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Editorial: Could misdiagnosis partly explain the rapid rise in ADHD?

Attention Alert Means Observation Warning And Safety

More and more children are being diagnosed with attention deficit hyperactivity disorder. Between 2001 to 2011, prescriptions for the treatment of ADHD increased by 72.9%. ADHD is a heritable brain disorder characterised by either inattention, hyperactivity or both. The most comprehensive review to date, estimates that around 5% of children and adolescents have ADHD.

This rapid increase in prescriptions has sparked significant debate about whether the disorder is being overdiagnosed.

Critics argue that the increase is due to a range of factors. They say a gradual broadening of the diagnostic criterion has devalued the diagnosis for those with serious problems, and they blame aggressive marketing by drug companies, hasty medical evaluations, and school teachers under pressure to produce high performing students.

Others believe that the increasing number of children being diagnosed and medicated is largely due to better detection methods. They argue that while there are risks of over diagnosis, under diagnosis is similarly problematic.

But there is another possible cause for the rapid rise of ADHD prescriptions which is rarely discussed, and that’s the idea that some of these kids diagnosed with ADHD are really suffering from post traumatic stress disorder (PTSD).

ADHD shares many of the same features of PTSD. Young people who have experienced toxic stress associated with adverse events frequently display hyper-vigilence and dissociation, which can be mistaken for the inattention typical in ADHD patients. Equally, PTSD symptoms such as risk-taking and behaviour dysregulation can look like the hyperactivity and impulsivity we see in ADHD.

Research into ADHD has found that it is more common in children who have experienced childhood trauma than those who have not (see this review paper by Banerjee and colleagues, and the results of a recent large study presented by Associate Professor Nicole Brown at the annual meeting of the Pediatric Academic Society). Studies by Szymanski and colleagues and McLeer and colleagues have also reported that children who experience childhood trauma are more commonly diagnosed with ADHD than PTSD.

Although ADHD is more common in children who have experienced trauma, there is no convincing evidence that the trauma itself has a causal role in the emergence of ADHD.  One factor that may partly explain this association between ADHD and child adversity is that the parents of children with ADHD are found to be at a higher risk of relationship instability, economic hardship, and parental psychiatric illness. Children who have ADHD and have a parent or parents with ADHD may be at particular risk of adversity. Research shows that compared to other parents, parents with ADHD report that they are less consistent in their parenting, are more likely to overreact, tend to monitor their children less and have fewer family routines.

Alternatively, given the numerous overlapping symptoms between the two disorders, it’s possible that a significant proportion of children who have experienced trauma and have been diagnosed with ADHD may be more accurately diagnosed as either having PTSD or both conditions.

If PTSD is being misdiagnosed as ADHD, there are significant implications. Children may be taking psycho-stimulant medication that is of no benefit. In children with features of both disorders, stimulant medication and behavioural interventions alone are unlikely to be effective, leaving the child, parents and clinician feeling helpless.

Part of the problem is that some clinicians rely too heavily on ADHD rating scales that only provide a picture of an individual’s behaviours.  While rating scales assess behavioural symptoms and their level of severity, they do not explain why a child may be presenting with these features.

This limitation highlights the need for practitioners such as psychologists and psychiatrists to screen for trauma exposure when assessing for ADHD. This is a challenging and time-consuming task. Clinicians need to develop trusting and respectful relationships with parents before asking about highly sensitive themes that are often layered with feelings of fear, guilt and shame.

If ADHD is to be accurately diagnosed and treated, we need to be more aware of the overlapping features of ADHD and PTSD. Clinicians need to move beyond hasty evaluations and dependence on rating scales by taking a respectful and curious approach to children’s early life experiences.


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