Hyper, or Hurting?

What looks like ADHD can be signs of childhood trauma

If a child acts inattentive and hyperactive in school, chances are very good he (it’s usually a boy) will be diagnosed with ADHD. Attention-deficit hyperactivity disorder affects an estimated 8-12 percent of children worldwide. The designation is so common it’s become a casual synonym for being scatterbrained (“I’m totally ADD today”), and its prevalence is self-propagating — the more people are aware of the disorder, the more likely they are to claim it as the cause of a problem.

Beyond the over diagnosis of kids who are hyper but healthy, there’s a graver consequence to this attention-deficit bandwagon. A small but growing body of research confirms what is, so far, a little-known fact — that the symptoms of post traumatic stress disorder (PTSD) can look exactly like those of ADHD. In other words, a distractible, impulsive, irritable child who looks to a teacher or caregiver like a classic ADHD case may actually be struggling to cope with abuse, divorce, natural disaster, or another serious trauma. It can be hard to tell the difference; in a 1994 study by researchers at the Medical College of Pennsylvania, trained interviewers assessed a group of troubled children and, not knowing the children were sexually abused, diagnosed 46 percent of them with ADHD.

“ADHD is not only the diagnosis du jour, it’s also the diagnosis of the decade,” says behavioral pediatrician Lawrence Diller, the author of three books on psychiatric drugs and children. “It represents, with medicine, a quick fix for the main manifestations of ADHD, but these are also manifestations of a half dozen other problems. It’s sad the amount of antipsychotics and anticonvulsants prescribed to children to suppress their acting out, which may be occurring because they’re living in an intolerable environment.”

Consider what happened to Julio, a fourteen-year-old in Massachusetts who entered high school distractible and inattentive, performing poorly in classes. Lisa Fortuna, a psychiatrist at Harvard Medical School, recalls how his parents struggled to get him to do his homework and complained that he acted impulsively, intruding on adult conversations at home. Julio was prescribed stimulants for ADHD. Soon after, however, he revealed two significant traumas in his past: As a child in the United States, he heard about war atrocities in El Salvador while his parents still lived there, and, later, he saw a friend shot and killed. Nightmares plagued him. Through therapy and medication for PTSD, Julio’s symptoms and schoolwork improved, even when he stopped taking drugs for treating ADHD.

Now, before teachers go recommending all their hyperactive students for a local Department of Social Services intervention, it’s important to keep the problem in perspective. Inattentiveness and hyperactivity do often signify ADHD, anxiety, or simply a child acting his or her age. However, for children who silently suffer abuse or grief, the leap to label them with ADHD can leave them without the help they truly need, and may even aggravate their symptoms.

Children 18 and Younger Who Are Prescribed Stimulants (Typically for ADHD)

Source: American Journal of Psychiatry Credit: Mark Wagoner

Regrettably, teachers and parents assessing kids’ behavior have limited measures to go on, and busy pediatricians often have little time to weigh other explanations when seeing a child with possible ADHD. As Diller says, “Checklists were meant to be used only in schools as assistance, but they have become a sign of diagnosis. They give you a fake sense of science.”

To curb the problem, Annan Paterson, a school psychologist in Novato, California, suggests that those in her position “work collaboratively with fellow educators, parents, physicians, and mental health professionals to do a comprehensive assessment.” Jerome Schultz, codirector of the Harvard Medical School’s Center for Child and Adolescent Development, says the key is to take a complete family history and assess the child’s behavior across multiple classes and settings. Pediatrician Lawrence Diller adds that doctors must work with schools to coordinate all aspects of a child’s treatment.

Most simply, though, the lesson in these caregivers’ experience is this: When we think we spot ADHD, we serve the child best by taking the time to look a little deeper.