In South Carolina where I practice, over 11.1% of children are currently diagnosed with ADHD and 13.1% have received the diagnosis at some point. The rural area in which I practice is also fraught with poverty – families often struggle to meet basic needs, high school students are unable to find jobs, etcetera. We know that poverty is a risk factor for the development of ADHD, and the South has also seen some of the highest rises in prevalence. It is also no secret that children with ADHD are more difficult to parent, teach, and engage with. They may struggle to listen to authority figures, putting them at risk for higher rates of disruptive behavior disorders such as ODD and CD, diagnoses which are also becoming more prevalent with low-income children. These individuals are at higher risk for aggressive behavior as they become adults.
What about poverty increases this risk, and how might we view these diagnoses – which are based on external observation (i.e. behaviorism) in a different lens? Poverty is associated with numerous risk factors for poor development in the broad categories of abuse, neglect, and household dysfunction – the 3 types of Adverse Childhood Experiences. If you’ve not read the ACEs study by Kaiser Permanente, I urge you to. It will change how you view the importance of mental health. Many of the 10 items on the ACE questionnaire capture what we would often consider in trauma informed care to be “little t” trauma – things that won’t quite fit the DSM-5 definition of trauma, but feel life threatening to a child. Some of the items in the questionnaire, such as physical or sexual abuse and physical neglect, may very much fit as life threatening events. It is important to understand this link between poverty and increased rates of ADHD, ODD, and ACE scores because once we see this wider picture, we can see the bigger player here – childhood trauma.
Let’s consider the externalized behaviors associated with PTSD: Marked physiologic reactivity after exposure to trauma, dissociation, avoidance of external reminders, irritable or aggressive behavior, hypervigilance, exaggerated startle response, problems in concentration, and sleep disturbance. These symptoms are strikingly similar to those required for an ADHD diagnosis – a diagnosis which is often made by teacher and parent report of behavior. Take a moment, get out your DSM, and compare these two diagnoses. You’ll likely be surprised by what you find. Add irritability or aggressiveness to a caregiver or other authority figure, and you’re met with ODD.
So what does this mean for us as clinicians, or even teachers and caregivers? When a child is struggling to pay attention, or becomes defiant, embrace the spirit of trauma-informed care. Ask “What has happened?” instead of “What is wrong?”. Because what happened is - in my experience - more often than not, trauma and ACEs. Trauma changes how children attach to others. It may make them suspicious or disrespectful to authority figures because those or previous figures may not have protected a child like they should have. An authority figure may have been emotionally abusive or committed sexual assault. Trauma changes the brain by rewiring it to constantly be on guard – fidgety, uneasy. Trauma causes ‘spaciness’ as children dissociate to protect themselves from what they perceive to be dangerous.
By asking “What happened”, by providing trauma screenings, it’s my hope that you’ll be able to view your child, your student, or your client as more than a constellation of behaviors that are “hard to manage”. You’ll see them as a person – a person who is acting out of hurt, out of lack of care and emotional support.
ADHD Poverty/Regional Correlations:
ADHD & ODD Comorbidity:
Poverty and ACEs:
Ben Hearn is a new professional who is currently working as a school-based counselor. He is passionate about working with trauma and enjoys applying the fields of neuroscience, philosophy, ethics, and psychopharmacology to counseling practice.