A taste of fish puts failing pupils on top
Parent: " I always worry when I go to pick up John from School; it seems that every day some problem has arisen. 1 feel people think that I'm just a bad parent ":
Parent: " Ben is so unpredictable; one minute he will be in a good mood, and the next he will be shouting at everyone. When we have other children around, he always goes over the top, acts very silly and bosses them around. He gets aggressive when they don't want to play with him. He can't see why"
Sibling: " I just feel so frustrated, it's always him, him, him. I can't ever finish talking to Mum about anything. He's always interrupting, being told off and having temper tantrums. Whatever we do together as a family he always spoils it. I sometimes feel that I don't exist ":
Neighbour: " I don’t understand why they can’t control her. I’ve complained so often...nothings done....give her to me for a month, i'd soon have her sorted out."etc. etc. I’d soon have her sorted out.
Despite persistent problems throughout his life, Tom was not diagnosed as suffering from Attention Deficit Hyperactivity Disorder until he was 24 years old. In a moving account of the impact on both her son and his family, Tom's mother Anne Douglas recalls the struggle to cope as-.Tom was growing up
For so many years, the torment and chaos of undiagnosed and untreated Attention Deficit Hyperactivity Disorder (ADHD) wreaked havoc on my son Tom's childhood and family life in general. As a baby and preschooler, Tom's severe hyperactivity, impulsive behaviour, distractibility and poor concentration meant that he raced through the surface of life like a runaway train, scattering people and objects as he went New toys, new people and new situations never satisfied him. Everything was a battle. Nothing captured his attention for long and he was relentlessly into everything.
Tom never learned from his mistakes, had no sense of danger, and bumps and bruises were the norm. The day always began from the moment he was awake with his exhausting and insatiable demands. No one was prepared to babysit because he was so exhausting and a liability. It was impossible to enjoy him and no fun to take him anywhere. His energy levels were incredible. As parents, we wondered where we were going wrong. The health visitor-said: 'He's not You really must be firmer with him and not let him get away with so much. Try giving him a soothing bath at midnight if he's active all the evening.' Tom's playgroup said: 'He's a real live wire and obviously only here for the social side of things. He is very active, doesn't concentrate, plays noisily and chats all the time.' Family friends said: 'Boys are like that He's just a handful. He'll grow out of it. 1'm sure if you were less stressed and firmer with him, he would settle down.' Our GP said: 'He's just hyperactive. He'll outgrow it by puberty. I'll arrange counseling for you, if you like.'
He's Just hyperactive'
I particularly remember a lengthy wait at my doctor's surgery, when my then 18 month old son raced incessantly around the waiting room, oblivious to my desperate attempts to keep him calm and occupied. l mentioned that he was a very active, difficult and defiant child, faintly hoping for some understanding and support. However, the doctor's casual remark that Tom was 'just hyperactive' failed to appreciate the significance of this extreme behaviour. The doctor offered no further suggestion, and I came away feeling further demoralised. Life continued to become more and more stressful. Increasingly, Tom seemed to be impervious to any form of discipline. He did not learn from his mistakes, was possessive and over competitive, was unable to share, was volatile and quarreled with friends. His only love was sport but even that always ended in rage or tantrums when things did not go right. When Tom did find something which interested him, he would become over-focused, intense and insist on a game being played endlessly. Co-operation was just not possible as, with him, it was all or nothing.
The arrival of his brother a few years later, who appeared to develop and behave more appropriately, increased our growing sense of worry about Tom's behaviour. By this time, it was also apparent that our 'whirlwind' was standing out as different from his peer group. His demanding and difficult to satisfy personality continued to make both his and our friendships and relationships fraught. Indeed, 1 became more and more isolated and lonely, wondering where I was going wrong and in need of support and some respite with never a let-up, or a moment of peace and quiet. I felt deprived of adult company and imprisoned by my unrewarding and exhausting daily existence. However, it was obvious that my participation in toddler dubs, coffee mornings etc., would mean constant supervision of Tom to prevent him hurling toys at, or disrupting, other children. Conversation would be impossible. Indeed, even attempts at telephone conversations at home were fraught with trauma as Tom repeatedly interrupted even the briefest call.
I desperately read all the child development and parenting books 1 could get my hands on to try and find better ways of managing and loving Torn, but our relationship was becoming very stressed as he constantly confronted and defied and was resistant to any attempts to improve the situation, no matter how hard one tried. Although I always seized any opportunity to praise Tom for 'good' behaviour or endeavours, these rarely occurred and could never be built on when they did.
Each every day task was an uphill struggle. Family mealtimes became an endurance exercise, as Tom strenuously resisted certain foods, regularly causing friction with his continuous verbal and physical defiance and non-conformity, always hypersensitive to the conversation, noises, actions or movements of others. He would only use a specific mug, cup, plate or spoon, and became quite hysterical if he could not do this. Tom would only sit on a particular chair and threw enormous tantrums if this was not possible. He was unable to concentrate on watching television unless things such as ornaments which were on the periphery of his vision were removed.
At school Tom was sociable, but gave up easily when things were difficult From an early age, it was felt he had the potential to do better and was just lazy, disorganised, forgetful and easily distracted. He was always easily upset and angry, but there were never tears - only tantrums. His reaction to events and situations at home and school was increasingly hypersensitive. Life was like walking on eggshells. I was encouraged to believe that Tom would gradually grow out of the behaviour and conform as he matured and settled down. While our friends were able to relax and enjoy weekends and family holidays, for us such events were becoming a regular nightmare. Having endlessly exhausted all the activity options at home, the only way to survive weekends was to arrange regular stimulating outings to save our sanity. Needless to say, these were marked by tantrums and insatiable demands with little enjoyment for anybody.
As Tom burnt off some of his hyperactivity, we were left feeling drained and trapped in a vicious circle. No matter what sort of outings and holidays might have been appropriate for his brother or us, it was essential to seek something that would primarily provide entertainment for Tom. Every holiday had memories of confrontations and the inability to relax as we tried to find a happy medium and address the needs of everyone. No one could really understand why we seemed to return from holidays as stressed as we were before we went, but there were so many places we just could not contemplate.
By the time Tom reached puberty, things were rapidly getting worse. Both at home and school, relationships were very strained. Life was one long round of arguments and tantrums from morning to night - only with more damaging effects. Tom also seemed to gain enjoyment from goading people, mostly dose family members. He never knew when to stop and was not satisfied until he had pushed someone to the limits. The harder one tried to ignore this, the more he would try to do it We were at our wit's end and desperate to know where to turn for help, yet feeling too ashamed to expose our apparent inability to bring up our child appropriately. Every parents' evening told stories of poor compliance, shoddy and incomplete work, class clowning, no homework, incessant talking and easy distraction both to himself and others. At this time, a tutor told me he felt Tom was 'different' from his peers. When I said I felt Tom did not seem to understand cause and effect, the teacher's rather patronising response was that 'at 13 years of age, of course he does!'. No amount of encouragement incentive, praise or reward made any difference. Tom would say, 'I don't want a reward, because I won't do it anyway'.
Increasingly, we realised Tom had little perception of how his verbally and physically impulsive behaviour affected others. He was extremely volatile and easily roused to anger when things did not go his way. And when things blew over, he failed to appreciate the effect' his reactions had had on those around him. It proved fruitless trying to rationalise or reason with him, as he had a tendency to see everything in black or white and must have the last word.
Tom's GCSE results were, of course, disappointing, but it was with mutual relief that he managed to achieve a few pass grades on a second attempt and go on to further education. However, the lack of structure, and demands on him for deadlines for assignments, further reading and research, meant that Tom struggled to maintain effort or interest. It became hard to believe that Tom's actions were not deliberately intended to annoy. Varying degrees of reward and punishment failed to motivate Tom to improve his ways. Far from having the desired effect, he often seemed to view punishment as a challenge to beat. Teachers dearly looked to us, as his parents, to improve the situation and obviously inherently questioned our discipline. When he came out of the restrictions of a school day, Tom would unleash all his frustrations and pent up energy at home.
Although finally scraping a further qualification, studying had dearly been a burden and held no interest for him. From infancy, Tom was constantly in trouble for being unable to learn from his mistakes and his confrontational attitude strained all his relationships. He tirelessly sought constant stimulation to avert endless boredom, and he could not concentrate long enough to hold conversations unless he was specifically interested. His childhood was marked by mutual frustration, anger and constant arguments, and thus he was never able to achieve to his potential at school or in further education. No amount of behaviour modification had any effect. His brother - who was brought up in the same way - had no such problems.
Late diagnosis
The very nature of Tom's condition prevented his accepting help. His life, and that of his family, continued to deteriorate. K was only with his entry into the working environment, and the realisation that he was being left behind as his brother and friends entered new and appropriate phases in their lives, that Tom was forced to acknowledge his problems and became motivated to take some action. He was finally diagnosed, at the age of 24, as having severe ADHD, which, untreated, had been compounded over the years by complications. He commenced an overdue treatment plan, which included the use of Ritalin.
Since then, the change in Tom's demeanour has been remarkable. He confided in me that he used to think he was a freak and now feels that he has so much to catch up on, to make up for lost time. The effective treatment has enabled him to concentrate, be reflective and participate in his life, instead of it taking control of him. This has given Tom a confidence in himself for the first time and he is keen to get on with his life. He realises how his untreated condition caused his academic underachievement as he could not meet deadlines, sustain the effort involved to study or concentrate long enough to read beyond the first line of a book.
Tom is now experiencing a real quality of life. Instead of criticism, accusation and rejection, he enjoys praise and a subsequent increase in his self esteem and confidence. He previously shied away from trying anything new for fear of failing once again. He can now enjoy conversations and has become confident enough to drive a car again for the first time since passing his test three years ago. However, he naturally feels a sense of bitterness at realising how much of his life was lost to him until now. Tom is motivated to continue with the treatment because he recognises that it is effective and that he is beginning to build on his successes and can now plan goals and a future for himself. There is no doubt he dearly needs his medication to be able to lead his life appropriately and fulfill his obvious potential, previously hidden underneath the chaos of untreated ADHD.
GP bias
However, Tom's courage in finally confronting his significant problems and complying with specialist-advised treatment and the breakthrough it offered - was very nearly sabotaged by the negative attitude of his GP. Rather than encourage Tom's efforts at improving the quality of his life, the GP allowed his own lack of knowledge of the condition and personal bias to undermine my son's participation in treatment at such a vital stage in the process. The GP refused to prescribe the necessary medication or to support Tom in any way - dearly unaware of the real handicap of ADHD and the aim and necessity of treatment. This was despite dear documentation of the many years of Tom's suffering and the obvious benefits achieved by medical treatment over several months, which now enable my son to undertake everyday actions that the rest of us take for granted.
It was only by continued parental encouragement that he eventually persisted with treatment. Tom still only has a temporary job although he is eager to prove himself capable of securing a permanent one. Let down by his GP, he was forced to pay privately for his prescriptions - taking a large proportion of a frugal salary. Unless he has the medication, he has little hope of being able to concentrate sufficiently to maintain the noticeable progress he has made in his job, nor of supporting himself in the future. Despite appeals to this effect, Tom's GP remained unmoved and unwilling to help him.
For almost 25 years, Tom's life has been utterly chaotic and distressing, both to himself and those who care about him. Those outside who were involved with him had little time for his erratic, volatile, immature and unreasonableS behaviour. Yet underneath it all, one sensed there was a lost soul desperately trying to feel normal. Effective treatment has unlocked a likeable and enthusiastic personality with great potential. Where once Tom had no future, at last he has the chance of being able to make the most of opportunities he has in life. His new-found determination has now enabled him, at last, to find another GP who appreciates the reality of ADHD, and who has an open-minded and understanding approach to Tom's needs. For Tom, and for his family, the relief is enormous.
It is vital that GPs, educationalists and other professionals are open-minded, become informed and acknowledge the existence and reality of ADHD, as well as their role in providing essential management and support. ADHD deserves to be taken seriously. Its effects need to be experienced to be believed. Sufferers are already serving a life sentence. Understanding and help is the key to their freedom:
Anne Douglas
Anne Douglas is
writing here under an assumed name to protect the identity of her son. Anyone
who would like to contact the author can write to her via The Editor; YoungMinds
Magazine, 102-108 Clerkenwell Road, London EC1 M 55A, and we will forward the
correspondence.
This article is based in part on material contained in chapters by Anne Douglas
in two new books - ADHD: Research, Practice and Opinion edited by Paul Cooper,
to be published in April by Whurr Publishers at E19.50 (tel: 0171-359 5979);
and Attention Deficit Hyperactivity Disorder Recognition, Reality and Resolution
by Dr G D Kewley, published by the LAC Press at £12.50 (plus f1.60 _ p&p)
in February (fax: 01403 260900)
A
taste of fish puts failing pupils on top
SEPTEMBER 28, 2003 - THE SUNDAY TIMES Jonathan Leake
A study of primary
school children has found that supplements of fish and plant oils could push
them from the bottom of class to the top in just two terms.
The study. which covered a dozen primary schools, concludes that giving youngsters
such "brain food" supplements causes dramatic improvements in reading
age and numeracy.
The authors claim the effects were so marked that some formerly disruptive pupils signed up for libary cards, while others developed a love of classical music. Overall, more than 40% are said to have improved their scores in intelligence tests. Submitted for possible publication in The Lancet, the medical journal, the study was based on the theory that modern diets lack some of the oils and fatty acids essential for the brain and nervous system. Dr Madeleine Portwood, a psychologist with Durham education authority who led the research, said the results were impressive. "A quarter of the 123 children given the supplements showed reading age improvements of between 18 months and 4.5 years. We had nine-year-olds go from a reading age of eight up to 13."
Head teachers across County Durham were asked to select youngsters who showed slight difficulties with learning, memory, concentration or behaviour. The children were given psychological and academic tests to measure their numeracy, literacy, memory, concentration, co-ordination and other factors. Half were then given the supplements and the rest a placebo for three months before being tested again. Many of the children on the supplements showed such improvements that the researchers decided to put them all on the supplements for a further three months. " We have to stress that not all the children benefited but there were clear improvements in more than 40%. That is highly significant for both schools and parents," said Portwood. Among the youngsters who showed startling improvements was Elliott Best, 9, whose academic performance and behaviour were all well below average for his age.
Andrew Westerman, head teacher at Timothy Hackwcn-th primary, where Elliott goes to school, said: "He had great problems writing anything down, his reading was poor and he couldn't concentrate. Within a few weeks of starting the trial all that had changed and he now describes his favourite lessons as writing stories and reading." This week Elliott will feature in the first programme of a new BBC series presented by Robert Winston called The Human Mind. Sheila Brown, Elliott's mother, said: "He got top grades in his Sats tests, developed a taste for classical music and wants me to take him to see the Moscow ballet."
The idea that psychological and intellectual abilities might be closely linked to diet is not new. However, the theory that a small group of fatty acid molecules might have a particularly powerful effect is recent and still controversial. One of its main architects was Dr David Horrobin, a British researcher, who discovered links between diets lacking such molecules and mental illnesses such as schizophrenia. Horrobin - who died recently - pointed out that three fatty acids, known as EPA, DHA and GLA, comprise up to 30% of brain and eye tissue. He suggested that early man would have evolved with a supply from freshly caught fish, shellfish, plants and other natural foods. Modern diets -especially if processed or long-life foods are heavily featured - are relatively deficient in all three acids. Portwood will post details of her work on a website (www. durhamtrial.org) tomorrow. "These children were slightly below par but essentially normal. It is possible some adults may also benefit," she said.
White fish, such as cod, haddock and plaice, also contain these fatty acids but at lower levelsThe Food Standards Agency recommends salmon, trout, and mackerel for people looking to increase their intake of fish oils. It warned recently, however, that some fish such as tuna and cod can contain high levels of mercury and dioxin, especially dangerous to pregnant women. The oils used in the study were extracted from sardines
What's
It Like To Have Add?
by Edward M. Hallowell, M.D.
Copyright (C) 1992
What is it like to have ADD? What is the feel of the syndrome? I have a short talk that I often give to groups as an introduction to the subjective experience of ADD and what it is like to live with it:
Attention Deficit Disorder. First of all I resent the term. As far as I'm concerned most people have Attention Surplus Disorder. I mean, life being what it is, who can pay attention to anything for very long? Is it really a sign of mental health to be able to balance your checkbook, sit still in your chair, and never speak out of turn? As far as I can see, many people who don't have ADD are charter members of the Congenitally Boring.
But anyway, be that as it may, there is this syndrome called ADD or ADHD, depending on what book you read. So what's it like to have ADD? Some people say the so-called syndrome doesn't even exist, but believe me, it does. Many metaphors come to mind to describe it. It's like driving in the rain with bad windshield wipers. Everything is smudged and blurred and you're speeding along, and it's reeeeally frustrating not being able to see very well. Or it's like listening to a radio station with a lot of static and you have to strain to hear what's going on. Or, it's like trying to build a house of cards in a dust storm. You have to build a structure to protect yourself from the wind before you can even start on the cards.
In other ways it's like being super-charged all the time. You get one idea and you have to act on it, and then, what do you know, but you've got another idea before you've finished up with the first one, and so you go for that one, but of course a third idea intercepts the second, and you just have to follow that one, and pretty soon people are calling you disorganized and impulsive and all sorts of impolite words that miss the point completely. Because you're trying really hard. It's just that you have all these invisible vectors pulling you this way and that which makes it really hard to stay on task.
Plus which, you're spilling over all the time. You're drumming your fingers, tapping your feet, humming a song, whistling, looking here, looking there, scratching, stretching, doodling, and people think you're not paying attention or that you're not interested, but all you're doing is spilling over so that you can pay attention. I can pay a lot better attention when I'm taking a walk or listening to music or even when I'm in a crowded, noisy room than when I'm still and surrounded by silence. God save me from the reading rooms. Have you ever been into the one in Widener Library? The only thing that saves it is that so many of the people who use it have ADD that there's a constant soothing bustle.
What is it like to have ADD? Buzzing. Being here and there and everywhere. Someone once said, "Time is the thing that keeps everything from happening all at once." Time parcels moments out into separate bits so that we can do one thing at a time. In ADD, this does not happen. In ADD, time collapses. Time becomes a black hole. To the person with ADD it feels as if everything is happening all at once. This creates a sense of inner turmoil or even panic. The individual loses perspective and the ability to prioritize. He or she is always on the go, trying to keep the world from caving in on top.
Museums. (Have you noticed how I skip around? That's part of the deal. I change channels a lot. And radio stations. Drives my wife nuts. "Can't we listen to just one song all the way through?") Anyway, museums. The way I go through a museum is the way some people go through Filene's basement. Some of this, some of that, oh, this one looks nice, but what about that rack over there? Gotta hurry, gotta run. It's not that I don't like art. I love art. But my way of loving it makes most people think I'm a real Philistine. On the other hand, sometimes I can sit and look at one painting for a long while. I'll get into the world of the painting and buzz around in there until I forget about everything else. In these moments I, like most people with ADD, can hyperfocus, which gives the lie to the notion that we can never pay attention. Sometimes we have turbocharged focusing abilities. It just depends upon the situation.
Lines. I'm almost incapable of waiting in lines. I just can't wait, you see. That's the hell of it. Impulse leads to action. I'm very short on what you might call the intermediate reflective step between impulse and action. That's why I, like so many people with ADD, lack tact. Tact is entirely dependent on the ability to consider one's words before uttering them. We ADD types don't do this so well. I remember in the fifth grade I noticed my math teacher's hair in a new style and blurted out, "Mr. Cook, is that a toupee you're wearing?" I got kicked out of class. I've since learned how to say these inappropriate things in such a way or at such a time that they can in fact be helpful. But it has taken time. That's the thing about ADD. It takes a lot of adapting to get on in life. But it certainly can be done, and be done very well.
As you might imagine, intimacy can be a problem if you've got to be constantly changing the subject, pacing, scratching and blurting out tactless remarks. My wife has learned not to take my tuning out personally, and she says that when I'm there, I'm really there. At first, when we met, she thought I was some kind of nut, as I would bolt out of restaurants at the end of meals or disappear to another planet during a conversation. Now she has grown accustomed to my sudden coming and goings.
Many of us with ADD crave high-stimulus situations. In my case, I love the racetrack. And I love the high-intensity crucible of doing psychotherapy. And I love having lots of people around. Obviously this tendency can get you into trouble, which is why ADD is high among criminals and self-destructive risk-takers. It is also high among so-called Type A personalities, as well as among manic-depressives, sociopaths and criminals, violent people, drug abusers, and alcoholics. But is is also high among creative and intuitive people in all fields, and among highly energetic, highly productive people.
Which is to say there is a positive side to all this. Usually the positive doesn't get mentioned when people speak about ADD because there is a natural tendency to focus on what goes wrong, or at least on what has to be somehow controlled. But often once the ADD has been diagnosed, and the child or the adult, with the help of teachers and parents or spouses, friends, and colleagues, has learned how to cope with it, an untapped realm of the brain swims into view. Suddenly the radio station is tuned in, the windshield is clear, the sand storm has died down. And the child or adult, who had been such a problem, such a nudge, such a general pain in the neck to himself and everybody else, that person starts doing things he'd never been able to do before. He surprises everyone around him, and he surprises himself. I use the male pronoun, but it could just as easily be she, as we are seeing more and more ADD among females as we are looking for it.
Often these people are highly imaginative and intuitive. They have a "feel" for things, a way of seeing right into the heart of matters while others have to reason their way along methodically. This is the person who can't explain how he thought of the solution, or where the idea for the story came from, or why suddenly he produced such a painting, or how he knew the short cut to the answer, but all he can say is he just knew it, he could feel it. This is the man or woman who makes million dollar deals in a catnap and pulls them off the next day. This is the child who, having been reprimanded for blurting something out, is then praised for having blurted out something brilliant. These are the people who learn and know and do and go by touch and feel.
These people can feel a lot. In places where most of us are blind, they can, if not see the light, at least feel the light, and they can produce answers apparently out of the dark. It is important for others to be sensitive to this "sixth sense" many ADD people have, and to nurture it. If the environment insists on rational, linear thinking and "good" behavior from these people all the time, then they may never develop their intuitive style to the point where they can use it profitably. It can be exasperating to listen to people talk. They can sound so vague or rambling. But if you take them seriously and grope along with them, often you will find they are on the brink of startling conclusions or surprising solutions.
What I am saying is that their cognitive style is qualitatively different from most people's, and what may seem impaired, with patience and encouragement may become gifted.
The thing to remember is that if the diagnosis can be made, then most of the bad stuff associated with ADD can be avoided or contained. The diagnosis can be liberating, particularly for people who have been stuck with labels like, "lazy", "stubborn", "willful", "disruptive", "impossible", "tyrannical", "a spaceshot", "brain damaged", "stupid", or just plain "bad". Making the diagnosis of ADD can take the case from the court of moral judgment to the clinic of neuropsychiatric treatment.
What is the treatment all about? Anything that turns down the noise. Just making the diagnosis helps turn down the noise of guilt and self-recrimination. Building certain kinds of structure into one's life can help a lot. Working in small spurts rather than long hauls. Breaking tasks down into smaller tasks. Making lists. Getting help where you need it, whether it's having a secretary, or an accountant, or an automatic bank teller, or a good filing system, or a home computer, getting help where you need it. Maybe applying external limits on your impulses. Or getting enough exercise to work off some of the noise inside. Finding support. Getting someone in your corner to coach you, to keep you on track. Medication can help a great deal too, but it is far from the whole solution. The good news is that treatment can really help.
Let me leave you by telling you that we need your help and understanding. We may make mess-piles wherever we go, but with your help, those mess-piles can be turned into realms of reason and art. So, if you know someone like me who's acting up and daydreaming and forgetting this or that and just not getting with the program, consider ADD before he starts believing all the bad things people are saying about him and it's too late.
The main point of the talk is that there is a more complex subjective experience to ADD than a list of symptoms can possibly impart. ADD is a way of life, and until recently it has been hidden, even from the view of those who have it. The human experience of ADD is more than just a collection of symptoms. It is a way of living. Before the syndrome is diagnosed that way of living may be filled with pain and misunderstanding. After the diagnosis is made, one often finds new possibilities and the chance for real change.
The adult syndrome of ADD, so long unrecognized, is now at last bursting upon the scene. Thankfully, millions of adults who have had to think of themselves as defective or unable to get their acts together, will instead be able to make the most of their considerable abilities. It is a hopeful time indeed.
Address Correspondences to:
Edward M. Hallowell, M.D.
328 Broadway
Cambridge, MA 02139
ADHD
for the Legal Profession
Dr GD Kewley and Mrs PA Latham
Attention-Deficit / Hyperactivity Disorder (ADHD) is a neuropsychiatric disorder relevant to the legal profession. It is due to brain dysfunction and can cause a number of potentially serious handicaps and is a major Public health problem. Some subgroups of people with ADHD are at increased risk of criminality, substance abuse, accidents, motor vehicle accidents, suicide, educational, behavioural and other psychiatric difficulties. It has a very significant financial cost to society. As awareness of the facts and reality of the condition rapidly develops, legal practitioners are increasingly being confronted with its implications.
The probable basis of ADHD is difficulty with rule governed behaviour and lack of behavioural inhibition. Those with associated early onset Conduct Disorder (CD), are at much greater risk of persistent criminal activity and substance abuse. Studies suggest that a significant number - possibly 30 per cent of those convicted of serious and recurrent offences - may have untreated ADHD and Conduct Disorder. Such people may therefore comprise a significant percentage of the total prison population, particularly in young offender institutions.
ADHD is:
• Internationally recognized
• Variable in presentation
• Biological, and genetic
• More common than generally realized
• Predisposes those with the disorder to educational, psychiatric and
social problems.
Identification
ADHD is a common but complex medical condition, affecting children and adults, characterized by excessive inattentiveness, impulsiveness, and/or hyperactivity' that significantly interferes with everyday life, and for which there is no other reason. The condition manifests itself in many ways - some children may he only inattentive, others may ~he persistently hyperactive, for some, hyperactivity may lessen with persistently hyperactive, The wide range of possible presentations can be confusing. There are also Many complications that may mask or overshadow the underlying core symptoms and worsen with time.
Research shows that ADHD is a genetic, inherited condition that can he effectively managed. Evidence of brain dysfunction has been found in cerebral imaging studies.! If untreated the disorder can significantly interfere with educational and social development and predispose to psychiatric and other difficulties.
Psychoanalytical approaches support a societal belief that poor parental discipline causes most children's behaviour problems. Such approaches generally ignore a biological basis to difficulties in self control, concentration, and hyperactivity that is present in some individuals. Widespread ignorance exists about attention deficit hyperactivity disorder and the need for, and aim of, medication as a component of treatment.-, Trite and simplistic explanations for the symptoms of the disorder are perpetuated which encourage the view that merely naughty children are being diagnosed to absolve parental responsibility.
British child-care professionals have traditionally used the more restrictive World Health Organization' International Classification of Diseases (ICD 10) term "hyperkinesis", which means severe, persistent hyperactivity. Many people wrongly believe that Attention Deficit Hyperactivity Disorder is the less severe form of hyperkinesis. In fact, hyperactivity is just one possible feature of the disorder and often the least of the child's problems'.
Core ADHD
Symptoms
• Inattentiveness
• and/or impulsiveness
• and/or hyperactivity
CommonSymptom
Patterns
• Hyperactivity only
• Impulsive/diminished hyperactivity
• Predominantly inattentive ADHD
• ADHD core symptoms masked by comorbidity
Complications
ADHD is very variable in its presentation. It is important to understand that ADHD is often found together with a number of other conditions, the symptoms of which often overlap.11 If a child has ADHD he or she is more likely to have other co-existing or complicating conditions, such as excessive oppositionality and conduct disorder, anxiety and depression, learning difficulties, obsessions, co-ordination and speech and language difficulties. At least 60-70 per cent of those diagnosed with ADHD also have one or more co-existing conditions, and the later the diagnosis, the more likely these are to occur. Many children, who have been suspended or expelled, or are in schools for children with emotional and behavioural difficulties, have ADHD with many co-existing problems.
These conditions frequently mask or camouflage the underlying ADHD and can make recognition and accurate diagnosis more difficult. There has been increasing acknowledgement of the concept of co morbidity - or co-existence of conditions and its treatment - over the past 7-10 years.
Common Co-existing
Conditions and Complications of Attention Deficit Hyperactivity Disorder
• Oppositional defiant disorder (ODD)
• Conduct Disorder • Depression
• Anxiety and obsessions
• Specific learning difficulties
• Speech and language disorder
• Bipolar disorder
• Co-ordination difficulties
• Substance abuse
• Dyspraxia
• Asperger's syndrome
• Tics and/or Tourette's Syndrome
• Sleep difficulties
Common Additional
Problems of ADHD
People with ADHD commonly exhibit a number of additional problems,
which are largely secondary and may get worse if the ADHD is not treated.
• Poor self-esteem
• Poor social skills
• Insatiability
• Variation in symptoms from day to day
• Excessive dogmatism
• Poor organization and management of time
• Relationship difficulties Lack of motivation
• Problems with rule-governed behaviour
• Over-sensitivity
• Vulnerability to stress
• Auditory short-term memory problems
• Physical symptoms relationships.
Yet again, others have under-achieved academically, have low self-esteem and
poor social skills, and may be anxious, depressed or obsessive.
Assessment
An experienced, comprehensive specialist assessment is required as the symptoms can vary so much between individuals and because ADHD is so easily confused with many other conditions, which must be excluded.
Management of ADHD
Medication is the option considered to have most benefit in treating the core symptoms of ADHD, ie, inattentiveness, impulsivity and/or hyperactivity as part of the comprehensive management. It frequently has a flaw-on effect to many of the other problems. Individuals with significant ADHD should be seriously considered for medical treatment. Medication should be seen as providing a "window of opportunity" that normalizes brain function and stabilizes the situation and allows other strategies to be more effective, making the sufferer less vulnerable to the stresses of the environment. The two medications that are available in the UK to treat ADHD core symptoms are meth- ylphenidate (Ritalin) lO mg and dexamphetamine (Dexedrine) 5mg. Studies show that approximately 90 per cent of children with ADHD will show a very significant improvement on medication. However, there will still be on-going difficulties in about 40 per cent, usually because of the co-existing conditions. Once the core ADHD symptoms are managed, the other problems can often be dealt with more effectively.
The management of a teenager with ADHD is a particular challenge to the professional. Often more than one medication is necessary, to treat some of the difficult complications. It must be appreciated that there are likely to be setbacks and difficulties in management that require fine tuning, patience and understanding.
One of the myths of ADHD is that it is outgrown by puberty and/or is not present by late teens. In reality, by teenage years, as ADHD is progressive, it is often much worse and compounded and masked by the other difficulties. Hyperactivity has often diminished, but there are often other problems. It is often essential to treat teenagers and also adults.
Possible Masked Presentations of ADHD
• School underachievement
and/or behavioural difficulty
• Special schooling, especially EBD (emotional and behavioural difficulties)
or dyslexic school
• Gifted children with self-esteem problems
• Children involved with Portage who also have poor concentration
• Early onset Oppositional Defiant Disorder/Conduct Disorder
• Those with predominantly inattentive problems Teenage suicide/attempted
suicide
• Those with Asperger's Syndrome
• Early onset substance abuse
• Infants with persistent crying/sleeping difficulties.
In 1996, despite the fact that up to one per cent of UK schoolchildren had severe hyperaaivity,8 only one in 30 of such children were on medication.' Medication usage must be seen in context of the incidence of the condition. There is therefore very significant under-treatment of this medical condition in the UK.
Conclusion
It is therefore vital that the legal profession has factual knowledge of ADHD. A great deal is already known about ADHD, research is increasing and the current under recognition in the UK means that large numbers of children with problems are overlooked. In children with severe complications, especially those with early onset Oppositional Defiant Disorder and Conduct Disorder, the underlying ADHD may he concealed and thus confuse or delay active treatment.
Those children tend to progress into lifelong criminal activity and antisocial personality disorder, comprising a large proportion of the criminal psychopaths. Those with persistent problems are strongly linked with the 5-10 per cent of offenders who commit 70 per cent of all homicides, rapes and serious assaults. The antisocial activity can range from premeditated acts of aggression through to impulsive actions. The theory that ADHD is a disorder of behavioural inhibition and impulse control with the associated difficulties in self-regulation, in rule-governed behaviour and development of a code of moral conduct is very relevant. Often, short-term memory difficulties mean that the offenders cannot remember what they have done in moments of extreme impulsivity. Being male is by far the strongest factor predisposing to crime. Many criminals are more vulnerable because they have brains that are dysfunctional, especially with regard to problems with impulse control.
The criminal justice, legal, police system and society in general, at the moment, appear to have a low awareness that there may be a genetic or biological basis to some criminal activity. h may well be worth screening prisoners for ADHD, especially those in young offenders' institutions, and as part of their sentence including the institution of effective treatment. It would seem more advantageous to these children and their relatives to identify them at an earlier age, when they are still at school, possibly in the care system, when treatment is more likely to be effective. ADHD may at times justify the consideration of mitigating circumstances; it is a biological explanation for some behaviour or actions, rather than an excuse.
There is a large and well-documented world literature on biological predisposition to crime, and the role of awareness of this in crime prevention. It is important that those involved in crime prevention fully understand the implications of this. Without such understanding, the basic notion that only environmental and social factors cause crime is perpetuated. The causes of crime are multi-factorial, but societal, environmental, economic and cultural factors alone do not yet give the total explanation for crime. Failure to take a wider view enables the high rate of chronic offending to continue and is cost-ineffective. The cast to Britain of juvenile crime is said to be £7 billion per year.
A long-term study from New Zealand has shown that the strongest risk factor for family and adult partner violence was childhood conduct problems and this has been virtually ignored in research and scarcely mentioned in the literature. Adult partners violent towards each other are also at increased risk of abusing their children. Studies suggest that the risk of child abuse is between three to nine times greater in homes where adult partners hit each other. Conduct Disorder also predicts many other undesirable outcomes, including teenage pregnancy (30 per cent of girls with Conduct Disorder) and the fact that 50 per cent of sufferers become involved in a violent intimate relationship.
Understanding the factual reality, and the suffering caused by ADHD and its importance as a public health issue for children and adults is vital, so that rational decisions can he made on the most appropriate provision of help. ;
Case History - Sam "Sam is now 18. From an early age he was hyperactive, impulsive, noisy and had poor concentration. His life was punctuated by numerous accidents as he had no awareness of danger or of cause and effect and never seemed to learn from his experiences - he broke nearly every bone in his hands during his skate-boarding obsession. Intelligent and quick-witted, Sam is a kind and caring lad with a well developed - if not somewhat excessive - sense of fun. He is an able sportsman and a creative and competent musician. Sam gained a reputation as the class clown and a loveable rogue but his IQ enabled him to achieve well in the more structured environment of junior school.
His work deteriorated in the larger classes in secondary school. His increasing disorganization led to failed homework and assignment deadlines. His self esteem decreased, he became depressed and was rude to teachers, being suspended on two occasions. Repeated detentions meant that his parents were regularly contacted because of his misdemeanours and underachievement. No amount of effort had been spared to give Sam and his older brother a caring and positive upbringing with good moral values. However, being easily led, Sam gravitated towards bad company and had repeated brushes with the law for physical impulsiveness. He began truanting. Friends persuaded him to make a bomb hoax call to his school which was captured on video. Fortunately, his head teacher saw beyond the moment, recognized his potential and prevented the matter being taken further by the authorities.
Unbeknown to his family, Sam had been introduced to drugs at the age of 13 and began to smoke cannabis regularly and steal from his mother to fund this and smoking cigarettes. Needing constant stimulation, entertainment and little sleep, as well as being fidgety and restless meant Sam was always out with friends, sometimes vandalising - often until well into the early hours.
Sam's intelligence, with little effort, gained good GCSE results. He went onto sixth form college. However, the lack of structure and intervals between lectures compounded his growing difficulties. During a free period, Sam was arrested in the local park for possession of a quantity of cannabis with suspected intent to deal - at the age of only 17. He was ' cautioned. This crisis resulted in referral for help which his mother had been abortively seeking for several years - her single parent-status having been blamed for his problems. He was belatedly diagnosed as having severe ADHD with oppositionality and associated substance abuse - a frequent complication of late-diagnosed ADHD - depression and low self-esteem.
Sadly, because of late diagnosis and the very nature of untreated ADHD, Sam could not co-operate with recommended medical and other management of his problems. Police cautioned him but he continued to gravitate downwards personally and socially. Although expected to achieve well in `A' levels, his poor attendance, concentration and other problems, resulted in expulsion just before the exams. Nine months later, Sam's continuing and untreated difficulties led to another arrest. In court his ADHD, good upbringing/environment and academic potential was cited, resulting in a conditional discharge and fine with a warning to stay away from drugs and bad company or face a severe penalty. ' Sam's untreated ADHD prevents him from halting his behaviour or concentrating long enough to consider the gravity of his situation, despite having an obvious high intelligence - or to motivate himself to get a job to pay the fine or support himself. Untreated, he will undoubtedly reoffend and be seen by society as someone who deserves his fate rather than as a victim of a medical condition, needing understanding and support - not punishment. Had Sam's problems been recognized and treated earlier, many of his difficulties could have been prevented. Until such time as he is able to recognize the need for help, his progressive ADHD is increasingly likely to have serious consequences.