Skip to main content
NCBI home page
European Journal of Psychotraumatology logoLink to European Journal of Psychotraumatology
. 2026 Aug 11;17(1):2697559. doi: 10.1080/20008066.2026.2697559

Association between trauma exposure and mental health among adolescents with attention-deficit hyperactivity disorder

Asociación entre la exposición a traumas y la salud mental en adolescentes con trastorno por déficit de atención e hiperactividad

Yu-Jui Wu a, Jong-Hau Hsu b,c, Tai-Ling Liu d,e,CONTACT
PMCID: PMC13463518  PMID: 42578754

ABSTRACT

Background: Adolescents with attention-deficit/hyperactivity disorder (ADHD) may be particularly vulnerable to trauma; however, patterns of trauma exposure and psychological responses in East Asian contexts remain underexplored.

Objective: To examine associations among ADHD, trauma exposure, and psychological outcomes, and to differentiate trauma-specific reactions from broader internalising symptoms.

Methods: This cross-sectional study included 295 adolescents aged 12–18 years (149 with ADHD and 146 controls). Adolescents and their caregivers completed validated measures of trauma exposure (Trauma Exposure Experience Questionnaire), trauma reactions (Revised Child’s Reaction to Traumatic Events Scale), anxiety (Multidimensional Anxiety Scale for Children), depression (Centre for Epidemiological Studies Depression Scale), and self-esteem (Rosenberg Self-Esteem Scale). All measures demonstrated excellent internal consistency (Cronbach’s α = .92–.95). Intergroup differences were examined using chi-square tests and t-tests. Hierarchical regression models incorporating ADHD × trauma exposure interaction terms, along with sex-stratified analyses, were used to evaluate associations.

Results: Adolescents with ADHD reported stronger trauma reactions (p = .039), greater depressive symptoms (p = .032), and lower self-esteem (p = .002) than controls. Logistic regression analyses indicated that physical assault (odds ratio = 3.11) and threats of violence (odds ratio = 3.77) were significantly associated with ADHD. Trauma reactions were strongly predicted by anxiety, depression, and trauma exposure across the sample. The interaction between ADHD and trauma exposure was not significant in the total sample (p = .600) or in stratified analyses.

Conclusion: Adolescents with ADHD in Taiwan are highly vulnerable to interpersonal trauma. Although ADHD does not moderate the association between trauma exposure and subsequent reactions, trauma responses are closely associated with comorbid anxiety and depression. These findings highlight the need for trauma-informed ADHD care that addresses internalising symptoms within relevant familial and cultural contexts.

KEYWORDS: ADHD, trauma exposure, depression, anxiety, PTSD

HIGHLIGHTS

  • Adolescents with ADHD are highly vulnerable to interpersonal trauma.

  • Trauma reactions are associated with anxiety and depression rather than ADHD.

  • ADHD does not moderate the association between trauma exposure and trauma reactions.

  • Trauma-informed care should target comorbid internalising symptoms.

1. Introduction

Childhood trauma has long been recognised as a critical determinant of developmental, psychological, and behavioural outcomes. Trauma exposure refers to the experience of objectively identifiable adverse or threatening events, including parental separation, physical assault, and threats of violence, and trauma reactions refer to psychological responses to such events. Trauma reactions include trauma-specific symptoms, such as posttraumatic stress disorder (PTSD), and general internalising outcomes, including depression, anxiety, and low self-esteem. Traumatic experiences can impair executive functioning (DePrince et al., 2009), contribute to academic and behavioural maladjustment (Shonk & Cicchetti, 2001), and increase the risk of PTSD (Copeland et al., 2007) and other psychiatric conditions, including anxiety, mood, and conduct disorders (Bauer et al., 2022). Although trauma is harmful across populations, emerging research suggests that its effects may be particularly pronounced in adolescents with attention-deficit/hyperactivity disorder (ADHD). Trauma has been linked to both ADHD onset and greater symptom severity and functional impairment (Brown et al., 2017; Sibley et al., 2020), highlighting the need for further research into how trauma may differentially affect adolescents with and without ADHD.

Adolescents diagnosed with ADHD may be especially vulnerable to adverse environments. Within this population, peer victimisation (Efron et al., 2021), parental marital disruption (Cohen et al., 2002), and exposure to domestic violence (Fuller-Thomson & Lewis, 2015) have been disproportionately reported. Although pharmacological treatment may reduce the risk of physical injury (Chien et al., 2017), family instability and interpersonal violence remain pervasive and may amplify ADHD-related vulnerabilities (Zhang et al., 2022). In particular, the manifestation of trauma reactions in adolescents with ADHD may differ from that in adolescents without ADHD. Inattentive symptoms are associated with a greater risk of adverse experiences (Lugo-Candelas et al., 2021). Moreover, trauma exposure in adolescents with ADHD is frequently accompanied by pronounced emotional dysregulation, which may exacerbate internalising difficulties such as depression, anxiety, and low self-esteem (Jelinkova et al., 2024; Stickley et al., 2019). These patterns indicate that the co-occurrence of trauma and ADHD may produce distinct clinical profiles, particularly in domains related to emotional functioning.

Neurobiological findings support these differences. Childhood adversity has been associated with cortical thinning and alterations in white matter integrity that are also implicated in ADHD (McLaughlin et al., 2014; Park et al., 2016). These changes may compromise affective and cognitive control (Nigg & Casey, 2005), potentially increasing susceptibility to the psychological consequences of trauma among adolescents with ADHD. Consistent with this hypothesis, traumatic experiences have been linked to severe outcomes in individuals with ADHD, such as psychosis, substance dependence, and delinquent behaviour (Barra et al., 2022; Hennig et al., 2017; Konstenius et al., 2017), raising the concern that trauma may uniquely exacerbate risk trajectories in this group.

Despite accumulating evidence for the link between trauma and ADHD, previous research on this topic has primarily been conducted in Western populations. Given that trauma exposure, internalisation patterns, and ADHD symptom expression vary across cultural, ethnic, and sociodemographic contexts (Gau, 2007), whether findings obtained in Western settings are generalisable to East Asian adolescents remains unclear.

Addressing this gap is essential to advancing the understanding of both shared and culture-specific pathways linking trauma and ADHD. Accordingly, the present study distinguished between trauma-specific reactions (e.g. PTSD) and general internalising outcomes (e.g. depression, anxiety, and low self-esteem) to examine whether ADHD diagnosis uniquely amplifies specific psychological trajectories following adversity.

On the basis of this theoretical framework and the clinical profiles of adolescents from an East Asian context, we formulated the following hypotheses: H1 (Differential Exposure): Adolescents with ADHD have greater exposure to direct interpersonal adversity (specifically physical assault and threats of violence) compared with adolescents without ADHD. H2 (Predictive Value of Trauma): Greater trauma exposure is a significant predictor of greater trauma reactions (PTSD symptom severity) and broader internalising symptoms (depression, anxiety, and low self-esteem). H3 (Testing the Moderating Effect): The association between trauma exposure and trauma reactions is stronger in the ADHD group than in the control group. H4 (Mechanisms of Internalisation): Across the sample, higher trauma reactions are positively associated with internalising symptoms, particularly among adolescents with ADHD.

2. Materials and methods

2.1. Participants

In this cross-sectional study, we recruited 295 adolescents aged 12–18 years between August 2023 and August 2024. The ADHD group included adolescents diagnosed with ADHD by board-certified psychiatrists according to the criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Participants in this group were consecutively recruited through referrals from outpatient physicians at two medical centres in southern Taiwan, and enrolment was completed after informed consent was obtained from the patients and their primary caregivers. The control group included 146 adolescents without a DSM-5 diagnosis of ADHD or other psychiatric disorders. These individuals were consecutively recruited from the paediatric departments of the same two medical centres through referrals by general paediatric outpatient physicians and were likewise enrolled after providing informed consent. The exclusion criteria for both groups included concurrent severe physical illness, a history of substance abuse or severe brain injury, comorbid autism spectrum disorder or other severe psychiatric conditions, and an inability to complete the required evaluations or examinations. A comprehensive explanation of the study’s purpose and procedures was provided to all participants and their primary caregivers.

2.2. Measures

Participants and their primary caregivers were consecutively recruited from outpatient psychiatry and paediatric departments and invited to autonomously complete the following questionnaires:

2.2.1. Primary caregiver questionnaires

2.2.1.1. Sociodemographic data

Sociodemographic data, including the participant’s gender and age and parental marital status and educational level, were obtained through a structured questionnaire. All participants were of Taiwanese nationality.

2.2.1.2. Chinese version of the Swanson, Nolan, and Pelham, Version IV Scale

The Chinese version of the Swanson, Nolan, and Pelham, Version IV Scale is a 26-item self-reported instrument used to assess ADHD and oppositional defiant disorder symptoms in adolescents (Gau et al., 2009). The scale comprises three categories: inattention, hyperactivity/impulsivity, and oppositional defiance. Each item is rated on a 4-point Likert scale, with higher subscale scores indicating more severe inattention, hyperactivity/impulsivity, or oppositional symptoms.

2.2.2. Adolescent questionnaires

2.2.2.1. Trauma Exposure Experience Questionnaire

The 7-item self-administered Trauma Exposure Experience Questionnaire (TEEQ) assesses trauma exposure in adolescents across seven categories that are culturally relevant in Taiwan, including natural disasters, physical assault, threats, sexual violence, witness of injury to others, and media-related violence. The TEEQ was developed based on the Traumatic Events Questionnaire (Crawford et al., 2008) and the Life Events Checklist for DSM-5 (Gray et al., 2004) and adapted for the Taiwanese context. Participants responded ‘Yes’ or ‘No’ to each item; a total trauma count was calculated based on these responses.

2.2.2.1.1. Chinese version of the Child’s Reaction to Traumatic Events Scale–Revised

The Chinese version of the Child’s Reaction to Traumatic Events Scale–Revised (CRTES-R) is a 23-item self-administered evaluation of psychological responses to traumatic events among children (Chen & Lai, 2012). The CRTES-R assesses symptom severity according to the diagnostic criteria for PTSD across three dimensions: intrusion, avoidance, and hyperarousal. Items are scored on a 4-point Likert scale, with higher total scores indicating more pronounced PTSD symptoms. Psychometric evaluation results revealed that the CRTES-R exhibited high internal consistency, with a Cronbach’s alpha coefficient of .94 for the full scale (Chen & Lai, 2012). In the current sample, the CRTES-R had a Cronbach’s alpha coefficient of .95, indicating excellent internal reliability.

2.2.2.1.2. Taiwanese version of the Multidimensional Anxiety Scale for Children

The Taiwanese version of the Multidimensional Anxiety Scale for Children (MASC-T) is a 39-item self-report instrument used to assess anxiety in individuals aged 8–19 years (March et al., 1997; Yen et al., 2010). The scale evaluates four core domains: physical symptoms, harm avoidance, social anxiety, and separation/panic. Responses are rated on a 4-point Likert scale, with higher total scores reflecting higher overall anxiety levels. The Chinese version of the MASC-T was standardised for Taiwanese children and adolescents and demonstrated excellent reliability and validity (Yen et al., 2010). The Taiwanese version of the MASC-T exhibited high internal consistency, with a Cronbach’s alpha of .87 in previous validation studies. In the current sample, the MASC-T had a Cronbach’s alpha coefficient of .93, indicating excellent internal reliability.

2.2.2.1.3. Chinese version of the Center for Epidemiological Studies Depression Scale

The Chinese version of the Center for Epidemiological Studies Depression Scale (CES-D) is a 20-item self-administered questionnaire that measures depressive symptoms in the general population, encompassing mood disturbances, appetite changes, sleep problems, sadness, loneliness, feelings of worthlessness, fatigue, and social withdrawal (Chien & Cheng, 1985). Items are rated on a 4-point Likert scale, yielding a single overall score that represents the severity of depressive symptoms. The Chinese version of the scale was edited by Chien and Cheng (1985) and demonstrated outstanding sensitivity and specificity (Yang et al., 2004). The Chinese version of the CES-D exhibited high internal consistency (Cronbach’s alpha coefficient = .90) in a previous study. In the current sample, the CES-D had a Cronbach’s alpha coefficient of .92, indicating excellent internal reliability.

2.2.2.1.4. Chinese version of the Rosenberg Self-Esteem Scale

The Chinese version of the Rosenberg Self-Esteem Scale (RSES) is a 10-item self-reported measure of current self-esteem according to subjective self-descriptions (Yen et al., 2014). Items are rated on a 4-point Likert scale, yielding a composite self-esteem score; higher values indicate a stronger sense of self-worth. In the study conducted by Yen et al. (2014), who enrolled Taiwanese adolescents, the RSES exhibited good internal consistency (Cronbach’s alpha coefficient of .83 for the total scale). In the current sample, the RSES had a Cronbach’s alpha coefficient of .93, indicating excellent internal reliability.

2.3. Statistical analyses

We examined differences in caregivers’ sociodemographic characteristics and in adolescents’ trauma exposure, trauma reactions, anxiety, depression, and self-esteem between the ADHD and control groups. Chi-square tests were performed for categorical variables and independent-samples t-tests were performed for continuous variables. Multivariate logistic regression was conducted to assess the associations between ADHD and specific types of trauma exposure. Hierarchical linear regression analyses were conducted to examine the associations between trauma exposure and trauma reactions and to test whether ADHD diagnosis moderates this relationship. Trauma reactions (CRTES-R scores) were entered as the dependent variable. In the regression models, demographic variables (age, sex/gender, parental marital status, and parental educational level) were included as covariates. Anxiety (MASC-T), depression (CES-D), and self-esteem (RSES) were also entered as predictors. Trauma exposure (TEEQ) and ADHD diagnosis were entered as main effects, followed by an interaction term (ADHD × trauma exposure).

Given the uneven sex distribution in the sample, additional analyses were conducted stratified by sex (male and female subgroups) to assess the robustness of the findings and to align with sex-sensitive reporting guidelines.

All analyses were conducted with IBM SPSS Statistics (version 27). The threshold for statistical significance was p < .05. A priori power analysis was conducted with G*Power 3.1. Based on a medium effect size, an alpha level of 0.05, and a desired power of 0.80, the required sample size was estimated to ensure sufficient power for t-tests, analysis of variance, and regression analyses. The final sample size (N = 295) met these requirements.

3. Results

3.1. Sociodemographic characteristics and psychological measures

Table 1 presents the sociodemographic characteristics, trauma exposure, and psychological measures of adolescents diagnosed with ADHD (n = 149) and control adolescents (n = 146). The ADHD group had a significantly higher proportion of male participants compared with the control group (p < .001). Participant age, carer sex/gender, and carer age did not differ significantly between the groups. Significant intergroup differences were observed in parental marital status and educational level: adolescents diagnosed with ADHD were more likely to have parents who were divorced, separated, or otherwise not married (p < .001), and their parents had received fewer years of education on average (p = .007). Among psychological measures, overall trauma exposure and anxiety levels did not differ significantly between adolescents with and without ADHD. However, adolescents diagnosed with ADHD reported significantly higher trauma reactions (t = 2.069, p = .039) and depressive symptoms (t = 2.153, p = .032) and lower self-esteem (t = −3.189, p = .002) than did adolescents without ADHD.

Table 1.

Sociodemographic characteristics, trauma exposure, trauma reactions, depression, anxiety, and self-esteem in adolescents with and without ADHD.

  ADHD (n = 149) Control (n = 146)    
  n (%) Mean ± SD n (%) Mean ± SD χ2or t p
Sex/Gender 149   146   20.086 <.001
 Female 30 (20)   65 (45)      
 Male 119 (80)   81 (55)      
Age (years)   14.53 ± 1.89   14.78 ± 1.99 −1.04 .275
TEEQ   1.41 ± 1.39   1.19 ± 1.21 1.437 .152
CRTES-R   16.26 ± 16.22   12.65 ± 13.61 2.069 .039
MASC-T   48.87 ± 13.66   46.56 ± 11.17 1.587 .114
CES-D   15.74 ± 12.77   12.83 ± 10.39 2.153 .032
RSES   18.52 ± 7.05   21.03 ± 6.42 −3.189 .002
SNAP-IV            
 Inattention   73.52 ± 25.78   33.89 ± 28.79 12.461 <.001
 Hyperactivity/impulsivity   42.99 ± 35.27   12.79 ± 22.07 8.833 <.001
 Oppositional defiance   64.59 ± 62.45   36.65 ± 31.40 7.512 <.001
Primary caregivers         −1.30 .196
 Female 115 (77.2)   103 (70.5)      
 Male 34 (22.8)   43 (29.5)      
Parental marital status         4.011 <.001
 Married 101 (67.8)   126 (86.3)      
 Other (divorce, separated, or other) 48 (32.2)   20 (13.7)      
Parental age   46.60 ± 6.39   47.48 ± 5.94 −1.232 .219
Parental educational level (years)   14.33 ± 2.38   15.08 ± 2.22 −2.727 .007
Open in a new tab

Abbreviations: TEEQ: Trauma Exposure Experience Questionnaire; CRTES-R: Child’s Reaction to Traumatic Event Scale-Revised (Chinese version); MASC-T: Multidimensional Anxiety Scale for Children (Taiwanese version); CES-D: Center for Epidemiological Studies Depression Scale; RSES: Rosenberg Self-Esteem Scale (Chinese version); SNAP-IV: Swanson, Nolan, and Pelham Version IV Scale (Chinese version).

3.2. Association between ADHD and trauma exposure

Multivariate logistic regression analyses adjusted for parental marital status and educational level, participant age and sex/gender., and MASC-T, CES-D, and RSES scores revealed significant associations between ADHD and specific types of trauma exposure. Physical assault (odds ratio [OR] = 3.113, 95% confidence interval [CI]: 1.065–9.102, p = .038) and threats of violence (OR = 3.766, CI: 1.539–9.216, p = .004) were significantly associated with greater odds of an ADHD diagnosis. By contrast, exposure to violence or graphic content through the Internet or other media was associated with lower odds of ADHD (OR = 0.500, CI: 0.283–0.883, p = 0.017). No significant associations were observed between ADHD and exposure to natural disasters, unexpected events, sexual violence or harassment, or observation of assaults or injuries (Table 2).

Table 2.

Association between trauma exposure and ADHD (Adjusted for parental marital status, parental educational level, age, sex/gender, and MASC-T, CES-D, and RSES Scores).

TEEQ Odds ratio (95% confidence interval) p value
1. Natural disasters 0.539 (0.463, 1.496) .832
2. Physical assault 3.113 (1.065, 9.102) .038
3. Threats of violence 3.766 (1.539, 9.216) .004
4. Unexpected events 1.287 (0.619, 2.674) .500
5. Sexual violence or harassment 7.295 (0.714, 74.535) .094
6. Observation of assaults or injuries 0.621 (0.338, 1.140) .124
7. Exposure to violence or graphic content through the Internet or other media 0.500 (0.283, 0.883) .017
Open in a new tab

3.3. Factors associated with trauma reactions and the moderating effect of ADHD diagnosis

Hierarchical regression analyses were conducted to examine the associations between trauma reactions (i.e. PTSD symptom severity) and psychological responses (i.e. depression, anxiety, and low self-esteem) and to test whether ADHD status moderates the effect of trauma exposure. To adhere to reporting guidelines and address the uneven sex distribution within the sample (80% male in the ADHD group), separate analyses were performed for the overall sample (N = 295) and for subgroups stratified by sex/gender (Table 3).

Table 3.

Hierarchical regression analysis for predicting trauma reactions (CRTES-R) stratified by sex/gender.

Predictors Overall Sample (N = 295) Male (n = 200) Female (n = 95)
  Standardised β (p) Standardised β (p) Standardised β (p)
Demographics      
 Age .154 (.008)** −.018 (.736) .037 (.665)
 Sex/Gender. −.114 (.050)* – –
 Parental Marital Status .136 (.019)* .133 (.014)* −.051 (.536)
Clinical symptoms      
 MASC-T (Anxiety) .376 (<.001)*** .273 (<.001)*** .398 (.004)**
 CES-D (Depression) .417 (<.001)*** .434 (<.001)*** .361 (.052)
 RSES (Low Self-Esteem) .132 (.061) .132 (.085) .170 (.238)
Main effects      
 ADHD Diagnosis .059 (.205) .054 (.327) .037 (.655)
 Trauma Exposure (TEEQ) .238 (.001)** .329 (<.001)*** .100 (.364)
Interaction effect      
 ADHD × TEEQ −.035 (.600) −.130 (.143) .088 (.392)
Open in a new tab

Note: N = 295 for total sample, n = 200 for males, and n = 95 for females. Standardised β coefficients are reported with p-values in parentheses.

Abbreviations: CRTES-R: Child’s Reaction to Traumatic Event Scale-Revised (Chinese version); MASC-T: Multidimensional Anxiety Scale for Children (Taiwanese version); CES-D: Center for Epidemiological Studies Depression Scale; RSES: Rosenberg Self-Esteem Scale (Chinese version); TEEQ: Trauma Exposure Experience Questionnaire.

* p ≦ .05, ** p < .01, *** p < .001.

In the overall sample, after adjustments for sociodemographic characteristics, higher levels of anxiety (MASC-T: β = .376, p < .001) and depressive symptoms (CES-D: β = .417, p < .001) were robustly associated with PTSD symptom severity (CRTES-R). Although ADHD diagnosis itself was not a significant predictor (β = .059, p = .205), overall trauma exposure was significantly associated with increased PTSD symptom severity (β = .238, p = .001). The interaction between ADHD diagnosis and trauma exposure (ADHD × TEEQ) was not significant (β = −.035, p = .600), suggesting that ADHD status did not significantly moderate the relationship between trauma exposure and reactions in the overall sample.

Sex-stratified analyses revealed largely consistent patterns across male and female subgroups. In the male subgroup (n = 200), PTSD symptom severity was significantly predicted by anxiety (β = .273, p < .001), depression (β = .434, p < .001), and trauma exposure (β = .329, p < .001) but not by the ADHD × TEEQ interaction (β = −.130, p = .143). In the female subgroup (n = 95), anxiety remained a significant predictor (β = .398, p = .004), and depression was marginally associated with PTSD symptom severity (β = .361, p = .052). Similar to the male subgroup, the interaction between ADHD and trauma exposure did not reach significance in the female subgroup (β = .088, p = .392).

Overall, PTSD symptom severity was greater in adolescents with ADHD than in adolescents without ADHD; however, the increased severity among adolescents with ADHD was primarily driven by these individuals’ elevated levels of comorbid internalising symptoms, particularly anxiety and depression, rather than a unique susceptibility to the effects of trauma exposure.

4. Discussion

To our knowledge, this is the first examination of trauma exposure and internalisation patterns among adolescents diagnosed with ADHD in an East Asian cultural context. Our findings indicated that although overall trauma exposure did not differ between adolescents with and without ADHD, those with ADHD were disproportionately exposed to direct interpersonal trauma – specifically physical assault and threats of violence – and displayed stronger emotional responses to trauma, which manifested as heightened depression and anxiety. These results suggest that adolescents diagnosed with ADHD do not necessarily experience trauma more frequently than other adolescents, but the type of trauma they experience and the intensity of their internalisation patterns may be distinct.

The elevated exposure to physical assault and threats observed among adolescents with ADHD in our cohort highlights the unique vulnerability of this population to interpersonal victimisation. Consistent with the findings of studies demonstrating that physical abuse increases the risk of ADHD (Fuller-Thomson & Lewis, 2015), our results suggest that in East Asian contexts characterised by authoritarian parenting and academic pressure (Gau & Chang, 2013), ADHD-related behaviours may be misinterpreted, thereby eliciting punitive responses from carers (Ouyang et al., 2008). For example, impulsivity or noncompliance may be misinterpreted as intentional defiance.

This phenomenon must be understood within the context of the strong heritability of ADHD (Faraone & Larsson, 2019) and its effects on domestic social environments. If carers themselves have undiagnosed or untreated ADHD, they may exhibit ADHD-related behaviours such as impulsivity or executive dysfunction, which may compromise their emotional regulation and parenting capacities, potentially leading to more reactive and coercive discipline. These findings indicate a complex intergenerational pathway where ADHD-related traits in both the child and the carers, along with cultural expectations of obedience, may exacerbate carers’ frustration and increase the risk of verbal and physical aggression. Consequently, threats of violence and physical assault may reflect a maladaptive cycle of family interactions rather than isolated traumatic events. Future research should incorporate formal assessments of parental ADHD symptoms to further elucidate how these genetic predispositions and family dynamics jointly contribute to the distinct trauma profiles observed in adolescents with ADHD.

Exposure to violent or graphic media content was negatively associated with ADHD in our cohort. Although unexpected, this result likely reflects the weaker pathogenic effects of indirect trauma compared with direct victimisation. Observation of violence against others may exert less influence on internalising outcomes compared with direct victimisation (Schwab-Stone et al., 2013). Moreover, familiarity with digital media among individuals with ADHD may reduce their perception of graphic media content as threatening (Thorell et al., 2024). Collectively, these findings highlight the need for providers to distinguish between types of trauma when evaluating risk in ADHD populations.

Our results demonstrate that trauma imposes a disproportionate psychological burden in adolescents with ADHD. Despite comparable levels of overall trauma exposure between the ADHD and non-ADHD groups, adolescents with ADHD reported significantly stronger trauma reactions and greater depressive symptoms. In the ADHD group, trauma reactions were strongly associated with both depression and anxiety. Initially, this pattern suggested that ADHD might amplify the psychological effects of trauma (the vulnerability hypothesis).

To further investigate this hypothesis, we performed moderation analyses to determine whether ADHD diagnosis significantly amplifies the effects of trauma exposure on trauma reactions. Our results reveal that the interaction between ADHD and trauma exposure (ADHD × TEEQ) was not significant in the overall sample (p = .600) or in sex-stratified subgroups (male: p = .143; female: p = .392). These findings suggest that PTSD symptom severity (CRTES-R) and internalising symptom severity (CES-D) are greater among adolescents with ADHD but that these responses to trauma are primarily driven by these individuals’ higher baseline levels of anxiety and depression rather than a unique diagnostic sensitivity to trauma itself. In East Asian environments, where limited family openness may exacerbate emotional vulnerability, these results shift the clinical focus toward managing comorbid emotional distress as a primary pathway for reducing the trauma-related burden in this population.

Self-esteem exhibited a distinct pattern: although adolescents diagnosed with ADHD reported lower self-esteem than those without ADHD, these differences were unrelated to trauma reactions. Rather, consistent with prior studies (Jelinkova et al., 2024; Shi et al., 2022), low self-esteem among adolescents diagnosed with ADHD may stem primarily from symptom-related challenges and social stigma. Thus, although trauma contributes substantially to depression and anxiety in adolescents diagnosed with ADHD, self-esteem difficulties may arise more directly from their experiences of this disorder.

Clinically, these findings reinforce the need for trauma-informed assessment in ADHD care. Adolescents diagnosed with ADHD may not report more trauma overall but are disproportionately affected by direct interpersonal trauma and its psychological sequelae. Routine screening for physical and verbal aggression, particularly within family contexts, can be crucial in identifying adolescents at risk for depression and anxiety. Interventions should combine ADHD symptom management with targeted support for trauma-related emotional vulnerabilities, especially in cultural contexts where family structures and parenting styles may heighten these risks.

4.1. Limitations

This study has several limitations. First, the observational and cross-sectional design precludes attribution of causality. Whether trauma exposure contributes to the development and severity of ADHD or whether adolescents diagnosed with ADHD are more prone to encountering and internalising trauma remains unclear. Second, participants were recruited from two medical centres in southern Taiwan, potentially limiting the generalisability of our findings to adolescents in other regions, rural settings, or different sociocultural contexts. Third, the reliance on adolescent and caregiver self-reports introduces the possibility of recall and reporting bias, which may have influenced the accuracy of trauma exposure and psychological measures. Additionally, trauma exposure was assessed according to binary yes/no responses on the TEEQ scale. We did not collect detailed information on trauma severity or timing, restricting the depth of our analysis. Fourth, we were unable to obtain contextual details regarding whether interpersonal trauma took the form of parental abuse, peer bullying, or community violence. These types of trauma may have distinct psychological and developmental implications. Fifth, we did not assess family dynamics, parenting styles, or caregiver psychopathology, all of which can play key roles in both ADHD symptom expression and trauma processing. Finally, although we observed differences in trauma patterns between our East Asian setting and previously studied Western contexts, we did not directly examine the cultural factors underlying these discrepancies. Future research incorporating longitudinal designs, multiple informants, and culturally sensitive measures is needed to clarify the temporal and causal pathways between trauma exposure, trauma reactions, and ADHD.

5. Conclusion

We are among the first to investigate trauma exposure and internalisation in adolescents with ADHD in an East Asian context. Our findings demonstrate that adolescents with ADHD were more likely to encounter direct interpersonal trauma, particularly physical assault and threats of violence, and to exhibit stronger trauma reactions linked to depression and anxiety than their peers without ADHD. Conversely, adolescents with ADHD were less exposed to indirect media-related trauma. Although ADHD status did not significantly moderate the association between trauma exposure and reactions in our formal moderation models, trauma reactions remain key contributors to depression and anxiety in this population.

Collectively, these findings highlight the need for providers to distinguish between direct and indirect trauma when evaluating risk and to recognise that heightened trauma reactions in adolescents with ADHD are closely tied to comorbid internalising symptoms. Consequently, trauma-informed ADHD assessment and care must prioritise the management of these comorbid symptoms while incorporating familial and cultural factors. Future research should further clarify how cultural contexts and family dynamics influence ADHD–trauma pathways to inform the development of more tailored clinical interventions.

Acknowledgements

The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Funding Statement

This study was supported by a research grant from the National Science and Technology Council of Taiwan (NSTC 112-2314-B-037-035-).

Disclosure statement

No potential conflict of interest was reported by the author(s).

Ethical considerations

The Institutional Review Boards of Kaohsiung Medical University (KMUHIRB-SV(I)-20220103) and Chang Gung Memorial Hospital (202301118B0) approved this study.

References

  1. Barra, S., Turner, D., Müller, M., Hertz, P. G., Retz-Junginger, P., Tüscher, O., Huss, M., & Retz, W. (2022). ADHD symptom profiles, intermittent explosive disorder, adverse childhood experiences, and internalizing/externalizing problems in young offenders. European Archives of Psychiatry and Clinical Neuroscience, 272(2), 257–269. 10.1007/s00406-020-01181-4 [DOI] [PMC free article] [PubMed] [Google Scholar]
  2. Bauer, A., Fairchild, G., Hammerton, G., Murray, J., Santos, I. S., Tovo Rodrigues, L., Munhoz, T. N., Barros, A. J. D., Matijasevich, A., & Halligan, S. L. (2022). Associations between childhood trauma and childhood psychiatric disorders in Brazil: A population-based, prospective birth cohort study. The Lancet Psychiatry, 9(12), 969–977. 10.1016/s2215-0366(22)00337-6 [DOI] [PubMed] [Google Scholar]
  3. Brown, N. M., Brown, S. N., Briggs, R. D., Germán, M., Belamarich, P. F., & Oyeku, S. O. (2017). Associations between adverse childhood experiences and ADHD diagnosis and severity. Academic Pediatrics, 17(4), 349–355. 10.1016/j.acap.2016.08.013 [DOI] [PubMed] [Google Scholar]
  4. Chen, Y., & Lai, C. (2012). Psychometric properties of the Chinese version of the child's reaction to traumatic events scale. Formosa Journal of Mental Health, 25(2), 163–189. [Google Scholar]
  5. Chien, C. P., & Cheng, T. A. (1985). Depression in Taiwan: Epidemiological survey utilizing CES-D. Seishin Shinkeigaku Zasshi, 87(5), 335–338. [PubMed] [Google Scholar]
  6. Chien, W. C., Chung, C. H., Lin, F. H., Yeh, C. B., Huang, S. Y., Lu, R. B., Chang, H. A., Kao, Y. C., Chiang, W. S., Chou, Y. C., Tsao, C. H., Wu, Y. F., & Tzeng, N. S. (2017). The risk of injury in adults with attention-deficit hyperactivity disorder: A nationwide, matched-cohort, population-based study in Taiwan. Research in Developmental Disabilities, 65, 57–73. 10.1016/j.ridd.2017.04.011 [DOI] [PubMed] [Google Scholar]
  7. Cohen, A. J., Adler, N., Kaplan, S. J., Pelcovitz, D., & Mandel, F. S. (2002). Interactional effects of marital status and physical abuse on adolescent psychopathology. Child Abuse Neglect, 26(3), 277–288. 10.1016/s0145-2134(01)00325-8 [DOI] [PubMed] [Google Scholar]
  8. Copeland, W. E., Keeler, G., Angold, A., & Costello, E. J. (2007). Traumatic events and posttraumatic stress in childhood. Archives of General Psychiatry, 64(5), 577–584. 10.1001/archpsyc.64.5.577 [DOI] [PubMed] [Google Scholar]
  9. Crawford, E. F., Lang, A. J., & Laffaye, C. (2008). An evaluation of the psychometric properties of the traumatic events questionnaire in primary care patients. Journal of Traumatic Stress, 21(1), 109–112. 10.1002/jts.20280 [DOI] [PubMed] [Google Scholar]
  10. DePrince, A. P., Weinzierl, K. M., & Combs, M. D. (2009). Executive function performance and trauma exposure in a community sample of children. Child Abuse & Neglect, 33(6), 353–361. 10.1016/j.chiabu.2008.08.002 [DOI] [PubMed] [Google Scholar]
  11. Efron, D., Wijaya, M., Hazell, P., & Sciberras, E. (2021). Peer victimization in children with ADHD: A community-based longitudinal study. Journal of Attention Disorders, 25(3), 291–299. 10.1177/1087054718796287 [DOI] [PubMed] [Google Scholar]
  12. Faraone, S. V., & Larsson, H. (2019). Genetics of attention deficit hyperactivity disorder. Molecular Psychiatry, 24(4), 562–575. 10.1038/s41380-018-0070-0 [DOI] [PMC free article] [PubMed] [Google Scholar]
  13. Fuller-Thomson, E., & Lewis, D. A. (2015). The relationship between early adversities and attention-deficit/hyperactivity disorder. Child Abuse & Neglect, 47, 94–101. 10.1016/j.chiabu.2015.03.005 [DOI] [PubMed] [Google Scholar]
  14. Gau, S. S. (2007). Parental and family factors for attention-deficit hyperactivity disorder in Taiwanese children. The Australian and New Zealand Journal of Psychiatry, 41(8), 688–696. 10.1080/00048670701449187 [DOI] [PubMed] [Google Scholar]
  15. Gau, S. S., & Chang, J. P. (2013). Maternal parenting styles and mother-child relationship among adolescents with and without persistent attention-deficit/hyperactivity disorder. Research in Developmental Disabilities, 34(5), 1581–1594. 10.1016/j.ridd.2013.02.002 [DOI] [PubMed] [Google Scholar]
  16. Gau, S. S., Lin, C. H., Hu, F. C., Shang, C. Y., Swanson, J. M., Liu, Y. C., & Liu, S. K. (2009). Psychometric properties of the Chinese version of the Swanson, Nolan, and Pelham, Version IV scale-teacher form. Journal of Pediatric Psychology, 34(8), 850–861. 10.1093/jpepsy/jsn133 [DOI] [PubMed] [Google Scholar]
  17. Gray, M. J., Litz, B. T., Hsu, J. L., & Lombardo, T. W. (2004). Psychometric properties of the life events checklist. Assessment, 11(4), 330–341. 10.1177/1073191104269954 [DOI] [PubMed] [Google Scholar]
  18. Hennig, T., Jaya, E. S., & Lincoln, T. M. (2017). Bullying mediates between attention-deficit/hyperactivity disorder in childhood and psychotic experiences in early adolescence. Schizophrenia Bulletin, 43(5), 1036–1044. 10.1093/schbul/sbw139 [DOI] [PMC free article] [PubMed] [Google Scholar]
  19. Jelinkova, K., Charabin, E., Miller, C., & Climie, E. A. (2024). Self-stigma of Canadian youth with ADHD and their parents. Journal of Attention Disorders, 28(12), 1598–1611. 10.1177/10870547241273161 [DOI] [PMC free article] [PubMed] [Google Scholar]
  20. Konstenius, M., Leifman, A., van Emmerik-van Oortmerssen, K., van de Glind, G., Franck, J., Moggi, F., Ramos-Quiroga, J. A., Levin, F. R., Carpentier, P. J., Skutle, A., Bu, E. T., Kaye, S., Demetrovics, Z., Barta, C., Auriecomb, M., Fatséas, M., Johnson, B., Faraone, S. V., Allsop, S., … van den Brink, W. (2017). Childhood trauma exposure in substance use disorder patients with and without ADHD. Addictive Behaviours, 65, 118–124. 10.1016/j.addbeh.2016.10.016 [DOI] [PMC free article] [PubMed] [Google Scholar]
  21. Lugo-Candelas, C., Corbeil, T., Wall, M., Posner, J., Bird, H., Canino, G., Fisher, P. W., Suglia, S. F., & Duarte, C. S. (2021). ADHD and risk for subsequent adverse childhood experiences: Understanding the cycle of adversity. Journal of Child Psychology and Psychiatry, 62(8), 971–978. 10.1111/jcpp.13352 [DOI] [PMC free article] [PubMed] [Google Scholar]
  22. March, J. S., Parker, J. D., Sullivan, K., Stallings, P., & Conners, C. K. (1997). The Multidimensional Anxiety Scale for Children (MASC): Factor structure, reliability, and validity. Journal of the American Academy of Child and Adolescent Psychiatry, 36(4), 554–565. 10.1097/00004583-199704000-00019 [DOI] [PubMed] [Google Scholar]
  23. McLaughlin, K. A., Sheridan, M. A., Winter, W., Fox, N. A., Zeanah, C. H., & Nelson, C. A. (2014). Widespread reductions in cortical thickness following severe early-life deprivation: A neurodevelopmental pathway to attention-deficit/hyperactivity disorder. Biological Psychiatry, 76(8), 629–638. 10.1016/j.biopsych.2013.08.016 [DOI] [PMC free article] [PubMed] [Google Scholar]
  24. Nigg, J. T., & Casey, B. J. (2005). An integrative theory of attention-deficit/hyperactivity disorder based on the cognitive and affective neurosciences. Development and Psychopathology, 17(3), 785–806. 10.1017/s0954579405050376 [DOI] [PubMed] [Google Scholar]
  25. Ouyang, L., Fang, X., Mercy, J., Perou, R., & Grosse, S. D. (2008). Attention-deficit/hyperactivity disorder symptoms and child maltreatment: A population-based study. Journal of Pediatrics, 153(6), 851–856. 10.1016/j.jpeds.2008.06.002 [DOI] [PubMed] [Google Scholar]
  26. Park, S., Lee, J. M., Kim, J. W., Kwon, H., Cho, S. C., Han, D. H., Cheong, J. H., & Kim, B. N. (2016). Increased white matter connectivity in traumatized children with attention deficit hyperactivity disorder. Psychiatry Research: Neuroimaging, 247, 57–63. 10.1016/j.pscychresns.2015.09.012 [DOI] [PubMed] [Google Scholar]
  27. Schwab-Stone, M., Koposov, R., Vermeiren, R., & Ruchkin, V. (2013). Cross-cultural findings on community violence exposure and internalizing psychopathology: Comparing adolescents in the United States, Russia, and Belgium. Child Psychiatry and Human Development, 44(4), 516–524. 10.1007/s10578-012-0344-8 [DOI] [PubMed] [Google Scholar]
  28. Shi, H., Zhao, H., Ren, Z., Li, X., He, M., Zha, S., Qiao, S., Li, Y., Pu, Y., Liu, H., & Zhang, X. (2022). Associations of parent-adolescent relationship and self-esteem with emotional and behavioral problems among Chinese adolescents. Journal of Affective Disorders, 311, 126–133. 10.1016/j.jad.2022.05.078  [DOI] [PubMed] [Google Scholar]
  29. Shonk, S. M., & Cicchetti, D. (2001). Maltreatment, competency deficits, and risk for academic and behavioral maladjustment. Developmental Psychology, 37(1), 3–17. 10.1037/0012-1649.37.1.3 [DOI] [PubMed] [Google Scholar]
  30. Sibley, M. H., Ortiz, M., Graziano, P., Dick, A., & Estrada, E. (2020). Metacognitive and motivation deficits, exposure to trauma, and high parental demands characterize adolescents with late-onset ADHD. European Child & Adolescent Psychiatry, 29(4), 537–548. 10.1007/s00787-019-01382-w [DOI] [PubMed] [Google Scholar]
  31. Stickley, A., Koposov, R., Koyanagi, A., Inoue, Y., & Ruchkin, V. (2019). ADHD and depressive symptoms in adolescents: The role of community violence exposure. Social Psychiatry and Psychiatric Epidemiology, 54(6), 683–691. 10.1007/s00127-019-01662-5 [DOI] [PubMed] [Google Scholar]
  32. Thorell, L. B., Burén, J., Ström Wiman, J., Sandberg, D., & Nutley, S. B. (2024). Longitudinal associations between digital media use and ADHD symptoms in children and adolescents: A systematic literature review. European Child & Adolescent Psychiatry, 33(8), 2503–2526. 10.1007/s00787-022-02130-3 [DOI] [PMC free article] [PubMed] [Google Scholar]
  33. Yang, H. J., Soong, W. T., Kuo, P. H., Chang, H. L., & Chen, W. J. (2004). Using the CES-D in a two-phase survey for depressive disorders among nonreferred adolescents in Taipei: A stratum-specific likelihood ratio analysis. Journal of Affective Disorders, 82(3), 419–430. 10.1016/j.jad.2004.04.008 [DOI] [PubMed] [Google Scholar]
  34. Yen, C. F., Chou, W. J., Liu, T. L., Yang, P., & Hu, H. F. (2014). The association of Internet addiction symptoms with anxiety, depression and self-esteem among adolescents with attention-deficit/hyperactivity disorder. Comprehensive Psychiatry, 55(7), 1601–1608. 10.1016/j.comppsych.2014.05.025 [DOI] [PubMed] [Google Scholar]
  35. Yen, C. F., Yang, P., Wu, Y. Y., Hsu, F. C., & Cheng, C. P. (2010). Factor structure, reliability and validity of the Taiwanese version of the multidimensional anxiety scale for children. Child Psychiatry and Human Development, 41(3), 342–352. 10.1007/s10578-010-0172-7 [DOI] [PubMed] [Google Scholar]
  36. Zhang, N., Gao, M., Yu, J., Zhang, Q., Wang, W., Zhou, C., Liu, L., Sun, T., Liao, X., & Wang, J. (2022). Understanding the association between adverse childhood experiences and subsequent attention deficit hyperactivity disorder: A systematic review and meta-analysis of observational studies. Brain and Behavior, 12(10), e32748. 10.1002/brb3.2748 [DOI] [PMC free article] [PubMed] [Google Scholar]

Articles from European Journal of Psychotraumatology are provided here courtesy of Taylor & Francis

RESOURCES