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Episode 30 with Catherine Fava
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Max and Tess are joined by Catherine Fava, Clinical Psychologist at Buckinghamshire CAMHS, to talk about her upcoming book about trauma and ADHD.
How does trauma manifest?
How can it look like ADHD?
Should we be flipping the way we approach assessment and treatment in these children?
Tess tries to open the can of worms which is the whole 'what is ADHD?' question- we have covered that before: https://zencastr.com/z/Mc2qvzd5
Enjoy!
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Transcript
Introduction and Podcast Format Change
00:00:07
Speaker
Hello! Hello! And welcome to the ADHD Science Podcast. I'm Max Davey. I'm Tess Davey. It has been a while. It has been a while. And yet again, we are deviating from our regular structure today.
00:00:19
Speaker
Yes, we are. Are we? Yeah, we've got different questions. Oh, I suppose that's true. Yes.
Tess Davey's Travels and University Involvement
00:00:24
Speaker
um But we're also deviating from a regular structure by you being in the country. I know. I've just come back from Barcelona and Prague. Which was described by somebody as a world tour yesterday. Well, the world tour continues shortly, which I'm sure you'll hear about once I'm done. Yeah, so this is the only test we get for basically the summer, isn't it? Well, luckily. More or less. And then when we know what the podcast is going to look like while I'm at uni, we will let you know. Yes, we will.
00:00:49
Speaker
um But we think Tess should still be in the podcast. That's what we think. That's what you think. LAUGHTER Anyway,
Catherine Fava's Work on Trauma and ADHD
00:00:58
Speaker
umen Catherine. Catherine. Catherine Fava is basically one of my colleagues who is writing. She is one of your colleagues.
00:01:05
Speaker
Yeah, okay. So I use an extra word that you don't need. This is a podcast which is usually so concise. God, I'm sorry. I'm not going Just kick me off now. No, I'm not going kick you off now. That's the whole point.
00:01:16
Speaker
um I'm publicly pressuring you to not leave the podcast. That's what I'm doing right now. Hey, Catherine. Catherine. Is basically one of your friend's workers. Actually one of my colleagues um at work. And she's written a book chapter about trauma and ADHD. And we haven't really talked explicitly about trauma and ADHD yet.
00:01:37
Speaker
It's a really important topic. And I think what Catherine offers particularly is the practicality of how you take all of this stuff that's in um academic papers and put it into practice yeah because she is a practitioner. She's a hard-working psychologist.
00:01:57
Speaker
So let us... Stop wasting your time we will get to the actual professional talking about what she came here to talk about. Yes, actual professional, Go!
00:02:08
Speaker
Right. Hello. Hello. Welcome to the ADHD Science Podcast. This is a first because it's someone I know in real life. You had your brother.
00:02:19
Speaker
I had my brother. no but that was our old podcast. okay And also, I don't know my brother in real life. Right. You do mostly speak to him over Zoom these days. Yeah, that's true. Catherine, we're joined by Catherine Barber, who, from my work,
00:02:35
Speaker
um Catherine is a psychologist at Buckinghamshire Cams. Catherine, welcome. Thank you. Thanks. um The reason why we've asked you to come is that you've contributed to a book, a chapter to a book, this upcoming book about trauma and ADHD. And it's a topic we haven't really properly tackled our large number of ah episodes, the number precise number of which I've forgotten for now.
00:03:04
Speaker
um I might insert future Max here to find to tell us tell us the number of episodes that we've done so far. So please introduce yourself and and and and start tell us how how you came to write a chapter on a book in that way.
00:03:18
Speaker
Yeah, of course. So yeah, thank you. I'm Catherine. I'm a consultant psychologist in the same team as Max in the NHS in Buckinghamshire Cams. So working, doing ADHD assessments, but also interventions for people with autism, ADHD. So offering psychological interventions.
00:03:38
Speaker
So that's me.
ADHD and Trauma: Observations and Challenges
00:03:39
Speaker
um Yeah. So how this came about. So this came about, I remember vividly because it was New Year's Eve and New Year's Eve is quite quiet at work and I wasn't doing anything exciting. So I was just kind of looking on the internet and trying to, um,
00:03:57
Speaker
find out or trying to get some help around how to do an ADHD assessment for a young person who has significant history of trauma. And I think the reason that was something I was trying to look into at the time is because I used to work in children's residential homes.
00:04:15
Speaker
So a couple of years ago in the same trust, I was based across children's homes and understandably the children that live there have experienced some horrific life events. Um,
00:04:28
Speaker
And a lot of them were either waiting to be diagnosed for ADHD or had been diagnosed and being treated for ADHD. And I just remember at the time thinking but but most most most children I'm working with in in residential homes are being suspected of ADHD.
00:04:45
Speaker
And that's really interesting and a kind of higher percentage of children than what you would get normally if you were anywhere else. So that just sparked my curiosity and thinking, why why is this?
00:04:57
Speaker
um but then being asked to do ADHD assessments as well. So part of my job in the children's homes was to um do assessments. I was more used to doing autism assessments because that's something that I had just done a lot more of.
00:05:12
Speaker
um But ADHD assessments were something that was a bit more new to me. And I just remember at the time thinking, how on earth do I do this? Because... how do I unpick what is ADHD and what is a trauma response? Because the ah the children were displaying lots of trauma responses, which made sense in that context.
00:05:34
Speaker
But it would, yeah, so i was kind of just looking online thinking there must be something out there that's going to help me in this area. And just finding that I got really stuck because I couldn't find anything.
00:05:45
Speaker
um And me being me thought, you know, this is a great idea and let's kind of, reach out to lots of people um across the world who I was kind of, as I spent lots of time Googling these things, I was coming across lots of people who had kind of were doing work in this area, but not really clinically. So not really for people like me who were doing assessments and trying to work out how to do assessments. um
00:06:17
Speaker
So I just fired off lots of random emails to lots of people across the world and just waited to see what came back. um And I got some really interesting responses back from lots of people.
00:06:28
Speaker
and And that's where it started, really. And we got our little group together of people who have been thinking. Great. right And the and and the the book, just to be clear, the book is upcoming at some point. we we can We can't give you a publisher or a publication date. No.
00:06:46
Speaker
It started off with kind of thinking that it would be an article, but now we've, The more that we meet and the more that we think it just is getting bigger and bigger. And we think that it would, a book would do it justice because then we could put the guidelines in the book, but we could also put all of our thinking into the book too.
00:07:06
Speaker
And then you can do a nice pretty cover on the front as well. so Exactly. And that's what I'm getting distracted by now is what what does the cover need to look like? yeah Because as we all know, you should judge a book by its cover. it's absolutely true. That's the most important
Understanding Trauma Responses in ADHD
00:07:19
Speaker
point. So we wanted to get into that a little bit and we want to ask you first off, what is trauma? How would you define it?
00:07:26
Speaker
Yeah, it's a really interesting question because the word trauma gets used a lot, doesn't it? In the media, by kind of people that just kind of use it and don't really understand much about what it is.
00:07:38
Speaker
Um, so I tried to help people understand trauma by splitting it into a trauma event and a trauma response. So the trauma event would be the thing that happened and that can vary hugely from some kind of single event, like a car accident or multiple events, um, of, um, you know, childhood abuse or neglect, for example.
00:08:02
Speaker
um And they're the kind of things that I was working with in the children's homes. So I guess the event is the thing that actually happened. And then the trauma response is how that child or person responded to the trauma event.
00:08:18
Speaker
And again, and that can be hugely different depending on the person, their personality, their support network, um any neurodivergence that they have.
00:08:30
Speaker
I closed the door so she couldn't come in. She's managed to work away.
00:08:38
Speaker
It's okay. She's not distracted me. Okay. So, yeah, so the trauma response as well can vary massively depending on the person. um So I think it's important to distinguish between those two things, that the event and the response.
00:08:51
Speaker
and But what we've been thinking mostly about within our thinking and with the book is the response, um because the event can be anything. And actually for people with ADHD, a trauma event could be something like being stopped from leaving a classroom when they really need to do that.
00:09:10
Speaker
It could be being restrained by a teacher when they really need to leave. you um So actually sometimes the events aren't kind of what we think they're not kind of people get caught up in thinking it should be something huge like a car accident or war.
00:09:26
Speaker
um But for children with ADHD, it's not always those big things. um So we don't try to get caught upon the event too much because it's not about the event. It's about how that person made sense of the event and why it was so significant.
00:09:45
Speaker
And the other I suppose the other thing to say is that what whereas something can be traumatic that you would not necessarily think is traumatic, something can not be traumatic that you would think was. It's entirely dependent on the person, isn't it?
Mimicking Symptoms: Trauma vs. ADHD
00:10:00
Speaker
I think, yeah, I mean, obviously there's a correlation between, yeah so there are probably some some events that a very few people would find traumatic. traumatic and and and very some ah other events that ah most people would find traumatic. But there's not there's no there's there's very few that no one would find traumatic or everyone would find traumatic. And I think that's really important. scattered in that way.
00:10:21
Speaker
Yeah. But I guess the the focus of our book and our thinking was very much on those children who have experienced the more but kind of relational and developmental traumas. So they're often the traumas that occur in the context of relationships.
00:10:36
Speaker
um and mostly with children, so when they're developing. Yeah,
00:10:44
Speaker
yeah just to bring that out, that's relational traumas, which are essentially, would it be fair to say those are sort of traumatic relationships, within which trauma occurs.
00:10:56
Speaker
Yeah. yeah and hey But it's rather than a car hitting you, it's a relationship hitting you over and over in a funny way. Yeah. Yeah. and And I guess what makes those the most difficult types of traumas to make sense of, particularly for children, is that, you know, they, ah as children, they rely on adults to keep them safe and to keep them alive.
00:11:16
Speaker
And if that adult is hurting them, um then kind of you can just imagine the conflict that creates in the the brain of that child of like, I need this person, I need an attachment with this person to keep me safe, but this person is head hurting me and causing me fear.
00:11:30
Speaker
So it creates a huge amount of conflict in that child's brain and and you know understandable, huge trust issues. and And they develop behaviours which serve to keep them safe and keep them alive, which which can look like ADHD.
00:11:46
Speaker
Well, i think I think that kind of brings us to the next question in a sense. does. um So we wanted to ask, how can trauma symptoms resemble ADHD? Yeah, absolutely. So I guess it's really important to remember that trauma responses are adaptive, so they're helpful and evolutionary. So, you know, running away from something that's dangerous.
00:12:14
Speaker
is really helpful because that's what's going to keep the person alive. Fighting something that's, you know, that's dangerous is also a survival strategy. So all of these behaviors are survival strategies and they're normal and they're things that brains have learned to do to keep safe.
00:12:32
Speaker
um But when you think about some of those, like we call them like fear responses or fight, flight, freeze responses, they do look to the, maybe the person who's not um curious or not maybe not even aware of what that child's life history is, to just look at the behaviour, you might think that looks like ADHD.
00:12:55
Speaker
um You know, the kind of typical diagnostic behaviours that people might be thinking about, the the um the impulsivity, you know, a child running away um that could be that could easily be a fear response of of kind of running away from a situation that they're scared.
00:13:14
Speaker
and And that becomes instinctive. It becomes something that they don't think about doing or plan to do. It's just their survival strategy, something they've had to do it a way of keeping safe, um which can look like impulsivity, um a struggle to pay attention in class or or another situation.
00:13:37
Speaker
settings that could be dissociation it could be a child who's zoning out and dissociating because they've been triggered by people around them or their environment or any number of things because and people can you just can you just sort of define what you mean by dissociating yeah yeah of course so dissociation is again it's a survival strategy it's a um thing that humans and and every animal does.
00:14:08
Speaker
um And it's it kind of gets the point where a brain shuts down as a way of trying to survive. You know we often see an animal as kind of animals almost playing dead. um That's a survival strategy. So that's something that um ah people have learned to do as a way of surviving.
00:14:28
Speaker
So dissociation is that way of shutting down to try and protect itself from any further harm. um Because what but brains aren't very good at doing is when ben traumas haven't been processed.
00:14:43
Speaker
Because people do experience difficult life events. you know Everyone does. But if you're able to process that event by talking to someone, by getting the support of people around you, by making sense of then that memory becomes like every other memory. It gets processed, it gets stored, and it kind of just finds its right place in the brain.
00:15:06
Speaker
But if that trauma memory doesn't get processed, maybe because they don't talk about it, they don't they're not encouraged to make sense of it from the people around them, or it just kind of doesn't make sense based on how they view the world, then that memory doesn't get processed. So it just becomes a really chaotic memory.
00:15:26
Speaker
It gets kind of stuffed in the brain in the wrong place. um And so those memories just fall out when I talk to kids to try to help them understand this process I compare it to a wardrobe so I say and you know I've got these kind of a really nice visual image of wardrobes but you've got two different wardrobes you've got one where all the clothes and the towels are folded they're put on the right shelves it makes sense. You can take out whatever you want to take out. That's a mythical wardrobe. We never have one of those in our house.
00:16:02
Speaker
Me? I haven't either, but wardrobe there. Anyway, yes, carry on.
00:16:10
Speaker
So they're kind of the nice memory, they're kind of the process traumas. They would look like a nice tidy wardrobe but where you can take things out, you know where they are. You can put things back and it's all just fine.
00:16:22
Speaker
But when memories don't get processed, they just get shoved into a wardrobe. They might get put in the wrong place. They don't get folded up. they And then the door is closed and they're just shoved in.
00:16:33
Speaker
But the problem with that is when you open the door, things start falling out. yeah um And you don't know what's going to fall out. You don't know when it's going to fall out. but it just, it becomes messy and uncontrollable.
00:16:46
Speaker
And you also don't know when the door's going to open, suppose. Yeah, there's lots of stuff. And you know, kids choose different metaphors, like computer systems and stuff. But I think it's helpful to think about um trauma memories as being like that. They just get shoved in.
00:17:02
Speaker
um So dissociation becomes that way of kind of protecting a brain from that. It's just like, just going to keep the door closed, um shut down. And just, yeah.
00:17:14
Speaker
yeah and And so that that can look like um can look like daydreaming. That can look like inattention. um But children might be dissociating, which is, again, is a and an adaptive trauma response.
00:17:29
Speaker
And to what extent are all of these trauma responses responses to a perceived threat, a real or perceived threat? Mm-hmm. Yeah, and that's the other thing that brains don't do a very good job of doing because I think they often assume that once a trauma's happened, so say a trauma happened in the context of a relationship, an adult, um but like one particular adult, if that person is confronted with another adult who might smell the same, who might look slightly similar, might be the same so kind height,
00:18:06
Speaker
that brain then jumps straight back into that person's a threat um because it struggles distinguish between kind of what's real and what's a memory. And so that trauma response... Sorry. Sorry, go So that trauma response jumps straight back in again because it just assumes that there's a threat when there's not a threat.
00:18:26
Speaker
um So you get the same behaviours. Yeah, i wonder if voices are also really important, the but the the the tone and... you know, pitch of a voice can be inflection, inflection, good word.
00:18:40
Speaker
Thank you. Can be, you know, can really remind you, can be very evocative, can't it? of Something that you half remember in your past.
Impact of Trauma on Development and Brain Function
00:18:50
Speaker
Yeah. Especially for the younger kids as well, like the ones that are pre-verbal.
00:18:55
Speaker
And that's when like the more of the body response stuff comes in, because you think, imagine a like a two-year-old who maybe doesn't have the words, can't talk, the event through to make sense of it their memories are going to be even more confused um and there's this i don't know whether you've heard of the book um the body holds the score but it's that idea that bodies do hold on to trauma memories too and that's when you get you might get the the hyper vigilance you know the the children who are kind of always turning around to see what's behind them or i'm not because i'm traumatized i'm turning around because our copy of
00:19:34
Speaker
The body keeps the score is behind me. I'm turning around. cool. It's a really good book. Very poor timing. It's a very good book. It's very well written. It is, but it's so true.
00:19:45
Speaker
um And again, that can look like ADHD, a child who's kind of always losing attention, looking behind them or kind of jumping at noises, getting distracted easily. um Again, on the outside would look a lot like ADHD.
00:20:02
Speaker
ah Go on. I was, well, this is a bit of a tangent, but I was wondering how this would apply to older children and young adults, because you get to a stage where you start being able to put your memories into words. And at that stage, do you think it becomes, well, I would assume that it would become a lot easier to distinguish between the two, because do you think that children are able at that point to tell you that that's why they're always looking around?
00:20:25
Speaker
Or do you think that those still get misconstrued? I guess that's a really good question. um And actually, what sprung to mind is kind of the huge, what's the word I'm looking for, but lot of people, people with ADHD also have autism.
00:20:43
Speaker
And I guess, you know, it may be that there's that struggle then to kind of understand those thoughts and feelings and to say, you know, this is why I'm feeling like this. This is why this is, this is why this. So that kind of real self-reflection, being able to self-reflect could also be quite difficult.
00:21:00
Speaker
I've not actually come across many children that are able to say, this is why I do that. Because I think it just feels very subconscious innate and it's just very automatic. Yeah.
00:21:12
Speaker
and that And again, that becomes hard because if you can't say I'm dissociating or or I did dissociate, um how are other people going to understand that's what's happening?
00:21:26
Speaker
So in that case, I wanted to ask if there was some sort of symptom that you thought mirrored the kind of later developing symptoms of ADHD like executive dysfunction. Do you think that there's like a response symptom that would mirror that?
00:21:42
Speaker
what's really interesting when you look at brain scans of children who have experienced mostly developmental trauma, but yeah, traumas in childhood compared to children that haven't, that executive functioning bit of the brain is a lot smaller.
00:21:57
Speaker
um Because I think there's a bit in the brain called the amygdala. And that's kind the more the primitive, like fear response bit of the brain. and And what It's really interesting when you look at brain scans because that bit of the brain is bigger for children who have experienced a lot of trauma and their prefrontal cortex at the front is smaller, um which again makes complete sense because if the fear bit of your brain is constantly firing, you're going to have less capacity to think, pay attention, talk, um learn.
00:22:36
Speaker
All of that is going to be impacted because the brain is constantly in kind of threat mode. Because you don't need to think when you're faced with a threat, you don't need to be able to kind of think and talk, you just need to survive.
00:22:52
Speaker
um So those bits of the brain become bigger. Yeah. I mean, tidying your room isn't really at the front of your mind when you're focusing on solely surviving, is it?
00:23:03
Speaker
that's ah That's a good point. I wanted to just mark at a particular milestone in our podcast, though, because I'm now going to explain something that you have brought up. executive dysfunction that's my job oh no what does that mean it was like when you asked about disassociating earlier i was like damn it like that's my job can we just quickly tell it to tell everyone and it's come up a lot in the podcast if you're a dedicated listener you will know but and if you're not you should be quickly do executive dysfunction
00:23:34
Speaker
Oh. Well, who's going to do it? Who's going to do it? I'll do it. Okay. It's basically getting stuff done, isn't it? It's basically going from what you would need to do, what you want to do, and planning the steps, and getting that stuff done.
00:23:46
Speaker
Yeah. And it sounds like a really trivial thing, but it's extraordinarily important i mean it's the and disabling for people with ADHD. I don't know if this is really oversimplifying it, but is it like the symptomatic overlap with like depression?
00:23:57
Speaker
that we see in ADHD? Is that like, like a very simple, easy way to look at it? i think I think people who don't understand. Okay, so executive dysfunction is an end point of lots of different psychological processes. Would you agree, psychologists?
00:24:10
Speaker
Yes, it's the planning, the organizing that all at all of those functions, which are super important. um But can Yeah, but can be effective.
00:24:25
Speaker
That's one of the most beautiful things about this podcast, I think, is me making a massively oversimplified so ah statement and then the two professionals that we have here being like, well, I know. It's kind of that. And then I'm taking over that mantle from you, Tess, I would assume.
00:24:39
Speaker
and was the same um So, that I mean, a way, what we've done so far is we've kind of set up the problem, is that essentially trauma responses, and we're setting aside trauma events because let that's less important.
00:24:55
Speaker
Trauma responses can look a lot like ADHD. People can't necessarily tell you whether a behavior is a trauma response or is indeed ADHD.
00:25:07
Speaker
And you may give a tantalizing response ah Hint, Catherine, just now, that if your amygdala is firing constantly
Developing Guidelines for Trauma-Informed ADHD Assessment
00:25:15
Speaker
throughout your childhood, you literally might develop the neurology of ADHD as a result of that chronic activation of your amygdala, because it will prevent the development of the sort of things that... You can think of ADHD as the brain not developing certain skills, but...
00:25:38
Speaker
in a way, it's slightly a negative way of thinking of the condition, but it's not not it's not wrong. I remember. and so and and And so sometimes you you won't develop those skills because your brain brain's too busy being fearful. Sorry, Tess, carry on. No, it's all right. i feel like we should get back to Catherine. No, no, it's fine. You go. What I was going to say, because day break this is going to be a big thing. Okay, go on.
00:25:58
Speaker
I remember us having a deeply complicated conversation in one of our Q&As, about at what point do you just have ADHD? If you have all of the symptoms and you have the neurology, at what point is it just ADHD?
00:26:13
Speaker
And that's a big, big question. So if you don't want to go into it we can skip over on. What you mean just ADHD? Because we were talking about what is ADHD. ADHD is a collection of symptoms with no distinguishable cause.
00:26:28
Speaker
Yes. Yeah. no, there's no, you can't point to something on a scan. Can you look at again collection of symptoms and be like, well, that's ADHD? Yeah. Well, I think that's really a version of what we have to go on to next.
00:26:40
Speaker
Yes. Sorry about that. I will link to the that that that episode in the show notes. Okay, I'm very sorry. um So how can you diagnose ADHD in someone who has suffered trauma?
00:26:54
Speaker
So, yeah, so as a group, we've been meeting for probably 18 months now. Yeah, because it's summer, isn't it? 18 months. um So we've got, I've managed to collect a great group of people. So we have a guy from Harvard who's been leading... um some of the work i've been doing in the States in exactly this.
00:27:14
Speaker
So they're a bit further forward than we are. um I recruited a researcher who at the time was at Glasgow University because I think the team at Glasgow have also been doing some thinking about this, but in a very kind of academic way.
00:27:27
Speaker
So she's been helping us think kind of academically, but our job has been to um translate that into a clinical piece of work. um We've got some psychiatrists.
00:27:39
Speaker
We've got a nurse who is an ADHD specialist who brings a huge amount of experience and personal experience um into our group. And we have a psychologist, David Tricky, who works for the UK Trauma Council.
00:27:57
Speaker
So he's helping us think um about all the trauma stuff because he's been doing a huge amount of work, particularly with the Anna Freud Centre, to try and get schools and other places to be more trauma informed um we've recently recruited a french psychologist who's helping us to think about self-medication um self-medication of adhd because that's something that um it's a speciality that she has but it's something we hadn't really thought about but it's but it's really important so that's another area that we will cover um so that's that's that's kind of grief so we've got a really kind of dynamic and just
00:28:36
Speaker
varied group both across the world but in different fields. um So how do you diagnose? And that's a really interesting question. That's obviously where we started. yet I feel you're feel you're avoiding the question. that's but that's That's the question that we started with, right? And we became quite um black and white, quite kind of thinking there must be a way, there must be a flow chart, there must be a table that we can generate, there must be something.
00:29:04
Speaker
that tells people this is ADHD or this is a trauma response or both, because it can be both. um But the more we went down that road of tables and things, it just it just generated more questions than it did answers.
00:29:21
Speaker
So I think we've scrapped that idea because what's actually more important is helping clinicians do assessments and to help them be curious.
00:29:34
Speaker
and open-minded rather than them being kind of rigid and wanting to put people into boxes um because that's not helpful. We want to support clinicians and encourage services to support clinicians to do more trauma-informed ADHD assessments.
00:29:55
Speaker
um So the guidelines have now become, I mean, yes, there is going to be a flow chart because that's still helpful. But it's become...
00:30:04
Speaker
But within the flowchart, that's kind of... I love flowcharts. Go on, carry on. No, it's it's a great looking flowchart. But um within that is kind of the the ethos and philosophy is what we think is the most important thing of just helping people who do assessments to be open-minded, to not go symptom chasing, to kind of say, yes, there's kind of, there's inattention, but to just kind of maybe notice that behaviour, but try and understand it, try and understand when it happens, where it happens.
00:30:34
Speaker
who it happens around, but to just really get below those behaviours, which sounds really simple, but I think it's not really been, it's not been written in the way that we're trying to write it, which is very much as a clinical tool for people who are doing assessments.
00:30:54
Speaker
There's been a lot of the academic thinking about it. There's loads of papers that say more people in care have ADHD. There's loads of papers that say that. So we know that there is We know that there is these kinds of increased rates of diagnosis, but we wanted to take it one step further to give people something to refer back to, to help them in the in the same way that I needed that help two years ago when I was in this situation.
00:31:22
Speaker
um and you've mentioned a few times trauma informed so a trauma informed assessment what's the difference between a trauma informed assessment and a less trauma informed assessment and by the way people think that Catherine is torturing any sort of animal in the background it is a cat we think it's a cat don't know if she got in I closed the door <unk>ary role angel court um fine
00:31:56
Speaker
but what is the difference between but question what is the difference between a trauma informed and a non-trauma informed adhd assessment yeah and that's sometimes some really basic things um you know you think about a child who has experienced developmental trauma they're going to be coming in to you know, you're typical let's think about a typical NHS building.
00:32:18
Speaker
They're going to be possibly in a waiting room that's full of people, full of noise, full of bright lights, full of different smells, a huge amount of uncertainty because they don't they have no idea what's going to happen, who they're going to see, anything like that.
00:32:30
Speaker
So straight away, that fear response is up. The amygdala is firing off because they're scared. They don't know what's about to happen. Yeah. And then, you know, you might get one or two or three grown-ups coming out that they've never seen before.
00:32:47
Speaker
And again, that, you know, that fear response just keeps firing. So I think
00:32:59
Speaker
mind if chuck her out the door? Help me! I am a poor cat! and i'm sorry that's it So this is not a video podcast, but that is a very cute cat.
00:33:11
Speaker
I'm not usually a cat person, but that's very attractive. Right. Right. She has gone. Right. where was So
Creating Safe and Effective Assessment Environments
00:33:21
Speaker
yeah. So sometimes it's just those really straightforward things like telling children who they're going to come to see, um, so that they have that idea of the person they're going to be faced with their name, what kind of things they like. Some are just, some of those things can just help a child to feel less scared.
00:33:39
Speaker
Um, asking about the environment. So, you know, are there any particular smells that they don't like, or ah do they have a safety object that they can bring in? I've had children bring in cats, dogs, toys, you know, safe adults, any of those kinds of things that just might help them to feel safe in that setting, because um how can you do an ADHD assessment or any kind of assessment when that child is scared? You're not going to see, you're not going to see them.
00:34:10
Speaker
um And so for me, that's one of the most important things is to just get down their fear response to enable them to kind of just feel safe in that environment so that you can get to understand how their mind works.
00:34:28
Speaker
Yeah, and that that that's really that's really important. And I think we miss that with trauma, and with lots of the talk of trauma and form doesn't actually drill down to what that means practically. So that's really, really helpful. And I sort of, I was a bit kind of,
00:34:43
Speaker
It looked a bit askance at the idea until I actually read what it was meant. And it was basically about making children comfortable where we are. I'm absolutely um completely on board with that. um But I suppose just to just to say that's great for the...
00:35:00
Speaker
you know, the person you're seeing in front of you. But of course, when we're assessing, that's only one element of several. And one of the most important things that we can, as clinicians influence is what questions we ask, and how we interpret the answers of, you know, what symptoms are you experiencing, when and where?
00:35:20
Speaker
So how does an understanding of the importance of trauma change the way that we ask those questions, just to kind of drill down to there's a proportion of our audience who probably do do these assessments and a proportion who yeah are experiencing do do so who experiencing these assessments themselves and might be wondering why questions are asked in certain ways.
00:35:45
Speaker
Yeah. I think one of the simplest things that I hold in mind is like a timeline. Um, I mean, so you know hopefully before we meet a child and family, we're going to have a sense of a little bit of their life experience.
00:36:01
Speaker
And that's the other thing is how much do we get that young person and family to retell their story again? Because they've probably told that story lots of times already. And so that we need to ask those questions. Do we need that child to tell the story again? Or can we read it? Can we talk to the parents away from the child?
00:36:19
Speaker
um Because each time that child retells that story, that brain is going to be jumping straight back into fear mode. And it's going to be, that child's going to be re-traumatized. So that's another huge thing about being trauma-informed is just asking ourselves and our colleagues, do we really need to hear that story again?
00:36:37
Speaker
or is there another way that we can find that out? um But I think regardless... Ironically, not talking about the trauma can be more trauma-informed than constantly bringing it back up because that's, yeah, and that's really interesting.
00:36:52
Speaker
Yeah. Almost paradoxical. But then we also can't ignore it because it's obviously a huge part of that child's life. And it's something that we do need to understand.
00:37:03
Speaker
ah But it is how we do it. and And it may be another thing that the book is really promoting is sequencing of assessments and possibly interventions, because it may be that it we can't do an ADHD assessment. Now knew maybe that we need that child to have a trauma therapy first.
00:37:21
Speaker
Yeah. And the set that would then kind of hopefully treat some of the symptoms of the trauma response to then enable us to do an ADHD assessment. And again, I don't think services are always set up to be like that. But you know, that I think that does make sense to do it that way round.
00:37:40
Speaker
um So just kind of sequencing and and formulating before jumping into assessment, which again, is backwards, because we often do assessment first and then formulation. um But to really understand that child, their life story, their context, their relationships, all of that becomes part of the assessment.
00:38:00
Speaker
um But I was coming back to the time was mentioning a timeline. So I think that's really helpful, because we can plot the trauma events onto a timeline, and try to understand how that child responded at each of those points.
00:38:17
Speaker
how What were they like before? What were they like afterwards? How did that change? Did the inattention start afterwards or was that there before? But just holding in mind the impact of each of those events on that child and those behaviours, I think that's just a really simple way of seeing, seeing the changes and kind of wondering at what developmental stage those things happened, because that's something really important too. you know Developmentally, a two-year-old is very different to a 12-year-old.
00:38:50
Speaker
And so a two-year-old is going to respond differently to a 12-year-old. So just be just being really curious about when did those things happen? What was the impact?
00:39:04
Speaker
And I think that In our head, none of those things are complicated, but it's just a change in thinking rather than being focused on the symptoms and the behaviors.
00:39:15
Speaker
We're trying really hard to understand what those behaviors might mean and and when they happen. And that pushes against a lot of, I mean, we talk a lot at work about efficiency, of course, and we're sort of responsible for trying to push efficiency.
00:39:32
Speaker
But on the other hand, that pushes ah the most efficient way, in a sense, I'm doing air quotes, is to simply count the symptoms because that will allow you to tick off the very flat.
00:39:46
Speaker
So I see that kind of assessment as a flat assessment, and of At a point of time, you have this amount of so this amount of symptoms. And that's very much what all of the kind of diagnostic criteria, they encourage that flatness, I think, very very explicitly, rather than what you're describing, which is more of a deep...
00:40:06
Speaker
Do you see what mean? Looking at the depth, looking at the time and also breadth in terms of all the different functioning of the child. And is that that's the tension that we're always dealing with when we're when we're trying to run services and assess.
00:40:21
Speaker
Yeah, yeah, definitely.
Proposed Approaches: Treating Trauma Before ADHD
00:40:24
Speaker
That's the reality of the you know settings at the moment is there's that massive increase in demand for assessments and then assessments naturally become quicker and faster and more streamlined, which for most children...
00:40:36
Speaker
is fine. But for this group of children, I don't think I don't think we can do that. Because I think, you know, if we're giving ah diagnosis of ADHD, I think that then overshadows everything else, we might then be um preventing that child from accessing ah trauma therapy, for example, because we just see that child through the lens of ADHD.
00:41:02
Speaker
um And so I think we have to be challenging of services that do that for this group of children that we just and that's one of the chapters in the book the one that I'm going to be writing is very much on that because we need to get commissioners and systems to understand that it's within doing things backwards like in in kind of this way kind of potentially doing the intervention first before doing the assessment or doing the formulation before doing the assessment I think
00:41:36
Speaker
It's what makes sense and it's what they be it's what that's the model they've been using in the States. um That kind of sequencing idea and it's been working really well. the which just At the moment, we're just not set up to deliver care like that.
00:41:49
Speaker
i So we would, just to be clear for people, we would assess, generally maybe diagnose, and then we would give treatment. What you're suggesting is that you would, I mean, you're sort of, you're a little bit assessing, you're starting and and ah a process of inquiry, you're doing a formulation, which I've always thought of as a,
00:42:08
Speaker
a kind of a narrative of how things what things mean and how things have happened and then you're giving intervention and then at the end of that intervention you may end up with a diagnosis but the diagnosis comes elsewhere in the process does that make sense Tess yeah I mean I guess so I mean, was it that you were suggesting that people who have had trauma in the past undergo some trauma treatment so that the symptoms which are ADHD symptoms can be more isolated?
00:42:37
Speaker
Yeah, almost kind of exposed. I think, yeah, sure. I mean, also good because it means that people who are traumatised are getting trauma treatment. them Exactly. Which is always a but a bonus, isn't Always a good thing.
00:42:49
Speaker
but One of the things I wonder about is um masking. so i' just i'm just explain why i was thinking about masking so a lot of the one of the most useful things i find with trauma is that trauma symptoms are ah and this is a generalization and it's not always the case but they are more likely to be situational so will occur more in particular situations more with particular i know that's why i'm basically plagiarizing tests in live
00:43:21
Speaker
like your sources on thymus sources um So they are more sexual relational that, you know, a particular place, a particular person, they're more likely to occur. That would and indicate more, perhaps more of a trauma, ah you know, trauma ah response than ADHD symptom.
00:43:41
Speaker
on on the balance of probabilities. It's sort Bayesian kind of, you know, wait what are your priors for how much it's likely to be ADHD and then you move it up and down depending on the context.
00:43:51
Speaker
Go on. See, I did write that, but the reason that I crossed it out is because I thought ADHD symptoms are kind of slightly situational. Like I find it, I'm sure everyone with ADHD who's listening to this or has made it this far will understand that in certain situations it's a lot easier Hey!
00:44:13
Speaker
I'm sure everyone listening with ADHD will understand that it's a lot easier to focus in some situations than others yes and I'm sure that that's much less um proper proper proper proportionally la la la la la proper for like potent potent prollife
00:44:34
Speaker
prominent. Prominent. I'm sure that's a lot less prominent in ADHD than it is in trauma responses. Yeah. But it's the reason that I didn't end up saying that in the end because I thought that it might kind of slightly cancel out. I'd be interested to hear your thoughts on that, Catherine.
00:44:48
Speaker
So we've rambled on a bit. I was going to get to my point. Oh, sorry. The other thing is that people talk about masking now. Yes, yeah, yeah, sorry. And the whole idea behind masking is that ADHD is quite situational and that you can mask at school and then unmask at home. So does the concept of masking and the concept of trauma symptoms, do they start to muddy the waters an awful lot when we're trying to decide what's a situational trauma symptom and what's the symptom of ADHD?
00:45:20
Speaker
I don't know you're honest that's not a conversation that we've had much of so it's just making me think um I guess what I what I was thinking is that trauma responses are a lot more automatic as in people don't have any control of over them they just happen it's just a response that the brain has to do um whereas I wonder if ADHD masking is more subconscious that it's something they've learned to do something they need to do but it's not necessarily an automatic response um I don't know that's kind of what I was thinking you ask someone have you been masking they will usually be able to tell you i mean actually a lot of the work on masking is based on the fact that people can tell you it's subconscious but it's identifiable like quite a lot of the time when I'm masking I don't realize I'm doing it until afterwards and i'm like oh
00:46:15
Speaker
Oh, I was. I was, and now I'm exhausted. yeah, yeah, yeah Yeah. But I mean, I think it is something to throw in the mix because it's becoming more and more talked about, isn't it, in assessments, this masking idea,
00:46:28
Speaker
um which we think is a thing. And we've we've had a very good guest age ages ago now. and Episode two was about masking back in the day. Was she the one with the lovely ah yellow jumper?
00:46:41
Speaker
She might have had a lovely yellow jumper. i think she had a lovely yellow jumper. I don't remember. i don't remember. And I guess the other thing about mass masking is within the context of relationships, isn't it? Because a person is much more likely unmask in a relationship that they feel safe in.
00:46:59
Speaker
um
00:47:02
Speaker
Which again, thinking about kind of psychological safety and trauma, that's, you know, it's the same. And so the using relationships as part of an ADHD assessment becomes important.
00:47:16
Speaker
You know, if you could, an ADHD assessment can then, you know, may need to take three sessions, four sessions, because it may take that long for a child to trust you. um yeah So again, it's just making me think about the importance of trusting relationships and how, again, services aren't designed in that kind of way to do an assessment over three sessions. Yeah.
00:47:39
Speaker
or to spend time getting to know the child, you know, all of these things that are just ah going to help that fear response to reduce. Yeah.
00:47:49
Speaker
Yeah. I just thinking if our manager has three sessions to do ADHD. No way! We haven't got time. Sorry, Alison. ah Anyway, shall we move on to our
Tailoring ADHD Treatment for Trauma-Exposed Children
00:48:03
Speaker
last question? i think we shall. I was waiting for the go-ahead. How does a history of trauma alter the treatment for ADHD?
00:48:11
Speaker
And you know what, this is another question that we've been really kind of battling over quite a lot, because as you know, there there is pharmacological treatment for ADHD. And um so the kind of couple of psychiatrists that we have in our group have been doing a literature review on this to look at the the effectiveness of ADHD medication for people with ADHD when there's a history of trauma.
00:48:36
Speaker
So that is something that's in progress at the moment, because again, there's quite a lot of academic um stuff out there, but nothing really that's in support of clinicians, particularly psychiatrists who find themselves in this situation where um they're maybe not clear or it's a bit blurry. Is it trauma response? Is it ADHD? Do we therefore not give them medication? Or do we give them medication? All of these things I hear our psychiatrists kind of just wonder all the time, because it is a bit of a dilemma, isn't it?
00:49:10
Speaker
um You know, because if you don't give the diagnosis of ADHD, then you're preventing access to that medication. um But it may be that that's not kind of our assessment isn't completely clear that it is ADHD.
00:49:23
Speaker
um So when we are hoping that the book will talk about um medical treatment four but for these cases. um In terms of the, you know, the behavioral psychological treatments, I don't think it changes a thing.
00:49:40
Speaker
I think, you know, the the kind of the change in the environment, the change in communication, how instructions are given, all of those things. I think if you're thinking about it through an ADHD lens, I think, you're thinking about it through a trauma lens, I think they're very similar.
00:49:56
Speaker
Okay. Because what actually underpins all of those things is just understanding the child. What do they need? What do they not need? What's going to help? What's not going to help? um So I think at that level, it becomes, you know, what what we kind of what we already know, you know, we just need to understand that child and their needs um and what we can do to support them.
00:50:20
Speaker
So I suppose that's really interesting. um ah Not quite what I expect you to say, which is which which is which is itself is interesting. I suppose what I would say, is someone's thinking about that, you think one of the things that's often said of traumatised children, children wither his let's say true children with a history of trauma, because it means...
00:50:40
Speaker
i Sometimes people talk say traumatised children, it it it almost feels like that is the only thing that defines them. So I'm not sure I really love the way that's used as a phrase.
00:50:53
Speaker
Anyway, um those children, often it's said that they don't respond in the same way to, for instance, behavioural management, so boundaries and consequences for certain behaviours.
00:51:07
Speaker
they you know they That will activate their trauma response and therefore... to you know therefore you shouldn't be using those you should be much more gentle and kind of you know non-passive resistance and all that sort of stuff um so does it change that does it change your recommendation when it comes to what parenting class they should do or what advice you should give about aggressive behaviors at home in the presence or absence of a history of trauma
00:51:38
Speaker
Yeah, I think when it comes to parenting, I think that probably has to be different because you are kind of the the parent, like the therapeutic parenting stuff, which you would be encouraging of parents who are parenting children who have a history of trauma.
00:51:55
Speaker
Boundaries is still a huge part of therapeutic parenting because a child who has experienced trauma and needs those boundaries in order to feel safe. those boundaries need to be done in a compassionate, safe, empathic way, but the boundaries do need to be there.
00:52:11
Speaker
So actually, therapeutic parenting talks a lot about boundaries as it does consequences. But again, consequences need to be offered in a compassionate way, but also in a kind of natural consequence kind of way that it's that consequence makes sense to that child. So it's not that you're just taking away the iPad because they've done something wrong at school because in their head that doesn't make sense um in my head it doesn't make sense either so well in my head that doesn't make sense either and I don't know why people do these things but anyway they do so those natural consequences to an extent what you're saying is that the difference is not actually that great because the therapeutic parenting is not that different to conventional parenting wisdom it's just applied in a different context yeah
00:53:00
Speaker
Good. So we don't have a problem. That's fine. Great. Sorted. Are we sorted? how Are we done, Tess? Have you got anything else you wanted to ask? Not particularly. No? Good. Excellent. We've got rundown of trauma and ADHD.
00:53:15
Speaker
Great. Thank you so much. ah We will mention, if we're still doing future episodes, when the book comes out. We will. you So, yeah. So I'm i'm guessing, Catherine, obviously I only know you as as someone at work.
00:53:29
Speaker
So don't i don't I'm assuming you're not somebody who posts on any kind of social media and people can follow you and stuff like that. No, none of that. So we will basically just put it out um through the charity's channels when the when the book comes out.
00:53:42
Speaker
We will look get ADHD UK to publicise that. And I hope people enjoyed it. if they've got If you've got any questions at home, um you can ask me and I'll ask Catherine.
00:53:53
Speaker
Yes. ah Shout through the tro through the wall next door. ah And um ah yes, but other than that, thank you very much, Catherine, for joining us. All right. If you have any ideas for a front page, that would be much appreciated. that iss Tess is actually genuinely very excellent at design. Okay.
00:54:11
Speaker
You are genuinely excellent at it. So come, you know, put your thinking cap on, Tessie. I can't think about anything right now. I'm exhausted. You are tired. right Well, let's go and have some tea. All right. Thank you very much. Bye-bye. Bye-bye. Bye.
00:54:28
Speaker
Right, so that was Catherine. Tess is still laughing about our intro. Peek behind the curtain. We do our outtro intro and then immediately we do the outro because we've already done the ah the episode. sorry, I think we need to have some deep breaths. ahead. Tess is still laughing about the ah the intro.
00:54:43
Speaker
um Please, please, please follow us at ADHD UK, that is, at all the social medias. ah um Please join our Facebook group, ADHD Science Podcast. um Please feedback. Catherine's not on social media, so you can't ask her questions, but you can ask me questions in the Facebook group. And I am on social media, but please don't find me. Please don't ask me questions. I don't want to answer them.
00:55:06
Speaker
That's my dad. He knows what he's talking about. I'm so kind of on social media, but it just look me up on Blue Sky and that's fine. ah And yes, we will have some more episodes without Tess over the um summer and those will be less good. They will. And then we will have to just see what happens.
00:55:26
Speaker
Yeah. All right. Goodbye. Goodbye for now. Bye.