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by Thomas G. Shafer, MD and Susan V. Shafer, RN, B.S.N.

Link to Part 1
Link to Part 2

So far we have discussed the difficulty in diagnosing the true cause of hyperactive behavior in children: citing the characteristics of true ADHD/ADD and various medical, neurological, sensory and learning problems which often confuse the issue. And now on to the Shafer's last Golden Rule: "All that is Psychiatric is not ADHD."

Let's face it, misdiagnosis of psychiatric problems in young people is a problem in and of itself. It is all too common to see ADHD over diagnosed in young children who have other problems and under diagnosed in adolescents who often have their ADHD behavior labeled as "acting out" or "a Conduct Disorder." The fact is that children with many forms of mental illness exhibit agitated and/or hyperactive behavior more often than not.

For example, some depressed kids can be sluggish and apathetic just like depressed adults. But agitated depressions with a lot of overactive "nervous" behavior is, in our clinical experience more the rule that the exception. And there are young children who show recurrent periods of agitation and hyperactivity who are actually exhibiting the early stages of manic-depressive illness in adolescence or, more rarely, even as younger children.

How do you tell? Well, insist on a thorough and detailed mental health evaluation for the child if there is any suspicion. If there is a strong family history of mood disorders, be suspicious. Ritalin can be beneficial for depressed kids since it is, in itself, an effective antidepressant but there are better ways to go, especially when you consider you are masking the true diagnosis. And, if you ever give Ritalin and similar stimulants to a Manic Depressive, watch out. Stimulant medications can set off a high you wouldn't believe and precipitate a full blown psychosis.

There are, sadly, children with severe developmental psychotic disorders such as autism, and childhood schizophrenia. Misdiagnosis as ADHD is usually not a big problem here since these poor souls typically show a lot of delay in developmental milestones, and, if misdiagnoses occur, are usually thought to be mentally retarded.

Susan is currently researching this topic for a Graduate School project (which piqued my interest), and we have both found that there is a big problem differentiating between young people with ADD/ADHD and those with post traumatic stress disorder, PTSD. This is complicated by the fact that it is not unusual for a child to have both conditions at the same time.

(This isn't hard to understand. ADHD can run in families and some hyperactive adults are known to consume excessive amounts of alcohol and display explosive anger when they do. So a non ADHD kid in an ADHD family can be the recipient of very traumatic abuse. And ADD/ADHD children can, frankly, be quite annoying so an affected child in a non ADHD family where there are loose behavioral control and/or alcohol problems is a set up for PTSD. (And I don't even want to think of mixing an ADHD child with an alcoholic, ADHD parent.)

Currently there is little clinical literature on childhood PTSD. This concerns us because we both fear this means that many professionals are not thinking of this condition, and therefore are nor looking for it. But it is definitely out there. And, even when ADHD and PTSD do not coexist, it can be difficult to tell the two apart. The truth is that young people with PTSD typically display the same levels of hyperactivity and many of the same behaviors as those with full blown ADHD.

So what is PTSD? Basically it is the reaction of the body and the mind to overwhelming stress. And this doesn't mean a reaction to what you or the examiner would personally consider an overwhelming stress. Young children can be overwhelmed by things we would consider relatively minor such as a broken bone or a minor diagnostic or surgical procedure. And adolescents can be over stressed, even to the point of attempting suicide, by things we adults would take in stride like breaking up with a boyfriend or having to move to a new town. Overwhelming stress is in the eye of the beholder and, remember, kids think and react differently than we adults do.

We have found though that people of all ages with PTSD do show some common characteristics. They have difficulty forming relationships with others, even peers, and tend to be "loners." (Remember, though, that a teenager who can't relate to adults is called "normal.") They have a tendency to frequently relive the trauma in the form of intrusive memories, nightmares and "flashbacks" where they re-experience the events as if they were back in time. (In individuals abused at a very young age, though, flashbacks can take the form of intense bodily situations without visual or verbal recall of the trauma and look a lot like panic attacks.) PTSD sufferers are often prone to intense mood swings and even sudden outbursts of rage. They avoid situations which may trigger memories and flashbacks. Often, they are very restless sleepers (which may present as night terrors in young children) and they have an overactive nervous system, leading to "wiggly" behavior.

So how do you tell the difference? Well, the obvious thing is to find out whether there is a history of trauma. Of course, overt sexual or physical abuse qualifies but remember what we said about trauma in kids? Did something happen which was unduly upsetting to them, not you? And we are not always talking abuse here. Families where there are histories of alcoholism or severe physical or mental illness can be quite stressful despite everyone's best effort.

And finally, a major risk factor for PTSD in children can be PTSD in a parent. Personally, I (Dr. Shafer) work with Vietnam veterans and I don't mean to imply that anyone is at fault here. My "guys" often go out of their way to prevent their problems from affecting their children. But the fact is that PTSD is "catching" and, to some degree is passed down for one or two generations. I have worked with children of combat vets who literally experience combat flashbacks and nightmares just like they were in Vietnam or Korea or wherever. And I have talked to and worked with children of Holocaust survivors who show classic signs of PTSD and dream about "the camps" as if they had actually been there.

So what is the bottom line here? Again get a thorough evaluation and raise your concerns about possible PTSD if you suspect it at all in your child. And notice that I said "thorough evaluation" since it is common to uncover PTSD only after multiple therapy sessions.

So, in conclusion, don't be afraid to be a "pesky parent." In this age of managed care and funding cutbacks for Medicaid and Community Mental Health Centers, you may have to become the "squeaky wheel" but you will still get the grease if you squeak long enough and loud enough. So trust your gut and take things as far as you have to to make sure that the true problem is properly diagnosed and effectively treated.

Hey, nobody said parenting was easy. But, whether parent or professional, there is nothing quite like seeing a child receive the proper treatment and educational attention and blossom to their full potential.


The Shafers are both graduates of the University of Virginia and have worked with childhood hyperactivity syndromes as both professionals and parents. Tom currently works for the Veteran's Health Administration and Sue is completing her Masters in Counseling at the University of North Alabama. Address: 213 Creekside Drive, Florence, AL 35630. (205) 760-9912


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