February 2024

In kindergarten, this adoptee ran around distracted, compulsively blew kisses at other kids, and then asked those same kids if they were mad at me—far too many times. In some distorted attempt to sooth my worries, I tied the tassels on my blanket into a million knots and licked my hands raw while other kids took their naps. Other times, I would just shut my brain off, and appear blank, absent, as if I was staring off into a daydream. One week, as the big test for numbers and colors approached, I couldn’t remember what color was what, so I broke a barrel of crayons apart in frustration trying to sort it all out. I didn’t understand at the time, but I was living with a constant fear of rejection and subsequent loss. Even my dreams were infected. I was a groggy kid in the early mornings, after having recurring nightmares in which President Ronald Reagan was giving me the color and number test, and that I kept failing over and over again, disappointing him, and in turn, the rest of the country.

This was the age that marked the beginning of being referred to as space cadet, clueless, and flighty. It’s when I became used to disappointed and stern looks from adults, when I grew accustomed to hearing sharp requests to pay attention! from—it seemed like—everyone. I was frustrated that I couldn’t learn like the other kids and grew to be ashamed of myself. In my little brain, I was distracted by a roaring sea of chronic worry: thoughts of my family members dying, my parents getting divorced, my brother getting sent away, my cat getting run over, or of me being abandoned or rejected in some other way—somehow. Instead of learning in class or at home, I was focused on how to make my mother laugh, or how I could help my dad quit smoking or how to fix my brother’s lying problem.

By the end of that year, in 1986, I took the first of many tests for learning disabilities. I was given a diagnosis of attention deficit disorder (ADD–inattentive type) and eventually placed in a special program in elementary school where I was given guidance on how to improve my executive functioning skills. I was allowed a quiet place to take tests, a teacher’s aide to read the test questions to me, and tips and tricks for time management and memorization. I was also put on stimulant medications that changed in dose and variety until my senior year of high school. I cannot remember the medication doing much of anything for me, and my grades did not improve. My attachment issues, chronic worry and hypervigilance, ruminating thoughts, and subsequent compulsive behavior was not touched upon by professionals and in turn was left to flourish. Throughout this article I will refer to this combination of symptoms as relational trauma, which is often referred to as CPTSD or complex post-traumatic stress disorder Today, as a seasoned attachment therapist, it’s clear to me that without attachment- and trauma-informed treatment, those executive functioning interventions didn’t stand a chance.

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In his book, Scattered Minds: The Origins and Healing of Attention Deficit Disorder, Gabor Maté, MD, explores the idea that years of varied brain and attachment research have pointed to: that ADD originates in early childhood stresses during the first years of crucial brain and personality development. He describes a wide amount of research illustrating the connections associated between early life stress and brain changes. (Maté, 2019 p. 80) Maté also stresses, in his writings and on his website, the importance for those of us diagnosed with ADD or ADHD to acknowledge and unravel our early childhood stresses. 

I was born heavily marinated in stress and fear, and these experiences continued through much of my childhood. For a long time into adulthood, I didn’t understand how that chronic stress from my birthmother loss and family chaos had truly impacted me. As an adoptee, my early life story was, well, not the best. My birthmother experienced my conception as a terrifying act of violence inside an inpatient psychiatric institution where she had resided for much of her adult life. She remained in that institution throughout her entire pregnancy and during that time had to be taken off her psychiatric medications. Once I was born, she was only able to hold me for five days before I was put into a foster home and then a month later removed again, from what I had come to know as home, and put into another situation with new people, my adoptive parents. My new parents had also adopted another child. The boy joined their family several years earlier when he was three years old. He had years of neglect and abuse behind him when he first arrived and, in turn, reasonably could not trust anyone. Occasionally our family also served as an emergency foster home for the state, and my brother and I witnessed some kids coming in and leaving. One time the kids had to leave suddenly. Something bad had happened in our home, I don’t remember what, but I can imagine that my brother and I must have felt on some level that we also, someday, might have to go.

My older brother’s oppositional behavior, my father’s very short fuse, and my mother’s panic disorder, did not blend well together. Nightly arguments, which most of the time turned into screaming and threats, ensued, and I listened, kneeling at the top of the stairs with my body tensed up in hypervigilance. I was so alert to the energy of my family that I grew to understand the sort of mood my parents or brother were in by the sound of their footsteps. While our father tried hard at times to cultivate moments of patience, he truly struggled to regulate his emotions, as did our mother, who was hospitalized with bouts of panic and depression for a few months when we were still very young. With all of these cards our family was dealt, there had never been a time in which I felt free of my own chronic social scanning in order to prepare for some kind of eruption, rejection, or loss. I also coped by becoming a very creative child, conjuring up whole worlds—worlds where I held more power and felt more protected than I did in my real one. My imagination gave me much-needed relief from the stress in my mind and body.

Despite how explosive things often were at home, I do believe that my parents did the best they could with their own histories behind them, and they often expressed their love to us. My mother was persistent and fought hard to get me services at school to help with my learning. She pushed for me to have a counselor in the learning center in our high school. Miss. S. was warmhearted and let me take tests in her office. The break from the pressure of a classroom helped, but my ruminative racing thoughts dogged on, even with that escape.

I believe that in my parents’ minds I really just needed to learn ways to pay attention better. I just couldn’t do it. I couldn’t seem to pay attention for very long no matter how hard I tried—even with those stimulant medications. I was both scared of and obsessed with my father. Besides being hot-tempered, he was hilarious, affectionate, and my favorite person. He would sit down with me after dinner sometimes, have me lay out my math homework on our Italian pizza parlor-esque tablecloth, and try to help me, and I would try to listen, but I would end up pretending to understand the information in order to please him and avoid his temper. At some point in middle school, I stopped what seemed to be an uphill battle of trying to get my brain to work the way it seemed everyone wanted it to. The pressure of letting people down and the fear of rejection (abandonment) had me worn out.  

After high school, which I narrowly escaped as a graduate, I spent my time in a pattern of working jobs that meant nothing to me and then getting fired from them. I stopped taking the stimulant medications and I found that alcohol soothed my chronic worry, so I drank as often as I could. After a good friend encouraged me to get into classes at a community college, something amazing happened. When sitting down to study with a rocks glass full of vodka or rum, I found that instead of feeling that old dread around homework, I found ease and comfort and in turn, I was able to focus and gain more organized access to my brain space and creativity. The problem was, when I started, I rarely could stop. But despite the daily hangovers, weekly blackouts, and morning heart palpitations, I excelled in college. My parents were shocked—and proud. Now, this is by no means an advertisement for using alcohol as an aid for focus, but it is an illustration of how it was the dis-ease in my body, not just a problem with my attention span, that had been the foremost barrier to my learning and concentrating.

In time, drinking gave me far more negative consequences than benefits. After more than a decade of trying to live with active alcoholism and bottoming out in various ways while somehow simultaneously earning several degrees, I took action to get myself sober and engaged in the recovery world. I also started to work with a trauma-informed therapist. The hypervigilance and racing brain came back with a vengeance when I put down alcohol, and I had to sit with it, and with other people in my recovery meetings, to better understand its origins. I learned in recovery about how the chaos and insecurity in my childhood had created early ongoing patterns in my thinking and stress response system. One of the most important skills I acquired during that time through trauma informed therapy was the ability to reframe my thoughts so that they, in time, have come to lean more naturally toward self-compassion rather than self-shaming and self-abandonment. Instead of hearing that inner voice that used to say, Why can’t you just pay attention? I now hear one that says, What do you need right now to ground yourself? 

I learned to listen to my wise intuitive inner voice and to question my fearful frantic one. Developing long-term friendships with others who were going through their own recovery processes also helped me with relational fears in more ways than I have space to discuss in this one article. In the world of addiction recovery, you are told that you will always be invited to come back no matter what, and that notion helped me feel deeply connected to the rooms and people I found there, even though I found those rooms intimidating at first. Finding the right medication was also a game changer, and for me, that was not the stimulant medication that I was prescribed as a kid, but instead, a selective serotonin reuptake inhibitor (SSRI) medication that was given to me to combat my anxiety. After I was able to get internally balanced, I was able to understand and use those executive functioning skills that had been presented to me so many years prior: skills like organizing my schedule into smaller segments, planning projects and study time for those projects far in advance, and pausing to go outside or do breathing exercises when I was feeling overwhelmed.

Our earliest experiences greatly impact our brain formation. About seven years into my sobriety journey, and after getting licensed as a mental health counselor in my thirties, I started to study early childhood trauma more extensively. I learned in depth about the complex family systems with adopted or fostered children like mine and about what happened to our little brains in the beginning of our lives. Construction of the brain starts while we are in utero and our early experiences influence and affect the architecture of our brains by forming “either a sturdy or a fragile foundation for all of the learning, health and behavior that follow.” (Harvard University’s Center on the Developing Child, 2007) When loss happens as a first experience, the brain and body may always remain on guard for more relational trauma and loss. All relinquished and adopted children start off early with a kind of extraordinary fear and loss. The process is explained in more detail in Nancy Newton Verrier’s book The Primal Wound and in more depth through many of the early childhood stress studies that have been conducted over the past 20 years. (Hambrick et al., 2019) Additionally, research shows that in fact early life stress exposure results in attention-deficit/hyperactivity disorder (ADHD)-like behavioral symptoms (Bock et al., 2017), and that children may respond to traumatic experiences with behaviors that mimic the symptoms of ADHD or, alternatively, trauma may exacerbate pre-existing ADHD in children. (Biederman et al., 2013)

With this knowledge under my belt, I found myself able to reflect on and understand why it was so difficult for me to concentrate in school. As a kid and teen who was consistently anticipating a new loss or disaster, I had been living half the time in a state of hypervigilance and hyperarousal, and the other half tuned out and stuck in my drained brain.

Never was relational stress or adoption loss discussed with me or my parents in regard to my problems with learning. This lack of discussion was problematic, of course, as I internalized my struggle with focus, impulsivity, and my ruminating mind as my own personal failing rather than the result of trauma. My teachers, testers, and my parents had been focused solely on an ADD diagnosis and behavioral modifications. I had no idea that my brain had formed and adjusted to the toxic stress I had been enduring from infancy onward. I didn’t know my brain was trying to protect me in some well-meaning (but malfunctional) way by keeping me on high alert and letting me rest and reset by shutting me down (dissociation).

Too many times to count in my work as a clinician I encounter professionals who have not yet learned or developed enough of an understanding to discuss symptoms of relational stress when they meet with their young client’s parents who are focused on an ADD diagnosis. This is a major disservice to our kids who eventually become adults with untreated trauma symptoms. For example, several years ago I was working at what one would consider a very progressive group therapy practice with about twelve other therapists, many in their first year or two of getting their clinical licenses. The practice held a training on ADD. An expert from an outside specialty group came in to educate our staff and share her knowledge about diagnosing ADD. She shared some good info on how to teach executive functioning skills as well as on key symptoms of ADD—trouble focusing and inattention, impulsivity, and at times hyperactivity. As many of these symptoms are also signs of  relational trauma, I asked her if and how therapists might discuss this trauma alternative in place of or in addition to an ADD diagnosis with clients or clients’ parents. I suppose that could be true, that it might be both, she said, but did not elaborate further. I thought that perhaps we would have more of a discussion on this possibility during the training, particularly after I broached that subject, but she just quickly moved on to discussing interventions. I was disappointed—but not surprised. While research is limited on the prevalence of trauma informed assessments, a 2017 Children’s Health Care study of 200 charts in the offices of developmental-behavioral pediatricians revealed that less than half—just 44%—had documented any anxiety or trauma history screenings. What needs to happen for trauma screenings to find their way to being prioritized in any setting where kids are being diagnosed for learning disorders?

Fortunately, there are some professionals who recognize the need for a conversation highlighting relational trauma and its impact on brain formation and focus. Some of them, including myself, work at Boston Post Adoption Resources (BPAR), a nonprofit that works specifically with relinquished children and adults. BPAR’s intake director, Erica Kramer shares, “A disproportionate amount of the kids who are referred to us have an ADHD or ADD diagnosis. The question is: Is this ADHD, or is it actually a relational trauma response?” Kramer says it’s essential that more clinical programs, like adoption and foster care agencies and counseling programs, educate all professionals to be trauma-informed. “If the professionals had known that this was a response to trauma,” she says, “that could have been life-changing. If foster and adoptive parents were told about how to parent a kid with a history of trauma, they would not have been blindsided. So many adoptive parents have told me, Nobody told me to expect this. I didn’t know.” 

I wanted to learn more about how specialists who are practicing trauma-informed care with kids who have been diagnosed with ADD are working with these kids and their parents. So, I met with Ken Barringer, a licensed mental health counselor and director of the Academy of Physical and Social Development in Newton, Massachusetts, to discuss his perceptions of ADHD diagnoses, traumatized children, and subsequent treatment. He’s worked at the academy since 1981. Barringer describes what typically happens when kids who have experienced trauma get an ADHD diagnosis without any attention to the impact of the trauma: “With younger kids if it’s trauma and it’s not treated as trauma, so we think they have a [strictly] behavioral problem and we don’t address it from a trauma standpoint, we’ll try behavioral techniques. These work—if anything—minimally effectively. Then medication is often the next step. So, for example, you might have a kid who is very anxious to begin with, and their anxiety has them acting out and now they are being given stimulant medication, so now things are going to be worse. Then people [professionals] often say, ‘Okay. It’s not enough intensive behavioral therapy’—which often becomes punishment—and ‘It’s not enough medication. We have got to start trying other [stimulant] medications or adding a new medication.’ Next thing you know, it’s years down the line and this kid has lost years of learning time because no one is understanding him. A lot of kids end up in behavioral-based programs that they shouldn’t be in this way. Now, if the acting-out behavior had been thought of as a trauma response and trauma-informed therapy had been instituted, then maybe that whole situation didn’t have to happen. Down the road, they end up possibly becoming addicted or having other adverse responses.”

During this part of the conversation with Barringer, I flashed back to my first counseling internship. I worked at a program for people who had nowhere else to go at that point in their lives for one reason or another and who were trying to stay sober inside of a very chaotic homeless shelter. It was quite a feat for those folks to attempt to achieve and maintain sobriety while staying in a place that could be considered an equivalent to hell unless one was numbed out. Those in the program had childhoods full of neglect, stress, and fear. It was more common for them to inform me about an ADD diagnosis given by a past provider during the intake session than it was for them to tell me about a trauma or anxiety diagnosis, and many of them had been prescribed stimulant medications in their childhoods, again, without attention paid to their symptoms of trauma. So many of them learned, as I had, to curb their anxiety and stress responses through alcohol as adults. It’s no wonder anxiety and alcohol use disorders have been linked (Smith, 2012), and no wonder alcohol acts as a (temporary) solution for so many—until consequences inevitably outweigh the benefits.

So, what is trauma-informed care? I ask Barringer. He describes the three Ss: “Structure, Support, and Safety, and snacks if you work with kids,” he jokes, then clarifies, “Keeping kids in highly Structured environments that will Support them leads to Safety.” Regarding the details of what a supportive environment looks like, Barringer suggests this: Instead of yelling “Pay attention!” to kids at a distance, move close to them and show compassion. “Parents, teachers, coaches have to buy into this [trauma-informed care] too,” he adds. “It’s hard to give valuable feedback from a distance, because it sounds just like noise. If it is a trauma response we’re dealing with, a raised voice can trigger the kid; we’ve got to move closer. I like the phrase, He is doing as well as he can. I tell parents, as much as you don’t like being in this interaction with them, they don’t either. It’s not as much up to them to change as it is up to you to change because you are the grown-up.”

Darci Nelsen, PhD, LMHC, BC-DMT, is a colleague of mine at Boston Post Adoption Resources who works extensively with relinquished children and adoptive parents. “When we focus strictly on behavior modification in order to decrease these behaviors,” she says, “we end up focusing too much on the ‘what’s happening’ versus the ‘why it’s happening.’” She echoes Barringer, remarking that if professionals neglect to rule out the presence of trauma, the child will be treated for behavioral symptoms and not actually resolve the real underlying issue that might be driving the behavior.

Nelsen then shared what she sees happen to the child’s narrative of themselves when there’s more focus on the what that is happening with their behavior versus the why. “There tends to be this message that gets internalized as I am incapable, or, I am bad because these things are happening to me. In early elementary years, children start to develop a sense of who they are as learners or peers, and when they are spoken to about their behaviors it becomes internalized as an internal narrative about who they are, and that becomes who they believe themselves to be.”

She goes on to describe first meetings with parents of adopted children who are diagnosed with ADHD or ADD. “They fully believe this is happening for their child. My first mode of intervention may not be challenging that parent initially or telling them that a differential diagnosis such as trauma may be important to explore—but instead, first having them consider that what is going on for the child might be a dysregulation of attention rather than a deficit. The child may be attending to something else, especially for children with histories of trauma or complex trauma. We can explain all those complex symptoms with things that show up with trauma: symptoms like inattention, hypervigilance, hyperarousal, and impulsivity. For someone who has experienced relational trauma, the stress-response system is on high alert and might present similarly to ADD or ADHD.”

For a child with trauma, she says what might look like My child is not able to pay attention to the teacher, might actually be them shifting their focus to signs of threats or danger. Nelsen adds, “I don’t want to minimize how hard it is to talk to children about these types of things. It is hard to talk to kids about relational trauma, about complex or chronic stress. For some children, it will be hard for them to acknowledge and understand that what they have experienced may have been harmful in some way. It might be hard for them to differentiate what trauma is from normal life. It’s important to talk about this in a non-shaming way, saying something like, What happened to you is not your fault, and the things you are doing in response are a normal response for what has happened to you. This allows children to start thinking, ‘This thing happened to me, and I do have a choice on how to respond and to feel my feelings.’ Parents can model this for kids—feeling their feelings and then self regulating—and providers can as well.”

So, do I think I meet the criteria for ADD today? Perhaps. Probably. I still misplace my keys on a regular basis, struggle to pay attention when I am not interested in the subject matter,  and I remain an impulsive personality type. But, with my relational trauma symptoms treated properly, and lessened, I have the brain space more available to plan, organize, execute, and accomplish my goals in a timely manner and, often, with gusto. Do I think some kids have strictly relational trauma and are being misdiagnosed with ADD? I’m really not sure. I want to be clear that I am not an attention deficit disorder expert and I am not writing this to reject the existence of the symptoms that create an ADD diagnosis. I am here to ask that we also pay attention to the impacts of relational trauma,  that we look at the root of a problem and start there.

I am not a person who believes in time spent wallowing in regrets. I believe in learning from all of our experiences, and that all problems, including our losses—no matter how awful—can teach us the most valuable life lessons. But I can’t help but wonder what it would have been like to have had someone like Barringer or Nelsen on my side when I was a kid. We still have so much to learn about focus and early relational trauma; and fortunately, experts are doing the work more now than ever, researching and investigating this. It’s the trickle down that takes too long, from psychological study to the average behavioral clinician toolbox. Can you imagine the learning and growth possibilities if we started treatment for ADD by talking about the impact of trauma? If professionals and parents helped acknowledge the relational trauma and encouraged kids to shake off that shame from their internalization of their attention problems? Perhaps one day kids can start to say to their own fearful and traumatized parts: I get it, I know why you are here and why you are spinning, I see you, I care about you, I get what you are trying to do . . .  but you need to step down.

Look at the fears. Start at the why. Cultivate compassion and security.  I’ll end with a Gabor Maté Quote: “Safety is not the absence of threat, it is the presence of connection.”