In My Psychological Shoes
It’s fair to say I have always been an ADHD sceptic. I’m not crazy about mental health diagnoses per se but I particularly grapple with the ADHD label. Admittedly, I have never been part of an “ADHD clinic” partly due to my scepticism, and partly because I feel uncomfortable being part of a process that diagnoses children from a young age. In my view, there are many different developmental trajectories children could travel down and I remain curious about who benefits from such a label.
My scepticism has grown with my experience. My curiosity about why a child displays erratic, unmanageable behaviour, and struggles to concentrate remains dissatisfied with the psychiatric perspective. I found when I met families, I heard stories associated with fearfulness, anxiety, and difficult early relationships, to name a few. As my understanding grew, I would often formulate that their current concerns were connected to their child’s early attachment experiences and early trauma, rather than ADHD.
ADHD v. Insecure Ambivalent Attachment
The characteristics of ADHD look like an Ambivalent Attachment Style. This is associated with receiving a particular type of care. We know that children who have developed an Ambivalent Attachment style are unsure if the adult(s) around them are going to meet their needs. This is because their care has been inconsistent. Sometimes their needs are met, sometimes they’re ignored, sometimes intervention is intrusive and intimidating, sometimes it’s shaming. Basically they aren’t sure of what they’re going to get or when they’re going to get it. Such parents tend to be preoccupied with their own needs, rather than their child’s.
One strategy the child may use is to up the ante. This maximises their chances of getting the adult’s attention, regardless of the response. These children are highly activated and behave in an impulsive and dysregulated manner that can come with a level of risk taking. Their cognitive capacity, their ability to think, is diminished. They find it hard to concentrate, are more likely to struggle academically, and their social skills are usually impeded. Their world is psychologically unsafe so it pays to be on the go. Yet they can be perceived as needy, maybe clingy, and find it hard to separate from the important adult(s) in their life. In fact, separation is a challenge for them.
Looking at the criteria for an ADHD diagnosis in the Diagnostic Statistical Manual (DSM – 5), all the “symptoms” are behaviours you would find in a child with an Ambivalent Attachment style; a child who has experienced trauma and is fearful and dysregulated. Concerning too is the subcategory which states for ADHD to be valid “symptoms do not occur during a psychotic episode and are not better explained by another mental disorder.” Where is the nod to this being a trauma related presentation? This also raises questions about the misdiagnosis of ADHD which can be avoided through a comprehensive psychological assessment and formulation.
When I remember some of the families I’ve worked with, I wonder what may have been happening in their lives that could not be spoken about. What did I miss? What wasn’t I told? With these cases, and those who had secured a diagnosis and medication, how much did the diagnosis become a defense, a way of avoiding the real underlying issues? Children speak volumes through their behaviour, making it imperative to remain reflective about what they are showing us when trying to make sense of their presentation within the context of their personal history.
What Psychology Can Offer
In formulating psychological difficulties I’m asking what has happened to someone rather than what is wrong with them. I’m not saying that everyone who comes to me has a traumatic history. It’s about being open minded about someone’s life, their experiences, and significant relationships. By remaining curious and offering safety, attunement, and empathy, reparative experiences can take hold. In my experience, this needs to happen with the parents or carers, offerings them a space to reflect on their child. The aim here is to empower them and to form a collaborative understanding of what might be going on. This includes thinking about difficult periods of the child’s life, and possibly the parent’s, unpicking family/parental trauma that has become the child’s, or thinking specifically about the child’s trauma and what this may mean to them. I have seen change take place through such work: it’s powerful and meaningful.
By focusing on the relationship, both therapeutic and between parent(s) and child, difficult traumatic times can be processed and understood. This allows a different dynamic to form; one that is not defined by trauma or a diagnosis. This permits families to move forward, down a different road than one that was anticipated months before.