ADHD- over diagnosing and over medicating and what can we do about it (part 2)
To continue this exploration I just wish from the outset to say that psychology is so often still a somewhat inexact science. Humans, particularly the little humans are complex and in an ever-malleable flow of development consistently reacting with their genes and environment. Therefore quite often what might be true neurobiologically one day, can be rendered moot the next year. However, my view is that it is because of this, that it is essential that we keep the conversation open! That we keep searching, reflecting and checking in to ensure we are supporting children in the most valuable ways day to day.
You are free to reject my thoughts and offerings, and likewise take it in board for further exploration if it resonates, makes sense and/or sparks your curiosity. In essence, these words are not gospel, I only invite you into the conversation…
Let’s take the next part of this discussion in sections.
When ADHD behaviour is really anxiety or trauma: treating the causes not the symptoms.
In my clinical opinion it is always worth considering that a presentation of ADHD or ADD, could be trauma in disguise. Hyper-vigilance and dissociation for example, can be mistaken for inattention, and impulsivity might be brought on by a stress response in overdrive.
Let me offer you a couple of examples…
During my trauma therapy training, one teacher and mentor, let's call him Joe was telling me a story about a little boy, 9 years old at the time, let’s call him Sam. Sam was presenting with such severe ADHD like behaviours that he was being expelled from school after school after school and the family were falling into disarray with exhaustion. Sam had been assessed and diagnosed ADHD by two psychiatrists and an educational psychologist. No-one knew how to help him. To cut a long story short, after months of building therapeutic alliance, playing games with and getting to know Sam, Joe had a gut feeling that some piece of the puzzle was missing, and began to explore Sam’s world, the people in it and their memories of Sam’s childhood so far. Eventually it was uncovered that there had been a string of traumatic incidents, when Sam was only 3 years old in nursery, where he was repeatedly put in a naughty spot for misbehaving. This naughty spot was a dark corner so frightening to Sam that he developed hyper-vigilance which spilled over into inattention and mis-behaving which became a vicious cycle. Every time Sam was told off for mis-behaving, his trauma was triggered stimulating more of the behaviours that were getting him into trouble in the first place and triggering him further and so on and so forth. Sam pattern matched being told off with with being frightened, and so every time he was told off, even for just not paying enough attention in class or doing anything a typical boy might do, he was triggered into extreme ADHD ‘like’ behaviours as a coping mechanism.
Once the trauma was processed, Sam became more informed and self-aware and the adults in his life were given tools to support him, Sam was no longer an ADHD child.
I worked once with a 16 year old girl diagnosed with ADD. In her case, there was a very clear and conscious incident provoking anxiety and PTSD symptoms however no one had made the connection and diagnosed her separately with ADD and PTSD. When in fact, in my view the ADD symptoms were really just PTSD symptoms that deserved time and treatment in their own right. Again, once the trauma was resolved, this adolescent though has an ongoing battle with anxiety, no longer struggled with inattention and began to thrive.
I worked with an adopted child for a short time who had been diagnosed and treated for ADD. The primal wound of adoption is often the root cause of the dissociation of self, provoking behaviours that look a lot like attention deficit, but are in fact, most simply put, symptoms of pre-verbal trauma. Following my hypothesis, once the parents engaged in attachment work and the child developed a more secure and true sense of self, the ADD at least somewhat, ‘lifted’.
In recent years, parents and experts have questioned whether the growing prevalence of ADHD has to do with hasty medical evaluations, a flood of advertising for ADHD drugs, and increased pressure on teachers to cultivate high-performing students. Researchers are beginning to draw attention to a compelling possibility: inattentive, hyperactive, and impulsive behaviour may in fact, in some cases, mirror the effects of adversity, and many paediatricians, psychiatrists, and psychologists don’t know how—or don’t have the time—to tell the difference.
As there is also no absolute evidence yet the data is cautionary but it’s clear that some 'misbehaving' children might be experiencing, or have experienced harm that no stimulant can fix. These children may also legitimately have ADHD, absolutely, but unless prior or ongoing emotional injury is treated, it may be difficult to see any dramatic improvement in a child’s behaviour.
On that note, is worth mentioning that there is also some evidence that parents with ADHD/ADD and even anxiety may be more likely to have children with ADHD/ADD, due possibly to the modelling of erratic behaviours. Children too have been known to emotionally attune to their parents or develop coping mechanisms for their parents somewhat chaotic or perhaps inconsistent behaviour, the end result being a child who presents with executive functioning challenges! In some households, the levels of stress and anxiety with ADHD parents can be high, and more sensitive children could find themselves affected by this, or develop anxiety, presenting as anxious enough to display hyper-vigilant and dissociative behaviours.
Taking the holistic approach we must also never rule out physical injury. Brain damage from head trauma goes undetected more often than you would think with children and developmental trauma can also impact how a child moves around in the world as they grow. I work with a few children whom early in life struggled with speech or co-ordination which resulted in attention deficit or hyperactive behaviours. In my view, these are (not always but) often simply coping mechanisms. As Bowlby (the pioneer of attachment theory) once said:
"Children either learn to shrink from the world or battle with it."
When either of these become a problem, isn’t it then more useful to become detectives and try to figure out why rather than slapping a plaster permenantly over the problem?
Trauma is not a bad word. It is an informative one. It is certainly not a word I want any shame to be evoked from. Trauma is just another word for upset or stress that had a particularly strong impact and very few of us will get through life without it! Healing is all about how we recognise and manage our more difficult experiences.
To this end, this is why I do not engage in absolute diagnosis but encourage an ongoing holistic approach. As a child’s counsellor, so much can be uncovered over time that begins to explain why a child might be struggling or behaving in ways that are challenging and it is a puzzle we put together piece by piece.
Thoughts for us to continue to at least consider while supporting children and young people…
When ADHD behaviour is a cry for connection: building secure bonds of attachment with your children.
In the new version of Raising Boys, Biddulph highlights the work of Dr Gabor Maté, who believes that:
“Rather than an inherited disease, Attention Deficit Disorder is a reversible impairment and a developmental delay, with origins in infancy. It is rooted in multigenerational family stress and in disturbed social conditions in a stressed society.”
Both Maté and Biddulph believe that the part of the brain which allows us to feel calm develops in the second six months of life.
“Reducing stress on mothers and ensuring good attachment during the age of six months to one year may be crucial to preventing ADHD in vulnerable children,” writes Biddulph.
“ADHD is real… but it’s also often over-diagnosed. It’s important to look at all possible causes - what might be stressing the child in his home, school or other locations.”
Attachment disorder is more commonly spoken about now, but as a concept is still apparently difficult for many professionals to grasp. It is an unconscious feeling of chaos, a feeling of fear because if a baby is not cared for then they will die. If a baby does not feel cared for, seen, heard, related to, attended to, joyously played with then there is unlikely to be a secure bond of attachment. This feeling stays with the child as they grow up and attachment issues, ADHD, ADD (and even autism spectrum disorders) can present in very similar or overlapping ways. ADHD and ADD can often present later in life when a child feels alone and unanchored, as a result of late onset insecure attachment patterns and/or relational trauma.
Very simply, we can think about insecure attachment as a child floating around in chaos trying to survive with no strong, safe adult to anchor them. When a child is securely attached, they explore the world in ways that seem somewhat more logical and organised due to having absolute trust and a sense of safety to where they are anchored, knowing they can never wander too far off course.
A wonder if we can think of ADHD an impairment, not a medical illness. Gabor Mate likens ADHD to poor eyesight, an impaired condition without an underlying disease. He explains in Scattered: How Attention Deficit Disorder Originates and What You Can Do About It that, while there may be a genetic predisposition, ADHD is far from predetermined or irreversible. Both genes and environment are needed to cause the impairment.
As a practitioner that believes it is the co-existing and integrating nature of genes and environment that shape us, I wonder…
He also says “ADD has much to do with pain, present in every one of the adults and children who have come to me for assessment…When a family as a family can begin to heal their wounds, their insecure bonds of attachment and pain together, they can often stop fighting against each other and begin to thrive together, even free of the impairments that were causing them to struggle.”
With every parent and generation doing the best they can, when considering the origins of ADD/ADHD behaviours, it is essential that we at least explore together, attachment and relationships.
When ADHD is a gift: how to nurture the artist or athlete.
I absolutely and loudly celebrate neurodiversity!
I love working with neuro-diverse children as they are the absolutely example of how most children do not come in tidy packages — they come with spontaneity, energy, and delicious individuality. Some have challenges that push them physically, cognitively, emotionally, and/or behaviourally. The good news is that creativity can support most of them.
I read about a student who was diagnosed with dyslexia when she was eight years old. She also had “language processing issues,” as she described them, and together these made her reserved. “I’ve always been a kind of shy person,” she said. "Except for one place: the stage. The stage fright thing never really fazed me as it does other people,” she continued. “If it’s a bad day or a good day I can have a whole different world.”
We hear it all the time: an actor or entertainer is rumoured to be dyslexic, or have an ADHD diagnosis, or some other barrier to traditional or mainstream learning. Are people who struggle in the classroom naturally drawn to acting? To art? To music? To athletics? And if they are, is it because these activities are appealing to their strengths, or a way of coping with their deficits?
A special gift?
In my view, the children I work with seem to have access to a part of themselves that other, more academic students find more difficult. Young people who might be exceptionally good at learning in the very traditional way are often very much in their heads, and in some ways can find it difficult to be in their bodies, their hearts, their feelings, their imagination. The young people who have more challenges in learning in the more traditional way can, I observe, sometimes have greater access to these creative and embodied parts of themselves.
The depths of their expression can seem greater at times, which makes them naturally gifted towards music, art, drama, innovation, philosophy and athletics.
Though not always easy to parent, I truly understand, value these strengths in your child, because it builds confidence which is crucial in the classroom. If children are too discouraged to try to succeed academically, then that lack of confidence is a huge inhibition. Confidence with other skillsets creates an entryway for them to walk through towards success, academically or otherwise.
I strongly believe that academic acuity is not the gold standard for achievement and success, however these creative skills can support your child’s academic journey. I know some ADD/ADHD children who learn better when listening to music or tapping rhythms with their feet. I know some who flourish in English through drama or in Science through innovation. I know some who can only study when with their athletic peers, learning to work as and feeling more grounded within a team rather than isolated and alone as ADHD/ADD children often feel.
For ADHD/ADD children it is crucial to do cross-curricular work. For young people who are able to find more success in doing artistic things, art becomes imperative to not even what they are learning, but HOW they LEARN to LEARN.
Think accelerated learning! Remember there is more than one way to learn.
Your child can do almost anything with the right support, toolkit and mindset.