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4. Psychological ADHD risk factors

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4. Psychological ADHD risk factors

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Author: Ulrich Brennecke
Review: Dipl.-Psych. Waldemar Zdero

Traumatizing experiences, but also stressful experiences that already cause considerable stress below the threshold of trauma, are risk factors for ADHD. Social risk factors increase the risk of ADHD.12
Massive maternal stress in the first years of childhood causes significant epigenetic changes in the children’s DNA.3

Stress in adolescence and childhood is a common cause of mental health problems later in life.4 For example, early childhood stress permanently changes the expression of corticoid receptors and thus the reaction of the HPA axis to acute and chronic stress.5 A basic description of the effects of early childhood stress and its epigenetic manifestation can be found in Eckerle.6

Early childhood or chronic stress, including traumatic experiences, also plays a role in the development of ADHD. Children who experience early childhood trauma, such as maltreatment, sexual abuse, separation from a caregiver, hostile parental behavior or war experiences, have an increased likelihood of developing ADHD symptoms. Conversely, studies show that people with ADHD have experienced a significantly higher number of traumatic events, especially in the context of relationships.
Traumatizing experiences can permanently change the dopaminergic system in the brain and thus increase the risk of ADHD.#

4.1. Growing up in a home (up to + 500 %)

Children who were exposed to multiple drug use by their mothers before birth and who subsequently grew up in institutions were found to be three times more likely to have ADHD between the ages of 17 and 227, corresponding to a prevalence of around 20%.89 In US child welfare agencies, the prevalence of ADHD is almost quadrupled at 19%.10
27% of former institutionalized children in Bucharest had ADHD at 4.5 years or 12 years or both.

Another study did not find an increased ADHD prevalence of 5.8% in homes without depriving living conditions, but a significantly increased ADHD prevalence11 of almost 4 to 7 times (19% to 29.3%) in children who had grown up for six months or longer in the harsh living conditions of Romanian orphanages.12
The later the adoption from the home, the higher the prevalence of ADHD.131415

4.2. Trauma as a cause of ADHD

4.2.1. Early childhood or chronic stress as ADHD risk (up to + 420 %)

Early childhood stress and chronic stress (neglect, deprivation, abuse, trauma) can be involved in the development of ADHD.162917
20% to 50% of all children who experience early childhood trauma develop clinical ADHD symptoms.161819

The number of stressful life events (measured with the Traumatic Events Screen Inventory for Children) correlated with more severe ADHD.20 The number of Adverse Childhood Experiences (ACEs) increased the risk of ADHD:21

  • 1 ACE: 2.1 times the risk of ADHD
  • 2 ACEs: 4.5 times the risk of ADHD
  • 3 and more ACEs: 5.2 times the risk of ADHD
  • Estimates of ADHD symptoms were higher for sexual abuse, emotional and physical neglect, and bullying.

The number of traumas correlates with the severity of ADHD22 as well as with the risk of ADHD.
Early childhood trauma (ACE) increased23

  • Hyperactivity and inattention more common in women than in men
  • Hyperactivity and inattention roughly equal in women
  • Hyperactivity in men stronger than inattention
  • Aggressiveness in women, mediated by ADHD symptoms

ADHD symptoms correlate with:24

  • K-SADS-PL values for post-traumatic stress disorder at the age of 14 and 1525
  • sexual and physical abuse before the age of 16 or 172627

A natural disaster during early childhood increased the risk of ADHD.28

A study of stress levels in children with ADHD found that severe stress levels in childhood and adolescence were associated with severe ADHD-HI or ADHD-I progression into adulthood, while children with low stress levels in childhood and adolescence often showed remitting ADHD (ADHD-HI as well as ADHD-I).29
Home eviction as a stressful experience correlated with increased depression and anxiety, but not with increased ADHD.30

The stress caused by early separation from the mother triggered hyperactivity and inattention in rats, which could be eliminated by MPH.31

Epidemiological data show that ADHD is associated with significantly increased levels of psychological stress. The functional changes in ADHD and PTSD are very similar. Several processes of stress-related disorders are likely to be extremely important in the etiopathogenesis of ADHD. Trauma or chronic stress in childhood is a high risk factor for severe mental health problems in adolescence or adulthood and is associated with neurobiological changes that impair attention, cognition and emotion regulation.32

Many children and adults with ADHD describe sexual abuse and/or other types of traumatization.33

A number of studies confirm a disproportionately high frequency of early trauma in people with ADHD compared to those not affected.343536373839404142434445 The same applies to brain injury trauma and otorhinological trauma. There is debate as to whether causation is involved or whether the symptoms of ADHD and trauma overlap 464748495051
Trauma is generally described as a contributory cause of psychological problems.5253

Early childhood stress (singular traumatic stress) and chronic stress are involved in the development of ADHD.16 A Swedish cohort study found 1.8 times more traumatic life events in persons with ADHD than in people without ADHD.54

20% to 50% of all children who experience early childhood trauma develop clinical ADHD symptoms.161819
Childhood maltreatment correlates with an increased risk of ADHD in adults.555657585960 Children with ADHD are more likely to be abused. One study found that girls with ADHD were three times more likely to be abused than girls without ADHD , while another study found that children with ADHD were also three times more likely to be abused, twice as likely to be physically abused and two and a half times as likely to be emotionally abused.616263
Child maltreatment, especially emotional maltreatment, also correlates with increased emotional dysregulation and reactivity.55

One study found a highly significant increase in the frequency of traumatic experiences among people with ADHD.64 The non-interpersonal events were barely increased, while the interpersonal events were massively increased compared to those not affected. More on this at ⇒ Trauma as a cause of ADHD.

Traumatizing experiences are intense stress experiences in the broader sense, e.g:

  • Frequent separation from the caregiver without replacement
  • Deprivation (emotionally poor relationship between parents and child)
  • Hostile / helpless behavior of the parents towards the child
  • Long-lasting couple conflicts / marital problems of the parents
  • Loss of parents65
  • War experiences
    A study of kindergarten-age children of refugees from war-torn regions showed that they were more “fidgety”, had an enormous urge to move and found it harder to concentrate. At the same time, they were described as being so traumatized that a hot glue gun made them cry. 66
  • Shocks (e.g. noise shock)
  • Ultimately, it can be any event that is associated with a subjectively perceived loss of control and/or danger to life

A person with ADHD reports

A person with ADHD-HI:
My mother is definitely a person with ADHD-HI. Nevertheless, I always felt securely loved by my parents and my grandmother, who was my main caregiver.
My family reports that I was a pure ray of sunshine as a baby (wish child): cheerful, slept well, everything was wonderful. Until I suffered a noise shock at the age of 2.5 (New Year’s Eve firecrackers right outside the bedroom window). My parents claim that I didn’t sleep at all for 3 months after that. Whether this is true or not - from this time onwards, according to their reports, I was exhausting and anxious. I would crawl under tables trembling, especially in front of jet fighters (which at that time were still breaking through the sound barrier and therefore making a huge bang). During thunderstorms at night, I fled to my parents’ bed in a panic until I was 12 or 14. Falling asleep was a drama for decades.

ADHD risk increases with the level of stress exposure

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 41.7.67
Odds ratios > 1 indicate a multiplication of the risk. An OR of 2 stands for a doubled risk, an OR of 3 for a tripled risk.
Disorganized attachment behavior is a risk element of ADHD.68 Attachment disorders in children in the first years of life lead to an activation of the DRD4 gene if there is a corresponding genetic disposition, which is also common in ADHD.69

Massive maternal stress in the first years of childhood causes significant epigenetic changes in the children’s DNA.3

Emotional abuse and physical abuse significantly increase the risk of ADHD and the symptoms of ADHD, as do unfavorable living conditions and school anxiety.70

A study of 110 boys found a highly significant increase in the frequency of traumatic experiences among people with ADHD.64

The Life Incidence of Traumatic Events (LITE-P) test asks:

  1. Child involved in car accident
  2. Child injured in another accident or in hospital
  3. Nearby person injured
  4. Family member in hospital
  5. Death of a family member
  6. Friend ill or died
  7. Child experienced fire
  8. Child experienced natural disaster
  9. Mutual injury/destruction of things between adults
  10. Separation / Divorce Parents
  11. Maltreatment of the child
  12. Child tied up / locked up
  13. Abuse of the child
  14. Child threatened
  15. Child robbed

On average, the 65 boys with ADHD had experienced almost every type of trauma more frequently than the 45 boys in the comparison group. The interpersonal events (traumas in the relationship context) were significantly higher than the non-interpersonal events compared to those not affected. The number of relationship-relevant IPE traumas also correlates with the intensity of hyperactivity and overall symptoms. In terms of age, inattention symptoms also correlate highly significantly with the number of IPE traumas.
Several other studies have come to similar conclusions.7172
Trauma from emotional neglect or abuse significantly increased the likelihood of ADHD.73

Unpredictable/conflicting rules or signals from parents or caregivers are another cause of early childhood stress. An increased incidence correlates with a higher likelihood of a mental (ADHD, anxiety, depression, externalizing problems, sleep disorders) or physical (obesity, abdominal pain, asthma, headaches) health diagnosis. Including unpredictable/conflicting rules or signals in the stress screening (QUIC-5) can explain risks for depression, obesity and sleep disorders that were missed by previous screening methods (PEARLS).74

Another cause
In contrast, another study reported that victimizing trauma increased the likelihood of ODD, but not ADHD.75

Assuming that one third76 to one half of all children and two thirds of all children in psychiatric samples exhibit trauma, a frequent overlap between ADHD and early childhood trauma is to be expected.77 However, this alone does not explain why the studies on trauma as a (co-)cause of ADHD predominantly found a higher number of early traumas in persons with ADHD than in non-affected people.78

A Finnish nationwide retrospective cohort study (1998 to 2018) of pediatric traumatic brain injury patients (n > 126,000) found a significant association between pediatric traumatic brain injury and post-traumatic ADHD medication use during a 20-year follow-up, the association was particularly pronounced after 4 years.79
Neurodegeneration due to craniocerebral trauma, subsequent neuroinflammation and oxidative stress was assumed to be the pathway of action, which could impair brain development and neurotransmitters and increase the risk of neurodevelopmental disorders.80

Another pathway for the development of ADHD is considered to be the interaction of early childhood trauma with genetic causes.81 A combination of a low-activity MAO-A gene variant, traumatic experiences in childhood and exposure to certain harmful substances, which in turn reduce MAO-A expression, increases the risk of ADHD particularly strongly.82
Children of mothers with early childhood traumatic experiences had an increased risk of ADHD83

Hypothesis on trauma as a cause of ADHD

Since ADHD correlates with a stimulus filter that is too wide open, which on the one hand can be a consequence of stress dysregulation, but on the other hand can also be understood as a manifestation of the genetic disposition for ADHD (high sensitivity), the question arises as to whether the early childhood stress load that manifests ADHD cannot be understood as a low-threshold traumatization of highly sensitive natures. It can be assumed that early childhood multiple traumas can trigger ADHD if there is a corresponding genetic disposition. The more sensitive a person is, the lower the required effect of a threatening stress situation to neurologically implement a traumatizing manifestation of stress regulation dysfunction.
It is well known that different personality types react differently to environmental influences. Introverts react more intensely to environmental influences than extroverts.84 The concept of high sensitivity according to Aron is closely linked to introversion.

This raises the question of whether such a low-threshold traumatization of people with ADHD, which in the case of ADHD typically occurs in the first 6 years of life, is accessible to therapeutic interventions and analyses at all.

The

  1. low memory capacity of people for events in the first years of life on the one hand and
  2. the fact that even impacts far below what non-affected people would consider to be a serious cause of trauma can trigger a traumatizing reaction in genetically predisposed people,

could obscure the view of such a cause.

Consequences of this idea are that the principles of EMDR therapy, which is recognized as effective for trauma, could be transferable to ADHD.

In trauma and PTSD there is a partial overactivation of the PFC, which can be effectively reduced by the bilateral sensory contacts in EMDR, which also correlates with the extent to which PTSD symptoms are reduced.85

People with ADHD are also more likely than average to be victims of violence and bullying (as a consequence of ADHD).86

4.2.2. PTSD (up to + 153 %)

  • 2.53-fold risk of ADHD (+153%) in war veterans with previous PTSD87
  • 2.19-fold ADHD risk (+ 119%) in war veterans with existing PTSD87

4.2.3. Stressful experiences in childhood and early adolescence cause persistent ADHD in adulthood

A study of stress levels in children with ADHD found that severe stress levels in childhood and adolescence were associated with severe ADHD-HI or ADHD-I progression into adulthood, while children with low stress levels in childhood and adolescence often showed remitting ADHD (ADHD-HI as well as ADHD-I).88

4.2.4. Traumatic experiences and dopamine

Although it is not yet certain that (early childhood) trauma increases the risk of ADHD (causally) through changes in the dopaminergic system, there is strong evidence that trauma in early childhood and adolescence permanently alters the brain’s dopaminergic system.89909192 One mediator could be that stress alters the HPA axis, which in turn exerts an influence on dopamine synthesis and dopamine receptors.93

The most important dopaminergic nodes of the stress network in the brain are:

Rodents show after early stress:

  • Flattened dopamine stress response in the mPFC9899
  • Increased tonic dopamine levels in subcortical areas100
  • Increased release of noradrenaline in response to acute stress98

Early childhood stress appears to cause an increased dopamine stress response in the striatum later in life101102

In humans, the dopaminergic system is primarily controlled by dopamine D2 and D3 receptors in most nodes of the stress network.103104105

Trauma in childhood correlated positively with the availability of D2 receptors in men and with the availability of D2 receptors in women.106

Early childhood trauma correlates with reduced levels of the dopamine degradation product homovanillic acid in blood plasma107 and cerebrospinal fluid108.
One study reports a correlation between the spatial extent of dopamine activity in the mPFC during acute stress and the severity of the stress experience in early or later childhood.109

4.2.5. Childhood trauma and other disorders

Traumatic experiences in childhood also increase the risk of other disorders such as schizophrenia110 and psychosis.111

4.3. Growing up in adoption ( + 200 %)

A study of Chinese adopted girls found an ADHD rate of 16.7%, which is around three times the usual prevalence.112 It remains to be seen whether this is a consequence of the adoption or the problems of the birth parents, which were then also the cause of the adoption approval. There would be some evidence for an influence of the latter factor if the prevalence of ADHD did not correlate with the length of stay in the home before the adoption (see previous section).

4.4. Relatively earlier school enrollment / older classmates (+ 34 %)

The youngest children in a class who start school have a 30% higher risk of ADHD than the oldest children in a class. A study of over 400,000 children in the USA showed that in the states in which a fixed age on September 1 determines school enrollment, 0.85% of children born in August, i.e. who reached school age immediately before the cut-off date, had an ADHD diagnosis (+35%) and 0.52% received ADHD medication, while of children born in September, i.e. who were on average 11 months older, only 0.63% had an ADHD diagnosis and 0.4% received ADHD medication. In the states where school enrollment was not fixed by age on a cut-off date, those born in August still had a slightly higher rate of ADHD compared to those 11 months older, but the difference was 0.08 percentage points instead of 0.21 percentage points.113
Similarly, a meta-analysis of three Brazilian cohort studies with 8 million participants and 164,000 people with ADHD found that those children in a class who were among the youngest by 4 months had a 34% increased risk of ADHD.114 Similar results were found in a study of 1,042,106 English children between the ages of 4 and 15.115 The risk of depression and intellectual impairment increased in parallel with that of ADHD.
A French registry study (n = 58 million) found that the youngest children and adolescents in a class were more likely to be diagnosed with ADHD and prescribed methylphenidate.116 Delaying (pre-)school entry by one year dramatically reduced inattention/hyperactivity in the following year (effect size = 0.73). The effect was primarily found in girls and lasted until the age of 11.117
A meta-analysis (19 studies from 13 countries with n = 15.4 million children) confirmed that the relatively youngest children in a class have an increased risk of ADHD (17 of 19 studies) and suspected the reason for the lack of effect in Denmark to be the later school enrollment of children with developmental deficits practiced there118

A Danish study (n = 418,396) found no influence of the age of children within a school grade on (more frequent / less frequent) ADHD medication. The authors attributed this to, among other things, the low ADHD prevalence, clear diagnostic criteria and high requirements for prescribing ADHD medication in Denmark and referred to studies in countries with high ADHD prevalence in which differences were found119

The results of the study are partly consistent with the fact that, according to a study in Canada, successful ice hockey players were more often than average among the older children in a class. The same was shown among Belgium’s soccer players, where the date of birth of the particularly successful players was for a long time primarily in August and September, because the cut-off date for determining the age for player selection was August 1. After this cut-off date was moved to January 1, the most successful players most frequently had their birthdays in January and February. A further study confirmed this “effect of relative age” throughout Europe.120
On the one hand, the effect is probably due to the selection criteria. However, this could only explain the differences in athletes that can arise due to different support. However, the parallel with ADHD suggests that there could also be an effect of the developmental lever of the opportunity/risk genes.

It is unclear how these differences can be explained in relation to ADHD.

One hypothesis is that younger children are more likely to be pathologized by their teachers due to their naturally immature behavior.121

Another hypothesis interprets behavioral problems less as a social consequence of the relatively young age within a class than as an absolute consequence of early school entry in general. In this study, however, no difference was found for ADHD.122 In our opinion, it is also likely that younger children start school earlier than older children. The extent of this influence on ADHD remains to be seen.
A meta-analysis found that younger relative age was not statistically significantly associated with persistence of ADHD at 4-year follow-up.123

Our hypothesis is that being among the youngest (and therefore the weakest) in a class could also be a psychological burden. It is well known that low social rank is a significant stressor. We are not yet aware of any studies on whether or to what extent this influences ADHD diagnoses in schoolchildren.

4.5. Urban environment

Growing up in an urban environment is also associated with increased risks for other disorders:124125126

In many studies, an urban environment improved cognitive abilities and showed preventive effectiveness against mental problems - even in older people.134

Growing up in an urban environment influences the dopaminergic system.135134

4.5.1. Little green growth in the vicinity of kindergarten / school / home (+ 20 %)

A very comprehensive study of nearly 60,000 children (4.4% of whom were diagnosed with ADHD) between the ages of 2 and 17 in 93 kindergartens/schools in Northeast China found a strong negative correlation of the amount of greenery (amount of plant life) in the kindergarten/school environment of children with ADHD. The less greenery there was, the higher the ADHD rate.136 A Canadian cohort study,137 a larger study from New Zealand138 and a smaller study of children in Barcelona139 and a meta-analysis140 came to similar conclusions.

The conclusions drawn from this are controversially discussed by the authors of the Chinese study:

  • It is conceivable that green plants have a general calming effect. As humans were still nomadic until 10,000 years ago, a green environment encoded the calming signal of food for millions of years. Humans could not survive for long in regions without green growth. This corresponds to the biophilia hypothesis.141
  • Green plants reduce noise. Increased street background noise levels correlate with increased behavioral and sleep problems.142 However, noise was not a risk factor in the Canadian cohort study.137
  • Green growth serves as a filter for air pollutants and thus reduces particulate matter and nitrogen oxides. Particulate matter and nitrogen oxides are discussed as ADHD risk factors (see there).
  • Studies on whether people in green regions do more sports / exercise more than people in less green (urban) environments do not come to any clear results.143
    Sports are a significant factor in preventing / reducing ADHD symptoms.
  • Poorer immune regulation can have adverse effects on brain development and behavior. Failure of immune regulation correlates with reduced exposure to macroorganisms and microorganisms. Green growth can enrich the microbial inputs from the environment that induce immune regulation.144

A very large Danish cohort study also came to the conclusion that fewer green plants in the living environment correlate with an increased risk of ADHD by up to 20 %.145
A meta-analysis came to similar conclusions.146 Another study found a 15% increase in the risk of externalizing behaviour if there was no green space within 300 metres of the home.147
The amount of vegetation in the environment (but not the amount of water) correlates with better working memory development in children.148

According to a cohort study, children who grew up in a rural environment from the age of 3 had a one-third (33%) lower risk of ADHD.138 The lower the proportion of vegetation in the environment, the higher the risk of ADHD.149

Green plants indoors could possibly also have a positive influence on stress levels and mental health.150

Urban environments also increase the risk of other mental disorders such as schizophrenia151
The risk of schizophrenia and ADHD is increased by inflammation. Particulate matter increases the inflammatory load on the brain. Particulate matter increases the risk of ADHD.

In Polish children aged 10 to 13, attention tended to be improved by tree cover, gardens and water areas and tended to be worsened by grass areas, in each case within 500 meters of the home address.152

One study found no association between green growth during pregnancy and early childhood and ADHD symptoms.153 In our opinion, this could be interpreted as an indication of more psychological effects.

4.5.2. Car traffic density on nearest road (+ 10 %)

The density of car traffic on the nearest road correlated with a 7% increase in externalizing symptoms and a 10% increase in the ADHD index.147
The data was collected in Europe from 2013 to 2016. At the times when leaded petrol was permitted, the pollution was probably significantly higher.

Living in the city was most strongly associated with autism+ADHD and least strongly associated with ADHD only compared to other environmental causes. Maternal smoking was associated with ADHD only, but not with autism only. Parental psychiatric history showed similar associations with all subgroups.154

4.5.3. Noise from roads and neighbors

In 9-year-old children, street noise and noise from neighbors correlated with ADHD.155 The result was independent of sleep problems.

4.6. Growing up in a dysfunctional neighborhood

Children who grow up in a dysfunctional neighborhood / dysfunctional urban environment are at increased risk for ADHD. Interestingly, this seems to be less the case for black children.156

Higher neighborhood poverty correlated with higher parent-reported ADHD and lower parent-reported medication use in the bivariate analysis. Poverty no longer correlated with ADHD in the multivariate analysis, but medication use still correlated negatively with ADHD.157

4.7. Class size

One study found that larger class sizes in Korea were associated with a reduced rate of ADHD. It was assumed that hyperactive, impulsive, inattentive or disorganized children are less noticeable in larger classes, meaning that class size does not influence the development of ADHD but rather its recognition158
In contrast, another study found that teachers in a larger class in the USA were more likely to notice indications of ADHD and therefore recognize ADHD more frequently than in a small class.159
A French article suggests that a higher level of stimulation (noise, visual distractions, large class sizes) is likely to reveal or reinforce instability, impulsivity and inattention and thus make ADHD more visible160
The influence of class size on the occurrence or frequency of diagnosis of ADHD is thus unclear.

4.8. Low educational attainment and ADHD mutually causal

A large registry study in the Netherlands (n = 1.7 million) found evidence that low educational attainment is a causal factor in the development of ADHD and that ADHD is a causal factor in low educational attainment.161

4.9. Only child

Since only children are likely to result predominantly from first births, and first-time mothers are much more likely to suffer birth complications (see under first-born status), which (certainly) increase the risk of ADHD, it would be surprising for us if only children did not have an increased risk of ADHD. It remains to be seen whether there are other risk factors.

A large Spanish registry study found a 3.1-fold risk of ADHD for only children compared to children with younger and older siblings.162
Preschool children aged 3 to 6 years had a 30% increased risk of ADHD if the children were only children in a large Chinese population-based study using parental data.163
Children with ASD had a significantly reduced risk of ADHD if they had an older sibling164

The German KiGGS study (n = 13,488) found no evidence of a link between the number of siblings and ADHD.165

4.10. Media

4.10.1. Early television consumption

Early TV viewing at the age of 1 and 3 years correlated with attention problems at the age of 7 years.166 Early TV viewing at the age of 18 months correlated with ADHD and ASD symptoms at preschool age.167

It must be questioned whether high television consumption by children at an early age is a causal cause of attention problems or whether parents with a lack of ability to pay attention due to their own psychological problems often leave children to their own devices and park them in front of the television. In the latter case, television consumption could also be merely a correlation and not necessarily a causal cause of ADHD. This is because - as will be described below - there are countless studies that prove that a caring, warm and secure attachment style can prevent ADHD even in the presence of a genetic disposition.
So while it is certain that intensive parental attention is a good protection against ADHD, no studies are known on this side that television deprivation prevents ADHD.
The fact that intensive television consumption as a substitute for personal attention correlates with a lack of personal attention is the more conclusive link from this point of view. The fact that television and internet consumption with age-inappropriate content can cause further damage is also likely to be certain.

4.10.2. Amount of media consumption does not cause ADHD, media consumption addiction correlates with ADHD

The amount of social media use has no influence on ADHD. Only media consumption addiction is associated with increased ADHD levels.168 Presumably, ADHD, hyperactivity and impulsivity are causal factors for problematic media consumption.169 Nevertheless, increased screen consumption in children appears to be able to impair attention.170
One study found that children with ADHD consumed 50% more media (183 minutes vs. 117 minutes).171

It has also been reported that screen consumption of more than 4 hours can cause “virtual autism” in children under the age of 6. However, this disappears again once screen consumption is reduced.172
Daily childhood television consumption of more than 5 hours correlated with a 63-fold risk of ADHD.173

High media consumption correlated with a 94% increased risk of ADHD (k = 6, n = 3,853) and a SMD of 0.07 (k = 9, n = 22,235) (Meta

4.10.3. Duration of online social activities

Using data from the Adolescent Brain Cognitive Development (ABCD) study, the relationship between duration of online social activity (OSA time) and ADHD problems was examined longitudinally. Longer OSA time correlated with more ADHD problems in early adolescence (girls only), while more ADHD problems did not predict longer OSA time. Only in boys was there a correlation between ADHD problems and later OSA time.174

4.11. Psychological factors without increased risk of ADHD

Growing up bilingual did not increase the risk of ADHD175

4.12. Psychological factors with risk reduction for ADHD

An immigrant status of the parents causes a reduced risk of ADHD176 within the first 2 generations.177

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