Is It ADHD or Trauma?

When kids are struggling with behavior and attention issues, the first explanation that comes to mind is often ADHD (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 clinical psychologist who is a trauma expert at the Child Mind Institute.

Some children who’ve been exposed to violence or another disturbing experience develop post-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 for PTSD. 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.

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

• 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) or oppositional (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.

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.

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.

Complicating the task of diagnosis, 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.

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-focused cognitive 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.”

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 or conduct 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.”

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.

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 another stressor, 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.”