ADHD or Early Interpersonal Trauma?

Attention-deficit/hyperactivity disorder (ADHD) has been a controversial diagnosis that began to steadily increase during the 1990’s. Since then, the numbers of children diagnosed with ADHD has risen to alarming numbers. According to the Centers for Disease Control, in 2016 a total of 6.1 million children between the ages of 2 and 17 were diagnosed with ADHD in the USA. Further, a recent study found that between 2003 and 2011, 2 million additional children were diagnosed with ADHD with 69% of these children currently taking medication (Visser et al., 2014).

The diagnosis of ADHD is often prompted by parent and teacher reports of the child’s behavior. A pediatrician, psychologist, or psychiatrist with expertise in ADHD then determine whether a child should be diagnosed with ADHD and subsequently medicated. Many psychologists and researchers have voiced their concerns over the widespread use of medication in children as young as four years old.
Moreover, nearly 2 out of 3 children with ADHD have a concurrent disorder with the highest being behavioral or conduct problems 52%, followed by anxiety 33%, depression 17%, autism spectrum 14%, or Tourette syndrome 1% (Danielson, Bitsko, Ghandour, Holbrook, Kogan & Blumberg, 2018).

The Impact of Early Relationships on Attention and Behavior in Children

We know that a secure relationship with a supportive caregiver sets the stage for optimal social, emotional and cognitive development. Secure children learn they are safe to explore their environment and at the same time, they are protected from elevated levels of stress through constant contact and support from their caregiver (Crittenden, 1988).

Children in secure relationships learn to rely on their thoughts and emotions to interpret an experience. They learn to integrate thinking and emotions and are able to use both thoughts and feelings to determine their reactions to any situation. In this way the early attachment relationship sets the stage for the development of information processing (Crittenden, 1988).

The positive outcomes of a secure relationship in infancy and childhood provide children with a set of competencies and skills that children with ADHD are lacking (Kissgen & Franke, 2016). Some psychologists are calling for a closer look at early traumatic relationships as a possible cause for ADHD symptoms (Dallos, Denman, Stedmon, & Smart, 2012). It may be that early trauma is being misunderstood by health professionals and children are being medicated for a disorder they do not have.

Chronic and repeated early childhood trauma sets the stage for a multitude of challenges that can impact a child’s development biologically, emotionally and cognitively. Early trauma expresses itself not just internally. Many traumatized children act out behaviorally. They may suffer from learning disabilities due to an inability to concentrate in school. It is important to understand that attention problems and aggression against self or others often manifest in children growing up in violent or neglectful households (Streeck-Fisher & van der Kolk, 2000).

The Need for An Accurate Diagnosis

Early trauma may look like ADHD. A child who has been exposed to ongoing traumatic relationships will behave differently than his or her peers in the classroom. Traumatized children may have difficulty concentrating, they may have learned aggressive behaviors at home and are unable to develop friendships at school. The high rates of concurrent emotional and behavioral disorders and ADHD strongly suggests these children are likely in need of therapy rather than powerful stimulant medications.
Before diagnosing a child with ADHD, it is important to look at the child’s early relationship history and investigate the possibility of other issues that may be going on at home or in the child’s past. Efforts should be made to rule out trauma before a prescription is written. If these steps are not taken, we are missing out on the opportunity to help our most vulnerable members of society.


Fabiana Franco, PhD

Fabiana Franco, PhD, is a clinical psychologist and former clinical professor at The George Washington University. She is president of the Trauma SIG of NY State Psychological Association and co-chair of the Intergenerational Transmission of Trauma and Resilience SIG at ISTSS.
National Register Credentialed since 2010