Trauma or ADHD? Considerations with cultural diversity

Why Cultural Humility Should Come First

Dr Alice Morgan · Clinical Psychologist · Starling Health Collective

If you're reading this because you scanned a QR code somewhere in the middle of my talk this weekend, welcome. You're probably still holding a lukewarm conference coffee and wondering what to do with the rest of your afternoon… maybe start here?!

Let’s start with a brief (composite) case study….Amara is nine. She arrived in Australia eighteen months ago, after two years moving through unsafe places, having lost her father somewhere along the way and having no idea whether he's alive. At school she's restless, doesn't finish her work, and doesn't seem to listen. Her teacher has raised ADHD. At home, her mother describes a completely different girl: calm, helpful, minding her younger cousin, sitting through three-hour family gatherings without complaint. “She is a good girl at home,” her mother told the clinician, and meant it as reassurance, not as a contradiction.

So which is it? Trauma? ADHD? Both? That's the question I spent thirty minutes with a room of clinicians on this weekend, and it's the question I want to unpack properly here, because a thirty minute presentation was never going to be enough.

Part of the difficulty is structural. ADHD and trauma share a wide, unhelpful middle ground of symptoms: inattention, restlessness, irritability, disrupted sleep, impulsivity. Rating scales pick up that middle beautifully and tell you almost nothing about what's driving it. Chronic stress in childhood also does something physical: it changes how the hippocampus, the stress-response system and the prefrontal cortex develop, which happen to be exactly the systems responsible for attention, memory and self-regulation. A child whose brain has spent two years learning that danger can arrive at any moment isn't performing restlessness in your waiting room – she has restlessness baked-in for a reason, and it's a good one.

The DSM-5-TR lists more than twenty conditions in its differential diagnosis section for ADHD: autism, anxiety, depression, bipolar disorder, conduct disorder, sleep apnoea, and on it goes. PTSD – or complex PTSD - isn't one of them. Not officially, anyway (reactive attachment disorder gets a mention, which is related in some ways to Complex PTSD, but it’s not the same thing).  ICD-11 is better – it mentions cultural context, complex trauma and PTSD as differential diagnosis, but this most recent version is the first time that trauma has entered the ADHD Arena.  This probably helps to explain why trauma is so often the thing we forget to rule out before reaching for an ADHD diagnosis, and why kids in Amara's position pick up a label before anyone has asked what happened to them before they reached the clinic room (that’s IF they even make it to your clinic room).

Enter cultural humility

This is where cultural humility earns its place in the conversation, and I should state (the perhaps obvious) upfront: I'm not from a culturally or linguistically diverse background. This means that I’m bringing my own cultural biases as a majority-culture white woman with me to this conversation, and needing to operate from a standpoint of cultural humility.  This term, coined back in 1998 by Melanie Tervalon and Jann Murray-García, stands distinct from the perhaps better-known term of “cultural competence”. Competence assumes there's a finite body of knowledge you can master about a culture, which is a nice idea until you remember there are hundreds of cultures and you could never master all of them (I can’t even master my own!). Humility asks something more honest of you instead: stay curious, notice the power gap between you and the family in front of you (this gap may widen or narrow depending on the culture), and treat yourself as a permanent work in progress rather than a graduate of some cultural training module. It's a less flattering stance, perhaps, but its definitely the more useful stance in this space.

Culture doesn't just sit quietly in the background while you assess a child, it actively sets the threshold for what counts as a problem in the first place. In settings where stillness and deference are prized, the hyperactive-impulsive child gets flagged fast, often as naughty. In settings where quiet compliance is the expectation, the inattentive daydreamer disappears into the furniture, especially if she's a girl – and this is amplified further if gender roles are pronounced within the culture. The effect isn't subtle, and it isn't confined to parent opinion. In Western Australia for example, children from non-English-speaking backgrounds have been found to be prescribed ADHD stimulant medication at roughly half the rate of their Anglophone peers. In Sweden, national register data on 2.7 million children found first-generation immigrant boys had less than half the likelihood of an ADHD diagnosis compared with native-born peers, a gap that had closed within a generation. The neurobiology didn't change between generations. Access, language and familiarity with the system did.

Which brings me back to Amara, and the gap between her school report and her mother's description of her at home. The temptation, when two informants describe two apparently different children, is to average it out, or decide someone must be exaggerating. Don't. That gap is the single most useful piece of information in her file. A child who can sustain attention through three hours of a structured, meaningful family gathering has attentional capacity that the classroom simply isn't drawing out of her. The question stops being “does she have ADHD?” and becomes “what is it about each setting that changes what we see?”

What to do differently on Monday morning

So what do you do with all of this when you've got twenty minutes and a family whose full story you can't yet read? A few suggestions:

●      If it’s needed, book the interpreter first, and make sure it's a trained interpreter rather than an older sibling.  Utilise the Interpreter’s knowledge of culture, trauma and expectations of children within their culture if they are from the same culture as the family (remember, the same language doesn’t necessarily mean the same culture).  TIS National is free, 24/7, for Medicare-rebatable care.

●      Ask who else should be in the room before you start. The default unit of one parent and one clinician is often the wrong one. There may be a Grandmother who is the primary caregiver or an Uncle that makes the decisions, or a bicultural worker who is the reason this family showed up at all.

●      Borrow from the Cultural Formulation Interview at the back of the DSM-5-TR. You don't need all sixteen questions if you don’t have time - five will change a first appointment: how would you describe this to your family, what do others think is causing it, what makes it better or worse, what help have you already sought, and what should I know to work well with you.

●      Treat a low score on a verbal or language-loaded cognitive test as a hypothesis, not a verdict, particularly for a child whose English is still emerging or whose nervous system is still running on high alert. Trauma alone can suppress working memory, processing speed and sustained attention on testing — the very domains an ADHD assessment leans on.

●      Corroborate function across settings before you conclude anything. If a child manages fine in one context and falls apart in another, that difference is data, not noise.  Analyse the behaviour in each situation and collaborate with the child – why are they jumpy at school or leave their seat in class?  What do they jump at?  Is it at the same thing?  Do they feel safe at school?  In a situation where Amara and her mother have been exposed to violence from men throughout their refugee experience, and she’s now sitting in a class where the only adult is male – does this surprise you?

None of this means talking yourself out of an ADHD diagnosis in a child who has also experienced trauma or migration. Plenty of these kids genuinely have both, and under-diagnosing real ADHD because it's easier to blame “still settling in” does just as much damage as over-diagnosing does. The point of cultural humility was never to make you doubt yourself out of a diagnosis. It's to slow you down long enough to ask better questions before you reach for one.  The research suggests that children with ADHD who have experienced trauma are significantly less likely to receive an ADHD diagnosis – often through a combination of access issues and clinician reluctance to diagnose both.  Yet the research also suggests that treating ADHD will also improve trauma symptoms, reduce anxiety and improve school functioning.  Where does this leave us?  Mostly back at the old Taco advert tag-line:  Why not both??!!

As for Amara: the formulation that fits isn't culture, or trauma, or ADHD. It's all three, held together and not ranked against each other. Her strengths at home are real. Her losses are real. And the attentional question remains open – her clinicians decide to support trauma treatment and housing stability first and monitor attention and executive functioning across settings, before prescribing ADHD medication three months later, following a period of psychoeducation and support.

If you want more than a thirty-minute slot

This is the kind of thinking I built our Educational Escapes around - time away from your usual caseload, working through trauma-informed and culturally responsive practice properly, considering complexity among a group of switched-on peers and incredible surroundings, with people who understand why you need the debrief as much as the content. No death-by-PowerPoint, no fluorescent hotel conference room. Just the good stuff, with a glass of something decent in hand.

Come Escape with us in Margaret River or Port Douglas. Bring the questions this piece raised. Leave the conference lanyard at home.

— Alice