The correlation between trauma and ADHD may be surprising however trauma maps itself out in the body in complicated and sometimes unexpected ways. The effects of trauma vary widely among those affected. Some symptoms are pronounced, such as depression, anxiety, substance abuse, and post-traumatic stress disorder (PTSD)[1]. Other symptoms are more subtle, such as people-pleasing[2], social withdrawal[3], and feelings of inferiority. Even subtle symptoms can vary in degree depending on the person affected and the type of trauma they experienced.
One of the most interesting facets of trauma and its symptoms is the undeniable overlap between trauma and other mental health conditions. There are so many trauma symptoms that any given mental health issues could be traced back to trauma, particularly in childhood. While this makes trauma a complicated illness to both diagnose and live with, it also offers insight into some mental health issues whose origins may be unclear.
One such condition is Attention-Deficit Hyperactivity Disorder, or ADHD. ADHD is a neurodevelopmental disorder that typically comes on in childhood.[4] In some affected children, the severity of the condition subsides as they enter adolescence and adulthood. For others, however, symptoms persist. The hyperactivity characteristic of the condition is most usually most pronounced in childhood and subsides later. Still, issues with concentration and attention can persist and come to disrupt normal, healthy functioning in adulthood. ADHD can impact our ability to engage in academic, professional, and relationship settings.[5] It has also been found to correlate with abuse of alcohol and other substances in adolescence and adulthood.[6]
What Is the Link Between Trauma and ADHD?
According to research published in Academic Pediatrics, children who have experienced significant stress and trauma, such as poverty, abuse, exposure to violence, and exposure to mental illness in the home, are more likely to be diagnosed with ADHD than children who have not had such experiences.[7]
According to the CDC, ADHD is one of the most commonly diagnosed neurodevelopmental disorders in childhood.[8] It is prevalent worldwide. Its prevalence has led to the wide distribution of ADHD medication among children. One of the issues with the prevalence of medication distribution regarding ADHD in children is that the symptoms exhibited in many children may, in fact, not be caused by ADHD but rather childhood trauma, more specifically Adverse Childhood Experiences, or ACEs.
Adverse Childhood Experiences
Adverse childhood experiences are traumatic events that disrupt a child’s normal, healthy development. They include abuse, neglect, poverty, discrimination, and family incarceration.
Studies on ACEs first began in the 1990s with a questionnaire developed by Kaiser-Permanente.[9] In the questionnaire, participants were asked to answer ‘yes’ or ‘no’ regarding their exposure to any of the following nine experiences:
- Physical abuse
- Emotional abuse
- Sexual abuse
- Divorce or separation of parents
- Incarceration of a family member
- Mental illness of a family member
- Exposure to domestic violence
- Alcohol abuse of a family member
- Illegal or prescription drug abuse of a family member
Exposure to ACEs – defined as traumatic experiences occurring before the age of 18 and which involve physical or emotional harm to the individual – has been found to increase a person’s risk of toxic stress.[10] It is widely understood that toxic stress can cause a range of physical, mental, and behavioural health complications. In childhood, toxic stress can lead to impaired neurodevelopment, behavioural issues, and complications to overall health.
Trauma as a result of ACEs shares many symptoms with ADHD. Other than impaired neurodevelopment, overlapping symptoms of the two include:
- Difficulty with concentration, memory, and learning
- Hyperactivity
- Easily distracted
- Difficulty listening and sustaining attention
- Restlessness
- Difficulty sleeping
Despite the clear overlap in symptoms, assessments for ADHD typically do not include evaluations for exposure to traumatic stress in childhood.[11]
The aforementioned study published in Academic Pediatrics, titled ‘Associations Between Adverse Childhood Experiences and ADHD Diagnosis and Severity‘, was carried out by investigators at the Children’s Hospital at Montefiore, New York (CHAM). Lead author of the study Dr Nicole Brown and her colleagues sought to improve how we approach, assess, and address ADHD diagnosis and management options.
The study found that among the 76, 277 children surveyed in the 2011-2012 National Survey of Children’s Health, those with parent-reported ADHD were more likely to score two or more points on the ACE questionnaire.[12]
Misdiagnosis
Exposure to ACEs in childhood has been found to lead to persistent trauma symptoms in childhood. It is important for care providers and parents alike to understand that ACEs can lead to trauma symptoms that can easily be mistaken for other conditions. If a child is misdiagnosed, they might be prescribed medication for a condition they are not suffering from.
If clinicians are not routinely identifying ACEs, particularly among children with behavioural concerns such as ADHD, there might be a heightened risk of missing an underlying trauma history or misattributing some of the symptoms of traumatic stress as solely those of ADHD.[13]
Further, there is evidence to suggest that many general paediatricians are not equipped with sufficient knowledge of ACEs and their impact on overall health. A separate report in Academic Pediatrics found that only around 2 percent of paediatricians report frequent use of ACE-based screening tools when evaluating a child’s health complications.[14] The same report states that almost half of paediatricians surveyed had ‘never heard of the ACEs screening tool.’[15]
Trauma-Informed Care
Medication is a great option to help those struggling with all forms of health complications manage their symptoms. Though over-prescribing of medication is a problem both in the UK and worldwide, it must be acknowledged that medication is useful and even necessary in some instances. Still, medication is not, and should not be, an immediate go-to solution for health issues.
Before medication is prescribed, clients with behavioural health issues such as ADHD may benefit from a trauma-informed approach to care. Trauma-Informed Care (TIC) is an approach to healthcare that understands the complex and pervasive nature of trauma in those affected. Practitioners of TIC first take a holistic approach to care. A safe environment and compassionate support are prioritised over any approach that may ‘inadvertently re-traumatise’ the client.[16]
Trauma, ADHD, and the Brain
Let’s take a look at how trauma impacts the brain. One of the main areas of the brain affected by trauma is the prefrontal cortex (PFC).[17] This is the part of the brain that governs executive function. It helps us complete tasks, keeps us focused on the task at hand, and prevents us from getting distracted. ADHD can be considered as dysfunction in the prefrontal cortex, given that the symptoms look a lot like poor PFC function.
Renowned psychologist and founder of Somatic Experiencing, Dr Peter A. Levine, speaks about the overlap between trauma and ADHD. ‘When I observe ADHD kids, they look to me very much like the kids that I’ve worked with many years ago before there was an ADHD diagnosis, who had trauma. When I would work with them, many of those symptoms go away’[18] claims Levine.
Hypervigilance is one defining characteristic of unresolved trauma. If, deep within the body, in the nervous system, we are experiencing danger and threat from an unprocessed event in the past, we are naturally going on to be on high alert, on the lookout for anything that might put us in danger. Consider, then, a school environment. A child sits in the middle of a classroom and has other children behind in front of him. The children are noisy, possibly throwing things. There is a lot of stimulation. For child trauma survivors, there is a deep need to be on the lookout for danger. While the classroom is generally a safe environment, it may not be perceived as such by the child’s nervous system.
As such, it is important for care providers, parents, and teachers to understand that what might look like ADHD from the outset might actually be presenting symptoms of trauma. If trauma is left unidentified and unaddressed, then we would be tackling ADHD with targeted therapeutic and medical approaches that are not appropriate.
If you have a client, or know of someone who is struggling to heal from psychological trauma, reach out to us at Khiron Clinics. We believe that we can improve therapeutic outcomes and avoid misdiagnosis by providing an effective residential program and out-patient therapies addressing underlying psychological trauma. Allow us to help you find the path to realistic, long-lasting recovery. For information, call us today. UK: 020 3811 2575 (24 hours). USA: (866) 801 6184 (24 hours).
[1] Center for Substance Abuse Treatment (US). Trauma-Informed Care in Behavioral Health Services. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2014. (Treatment Improvement Protocol (TIP) Series, No. 57.) Chapter 3, Understanding the Impact of Trauma. Available from: https://www.ncbi.nlm.nih.gov/books/NBK207191/
[2] Mandeville, Rebecca. “The Trauma Response Of ‘Fawning’ (Aka ‘People-Pleasing’) – Part One”. Acesconnection, 2020, https://www.acesconnection.com/blog/the-trauma-response-of-fawning-aka-people-pleasing-part-one. Accessed 24 Feb 2021.
[3] Charuvastra, Anthony, and Marylene Cloitre. “Social Bonds And Posttraumatic Stress Disorder”. Annual Review Of Psychology, vol 59, no. 1, 2008, pp. 301-328. Annual Reviews, doi:10.1146/annurev.psych.58.110405.085650. Accessed 24 Feb 2021.
[4] Magnus W, Nazir S, Anilkumar AC, et al. Attention Deficit Hyperactivity Disorder. [Updated 2020 Jun 29]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441838/
[5] Magnus W, Nazir S, Anilkumar AC, et al. Attention Deficit Hyperactivity Disorder. [Updated 2020 Jun 29]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441838/
[6] Zulauf, Courtney A. et al. “The Complicated Relationship Between Attention Deficit/Hyperactivity Disorder And Substance Use Disorders”. Current Psychiatry Reports, vol 16, no. 3, 2014. Springer Science And Business Media LLC, doi:10.1007/s11920-013-0436-6. Accessed 24 Feb 2021.
[7] Montefiore Health System. “Family stressors and traumatic childhood experiences linked to ADHD diagnoses in children.” ScienceDaily. ScienceDaily, 11 October 2016. <www.sciencedaily.com/releases/2016/10/161011130010.htm>
[8] “What Is ADHD?”. Centers For Disease Control And Prevention, https://www.cdc.gov/ncbddd/adhd/facts.html#:~:text=ADHD%20is%20one%20of%20the. Accessed 24 Feb 2021.
[9] “About The CDC-Kaiser ACE Study |Violence Prevention|Injury Center|CDC”. Cdc.Gov, https://www.cdc.gov/violenceprevention/aces/about.html. Accessed 24 Feb 2021.
[10] “What Are Aces? And How Do They Relate To Toxic Stress?”. Center On The Developing Child At Harvard University, https://developingchild.harvard.edu/resources/aces-and-toxic-stress-frequently-asked-questions/#:~:text=Experiencing%20many%20ACEs%2C%20as%20well,on%20the%20body%20and%20brain. Accessed 24 Feb 2021.
[11] Overmyer S, Taylor E, Blanz B, et al. Psychosocial adversities underestimated in hyperkinetic children. J Child Psychol Psychiatry. 1999; 40:259–263.
[12] Brown, Nicole M et al. “Associations Between Adverse Childhood Experiences and ADHD Diagnosis and Severity.” Academic pediatrics vol. 17,4 (2017): 349-355. doi:10.1016/j.acap.2016.08.013
[13] Brown, Nicole M et al. “Associations Between Adverse Childhood Experiences and ADHD Diagnosis and Severity.” Academic pediatrics vol. 17,4 (2017): 349-355. doi:10.1016/j.acap.2016.08.013
[14] Kerker, Bonnie D et al. “Do Pediatricians Ask About Adverse Childhood Experiences in Pediatric Primary Care?.” Academic pediatrics vol. 16,2 (2016): 154-60. doi:10.1016/j.acap.2015.08.002
[15] Brown, Nicole M et al. “Associations Between Adverse Childhood Experiences and ADHD Diagnosis and Severity.” Academic pediatrics vol. 17,4 (2017): 349-355. doi:10.1016/j.acap.2016.08.013
[16] “What Is Trauma-Informed Care?”. Socialwork.Buffalo.Edu, http://socialwork.buffalo.edu/social-research/institutes-centers/institute-on-trauma-and-trauma-informed-care/what-is-trauma-informed-care.html. Accessed 24 Feb 2021.
[17] Arnsten, Amy F.T. et al. “The Effects Of Stress Exposure On Prefrontal Cortex: Translating Basic Research Into Successful Treatments For Post-Traumatic Stress Disorder”. Neurobiology Of Stress, vol 1, 2015, pp. 89-99. Elsevier BV, doi:10.1016/j.ynstr.2014.10.002. Accessed 24 Feb 2021.
[18] Somatic Experiencing Trauma Institute. “Peter a Levine, PhD Speaks to ADHD in Relation to Trauma.” YouTube, 7 May 2011, www.youtube.com/watch?v=FkBFJN5vRTw. Accessed 24 Feb. 2021.