From Chaos to Coherence

Psychotherapy with a Little Boy with ADHD

Elisabeth Cleve

• Publisher: Routledge
• Year: 2018
• Print ISBN: 9780367324605
• eBook ISBN: 9780429914119
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

'... I am flooded with warmth for this little expert on the art of living, who has just realised that even he has the possibility to live a long life. My interpretation is that he trusts he will get the time he needs in therapy to reach, first adulthood, and, then, old age. Right now he believes he will continue to be in therapy for the rest of his life. He cannot imagine that it is going to come to an end. However, I have started to think about when we will have to part and I am not looking forward to it...'

Chapter One
Our first meeting in the waiting room

How do you do

When I meet Douglas for the first time, I see a tall, brown-skinned, six-year-old boy of African origin who darts around the waiting room in every direction. He has come with his adoptive parents, Margareta and Gunnar, for a psychological assessment, which I am going to conduct.

The boy is hyperactive and lacks a firm posture. He flings himself about and slobbers. He is in constant motion and spreads a strong feeling of agitation around himself. He kicks his feet around, bumps into the furniture, and knocks a flowerpot on to the floor. Suddenly he jumps up and, before anyone has a chance to stop him, he scuffs the wall with his feet. Douglas does not, so to speak, always have his head up and his feet down. He is wearing new clothes, which just hang there on his body. Nothing is buttoned and nothing seems to fit. Douglas seems to have shut off the normal ability to feel in various parts of his body. In all the tumult he is causing, one of his shoes falls off and I notice there is a pebble in it. He has had that in his shoe without showing any reaction of pain. He has not noticed anything. He gives the impression of living in a constant state of pain and thus a little stone in his shoe is neither here nor there.

Douglas appears to be in a state of psychological dissolution and has a severe lack of inner structure. He breaks loose from his dad’s grip and rushes at other adults who are sitting in the waiting room. He seems to perceive other children who are also there as objects. He pushes them aside, regardless of whether or not they are in his way. It is hard to understand what Douglas’s intentions are. If he actually has any, he is certainly unable to hold on to them. He is near-sighted and is wearing thick glasses, but it is hard to determine how he sees or what he sees. He does not focus his eyes on anything even for a moment. He does not look me in the eye, nor even glance in my direction. He also behaves as though he does not hear anything since he neither listens nor answers when I speak to him.

Gunnar is finally forced to get a new grip on his son. He wrestles him down and holds on to him so he cannot move, which seems to be completely necessary. The grip, good and secure, makes it possible for Gunnar and Margareta to talk with Douglas. It has a calming effect on him and he sits down on the couch between his mum and dad. The scene is painful for his parents, of course. Margareta has tears in her eyes and Gunnar shakes his head.

Since I have not yet had a chance to greet Douglas, I want to take his hand and tell him my name. His mum lifts his hand forward towards mine and I take a firm grip on it. I hold on to his hand, even though he starts to pull and tear away, while I introduce myself. I also tell him that all of us will go up many stairs to the room where Douglas and I are going to be. I say that his parents will meet a lady named Birgitta, who is going to talk with them in a room next to ours. When I have finished speaking and let go of 1 his hand, he takes aim to kick me in the shins. I have expected this and I am also faster than he is, so his kicks are left hanging in the air. After half an hour we are ready to go up the stairs and start the session in my room. Douglas quickly breaks away from his parents and me and dashes up all the stairs. He does not know where he is going, nor does he seem to care where he will end up. It could be somewhere! It could be nowhere!

This is the first of the five visits, during a span of three weeks, which it takes me to conduct a psychological assessment on Douglas.

Chapter Two
Douglas's life history

During the period of time it takes for Douglas to go through all the testing, Margareta and Gunnar visit Birgitta three times. To her, they describe their son’s life before and after adoption as well as their family situation right now. Margareta and Gunnar have known each other since their youth. They married early and looked forward to having a family. However, Margareta failed to become pregnant. They took a fertility test but it was not possible to determine the cause of their childlessness. After having been childless for ten years, they decided to apply to adopt a child. They were approved as adoptive parents. After a two-year wait, they were asked if they would like to adopt a little boy who did not have any parents.

The boy’s name was Ogar and he had been born to African parents in France. To start with, Margareta and Gunnar received photographs of him and a short description of his first years of life. After they had looked at the pictures, they asked to know more about the boy’s background. By mail, they received some documents prepared during the French adoption investigation, translated into Swedish. They read everything over and over again and had many discussions about whether they would be able to be good parents for this boy, who had suffered such deprivation. Both of them knew all along, despite all the discussions for and against, that they would give a positive reply and receive him as their son. They had a deep longing for a child and had already become attached to the cute brown boy in the pictures. He was said to be three years old. A short time before the adoption they found out that, in fact, he was one year older.

Ogar, who in Sweden was given the name Douglas, did not start his new life without a history, as many other adoptive children do. Margareta and Gunnar travelled to France to collect him from the orphanage when he was four years of age. It was a fantastic experience for them to become parents at last. They received additional information about their son’s earlier life through talks with the staff at the orphanage and through what they saw for themselves during their visit there.

When Douglas had lived in Sweden a little more than a year and was five years old, Margareta and Gunnar were given a chance to adopt an Indian girl, Nanding, who was eighteen months old. She had lived with her biological mother during her first year of life, but had been placed in an orphanage in southern India at the age of one when her mother fell ill. The child went on living at the orphanage for six months after her mother died. This is all that is known about her background.

Douglas stayed at home in Sweden with some relatives whom he knew well when his parents went to India to fetch Nanding. They later gave her the Swedish name Ninni. The only thing she possessed when she made her journey to Sweden was a piece of paper bearing her biological mother’s fingerprint. At last Margareta and Gunnar had their family, with two children, big brother Douglas, who was now five years old, and little sister Ninni, who was a year and a half.

Before adoption

The adoption investigation conducted in France describes Douglas from the time he was taken to the orphanage at the age of eighteen months. It states that his biological mother died when he was at the orphanage. There are some notes about her, her name and age and the fact that she was a Muslim. She had only two years of schooling and could barely read and write. She entered France illegally at the age of twelve. She was unmarried and had given birth to several children, the eldest of them when she was only thirteen years old. One child had died after being taken to an orphanage and another had died after an illness. Ogar was the youngest son. His mother had used drugs and lived in miserable poverty. Perhaps she had not found any other way than prostitution to make a living. About Ogar’s father, the papers say only that he was of “the black race” and nothing more. A father’s name is not given to any of the children born to this woman. In contrast, the children’s first and last names, as well as the dates of their births and deaths, are carefully noted.

It is not known where Ogar lived up to the time he was picked up and placed in the orphanage. A woman on the staff there told Margareta that she believed Ogar had spent most of his time in a “box”, which functioned as his bed and home. Sometimes he got something to eat but never enough. When Ogar arrived at the orphanage he was severely undernourished and had constant bouts of diarrhoea. He had lice and worms and was in poor condition.

He was given nourishment and medicine to the extent that these were available at the orphanage, which had quite limited resources. It is recorded in his documents that “his biological mother did not show any interest in her son”. She was most probably in very poor shape, both physically and psychically. When the authorities tried to find her in connection with the adoption, they learned that she had died.

When Ogar was three and a half years old, the investigation on putting him up for adoption in another country was completed. In the final report, which came out when he was almost four years old, it is stated:

Ogar is a boy who is almost four years of age. He is of the black race and his behaviour is abnormal. He lets out piercing screams and has cramp-like spasms and a hard time with balance. He does not seem to know how to use his hands and his movements are uncoordinated. When he arrived at the orphanage he did not understand French but he could say just a few words in an African language. After one year he understands French but cannot really speak it. He does not always react when spoken to, probably because of a hearing impairment. He is afraid of other people. Ogar needs to learn how to concentrate so that he can sit still and play with something. He sometimes bangs his head violently on the floor and goes on until someone stops him. He enjoys playing the drums.

There are also comments about how the orphanage was poorly equipped and that no member of the staff had established a relationship with Ogar. The court decided that “the boy may be put up for adoption in another country because that will give him opportunities to develop.” At this time the boy got his first glasses but no hearing aid. He got his French citizenship and was taken to his new family in Sweden when he had just had his fourth birthday.

Everything written in Ogar’s file gives evidence of extreme deprivation. The people who carried out the adoption investigation were determined to write candidly and to keep Ogar’s needs in focus at all times. The notes are carefully recorded. It must have been a delicately balanced task for them to document the boy’s condition accurately and at the same time not scare away future adoptive parents. These documents were the most important thing for Douglas to have with him on his journey to Sweden. Douglas’s parents have gradually let him know everything that is written in the adoption investigation. Douglas calls the documents his “importantic papers” and Margareta and Gunnar keep them locked in a safe-deposit box. They give me a copy to read and keep.

It is painful to read about Douglas and try to imagine his life as a tiny baby and infant. It fills me in part with dread to think of what all this could mean for his future development but also with admiration to think of the strength the boy must have had in order to survive. It has been important for me to read everything over and over again. It is necessary to scrutinize everything that is written, both on and between the lines. This is invaluable for me in my endeavour to understand the links between the fragments of Douglas’s past that are known and his present way of functioning.

After adoption

It did not take long for Margareta and Gunnar to realize that Douglas was not like other children. It was hard to get a response from him. He spread anxiety wherever he was because he could not keep still. Thus they began their rounds of clinics, hospitals, doctors, and other experts to have their son undergo various examinations. It was urgent to determine the status of his health, both somatic and psychological.

He was vaccinated and given medicine and his weight increased rapidly. The bouts of diarrhoea, which Douglas had experienced his entire life, tapered off. After a short time he started to understand Swedish but could not speak the language himself. His parents turned to a mental health care centre for children, where they were told how important it was to work on improving the attachment between Douglas and themselves. He underwent check-ups for sight and hearing, where he had a hard time cooperating. Douglas made terrible scenes every time, because he became terrified if somebody other than Margareta came close to him.

Margareta took parental leave from her job for three years. She tried to leave Douglas for a couple of hours now and then in small child-care groups, but it never worked. What Margareta remembers from these first years is how she always had to hold on to Douglas with one hand while she carried his sister in the other arm. If Douglas happened to get more than a metre away from her, he might let out that piercing scream. He never wanted to let her out of his sight. It was as though he thought she had disappeared forever if she was in the next room. Margareta wanted to start working part-time when Douglas was six years old. At that time he made a new attempt to be in a little group at a day-care centre but neither the centre nor he could take it.

Everything was easier with his sister. Margareta and Gunnar believe that she was made to feel more secure as a baby and thus seems to have coped with her stay at the orphanage in India relatively well, even though it was a “poor institution for abandoned children”.

The situation in the family is catastrophic by the time Margareta and Gunnar bring Douglas to me for a psychological assessment. They cannot leave the two children alone in the same room, even for a moment. Douglas might push his sister down the stairs, and indeed he has done so twice. She had fallen down head over heels. All of the dangerous utensils in the kitchen, such as knives, forks, and scissors have to be kept locked up, since Douglas handles such things so recklessly.

Douglas’s parents describe their son’s great difficulties in communicating with other people. He does not know what to do, has no ability to play, and no interest in other children. It is hard to know what he hears and what he understands, as well as how he is going to react. He is in constant motion and can never concentrate. He is silent and still only when he sleeps. Margareta and Gunnar usually sit beside their son’s bed when he is sleeping, since this is their only chance of chatting to him in peace and quiet.

He has stopped going to the day-care centre where he has been enrolled for a short time. The family’s social life is almost non-existent since their friends find it too exhausting to be around Douglas and his uncontrolled behaviour. Margareta and Gunnar are constantly worried that he will put himself or someone else in danger. Wherever they turn, they are met with criticism of their son’s behaviour and they find this extremely discouraging.

“He’s very different from other children. But we love him so much anyway,” both of his parents tell me sorrowfully.

Both Margareta and Gunnar are exhausted from their constant worrying. They are afraid that they will not make it as adoptive parents. They hope that the assessment we are about to make will result in both Douglas and themselves getting the psychological support they need. They themselves are extremely keen on getting support to cope with the difficult task of being parents to Douglas. Their greatest desire is to live the life of an ordinary family together with their two children.

Chapter Three
The psychological assessment

Here we go

Douglas goes through a comprehensive psychological assessment, which I conduct. My wish is to obtain a picture of his psychological and neuropsychiatric status as well as an idea of his intellectual capacities. I use tests that measure several different aspects of his personality. It is necessary to carry out a broad psychological survey in order to illuminate both Douglas’s strong and weak sides. He is tested with so-called projective personality tests, which elucidate u...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Contents
• Dedication
• ACKNOWLEDGEMENTS
• ABOUT THE AUTHOR
• FOREWORD
• INTRODUCTION
• CHAPTER ONE Our first meeting in the waiting room
• CHAPTER TWO Douglas's life history
• CHAPTER THREE The psychological assessment
• CHAPTER FOUR The first year of psychotherapy
• CHAPTER FIVE The second year
• CHAPTER SIX The third year
• CHAPTER SEVEN The fourth year
• CHAPTER EIGHT The fifth year
• CHAPTER NINE The sixth year
• CHAPTER TEN The seventh and last year of psychotherapy
• CHAPTER ELEVEN Has it been worth it?
• CHAPTER TWELVE Psychotherapy for children with emotional and neuropsychiatric disturbances
• CHAPTER THIRTEEN Concluding remarks
• BIBLIOGRAPHY
• APPENDICES