ADHD or Trauma? Similar Symptoms and How to Tell Them Apart

A sensitive subject. This article speaks of trauma. If you find it hard to read, taking a break is a good idea. If you are going through a current crisis, you can reach the 112 emergency call center in Turkey, and you can ask for referral from the ALO 183 Social Support Line.

One of the things I was asked most after the diagnosis was this: "Do you really have ADHD, or did something happen to you?" Most of those who asked meant well. Still, it touched something inside me, because I had asked myself the same question.

Think of someone who cannot gather their attention, who is constantly on guard, who reacts harshly to small things, who cannot sleep. This description fits ADHD, and it fits post-traumatic stress disorder as well. Two pictures resembling each other this much raises a serious question both in diagnosis and in treatment.

Why they look so alike

Post-traumatic stress disorder is a condition that develops after a severe event that was experienced or witnessed, and is defined by symptoms of re-experiencing, avoidance, negative thoughts and feelings, and hyperarousal.

Some of these symptoms, especially the hyperarousal cluster, look very much like ADHD:

• Difficulty concentrating. In ADHD attention is distracted; in trauma it becomes hard to focus on anything else because the mind is locked onto danger.
• Restlessness. In ADHD a need to move; in trauma a state of being on guard.
• Irritability and angry outbursts. Seen in both. I wrote about this side in the article on angry outbursts in ADHD.
• Sleep problems. Common in both.
• Impulsive or risky behaviors. Can appear in both.
• Mood swings. Marked in both; I dealt with the mechanism on the ADHD side in the article on emotion regulation.

The clinical assessment by Szymanski, Sapanski and Conway (2011) emphasizes that cognitive and emotional impairments arising in response to trauma, such as difficulty concentrating, mood swings, irritability and hyperarousal, can overlap with ADHD symptoms or make them worse. In the glossary it is called symptom overlap.

The same behavior can come from two different places. Looking at the behavior is not enough; you have to look at where it comes from.

The two can also be together

There is a detail here that reassured me: the question does not always have to be "which." Often the answer can be "both."

The systematic review and meta-analysis by Spencer and colleagues (2016) found a two-way relationship between the two conditions:

• In people with ADHD the risk of post-traumatic stress disorder is about 2.9 times higher.
• In people with post-traumatic stress disorder the likelihood of ADHD is about 1.7 times higher.

Several explanations are discussed for why this relationship runs both ways.

ADHD can increase the risk of trauma. Impulsivity, risky behaviors and attention problems can raise the likelihood of accidents, injuries and encountering dangerous situations.

ADHD can make recovery after trauma harder. Difficulty with emotion regulation can contribute to symptoms becoming more lasting after an event.

Trauma can produce ADHD-like symptoms. Especially traumas that are experienced in childhood and are ongoing can leave marks on attention and behavior that look very much like ADHD. You can look at the glossary entries on developmental trauma and adverse childhood experiences.

Does trauma cause ADHD

This question is asked often and needs a careful answer.

ADHD is a neurodevelopmental condition in which heredity plays a very strong role. Reviews based on twin studies give the heritability of ADHD as about 74 percent (Faraone and Larsson, 2019). I gathered this side in detail in the article on whether ADHD is hereditary.

This high rate does not fit with the idea that ADHD arises in most cases as a result of trauma. So the generalization "trauma causes ADHD" is not supported by the evidence.

But that does not mean trauma is unimportant. Trauma:

• Can produce symptoms that look very much like ADHD and be mistaken for ADHD.
• Can make existing ADHD symptoms worse.
• Can be present alongside ADHD, as a separate condition.

This distinction matters a great deal in practice, because the treatment approaches are different. Mistaking trauma for ADHD, or explaining ADHD only with trauma, can lead to missing or wrong treatment.

I dealt with how the subject is reflected in popular books in the article on The Body Keeps the Score.

What is looked at in telling them apart

A specialist makes the definite distinction. The main clues looked at in an assessment are these.

Time of onset. ADHD symptoms have been there since early childhood, independent of a particular event. Trauma-related symptoms often begin or become marked after an event. That is why the question "when did these symptoms start, what was it like before" is at the center. This is also what convinced me: when I looked at my own childhood, there was a child who did the homework on the last night, who looked out of the window in class, who was scattered even when nothing had happened.

Connection to the trauma. In post-trauma conditions the symptoms are often triggered by things that remind of the event: particular places, sounds, smells, people. ADHD symptoms are independent of this kind of trigger; they are more widespread and show continuity.

Re-experiencing and avoidance. Nightmares, involuntary memories and staying away from things that remind of the event are symptoms specific to post-traumatic stress disorder. In ADHD these do not appear typical.

The nature of attention. In ADHD attention is generally scattered and fluctuates with interest. In trauma attention is often locked onto threat; the person is constantly scanning the surroundings and cannot focus because they do not feel safe.

Developmental history. Is it a pattern that has continued since childhood, or a change that appeared after a certain period? Family accounts and old school records help here. I wrote the whole process step by step in the article on how adult ADHD is diagnosed.

The European consensus statement recommends systematic screening for accompanying and confusable conditions in the assessment of adult ADHD (Kooij et al., 2019). The glossary entry on differential diagnosis summarizes this.

When you go to an assessment, telling, as far as you can, when the symptoms began, what it was like before, and the hard events you have lived through helps the distinction be made correctly. If you find it hard to tell, saying so is enough too; you can decide with the specialist how to proceed.

What is done when they are together

If the two conditions are together, both need to be addressed.

Psychotherapy aimed at trauma. There are evidence-based psychotherapy approaches for post-traumatic stress disorder, and this is the basic intervention for the trauma side.

An approach aimed at ADHD. Psychoeducation, skills-focused support and, if needed, medication. Both the diagnosis and the decision about medication are the doctor's job.

A matter of order. Which is addressed first, or how they are addressed together, varies from person to person. Sometimes the easing of ADHD symptoms lets the person take part better in trauma therapy, sometimes the weight of the trauma requires priority.

Safety and predictability. Especially in children, a safe and predictable environment lays the ground on both sides.

The cost of looking in the wrong direction

Mistaking trauma for ADHD leads to the person not getting the support they need for what they went through; the symptoms continue despite treatment, because the real source is not touched.

Explaining ADHD only with trauma, on the other hand, leads to a neurodevelopmental condition that has lasted for years being missed and to support that could have been effective arriving late.

The most common shortcoming, in my view, is the third: not seeing both.

Today I answer my own question like this. The question "did something happen to you" is not a wrong question, but it is wrong when asked on its own. The right question carries both at once: when did these symptoms begin, what triggers them, and which one, if I do not see it, will make me lose my years again?