Children's ADHD symptoms similar to those for chronic stress

At a time when many families are looking for back-to-school bargains, others are coming into their pediatricians' offices looking for answers about their children's behavior.

"He never stops moving." "His teacher thinks I should have him tested." "She can't pay attention in class." "I think he needs medication to keep him still."

Pediatricians hear these concerns year-round, but they take on a more frantic urgency as school approaches. Many of these concerns are legitimate. But the more we learn about attention deficit hyperactivity disorder (ADHD), the more we realize one label does not fit all, especially for more impoverished or stressed households.

A recent report from the U.S. Centers for Disease Control and Prevention states that about 10 percent of American children have a diagnosis of ADHD. According to the CDC, some signs that a child might have ADHD include squirming or fidgeting, difficulty getting along with others, talking too much, daydreaming a lot, often forgetting or losing things, taking unnecessary risks, making careless mistakes, and having a hard time resisting temptation.

Of course, all children do these things. The difference is that a child with ADHD exhibits the behaviors more than is normal for his age and developmental level, does it both at home and at school, and suffers harm to social or educational functioning. The same study showed that children with public insurance - generally lower-income kids - were also more likely to have an ADHD diagnosis than children who are privately insured.

Here's one story to illustrate why I believe this to be the case.

Last week, a mother came in with her 5-year-old boy, whom I have been caring for since birth. She and his preschool teachers were concerned because he was always fidgety, would get out of his seat often, and would forget instructions soon after they were given.

Sounds like he might meet ADHD criteria, but knowing his early childhood experiences made me hesitant to give him that label.

Certain parts of the developing brain are very sensitive to stress hormones such as cortisol and adrenaline. In normal doses, these chemicals help us act quickly - to escape that charging dog or to remember the date of the Franco-Prussian War on a test. But at high doses, the results aren't at all helpful.

A tiny almond-shape area of the brain called the amygdala is responsible for storing memories, as well as for teaching us to react quickly to threats.

A child whose amygdala has been overwhelmed by constant stress might perceive threats differently than a child raised in a calmer environment. A teacher asking a question could make a chronically stressed child combative, fidgety, or forgetful.

Another area of the brain that has numerous receptors for cortisol is the hippocampus, a seahorse-shape structure responsible for memory and inhibition. Children exposed to toxic stress might have memory problems, make careless mistakes, lose inhibitions, or take unnecessary risks. Sounds like ADHD. But it may not be ADHD - and it won't be helped by typical ADHD therapy.

Two recent studies, one in JAMA Pediatrics and one in Nature Neuroscience, show that children growing up with the relentless stress of childhood poverty have alterations in these two crucial brain regions, as well as brain areas responsible for language, reading, and executive functions. All of this can result in behaviors that are easily misinterpreted as learning issues and ADHD.

The rate of childhood poverty in the United States for children under 5, the most critical time for brain development, is 25 percent - one in four.

Another recent study showed that children who had four or more adverse childhood experiences, such as abuse, domestic violence, parental divorce, or parental incarceration, were almost three times more likely to use ADHD medications compared to children with three or fewer adverse experiences. But is it really ADHD, or a coping response to those experiences?

Early childhood trauma, poverty, and stress put children on a trajectory for symptoms that mimic and, in essence, meet the criteria for ADHD, but it's more their biography then their biology.

Back to my 5-year-old patient. He and his mother, along with two younger siblings, live near St. Christopher's Hospital for Children, in a North Philadelphia community where more than half of all adults have had four or more adverse childhood experiences. The child-poverty rates in his neighborhood are among the worst in the nation.

By the time I saw him for his checkup, he had moved several times. His father was incarcerated for domestic violence. His mother was trying to create a good home for her children while struggling with her own negative childhood experiences, as well as depression. The continuous traumatic stress on my patient's developing body and brain most likely had manifested in his present symptoms.

He needed help, but labeling him as ADHD and medicating him without also considering the sources of his stress would be like treating a laceration without addressing the trauma that caused it.

I referred the boy and his mother to the Children's Crisis Treatment Center for trauma-informed care, as well as family therapy. I also tried to help his mom understand that, although his symptoms were possibly due entirely or at least in part to his life experiences, this was not her fault.

I consulted our social-work team to help his mom find assistance so that meeting her family's basic needs would not be such a struggle. I also urged her to seek counseling for her depression, explaining that even if she were reluctant to go for herself, she should consider how it would help the children she clearly loves.

The first day of kindergarten for my patient is Sept. 17 - first day in a new classroom, a new group of friends. And, I hope, he will start the new year with resources that will help him learn the coping skills he will need to succeed in kindergarten and in the future.

Hospital for Children. Dtaylor01@drxeelmed.edu