ADD/ADHD: When Might Symptoms Signal Child Abuse?

A clean, well-groomed, apparently healthy 6-year-old girl was accompanied by the school nurse and special education teacher to an initial visit with a consulting pediatrician. The appointment had been arranged by the principal at the child’s school who knew this clinician had a special interest in children with behavior disorders.

In preschool the child’s erratic, disruptive behavior had prompted evaluation by the school nurse and school psychologist. She was given a diagnosis of attention deficit disorder (ADD). She had been referred to the local mental health clinic but, because of her mother’s work schedule, few of the appointments were kept.

The mother was young, single, and worked at several poorly paid jobs, but had been very cooperative with the school’s recommendations that the child be evaluated and treated. Documentation confirming the child’s behavior patterns, including classroom observation, came from 2 psychologists’ reports and from several physicians. According to these reports, the child had met all the DSM-III (the edition available at the time) criteria for a diagnosis of ADD. A list of medications revealed that the child had at various points been prescribed all drugs that were FDA-approved at that time to treat the disorder, as well as other medications used off-label. 

It is common for children with ADD to be subdued and relatively inhibited  during a first encounter with a new physician. When the consulting pediatrician first saw her, however, this child was so disruptive that she had to be removed from the room so that the consultation could proceed. The pediatrician suggested that there could be an undetected problem with medication compliance at home. A treatment plan was developed to have all medications administered as prescribed at school by the nurse. This plan was executed, but there was no change in the child’s behavior. She was then referred to an in-patient pediatric psychiatric unit. The diagnosis of ADD was again confirmed and medication dosage was doubled. After 6 weeks of inpatient treatment, the child returned to school but the teachers complained that she was “dull” and too sleepy to do her work.

During this time the child’s mother continued to cooperate with the school’s suggestions and was supportive of the inpatient referral. She was rarely seen in person, however.
  
When should a behavioral disorder like ADD/ADHD be questioned as a manifestation of abuse?Click here for discussion.

This child was treated for 6 more months, but therapy failed to ameliorate her behavioral problems. During this period, authorities at school first began to notice bruises on the child and child protective services was notified. Investigation revealed that the mother had been living with a series of abusive men. After physical examination, the child was made a ward of the court on the grounds of physical and sexual abuse at home.

Under careful questioning, the child was able to begin talking about what she had experienced. A year later, in a stable foster home and under the care of her primary care physician and a mental health team, her behavior was acceptable and she was no longer taking medications. She passed first grade without any further problems and was adopted by the foster family. Her mother’s parental rights had been permanently terminated and she was imprisoned for her participation in the abuse. The child was subsequently lost to follow up after the family moved out of state.

Lessons (Painfully) Learned
If there appear to be details missing in this account of the case, there are. I was this child’s consulting pediatrician during my first year of private practice. I initially missed the diagnosis of abuse. It was this case, along with several others, that drove my interest in child abuse. . . its detection and correction.

Today, the diagnosis of abuse would have been quickly apparent. At the time, however (more than 20 years ago), there was no literature that linked child abuse and ADD/ADHD. A correlation has since been established but important questions remain. Chief among these:
• Does abuse play an etiologic and/or exacerbating role in the development of ADD/ADHD?
• Are abuse-related externalizing and associated behaviors being misdiagnosed as ADD/ADHD?

I have seen only one similar case of ADHD-like behavior as a result of child abuse since the case described here. But because of what I learned 20 years ago, this time it took less than a month to make a presumed diagnosis and to get child protective services involved.

Teaching Points
• Stay alert to the potential for abuse among children with apparent ADD/ADHD symptoms, especially in children with erratic attention patterns.
• Pursue the possibility of abuse in cases of ADD/ADHD or other behavioral dysfunction where there is consistent treatment failure and/or other features that do not follow standard medical reasoning.
• Enlist help from school officials, child protective services, or other child welfare bodies at the first suspicion of child abuse in any form.

References:

References

1. Briscoe-Smith AM, Hinshaw SP. Linkages between child abuse and attention-deficit/hyperactivity disorder in girls: behavior and social correlates. Child Abuse Negl. 2006;30:1239-1255.

2. Ouyang L, Fang X, Mercy J, et al. Attention-deficit/hyperactivity disorder symptoms and child maltreatment: a population-based study. J Pediatr. 2008;153:851-856.

Additional Reading

Shipman K, Taussig H. Mental health treatment of child abuse and neglect: the promise of evidence-based pratice. Pediatr Clin N Am. 2009;56:417-428.