Wednesday, 6 August 2014

Childhood Trauma : Misdiagnosis, exacerbation and culprit with ADHD

From actually a very recent Healthline dotcom article we were able to pick up on some points from our last self help group's dicussion and take them up again with our first post summer semester meeting.

The article reported some follow up analysis in presumably adolescents and children with a historic diagnosis adhd, which delved into then to what type and occurence of traumatic experiences in early childhood the patients had.

The supposition was once again the overdiagnosis or more accurately then the misdiagnosis of ADHD, and then juxtaposing this accusation with the level of medication used in Canada. Without drawing any conclusions on actual level of innappropriate courses of action, the article placed the concepts:

1) ADHD can easily be the incorrect diagnosis for what is more likely post-traumatic-stress-disorder(s) (more over a syndrome as it should be called IMHO)

2) ADHD afflicted can experience some acute-traumatic-childhood-experiences (ACEs) as far more dramatic and react in a disproportionate way compared to normal children. Further more, some events which could be frightening or just regarded as a reasonable  challenge for a normal child, may be experienced at the time or in retrospect as highly traumatic and emotionally disturbing for the ADHD sufferer.

3) ADHD as the source to traumatic events: the disease can lead to more stressful relationships at home, or create traumtic events due to impulsiveness or lack of appropriate handeling to prevent some unwanted event or series of links which lead to catastrophe, such as in spiralling substance abuse which is common amongst socially delinquent adhd sufferers.

The article states very succinctly that in first taking the "history" at the primary point of care it should be a complete childhood history which uncovers any underlying behavioural symptoms. In all the scenarios above the key is to identify if there is a history of erratic, impulsive, attention deficit behaviour prior to a major traumatic event in the patient's history. Alternatively then choosing to create a differential diagnosis with Post Traumatic Stress Disorder which bares many of the same symptoms as ADHD and often occurs in the peripubescent period, when divorce or outside street violence are more likely to affect an older child due to how parents and society now see them ie they are old enough to be considered open for more, be that a bad presumption of course. Parents choose to wait to separate until the children are older for various reasons, partly in the false belief a 9 to 12 year old will tackle divorce better. Adolescents may begin seeing a 10 year old as a potential acceptable target for bullying or so far as even involving them in gang violence.

In our own group, bar one member,  we could all actually  see that we had a running symptom list of ADHD which became clear earlier than the "coming of age" i describe above, prior to age 10.

Nearly all members of our group had experienced some form of acute, traumatic event or longer term emotionally disturbing situation in childhood and also could see that as adults ( our group is mainly those diagnosed with ADHD over age 25) their ADHD did indeed contribute to negative, acute life events as follows:

1) perceiving some events as traumatic at the time, and being now even embarressed to admit this because they seem relatively normal: losing a job, getting dumped by a partner or being involved in frightening confrontations under the indfluence of alcohol or other substances of abuse

2) not having the ability to tackle some events: commonly with us : allowing issues to grow over time and to then explode, often in a social stress context. Second to this was contributing to the tension and traumatic outcome of an event, particularily when splitting up with a lover or in the work place.

3) Directly causing traumatic events in childhood or adulthood.

On this latter point we found a rich seam of material came forward in our self help grouo.  Committing crime, overdosing on drugs, violence tinged drinking bouts, attempted suicide, aggressive driving leading to crashes,  violence in the family, provocation and fighting were the more dramatic we could raise from our members. Splitting up from a partner or friend more acromoniously than needed to be (or that indeed creating an irreversible chasm) was more often cited, often with regret,  across all our dozen or so present.

Storming out of jobs or sibling meetings was also quoted as being umpulsive events which lead to some disproportionately dire consequences.

More subtle examples were opting to be together with "innappropriate" partners, which often statred from an impulsive one night stand which lead to a longer unbeneficial relationship which a more clear headed, assertive person would have avoided. The same was true with jobs or entire career paths, notably sales careers in several of us which prove to be unfullfilling yet seemingly a good idea for people lacking qualifications or wanting a career change.

The key thread we could trace here, being picked up on from our assertiveness training we have included a paid course leader to come in for, is that very lack of assetiveness which is really the main handicap to adult life for the ADHD afflicted.

How is this lack of being objective and being able to make more appropriate actions affected by adhd?

The disease is like a perfect storm as one participant put it , whom has researched it and related back to their own life. In outset we can negatively affect those around us, which in work and family life loses us trust and respect. We are not taken seriously, or worse are seen as problematic. Then we lack some social atennae, further to this we fail to pick up on both social ques and we fail to gather information in a balanced and rational way. We may suspect a partner is having doubts, or a company is considering our future with them, but we either miss the tell tale signs, linger on paranoic perceptions or fail to make a case for ourselves and then take the bull by the horns.

The majority of the group agreed that they were very often conflict averse when there was serious miscontent around them or grounds for arguement, while conversely they went on to act rashly and with impulsive often aggressive conflict handling. Many agreed they were bad at "nipping it in the bud" and let issues simmer rather than addressing them, and this often may have lead to exagerrated outcomes or avoidable courses which relationships instead spiralled downwards from.

A key thing people expressed about impulsiveness, the hallmark of adhd if you like, was that it usually had a largely emotional start point. Bored, angry , frustrated, sexually aroused or high......these  were common trigger feelings,  or trigger related emotions.

This emotional status lead to often innappropriate actions and some dire consequences. Also once a route was embarked upon from a single impulsive episode,  be that substance abuse, an unsuitbale partner or a new career, then often there was a chain effect of more and more emotional triggers for irrational and impulsive behaviours.

There was in effect a viscious circle where the afflicted was exposed to more difficult situations emanating from their initial impulsiveness and found themselves in a new trigger point, and so on and so on. These emotions were in our group paticularily negaitive stress, fear, paranoia on the one side while being either from sexual or substance gratification on the other.

Several of us further expressed that we went through the same type of aroused trigger state and took.impulsive actions through adolescent or adult life as if we enjoyed it or as if we felt it was correct to "go with our gut feeling". These then were either spread out through differing life situations, or coiled into a downward spiral as discussed above. In terms of socially "deviant" behaviour the latter included ' sex and drugs and rock and roll' lifestyles for some. For others it was a descent into gambling , petty crime , or debt they could not repay. For others it was poor decision making on partners or jobs or both in several of us. For a small number it was extra'marital sex which they found had happened repeatedly.

To some extent then there is a learned behaviour pattern. Either it is self-normalised as is a human tendency to see oneself and ones actions as normal and rational. Alternatively there is a gratification element where the outcome positively reinforces the impulsive behaviour and the poor, emtionally loaded decision making. As a sub grouping within gratification and more often associated to teenage bravado in adhd 'victims' was that the impulsive risk taking in itself was a source for excitement and stimulation ,mannifest in differing ways throughout life.

One member of the group had a differing view point on the source of their issues being external, from a "cloud burst" of three traumatic events as a teenager and we have advised her to seek rediagnosis as she may have confused symptoms
of post traumatic stress disorder with adhd and thus require a different route in therapy. Several of us proposed (after her quite emotional departure from the session) that we could have symptoms of the same which are intertwined with those of adhd. As mentioned we could have created traumatic events by mis-virtue of our disease or could be affected more adversely due to our common mental affliction. Along that route it was discussed that  our previously preclinical adhd then was exacerbated by trauma with our eventual adult diagnosis being set only in loose connection to what for we as individuals as an emotional watershed.

Seeing the complete history of the patient back to pre pubescent childhood or back to before trauma and separating out environmental and social. background is always then going to be a challenge for front line physicians and psychologists.


As a follow up to the blog above:  the lady.member mentioned went on to be diagnosed with severe post traumatic stress syndrome. Her mid teenage years were smattered with symptoms common to adhd, but there was no previous history from her earlier childhood when she had been a diligint pupil and musician. She no longer attends our group, but has offered to talk to future groups about the affliction in order for other innappropriately diagnosed, or double belasted sufferers to consider their own history and seek advice and possible rediagnosis.

Two other group members now also consider if physical trauma has caused them to be afflicted by adhd or show symptoms. One had a head injury on a stolen motorbike while they were an unruly teenager, but otherwise thought they were mentalilty sharp prior to injury. Another reported late teenage substance abuse : after treatment for a broken femur involved diamorphine, they tried to self releive with illicit drugs at home, post operatively , and went into OD. They are very uncertain if they really were adhd before hand, having had their diagnosis age 32.

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