“I was struck by the confusion or over-eagerness–or both–to take one diagnosis over another,” Szymanski says. “To get a picture of trauma from a child is much harder than looking at behavior like impulsivity, hyperactivity. And if they cluster in a certain way, then it’s easy to go to a conclusion that it’s ADHD.”
A previous edition of the Diagnostic and Statistical Manual of Mental Disorders urged clinicians to distinguish between ADHD symptoms and difficulty with goal-directed behavior in children from “inadequate, disorganized or chaotic environments,” but that caveat does not appear in the latest version. Unearthing details about a child’s home life can also be challenging, Szymanski says.
A child may withhold abuse or neglect to protect his family or, having normalized that experience, never mention it all. Clinicians may also underestimate the prevalence of adversity. The Adverse Childhood Experiences Study, a years-long survey of more than 17,000 adults, found that two-thirds of participants reported at least one of 10 types of abuse, neglect, or household dysfunction. Twelve percent reported four or more. That list isn’t exhaustive, either. The study didn’t include homelessness and foster care placement, for example, and the DSM doesn’t easily classify those events as “traumatic."
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.