Many diagnoses given to children are accurate – and for some conditions, such as autism spectrum disorder (ASD), there’s indisputable neurological evidence.
That being said, we must remain aware of misdiagnosis, which is often preventable if we are trauma-informed.
Underlying causes of painful life experiences, particularly trauma and loss, can fuel challenging or disturbing behaviour and awkward ways of relating to others. These painful life experiences can result in symptomatology very similar to some of the most common child diagnoses.
My worry is that after a diagnosis, people assume that this is the answer, so the painful events in the child’s life that may be triggering his or her behaviour remain unheard. In contrast, in trauma-informed schools, communities and child professional practices, we ask two questions: Why is the child behaving like this? What has happened to the child?
Where there has been a misdiagnosis, the latter often explains the former. When childhood trauma is heard, the attention deficit hyperactivity disorder (ADHD)-type or autism spectrum-type behaviour makes perfect sense.
The child’s behaviour and ways of relating are entirely understandable as coping mechanisms and defences resulting from traumatic experiences, and a lack of an emotionally available adult to help them through a painful event. The unheard narrative flies in the face of health and safety. We can’t just have physical health and safety – our minds must be protected too. Without incorporating mental health into our protective policies, we are failing to protect children from the consequences of misdiagnosis and ineffective treatment.
If we are not trauma-informed, ensuring before giving any diagnosis and medication that we have heard the child’s life story to rule out trauma, we are in danger of damaging that child psychologically, and possibly neurologically, when giving them
medication for a condition they don’t actually have.
Some people might hope that misdiagnosis is a rare occurrence. I’m afraid not. The adverse childhood experience (ACE) study carried out on 17,000 people in the United States, found that if you have experienced several ACEs, you have a high chance of being diagnosed with ADHD, conduct disorder or being on the autism spectrum (Anda et al, 2005).
As the number of ACEs increases, so does the likelihood of a child or teenager being given a psychiatric diagnosis. In one study, 100 children were told they had ADHD by school staff. Only three were correctly diagnosed (none of the three had ACEs); the rest had experienced multiple traumas (see the work of Dr Nadine Burke Harris and also the Aces too High website in the US).
Symptomatology of ADHD and several other common child diagnoses often matches childhood trauma and loss: agitation, difficulty concentrating and hyperactivity.
Some of these children are then permanently excluded from schools as a result of their psychological distress presenting itself through their behaviour (Ford et al, 2017). It is a gross failure of empathy to exclude traumatised children because of their difficult behaviour, without asking what has happened to them. And we know when we do ask what has happened, find a high ACE score, and provide an emotionally available adult to help them to grieve, work through and make sense of what happened, symptoms are alleviated. The evidence is overwhelming; there is a huge body of research discussing what is called “social buffering” or “protective factors” (Gunnar, 2017).
Research that looked at 47,000 areas of the brain comparing autistic and non-autistic brains showed reduced cortical functional connectivity in areas to do with theory of mind (interest in other people and the ability to imagine what someone else might be thinking or feeling), emotion and social processing, and sense of self in the autism spectrum (Cheng, et al 2015).
Seb, 11, was a foster child who experienced seven different placements after he was moved from his birth parents following an abusive background. Seb was diagnosed with ASD.
Just like many children on the autism spectrum, Seb had a need for order, for sameness and repeated routines. He would show extreme anxiety with any changes. He had a difficult journey to school, and was often heard recounting to himself each step of his journey: “I am going to walk to X, then cross the road, then get the bus.”
This over-attention to detail and high level of anxiety is a common characteristic of ASD. Yet, it is also a common trait in children with traumatic pasts.
With such chaotic home lives, their anxiety around change and need for order is understandable. Seb also found the social world very difficult; he had poor eye contact, a bland expression and never smiled. He showed no interest in what other people thought or felt.
Finding the social world difficult and wanting to avoid it is also a common trait for traumatised children. Seb was unable to show empathy, which again is an autism trait, but it is also a trait of developmental trauma, not because of a neurological issue (as with ASD) but because the pain caused Seb to distance himself from his own and other people’s feelings.
However, Seb began working therapeutically with a psychologist (Martha) who listened to his life narrative. She questioned his diagnosis of ASD after finding he lied well, which is uncommon for children on the autism spectrum due to poor theory of mind.
Second, using drawing and metaphors, he could symbolise his painful life experiences. Children with a correct ASD diagnosis can find images and metaphors difficult and tend to live in a more literal world.
Seb was insightful about what fuelled his parents’ cruelty and over time became interested in Martha and asked her questions about her life, showing good communication skills. So Martha knew he had no problem with theory of mind or social and emotional processing. Seb worked through and grieved his traumatic life experiences and went on to do very well.
Many children don’t have the opportunity to tell their story – often because people show no curiosity and don’t see how vital it is to know. Consequently, these children are left with an unheard narrative. Let’s change that and demand trauma-informed inquiry before any diagnosis is given.
- Dr Margot Sunderland, a child psychologist neuroscience expert, is director of education and training at the Centre for Child Mental Health, a not-for-profit provider of CPD and training programmes for school staff. She is also co-director of Trauma Informed Schools UK. Visit www.childmentalhealthcentre.org and https://traumainformedschools.co.uk/
Selected references
- How early childhood experiences affect children’s future, presentation, Dr Nadine Burke Harris, End Violence, Montenegro, 2017: http://bit.ly/2H2qCgY
- Aces too High is an American website reporting on research about ACEs: https://acestoohigh.com/
- The enduring effects of abuse and related adverse experiences in childhood, Anda et al, European Archives of Psychiatry and Clinical Neuroscience 2005: http://bit.ly/2UbxHiT
- The relationship between exclusion from school and mental health, Ford et al, Psychological Medicine, 2017: http://bit.ly/2NxApwH
- Social buffering of stress in development, Gunnar, Perspectives on Psychological Science, 2017: http://bit.ly/2tJ1LXC
- Autism: Reduced connectivity between cortical areas involved in face expression, theory of mind, and the sense of self, Cheng et al, Brain, 2015: http://bit.ly/2Vmhtnl
- It’s OK to ask about past abuse, Edwards, Dube, Felitti & Anda, American Psychologist, 2007: http://bit.ly/2EyKZk6
- The relationship between early adversities and attention-deficit/hyperactivity disorder, Fuller-Thomson & Lewis, Child Abuse & Neglect, 2015: http://bit.ly/2VnSv70