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Relationships between childhood trauma, PTSD, and ADHD among adult substance users

Relationships between childhood trauma, PTSD, and ADHD among adult substance users. Vanessa Watson 1 , Ali Marsh 1,2 , Felicity Miller 1 1 School of Psychology, Curtin University, WA 2 Next Step Drug & Alcohol Service, WA. ADHD and PTSD?. ADHD and PTSD. Share numerous common symptoms.

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Relationships between childhood trauma, PTSD, and ADHD among adult substance users

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  1. 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

  2. ADHD and PTSD?

  3. ADHD and PTSD • Share numerous common symptoms. • E.g.: • Heightened startle response • Inattentiveness • Feelings of detachment • Irritability • Anger outbursts

  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

  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).

  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

  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)

  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).

  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

  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.

  15. Experience of traumatic events up to 18 years of age

  16. PTSD and ADHD in clients reporting childhood trauma

  17. PTSD in clients with and without ADHD

  18. Childhood trauma and ADHD Child trauma No Yes Total Child ADHD No 12 28 40 Yes 4 50 54 Total 16 78 94

  19. ADHD symptomatology mean (SD) Adult Adult Child inatt hyp/imp total No child 1.81 1.94 34.81 trauma (1.72) (2.27) (21.01) (n=16) Child 3.72 4.13 53.63 trauma (2.71) (2.69) (24.21) (n=78)

  20. Mean adult ADHD score for repeated trauma groups

  21. Mean child ADHD score for repeated trauma groups

  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

  23. Argument 1 Among abused children, ADHD is a risk factor for the development of PTSD. TRAUMA PTSD 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

  25. Argument 3 Childhood trauma exerts biological & psychological effects that lead to the development of both ADHD & PTSD through independent pathways. PTSD 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

  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?

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