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Reframing ADHD

March 15, 2017, by Joel Schwartz, PsyD

Reframing ADHD

I recently joined a Facebook support group for adults with ADHD (which I have). I have been very saddened to see that so many there see themselves as deficient and that medications are the only answer to their problems. The pathology paradigm pushed by pharmaceutical companies has worked. We have created a class of demoralized people who feel unworthy and damaged unless drugged. (Note: I am not discounting that medications can do wonders for some nor am I minimizing how difficult it is to have ADHD. For many, medication may be part of the answer in managing this complex and multifaceted condition.)

Yes, having ADHD means that we are at a disadvantage when it comes to the way we are supposed to interact, study, and work in this society at this given time in history. The label in and of itself ADH Disorder, assumes ADHD is a result of a dysfunctional brain. There is no proof of this - since function/dysfunction depends on context and in some contexts ADHD people perform better than neurotypical people. When the ADHD person is given the freedom to make their own education and life, that person almost always does incredibly well. Although the research isn't clear, some have concluded that people with ADHD tend to have higher than average overall intelligence (often times lower scores can be attributed to lack of focus on the long-winded IQ tests - an inherent bias against ADHD people in testing itself). In hunter-gatherer tribes, those with commonly associated ADHD genes perform the best (Eisenberg, Campbell, Gray & Sorenson, 2008) . We are natural hunter/gathers forced into the boring life of farmers. WE are not deficient. Education and work spaces are. The 9-5 (and more if you are in America) hyper work life is. We are not. We are misfits, not unfit.

There is a convincing body of research suggesting parental judgment, stigma, and other forms of ableism contribute significantly to negative ADHD outcomes. Parents who see ADHD in a positive light tend to have better functioning ADHD children (e.g. Lench, Levine, & Warren, 2011).

We must remember that almost every human trait is deeply contextual - what hurts in one situation helps in another. So here as some ways to reframe traits typically seen as negative in ADHD people:

1. We do not have processing deficits. We find meaning and beauty in everything, meaning we don't screen out what others would. Because of this we are romantic, open to experiences, and highly creative. We pay attention to what others do not, and therefore make connections others do not. We process DIFFERENTLY, not INCORRECTLY.

2. We are not impulsive. We are experimental. We are passionate. We do not fit in with the boring world of soul-crushing rules and regulations that inhibit our natural creativity and freedom. If we are allowed to express ourselves naturally, we are great problem solvers, uniters, movers, and shakers.

3. We are not inattentive. We are attentive to EVERYTHING. See number 1. This is not a deficit. This is a sensitivity that, when harnessed, makes us interpersonally adept and aware, tuned into others, makes us great artists, and keeps us connected even when our conscious minds are elsewhere.

4. We are not irresponsible. We are playful. And if we are allowed to play, we will get amazing things done. But if we are shamed for being us, we will shut down and not perform.l

5. We are not too sensitive. We are compassionate, artistic, romantic, passionate, loving, affected by injustice, and caring.

6. We are not reactive. We are responsive. If we are react badly, it is because something negative ACTUALLY happened. Just because others are insensitive doesn't make us wrong. Don't shut us down.

7. Please feel free to add your own...

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September 11, 2016, by Joel Schwartz, PsyD ·

Disorganized Attachment – An Explanation for Non-Clinicians

Many clients who end up in the therapeutic chair or couch are impacted by a disorganized attachment style. Disorganized attachment serves as a diathesis (risk factor) for many difficult psychological syndromes including depression, dissociative disorders, various personality disorders (especially Borderline and Narcissistic Personality Disorders), PTSD, and Complex PTSD. I have found it useful to explain the etiology and manifestation of disorganized attachment to my clients as a way to begin understanding their confusing and dysfunctional coping methods and behaviors. However, my search of the web has yielded little information for the non-clinician. As such, here is my jargon free explanation. Most of these ideas are from the research of Mary Main and her colleagues:

Usually, when infants and young children are frightened or sad they approach their parent or caregiver for safety and comfort, something called "Attachment." The attachment system is a biological imperative in most social mammals. That is, we are hard wired to seek security of other mammals in times of great distress (and to provide comfort to distressed others), and this hard wiring is as important to our survival as is eating and drinking - perhaps more so. In the first half of the 20th century, Harry Harlow and colleagues did a series of studies on Rhesus monkeys and found that the need for contact with a comforting figure took precedence over food. This is why we cling on to abusive partners and parents. Our need for "contact comfort" is deeper than the need for physical safety.

When a parent or caregiver is able to empathize, soothe, and care for their children, it teaches the children how to handle their own uncomfortable emotions and be caring and empathetic toward others. They also learn healthy boundaries and know how to seek out and rely on others for help. This is the basis of healthy interpersonal relationships and is called “secure attachment.”

However, when parents react to their children’s efforts to receive comfort, empathy, and security in a frightening way, it can adversely affect their children’s ability to cope with emotions and engage in healthy relationships. Sometimes, parents do not even mean to be frightening. Often, parents can be frightening when they are abusive. However, parents can also be frightening if they have unresolved traumas of their own, are excessively anxious and reactive, or have some other psychological difficulty that results in frightening behavior, or acting afraid of the child.

When the people who are supposed be a source of safety and security are also the source of danger and insecurity, it results in “fright without solution.” As a result, two things may happen: 1) Children in these situations tend to disconnect from reality – they dissociate. They may lose track of time, have out of body experiences, see reality as distorted, feel like events happen to someone else, or have strange and incomplete amnesia episodes. 2) They grow up coping in a confusing way – basically, they are programmed to both approach and avoid caregivers at the same time. As a result, when these children grow up, they experience intimacy as scary. When people try to be kind to them, they may freak out. They may really want to get close to someone, but are also scared at the same time and unable to open up or share.

I once had a client who described being frightened at a party. She ran away and hid in the coat closet. While there she was wishing so badly that her boyfriend would come and get her. But at the same time, she was afraid to be found. She wanted to be close to and far away from her boyfriend at the same time. Another client had a mother with disorganized attachment. She was not able to be close to her children without being mean and critical. She would hug, and cuddle them, telling them how much she cared and loved them, but at the same time would critical, rejecting, and cruel. It is because even with her children, she wanted to be close and far away at the same time.

When people who have disorganized attachment experience psychological trauma, they very frequently experience PTSD. But their PTSD is much more complicated and difficult to treat because when a securely attached person has PTSD, they can quickly trust their therapist and allow themselves to be cared for. When someone with disorganized attachment gets PTSD, it is difficult to treat because the process of learning to trust a therapist is frightening. They want to rely on a therapist and run away from the therapist at the same time. When the therapist tries to care and empathize, or the person feels themselves beginning to trust, that is the moment they start to get scared and want to run away or end treatment. Sometimes this dynamic is expressed in a manner that sabotages treatment, such as frequent no shows, provocative behavior, or a flight back into pathology or substance use. As a result, it often requires the therapist to work intensely on the therapeutic relationship for a long time before directly working with symptoms or other syndromes.

This manifests in the sexual arena as well. The person with disorganized attachment may crave closeness and distance at the time, so they engage in sexual behaviors that have both of these needs met. They may sleep with many partners to avoid deeper intimacy and connection. Or they may create distance between themselves and sexual partners during sex. Or they might find safety in the disconnected autonomy of cyber sex or pornography.

Working with people who have disorganized attachment can be difficult. Often, informing them about the reasons for their seemingly strange behaviors is an important first step.

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July 19, 2015 ·

Unplug Electronics and Plug in to Life!

I have been hearing from a lot of people lately that they feel “disconnected,” “lonely,” “irrelevant,” and “lost.” When I ask them what has changed, they all seem to attribute this to job stress, pressures of daily life, or just plain depression, like it’s an expected state of mind. When I ask, most of them do not engage in as much physical movement as they report that they used to do.

Some report that watching movies, TV, and video games, as well as social media as their go-to recharge activities. I am hearing this often enough that I cannot ignore the correlation. I believe that as a society, we are forgetting how to feel. Let me clarify, we are losing touch with our actual environment by replacing sensory input with virtual experiences. Behaviorally speaking, we are teaching ourselves not to have to use all of our senses, in essence a sort of reverse evolution.

I am not saying to go back to the horse and buggy days, but I do feel that we should consider limiting our exposure to electronics and media and supplementing each day with physical experiences and face-to-face interactions. And I mean EVERY DAY. We are designed to move. We are wired to communicate with others and connect with our immediate environment; touch, smell, listen, taste, and see what is around you. Some call this mindfulness; I call it being human. Use technology as a tool when needed, but take breaks and remember to plug in to life. I believe that you will soon find that you will feel more connected, less lonely, more relevant, and less lost. Let me know how it goes if you are inclined. I would love to hear from you.

autistic female

January 21, 2015 ·

Autistic Females - Hidden for Too Long

While it is true that there seems to be many more autistic males than females, new research combined with testimonials of many hidden autistic women suggest that the sex-gap may be narrowing. The diagnostic criteria for identifying autism in the DSM is highly male-centric. This continues a long trend in medical and psychological research of basing experience from a male standpoint. For example, Lai et. al. (2011) found the ADOS-II, considered the gold standard in autism assessment, correctly identified autistic females 20% of the time. A recent study found similar results using a computerized version of the ADOS-II (Rynkiewicz et. al. 2016).

Part of the problem is that the entire basis of the DSM, that meaningful diagnoses can be given based only on observable symptoms, is completely insufficient for identifying the problems that bring clients into the consulting room. What is missing is an important subjective dimension - the lived experiences of our clients in informing how they are to be treated. When we honor this, diagnosis and treatment become a meaningful conversation between clinician and client as opposed to the all-knowing professional making proclamations from on-high.

Another reason diagnosis can be difficult is that many autistic people learn to cope with their neurology, thus blinding professionals to their struggles. This is especially true of autistic females. Autistic females appear to be more socially adept than autistic males. Like their male counterparts, they frequently make social mistakes and are easily overwhelmed in social situations. However, unlike their male counterparts, autistic females tend to be much more socially motivated. Because of this, they tend to learn how to fit in. They are careful studies of social interactions and have learned to copy social behavior. However, because they are essentially faking social competence, it takes a lot out of them. It is a costume that feels constraining and hot to the point of crushing. Many professionals miss this key diagnostic feature as a result.

Autistic females become easily overwhelmed and tend to isolate for long periods of time or get hyperfocused on specific interests as a manner of coping with anxiety and an over-sensitive nervous system. Whereas autistic males tend to have highly narrow interests, such as a fixation on a certain type of vehicle, road maps, or weather patterns, female fixations tend to be more gender conforming and broad, and are therefore missed as diagnostic. Some examples of these fixations include fantasy novels, specific TV shows, fashion, music, body image, or animals. What differentiates this from a hobby is the extreme fixation and inability to “leave it at home” when out in the world. Also, because many females have been shamed or have been told they are annoying for talking about their intense interest, many have learned to hide these behaviors from the social world. One autistic woman I know is a passionate photographer - her phone storage constantly needing expanding as it is filled with pictures. This woman scans through her 1000s of pictures while in social situations as a way to screen out the rest of the world. To others, she looks like any other person engrossed in their phone. To her, it is an essential mode of survival.

Finally, many professionals base autism diagnoses on the concept of "theory of mind." In essence, early studies of autistic children (mostly males) showed they were unable to conceptualize that others' minds were different from theirs. Newer research has shown that, if properly motivated, many autistic children do, in fact, have theory of mind - they just do not recognize that they need to use it (e.g. see Chevallier, et.al. 2012). Because autistic females are socially motivated, they tend to have very good theory of mind. In fact, because of histories of rejection, an ability to hyperfocus, and being very sensitive to minute changes, autistic females may actually have overcompensated, thus possessing superior theory of mind at times. Many autistic females are highly intuitive and may identify as being an "empath."

Like autistic males, autistic females are susceptible to meltdowns, sensory overwhelm, and anxiety. Because this can look like extreme moodiness, autistic women are often misdiagnosed with Bipolar Disorder. Also, many autistic women's relationships tend be “all on” or “all off." They can vacillating between intense interest and focus to social withdrawal due to overwhelm or losing trust in others. Because of this, they are frequently misdiagnosed as having Borderline Personality Disorder. Autistic people in general require familiarity, and as a result are often diagnosed with Obsessive Compulsive Disorder, which often misses the primary reason for needing rituals and consistency. Finally, autistic people in general have difficulty with executive functioning and focusing on non-preferred topics, leading frequently to an incorrect ADHD diagnosis. As a result, autistic females are treated like mental patients and are given strong drugs that interact poorly with their extra sensitive nervous systems, often making them worse. Simply informing and educating these individuals about their diagnosis can bring about immediate positive change. It allows these women to view themselves as quirky and sensitive people, part of a tribe consisting of influential and artistic people, instead of lifelong mental patients.

Some common experiences of females on the spectrum are:

  1. Feeling like they are aliens, faking fitting in.
  2. Moving from social group to social group throughout life because they cannot find a place to fit in
  3. Social overwhelm above and beyond social anxiety – their brains may literally turn off or dissociate to avoid the bombardment of social stimulation
  4. Sensory issues – hypersensitive to touch (for example cannot wear certain fabrics, bothered by rumples in bed sheets, or require intense deep pressure to help regulate their anxiety), highly sensitive to smell (for example intolerance for any body smells or being able to smell bad food before others), light sensitivity, and picky eating due to difficulties with certain food textures and tastes.
  5. Intelligent and complex, but strangely incapable of doing well in certain subjects.
  6. Often confused at work because they are able to get the job done and perform well, but cannot fit in socially and are seen as a poor team player.
  7. Affinity for animals or objects over humans (sometimes manifesting in odd collections that may somewhat resemble hoarding or in owning many pets).
  8. Perceived to be snobby or self-centered because of difficulties with typical “back and forth” of social interactions and social rigidity.
  9. Transgender phenomena: compared to the neurotypical population autistic females have greater incidence of transgender issues. This may have something to do with the “extreme male brain” theory of autism proposed by Baron-Cohen. However, this idea has significant criticism. Recent evidence suggest that males on the spectrum are also prone to being transgender.

For more information, I highly recommend Aspergirls by Rudy Simone and the books of Tania Marshall. Understanding of autistic females is still in its infancy. As such, unless a professional has specific interest or training in identifying autistic females, they are likely to miss important nuances of the condition and give an incorrect diagnosis. If this resonates with you or describes one of your clients, I am available to provide assessments and consultations.

This article was written by Dr. Joel Schwartz click here to view the original article

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