by Janet Wozniak, M.D., Margaret Harding Crawford, B.A., Joseph Biederman, M.D., Stephen V Faraone, Pl-1.D., Thomas J. Spencer, M.D., Andrea Taylor, B.A., and Heather K. Slier, B.A.
American Academy of Child & Adolescent Psychiatry

Reprinted with permission of the American Academy of Child & Adolescent Psychiatry and Lipincott Williams & Wilkins, publishers.

ABSTRACT

Objective: To examine the relationship between trauma and attention-deficit hyperactivity disorder (ADHD), evaluating whether ADHD increases the risk for trauma, the risk for posttraumatic stress disorder (PTSD), or the risk for trauma-associated psychopathology.
Method: Data from a longitudinal sample of 260 children and adolescents with and without ADHD were examined. All were evaluated comprehensively with assessments in multiple domains of functioning including systematic assessments of trauma and PTSD. Comparisons were made between traumatized and nontraumatized youths with and without ADHD.
Results: No meaningful differences were detected in comparisons between ADHD and control children, either in the rate of trauma exposure or in the development of PTSD. Although trauma was associated with the development of major depression, this effect was independent of ADHD status. In contrast, bipolar disorder at baseline assessment was a significant risk factor for subsequent trauma exposure.
Conclusions: ADHD was not found to be a risk factor for either trauma exposure or PTSD, but childhood mania was. If confirmed, this finding stresses the potential severe clinical sequelae of childhood mania in children. J. Am. Acad. Child Adolesc. Psychiatry, 1999, 38(1):48-55.
Key Words: trauma, mania, attention-deficit hyperactivity disorder, comorbidity.

The association between trauma and attention-deficit hyperactivity disorder (ADHD) has been a source of controversy and debate (Cuffe et al., 1994). Various studies have suggested an association between ADHD and trauma or posttraumatic stress disorder (PTSD) (Famularo, 1996; Glod, 1997; Glod and Teicher, 1996; Merry and Andrews, 1994; Riggs et al., 1995). However, despite the obvious importance of this issue, the association between ADHD and trauma has not been systematically examined, and few studies have addressed the temporal sequencing of PTSD or trauma and comorbid conditions (Pfefferbaum, 1997).

Since both ADHD and trauma are common problems of childhood (Breslau et al., 1991; Giaconia et al., 1995), an overlap between ADHD and trauma may occur by chance alone. However, it can also be argued that the impulsive behaviors associated with ADHD could lead to traumatic experiences (Cuffe et al., 1994), and if so one would expect children with ADHD to have higher than expected. rates of trauma compared with non-ADHD controls. It is also possible that the presence of ADHD in a traumatized child might lead to a more severe posttraumatic clinical picture, which in turn could bring these children to the attention of trauma centers. To our knowledge, there are no answers to these important questions in the extant literature.

Because traumatized children frequently are agitated and inattentive, they may present with ADHD-like behaviors, raising important clinical questions as to whether they have ADHD or trauma-associated phenomena. The presence of PTSD symptoms of increased arousal, such as poor concentration and exaggerated startle response, may mimic ADHD, leading to the potential misdiagnosis of ADHD in these children. Recent work by our group and others has documented that ADHD is a highly familial disorder (Biederman et al., 1992). Thus, if ADHD symptoms in traumatized children represented a reaction to trauma and not "true" ADHD, we would expect to see an absence of familiality of ADHD in such children. However, if traumatized children with ADHD-like features have ADHD, it should be associated with a familial pattern similar to that of other cases of nontraumatized children with ADHD.

A major factor that greatly complicates the search for understanding the association between trauma and ADHD is the high level of psychiatric comorbidity within ADHD. Converging evidence from clinical and epidemiological samples has documented that ADHD is frequently comorbid not only with conduct disorder, but also with anxiety disorders as well as bipolar and unipolar mood disorders (Biederman et al., 1992, 1996b; Butler et al., 1995), which have also been associated with trauma and PTSD. For example, in a large sample of urban young adults, Breslau et al. (1991) found that childhood conduct disorder and preexisting anxiety and depressive disorders were risk factors for exposure to trauma. Similarly, in the National Comorbidity Survey, Kessler et al. (1995) found an association between PTSD and mood (depression and mania), anxiety, substance abuse, and conduct disorders.

Nowhere is the problem of comorbidity more complex than in the case of juvenile mania. Since juvenile mania is commonly associated with extreme violence and severe behavioral dysregulation (Wozniak et al., 1995a), it could either be a reaction to or lead to trauma exposure. Thus, disentangling the association between ADHD and trauma or PTSD requires a careful evaluation of the contribution of psychiatric comorbidity in general and mania in particular.

Although PTSD is frequently associated with trauma, it does not develop in every traumatized person. In fact, data from the National Comorbidity Survey indicate that PTSD develops in only a minority of traumatized subjects (Kessler et al., 1995). This finding raises the possibility that antecedent risk factors may be operant in some individuals that increase the risk for PTSD or other posttraumatic complications. Whether ADHD or any of its comorbid conditions represent a risk factor for PTSD in children is unclear, but the cognitive and social impairment, impulsivity, and comorbidity with conduct disorder, anxiety disorders, depression, and mania that has been noted in ADHD children might place ADHD children particularly at risk for PTSD or other complications of trauma such as mood and anxiety disorders.

The purpose of this study was to evaluate systematically the association between ADHD and trauma using a longitudinal data set of a large sample of referred children and adolescents with ADHD and non-ADHD controls. We tested several research questions: (1) Is ADHD a risk factor for trauma? If that were to be the case, we would expect children with ADHD to have higher rates of trauma than controls. (2) Do children with ADHD symptoms and trauma have "true" familial ADHD, or are these children manifesting the arousal symptoms of PTSD mimicking ADHD? If these children have "true" familial ADHD, we would expect to find ADHD to be equally familial irrespective of trauma exposure. (3) Does ADHD increase the risk for PTSD? If that were to be the case, we would expect the rates of PTSD to be higher in traumatized ADHD children than in traumatized non-ADHD children. (4) Does ADHD increase the risk for trauma-associated depression and anxiety? If that were to be the case, we would expect posttraumatic rates of depression and anxiety to be higher in traumatized ADHD children than in traumatized controls. (5) Do other conditions comorbid with ADHD (conduct disorder, anxiety, depression, mania) increase the risk for trauma or PTSD? If that were to be the case, we would expect that children with these conditions would be more likely to experience a trauma or develop PTSD after a trauma than children without these conditions.

METHOD

Detailed study methodology has been previously reported (Biederman et al., 1992, 1996a). We sampled families through white, non-Hispanic, male probands between the ages of 6 and 17 years. The original sample included 140 ADHD and 120 normal control probands ascertained from psychiatric and nonpsychiatric settings (Biederman et al., 1992,1996a).These groups had 454 and 368 first-degree biological relatives, respectively. After complete description of the study to the subjects, written informed consent was obtained. Potential probands were excluded if their nuclear family was not available for study or if they had major sensorimotor handicaps, psychosis, autism, a Full Scale IQ less than 80, or had been adopted. ADHD and control children were assessed at baseline and reassessed at 4-year follow-up with identical assessment methodology. Subjects were evaluated by raters who were blind to the clinical status and ascertainment site of the probands. All follow-up assessments were made by raters who were blind to prior assessments of the same subjects. At follow-up, 91 % of the ADHD and the normal control probands seen at baseline were successfully recruited. There were no significant differences between subjects successfully followed up and those lost to follow-up on any of the measures used in this study (Biederman et al., 1992).

All children were evaluated using the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Epidemiologic version (Orvaschel and Puig-Antich, 1987); evaluations were based on independent interviews with the mothers and direct interviews of probands and siblings, except for children younger than 12 years, who were not directly interviewed. Diagnostic interviews of mothers and fathers used the Structured Clinical Interview for DSM-III-R. Diagnoses were considered positive if, on the basis of the interview results, DSM-III-R criteria were unequivocally met. For every diagnosis, information was gathered regarding the associated level of impairment, ages at onset and offset of symptoms, number of episodes, and treatment. Based on 173 interviews, the median x was 0.86.

A sign-off committee of board-certified child and adolescent psychiatrists and adult psychiatrists chaired by the senior author resolved all diagnostic uncertainties blindly. We used 2 or more anxiety disorders to summarize the presence of a clinically meaningful anxiety syndrome and refer to this as "multiple anxiety disorders." For children older than 12, diagnosticians combined data from direct and indirect interviews by considering a diagnostic criterion positive if endorsed in either interview. At baseline, assessment was lifetime; at year 4, assessments reflected the interval since the prior assessment.

Diagnoses presented for review were considered positive only if a consensus was achieved that criteria were met to a degree that would be considered clinically meaningful. By "clinically meaningful" we mean that the data collected from the structured interview indicated that the diagnosis should be a clinical concern because of the nature of the symptoms, the associated impairment, and the coherence of the clinical picture.

Socioeconomic status was assessed (Hollingshead, 1975) as well as the DSM-III-R Global Assessment of Functioning (GAF) (0 = worst to 90 = best). Rates of hospitalization were also reported as a reflection of functioning.

We collected PTSD and trauma information at the follow-up only, reflecting the 4-year interval since the baseline assessment. Consistent with DSM-III-R conceptualization of trauma, we considered probands as having been exposed to a traumatic event if they endured an event outside the normal range of human experience. Thus, trauma included violence, any physical or sexual abuse, rape, any life-threatening experience, and witnessing or experiencing a terribly frightening event in which they or another person were in danger of being killed or badly hurt. All assessments of trauma were reviewed by the previously described committee of board-certified child and adolescent psychiatrists to ensure that the experiences reported were out of the realm of usual human experience and would be markedly distressing to anyone as defined by DSM-III-R (Orvaschel and Puig-Antich, 1987).

The diagnosis of PTSD was derived from the module on this disorder from the Diagnostic Interview for Children and AdolescentsRevised. A diagnosis of PTSD was given if the subjects met full criteria for PTSD as defined by DSM-III-R, that is, at least 1 symptom from criterion B (reexperiencing the traumatic event), at least 3 symptoms from criterion C (avoidance of stimuli associated with the trauma or numbing of general responsiveness), and at least 2 symptoms of increased arousal from criterion D. We used the Pearson x2 (for nominal dependent variables) and t tests (for normally distributed continuous dependent variables). Statistical significance was determined at the 5% level.

RESULTS

Twelve percent (n = 15) of the 128 ADHD probands and 7% (n = 8) of 109 non-ADHD comparison subjects. reported a trauma during the follow-up period (not significant). The rate of PTSD was low among ADHD probands (2%;n= 2) and not significantly different from the control group in which no subjects developed PTSD. For the purpose of this analysis, the proband samples were stratified by the presence or absence of trauma into 4 groups: (1) ADHD without trauma (ADHD;n= 113); (2) ADHD plus trauma (ADHD + trauma;n= 15); (3) controls without trauma (controls;n= 101); and (4) controls plus trauma (controls + trauma;n= 8).

Although the groups did not differ in social class or family intactness, a significant difference was identified in age, accounted for by the somewhat younger age of ADHD probands (Table 1). Thus, subsequent statistical analyses are corrected by age.

No meaningful differences were found between ADHD and control probands in the types of trauma experienced by each group (Table 2). The most common traumas in both groups included witnessing a disturbing or violent event (n = 6), being involved in a serious accident (n = 6), being threatened with a weapon (n = 3), and being sexually abused (n = 3). All traumas reported were isolated events with the exception. of the abused children and the combat victim, who experienced repeated traumatization.

A positive family history of ADHD was identical (40%) in ADHD probands with and without trauma, and both ADHD proband groups differed from controls in the familiality of this disorder (Fig. 1).

No meaningful differences were identified in comparisons between the ADHD probands with and without trauma and controls with and without trauma on baseline or follow-up rates of oppositional disorder, major depression, dysthymia, multiple anxiety disorders, alcohol abuse, drug abuse, or the mean number of psychiatric disorders. In contrast, trauma-exposed ADHD probands had significantly higher baseline rates of bipolar disorder than the nonexposed ADHD probands (Table 3).

At the 4-year follow-up we found no significant differences between ADHD probands with and without trauma or controls with and without trauma on rates of new-onset conduct disorder, bipolar disorder, any anxiety, alcohol dependence, or drug dependence. However, regardless of the presence of ADHD, the trauma-exposed probands had significantly higher rates of new-onset major depression and dysthymia (Table 3). Regardless of the presence of trauma, ADHD probands were more likely than controls to develop anxiety and substance use disorders.

Although the rate of PTSD was higher in ADHD probands exposed to a traumatic event than in controls (13% versus 0%, not significant), only 2 ADHD probands exposed to a traumatic event developed PTSD. This represents an overall rate of PTSD of 1 % (n = 2) in the sample as a whole (N= 237) and a rate of 9% among all traumaexposed probands with and without ADHD (n = 23).

Overall, GAF scores at baseline and follow-up were worse in ADHD probands versus controls, regardless of the presence of trauma. Furthermore, at follow-up, the ADHD probands with trauma had significantly worse scores on the GAF scale than those ADHD probands without trauma (48.8 versus 53.7) and significantly worse scores than controls with trauma (48.8 versus 65.1) (Fig. 2). Hospitalization occurred only among ADHD probands and at a slightly higher rate among ADHD probands with trauma versus ADHD probands without trauma. This finding, however, did not reach statistical significance.

DISCUSSION

Using data from a large longitudinal sample of well-characterized boys with and without ADHD, we failed to find meaningful associations between ADHD, trauma, and PTSD. Instead, we identified early bipolar disorder as an important antecedent for later trauma. If confirmed, this finding would suggest that the severe psycho-pathological picture associated with juvenile mania could lead not only to severe morbidity in affected youths, but also to trauma.

Our finding showing that ADHD was familially indistinguishable in traumatized and nontraumatized children with ADHD argues against the hypothesis of etiological associations between ADHD and trauma. Instead, this finding suggests that clinicians should consider ADHD in the differential diagnosis of a traumatized child if the symptoms of the disorder are present rather than automatically attributing these symptoms to part of a posttraumatic syndrome.

We also failed to find ADHD to be a significant risk factor for the development of PTSD among traumatized children. In fact, only a small minority (9%) of traumaexposed probands developed PTSD irrespective of their ADHD status. The finding that PTSD developed in only a small minority of traumatized children is consistent with results in adults reported in the National Comorbidity Survey that also documented that PTSD develops in only a minority of traumatized adults (Helzer et al., 1987; Kessler et al., 1995). The literature suggests that protective factors operating at various stages of development may buffer children from posttraumatic suffering. For example, in a study of children and adults surviving Scud missile attacks in Israel, symptoms in children correlated with symptoms in their mothers. These authors concluded that maternal stress-buffering capacity plays a crucial role in minimizing suffering in traumatized preschool children (Laor et al., 1997). In addition, a study of adolescents exposed to an earthquake found that depressive symptoms in adolescents not treated with psychotherapy worsened over time, while those receiving brief trauma/grief-focused psychotherapy treatment demonstrated improvement in PTSD symptoms but no change in depressive symptoms (Goenjian et al., 1997). Additional studies addressing protective and risk factors unique to children may help identify traumatized children at risk, allowing more effective targeting of services after trauma or disaster. Although additional research is needed to help identify which factors mediate the development of PTSD in traumatized children, our results suggest that children may not be more vulnerable than adults to developing PTSD after a trauma. If confirmed, our findings should encourage clinicians to examine alternative diagnostic formulations other than PTSD in traumatized children with abnormal behaviors.

Although we found a significant association between trauma and the development of subsequent major depression and dysthymia, these associations were independent of ADHD status. This suggests that depression may be a nonspecific response to trauma in children with and without ADHD. These findings in traumaexposed children with and without ADHD are consistent with the literature that also identified high rates of depression among subjects with PTSD (Breslau et al., 1997; Hubbard et al., 1995). For. example, Giaconia et al. (1995) also found that adolescents with PTSD had higher rates of depression.

Although the adult literature suggests that anxiety is a common sequela of trauma, we did not find anxiety to be a common outcome of trauma whether or not ADHD was present. While these results are preliminary, it may be that anxiety is a more common sequela of trauma among adults than children. Future follow?up studies evaluating traumatized children may shed additional light on the associations between ADHD, anxiety, and trauma in a developmental context.

While there is a body of literature assessing rates and correlates of PTSD following trauma (Breslau et al., 1997; Hubbard et al., 1995; Kessler et al., 1995), little has been written on antecedent risk factors for trauma. Our results showed that the diagnosis of bipolar disorder at baseline assessment in children with ADHD was the most significant predictor of the development of later trauma during the 4-year follow-up period. Although not entirely surprising, this finding, to our knowledge, has not been previously reported. Considering that mania is a very severe disorder with high rates of explosiveness, aggression, impulsivity, and poor judgment (Wozniak et al., 1995a), it could predispose an affected child to trauma exposure. In addition, we and others documented than mania is a strongly familial disorder (Strober et al., 1988; Wozniak et al., 1995b). Thus, a manic child may be surrounded by similarly disturbed relatives who could become perpetrators of trauma or place a child at risk for trauma.

However, since all the bipolar children in our study also had ADHD, we do not know whether mania predisposes children to trauma outside the context of ADHD. Although both ADHD and bipolar disorder are associated with impulsivity and poor judgment, ADHD plus bipolar disorder and not ADHD alone significantly increased the risk of trauma exposure. This finding further supports the notion that the mania diagnosis in childhood is distinct from that of ADHD. Considering that ADHD plus mania is often characterized by excessive impulsivity, poor judgment, hypersexuality, and extreme irritability which is often violent (Geller and Luby, 1997) suggests that the combination of ADHD .and mania should raise a clinician's suspicions regarding a child's vulnerability to trauma.

Similar associations between trauma and mania have been reported in adults. Kessler et al. (1995) found elevated lifetime rates of mania among adult and adolescent (aged 15 through 54 years) subjects with PTSD. Helzer et al. (1987) reported a strong association between manic-depressive illness and PTSD in adult subjects but did not determine whether mania was primary or secondary to the trauma. This report further suggests that behavior problems including "stealing, lying, truancy, vandalism, running away, fighting, misbehavior at school, early sexual experience, substance abuse, school expulsion or suspension, academic underachievement, and delinquency" prior to age 15 predicted later PTSD (Helzer et al., 1987). Not surprisingly, the authors concluded that "this association may mean that persons with such behavior in childhood had a greater likelihood of experiencing trauma later on" (p. 1632). However, because of lingering skepticism surrounding the diagnosis of mania in children, bipolar disorder has not been routinely assessed in pediatric populations.

If childhood mania is a risk factor for subsequent trauma, this finding could have important clinical and therapeutic implications. When traumatized children present with severe irritability and mood lability, there may be a tendency by clinicians to attribute these symptoms to having experienced a trauma. Our longitudinal results, in contrast, suggest the opposite: mania may be an antecedent risk factor for later trauma and not represent a reaction to the trauma. If confirmed, these results could help dispel the commonly held notion that mania-like symptoms in youths represent a reaction to trauma.

Our findings showed markedly lower GAF scores among traumatized ADHD youths as opposed to controls with trauma or ADHD children without trauma, indicating severe psychosocial dysfunction in these children. This finding might shed light on the clinical observation that a preponderance of traumatized children referred for treatment have ADHD symptoms. While our findings suggest that ADHD does not confer any particular risk for trauma, PTSD, or other posttraumatic conditions, traumatized children with ADHD function worse than traumatized children without ADHD, and thus may be more likely to present for treatment.

The findings reported in this study must be seen in light of methodological limitations. Since we assessed trauma only for the 4-year follow-up period and did not make a lifetime assessment of trauma, we cannot rule out the possibility that trauma could have predated or contributed to the development of bipolar disorder in some children. However, if trauma were to lead to mania rather than the other way around, we should have found that children without mania traumatized during the follow-up period would be more likely to go on to develop mania. This was not the case in our study.

Our number of trauma-exposed subjects was relatively small (n = 23), and a very small number of traumatized subjects (n = 2) went on to develop PTSD. To avoid incurring a type I error, however, we used a low threshold for statistical significance despite multiple tests. Nevertheless, our results should be viewed as preliminary until confirmed with larger samples.

In addition, parents and children may be reluctant to disclose trauma to medical evaluators for fear of reporting to the local authorities, further contributing to the possibility of unreported trauma. Nonetheless, the longitudinal design of this study allowed for the opportunity to evaluate specific risk factors predisposing children to trauma which occurred during the follow-up period as well as to evaluate posttraumatic effects beyond the diagnosis of PTSD.

Despite these considerations, our results failed to find meaningful associations between ADHD, trauma, and PTSD. Instead, we identified early bipolar disorder as an important antecedent for later trauma, and dysthymia and major depression as important complications of trauma. If confirmed, these findings would suggest that the severe psychopathology associated with mania can lead not only to severe morbidity in affected youths, but also to trauma. More work on this important subject is warranted.

Clinical Implications

This study demonstrates that children with ADHD and trauma have the same family history of ADHD as children with ADHD without trauma. This result suggests to clinicians that traumatized children with symptoms of ADHD should be evaluated and treated for ADHD, rather than having their symptoms ascribed to a PTSD diagnosis. Our longitudinal design also led to the finding that childhood mania is a significant risk factor for trauma and suggests to clinicians that mood lability in traumatized children may precede rather than represent a sequela of trauma. This would further suggest that manic children in particular are at risk for trauma, possibly because of their reckless, disinhibited state, and should be monitored closely to avoid trauma. Our results also suggest that after a trauma, children are most likely to develop depression, rather than PTSD or anxiety disorders. If confirmed, these findings aid clinicians in their diagnostic approach to traumatized children: Rather than attributing psychiatric symptoms in a traumatized child to PTSD, clinicians should be alert to the possibility of antecedent ADHD or mania in traumatized children and to the possibility of depression as a complication of trauma.

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