IMPORTANT NOTE: This article considers the possible link between childhood trauma and ADHD. However, to clear up any possible misinterpretation of this article, it is important to state at the outset that ADHD is undoubtedly a genuine disorder and it is not by any means implied below that all cases involve underlying trauma.
In the USA, about one in every nine children is diagnosed with ADHD; this equates to a total of 6.4 million American youths.
But should a significant proportion of these young people’s primary diagnosis be one of PTSD, not ADHD?
Many experts think so. Post Traumatic Stress Disorder (PTSD) may be misdiagnosed as Attention Deficit and Hyperactivity Disorder (ADHD) in up to a million children per year in the USA.
The psychologist, Brown, an expert in the field, has drawn attention to the fact that many children who have been diagnosed with ADHD have symptoms that one would expect to find in people suffering from PTSD such as difficulty controlling behaviour/impulsivity, severe mood fluctuations, hypervigilance and dissociation ( or ‘zoning out’).
The confusion may arise when such symptoms are mistaken for those of ADHD. For example:
- – difficulty controlling behaviour/mood fluctuations may be seen as wilful disruptiveness.
- – hypervigilance may be seen as distractability.
- – dissociation may be seen as deliberate inattention/lack of focus (indeed, I suffered from this when I was eight. I didn’t respond to my name in class, so lost and caught up was I in my internal distressing thoughts, leading to my teachers suspecting that I was going deaf. I was taken for an ear test, but there was nothing whatsoever wrong with my hearing – let this serve as a salutary lesson to teachers as to how a child’s distress may manifest itself in unexpected ways and be misinterpreted entirely; indeed, another good example is the possibility that a child’s anger is serving to soothe his / her emotional pain.
Brown’s suspicions that, often, children diagnosed with ADHD should have been diagnosed with PTSD were heightened further by the observation that standard ADHD treatment did not work for many children.
Perhaps, then, Brown hypothesised, these children were, in fact, ‘acting out’ (what psychologists refer to as ‘externalizing’) their distress caused by living in a dysfunctional family (the children in the study came from low-income families and were known to live in environments in which high levels of stress and violence were prevalent).
To examine the issue further, Brown set up a study looking at the overlap between the symptoms of ADHD and the effects of traumatic stress on children caused by maltreatment and abuse.
The study was based on a survey of 65,000 children in the USA, and the results showed that those who had been diagnosed with ADHD also had a significantly higher than average chance of coming from a background of divorce, poverty, violence and/or families who misused drugs and alcohol.
Indeed, those who had experienced the great stress of 4 or more ADVERSE CHILDHOOD EXPERIENCES (ACEs) were three times more likely to have been diagnosed with ADHD and prescribed medication for it than those who had not experienced any.
The psychologist, Szymanski, derived similar results from a study of 63 children who had been treated by a psychiatric hospital. On average, the children had suffered 3 ACEs, yet only 8 per cent had been diagnosed with PTSD, while 33 per cent had been diagnosed with ADHD.
Another study (Burke et al., 2011) of relevance involved the analysis of 701 children’s medical records. The children involved came from violent and economically deprived neighbourhoods in the Sans Francisco area.
It was found that two-thirds of the young people had experienced at least one ACE, and 12 per cent had experienced four or more ACEs. Further analysis of the data revealed that the more ACEs the children had experienced, the more likely they were to display behavioural problems.
Significantly, the researchers involved in the study expressed the concern that many such children may be receiving diagnoses of ADHD when a diagnosis of PTSD, or other stress-induced conditions, would be more appropriate. It was suggested that this error might be occurring because symptoms of severe stress, such as hyperarousal and cognitive dysregulation were being mistaken for signs of ADHD.
Furthermore, Techer et al.conducted research that found that approximately 1 in 3 children who have experienced severe abuse meet the diagnostic criteria for ADHD and that children who are particularly at risk of going on to develop ADHD-like behaviour experienced such abuse very early in life.
Techer also draws our attention to the fact that ADHD is reliably found to be associated with abnormal neuroanatomy (brain structure) – specifically, a smaller than normal cerebellar vermis. Based on this and other evidence showing a link between physical brain abnormalities (e.g. in the mid portions of the corpus callosum) and the emergence of symptoms similar to those found in ADHD such as impulsivity Techer suggests that abuse in early life may result in physical alterations of the brain’s structure which, in turn, create ADHD-like symptoms.
The above studies suggest that, in some cases, PTSD me be mistakenly diagnosed as ADHD and that many children could be wrongly diagnosed with ADHD whereas their primary diagnosis ought to be one of PTSD. Some estimates suggest that up to one million children per year could be misdiagnosed in this way.
If some children are being treated for ADHD when they should be being treated for PTSD, their treatment may be inappropriate.
Indeed, one treatment for ADHD is the prescription of stimulants. However, this could worsen symptoms of agitation (agitation is a symptom of PTSD).
Furthermore, treatment for ADHD does not deal sufficiently with the emotional and psychological distress that the child with PTSD suffers.
Very obviously, the above does not in any way imply that all cases of ADHD should, in fact, have been diagnosed as PTSD and, equally obviously, a child may simultaneously fulfil the diagnostic criteria to be considered to be suffering from both conditions (i.e. justifying a co-morbid diagnosis; indeed, research suggests the two conditions share familial risk factors) which is why I include the following warning: N.B. Any changes in medication should only be made on the advice of a suitably qualified professional who is familiar with the specific case under consideration.
One reason that has been suggested is that the companies producing the drugs for ADHD use advertising campaigns which, in effect, encourage the diagnosis of ADHD and its treatment, thus increasing their profits.
A second suggestion as to why ADHD may be being misdiagnosed as PTSD is that the assessment of children by clinicians is not extensive or thorough enough due to time and financial restrictions. A fifteen-minute or half-hour appointment is not enough to evaluate, sufficiently, a child’s mental state and factors related to his / her home life that may be damaging it.
It is also worth reiterating how there exists an overlap between the symptoms of ADHD and the symptoms of PTSD (e.g. Daud, 2009); these include, sleep difficulties, giving the impression of not listening in class, restlessness, disorganisation, restlessness and easy distractibility.
WHAT IS THE DIFFERENCE BETWEEN ADHD AND PTSD?
Perhaps the best way to demonstrate how ADHD and complex PTSD differ from one another is to list symptoms SPECIFIC to each condition followed by a list of the symptoms that both ADHD and complex PTSD have in common. I do so below:
SYMPTOMS SPECIFIC TO COMPLEX POSTTRAUMATIC STRESS DISORDER :
- feelings of shame and guilt
- risk-taking behaviours
- proneness to aggressive behaviours
- self – destructiveness
- perpetual feelings of being on ‘red alert’ / under threat
- avoidance behaviours
- outbursts of rage/anger
SYMPTOMS SPECIFIC TO ADHD :
- problems following instructions
- fidgeting and squirming
- poor organisational skills
- excessive talking
- interrupting or intruding on others
- losing items that are necessary for tasks and activities
- difficulty concentrating
- problems with waiting and turn-taking
SYMPTOMS THAT ADHD AND COMPLEX PTSD HAVE IN COMMON :
- sleep problems
- giving the impression of not listening
- problems with concentration
The above lists are based on research conducted by The National Child Traumatic Stress Network (NCTSN).
To reiterate what I said in the opening paragraph of this article, however, ADHD is a very real and genuine condition and, whilst it is acknowledged that it cannot be diagnosed by any biological tests at present (though this may change), advocates of the reality and potential seriousness of the condition point out that it has been linked to abnormalities in the growth and development of the brain and that it runs in families. It is also associated with increased morbidity and mortality.
Although many individuals with ADHD eventually appear to ‘outgrow’ it, about 1 in every 25 adults has a diagnosis of ADHD and it is likely that many others also have the condition but, as yet, remain undiagnosed.
Does Betrayal Trauma Increase The Risk Of ADHD?
Betrayal trauma is a term which comes from betrayal trauma theory which was developed by Freyd (1994). Essentially, an individual may experience betrayal trauma when betrayed by a person to whom s/he is very close and upon whom the individual depends for their safety, security and survival and with whom there had been a deep bond of trust. For example, a child betrayed by a parent or primary carer may be at risk of developing betrayal trauma as a consequence, whereas betrayal by a relative stranger with whom the child was not close and had not built up a bond of trust would not lead to betrayal trauma.
THE EFFECTS OF HIGH-LEVEL BETRAYAL ON THE CHILD’S EXECUTIVE SYSTEM COMPARED TO THE EFFECTS OF LOW-LEVEL BETRAYAL.
WHAT IS MEANT BY EXECUTIVE FUNCTION?
Executive function refers to the brain’s ability to successfully carry out various cognitive processes (i.e. mental processes which enable us to gain knowledge and understand things) that help the individual:
- monitor and control behaviour
- achieve goals
- pay attention
- inhibit impulses
- problem solve
- operate working memory (working memory is the part of the memory system that stores information temporarily. It facilitates reasoning and helps to guide our behaviour).
RELEVANT RESEARCH STUDIES:
Research carried out by DePrince et al. (2009) involved 3 groups of children as follows:
GROUP 1: Those in this group had not experienced significant trauma.
GROUP 2: Those in this group had experienced trauma that involved a high level of betrayal (i.e. betrayal by a close family member leading to trauma).
GROUP 3: Those in this group had experienced trauma that involved a low level of betrayal (i.e. betrayal by a non-family member leading to trauma.
The aim of the research was to establish if which of the above three groups the child was in was related to the quality of his/her executive function.
HOW WAS EXECUTIVE FUNCTION MEASURED IN THIS STUDY?
In order to get an indication of the children’s executive functioning the following were measured:
- working memory
- auditory attention
- processing speed
RESULTS OF THE STUDY:
It was found that:
- The greater the number of traumatic events involving family members, the poorer, on average, was the executive functioning.
- Those children who had experienced trauma without family members being involved did NOT have impaired executive functioning.
Later research conducted by Freyd and colleagues (2008), which was focused specifically on ADHD, involved the study of individuals who had experienced childhood abuse or neglect. in comparison with children who had suffered no significant abuse or neglect. This study found that:
those who had suffered significant abuse or neglect in childhood showed significantly poorer attention and impulse control than those who had not suffered significant abuse or neglect during childhood.
The first study referred to above suggests that trauma which involves a high degree of betrayal is associated with impaired executive function in the individual who experienced the betrayal trauma. The results of the second study suggest abuse and neglect increase an individual’s risk of developing ADHD; unfortunately, however, in the second study, it was not recorded if the kind of trauma the participants had suffered was betrayal trauma or not.
These findings have serious implications for the causes of ADHD which is an executive function disorder. However, further research is needed in order to elucidate further the link between betrayal trauma, non-betrayal trauma and ADHD.
More recent studies (e.g. Hulette et al.2011) have shown that children who have been in foster care (and are therefore likely to have experienced betrayal trauma) are at significantly increased risk of suffering from pathological dissociation. Pathological dissociation is most commonly a symptom of PTSD/complex PTSD but could be mistaken for inattentiveness increasing the risk of being misdiagnosed with ADHD.
Martin, Christina & Cromer, Lisa & Deprince, Anne & Freyd, Jennifer. (2013). The Role of Cumulative Trauma, Betrayal, and Appraisals in Understanding Trauma Symptomatology. Psychological trauma : theory, research, practice and policy. 52. 110-118. 10.1037/a0025686.
Becker-Blease, Kathryn & Freyd, Jennifer. (2008). A Preliminary Study of ADHD Symptoms and Correlates: Do Abused Children Differ from Nonabused Children?. Journal of Aggression, Maltreatment & Trauma. 17. 133-140. 10.1080/10926770802250736.
Freyd, Jennifer. (1994). Betrayal Trauma: Traumatic Amnesia as an Adaptive Response to Childhood Abuse. Ethics & Behavior – ETHICS BEHAV. 4. 307-329. 10.1207/s15327019eb0404_1.
Hulette AC, Freyd JJ, Fisher PA. Dissociation in middle childhood among foster children with early maltreatment experiences. Child Abuse Negl. 2011 Feb;35(2):123-6. doi: 10.1016/j.chiabu.2010.10.002. Epub 2011 Feb 26. PMID: 21354620; PMCID: PMC3073131
- For useful advice about whether a child has ADHD or the effects of traumatic stress, you may wish to read this (CLICK HERE) helpful article from WebMD.
- For information about complex PTSD from one of the UK’s leading mental health charities (MIND), CLICK HERE).
- Another useful external link: NHS information about ADHD (CLICK HERE)