Tag: ADHD

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.

Everything You Need to Know About IEPs and 504s

 (for Children and Teens with ADHD)

Navigating the ins and outs of getting help for your child in school can be overwhelming, especially when it feels like everyone is speaking a language you’re not familiar with! This week, I’ll help demystify two very different avenues of accessing school support for your child or teen – I’ll share  everything you need to know about IEP and 504 plans for children and teens with ADHD. You’ll be able to advocate for them more effectively and they’ll be able to manage classes and homework with more ease and success.  

 

Many kids with ADHD struggle in school–not just with accessing what they know when they need to use it but also with co-occurring learning disabilities that occur about 70% of the time.  There are several paths that lead to the provision of an Individualized Education Plan (IEP) or Section 504 Service Agreement (504 SA) for your child, but they all start with one thing – concern that your child may need additional support to be successful in school, and a psychoeducational or multi-disciplinary team evaluation to determine why they are struggling.  Your child’s school might request to initiate this evaluation, you might request an evaluation, or you might provide the school with documentation of your child’s existing disability or neurodivergence…there are many different scenarios in which a student can be referred to determine eligibility. 

 

Where to begin the process

Ultimately, everyone wants to ensure that if your child does need modifications or accommodations due to neurodivergence, they receive tools and strategies to be successful at school. This process often starts with a team meeting (that you or your school team typically have to formally request) to discuss concerns that can

 lead to a psychoeducational evaluation, functional behavioral assessment or recommendation to meet with your primary care provider. If your child already has a diagnosis of ADHD and/or an evaluation that you obtained privately, then this meeting will most likely discuss the information that you already have, and any impact on school performance. Either way, you and the school team will discuss what’s going on and the team will decide whether a school based evaluation is appropriate to determine if your child is eligible under IDEA for an IEP or Section 504. If so, then they will develop a plan that outlines what, how, and where any needed supports or accommodations will be provided.  

Now that we’ve laid out how to begin, let’s talk about the basics of an IEP and 504, what each of them is (and is not), and who they are appropriate for. In order to do this, I will be using the word ‘disability’ here when referring to ADHD instead of ‘difference’ because school based services are only provided based on the determination of a disability. 

Individualized Education Plans–IEPs

An IEP – “Individualized Education Plan”  is a legal document that outlines what supports and services your child will receive as a result of being found eligible for special education under a qualifying disability category.  Federal law under IDEA guarantees a free and appropriate education to all students. IDEA is about facilitating academic achievement and progress. IEPs are just one component of what falls under the umbrella of “Special Education” for children ages 3 through 21 in schools.  They offer a road map for teachers, support staff, related service providers, parents, and other team members to follow.  

The Details of an IEP

An IEP can only be drafted after the school has conducted a psychoeducational evaluation (or you bring one that the district accepts), shared the findings with you, and all participants agree that the student is eligible for special education under a qualifying disability category. The named disability has to be found to negatively impact their educational performance so that the student needs specialized support and services to make progress educationally. While disability categories can vary from state to state, federal law under the Individuals with Disabilities Education Act (IDEA, Part B) identifies thirteen categories of disability, including: Other Health Impairment, Specific Learning Disability, Traumatic Brain Injury, Orthopedic Impairment, Hearing Impairment, Emotional Disturbance, Autism, Speech/Language Impairment, etc. 

An IEP is characterized by the modifications that are deemed necessary to make the curriculum more accessible for the student to be successful. These are changes to what is taught or expected, through specialized instruction or the provision of related services (behavior supports, PT/OT, Speech, etc.).  An IEP means that the student has been found eligible for Special Education. 

ADHD and IEPs

Under IDEA, ADHD is considered an “Other Health Impairment.” The psychoeducational evaluation by the school cannot diagnose ADHD per se but will indicate that a child has the symptoms or behaviors commonly seen in attention disorders. This means that you will have to take the report back to your primary care provider or a licensed therapist for a formal diagnosis or clinical/medical follow-up. It’s a complicated process but worth it in the end to get services at school. 

 

Section 504 Service Agreement – 504 Plans

A “504 Plan” or “Section 504 Service Agreement” is a civil rights law that refers to

Section 504 of the US Rehabilitation Act of 1973.  It is a legal document that outlines what accommodations your child needs to ensure equitable access in their schooling.  

A 504 SA can only be drafted after the school has conducted an evaluation or reviewed one that you have provided and discussed the findings with you. All participants agree that the student has a disability that limits their functioning in one or more “major life areas” and qualifies for protection as a result.  ​​These functions include such things as self-care, performing manual tasks, walking, seeing, speaking, breathing, learning, working, eating, lifting, bending, reading, concentrating, thinking, communicating, and more. 

504 Plans Level the Playing Field

A 504 is characterized by the accommodations that are necessary for the student to access the curriculum. It is designed to “level the playing field”. 504’s eliminate barriers to allow students with disabilities to access the same activities and programs as their non-disabled peers. It offers protection to persons with disabilities from discrimination based on their disability. Again, within this definition, ADHD qualifies as a disability. 

Students – at any level – who attend a school program that receives federal funding can be eligible for protection under a 504 Service Agreement. They require accommodations to access the General Education setting.  This means a student who is enrolled in preschool, elementary, secondary, postsecondary, vocational, or adult education can qualify, regardless of age. 

 

With the technical information about IEPs and 504 plans out of the way, let’s look at some common misconceptions and the real truths. 

Myths vs. Facts about IEP AND 504 Plans

MYTH:  My child was diagnosed with ADHD by her psychiatrist/family doctor/specialist, she should have an IEP. 

FACT: She should have an IEP only if progress at her grade level is negatively impacted by her ADHD symptoms. 

A common misconception that many parents have is that a diagnosis of ADHD, “dyslexia” (or a specific learning disability), ASD, Anxiety, etc., made by a medical professional, means that their child automatically needs Special Education programming and an IEP.  This is only true when there is an educational impact because the symptoms of that diagnosis make learning at grade level difficult for the student. 

If she is learning at grade level, but needs accommodations like extra time on tests, verbal directions, etc., to address symptoms of ADHD, then a 504 SA could be appropriate. 

 

MYTH: Our son’s outside executive functioning coach thinks he has ADHD and maybe dyslexia. She thinks the school should diagnose him.  

FACT:  A school cannot diagnose a student with ADHD or diagnose dyslexia. For a clinical or medical diagnosis, you should follow up with a primary care provider or licensed therapist. But, if the school were to do an evaluation and also find him eligible under IDEA, he would have educational eligibility under “Specific Learning Disability” and “Other Health Impairment”, and an IEP could be drafted. Remember that in schools, ADHD is considered an “Other Health Impairment”, and dyslexia is considered a “Specific Learning Disability”. The reality is that the same diagnoses a child receives from an outside clinical/medical professional exist in schools but may be categorized or called something different. No wonder parents get confused!

 

When considering whether an IEP or 504 SA may be appropriate for your child at school, here are 5 key takeaways:

 Key Takeaways

  1. An IEP makes mandatory adjustments and modifications, a 504 SA affords access and makes some accommodations. 
  2. Not all students with neurodivergence need special education!
  3. Clinical and medical diagnoses and educational disabilities are often two different versions of the same language.
  4. A school-based evaluation determines eligibility for special education or a 504 SA. 
  5. Going through the process of determining what types of services are best for your child can be very confusing. Get the support you need by talking with your primary care provider, licensed therapists, special education advocates or knowledgeable coaches.

Overcoming ADHD Brain Fog

Dear Dr. Saline:

I’m a 30 year-old AuDHDer who would love your input. I pride myself on my ability to focus and concentrate on what needs to be done. I’m achievement-oriented and used to be able to blaze through a to-do list. Lately though, brain fog has been hitting me hard. It’s been a period of very high stress. I find myself struggling to make sense of things people say which I would previously decode with ease. I’m hoping this is temporary but it’s embarrassing. What can I do? 

Thanks!

Crystal

Dear Crystal-

Brain fog can certainly be disorienting, confusing and even a bit scary for folks with and without ADHD or autism. Brain fog refers to a group of symptoms that impact how you function cognitively–your thinking, your recall and your concentration. It can also reflect difficulty with making decisions, mental fatigue, slower response time and uncertainty. While we don’t know what causes brain fog exactly, research shows that it’s associated with chronic fatigue syndrome, long COVID, chemotherapy, autoimmune conditions or depression. But, brain fog is not a medical condition so you can’t be diagnosed with it. It’s more like a set of symptoms that arise when something else is going on and you are not thinking as clearly as you could.

As you have shared, the symptoms of brain fog can make it difficult for people to engage in conversations, perform routine daily tasks and follow instructions. Plus, brain fog differs from person to person, particularly women. In fact, it disproportionately affects women because of hormonal changes related to menstruation and menopause. For folks with ADHD who already struggle with focus, memory and organization, stress can bring on brain fog by overwhelming weaker executive functioning skills. 

Develop coping strategies for daily stress

Of course, living with ADHD and AuDHD means living with a baseline of stress that neurotypical adults don’t have to deal with. The consistent inconsistency of being neurodivergent leads to being unclear– if you will follow through on things, if you will arrive on time, and if people will like you. You may freeze in the moment, unsure of what to say or do. Perhaps you lose your train of thought more often and get distracted more easily. Or, maybe you interrupt others or say something awkward without knowing it. This is especially tough in the middle of social situations, peer interactions or important work meetings.

Rely on coping strategies

Crystal, it seems like you’ve developed some useful coping tools to help you make sense of what others are saying to you and respond effectively. I can’t even imagine how frustrating it is for you to deal with this disorienting brain fog. And, let’s be honest, everybody spaces out sometimes. Yes, this may happen more intensely and more often for folks living with ADHD due to how their brains are wired. You are not alone in your embarrassment when this occurs. But, being upset with yourself for something that you cannot control only increases your stress and worsens the very brain fog that is troubling you in the first place.

It seems that  the question you are asking is, “How do I navigate these moments with more ease and less self-criticism?” I think your first step to lower your stress. I am a big fan of being authentic. Authenticity means being transparent and non-defensive when you miss a comment in a conversation or do something that you later regret. Self-care, exercise and self-compassion are all ways to reduce the tension in your life and hopefully the brain fog too. Try these  strategies to lower your stress.

4 techniques to manage brain fog in your life:  

1. Reduce stress by focusing on one task at a time: In today’s busy, constantly connected world, we live with too much to do and not enough time to reset. When we take a walk while talking on our phone or scroll while eating lunch, we don’t actually give ourselves the true break that we really need. We shred our time into distracted chunks instead of having space to exhale and regroup. When we multitask, we stress our brains and exhaust ourselves. Opt for single tasking as often as possible. You may not be able to eliminate all media multitasking habits but, with single tasking, you’ll feel more productive and less stressed.

2. Get enough sleep:Nothing weakens our coping abilities like a lack of sleep. Many people with ADHD struggle with sleep issues. Typically, folks wrestle with three aspects of sleep: falling asleep, staying asleep and waking up. It can be tough to turn off your mind. Perhaps you experience racing thoughts, intrusive worries or a fitful night of sleep marked by “tossing and turning” throughout the night.

Some people sleep so deeply that they struggle to get up in the morning, requiring numerous alarm clocks or physical reminders. Think about your sleep needs: how much, when and what helps you relax. Practice consistent sleep habits by going to bed and waking up at the same times and staying off screens for at least thirty minutes before you nod off.

3. Exercise regularly: I cannot emphasize enough how much exercise helps with clear thinking. The endorphins that are released during exercise enhance focus and increase your overall sense of well-being. Moving your body has been found to improve motivation, build energy and reduce confusion. The Centers for Disease Control (CDC) recommends that adults engage in at 150 minutes per week of moderate-intensity activity such as brisk walking, running, biking, etc. Of course, eating well helps your overall health too. So the next time that you are feeling brain fog descend, try to move your body and see what happens.

4. Chunk your activities and write things down: Instead of relying on hyperfocus, try breaking tasks down into 30-45 minute work blocks. You want to give your brain time to reset and rest a bit throughout the day rather than go intooverdrive and burnout. It can be tough for a lot of people who like to hunker down and plow through a set of projects. But overworking like this uses up the natural glucose fuel in the brain and then relies on cortisol. You wind up creating stress that doesn’t need to be there. Trying to remember everything also adds pressure. Give yourself a break and write things down. This also reduces stress and gives you the visual cues you need to be productive and stay focused.

Aim for reducing brain fog not eliminating it

Learning how to schedule adequate down time to integrate and process information, asking for someone to repeat what they said without self-criticism and taking care of yourself with good sleep, nutrition and exercise habits will reduce your overwhelm and your shame. Remember, brain fog is not your fault; you didn’t choose this. Instead, just explain what’s going on to someone when it is happening and move on. You’ve got this!

“I wish more people understood how it felt to be neurodivergent”: What to Know About Neurodiversity

Time for a societal change? Awareness of neurodiversity is one step, acceptance and valuing these differences are the goals. This would mean a shift from ‘corrective’ behaviour therapy offered by Early Intervention centres. Here’s what to know about the Neurodiversity movement.

‘There is nothing wrong with being neurodiverse. It is simply a different way of thinking. Some of the greatest minds in history are suspected of being neurodiverse and their discoveries have changed the world. If as a society, we could find a way to embrace neurodiversity and support individuals rather than treating it as a problem to be solved, we might be a lot further in finding solutions for some of the major problems we are currently facing’ says Donna who is neurodivergent herself and has two neurodivergent children. As Autism Acceptance Week (previously referred to as Autism Awareness Week) nears, two mamas and Speech and Language Therapists Fátima Ionescu and Melanie Muttit advocate for a societal change to move from awareness of autistic individuals and neurodiversity to acceptance, support and inclusivity instead. The autistic community would like us to move away from Autism Awareness and instead to Autism Acceptance due to the ableist views and perceptions created by Autism Awareness Day. This would also mean not aiming to “fix” or “correct” neurodivergent attributes and characteristics as some Early Intervention centres aim to do and instead looking for neurodiverse-affirming approaches

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How do I avoid the perfectionism trap?

Dear Dr. Saline, I recently started my first full-time job after graduating from college and feel like I’m struggling with the adjustment. I’ve had the usual ups and downs in school which come with ADHD. But now that I’m working, my tendency toward perfectionism has become overwhelming. Worst of all, I don’t think my work is any better as a result of all the extra effort I put into it. Do you have any advice on how I can get unstuck from the perfectionism trap? Thank you, Kathy

From Dr. Saline:

Dear Kathy, First of all, congratulations on your first full-time job! It’s an important milestone, and it’s natural to take time to figure out new routines and skills as you make this transition. Wanting things to go well reflects your desire to do well. But when this desire morphs into a need for everything to be just right, anyone can tip over into complicated perfectionism. Perfectionism is a common issue for kids and adults with ADHD who simply want to avoid making another mistake (again). While banishing perfectionism forever may be your goal, it’s not that realistic. Instead, you can learn to turn down its noise and create more effective coping strategies for motivation and quality.

Perfectionism and ADHD

For folks with ADHD, perfectionism can be a way to overcompensate for feeling not good enough or being “less than.” It’s also a way to hyperfocus on a task, project, or idea as you push yourself to get “just right.” The trouble with perfectionism is that it can be a double-edged sword. When used productively, it can be a driving force in helping you do your best work. But it can also create a great deal of troubling anxiety that actually hinders progress. It’s all too easy to get stuck on one detail, go down a rabbit hole, and then lose sight of the bigger picture.

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How 3 Useful Changes Can Make Positive Differences in Your Life

HOW 3 USEFUL CHANGES CAN MAKE POSITIVE DIFFERENCES IN YOUR LIFE

Proactive change is a fascinating thing. It’s the type of change you seek when you desire a shift in your life. You might have identified an area you want to improve, a behavior you want to stop, or a wish you want to manifest. You are ready for a transformation but may feel overwhelmed with where to begin or what to focus on. Change is possible through desire, small steps, and support.

This week, I attended the educationally stimulating ICD Virtual Conference, “Shining a Spotlight on ADHD.” There were three terrific speakers- Melanie Sobocinski, PhD, PCC, Sharon Saline, Psy.D, and Ari Tuckman, PsyD, MBA. They shared a wealth of information. I’m focusing on three ideas I learned about change that I thought would be especially helpful.

Read the article! Oh, So Organized

Midyear Reboot: Five Strategies for Building Effective Habits

Midyear Reboot: Five Strategies for Building Effective Habits

AS WE APPROACH THE MIDPOINT OF THE SCHOOL YEAR, many parents notice that their children are less motivated and less engaged than they were in September. Perhaps their grades were disappointing or they struggled socially. If they’re in middle or high school, they may have changed schedules and teachers and are dealing with new experiences daily despite a general sense of blah. Developing new habits in order to set themselves up for success both in and out of school is what’s called for. This is a great opportunity to pivot and create habits that promote positivity and success. Even though change can be tough, doing the same thing that isn’t working likely results in defeat.

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How To Get An Accurate Diagnosis For A Child Who May Have ADHD

How To Get An Accurate Diagnosis For A Child Who May Have ADHD

If you have a child or teen who seems to be struggling more with low motivation, keeping up with school work, and organizing things from clothes to projects to chores than at the beginning of the school year? The winter doldrums are no joke for many students, especially those who may have ADHD or live with neurodivergence. This is a good time of year to look under the hood and investigate what’s going on for them and why they are wrestling with productivity and performance. While this process can seem daunting, investigating what is happening will offer information about their cognitive and emotional functioning.

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Using a Dopamine Menu to Stimulate Your ADHD Brain

Using a Dopamine Menu to Stimulate Your ADHD Brain

Your brain is a Tesla. When its battery becomes depleted, it needs to stop and recharge. You know the feeling when your power is draining down, but you don’t always know how to replenish it. Many of us grab our phones for a ‘quick’ doom scroll or a game of Geometry Dash. Others eat a cookie. This behavior is understandable, but it’s not helpful. “Most of us don’t spend hours scrolling through social media because we think it’s a good use of our time; we do it because we are looking for the stimulation we need to function,” says Jessica McCabe, the creator and host of How to ADHD, a popular YouTube series, and author of the new book How to ADHD (#CommissionsEarned).

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How to Control Your Anger When ADHD Emotional Reactivity Kicks In

How to Control Your Anger When ADHD Emotional Reactivity Kicks In

Yes, the ADHD brain is wired to overreact and to feel emotions intensely. But you are not your ADHD reactivity. Here, learn how to change your reactive, habitual anger responses with thoughtful, soothing responses.

It starts with a trigger. In an instant, a volcano of anger and negative emotion erupts. Before you can process what’s happening, you say or do things that you will surely regret later. But you can’t stop yourself. If we’re being honest, sometimes it feels good to let it all out. Living with attention deficit hyperactivity disorder (ADHD) means living with a stress-producing condition that begets emotional reactivity.

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