Professor Michael Fitzgerald

Andy Warhol and Konrad Lorenz are two persons with Asperger’s syndrome. The diagnosis of Asperger’s syndrome is important in Adult Psychiatry because it can be confused with schizophrenia. Asperger’s syndrome cannot be scientifically and clearly differentiated from High Functioning Autism and the diagnosis are used interchangeably. Similarities between the two conditions include difficulties in interpersonal relationships, problems in non-verbal communication, narrow repetitive routines and interests. In Asperger’s syndrome there is no clinically significant general delay in language according to DSM-IV although this criterion is now highly controversial as language difficulties of one sort or another are often seen particularly of the semantic pragmatic variety. It has also been suggested that the persons with Asperger’s syndrome have a later onset of problems and are diagnosed at a later stage and can show in a minority of persons significant antisocial behaviour. Indeed for the majority of persons with Asperger’s syndrome very high moral behaviour is a characteristic. Whatever about the similarities or differences between High Functioning Autism (and there are more similarities) or Asperger’s syndrome the diagnosis of Autism Spectrum Disorder is currently the most accurate diagnosis.

Andy Warhol is a classic person with Asperger’s syndrome. Andy Warhol was born in 1928 and died in 1987. He was one of the most famous artists of the 20^th century and his most famous saying was ‘In the future, everyone will be famous for 15 minutes’. He had an eccentric father which is not uncommon in this situation and was bullied at school which is also very common in this situation. His mother was even more eccentric than his father. His mother would make statements like ‘I am Andy Warhol’. His art could be extremely repetitive something that’s typical in persons with Asperger’s syndrome. An example here is the Campbell soup can. He particularly liked screenpainting which provided him with a quick and easy way of indulging his penchant for repetition. He had enormous deficits in interpersonal skills and was to a large extent socially incompetent. Like many people with Asperger’s syndrome he did want to make close relationships but lacked ‘know-how’. He stalked Truman Capote. He experienced himself as an alien like Temple Grandin another famous person with this condition. He clearly had a very narrow obsessive interest in art. He was a workaholic. He was an obsessive collector and a great deal of what he bought he never took out of the wrapping paper. He was a singular person. He had an autistic mechanical mind. He loved machines of all sorts. He had the typical high-pitched tone of voice persons with Asperger’s syndrome have. He had an immature personality. He was very naïve. He had the classic motor clumsiness of Asperger’s syndrome and suffered a great deal from anxiety. His fear of hospitals meant that he delayed going to hospital when he developed acute abdomen and he died soon after the operation.

The late Konrad Lorenz the animal behaviour researcher was born in 1903. Asperger’s syndrome helps to explain some of his actions in his life. He was addicted to animals and the study of animal behaviour. He is famous for his research on imprinting. An interest in nature is particularly not uncommon in persons with Asperger’s syndrome. He was very lucky to have a supportive wife as he had what is now called an ‘Asperger type’ marriage where the wife supports, contains, and grounds the person with Asperger’s syndrome. Lorenz tended to speak in monologues. He was an autodictat. He showed evidence of significant interpersonal difficulties and lack of empathy for people. This didn’t stop him being a great ethnologist. He also suffered from mood swings. Control was very important to him. He was both a collector and very much in scientific terms a systematizer. His first fascination was with the Jackdaw and later he became fascinated with fish and with ducks. While he served in the German army during the 2^nd World War and was accused of being a Nazi but I don’t think that he was a Nazi. It was his Asperger’s syndrome and naivety that made him write about degeneracy in men of other races. Leon Eisenberg accused him of his writing been ‘redolent of concentration camps’. He was not a racist but he was extremely naïve. Konrad Lorenz in reply to Leon Eisenberg’s criticism stated “the 1940 paper tried to tell the Nazi’s that domestication was much more dangerous than any alleged mixture of races”. During the war Lorenz worked as a neurologist in a psychiatric unit. Later in life Konrad Lorenz was equally naïve in accepting the Schiller Prize from a neo-Nazi group. Konrad Lorenz was politically naïve about the implication of these matters and was not a Nazi. He was a person with Asperger’s syndrome.

The evidence for Vincent van Gogh’s mood disorder has been extremely well documented. This article suggests that in addition he had a dual diagnosis that is Asperger’s disorder as well. He had an unhappy early life and had behaviour problems in childhood. His father was described as being as cold as iron by A. J. Lubin. Even as a child he was a strange person and could not cope with normal school. He showed evidence of severe social impairment. In a way he was like an alien on earth. He had a wish for good social interactions but was unable to achieve them. He was very much a loner. He was also an outsider. He alienated people. This was not deliberate but he did not know how to win them over. He was regarded as an eccentric. He was a workaholic and narrowly focussed on his art. He read books incessantly. He had significant non-verbal behaviour problems.

According to Lubin he often dressed in rags. He had strange dietary habits. He was not a fluent speaker. His suicide was likely to be due to his mood disorder and his Asperger’s syndrome. Suicide is not rare in these two conditions. Alternative explanations of his problems have been presented like Meniere’s disease and acute intermittent porphyria but these are not likely as explanations. One of the difficulties in psychiatry is that once a diagnosis is made for example Mood Disorder additional diagnosis like Asperger’s syndrome are then not considered. Mood problems are common in patients with Asperger’s syndrome.

This book is essential reading for parents, children, and adolescents with Attention Deficit Hyperactivity Disorder and for General Practitioners, Paediatricians, Child Psychiatrists, and Doctors working in Community Services. It is comprehensive, and very practical and answers most of the questions that parents and professionals ask about Attention Deficit Hyperactivity Disorder. In addition it has a useful Appendix of Organisational Contacts for parents and also a useful reading list for parents and professionals. It discusses in detail the diagnosis of Attention Deficit Hyperactivity Disorder as well as the causes of Attention Deficit Hyperactivity Disorder. It gives proper weight to biological and genetic factors. It also tackles the issue of ‘blaming’ the parents for the disorder.

In my experience the tragedy of Child Psychiatry / Child Psychology in the 1970s in Ireland, 1980s and indeed early 1990s was the tendency to see children’s problems with Attention Deficit Hyperactivity Disorder as being due to inadequate parenting. This had a devastating and negative effect on parents. The therapists of a family or psychodynamic orientation particularly took the view that the child’s problems were caused by the family dynamics. Indeed this false view of Attention Deficit Hyperactivity Disorder still occurs. Wilkinson provides an accurate and balanced view of this complex topic. Wilkinson gives a superb and detailed understanding of the Clinical and Educational Psychologist Assessment of persons with Attention Deficit Hyperactivity Disorder. He answers in detail the kind of questions parents asked about what Psychologists do.

One minor quibble is that there is no index and in the next edition of this most valuable book I hope that he will add in a Chapter on Adult Attention Deficit Hyperactivity Disorder

Automobile crashes are one of the leading causes of deaths in adolescents. Accidents are three to four times more frequent in persons with Attention Deficit Hyperactivity Disorder. The Attention Deficit Hyperactivity Disorder driver is three to four times more likely to be at fault. The Attention Deficit Hyperactivity Disorder driver is six to eight times more likely to loose their license. The treatment of Attention Deficit Hyperactivity Disorder with stimulants improves the performance of the driver. There is a serious lack of attention being given to the impact of Attention Deficit Hyperactivity Disorder on driver’s performance in relation to accidents in Ireland. Unfortunately adult Attention Deficit Hyperactivity Disorder is not uncommonly missed as a psychiatric diagnosis.

Adults with Attention Deficit Hyperactivity Disorder have difficulties tending to tasks and activities and inhibiting their impulses. They have a poor ability to sustain attention over long periods, and are unable to concentrate on short, focussed work. They act without thinking, often resulting in reckless and impetuous behaviour. Indeed, impulsiveness may be an important defining characteristic of Attention Deficit Hyperactivity Disorder in adulthood. Although they do not necessarily present with the overactive behaviour frequently seen in children they feel restless. As a result an individual may act without reflection or consideration for the consequences of action. They may be disorganised, forgetful, and have planning deficits and poor time management skills. Impetuous novelty-seeking behaviour may result in criminal acts, substance misuse and dependence according to Susan Young a psychologist who focuses on adult Attention Deficit Hyperactivity Disorder. About 4.4% of adults in the community have adult Attention Deficit Hyperactivity Disorder. Unfortunately there is an error in DSM-IV diagnosis for Attention Deficit Hyperactivity Disorder. Particularly with adults the age seven cut off is unsatisfactory and it is likely in future that onset in primary school or before the age of 12 will be accepted rather than onset before the age of seven. In making the diagnosis multiple informants are very helpful or information from parents of a person with adult Attention Deficit Hyperactivity Disorder or school records to improve diagnosis. It is more common in males than females. Clearly there is a great deal of comorbidity particularly in the area of Antisocial Personality Disorder, substance misuse, and depression. They have often poor occupational histories and considerable breakdown in the long term in interpersonal relationships, marriages etc. They often feel socially isolated and misunderstood. This is unfortunate since there is relatively good treatment available. Nevertheless they can be successful particularly in the artistic areas. John Osbourne, Clark Gable, Jesse James, George Carman, and Kenneth Tynan had adult Attention Deficit Hyperactivity Disorder. Doctors can also have adult Attention Deficit Hyperactivity Disorder and the following questions are often worth considering:

(1) Do you have difficulty concentrating or focussing your attention on one thing?

(2) Do you often start multiple projects at the same time, but rarely finish them?

In terms of driving behaviour Methylphenidate (Ritalin / Ritalin LA) significantly reduces inattentive driving errors. It would appear that for those driving in the early evening including during the day Concerta XL (Methylphenidate) which lasts for 12 hours would be more relevant. This is also a form of slow release Methylphenidate and is off label in Ireland for adults. Of course accidents do occur in the evening and so good attention is particularly required at this time. There is also a new medication the first non-stimulant medication available in Ireland for Attention Deficit Hyperactivity Disorder on a named patient basis called Atomoxetine (Strattera) which is active over the 24 hours. This has slow onset and has to be taken seven days a week. This would seem to have a place when you are particularly focussing on wanting to have a person on continuous treatment as it does not wear off. It would particularly appear to be important for late evening / night, the time of maximum danger for accidents. Adolescents with Attention Deficit Hyperactivity Disorder also benefit from cognitive / behavioural therapy which focuses on the inhibition of impulses, time management, organisational skills, problem solving skills, anger management, decision-making skills, social skills training, and improved social perception. Persons with Attention Deficit Hyperactivity Disorder need to be educated about it. Once the diagnosis is given to them it can suddenly make sense of their lives and sometimes of the chaos of their lives. It is difficult to get a chaotic life into order if one doesn’t understand what the problem is. Genetic factors play a major role in Attention Deficit Hyperactivity Disorder. The problem of adult Attention Deficit Hyperactivity Disorder and accidents is a matter that should be taken up by professional psychiatric bodies and by consultants in Accident and Emergency Departments who are often on the receiving end of problems with Attention Deficit Hyperactivity Disorder. Organisations involved in road safety should also examine this issue.

Kurt Cobain was wrong – the treatment of Attention Deficit Hyperactivity Disorder with Methylphenidate does not predispose to substance misuse indeed precisely the opposite is true. Adults with Attention Deficit Hyperactivity Disorder have difficulties tending to tasks and activities and inhibiting their impulses. They have a poor ability to sustain attention over long periods, and are unable to concentrate on short, focussed work. They act without thinking, often resulting in reckless and impetuous behaviour. Indeed, impulsiveness may be an important defining characteristic of Attention Deficit Hyperactivity Disorder in adulthood. Although they do not necessarily present with the overactive behaviour frequently seen in children they feel restless. As a result an individual may act without reflection or consideration for the consequences of action. They may be disorganised, forgetful, and have planning deficits and poor time management skills. Impetuous novelty-seeking behaviour may result in criminal acts, substance misuse and dependence according to Susan Young a psychologist who focuses on adult Attention Deficit Hyperactivity Disorder. About 4.4% of adults in the community have adult Attention Deficit Hyperactivity Disorder. Unfortunately there is an error in DSM-IV diagnosis for Attention Deficit Hyperactivity Disorder. Particularly with adults the age seven cut off is unsatisfactory and it is likely in future that onset in primary school or before the age of 12 will be accepted rather than onset before the age of seven. In making the diagnosis multiple informants are very helpful or information from parents of a person with adult Attention Deficit Hyperactivity Disorder or school records to improve diagnosis. It is more common in males than females. Clearly there is a great deal of comorbidity particularly in the area with Antisocial Personality Disorder, substance misuse, and depression. They have often poor occupational histories and considerable breakdown in the long term in interpersonal relationships, marriages etc. They often feel socially isolated and misunderstood. This is unfortunate since there is relatively good treatment available. Nevertheless they can be successful particularly in the artistic areas. John Osbourne, Clark Gable, Jesse James, George Carman, and Kenneth Tynan had adult Attention Deficit Hyperactivity Disorder.

Kurt Cobain had Attention Deficit Hyperactivity Disorder, and was prescribed Methylphenidate when he was at school. Unfortunately he only took it for three months. The impression was given later that this was a factor in his developing substance abuse. Indeed precisely the opposite is the truth. Persons who are treated for Attention Deficit Hyperactivity Disorder on a continuous basis with Methylphenidate are less likely to abuse substances as they get older. The abuse of drugs like cannabis or cocaine is often a feature of self-medication for Attention Deficit Hyperactivity Disorder. The increased use of cigarettes by persons with Attention Deficit Hyperactivity Disorder may also be done for the same reason. There is no doubt that persons with Attention Deficit Hyperactivity Disorder have an earlier onset of cigarette smoking and a greater use of it. There is no evidence for long term risks for substance use disorders in persons prescribed Methylphenidate. Indeed there is a reduced likelihood of substance misuse if Attention Deficit Hyperactivity Disorder is properly treated with stimulants. This doesn’t mean that there aren’t some risks from stimulants i.e. through diversion. A new medication for Attention Deficit Hyperactivity Disorder Atomoxetine has been shown to have no greater abuse liability than Desipramine an antidepressant or placebo. Unfortunately Attention Deficit Hyperactivity Disorder is a serious condition which requires early intervention and the misinformation about it is preventing some children from getting the treatment that they need.

Children with Attention Deficit Hyperactivity Disorder are at risk of increasing complications as they get older. They start in childhood with Attention Deficit Hyperactivity Disorder alone and then can develop disruptive behaviour disorders, oppositional disorders, challenging behaviour, and later from about 14 years onwards they experience often school exclusion, substance abuse, mood disorder, conduct disorder, and finally antisocial personality disorder and often get involved with the law at the same time. Of course this trajectory only occurs in those with severe Attention Deficit Hyperactivity Disorder and severe complications. Comorbid Oppositional Defiant Disorder occurs in over 40%, Conduct Disorder in 20 to 56%, delinquent and antisocial activities in 18 to 30%. Many continue their problems into adulthood and they are more likely to enter the workforce at unskilled or semi skilled level. They are twice as likely to be dismissed from their employment, tend to have many more jobs than the average, and to show much lower work performance than the average.

In examining motor vehicle driving risks persons with Adult Attention Deficit Hyperactivity Disorder are 60% more likely to have a crash with injuries as compared to 17% of the general population. As well as having much more accidents they tend to have worse accidents. They have four times higher risk of having sexually transmitted diseases because of their earlier onset of sexual activity and their increased number of sexual partners. In addition they are less likely to employ contraception and spend less time with each partner than the average population. Girls with Attention Deficit Hyperactivity Disorder are over 9 times more likely to have a teen pregnancy than those without Attention Deficit Hyperactivity Disorder. The judicial costs of having Attention Deficit Hyperactivity Disorder are vastly increased as compared to people without Attention Deficit Hyperactivity Disorder. In America it has been estimated that the total criminal costs for persons with Attention Deficit Hyperactivity Disorder and Conduct Disorder combined are 37,830 dollars.

Unfortunately Adult Attention Deficit Hyperactivity Disorder is largely missed as a diagnosis. It appears to me that the next most missed diagnosis in adults is Asperger’s syndrome which nowadays tends to misdiagnosed as Mild Bipolar disorder. It tended in the past (and this still occurs in the present) to be misdiagnosed as Personality disorder or Schizophrenia. This meant they didn’t get the treatment they needed and got inappropriate treatment. A typical example is the novelist who was nominated for a Nobel Prize Janet Frame who was diagnosed with Schizophrenia outside Europe. She was put on a list for lobotomy in 1952. She was told by the Maudsley Hospital later that she did not have Schizophrenia. She died in 2004. In actual fact she had Asperger’s syndrome. There may be thousands in a similar situation throughout the world with misdiagnosis of psychiatric disorder. Hopefully the Irish College of Psychiatrists, Irish Psychiatric Association and those responsible for C.M.E. will take up this issue.

Going back to Kurt Cobain he would have a much greater chance of having survived if he persisted taking his Methylphenidate on a regular basis and had intensive multimodal treatment for his Attention Deficit Hyperactivity Disorder and associated problems. He showed the majority of comorbidities that one can get with Attention Deficit Hyperactivity Disorder. It was not surprising that he completed suicide.

Autism, Asperger’s syndrome, Stalking, and other reasons for legal contact.

While most people with Asperger’s syndrome (who have higher functioning autism) are highly moral, highly ethical, a small minority get in trouble with the law. This is probably slightly more common in those with Mild Learning Disability and Autism. Persons with autism may get into difficulties with the law according to Denis Debbaudt an American expert on this issue because of:

It is critical that professionals for example the police and staff working in forensic settings are aware of these features. Persons with autism are also easily led by others and as already stated misunderstand social cues. Their obsessional thinking may have an aggressive theme. In one inpatient setting for Learning Disabled Offenders in the U.K. 12% had autism. There is insufficient training within forensic services on autism in most parts of the world. Hopefully the Irish College of Psychiatrists, the Irish Psychiatric Association, and police authorities will deal with this matter in full. Police, parents and other professionals need to be able to identify the possibility that a person that they are interacting with may have autism or Asperger’s syndrome so that police and other contacts are less stressful for the person with autism or Asperger’s syndrome. In the U.S. research indicates that persons with developmental disabilities are approximately 7 times more likely to come into contact with law enforcement than others. There is only a small likelihood that in the first instance the autism will be recognised either by the police or other professionals involved.

Persons with autism also can get involved in stalking and one of the reasons that persons with Autism Spectrum Disorders are predisposed to stalking according to Tom Berney a U.K. Psychiatrist is that they have impaired perception of social signals, misinterpretation of rules, misinterpretation of relationships, lack of awareness or concern for the outcome, and a focussed obsessive interest. While this occurs it is not common.

Digby Tantum states that sexually motivated crimes are also unusual and when they occur may be a consequence of a lack of understanding on the part of the person with Asperger’s syndrome. Persons with Asperger’s syndrome may be aggressive and commit offences against other people, but it is unclear how frequently and what proportion of people with Asperger’s syndrome are at risk of doing so. Many people with Asperger’s syndrome have a hypertrophied sense of right and wrong and are unusually conscientious and unwilling to break the law. The Asperger’s syndrome are more likely to be victims than perpetrators. Nevertheless even though it is uncommon persistent violence by a person with Asperger’s syndrome is a particularly difficult problem. Men with Asperger’s syndrome are over represented in a survey of one U.K. Secure Hospital. Violence by a person with Asperger’s syndrome often has some special features. It may be triggered by idiosyncratic stimuli nourished by rumination over past slights; displaced from provoking the person onto a safer target at a later date; and uninhibited by empathic response to the intended victims fear. Sometimes the explanation for violence may be similar to that given by Raskolnikov in Dosteyevsky’s Crime and Punishment: that is it is of an experimental nature. It is often a wish to experience a sense of mastery and control over another person. They may also do it to test their predictions about how others would behave in such extreme circumstances.

It is worth noting that Asperger’s syndrome can occur in people of talent like Casal, Kierkegaard, E. Hopper, A. J. P. Taylor, Goethe, van der Post, Columbus, O. Wells, and ‘H. G.’.

The road to homicide in adolescents and young men can be quite a long one. When you look back with 20-20 hindsight one can not uncommonly observe that the person when a small child had a difficult temperament. They were unmalleable and very difficult to rear. Temperament has genetic underpinnings. The factors leading to homicide are a combination of nature and nurture or genes and environment. By the age of three the child may be brought to a Child Psychiatrist because they are hyperactive and impulsive. By the age of four they may very well have been in two or three preschool playgroups where they are unmanageable because of their poor attention and hyperactive impulsive behaviour. At this stage they would meet the criteria for Attention Deficit Hyperactivity Disorder hyperactive type. Unfortunately if they see professionals at this age their problems are likely to be attributed to parental management failures. This is often absolutely untrue. When they start primary school the same situation occurs in the classroom i.e. poor concentration, poor attention, forgetful, disruptive, hyperactive, impulsive. Again the parents may be falsely blamed.

It is only a short time before an additional diagnosis is added in i.e. Oppositional Defiant Disorder. This will cause the school and parents great problems, even more than the Attention Deficit Hyperactivity Disorder. A few years later the diagnosis of Conduct Disorder will be added with significant disturbances of conduct including bullying, being cruel to people or animals, stealing, fire setting, staying out late at night without parental permission, etc.. Into adolescence indeed even early adolescence there will be the use of street drugs like cannabis and alcohol. This drug and alcohol use will escalate during adolescence. Suspension from school will not be uncommon and finally a pupil will be asked to leave school and will become a drop out. Then they are on the streets, which is probably the most dangerous place of any in Ireland where there is massive availability of drugs. Delinquent acts will then take place, which can escalate to assaults. The drug and alcohol abuse will increase. There will be linking up with peers of a similar persuasion and with similar problems and then grievous bodily harm or a homicide is waiting to happen.

For example on the night of the homicide it will not be uncommon for a group of these adolescents or young men to have taken a great deal of drugs and alcohol which make them even more impulsive and they will pounce on an innocent victim or possibly somebody who might have said something to them. They will then go through the legal system, which will charge them with murder and give no credence to anything that has happened before. Because persons with hyperactive impulsive behaviour are likely to have accidents it wouldn’t be rare as well that there might be some brain damage from previous accidents. Over 18s receive a diagnosis of Antisocial Personality Disorder but their adult Attention Deficit Hyperactivity Disorder will be missed and therefore untreated. What these children, adolescents, and adults need is early intervention and active treatment. Blaming parents so popular with right wing people. This is completely unhelpful and only aggravates the situation. Clearly this is not the only road to homicide as others will show evidence of psychosis, paranoid personality disorder, etc.. Clearly in Ireland the appalling abuse of alcohol in adolescents and young people is a major factor. If the legal age for drinking was put up to 21 years it would help. Unfortunately these very disturbed young men or adolescents would probably acquire it anyhow from some other source. Nevertheless reducing availability could only help.

Early intervention is critical and it might be worth considering treating Attention Deficit Hyperactivity Disorder in those over age three with Dexamphetamine, which is licensed, in addition to behavioural interventions. Oppositional and Defiant Disorder may need the addition of Clonidine or Risperidone which are both off label. Anti-depressants will often need to be added in and these people in the course of their career will often show clear evidence of depression. For adolescents and children who have difficulty remembering their medication there is an eight hour medication called Ritalin Long Acting is helpful. For those adolescents who have to study after school then Concerta XL which is 12 hours of duration once a day is helpful. Finally for those adolescents and young men who need 24 hour treatment there is then Strattera the first non-stimulant treatment for Attention Deficit Hyperactivity Disorder which is available on a once daily medication. This is licensed in the U.K. and USA etc. and is available in Ireland at present on a named patient request.

Inappropriate focus on multidisciplinary teams means that there is wastage of professional time that could be used in seeing patients. This does not occur in adult psychiatry where the patient rather than the team is the major focus.

These very disturbed adolescents and young people described in this article need very energetic complex and multiple psychopharmacological intervention as well as multimodal other therapies including psychotherapy, family therapy, and behaviour therapy. Schools also need small classes to deal with these very disturbed children and adolescents. Ejecting them from schools something which is so common is the straw that ‘breaks the camel’s back’ and putting them on the streets massively increase their risks. Because of the disturbance in school they will not uncommonly need full time Special Needs Assistants and because they often have comorbid difficulties for example specific learning difficulties they will also need extra resource teaching. What they don’t need is criticism or blame and their parents don’t need criticism or blame, which is so often available from a whole variety of professionals. Particularly those with right wing leanings. The most negative factor that they can have in their career trajectory is endless criticism and blame. This is an unnecessary and tragic environmental factor. Children with ADHD should have equal rights to education and psychiatric treatment as all other children in the state. Untreated the outcome may be tragic for themselves (e.g. completed suicide because of the impulsivity of ADHD) or fatal for other citizens because of homicide or death themselves in car accidents. Adult ADHD is associated with high accident rates.

Attention Deficit Hyperactivity Disorder has highly significant genetic associations and occurs in 4.4% of the adult population. It is the most commonly missed adult psychiatric disorder in Ireland, the majority of persons with it not being diagnosed. Hopefully the Irish College of Psychiatrists / Irish Psychiatric Association will take up the matter soon. The Royal Academy of Medicine in Ireland is organising meetings on Attention Deficit Hyperactivity Disorder next year.

Adult Attention Deficit Hyperactivity Disorder is characterised by poor concentration, shifting of activities frequently, day dreaming, being easily distracted, problems organising time, poor attention to detail, difficulty listening, is impatient, acts without thinking, talks out of turn, has impulsive urges, has temper tantrums, has a restless feeling, has motor hyperactivity, has difficulty remaining seated during meetings, and difficulty working quietly.

Persons with High Functioning Autism or Asperger’s syndrome can show considerable creativity. Indeed they have the capacity for extreme creativity in a small number of cases. Evidence of minor creativity would be more common. The features of autism / Asperger’s syndrome that would enhance creativity would include intense focus on narrow interests. It is rarely possible to make major advances in science without this narrow intense focus. The lack of interest in emotional issues means that there is far more time available for intellectual mathematical, philosophical, and other scientific pursuits. Their time is not taken up with interpersonal relationships and with ordinary everyday life. They are often workaholics and their whole life is devoted to their creative pursuit. Persons with autism often have abnormal brain functioning and indeed brain structure and these deficits in some way enhance creativity. This kind of creativity has genetic underpinning of a type that has not yet been fully elucidated. Heritability factors account for about 93% of the variants in the aetiology of autism / Asperger’s syndrome. The following are some examples of this creativity.

Henry Cavendish (1731 – 1810) had High Functioning Autism / Asperger’s syndrome. He was an enormously successful scientist. He had enormous difficulties in interpersonal relationships. He was a man of enormous routines and regularities in his conduct of his life. He was very poor at speech making. Nevertheless he could be very precise in his use of language. He lacked empathy in interpersonal relationships and Berry notes Cavendish’s “striking deficiencies as a human being”. Indeed “his habitual profound withdrawal lead one contemporary to characterise him as ‘the coldest and most indifferent of mortals’”. He had an awkward gait and there is absolutely no doubt that like Newton and Einstein he had High Functioning Autism / Asperger’s syndrome.

Charles Babbage (1792 – 1871) also had High Functioning Autism / Asperger’s syndrome. He was the father of the modern computer. He was an autodictat. He spent a great deal of his life trying to build calculating machines. The first one was called a ‘difference engine’ and the second an ‘analytical engine’. According to Swade Babbage’s engine ‘gave new impetus to the notion of a “thinking machine” and stimulated the debate about the relationship between the mind and physical mechanism’. He had major problems in interpersonal relationships. He worked largely in isolation. He had a socially immature personality not uncommon in persons with High Functioning Autism / Asperger’s syndrome. He suffered from anxiety and depression. He was an excellent mathematician. He was described as an eccentric and comic figure. He was naïve and showed a lack of commonsense.

Archimedes (C 287 – 212 BC) also had High Functioning Autism / Asperger’s syndrome. He was an extremely eccentric individual spending as much of his life isolated in solitary. He had a good mechanical mind. He invented what is called the Archimedes screw for pumping water which is still used to this day. He was highly regarded as an engineer and inventor. He only liked to talk to mathematicians. He was the discoverer of what is called the Archimedes principal i.e. that the floating body will displace its own weight in fluid. He was an obsessive mathematician. He neglected his personal hygiene. Like Newton he left his meals untouched when he was deep in mathematics.

Norbert Wiener (1894 – 1964) was another mathematician with High Functioning Autism / Asperger’s syndrome. He was an autodictat, a linguist, and a rather absent minded professor. He was a socially immature child. He lacked empathy and was tactless with people. He was rather a lone wolf and was uncertain about how to conduct conversations. He was a very poor teacher. He was very routine bound. He was a rather clumsy child which is not uncommon with HFA / ASP and indeed like many others he suffered from anxiety and depression. He was described as being very eccentric.

Nikola Tesla was a famous electrical inventor who had High Functioning Autism / Asperger’s syndrome. He had a photographic memory. He was a linguist. He was an avid reader. He had an obsessive compulsive personality type. He was an autodictat. He had major difficulties in social relationships, was socially immature and naïve. He was extremely controlling and spoke with a high pitched voice. He was extremely naïve in dealing with people who would finance his inventions. He was very much a loner and remained unmarried and was extremely interested in pigeons. He had no capacity to manage money. His main interest was in inventions. He was the inventor of radio among many other things.

The mathematician David Hilbert (1862 – 1943) had High Functioning Autism / Asperger’s syndrome. He was a great mathematician. He showed eccentric interpersonal behaviour and was socially immature. His only interest was in discussing mathematical subjects. He showed extreme self control. Routines were extremely important to him. He tended to show repetitive language. Nevertheless he was very precise in his use of words. He showed lack of empathy. He believed no scientist should marry. He suffered from anxiety and depression.

The great English mathematician G. H. Hardy had High Functioning Autism / Asperger’s syndrome. He was a very eccentric man who never married. Routine was extremely important to him. His great interest in life was mathematics. He loved cats. He was extremely honest in his behaviour. Later he suffered from depression and attempted suicide. Attempting suicide is not uncommon in persons with High Functioning Autism / Asperger’s syndrome.

Dimitri Mendeleyev who developed the periodic table in chemistry had High Functioning Autism / Asperger’s syndrome. He had major difficulties in interpersonal relationships. He was most eccentric looking. He cut his hair once a year. He had tremendous focus on chemistry and on chemical elements and it was this intense focus that brought him success. Like so many successful people with HFA / ASP he performed poorly in school.

The most classic person of all with Asperger’s syndrome was Edward Teller the father of the H Bomb and the subject of a recent book called Edward Teller – The Real Strangelove from Harvard University Press.

Asperger’s syndrome is characterised by avoidance of eye contact, problems reading non-verbal behaviour, being a loner with a lack of social know-how, having problems sharing thoughts, and problems with empathy. They often speak with a high pitched or unusual tone of voice and repeat phrases. Gillberg calculates that 0.3% to 0.5% of the population has it. they like routine and have preservation of sameness. As children they often line things up, flap their hands, and are fussy eaters. They often have narrow obsessive interests in engineering, mechanics, astronomy, science, palaeontology, etc. It is one of the most missed diagnosis in adult psychiatry. They are misdiagnosed as Schizophrenia Personality Disorder and a wide variety of other diagnosis. This leads to inappropriate treatments which only aggravate the situation. hopefully the Irish Psychiatric Association, Irish College of Psychiatrists, and the Mental Health Commission will examine the issue. Psychiatric CPD has failed in relation to Asperger’s syndrome and indeed adult Attention Deficit Hyperactivity Disorder which in reliable epidemiological studies in USA affects 4.4% of the population.

The effect of chemical dependency either alcohol or drugs in children is very great. Parental alcoholism or drug abuse of a serious kind has a hugely detrimental effect on the family atmosphere and on the parent’s ability to rear their children. Children in these families live in a climate of anxiety and fear. There is enormous unpredictability and uncertainty in the families. The children never know what to expect or what is going to come next. They are in a state of bewilderment. A recent advertisement on the billboards asked why is mummy strange after she works late? This was the best that a child could make out of mother’s drinking. These children live with constant fear of catastrophe. They develop a sense of the world as being catastrophic and dangerous. They mistrust everybody and everything. They are confused by what is going on. They witness domestic violence, parental blackouts, and the whole paraphernalia of drug addiction with syringes, needles, rolling paper, and indeed they may have to assist in this process by holding, buying or giving drugs to a parent. They suffer enormous shame and also indulge in a great deal of self-blame and guilt. Young children tend to blame themselves for things that happen in the family. They may also be frightened by the families contact with drug dealers and the lack of finances. They will lack money for school books, clothes, and experience poverty.

There are huge communication deficits in the family and this is increased by the denial about what is going on in the family and the denial by parents of their chemical dependency. They are aware of the importance of secrecy and not disclosing what is happening in the family. Timothy Rivinus in his book Children of Chemically Dependent Parents published by Brunner-Mazel, New York, 1991, states that children of alcoholics live “thousands of little debts of their parents each year”. These children are often ‘shell shocked’ by the traumas that they witness and show symptoms of Post Traumatic Stress Disorder with repetitive fearful dreams and intrusive thoughts about events that they have witnessed in the family. It is not uncommon for parents suffering from addiction to be hostile, abusive, and critical of their children. The children have massive unmet needs in terms of nurturing, empathy, and the experience of normal family life.

It is not surprising that these children often suffer from depression, hopelessness and low self-esteem. They develop a false self to protect themselves from the outside world. They are often mistrustful of people and can become masochistic and self-destructive themselves in their later behaviour. In later life they can engage with destructive partners. Suicidal behaviour is also not rare in these circumstances as children. They can also become pseudo-adults and heroic figures looking after their parents. This reversed parenting is not healthy and can lead to later difficulties if not talked out. Sometimes it can be used in a more healthy fashion by these children as adults becoming therapists or engaging in the helping professions themselves. These children often show symptoms of Attention Deficit Hyperactivity Disorder, Oppositional Defiant Disorder, Conduct Disorder, problems in attachment with human beings, as well as eating disorders, delinquency, substance abuse, and other acting out disorders. In School they will often have educational problems and may engage in truancy. If mother drank very excessively during pregnancy they may show evidence of foetal alcohol syndrome.When these children grow up and become parents themselves they may either over indulge their own children and become enmeshed with them. As adults these children of alcoholics may not have a clear vision of their parents, they may not be aware of the positive aspects of their parents. Recovering these positive aspects of their parents is of critical importance to mental health. When they marry they may expect their spouse to cure the hurt child in them and this is often an excessive and impossible demand. They really have to come to terms with being a child of an alcoholic or chemically dependent parent but not become a victim. This can be helped by them working out an accurate narrative of their life experience.

Protective factors for these children can include having a high I.Q., an easy temperament, support for these children from a sibling from a non-alcoholic parent, or from a mentor at School. Al Teen where the secrets and denial in the family can be tackled and the child’s history can be spoken openly can be quite helpful.

Unfortunately professionals working with children do not often take sufficiently detailed drug and alcohol histories from parents. This can lead to very confused understanding of the family. Unfortunately in Adult Psychiatry there is a huge denial of the impact of the alcoholic parent on the child and Adult Psychiatrists refer children for counselling or to a Child Psychiatrist only on the most infrequent occasions. In addition the parents and indeed the children can have undiagnosed and untreated Attention Deficit Hyperactivity Disorder which may underlie many of the problems. This lack of identification of this condition can also mean the treatment is either inadequate or misguided. Early and proper early intervention with both psychotherapeutic behavioural and family interventions as well as active pharmacological treatment of Attention Deficit Hyperactivity Disorder can significantly reduce later problems.

Worldwide there is about one death every 40 seconds and about one million suicides per year. Suicide is the leading cause of death worldwide, particularly in younger people.

According to Dr. John Connolly there has been a twelve-fold increase in suicide between 1960 and 2000 in 15 to 34 year olds. The Union of Students in Ireland has estimated that 25 persons per year between the ages of 20 and 24 complete suicide. In data collected during 2002 the National Suicide Foundation Registry found that there was increased Parasuicide by 5.7% in the Midland Health Board, 11.9% in the Mid Western Health Board, 8.5% in the South Eastern Health Board, and 12.7% in the Southern Health Board. They also pointed out that Parasuicide was highest among young women aged 15 to 19 with 1 per 160 of the total population of 15 to 19 year olds being involved. Parasuicide rates were higher in urban areas and varied between 63 per 100,000 in Leitrim and 429 per 100,000 in Limerick. They found that alcohol was involved in 46% of male suicides and 38% of female suicides. Parasuicide made up 1% of all casualty attendances. The types of drugs used in overdose include (a) 40% minor tranquillisers, (b) 43% at least one analgesic drug (Paracetamol involved in 30% of drug overdoses), (c) 23% antidepressants (18% SSRI), (d) Paracetamol was involved in 33% of overdoses by women and 23% of overdoses by men.

It is clear that there are major associations between suicidal behaviour and alcohol or drug abuse. There is a higher risk if there is an easily available method and higher risk in populations of persons who are depressed and persons with schizophrenia. Hopelessness is closely associated with suicidal behaviour. Other factors include narcissistic wounds to the personality i.e. shame or public humiliation. Imitation plays a role for example after Marilyn Monroe’s death. Unemployment and genetic factors are also important. The social contact factors include anomie, alienation, western industrialised societies, sense of meaningless in life, ‘worship of the Euro’, a history of sexual abuse, drop out from education, and bullying can also be factors. Other factors include poor problem solving skills, relationship problems and loneliness, as well as having a history of impulsivity and Attention Deficit Hyperactivity Disorder. Another condition sometimes involved is persons with Asperger’s syndrome, which is a social relationship disorder. Personality features associated with suicide and behaviour include antisocial behaviour, emotional dysregulation, and depressive personality.

Males are at increased risk of suicide because it is harder for them to find an identity in our society and they often have a sense of being lost. They have greater difficulties in expressing their feelings particularly emotional feelings and describing interpersonal difficulties. The female has better verbal skills, better empathy, better interpersonal skills than the male and this is important in reducing completed suicide. The male mind is more of a mechanical mind which is less good at emotional processing.

Almost anything can be a warning sign of suicidal behaviour in adolescents but the following have been noted: truancy, poor school performance, anxiety and depression, withdrawn behaviour, change in behaviour, sleep disturbance, impulsiveness, and low frustration tolerance. Protective factors against suicidal behaviour include prior experience of self-mastery and success, good mental health, and healthy socialising and coping strategies, as well as success at school and work.

In assessing the adolescent with possible suicidal ideas or actual suicidal ideas it is important first to listen and then not to panic and to realise that purely legalistic thinking will interfere with one’s ability to listen to the patient. It is important to ask relevant questions including thoughts and intensions about suicide, plans, wills, available methods, family history of suicide, imitation issues, depression, and hopelessness. If a school teacher or anybody else becomes aware that an adolescent is suicidal it is important to remain in touch with them to give them a telephone number or mobile and to take action to bring the matter to the attention of their family. It is one of the few areas were confidentiality to a friend does not apply. Keeping the friend alive is all that matters. The adolescent will often need to get first in touch with their G.P. and then with a Psychiatrist or Psychotherapist / Counsellor to deal with the matters that are concerning them. Sometimes these contacts need to be on a daily basis in the early stages of treatment.

In terms of postvention that is dealing with a family post suicide it is important to avoid fault finding or blame. Truthfulness is very important. The family need time to work through the feelings they have in relation to the suicide and this may reduce the likelihood of intergenerational effects later on.

In terms of suicide prevention in schools it is important that adolescents are helped to deal with stress and distress and learn life skills. They have to be thought to manage stress, loss, how to manage upset of a break-up of a relationship, and academic problems. Developing problem solving is critical. Some isolated students also need very much to develop social skills and active programmes to prevent bullying in school are of critical importance.

Dr. Arnold Ludwig studied the New York Times Book Review Biographies from 1960 to 1980 and found that 18% of the poets he studied had completed suicide. According to Jamison Ludwig ‘compared individuals in the creative arts with those in other professions (such as businessmen, scientists, and public officials), he found that the artistic group showed two to three times the rate of suicide attempts’ (Jamison, 1993).

Jamison also points out that ‘biographical studies, as well as investigations conducted on living writers and artists, show a remarkable and consistent increase in rates of suicide’. She points out that ‘the artistic groups .. demonstrate up to 18 times the suicide rate’ compared to the expected rate in the general population. This is higher than found in the Ludwig study.

Jamison points out (that the following artists completed suicide: Heinrich von Kleist, Ann Sexton, George Trakl, Marina Tsvetayeva, Ernest Hemmingway, Malcolm Lowry, Virginia Wolff, Vincent von Gogh, Arshile Gorky, Mark Rothko, Nicolas de Stael, Thomas Lovell Beddoes, John Berryman, Thomas Chatterton.

Jamison also points out that the following made a ‘suicide attempt’: Charles Baudelaire, William Cowper, Edgar Alan Po, Percy Bysshe Shelley, Francis Thompson, Maxim Gorky, Hermann Hesse, Hector Berlioz, Eugene O’Neill, Mary Wollstonecraft, Robert Schumann, Dante Gabriel Rossetti.

A. Alvarez stated in his book The Savage God that ‘a suicidal depression is a kind of spiritual winter, frozen, sterile, unmoving. The richer, softer, and more delectable nature becomes, the deeper that internal winter seems, and the wider and the more intolerable the abyss, which separates the inner world, from the outer. Thus suicide becomes a natural reaction to an unnatural condition. Perhaps this is why, for the depressed, Christmas is so hard to bear. In theory it is an oasis of warmth and light in an unforgiving season, like a lighted window in a storm. For those who have to stay outside, it accentuates, like spring, the disjunction between public warmth and festivity, and cold, private despair’. Lord Byron also suffered considerable suicidal thoughts. Percy Bysshe Shelley also experienced considerable suicidal thoughts. Graham Green experienced suicidal thoughts. William Styron in his book Darkness Visible wrote about his suicidal depression and stated ‘the pain is unrelenting, and what makes the condition intolerable is the foreknowledge that no remedy will come – not in a day, an hour, a month, or a minute. If there is mild relief, one knows that it is only temporary; more pain will follow. It is hopelessness even more than pain that crushes the soul. So the decision-making of daily life involves not, as in normal affairs, shifting from one annoying situation to another less annoying – or from discomfort to relative comfort, or from boredom to activity – but moving from pain to pain. One does not abandon, even briefly, one’s bed of nails, but is attached to it wherever one goes’. For Leo Tolstoy ‘the thought of suicide came to me as naturally then as the thought of improving life had come to me before’.

It would appear that the great artist experiences both tremendously deep and complex emotions. They have access to emotional experiences and the extremes. The complexity of their emotional life is great. All this is very helpful for their creativity but also makes them more likely for suicidal thoughts and suicidal behaviour. They are less logical and rational then non-artistic people and are governed by the logic of emotions. Of course the logic of emotions is very often not logical. This makes them more vulnerable to suicidal experiences.

K. Jamison in her book Night Falls Fast states that ‘I have a hard-earned respect for suicides ability to undermine, overwhelm, outwit, devastate, and destroy’. Jamison is an Honorary Professor of English at the University of St. Andrews in Scotland has Bipolar disorder and has attempted suicide. This experience appears to be more common in persons with major artistic creativity than the general population.

Of course one has to be very careful with selected samples of geniuses with artistic ability. They are no way representative of the total population of persons with artistic creativity. Of course there is clear association between depression, suicide, and artistic creativity. What the prevalence of these might be in the total population of artists in Ireland is unknown. We can’t generalise the total population.

It is interesting that both Ann Sexton and Abbie Hoffman received Manic Depressive Disorder diagnosis and were given lithium but stopped taking the lithium and completed suicide thereafter. It is possible to reduce the suicide rate in artistic people with proper treatment of their psychiatric problems. It is likely that the vast majority of artistic people who complete suicide have psychiatric problems. Clearly an additional factor is that abuse of alcohol and drugs is not uncommon in artistic people. There is a myth that alcohol increases creativity. What alcohol does is to increase depressive feelings and not creativity. Alcohol and drug abuse is clearly also associated with depression. Indeed it appears to me that being creative is what keeps people alive. It would appear to me that suicide and depression are much more common where the artist experiences a creative block and that they are particularly vulnerable at that point. The great philosopher Ludwig Wittgenstein as illustrated in the book Autism and Creativity was able to resist suicide by a continuing ability to be philosophically creative as a research philosopher. Indeed it may be that a creative block leads to depression leads to alcohol abuse leads to suicidal behaviour.

In terms of social drinking this is an entirely different matter. It is unlikely that ordinary social drinking will have a negative effect on creativity and indeed might have a positive effect. Stephen Pritzer points out that ‘many writers recognise they could not write well while they were drinking. F. Scott Fitzgerald and Ring Lardner said they went on the wagon when they worked’. He also points out that ‘writers who used alcohol occasionally saw it as an aid in getting started or a stimulus when they were tired’. This makes sense. Clearly excessive drinking is damaging but smaller amounts might be positive for social functioning and indeed for physical health generally. One must also remember that there is often a depressed period following a creative spurt. This has to be managed by a creative writer. Of course in addition the vast majority of artists are poorly paid and suffer a great deal of financial stress. It is a very insecure profession. It is hardly surprising therefore then that it is stressful and this stress makes people in this profession more vulnerable to anxiety and depression. Clearly there are genetic factors in relation to creativity, alcohol abuse and depression. The alcohol abuse only makes it much more likely that the artist will not be able to produce their potential. I don’t believe the story that Coldridge wrote Kublai Khan while on opium. If it is true then he could only have been taking very minor amounts. It is interesting to compare this with great mathematicians, scientists, and inventors (Fitzgerald, 2004). The stress in their life was generally much less than those with artistic creativity. In addition great scientists, inventors, etc. often find very useful places for themselves in society either in the academic world or in the industrial world and therefore do not have insecure lives from a financial point of view. They are also in general far better paid financially. Not every highly successful artist is capable as well of dealing with fame. They may feel they have to continue to produce great work which they may no longer feel able to. They may engage in self destructive paths of drinking and notoriety with suicide as an outcome. Being successful may set the bar too high for them and they may be unable to repeat it and therefore develop writers block followed by depression and alcohol abuse.

Ludwig A. M. (1992). Creative Achievement and Psychopathology: Comparison among Professions. American Journal of Psychotherapy, 46, 330 – 356.

Pritzer S. (1999). Encyclopaedia of Creativity. Academic Press: San Diego. Edited by M. Runco and S. Pritzer.

There is some evidence for an association between religious practice and positive mental health in the Irish context. In a study of mothers coping with a child or adolescent or indeed adult with autism Patricia Coulthard and myself found that carers who sought comfort in prayer had significantly better mental health than those who did not. There are many forms of prayer, one type is petitionary prayer, but all have the acknowledgement of a supreme being in common. Therefore not only is the person praying physically carrying out an activity, praying, they are also in some sense handing the problem on, by deferring to a higher authority. This may lessen feelings of guilt and responsibility. This change of attribution away from the self, combined with the physical activity of doing something may aid the carer to cope more adequately.

In the Irish context in this study carers reported significantly more support from their personal beliefs than from organised religion. The formal churches to which they belonged did not help them to cope and were rarely there as a resource.

The various clergymen did not seem to know how to relate to a mother who suddenly has an autistic child diagnosed. The churches to which the participants in our study belonged did not have an outreach to these isolated families with a child with autism. The clergy seemed to need to be educated on how to manage this crisis situation and as to the spiritual support they could give to these families with an autistic or disabled child. This may be just the occasional visit to acknowledge the existence of the child with autism in the family. These children with autism have been baptised into their church and are just as valid members as the rest of the parish.

Around the time of the diagnosis of the child with autism 23 of the 60 mothers studied prayed to deal with the stress. When the children were at the primary school age 37% of the families used prayer as a coping resource and indeed in some situations the mother’s faith kept her going. At the time of adolescence 17 out of the 60 mothers sought comfort in their religious beliefs or prayed as a coping mechanism. When these children with autism were adults 6 out of the 60 parents still prayed for a magic cure. In all approximately half of the mothers used prayer as a coping strategy. Those who sought comfort in prayer had statistically speaking better mental health.

In another study conducted in Ireland in the 1980s by Professor Hannah McGee and myself and published in Pathways to Child Hospitalisation which was about the home versus hospital care of children with gastroenteritis. We found that statistically far more of the mothers who were able to manage their child at home and didn’t need to have their child in hospital often attended religious services and indeed often did this accompanied by their partner. Clearly this association between religious practice and mental health needs to be teased out more in the Irish context. There is no such thing as a ‘god gene’ indeed the concept is absurd but there is a personality predisposition to spirituality.

Geoffrey Kluger in an article Is God in our Genes? Time, October 25^th, 2004, Page 62 – 72 discusses the Temperament and Character Inventory (TCI). ‘Among the traits that TCI measures is one known as self-transcendence, which consists of three other traits: self-forgetfulness, or the ability to get entirely lost in an experience; transpersonal identification, or a feeling of connectedness to a larger universe; and mysticism, or an openness to things not literally provable. Put them all together and you come as close as science can to measuring what it feels like to be spiritual’. “This allows us to have the kind of experience described as religious ecstasy” says Robert Cloninger. Hamer studied spirituality using ‘Cloninger’s self-transcendence scale, placing them on a continuum from least to most spiritually inclined. Then he went poking around in their genes to see if he could find the DNA responsible for the differences. Spelunking in the human genome is not easy, what with 35,000 genes consisting of 3.2 billion chemical bases. To narrow the field, Hamer confined his work to nine specific genes known to play major roles in the production of monoamines – brain chemicals, including Serotonin, Norepinephrine and dopamine, that regulates such fundamental functions as mood and motor control’. He found ‘a variation in a gene known as VMAT2 – for vesicular monoamine transporter – seemed to be directly related to how the volunteers scored on the self transcendence test. Those with the nucleic acid cytosine in one particular spot on the gene ranked high. Those with the nucleic acid adenine in the same spot ranked lower’. Twin studies have shown similarities in their spiritual feelings. Thomas Bouchard stated ‘whether we are drawn to God in the first place is hard wired into our genes’. He also stated ‘it is completely contradicted my expectations’. Michael Persinger states that the god experience ‘is a brilliant adaptation. It is built in pacifier’ for example to do with the contemplation of our death. This is the opposite to novelty seeking. It is possible though that religious ecstasy might be more closely linked to novelty seeking. A book on the topic is called God Gene: How Faith is Hard Wired into Our Genes, Doubleday, 2004 by Dean Hamer. In personality traits such as discussed here multiple genes of small effect are operating

I read with interest a recent comment by Dr. Ronald Boland that in a survey of parents more than a quarter (were) ‘reluctant to vaccinate their children because of worries of vaccine safety and did not believe in infant vaccines at all’. This is unfortunate. It appears to me to be largely due to false information being distributed over the years through the media and by a publication in a prestigious medical journal, which under mines the great faith, the medical professional has in the peer reviewed process. Six years after the report, an incredibly long time, ten of the thirteen authors of this article retracted what they wrote and stated that their original paper did not support the conclusion that the vaccine was to blame for autism.

It is interesting to see what the media has said about MMR and autism over the years. The Daily Telegraph had the best headline ‘Chattering class endangers child lives over MMR’. Claudia Winkleman in the Daily Telegraph has the following headline ‘I didn’t want the MMR – and now my baby has measles’. She goes on to state ‘Jake tosses in his comfy cot and moans in his sleep. Yes I am a class A idiot: my son is ill – and it is my fault’. Another excellent report in the Irish Times stated ‘Beware of giving bad reports a shot in the arm’. Unfortunately this is what the media has done over many years. Misinformation and false information sells newspapers. One might think that the media might have some concerns about false information and the potentially fatal affects of it. A false story is a good story from the media point of view because it sells newspapers while truth is not of interest very often. Many media outlets have lawyers to check on libel and maybe they should also have relevant medical doctors to check the veracity of medical information. Because of the focus on the ‘bottom line’ it is highly unlikely that this will take place. Of course doctors also have to take responsibilities for this because very few doctors ring up and point out to media sources the falsity of the information that they are giving out. Doctors only tend to respond when they are asked.

Another more recent media headline from the Sunday Times was ‘Vaccine patents and the MMR scare doctor’. Another headline from the Irish Times ‘Parents urged to have rethink on MMR after measles cases treble’. Another heading from the Medical Press ‘Latest figures show uptake rates from primary vaccines continue to fall’. Colin Tudge writes in an article called ‘Mad, bad and dangerous: whether it is the MMR vaccine or GM foods, people distrust what scientists tell them’. This was in the New Statesman. The Irish Times in 2003 has a headline ‘Research finds no ill-effects from triple MMR injections’ and quotes Dr. O’Herlihy as saying that the Republic was witnessing the beginning of another outbreak of measles. Dr. Ray O’Connor in an article entitled ‘MMR vaccine: controversies and fallacies in Modern Medicine’ states ‘measles is a particularly nasty disease. Many doctors and parents have not seen a case of measles, and its severity – even on complicated cases – it is often forgotten’. He discusses the complications including severe cough, breathing difficulties, ear infections, pneumonia, and conjunctivitis. He also discusses rare serious complications of measles including acute encephalitis and sub-acute sclerosing pan-encephalitis. He puts the death rate at 1 to 2 per 1,000 infected people. The Irish Medicines Board in their newsletter points out that more than 500 million doses of MMR vaccine have been used worldwide and that there was no evidence to support the suggestion that single component vaccines should be administered separately. They also point out that mono component vaccines given sequentially, children would be at risk of infection for longer periods.

Brian O’Shea in the Journal of the Irish Psychiatrist points out that the number of reported cases of measles jumped from 243 to 586 during 2000 / 2003. More recently the Medical Research Council in the United Kingdom in a study of more than 5,000 U.K. children has ruled out any link between MMR, the measles, mumps, and rubella triple vaccine and autism. This should be the last word but certainly will not. There are many other authoritative reports and papers that have come to a similar conclusion. Despite all this the Sunday Times in 2004 reports on a product that was made ‘by giving the measles virus to mice and extracting their white blood cells, which were then to be mixed with human cells before being infected into pregnant goats. After the goats gave birth their first milk was to be collected, and made into capsules and given to children’. This was called a ‘combined vaccine / therapeutic agent’. Professor Tom McDonald an immunologist described the recipe as ‘total bollocks’. Another immunologist has a so-called ‘cure’ for autism who ‘sells a six month complete cure’ for autism, which he prepares in his kitchen using his own bone marrow. This has echoes of the potions of the early 19^th century. Those of us who work with children with autism are constantly being bombarded with ‘miracle cures’ for autism. Unfortunately these raise parent’s hopes which are then dashed fairly quickly.

I have seen over 900 persons with autism and Asperger’s syndrome. I have never seen a person with autism or Asperger’s syndrome that was ‘caused’ by a vaccine. Autism is highly genetic. Autism is not a side effect of MMR.

John Donne ‘No man is an island, entire of itself … any man’s death diminishes me, because I am involved in mankind; and therefore never send to know for whom the bell tolls; it tolls for thee’.

Suicidium is derived from the Latin words ‘sui’ self and ‘caedo’ to kill. The Romans said ‘sibim mortm conscies consciscere’ in other words “procure his own death”.

Ancient authors against suicide include Pythagoras, Socrates, Plato, Aristotle, and Virgil.

During the Trojan War, Ajax, one of the Grecian heroes, slew himself, in a fit of passion, brought on by offended vanity. Lycurgus, the legislator of Sparta, was one who completed suicide.

Judas Iscariot AD 33, Pontius Pilate AD 36, Zimri 929 BC King of Israel, Eleazar 164 BC, one of the Maccabees, Saul 1050 BC the first King of Israel, Samson 120 BC Judge of Israel.

According to Westcott there were 24 suicides per million in Ireland in 1883. This can be compared with 48 per million in Scotland in 1881 and 101 per million in Sweden in 1887. The rate in Switzerland in 1881 was 240 per million, in Denmark 265per million in 1878 and in Saxony 409 per million. In the 19^th century Briere de Boismont put the number one cause of suicide as mental illness but motive only counted for the most commonest assessment or lack of assessment of suicide. The third cause of suicide was alcoholism. Of the 600,782 cases observed by Falret the following proportions were calculated by him ‘caused by misery 1 in 7, loss of fortune 1 in 21, gambling 1 in 43, love affairs 1 in 19, domestic troubles 1 in 9, fanaticism 1 in 66, calumny, wounded self-love, and failed ambition 1 in 7, remorse 1 in 27’ For Lisle the first cause of suicide was mental illness, the second one was unknown, the third was to avoid pain, the fourth was domestic troubles, the fifth was debts, the sixth was misery, the seventh was habitual roguery. There were unusual causes including political excitement, religious fears, suicide after crime, rivalry in business, disgust of military life, disappointment in love, nostalgia. Westcott in 1885 noted while crime was falling suicide was increasing and that while it awakens sympathy on behalf of the unhappy victims, we should stimulate our exertions towards promoting the diminution of this plague.

In the 1850s suicide was not more common in industrial areas than in rural areas. At this time those at high risk for suicide were doctors, barristers, and butchers. At low risk were quarrymen, ministers, and fishermen. It took a whole generation before people realised that railways could be used for suicide. Morselli stated the prevalence of men over women was least in youth, greatest in adults, whilst it becomes small in old age. Anderson points out that in the middle of the 19^th century what was distinctive about suicide in the city was its exceptional frequency among young people, especially young men. Indeed between 1861 – 1870 the suicide rate for young men and women aged between 15 and 24 years were respectively as much as 71 and 58% higher than those of the rest of the country. Morselli warned women that taking part in politics would lead to ‘infallibly to higher suicide rates’. Morselli believed that the emancipation of women would lead to higher suicide rates. Durkheim (1897) comment was similar. He said ‘women kills herself less . . because she does not participate in collective life in the same way’. In the 19^th century in married female suicide was often blamed on seduction according to Anderson. Unfortunately at this period novelettes presented suicide as the appropriate response to a girl in difficulties. Victorian domestic servants according to Anderson were believed to have high rates of suicide, as well as unwanted pregnancy, drunkenness and theft. Honeymoon suicides were also not uncommon. The effects of masturbation were also a source of massive anxiety. According to Anderson the chaplain’s office in Clerkenwell Prison was possibly the first suicide prevention agency and it focussed on churchmanship and social work.

In the 1870s emigration to Canada was offered to some who attempted suicide. Alcohol was also a huge factor in 19^th century Suicidology. As Anderson points out there was a belief in the 19^th century that suicide could be reduced if the press stopped reporting it ‘in detail’. This has echoes of today.

Uganda is very much in the news at the moment because of the national elections and the unjustifiable controversy over Irish aid to Uganda, which in my opinion is well spent and accounted for. Uganda is a very poor country, which has been ravaged by war in the not too distant past. You can still see burnt out tanks at the side of the road. Security is a big issue and expensive in Uganda. My Hotel had three ring of security – the outer ring having armed guards. The second ring checked for guns which were not allowed in the Hotel. The third or inner ring of security protected the bedrooms. Not surprising I did not see any of the “Irish glitterati” on holiday or buying holiday homes. Uganda is on the equator, with wonderful sunshine and low humidity during my visit.

I also saw birthday parties for children in Uganda and weddings, which wouldn’t be out of place in Shrewsbury Road, Dublin 4. There is a privileged class as well. There is much greater in general family support in Uganda compared to Ireland. Rejecting families of the kind that you see in Ireland are much less common in Uganda and when they occur, they occur within the more educated classes.

The people dress very neatly and well. Because most of them are not overweight obviously then can carry clothes very well. At weddings the attire is simply magnificent. The average wage of people in the Hotel industry is 100 dollars per month. The hours are extremely long.

In Uganda particularly in the less educated classes polygamy is a status symbol and so a man having three, four or more wives is not uncommon. I wonder how Family Therapists or the Mater Hospital would handle this kind of family?

At the time I was there families were storing up on flour / grain for fear of social political implosion and there was a lot of anxiety and confusion about the upcoming presidential election. The leader of the opposition had been jailed. It was December 2005 the beginning of the national elections. I saw massive gatherings of political supporters with much noise. There is considerable fear in Africa of the growth of the “Mugabe syndrome”.

As you walk around you see endless people walking appearing to walk forever and then other huge numbers of men sitting around under employed. The pace of life is about one fifth that of Ireland. In the northern area where the Civil War is raging everybody has to go into the compounds at 3 p.m. in the evening for fear of attack or abduction.

Children are abducted and used as basically sex slaves for commanders of the rebel army. When these come back or rescued they often describe that they have been the “wife” of a commander. The higher up the commander that they have been the more status they have. When they are abducted their first task maybe to kill their parents. Caroline Moorehead pointed out that the Lord’s Resistance Army appeared to be defeated in 2002 but then abducted a further 8,400 children. There are about 300,000 child soldiers in the world.

In one tribe the men sit around all day drinking a low alcohol brew and everybody drinks from this central container while the women go out to work the fields etc. Children have their first taste of alcohol at baptism. It is hardly surprising alcohol problems are a major feature. Since the Afghan war drugs are being re-routed through Africa that formally went through Europe and this has led to increased drug problems in Africa.

The largest Hospital has a 9 year old CT scan which has scanned over 10,000 patients. In this Hospital there is a ratio of 1 nurse to 20 patients during the day and 1 nurse to 50 patients at night. The largest Hospital has a 1500 bed capacity and 80 to 100 deliveries per day of babies. I read in a newspaper that 53 is “a very advanced age”.

I attended psychiatric inpatient assessments and I saw HIV, syphilis, and many organic psychosis. In the psychiatric setting it is not uncommon for HIV to present as an acute manic psychosis.

There was a great deal of police contact in relation to inpatients. I also saw traditional family problems. An OPD session would have 50 patients for one psychiatrist. There was 3 to 10 patients admitted per day in the Hospital. I worked with a psychiatric clinical officer which is basically a CPN who has permission to diagnose and treat psychiatric illness. She was superb in her diagnosis, assessment, and medical treatment. Certainly we are going to see more of these performing throughout the world in the future. Long waiting lists particularly in Child Psychiatry in Ireland could be solved if we had child psychiatric clinical officers who had extra training i.e. child psychiatric nurses with some extra training maybe in diagnosis and assessment so that they could assess people on the waiting list and referred more complex cases for multidisciplinary or child psychiatric assessment. There was none of these endless wasteful multidisciplinary team meetings so common in Ireland. The psychopathology was much more severe than we would see in Ireland.

The quality of the Registrars is similar to Ireland. I heard of one case while I was there where a traditional healer had fractured the skull of a patient. This traditional healer as part of his treatment was to beat the patient. The medications they use in the public service are Chlorpromazine, tricyclics, Haloperidol, diazepam, Chlordiazepoxide and lithium. Psychologists have Cognitive Behavioural Therapy orientation. In the Hospital the patients were uniformed in blue, green, etc.. The junior doctors wear white coats.

Every time a doctor or other health professional is taken from a developing country and retained in Ireland the government as part of its development aid should repay the full cost that the developing country had invested in training this health professional. Ireland undermines health care in developing countries by taking vital health care professionals from them.

Christmas is a small event. I noticed no evidence in Entebbe Airport (famous for the Israeli raid on Entebbe) but I heard Silent Night being sung on the radio in Nairobi Airport three days before Christmas but that was about it.

When people think of Malaysia what first comes to mind are the Petronas Twin Towers of Kuala Lumper. It has a population of about 25 million. The British during their time there left good structures which are benefiting Malaysia today unlike the behaviour of the Dutch in Indonesia.

During my time there I spent most of my time in Penang and at the Penang Medical School associated with RCSI and UCD. The founder of Penang was Francis Light who is reported to have hit upon a cunning method of getting the surrounding jungle cleared to make way for the town. He loaded a canon with Spanish Silver Dollars, fired them into the forest, and invited local labourers to hack their way through the undergrowth to get to the money. Alfred Russell Wallace who discovered the evolution of the species at the same time as Charles Darwin lived in Malaysia. The climate is warm and balmy. The cost of living is much cheaper than Ireland and one can have an excellent dinner for €8. Some companies are moving out of Malaysia to China because of cheaper labour in the same way they are moving out of Ireland. Welfare is provided through Religious Organisations rather than the State. There is massive pressure on the children at school particularly Chinese children and grinds start from the age of six onwards. Walking around the parks one sees endless monkeys roaming free. I was also told that the hills behind Penang have interesting walks but cobra snakes tend to frequent these places. I was told that they didn’t attack one if they weren’t disturbed. I decided this was an experiment that I wouldn’t make. The “Ryanair” airline of Malaysia is called Air Asia and works on the exact same model. I observed construction workers from my hotel window working 40 storeys up without protection. It made me dizzy to watch them. It reminded me of the Irish workers in the early days of Manhattan while working on the skyscrapers worked also without protection. There are endless motorbikes there who weave in and out quite similar to the couriers in Dublin but much more dangerously and much faster. People on motorbikes wear their coats back to front as this helps the circulation of air.

The Penang Medical College is extremely successful. It is approximately ten years old now. On my first day I met the Dean Amir and the President of the College Rathlingan a Physicist. I had a chat with Professor William Shannon from RCSI who told me about developments in general practice in Malaysia. He pointed out that there was major need for development of professional training programmes for General Practitioners. I was told that Dean Muiris Fitzgerald has been a regular visitor particularly in relation to graduation issues. They were looking forward to Professor Niall O’Higgins President of the Royal College of Surgeons in Ireland visit soon. Professor Noel Walsh was a distinguished Professor of Psychiatry at UCD and spent a number of years as a pioneer with the Penang Medical College where he learned to speak Malay to huge approval of the local population. I also visited a Centre called the Lion Centre for children with autism which works along similar lines to Centres in Ireland. They gave me a book called The Reach Way to Transformation which had a Foreword by Professor Noel Walsh. He arranged for medical students to visit this Centre during their undergraduate training. I was told that medical education can cost up to 150,000 Euros but that there are scholarships. I met quite a number of medical students who the previous year had been at the Royal College of Surgeons in Ireland for their earlier medical education. I had eleven professional / parent contacts during my visit there including five lectures and meetings with parents of children with autism, meeting with professionals, visits to Inpatient Psychiatric Units, and Outpatient Child and Adult Psychiatric Services.

In the Child Psychiatric Outpatients I met Dr. Lai a Child Psychiatrist. On his wall he had a poster giving 88 ways to praise a child and another poster stating that families must try to achieve marital and family harmony. I observed custody and access discussions there which were identical to Ireland using the same language and just as acrimonious. In the Child Psychiatric Outpatients they used the Swan Scales for Attention Deficit Hyperactivity Disorder and also the Vanderbilt Attention Deficit Hyperactivity Disorder Diagnostic Teachers Rating Scale. The rates of Attention Deficit Hyperactivity Disorder seem very common and the treatments were the same as in Ireland. The standard of psychiatry was the same as in Ireland. In the Adult Psychiatric Outpatients some of the conditions would be different from Ireland in that there was koro which is the feeling that the penis is being withdrawn into the abdomen, amok and latah. It seemed easier to diagnose psychosis because as in Uganda I observed that patients were more willing to be explicit about their psychotic symptoms. The Adult Psychiatrists were doing research work on Sertindole which is a medication for the treatment of psychosis. There are about 10 million children under 17 in Malaysia, 14 Child Psychiatrists which works out at about one Child Psychiatrist per 800,000. I was pleased that the interest of the services was in providing direct assistance to patients rather than sitting around in teams discussing patients. I liked the Malaysians very direct way of seeing patients and helping them out to the best of their ability without the ‘team games’ so prevalent in other countries. Of course teams are very relevant for about 5% of referrals where one is dealing with very complex psychological, social and psychiatric situation.

I had an opportunity to lecture to professionals from Penang as well as from the mainland up to the Thai border and I became aware that people with multiple disabilities tended to be placed together. This was not ideal but persons with autism were beginning to be separated out for their own services.

I met Professor Leela Ryan who is a much appreciated Consultant Psychiatrist in the South Western Area Health Board in the Naas Hospital is now playing a major role in Psychiatry in the Penang Medical School and is a key figure there.

I met Professor Saroja who is head of the Psychiatric Department and during the Tsunami which hit Malaysia and drowned people she developed with her colleagues an excellent Early Intervention Programme which was used throughout Asia.

Because of overcrowding in some schools, schools have one group of pupils coming in the morning and a second group of pupils coming in the afternoon. This reminded me of Makere University in Uganda where some students would attend in the middle of the night because of a lack of places etc. during the day. Many of the population were Muslim and I was very impressed by their behaviour and the kind of country they had created with brilliant Chinese businessmen and Indians. Nevertheless I did notice some concerns in the front page of a local newspaper which had the headline “Hugging and kissing in public: freedom or indecent behaviour?”. Malaysia is a country which symbolises Asia and is worthwhile a visit. There is a mix of private and public hospitals just as in Ireland and medical tourism is big business particularly from Indonesia. The issues that they have to face particularly in relation to infections are massively different from the issues in Africa.

Certain aspects of Autism and Asperger’s syndrome remain controversial in

Ireland

. These controversies cause enormous distress to families of persons with Autism. In reality these controversies are unnecessary and the distress to families is unnecessary, particularly as these families have sufficient demands on them with their child with Autism without unnecessary artificially created controversies.

The first controversy the families have to face is the controversy over narrow versus broad spectrum diagnosis of autism. The old fashioned concept of Autism, called Kanner’s Autism, which is a narrow conception of Autism is no longer believed by anyone. Instruments called the Autism Diagnostic Interview and Autism Diagnostic Observation Scale are examples of instruments focussing on narrow Autism. Professor Michael Rutter pointed out that “the ADI-R is not a perfect instrument”. He is 100% correct about this, indeed most of the ‘seasoned’ critics of the ADI-R believe it to be a highly imperfect instrument. Adam Feinstein noted that at the International Meeting for Autism Research in London in 2008 that many of the most highly regarded researchers in Autism in the world ‘lambasted the tool (ADI-R) for missing many cases of Autism”, and that it was “an expensive and ineffective instrument”. It is extremely expensive and it is prohibitive for the developing world, and inhibits the possibility of research in Autism in the developing countries. At the 2008 meeting, which I attended, I heard researchers from

Australia

complaining about its prohibitive cost.

Professor Dorothy Bishop, Professor of Development Neuropsychology at the University of Oxford criticised the ADI-R for the vast time it takes for “training” in the use of the instrument, “time for administration and time for scoring, and consensus coding”. Professor Bishop correctly pointed out that “if you could be shown that there were real benefits in accuracy of diagnosis from adopting this lengthy procedure” then she would be happy to go along with these tedious assessment procedure and instrument. There is absolutely no evidence for this tedious long-winded assessment procedure. Professor Bishop correctly concludes that “the originators of the instrument have never demonstrated that you actually need such a long process – it is really more an article of faith to them”. This has echoes of religious faith that has no place in science.

I have found the proponents of this instrument in a number of countries are fanatical in their support of the ADI-R, indeed have a “religious” faith in its value. Professor Bishop also points out that in relation to the ADI-R-ADOS that there are “plenty of children who come out as meeting criteria on one instrument only, and there seems to be no sensible guidelines as to how you proceed, other than to seek expert clinical opinion. Professor Bishop recommends “doing studies to see what is the minimal set of items you have to get reasonable diagnostic accuracy and I doubt that we really need a three our interview for each case”.

I am continuing to see parents with children with Autism who come to me in great distress and tears because they had been told their children did not meet criteria for Autism based solely on these tests, when it was absolutely clear to me and to the parents that the parents had classic Autism broader phenotype - Autism Spectrum Disorder. How long more am I going to have to deal with parents in tears? I don’t think parents should have to suffer unnecessarily because of the above reasons. Their energy should be put into therapeutic activities for their children, not having to go from one professional to another to get a formal diagnosis.

Autism is very commonly associated with low functioning and Learning Disability. This is a false conception of the condition. High Functioning Autism or Asperger’s syndrome can occur in persons with very high I.Q. and indeed ability of genius proportions. The following people demonstrate this high ability as well as High Functioning Autism:

Kurt Godel was very much a loner and a genius. He was fascinated by mathematics and contributed greatly to it. He was a linguist and an autodictat. Even in junior school he was fascinated by mathematics and physics. He was socially immature and had severe difficulties in social relationships. He had non-verbal behaviour difficulties and had a tremendous capacity for focus on mathematical problems. He was extremely naïve. He suffered from severe depression. His verbal contributions are characterised by extreme brevity. He was also quite paranoid and fearful of emissions from refrigerators.

Mendel was a genius who was also very much plodding in his work, hard working, and completely single minded. He proposed laws of inheritance that ultimately became the underpinning of the science of genetics. He had severe difficulties in social relationships. He was extremely shy. In front of a class he was an extremely poor teacher. In teaching he never was fully certified and was always a substitute teacher. He was a man of absolute routines. He regarded his plants as his children. He was a monk who became rather paranoid and saw his fellow monks as traitors.

Hans Christian Andersen was a great storyteller. He was socially immature. He had very significant social interactional problems. He was very much a loner. He never married. He was a great writer of fairytales and showed enormous creativity in this area. He read an enormous amount of books. He was bullied and called names at school. He was very much an outsider. He spoke with a high pitch tone of voice. He was extremely obsessive. He was very ritualistic in his behaviour. He was very controlling and at meal times his food had always to be served first. He suffered very much from depression throughout his life. He had identity diffusion. He wrote endlessly and compulsively.

Archimedes was a great Greek mathematician and inventor. He was a loner. He was mechanically and mathematically minded. He hyper focussed on his researches. His interests were extremely narrow. He would forget to eat his meals. He was regarded as extremely eccentric.

There are few conditions that have received as much coverage in the popular press in recent times or have been the subject of as much controversial debate as autism. Public awareness regarding the condition has grown exponentially but many healthcare professionals may still lack confidence in making the diagnosis of autism according to Dr. Louise Gallagher who has conducted genetic research in autism at Trinity College Dublin.

This article aims to give an overview of the disorder of autism staring off with a clinical description and diagnostic criteria. Theories on causation and a review of the current accepted interventions will also be outlined.

It can be associated with ability of genius proportions. Examples include Godel, Hans Christian Andersen, Gregor Mendel, Archimedes, and Charles Lindberg.

Autism is a neuro-developmental disorder of childhood that was first described by Leo Kanner. He described a group of children with impaired language, lack of eye contact, lack of social interaction and repetitive behaviour. In 1944, Hans Asperger published a paper describing a pattern of behaviours in several young boys who had normal intelligence and language development, but who also exhibited autistic-like behaviours and marked deficiencies in social and communication skills. Asperger’s syndrome went largely unrecognised until the 1980s. Now it is commonly used to describe individuals with an Autistic Spectrum Disorder and normal intellectual functioning.

Asperger’s syndrome, and described the following difficulties in the first two years of life of children with the condition:

(d) A significant reduction in the wish to communicate verbally or non-verbally.

(f) No imaginative play or if it does occur it is confined to one or two rigid patterns.

Gillberg’s diagnostic criteria for Asperger’s syndrome: social impairments; narrow interests; repetitive routines; speech and language peculiarities; non-verbal communication problems; motor clumsiness.

High Functioning Autism or Asperger’s syndrome is not uncommonly misdiagnosed as Schizoid, Narcissistic Borderline or Obsessive Compulsive Personality Disorder or Schizophrenia.

Heritability estimates of over 90% have been made in relation to autism. Louise Gallagher points out that approaches to genetic studies have involved candidate gene studies and genome-wide, affected, sib-pair linkage studies. Association studies with variants within the Serotonin transporter gene have been conducted based on the well-established findings of elevated platelet Serotonin. Findings between studies have been inconclusive to date. Other genes, which have been studied, include UBE3A, GABRB HOXA1/B1, all of which have had conflicting reports of association. Reelin and WNT have had initial studies reporting association but these require replication.

Seven genome-wide linkage studies have been published to date and a large number of regions of putative linkage have been identified. The most convincing evidence has been found on Ch2q and 7q. Efforts are underway to narrow these regions down to find candidate genes.

A comprehensive management plan should be put in place once the diagnosis has been established. Management involves a multidisciplinary approach involving the following:

Speech and Language Therapy is essential and should be provided regularly (at least once a week) for children with speech and language delay. Pharmacotherapy has limited application but Ritalin may be considered in the presence of marked hyperactivity although children with autism are reported to be more sensitive to the side effects. Risperidone has been shown to have some beneficial effects on global assessments of psychiatric morbidity but not on individual autistic symptoms. Naltrexone has been reported to have beneficial effects on self-injury and stereotyped behaviours but well-controlled clinical trials are still required. SSRIs are widely used in the US but not in Europe. There are some reports of improvements in repetitive behaviours but randomised, controlled trials (RCTs) are required. The use of Melatonin in sleep disorders including those associated with autism, has been reported as beneficial by a number of groups. Again there is an absence of well-controlled RCTs.

As mentioned above, the evidence supporting a casein and gluten-free diet is limited. Knivsber et al. report an overall benefit in their review of the area but the studies in question have a number of methodological flaws including small sample sizes. Secretin has not been shown to be helpful.

The following examples of people with High Functioning Autism or Asperger’s syndrome and contributors of genius.

Charles Lindberg was a great aviator. He was a loner as a child. He was painfully shy in social relationships, he was naïve in accepting an award from Hitler. He liked solitude. He was extremely logical and obsessed with aviation. He also worked on the issues in high altitude flying and on a pump that blood could be pumped if the heart was being operated upon. This work was carried out at the Rockerfeller Institute. His greatest achievement and one that he was well suited for was in flying solo across the Atlantic over Ireland to Paris. The link between psychiatric disorders and genius has often been made and these are further examples of that link.

The prevalence of Adult Attention Deficit Hyperactivity Disorder is between 1 and 5%. Both DSM-IV and ICD-10 criteria recognise that symptoms of Attention Deficit Hyperactivity Disorder and Hyperkinetic disorder persist beyond childhood into adulthood. However neither classification gives fixed thresholds for the number of symptoms required to make a diagnosis in adults. DSM-IV criteria suggests that adults with only some of the symptoms of Attention Deficit Hyperactivity Disorder should be given a diagnosis of Attention Deficit Hyperactivity Disorder in partial remission; however, this diagnosis seems to underplay the significant impairments seen in adults no longer meeting the full DSM-IV criteria. There is no doubt that symptoms of adult Attention Deficit Hyperactivity Disorder should be judged with reference to developmentally appropriate norms. The expression of Attention Deficit Hyperactivity Disorder in adults is different from that in children and the diagnostic descriptions of symptoms are not easily applicable to adults. For example physical activity in children is replaced by constant mental activity, feelings of restlessness and difficulty engaging in quiet sedentary activities in adults. Compared to the diagnosis in children, a diagnosis of Attention Deficit Hyperactivity Disorder in adults is also heavily dependent on self-reporting symptoms. For that reason an independent informant particularly one who had knowledge of the adult in childhood is particularly important. In addition school reports can be most helpful. Girls particularly with Attention Deficit Disorder without the hyperactivity tend to be under diagnosed and under treated. In Adult Psychiatry Attention Deficit Hyperactivity Disorder is probably one of the commonest missed diagnosis, the second most commonly missed diagnosis being Asperger’s syndrome. What is treated is the comorbid anxiety, depression, or drug abuse and the underlying Attention Deficit Hyperactivity Disorder is left untreated with serious consequences.

The key element in diagnosis is the lifetime and persistent history of symptoms with impairment in either school, work, home, or interpersonal relationships. This was emphasised at a recent meeting of the European Network for Attention Deficit Hyperactivity Disorder in Frankfurt.

Treatment should focus on psychoeducation for persons with Attention Deficit Hyperactivity Disorder, as well as pharmacotherapy, and in addition the treatment of comorbid disorders. Stimulants like Methylphenidate are used in the treatment of adults. Long acting Methylphenidate for example Concerta is being used off label for adult Attention Deficit Hyperactivity Disorder. Atomoxetine (Strattera) which is licensed for adults in the United States and is available in Ireland on a named patient basis is being used for the treatment of Attention Deficit Hyperactivity Disorder. It is the first non-stimulant medication for Attention Deficit Hyperactivity Disorder. I have found that the tricyclic antidepressants are unfortunately rather ineffective. The core symptoms of Attention Deficit Hyperactivity Disorder require pharmacological treatment. The other behavioural associated problems or disorders can benefit from psychotherapy, cognitive, supportive, etc..

It is possible that Adult Attention Deficit Hyperactivity Disorder may belong to a more severe and more genetically effected condition. Morbidity and mortality are both increased in adults with Attention Deficit Hyperactivity Disorder. It appears that Attention Deficit Hyperactivity Disorder can result in more accidents including traffic accidents and alcohol and drug abuse. There is evidence that where Attention Deficit Hyperactivity Disorder has been adequately treated the rate of substance abuse was less. It is important to reiterate that in adulthood the features of Attention Deficit Hyperactivity Disorder that are most common are inattention, impulsivity, poor organisation, and restlessness. Attention Deficit Hyperactivity Disorder can be associated with creativity for example Kurt Cobain who had diagnosed Attention Deficit Hyperactivity Disorder in childhood, Oscar Wilde, Lord Byron, Ernest Shakleton, and Richard Brinsley Sheridan.

Adult Attention Deficit Hyperactivity Disorder is of critical importance in services treating drug problems, personality disorders, and forensic services. The rate of Attention Deficit Hyperactivity Disorder in Mountjoy Prison is much higher than in a non-prison population. A recent edition of the Journal (2003) Drugs: Education Prevention and Policy emphasised the association of adult Attention Deficit Hyperactivity Disorder, Antisocial Personality Disorder and substance misuse. Despite this clinicians have a reluctance to take Attention Deficit Hyperactivity Disorder into account at the diagnostic and therapeutic level. The reluctance to accept the diagnosis is even more puzzling because of its very high heritability which is higher than many conditions psychiatrists treat. There should be regional centres for the treatment of adult Attention Deficit Hyperactivity Disorder but this is not possible with the catchment area arrangement. Therefore one Consultant Psychiatrist in each catchment area should take a special interest in adult Attention Deficit Hyperactivity Disorder.

About 80% of all suicides are male. Alcohol and substance misuse is commoner in males and unemployment may be a more significant risk factor in males who complete suicide. It appears that it may be harder for males to find their role and identity in our society where ‘a credit card is all you need’.

It is hardly surprising then that the unemployed male who may see themselves at the bottom of the male hierarchy is more likely to suicide.

Unemployed males would appear to suffer significant identity diffusion, be on a different track to other males, employed and driving their BMWs.

Indeed the difficulties with the male finding a role and being lost are particularly a feature of young male adulthood. The Sunday Times in 2004 stated that ‘the sperm bank is the perfect father’ and had another statement as follows ‘women longing for a baby (but) decide to go it alone’. The male has become more marginalized in our society in recent times. Females have entered the workplace in great numbers but still have retain their fundamental biological role that is in reproduction.

The male brain has strengths in mechanics, engineering, and mathematics. These talents do not help in the mental processing of psychological distress. In addition males tend to be more aggressive, impulsive, and are therefore at increased risk of engaging in fatal suicidal behaviour. Simon Baron-Cohen points out that good systematisers are also skilled at understanding and exploiting natural systems. The males are therefore good as hunters and trackers. The male is good at mechanical systems and constructing tools. The male is good at making weapons and fighting. Good systematising helps the male to be good at working on the stock markets. Males are particularly good at climbing hierarchical poles. The combination of low empathising (male) and high systematising (male) means a rapid ascent to the top of the ‘social pile’. Males are more single minded. Nevertheless all these feature may make suicide more likely.

Males in severe psychological distress using the ‘stiff upper lip’ strategy are particularly at risk. It is possible that some of them feel that being in distress is to be unmasculine is to be lacking machismo, which is experienced as intolerable, who then in this highly distressed state undertake suicide. Males are better at map reading. The male language is sometimes more egocentric. Males are more aggressive and get involved in more crime and homicide. Systematising is our most powerful way of understanding and predicting the law – governed inanimate universe. Understanding the inanimate universe is not much good when a human being male is highly stressed and contemplating suicide. A great deal of this material is also covered in my book Autism and Creativity: Is there a link between Autism in Men and Exceptional Ability? Published by Brunner-Routledge, 2004. The extreme male brain theory of autism is based on superior systematizing.

The female brain according to Simon Baron-Cohen is hard wired for empathy, and the male to understand and build systems. In the long term it is likely that the human genome will pinpoint multiple genes of small effect that control empathising and systematising. Females are better at sharing and turn taking, at responding empathically to distress of other people, are better at being sensitive to facial expressions, and value relationships more.

Empathising is the drive to identify another person’s emotions and thoughts, and to respond to these with appropriate emotion. Females are high in empathising and low in systematising. Females are much better than males at reciprocal communication. Females are also better at reading non-verbal behaviour. Females tend to be more compassionate and tolerant. Females have superior capacity at communication and interpersonal relationships which may mean that they are less vulnerable to completing suicide.

There has been a major controversy in the media because of the relationship between suicidality in children and adolescents and SSRI antidepressants. The FDA (Food and Drug Administration) in America state that antidepressants increase the risk of suicidal thinking and behaviour (suicidality) in children and adolescents with major depressive disorder and other psychiatric disorders. Anyone considering the use of an SSRI or any other antidepressant in a child or adolescent must balance this risk with the clinical need. Patients who are started on therapy should be observed closely for clinical worsening, suicidality, or unusual changes in behaviour. Families and care givers should be advised of the need for close observation and communication with the prescriber. Pooled analyses of short term placebo / controlled trials of nine antidepressants (SSRIs and others) in children and adolescents with major depressive disorder, Obsessive Compulsive Disorder, or other psychiatric disorders have revealed a greater risk of adverse events representing suicidal thinking or behaviour (suicidality) during the first few months of treatment in those receiving antidepressants. The average risk of such events on drugs was 4%, twice the placebo risk of 2%. No suicides occurred in these trials. This is a good and reasonable summary of the current situation. It emphasises close monitoring in the early weeks and suggests close attention to risks / benefit of the medication. Clearly the benefits will outweigh the risks in those with more severe depressive states.

It is interesting that efficacy could not be established for the SSRIs except for Fluoxetine in paediatric usage. It is important as well to note that major depression increases the risk of childhood suicide about 12 fold. More than half of the kids with this disease try to kill themselves, and about 7% do complete suicide according to USA Today 2004. One has to measure this against the fact that 2 in 100 children on antidepressants become more suicidal because of the pills and there were no reported suicides again according to USA Today 2004. The reasons for the increased suicidality might be due to the fact that the medications can increase impulsiveness and that as the children who have been depressed become more energetic this increases the likelihood of suicidality. It is interesting that there isn’t evidence for the tricyclic antidepressants in children but the current controversy might drive clinicians because of the concerns about the SSRIs to go back to prescribing the tricyclic antidepressants which are generally regarded to have higher side effect rates. This would be a retrograde step. The worry is now is that some severely depressed children wont get the antidepressant treatment they require because of the current controversy. Indeed a report in USA Today states that some doctors ‘fear kids could be denied needed care’. This is where the good clinician comes in who is able to weigh up the risks and the benefits, who is able to identify a depression as being severe and in need of antidepressant treatment. Clearly mild depressions should be treated with psychotherapy. The British Medical Journal 2004 came to a reasonable conclusion that doctors should not hesitate to use antidepressants for clearly defined depressive disorders but they should carefully monitor patients in the first weeks of treatment. There is a signal for suicidality when you look at studies of antidepressants that is the SSRIs nevertheless a report in the Journal of the American Academy of Child and Adolescent Psychiatry 2004 stated that ‘none of the reported differences with regard to suicidality between any of the drugs and placebo are statistically significant’. This report claims that there has been an underestimation of the reduction of suicidality in patients treated with antidepressants. My own personal conclusion is that there is a signal for suicidality but this can be managed within the context of the doctor patient relationship and careful monitoring in the early weeks after prescription. It is difficult to communicate this common sense approach in the context of media controversy.