ADHD and Trauma

A child who lives in a chaotic, verbally/physically/sexually abusive environment usually has great difficulty sustaining attention, is probably highly distractible, and may spend most of his or her time zoning out (dissociation) as a way to escape the painful realities of his or her life.

But at first glance, especially in a classroom setting, these symptoms can look just like a classic case of ADHD Inattentive Type. But the sad reality may be that these are more symptoms of trauma and massive anxiety.

Or alternatively, a child from a similar environment may be hyperactive, out of control, shoot his mouth off, and be destructive as a way of acting out his distress and expressing unmitigated anxiety and panic. Again, it might also look like classic ADHD, Hyperactive-Impulsive Type.

That's why it's crucial that an ADHD evaluation includes a detailed history, especially a trauma history, to make sure we really know what we're dealing with and to not just assume we're dealing with ADHD by itself. If a child suffering from trauma is mistakenly diagnosed as simply ADHD, the trauma (the real cause of the behavioral symptoms) is left untreated and no amount of ADHD counseling and/or medication intervention will improve the true situation.

And is some cases, especially with the incorrect medication being prescribed, it can actually make things worse.

One of the ways we can evaluate trauma is with the ACE, a 10-question test of Adverse Childhood Experiences, a simple questionnaire with 10 categories of childhood trauma, five of which are personal including physical abuse, verbal abuse, sexual abuse, emotional neglect and physical neglect. The other five questions are related to family members like having an alcoholic/addict parent, a mother who suffers domestic violence, an incarcerated family member, a family member with a diagnosed mental illness and the loss of a parent through death, divorce or abandonment.

An affirmative answer to each question gives a score of 1.

One of the more significant outcomes of the 17,000 person ACEs study was that the higher the score, the significantly higher incidence of physical disease in later life as well as depression, violence and suicide. Another finding was that many of the participants in the original study had usually experienced more than one kind of trauma at a time which further complicated matters in their lives.

In 2014, Dr. Nicole Brown, MD, MPH, MHS, FAAP and her colleagues analyzed data from the National Survey of Children's Health. They studied 65, 680 children aged 6-17 whose parents answered questions about ADHD diagnosis, the severity and the use of medication as well as including 9 of the ACEs questions like poverty, death of a parent, divorce, domestic violence, neighborhood violence, substance abuse, incarceration, mental illness in the family and discrimination.

They found that around 12% of the children were diagnosed with ADHD and their parents reported more adverse experiences than the parents of children who didn't have ADHD.

The parents of children with ADHD also reported a higher number of ACEs (Adverse Childhood Experiences) compared with the children who

have ADHD.

The results were that 17% of children with ADHD had an ACEs score of 4 or more compared to 6% of children without ADHD.

So what does all this tell us? Basically, that when conducting an ADHD evaluation, it would be helpful if the evaluating clinician also conducted an ACEs evaluation too so that even if there is an ADHD diagnosis, any underlying trauma can also be addressed and treated.