How childhood trauma could be mistaken for ADHD

 

Acry

[Photo credit: woodleywonderworks, Flickr]

Dr. Nicole Brown’s quest to understand her misbehaving pediatric patients began with a hunch.

Brown was completing her residency at Johns Hopkins Hospital in Baltimore, when she realized that many of her low-income patients had been diagnosed with attention deficit/hyperactivity disorder (ADHD).

These children lived in households and neighborhoods where violence and relentless stress prevailed. Their parents found them hard to manage and teachers described them as disruptive or inattentive. Brown knew these behaviors as classic symptoms of ADHD, a brain disorder characterized by impulsivity, hyperactivity, and an inability to focus.

When Brown looked closely, though, she saw something else: trauma. Hyper-vigilance and dissociation, for example, could be mistaken for inattention. Impulsivity might be brought on by a stress response in overdrive.

“Despite our best efforts in referring them to behavioral therapy and starting them on stimulants, it was hard to get the symptoms under control,” she said of treating her patients according to guidelines for ADHD. “I began hypothesizing that perhaps a lot of what we were seeing was more externalizing behavior as a result of family dysfunction or other traumatic experience.”

Considered a heritable brain disorder, one in nine U.S. children—or 6.4 million youth—currently have a diagnosis of ADHD. In recent years, parents and experts have questioned whether the growing prevalence of ADHD has to do with hasty medical evaluations, a flood of advertising for ADHD drugs, and increased pressure on teachers to cultivate high-performing students. Now Brown and other researchers are drawing attention to a compelling possibility: Inattentive, hyperactive, and impulsive behavior may in fact mirror the effects of adversity, and many pediatricians, psychiatrists, and psychologists don’t know how—or don’t have the time—to tell the difference.

Though ADHD has been aggressively studied, few researchers have explored the overlap between its symptoms and the effects of chronic stress or experiencing trauma like maltreatment, abuse and violence. To test her hypothesis beyond Baltimore, Brown analyzed the results of a national survey about the health and well-being of more than 65,000 children.

Brown’s findings, which she presented in May at an annual meeting of the Pediatric Academic Societies, revealed that children diagnosed with ADHD also experienced markedly higher levels of poverty, divorce, violence, and family substance abuse. Those who endured four or more adverse childhood events were three times more likely to use ADHD medication.

Interpreting these results is tricky. All of the children may have been correctly diagnosed with ADHD, though that is unlikely. Some researchers argue that the difficulty of parenting a child with behavioral issues might lead to economic hardship, divorce, and even physical abuse. This is particularly true for parents who themselves have ADHD, similar impulsive behavior or their own history of childhood maltreatment. There is also no convincing evidence that trauma or chronic stress lead to the development of ADHD.

For Brown, who is now a pediatrician at Montefiore Medical Center in the Bronx, the data are cautionary. It’s not evident how trauma influences ADHD diagnosis and management, but it’s clear that some misbehaving children might be experiencing harm that no stimulant can fix. These children may also legitimately have ADHD, but unless prior or ongoing emotional damage is treated, it may be difficult to see dramatic improvement in the child’s behavior.

“We need to think more carefully about screening for trauma and designing a more trauma-informed treatment plan,” Brown says.

Dr. Kate Szymanski came to the same conclusion a few years ago. An associate professor at Adelphi University’s Derner Institute and an expert in trauma, Szymanski analyzed data from a children’s psychiatric hospital in New York. A majority of the 63 patients in her sample had been physically abused and lived in foster homes. On average, they reported three traumas in their short lives. Yet, only eight percent of the children had received a diagnosis of post-traumatic stress disorder while a third were diagnosed with ADHD.

“I was struck by the confusion or over-eagerness–or both–to take one diagnosis over another,” Szymanski says. “To get a picture of trauma from a child is much harder than looking at behavior like impulsivity, hyperactivity. And if they cluster in a certain way, then it’s easy to go to a conclusion that it’s ADHD.”

A previous edition of the Diagnostic and Statistical Manual of Mental Disorders urged clinicians to distinguish between ADHD symptoms and difficulty with goal-directed behavior in children from “inadequate, disorganized or chaotic environments,” but that caveat does not appear in the latest version. Unearthing details about a child’s home life can also be challenging, Szymanski says.

A child may withhold abuse or neglect to protect his family or, having normalized that experience, never mention it all. Clinicians may also underestimate the prevalence of adversity. The Adverse Childhood Experiences Study, a years-long survey of more than 17,000 adults, found that two-thirds of participants reported at least one of 10 types of abuse, neglect, or household dysfunction. Twelve percent reported four or more. That list isn’t exhaustive, either. The study didn’t include homelessness and foster care placement, for example, and the DSM doesn’t easily classify those events as “traumatic.”

It’s not clear how many children are misdiagnosed with ADHD annually, but a study published in 2010 estimated the number could be nearly 1 million. That research compared the diagnosis rate amongst 12,000 of the youngest and oldest children in a kindergarten sample and found that the less mature students were 60 percent more likely to receive an ADHD diagnosis.

Though ADHD is thought to be a genetic condition, or perhaps associated with lead or prenatal alcohol and cigarette exposure, there is no brain scan or DNA test that can give a definitive diagnosis. Instead, clinicians are supposed to follow exhaustive guidelines set forth by professional organizations, using personal and reported observations of a child’s behavior to make a diagnosis. Yet, under financial pressure to keep appointments brief and billable, pediatricians and therapists aren’t always thorough.

“In our 15-minute visits—maybe 30 minutes at the most—we don’t really have the time to go deeper,” Brown says.

If she suspects ADHD or a psychological condition, Brown will refer her patient to a mental health professional for a comprehensive evaluation. “You may have had this social history that you took in the beginning, but unless the parent opens up and shares more about what’s going on in the home, we often don’t have the opportunity or think to connect the two.”

Caelan Kuban, a psychologist and director of the Michigan-based National Institute for Trauma and Loss in Children, knows the perils of this gap well. Four years ago she began offering a course designed to teach educators, social service workers and other professionals how to distinguish the signs of trauma from those of ADHD.

“It’s very overwhelming, very frustrating,” she says. “When I train, the first thing I tell people is you may walk away being more confused than you are right now.”

In the daylong seminar, Kuban describes how traumatized children often find it difficult to control their behavior and rapidly shift from one mood to the next. They might drift into a dissociative state while reliving a horrifying memory or lose focus while anticipating the next violation of their safety. To a well-meaning teacher or clinician, this distracted and sometimes disruptive behavior can look a lot like ADHD.

Kuban urges students in her course to abandon the persona of the “all-knowing clinician” and instead adopt the perspective of the “really curious practitioner.”

Rather than ask what is wrong with a child, Kuban suggests inquiring about what happened in his or her life, probing for life-altering events.

Jean West, a social worker employed by the school district in Joseph, Missouri, took Kuban’s course a few years ago. She noticed that pregnant teen mothers and homeless students participating in district programs were frequently diagnosed with ADHD. This isn’t entirely unexpected: Studies have shown that ADHD can be more prevalent among low-income youth, and that children and adolescents with the disorder are more prone to high-risk behavior. Yet, West felt the students’ experiences might also explain conduct easily mistaken for ADHD.

Kuban’s course convinced West to first consider the role of trauma in a student’s life. “What has been the impact? What kind of family and societal support have they had?” West asks. “If we can work on that level and truly know their story, there’s so much power in that.”

As a school official, West sometimes refers troubled students to a pediatrician or psychiatrist for diagnosis, and meets with parents to describe how and why adversity might shape their child’s behavior. In her private practice, West regularly assesses patients for post-traumatic stress disorder instead of, or in addition to, ADHD.

Though stimulant medications help ADHD patients by increasing levels of neurotransmitters in the brain associated with pleasure, movement, and attention, some clinicians worry about how they affect a child with PTSD, or a similar anxiety disorder, who already feels hyper-vigilant or agitated. The available behavioral therapies for ADHD focus on time management and organizational skills, and aren’t designed to treat emotional and psychological turmoil.

Instead, West teaches a traumatized child how to cope with and defuse fear and anxiety. She also recommends training and therapy for parents who may be contributing to or compounding their child’s unhealthy behavior. Such programs can help parents reduce their use of harsh or abusive discipline while improving trust and communication, and have been shown to decrease disruptive child behavior.

Szymanski uses a similar approach with patients and their parents. “I think any traumatized child needs individual therapy but also family therapy,” she says. “Trauma is a family experience; it never occurs in a vacuum.”

Yet finding a provider who is familiar with such therapy can be difficult for pediatricians and psychiatrists, Szymanski says. Though some hospitals have centers for childhood trauma, there isn’t a well-defined referral network. Even then, insurance companies, including the federal Medicaid program, may not always pay for the group sessions commonly used in parent training programs.

Faced with such complicated choices, Szymanski says it’s no surprise when clinicians overlook the role of trauma in a child’s behavior and focus on ADHD instead.

While there are few recommendations now for clinicians, that will likely change in the coming years. The American Academy of Pediatrics is currently developing new guidance on ADHD that will include a section on assessing trauma in patients, though it won’t be completed until 2016.

Dr. Heather Forkey, a pediatrician at University of Massachusetts Memorial Medical Center, who specializes in treating foster children, is assisting the AAP. Her goal is to remind doctors that inattentive and hyperactive behavior can be traced back to any number of conditions—just like chest pains don’t have the same origin in every patient. Ideally, the AAP will offer pediatricians recommendations for screening tools that efficiently gauge adversity in a child’s life. That practice, she says, should come before any diagnosis of ADHD.

When speaking to traumatized children inappropriately diagnosed with ADHD, she offers them a reassuring explanation of their behavior. The body’s stress system, she says, developed long ago in response to life-or-death threats like a predatory tiger. The part of the brain that controls impulses, for example, shuts off so that survival instincts can prevail.

“What does that look like when you put that kid in a classroom?” Forkey asks. “When people don’t understand there’s been a tiger in your life, it looks a lot like ADHD to them.”

This story was produced for ACEs Too High and originally appeared on The Atlantic.

31 responses

  1. I am not disputing the findings but what about an even more basic root cause…nutrition? Typically low income diets are full of cheap food alternatives that are full of chemical preservatives, artificial food coloring, GMOs, hormones, etc…the list is endless.

  2. Oh for the love of pete, how about we stop asking why children aren’t learning and start asking how they learning and then compare that to the teaching methods. Ever notice how not one single school based evaluation mentions that perhaps the teaching practices don’t match the child? Ever wonder why we have good studies showing that as much as 20% of the population has Dyslexia, and yet your typical elementary may have less that 1% identified as Dyslexic? I can’t begin to enumerate the number of teachers I’ve spoken to that say they’ve never had a Dyslexic student. Anyone ever wonder why we have studies showing the youngest children in the class are the most likely to be diagnosed with ADHD? What about those children who don’t have traumatic childhoods, that have symptoms according to the teacher? How about those who are rated as normal by the parents and daycare, but the school teacher puts them as severely ADHD? How many visual spacial and kinesthetic learners are misdiagnosed as ADHD? Heck, the kinesthetic learner can qualify even if they have the focus of a bomb defuser. What we need to do is stop making excuses for not teaching to these children’s strengths. We need to stop making excuses for not identifying Dyslexia and other learning disorders. We need to stop making excuses to put kinesthetic learners on Ritalin and Adderall. We need to have teachers who can and will teach to visual-spacial learners. Yes, children use all of these, but some are much more so than others. Let’s quit medicating students because of our own inflexibilities and desire to make students sit down and shut up, so that we can stand up, verbally vomit a bunch of info, and then deciding that little Johnny is lazy and has ADHD because he didn’t learn a bit of that verbal vomiting. Stop teaching them that this is the way it is, and start teaching them why it is this way. Children are designed to use all of their senses to learn, and we do out best to drill that out of them as quickly and thoroughly as possible. Lets stop medicating the ones that don’t go along with that scheme. If anyone would bother to stop for a minute and ask how this child learns, they would usually find that the so called ADHD child is a spacial learner, and very likely requires a high kinesthetic component. We would also find a very high percentage of them have Dyslexia or some other learning difference. But instead of finding a way to teach them that works, we drug them up and put weighted vests on them and velcro on their desks, and keep them in from recess for getting out of their seat. My goodness people, not everyone processes incoming information the same way or at the same speed. We need to find ways to teach them not find ways to drug them up. Teach to their strengths, use their multitasking brains so they can web everything together. Instead of shutting down their brains, how about we start using ours!

  3. For 16 years, I’ve been an advocate in the area of Adult ADHD. You know, the parents of these kids with ADHD.

    I started by organizing public lectures about ADHD in my community (Silicon Valley). And what I noticed is that the people who didn’t seem to be getting any traction with their children (who had ADHD) were the people whose own ADHD was obvious to everyone but themselves.

    This is one reason I have focused on Adult ADHD: because this highly neurogenetic syndrome affects all aspects of adult life, especially parenting and many other domestic issues affecting any children living in the home. There are higher rates of conflict, more substance abuse, higher rates of IPV, more traffic accidents, lower employment, more bankruptcies, more divorces, etc. Everyone in the family can be at the mercy of unrecognized, untreated ADHD — the adult who has ADHD, the spouse, and most certainly the children. They have not only the genetic vulnerability but also the impact of living with chaos and confusion, and sometimes high conflict.

    In short, it is little short of child abuse to treat children for ADHD without screening the parents. When I mentioned this in an online group years ago, one physician left in a huff.

    It is not easy to reach these parents. They often think they are “compensating” well. Their “denial” can be immense.

    A pilot study recently looked at treating first the mothers of children with ADHD (that is, those mothers who were diagnosed with ADHD).

    For many years, we’ve gotten this backwards: treating the children first. While in the case of foster homes and the like, treating pediatric ADHD might be the biggest chance for positive change that child will experience, I always recommend that the entire family be evaluated before a child is treated.

  4. My stepdaughter was thought to have ADD/ADHD by school authorities, but no one ever thought to look into the situation at home. Unfortunately, she was living with a single mother with Borderline Personality Disorder who was adept at covering up what was truly going on outside of the school environment. When my stepdaughter lived with her father and myself for almost 2 years, teachers at the small rural school she attended (we lived in a different state) did not see any sign of ADD/ADHD, just saw a child who was 3 years behind in reading and who had delayed motor skills. By the time she left us, she was reading on grade level – but once back home she resumed her previous behaviours in school. Unfortunately, schools are not adept at recognizing symptoms of trauma and PTSD – and even if they do, there is little they can do unless a child shows signs of physical abuse.

  5. Pingback: adhd or trauma | Deborah Rasso, LMHC - Psychotherapist

  6. This intrigues me. My 6 y.o son was diagnosed with ADD several months ago after spending a few days on a psych ward. He HAS been through multiple traumas, including watching his father abuse me, being abused himself, divorce, an abrupt move, and possibly even the hospitalization. He’s been on several medications since then, and the combination that he’s on now seems to be helping. I do wonder, though, if his “symptoms” could be his way of coping with the trauma he’s been through.

  7. In other words, even though this article is very carefully worded to suggest otherwise, ADHD is made up. We know so little about it, yet we prescribe our kids Amphetamine based drugs for it, sounds great for the developing already traumatized mind. Not. All your kids need is your time. I know behavioral issues are a monster of their own but the problem is not the child, the child is having a problem, and until some over worked parents pull their heads out of the sand and actually parent, be a source of not just financial support but emotional and everything else, nothing will change. No medication out there has been proven to work for anything more than short term, then after that the body and brain gets to cope with withdrawals and a new type of chemical to change the way shit gets from point A to point B in our brains.

    • Thanks for your comment, Ashley. Parents need support, too. They’re often passing on what they’ve grown up with, and, because many have to work long and hard just to put a roof over the heads of their kids and food on the table, they’re stressed out.

    • Thanks Ashley,

      It is true that your environment can contribute to the development of ADHD, however it is not the only factor at play. In addition parents with undiagnosed ADHD probably are those who work more in lower paying roles and spend less time with their families because of the inner turmoil they experience and stress at work? ADHD makes patients susceptible to developing secondary conditions such as depression, bipolar, and post traumatic stress disorder to name a few. Can you imagine having to hold down a job that you struggle with and keep the house, yard, car and your kids in order with all of this going on?

      I wasn’t diagnosed until my adult life because no one knew that girls could have ADHD and my parents didn’t believe it was real (they taught me the same thing). I have struggled my whole life because of this and wasted 7 years of my life trying to sort myself out through therapy for the idiopathic depression and anxiety I suffer from. Now I know it’s ADHD and I can start to forgive myself for all the things I’ve failed at and for the things I continue to find extremely difficult.

      Dexamphetamines have helped me get my life back, CBT helped with my thinking due to trauma and things learned from my parents but anti-depressants never helped me get better.

      The frustrating part of ADHD for me is people don’t believe it is real and assume your lazy or making shit up because you can perform well sometimes but not all the time. People don’t know enough about ADHD because they don’t want to know. They want to make excuses like “everyone feels like that sometimes” to which I think “maybe you could try feeling like that all the time?”.

      Once a childhood has been lost it’s too late. If drugs don’t help then don’t use them? ADHD treatment is all about trial and error not “take this pill”. If your doctor sounds like that run in the opposite direction!

  8. I must say as a parent of adopted children who were traumatized in their bio/foster lives…no matter the cause, whether it be circumstantial, heredity, genetics, whatever, I know this for certain. My children were suffering, being passed over and written off in school, teased by classmates. They are both in therapy and have been since 2011, and we have successfully peeled back the onion skin of Reactive Attachment Disorder as well as some other behavioral issues pre-medication. After many of these issues were figured out, we had come to the end of our behavioral fixes and still had the ADHD symptoms that were almost impossible to deal with and maintain sanity in the house. They are both on meds now and are excelling in school, able to focus on their extra curricular activies (which the love), they are not written off as unhelpable or just misbehaving… No matter the cause, the meds have improved my children’s quality of lie as well as my own. They are thriving. I am satisfied. We spent two full years devoted to finding a way of helping them live a more normal, happy life. This continues as any normal family. But now, it is different. It is happy…mainly for my children.

  9. I wonder if traumatic experiences are the only environmental factor being explored. Particularly, comparing biological families to adoption cases where the children were adopted as infants. This is not to suggest that ADHD parents cannot be wonderful parents. I want to ask if, left undiagnosed and untreated, could an ADHD parent create environmental conditions in which the child unintentionally mimics the symptoms? If so, is it possible that it’s not as hereditary as we are led to believe since it cannot be isolated with DNA analysis?

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  15. The fatal error being made here is to imagine that ADHD is a genetically based disease. As per all other “conditions” listed in the DSM, ADHD is a clinically defined syndrome.

    I personally was diagnosed ADHD 6 years ago at age 46- the first in my family, and both of my children also fit the diagnosis. Many of my friends also have ADHD children- without having had ADHD themselves.

    I am now 52, and have worked in medicine since age 25. The incidence of the condition is clearly on the increase in a manner not consistent with genetic causation. The difference in incidence between Europe and the US, and the differences in incidence within the US are also inconsistent with a genetic causation.

    I work mostly with ADHD patients and would make the following suggestions:
    A chronic attention problem will generate recurrent traumatic experiences. That is easy to understand but can be expanded upon:

    Attention problems delay new learning severely- causing difficulties with falling behind in school and at work, and hindering the neuroplastic development of the brain. Effectively this can create a self perpetuating situation where the inattention feeds back and traps the individual in dysfunction.

    Any child who has inattention and emotional instability is difficult to handle- especially if the parents have their own vulnerabilities. This will lead to a situation of a difficult emotional climate in any family where the ADHD dynamic is operating- and may well generate more traumas.

    In fact I have not dealt with any ADHD individual not impacted upon by emotional trauma.

    In short- there may well be a dynamic positive feedback loop between attention problems and trauma.
    In this context the dichotomy between “ADHD” and complex trauma really is a false one.

    Deciding the exact cause can be very difficult- but unravelling the problem is much less so:
    Proper management of the syndrome we choose to call ADHD needs to be thorough, and involve attention to psychosocial issues whether or not stimulants are used.

    As for the decision to use stimulants– it is really not all that hard:
    Stimulants improve attention and allow new learning. Very often the absence of new learning can maintain ADHD. The correct approach in my books should be to offer comprehensive treatment involving psychosocial interventions as a matter of course in every case of ADHD and consider the option of a therapeutic trial of stimulants in every case of ADHD- even if trauma is part of the syndrome. However- the trial needs to be closely monitored with a view to assessing its effectiveness.

    • I would also highlight that in his book Scattered, Dr Gabor Mate highlights trauma as a cause of ADHD, and that equally it is acknowledged by experts in childhood trauma that it can adversely affect childhood development.

    • Has there been any investigation into the possibility of heavy metal toxicity?
      Also poor diet, omega 3 deficiency?
      Stress, of course, has its’ own legacy of impaired digestion and repair.
      Am not ignoring the significant contribution that emotional trauma plays, but am curious about other possible contributing factors.

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  17. I am so glad these issues are being studied! My niece, who is now 20, was diagnosed with ADHD in early elementary school. I wondered even then (before I had gotten my own college degrees) whether that diagnosis was accurate. Sure, she was hyperactive, chatted incessantly, had poor concentration etc., but she also was raised in a home with an alcoholic father, financially lacking parents, parents who loved her but related dysfunctionally to each other (yelling at each other, separations, cursing by both parents etc) Because my sister protected her to the extent that she could (and a few years later, her little brother) and did her best to leave the house if their father was drunk, didn’t leave them with him if he’d been drinking etc., DHS wouldn’t do anything. When my nephew started school, he too was diagnosed ADHD. They have both been on medication for it and their pediatrician concurred with the school’s impressions! I have long felt that if the environment had been healthier–or at least looked at more thoroughly, these kids MIGHT not have been given the ADHD diagnosis. And if they had, after investigating, the outcome would have been better because they’d have the full picture.

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  21. I was 5 when my father disappeared into a mental institution diagnosed with schizophrenia (wrongly, he was bipolar) and my grandparents on his side of the family, stand up Catholics that they were, threw us out onto the street. They were well-to-do and gave us no help: my mother’s fight for survival was epic. The blow destroyed me. For years nobody could get through to me, I was classic Tommy; a walking vegetable. Luckily there were no drugs to write me off with back in the 70s. People think kids are so resilient just because they can function on a basic level of breathing and eating and sleeping and growing. Ha! ‘Fine’ is relative, but it is true that where there is life there is hope.

  22. Really interesting article. As someone who works with a mental health organization, especially men with trauma, I find that most of our poor clients struggle with the effects of early childhood trauma, as well as current trauma. We have as an organization developed the TREM model for helping women with trauma and have added, M-TREM, for men, G-TREM, for girls and now B-TREM, for boys. They are practically based, psychoeducational groups designed to help those who suffer from trauma learn about its roots and its effects, and to developing new coping skills to help them lead happier, more productive lives. I will forward this article on to all I know who work in the field.

  23. Excellent article! Thanks to a school psychologist who dared to disagree with our adopted son’s neurologist, we dug deeper. Had we accepted the initial ADHD diagnosis, our son would have been on medication that would exacerbate his challenges. Instead we now have a child whose self-esteem is building and whose negative behaviors are diminishing, thanks to the right medicines and therapy.

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