Attention Deficit Hyperactivity Disorder (ADHD) is a very prevalent and common neurobehavioural disorder in children and adults. It is considered to be a developmental disorder and is recognised when children display inappropriate levels of hyperactivity, impulsivity, and inattention (American Psychiatric Association, 2013). It is now the leading diagnosed health condition for children in western countries and is now reported to have a worldwide prevalence of anywhere between 1% to 18% (Polanczyk, de Lima, Horta, Biederman and Rohde, 2007; Spitzer, Schrager, Imagawa and Vanderbilt, 2016). Whilst rates in Ireland tend to be lower, there is a feeling from some that numbers are on the increase (irishexaminer.com, 2013). For the purposes of this article, it is important to note that the rates of diagnosis for children within the child protection system are up to three times higher than that of the general population (Klein, Damiani‐Taraba, Koster, Campbell, and Scholz, 2015; McMillen et al., 2005; Sonuga-Barke, Daley, Thompson, Laver-Bradbury and Weeks 2015). As of yet, no study has been able to definitively establish why this is so. However, a number of theories have been put forward by researchers and clinicians (Howe, 2010; Panzer and Viljoen, 2003; Tarver, Daley and Sayal, 2014; Thapar, Langley, Asherson and Gill, 2007), which include ideas that the behaviours perceived by professionals to be ADHD could be something else entirely.
The following literature review was undertaken to explore the link between certain childhood adversities and the misdiagnosis of ADHD in children within child protection systems. It was conducted using an extensive search and data analysis of literature and data (using Google Scholar, ResearchGate, Academic Internet Journals and Kent University Library Systems?) which relates to ADHD behaviours and brain development, child protection and the effects of childhood trauma and adversity.
ADHD and misdiagnosis
As we start to discover more about the presenting behaviours and after effects of childhood adversity and experienced traumas, a plethora of evidence is beginning to emerge which supports the view that both ADHD and certain experienced traumas will present an overlap in symptomatology. For example, those children who have experienced childhood neglect or emotional abuse can often display similar sets of behaviours and cognitive deficits that are also associated with ADHD. This makes it very possible for a child to be misdiagnosed as both conditions have the potential to mimic one another in their presentations (Haber, 2003; Handler and DuPaul, 2005:).
Brain studies on ADHD and childhood trauma
In child protection cases where emotional neglect, early deprivation and relational trauma has been identified, these children have been reported to experience other mental health disorders such as anxiety, depression, and difficulties with sleep (Ouyang, Fang, Mercy, Perou and Grosse, 2008). Recent research has found that the same list of mental health disorders can also co-occur alongside ADHD (Verkuijl, Perkins and Fazel, 2015). Indeed, when we compare certain brain development studies for both ADHD and child maltreatment, the results appear to show significant similarities in the areas of the brain that are affected by both ADHD and childhood trauma (De Brito et al., 2013; Kelly et al., 2013). These brain areas are responsible for emotional regulation, decision making, sequential and/or semantic memory and social and emotional processing (Nakamura et al., 2001; Onitsuka et al., 2004; Snowden, Thompson and Neary, 2004). Furthermore, Perry (2006) states that certain types of maltreatment can have a negative effect on a child’s ability to maintain concentration and attention, process sensory information and manage emotions. When such behavioural traits are also reported to be associated with ADHD, it is clear to see why a crossover in the diagnosis of the two conditions exists, especially when we directly compare the observed behaviours and cognitive functioning in these individuals. Short attention spans and lapses in concentration can be present at all times, but are likely to be noticed more in an environment where a child has to concentrate and sit for long periods or be around large groups of people where the behaviour of others can be misinterpreted.
Trauma and hypervigilance
D’Andrea et al (2012) support Perry’s earlier view and adds that the after effects of certain childhood traumas can greatly affect the attention span and executive functioning of an individual (Perry, 1995; 2000; 2006). If a child has been witness to sporadic bouts of violence and excessive levels of shouting and aggression, a child’s brain will ‘hardwire’ itself to remain in a constant state of alert. Due to the unpredictable nature of these events, a child is unable to predict when the next event is likely to occur and therefore, their only way to protect themselves is to remain alert and hypervigilant.
Hypervigilance is a common after effect of certain childhood traumas that will affect a person’s ability to process, retain and recall information (De Bellis and Zisk, 2014). A person who is hypervigilant may appear to be on edge in the general sense, but if a child is showing hypervigilance in a classroom, they may instead appear to others as fidgety and distracted. If a child’s brain unconsciously tells them that they must scan their environment for potential threats and dangers at all times, it can make it difficult for them to give their full and undivided attention to a task in hand. Furthermore, if a teacher tries to gain their attention by shouting at them, the child may also unconsciously interpret the body language, facial expressions and movements of teachers and other students to be threatening, especially if they are caught off guard. It is then easy to see how a child in this situation can end up being referred to by professionals as defiant, disruptive and in some cases, unpredictable. This can often trigger an investigation into ADHD instead of considering the possibility that a child has been maltreated. This begs the question as to whether or not the diagnostic pathway is fit for purpose when we are dealing with children who are involved in the child protection system.
Developmental trauma disorder
The Diagnostic and Statistical Manual of Mental Disorders (DSM) is published by the American Psychiatric Association and is currently the leading manual used by clinicians. Van der Kolk et al (2009) suggested that there is a real need for a reclassification in diagnoses for children who have been maltreated due to the considerable overlap in the presenting symptoms of ADHD and experienced ‘interpersonal trauma’. Interpersonal or ‘Relational’ Trauma is a term used to describe an event that a person experiences and/or is witness to whereby they become personally traumatised by doing so. Such experiences can include (but are not limited to) domestic violence, physical, verbal and sexual abuse, neglect, the sudden loss or the feeling of abandonment and substance abuse. In a survey involving 1699 children, they found that many children who had experienced interpersonal traumas were ending up with a diagnosis of ADHD, as no clinical diagnosis existed which could successfully capture the true clinical presentations of these children. Van der Kolk and his team shared their findings with the group work advisers for the DSM and made a proposal to include a ‘Developmental Trauma Disorder’ (DTD) diagnosis for children and adolescents in their 5th edition of the manual. In the proposal, he stated that the current terms for ‘hyperactivity’ and ‘attentional’ problems were too generalised. Reference was also made to an increased likelihood that a child who has been through some form of interpersonal trauma will instead be diagnosed with ADHD. Van der Kolk’s proposal for the inclusion of DTD was unfortunately rejected by the group. Instead, we saw the newest publication of the manual in 2013 (DSM-5) widen its criteria to meet a diagnosis for ADHD. Therefore, it is now possible for mild and moderate presentations of ADHD behaviours to be eligible for a diagnosis. This raises concerns in the field of child protection and many worry that there is now a heightened risk of misdiagnosis. It means that many young people who are experiencing adversity could slip through the net (Van der Kolk et al, 2009).
The diagnostic pathway
At present, clinicians seem to be in command of the diagnostic process for ADHD, when in some cases, they may not be in the best position to establish the cause of the presenting behaviours. Making a diagnosis of ADHD in the UK and Ireland relies on large pieces of subjective information. This is collected via parent/teacher feedback on observed difficult behaviours (that can greatly be influenced by personal feelings), and screening tools (Conors, Sitarenois, Parker and Epstein, 1998; Goodman, 1997). Behavioural observations tend to happen in a clinical setting and not in the family home. In a scenario where a child has been maltreated, clinicians should pay careful attention to the direct observation of ongoing family dynamics and the relationships that the child has in their lives in order to rule out the presence of an experienced or ongoing trauma. It is therefore unfortunate that current clinical practice does not allow the time nor the flexibility to directly observe family interactions in the home environment. This could create an argument for child protection professionals to become more involved in the ADHD screening processes. At present, they are rarely asked to contribute their feedback or personal observations on family functioning and relationships, yet the identification of ADHD and childhood adversity is largely reliant on a professional’s skilful ability to gain a truthful and accurate picture of what life is like for the child in question.
Implications and conclusion
When substantial evidence suggests that the after effects of childhood trauma and ADHD has the potential to display similar difficulties in behaviours and cognitive shortfalls, why is more
not being done to raise the awareness of this in the field of child protection and education? To receive a diagnosis of ADHD can be a life changing event for a child and their entire family, but if a misdiagnosis occurs, there could be catastrophic consequences. The most popular concern lies in the notion that a child’s physical health is being put at risk whenever they are wrongfully diagnosed with ADHD and given medication when they do not need it. This is indeed concerning, but perhaps what is even more shattering to imagine is the idea that no amount of medication is going to heal any previous trauma that the child may have been through. To miss a case of past or ongoing child maltreatment in favour of a wrongful ADHD diagnosis will affect the way an individual relates to the people around them and could create a higher risk for the child to develop further psychiatric difficulties in the future (McMillen et al, 2005). With so much at stake for the children and families involved in the diagnostic process, it is important that practitioners are able to distinguish between the two presenting conditions. Therefore, it is imperative that both areas are treated with an equal interest and are studied side by side.
In order to move away from what Thomas, Mitchell and Batstra (2013) refer to as the ‘clinical subjectivity’ of ADHD diagnosis, the knowledge base for professionals needs to improve. In cases where a diagnosis of ADHD is sought for a child who comes from a family where intergenerational traumas exist, practitioners should have the confidence to question the diagnostic pathway and suggest alternative investigative routes when trying to establish a cause for the challenging behaviours. This way, practitioners could then start to look at the presenting symptoms of a young person in the child protection system through an objective lens and ensure that better outcomes are achieved in the future.