The importance of a correct diagnosis.
What is ADHD?
According to the DSM-V (American Psychiatric Association, 2013), Attention Deficit Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder characterized by a persistent pattern of attention deficit and/or hyperactivity that is maladaptive for the patient, is present since before the age of 12 and interferes with daily activities.
Usually its diagnosis is made in childhood and often lasts until adulthood. Children with ADHD may have problems paying attention, controlling impulsive behaviors or being excessively active, depending on the type and symptoms of ADHD that occur. These may present in different ways. different form: one in which inattention predominates, one in which hyperactivity/impulsivity predominates or a combination of both.
What is complex trauma and PTSD?
Complex trauma refers to exposure to multiple traumatic events that are severe and pervasive, such as exposure to a natural disaster, exposure to domestic violence, and/or child abuse: physical, sexual, emotional, or neglect of needs. basic characteristics of a child, what makes recognizing complex trauma challenging is that it is subjective, and a child's "post-traumatic stress" response depends on:
- the child's temperament
- the developmental age when the trauma occurred
- the severity and duration of the trauma
- risk factors such as an unstable family environment
- protective factors, such as a supportive family and a consistent school environment.
Posttraumatic Stress Disorder (PTSD) is a form of anxiety that occurs after a traumatic event. Symptoms can be subdivided into categories such as intrusions, avoidance, negative alterations in cognition and mood, alterations in arousal, reactivity, as well as nightmares and frequent and unwanted memories in which the traumatic event is reproduced.
People with PTSD avoid stimuli associated with the trauma and feel emotionally cold and lose interest in everyday activities. Depression, anxiety and substance abuse are common in people with PTSD.
The relationship between ADHD and PTSD
The data seem to indicate that there is an overlap of symptoms between ADHD and PTSD, so that a patient who suffers from trauma may manifest symptoms of ADHD in such a way that the symptoms are confused. This overlap of symptoms makes it difficult to make a correct diagnosis, in addition to the difficulty of taking into account all the variables at the time of evaluation, consequently, an erroneous diagnosis can be made.
In an investigation by Ulloa and Navarro (2011) of 100 children, 22% reported violence between their parents, 39% were diagnosed with ADHD, apparently the type of emotional abuse was observed in 77% of the cases. and physical abuse in 41%, consequently, child abuse and abuse could be predictors of conduct disorder including ADHD.
Another study carried out by Lipschitz et al (2002) highlighted the variability in symptoms and behaviors in children who had been physically or sexually abused; these children could present aggressive behaviors, anxiety, excessive attachment, fears, hyperactivity, sleep problems, periods of isolation and sadness, eating problems, regression in play or delayed development, these children are usually diagnosed with depression, adjustment disorder, oppositional defiant disorder, ADHD and/or PTSD.
Lieberman et al (2011) studied trauma in preschool age and found that those children who were exposed to domestic violence showed greater negative effects, less appropriate responses, more aggression from peers, and more ambivalent relationships with their caregivers than with their peers. Peers further suggest that the social, emotional, and cognitive abilities of children with ADHD may be greatly distorted when trauma is experienced.
Early exposure to traumatic events and attention problems that can later lead to PTSD, ADHD or a mixture of both, according to Husain et al (2008), who concluded that there was a great similarity in the symptoms of PTSD and ADHD, having a direct relationship between attention problems and exposure to trauma, also considering the need to be careful in the diagnosis of ADHD if there is evidence of exposure to childhood traumatic events.
ADHD cannot directly cause PTSD, however, childhood trauma can trigger symptoms compatible with ADHD, thus, many children who are treated with medication for ADHD cause the symptoms to persist over time, not to decrease or decrease. disappear, because it was actually PTSD.
To further complicate the diagnosis, it is also possible for a child to have ADHD and PTSD at the same time, this happens when a child with ADHD has had one or more traumatic experiences, in fact, children with ADHD are 4 times more likely to develop PTSD than those children without ADHD, since they can put themselves in situations that can cause trauma, making their symptoms even more serious.
Signs and symptoms of trauma that can be confused with ADHD
Symptoms of complex trauma or PTSD may include the following:
Hypervigilance: Children who have been exposed to one or more traumatic events are more sensitive to signs of danger or threat, which causes them to be in a permanent state of high alert, which prevents or makes it difficult for the child to stay sitting and paying attention calmly, this symptom can be confused with hyperactivity or impulsivity in ADHD.
Reliving traumatic events: Children who have experienced one or more traumatic events may repeatedly re-experience traumatic events in their mind, which may appear to be distracted or distracted; this may be confused with difficulty paying attention in the brain. ADHD.
A negative view of others: Exposure to traumatic events can cause children to have a tendency to perceive people as hostile and assume that they have negative intentions towards them, this can cause them to present behaviors that seem impulsive, with negativistic behavior or opposition, behaviors that children with ADHD usually develop, however, these behaviors have their origin in fear, their fight or flight system is activated when faced with a perceived threat even if there is no danger to protect themselves from it.
Difficulty with executive functions: Like children with ADHD, those who have experienced trauma tend to have problems with executive functions, such as maintaining concentration, planning tasks, handling and managing emotions, or reflecting before acting.
Some of the symptoms that may overlap in childhood PTSD and ADHD are the following: difficulty concentrating or learning in school, easily distracted, seeming not to listen, increased disorganization, hyperactivity, agitation and motor restlessness, impulsive behaviors, intrusive thoughts and social difficulties.
In addition, children who have experienced trauma may present: problems with anger and stress control, anxiety, depression, behavioral problems, learning difficulties, restlessness and hyperactivity, difficulty concentrating, problems with their personal relationships.
Causes and consequences of misdiagnosis
When a child is presented to the specialist as a child who is not able to concentrate on his task, stay organized, cannot control his behavior or sit still, he is usually diagnosed with ADHD, however, Post-Traumatic Stress Disorder (PTSD) or circumstances of social adversity, are not usually directly contemplated in the diagnosis.
Context and culture influence the manifestation of ADHD, with respect to a child's behavior, environmental or traumatic factors can affect and interfere with behavior, as can childhood trauma and PTSD, however, this is not mentioned as a differential diagnosis in the DSM-V, often causing a misdiagnosis of ADHD in patients with PTSD or undetected trauma, which can accentuate or exacerbate symptoms, such as hyperactivity, aggression, and physical attacks.
The false positive diagnosis of ADHD includes inadequate treatment, secondary psychological effects on the patient, economic burden on families, social labeling, stigmatization and unnecessary medication, in addition to the lack of treatment of the patient's real condition.
Research has found that a large number of children diagnosed with ADHD were in an adverse environment, such as living in divorced families, in situations of social exclusion or poverty, violence, mistreatment, abuse and drugs, however, these factors were not taken into account. taken into account when making the diagnosis of ADHD.
According to the National Children's Survey, research concluded that there was a pattern between the diagnosis of ADHD with 9 out of 10 adverse childhood experiences, such as poverty, divorce, death of a parent or guardian, domestic violence, violence in their environment social or school, physical, psychological or emotional abuse, family mental illness and discrimination, the parents of 12% of children diagnosed with ADHD reported a higher incidence of these events than those children without ADHD.
This indicated that children with 4 or more adverse childhood experiences were 3 times more likely to be diagnosed with ADHD and treated with medication, in addition to being more likely to have a parent or guardian also diagnosed with ADHD, compared to those children who had 3 or fewer adverse experiences.
Various studies have shown that a low percentage of clinical referrals for ADHD to specialized centers are correctly diagnosed with ADHD. Cotuono (1992) evaluated 92 children who had been diagnosed with ADHD and after a complete and exhaustive evaluation, taking into account family, psychosocial and comorbid factors, only 22% of them met the diagnostic criteria compatible with ADHD.
Ford et al (2000) indicates that the presence of ADHD is much more frequent in children who have been exposed to physical abuse or abuse. Other authors reached the same conclusions. In their studies they highlight that child abuse and emotional neglect are more common in people with ADHD compared to other patients who did not have this condition.
If the trauma goes undiagnosed and a child is treated with ADHD stimulant medications, in some cases this medication can increase anxiety related to the trauma, causing children to be more hypervigilant and on edge, requiring a change. to non-stimulant medication, in addition to receiving treatment that addresses trauma such as Trauma-Focused Cognitive Behavioral Therapy.
Children who present with behavioral problems resulting from unrecognized PTSD tend to be stigmatized, especially if they are diagnosed with a behavioral disorder such as oppositional defiant disorder or conduct disorder, for example, when the child is being seen in a school. Through the behavioral lens, they tend to be more likely to remove you from class, suspend you, punish you, or even expel you.
"If the trauma is not detected, it will be difficult to treat"
Recommendations for a correct diagnosis
An exploration of trauma or exposure to adverse experiences in childhood in the evaluation of ADHD helps to have a more accurate diagnosis of whether the patient has ADHD or not, along with the corresponding treatment.
It is advisable to reflect on the patient's personal medical history that can explain the origin of the causes of the symptoms, whether ADHD, complex trauma or post-traumatic stress; To do this, it is necessary that in the interview with parents, relatives and friends, medical and psychosocial situations that may resemble ADHD are ruled out.
In cases of possible ADHD diagnosis, it is recommended to take medical histories of past events and screen for PTSD to reduce the chances of a misdiagnosis and thus be able to apply the most effective treatments and approaches.
Children with PTSD present symptoms that are not consistent with ADHD, such as intrusive and disturbing thoughts, avoidance of things, places or people that remind them of the traumatic experience.
Knowledge about the prevalence and types of traumatic experiences in the childhood of those children who are diagnosed with ADHD will help to better address the accuracy of the diagnosis and its treatment.
If after reading this article, you still have questions, I invite you to write them in the comments so that I can help you resolve them, and if you liked it, you are free to share it with whoever you want so that they can also know everything about the importance of a correct diagnosis.
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Thank you for coming this far, I hope you enjoyed reading.
Psic. Ylenia Abril - Tu espacio mental
Bibliography
- Vértices Psicólogos (2015). Los últimos estudios apuntan a que el TDAH y el trauma están relacionados. http://www.verticespsicologos.com/agora-psicologia/noticias/trauma-infantil-y-TDAH-torrelodones
- Aguirre, M. et al (2022). Trastorno por déficit de atención e hiperactividad y su relación diagnóstica con el Trastorno por estrés postraumático infantil: Una revisión sistemática. https://dialnet.unirioja.es/servlet/articulo?codigo=8265637
- Miller, C. (2022). ¿Es TDAH o trauma? Child Mind Institute. https://childmind.org/es/articulo/es-tdah-o-trauma/
- Staniland, J. (2019). El niño desatento, impulsivo e hiperactivo: ¿está el trauma infantil enterrado entre el TDAH? Child Development Clinic. https://www.childdevelopmentclinic.com.au/adhd-and-complex-trauma.html
- Manual MSD (2020). Trastorno de estrés postraumático (TEPT). https://www.msdmanuals.com/es-mx/professional/trastornos-psiqui%C3%A1tricos/trastorno-de-ansiedad-y-trastornos-relacionados-con-el-estr%C3%A9s/trastorno-de-estr%C3%A9s-postraum%C3%A1tico-tept
- CDC (2022). Trastorno por Déficit de Atención e Hiperactividad (TDAH). https://www.cdc.gov/ncbddd/spanish/adhd/facts.html
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