How childhood trauma could be mistaken for ADHD



[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.

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California Assembly Health Committee OKs ACEs resolution 16-0

ImageThe California Assembly Health Committee today approved, by a vote of 16-0, a resolution to encourage statewide policies to reduce children’s exposure to adverse childhood experiences. California took a page from Wisconsin’s playbook with the introduction of legislation (California Assembly Concurrent Resolution (ACR) No. 155) on May 28. It drew upon ideas from Wisconsin’s legislation (Senate Joint Resolution 59), approved by the legislature this early this year. Both the Wisconsin resolution and the California proposal encourage state policy decision-making to consider the impact of early childhood adversity on the long-term health and well being of its citizens.

Before the vote was taken on June 17, the lead sponsor of the California bill, Assemblymember Raul

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Vermont first state to propose bill to screen for ACEs in health care


Dr. George Till, Vermont state legislator and physician

When Vermont State Legislator and physician Dr. George Till heard Dr. Vincent Felitti present the findings of the CDC’s Adverse Childhood Experiences Study at a conference in Vermont last October, he had an epiphany that resulted in a seismic shift in how he saw the world. The result: H. 762, The Adverse Childhood Experience Questionnaire, the first bill in any state in the nation that calls for integrating screening for adverse childhood experiences in health services, and for integrating the science of adverse childhood experiences into medical and health school curricula and continuing education.

That Vermont would be the first in the nation to address adverse childhood experiences so specifically in health care at a legislative level isn’t unusual. More than most states, Vermont is a “laboratory of change” for health care. It has embraced universal health care coverage for all Vermonters, and it passed the nation’s first comprehensive mental health and substance abuse parity law. (Washington State passed a law in 2011 to identify and promote innovate strategies, and develop a public-private partnership to support effective strategies, but it was not funded as anticipated. The Washington State ACEs Public-Private Initiative is currently evaluating five communities’ ACE activities.)

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Arresting our way out of drug crisis is yesterday’s theory, says VT Gov. Shumlin; urges public health approach

AshumlinState of the state addresses—like the State of the Union—tend to cover a wide range of topics from the economy to health care to education.  Vermont Governor Peter Shumlin broke the mold when he devoted his entire 2014 State of the State address to the state’s drug addiction crisis.  The rising tide of drug addiction and drug-related crime spreading across Vermont is “more complicated, controversial, and difficult to talk about” than any other crisis the state confronts, he said.

“We have lost the war on drugs,” he said. ” The notion that we can arrest our way out of this problem is yesterday’s theory.”  Even though Vermont is the second smallest state in the union (pop. 626,600), more than $2 million of heroin and other opiates are being trafficked into the state every week. Shumlin expressed alarm over the increase in the deaths from heroin overdose that doubled in 2013 from the year before and the 770 percent increase in treatment for opiates.

Shumlin told emotional stories of young Vermonters becoming addicted to prescription opiates and heroin — one recovered, one died from an overdose. While stories of young and promising individuals dying from heroin overdoses may grab headlines, data from the Centers for Disease Control and Prevention (CDC) show that deaths from prescription opioid pain relievers — such as codeine, methadone, and oxycodone — between 1999-2008 now exceed deaths involving heroin and cocaine combined.

CDC reports that in 2008, 36,450 deaths were attributed to drug overdoses in the U.S.  Opioid pain relievers were involved in 14,800 deaths (73.8%) of the 20,044 prescription overdose deaths.  The drug overdose death rate of 11.9 per 100,000 (Vermont’s rate was 10.9 per 100,000) was roughly three times the rate in 1991. Prescription drugs accounted for most the increase.  An April 12, 2012 statement from the Office of National Drug Control Policy reported that death from unintentional drug overdoses is greater than car accidents, the leading cause of injury in the U.S.

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Violence Against Women Act flounders, sinks in 112th Congress…

VAWA…and Sen. Patty Murray intends to reintroduce it. Here’s a great analysis of what happened to the legislation — passed in 1994, with the leadership of then-Sen. Joe Biden — and reauthorized without problems until Oct. 2011, “after conservative lawmakers balked at the addition of expanded protections for undocumented immigrant, Native American, and LGBT victims of sexual assault.” As author Tara Culp-Ressler, an editorial assistant at ThinkProgress, noted on

As the legislation hung in the balance this past year, Rep. Gwen Moore went to the House floor to recount the story of her own sexual assault to explain why this country needs VAWA. Moore said that as she watched Republican men begin to stall the reauthorization of the bill, “it brought up some terrible memories for me” of both the

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Pediatrics academy tells baby docs: your new job is to reduce toxic stress

According to research over the last 15 years, there’s no doubt now that child trauma causes toxic stress on the brains of babies and children, which causes short-term harm and long-term health consequences. So, it’s not a big surprise that the American Academy of Pediatrics issued a policy statement about the issue. What’s significant is the advice to pediatricians: Radically change how you do your job and take new approaches to protect those fragile developing brains.

The report advised pediatricians to:

  • Integrate a psychosocial approach into doing medicine. “Psychosocial problems and the new morbidities should no longer be viewed as categorically different from the causes and consequences of other biologically based health impairments.”
  • Incorporate into medical school and continuing education classes the knowledge of how childhood toxic stress affects “disruptions of the developing nervous, cardiovascular, immune, and metabolic systems, and the evidence that these disruptions can lead to lifelong impairments in learning, behavior, and both physical and mental health.” A technical report, in press, will provide more details about this.
  • Take an active leadership role in educating everyone — public, policy makers, educators, etc. — about the long-term consequences of childhood toxic stress.
  • Advocate for “new, evidence-based interventions (regardless of the provider or venue) that reduce sources of toxic stress and/or mitigate their adverse effects on young children.”

Another study shows abuse-physical illness link

In a review of 24 studies of more than 48,000 adults, researchers found that child abuse raises the risk of physical illness as much as psychological problems, according to a recent article in Medical News Today.

The study was published in this month’s issue of Psychosomatic Medicine: Journal of Biobehavioral Medicine. Picture 8

According to study co-author Cinnamon Stetler, Ph.D., an assistant professor of psychology at Furman University in South Carolina:

“Your exposure to really severe stressors like abuse in childhood may program the body’s stress system to respond in ways that may be adaptive in the immediate environment, but over the long term can be maladaptive and take their toll.”

In the study’s conclusions, the researchers said:

However, studies often fail to include a diverse group of participants, resulting in a limited ability to draw conclusions about the population of child abuse survivors as a whole.

That’s one reason so many organizations are starting ACE Studies of their own. This year, six states — Arkansas, California, Louisiana, South Carolina, Montana, New Mexico and Washington — are including the ACE questionnaire in their Behavioral Risk Factors Surveillance System (BRFSS), which each state does every year to assess its population’s health status.

Unhealthy habits – to many, they’re solutions, not problems

On Monday, the local NPR station, Kansas Public Radio, broadcast “Why Unhealthy Habits are Hard to Change”, as part of their regular and always interesting health coverage. Brian Thompson interviewed Kansas State professor Dr. Matthew Palmatier.Picture 7

One thing that Palmatier didn’t bring up is something that many of Dr. Vincent Felitti’s patients told him when he was first exploring the link between the obesity and child trauma: They didn’t see their weight as a problem. They saw it as a solution.

Here’s an example. Several years ago, I attended a conference about child sex abuse. A woman who was quite overweight told her story of years of struggle with trying to shed pounds. She’d been to Weight-Watchers, to special diet clinics, under the care of physicians….you name it, she’d tried it. Each attempt started out well. She lost 10 pounds. 20 pounds. 30 pounds. But at some point, she said, she’d always panic, flee the program and put all the weight back on in a matter of weeks. It took her years to connect this reaction with an event in her childhood. When she was seven, her father raped her in front of her sister, who was just a couple of years older. While he was raping her, he told her the only reason he wasn’t doing the same thing to her older sister is that she was too fat. So, being fat was a way to protect herself.

But that doesn’t mean that everyone who’s obese has suffered child sex abuse, and the ACE Study research bears that out. Food wasn’t my drug of choice, said another woman at this conference.  It was alcohol, which numbed her to the sexual abuse that her father subjected her to, along with his friends. She was very thin. Other people use illegal drugs — cocaine, methamphetemine, heroin, prescription painkillers — or smoking or inappropriate sexual behavior or work. The list goes on, and that list translates into unhealthy lifestyles that lead to adult onset of chronic diseases.

These are grim, grim stories, but very common. Also, childhood trauma doesn’t only refer to one of the three abuses: physical, sexual or emotional. The trauma measured in the ACE Study includes witnessing a mother being battered, a parent who disappears through death or divorce, and a member of the family who’s been imprisoned, is mentally ill or an alcoholic (or other drug abuser).

What’s pretty clear, once you scratch the surface, is that many people who engage in these unhealthy lifestyles feel to their very core that overeating, smoking, binge drinking or keeping a buzz on, having lots of sexual partners, working 80 hours a week — all these things help them cope with some very difficult memories and feelings. For many, these unhealthy habits aren’t problems; they’re solutions. So, it doesn’t seem as if any amount of telling them it’s a problem is going to make much of a difference. So, what will?

High ACE scores linked to early mortality

It’s pretty striking, says Dr. David Brown, the lead author on research released by the American Journal of Preventive Medicine last week, Picture 6that examine the link between child trauma and early mortality. “It’s pretty striking that someone with six or more ACEs died 20 years earlier.”  Brown, an epidemiologist at the Centers for Disease Control and Prevention, is part of the Adverse Childhood Experiences Study, a joint project of the CDC and Kaiser Permanente in San Diego. Here’s the link to the AJPM article: Adverse Childhood Experiences and the Risk of Premature Mortality.

Several organizations did articles about the research. I did two in the Lawrence Journal-World:

Traumatic childhood takes 20 years off life expectancy
Social service agencies, public health communities use ACE, but not medical community

Here are two other good articles:

Is Life Expectancy Reduced by a Traumatic Childhood? in

Childhood May Shorten Life by 20 Years on

If you run across any others that aren’t repeats of the press release, please add them. Somewhere on this blog, I’ll put them all together.

Although the interest about the effects of child trauma isn’t particularly high the traditional media as yet, AJPM managing editor Charlotte Seidman says that the first ACE Study published in 1998 has been in the top-five or top-ten most viewed on the AJPM site every year since its publication.

Sad kids more likely to be obese adults

Here’s an interesting study that seems to bear witness to the findings in the ACE Study that link child abuse — physical, sexual and emotional — to adult obesity:

From MedPage Today, a review of a study from the journal, BMC Medicine, in which Andrew Picture 6Ternouth, PhD, of the Institute of Psychiatry at King’s College in London, with co-authors David Collier and Barbara Maughan found that:

Sad youngsters are more likely to grow up to be fat adults, particularly if the unhappy child is a girl, according to a British study of more than 6,500 adults who were born in 1970.

The study’s part of the 1970 Birth Cohort Study of 16,496 people who were born in England and Wales. More details:

  • The strongest predictors of adult BMI were BMI at age 10 and parental BMI.
  • Self-esteem, self-reported worrying, self-reported nervousness, and locus of control all significantly predicted weight gain.
  • There was significant interaction between emotionality and locus of control and gender — the impact of these factors was greater in women than in men.
  • Childhood emotional problems predicted weight gain in women only. Childhood self-esteem predicted weight gain in both men and women, although the effect was stronger in women. An external locus of control predicted weight gain in both men and women.
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