1. Vanessa Watson1, Ali Marsh1,2, Felicity Miller1
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
Client experiences and clinical observations- Ali?
Private doctors diagnosing ADHD in most drug users they saw and prescribing stimulants

2. ADHD and PTSD?
Traditional conceptualisations of these disorders would view them as quite distinct from one another

3. ADHD and PTSD Share numerous common symptoms. E.g.:
Heightened startle response
Inattentiveness
Feelings of detachment
Irritability
Anger outbursts
But why would we even compare the two?

4. 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
ADHD prevalence in community is 3-7%. PTSD prevalence is ?
McLeer et al - 26 children
Merry & Andrews- 95 children
Glod & Teicher- 19 children
Note: these studies did not screen for other types of abuse; they concluded that findings were a result from sexual abuse but may be other abuse as well. .

5. 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).
Ackerman- screened for type of abuse, 204 children
Famularo- 117 children removed from family of origin due to severe maltreatment
Briscoe et al (2006). Linkages between child abuse and attention deficit/hyperacticity disorder in girls. Behavioural and social correlates. Child Abuse and Neglect, 31(11),
Briscoe-Smith et al – documented abuse

6. 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?

7. 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
Australian Treatment Outcome Study – opiate dependent seeking treatment
PTSD rates depend upon the sample lifetime PTSD prevalence 41%, 12 month PTSD symptoms 31%
higher PTSD prevalence for rape or sexual molestation
women reported higher lifetime PTSD rates than men (61% vs 37%)
AOD used to self medicate

8. 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

9. 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.

10. 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)
39 on psychiatric medications

11. 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.

12. 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).
Note: for all scales, participants are asked only to report symptoms of they are not due to drug effects

13. Measures
Trauma Questionnaire. 7 classifications of trauma as per DSM-IV, assessed for 0-6, 7-12, 13-18, >18 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
Trauma questionnaire: Adapted from the Traumatic Antecedents Questionnaire (Herman et al., 1989) and the PTSD module of the CIDI used in the National Survey of Mental Health and Well-being (Andrews et al., 1999)).

14. 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.
Due to the difficulties experienced by participants in defining emotional abuse and neglect, this type of trauma was excluded from all further analyses.

15. Experience of traumatic events up to 18 years of age
Threat of serious harm
Witnessing serious harm or death
Shock by learning about serious harm or death of a loved one

16. PTSD and ADHD in clients reporting childhood trauma

17. PTSD in clients with and without ADHD
PTSD was significantly more common in clients who met diagnoses for child, adult or either ADHD diagnoses. These results are for child ADHD. χ2 (1, 87)= , p < .001

18. Childhood trauma and ADHD
Child trauma
No Yes Total
Child ADHD No
Yes
Total
Those who reported experiencing childhood trauma were significantly more likely to report symptoms meeting criteria for ADHD in both childhood and adulthood. Only child figures reported here: χ2 (1, 94) = 8.304, p = .004.
Of those who reported experiencing childhood trauma (n = 78), 64.1% met criteria for child ADHD compared to 25% of participants who did not report childhood trauma.

19. ADHD symptomatology mean (SD)
Adult Adult Child inatt hyp/imp total
No child
trauma (1.72) (2.27) (21.01)
(n=16)
Child
trauma (2.71) (2.69) (24.21)
(n=78)
Childhood trauma was associated with significantly greater ADHD symptomatology than no trauma. Clients who reported experiencing childhood trauma had significantly higher scores on all measures of ADHD: adult innattentive sympoms, adult hyperactivity/impulsivity and childhood symptom total. Manova: F(3, 91) = 3.854, p = .012, ηp2 = .114[1]. [1] ηp2 = partial eta squared, a measure of effect size. This effect size indicates that 11.4% of the variance in ADHD symptomatology can be accounted for by childhood trauma. Follow up Anovas indicated significant differences for each type of indice.

20. Mean adult ADHD score for repeated trauma groups
Repeated trauma: occasionally or moderately, frequently. First age of repeated trauma (2 or 3 – occasionally or a lot)
No repeated trauma: n=8
0-6 repeated trauma, n=33
7-12 repeated trauma, n=17
13-18 repeated trauma, n=13
Adult repeated trauma, n=16
Post hoc comparisons with bonferoni adjustment indicated those who first experienced repeated trauma as adults had significantly fewer symptoms of inattention and hyperactivity than those who first experienced repeated trauma t younger ages.

21. Mean child ADHD score for repeated trauma groups
Similar results for childhood ADHD

22. 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
61% of individuals who reported childhood trauma also met criteria for child ADHD, versus 22% no trauma

23. Argument 1
Among abused children, ADHD is a risk factor for the development of PTSD.
TRAUMA
PTSD
A moderated binary regression analysis was conducted to test this model, with PTSD diagnosis (y/n) as the binary outcome, childhood trauma and child ADHD as predictors entered on the first step, and the interaction of childhood trauma x child ADHD on the second step. The model predicts a significant interaction between childhood trauma and child ADHD. This was not found for either child or adult ADHD, indicating that this moderator model could not account for the observed relationships between childhood trauma, PTYSD and ADHD.
ADHD

24. Argument 2
Childhood trauma leads to PTSD, which results in behaviours such as hyperactivity & inattention that resemble ADHD symptoms.
ADHD-like behaviours
TRAUMA
PTSD
The mediated model was tested with binary regression analysis. This model predicts a significant relationship between childhood trauma and ADHD that reduces to non-significance when PTSD diagnosis is controlled for. Child ADHD was entered as the binary outcome, childhood trauma was entered on step 1 and PTSD diagnosis on step 2. Results indicated that even after controlling for PTSD, therefore not supporting this model

25. Argument 3
Childhood trauma exerts biological & psychological effects that lead to the development of both ADHD & PTSD through independent pathways.
PTSD
The model was tested with binary regression analysis. This model predicts a significant relationship between childhood trauma and ADHD that remains when PTSD diagnosis is controlled for. Child ADHD was entered as the binary outcome, childhood trauma was entered on step 1 and PTSD diagnosis on step 2. Results indicated that even after controlling for PTSD, therefore supporting this model.
TRAUMA
ADHD

26. 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

27. 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
After this slide, link back to early repeated trauma. Trauma may impact on self-regulation at any stage in childhood, not just years. Needs more research
Mention DBT research here, and link between ADHD and BPD

28. Implications cont
Importance of thorough assessment when ADHD is present
Caution re stimulant medication

29. 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?
Affect and attention regulation
Research shows DBT effective for treating ADHD