ADHD? ODD? It Could Be Trauma

Symptoms and responses following trauma or during chronic exposure to stress can look like many other disorders. Two of the most common diagnoses in the school setting for children of all ages are Attention Deficit Hyperactivity Disorder (ADHD) and Oppositional Defiant Disorder (ODD). It is very common for trauma to be mistaken as ADHD or ODD, even by the most well respected and experienced educators. The differential diagnosis isn’t easy, but it is helpful to understand how and why this common mistake is made.

The differential diagnoses between trauma, ADHD, and ODD present significant challenges. First, there are several overlapping symptoms of PTSD, ADHD, and ODD. The diagnoses are not mutually exclusive, and there are currently significant assessment limitations.

This reality is terrifying and convicting for many educators. Often, it is the classroom teacher who first suggests the idea that a child may have ADHD, and this suggestion typically results from the child not “fitting into the box” of behavior expected of students in traditional learning environments. Uninformed educators, social workers, parents, and even medical professionals can quickly turn this suggestion into a misdiagnosis if they are not asking the right questions. In the end, a child who has experienced trauma and needs therapy may instead receive medication to treat a condition they do not have.

FOCUSED FOLLOW-THROUGH

When children present salient symptoms that PTSD and ADHD share, begin to ask yourself: “Is it PTSD or ADHD? Both?” Unfortunately, this question is not an easy one to answer.

FOCUS FURTHER

Learn more about overlapping symptomology in the eLearning course Trauma-Informed, Resilience-Focused Assessment and Differential Diagnosis:

To learn more about overlapping symptomology, or to make better decisions when diagnosing mental and behavioral health disorders, consider these offerings from Starr Commonwealth.

Understanding Private Logic and Behavior

Imagine an eleven-year-old student who, their entire life, has experienced that when adults in their home yell, someone gets hit or hurt. And then this student is in your classroom and you, in a well-intentioned and benign manner, raise your voice to get the attention of the class. When this happens, he is immediately triggered based on his past experiences. And then his best friend sitting next to him pokes him in the shoulder. The student reacts, possibly hitting his best friend. On the surface this looks like an irrational, unstable, and aggressive behavior. But underneath, based on the what is called the student’s private logic, there is some level of rationality to what has occurred, but his body is still scared. We have to be curious rather than certain when observing behavior that seems to not make sense on the outside.

There is a distinct link between a student’s private logic and their behavior. Private logic can be described as how a person views themselves, others, and the world around them. Private logic is created as a result of experiences. Based on that logic, they act accordingly. Think of private logic as an invisible backpack. In the backpack, a student carries around beliefs about themselves, beliefs about the adults that take care of them, and lastly, beliefs about other people they interact with in their lives and beliefs about the world. This logic is a result of experiences – both good and bad – over the course of development and life. If their lives have been filled with fear, abandonment, and anger, their private logic will be consistent with those experiences. They will view themselves as scared and powerless, others will not be trusted, and the world to them is seen as a scary place. If their lives have been filled with comfort, connection, and love, their logic will be consistent with those experiences. They will view themselves as capable and valued. They will see others as consistent and approachable, and will view the world as filled with opportunities of goodness and hope.

FOCUSED FOLLOW-THROUGH

So, the next time a child you work with makes a comment about themselves or others, or acts in a particular way—either positive or negative, remain curious! Based on what I just witnessed:

“How might this child view themself? How might this child view others? How might this child view the world?” Then, approach your care with their world-view in mind!

FOCUS FURTHER

Learn more about Private Logic in
the eLearning course Children of Trauma & Resilience:

To learn more about private logic, or to incorporate private logic-focused resources into your profession, consider these offerings
from Starr Commonwealth.

Trauma in Disguise: Introducing Trauma-Informed, Resilience-Focused Assessment and Differential Diagnosis

Trauma-Informed, Resilience-Focused Assessment and Differential Diagnosis is available now. Below, Dr. Cae Soma explains the origins of this course.

How can one benefit from taking Trauma-Informed, Resilience-Focused Assessment and Differential Diagnosis (TIRFADD)?

TIRFADD begins to explain to professionals how and why mental health disorder symptoms and reactions we see can be misinterpreted. We call this “trauma in disguise”, and make critical connections through symptoms and reactions displayed by the child. These behaviors look and sound like other mental health disorders. What TIRFADD teaches is centered around an overlap in symptomology. In addition, it’s not enough to say there’s an overlap—we need to know why this overlap exists. So, TIRFADD explains how the manifestation of trauma in the body, overtime, often appears as other disorders

What’s most fascinating, and an issue we dive deeply into in the course, is that the onset ages of mental health disorders follow the exact course of what’s happening in the body for those experiencing trauma:

 

More and more research has been done about how trauma looks like every other mental health disorder. It starts with anxiety disorders and moves up into behavior disorders, mood disorders, and at the high school level we begin to see all of the at-risk coping skills (substance abuse, gang involvement, self-harm). We have known for a long time, at the clinical level, that these kids don’t have true ADHD. It then shifted to educators, where well-intentioned teachers refer parents to ADHD screenings.

Doctors have not been trained in either med school or residency about the overlapping symptoms of mental health disorders and trauma. So, of course, a well-intentioned physician is trained to diagnose mental health disorders. That child may fit the criteria of a mental health disorder, but physicians are not approaching with a trauma-informed lens. When this occurs, either the symptoms and behaviors get worse, or things don’t get better. When things do get better, it’s because there is a true ADHD. Unfortunately, usually that does not happen—usually things get worse.

This course was created for any practitioner, or parent for that matter, who has found themselves in this difficult situation.

How did the overlap between trauma and ADHD symptomology, and subsequently the need for this course, come to be?

Beginning in 2005, there has been a proposal for the Diagnostic and Statistical Manual of Mental Disorders (https://www.psychiatry.org/psychiatrists/practice/dsm - American Psychiatric Association) to include a new diagnosis known as Developmental Trauma Disorder. Starr has been teaching about it, and support the proposal of that diagnosis. Put simply, it explains how a child grows and develops within the context of toxic stress and trauma, of course they’ll have these symptoms like ADHD, etc. This was the first place where our attention was caught with overlapping symptomology. They put into words what we had experienced with children. Unfortunately, it has yet to be adopted for the DSM. We teach about DTD because it would be a tremendous diagnosis. As opposed to PTSD, DTD would explain that symptoms and reactions have been compounded over a lifetime, not based on a single event. For now, and with the help of TIRFADD, physicians can use whatever diagnosis they may need to get the best service for kids, but with the understanding that what’s driving that diagnosis is probably trauma. In this course, we’re going to give you as much information as we can to be as aware as possible about the overlapping symptomology. It’s a difficult subject, as it’s not black and white. We can’t just follow the symptom and reaction – most likely you’ll get what you’re looking for.

We must remain curious and explore the possibility of what role underlying trauma may be playing in our children’s behavior.

Trauma and Resilience Summit Panel and Film Viewing

As part of the Summit experience, Starr is excited to announce that a panel of experts will be assembled to provide their first-hand experience in healing trauma and building resilience in clinical, educational, and residential settings.

A special introduction will be given by Starr Commonwealth President & CEO Elizabeth Carey, where she will share her perspective on the intersection of human services, healthcare, and education, in addition to the many opportunities for future partnership to continue to empower professionals,  heal trauma, and build resilience in all children – so all can flourish.

Meet the Panelists

Mackenzie Bentley, MA, LMFT, Director of Therapeutic Services at Starr Albion Prep; oversees the clinical treatment program of at risk youth ages 12-18 years of age. Mackenzie supervises master level licensed therapists who work with various populations through evidenced based practices.

Mackenzie graduated with her master’s degree in counseling psychology with an emphasis in marriage and family therapy from the University of San Francisco in 2011. She has a passion and investment in supporting the development of adolescents and has been facilitating that growth to youth on Starr Commonwealth’s campus for almost 7 years.

Mackenzie is also the lead trainer on the topic of Commercial Sexual Exploitation of Children (CSEC) for Starr Albion Prep and facilitates CSEC groups on campus.  She also has extensive experience serving diverse populations of troubled youth including those on the autistic spectrum.

What excites you most about the evolution of the field of trauma-informed, resilience-focused care?
"Working in the child and welfare division of residential placement, it is fulfilling the amount of resources offered through a trauma-informed lens to direct care staff, teachers, parents, and therapists which allows us to facilitate growth and resilience in youth in a more person centered way."

How have trauma-informed, resilience-focused practices transformed your approach to your profession?
"While I may not have always called my approaches to helping students or families "trauma-informed" I have always held the belief that the work that either I,  or those apart of my team do,  are responsible for helping our youth or families, rather than hurt them. Our mission has to be 'To heal, not to re-traumatize"- even if not intentional. My therapeutic approach has always been from a systems perspective in that it takes a team to meet all the needs of the family or youth, not just one person."

Why are you driven to heal the children, families, and/or communities you support?
"The children we serve are the upcoming adults that will influence my future and the wellbeing of our generations to come. If there needs to be placements for students like those that we serve at Starr Albion Prep, I would like to be a part of the teams that get to support those students as I believe every child has a chance even if they were not given the chance early on in their childhood to be successful."

Erica Giron is a Student Support Services Coordinator for Battle Creek Public Schools, serving 4 secondary buildings to drive the district’s transformation. She has a Special Education background with endorsements in the areas of Emotional Impairments, Learning Disabilities and Language Arts. Erica is a proud graduate from Western Michigan University’s College of Education. Her experience in teaching is at the middle and high school level in Battle Creek, Kalamazoo and Albion. Erica comes from a diverse background in educational experiences including, a Special Educator, a middle school English teacher, a program coordinator and teacher for an alternative middle school program and other district initiative alignment work with Trauma Informed Care and Restorative Practices. She has also taught at Starr Albion Prep, a residential treatment facility in Albion, MI where she worked with students who are in the programs of Abuse and Neglect, Juvenile Justice, and Sexually Reactive Youth. In addition to serving Battle Creek Public Schools, Erica currently also supports the City School District of Albany New York with similar services.

Erica was born and raised in New Jersey until she was 13 years old when she made the decision to move to Michigan with the goal of creating a strong relationship with her father and his family. She has happily lived in the Kalamazoo area ever since. Her passion for trauma and resiliency comes from personal experiences in her own past and wanting to give back in a way that people in her life gave for her. Erica is able to train not only from an educated perspective, but also from the lens of someone who has had similar experiences in her own life.

A Jackson, MI native, Heather Stiltner is a Licensed Professional Counselor in the State of Michigan, in addition to being a Nationally Certified Counselor and a Certified Trauma Focused Cognitive-Behavioral Therapist. She obtained her Bachelor of Arts degree from the Spring Arbor University, majoring Business Management. Her graduate work was completed at Siena Heights University in Organizational Leadership. Additionally, she obtained a second Master’s Degree at Spring Arbor University in Masters of Counseling.

Heather’s work with children, teenagers, and their families began shortly after her obtaining her BA as she developed, implemented, and directed an innovative non-profit agency, The Lily Missions Center, in Jackson. The Lily Missions Center serves children and families by providing a safe, free place to go after school for food, academic skills, extracurricular experiences, and social engagements.

Heather’s clinical experience includes home-based counseling, out-patient therapy, therapeutic work with victims of sexual abuse and human trafficking, and counseling for teens and their families in residential placement. She combines her clinical counseling expertise with her leadership and business knowledge to offer clients a unique perspective of evidence-based interventions to address life challenges and build resilience.

She is currently on staff at Starr Albion Prep, a Sequel site, operates The Lily Missions Center, and provides clinical supervision for LLPCs in the community.

Amy Swis is a licensed Clinical Social Worker as well as a Licensed Trauma Trainer. I have been working with children, adolescents, families, and the community at large for over thirty years. I have worked internationally as a Peace Corps Volunteer and domestically as a School Social Worker, Supports Coordinator, Disability Advocate, and Youth Worker. I have worked as a School Social Worker for Airport Community Schools, Dearborn Public Schools, and Detroit Public Schools. Currently, I am a School Social Worker at Lincoln Park Public Schools. A primary focus for Lincoln Park Public Schools is a Trauma Informed and Resiliency Focused approach with students and a Self Care component for staff. Building capacity within our practice and the district is a passion in order for staff and students to lead pro-active lives. This will empower neighborhoods and the communities we serve; more specifically for marginalized citizens.

What excites you most about the evolution of the field of trauma-informed, resilience-focused care?
"What excites me about the evolution of trauma-informed, resilience focused care is the neuroplasticity of the human brain."

swis class displaying circle of courage

How have trauma-informed, resilience-focused practices transformed your approach to your profession?
"It is a fascinating and exciting time in my career for new strategies.  I am proud to be involved with a school district that embraces this approach and is leading the way in a new paradigm shift."

Why are you driven to heal the children, families, and/or communities you support?
"I believe in healing children, families, and communities because it builds capacity in our homes, neighborhoods, and personal/professional lives while strengthening relationships."

Kim Wagner has been an occupational therapist for 26 years with 20 of them in the public school system.  She also worked many years at sensory clinic and sensory camp.  Kim has a master's degree in occupational therapy with a minor in early childhood development.  She has also been certified in Infant Massage, Brain Gym, The Alert Self-Regulation Program, Trauma Informed Trainer (by STARR Global) and the Sensory Integration Praxis Test and Treatment.  Kim currently works in Lincoln Park schools as an OT for the general education population.  Kim is on the Behavior Support team and is part of the Trauma Informed Team. Kim's focus in her current position is providing regulation, sensory and trauma informed behavior support to students and teachers for a more successful educational experience.

What excites you most about the evolution of the field of trauma-informed, resilience-focused care?
"Over my years as an occupational therapist in the public school sector I have seen more and more students referred to special education programs.  Many of these students did not fit into a program, they may have exhibited some “EI type behaviors” (Emotionally Impaired) but did not fully meet the criteria for that eligibility.  Or they had sensory seeking behaviors but did not appear to truly have ADHD. I witnessed students in the general education setting who put their heads down and refused to do any work or had severe behaviors and were punished with removal or privileges revoked.  Many of us knew these were not “bad kids” or children who belonged in a secluded setting but we did not have the right answers as to the “whys” of their behavior or how to help these children.  And then we learned about trauma and how it affects the brain, how it affects a child’s development and a child’s whole life.  We started asking the right questions and coming up with some right answers as a result.  I am excited that trauma-informed, resilience- focused care is not only being investigated but programs are developing.  This means that all children will benefit.  This means that educators will have more resources at their disposal.  Research shows that all staff and students benefit from trauma-informed practices being implemented in the school system whether they have themselves experienced trauma. The National Association of School Psychologists have identified that trauma-informed practices promote feelings or physical, emotional and social safety for students and staff. I am ecstatic that children are now being looked at as just that, children – not good or bad, not a label or an eligibility, but children first.  We have a long way to go but I believe we are on the right path.  I know we are in Lincoln Park, I have seen so many positive changes."

How have trauma-informed, resilience-focused practices transformed your approach to your profession?
"I am definitely more curious and empathetic than I used to be.  I have worked for a long time with students on sensory regulation, so in regards to sensory processing I have always been open and curious, observing children to figure out what type of sensory input they need for success and comfort.  However, that did not always apply to my work with students regarding challenging behaviors.  Through education on trauma, its effect on us, and resilience practices I have become more open and curious when challenging behaviors are involved.  I observe, interact, engage and explore more, asking students what they need and offer suggestions as to what might help them feel more secure.  I notice our district does not go straight to punitive measures anymore and I have become creative with restorative resolutions working on repairing relationships rather than them being further torn down.  I, along with my colleagues, hear our students’ voices more now."

Why are you driven to heal the children, families, and/or communities you support?
"I am naturally a very empathetic person; I don’t think anyone who goes into our fields are not empathetic.  We are driven to help others.  For a long time I thought helping was fixing.  I learned through a family difficulty that fixing is not helping.  Supporting and providing resources helps others become more independent and leads to healing.  In my previous school position, I worked with students individually or a small group but in a setting separate from a classroom.  I did not see the change I hoped for, for my students.  I transferred to my current school district and my role was vastly different.  I was able to help whole classrooms, whole schools and was responsible for the whole district.  It was overwhelming but exciting.  My primary role is on the Behavior Support Team working with students who have severe behavior.  I met a student who had been severely abused by his own family member.  He was abused physically and sexually and deprived of any comfort at a very early age.  I saw the damage that abuse did to this child.  He was in “flight or fight” mode all of the time, never in “freeze” mode.  He eloped out of the classroom multiple times in an hour.  The slightest challenge or sense of being overwhelmed sent him into acts of physical aggression I had never seen before in anyone.  And my heart broke.  Cognitively I knew abuse happens, but I had never realized the depths of its damage.  This poor child was out of his skin all of the time.  He has gotten a lot of help and stability and is doing so much better, but it will take years for him to feel safe.  I pray that he finds continued peace and comfort.  Any time my job feels overwhelming or difficult, or I am faced with a student who is exhibiting damaging and frustrating behaviors, I think of that first little boy.  I know that I have to show up for him and all of our children every single day because they deserve it."

Following our expert panel, we will be showing the film Resilience: the Biology of Stress and the Science of Hope, with a Q&A with Starr Director of Professional Training & Coaching Kathy Hart.

This event is free and open to the public. We encourage all attendees to invite their colleagues to this important forum. If you know someone who is driven to heal, refer them to our RSVP page, and you'll receive a coupon code for 20% any eLearning product on our store when they attend.

Register for the full summit