When Experts Miss Trauma in Children

It has been estimated that each year, over one million children in the United States are misdiagnosed with a mental illness that could be better explained by trauma. That’s a lot of children inaccurately being labeled with a mental illness. The problem of misdiagnosis is important. If we misdiagnose or mislabel a child with a mental illness, we run the risk of recommending or providing treatment that will potentially not alleviate or address the child’s core problems.

For example, one child displays many attention problems at school. He is diagnosed with attention deficit hyperactivity disorder (ADHD) and treated with a stimulant medication. It works great. A second child also is showing attention problems at school, but the stimulant medication doesn’t seem to be working as well for her.

When looked at more closely, it turns out that the second child has a traumatic/chaotic past and horrifying current living situation, causing many of the same attention problems exhibited by the first child. In this case, the second child may not need the stimulant medication. She needs the trauma at home to be addressed. Clearly the two children have different needs, which require different treatment, even though at first glance they appear similar.

We must do better. And we can do better.

The first way to begin to address the misdiagnosis of trauma is to better understand what trauma is. Sexual assault, abuse, neglect, and violence are classified as major trauma. However, there exists a second level of trauma, just as deadly in some instances. We can classify this as daily trauma. This includes the toxic stress of living in poverty, of struggling with inner-city life, or of dealing with any number of stressful life circumstances beyond our control.

Busy professionals often fail to notice or consider this second type of trauma. When added together, however, these daily toxic stressors can affect children in a variety of ways. Some look very similar to other mental illnesses and lead to misdiagnosis.

I theorize that there are two main pathways to misdiagnosis. The first I call the “arousal pathway” or “AP” pathway. These children often present with externalizing problems and behaviors. They are acting out against something or are displaying behavior problems or attention difficulties brought on by daily trauma. Often they are labeled with conduct disorder or ADHD. Their symptoms may make them eligible for these diagnoses. A deeper look at their trauma, however, may suggest it’s the trauma symptoms, not the behavior or attention problems, that need to be addressed.

The second pathway I refer to as the dissociative/affective pathway, or “DAP.” These children are internalizers. In other words, the trauma in these children’s lives causes them to turn inward to cope. They often get labeled with these internalizing disorders, or go completely unnoticed. They often are misdiagnosed with depression or an anxiety disorder. They also are the children who typically receive no diagnosis at all. They could be the shy kid in the classroom who barely talks, or doesn’t speak at all.

Every child diagnosed with a mental illness does not fall on one of these two pathways of misdiagnosis. We do get things right and the vast majority of professionals do spend the time necessary to make sure that they are seeing the whole clinical picture. However, misdiagnosis remains a huge problem and does occur. We must make every effort to uncover what is going on in the lives of the children we work with in order to be sure that what we are diagnosing is an accurate representation of the situation.