ADHD Weekly 2017-09-28

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Did you know that children in foster care are three times as likely to have ADHD than other children? And almost 9 out of 10 foster children have experienced a traumatic event at least once, while many have experienced traumatic domestic conditions.

Some children enter foster care because their birth family’s environment may have been unstable or even violent, creating for those children not just one traumatic event, but an ongoing climate of trauma. For young children, such conditions can affect the neurodevelopment of their brains. 

“Traumatic…experience in adults alters the organized brain, but in infants and children it organizes the developing brain,” according to researchers Bruce Perry, MD, PhD, and Ronnie Pollard, MD.

Treating foster children

Meeting the needs of children in the foster care system, and helping them to either return to their families or be adopted into new, loving families is a struggle, especially when the symptoms of ADHD and trauma can not only be similar but may also aggravate each another.

Lisa Dominguez, LCSW-C, the director of Clinical Services for the Center for Adoption Support and Education (C.A.S.E.), says her agency sees many children with an ADHD diagnosis. Frequently, she says, the child is struggling with a combination of ADHD and trauma symptoms. Or, she adds, the child has been misdiagnosed with ADHD when the difficulties—hyperactivity, inattention, behavioral issues—are actually related to trauma symptoms.

Ms. Dominguez says working with caregivers, educators, and prospective parents to better understand the intersection of trauma and ADHD is an important step in helping children recover from trauma and become successful later in life.

How kids wind up in foster care

Very often children who have a diagnosis of ADHD have inherited the condition from their parents. Adults with undiagnosed or poorly managed ADHD are at greater risk for underemployment or unemployment, difficulties in their social lives and with spouses or partners, may have co-occurring substance abuse disorder and may also have undiagnosed co-occurring mental health conditions that interfere with daily life. These challenges can lead to problems in parenting or in some situations, create unsafe living situations for their children.

Some of the reasons a child might enter the foster care system can relate to the mental stability of parents. In many cases, child welfare agencies are called in to remove the child from an unstable home environment. Statistics from the Administration for Children and Families, Children’s Bureau, June 2016 Report:

• There has been abuse, including physical (13 percent), or sexual abuse (4 percent). 
• There has been neglect (61 percent), such as basic physical needs are not met, the child is left alone for a long period of time or needed medical care is not provided. When a child goes without basic needs, this is cause for the courts to remove the child from the home. Neglect can also include lack of food or clean living environment
• The family has inadequate housing or living circumstances to raise a child (10 percent).
• A parent has been sentenced to prison and there are no other family members to care for the children (8 percent). 
• There is drug abuse or addiction in the child’s home (32 percent; often occurring along with neglect).
• The child’s parents or guardians have died or cannot be located and there are no other family members available to care for the child (1 percent).
• The parent experiences an illness that prevents him from caring for his children or otherwise coping with child care and there are no other family members who can help (14 percent).
• Occasionally, a child might enter foster care if a parent chooses to relinquish parenting rights and voluntarily places a child in the foster care system (1 percent). Although there are cases where a child’s disability or behavior may prompt such a decision, there are other reasons why a parent might find this to be the better choice in difficult circumstances.

All these circumstances can be traumatic for a child, as well as the act of being removed from her home. Frequently children feel a sense of guilt or shame, wondering if they are somehow the reason for the separation from their parents, even though it is not true.

“Given these kids were [placed] for adoption or into foster care, it is likely that they may carry genes for ADHD, as well as other mental illnesses (bipolar disorder, addiction, depression, etc.),” says Roberto Olivardia, PhD, a clinical psychologist and lecturer in Psychology for the Department of Psychiatry at Harvard Medical School. Dr. Olivardia is a member of the CHADD Professional Advisory Board. “That, coupled with an environmental expression of those genes, can make for a complex profile.”

Medication management alone for ADHD would not be effective, he says. The focus should be on a comprehensive treatment plan taking into account co-occurring conditions, previous abuse, and social and economic factors that have affected the child.

Trauma often seen as ADHD in foster care

In 2016, there were more than 427,000 children in foster care; 53,549 were adopted through public child care agencies. More than a quarter of children in foster care have been diagnosed with ADHD. It’s estimated that 90 percent of children who are in foster care have experienced one or more traumatic events; many have endured persistent trauma in their lives.

Although these numbers show how common the co-occurrence of ADHD and trauma is, when professionals and caregivers work with a young child, Ms. Dominguez says they can attribute shared symptoms to the wrong disorder.

“Everyone always assumes it’s ADHD first,” she says. “The ADHD is being treated and the trauma is not. Often the trauma piece is being missed.” Without addressing the trauma, treatment of ADHD may not succeed, she says.

Symptoms of impulsivity and hypervigilance related to trauma can be mistaken for hyperactivity related to ADHD, while disassociation or freezing-up — symptoms of trauma — could look like inattention. Many children grieve the separation from their families, blame themselves and are fearful of either never seeing their parents again or that they will be separated from their foster or adoptive parents in the future. This grief and fear can be expressed in disruptive behaviors. These are symptoms of trauma, she says, and need to be recognized and treated as such.

Helping children in foster care 

Children usually experience multiple placements before they are able to return to their families of origin or are adopted into new families. Ms. Dominguez says this makes continuity of care and development of attachment difficult. Children need to establish trusting relationships with new adults before treatment for trauma can be effective.

Foster parents, adoptive parents, and caregivers need to be trained to understand how trauma affects a child, along with parent education on ADHD. C.A.S.E. works with public social services in several Maryland and Northern Virginia jurisdictions to help children and caregivers deal with the effects of trauma. Ms. Dominguez refers to this as “trauma-informed parenting.” 

“Some children present with extremely challenging behaviors,” Ms. Dominguez says. Often adults respond to a child’s behaviors with discipline, rather than recognize those challenging behaviors as stemming from trauma and/or co-occurring ADHD. “By parenting from a trauma-informed perspective, we see what the child is trying to communicate to us instead.”

The first step to helping children in foster care, Ms. Dominguez says, is to make sure the child receives a good assessment from a clinician who understands ADHD, trauma, and the disturbances in a child’s life that occur before and/or during foster care. Any treatment plan that addresses only ADHD or only trauma cannot succeed. Here are some steps adults can take to help children experiencing trauma symptoms and ADHD:

• A thorough assessment for trauma, ADHD, and other co-occurring conditions. Knowing what a child is dealing with, from medical and social histories, is imperative to designing proper treatment for that child.
• Design a treatment plan and team to work with the child. This would include parent training, along with behavioral management techniques, and, when appropriate, medication management. 
• Work with parents and caregivers to develop realistic expectations for their children in addition to parent training for trauma, ADHD and co-occurring conditions. Therapy and family support is an important part of the process. Children and parents come to learn what are triggers for poor behavior, how they are related to past traumas and how ADHD is involved in the children’s responses. Once those triggers are known, parents can work with children to develop healthier responses.

 

“Parents and caregivers need to really understand that good trauma treatment has to go hand-in-hand with skills building and traditional ADHD treatment,” Ms. Dominguez says.

Moving from foster care to families 

When a child cannot return to her family of origin, the goal is adoption in a loving family. It can sometimes take years for a child to be adopted, either by her foster parents or new parents. Most foster children are constantly fearful of a possible reversal of placement or adoption, which can be devastating.

“People belong in a family,” Ms. Dominguez says. “That’s where children need to grow up. That’s the lifelong connection; it’s knowing you have someone to call if you need something, someone to call when you have great news.”

C.A.S.E. counsels prospective parents to have realistic expectations for their child, who has come to them struggling with a lifetime of separation, trauma, ADHD, and other possibly co-occurring conditions. Building and sustaining a trusting relationship with the child is key to helping the child deal with past trauma, and to ensure a successful placement. 

“Parenting children with a trauma history requires a different style of parenting,” Ms. Dominguez advises. “It takes time and support. You need to surround yourself with people who understand the unique needs and challenges of children who have experienced trauma and neglect. I think so many parents want to keep the past in the past. But we need to honor the past and understand how your child’s early beginning impacts what happens now.”

Where to look for help

• Center for Adoption Support and Education
• The National Child Traumatic Stress Network
• Treatment for Childhood ADHD

Are you a foster or adoptive parent? How can parents help children cope with traumatic conditions?

The majority of children in foster care are coping with both trauma and ADHD. Parenting from a trauma-informed perspective can help children recover and lead fulfilling lives.