THE ROLE OF TRAUMA IN ADHD AND SUBSTANCE ABUSE AMONGST CHLDREN AND ADOLESCENTS Debra Kaminer Department of Psychology / Child Guidance Clinic University of Cape Town

COULD PSYCHOLOGICAL TRAUMA BE THE COMMON PATHWAY FOR ADHD AND SUBSTANCE ABUSE AMONG A SUB-GROUP OF CHILDREN AND ADOLESCENTS WITH THE DUAL DIAGNOSIS? SOME CASES OF ADHD MAY BE MIS-DIAGNOSED POSTTRAUMATIC STRESS DISORDER (PTSD) LEFT UNTREATED, THE TRAUMATIC STRESS THEN RESULTS IN A SUBSTANCE ABUSE DISORDER

THE RELATIONSHIP BETWEEN ADHD AND TRAUMA Children with trauma histories are more likely to be diagnosed with ADHD than children without trauma histories Fumularo et al. (1996): 35% of maltreated children met criteria for ADHD (vs. 3-5% of general population) Weinstein et al. (2000): 25% of sexually abused children met criteria for ADHD (vs. 3% of non-abused children) Merry & Andrews (1994): children who had sexual abuse histories had double the rate of ADHD than children in a community sample

THE RELATIONSHIP BETWEEN ADHD AND TRAUMA High rates of comorbidity between ADHD and PTSD 23% - 37% of children with PTSD also meet criteria for ADHD, with higher comorbidity rates amongst sexually abused children (Famularo et al., 2996; McLeer et al., 1994) Husain et al. (2008): 66% of war-traumatised children with clinically significant attention problems also met criteria for PTSD

POSSIBLE EXPLANATIONS FOR RELATIONSHIP BETWEEN TRAUMA / PTSD AND ADHD ADHD and PTSD share a common vulnerability (e.g. dysregulation of noradregernic system implicated in both disorders) ADHD may be a risk factor for trauma exposure Trauma exposure may act as a catalyst for ADHD or move the child from a pre-existing subclinical syndrome to disorder Traumatic events may reduce caregiver coping which may in turn result in an increase in adult reporting of children’s behaviour dysregulation (while families who have not experienced trauma may be less likely to report children’s behavioural dysregulation)

POSSIBLE EXPLANATIONS FOR RELATIONSHIP BETWEEN TRAUMA / PTSD AND ADHD Symptoms of PTSD mimic ADHD and are therefore misdiagnosed as ADHD (Cuffe et al., 1994; Weinstein et al., 2000; Wozniak et al., 1999) PTSD includes: Intrusive symptoms (memories, nightmares, flashbacks of traumatic event) Avoidance symptoms (avoiding reminders of the trauma) Hyperarousal symptoms: Poor concentrationMay resemble an Exaggerated startle responseADHD-like Irritabilitysyndrome involving Sleep difficultieshyperactivity, Hypervigilanceinattention and impulsivity

POSSIBLE EXPLANATIONS FOR RELATIONSHIP BETWEEN TRAUMA / PTSD AND ADHD Complex Post Traumatic Stress (Courtois & Ford, 2009) or Developmental Trauma Disorder (van der Kolk, 1995) Result of prolonged child abuse by a close attachment figure Symptoms of inattention, distractibility, poor planning, impulsivity Both PTSD and complex traumatic stress are characterised by chronic biological, emotional and behavioural hyperarousal and an inability to self- regulate this hyperarousal

POSSIBLE EXPLANATIONS FOR RELATIONSHIP BETWEEN TRAUMA / PTSD AND ADHD If trauma history is not specifically explored in clinical interview, it is possible to mis-diagnose PTSD as ADHD, or to miss the trauma-based etiology of clinically significant attentional, hyperactivity and impulsivity problems Treatment may therefore not be trauma-focused, resulting in poor treatment outcomes, chronic hyperarousal and, in the longer term, attempts to ‘self-medicate’ or ‘self-soothe’ through substance use

TRAUMA AND SUBSTANCE ABUSE High comorbidity between PTSD and substance abuse disorders in adult trauma survivors: 52% of men with PTSD have an alcohol use disorder, and 35% a drug use disorder 28% of women with PTSd have an alcohol use disorder and 27% have a drug use disorder Similarly, children exposed to trauma (especially abuse and maltreatment) are at higher risk than non-traumatised children for developing alcohol and drug use disorders in late childhood and adolescence (Clark et al., 1997; Giaconia et al., 1995)

TRAUMA AS ONE POSSIBLE PATHWAY TO ADHD AND SUBSTANCE ABUSE COMORBIDITY? TRAUMA EXPOSURE PTSD OR COMPLEX TRAUMATIC STRESS THAT MIMICS ADHD TRAUMA REMAINS UNTREATED SUBSTANCE ABUSE