Effects of Childhood Trauma on Childhood ADHD Diagnosis

Background of ADHD  


Early 1900s

In 1902, Sir George Still became the first person to describe ADHD. He described it as "an abnormal defect of moral control in children," but he did not give the phenomena a name. Later, in the 1930s, Dr. Charles Bradley found that when he gave school children the stimulant, Benzedrine, their behaviors began to improve.


Late 1900s

In 1955, the FDA approved Ritalin—which later became an extremely popular medication for treating hyperactivity, and later ADHD. This led to the federal government funding research on the effects that stimulants have on children diagnosed with hyperactivity in 1967. In 1980, the 3rd edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) recognized attention deficit disorder (ADD). However, scientists did not attribute hyperactivity as a common symptom of ADD, so the DSM listed two subtypes of ADD: ADD with hyperactivity and ADD without hyperactivity. In 1987, the DSM released a revised version of DSM-III where the ADD with hyperactivity subtype of ADD was renamed Attention Deficit Hyperactivity Disorder, or ADHD. Throughout the 1990s, the number of children diagnosed with ADHD begins to soar as more medication become available. The increase in diagnoses is contributed to several factors, including: doctors were able to diagnose ADHD more easily, parents were more aware of the symptoms and chose to get their children tested, and more children were truly developing ADHD.


Early 2000s

In the early 2000s, the DSM came out with their fourth edition, DSM-IV. In this edition, ADD was combined into ADHD and it established three subtypes of ADHD: combined type ADHD, predominantly inattentive type ADHD, and predominantly hyperactive-impulsive type ADHD. There is still much research surrounding ADHD today, because there is still so much more we don't know. However, the United States does have one of the highest rates of ADHD diagnoses in the world.


Discovering the Link Between ADHD and Trauma

During residency at Johns Hopkins Hospital, Dr. Nicole Brown noticed that a high majority of low-income patients were diagnosed with ADHD. Not all of the patients were reacting well to their treatment plans. Dr. Brown then hypothesized that many of these patients were actually exhibiting symptoms of trauma—not ADHD—and that symptoms of trauma are easily mistaken for symptoms of  ADHD.  



Research on ADHD and Trauma  



ADHD Overview

The Center for Disease Control describes people diagnosed with ADHD as having "trouble paying attention, controlling impulsive behaviors, or be overly active." ADHD is one of the most common neurodevelopmental disorders; in the United States, approximately 11% (or 6.4 million) children ages 4-17 have been diagnosed with ADHD; most children diagnosed with ADHD are boys. Students with ADHD may struggle in a classroom setting where they are expected to sit quietly for extended periods of time.


Symptoms of ADHD

Children with ADHD show many signs of the neurodevelopmental disorder throughout their day-to-day activities. These symptoms include:

  • Difficulty sustaining attention: students with ADHD may not have the attention span necessary to learn in a traditional learning environment.
  • Struggling to follow instructions: students with ADHD may not be able to follow instructions throughout the school day due to their inability to sustain attention while directions are being given.
  • Difficulty with organization: students with ADHD may have clutter in and around their desks and backpacks, and they may also easily lose papers, assignments, etc.
  • Fidgeting or squirming: students with ADHD may struggle to sit still in a chair, resulting in them rocking the chair back and forth, wiggling their bodies, touching things on and near their desk, etc.
  • Difficulty waiting or taking turns: students with ADHD may find it hard to wait and take turns, resulting in them calling out during class.
  • Talking excessively: students with ADHD may talk more often than students without ADHD, including during quiet times of the day, while other students are talking, while the teacher is talking, etc.
  • Losing things necessary for tasks or activities: students with ADHD may easily misplace things or forget where items necessary for a task or activity are. This is related to their difficulty with organization.
  • Interrupting or intruding upon others: students with ADHD find it difficult to wait and take turns which may result in them interrupting their peers or teacher. They may also be unaware of personal space, resulting in them intruding upon the personal space of those around them.


Diagnosing ADHD

While the causes of ADHD are unknown, studies have shown that the chances of a child being diagnosed with ADHD are increased with:

  • Genetics
  • Exposure to lead or pesticides during early childhood
  • Being born prematurely
  • Having a low birth weight
  • Brain injury
  • Prenatal exposure to alcohol or drugs.

There is no single test to diagnose ADHD. Rather, doctors must rely on:

  • Ruling out other issues
  • Having parents and teachers use a checklist to rate the child's symptoms
  • Looking at the child's family medical history


Treatment for ADHD

Additionally, ADHD symptoms can worsen or increase with the presence of family stress.  The CDC states "although ADHD can't be cured, it can be successfully managed and some symptoms may improve as the child ages."

Treatment techniques for children with ADHD usually include a combination of two or more of the following:

  • Educating the parent and child about ADHD
  • Behavioral therapy
  • Mental health counseling for the child and family
  • Parent training programs
  • Educational modifications and supports (504 plans, etc.)
  • Medication


Childhood Traumatic Stress Overview

The National Child Traumatic Stress Network characterizes childhood traumatic stress as "a psychological reaction that some children have to a traumatic experience in which they are involved or have witnessed...Traumatic experiences can affect the brains, minds, and behavior of even very young children." Up to 50% of children have experienced some sort of traumatic event in their lifetime.

Traumatic events children may be exposed to include (but are not limited to):

  • Car accidents
  • Unexpected death of a loved one
  • Serious injuries
  • Life-threatening disasters
  • Violent acts
  • Acts of physical or sexual abuse
  • Neglect or abandonment


Symptoms of Childhood Traumatic Stress

Children experiencing trauma show many signs of this throughout their day-to-day activities. These symptoms include:

  • Feelings of fear, helplessness, uncertainty, or vulnerability: students experiencing trauma in their lives may begin to show signs of feeling like they aren't capable, they may show signs of being afraid, and they may become increasingly vulnerable to those around them.
  • Increased arousel, edginess, and agitation: students experiencing trauma may appear to be on edge throughout the day and they may become agitated extremely easily.
  • Avoidance of reminders of trauma: students experiencing trauma in their lives may avoid people, places, or things that remind them of the trauma. This could mean avoiding men, avoiding certain rooms or spaces, etc.
  • Irritability, or quick to anger: students experiencing trauma in their lives may begin to react more quickly and with more anger in situations than they had before the trauma or compared to other students of the same age.
  • Feelings of guilt or shame: students experiencing trauma may show signs of feeling shame or guilt for things they do throughout the day.
  • Dissociation, feelings of unreality, or being "outside of one's body": students experiencing trauma may appear distracted or as if they are daydreaming throughout the day.
  • Continually feeling on alert for threat or danger: students experiencing trauma may be quick to react to any words or actions that makes them feel threatened or as if they are in danger. They are always on watch for threats.
  • Unusually reckless, aggressive or self-destructive behavior: students experiencing trauma may experience an increase in reckless, aggressive, or self-destructive behaviors in the classroom, on the playground, and in other areas of the school day.


Diagnosing Childhood Traumatic Stress

A child's reactions to a traumatic event depends on several factors, including their temperament before their exposure to trauma and the support system available to them at home. When assesses childhood trauma, doctors are assessing for many different things, including:

  • A range of events and the time they occurred to link these traumatic events to certain developmental stages
  • Symptoms such as PTSD
  • High-risk behaviors
  • Family environment
  • Functional impairments
  • The child’s strengths, abilities, resilience, and support sources available to the child.

This information can be gathered through a variety of ways and perspectives. It is often gathered through interviews or observations of the child, caregiver, teachers, or other relevant sources. It is extremely important that assessments be conducted in an ongoing manner, because as children develop they take part in new experiences—these new experiences can become new stressors for the child. Treatment for childhood traumatic stress is different for each child depending on the trauma. However, treatment plans often include:

  • Providing the child with a safe environment full of routine
  • Teaching coping skills to children
  • Talking about the traumatic event in a setting that allows the child to resolve their feeling
  • Correcting the child when their memory about the event become distorted or untrue
  • Helping the child to regulate his/her emotions, behaviors, and physiological reactions to the trauma.  


Overlap between ADHD and Childhood Traumatic Stress

There are many similarities in symptoms of ADHD and symptoms of childhood traumatic stress. Doctors, parents, teachers, etc. must be able to look at all of the symptoms the child is showing in order to determine whether the child has ADHD, childhood traumatic stress, or even both.

The overlapping symptoms of ADHD and childhood traumatic stress include:

  • Difficulty concentrating or learning in school: both students with ADHD and students experiencing trauma may show signs of having difficulty concentrating or learning within a school setting.
  • Easily distracted: both students with ADHD and students experiencing trauma may become easily distracted or off-task throughout the school day.
  • Often doesn't seem to listen: both students with ADHD and students experiencing trauma may appear to not listen to instructions, adults, or their peers.
  • Disorganization: both students with ADHD and students experiencing trauma may be disorganized when it comes to their desk, folders, backpack, etc.
  • Hyperactive: both students with ADHD and students experiencing trauma may show signs of hyperactivity throughout the day, making it difficult for them to sit still or focus on learning.
  • Restless: both students with ADHD and students experiencing trauma may become restless during the school day, making learning a difficult task.
  • Difficulty sleeping: both students with ADHD and students experiencing trauma may have difficutly sleeping throughout the night, leaving them tired throughout the school day.



Application in the Classroom:  

Students going through childhood trauma often have difficulty expressing the distress they feel. Their treatment must be individualized to fit their needs; it is critical that students experiencing trauma are not placed on medication for ADHD, because these students must work through the emotions that they are feeling. They often try their best to mask their emotions so that teachers don’t notice what it truly going on inside their minds.

Students experiencing trauma face many obstacles to learning:

  • Difficulty forming and maintaining relationships with teachers
  • Difficulty with self-regulation
  • Negative thoughts consume the child
  • Hypervigilance
  • Problems with executive functioning

Students experiencing trauma may also have a hostile attribution bias: they believe that everybody is out to get them, often causing them to hear the things we say in a much more exaggerated and aggressive way. Additionally, hypervigilance is easy to mistake for hyperactivity. This leads to students experiencing trauma to be misdiagnosed with ADHD and thus, being placed on a medication that cannot help them. Also, executive function challenges are common for students experiencing trauma as well as students with ADHD. Thus, teachers must be able to recognize other signs and symptoms in order to distinguish between the two. Being able to distinguish whether a child is exhibiting symptoms of ADHD or symptoms of trauma can help create a meaningful treatment guide for the child.  



Suggestions for Teachers:  

As teachers, there are many important things to know when teaching a child who is processing through trauma, as they must be treated on an individual basis, and thus cannot be treated as a child with ADHD: these children may become distracted in the classroom; however, teachers should not fix this through reprimanding students. Instead,

  • Positive affirmations: Give the student positive affirmations
  • Use reminders: Use verbal or visual reminders about what to do or how to act
  • Structure: Have a structured and predictable classroom to students who are processing through trauma
  • Signs and cues: Use visual signs and cues around your classroom so that your students can easily decipher what will happen next
  • Recognize the child's perception: Realize that it’s the child’s perception that matters, not ours. Regardless of the reality of the child’s situation, it is their thoughts and feelings that determine the severity of the situation. Trauma may not come through violence in the home, and we must not limit our perception of trauma to simply home violence.
  • Empathy and flexibility: You don’t have to know exactly what’s going on in the child’s life to help. Respond to the child with empathy and flexibility regardless of how much information you have on the subject
  • Set students up for success: Empower students and build their confidence by setting them up for success in the classroom
  • Show support: Verbalize your support for the student so they feel safe in your classroom
  • Use brain breaks: Set time for frequent brain breaks to help keep students on track. This is especially important for students struggling with executive functioning.
  • Ask: Ask students “How can I help you?”
  • Change your attitude: Change your attitude from “What’s wrong with that kid?” to “What’s going on in that kid’s life?"

Additionally, rather than disciplining students, try working with individual students on a way to change their behavior. This helps students understand that they are loved and cared for, and they are more likely to respond to you. When students begin to misbehave, acknowledge their emotion and try to verbally identify the emotion. This allow the student to identify the emotion they are feeling, and it can help them express their feeling in a more appropriate way. Acknowledging and identify the child’s emotion may help prevent the child from feeling alienated within the classroom.

Teachers can also help students develop self-regulation by starting first with co-regulation. Through co-regulation, teachers coach students to help them work through their emotions, until they have gained enough autonomy to work through their emotions on their own. Students experiencing trauma are more successful when teachers celebrate student success and learning; teaching a growth mindset approach in the classroom is also an extremely valuable tool for students experiencing trauma.

When students experiencing trauma begin to show hypervigilance, teachers must try to match their emotion in a controlled manner. This can show students that you understand what they are trying to tell you, and it helps students make a connection with their teacher. Finally, be sure to give students as much positive attention as possible to help them throughout the days. Doing so helps the child’s confidence, and it can help them feel successful and competent in-and outside of the classroom.



Helpful Websites for Educators



This blog offers 10 helpful tips on how to treat students experiencing trauma in the classroom. It also briefly goes over what types of events can cause trauma.  



This article shares real world experiences and input from teachers on how they are helping students experiencing trauma become successful in their classroom. It also gives an insight on what trauma-informed education is.  



This article shares examples of how trauma can manifest itself in a child. It provides insight on how to treat a child going through trauma and lists some of the symptoms. This is helpful to know, because understanding the symptoms of childhood trauma can help a teacher disstinguish between ADHd and childhood trauma.



 This is a PDF link to a book about trauma sensitive schools and what they do to help students who struggle with trauma learn.  It covers the impact of trauma on learning, a flexible framework action plan for schools, and policy recommendations.




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