Dear Dr. Saline,  Yesterday, I received a phone call from the school counselor about my daughter, age 12. She’s not completing her work in class, often forgets to turn in her homework, can’t recall directions, and spaces out during lessons. When she’s frustrated with an assignment, she loses her temper quickly. She’s been losing friends too. Based on some research, I’ve noticed these behaviors at home, and I think that she is showing “classic” symptoms of ADHD. But, at our last visit with Dr. Picone, he seemed to minimize my concerns about attention issues and talked about depression instead. He wanted to give her Prozac, but I refused. I think she is being underdiagnosed or misunderstood as a young Black girl, but I don’t know exactly what to do. Can you please explain how ADHD looks in Black and Brown girls and what I can do to figure this out? Thank you, Michelle. Sign-up for my newsletter + Free Handout | Ask Dr. Saline  

From Dr. Saline 

Dear Michelle: I’m sorry to hear that you and your daughter are having such a frustrating experience. I’m glad that you waited to give her Prozac without more information. Unfortunately, many physicians, therapists and educators treat BIPOC children and teens differently than they do white kids. BIPOC boys and girls are less likely to be evaluated for ADHD even though they may show the same level of symptoms. Unfortunately, this is often due to implicit bias about Black and Brown people in the United States. We must acknowledge that structural racism affects outcomes. Practitioners have to take the time to investigate and receive training about the nature of our biases and how they could emerge in treatment. Sadly, Black and Brown people in America have been subjected to unfair treatment by health care and mental health practitioners over the years and have been coerced to be subjects in inhumane studies as well (e.g., the Tuskegee Syphilis Experiment). This makes it harder for them to trust a system to help when it’s caused so much harm in the past.

Misdiagnosing ADHD Symptoms

So many girls are referred for counseling for anxiety or depression without considering other factors such as attention or learning challenges. This is especially true for Black and Brown girls. They may hide what’s really happening to avoid getting in trouble, being considered stupid, or getting teased. Misdiagnosing or overlooking ADHD symptoms means that your daughter, like other kids with ADHD, is more likely to engage in risky behaviors and substance use and demonstrate serious mood disorders later in life. This is especially true for ADHD in Black and Brown girls. They often come across as older than they actually are. This complicates things for kids with ADHD, who can be up to three years less mature than their peers. Plus, many BIPOC parents think that ADHD is another unwanted label. It may be possible that their students deny their struggles in an effort to comply with this cultural belief.

Client Experience

Recently, the father of one of my clients, a ten-year-old African-American male who was just diagnosed with ADHD and dyslexia, said to me: “Dr. Sharon, I don’t want him to have another label. It’s hard enough growing up Black today. This could just be something else that holds him back.” This is a very valid concern, and I really empathize. However, research shows that kids of all ethnicity with ADHD do better with useful interventions at school combined with family therapy to develop effective strategies at home and, lastly, medication. While pills don’t teach skills and the decision to take medication is personal, it is worth noting that the combination treatment produces the best results. Many families, especially those with limited access to health care, can be misinformed about the effects and benefits of medication. Do some research on well-respected sites such as ADDitudemag.com, Chadd.org, add.org, WebMD.com, Healthline.com, or Understood.com.

“While pills don’t teach skills and the decision to take medication is a personal one, it is worth noting that the combination treatment produces the best results.” ~ Dr. Sharon Saline, Clinical Psychologist

Getting An Accurate Diagnosis

Let’s look beyond your daughter’s symptoms to what else might happen. Almost 64% of kids with ADHD have a co-occurring second diagnosis, often a learning disability, anxiety, or something else. Unfortunately, many educators and providers over-focus on the secondary diagnosis or make character judgments without investigating further, especially for BIPOC kids. Too many adults zoom in on objectionable behaviors without sufficiently considering racial, socioeconomic, and psychological stressors. That’s why getting a valid diagnosis is critical.

Two Ways to Get An Evaluation:

1) Go to the principal or guidance counselor at her school and ask how you initiate a special education evaluation, or go directly to the pupil services office for your school district and initiate the process. 2) Check with your insurance company and your doctor’s office for referrals of people who perform assessments. In my last Ask Dr. Sharon blog, I detailed what to look for in this evaluation, but it should include tests of intellectual capabilities, visual and spatial processing skills, and rating forms that target anxiety, trauma, depression, and executive functioning skills. It’s important for the evaluator to understand that life stressors may worsen executive functioning skills. Remember, schools can’t diagnose ADHD because it is a health condition, but they can say that results point in that direction.

Research

Recently, a new study from the CDC found an alarming increase in sadness and exposure to violence among teen girls. This is particularly alarming for neurodivergent girls, particularly those of color, who are frequently misperceived by adults as older than they are, may be unfairly targeted as being aggressive, and may already lack self-esteem or confidence. When you add into the mix that inattentive girls are often diagnosed later in life because so many adults miss the signs or ignore them, the risk of missing ADHD in BIPOC girls increases. Instead, there are multiple referrals for anxiety, depression or oppositional behaviors. Then these girls can be excluded from their peers because of missing social cues or spacing out during the conversation at lunch.

In Conclusion

If your daughter receives a diagnosis of ADHD, help her take ownership of it. As a family, seek out research, so all of you fully understand what it means to wrestle with attention issues as a person of color. Learning about how her brain works are critical to accepting her challenges and advocating for her needs. It’s very important for Black and Brown kids to be able to identify what is helpful, what is working, and what they need so they feel empowered as learners and as neurodivergent adults. This will set the stage for self-advocacy throughout their lives. With a thorough evaluation, thoughtful interventions at school and home, and possibly medication, your daughter can thrive and develop into the productive, successful, and confident adult you want her to become. Thank you for your question! Be sure to join my upcoming webinars to learn more.  

 

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Dear Dr. Saline,  What is the main skill to work on with someone to help with their executive functioning difficulties? Assuming they are not on meds. Sign-up for my newsletter + Free Handout | Ask Dr. Saline  

From Dr. Saline 

Dear M: When I work with people to improve their executive functioning skills, we start with their primary areas of concern–the parts of daily life that are persistently tough for them. Since you didn’t mention your primary challenges, I recommend beginning with self-evaluation to find your main skill. Then, find a quiet time to reflect on these questions.

Questions to Consider:

• What are the performance or productivity issues that challenge you the most?
• How well can you manage your emotional reactivity or impulse control?
• How easily are you distracted from the task at hand? 
• What helps you maintain focus and stick with goals?
• Do you find that you become overwhelmed and shut down more than you would like?

If I had a magic wand…

Once you have considered these questions, ask yourself: If I had a magic wand and could change one thing about myself, what would it be? Then, consider all your responses and choose ONE main skill you would like to improve first.

How to start the process of change

Here are some tools you can use along the way to start the process of change: Inhibition and Emotional Control: Slow things down, pause before responding to anything, expect setbacks, and create a plan for recovering and making amends. Initiation:  Break things down into smaller components; use Apps to assist you; reduce perfectionism so you can begin and complete things without pressure; decrease avoidance by starting with something easy to get rolling. Organization: Lay out steps for completing tasks; create daily routines; make spaces for dealing with and storing materials. Prioritizing: Do a brain dump to help you distinguish between what’s urgent and important; break that list down into a smaller list of 3 tasks and then identify their components in terms of time and values. Sustained attention and Goal-directed persistence: Consider possible obstacles to maintaining focus; create a system of reminders to redirect your attention after you have drifted off; set realistic goals based on your actual capabilities and schedule breaks. Working memory: Write things down where you can find and remember them; use alarms, alerts, and notifications; take notes during important meetings, classes, or conversations; if note-taking is difficult for you, brainstorm solutions with your supervisor, professor or partner that may include recording things or let caring coworkers or friends assist you by taking notes (you may also ask for ADA accommodations).  Metacognition: Ask yourself questions that help you monitor and evaluate your productivity and emotional regulation and measure your progress toward your goals. Questions to start with: “How am I doing?” “What helped me before that I could apply to this situation?”

“Improving executive functioning skills takes practice, patience, and determination. While medication can be very helpful, pills don’t teach skills.” ~ Dr. Sharon Saline, Clinical Psychologist

Research

Recent research from the Florida International University Center by Dr. William Pelham found that, while medication-assisted children helped children complete more seatwork, improve their classroom behavior, and reduce rates of getting in trouble, children learned the same amount of subject material such as math, vocabulary, social studies, etc. as their peers. Another study by Dr. Pelham also emphasized the importance of behavioral therapy to learn tools and strategies to succeed at home, work, school, and social environments. Does this mean that people should stop taking medication? Absolutely not. But it underscores the importance of learning executive functioning skills for practical daily living. 

In Conclusion

All human beings have executive functioning skills managed by the prefrontal cortex of our brains. Executive functioning skills describe the directive capacities of the brain.  They work as a command center: connecting, prioritizing, and integrating cognitive functions moment by moment. They are responsible for self-regulation, linking memory to what we see and think about right now, self-awareness and judgment, and actions related to productivity and performance. People with ADHD have significant executive functioning challenges, with some areas of severity that can be quite impairing.  

 

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Dear Dr. Saline,  My son is now a junior in high school and is having trouble with the increased workload. I suspect something may be wrong. Where do I start with the process of getting him evaluated and diagnosed for ADHD?  Sign-up for my newsletter + Free Handout | Ask Dr. Saline

From Dr. Saline

For children and teens up to age 18, receiving an accurate diagnosis of ADHD can be a complicated, confusing, and frustrating experience. Often parents receive contradictory or inadequate information about the process, and navigating the maze toward diagnosis and treatment can be perplexing. In particular, the tween and teen years are development stages when trouble with attention, organization, and distractibility come to the forefront. As kids switch classes, confront more complex academic work, cope with social dynamics and pursue extracurricular activities, their lives demand that they develop and apply more sophisticated executive functioning skills. So it’s common to see challenges, anxiety, and even depression when they struggle to keep up. Typically, there are three ways to obtain a diagnosis of ADHD; quite honestly, TikTok is not one of those paths. While social media may alert your adolescent that some of their difficulties might meet the criteria for ADHD, it is not a reliable source of a diagnosis.

Evaluator Options Include:

• Primary care providers (nurse practitioners, pediatricians, physician assistants)
• Mental health professionals (including psychiatrists) and
• Using school resources

Whichever route you choose, ensure the person understands and has significant experience with ADHD.  This person will conduct a thorough individual and family history with you and your child. Then, let’s look at a few options. 

Private Professional Options

1. Primary Care Providers

If your child’s issues might be related to attention, you may have already started researching ADHD. Start by talking with your primary care provider or pediatrician because they have likely known your child for years and have been advising you all along. They will probably give you some forms to fill out with rating scales (and take you to the school) to get a sense of daily functioning and trouble spots and talk with each of you about behavioral, emotional, and cognitive issues. If the forms indicate ADHD, they may refer you for counseling, coaching, or a psychoeducational evaluation (private or through the school district), discuss medication options with you or give you the name of a local psychiatrist.

2. Mental Health Professionals

Whether your child or teen is already in therapy or has just been referred, your licensed counselor, social worker, or therapist will want to assess their primary concerns and symptoms to determine a diagnosis and create a treatment plan. Like your pediatrician, this provider will usually show a thorough developmental and family history and give you forms similar to the ones the pediatrician uses before making a diagnosis. Often, they will consult with your pediatrician, your child’s classroom teachers, and other school personnel. Suppose the therapist or psychiatrist has additional concerns or thinks more data is warranted. In that case, they may also recommend  ‘testing,’ especially to rule out any learning issues or for clarification of what’s going on. Some psychiatrists offer therapy in addition to prescribing medication, and others only focus on medication management. All of these folks are capable of diagnosing ADHD.

Formal Psychoeducational Evaluations

Psychologists and neuropsychologists are trained to do formal psychoeducational evaluations (e.g., testing).  Speech and language pathologists (SLP) and special education teachers can conduct more minor, specific tests. These evaluations include assessments of cognitive functioning (including verbal, visual-motor, working memory, and processing speed), other visual, verbal, math, and written skills, grade-level competencies, and emotional issues. These evaluations can be highly informative to you and your teen because they provide a glimpse into your child’s brain works, strengths, and challenges. When you choose a private evaluation (as opposed to testing through the school), you have more control over the person who does it. But ensure the evaluator takes the necessary time to explain the results thoroughly. These reports can be dense, confusing, and overwhelming. Ask all your questions and request a follow-up meeting if you need it. 

School Resources and ADHD Evaluations

Many parents first learn about their child’s challenges with concentration and focus from a classroom teacher, school counselor, or principal. While these conversations can be painful, the information educators share is essential to why your child is struggling in school. Understand that public schools in the USA can name attention, concentration, and memory issues, but they cannot legally diagnose ADHD since it is considered a health issue. However, they are mandated under IDEA (Individuals with Disabilities Education Act) to assess students for possible learning disabilities, including ADHD, and, if there are conditions that interfere with learning, to provide accommodations.

How to Start the ADHD Evaluation Process

1. Begin with a parent meeting with a guidance counselor or vice principal who knows your child. 2. Discuss your concerns and see what they advise. Often, they might suggest that teachers make some minor changes in the classroom. If those are not satisfactory or you believe your child needs more support, then you have the right to request a formal evaluation, including a team meeting. This request can be made at the school or the district office. 3. What typically follows is the beginning of a thorough evaluation that is similar to private ‘testing’ but may also include additional information about speech and language skills and occupational functioning. These are similar to private ‘testing’ because they offer rich information about your child and the additional benefit of direct contact with their educational environment. However, some school districts prefer to do their evaluations but may need to wait longer than you want. 4. You also have the right to present your report. Schools can’t diagnose ADHD because it is a health disorder. You will need to share the information with your primary care provider, psychiatrist, or mental health professional to get an official diagnosis. 5. Next, a team meeting will be convened to determine the type(s) of special needs your child may have and whether they are eligible for mandated services. If your youngster qualifies, then the team will make recommendations and create an IEP plan or design the 504 at a later time.

In Conclusion

Many kids with ADHD also have reading, writing, or math difficulties which qualify as learning disabilities. Schools can  diagnose these issues. Moreover, if they are blocking academic progress, support services will be provided. You can see how complex this process can be. Take a deep breath, and stick to what you know is true about your child. Don’t get intimidated by anyone who may dismiss your concerns. Trust your instincts, and realize that you know your kiddo better than anyone else. Collaborate on creating a plan that offers the help your student needs. Stay curious, ask questions, listen with an open mind, know your rights and advocate fiercely. If you need more support, seek it out. You’ve got this!

 

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The beginning of a new year typically marks the middle of the school year and mid-year report cards. Of course, students with ADHD want to do well in school, and most of them put a lot of effort into their work. But at the same time, they must contend with issues around focus, organization, distractibility, impulse control and time management, and their academic workload. It’s a lot to handle, and often grades may suffer as a result. To better address your child’s needs, you’ll need to figure out what your child is struggling with to find the proper support. So let’s take a step back and see how you can prepare your response to a disappointing report card and a disappointed child.

Be an ally, not a critic

It’s safe to assume your child is already disappointed and frustrated with his lackluster report card, so responding with anger, lectures, and punishments will only intensify your child’s stress. You may feel upset and concerned: this is entirely understandable. However, addressing your feelings in private before speaking with your child or teen would be best. Taking time to process what’s happened and your frustration will leave you in a much better position to talk with your kid. Your child will feel connected, comforted, and heard when you are calm, attentive, and constructive. This is when brainstorming and collaboration about how best to move forward will take place. 

Read between the lines

“Listen more, speak less” is an effective parenting strategy to help your child get through a tough time. Don’t assume you know what’s happening or rush toward a resolution. When your child is going through a challenging situation, they need to get things off their chest. Maybe even cry or get their frustration out on a punching bag or old pillow. Give your child a chance to vent. When they feel they can share what’s on their mind with you without anger or judgment, they will feel more connected and likely to open up even more. Please encourage your child to share their thoughts about what happened with their grades. Be ready to read between the lines and ask for clarifications, so you have the whole story. Avoid asking ‘why’ and stick with ‘how, when, and what.’ For example, when your child says, “I hate school,” or “My teacher hates me,” it could mean the teacher frequently reminds them to pay attention. Or the child doesn’t fully understand the teacher’s expectations and keeps falling short. Instead, ask them, “How do you know this? What things does your teacher say or do to show their hatred?” The more specific the information you gather, the easier it will be to make a collaborative plan for moving forward. So it’s up to you to first listen and ask questions to get to the bottom of the issue.

Set realistic academic goals for the remainder of the school year

Together, explore realistic and achievable goals for the next term based on their current performance. Identify what small steps they can take to make some progress. Remind your child that even if their grades don’t go up significantly, they show growth in other ways; that’s a substantial accomplishment too. For example, if your teen makes it a habit to get homework help from their math teacher once a week, that’s excellent progress. Ask your child or teen what types of support have been helpful in the past and would be useful now. For example, is there a teacher, friend, or counselor they have a good relationship? Then, get your youngster to come up with one or two suggestions for improving their study habits and grades. And if you haven’t done so already, reach out to teachers and guidance counselors to better understand what resources are available for your child.

Make sure your child has the proper academic support in school and at home

If your child or teen does not already have mandated supports at school (in the United States, these would be 504, IEP, and behavioral plans), then request a team meeting or fill out the necessary forms to get this process started. If a support plan is in place and your child is still struggling, as evidenced by their disappointing report card, set up a meeting with the team to find out why the plan isn’t working more efficiently. Make it possible for your child or teen to participate in these meetings. We want them to feel part of a process that’s for them so they will be more willing to participate in it.  While you can’t oversee what’s happening daily at school, you can provide effective support at home. First, make sure your youngster has a quiet place to study. Next, enforce effective study habits by equipping them with tools such as checklists, alarms, reminders, and practical daily routines. Finally, collaborate on and use age-appropriate incentives. Remember to rely on natural and logical consequences rather than punishments to motivate your student. Most importantly, celebrate each win, no matter how small. Going from a C- to a C may not seem like much to cheer about for your standards, but it could be a world of improvement for your child or teen. It reflects an improvement based on a lot of effort on their part. Your child or teen with ADHD does want to do well. With your empathy and support, they will shine.

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