Diagnosing: Is It ADHD—Or Trauma?

It seems like a relatively simple diagnosis. That student, the one three rows down, second seat over, looks like she’s about to fall out of her seat from fidgeting. She’s distracting the other students around her and doesn’t seem able to focus on any one thing for long. Has she even been paying attention to the lesson? Nope. Must be ADHD.

And it very well could be. Among other symptoms, ADHD (attention deficit/hyperactivity disorder) is hallmarked by an inability to focus and a tendency toward hyperactivity. But when Dr. Nicole Brown looked more closely into these typical symptoms, she uncovered something else that might cause this behavior: Trauma.

A resident at Johns Hopkins Hospital in Baltimore, Brown saw many patients diagnosed with ADHD who did not respond well to the usual behavioral therapy or stimulants prescribed for the disorder. Yet she also noticed that these patients came from communities and homes of stress and violence. This prevalence is what led her to a different theory:

"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," Brown told The Atlantic. Looking beyond Baltimore to a national survey of over 65,000 children, she found that those diagnosed with ADHD also had several adverse childhood experiences—ACEs—such as abuse, poverty, and neglect. The more ACEs a child had, the more likely they were on ADHD medication.

Can it be both?
ADHD is already a hot topic, if not a buzzword; yet even with growing claims that the rash of diagnoses could be due to overhasty evaluations by harried pediatricians or the prevalence of ADHD drugs, Brown advises caution in assuming too much about what happens in the child’s home. "'We need to think more carefully about screening for trauma and designing a more trauma-informed treatment plan,'" she says. For her, it’s not necessarily an either-or diagnosis. These children could still have ADHD, but failure to treat the emotional damage inflicted by traumatic events could hamper behavioral improvement overall.
 
Dr. Kate Szymanski, an associate professor at Adelphi University’s Derner Institute, agrees. The majority of the children she studied from a psychiatric hospital had experienced several traumas while living in foster homes, yet more had received a diagnosis of ADHD than PTSD (posttraumatic stress disorder). While it can be difficult to uncover all the details of home life, Szymanski was "'struck by the confusion or over-eagerness–or both–to take one diagnosis over another. To get a picture of trauma from a child is much harder than looking at behavior like impulsivity, hyperactivity.'"

What about treatment?
Other concerns involve determining treatment options available for trauma versus ADHD--and recognizing the difference in patients in the first place. Caelan Kuban, a psychologist and director of the National Institute for Trauma and Loss in Children (MI), acknowledges that it takes training to tell the difference between trauma and ADHD. She holds a seminar to help educators and other professionals view children in their care from a person-centered point of view, rather than relying on their own assumptions.

Kuban’s course inspired social worker Jean West, who now considers the possible role of trauma first in a student's life. As ADHD therapies focus more on organizational and time management issues than psychological, West assesses her patients for PTSD as well as ADHD, and teaches children of trauma tactics for how to cope with their emotional turmoil.
 
What you can do now:

• Download our free Trauma-Informed Care Resources Guide.
• Learn more about the behavioral health impact of traumatic events on kids.
• Pick up the Trauma TIP from SAMHSA.
• Help build a Trauma-Informed Culture of Care, from support to becoming an Instructor yourself.
• Check in on the American Academy of Pediatrics, which is developing new guidance on ADHD that will include trauma assessment (to be completed in 2016).

Considering the role of trauma in a child’s life brings many questions. The robust network that exists for ADHD is somewhat lacking when it comes to trauma-informed care, especially when we realize that childhood trauma is not an isolated event, but a whole-family experience. And from family to community, the impact of these experiences can have lifelong effects.

How have you used trauma-informed care in your work or home?