9/15/2016

ADHD Tipping Points: Why people with ADHD suddenly seem to fall apart, and what you can do about it

In a recent webinar, ADHD coach and mother of an ADHD son Laurie Dupar introduced the concept of a "tipping point.

In her coaching practice, Laurie met many people diagnosed as adults as late as middle age. Often, they had functioned well in school, at work, and in their relationships, until their lives suddenly seemed to fall apart--at which point they were finally diagnosed. Laurie developed the concept of a "tipping point" (similar to what I call "hitting the wall") to describe this phenomenon. She then looked for patterns in her clients' lives to explain why these bright, successful adults were able to function so well for so long, and then suddenly could no longer do so.

Image result for dominoes falling
Like a domino, a tipping point can cause many areas of life to fall apart at once.

Tipping points occur because undiagnosed people have always had an ADHD brain with ADHD strengths and weaknesses. However, these traits may have never disabled them before because they found ways to compensate, and their physical and social environments allowed them to do so. 

To the person with ADHD, a tipping point may feel like one is falling apart. It might also feel like confirmation that one wasn't good enough and was just pretending all along--"now it's finally caught up with me, and everyone can finally see I'm just faking being good enough." In reality, a tipping point does not reflect a person's intelligence, hard work, or competence. It simply reflects that new life circumstances make it impossible to compensate for, manage, and hide one's ADHD traits. When capable adults can no longer cope, and their strategies either no longer work or actually become counterproductive, their ADHD may suddenly become obvious.

Laurie argued that the best way to deal with tipping points is to predict them in advance and head them off before they begin. Tipping points involve so much pain and confusion that it can be easier to prevent them than to cope with them.

Laurie most often sees tipping points when:
  • A child moves from elementary school to middle school, middle school to high school, or high school to college.
  • An adult gets promoted at work.
  • An adult marries, or has a new baby.
  • An adult woman goes through menopause.

Changes in physical environment. Moving to a new home or a new workplace can trigger a tipping point. We often overlook the importance of the light, sound, crowding, traffic flow, and other factors of the physical environment, but they can impact us both directly (in terms of comfort and distraction) and indirectly (in terms of making productivity routines easier or harder to implement).

New life roles. When a child transitions from one level of schooling to another, they face new expectations for organization, social, and academic functioning. For example, a new middle school student must move between classes with different teachers and track assignments in a planner, while navigating increasingly cliquey peer groups. An adult promoted at work may be expected to spend less time on the tasks where she previously excelled, and more time on managing others doing those same tasks. These role changes involve changes in identity and can stress anyone, but may be even harder for those with ADHD, especially if they involve less time or greater need for executive functions.

Changes in family dynamics. Sometimes happy changes, such as marriage or a new baby, can trigger an ADHD tipping point. These events involve new demands from others that may push one's executive functioning to the limit--such as when a new partner expects an ADHD person to keep a spotless, organized home. Or, as with a new baby, they might reduce the time one has to implement strategies that used to help them. (As Laurie points out, adults with ADHD often "use time to make up for things we've been missing." New family members also means more stuff and clutter.

Changes in physical health. Many adult women are diagnosed at menopause because hormonal changes drastically alter their functioning. Laurie Dupar claims that estrogen helps dopamine bind to neural receptors, and thus dopamine becomes less effective when estrogen levels drop. (Note: smaller drops in estrogen levels also occur during menstrual periods, which may explain some women's claims that they have more difficulty managing their ADHD during their period). Hormonal changes during adolescence could also intensify ADHD symptoms or make them harder to manage, but they might be overlooked because teenagers are expected to be "moody" and impulsive.

Changes in activity level. High school athletes may have difficulty transitioning to college if they do not pursue college sports, both because they lose a great deal of structure to their time and because of the reduced physical activity itself. Physical injuries that cause a sudden drop in activity level can also cause adults to struggle in seemingly unrelated areas of work and school.

Changes in sleep. Prolonged sleep deprivation can cause people without ADHD to exhibit ADHD symptoms like distractibility. It will only intensify ADHD symptoms in those who actually have ADHD. ADHD traits often mean that it takes more energy to complete everyday tasks than it does for other people, thus sleep becomes more necessary, and lack of sleep more impairing than for the average person.

Changes in technology usage. While many people with ADHD swear by using mobile phones to set alarms, access their calendar from anywhere, and stay organized, new technology implemented thoughtlessly can disrupt analog organizational strategies without providing a replacement. For example, Laurie has worked with doctors who reached a tipping point during a transition from paper medical records to electronic ones. Doctors could no longer, for example, use the size of the stack of medical records on their desk as a clue to how much time was left to spend on them. Electronic records can also prevent use of tactile strategies. People with ADHD need to ensure that the technology they use offloads working memory demands rather than increasing them (e.g., by requiring one to hold information in working memory from one screen to the next).

Usually, a combination of these factors triggers the tipping point, because life changes typically affect several of them. For this reason, the transition to college can challenge even the most talented people with ADHD. Many college students are academically prepared for college, but relied on structure from home. They may not know how to structure their own time and tasks, they may not get enough sleep, may engage in less physical activity, and may have less control over their physical environment due to roommates with different preferences. Meanwhile, they face very different (and less clearly-communicated) academic and social expectations. Pretty much every factor listed (with the possible exception of physical health) plays into the transition to college. Incoming college students with ADHD may not realize that the self care and social demands of college may prove challenging even if the academics do not, and the typical disability services office, focused on academic access, may not offer much help.

This analysis underscores the fluidity of ADHD, and the continuity between those who can be diagnosed and those who cannot. The Diagnostic and Statistic Manual of Disorders (DSM), which provides the basis for diagnosis, emphasizes that ADHD should be diagnosed not based on whether a person displays frequent inattention, hyperactivity, and impulsivity, but based on whether these disable a person and causes them distress. A person may have an ADHD neurotype (for example, dysregulated dopamine systems in their brains, delayed prefrontal cortex development, and reduced prefrontal cortex activity during executive function), but they may only have the disability ADHD when they can no longer compensate for these traits or their environment makes these traits a sufficient liability to cause disability and distress. Thus, a person could theoretically go back and forth over their lives between having ADHD and not having ADHD!

Laurie lays out a simple but powerful approach for dealing with tipping points:
  1. Try to predict whether a tipping point is coming. Are you or a loved one with ADHD about to transition to a new school or work environment? Are there upcoming changes in family dynamics? Are you about to move?
  2. If a tipping point has already happened, ask yourself what changed. Physical health (including activity level and sleep)? Physical environment? Social environment? Consider all possible variables.
  3. What were you doing before the tipping point that helped you in the same situation? Or, if the tipping point hasn't happened yet, what strategies are working for you now? (Not all of these may have been consciously developed. For example, a woman stopped coming to meetings on time after her promotion, only to realize that she had been relying on a neighboring coworker to see when to get up from her desk). 
  4. Create a structure that will work in a similar way. 
  5. Laurie Dupar didn't mention this step, but it's extremely important: Test your strategy to see if it works! Maybe you guessed wrong about what aspect of your old environment to replicate. Or, maybe you guessed right, but your strategy was too complicated or too hard to use. If it doesn't work, you may have to start over and develop a new one.
  6. Consider working with an ADHD coach. This coach does not have to be local, because coaches are trained to work with clients remotely. However, because coaching is a new profession with still-developing credentials, Laurie recommends asking coaches where they trained, how long they have worked, and how many clients they have helped. In particular, one should ask how much experience the coach has with people in your situation (e.g., college students, middle-aged women).
Laurie's stories also highlight the importance of listening to people with ADHD and paying attention to seemingly unimportant details. Sometimes, a life transition can cause a tipping point for different reasons than one might expect. For example, she worked with a young man, formerly a good student, whose grades dropped after moving to a new school. He was happy with the new school, his motivation was high, and he was not discouraged by his poor grades. The change in school did not appear to cause his problems, so Laurie moved on to understanding the changes associated with moving house. It turned out that before he moved, this young man used to set aside a specific amount of time to relax by shooting hoops in the backyard. This left him mentally prepared to focus on studying. At his new house, there were snakes in the backyard and he was afraid to go outside. Thus, he could no longer use this routine, and his concentration (and studying) suffered. Disruptions to one's functioning can often be like this--small, prosaic, and hard to identify without asking the right questions.

In short, I gleaned the following from Laurie's talk:
  1. Tipping points are common among people with ADHD, and nothing to be ashamed of. If you are going through a tipping point, do not blame yourself or judge yourself to be inadequate. "Remember, you've always had ADHD...you have the ability to compensate somewhere." The longer you've gone before the tipping point, the more you've used your talents, creativity, and hard work to succeed.
  2. ADHD traits (inattention, hyperactivity, impulsivity) and the neurodevelopment that creates them are lifelong. However, ADHD, the diagnosable disability, may not be, and a person can move into or out of ADHD status over a lifetime. Thus, clinicians and researchers must develop a sensitivity both to ADHD traits and to the subtle changes in the physical and social environment and in physical and mental health that determine disability status.
  3. Certain common life changes can make ADHD traits disabling and can cause people to get diagnosed. These include changes in environment and in role. The interactions between such life changes and ADHD traits needs more attention and research.
  4. ADHD tipping points can be managed, with awareness. You need to figure out what was working for you and how to implement something similar in your new environment or role.
  5. Understanding and treating ADHD requires both an understanding of ADHD traits (which can be approached scientifically by external experts, like researchers and clinicians) and an understanding of the subtle ways ADHD traits manifest in an individual's life (which can be best understood by the person with ADHD). Thus, people with ADHD should be at the center of research and treatment.
Have you, a family member, a friend, or a student gone through a tipping point? What helped? Do you know of any research that takes the interactions between physical and social environment and ADHD traits into account? Please share your thoughts!