Thrive | Emerge™


Like A Spinning Top:
How To Manage "Spin Out" In Young Adults with ADHD

I recently heard the story of a young adult patient who had to leave college because of emotional challenges related to her ADHD. She’d been doing so well in the second semester of her freshmen year – meeting the academic demands, getting good grades, gathering a group of friends who dearly loved and supported her. Everything looked right from the outside.

But then over the course of no more than two weeks, the house of cards fell apart, undermined by the emotional dysregulation so characteristic of many with severe ADHD and Executive Dysfunction. She spun out -- not because she wasn’t trying, not because parents and counselors and deans didn’t care, but because the ADHD brain is home to a tough gremlin that sneaks up from behind and takes you down fast and hard.

Spin out -- driven by the emotionally dysregulated ADHD brain -- is a very real, very painful experience for the young adult. Cleanup work can take months, complicated by the emotional scarring that accompanies the experience – grief, loss of self-esteem, learned helplessness.

At the root of the problem is a biological glitch: a prefrontal cortex that fails to adequately monitor and modulate the storms arising from the emotional center of the brain. What neuro-developmentally typical peers can do relatively easily – learn to successfully balance the growing emotional, logistical and energetic demands of an independent existence – the ADHD young adult can master only in fits and starts. At some point, the brain slips off the rails and the system crashes to the ground.

Think of the ADHD brain like an engine running on 5 out of 6 cylinders. Everything hums along fine for a while and then, Bam! What was smooth and steady is suddenly out of kilter. Or consider a spinning top: only one point of contact with the ground – enough to hold it steady when the speed and rhythm of life is just right, balanced just so. But one small perturbation and the system spins wildly out of control. For young adults with this problem, the brain is an inherently hypersensitive and unstable regulator of emotional experience.

So what caused this patient to slip off track, what let the gremlin slip in? The picture is confusing, but here are some of the factors that seem to contribute to this round of destabilization (there will be more rounds in the future):

  • She was pushing too hard, socially and academically.
  • She wasn’t using her support on a daily basis.
  • She began smoking more marijuana to quiet the emotional distress, which led to feelings of being disconnected and consequently to feeling less stable.
  • She wasn’t using healthy grounding and emotional self-control techniques.
  • In the name of independence, she had cut herself off from a key support source: her parents – “I need to do this on my own” was, unfortunately, a far more compelling emotional dictate than “I need to recognize my limitations and get help.”
  • She “didn’t want to bother people” so when things got really bad, she was emotionally isolated.
  • She didn’t recognize what spinout looked like, didn’t know her own red flags and didn’t know when to get help.
  • She didn’t understand how fragile the emotionally dysregulated brain can be, and that she needed continual monitoring, support, nurturing and grounding.

This patient is far from alone in this experience of spin out. I have seen similar patterns repeated multiple times in the lives of young adults. And here is the painful but urgent message: without careful monitoring and careful structure, the emotionally dysregulated ADHD brain cannot sustain the demands of young adulthood.

What can we do to help? The key to successful treatment lies in COORDINATION and MONITORING – what I would call “real time care”. The ADHD gremlin rises quickly and powerfully – so time is of the essence. And by time I mean not months or weeks, but days and hours. The brain of the ADHD young adult dysregulates quickly, so there is little time for reflection and observation.

A crisis plan needs to be in place beforehand, and the parties on the treatment team (parents, practitioners, young adult, college personnel) need to be on board with their roles. Observation needs to be constant; and the young adult needs to be vigilant about self-care, self-observation, self-regulation and utterly transparent with the people caring for her.

Here are some specific approaches that I believe are critical:

  1. Emotional self-regulation techniques, such as the mindfulness techniques taught through Dialectical Behavior Therapy.
  2. Weekly contact with a therapist
  3. Weekly contact with an Executive Function Coach (they’ll need this to keep their treatment on track)
  4. Daily check-ins with parents about emotional status
  5. Recognition of “red flags” that the brain is starting to falter
  6. Medication – for ADHD, anxiety, depression and mood stabilization
  7. No or extremely controlled substance use
  8. Regular exercise – at least three times a week
  9. Good nutrition
  10.  Good sleep
  11.  Going to a college close to home where support and monitoring is relatively easier for parents and professionals to do
  12. A tightly coordinated team and treatment plan among parents, young adults and practitioners
  13. A body/ energetic grounding treatment – for example, acupuncture
  14. A good social network
  15. A very clear, detailed checklist of the above activities that the young adult can use to monitor their adherence to treatment
  16. Emergency contact numbers – family, professionals, friends – and if necessary, the phone number for a crisis counseling center
  17. A plan for a break when they start to slip – perhaps a few days off school or coming home if things get bad
  18. Coordination with the college so that they understand the particular needs of your young adult and the role the college will play in providing the support necessary to maintain your child’s psychological stability

As parents of these children, we should be realistic about their path to independence: it will much rockier, much more demanding and with a much slower pace than developmentally typical peers. We will share their sadness, frustration and hopelessness. But with intensive, well planned structure and support, our young adults can avoid repeated failures and move forward with their lives.