Trauma and traumatic stress, according to a growing body of research, are closely associated with attention deficit hyperactivity disorder (ADHD or ADD). Trauma and adversity can alter the brain's architecture, especially in children, which may partly explain their link to the development of ADHD.
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Trauma and traumatic stress, according to a growing body of research, are closely associated with attention deficit hyperactivity disorder (ADHD or ADD). Trauma and adversity can alter the brain’s architecture, especially in children, which may partly explain their link to the development of ADHD. ADHD and trauma can also present similar symptoms, which may complicate assessment. Trauma, if present with ADHD, can exacerbate ADHD symptoms. At the same time, ADHD may also increase the risk of exposure to trauma.
Our increasing knowledge of trauma’s impact necessitates trauma-informed approaches to ADHD assessment and treatment. For clinicians, especially, it’s critical to understand the relationship between ADHD and PTSD, what traumatic stress does to the brain, what may constitute trauma (including who is more at risk for experiencing unique traumatic stressors), and how to protect young patients against it.
Traumatic stress, apart from other factors like premature birth, environmental toxins, and genetics, is associated with risk for ADHD. The connection is likely rooted in toxic stress – the result of prolonged activation of the body’s stress management system.
When confronted with an acute adverse stressor, the body releases adrenaline, triggering the fight or flight response. Cortisol, a stress hormone, is also released, helping to mobilize the body’s energy stores, activate the immune system, and even briefly enhance memory.
When this stress response is activated in children in the context of supportive adult relationships, these physiological effects are buffered. However, when these buffering relationships are unavailable, and when the stress response is long lasting, toxic stress may be the outcome.
Toxic Stress and the Brain
Studies indicate that toxic stress can have an adverse impact on brain development in children. Regions of the brain involved in fear, anxiety, and impulsivity may overproduce neural connections, while areas dedicated to reasoning, planning, and behavioral control may actually produce fewer neural connections. This may lead to what we term maladaptive behavioral responses – they include ADHD and other conditions like anxiety and mood disorders.
Toxic levels of stress hormones can even cause neuronal cell death, especially in the prefrontal cortex (a region associated with executive function, self-regulation, and attention) and the limbic systems (associated with learning, memory, emotional regulation, and reactivity).
Another way to understand how traumatic stress impacts ADHD and overall well-being is to look at the science behind adverse childhood experiences (ACEs). ACEs are stressful or traumatic events occurring before the age of 18 that have negative effects on physical, social, and emotional well-being. They include but are not limited to:
As ACEs accumulate, they also increase the odds of high-risk health behaviors and can eventually lead to the most severe outcome associated with ACEs: early death.
One study of more than 17,000 adults found that, as participants reported more adverse experiences in childhood, the chances of participating in risk behaviors and of developing a chronic disease also increased.1 According to the study, adults with four or more ACEs are:
More than twice as likely to have heart disease and experience stroke
At about four times greater risk for chronic bronchitis or emphysema
The same study found that more than half of adults reported at least one adverse childhood experience, and more than a quarter reported two or more. Another national survey on children found similar results.2
ADHD severity increases as ACE scores increase. Socioeconomic hardship and having a caregiver with a mental illness significantly increase the odds of a child having moderate to severe ADHD.
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Our study, as is the case with many studies on ACEs and health, has some limitations:
These studies do not measure when trauma occurred, its duration, or its severity.
ACEs in these studies are also weighted equally, when in reality, some traumas are much more impactful than others.
ACEs are past traumatic events, meaning there may not be a current experience of trauma.
A history of adverse experiences in childhood alone isn’t diagnostic of having trauma.
Difficulty concentrating and learning in school
Distractibility
Disorganization
Often doesn’t seem to listen
Difficulty sleeping
Restlessness
Hyperactivity
Trauma can make children feel agitated, troubled, nervous, and on high alert — symptoms that can be mistaken for ADHD. Inattention in children with trauma may also make them disassociate, which can look like a lack of focus — another hallmark symptom of ADHD. The fact that ADHD and child traumatic stress frequently co-occur with other conditions like mood disorders, anxiety, and learning disabilities make it all much harder to tease apart.
Traumatic stress can worsen ADHD symptoms. Up to 17% of trauma-exposed children meet ADHD criteria, and the co-occurrence of each worsens the effects of the other. Trauma also impacts specific brain regions that may also increase:
Inattention, impulsivity, and hyperactivity
Social difficulties
Learning difficulties
Symptoms of common co-occurring disorders (mood disorders, anxiety, conduct disorder)
ADHD is characterized by deficits in attention, behavioral inhibition, and regulation. PTSD is characterized by avoidant and hypervigilant behavior, and re-experiencing of the trauma.
ADHD’s symptoms are pervasive and cause significant functional limitations. PTSD causes physiologic, cognitive, and emotional changes in how a person processes stressors.
Interpersonal and self-regulatory problems
Substance abuse
Co-occurring mental health disorders
Children with ADHD also have higher rates of child maltreatment and accidental traumas (i.e. injury).
Trauma and Children of Color
Studies show that individuals who experience microaggressions and persistent racism also demonstrate sustained toxic stress responses. Children of color are also at increased risk of living in concentrated poverty, which is tied to moderate and severe ADHD as well as having an ADHD diagnosis.
Psychosocial History
The standard screening tools for ADHD symptoms don’t systematically identify family environment factors, high-risk behaviors, and other adversities. Many clinicians neglect to ask about adverse childhood experiences – a recent study found that approximately one-third of pediatricians do not usually ask about any ACEs, while 4% reported usually asking about all ACEs types.4 To forgo assessing psychosocial history means missing out on factors that play a role and potentially worsen ADHD symptoms, or inadvertently confusing traumatic stress for ADHD.
Clinicians should assess for traumatic events and the time they occurred while assessing for ADHD. A range of trauma screening tools are available (for a list of trauma screens, visit The National Child Traumatic Stress Network).
It’s also important to assess the child’s strengths and sources of support, as they can build their capacity for resilience and can be leveraged when managing ADHD, traumatic stress, or both. Clinicians should gather information from a variety of perspectives, including parents, the school, other people in the child’s life, and even the child, if appropriate.
Minimize the Effects of Trauma & Toxic Stress
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Several factors are known to buffer the effects of trauma and toxic stress in children, like:
A supportive family environment and social networks
Concrete support for basic needs
Nurturing parenting skills
Parent employment and education
Access to health care and social services
An integrated healthcare model that includes wrap-around care coordination and partnerships with schools and community-based organizations is the best way to optimize these powerful, protective factors.
Trauma-Informed Care
Clinicians should remember these four “Rs” associated with trauma-informed care:
Realize the widespread impact of trauma and understand potential paths for recovery
the widespread impact of trauma and understand potential paths for recovery Recognize the signs and symptoms of trauma in patients, families, staff, and others involved
the signs and symptoms of trauma in patients, families, staff, and others involved Respond by fully integrating knowledge about trauma into policies, procedures, and practices
by fully integrating knowledge about trauma into policies, procedures, and practices Resist re-traumatization of children and the adults who care for them
Clinical judgement on medication. Some studies suggest that those with PTSD symptoms may not react well to stimulant medications, which are first-line treatments for ADHD.
Some studies suggest that those with PTSD symptoms may not react well to stimulant medications, which are first-line treatments for ADHD. Psychotherapy , including trauma-focused cognitive behavioral therapy (CBT).
, including trauma-focused cognitive behavioral therapy (CBT). Relaxation and stress-management skills. Emerging science shows the benefits of mindfulness strategies as adjunctive treatment for children with ADHD, which has shown positive impacts on children who experience trauma.
The content for this article was derived from the ADDitude Expert Webinar “How Stress and Trauma Affect ADHD in Children of All Colors — and How to Heal the Wounds” by Nicole Brown, M.D., MPH, MHS, which was broadcast live on October 15, 2020.
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1 Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., Koss, M. P., & Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. American journal of preventive medicine, 14(4), 245–258. https://doi.org/10.1016/s0749-3797(98)00017-8 2Bethell, C. et. al. (2014). Adverse Childhood Experiences: Assessing The Impact On Health And School Engagement And The Mitigating Role Of Resilience. Health Affairs, 33(12). https://doi.org/10.1377/hlthaff.2014.0914 3 Brown, N. M., Brown, S. N., Briggs, R. D., Germán, M., Belamarich, P. F., & Oyeku, S. O. (2017). Associations Between Adverse Childhood Experiences and ADHD Diagnosis and Severity. Academic pediatrics, 17(4), 349–355. https://doi.org/10.1016/j.acap.2016.08.013 4 Kerker, B. D., Storfer-Isser, A., Szilagyi, M., Stein, R. E., Garner, A. S., O’Connor, K. G., Hoagwood, K. E., & Horwitz, S. M. (2016). Do Pediatricians Ask About Adverse Childhood Experiences in Pediatric Primary Care?. Academic pediatrics, 16(2), 154–160. https://doi.org/10.1016/j.acap.2015.08.002
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