The road to homicide in adolescents and young men can be quite a long one.  When you look back with 20-20 hindsight one can not uncommonly observe that the person when a small child had a difficult temperament.  They were unmalleable and very difficult to rear.  Temperament has genetic underpinnings.  The factors leading to homicide are a combination of nature and nurture or genes and environment.  By the age of three the child may be brought to a Child Psychiatrist because they are hyperactive and impulsive.  By the age of four they may very well have been in two or three preschool playgroups where they are unmanageable because of their poor attention and hyperactive impulsive behaviour.  At this stage they would meet the criteria for Attention Deficit Hyperactivity Disorder hyperactive type.  Unfortunately if they see professionals at this age their problems are likely to be attributed to parental management failures.  This is often absolutely untrue.  When they start primary school the same situation occurs in the classroom i.e. poor concentration, poor attention, forgetful, disruptive, hyperactive, impulsive.  Again the parents may be falsely blamed.

It is only a short time before an additional diagnosis is added in i.e. Oppositional Defiant Disorder.  This will cause the school and parents great problems, even more than the Attention Deficit Hyperactivity Disorder.  A few years later the diagnosis of Conduct Disorder will be added with significant disturbances of conduct including bullying, being cruel to people or animals, stealing, fire setting, staying out late at night without parental permission, etc..  Into adolescence indeed even early adolescence there will be the use of street drugs like cannabis and alcohol.  This drug and alcohol use will escalate during adolescence.  Suspension from school will not be uncommon and finally a pupil will be asked to leave school and will become a drop out. Then they are on the streets, which is probably the most dangerous place of any in Ireland where there is massive availability of drugs. Delinquent acts will then take place, which can escalate to assaults.  The drug and alcohol abuse will increase.  There will be linking up with peers of a similar persuasion and with similar problems and then grievous bodily harm or a homicide is waiting to happen.

For example on the night of the homicide it will not be uncommon for a group of these adolescents or young men to have taken a great deal of drugs and alcohol which make them even more impulsive and they will pounce on an innocent victim or possibly somebody who might have said something to them.  They will then go through the legal system, which will charge them with murder and give no credence to anything that has happened before.  Because persons with hyperactive impulsive behaviour are likely to have accidents it wouldn’t be rare as well that there might be some brain damage from previous accidents.  Over 18s receive a diagnosis of Antisocial Personality Disorder but their adult Attention Deficit Hyperactivity Disorder will be missed and therefore untreated.  What these children, adolescents, and adults need is early intervention and active treatment. Blaming parents so popular with right wing people.  This is completely unhelpful and only aggravates the situation.  Clearly this is not the only road to homicide as others will show evidence of psychosis, paranoid personality disorder, etc.. Clearly in Ireland the appalling abuse of alcohol in adolescents and young people is a major factor.  If the legal age for drinking was put up to 21 years it would help.  Unfortunately these very disturbed young men or adolescents would probably acquire it anyhow from some other source.  Nevertheless reducing availability could only help.

Early intervention is critical and it might be worth considering treating Attention Deficit Hyperactivity Disorder in those over age three with Dexamphetamine, which is licensed, in addition to behavioural interventions.  Oppositional and Defiant Disorder may need the addition of Clonidine or Risperidone which are both off label.  Anti-depressants will often need to be added in and these people in the course of their career will often show clear evidence of depression.  For adolescents and children who have difficulty remembering their medication there is an eight hour medication called Ritalin Long Acting is helpful. For those adolescents who have to study after school then Concerta XL which is 12 hours of duration once a day is helpful.  Finally for those adolescents and young men who need 24 hour treatment there is then Strattera the first non-stimulant treatment for Attention Deficit Hyperactivity Disorder which is available on a once daily medication. This is licensed in the U.K. and USA etc. and is available in Ireland at present on a named patient request.

Inappropriate focus on multidisciplinary teams means that there is wastage of professional time that could be used in seeing patients. This does not occur in adult psychiatry where the patient rather than the team is the major focus.

These very disturbed adolescents and young people described in this article need very energetic complex and multiple psychopharmacological intervention as well as multimodal other therapies including psychotherapy, family therapy, and behaviour therapy.  Schools also need small classes to deal with these very disturbed children and adolescents.  Ejecting them from schools something which is so common is the straw that ‘breaks the camel’s back’ and putting them on the streets massively increase their risks. Because of the disturbance in school they will not uncommonly need full time Special Needs Assistants and because they often have comorbid difficulties for example specific learning difficulties they will also need extra resource teaching.  What they don’t need is criticism or blame and their parents don’t need criticism or blame, which is so often available from a whole variety of professionals. Particularly those with right wing leanings.  The most negative factor that they can have in their career trajectory is endless criticism and blame.  This is an unnecessary and tragic environmental factor.  Children with ADHD should have equal rights to education and psychiatric treatment as all other children in the state.  Untreated the outcome may be tragic for themselves (e.g. completed suicide because of the impulsivity of ADHD) or fatal for other citizens because of homicide or death themselves in car accidents.  Adult ADHD is associated with high accident rates.

Attention Deficit Hyperactivity Disorder has highly significant genetic associations and occurs in 4.4% of the adult population. It is the most commonly missed adult psychiatric disorder in Ireland, the majority of persons with it not being diagnosed. Hopefully the Irish College of Psychiatrists / Irish Psychiatric Association will take up the matter soon. The Royal Academy of Medicine in Ireland is organising meetings on Attention Deficit Hyperactivity Disorder next year.

Adult Attention Deficit Hyperactivity Disorder is characterised by poor concentration, shifting of activities frequently, day dreaming, being easily distracted, problems organising time, poor attention to detail, difficulty listening, is impatient, acts without thinking, talks out of turn, has impulsive urges, has temper tantrums, has a restless feeling, has motor hyperactivity, has difficulty remaining seated during meetings, and difficulty working quietly.

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