Neurodivergent Affirming Therapy with Dr. Rachel Fryman

In this episode, Dr. Rachel Fryman talks about the challenges neurodivergent people face, and how neurodivergent affirming therapy can be helpful. We discuss the delicate balance of helping but not enabling, using scaffolding, and other tips.
Dr. Rachel Fryman, PhD, LCSW,  specializes in supporting adults navigating daily life and transitions with a trauma-informed and neurodivergence-affirming approach. Together with clients, she explores the impact of the past and distracted living on relationships, academic achievement, job performance, and overall well-being. Rachel works collaboratively in sessions to identify and incorporate strategies to manage challenges, so that every day is less stressful and more meaningful. She is an assistant professor at Yeshiva University Wurzweiler School of Social Work. She consults, lectures and researches on the intersection of  Judaism and mental health.
https://www.psychologytoday.com/us/therapists/rachel-fryman-west-hempstead-ny/403857
https://www.attentiontherapyny.com/


https://podcasts.apple.com/us/podcast/preparing-your-child-with-adhd-ld-for-college-and-for/id1500215343?i=1000566616338
Cover art by Charlotte Feldman
Please note that while I am a pediatrician, I am not your child's pediatrician. This podcast is for informational purposes only and does not constitute medical advice. For any medical concerns or decisions, please reach out to your child’s health care professional.

Transcript

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Welcome to Kids Matter. I'm Dr. Elisa Minkin. As a pediatrician, mom and grandma, I understand how challenging it can be to help our kids grow into their best selves. We are so much more powerful together. Here I will be sharing the knowledge and wisdom of a wide range of people who understand and care deeply about children. I'm hoping for your input as well because kids really do matter. They are our future. Welcome back Today. I am here with Dr. Rachel Fryman. Hi, how are you? Hi. Good to see you again.. Dr. Rachel Fryman specializes in supporting adults navigating daily life and transitions with a trauma-informed and neurodivergence affirming approach. Together with clients, she explores the impact of the past and distracted living on relationships, academic achievement, job performance, and overall well. Rachel works collaboratively in sessions to identify and incorporate strategies to manage challenges so that every day is less stressful and more meaningful. She's an assistant professor at Yeshiva University, WT Weiler School of Social Work. She consults, lectures and researches on the intersection of Judaism and mental health. So I'm really excited. This is not my first rodeo with you. I'm excited to have my second interview with you. And my first one was for a podcast through the Jewish Orthodox Women's Medical Association or Jona. And I'm going to link to that episode too because I feel like this takes off where that one left off and you've moved up in your age group that you work with. And we're gonna talk about that age group, but I still want to keep it from the lens of the parents' mindset as well. Mm-hmm. Because, and and my work has only evolved exactly. I'm still working with young adults and adults and, and parents a lot around parenting and co-parenting and neurodivergent parenting for neurodivergent parents as well. So it's been a few years, but it's so exciting to, to be able to have these conversations again. Absolutely. And that was what I was hoping you were doing, was working with Neurodivergent parents. Because that's a really important niche that I think is underserved. So I'm really, really excited to talk to you about all of these things today. So let's start. Let's start with, let's start with just actually a definition of what we mean when we say neurodivergent or neurodivergence. So neurodiversity is a sociological term that came about by Judy Singer a while back, and has been adopted, I think, by the mental health community and really advocates in the mental health community saying. I don't need a diagnosis. I don't need to be a DHD. I don't need to be autistic. I don't need to be a learning disability. I don't need to be defined by my anxiety, my depression, my diagnosis. I want to embrace the fact that I think differently. I operate differently and neuro divergence and neurodiversity as the umbrella. Term in, in includes all different abilities and as a sociological term that I think that has been adopted by the mental health community. It's empowering. It takes away the labels. If someone doesn't fit exactly with the definition, is it? A DHD, is it autism? Is it a bit of both? Especially for the women that I work with who might not meet diagnostic criteria for one or the other combined. So having a rule out of something it, it can be very affirming to be able to say. I'm neurodivergent. I have clients that come to me saying, I am neurodivergent spicy. I'm, I have a neuros, spicy, you know, I think outside the box. Right? And it can be very affirming to, to be able to belong to this community of people who think differently, who are not limiting themselves to DSM diagnostic statistical manual diagnoses but are self-identifying. As different, differently abled. I love that. And I love that it's not a pathologizing lens. Yeah. And you don't need a diagnosis. Like you said, not everybody fits into the box. The whole concept is we don't need to fit into a box. Right. Right. And for women, and maybe this is an important conversation to have, so for so long, women were not being appropriately diagnosed. Right. The, the DSM more or less was, was. Geared towards diagnosing boys and and men for A DHD and autism. And the criteria that was included in the DDSM was more geared towards male gender. And that meant that the research agenda was more geared towards male gender. And then the clinical interventions were more for male gender. So women, girls have been excluded from. The diagnosis from the research agenda and from the clinical interventions. And there's been a ton of work over the last decade and a half or so to close the gender gap. Something that I'm really interested in have been following, just this year I, I read a new book that came out on autism from the uk. And bridging that gap, closing that gap on diagnosis of women with autism by a neuropsych by a neuroscientist who literally is studying the, the women's brains are different, and I, I think when we're having these conversations about gender and neurodivergence, it's really important to. Identify that women might not meet all the criteria for A DHD. You know I, I'm interested in emotional dysregulation for a DH adhd. Hmm. Which is actually not one of the diagnostic statistical manuals criteria for a DH adhd. Right. Which is so interesting. The European consensus that came out in 2019. Does include emotional dysregulation and that is really, really affirming for women who are neurodivergent, who identify with the emotional dysregulation of A DHD, even though it's not in the DSM for autism, the research agenda, it has also been more gender towards male presentation. You know women are really good at masking, at covering up in the neurodivergent community. I've heard about camouflaging as well, like blending in, and the cost of that is that burnout. It's the depression, it's the anxiety. If it's the self-harming it. It's the exhaustion, it's the perfectionistic you know, tendencies that that come along with, with trying to fit in. So when we're talking about neurodivergence we're creating a language for people who might be Audi, DHD, might have a bit of both. And now that we have the DSM five, you can be diagnosed with a DHD and with autism. You might not meet full CRI criteria for either. And then the neurodivergent label can be really, really empowering. Right. Just so to be clear, ODHD is not a DSM diagnosis? No. It's a term that's taken over in social media. Yep. Which has its pluses and minuses to be fair. But the ability to be seen and to be able to find what your challenges are. Your strengths and find your community is, is a very powerful thing, right? I like that you don't have to have a diagnosis to understand yourself or to get help and to even understand that the diagnosis might have left you out. Yeah, and, and that you might be masking, you might be camouflaging, you might actually meet diagnostic criteria, but the diagnostic criteria at that moment is not necessarily evaluating how, how you, how you truly present. And, and I've heard that from women who, you know, they're able to mask, they might not meet full diagnostic criteria and then at certain points in their life are able to look back and be like. No. You know what, when I was a kid, I really, I was that kid. I, you know, for A DHD and for autism, there has to, it, it can't come out of nowhere. So something, one of the things that I'll, I'll do with clients is really do a thorough evaluation with them of like, when did. Struggles begin. And that's like kind of a developmental bio-psychosocial spiritual assessment that starts way back when. And if someone is struggling with attention with organization, with time management with emotional regulation, and it's happening all of a sudden, well then it, it, it's not necessarily neuro neurodiversity that we're, we're neurodivergence that we're looking at. We're looking at, and in this. Situation, is there anxiety? Is there depression? Is there you know, is there a trauma that's happened? Is there a medical, underlying medical condition? And then, you know, those are, those are criteria that we're looking at. And, and it is really important in those situations to work with a physician. Because if there is an underlying medical issue that's caused this change you know, you, you wanna make sure that, that they're being taken care of. So. For A DHD from childhood. You know I think part of the work for adult diagnoses, which are the population I'm more or less looking, working with now, is being able to think back, like how their life could have been different, would've been different and how to process that. New diagnosis as an adult and then plan appropriately, figure out the supports that they need to be able to thrive as a, an adult with neurodivergence. That's terrific. But I wanna dig a little bit into who needs a diagnosis, what the value of a diagnosis is, because I think you can be criteria for a diagnosis and choose not to get it. Yeah. Right. You can still get help, especially when you're older and you're not necessarily getting help through the label. When you're younger, you're a kid. You might, you need to get whatever label you need to get the services you need. Right. But when you're an adult, it's not the same calculus number one. Sure. Right. You may not wanna identify. As a specific diagnosis, right? You may not even want neurodivergent, but that's a separate conversation. But at times it can really, really be important at any age, right? So I wanna hear your thoughts on that, please. Right. So for many years I've been speaking to families about the importance of a thorough neuropsychological evaluation. Because A DHD has so many comorbidities, we know that increased learning disabilities. So whether it's dyslexia or dysgraphia, so difficulties with reading or with numbers, auditory processing disorders all have higher comorbidities with A DHD. So if there is a known diagnosis of A DHD one of the, one of the things that I, I've worked with families over the years has been the importance of a thorough neuropsychological evaluation. That might also, you know, screen for anxiety and depression and maybe, you know, if there's if there's concerns including you know, an evaluation for autism. It really depends on what the neuropsychologist decides. And then that information is used to rec, make treatment recommendations. It's used to make testing and school accommodations and, and becomes a living breathing document that, that. You know can be a tool for the family to use in school and support them with either 5 0 4, which is a medical accommodation plan. So extra time or classroom accommodations or an IEP plan, an individualized education plan. Which will then possibly offer if they qualify resource room, ot, pt, speech, vision assisted technology so services in school as well as the testing accommodations and classroom accommodations that would be recommended by the neuropsychologist in collaboration with the family and maybe with the physician, the therapist, and, and ev and the teachers. Right. So you're talking about a 5 0 4 or an IEP? You're talking about kids in the school system until graduating from high school. Right? I was actually, first of all, there's an intermediate period where you go to college and grad school where that system doesn't apply, and I do wanna let you talk about that so that, so that, so, we, it's, it's actually in New York State for example, there are services like Access vr which will extend through college. And in many colleges you bring your IE or declassified IEP or 5 0 4. So at the end of high school, you're given a document if you had services or accommodations in high school. And the responsibility is for the college student and their family to then bring it to the college. Office of Disabilities or Office of Accommodations, every school kind of has their own service services and then work with the college to make the accommodations. So this isn't a given, it, it's the on the onus is on the family to bring the neuropsychological, to bring the declassified IEP or 5 0 4, and then see what they qualify for in terms of testing and classroom accommodations at the college level. Similarly there are accommodations for graduate school application tests. So if someone is, is planning to use their accommodations on graduate school admissions tests to really make sure that they have a track. Like a record of that. They are using their accommodations, they've updated their testing, they've updated their doctor's notes so that, you know, if they choose to apply to graduate school with accommodations, or need accommodations or graduate school admission tests, whatever the discipline. So if it's for business school or medical school or law school, that there is a, a record that they've been using accommodations consistently. That's a good explanation. Just for clarity, this is under the American Disability actor ada. Yeah, so the ADA Act does protect much of this. I have worked with, with clients in the past who have even studied for licensing tests. So after graduation, they've applied for accommodations for licensing tests. Each state might have to review the documents. Then decide on a state by state basis what accommodations they want to give based on the doc available documentation. So this documentation record kind of starts in, in elementary school or high school or whenever accommodations are, are being given or when testing is being done. But it can extend through college and into, into the workplace as part of the a DA act. Correct. I'm gonna just put a plugin for early diagnosis here. Yeah. No, because as pediatrician I've seen the situation where they're graduating high school and all of a sudden they wanna get diagnosed as something, or they wanna get accommodations on testing and it's actually harder. To do that at that point. Yes. But even just from a, a pragmatic standpoint of it's always better to know what you're dealing with earlier. Right. And, and the research indicates that early intervention, like there's been a bunch of studies on, on boys with a DHD and you know, the, that, that when properly medicated, so diagnosed, medicated, treated, so the multimodal approach of medication and therapy in early in. Intervention by adolescents. Those boys mitigate a lot of the risks that come along with undiagnosed A DHD, such as substance abuse, harmful behaviors antisocial behaviors. So, you know, the, we might be concerned about the labels, but the research. At least preliminary research of these boys into adulthood does indicate that early intervention, meaning man medication management, appropriate treatments that the, the, those boys are actually thriving. You know, I'm glad that you mentioned labels. Because there is definitely a concern of stigma, but there is a real issue with labels as well. Yeah, it's not, it's a double-edged sword. Right? And so if you think of these issues as being on a spectrum, right? It's not that you're either normal or not. We just talked about calling yourself neurodivergent as a variety of normal, right? Like we're expanding, we have a paradox here, right? Sure. We're trying to get help. When is it a disorder and when is it just a variation of normal? Right.'cause you would think you would need a diagnosis if you had a disorder, but not if you're just quirky. Right. So I, I think the quirky can be embraced, but if someone is really struggling, the label can also be really affirming. Mm-hmm. There's a classic a DHD book that I always go back to. You mean I'm not crazy, lazy, or stupid? Mm-hmm. Great book title, an older book, but the, the term, the terms, I think of. Being diagnosed and then knowing that there's not something wrong with you that you just think differently, in my experience, has been really, really empowering because you know something's wrong deep down if you have a terrible time with time management, if you have, if you're always losing things, if you're forgetting to call back friends, if you have a hard time with your emotional regulation, if you can't fall asleep or you can't wake up in the morning and you're really, really struggling with routine. Doing your homework, getting assignments in, you know, you're different. You know, you're different than your friends, but you might not know why until there's a diagnosis. So often, you know, especially the girls that I work with might have had a social anxiety diagnosis, a depression diagnosis, and anxiety diagnosis, panic disorder, diagnosis. They're getting diagnoses because they're struggling, right? But the underlying issue might be and often can be. A DHD that isn't being managed. And when the A DHD is addressed, the, the anxiety, the depression, the, the other symptoms I don't wanna say dissipate overnight. They, there are comorbidities, they can coexist, but often it, it is really, really empowering mm-hmm. For clients to know that it, they, that, you know, they are neurodivergent, that they think differently. And that, that with the appropriate treatment. So I always think the gold standard is multimodal approach. Mm-hmm. Even though medication in A DHD is often you know, what's tried first that with the medication and with whether it's executive functioning support, tutoring OT, speech. Coaching, whatever the other services are to support the neurodivergent thinking that that, that the symptoms do alleviate you. You know, you might, there might be times where the medication has to be adjusted or the services have to be changed, or you have to go back for therapy or what whatnot. But just having the diagnosis, you know, you know that, that you can, you know, A DHD is highly treatable but. Untreated. It's also highly destructive. And, and that's something that, you know, especially when I'm working with adults they've found in their own lives. Exactly. And what I'm thinking about is, okay, it's a spectrum, but the bottom line is function, right? The bottom line is intensity, duration, frequency of the issues that it's not a black and white thing. It's not like mm-hmm. In every setting, you either have a functional issue or you don't, and that at different points in your life, you may be pushed from just being a little different, a little quirky to having a functional problem. And that's where you come in and I wanna hear more about what you do, especially because I think one of the challenges once you leave high school, once you turn 18, the bulls in that young adult's court. Right. Primarily. Primarily. And I think that's where it's really, really important to think about the neurobiology of how of the adolescent brain, you know, adolescents are not fully developed until the, the adolescent brain is not fully developed until 25. Even though legally at 18 your, your kiddo is independent. And I, I would even argue that it takes longer with a DH, adhd, my grandma always used to talk about like a young 21. You know, someone's a young. 22, a young 23, they might appear more immature than their friends. And, and that's okay. The same way that developmentally a neurodivergent kiddo you know, takes longer to adjust to middle school and then longer to adjust to high school. Well, it might take longer for them to adjust to college also. You know, do they need a gap year? Do they need a year off to work, to travel to think about what they wanna be when they grow up, and what, where they wanna go when they grow up? Do they need some more time to learn life skills? So although, you know, an adolescent 18-year-old is officially a grownup at when they're going to college, they, they still often do need family support. And that's, I think something that really does come up. For those of us working with Neurodivergent College students, that the, that the family support is really, really important to help that transition to college. And that the scaffolding. A different level of support really have to have to depend on each individual case. You know, I always say when you've met one person with a DHD, you've met one person with a DHD we're talking about there's inattentive type, there's hyperactive type, there's combined type, there's different severities of it, as you pointed out. So depending on how the A DHD is managed by medication, by therapy. By severity can really determine how much parental support is necessary. And, and you know, going forward how that young adult, adult manages transitions really does depend on their support system and the support system that they built for themselves After, you know, having their parents maybe advocating for them. That's great. First of all, you took that line from Dr. Stephen Shore, who's a fellow Long Islander who said, if you've met one person, autism, the autism spectrum, you've met one person on the autism spectrum. And that's part of the Neurodivergent family. I, I, I'm inviting him for Is that where, and, and I think he might have also taken Yes. He he's actually a, a, an old colleague from a, from a Adelphi. Amazing. He's awesome. He's amazing. And I interviewed for Jon. Now I have to link to that as well. Please do. Please do. Yes. So, and, and with the A DH adhd, it's the same, you know, the, the diversity within the diagnosis and, and that doesn't even include the emotional dysregulation piece that isn't even accounted for in, in the DDSM. So. You know, when we're talking about transitions, those tend to be the times that adults really do need a lot of support. Graduating college, beginning or ending relationships beginning a new job, looking for a new job, managing at a new job, moving new roommates, new living circumstances starting a relationship, ending a relationship. Becoming parents for the first time, becoming parents for the second time or third time. Difficulty with work, difficulty in relationships. Something that when I turned 40, I, I decided I was gonna start supporting couples, neurodivergent, couples. Amazing. So I trainings on with EFT and Gottman. I'm in the middle of Gottman trainings now to really support couples who are. Married or in committed relationships and are having transitions within their relationships and how to support them as a couple, whether it's one neurodivergent partner or both. Because those transitions tend to be tremendous stressors. Transitions are hard for everyone. They're even harder for neurodivergent individuals who struggle with either the rigidity of, of, you know, this is how I do things and this is how I'm comfortable doing things. Or the difficulty of maintaining routine and structure, especially as changes are going on. Absolutely. That's amazing. I will underscore what you said about the developing brain. I don't think any 18-year-old today is truly an adult, no matter how neurotypical they are. But if you're a neurodivergent, I've heard like a calculus of something like two thirds to even 50% of their chronological age. Wow. So a 20-year-old could be like a 10-year-old if it's severe enough. And I've seen that. Right. Yeah, as a pediatrician, and I really wanna implant that in parents' minds. Mm-hmm. In terms of managing expectations. But here's the tricky part, and I really wanna hear your thoughts on that. How do you balance scaffolding support as a parent and not enabling and overdoing it? Yeah, that's a hard one. A hard one. And when I'm working with parents, when I'm working with families and the adolescent, the young adult is the identified client. Something that I ask the parents before we start working together is, how involved do you wanna be? What's your comfort level? You know your child best and you know your needs best. And to really support the parents as well in identifying what works for them. You know, a lot of parents get to be empty nesters when their, when their kids go to college or enter the workforce. The, the parents that I'm working with are acknowledging that they are supporting their kiddos for longer, that their kids might move home at different times and, and that support system looks different. So you know, how do we address the scaffolding? It's really on a case by case basis, depending on the needs of each individual family. And, and I think that's an important conversation for parents to have with each other for parents to have with their children. And, and to really identify what, what they're able and, and, and willing to, to do into adulthood. That's a really good answer and it's very fair. Bottom line is it depends. Yeah. But I'm gonna push back here and the reason I'm pushing back is because what I see as a pediatrician is that it's very common for the parent to have trouble tolerating their child's discomfort. Yeah. The only way you can grow. Yeah. Right. Is by pushing through discomfort. Mm-hmm. And how do you help the parent? Back off appropriately when they're overdoing it because they may say, this is my comfort zone, but that may not be the healthy zone for that child, young adult. Right, right, right. And, and, and, right. And how do you parent an adult child? Right. And I think that's a question for all parents, and especially for neurodivergent parent for parents with neurodivergent children who, who have been so involved in advocating for their kiddos. And, and that that transition is definitely a, a challenging one. So you mentioned. You didn't say it, but you were implying that this concepts a grit of resilience mm-hmm. Of, of supporting young adults with launching. Right. And, and I think that if we're looking at the literature, we, we need to be especially mindful of setting our kids up to succeed by giving them therapy, by giving them tools and, and doing that, you know, when it's developmentally appropriate. So something parents can do is offer to support. There are kids with a job coach, with a relationship coach with social skills. And again, this is the expense of having a neurodivergent child. It is costly. I, I would argue that a job coach can help save money in the long run. If, if someone can keep employment, that relationship coach is, can be helpful to support. Developing healthy friendships, healthy relationships. We know people who are in meaningful attached relationships are happier, they're healthier, they live longer. So if we're looking at, you know, how to support adult children something to do is to continue to, whether it's financially or emotionally, help them be linked with services that, that they need while they. While they're figuring things out. So that scaffolding can be with empowering them. Is it going to your psychiatrist? Are you financially helping them? Are you helping them with resources to identify appropriate providers in their college town or where they move? As as young adults are you supporting them with. You know, cleaning help from time to time. I always say cleaning help is, is cheaper than a divorce to my couples even if it's an upfront expense. So really thinking about the financial commitment as well as the emotional commitment. That, that you wanna make as, as parents of adult children? That's a great explanation. I just wanna push back on one thing and go back a little bit to the neuropsych and to acknowledge that not everybody has the money to pay Yeah. For any of these things. Yeah. Even as the neuropsych can have a true value, especially if you get a later diagnosis. Yep. If your kid is younger, you can get it through the school system. It's not exactly the same thing, but once you're older, you may need to just a thought, oh yeah, this is, this is, this is. This is something I struggle with as, as a clinician. You know, for many, many years I, I did accept insurance. I recently stopped accepting insurance just because, you know, I, I have an academic position as well, and the time that I do give to, to clinical work is limited. But there are really great. Coaches. Mm-hmm. There are really great clinics. I trained at a clinic that took insurance and su even supporting your kiddo with health insurance, giving them the tools to find a provider in network. Finding apps that support their executive functioning, that support their routine. There are some really great affordable apps that have replaced a, a lot of. Coaching I don't wanna say therapy, but there are coaching, executive functioning apps, mindfulness apps that are, much more affordable and, and can either supplement in-person the psychotherapy especially while someone's doing well, and, and to acknowledge that there might be times of transition where they need to be seen in person. But that there are many, many services and many, many supports. Chad is an amazing resource, C-H-A-D-D, attitude Magazine. There are support groups, there are meetups, but to find a community does not necessarily have to cost in a money that's in addition to the health insurance expenses, which. Also, if someone's unemployed and struggling, there are you know, it is definitely difficult. So just talking about intersectionality and, and, and thinking about privilege and vulnerability. Vulnerability is, is definitely a consideration. Right. And also build your village. I feel like we've become such a transactional society and getting people in your circle who can help. Not for money, right? Just building relationships. So that the burden is not just on the parents. It's really, really hard to be a parent in general. It's really hard to parent for twice the amount of time.'cause that's how long it took your kid to get mature enough to be self-sustaining if ever. Yep, yep. So yeah. And, and there are, and there are services, there is access vr, for example, in New York State that lasts through college. There are, coaching services and and, and like job placement services that, that might not specialize in, in, in supporting neurodivergent, but do specialize in supporting young adults and, and really finding those services. Working with your young adult to identify what they need and how to best find that support can be really empowering as, as a model of how they're gonna go forward into their adulthood figuring out what they need. Right. And support groups. Right. I mean, I believe that there are various support groups, either in person or online. For, for the, a young adult neurodivergent person, but also for the parent who has to navigate something really tricky. Right. Yeah, there are, there are definitely community groups, different Chad chapters, C-H-A-D-D have different different offerings. At the International A DHD conference last year had the privilege of meeting different chapter presidents and hearing about all the amazing work that individual chapters are doing. So really the, the, the wonderful thing about the neurodivergent community is that they're extremely welcoming. And, and really supportive. And whether it's online or through local chapters, there are great resources out there. That's true. And this is a great place to end., So thank you so, so much for doing this with me. I really appreciate it. Thank you, Alyssa. You got it. Thank you for listening to Kids Matter. Raising Healthy, happy Children Takes a village, and I'm grateful you are part of ours. If today's conversation resonated with you, please share this episode with another parent, grandparent, teacher, or anyone who cares about kids. Together we can build a supportive community our children deserve. I'd love to hear from you. Share your thoughts, questions, or suggestions for future topics at Kids Matter podcast@gmail.com. With no explanation for your voice truly matters. Until next time, keep advocating for the children in your life because kids really do matter. They are our future. I'm Dr. Elisa Minkin and this has been Kids Matter. Please note that while I am a pediatrician, I am not your child's ped. This podcast is for informational purposes only and does not constitute medical. For any medical concerns or decisions. Reach out to your child's healthcare professional.