Sometimes I see children in my practice diagnosed with Attention Deficit Hyperactivity Disorder (ADHD). After weeks of therapy, elements are revealed and I often catch myself asking: ‘Is this really ADHD, or trauma related, or both?’ The complaints of inattention and impulsivity from school and at home can demarcate that it is a case of ADHD. But exposure to trauma can often show up as symptoms of ADHD. And trauma is often overlooked in ADHD diagnosis. The question has intrigued me to share my two cents about the two topics in this blog and see how we can avoid a misdiagnosis.
Children diagnosed with ADHD have several noticeable symptoms (or a sign of a disorder). First, they are fidgety. They often can’t sit still and need something to fiddle with, either in their hands or feet. This unsettling energy means they need to be moving most, if not all, of the time. Second, they day dream more often than most people do and that often means they will struggle to pay attention in terms of what is being said to them or being asked of them. And lastly, they are impulsive. They will blurt out answers before a question is even asked, not wait their turn and do things without thinking about the consequences. In a school setting where there is a lot of structure, demands, and long hours, it can be a nightmare of a place for a child with ADHD to be in. Moreover, their symptoms can impact the quality of their social relationships (i.e. difficulty making and retaining friends), academic performance and work-life balance.
Unbeknownst to many, children who have been exposed to a trauma (or repeated trauma), such as violence or abuse (i.e. physical, sexual, verbal) at home and/or within their communities do the same things as ADHD children. Like their ADHD peers, they often struggle to understand signs of danger or threat, such as not looking when crossing a busy road, or being super friendly towards strangers. These signs can cause them to be easily startled and unable to calm down, especially when asked to, even repeatedly. Sometimes, they may become paranoid, thinking that people are out to get them. As a result, they are prone to throw tantrums (i.e. their tempers can go from 0 to 10 in a matter of seconds). They may also have intrusive thoughts about what they’ve been exposed to and that in itself can make them look like they are day dreaming and distracted without their control. (They often lack self control which is rooted in the prefrontal cortex of our (second) brain–the area responsible for planning, problem-solving, and decision making–that often reacts this way to trauma.) While some children can develop Post-Traumatic Stress Disorder (PTSD), in other cases, children can develop these symptoms and not meet the PTSD diagnosis. This is sometimes referred to as ‘Complex Trauma’ and these children, too, can be (mis)diagnosed with ADHD.
Common PTSD symptoms that may look like ADHD
Adding more confusion to the issue, children can also have both-that is ADHD and PTSD. Below I list common PTSD/Complex Trauma symptoms that may look like ADHD symptoms:
hyper arousal: children do not have a (strong) radar to pick up signs of danger or threat, particularly because they are always on high alert for danger with stress hormones racing constantly throughout their body, making it hard for them to regulate properly and find inner calm. This can look like hyperactivity and impulsivity of ADHD.
reliving the trauma in their minds: children may look spacey and distracted like children with the inattentive type of ADHD if they’re having random and intrusive thoughts of the traumatic event, making it difficult for them to switch off their thoughts and be in the present moment. The issue is that the trauma was too much for the child’s brain to comprehend, thus s/he is constantly replaying (almost obsessively) to understand it in their heads in order to digest it and move forward.
negative view of others: children who have been exposed to trauma have a tendency to see people as hostile and assume people will hurt them, even those who show time and time again that they can be trusted. This can cause them to act out in ways that don’t make sense (looks like impulsivity, a hallmark of ADHD), including constantly saying, ‘No’, to authority, such as to the teacher, not following directions or wanting to do what they want (seen as oppositional behavior that ADHD children can also develop). At the root of the opposition is a lack of distrust for authority and fear because it was authority that did them wrong in the first place when they were supposed to be protecting them. So, in the child’s mind s/he may think: ‘Why should I obey you, if you can hurt me like my father, or my teacher?’ They are so hurt by the pain that they begin to program themselves to rely only on themselves to survive. They are willing to fight at any cost to defend their existence and importance in this world, thereby arousing their fight or flight system constantly, anticipating the worst scenario, even when there is no threat or at the smallest of things (ie. trigger), such as what people say or do. The children who flee at any provocation can end up developing depression and anxiety.
difficulty with executive functions: Like their peers with ADHD, traumatised children tend to have trouble staying focused, planning how to get things done, managing their emotions and thinking before they act. For instance, children will often say: ‘I don’t know’ on homework assignments that they have seen before due to poor memory recall (hijacked by the trauma) and ‘I feel stuck’ to describe their emotions when they don’t know how to plan to study for exams ahead of time.
A clinician-whether someone making the diagnosis and/or treating a child-should be able to identify the behaviors of ADHD or trauma within the context of the child’s history. Children who are hyperactive and impulsive will most likely have behaviors that do not match with trauma, such as interrupting, talking excessively, running down hallways, to name a few examples. Having a variety of hyperactive and impulsive symptoms would point to ADHD. In the same breath, children with PTSD symptoms may not have ADHD symptoms, such as experiencing intrusive thoughts which is not a symptom of ADHD.
Another symptom of PTSD would be avoiding things that remind the child of the traumatic experience, especially if the clinician knows what kind of trauma the child has been exposed to because PTSD is often a cry for safety-to feel safe in their bodies and within their environment(s). Not wanting to go home for example is not part of a ADHD diagnosis, but a signal of an unhappy child with PTSD.
As already stated, it is possible for children to have both ADHD and PTSD. In fact, research shows that children who have a traumatic experience are four times more likely to develop PTSD than children who aren’t exposed. And their trauma symptoms are often more severe than children without ADHD. Brain scans show that ADHD and PTSD are associated with brain abnormalities which could explain why the risk is higher. That means that children with ADHD need additional and proper attention and support in case they have experienced trauma, along with a PTSD screening. That is also to say that children with PTSD should be screened for ADHD just to be on the safe side.
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