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Attention deficit hyperactivity disorder (ADHD) is one of the most feared and misunderstood of all medical conditions. Despite over 200 scientific papers being published on this neurological condition every year, it remains stigmatised and controversial. Some doctors don't even believe it exists.
Yet it is estimated that as many as 3-5% of the childhood population, and over one million adults in the UK are affected by ADHD. These people are often described as stupid, lazy, disorganised, wild, out of control or woozy on drugs. But the reality is altogether more complex, and deeply moving.
The Hills
Brian and Eleanor Hill think that Liam, their five-year-old son, could have ADHD. He is fearless, impulsive and rarely does what he is told. He is constantly on the go and Brian and Eleanor cannot take their eyes off him for a minute. They have tried all the conventional parenting techniques to control him, but nothing works. Eleanor feels she has been driven to the very edge by her son's behaviour. "I never thought I could dislike a child so much," she says.
The Fishers
In Charlotte Fisher's household, ADHD is normal. Both she and her children, Jazmine (11) and James (7), have already been diagnosed with it. All three show the classic symptoms of this neurological condition - inattention, hyperactivity and impulsiveness. The result is a household with extremes of behaviours, chaos and disorganisation.
Scientists believe that people with ADHD behave the way they do because they have key differences in the frontal lobes of their brains - the part that plays an important role in the way that we control our impulses. People with ADHD have difficulty suppressing their impulses and therefore respond to more cues than the average person. Rather than failing to pay attention, they pay attention to everything. This means they're often overloaded with information they cannot filter out. These people are unable to stop and think about a situation, to 'apply the brakes' and consider the consequences before they act.
In spite of the difficulties that they face, the Fishers are a happy family and proud of who they are and what they can achieve. Both Jazmine and James have impressive talents. James shows great promise at football and has recently won a place at a local football school of excellence. Jazmine has an exceptional artistic ability. She has won a number of prizes for her intricate drawings and delicate water colour paintings.
Undiagnosed ADHD
The Fishers have not always had such a positive outlook on life. Just three years ago, before any of them were diagnosed, life was very different. James was extremely hyperactive and had violent and aggressive tendencies. Jazmine was hyperactive too, she had problems concentrating at school and suffered from extremely low self-esteem. Like many children who are diagnosed with ADHD, Jazmine's condition was made much worse by the presence of another condition - or co-morbidity - running alongside the ADHD. In Jazmine's case the co-morbid condition was dyslexia.
The most common co-morbidity is Oppositional Defiant Disorder or ODD. Over 50% of children diagnosed with ADHD have a substantial problem with ODD, a condition which makes them hostile, defiant and extremely difficult to parent. Doctors believe that ODD is a learned behaviour which children develop as a defence mechanism - a way of coping when they are constantly being told off for behaviour they simply cannot control.
The diagnosis of her children's ADHD brought Charlotte's own life into focus. As she found out more about the condition, she realised that ADHD had been the problem her whole life. As a child Charlotte was constantly in trouble and found it difficult to fit in with her peers. She couldn't concentrate at school and her teachers described her as unruly and out of control.
She left with few qualifications and started to take drugs. Like many adults who have been diagnosed with ADHD, Charlotte believes that her drug taking was a form of self-medication. She found that stimulant drugs like cocaine had an unusual affect on her - they actually calmed her down. But these drugs were addictive and made her ill too. They also didn't help with the bouts of severe anxiety that she had suffered all her adult life.
Once she had recognised her own condition, Charlotte was able to seek the help she so desperately needed. But there are only two adult ADHD NHS clinics in the UK and she had to wait a year for an appointment. Finally, at the age of 30, she was diagnosed and treated for the condition - and able to turn her life around.
Medication
Charlotte, James and Jazmine now all take methylphenidate, a stimulant drug most commonly known by the brand name Ritalin. Methylphenidate helps to control some of the core symptoms of ADHD. It works mainly by increasing available levels of the chemical dopamine in the affected areas of the brain. This helps to modify their levels of hyperactivity, impulsivity and sustained attention.
The treatment of ADHD with medication remains controversial. There's ongoing concern about the possible overuse of stimulant drugs. But with regular monitoring and support Charlotte has found that medication has provided her family with a crucial window of opportunity in which she can control her thoughts and her children can learn how to behave, build relationships and lay the foundations of a normal life.
The Diagnosis
With the Hills family at crisis point, Brian and Eleanor feel that their lives are anything but normal. But help is at hand, Liam has been seen by doctors at his local Child and Family Mental Health Unit. For six months the ADHD team led by Community Paediatrician Dr Saroj Jamdar have worked closely with the family. A detailed report of Liam's behaviour since birth has been complied with information from his parents and his school. Independent classroom observations have been carried out and a thorough medical report has ruled out any physical ailments.
With all this information now in place, Liam can be given a diagnosis of mild ADHD and oppositional defiant disorder.
For Brian and Eleanor a confirmed diagnosis is an important step forward, allowing them to understand and make sense of Liam's behaviour, and offer him the support that he needs. They have been lucky to identify Liam's problem at such an early stage - but now face the difficult decision of which course of treatment to take. Both Brian and Eleanor have reservations about medicating their son.
Behaviour management and non-pharmacological treatments
Not all children with ADHD need medication and there are a number of non-pharmacological treatments that effectively help to control symptoms too such as behaviour management advice for schools and parents, specialised parent skills training and family and individual therapy.
Because Liam's ADHD is mild, and because he is still so young, Dr Jamdar, Brian and Eleanor decide that at this stage, medication is not necessary. Instead the family will enrol on a specialised parent skills course which will address both Liam's oppositional behaviour and his ADHD. Liam's progress will be monitored and medication still remains an option for the future.
Even when a child is being medicated, it is recommended that behaviour management strategies are always provided in conjunction with the drugs. Charlotte has asked for help from clinical psychologist and ADHD specialist Dr Angel Adams. She feels that although the medication helps to control her thoughts and hyperactivity, she needs help disciplining the children. She also wants more control over her own mood swings which are particularly bad in the morning - when she feels under pressure to get the children organised and ready for school on time.
Dr Adams suggests Charlotte uses a token system adapted specifically for ADHD children. The rewards they earn with this system are powerful, frequent and above all immediate. She also introduces a list outlining a morning routine for each family member. By breaking this time down into smaller, more manageable sections, the morning becomes less stressful.
For both the Fishers and the Hills there is no quick fix. But with the right support, children and adults with ADHD can control their symptoms and lead happy and fulfilled lives.
Further reading:
ADHD - The Facts by Mark Selikowitz Oxford University Press
ADHD Parenting Handbook, Practical Advice for Parents from Parents by Colleen Alexander-Roberts , Taylor Trade Publishing
Out of the Fog, Treatment Options and Coping Strategies for Adult Attention Deficit Disorder by Kevin R. Murphy and Suzanne Hill, Hyperion Books
Driven to Distraction: Recognizing and Coping with Attention Deficit Disorder from Childhood through Adulthood by Edward M. Hallowell, MD and John J. Ratey, MD. Touchstone Books, 1992. ISBN #0-684-80128-0
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