Podcast: Understanding ADHD in Kids & Teens

Episode Transcript

Jenn: Welcome to Mindful Things.

The Mindful Things podcast is brought to you by the Deconstructing Stigma team at McLean Hospital. You can help us change attitudes about mental health by visiting deconstructingstigma.org. Now on to the show.

Scott: Hello, everyone. Thanks so much for joining us today. My name is Scott O’Brien. I oversee McLean’s Education Outreach initiatives.

We’ve hosted many webinars over the years. And one topic that consistently comes up no matter which session we’re in is ADHD.

People ask lots of questions in our sessions, and ADHD just constantly comes up, questions about the condition itself, how it relates to other disorders, how symptoms can lead to it being sometimes confused for other disorders.

So today, Dr. Roberto Olivardia has generously offered to come back and talk to us about all things ADHD and answer your questions.

Alright, let’s do this. Dr. Olivardia, thank you so much for being with us today. Over to you.

Roberto: It’s great to be here, Scott. And so for people to know who I am, I’m a clinical psychologist. I actually did all my clinical training at McLean Hospital. I did my internship there many years ago.

And I have a private practice in Lexington where I specialize in the treatment of ADHD as well as obsessive compulsive disorder. I specialize in the treatment of eating disorders and body image issues in boys and men.

But with this issue, particularly with ADHD, I also come from this from a very personal perspective. I have ADHD. I have two teenagers, a son and a daughter, with ADD. I came from a family of people with ADD.

So I come from a personal perspective as someone who has it, as a parent, and as a professional. And I’m very much looking forward to the session and answering people’s questions.

And just to say a little bit, a sort of spiel about ADHD before we get into the questions and answers is why I’m so grateful that we’re doing this is I feel that ADHD, which stands for attention-deficit/hyperactivity disorder is actually one of the most clinically underappreciated conditions.

So it’s not a mental illness. It’s not, when we talk about ADHD, it’s not in the same vein as depression, for example. When people are depressed, they are very different and may see the world in very different ways than when they’re not depressed.

With ADHD, it’s more of a condition of neurodiversity. It’s just kind of a way someone is wired and is oriented to the world that can provide many challenges for that person. And if they get the treatment that they need and are using the right strategies, that same brain could be an asset for them.

And with ADHD, when it’s undiagnosed, when it’s untreated, really runs the risk of being probably one of the most treatment interfering conditions. So most people with ADHD have a comorbid issue. About 30% of people with ADHD have anxiety. You’ll see 20% will have a mood disorder.

People with ADHD carry a much higher risk for any kind of addictive behavior. Whether we’re talking about cannabis, alcohol, sex, porn, gambling, shopping, any kind of impulsive, binge eating. I work with many men with ADHD and binge eating disorder.

So if we don’t treat the ADHD, then treating any of those conditions is going to be much, much harder to do. So it’s so important to have an understanding of what we’re talking about with ADHD. And in a nutshell, what it is is you have these different collection of symptoms.

The name is a bit of a misnomer. It’s not that people with ADHD lack attention or have a deficit in attention. It’s more a dysregulation of attention.

So for parents out there, or teachers may definitely relate to this where you can have your child or a student really be all over the place and have no attention span for certain things. And then for other things have an enormous attention span, what we call the hyperfocus.

So I did not like school very much prior to college. And so I would be in my head, in my imagination, because that was much more interesting to me than what was going on in most classes. And it was very, very difficult for me to regulate my attention in class.

Now it wasn’t that I wasn’t a learner though. I loved to learn. I always loved to learn. I just didn’t like to learn what I was being taught in school.

So when I would go home, I would read encyclopedias and I would go to bookstores and just read random chapters of random things to sort of take in and hyperfocus.

I’m a huge music fan. Like I could tell you to this day, when certain albums were released and where they placed in the billboard charts, and like all of that kind of information I would soak in.

So you see this real dysregulation and it could even be class to class. I mean, I remember when my parents came home from a PTA meeting when I was in seventh grade, and they had this puzzled look on their face, as they often did with me.

And they would say, “Well, we’re confused because we met with five teachers who kind of were describing a different person. This one teacher said you were the star student of the class, that if everyone could be like you, her job would be great, ‘cause you were so participative.”

And that was my English class ‘cause I had a teacher who was so engaging and she had the desks in a circle in the class, which I remember the first day of class being like, “Oh cool, stuff is happening here. Like we’re going to engage.”

My history teacher who I frankly, wasn’t a big fan of the subject and his presentation was very monotonous and very sort of drone in some ways, “He says you have a sleep problem because you’re sleeping in the class all the time.”

I had another teacher that actually advised my parents that I should get checked as to whether I have a bladder issue because I was going up, going to the bathroom all the time. And I’m like, “No, I don’t have to go to the bathroom. I’m just trying to find a reason to get out of the class multiple times in a day.”

I had another teacher who said, I couldn’t shut up. I had diarrhea of the mouth because I was very hyperverbal and impulsive because it was a form of basically, now I understand, self-stimulation.

So you can see these wildly different presentations, and with ADHD, it’s really about the context that we’re talking about. So it’s not a, oh, here’s this kid or this adult that just lacks attention or functions a certain way throughout the day.

I am always interested as a clinician, as a parent is what is the right environment that’s going to support that person? So you have attention dysregulation, impulsivity, which isn’t always the sort of conduct disorder kid.

It could be being hyperverbal. It could be the fidgeting, getting out, having a hard time getting out of seat, blurting things out loud. And then you have the hyperactivity, which those are the kids and young adults that tend to get diagnosed, but not everybody has the hyperactive symptoms.

You can have ADHD, more inattentive presentation. And in fact, a lot of girls are underdiagnosed with ADHD because they might not present in the same kind of hyperactive ways as boys typically do.

It’s a myth that boys outnumber girls in having ADHD, boys outnumber girls in identification of ADHD. There’s vastly underdiagnosed. The good news is that we’re better today at diagnosing ADHD than we were when, years ago.

When I was a kid, I wasn’t diagnosed with ADHD when I was a child, because the kids who were diagnosed then were the kids with conduct disorders who were very combative.

Now I was not a goody two shoes either. Like I loved mischief or I used to call them my shenanigans, but I knew that line. I didn’t want to be disrespectful to other people, but I could definitely be a class clown.

Those kids were not diagnosed with ADHD back then. So we were better at identifying it and understanding it. But the biggest part of ADHD are the problems with executive functions, which are all the cognitive processes that our brain does to get things done.

Our ability to manage time, to regulate our emotions, to prioritize, to organize stuff in our lives, as well as information in our head, our working memory. Now this is something that goes beyond school.

And this is why ADHD, which still sometimes gets looked at in clinical circles as just an academic issue is if anything, it’s the cornerstone of living life and adulting, especially as you become an adult, you have to show up at appointments on time and you have to organize things.

You have to shift your attention from doing one thing to another. If you have that kind of job or as a parent, you have to do that all the time.

So that’s very difficult for people with ADHD. And studies will show that, that basically, certainly prior to the age of 30, you think of someone with ADHD as sometimes having a third less their chronological age in executive functions.

Now that doesn’t mean a third less their chronological age in intellectual capacity. So I’ve worked with many people who are wise beyond their years.

I mean, I’ve worked with young kids who are so smart in terms of the stuff that comes out of their mouth, but their executive functions are that of someone much, much younger. And that’s so important. It’s for parents to understand of what is this person capable of doing.

Now that doesn’t mean we can’t work with them. And that’s what hopefully we could talk about in this hour of how do we help those individuals, but understanding that a lot of people with ADHD are doing the best that they can do.

And it might be confusing ‘cause it’s like, wait a minute, I know you’re smarter than that. I mean, many of us with ADHD have heard very like, “You know better. Why would you do that? What made you think that would work that way?”

And, “Of course you’re going to be late. You woke up too late. You should have studied for that test.” All of those things that it’s just hard for people to execute.

So it affects about eight to 10% of the population. It often gets accused of being overdiagnosed. I find it’s definitely for the most part underdiagnosed, there are some people who absolutely get diagnosed with ADHD who don’t have it.

I find the opposite is more often the case, the people where I might see them maybe for treatment of OCD or an addiction or some other problem, and no one ever sort of assessed and understood that ADHD was at the foundation of it.

And one of the things I hope is the main takeaway I want people to get from this is understanding the ADHD to me is the foundation of which if that’s not treated and understood and identified…

And for that individual to have the correct self-talk because it could be very easy to slip into thinking of yourself as a loser or thinking of yourself as someone who can’t do things the way that normal people can or can shame yourself.

If you’re blurting out loud and you get negative feedback from peers or, in all of those ways, you can see how that can spiral into later problems with mood, with depression, with self-esteem, with those things, which then absolutely have to be treated, but at the foundation of it could be this untreated ADHD.

So that’s sort of it in a nutshell and would love Scott to go into any questions that people have and we could expand on any or all of those points.

Scott: So thank you so much. That was fantastic. And incredibly helpful. I have a couple of questions for you based on that.

Roberto: Sure.

Scott: One of the things that you brought up in there that I thought was really interesting was you mentioning that boys don’t necessarily have ADHD more than girls, but it’s more actively diagnosed in boys than in girls.

Would you speak a little more to that? I think it’d be interesting for people to hear essentially, what are we as a large community missing about ADHD in girls? Is the presentation different?

Are we assuming that it’s something that it’s not? I mean, things like that I would be, yeah, I’d really like to hear more about that.

Roberto: Definitely, so part of it is how we socialize. I mean, we still have, even though there’s a lot of good work of changing this, but we still have these socialized roles of boys and girls.

And so when I worked with young women or women who when they would tell me accounts of them being in school and they wanted to get out of their seat and they wanted to, they felt that kind of hyperactivity, but they felt if they did that, that they would be looked at as really weird.

Versus, like boys, it’s almost as yeah, boys will be boys, they have a motor and they’re rambunctious. Like there’s more of an allowance basically for boys to kind of be rough and tumble and kind of be even like misbehaved honestly in ways.

Like for a girl to be misbehaved almost has more of a social stigma to it, even amongst peers. I’ve worked with a lot of women who have ADHD who say that sometimes their female peers would look at them and be like, “What is your problem? Like, calm yourself.”

Whereas for the boys, they wouldn’t get that kind of feedback. If anything, they might get laughter from their male peers that sort of encourage that behavior. So you imagine the girl with ADHD who then is like, “Okay, I have to hold it in, pull it together.”

We do know that girls with ADHD are more likely to compensate with perfectionism, with high anxiety. So this is the other thing, you can be a perfectionist and have ADHD.

I’ve worked with people, particularly adults who interestingly, a lot of adults with ADHD might get diagnosed when their children do. And then they realize, hmm, this is very familiar what my child is explaining.

But they realized they really overcompensated by just double checking, triple checking, quadruple checking their homework to make sure there was no and wanting to be like the perfect student and the perfect person and the perfect girlfriend and the perfect mother and all of that that no one would’ve known how much stress and how much that took out of them.

Because with ADHD, it’s not about just the result. And this is why even the best form of assessing it is through a clinical evaluation. Neuropsychological testing is not the standard of evaluating or diagnosing ADHD.

Neuropsych testing is extraordinarily helpful for assessing learning disabilities of which 50 to 60% of people with ADHD have a learning disability. They’re very helpful in cognitive, other cognitive issues. Certainly if people have cognitive injuries or things like that, but with ADHD, there’s actually a high false negative rate.

You can have somebody who really pulls out all the stops and has all that attention, and they really want to do well on the test who can score higher on a test.

But then in real life regulating their attention for two hours in something is not the same as regulating your attention for this one test in a one to one correspondence in a distraction free room.

It just doesn’t carry, it doesn’t generalize. So for a lot of girls I work with, they’ll talk about perfectionism being very highly anxious and that anxiety, that fear of either being a failure or the fear of people thinking that they’re really strange.

Or if they would space out in the middle of a conversation, they would be like, “Oh my God, I couldn’t imagine if I said, ‘Oh, could you repeat that?’” Then they would internalize like, “What do you mean? Like you didn’t hear that or you didn’t understand that.”

So we see that. The other thing though, is even in impulsivity, how impulsivity can show up is very different. So with, there’s actually girls with ADHD have a higher risk of self-harm behaviors. And so with cutting, with higher risk of borderline personality disorder. So eating disorders, particularly bulimia and binge eating disorder.

Those populations should always be, in my opinion, always assessed for potential ADHD. So it’s not that the impulsivity always has to come out in, oh, this is the kid that’s bouncing off the walls.

It could be impulsive in a lot of other ways, in more secretive ways, like a disorder like bulimia nervosa could be a very secretive disorder, but one that definitely entails this sort of problem with emotional regulation and impulsivity.

So we’re starting to understand that. And then frankly, with women I work with who are moms, they feel a lot of shame because they might be comparing themselves maybe to the other mom that is working, is making the brownies for the bake sale, is attending the soccer games, and for the moms with ADHD, they’re like, “I’m not one of those people. I don’t know how, you know, they do it.”

And it’s not that I haven’t worked with dads who feel that as well, but again, in a lot of sort of socialized roles that, dads tend to be more forgiving around those particular things. Now with men, it can come out in different ways, but with a lot of the women I work with, they’re very, very hard on themselves.

Scott: Thank you, that was really interesting. Some of those things I actually did not know myself. That’s great.

Someone’s asking about a clinical, you mentioned a clinical evaluation. Would you just give us kind of a brief idea of what exactly that entails?

Roberto: Absolutely. So with the clinical evaluation, it’s really, it’s meeting with a provider that definitely has specialty and expertise with ADHD.

And a lot of it will be, first, getting a sense of, well, what are the things that are getting in your way? Like what are the certain challenges that you have? Having an understanding of is this something that has always been an issue for you? Is this something that is contextual?

Because sometimes people will say, “Oh, I don’t think I had, I didn’t think I had ADHD until the pandemic,” for example, is a perfect example where I had a lot of people who were like, “I don’t know, this has never really happened to me before.”

But what they realize is without the structure that they were in, they really kind of, they couldn’t self-regulate in a lot of ways. So I often will ask, like, what situations or systems work well for you? Which don’t? Is this something you notice when you were younger?

And what gets missed in a lot of surveys that people might click in on the computer, whatnot is, did you fail school? Did you repeat a grade? Well, certainly, there’s some people with ADHD where that happens, but there are, most people with ADHD that might not happen.

Like I never failed a class, but if you asked me, but then in a clinical evaluation I would ask, “Okay, so you got straight A’s,” like I’ve worked with people with ADHD who’ve gone to Brown, who’ve gone to MIT, who go to Harvard.

I’ll ask them, “Well, what was that like getting there?” Oh, and then you hear the stories of that I could personally relate to. Yeah, I pulled more all-nighters than I could even think about. I’ve had those stories myself. I mean, in college before you can... there was no internet back then to submit online.

I was literally the paper off the printer, running to the professor’s office across campus before four o’clock before that door shut. I mean, it was like something out of like a movie, panting and sweating getting the paper in.

And I’d get an A on the paper because I write well that, that was a strength of mine, but the behind the scenes was like, I mean, it was chaos. I mean, there was a certain chaos attached to it. If, I would fall asleep a lot in classes in high school, for example.

So I had to overcompensate by, when I would have students or peers of mine that would say, “Oh, I just study from the notes.” And I’m thinking, okay, well, that’s assuming you’ve written notes. I didn’t write notes.

Like I called them EEG notes because they would look like hard. I’d start to write and then I’d fall asleep and up and down. And it would look like some graph. And I’m like, I didn’t write notes. And frankly, I never learned how to write notes.

Like this is one of those things just like with learning issues, which also, I think I probably had an undiagnosed learning disability as well with reading and, that these things are just assumed. Like I remember when, in seventh grade in particular, okay, write notes, it’s like, how do you do that? What’s important, what’s not?

I have to now determine all of that while regulating my attention, listening to the teacher. I didn’t write notes. So my form of study is I had to literally reread pages and pages sometimes if I cared enough to do well in the class, which some of the classes I did, some of them I didn’t, but it would entail me literally rereading the chapter of a textbook.

And my friends were like, “Why are you doing that?” I’m like, I can’t do it any other way. Like that’s the way I have to do it.

So when I hear those kinds of stories, when I hear impulsive behaviors, that again, that other people might not realize with a person’s like, “Yeah, in order for me to go to sleep every night to ground myself, I need to drink three to four glasses of wine.”

That’s not me. That’s sort of what I hear sometimes or some patients of mine who feel like they have to self-medicate with cannabis, because it’s so hard for them to get to sleep, to almost ground themselves, which is a very common thing for people with ADHD.

So you hit, what is their day to day functioning, their sleep habits, their eating habits, the things that, their executive functions in general. Now you get a picture of that.

And now you’re also trying to make sure this isn’t due to something else. And so part of when I do a clinical evaluation is assessing for anxiety, which again, now 30% of people with ADHD have anxiety, but I’m determining, what’s kind of the driver?

Is this person anxious because their life is just not organized very well because of their ADHD? Or does this person have a primary anxiety disorder, which then impacts their ability to be attentive, which is not ADHD?

That’s an anxiety, like OCD, for example, if I’m working with someone with OCD who’s like, “Yeah, I can’t pay attention to the teacher ‘cause I’m ritualizing in my head.” Well, that’s not ADHD. That’s OCD.

Now I have patients that have both ADHD and OCD, and interestingly, they can tell me, they’re like, “No, I know that this time I was ritualizing. And then this other time I was so bored that then I started to obsess about something.”

So it was like the ADHD hit first, then the OCD. I assess for depression and mood disorders and the same thing.

I mean, many people can have both, but I’m trying to understand are these what we would call these ADD traits and symptoms all due to the depression or in fact is some of the depression due to the ADHD?

And then what might have started with the ADHD and then just became its own animal, in a way, I mean, we see that with addiction all the time that people who really, I mean, we see particularly with cannabis dependence is probably the most widely used substance for people with ADHD, that develop a dependence.

And it started, most of my patients with ADHD, for example, who are addicted to cannabis do not say I was looking to get high all the time. What they will say is, “I love weed because it helped me fall asleep. I was able to be in my body and focus. I was able to not get so emotionally dysregulated.”

It’s all self-medicating ADHD. Now cannabis is not a treatment for ADHD at all. It has a very negative neurological impact to a developing brain, but I understand the appeal of it if it’s doing those kinds of things.

So now we understand, oh, this is really the ADHD. And at the same time, we also have this now problem with cannabis or in the case of an eating disorder, we have this bulimia, this binge eating disorder that now also has to be treated.

So I’m also trying to sort of tease out what are those other disorders, and sleep... Everyone with ADHD has a problem with sleep. I am a poster child, Scott, for sleep disorders and sleep problems that I could do a whole webinar on just sleep, I mean, you name it.

I was a sleep walker, sleep talker, sleep paralysis, night terror, sleep apnea and just the psychological relationship people with ADHD have with going to sleep. We don’t want the day to end. We like the nighttime.

We sometimes get a burst of energy at 10:00 or 11:00 o’clock at night when the world is asleep, no one’s going to bother me. But I want to understand, is that due to the ADHD, or sometimes people have sleep disorders that can look like ADHD in that way.

So would really be going through all of those things. Now for any student, any young person, I also recommend neuropsych testing because 50 to 60% of people with ADHD have a learning disability and that is best assessed through neuropsych testing.

And I also think if people can get neuropsych testing, it can be a very interesting way of just understanding how your brain works and how it processes certain parts of information.

But having that clinical piece is really important because that goes more beyond the, okay, did you fail a class? Like, I’m not late. I’m a very punctual person. Now when I was in high school, I was late all the time.

But part of it too, especially for adults is a clinical evaluation is definitely more necessary because a lot by adulthood, some people have found compensating ways. Now it doesn’t mean it didn’t come with a price in that, but you’re always looking for sort of the behind the scenes sometimes of things that might not be so obvious.

Scott: I want to come back to evaluation in just a minute, but you’re mentioning or talking about your college experience and how your college experience was significantly impacted by ADHD.

Once people are transitioning out of college into the workplace, I think it becomes, makes for kind an interesting situation, we’ll say. What are your thoughts around disclosing ADHD to your employer?

Roberto: It’s a good question. So first, just to note about school, and this is particularly for parents out there who might be very worried when they see their middle schoolers or high schools.

And they’re like, oh my gosh, if college is in their future, ‘cause college is not for everybody or satisfying everybody’s goals, but they’re like, how does, college is never going to work or beyond that, it really, again, depends.

I had a much harder time in high school than in any like 10th grade in particular was the worst, but high school was harder. College was far easier. Although again, there are challenges that produce themselves, but the scheduling, I had more flexibility of time.

And most importantly, I knew I wanted to go into psychology ‘cause that was the only class in high school that I liked, the one class that I was excited about. And I thought, okay, there’s got to be something to this ‘cause I’ve never felt this way about any other class.

And being, I went to Tufts University as a clinical psych major. I double majored in child study. I loved it. I loved philosophy classes I loved, but it still showed up.

Getting a PhD was even easier because it’s all clinical psych and it’s integrated with training, and being at McLean Hospital was like, amazing. It’s like an engaging, it’s like this is what I want to do.

So strangely enough, and this is not, I mean, it was a lot of hard work, but it was easier for me emotionally, honestly getting a PhD than high school was, and that might shock people, but this is the thing with ADHD.

It makes sense. If you understand how ADHD works is that I was constantly stimulated as a PhD student. It was everything that was 100% relevant to me.

So now going to your question about work is, this is why with ADHD, I remember when I was in third grade, we had to write a paragraph of a fictional character we related to and I wrote without, I mean, gosh, how diagnostic is this, I wrote that I related to Goldilocks from “The Three Bears.”

And I remember being like “What, like Goldilocks?” And I was like, yeah, ‘cause with Goldilocks, this bed was too hard and this was too soft and this was just right. And this porridge was too hot and this porridge was too cold and this was just right.

And I said, my teacher, Ms. Wade, who was wonderful. I said, “Ms. Wade, I feel like for some people they’re just right is like this and for me, my just right is like this.” And I look back, I’m like, “Wow, that was pretty intuitive of me.”

But that’s what it’s like for people with ADHD, we have to find that sweet spot. And that’s why that fit of, if your child is going to college, that fit is so important, relationships, and then workplace and career is so important.

So making sure that someone is going into a career with an understanding of, if they understand their ADHD, where is this going to present challenges and issues for me, what actually of this brain is going to be an asset in this work that I’m doing?

So to your question with employers, it really depends. So I’ve had some clients who definitely they will disclose. They say, look, I have ADHD. And I think part of it is understanding or having that person explain what that means.

Because even like my ADHD could present very differently than somebody else’s ADHD. So you can have 10 people in a room with ADHD and there will be something that we will all relate to. There’s a common sensibility that we all will relate to.

And then there’ll be aspects that just manifest differently depending on our personalities and depending on where we grew up, gender, ethnicity. So many intersectional variables that play a part.

So for that person to be, if they’re going to talk to their employer, to be very specific and my ADHD makes the two hour meetings that we have with a lot of detail, it makes it very, very difficult for me to maintain my attention.

So now the other thing typically that makes for a more productive conversation is what are you actually asking for as the employee? So is it that you’re saying, so I don’t want to be part of those meetings, but if that’s a part of your job, you have to be part of those meetings.

Is it I would like if it’s okay to maybe just take a 10 minute break from those meetings and come back in, even though I know I might miss that 10 minutes, but that could really make a powerful difference in me just kind of regulating my attention.

Is it okay if I have an iPad that I can write on or take notes and, because it’s hard for me to just sit there and not take notes. Is it okay if I have something to fidget with, that’s not going to be distracting for other people.

And these are the things that is, young people, I want everyone with ADHD to know how to self-advocate, ‘cause my son was diagnosed at six with dyslexia and ADHD. And so much of the work was how do you, one, just you own it and not feel any shame around it.

And then, B, say, well, what is it that I need and how do I build relationships with my teachers and then employers? Now the truth is I don’t say as a blanket statement, absolutely tell your employer because the truth is, some employers are not receptive to it and get very defensive.

I’ve had clients that have been told by their employers that that’s not a real thing. That’s just this bogus diagnosis. So I think the bigger thing is how to still communicate what you need or what you look for, whether you say I have ADHD or if I have a problem remembering so many people’s names for example.

And so I might need some help with that. Or I have a hard time with getting things done unless I have a deadline. And sometimes employers actually really appreciate these conversations ‘cause...

So sometimes it could be like, so if you’re assigning me, can you just tell me, get it done Thursday at noon and I can get it done. And I do that today. Like when I write articles or things for certain publications and the editor will be like, “Oh, just get it done when you can.”

I’m like, you need to tell me, I need it done by this date, Roberto and I will get it done. Now years ago that get it done could be literally five minutes before the time, now it’s a lot better, but it would be done. It would be done.

And so sometimes it’s just even, people find in disclosing it, it’s just giving the other person a context because where it can also be very helpful is you don’t want your boss, your employer to think that you’re lazy, to think that you’re irresponsible.

And I’ve heard that from a lot of clients who have been told that, like, “We think you’re lazy. We know you’re smarter.” Like all of those messages that sometimes kids hear when they’re in school, like, “We know you have better potential and you’re not applying yourself.”

It could be very useful then to say, “I understand what you’re saying. I have ADHD, this is what it is. And this is what it is for me.” And most importantly is that you’re still responsible ‘cause I say this even to young kids, like we want an understanding and you still are responsible for getting certain things done.

It’s not an excuse. It’s an understanding like I have ADHD, I might have to do it differently, but I still have to get it done. ‘Cause I remember working, this young kid who’s eight and he has ADHD and we had a meeting with the parents and he said, “Yes, see mom, I don’t have to do any chores. I have ADHD.”

I said, “Well, no, you still have to do the chores, but we’re going to all work together as, you know, how you do the chores or what expectation of what chores, but you still have to do stuff.” If anything, now with ADHD, there’s a bigger responsibility to understand how you work to get those things done.

Scott: So that was super helpful, thank you. It’s really great to hear you talk about not only, I mean, I think disclosing can be really important in the workplace just so people have a better understanding of what’s going on and the kind of pain points might be for you.

‘Cause I think a lot of people are going to have empathy for an employee who has, call them unique needs, but no, you might do things a little differently than say, I might expect you to do them, but also I think it’s like super valuable to come into that situation and also be able to explain to me what that means for you and what would be really helpful for you.

Because for me to hear, oh, I have ADHD as an employee, I’d be like, oh, okay, I’m glad you trust me enough to tell me that, but if you’re able to come to me and say, “I really need deadlines. I need,” some kind of structure of some sort or different things like that.

I mean, that is very, I would say easy for, to accommodate and super helpful because it might be frustrating for a manager to hear like, or off putting at first, I can understand it. Or for managers like, “Oh, what does this mean? That you’re not going to be able to get your job done?”

And for you to go, “No, I can do my job as well as everyone else can and probably better, but there are things that are going to help me succeed that I need that other people might not need in order to succeed.”

Roberto: Exactly, and even like I’m working with someone now who had a conversation with her employer and it was basically she, and I could relate to this.

I cannot read long articles on a computer. I like things printed out. I like to turn a page. I like to make... It’s like if it’s a short article, yes, I can scroll through it online. But it to me is I can’t relate to it. It’s a very, very strange, like I can’t read, I either hear books on audible or I need the physical book.

I could never read a book on a computer. I don’t know how people do that. So her conversation with him was simply because she would get these weird looks of, she would print these things on the printer. That would be like 200 page documents for the field of work that she’s in and people like, why?

So she’s like, I just explained to him, look, part of my ADHD and learning. She has a history of learning disabilities is “It’s very difficult for me. I lose track if it’s on a computer, I can’t take notes to really emphasize the points, I have to print it out.”

And it’s like, okay, sometimes it’s like, great. You’re doing what you need to do. And for a lot of employers, it shows actually a lot of investment on an employee’s part because it’s like, oh, you want to succeed and do what you’re asked to do so if you’re coming to me with like, how can I do this better?

Most of the time those conversations go very well. In fact, I would say probably in the last 10 years, I’ve heard more and more from clients of mine who have had these conversations, who their employer will either say that they have ADHD.

They have a child with ADHD, they understand it versus like even 20, 25 years ago, I would hear more judgments. So just for people to know in general, there’s a lot less stigma attached to ADHD than there used to be.

And for older people out there who might have young children who maybe their experience was very stigmatized for a lot of young kids and it doesn’t mean that there still isn’t some work to do around that narrative, but most young people know, or have a peer that has ADHD.

Whereas when you, in the 1970s, it was like this sort of bad, like, oh, those are the bad kids. Like the ADHD was seen as there was this real stigma attached to it that you don’t want to sort of have any part of in that way.

Scott: Thank you. So I’m going to shift gears just a little bit, lots of great questions from the audience around kids and teens around ADHD.

So thank you everyone for sending these over. One of the more common topics is around executive functioning skills and what parents can do to help their kids enhance the skills they have.

Roberto: Yeah, so first is, like I said before, always just have that frame of mind of that child with ADHD could have the executive functioning skills a third less their chronological age.

So if you have a 15-year-old, they could have the intelligence of a 25-year-old, but their executive functions could be that of a 10-year-old. And that could be very weird.

Now imagine though, for the person with ADHD, that can also be very weird because I used to even question like, how am I able to have these big ideas and philosophical thoughts and be very, as creative as I was and literally walk from one room to the next and not remember why I walked in that room.

But I could tell you every member of my first grade class and where we sat, like I have a very visual memory for certain things so it can be confusing. So first for parents to understand that.

Secondly, to understand that and also understand that your child still has to learn these skills because I have wonderful parents that I’ve worked with who think, “Oh, because they have ADHD, I should do everything for them.”

It’s like, no, because soon enough they’re going to be out of the house and they need to learn those skills. So it’s this kind of negotiation that any parent of an adolescent is experiencing anyway, that’s sort of like, okay, how much independence, but with ADHD, it’s even more so.

And sometimes it can create this dynamic called a hostile dependent relationship where particularly with older teens who don’t want the help, they reject that because they’re like, “I’m independent, I want to be.”

And the parents are like, “No, trust me, you need this help.” And the parents are fearful that their kids is going to fall flat on their face. And so they might overcompensate and be seen as like helicopter parents.

And I put that in quotes because that term sometimes is unfairly. Well, I’m not a big fan of the term in general, but it’s particularly unfairly used for parents of ADHD kids who are sometimes told by their own family members or peers like, “Oh, you’re babying him,” or “You’re doing too much.”

It’s like, well, wait a minute, if ADHD is in the picture, you do have to support and scaffold things in a different way than a neurotypical kid. So part of those executive functioning skills is focusing on what are the things that are mainly getting in the way?

And with ADHD, I think of it this way, that ADHD people, like, we’re wired towards what is going to stimulate us. I think of ADHD, honestly, as an orientation, like an identity. I mean, I really do, like to me, and I don’t say everybody has to see it this way.

I feel I am it rather than that I have it because the lens of how I live my life and gravitate towards things, the successes, the not so great moments really could be in my world encapsulated by this brain and the way that I understand it.

And so part of it is because we’re so wired for stimulation, we’re looking outwards, there’s this external orientation we almost, and internally those executive functions aren’t maybe working as well.

We need to kind of make them concrete. We need to basically put out in the external world, all of the things that should be happening internally, but just aren’t. I don’t know how people just kind of...

I remember in college when friends of mine would go catch a flight, and they didn’t have anything written down and they’d pack and they’d be like, oh yeah, the flight’s at whatever time, I’ll get to the airport at this time.

I’m like, how do you do that? Like, to this day, I have to write down, okay, if the flight is leaving at seven, I have to be at the airport at five, which means I have to leave my house at this time, which means I should go to bed at the, I need to see it visually to know how it’s going to work.

And that’s true for everything. Like my daughter and I are going to a concert this Sunday night, we’re seeing Lil Nas X. And I’m like, okay, so the concert starts at this time. What is the parking situation like?

It’s the new venue in Fenway, MGM Hall, or I don’t know what it’s called. What time do we have to leave the house? What is traffic typically like? Like I have to visualize and it has to be written down so that I have a sense that I’m on the right track with time.

So with adolescents, with kids, it’s that same idea. There’s actually a great product called Time Timer, which is basically a clock. And it has like, you can set to shade in red.

So if let’s say someone has a half hour before they have to get to school, it shades it in red. And as time goes on, the red disappears. And that gives a visual component to time because I can tell you, I never liked digital clocks. I never liked digital.

To me it’s like a bunch of numbers. They mean nothing to me. I always liked or needed clocks where you can see, oh, the hand is getting closer to the 12, like movement is sort of happening. And so even how we interpret time, and those kinds of things could be really helpful.

And then also talking with your kid or teen because they want to feel respected and they want to understand, and you want them to see it as a collaboration. It’s not like you, ‘cause parents, we don’t want to be naggers either.

We don’t want to be in that role, in that position and saying, “Come on, you got to get ready, you got to get ready, you got to get ready, you got to get ready,” and the kid feeling nagged that it’s happening to them.

You want to sort of approach it as, “Okay, you have an issue with getting to places on time. I want to help you with that. But I can’t do the work for you. So what would be helpful for you?”

And it could be sometimes okay, just, and for the kid to feel comfortable saying, “You know what? I might need like, ‘Oh, you have 20 minutes left. You have five minutes left.’” And if the parent’s okay with doing that.

Now a parent might say, you know what? I have your three younger siblings I have to take care of. I can’t do that.

And that’s perfectly fine because parents have to also set their boundaries and understand that in the real world, your child might not have somebody, they might not have a spouse or a partner that’s going to do that.

So it’s like, okay, but I understand your need for needing that. So what if we set on your phone an alarm for 20 minutes beforehand, five minutes beforehand. Oh, great. So that’s satisfied. And both of us are getting our needs met because we don’t want the child to be like, oh, I can’t do that so figure it out yourself.

But as a parent, and this is important for parents, we don’t want them always feeling like they have to overextend themselves and do the work like, oh, a good parent would remind their kid 30 minutes left, 15 minutes left.

And it’s like, no, what we want to do is ‘cause you have to acknowledge your own self-care, but also know that whatever you’re doing, it’s still helping your child because in the real world, your child’s not always going to have, your child’s college roommate, I guarantee you is not going to be like, “Hey dude, your class is in 30 minutes. Oh, it’s in 15 minutes. Five minutes.”

They’re not going to do that. So they have to start to figure out those kinds of things. In school, if your child’s having a hard time regulating their attention to be like, okay, well, what helps? Does it help to sit in front of the class where the teacher’s right there? Does it help if you’re doodling?

‘Cause fidgeting actually used to be seen as a distraction. And what we know is that fidgeting actually stimulates the frontal lobe, which helps people with ADHD focus. There’s a great little book called “Fidget to Focus.” I would recommend to people out there.

And it’s a great book that really talks about the science and neurology of what happens when people with ADHD fidget. And that was like one of those books early in my journey reading. I was like, “Oh, that total and complete sense.”

Of course you don’t want a fidget that is distracting. Like some of these fidget spinners that have lights and whirling sounds, it’s like, okay, well now that’s not helping you ground. So you want to make sure... But I want kids, adults, anyone with ADHD.

And I always say, particularly to younger people I work with is I say, part of this is frankly, everybody has to do this, but especially those of us with ADHD is you’re going to be your own researcher. You’re going to be your own detective.

I want you to think of this as just data collection. So what works for you, what doesn’t? What do you notice? And part of this is in mindfulness skills too, because ADHD people, we have a hard time being in the moment.

We’re kind of ejecting and going into moments all the time, which is why people with ADHD often will have trouble with sleep, will have what’s called poor interoceptive awareness, which means tuning into what’s happening in the body.

Am I hungry, am I tired? Do I have to go to the bathroom? People with ADHD have a hard time with all of those things. Like eating, for example, my thing was like, if there’s food I like in front of me, well, of course I’m hungry.

There’s food in front of me that I like, like the idea that people would say, “No, I’m satisfied,” even though there’s this food, it’s like, what? I don’t even understand, how do you do that?

Or my motto with sleep was sleep happens when there’s no more fun to be had or when there’s nothing left productive to do, the idea that no, I have to tune in, my body needs sleep, despite the fact that there might be fun stuff happening.

I had to learn that like in a way that I would see other people just go to bed and so you want them to sort of know how to be in the moment, what works for them, what doesn’t. If they’re sitting by the window, I like to sit, I need a window.

I was not the kid that would get distracted and look out the window. If I was in a room with no windows, I would be in my head the entire time. So it’s different for different kids, but just starting that process of having the kid even be mindful to themselves of what works and what doesn’t.

Scott: Fantastic, thank you. I’ll give you a second and I want you to get my next one. There we go, alright.

Would you speak to us briefly about the connection between traumatic events or adverse childhood experiences and ADHD?

Roberto: Yeah, so it’s a great question. And that’s a field with trauma and ADHD, I would say is really just beginning to get adequately looked at in research.

And I think part of that is because ADHD in general is becoming more and more clinically understood and more clinically appreciated in other fields because the ADHD community in a lot of ways, I felt for years, has kind of been in its own bubble.

And my mission has always been when I give talks like even in the ADHD world, most of my talks are around comorbidity. So I’ve given talks about ADHD and you name it, sleep, binge eating disorder, BDD, drug addiction, but then I also go to the OCD conference and talk about ADHD and OCD.

I go to eating disorder conferences and talk about ADHD and binge eating disorder to try to bring that bridge together for the ADHD community to understand these comorbid issues and these other comorbid... And trauma is one of those that is, I would say, just starting now to be looked at.

So what we know from research is people with ADHD do have a higher risk of traumatic events. Now, part of that is we understand that ADHD is highly genetic, it’s highly heritable. So if you have ADHD, chances are one or both of your biological parents have ADHD.

Now how their ADHD manifested is going to affect obviously their parenting and how you were parented. So, for example, if you have someone with ADHD who coped with it by developing, let’s say a drug addiction or drug problem has very poor executive functions.

Let’s say they then have a child and their executive functions of parenting that child of regulating their emotions, their addiction could make that environment perhaps very chaotic and very unsafe for that child, which then could bring about issues with boundaries and bringing people into that circle that might not be safe for that child.

So you can see how, even with ADHD, if it’s not treated, if it’s not dealt with in that way, could lend itself to those kinds of things. Also people with ADHD, I mean, we kind of are sensation seekers. That need for stimulation doesn’t always come in the form of pleasure.

I mean, everything that’s pleasurable is stimulating, but not everything that’s stimulating is pleasurable. I mean, as a kid, I did like crazy, dangerous things that like now I look back I’m like, “What was like I thinking?”

But stuff that really could have set me up for bad situations, and luckily didn’t happen. But sometimes people with ADHD also aren’t, because they have a hard time sometimes being grounded or tuning into certain signals.

And of course in no way, shape or form, does this make them responsible for any traumatic thing that happens to them, but might not always be cognizant of those situations. So we know that people with ADHD have a higher, are more likely to have a history than neurotypical peers of physical and sexual abuse.

Now then you have how, even when there’s trauma, whether it’s related to the ADHD or not related to the ADHD, with trauma impacts one’s executive functions, can impact one’s certainly self-esteem, one’s concentration and focus, particularly if there’s dissociation involved with the trauma, which is now, if someone also has ADHD is impacting a system that already has certain challenges, with all of those things, with being in the body, with focus, with attention.

And with that, we’re understanding too, that it’s not a one plus one equals two, that the whole is greater than the sum of its parts, that with trauma, with ADHD…

Well, one, it’s still very important to carefully tease out because trauma, especially, and with people who have trauma and ADHD, the ADHD sometimes could really not be looked at because, understandably, we want to look at the trauma, but one’s ability to even process trauma could be impacted by their ADHD.

And so we always, again, have to keep an eye on how ADHD plays a role in people’s ability to even do that kind of treatment and do that, the kind of work that that would involve.

And I’ve worked with people who have traumatic events and even how they process their sense of self, it turns out, if they have a very negative self-view and think of themselves as people who are weak or who are stupid, sometimes it goes even before the trauma.

And with the ADHD, they realize, “Oh, I’ve always thought of myself as a stupid kid. And so when I was being abused in this relationship, a part of me felt like I deserved it.”

And one, there’s work in the field. One of my colleagues, Stephanie Sarkis who’s based in Tampa, Florida, she does a lot. Actually she just came out with a new book about toxic relationships.

But she talks a lot about how people with ADHD are more prone to being gaslighted, are more prone to even being in abusive relationships sometimes because their self-esteem might be so low from the negative messaging around the ADHD. So it’s so important to understand all of those components.

Scott: Wow, that’s very good to know. So, I’m sorry, one more time, Stephanie Sarkis you said?

Roberto: Yeah, Sarkis, S-A-R-K-I-S.

Scott: Cool, thank you. One last question and I promise, I’ll let you go.

Roberto: Sure.

Scott: Not everyone has access to a licensed professional who’s an expert in ADHD.

For folks that are concerned about themselves, or maybe a loved one, are there any evaluations or self-assessment tools that you’d recommend that people potentially utilize before taking that next step to maybe have to go outside of their local area to find someone who’s an expert?

Roberto: Yeah, so usually, so, if we’re talking about someone who’s in school, like a public school system, it could be free through a public school system of an evaluation of beginning to assess, getting teacher observations and things like that.

And for parents also to share what they see at home, because that’s the other thing. Sometimes, the student at school, again, if they’re overcompensating, could look fine at school and then the parents see the meltdown at home.

The parents are like, “Oh, you don’t know what it’s like to get my child to do homework,” or “It takes him four hours to do something.”

Like a client I’m working with now, it took him four hours to do something that I said to the parent, you should be talking to the teacher about this. And when they did, the teacher said, “Oh, no, like, that should only take 30 minutes at most. I don’t want your child to be doing that.”

And the teacher was so wonderful in working with the child and the parent to say, let’s modify this or adjust this because that is not sustainable in those kinds of ways. So reaching out to the school.

And then checking out, there are some really good websites I highly recommend. One is understood.org, and Understood, it’s really geared to parents to help with their children who have learning disabilities, ADHD.

And they have a lot of surveys and things that are just more pointed towards trying to see if this is an issue for your child or for you. ADDitude, which is A-D-D-I-T-U-D-E, additude mag like as a magazine, additudemag.com is a wonderful site as well.

I’m actually on the scientific advisory board for ADDitude and they’re a free site with chock-full of articles, information, free webinars, podcasts, because I find the best way is for people to just educate themselves a lot about what ADHD...

And then you’ll find that people who, where it is something that’s present for them, they’re like, “Oh, I can relate to this.” Even in our conversations that, there will be people who might have heard an anecdote that I shared and be like, “Oh, I totally know what that is. I can understand that.”

And to know with ADHD, obviously it doesn’t mean like, oh, because I relate to this one thing I have ADHD, but you start to see this collection of ways you sort of understand. And on ADDitude, there are a lot of self-screeners and resources for books and things like that, that people can check out to have an understanding of it.

Scott: Thank you so very much. Thanks everyone. This concludes today’s webinar. Take care.

Jenn: Thanks for tuning in to Mindful Things! Please subscribe to us and rate us on iTunes, Spotify, or wherever you listen to podcasts.

Don’t forget, mental health is everyone’s responsibility. If you or a loved one are in crisis, the Samaritans are available 24 hours a day at 877.870.4673. Again, that’s 877.870.4673.

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The McLean Hospital podcast Mindful Things is intended to provide general information and to help listeners learn about mental health, educational opportunities, and research initiatives. This podcast is not an attempt to practice medicine or to provide specific medical advice.

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