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Anxiety disorders – Part 1: Overview

Anxiety – about bad things that might happen, or not being accepted by others, or not being able to handle what’s expected of us – we’ve probably all been there at times. But the teenage/young adult time of life, when the overarching concern is Finding One’s Place in the World, is especially ripe for worry.

In this unfair world of ours, atypical young people are even more prone to anxiety than their peers. So not only do they have to try to cope with neurologically-based difficulties in learning, staying on-task, and socializing – they have to deal with the anxiety about not measuring up. And the ways anxiety impacts them can be as challenging for these young people as their other diagnoses.

Since anxiety is so common in neurodiverse young people, whatever their diagnosis, it’s a topic worth exploring here on the Cinder Cone. As it turns out, I found such a large amount of anxiety-related information worth sharing that it needs to be spread over at least two posts.

We’ll start with some interesting factoids and a look at the types of anxiety disorders.

When seeking an overview, I learned a lot from this Wikipedia article. Here are some excerpts:

Anxiety disorders are a category of mental disorders characterized by feelings of anxiety and fear,[2] where anxiety is a worry about future events and fear is a reaction to current events.

Anxiety disorders are partly genetic….

They often occur with other mental disorders, particularly major depressive disorder, bipolar disorder, certain personality disorders, and eating disorders. The term anxiety covers four aspects of experiences that an individual may have: mental apprehension, physical tension, physical symptoms and dissociative anxiety.[5] The emotions present in anxiety disorders range from simple nervousness to bouts of terror.[6]

[B]etween 10 and 20 percent of all children will develop a full-fledged anxiety disorder prior to the age of 18,[122] making anxiety the most common mental health issue in young people.

Anxiety in children has a variety of causes; sometimes anxiety is rooted in biology, and may be a product of another existing condition, such as Autism or Asperger’s Disorder.[124] Gifted children are also often more prone to excessive anxiety than non-gifted children.[125] Other cases of anxiety arise from the child having experienced a traumatic event of some kind, and in some cases, the cause of the child’s anxiety cannot be pinpointed.[126]

Anxiety among adolescents and young adults is common due to the stresses of social interaction, evaluation, and body image.

Anxiety and depression can be caused by alcohol abuse, which in most cases improves with prolonged abstinence. Even moderate, sustained alcohol use may increase anxiety levels in some individuals.[32] Caffeine, alcohol and benzodiazepine dependence can worsen or cause anxiety and panic attacks.[33]

See? That’s interesting stuff, isn’t it?

The experience of “having anxiety” varies – not just in intensity, but in what triggers the unease. For the following summary of types of anxiety disorders, my sources here are Wikipedia (again), this article from HelpGuide.org, and this article about childhood anxiety disorders. See if any of these conditions are familiar in yourself or someone you know:

Generalized Anxiety Disorder: People with GAD are chronic worrywarts, to the point where it distracts them from everyday activities. The worries are “persistent, excessive, and unrealistic.” Sufferers often have unfounded foreboding that disaster is in store. GAD is more common in women, and the risk is highest from childhood to middle age. “Children with GAD tend to be very hard on themselves and strive for perfection. They may also seek constant approval or reassurance from others.” [I assume the same is true of teens.]

Panic Disorder and Agoraphobia: Panic disorder involves repeated, unexpected panic attacks. People who suffer these attacks also live in fear of having more panic attacks. Panic disorder typically develops in early adulthood, with women again more prone to suffering this form of anxiety. Agoraphobia is included here because many people with panic disorder avoid places or situations where previous panic attacks occurred, such as crowded public places where it may be hard to escape – including air travel.

Phobia: Sufferers experience overwhelming fear or anxiety when confronted with a specific thing or situation. Most phobias arise unexpectedly during the teen years or early adulthood; that is, before the phobia took hold, the phobic person hadn’t been bothered much by the feared object. People with a phobia usually understand that their reaction is out of proportion to the risk, but they are still overwhelmed and often rearrange their daily activity to avoid the trigger.

Social Anxiety Disorder: This is an intense fear of negative social interactions or public embarrassment. It usually begins in childhood or adolescence, especially the early teen years. Performance anxiety (such as speaking in public) is one form of SAD. A person who actively tries to avoid feeling this type of anxiety may end up in partial or complete social isolation.

The article about childhood anxiety disorders lists selective mutism as a separate category, but it’s related to social anxiety. This is where the individual (usually a child) refuses to speak in situations where talking is expected or necessary. The individual may be talkative in other settings but will not communicate in certain situations (like school). Our son Nathan exhibited selective mutism during his high school years, when he was at his most miserable. Teachers, counselors, and other adults could not get much out of him.

Obsessive-compulsive Disorder: Obsessions are persistent, intrusive, distressing thoughts. Compulsions are urges to repeatedly perform certain acts, often as a way of dealing with the obsessive thoughts (since the house might get broken into, I’ll keep rechecking whether the door is locked). People with OCD usually recognize how irrational they are being, but they feel powerless to stop. Children with OCD are often diagnosed around the age of ten. Boys tend to develop the condition sooner, while for girls the onset is more likely in adolescence.

Separation Anxiety Disorder: This involves an exaggerated level of worry about bad things happening when separated from a person or place. I always thought of this as purely a childhood phenomenon, but Wikipedia says it affects 7% of adults (maybe some cases of homesickness fall in this category?). However, children who suffer from separation anxiety usually have a more severe experience of it than adults – probably because they are so dependent on their parent or caregiver.

Post-traumatic Stress Disorder: PTSD results from exposure to an extreme negative situation (especially violence), or chronic exposure to a severe stressful occurrence. (Note that Wikipedia includes bullying as one potential cause of PTSD.) Symptoms include flashbacks or nightmares; hypervigilance; avoidance of people or similar situations; and depression, irritability, or emotional numbness. Women are more likely than men to develop PTSD after surviving a traumatic event. I’ve read elsewhere that parents of special-needs children may develop PTSD.

 

The effects of anxiety can be significant. It can skew interactions with others and impede the ability to focus and get things done. It may also contribute to physical woes like digestive system problems, headaches, fatigue, and insomnia. And those problems can in turn trigger worries ….

Anxiety can diminish our quality of life, damage relationships, and even impact our physical well-being. Young people who are affected by anxiety often turn down fulfilling opportunities that they would otherwise gobble up. When you’re in the process of becoming an adult, avoidance behavior can really derail the course your life takes!

What can be done? I’m glad you asked! In the future, we’ll look at ways to cope with anxiety symptoms and to subdue the troublesome thoughts themselves.

 

 

 

Deficits in visual functioning (encore presentation)

Since summer is the time for reruns, I took the opportunity to search the archives for a deserving post that, for whatever reason, hasn’t received many all-time views.

Originally posted in 2012, this one discusses vision therapy. It’s a good reminder that our atypical young people may have undiagnosed deficits in visual functioning that are affecting their performance in school and in life.

 And so, without further ado, I give you this encore presentation of a post originally titled “Vision problems can affect school performance.”

***

The (original) title of this post may seem like a no-brainer. “Yeah, if you need glasses and don’t have them, that’s a problem!”

But what our family learned is, there’s more to vision than how sharp or blurry the world looks ( = “eyesight.”)

When Nathan had his multidisciplinary educational assessment (at Big Springs Educational Therapy Center in Riverside CA), one of the things they looked at was visual functioning. This included how smoothly the student’s eyes tracked together across the printed page, whether both eyes were in alignment, how well the student recognized shapes that were rotated, and other things we don’t normally think about.

Deficits with visual efficiency make tasks like reading or taking notes from the board pretty challenging and tiring. If this is happening with a kid who also has attention deficits, or poor hand-eye coordination, you’ve got a recipe for giving up on schoolwork.

We had known Nathan’s eyes got tired during homework sessions, but so did the rest of him! (Half the time spent on “homework” was taken up with procrastination, tantrums, discussions, pouting, etc.) In any event, the assessment revealed that Nathan did have some genuine visual functioning deficits. It was suggested that he have a “developmental optometric evaluation” where a specialist could pinpoint the problems and provide therapy to correct them. Big Springs gave us a list of local vision therapy providers, and we chose the one closest to us:  Hospitality Eyecare Center in San Bernardino. (These days, you can google “vision therapy” for your area to find a provider.)

The Eyecare Center confirmed that Nathan had 20/20 eyesight, but some eye tracking and binocular coordination problems. We then had four months of office visits for therapy, twice a week, with some exercises to do at home between appointments. At the end of the four months, Nathan was re-evaluated and all of the deficits had been corrected.

So did this pay off? Did Nathan’s schoolwork experience improve? Hard to say. Nathan never admitted to noticing a difference after the therapy. (It was another weapon in his arsenal of, “You drag me to these appointments and they never do any good.”) He did pretty well in his next school year – 7th grade – when more note-taking and reading are expected. But by 8th grade, other factors sent him into a tailspin from which he never really pulled out.

I know another mom whose daughter had vision therapy. The daughter did not have any other big-time learning disabilities, but struggled with reading. They were skeptical about vision therapy, but she went through all the therapy sessions – and reading became much, much easier for her as a result. So vision therapy might be something you want to look into (ha ha, lame joke), especially if your student avoids reading, complains of tired eyes, etc.

The narcissists in our midst

Recently our son Nathan decided that because he’d run out of things to say, he would stop seeing his current psychologist. While his decision was a little disappointing, we appreciated it when Nathan suggested that my husband and I use his next appointment to get Dr M’s impressions.

Dr M told us he too was disappointed that their sessions would be ending. He had looked forward to seeing Nathan: “He’s no barrel of laughs, but he’s so interesting!”

As far as diagnoses, Dr M stated that Nathan fits the criteria for Aspergers AND schizoid personality disorder. (The previous psychologist, Dr S, believed that Nathan had schizoid personality disorder, instead of Aspergers. This post talks about the confusion between the two disorders.)

While I was still absorbing the dual diagnosis, Dr M added, “Oh, and he has a narcissistic streak.”

That statement also gave me pause. Nathan, who avoids people and doesn’t care about his appearance, a narcissist?

Clearly, it was time to find out more about narcissism. What is it, exactly? And is it more common in people who have other neurological differences?

It turns out that lots has been written about narcissists and narcissistic personality disorder (NPD), which affects 1% of the population. No doubt you’ve crossed paths with at least a few “official” narcissists in your lifetime.

The supportive website regarding personality disorders, Out of the Fog, supplies this in-a-nutshell summary:

Narcissism is characterized by an extreme self-interest and promotion with an accompanying lack of concern for the needs of others.

Behaviors that typify narcissists include expecting special treatment, lying, manipulating people, and shifting blame. Doesn’t that scream “stay far, far away?” And yet, narcissists can be fun, charming, and talented. (By the way, being stuck on how good-looking they are – which many of us laypeople equate with narcissism – isn’t necessarily a big part of the package.)

The DSM-V criteria for diagnosis can be seen in this Wikipedia entry. (In most articles that I read about narcissism, the criteria referenced were from the now-oudated DSM-IV.)

Basically, according to DSM-V, a narcissist is impaired by:

  • excessive reference to others in evaluating his/her self-esteem
  • having personal standards that are unreasonably high (I am exceptional) or too low (I am entitled)
  • little ability to recognize or identify with the feelings and needs of others
  • largely superficial relationships: little real interest in the other person, coupled with a need for personal gain
  • grandiosity (self-centered, condescending, entitled)
  • excessively seeking admiration

For an official narcissism diagnosis, these traits must be stable over time and across situations; unusual for the person’s developmental stage and social/cultural environment; and not explained by substance abuse or physiology (like head trauma).

About that developmental stage: I’ve read that teenagers in general tend to display narcissistic traits (no kidding!) Furthermore, maturity is typically delayed for people with ADHD and other disorders (raise your hand if you’re hanging on until their late 20’s!) So we might be seeing narcissistic traits well past the teen years. But when the traits strongly persist past the age of 30, there’s reason to suspect NPD.

Regardless of whether the narcissism in your loved one is transitional or here to stay, it can be really difficult to deal with – anywhere from “irritating” to “exhausting” to “toxic.”

To help us understand what we may be dealing with, the page about narcissism on the Out of the Fog website includes: a long list of unofficial characteristics often seen in narcissists, the old DSM-IV criteria, and a brilliant essay titled “What it feels like to live with someone with NPD.”

The Out of the Fog website also provides a toolbox of what seems to help, as well as what doesn’t work, when dealing with individuals with personality disorders. You can also search the support forum for discussions similar to your situation, or find pages with links to books or other websites dealing with NPD.

There is no cure for NPD. Therapy may help, but narcissistic individuals are unlikely to seek or consent to therapy. If they do, their focus tends to be on blaming others, and they will probably resist personal change. The rest of us are the ones who can benefit from tips and therapy for the ongoing damage narcissists cause.

As for what causes NPD to develop, I’ve been squirming because many articles talk about poor parenting: too indulgent, too neglectful, too erratic, too dependent on our children for our own self-esteem, or we modeled manipulative behavior. Jeez, did we do any of that? Severe emotional abuse is also mentioned as a factor. Did that happen?

But Psychology Today states that genetics plays a significant role (up to 50%) in the development of narcissism. Other recent research points to neurological differences as a potential cause. Phwew: maybe we’re off the hook!

Neurological differences also result in conditions like ADHD, Aspergers, and bipolar disorder. What is their relation to narcissism?

This excerpt from the Out of the Fog essay addresses co-occurring disorders:

Narcissists are addictive personalities and narcissism is commonly co-morbid with addictions to drugs, alcohol, sex, food, spending and gambling. It has been suggested that Narcissists have a higher rate of ADHD than the general population.

Another discussion reinforces the idea of a relationship between ADHD and personality disorders, including NPD. Findings suggest that people diagnosed with ADHD in childhood are more likely to meet criteria for a personality disorder in adulthood, often one of the impulsive or “Cluster B” personality disorders. Besides narcissism, these include Borderline, Antisocial, and Histrionic PDs. The discussion goes on to state that no one really knows the nature of the relationship between ADHD and PDs.

This link, although framed to address struggling marriages, does a great job talking about the similarities and differences of people with Aspergers or narcissism. They both seem to be self-absorbed and have little regard for others’ feelings. But in contrast to narcissists, Aspies don’t need the approval of others and prefer not to be noticed; depend on rules, instead of imagining they’re exempt; and overlook others’ feelings out of “blindness” rather than conniving.

Here is a post from the blog “Mind Retrofit”, written by an Aspie who’s done a lot of Internet searching on the differences between Aspergers and narcissism – with the emphasis on differences.

If you are wondering about how schizoid personality disorder compares to narcissistic personality disorder, this article provides a nice summary. Both can appear arrogant, but people with schizoid personality disorder do not want to interact with others, whereas the narcissist craves interacting with people to “prove” his/her superiority.

Finally, I found this article about narcissism and bipolar disorder. Just as Aspies and narcissists share a key characteristic (disregard of others’ feelings), people with bipolar disorder and narcissism share the trait of grandiosity. The distinction is that narcissists display grandiosity all the time, whereas the bipolar individual mainly shows the trait during mood phases. However, the article also states that about 5% of people with bipolar disorder have narcissistic personality disorder. So, as in people with ADHD, NPD occurs in the bipolar population at higher rates than in the general population.

Almost all of us display narcissistic traits from time to time, or maybe some of the traits at low levels all of the time – but that doesn’t mean we all have NPD. The disorder occurs when someone’s inflated sense of self and determination to get what s/he wants consistently presents problems in social interactions.  Narcissism seems to be on a spectrum – which means that those with NPD can differ in how annoying or toxic they are.

It isn’t known for sure what triggers narcissism, but biology and upbringing may contribute, either separately or in combination. Narcissism seems more prevalent in people with ADHD or bipolar disorder, for reasons that appear to be unclear.

At this point I don’t really agree with Dr M’s statement about Nathan having a narcissistic streak. Nathan values his own thoughts and not those of others, but he isn’t making an effort to impress anyone about anything. However, I do see a lot of narcissistic traits in our other son, Alan. It makes for some tough interactions, but we’ll do what we can to contain the damage and hope for the traits to lessen over time.

A final note: None of the material here is meant to take the place of an official diagnosis. You may develop suspicions based on what you’ve read (as I have), but you (and I) may be mistaken, especially because so many narcissistic traits overlap with other personality disorders and mental disorders. Let a professional do the diagnosing.

Temperament types and mental health challenges

This post from two years ago introduced the idea of temperament types and how understanding them can improve parenting outcomes. Now we’ll take a look at the correlation – or confusion – between temperament and atypical mental patterns.

In researching this on the internet, I hoped to find expert advice to pass along. Alas, I didn’t uncover a whole lot of material. In addition, none of the search results used the temperament types described by David Keirsey, which were the framework for the original post.

Before sharing what I did find, here’s a look at what we’ve learned from therapists over the years regarding the Keirsey temperaments and mental health challenges.

Our family counselor introduced us to the concept of temperament types when our sons were in elementary school. The table below is extracted and paraphrased from one she gave us. (Since the temperament types go by a variety of names, I’ve included the two-letter abbreviation of the traits that define them – e.g., Guardians (SJ) are Sensing and Judging – in case you know the types by different names.)

Idealists – NF Rationals – NT Guardians – SJ Artisans –  SP
What they value most Relationships, interior journeys Knowledge, logic Order, fairness Freedom, action
Views on authority and respect Compliant; respect integrity They are their own authority; respect competency Non-critically compliant; respect status and authority Must be challenged; respect strength and bravery
Common mental disorder Dissociation, eating disorders Phobias, obsessive Depression, psychosomatic Rage, addictions
Common person-ality disorder Histrionic, borderline Obsessive-compulsive, avoidant Passive-aggressive, borderline Narcissism, antisocial

Many Artisans (adventurous freedom-seekers) run into trouble because their priority is experiencing life in the here and now, on their own terms. On the other hand, many Rationals (big fans of logic) won’t conform to societal norms unless it makes sense to them.After our family counselor educated us about these types, she said, “All four types have their strengths and weaknesses – but which two types do you think have the easier time getting along in society?”

The answer was the Idealists (people-oriented) and the Guardians (dependable rule-followers).

Our younger son Alan is an ESTP – one of the Artisan types. They tend to be in the Arts, or enjoy working with tools. When Alan’s attention problems in high school led us to seek an official ADD diagnosis, his first psychologist (also an adherent of the Keirsey model) said he didn’t really believe in ADD or ADHD – that it was more a matter of temperament, not a disorder. And indeed, many of the attributes of Artisans (like impulsivity) overlap with ADHD characteristics.

A few years later I shared the psychologist’s statement with our family counselor (whom we visited only as needed). “Hogwash!” was her response. For one thing, she said numerous studies have shown definitive differences in the brains of people with ADHD. No such brain differences are seen among temperament types. In any event, Alan has since been diagnosed with ADD by a psychiatrist.

Meanwhile, our older son Nathan is an INTP – one of the Rational types. Rationals are the techies, engineers, and/or sci-fi “nerds.” We’ve heard it said that all Rationals are on the autism spectrum to some degree. I don’t know how true this is, but certainly there is some overlap; neither Rationals nor people on the spectrum are known for having innate people skills. As I’ve shared in other posts, Nathan was found to be autistic-like by school psychologists, and was diagnosed with Aspergers (or is it schizoid personality disorder?)

Now, on to what turned up in my internet research.

Dr. Barbara Keough is one researcher whose work is frequently referenced. She and her colleagues at UCLA preferred to use a temperament model first proposed by Alexander Thomas and Stella Chess, with definitions of nine dimensions later put forth by Jan Kristal. This seems to be a framework well-suited for issues concerning child development and family dynamics.

The dimensions defined by Kristal are:

  • Sensory threshold
  • Activity level
  • Intensity
  • Rhythmicity
  • Adaptability
  • Mood
  • Approach/withdrawal
  • Persistence
  • Distractibility

These have been found to cluster into three constellations of temperament:

“Easy” children are typically adaptable, mild or moderate in activity and intensity, positive in mood, and interested in new experiences.

“Difficult” children tend to be intense, low in adaptability, and negative in mood.

“Slow-to-warm-up” children are upset by change, are characteristically reluctant and withdrawing in new situations, and shy with new people, although given time they adapt slowly and well.

The above list was copied from an article by Dr. Keough on the Great Schools website. More description of the nine dimensions can also be found there. Honestly, it’s tempting to copy and paste the whole article into this post! I’ll restrain myself by pasting in just one more excerpt, which is a paragraph about learning disabilities and temperament:

It is important for parents to understand that there is no single temperament profile that characterizes all children with learning disabilities. Like other children, a child with LD has his own unique and individual temperament. This is not to imply that LD and temperament may not overlap, because in many instances there are similarities between the signs of LD and the characteristics of difficult temperaments, especially in traits of distractibility, intensity, and low persistence. Too often, however, temperament characteristics of a child with LD are assumed to be part of the LD itself, rather than an individual variation in behavioral style. This confusion tends to over-emphasize the idea of disability, and overlooks the individuality of a child with LD.  When you can see and interpret a child’s behavior through a temperament “lens” it helps you sort out what are signs of LD and what is temperament.

When I first read about the three constellations of childhood temperament, I was a little puzzled: “Really? All children fit into one of those three categories?” This article, while geared toward early childhood development, gives the answer. It says that only about 65% of children have temperaments that fit into one of those three types. (The other 35% must be more spread out in the statistical results.) The article goes on to discuss the importance of adults being able to recognize their own temperaments and those of the children in their charge. Making adjustments and allowances for the differences can minimize conflicts, misunderstandings, and bad feelings.

This article makes much the same point, stating that parents should try to tailor their parenting styles to the individual needs and temperaments of each child. It cites one study of mothers with children aged 8 to 12. The results showed that “when a mother’s parenting style matched up well with her child’s temperament, the child experienced half as many symptoms of depression and anxiety.” In particular, the degree to which a parent is attuned to a child’s levels of fearfulness, frustration, and self-control may have the greatest impact on the youth’s mental health.

If you are a parent who is now experiencing depression and anxiety because until this moment you’ve had more of a “my way or the highway” style, you may be wondering how to learn more about temperament types. Nurture by Nature, a book I mentioned in the original post, is a very useful guide to the 16 Keirsey temperament types (4 subtypes in each of the four main types). A similar book, which I haven’t read, is Parenting by Temperament by Nancy Harkey.

I’ll close with two links that focus on mental health conditions first, then discuss connections to temperament.

An article on ADHD discusses a preliminary study of kids ages 7-11. The researchers were able to group these children with ADHD into three temperament categories: mild ADHD, surgent ADHD, and irritable ADHD. Those in the mild group had ADHD symptoms, but otherwise their temperaments were like kids who didn’t have ADHD. The surgent ADHD kids were very excitable, with high activity levels. The irritable type had high levels of anger, fear, and sadness, and were hard to soothe.

The researchers found that in the irritable type, two brain regions – the amygdala and the anterior insula – are less in sync than in children of other types. Both of these regions have a role in emotional behavior. The researchers also found that children in the irritable ADHD type were the most likely type to develop another mental health condition, such as mood problems or anxiety.

The second link is from MentalHelp.net, which has a whole series of informative articles on suicide. This one, on the biological factors that contribute to suicidal thoughts, includes a section on temperament. It mentions two temperaments that tend to be displayed by suicidal adolescents and adults. The first is known either as “depressive/withdrawn,” “negativistic/avoidant,” or “high in neuroticism.” People with this temperament have difficulty controlling their negative moods and tend to overreact to stressors. This temperament is also prone to having a history of being abused or having inadequate relationships with caregivers.

The second temperament type found in suicidal people is known as “impulsive/aggressive” or “negativistic/avoidant/antisocial.” They have difficulty controlling their anger, may have a pattern of reckless or irresponsible behavior, and tend to abuse alcohol or other substances. Their tendency to make snap decisions means that they may commit suicide without being particularly depressed or anxious. “Children with this temperament type often have histories of abuse (particularly sexual abuse).”

The article goes on to discuss three factors that influence temperament:

  • the genes that control the regulation of the neurotransmitters norepinephrine and serotonin
  • the environment – such as how much and what kinds of stress one is exposed to, and how the stress levels match up with one’s innate coping skills
  • the negative responses of caregivers and peers to a child’s difficult temperament. These increase the likelihood of  stress, and influence further personality development and the risk of mental disorders

And so ends my research roundup. Not much of it relates directly to teens and young adults. Some of it is inconclusive, while other points seem pretty obvious.

I’m still confused (but fascinated) about how temperament, social relationships, and mental health intertwine. One thing seems clear: these researchers agree that teachers, caregivers, and parents who take a youngster’s temperament type into account will have better results in the short term and increase the chances of a well-adjusted adult in the long term.

 

 

 

 

 

 

 

Assorted things to know about adult ADHD

I was contacted last week by someone from Healthline.com who saw the blog post about law enforcement careers and ADHD and sent along a link to Healthline’s latest infographic on ADHD (attention-deficit/hyperactivity disorder) statistics.

And I thought, “Cool! I’ll share this in a new post, and scrounge around the Internet for other informative items about ADHD, and put them in the post too.”

So that’s what this is.

The Big Picture

Click this link to see the statistics Healthline.com compiled about ADHD in the US. (Click here to see more information about ADHD from Healthline.)

It says 4% of the adult population has ADHD – that’s one out of every 25 people. It’s likely that you know a few adults who qualify for a diagnosis. (From another source, I read that many adults with ADHD may have been diagnosed as kids – around 60% of children with a diagnosis will have ADHD as adults – while others compensated well enough to get by in childhood, but can’t do it when faced with the complex demands of adulthood.)

As a geographer, I was most curious about the map that shows where ADHD is most and least common. The results surprised me a little – how about you? (I quickly Googled the reasons for the geographic distribution of ADHD in the US, and found that “further studies are needed.” We’ll check back in a few years….) The socioeconomic and racial trends are interesting also.

If you are curious about the costs of ADHD, scroll a little further down the Healthline page. The consequences of ADHD in children and adults cost Americans at least $42.5 billion each year. That isn’t just the cost of medicine and treatment; loss of work, educational expenses, and juvenile justice costs are included.

If we included the criminal justice system as a whole, not just juvenile justice, the cost figure would be much higher. This blog, from a Canadian adult ADHD coach, discusses the proportionately high incidence of ADHD (especially untreated ADHD) in the prison population, as documented in several studies around the globe. As the author says, “crime & jail are costly, treatment is cheap.” (We need to be clear, though, that the great majority of adults with ADHD are law-abiding citizens.)

Overviews at a More Personal Level

The big picture of how ADHD impacts society is important. What’s crucial for most of us, however, is getting help to cope with our own symptoms, or help for our loved ones, friends, or coworkers.

This link from Helpguide.org provides a good, upbeat starting point for learning about the symptoms and available coping strategies for adult ADHD. Here is an excerpt:

 …[T]he challenges of attention deficit disorder are beatable. With education, support, and a little creativity, you can learn to manage the symptoms of adult ADD/ADHD—even turning some of your weaknesses into strengths. It’s never too late to turn the difficulties of adult ADD/ADHD around and start succeeding on your own terms.

I also found this page from the Cleveland Clinic website interesting, because it’s written from a clinician’s perspective. Among the notable pieces of information in this link are:

  • that ADHD is the most heritable of psychiatric disorders.
  • a summary of what’s different in brain anatomy and neurochemistry for people with ADHD
  • a table summarizing common dysfunctional behavior patterns in adults
  • a flow chart for how to diagnose ADHD in adults (a behind-the-scenes look!)
  • a table of disorders commonly associated with, or having symptoms similar to, ADHD
  • a table of medications that may be prescribed for ADHD

Young Adults and ADHD

Young adults emerging from the structured existence of high school and living with parents can find the transition to independence especially tough going if ADHD symptoms are a factor. Becoming an adult is challenging enough even without having deficits in organization, focus, follow-through, and impulse control!

This webpage from ADDvance.com includes lots of links to information about going to college, and a couple of links for those who may not be college-bound.  The challenges of young adults with ADHD entering the workforce are discussed here, at Healthychildren.org. The link covers the reasons why the individual may find employment stressful, and why supervisors may be unhappy with job performance. Possible solutions are presented.

The good news is, many colleges, training programs, and employers (especially bigger ones) offer supports for people with ADHD and other invisible disabilities. The not-so-good news is, the supports may not be super effective (underfunded, understaffed, not a priority, etc.) And the supports in higher education or the working world won’t be available if you don’t have an official diagnosis, or if you don’t let it be known that you have an official diagnosis.

Getting a Diagnosis

Follow this link to find out what the Mayo Clinic has to say about getting evaluated for ADHD – including which professionals can do the diagnosis, and what they are likely to do in determining the diagnosis.

If you’re not sure you’re ready to take this step, it might be a good idea to first take at least one online test that prescreens for ADHD symptoms. Here is one such test.

“ADHD” covers a wide range of symptoms. Experts have different views about the existence of various types of ADHD. For instance, the American Psychiatric Association recognizes three types of ADHD: predominantly inattentive, predominantly hyperactive-impulsive, and combined. Dr. Daniel Amen, whose use of SPECT scans was discussed in this post, has identified six types of ADD.

It’s safe to say that treatment is more likely to be effective if it’s tailored to the type of ADHD the individual has. When choosing a mental health professional, it would be a good idea to find out how specific s/he gets in ADHD diagnosis and treatment.

Treating the Symptoms

Getting a diagnosis doesn’t necessarily mean you’ll be taking medication for it the rest of your life. Several of the links above, and several other posts in this blog, give suggestions on how to manage the negative aspects of ADHD. Here is one example of a webpage offering tips.

Having a coach, seeing a counselor, making lifestyle adjustments, exercise, spending time outdoors, dietary changes, and nutritional supplements have all helped other people. Alternative therapies may be worth a try. So while medication can be a powerful tool that yields dramatic improvement, it isn’t the only tool available.

No matter what path of treatment is chosen, it’s way better to deal with having ADHD than to live in denial and do nothing. Many adults with undiagnosed or untreated ADHD self-medicate through substance abuse. Untreated ADHD also allows the behavioral and psychological traits that often go with it (like depression, conduct disorders, anxiety, etc.) to cause more misery than they would otherwise.

Some people believe ADHD should be considered a “style” rather than a “disorder.”  The first psychologist who saw our son Alan was of this persuasion. It’s a point worth acknowledging, since ADHD often comes with positive traits, including energy, creativity, flexibility, and intuition. However, the views stated in this link are by far the most common: that ADHD is a “psychiatric disorder” because it is a “condition that involves mental functioning that causes significant impairment.”

The Big Picture, Part 2

In closing, I was interested in this from the Centers for Disease Control and Prevention, especially the part that talks about their research agenda. With all the studies that have been done, it surprised me how many basic questions about ADHD still don’t have an answer. I wonder if there’s adequate funding, or any funding, for the proposed research. But it’s good to know that the CDC is hoping to get a handle on the social and economic burden of ADHD, the risk factors (and therefore possible prevention) of ADHD, and what the most effective interventions are.

***

The information gathered above isn’t exhaustive – but I decree it to be enough for now! The big takeaway from it all for me is that ADHD is a disorder with underlying biological causes. Someone with ADHD isn’t just being a “jerk” or a “space cadet”, and can’t become more organized and less impulsive through force of will. With support, adults with ADHD can minimize the negative aspects and find a niche where their positive traits are valued. When this happens, individuals, families, the workplace, and society as a whole will all benefit.

 

 

 

Fetal alcohol spectrum disorders – beyond childhood

In the pre-adoption classes that my husband and I took more than twenty years ago, the instructors emphasized that the babies being placed for adoption probably had one or more strikes against them. Among the potential disorders the infants might have had was fetal alcohol syndrome (FAS). We read the handouts about FAS, and concluded that the deficits and difficulties that come with it would’ve been a huge challenge for us.

As it turned out, both of the babies we adopted had had unfortunate prenatal circumstances, but alcohol exposure was not among them – at least, not according to the birthmothers or those who knew them. The social worker for our younger son did inform us that Alan had been born with meth in his system (and that his birthmother smoked a pack of cigarettes a day). But since Alan became an easygoing little boy who did well enough in school, we thought that he’d escaped any bad consequences of his birthmother’s habits.

Over the years I gradually forgot about fetal alcohol syndrome, to the point where I recently saw the acronym FAS and wondered what it stood for.

Since this blog attempts to cover situations that fall through the cracks, I am a little embarrassed that until now, FAS has fallen through the blog’s cracks! Let’s remedy that by looking at the behavioral and learning challenges of FAS in teens and young adults.

First of all, it seems that over the past 20 years, the terminology has been updated. Prenatal alcohol exposure leads to aberrations in brain formation that cause what are now broadly referred to as fetal alcohol spectrum disorders, or FASDs. FAS is the most severe end of the fetal alcohol spectrum. What used to be known as fetal alcohol effects (FAE) are now referred to as either alcohol-related neurodevelopmental disorder (ARND) or alcohol-related birth defects (ARBD). These are the diagnoses used when the individual has some but not all of the characteristics of FAS. If the concerns are primarily behavior- and learning-related, the diagnosis might be ARND. If the impacts are more on the physical side of things, ARBD might be the diagnosis.

For children who have an FASD, early intervention and a stable home environment are recommended to lessen the impacts. But for whatever reason, many individuals don’t receive appropriate therapy as a child, and/or their parents don’t get the appropriate educational, social, and psychological support services. The youngster’s home life may be chaotic and stressful. Without interventions, some major and persistent struggles are in store for the individual with an FASD.

According to WebMD, students with FAS have higher rates of suspensions and expulsions, difficulty getting along with others, disobedience, and truancy. Problems with controlling anger and frustration, and with understanding the motives of others, often lead to violent behavior in teens and adults, which in turn can lead to criminal charges. People with FAS are also more easily persuaded and manipulated, and therefore can become unwittingly involved in illegal activities. Even if they aren’t in trouble with the law, adults with FAS often have trouble holding a job and living independently. More than one-third have significant substance abuse problems at some point in their lives.

From what I’ve read, the struggles caused by FASD tend to be lifelong. But let’s back up a second. What are the symptoms of FAS? The characteristics may include:

Physical: abnormal facial features; small head size; below average height and body weight; problems with heart, kidney, or bones; central nervous system problems

Neurological: problems with attention, memory, learning, communication, and/or social skills

Psychological: depression, psychotic episodes, substance abuse

As you can see, FASDs can have a lot in common with ADHD, learning disabilities, and conduct or personality disorders. When a teen or young adult has a combination of those traits, prenatal exposure to alcohol (or other drugs) is possibly the underlying cause. However, clinicians frequently fail to recognize FASDs and assign other diagnoses instead.

I found an informative link, which seems to be from the FAS Community Resource Center, that indicates how FAS goes beyond merely having a collection of co-occurring individual disorders.The link provides detailed descriptions of the challenges faced by adults with FAS. It’s pretty wordy but has some great information, which I’ll attempt to summarize below. (Much of the phrasing is taken directly from the text.)

Problems with cause-and-effect relationships and impulse control – Individuals have difficulty learning from experience or grasping consequences. The ability to reflect on the outcome of actions, inaction, or impulses is faulty, works only sporadically, or is missing altogether. This makes it hard to delay gratification or work towards long-term goals.

Problems with the ability to generalize information – Individuals can’t apply what has happened before to the current situation. It’s hard to see shifting possibilities, and to apply “rules of thumb.” The first solution to a problem is usually seen as the only solution, even when it clearly doesn’t work. The person is continually surprised by adverse reaction to their repeated misbehavior.

Problems with understanding concepts and abstract thoughts – Individuals are unable – not unwilling – to conceptualize and abstract basic human interactions. The person has difficulty with time, money, numbers, and concepts like honesty, integrity, responsibility, and values. It’s hard to understand the abstractions in everyday language, such as “if”, “then”, “later”, “maybe”, “should”, “would”, “could”.

Problems with perseverative behavior – The person has a rigid way of looking at things, refusing to let go of an idea, and refusing to consider any other explanation. Trying to talk sense, rationalize, or otherwise intervene makes the situation worse.

Problems with the ability to conceptualize, internalize, and structure time – Individuals are unable to internally structure time or pay much attention to it. This leads to missed appointments and tardiness. It is difficult to track days of the week, months, seasons, and important dates. It is challenging to read an analog clock, especially if the numbers aren’t on the clock face. It is difficult to understand the subdivisions of time, such as 60 minutes in an hour, but 24 hours in a day – and each of the 12 “hour numbers” occur twice in a day! (a.m. and p.m.).

Problems with short term memory – Information may be learned, stored, and retained for a while, only to disappear without warning, and reappear just as suddenly, all with no predictable pattern. Difficulties with sequencing have serious implications for being able to “tell the truth.” An adult with FAS/E is not a “liar” in the commonly accepted sense of the word. The adult may say “untruths” when interpretation of what has been incorrectly stored to begin with runs headlong into a distorted perception of the environment and one’s relationship to it.

Problems in all areas of processing information, particularly auditory – Information input, memory, integration, and output are all impaired in adults with FAS/E. The link between input and output is defective. Despite the significant processing deficits, individuals are highly verbal, giving the impression of being more functional than they actually are.

Summary: The behaviors and functions associated with FAS/E become more obvious with increasing age as we expect people to become more self-directed, self-motivated, and self-controlled. Independent living as adults requires extensive, intensive, comprehensive, and continuing supports in place.

***

I’ll tell you what: learning all of this has been a huge “aha” moment for me, because since his early teens, Alan has exhibited traits falling in every one of the “problem” areas outlined above. The traits haven’t been extreme, but they have definitely been a big challenge for all of us. Alan’s behaviors and deficits in functioning have been baffling, and caused a whole lot of tension and frustration over the last several years – especially because they’ve come packaged in a highly verbal, seemingly competent guy with a lot of negative attitude. Until now, I had not seen his traits grouped together and given a name. The possibility that Alan has ARND will help me reframe my outlook on his actions and choices – and redirect my radar for things that may help him.

Remember how I said that Alan’s birthmother had used meth while pregnant? Well, in our pre-adoption classes we’d been told that although the evidence was unclear, prenatal meth exposure was believed to cause fewer problems compared to other drugs used by pregnant women. Today the evidence still isn’t clear, but I did find this article saying that meth by itself may cause more damage than alcohol does – and when meth and alcohol are both used during pregnancy, the effects are especially damaging. Hoo boy.

If you have insight into young adults grappling with an FASD, please share your story with us. If you need resources to help someone with an FASD, please check out this link from the Friendship Circle. They’ve gathered links to 17 resources and organizations related to fetal alcohol syndrome. Note that one of the books in the link, titled Fantastic Antone Grows Up, is a nonfiction book that relates specifically to teens and adults with FAS.

Finally, you might want to read this story about a few young adults in Minnesota with FAS and how they are coping. The treatment center at Westbrook farm sounds like a great program! More facilities like it are badly needed, to give teens and young adults with an FASD a better chance at navigating through life.

UPDATE: Here are some excerpts of information Val Lipow, President of the FASD Network of Southern California (see her comment below) shared with me on LinkedIn:

Everything posted to the post you shared is accurate. Exposure to other toxins may put the developing brain at risk of damage, but prenatal alcohol exposure has very specific effects to the brain and other structures of the baby in utero. Remember, alcohol is a chemical solvent, and it affects the cells in each developing prenatal system. It causes structural damage to the brain, and some of these changes interfere with the smooth transmission of neurochemical transmitters that send commands and messages in the brain and between the brain and other systems.

Children born from every ethnic group and every socioeconomic class are affected. FASD affects an estimated 1 in 100 births in North America, and the actual occurrence may be closer to 4 in 100: http://www.ncbi.nlm.nih.gov/pubmed/9451756?log$=activity. Few people are aware that FASD affects more persons than autism, Down syndrome, cerebral palsy, cystic fibrosis, spina bifida, and sudden infant death syndrome combined.

FASD affects persons across the globe, especially in North America, Europe, and Africa.

While intellectual impairment (“mental retardation”) is common among persons affected by prenatal alcohol exposure, many FASD-affected individuals have an average or above-average IQ.

Whether intellectually impaired or not, affected persons … often have coexisting mental health diagnoses, emotional and sensory dysregulation issues, and/or or learning disabilities. These issues cause the person to have cognitive and adaptive functioning abilities typically much lower than expected for their chronological age.

Aspergers, or schizoid personality disorder?

Making diagnoses can be tricky business. In the medical world, even with all the lab tests and imaging currently available, physicians frequently have a hard time pinpointing the best label (never mind the best treatment) for a set of symptoms. Diagnoses are even squishier in the mental health world, where labels are based primarily on how an individual behaves and feels; lab tests and imaging are rarely used.

Elsewhere in this blog I’ve documented how the diagnoses for our son Nathan changed over time. In his late teens, the notion that he had Aspergers took hold. Psychological tests at his high school qualified him as “autistic-like”; the psychiatrist who finally provided an official Aspergers diagnosis said of Nathan, “He has it, in spades!”

Nathan has been through a few mental health professionals since then. All of them seemed to be on board with the Aspergers diagnosis, although the emphasis of their treatment was on Nathan’s depression, which had reached crisis levels (0r depths).

Nathan started seeing his latest psychologist (Dr S) last July. I gave my input in the first session, and subsequently sat in the waiting room during their monthly sessions. By February’s appointment, I decided it was time to ask Dr S about his impressions, and whether there were adjustments we should make in supporting Nathan’s journey through life.

Dr S asked me what I saw as Nathan’s challenges. I replied, “Blah blah blah his depression, and blah blah blah Aspergers…”

Dr S interrupted me. “Oh, I don’t see any signs of Aspergers. I think Nathan has schizoid personality disorder. Have you ever heard of it?” I shook my head. He then showed me the diagnostic criteria for this scary-sounding label.

“Wow, that does seem to fit him!” I said.

Dr S turned to Nathan. “Are you curious about this?”

Nathan grimaced. “Not really.” He declined to read the diagnostic criteria.

Dr S told me two major things about schizoid personality disorder. First, it would be pointless to try to get someone with Schizoid PD to socialize if s/he doesn’t want to. Second, he said people with Schizoid PD rarely hold jobs.

I left his office trying to wrap my head around this new framework for Nathan’s condition. My new task was to find out more about Schizoid PD. I also wondered how common it is for the diagnosis to be switched with Aspergers or autism spectrum in general. The following is what I have found.

First, it helps to know what a personality disorder is.  This summary from the Mayo Clinic is in plain language (compared to the others I found):

A personality disorder is a type of mental disorder in which you have a rigid and unhealthy pattern of thinking, functioning and behaving. A person with a personality disorder has trouble perceiving and relating to situations and to people. This causes significant problems and limitations in relationships, social encounters, work and school.

In some cases, you may not realize that you have a personality disorder because your way of thinking and behaving seems natural to you. And you may blame others for the challenges you face.

Among the better-known personality disorders are the paranoid, narcissistic, and antisocial personality disorders.

Like all personality disorders, Schizoid PD doesn’t become evident until the teen years or early adulthood. It is more common in males, and is thought to affect 1 – 5% of the population.

Here is a summary of Schizoid PD symptoms, copied from this link to Psychology Today:

The schizoid personality rarely feels there is anything wrong with him/her; symptoms are an indifference to social relationships and a limited range of emotional expression.

  • Takes pleasure in few, if any, activities
  • Does not desire or enjoy close relationships, including family
  • Appear aloof and detached
  • Avoid social activities that involve significant contact with other people
  • Almost always chooses solitary activities
  • Little or no interest in sexual experiences with another person
  • Lacks close relationships other than with immediate relatives
  • Indifferent to praise or criticism
  • Shows emotional coldness, detachment or flattened affect
  • Exhibits little observable change in mood

It is important to know that Schizoid PD is not schizophrenia, and it isn’t schizoaffective disorder. Both of those involve psychotic symptoms such as hallucinations and delusions. People with Schizoid PD are in touch with reality. That being said, there does seem to be a relationship between Schizoid PD and schizophrenia: they turn up in the same families, and individuals with Schizoid PD may be more likely to develop schizophrenia than the general population. Another condition, called schizotypal personality disorder, has similarities to Schizoid PD but (from what I gather) involves more fear and eccentric behavior.

Other informative links about Schizoid PD are from Wikipedia (lots of detail here!) and the Mayo Clinic. It was disturbing in the latter link to read that one of the risk factors for Schizoid PD is “having a parent who was cold or unresponsive to emotional needs.” I immediately thought of the times I was understated or annoyed in reacting to Nathan’s many meltdowns. Ah, parental guilt! The Wikipedia entry softens this somewhat by saying that the link to parental aloofness is a hypothesis, not a certainty.

Speaking of guilt, I found a website called Out of the FOG, which provides support for family members of someone with a personality disorder. FOG stands for Fear, Obligation, and Guilt – common reactions for those dealing with such a person. Anyway, if you follow the OOTF link above, you’ll see a list of 30 traits that are common in people with Schizoid PD, and toward the bottom of the page is the official diagnostic criteria from the DSM (Diagnostic & Statistical Manual of the American Psychiatric Association).

It appears there are no really great treatments for Schizoid PD. Psychotherapy may help, if the individual decides s/he wants to make progress in coping with society. Medications can be prescribed for some of the symptoms that go along with the disorder, such as depression and anxiety.

As for a diagnosis switching between Aspergers and Schizoid PD, it seems to be a fairly common occurrence. A book about Aspergers published in 2007 that I found on our bookshelf says that some researchers believe Aspergers and Schizoid PD might be the same thing. This article by Barbara Nichols from October 2013 talks about the differences but also says some believe Schizoid PD may be on the autism spectrum. The controversy continues. (The nifty diagram (with teeny-tiny print) at the top of this post was taken from this article).

Internet forums are a good way to find out what others have to say. Here are links to three forums on the topic of Aspergers vs Schizoid PD. This one from Wrong Planet gets into other diagnoses besides Schizoid PD that may come up in the Aspie community. The explanation given by Anasthasia in this Psych Forum is one of the clearest I’ve come across. Among other things, she says that an Aspie struggles with reading social cues; a Schizoid can read them but doesn’t care to. This thread in a forum on CosmoQuest gets off-topic, but was notable to me for posing the idea that Schizoids can change their sociability with a lot of will power, but Aspies are wired differently and therefore cannot.

One last link about the differences: for those of you who watch the BBC “Sherlock” series (with Benedict Cumberbatch), here is someone of the opinion that Sherlock has Schizoid PD, not Aspergers.

Which diagnosis do I think fits Nathan better? I’m still a little confused, but the balance is tipping towards Schizoid PD. Sadly, I won’t be able to ask Dr S any follow-up questions: he passed away suddenly 13 days after Nathan’s February appointment. Nathan, who dislikes almost everyone, seemed to be fine with Dr S and their sessions. He expressed surprise but no other emotion on learning of his therapist’s passing.

 

 

 

 

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