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.'

Wednesday, 6 August 2014

Childhood Trauma : Misdiagnosis, exacerbation and culprit with ADHD

From actually a very recent Healthline dotcom article we were able to pick up on some points from our last self help group's dicussion and take them up again with our first post summer semester meeting.


The article reported some follow up analysis in presumably adolescents and children with a historic diagnosis adhd, which delved into then to what type and occurence of traumatic experiences in early childhood the patients had.

The supposition was once again the overdiagnosis or more accurately then the misdiagnosis of ADHD, and then juxtaposing this accusation with the level of medication used in Canada. Without drawing any conclusions on actual level of innappropriate courses of action, the article placed the concepts:

1) ADHD can easily be the incorrect diagnosis for what is more likely post-traumatic-stress-disorder(s) (more over a syndrome as it should be called IMHO)

2) ADHD afflicted can experience some acute-traumatic-childhood-experiences (ACEs) as far more dramatic and react in a disproportionate way compared to normal children. Further more, some events which could be frightening or just regarded as a reasonable  challenge for a normal child, may be experienced at the time or in retrospect as highly traumatic and emotionally disturbing for the ADHD sufferer.

3) ADHD as the source to traumatic events: the disease can lead to more stressful relationships at home, or create traumtic events due to impulsiveness or lack of appropriate handeling to prevent some unwanted event or series of links which lead to catastrophe, such as in spiralling substance abuse which is common amongst socially delinquent adhd sufferers.

The article states very succinctly that in first taking the "history" at the primary point of care it should be a complete childhood history which uncovers any underlying behavioural symptoms. In all the scenarios above the key is to identify if there is a history of erratic, impulsive, attention deficit behaviour prior to a major traumatic event in the patient's history. Alternatively then choosing to create a differential diagnosis with Post Traumatic Stress Disorder which bares many of the same symptoms as ADHD and often occurs in the peripubescent period, when divorce or outside street violence are more likely to affect an older child due to how parents and society now see them ie they are old enough to be considered open for more, be that a bad presumption of course. Parents choose to wait to separate until the children are older for various reasons, partly in the false belief a 9 to 12 year old will tackle divorce better. Adolescents may begin seeing a 10 year old as a potential acceptable target for bullying or so far as even involving them in gang violence.

In our own group, bar one member,  we could all actually  see that we had a running symptom list of ADHD which became clear earlier than the "coming of age" i describe above, prior to age 10.

Nearly all members of our group had experienced some form of acute, traumatic event or longer term emotionally disturbing situation in childhood and also could see that as adults ( our group is mainly those diagnosed with ADHD over age 25) their ADHD did indeed contribute to negative, acute life events as follows:

1) perceiving some events as traumatic at the time, and being now even embarressed to admit this because they seem relatively normal: losing a job, getting dumped by a partner or being involved in frightening confrontations under the indfluence of alcohol or other substances of abuse

2) not having the ability to tackle some events: commonly with us : allowing issues to grow over time and to then explode, often in a social stress context. Second to this was contributing to the tension and traumatic outcome of an event, particularily when splitting up with a lover or in the work place.

3) Directly causing traumatic events in childhood or adulthood.

On this latter point we found a rich seam of material came forward in our self help grouo.  Committing crime, overdosing on drugs, violence tinged drinking bouts, attempted suicide, aggressive driving leading to crashes,  violence in the family, provocation and fighting were the more dramatic we could raise from our members. Splitting up from a partner or friend more acromoniously than needed to be (or that indeed creating an irreversible chasm) was more often cited, often with regret,  across all our dozen or so present.

Storming out of jobs or sibling meetings was also quoted as being umpulsive events which lead to some disproportionately dire consequences.

More subtle examples were opting to be together with "innappropriate" partners, which often statred from an impulsive one night stand which lead to a longer unbeneficial relationship which a more clear headed, assertive person would have avoided. The same was true with jobs or entire career paths, notably sales careers in several of us which prove to be unfullfilling yet seemingly a good idea for people lacking qualifications or wanting a career change.

The key thread we could trace here, being picked up on from our assertiveness training we have included a paid course leader to come in for, is that very lack of assetiveness which is really the main handicap to adult life for the ADHD afflicted.

How is this lack of being objective and being able to make more appropriate actions affected by adhd?

The disease is like a perfect storm as one participant put it , whom has researched it and related back to their own life. In outset we can negatively affect those around us, which in work and family life loses us trust and respect. We are not taken seriously, or worse are seen as problematic. Then we lack some social atennae, further to this we fail to pick up on both social ques and we fail to gather information in a balanced and rational way. We may suspect a partner is having doubts, or a company is considering our future with them, but we either miss the tell tale signs, linger on paranoic perceptions or fail to make a case for ourselves and then take the bull by the horns.

The majority of the group agreed that they were very often conflict averse when there was serious miscontent around them or grounds for arguement, while conversely they went on to act rashly and with impulsive often aggressive conflict handling. Many agreed they were bad at "nipping it in the bud" and let issues simmer rather than addressing them, and this often may have lead to exagerrated outcomes or avoidable courses which relationships instead spiralled downwards from.

A key thing people expressed about impulsiveness, the hallmark of adhd if you like, was that it usually had a largely emotional start point. Bored, angry , frustrated, sexually aroused or high......these  were common trigger feelings,  or trigger related emotions.

This emotional status lead to often innappropriate actions and some dire consequences. Also once a route was embarked upon from a single impulsive episode,  be that substance abuse, an unsuitbale partner or a new career, then often there was a chain effect of more and more emotional triggers for irrational and impulsive behaviours.

There was in effect a viscious circle where the afflicted was exposed to more difficult situations emanating from their initial impulsiveness and found themselves in a new trigger point, and so on and so on. These emotions were in our group paticularily negaitive stress, fear, paranoia on the one side while being either from sexual or substance gratification on the other.

Several of us further expressed that we went through the same type of aroused trigger state and took.impulsive actions through adolescent or adult life as if we enjoyed it or as if we felt it was correct to "go with our gut feeling". These then were either spread out through differing life situations, or coiled into a downward spiral as discussed above. In terms of socially "deviant" behaviour the latter included ' sex and drugs and rock and roll' lifestyles for some. For others it was a descent into gambling , petty crime , or debt they could not repay. For others it was poor decision making on partners or jobs or both in several of us. For a small number it was extra'marital sex which they found had happened repeatedly.

To some extent then there is a learned behaviour pattern. Either it is self-normalised as is a human tendency to see oneself and ones actions as normal and rational. Alternatively there is a gratification element where the outcome positively reinforces the impulsive behaviour and the poor, emtionally loaded decision making. As a sub grouping within gratification and more often associated to teenage bravado in adhd 'victims' was that the impulsive risk taking in itself was a source for excitement and stimulation ,mannifest in differing ways throughout life.

One member of the group had a differing view point on the source of their issues being external, from a "cloud burst" of three traumatic events as a teenager and we have advised her to seek rediagnosis as she may have confused symptoms
of post traumatic stress disorder with adhd and thus require a different route in therapy. Several of us proposed (after her quite emotional departure from the session) that we could have symptoms of the same which are intertwined with those of adhd. As mentioned we could have created traumatic events by mis-virtue of our disease or could be affected more adversely due to our common mental affliction. Along that route it was discussed that  our previously preclinical adhd then was exacerbated by trauma with our eventual adult diagnosis being set only in loose connection to what for we as individuals as an emotional watershed.

Seeing the complete history of the patient back to pre pubescent childhood or back to before trauma and separating out environmental and social. background is always then going to be a challenge for front line physicians and psychologists.


As a follow up to the blog above:  the lady.member mentioned went on to be diagnosed with severe post traumatic stress syndrome. Her mid teenage years were smattered with symptoms common to adhd, but there was no previous history from her earlier childhood when she had been a diligint pupil and musician. She no longer attends our group, but has offered to talk to future groups about the affliction in order for other innappropriately diagnosed, or double belasted sufferers to consider their own history and seek advice and possible rediagnosis.

Two other group members now also consider if physical trauma has caused them to be afflicted by adhd or show symptoms. One had a head injury on a stolen motorbike while they were an unruly teenager, but otherwise thought they were mentalilty sharp prior to injury. Another reported late teenage substance abuse : after treatment for a broken femur involved diamorphine, they tried to self releive with illicit drugs at home, post operatively , and went into OD. They are very uncertain if they really were adhd before hand, having had their diagnosis age 32.


Thursday, 5 June 2014

Personal Experiences of The First Steps to Diagnosis

The first stage to solving a problem, is admitting there is one.

In our recent spouse sub group meeting, the discussion focused on experiences and memories of how the long trail to diagnosis and help began.

In adult diagnosis it seems that the symptoms lead to a viscious circle of the relation between a disturbed lifestyle and carrier, fuelling further poor decision making, leading to a higher level of stress which then exacerbates the individual's, in this case mostly husband's, summation of their life situation and makes their decision-making yet worse.

Under the ongoing higher stress level, it often becomes clear to those around at home and colleagues at work that the person has impaired judgment or lacks a certain mature objectivity in dealing with everyday challenges. Behaviour can become more erratic as the combination of stress and underlying psychological challenge (read illness!) fuel this viscious circle.

Generally in our group, the effects lead to either a slow but certain deterioation in family relations, a career impass or failure, or a combination of the two precipitated from either pole , family or workplace.

Other eventual realisations that there were serious issues to address were more subtle, but stilleither from family or work as a source which either precipitated or amplified the situation. As in this account-

" My Husband first noticed that he had real concentration problems when he was accessing interrnet banking using a digital key code dongle. In the two seconds from reading to code to typing it in on the laptop he would simply forget the code, and had to fumble with the key in one hand and the other on the keyboard so he could type the number's in from right infront of his eyes.  At work he had landed a pretty appropriate sounding job, but I felt he was getting used and the type of run around I had known him go through, and could guess had happened before from his CV which was littered with short term contracts, erratic changes of jobs and outright failure with dismissals.

This job was in market research using internet tools, both of which my husband has education in, but it showed a weakness apparently in that he was not getting past the "foot soldier" stage in many jobs, while being able to cope with some situations as a real professional, he often failed to be able to deliver on boring, repetitive tasks or work that demanded a high degree of precision or concentration.  

Previously I had blamed his fiery temperament, a degree of social angst he always had for authority personailities,  and often the situation he allowed himself to get into, but it became apparent after he lost this latest job that he needed help with his concentration , aged over 40 by now.

It seemed to me initially that he had run out of steam in his career, and was sufffering from quite severe stress which was destroying his concentration, and this is probably partly true. However he confided in me that in fact he had always suffered some degree of concentration problems in relation to summative tasks, wrtiting prose or essays and even in writing e/mails he often wondered how on earth he had managed to concoct some of the e/mails he read later or was confronted with from managers and colleagues who were rather frustrated with him at times I hear.

He sought help, and the first pyschologist was really pretty useless,. prefering some obtuse methods and taking a "go slow" approach to getting to know the patient. He traced the history back to an impasse aged 15 to 16 when my husband had unexpectedly had a major set back in his academic progression and had to resit just about all subjects in order to gain university entrance, which from his previous year's straight A in 7 subjects was a surprise.

Luckily the psychologist towards the last of the sessions decided that a referral to a neuropyschologist was worth the trouble, and agreed with my husband that a more structured type of work such as book keeping or purchasing would suiit him better than his previous arena of marketing which is very personality driven.   Had the psychologist not done this, my husband would be to this day probably none the wiser.

The Neuropsychologist ran several basic concentration tests and to my husband's and my own astonishment, proposed that the diagnosis was moderate to severe ADHD.

All the years my husband had been able to compensate for  this ailment when able to work at his own pace, such as in academia but was then hindered later in his career.To me it became also very apparent  also this ADHD was the route for his social angst and often crass if amusing behaviour, jokes and social interactions which many tired of as he grew out of the 20 something set up and tried to get on with adults now his own age and older at work and sports.

  So when he came to the working world, jobs which required him to summate information for example, from  less concrete or more complex sets of data or information, and thosse which demanded a high level og social skills and a thick skin, were an obvious route to failure. Intellectually he was attracted to marketing, but his personality I must say and then his ADHD made it a terrible choice of career.

The story has a happy ending to some extent> he went on a course of ritalin and eventually tolerated the slow release, tarmic absorbed preparation. He made a couple of very logical choices in career followed by a very emotionally driven choice which was coloured by "not having looked a gift horse in the mouth" and allowing himself to be placed in a poor situation having accepted a new seemingly much better aligned job in terms of the family. This he however managed to grasp very quickly, but he did make a misjudgement in terms of the local labour market in terms of negotiating a contact as a way out, rather than bending with the wind and finding a new job.

On the down side I feel myself exhuasted by him. He still lacks some empathy and a level of self control I really want in a partner and father to our children. So much of his personaility is obviously influenced by this disease it is difficult to see what is him and what is disease, and to consider why he reacts unpredicatbly either quite laid back, or very engaged or with emotion and often that is anger.  It is just the lack of an even keel that we experience and we have agreed a "T" time out where he can live away and build his career a bit coming home just on weekends and school holidays, so tiring I feel it has been and so much he needs to get his medication sorted to a level of benefit versus the "speed" side effects he hates.

Right now he is in a bit of a malaise with jobs, being a practical house father while I work and study part time, but his reasoning and ability to present himself and think through applications and the process seem to be much better judging by the letters he asks me to proof read, or the suggestions he makes for family logistics if he is to live away during the week.

Emotionally he has grown a lot but also he has come off ritalin due to him feeling too "geared" by it in his current situaiion as  a laid back house father life style. We see very much that his anger management is impaired, and although he is a little less irritable maybe, he seems more prone to sudden unexpected over reaction and anger. Now we all can confront him more, and realise that this is a diseased part of him, like a boil needing burst and soutred.

However, I am fairly convinced that we can thank the day he couldn't log into his internet banking, a passing remark and resulting appointment for the Neuropsy' and his own interest in getting better for the progress he has made and the building blocks of a longer lasting career he is making so as to prepare for the second half of his working life and take us forward to more financial security and well being."

Other group members offered both even more subtle events that lead to a realisation that there was an illness, while others had far more alarming stories of stormy mood swings, substance abuse and minor violence. All lead to the following two family or individual realisation

1) the afflicted house member had a comparitively immature way of tackeling some sources of stress, some social circumstances > this became more apparent as they grew older, rather contra to the perception of ADHD as peaking in teenagers. In fact it usually appeared to get worse with age to the point diagnosis was perhaps inevitable.

In most all cases the seeds could be traced back to adolesence.

In some of our group of 20 or so participant afflicted, the person seemed to never grow up, but sustained a long term relationship with their spouse. THey could see that their earlier crassness and youthful energy was somethign they didn'grow out of.

2) In others as above citation, the disease showed its head by a pattern of relationship or career turmoil while the diagnosis was sought after a particularily stressful period of the afflicted or their family.

In both types of case, there had been a history of the erratic behaviour and poor tackeling strategies from the sufferer, which "came  to a head" as many agreed was a good way of putting it, rather than perhaps a contrasting pathology whereby a traumatic or stressful event leads to a proximal stress related neurosis. It can then be difficult for the psychologist or physician to see the wood for the trees, when confronted with a post traumatic situation. The long term lack of an "even keel" in life is overlooked as a group of trivial and unrelated personaility quirks, rather than the actual root cause or exacerbating factor of the symptoms the patient presents with.

It is our family help group and indeed clinical contention,  that ADHD in adults is vastly under diagnosed, whereas the exact reverse is true in the medical establishment's approach to teenagers in many western countries now, where disruptive behaviour, lack of self discipline and willfull mischief are often wrongly labelled as having ADHD as the source.

ADHD indeed renders many of life's more challenging situations worse, and can of course help to create very negative situations, while then also hindering the sufferer from tackeling those. Neagtive Stress probably excaserbates the whole cloud of symptoms that really the world around the individual experience far more than the afflicted themselves, and this seems to be characteristic of the ailment in teenagers too, where often they do not have a rational explanation for their behaviour or cannot summate why they acted as they did.