ADHD has been linked to eating disorders and loss of control of eating, including binge eating and overeating (Biederman et al, 2010; Yoshimasu et al, 2012; Egbert, 2018). There is little information on whether these associations occur during early childhood, and few studies have investigated these associations prospectively. The aim of this study was to assess the magnitude and direction of associations between childhood symptoms of ADHD and eating behaviours.
Participants were from the Newborn Epigenetic Study, which is a pre-birth cohort initiated in 2005 that examines the effects of early exposures on epigenetic profiles and developmental outcomes. ADHD symptoms from the clinical problems subscales (attention problems and hyperactivity) were measured using the Parent Rating Scales from The Behaviour Assessment System for Children second edition (BASC-2).* This is a valid and reliable comprehensive scale appropriate for use in children aged 2‒11 years. The Children’s Eating Behaviour Questionnaire (CEBQ) was used to assess eating behaviours.† Children’s height and weight were also measured to calculate body mass index (BMI)-for-age z scores.
Of the 470 mother–child pairs included in the cross-sectional sample, 100 mother–child pairs participated in both the earlier (2011‒2013) and follow-up (2016‒2018) surveys (prospective sample used for latent change score [LCS] modelling).‡ The mean (standard deviation [SD]) age of children in the cross-sectional sample (n = 470) was 3.7 (1.9) years (50.4% male); most children (60.9%) were of a normal/healthy weight (5th to 85th percentile), 18.5% were obese (>95th percentile), 11.1% were overweight (85th to 95th percentile) and 9.6% were underweight (<5th percentile). The mean (SD) T-score for BASC-2 attentional problems was 50.12 (9.2) and 47.9 (10.4) for hyperactivity; 17% (n = 79) and 11% (n = 51) of children had T-scores ≥60 (‘at risk’ or ‘clinically significant’ ranges) for attention problems and hyperactivity, respectively. The mean (SD) CEBQ scores ranged from 1.4 (0.6) for emotional overeating to 3.6 (0.8) for enjoyment of food.
In the cross-sectional sample (n = 470), controlling for maternal race and education, child’s age, gender and BMI z-scores, attention problems were significantly negatively associated with enjoyment of food (B = ‒0.20, 95% confidence interval [CI] –0.35 to –0.05) and significantly positively correlated with food responsiveness (B = 0.19, 95% CI 0.03–0.34), emotional overeating (B = 0.08, 95% CI 0.02–0.14), desire to drink (B = 0.28, 95% CI 0.08–0.48) and slowness in eating (B = 0.17, 95% CI 0.04–0.29). Hyperactivity was significantly positively associated with food responsiveness (B = 0.42, 95% CI 0.24–0.60), emotional overeating (B = 0.09, 95% CI 0.02–0.15), desire to drink (B = 0.51, 95% CI 0.29–0.74), slowness in eating (B = 0.18, 95% CI 0.04–0.33) and satiety responsiveness (B = 0.16, 95% CI 0.002–0.31). Data from LCS modelling in the prospective sample (n = 100) showed that the greater the attentional problems during the preschool years, the greater the changes in food responsiveness (p = 0.01), emotional overeating (p < 0.001) and satiety responsiveness (p < 0.001) from preschool to childhood years. Similar effects were observed for hyperactivity for emotional overeating (p = 0.01) and satiety responsiveness (p = 0.01). Changes in ADHD symptoms during preschool to childhood years were not significantly associated with eating behaviours during preschool. This suggests that early ADHD symptoms are significantly related to changes in eating behaviours from early (aged ~4 years) to later (~aged 7 years) childhood but not vice versa. Results from LCS modelling also showed that greater attentional problems (p = 0.048) and hyperactivity (p = 0.01) symptoms at preschool age were associated with greater changes in BMI from preschool to childhood. However, greater BMI at preschool age was not statistically significantly associated with changes in ADHD symptoms from preschool to childhood age.
These findings should be interpreted in the context of some limitations. For example, the study was conducted in a community sample based in the southeast of the United States, which may limit the generalisability of these results to other populations and clinical samples of children diagnosed with ADHD. Also, although causal links can be inferred from prospective associations, further studies would be required to determine causation. LCS modelling tested the relationship between ADHD symptoms and eating behaviours from two discrete time points (preschool and childhood); however, it cannot be predicted whether these associations continue across a lifespan and also to what degree they impact the future risk of obesity. Finally, parent-reported measures were used to assess ADHD symptoms and eating behaviours, which could lead to reporting bias.
In conclusion, the authors highlighted that this study provides insight into the association between ADHD symptoms and eating behaviours, suggesting that ADHD symptoms may occur before problematic eating behaviours. In light of these findings, clinicians may want to discuss with parents the impact that early ADHD symptoms may have on eating behaviours and the risk for dysregulated eating and subsequent obesity.
*The BASC-2 includes a set of age-appropriate questions regarding preschool and child behaviour, with fewer questions for hyperactivity and attentional problems in the preschool version. Therefore, the average score was used to equate the preschool and child versions. The internal reliability for the cross-sectional sample (n = 470) was 0.80 for the hyperactivity subscale and 0.77 for the attentional problems subscale. When children were aged ~7 years at the follow-up time point (n = 100), the internal reliability was 0.86 for the hyperactivity subscale and 0.84 for the attentional problems subscale. T-scores are presented for descriptive purposes; scores between 60 and 70 are considered ‘at risk’ and scores ≥70 are determined ‘clinically significant’
†Items for the CEBQ were developed from focus groups and interviews with parents of children aged 1‒12 years. Items have Likert scale response options ranging from 1 (never) to 5 (always). Only four food-approaching behaviours were included in these analyses: food responsiveness; enjoyment of food; emotional overeating; and desire to drink. Two food-avoidant behaviours were also included: satiety responsiveness and slowness in eating. The CEBQ has shown high internal consistency, good test–retest reliability and stability over time. The Cronbach’s alpha for each subscale ranged from 0.65 to 0.90 (n = 470) and 0.70 to 0.88 at the follow-up time point when children were aged ~7 years (n = 100).
‡The mean (SD) age of children in the prospective sample was 7 (1.52) years. There were no significant differences between the cross-sectional sample (n = 470) and the prospective sample (n = 100) in terms of maternal race (p = 0.50), education level (p = 0.35), child’s gender (p = 0.30) or maternal age at delivery (p = 0.95). However, mothers from the cross-sectional sample had a significantly higher pre-pregnancy BMI than mothers in the prospective sample (p = 0.02)
Biederman J, Petty CR, Monuteaux MC, et al. Adult psychiatric outcomes of girls with attention deficit hyperactivity disorder: 11-year follow-up in a longitudinal case-control study. Am J Psychiatry 2010; 167: 409-417.
Egbert AH, Wilfley DE, Eddy KT, et al. Attention-deficit/hyperactivity disorder symptoms are associated with overeating with and without loss of control in youth with overweight/obsesity. Child Obes 2018; 14: 50-57.
Fuemmeler BF, Sheng Y, Schechter JC, et al. Associations between attention deficit hyperactivity disorder symptoms and eating behaviors in early childhood. Pediatr Obes 2020; 15: e12631.
Yoshimasu K, Barbaresi WJ, Colligan RC, et al. Childhood ADHD is strongly associated with a broad range of psychiatric disorders during adolescence: a population-based birth cohort study. J Child Psychol Psychiatry 2012; 53: 1036-1043.