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.