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5. Parents and family as ADHD risk factors

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5. Parents and family as ADHD risk factors

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The influence of parents and family on children’s ADHD risk can only be clearly classified as a physical or psychological cause in a few cases.
Examples: While physical illnesses of the parents indicate a genetic risk for the offspring and thus a physical cause, this is not clear in the case of mental disorders of the parents. In most cases, these represent a genetic risk, but usually also increase the psychological stress within the family. Low socio-economic status can be a consequence of parental ADHD (ADHD drastically impairs educational opportunities and career prospects) and can also have a psychological impact on children. Even parental behavior (“parenting”), which is certainly a psychological influencing factor, is also reciprocally influenced by ADHD symptoms in children.

Children whose parents were unmarried or unemployed or without social security or had a “very high” economic burden of childcare or where at least one parent had a disability certificate had a 21% increased risk of ADHD, a 36% increased risk of learning disability and an 80% increased risk of ASD at the age of 5.5 years. This affected 10.8% of the 19,185 children.1

5.1. Incomplete families

People with ADHD suffer more frequent separations in their relationships (even in adulthood) than people without ADHD. In this respect, the extent to which an increased divorce or separation rate is a consequence of ADHD in the parents, which is then also genetically transmitted to the children, and the extent to which incomplete / single-parent families contribute to ADHD is an open question.

5.1.1. Divorce (+ 193 % to + 384 %)

Divorce: children’s ADHD risk increased by 193% to 384% (meta-analysis, k = 11, n = 11,929)2 This result is not consistent with our experience. The value seems excessive to us.

5.1.2. Single parents (+ 61 %)

Single parent: 61% increased risk of ADHD (meta-analysis, k = 5, n = 1,174,547)2
Single-parent families increase the risk of ADHD in children.3456

Single parents naturally have a higher risk of not being able to give their children enough loving care and security. However, there are single parents who are very good at this. The decisive factor is not the amount of time that (part-time/working) parents can spend (less) with their children, but whether the children have the constant and secure feeling that they are accepted and loved at all times, just as they are.

5.2. Low socio-economic status of the family of origin (+ 63 % to + 310 %)

When determining the % values, the two lowest and the two highest values out of 9 values were not taken into account.

Children from “lower class” families are more likely to have ADHD74 8 and are more likely to receive ADHD medication.95
Children from the lower stratum have about twice the risk of ADHD (+100%) as children from the highest stratum (in a 3 stratum model).10

Cramped living conditions also increase the risk of ADHD in children4
Poor family financial resources correlated with a 2.12-fold risk (+112%) of ADHD symptoms at kindergarten age in the US.11

The overall prevalence of ADHD in children and adolescents was found to be 2.2% in the 2007 Bella study12 (which we consider to be too low). A Bella sub-study with n= 2500 subjects between the ages of 7 and 1713 puts the prevalence in the parents’ assessment at around 5%. Both studies confirm a strong divergence in prevalence according to social class. According to the 2007 Bella study, the middle class has an average prevalence of 2.3%, while the lower social class has a prevalence of 3.7%, which is more than four times as high (+ 310%) as the upper class (0.9%).14 The Bella sub-study reports an approx. 2.57-fold prevalence of ADHD (+ 157 %) in the lower social stratum (at 7.2 %) than in the upper stratum at 2.8 % (with 3 strata).13
In a Danish cohort study, the children’s risk of ADHD increased15

  • by 2.1 percentage points (+ 57 %) for parents with a low income
  • by 2.3 percentage points (+ 63 %) if the parents are unemployed
  • by 3.5 percentage points (+ 95%) for parents with a low level of education
  • by 4.9 percentage points (+ 133 %) when all three criteria were met.

The fact that this pattern is not limited to ADHD, but is found identically in other mental disorders, e.g. anxiety, depression or disorders of social behavior, is seen by us as strong evidence to confirm the thesis of stress as the cause of mental disorders. These other mental disorders, like ADHD, are also based on a multigenetic disposition that is epigenetically manifested by stress exposure in early childhood.161718

⇒ Candidate genes and early childhood stress as a cause of other mental disorders

Interestingly, in one study, families with a high socioeconomic status did not benefit from behavioral therapy in addition to drug treatment. Only families with a low socioeconomic status benefited more from a combination therapy of medication treatment and behavioral therapy than from medication treatment alone.19

We suspect that the decisive factors are not so much socio-economic status (income or the size of the home itself), but that these circumstances correlate more frequently with inappropriate parenting methods and parents’ own problems (the latter influencing the socio-economic status of the parents on the one hand and being hereditary on the other).
Pure behavioral therapy has a clear focus on symptom reduction. It is conceivable that families with a high socioeconomic status have a greater ability to adapt their behavior to given circumstances. Such a higher ability to adapt behavior would already have a behavior-correcting effect per se and would anticipate the behavioral adaptations through behavioral therapy.

Parents of ADHD children showed elevated scores of cognitive weaknesses (IQ, reading tasks, verbal fluency), the highest stress scores of all parent groups compared, the most ADHD symptoms, and poor reading performance.20

There is also evidence that (with regard to people with ADHD) environment-centered psychotherapies (interventions in the family, with parents, in kindergarten or at school) are more effective than patient-centered behavioral therapies. In some cases, patient-centered behavioral therapies have been denied effectiveness.21 This is likely to be particularly true for younger children (up to 6 or 8 years).
This could indicate that external factors are a significant cause of ADHD in children.

Among college students, poorer financial resources also appear to correlate with increased ADHD symptomatology.22 There was no correlation with (self-induced) student debt.

A genetically predicted one SD lower socioeconomic status causally predicted a 5.3-fold ADHD risk (+ 430%), while conversely ADHD only very slightly causally caused socioeconomic status. A genetically predicted one SD higher family income causally predicted a 65% lower ADHD risk. Again, the reverse effect was small.23

5.3. Diabetes of the parents (up to + 286 %)

5.3.1. Diabetes of the father (+ 286 %)

Among 5-year-old children, the risk of ADHD was increased by 286% if the father had diabetes.24 The question was “Does the father of the newborn currently have diabetes mellitus diagnosed by a doctor?”, so the type was not determined.25

5.3.2. Gestational diabetes of the mother (+ 53 %)

Gestational diabetes in the mother increased the risk of ADHD in the offspring by 53%.26

5.4. Heart disease of the mother (+ 189 %)

Among 5-year-old children of mothers, the risk of ADHD was increased by 189% if the mother had heart disease at birth.24

5.5. Psychological problems of the parents (up to + 125 %)

Parental mental health problems increase the risk of ADHD in children.275
Parental mental health problems could be an environmental and/or genetic influence.

5.5.1. Depression (+ 42 to 125 %)

Depressive symptoms in the father or mother increase the children’s risk of ADHD8

  • by 66 %28
  • by 42 % to 125 %:29
    • before pregnancy
      • Depression of a parent:
        • ADHD + 92 %
        • ASS + 63 %
      • Depression of the mother:
        • ADHD + 125 %
        • ASS + 101 %
    • during the birth
      • Depression of a parent:
        • ADHD + 72 %
        • ASS + 88 %
      • Depression of the mother:
        • ADHD + 75 %
        • ASS + 58 %
    • in the first year of the child’s life
      • Depression of a parent:
        • ADHD + 71 %
        • ASS + 110 %
      • Depression of the mother:
        • ADHD + 55 %
        • ASS + 59 %
    • in the 2nd to 4th year of the child’s life
      • Depression of a parent:
        • ADHD + 52 %
        • ASS + 101 %
      • Depression of the mother:
        • ADHD + 55 %
        • ASS + 64 %
    • from the age of 4 of the child
      • Depression of a parent:
        • ADHD + 42 %
        • ASS + 85 %
      • Depression of the mother:
        • ADHD + 43 %
        • ASS + 65 %
  • maternal depression increases the risk of ADHD and ASD in offspring more than paternal depression30

5.5.2. Bipolar Disorder (+ 100 %)

  • Bipolar Disorder in a parent doubles the risk of ADHD31

5.5.3. Antisocial personality disorder of the father

Antisocial Disorder in a parent is a huge (and usually violent) risk for ADHD in the offspring.4

5.5.4. Alcohol problems of the father

Alcohol problems in the father increase the risk of ADHD in the offspring.3

5.5.5. ADHD of the parents

Parents with ADHD not only increase the risk of the child inheriting ADHD genetically, but also independently increase the risk of being taught dysfunctional lifestyle habits. At the same time, it can be an advantage for a child with ADHD if parents have learned to cope well with their ADHD and are therefore much more aware of functional compensatory coping strategies. However, there is a not insignificant proportion of parents who are themselves affected and do not want to admit this to themselves. This often leads to additional conflicts due to a more or less conscious rejection of the behavior of the person with ADHD, for which the child is not responsible.
Furthermore, even the most committed parents - like everyone - may not always be up to date with their own theory.

One study examined the influence of mothers’ ADHD on children’s ADHD to determine whether parent-child similarity improves or worsens parenting. Children’s ADHD symptoms correlated with mothers’ negative comments and mothers’ ADHD symptoms correlated with mothers’ expressed negative emotions. Nevertheless, maternal ADHD symptoms appeared to moderate the effects of children’s ADHD symptoms on negative parenting. Parents’ responses to children with severe ADHD symptoms were more positive and affectionate when the mother also had severe ADHD symptoms.32
Another study from 2006 found that 95% of Polish parents physically punished their children, which can be considered abuse. Parents with ADHD used more severe forms of corporal punishment. Parent training resulted in 72% of parents using other forms of punishment.33 Also among Iranian parents, those with ADHD used corporal punishment more often and showed less parental warmth.34

Mothers with ADHD showed more problems monitoring their children’s dental care and health.35
On the other hand, children with ADHD symptoms in Spain had a higher risk of36

  • Caries (OR: 2.16)
  • Extraction (OR: 1.42)
  • Restoration (OR: 1.47)
  • Bleeding gums (OR: 1.64)
    The increased caries risk persisted even when the analyses were restricted to middle/higher social class families and children with low sugar consumption, good oral hygiene habits and regular visits to the dentist.

5.6. One parent in prison (+ 10 % to + 114 %)

Incarceration of a parent: 10% increased risk of ADHD (meta-analysis, k = 3, n = 4,073)2 A registry study found a 114% increase in the risk of ADHD between the ages of 3 and 5 (HR = 2.14) (registry study, n = 631,695).37

5.7. Unintended pregnancy (+ 105 %)

A prospective cohort study (n = 7,910) over 16 years found that unintended pregnancy correlated with hyperactivity symptoms in the children at age 8 (+ 108%), but not with ADHD symptoms at age 16 (+ 13%, not significant).38

5.8. Low level of education of parents (+ 3.5 % to + 95 %)

The benchmark in each case is the highest educational qualification achieved.

5.8.1. Level of education and ADHD risk

Low education of the mother39 or the parents3 increases the children’s risk of ADHD.
Children of parents without a university degree had twice the risk of ADHD as children of parents with a university degree40
A lower level of education of the mother is said to correlate with an increased screen consumption of the children, which in turn correlates with behavioral problems.41
In a cohort study in Denmark, a low level of parental education correlated with a 3.5% increased risk of ADHD in children.15 Children of parents who were unemployed and had a low income and a low level of education were found to have a 4.9% higher risk of ADHD.
An Ethiopian study found an approximately tripled risk of ADHD in children due to illiteracy of the mother42

  • by 72% if the mother has a college degree (college/university) in 5-year-old children in a cohort study in Taiwan 24 (not statistically significant)
  • by 50% for a senior high school graduation (12th grade) of the mother in 5-year-old children in a cohort study in Taiwan 24 (not statistically significant)
  • by 94% for a junior high school graduation (9th grade) of the mother in 5-year-old children in a cohort study in Taiwan 24 (not statistically significant)
  • by 29% for elementary school graduation (6th grade) of the mother in 5-year-old children in a cohort study in Taiwan 24 (not statistically significant)

In a Danish cohort study, the children’s risk of ADHD increased15

  • by 3.5 percentage points (+ 95%) for parents with a low level of education

A genetically predicted one SD higher educational attainment causally predicted a 70% lower risk of ADHD.23

5.8.2. Education level and ADHD severity and treatment

Children of parents with low educational attainment had more severe ADHD symptoms and a nearly doubled risk of severe ADHD symptoms. The association was independent of genetic and family environmental factors. The transfer of this model to depression was weaker and could be fully explained by common genetic factors43
Children of parents with poorer education were significantly less likely to receive adequate treatment for their ADHD.44

5.9. Injuries to a parent (+ 69 %)

Children and adolescents (aged 5 to 17) whose parent had to receive medical treatment for an unintentional injury showed in a registry study:45

  • a 69% increased risk of ADHD
  • a higher Washington Group Composite Disability Scores (OR 1.77)
  • a 129% higher risk of personal injury
  • 49% higher risk of own emergency doctor visits

It remains an open question whether the increases in risk are a psychotraumatic consequence of the parent’s injury or a consequence of the fact that the genetic heritability of ADHD is 80% and the parent’s injury was a consequence of their own ADHD, as ADHD is known to carry a higher risk of injury or emergency room visits.

5.10. Age of parents (+ 14 % to + 66 %)

5.10.1. Young age of parents (+ 14 % to + 66 %)

A Danish coparent study (n = 943,785) found a more than doubled risk of ADHD if the parents were 20 years old or younger, compared to parents 26 to 30 years old.46 Children whose mother does not have ADHD have a 14% increased risk of ADHD if one parent is younger than 20 years old. Children whose mother has ADHD have a 92% increased risk of ADHD if one parent is younger than 20.4748 Another study also reported that younger fathers were more likely to have children with ADHD than older fathers.49 One study reported a 32% reduced risk of ADHD for every 10 years increase in maternal age. However, the correlation was attenuated by other factors. These were:50

  • Family income
  • Training of the caregiver
  • Polygenic ADHD risk score
  • Duration of breastfeeding
  • Prenatal alcohol exposure
  • Prenatal tobacco exposure

In a cohort study, children with ADHD also had younger than average mothers51
under 24 years: 1.66 times (+ 66 %)
25 to 29 years: 0.92 times (minus 8 %)
30 to 34 years: 0.66 times (minus 34%)
over 35 years: 0.58-fold (minus 42 %)

Another study also reports this, supplemented by an increase in learning problems among particularly young (20 to 24 years) and particularly old mothers (35 to 39 years).52

In a larger study, almost 2 out of 3 young mothers reported at least one mental health problem. Almost 40% had more than one. Young mothers were two to four times more likely to have an anxiety disorder (generalized anxiety disorder, separation anxiety disorder, social phobia and specific phobia), attention-deficit/hyperactivity disorder, oppositional defiant disorder or conduct disorder than older comparison mothers or women aged 15-17, and two to four times more likely to have more than one psychiatric problem.53

One study found no correlation between the age of the mother and the offspring’s risk of ADHD.54

5.10.2. Increased age of the mother (+ 55 %)

A Taiwanese cohort study found a 55% increased risk of ADHD in 5-year-old children of older mothers24 of 35 years and older25.

5.11. Employment status of parents

5.11.1. Unemployment of parents (up to + 63 %)

Unemployment of parents correlated with an increased risk of ADHD in children

  • by 48% at the age of 5 years if the mother was unemployed in a cohort study in Taiwan, compared to children of mothers who worked during the day (not at night / in shifts / in alternating shifts)24
  • by 4.9 % in children of unemployed parents with a low income and low level of education. Unemployment or occupational problems of the parents increased ADHD symptoms in children.6
  • by 2.3 percentage points (+ 63 %) in a cohort study in Denmark15

5.11.2. Occupation of the mother

The risk of ADHD was increased among 5-year-old children of working mothers

  • by 84 % when switching between night-time and daytime working hours24 (not statistically significant)
  • by 73 % when mothers work at night24 (not statistically significant)
  • by 12 % for working hours that took place during the day and at night24 (not statistically significant)

5.12. Thyroid problems in the mother (+ 23 %)

However, maternal hyperthyroidism, which was first diagnosed and treated after the birth of the child, increased the risk of ADHD in the child by 23%, while hypothyroidism diagnosed in this way increased the risk of ASD by 34%.55

5.13. Parenting / parental behavior

The influence of family factors on the development and maintenance of mental disorders in children and adolescents, has been extensively studied.56

5.13.1. Attachment behavior of parents in the (first) years of childhood

5.13.1.1. Poor bonding behavior of the mother/parents in the (first) years of childhood

A child’s lack of secure attachment to the mother, like social and emotional deprivation, has extensive negative effects on the child’s mental health, even later in life.57 Insecure attachment promotes ADHD (meta-analysis, k = 29)58

The security of the infant’s bond with the mother or the central caregiver determines the level of the stress hormone cortisol in the baby’s brain.

Disorganized attachment behavior is a risk element for ADHD.59 Attachment disorders in children in the first years of life lead to activation of the DRD4 gene, which is also frequently involved in ADHD, if there is a corresponding genetic disposition.60 A lack of parental persistence has been cited as a risk factor for ADHD,61 whereby persistence is an ADHD symptom and can therefore also be an expression of ADHD in the parents and thus of genetic transmission.

Massive maternal stress in the first years of childhood causes significant epigenetic changes in the children’s DNA.62

Borderline, which typically results from intense stress-inducing attachment disorders with attachment figures in early childhood (first 2 years) due to physical, sexual or psychological abuse, has a significant comorbidity with ADHD.63

5.13.1.2. Emotionally withdrawn father behavior in infancy

One study observed father-baby behavior and its influence on children’s emotion regulation in infancy and ADHD symptoms in middle childhood.
Fathers’ emotional withdrawal in infancy and minimizing responses to children’s anxiety in toddlerhood predicted the development of ADHD symptoms in middle childhood. Fathers’ parenting performance at 8 and 24 months of children’s age significantly influenced ADHD risk at age 7 years through toddlers’ difficulties with emotion regulation64

5.13.3. Parents’ parenting behavior

Parental education is likely to have only a minor influence on the development of ADHD in children. The influence on how well children can cope with existing ADHD is likely to be stronger.

Nevertheless, numerous studies confirm an influence of parental education on ADHD in children 65 66 67 68 69 70 71 72 73 74 75 76 7778

SHR, an ADHD model animal, was raised by non-ADHD rat mothers, and vice versa. This showed that79

  • motor hyperactivity depended entirely on the parentage
  • the social behavior was primarily determined by the rearing mother
  • attentional orienting behavior was influenced by both the parentage of the offspring and the parentage of the mother
  • the anxiety-related behavior was influenced by an interaction between the parentage of the offspring and the mother

Enriched environment, an environment with plenty of stimulation and manageable challenge, reduced ADHD symptomatology in SHR.80

A distinction must be made in parental education between56

  • Attitude (parents’ internalized cognitions and beliefs about parenting, including parental goals and knowledge)
  • Behavior (way of acting in certain situations)
    even if the behavior is strongly influenced by the attitude.

5.13.3.1. Authoritative parenting style

Authoritative parenting involves clear expectations, consistent rules and a supportive, nurturing environment.
Discipline: Focuses on teaching, with explanations of rules and consequences.
Communication: Open and reciprocal. Parents actively respond to the children’s perspectives.
Results: promotes high self-esteem, academic success and social skills in children.
An authoritative parenting style correlated with

  • less frequent cyberbullying81
  • less problematic Internet use81
  • promoted a more positive parent-child relationship81
    • which in turn contributed to a reduction in cyberbullying and problematic internet use
  • less common ADHD82

5.13.3.2. Authoritarian parenting style

Authoritarian education emphasizes high standards, strict rules and obedience.
Little warmth or responsiveness from parents.
Discipline: Punishment-oriented, with little explanation or consideration of the child’s perspective.
Communication: One-way, with limited dialog or opportunities for children to express their opinions.
Results: impairs self-esteem83, promotes anxiety and emotion regulation problems in children
An authoritarian parenting style

  • correlated with more frequent ADHD8284858186
  • increased learning problems81

5.13.3.3. Permissive parenting style

Permissive parenting has few requirements, few rules and provides little structure, combined with a high degree of warmth and responsiveness.
Discipline: indulgent, with a tendency to avoid confrontation or setting boundaries.
Communication: Very open and accepting, children are often treated as equals.
Results: May promote impulsivity, difficulty with self-control, and risky behavior.
A permissive parenting style correlated with

  • more frequent ADHD than with the authoritative parenting style, but less frequent ADHD than with the authoritarian parenting style82
  • less common ADHD than authoritarian and overreactive parenting style84

5.13.3.4. Overreactive parenting style

  • aDHD more common than permissive parenting style84

5.13.3.5. Overprotective parenting style

  • more frequent ADHD8786
  • frequent fear87

Parental warmth and consistency have a positive effect on the social-emotional behavior of children with ADHD.88

A distinction must also be made between:89

  • positive parenting behavior56
    • Emotional responsiveness, parental warmth (the extent to which parents are supportive, accepting, nurturing and warm towards their child)90
      • SMD minus 0.16 (reduced risk of ADHD; meta-analysis, k = 10, n = 2,475)2
    • Behavioral control (parental practices such as guidance, leadership, limit setting, and monitoring where children can identify clear and consistent expectations that help them regulate their behavior)
    • Granting autonomy (the extent to which parents support their children’s autonomy, i.e. the independence with which children are allowed to act and make decisions for themselves)91
  • negative parenting behavior56
    • Overreaction92
    • Psychological control (intrusive and manipulative parental behaviors specifically designed to control the child, taking advantage of the emotional parent-child relationship)
      • SMD 0.17 (meta-analysis, k = 4, n = 682)2
    • Strict control (a range of highly destructive parental practices such as psychological and physical punishment, neglect and intrusiveness)
      • SMD 0.19 (meta-analysis, k = 7, n = 3,407)2
    • Mistreatment
      • physical and emotional abuse, neglect, sexual abuse or unspecified maltreatment: 627% increased risk of ADHD (meta-analysis, k = 6, n = 1,878)2
      • physical abuse: SMD 0.39 (meta-analysis, k = 4, n = 1,406)2

There are feedback effects:93

  • a genetically determined impulsiveness and social withdrawal of the child promoted a strict parental upbringing
  • a genetically determined sunny disposition of the child promoted parental warmth
  • genetically influenced characteristics of the children reinforced positive parental influences on the child’s development or protected the children from strict parental upbringing

Parental parenting behavior was also found to have a significant impact on the child’s ADHD symptoms.

  • ADHD symptoms of the raising mother and hostile parenting behaviors promoted ADHD symptoms of the child in adoptive families as well94
  • genetic ADHD-related temperament traits in the child promoted hostility in genetically unrelated mothers, which in turn increased ADHD symptoms in the child94

Details

How much time parents can spend with their children is not the decisive factor. It is much more important that children can absolutely rely on the fact that they are accepted, welcome and loved in every situation and especially when they misbehave. This does not mean that children are allowed to do whatever they want. Good, warm parenting is able to consistently limit inappropriate behavior by evaluating undesirable behavior without simultaneously devaluing the child as a person (your behavior is not ok, you are ok). A lack of rules (and even worse: rules that only sometimes apply) are barely tolerable for children because they take away all security. The question of a mandatory “parenting license” is the subject of legal and ethical discussions.73

Figures

10.5 million households in Germany have dogs.95(Stand 2014)
8.1 million families in Germany have underage children (as of 2014).
A Google search for parenting course OR parenting courses finds 169,000 results. (20.10.2015)
A Google search for dog school finds 1,240,000 results. (20.10.2015)

5.14. Stress in the mother during childhood

Stress in the mothers of 5- to 13-year-old boys with ADHD tended to increase their ADHD symptoms 12 months later and significantly worsened the children’s quality of life.96. Parental stress generally correlated with increased ADHD symptoms in children.6

5.15. Family instability, constant arguments between the parents

A high level of stress in the primary family correlates with an increased risk of ADHD.3456

Family conflicts and ADHD

“Chronic family conflicts, reduced family cohesion and confrontation with parental psychopathology (especially on the mother’s side) are found more frequently in families with people with ADHD than in control families”.97
The risk of children developing ADHD (odds ratio) increases with the level of psychosocial stress (Rutter indicator, RI). With an RI of 1, the odds ratio is 7, with an RI of 4 it is 41.7 (68). Odds ratios > 1 indicate an increased risk.98

Progression studies do not find complete persistence even during childhood and adolescence and confirm a frequent coincidence with family problems and parental problems.99 Conversely, a high level of family cohesion and social support has a protective effect against ADHD.100

5.16. Parents are less able to reflect on their parental role

Lower parental reflective functioning correlated with ADHD in children.8 Parental reflective functioning is defined as the parents’ ability to reflect on their own and their child’s inner mental experiences.

5.17. Maternal nasal allergy

Among 5-year-old children, the risk of ADHD was increased by 41% if the mother had a nasal allergy, although the result was not statistically significant by a narrow margin (p = 0.059)24

5.18. High blood pressure in the mother

Among 5-year-old children, the risk of ADHD was increased by 137% (not statistically significant) if the mother had hypertension.24 The information was collected by asking “Do you currently have hypertension diagnosed by a doctor?”. According to Taiwanese guidelines for the prevention and control of hypertension, a diagnosis requires at least three blood pressure measurements and the average of three separate measurements taken at different times, consistently showing a systolic blood pressure of ≥ 140 mmHg or a diastolic blood pressure of ≥ 90 mmHg.25

5.19. Family factors with risk reduction for ADHD

Immigrant status of parents causes a reduced risk of ADHD101 within the first 2 generations.102

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