by Martha McKeon Lynch
This article is based on research I carried out as submission for my MSc in Adolescent Psychotherapy. The study is titled: Therapists’ experience of working with adolescents with ADHD diagnoses: An interpretative phenomenological analysis. As suggested from the title, this is a qualitative study. It involved in-depth one-to-one interviews with four participants who are experienced psychotherapists. Each participant has over 20 years of experience in the field of mental health, all having worked with adolescents with ADHD diagnoses. Two of the participants have over 20 years and one 15 years of experience specifically in this area. The fourth participant, an adolescent psychotherapist, has experienced working with ADHD over the last five years. Three main themes emerged from this study. The first theme – ‘The broken adolescent’ – encapsulates the therapists’ sorrow and frustration in regard to the shame that young people with ADHD often experience. Each participant discussed how the diagnosis alone has connotations of stigma. The second theme – ‘I’ll hold the hope’ – highlights the challenges in the work, along with the therapists’ worry for the young people with ADHD who do not receive sufficient support. The importance of having faith in these youngsters who frequently face challenges is evidently important for the adolescents and the therapist themselves. The third theme – ‘If you treat a person, you win every time’ – illustrates the value of connecting, showing that each participant relates with the young person as a whole individual rather than focusing on the diagnosis and behaviours. The importance of this relationship brings light to both the therapist and the client in an area that can often feel murky due to the shame and stigma associated with this diagnosis. This article aims to discuss these topics in conjunction with foundational information to anchor and support the theories. My research prompted questions regarding the implication shame has for these adolescents’ developing self-identity. These are highlighted and considered in the aforementioned themes. My humanistic and Gestalt training is reflected throughout this exploration. The terms ‘contact’ and ‘relational’ refer to the ebb and flow between two people and how they communicate with each other.
What we know about ADHD
The Diagnostic and Statistical Manual for Mental Disorders (DSM-5) defines attention deficit hyperactivity disorder (ADHD) as a neuro-developmental disorder which characteristically includes symptoms such as continuous patterns of inattention and/or hyperactivity impulsivity which impacts on the person’s functioning and developmental process (American Psychiatric Association, 2014). In addition to this, the ADHD Institute (2019) states that the condition typically includes traits such as difficulty with concentration, organisation and the experience of extreme emotions. ADHD is one of the most diagnosed developmental disorders in children. It affects approximately 3-9% of children and adolescents and 2% of adults with males being statistically three times more likely to receive the diagnosis than females (HSE, 2019; ADHD Institute, 2019). It is believed that genetic, neurological and familial factors play a role in the aetiology of ADHD (Barkley, 2005; Thapar et al., 2013; ADHD Institute, 2019). The low rate of dopamine signalling is thought to be the cause of the majority of symptoms (Tripp & Wickens, 2009). Neurological studies of people with diagnosed ADHD highlight the decreased volume in some sections of the brain as compared to controls, such as the prefrontal cortex, which appears to be responsible for thought analysis, concentration, focusing and behavioural management (Mostofsky et al., 2002; Castellanos et al., 1994, 1996, etc; Filipek et al., 1997; Hynd et al., 1993; Mataro et al., 1997). In addition, Hoogman et al. (2017) conducted a large quantitative study which showed a correlation between lesser volume in the nucleus accumbens, amygdala, caudate, hippocampus and putamen regions of the brain in people with ADHD. These regions play roles in reward circuitry, dopamine and serotonin which are responsible for desire and inhibition, long-term memory, spatial awareness and movement. They report that the difference in the amygdala can explain the extreme emotions people with ADHD experience. The amygdala helps to encode traumatic memory and activate the fight or flight response (Levine, 1997). Similar decreases in brain volume are present with some depressive mood disorders (Jenco, 2017; Bearden et al., 2001; Drevets, 2000). Other similarities in the neurology of ADHD are apparent in people who present with post-traumatic stress disorder (PTSD), including in the prefrontal cortex, the amygdala and the hippocampus areas (Martínez et al., 2016). van der Kolk (2015), a trauma specialist, describes that many people who receive the diagnosis of ADHD are suffering from trauma. In his study of childhood PTSD he learned that a consistent profile for the traumatised children included: “(1) a pervasive pattern of dysregulation, (2) problems with attention and concentration, and (3) difficulties getting along with themselves and others” (van der Kolk, 2015: 158). The ADHD Institute (2019) state that there is a significant comorbidity with ADHD including anxiety disorders, mood disorders, oppositional defiance disorder (ODD), conduct behavioural disorder (CBD), personality disorders, sleep disorders, learning disabilities and substance abuse. Additionally, Kewley (2001) highlights that adolescents with ADHD are statistically more likely to engage in early substance abuse, to experience depression, teenage pregnancy and are more susceptible to becoming involved in criminal activity. Sadly, a higher rate of suicidal ideation and completed suicide are also present in adolescents with ADHD (Impey, 2012; Balazs & Keresztenv, 2017). This information suggests that for the young person with ADHD, in addition to the usual task of adolescent development, the potential for the presence of additional challenges is increased.
Adolescence, by its nature, is a developmental stage which involves physiological, psychological and interpersonal changes. Siegel (2014) describes the pruning and myelination process associated with typical adolescent brain development as a major neurological remodelling. Increased frontal lobe development results in new evolved and complex ways of thinking and experiencing their environment. More robust links develop between the prefrontal cortex and other areas in the brain such as the hippocampus and the executive functioning regions. Ideally, this will result in the evolution of emotional processing, evaluating risk and regulating impulsivity, meaning the adolescent’s developing brain learns to utilise memories and experiences in decision making. The process continues into the mid-twenties. This brain remodelling aids the developing adolescent to further differentiate from the family and eventually be secure in living independently. Young people gain new awareness as they move into the stage of adolescent development, forming a sense of self and meaning of who they are in the world and in relation to others (McConville, 1995). According to Starrs (2019) environmental factors need to nurture and support in order for the young person to navigate the task of adolescence successfully. The developmental nature of adolescence, in addition to the neurological differences responsible for poor impulse control and decision making experienced by young people with ADHD, means this endeavour is likely to involve significantly more challenges for them. This considered, what happens to the young person with ADHD whose developmental instinct is seeking to understand who they are as a person through relationships with others?
ADHD and forming a sense of self
Perls et al.’s (1951) perspective was that a person cannot know himself in solitude but rather in how he relates with others and his environment. This gives food for thought regarding how a young person navigating adolescent development with an ADHD diagnosis may be impacted when they are forming their self-identity. McConville (1995) asserts that adolescent development is a time when the young person becomes increasingly aware of their inner world, and is beginning to form a more solid sense of who they are. People learn about themselves through relationships with others, internalising the interactions, especially with those important in their lives, as messages about themselves. The perspective of McConville (1995), Starrs (2019) and Siegel (2014) is that the task of adolescence is to assemble a sense of self in the world ideally as an independent and self-assured person. What happens if the young person does not experience supportive, empathic and positive messages about him/ herself?
Gabor Maté (2000), a leading physician and psychotherapist in the field of ADHD, believes that ADHD is a reversible developmental delay stemming from infancy. More specifically he believes it originates from multigenerational family stress and a distressed society which results in these young people being predisposed as highly sensitive individuals. Maté (2000) claims that this sensitivity is experienced with touch, sound, sight, smell and emotional stimuli, resulting in difficult experiences having traumatic impacts on them. Martínez et al.’s (2016) research supports this ideology as they conclude that people with ADHD are more likely to suffer PTSD if they experience traumatic events. The participants in my research highlight that adolescents with ADHD are frequently misunderstood and shamed in their interactions with others. This is undoubtedly traumatic as these experiences threaten their integrity on an interpersonal level. Sadly, the friction in these young peoples’ relationships is often with parents, teachers, peers and other influential people in their lives. The data evidenced that these adolescents are often perceived as defective, and experience continuous ruptures in relationships resulting in them becoming understandably defensive.
Their neurological makeup, impulsive tendencies, along with their underdeveloped reflective skills results in the perception that people are treating them like they have done something wrong. However, they may not understand why. Continuous experiences in this manner translate to the young person as ‘there is something wrong with me.’ This compromises their psychological integrity which confirms that trauma is often present as previously identified (Maté, 2000; van der Kolk, 2015; Szymanski et al., 2011; Daud et al.,2009). Adolescents with ADHD who experience dismissive or hostile interactions in their relationships will develop negative feelings about themselves and others, resulting in the young person forming a sense of self through a shame tinted lens. “Shame is above all a relationship wound” (Brautigam-Evans, 1994, cited in Lee & Wheeler, 1996: 150). This study supports the previous research by Krueger and Kendalls (2001) that drew attention to the fact that adolescents with ADHD commonly perceive their diagnosis as negative and have antagonistic views of themselves and others due to their experiences. The data and literature reviewed suggest that the shame and misunderstanding experienced by these young people, is problematic for the adolescent’s formation of a positive sense of self.
What are the implications of shame becoming part of self-identity?
“Instead of asking why a disorder or illness develops, we ask why a fully self-motivated and self-regulated human personality does not” (Maté, 2000: 42). The likelihood of high levels of shame and trauma in these young people’s lives indicate that challenges are probable as they begin to negotiate their way in the world. Stuewig et al. (2016) identify that children who experience shame are prone to a trajectory of dangerous behaviours, including engaging in risky sexual activity, substance abuse and involvement in the criminal justice system. It seems that the aforementioned challenges associated with ADHD coinciding with experiences of shame are likely to result in a higher risk of these young people engaging in maladaptive behaviour. The three more experienced ADHD therapists in this study each state that the outcome of these young people ending up in the criminal justice system is a huge concern, particularly for the impulsive ADHD adolescent who is lacking support. What happens to the adolescents who have ADHD and do not receive the support they need? The three participants suggest that these are the people who end up having significantly difficult lives, participant three stating that: “these are the people who fill our prisons” (Participant 3: 22, 5).
The high suicide rates, addiction and prison outcomes for young people with ADHD suggest that more education and understanding is needed regarding this stigmatised diagnosis. These trajectories do not reflect experiences of people who are self-assured, with high self-esteem, and ultimately have a positive self-identity. When considering the likelihood that shame and trauma are part of these people’s lives, it seems unjust that young people with ADHD characteristics are not being understood and cared for sufficiently. My study highlights the importance of support and empathy for these adolescents. Ideally this will occur in the home, with teachers and other primary caregivers in their lives. If there is a lack of constructive contact in these relationships, it is vital that their yearning for healthy connection is met by someone.
The importance of connection and relationship
What becomes apparent from this study is the value of connection and positive relationships for the adolescent with ADHD. Boersma et al. (2014) identify that a relational approach counteracted some aspects of shame for the client, in research where a compassionfocused therapy was used. Although Boersma et al.’s (2014) study was relatively small it has interesting implications for further research. Barkley (2005), CHADD (2019) and Harvard Health Publications (2008) all suggest that a multi-modal approach for treating ADHD is the most beneficial. This includes the use of medication in conjunction with psychosocial treatments which focus on behavioural modification. Unfortunately, this means the relational contact aspect is not at the forefront. These approaches have not been found to be useful for treating trauma (van der Kolk, 2015) nor do they focus on healing shame.
When the high levels of criminal involvement, addiction and other risky behaviours, as well as suicide in the ADHD population, are considered, it is evident that other approaches, as support, warrant further research. Each participant in my study spoke about seeing the whole person as opposed to seeing behaviours, symptoms or a diagnosis alone. There is a gap in research regarding humanistic therapies as an approach to working with people with ADHD diagnoses. My research hypothesises that relational support and connection alleviate feelings of shame which is supported by Boersma et al. (2014). This merits further, more comprehensive studies into relational and humanistic therapies as support for adolescents with ADHD diagnoses.
Information regarding the creation of rich contact with a sometimes reticent young person emerged from my data, as well as the benefits of engendering this positive relationship. Unsurprisingly, considering the aforementioned likelihood of shame and hostility experienced previously in relationships, there can be challenges engaging these adolescents with support. The use of humour in order to connect and create comfort in the relationship was evident from the participants. Additionally, having shorter sessions respects the adolescent’s ability to focus. The use of colourful language, symbolism and metaphor, storytelling and artwork as well as other creative methods evidently generate a sense of ease and relatability. This encourages the establishment of a positive relationship. Starrs (2019) refers to sideways contact as a means of initiating a connection with the adolescent in a manner that will not be threatening or intense for them. She advocates the use of sandspace, games and other creative methods to support the contact, hence building a sense of safety in the relationship.
As well as highlighting ways to create meaningful contact, each participant’s sensitivity and respect toward these adolescents together with a deep sense of understanding and empathy was palpable.
The need for more understanding and sufficient support for adolescents with ADHD
Shame was frequently reported to interviewees by adolescents with ADHD regarding their contact with educators. This suggests a need for psycho-education for teachers which focuses on an understanding of the neurological aspects of the diagnosis, as well as an explanation which encourages the understanding of an inability to behave in a certain manner, rather than unwillingness to. This would be beneficial in minimising shame and vilification of these young people thus encouraging the development of a more positive sense of self.
According to HADD (2019) many people in Ireland with ADHD are undiagnosed. They estimate that there is one psychiatrist per 168 children/adolescents with the diagnosis and it can take up to one year or more for a public consultation. My research clearly identifies that young people with ADHD need support. The evidence that they frequently do not receive this is witnessed by the experienced ADHD therapists in my study and is highlighted through the common challenging life trajectories often experienced by these young people. The participants suggest that the Irish Mental Health Service is failing these adolescents. The Child and Adolescent Mental Health Service (CAMHS) are limited in the support they can give due to high intake rates and urgent cases taking the frontline. This study and the reviewed literature suggest that an increased number of psychotherapists in the Mental Health Service would benefit adolescents with ADHD who have encountered shame and trauma in their lives. When we consider that the young person’s brain is still developing well into the mid-twenties, the fact that support is generally withdrawn when young people reach 18 seems problematic. As well as further utilisation of psychotherapists, perhaps other avenues could be explored and made available. For example, ADHD Ireland holds talks, support groups and has a helpful website for those with the diagnosis, parents of children with ADHD, and professionals. It is a charity organisation and there could be benefits from further recognition and validation of what it offers.
ADHD is a substantive issue, its characteristics and society’s lack of understanding often significantly impacting on those with the diagnosis. ADHD is evident through brain imaging scans informing us that it has neurological associations. Biological and genetic components along with family and social environments evidently are important considerations. Why does ADHD exist to begin with? Perhaps it is attributed to trauma, or it is part of neurodiversity and maybe it is due to genetic makeup. Possibly each of these factors has a role to play. Whatever the reason, there is a compelling need for the stigma to be challenged in this debate. The conflict between the stigmatised labelling of ADHD versus the absolute need for these young people to be treated with greater understanding is undermining a more compassionate and empathic response. When the challenges and the possibility of trauma being part of these adolescent’s life story is contemplated, the likelihood of shaming experiences becoming part of their self-identity is disheartening.
My study highlights areas for further research regarding humanistic and relational approaches to the treatment of ADHD. The care and empathy all participants in this study hold for their young clients with ADHD is striking and admirable. Relational support and connection help young people make positive relationships with others, hence healthier relationships with themselves. In my opinion, more understanding, education and support for people with ADHD characteristics and the people around them would be significantly beneficial. The participants in this study show that therapists who provide this support are available, however, the mental health system does not prioritise the relational focus as part of the approach. This seems a pitfall when the option of this therapeutic input is accessible and not being utilised to its full potential.
The interviews for this study illuminated the energy, colour and fun adolescents with ADHD bring as well as the extreme challenges they face in the world. These young people are worthy of appreciation and understanding. The therapists who sensitively respect, support, encourage and advocate for these adolescents need to be availed of and their wisdom in this area valued. I know that many parents, educators and other people are doing wonderful work with adolescents with ADHD which also must be acknowledged. Perhaps if we strive to look at ADHD and how to approach support through a different and more compassionate lens, we can encourage young people with ADHD characteristics to do the same, hence encouraging the growth of a more positive self-identity:
Submerged beneath a surface rippling with superficial and childish impulses are truer impulses for meaningful activity, the assertion of her autonomy, the pursuit of her own truth and human connectedness
(Maté, 2000: 245)
Martha McKeon Lynch MSc. is a psychotherapist working with adults and specialising in adolescent psychotherapy and development. She runs a busy private practice in Galway City.
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