Road Traffic Accidents and Adolescent / Adult Attention Deficit Hyperactivity Disorder.

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Automobile crashes are one of the leading causes of deaths in adolescents.  Accidents are three to four times more frequent in persons with Attention Deficit Hyperactivity Disorder.  The Attention Deficit Hyperactivity Disorder driver is three to four times more likely to be at fault.  The Attention Deficit Hyperactivity Disorder driver is six to eight times more likely to loose their license.  The treatment of Attention Deficit Hyperactivity Disorder with stimulants improves the performance of the driver.  There is a serious lack of attention being given to the impact of Attention Deficit Hyperactivity Disorder on driver’s performance in relation to accidents in Ireland.  Unfortunately adult Attention Deficit Hyperactivity Disorder is not uncommonly missed as a psychiatric diagnosis.

 

Adults with Attention Deficit Hyperactivity Disorder have difficulties tending to tasks and activities and inhibiting their impulses. They have a poor ability to sustain attention over long periods, and are unable to concentrate on short, focussed work. They act without thinking, often resulting in reckless and impetuous behaviour.  Indeed, impulsiveness may be an important defining characteristic of Attention Deficit Hyperactivity Disorder in adulthood.  Although they do not necessarily present with the overactive behaviour frequently seen in children they feel restless.  As a result an individual may act without reflection or consideration for the consequences of action.  They may be disorganised, forgetful, and have planning deficits and poor time management skills.  Impetuous novelty-seeking behaviour may result in criminal acts, substance misuse and dependence according to Susan Young a psychologist who focuses on adult Attention Deficit Hyperactivity Disorder.  About 4.4% of adults in the community have adult Attention Deficit Hyperactivity Disorder.  Unfortunately there is an error in DSM-IV diagnosis for Attention Deficit Hyperactivity Disorder. Particularly with adults the age seven cut off is unsatisfactory and it is likely in future that onset in primary school or before the age of 12 will be accepted rather than onset before the age of seven.  In making the diagnosis multiple informants are very helpful or information from parents of a person with adult Attention Deficit Hyperactivity Disorder or school records to improve diagnosis.  It is more common in males than females.  Clearly there is a great deal of comorbidity particularly in the area of Antisocial Personality Disorder, substance misuse, and depression.  They have often poor occupational histories and considerable breakdown in the long term in interpersonal relationships, marriages etc. They often feel socially isolated and misunderstood.  This is unfortunate since there is relatively good treatment available.  Nevertheless they can be successful particularly in the artistic areas.  John Osbourne, Clark Gable, Jesse James, George Carman, and Kenneth Tynan had adult Attention Deficit Hyperactivity Disorder.  Doctors can also have adult Attention Deficit Hyperactivity Disorder and the following questions are often worth considering:

 

(1)       Do you have difficulty concentrating or focussing your attention on one thing?

 

(2)       Do you often start multiple projects at the same time, but rarely finish them?

 

(3)       Do you have trouble with organisation?

 

(4)       Do you procrastinate on projects that take a lot of attention to detail?

 

(5)       Do you have problems remembering appointments or obligations?

 

(6)       Do you have trouble staying seated during meetings or other activities?

 

(7)       Are you restless or fidgety?

 

(8)       Do you often loose or misplace things?

 

In terms of driving behaviour Methylphenidate (Ritalin / Ritalin LA) significantly reduces inattentive driving errors.  It would appear that for those driving in the early evening including during the day Concerta XL (Methylphenidate) which lasts for 12 hours would be more relevant.  This is also a form of slow release Methylphenidate and is off label in Ireland for adults.  Of course accidents do occur in the evening and so good attention is particularly required at this time.  There is also a new medication the first non-stimulant medication available in Ireland for Attention Deficit Hyperactivity Disorder on a named patient basis called Atomoxetine (Strattera) which is active over the 24 hours. This has slow onset and has to be taken seven days a week. This would seem to have a place when you are particularly focussing on wanting to have a person on continuous treatment as it does not wear off.  It would particularly appear to be important for late evening / night, the time of maximum danger for accidents.  Adolescents with Attention Deficit Hyperactivity Disorder also benefit from cognitive / behavioural therapy which focuses on the inhibition of impulses, time management, organisational skills, problem solving skills, anger management, decision-making skills, social skills training, and improved social perception.  Persons with Attention Deficit Hyperactivity Disorder need to be educated about it.  Once the diagnosis is given to them it can suddenly make sense of their lives and sometimes of the chaos of their lives.  It is difficult to get a chaotic life into order if one doesn’t understand what the problem is.  Genetic factors play a major role in Attention Deficit Hyperactivity Disorder.  The problem of adult Attention Deficit Hyperactivity Disorder and accidents is a matter that should be taken up by professional psychiatric bodies and by consultants in Accident and Emergency Departments who are often on the receiving end of problems with Attention Deficit Hyperactivity Disorder.  Organisations involved in road safety should also examine this issue.

Book Review: Straight talk about Attention Deficit Hyperactivity Disorder

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by William K. Wilkinson. Published by the Collins Press: Cork, 2003

This book is essential reading for parents, children, and adolescents with Attention Deficit Hyperactivity Disorder and for General Practitioners, Paediatricians, Child Psychiatrists, and Doctors working in Community Services.  It is comprehensive, and very practical and answers most of the questions that parents and professionals ask about Attention Deficit Hyperactivity Disorder. In addition it has a useful Appendix of Organisational Contacts for parents and also a useful reading list for parents and professionals.  It discusses in detail the diagnosis of Attention Deficit Hyperactivity Disorder as well as the causes of Attention Deficit Hyperactivity Disorder.  It gives proper weight to biological and genetic factors. It also tackles the issue of ‘blaming’ the parents for the disorder.

In my experience the tragedy of Child Psychiatry / Child Psychology in the 1970s in Ireland, 1980s and indeed early 1990s was the tendency to see children’s problems with Attention Deficit Hyperactivity Disorder as being due to inadequate parenting.  This had a devastating and negative effect on parents.  The therapists of a family or psychodynamic orientation particularly took the view that the child’s problems were caused by the family dynamics.  Indeed this false view of Attention Deficit Hyperactivity Disorder still occurs. Wilkinson provides an accurate and balanced view of this complex topic.  Wilkinson gives a superb and detailed understanding of the Clinical and Educational Psychologist Assessment of persons with Attention Deficit Hyperactivity Disorder.  He answers in detail the kind of questions parents asked about what Psychologists do.

One minor quibble is that there is no index and in the next edition of this most valuable book I hope that he will add in a Chapter on Adult Attention Deficit Hyperactivity Disorder

Vincent van Gogh Mood disorder and Asperger’s syndrome.

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The evidence for Vincent van Gogh’s mood disorder has been extremely well documented.  This article suggests that in addition he had a dual diagnosis that is Asperger’s disorder as well.  He had an unhappy early life and had behaviour problems in childhood. His father was described as being as cold as iron by A. J. Lubin.  Even as a child he was a strange person and could not cope with normal school. He showed evidence of severe social impairment. In a way he was like an alien on earth. He had a wish for good social interactions but was unable to achieve them.  He was very much a loner. He was also an outsider.  He alienated people.  This was not deliberate but he did not know how to win them over. He was regarded as an eccentric.  He was a workaholic and narrowly focussed on his art. He read books incessantly. He had significant non-verbal behaviour problems.

According to Lubin he often dressed in rags.  He had strange dietary habits.  He was not a fluent speaker.  His suicide was likely to be due to his mood disorder and his Asperger’s syndrome.  Suicide is not rare in these two conditions.  Alternative explanations of his problems have been presented like Meniere’s disease and acute intermittent porphyria but these are not likely as explanations. One of the difficulties in psychiatry is that once a diagnosis is made for example Mood Disorder additional diagnosis like Asperger’s syndrome are then not considered. Mood problems are common in patients with Asperger’s syndrome.

Andy Warhol and Konrad Lorenz: Two Persons with Asperger’s Syndrome

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Andy Warhol and Konrad Lorenz are two persons with Asperger’s syndrome.  The diagnosis of Asperger’s syndrome is important in Adult Psychiatry because it can be confused with schizophrenia.  Asperger’s syndrome cannot be scientifically and clearly differentiated from High Functioning Autism and the diagnosis are used interchangeably. Similarities between the two conditions include difficulties in interpersonal relationships, problems in non-verbal communication, narrow repetitive routines and interests.  In Asperger’s syndrome there is no clinically significant general delay in language according to DSM-IV although this criterion is now highly controversial as language difficulties of one sort or another are often seen particularly of the semantic pragmatic variety.  It has also been suggested that the persons with Asperger’s syndrome have a later onset of problems and are diagnosed at a later stage and can show in a minority of persons significant antisocial behaviour.  Indeed for the majority of persons with Asperger’s syndrome very high moral behaviour is a characteristic.  Whatever about the similarities or differences between High Functioning Autism (and there are more similarities) or Asperger’s syndrome the diagnosis of Autism Spectrum Disorder is currently the most accurate diagnosis.

 

Andy Warhol is a classic person with Asperger’s syndrome. Andy Warhol was born in 1928 and died in 1987.  He was one of the most famous artists of the 20th century and his most famous saying was ‘In the future, everyone will be famous for 15 minutes’. He had an eccentric father which is not uncommon in this situation and was bullied at school which is also very common in this situation.  His mother was even more eccentric than his father.  His mother would make statements like ‘I am Andy Warhol’. His art could be extremely repetitive something that’s typical in persons with Asperger’s syndrome.  An example here is the Campbell soup can.  He particularly liked screenpainting which provided him with a quick and easy way of indulging his penchant for repetition.  He had enormous deficits in interpersonal skills and was to a large extent socially incompetent.  Like many people with Asperger’s syndrome he did want to make close relationships but lacked ‘know-how’.  He stalked Truman Capote.  He experienced himself as an alien like Temple Grandin another famous person with this condition.  He clearly had a very narrow obsessive interest in art.  He was a workaholic.  He was an obsessive collector and a great deal of what he bought he never took out of the wrapping paper.  He was a singular person.  He had an autistic mechanical mind.  He loved machines of all sorts.  He had the typical high-pitched tone of voice persons with Asperger’s syndrome have. He had an immature personality. He was very naïve. He had the classic motor clumsiness of Asperger’s syndrome and suffered a great deal from anxiety.  His fear of hospitals meant that he delayed going to hospital when he developed acute abdomen and he died soon after the operation.

 

The late Konrad Lorenz the animal behaviour researcher was born in 1903.  Asperger’s syndrome helps to explain some of his actions in his life.  He was addicted to animals and the study of animal behaviour. He is famous for his research on imprinting.  An interest in nature is particularly not uncommon in persons with Asperger’s syndrome. He was very lucky to have a supportive wife as he had what is now called an ‘Asperger type’ marriage where the wife supports, contains, and grounds the person with Asperger’s syndrome.  Lorenz tended to speak in monologues.  He was an autodictat.  He showed evidence of significant interpersonal difficulties and lack of empathy for people.  This didn’t stop him being a great ethnologist.  He also suffered from mood swings.  Control was very important to him.  He was both a collector and very much in scientific terms a systematizer.  His first fascination was with the Jackdaw and later he became fascinated with fish and with ducks.  While he served in the German army during the 2nd World War and was accused of being a Nazi but I don’t think that he was a Nazi. It was his Asperger’s syndrome and naivety that made him write about degeneracy in men of other races.  Leon Eisenberg accused him of his writing been ‘redolent of concentration camps’.  He was not a racist but he was extremely naïve.  Konrad Lorenz in reply to Leon Eisenberg’s criticism stated “the 1940 paper tried to tell the Nazi’s that domestication was much more dangerous than any alleged mixture of races”.  During the war Lorenz worked as a neurologist in a psychiatric unit.  Later in life Konrad Lorenz was equally naïve in accepting the Schiller Prize from a neo-Nazi group.  Konrad Lorenz was politically naïve about the implication of these matters and was not a Nazi.  He was a person with Asperger’s syndrome.