Month: October 2024

Dear Dr. Sharon: my teen with ADHD won’t take his medication!

Dear Dr. Sharon –  

My 15 year old son was diagnosed with ADHD 2 years ago, and has been prescribed a stimulant medication since then to help with his symptoms.  He had no problems taking the medication until the last 6 months, and now often refuses to – he says he “doesn’t like how it makes him feel”, and that he doesn’t feel as creative when he takes it (he’s a talented sketch artist!).   His teachers, our family, and even him, all notice a difference when he does adhere to the medication schedule though – but the fights and back and forth arguments are exhausting, for all of us.  What can I do?
–Collette

Dear Collette – 

 Thank you for reaching out! Many parents of adolescents with ADHD wrestle with similar challenges. As teens try to figure out who they are, what they value and where they fit in, they often struggle to balance their desire for independence with their continued reliance on their parents. This dance occurs within the context of raging hormones, social media ideals, academic pressures and shifting peer dynamics. When you add ADHD to the mix, it’s really a bubbling witch’s brew (sorry–I couldn’t resist the seasonal pun!).  Let’s unpack some of the “why” in your question, then tackle the “how” together.

-Dr. Sharon

 

Adolescence and ADHD

A teenager’s opposition is a force to be reckoned with! 

The parent-child push and pull during adolescence can be both frustrating and confusing. I applaud you for your thoughtful and patient approach to what is a tumultuous period of development for any child. From his perspective, there is a valid and real reason that he has been refusing to take a medication that has historically been helpful to him. 

Many teens who refuse or skip taking medication for their ADHD symptoms are testing limits, exploring their independence, or want to see what they are able to accomplish on their own. While teen resistance and refusal is nothing new, managing the symptoms and treating ADHD consistently and correctly during the teen years builds an important foundation for their upcoming transition to adulthood. 

Research has long indicated that the best treatment for ADHD in children and teens is a combination of cognitive behavioral interventions to improve executive functioning skills, parent training and medication. Let’s address your questions by first uncovering how medications for ADHD work. 

 

Medications for ADHD and How They Work

Since you are asking about medication and how to manage your son’s refusal to take it, let’s zoom out and take a brief look at medication for ADHD in general.

ADHD medications have evolved significantly since the introduction of Ritalin in the 1960s (the first of its kind to gain FDA approval for use with children). Today, parents are able to choose from a spectrum of pharmaceutical options to address the symptoms of ADHD in their child. 

Medications used in the treatment of ADHD symptoms work by increasing the availability of two primary neurotransmitters in the brain: dopamine (involved in motivation, pleasure and satisfaction) and norepinephrine (involved in focus, the stress response and alertness). These medications fall into two main categories: stimulants (Ritalin, Metadate, Focalin, Adderall,Vyvanse, Journay, etc.) and non-stimulants (Strattera, Intuniv, Clonodine, Qelbree, Wellbutrin, etc.). 

As the levels of these neurotransmitters change, some of the symptoms of ADHD improve. We see longer attention spans, reduced hyperactivity and impulsivity and better self-regulation. But, as I like to say, pills don’t teach skills. They frequently act as a catalyst to help people retain tools and techniques to manage executive functioning challenges. My strong recommendation is that therapy or coaching play a significant role in any treatment plan.

 

Managing Side Effects

While it is true that side effects may be observed or reported in children, teens and adults who take these medications, the benefits often outweigh them. But, negative side effects are the most common reason given by children for not wanting to follow their prescribed regimen – things like loss of appetite, headaches, dry mouth, being more easily angered, and trouble sleeping can bedisconcerting. Many side effects, though, can be resolved with adjustments to dosage, timing of medication, or the body’s adaptation to the effects of the prescription.

For your son, it sounds like the decision to pursue medication as a part of his treatment plan was one that you carefully considered and that has been largely beneficial.  It also seems like everybody sees the positive results of the medication. The problem is that he doesn’t “feel like himself.” His mind doesn’t wander into creative jaunts the way he likes which works well in math class but not as much in art. Plus, no parent wants their child to feel “less than” anything, least of all like themselves!  

 

Medications shouldn’t affect personality-while medications for ADHD help manage behaviors, they are not created to affect personality. 

Personality is a combination of traits that are unique to each individual. It’s what makes your son–“him.” If anybody taking ADHD medication experiences a blunted affect – seeming withdrawn, more quiet, less engaged – or becomes more hostile and emotionally volatile, then it is essential to contact your provider immediately. Something needs to be tweaked or even stopped which must be done under medical supervision.   

 

Adolescent Medication Refusal

A teen’s opposition is a force to be reckoned with. From his perspective, there is a valid and real reason that he has been refusing to take a medication that has historically been helpful to him. I applaud you for your thoughtful and patient approach to what is a tumultuous period of development for any family. 

Growing up with ADHD, many kids feel different, less than and struggle to find things they like about themselves and feel proud of. Whether it’s sports, art, music or theater, having an area where you feel competent and confident is essential to countering the negative messages you receive about being neurodivergent. These interests and hobbies also build essential self-esteem. The fact that your son enjoys his artistic creativity is a real asset for resilience and positivity.

“Why now?” Questions to Ask…

I am curious about what might have changed in the last 6 months for your son to report that he “doesn’t like how he feels” when he takes his medication. It’s always worth asking “Why now?” when somebody wants to make this shift. While it is worth reaching out to teachers who really know him, the best place to start is talking with him. 

I’m sure you’ve tried this but here are a few suggestions:  

  • Did someone make a comment that he took to heart?
  • Has he had less opportunity for creative pursuits recently? 
  • Did his schedule recently change?
  • What is missing when he takes his medication that he wants back? 
  • Could you come to a compromise agreement about taking the medications during the school week but not on the weekends as an experiment?

Any information you gather will help you be able to get a sense of the bigger picture, to identify what may have triggered these recent refusals, and address the underlying cause. 

Tips to Reduce Conflict about Medication

Here are four tips to reduce conflict over taking medication and maintain positive connections with your teenager:

#1 – EDUCATION IS KEY! This is a natural opportunity for education surrounding their ADHD. Make a time to discuss what their symptoms look like, how medication they are  prescribed works and what their experience is like when they take and when when they don’t. It can be very useful to contact your child’s prescribing physician and schedule an appointment to gather more information too. If your child is refusing the medication, then this appointment is critical. You want them to talk to their provider about what’s going on (with or without you in the room). 

#2 – TALK ABOUT EXECUTIVE FUNCTIONING SKILLS: While it may appear as outright medication refusal or a willful  non-adherence, underlying executive functioning skill deficits can contribute to a pattern of refusal. Troubles with self-regulation, working memory, organization, procrastination and time management affect productivity and following schedules. With their Now/Not Now brains and preference for immediate gratification, teens with ADHD may forget how their medication helps them as a student, as a tennis player or as a cellist. Work together to create doable routines and organizational systems for following medication regimes so your teem is an active participant in their treatment plan.

#3 – AVOID THE HELICOPTER: Parental scaffolding helps teens prepare for adulthood by helping them practice independence. Instead of telling older teens and young adults that they must take medication, discuss options with them. Explore ways to improve executive functioning skills with therapy, coaching or other activities. Point them towards resources instead of telling them what they have to do: use collaboration so they have skin in the game. As the parent of two emerging adults, I know how tough it can be to witness our children struggling and succeeding on their own terms. Although it’s much easier to say what we think and tell them why we are right, this type of communication doesn’t result in a trusting relationship. Scaffolding strategies will show more respect for their growing maturity.

#4 – REMEMBER BIOLOGY: The ADHD brain matures more slowly than neurotypical brains–as much as three years. When you normalize their ADHD-related struggles as part of their biology and their genetics, you help to reduce their discomfort about being ‘different’. There is no shame in needing assistance with learning certain skills, routines or behaviors if your brain lacks adequate dopamine or norepinephrine.  

 

 

 

 

The ADHD Iceberg Explained: Hidden Symptoms, Challenges and Strategies

“ICEBERG! Right ahead!!!” 

 

Perhaps you remember this famous line from the iconic 1997 movie, “Titanic”, starring Leonardo DiCaprio and Kate Winslet.  The ship’s captain alerted the passengers and crew of the historic vessel that they would soon strike a nearby iceberg that had been largely invisible, with 90% of the hulking iceberg being obscured underwater. 

Within 30 seconds of sighting the iceberg, the ship made impact, sending the passengers and crew scrambling for safety amid the frigid waters.  Had they been able to see more than just 10% of the iceberg – what was  hidden below the surface –  and adjust their course, disaster might have been averted.   

While certainly an excellent scene in the movie, the lessons learned from the ship’s collision with the iceberg are also a glimpse into the visible and invisible challenges of ADHD.  The tip of the iceberg – the 10% we can see – represents behaviors and symptoms that are characterized as being “external”; meanwhile, the largest portion of the iceberg (what we can’t see) – represents those hidden symptoms and challenges that go unseen, characterized as being “internal”. 

To celebrate ADHD Awareness Month, I’d like to explore the less visible ways ADHD impacts our lives and relationships. Let’s break down the ADHD Iceberg (first coined and depicted by Chris A. Ziegler Dendy) and how to manage it. You’ll be able to avoid unforeseen dangers and have smoother sailing. 

 

The Iceberg We Can See – The External 

Externalizing behaviors are frequently seen in the classroom, at the workplace and at home. They are easily observable and measurable, typically manifesting in inattention, impulsivity, and hyperactivity. They are related to conscious executive functioning skills such as verbal, behavioral and emotional impulse control, organization, time management, initiation and prioritizing. In children and teens, we see this tip of the ADHD more in boys than girls in common behaviors such as fidgeting, talking too much, interrupting others, moving around the classroom and physical aggression.

In adults, externalizing behaviors can manifest as missed deadlines, trouble with finances, tardiness, disorganized living spaces, difficulty remembering important dates or events, interrupting others, talking too much, job instability and strained relationships.

 

The Iceberg We Can’t See – The Internal 

Internalizing ADHD behaviors are characterized as being less observable to others and frequently rely on someone’s self-report of their challenges in managing them. These internal traits include a restless or wandering mind, low self- esteem, distractibility, inability to sustain attention, trouble with shifting or flexibility, overwhelm, limited self-awareness, poor working memory and shame. 

Both types of these challenges exist in some form for everybody with ADHD. What’s under the surface of the water often shows up in combination with anxiety or depression, especially in   girls and women with inattentive ADHD. Since these traits are less disruptive in a classroom, girls are less likely to be referred by educators which accounts for why women are one of the largest groups seeking ADHD diagnoses today. Dealing with all of these issues requires patience, sensitivity, and a genuine desire to understand the “whole person.” 

 

Masking and the ADHD Iceberg

When the symptoms of ADHD remain hidden within the ADHD iceberg model, people rely on a  coping response called “masking.” Both children and adults can engage in masking behaviors.  Masking allows the person to conceal how their condition affects and limits their functioning. 

ADHD masking is about conforming to neurotypical standards to avoid the shame and stigma related to being neurodivergent. It typically develops as a coping tool in childhood that continues into adulthood even though it may no longer be useful. Over time, masking becomes tough to maintain and prevents people from sharing who they really are.

 

The Consequences of Masking and the Unseen ADHD Iceberg 

“I appear very organized to the outside world, but only because I spend an immense amount of time and energy putting everything together.” Cady, age 36

 

Masking with ADHD, while initially useful, may actually delay or sabotage a formal diagnosis and inadvertently foster the development of mental health issues such as anxiety or depression. Keeping symptoms of ADHD submerged and pretending they don’t exist to the outside world takes a great deal of energy. Diagnosed individuals who knowingly hide their challenges often worry profusely about being exposed and fear potential rejection or judgment. 

Avoiding the unseen ADHD iceberg often exacerbates perfectionism and imposter syndrome. Going above and beyond, overpromising more than you can deliver and feeling overwhelmed in the process, you may hope to distract others from the inadequacy you deeply feel. In addition, years of intentional or unintentional masking can muddy one’s sense of self so you lose track of who you really are. Hiding the challenges of living with ADHD interferes with your ability to accept the brain you have, take pride in your strengths, and do more of what works.

 

 

4 Tips to Navigate the ADHD Iceberg

 

  1. Celebrate Strengths: Encouragement to focus on your strengths provides the space for you to be proud of who you are and embrace neurodiversity. It helps you to avoid the narrative that ADHD is something that bothers others, and should be hidden. It reduces the pressures to conform to others’ ideals. Some strengths of living with ADHD include: being energetic, spontaneous, enthusiastic, curious, creative, having quick thinking, being able to hyper-focus on what you love to do.
  2. Begin Journaling: Writing in a journal can help you process emotions and gain insight into your experiences. Your needs – and potential solutions – will become apparent as you consider these questions:
          1. If you weren’t masking, what else would you be doing?
          2. What obstacles or fears interfere with sharing your true self?
          3. How do your personal expectations help to maintain the submerged part of the ADHD iceberg? 
          4. How can you make different, genuine choices in your behaviors or responses at home, at work or with friends? 

3. Change Your Focus:  Many people overcompensate for the deficits they think they have by overcommitting, overpromising, denial or avoidance. The negative self-talk that often accompanies masking can be shifted with paying attention to what is working. I recommend that you write or dictate three good things that happened in your day, ending with something you are grateful for each night before going to sleep. These positive items can be simple or complex. For example: 1) I wore my favorite shirt today; 2) I got the kids to school on time; 3) My boss liked my report. I’m grateful for the latte I had after lunch. This will take some practice but there’s research that shows this process really works. 

4. Practice self-compassion. Treat yourself the way you would act with a close friend, a child or a beloved pet. Be kind, forgiving and understanding. Your masking developed to assist or protect you in the past but it may no longer be necessary. Hiding who you really are makes it impossible for you to obtain the assistance you need to be successful and share the wonderful parts of yourself with the world. Instead of judging yourself for being less than, cut yourself some slack. Put on your cloak of courage and learn to love your challenges instead of submerging them.