Journal Article Review: ADHD and Trauma
- Clinical Services Team
- Nov 10
- 8 min read
Updated: 9 hours ago
WCF Clinical Team
The Inattentive, Impulsive and Hyperactive Child: Is Childhood Trauma Buried Amongst ADHD?
A study from by Jessica Staniland, Clinical Psychologist - Psychologist BPsych (Hons) MPsych(Clinical) 2019
ADHD is a Neurobiological Developmental Disorder, meaning it’s related to the brain, runs in families, and impacts a child’s development and ability to learn. 1 in 20 children are diagnosed with ADHD at some point in their lives.
The main symptoms include impulsivity, hyperactivity, distractibility, poor concentration, racing thoughts and emotional reactivity. Interestingly, these symptoms can also be seen in chronic hyper-arousal after trauma.
In response to trauma, a child’s developing brain can become programmed to “look out” for behaviour, activities, or events they perceive as threatening. This “hyper-vigilance” can often mimic hyperactivity and distractibility associated with ADHD.
What may appear as inattention and “daydreaming” behaviour often seen in ADHD may actually be symptoms of dissociation or subconscious avoidance of trauma triggers.
Intrusive thoughts, memories or other reminders of trauma may make children feel confused, agitated, and nervous which may mimic impulsivity and aggression often seen in ADHD.
Brain development studies for ADHD and child maltreatment show significant similarities in the areas of the brain that are affected (areas responsible for emotional regulation, decision making, memory, social processing and concentration).
Children who have a trauma history tend to have more severe ADHD symptoms than in either diagnosis alone and have poorer overall functioning.
Is it ADHD or Childhood Traumatic Stress: A Guide for Clinicians (August 2016):
A number of researchers believe that child traumatic stress can sometimes be mistaken for ADHD because of the overlap between ADHD symptoms and the effects of experiencing trauma and that the risk of misdiagnosis is high.
Unless symptoms are examined closely, the profiles of child traumatic stress and ADHD can appear to be similar. For example:
Young children who experience trauma may have symptoms of hyperactivity and disruptive behaviour that resemble ADHD.
Trauma can make children feel agitated, troubled, nervous, and on alert. These behaviours can be mistaken for hyperactivity.
What might seem like inattention in children who experience trauma might actually be symptoms of dissociation (feelings of unreality or being outside of one’s body) or the result of avoidance of trauma reminders.
Among children who experience trauma, intrusive thoughts or memories of trauma (e.g., feeling like it is happening all over again) may lead to confused or agitated behaviour which can resemble the impulsivity of ADHD.
ADHD and Complex Trauma
This article also identifies that children experiencing a series of adverse life events early in life, also referred to as Complex Trauma, share a constellation of symptomatology found in children diagnosed with ADHD.
This study was based upon chart reviews of 79 children and adolescents receiving treatment at an urban children’s psychiatric hospital. Participants, ages 8–18. Most participants in the study had experienced adverse life events including, but not limited to, physical or sexual abuse, neglect or maltreatment, abandonment by a biological parent or caretaker, and exposure to domestic or community violence.
Dominance in neuropsychology perspective of ADHD, view that it lies in structural abnormalities in the brain, which leads some to endorse medication as a treatment of choice.
Environmental and psychological perspectives on ADHD continue to struggle to gain support
More recently, Behavioural Therapy (BT) at home and at school has gained some traction, and several studies have been conducted establishing the use of this modality as an effective treatment for ADHD children in conjunction with medication.
Currently, the field seems to have reached an impasse where a combination of both Neurological and Behavioural approaches are being touted as offering the best treatment results
Even the Behavioural Therapy approach is offered from the perspective that the child’s need for behaviour modification stems from executive functioning deficits that may be neurological in nature.
Trauma and ADHD – Association or Diagnostic Confusion?
A Clinical Perspective. Kate Szymanski, Ph.D.Linda Sapanski, M.A.Francine Conway, Ph.D. Journal of Infant, Child, and Adolescent Psychotherapy, 10:51–59, 2011
Comparing the diagnostic categories of ADHD and PTSD. Avoidance symptoms of PTSD are understood as a defensive response to the cognitively and emotionally overwhelming experience of traumatic event. They include purposeful efforts not to think about trauma as well as more general experiences of not attending to stimuli, high distractibility, and forgetfulness (APA, 2000). These symptoms mirror those of the Inattentive cluster of ADHD, which include inattention, distractibility, and avoidance of activities (Ford et al., 2000). PTSD’s Hyperarousal cluster is conceptualised as an innate protective mechanism within the body to defend itself from future traumas. Hyperarousal symptoms are characterised by a pattern of increased arousal such as hypervigilance, irritability, and an exaggerated startle response (APA, 2000). Again, many of these symptoms are similar to those of the Hyperactivity cluster of ADHD such as fidgeting, excessive moving around, and restless-ness (Ford et al., 2000; Cuffe et al., 1994; Wozniak et al., 1999). Similarly, PTSD’s symptoms of intrusive recollection and the re-experiencing of traumatic memories can present as ADHD’s symptoms of difficulty in organisation and incapacity to listen. In children, re-experiencing may also lead to disorganised, agitated behavior, as the sudden remembering of frightening or painful memories may overwhelm children’s developing coping mechanisms. Feelings of anxiety that characterise PTSD can mirror the Impulsivity cluster of ADHD.
Trauma’s impact on emotion dysregulation in children renders them particularly vulnerable to ADHD symptomatology. In highly traumatised population the ratio of ADHD to PTSD diagnoses was 4:1, with only eight per-cent of the sample diagnosed with PTSD.
According to DSM-IV-TR, a diagnosis of ADHD should not be given to “children from inadequate, disorganised, or chaotic environments” if the children “have difficulties in goal-directed behavior,” which is a common struggle in traumatised children (DSM-IV-TR; Daud and Rydelius, 2009). Therefore, extra caution needs to be taken when children with the history of trauma are evaluated for ADHD, as the overlap with the symptoms of PTSD and other trauma-related psychopathology can easily lead to misdiagnosis. It is likely that PTSD diagnosis is underrepresented in this clinical sample because trauma symptoms have been mislabeled as ADHD symptoms.
ADHD symptoms considered more external and easier to detect.
Difficulty with affect modulation resulting from trauma exposure may either create vulnerability for ADHD or may exasperate the disorder’s symptomatology.
Alan Sugarman introduced that ADHD is being understood by too many professionals and parents around the world as a neurologically or biochemically based disorder for which stimulant medication is the treatment of choice. Found that early trauma contributes to the symptoms for which children are diagnosed with ADHD.
Alan Sugarman (2006) Attention deficit hyperactivity disorder and trauma1, The International Journal of Psychoanalysis, 87:1, 237-241
Treatment Options
ADHD:
Educational adjustments for learning in school
Parent/Carer Behaviour Management Strategies delivered in a group or individual setting
Stimulant Medication if recommended by a Developmental Paediatrician/Psychiatrist
Trauma:
Therapy with a Psychologist who may utilise Trauma-Focussed Cognitive Behaviour Therapy (TF-CBT) and anxiety management techniques
Sensory Regulation Activities as recommended by an Occupational Therapist
Anti-arousal or anti-anxiety medications where recommended by a Child and Adolescent Psychiatrist
Children with ADHD and Complex Trauma backgrounds need (Similarities to ARC):
Consistency, predictability, and routine within their lives - both at home and school
Help to develop lasting, safe, and predictable relationships
Key support people whom they feel comfortable going to, who understand them, and can empathise with them
A sense of control through being provided limited choices
To learn to build on their strengths and resiliency!
How Do We Treat Child Traumatic Stress?
Each child's treatment depends on the nature, timing, and degree of exposure to trauma. Some children may not be ready immediately to talk about their trauma, and clinicians should move at a pace that is tolerable for the child.
There are a number of effective treatments for trauma, which typically include at least some of the following components:
Promoting safety and building routines and rituals
Teaching children stress management and relaxation skills to help them cope with distress and trauma reminders
Talking about traumatic events in ways that enable children to master painful feelings and resolve the impact the events have on their lives
Correcting untrue or distorted ideas about what happened and why
Enhancing children’s ability to regulate emotions, behaviours, and physiological reactions
This article states that the evidence base for pharmacotherapy for children with symptoms of traumatic stress remains limited.
How Do We Treat ADHD?
For children, a comprehensive treatment plan can include all or some of the following based on the unique needs of the child, available resources, and prioritisation of need:
Parent and child education about ADHD diagnosis, its causes, and the course of treatment
Behavioural therapy for the child to manage his/her behaviours and acquire new skills
Mental health counselling for the child, as well as the family, to address relationship, self-esteem, discipline, and parenting concerns, among other issues
Parent training classes or programs to help them address the child’s behaviour
Educational program modifications and supports
ADHD medication, in conjunction with regular monitoring
The treatment for ADHD typically focuses on symptom management. While medication is the most widely used ADHD treatment, behavioural interventions are also a major recommended component of treatment for children who have ADHD. For young children, paediatricians generally recommend behavioural treatments first and medication only when needed.
Behavioural therapy provides the parents and children with techniques to teach and reinforce positive behaviours and skills. Use of positive reinforcement, consistency, problem-solving techniques, and communication are also important. What may work for one child may not work for another. For children of any age, it is important to continually monitor to determine whether the treatment is working.
The most common and effective treatment for teens with ADHD combines medication and psychosocial behavioural treatment approaches. Although the symptoms of ADHD may change with age, teens still require treatment to target these symptoms and may require treatment into adulthood.
Youth with both ADHD and trauma have been shown to have higher lifetime rates of almost all psychiatric disorders, leading to more severe outcomes.
Impacts of stimulant medication
Interventions in ADHD: A comparative review of stimulant medications and behavioral therapies Adnan Rajeh, MDa,b, *, Shabbir Amanullah, MD, FRCPsych, CCT, FRCPC, Adjunct Professorc , K. Shivakumar, MD, MPH, MRCPsych, FRCPC Consultant Psychiatrist, Associate Professord , Julie Cole, BA, MLISe Asian Journal of Psychiatry. Volume 25, February 2017, Pages 131-135
Stimulants have been used in the treatment of childhood ADHD for about 70 years (Bradley, 1937). They are mainly composed of Methylphenidate and Amphetamine compounds. These medications in the treatment of ADHD have been extensively studied and have proven to have significant short-term efficacy for all degrees and subtypes of ADHD.
Overall, it is clear that lack of treatment causes poorer long-term outcomes. Studies show that treatment may improve the long-term outcome for some individuals and certain subtypes but not to the level of healthy controls.
The main concern when stimulants are prescribed are their side-effects as well as their effects on comorbid conditions (Craig et al., 2015). Main adverse effects of stimulants are (Efron et al., 1997):
Appetite suppression, being the most severe.
Insomnia.
Irritability.
Proneness to crying.
Anxiousness (sadness/unhappiness).
Nightmares.
Studies have associated stimulants with negative mood changes becoming apparent around 4 months after the start of treatment.
Long term side effects are not well researched (Craig et al., 2015). The lack of data is alarming especially when long term benefits of stimulants are not established clearly. There is a need for well-designed studies to answer these questions.
It seems that behavioural methods of treatment have the potential of long-term benefits if applied properly and sustained until adopted by patients in their day-to-day lives.
In a study by Klein and Abikoff involving 89 children with ADHD, it was concluded that methylphenidate and stimulant/ behavioural therapy combination treatments were significantly superior to behaviour therapy alone.
Current evidence suggests that with good compliance stimulants are effective in controlling ADHD symptoms. They are relatively safe and well tolerated for at least 3 years. Short term advantages over other forms of treatment are clear.
Behavioural treatment, on the other hand, lacks long term randomised placebo-controlled studies. More recent studies suggest a very promising role for CBT in controlling ADHD symptoms and improving functional, academic, and social outcomes. It does not have the same efficacy as stimulants but has less side effects and better long term cognitive results in adulthood.
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