosed in a child, the Particularly concerning for the CPS involved child are the
impairment ‘should be present in multiple settings (home, multiple potential causes of behavioural and social functioning
school, foster care, etc.), in multiple domains’ (p. 5) and after deficits in addition to ‘primary’ ADHD. The Canadian Inci-
a period of watchful waiting (up to 10 weeks). Diagnosis is not dence Study of Reported Abuse and Neglect-2008 (Trocmé et al.
done by a GP or paediatrician, rather by a multidisciplinary 2010) found that 46% of children with exposure to sub-
team of clinicians (mental health experts, paediatricians, social stantiated maltreatment had developmental or behavioural
workers, educators). The team also includes the family (both problems. Maltreatment itself is a risk factor for emotional-
foster and biological family) and the child. For a diagnosis to behavioural disorders, language problems, cognitive deficits,
occur, the child has to meet both the Fourth Edition of the anxiety and disruptive behaviour disorders (Dozier & Peloso
Diagnostic and Statistical Manual of Mental Disorders (DSM- 2006; Pears et al. 2008; Stirling & Amaya-Jackson 2008; Mills
IV) and the International Classification of Diseases-10 (ICD- et al. 2011). Physical abuse, for example, has been linked to
10) and have at least moderate psychological, social and externalizing behaviours (Briscoe-Smith & Hinshaw 2006)

© 2014 John Wiley & Sons Ltd, Child: care, health and development
4 B. Klein et al.

while childhood sexual abuse has been more directly linked to ADHD-focused medication and behavioural strategies if
post traumatic stress disorder and internalizing behaviours other factors are not adequately addressed. A review of the
(Whiffen & MacIntosh 2005). treatment of problems associated with ADHD and maltreat-
Parents of CPS involved children have disproportionately ment is beyond the scope of this article. There exists ample
high rates of cognitive problems (McConnell et al. 2011), which evidence-based literature on the management of noted possible
may result in increased genetic predisposition to cognitive contributors to ADHD-like symptoms, including anxiety
behavioural problems, the effects of vulnerable parenting (Peters & Connolly 2012; Reynolds et al. 2012), mood (Clark
(Bayer et al. 2011) and the negative interaction of challenging et al. 2012), academic (Snowling & Hulme 2011) and disruptive
children with challenged parents (i.e. transactional model) behavioural (Eyberg et al. 2008; Peters 2008) problems.
(Sameroff 2009). In other words, ‘primary’ ADHD may often Effective treatment requires identification of specific problem
share a complex picture with effects of maltreatment, vulner- areas. ADHD-like symptoms in children with histories of abuse
able parenting and predisposition to other cognitive and mental should prompt broad evaluation of child functioning domains,
health problems, all of which may play a role in the final including language skills, variation in temperament, cognitive
common pathway of the child who has difficulty heeding adult and academic skills, social skills; and anxiety and mood symp-
direction and interacting pro-socially with peers. Practically, the toms. For example, a simple targeted intervention, such as con-
complex myriad of risk factor and potential contributors to sistently adjusting the language level of instruction for a
behavioural dysfunction frequently belies productive diagnostic language-delayed child may enhance the child’s overall behav-
labelling. ioural functioning substantially. As well, careful scrutiny of the
Linares and colleagues (2010) furthermore suggests that the proximal and distal environment is required to identify prob-
ADHD exhibited by children in foster care placement might lematic interactions with the child. For example, poorness of fit
reflect transitory difficulties in life. They followed 252 children between the child’s temperament and parent or teacher, or
who entered foster care prospectively, in order to assess their inadequacy of identification of exceptionalities and support in
child’s baseline and pre-discharge inattention and hyperactivity the school environment may increase the emotional stress
levels. They administered 4-yearly assessments for each child burden on an already vulnerable child, and contribute to emo-
and acquired information on the child’s behaviour from multi- tional behavioural decompensation that may mimic ADHD
ple sources. Their primary findings were that, after controlling symptoms. However, examination of the literature indicates
confounders, the level of the child’s inattention and hyperactiv- that current diagnostic guidelines are inadequate for children
ity tended to decrease over time. Both biological and resource with complex histories such as maltreatment, and that manage-
families tended to report lower rates of hyperactivity and inat- ment focuses primarily on psychotropic medication adminis-
tention even after controlling for medication. These findings tration instead of focusing on a more holistic approach to
were not supported by teachers’ ratings, which did not change ADHD management.
over time. Based on their results, Linares and colleagues (2010)
suggested that the behavioural symptoms exhibited by children
Psychotropic utilization among children in care
in care may be temporary and may improve over time on their
own as the child adjusts to being in care. They also found that According to Raghavan and colleagues (2005), 13.5% of chil-
the higher average rating of inattention and hyperactivity dren in care are using psychotropic medications which is two to
among foster parents was associated with decreased parental three times the rate of children in the community. Zito and
warmth and increased parental hostility towards the child. Man- colleagues (2008) also reported that the rate of psychotropic use
agement of ADHD symptoms among children involved with among youth in care was 3–11 times higher than the general
CPS should take into consideration these findings. population. Zito and colleagues (2008) also found that approxi-
mately 41% of children in foster care were using 3 or more
classes of psychotropic medications at the same time (also
Management of ADHD or ADHD-like symptoms in
known as polypharmacy). ADHD had the highest rate of diag-
maltreated children
nosis among these youth (38%) followed by depression (35%)
As we have seen, children in care frequently have a complex (Zito et al. 2008). Concerns over the mental health of children
mixture of contributing factors and co-morbidities comp- in foster care led the US Department of Health to review medi-
licating the overall picture of ‘ADHD-like symptoms’. Symp- cation administration and adherence in this population. In
toms and functional impairments may persist despite April 2012, the ACF (Administration for Children in Families)

© 2014 John Wiley & Sons Ltd, Child: care, health and development
ADHD and child protection 5

90.00%
80.00%
70.00%
60.00%
50.00%
40.00%
30.00%
20.00%
10.00%
0.00%
no yes no yes no yes
5-9 years 10-15 years 16 plus

Society FH OPR FH Society GH OPR GH Kinship Customary C

Figure 1. Percentage of children reported to be on psychotropics by age and placement type. Please note that kinship, group home and customary care
placements represent a significantly smaller number of placements compared with foster home placements. FH, foster home; OPR, Outside Paid
Resource; GH, group home; CC, Customary Care.

authored a report on the oversight of psychotropic medications ment itself exacerbates mental health symptoms, or that
for children in foster care. In this report, they outline how a physicians have a propensity to treat these children more readily
large proportion of children in foster care in the USA are being with medication because of their placement situation.
provided with too many psychotropic medications with little or In sum, the rates of ADHD diagnosis and treatment for chil-
no oversight by their respective states. The finding that children dren in CPS care are consistently reported as much higher than
in care are being provided with medications (stimulants) at the general population. The concern that follows is of possible
higher rates than the general population appears to be wide- inappropriate use of ADHD medications for emotional and
spread (ACF-Administration for Children and Families 2012). behavioural problems that are not well explained by the diag-
Certain subgroups of CPS involved children have also nosis of ADHD (Samuels 2012), even though there is overlap in
been associated with higher psychotropic medication use. For symptomatology. What is different about ‘ADHD’ or ‘ADHD-
example, children in restrictive placement setting such as group like symptoms’ in the CPS involved population compared with
homes were more likely to receive psychotropic medications the general population to account for this difference? The likely
than those who resided in foster family homes (p. 3, ACF 2012). answer is that there are other contributing factors lurking below
In Ontario, Canada, data from the ONLAC (2011) database the surface such as attachment difficulties, temperamental vari-
revealed that children living in group homes had the highest ations, language deficits, and anxiety and mood symptoms mas-
percentage of children who were reported to be taking psycho- querading as ‘ADHD-like symptoms’ in addition to ‘primary’
tropic medications (69–72% for children 5–15 years of age) ADHD. Furthermore, a general lack of access to psychosocial
whereas this rate decreased to (29–54%) in foster homes and treatment measures and the capacity to implement them by
dropped even further for children residing in kinship homes parents and teachers is the experience of those who work with
(25%–29% for the same age range). According this report, these these children.
differences were statistically significant at a P < 0.01 level (X2 =
45.483, P = 0.00 for 5- to 9-year-olds; X2 = 707.03, P = 0.00 for
Policy implications
10- to 15-year-olds) (see Fig. 1). Similar findings are reported in
the USA (Zito et al. 2008). The development of policies and appropriate guidelines for
The reason for high medication rates in more restrictive settings diagnosing ADHD is imperative for this population. ADHD
is not clear. According to the ACF,‘medications are being overused diagnostic guidelines that currently exist for the general popu-
to manage emotional problems and disruptive behaviours that lation in the UK have relevance for children who have experi-
might be better addressed by non-pharmacological approaches’ enced maltreatment (e.g. emphasis on the use multidisciplinary
(p. 11, ACF 2012). While it is possible that the children with teams and on the role of environmental factors).
greatest psychiatric morbidity find themselves in the most restric- Children with ADHD-like symptoms and maltreatment his-
tive environment, it is also possible that the group home environ- tories require individualized care. A longitudinal study by

© 2014 John Wiley & Sons Ltd, Child: care, health and development
6 B. Klein et al.

Proctor (Proctor et al. 2010) illustrates that the behavioural by Pelham et al., the estimated cost of illness (COI) for
trajectories of children in care are heterogeneous and therefore ADHD could be between $12 000 to $17 000 US dollars
also calls for tailored approaches. Proctor et al. followed 279 per individual (Pelham et al. 2007; Marks et al. 2009) which
children who had entered child welfare at around 3 years of age translates to billions of dollars spent in treating lifetime
and measured their behaviour at ages 6, 8, 10, 12 and 14 years ADHD.
of age. Positive trajectories for children were associated with
child’s early cognitive ability, social competence, long-term car-
egiver stability, and low frequency of physical abuse in middle
Conclusion
school and adolescence. Proctor also found that some children
with initially positive trajectories worsened while others A review of the literature of ADHD among maltreated chil-
improved or stayed the same. dren revealed that children involved with CPS are diagnosed
Comprehensive baseline assessments of the child’s mental and treated for ADHD at higher rates than the general popu-
health, cognitive capabilities and academic functioning are lation. Although this review was not a systematic review nor
required as soon as they are admitted into care. Monitoring of did it include research from non-English countries, and might
mental health status and functional abilities should occur have excluded some other relevant search engines, results
throughout their experience in care including follow-up meas- suggest that current diagnostic guidelines and treatment
urements 6 months after they exit care. options are not appropriate for children involved with CPS.
In addition to the increased emphasis on emotional- This is due to the fact that is overwhelmingly likely that
behavioural skills, decreased reliance on pharmacotherapy may mechanisms associated with maltreatment contribute to
be beneficial for children who might age out of care and who ADHD-like symptoms in many CPS involved children. Chil-
will be unable to afford to pay for the many medications paid dren with such histories are much more likely to have other
through child welfare coffers. factors contributing to behavioural and attentional regulation
Educating teachers, foster parents and other stakeholders difficulties that may overlap with or mimic ADHD-like symp-
about the mental health needs of children in the child welfare toms, including language and learning problems, PTSD,
system especially regarding emotional regulation, is essential as attachment difficulties, mood disorders and anxiety disorders.
they are inadequately equipped to recognize symptoms of These entities have distinct therapeutic implications, and harm
trauma thus leading to misinterpretation of emotional behav- may be done if the child is misdiagnosed, including prolonged
ioural symptoms as volitional (Peters 2008). exposure to unhelpful medications, stigmatization, a feeling of
Increased partnerships between child welfare agencies, being misunderstood and opportunity cost in treating other
mental health organizations and schools will increase the like- problems. A reassessment in the approach to ADHD-like
lihood that children receive optimal treatment. In North Caro- symptoms in children exposed to confirmed (or suspected)
lina, a collaborative community protocol was developed by maltreatment (e.g. neglect, abuse) is required. The presence
health care providers, educators and child advocates regard- of clinically relevant ADHD-like symptoms in CPS involved
ing the assessment and treatment of children with symptoms child should signal the need for comprehensive assessment,
of ADHD. Multidisciplinary collaboration also creates efficien- including mental health, cognitive and academic evaluations,
cies in collection of data and increases the quality of commu- because functional problems one or more or these domains
nication among different service providers (Foy & Earls 2005). are likely to be contributing to presenting clinical picture.
In Canada, a Southern Ontario child welfare agency has Furthermore, the clinician responsible for making the diagno-
formed an alliance with a local pharmacy to assist them sis (e.g. paediatrician, psychiatrist) requires at the least a
in monitoring medication administration for children in their rudimentary team including educational, developmental and
care, some of whom were found to be over medicated under a mental health expertise, virtual if necessary, in order to for-
group home care setting. This partnership has led to an mulate individual plans of care for these vulnerable children.
improvement in administration and adherence of treatment Appropriate practice guidelines regarding ADHD diagnostic
protocols. Partnerships with community agencies will play a and management practices for children in CPS care are war-
key role in ensuring the safety and mental well-being of all ranted both in the USA and in Canada. Increased education
children in care. for caregivers, teachers and child welfare staff on the effects of
It is also important to highlight the economic impact of maltreatment and often perplexing relationship with ADHD-
ADHD on our society. Based on a literature review conducted like symptoms and co-morbid disorders is also necessary.

© 2014 John Wiley & Sons Ltd, Child: care, health and development
ADHD and child protection 7

Caspi, A., McClay, J., Moffitt, T. E., Mill, J., Martin, J., Craig, I. W.,
Key messages Taylor, A. & Poulton, R. (2002) Role of genotype in the cycle of
violence in maltreated children. Science, 297, 851–854. doi:
• Children involved with CPS are diagnosed and treated for 10.1126/science.1072290.
ADHD at higher rates than the general population. Clark, M. S., Jansen, K. L. & Cloy, J. A. (2012) Treatment of
childhood and adolescent depression. American Family Physician,
• Children involved with CPS are provided with psycho-
86, 442–448.
tropic medications at higher rates than general population
Dozier, M. & Peloso, E. (2006) The role of early stressors in child
• There are higher rates of children diagnosed with ADHD health and mental health outcomes. Archives of Pediatrics and
in group home settings when compared with family-based Adolescent Medicine, 160, 1300–1301. doi: 160/12/1300 [pii]
foster care and kinship care 10.1001/archpedi.160.12.1300.
• Children with maltreatment histories are much more Eyberg, S. M., Nelson, M. M. & Boggs, S. R. (2008) Evidence-based
likely to have other factors contributing to behavioural and psychosocial treatments for children and adolescents with
attentional regulation difficulties that may overlap with or disruptive behavior. Journal of Clinical Child and Adolescent
Psychology, 37, 215–237. doi: 792194652 [pii] 10.1080/
mimic ADHD-like symptoms, including language and
15374410701820117.
learning problems, PTSD, attachment difficulties, mood
Fallon, B., Trocme, N. & MacLaurin, B. (2011) Should child
disorders and anxiety disorders. protection services respond differently to maltreatment, risk of
• Diagnosis should be conducted within a multidisciplinary maltreatment, and risk of harm? Child Abuse and Neglect, 35,
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Harpin, V. A. (2005) The effect of ADHD on the life of an individual,
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