What if it's not ADHD?

“A correct diagnosis is three fourths the remedy.” (Mahatma Gandhi)

It turns out that trauma is sometimes misdiagnosed as ADHD.

Me, every time I learn yet another shocking fact about trauma.

Quick disclaimer before we dive in: this article might elicit strong reactions among people diagnosed with, or suspected of, trauma and/or ADHD and their allies. I’ve done my best to review, understand and summarise the still-developing science on these two conditions as it stands today - if you want to add to the picture do so in the comments. For me the risk of exploring the intricacies of ADHD and trauma is one worth taking. I became aware of the confusion between the two in a conversation with another trauma survivor. Misdiagnosis costs time, money, opportunities and self-esteem, and survivors have little to spare.

How are trauma and ADHD similar?

Inattention, impulsivity and hyperactivity (especially in children) are traditionally seen as the hallmarks of ADHD. When you think about it though, we often see the same manifestations in trauma survivors albeit we describe them using different language:

• Dissociation - a popular trauma coping strategy - is at its core an attention diversion mechanism, a disconnect from here and now;

• Emotional dysregulation - a key consequence of trauma - often translates into an irresistible urge to take instant action aimed at changing the emotional state at the expense of delayed and strategic, rational behaviour;

• The anxious restlessness and constant scanning for danger that trauma survivors typically exhibit can easily be interpreted as stand-alone hyperarousal or fidgetiness.

There is growing consensus that ADHD goes beyond the holy trinity of inattention, impulsivity and hyperactivity. Particularly in adults ADHD can present as working memory and executive function deficits (forgetfulness, losing items, not being able to prioritise and focus, lack of attention to detail, starting many things and finalising few etc.), mood swings, impatience and irritability. Again, upon close inspection all these could be explained through the neurological changes and emotional reactivity and dysregulation resulting from trauma.

Both ADHD and trauma often run in the family. Having a parent with either of these conditions increases the likelihood that the next generation will have it too, though the mechanism underpinning the inheritability of each is likely distinct and involving complex interactions between genetic profile and environment.

How are Trauma and ADHD different?

The fundamental difference lies in the root cause of the symptomatic behaviours.

ADHD is presumed to be caused by a combination of genetics, brain structure and function (e.g. distinct frontal lobe activity, lower levels of dopamine, frequent activation of the default mode network etc.) and is viewed as a form of neurodiversity. Environmental factors such as complications at birth, nutrition, toxins, stress or trauma can influence gene expression and exacerbate ADHD symptoms but they’re not a pre-requisite. You can live a healthy, adversity-free life and still have ADHD. There is no cure for ADHD, but symptoms can be managed through medication, counselling, and adoption of appropriate life skills and strategies.

Trauma originates in overwhelming negative experiences that change the way the brain and one’s internal world operate. Some people may be more vulnerable than others, but an external traumatic event (or events) is always present. Trauma is also marked by a perceived sense that one is no longer safe in the world, which is not the case with ADHD.

Trauma survivors can make a full(ish) recovery and rewire their brain through specific interventions such as somatic experiencing, neurofeedback, EMDR and MDMA-assisted therapy. While some symptoms can be managed through long-term medication this is no longer viewed as the gold standard in the treatment of trauma.

Why is misdiagnosis happening?

Trauma and complex PTSD remain rather niche expertise areas, and most GPs, therapists and special educational needs professionals lack an in-depth understanding of its causes, manifestations and treatment options. The more we talk about trauma the more people may be persuaded to explore the topic in depth, understand the nuances and be able to correctly spot it in themselves and others.

Some frontline health and education specialists are reluctant to ask questions that explore the possibility of adverse childhood experiences and trauma. They may feel unprepared to do this competently, or worry about upsetting the person they are dealing with or their family.

ADHD is also a more palatable diagnosis than trauma to take away for the person being assessed. ADHD is no one’s fault, but trauma is. ADHD shifts the focus on the future, trauma turns you to the past. Accepting you’ve experienced trauma is often the beginning of a painful journey of reexamining history, reassessing yourself, and redefining key relationships.

In conclusion, are ADHD and trauma two separate things?

The honest answer seems to be, we don’t know yet.

A person can have ADHD, a history of trauma and a whole range of post-traumatic symptoms, or both. There’s a significant overlap between trauma and ADHD symptoms and not enough awareness, which makes differential diagnosis difficult.

This meta-analysis found that there is a bidirectional relationship between trauma and ADHD, meaning if you’ve experienced trauma you’re more likely to have ADHD and vice-versa. We’re still learning about how these two conditions interact, and what may be some of the common neurological mechanisms involved.

What does this mean in practice?

If you suspect you have ADHD or have been recommended an assessment make sure you’re seeing someone who takes a wholistic view of your current and past circumstances, and who has a good understanding of how ADHD might overlap, interact, or otherwise relate with other conditions. The same goes if you’ve been diagnosed with ADHD but something feels off and medication or therapy are not doing the job you were promised.

Where can I learn more?

I’ve come across a lot of great content while researching this piece. Here are some links in case you want to go down the rabbit hole:

Can PTSD be mistaken for ADHD?

ADHD and Trauma in Children: Overview, Signs, Treatment

Is It ADHD or Child Traumatic Stress? A Guide For Clinicians

As always, thank you for tuning in and I look forward to your reactions.

Adina