Examining Food Insecurity in Relation to ADHD and Cognitive Disengagement Syndrome Symptoms in Early Adolescents

Abstract

Approximately 13.8 million U.S. households face food insecurity, which severely affects child development, with more than half of these households including children. Research links food insecurity to cognitive deficits and mental health challenges, highlighting the need for thorough understanding and intervention. Although existing studies have explored the association between food insecurity and internalizing symptomatology, less research has examined food insecurity in relation to attention-deficit/hyperactivity disorder (ADHD) symptoms. Further, no studies have explored the connection between food insecurity and cognitive disengagement syndrome (CDS) symptoms, closely related to ADHD symptoms. Despite extant research linking CDS to environmental factors, empirical attention to its potential association with food insecurity is notably lacking. Additionally, adolescents, almost twice as likely as younger children to experience household food insecurity, are likely more aware and respond differently to challenges during this developmental period. Accordingly, this study investigated the unique associations of ADHD dimensions and CDS symptoms related to food insecurity in early adolescents (N = 136, ages 10-12). Controlling for age, sex, race, and medication use, no informant’s ratings of ADHD symptom dimensions were uniquely related to food insecurity. In contrast, higher parent-, teacher-, and youth self-reported CDS symptoms were uniquely associated with greater food insecurity. This finding was robust to additional control of family income for teacher- and youth self-reported CDS symptoms. These findings highlight the complex link between food insecurity and mental health, suggest a connection with CDS symptoms, and stress the need to address food insecurity as a public health priority, especially in early adolescence.

Food insecurity, characterized by disrupted eating patterns or a decrease in dietary quality due to the inability to access sufficient and nutritious food, represents an enduring challenge within the United States (Nord et al., 2005). Recent statistics indicate that an estimated 13.8 million households in the United States grapple with food insecurity, and alarmingly, more than half of these households include children (Coleman-Jensen et al., 2019). An extensive body of research has established a compelling link between food insecurity and a range of adverse consequences for children and adolescents, including cognitive deficits, hindered growth, and development, as well as increased rates of depression, suicidal ideation, and other indicators of poor mental health (Shankar et al., 2017). Given the widespread prevalence of food insecurity among children and its potential to profoundly impact children’s development, investigating and addressing food insecurity stands as an essential public health priority.

Although numerous studies connect youth food insecurity with increased levels of internalizing symptomatology (see Arenas et al., 2019), relatively fewer studies have examined other mental health domains, including developmental and behavioral conditions. Attention-deficit/hyperactivity disorder (ADHD) is one of the most prevalent psychiatric diagnoses in children and adolescents, often persisting into adulthood (Sonuga-Barke et al., 2023). It is a complex, multifactorial condition with the primary symptoms including age-inappropriate levels of inattention, impulsivity, and hyperactivity (Sonuga-Barke et al., 2023). Diet and nutrition have been suggested to play a role in the pathophysiology and management of ADHD, or perhaps for a subset of youth with ADHD (Nigg et al., 2012), with emerging evidence highlighting their importance in brain development and functioning (Lange et al., 2023). Consequently, there is an emerging body of research exploring the link between food insecurity and ADHD. To date, some large-scale epidemiological, observational, and intervention studies have examined the connection between food insecurity and dimensional ADHD symptoms, both cross-sectionally and longitudinally. In the sole study with children formally diagnosed with ADHD (N = 124; ages 6-12 years), household food insecurity was found to be associated with greater symptoms of ADHD, oppositional defiant disorder (ODD), and disruptive mood dysregulation disorder (DMDD), as well as emotional symptoms and conduct problems (Hatsu et al., 2022). After adjusting for sex, parent marital status, income, and parent psychopathology, food insecurity was associated with more severe emotional symptoms, conduct problems, and total behavioral and emotional difficulties but was no longer significantly associated with ADHD symptoms. In a study conducted with a sample of 2,870 three-year-old children living in the United States, the severity of food insecurity was significantly related to higher hyperactivity and inattention (Whitaker et al., 2006). Additionally, another large study (N = 8,600) found that food insecure adolescents had higher parent-reported hyperactivity scores than adolescents who were food secure (Poole-Di Salvo et al., 2016).

Studies have also shown that food insecurity has a longitudinal impact on ADHD symptoms, with parents of children ages 4-14 years (N = 2,810) experiencing a persistent state of food insecurity reporting a two-times increased likelihood of their children exhibiting hyperactivity and/or non-compliant behaviors approximately two years later, on average (Slopen et al., 2010). Finally, in a large sample of Canadian children aged 1.5-8 years old (N = 2,120), food insecurity predicted a two-fold increased likelihood of persistent hyperactivity and inattention over the course of seven years, even after controlling for other child and family characteristics (Melchior et al., 2012). Despite some indication that food insecurity may be associated with ADHD symptom severity, the findings are inconsistent, and the small literature has limitations, including primarily focusing on early childhood and relying solely on parent-reported ADHD symptoms and difficulties, underscoring the importance of additional studies examining food insecurity and ADHD.

Cognitive disengagement syndrome (CDS; previously termed sluggish cognitive tempo) is characterized by hypoactivity, mental confusion, and excessive daydreaming (Becker, Willcutt et al., 2023). Prior investigations have established that these behaviors are strongly related to but empirically distinct from ADHD symptoms, including ADHD inattentive (IN) symptoms (Becker, Leopold, et al., 2016). Elevated CDS symptoms are prevalent in approximately 25-40% of youth with ADHD (Barkley, 2013; Burns et al., 2024; Servera et al., 2018). Although initially assumed to lie entirely within the realm of disruptive behavior and attention disorders, there is growing indication that CDS may also be understood under the internalizing spectra of psychopathology (Becker & Willcutt, 2019), with a strong association with internalizing problems such as anxiety, depression, and suicidality (Becker et al., 2023; Kaçmaz et al., 2024). Numerous studies have demonstrated CDS to be linked with an increased risk of internalizing symptoms even after controlling for ADHD (Becker, Burns, et al., 2020; Garner et al., 2013; Smith et al., 2019). Furthermore, although ADHD-IN symptoms are associated with greater externalizing symptoms, findings often indicate CDS is not significantly associated, or is negatively associated, with externalizing behaviors after controlling for ADHD-IN (Becker et al., 2018; Bernad et al., 2014; Lee et al., 2014).

As research on CDS has advanced, there is a clear need for additional studies to examine possible underlying causes and associations of CDS (Becker et al., 2023). Of note, CDS symptoms may be less heritable than ADHD symptoms, with CDS symptoms showing moderate heritability and larger non-shared environmental influences (Moruzzi et al., 2014; Willcutt, 2020). However, remarkably few studies have examined environmental factors that may be related to CDS symptoms (for a recent review, see Fredrick et al., 2023). Extant research has found various prenatal and early childhood factors, such as prenatal exposure to alcohol (Graham et al., 2013), maternal smoking (Camprodon-Rosanas et al., 2017), and greater iron deficiency during infancy (East et al., 2023), to be associated with higher CDS symptoms in children and adolescents. Additionally, studies examining psychosocial factors in relation to CDS have demonstrated that CDS is associated with lower income (Becker, 2014; Dvorsky et al., 2021), adverse family environments (Fredrick et al., 2019), and exposure to interpersonal trauma (Musicaro et al., 2020), though these findings were based on relatively small, cross-sectional studies. Considering these associations and the suggested, though far from definitive link between food insecurity and inattentive symptoms, it is plausible that food insecurity may also be connected to CDS, a relationship that remains empirically unexamined.

In additional support of this possibility, children with elevated CDS symptoms are described by themselves and their parents as daydreamers and often engage in imaginative activities and have been said to mentally reside in their own worlds (Becker et al., 2022). In a qualitative study exploring the psychological distress of food insecurity from the perspectives of 60 children, a 7-year-old mentioned coping with food insecurity by relying on an imaginary friend to feel better when hungry (Leung et al., 2020), even going as far as “eating” imaginary food to satisfy their hunger. Combining these observations, it may be that when youth experience food insecurity, the nature of their imagination may lean more towards food-related themes, potentially contributing to and/or exacerbating CDS symptoms.

Current Study

The aim of the current research was to examine the ADHD dimensions and CDS symptoms in relation to food insecurity among young adolescents. Numerous uncertainties persist regarding the connection between these disorders and early life experiences, as well as discrepancies across studies. This knowledge gap leaves individuals, healthcare providers, and policymakers with incomplete or inaccurate information about the potential risks and opportunities for early intervention in children's behavioral health and neurodevelopment (Becker et al., 2023; Sonuga-Barke et al., 2023). Although existing literature has primarily focused on food insecurity and ADHD symptoms in young children (Hatsu et al., 2022; Melchior et al., 2012; Whitaker et al., 2006), our study explores this association in early adolescents (through their caregiver’s perspective of household food insecurity), recognizing the potentially distinct experiences of food insecurity within this age group. Adolescents are more actively involved in household activities and may exhibit heightened awareness of food insecurity (Dush, 2020). Additionally, adolescents are almost twice as likely as younger children to experience household food insecurity (Moffitt & Ribar, 2016). Further, this is the first study to our knowledge that examines the relation between multi-informant (parent, teacher, and self-report) ratings of ADHD dimensions and CDS symptoms in relation to caregiver-reported household food insecurity. Building on prior research that has identified a link between food insecurity and ADHD symptoms, we hypothesized that higher ADHD and CDS symptoms would be associated with greater food insecurity.

Methods

Participants

Participants were 136 early adolescents (ages 10-12 years). Characteristics of the adolescent participants and their caregiver/family are summarized in Table 1. There were approximately an equal number of female and male adolescents. Approximately half of the sample met diagnostic criteria for ADHD based on the K-SADS conducted with the adolescent’s caregiver (primarily biological mothers).

Table 1.

Sample Characteristics (N = 136)

Adolescent Characteristics
	M ± SD
Age	10.82 ± 0.80
	n (%)
Sex
Female	70 (51.5)
Male	66 (48.5)
Race
American Indian/Alaskan	0 (0.0)
Asian	4 (2.9)
Black	30 (22.1)
Multiracial	23 (16.9)
White	79 (58.1)
Hispanic/Latinx	16 (11.8)
Psychiatric diagnosesa
ADHD - PR	70 (51.1)
Any externalizing (ODD)a - PR	8 (5.9)
Any anxiety - PR	22 (16.2)
Any anxiety - SR	19 (14.0)
Any depression - PR	2 (1.5)
Any depression - SR	2 (1.5)
Psychiatric medication use	37 (27.2)
Caregiver/Family Characteristics
	n (%)
Relationship to Child
Biological Mother	114 (85.9)
Biological Father	8 (7.6)
Stepmother	1 (0.6)
Adoptive Mother	9 (4.1)
Adoptive Father	1 (0.3)
Foster Mother	1 (0.3)
Grandmother	2 (0.9)
Household Incomeb
Under $20,000	8 (6.1)
20,001-40,000	15 (11.4)
40,001-60,000	15 (11.4)
60,001-80,000	20 (15.2)
80,001-100,000	12 (9.1)
100,001-120,000	11 (8.3)
Over $120,000	51 (38.6)
Highest Primary Caregiver Educationc
High school degree or less	12 (8.9)
Partial college	25 (18.5)
College graduate	56 (41.5)
Graduate/professional degree	42 (31.1)

Note. ADHD = attention-deficit/hyperactivity disorder. ODD = oppositional defiant disorder. Anxiety disorders = presence of generalized anxiety disorder, social phobia, panic disorder, and/or posttraumatic stress disorder (PTSD). Any depression = presence of major depression or dysthymia PR = parent-report. SR = adolescent self-report.

^aCurrent psychiatric diagnoses were assessed using the Kiddie Schedule for Affective Disorders and Schizophrenia for School-Age Children (K-SADS). Only caregivers were administered the ODD and PTSD modules. No participants met criteria for conduct disorder.

^bFour caregivers did not provide family income.

^cOne caregiver did not provide education.

In addition to being ages 10-12 years, inclusion criteria included a standardized score ≥ 80 on the Peabody Picture Vocabulary Test, 5^th Edition (Dunn & Dunn, 2019) used as a proxy for IQ, willingness to discontinue any stimulant medications for ADHD 24 hours prior to the research visit, and sufficient English language ability to complete the measures. In addition, children were excluded if the caregiver reported a previous diagnosis of autism spectrum disorder, bipolar disorder, or psychosis, or a significant visual, hearing or speech impairment precluding their ability to complete the measures.

Procedures

All procedures were approved by the Cincinnati Children’s Hospital Medical Center Institutional Review Board. Participants were recruited from a variety of sources, including media advertisements (e.g., television, Facebook, Instagram, Nextdoor), community flyers, and e-mail distribution within a Midwestern children’s hospital. To assure a range of CDS symptomatology, several versions of advertising materials were generated (e.g., some specifying daydreaming, mental confusion, and slowed behavior/thinking, and some not targeting any attentional problems).

Interested caregivers completed a brief REDCap© survey that included initial inclusion criteria (e.g., child’s age). Families meeting initial inclusion criteria were scheduled for an in-person research visit. After caregivers and adolescents provided informed consent and assent, respectively, study measures were collected. Caregivers also completed a consent to release to gather teacher ratings. Participants taking stimulant medication for ADHD were instructed to withhold medication on the day of their research visit.

The food insecurity measure was not initially included in the study battery and was added after data collection had already begun. Consequently, food insecurity data were collected from 136 of the 341 caregivers enrolled in the broader study (see Becker et al., 2024 for additional details). Participants with and without food insecurity data did not significantly differ in family income, child age, child sex, child race, child ethnicity, or parent-, teacher-, or adolescent-reported ADHD-IN, ADHD-HI, or CDS scores (all ps > .05). Teacher ratings were obtained for 120 of the 136 participants included in this study.

Measures

Accountable Health Communities (AHC) Health-Related Social Needs (HRSN) Screening Tool.

The HRSN (Centers for Medicare and Medicaid Services, 2019) is a brief measure of social determinants of health (SDoH) completed by caregivers in the present study. Items assess numerous SDoH factors, and in the present study we used two items assessing food insecurity: (1) “Within the past 12 months, you worried that your food would run out before you got money to buy more,” and (2) “Within the past 12 months, the food you bought just didn’t last and you didn’t have money to get more.” Both items were rated on a three-point response scale (often true, sometimes true, never true). A total sum score was used as the measure of food insecurity in this study (α = .85). The food insecurity measure was scored such that higher scores indicate greater food insecurity.

Child and Adolescent Behavior Inventory (CABI).

Caregivers and teachers completed the 15-item CDS, 9-item ADHD-IN, 9-item ADHD-HI, 6-item anxiety, and 6-item depression scales from the CABI (Burns et al., 1987-2021). Each item was rated on a six-point scale for the past month (0 = almost never [never or about once per month], 1 = seldom [about once per week], 2 = sometimes [several times per week], 3 = often [above once per day], 4 = very often [several times per day], 5 = almost always [many times per day]). Scores on the 15-item CABI CDS items (e.g., “gets lost in own thoughts,” “easily confused,” “daydreams”, “low level of activity”) have demonstrated strong structural validity (including discriminant validity from ADHD and other psychopathology symptoms including depression, anxiety, and oppositionality), excellent reliability (internal consistency, test-retest, inter-rater), invariance (across a one-month interval, sex of rater, community/clinical samples), and independent correlates relative to ADHD symptoms (for a review, see Becker, 2021). Cronbach’s alpha reliability for the current sample of participants for the parent (teacher) CABI CDS, ADHD-IN, ADHD-HI, anxiety, and depression scores were .95 (.96), .96 (.96), .93 (.95), .79 (.77), and .89 (.89) respectively. Mean CDS, ADHD-IN, ADHD-HI, anxiety, and depression scores were used in the current study.

Behavioral Assessment System for Children (BASC-3) Self-Report of Personality (SRP).

The BASC-3 SRP (Reynolds et al., 2015) is a multidimensional self-report measure. Measure items contain descriptors of behaviors that are rated on a four-point scale of frequency (i.e., 0 = never, 1 = sometimes, 2 = often, and 3 = almost always). As in other studies examining ADHD symptom dimensions (Barden et al., 2023; Childs et al., 2022), the BASC-3 Self-Report of Personality (SRP) Attention Problems and Hyperactivity clinical scales were used to have self-report measures of ADHD-IN and ADHD-HI symptoms, and the anxiety and depression clinical scales were used to assess internalizing symptoms. Scores from these subscales have shown adequate reliability (e.g., αs ≥ .70) and validity (e.g., associations with functional outcomes) in previous research in children and adolescents (Doumas & Midgett, 2023; Reynolds et al., 2015; Tan et al., 2021).

Child Concentration Inventory, Second Edition (CCI-2).

Child self-report of CDS was measured using the CCI-2 (Becker, 2015). The CCI-2 items parallel the 15 items of the CABI parent-reported CDS scale (e.g., “I get lost in my own thoughts,” “I feel confused”). Items are rated on a four-point scale (0 = never to 3 = always), with higher scores indicating a higher frequency of CDS symptoms. Previous research indicates moderate correlations with parent-reported and teacher-reported CDS (rs = .29-.36) (Sáez et al., 2019). For the current study, mean scale scores were calculated using 13 CDS items that showed discriminant validity from adolescents-reported ADHD-IN symptoms (Becker et al., 2020). In the present sample, α = .88.

Data Analyses

First, descriptive information regarding rates of food insecurity in the sample is provided. Second, bivariate correlations among study variables were examined. Third, separate multiple regression analyses were conducted for each rater, examining whether ADHD and/or CDS symptoms (independent variables) were uniquely associated with food insecurity (continuous; dependent variable). These models allowed for examining the unique relations of ADHD and/or CDS symptom severity in relation to food insecurity. Adolescent age, sex (dichotomous), race (dichotomous), ethnicity (dichotomous), and psychiatric medication use (dichotomous) were included as covariates. Finally, sensitivity regression analyses were conducted that included the same variables listed in the previous sentence, while also including family income as an additional covariate to account for the strong association between lower family income and food insecurity. We also considered including anxiety and depressive symptoms but ultimately did not covary internalizing symptoms given food insecurity was not significantly associated with any informant’s ratings of either anxiety or depression (see below). The a priori level of significance for all analyses was set at p < .05.

Results

Descriptive Information

Responses to the two food insecurity items administered in the current study are summarized in Table 2. As shown, for both items approximately 85% of caregivers indicated that in the past 12 months it was “never true” that they would run out of food before having money to buy more or that the food they bought didn’t last before they had money to buy more. Approximately 10% of caregivers indicated that each of these items were “sometimes true” in the past 12 months. In combining responses to either question that were either “sometimes true” or “often true,” 14.7% of the sample were classified as experiencing food insecurity in the past year.

Table 2.

Frequency of Item Responses on the Food Insecurity Items in the Study Sample

Variable	% (N)
Item: “Within the past 12 months, you worried that your food would run out before you got more to buy more.”
1. Often true	5.1 (7)
2. Sometimes true	9.6 (13)
3. Never true	85.3 (116)
Item: “In the past 12 months, the food you bought just didn’t last and you didn’t have money to get more.”
1. Often true	2.9 (4)
2. Sometimes true	9.6 (13)
3. Never true	87.5 (119)

Note. N = 136.

Bivariate Correlations

Bivariate correlations among study variables are presented in Table 3. As shown, food insecurity was not significantly associated with adolescent self-reported ADHD-IN or ADHD-HI symptoms, parent-reported ADHD-IN symptoms, teacher-reported ADHD-HI symptoms, or with parent-, teacher-, or adolescent self-reported anxiety or depressive symptoms (all ps > .07)¹. Higher food insecurity was associated with higher teacher-reported ADHD-IN symptoms (r = .182, p = .047) and higher parent-reported ADHD-HI symptoms (r = .223, p = .009). In addition, significant correlations representing small-to-medium effects were found between food insecurity and higher CDS symptoms across all three informants, including parent-reported (r = .258, p = .002), teacher-reported (r = .256, p = .005), and adolescent self-reported (r = .213, p = .013) symptoms. As food insecurity was not significantly associated with any informant’s ratings of anxiety or depressive symptoms, internalizing symptoms were not considered further.

Table 3.

Means, Standard Deviations, and Bivariate Correlations of Study Variables

Variable	1	2	3	4	5	6	7	8	9	10	11	12	13	14	15	16	17	18	19	20	21	22
1. Age	--
2. Sex	.08	--
3. Medication use	.03	−.20*	--
4. Race	−.07	−.01	−.25**	--
5. Ethnicity	.08	.17*	−.02	−.13	--
6. Family income	.10	.02	−.02	−.24**	−.04	--
7. Food insecurity	−.08	−.18*	−.02	.18*	−.07	−.50***	--
8. PR ADHD-IN	.05	−.21*	.38**	−.01	−.12	−.16	.15	--
9. TR ADHD-IN	−.22*	−.27**	.38**	.14	−.06	−.29**	.18*	.45***	--
10. SR ADHD-IN	.19*	.06	.30**	.03	.03	−.06	−.01	.49***	.36***	--
11. PR ADHD-HI	−.01	−.31***	.49**	.06	−.09	−.17*	.22**	.71***	.43***	.37***	--
12. TR ADHD-HI	−.05	−.30***	.40**	.07	−.15	−.17	.15	.29**	.59***	.20*	.38***	--
13. SR ADHD-HI	.11	−.01	.36**	.07	−.02	−.10	.04	.42***	.37***	.79***	.44***	.33***	--
14. PR CDS	.01	−.11	.23**	−.06	.08	−.30***	.26**	.68***	.31***	.41***	.46***	.18	.29***	--
15. TR CDS	−.18	−.13	.34**	.05	.05	−.29**	.26**	.39***	.71***	.29**	.30**	.28**	.27**	.43***	--
16. SR CDS	.15	.02	.26**	.11	.10	−.24**	.21*	.42***	.32***	.69***	.37***	.17	.64***	.43***	.34***	--
17. PR Anxiety	−.08	−.02	.24**	−.09	−.02	−.20*	.14	.49***	.31***	.41***	.39***	.21*	.36***	.50***	.25**	.30***	--
18. TR Anxiety	−.07	.09	.26**	−.06	−.07	−.16	.05	.16	.27**	.09	.09	.23*	.14	.27**	.38***	.17	.19*	--
19. SR Anxiety	.13	.16	.17*	−.07	.09	.04	.01	.18*	.05	.62***	.14	.02	.63***	.24**	.12	.56***	.37***	.15	--
20. PR Depression	.01	−.03	.27**	.00	.18*	−.12	.13	.37***	.20*	.24**	.27**	.10	.18*	.58***	.25**	.31***	.44***	.21*	.24**	--
21. TR Depression	−.06	.10	.15	.17	.06	−.26**	.16	.12	.35***	.18	.06	.19*	.12	.15	.47***	.23*	.04	.54***	−.02	.12	--
22. SR Depression	.10	.02	.25**	.03	−.01	.01	.04	.27**	.19*	.54***	.17*	.15	.52***	.29***	.16	.48***	.27**	.27**	.57***	.48***	0.16	--
Mean	10.82	--	--	--	--	--	5.65	1.92	1.48	55.99	1.31	0.91	56.46	1.00	1.13	1.13	0.70	0.36	11.65	0.30	0.34	4.71
SD	0.80	--	--	--	--	--	0.89	1.44	1.41	11.99	1.29	1.17	12.55	0.95	0.99	0.55	0.79	0.59	7.06	0.54	0.65	4.45

Note. N = 136 (n = 120 in correlations involving teacher ratings, n = 132 in correlations involving family income, and n = 117 in correlations involving teacher ratings and family income). For sex, 0 = female, 1 = male. For medication use, 0 = not currently taking any prescribed psychiatric medication, 1 = currently taking a prescribed psychiatric medication. For race, 0 = non-White, 1 = White. For ethnicity, 0 = non-Hispanic, 1 = Hispanic. ADHD = attention-deficit/hyperactivity disorder. HI = hyperactivity-impulsivity. IN = inattention. *p<.05. **p<.01. ***p < .001.

Regression Analyses

Regression analyses were conducted examining each informant’s ratings of ADHD symptom dimensions and CDS symptoms in relation to food insecurity, above and beyond age, sex, race, ethnicity, and medication use. Next, analyses were re-run with the addition of family income as an additional covariate. Results are summarized in Table 4.

Table 4.

Regression Analyses Examining Demographic Characteristics, ADHD Symptom Dimensions, and CDS Symptoms in Relation to Food Insecurity in Early Adolescents

	Food insecurity (no control for family income)				Food insecurity (including control for family income)
	B	SE	β	t	B	SE	β	t
PR Symptoms
Age	−0.05	0.09	−0.04	−0.48	−0.00	0.09	−0.00	−0.04
Sex	−0.22	0.15	−0.13	−1.45	−0.27	0.15	−0.15	−1.89†
Race	0.26	0.16	0.15	1.68†	0.09	0.15	0.05	0.58
Ethnicity	−0.17	0.24	−0.06	−0.73	−0.21	0.22	−0.08	−0.98
Medication use	−0.22	0.20	−0.11	−1.11	−0.24	0.18	−0.12	−1.30
ADHD-HI	0.16	0.09	0.23	1.83†	0.12	0.08	0.18	1.48
ADHD-IN	−0.15	0.09	−0.24	−1.64	−0.10	0.08	−0.17	−1.25
CDS	0.32	0.11	0.34	2.95**	0.16	0.10	0.17	1.60
Family income	--	--	--	--	−0.19	0.04	−0.43	−5.26***
TR Symptoms
Age	−0.03	0.11	−0.02	−0.26	0.01	0.10	0.01	0.07
Sex	−0.28	0.18	−0.15	−1.59	−0.35	0.16	−0.19	−2.19*
Race	0.23	0.18	0.12	1.26	0.07	0.17	0.04	0.41
Ethnicity	−0.17	0.28	−0.06	−0.60	−0.13	0.25	−0.04	−0.52
Medication use	−0.28	0.23	−0.13	−1.25	−0.30	0.20	−0.14	−1.47
ADHD-HI	0.12	0.10	0.15	1.23	0.10	0.09	0.12	1.12
ADHD-IN	−0.11	0.11	−0.17	−1.09	−0.15	0.10	−0.22	−1.57
CDS	0.34	0.13	0.36	2.69**	0.26	0.11	0.27	2.24*
Family income	--	--	--	--	−0.21	0.04	−0.46	−5.38***
SR Symptoms
Age	−0.08	0.09	−0.07	−0.85	−0.02	0.09	−0.02	−0.28
Sex	−0.29	0.15	−0.16	−1.91†	−0.31	0.14	−0.17	−2.21*
Race	0.22	0.16	0.12	1.39	0.08	0.15	0.05	0.55
Ethnicity	−0.15	0.23	−0.05	−0.64	−0.21	0.21	−0.08	−0.99
Medication use	−0.09	0.19	−0.05	−0.48	−0.13	0.17	−0.07	−0.78
ADHD-HI	−0.00	0.02	−0.00	0.02	−0.00	0.02	−0.00	−0.03
ADHD-IN	−0.04	0.02	−0.27	−1.87†	−0.03	0.02	−0.21	−1.56
CDS	0.68	0.19	0.42	3.55***	0.45	0.18	0.27	2.46*
Family income	--	--	--	--	−0.19	0.04	−0.43	−5.42***

Note. For medication use, 0 = not currently taking any prescribed psychiatric medication, 1 = currently taking a prescribed psychiatric medication. For sex, 0 = female, 1 = male. For race, 0 = person of color, 1 = White. For ethnicity, 0 = non-Hispanic, 1 = Hispanic. ADHD = attention-deficit/hyperactivity disorder. HI = hyperactivity-impulsivity. IN = inattention. PR = parent-report. SR = self-report. TR = teacher-report.

^†p < .10.

^*p<.05.

^**p<.01.

^***p < .001.

Above and beyond ADHD symptoms and covariates, higher CDS symptoms remained uniquely associated with greater food insecurity. This unique association was consistent across parent-reported CDS symptoms (β = 0.34, t = 2.95, p = .004), teacher-reported CDS symptoms (β = 0.36, t = 2.69, p = .008), and self-reported CDS symptoms (β = 0.42, t = 3.55, p = .0005).

When the strong association between family income and food insecurity was also included (by adding family income as an additional covariate), parent-reported CDS symptoms were no longer significantly associated with food insecurity (β = 0.17, t = 1.60, p = .113). However, both teacher-reported (β = 0.27, t = 2.24, p = .027) and adolescent-reported CDS (β = 0.27, t = 2.46, p = .015) symptoms remained unique associated with greater food insecurity. No informant’s ratings of ADHD symptoms were uniquely associated with food insecurity in the regression models (Table 4).

Discussion

This study examined ADHD dimensions and CDS symptoms in relation to food insecurity in a sample of early adolescents. Approximately 14.7% of our sample reported experiencing some type of food insecurity in the past year, which is very similar to the 2022 national average for food insecure household with children in the United States (12.8%; Rabbitt et al., 2023). Findings were partially consistent with our hypotheses. In contrast to expectations, no informant’s ratings of ADHD were related to food insecurity. However, higher parent-, teacher-, and self-reported CDS symptoms were related to increases in food insecurity. Furthermore, teacher- and self-reported CDS symptoms remains associated with food insecurity, even after controlling for ADHD symptom severity, child demographics, and family income. To our knowledge, this is the first study to examine the association between CDS symptoms and food insecurity and provides important preliminary support for the importance of examining environmental and socio-cultural factors that may contribute to the presence or severity of CDS symptoms.

Although direct examination of mechanisms was not conducted given the cross-sectional design of the study, there are several potential explanations for the correlations between CDS symptoms and food insecurity specifically. First, researchers have suggested that food insecurity may lead to low caloric intake, ultimately resulting in inadequate nutrition. Proper nutrition is imperative for the growth and functioning of the brain, and insufficient access to nutritious food can likely impact cognitive abilities and function (Nyaradi et al., 2013). In another qualitative study exploring systemic barriers for hungry children from the perspectives of a middle school teacher, a high school teacher/counselor, and a food bank distributor, one teacher explained that she can visibly see how affected her students are when not getting proper nutrition, evidenced by “their inability to concentrate and/or focus in class and retain academic information,” as well as students’ “daydreaming” (Hinsley, 2018). This is particularly relevant to this study, as daydreaming is a cardinal component of and the most frequently used symptom to define CDS (Becker et al., 2016).

Relatedly, an additional factor that might potentially elucidate the connection between food insecurity and CDS symptoms is rumination, characterized as the contemplation of distressing experiences, the quest for meaning in negative events, and the consideration of actions that can be taken to alter the situation related to negative events (Fritz, 1999). Reflective rumination is often considered to be more adaptive (Treynor et al., 2003), whereas brooding rumination has been more generally and consistently linked to negative outcomes (Burwell & Shirk, 2007; Verstraeten et al., 2010). Food insecurity is a significant stressor (Ciciurkaite & Brown, 2022), and it may prompt children to engage in more rumination about the availability of food, how they must ration to ensure an adequate supply for the future, and more broadly about other related financial and social stressors. Furthermore, children facing food insecurity may develop maladaptive coping mechanisms, including rumination, as a means of addressing the challenges and uncertainties associated with insufficient food. Indeed, CDS has been linked to high levels of rumination which is presumed to be due to high sensitivity to internal stimuli (Becker et al., 2020; Fredrick et al., 2020; Fredrick et al., 2023). In a qualitative study exploring the impact of food insecurity on psychosocial health among college students, numerous participants remarked on the mental trade-off between contemplating food and cognitive functioning, including aspects related to mental confusion/fogginess. As one participant shared, “When you're so stressed about food all the time, that takes a lot of mental power. You need room for creativity; you need room to do certain things. But, if all that’s in your head is cluttered, everything becomes blurry. You’re not focusing on the bigger picture. You’re only focused on what’s happening next” (Meza et al., 2019). Relatedly, youth with elevated CDS symptoms can be highly imaginative (Becker, Fredrick et al., 2021), and a qualitative study investigating the psychological distress of food insecurity found distraction from or using imagination to cope as a prominent theme (Leung et al., 2020). This might also explain why a significant association between ADHD symptoms and food insecurity was not observed in our study, despite prior research suggesting a potential link. Although a handful of studies have linked food insecurity with ADHD symptoms, especially inattention, our understanding often centers around ADHD inattention manifesting as external distractibility. In contrast, CDS is more closely tied to internal distractibility (Wiggs et al., 2024), wherein rumination, imagination, and daydreaming would be more distinctly associated.

Finally, it is interesting to consider sleep as a potential mechanism linking CDS and food security. Numerous studies, primarily in adults, have established a connection between food insecurity and compromised sleep health (Ding et al., 2015; Jordan et al., 2016; Liu, 2014; Whinnery et al., 2014). Although limited, there is also one study of this relationship in children. In a study of 362 low-income preschool-age children, food-insecure children were approximately two times more likely to experience poor sleep quality compared to food-secure children, even after adjusting for socioeconomic indicators (Na et al., 2020). Furthermore, a small but growing number of studies have found robust associations between insufficient and low-quality sleep (e.g., difficulties falling asleep, waking issues, and restless sleep) with CDS symptoms (Becker et al., 2016; Fredrick et al., 2022; Mayes et al., 2023; Rondon et al., 2020). Experimental work has also shown that shortened sleep duration is causally related to increased CDS symptoms (Becker et al., 2019; Garner et al., 2017). If disrupted sleep is a causal contributor to CDS symptoms and food insecurity is indeed linked to compromised sleep health, sleep could offer a plausible pathway for the observed association. In this context, a child facing food insecurity may encounter obstacles in obtaining both quality and sufficient sleep, potentially contributing to the manifestation of CDS symptoms.

Strengths and Limitations

This study had several strengths, including use of well-validated measures and a multi-informant approach to assess both ADHD and CDS symptoms. However, it is essential to acknowledge limitations, which highlight important avenues for future research in this area. Firstly, due to the cross-sectional nature of the data, causal or temporal inferences about the role of food insecurity in CDS is not possible. No studies have predicted whether food insecurity precedes or predicts later CDS symptoms, and none have prospectively followed children experiencing food insecurity in relation to CDS/ADHD specifically. Additionally, while we established a relationship between CDS and food insecurity, the cross-sectional design precluding us from examining potential mechanisms. In the future, longitudinal studies may provide a clearer picture of the role food insecurity plays in the etiology and course of CDS. Furthermore, the use of the AHC HRN screening tool in this study for a brief assessment of food insecurity may not have fully captured the entire spectrum of household food insecurity. It is also important to note that this measure is completed based on the caregiver’s perspective of food insecurity, rather than the adolescents. Although evidence links parental household food insecurity with mental health symptoms in adolescents (Bradette-Laplante et al., 2020; Whitsett et al., 2019), other research indicates that adolescents’ self-report of food insecurity may differ from their caregivers’ reports, potentially leading to varying impacts on their mental health (Frank & Sato, 2023). Alternative measures, such as the Household Food Security Survey Module (Coleman-Jensen et al., 2014), are better equipped to monitor the extent and severity of food insecurity from both caregiver and child perspectives. Finally, it is important to note that the sample had relatively high income and education levels, with a relatively small proportion of our families (14.7%) reporting any degree of food insecurity. As such the current sample may not reflect the general population, limiting the generalizability our findings. Future research should determine whether the present findings replicate among a larger and more socioeconomically diverse sample, and perhaps a sample with a larger percentage of food-insecure families, especially given the association between lower family income and CDS symptoms (Becker, Leopold, et al., 2016).

Clinical and Policy Implications

Overall, although necessarily tentative given the cross-sectional design and small sample which required replication, the results of this study suggest that multi-informant CDS symptoms in adolescents are significantly associated with caregiver-reported household food insecurity. These findings have several implications for clinicians and policy makers. Firstly, it suggests that more routine screening for both CDS and household food insecurity should be a standard practice during mental health visits. Such screenings can be seamlessly incorporated into intake interviews and mental health appointments using brief, validated measures like the two-item Hunger Vital Sign (Hager et al., 2010). To increase practicality of CDS assessment, clinicians can administer CDS-specific rating scales (e.g., CABI CDS subscale) or the Barkley Sluggish Cognitive Tempo scale (see Becker, 2021).

Clinicians can take several steps to help adolescents and their families experiencing food insecurity. Once an adolescent is identified as food-insecure, clinicians can normalize and validate their experience, particularly addressing the shame often associated with household food insecurity (Connell et al., 2005). Clinicians can explore how food insecurity impacts distress and current functioning, helping adolescents find ways to alleviate stress. Therapeutic interventions might include food-related problem-solving, teaching stress coping skills, and helping teens build community and social networks. Additionally, clinicians can direct adolescents and their caregivers to food access resources (e.g., food banks, food pantries, government food assistance programs) and, if needed, work to increase their motivation to seek the necessary assistance.

While individual-level interventions can benefit families, food insecurity must be understood within a broader context of economic and structural challenges. Thus, macro-level interventions are essential to reduce food insecurity and its subsequent impact on families and society. A qualitative study aimed at understanding teen food insecurity revealed that teens themselves advocate for large-scale educational initiatives. These initiatives should aim to increase awareness and education about food insecurity, stigma, and bullying, particularly among school staff and administration (Burris et al., 2020). Moreover, given the effectiveness of federal nutrition programs—such as the Supplemental Nutrition Assistance Program (SNAP), Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), National School Lunch Program, School Breakfast Program, and Child and Adult Care Food Program (CACFP)—efforts should be made to protect, strengthen, and expand these programs to improve youth health (Hartline-Grafton & Hassink, 2021).

Conclusion

This study marks an important step towards understanding the potential relationship between ADHD and CDS symptoms in relation to food insecurity. To our knowledge, this is the first study providing evidence of a direct relationship between higher teacher- and self-reported CDS symptoms and parent-reported household food insecurity among adolescents, even after controlling for ADHD symptom severity and family income. Therefore, it may prove clinically useful to routinely screen children for food insecurity (which is in line with the recommendation of the American Academy of Pediatrics; (Pediatrics et al., 2015), especially for those exhibiting CDS symptoms. Such screening would help identify children experiencing food insecurity, enabling targeted nutritional support and interventions to enhance their mental well-being. Furthermore, there is an urgent need for effective policies targeting the reduction of household food insecurity and the promotion of adolescent mental health. Additionally, further research is required to explore food insecurity as a potential predictor of the emergence, intensity, and persistence of CDS symptoms throughout development.