Recent studies have shown a notable similarity between the behavior of children diagnosed with ADHD and the behavior of children living in traumatic and abusive situations:
Though ADHD has been aggressively studied, few researchers have explored the overlap between its symptoms and the effects of chronic stress or experiencing trauma like maltreatment, abuse and violence. To test her hypothesis beyond Baltimore, [Dr. Nicole] Brown analyzed the results of a national survey about the health and well-being of more than 65,000 children.
Brown’s findings, which she presented in May at an annual meeting of the Pediatric Academic Societies, revealed that children diagnosed with ADHD also experienced markedly higher levels of poverty, divorce, violence, and family substance abuse. Those who endured four or more adverse childhood events were three times more likely to use ADHD medication.
Interpreting these results is tricky. All of the children may have been correctly diagnosed with ADHD, though that is unlikely. Some researchers argue that the difficulty of parenting a child with behavioral issues might lead to economic hardship, divorce, and even physical abuse. This is particularly true for parents who themselves have ADHD, similar impulsive behavior or their own history of childhood maltreatment. There is also no convincing evidence that trauma or chronic stress lead to the development of ADHD.
For Brown, who is now a pediatrician at Montefiore Medical Center in the Bronx, the data are cautionary. It’s not evident how trauma influences ADHD diagnosis and management, but it’s clear that some misbehaving children might be experiencing harm that no stimulant can fix. These children may also legitimately have ADHD, but unless prior or ongoing emotional damage is treated, it may be difficult to see dramatic improvement in the child’s behavior.
“We need to think more carefully about screening for trauma and designing a more trauma-informed treatment plan,” Brown says.
Dr. Kate Szymanski came to the same conclusion a few years ago. An associate professor at Adelphi University’s Derner Institute and an expert in trauma, Szymanski analyzed data from a children’s psychiatric hospital in New York. A majority of the 63 patients in her sample had been physically abused and lived in foster homes. On average, they reported three traumas in their short lives. Yet, only eight percent of the children had received a diagnosis of post-traumatic stress disorder while a third had ADHD.
“I was struck by the confusion or over-eagerness–or both–to take one diagnosis over another,” Szymanski says. “To get a picture of trauma from a child is much harder than looking at behavior like impulsivity, hyperactivity. And if they cluster in a certain way, then it’s easy to go to a conclusion that it’s ADHD.”
A previous edition of the Diagnostic and Statistical Manual of Mental Disorders urged clinicians to distinguish between ADHD symptoms and difficulty with goal-directed behavior in children from “inadequate, disorganized or chaotic environments,” but that caveat does not appear in the latest version. Unearthing details about a child’s home life can also be challenging, Szymanski says.
A child may withhold abuse or neglect to protect his family or, having normalized that experience, never mention it all. Clinicians may also underestimate the prevalence of adversity. TheAdverse Childhood Experiences Study, a years-long survey of more than 17,000 adults, found that two-thirds of participants reported at least one of 10 types of abuse, neglect, or household dysfunction. Twelve percent reported four or more. That list isn’t exhaustive, either. The study didn’t include homelessness and foster care placement, for example, and the DSM doesn’t easily classify those events as “traumatic.”
It’s not clear how many children are misdiagnosed with ADHD annually, but a study published in 2010 estimated the number could be nearly 1 million. That research compared the diagnosis rate amongst 12,000 of the youngest and oldest children in a kindergarten sample and found that the less mature students were 60 percent more likely to receive an ADHD diagnosis.