By Meg Kapil, MA, CCC-S, RCC
Note: This article is a supplement to All of me: A whole-person approach to supporting neurodiverse clients published in the Fall 2021 issue of BCACC’s Insights magazine.
It is imperative that neurodiversity is approached with the whole person in mind and with a strong understanding of the interweave of mental health, stress and emotion regulation, and learning regulation. This holistic perspective towards thriving, optimal functioning and flourishing mental health is built on understanding the neurodiverse mind and presenting practical strategies and processes to support this aim. Mental Health is widely viewed as a state of well-being that supports individuals to cope with stressors, work productively, and function as a contributing member of society (World Health Organization), this is indeed what we are working towards in our support of neurodiverse individuals.
While it may seem daunting to address all of these pieces, a research-supported, three-layer approach to mental health can guide your work. As you are introduced to these three layers, note that you may not always approach support in this order; your approach will of course be informed by the individual client you are meeting with. However, if you run into challenges and things are not going well, a neurosequential and trauma-informed approach tells us to go back to the preceding layer (Perry, 2009). This is when considering these layers as sequential is important and arms us with the knowledge that a person does well if they can (Greene, 2014). And if they aren’t doing well, the layers give you a place to look for unmet needs or lagging skills. While it is not possible in this article to discuss all the neurodiverse variations you might encounter, a few relevant considerations will be included as we proceed through each layer with the main focus on understanding an ADHD mind.
Very briefly, ADHD is a neurodevelopmental syndrome affecting the brain’s self-management system that interferes with functioning and development, including emotion regulation, motivation, academic success, learning, and social interactions (Brown, 2013; Goldrich & Goldrich, 2019). While previously, ADHD was understood in terms of challenging behaviours, it is now considered a broad issue of self-regulation (including executive function challenges) from poor patterns of connectivity and maturation between brain regions (Brown, 2013).
Layer One: Stress and Emotion Regulation
According to the theory of constructed emotion (Barrett, 2017), emotions are not universal or built-in but constructed over time. Emotions emerge from physical properties of your body, a flexible and adaptive brain that wires itself according to the environment it resides in, and your culture and upbringing that provide that environment. Your brain uses past experiences to build a hypothesis or simulation and then compares this to your current experience via your senses. Your brain then imposes meaning on this after the fact and decides what is relevant and what to ignore. An instance of emotion is constructed when your brain makes meaning from the combination of past information, sensory information from the external world, and from internal information (e.g., body sensations, thoughts) and prescribes action.
Stress is constructed just like other emotions with some stress being positive and some negative. Instances of stress are constructed via the same brain mechanisms that construct other emotions. The sensory inputs for stress and emotion are the same and the same pair of neural networks (e.g., interoceptive and control) have the same function in emotion and stress. The only difference is the end result and whether your brain categorizes the sensation and experience as stressful or emotional. Your brain then issues predictions about the budget of your body relative to the outside world and makes meaning.
Inner motion or movement of your body that is recognized by your brain is called interoception. Your brain is constantly keeping track of what is happening in your body and then explains these sensations by assigning meaning to them. For example, recognizing a rapid heart rate can be explained as fear or excitement depending on the context. Your brain models the world from the perspective of someone with your body and your experience and predicts sensory consequences of movements inside your body.
Now consider all of this within a neurodiverse system that is predisposed to heightened sensitivity to threat and interoceptive information (Brown, 2013), as well as overwhelm from sensory input. These factors contribute to how emotion and stress are constructed within a neurodiverse system as more overwhelming and more threatening. This interpretation is what fuels the big reactions and actions from neurodiverse individuals. The brain makes meaning of the current emotion from past experience (which are often overwhelming), current sensory information which can be experienced as aversive, from internal information like body sensations and thoughts (filtered through the heightened predisposition to detect threat), and action as prescribed consciously (intentional behaviours) and/or sub-consciously (stress behaviours) (Delahooke, 2019).
With all this in mind, a neurodiverse system is often experiencing a situation differently than a neurotypical. A classroom setting for example can elicit past recollections of feeling overwhelmed or ashamed, heightened internal sensations such as heart rate and muscle tension along with critical or negative thoughts that are interpreted as threatening. With this understanding of what is happening within the neurodiverse system, it is not a surprise that the neurodiverse person experiences more stress, anxiety, or overwhelm (Brown, 2013) and the prescribed action is defensive behaviour (e.g., anger, frustration, task avoidance) in response to this experience. Thus, the priority becomes regulation of the stress and emotional response first. ADHD brains experience emotions more intensely, with the bottom-up brain signals (e.g., emotional reactivity, limbic system) dominating the top-down signaling (e.g., intentional signals based on goals and learning, prefrontal cortex) (Dodson, 2019).
A full exploration of stress and emotion regulation is beyond the scope of this article, however a framework I follow has three main points of focus: 1) Adult regulation first, 2) Short term focus, and 3) Long term focus and health habits over time. I will describe each of these briefly here.
Adult Regulation First
With the mind defined as relational decades of research on attachment theory, and emerging neuroscience findings regarding mirror neurons and the importance of co-regulation during times of distress, we know that humans impact other humans (Siegel, 2020). Although the adult (e.g., parent, teacher, counsellor) is not necessarily the cause of the other person’s distress or dysregulation, the adult does have a choice whether to make the situation better or worse. We have long known that how a person makes us feel matters more than what they say or do (Ainsworth, 1967). Thus, to impact any person positively, and even more so a neurodiverse person given their extra threat sensitivity and sensory sensitivity (Posner et al., 2011), attending to your own regulation first is critical. This will include regulation of body sensations and cognitions. Effective regulation also includes awareness of the assumptions and implicit views you have about the neurodiverse person. For example, without understanding, a neurodiverse person is more likely to perceive your facial expression as threatening (Stringaris et al., 2018), you might assume they are “overreacting” or being “irrational.” When you understand and have empathy for their experience, you will instead recognize your role in co-regulating their reaction and not take behaviours and words sent your way as personal. Instead, you will perceive a stress response that completely makes sense when you understand a neurodiverse mind.
The vast expanse of attachment research can be succinctly understood and communicated to adults who support neurodiverse people with the four S’s outlined by Daniel Siegel and Tina Payne Bryson (2020): Seen, Soothed, Safe, and Secure. With neurodiverse individuals, the missing pieces of the attachment equation are typically Seen and Soothed, which then make Safe and Secure impossible. The Seen comes from understanding what it is like to have a neurodiverse mind such as sensory and threat sensitivity and communicating that understanding with empathy and compassion. The Soothed comes from appropriate co-regulation, which of course rests on adult regulation first. Most of all, strive for the “mutual delight” describe by Mary Ainsworth (1967) that is integral to a secure relationship. All of us thrive when we know the supportive adults around us see our strengths and gifts, as well as our challenges, and accept and “delight” in us just as we are.
Short Term Focus
Regarding co-regulation, a neurosequential understanding of development guide us by attending to regulate first, then relate, then reason (i.e., Bruce Perry, 2009, 2020). Regulate refers to non-verbal or minimally verbal interactions designed to communicate safety. This differs according to an individual sensory profile and might include distraction and encouraging movement. For example, this might be walking for one person, touch (if appropriate) for another, or respecting a person’s need for space and physical distance for another Delahooke, 2019). Relate refers to relationships and we can include the four S’s of attachment here. If relate is not going well, go back to regulate until a person is ready to engage with us socially. Polyvagal theory (Porges, 2011) helps us understand this also, as we know that in a state of sympathetic arousal (e.g., anxiety, stress, frustration, anger) or immobilization (e.g., despair, shame) a person is not able to socially engage. And finally, reason refers to problem solving and reflecting and generally talking about things. A common error adults often make is attending to reason first. When a person is not adequately regulated, this usually goes really badly. While dysregulated, the other person is still seeing you as a threat and responds accordingly.
At times when the other person is highly activated (aka “freaking out”) just validate their emotional experience (this is again where understanding what things look like from within a neurodiverse mind is important) and provide either reassurance or set limits depending on the situation. That is all you need to do in the short term. A lot of conflict arises from trying to ‘reason’ at this point of focus, when it cannot possibly work with the person in a defensive state (e.g., sympathetic arousal; refer to Porges, 2009). Instead, simply validate their experience and reassure or set limits with a bridge to later when everyone is regulated enough for reasoning again.
Long Term Focus
In terms of healthy habits and effective stress and emotion regulation over time, this is most of what we do in the counselling office. Most counselling offices, and even virtual offices, are really nice places and spaces and designed not to be stressful. We work on all sorts of strategies with clients like breathing, cognitive reappraisal, and mindfulness. Research tells us what works, except that it is very, very hard for a person (especially a neurodiverse child) to put this into practice at the time when they are very distressed. Over time, for example, mindfulness can enhance top-down intentional regulation of attention and emotion (Mitchell et al., 2015) and neural circuity such as the default mode network (Fair et al., 2010). However, you will only be able to teach this and develop mindful awareness when the individual is already in a regulated state. Over time and from much repetition, an individual will be able to draw on strategies and practices while dysregulated, but it takes considerable practice while regulated to achieve this. Thus, being clear with adults who are tasked with co-regulation, about expectations and the difference between how to respond in the short term (high activation) and the long term (regulated state) saves a lot of frustration and increases success.
Layer Two: Interpersonal and Intrapersonal Communication
Interpersonal Communication: The basics
With ADHD systems in particular, there is increasing evidence of heightened sensitivity to perceptions of rejection, or Rejection Sensitive Dysphoria (RSD) (see Dodson, 2021a). RSD is also considered to play a role in challenges with interpersonal communication and intrapersonal communication. One proposed mechanism for RSD includes the sensitive threat response system (e.g., HPA axis, sensory information) (Nigg et. al, 2020; Stringaris et al., 2018) that will contribute to a neurodiverse person interpreting as a threat, criticism, or rejection what might appear neutral to another. Another possible mechanism is the default mode network in the brain that scans for information within us and in others and our environment, essentially being active when we are “idling.” In neurotypicals, this neural network is only on when a person is idle. When they have something to do, their task positive network is active. These two systems operate in opposition with each other. In ADHD minds, the default mode network interferes with goal directed activity and does not turn off when attention circuits are on (Brown, 2013; Fassbender et al., 2009). This functionally creates excess “noise” for the person. A further influence is the tendency of the ADHD mind to hyper focus on something of interest, kind of like tunnel vision, without the awareness of how others may be impacted. What this means functionally is that the ADHD mind has a hard time noticing what cues are relevant and struggles with being attuned to others, something a neurotypical takes for granted.
Armed with this understanding that ADHD minds may interpret a neutral cue as a threat or rejection, and that they really struggle to “read the room,” social interactions can be really difficult and upsetting (Stringaris et al, 2018). The first priority is to support ADHD minds with attunement, that is being able to interpret social cues and accurately read the experience of others. This is most effective if you can do this by asking reflective questions (e.g., “What do you think I’m thinking right now?”; “What was that like for me?”) and gently and kindly increase awareness of what to look for (e.g., “You can see that [name] is upset by their expression, body language, and words”), and what to do for improved interactions (e.g., social skills, boundaries). From a neurotypical perspective, it may look like a neurodiverse person is crossing a boundary or being disrespectful, but in my experience, that is not the case. They often struggle to “read the room” and really are baffled by the reactions of others. These skills can be taught, not by just telling someone what to do (and especially not in a shaming manner) but by showing them with understanding and compassion and scaffolding their growth with practical support. This is resource heavy at first and pays off in the long term; there really is not a shortcut here.
Without practical support and understanding, the neurodiverse person really is at risk for rejection and neurotypical assumptions that they crossed a boundary “on purpose.” Many of the amazing neurodiverse individuals I have met arrive with such a huge history of rejection and negative feedback that mostly arises from others misunderstanding how their minds work. As you can imagine, the ripple effects of this history extend beyond their interactions with others to include how they relate to themselves.
Intrapersonal Communication
From the previous section, it is not a surprise that many neurodiverse individuals are at risk for anxiety and depression (Brown, 2013) and a very critical and negative self-perception. This is just mirroring what they have heard and internalized from others. Supporting neurodiverse individuals to know their own minds and consequently know their strengths is paramount. For example, you will find strengths like creativity, empathy, energy, determination, problem solving, imagination, humour, compassion, and so much more in neurodiverse individuals. Further supporting self-compassion (Neff, 2003) and a kinder relationship with themselves is also important, and often not easy. Finally, I have found it helpful to understand how the myriad negative interpersonal interactions a neurodiverse person experiences in a neurotypical world, combined with a sensitive threat-detection system, can result in deep negative core beliefs of unworthiness and feelings of shame. I have addressed these from a trauma-informed perspective and addressed specific memories with EMDR (see Adler-Tapia & Settle, 2012). There are of course many other options regarding how to work with this history of interpersonal and intrapersonal wounds, just be aware that this is especially relevant for the neurodiverse community.
Layer Three: Regulation of Learning
Even though I have presented them sequentially, these layers do not have to be addressed in a linear manner. For example, look for moments of regulation and get to work on layer three right away, but go back to layer one and layer two when the individual is dysregulated. Addressing learning and strategies can be ineffective when the individual is in a dysregulated state, (Perry, 2009; Porges, 2011; Siegel, 2017).
Poor regulation of learning can also be a significant stressor and be a factor in emotion regulation challenges. The layers interact reciprocally, and you will be more successful by attending to all three. Challenges with learning can be incredibly defeating, create a gap between potential and performance, and can contribute to both poor stress and emotion regulation (Layer one) and low self-worth/self-compassion by contributing to faulty negative self-beliefs (Layer two). What are often considered mental health considerations are typically addressed separately from learning, school, and work considerations. However, all of this is occurring within the same person. Further, a complete state of mental health includes the presence of positive emotion, regulation of negative emotion and stress, and attaining personal internal standards and goals (e.g., school success, healthy relationships, autonomy) (Keyes, 2002, 2005; Ryff, 2015). Truly supporting well-being and thriving rests on attending to the puzzle pieces of being well (Layer one and two) and doing well (Layer three).
Further, many learning challenges co-exist with ADHD. Some examples include challenges with time, sequencing, and poor working memory (Brown, 2013). Also, learning disabilities such as dyslexia and dysgraphia (Brown, 2013) will need to be addressed specifically. A full psycho-educational assessment can provide you with information about the specific areas of learning challenges and guide next steps. All of this is supported by working from a self-regulated learning perspective that addresses learning processes including task understanding, goals and plans, strategies and tactics, and reflection and adaption (Winne & Hadwin, 2008; Zimmerman, 2000). Consider continual and reciprocal process of awareness and change. Very simply, address the learning challenge area, come up with an evidence-based strategic approach, define how you will know progress has been made, reflect on whether any changes or adaptations are needed, and repeat. Addressing regulation of learning is intentional and systematic. Next, I will introduce a few areas of learning regulation challenges that often occur in ADHD minds, and strategies to address these challenges.
Interest-based attention system
Even though inattention is in the diagnostic criteria for ADHD, a more accurate description is variable attention or an interest-based nervous system (Dodson, 2021b, 2019). ADHD minds struggle as much with hyper-focus and inconsistent attention as inattention (Dodson, 2019). For example, it can feel easy to engage with an area of interest but really struggle to engage with tasks or situations that are assessed as ‘boring’. Thus, ADHD minds will need support to shift attention, especially out of something interesting (e.g., video games) to something less interesting (e.g., homework). Switching out of an activity that has hooked the attention and affect of a neurodiverse mind can feel like a threat, stressful. Often, a stress response such as anger will ensue. You can mitigate this stress response by “getting into their world” or asking questions and being curious about what they’re doing and reminding them they can return to the interesting thing at the later date. Threats don’t work well here; they only serve to dysregulate an already sensitive to threat system.
ADHD can have variable patterns of functioning (Brown, 2013). An ADHD mind can engage in complex effortful tasks if they are interesting. However, if something is assessed as boring, the perception is that this will be very demanding on the system, and the person may shut down. This is actually a motivation challenge (Brown, 2015) or a stress response and not being ‘lazy’ as is commonly claimed. The person will benefit from support and getting moving on the task, even if that just means writing your name down. Just create some movement in the direction you want. To increase a person’s perception that they are capable, or have self-efficacy, you need to help facilitate a mastery experience or an experience of success (Usher & Pajares, 2008). Thus, more support not less usually improves outcomes.
Non-Verbal Working Memory And Time Conceptualization:
If you are neurodiverse, especially if you have an ADHD mind, you likely have been accused of being “not responsible” and “not organized” and “not living up to your potential.” These comments are of course deeply hurtful and inaccurate. They are also typically delivered without any clarification about what is meant or unsupported by practical strategies regarding how to improve. ADHD minds often struggle with poor non-verbal working memory and poor conceptualization of time (Brown, 2013; Nigg, 2017). What this means functionally is the person is unable to “picture” the end point and consequently how to get there (sequencing) or how far away that end point is. ADHD minds are perpetually in the present and do not easily the beginning, middle, and end of a task.
For example, consider if an ADHD mind is asked to clean their room within the next two hours. To complete the task, they are not easily able to picture “clean room,” are not able to determine how far away two hours is, and are not able to draw an imaginary mental map of how to get from here to “clean room.” Furthermore, all of this is perceived as effortful and not interesting. Thus, when attention is grabbed by something more interesting and immediate, like playing with a toy or scrolling through your Instagram feed, “clean room” is quickly forgotten. The reason the room is not cleaned is not because the person with ADHD is lazy as they are so often accused; it is the function of challenges related to the interest-based attention system, poor non-verbal working memory, time conceptualization, and sequencing.
The solution is to provide a picture of the end point first. Thus, an actual visual of what “clean room” looks like in this example and perhaps a clear description of what a finished project looks like for another example. Then, help the person to create a visual map including tracking of time of how to get from here to the end point, provide them with support to get started, checkpoints along the way, and reinforce efforts and progress.
Reward Assessment Challenges
Another common challenge often experienced by ADHD minds is related to assessment of rewards, namely frustrative non-reward and not being able to keep in mind a distal reward (Scheres, 2007; Volkow et al, 2010). You already know that ADHD minds struggle with being able to picture something farther away. This might lead to an ADHD mind expecting a reward sooner and being frustrated when it does not happen. This also impacts motivation and trying to keep in mind a reward that is far away. The short-term reward usually wins as a result.
Consider a student that needs to work on an academic task for a couple of hours. The long-term reward will be completion of the task (internal reward from a job well done) and perhaps a break or a treat (external reward). However, their friend sends them a message that they’re online right now, can they play a game? The distal reward vanishes and is replaced by the short-term reward (the video game). This is amplified when the task is perceived of as effortful and challenging, which can elicit a stress response (hint: go back to layer one). To counter this pattern, break the task down in much smaller, more clearly defined and manageable chunks. Remove short term distractions like phones and other notifications. And build in more frequent and proximal rewards such as taking a break. Finally, having a regulated adult alongside and using creativity to generate interest in the task will further help keep things on track.
With the mind and development increasingly viewed as relational (Schore & Schore, 2008; Siegel, 2020; Siegel & Payne Bryson, 2020), this approach truly considers the neurodiverse person as a whole system of experiencing and interacting. Most of all, this informed way of moving with the neurodiverse people in your counselling practice and your life is respectful and honours the unique gifts and strengths of these beautiful hearts and minds.
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Meg Kapil is an RCC in private practice, PhD candidate researching the interweave of mental health, stress regulation, and learning, and passionate about understanding and supporting the whole person.
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