ADHD and trauma

Dr. Monica Johnson joins Laura to talk about a topic that comes up a lot on ADHD Aha!: ADHD and trauma. She explains how trauma and ADHD can look alike and whether ADHD can lead to trauma. Dr. J, as she’s known, also talks about misdiagnosis, treatment, and how to support someone who’s struggling. 

Get more helpful insights from Dr. J on ADHD and..., a podcast in our MissUnderstood channel for women with ADHD. 

This episode contains discussion about trauma, PTSD, and examples of traumatic events. It’s intended for educational purposes, but may not be for everyone. You can visit mentalhealthhotline.org, or rainn.org for support.

Related resources

• 6 ways ADHD and PTSD can look alike

• Trauma, learning differences, and kids of color (from The Opportunity Gap podcast)

• MissUnderstood: The ADHD in Women Channel

Timestamps

(04:05) Dr. J defines trauma

(05:18) The difference between trauma and PTSD

(07:59) Can trauma cause ADHD? Can ADHD cause trauma?

(09:51) Misdiagnosis

(16:50) What happens when you have both ADHD and trauma

(19:25) Possible treatment

(23:54) How can caregivers and loved ones support someone who has ADHD and trauma

(28:13) More on ADHD and... on the MissUnderstood podcast channel

We love hearing from our listeners. Email us at ADHDAha@understood.org.

Episode transcript

Laura: This is "ADHD Aha!," a podcast where people share the moment when it finally clicked that they have ADHD. My name is Laura Key. I head up our editorial team here at Understood.org, and as someone who's had my own ADHD "aha" moment, I'll be your host.

I am here today with Doctor Monica Johnson, aka Dr. J. Dr. J is a licensed psychologist and an esteemed Understood Expert. We work together a lot and so I'm thrilled to finally have you on "ADHD Aha!" Welcome.

Dr. J: Yes. Thank you for having me.

Laura: And for those of you who don't know, and we will talk about this a little bit later, but Understood — we are so excited about this — Understood recently launched a podcast channel, not just one show, but a channel for women with ADHD.

And Dr. J is a host of one of the shows in that channel. That show is called "ADHD and...", it's where Dr. J unpacks so many issues and topics that correspond with ADHD, particularly for ADHD and women. And we are just so grateful that you're doing that. You're doing an awesome job. Everybody go check it out. Are you having fun doing it?

Dr. J: Yeah. You know, as an introvert, there are parts of it that I am, like, growing like, into. But I enjoy that I'm able to give information to people and be helpful to people who have ADHD, for sure.

Laura: You're an introvert?

Dr. J: Oh, 1,000%.

Laura: I never would have guessed that.

Dr. J: And that's what everyone says. But if I could live mostly alone 90% of the time, I would be totally fine with that.

Laura: I told somebody once, "I'm like, you know, I think something that people don't realize about me because I'm so, I can be so outgoing is that I really I just crave solitude. Most of the time."

Dr. J: You know, and I think this maybe even gets into some of the things we'll talk about on the topic today, but a lot of times we judge things based on like the surface of something. So, like I present as like very funny and gregarious and like all of these things, which is true. It's true. I am all of those things.

So, but you associate that with extroversion. And so, you then assume that I'm an extrovert when really I'm an introvert who's using skills to project my personality into a situation that is uncomfortable for me.

Laura: That makes a lot of sense. And thank you for the nice assist here and the nice transition point to talk about what we're here to talk about today. So, listeners, I really wanted to bring Dr. J on the show today to talk about ADHD and trauma, which is a topic that comes up a lot on "ADHD Aha!".

I have to admit that sometimes I even feel like I don't know how to unpack some of this with some of my guests because I'm certainly number one, not an expert on this and Dr. J is, and there's just a lot of questions about it. What is trauma and how are these symptoms overlapping? We're going to get into all of that. Dr. J, do you want to share a little bit about your experience in this area before we dive into some questions?

Dr. J: Oh, sure.

Laura: I put you on the spot.

Dr. J: Yeah, yeah. So, I've worked with a lot of different populations, and all of them have had trauma. You know, I started off working in the forensic population. So, a lot of those people have histories of traumatic experiences in childhood. So, we have, like, ACEs, adverse childhood experiences. So, when you look at a lot of people who end up in jail, a lot of times they hit a lot of those markers.

And for a long time, I also worked with the homeless population. I think it goes without saying there's a lot of trauma within that population. And I've also spent so many years just working in community mental health and working with individuals who have had trauma from molestation in childhood, sexual assault, just different things like that.

(04:05) Dr. J defines trauma

Laura: OK. I'm so glad that you're here today. And I think a good place to start is, could you define trauma?

Dr. J: I can do my best. Sometimes, I don't think we have come up with the definition of trauma. So, when you're thinking about trauma, basically what it is, is an emotional response to an event. So, this event could be something like a natural disaster. It could be abuse — whether that be emotional abuse, physical abuse, sexual abuse. It could be an accident, crime. There's a lot of different things that can be classified as trauma.

And so, that's some of the difficulty of it. We also have introduced this concept of complex trauma, which then encompasses more of this kind of everyday or smaller — smaller is the wrong word — but let's say like instead of a hurricane, you know, it's racism or bullying or these other traumas like that that can also lead to trauma responses in individuals.

(05:18) The difference between trauma and PTSD

Laura: And PTSD, I feel like sometimes trauma and PTSD get used interchangeably. I imagine that that's not accurate. Could you talk about the difference?

Dr. J: I think one of the things to keep in mind is that everyone experiences trauma, right? So, if you look at the data on ACEs, the adverse childhood experiences, over 60% of people have at least one of the things that we qualify as an ACE, right? So, I just like to put that information out there that, like, everyone will experience trauma and probably will have a variety of experiences throughout their life that they would classify as a trauma or a traumatic experience.

When it comes to PTSD, and that even our definition of that has changed. So, like back in the day, one of the issues we had with the PTSD diagnosis is that you had to directly experience a traumatic, distressing, life-threatening event. And then we started to kind of flesh that out because there are other people who also can kind of qualify.

So, like, for instance, if you are a child and you witnessed domestic violence, or for myself as a psychologist, because I'm exposed to so much traumatic experience. So, then we have like vicarious trauma. So, if I'm dealing with trauma all day, I can start to develop some of these reactions like myself. And from that, then you have a series of different responses that can come up.

So, a lot of the criteria around PTSD relate to having like intrusive thoughts, memories, flashbacks in terms, as a response to the trauma. A persistent avoidance is a common thing, so you're trying to avoid anything that might trigger a memory. And then you also have something what we called marked reactivity. So, that means that you can have emotional regulation issues, so you might have irritability or anger or outbursts. It can also bring about like reckless behavior and impulsivity.

People will have something called hypervigilance where you're just kind of on edge all the time and like worried about something occurring. And so, you can also have your view of yourself or your view of the world be changed, or one of the symptoms of PTSD, meaning that you might have a negative perception. So, you might feel like you're tainted or broken or the world is a vicious and horrible place and I can't ever be safe. So it can mark you in those ways as well.

(07:59) Can trauma cause ADHD? Can ADHD cause trauma?

Laura: I want to ask you, number one, can trauma cause ADHD?

Dr. J: So, from what I know of the research, trauma does not cause ADHD. But you can see ADHD symptoms because executive functioning, that's a capacity for all of us and for all of us, we have a finite amount of it and we have different things competing for it. So, when you have PTSD, if you remember, I talked about like intrusive thoughts and memories and dreams and also wanting to avoid all of those things, that requires a lot of executive functioning for that to operate.

And so, if I'm having a lot of traumatic reactions, I will also see that I have trouble with things like concentration and memory, because I don't have the executive functioning capacity left over for these other things.

Laura: I also want to ask the reverse of that question. So, can ADHD cause trauma? Can ADHD lead to trauma?

Dr. J: So, again, from the research, no, I mean obviously they can be co-morbid. You can have ADHD and have a traumatic event and develop like PTSD. But ADHD isn't necessarily going to lead to you having a traumatic experience. Or I should say to the point of where it would be PTSD, right?

Laura: Got it. OK.

Dr. J: So, because you have ADHD, let's say you have ADHD and you're bullied.

Laura: Right.

Dr. J: You know what I mean? You're bullied because you're not doing well in school, right? So, then you can say, "Well, my ADHD caused me..." you know, you can walk through that kind of like line of events with it, but it's not necessarily a direct causation between these things.

Laura: Got it. And other things like people with ADHD may experience more failures.

Dr. J: Yeah, yeah.

(09:51) Misdiagnosis

Laura: Sometimes I hear like some professionals like kind of diminish ADHD and like they're more like, "No, this is just all trauma that we're seeing." Like, what is that conversation like?

Dr. J: I don't know that it's a conversation that I participate in. ADHD is real.

Laura: Thank you, Dr. J. I think it's just something I've heard occasionally in passing that like, people think that there's a lot of...well, I guess that's my question. Is there, miss... Like, is there a lot of misdiagnosis happening as far as you understand, between like, say, PTSD versus ADHD, when in reality it's both or one or the other?

Dr. J: Yeah. So, there definitely can be misdiagnosis that can happen particularly around and in our present say with like ADHD. I think over time we've gotten a deeper understanding of ADHD. I mean, there was a period of time where we thought that if it didn't happen in childhood and it didn't get diagnosed in childhood, like, certainly this person doesn't have like ADHD.

You can also have the provider themselves, whether it's a mental health professional like myself or a medical doctor, they can have their own biases about giving certain diagnoses, and that could be the diagnosis itself. Or they could have certain implicit biases that can make them underdiagnosed or overdiagnosed a certain thing. So, to give an example of that...

Laura: Yes please. Yeah.

Dr. J: Traditionally speaking, African-Americans have been overdiagnosed with schizophrenia and underdiagnosed with bipolar disorder, even though there is a big overlap between the two of them. And things like that can lead to issues.

There's also the idea with like borderline personality disorder. A lot of people view that as a female, you see?

Laura: Right.

Dr. J: But there are a lot, men have BPD just like women do. And this comes up with anything. So, like with ADHD, there are kind of gender differences and how symptoms represent themselves. The symptoms are the same. It's just that they're represented in a slightly different way.

Laura: Do you have any examples of overlapping symptoms or between ADHD and trauma that's, that may look different? They seem gendered, whether that's just from like the clinician perspective or from like a societal perspective.

Dr. J: Something that could be gendered would be like the irritability and like anger outbursts, like, you know, again, women don't typically get like physical, like when they're angry. Obviously there are some women who do, right?

But like as a general statement, that is something that can be true when it comes to the expression of anger. Whether it be more of an externalizing, so this is something another person can see versus internalized anger, like, "I'm going to beat myself up and make myself feel bad about things."

Laura: Have you ever had to explain a misdiagnosis between ADHD and trauma — whether they were misdiagnosed with trauma or misdiagnosed with ADHD — to one of your patients?

Dr. J: I'm confident I have. So, I guess something to kind of explain kind of like that overlap and how it happens is if you couldn't see me right now, right? And I came to you and I said I was suffocating, and that's the only information that I could give you that you were going to get right now, what would be something that you would think could be happening to me?

Laura: Where does my head go with that? I'd be like, "Oh, somebody is really like not giving her any space." That's what I would like.

Dr. J: OK. So, that's one example, right?

Laura: Right.

Dr. J: So, when we look at the actual Merriam definition of suffocation, right? I believe the first one is dying from like air restriction. So, like being incapable of breathing.

Laura: I had another image in my head too. I like didn't want to go there because it felt really dark. But yeah.

Dr. J: Yeah. The second definition is like just having difficulty breathing. And the third definition is what you brought up. So, feeling like you are trapped or oppressed in some way. So, if all we have is the information of suffocation, as we're already talking through this, there are probably half a dozen where we could be drowning, we could be on fire, we could have a cold. Like there could be so many things that are like going on.

And so, this is where we have to have an understanding of nuance, and we also have to have an understanding that while we know our own system in ourself, we're not always the best interpreter, at least in the beginning, until we develop better skills and better self-awareness, mindfulness, like all of those sorts of things.

So, when it comes to talking to people about like a potential misdiagnosis, right? Like some of these people are mad. And then I'll explain to them. But see, there's all these ways in which it's very easy to like misdiagnose something because all we had was this piece of information. And then over time, we were able to get more information to say that, like, I wasn't suffocating because of, you know, an emotional reason. I was suffocating because I fell in a pool and I can't swim and like, I'm drowning right now.

And so, that's some of the approach that I take with people, is getting them to understand that side of it, that like, it can happen, that a diagnosis can occur. And it's not necessarily because of anybody having like a bad faith on either side of the equation.

And also I use that example to explain to people that, like, you can't necessarily know what's going on with you just by looking at what's going on with someone else, because they might be describing suffocation, and you're like, "That's totally me. I'm suffocating,"but you don't know their whole story. And so, they're, what's causing them to suffocate might be different than what's causing you to suffocate.

And so, the same thing comes up in a mental health diagnosis. You can take something like having an issue with, let's say, reckless behavior. And people with ADHD have that issue. People with PTSD also have that issue.

Laura: Right, right.

Dr. J: People with ADHD typically have that issue because they have trouble with impulse control, like it's fundamentally a part of their issue. Somebody with PTSD, they may be engaging in this reckless behavior is one of their avoidance strategies.

So, fundamentally, the root of what is causing the thing that we see on the surface is different. And if we're not aware of these nuances, what happens then is we intervene in the wrong way, because the way to treat a person who is suffocating from drowning is different than treating someone who's suffocating because they're on fire.

(16:50) What happens when you have both ADHD and trauma

Laura: So, we have ADHD and we have trauma, which are two separate things. And we've talked a little bit about potential misdiagnosis and how they can look similar. Let's talk about when someone has both and how they can fuel one another. Do you have any examples?

Dr. J: So, the easiest way to start with that is also to talk about some of the more of the ways that they like overlap. So, what is true for all mental health disorders is that if we are taking care of our body, it will very much like help with our mind. So, some of the way they overlap: people with ADHD often struggle with getting into like routines or maintaining routines around eating and sleep and all of those things. The same thing is true for those with PTSD or trauma.

When you look at things like ACEs, again, I keep going back to that because it's important people should know about their ACEs. But, you know, people who have aces, they're like more likely to smoke, more likely to eat poorly or be overweight. Like, you see all of these like, trends that come up. And so some of the ways that they can influence each other is they're both hitting on the same issue.

So, ADHD messes with sleep. PTSD also messes with sleep. And so, it's like, well, what's messing with my sleep today? Is it the ADHD or is it the trauma? Did I have a nightmare about my car accident or am I just disruptive, you know?

Laura: Or am I worried that am I having like, you know, restless thinking about my potential nightmare that I'm going to have or whatever.

Dr. J: Right. Other ways that they can influence each other is like your negative self-assessment or self-perception of yourself. So, it's very common for people with ADHD to like, have an impaired self-esteem because they have experienced more failure.

Laura: Right, right.

Dr. J: And they maybe have been told that they're no good and all of those things, right? And then with PTSD, oftentimes people blame themselves for their trauma or think, "It's my fault. I'm tainted in some way. I'm a terrible person. Like, I deserve this," right?

Laura: Yeah.

Dr. J: And so again, when you have that double whammy, you know, it's like, "Well, I'm failing at school, at home, I have these traumas that are happening. It's 24/7 like all the time."

Laura: Yeah. That's hard. That's a shame monster right there.

Dr. J: Oh, absolutely it is.

(19:25) Possible treatment

Laura: Let's talk a little bit about treatment. And I know in context and nuance, every person is different. But I think at the foundational level how you treat trauma is not how you treat ADHD one-to-one.

Dr. J: Yeah, there would definitely be some differences likely in the treatment. But I think something to note too is that sometimes there is a ripple effect. As you're kind of treating something else, it'll naturally help other things like resolve.

You know, I've had people who had another diagnosis and trauma, and we started with their other diagnosis and they got to a point where it's like, oh my, not that the PTSD went away, but that they like noticed even without doing the targeted treatment, that they were already seeing some difference in their PTSD symptoms.

Laura: I've definitely talked with some folks on my show because on "ADHD Aha!" we talk about what led you to realize you might have ADHD and in some cases with some folks that might be, "Oh, I was struggling with substance abuse. And then I got sober and then I realized something was still off." And now that there's this other thing, like whack a mole that's like popping up.

Dr. J: Yeah, I mean, it can happen. Particularly there are some people that just have one thing going on.

Laura: Right.

Dr. J: And that's true. And then sometimes you have a few different things going on, and you may not know that at the beginning of treatment, sometimes as you're going through treatment, things kind of come to the surface. And it's because just one thing had a louder alarm than like the other things.

Laura: In terms of clinical treatments, what are treatment methods that are kind of like gold standard? And we're not saying that these work for everybody. This isn't a recommendation, everyone, for what treatment you need as an individual. But like what are gold standard style of treatments that are good for ADHD and good for trauma, in which things like usually are only good for one or the other?

Dr. J: So, the first thing that I will say is based on research, there are things that we have called like common factors that are the most important parts of therapy. So, I'm going to mention some specific modalities. But really truly it's important to get in and see someone who, to whatever degree you can feel connected with. Someone that you feel like I can sit in a room every week and feel like I can get something from this person and be open with this person. That's like just baseline.

I would say, generally speaking, just based purely on the research, people who have a cognitive behavioral background is usually like a safe bet just because like people who are CBT, they are going to teach you skills. And a lot of what we do in executive functioning, coaching, and things like that is we're teaching people skills to help them overcome some of the natural deficits that they may have with ADHD.

For instance, like people may have a lot of issues with time management and organization. So, we're going to give you tools and tips and tricks for how to like, work through and work around that. Because when you have a diagnosis of ADHD, your relationship with it might change over time.

Laura: Right.

Dr. J: You might be like, "When I was a kid, my ADHD like sucked. And then, you know, I got around 40 and it wasn't that bad." You know, like a lot of people have that experience. And even if you take medication and all of those things, you still need the skills.

And so, I would say, like a cognitive behavioral therapist who has a background in working with people who have like, thinking and learning differences is going to be helpful because they'll be able to look at you, assess where your skill deficits are, and then give you like targeted, interventions around each of those different like deficits.

And there's also a lot of evidence-based cognitive-behavioral treatments that work for PTSD as well. So, things like cognitive processing therapy, prolonged exposure, are two of the most well-researched examples. But there's also other treatments for trauma like EMDR, internal family systems, which fall more into psychodynamic human or IFS, psychodynamic, humanistic different kind of approaches.

(23:54) How can caregivers and loved ones support someone who has ADHD and trauma?

Laura: How can caregivers and loved ones support someone who's dealing with both ADHD and trauma?

Dr. J: I would say the first thing is having patience. One, emotionally, they may have moments where they have a lot of emotional dysregulation. So, like that family that's supporting them may have some difficult times with this person. This irritability, these anger outbursts, like all of these things are really hard to like, cope with sometimes. So, I think that's really important.

I think communication too is really key in these situations, in terms of communicating with that person and getting a sense of how does this impact you on a day to day? And let's work together and collaborate and problem solve on like, how could I effectively like help you in this situation?

So, if you're living with someone with ADHD, you might hate giving them reminders, but it's like if that's one of the ways that you can like be helpful. It's like, OK, like like let's lean into I know that I will have to remind this person two times to do this one thing, and that's OK. And let's put systems in place that allow us all to kind of unify around these topics.

I would also say if you are supporting a loved one with mental illness, regardless of what it is, do your own education around it and also get support around it if it makes like sense for you. I know a lot of people who are in a caregiver capacity, or they have family members that do have multiple diagnoses or severe diagnoses like schizophrenia. And oftentimes you need support around how to support like this person.

Laura: Yeah.

Dr. J: Because you go through complicated feelings. Like sometimes you feel like you're a horrible person because you're mad at them and you're mad at their mental illness, and you feel guilty and shame and all of these things. And so, it's important to find community where you can fully express those complicated emotions and be validated and get, you know, constructive feedback and support around those things.

Laura: Have we missed anything in this conversation? What should we still talk about when it comes to ADHD and trauma?

Dr. J: I mean, if I've answered all of your questions, I mean, if you have other questions...

Laura: I don't. I don't at this point. I'm like, basically what I just asked, do you see what I just said there? I said, can you do my job for me? And that was my own insecurity coming through and also wanting to make sure that you had a platform to talk about anything that maybe I didn't ask you. Yeah.

Dr. J: Yeah. No, no, I just hope that anybody who's listening who does have PTSD and ADHD, that they have an understanding that even if their lived experience in this moment is one that is very heavy, that like go to treatment or get access to treatment in whatever way that you have capacity for at this time and that things can truly get better. Like I feel like I'm that like, hokey person, but it's just me.

Laura: It's not hokey. Yeah. It's important.

Dr. J: Like I just have seen so many people with so many lived experiences and co-morbid diagnoses that like, I know that things can improve over time. And I think the second thing that I'll just drive in again is don't forget your fundamentals.

And I think one of the issues with some of the things that are going on currently is we're always looking for like the hack. It's like, there must be a hack for this, there must be a shortcut for that, you know? And something that I always say to people is, if you're thirsty, my first response is going to be to give you a glass of water. We can sit out here and get into electrolytes and Gatorade and whatever, but like it's like, just get to your like fundamentals.

So many patients I have, if they get a week of actual sleep, it's like a night and day difference.

Laura: Yeah.

Dr. J: Does it fix the fact that they have a job they don't like? No. But they can deal with that a lot better, and they have the mental capacity to now look for a job. You know? And so, those are the pieces that I really want people to know, because I know there are people who don't have easy access to mental health. And I just want people to know that you can do a lot with, like, fundamental things like this.

(28:13) More on "ADHD and..." on the "MissUnderstood" podcast channel

Laura: Can we talk a little bit about "ADHD and..." quickly and the "MissUnderstood" channel?

Dr. J: Oh sure. Yeah.

Laura: Because can I just tell you that when I first listened to the trailer for "MissUnderstood," I was cracking up at the very end. I think that was you saying "We have like a Golden Girls level ADHD roundtable thing happening here."

Dr. J: That probably was me.

Laura: OK, so it's you, it's Cate Osborn, aka @Catieosaurus, and Jaye Lin, the ADHD coach, and maybe more people to come. And very exciting. I just want people to check it out.

Dr. J: Yeah.

Laura: It's so great. What have you enjoyed about it so far?

Dr. J: Oh, I enjoy the whole like process, even just like working with people at Understood. I like it a lot. But yeah, the podcast is all about ADHD and like everyday life. So, like other things that come up. So, we've covered topics already like anger and perfectionism, and imposter syndrome was one that's already out, I think. And so, it's just covering these different topics of like, "OK, I have ADHD and I got other problems, OK?"

Laura: Yeah, yeah.

Dr. J: "I need some information about how as a person with ADHD, do I cope with "blank" like, you know, fill in the blank. And so, I'm hoping over time, like people send in like questions or topics they would like for me to like, talk about because I enjoy doing that sort of thing. It makes me happy to know if I can give someone a nugget or like a bright spot, like it's like, "Here, here you go. Like, hopefully this can carry you through to the like next step."

Laura: I have no doubt that people are going to start sending things in. So, everybody, we're going to put links in the show notes. We'll put links to more resources on ADHD and trauma, all of which I'm sure is content that you either worked on with us or reviewed for us, Dr. J.

We'll put links to "MissUnderstood." You can search in your platform of choice, your podcast platform of choice for "MissUnderstood." That's one word — see what we did there? A little play on words, "miss" with two S's — the ADHD in women channel, and then the show that Dr. J is hosting is called "ADHD and..." Thank you so much for being such an important part of everything that we're doing and Understood, and for being here.

Dr. J: Oh, of course. I enjoy you all's mission, and I feel very honored to be able to participate and help in any way I can for sure.

Laura: As soon as we decided to create this channel, we were like, "Dr. J has to be part of it." That was like rule number one. So, all right, cool. Thank you so much for being here today. I imagine we will meet again soon.

Dr. J: Yeah. Thank you.

Laura: Thanks for listening. As always, if you want to share your own "aha" moment, email us at ADHDAha@understood.org. I'd love to hear from you. Be sure to check out the show notes for this episode. We have more resources and links to anything we mentioned.

This show is brought to you by Understood.org. Understood is a nonprofit organization dedicated to empowering people with learning and thinking differences like ADHD and dyslexia. And if you like what you hear, help us continue this work by donating at Understood.org/donate.

"ADHD Aha!" is produced and edited by Jessamine Molli. Jessamine, are you there?

Jessamine: Hi everyone, I'm still here.

Laura: And Margie DeSantis.

Margie: Hey, hey.

Laura: Our theme music was written by Justin D. Wright, who also mixes the show. Ilana Millner is our supervising producer. Briana Berry is our production director. Neil Drumming is our editorial director. Creative and production leadership from Scott Cocchiere and Seth Melnick. And I'm your host, Laura Key. Thanks so much for listening.