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#216083 - 04/07/08 08:57 AM ADHD may be trauma related
Ken Singer, LCSW Offline
Moderator Emeritus
MaleSurvivor

Registered: 08/24/00
Posts: 5780
Loc: Lambertville, NJ USA
Diagnosis: ADHD—or Is It Trauma?
Hyperactive, yes. Attention problems, check. But it’s not ADHD.
By Maia Szalavitz for MSN Health & Fitness


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When Dawn adopted her 7-year-old nephew, Dylan (not their real names), she expected a difficult initial adjustment. The 51-year-old Wisconsin homemaker, who is married to an attorney, has 10 children—eight adopted, two biological—and jokes that her occupation is “laundry.” She knew that Dylan had been starved and neglected by his cocaine-addicted mother.

But what Dawn didn’t expect was for her nephew to be diagnosed with attention-deficit/hyperactivity disorder. “He was climbing the walls,” she says. “He couldn’t even sit still to eat.” At school, he wasn’t learning because he was in constant motion.

Dawn suspected that Dylan’s main problem wasn’t really ADHD. Her pediatrician wanted him evaluated and suggested medication. “It was tempting,” she says, but “I had a gut feeling I should wait.” Dawn believed that her nephew’s inattention and over-activity were linked instead to his disrupted parental relationships and chaotic early experience.

Identifying trauma

Dawn’s maternal intuition about the effects of trauma on attention is increasingly backed by science. “The big problem is that people just don’t identify trauma in kids,” says Claude Chemtob, professor of psychiatry and pediatrics at Mt. Sinai Medical School in New York City, who recently published a study of children who were attending preschools near the World Trade Center on Sept. 11, 2001.

Though we tend to think of traumatic experiences as rare, in fact, by age 16, seven of 10 children have been exposed to at least one potentially traumatic event—such as a natural disaster, severe car accident, child abuse or the loss of close family member—according to a study of a representative sample of more than 1,400 children living in North Carolina published in 2007.

In Chemtob’s 9/11 study, even children who saw people jump from the towers tended not to have lasting problems. But preschoolers who had experienced multiple traumatic events were 16 times more likely to have attention problems—and 21 times more likely to be overly emotionally reactive and/or to show symptoms of depression and anxiety—than children who had not had such experiences.

But, if other studies of similar children are a guide, many of these severely affected children would probably not meet criteria for post-traumatic stress disorder. Studies following children with known trauma exposure find that they are much more likely to suffer other anxiety disorders or depression than classic PTSD.

Indeed, despite the high prevalence of potentially traumatizing experiences, less than half a percent of the children followed in the North Carolina study could be diagnosed with PTSD. However, 40 percent of those who had had such experiences qualified for at least one diagnosis, often depression or anxiety disorders.

As a result, many traumatized children whose behavior has clearly been affected by their experiences aren’t diagnosed with PTSD—or diagnosed at all. Chemtob notes that “virtually none” of the children in his study were getting any kind of treatment, despite symptoms severe enough to warrant it.

Other children are vulnerable to being labeled with an alphabet soup of diagnoses, including ADHD, because trauma profoundly affects many different parts of the brain and can produce widely varying behaviors and outcomes.


Not hyperactive, but hypervigilant

Dylan had seen his mother use drugs and had witnessed a stabbing. In response, his developing brain—in an effort to protect himself—would have tried to predict which adult moods were most likely to erupt in violence.

“These children are hypervigilant because they are looking for dangers or threats,” says Frank Putnam, professor of pediatrics and psychiatry at Cincinnati Children’s Hospital. “They become exquisitely attuned to sights, sounds and especially facial expressions or tones of voice that might be linked with impending trouble.”

Hypervigilance can look like hyperactivity or inattentiveness in school because these children are paying attention to “distractions” like the teacher’s face or another child’s movements, not their schoolwork. A slammed door might prompt them to jump from their seats—and cause a “fight or flight” response that might seem aggressive or defiant.

Trauma can also produce what’s known as a “dissociative” reaction. When a threat is physically inescapable, the body prepares for injury by slowing heart rate and breathing. The brain is flooded with endogenous opioids—the brain’s own painkillers—which cause numbness. In extreme cases, the person feels like he has “left his body” and is watching events from outside.

A sight, sound, smell or memory can trigger a return to this state. “Children may space out and appear to be daydreaming,” Putnam says. “They lose contact with reality and become involved in an internal world. Teachers see a child who is never paying attention. They still have their math book out when the teacher has moved on to history.”

Many children who are diagnosed with ADHD, Putnam believes, may actually be suffering from trauma. “There is probably a significant group of kids with traumatic hypervigilance or dissociation that interferes with attention and increases arousal and activity levels,” who are misdiagnosed, he says.

What’s worse, children suffering trauma symptoms actually have higher than normal levels of neurotransmitters like adrenaline and noradrenaline (norepinephrine), according to Putnam. These same transmitters are raised even further by stimulants like Ritalin that are commonly prescribed for ADHD.

“Does it make sense to give kids who already have higher levels of these neurotransmitters a stimulant?” Putnam asks.

Interestingly, a second-line medication mostly used for young children with ADHD, called clonidine, reduces the release of these neurotransmitters. Clonidine is also used to treat traumatized children for exactly that reason—because it calms the hyper-active stress system.


Parents need to be proactive

“To some extent, it really doesn’t matter what you call it, but how you treat it,” says William Copeland, assistant clinical professor of psychiatry at Duke University Medical Center, an author of the North Carolina study.

Copeland, however, disagrees that trauma symptoms are frequently mistaken for ADHD. “I think it’s fair to say that there are some situations where they can look the same,” he says, but, he explains, by taking a thorough history, most clinicians will discover the truth. It’s also possible to have both conditions: In fact, ADHD itself has been linked with an increased risk for PTSD.

Unfortunately, most traumatized children are treated by pediatricians who receive little training in childhood behavioral disorders. Although half of a typical practice involves behavior problems, most pediatricians only get six weeks of training in these issues, according to Floyd Sallee, professor of psychiatry at the University of Cincinnati.

“Very few pediatricians take a detailed history of traumatic events and they are certainly reluctant to look for things like possible sexual abuse,” Sallee says. In fact, discomfort about asking parents about abuse issues in the World Trade Center sample led to such questions being excluded from the trauma screening used in the study.

So if parents even suspect that their children’s attention problems might be trauma-related, they are the ones who need to bring it up with their doctors, experts agree. If, like Dylan, a child comes from a known chaotic environment or has been adopted from an orphanage or foster care, screening for traumatic symptoms is essential, says Sallee. Placement itself (except adoption of a newborn or extremely young infant) is considered potentially traumatic.

As for Dylan, he’s 13 now and not on medication. Dawn calls him “a loving, caring, beautiful boy,” and says that what helped was counseling, lots of food, a very predictable household routine—and an abundance of love and family support.


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#216218 - 04/07/08 04:00 PM Re: ADHD may be trauma related [Re: Ken Singer, LCSW]
JustJeff Offline
Guest

Registered: 03/19/08
Posts: 262
Wow. This news article makes me wonder do i really have ADHD, or have i been misdignosed and really have something else? makes me wonder, eh, it's probably to late to get a redignoses, it'll probably be to tramatic for my brain to handle, probably because the effects of withdrawal from the medicine is not wildly known.

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#216229 - 04/07/08 04:11 PM Re: ADHD may be trauma related [Re: JustJeff]
Ken Singer, LCSW Offline
Moderator Emeritus
MaleSurvivor

Registered: 08/24/00
Posts: 5780
Loc: Lambertville, NJ USA
Being misdiagnosed and continuing on the meds may not be the solution. If you are properly diagnosed (and nobody is saying that the diagnosis for you is wrong at this point but it might make sense to copy the article and bring it to your doc who does the ADHD meds.)

He may want to try either a different med that might address the trauma rather than the ADHD or wean you off completely and let the therapy do its work.


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#216249 - 04/07/08 04:46 PM Re: ADHD may be trauma related *DELETED* [Re: Ken Singer, LCSW]
awakening Offline
Member
MaleSurvivor

Registered: 01/01/08
Posts: 342
Post deleted by awakening


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#216253 - 04/07/08 05:02 PM Re: ADHD may be trauma related [Re: awakening]
dannym Offline
Member
MaleSurvivor

Registered: 03/24/07
Posts: 543
Loc: Boulder, Colorado
Hey, Gregory, I agree - I have been working with disabled kids for over 20 years, and I have found that clinicians tend to label kids with "junk" terms like cerebral palsy, ADHD, BiPolar without a lot of fact checking, history taking. Not all, of course, but many. For me, it is valuable because it describes some of the symptoms, so I know what to expect when I start with a child but... and here's the biggie .... it doesn't MATTER what we call them! Each person is so unique, you need to evaluate what they need at a particular time and go with that. And what they need is constantly changing....

When I have graduate students interning with me, I always tell them that what they see in the reports from home, schools, hospitals is a TINY piece of the information... it is their job as clinicians to evaluate every minute what each client needs at that time... and be willing to change what they are doing. I use the anology that if all you have is a hammar, everything looks like a nail. We need to help clinicians see that just because they have a set of pharmaceuticals at their disposal, they are not the ONLY tools that are needed.

Sorry to jump in with that... I will get off my soapbox before I hurt myself and have to go to the ER... hmmmm, wonder what meds they'd give me?

Dan

_________________________
"You should listen to your heart, and not the voices in your head."

Marge Simpson

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#216320 - 04/07/08 09:18 PM Re: ADHD may be trauma related [Re: dannym]
rehpotsirhcs Offline
Member
MaleSurvivor

Registered: 10/10/07
Posts: 204
I've never been diagnosed with ADD/ADHD but this article hits close to home. I think I dissociate a lot in class with a lot of "numbness". Mostly all I think about while I'm in this state is sex stuff. Sometimes I even get up during a class lecture and open the classroom door. It bothers my teachers but I don't remember doing it.


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#216335 - 04/07/08 10:11 PM Re: ADHD may be trauma related [Re: Ken Singer, LCSW]
onlyakid Offline
Member
MaleSurvivor

Registered: 03/31/04
Posts: 1552
Loc: New Jersey
Thanks for the article Ken. I've always contended that my ADD diagnosis was more from my chaotic childhood of my father being sick and my parents fighting, now I have research to back me up.

Jason

_________________________
"Being with people that understand you...Priceless"

"and i don't want the world to see me, cause i don't think that they'd understand"

"You don't know what love is...you just do as your told"

"My life has changed. What you take as a simple thing, is not so simple for me anymore"


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#216342 - 04/07/08 10:30 PM Re: ADHD may be trauma related [Re: onlyakid]
JustJeff Offline
Guest

Registered: 03/19/08
Posts: 262
Yea, I totally agree with some of there view's. i believe i have been misdignosed and that i don't really have ADHD, like the guy before me posted, i to have not been content with my dignosis and believe it's wrong, next time i see my doctor, i'll bring it up.

_________________________
.

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#216377 - 04/07/08 11:57 PM Re: ADHD may be trauma related [Re: JustJeff]
supertalented Offline
Member
MaleSurvivor

Registered: 03/30/08
Posts: 8
Loc: New York
I think what is also important to note is the fact that adhd can lead to, or make a child more vulnerable to trauma. That insight has helped me in understanding my history and my shrink in treating me now.



Edited by supertalented (04/07/08 11:58 PM)

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#216393 - 04/08/08 12:45 AM Re: ADHD may be trauma related [Re: supertalented]
mogigo Offline
Member
MaleSurvivor

Registered: 04/24/07
Posts: 1331
Loc: Colorado
Had to chime in as well, diagnosed ADHD as well, Ritalin for 4 years. Wonder now if I was misdiagnosed.

What a shock \:\) more issues

Stay strong
Mike

_________________________
Thriving

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