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.