Episode 174: Grief and ADHD: Exploring Misdiagnosis [featuring Debi Frankle]

Show Notes

In this episode, I speak with Debi Frankle, an LMFT and self-proclaimed "grief nerd". We tackled a topic that's rarely discussed but extremely important – the misdiagnosis of grief when ADHD is prevalent.

3 Key Takeaways:

1. Importance of Comprehensive Loss History: Debi emphasizes the need for therapists to thoroughly assess loss histories, not just recent events but all significant losses throughout a client's life. This helps in understanding the broader context of their behaviors and symptoms.
2. ADHD and Grief Overlap: Grief can exacerbate ADHD symptoms like difficulty concentrating, frustration tolerance, and impulsivity. It's crucial to distinguish between the two for appropriate diagnosis and treatment.
3. Misinterpretation and Communication in Grief: Statements meant to console, like "they're in a better place," often miss the mark and can feel minimizing. More effective communication includes acknowledgments like, "I have no idea what to say," or even offering a simple hug.

This episode is a must-listen for mental health professionals and anyone looking to understand the intricate relationship between grief and ADHD better.

More about Debi:

Debi is a self-proclaimed grief nerd. She has known a lot of dead people over her lifetime, experienced many other life-changing losses (including a chronic illness that frankly sucks some days), is trained in grief counseling (in fact, she still goes to trainings herself!) and has been a grief skills educator and trainer over the last 20+ years and writes long run-on sentences, much to her high school English teacher’s dismay.

Debi lives in Los Angeles where she can frequently be found with dirt under her fingernails for she proudly carries on her family’s tradition of amateur gardening. This year she is knee-deep in artichokes, summer squashes, and corn to complement whatever meat her husband is cooking on the smoker on the weekends. 

• Check out Debi's trainings and services on her website: privatepracticegrief.com

🎙️Listen to more episodes of the All Things Private Practice Podcast here
🎙️Spotify
🎙️Apple
🎙️YouTube Music
▶️ YouTube
✈️ Check out available Retreats
🗨️ Join the free Empowered Escape FB Community
🗨️ Join the free All Things Private Practice FB Community

A Thanks to Our Sponsors: The Receptionist for iPad & Alma!

✨ The Receptionist for iPad:

I want to thank The Receptionist for iPad for sponsoring this episode.

This podcast is sponsored by The Receptionist for iPad, a digital check-in system that eliminates the need to walk back and forth from your office to the waiting room to see if your next appointment has arrived. Clients can securely check-in for their appointments and you'll be immediately notified by text, email, or your preferred channel. Break free from interruptions and make the most of your time. I've been using them for almost three years now and it saves me hours in my week.

Start a 14-day free trial of The Receptionist for iPad by going to thereceptionist.com/privatepractice. Make sure to start your trial with that link. And you'll also get your first month free if you decide to sign up.

✨Alma

I want to thank Alma for sponsoring this episode.

Building and managing the practice you want can be challenging. That’s why Alma offers tools and resources to help you build not just any practice, but your private practice. They’ll help you navigate insurance, access referrals who are the right fit for you, and efficiently manage administrative tasks — so you can spend less time on the details, and more time delivering great care. You support your clients. Alma supports you.

Visit helloalma.com/ATPP to learn more.

Transcript

PATRICK CASALE: Hey, everyone. You are listening to another episode of the All Things Private Practice podcast. I'm your host, Patrick Casale. I'm joined today by a good friend of mine and colleague, Debi Frankle. She is a grief nerd, as she likes to label it, LMFT out in California, all things grief, really, really wonderful human being.

And today, we're going to talk about a really interesting topic, which is the misdiagnosis of grief when ADHD is prevalent. So, Debi, thank you so much for coming on. I know we've been trying to do this for a while. And I'm really happy to have you here.

DEBI FRANKLE: I am really, really happy to be here, really. I love your podcast. Oh my gosh. I was just listening to the one about HIPAA. And that was really, really good information.

PATRICK CASALE: Thank you. Yeah, I have to give major props to Liath Dalton of Person Centered Tech. Because, wow, what a wealth of knowledge. I came away feeling like I learned so much. I also came away feeling like, "Oh, shit, am I not doing things [INDISCERNIBLE 00:01:57]. But I appreciate that.

So, tell me a little bit about you know, I know you moderate the Facebook group for Private Practice Grief. I know you're very heavily involved in the grief community. Definitely, you and Jill Johnson-Young are my two like go-to's. Whenever grief comes up I'm like, "Talk to Debbie, talk to Jill." And I think that is so, so crucial in this profession.

But you floated the topic about grief and ADHD. And I'm just curious about the why and what feels really important for you to hit on when we talk about both of those things?

DEBI FRANKLE: Okay, so I'm going to start with the why is because I have ADHD and which, actually, was not even a diagnosis in the mid-60s when my sister died. So, my mom and dad, my mom was exposed to rubella in the mid-60s, and while she was pregnant with my sister. And my sister died, I mean, at four days old. So, I was seven. Six to eight is such a precarious, you know, developmental stage for kids because all of a sudden they understand permanence and the seriousness of stuff.

And so, my parents in the mid-60s, there were no grief support groups. You know, it was you move on, and we don't talk about it. And they didn't get any support that they needed.

And so, the reason why I wanted to do this topic is because when I looked back at that time, you know, is my parents are really good about telling me what happened. But then, after that it was, "We don't go there. You know, we don't talk about what happened."

And within a year and a half, I was needing speech therapy. Actually, my fourth-grade teacher wanted to hold me back. You know, I was in special classes in fifth and sixth grade. And in sixth grade, I was with special class with two other girls and 11 boys. So, you tell me that that wasn't an ADHD group and class. But nobody was talking about or looking at how did the whole grief in the family play out?

And so, you know, I think that there's a lot of grief with having ADHD and all that we miss out on. But I also think and know that there are too many kids that I've worked with who come in who… I remember one boy who would just had a lot of hyperactivity, so a lot of fidgety, a lot of bounce. Well, his dad had died from suicide and mom wanted to protect the kids and didn't tell them. And so, it comes out, I think, where the ADHD symptoms end up getting exacerbated. And then, we end up focusing on that without really doing a whole loss history of what's been going on. And loss history mean doing that, asking about losses that happen. Not just like, "Oh, well, what happened the last six months or even a year?" It's like do a whole loss history because that stuff comes up over and over again later on. Does that make sense?

PATRICK CASALE: Yeah, it does. And I think it's something that probably a lot of people right now are listening to and thinking like I've never put the correlation between ADHD, and grief, and loss. And how grief and loss symptoms can certainly exacerbate or show up as intensified ADHD symptoms, especially, in young kids and young adolescents where everyone's always assessing behavior, and everyone's always assessing attention, and the ability to focus.

And there could be so much disruption behind the scenes that we're not even thinking about because maybe when you were a young child you did have a significant loss. Or maybe it was a divorce in the family, or maybe it was, you know, whatever, a pet loss, or anything that felt really traumatic and significant.

And we all know, like, the grief process is typically not very linear. And it can just show up in ways where memories, senses, scents, environments, like sounds can really start triggering certain reactions.

DEBI FRANKLE: Absolutely.

PATRICK CASALE: So, I think this is a very interesting topic, and honestly, one that I have never really thought about much before.

DEBI FRANKLE: Yeah, it's one that that I see a lot. You know, there's another case that I had done a psychosocial history on women who had come into that. I worked in patient hospitals for many, many years. And a woman had gotten admitted because she had a psychotic break. Thought that she was four years old. She was actually in her early 80s, I think.

And when I was able to get some history from one of her siblings, he had told me, well, when she was five their mom had died. This was in the 1920s. And so, all the kids ended up in an orphanage because dad couldn't take care of them. Well, she had four brothers. They all ended up at one orphanage. She ended up at another one at five.

And so, it was like, well, then the symptomology makes so much more sense as well. Why wouldn't she want to believe that she's four, you know? And so, you know, we look at, if people go, "Well, that's pathological grief." It's like, you know what? I don't think that's pathological. It makes so much more sense of the symptomology with the loss, and the hopes, and the dreams, and the expectations that come along with that.

So, you know, I think, again, you know, I really, really want to be able to share the importance of doing a really good loss history so that we can start identifying that, you know? So, we can even look at the whole entire family system, of how everybody reacted to the loss, you know?

And kids and adults with ADHD do that much more behaviorally, you know, or you know, get fragmented, or have a really hard time concentrating and paying attention, which is a really common sign of grief is that people have a hard time concentrating. They have a hard time paying attention. Well, that just exacerbates all of all of the, say, symptoms of attention disorder anyway. Yeah.

PATRICK CASALE: Yeah, there's a lot of overlap. So, it's really tricky, right? So, if you don't-

DEBI FRANKLE: It's huge.

PATRICK CASALE: …suss it out and you don't assess for it really intentionally and thoroughly, it's really easy to mislabel or misidentify something. And if we're talking about ADHD, which is a neuro-developmental disorder, which is a lifelong disorder, and disabling condition for a lot of people, you know, we want to get it right. And we want to also be able to suss out like what is what so we can treat things appropriately.

So, what are common symptoms and traits that you would see, you know, as a young kid or adolescent, or even young adult who is ADHD, who has an ADHD profile, but also, has a significant grief history? What types of correlations are we looking for here?

DEBI FRANKLE: A really good idea. Yeah, it's really good, is, I think, having a really hard time and not just concentrating, but with frustration tolerance is not being able to wait, not being able to, it's the tolerance of other people are doing and saying stupid things. And we don't like them. And they're snappy. But, you know, grievers are really snappy and irritable. Okay? Is that the world feels really different when you've had a really significant loss.

And so, you know, they start noticing that the stuff that seemed important isn't important anymore. And now, the stuff that seems really insignificant is what other people are talking about. And if you have a hard time in the first place being able to tolerate or read social cues, then it's going to be even more of a problem. Yeah.

PATRICK CASALE: Yeah, so you're [CROSSTALK 00:11:52]-

DEBI FRANKLE: Yeah.

PATRICK CASALE: …more interrupting. You're going to see more frustration. Maybe you're going to be more blunt and direct in your communication. I imagine coming off as rude, or dismissive, or like you don't care about what the other person is saying. And in reality, it's like my distress tolerance is significantly diminished because I'm living in an altered state of my reality where things are just not the same anymore.

DEBI FRANKLE: Exactly. And so, you've also just described grievers who's, we'll take the example of loss of a loved one. All of a sudden, their loved one isn't there, and people are saying things that are not helpful at all. Like, you know, they're in a better place, and you know, well, at least they're not suffering anymore. And so, it's hard to even just tolerate that. And then, if you have a hard time with that in the first place, it's going to feel even more torturous. Yeah.

PATRICK CASALE: That makes a lot of sense. So, I think it sounds like trying to link a correlation and connection between impulse control, the ability to regulate emotions and reactions. And then, the reality of, like, things have shifted so drastically and I'm kind of becoming really not desensitized to the world, but quite cynical or callous in some ways when people are telling you things that are not useful.

And I've had this conversation before on here when we talked about grief. Jill was one of the first people I had on the podcast. We talked about like, when people say they're in a better place, or they offer whatever they can offer, so often it's because they're trying to almost comfort themselves by trying to say the appropriate thing without having the difficult conversation.

And I think that's really challenging for people where it's almost like, how do I try to offer my condolences, but I don't know what to say? But when I do that, I end up saying the wrong thing, and it's not actually hitting the mark. It's not actually landing.

DEBI FRANKLE: Right. And often, and Jill and I have talked about this a lot, you know, often people would just say, "I have no idea what to say." That would be more true. And you know, more people will tell me, "I just wish people would either be truthful and say they don't know what to say or just offer me a hug."

PATRICK CASALE: Yeah, absolutely.

DEBI FRANKLE: You know, for us to take a look at all the non-verbal ways that we communicate, and those are the ways that people will have a hard time being able to read those cues that then it those and gets misunderstood even more, you know? And so, I often will talk about the head tilt, is [INDISCERNIBLE 00:14:41]. So, have you gotten the head tilt yet?

PATRICK CASALE: Give us a visual example of what you mean by that.

DEBI FRANKLE: Almost everybody knows what it's like…

PATRICK CASALE: Just so I [CROSSTALK 00:14:53].

DEBI FRANKLE: And, you know, it's always interpreted as, "Oh, poor you. I feel bad for you. I pity you." And when all of a sudden the world seems really, really different, you know, then it's even more confusing, and we feel more helpless. And so, then it's, "Oh, poor you." Feels even ickier.

PATRICK CASALE: Yeah, it's almost minimizing in a lot of ways, as if you don't really see me or you don't really understand the struggle. And I think that happens a lot when we're talking about grief in all different ways. Like, it could be a grief process around a diagnosis when someone discovers, "Hey, I am ADHD. Hey, I am autistic. Hey, I have bipolar disorder. Hey, I have cancer." There's grief around that diagnosis.

DEBI FRANKLE: Absolutely.

PATRICK CASALE: Grief around the loss of someone, that's very clear. Grief around life circumstances changing. Like, I've even talked about grief around if you are actively addicted to something, and then, you've moved into a recovery space. Although it sounds really bizarre and counterintuitive, there is still grief around the loss of people, places, and things that you became familiarized with.

I know for my gambling addiction, like, am I happy I'm no longer gambling? Absolutely. Do I sometimes have grief around like casinos that I can't go to, people I used to spend time with, places I used to go on a regular basis? Sure. But that doesn't mean that those emotions are not very complex and very nuanced.

DEBI FRANKLE: You know, I'm so glad you brought that up. It's actually something that I always include when I do trainings, when we talk about different types of losses. And I'll always include, here's this, you know, I put it under disenfranchised grief of losses that are minimized or aren't seen, of, oh, wait a minute. What happens when somebody gets clean or sober? Okay? You know? Or you know, isn't using whatever substance that they were using, whether that's gambling, whether that's food, whether it's gardening, like doesn't matter.

And the loss of that, you know, the thing that you go to, to make yourself feel better that now I'm not using that anymore, and that definitely has a whole bunch of uncomfortable feelings and sensations.

PATRICK CASALE: There's so much identity wrapped up in that too, where you lose your identity in a lot of ways. I think that's a loss that we don't talk about very often. I often talk about on my other podcast with Dr. Megan Neff, the Divergent Conversation podcast of grief and relief of our adult autistic diagnoses, where we grieve our childhoods, which could have been different from a different lens. We have some relief in acknowledging this is why our realities are the way that they are.

But that is a complicated grief system that does not just go away because you're experiencing these emotions, these reactions, these processes, these sensory overwhelm and overloads on a daily basis, sometimes minute-by-minute. So, it's always in your face. It's just a matter of like, well, how are we going to work through this? How are we going to have acceptance over the grief that we're experiencing?

And then, there's the existential grief too, of just the acknowledgement of like, you know, life is forever altered as I know it. And I think that can be really, really complicated for people that have any sort of neurodivergence.

DEBI FRANKLE: Absolutely. And, you know, identity is identity. Loss of identity is so interwoven in grieving experiences, in whatever loss is. What does that mean for me? How do other people see me? How do I see myself? How do I assume that other people see me? Yeah.

I also like to think of, you know, when somebody gets diagnosed, is that what was going on that led up to that diagnosis, you know? And who did you have to talk to about it, you know? I like to ask, you know, who got you? Who got it? Often, many people will say, "Nobody did." You know? Is that grief is so isolating. Yeah.

PATRICK CASALE: Yeah, absolutely. For sure.

DEBI FRANKLE: And then, how do we interpret the diagnosis? What does it say about us?

PATRICK CASALE: Absolutely. I think your sense of self can be really rocked when you have to process that, if you feel like you're isolated and alone. I also think that compounded, or complex grief, or a consistent grief history, which I think is why it's so important to do a thorough inventory is you can then start to get misdiagnosed with maybe borderline personality disorder, complex PTSD, if you've experienced X amount of trauma. And your reaction to that trauma is presenting a certain way, reacting a certain way, experiencing life a certain way, it's very easy to get misdiagnosed with all sorts of things which coincide with being misdiagnosed as ADHD or autistic. A lot of these things overlap, a lot of similarities, yet they're not the same.

So, I think it's very easy to get into this, like, almost this rabbit hole of, like, what is it? You're on like WebMD Googling symptoms, and all of a sudden you're diagnosed with everything under the sun. And ultimately, in reality, it's like we're not really thoroughly looking at different portions of life and different contributing factors here, either.

DEBI FRANKLE: Yes, and with trauma work grief is knotted with trauma. And we have really, really great, wonderful interventions and therapies that are focused all on trauma. And actually, I do a course on untangling grief from trauma because there's so much loss that often we don't ask about that other stuff, is that we don't talk about all of the loss of safety and trust, you know? Loss in our own identity. What does that mean? Yeah.

You know, there's also, you know, a loss that will have a primary loss. And then, we have a whole lot of secondary losses. So, we have a loss of a parent due to death, divorce, addiction, estrangement. Then there's all this secondary loss of who the other parent has been because that other parent is not the same anymore either. You know?

I know when I was a kid, after my sister died, my mom was just off. She would get more headaches. She'd get more back aches. I'd want to stay home and keep her company more, you know?

You look at loss of a parent of, you know, loss of safety and trust, you know? The eight-year-old who worried about who was going to get him to school on time after his mom's suicide, and that he wasn't really quite sure. In fact, he actually told dad, "You know, I'm a little…" He's such a great kid. "I'm a little worried dad, because, you know, you've only been a dad and you haven't been a mom. And mom did a lot." Yeah, you know, changes in roles, yeah, where a lot of oldest kids then take on extra chores. But I don't think it's always the oldest kids, by the way. It can be any of the other kids. Is that all of their roles have changed, you know? Look at loss of family structure and routines.

Yeah, there's often then financial strain or less contact with the other parent that's not there anymore with their family, you know? It was change of families or change of friends, you know? Maybe dropping out of activities that the other parent was involved in.

So, then you've got all of that with a kid who needs to have structure and needs to have the same stuff. Okay? Is that then that throws everything off. And then, you're having more temper tantrums. Yeah.

PATRICK CASALE: Yeah. And then, in school, you might be circling back, you might be getting misdiagnosed as either oppositionally defiant, or ADHD, or, you know, there might be behavioral issues at home. But again, circling back to the fact that a lot of times we're not assessing for grief, and a lot of times we are sticking to this very black-and-white thinking when it comes to grief recovery, which is like, go through the stages, and then, voila, cured. And then, it will never impact you, again, which we know [CROSSTALK 00:25:09].

DEBI FRANKLE: Okay, I'm just going to put this out there because I know that there's a lot of people that listen to your podcast, so I'm going to take time to say, can we please do away with the stages that were appropriate and are appropriate for people who are dying? It's a different process.

But the stages often end up, you know, making people feel like they're crazy, you know? The one consistent remark that I get, that we've gotten for 30 years in our counseling center because we focus on grief, is there must be something wrong with me because, you know, I accept it, I'm in acceptance. It's like, well, what does accept mean anyway? And, especially if the loss is so unacceptable, right? So, you know, it's the way that we language grief is so interwoven in how we deal so poorly with grief and pain.

PATRICK CASALE: It's a topic that I think society doesn't like to touch because it's uncomfortable.

DEBI FRANKLE: Right.

PATRICK CASALE: And if we can move from anger to denial to acceptance, to, you know, whatever the stage is, all of a sudden it's like, well, how come this isn't hot going in this, like linear fashion? And how come I, having moved from stage to stage in an appropriate amount of time? And how come I keep circling back to anger, or how come I keep circling back to this? And it's just so complicated. I think it's just a complicated topic that we so often just don't give space to.

Even for business owners that are listening, like there's grief around leaving a job, there's grief around starting a business, there's grief around shutting a business down. For those of you listening who are thinking, "I don't know if I want to be a therapist anymore." There's grief around that process because that's identity woven. And that comes with a whole bunch of shit. So, very complex and very dynamic.

And I don't know if you can see the shirt I'm wearing right now, Debi, but I'm wearing an Anthony Bourdain shirt [CROSSTALK 00:27:14]-

DEBI FRANKLE: Yeah.

PATRICK CASALE: …yesterday.

DEBI FRANKLE: Yeah. I love it.

PATRICK CASALE: And just so my brain can diverge real quickly, when Debi and I were at a conference in Hawaii a few years ago, we stupidly went to see this Anthony Bourdain movie with a bunch of grief therapists. Debi [CROSSTALK 00:27:27]-

DEBI FRANKLE: I remember, yeah.

PATRICK CASALE: …experienced an enormous amount of grief while watching that movie. And what better space to be than Hawaii with two wonderful grief therapists. But in reality, it was very challenging. And I think that also helped me lead me to my own autistic diagnosis discovery because I felt like I related so much to Anthony Bourdain's story in so many ways. And I started doing more reading and assessing. And I was like, "I think Anthony Bourdain was autistic. Like, I think all these things match up." And then, all of a sudden, here's my diagnosis a couple years later. And I'm like, "Oh, shit. Like, Anthony Bourdain has become a special interest of mine." So, it's very fascinating.

But nevertheless, grief is one of those things. And I think that you can have grief around celebrity losses that you've never met, that you've never had any contact with. When people's favorite singers die, when people's favorite actors or actresses die it impacts you, especially, for neurodivergent folks who have these feelings of special interest around songs, or shows, or movies, or music, or something that has really been moving. So, it's just very, very complicated.

DEBI FRANKLE: You know, also, you bring up a really good point, is that I think that when we get new information then we have to go back and look at the whole puzzle all over again. It's like when I've had kids who or adults who have found out this piece of, "Oh, wow, wait a minute, it wasn't an accident. My parent was murdered." Or, "My parent died by suicide."

And then, you have to go back. I remember a dad after one of his kids had found out that his wife had died by suicide, and he was upset that his kid, all of a sudden, was starting to act out, was getting a little more mouthy, so to speak, until I was like, "Wait a minute. Hold on. But his mom just died." And he was like, "No. That was two years ago." I said, "No, he just got new information, which means that you got to go through the whole history all over again." It's like, wait a minute, I thought I had the whole puzzle all finished. Now, I find out there's all these key pieces that now I got to redo the whole thing. And then, how exhausting that is.

PATRICK CASALE: Yeah, yeah. You may have moved through your acceptance phase, or whatever the case may be, and tidied that up, and put that away, and compartmentalized it. And all of a sudden you have to unlock everything again, and reassess it, and look at it from a different perspective. And that comes with newfound information and newfound emotion, too.

So, this is a very complex topic. And I'm glad to know that you, and Jill, and other people out there are just doing some phenomenal work, having very difficult conversations with people on sensitive subjects that are really impactful. And I think that it's really important to just continue to talk about and continue to address.

So, I just want to thank you for coming on and sharing your perspective on this, especially, around a topic that is so taboo for so many people.

DEBI FRANKLE: Yeah, yeah. Well, thank you. I really, really appreciate the opportunity to be able to come and share some of this information with people, which I just think it's just a part of our lives.

PATRICK CASALE: It is. And it's an important one to really lay eyes on and have conversations around. So, thank you so much, Debi. And just share with the audience where they can find more of what you've got going on and where they can reach you.

DEBI FRANKLE: You know, come on over to privatepracticegrief.com. And I've got, actually, a course coming up in the end of July. And I've got another one on untangling grief and trauma. It's a four-week course. I love doing this course because I also include prolonged grief disorder, which, you know, we can do a whole another podcast on prolonged grief disorder. But I have a whole training for that so that people can really take a look at what is it and what it isn't. And so, that's in the end of July.

And then, I've got in September, I'm actually doing my annual grief skills six week really, really deep dive. So, you really want to learn about how to deal with grief, come join me in September. So, privatepracticegrief.com.

I also have my Facebook group, Private Practice Grief for clinicians, health, and professionals who want more information, more talk about grief, because I'm a nerd and I love talking about grief.

PATRICK CASALE: Love it. All of that information will be in the show notes that all of you have easy access to all of Debi's information and upcoming courses. Debi, thanks so much for coming on. And hope to see you on top of another Hawaiian mountain top sometime soon.

DEBI FRANKLE: Yeah, thanks.

PATRICK CASALE: To everyone listening to the All Things Private Practice podcast, new episodes are out every single Saturday on all major podcast platforms and YouTube. Like, download, subscribe, and share. Doubt yourself, do it anyway. See you next week.