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Mentalization And ADHD: Why Perspective Disappears Under Stress · Inside The Consulting Room - Understanding the Child Behind the Behaviour

• 0:00
  SPEAKER_00: Hello, this is Kim Lee.
• 0:01
  SPEAKER_00: Welcome back to the series on mentalization.
• 0:04
  SPEAKER_00: Now I've spoken about how this process is formed, how it builds and develops, but I want to talk about how it's also compromised.
• 0:15
  SPEAKER_00: So in this episode, I want to talk about mentalization and ADHD.
• 0:22
  SPEAKER_00: Now, very often parents will tell me or ask me, why does my child seem to understand things perfectly one moment and then completely loses perspective the next?
• 0:34
  SPEAKER_00: And this is one of the most common questions I hear from parents who have children with ADHD.
• 0:41
  SPEAKER_00: And many describe the same kind of experience.
• 0:43
  SPEAKER_00: The child can be loving, thoughtful, empathetic, insightful, and yet when emotions run high, all of that seems to disappear.
• 0:53
  SPEAKER_00: And arguments escalate rapidly, perspective vanishes, and things are said or happen that later cause regret.
• 1:02
  SPEAKER_00: And this is because feelings become overwhelming.
• 1:06
  SPEAKER_00: And if we think back to brain structure, when feelings are overwhelming, the executive parts, the executive function in the prefrontal cortex, the thinking brain, that gets completely overwhelmed.
• 1:22
  SPEAKER_00: Sometimes parents say, why can't they just stop and think?
• 1:27
  SPEAKER_00: And the answer really lies not so much in motivational character, but in the relationship between ADHD and mentalization.
• 1:38
  SPEAKER_00: As we've explored through the series, mentalization is our capacity to understand ourselves in terms of and others in terms of feelings, thoughts, wishes, and intentions.
• 1:51
  SPEAKER_00: But mentalization depends heavily upon something else, and that is the ability to pause, to slow down, to stop, to tolerate emotional discomfort.
• 2:04
  SPEAKER_00: And many of the children I work with really have this part of themselves quite compromised.
• 2:12
  SPEAKER_00: And it's also true of some parents as well.
• 2:16
  SPEAKER_00: So if you can imagine a parent and a child both in a similar kind of state, well, you can probably work the rest out.
• 2:24
  SPEAKER_00: But it's it's about being able to hold multiple perspectives in mind simultaneously.
• 2:30
  SPEAKER_00: And I guess that in simple language means the capacity to think and feel at the same time.
• 2:37
  SPEAKER_00: Now, these are precisely the capacities that ADHD can compromise.
• 2:43
  SPEAKER_00: Russell Barclay famously described ADHD not as a disorder of attention, but as a disorder of self-regulation.
• 2:53
  SPEAKER_00: Now, in many respects he was right because attention is only part of the picture.
• 2:59
  SPEAKER_00: ADHD affects executive functioning, and executive functioning is what allows us to stop, think, reflect, and respond rather than react.
• 3:11
  SPEAKER_00: The child with ADHD often experiences emotions intensely and immediately.
• 3:18
  SPEAKER_00: They may feel disappointment, frustration, embarrassment, excitement or rejection with enormous force.
• 3:26
  SPEAKER_00: Before the thinking brain has had time to engage, the behavior's already happened.
• 3:31
  SPEAKER_00: The words have been spoken, the doors have been slammed, the regret follows, then shame, and then very often confusion.
• 3:39
  SPEAKER_00: And this is because children with ADHD genuinely do not understand why they have reacted so strongly.
• 3:47
  SPEAKER_00: Parents sometimes mistake this for manipulation or defiance.
• 3:52
  SPEAKER_00: Peers may just assume the child doesn't care.
• 3:56
  SPEAKER_00: But underneath these behaviors, something very different may be happening.
• 4:00
  SPEAKER_00: The capacity to mentalise has temporarily gone offline.
• 4:04
  SPEAKER_00: Not because the child lacks empathy or conscience, but because emotional intensity has outrun reflective thinking.
• 4:14
  SPEAKER_00: This is why ADHD is so often associated with emotional impulsivity.
• 4:20
  SPEAKER_00: And it's why many children struggle to think clearly when distressed.
• 4:25
  SPEAKER_00: And perhaps nowhere is this seen more clearly than in rejection.
• 4:30
  SPEAKER_00: Many children and adolescents appear unusually sensitive to criticism, exclusion, or disappointment.
• 4:38
  SPEAKER_00: It could be a correction, a friend's rejection, a parent's frustration, or a sibling teasing.
• 4:45
  SPEAKER_00: Even what others might experience as unpleasant for them can feel overwhelming.
• 4:52
  SPEAKER_00: Some clinicians refer to this as rejection-sensitive dysphoria.
• 4:58
  SPEAKER_00: Now, whether or not we use that term, many parents will recognize the experience.
• 5:04
  SPEAKER_00: The smallest criticism can feel enormous.
• 5:07
  SPEAKER_00: And once shame enters the picture, mentalization often collapses.
• 5:13
  SPEAKER_00: The young person no longer thinks mummy's annoyed because she's worried.
• 5:17
  SPEAKER_00: Instead, they experience nobody understands me, everyone hates me, I'm useless.
• 5:22
  SPEAKER_00: Similarly, parents may stop wondering about what is happening beneath the behavior.
• 5:28
  SPEAKER_00: Instead, they become exhausted, angry, frustrated, and they begin to only see the behavior itself.
• 5:36
  SPEAKER_00: In those circumstances, everyone's capacity to mentalize begins to collapse.
• 5:41
  SPEAKER_00: And this is one of the tragedies because ADHD rarely affects only the child, it affects relationships, and relationships are why mentalization lives.
• 5:52
  SPEAKER_00: The same is true in adult relationships.
• 5:54
  SPEAKER_00: If one party in an adult relationship has a compromised capacity for mentalization, then it is likely that they will behave in ways which create gaps in the relationship, areas of misunderstanding that can't be rectified.
• 6:14
  SPEAKER_00: Not because they are intellectually unable, but because something happens internally that causes them not to be able to predict how their actions may be experienced.
• 6:28
  SPEAKER_00: Or indeed come back and repair something after they become aware of that.
• 6:34
  SPEAKER_00: And this is not the same as avoidant behavior.
• 6:40
  SPEAKER_00: It doesn't mean that people with ADHD can't be avoidant as well.
• 6:44
  SPEAKER_00: But I think when we come back to children, then we have to understand exactly how this is put together and also the importance of once again the relationship.
• 6:57
  SPEAKER_00: Because as Siegel, Daniel Siegel reminds us, it's the integration is the foundation of emotional health.
• 7:05
  SPEAKER_00: But integration becomes really difficult when emotions arrive at such speed and such intensity.
• 7:13
  SPEAKER_00: There's little opportunity for reflection.
• 7:16
  SPEAKER_00: And this is why children with ADHD often need something very different from what adults instinctively provide.
• 7:24
  SPEAKER_00: They need slowing down, not speeding up.
• 7:29
  SPEAKER_00: They need curiosity, not criticism.
• 7:32
  SPEAKER_00: They need co-regulation and not confrontation.
• 7:36
  SPEAKER_00: Because children with ADHD often borrow emotional regulation from the people around them.
• 7:43
  SPEAKER_00: And when everyone becomes dysregulated, then nobody can think clearly.
• 7:48
  SPEAKER_00: So perhaps one of the most painful misunderstanding or misunderstood elements about ADHD concerns empathy because parents maybe believe my child doesn't care.
• 8:01
  SPEAKER_00: But actually they do, often profoundly.
• 8:05
  SPEAKER_00: Many children with this difficulty are deeply empathic.
• 8:09
  SPEAKER_00: They feel intensely, sometimes too intensely.
• 8:14
  SPEAKER_00: But the problem is not the absence of emotion, it's that emotions can become so powerful that perspective disappears.
• 8:23
  SPEAKER_00: Mentalization is overwhelmed by feelings, and this has consequences.
• 8:29
  SPEAKER_00: Children with ADHD interrupt because they're excited or angry because they're hurt, appear selfish because they're overwhelmed, forget promises because working memory has failed, or just seem indifferent because shame has become unbearable.
• 8:45
  SPEAKER_00: They still require structure, consistency, and accountability.
• 8:50
  SPEAKER_00: And accountability is really important.