Monday, April 2, 2012

ADHD in the family

I am continuing on the same topic i.e. the reactions( to receiving a psychiatric diagnosis for their children)  of two middle class, highly literate, urban, professional class, south Indian.
This time I wish to talk about two relatives of mine: one set of relatives  has a son and daughter with ADHD, live in USA, both parents are working, highly involved in their children’s academics and the children are highly intelligent and both have symptoms of  moderate ADHD... yet, parents have not gone to a psychiatrist or peadtrician  to seek help. They have received a few but not serious comments/complaints from school ;  at home, they have a tough struggle, dealing with the two kids. But they are managing to somehow pull it together and manage  with their own professions & lives  and the children’s academics and extra curricular activities.(by extra curricular activities I mean taking the kids to piano classes, swimming classes, etc on weekends)
The other set of relatives live in Bangalore, India; both parents are highly literate, both are working and  have two children of whom one has ADHD but much milder level than the 2 children in USA; this child has average or slightly above average intelligence, is managing to get between 60 and 85% and this child loses marks due to careless mistakes caused by inattentiveness.
Both sets of parents agree that their children are inattentive and hyperactive. But both sets of parents also:
1)refuse to go to a peadtrician/doctor/psychiatrist to get a diagnosis
2) will never consider medication, even if the child gets a diagnosis and is prescribed medication.
3) all 4 parents involved are in varying levels of denial about the ADHD of their children.
Before you, my dear reader wonder, whether these 3 kid relatives of mine are truly ADHD or it is only my theory, let me explain.  I have seen less symptomatic kids than these three kid relatives of mine, getting a diagnosis and treatment in Canada.
I can sort of understand the denial of the problem of the parents whose ADHD is only mild but it’s difficult to understand the denial of the parents whose child’s ADHD is so obvious and severe.

The denial can be of two types: (1) they truly do not believe that their child has a problem; (2) they know the child has a problem but will not admit it.
I have seen so many cases where 'love is so blind' that people live in denial about issues which are so obvious to any outsider.
There are so many possible outcomes for these three kids.
aThe children do not get treated but the parents continue to handle them with their best efforts until they outgrow these symptoms or develop coping strategies to improve their attention and channelize their energy.
bThe children do not get treated but as they grow older and the subjects at school need greater attention and focus, they deteriorate in studies
cThe children get treatment when their parents finally accept and they get better because of the treatment.
dThe children get treatment but do not respond to the medication.
The type of outcome I see in other children with the same disorder such as dropping out of school, developing conduct disorders, etc seems pretty remote in these two families as the parents have a pretty tight grip on their kids.
What fascinates me as I observe these 3 kids is that family, education of parents, the culture(Indian-Hindu culture) to which they belong are playing a role which is far stronger than the biological effects of whatever is causing the ADHD!
The high levels of education in the parents (two PhDs, one Masters and one Bachelors) should ideally indicate that the parents are more open to acceptance and treatment. Instead it is the opposite! Greater the education, greater the denial! Higher level of education correlated with stronger denial of a  diagnosis such as DD, ADHD, Autism is another strange thing I see among the Indians I know.
Theoretically the  prognosis would be poor for kids with severe ADHD but, touch wood, the two siblings growing in USA, are toppers at school, thanks to diligent parents and the protectively high IQ they have.
There is no chance that the kids will even think of dropping out of school…they are surrounded by families and neighbours and other kids who are doing well in school; they have not come across anyone dropping out of school in their lives and so the idea will not cross their minds. Every adult they know is some sort of professional and from  a young age, they aim to similar education and futures.
Both sets of parents are typical south east Asian in their attitudes: both have relatively high academic expectations from their children and giving up academically is not even an option for these parents. The truth is that  if a child considers studying a non-science subject in University, the child is considered as an academic failure! Therefore, I cannot imagine, any of these kids dropping out of school.
As far as I know,  all three kids seem pretty happy, enjoy playing, watching television and show no signs of anxiety, depression, etc. One of these three, a boy, shows slight conduct problems at home. Except for this,  I do not perceive them as having any other  major issues due to the ADHD.
I would like bring in here  two other kids, who had ADHD as children  but were not treated. One was a child in the late 50s or early 60s and people did not know of ADHD in India then…he was simply considered very naughty and beaten when his behaviour got out of hand. He went on to complete his Masters, get a job, but unfortunately committed suicide in his 20s. As an adult, he was, until his suicide, doing well at  University and at his job.To what extent, there is a connection between his adult-age depression & suicide to his childhood ADHD, I cannot comment.


The other did receive a diagnosis but his mother refused medication and he is now studying medicine in an Ivy League college in USA.
Thinking about these two non-medicated ADHD kids-current adults, I am wondering if these kids would have done better if they had had medication in childhood; OR


 if they would have done worse in some ways as the medication affects their brains negatively in the long run; OR


 if there would have been no difference at all, even if they had been medicated; I am fascinated by the idea of people who deny the diagnosis(of their children) and keep struggling and manage to achieve their goals.
 Does acceptance of a diagnosis, somehow, make one fight less ?

Can qualities like will power, determination, never give up attitude,

 overcome the effects of receiving  these psychiatric diagnosis? This

 is one thought which I often mull about. If diagnosis did not exist,

would people, have continued to carry on with their lives? If there


is no available treatment, then would absence of a diagnosis be

more helpful & less harmful than giving a diagnosis and no help?

People's reactions to diagnosis, people's acceptance of diagnosis, people's rejection of diagnosis has always facinated me. The cultural factors in play is amazingly unpredictable. Here is one example of  a quirky reaction to diagnosis. When I was working in India, in a general hospital, my collegue communicated to a low-literate patient that he was HIV positive. She explained the possible symptoms, possible course of HIV, the precautions he had to take and so on. He was relaxed, calm and almost cocky during her talk. He said, "Dont worry Doctor. I know I am going to be fine." He and several other patients who were HIV positive and of  low literacy level & lower economic status showed a similar unfazed and  cocky attitude, when given this diagnosis and information. The reaction of  college educated  HIV positive patients to being given this diagnosis  was that of severe depression and a sense of devastation. The cocky attitide of the low literate HIV positives continued for years after the diagnosis, i.e. even after they had plenty of time to absorb the information.
 I remember how upset my collegue would be to see a HIV positive report for either  a very young or a newly married patient. It almost broke her heart to see the report and break the news to the patient. However, if these guys happened to be of low literacy, they had that cocky, 'dont worry doctor' attitude! She seemed to be more upset by the HIV diagnosis than the patient! Illiteracy/ignorence can surely be a blessing at times. The less you know, the less you worry. The thought that people who dont know are happier and sleep better than the knowers and worriers is something to think about.




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