Tag Archives: ADHD

Finding strength in sensitivity

By Lindsey Phillips September 24, 2019

When Louisa Lombard, a licensed professional clinical counselor in private practice in California, worked as a school counselor, parents would sometimes come to her saying, “My child is so sensitive. I don’t know why he’s like this. Everything is such a big deal. I parent my children the same way. Why is he like this? His brother’s doing great in school and not throwing tantrums and crying. What’s wrong with this kid?”

In actuality, nothing was “wrong” with the child. What the parents didn’t know was that their child had an innate temperament trait referred to as sensory processing sensitivity. Approximately 20% of the population has this sensitivity trait and is categorized as a “highly sensitive person.” Narrow that focus to the therapeutic world, and closer to 50% of psychotherapy clients possess this trait, according to Elaine Aron, a pioneer in the field of sensitivity, in Psychotherapy and the Highly Sensitive Person.

People with this trait often look carefully before entering new situations or retreat from overwhelming ones. For this reason, they are sometimes mislabeled as being shy, when in fact, an estimated 30% of highly sensitive people are extraverted.

Because no one person’s experience is the same, Aron identified four basic characteristics of the highly sensitive person (also known as the DOES model):

  • Depth of processing
  • Overstimulation
  • Emotional responsiveness and empathy
  • Sensitivity to subtleties

Aron points out that the sensory processing sensitivity trait is a survival advantage in some situations because it allows individuals to process information more thoroughly and increases their responsiveness to the environment and social stimuli.

So, why do highly sensitive people — who have this survival advantage — make up roughly 50% of therapy clients? Julie Bjelland, a licensed psychotherapist in private practice in California, thinks the number is so high because highly sensitive people are a) more responsive to therapeutic work and self-help and b) more likely to have higher levels of stress, anxiety and depression.

Heather Smith, an assistant professor of human development counseling at Vanderbilt University, posits that because these individuals process deeply, they are more inclined to seek out answers and are drawn to counseling for its penetrating conversations. In addition, she says, these clients may have developed low self-esteem because of negative stereotypes about sensitivity, or they might want tools to help them navigate times when they feel more emotional intensity.   

Misdiagnosing a trait for a disorder

According to Erica Sawyer, an American Counseling Association member in private practice in Vancouver, Washington, misdiagnosis of the highly sensitive person often occurs because people aren’t aware that the trait exists or of the trait’s specific characteristics. The scientific name for the trait — sensory processing sensitivity — doesn’t help. The similarity in name between sensory processing sensitivity and sensory processing disorder often leads to confusion. But sensory processing sensitivity is a temperament trait, not a disorder. (Aron notes on The Highly Sensitive Person website, hsperson.com, that sensory processing disorder, on the other hand, is a neurological disorder involving the senses.)

As Lombard points out, most therapists receive limited training on temperaments. She first learned about sensory processing sensitivity after graduate school when her oldest daughter started showing signs of the trait, including being sensitive to noise, facial expressions and food. As Lombard learned more, she realized that she is also highly sensitive. She had long suspected that she had attention-deficit disorder because she had a hard time paying attention in her college classes if another student was kicking a desk in a rhythmic pattern behind her or if there was a bright light overhead in the room.

In fact, because highly sensitive people can get overwhelmed and overstimulated more easily when a lot is going on around them, they can commonly be misdiagnosed with attention-deficit/hyperactivity disorder (ADHD), Bjelland says. However, whereas a highly sensitive person is typically able to concentrate in the right environment — when at home in a quiet room, for example — someone with ADHD might not be, she explains.

One confusing aspect to the highly sensitive temperament is that it doesn’t necessarily produce problems in daily life other than overstimulation, says Smith, a licensed professional counselor and an ACA member. Thus, when clinicians hear about a client’s distress due to overstimulation, they can erroneously attribute it to symptoms of a disorder, she explains. To help prevent this, Smith recommends that counselors investigate whether a client’s issue (such as anxiety, stress or an inability to concentrate) decreases if he or she is no longer in an overstimulating environment. If the client’s issue is still present, then it might be a symptom of a disorder.

Smith also points out that counselors often rely on observable behaviors to indicate a possible symptom or disorder. However, depth of processing is not easily observable, she notes. To help counselors learn to identify this characteristic, Smith describes some cues: Highly sensitive people think more about the meaning of life. If in an environment where they are not overstimulated and their ideas are valued, they have the ability to describe all facets of a problem and generate potential prevention steps or solutions — often before others realize there is a problem. They are observers, not the ones to jump into action. They often don’t make decisions quickly. When they speak, it seems as though they have grasped the insight or concept quickly, in large part because they have been thinking about all of these connections for most of their lives.

One tool that can help counselors assess for sensory processing sensitivity is Aron’s 27-item self-test (see hsperson.com/test/highly-sensitive-test). Smith, Julie Sriken and Bradley Erford analyzed the strength of this scale and found it to be a valid screening instrument that counselors can use in their practices (see “Clinical and Research Utility of the Highly Sensitive Person Scale” published in the Journal of Mental Health Counseling.) Smith presented on this topic at the ACA 2019 Conference.

However, to avoid labeling, Smith cautions counselors against placing too great an emphasis on the cutoff score of this self-test. Instead, she recommends having a conversation about how the client marked each item on the scale. This approach focuses less on the total score and more on the person’s experience overall and with each item.

Smith also advises counselors to be careful about interpreting the results from these test items or problem-solving a client’s distress too early on the basis of these initial conversations. In addition to risking misdiagnosis, counselors run the risk of not being seen as credible by clients who have been deeply thinking about issues related to this trait for a while, she says.

Wired differently

Misunderstandings about the sensory processing sensitivity trait also occur when it is assumed that this population is just sensitive to lights and sounds. It is more than that. The brains of highly sensitive people are wired differently than the brains of other people. A 2018 post on the website Highly Sensitive Refuge notes four differences in the brains of highly sensitive people:

  • Their brains respond to dopamine differently.
  • Their mirror neurons (which allow people to “mirror” the behaviors of others and be more empathetic) are more active.
  • They experience emotions more vividly than others (as enhanced by their ventromedial prefrontal cortex).
  • Their brains are more finely tuned to noticing and interpreting other people.

A recent fMRI study published in Brain and Behavior found that highly sensitive people have increased brain activation in regions related to awareness, action planning, empathy, and self-other processing. Lombard, who specializes in working with teenagers and adults who are highly sensitive, shows clients brain scan images from studies such as this one to illustrate how the highly sensitive brain differs in emotional situations such as watching a scary movie or seeing a picture of a loved one. She finds that these images help normalize the trait for clients.

On a podcast for Unapologetically Sensitive, Esther Bergsma, a counselor in the Netherlands and an expert on high sensitivity, reported that highly sensitive people have more brain activation, especially in the areas surrounding social context (e.g., wondering what others think about them, how others view them, or if others accept them). Bergsma pointed out that always being tuned into social contexts is a strength; it is only when people can’t regulate their emotions well that it leads to increased anxiety and stress.

Because people who are highly sensitive have to process more information and can experience nervous system overload as a result, they can be prone to chronic health conditions if they do not have adequate self-care and downtime, says Bjelland, author of The Empowered Highly Sensitive Person: How to Harness Your Sensitivity Into Strength in a Chaotic World.

She likens the way that highly sensitive people deeply process information to cups of water being dumped into the nervous system (“the container”). Highly sensitive people might have 100 cups that they dump into the container, whereas other people have only a few cups to dump. In other words, these individuals notice and process more detail. For example, a highly sensitive child in a classroom might simultaneously notice that a teacher is upset and the happy expression on a classmate’s face across the room and a tree branch tapping against the classroom window.

One way to simplify these brain differences is to think of the brain as two parts: the emotional brain and the cognitive brain. The emotional part of the brain in highly sensitive people is more activated, and if it becomes too activated, the cognitive part of the brain goes to sleep in a sense, Bjelland says. “That’s why [highly sensitive people] might have a hard time with emotional regulation and can get stuck in worry, rumination, anxiety and overwhelm,” she explains. “During times of high stress, the brain cannot tell the difference between a real threat and a perceived threat, so it sends out alarm bells in the system to prepare for fighting or fleeing. In those moments, [highly sensitive people] can’t even access facts, memory and rational thought because that all comes from [the] cognitive brain.”

However, counselors can teach clients ways to reactivate the cognitive brain to support their system and to let the brain know that it isn’t time to send out those alarms, Bjelland continues. For example, she uses a simple breathing technique to calm the body and let the brain know that the person isn’t in danger. Clients breathe in for four counts, hold for two counts, and exhale for seven; they repeat this for about five to seven breath cycles. “The exhale is very long and slow because that sends a signal to your brain that you are not in danger and that it can stop sending out adrenaline and stress hormones. When you exhale slowly, your brain realizes you are OK because that is not how you breathe when you’re in danger,” she explains.

The counting part (whether done out loud or silently) is important because it helps “wake up” the cognitive part of the brain, she adds.

Reframing the perception of sensitivity

As a highly sensitive person herself, Bjelland grew up hearing the negative messages often directed toward people with the sensory processing sensitivity trait: “Why are you so sensitive? What’s wrong with you? Why are you reacting that way?” When people hear those messages as children, she says, they do begin wondering what is wrong with them.

That internalized message is why psychoeducation about the trait is so important, along with validating clients’ experiences. Most highly sensitive people spend their entire lives feeling misunderstood and that something is different about or wrong with them, Bjelland says. Therapy is the place where these clients can begin changing this narrative and turning it into something empowering, she notes.

In her experience working with this population, Bjelland finds that clients often have a transformative experience once they realize that their temperament is normal, that they are not alone, and that they can take steps to improve their experience.

On the other hand, Smith has noticed that some highly sensitive clients experience a grief response after first learning about the trait. They may need time to grieve that they are unlike the other 80% of the population and yet live in a world designed by those without the sensitivity trait, she observes.

Sawyer, a licensed mental health counselor and art therapist, also helps clients reframe their negative experiences, such as being labeled crybabies as children. Counselors can help clients understand that they feel both negative and positive emotions more intensely than other people do. So, when they cried, they were just naturally expressing what they were sensing, which is normal for someone with this trait, she explains.

“They don’t have the problem,” Sawyer says. “It’s the perception that they have a problem that can turn it into one.” So, rather than thinking that they can’t control their emotions, clients can come to understand that with the right support, they can regulate their emotions. They can also take pride in the fact that they feel not only sadness on a deeper level than most people do but also experience incredible happiness, Sawyer says.

Lombard carefully selected the name of her private practice, Strong and Sensitive, to counter the tendency to equate sensitivity with weakness. Many of her clients come in with low self-esteem because of negative stereotypes about being sensitive. She reassures them that it is a normal temperament variation and not a problem. By normalizing the trait, counselors can help clients to embrace it and see it as a strength rather than a weakness, Lombard adds.

Smith teaches clients to more effectively communicate with those who seem to point out sensitivity as a problem. For instance, rather than taking on the onus to defend their sensitivity, clients could ask the other person, “What part of my sensitivity are you having a problem with?” This question reverses the normal assumption that something is wrong with the client’s sensitivity and shifts the conversation to how the other person may need to adjust his or her language or thinking to help problem-solve the relationship dynamic.

Susceptibility to the environment

Research has shown that in a positive developmental environment, highly sensitive children are more likely to thrive than are their peers who are not highly sensitive. However, in a stressful environment, highly sensitive people tend to do worse than do their peers who are not highly sensitive. In other words, this population is highly susceptible to both the good and bad aspects of their environment — a concept known as differential susceptibility.

A highly sensitive person once told Bjelland that when she was younger, her parents made her wear a wool sweater. After repeatedly asking her parents if she could stop wearing it because the material bothered her, they simply replied, “Wear it anyway.” Bjelland notes that this is an example of a highly sensitive person not being supported, and that circumstance can lead to problems.

Bjelland has also noticed that if a highly sensitive child has anxiety, then almost always one or both parents do too. Therapists can’t easily help anxious children if they have an anxious parent, she says, because the child mirrors the parent and will feel unstable if the parent also feels that way.

Parents who are highly sensitive should also be on counselors’ radar because they can suffer from overstimulation and neglect of self-care, Lombard says. The highly sensitive population is also more negatively affected by sleep deprivation, which is common for parents of young children, Lombard notes. She has noticed that highly sensitive parents are sometimes so focused on being the best parents they can be that they don’t take good care of themselves, pumping breast milk constantly or not making time for meaningful adult conversation, for example.

Lombard and Sawyer both recommend that highly sensitive parents get extra support in the form of family members, friends, daycare or a nanny. If finances are an issue, these parents could consider setting up a rotation with another trusted parent to watch each other’s children on occasion, Lombard says. She also encourages highly sensitive parents to wear earplugs or noise-reducing headphones when appropriate because they turn the noise down a bit and can lessen overstimulation.

Other life changes such as a death in the family, menopause, illness or other stressful events can make highly sensitive people feel unbalanced and overwhelmed, especially if they aren’t taking care of themselves, Bjelland says. If they experience too much emotional activation, they may temporarily lose access to the tools and strategies they normally use to cope with overstimulation, she adds.

To counter this, Bjelland tells clients to keep a “positive journal” to record positive events, such as someone saying something nice to them, or techniques that make them feel good, such as going on a hike in nature. Then, when they are having a bad week, they will have a visual record of self-care tips and positive reminders.

The acceptance of sensitivity within a culture also affects one’s environment. Some clients, but especially men, deny having this temperament because society reinforces the idea that sensitivity is not a positive characteristic, Smith says. (Research suggests that the sensory processing sensitivity trait is equal among men and women.) Thus, counselors should be careful about labeling clients as highly sensitive.

Lombard agrees. In fact, if a client grew up in a machismo culture that considers sensitivity to be negative for men, then she might not directly use the term “highly sensitive person” because it may distract from their treatment or therapeutic progress. “Depending on the culture and family of origin, men can carry more shame around [their heightened] sensitivity,” Lombard says. Instead, she mentions that all people have different temperaments and explains that some situations, such as witnessing a car accident, for example, might affect them differently. She also teaches these clients many of the same coping skills without labeling them as being for highly sensitive people.

Bjelland, who is a global educator on this trait and teaches courses for highly sensitive people, doesn’t see as many self-esteem issues in cultures where sensitivity is more accepted. “In the United States where it’s not so accepted, we see a lot of self-esteem issues. And that’s connected to shame too. Most of us walk around with the narrative that something is wrong with us because that’s what we’ve been told,” she says. “Helping to change the client’s narrative to a positive one, where they recognize why this trait is important to the world, is incredibly important.”

Recently, a male client who identified as highly sensitive came to see Sawyer because he needed a safe space to talk. He was struggling to find and maintain a romantic relationship because he found that women often wanted a stereotypical man — someone bold, assertive and athletic. As they talked, Sawyer discovered that he had internalized the belief that being sensitive was negative, which caused his own social anxieties and made relationships even harder for him. After Sawyer reassured the client that he possessed a normal temperament trait and explained its four main characteristics, he felt less self-judgment.

Although simply providing psychoeducation around the trait can be liberating for some clients, counseling often requires a longer process to help clients begin shifting their negative self-perception of being “weak” or “weird,” she adds.

Mindful changes in an overstimulating world

The good news is that highly sensitive people can makes changes so that their lives are more compatible with this trait and they can more readily cope with the challenges posed by living in an often insensitive and overstimulating world.

Bjelland recommends that highly sensitive people carve out two hours of alone time per day and dedicate one complete day each week to downtime. Not surprisingly, many clients balk at this suggestion, saying they don’t have the available time to do that. Bjelland will ask them to try it for one week and, according to her, they will universally report that they had more energy and were more productive because they were more focused, calm and balanced.

Bjelland also advises clients to follow a slower routine in the morning to help set the tone for the day. Why? Think of the nervous system like a motor, she says. If a highly sensitive person jumps out of bed to get the kids ready for school and then races into work, their nervous system revs up, she explains.

The process of slowing down applies to the bedtime routine as well because, as Bjelland points out, this population often struggles with sleep issues. “If a highly sensitive person wakes up from having a good night’s sleep, they get to have their full 100 points of energy for the day, but if they’re having sleep issues, maybe they’re only going to get 50 points for the day, and they’re already starting out depleted,” she says.

She often tells clients to adopt a ritual of doing the same five things before bed, such as taking a warm bath, reading a nonstimulating book, listening to soft music, meditating, and shutting off all electronics. By the time they reach the third action, the brain realizes sleep is coming, she explains.

“You’re teaching them a new type of self-care because [they’ve] been trying to do what the 80% [of the population that is not highly sensitive] are doing, and it’s not working,” Bjelland adds.

Smith agrees that counselors may need to have conversations centered on how self-care for these clients may differ from what rejuvenates other people. For example, if a highly sensitive person tries to relax by going to a concert with lots of lighting and sound effects after work with friends, he or she may instead feel drained and overstimulated by the end of the night.

Overstimulation is a difficult challenge for people with the sensory processing sensitivity trait because they need so much downtime, Lombard points out. She finds mindfulness techniques helpful for teaching these clients how to stay in the moment and self-regulate. For example, a highly sensitive person may find a coffee shop with loud music and people talking overstimulating. However, counseling can provide the client with strategies to successfully navigate such a space. For instance, perhaps the client limits his or her amount of time in the coffee shop or brings noise-canceling headphones, Lombard suggests.

Because these clients feel so deeply, they often need help learning to calm their nervous systems, Lombard continues. Highly sensitive people “are taking in so much more sensory information, and it’s really overwhelming,” she says. “And sometimes [they’re] not even aware, if [they’re] not mindful, of what it was that made [them] feel down or anxious.” She asks her clients to meditate daily using an app such as Calm or Ten Percent Happier and practice breathing techniques to help them become more mindful, present and calm.

Sawyer also suggests that clients use meditation apps such as Headspace or Insight Timer and practice yoga. Sometimes, even the simple act of closing one’s eyes, listening to nature sounds, or going to a quiet spot such as a bathroom or car can be helpful, she adds. The key is finding activities that “help retrain the brain to slow down [and] pay more attention to what’s happening in [the] body,” she says.

Retraining the brain in this way also helps highly sensitive people realize that they have some control and do not have to feel overwhelmed all the time, Bjelland says. For example, every time clients catch their mind wandering during meditation and bring it back to what they’re focusing on, such as their breath, it is like strengthening a muscle. Then, if clients become overwhelmed at work or a large event, they have trained their brains to notice, and they recognize that they need to take a break, she explains.

To help clients exercise this “muscle,” Bjelland instructs them to ask themselves two questions every time they go to the bathroom: 1) How am I doing? and 2) What do I need? This process makes them aware of preventing depletion or overwhelm, she explains. “Highly sensitive people tend to be very externally focused because they’re always scanning the environment for other people’s needs,” Bjelland says. “Most highly sensitive people need to be taught how to explore internally to learn what they need without always filtering it through other people’s needs.”

Of course, the heightened sensitivity to one’s environment also has benefits. Smith has often heard highly sensitive people talk about spending time in nature because there isn’t as much stimulation there. It is a place where they can escape and delight in the beauty of the natural world.

For some highly sensitive people, listening to a bird chirp or watching a sunset can elicit intense feelings of joy or elation, Sawyer says. Spending time in nature — simply walking barefoot in the grass, for example — can also help calm the nervous system, she adds.

Lombard recommends that counselors take these clients outside if they can or, alternatively, bring the natural world into their offices with nature sounds or a water fountain to help create a sense of calm. Lombard has noticed that clients often feel calmer when they see, touch or hear water, so she frequently has clients listen to the sounds of a rainstorm or flowing brook.

Learning to communicate one’s needs

Although highly sensitive people’s empathetic nature often makes them great partners in life and work, relationship issues are one of the primary reasons that they seek counseling. “Highly sensitive people in relationship are going to be so attuned to what the other person is feeling that sometimes they allow that to dominate over their own needs,” Smith says. For example, they may take on more work to please their boss even when they are already overwhelmed.

Smith finds role-play beneficial for helping these clients learn how to assert themselves in relationships. In counseling, they can safely practice communicating their own needs even if it initially seems strange or dramatic to them, she says.

Because highly sensitive people often hold themselves up to the standards of the 80% of the population that is not highly sensitive, they may not be aware that they need more downtime or need to do less so they can maintain their health and wellness, Sawyer says. To help these clients identify their needs and build new habits and coping strategies, she sometimes has them create a values collage of images that speak to them or make them feel good. Through this visual exercise, clients often will discover a common theme, such as nature. The values collage also serves as a reminder of ways that clients can calm an overstimulated nervous system the next time they find themselves in a stressful or overwhelming situation, Sawyer says.

For example, if a client’s collage contains mainly pictures of the ocean, Sawyer will ask how much time the client is spending near the beach or water. If the client says only once or twice a month, Sawyer will recommend increasing the time that the client engages in activities that will replenish them. For example, the client could go for regular walks on the beach or, if that isn’t feasible, pull up YouTube videos of ocean waves and sounds or simply take a bath to connect with water.

Working with these clients also involves helping them learn to set boundaries and communicate their needs, Sawyer says. She finds that nonviolent communication, an approach developed by psychologist Marshall Rosenberg, is a useful tool for highly sensitive people because it provides them with structure for setting boundaries. This type of communication involves:

  • Observing what does or does not contribute to their well-being
  • Identifying how they feel in relation to what they observed
  • Identifying the needs or values that cause their feelings
  • Making a request to fill that need or have that need met (the concrete actions they would like to see)

Sawyer provides a hypothetical case example. A highly sensitive person is worried about going on vacation with her friends because they are extraverted. The client also fears she will be expected to participate in every activity they have planned and that she won’t get enough downtime. First, Sawyer would help this client identify her needs and preferences for this trip. The client says she would like to have the room farthest away from the common areas because it will provide less stimulation if others stay up late talking. She would also like to tell her friends that she will opt out of an activity to stay in and read.

Next, Sawyer and the client discuss her fear of appearing antisocial if she communicates these needs to her friends. Sawyer uses emotional freedom techniques to help the client ease that fear and calm her nervous system. She asks the client to identify her fear. The client responds, “I feel nervous about talking to my friends.” Sawyer then asks where she feels that fear. The client says, “My stomach feels like it has butterflies.”

After ranking the intensity of the feeling (on a scale from 1 to 10), the client taps different pressure points while repeating the phrase, “Even though I feel nervous about speaking to my friends, I deeply and completely accept myself.” The goal is to have the intensity of her fear drop to a 2 or below.

Next, Sawyer and the client role-play scenarios of the client having this conversation with her friends. For example, she could say, “I’m someone who needs downtime. Would it be OK if I stay in from an outing so I don’t feel so anxious?” or “I’m excited about this trip and love hanging out with you, but I wanted to let you know that I will probably need a couple hours of alone time each day.”

Being a more sensitive counselor

Highly sensitive people “have higher responsivity to counseling interventions,” according to Smith. “Where they have positive fit with the counselor, they do better or they have more of a treatment response, and they seem to get more out of the counseling relationship.”

But how can counselors ensure that they are a good fit for a highly sensitive client? Smith recommends that counselors first think about their own temperament because it will inform any strategy they use. Are they highly sensitive, or are they among the other 80% of the population? At the same time, highly sensitive therapists shouldn’t assume that clients’ experiences are the same as their own, she adds.

“The 80% are very capable of working with highly sensitive people, but they need to be very careful of their own biases because they represent the majority,” Smith continues. “They may jump to a conclusion, or they may have some internalized negative biases of people who are highly sensitive.” If counselors aren’t aware of their internal biases, they risk unintentionally perpetuating some of those negative messages in the therapeutic process, she says. “And the highly sensitive person is coming to counseling because they’re looking for something different than what they’re getting in society.”

The good news is that “many counseling approaches would work well if the counselor is able to adapt it in light of what they know of the client’s high sensitivity,” Smith says. For example, if the counselor stares intently while the client is doing a sand tray intervention, then the client could become overstimulated and have a negative experience, making the intervention less effective, she explains. Instead, the counselor could step back and say, “I’m going to let you do this activity for 10 minutes. I’ll be over here doing my notes.”

Counselors should also think about the way they use language and how the highly sensitive person might perceive it. “The highly sensitive person is probably going to pick up more on nuanced language because, in general,” Smith says, “they’re wired to pick up more subtleties in their environment.” This also includes tone of voice, surroundings in an office, and nonverbal language, she adds.

Bjelland advises counselors to consider the environment in their offices. Is the lighting too bright? Is the client looking into a window? What is the texture of the couch? Does the office have a lot of strong smells such as cleaning products, perfumes or incense?

Smith also cautions counselors to be careful with cognitive behavior therapy. Because highly sensitive people process their environment and emotions deeply, asking them to think about cognitive distortions — the simple ways that the mind convinces a person that something isn’t true — can seem simplistic to them. It can even come across as patronizing to ask a highly sensitive client to reframe a cognition when he or she is having thousands of cognitions on a very deep level, Smith adds. Instead, she suggests saying, “Are these cognitions or depths of processing working well for you, or are these cognitions moving more into rumination?”

Counselors should also be careful when using interventions that might not value the depths of processing because they may unintentionally indicate that there is something wrong with the way the client is processing information, she notes.

Counselors also have the opportunity to reinforce clients’ gift of high sensitivity by validating the strengths and positives of the trait, Smith says. For example, a teacher might feel frustrated because he or she can’t soothe a crying boy. But a highly sensitive child in that same class probably would have noticed that the boy is upset because his crayon rolled under his desk, or the highly sensitive child might even notice the crayon rolling under the desk before the other child does and could grab it and prevent the boy from getting upset in the first place.

Thus, working with highly sensitive people can have far-reaching effects. As Bjelland points out, “You’re really creating a domino impact across the globe when you help a highly sensitive person lift off that layer of overwhelm and help them access those gifts and teach them how to care for their sensitive system because when they are thriving, they go out and help people and make a difference in the world. It’s just who they are.”

 

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The highly sensitive therapist

Many professional counselors don’t just treat highly sensitive clients — they have the sensory processing sensitivity trait themselves. Find out how they manage the benefits and challenges of this trait in the article “Advice for the highly sensitive therapist,” available exclusively at CT Online.

 

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Lindsey Phillips is a contributing writer to Counseling Today and a UX content strategist living in Northern Virginia. Contact her at hello@lindseynphillips.com or through her website at lindseynphillips.com.

 

Letters to the editor: ct@counseling.org

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Taming impulses

By Lindsey Phillips August 5, 2019

About five years ago, a young client walked reluctantly into Jennifer Skinner’s office. In addition to impulse-control issues, the 10-year-old had been diagnosed with attention-deficit/hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD), struggled with issues around being adopted, and had medical concerns. This long list meant the boy was often being told what to do and felt powerless.

Shortly after the boy’s parents dropped him off, he walked out of Skinner’s office and headed toward his house a few blocks away. Skinner, a licensed professional counselor (LPC) at Kettle Moraine Counseling in Wisconsin, quickly followed. She told him she wasn’t going to stop him from going home, but she was going to make sure he got there safely. Hearing this, the boy circled back to Skinner’s office and locked her out. Skinner stayed calm, and eventually he let her back in.

According to prevalence data cited by Psych Central, 10.5% of Americans have an impulse-control disorder. Even so, Skinner, a licensed professional school counselor who works with students with self-esteem, impulse-control and other social-emotional issues, says that impulsiveness is often poorly understood or is not on people’s radar. She rarely has clients present and tell her they are impulsive.

Similarly, Laura Galinis, an LPC in private practice in Georgia, affirms that when she uses the term impulsivity to describe her work with clients, she is frequently met with blank stares.

Impulsiveness comes from an internal place in which individuals either react without thought or can’t stop themselves from doing the impulsive behavior, says Skinner, a member of the American Counseling Association. Sometimes, if these individuals don’t yell or lash out, they will be left feeling unsatisfied, she adds.

Edward F. Hudspeth, an associate dean of counseling at Southern New Hampshire University, acknowledges that “some impulsivity is just a natural part of growing up [and] learning from situations.” It becomes a problem, however, when repeated consequences and societal pressures have no impact on the person’s impulsive behavior. “Basically,” adds Hudspeth, a member of ACA, “you’re saying that everyone around you and even consequences are of no value to change [your] behavior. It’s just, ‘I’m going to be impulsive,’ and nothing seems to stop this.”

According to Galinis, impulsivity is an inclusive term that describes the ways that people disconnect from themselves, their relationships and their reality. The majority of her clients come in because they are having relationship problems or because someone suggested they seek help. She finds that “the deeper root is not really feeling present when you make decisions.” To her, this means that impulsive behavior can take several forms, including sleeping with lots of people indiscriminately or drinking or spending more than one wants to.

Because impulsivity can be broadly defined, Galinis recommends asking clients what they mean when they say they struggle with impulsivity. She also suggests questions that will help counselors determine whether a client’s impulsivity has gone too far:

  • Has the client been unsuccessful in attempts to fix the impulsive behavior?
  • What consequences is the client facing because of impulse-control issues?
  • Is the client’s impulsive behavior causing problems in relationships, with finances or with work?
  • Does the client’s impulsivity stem from not setting parameters, or is the client disassociated and being prompted to engage in behaviors he or she may not want to do?
  • Is there a pattern with the client’s impulsivity? Does it show up in just one relationship or across the board?

Impulsivity across the life span

Impulse-control disorders are often first diagnosed in childhood, but as Hudspeth points out, they can occur across the life span.

Children with impulse-control issues will often act on impulsive desires because their prefrontal cortex, which regulates impulse control, has yet to fully develop, explains Hudspeth, who is both an LPC and a registered pharmacist. In adults, he finds that impulsive behavior shifts in terms of its intensity. For example, impulsive behaviors that showed as verbal outbursts and some physical aggression as a child would develop into something more disruptive and destructive as an adult, he says.

Galinis, whose specialty areas include impulsivity and trauma, agrees that some people remain impulsive into adulthood unless treated. Impulse-control issues just look different across age ranges, she says. Often, adults can hide or delay the consequences of impulsive behavior because they are more independent, typically coordinating their own schedules, funding their own lifestyles and so on, she says. Teenagers, on the other hand, may be referred to counseling because they are spending too much time on their phones in school. But with adults, the impulsivity progresses beyond simple phone addiction to behaviors that cause relationship issues, such as an impulse to watch pornography or to spend money online.

Shifting societal norms for young adults have created a different developmental stage, known as emerging adulthood, for people ages 18-26, says Hudspeth, co-author of a chapter on impulse-control disorders and interventions for college students in the book College Student Mental Health Counseling: A Developmental Approach. He explains that members of this age group aren’t at the same level of brain development that they would have been 30 years ago. That’s in part because they no longer feel pressured to instantly get a job in their early 20s and start a family, he says. Instead, they often have a period of exploration before emerging as adults.

“Add that to impulsivity, and you get a lot of chaos and a lot of strange behaviors,” Hudspeth continues. “They’re adults. They have adult rights. They can consent to things. They can do things without the approval of someone else, so it presents the opportunity for a lot more riskiness and impulsivity.” For example, it’s not uncommon for these young adults to engage in impulsive behaviors such as taking a last-minute vacation while trying to hold down a job.

Hudspeth, president-elect of the Association for Creativity in Counseling, a division of ACA, points out that impulse-control disorders have morphed over the past three versions of the Diagnostic and Statistical Manual of Mental Disorders (DSM), so diagnosing and treating impulsivity can be challenging. In 2013, the DSM-5 published a new chapter on “Disruptive, Impulse-Control and Conduct Disorders.” Intermittent explosive disorder, pyromania, kleptomania, conduct disorders and ODD were included under that heading. At the same time, disorders such as gambling, sexual addiction and trichotillomania were moved out of the impulsive category. 

The new DSM-5 chapter attempts to limit the misconception that impulsivity is only a childhood issue by bringing in the developmental perspective and detailing that these disorders can also show up in different forms in adolescence and adulthood, Hudspeth says. In fact, while doing research for a book chapter in Treating Disruptive Disorders: A Guide to Psychological, Pharmacological and Combined Therapies, Hudspeth found that intermittent explosive disorder is often underdiagnosed and misdiagnosed because it was previously included in a chapter on childhood disorders in the DSM.

Counseling professionals need to be aware that impulse-control disorders can occur across the life span and not just during a particular developmental phase, he says.

Symptom or disorder?

For counselors, the challenge is not necessarily determining whether a client is impulsive but rather figuring out if impulsivity is the main presenting issue or a symptom of other issues such as substance use, ADHD or trauma, Hudspeth says. For this reason, the initial intake and assessment are crucial with regard to impulsivity. Hudspeth advises counselors to look beyond clients’ observable impulsive behaviors to try to figure out what is initiating those behaviors. Why and in what situations are clients being impulsive?

Skinner says it is common to see dual diagnosis with impulse issues. For example, ODD, conduct disorders, eating disorders, addiction and ADHD all have impulse control as a symptom.

Galinis finds that trauma is often an underlying cause of impulsivity. In fact, she says she has yet to see a client struggling with impulsivity who doesn’t also have some trauma attached to it.

Hudspeth concurs: “Trauma and abuse will make a person very hypervigilant and impulsive, and if it’s just treated as an impulse-control disorder, you’re never getting to the core issue.” He advises counselors to ask clients whether a history of trauma, abuse or neglect is connected to their impulsive behavior, either directly or indirectly. If there is, then counselors should approach impulsivity from a different perspective than they would if it were just part of ODD, ADHD or another disorder.

In addition, Hudspeth suggests asking clients the following questions: What is their developmental history? What was their temperament as a child (e.g., easy to soothe, difficulty eating or sleeping)? Where does the impulsive behavior occur (e.g., at school, at home, in the community, everywhere)? Is the person generally well-controlled but then suddenly explode? Does the person make spur-of-the-moment decisions such as taking a weeklong vacation at the drop of a hat?

Because inadequate sleep can make it more difficult to manage impulses, counselors should also ask clients about their sleeping habits, Skinner adds.

It also can be beneficial, if given consent by the client, to speak with others who are around the client on a regular basis, Hudspeth says. All of these situational factors can help counselors determine how best to treat the impulsive behavior, he explains.

Contextual factors such as culture, gender and socioeconomic status also can play a role. Hudspeth points out that every culture perceives and deals with impulsivity differently, so counselors need to consider these factors too. For example, are clients being impulsive because they feel they may never have that experience again or because they’ve never had that experience before and thus don’t have a tool in their toolbox to deal with it? “If it’s an experience that you don’t have on a regular basis and your brain hasn’t collected enough evidence on how to deal with it, then you [may be] impulsive,” Hudspeth observes.

Some recent studies suggest that living in poverty can lead people to opt for short-term rather than long-term rewards. For example, the well-known marshmallow experiment (in which a child’s ability to delay gratification of eating a marshmallow predicted better life outcomes) has recently been challenged by Tyler Watts, Greg Duncan and Haonan Quan’s 2018 study that aligns one’s social and economic background with the ability to delay gratification.

Factors such as trauma, depression and poverty can all affect people’s abilities to regulate their impulses and can make it difficult for them to see the world outside of themselves, Skinner adds.

Thus, to get a better sense of clients’ skills for handing their impulses, counselors should ask how they respond in new or unfamiliar situations, Hudspeth says.

Hudspeth also warns counselors not to latch on to the initial report or diagnosis too quickly when it comes to impulse-control issues. “There’s a lot more behind it than just the symptoms that somebody has reported,” he explains. “It takes a thorough comprehensive intake with assessment and then the willingness to more or less change as you know more.” He advises counselors to consider the first 90 days with the client as a continual period of assessment in which the diagnosis could change as the counselor learns more.

The shame of impulsivity

With impulse-control disorders, the client’s distress can adversely affect the well-being and safety of others and even violate others’ rights (through aggression or destruction of property, for example).

Impulse control “is one of those disorders that could be considered to be both internal and external,” Hudspeth says. “Internally, you’re not stopping yourself from doing something that’s impulsive. Externally, you’re affecting others. You’re in their space. You may be disruptive. You may be yelling. The origins are internal, but how it displays and who it affects is the individual and everybody around them.”

People who struggle with impulsivity often act without thinking and frequently lament their actions almost immediately afterward, which means their lives might be filled with regret, Skinner says. That consistent presence of regret can turn into shame, she adds.

In fact, one huge warning sign that clients’ impulsivity is getting out of hand is when they try to keep their impulsive behaviors a secret, Galinis points out. Even clients with whom she is familiar will sometimes mention impulsive behaviors they have been hiding from her, especially if they involve vulnerable topics such as sexual behavior or addiction. This secrecy results from the sense of shame these clients feel over their behavior and lack of impulse control, she says.

When clients mention being anxious or having uncomfortable emotions, counselors should check in to see how they are handling those emotions, Galinis advises. Asking how clients are coping often opens a door into the unhealthy and impulsive ways they are attempting to manage those feelings, she adds.

With her younger clients who have trouble identifying and communicating their feelings, Skinner likes to read books such as Bryan Smith’s What Were You Thinking? Learning to Control Your Impulses, about a boy whose impulsivity often gets him in trouble. Eventually, the boy learns to control his impulses by thinking about the possible consequences of his actions.

“Reading stories with clients, especially with children, takes the focus off of them, helps them realize they’re not the only person who is struggling with [impulsivity], and shows them possible solutions,” she says.

Engaging emotions and the senses

Impulse control “is not often based in logic,” Galinis says. “It is an emotional experience that drives the behavior, so we need to be able to incorporate the emotions into it because logic is going to fall short every time.” Counselors can’t simply tell people to stop being impulsive. Instead, she explains, they have to help clients understand their emotions and connect them to their behaviors.

“Sometimes we will act on an emotion before we even realize that we are having that emotion,” Skinner notes. For instance, a child might instinctively yell when a teacher enforces limits on the child. Children don’t necessarily know how to handle their feelings when someone makes them mad, so they just react, Skinner explains.

Thus, a large part of her work with clients involves helping them understand their emotions. “Just being able to name your emotions takes … the reactive part of the brain offline and allows your executive functioning to come into play more, and as soon as your executive functioning is coming into play, you’re going to have a better response to the situation,” Skinner says.

She often uses the Disney-Pixar movie Inside Out to explain to younger clients how each emotion has a purpose. “Emotions don’t just happen out of the blue,” she says. “They happen because we have a need that needs to be met.”

To help clients develop a habitual awareness of their emotions, Galinis has clients pick a number on the clock in her office. Then, she tells them that every time they see that number anywhere throughout the course of their day, they should check in on how they are feeling in the moment.

Skinner also gets creative to help clients better understand and name their emotions. For instance, she asks clients to play feelings charades (in which they name and act out all of the feelings they can think of). She also has clients look through magazines and find different emotions on people’s faces. Sometimes, she has clients make up stories about why the person in the magazine feels that way. “That [exercise] helps develop empathy and perspective taking, and both of those things are really important in treating impulse-control disorders,” she says.

Skinner also advises parents and caregivers to continue these exercises at home by pausing when reading stories or watching television to discuss characters’ emotions. She recommends asking questions such as “What do you think this person is feeling right now?” and “Why is the person feeling this way?”

She explains that guiding clients to develop a broad, robust vocabulary about their emotions will help them learn over time to act, not just react, when they are feeling impulsive.

Slowing the process down

Because impulsivity is a quick response, Galinis’ goal is to help clients slow down. She wants clients to connect to their feelings without flooding their emotions, she says. To help clients achieve this balance, she often uses somatic experiencing, which aims to regulate or reset the nervous system by releasing the energy accumulated during stressful events.

For example, if a client is talking about an event that was triggering during the week, Galinis may stop the client upon noticing that he or she is getting agitated and ask what the client is feeling in the body. If the client responds, “My hands are clenched,” she will direct the client to hold that feeling and then ask what the clients wants to do. The client may say, “I want to punch something.” Then, with Galinis’ help, the client will follow through with the punch in slow motion. According to Galinis, this technique helps clients get “unstuck” so they can fully process their impulse and the emotions in their body.

Galinis also has clients create a timeline of feelings and actions surrounding an impulsive behavior. For example, she may have clients walk her through what they noticed from the moment they woke up until the moment they impulsively started watching pornography, even though they hadn’t planned to or didn’t want to. As they talk through this event, she will ask what they notice in their body. Is their heart rate elevated? Does their stomach feel swirly?

If clients notice a change in their body, Galinis tells them to hold on to the uncomfortable feeling for a minute rather than immediately trying to get rid of it or run away from it. This process helps clients build up distress tolerance so that when they’re feeling uncomfortable, they are less likely to feel the need to escape and act impulsively, she explains.

Like Galinis, Skinner uses behavioral sequencing to help clients connect their thoughts, feelings and actions. She asks clients: What is the problem? What happened before you acted out? What happened and what were you feeling during the impulsive behavior? What was the outcome? “Through that process, we try to figure out offramps from that one trajectory that they are on,” she says.

Skinner also finds mindfulness useful with impulse-control disorders because it helps clients understand what is happening in the body. She recommends the 5-4-3-2-1 grounding technique, which engages the senses to help clients get back to the present. With this technique, counselors tell clients to take a deep breath and name five things they see, four things they feel, three things they hear, two things they smell and one thing they taste.

Skinner says meditation is one of her favorite tools for addressing impulsivity because it calms the nervous system down, which allows clients to make better choices instead of just reacting.

Galinis keeps tactile sensory objects such as stress balls, stuffed animals and a cozy blanket in the counseling room to make clients feel more comfortable and to help them calm their body down. Sometimes she even lets clients take a calming stone or an essential oil home with them because it serves as a tangible reminder of what they are working toward and aids them in finding that sense of calm they experienced in her office.

Learning control through play

Impulsive behaviors can frequently impede on the rights and safety of others. This means that many clients who enter counseling for impulsivity might not be there of their own accord. In fact, Skinner says that 95% of the time, her child and adolescent clients are seeing her at someone else’s suggestion.

Understanding that these clients may be reluctant participants in counseling, she uses creative counseling techniques such as games and role-playing. Any activity “where kids have to really stop and think about what their body is doing and pay attention to their surroundings is really helpful and fun” for them, she says. Games also help take the focus off of the client and their “problem,” she adds.

Skinner particularly likes to use the therapeutic board game Stop, Relax & Think with clients who struggle with impulse control. The objective of the game is to help impulsive children think before they act. Players move through the Feelings, Stop, Relax and Think stations on the board, collecting chips along the way.

With the feeling cards, clients name how they would feel in different situations. For example, if the card says, “Your brother hits you,” the client might respond, “I would be angry and want to hit him back.” The cards support clients in better understanding not only their own feelings but also the other players’ feelings, which helps them develop perspective taking, Skinner says.

When players land on a stop sign space, they have to perform an action such as patting their head and rubbing their stomach — which, as Skinner points out, requires a lot of concentration — until another player says, “Stop.” If the player stops immediately, then he or she gets a chip.

Skinner loves that clients can judge counselors when landing on this space. Children, especially ones with ODD, often feel powerless, she points out, and this stopping activity allows them to feel empowered in a safe, healthy way. Sometimes Skinner will purposely fail to stop in time. She wants clients to know that she’s not perfect and doesn’t expect them to be either. It also allows her to model appropriate behavior when someone is frustrated or makes a mistake. 

The relax spaces on the board help clients learn how to calm their bodies. The space may instruct them to take three slow breaths, think about white clouds, or say “I am calm” three times. With the think cards, players come up with ways to handle different scenarios (such as a friend breaking their favorite toy) and earn a token if it is a good plan.

Skinner also uses games such as Uno and Parcheesi to help clients learn how to wait their turn and practice impulse control. In addition, she recommends basic childhood games such as Mother May I; Red Light, Green Light; Simon Says; and Follow the Leader. She says counselors can even stage relay races in which children have to walk carefully while balancing a marshmallow on a spoon. These types of games also work well for group counseling sessions, she adds.

Hudspeth, editor of the International Journal of Play Therapy and The Journal of Counselor Preparation and Supervision, agrees that games are a great way to help child and adolescent clients learn to focus and grasp that there is a sequence of events they must follow to get what they want. Take darts, for example. “Just throwing the dart at the wall is not going to get you points,” he says. “Taking time to aim at the place that’s going to get you the most points is more likely to get you to the place of winning the game.” 

When sessions become impulsive

Sometime clients’ impulsive behaviors spill into the counseling session. When this happens, Skinner reminds counselors to be calm, ignore the bad behavior and reward the positive behavior.

When Skinner worked as a clinical intern at an outpatient clinic with youth who experienced trauma, she had clients whose impulsive and aggressive behavior resulted in overturned chairs and tables and smashed lamps in the office. When this happened in group settings, she would get the other kids out of the room and then make sure the child having the impulsive reaction stayed safe. Other than that, she would show no reaction to the outburst and praised the child when he or she calmed down and regained control.

Control is a big part of impulsivity, Hudspeth points out. For this reason, he uses play therapy, which provides clients with a sense of control but allows counselors to set limits and model appropriate behavior in a safe, trusting environment. For example, with children with impulsive behaviors, Hudspeth would tell them they were allowed to do anything in the playroom as long as they didn’t hurt themselves. This statement might not have been one hundred percent true, he says, but it helped the children feel a sense of control. Then, if a child picked up a Nerf gun and shot darts at him, he would respond, “I am not for shooting, and if you choose to shoot me, you choose not to play with that toy.” After setting this limit, he would offer the client an alternative (and more appropriate) behavior such as shooting the wall.

Skinner and Hudspeth both point out that counselors might also have to train parents to use this method at home to help their children make progress with the impulsive behavior. Often, people assume that children understand what is happening during the impulsive moment, so they may yell or remove children from the situation without giving them a reason, Hudspeth says. “By setting the limit and giving them the alternative and then telling them what the consequence is, you’ve spelled it all out,” he explains. “There’s nothing left to wonder about as a child.”

One realization Skinner had was that clients with impulse-control issues, and especially those with ODD and conduct disorder, could trigger her own impulsive and angry reactions. She acknowledges that sometimes it is difficult as a counselor to hear what certain clients are doing to other people or how they are reacting. In fact, she admits once making a snarky comment to an adult client who was rolling his eyes and being defiant throughout a session. Skinner says she instantly felt terrible and knew that her comment wasn’t helpful to the counseling process.

The experience taught Skinner that she has to temper her own impulses and focus on giving clients what they need in session. She says she also learned that she needs to take a moment between sessions to calm down and prepare for the next one. Even if all she has available is 30 seconds, she closes her door, takes a deep breath and centers herself.

It’s quite possible that counselors will face challenging moments with clients who struggle with impulse control. Five years later, Skinner is still working with the client who stormed out of the counseling session determined to walk home, only to turn around and lock her out of her own office. Thankfully, he has come a long way since that first meeting

Challenging sessions still occur in which the client comes in and won’t say a word. Skinner simply responds, “That’s OK. I guess this is going to be a quiet one. Let me know if you want to do anything.” Sometimes, the client will say that he wants to play a game.

“But within that space, he has learned how to control himself a little bit,” she says. “He has learned that he has some control over his life. He has found his voice … and he’s been able to assert himself with adults in a calmer and more appropriate way.”

 

 

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Lindsey Phillips is a contributing writer to Counseling Today and a UX content strategist living in Northern Virginia. Contact her at hello@lindseynphillips.com or through her website at lindseynphillips.com.

Letters to the editor: ct@counseling.org

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Parent-child interaction therapy for ADHD and anxiety disorders

By Donna Mac March 6, 2019

When one hears the term “parent-child interaction therapy” (PCIT), it might be assumed the therapy’s purpose is solely for that specific use — i.e., for parents to use with their children. However, this couldn’t be further from the truth. In fact, PCIT can be used in therapy sessions, then the therapist can teach the child’s teacher how to use PCIT in the school environment and, of course, the therapist can teach parents how to use these skills at home and in community settings, all in an effort to coordinate and synchronize treatment across settings.

Sheila M. Eyberg developed PCIT in the 1970s out of the University of Florida. It was built from multiple theories of child development, including attachment, parenting styles and social learning. In the past, PCIT was intended mostly for children 2 to 7 years old with disruptive emotional disorders and behavior disorders such as attention-deficit/hyperactivity disorder (ADHD) and oppositional defiant disorder. The purpose of PCIT was to work on rapport building and to enhance the relationship between the child and parent, for the child to develop more intrinsic motivation to comply and for the parent to develop more positive feelings toward the child — a cycle that can then be positively repetitive.

In addition to disruptive disorders, PCIT also seems to help children with anxiety disorders. In particular, there is research demonstrating its efficacy with the anxiety disorder of selective mutism. Therefore, clinicians have also begun using it for social anxiety disorder, social phobia, school phobia and agoraphobia. In school and community settings, PCIT is used as an antecedent intervention that helps shape the environment to create an emotionally safe space for these types of anxiety disorders to be more effectively managed. (It should also be noted that PCIT can be used to treat ADHD and anxiety beyond age 7 with simple modifications.)

The goal of this therapy is to produce more prosocial behaviors, regardless of the diagnosis. For example, with anxiety disorders that specifically manifest as a fear of being around people or communicating with others, the goal is for the child to be less inhibited and avoidant. The child’s symptoms might include struggling to leave the home, averting eye contact, displaying a shrinking body posture and having frozen reactions, both in terms of a lack of verbal response and a lack of body movement (think of a “deer in the headlights” appearance). The goal in such cases is to help these children manage their symptoms so they can present in a socially expected manner.

On the other hand, children with ADHD can present as too disinhibited, demonstrating hyperactive, impulsive, incessant and intrusive behaviors, so the goal is to adjust those behaviors to be more inhibited.

Subsequently, the PCIT goal for both of these populations is to produce more desired social behaviors, which will lead to better social outcomes, thus perpetuating the cycle in a positive manner. When children receive positive social feedback, they are likely to keep using these skills in an effort to continue engaging in positive interactions.

Addressing self-esteem

PCIT is a relationship-enhancing therapeutic technique. The concepts from this therapy that I use with children who have either ADHD or avoidant anxiety disorders revolve around Eyberg’s child-directed interaction (CDI) and PRIDE skills. CDI and PRIDE go hand in hand and, when combined, have been shown to build rapport with the other person and build confidence and self-esteem within the child (in an effort to manage both disruptive and anxious-avoidant behaviors). If a child feels comfortable with a certain relationship, that child may feel more valued, worthy and confident and have stronger self-esteem. As a result, the child will be less anxious, better able to manage disruptive impulses and more likely to use expected social skills.

Children with ADHD often struggle with their self-esteem because of the amount of negative feedback they tend to receive on a daily (or more frequent) basis: “Don’t touch everything in this store.” “Stop asking me if we can go to the pool.” “Leave your sister alone.” “Why can’t you just behave?” Yet if a child receives positive feedback versus corrective feedback in an approximate ratio of 4-to-1, the child will be more likely to comply with the directive to “stop asking that question,” to “leave your sister alone,” etc.

Children with the avoidant types of anxiety disorders also struggle with self-esteem because of the negative judgments they assume and perceive that others are making about them. When these children receive praise, it helps them feel less anxious. In turn, when their brains are stabilized, they are more able to use their actual abstract counseling strategies (such as cognitive behavior therapy, or CBT) on themselves to manage their anxiety and actually “leave the house,” “maintain eye contact,” “use complete sentences” (rather than one-word answers), etc.

In therapy, PCIT can be used as a stand-alone treatment, but I recommend combining it with other therapeutic treatments such as operant conditioning, exposure therapy and CBT. Of course, the use of CBT will depend on the age of the child and whether his or her brain is developed enough to process abstract counseling strategies. Children don’t usually possess this ability until age 7 or 8. It should be noted that use of these treatment techniques (alone or in combination) does not guarantee success or an absence of symptoms.

Implementing PCIT with CDI and PRIDE

Some professionals refer to CDI as “child chooses.” Regardless of the terminology, during this portion of PCIT, no directives are to be given to the child and no questions are to be asked until CDI has been used for at least three minutes. This allows the child to feel positive about himself or herself because nobody is giving directions to correct something that the child was “doing wrong” upon entering a room or during a new transition.

When children feel positively about themselves, they are more likely to comply later down the line. Therefore, it should be noted that CDI is not a time to criticize. CDI means that the child will choose something to do without any adult direction. The adult (whether that is the counselor, the parent or the teacher) is to observe what the child does and give the child physical space if the adult’s presence seems to agitate or increase anxiety in the child. After at least three minutes of CDI, the adult uses PRIDE skills (verbal interaction from the adult) when the child seems more emotionally regulated. PRIDE is an acronym that directs the adult to offer the child labeled praise, reflection, imitation, description and excitement/enjoyment (in the adult’s voice).

As a real-life example, let’s say that “Alison” is in homeroom at school first thing in the morning. At the therapeutic school in which I work, this is where the students meet in the mornings to get any homework lists, eat healthy food, use coping skills, check in with their teachers and therapists, and practice socializing with peers appropriately. CDI is used immediately upon students’ arrival.

In this case, Alison puts her backpack on the floor upon entering the room, then goes to sit at her desk (her backpack is not where it is supposed to be, plus it is open, with its contents falling out). When Alison enters the classroom for the first time, it is time for CDI, so the teacher is not to direct her to move the backpack, at least for a few more minutes. (If your first interaction involved someone telling you to correct something, think about how you would feel.)

At her desk, Alison eats an apple, and then a peer asks Alison for a piece of paper. Alison silently gives her peer the paper, without offering any eye contact, and then gets up to throw away the apple she just finished eating. She then remembers to get her assignment notebook out of her desk. Even though Alison’s backpack is open on the floor with papers, food and more disorganized contents spilling out, the teacher doesn’t direct her to do anything until after offering Alison the full array of PRIDE skills:

  • Praise: Praise appropriate behavior. This should be specific labeled praise about what is positive. In this case, it could be any number of things: “Alison, thanks for sharing your paper with Sarah. You are so helpful” or “Thanks for throwing away that apple in the garbage. You are very responsible” or “You remembered to get out your assignment notebook. You have a great memory!” This labeled praise includes helpers to build confidence in Alison related to both her IQ and her EQ (emotional intelligence), therefore lessening her anxiety and helping her manage her impulsivity.
  • Reflect: Reflect appropriate talk. This means the adult reflects back what the child says to them. For example, when Alison is done with her assignment notebook, she asks the teacher, “When is the fire drill?” The teacher is to reflect the main concept of the question. In this case, the teacher might say, “I am glad you want to know when the fire drill is so you can be prepared. That is very responsible of you. It is at 9.” Reflection is key to letting children know you are really listening to them. And if someone is listening to them, then they feel valued, understood, worthy and accepted, lessening their anxiety and raising their self-esteem. In this case, the teacher also offered more labeled praise about Alison being prepared and responsible.
  • Imitate: Imitate appropriate social behaviors. If Alison takes out paper and colored pencils to draw as a “quiet coping” skill during the appropriate time, the teacher takes note of how to imitate this same concept down the line. “Your drawing just reminded me of something, Alison. When all of the homeroom students have arrived, we can all play that drawing game we played a few weeks ago. Would you be willing to lead the game since you really understood it last time and are such a talented artist?” This lets Alison perceive that she is worthy because she was doing something that the teacher also wants to do (artwork). This serves to lessen Alison’s anxiety. It also helps her realize that she can in fact be a leader herself, increasing her self-confidence.
  • Describe: This is the time to give behavioral descriptions. Simply describe what the child is doing, which shows the child that someone is both attending to them and giving approval of their actions. This serves to increase the child’s confidence and decrease anxiety. For example, the teacher might tell Alison, “You’re drawing a sports car with a mountain in the distance. That looks fast and powerful yet peaceful at the same time. That’s pretty impressive and creative that you’re able to capture all of that in one picture.” This description also includes more labeled praise pointing out that Alison is creative.
  • Excitement/enjoyment: Demonstrate excitement in your voice, which is key to attending skills. This strengthens the relationship with the child and allows the child to experience many positive feelings. This also increases the chances the child will comply when you give a corrective direction.

It should be noted that some people with anxiety fear receiving positive praise in front of other people. If this is the case, adjustments can be made to the treatment technique.

In Alison’s case, all of the PRIDE letters were used, and she received even more than the allotted three minutes of CDI time. Alison’s CDI time included getting to choose to eat her apple, asking her fire drill question and taking out paper to draw a picture. Once CDI and PRIDE have been used, the teacher can move to adult-directed interaction, in which the teacher can finally:

  • Ask questions: “Alison, do you have your math assignment from last night?”
  • Direct some peer interaction (such as getting the students together for the drawing game referenced earlier).
  • Give instructions (such as addressing that backpack issue): “Alison, it would help us out if you could close your backpack and put it in your locker. I would hate for anything of yours to get lost or for someone to get hurt tripping on it.” When Alison complies with that direction, the teacher can follow up with more labeled praise: “Thanks for following directions.” One caveat: Never say, “Thanks for listening.” There is a big difference between someone “listening” and someone “following directions.”

Other considerations

The CDI/PRIDE skills/adult-directed interaction combination should be used in the child’s home continuously, at play dates in others’ homes, at school and community activities and, of course, in the therapy office. PRIDE continues to be a way of communication, so it doesn’t stop when the conversation gets going.

In the therapy office, once emotional regulation has been established with the combination of CDI/PRIDE/adult-directed interaction, the counselor can move to reminding the child of the operant conditioning plan, then work on CBT skills or exposure skills to continue building strategies to manage impulsivity or anxiety.

If children’s ADHD symptoms are impairing their social and educational functioning with significant intensity, frequency and chronicity, it is also likely that a psychiatrist will prescribe a stimulant medication. ADHD is a genetically based, neurobiological disorder that affects many parts of the brain. Medication can touch parts of this, especially when it comes to dopamine and norepinephrine disruptions, but it can’t adjust everything. Even for the parts of the brain that can be medicated, medication doesn’t guarantee an absence of symptoms. That is why it is crucial to continue using therapeutic techniques as antecedent management and counseling strategies to help children function in their different environments.

In terms of anxiety, for those suffering impairment in their social and educational settings on an intense, frequent and chronic level, the first line of medication will likely be a selective serotonin reuptake inhibitor (SSRI). This is because the main area of the brain affected is serotonin (in addition to anxiety affecting norepinephrine, glutamate and the limbic system structures of the hippocampus, hypothalamus and amygdala). Again, however, an SSRI will not guarantee an absence of symptoms, which is why therapeutic techniques, exposures and counseling strategies remain key.

 

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For more examples of how the attending skills of CDI, PRIDE and others related to PCIT can be used in school settings, home situations and community/recreation settings, please reference my two books: Toddlers & ADHD and Suffering in Silence: Breaking Through Selective Mutism.

 

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Donna Mac is a licensed clinical professional counselor in her 12th year working for AMITA Health in one of its therapeutic day school locations. Previously, she was a teacher in both regular and special education settings. She has three daughters, including identical 9-year-old twins diagnosed with ADHD hyperactive/impulsive presentation and selective mutism anxiety. Contact her at donnamac0211@gmail.com or through her websites: toddlersandadhd.com and breakingthroughselectivemutism.com.

 

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Counseling Today reviews unsolicited articles written by American Counseling Association members. To access writing guidelines and tips for having an article accepted for publication, go to ct.counseling.org/feedback.

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Working memory: A review for children’s mental health providers

By Jerrod Brown and Tracy Packiam Alloway October 1, 2018

Working memory is an essential cognitive skill that allows an individual to learn through the processing and manipulation of information. In other words, working memory is the process through which information is manipulated and then linked to other existing memories.

A wealth of research has investigated the capacity of working memory in children. Working memory is different from short-term memory, which simply stores pieces of information for a limited period of time. Working memory allows an individual to maintain information for use in intricate tasks such as higher-order thought, organization and planning, and language comprehension. Working memory also enables children to perform several important functions, including learning new information, comparing and contrasting different concepts, and making informed decisions.

Working memory is composed of three important tasks:

1) Maintaining new pieces of information for subsequent use

2) Filtering out information that is not relevant to the task at hand

3) Manipulating the relevant information to perform the given task (e.g., navigating to a destination)

Working memory capacity is dependent upon a number of abilities, including attention, behavioral control and cognitive flexibility. Attention is an individual’s ability to focus on a given task while blocking out distractions and other irrelevant information. Behavioral control is the ability to manage one’s impulses and emotions. Cognitive flexibility is the capacity to adapt to feedback and evolving needs.

Children affected by working memory deficits may experience a host of academic, behavioral and emotional issues. The deleterious impact of working memory deficits on academic achievement is apparent in students, from those entering preschool to young adults in college. These impairments may be even more pronounced among children who are affected by various problems related to mental health.

Deficits associated with working memory can negatively impact how a child navigates all areas of life, from academic performance to social interactions. As such, children’s mental health professionals should become familiar with working memory deficits and their impact on day-to-day functioning. Increased awareness and understanding of these problems will help professionals maximize the effectiveness of services provided to these children.

To that end, this article reviews multiple considerations related to working memory that all children’s mental health clinicians need to know.

 

Academic performance: In children, working memory has been linked to everything from academic performance to the symptoms of neurological, developmental and psychological disorders. Working memory is also important from kindergarten to the tertiary level, and is an excellent predictor of academic success, longitudinally.

Assessment: Working memory can be assessed in a reliable and valid manner in children as young as 3. Early identification of working memory deficits that are supported by appropriate interventions can lead to positive outcomes throughout the individual’s life span. A study of more than 3,000 students found that approximately 10 percent had working memory problems that led to learning difficulties in the classroom (see ncbi.nlm.nih.gov/pubmed/19467014). As such, early identification and intervention are key to long-term success.

Attention, behavioral and social problems: Several theories of cognitive processing posit that working memory plays an essential function in attention. In addition, deficits associated with working memory can sometimes contribute to problematic behaviors resulting in school-related and social consequences. This is especially the case when the child has not been properly assessed, treated and supported. One of the most consistent findings in research studies is that students with attention-deficit/hyperactivity disorder have poor working memory, particularly when they have to remember visual information, such as graphs or images.

Classroom difficulties: Working memory impairments often contribute to difficulties in the classroom. For example, students with working memory impairments may have trouble remembering instructions, completing complicated tasks, and comprehending and abiding by directions to solving a math problem or writing a sentence.

Creativity: Although relatively few studies have investigated the role of working memory in creativity, Larry Vandervert and colleagues have posited that working memory is one of the building blocks of creativity (see tandfonline.com/doi/abs/10.1080/10400410709336873). Their rationale hinges on the assumption that working memory serves as the “blackboard of the mind,” enabling an individual to manipulate and combine a variety of pieces of information and ideas in different ways. A study with college students reported that working memory was associated with one particular aspect of creativity — flexibility, which relates to breadth of thinking.

Environmental considerations: An important consideration for children with working memory deficits is limiting their exposure to environments and influences that could exacerbate such issues. These issues may include exposure to caregivers who abuse substances, neglect and maltreatment, and environments filled with chaos and chronic stress.

Importance of early identification: Working memory deficits in preschool may predict the likelihood of dropping out of high school. However, some research offers hope for the development of early interventions that strengthen working memory and the reduction of risk for dropping out of high school.

Information overload: Deficits in working memory can result in children experiencing information overload during learning-based activities. As a result, these children may act out behaviorally or withdraw socially. When misidentified or undertreated, these issues can negatively affect children’s emotional and behavioral health.

Intervention: Interventions that improve working memory hold the potential to positively benefit children’s classroom performance across a range of subjects (see ncbi.nlm.nih.gov/pubmed/20018296). These gains were maintained eight months later (see sciencedirect.com/science/article/pii/S0747563212003032). As such, children’s mental health providers play a vital role in the identification and treatment of working memory deficits.

Learning performance: Problems meeting the learning requirements of school may be attributed to deficits in working memory. Working memory predicts reading and math performance among students with learning disabilities. These associations remain even when controlling for the student’s intelligence and knowledge of language and math. These issues can persist across the child’s life span when such deficits have not been identified, treated and supported.

Learning styles: A prevalent argument in the education research community is that learning styles have a significant influence on how well students will do in school. The learning styles theory argues that individuals learn best in different ways. A popular framework for learning styles is one that separates Verbalizers from Visualizers, and Holistic thinkers from Analytical ones. A study with high schoolers found that students with good working memory excelled at all subjects, regardless of their learning style preference. One explanation is that although students may have a certain preference for acquiring knowledge, those with good working memory won’t be held back if information is not presented in their preferred learning style because they can adapt their learning style to different learning situations.

Note taking: The inability to remember several manageable pieces of information while performing another task such as taking notes on a lecture is an example of a working memory deficit. This can present challenges in group treatment settings in which participants are required to take notes while listening to a live lecture.

Problem-solving: Enhanced working memory capacity can result in improvements in the ability to learn and to solve problems. When working memory is impaired, decision-making and problem-solving abilities can be negatively affected. Treatment providers should consider screening clients for working memory impairments when decision-making and problem-solving abilities are impaired.

Theory of Mind: Theory of Mind (ToM) is the skill to appreciate that the conduct of others is motivated by their opinions, wishes and other mental states. The maturation of ToM has been linked to the cognitive development of both behavioral control and working memory. Working memory has also been linked to false belief and verbal deception in 6- and 7-year-olds.

Thought suppression: Research suggests that working memory could play an important role in the suppression of unwanted or obsessive thoughts. As such, helping children strengthen their working memory capacity should be considered when providing supports and services to individuals struggling to cope with such thoughts.

Trauma: Working memory deficits have been observed in individuals suffering from posttraumatic stress disorder (PTSD). In particular, common PTSD symptoms such as hypervigilance, reliving trauma memories and avoidance of reminders of trauma may interfere with working memory processes.

Underidentification: Despite the previously mentioned consequences, working memory deficits often go unrecognized and untreated in children’s mental health settings. In some instances, professionals may misinterpret working memory impairments as issues with behavior, impulse control and attention. In a survey of classroom teachers, most knew what working memory was but were able to correctly identify only one or two classroom behaviors associated with working memory deficits.

Understand: Professionals should strive to understand the potential consequences associated with working memory deficits in children. Exploration of how working memory deficits may affect academic, emotional, social and interpersonal capacities is of significant importance. Children’s mental health treatment providers should consider incorporating working memory screening and intervention strategies into their clinical programming.

 

Conclusion

Deficits associated with working memory can have profound and diverse impacts on children. Mental health providers are likely to encounter children on a regular basis who are affected by working memory deficits. To minimize the consequences of working memory deficits, clinicians should become more familiar with the implications these problems have on screening and assessment, treatment and educational outcomes, and social functioning abilities. We highly recommend advanced training in working memory for professionals who provide children’s mental health services.

 

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Jerrod Brown is an assistant professor and director of the master’s degree program in human services with an emphasis in forensic behavioral health at Concordia University in Minnesota. He has also been employed with Pathways Counseling Center in St. Paul for the past 15 years. He is the founder and CEO of the American Institute for the Advancement of Forensic Studies and editor-in-chief of Forensic Scholars Today and the Journal of Special Populations. For a complete list of references used in this article, contact him at Jerrod01234Brown@live.com.

 

Tracy Packiam Alloway is a TEDx speaker and an award-winning psychologist. Her research has contributed to scientific understanding of working memory, specifically in relation to education and learning needs. Her research has been featured on or by Good Morning America, Today, Forbes, Bloomberg, The Washington Post, Newsweek and others.

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Understanding adult ADHD

By Donna Mac November 20, 2017

Many people ask, “Isn’t ADHD something that kids grow out of?” When people think of attention-deficit/hyperactivity disorder (ADHD), they usually picture a child “bouncing off the walls” and then being unable to follow directions to stop that behavior.

In mainstream society, we don’t see adults bouncing off the walls, so it makes sense that people wonder if ADHD is something that is “grown out of.” In addition, ADHD usually isn’t diagnosed for the very first time during adulthood. Because the onset of ADHD typically is prior to age 4, it is usually first diagnosed in childhood. Therefore, people don’t tend to think of ADHD as an “adult condition.” Rather, they might assume that it’s isolated as a childhood condition.

It is important to remember that ADHD is actually a genetic condition. It affects the brain’s neurotransmitter system of dopamine and norepinephrine, brain waves and connections, and the actual structure of the brain, specifically the frontal lobe and prefrontal cortex, cerebral volume, caudate nucleus and gray matter/white matter. In addition, certain environmental factors can further exacerbate a person’s symptomology. Regardless, ADHD is actually a “brain condition,” which means that it can also affect adults.

Going back to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, there was a chapter that included mental health diagnoses that were all first diagnosed in “infancy, childhood or adolescence.” ADHD was one of the diagnoses included in that chapter. Therefore, some people figured those disorders were not likely found in adults. However, the chapter’s title didn’t specify that those disorders weren’t found in adults; rather, it indicated that they were typically first noticed in childhood.

When the fifth edition of the DSM (DSM-5) was written, the task force offered more clarification for those disorders, so that the entire chapter was actually eliminated and the diagnoses in that chapter displaced. Due to the revision, ADHD was moved to the new “Neurodevelopmental Disorders” chapter, to more accurately reflect that the disorder is related to the biology of the brain.

In writing the DSM-5’s revisions for ADHD, there was also a symptom threshold change for the adult qualifiers. The purpose of the change was to reflect the substantial evidence of clinically significant ADHD impairment in adults within social, occupational and educational settings, in addition to difficulties with maintaining daily living responsibilities. To qualify for an ADHD diagnosis according to the DSM-5, an adult needs to meet only five symptoms, instead of the six required for children, in either of the two presentations (hyperactive/impulsive and inattentive/disorganized).

 

Growing out of ADHD?

At this point, it has been well-established that adults can have ADHD, so the question now becomes: Is it possible for a child with ADHD to experience symptom reduction (or elimination) as he or she transitions to adulthood? The answer is tertiary: yes, no and sometimes!

As children with ADHD grow into adolescence, research does show that up to two-thirds will experience a noticeable reduction in motoric restlessness or hyperactivity. Because of the manner in which the brain develops during this period, there can be an opportunity for rewiring in which the neurons proliferate and then are pruned back to complete the development of the frontal lobes.

With this particular symptomology of hyperactivity and motoric restlessness being reduced or eliminated, however, it is still possible that the person’s other ADHD symptoms may remain. The remaining symptoms are likely the ADHD core symptoms of impulsivity, impaired attention and lack of intrinsic motivation. Research shows that these symptoms will likely continue to some degree — possibly still to a clinically significant degree — but they might also be less impairing than they were for the person during childhood.

So, to answer the question of whether adults can experience ADHD symptom reduction or elimination, here is a recap:

  • Some symptoms in adults will dissipate completely.
  • Some symptoms will lessen.
  • Some symptoms will remain the same.
  • Some symptoms will change by being expressed differently than they were in childhood.
  • Sometimes, the symptoms will remain, but they will appear less impairing because the adult has developed strategies to manage the symptoms.

As we examine how adult ADHD symptoms can be expressed, think about ADHD as a brain disorder stemming from an inability to self-regulate and executive functioning deficits. These functions allow us to plan, change flexibly from one course of action to another, inhibit actions (impulse control) and modulate affect. Executive functioning also includes organizational skills, emotional control, working memory and short-term memory, time estimation and time management, focus and attention, problem-solving, verbal reasoning, intrinsic motivation, task initiation and shifting gears. If a deficit is present in any of these areas, think about how much more difficult an already stressful job would be, in addition to how one might struggle with maintaining relationships, raising a family, completing daily living responsibilities and remaining connected in the community.

 

Childhood vs. adulthood scenarios

With all of the possible ADHD deficits stemming from its different presentations and with different degrees of impairment, these symptoms can be expressed in adults in a variety of ways. The scenarios below showcase how ADHD symptoms might remain similar in adulthood as in childhood, or how the symptoms’ expressions can also change over time.

  • Think about a child with ADHD constantly getting out of her seat at school. That can be the same adult tapping her pen or shaking her leg at her desk at work.
  • Think about a child with ADHD constantly talking to her “neighbor” in school while the teacher is talking. That might be the same adult unintentionally getting her co-workers off-task during a meeting.
  • Think about a child with ADHD impulsively pulling a toy out of another kid’s hand, struggling to take turns and share. That sounds like the same adult struggling to “take turns” while he is talking and expressing ideas with his co-workers.
  • Think about a child with ADHD refusing to shut off her video game. That might be the same adult finding it difficult to get off of her social media accounts.
  • Think about a child with ADHD unwilling to compromise with friends, always wanting his own way instead. That sounds like the same adult insisting his wife watch “his show” or listen to “his radio station.”
  • Think about a child with ADHD carelessly rushing through her trumpet scales (a dreaded, nonpreferred task) in an attempt to get to the preferred part of her trumpet practice sooner, which is playing the actual song. That could be the same adult at work, carelessly rushing through writing a report, to more quickly get to the things she actually enjoys doing at her job.
  • Think about a child with ADHD always trying to get away with doing less at school (maybe by not “showing” his required math work). That might be the same adult also trying to get away with doing less at his job.
  • Think about a child with ADHD being dragged out of bed and taking “forever” to get dressed, eat breakfast and groom herself. That may be the same adult constantly being late for work or other appointments.
  • Think about the bedroom of a child with ADHD looking like a tornado hit it. That could be the same adult whose wife is nagging him because his dirty laundry is all over the bedroom floor, or whose boss is upset with him because he presents poorly at work with a disorganized, messy desk.
  • Think about a child with ADHD incessantly begging her parents for something to obtain immediate gratification for herself: “Take me to the pool. Take me to the pool! Puh-Lease!” That sounds like the same adult refusing to take “no” for an answer in other social relationships.
  • Think about a child with ADHD disregarding minor details with his schoolwork. That could be the same adult overlooking “minor details” in other areas of life, such as neglecting to wear his identification badge at work, forgetting to check the “change oil on this date” sticker in his car or, worse, forgetting to check the gas tank.
  • Think about a child with ADHD struggling to get started with her chores at home. That can be the same adult struggling to initiate, sustain or complete daily living responsibilities at home. For example, she may buy groceries, get them home and put the items away in the kitchen. However, the items needing to be placed elsewhere in the house (shampoo, body wash, etc.) remain in the grocery bags on the kitchen counter. After her husband nags her for a day to put the rest of the items away, she eventually moves the grocery bags upstairs to the bathroom and places the bags on the bathroom counter. After her husband nags her another day, she eventually takes the items out of the bag and puts them under the bathroom cabinet.
  • Think about a child with ADHD climbing the drapes in a banquet hall at a wedding. That could be the same adult craving a dopamine rush as she is darting in and out of traffic at high rates of speed. Remember, when it comes to dopamine, people with ADHD either don’t produce enough, retain enough or transport it efficiently. Dopamine is a “feel good” neurotransmitter (in addition to being the main “focus” neurotransmitter), so when individuals are recklessly impulsive, they are likely feeling understimulated and attempting to stimulate their dopamine level to “feel good.”

However, people with ADHD can be notoriously impatient. In the driving scenario above, it may not be about stimulation; it might be about her impatience. In a third scenario, this person could also be darting in and out of traffic because she is late for something because people with ADHD can also be notoriously late.

  • Think about a child with ADHD hyperfocusing on something — likely a preferred activity that seems irrelevant to others. Many times, this is because of norepinephrine. We require this neurotransmitter to help us pay attention to things that are either boring or challenging. When this neurotransmitter is not produced enough, retained enough or transported efficiently, as in people with ADHD, it can be a struggle to pay attention in boring and challenging situations. However, when people with ADHD really enjoy something, norepinephrine can actually be stimulated, and then they can hyperfocus.

Now think of the adult hyperfocusing at home on something that appears irrelevant. This person also then has a propensity toward becoming overwhelmed with all of the other dreaded, nonpreferred tasks on her “list of things to do.” She may use the hyperfocus ability with something that she enjoys as a misguided coping strategy to avoid the nonpreferred tasks. This further perpetuates her feelings of being overwhelmed with everything that she’s supposed to be doing and not getting accomplished.

  • Think about a child with ADHD struggling to pay attention to his teacher. That sounds like the same adult struggling to remain focused as he and his wife have a conversation at the dinner table. Then, the next morning, when he doesn’t get out of bed when he’s supposed to, she wonders why he didn’t get up early to take the dog to the vet. It’s possible that he wasn’t focusing on their conversation the previous night, so he didn’t actually know he was responsible for this. Or, he did know, but he struggled with time management. Or, he struggled with intrinsic motivation to get out of bed to get things accomplished for the day. Or, he was paying attention to the conversation, remembered it and was actually motivated to take the dog to the vet, but he forgot to set his alarm clock.

With this type of situation, it can be unclear why he didn’t get up that morning because it could have been from any number of ADHD symptoms — or a combination of some of them.

 

Other experiences

According to the Centers for Disease Control and Prevention, people with ADHD also experience other situations that I didn’t necessarily address specifically in the scenarios above. People with ADHD can experience:

  • More unplanned pregnancies and sexually transmitted diseases
  • Higher arrest rates and propensity for repeating offenses
  • More aggressive behavior (This does not mean that all adults with ADHD are aggressive. In fact, most are not. But the rates of aggression among those with ADHD are higher when compared with those in the general population.)
  • More speeding tickets
  • More shoplifting convictions
  • More money management issues, impulsive spending habits and credit card debt
  • More substance abuse (higher in unmedicated ADHD patients than in the general population)
  • More risk-taking behaviors
  • Higher rates of smoking (in unmedicated ADHD patients)
  • Higher rates of depression (especially among males) and anxiety
  • Comorbid diagnoses (more than half of those with ADHD have a dual diagnosis)
  • Low self-esteem due to perceived failures at school or work and due to struggles in relationships

In looking at all of the different issues and scenarios related to ADHD and presented in this article, it is important to note that all adults will be late to an appointment once in awhile, lose something important, become overwhelmed with their “list of things to do,” interrupt during a conversation or even get a speeding ticket. These situations are all within normal limits as human beings. It becomes clinically significant only when a variety of these instances occur chronically and intensely and also interfere with the person’s functioning.

Adults with noticeable ADHD symptoms can sometimes manage these symptoms. This can be done in a number of ways:

  • An ADHD medication regimen
  • Psychotherapy to learn strategies to self-regulate
  • Neurofeedback to help strengthen connections in the brain
  • Holistic practices of consuming nutrients that promote proper brain functioning, including zinc, vitamin C, omega 3 fatty acids and protein
  • Exercise to increase blood flow in the brain, specifically in the neocortex where it’s needed to increase focus and decrease impulsivity

A combination of treatment modalities may be most effective so that adults with ADHD can continue to function well in their respective environments.

Because of the multifaceted origin of this disorder and the external variables each person experiences, ADHD symptoms can come across differently, so each person with ADHD (child or adult) will not present the same, even among the same presentation. Some individuals will have overtly noticeable symptoms. In the case of other individuals, outsiders may not even notice their symptomology, especially if they have learned to cope with their ADHD and self-regulate.

 

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Donna Mac is a licensed clinical professional counselor treating adolescents in psychotherapy who are transitioning to adulthood. She is also the author of the book Toddlers & ADHD, which can actually be applied across the life span. Find out more via her website, toddlersandadhd.com or email donnamac0211@gmail.com.

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.