ADHD symptoms? Psychologists, psychiatrists should consider child maltreatment as the cause before prescribing meds

Adhd-facts1While reading a 2007 press release from the National Institute of Mental Health (NIMH), I became unusually hopeful for youths diagnosed with attention deficit hyperactivity disorder (ADHD). A study performed jointly by the NIMH and the National Institute of Health revealed the brains of youths with ADHD develop normally but at different rates. In the prefrontal cortex, development was delayed three years on average in youths diagnosed with ADHD. This region of the brain is associated with higher-order executive functions and is responsible for coordinating actions with thoughts according to a person’s goals and intentions.

But while development of the prefrontal cortex lags in youths with ADHD, the motor cortex, which controls voluntary body movement, matures faster. These combined changes correlate with behaviors seen with ADHD: fidgety, restless bodies that have difficulty inhibiting behavior and focusing attention. These behaviors impact their ability to do well in reward-based systems that require delaying gratification while working towards long-term goals (that is to say, school).

Much can be gleaned from this study about the causes of ADHD as well as best treatments. Here, I thought, was evidence that implied ADHD was as much influenced by environmental conditions as yet-to-be-determined genetic markers. But then I read the NIMH press release’s conclusion:

“In future studies, the researchers hope to find genetic underpinnings of the delay and ways of boosting processes of recovery from the disorder.”

I was dismayed. Granted, the study dates back to 2007, but so does evidence about the relationship between ADHD-like symptoms and exposure to trauma, particularly in children who have been either physically or sexually abused, or both. In one study of sexually abused girls, 28 percent met diagnostic criteria for ADHD — compared to only 4 percent of the subjects in the non-traumatized control group. The impact of combined sexual and physical abuse is even more startling. In another study (cited in a presentation by psychiatrist Bessel van der Kolk for the National Child Traumatic Stress Network), 67 percent of boys with histories of both physical and sexual abuse displayed the symptoms for ADHD. In this study, 40 percent of boys with histories of sexual abuse only and 36 percent of boys with histories of physical abuse only also met the criteria for ADHD.

Changes in brain development have both genetic and environmental origins. At birth, the human brain is grossly underdeveloped. It takes as much as twenty years to reach full maturity (some say longer), increasing in size by more than 300 percent during its development. Throughout this maturation process, the brain’s developmental path is modulated by experience. Genetic programming guides the process, but appropriate and expected responses from the environment keep development on track. And of course, childhood abuse is not one of these appropriate and expected responses.

David J Linden, a professor of neuroscience at John Hopkins University School of Medicine and author of The Accidental Mind, gave the following explanation of the interaction between genes and the environment in the development of the human brain:

Although the overall size and shape of the brain and the large-scale pattern of connections between brain regions and cell types are instructed by genes, the cell-by-cell details are not. The precise specification and wiring of the brain depends upon factors not encoded in the genes (called epigenetic factors), including the effects of the environment. [p. 52].

Furthermore, the impact of the environment can be profound enough to alter how genes function. Quoting Linden:

In the past, there has been a tendency to imagine that genes and behavior interact in only one direction: genes influence behavior. We now know that the environment, broadly considered, can also influence gene function in brain cells. In other words, nurture can influence nature and vice versa. Causality, in the brain, is a two-way street. [p. 55].

Like the scientists at the NIMH, trauma-focused researchers are concerned with the relationship between mental ritalindisorders and brain development. However, they look at the environment’s contribution to mental disorders rather than focusing on genetic influences. For example, researchers working with children exposed to traumatizing events have identified a list of difficulties children often have after being exposed to traumas such as chronic physical or sexual abuse. These include: difficulty controlling emotions, problems concentrating, difficulty with impulse control, and aggressive or risk-taking behaviors — all symptoms of ADHD. Some trauma-focused researchers, including van der Kolk, have suggested adding a new diagnosis to the Diagnostic and Statistical Manual of Mental Disorders — “Developmental Trauma Disorder” — that would include addressing ADHD-like symptoms from a trauma-informed perspective. Rather than waiting for elusive “genetic underpinnings,” this disorder would point directly to what often causes ADHD-like symptoms: multiple or chronic exposure to one or more forms of interpersonal trauma — and childhood abuse is a primary type.

Does trauma-focused research imply all children diagnosed with ADHD have been abused? Certainly not. But such research should persuade institutions like the NIMH to exercise their ethical responsibility and encourage mental health professionals to consider childhood abuse as the reason for ADHD-like symptoms — and well before prescribing medications, particularly when intervention in the child’s environment is most needed.

© 2013 Laura K Kerr, PhD. All rights reserved.

Laura K. Kerr, PhD, IMFT is a Mental Health Scholar and Registered Marriage & Family Therapist Intern in the San Francisco Bay Area. For more information, visit her website.

21 responses

  1. Pingback: Taking the Cognitive Style Test | Musings of an Aspie

  2. My bf is 21 years old. He’s been through terrible things in his life between his parents. We’ve been together for almost 3 years. He’s told me his dad used to starve him, put him in the closet and lock him in there, abuse him, verbally abuse him and even molested him before. My bf recently told me he has ADHD and he took medication for it before. He doesn’t now and it seems like his attitude is getting worse because he hasn’t taken any medication. His behavior is different to the point where he may need to use it again or may even need therapy to see what’s wrong. He treats me bad, his mom, his attitude is terrible and he cant control his anger when he is upset. I know sometimes he doesnt mean to do it. I’m scared and worried, and wanted to know can all of this be the reason why he has ADHD?

    • Understandably, you sound distressed and worried. However, I cannot give a diagnosis, or make causal connections, for someone I have never met. To do so would be unethical. I’m sorry I can’t provide further help.

  3. Well said – “such research should persuade institutions like the NIMH to exercise their ethical responsibility and encourage mental health professionals to consider childhood abuse as the reason for ADHD-like symptoms — and well before prescribing medications, particularly when intervention in the child’s environment is most needed.”
    I very closely know a little boy who is being sexually and physically abused by his mother and mother’s dysfunctional family. The mother is hell bent on putting the child on ADHD meds. Probably this is one of the tools abusive parents use to manipulate police and CPS that doesn’t take much efforts in protecting the child. Obviously the abuser is not going to admit that he is sexually and physically abusing the child. Based on shallow investigations they close cases and the children are being constantly threatened and silenced into accepting abuse as a part of their life and are victimized in their own homes. I have also seen schools ignoring the signs of abuse in children and doing what’s convenient to them. At least mental health professionals should consider abuse as the reason for ADHD like symptoms – all of us dealing with children in personal life or in professional settings have moral and ethical responsibility to protect children as they cannot protect themselves.

    • Hi Dia,
      If you know a child is being abused, it is imperative that you call Child Protective Services in your area. You can make such calls anonymously if you are concerned you will put yourself or the child in danger. However, a call needs to be made as soon as humanly possible. If you are uncertain who to contact or what to say, please feel comfortable contacting me: http://www.laurakkerr.com/contact/ . Most cities and/or states have “Child Protective Services” departments with toll free numbers.

      • Hi Dr. Kerr,
        Thank you for your prompt reply. I have sent you an email with details hoping that the little boy gets help.

  4. Just stumbled upon this, as I was trying to find something to support the possibility that some children who are abused or have extremely chaotic homes may present as ADHD – which helps the parents hide the abuse and blame the victim (“ADHD” child) for being ‘so difficult.’
    This was my situation.
    I do not believe I have or have ever had ADHD, but my physically and psychologically abusive disordered (NPD) mother insisted I did. We had to get family therapy, when a friend of mine reported my mother’s abusive behavior to my high school guidance counselor. My mom convinced the Psychiatrist that I needed to be medicated because I was making her life so hard. I was forced to take Ritalin, even though it caused my heart to palpitate/race and gave me the shakes. As an older adult and mother, I sought out therapy to deal with some issues and my therapist helped me work through the trauma I experienced as a child. She suggested that the ADHD “diagnosis” as a teenager was simply a way for my mom to blame me for her abuse, get sympathy for having such a “difficult child,” and distract attention from her behavior.
    Certainly, this isn’t the case for all children, but I have to wonder how many mothers have dragged their children to a mental health professional seeking a diagnosis to explain why they have such a hard time dealing with their children in a loving, supportive, and appropriate manner. My mom even had me convinced that I was distracted, careless, and unable to pay attention – that something was wrong with me. Being yelled at, blamed for anything and everything, ridiculed, physically abused, threatened, not shown love/acceptance, and living with total dysfunction can make a child fidgety, nervous, socially awkward, and distracted.

    • If you look at the research of Dr. Victor Carrion at Stanford University, you’ll find a lot of information that backs up your experience. You certainly didn’t deserve to have to live through any of that. Congratulations for doing the hard work to figure this out.
      Cheers, Jane

    • I can imagine how it must have been to deal with abusive parent. You are a brave child plus you were fortunate to have a therapist that understood the real situation. I know a little boy whose mom is pushing him into ADHD meds to hide sexual and physical abuse. The therapists, school, police & CPS are with the abusive mom and not with the helpless child.

      • Hi Dia,
        If you know a child is being abused, it is imperative that you call Child Protective Services in your area. You can make such calls anonymously if you are concerned you will put yourself or the child in danger. However, a call needs to be made as soon as humanly possible. If you are uncertain who to contact or what to say, please feel comfortable contacting me: http://www.laurakkerr.com/contact/ . Most cities and/or states have “Child Protective Services” departments with toll free numbers. You can always ask for a second visit or alternative social worker to look at the case if you feel CPS is being negligent in their responsibilities.

  5. I have a Jimmie Neutron like kid. I hope greatly that nothing traumatic has affected him but I think he just has a lot going on in his mind and he hasn’t physically matured or mentally. I see him taking out his frustration as energy. Is there any way to focus him? Or expend all that energy? I would not like to treat him with drugs…

    • Hi Charlie,
      Love your description of your son—”Jimmie Neutron.”
      I appreciate your concern that nothing traumatic has happened to your son. Such a thought is pretty alarming.
      Since you are worried about his development and that he is having difficulty handling his emotions, have you considered going with him to see a counselor? Giving therapeutic advice over the web is not my forte or inclination. Yet I have confidence in well-trained marriage and family therapists who focus on working with kids and families. Not only might you gain a supportive and informed perspective, but also some suggestions directed to your unique son and family situation.
      Best of luck,
      Laura

  6. Funny. I read that NIMH press realease and felt a profound RELIEF that my teen son’s delayed executive skills development was being acknowledged as potentially genetic. He has no ACEs, and it drives me crazy to only read about these delays in the context of trauma! FYI – I also have no ACEs, though I almost certainly had undiagnosed delays in executive skills development. “Late bloomer” sounds quaint, but it is very difficult to fully make-up for those lost years of early adulthood which are among our most productive. I see the same pattern in my father (who has a few ACEs, admittedly) and in some of my siblings (who I think are ACE-free), as well; success came later in life and was probably “capped” to a degree by the late starts. It’s anecedotal, but I think I have seen the evidence of a genetic basis for executive skills development delays. There IS value in recognizing the possiblity of a genetic origin. Thanks for your great blog. I subscribe and repost frequently!

    • I appreciate your perspective. More than one trajectory can lead to behaviors and experiences, especially something as complicated as ADHD. As a trauma-focused therapist and researcher, I see the lack of attention given to maltreatment as one trajectory that needs highlighting. But as I mentioned in the article, abuse is not the only way ADHD comes about. Thank you for sharing your experiences and thus contributing to a more nuanced dialogue.

  7. This is interesting and important research which hopefully will lead to more expansive thinking in clinicians about the role of environmental context in behavior. As you say, though, the causes for ADHD-like behavior can be many, and I have some concern that “trauma-aware” thinking’s dark-side could be something of a witch-hunt for abusive parents which could have tragic consequences. It’s so hard for people to maintain balance in their thinking and to remember that life is very complex and no one theory, finding, or philosophy can capture it all.

    • You make a very important point. Parents need support, not condemnation. The reality may be that just like genes can be inherited, so can poor parenting skills be “inherited.”

  8. Dysfunctional family dynamics need not be explicit maltreatment but can still be traumatic and effect children as though it were abuse. It’s important not to alienate parents who might be willing to address family dynamics as well as not miss bad dynamics just because it’s not super obvious abuse and therefore medicate a kid who can again, be helped by improving dynamics. Seems there is lots of room for gray area in this stuff.

    • Yes, I completely agree with you. The studies I shared focused on actual abuse, and yet there are other factors that are social (and even possibly environmental) that could contribute to ADHD-like symptoms. Thank you for broadening the perspective.

  9. thank you for publishing this. In retrospect, my step-son had an ACE score of 7 by the time I became part of the family…when he was 3 years old. His dad– a Vietnam vet with 12 different psychiatric diagnoses from the VA and the private psychiatric systems who was raising the child with a series of step-moms–managed to finally find a psychiatrist to diagnose ADHD when the child was eight. Lots of meds followed–none helped. Prior to that, the pediatrician and counselor I took the child to identified him as having horrible parenting and a traumatic childhood. Their official diagnosis was adjustment disorder, chronic. I hope that child psychiatrists will begin to look beyond what (biological) parents report about their children and look at what parents do to their children.

  10. I hate it when that happens! And it looks like your first comment didn’t show up in our comments log either. Thank you for still taking the time to reach out. We appreciate your feedback.

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