The relationship between PTSD symptoms and attention problems in children exposed to the Bosnian war.(post-traumatic stress disorder)(Disease/Disorder overview)

The authors examined the mediating role of posttraumatic stress symptoms in the relationship between traumatic event exposure and attention problems in a sample of 791 Sarajevan children exposed to the Bosnian war. They hypothesized that because of similarities in the arousal symptoms of posttraumatic stress disorder (PTSD) and the hyperactive-inattentive symptoms of attention-deficit/hyperactivity disorder (ADHD), PTSD symptoms would mediate the relationship between trauma exposure and attention problems. The findings support the hypothesis. The findings also show evidence of a reporter effect, whereby the relationship between trauma symptoms and attention problems was strongest when both types of symptoms were reported by school officials. Given the potentially spurious relationship between trauma exposure and attention problems, careful consideration must be given to the diagnosis of traumatized youth who present with ADHD symptoms. In accordance with practice guidelines, a multi-informant, multi-measure approach in the assessment of attention problems is strongly recommended.

Keywords: behavioral assessment; at-risk populations; behavior(s); comorbidity; emotional and violence adjustment

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Children exposed to war atrocities often experience clinically significant levels of reexperiencing, avoidance or numbing, and hyperarousal symptoms, which together make up the syndrome of posttraumatic stress disorder (PTSD; Allwood, Bell-Dolan & Husain, 2002; American Psychiatric Association, 2000; Dyregrov, Gupta, Gjestad, & Mukanoheli, 2000; Goldstein, Wampler, & Wise, 1997; Kinzie, Sack, Angell, Manson, & Rath, 1986; Nader & Pynoos, 1993). In addition to increased risk for PTSD, many children who experience severe trauma also experience symptoms of attention-deficit/hyperactivity disorder (ADHD), which is marked by a combination of extreme inattention, impulsivity, and hyperactivity (American Psychiatric Association, 2000). Famularo, Fenton, Kinscherff, and Augustyn (1996) found that in their sample of 117 maltreated children, 35% met criteria for ADHD. Similarly, Weinstein, Staffelbach, and Biaggio (2000) found that about 25% of the sample of children, who were sexually abused met criteria for ADHD, compared to only 3% of the nonabused sample. In addition to the relationship between trauma exposure and attention deficits, comorbidity rates of 23% to 37% have been found for PTSD and ADHD (Famularo et al., 1996; McLeer, Callaghan, Henry, & Wallen, 1994). The association between trauma exposure and attention problems, and the comorbidity between PTSD and ADHD, raises relevant etiological and clinical issues.

Etiological Implications of the Exposure-Attention Relationship

Relations between trauma exposure, posttrauma symptoms, and attention problems suggest several possible explanations. First, because ADHD and PTSD syndromes share a salient symptom, poor concentration, it is possible that diagnostic overlap simply reflects symptom similarity rather than a conceptual or etiological relationship. In fact, researchers have suggested that the symptom-level overlap of PTSD and ADHD might partially account for some posttrauma ADHD diagnoses as well as comorbid diagnoses of PTSD and ADHD (Ford et al., 2000; Weinstein et al., 2000). Symptom similarities might be particularly perceptible with more general symptom descriptions (e.g., difficulty concentrating) as opposed to more molecular symptom descriptions (e.g., attention problems associated with preoccupying thoughts of trauma).

A second possible explanation is that both attention deficits and trauma response share a common etiology or vulnerability. For example, ADHD is a neurodevelopmental disorder purported to be characterized by dysregulation of the central noradrenergic system (see Biederman & Spencer, 1999, for review). Similarly, PTSD is characterized by noradrenergic dysregulation, particularly, the activation of the hypothalamic-pituitary-adrenal axis (Goenjian et al., 2003). Although no known studies have examined possible neuroendocrinological similarities in children with ADHD or PTSD, separate research of these two disorders indicates that similar etiology might be at work in the behavioral dysregulation and attention problems common to both disorders. Of course, this explanation does not account for the relationship between ADHD symptoms and trauma exposure, which may be better explained by a causal model.

Causal explanations reflect a third way attention problems and trauma exposure and response may be linked. ADHD may be a risk factor for trauma exposure and later PTSD symptoms; children with ADHD may put themselves in riskier situations and be at higher risk for victimization or other trauma exposure than their non-ADHD peers. In keeping with this causal model, Barkley, Guevremont, Anastopoulos, DuPaul, and Shelton (1993) found that during the course of 3 to 5 years, drivers with ADHD were 4 times as likely to be involved in an automobile accident when they were driving as compared to drivers without ADHD. This finding has been consistently replicated with young adults with ADHD (see Barkley, 2004), indicating that aspects of ADHD (e.g., impulsivity, inattention) might be a substantial vulnerability factor for some types of trauma exposure. Similarly, Ford and colleagues (2000) found that youth with ADHD were more likely to experience maltreatment as compared to youth with adjustment disorder. However, some research fails to find support for this "risky behavior" hypothesis (Wozniak et al., 1999), and still other studies suggest that attention deficits might emerge secondary to trauma exposure.

As opposed to the ADHD-to-exposure causal relationship, a fourth explanation suggests an exposure-to-ADHD relationship. This direction of causality might occur in two ways. First, children exposed to trauma might be more likely to express ADHD symptoms. Becker and McCloskey (2002) suggest that extreme stressors, such as trauma exposure, might be a catalyst for symptom expression (e.g., dysregulation) in children with ADHD. Indeed, the posttrauma environment (e.g., following the sudden traumatic loss of a loved one, following disclosure of abuse) is often associated with increased environmental and emotional chaos that might lead to behavioral dysregulation in children. This behavioral dysregulation might then worsen a preexisting disorder or move the child from subclinical syndrome to disorder. Similarly, the posttrauma environment might tax adult coping skills and lead to decreased tolerance for previously acceptable or marginally acceptable child behaviors. Thus, adult reports of children's behavior dysregulation, including attention and hyperactivity symptoms, might increase posttrauma.

A second form of this exposure-to-ADHD explanation proposes that the link between PTSD and ADHD actually reflects symptoms of PTSD that mimic ADHD. As suggested by Cuffe, McCullough, and Pumariega (1994) and Wozniak et al. (1999), PTSD arousal symptoms (e.g., poor concentration, exaggerated startle response, irritability, sleep difficulties, hypervigilance) might resemble an ADHD-like syndrome involving symptoms of hyperactivity and impulsivity. In support of this hypothesized relationship, Glod and Teicher (1996) found that abused children had significantly higher activity levels (i.e., hyperactivity) than nonabused children. This difference was largely accounted for by the presence of PTSD symptoms; the activity level of abused children without PTSD was similar to that of nonabused children. These findings suggest that PTSD symptoms (e.g., hyperarousal) might serve as a mediator in the relationship between trauma exposure and at …