It’s not clear how many children are misdiagnosed with ADHD annually, but a study published in 2010 estimated the number could be nearly 1 million. That research compared the diagnosis rate amongst 12,000 of the youngest and oldest children in a kindergarten sample and found that the less mature students were 60 percent more likely to receive an ADHD diagnosis.
Though ADHD is thought to be a genetic condition, or perhaps associated with lead or prenatal alcohol and cigarette exposure, there is no brain scan or DNA test that can give a definitive diagnosis. Instead, clinicians are supposed to follow exhaustive guidelines set forth by professional organizations, using personal and reported observations of a child’s behavior to make a diagnosis. Yet, under financial pressure to keep appointments brief and billable, pediatricians and therapists aren’t always thorough.
“In our 15-minute visits—maybe 30 minutes at the most—we don’t really have the time to go deeper,” Brown says. If she suspects ADHD or a psychological condition, Brown will refer her patient to a mental health professional for a comprehensive evaluation. “You may have had this social history that you took in the beginning, but unless the parent opens up and shares more about what’s going on in the home, we often don’t have the opportunity or think to connect the two.”
Caelan Kuban, a psychologist and director of the Michigan-based National Institute for Trauma and Loss in Children, knows the perils of this gap well. Four years ago she began offering a course designed to teach educators, social service workers and other professionals how to distinguish the signs of trauma from those of ADHD.
“It’s very overwhelming, very frustrating,” she says. “When I train, the first thing I tell people is you may walk away being more confused than you are right now.”
In the daylong seminar, Kuban describes how traumatized children often find it difficult to control their behavior and rapidly shift from one mood to the next. They might drift into a dissociative state while reliving a horrifying memory or lose focus while anticipating the next violation of their safety. To a well-meaning teacher or clinician, this distracted and sometimes disruptive behavior can look a lot like ADHD.
Kuban urges students in her course to abandon the persona of the “all-knowing clinician” and instead adopt the perspective of the “really curious practitioner.”
Rather than ask what is wrong with a child, Kuban suggests inquiring about what happened in his or her life, probing for life-altering events.
Jean West, a social worker employed by the school district in Joseph, Missouri, took Kuban’s course a few years ago. She noticed that pregnant teen mothers and homeless students participating in district programs were frequently diagnosed with ADHD. This isn’t entirely unexpected: Studies have shown that ADHD can be more prevalent among low-income youth, and that children and adolescents with the disorder are more prone to high-risk behavior. Yet, West felt the students’ experiences might also explain conduct easily mistaken for ADHD.
Kuban’s course convinced West to first consider the role of trauma in a student’s life. “What has been the impact? What kind of family and societal support have they had?” West asks. “If we can work on that level and truly know their story, there’s so much power in that.”
As a school official, West sometimes refers troubled students to a pediatrician or psychiatrist for diagnosis, and meets with parents to describe how and why adversity might shape their child’s behavior. In her private practice, West regularly assesses patients for post-traumatic stress disorder instead of, or in addition to, ADHD.
Though stimulant medications help ADHD patients by increasing levels of neurotransmitters in the brain associated with pleasure, movement, and attention, some clinicians worry about how they affect a child with PTSD, or a similar anxiety disorder, who already feels hyper-vigilant or agitated. The available behavioral therapies for ADHD focus on time management and organizational skills, and aren’t designed to treat emotional and psychological turmoil.
Instead, West teaches a traumatized child how to cope with and defuse fear and anxiety. She also recommends training and therapy for parents who may be contributing to or compounding their child’s unhealthy behavior. Such programs can help parents reduce their use of harsh or abusive discipline while improving trust and communication, and have been shown to decrease disruptive child behavior.
Szymanski uses a similar approach with patients and their parents. “I think any traumatized child needs individual therapy but also family therapy,” she says. “Trauma is a family experience; it never occurs in a vacuum.”
Yet finding a provider who is familiar with such therapy can be difficult for pediatricians and psychiatrists, Szymanski says. Though some hospitals have centers for childhood trauma, there isn’t a well-defined referral network. Even then, insurance companies, including the federal Medicaid program, may not always pay for the group sessions commonly used in parent training programs.
Faced with such complicated choices, Szymanski says it’s no surprise when clinicians overlook the role of trauma in a child’s behavior and focus on ADHD instead.
While there are few recommendations now for clinicians, that will likely change in the coming years. The American Academy of Pediatrics is currently developing new guidance on ADHD that will include a section on assessing trauma in patients, though it won’t be completed until 2016.