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.'

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