PTSD and ADHD – Are We Misdiagnosing?

I recently came across a study in the journal Child Abuse & Neglect that disturbed me.

Victor Carrion, MD led a team of Stanford University researchers who looked at children living in a poor, violent neighborhood.

This study built on past findings which associated worsening adult health to their childhood exposure to nine types of adverse childhood events.

PTSD and treating trauma

The investigators most recently found a strong link between adverse childhood experiences such as abuse, trauma and neglect, and the children’s mental and physical health.

Reviewing the medical charts of 701 pediatric patients from the Bayview Child Health Center in San Francisco, they found that 67% of the children had experienced 1 or more categories of adverse childhood experiences (ACEs). Even worse, 12% had experienced 4 or more ACEs.

Increased ACE scores correlated with increased risk of learning/behavior problems and obesity.

I’m sure that for most of you, this research isn’t necessarily surprising.

What did disturb me, though, was the suggestion by the investigators that these children may be getting misdiagnosed with ADHD rather than with PTSD or another trauma-related disorder.

It has noted that the child’s hyperarousal and cognitive difficulties could easily pass as symptoms for ADHD if the practitioner did not know to look for signs of trauma.

Children can heal from PTSD, but only if they are receiving the correct treatment. Just think of the ramifications of a traumatized child not only receiving no trauma interventions, but also being treated for something else.

The mistake may be made more frequently than we think, as many disorders have similar symptoms to PTSD.

I just interviewed renowned researcher Stephen Porges, PhD, as part of the New Treatments in Trauma teleseminar series.

Porges, the creator of the Polyvagal Theory, is an expert on the interaction of the brain and the nervous system during trauma and has some unexpected insights into the physiological similarities between autism, PTSD, and other disorders.

During our interview, Stephen and I discussed:

o What Practitioners need to know about Trauma and the Nervous System o Brain vs. Body Emphasis for Trauma Treatments: What the Polyvagal Theory Tells Us o How the Polyvagal Theory Refines our Understanding of Trauma o What does PTSD have in Common With Autism Disorders? o The Application of Polyvagal Theory to the Understanding and Treatment of Autism Spectrum Disorders o Treatment Implications from the Vagus Nerve

It’s not too late to get access to this and many other packed interviews. You can get the full story by clicking here.

Please leave a comment below.


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46 Comments

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  6. shara short, st louis mo says:

    Please send me contact and referral information for psychiatrist/psychologists in the St Louis MO area that understand and practice in this area. I have a grandson in need of help. Or please call. my cell is (314) 580-6635……thank you shara short

  7. Heather Alawawda, Researcher University of Cincinnati says:

    I was diagnosed with Complex PTSD at the age of 15 and was just diagnosed with Adult ADHD Combined Type this year which means that I show signs of hyperactivity, impulsiveness, and inattentiveness. As I looked back on my personal history, before the abuse even played out, I showed signs of ADHD. As young as 5, I started stealing, blurting out obscenities, teasing and picking on people, always defiant, restless, and I couldn’t pay attention..I would daydream almost constantly while in school, anywhere really. So is it possible to have both? Absolutely! See there’s a difference between the two disorders, PTSD is acquired through experience, ADHD is largely genetic and can be explained by a recurring lack of the neurotransmitter dopamine in the brain. My uncle on my mother’s side has it, my dad has it, my twin cousins have it, and now I have ADHD.

  8. Cassandra says:

    Would you mind posting a link to the study in the Child Abuse & Neglect journal that you reference in the first line? I’m sorry if you’ve already posted..there are too many comments to sift through to see if it’s already posted. Thank you.

  9. Nikki Thomson - In 2nd year of an MA in Clinical Counselling in UK says:

    I have been looking for information on misdiagnosing PTSD as ADHD. I am wanting to look further into this area because having had a child who supposedly has ADHD I have been fascinated in the similarity between the symptoms for anxiety and those of ADHD/ADD. We have recently been studying trauma and there seems to be so much to do with the limbic nerve and fight or flight that could mean a child who is severely anxious or traumatised is in constant startle mode and is being prescribed ritalin. If you have any further information or advice on where to look I would be very interested to have any feedback.

  10. Ruth,
    Excellent article, completely important subject so often confused. I’m participating in a Attention Talk Radio interview 7-3-13 at 8PM on this important subject, and just posted an article which may be of interest to your readers with specific references on ADHD/PTSD matters.

    Links to references and the Attention Talk Radio program here:
    http://www.corepsych.com/2013/07/adhd-and-ptsd-connected/

    Thanks!
    cp
    Dr Charles Parker
    Author: New ADHD Medication Rules – Brain Science & Common Sense
    Reviews: http://adhdmedicationrules.com

  11. Nancy Shafer says:

    I want to go back to college and finish a degree. The worse thing I’m facing about that is fear I can’t operate the computer. I can sure read how to do it better off that stuff than on it.

  12. Nancy Shafer says:

    I’ve been treated for the last 30 years for PTSD or Developmental trauma issues. I’ve done okay on .5 of Klonapin three times a day, not great but then I was diagnosed late in life. Recently, I was given a whole new set of diagnoses, including ADD and prescribed dexadrine. I’ve been miserable. I ache all over. I have all the symptoms of PTSD and have had since I was a child, the flashbacks, nightmares, startle, poor relationships and work history. I just can’t stand to think of living on this dexadrine for the rest of my life. The sleep disorder was bad enough with just the PTSD.

    I don’t know where to go. I can’t imagine why this clinician would want to upset the apple cart at this time iin my life. Any thoughts on this?

  13. jeanie gartin says:

    Thanks for sharing Matthew. Anyone that overcomes severe addiction is amazing in my book! Keep sharing your success story.

  14. jeanie gartin says:

    Hi, I read through most of the comments (scanned through a few, so hope I am not repeating much you’ve already heard). I am currently trying to figure out if I have PTSD or ADD. On a hunch, due to experience, I am guessing both.

    I just read Gabor Mate’s “Scattered” – awesome! Anyone interested in this subject should read it. He’s a fabulous and insightful writer. (i saw that he was mentioned)

    My theory is that all the related disorders are all due to a sensitive nervous system. Whether it be PTSD or ADHD, ADD. That is why they are closely related. While I think anyone going through a troubled and traumatic childhood would display some level of PTSD, my observation is that only someone with a more sensitive genetic make-up would result in long time PTSD or ADD that would conflict with their functioning in the world.

    I study the differences between my sister and I a lot (our mother was a drug addict, and you can image the rest). My sister can handle intense stress and keep her mind about her. I, on the other hand, get easily overstimulated and will break down easily, my brain will shut down and I become a total air-head. Recently I did 23andme(genome mapping) and found out a lot of this has to do with sensitive genetic make-up. As a lot of you may know ADHD is linked to lower levels of dopamine which I have the genetic disposition for, amongst many other markers(this is a huge other conversation). Note, that I say genetic disposition. Because if you have outside triggers (trauma, toxic environmental load) your genetic mutations will so-to-speak be turned on. If you grow up in a good environment, do not experience trauma, etc. if you have a sensitive genetic make-up then your “sensitive” mutated genes will not be turned on and you will be as good as anyone else.

    My point is, is that using genetics and nutrition known as nutrigenomics can help balance your chemistry and so can the right medication if you are lucky to find the puzzle piece that fits. I have been avidly against medication(being my mother is a pill popper). I agree with others here it needs careful monitoring, and upset by overmedicating children(pisses me off). However, I am recently considering medication for the simple fact that therapy alone maybe ineffective, this is a huge leap for me to say this. I’ve done tons of therapy. It’s helpful, but does not address the entire problem. What I am saying, is that even if it’s PTSD and not ADHD, there is still a physiological component that cannot be ignored, and this is being ignored by others that feel the way I do(medication scares you because the way you see it used in our society). I’ve seen 3 therapist who said I didn’t have ADD but rather PTSD, my guess is because they didn’t want me on medication, but I am still dealing with the same problems that I sought them out for. I agreed with their values, and that’s why I worked with them. But the more I educate myself, the more I am understanding the positive use of medication under the right circumstances. I am a yoga teacher, I believe meditation can help, nutrition can help, exercise is amazing, but despite living a very healthy lifestyle I still struggle with the same issues.

    I don’t know the answers, I am just beginning to see what I need to work on to make a difference in my life, and their is a lot of confusion about the subject. But I want more out of my life, and I hope to find the answers, and then maybe I can help others on this frustrating path.

    • Mary says:

      WOW! I feel very connected to you right now! My childs mother was severly injured by a drunk driver and now lives in a nursing facility, my child was 4yo at the time. Her father had recently left the family home to move in another womans family home, so recently that my child had never evern seen the other woman. My child was also injured in this accident and when she wok up in the hospital after her trama surgery the other woman was in the room with her. Her father then took her to live in the other families home. She began to “act-out” and was diagnosed with PTSD and ADHD/ADD. She was also diagnosed with anorexia…AT 5 YEARS OLD!! She lived with her father and her step-monster for 2 years until he brought her to live with me, a family friend. After telling a national talk-show that the step-monster wanted to kill her the state stepped in and gave custody of this “damaged” child to me and my husband. We have been her “parents” now for 8years we/she is STILL stuggling with getting her mind AND emotions right! The pills have caused severe side effects, and her grades are terrible…she’s maturing but not as quick as her hormones… I feel like when we get a step ahead that something in her “family” happens to bring her 4 steps back(her father gets regular, court-ordered visitation). I hate to be at odds with that family, but they are truley idiots…but, they do love her, even though they are stupid. You have mentioned a few things we have done, but you have also mentioned a few routes that I will try to explore! THANK YOU for sharing!!!

  15. Matthew says:

    I defiantly feel PTSD and ADHD are commonly misdiagnosed and linked. Attending therapy (after many years of drug abuse both uppers and downers) I discovered a major factor I had never though of before. My very first childhood memory (and one of the clearest) is hearing and watching my father and his brother in a major fight – blood – people going through windows/walls. I had originally attended to the therapy for both help with drug addiction, and because I wanted a person I could tell anything to without judgement.

    Being in chemical depression, and struggling to stay clean – I told my psychotherapist everything I could think of, truthfully. He prescribed a low dose of effoxor (which for me works great) for GED/Social anxiety. What I now realize, going into him, I was essentially looking for a narcotic, but as he is a no-bullshit type of he recognized my Anxiety disorder, and saw right through my attempt for a Ritalin/Adderall script. He made me realize my own self-doubt, self-confidence problems that were coming from my ‘fight or flight’ response – as I have always flown in most situations.

    My grandfather told me stories of the beaches of normandy (as he was a marine in the 4th wave of omaha) and how the man next to him had his head blown off. (as a teen, not child)

    Looking back I really feel my grandfather had, like many veterans gone untreated for PTSD. After the war, he was a ‘functional alcholic’ he was never mad, or angry, or even happy while drinking – it seemed he only drank to kill the pain.

    My father was born many years after WWII, and I think genetically PTSD untreated, can be passed on to children – or at least the anxiety disorders that come with it. ADHD is extremely hard to diagnose, and I am thankful I got a real doctor who recognized my attempt to ‘get an Adderall’ prescription – as I know all I would have done was abuse it. When you have an anxiety disorder, anything to kill the pain becomes addicting.

    It has been 9 months since I started attending therapy and taking Effexor. While I dislike the side effects – I have learned many of them come from nutritional deficiency. I have steadly improved my work habbits, excersise, diet, and most of all staying away from narcodics.

    I no longer run from my emotions, but try to let them flow, understand them, and deal with them.

    My life has never been better – and had I just been given a CNS stimulant – it would have only covered up the pain – and led to more problems.

    My therapist, literally, saved my life. Now I attend monthly, and talk about the real things going on in my life, instead of struggling to understand my past.

    I think this article has hit the nail on the head – too many children today are being given CNS stimulants. Effexor for me treats my anxiety, which also allows me to learn to adjust to my ADHD/Bipolar/OCD type symptoms.

    Matthew

  16. Hey!!I’ll definitely have to check out Sean’s post. And I love the idea of blogging about a failure and how you learned from it. I’ll have to do that one soon

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  18. I get more depressed & anxious during the day too & my theory on this is that at night, especially late at night, the rest of the world is shut down/asleep except maybe for bars & nightclubs so you don’t feel pressured to go out & achieve something, go out into the world & achieve anything like “normal” people are doing. The rest of people out in the world all seem so much more functional & happier than those of us w/depression/anxiety disorders & that in itself is depressing & causes insecurity/anxiety. It’s like during the day there’s too many choices one can make which becomes overwhelming. I read an article in “New York” magazine about ‘happiness’ & it mentioned that people in general feel overwhelmed by having too many choices for everything nowadays & are afraid they are making the wrong choice, for example, there’s like 50 different types of toothpaste to choose from nowadays vs. maybe 10 in the ’70s-’80s. At night there’s not much that can be achieved, you can’t “go out & get ‘em” so to speak which is a relief. Another interesting point the article made is that low income/poverty in & of itself is not depressing but the perceived disparity between low & high income groups IS depressing, i.e being poor & surrounded by rich people. Anyway, yeah there should be better meds for anxiety besides the benzos & SSRIs. You’d think they’d have come up with something new by now…

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  20. John Schureman says:

    I am a bit amazed at the lack of scientific awareness of the symptom cluster, tragic known as ADHD. As was said in one international of neurological psychologists in Boston, 2006; the only accurate term left in ADHD, is Disorder. A popular myth is the disorder is over-diagnosed while in fact, especially in California, there is no other DSM nostrum moor over looked. The NIMH followed 3,000 children for three years, inspecting their nutritional and mental health. In February of 2010, they concluded the rate of ADHD was 8.6% (mostly male) with the distant second place childhood psychopathology was depression at 3.4% (mostly female). In adulthood, the national average, typically consider low is 5% with a one to one gender ratio. California reports to the CDC a 2.2% and ranks number 49 is the use of medication.
    Maslow observed “if all you have is a hammer, everything seen become a nail.” In reading the critiques, it is clear the current understanding of this pernicious disorder is not understood as sub-optimal self-regulation and not an attentional deficit. Of the thousands of ADHD persons, age 5 to 85, attention is not the problem. An ADHD can watch TV or play a video game for hours on end without failing to attend.
    The basic problem with self-regulation, separating the disorder from PTSD, is their “cross temporal organization of self-efficacious behavior.” The various disorders with attentional control challenges, will not have an early onset of poorly organized behavior, lack intrinsic motivation and the necessary cognitive energy to met to normal developmental demand of life. Typical long-term symptoms include academic underachievement, easily bored, problems delaying immediate gratification for greater future reward, and poor self-efficacious decision-making. Like stage one Alzheimer, the processing speed if low, verbal fluency poor, working memory slippages, and impaired strategic decision making.
    Often reading fluency and comprehension is suboptimal (can’t read for pleasure by age 9), social insensitivity, overly verbalize thoughts, fail to follow thought with commitments to self or other, dead line projects, and avoid dull, boring, and monotonous work the is social critical. The clinical presentation is invisible or hidden to the here-and-now interview process.
    Given the enormous co-morbidly associated with the disorder; MHP should have more than one hammer, and not reflexively presuppose the problem is over observed. Medication is not an easy answer and requires careful, vigilant monitoring, as is rarely seen within our local communities.
    Never medicate without knowing upstanding its effective use. First understand the 21st Century science behind the disorder, The educate the person before ever medicating.

  21. Kimberly says:

    I couldn’t agree more. I treat kids of divorce. Loosing family is traumatic for kids and they often exhibit ADHD symptoms but what I found is that it’s really anxiety and depression. Thanks for opening up this conversation.

  22. Dr Andrew Kinsella says:

    In reply to Urban Sundvall,
    I would comment that ADHD is effectively a clinical syndrome- a descriptive category. This is the trick about the diagnosis- fitting the descriptive category of ADHD actually does not exclude the presence of processes like trauma being involved in the causation.
    If we are to apply DSM purely and accurately we have to recognise that it does not even entering into postulating causes for the symptoms.

    Equally- I agree fully with the value of mindfulness and relaxation therapies for ADHD- but believe that they can be applied directly to ADHD management. Certainly in the patients I am seeing mindfulness and relaxation therapies can be highly effective, and often more effective than stimulant medication. I think we have made a serious mistake in allowing the diagnosis of ADHD to be conflated with the idea of stimulants as the only effective treatment- which is where the orthodox way of thinking is drifting by default.

  23. In regard to Dr Andrew Kinsella’s comment;
    “I would also stress that I fully agree with most of the posters here that more non drug treatment needs to be made available for ADHD.’
    I would like to comment that as a Hypno-Psychotherapist who specialises in HypnoAnalysis (HA), it has been my experience that, in every case of ADHD refered to me,PTSD has been the real problem. Childhood trauma and its bottled up emotions, has been what we through HA, have been able to resolve. The real cause that triggered the symptoms.
    PTSD is such a complex problem that requires a multifaceted individual-oriented approach. CBT,DBT & EFT, as well as other traditional Psychotherapeutic approaches all have their place in my ‘Toolbox’ as an adjunct to the Analysis work under hypnosis.
    Even just the Hypnotic Relaxation tool does so much to restore a traumatised persons belief that change may be possible. It is a tool that I firmly believe everyone who works with traumatised people can use beneficially.

  24. Dr Andrew Kinsella says:

    The above comment also applies to Dianne Rae’s comment.
    Making the diagnosis of ADHD does not make any assumption about the cause. My opinion is that trauma is pivotal in creating the ADHD state. Gabor Mate has already been mentioned here- and I would strongly recommend anyone interested in the causative role of trauma in producing ADHD look at his excellent book “Scattered”.

  25. Dr Andrew Kinsella says:

    I would also stress that I fully agree with most of the posters here that more non drug treatment needs to be made available for ADHD.

    ADHD is always associated with unsatisfactory environments, and it is those unsatisfactory environments that we have the greatest difficulty attending to.

    Much as I admire Sir Ken Robinson, he actually misses the point of DSM diagnosis when he states that the problem with focus occurs “because of boring environments”.
    The DSM diagnosis of ADHD describes a syndrome, and does not attribute any cause to the syndrome- so being the kid who has difficulty attending in the “boring environment” of the maths class, when the rest of the class is coping with the boredom is more typical of the diagnosis than excluding of it.

    The point is that for ADHD to be diagnosable the difficulty with attention has to occur and be impairing in multiple environments for the diagnosis to be legitimate. IE a kid who is doing alright in all areas but for one class (due either distasteful subject matter, or an objectionable teacher- and they do exist) does not qualify for the diagnosis of ADHD.

  26. Dr Andrew Kinsella says:

    It is very important to be aware of the distinction between ADHD and bipolar, as the presentation can be similar. I am involved in a local ADHD support group, and almost every one of us was misdiagnosed as bipolar for many years, and suffered considerably because of that misdiagnosis. In some cases bipolar was also present, but the ADHD diagnosis was missed because of the bipolar diagnosis being made first.

    Russell Barkely actually argues that most of “bipolar 2 and rapid cycling bipolar” are really ADHD, and I suspect he is right.

    This short clip from Russell Barkely highlights some of the differences:

  27. I conduct psychological evaluations on individuals that often need a differential diagnosis. The symptoms of trauma, ADHD, and Bipolar Disorder can look similar. My last assessment was to discern between Schizoaffective Disorder and Bipolar Disorder with psychotic features. This poor woman had such a trauma presentation, and assessments validated PTSD, Borderline PD, and Schizoaffective DO. She also revealed ADHD based upon the CPT-II, learning difficulties, and clinical interview. The group of psychologists I work with, in general, tend to believe that trauma is more prevalent in the population we serve. While testing all clients is not feasible, of course I would recommend an assessment of diagnostic clarification.

  28. Deasr Ruth, thank you for your incredibly informative series. Unfortunately I was unable to participate in your most recent interview with Dr Stephen Porges. Might I add that on children diagnosed with, for example, natal trauma, ADHD, dispraxia, bipolar, chronic bedwetting, I have observed a characteristic ‘nervous twitch’ that manifests diagonally across the solar plexus when the patient is lying flat on their back. By applying very soft finger pressure on certain acupuncture points (under the occipital ridge and then around the ankles and the fingers) and slowing the patient’s breathing, The families often report a virtually ‘miraculous’ change after just one session. I should explain that I am not a doctor but a scientist and ‘natural born healer’ since childhood, and professionally in London, England, since 1996. Could this be a polyvagal response?

  29. liz says:

    Thank you for this important conversation. I work in a medical clinic as a social worker, where providers with zero to little mental health training are asked to prescribe. It seems so cruel to give a stimulant to a traumatized child. They worsen, and then they are further misdiagnosed as conduct disordered, etc.
    Unfortunately, the population I see have a problem with mental health and are more likely to be willing to get a prescription from a primary care provider than to seek out appropriate treatment. And of course, nobody wants to pay for treatment.

  30. Sherry says:

    I am living this question in ways & I think more conditions than just ADD get diagnosed when trauma is at the root. And this can happen with adults as well as children, & can be devastating.

    I grew up in an abusive home environment, & experienced other traumas as well. I was diagnosed & treated off & on since my teens for depression(over 20 years) but nothing has been truly effective. Several years ago I had a experience that took it all to a whole other level of disconnect for me.

    Fairly recently, I finally found a Dr. who brought both PTSD & ADD to the table. PTSD made so much sense. ADD made sense too. I dove deep into more research about both. I have had many symptoms that relate to both. I am not not convinced I truly have ADD. I suspect that the symptoms that presented stem from a form of (complex) PTSD.

    Either way, my life has been challenging & painful in so many ways because of these symptoms which I have experienced for such a long time. I am on track with some understanding, a direction & some beginning tools. My Dr. helped me take the first steps in recognizing & some medication, but she is not an experienced in PTSD/trauma or ADD. As I am asking this question, we have been addressing both PTSD & ADD. I am trying to figure out the next step. There are so many parts of my life that I need to put back together. I am continuing to search for tools, help & support in dealing with the trauma. I want to do some somatic therapy. It seems if I can find my way back out of that, then I can see if ADD symptoms still are around…Can you heal the trauma symptoms completely? It’s alot to take in & process & make sense of, but I am working hard to do that~

    I agree with Diane above about safety, & it is my experience. If you do not feel safe, then Everything else in one’s life is compromised by the loss of energy & focus from that. It seems I have spent most of my life in that (physiological) state of feeling unsafe, & on guard (“hyper”-arousal). So I know what it feels like. I have experienced moments/times when I felt some relief from it. As a child, teen & even as an adult — when I have been able to spend some period of time in clearly safe & caring environments my symptoms relax, subside, lessen…

    I agree that a family of some sort– a support system— is the foundation…consistent safety, connection, care & support; that is what parent’s a families are supposed to provide..but what happens to those children & adults who dont have that…
    I believe if we could start with this base of helping to get safety & connection (basic survival needs met) the other healing modalities would be so much more effective. Our culture is also so independent & technologically drive (both wonderful) but a common side effect is more separation, less true, present, intimate connecting… I agree with Monica above, that we need some cultural changes as part of this…

  31. This has been a passion of mine for so long- since attending my first training with Dr. Bruce Perry at http://www.childtraumaacademy.org

    It is so frustrating that it doesn’t seem like we have made ANY progress in this area in the last decade. Giving someone with hyperarousal symptoms and flashbacks a stimulant is the exactly wrong thing to do.

    I did a meta-analysis comparing brain studies on this population for my thesis. It was really enlightening for me. http://millennium.csustan.edu/search~S11?/apalmer/apalmer/1%2C4%2C4%2CB/frameset&FF=apalmer+miranda+lynn&1%2C1%2C

    There is also a great comparison table… I can’t recall the author at the moment that compares the symptomology of both and shows just how easily this misdiagnosis can be made if you aren’t screening for trauma.

    • Kia Lauridsen says:

      Hi,
      I am a Danish psychology student, who is very much interested in the link between ADHD and
      PTSD, about which I’m currently writing a paper. But I cannot find your thesis anywhere, and would very much like to read it?
      Kind regards, Kia Lauridsen

  32. Monica Olsen says:

    I was fortunate enough to work in a domestic violence shelter for women and children right out of my masters program 11 years ago. I had never seen so much chaotic behavior in children. They had been exposted to the most traumatic, abusive, neglectful environment imaginable and what do you think most of them were diagnosed with — you guessed it ADHD. I became immediately interested in learning all I could about trauma.

    I am fearful that as long as we are moving towards a prescription focused culture for treatment children’s problems – we will continue to see the patient as having the diagnosis that most closely matches the available treatment – pills. It is not uncommon in my work to see children at very young ages diagnosed with bipolar and schizophrenia – and prescribed a boat load of medications.

    I am not sure how we will ever turn this culture around, but I am doing my part, educating providers on the reality of ‘trauma’ looks like and are effective non prescription treatments can be.

  33. Diane Rae says:

    Many of the children I worked with who had a diagnosis of ADHD were misdiagnosed as well. They had been traumatized – repeatedly. When they felt safe, once they had worked through (with play, sand, water) the symptoms of ADHD disappeared. They have to know that the people they are with are able to keep their environment (and them) safe and only then will they be able to settle down and be their true selves. I came to think that actually the cluster of symptoms of ADHD were in fact, indicative of traumatization.

  34. Graham Bottoms says:

    ADHD seems to be the saveur du jour (though some would argue that it is now bipolar dx.) but some education commentators such as Sir Ken Robinson suggest that ADHD is overdiagnosed because classes are boring and over-emphasize math and english rather than, for instance, the arts, or indeed more vocational subjects; and opines that we medicate (as well as ‘educate’) the creativity out of many of our students. Note that I also deeply feel the verity of the ACE data, which is amplified so well in books such as “In the Realm of Hungry Ghosts” by Gabor Mate. The prejudicial events suggested by ACE data, together, perhaps, with toxic effects of DA in utero (ref Malbin’s fetal alcohol spectrum disorders) seem plausible explanations for a cluster of disorders, including ADHD, BPD, CD, substance issues, etc.

  35. Linda S Jones, MS LLP says:

    I find the misdiagnosis of ADHD or missed PTSD diagnosis frequently. Most especially in the community mental health population. These children are often traumatized and on multiple medications. One thing I see frequently is many of the medications that are prescribed for the treatment of ADHD seem to increase aggression in the child. Which only makes the picture look worse and leads to more medication. It is a terrible cycle and only makes the child feel more traumatized.

  36. I certainly agree about the overdiagnosis. Year ago in the public school sector, I often thought ADHD and the resultant prescription was too often a family system issue than and individual child issue. I no longer work with children, but the adults I see (about of a quarter of my practice is explicitly trauma related)seem far too often to have been diagnosed by a PCP and put on a variety of cocktails. My suggestion is that PCP’s have some preparation in ADHD dx, and very little in trauma work. Thus, it seems pretty likely that ADHD for kids and adults, as well as GAD are too easily diagnosed and prescribed with the result that I end up with adults in my practice who’ve been on meds for years to manage their hypervigilant nervous systems with little or no attention to the origins of their hyperarousal. When the trauma is unveiled and attended to they begin to heal themselves. If van der Kolk and colleagues are successful with “Childhood Trauma Disorder” in DSM VI, how can we filter that into the general medical practice to give it equal attention to the too easily catergorized ADHD?

    • Mark Sawyer says:

      “If van der Kolk and colleagues are successful with “Childhood Trauma Disorder” in DSM VI, how can we filter that into the general medical practice to give it equal attention to the too easily catergorized ADHD?” Per my comment above, I hope that “Childhood Trauma Disorder” can be defined in terms of a spectrum, a la ASD. The Polyvagal Theory postulates than any situation where the Sympathetic system fails is potentially a traumatic, immobilizing event. That covers a lot of ground, with lots of gradations and complexity. As I mention above, my perspective as a childcare provider, trainer and administrator has brought me face-to-face with the “cry-it-out” paradigm that prevails among many (most?) parents and caregivers of infants. “Cry-it-out” is synonymous with a failure of the sympathetic system, and a default to traumatic immobilization. In other words, trauma is becoming part and parcel of the mainstream experience of infancy in the US….

  37. Janet Norton says:

    I’m interested in the definition of “trauma”. Could we be missing or misdiagnosing many of these children (and adults for that matter) because the formal definition of trauma bypasses the perceptions of the individual who experienced the event(s)? For example, different people have varying thresholds of pain; could it be the same regarding trauma? Would SPECT scans reveal any of this?

  38. Dr Andrew Kinsella says:

    As a further point I would stress that the emphasis on ADHD as a childhood illness is really very limited. It is very widely prevalent in adults, and arguably has far worse impacts in adulthood.

    Equally Adult ADHDh is often co-morbid with one or more other psychiatric diagnoses that are best understood as complications of poorly treated ADHD. In this context one diagnosis is better understood as not confining the problem to that diagnosis, but only as describing one dimension of an individual’s presentation.

  39. Over the last 25 years as a counselor with a specialization in trauma I have been concerned about the growing number of children who I have seen who have been diagnosed with ADHD. What I have found in the history of every child I have worked with is there is a truama history. They may not present with all of the PTSD criteria but they are exhibiting differing degrees of trauma symtpoms which include difficulties staying on task, difficulties sitting still, difficulties with concentration etc which show up as problems in school. Their hyperactivity ‘like a motor running’ can also be a hyperaroused fear-reactive nervous system due to the ongoing stressful and traumatic experiences they may be having at home. In my work with adults in a Community Mental Health facility I also found that all of the patients that I worked with had traumatic or multiple traumatic histories which no one had ever addressed with them. With all that is known now about the brain and how experience in general and trauma specifically changes the structure brain and organizes assessing for trauma history is no longer a nice idea it is imperative. Research shows that insults in the womb as well as birth trauma can have a long term impact on stress sensitivity that doesn’t show up until children get into school. I don’t understand that with our ability through SPECT and other scans those are not being used more in diagnosis because of the physical evidence they provide not just behaviors on a checklist that could be generated from multiple events. I have been a witness to school systems telling parents their children are ADD or ADHD and telling them to get their children medication. If they don’t Child Protective Services has been called and the parents are made to give the child medication and are accused of medical neglect even after the child did not respond well to the medications. My experience has been if they don’t respond well to a medication they are either put on a different one or given other medications to counter act the perception that the child is experiencing side effects. Before you know it you have a child on 10 medications. Their trauma histories are not getting identified and they are caught in the gerbil cage of ‘we just haven’t got the therapuetic dose where it needs to be’. meanwhile if they parents are the source of the child’s anxiety and trauma that goes unnoticed. The human cost is beyond measure but the financial cost of this type of ‘therapy’ is astronomically high on a medical system that is straining under the high cost of doing business as usual. The research on the brain, trauma, attachment, stress and relationships shows that we cannot continue doing business as usual. In the area I live in I have been a voice screaming in the face of a hurricane of business as usual. It is great to find other voices who get it.

  40. Dr Andrew Kinsella says:

    There is actually a very strong link between ADHD and PTSD, but in most cases the causative chain goes the other way. ADHD carries with it enormous risk of PTSD, and many adults with lifelong ADHD are at great risk of PTSD episodes late in life. PTSD however exacerbates ADHD very greatly.
    There is an enormous difference in response to medication though, as when the primary symptoms are PTSD- stimulants almost invariably worsen the anxiety symptoms.

    There are many similarities, and almost all ADD patients that I have seen have very high emotional sensitivity, which I believe predisposes to PTSD as well as ADHD.

    One of the commonest sources of trauma for ADHD children though is schoolyard bullying and the aggressive disciplinarian tactics used by many teachers.

    My practice nowadays almost exclusively deals with ADHD adults, a situation that arose out of my very belated diagnosis with ADHD. One of the most interesting and consistent features of ADHD in adults is that the overwhelming majority of us who can actually remember our time at school, felt alienated by school and were the victims of recurrent and severe bullying- which arose because our different attention style marked us out as different. Many ADHD adults however found their school years so intolerable that they have largely repressed the memory of their schooldays.

    For a fuller review of the inadequacies of our schooling systems I would strongly recommend you all read “The Underground History of American Education”by John Taylor Gatto, available online at http://www.johntaylorgatto.com

    Interestingly Porges highlights the hyperactivity and irritability of many pre ADHD infants as a risk factor for the sort of unstable attachment that can be associated with ADHD, and i am sure he is right in that observation.

    • Mark Sawyer says:

      Given our present “cry-it-out”/”don’t-spoil-the-baby” culture around infant care, my guess is that trauma is the baseline cause, provided we think of trauma as a spectrum diagnosis. Porges describes the Polyvagal System as a hierarchical arrangement consisting of a social engagement capacity as the first line of defense against environmental challenges, followed by Sympathetic fight/flight, and when all else fails, immobilization (the trauma response) via the unmyelinated vagus. In Polyvagal terms, the hyperactive baby actually is better off than a baby prone to immobilization. However, pervasive cry-it-out parenting and caregiving push the typical infant into a trauma state of immobilization quite often; regardless of whether a baby is genetically predisposed to hyperactivity or immobilization, all children (pretty much) end up getting the same dose of immobilzation. (In my direct experience working with infants and their caregivers, the crucial issue for hyperactively disposed children is that the caregiving be unflagging, while for children who tend toward immobilization, that caregiving be proactively stimulating.) Unfortunately, for neither grouping of children is the prognosis good, given the poor financial and working conditions under which infant childcare typically happens, and the resulting difficulty in finding highly motivated and emotionally available caregivers…

  41. Barbara says:

    I don’t think there is any doubt that the first diagnosis that most children receive when assessed by a therapist or psychiatrist with symptoms like inattention or lack of ability to focus or concentrate is ADHD. And, once children have this diagnosis, it is rarely removed…others are just added. As a licensed clinical social worker, I work as a clinical specialist overseeing children’s mental health programming. These programs include intensive case management for children and a waiver program that puts a team of mental health professionals to work with the family of a child with serious emotional issues. Within these programs, and I’d like to think this is true of many others that have extensive experience in working with these children, we are able to recognize the signs and symptoms of PTSD. We may not be in a position to change the diagnosis of record, but we do not feel constrained to live within the confines of an ADHD diagnosis. We design our work with the family to address what is obvious to us…the child’s behaviors relate to past trauma. It can certainly look like ADHD initially, but it is so simple to rule out ADHD through a medication test period. If the ADHD medication works, then the child had ADHD. If it doesn’t, look for something more complex in the history. Most of the children we work with have been victims of a (or more than one) traumatic event. What does need to be recognized too is that there are a few children with PTSD who also have ADHD. That can be difficult to sort out because the some of the symptoms can be so similar. To be sure, the number of children suffering the effects of PTSD in country and our world is tragic. Often it is the result of parents not being able to keep their children safe…and often what we find is that the parents of these traumatized children are untreated victims of trauma themselves. It becomes an intergenerational problem when trauma victims (parents) are not emotionally equipped to prevent trauma from occurring in the next generation.

    • Andrew Minty says:

      Yep. First a teacher has the parent take the child to a doctor and the parent tells the doctor they may be adhd, then the doctor prescribes some medication to see if it makes a difference. The child is now medicated, and officially adhd. I was prescribed ritalin as a child.. My troubles began when another boy in first grade knocked my books off my desk on purpose, my response was to toss his textbook out the open 2nd story window. I was tied to my chair the rest of the day, and denied recess the rest of the year including lunch time, and put on medication until the 7th grade when I opted to stop taking it because it made me feel like I had to urinate all the time. My grades went up.

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