by admin | Feb 24, 2014 | Homoside
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.
by admin | Feb 24, 2014 | Aspergers, Autism
While most people with Asperger’s syndrome (who have higher functioning autism) are highly moral, highly ethical, a small minority get in trouble with the law. This is probably slightly more common in those with Mild Learning Disability and Autism. Persons with autism may get into difficulties with the law according to Denis Debbaudt an American expert on this issue because of:
(1) Dangerous wandering.
(2) May not respond to commands or instructions.
(3) Lack of eye contact, may be misinterpreted as a sign of guilt.
(4) May not recognise police uniforms, badges or vehicles.
(5) Have a poor reaction to change in routine.
(6) May reach for shiny objects.
(7) May invade personal space of responder.
(8) Inappropriate social responses.
(9) Inappropriate laughing or giggling.
(10) False confession or misleading statements during questioning.
(11) Associated medical conditions like epilepsy.
(12) Behaviour misunderstood by others resulting in calls for assistance.
(13) A high pain tolerance.
(14) Atypical responses during emergencies.
It is critical that professionals for example the police and staff working in forensic settings are aware of these features. Persons with autism are also easily led by others and as already stated misunderstand social cues. Their obsessional thinking may have an aggressive theme. In one inpatient setting for Learning Disabled Offenders in the U.K. 12% had autism. There is insufficient training within forensic services on autism in most parts of the world. Hopefully the Irish College of Psychiatrists, the Irish Psychiatric Association, and police authorities will deal with this matter in full. Police, parents and other professionals need to be able to identify the possibility that a person that they are interacting with may have autism or Asperger’s syndrome so that police and other contacts are less stressful for the person with autism or Asperger’s syndrome. In the U.S. research indicates that persons with developmental disabilities are approximately 7 times more likely to come into contact with law enforcement than others. There is only a small likelihood that in the first instance the autism will be recognised either by the police or other professionals involved.
Persons with autism also can get involved in stalking and one of the reasons that persons with Autism Spectrum Disorders are predisposed to stalking according to Tom Berney a U.K. Psychiatrist is that they have impaired perception of social signals, misinterpretation of rules, misinterpretation of relationships, lack of awareness or concern for the outcome, and a focussed obsessive interest. While this occurs it is not common.
Digby Tantum states that sexually motivated crimes are also unusual and when they occur may be a consequence of a lack of understanding on the part of the person with Asperger’s syndrome. Persons with Asperger’s syndrome may be aggressive and commit offences against other people, but it is unclear how frequently and what proportion of people with Asperger’s syndrome are at risk of doing so. Many people with Asperger’s syndrome have a hypertrophied sense of right and wrong and are unusually conscientious and unwilling to break the law. The Asperger’s syndrome are more likely to be victims than perpetrators. Nevertheless even though it is uncommon persistent violence by a person with Asperger’s syndrome is a particularly difficult problem. Men with Asperger’s syndrome are over represented in a survey of one U.K. Secure Hospital. Violence by a person with Asperger’s syndrome often has some special features. It may be triggered by idiosyncratic stimuli nourished by rumination over past slights; displaced from provoking the person onto a safer target at a later date; and uninhibited by empathic response to the intended victims fear. Sometimes the explanation for violence may be similar to that given by Raskolnikov in Dosteyevsky’s Crime and Punishment: that is it is of an experimental nature. It is often a wish to experience a sense of mastery and control over another person. They may also do it to test their predictions about how others would behave in such extreme circumstances.
It is worth noting that Asperger’s syndrome can occur in people of talent like Casal, Kierkegaard, E. Hopper, A. J. P. Taylor, Goethe, van der Post, Columbus, O. Wells, and ‘H. G.’.
by admin | Feb 24, 2014 | ADHD
Kurt Cobain was wrong – the treatment of Attention Deficit Hyperactivity Disorder with Methylphenidate does not predispose to substance misuse indeed precisely the opposite is true. 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 with 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.
Kurt Cobain had Attention Deficit Hyperactivity Disorder, and was prescribed Methylphenidate when he was at school. Unfortunately he only took it for three months. The impression was given later that this was a factor in his developing substance abuse. Indeed precisely the opposite is the truth. Persons who are treated for Attention Deficit Hyperactivity Disorder on a continuous basis with Methylphenidate are less likely to abuse substances as they get older. The abuse of drugs like cannabis or cocaine is often a feature of self-medication for Attention Deficit Hyperactivity Disorder. The increased use of cigarettes by persons with Attention Deficit Hyperactivity Disorder may also be done for the same reason. There is no doubt that persons with Attention Deficit Hyperactivity Disorder have an earlier onset of cigarette smoking and a greater use of it. There is no evidence for long term risks for substance use disorders in persons prescribed Methylphenidate. Indeed there is a reduced likelihood of substance misuse if Attention Deficit Hyperactivity Disorder is properly treated with stimulants. This doesn’t mean that there aren’t some risks from stimulants i.e. through diversion. A new medication for Attention Deficit Hyperactivity Disorder Atomoxetine has been shown to have no greater abuse liability than Desipramine an antidepressant or placebo. Unfortunately Attention Deficit Hyperactivity Disorder is a serious condition which requires early intervention and the misinformation about it is preventing some children from getting the treatment that they need.
Children with Attention Deficit Hyperactivity Disorder are at risk of increasing complications as they get older. They start in childhood with Attention Deficit Hyperactivity Disorder alone and then can develop disruptive behaviour disorders, oppositional disorders, challenging behaviour, and later from about 14 years onwards they experience often school exclusion, substance abuse, mood disorder, conduct disorder, and finally antisocial personality disorder and often get involved with the law at the same time. Of course this trajectory only occurs in those with severe Attention Deficit Hyperactivity Disorder and severe complications. Comorbid Oppositional Defiant Disorder occurs in over 40%, Conduct Disorder in 20 to 56%, delinquent and antisocial activities in 18 to 30%. Many continue their problems into adulthood and they are more likely to enter the workforce at unskilled or semi skilled level. They are twice as likely to be dismissed from their employment, tend to have many more jobs than the average, and to show much lower work performance than the average.
In examining motor vehicle driving risks persons with Adult Attention Deficit Hyperactivity Disorder are 60% more likely to have a crash with injuries as compared to 17% of the general population. As well as having much more accidents they tend to have worse accidents. They have four times higher risk of having sexually transmitted diseases because of their earlier onset of sexual activity and their increased number of sexual partners. In addition they are less likely to employ contraception and spend less time with each partner than the average population. Girls with Attention Deficit Hyperactivity Disorder are over 9 times more likely to have a teen pregnancy than those without Attention Deficit Hyperactivity Disorder. The judicial costs of having Attention Deficit Hyperactivity Disorder are vastly increased as compared to people without Attention Deficit Hyperactivity Disorder. In America it has been estimated that the total criminal costs for persons with Attention Deficit Hyperactivity Disorder and Conduct Disorder combined are 37,830 dollars.
Unfortunately Adult Attention Deficit Hyperactivity Disorder is largely missed as a diagnosis. It appears to me that the next most missed diagnosis in adults is Asperger’s syndrome which nowadays tends to misdiagnosed as Mild Bipolar disorder. It tended in the past (and this still occurs in the present) to be misdiagnosed as Personality disorder or Schizophrenia. This meant they didn’t get the treatment they needed and got inappropriate treatment. A typical example is the novelist who was nominated for a Nobel Prize Janet Frame who was diagnosed with Schizophrenia outside Europe. She was put on a list for lobotomy in 1952. She was told by the Maudsley Hospital later that she did not have Schizophrenia. She died in 2004. In actual fact she had Asperger’s syndrome. There may be thousands in a similar situation throughout the world with misdiagnosis of psychiatric disorder. Hopefully the Irish College of Psychiatrists, Irish Psychiatric Association and those responsible for C.M.E. will take up this issue.
Going back to Kurt Cobain he would have a much greater chance of having survived if he persisted taking his Methylphenidate on a regular basis and had intensive multimodal treatment for his Attention Deficit Hyperactivity Disorder and associated problems. He showed the majority of comorbidities that one can get with Attention Deficit Hyperactivity Disorder. It was not surprising that he completed suicide.
by admin | Feb 24, 2014 | ADHD
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.
by admin | Feb 24, 2014 | ADHD
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
