ADHD and Me

Hi. I’m Jai. I’m 8 years old. This is my story. My doctor says I have an illness. I don’t feel sick. But I do know that grown-ups around me are annoyed with me most of the time. I’m constantly being told, “sit still’’, “stop dreaming”, “pay attention”. I can’t seem to be able to do just that.

In class, I seem to lose track of what the teacher says. I try to listen, I really do. I start doing what she says, then I notice the insect fluttering on the window pane, I see the boy in the row ahead tapping his fingers on the desk, the office boy walking down the corridor and the sound of laughter from the next classroom. I don’t realise I have left my seat till teacher tells me “Jai, return to your seat”.

My parents are frequently called to school to meet my class teacher. They are unhappy with my marks. They think I’m careless and lazy because I take all evening to do my homework. I tell my mother that I try hard. I feel sad and frustrated that she doesn’t understand or believe me. Some of the other children make fun of me specially when I can’t answer in class. Mostly, I haven’t heard the question. They don’t like to play with me as I get excited and can’t wait for my turn.

Things changed about 6 months back. My parents took me to a special doctor. The doctor seemed to understand that I was not being naughty or disobedient. He talked to me, looked at my exercise books and listened to my parents. He told my parents that I had an illness, ADHD. I needed medicines for treatment of ADHD to improve my focus and concentration. I also need structure and routine in my life. It was such a relief to know it was not my fault.

A lady at the doctor’s clinic gave me some puzzles and games to do. I liked her; she spoke slowly and clearly. She explained things one at a time and did not mind repeating herself when I did not get her the first time. She helped us draw up a time-table - we had such fun doing that because she made time for everything I want to do. Now I have a study time, a play time, TV time, all clearly written in the big chart I helped to make. It reminds me of what I have to do and gives me enough time to prepare for it. Mother says I sit quietly for longer periods. Teacher says I pay more attention and don’t disturb other kids in class. She is more patient with me too.

Understanding ADHD and Helping Me

Doctor says there are many children like me. Here’s what you can do to help me and others like me.

• Help me focus. Make sure I’ve heard you and understood what you want me to do.
• I sometimes don’t realise I’ve left my seat. Please remind me to stop and think.
• I need structure and routine in my life.
• I need to know what comes next.
• Please give me time to adjust to any changes in my schedule.
• Please let me learn at my own pace, I get confused and make mistakes when you ask me to hurry up.
• Please give me instructions one step at a time. Make me repeat them.
• Please give me short work periods and small goals to start with.
• Please give me immediate feedback; did I do things the right way?
• Do give me praise even if I succeed only partially. Please don’t wait till I’m perfect.
• Don’t always find fault with me. Please praise me and reward me when I do something well.

Thank you for being patient with me.

Dealing with Grief

Dealing with grief is a process of acceptance

Grief is the response to losing someone to death. All of us understand that death and loss of a loved one is a part of life. However, the reality of death often leads to feelings of shock, sadness and confusion. Acute grief occurs in the immediate aftermath of the loss. It is intensely painful characterised by sadness, crying, constant thoughts of the deceased, disturbed sleep, appetite and disinterest in one’s own self and others. In a majority of cases, this is followed by integrated or abiding grief in which memories of the loved one mingle with sadness and longing but it does not persistently occupy the mind or disrupt normal day-to day activities.

“Well, everyone can master a grief but he that has it.”

William Shakespeare. Much Ado About Nothing. III.ii.25

Loss through death affects each of us differently. How one feels depends on the nature and circumstances of the loss, one’s beliefs and religion, age, relationships and one’s own physical and mental health. A sudden or violent death, death of a child or loss of a long-time spouse are always more difficult to accept. If the relationship with the departed person was difficult, the grief is more complicated and may take more time to work through.

Stages of grief

5 stages of the grieving process has been described. The stages do not necessarily come in order, nor are all the stages experienced by every person. One may return or go through one or the other stage several times before acceptance of the loss.Grief is a process and not just a state. During the process of grieving and bereavement a person may experience many emotions during the course of bereavement- helplessness, anger, sadness, denial, despair and yearning are common.

Denial

The first stage is the stage of denial ('It's not true’; ‘There must be some mistake.’) This is a normal defence mechanism which helps to cushion the immediate shock.

Anger

Once the reality sinks in, the pain is often redirected and expressed as anger. ‘Why me?’; ‘Its not fair’; ‘How can this happen to me’; are the common reactions in this phase. Anger may be directed towards objects, strangers, the doctors or family members, God; or even towards the deceased person- ‘How could you leave me alone?’

Bargaining

A promise of good behaviour or an attempt to strike a bargain (‘I will always listen to you’, ‘I will never worry you again,)’ is often the reaction at this stage.

Depression

Sadness and regret are mingled and one may often say ‘There is no point in life; - I may as well die too’.

Acceptance

At this stage emotions are stable and calm.

Strategies for dealing with grief 

Though each one copes differently, the following strategies may help you cope with your feelings and come to terms with your loss.

1. Talking about your loss: It may be difficult for you initially- but in time it helps to talk about your loss and your feelings with a trusted family member or friend or a counsellor.
2. Accepting your feelings : The anger, guilt, helplessness you may feel are normal and part of the grieving process. There is no guilt or shame in accepting them; and it paves the way for healing.
3. Taking care of yourself : Establishing a routine with regular meals, exercise and adequate rest is important for your physical and mental health.
4. Reaching out to others: Working with people less fortunate, or carrying on the legacy of the deceased (teaching, helping in the community) helps to give meaning to life.

When to seek professional help

• Though different people take different times, intense and persistent grief continuing over a period of six months may require professional help.
• Loss due to suicide is among the most difficult to bear. In such cases, counselling during the first weeks is both advisable and beneficial.
• Inability to cope with or resume daily life or work activities, intense sorrow or pain which does not subside with time, inability to maintain or build relationships are indications to consult a mental health specialist.

Recovery from grief is a highly individual process. Each individual works through grief on their own with time, using their own personal ways of coping. Acceptance, rationalisation, humour, distraction, prayer, avoidance of reminders are some of the many ways in which people cope. Social support and healthy habits contribute to recovery which may take a few months or even a year.

Mental Illness Myths and the Media

Media portrayals of mental illness propagate prevailing myths and increase associated stigma.

Media and Stigma

Mass media – TV, cinema and newspaper – are the primary source of mental health information for the general public. The mentally ill are usually shown in poor light; and images of unkempt, violent and dangerous men predominate. This greatly affects the public’s view of the mentally ill, causing them to fear, avoid or discriminate against people with mental illness. This is even true for TV programs and stories for children. From an early age mental illness is seen as less desirable than other illnesses.

Negative images such as these affect those with mental illness, damaging their confidence and self-esteem. It makes them more isolated and withdrawn and they are more likely to stay away from therapy. In one study, as many as 50% of patients reported that a negative media portrayal had a negative impact on their illness, with 34% saying that it directly led to an increase in depression and anxiety.

Government policies are also affected by prejudiced media  portrayals of mental illness. Since people with mental illness are seen as anti-social, prone to violence and a potential danger to society, government policies tend to restrict and isolate instead of being more broad-based.

5 Media Myths on Mental Illness

Myth 1 – People with mental illness are violent and unstable

Almost two-thirds of all stories about the mentally ill in both the news and entertainment media focus on violence. While it can happen, most violent crimes are in fact committed by people without mental illness. But a crime committed by a person with mental illness is blown out of proportion by the media instead of being seen as something rare and out of the ordinary. Studies in fact indicate that the mentally ill are more likely to be victims of violence rather than the offenders.

Myth 2 – They do not get better and treatment is ineffective

The truth is that even severe psychiatric disorders can be treated effectively and people can lead normal lives at work, at home and in the community. While treatment of psychiatric disorders has evolved, the media continues to show outdated practices. This highly inaccurate portrayal often prevents both the mentally ill and their families from seeking treatment.

Myth 3 – Mental health professionals are evil, mentally unstable, or unethical

The diagnosis and treatment of mental health disorders requires patience, skill and comprehensive evaluation. Mental health care professionals spend years in acquiring the qualifications and training required. Yet media portrayals undermine the integrity of these professionals. This further discourages people who are already hesitant to seek treatment.

Myth 4 – Teenagers with mental illness are just going through a phase

This encourages parents of teenagers to ignore symptoms as something that teenagers will outgrow. Movie portrayals of the teenager as a ‘rebellious free spirit’ further glamorises it in the eyes of the teen. The truth is that the onset of many serious psychiatric illnesses is in adolescence or early adulthood and early treatment offers the best outcomes.

Myth 5 – There is a genius behind every mental illness

While some people with mental illness are undoubtedly gifted, a vast majority of people with mental illness are ordinary individuals who want to get on with their lives and work productively. This caution is specially true for parents of children and adolescents; who view the role of the therapist as one who will unlock the hidden genius in their child. These unrealistic expectations put unnecessary pressure on children, often leading to a relapse; or a loss of faith in the treating clinician.

Sympathetic but exaggerated media portrayals may do more harm than good. Simple achievements need to be highlighted just as much. As an example, while the media annually highlights the success of children with physical disabilities in the board exams, yet no story deals with the successes of those with children struggling against schizophrenia and other mental illnesses. Sharing such stories will increase awareness among the public about how regular treatment and supportive therapy can help a child return to normal functioning.

The media’s defence is that the public is not interested in watching something dull and boring, and that they need to dramatize and exaggerate portrayals. However, authentic stories of mental illness have heartbreak, drama, humour and everything in between. Sensitive and accurate portrayals by the media will go a long way in removing the stigma and isolation associated with mental illness, bring the ill into the ambit of treatment, and improve their integration into society. This level of reporting can only be  reached with considerable effort. We need to understand the media are geared towards sensationalism, and the facts regarding mental illness and the people affected by them are more nuanced.

References

1. Dara Roth Edney. Mass media and mental illness: a literature review. Canadian Mental Health Association. 2004. Accessed 21-Sep-2015
2. Murphy NA1, Fatoye F, Wibberley C. The changing face of newspaper representations of the mentally ill. J Ment Health. 2013 Jun;22(3):271-82. doi: 10.3109/09638237.2012.734660. Epub 2013 Jan 16.
   
3. Patrick W Corrigan and Amy C Watson. Understanding the impact of stigma on people with mental illness. World Psychiatry. 2002 Feb; 1(1): 16–20.

Aptitude Testing & Work Choice – evolutionary perspective

Aptitude testing for responsible work choice

Aptitude testing for career guidance has existed only since the 1930s. Aptitude testing was not needed until work choice became freely available about 200 years ago. Before that a person had no choice in his field of work. People trained for whatever their parents did. If they had access to patronage or money they could take up a profession. Now, with the concept of Right to Education, governments seek to extend career choice to all socioeconomic strata. With this new privilege of work choice comes the responsibility of choosing wisely. Aptitude testing takes into account abilities, personality, intelligence and motivation for making a career choice.

Work choice

a brief history

For 10,000 years we did the work our parents did. In the initial millennia of mankind’s existence, work was necessary for survival. Primitive man was a hunter-gatherer to fulfil the biological need for food. As the first human settlements evolved man became a cultivator. He learnt to fashion tools, and make storage vessels. This gave rise to occupations like farming, pottery, and weaving. Densely populated centres evolved, as in Jericho. Families specialised in different trades. Son followed father in the family occupation. Skills were learnt and passed on from one generation to the next. Social hierarchies were formed loosely based on occupation. This often comprised a ruling class of administrators, the merchants, and then the labourers.

In India, occupation formed the initial basis of the caste system. Did an individual have the freedom to choose his profession or trade? The Mahabharat tells us the story of Eklavya, a tribal who wished to become an archer. Drona, the greatest teacher of the time, refuses to take him on. Eklavya through an extraordinary feat of dedication and disciplined study becomes a better archer than Prince Arjuna. However, though he had undoubted skill, aptitude and interest; he was not allowed to transgress the rules of society. Martial art was reserved for the warrior caste – the Kshatriyas – and Ekalavya was punished for aspiring to the same.

5000 years ago the first script evolved. Writing of language in a cuneiform script developed in Mesopotamia (Sumer) in 3200BCE. This heralded a radical change in the way knowledge was communicated and disseminated. Education was imparted informally to groups of children until the age of 13-14yrs. Thereafter these usually followed in the profession of their fathers.

2000 years ago we see the first example of career screening. The Jews selected brighter boys to continue studies as disciples of the rabbi. They would then become masters and rabbis themselves. However, the individual himself had no choice in the matter.

1000 years ago the elite had access to education through universities. The University of al-Qarawiyyin in Fes, Morocco, is the oldest existing, continually operating and the first degree awarding educational institution in the world. An important development in choice of education is the concept of academic freedom. This concept originated in University of Bologna (est 1088 CE, still extant) which was the first to guarantee students freedom in the interests of education. The university also gave students a choice in the curriculum to be studied. However, university education was still for a privileged few and limited to a career in the church or as a professional (law or medicine).

500 years ago formal apprenticeship was first originated. A young person usually between the ages of 10-15yrs was formally bound to a master craftsman for 3-7 years. A supply of labour in a particular trade and a certain standard was thus ensured. In the early 17th century children of paupers and vagrants were put under compulsory apprenticeship – refusal could lead to imprisonment. Later children of the gentry apprenticed to merchants, manufacturers, doctors and lawyers. By the 18th century, apprenticeship existed in every level of society except the highest. However even then, the boy himself had little or no say in his career. Career was dictated by the financial situation of the father and availability of a master. The poor had no choice.

200 years ago educational reforms were initiated when the UK National Education League began its campaign for free, compulsory and non-religious education for all children in the 1870s. Students can now take up any of a whole gamut of ever increasing fields. There is now a surfeit of careers to choose from. Students are now forced to choose between subjects when they transition from secondary school to high school. From an absence of choice they are confronted with an array of career choices. It is now important to choose a career in which the individual has a high chance of success and job satisfaction.

80 years ago aptitude testing for job screening and career guidance was developed by the US Employment Service to improve the fit between the individual and the job. Many other aptitude tests have been developed since. Aptitude tests are used in career guidance to measure different abilities and match them with the requirements of various work fields. Given the importance of work in relation to individual well-being, aptitude testing is now a basic tools in job selection. Aptitude testing combined with assessments of soft skills like personality and work style provides comprehensive data for individual career guidance. However, even today, society at large believes that career decisions happen ‘naturally’. Though so much has changed – higher education is easily available, social and gender restrictions have eased and we can choose to do what we are good at – many of us still follow the path of least resistance and do just as our forefathers did 10,000 years ago.

References

1. Kathleen Mary Kenyon. Encyclopedia Bratannica. Jericho. http://www.britannica.com/EBchecked/topic/302707/Jericho Accessed 21-Apr-2015
2. The History of Education. Ed Robert Guisepi. http://history-world.org/history_of_education.htm Accessed 21-Apr-2015
3. Wikipedia. University of al-Qarawiyyin. http://en.wikipedia.org/wiki/University_of_al-Qarawiyyin . Accessed 02-Apr-2015
4. Wikipedia. University of Bologna. http://en.wikipedia.org/wiki/University_of_Bologna Accessed 06-Apr-15
5. Family Search. Apprenticeship in England. https://familysearch.org/learn/wiki/en/Apprenticeship_in_England Accessed 08-Apr-2015
6. The 1870 Education Act. http://www.parliament.uk/about/living-heritage/transformingsociety/livinglearning/school/overview/1870educationact/ Accessed 09-Apr-2015
7. John F. Reeves. Aptitude Assessment for Career and Educational Guidance. http://www.theworksuite.com/id15.html Accessed 08-Apr-2015

Treat schizophrenia even if your teenager refuses

Treat schizophrenia as you would any other serious medical illness in your teenager

"My 18yr son is aggressive, hearing voices, and not sleeping."

"Since the last two months he is not attending college. He talks to himself in his room and is not going out with his friends."

"He feels he is being tracked through the TV and yesterday assaulted his mother when she put it on."

"We tried taking him to our doctor but he refuses saying there is nothing wrong with him."

This is a common introduction to the more severely ill teenagers presenting at Pathfinder Clinic.

Why teenagers with schizophrenia refuse to see a psychiatrist 

Teenagers refuse to see a psychiatrist for illness related and personal reasons

Illness related factors

Schizophrenia is a brain disease. Your teenager has difficulties recognising his own symptoms. In schizophrenia there are changes in brain structure, chemistry and functioning. The individual is unable to recognise the problems in thinking, and perception. They hear voices threatening harm to themselves and their families. The  same voices command them not to see the doctor. Reality is distorted and they are unable to correct it through feedback from others. Your teenager perceives this distorted internal image of the world as the real one. They attribute their problems to the external environment. Technically this is termed as a lack of insight. The disease process prevents them from seeing these distortions as an illness. Because of the illness they refuse to see the doctor or take medications.

Personal reasons

Many adolescents refuse or drop out of treatment due to stigma of mental illness. They have high levels of self-stigma. They believe that schizophrenia is a result of a laziness, weakness or incompetence. This belief is reinforced by parents, society and friends who give advice like

"You really need to get your act together"

or

"You better snap out of it or people will think you’re crazy."

So in their mind your adolescent rationalises the problems as being outside themselves

 – "You won’t let me do what I want and now you are trying to label me as crazy, you need therapy, you go to the doctor."

Taking medication is seen as an acknowledgement of their own failure. To the teenager denial of illness and rejection of medical care appears more acceptable.

Parents

Parents of an adolescent with schizophrenia are working through their own public stigma. They may see schizophrenia as occurring due to faulty parenting and lack of control. They struggle against the stereotype of their son or daughter as incompetent and requiring supervision. They mistakenly fear they will need to protect the teenager from being labelled and shunned socially. In their mind going to the doctor will accelerate the stigmatising process. So the symptoms are ignored or controlled to the greatest extent possible. This may include keeping the teenager out of school or college for months until the exams are due. When the illness makes life unbearable at home they seek medical help. This is often in an atmosphere of shame and a sense of failure. Many families are unable to overcome these prejudices. They delay treatment for decades until they realise there may be no one to care for their son or daughter when they are gone.

The advisers and 'well wishers' of teenagers and their families are a third set of influencers whose lack of specific knowledge can reinforce self-stigma. Statements like

"Send him to us for a few weeks and he’ll be OK"

and

"Avoid ‘psychiatric’ medications because they are addictive"

or

"Medicines will cause permanent damage"

add further obstacles to the path to standard and adequate treatment.

When the adolescent is functioning well on the medication these misinformed 'well wishers' are the ones who advise

"What do you need the medicine for? I can see nothing wrong with you"

and set the stage for relapse and refusal to meet with the doctor when the illness relapses

 – "Chacha said there is nothing wrong with me, why are you trying to label me?"

What to do?

Refusing help for schizophrenia is not an option.

• We have already seen what can be done to get a reluctant patient to see the psychiatrist. 
• However, for schizophrenia, more urgent measures may be required.  Involuntary admission to a mental health facility for initiation of treatment may be needed. This is especially so when the adolescent is violent, suicidal, using addictive substances, or repeatedly missing from home. Involuntary admission helps in the same way that it helps get your adolescent admitted to hospital if they had dengue fever even if they did not want it. There are provisions in the Mental Health Act to ensure this is done in safety with respect for your adolescent’s rights. After they receive treatment and brain function returns to normal they will thank you. For they will be relieved from the terrors of reality distortions and desperation of suicide thoughts. 
• Once treatment is initiated ensure they take medications every day as prescribed. Don’t take on any other responsibility regarding the medication. Leave that as a dialogue between your teenager and their psychiatrist. Just make sure it continues to happen.

Why teenagers with schizophrenia must get treatment even if  they don't want it

Brain cell death

Schizophrenia is associated with death of brain cells and shrinking of brain volume. The longer the duration of untreated symptoms the greater the toxic “dose” of delusions and hallucinations delivered to the developing adolescent brain. Delusions and hallucinations are merely the tip of the iceberg – underlying brain changes have already set in. When treatments are delayed for more than a week the illness becomes even more severe and impairing. The person is less likely to recover, and is at greater risk for addiction to cannabis and other substances. These negative changes related to delay persist even after a year when treatment is finally started.

Academic impact

Schizophrenia symptoms make it difficult for the teenager to attend school or college. There is difficulty focusing. In the earliest stages there is an accelerated deterioration in academic performance. This usually takes place in late adolescence. Research suggests this may be a marker for schizophrenia onset. Deteriorating academic performance is seen even before social or other symptoms to appear. Unfortunately this is the very stage of life at which academic performance is critical and shapes career choices for adult employment. Many formerly brilliant students are anguished when they are suddenly struggling to even pass their exams. In fact studies have shown schizophrenia is more likely to affect those who excel at academics, making it all the more devastating. Missing or failing in board exams has an adverse impact that timely treatment can obviate.

References

1. Compton MT, Gordon TL, Weiss PS, Walker EF. The "doses" of initial, untreated hallucinations and delusions: a proof-of-concept study of enhanced predictors of first-episode symptomatology and functioning relative to duration of untreated psychosis. J Clin Psychiatry. 2011 Nov;72(11):1487-93. doi: 10.4088/JCP.09m05841yel. Epub 2011 Jan 11.
2. Fung KM, Tsang HW, Corrigan PW. Self-stigma of people with schizophrenia as predictor of their adherence to psychosocial treatment. Psychiatr Rehabil J. 2008 Fall;32(2):95-104. doi: 10.2975/32.2.2008.95.104.
3. Guo X, Li J, Wei Q, Fan X, Kennedy DN, Shen Y, Chen H, Zhao J. Duration of untreated psychosis is associated with temporal and occipitotemporal gray matter volume decrease in treatment naïve schizophrenia. PLoS One. 2013 Dec 31;8(12):e83679. doi: 10.1371/journal.pone.0083679. eCollection 2013.
4. Harrigan SM, McGorry PD, Krstev H. Does treatment delay in first-episode psychosis really matter? Psychol Med. 2003 Jan;33(1):97-110.
5. Karlsson JL. Psychosis and academic performance. Br J Psychiatry. 2004 Apr;184:327-9.
6. Strauss GP1, Allen DN, Miski P, Buchanan RW, Kirkpatrick B, Carpenter WT Jr. Differential patterns of premorbid social and academic deterioration in deficit and nondeficit schizophrenia. Schizophr Res. 2012 Mar;135(1-3):134-8. doi: 10.1016/j.schres.2011.11.007. Epub 2011 Nov 29.
7. Penttilä M, Jääskeläinen E, Haapea M, Tanskanen P, Veijola J, Ridler K, Murray GK, Barnes A, Jones PB, Isohanni M, Koponen H, Miettunen J. Association between duration of untreated psychosis and brain morphology in schizophrenia within the Northern Finland 1966 Birth Cohort.Schizophr Res. 2010 Nov;123(2-3):145-52. doi: 10.1016/j.schres.2010.08.016. Epub 2010 Sep 15.

Want more references? View my collection, "Teenagers with schizophrenia need treatment even if they don't want it" from PubMed