I thought to myself, ’How had I not grasped the significance sooner?’
I'll start from the beginning:
Some time ago I learned that the process of myelination in adolescence is when the brain begins to improve ‘the efficiency of information processing, and neural connections between the prefrontal cortex and other regions of the brain’. In other words, the complex circuitry of the brain insulates itself progressively throughout childhood. The general consensus is that myelination begins at birth and continues in to our mid-twenties.
Thanks to Graham Music, one of the many amazing lecturers I had when training at The Tavistock years ago, I had a vague idea that this facet of brain development was likely significant for neurodivergent young people although I did not yet have a wider context as to why. While I was fascinated by the passion with which Graham spoke and wrote about brain development in relationship to his psychotherapeutic work, at that time my mind was still getting to grips with the fundamentals of my training. Since my dyslexic brain always needs an experiential hook to hang information on, I could not yet attach the significance of the myelination process to the working model I was developing as a burgeoning psychotherapist. As the works of psychoanalytic icons like Bion, Winnicott and Klein were at the forefront of my thinking, I was not fully able to take in Graham's messages; but the feeling of its significance lingered.
Years went by.
... then ...
This February I attended an incredible two day training with Lisa Ferentz, from the Ferentz Institute in Maryland: Treating Self-Destructive Behaviours in Trauma Survivors: An Effective, Strength-based, De-pathologising Model. Amongst the wealth of ideas she presented I had a crystallising moment. It was one of those moments when various thought fragments which had been floating around in my mind suddenly cohered into a unified understanding.
Although Ferentz was discussing myelination in the context of trauma survivors, I felt a whole new vista in my work with neurodivergent teens open; especially regarding ADHD
As both a therapist and neurodiversity consultant my approach to working with parents, schools and organisations follows a common path. The primary focus is not, in the first instance, on sharing a range of support strategies. I know this might sound odd but what I have learned over the years is, whilst offering strategies may be an end goal, those involved first need to develop a common understanding and language around a given subject matter before attempting to mediate it. To my mind understanding the nature of an issue must precede the implementation of any strategy, otherwise even the best strategies will inevitably break down under the weight of other perceived priorities. In my experience, offering a framework for parents and organisations to develop a shared set of definitions, understandings and an agreed way to talk about complex matters allows for more constructive conversations around neurodivergent young people to begin.
Essentially, if we know why we are doing something, we are more likely to do it.
My hope is that if I can help open the Pandora’s box of misinformation and misperceptions around neurodiversity in a controlled and supportive way, new thinking can begin to emerge.
Amongst significant misconceptions I push hard to challenge regarding ADHD are preconceived ideas around making 'choices’ in the typical sense of the word. While of course as children grow they need to learn to take responsibility for their actions (e.g. make good choices), we adults as their guiding facilitators really need to understand the Sisyphean struggle the ADHD child can face when learning to manage a mind that simply works differently then we expect or anticipate.
In professionals trainings and family consultations I generally focus on highlighting four aspects of brain function which are impaired in ADHD (summarised beautifully in the short video in the resources below). Whilst I am fully aware this does not tell the whole ADHD story, the idea is to give those with no previous understanding a toehold from which they can begin to build a working model of what is happening silently in a child/young person's brain.
1. Frontal lobe
This region (home of the prefrontal cortex) controls high-level functions such as:
*Attention
*Organisation
*Executive Functioning
2. Limbic system
The part of the brain involved in our behavioural and emotional responses, especially when it comes to behaviours we need for survival: feeding, reproduction and caring for our young, and fight or flight responses. This region REGULATES our emotions and attention.
3. Basal Ganglia
The basal ganglia are a set of brain structures located beneath the cerebral cortex that receive information, transmit it to motor centres, and return it to the part of the cerebral cortex that is in charge of motion planning. It is also integral to pleasure and reward processing.
4. Reticular Activating System
A network of neurons extending from the top of the spinal cord up to the thalamus (the body’s sensory and motor information relay station) which filters incoming sensory stimuli and redirects them to the cerebral cortex, activating the cortex and influencing our state of physiological alertness.
My aim in highlighting this is to really help parents and schools understand that many functions of the brain we rely on to modulate our responses, manage impulses and organise our thinking are indisputably challenged in the ADHD brain. This is not making a judgement one way or another. It is simply important to view this with the same factual acceptance as those with myopia needing glasses.
The point is, sometimes things we adults perceive as active choices, are not really 'choices' at all, but impulsive reactions to information or experiences that the child genuinely is struggling to process and make sense of.
Understanding the mechanisms behind one's lived experience and the accompanying frustrations are, in large part, what intervention of any kind should be targeting. Regardless of whether a child is on medication or not, bringing to light this very real but hidden struggle, while providing meaningful and age appropriate ways for kids to think about their experiences and view themselves in a positive light, is often more than half the battle.
Coming back to Ferentz - HOW she described the myelination process instantly triggered a realisation in my mind regarding its implications for our neurodivergent kids, especially those with ADHD. She spoke of the neural network in the human brain as an intricate set of exposed live wires. She described how all the wires are in place and firing, but each of the wires themselves have not yet been insulated. What this means is, like exposed wires in any electrical circuit, even if the signal is travelling along the correct wire, the lack of insulation will cause interference between other surrounding information channels which, at moments, will inevitably cause static and chaos.
Teenage-hood in a nutshell.
Ferentz also explained how the myelination process is progressive, starting at the back of the brain and slowly moving to the front.
This means the brain first ‘insulates’ the wires around our limbic system where our vulnerable fight, flight, freeze reactions are located. This enables us to slowly develop the capacity to manage our survival alert systems more effectively.
Over time this process progresses through the brain to the prefrontal cortex, the ‘thinking brain’, where all of our executive functioning and decision making abilities develop. Over the course of this journey, which lasts into early adulthood, our brains need to manage ever increasing amounts of information at exponentially increasing speeds. This means when we enter adolescence there is ever more 'input' we need to cope with whilst also battling the interference from other frenetic, live wires in the brain network which are still raw and exposed.
The link I made whilst listening to Ferentz was that much of the 'wiring' identified as presenting challenges in the ADHD brain, is the very same 'wiring' that is linked to the natural impulsivity and hypersensitivity due to lack of myelination which impacts us all in growing up.
A double whammy for ADHD kids, especially adolescents!
Interestingly, since engaging with this avenue of thought I have discovered I am far from alone in making this connection. I have come across numerous studies exploring a possible link between ADHD and 'dysregulated myelination' and how it may effect brain development across the lifespan. Some researchers are taking this one step further and questioning if the myelination process itself is implicated in those with ADHD.
This has certainly given me pause for thought.
Not that this would really change my thinking around ADHD or intervention approaches, but it could give us a greater understanding of what is at play. Further, for some struggling to grasp the child's experience, it may make the reality of certain challenges easier to comprehend and accept; not to mention helping those with ADHD teens recognise that their child's experience of adolescence may be significantly more intense than previously appreciated.
I also believe that understanding certain fundamental aspects of development, like the myelinating brain, whether it is ultimately determined to be linked with ADHD or not, speaks even more profoundly to why proactive early intervention is so important. I find so often when working with parents, if we can build a shared understanding of some of the core factors at play, we can begin to craft constructive narratives, not just around challenges but also around strengths. Early intervention can also help children and young people grow up with an understanding that there is nothing 'wrong' with them and instead internalise the idea that there is, and always has been, a "diversity of human minds ...[and]...it is expected for brains to be different and unique". For all involved this fosters a mindset of curiosity versus criticism; possibilities versus limitations.
I am, of course, extremely aware that this more supportive path is sadly not the one that all young people have the chance to walk. This makes it all the more important to offer opportunities for bettering understanding when and where we can.
I truly believe that as we grow to understand the brain and all its fascinating intricacies, whatever that comprises, there can be extraordinary strength and self-knowledge to gain.
Resources:
0:03 / 1:10
The Neuroscience of the ADHD Brain:
ADHD Podcasts with Fin O'Regan:
Reference and information sources:
Graham Music: Psychotherapist, trainer, supervisor, lecturer & author. Nurturing Natures UK
Murphy, K. (2023). A guide to neurodiversity in the early years. Anna Freud Centre
Lesch, KP, Editorial: Can dysregulated myelination be linked to ADHD pathogenesis and persistence?, The Journal of Child Psychology and Psychiatry, Volume60, Issue3, pp 229-231, March 2019
Lisa Ferentz, The Ferentz Institute, Baltimore, Maryland, USA
Lumen Learning, Brain Changes during Adolescence, Lumen Adolescent Psychology