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Thursday, July 17, 2014

Trauma and ADHD: Think “And," Not “Or”

From Psychology Today's Blog
ABCs of Child Psychiatry

By David Rettew, M.D.
July 14, 2014

Mental health professionals continue to get stuck in needless territorial disputes. Case in point: a recent article in the The Atlantic by Rebecca Ruiz entitled “How Childhood Trauma Could Be Mistaken for ADHD.” The piece describes well what is an entrenched debate over the role of trauma in child behavior problems and, in particular, whether a history of trauma should essentially disqualify someone from being diagnosed with disorders such as ADHD.

My first reaction when I heard about the article was something like… here we go again, with one more person jumping on the anti-ADHD bandwagon and attributing every childhood behavior problem to the direct effects of trauma and adverse child events. A few deep breaths and read paragraphs later, however, I was able to find several ideas expressed in the article to applaud.

The main point of the article was to argue that many children who manifest behaviors of ADHD often come from disrupted environments and have suffered many adverse child events. It is important to recognize these events and address them. Medications can’t fix a chaotic or abusive environment.

Good so far. Certainly physicians can be guilty of getting overly focused on child symptoms and medications while not paying enough attention to the factors that might be driving or exacerbating them. In our own clinic, we have taken major efforts to incorporate a process called the Vermont Family Based Approach that is specifically designed to expand the focus of our evaluations to the entire family and the complex environment in which children live.

Unfortunately, however, the article rapidly falls in the increasingly tiresome us versus them, correct diagnosis versus incorrect diagnosis, good doc versus bad doc mentality that so pervasively permeates our field. We just can’t seem to get out of stepping into these same holes, especially when it comes to ADHD and trauma.

While the article itself is relatively balanced, it can easily be misinterpreted by those pushing the increasingly trendy position of “ADHD is not real and is really is all the result of …..(insert trauma, poor sleep, bad nutrition, inadequate schools, etc.).

I offer a few ideas for why this perspective is in need of revision:

1.) Kids have only one brain that responds to both genetic and environmental factors. Attention and self-regulation begin to be learned early in life. When a negative environment impacts that developmental process, the brain physically changes. There is no evidence that kids who meet criteria for ADHD but have trauma histories have a brain that is any less “ADHDish” than kids with ADHD who come from stable happy households. We need to get rid of these bizarre dualistic notions that imply separate brains for separate disorders. While it is true that severe anxiety can sabotage attention, many of the youth in question here have struggles with both real anxiety and real attention problems.

2.) Most parents don’t choose to traumatize their kids. Instead, many of these parents are struggling 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.

3.) There is little evidence that doing “trauma work” fixes these supposedly misdiagnosed children, especially when the trauma is no longer occurring. Yes, a 15 minute “med check” for a child in a tumultuous environment is wildly inappropriate as a sole treatment, but so is a pleasant 45 minutes of play therapy while struggling parents sit outside in the waiting room.

You will notice if you read the fine print of articles like this that none of them references a study demonstrating that you can cure ADHD if you only …. (do trauma work, get a kid to sleep, feed him healthy things, etc.) and that is because such a study does not exist.

Please do not interpret this last sentence to mean that I don’t believe that trauma and other environmental factors aren’t incredibly important in the mental health of children. They certainly are. It’s just 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.

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David Rettew, M.D. is a child psychiatrist and Associate Professor of Psychiatry and Pediatrics at the University of Vermont College of Medicine. He is the author of Child Temperament: New Thinking about the Boundary between Traits and Illness, published by W. W. Norton in 2013. Dr. Rettew is the Training Director of the UVM Child & Adolescent Psychiatry Fellowship, and the Director of the Pediatric Psychiatry Clinic at Fletcher Allen Health Care.

He received his undergraduate degree in psychology at the University of Pennsylvania before working at the National Institute of Mental Health. He received his medical degree at the University of Vermont and then did both his adult and child psychiatry training at Harvard Medical School within the Massachusetts General and McLean Hospital program.

Follow him at @PediPsych and like PediPsych on Facebook.

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