ABBREVIATED PRESCRIBING INFORMATION

Risperdal* Consta™ Injection (Risperidone).

See SmPC before prescribing.
USES: Schizophrenia. Other psychotic conditions, in
which positive and/or negative symptoms are prominent.
Not licensed for behavioural symptoms of dementia.
DOSAGE(IM): Adults: 25mg every 2 weeks (alternate
buttocks); consider 37.5mg if stabilised on more than
4mg/day oral. Consider 12.5mg increase after 4 weeks.
Maximum; 50mg every 2 weeks. Ensure prior tolerabiiity
with oral risperidone. Supplement with oral risperidone for
ADHD and its
first 3 weeks as appropriate. Elderly: 25mg every
2 weeks, plus oral cover as above. Renal and hepatic
impairment: Caution, 25mg every 2 weeks if minimum
As a mother of four children, three of whom have
2mg oral loierated following titration. Children and
adolescents under 18 years: Not studied CONTRA-
been diagnosed with ADHD, there's not much that
INDICATIONS: Hypersensitivity. PRECAUTIONS:
Not recommended for behavioural symptoms of dementia
Debbie Dean doesn't know about this disorder. Here she
because of threefold risk of cerebrovascular adverse
events. If history of CVA/TIA, consider risk carefully Care
describes what life has been like and dispels a few myths
with other risk factors tor cerebrovascular disease.
Orthostatio hypotension. Cardiovascular disease. Drugs
along the way. Introduction by Stephan Kirby
prolonging QT. Reduce dose if hypotension, if tardive
dyskinesia consider stopping all antipsychotic drugs,
Parkinson's disease. Epilepsy. If Neuroleptic Malignant Introduction
Syndrome, stop all antipsychotics. Monitoring in diabetics
This paper probably differs from others in this journal, in that it was originally submitted by Debbie
and those with risk factors for diabetes advisable. Advise
of potential for weight gain. Advise not to drive or operate Dean as an assignment for a third-year module during her mental heaith nurse training. The
machinery if alertness affected. Acute withdrawal assignment was highly commended by the assessing academics, and was recorded and rewarded
symptoms, recurrence of psychoses. Recommend
as such. Now we know that this goes against convention for such journals but the content of that
gradual withdrawal, PREGNANCY: li benefits outweigh
risks, LACTATION: Avoid. INTERACTIONS: Centrally assignment was so unique that I felt it warranted promotion.
acting drugs, dopamine agonists, hepatic enzyme-
What makes it unique is that Debbie is one of those rare people; a mother and a mature student
induoing drugs. SIDE EFFECTS: Insomnia, agitation,
anxiety, headache, somnolence, dizziness, impaired nurse. Nothing unique or rare in that, you may say, but when you consider that the burden of
concentration, blurred vision, sexual dysfunctions, undertaking mental health nurse training alone is highly stressful but added to this is the stress of being
urinary incontinence, rash, other allergic reactions.
a mother to four children (one daughter and three sons) - and her three sons have been ail diagnosed
Extrapyramidal symptoms, orthostatic dizziness,
hypotension, tachycardia and hypertension. Increased with attention deficit hyperartive disorder (ADHD).
plasma prolactin, hepatic enzymes, changes in white cell
This article is an abridged version of that assignment and it has been edited to conform to
and platelet levels. Oedema, water intoxication with
hyponatraemia, tardive dyskinesia, body temperature publication requirements but we hope that we have managed to retain the sense of poignancy that so
dysregulation and seizures. CVAs, Very rarely;
captured the imagination of the assessing academics with its warmth and humanity. We have decided
hyperglycaemia and exacerbation of pre-existing
diabetes. Weight gain or loss, depression, fatigue, to reduce the critical analysis of ADHD which formed a basis for the more personal element of the
nervousness, sleep disorder, apathy, syncope, injection original assignment, to a deliberately brief explanatory section - preferring to leave the focus of the
site reaction.
article as 'Debbie's tale'.
LEGAL CATEGORY POM.
As a precursor to this article being prepared for publication, Debbie's family - especially her children
ACTIVE INGREDIENT: Risperidone
PRESENTATIONS, PACK SIZES, PRODUCT - were consulted and all gave their permission for us to progress with this.
LICENCE NUMBERS & BASIC NHS COSTS: We hope, in this - the unfolding story of Debbie's family life - that the reader shares and appreciates
25mg prolonged-release injection (PL 0242/0375)
not only the pain and agonies faced by both her and her family, but aiso the love and warmth that
1 dose; £82.g2; 37.5mg prolonged-release injection
(PL 0242/0376) 1 dose; ei 15.84; 50mg prolonged- underpins life and supports and carries them through the hard times.
release injection (PL 0242/0377) 1 dose: £148.55
FURTHER INFORMATION AVAILABLE FROM Stephan Kirby MSc, PgC(LST). Dip MDO. RMN.
PRODUCT LICENCE HOLDER: Jsnssen Cilag Ltd, senior lecturer (forensic mental health), School of Health and Social Care,
Saunderton, High Wycombe. Buckinghamshire HP14 4HJ University of Teesside, Middlesbrough. Cleveland
UK,
© 2005 Janssen-Oiiag Ltd
keywords
APIVER290305C
^'^ trademark > carers ADHD: a definition
® registered trademark Green and Chee (1997) state that: Attention deficit
> children, behaviour
Date of preparation: April 2005
> family centred care disorder (ADD) and Attention deficit hyperactive
00005847
> parenthood disorder (ADHD) are both neurological conditions
charactensed by three primaiy symptoms: a decreased
JANSSEN-ClLAGi The5e keywords are based on the
ability to pay attention; difficulty in controlling impulses;
subject headings from the British
Nursing Index. This article has been increased motor activity.
¥nth thanks to th« sanrice users who helped In subject to a double-blind review.
the development of this campaign

20 mental health practice June 2005 vol 8 no 9

impact on family life
A
DHD is one of the most common disorders of
childhood and adolescence {Guevara 2001). It is a
complex problem, as there are various types and the
condition may include language and learning problems. In a
few children it co-exists with one of two serious psychiatric
disorders, either oppositional defiant disorder (ODD) or
conduct disorder (CD) (Dalsgaard ef a/2002). This can cause
immense disruption in an already disturbed life created by the
ADHD. ODD has been described as being the developmental
precursor of CD (Angold and Costello 2001).
In everyday life, people often describe children who become
excitable, boisterous or disobedient as hyperactive, and wee
versa. However, in a professional context the term refers
to a more severe and long-lasting problem. While ADHD
is a persistent pattern of inattention, hyperactivity and/or
impulsivity. Ball (2001) claims that it is more pronounced and
extreme than is typically observed in individuals at a similar
stage of development.
The causes of ADHD are said to differ; however, two causes
are often discussed as the main cause of ADHD. The first
is said to be genetic. Researchers such as Green and Chee
(1997) have shown in twin studies that if one identical
twin has ADHD there is a 90 per cent chance that the other
identical twin will have ADHD, It has also been observed
that the parents of children diagnosed with ADHD were also
inattentive and often in trouble during their school days,
frequently stigmatised as a 'naughty child'.
Second, and more controversially, there is the theory that
ADHD could be caused by 'bad parenting'; however, this is
a misconception perpetuated by the media. Regularly, the
media imply that ADHD is a trendy diagnosis imported from
north America to excuse a modern epidemic of appalling
behaviour among children who have not been parented
properly (Hart 2003). This idea is, in reality, not feasible, as
not all children with ADHD come from unstable and dys-
functional families. Knowing this can alleviate any burden
a parent may feel - no matter what family life is like, the
child would still have ADHD. Unfortunately, it appears that
as more is known about ADHD, there is an equal increase in
the number of children being diagnosed, placing increased
burdens on families and professionals.
Living with ADHD
Living with ADHD can be equally frustrating for the child
and parents- Children with ADHD are often labelled as
'difficult' which is annoying for both parties concerned.
Greer (2003) reminds us that children with undiagnosed
ADHD are generally misunderstood and experience failure
at every turn. But this can also be the case after diagnosis,
as many people believe that once the child is on medication
(invariably Ritalin) all symptoms will instantly, miraculously,
cease; if they don't then it must be the child being 'naughty'
deliberately
Unfortunately, rarely does medication work in such a
fantastic way. It does assist in increasing attention and
reducing the impulsivity but it does not eliminate all of the
symptoms. C hildren with ADHD find it extremely difficult to
complete 'ordinary' everyday tasks with accuracy, they are
constantly losing things, are late for school, and can forget
simple instructions if more than one thing is requested. This
behaviour impacts on family, school and social life. In the
home environment families can experience more negativity
in their social life (Kendall et al 2003).
As previously stated, I am a mother of four children, three
of whom (the boys) are diagnosed with ADHD. Although I
am not an expert on ADHD I can explain how it affects the
family structure; for life with children diagnosed with ADHD
IS anybody's worst nightmare. Home life has to be very
organised to the point that it's more like a military regime
rather than a relaxed, homely atmosphere.
My eldest son was diagnosed with ADHD ten years ago, at
the age of five, when it was quite unheard of in this area. The
GP was reluctant to prescribe Ritalin as he was not up to date
on the medication, even though he had been informed by
the child psychiatrist that this was the appropriate treatment.
Therefore, we had to visit the child psychiatrist in Newcastle
June 2005 vol 8 no 9 mental health practice 21
Debbie Dean and (a 100-mile round trip) just to collect prescriptions. guidelines that govern the school's punishment system and
her three sons Over the years I have noticed a massive rise in the number feel that often riotous behaviour in classes is caused (and
Corey (in blazer), of children diagnosed with ADHD, including my twin boys, perpetuated) by 'unknowledgeable do gooders' who argue
Josh (middle), who were diagnosed at the age of six. It was acl<nowledged that children should not be punished, and so these days
Shawn, (in that just before the twins left primary school there were in teachers do not have the power to chastise pupils. Admit-
football top) fact six children in their class who were diagnosed with ADHD tedly, in the past, punishment was extreme in some cases,
and taking Ritalin, This isa remarkable proportion of children but surely there can be a happy medium.
considering there are only about 30 children in a class. Mainstream schools are also not very well up on behaviour
problems. Even in these more enlightened days, teachers
Children with ADHD and school often believethatachild with ADHD is just causing trouble
Keeping my children in mainstream school, which I discussed because he or she wants to, therefore, the child will get
with the school, was seen to be to their advantage as their stigmatised, I have found that if there is trouble and any of
education is obviously of primary concern. However, I per- the children with ADHD are even in the vicinity the teachers
sonally feel that it is not fair on my - or other - children to automatically presume that they are the cause, and, without
have their education disrupted. Although, once again, as asking any questions, they are immediately removed and
a parent, we obviously do not know what is best for our blamed. This often worsens the situation as the child then
children and our wishes are pushed aside. attempts to put forward the truth.
Mainstream schools find it extremely difficult to control School staff should receive some - or further - training
children that are out of the ordinary and who do not con- in psychiatric disorders in children to assist in better coping
form to rules and regulations. At present I get at least two strategies and management of situations. One solution to
phone calls a week from my children's' school requesting an inattentive child who is easily distracted would be to sit
that I pick them up, as they cannot cope with them. As a him or her in the front row of the class, as the child would
result my children's education is very fragmented and they then be able to concentrate more fully without distractions
will not stand a chance when it comes to exams. I feel that it going on in front of them.
should be at the school's discretion to chastise a pupil if they
are causing disruption rather than just sending them home. School and medication
What does that achieve? The child has a day off school and Medication is also a major issue with school life as the
misses out on more learning and falls further behind. teachers see it as solely the child's responsibility to go to
Children with ADHD are not stupid; they know the system, the office and collect the tablets at lunchtime, rather than
and their rights. If they feel like a day off school then they a joint effort. In a (so-called) normal child this would not
can 'play up' and get one. I am aware of the policies and be an unreasonable request, however, one of the more

22 mental heaith practice june 2005 vol 8 no 9

obvious characteristics of ADHD is forgetfulness. Frequently, now 15, has decided that he no longer wants to take
when I am asked to collect one of the children, my initial Ritalin - so he doesn't. His (child) psychologist feels he
question is, 'Have they had their lunchtime medication?' All is old enough to decide what he wants and, just because
too often they haven't. we are his parents, we can't force him. I did tell the psy-
I cannot see the situation improving. If the school does not chologist that I would be willing to 'shove them down his
see the importance of medication and therefore seek the throat', but unfortunately he said this was not allowed.
children out at lunchtime then the children will invariably Something feels amiss when parents do not have a say
forget about it and the school, and, ultimately, the parents in what they want for the child, especially when they are
have to deal with the situations that are likely to arise from the ones who have to put up with the ensuing chaos and
this. I can fully understand that teachers are busy, but simply are left to pick up the pieces. As parents we want him to
giving the afternoon medication to one of their pupils would continue with the medication; it is just unfortunate that
alleviate a host of problems. This would be better for the we can do nothing about it.
child, as he or she would be more settled, and the teachers,
as this could help prevent any major disturbances that they Treatment options?
clearly are unable to deal with. Contrary to what the literature says about 'multimodal
Another problem I have encountered with the education therapy being the winning combination' my children have
system is an apparent unwillingness to complete assess- never once been offered any form of therapy other than
ment forms truthfully and accurately I am convinced this medication. Do we not get these therapies because we iive References
is 'unwritten' school policy which says that they are not to in the wrong area? Is it a postcode lottery? We have been Angold A, Costello EJ (2001)
admit to other professionals that they cannot cope. told that the only effective direction to take with ADHD is The epidemiology of
medication, unfortunately the medication alone is just not disorders of conduct:
nosological issues and
Sociatising with children with ADHD cutting it- Similarly, we have never had any form of support comorbJdJty. In: Hill J,
The social side of life with children with ADHD is extremely from any outside agencies and this just reinforces my feeling Maughan B (Eds) Conduct
difficult to organise. Even something as simple as a fam- that, in general, the majority of professionals do not really Disorders in Childhood
ily day out can become a major ordeal the boys become care, it is just a job to them and they can go home to their and Adolescence.
'normal' lives. I really doubt if they, for all their qualifications Cambridge, Cambridge
very excitable and when outside of their normal and safe University Press.
routine, become more hyperactive and extremely boister- and knowledge, can really begin to understand what it is
Ball C (2001) Attention-
ous. Sometimes this is embarrassing, like to live in a household with one deficit hyperactivity
but very often just leaves the rest child with ADHD, let alone three disorder and the use
of the family desperately worn out. children. of methylphenidate.
Psychiatric Bulletin 25,
People outside the home often stare 'People outside the home 304-306.
when the boys are 'playing up' and
have been heard on more than one
often stare when the boys Looking on the bright side Dalsgaard Sefa/(2002)
I suppose on the plus side the hyper- Conduct problems,
occasion to say, 'I would give him a are "playing up" and have activity does tend to decrease as the gender and adult
hard slap if he were mine'. This is psychiatric outcome of
been heard on more than one child gets older, as it has now with children with attention-
very annoying and leaves parents my eldest son. Unfortunately his deficit hyperactivity
feeling inadequate because they occasion to say "I would give challenging behaviour is becoming disorder. Bntish Journal of
are thought to be unable to control Psychiatry. 181,416-421.
their child. However, if I am feeling
him a hard slap if he were more of an issue; and after reading
the literature around ADHD I now Greer JE (2003) ADHD-
particularly worn down I am tempted mine". This is very annoying wonder if he has developed ODD.
separating fact from
to tell them to simply mind their own fiction. The Exceptional
business and go away. Therefore,
and leaves parents feeling His behaviour fits the symptoms of Parent. 33, 11.
ODD exactly: he always says 'no' as Green C, Chee K (1997)
family outings are quite often put on inadequate because they a matter of pnnciple; he constantly Understanding ADHD.
the back burner, as I prefer to take
are thought to be unable to challenges anything he has been London. Ebury Press.
the boys out separately for better told; he regularly argues that black Guevara JP (2001) Evidence
management of them. control their child.' is white; is immensely annoying, and
based management
of attention deficit
Having brothers with ADHD has is never to blame for anything - it hyperactivity disorder.
had a major impaa on my daughter: is always someone else's fault. It's British MedicalJournal.
as if he waits for me to draw the line so he can, at worse, 323, 1232-1235.
she gets much less attention than she needs and deserves Hart D (2003) Children
as most of my time has to go to the boys. Throughout rub it out, or, at best, simply jump over it. The possibility
with ADHD spend
her school life my daughter has had to take frequent time of my son having ODD could also account for the fact that longer playing computer
out of school because that was the only chance she had the medication is not as effective as it should be. So we games. New research
of spending quality time with me without the boys taking have yet more questions for the child psychiatrist, not that finds excessive but
it particularly matters, as there is no medication or other impoverished 'media diet'
over. She rarely had her friends round to the house when chosen by children with
she was younger, preferring to go to their homes, as her treatments for this disorder. But children are supposed to
ADHD.
brothers easily embarrassed her and caused chaos, espe- grow out of it (yippee!)- http://vwvw.rcpsych ac.uk/
cially if there were other people around. She frequently The main dilemma for parents with children diagnosed
press/preleases/pr/pr_4 7 5.
had to manage by herself with things such as homework htm (Last accessed: May
with ADHD is that the parents often have to cope with 4 2004)
and school projects as the boys' needs always seemed to so much hassle, torment and upset (caused either inno- Kendall Je( a/(2003)
outweigh hers: very often it was a challenge just to try and cently or otherwise) by the child that they can become Children's accounts
keep harmony so that she could get on with her homework. complacent in maintaining a consistent approach to of attention deficit/
Recently, we were discussing her life with the boys and she their care, just to get an easier life. This obviously can be
hyperactivity disorder.
told me that, 'while she loves them, life has been pure hell htlp://proquest.umi.
detrimental for, as with all children, when you give them com/pqdweb'index=4Sd
at times'. All things considered I feel very lucky that she has an inch they will take a mile and this is especially true of )d000000345505821SS
turned into a very well-grounded young woman. thechild with ADHD •
html (Last accessed. April
Monthly runs to the hospital are now becoming just a 16 2004)
routine excuse for more family disputes. My eldest son. Debbie Dean, student mental health nurse

June 2005 vol 8 no 9 mental health practice 23