Comorbidity and its Implications for Socialization

In this post, I discuss ADHD's intersections with three common co-morbid disorders and/or neurotypes and how understanding overlapping symptoms and traits can in turn help educators accommodate these students in social-emotional situations. Comorbidity is defined as more than one physical or mental health disorder co-occurring in the same person, as well as the effect that secondary conditions might have on one primary condition, in our case ADHD (Cucunic 2021). Three common disorders that co-occur with ADHD include autism spectrum disorder, anxiety disorder(s), and sensory processing disorder.  Although these three disorders have numerous symptoms that affect all aspects of the child's life (that could be turned into an entire research project itself), I will specifically focusing on differences in regulating emotions and social communication. 

Autism Spectrum Disorder (ASD)

Although the DSM-V lists ADHD as an exclusion criteria for ASD, 30-50% of people with ASD show symptoms of ADHD, and 2/3 of those with ADHD show symptoms of ASD (Davis and Kollins 2012, Leitner 2014); both disorders affect the central nervous system: a region responsible for "movement, language, memory, and social and focusing skills" (CHADD). The main difference between the two disorders is that ADHD is characterized by differences in the regulation of attention, impulsivity, and emotions, ASD typically manifests as "core social dysfunction and restrictive-repetitive behaviors" (Leitner 2014). When these conditions co-occur or a student shows traits of both (whether they are diagnosed for neither, one, or both), they shape the child's social-emotional experiences in significant ways. Children with ASD might have language differences (often called "delays") or difficulty reading both body language and social cues, as well as in their responses to and processing of sensory stimuli (e.g., textures in clothing and food). Autistic children may also interpret figurative language literally, avoid eye contact, isolate themselves, and/or engage in self-stimulatory behaviors (i.e., stimming) (CHADD, Leitner 2014). Children with ADHD but not ASD can typically read social cues if they are successful in focusing on them. However, inattention, emotional dysregulation, or overstimulation during conversations makes this difficult, as do issues with impulsivity in making them appear rude and/or socially awkward (HowToADHD, CHADD). Children with ADHD, like their autistic counterparts, also sometimes engage in stimming behaviors for the reason of managing external sensory information. 

When ADHD and ASD traits are co-morbid in a child, the child is likely to exhibit impulsivity and inattention coupled with social/communication differences and sensory issues. Additionally, children with ADHD, ASD, or both "could not be distinguished from one another" in their "emotional recognition" and that neurodivergent students "used lower levels of social perspective taking coordination in their definition of problems, identification of feelings, and evaluation of outcomes" (Leitner 2014). Research has also shown that low dopamine levels, inattention, and impulsivity can make students with ADHD appear self-centered or narcissistic (Edge Foundation). This is not to say that a child with ADHD and/or ASD do not have empathy for others; this is a dangerous stereotype that prevents us from meeting our students' actual needs and viewing their traits and capabilities from an asset-based perspective (Rudy 2020). This misunderstanding also prevents us from examining how normed, arbitrary (read: neurotypical) standards for socializing and managing students' social-emotional health may not work for some neurotypes, and that the greater problem is actually a lack of societal flexibility and acceptance (Autism Self-Advocacy Network).

If a child with ADHD has co-morbid ASD or shows traits of ASD, it is important to accommodate a child's social-emotional needs in an inclusive way that does not fault the child. It's important for educators to view their students as both individuals separate from their dis/abilities and as individuals inextricable from their ASD and/or ADHD, understanding that this inextricability is in no way negative. Educators must know their students' specific social, emotional, and sensory profiles, their unique interests and communication styles, in order to accommodate them in inclusive (e.g., UDL) settings. Making weighted blankets and sensory toys available and varying the noise/light levels in the classroom, for instance, will help children with traits of ASD and ADHD to feel more comfortable in that environment and mitigate the effects of sensory overload on social interactions with peers (Children's Hospital of Philadelphia). Additionally, encouraging other students to use concrete language in social and academic interactions, creating a culture of unconditional patience and inclusion in the classroom (a difficult process which I discuss more in-depth in Interventions), using social stories (in a non-coercive, non-ableist way), and talking through social behaviors with children can help them process stimuli (e.g., their peers' behaviors) and make sense of their environments. 

Note: I am not autistic and I feel like there is so much more information available about this topic that I don't feel qualified to speak on, so here are a few autistic-penned resources I recommend for those interested in reading about autism's impact on social behaviors: from the Autism Self-Advocacy Network, Lydia X. Z. Brown, and Autism and Race.

Anxiety Disorders

Anxiety disorders are broken down into several major categories, including generalized anxiety disorder (GAD), social anxiety, and panic disorders. Children with GAD experience "persistent worry or anxiety about a number of areas that are out of proportion to the impact of the events" (Mayo Clinic); social anxiety is described as "an intense, persistent fear of being watched and judged by others" (National Institute of Mental Health), and panic disorders include episodes of "sudden ... fear and anxiety that cause physical symptoms like a racing heart, fast breathing and sweating" (Cleveland Clinic). When co-morbid with ADHD symptoms, especially with hyperactive-type ADHD, an anxiety disorder can intensify impulsivity, inattention, and rejection sensitivity in children (Bonior 2019). Children with both ADHD and an anxiety disorder may become restless and easily overwhelmed by situations and stimuli (Olympia Therapy). The American Academy of Pediatrics (AAP) states, however, that

children with an anxiety disorder ... experience more than a general lack of focus or a restless response to boredom. Their anxiety and worry are clear-cut, often focusing on specific situations or thoughts. They may seem tense, irritable, tired, or stressed out. They may not sleep well, and may even experience brief panic attacks -- involving pounding heart, difficulty breathing, nausea, shaking, and intense fears -- that occur for no apparent reason. While their school performance may be equivalent to that of children with ADHD alone, they tend to experience a wider variety of social difficulties and have more problems at school than children with ADHD alone. (2004)

In other words, although children with ADHD may experience sleep problems or appear irritable and hyperactive, it's important to consider the source of these symptoms and whether they stem from intense fear/anxiety or differences in executive functioning. While it is not an educator's job to diagnose a child with ADHD, an anxiety disorder, or both, it's helpful to have at least a preliminary understanding of how the disorders are different and how their symptoms manifest, diverge, and overlap. Persistent anxiety -- either due to a pre-existing anxiety disorder or trauma from bullying and/or abuse -- can exacerbate social-emotional difficulties in children with ADHD. Children with social anxiety and inattentive-type ADHD, for instance, might get distracted and drift off in class and be afraid to ask for help or answer the teacher's question due to real or perceived social judgement (NIMH, AAP 2004). Children with an anxiety disorder and ADHD may withdraw from social situations and/or appear socially awkward because they are nervous about interacting with peers. Additionally, Kerry J. Heckman notes that having ADHD alone can cause a child a great deal of trauma and anxiety based on how they are treated in a neurotypical society:

People with ADHD are often bullied, feel that they don’t fit in, struggle academically and socially in school, and are admonished by adults for behaviors over which they have little control. The body’s chronic stress response is commonly referred to as the “fight or flight” response. Another name for it is “sympathetic arousal,” because it is an activation of the sympathetic nervous system. Sympathetic arousal is the body’s involuntary response to danger and causes adrenaline and cortisol to rush through the body, heart rate to increase, muscles to become tense. If this response happens repeatedly -- as it does for individuals with ADHD navigating daily disappointments, admonishments, and blows to their self-esteem -- the body learns to treat everything it encounters as a dangerous threat. Over time, it creates fixed action patterns in the body’s tissues, such as habitual muscle tension (clenching jaw or raised shoulders), digestive distress, and neurons that fire the same way repeatedly (defensive behavior patterns). All of these are signs of dysregulation. The nervous system has learned to respond to past events as if they are happening in the present. (2020)

If a child is diagnosed with or suspected to have ADHD, an anxiety disorder, or both, it's crucial for educators to show patience and to give children what they need. Children with ADHD and high levels of anxiety must be made to feel safe in their classrooms and find a sense of belonging. Establishing classroom routines, providing quiet work time and sensory-friendly spaces, supporting and monitoring social interactions, and being consistent and restorative in terms of behavior management are some examples of interventions for helping these children feel welcome in the classroom.

Sensory Processing Disorder (SPD)

UNDER CONSTRUCTION

ADHDers' Friendship Assets

Students with ADHD have a lot to offer their peers. It is the job of educators in anti-ableist, inclusive environments to help children with ADHD access their inner strengths instead of focusing exclusively on emotional "deficits," socially unacceptable symptoms, and areas for growth. Educators must view ADHD as a neurotype -- as a different way of being; as what I term a "complicated strength" -- and the environment needs to accommodate the student as opposed to forcing the child to conform to normed standards of social-emotional functioning.  

As a child (and to this day), I was highly creative, outgoing, and motivated to succeed despite/alongside the challenges that came with having ADHD; I was energetic, talkative, and full of ideas, eager to share what I was capable of with the world. Once I came to terms with my ADHD and saw it as a complicated strength, I saw my tendency to daydream (my "inattention") as the thing that allowed me to produce a large body of creative work: poems, drawings, and short stories. I took great pride in my bouts of "hyperfocus," divergent cognition (which allowed me to think about problems creatively), and feverish artistic production (White 2019, Nadeau/ADDitude Magazine); the work I produced both helped me to express myself (joys, frustrations and all) and allowed other people to see who I really was and what I could do when presented with the proper conditions to succeed. I am lucky that I had opportunities to share my poetry and art with my teachers and classmates, and the creative and performing arts groups I joined inside and outside of school were outlets for my hyperactivity and led to years-long friendships with other talented, neurodiverse students. 

Yes, I am neurodevelopmentally dis/abled, but that does not mean I did not develop socially; I simply took the scenic route. I felt things very deeply, I came to accept that I would never be popular, that masking my symptoms did more harm than good. And I knew that the friends who did stick around, who did reciprocate, were real. 

Students with ADHD have the potential to channel their energy, dynamism, and brainpower into thoughtful pursuits if given the space to do so. Janice Sawinski notes that cultivating favorite hobbies can help students with ADHD find a "sense of purpose" and work on "interpersonal competence" (i.e., social skills) (2008). If children with ADHD are encouraged to pursue what they love -- and if in turn these environments are designed and/or shaped to accommodate neurodevelopmental differences -- students will have an easier time connecting with peers who have similar interests and personalities. Starting with what the child with ADHD has to offer contributes to students' self-definition and their feelings of having a place in the world. 

Nonetheless, communication can still be a challenge for students with ADHD, and we can't ignore the impact that hyperactivity, inattention, and impulsivity can have on a student's ability to navigate productive conversations with peers. Interrupting a conversational partner, for instance, is seen as rude and ultimately distressing for both parties. The diagnostic criteria for ADHD frames impulsivity and hyperactivity as impairments (DSM-V, pg. 59-60) because these traits can inhibit social-emotional functioning. But what if we reframed these traits -- at least in certain situations -- as a neurodivergent student's way of communicating honestly and openly? Matt Curry writes:

I believe that for most of us, these defects or weaknesses – when channeled properly and perhaps even celebrated – can become our greatest strengths....ADHD is my superpower. It gives me an incredible amount of energy, which allows me to multi-task and to get stuff done. It also makes me intense, impulsive, fidgety, anxious, and impatient sometimes. It makes me controlling, scattered, and extremely blunt; I sometimes blurt out inappropriate things at inappropriate times. But it also helps me get people pumped up and headed in the direction I want them to go. It makes me unafraid of chaos and assertive in the face of conflict. I’m decisive, I take action, I execute. My ADHD allows me to be creative at a million miles an hour. Going off on tangents is fun; I love it. (Curry 2018)

Educators must evaluate the context of interactions to understand the ways that a child's ADHD traits can be turned into assets. The Kennedy Kreiger Institute and Dr. Alison Pritchard note that

a 'super power' can become a problem if exhibited in the wrong context. For instance, impulsivity, a common symptom of many with the diagnosis, is not preferred when driving through an intersection or when playing chess. However, it might be a preferred attribute in a context like improvisational comedy. (KennedyKreiger.org)

Visit the Interventions page for information about how to approach that "misbehavior" and impulsivity that some children with ADHD struggle with; in addition to helping neurodivergent students learn to self-monitor and reflect on their social behaviors, educators must also encourage their peers to be patient, to hold space for and honor different communications styles.

Finally, it's crucial for educators to recognize how to help their students with ADHD use their heightened emotional sensitivity as pathways to perception and self-knowing. Lizzy Arnold, a member of the National Center for Learning Disabilities' Youth Leadership Council, writes:

Like any child, working through social-emotional difficulties with a non-judgmental adult figure can increase children's capacities for metacognition and self-efficacy. Educators must not view a child's diagnostic and/or behavioral labels as fixed deficits but rather as complicated strengths that make their lives challenging but fruitful. Ask children who you've labeled as "inattentive" what they've been dreaming about lately. Ask children who you've labeled as "hyperactive" what excites and frustrates them. Tell children with emotional "dysregulation" or rejection sensitivity that you admire how widely and deeply they feel. Reframing children's behaviors in social situations and fostering intentionality (e.g., social stories, mindfulness) can help children with attention and hyperactivity issues flourish as they are. 

@drhallowell

##ADHD is a way of being. Embrace it! You have some wonderful traits! ##NedTalks ##neurodiverse ##strengths

♬ original sound - Dr Ned Hallowell

Social-Emotional Challenges for Black and Latine Students with ADHD

Like all children, non-White children are not a monolith and individuals face discrimination based on their personalities, subsets of symptoms, and how their race, class, and other intersecting identities are viewed by White educators (e.g., model minority status of Asian-American students). I specifically focus on Black and Latine students in this post, but future research should focus on ADHD's social-emotional impacts on children of Asian or Indigenous descent.

Dis/ability and race

Notions of race and dis/ability are deeply intertwined. According to DisCrit: Dis/Ability and Critical Race Studies, the tradition of scientific racism has led not only to the belief that Black and Latine people are biologically and intellectually inferior to Whites (Annamma, Connor, and Ferri 2016, pg. 9-10) but also to the construction of an educational system built on this belief. Policy factors (e.g., funding, redlining) have led to decreased opportunities and social protections for young children of color, especially those in poor neighborhoods, and the toxic stress and chronic trauma from maltreatment by educators at the interpersonal and district levels directly stunt Black and Latine children's neurodevelopment (Harvard Center on the Developing Child 2007). When coupled with notions of dis/ability -- especially given how the belief that Black and Latine students are cognitively inferior has historically been used to dehumanize them -- we are confronted with how "subjective societal interpretations of and responses to specific differences from the normed (White) body" are weaponized against children of color and their families (Annamma, Connor, and Ferri 2016, pg. 10). In fact, on a very literal level, "dis/ability status justifies segregation and unequal treatment for students of color compared to their White counterparts;" Black students are three times as likely to be diagnosed as emotionally disturbed, 67% more likely to be removed from school grounds, and 13 times more likely to be arrested in school compared to White students (pg. 11-15). 

In terms of ADHD specifically, children of color are not diagnosed as often compared to their White counterparts (Frye 2017, Nigg 2020, Morgan et. al. 2013). However, due to racial trauma and stereotyping, the social-emotional challenges that come with ADHD may worsen in Black and Latine students, hearkening back to the research done by the Center on the Developing Child mentioned in the previous paragraph. DisCrit's assertions complicate this; despite systematic under-diagnosis (or the over-diagnosis of White students, perhaps), there is tension between overrepresentation of Black children in "emotional disturbance" and intellectual disability categories and the under-diagnosis of children of color for ADHD. Psychiatrists' racist biases, such as the framing of Black men, for example, as violent and unpredictable, may "impact how they read the very same symptoms" of ADHD from child to child (Frye 2017). As a result, Black children with ADHD's behaviors may be misread as inherent to their Blackness and not as a symptom of a neurodevelopmental condition; when Black children are diagnosed with ADHD, however, many families of color see ADHD as a racist label used to further stigmatize their children (Frye 2017, Coker/Understood.org 2020). For this reason, an ADHD diagnosis is often frowned upon in communities of color, and Black parents can be mistrustful of doctors diagnosing their children due to historical violence against Black people from the medical community (Frye 2017, Coker/Understood.org 2020). Dr. Tumaini Coker, whose children were diagnosed with ADHD, states of psychiatrists: 

You’re just trying to point something that’s wrong with my kid. And this is another way to kind of, you know, find a way to hold my kid back or these kind of things....It can be true that, yes, the child has ADHD, but can also be true that there’s a significant amount of implicit bias that the teachers or the school system is putting on that child. And that’s really tough place for a parent of a Black child to be. Because you know that there’s some element of need educationally for that child. But then you also know that, yes, there’s this element of racism, both structural and interpersonal racism, that’s impacting the kid in school. And to navigate that and to figure out each day, you know, which is which, it’s hard.

Latine students with ADHD may also face obstacles related to cultural expectations. From the podcast InIt:

                            

Racism and ableism writ large -- as with more specific environmental, political, and neurodevelopmental factors -- are ubiquitous and mutually reinforcing, and these factors will inevitably affect the neurodivergent child of color's social world.

Socialization of Black and Latine students with ADHD

The social experiences of Black and Latine children with ADHD vary based on school demographics, the surrounding communities, and of course the individual personalities and symptoms of students, but are ultimately informed by the stacked stigmas of being non-White and dis/abled, policies around dis/ability and education (e.g., IDEA and LREs), and the lingering effects of school integration (Anderson, Saleem, and Huguley 2019, Teachers College 2004). The American educational system has not been built with the assets and needs of Black and Latine dis/abled children in mind; according to Anderson, Saleem, and Huguley, students report that "teachers and staff omit Black youth from advanced course recommendations, disproportionately scrutinize the behavior of Black boys, or choose to leave racially representative content out of the curriculum" (2019), exacerbating feelings of social isolation and intellectual-behavioral inferiority in Black and Latine students. The National Center for Learning Disabilities similarly reported that "students with learning and attention issues often experience feelings of failure, lack of acceptance among their peers and high levels of bullying, which can increase the risk of misbehavior and absenteeism" and further contribute to the school-to-prison pipeline that already affects students of color (NCLD 2017). Black and Latine students with ADHD, dealing with challenges that come with both their race and dis/ability, may then be labeled as untrustworthy, unintelligent, or unstable by their teachers and peers because the system has been designed for White, neurotypical students (Harper 2017, Anderson, Saleem, and Huguley 2019).

In terms of special education itself, Kristen Harper reports that "in 2014, children of color with disabilities -- including 17 percent of Black students, and 21 percent of Asian students -- were placed in the regular classroom, on average, less than 40 percent of the school day" (2017). They also note that IDEA provisions intended to benefit students of color are underutilized in many districts (Harper 2017); NCLD adds that other district-wide programs such as social-emotional learning (SEL) initiatives are often not shaped to meet the needs of dis/abled students (NCLD 2017). This means that Black and Latine students diagnosed with and receiving accommodations for ADHD will not be adequately integrated with their neurotypical, often White peers, and will not receive sustained, engaging, and culturally relevant social and emotional support from their teachers that centers these children's assets and areas of need.

Although what ultimately needs to take place is systemic change at the school design, cultural, and policy levels, it's important that educators and administrators designing social-emotional interventions for ADHD and other dis/abilities understand the pernicious ways that racism and ableism work together to systematically exclude and violate dis/abled children of color. If teachers, administrators, parents, and others in the school community continually frame Black and Latine children's behavior through a deficit lens, they are in turn ignoring race, class, and dis/ability related stressors (again, due to the systems in place) and the nuanced social-emotional and neurobiological needs of these children.

Struggles & Stigma for Girls* with ADHD

*Children who have been socialized as girls, regardless of actual gender identity. 

Current research on ADHD in girls

Girls with ADHD face (at least) two stacked stigmas: sexism and dis/ability, plus any other intersecting identities, for instance race and class, which can prevent access to comprehensive and timely diagnosis and treatment. Girls are systematically under-diagnosed for ADHD compared to their male counterparts, and are mostly classified as the inattentive subtype because of social expectations for female behavior (e.g., being demure, calm, attentive) (Grskovic & Zentall 2010, Kok et. al. 2016). Further, even though girls exhibit similar symptoms to boys -- for instance lack of focus, hyperactivity, and stimming -- girls with ADHD are more likely to mask these symptoms than boys, pushing themselves (often in unhealthy ways) to conform socially and overachieve academically (Faulkner 2020). 

In examining the social experiences of girls with ADHD, educators not only can identify specific areas of social-emotional need but also explore the mutually reinforcing relationship between biology and culture and how this dynamic influences friendships and socialization in neurodivergent girls. Grskovic & Zentall, quoting research from Mikami and Hinshaw (2006), note that elementary-aged girls with ADHD are more likely to develop substance use and eating disorders as adolescents (i.e., self-medicating behaviors), likely due to both their symptoms and indirectly from the trauma and low self-esteem caused by ableism, social "delays," and unstable friendships (pg. 171-2). In their study of 262 girls with ADHD and their parents, Grskovic & Zentall found that, in addition to the attributes described above, neurodivergent girls were likely to be labeled as "dreamers, fantasizers, or readers" who were "always in love" (pg. 173); this can be seen as both a description of how symptoms may manifest and a reflection of how society frames young girls' behavior as frivolous and flighty. 

Girls with ADHD tend to struggle with high levels of stress and anxiety because of their chronic failure to conform socially and are prone to internalizing these negative feelings about themselves (Jacobson/Child Mind Institute); according to Kok et. al., girls with ADHD also "display a different pattern of comorbidity than boys; comorbid internalizing disorders (i.e. anxiety and depression) and emotional dysregulation are more prominent in girls, whereas boys are more likely to present with externalizing, disruptive disorders" (pg. 2). (The key phrase here is "more likely," as predominantly hyperactive-impulsive girls who are likely to exhibit "externalizing" symptoms exist even though they have not been the focus of recent research. [In other words, because of sexist societal norms, there may be an unconscious bias in research that frames the externalizing symptoms of girls with ADHD as less notable or noticeable.])

Sexism and social struggles

In previous posts, I've outlined how ADHD symptoms are often externalized as socially unacceptable behaviors that make a child a target of ridicule in classrooms and social situations. When considered alongside one another, sexism and ADHD's social impacts are mutually reinforcing; neurodivergent girls face harassment and maltreatment as a result of both their gender and ADHD behaviors. Kok et. al. writes that

as girls in general usually have tighter and more intimate social networks, and as the peer relationships of girls involve higher peer attachment, disruption to such relationships may impact more negatively on girls than on boys. Second, low self-esteem is more prominent in girls with ADHD relative to typically developing (TD) girls as well as to boys with and without ADHD. Third, children typically tolerate higher levels of ADHD symptoms in boys than in girls, and many typical ADHD symptoms are considered more deviant for girls relative to boys. This may be explained by gender expectations of how girls are supposed to behave. Girls with ADHD therefore may stand out from their peers to a higher extent than do boys. (pg. 3)

Because neurodivergent girls have less practice with stable friendships and friendships are not reciprocated as often, they might be less attuned to and less skilled in picking up on social cues, which is further intensified by their inattention and impulsivity (HowtoADHD, Grskovic & Zentall 2010). At the same time, girls with ADHD tend to be aware of their "social failure and rejection" and experience high levels of guilt (Grskovic & Zentall 2010) because society puts girls' achievements and social images at the center of the school experience.

When designing social-emotional interventions for students with ADHD, it is crucial to consider how female children are often left behind, how their struggles may be minimized or misunderstood, and how their voices might not be heard in conversations about the academic and social-emotional accommodations that affect them directly.

@americanahhannah

(Based on documents my Psychiatrist shared with me) Ima incorporate ADHD tiktoks into my acct. now😄 ##adhd ##adhdcheck ##adhdprobs ##adhdinwomen

♬ sweater weather x i wanna be your girlfriend - snail dallon weekes

@claraandherself

The last one I think we can all relate to 😁 ##adhdinwomen ##adhd ##neurodivergent

♬ Pieces (Solo Piano Version) - Danilo Stankovic

@urlocalautistic

no one asked but here u go... ##adhd ##adhdingirls ##hyper ##fyp

♬ original sound - evie siddle

@drhallowell

How to spot ##ADHD in a 10 year old girl ##adhdwomen ##daydreamer ##internationaldayofthegirlchild ##distraction ##superpower

♬ original sound - Dr Ned Hallowell

Masking

What is masking and what does it look like?

Masks refer to learned social, emotional, and academic behaviors that compensate for and/or hide ADHD symptoms (Varnel 2019, ADHD/AS/Dyslexia Family Resources Brussels [AFRB] 2009). Similar to the technique described in and by people with autism, masks emerge over time in response to the inability to cope with or be accepted by the neurotypical world. More than simply managing one's symptoms, masking is a quietly debilitating process of repression that leads children to develop "burn-out, depression, anxiety, and sometimes addictive behaviors" (AFRB 2009) and potentially miss out on early diagnosis and treatment for their ADHD (ADHDSurprise 2019). Masking has long-term effects, including self-medication and chronic under-functioning in academic and work environments (AFRB 2009). In addition to the emotional consequences that masking has on the neurodivergent child (discussed below), masking may lead adults in the child's life to deny that there is a problem, since symptoms are not as detectable as they would be without the mask (AFRB 2009, ADHDSurprise 2019). 

Masking can look like:

• Increased anxiety and/or hyper-vigilance 
• Isolation and withdrawal from social and/or academic situations
• Emotional repression (especially if the child is normally vibrant and/or hyperactive)
• Imitating other children's social behaviors  
• Increased inattention or, alternatively, hyperfocus
• Obsessive organization of materials and work
• Sleep problems
• Low self-esteem
• Lower-than-expected academic achievement, even with accommodations
• Excessive time spent on homework (e.g., re-reading, editing)
• Body tightness and/or control over movements, fidgets, or tics 

Neurodivergent children might mask for a variety of reasons based on their individual personalities and symptoms. Masking is sometimes a conscious undertaking -- especially in adults who have had opportunities to examine their behavior for years following a diagnosis -- but for most children the process is unconscious, as it was for me and for many other childhood-onset ADHDers I've spoken to. One of the main reasons for masking is that of social acceptance and conformity.  

Masking and social behaviors

Children with ADHD often mask because they find it difficult to function and be accepted as they are with visible symptoms. Because neurodivergent students may exhibit socially unacceptable behaviors (Stewart 2017) such as inattentiveness or interrupting during conversations, their concentrated efforts to act in socially acceptable ways (and appear neurotypical) are ways of seeking connection, integration, and approval. Nicole Faulkner writes in The Irish Times of her experience as a girl with ADHD:

Neurodivergent women often slip through the cracks of diagnosis because they can appear smart or gifted....We work extra hard to prove ourselves. Combined with hyperfocus ... this results in flashes of brilliance. We’re also experts at masking symptoms. We form habits by mirroring the social behaviors of those around us....Burnout is what happens when the mask slips. Your entire world comes crashing down, and you don’t have the executive function to figure out which way is up. (Faulkner 2020)

Similarly, Pina Varnel notes that "masking ADHD is extremely exhausting and muddying sense of self [sic]." For years, I did not realize that I was masking, that many of the prosocial behaviors I'd been forced to cultivate to offset my ADHD symptoms were artificial and tiring for me to maintain. I recall trying to act "like the other girls" in middle school by whispering when the teacher called on me in class (instead of speaking loudly with an "unregulated" volume), repressing my emotional reactions, and hyper-focusing on schoolwork, socializing, and eating habits (all of which were challenging for me). Although I was "high-achieving" and medicated for my ADHD and my sensory processing issues, medication alone was not enough to fully mask my symptoms and make me feel "normal." 

It would seem that ADHD symptom management, then, requires comprehensive medical and social-emotional intervention that emphasizes not only comfortable and relevant behavioral shifts for the child but also principles of anti-ableism, self-worth, and community acceptance. 

Social Challenges for Students with ADHD

It is important to note that children with ADHD are not a monolith and that our students experience symptoms along a spectrum, all of which contribute differently to problems with socialization and friendship development. The following post attempts to illuminate some of the noteworthy social dilemmas that children with ADHD face.

Students with ADHD often struggle with peer rejection due to hyperactivity-impulsivity, emotional dysregulation, and even the stigma of having an IEP/504 (Mikami & Normand 2015, DeWitt 2011). Students -- especially those socialized as girls -- may sometimes choose to “mask,” or hide their ADHD symptoms, in order to be accepted by their neurotypical classmates (ADHD/AS/Dyslexia Family Resources Brussels [AFRB] 2009). Children also may deal with rejection sensitivity, which means that they react in ways that are perceived to be extreme or inappropriate to peer rejection (e.g., shutting down, social withdrawal, explosive anger or sadness) (Bhandari 2020, HowToADHD, Lechene 2020). Because of "conduct problems" (Kok et. al. 2016, pg. 1) related to a deficiency in dopamine that helps children to "regulate emotional responses" (Duggal and Hammond 2020), children with ADHD may acquire the stigma of being unstable, unpredictable, or overly sensitive. Persistent inattention may also contribute to students' missed social cues; forgetfulness around social commitments; and the initiation of plans, relationships, and conversations (San Diego ADHD Center for Success). Additionally, sensory issues such as those that accompany the co-morbid condition of sensory processing disorder (SPD) may make children with ADHD adverse to physical touch such as hugging (sensory-avoidant) or, alternatively, a need to be touched and held all of the time (sensory-seeking) (Varnel 2019, San Diego ADHD Center for Success). The misunderstandings and stigmas that accompany the manifestation of symptoms contribute to a chain reaction of emotional instability caused by and causing unsteady friendships.

A literature review conducted by Kok et. al. around peer functioning in girls with ADHD states that "all of the thirteen studies included reported that girls with ADHD, compared to TD (typically developing) girls, demonstrated increased difficulties in the domains of friendship, peer interaction, social skills and functioning, peer victimization and externalizing behavior" (pg. 1). (Gender differences are discussed more explicitly in the post Struggles & Stigma for Girls* with ADHD.) Mikami and Normand note similar findings, citing children with ADHD's "difficulties in being accepted and befriended by peers, ... poor quality and stability in any friendships they do have.... and their tendency to have fewer, or no, reciprocated friendships" (Mikami & Normand 2015, pg. 30). They add that studies tend to focus on changing ADHD students' "inappropriate" behaviors and less on "effective treatments" for peer rejection, "multifaceted peer group factors" (such as the frequent development of cliques in school communities), and ableist framings of how children with ADHD should act (pg. 30). This handbook attempts to explore these gaps in research and suggest future directions for not only helping students with ADHD acquire important social-emotional skills but also "investigate approaches that help the typically developing peer group to reduce stigma about ADHD behaviors and enhance acceptability of individual differences" (pg. 35).

Because ADHD is in many ways an invisible disability -- meaning a student could have ADHD and someone wouldn't be able to tell by looking at them -- they may be labeled as careless, unsympathetic, and rude in the school community (CHADD) and be subject to "exclusionary behavior" and "reputational bias" that corroborate stigma and low self-esteem (Mikami & Normand 2015, pg. 32). Yet, as Mikami and Normand suggest, it is also important to analyze how children's interactions -- which are inevitably informed by ableist power dynamics and a need to conform -- and the negative behaviors of neurotypical children exacerbate the social-emotional challenges of students with ADHD. I explore this multidimensional relationship further in the page Friendship Development.

@stina905

ADHD can make some things hard we don’t even realize it affects. #bffgoals #friends #adhdprobs #tiktoktherapist #connection

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@nylabyo

#adhdtiktok #adhdinwomen #adhdprobs #adhdfriends #friendship #adhd #love #peace

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Neurodiversity

What does it mean to be neurodivergent?

The term neurodiversity was coined in the late 1990s by sociologist Judy Singer, was quickly adopted by the autistic community, and then employed by allistic (non-autistic) individuals with other neurological and neurodevelopmental dis/abilities. Neurodiversity, as defined by Understood.org, is "the view that brain differences are normal," natural variations in humans, "rather than deficits." At first glance, this concept seems simple enough: a response to an aggressive societal emphasis on sameness and normativity. If we begin to view dis/abilities and neurodevelopmental variations such as ADHD as "normal," people (in our case, children ages 5-14) with these conditions might receive higher-quality, more equitable treatment and accommodations in workplaces and schools.

Yet, there are a few competing ideologies at play here, one of which separates society into "neurotypicals" and "neurodivergents." This framework asks us to define those categories and who falls under each: a slippery slope indeed. Endless questions emerge: who are these so-called "neurotypicals" and "neurodivergents?" Must students in the latter category have a diagnosis, a documented brain variation, a dis/ability? Is neurodiversity a spectrum? On the other hand, what constitutes "typical?" Does the "typical" brain even exist, and how can we understand neurodiversity not as a new configuration of "normal" but instead as a rejection of normativity entirely?

People who claim the label "neurodivergent," like myself, do so because we identify as having a neurodevelopmental, neurological, or cognitive difference, such as ADHD, autism, Downs, dyslexia, or any other number of diagnoses. In this light, what makes someone "neurotypical" or "neurodivergent" is not entirely arbitrary. However, I want to challenge us to think more broadly and deeply about conceptions of difference. Even though we could argue that everyone in society has some kind of "difference" (which I will unpack further in the next section), there are observable variances in brain function and activity in individuals with ADHD. Notably, there is a faster uptake of dopamine and norepinephrine in the prefrontal cortexes of people with ADHD, which affects executive functioning, working memory, and processing speeds.

Differences in dopamine levels in brains with and without ADHD.

Source: Sara Bellum, National Institute on Drug Abuse

Despite the biological basis for these "disorders," we must also consider neurodiversity through the social model of disability, which asserts that neurobiological conditions like ADHD and autism are partially socially constructed, that the challenges that come with being neurodivergent are magnified by an ableist society that punishes any deviation from the norm. The social model of disability is, as it turns out, key to our understanding of children with ADHD's social experiences.

Ontologies of “normal”

A TedX Talk given by Todd Rose in 2013 elucidates "the myth of average." Rose discusses how "average" is an arbitrary term and that in designing our world to fit the "average" brain, we do little to make our world more inclusive. Centering diversity and inclusion work on notions of neurotypicality -- prescribed normative behaviors and ways of thinking -- we instead reify harmful, inflexible systems that exclude students with variations.

The Institute for the Study of the Neurologically Typical, a website created by autistic people, reverses notions of normalcy by defining "neurotypical" as "a neurobiological disorder characterized by preoccupation with social concerns, delusions of superiority, and obsession with conformity," going on to note neurotypicals' "overdeveloped" social skills and "difficulty communicating directly" (Enghal/ISNT 2002). Although I am not autistic, as a neurodivergent person who has struggled with social skills throughout my life, I found this description both amusing and important. The site reveals the tension between pride in feeling "atypical" and acknowledging the dangers of the normal/abnormal dichotomy. We can hold this tension close; we can reject the existence of normativity while also acknowledging the neurodivergent person's right to label themselves based on 1.) their location in an ableist society, 2.) their diagnosis, and 3.) how they feel.

On many occasions, I have run into so-called "neurotypical" people who end up saying such phrases that make my skin crawl: "We all have a little ADHD," "I'm a little OCD," or the famous, "We all have issues." From this final statement, it would seem that many people, perhaps unknowingly, have an inchoate understanding of neurodiversity and the "myth of the average." And, of course, everyone faces mental health challenges throughout their lives. However, at its root, the statement "we all have issues" has been used as a way for neurotypicals to avoid uncomfortable conversations about ableism, to absolve themselves of ableism without having to actually do the work of untangling their biases. Ultimately, "we all have issues" is a reflection of the neoliberal fantasy of unity (read: conformity) and invalidates the very real lived experiences of people with neurobiological variations who are treated unfairly by an ableist society.

Neurodiversity and the social world

As an educator (and former public school student), I ask: is neurodiversity ubiquitous or does it only apply to people with noted or perceived brain/developmental differences? In an ableist world, it seems that anything that deviates from the norm is a "disorder," but the stigma and struggles that neurodivergent people endure are real. One such challenge are the feelings of isolation among members of the neurodivergent community as a result of our symptoms and the social stigma of having a dis/ability. While there are no easy answers, these challenges can be ameliorated through a greater sense of inclusion and community, as well as an acknowledgement of the role ableism plays in our schools. No two students with ADHD are alike, but through a nuanced framework that emphasizes neurodiversity and a Universal Design for Learning (see: Interventions) over tiered education and segregation, we can create greater social access and support for neurodivergent students.