How can we best support students with ADHD?

Dr. Saline: Inconsistency in motivation, inconsistency in the predictability of what you can and cannot do is one of the most challenging aspects of living with ADHD.

Kevin: Attention deficit hyperactivity disorder, known as ADHD, is among the most common mental conditions in children with an estimated six million children having been diagnosed with the disorder. Children with ADHD often feel misunderstood, and their parents often feel uncertain of the best way to be there for their child. What is ADHD, and how does it impact children? What should parents and educators know about this disorder? And how can we best support students with ADHD? This is “What I Want to Know,” and today I’m joined by Dr. Sharon Saline to find out.

Dr. Sharon Saline is a clinical psychologist and ADHD expert. She specializes in an integrative approach to managing ADHD, anxiety, executive functioning skills, learning differences, and mental health in neurodivergent children, teens, and adults. She joins us today to discuss how we can best support students with ADHD. Sharon, welcome to the show.

Dr. Saline: Thank you for having me. It’s great to meet you, and I’m looking forward to our conversation.

Kevin: So, you know, based on your bio, you have 30 years of clinical experience in this field, but I want to go back a little bit. Let’s talk about, you know, what inspired you to do this work. I mean, for many, this isn’t the type of thing you say you want to do when you’re a kid and you aspire to a future work life. So talk about what led you to this important work.

Dr. Saline: That’s a very interesting question, and we could spend the whole time talking about that. So I’m just going to try to consolidate my answer as much as possible. I never thought I wanted to be a psychologist. I was working with the Boston Youth Theater in the early ’90s, I guess the late ’80s. And we were, you know, I was working with inner city kids in Boston doing theater. And I found that I was more interested in their personal stories than in the production itself. And that was true in some other aspects of my work. At that time, I was teaching theater to kids, and I found that I was drawn to working with the kids. And so I decided to pursue a graduate degree in psychology, and I focused on children and families. And over the years, of course, that led to all kinds of different topics of interest.

I actually wrote my dissertation on gender differences in children’s dreams . . .

Kevin: Wow.

Dr. Saline: . . . and then went on to focus on ADHD a little bit later when actually my nephew was diagnosed with ADHD. And my brother then realized he had it. And I found that that dovetailed with the clients who were coming into my office and the clients I was seeing at school consultations.

There was just like this whole sort of synchronicity of events to spend some time doing a deeper dive into the subject, and I’m so glad that I did. I’ve learned a lot, and in recent years, as the diagnostic criteria has changed and more information on women, post-menopausal women with ADHD has come out, I’ve learned that I have a mild form of ADHD myself too.

Kevin: You know, first of all, I’m married to a psychologist, so I understand. I viscerally connected with your story when you talked about, you know, working in the play and wanting to know more about the personal stories. I mean, I hear that, and I’ve witnessed that with my wife for many years. There is something I think truly special about folks like you and my wife, who have that inherent gift to explore where folks are coming from and how to help cure or at least provide some support for challenges associated with that, because that’s not a skill set that everyone has.

Dr. Saline: Well, I think that’s true, and I think that also there’s been a change, at least in the type of psychological work that I do, in that it’s not just where you’re coming from, but it’s where you want to go.

Kevin: Yeah.

Dr. Saline: How do you want to live your life today and in the future? That the past is behind you, but it informs what you’re doing now. And you have the opportunity to make changes to create the life that you want to lead. And I think that’s really important for all folks, but it’s particularly important for those who have ADHD or who are neurodivergent because they’ve often come up through the years with what I would call the thousand paper cuts of trauma.

Kevin: Yeah.

Dr. Saline: Not necessarily single incident trauma or chronic trauma, but what we call complex trauma, a mix of these things. And a sense that you’re never good enough, that you’re always waiting for the next shoe to drop, a way in which you feel stupid and excluded and not good enough. And so I think working with kids and trying to assist with that while they’re experiencing it is helpful. But then being able to work with adults to unpack the patterns that they develop in those years and shift them now that they’re an adult and they have, you know, although the mature resources and tools to deal with things differently,

Kevin: You know, I want to really unpack ADHD, but I did also want to talk about where we are generally in this country as it relates to mental health and the mental health of our children, the mental health of everyone, but particularly our children. COVID sort of was a revealing force of nature, if you will. And, you know, schools, families, societies overwhelm with, you know, dealing with mental health challenges that, in some ways, some were apparent and some were being dealt with. But in other ways, some just weren’t as known or obvious to people. And we’ve seen that particularly in schools. And putting that on the one hand Sharon, but on the other hand, this sort of mammoth change in how folks in your field look at these challenges, you know, treat these challenges, these treatment modalities in the psychology world have come a huge way from where they were, you know, 15, 20 years ago.

So when you look at that entire space of mental health, you know, and there’s just this overabundance of need out there, how do you discern where to begin? Because every psychologist I know, they’re filled up. You know, you can’t get scheduled. For child psychologists, it’s the same thing. How do you work through that, recognizing that we’re in a new age of need and I think opportunity?

Dr. Saline: I think that one of the challenges that mental health practitioners are facing now is this wave of post-traumatic stress disorder that people are living with post-COVID. Sometimes it qualifies for the disorder itself, meets the standards. And sometimes it’s just the sort of post-COVID trauma that’s lingering around. And I think that we can’t really determine, “Oh, I’m going to see you because your need is more important than the need of this person over here.”

Kevin: Right.

Dr. Saline: You know, I work with children, teens, adults, families, and couples, and everybody is struggling in different ways. And part of what’s happened during COVID is for young people, and I see this in the schools where I consult all the time, teachers will tell me that fourth graders seem more like second graders, that sixth graders are more like fourth graders, ninth graders seem like seventh graders. That there’s a loss of not just cognitive ability, skills, tools that they weren’t able to obtain well in COVID, but emotional maturity, social maturity. And for our neurodivergent learners, who were in possibly the worst situations they could be in, having to learn on-screen, unsupervised, for the most part, without the support that they were used to in the classroom, having people look at them directly, which increased social anxiety, all of these things have had a lasting effect on our learners.

I think people are starting to turn the corner, but they’re carrying around a legacy of anxiety and some depression as a result of that. It’s changing. I mean, I think the Surgeon General came out with this really crucial report in May about loneliness and isolation in mental health concerns for children. And these concerns are even greater for children of color, who have many more barriers to access for care and adequate treatment.

The fact is that if you’re a person of color in certain parts of this country, there’s bias towards you the minute that you walk in the door for a clinic or to see a provider. Bias for kids that they look older, they’re treated older than their Caucasian peers, bias about the kinds of labels and diagnoses that they should receive or are receiving. And then, of course, for people of color themselves, for parents, a lot of distrust of the mental health and health systems, based on years and years of mistreatment.

So it’s very complicated. And so, you know, what the research shows is actually under-diagnoses and proper treatment in communities of color. And the public belief is that it’s over-diagnosis and overtreatment in communities of color, which is very interesting.

Kevin: It is fascinating. I’m certainly well aware of a lot of what you said. But let’s talk about ADHD more specifically. And let’s start with the basics, because you hear people say, “Well, so-and-so is on the spectrum,” which has kind of taken on a life of its own. You know. And sometimes people who say that, they may not even know what they mean. It’s become almost a way to say I don’t know if othering is the right way, but, you know, “There’s just something different about, this person.” You know?

Dr. Saline: Yes.

Kevin: And so define ADHD, and also let’s talk a little bit about the signs that parents should look for, because in this whole world of mental health challenges, and I say opportunities, the lines are blurred for those who are not knowledgeable.

Dr. Saline: It’s true. So ADHD is a chronic condition. It’s a neurobiological condition that affects the areas of attention, concentration, and performance. And it manifests in three different categories — hyperactive, impulsive, inattentive, or a combined type. And the symptoms of ADHD, I don’t like to use the word impairments, but the challenges that we see in those areas are more frequent and severe than we would expect in a person of the same age.

And in order to receive a diagnosis of ADHD, according to the DSM-5, which is the “Diagnostic and Statistical Manual” we use here in the United States, you have to have 6 out of 9 symptoms in 2 areas of functioning before the age of 17. And after the age of 17, you have to have 5 out of 9 symptoms. And these symptoms have to appear before the age of 12.

Now, this is quite controversial, Kevin. I actually just returned from the APSARD Conference in Florida, which is the research conference for ADHD. And there are some very brilliant people who are working on setting up guidelines for adults with ADHD, because if you are an adult with ADHD, you may not have demonstrated symptoms before the age of 12, and you may not have demonstrated symptoms before the age of 12 for a whole number of reasons. People who have high cognitive intelligence can compensate for their deficits in working memory or processing speed for a long time until they’re met with challenges that have to do with prioritizing and planning and working memory and emotional control and organization and initiation, these are all executive functioning skills that we all have. When you have ADHD, your executive functioning skills are more seriously impaired than when you don’t have ADHD.

And so what we want to find out is what are those areas where you’re struggling? What are those six out of nine symptoms? And that’s where we would begin to work with you on creating tools and improvements that are both cognitively based but also might include medication. Because ADHD is a neurobiological condition, it is not a figment of your imagination. Everyone doesn’t have a little bit of ADHD. It doesn’t work like that. Might you be inattentive sometimes? Sure. Might you have some trouble focusing at times? Of course. But does that mean you have ADHD? Probably not, unless these symptoms are severely impacting your ability to function at school, at home, at work, socially, etc.

Kevin: What’s fascinating about this, you talked about controversies, and one of the controversial aspects of this diagnosis is that, and particularly you mentioned, you know, kids of color and underserved communities, that in school settings, they’re often misdiagnosed. And, as you said, some of these symptoms may not even reveal themselves to a later age. And labeling of kids as being not competent, not being able to function properly in a school environment. And then the way these kids are impacted by all of that has become not only a challenge, but it’s been devastating. So talk a little bit about a teacher in a school setting, what they should be looking for, which leads to a potentially proper diagnosis by the proper official, as opposed to some colleague in the classroom over saying, “Oh, that kid just doesn’t so and so and so and so.” And there’s so much of that in our schools.

Dr. Saline: There is a lot of it. And here’s the thing. Inattention, or having trouble sitting still, can be related to a number of factors — depression, anxiety, trauma. It’s not just about having ADHD. Does ADHD, you know, travel alone? Is it like a pure ADHD? Rarely. I ask my colleagues, “Do you think there’s a pure ADHD?” I asked several of these, you know, international leaders at this conference. And they’re like, “No, ADHD always travels with something, learning disabilities . . .”

Kevin: I like that. I like that description. It doesn’t travel alone, I love that.

Dr. Saline: It rarely travels alone. You have learning disabilities. You have anxiety, depression. Those are the big three. Interestingly, if someone is on the autism spectrum, particularly level one autism, 50% of those kids have a diagnosis of ADHD. But only 14% of kids with ADHD have a diagnosis of ASD.

You asked me if there’s a spectrum of ADHD. It doesn’t quite work like that. It’s not like, oh, I mean, that’s not generally, I think, how people would think about it. And it’s not like you’re pregnant or you’re not. It’s not that sort of black and white. But you can have mild ADHD, you can have moderate ADHD, you can have more severe ADHD, but you share challenges with these executive functioning skills that are somewhat debilitating. And what we see often with people with ADHD are difficulties with emotional regulation, difficulties with a working memory. So it’s hard to pull up something that you know and apply it to a situation that you’re in, even though if you weren’t under pressure in that situation, you’d probably be able to give the answer.

For teachers in classrooms, what I see happens most often is that the squeaky wheel gets the grease. So the child who is physically active, who has trouble sitting still, who’s interrupting, who’s raising their hand, who’s talking to their peers, who’s fidgeting, they’re the ones who are tagged as, “I think this child might have ADHD.” And the child who is a little bit dreamy, who may be looking out the window and you need to call their name to bring them back, the child who as a girl, for instance, might be chatty but isn’t acting out, but is kind of a big talker, these are the kids who tend to get overlooked, whether they’re girls or boys, because they’re not what we consider the standard type of ADHD, which is basically modeled on hyperactive, impulsive boys. And so I’m constantly trying to get people to broaden the lens that they look through when they see kids.

The other thing that we want to remember is that, particularly for girls, girls are referred for anxiety and depression or somatization problems and not for attention, because they may be able to mask their attention issues. And so when someone comes with an anxiety or depression, that’s a referral, I always ask. I want to do, you know, an in-office screening for ADHD. And I want to ask questions about their performance at school.

Again, you know, for those kids who we consider twice exceptional or gifted, they have this additional challenge, where, you know, their verbal comprehension might be very high, or their visual spatial skills might be very strong, but their processing speed is slower. And so it’s kind of like one of my clients said to me. She was 12, and she’s like, “It’s like this, Dr. Sharon. A file comes in my brain and the papers go everywhere. And I start to pick up those papers. And then the next file comes in my brain, and those papers go everywhere. And then the next file comes in my brain, and those papers go everywhere. And I’m so overwhelmed because I’m still trying to pick up the papers from the first file.”

Kevin: Wow. Yeah.

Dr. Saline: Wow. Right?

Kevin: Yeah.

Dr. Saline: And that’s the girl who doesn’t get noticed.

Kevin: That’s such an apt description. Sharon, I have a couple more questions. I find this conversation so important. I could talk to you for a lot longer, but a couple more questions. One, what . . .

Dr. Saline: I’ll come back anytime, Kevin. I could talk to you too. Invite me back. We can do a whole session on anxiety and ADHD. It’ll be fun.

Kevin: And it’s so prevalent in our schools. And I think that many teachers and administrators struggle with how to deal with this. So the one question I really wanted to get to, and then I have one more, is what are some of the do’s and don’ts? Let’s say a child has this diagnosis. Talk a little bit about the do’s and don’ts, because I do think that having a toolkit on how to support kids with this diagnosis is really, really important. And it begins with some of those personal interactions.

Dr. Saline: Absolutely. It’s critical. So some of the do’s and don’ts, do nurture a growth mindset. A growth mindset says you’re going to take a risk. You’re going to see what happens. If it works out, cool, do it again. If it’s not working out, that’s not a problem. There’s nothing wrong with you. You’re not a failure. We’re going to step back. We’re going to, you know, pivot and figure out what else we can do, and then we’re going to try again.

Many people with ADHD are black and white thinkers, and they have fixed mindsets. I’m this way and it’s bad, and I’m not going to change. I have a really bad attention span. And kids will tell me they have a bad this, that all the time. We want to change their vocabulary from that. So we really want to nurture a growth mindset. Find their islands of competency, their strengths, nurture those.

You may be that charismatic adult, that mentor, that person who believes in them. They need people to believe in them, so that’s important.

In my book, I talk about using my five C’s approach to ADHD. And this is a self-control, compassion, collaboration, consistency, and celebration. You can put a link to that in the show notes, I’m sure.

Kevin: Yes, we will.

Dr. Saline: And I’m also happy to offer a downloadable gift to your listeners that sort of lays out a little bit of this information if you do that. And if not, you guys go to my website and you can sign up for my email, and you’ll get your own gift on your own. It’s www.drsharonsaline.com.

So the first thing is we want to, you know, nurture a growth mindset. The second thing is we want to replace the term ADHD with a term that feels closer to what a child is actually experiencing. So instead of “I have ADHD, which means I’m going to have a disorder and I’m sick and something is wrong with me,” could you have an attention wandering brain? Could you have a dreamy brain? Could you have a fast brain? Could you have a very fast, funny brain? Whatever it is. Like what kind of brain? I have a figure-it-out brain. I like to figure things out.

Kids have languages for that. Even teenagers will come up with something. But we want to come up with a name for your brain that makes sense to what you’re living with . . .

Kevin: Yeah.

Dr. Saline: . . . because nobody wants to have a disorder. You don’t want one, I don’t want one, and they definitely don’t want one. So that’s the second thing.

The third thing is collaborate with the school and at home on a couple, ideally one, but we’ll say two executive functioning skills that you really want to see changes in. One of the mistakes adults make with kids with ADHD is trying to intervene on several executive functioning skills simultaneously.

So I don’t know about you, Kevin, but I can only really work on changing one thing at a time. My husband says, “Can you turn off the outside light when you come in from work? Can you not keep your briefcase on the counter? And by the way, could you interrupt me less?” I said, “Which one do you want?” And he says, “Interrupt me less,” which was too bad for me because it’s the hardest one, right?

Kevin: And the light stays on.

Dr. Saline: And the light stays on, exactly, because I still have to turn the light off anyway. And how are we going to do this? We’re going to collaborate with our kids. What would they like to see different about how they’re functioning, how they’re doing? And that I’m sure is on your list, start with that because then they have buy-in and they want to work with you.

And let’s listen to their ideas. Maybe 90% of what they have to say makes no sense at all. But maybe 10% is something that you could put into what you’re doing. Kids have ideas, and kids with ADHD are very creative, outside-the-box thinkers. They’re also part of a generation today that expects to have a say. This generation expects to have a say. It doesn’t mean they’re always going to get it, but they expect to have one. So let’s use that to help them buy in.

And the last thing is celebrate the wins. Let’s notice, validate, and encourage any efforts towards the changes that we’re trying to make. You know, what the message that these kids get so often is not enough, not good enough, not smart enough, not paying attention enough, you name it. And then that continues into adulthood.

Kevin: Yeah.

Dr. Saline: We want to shift that early by saying, “Wow, I saw that you started to work on your math worksheet. You put your name down, and you did a little bit on that first problem. Way to go. I’m circling back now in the classroom to see where we can go next.” You know, those kinds of things instead of, “How come you only got this much done?”

Kevin: Yeah, that makes a lot of sense. Good stuff. What could schools be doing differently when it comes to this issue? And you did talk about it in terms of working with parents on addressing, you know, one or two executive functions. But what other quick things come to mind in terms of what schools could do differently to help kids with ADHD?

Dr. Saline: I think many schools, honestly, Kevin, think they know all about ADHD and executive functioning skills. “I’ve heard about it. I understand it. We know. Let’s move on to the next hot topic.” And I would say pause. Actually, there’s more for you to learn.

Neurodivergence is a huge issue right now. We all have different types of brains. We all learn differently, and we want to normalize that. And we want to encourage schools and teachers to have tools at their fingertips to teach executive functioning skills to all their students, not just their neurodivergent students, because everybody needs to know how to create a plan, how to prioritize, what’s the difference between something that’s urgent and important. How do you use a calendar? How do I limit my distractions online? You know, these are skills that everybody needs.

And so, you know, what I would consider suggesting to schools is to broaden how you’re teaching your teachers to explain and use executive functioning skills in the classroom. That should be taught alongside, you know, math and English and social studies at the same time. “Okay, for this assignment, we’re going to be writing a paragraph.” What of those executive functioning skills do you think you’re going to need alongside the materials? I’m going to need blah, blah, blah. I’m going to need to use an outline. So I’m going to need help with figuring out what the first step is.

Kevin: Yeah. Really good stuff. Dr. Sharon, Saline, I really appreciate it. By the way, next time we talk, I’m going to open up one big question. What is normal? You talked about normalized, we’re going to talk about what is normal because I think there’s a new normal in terms of how we view the brain and all of its functions. But that’s another conversation.

Dr. Saline: I totally agree. Please invite me back so we can talk about the new normal. I think it’s important also to remember that motivation is a challenge for people with ADHD and a lot of neurodivergent students. And the thing that I would like to leave educators with is this thought. Inconsistency in motivation, inconsistency in the predictability of what you can and cannot do is one of the most challenging aspects of living with ADHD. You can have one day where you’re on your game and you’re really hitting it, and then the next day you’re at 50% and you don’t know why. And it’s part of having ADHD. It’s not because something is wrong with you. It goes like that. And that is very challenging for kids, and it’s very challenging for the adults in their lives as well.

Kevin: Well said. Dr. Sharon Saline, thank you so much for joining us on “What I Want to Know.”

Dr. Saline: Thank you so much for having me, Kevin, and please invite me back sometime. This was so much fun.

Kevin: I certainly will. Thank you. Thanks for listening to “What I Want to Know.” Be sure to follow and subscribe to the show on Apple Podcasts, Spotify, or your favorite podcast app so you can explore other episodes and dive into our discussions on the future of education. And write a review of the show. I also encourage you to join the conversation and let me know what you want to know using #WIWTK on social media. That’s #WIWTK.

For more information on Stride and online education, visit stridelearning.com. I’m your host, Kevin P. Chavous. Thank you for joining “What I Want to Know.”