Is It ADHD or Trauma

childmind.org/article/is-it-adhd-or-trauma

Why the symptoms are often confused, and how to avoid a misdiagnosis

Writer: Caroline Miller

Clinical Experts:
Caroline Mendel, PsyD
, Jamie Howard, PhD

When kids are struggling with behavior and attention issues, the first explanation that
comes to mind is oftenADHD

(attention-deficit hyperactivity disorder).  

But exposure to trauma can also cause symptoms that look like ADHD. And  trauma
can be overlooked and left untreated when kids are misdiagnosed with ADHD.

Children with ADHD can be fidgety (always getting out of their seats), distracted (not
paying attention to the teacher), and disruptive in class. Kids who have had a
traumatic experience – or repeated exposure to violence or abuse – do some of the
same things, explains explains Jamie Howard, PhD, a clinicalpsychologist

who is a trauma expert at the Child Mind Institute.

Some children who’ve been exposed to violence or another disturbing experience

developpost-traumatic stress disorder

(PTSD). There are also many kids who experience repeated traumatic events in their
home or community who develop these symptoms, even though they don’t meet all
the criteria forPTSD.
This is sometimes called “complex trauma,” and these kids, too,
can be misdiagnosed with ADHD.

And to add to the confusion, kids can also have both ADHD and trauma.

Signs of trauma that can be confused with ADHD

Symptoms of PTSD or complex trauma that might look like ADHD include:

1/5
 Hyperarousal. Children who’ve been through a trauma, or exposed to repeated
trauma, are unusually sensitive to signs of danger or threat. “If you’re on high
alert for danger — if you have all sorts of stress hormones surging in your body
— it’s going to make it hard to sit still and calmly pay attention,” explains Dr.
Howard. “That can look like the hyperactivity and impulsivity of ADHD.”

Reliving traumatic events. Kids exposed to trauma may mentally re-

experience traumatic events, and that can make kids look spacey and
distracted, like kids with the inattentive type of ADHD. “If you’re having intrusive
thoughts about a traumatic event you’ve been through, you’re not attending to
the present moment,” notes Dr. Howard. “You’re distracted because you’ve been
through something so big that your mind can’t digest it.”

A negative view of others. Kids who’ve experienced trauma have a tendency

to perceive people as hostile, to assume they have negative intentions towards
them. That can cause kids to act out in ways that can look impulsive (a symptom
of ADHD) oroppositional
(something kids with ADHD often develop). But in kids
with trauma, it’s a response to a perceived threat. “Their fight-or-flight system
has been activated and is firing even when there is no danger present,” notes
Caroline Mendel, PsyD, a clinical psychologist at the Child Mind Institute.

Difficulty with executive functions. Like kids with ADHD, children who’ve
experienced trauma tend to have trouble with executive functions like staying
focused, planning how to complete a task, managing emotions or thinking things
through before acting.

How can you tell whether a child has ADHD or trauma?

The first step in distinguishing what’s causing a child’s behavior is to consider their
history — to find out if they’ve been exposed to trauma, and the timeline of their
symptoms— whether they appeared earlier or after than the trauma.  It’s also useful to
find out whether there is a family history of ADHD, Dr. Mendel notes, because kids
whose close relatives have ADHD are more likely to have it themselves.

A clinician looking at all the symptoms a child is exhibiting would be able to identify
behaviors of ADHD that distinguish it from trauma, and vice versa. For instance, notes
Dr. Howard, kids who are hyperactive and impulsive have behaviors that don’t map
with trauma: “Interrupting, excessive talkativeness, running down the hallway.” Having
a variety of hyperactive and impulsive symptoms points to ADHD.

In the same way, kids with PTSD have symptoms that are not consistent with ADHD.
For instance, they experience intrusive, disturbing thoughts— not a symptom of
ADHD.

2/5
Another symptom of PTSD is avoidance of things that remind you of the traumatic
experience. As Dr. Howard puts it, “Are they avoiding going home? Getting in a car?
Lingering in the hallways at school? Especially if you know what trauma they’ve been
exposed to, consider if there’s a strategic component to some of their behaviors,
because with PTSD it’s all designed to keep you safe.” Again, this kind of avoidance
does not stem from ADHD.

Kids can also have both ADHD and PTSD

Complicating the task ofdiagnosis,

it’s also possible for kids to have both ADHD and PTSD.

In fact, there is evidence that children with ADHD who have a disturbing experience
are four times as likely to develop PTSD than kids without the disorder. And they’re
likely to experience more severe trauma symptoms than kids without ADHD.

Imaging studies show that ADHD and PTSD are associated with similar irregularities
in brain functioning, which could explain the heightened risk. And that heightened risk
means that children with ADHD need extra attention and support in case of a
traumatic experience, and should be screened for PTSD, notes Dr. Mendel. Kids
diagnosed with PTSD should be screened for ADHD, too.

Why is it important to rule out trauma?

If trauma goes undiagnosed and a child is treated with stimulant medication for
ADHD,  in some cases the medication can increase trauma-related anxiety, making
children more hypervigilant and on edge. If a child is known to have both ADHD and
PTSD and stimulant medication makes them more anxious, a clinician would likely
decide to switch to a non-stimulant medication.

Most important, when signs of trauma are misdiagnosed as ADHD, children are
unlikely to get the specific support they need to deal with the trauma in a healthy way.
Unless they get treatment that addresses the trauma with something like trauma-
focusedcognitive behavioral therapy

(TF-CBT), their symptoms aren’t likely to improve. “ADHD treatment is not going to
help them process the trauma,” explains Dr. Mendel. “It won’t help with their
relationships with others, how they see the world, how they view themselves or their
future. They’re still going to have difficulties managing the thoughts and feelings that
come along with having experienced the trauma.”

3/5
In addition, kids who have behavior problems stemming from unrecognized PTSD
tend to be stigmatized, especially if they are diagnosed with a behavior disorder like
oppositional-defiant disorder orconduct disorder.

“If a school is seeing a child through a behavior lens, they’re going to be more likely to
remove them from the class, to suspend them, even to call 911,” observes Dr.
Mendel.  “And again, that is not the supportive environment that a child who has
experienced trauma needs to heal.”

Why is trauma often overlooked?

If a child is having trouble in school, even a well-intentioned clinician may run down a
quick list of the symptoms and conclude that the issues are due to undiagnosed
ADHD. And, without a more thorough evaluation, that diagnosis can seem like the
simplest explanation. “ADHD screening tools are great for identifying children who
need support,” notes Dr Mendel. “But if we rely on ADHD checklists alone, without
looking at the big picture, it may lead to misdiagnosis.”

Parents might not see a link between the child’s behavior and possible trauma — or
they may not feel comfortable talking about disturbing experiences the child might
have had. As a result, they may not volunteer information about it unless they’re
directly asked. And a clinician might well be reluctant to ask about trauma — which
includes things like domestic violence, abuse and neglect — out of worry that it might
damage their relationship with the family.

Who is most at risk?

It’s especially critical to be alert to the possibility of misdiagnosis in communities
where there is a high level of violence. “In populations where kids are exposed to a lot
of community violence, there are higher rates of ADHD diagnosis,” Dr. Howard notes.
It’s possible that some of those diagnoses are missing signs of trauma.

Kids are also more at risk where there is poverty, whether it’s in urban or rural
communities, explains Dr. Howard. “Where there’s poverty, there’s more trauma, and
usually fewer educational resources and taxed teachers.” And kids often hide
traumatic events, lack the words to explain them, or don’t see or understand them for
what they are.

Studies show that students of color are more likely to be treated as behavior problems
than white students, which can lead to misdiagnosis. “We know that BIPOC students
are more likely to be referred and suspended for disciplinary reasons than their white
peers,” notes Dr. Mendel. “But there’s also a higher likelihood of them experiencing
traumatic events, whether it’s racial trauma or anotherstressor,

4/5
 like poverty or community violence.”

That said, trauma can happen anywhere, to any child, and is often invisible to
outsiders. “You don’t know if there’s domestic violence going on at home,” says Dr.
Howard. “You don’t know if a child’s been in a terrible car accident.” As a clinician, she
says, “You should always consider what’s happened to this child that might be causing
them to behave this way.”

That’s why, Dr. Mendel adds, a series of questions about traumatic events should be
part of a standard evaluation for any mental health challenge. If it’s standard
procedure, a family might be less likely to feel singled out by questions about possible
trauma, she notes. “Asking those questions should be part of a diagnostic evaluation
for any disorder. Look at the symptoms of depression, there’s some overlap with
trauma. Look at symptoms of anxiety, there’s overlap with trauma. You always want to
make sure that you have the full picture.”

This article was last reviewed or updated on March 3, 2022.

5/5