Listening: An Occupational Hazard
Recently, another neighbor asked me to come talk to her about her adult son’s increasingly out of control behavior. It might seem strange for me to be asked to listen to yet another family situation in the neighborhood, but you can’t make this stuff up. And, isn’t being asked to listen sort of an occupational hazard for people in the helping professions?
Anyhow, I’ve known the son since he was in elementary school. I remember this young man being diagnosed with ADHD and some work-arounds being offered, but no special education services offered—or at least they were not accepted by the parents, if offered.
This public elementary school is small but very sophisticated in picking up on learning issues and this lack of special education plan was completely different from my own son’s experience in the same school; he’d had a reading disorder caught early in the second grade and special education services were offered and accepted through to middle school.
As she spoke, I reflected on problems often associated with ADHD that I had witnessed in this man when he was young:
Inattention: Wandering off task, lacking persistence, difficulty sustaining focus
Impulsivity: Making hasty actions that occur in the moment without first thinking about them and that may have high potential for harm; or a desire for immediate rewards or inability to delay gratification. An impulsive person may be socially intrusive and excessively interrupt others or make important decisions without considering the long-term consequences.
My neighbor’s increasing dismay came from her now-adult son’s escalation of impulsive, threatening behavior. He’d already been in trouble with the law and now was focusing his anger and blame for his situation on his mother and stepfather. He would call and scream obscenities at them.
I was reminded that ADHD untreated as a child can lead to feelings of low self-esteem and, according to the CDC, health risk problems such as smoking, abnormal risk-taking and impulsive behaviors, risk for injury, substance abuse, and criminality. In addition, untreated ADHD often co-occurs with other disorders such as oppositional defiant disorder (ODD), conduct disorders (CD), and substance abuse—all of which can be manifested in behaviors that violate the rights of others (e.g., aggression, destruction of property) and/or that bring the individual into significant conflict with societal norms or authority figures. However, in the DSM-5, ADHD is listed with the neurodevelopmental disorders so this association can be lost.
Although not immutable, the trajectory of ODD and CD can lead to antisocial personality disorder (APD) in adulthood. In the latest DSM, APD is defined as:
A. Significant impairments in personality functioning manifest by:
1. Impairments in self functioning (a or b):
a. Identity: Ego-centrism; self-esteem derived from personal gain, power, or pleasure.
b. Self-direction: Goal-setting based on personal gratification; absence of prosocial internal standards associated with failure to conform to lawful or culturally normative ethical behavior.
2. Impairments in interpersonal functioning (a or b):
a. Empathy: Lack of concern for feelings, needs, or suffering of others; lack of remorse after hurting or mistreating another.
b. Intimacy: Incapacity for mutually intimate relationships, as exploitation is a primary means of relating to others, including by deceit and coercion; use of dominance or intimidation to control others.
B. Pathological personality traits in the following domains:
1. Antagonism, characterized by:
a. Manipulativeness: Frequent use of subterfuge to influence or control others; use of seduction, charm, glibness, or ingratiation to achieve one’s ends.
b. Deceitfulness: Dishonesty and fraudulence; misrepresentation of self; embellishment or fabrication when relating events.
c. Callousness: Lack of concern for feelings or problems of others; lack of guilt or remorse about the negative or harmful effects of one’s actions on others; aggression; sadism.
d. Hostility: Persistent or frequent angry feelings; anger or irritability in response to minor slights and insults; mean, nasty, or vengeful behavior.
2. Disinhibition, characterized by:
a. Irresponsibility: Disregard for—and failure to honor—financial and other obligations or commitments; lack of respect for—and lack of follow through on—agreements and promises.
b. Impulsivity: Acting on the spur of the moment in response to immediate stimuli; acting on a momentary basis without a plan or consideration of outcomes; difficulty establishing and following plans.
c. Risk taking: Engagement in dangerous, risky, and potentially self-damaging activities, unnecessarily and without regard for consequences; boredom proneness and thoughtless initiation of activities to counter boredom; lack of concern for one’s limitations and denial of the reality of personal danger.
I didn’t say all this; just listened to my friend for a long while and expressed concern for her situation. She wasn’t really asking for more than an empathetic ear. Meanwhile, my mind scrolled through what I know about how kids can grow up to have pathological personality disorders that greatly affect others and wondered why it all sounded so familiar recently.
Shaw M, Hodgkins P, Caci H, et al. A systematic review and analysis of long-term outcomes in attention deficit hyperactivity disorder: effects of treatment and non-treatment. BMC Medicine. 2012;10:99.
American Psychiatric Association. DSM-IV and DSM-5 criteria for the personality disorders. 2012.
ADHD Long-term Outcomes: Comorbidity, Secondary Conditions, and Health Risk Behaviors. Atlanta, GA: Division of Human Development and Disability, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention. June 9, 1999.
Leslie Durr, PhD, RN, PMHCNS-BC is an advanced practice psychiatric-mental health nurse with a private psychotherapy practice in Charlottesville, Virginia.
The views expressed on this blog are solely those of the blog post author and do not necessarily reflect the views of Psych Congress Network or other Psych Congress Network authors.