ADHD Diagnosis Conceals the Family Story

Stories are how we find ourselves in events that otherwise make no sense.

James Hillman, Parabola, Vol IV, No. 4, 1979

Dave: I am a psychiatrist on a medical school faculty and participate in the training of psychiatry, family medicine and pediatric residents. But I am an alternative psychiatrist who believes in families, who believes people can take the place of medication. The psychiatry residents work with difficult cases. Psychiatry, of course, is a medical specialty, and there is a long cherished belief that Psychiatry should be practiced like other medical specialties. There is a problem. Psychiatry is not like other medical specialties. One difference is that it is the medical specialty most immersed in the culture.  Virtually none of the residents see families except when they are being supervised by me.

Good physicians take a clinical history in the interest of arriving at a diagnosis. While the clinical history is a review of ‘facts’, there are in fact, few ‘facts’ about human experience. Different examiners will get different histories depending upon what they ask about. Different family members give different reports of the same set of events. In my view clinical histories are a form of fiction pretending to be ‘objective’.

Stories, on the other hand, are clearly made of imagination and metaphor and are understood to be ambiguous. They are embedded in the language of literature and, thus, have much more capacity for describing human experiences. Stories stimulate reflection and a wish to find creative solutions to life’s contradictions. They help us to locate ourselves in situations that otherwise don’t make much sense.

“Clinical histories” embody some version of authority based on objectivity. My view is that in psychiatry this is pseudo-objectivity. It looks like “objectivity” but I cannot view another person objectively. I can look at an x-ray of a joint objectively, but not a person. Pseudo objectivity leads to pseudo certainty. In the perpetual chaos and crisis of modern living, even pseudo-certainty is deeply gratifying to people (parents and spouses) distressed by upset and uncertainty in their relationships. But there are problems, the narrowed history taking method limits what can be known, and the diagnosis derived there from establishes a person in the role of patient and helps to keep them there.

Clinical Illustration:

A psychiatry resident in our training program was troubled about one of her patients, a 9-year-old boy, Justin, with a blend of ADHD and OCD. The psychiatrist talked about her work with the boy and his mother in a group supervision session. She felt frustrated and perplexed by her interactions with them. The boy’s behavior did not make much sense. The psychiatrist was frustrated by the mother’s exclusive and elaborate attention to symptoms. The father had been to only a few sessions. He was a hard-headed engineer who traveled a great deal. Justin had been evaluated and diagnosed by a specialized ADHD clinic.  So there was a diagnosis based on a clinical history and assessment.

Dr. A. is not a single-minded medication manager and she was dissatisfied with the ADHD evaluation. She was attempting to figure out what the problems behind the problem were. The father could be away for three-to-four months solving an oil field problem in Iraq. Because of mother’s work obligations the paternal grandmother, Lucia, brought Justin to appointments most of the time. The mother, Linda, came to some of the sessions. She always had a problem list, a report of Justin’s problematic behavior combined with dissatisfaction about the medication regimen, more was needed or another one was needed, but medication was needed. Justin’s problems persisted and the doctor’s suggestions were insufficient.

As is common in clinical work the psychiatrist wanted the “customer” to be satisfied. The mother’s dissatisfaction and distrust caused the young psychiatrist to question her own competence. The psychiatrist didn’t know it until our supervision session, but she didn’t trust the mother. That is almost always the case in problematic clinical situations. The patient’s distrust of the doctor is explicit. The practitioner’s distrust of the patient is unfortunately not acknowledged.

Justin was 9, a lively talkative kid, a good athlete, but afraid to sleep in his room alone. Thus, he always slept with his mother. The boy’s behavior and the sleeping arrangements were different when father was home. Dr. A indicated that Lucia, father’s mother, who brought the boy to most appointments, was viewed as problematic. There was tension between the boy’s mother, Linda and the paternal grandmother.

I suggested Dr. A bring the family in for a consultation. The purpose of a consultation is to help the doctor be more helpful to the family. It is a way to introduce family systems thinking and language into medically oriented cases. A consultation means the doctor schedules an appointment with the family and includes me. We suggest all involved be included; all who are concerned about and affected by the child’s behavior. In this case there was an older brother, Howard, 15, a widowed maternal grandmother, Maria, and a long divorced and widowed paternal grandmother, Lucia. Father, Thomas, was on assignment in Venezuela and not available. I could have skyped him in, but intuition said don’t do that for this one, it is already complex and Skype too often adds a not-helpful layer of distraction.

I begin a consultation by having the doctor tell me about her work with the family while the family listens.  She was cautious in what she said, reviewing the case in outline fashion. For some reason, I was affected by her cautiousness as the interview began. I direct my questions to what the family is like, what pressures them when they are not worrying about the identified patient. I felt perplexed by the interview. This family was difficult to engage. Their manner of speaking was stilted, their answers short.

The boy was well behaved and well spoken during the interview. There was a sense of tension amongst the women. They began by talking about Justin. It is easy to talk about the problem child. I steered them toward the family but there were no stories. They sounded abnormally normal.

I tried going backward into how the grandmothers grew up. Lucia was interested in the question. She liked regulation and order and asserted her viewpoint, suggesting Linda and Maria were disorderly. Her story was that order was imposed on her in her growing up years. Her father was a machinist who laid down the law at home, her mother a compliant homemaker. Lucia married a young state police officer and they had two boys in three years. The police officer was rigidly rule-bound and looked down on her, he was far more committed to his career than to her. They divorced in the fourth year of marriage a year after the second son was born. She never remarried.  She raised her two sons alone.

I felt uneasy about the interview and about 30 minutes in said I had to check something with my secretary. This is like the basketball team calling time out when the game is not going well. I needed to talk to my inner coach. When I left the room I thought, why does this feel so unproductive? They are answering questions, but it is as if they are not saying anything. I don’t know anything. There is no story just facts. I wonder what they afraid of, why they are being so careful?

They didn’t tell stories. They reported events, question and answer. This is a dysfunction, a culturally invisible symptom which suggests an inability to talk about relationships, an inability to turn experience into a narrative, a story. Events don’t make much sense, they do not weave together.

I went back in and told them they were being too careful. When an interview is flat I need to disrupt the thinking. If a family or a person is having a difficult time, is psychotic or depressed I ask questions like this, “Is there anyone who hopes you will fail as a mother?” This sort of question moves the focus from intra-personal to inter-personal. It tends to decrease defensiveness and engage thought.

I asked Linda if there was anyone who would be happy if she failed as a mother. She looked at me, not comprehending, or if comprehending not wanting to answer. She was self-reflection averse.

Lucia, the critical grandmother, her mother-in-law, surprised me when she said, “It is strange you should ask that question.” Then she reiterated her reflection on her life as a divorced single mother who was constantly criticized by her ex-husband. He was a rigid judgmental man. “I felt like I couldn’t do anything right. He worked all of the time spent most nights in the barracks. I never thought of it the way you just said, but it was like he wanted me to fail. I never thought of it like that.”

Then Justin’s mother said, “But that’s my problem with Thomas (Justin’s father)”. She then elaborated a list of his domineering critical officious ways, nothing is neat enough for him, I am too lenient with the boys….

After that some undercurrents surfaced. Lucia was like her son, always correcting. Then it came to light that 20 years ago Lucia had objected to her son Thomas’ romance with Linda. He had been “infatuated” with her. Lucia was opposed to the romance and of course, the marriage. The women had a duel with invisible tasers, exchanging hostile innuendos. It didn’t go anywhere, just reconfirmed existing hostilities.

The maternal grandmother, Maria, took her turn with curious pleasure. She came from a family similar to Lucia’s. Her father was a steel worker but their living pattern was under-organized, there was not so much authoritarianism. Her mother asserted more influence with a mixture of anxiety and irritability. “What was Nick’s mother like when she was a little girl?” I asked. Grandmother, a playful twinkle in her eyes, raised her eyebrow, “I hate to say this, but she was just like him (pointing at Justin). I had to drag her to the school bus every morning. She was afraid to go to school.” Later, of herself, she said, “When I was a girl I was afraid of everything. I was the youngest.” Maria was the third child. There was a sister born two years before her who died from a congenital heart problem at 4 weeks of age. She was parented with apprehension; naturally her parents were afraid another baby could die. And apprehension may have been part of her parenting, thus her daughter was “afraid of everything”. A few more fragments then, amused with herself, she said, “I slept between my parents.” She was referring to our earlier discussion about Justin sleeping with his mother.

Story fragments were emerging. The grandmothers were talking about what they were uncertain about, grounding experience in story fragments. They were still cautious, but common themes were emerging, shared frustrations. There was evidence of unresolved resentments. All three of the women had unrewarding marriages. There was evidence of multi-generational patterns.

At the end of the interview as time was running out I asked, “Any questions?  Linda, appeared angry, her tone challenging but constrained. “Yes, so the plan is what now?” This is a symptom. It says, I am disturbed by this conversation and it’s time for you to appease me.

I have limited capacity for appeasing. I laid back, my posture casual and answered: The plan is to try something different between now and the next interview, don’t tell anyone what you are doing, then talk about it when you next see Dr. A.”

Linda’s fury persisted. “I could just throw out all his medications and let him do whatever he wants!”

“That is an interesting idea, you can do what you want to do. But I would consider using your head. I am suggesting you do something creative rather than destructive.”

“How is this supposed to help Justin?”

“I don’t know yet. But it helps us understand why he worries so much about his family.”

“Who said he worries about his family he has ADHD?”

“I did. I think his ADHD comes from his worry about his family.”

They took some time gathering up their things and headed for the door. The grandmothers and the boys said good-bye. Linda did not look at me. I was being negatively hallucinated.

At the end of the interview the paternal grandmother was thoughtful and appreciative in her leaving. I suspect she told enough of her story to discover part of herself, to feel acknowledged. I thought afterward that her emphasis on order was a cover for her hunger for intimacy.

This was a family with little capacity for telling stories. Thus they had very limited self-awareness and focused on Justin’s misbehavior. There was very little satisfaction. It is possible to see how his misbehavior and his diagnosis is needed to maintain an unrewarding stability, to cover the omnipresent hunger for nurture and intimacy. They were all caught, clinicians and family, cornered by the imagination deadening clinical history and the diagnosis.

My report is a bit clumsy and awkward, but that is the way of family interviews in complex situations. The good news is that both the psychiatrist and the therapist felt supported, even inspired  by the interview. It gave them a way to improve their balance in relation to the family. There was enough story to help them see what the family struggles were, to see what was hidden behind the persistent elaboration of symptoms. We shall see what happens next.