A Penn student of mine, Giulliana Gonzalez, wrote this compelling editorial – food for thought for parents, youth workers and prescribers alike. I am honored that she is allowing me to share this:
Are We Mis-Medicating Traumatized Children?
According to the American Psychiatry Association (APA), Attention Deficit Hyperactivity Disorder (ADHD) is the most common neurobehavioral disorder in children in the United States. Over the last few years, the rate of ADHD diagnosis has increased dramatically, and the CDC reports that five percent of children currently have ADHD. Changes in diagnostic criteria and increased advertising encouraging the use of medications to treat “problematic” behavior and “reveal his true potential” have both contributed to this increase. Additionally, sensational media’s emphasis on the over-prescription of these “dangerous” drugs has lead to public concern. The true issue, however, is whether these drugs are being misused in children who might not have ADHD.
A lack of awareness of how symptoms of post-traumatic stress disorder (PTSD) can resemble ADHD can lead to misdiagnosis and unaddressed trauma. There is little research discussing the misdiagnosis of ADHD in children presenting with PTSD. Children with PTSD may experience hyper-vigilance, irritability and difficulty concentrating which may resemble ADHD symptoms. Despite these similarities, the APA does not include PTSD as a differential diagnosis of ADHD.
While an ADHD evaluation focuses on behavior, a PTSD evaluation focuses on identifying trauma. Thus, a lack of adequate history may lead to misdiagnosis. Furthermore, symptoms of PTSD can present a year after the trauma occurred, thereby making the assessment process more challenging. Sexually abused children most commonly develop PTSD, but children who experience other types of trauma such as family dysfunction, car accidents, or gun-related violence can also develop PTSD.
Studies show the tendency of abused children to develop ADHD-related symptoms. Despite these findings, there is little discussion about the importance of including PTSD as a differential diagnosis of ADHD. Although in some cases both ADHD and PTSD may be present, failure to diagnose or misdiagnosing PTSD can have devastating effects. If medications aimed at improving symptoms of ADHD mask the PTSD related behavioral concerns the underlying trauma might not be identified. Unaddressed trauma may lead to more pervasive problems. In contrast to treatment for ADHD that focuses on behavior and academic functioning, treatment for PTSD focuses on the emotional distress the child has experienced. Thus, treatment for ADHD centered on the child’s “problematic behavior,” can aggravate feelings of guilt or shame in victims of PTSD.
Inclusion of PTSD as a differential diagnosis of ADHD may cause speculation that opening this can of worms can further traumatize children. However, studies demonstrate that this is not true— asking victims about trauma does not cause further harm. Instead, addressing their emotional distress is the first step on the road to recovery. Additionally, childhood traumatic experiences are greatly associated with poorer health outcomes, increased risky behavior, and chronic diseases in adulthood. Thus, it is important to encourage open communication about trauma and implement appropriate interventions to prevent lifelong consequences.
Although the media’s coverage on ADHD medication overuse raises concerns, the lack of attention to the potential mis-diagnosis and subsequent mis-medication of children with PTSD bears consequences too serious to disregard. As Steven Sharfstein, President of the APA said, “Trauma is to mental health as smoking is to cancer.” Perhaps the media should shift their focus on shunning medication use for ADHD, to advocating for improved ADHD and PTSD diagnostic criteria in children.