ADHD or Trauma Response

Shirley Katz, Ph.D., RP, CCC
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Differentiating ADHD from Trauma
ADHD diagnoses and requests for assessment have significantly increased in recent years. Research suggests that the trend is a result of increased awareness, reduced stigma, and better diagnostic practices, rather than a rise of ADHD.  For example, ADHD in women and girls can look different, and in the past may have been overlooked but now are increasingly identified.  Currently, statistics indicate that about 6% of adults have a current ADHD diagnosis and about half were diagnosed as adults.  Actual incidence has not increased.
It is noteworthy that ADHD and trauma response can look similar. Shared symptoms like distractibility or inattention, restlessness and fidgeting, emotional dysregulation make diagnosis and treatment complex.  Treatment for ADHD and treatment for Post Traumatic Stress response are different, though both can look similar and have negative impacts on work, school and relationships.
Key Distinctions
ADHD is a neurodevelopmental disorder with symptoms usually beginning in childhood with persistent difficulties in functioning are seen across settings.  Challenges are seen in self-regulation, working memory, and organization.  Hyperactivity, if present, is chronic and not linked to anxiety or perceived threat.  Recent research also elaborates on adult ADHD symptoms to include feelings of mental hyperactivity or a sense of restlessness without obvious physical hyperactivity.   In the case of trauma response, symptoms emerge after a traumatic event, or chronic adverse experiences.  Difficulties focusing or attending and staying on task are a result of being hypervigilant and constantly monitoring for threat.  Being ‘hyper’ looks more like anxiety or being on edge.  Symptoms can fluctuate depending on exposure to triggers or reminders of trauma. ADHD and PTSD can co-occur.
Assessment Considerations
When clinicians who diagnose want to differentiate, they explore if the symptoms are more suggestive of trauma.  For example, do they include intrusive memories or flashbacks, avoidance of trauma reminders, emotional numbing or dissociation experiences?  Is there an exaggerated startle response?  Are the symptoms tied to a specific traumatic experience or experiences?  Are symptoms worse with reminders of the traumatic experience? Do the symptoms show consistency across settings and over time?
Identifying Trauma
Trauma can mimic ADHD and contribute to misdiagnosis.  Accurate diagnosis helps with treatment, and should include a developmental history, trauma assessment, and evaluation of the context and timing of symptoms.  If someone has already been diagnosed, a psychotherapist can help with the treatment plan.  Sometimes, related to the amount of time therapists spend getting to know clients, they can recognize when a person needs a diagnosis and when there has been one or multiple traumas.
Some people do not recognize their experiences as traumatic. 
There are many experiences that impact mental wellness and some of them can be normalized by the context or social environment a person is living in. There is no real consensus about shared trauma.  Sometimes a good therapist can identify experiences and their impact and help a client get the treatment they need.  For example, scholars have begun to discuss how the COVID-19 pandemic and associated lockdowns/quarantines impacted people as a form of collective trauma.   Shared or collective trauma events are those that are experienced by groups or societies at the same time, which disrupted shared assumptions about safety and predictability, and impacted social connection. Researchers have argued that COVID-19 fits this description as it involved uncertainty, prolonged stress, grief, social isolation and widespread threat of illness and death as well as economic disruption.  Some scholars note that the lockdowns increased anxiety, depression, sleep disturbance loneliness, grief and loss, stress symptoms, disruptions to routines, identity, and belonging.  This was worse for those with prior traumas, or people who experienced severe isolation, significant loss, violence at home, etc. Many people with obsessive-compulsive symptoms got worse during and after the COVID-19 pandemic and some people began to experience OCD at that time.  For some people, the impact of the pandemic persisted.  If symptoms that look like ADHD only emerged after lockdowns, it may be worthwhile to explore if the stress of the pandemic had a long-term impact.  Not everyone was impacted the same way.  Some were resilient, adaptive and learned coping strategies, some were negatively impacted in ways that might persist.  A person does not have to meet the clinical threshold for PTSD to be helped with distress or symptoms that result from these experiences.
 Treatment Differences
In ADHD treatment, the therapist may act as a type of coach, teacher or skills trainer to help with client self management.  After getting to know the client and developing rapport and trust, they may help clients to develop compensatory strategies for executive function issues (time management, organization, task initiating).  They may use CBT, Behavioral strategies or psychoeducation to improve day-to-day functioning and reduce impairment.  Treatment is usually focused on the present and future, focused on adapting to a condition rather than processing the past. In trauma treatment, the focus is on safety.  The role of the therapist may be more on meaning-making, challenging unhelpful beliefs about the experience, facilitating emotional processing and improving coping with stress – focused on recovery from the psychological and physiological impact of the traumatic experiences.  It may involve understanding how the past continues to shape present patterns.  Initial stages would include stabilization, then processing and integration rather than moving into skill acquisition.   Importantly, people with symptoms of PTSD can respond variably to ADHD medications. Stimulant medication may improve attention and executive functioning in those with co-occurring ADHD, but can also exacerbate anxiety, hypervigilance, and sleep disturbance.   This is more complicated when these issues co-occur. 
A Registered Psychotherapist can help a client identify what kinds of symptoms they are experiencing, and understand whether they have always been there, or emerged after an experience, either personal or shared, one time or chronic.  While a Registered Psychotherapist does not diagnose mental disorders the way a Psychologist or Medical practitioner does. However, a core competency is to be able to understand, recognize, assess and work with diagnostic formulations and symptom presentations as part of conceptualization issues, treatment planning and progress monitoring.  If you are dealing with symptoms of distress, whether from an identified experience or not, it can be worthwhile to discuss your experience and your wellness goals with a trusted therapist who may, as part of treatment, may suggest seeking out a differential diagnosis or refer you to an appropriate resource.  Reach out and ask for a consultation if needed.
 
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