Relationships between childhood trauma, PTSD, and ADHD among adult substance users

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Relationships between childhood trauma, PTSD, and
ADHD among adult substance users

• Vanessa Watson1, Ali Marsh1,2, Felicity Miller1
• 1 School of Psychology, Curtin University, WA
• 2Next Step Drug Alcohol Service, WA

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ADHD and PTSD?
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ADHD and PTSD

• Share numerous common symptoms.
• E.g.
• Heightened startle response
• Inattentiveness
• Feelings of detachment
• Irritability
• Anger outbursts

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PTSD and ADHD in sexually abused children

• McLeer et al. (1994)
• Most common diagnoses were ADHD (46) and PTSD
  (42.3)
• ADHD and PTSD comorbid in 23.1
• Merry Andrews (1994)
• Most common diagnoses were PTSD (18) ADHD
  (13.6 )
• Glod Teicher (1996)
• 68 met PTSD criteria, 18 met ADHD criteria
• All of the ADHD children met criteria for PTSD

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PTSD and ADHD in children physically and/or
sexually abused

• Ackerman et al. (1998)
• 35 diagnosed with ADHD
• boys both physically sexually abused were most
  likely to meet ADHD criteria (75)
• Famularo et al. (1996)
• ADHD was significantly more common among abused
  children with PTSD (37) than without PTSD (17)
• Briscoe-Smith et al. (2006)
• physical sexual abuse more common in 6-12 yr
  old girls with ADHD (14.3) than without ADHD
  (4.5).
• abuse found mostly in combined subtype (not
  inattentive).

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Some unanswered questions

• Why are there such high rates of ADHD among
  abused children?
• How can we attempt to explain the observed
  relationship between childhood trauma, ADHD, and
  PTSD?
• Does this relationship apply to an adult
  population?

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Trauma PTSD are common in AOD treatment
populations

• Trauma exposure usually around 80-90
• More than half report physical abuse
• More than half report sexual abuse/assault
• PTSD rates usually around 30, higher in women

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ADHD is common in AOD treatment populations

• ADHD rates in AOD treatment populations estimated
  at 15-37
• Compared to ADHD rate of 3-7 in the general
  community
• Childhood ADHD continues into adulthood 30-75 of
  the time

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Study Aims

• To replicate and extend preliminary research into
  links between childhood trauma, PTSD and ADHD to
  an adult drug treatment sample.
• To explore explanations for the prevalence of
  ADHD among people who have experienced childhood
  trauma.

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Participants

• 97 clients (44 men, 53 women, mean age 34.7 yrs )
  in AOD treatment in govt and non-govt services in
  Perth metro area
• AOD treatments
• addiction pharmacotherapies (26)
• outpatient counselling (78)
• clinical psychology (23)
• inpatient rehabilitation (46)
• inpatient withdrawal management (11)
• Alcoholics Anonymous/Narcotics Anonymous (44)

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Drug use

• Preferred drug
• amphetamines 28.9
• opiates 27.8
• alcohol 27.8
• cannabis 11.3
• prescription medication 3.1
• 41 out of the 94 participants reported AOD use in
  the previous month.

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Measures

• ADHD Behaviour Checklist for Adults. This
  self-report checklist assesses current ADHD
  symptomatology in adults (Murphy Barkley,
  1995).
• Wender-Utah Rating Scale (WURS). Childhood ADHD
  was assessed using the 25-item version of the
  WURS (Ward, Wender, Reimherr, 1993).
• Modified PTSD Symptom Scale (MPSS) To meet
  criteria for PTSD, participants had to report
  experiencing at least one re-experiencing, three
  avoidance, and two arousal symptoms, as per
  DSM-IV criteria for PTSD.(Falsetti, Resnick,
  Resnick, Kilpatrick, 1993).

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Measures

• Trauma Questionnaire. 7 classifications of trauma
  as per DSM-IV, assessed for 0-6, 7-12, 13-18,
  gt18 age groups in terms of frequency/intensity on
  a 1-5 scale.
• Physical abuse
• Sexual abuse
• Threat to physical safety
• Witnessing injury or death of another
• Shock from learning about serious harm or death
  of a loved one
• Emotional abuse/neglect
• Other includes military combat, serious
  accident, natural disaster

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Results

• 85.6 of participants reported experiencing at
  least one traumatic event as a child (0-18
  years).
• Excluding emotional trauma, 82.9 of participants
  reported experiencing at least one traumatic
  event in childhood.
• 43.2 of participants met criteria for both child
  ADHD and current PTSD.

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Experience of traumatic events up to 18 years of
age
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PTSD and ADHD in clients reporting childhood
trauma
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PTSD in clients with and without ADHD
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Childhood trauma and ADHD

• Child trauma
• No Yes Total
• Child ADHD No 12 28 40
• Yes 4 50 54
• Total 16 78 94

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ADHD symptomatology mean (SD)

• Adult Adult Child inatt hyp/imp total
• No child 1.81 1.94 34.81
• trauma (1.72) (2.27) (21.01)
• (n16)
• Child 3.72 4.13 53.63
• trauma (2.71) (2.69) (24.21)
• (n78)

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Mean adult ADHD score for repeated trauma groups
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Mean child ADHD score for repeated trauma groups
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Conclusions so far

• ADHD, whether childhood or adulthood, was
  significantly more prevalent among those who had
  experienced childhood trauma and among those who
  met criteria for PTSD.
• Half those reporting childhood abuse had comorbid
  PTSD and ADHD
• Childhood repeated trauma was associated with
  more severe ADHD symptomatology
• Different forms of childhood abuse

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Argument 1

• Among abused children, ADHD is a risk factor for
  the development of PTSD.

TRAUMA
PTSD
ADHD
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Argument 2

• Childhood trauma leads to PTSD, which results in
  behaviours such as hyperactivity inattention
  that resemble ADHD symptoms.

ADHD-like behaviours
TRAUMA
PTSD
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Argument 3

• Childhood trauma exerts biological
  psychological effects that lead to the
  development of both ADHD PTSD through
  independent pathways.

PTSD
TRAUMA
ADHD
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Limitations

• Cross sectional data
• The sample was substance users
• The vast majority had experienced childhood
  trauma
• Self report
• Retrospective report of childhood ADHD
• Childhood ADHD diagnosed with cut-off scores
  rather than DSM-IV criterion (WURS)
• Age issues

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Implications

• Perhaps there are two possible pathways into an
  ADHD diagnosis
• non-trauma, more genetic
• trauma
• Consistent with research showing that childhood
  trauma impacts on the development of self
  regulation, leading to attentional difficulties
• Childhood trauma affects neurobiological
  development
• Childhood trauma in the form of familial abuse
  impairs attachment, resulting self regulation
  impairment

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Implications cont

• Importance of thorough assessment when ADHD is
  present
• Caution re stimulant medication

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Questions to consider

• What are the implications of this research for
  conceptualisations and treatment of ADHD?
• Are there differences between traditional ADHD
  and trauma ADHD?
• What else could we be missing by focussing too
  narrowly on associations between trauma and PTSD?
  
• How would you treat an individual who was
  traumatised and exhibited attentional
  difficulties?
• What role could the therapeutic relationship have
  in resolving ADHD/trauma issues?
• Where would you place your priorities in treating
  an individual with trauma-PTSD-ADHD symptoms?