Month: March 2023

Ask Dr. Saline: Teen boys with ADHD, Anxiety, and Depression

Teens in schoolRecently I’ve received several questions about how to care for teen boys with ADHD, anxiety, and depression. So rather than answer one reader question this week, I’ll respond to everyone who has written to me with questions about helping their teenage sons. Sign-up for my newsletter + Free Handout | Ask Dr. Saline

From Dr. Saline 

The teenage years can be stormy, especially for boys with ADHD. Teen boys, in particular, often struggle with fitting in, managing both verbal and emotional impulsively, and carving out a space for themselves to practice connected independence. All periods of developmental transitions have their ups and downs, but ADHD tends to introduce more intense levels of moodiness, anxiety, and opposition in both boys and girls. If moods, anxiety, and low self-esteem are left unchecked, many teens with ADHD can develop depression. That’s why it’s so important for parents and caretakers to keep a watchful eye on their kids, noticing sadness, worrying, or social isolation. Sadly, all too often, boys will hide their true feelings until the tension builds up so much that there’s an explosion of words or actions that they later regret. Caring parents can offer them alternatives that foster self-control and confidence by providing conversation, connection, and support opportunities. 

ADHD, Anxiety, and Depression

teen boy looking at himself in the mirrorWhile ADHD and anxiety are two different conditions, they frequently coexist in kids and teens– about 30% of the time. Just like ADHD, anxiety manifests itself differently in different people. Generalized anxiety, phobias, panic attacks, and social anxiety are just a few of the more common types of anxiety seen in teen boys. Most importantly, anxiety can lead to depression if left untreated. Pay attention to your child’s behaviors, words, or symptoms. As needed, seek help from your primary care provider, school counselor, current therapist, or coach.  

What’s Behind Gaming

hands holding gaming controlMany parents I speak with vent their frustrations at how much time their sons with ADHD spend on video games. Gaming is less about laziness and more about socializing and a sense of accomplishment. Boys with ADHD often have difficulties with face-to-face social interactions. They may feel uncomfortable maintaining a conversation or relating to people. But they still want and need to find a social outlet, which is what gaming provides. Whether they play group or cooperative games online or play independently, gaming provides opportunities for connection and collaboration in a safe and comfortable environment. Gaming also provides boys with ADHD a sense of accomplishment they may not be able to find in school or at home. If they can beat a competitor, unlock a new level, or win prizes, it gives kids a huge sense of achieving something. When we view gaming through a more compassionate lens, we begin to understand more deeply what it is that boys with ADHD need to feel good about themselves. The issue with gaming, as with any screen usage, is the amount of time your child spends on it to the exclusion of other activities. Gaming works best as one part of a balanced life diet–not the main course. Eating, sleeping, using the bathroom, playing sports, participating in the school musical, and hanging out with friends in real time are all equally important in developing a healthy sense of self-worth and engagement in the world. ` That said, monitoring gaming to ensure your teen is safe and responsible online is important. And if gaming is still taking up a disproportionate amount of time by your standards, work on setting limits and redirecting your child toward alternative activities, providing a similar sense of acceptance and accomplishment.

Set Reasonable Limits

If you feel your teenager is spending too much time on gaming or social media, it’s time to set some reasonable limits together. First, discuss your goals with your parenting partner (if you have one). Consider factors like what’s appropriate on school nights vs. weekends, what needs to be completed before gaming, and how to help your son self-monitor with alarms and other reminders.  father and teen son talkingSet aside a calm moment to discuss gaming limits with your teen. In the spirit of collaboration, ask him first about his gaming and overall screen use observations, seeking his perceptions of what’s working and what isn’t. Then explain some of your ideas about why some limits are necessary and ask for his input. He’ll be more likely to comply if he’s part of the process. Clarify that want-to’s (like screen-time) can be earned after the have-to’s (like homework and chores) are finished. Consider ways in which your son can earn extra time on his devices to give him a little extra motivation to take care of his responsibilities. When limiting one activity, provide some other options to redirect and give your teen something else to do and look forward to. “Go read a book” will probably not be a welcomed solution. But taking the dog for a walk, going for a bike ride with you, or going out for ice cream with a friend may be more interesting. You know your child best, so propose something that will spark his interest and foster connections with the people in his life.

Manage Teenage Meltdowns with Grace

teen boyMeltdowns are a fact of life for most teens, especially those living with ADHD. Stress, frustration, and anxiety can escalate quickly and take a while to settle. When you see a storm on the horizon, the first step is for you, as the parent, to stay calm by slowing down your reactivity. If you need to take a moment in a different room, then step out and do what you can to gather yourself. You will be more likely to manage a meltdown with grace this way.  Next, try to understand what’s behind your teenager’s tantrum. When kids, especially boys with ADHD, are overwhelmed by big feelings, it’s tough for them to articulate what they need. Meltdown mode is a direct expression of their raw feelings. It’s a signal to you that things are not okay with them. Resist reacting and choose to respond using observations (“It seems like you are really upset right now. Let’s take a break to settle and come back in 15 minutes.”) Wonder to yourself if they might be hungry or tired and offer them a chance to eat something and chill out for a bit. Then you can circle back to dealing with more complex issues like getting a bad grade or being left out of an activity. Do your best to remain compassionate and clear when your son acts out. He’s just trying to express his distress to you so you become upset, and then he’s free and clear. It’s an import/export business. If you don’t take on his rage by engaging with him, then he’s learning slowly by slowly to manage it himself. It’s a tall order, but it will help both of you weather the storm.

Offer Empathy and Support

Your child’s teen years are a time of major transitions (physically, socially, psychologically, and cognitively). With these changes come big emotions and, sometimes, great discomfort. Kids with ADHD have their fair share of challenges, and emotional dysregulation is a key part of the package. Instead of focusing on a problematic behavior, try to understand what’s behind it, what needs are going unmet, and how to offer support best.  Thank you for your question! Be sure to join my upcoming webinars to learn more.  

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How to Improve the ADHD Brain’s Working Memory

teacher with students looking at microscopeWorking memory is an essential aspect of executive functioning and is challenging for many kids and adults with ADHD. Working memory allows us to hold several things in our thoughts at once and do something with them. It is also fundamentally linked to emotional control: when we perceive a thought, behavior, interaction, or activity as important and meaningful, it gets transferred into longer-term memory. This is how we draw on past experiences to apply ideas and solutions for current or future situations. Without it, people wouldn’t recall things from even a few moments ago. It’s really important to understand that working memory challenges, along with processing speed issues, can be a natural part of having ADHD. They don’t cause ADHD; they come with it. Fortunately, there are several strategies kids and adults with ADHD can use to improve their working memory.  Sign-up for my newsletter + Free Handout | Ask Dr. Saline

Three Types of Memory

memory brain graphicThere are three different types of memory: 

  • Short-term memory
  • Working memory
  • Long-term memory

It’s generally believed that short-term memory is super quick: it stores information briefly, just long enough to use the retained information, and then quickly forgets it (like a temporary verification code).  Working memory allows us to process information without losing track of other tasks we’re performing. It is related to short-term memory but it lasts slightly longer and is involved in the manipulation of information. Working memory allows us to retain someone’s name throughout a conversation or follow a set of directions. Long-term memory involves the storage and recall of information over a long period of time (days, weeks, years). Your childhood memories, favorite songs, and the faces of loved ones are all processed through long-term memory. 

Working Memory and ADHD

Kids and adults with ADHD often experience working memory challenges which contribute to challenges with executive functioning and emotional control. These issues manifest and become problematic if you need to commit something to memory and act upon that information but struggle with how. Or, if you are overwhelmed by big feelings and stimulation in a social situation, you may say or do something impulsively without recalling what you did previously that worked.  notebooks in box For example, let’s say that your teacher asks you to collect your classmates’ journals, alphabetize them by last name, and place them on top of his desk. By the time you’ve gathered all the journals, you’ve forgotten the next step. Or, you vaguely remember you’re supposed to sort the journals but can’t remember whether to sort by first or last name. With this roadblock, you are not able to complete the task without getting help. A similar situation could arise at work too. Perhaps you are asked to summarize the meeting as it wraps up but you stumble with recalling and articulating what’s occurred. When your brain flags something as emotionally important, it’s transferred down the memory line and converted into long-term memory. This is why emotions and working memory are so intricately related. Short-term, immediate memory for simple tasks gets processed first. Information that is more complex and demanding goes into working memory. If it’s tagged with emotional importance or special relevance, it ends in long-term memory. It’s a very complicated process. 

How to Improve Working Memory

Repetition 

teacher and little boy making hand gesturesRepetition is one of the most effective ways to improve working memory. It even helps to pair an action or movement with a word or phrase. I once had a client who needed to learn Spanish, so he created a special movement for each word to help him remember it.  If you’re learning lines for a play or memorizing a presentation, improve retention by reading and practicing right before you go to bed and first thing when you wake up. There are fewer distractions and interruptions on either side of sleep so you’ll have a better chance of remembering things. 

If you are giving instructions to a child or teen with ADHD who struggles with working memory, use my rule of three: 

  1. Make eye contact.
  2. State the direction.
  3. Have the child repeat the direction back to you twice.

The first time you repeat directions, you ensure that the child heard the instruction correctly. The second repetition sends the direction down the memory line because it is held in the working memory before being restated and then it moves along to long-term memory.

Routines

Using a routine in tandem with repetition can help improve performance as well. Creating routines is another form of repetition that can help with working memory. If you repeat the same set of tasks consistently,  you will be less likely to forget one or more of those tasks or related details. This is why morning and evening routines help kids focus on what needs to be done.

Reminders

reminder post-it notesThere is a difference between giving cues and being a reminder machine. In the first instance, you alert your child or teen and/or yourself to something that needs to occur. In the second, you are telling your kids what to do so they don’t develop any skills or agency. For example, instead of telling them for the millionth time to put their dishes in the sink after breakfast and grab their backpack, refer them to a list of activities for the morning routine on the refrigerator. You can also do this for yourself with useful apps where you record your have-to’s, set alarms or alerts to remind you, and then cross things off the list if you want. Take advantage of checklists, alarms, to-do lists, and reminders to jog your memory (or theirs) in case people lose focus. This will ensure everybody is able to complete a process or set of instructions independently. It will also decrease overwhelm and build self-esteem. When you develop the resources you or your kids need, things can run more smoothly and you all will feel a sense of success.

Break it down

Many folks with ADHD struggle to remember complicated tasks. The fewer things you have to remember, the more likely you’ll be to remember them. Break down large projects or lists into smaller parts to reduce the scope of what’s in front of you. When people work on one thing at a time, they reduce the brain fatigue that comes from multitasking. This also allows you to maintain concentration more easily. Then you can get things done and see real progress. 

Improve Working Memory by Accepting Your ADHD Brain

It’s important to understand that ADHD brains are unique, not broken or bad. If you or your child experience issues with working memory, focus on equipping yourself with effective tools and strategies to improve your memory instead of paying attention to self-criticism and ‘deficiencies.’  smiling teen boy with book and friendsWhen your child or teen says “I have a bad memory,” reframe their view of how their brain works. Lower amounts of dopamine and norepinephrine in ADHD brains can explain working memory struggles. Describe working memory to your kids (and partners, friends, or colleagues) as the search engine of their brain whose wires need some tweaking. Those adjustments come in the form of reminders, alerts, and alarms. Normalize forgetfulness as something that happens to all people and share your tools for recalling tasks. Be playful: create fun acronyms or zany associations to jog the memory circuitry.  Accepting your unique ADHD brain goes a long way toward improving self-esteem and finding working memory solutions which work for YOU.   

The ADHD Conflict Resolution Guide: Tools and Scripts for Settling Disagreements

two people standing apart going in different directions

The best way to handle conflict is to prepare for it by creating a conflict resolution plan in advance.

In this article, Dr. Sharon Saline shares the best way to handle conflict within families and in other relationships. In this article, you will find scripts and ideas for handling disagreements with tools like reflecting listening, the STAR method, and more. Read More>>  

Read Dr. Saline’s latest blog post:

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Ask Dr. Saline: Woman Diagnosed with ADHD at 40 Years Old

Woman with hand on head and eyes closed Dear Dr. Saline: I figured out I had ADHD about 10 years ago when my daughter was diagnosed. I have never been diagnosed because it was obvious to me after I learned so much. Now that my children are grown I have been concentrating more on myself. Is there a benefit, besides medication, to being diagnosed? I’m 50 years old. Thanks! Denise Sign-up for my newsletter + Free Handout | Ask Dr. Saline

From Dr. Saline 

Dear Denise: This is an important question and I’m glad you are asking it. ADHD in women can look very different than it does in men which is why it is so often misunderstood and misdiagnosed. Before I answer your question directly, let’s look at ADHD in girls and women in context. Most of the research about ADHD has long been centered on males and the externalizing symptoms of ADHD: hyperactivity, impulsiveness, aggression, fidgeting, excessive movement, visible restlessness, disorganization, loudness, trouble waiting, interrupting, and overtalking. In fact, boys are more likely to be diagnosed with ADHD than girls (12.9% compared to 5.6%). (Danielson ML, Bitsko RH, Ghandour RM, Holbrook JR, Kogan MD, Blumberg SJ. Prevalence of parent-reported ADHD diagnosis and associated treatment among U.S. children and adolescents, 2016. Journal of Clinical Child and Adolescent Psychology. 2018, 47:2, 199-212.)

ADHD in Girls vs. Women

But ADHD manifests differently in girls and women which is why it tends to be diagnosed later. Girls are far more likely to experience the internalizing symptoms of ADHD: excessive talking, tardiness, disorganization, inner restlessness, distractedness, overwhelm, perfectionism, self-harm, social awkwardness, dreaminess, or early sexual activity. These traits are less disruptive in a classroom so girls are less likely to be referred by educators for an evaluation. In addition, many girls develop strategies to overcompensate for their struggles with inattention and mask their academic and/or social difficulties. As they mature and the demands on their executive functioning skills intensify, their coping methods are less effective. They become overwhelmed, anxious, or depressed. Frequently, girls and women are referred for these mood conditions or self-harming behaviors and their attention issues are overlooked.

Hormonal Shifts & ADHD

In addition, hormonal shifts in the menstrual cycle affect the symptoms of ADHD, increasing distractibility, mood changes, and forgetfulness. The onset of perimenopause and menopause can lead to extreme mood and cognitive shifts related to the declining levels of estrogen and progesterone. Women who may have experienced mild symptoms of ADHD (known or unknown) may suddenly experience issues that seem ‘new’ and distressing to them including decreased working memory and time management abilities and increased impulsivity, reactivity, disorganization, and overwhelm.   

“ADHD manifests differently in girls and women which is why it tends to be diagnosed later. ”

 

Research

With the popularity of TikTok and other social media outlets, many women have been diagnosing themselves. In a recent study by Anthony Yeung, Enoch Ng et. al., the authors reviewed 100 videos and found that 52% were misleading and 71% misattributed symptoms to ADHD. I believe very strongly in the value of obtaining an accurate diagnosis from a mental health professional rather than a video. It’s important to discuss the symptoms and patterns of ADHD in your life with someone who is trained in this area, whether or not you decide to pursue medication. If you choose to obtain a psychoeducation evaluation, you will additionally learn a lot about how your brain works and understand strengths and challenges more fully. If you don’t, you can still assess your executive functioning skills with rating scales that a professional will explain to you.  Women dancingYour ADHD likely was present when you were younger, just like your daughter. But, people knew so much less about ADHD in women and girls at that time. One study found that 74% of girls who were diagnosed with ADHD in childhood persisted into adulthood. (Yeung, A., Ng, E., & Abi-Jaoude, E. (2022). TikTok and attention-deficit/hyperactivity disorder: A cross-sectional study of social media content quality. The Canadian Journal of Psychiatry, 67(12), 899–906.  Being able to look back on some of your previous challenges in school, at home, or with peers now with the new information you have about ADHD in girls and women can put so many things into perspective. For many women, a formal diagnosis brings relief and context to behaviors that have long been puzzling. For others, there is grief about the years they lost feeling misunderstood. 

In Conclusion

I strongly encourage you to find someone to work with you who really knows about ADHD in women. This is essential to receiving the help you need to accept the wonderful, unique brain you have. Instead of listening to the inner critic and its messages of doubt and judgment, embark on a journey of learning the executive functioning skills you need to live your best life as a woman with ADHD. Join a group, listen to podcasts, seek a knowledgeable therapist or coach, and practice radical acceptance. Connect with others who have shared a similar journey so reach out to the sisterhood of neurodivergent women. You are not alone.   

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