This report is Part 2 of a special Psycom Pro series on the external factors that affect ADHD diagnoses and treatment outcomes. Part 1 explores how race and culture can impact acceptance of an ADHD diagnosis.

Making an ADHD diagnosis – and then managing it – is complicated due to the disorder’s multidimensional attributes.1 Research indicates those with ADHD have high rates of co-occurring disorders, including:

  • Oppositional Defiant Disorder (ODD)
  • Disruptive Mood Dysregulation Disorder (DMDD)
  • Conduct Disorder (CD)
  • Learning disabilities
  • Other mental health conditions such as depression and anxiety disorders.2,3

(Editor’s Note: The prevalence of these comorbidities can be found in our data slideshow. )

Add to this the collective effects of bio-socio environmental factors, and the charge of issuing an accurate diagnosis and effective treatment can be impeded. Yet, getting it right is crucial to patients’ long-term quality of life and function as neurodevelopmental delays typical in those with ADHD, along with interdependent socioenvironmental factors, can adversely affect their health, academic achievement, and socioeconomic status.4,5

Let’s take a closer look at how some of these external influences – namely, parental stress and childhood trauma – can present diagnostic challenges, disease persistence, and outcomes with ADHD.

Understanding the Role of Adverse Childhood Experiences

According to the CDC, adverse childhood experiences (ACE) are common, with one in six individuals reporting exposure to four or more ACEs.6 Types of ACEs considered to be potentially traumatic events occurring in childhood (age 0-17 years) include:7

  • Abuse: emotional, physical, sexual
  • Neglect: emotional, physical
  • Household dysfunction: incarcerated relative, mental illness, mother or stepmother treated violently, parents separated or divorced, substance abuse

Toxic stress from ACEs has a far-reaching negative impact on health and quality of life, including brain development, academic performance, economic security, and relationships, 8,9

ACE and ADHD are also intricately linked.10 Children with ADHD have higher risks for ACE exposure and those with greater number of ACEs experience more severe ADHD symptoms.11

Children born preterm are at greater risk from persistent negative socioenvironmental conditions such as toxic stress, and poverty.12 They are also more vulnerable to neurodevelopmental disorders including ADHD.13

(Editor’s Note: More on ACEs and comorbidities our sister site,

Identifying Children at Risk for ACE and ADHD

Stress, conflict, and trauma are correlated with ADHD advancement, and severity of symptoms but are less often considered during evaluations and in developing intervention strategies.14,15

Studies show children experiencing ACEs such as trauma, racism, divorce, poverty, family incarceration, and other harmful circumstances can manifest behavioral symptoms such as aggression, irritability, impulsivity and other behaviors similar to ADHD often confounding screening and diagnosis.16-19

Symptom similarities between ACE and ADHD can lead to misidentification of trauma-related behavior as ADHD or discount the attenuated behavioral symptoms resulting from toxic stress as solely related to ADHD.16

Nekeshia Hammond, PsyD, a psychologist, ADHD specialist, and national speaker on child mental health and parental wellness told Psycom Pro, “While the CDC notes that approximately two-thirds of children with ADHD have another mental health condition or issue, it cannot be ignored how imperative it is for professionals to look at the ‘bigger picture.’ The bigger picture includes gathering detailed information about a child, such as their current risk factors and protective factors, as well as introducing customized strategies that work based on their strengths, needs, and experiences.”

Childhood trauma and negative memory bias (ie, remembering bad memories rather than good) also advances the onset, severity, and long-term persistence of ADHD and other mental health conditions, including anxiety and depression.20

Studies show that stress worsens cognitive and emotional dysregulation during adolescence due to delayed prefrontal cortex maturation in children diagnosed with ADHD.13, 21 High levels of stress exposure from childhood to adolescence also raises risks of continuation of ADHD symptoms and other comorbid mental health conditions into adulthood.22

According to Billie Samantha Schwartz, PhD, a psychologist with Children’s Hospital of Philadelphia, “It may be helpful to look at item-level analysis when screening for ADHD and ACEs to help in thinking through impairment.” Dr. Schwartz offers a few considerations:

  • Is this child’s difficulty with concentration due to neurodevelopmental factors beyond his/her control or is there something happening in the child’s life that is intrusive and making it difficult to pay attention?
  • Is the child really that easily distracted or is it a factor of community violence or parental arguments/disagreements that are preventing adequate sleep?

She explains that children’s behavior is shaped in many ways and that it is important not to overlook their environment to gain a better understanding of adaptive functioning in comparison to stand-alone symptom presentation. “As prevalence data on ACEs and ADHD have shown, there is an important relationship between ADHD and childhood adversity warranting the need for routine screening. By taking the time to ask sensitive questions about potential adversity, these efforts will hopefully mitigate the confluence of symptoms of ADHD and trauma,” she advises.

When Parental Stress Factors Into ADHD Care

ADHD has profound long-term adverse effects on family dynamics and bidirectionally effects stress of the child – and the parent or caregiver.23 Parental stress stemming from perceived imbalances in their roles (eg, time demand and coping skills) can lead to multiple poor outcomes for families but is often overlooked by clinicians.24

Implications include:25

  • worsening of a child’s ADHD symptoms
  • breakdown in parent-child relationships
  • poor response to interventions
  • increase in adverse parenting strategies (use of corporal punishment, use of directive rather than supportive strategies)
  • poor parental mental well-being and perceived quality of life

Studies of parents with lived experience caring for children with ADHD report:19, 26,27

  • lack of support
  • social stigma
  • struggles with their own emotional and social functioning
  • burdens of coping with a child’s behavioral symptoms negatively affect their well-being and stress levels.

Further, parents report social isolation and perceived negative judgments from academic and clinical professionals – all of which increases their own stress and influences their interactions with their children.20

Says Dr. Schwartz, “Parental stress can be multifaceted and a potential barrier to care, stretching beyond the individual difficulties of managing their child’s disruptive behavior. One or both parents may have their own diagnosis of or experience with ADHD, not to mention their own history of adverse childhood experiences or complex trauma.”

For these reasons, it is of the utmost importance to understand a parent’s own level of distress tolerance while providing interventions for youth, advises Dr. Schwartz. Specifically, she recommends that behavioral health professionals provide support and empathy for helping parents manage the emotional and psychological impact that ADHD can have on their home and school life.

“Often, this type of support can be included in the child’s therapy sessions by using a positive parenting framework with room for supporting parental emotional stress,” she explains. “However, if it becomes clear that a parent is in need of more support, then a referral to an outside provider (eg, individual or family therapy) may be warranted… Parents of children with ADHD and/or a history of toxic stress can be emotionally exhausted and generally under tremendous pressure. Don’t be afraid to ask a parent how they manage their own distress during difficult parenting moments, with special attention given to gauge their support system and overall help-seeking behavior.”

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Taking a Comprehensive Approach to ADHD Assessment

Numerous socioenvironmental determinants affect family emotional and physical functioning and quality of life. These can include physical or psychiatric comorbidities, parents’ own mental health status, and the impact of ACEs.

To avoid misattributing trauma behavior to ADHD, or failing to evaluate the underlying effects of ACE on ADHD severity, a holistic approach to screening and diagnosis should delve into:10,11

  • trauma history, including the incorporation of an ACE score
  • socioenvironmental influences
  • parent-reported ADHD symptoms
  • disease severity
  • school-based behavior assessment
  • parent/family history of ADHD, ACE

Dr. Hammond noted, “Trauma, stress, and ADHD all have overlapping symptoms, which is why it is so important to do comprehensive psychological testing, for example, to ‘tease out’ the symptoms and to understand what is really going on with the child… An example would be when a child is not aware of the impact of their ADHD on their life. They may be ‘in denial’ of their symptoms or simply not fully aware of how their attention difficulties are impacting their daily life.”

Further, clinicians should be aware that there may be discrepancies between parent and child subjective ratings of a child’s quality of life.28,29 For example, parent ratings may be affected by their own QoL perceptions based on caring for a child with ADHD. Studies have found greater inter-rater agreement for external behaviors (ie. aggression, hyperactive behavior) compared to internal behaviors (ie, sadness, worry, fatigue).28,31 Evaluating both perspectives may provide important context regarding underlying family circumstances contributing to quality of life perceptions.

Parents are integrally linked to a child’s wellbeing. Therefore, it is important for providers to assess parental factors of stress, reduce stigma associated with causes of ACE such as poverty, and develop strategies to provide parental training and support resources (see a list below) to improve family outcomes. She adds, “There also needs to be more emphasis on prevention efforts related to trauma.”

In the presence of ACEs, clinicians can incorporate trauma-informed care models to improve social-emotional well-being for the family unit. According to a SAMHSA Issue Brief, Key Ingredients for Successful Trauma-Informed Care Implementation, healthcare organizations can change organization culture and create safe environments for patients by adapting a trauma-informed care model. The report highlights the importance of communicating with compassion and respect to reduce stigma, being aware of cultural aspects of trauma, and adjusting terminology for individuals with low health-literacy levels.30

Dr. Schwartz explained, “While there are a number of resources that exist to assist in screening ACEs and diagnosing ADHD, there is less guidance on how to directly adapt the two for clinical practice. A good first step is to get educated in trauma-informed care… [in order to] become more fluent in understanding adversity and how it affects child development, problematic behavior, and ADHD-like symptom presentation in the home and school setting.”

Both SAMHSA and the National Child Traumatic Stress Network provide professional training in trauma-informed care (see a list of resources below).

Dr. Schwartz also recommends the use of motivational interviewing, which focuses on the principles of empathy, empowerment, and promotion of self-efficacy. “Motivational interviewing can be a useful tool to help elicit change talk when talking to parents about adversity, help-seeking behavior, and ADHD” in general.

Overall, advises Dr. Schwartz, a comprehensive approach will take into account both “context and content” in ADHD diagnostic formulation and treatment planning – a key step in providing excellent care.

Resources for Clinicians Diagnosing ADHD

Back to Part 1 of this series on ADHD Diagnosis and External Factors

References
Last Updated: Jan 6, 2021