ADHD and PTSD

I have been practicing as a psychotherapist, service leader, and social worker for over 27 years. I have worked with children and adults coping with both trauma wounds and ADHD. If you are an adult or a parent/carer reading this article/blog today and you or your child have experienced trauma and/or attachment wounds this is for you.

Complex Trauma (C-PTSD) or PTSD (Post Traumatic Stress Disorder) is a diagnosable condition, but there are factors to assess to see whether you meet the criteria. The American Psychiatric Association (APA) revised the diagnostic criteria for PTSD in the fifth edition of its Diagnostic and Statistical Manual of Mental Disorders (DSM-5) in 2013. The criteria for PTSD in the DSM-5 include:

Exposure to a traumatic event:
This can include directly experiencing the trauma, witnessing it, or learning that a close friend or relative was exposed to it. Examples include a persons experience of a traumatic car accident, being sexually or physically assaulted, hearing about a close loved ones traumatic experience, having grief or birth trauma, or experiencing childhood physical, sexual or emotional traumas.
Re-experiencing the event:
This can include recurrent memories, nightmares, dissociative reactions, or prolonged psychological distress, usually impacting several areas of their daily life.
Alterations in arousal:
This can include hypervigilance, sleep disturbances, or aggressive, reckless, or self-destructive behavior.
Avoidance:
This can include avoiding distressing memories, thoughts, or reminders of the event.
Negative alterations in cognition and mood:
This can include persistent negative beliefs, distorted blame, or trauma-related emotions.
Other symptoms:
This can include irritable behavior, angry outbursts, problems with concentration, or an exaggerated startle response. It is often difficult for educators to determine whether the child in school is disruptive due to trauma, having ADHD or another neurodevelopmental feature in their presentation or is oppositionally defiant. In my experience, it is best to have your child assessment by mental health and/or neurodevelopmental experts that can help your child manoeuvre the educational setting.

ADHD is a Neurobiological Developmental Disorder, meaning it’s related to the brain, runs in families, and impacts a child’s development and ability to learn. 1 in 20 children are diagnosed with ADHD at some point in their lives.
The main symptoms include impulsivity, hyperactivity, distractibility, poor concentration, racing thoughts and emotional reactivity. Interestingly, these symptoms can also be seen in chronic hyper-arousal after trauma.

Confusions around Trauma and ADHD

Below highlights the overlap between symptoms:

Why is there so much overlap?

In response to trauma, a child’s developing brain can become programmed to “look out” for behaviour, activities or events that they perceive as threatening. This “hyper-vigilance” can often mimic hyperactivity and distractibility associated with ADHD.
What may appear as inattention and “daydreaming” behaviour often seen in ADHD may be symptoms of dissociation or subconscious avoidance of trauma triggers. Often individuals in education or in the workplace can be impacted in attainment and achievement due to this common misunderstanding. It is only through employers or educators having knowledge about the individuals condition that the person can reach their potential. Often these individuals are highly intelligent, only to be pushed out of opportunities and education due to misunderstandings of their presentation.
Intrusive thoughts, memories or other reminders of trauma present in these individuals in sometimes only one emotion “anger”. This is the person’s only way of expressing a wide range of emotion including frustration, sadness, upset, distress, feeling unsafe, etc. There cognitive systems (due to where the trauma sits in their brains), are not working together as do in persons not suffering any traumas or neurodevelopmental concerns. Their trauma is often clinically stuck and not able to be processed.
Developmental studies of the human brain demonstrate that individuals suffering with these presentations result in having difficulties with emotional regulation, decision making, concentration, social processing, and memory.

Personally, I am also a mother whose child suffered trauma and has ADHD. He has familial links to ADHD through my side of the family. I also have ADHD. I struggled with giving my child “labels” when he was young and noticed my feelings of guilt for him having to suffer in this way. Although he had challenges as a young person, he has thrived later in life. Not all young people are so lucky, and many adults I treat are still not able to manage the remnants of having both ADHD and complex trauma. It is true that often parents will under-report trauma due to fear of blame, shame and guilt. Teachers, GP’s/doctors, and mental health or other clinicians do not always ask the right questions to fully understand the persons presentation. Complex trauma is misdiagnosed as ADHD due to the significant overlap between presentations, however it is very possible that the individual could have both. It is a known fact that children who experienced trauma and/or attachment wounds as child have more severe ADHD symptoms if they have this diagnosis.

Dr Samuele Cortese, psychiatrist, (Solent NHS, and Southampton University) is a leading expert on ADHD in children and adolescents. In a recent CAMHS study/article in acamh.org, he postulated about the high risk of suicidal ideation or attempts in this population:

There is a link amongst these behaviours in adolescents, up to one third of those with suicidal ideation have been found to go on to develop suicidal plans, and 33% of these make a suicidal attempt, and eventually it has been reported in the literature, according to this recent study, by colleagues, that 60% of those with a plan versus 20% of those without a plan make a suicidal attempt, and 60% of first attempts have been found to be planned.

So in terms of prevalence, clearly these figures highlight the clinical and the public health relevance of this topic. The cross-nation lifetime prevalence for suicidal ideation has been found to be around 9%, suicidal plans 9.2 and suicidal attempt 2.7. In terms of risk factors, of course there are several risk factors for suicidal behaviours which are related to several mental health conditions and other situations. However, if we look at the strongest evidence it turns out that mood disorder is really the main important risk factors, at least in developed countries. While interestingly in developing countries the risk factor with the highest, the strongest link with these behaviours has been found to be related to the presence of impulse and control disorders.

Is it a lost cause, what can be done?

If you suspect you have symptoms of PTSD and/or ADHD, seek help. There are many experienced practitioners that can help. If you are employed, there is likely to be a neurodiversity policy within the workplace, and seek out help through your EAP, or local leads in those areas.

If you are a parent/carer of a child who you think has been misdiagnosed with ADHD, when in fact you feel may be trauma or attachment based, trust your gut instincts and advocate for your child’s needs.

Children and adults with ADHD and/or complex trauma and attachment wounds need to feel a level of safety, control, consistency and routine can help them manage throughout the week. Young people need key people in their environments both at home and school who they feel understand and empathise with them. When people have these experiences, having too many choices can feel overwhelming, providing them with limited choices feels safer. Building skills such as resiliency and facing the fear/anxiety anyways to develop that resiliency is key. A parent may feel the need to “rescue” the young person at every stage, however, that does not help the young person develop their own skills. Conversely, if the young person was ignored or emotionally neglected this can make the individual feel unsafe and not held. It can feel like a balancing act, but you can do this.

What can be done?

ADHD:

Adjustments for learning in school, and the workplace. Examples include extensions on deadlines for work/projects, allowing one earphone in to have background soothing noise, having an exit card, or time out space, providing quiet areas for work outside of busy office or school spaces.
Parent Behaviour Management Strategies for children and adolescents
Joining a local parent/carer group for support and “top tips”.
Mindfulness strategies – recent research has contended that utilisation of a mindfulness approach to a person’s daily routine helps soothe the brain and body. This enables the person to become more aware of body sensations and integration between the two parts enabling more calm moments.
Stimulant Medication if recommended by a Developmental Paediatrician, or psychiatrist. Many adults living with ADHD, and parents/carers are reluctant to consider medication, however in my practice I have seen the benefits for certain individuals with high risk factors and moderate-severe presentations. In cases where I have seen a before and after picture, I have observed strong improvement in their activities of daily living across all environments.

Trauma:

Therapy with practitioners specialising in both neurodevelopmental and trauma informed practice is recommended. NICE guidance highlights both TF-CBT and EMDR for trauma and attachment wounds. I practice in EMDR and utilise mindfulness and hypnotherapy alongside the therapeutic approach to bring about change.
Sensory Regulation Activities. Some of my clients’ parents/carers, and themselves have come to realise the importance of sensory needs. These could include smelling their favourite fragrances, rubbing lotion over their bodies, having a picture of their favourite beach/holiday on their desk or in their rooms, mindfully eating their favourite food, having a weighted blanket on the sofa or in their bed, touching and playing with fluffy or tangible fidget items to bring stability.
Anti-anxiety medications where necessary, prescribed by a GP or psychiatrist.
Exercise routine that enables endorphins within the body to be released helping to manage balance and soothing to the whole system. This does not have to be at the gym, and I have found to enable the sensory benefit, that walking or running in the woods, on a beach, or somewhere that provides an engaging experience is the best.

In conclusion...

Individuals presenting with both ADHD and C-PTSD are at higher risks for suicide, long term health conditions such as diabetes, heart failure, COPD, cancer, etc. There are misconceptions in educational facilties, workplaces, and home environments that will be detrimental to the individual meeting their full potential in life. Often these individuals are misunderstood, resulting in feelings of abandonment, isolation, trouble with making and sustaining relationships, increased risks of suicide and substance misuse to self-medicate, and significant mental health complications later in life. However, one important last note is there is hope, and it is not a weakness to ask for help. If you know or are the individual with these issues, be an advocate, seek help and become more informed. Knowledge is power.