But is it ADHD?

ADHD – What I’ve learned as a neurodiversity-informed coach, and educator.

So many myths and legends, so little time. ADHD, ADD, ASD, GAD, BPD…Alphabet soup…We’ve all got a bit of a view – self-diagnosing, and often willing to attribute the behaviour of others or excuse our own shortcomings to neurodiversity – diagnosed or not. Our brains are meaning-making machines and we love a clear narrative to explain it all. But whether the narratives and patterns that get created in the mind of the person, the family, and the schooling system around them help or not is another matter.

In my coaching work, I get to support families across a whole spectrum of issues – from crisis points, through typical teenage growing pains and sticking points, or providing proactive support. It’s not surprising how often neurodiversity is suggested as a potential source of all woes. And it’s interesting how the process of looking at sticking points through that lens can provide relief – or not.

My point here is how we can work with realities and possibilities, and not stay in stasis whilst waiting for a diagnosis. Or stay stuck in the aftermath of a diagnosis where ‘can’t do’ narratives create limiting beliefs that suppress productive action.

I’m not promoting whether or not to seek diagnoses, or whether or not to go for medication – this is meant to be neurodiversity informed general advice and information with the aim of helping parents and educators from a coaching perspective. Not a replacement for getting specialised clinical help.

Who decides? Who to talk to?

In school as education professionals, there is a baseline common understanding and reasonable acceptance that it us helpful to identify and work with different forms of learning needs to develop a strategy that will support progress and growth and mitigate challenges. Sometimes where sticking-points become protracted or increase in intensity, duration and concern, it’s often suggested that an assessment for neurodiversity might help.

It’s important, though, to remember that diagnosis is generally not in the wheelhouse of school-based expertise. And there may be other possible issues in the mix- for instance General Anxiety Disorder where school refusal is concerned… Teasing out the threads of a complex pattern of behavioural, functional and relational challenges needs to stay in the realm of specialist psychiatrists, and funnelling towards one specific diagnosis and waiting for that may delay struggles – and suffering – unnecessarily.

The first port of call is usually the GP who is able to make onward referrals. And anyone involved in assessing a child for Autism or ADHD should be registered with the Health and Care Professions Council (HCPC) or the General Medical Council (GMC). If you are able to, and choose to get a private diagnosis, then due diligence research needs to be thorough. Is the practitioner experienced with working with children? And is it clear that they follow NICE guidelines…

Parent responses…

For parents there can be a very different emotional loading that goes with the territory of labelling one’s child as having ‘special needs’. And when it comes to Neurodiversity, the very essence of the label has the word ‘Deficit’ or ‘Disorder’ inherent to it. It’s difficult for parents to decide whether their experience is outlying or not – the sample size of a typical family is relatively small! And sometimes our expectations are not developmentally accurate – so how to tell whether the frustrations you’re experiencing are just a phase, the sharper end of typical growing pains, or something else…

Parent worry – with some justification – that the acquisition of a diagnosis will mean a reduction in expectations, responsibility, a capitulation. And sometimes, that can be the initial holding reaction – of helplessness and reliance on the diagnosis to support avoidance or ‘can’t do’ narratives. As with everything, it ain’t what you do with a diagnosis, it’s what you are going do with it going forward that’s going to count the most.

Others may be truly struggling with behaviour and relationships at home, and the pressure on their child to conform with homework and schoolwork. Having tried everything, for them a diagnosis may come as an explanation, a vindication for their struggles, a relief.

Neurodiversity is a highly heritable trait – and that can mean parents may either dread or embrace the possibility with their own unique family narratives of the struggles that have been experienced – if not by them directly, then by other family members.  All of us as parents, want our kids to not go through the same struggles we did, and this understandably changes the dynamics. Where there’s a parent with a diagnosis, there’s generally greater recognition and acceptance. There are genetic components to ADHD. Rates of heritability are shown to be 75% – with gene variants found in children with ADHD that are not found in control groups (Elia et al. 2010; Guan et al. 2009; Rietveld et al. 2004). (Credit to Dr Stephanie Sarkis – Section 1 of the outstanding Mindsight Institute training in ADHD Across the Lifespan: Assessment, Medication, and Non-Medication Essentials)

From questioning to productive action…

The question is whether the wait for a diagnosis is going to keep everything in limbo for months (even if the private route is taken), and how the diagnosis is going to land – and whether productive action is taken on a lifestyle and relational level to support and healthily work with the unique cocktail of executive function challenges that are being experienced by the young person – and their family – and their teachers and classmates…

It takes a good deal of time to assess for ADHD or ASD, and that’s whether you go through the CAMHS route, or privately. It’s not a straightforward process either. There are no quick and easy diagnostic tests. You can’t – yet – scan a brain for ADHD. Although research over many years shows that there are structural and functional differences between an ADHD brain and a non-ADHD brain, the diagnostic criteria are assessed by a psychiatrist and cross-checked by observations by parents concerning areas of functioning / dysfunction in homelife, and triangulated with observations from the school.

There are a number of companion-pieces that can go alongside ADHD – anxiety, depression, guilt, shame, negative self-image arising from difference and not meeting age-related expectations…that can later morph into rejection sensitivity. Schools can differ wildly in their approaches to making reasonable adjustments, and parents are not necessarily given the toolkits that would help them in their relationship with their growing child and adolescent. A diagnosis is a very good starting point and delaying can mean an accumulation of ‘co-morbidities’. But as awareness unfolds, some productive action can also help. Even without the label of a diagnosis, an objective, non-judgmental ability to name the specific areas of struggle helps. As does a sense of what can help and exploring ways of skill-building and scaffolding around the struggles.

Certainly, having a child with ADHD is parenting plus. And I have worked over many years, supporting parents of teens particularly with re-orienting expectations, communication strategies, and how to use their relationship with their child more productively to steer away from continuous checking, corrective action, fixing and solving which rapidly runs out of road as the teen years kick in and is experienced as control and disconnection.

Here are some baseline ideas to know and bear in mind about ADHD.

Sources: ADHD – What the Science Says – Russell Barkley, Dr Stephanie Sarkis: Changing the ADHD brain, Unmasking Bullying in Adults: Brooke Schiffman

1. ADHD does exist, it is absolutely real. There are distinctive neurological and biological differences which need to be understood. It’s not purely a behavioural issue.
2. It is a lifelong condition – you don’t grow out of it. It can be debilitating. It is treatable, especially when self-regulation and executive function challenges are met with healthy and informed strategies. At least 50% of children retain ADHD symptoms into adulthood (Dr Stephanie Sarkis). ADHD adults find their thriving through making life choices and career choices and working contexts that play to and release their strengths rather than chase their challenges…Understanding and working with your own unique nervous system and executive function challenges is key to crafting this.
3. There are differences in brain structure: smaller pre-frontal lobes in children with ADHD, the pre-frontal cortex takes longer to develop (Mahone et al 2011). There are differences to the temporal lobes resulting in time-blindness (Dr Ari Tuckman’s famous quotation is that for the ADHD brain, there is ‘Now or right now’). The cerebellum, the area of the brain that helps support balance and movement is smaller – which can be linked to the challenges of needing movement in order to better manage attentional focus.
4. A young person with ADHD’s brain also functions differently. Higher levels of cortisol, thinner cerebral cortex, a disconnect between the frontal cortex which regulates attention and the visual processing areas of the brain, and differences with the uptake of neurotransmitters which regulate brain function. Dopamine (regulates movement, motivation, memory, mood, reward processing), serotonin (mood, sleep-wake cycles, appetite), and norepinephrine (mobilization, attention, focus) are at a lower level. (Volkow et al 2009). There are also differences in the brain’s ability to refine GABA – which helps inhibit movement, stress and anxiety, and prevent the nervous system going into overdrive – and helps with sleep regulation. (Dr Stephanie Sarkis)
5. A young person with ADHD may be 1-3 years behind their chronological age in some aspects. This needs to be borne in mind eg in the approach to communicating instructions, allocating jobs and calibrating expectations in home-life. Otherwise, the school years and homelife may form really depleting cycles of the young person feeling their differences, affecting their sense of self and relationships with others.
6. It affects 3-6% of the world’s population (Kessler et al 2011).
7. There are 3 types of ADHD: inattentive, hyperactive/ impulsive, a blend of the 2. In the US, according to the DSM-5 diagnostic criteria would be met by impairment in at least 2 of the school, family, peer-to-peer aspects of a child’s life pre-12 years old.
8. Untreated, there are several co-morbidities and risk factors that can accumulate: anxiety, depression, substance abuse (6 times more likely than for non-ADHD population), relationship problems, chronic stress and burnout.
9. The life-span of the ADHD population is around 7 years shorter – higher rates of accidents, obesity, head injury, divorce, addiction, and debt.
10. ADHD can have a massive impact on the experience of school and work relationships and belonging throughout the lifespan. Research has shown that in the general population 20% experience bullying in childhood, and 10% in adulthood. The rate is far higher for ADHD children: 47%. 16% of those will go on to become bullies themselves. A larger proportion of ADHD children who were bullied as children also report being bullied as adults. According to Dr W H Dodson’s research in the US, 70% of ADHD third graders (8-9 years old) don’t have a reciprocal friend. In my work supporting school-based professionals with ADHD, when things are good, they are very very good. But when things go awry they can spiral. Setbacks can precipitate an extremely precarious sense of belonging that usher in hyperfocus, fight-flight-driven responses leading to over-compensation that raises the stakes and primes misreadings in relationships at work, rejection sensitivity responses, and cycles of burnout.

Useful resources:

https://stephaniesarkis.com/

Her podcast – Talking Brains.

https://stephaniesarkis.com/blog/category/talking-brains/

Recommended resources: https://stephaniesarkis.com/blog/series/my-recommended-books/

Always make sure your sources of information are researched, peer-reviewed, reliable…

https://chadd.org/

How does this backdrop of knowledge land? I certainly hope that this helps ground some of the narratives that abound – eg about neurodiversity being something of a lifestyle choice or a ‘get-out-of-jail’ card on the accountability stakes.

How should this set of information activate us as adults who might suspect of know of our own neurodiversity? Or who play a key role in the care of and education of young people?

Here’s the thing. Whilst you can’t cure ADHD – you can move the dial on many executive function challenges with practice and informed strategy. Some schools are more proactive than others in suggesting, promoting and recommending investigations. This is sometimes coming from experience over the years of the mental health and self-esteem challenges that can rapidly accumulate when untreated, or unattended to. Especially in adolescence and in very selective school environments.

A brain that is lacking in balance in terms of its chemistry will find ways to regulate it. In healthy ways or unhealthy ways. Hence repetitive movements and hyperactivity being a way to get a brain chemical boost. Risk-taking behaviour will also give a brain-boost – but may bring with it unintended consequences.

Exercise is deemed an essential part of non-medication treatment for ADHD in order to stimulate the cerebellum and free up the frontal lobes for focus. Research has shown that 5 minutes exercise decreases executive functioning challenges…

In choosing a school for someone who needs movement in order to function at their best, choosing an environment that values and promotes time for sport within and outside the curriculum is hugely helpful – as opposed to a land-locked school with limited play areas on-site. Similarly, thinking about the daily commute to school – skilling up for safely cycling to and from school as opposed to a more sedentary commute may help.

When I look at the struggles in family life with parents, we look together at the routines, ask more nuanced questions that help tune in to the regulatory challenges and unmet needs that can lie behind routines, expectations and communication patterns that are just not working, leading to power-struggles, conflict-loops and worsening relationships.

These approaches help more immediately make accommodations that can start to turn around a chasing-deficits downward spiral into a building-on-strengths uplift.

Another issue that impacts on relationships between ADHD children and teens and the adults in their lives is the way we communicate. We can make significant and relatively easy adjustments that are going to acknowledge that where Executive Functioning is slowly (in all children and adolescents) or more slowly (in ADHD brains) developing that will help scaffold and support routes to success – both in the home and in school.

Executive functioning is housed in the pre-frontal cortex, the part of the brain that is last to fully develop. These skills and capacities are crucial in helping direct, process, manage, disseminate and store information. Lengthy instructions with lots of sub-clauses, or a list of instructions are likely to be a losing ticket where the working memory or the ability to reconstitute information is under-developed.

Communication hacks:

• Shorter, direct, clean, and clear communication.
• Using name, eye contact, two feet on the ground (rather than over the shoulder) (Kim John Payne) It’s crucial to get their attention first.
• Written instructions, or recorded instructions. (Eg homework or project tasks, shopping errands). Especially if the instructions are multi-step. Writing down and systematizing steps reduces anxiety considerably.
• In the classroom, simplify instructions, and display them on the board. Avoid lengthy explanations and lots of sub-clauses to instructions. Allow instructions to land and embed. Repeat in the same simplified form at the end if lots of extra explanation has been required.
• Getting them to repeat back the instruction – to help embed the information. Get it – got it – good.
• Remember time-blindness – and agree / collaborate on strategies to manage timings to keep on track for deadlines. What they can do, what the obstacles might be, how you might help…
• Think about tone. Tone always trumps content. Tone can get in the way and brings an emotional upheaval and interrupts communication (Brendan Mahan). Don’t have a hard conversation when you are revved up…
• Triage. Don’t overwhelm. One thing at a time.
• Remember that there are 2 parts to communication, the verbal, cognitive element, and the emotional element. Much of this is non-verbal.
• Help them feel seen, heard and connected.
• Slow down. And don’t take things too personally – eg if they interrupt.
• De-escalate or you’ll get no-where
• Building on strengths is always a safer, more secure route to getting traction and engagement. Chasing, corralling and pre-empting deficits, less so. Positive reinforcement is so much more relevant and important especially for an ADHD brain which is often from an early age already sensitive to difference, disappointment, awareness of otherness and lagging skills…What you focus on, grows as Barbara Friedrickson famously said. You focus on the problems and obstacles, they will grow. You focus on the emerging capabilities, they will grow quicker.

Executive functions skills develop over time in neurotypical children too – and do so more securely when scaffolded by practices that support them. IF your child has a diagnosis or not, there are many ways in which family life, and the parent-child relationship can develop these skills with more traction and less stress.

I hope this helps as a starting point. Please do share this with fellow parents, friends, colleagues for whom this might be relevant.

Do get in touch, especially if you think that you’d like some parent / family coaching to work on creating cycles of uplift and growth around relationship and routines where growing brains – of all kinds – are concerned.

If you are an adult with ADHD, also consider getting advice and support – whether of a therapeutic or neurodiversity-informed coaching nature – to help identify and change patterns that serve you less well and build the skills that will help you inhabit your fuller capacities with more enjoyment, more calm, and less stress.