Mental Health, Attention Deficit Hyperactivity Disorder (ADHD) and Foster Care

Having ADHD can affect more than attention and impulsivity; it influences emotional regulation, self-esteem, and social relationships¹. Comorbidity between ADHD and mental health difficulties is high: in a UK based study of children in foster care conducted in 2007, around 69% of those with ADHD also had a diagnosis of another disorder². There are common links with anxiety, depression, oppositional defiant disorder, substance misuse and sleeping difficulties.

Why do mental health issues co-occur with ADHD?

• Young people with ADHD may find it difficult to regulate their emotions, such as frustration, anger and sadness.
• ADHD is associated with executive functioning difficulties which can make organising tasks or managing thoughts more challenging. These challenges may contribute to increased stress or feelings of frustration, especially in environments that are not designed with neurodiverse needs in mind. It’s important to recognise that these experiences are not a reflection of someone’s abilities or worth.
• Being impulsive or distractable can harm peer relationships which can bring many social challenges such as being lonely or being rejected by others.
• ADHD is often underdiagnosed in girls, which can contribute to poorer mental health outcomes, as their ongoing struggles may go unrecognised and become increasingly difficult over time.

¹ National Institute for Health and Care Excellence [NICE], 2018
² Ford, T., Vostanis, P., Meltzer, H., & Goodman, R., 2007

How might co-occurring mental health difficulties and ADHD present?

• Children may present as irritable, having ‘meltdowns’, refusing to go to school and showing oppositional behaviours.
• Teenagers may present as anxious and/or depressed. They may self-harm or misuse substances.
• In adults, co-morbid ADHD and mental health difficulties may present as being chronically stressed, ‘burning out’, or high levels of anxiety/depression.

How can we support children, young people, and adults with co-morbid ADHD and mental health difficulties?

• Current NICE guidelines (2018) state that individuals with ADHD should receive support through multi-disciplinary care, regular reviews, psychological interventions, and environmental adjustments, especially when mental health difficulties are also present.
• Medication is available for both ADHD and mental health conditions; however, advice should always be sought from a trained medical professional.
• Therapy: this can include psychoeducation to build an understanding of themselves.
• Lifestyle choices: this can include having structure, exercising, sleeping well and mindfulness.

How do we relate mental health and ADHD to being a young person in foster care?

A young person in foster care who has a diagnosis of ADHD may face intersections of neurodevelopmental and emotional challenges. Children in care are three times more likely to be diagnosed with ADHD than their non-care peers³. When ADHD co-occurs with complex trauma, the effects are magnified, leading to heightened challenges in emotional regulation and functioning⁴.

Challenging behaviours are often misinterpreted as deliberate or ‘bad’ when they may actually reflect underlying issues like hypervigilance, unmet emotional needs, difficulties with executive functioning, or feeling overwhelmed. Around 60% of children in care meet criteria for at least one mental health difficulty (such as anxiety or depression) and 30% experience overlapping ADHD, emotional and behavioural difficulties⁵. Without trauma informed understanding, behaviours risk being misinterpreted and mishandled.

Mental health can be impacted by ADHD leading to low self-esteem, school exclusion, under achievement and peer rejection. Emotional dysregulation may present as meltdowns, defiance or risk-taking behaviours, which can be coping mechanisms for children managing both ADHD and trauma⁶.

Untreated mental health issues such as anxiety and depression can be often masked by externalising behaviours such as:

• Aggression (kicking, hitting, yelling, screaming, threats)
• Defiance (refusing directions, arguing, rule breaking)
• Impulsivity (shouting out, interrupts, intrusion and acting without thinking)
• Hyperactivity (lots of movement, fidgeting, unable to sit, disrupting others)
• Destruction of property (breaking things, damaging things)
• Lying/Stealing (impulse control issues or unmet needs)
• Running away
• Sexualised behaviours.

How can foster carers support with mental health and neurodiversity?

• Create a safe and predictable environment, which includes structured routines, clear expectations and visual schedules. It is really important to be patient and consistent in your approaches to establish relationship stability and trust.
• Learn and adapt to the child’s neurodiversity; this can include accessing training for ADHD and potential sensory needs, alongside trauma informed care. Responses do need to be tailored to the young person’s communication and emotional needs. It is essential to use calming techniques, such as offering quiet spaces, sensory tools or mindfulness.
• Understand behaviour as communication, think about what the behaviour is telling you as a carer instead of reacting punitively. It may be useful to keep a diary of the behaviours to identify patterns to reveal any unmet needs or potential triggers.
• Advocate for assessments and services, this includes ensuring SEN support is put in place at school.
• Emotional and relationship support. It is really important to show unconditional positive regard by separating the child from the behaviours they show. Using the PACE (playfulness, acceptance, curiosity, empathy) model is an excellent trauma informed approach to supporting young people with complex trauma.

⁶ (Reichert et al, 2025).