The ADHD Algorithm Part 3: The Encircling Nuances

Over the last month, I have written about Attention Deficit/Hyperactivity Disorder (ADHD) to pursue a greater personal knowledge of the subject and offer insights to the Center for Family Transformation’s readers. In the first post, I laid out a general landscape of ADHD, notably its definition, symptoms, statistics, and myths. Two weeks later, I discussed an internal chain reaction (which I called an algorithm) defining what often drives those with ADHD to unhealthy coping mechanisms like rage, avoidance, addiction, and more. In that second post, I offered thoughts around mechanisms, which I denoted as off ramps, to stop the chain reaction. Some of those mechanisms were psychotropic medication, behavioral intervention, emotional regulation, and parenting foundations. This brings us to our third and final installment of The ADHD Algorithm, which I am calling The Encircling Nuances.

Nuances are defined as subtleties within a topical field. The segments of this post will develop details on three subtle areas within the ADHD experience which I heard about tangentially. I feel these subtleties merit more discussion based on the impact they observably have on my clients. The first topic is how marriage is impacted with a partner who has untreated ADHD. Notably, there are entire books on this, so I will merely open conversation and supply direction for further research. The second topic I will journey into is around co-occurring diagnoses, like ADHD and conduct disorders, addiction, mood disorders, PTSD, etc. On this note, I explore a non-clinical, ADHD-related phenomenon called Rejection Sensitivity Dysphoria (RSD). Rejection is magnified for my clients with ADHD. I will explore why. The third topic is around ADHD stigmas, from under/over-diagnosing ADHD in certain populations to under/over-treating this disorder. It is a professional goal of mine to make mental health treatment fair, objective, and accessible to all who need it.

Nuance #1: ADHD in marriage

Let’s start with ADHD in marriage. Readers will notice me quoting Dr. Tiffany Brown-Bush often, as I interviewed her for this post. She is a doctor of natural medicine and an integrative mental health therapist in Cornelius, North Carolina. She is also a friend, colleague, referral source for the CFT, and local expert on Attention-Deficit/Hyperactivity Disorder. In the interview, she told me she became an ADHD specialist almost by accident. Shortly after she got married to her partner, they realized her husband’s mind worked differently than hers. They came to find he was neurodivergent with ADHD (1). Much of Dr. Brown-Bush’s current vision, which is to “end the stigma and hopefully, as holistically as possible, really care for the sensitive ADHD brain,” developed out of her own growth experiences in marriage. Dr. Brown-Bush described some tips she wants every spouse to know if they have a neurodivergent partner (with ADHD as one type of possible neurodivergence). She said, “you don’t get to apply neurotypical values and rules and judgement to your spouse. The rule book for how you think your relationship should go [changes]…you have to throw preconceived notions out the window.”

The next question that I imagine pops into a reader’s mind is: what are neurodivergent values and rules and judgements? Essentially, she’s referencing reconsidering expectations. Dr. Brown-Bush encourages something called radical acceptance, which is an Acceptance and Commitment Therapeutic term. When a person radically accepts a situation, his or her thoughts shift from what he or she thinks life should be in that moment (i.e., expectations) to what they are (2). Dr. Brown-Bush acknowledges that when someone is more accepting and less judgmental, that person can approach relationships and challenges with more openness and grace. Next, Dr. Brown-Bush inspires these spouses to investigate their individual thought processes toward their partner’s ADHD; this certainly impacts the marital interactions! Then, the couple can begin to learn tools that offer improved self-regulatory responses, communication skills, and interpersonal experiences. Dr. Brown-Bush is one among many therapists and clients who recommend the book The ADHD Effect on Marriage: Understand and Rebuild Your Relationship in Six Steps by Melissa Orlov to me. According to their suggestions, this resource is a treasure trove for the couple attempting to restore a mutual connection (and get out of the co-dependent, parent-child relationship that can occur in couples with ADHD). My encouragement is for partners to read this book together and talk about it with other couples who have ADHD. If things get painful before they get better, check out Ms. Orlov’s blog post on 9 Tips for When Non-ADHD Spouses Just Can’t Cope Anymore (3).

Nuance #2: co-occurring disorders

The next nuance for discussion is how co-occurring disorders manifest within the ADHD experience, from conduct disorders (typically in childhood) to addiction, mood disorders, PTSD, and more. In fact, as described by Dr. Theresa Cerulli (4), having ADHD plus another psychological disorder is the norm versus the exception. She cites a 2017 study by Katzman et al. outlining that 80% of adults and 60% of children have at least one additional diagnosis (5). This matches precisely with my experience as a clinician and confirms why many of my clients come to me with a more prominent issue, then they subsequently indicate they have ADHD. Dr. Cerulli indicates in her same article that this is currently referred to as Complex ADHD. What might a reader take away from this? As with most comorbid diagnoses, it is best practice to treat each diagnosis at the same time. Said another way, if a person has a mood disorder (like anxiety and depression) alongside untreated ADHD, and only one disorder is acknowledged and treated, it will be difficult for that person to find wellness.  I have personally seen this in my work. After treating clients for months managing only the mood disorder, it was not until we noticed and treated unmanaged ADHD that we started seeing results.

That leads me to consider Rejection Sensitivity Dysphoria (RSD). I first heard about RSD from a client who was overcoming addiction, mood disorders, and life transition all while improving his approach to ADHD. He commented on RSD as a part of his anxiety and depression that really troubled him. According to William Dodson (6), RSD “can mean extreme emotional sensitivity and pain” triggered by the feeling of rejection or falling short of one’s own expectations. Because ADHD and RSD are neurological versus psychological, this can literally mean that emotional pain is felt more physically and severely than in non-ADHD individuals. Check out this blog post by ADDitude Magazine with how RSD feels to individuals with ADHD…like punches, knives, or daggers (7). It was eye-opening for me as a psychotherapist, remembering my client’s resultant social anxiety and people-pleasing at the cost of avoiding RSD. Conclusively, there are two things I want readers to hear on this topic. First, Dodson (6) outlines that almost everyone with ADHD experiences RSD at some level, so you are not alone. Second, there are some ways to reduce its effects. Dr. Brown-Bush notes she helps her clients do this using brain education, body soothing, mental grounding, natural supplementation, and more. Also, spouses can help their ADHD partner calm down (i.e., using co-regulation) when individuals with ADHD are emotionally aroused during RSD.

Nuance #3: stigmas associated with ADHD

Onto the last nuance: the stigmas associated with ADHD, particularly surrounding how ADHD is diagnosed and treated in minority populations. “ADHD is misunderstood by many people, but within the BIPOC (Black, Indigenous, and People of Color) community, it has been a slower arrival to understanding trauma, mental health, and brain health,” said Dr. Brown-Bush as she reflected on her own experience. “What we’ve been taught during childhood is that children who cannot focus are bad [and it’s their behavior that is the problem]. That’s changing, and it’s beautiful.” Dr. Brown-Bush encourages her clients to invest in understanding ADHD as a brain function versus behavioral problem, intellectual disability, or parenting inadequacy. ADHD does not fit criteria for any of the latter. Particularly with ADHD, parents and teachers are starting to screen their children for this condition instead of denying it or using it as an excuse, reducing unruly behavior to being solved with a pill. She noted considering natural remedies and behavioral tactics, waiting to get on amphetamine medications until after age 18 if at all. This gives the brain “more time to myelinate instead of developing around the amphetamine.” She referenced her education through The Amen Clinic via Dr. Daniel Amen as influential in her thinking. Finally, on this topic, I came across Evelyn Polk Green’s blog post entitled We Need to Talk about ADHD Stigma in BIPOC Communities (8). It is powerful. Ms. Green elaborates on a similar experience to Dr. Brown-Bush where ADHD children of color and their parents live through a blaming-the-victim situation. I highly encourage reading Ms. Green’s post. My hope is that it compels readers to determine how they can play a role in reducing the stigma she discusses.

Conclusion

This final blog post culminated my initial journey, as I am sure there will be many more, around better understanding ADHD. I only scratched the surface. Thank you for coming along on this educational ride. Don’t stop learning! As you do, reach out to us at the Center for Family Transformation by commenting on our blog posts or emailing me directly with stories about how you are helping those with ADHD live their best lives.

References

1. Wiginton, K., & Bhandari, S. (2021, April 7). What is neurodiversity? [Blog post]. WebMD.com. Retrieved from https://www.webmd.com/add-adhd/features/what-is-neurodiversity
2. Robbins, S. (2020, April 5). The flexible mind – part 1 [Blog post]. Familytransformation.com. Retrieved from https://www.familytransformation.com/2020/04/05/the-flexible-mind-part-1/
3. Orlov, M. (2012, January 4). 9 tips for when non-ADHD spouses just can’t cope anymore [Blog post]. ADHDMarriage.com. Retrieved https://www.adhdmarriage.com/content/9-tips-when-non-adhd-spouses-just-can-t-cope-anymore
4. Cerulli, T. (2021, September 16). What is Complex ADHD? Symptoms, diagnosis, & treatment [Blog post]. ADDitudeMagazine.com. Retrieved from https://www.additudemag.com/complex-adhd-symptoms-diagnosis-treatment/#footnote1
5. Katzman, M. A., Bilkey, T. S., Chokka, P. R., Fallu, A., & Klassen, L. J. (2017). Adult ADHD and comorbid disorders: clinical implications of a dimensional approach. BMC Psychiatry, 17(1), 302. https://doi.org/10.1186/s12888-017-1463-3
6. Dodson, W., & Saline, S. (2021, August 24). How ADHD ignites Rejection Sensitivity Dysphoria [Blog post]. ADDitudeMagazine.com. Retrieved from https://www.additudemag.com/rejection-sensitive-dysphoria-and-adhd/
7. Rodgers, A., & Kalyn, W. (2021, July 22). How does RSD really, actually feel? [Blog post]. ADDitudeMagazine.com. Retrieved from https://www.additudemag.com/rsd-rejection-sensitive-dysphoria-experiences/
8. Green, E. P. (2021, April 19). We need to talk about ADHD stigma in BIPOC communities [Blog post]. ADDitudeMagazine.com. Retrieved from https://www.additudemag.com/adhd-stigma-bipoc-communities/
9. Amen Clinics. (n.d.). Attention Deficit Disorder (ADD/ADHD) [Blog post]. AmenClinics.com. Retrieved from https://www.amenclinics.com/conditions/adhd-add/