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

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

Low Actual Referral from Physicians to Psychological Therapy

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

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

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

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

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

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

Few Clinical Trials on Alternatives to Medication

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


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

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

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

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

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

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





Further Reading

http://www.chadd.org/Understanding-ADHD/Parents-Caregivers-of-Children-with-ADHD/Symptoms-and-Causes/Researchers-on-ADHD-Research.aspx

http://www.additudemag.com/adhd/article/912.html

http://www.help4adhd.org/en/treatment/behavioral/WWK21

http://www.helpforadd.com/mta-study/

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.

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.'

ADHD: The Teenage Over Diagnosis and Adult Under-Diagnosis ?

As I have blogged before we have personal experience with ADD/ADHD in both adults and children, and have reviewed much of the leading current literature and reviews of papers. In this qualitative review, we discuss a practical and critical approach to the disease, from a perspective of the over diagnosis amongst "youth"- the plague-and-the-pills, and from the point of view of adults who actually have life ling ADHD, but whose symptoms only are apparent during life crises or general under-achievement for example.

The enigma at the core of ADHD (over ADD alone) is that it is contradictory in nature: it goes between phases of AC and DC if  you like. The name given to the disorder was of course coined from the  description of the presenting-symptoms which are socially interpreted. The symptoms were defined externally, classically from how the school child could not concentrate and was then also overly active, when compared to the average child. "They can't listen and they just can't sit still".

The actual bipolar nature however was discovered somewhat later, when the attention deficiency  was uncovered as actually being the reverse of hyper-activity: the brain was chronically under stimulated in those afflicted with ADD and ADHD in its' 'true sense', when experiencing those phases of lack of focus, distractability and drowsiness.

Later on research in neurology and new psychological assessments confirmed this, and further demonstrated the link between the under stimulated higher thought processes, and the super-stimulation pathways present in ADHD, which then try to "kick start" the brain and actually lead to classically uncontrolled streaming thoughts, and in many cases a reduction in natural inhibition  leading to dangerous or socially crass behaviour.

So the circle was closed: the ADD was related to the ADHD and often children in particular were experiencing a bipolar disease, and living with the frustrations of a lack of concentration at both poles.

Differential Diagnosis as a Counter to the Over-Diagnosis of ADHD

There above then, you have the ætiology and diagnosis in a nutshell: however ADHD is amongst the most over diagnosed and correspondingly over-medicated area in teenage mental health. In some school classes it has been seen as the predominant chronic medical affliction.

On the other hand, in adults not previously diagnosed with ADHD as children, and  presenting potentially with symptoms for the first time, it is likely that ADHD is very often misdiagnosed as depression and bipolar-depressive disorder. The extent of this in adults, has not been established while over diagnosis in teenagers is a "hot potato" in health authorities.

 Resulting medication and psychological exercises or therapy then can lead to patients continuing with difficulties and also developing a focus-complex : in the teenager the incorrect (or patient lead ) diagnosis of disease can be offered as an excuse for attitudinal and behavioural problems which should be tackled with motivation and schooling methods; For adults, there can be a focus on reactive depression, or other longer term  negative events in life which in fact are not the source of the bipolar behaviour, rather it is an internal disease.

Economic and Societal Importance

Differential diagnosis for both ADHD and then the mono-polar Attention Deficiency Disorder is therefore important for public health authorities to assert within their structures so as to reduce the burden on mental health services and pharmacy budgeting in child health which is heavily subsidised with tax payers money. Also for private practitioners alike,  they should consider the potential for litigation stemming from aberrant and potentially damaging medication with "Ritalin" and related substances for patients who are actually not relevant or even should have a contra-indication for such stimulants.

The key questions for the medical delivery system are then :

a) does this teenager actually have a social-problem, which can and should be tackled with social, educational and parental means or is this an ætiology of ADHD likely to respond to drugs, diet and concentration regimes?

b) Does this adult presenting with situation reactive symptoms actually have an underlying ADHD which has a negative influence on their life and has contributed to the current malaise and indeed is a major factor in creating or exacerbating the negative situation or crises.

In the cases of a disease being misdiagnosed,  the a path for treating ADHD or treating a different condition is counter productive and even can be contra-indicated from the medical point of view and is a misuse of funds. A reactive depression may be a meta-symptom in adults for example, relating to a life event, but if sufficient patient history points to ADHD then a longer term investigation and treatment of the disease will be cost effective.

In the case where a "null" diagnosis- this patient has no sickness, just a social problem: then this is important to establish that the prevalence, especially amongst teenagers, is a system problem: that schools and social services have then a responsibility to modify methods and take remediation of those pupils with the worst attitude problems.

This is then a case for systems management outside the health profession. However as a gate keeper,  practitioners being there a sceptical police who alert the educational authorities that there is a social problem being presented as ADHD on a basis frequent enough to merit immediate intervention and longer term system re-evaluation. Schools then must find new ways of teaching which manage unruly students, including them and borderline students in general classes and excluding them from ordinary academic classes when their attitudes lead to disruptive behaviour and contaminate other pupils.

What Are the Alternative Diagnoses and to What Extent Are We Discussing a Societal Perceived Disease?

The crux of the matter in over-diagnosing teenagers as having ADHD is that there is on the one hand, a perceived nuisance and non conformity issue: in highly structured schooling or in societies (for example small towns) where people have often "modest " behaviour patterns, a higher level of activity, of physical and mental energy can be misinterpreted and indeed the individual can be  labelled as having the disease. In more normal classrooms, poor discipline and weak leadership can also result in an unruly class, with ring leaders using "ADHD" as a scapegoat.

The more intelligent child ;  the more communicative child ; the more physically active child ;  the poorer socialised child, the child who seeks social leadership by disruption : ADHD as a sickness has a social element but it is a disease, while the cultural interpretation of misbehaviour and hyperactivity is realistically the first step to differential diagnosis: IS THIS A SOCIAL PERCEPTION ISSUE and not a disease in this child ?

The very reverse can be true in adults: The adult is diagnosed as being socially inept, prone to moods, rebellious, "slow on the take up", and a poor learner: an "odd-ball" in many cases. So it is perhaps symptoms of depression actually are those which the patient presents with, or alternatively they are referred to psychological services by a family member or doctor. In the worst cases of course, they are referred by the courts or the prison authorities. It is these criminal cases perhaps which are taken most seriously as having a root in a disease, ADHD.

To summarise this little dilemma ; in the child a diagnosis of disease has more prevalence, where as in the adult, the social circumstances and personality issues are often the misdiagnosis or "sub clinical" . This is kind of a para-thesis : the "fundamental attribution error" in a new context, where unruly or ADD behaviour in children is over diagnosed as being an inherent neurological disease, where as in adults the social history and personality defect become the focus.

Differential Diagnoses Proposed:

1) Is this a social-judgemental problem or actually a disease in the child? Is the social referral of an adult the reverse, actually possibly ADHD?

2) If this is a hyperactivity disorder, is there a bipolar nature with "down" times somewhat cyclical?

a) Does the "down time" come after prolonged periods of hyperactivity and reduced sleep?
- seek also information on hypo-mania and other super-stimulated disorders. Including brain damage and neurological hyperactivity as a post traumatic event chronic reaction. - Test also for substances of abuse in the amphetamine like area.

b) Does the "down time" come at particular times of day or on a fairly predictable cyclical pattern ?
- this can be seen in many ADHD cases, but also it could be related to diet- for example lactose intolerance/lactose to opiate metabolism, diabetes or early stage blood sugar homeostatic problems, poor diet, irregular eating times;  Also insomnia/parasomnia and narcolepsia are also areas to uncover.

c) Misdiagnosis: Stress, PTSS, Depression in adults:  is the adult in particular, seemingly themselves the cause of the stress or depression? Has their behaviour actually created the situation which is the source ? Should a similarly qualified or experienced person cope with the sources of stress or depression better ? Has the patient actually a longer history of ADHD like symptoms ?

d) is the ADD person being misdiagnosed with depression ? In fact is the bipolar nature of a patient suppressed by social circumstances and personality and infact they have both the AD and the HD sides ?

e) Is the patient self diagnosing? A whole topic in itself:

Initial Diagnosis as Ammunition for Googling, and the Internet for Self-Fulfilling-Illness ?

The actual diagnosis of ADHD is of course for the vast majority, outside neurological research institutes. Diagnosis at the GP, psychologist or psychiatrist is based on a consultation by in large, with in some cases a bank of traditional concentration, attention, short-term memory and "boredom" fatigue tests.

The Danger in using pateint-provided-history alone is that of course, a teenager may be inventing their ADHD to gain attention (Munchhausen?), to find an excuse for lack of discipline and effort in class when they could change-their-ways consciously, or in the worst cases, effecting the procurement of Ritalin for resale as a substance of abuse? Furthermore an initial discussion can plant keywords literally for later Googling in the patient's own time, and they can return with a construct matching their issues to ADHD ( or the reverse, following a lead word from the first consultation into a misdiagnosis).

Using a Bank of Neuro-Psychological Tests and Questionnaires to Assist in Differential Diagnosis of ADHD:

The bank of simple and well proven, normalised tests for attention deficiency is actually a route to which some adults are delivered as presenting with life long ADHD. Often administered by specialist neuro-psychologists, the patient may have had a referral for a provisional diagnosis of post-traumatic-stress, or potentially brain damage or several other routes to this little circus of elementary and well established motor-cognitive, memory and motivation  tests.

These tests then are sometimes concluding that ADHD is a probable ætiology from a different route to the neuro- psychologist's desk.  However it is our contention that such a bank of tests be conducted on all teenagers who present with socially-diagnosed ADHD. 

One of the key's to their applicability in teenagers is that some of the tests use a subterfuge, and also they set goals which a teenager may either like to meet  (or fully reject, demonstrating a larger social problem). The subterfuge is in the test appearing to be a trial or puzzle, an aptitude test, when actually measuring things like attention span, short term memory or motivation for tasks.

Some studies with control non ADHD subjects in single blind studies where the ADHD is clearly established in the patient group, have not shown effectiveness, while on the other hand other studies have shown that the reverse is the case, and adult specific studies suggest that tests can establish a differential diagnosis where symptoms are non specific, resulting from social crises or other "bi-products" of the ADHD afflicted person.

The bank of tests is then usually administered by a neuro-psychologist and this is important because they may be able to identify other motor-cognitive diseases by the demeanour and physical approach the patient takes to the tests, and in considering the results.

Sometimes a more directed ADHD questionnaire is 'administered' to help explore the patient's social behaviour and perceptions around attentiveness, concentration, thought and day-dreaming etc. Alternatively a wider questionnaire which may be used as a means to open discussion or to exclude other illnesses is administered by the psychiatrist. These stages could be partly moved to the GP surgery or even school nursing station for administration such that a degree of triage is conducted at lower cost to establishment and at lower risk of contaminating the patient with the self-gratification that escalation to consultant psychiatry service entails.

Also adults who present with situational reactive depressions and stress related disorders, should be questioned on their earlier life and patterns of problematic interactions, lack of assertiveness, social ineptness etc to establish if there is cause to follow a route of finding ADHD as the "carrier signal" to which other disruptions are amplified: such as depression and stress at work, and a lack of assertiveness and sound- judgement in situations which leads to negative consequences or even chaotic, downwards spiral in risk taking, revenge, and other over-reaction or inability to handle circumstances.

Neurological tests then should be chosen from a bank of tests which are all culturally normalised for the nation or region. Physicians and psychologists may like to actually normalise these tests to a local area or indeed to a school authority such that average responses are mapped and a mean deviation threshold for diagnostically valuable results is established in the special context. This can be done on a relatively small sample size, chosen from a definable and finite sub-population eg 15 year old school pupils in a county.  Also a further blind trial can be conducted where those with clear ADHD diagnosis are fed into 'healthy' candidate studies. 

Failures in these tests may be attributed to a lack of normalisation perhaps, but also to using them only selectively: the "consultation" and overall assessment is taken in a context of a fairly intense series of
tests, where the net result is also indicative of ADHD by virtue of attention span flagging, and the same measure being analysed by disparate techniques.

Conclusion: ADHD - Cut to the Quick , Sift out the Fakers.

To repeat what we conclude above, our contention is that ADHD is over-diagnosed in children (esp. adolescents)  and under-diagnosed in adults by patient provided histories or subjective reports from from private or public social bodies around the afflicted.

 Many medical authorities require by statute that patients be referred to a psychiatrist prior to medication, and this should be standard practice once the first steps to establish that a "rigorously skeptical" differential diagnosis is under way. This is to prevent that on the one hand, the teenage patient has not been given a bias in language towards ADHD, and on the other, that an adult is not being misdiagnosed when ADHD is actually the "vector of their misfortunes" .

In the case of the teenager we want to avoid the case where after initial consultation,  they self diagnose by Googling the topic and misrepresent their symptoms or misreport the wider symptoms which may point to another disease or actually have just a "social problem". In the adult presenting with stress, or a strong reactive depression, or series of life crises for example then