Intimate Partner Violence (IPV) encompasses various forms of abuse, including physical, sexual, and psychological abuse, occurring within romantic relationships (WHO, 2021). Sexual violence (SV) refers to coercive or non-consensual sexual acts carried out against individuals who do not provide, or are unable to provide, consent. Violence, including SV, can happen both within and outside the context of intimate relationships and can impact individuals of all genders, though the consequences are often more severe and enduring for women than for men (Martinez et al., 2022). In the UK, the lifetime prevalence of IPV and SV among women is as high as 24% (WHO, 2021). IPV leads to emotional distress, increased suicidal thoughts, and suicide attempts among victims (Ellsberg et al., 2008).

One of the authors of this blog, Janhvi, recently trained in counselling, and worked with clients aged 16–25 years old. Clients presented with a range of challenges, including IPV. During this training, there were challenges in genuinely empathising with perpetrators of violence: why would somebody hurt someone they love? Every relationship goes through difficult times, where both partners experience, and unintentionally cause, emotional pain. While not all these situations may be considered violent, it is crucial to recognise when behaviours are abusive, and to understand the factors which increase the risk of such behaviour being perpetrated in relationships. Violence has severe consequences for victim/survivors, and can have a lifetime impact on wellbeing (Buitelaar et al., 2014). Thus, understanding the causes and impact of violence on both perpetrators and victims is essential.

Previous research has demonstrated a correlation between IPV and adverse mental health problems like depression and anxiety symptoms, as well as adverse health behaviours, such as increased substance use (Scoglio and Zhu., 2023). However, unlike mental health conditions such as depression and anxiety, studies examining the possible relationship between ADHD and IPV are minimal. Studies such as that by Arrondo et al (2023), which is the focus of this blog, can help develop our understanding of risk factors for violent behaviour, and the behavioural differences that may underly it.

Arrondo et al (2023) systematically reviewed 14 research papers to look at the association between ADHD and perpetration or victimisation of IPV and SV. The research defined IPV as comprising various forms of harm occurring within romantic relationships, such as physical, sexual, or psychological abuse. Sexual violence was defined as non-consensual sexual acts, whether within or outside intimate relationships. While these definitions provide a framework for understanding these complex forms of harm, it’s crucial to recognise that these definitions may not fully reflect the multifaceted nature of harm and abuse occurring within intimate relationships, underscoring the need for a comprehensive and inclusive approach to addressing these issues.

Methods

Arrondo et al (2023) conducted a systematic review and meta-analysis to investigate the relationship between ADHD and exposure to, and perpetration of, IPV and SV, and reported their study in accordance with 2020 PRISMA guidelines.

Among 8,904 studies that met their search criteria, they included and analysed 14 studies which provided data on the study question, in order to estimate pooled IPV and SV occurrence ratios in ADHD using random-effects models. The final analyses included seven studies on SV, five studies on IPV and two studies on IPV which reported SV as an outcome. The Newcastle-Ottawa scale was used to assess the risk of bias in each included study (Wells et al., 2000).

Results

Included studies often reported that violence was often bidirectional, that is, IPV is perpetrated and experienced by both the partners towards each other. Additionally, individuals with ADHD experienced more IPV and SV, and were more commonly perpetrators of IPV and SV, than the general population.

The 14 studies included cross sectional (n=9), cohort (n=2) and case-control studies (n=1). After the results were examined, all analyses except for SV found high levels of heterogeneity between the studies. This means that although there was evidence for relationships of IPV and SV with ADHD, the studies were generally all very different from one another.

The following are the results found after comparing perpetration and victimisation experiences in IPV and SV on people diagnosed with ADHD:

ADHD in intimate partner violence (IPV) perpetration

• Results of 1,049,598 individuals in six studies indicated that people diagnosed with ADHD perpetrated IPV more commonly than individuals without an ADHD diagnosis (OR 2.5, 95% CI 1.51 to 4.15).

ADHD in intimate partner violence (IPV) victimisation

• Results of 48,619 individuals in four studies suggested that individuals with ADHD had a greater risk of IPV victimisation compared to those without ADHD (OR 1.78, 95% CI 1.06 to 3.0).

ADHD in sexual violence (SV) perpetration

• Results of 3 studies with a sample of 28 785 people found that individuals with an ADHD diagnosis were more likely to perpetrate SV than individuals without ADHD (OR 2.73, 95% CI 1.35 to 5.51).

ADHD in sexual violence (SV) victimisation

• Meta-analysis of 6 studies with a pooled sample of 62 871 people found greater risk of SV victimisation in individuals with ADHD (OR 1.84, 95% CI 1.51 to 2.24) compared to those without an ADHD diagnosis.

Strengths

This was a comprehensive systematic review and meta-analysis which was reported according to PRISMA guidelines, and there were sufficient studies to estimate meta-analytic pooled effect estimates for the main questions. Additionally, the study used the Newcastle–Ottawa Scale (NOS) to assess the quality of the studies, independently assessed by the authors of the primary research. This scale assigns a maximum score of nine stars, with any study scoring six or less being categorised as having a high risk of bias. Not only did the study reveal disparities in the prevalence of ADHD within the population, but it also held substantial implications for addressing future cases of IPV and SV. The study underscored the significance of psychoeducation as a potential risk management strategy.

Limitations

The authors found high levels of heterogeneity for a number of their comparisons, suggesting that the true associations in particular populations might be quite different from the estimates reported in this study. Heterogeneity sources could include different populations, study designs, or measurement of exposures and outcomes (e.g., self-report versus clinician reported ADHD), among others. Observational epidemiological studies are usually unable to take account of changing historical contexts. For instance, it was not possible in this review to take account of the impact of the Covid-19 pandemic on IPV and SV, or changes in ADHD diagnostic practice over time.

Moreover, there is evidence that ADHD treatment can reduce ADHD symptoms, but this was not assessed in this systematic review. The authors were not able to take account of confounders within each included study, e.g., through a meta-regression approach. Additionally, most included studies were written in English and were based on data collected on Western populations. This demographic focus may influence the generalisability of the findings to other linguistic or cultural contexts, highlighting the necessity for research in diverse settings which can enrich our understanding of IPV and SV in ADHD.

Implications

Based on the results of their meta-analysis, the authors suggest that core symptoms of ADHD, such as difficulty in emotional and behavioural control, impulsivity, and hyperactivity, could represent causal factors that lead to increased prevalence of IPV and SV exposure and perpetration in individuals with ADHD.

But should the evidence provided by this paper, the message that ADHD may be a risk factor for perpetration of IPV, change our outlook towards those who perpetrate IPV? When addressing this question, it is important to understand risk factors and adverse outcomes in ADHD, whilst taking care not to add to the stigma which surrounds ADHD. Mechanisms linking symptoms of ADHD to IPV perpetration might provide intervention opportunities, which could improve the safety of victims. For example, currently there is limited evidence on whether ADHD management might reduce IPV risks.

Although alcohol use was not meta-analysed as an outcome, the authors highlighted alcohol use as a potential moderating factor in IPV perpetration and victimisation. Based on these findings, Arrondo et al. propose that psychoeducation in ADHD about alcohol should be considered as an intervention for individuals with ADHD and their families.

The evidence gathered and summarised by Arrondo and colleagues suggests that mental health professionals, and other health professionals coming into contact with people diagnosed with ADHD, should consider enquiring about exposure to and perpetration of IPV and SV. People diagnosed with ADHD and their families might benefit from conversations with health professionals about risks, especially where IPV has already been identified. IPV victimisation and perpetration is often experienced by both partners, and it is important to bear this in mind as professionals approach couples and families, especially aiming to avoid vilifying neurodiverse people, or people with mental health conditions. In considering this, the clinical goal might be to comprehend and show empathy without contributing to stigmatisation. More research on the role of alcohol in influencing the relationship between ADHD and IPV might suggest targeted intervention strategies. The review found that most studies on perpetrators of IPV were focused on men, and most studies of victims were focused on women. Therefore, there is more to be learnt about the occurrence and impact of IPV perpetration in women with ADHD, for example.

In conclusion, this study shows that individuals with ADHD are more likely to experience IPV and SV, both as victims and perpetrators. We need better understanding of the underlying causes and effective treatments for individuals with ADHD to reduce their exposure to, and perpetration of, IPV and SV.

Links

Primary paper

Arrondo, G., Osorio, A., Magallón, S., Lopez-del Burgo, C., & Cortese, S. (2023). Attention-deficit/hyperactivity disorder as a risk factor for being involved in intimate partner violence and sexual violence: a systematic review and meta-analysis. Psychological Medicine, 1–10. https://doi.org/10.1017/S0033291723001976

Other references

Scoglio, A. A. J., & Zhu, M. et al. (2023). [Intimate Partner Violence, Mental Health Symptoms, and Modifiable Health Factors in Women During the COVID-19 Pandemic in the US], 1–10. https://doi.org/10.1001/jamanetworkopen.2023.2977

Buitelaar, N.J., Posthumus, J.A., Scholing, A. et al. Impact of treatment of ADHD on intimate partner violence (ITAP), a study protocol. BMC Psychiatry 14, 336 (2014). https://doi.org/10.1186/s12888-014-0336-2

Ellsberg M, Jansen HA, Heise L, Watts CH, Garcia-Moreno C: Intimate partner violence and women’s physical and mental health in the WHO multi-country study on women’s health and domestic violence: an observational study. Lancet. 2008, 371 (9619): 1165-1172.

Romero-Martínez, Á., Lila, M., Sarrate-Costa, C., Comes-Fayos, J., and Moya-Albiol, L. (2023). The Interaction between Attention Deficit Hyperactivity Disorder and Neuropsychological Deficits for Explaining Dropout and Recidivism of Intimate Partner Violence Perpetrators. The European Journal of Psychology Applied to Legal Context, 15(1), 33 – 42. https://doi.org/10.5093/ejpalc2023a4

World Health Organization. (2021). Sexual and Reproductive Health and Research Fact Sheet. WHO REFERENCE NUMBER: WHO/SRH/21.9. Retrieved from https://www.who.int/publications/i/item/WHO-SRH-21.9

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