Recent research studies indicate that as many as ten percent of Jewish Israeli children are diagnosed with attention deficit hyperactivity disorder (ADHD). Events of the past month indicate that almost all Israeli children are suffering from traumatic events. Hundreds of children have been exposed to acts of barbaric violence. Many have been orphaned as a result of terrorism. Some as a result of war. With approximately 300,000 men having been ordered to leave their homes for compulsory military service, thousands of families have been transformed overnight into single-parent units, with mothers being responsible for 100 percent of child care and management. In addition, thousands have been displaced from their homes due to the threat of missile attacks on civilian populations.
The National Child Traumatic Stress Network, 2016
In simple terms, trauma, which by definition, has been considered a “rare and infrequent event”, is now a banal aspect of living in the State of Israel. The medical model that views trauma as rare and infrequent is clearly untenable in light of the current reality. The effects of displacement from home and school, death or absence of a parent, and the “emotional and physical overload” of the parent physically present, all create a traumatic environment that is challenging and often overwhelming for the developing soul of the child.
The situation is complicated by the fact that ADHD, which is a relatively common challenge facing Israeli children, presents behaviorally with many of the same symptoms as trauma. As displayed in the figure below, symptoms such as difficulty concentrating, high levels of distractibility, inattention, disorganization, hyperactivity, restlessness, and difficulty sleeping characterize both ADHD and reactions to trauma. The overlap reflects a common, neurological hyper-vigilance through which the brain is programmed to be on the lookout for potentially threatening behaviors. Triggers that remind children of traumatic events can create confusion, inattention, and impulsivity. Some studies indicate that children with ADHD are, in fact, more vulnerable to being victims of traumatic events than the neuro-typical child.
Whatever the underlying reason, it is clear that underlying trauma can be easily confused with ADHD. When the underlying trauma is not recognized, the potential emotional damage to the child can be overwhelming. In Israel today, the most common treatment for ADHD is psychostimulant medication in the forms of Ritalin, Concerta, Vyvanse, or Attend, just to list some of the more common ones. Theoretically, these stimulant medications, stimulate the frontal lobes of the brain and enhance executive functions such as planning, organization, and control of impulsivity. However, if the underlying cause of the child’s behavior is exposure to trauma, then stimulants are likely to either heighten symptoms or allow the child to bury them deeply into his or her unconscious. In either case, the emotional damage to the child may be extensive.
So, what is a parent to do? Several ground rules may help significantly.
1. Parents tend to underreport exposure to trauma. There are many reasons for this, ranging from the parent’s sense of guilt and blame to simple ignorance. However, in meeting with any physician, nurse, or mental health professional parents must share any concerns they may have for the child’s exposure to potentially traumatic experiences.
2. Children can seem “Okay” on the outside when they are very much “not okay” on the inside. Just because your child is not displaying any behavioral changes does not mean that they are not struggling internally with tremendous emotional chaos. It is important to pay attention to details such as off-hand comments, drawings, or play that strike you as somewhat odd. Sometimes, recognizing these signs provides the only evidence we have that a child is dealing with emotional issues.
3. Never treat ADHD or trauma only with medication. Large, longitudinal studies support the fact that ADHD is best treated when both medication and behavioral therapies are combined. Ritalin ought never to be considered a magical solution. All cases of ADHD-like symptoms also have emotional and social ramifications. All children with ADHD need to also be treated therapeutically beyond medicine.
4. Parents are also living under trauma. It is essential to engage and enhance self-care and self-compassion during these times. To paraphrase the wise Talmudic sage, Hillel, “If you do not care for yourself, who will care for you”? Self-care activities may involve mundane things such as exercise, listening to music, or having your toenails manicured. If you are of a more spiritual ilk, self-care may manifest itself in reading Psalms or Torah study. Especially now, when your children need you more than ever, it is essential to care for yourself.
5. Schedule your days amid Chaos– Although many of the regular institutional structures such as schools and community centers are functioning only partially, children with either ADHD, trauma, or both, feel secure when they are in a set routine. The more routinized your child’s daily schedule becomes, the more security he or she will experience. Even if you are totally on emotional overload, now is the time to get out the charts and schedules and to follow routine. Routinization is a common way for humans to cope with uncertainty and in these uncertain times, habits and routines are essential for emotional well-being.
6. Ask for help. In today’s society, many of us have been conditioned on rugged individualism and “toughing it out”. These concepts are simply not in sync with human nature. We are deeply social creatures and in times of stress, it is essential to seek support from those around us who may be able to offer it. It will be surprising to discover that in most cases, the one offering support is helped at least as much as the one who receives it.
No one of sound mind would volunteer to be placed in a traumatic situation. However, given that we are here, like it or not, we have an opportunity to enhance our sensitivity to our own emotional life and that of our children. ADHD is a serious issue. Trauma can be debilitating throughout the lifespan. Let’s utilize our current reality to pay close attention to ourselves and our loved ones. There are no quick fixes for our geopolitical, neurological, or psychological challenges. Paying attention and acting intelligently are tools at our disposal to create calmness and clarity amid chaos.