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 ljhanbury@outlook.com

More from Community Care

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

  1. londonboy April 10, 2017 at 7:47 pm #

    I find this an alarming and sinister article on a number of fronts.
    The author, who appear to have no clinical qualifications but does have a dissertation it would seem, makes sweeping claims without reference to as much as one clinically validated study to back up claims. This seems to be the latest attempt to equate the difficulties of those who have survived traumas such as war with those of a child whose Mum may be say chaotic, depressed and poor by linking an issue of over-diagnosis with neglect. This is tantamount to scapegoating and victim blaming in my book. It plays to a narrative of the ‘feral poor’ rather than one of health inequalities. Social workers should steer well clear of this simplistic stuff – it is not science, it is prejudice.

    • John April 12, 2017 at 10:55 am #

      Have you read the article properly? The author is not saying that ADHD does not exist. She is saying that it can be misdiagnosed (which appears to be based on academic research and observation). I cannot see why this would be classed as ‘sinister’ at all. Surely us as social workers need to be aware of the signs and symptoms of both?

    • L Hanbury April 12, 2017 at 4:56 pm #

      Dear londonboy,

      I would like to offer you the opportunity to read the large amounts of research that I am referring to. The dissertation includes current up to date knowledge and findings from a wide range of sources, leading clinicians and researchers from all over the world. What I did is put their findings together and add it to my own extensive experience in working intensively with families for many years. The research also attempts to raise further awareness in that ADHD type behaviours can become present in any person’s life regardless of their socioeconomic status, as can domestic violence and mental health problems etc.

      I have worked with true cases of ADHD where the taking of medication mixed with an intensive behavioural intervention has really made a difference for some of these young people, but I have also had the courage to question a diagnosis when I felt that something had been missed and/or not considered when it should have been. This is a subject that I am extremely passionate about and I would never misrepresent a true case of ADHD.

      Please do get in touch if you want to read the full literature review. I would urge you to do so as I think you may have taken parts of this article out of context.

      Best wishes,

      L J Hanbury

  2. Bluebell April 11, 2017 at 8:36 am #

    Well, I am not a social worker, but married to someone with ADHD, and we have a grown up child with ADD – is it not possible that in some cases, it’s a question of a parent having undiagnosed ADD/ADHD and it’s been passed on? I see the chronic disorganisation, forgetfulness, failure to comprehend anything but short sentences and instructions, hyper-reactivity, losing things, the generally chaotic life in practical and emotional terms…..Just living their own life is a struggle, never mind having to look after children too!

  3. Chris April 11, 2017 at 12:50 pm #

    I guess the key question is how should the families be supported. Are the support requirements for a child with ADHD similar to a child suffering from hypervigilance and the effects of child hood stress? The article stresses the need for undestanding the causes of the behaviour and the need to differentiate between ADHD, Inattentiveness and hypervigilance. I am not sure if this is necessarily the case but an awareness will help inform practice.
    Chris . Soon to be Student Social Worker

  4. Zoie April 11, 2017 at 2:53 pm #

    See the link between Adverse childhood experiences ACE’s and adhd.add.agressiveness.depression.bipolar.. all possibilities bc of the ACE’s ability to rewire the brain in young children.. excellent article

  5. I Goodman April 11, 2017 at 11:19 pm #

    As a middle-aged female social worker with ADHD and history of childhood trauma, I am thrilled to have read such an insightful article. Thank you, thank you!

  6. Nat April 12, 2017 at 9:38 pm #

    I appreciate publishing this piece.

    Only yesterday I assessed a client in the capacity of my MH SW role, she told me that when she was young her teachers said that she had ADHD, reporting to get distracted and bored easily. The client alluded that her longstanding depression and generalised anxiety arises from childhood trauma. Another example of labelling abnormal behaviours through the medical lense rather than viewing it as being triggered by child neglect and abuse.

    • Ross April 13, 2017 at 2:04 pm #

      How do you know she does not have adhd ? I was told as a child i had adhd but nothing was done about it until i was 46. another family member 25 and another 31. It does cause anxiety and depression in many people. you can have childhood trauma and adhd.

    • Teresa fitzgerald April 17, 2017 at 4:58 pm #

      I was neglected as a child suffered depression and anxiety in my 20s , I left care with no support from social services . I have two children who where both diagnosed with ADHD , I was diagnosed at 48 . I started the first ADHD parental support group in liverpool . In 2006 started the first Adult ADHD support group in Liverpool, eventually in 2010 we became a Social Enterprise. Since 2001 I have supported thousands of people/families with the condition. I would say most cases are innate , more than cause and effect from childhood trauma. I have data since 2001.

  7. Planet Autism April 12, 2017 at 10:21 pm #

    I think this article is way off base. In fact so many children with neurodevelopmental conditions such as ADHD and autism are misdiagnosed with attachment disorder and parenting blamed. THAT’S why there are so many children in the care system with neurodevelopment conditions!! They are a combination of either: parents being blamed and unsupported resulting in failure to cope or parenting being blamed as far as false accusations of abuse or neglect and misdiagnosis or attachment disorder resulting in the children being wrongfully taken into care.

    Perhaps the author would care to do a study on when the diagnosis was received because that might give some helpful information. Sometimes children are taken and parents disbelieved and later they are diagnosed whilst in care, proving the parents right all along. But no apology received, no returning of children.

    In the UK it’s actually very hard to get diagnosed with ADHD and autism as the NHS also has the parent blame culture and all assessments are differential and NICE guidance states to consider environment and factors which may mimic a condition. So the assumptions made by the author are actually incorrect.

    Look into the truth about vaccines and other environmental toxins if you want to know why neurodevelopmental disorders are on the rise.

  8. Ross April 13, 2017 at 2:00 pm #

    I have ADHD as does 5 of my close family members, I was diagnosed as an adult as were 2 of my family members. while i agree the artical has merit, but as a former social worker with 13 years experience i feel there is so much more to ADHD.

    My symptoms are mainly things like interrupting people in mid sentence, flitting between subject when talking, forgetfulness, etc. At work i found explaining to clients and other professionals why i did this, for instance, i didnt want them to think i was deliberately being rude if i interrupted them. However i was told by 2 local authorities that sharing i had ADHD was a breech of boundaries. I was also informed that sharing i had ADHD with a 17 year old client who also had ADHD was me over identifying with him. I also have dyslexia but no one raised any concerns about me sharing that at work ! !

    I spoke with the HCPC who said they did not feel this breached any boundaries as it enabled better communication and understanding between myself and clients. I feel the LAs response to me sharing that i have ADHD demonstrates how they negatively view ADHD which i feel is discrimination.

    The artical discusses childhood trauma. ADHD is inherited so therefore it would be likely that a parent or grandparent has it. This would have an impact on how the parent was raised, which in turn impacts on how the parent then parents their own children, so yes, it can be a crazy environment to live in, there can be lots of screaming and shouting. ADHD people often have sleep problems which makes things worse.

    Unfortunately when CAMH diagnose a child with ADHD no discussion takes place to see if the childs parents may have ADHD. While ADHD symptoms can ease as we get older, for some they dont and even if they do life is still very hard. The years of living with an diagnosed condition that has a negative impact on all areas of a persons life can take its tole causing things such as depression, social exclusion, substance misuse and DV. Diagnosing a child with ADHD but not assessing the parent is a sticking plaster as the parent may still find parenting the child difficult due to their own undiognosed ADHD .

    I worked with a family where the parent demonstrated many of the adult ADHD behaviors. I wrote about this in my assessment and requested a assessment take place. Firstly i was told i was not qualified to make such a diagnosis. I explained i was not making a diagnosis, i was merely explaining what i had seen and how the behaviors where similar to those with ADHD. I explained that SWs do this all the time in assessments when they believe a parent may be suffering with depression but was still told i needed to take the information out of the assessment.

    I would also like to stress the point that when an adult is being assessed for ADHD it needs to be done by an expert who deals with assessing ADHD on a regular basis. This is because the symptoms can appear similar to depression, Bi Polar and personality disorder so can easily be miss diagnosed. Similarly i worked with a lad a few years back who had Aspergers but also showed many adhd behaviors. The CAMH worker refused to assess him saying adhd and Aspergers dont co exist which is rubbish.

    It took me 3 years to get a diagnosis on the NHS. Initially after trying for a year through the NHS i paid to have a private assessment by a leading ADHD specialist, however the NHS would not accept this so i had to wait another 2 years to be assessed again at the Maudsley Hospital in London…..what a waist of tax payers money !

    Many children and adults with ADHD have another disability which co exists, such as dyslexia, bi polar and aspergers and so on. From my own experience and that of my family, you know if you have ADHD when you start taking the medication. The medication should make a person feel like they did before but with a better outcome in regards to their behaviors. They should not feel buzzy or hyper after it. Of they do they are over medicated or dont have ADHD

    Unfortunately it appears most children diagnosed with ADHD years ago had their cases closed after the age of 18; as if by magic the ADHD would disappear ! A great many more have been left undiagnosed

    So when a client is constantly late, forgets doctors appointments, has a messy house, loses things often, shows poor ability to plan ahead etc etc please consider it may be due to ADHD and not just because they dont care or are being awkward.

    • Shell April 18, 2017 at 10:54 pm #

      I am not sure that I agree with the assertion ‘and the socioeconomic backgrounds most commonly associated with ADHD’. How does a neurobiological condition become conflated with socio-economic status?

  9. Matthew - meandminimees April 14, 2017 at 12:34 pm #

    My boys were diagnosed to have ADHD – and treated accordingly.

    They suffered from huge trauma in their early childhood. We live with it on a day to day basis. They are now teenagers and the affects of their early life experiences is triggering so much. These children and young people need the right support, not just a label on which to walk away from or to medicate.

    We have now had the right ‘diagnosis’, but still support and understanding is so hard to come by. Thank you for this article. Those with ADHD need the right support, along with those who have other diagnosis. Treatment and support is different.

  10. Jay April 14, 2017 at 4:51 pm #

    Brilliant article, as a Camhs social worker, we are faced with parents seeking a label or locate the problem solely with the child and is not willing to consider it as a relational disruption i.e attachment disorder

    • AntiProfessionalIncompetance April 25, 2017 at 7:07 pm #

      Attachment disorder is very rare, however this appears to be ignored by many professionals. More likely to have ADHD or Autism than attachment disorder. But appear that many CAHMS / Social Workers more interested in parent blaming than accurate diagnosis that would get children the help they need. You are all like lemmings falling over each other to diagnose the sexy new buzz word condition. Unfortunately it is the children that end up falling off the cliff not you.

  11. londonboy April 15, 2017 at 5:50 pm #

    I’ve written a long response to be found here

  12. Elderside play theeapy April 15, 2017 at 8:22 pm #

    Finally ! Having worked in both sectors over the past 25 years I have witnessed both types of adhd and can confirm these statements. Currently working as a behaviour specialist can see often reluctance by doctors to prescribe medication and rightly so. This condition is both environmental and clinical in many many cases.

  13. L A worker 2 April 17, 2017 at 7:53 pm #

    With 10 years experience in child protection I think there is validity in looking at severe neglect and abuse and how children’s behaviours can mimic adhd. I see children labelled by parents who are unable to reflect on parenting styles due to their own issues and this can result in children being medicated. Often the medication doesn’t work and then other things are blamed. When these children are moved and given robust structure, boundaries and love, we often see some of their behaviours reduce – I wonder why?

  14. Shane April 17, 2017 at 9:40 pm #

    I have first hand knowledge of how difficult children can be. I met my wife knowing that her son had difficulties but his sister hadn’t. I quickly noticed that the latter was not true. We took the sister to CAMHS, hoping for a diagnosis of Aspergers. She had the traits for Aspergers, but they declined to diagnose. We tried for 3 years, the child was violent, lied constantly, aggressive to all family members, stole money and items without any concerns for consequences, it got that bad we took her to the police station and she just laughed at the officer, when I tried again her mother begged me not to report it again when she had turned 16. I found letters in her room wishing we were all dead, she tried to electrocute her mother by cutting a power cord. She flicked lit cigarettes behind her wardrobe which could have set the house on fire with us all inside. I got her a youth worker as all the problems we were having. We reported all this to her specialists and the problems that was going on, that includes a disability social worker that was refused.
    So summarising is no one works with families or perceives problems as exaggerated. The child had seen a psychiatrist, psychologist and a professor. We got no help what so ever, which now I’m estranged from them now after 5 years with them all.
    So a week ago I went through my paperwork and found a letter from the girls doctor which listed all her diagnoses and to my knowledge she wasn’t diagnosed with ADHD. This letter had her diagnosed with ADHD, looking back I’m not surprised with her behaviour as she had not been treated for ADHD.