Tuesday, 1 November 2016

Alternative Diagnosis - The Personality Connundrum in Disruptive Behaviour and Impulsive People

ADHD is not a diagnosis of preference in France, where health professionals and parents alike are averse to the neurobiological train of thought which is currently so pervasive in the US and many other western countries.

There are of course various studies and on going research programmes which claim to show that ADHD is related to a disordered or paratypical brain activity, which may be related in turn to a misbalance in dopamine and seratonin acitivity and metabolism. The current umbrella theory is that ADHD is typified by a lack of  neural activity in terms of the cognitive and "central coretex narative"   to which the brain eventually sets off an internal, subconscious alarm and tries then to wake up or you could say, jump start the brain by creating over stimulation of the weaker neural processes. So on the one side we see typical 'glue brain' attention deficy periods, and then rushing of thoughts and disruptive behaviour. This is then bipolar in nature. Hence stimulant therapies such as Methylphenidate, are prescribed because they both match the notion of neuroligical aetilogy and because these drugs do work in a proportion of cases.

However, a disruptive pupil who does not pay attention is then given a social based diagnosis with no actual investigation as to the underlying neuro biological symptoms. The prescription drugs are shown to work in the studies, so why should we seek a more expensive route for differential diagnosis, involving both brain activity and a wider social and personality discussion with the family?  The drugs work of course to the threshold for acceptable efficacy that the FDA and other medical authorities stipulate. However that varies betweeen studies and treatments, as do the criteria for initial diagnosis and inclusion to the clinical trials, which may be far more stringent or preloaded than actual diagnostic practice at the primary health care front line.

In the clinical trials,  there are always two groups though which are then brushed under the carpet when the efficacy is over 40%. The first are non responders, and the second are those who withdraw or are withdrawn due to side effects. Here we touch on the elephant in the living room of chemical medicine: that we often do not fully know the aetiology of a disease at the molecular level, yet we follow a course of drug introduction which are shown to have positive effects on symptoms, bind receptors believed to be involved or are variants of earlier chemicals found to have more specific effect, less side effect, or even as in the famous cases of Viagra and One Alpha, that drugs being experimented upon in one disease area, had powerful indications in another seemingly unrelated one.  We can say with some confidence that up to a third of patients do not respond to  ADHD medicines, depending on the diagnosis and probably the genetics of that population. We can also say that a small proportion will experience side effects, often the 'amphetamine' like experiences of grinding teeth, more micturition and so on.

The 'cures' are to an extent a magic bullet, a key to the lock. But only if you care to see the lock as you have been told to look at it. The trouble is that the pyschological and social therapies or you could say, regimes, which could equally well be employed are more nebulous, outside France that is. They vary and perhaps demand a referal and further diagnosis. Also compliance and attendence may be far lower than for popping a pill before breakfast.

The French take a different stand point, where chemical intervention is the last resort it seems, and is prescribed in less than 0.5% of cases. They consider rather first, the social conditions and context for the child's "misbehaviour" and think more in terms of neuroticism, angst and post traumatic stress for the more severe cases presenting. Milder cases are often considered as just what they present as: misbehaviour - innapropriate talking, impulsiveness and other disruptiveness and a lack of concentration-  in school most often. Alternatively the child may be considered to be just bored, understimulated, with some topics at school.

Here we reach a crux of the cultural differences between several entire systems: medical, pharma business, political and cultural. In countries which show high prescription of ADHD medicine in children, there is most often also a political agenda to make schools less liberal in thinking, and more 'sqaure' in terms of producing better 'hard skills' for the jobs market down the line. The USA, the UK and even Norway under the latest government are all examples of this, where Ritalin (TM) in particular is prescribed first line by many physicians and psychiatrists. Creative subjects and time on them in school have been reduced, and "sqaure" subjects like maths and grammar are even introduced into creative education and physical activities. At the same time many western countries have relaxed direct to consumer market communication, and the borders are fully blurred by the free flow of informatuion on the internet. Physicians have the lock and key now to "arrest" this disruptive behaviour rather than 'wasting time on wooly and lengthy' psychological approaches as was mentioned to the author by a GP.

What alternative diagnoses could or should be aired ? Should we follow more closely the French approach, or would it burden the health care system without the same efficacy as "pill-pushing"?


Our group of adult ADHD sufferers have evolved with most actually now dropping out of the prescription drug programme. Some feel well managed though, especially when using the slow release formulations of the stimulant therapies. Most though either did not tolerate, did not comply enough, or simply did not want to continue on prescribed medicines. Since our group is a little biases and 'self selecting' when it regards further therapy, we cannot say that they are representative what so ever, yet the routes they are exploring in and outside of the health care system are illuminating.

They take us on a laymans journey through their own lives, diagnosis, "first line" treatments they recieved and then why they chose to take the route away from medication, and even to reconsider if their diagnosis was correct in the first place. ( the cases will be expanded , come back to the blog for more later)

CASE A  in their own words

" Getting a diagnosis of ADHD as a man in my forties came as a surprise. In fact with some disbelief. How could I have come this far in life ? University and business school education??  Both the cognitive tests I took and the following discussions with a clinical psychologist and then consultant psychiatrist were almost like getting a diagnosis of cancer. A tumour of the personality. A metastasized, malignant burden on my psyche.

I wasn't by any means devastated, because I knew I was unhinged, which is why I sought help,  and I knew there was now a "cure" with proven clinical effect. Four years on I feel though that I have come full circle to actually reconsider my own diagnosis and the nature of the disease in context of wider personality traits and neuroses.

To kind of contradict this last statement, I actually do believe very firmly that I have neurological ADHD. I have classic symptoms of under stimulation followed by rushing thoughts. I responded well enough to the slow release Ritalin formulation, having had marked amphetamine like side effects and bad stomach from the normal preparation. I had great concentration when dosed up on normal tablets, and more even productivity at work, but found I was grinding my teeth, going to the toilet often, my stomach was getting crampy and I found it hard to sleep at night. I was also experiencing a marked 'down' in the early evening when I would often become drowsy or irritable. The slow release was very much more expensive for me, and came with some bowel disruption. Also I felt that the positive effects were wearing off after three months, while the peeing and the distrubed sleep continued.

During the consultations with first my district psychologist, then the clinical psychologist and then consultant at the hospital I had said over and over again that I thought there was a parallel emotional disturbance that I would like to address, related to some childhood trauma including berievement and some quite serious bullying. That was brushed aside and the route forward was management by Ritalin. After this I had only one short consultation with the consultant, really to see how I was tolerating the normal tablets and if I was benefiting. My plea for more support and investigation of the social and emotional elements I thought were important, were simply brushed aside. I changed the formulation through my GP to the tarmic release and realised that if I wanted some kind of ongoing psychological support, I was going to have to beg for it or come seeking a new diagnosis!

At a couple of points in the consultations I realised it may be going towards these stimulant, neuroactive chemical treatments and asked if there was alternatives. The medical profession went vague on me hear. When I raised the history of valium, that was considered not relevant because these new drugs were shown not to be habit forming. With less than five years of experience and a powerful pharma lobby, it is really too soon to tell IMHO.  No alternatives were suggested. It looked like they were only available via charity and self-help groups.

In the course of this I made some bad career decisions and after a lot of turmoil in the work place, caused largely by circumstances and not myself, I was unemployed two times with only a short period of work in the middle. It felt like a perfect storm for damming me for my own impulsiveness in moving jobs in the first place, and not having a more successful and stable career - this is where and why my ADHD is in the picture as a diagnosis and kind of journey through the whole rigermorole of pharma dominated diagnosis. So I was feeling disillusioned and back to worse than square one.

Luckily I took a nother journey of self discovery and self therapy.  Firstly I accepted an anger management course after the stress of losing my first short lived job having moved from a stable job, buibbled over to family life. This made me think about the impulsiveness of my behaviour in terms of making bad decisions and often becoming angry or withdrawn, or eratic. All features of the 'fight or flight' response.  The self management included firstly seeing your self as others see you when you fly into a rage or become irritable and snappy over a period of time. Also to stop, and back up and assess the situation.

Another fortuity was that my local council have a community psychiatric care centre, which began to offer an open course on Cognitive Based Therapy (CBT) for stress and berievement etc. This built upon my anger management in terms of self awareness and analysing my own feelings and responses before rushing to conclusions and potentially innappropriate and impulsive behaviour.

Not to go into details of a well documented therapy,  I had some real benefits from CBT and could address more of the emotional status issues I experienced. For example, I decided that my stress stomach and panic attacks in the middle of the night were coming from the acid reflux starting my body on the route to negativity, not that I had overly neurotic dreams or semi conscious anxiety. My body and brain wer interpreting my stomach complaint as being a sign of stress, and tyring to offer 'peri conscious' interpretations. As I learned in anger management, these biological routes do not get any better, rather they seem to get more 'hard wired' and become 'second nature'- the normal, the status of choice to act with.

Also I used the alternative resolution techniques to address not only my 4am panic feelings, but also elements of social angst, and how I interpret situations which have gone badly for me. Furthermore I could use the tackling techniques to put my current unemployment as an opportunity to heal and be with the family before the economy picks up and it is easier to get a job.

I haven't stopped there though. I have gone on to look at how my personality may be internally always in conflict. I recently uncovered articles which to some extent challenge the polar personality trait scales- I used to describe myself as an "inner directed extrovert" yet in fact, I am more of an introvert with a compulsion to seek social contact as some way of resolving the inner intimacy-imposed isolation dilema. ( I studied two years of psychology at University while majoring in molecular biology)

It is a big chicken and egg with this and perhaps circular- these personality traits and inner conflict may be in part or whole generated by a neurological condition. However perhaps the condition, being a bit slow in the mornings and having rushing creative thoughts, is the lesser of the evils, and is either masked or exacerbated by my neurosis. I consider that my CBT and Anger Management route has been more fruitful for me by a long margin than the improved concentration and slightly more even temperament on Ritalin.

To myself I am kin dof a puzzle wrapped in inexplicability and clouded by insecutiry and failures which are by in large on the job front, not my fault. As a little boy I was bashful and bumptious and kind of being sociable was something which I tried hard at, yet was completely inept at. I grew a kind of clowning personality, with a very brash side, but made new friends easily all my life.  I fitted well into academia and performed above average and also had a lot more curiosity and imaginative thinking than most peers, whcih got me noticed and ear marked as a future professional scientist. Yet I hated tedious lab work, I just had no patience and I wanted to experience other things in life than being a poor student and post doc through my 20s.

I sought some good degree of excitement in career and hobbies as a kind of way of addressing my inne5r drive to suceeed in something interesting. However I often fel ldown socially, failing to make key relatioinships on a professional level and falling into being the kind og rebel-without-a-cause employee. I struggled to meet 'the right girl' and got involved with some wrong types, wrong time-of-life, wrong situation. My impulsivity drove me to change girls and change jobs like a crazy guy. That was fine as a young bachelor, but evenutally a 'portfolio' career as I was told to use as a euphenism I guess, rubs thin as a middle aged man on the job market.

I do feel that I have made more progress in a year of CBT and reflectiveness, self awareness, self arrest and some meditation to boot, than I did in a year with Ritalin. Also where as for me at least, the drug tickled at the symptoms, the psychological approach takes me into how I tackle much wider aspects of life than just concentration failure. I also think CBT helps me as a parent, a friend to others and that when I do get back into work, it will help my performance and relationships and eventually help me become a better people manager. "

Friday, 30 October 2015

Cognitive Therapy and ADHD - An Alternative or Adjutant to Drugs ?

From our own adult ADHD group we know that the majority have been prescribed psycho-active drugs, and despite many positive experiences, compliance, side effects and 'toleration' requiring hirer dosing are all reported by those who did not want to continue. No one in our group was directed to pyschological therapeutic regimes, such as cognitive behavioural therapy  (CBT) , relaxation-meditation, hypnosis, music therapy, working memory training, neurofeedback or diet-lifestyle-career councelling.

Low Actual Referral from Physicians to Psychological Therapy

Although some those general practitioners who had referred our participants further to psychological /psychiatric services had mentioned that they believed non drug based regimes would be available, the actual outpatient based handling was limited to gathering the personal history, confirming diagnosis and then going right onto prescribing 'Ritalin'. No alternative was offered and when two of our group had asked senior psychiatrists during such final consultations about alternative non pharma regimes, they were told that nothing was available or that no such route could be funded.

This may not be a surprise because most western physicians now believe that the disease is well managed in both children and adults at the end of one penned line of ink - Rx. There is a magic bullet, They will be cured. Efficacy can be debated in terms of both percent responders and those who do not 're-present' with symptoms. However the patients who are directed down this route may feel that this is an all or nothing because it is culturally accepted that Ritalin and other preparations, "cure" adhd.

Efficacy and the Lost Large Minority of Poorly Managed Patients on Drug Regimes

As the director of the then Glaxo-Smithkline Beecham said " I know that our drugs do not work on up to half of the patients treated, and I want to know which half they do work in" when the science of pharmacogenetics  promised to reveal the genetic markers and biomechanisms which explain 'resistance' , 'tolerance' (re. the specific interpreation of these terms in light of pharmaceuticals) and fast metabolism. Hence patients could be screened for these and hence their low probability for a successful treatment by a particular drug. However so far genetic testing  or biomarker assesment in relation to prescribed pharmaceuticals is limited to 'higher value' and higher risk regimes due to cost constraints and it could be argued an antipathy from Big Pharma who want their drugs prescribed as often as possible and is safe within the patent pending period.

Perhaps our group is quite representative of the adult experience with ADHD Medication in that around 3 in 10 report that drugs did not work, while a further 3 more in each ten (of 20 participants) reported leaving the prescribed regime due to the factors above (side effects, 'tolerance', disturbed compliance, price of medication all played a part for us) . Another 2 participants reported coming off the drugs and having a significant, lasting improvement in concentration and mood.

This last point highlights what we believe should be debated within clinical and social support services. That ADHD is one of those mental diseases which can be 'learned out of'. In the case of the minority who had come off the drug, but felt that they had this lasting benefit, could it be that the drug helped the brain learn new tricks ? Once again, it would not be in the interests of Big Pharma nor general practitioners to have patients leave what is prescribed as chronic and indefinite therapy, and a single piece of paper, single consultation, single referall "cure" from the general practitioners standpoint..

Few Clinical Trials on Alternatives to Medication

There are very few clinical trials of psychological treatments and the author is at this time still trying to consider the value of the results (many are multi-modal and part pharm and not comparitive to the exclusion of pharma)  and to find any reference to trials of CBT on adult adhd, where it may be most appropriate and effective.

Cognitive BehaviouralTherapies (CBT) Engaged by Patients By Accident or Self 'Prescribing'.

Cognitive based therapies have evolved in the post war era as highly effective for those participants who are diligent and receptive. ( Here in lies the compliance issue when compared to simply popping a daily pill when considering clinical trials) They are steadily replacing freudian derived pyschotherapeutic therapies in areas like angst, depression and most of all in stress management, and are seen as an alternative to medication by many psychologists if not so many physicians unfortunetly.

CBT is based on conscious methods and not obtuse routes to making the patient / participant understand the sub conscious nature of many feelings and how these produce often undesirable thought patterns (NAT - negative automatic thought for example). In essence awareness to this phenomena coupled to self 'arrest' of symptoms and situation / emotional analysis techniques are effective in a wide range of 'conditions' such as the above, but also they form the core of Anger Management offered by many services and charities.

It is via this route that several of our group had come into CBT, because their disruptive, impetuous and even violent behaviours lead them to be referred to self accept anger managment courses. The CBT based therapies are aimed at adults due to the quite high level of learning or maturity you might say, which is required in contrast to that which could be expected in children. However CBT is very much a part of many parental -strategy -therapies for ADHD too, and it is likely that an increasing body of work will arise in this area due to the quite widely held opinion that drugging children is always wrong for such ailments.

It would be interested to look at longditudinal studies or comparitive efficacy reviews where CBT was compared to both just ADHD medication and the combination, but the issue of compliance will still be there - how many complete the course which can be many hours over many weeks or months, followed by the accompanying need to really learn and practice the techniques and tools whcih are taught.

For our group we can report that participants had positive experiences with Anger Managment in particular and that CBT was something they were interested in terms of their wider set of symptoms and as an alternative to the drug regime and its inadvertent side effects and long term quiestion mark.

Further Reading





Tuesday, 13 October 2015

ADHD and Meta Symptoms / Spin Out Life Problems

It is well documented that ADHD in adulthood has wide ranging, detrimental effects on the person whom is afflicted and their relationships. For example some authors quote research which shows that the rate of divorce where one partner is a sufferer, is double the average for the population.

In fact within our group it was often the symptoms which exbibited in failed relationships, disrupted careers, substance abuse and petty criminality which lead eventually to the diagnosis of ADHD in adulthood. For our group the majority of participants are in that category, with a few more being 'rediagnosed' having had a childhood period of treatment or awareness, the supposition that they had grown out of their behaviour was clearly wrong.

Stress is both a result of the uncontrolled disorder, and of course stressful situations exacerbate the individual's negative experience in their often poor ability when tackling the challenge and resulting reduced capacity to create positive or acceptable outcomes and indeed sensible compromises.

ADHD then lowers the threshold often to what is perceived or experienced as stressful. If we define stress as always a negative feeling, while stimulation may be both this and positive..... and do not take the route to discussing what stress is, for better or worse, as some authors do. Stress then by our definition, is an unwanted feeling caused by some external  stimulus (or you could argue a largely internal negative course of thinkiing or actions) . The normal or average person in a western society will learn to tackle this with different methods, including of course removing the source or seeking outside help. Often what is considered a mature tackling method will be to assert an objetcive approach and try to detach emotions from the stimulus and thus reduce stress in fact, and aid successful cognitive solutions.

A large minority of participants in our group have attended or been 'prescribed' or even legally bound to take part in courses which can be categorised into:   anger management, assertiveness, coping with stress. The key route for improvement of behaviour in all of these is the 'mature-assertive' approach. This is about recognising the emotional element in interpreting and acting on stimuli and situations, and breaking the link to automatic, often semi subconscious response and most often laiden with unduly negative interpretations.

Responsiveness to this type of course amongst our group is varied from no effect recalled to very strong positive outcome in that new tackling methods were learnt. It is impossible to draw conclusive, quantitative proof that these type of courses and their common approach to breaking automated, negative behaviours, from the discussions in our group. However qualitatively we can propose that psychologists and physicians should recommend a specific type of course or adopt this approach more in their own therapy. We do this, from sound ethical ground
because the course can do no harm, and the potential for positive influence is very high.

This brings us back to the contention that the use of psychomodulatory medication , most often Ritalin today, is onl;y part of 'curing' adhd ie reducing symptoms to a stage where the individual does  not have adverse effects on their own lives and those around them. Alternatively we can propose that medication is not the best route to tackling the disease because there is no long term clinical studies which assess lifetime use of these drugs, to ascertain if they become tolerated (ie reduced effect over time ) or if side effects become more prevalent.Or indeed the ethical question that individuals become normalised to a level of functionality in society, and in fact are not realising their potential in life.

The Author's Conclusion
Courses with the approach described above can really only help people to have more insight to their feelings, their thoughts or lack of them, and what they can do about them in terms of both the base symptoms of the disease and their abilities in tackling stressful situations and life shaping decision making.

Tuesday, 15 September 2015

Looking for Positive Sides from ADHD - Affliction or Blessing ?

Our group have never really touched in any depth or involvement upon the concept that ADHD is actually a positive force in enabling creativity. As one author recently described, perhaps we should look to extenuate the positive sides of hyper activity and question our education systems for not embracing the symptoms or offering alternative appraoches to teaching kids who are diagnosed ADHD. Once again it is a contention that there is mass over diagnosis too, and this is largely attributable to classroom 'misbehaviour'. Are we actually denying all children enough opportunities for creative outlet, and more captivating methods of teaching as we rush towards aligning our western school systems to a 'Three R's' teach and test system in order to score higher on PISA tests, and to marketise the public education system?

Some authors and commentators point to ADHD being purely a facit of modern conformity in an increasingly economically conservative education system, a good review here at collective-evolution, that is to say a system which the New Right have laden with testing in the 3 Rs which uses up more time and focus, to the cost of more creative and abstract activities in the classroom - teaching having become increasingly aimed at making and rewarding sqaure pegs in square holes. The trouble with all the New Right's (neo conservative's) agenda in using the PISA test as a benchmark for the relative success of schooling is that Finland leads the way, and does most all things in a very different way than that which the New Right would like. Much of the neo conservative agenda is driven by ideology as vehemntly as Stalinism, blind to opposition and running rough shod over educational bodies, pedagogical experts and the teachning profession.

It is ironic of course that much of the new wealth creation in the west then which has fuelled the rise of the neo conservative nouveau super riche and affluent "MBA middle class", have come from highly creative and entrepreneurial sources. The perfect example being Steve Jobs, whose legacy is now one of the world's biggest five Stock Market listed companies and employers. He certainly seemed to be very selective in what he chose to focus on, and what advice or criticism he allowed to penetrate his armadillo like ego -skin. You could  look at all the stock market stars of the post internet bubble, Google, Facebook, Amazon and many small to medium size Gazelle companies, and consider that the key force in establishing their critical mass in the market has been creativity and not conforming to conventions and rigid ways of practicing business development. The companies may have become sqaure in their need to go to IPO and report quarterly accounts and strategy to the "Street" but their fundamental value propositions were forged by highly creative individuals and often their R&D is stil true to this, so as not to kill the golden-goose as so  many take overs and floatations have done before.

Also the Leadership of for example the UK, come from an academic 'Elite' who had their self confidence, vision and social abilities forged at the most exclusive schools, namely Eaton and Harrow etc, where there pupils are offered a very diverse approach to building society's future leaders - in sports and arts in particular, and in pupils being ecouraged to be confident in self expression and self determination. Not so popular a theme perhaps in Tory circles,  of what state schools could do in order to create more success oriented individuals and see the individuals amongst the PISA orientated testing and statistics.

Politics aside, the opposite proposition is that ADHD for the vast majority is more an affliction than a gift, and that the disruptive patterns of brain activity and resulting behaviour are more destructive for the majority of individuals. just as very very few autistic children become world leading arcitechts or musicians, a small number of ADHD diagnosed kids go on to have truly exdceptionally successful lives. You can argue that of course, education fails them. And that is the crux of the matter which we will blog on again after som further discussion at our next group meeting.

Tuesday, 14 October 2014

Bad Calls II : Risk Taking and ADHD in Adults

In our last bad-calls we considered decision making, and part of this is of course attitude to risk taking and how sufferers tackle risk differently from average western people.

Risk is of course an every day part of being human, from our early perceptual development until the second we die. It can be broken down into a process>

> A stimuli presents itself or an idea arises
> The individual may have a peri-conscious aversive reation or an arousal reaction
> Risk is partly assessed in terms of a consideration of what could happen. outcome cognition.
> An action is taken / or inaction a passive response, / or the risk is avoided actively
> The action or event is experienced and percieved in real time and in cognitive capture time room
> a psyco-emtional summary is made probably before the brain actually consciously interprets what happened
> A risk appraisal process takes place at the time, but this can also be an ongoing process, a life long memory
> A new attitude is shaped based on the cognition of the risk taken and any reward or penalty

ADHD affects most likely all stages of this process, and that is what leads probably to so much risk taking being associated to the disease amongst unruly teenagers. In fact it could perhaps be demonstrated that a large minority of teenage ADHD sufferers are the opposite, inb being particularly risk aversive because the disease affects their cognitive ability, and they verge on using a flight response as the emotional reckoning.

I started with the bullet point ' a stimuli presents itself or an idea arises' to point out that ADHD influences not only how sufferers react to situations, but also how they may self stimulate from being planely in the deficacy stage or they may be over stimulated by a possibility which presents itself.

This is then pretty inseparable from the next part of the chain, where there is a peri-conscious assetion  leading to an emotional status, maybe linked to the flight or fight response, but also refering to previous learning experiences, and in the ADHD sufferer, the level of stimulation.

It is proposed by many authors that sufferers often self stimulate or seek out stimulating experiences or of course substances in order to in a way tackle the low phase of the attention deficy. The next stage then of considering potential outcomes, or in visualising the possible course of events, or in preparing a motory response, the ADHD sufferer has an abnormal relationship to risk taking, loaded at the earlier stages. 

Now at this key, conscious decision making level the ADHD sufferer often mis calculates the level of risk. As we propose from our group experience, some are actually risk aversive and over emphasise negative outcomes. This is probably a difference in the group of those presenting with adult diagnosis, not previously caught in the teen years when so many are, because risk aversion is not associated to the disease and nor does it often lead to doctors visits, quite the reverse.

ADHD sufferers are then handicapped in making the conscious cognitive processes by either being in the AD phase or in the Hyper stimulus stage. For adults 'normal /mature' behaviour would be to gather more information on an unkown risk, by refering to memory peri-consciously or via motor memory, or by seeking out new queues and information from the environment or people with them. ADHD are more likely to make a decision based on the feeling they have to make a decision, they rush into action before maybe stepping back, or they back off completely avoiding then the risk.

Our groups over the years have shown probably the gamete of risk taking, with as mentioned the earlier population of the group being younger, teenage diagnosed struggeling in young adult hood, and now the move partly by design, over to older sufferers diagnosed over the age of 21 all the way up to over 50 years old for first correct diagnosis.

Types of Risk

Physical motor-activity risks

this covers sports, high risk endeavours like bungee jumping, and of course most damagingly , motor vehicles.

Social Risks

This covers some of the rash, crass or socially aversive  behaviours and may be in part damaging because the risk is completly over emphasised and a fear element can be present at outset.

Stimulatory Risks

This probably covers sex, drugs, & rock and roll. Usually a reduced level of inhibition is typical. 

Further Thoughts On This

It is clear that the entry phases and the cognitive phase then are adversely affected by ADHD, as is then the action phase where a dispropotionate response or aversion is typical in the disease it seems. In fact the same person afflicted by this may show both these poles of behaviour depending perhaps on their previous experience, and their brains status in the deficy-super-stimulatory pathway of the disease.

This leads right on to the learning outcome, whcih is a new attitude to that particular situation, or in fact a new attitude to risk  in general. If the sufferer experiences a postive feedback socially or from a euphoria of adrenalin, seratonin and adrenalin, then the risky taking behaviour is positively reinforced. The same could be true of a stong aversive reaction, but then the stimuli is removed so perhaps another time the outcome will be self gratifying and a risk be taken.

As mentioned in previous posts, risk taking is prominent in ADHD sufferers, or rather the under emphasis of potential negative outcomes and the over emphasis of potential for reward and personal gratification are biased towards basically making bad decisions and then enjoying the outcomes and learning somethign positive from those in a loop if you like.

The most extreme ADHD thrill seeking teenagers and young adults, have in common with Hypomaniacs a tendency to be self destructive physically, where as the older group shows that the affliction can present a chain of bad decision making throughout life. ADHD people cannot summate information correctly, they cannot weigh up different outcomes and often they rush into action before making a more cognitive appraisal.

This can be more sublte than Sex and Drugs and Rock & Roll, or jack ass behaviour., It can show itself in poor choice or partners, reduced social acceptance in groups or at work,  financial imprudence, and most of all in adults, changing jobs frequently.Risk assessment ability is maybe not the explanation for all , but it is an important  factor in much of what goes a wry for sufferers through their lives.

As with other types of behavioural modification, perhaps physicians and psychologists have to use techniques from anger-management and assertiveness-in-the-work-place. The sufferers probably most of all need to firstly recognise the behaviour pattern and secondly, back up and learn to make a conscious assessment of the situation and buy themselves time before they either act or ar passive in response.

Monday, 29 September 2014

How ADHD Affects Careers

It is well documented that ADHD in adult life can very much affect the individual and those around them, most often in  deliterious ways. In fact frequent changes of jobs, turbulence in the workplace, under achievement and getting fired more than average is part of the diagnosis from the case history for those not diagnosed from childhood or adolescence.

ADHD is typified in adult life by disorganisation and distraction, two rather unfortunate handicaps in the workplace. In the author's experience, sufferers are  under represented in middle or higher management, and totally absent from those who work in the main three professions, Law-Accounting-Medicine. For the latter cases it seems that the demands in academia are too high in terms of volume of work, attention to detail and precision in completing practical examples.

It is also very typical that the sufferers tackle some tasks with real skill and ability to deliver on task, while other tasks or situations are handled with below acceptable standard. This is related to a high level of motivation for the task and it seems the low stimulation of the brain is circumvented by a level of arousal followed by acceptable performance, or actually extremely good performance in that one task. Also there can be social or economic rewards which stimulate the person to arouse their brains and achieve results.

Some successful celebrities, sports stars and entrepreneurs come "out" as ADHD, with eithr childhood or adult or self diagnosis, and even claim that the highs in mental activity,  and actually getting bored with, or avoiding mundane tasks meant that they could perform in a role they loved, or that they avoided what they found dull and found a talent in their non-conformist life style and career. Over the last decade many comedians, including of course the late great Robin Williams, have admitted to BiPolar depressive or hypomanic disorders. It seems likely though that many comedians in particular actually suffer from ADHD and have found a life style of self stimulation, positive stress and social gratification which in effect 'self medicates'.
However for the majority of adult sufferers there is no great reward for having ADHD and its on-off nature, and not being able to get on or hold down a normal job.
Career Path
> Several career changes, or no real career building
> Lower Achievement than peers
> Changes Jobs More Often Than Average
> Is Disatisfied with Own Abillity, Or Wonders Why They Have Not Got Further
> Well above average dismissals or failed to get rehired after temp or probationary period
> Some major conflicts with line management, coworkers or company HR or higher management
> Have disciplinary action or written demands for approval
> Quits jobs due to stress, times of conflict, fear or being fired, boredom and lack of promotion
Work Place Conduct
> Is distractable
> Does not follow instructions or training
> Does not remember instructions, methods or procedures
> bad time keeping on arriving or leaving work or for meetings etc
> poor time/task management and prioritisation
> Difficulty with summarising information or events
> difficulty in communicating clearly, especially in e-mail
> finds they irritate managers
> fails to finish tasks completely
> Distracts others and is talkative or 'PM happy' ie internal text messages are frequent
> Gets irritable in meetings or training lectures when they are not leading or involved
> Impulsive, can take rash decisions or act on the first course of action they think of
> Sees tasks, challenges, and work relationships subjectively and has difficulty with objectivity
>  Is poor at having balanced discussions, resorts more to arguments or one sided approaches
> Can show anger or frustration over situations others would tackle.
> Becomes tired and lacks concentration at some points in the day
> gets bored and easily distracted from repititve tasks
> Lacks attention to detail and does not check work before it is submitted or completed
> Fails to perform as well on average as other similarly qualified coworkers
> Can be insolent and resentful of management asking them to do dull or demanding tasks
> Often feel disappointed with employers overlooking them for promotion, or paranoid about not getting a better deal at work
> Can be conflict averse due to fear of becoming angry or of loosing control of the sitation by becoming passive.
> Used to negative outcomes from some types of management discussions, learned inability, passivness
> low self esteem, or fragile 'bubble ego' or excessive modesty.
Positive Sides
> Has high energy and dedication to tasks they really like to do
> Can be very creative
> Can be positive socially , lively and interactive with coworkers
> Can be suited very well to some types of jobs having perhaps started in a company in another job
> Can think laterally in some circumstances, and present many different solutions or scenarios, and evaluate these for relevance, likelihood or applicability
> Can act with quick wits or actions when presented with a pressing challenge
Tackling Strategies
Most of the medical and psychiatric literature and web info in English refers to medication as being an important part of management, and is often vague on other techniques other than calling it "councelling" or "concentration techniques" without going into any real detail. Clinical trials are generally not conducted on such therapies or self help strategies, they would be complex, expensive and probably less conclusive than pharmaceutical trials, and that is one reason that there is less about them in the medical literature - they are less well documented and physicians and psychiatrists are wary of quoting them, and would rather grab for a known management of the disease by Ritalin and other preparations. Often then the social and psycho cognetal approaches are suggested as a nice to have secondry approach, with an aire of patronisation in some papers.
The authors have yet to examine or translate the French literature because they take a very different approach to ADHD, and although they tacitly accept hyperactivity and attention deficiency exist, they take a strucutred approach to improving concentration in particular for sufferers at school. In this way they exclude the mass over diagnosis, by virtually denying it is a disease in some quarters, and thus picking up low motivation, lazy and distractable students and those with social background related problems in this approach AND giving some benefit to the ADHD sufferers.  Many in France also see diet as important and recommend a change to a healthier diet and avoidance of high sugar foods, and highly refined carbohydrates and hihgly processed foods with many chemical additives.
So in our group, and over the history of moderating the group as it has evolved and reformed itself over 5 years, we have collated many anonymised comments or histories on how individuals tackled their challenges in working life, and what non medical help was sought or offered.
1) Moving where the work is, or down sizing to meet lower income expectations - two related strategies which overcame the issues or swapping jobs or being fired and then often acepting a lower anticipated long term income and down sizing , or indeed being  disabled out the workforce in a couple of our current group ( far more prominent in our first incarnations when earlier members were younger and more volatile in nature)
We have had very few women in our group after the first younger participants fell away, so it is hard to judge if women are more likely to drop out by getting married or cohabiting with a man who creates most of the income.
The latter is a rather sad indictment of not seeking help, and not self fullfilling, however it is compensated by
2) FInding work which really interests or rewards
This was often lower paid but sometimes it has involved moving into sales or a more sociable job, where creativity and personability is rated higher than precision, analysis, summation, calmness and focus on repetitive tasks over time.   So the most typical example is sales, where an economic and often social reward seems to stimulate the sufferer who then can be very turned-on in the sales call, while being able to be distracted or on 'low cycle' between sales calls. Sales people are known for their varied abilities in administration anyway.
One long term member of the group has done stand up comedy, and has in fact been paid and invited to other venues.
Others have moved into care work with handicapped people or the elderly, which is a big career sector for the semi skilled locally here.
3) FInding work which is Better Structured
For those in our current group of more mature sufferers, average age around mid 30s, this was also a marked career tendency in those which had been able to follow a more stable career and shift jobs less often, and end up with the better wages of the group.
This was often in industry, or in administration within industry, and it may strike the reader that this would seem the type of repetitive, dull work which ADHD sufferers should avoid.
The key difference is that these jobs offered a high degree of structure and business or quality processes. One described their job in technical admin' as having 'hand  rails' and small intermediate goals which maeant than when they felt low on concentration, they had at least the next stage to complete, and when they were a little hyper, they could come down off the high and have a natural process to follow. Several agreed, and this has also been the councellors past experience with other more successful members. Often these jobs had a degree of variaability, each type of task having its own proceduralk systems,. These were most often in larger companies, where of course they have the need to reduce human error by having systems which can be taught and which integrate to other functions in their value= and admin= chains.
4) Better structuring work and goals themselves
This was a more cross the board opinion, which showed the benefit of group therapy and discussion, because it mannifests itself in many different ways. These days people often use personal mobile devices, and the work PC or laptop to help in particular with
>Having a to-do list on the computer
> Prioritising tasks and goals from this list (s)
Breaking down the task into sub components with notes on the computer
Describing the task in their own words or cut and pasting from instructions or asking coworkers by email for help and pasting in the best answers
> Scheduling the Task
> Holding a calendar with alarms. Making those alarms or other pre/alarms such that they make meetings, or start to finish off tasks with enough time to do this before the appointment time or due date
> Building small systems in software or with colleagues, or even wihtin a department which help them deliver and integrate their work to others.
Some without daily use of laptops, simply wrote post it notes, or had a small diary at hand. Others took an approach of using other people to help them organise their day and remember appointments, and this for a couple of entrepreneurs was tantamount to having a cheap PA in missusing young office staff or spouses who worked in their small business.
5) Self Knowledge
Leading on from the last point in 4, because particulary now the group dynamic is older, the younger members have nearly all fallen away completely, then there is a large amount of using self knowledge to make decisions about what type of work, tasks and motivations they have in general, and how these may vary through a working day.
At the lower end of productivity and wealth, there were as mentioned the medically disabled, who in fact probably dont have the strongest symptoms amongst the older dynamic (a reverse of the early incarnation demographics!!) They have learned that they do not function well in working life and have chosen to seek medical help, and indeed to some extent you can see this as fraudulent when they start to reach out for other conditions like having a bad back, or social angst to then boost up their chances of getting invalidity benefits.
Also at the lower end there were a few and have been before, who work in practical work, like mechanics or gardening, and are mostly not fully qualified. They know they are not very productive compared to some, but their employers often pay them a lot less, or allow them to work part time, or give them more interesting tasks to do. They have a longer term relationship with the employer, while actually in only a few cases over the years whcih have come to light, has the employee discussed or had a case worker discuss their diagnosis, or reduced capacity without knowing it was ADHD. The work place then had been altered for their needs to some extent, or their sphere was tailored to them. 
Further up the listings of income and success have been some academics and journalists, who have thrived on creativity and not been tied down to doing tasks they do not like.
Then as mentioned there was a group of admin and techno/crats, who had chosen to some extent consciously to follow a more structured career, often down sizing from other jobs, but just as often happening to find a niche were they could perform and actually acheive more..
Above this there have been few managers, but a good few high earning sales personnel, some of whom tried and did not do well at sales management or in other functions. Also there have been a number of self employed people who are relatively successful, self actualising a lot, on varied incomes. They come to the group most often due to their spouses asking, or because in fact they have difficulty with romantic relationships, or in a couple of cases because they could not retain staff or had conflict with staff they felt they could not resolve easily because of lack of assertiveness
6) Alternative Self Selected Tackling Strategies or Qausi Medication
The most common of these in the first two years of the group, was substance of abuse. It is usually difficult for drugs and alcohol (which we always categorise as a drug too) to be seen as anything than exaverbating ADHD or leading to a false diagnosis of the condition in the first place. However some sufferers use the "upper/downer/make-it-go-awayer" approach to self medicating. This can take the form of once substance of abuse in one category, usually either narcotic or barbituate /amphetamine and we include alchohol as a narcotic in this fashion most often, if it is not being used to self release from inhibitions. Some however in the earlier days, amongst younger adults, used an interesting course of using the uppers for the desired effect in the morning, before going out, or before what ever event or situation was anticipated (sometimes criminal of course) While then using the downers, such as cannabis, to relax, counter act the amphetimines,  or come down from the hyperactivity of the disease perhaps itself. For ethical reasons we cannot discuss any positive effect of this, and indeed we will not take this any further here, other than pointing out that it happens and some people actually consciously use drugs of abuse to try to tackle everyday life and the symptoms of ADHD.
As the group evolved, and also due to another local initiative to involve all people with psychological diagnosii to participate in sport, more and more members reported positive effects of sport and physical activity. Some noted that longer bouts of even activity seemed to be more beneficial to concentration and in changing training pattern from short burst intensity sessions over to longer sessions they found that they had improved both concentration and how they tackle situations. THis is one area which is amenable to clinical trials, single blind at least.  Numerous studies have linked exercise to improved cognitive abilities and even effects on the number of nerve cells in the brain. It is something which the group recommends new members, and older members who are less active are also encouraged to just go out for long gentle walks etc. Cycling, running and xc skiing are the predominant 'endurance' sports here incidentally. A small minority had participated in marial arts, or had even in two members become very proficient and they felt that the concentration and means of training up to the levels of skill, stregnth and  concentration were quite probably very therapeutic for themselves.Lateral studies between ADHD sufferers and their level of activity, and type of activity could be conducted with potentially conclusive or indicative results, while longdituninal studies on individuals starting on a new course would also be indicative as to any benefit from low technique sports, longer duration sessions or concentration sports like martial arts and XC skiing.

Meditation was a far less commonly noted therapy, and was part of the marital artists repertoire. Hypnotherapy has been reported, with no detail or value discussed. A few had sought quasi qaulified help or alternative therapies, without any notable success, but a good feeling about having done it.
Very few over the last five years had self selected concentration exercises, and there was no real conclusion from them or those who had been through them after referral.More on that below.
Diet has been an issue for several, especially those with children who have begun to show signs of possible ADD /ADHD, and it is often discussed in the group without any conclusive nature, but that many feel the benefit of a healthier 'whole food' diet with fish and omega 3 supplements. There are some internet sources who claim that in fact (some?) ADHD is caused by lactose metabolism defects and a dairy free diet can totally alleviate the symptoms in children especially. This has not been clinically trialled in adults at least, the non dairy, non sugar diet has been trialled in children with indicitative results (but the diagnoses of the entry groups has in the larger studies come into question for over-diagnosis, thus either diluting the effects or actually beingn the contributory sub group of those with a lactose metablism problem displaying some signs of ADHD) Lactose free diets have  been tried by pastt and present group members with some reporting positive effects.
The authors opinion is this:
> generally healthier eating and lifestyle can help alleviate the signs and symptoms of ADHD, and there may be a molecular explanation for this directly interacting with the disease mechanism, or just a more general effect on the brain as is now documented scientifically.
>Specific diets may reveal that ADHD like symptoms are casued by intolerances, and this can lead to misdiagnosis of course. We moderate our group in an ethical manner, and we therefore allow the topic of lactose free diet be aired without provoking it ourselves or particularly antagonising it. We moderate this to a short term try-and-see due to the potential loss of calcium and protein intake some people with traditional or less healthy diets may encounter. We say that if they feel benefit, they should go quickly to their GP for dietary advice
> Also specific sports or types of freetime activity should be studied to reveal positive effects on the actual disease, or general  "lifting" effects.
>  Concentration exercises have been studied clinically, with we feel inconclusive results on balance, and an issue in compliance and once again, pre screening for correct diagnosis. Also they are nealy all from younger age groups, so the nature of the exercises may not be so applicable or effective in adults. Perhaps studies published in french, where the opposite is sometimes true, that ADHD is not diagnoses but considered a concentration deficiency which can be 'taught out' of pupils,  have not been considered by us yet. We express a keen interest in this area and hope to be able to have some kind of path to go on at some point in time, and to be able to present intersting exercises mediated via books or web sites, or even Apps of course now, which have proven effect and are enjoyable or really worth the effort.
7) Courses, Therapies , The Help Group Itsef
Outside Norway, where we hold this group in native language, in english speaking western countries there has been a big focius since the 1980s on assertiveness training for managers, and for staff who are seen to perhaps need help in making assertions and taking action.  This was absent completely from comments taken now or earlier, apart from the course leaders who had been on these courses (both non norwegian by coincidence and fortuity) . However over the years a notable large minority had either been referred to a psychologist by their employer, or to family councelling, or as the most common prior to any diagnosis, over to Anger Management
Anger management courses through out the western world are no doubt made up of a high proportion of ADHD sufferers, and those others with post traumatic stress from childhood or adult exposure to violence. Some of course have ADHD and been exposed to trauma or caused traumatiic situations which exacerbate their poor lives.
There seems to be a lot of common ground though, and the councellors are taking this as a conclusion, that there should be a public or private offering of anger managment and for the less peppery of temperament, assertiveness training based on anger mangement techniques. One councellor currently teaches  and leads alternatives-to-violence courses for sufferers and health professionals. That is why they arre involved with the ADHD group, and they are suprised that the passivitiy or learned helplessness is very aa-kin to the type of feelings their other sufferers have, who are often probably ADHD and sometimes have had a diagnosis, or go on after a recommendation from ATV to seek diagnosis.
The self help group over the last five years as mentioned has evolved from being populated by mainly young adults with disturbed lifestyles, mostly having had the diagnosis in their teenage years, to being a far more mature group, and this is not perhaps purely coincidence. Younger sufferers were also seemngly more heavily affected, and less able or willing to contribute constructively. Many came with partners, parents or some kind of guardian figure. Now we have a group of older who come voluntarily, the majority having adult diagnosis while some have not yet had the diagnosis and wanted to share their stories or hear from others to decide if they should seek professinal help. Some feel it is a but of an insult to either bare the label, or even a stigma, while others feel frustrated that they did not get earlier diagnosis, often having had brushes with the medical profession around the edges but not on the cause. Most feel that mediication alone is not the answer in the bigger picture, several have stopped or refused ritalin, and discussion on mediaction forms a confidential part of our process, where we remind everyone that it must be voluntarily discussed or presented and it stays in the room, with off line discussions being avoided due to the risk of stigmatisation from outside.
Experiencs with the symptoms of the disease, most often the deliterrrious effects, experiences with the health profession, often frustrating, experiences with medication, very mixed, and then the experiences of how people tackle working life, romance, relationships, partenthood, crisis in life and so on and so on, form the rich content of our self help group. In our last quality evaluation , which was audited unofficially so far by the district psychological services, members  expressed overwhelmingly that they felt both emotional support from attendance, and also practical benefits in relation to self awareness and tackling strategies, as well as where they may like to go to look for further professional help or alternative techniques.

Wednesday, 27 August 2014

Bad Calls: The Decision Making Consequences of ADHD

Our group is a collection of adults afflicted by ADHD both directly and indirectly as spouses and family. Many have had a diagnosis or clear incling that they had the disease since they were children, particularly notable as teenagers or in the toddler to preschool years, while actually the majority did not recieve the diagnosis until well into adult life.

Those in the latter category, can all relate back with retrospect to their own childhood behaviour and also how they suffered as late teenagers and  young adults in particular, having missed the diagnosis and any opportunity for therapy or at least confronting the disease.

In our latest theme we chose as a whole discussion evening, we found a lot of agreement on one issue: that ADHD sufferers make bad decisions.

Bad decision making seems to centre around a distinct lack in assertiveness, especially where there is stress, a social gratification back-drop or an emotional element in the circumstances around and feelings of the afflicted.  Assertiveness is the key concept that we discussed as a potential therapeutic direction, which only two of our group had actually brushed on in their lives both in relation to job training courses and not anything to do with the medical establishment.

Typically psychiatrists talk about dampening the impulsiveness of the disease as a key goal in either the US lead medication route, or the French and Liberal view on corrective behavioural therapy and education for families. In the experiences of the group then, these peak impulsive episodes caused most harm to their lives and those around them, and the stimulant medication coupled to counselling had assisted most in tackling the 'outbreaks'.

What had not been properly addressed was the larger picture of poor decision making and why perhaps impulsive decision making is so prevalent in the afflicted.

One theory about the prevalence of properly diagnosed ADHD, and the over diagnosis plague, is that western societies have become more individualistic and free in terms of how collective norms of behaviour are fragmented from the older mass collective way of life. The New Right point to a lack of discipline in liberalised education systems and the removal of many forms of punishment. The fact is though that we do not really know the prevalence of ADHD historically in the days when education was highly structured, over a shorter period in childhood and arguably less productive in that the masses of working class came out very poorly educated compared to today's average scores in the G20 countries. So it is difficult to seperate out the actual prevalence over the years, while it is easier to point the finger at the medical establishment for creating conditions for overdiagnosis- Psychiatristsc psychologists and general practictioners are sensitised to the spectrum of symptoms <  Schools become triage for disruptive pupils, parents look to blame a disease rather than their own poor discipline.
Puttng the plague of over diagnosis to one side, we can not really draw any conclusion about ADHD being something which has flourished under the modern society as a disease> it could have been a sub clinical disease prior to the widespread awareness of its symptoms which match those of poorly disciplined, ego centric children too. The effects of the disease on individuals may have actually reveresed. In the days prior to full school education, ADHD sufferers may have been labelled as lazy or dizzy or what ever, and are very likely to have performed poorly in economic productivity out in the real world post education, we just dont know. An arguement can be made that the modern liberal success story of full education to age 16 and the freedom of thought and opportunity society now embelleshes youth with, has actually reversed the fortunes for many sufferers who can find careers, sports or self employment through which they fulfill themselves despite the handicap, or because of their hyperactivity and impulsiveness.

Back then to decision making> in our group the reason for adult diagnosis was usually centred around a chain of bad decisisson making or the consequences of poor judgement and rash actions. The reason for poor decision making was discussed and to summarise it is not just seen as the impulsiveness. Rather the impulsiveness is the turning point with the seeds of bad decisions sown long before, in the inactive 'glue brain" phase of the cyclical symptoms. Many agreed that they could not sum things up, they could not counter argue, that they felt stressed out and frustrated with themselves for failing to think. Some agreed they felt like a ' rabit caught in the headlights' staring at the approaching issue without a sense of their ability to interact and interpret it. Often this lead to aggression and compulsiveness. Some form of action was taken in the rash, hyperactive phase, as if there had to be a release of the tension.

Often this was also driven by the family, friends, colleagues or who ever they interacted with. There was an element of feeling that you were being treated with 'kid gloves' , patronised, and being lead into a course of action. Upon reflection several said that their family and colleagues would expect some form of outburst or to the contrary indecisiveness. Therefore perrhaps ADHD sufferers load the dice by their previous social interactions, and those around them seek to exercise a level of control over them and discuss with others how to impose some structure onto them. In the work place, several felt openly exploited, that their employer knew that they would make a noise but comply, and that their employer could use the threat of being fired or the emotional eraticness as an arguement to make them comply to tasks which were not in their interests, and perhaps unreasonable.

Several talked more about how they struggle to come to decisions, how they try hard to internalise things and often fail completely to make balanced decisions at the time, and also fail to avoid making decisions. They feel that they must make a decision in many situations. Also the threshold for feeling stressed out about having to make a descion or react to some challenge, was proposed as being much lower for sufferers. They in fact found it harderr to counter argue or to simply walk away from a decision with some postponing tactic.  Ironically they often found that was a stance taken by people around them when they confronted them, expecting a decision. ADHD seems to affect both sides of this social equation, in that sufferers can be interpreted as impulsive, bullish, over enthusiastic and outright pushy by people they are approaching for answers or actions from.  There is a lapse in many of the social queues which 'normal' people have in dealing with others. Also there was discusses the social stigma of being the implulsive, enthusiastic, high and low dizzy one in a social group or work situation. Several meant that freinds, family and especially colleagues lacked respect for them and made fun of them when they were being impulsive or indecisive, while worse, taking advantage of this in social settings to tease or even humiliate the sufferer. As mentioned above there was also grounds for explotiative actions from bosses or coworkers.

So there is also an element of self -fulfilling prophecy in the picture of the social environment. You are open to be handled in a Parent-Child approach from family members and colleagues even as an adult.

It seems that ADHD sufferers are ill equiped to tackle many types of decision making, especially where there is complexity or a social-emotional context. Where as normal successful people often weigh up situations and react immediately when they are being treated unfairly, ADHD let it simmer and then just plain boil over to use the group's vernacular.

Several techniques were then discussed over an on-line 'chat' meeting and will be discussed both at the group and with clinicians and families later.

One is the Time Out> this is just to ask family or friends to wait a bit. In work situations this is using postponing tactics - I'm busy right now, can I get back to you?  I'm just finishing this ...please let me get back to you. Or simply, I am really fatigued right now, can we talk when I feel able to discuss this?

Another technqiue from assertive training was to learn to say no three times to an agressive boss or in a situation where you really think you are going to be exploited.

The most interesting suggestions were from experiences with assertiveness courses where the Adult-Child issue is addressed with respect of adult life, not childhood. These are various techniques which aim to firstly recognise when there is an element of patronisation, or expected subordination or presumed authority over everything. Here the case is to qualify and make the case objective rather than the 'parent' demanding the 'child' do something.

Here is a quote we have asked permission to publish anonymously

" I was out of the blue called into the bosses office. I hate being called into the bosses office without any explanation, as I feel it is a tactic against me, which is followed up by some authoritarian demand or criticism. This time was probably the worst of my entire career. They wanted me to move to an inferior position, giving up my respobnnsibilities and therefore my chance of a promotion which was part of my personal development plan agreed with my line manager two months before. I reacted with emotion, angrily, but did manage to qualify if there was discontentment with my performance. Another ambush ensued where the VP of the department was called in to put  a soft rubber stamp on the move. I felt that I could fight, but would lose. It was a kind of fight or flight, and I chose to give up to be honest. Soon after I also discovered that my position was being offered to an internal candidate who had been asking for a move for two years, but passed over at the time my position was actually advertised. This just made me more angry.  Further more to insult the injury, the guy I was going to work with had to some extent being subordinate to me, and was actually being promoted to being my boss! He had less experience and qualifications than me!!!  I reacted by being angry, sultry, sarcastic and then withdrawn.

In retrospect I had many cards on my side. I had a written agreement with the firm. I was being discrimminated against as a foreigner. They had no need to do this at that time either, we were mid in a large delivery phase and I had sorted out a lot of mess with sub suppliers and identified a new sub supplier to work with to take up capacity and learn our quality demands. I could have at least negotiated a temporary move, linked to my pay rise. I could have just asked a lawyer or the advice bureau at the national employment agency which is free.

Instead I cursed myself for not having done something earlier in getting more of my future on paper. I cursed myself for not being in a trade union. I went round like a pissed off teenager for a month.

What I should have done was calmly said this was not acceptable or tried to defer the situation. I could have avoided escalating it to the VP and eventually gone over even his head. Only if I had time to think clearly and sum up the facts.'