It is easy to get stuck into territorial disputes, and one of the most common ones I hear in relation to child mental health is the question of whether a child with a trauma history should be thought of as having “real” ADHD or whether it is better to conceptualize the difficulties as being more directly related to trauma. A great illustration of what many consider to be an important diagnostic dilemma comes from a recent article in the The Atlantic by Rebecca Ruiz entitled “How Childhood Trauma Could Be Mistaken for ADHD.”
The main point of the article was to argue that many children who manifest behaviors of ADHD come from chaotic environments and have suffered many adverse child events. Experts quoted in this article advocated that it is important to recognize these events and address them, and that medications can’t fix a chaotic or abusive environment.
Nothing really to argue about so far. Certainly we can be guilty from time to time of getting overly focused on medications while not paying enough attention to the factors that might be driving or exacerbating the problem.
Unfortunately, where the article lost me was its repeated return to the us versus them, correct diagnosis versus incorrect diagnosis, good doc versus bad doc mentality that so pervasively permeates our field. When it comes to trauma and ADHD, this false dichotomy, in my view, would be similar to a physician stating something like, “He has a history of smoking so I don’t think this is real COPD but rather a reaction to the cigarettes.”
Let me offer a few other points for why I think some of these debates between the “biological” people and the “trauma” people are ultimately moot.
- Kids have only one brain that responds to both genetic and environmental factors. Attention and self-regulation skills begin to be learned early in life. When a negative environment impacts that developmental process, the brain physically changes. Thus, it shouldn’t be surprising that there is no evidence that kids who meet criteria for ADHD but also have trauma histories have a brain that is any less “ADHDish” than kids with ADHD who come from stable happy households. Yet somehow, a dualistic perspective that essentially implies separate brains for separate disorders continues to exist. While it is true that severe anxiety can sabotage attention, in my experience it is much more common that children who have suffered many adverse events, especially early in life, present with both real anxiety and real attention problems.
- You can’t ignore genetics. When it comes to children with trauma histories, many of their parents struggle with psychiatric disorders themselves including, not the of least of all, ADHD. This fact does not excuse parents of responsibility, but it is important to remember that these children can get a double dose of at-risk genes and at-risk environments. The vast majority of studies that link environmental trauma to negative child behavior do not take genetics into account, and the few that do paint a much more complex picture than is generally expressed in this article cited above.
- There is little evidence that doing “trauma work” fixes these supposedly misdiagnosed children, especially when the trauma is no longer occurring. While I would be one of the first to agree that a 15 minute “med check” for a child in a tumultuous environment is wildly inappropriate as a sole treatment, I would also have to add that a pleasant 45 minutes of play therapy while struggling parents sit outside in the waiting room is no better. Of course trauma and other environmental factors are incredibly important in the mental health of children. The point is that dismissive explanations of ADHD don’t hold water in study after study.
What can we do instead? The bottom line here is a need to throw out our “this or that” thinking and understand that reactions to adverse environments can contribute to ADHD or be part of ADHD rather than necessarily be mistaken for ADHD. These kids and the families who care for them deserve clinicians who can look at the big picture and proceed with comprehensive multi-faceted interventions. Looking at the world too narrowly through a particular lens (whether it be trauma or ADHD or many other things for that matter) holds everybody back and does not do justice to the amazing complexity of the brain.