Meta-analysis: ADHD may factor in involvement in intimate partner, sexual violence

Individuals with attention-deficit/hyperactivity disorder (ADHD) appear to be at increased risk of being involved in cases of violence, such as intimate partner and sexual violence, according to the results of a meta-analysis.

Pooled data from 14 studies, which involved 1,111,557 individuals, showed that individuals with ADHD had greater odds of being involved in intimate partner violence as perpetrators (six studies; odds ratio [OR], 2.5, 95 percent confidence interval [CI] 1.51–4.15) or victims (four studies; OR, 1.78, 95 percent CI, 1.06–3.0). [Psych Med 2023;doi:10.1017/S0033291723001976]

Likewise, individuals with ADHD had greater odds of being involved in sexual violence as perpetrators (three studies; OR, 2.73, 95 percent CI, 1.35–5.51) or victims (six studies; OR, 1.84, 95 percent CI, 1.51–2.24).

The findings were consistent across various analytical approaches.

Intimate partner violence and ADHD

“Our results on intimate partner violence are consistent with evidence that individuals with ADHD tend to have poorer intimate relationships and higher rates of ruptures,” the investigators said. [Arch Gen Psychiatry 2012;69:1295; J Atten Disord 2021;25:1466-1478; J Marital Fam Ther 2021;47:664-681]

“Adults with ADHD tend to be less satisfied in their relationships than individuals without ADHD. Conversely, the romantic quality of their partners is also lower, with almost all individuals indicating that symptoms interfere in the relationship,” they pointed out. [J Atten Disord 2004;8:1-10; J Marital Fam Ther 2021;47:664-681]

With ADHD being characterized as a disorder of self-regulation that includes control difficulties over the emotional domain, the combination of frustration building and poor behavioural and emotional control is believed to factor in the association between ADHD and intimate partner violence, both as victim and perpetrator. [Front Psychol 2019;10:1919]

“On the one hand, the core symptoms of ADHD could put individuals at risk of being victimized by individuals without ADHD but with violent tendencies. On the other hand, hyperactivity, impulsivity, and emotional dysregulation could facilitate the victimization of a partner by some individuals with ADHD,” the investigators explained.

Sexual violence and ADHD

How ADHD might be a risk factor both for being the victim or the perpetrator of acts of sexual violence during adolescence or adulthood could be partly explained by the fact that cases of sexual violence are largely limited to couples, according to the investigators. This is supported by the fact that two of the included studies reported that sexual violence occurred solely in the context of intimate partner violence. [Trauma Violence Abuse 2023;doi:10.1177/15248380221146800]

“If ADHD increases the risk of being involved in intimate partner violence, it could secondarily also increase the risk of sexual violence,” they said.

Other factors that could mediate the relationship between ADHD and involvement in sexual violence include alcohol intake and impulsivity/hyperactivity and inattentiveness by sex.

“Individuals with ADHD tend to drink more and … alcohol intake has also been linked to an increase risk of being a sexual victim or perpetrator,” the investigators noted. [Drug Alcohol Depend 2018;184:33-41; Trauma Violence Abuse 2023;doi:10.1177/15248380221146800]

Meanwhile, “impulsivity and poor self-control have been related to violent acts, whereas inattentiveness might put individuals at a greater risk of being victimized in general,” they added. “Since inattentive symptoms are more common in female individuals with ADHD, future studies might show an interaction between sex and role (victim/perpetrator) within violence.” [PLOS Med 2021;16:e1002995; J Interpers Violence 2021;36:NP3241-NP3262]

Not a cause for stigmatization

While the present data have important clinical and social relevance, the investigators emphasized that intimate partner and sexual violence are outcomes that are rare or do not occur frequently in the studied population.

“As such, the results should not be used to stigmatize individuals with ADHD, as most individuals with the disorder will not be involved in a case of intimate partner violence or sexual victimization,” they pointed out.

Then again, the risk increase for perpetrating or being the victim of violence should not be discounted, as intimate partner and sexual violence can have lasting consequences in people who suffer them, according to the investigators.

“[This study] should inform evidence-based psychoeducation with individuals with ADHD, their families, and partners about relationships and sexuality. By acknowledging that ADHD can increase the risk of being involved in a case of intimate partner violence or sexual violence, but also that this risk is moderated by many other contextual or personal factors, we can help individuals to be more aware of violence-leading situations and prevent them,” they said.

Most the studies included in the meta-analysis involved adolescents or young adults. ADHD was identified through symptom scales, self-reports, clinical diagnoses, or information in registers. Violence was evaluated through self-reported questionnaires and legal registries. Based on the Newcastle–Ottawa Scale, evidence of bias risk was seen in most studies with ascertainment of ADHD being the most critical item, and 65 percent of the studies were deemed at high risk of bias.