Monday, April 10, 2017

Clinical and Research: What social workers need to know about ADHD, trauma and neglect

What social workers need to know about ADHD, trauma and neglect

Social workers need more understanding of how trauma impacts behaviour to help prevent maltreated children being misdiagnosed with ADHD, says Laura Hanbury

By Laura Hanbury, researcher and former local authority ADHD lead

Children in the child protection system are three times more likely to have a diagnosis of attention deficit hyperactivity disorder (ADHD) than the general population. Why is this the case? It’s possible that children with ADHD are more vulnerable to parental abuse and neglect because of their challenging behaviour and the socioeconomic backgrounds most commonly associated with ADHD.
However it’s been recognised for a number of years that the behaviours we associate with ADHD, such as inattention and difficulty regulating emotions, are very similar to those typically exhibited by young people who have experienced chronic stress and maltreatment.
Trauma can affect the parts of a child’s brain that are responsible for things like memory retention, social and emotional processing and decision making so it’s clear how differentiating between the causes of such behaviours can be difficult and researchers have cautioned that misdiagnosis or over diagnosis of ADHD is very possible.
So I was struck to see that, although there are plenty of studies and statistics that tell us diagnosis of ADHD is on the rise, I could find little research specifically related to the potential overlap of symptoms of ADHD and childhood adversity when I recently carried out a rigorous literature review of both topics.
A high number of the referrals I recieved as a local authority lead on ADHD also left me feeling that something is not quite right – my work with many children with ADHD and their families showed that some form of relational trauma and/or ‘bonding break’ had occurred in their life.

Widened criteria

Social workers won’t be surprised to hear that research confirms large and growing numbers of children are being diagnosed with ADHD. But not all may be aware that the latest version of the tool their colleagues in CAMHs use to make diagnoses – the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published in 2013 – widened the criteria. Mild and moderate presentations can now be diagnosed as ADHD, when the behaviours could be the result of something else entirely.
This creates the risk that because a clinical diagnosis is in place, social workers may – perhaps unconsciously – assume that ADHD is the reason for a child’s difficult temperament or parent’s angry outbursts and feel reassured that they don’t have to look more closely at what’s going on in the family. Indicators of neglect and abuse might then be missed.
To me, this seems the wrong way around and potentially dangerous.Social workers who observe children and their families at home and build relationships with them could be best placed to advise clinicians on what they think is the cause of a child’s difficult behaviours.
I know from my role that when I paid more attention to the observation of family dynamics and relationship building when supporting the family, the trust created seemed to make them more comfortable to share their past stories with me.
It concerns me that a diagnosis of ADHD can be made by clinicians without input from other professionals who may be working the family and without needing to investigate a parent’s own childhood experience and mental health history.

Confident to question

So if a child appears hyperactive and inattentive, social workers should feel confident enough to question whether these behaviours could be associated with hypervigilance or dissociation – signs of trauma – instead of ADHD, especially if our services are involved.
For example, a ‘hyperactive’, defiant, disruptive or unpredictable child might actually be in a constant state of ‘alert’ (hypervigilance) as they are always looking to protect themselves from potential dangers or threatening behaviours from others. Perhaps they have witnessed domestic violence from a young age, live with a parent with significant mental health problems, or a parent appears to them as emotionally inconsistent for other reasons. They live in environment that is sporadically scary and unpredictable.
Such a child is likely to unconsciously interpret the body language, facial expressions and movements of teachers and fellow pupils, for example, as potentially threatening – especially if they are caught off guard.
It’s easy to see how the ‘disruptive’ behaviour that follows could lead to an ADHD diagnosis and medication rather than the appropriate social work support and intervention for the family.
Similarly, hypervigilance affects our ability to process, retain and recall information. If your brain has had to wire itself to be alert at all times, it’s difficult to give your full and undivided attention to the task at hand.
We can all relate to this when we experience short bouts of stress and anxiety, but imagine having learnt very early to continually scan your environment for dangers and threats before you could fully relax and concentrate on anything. Or not being able to relate to others in a way which allows you to trust and read social signals. Or being unable to fall asleep at night as your mind struggles to make you feel safe.
These behaviours – lacking focus, being fidgety, trouble sleeping and so on – can also too quickly be assumed to be ADHD.

Joint working

The relationship between childhood adversity and ADHD is complex; they could co-exist and social workers need in-depth knowledge of both, and how to best work with children exhibiting these behaviours and their families. And there is still a long way to go in researchers’ understanding of ADHD as a condition.
But what’s clear is that a clinician simply giving a diagnosis of ADHD without considering the views and thoughts of social workers may end up doing nothing more than relieving professionals, parents and carers of having to deal with the root causes of a child’s complex behaviour patterns.
We hear much about improving joint working and information sharing between CAMHS and social care; I would argue that the potential for overlap between ADHD and trauma is a significant reason to develop our working relationships and training and knowledge of these areas.

If you are interested in this research and want to read a copy of the author’s dissertation ‘Could the diagnosis of Attention Deficit Hyperactivity Disorder (ADHD) be considered as an indicator of childhood trauma for child protection professionals?’, please contact

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