THE STEP-BY-STEP DEVELOPMENT OF ANXIETY-HYPERACTIVITY
Part II
Most clinicians are used to a 1:1 approach. The flood of data when family and beyond is added can seem confusing at first. A systematic attack, focusing in on possible split fields, helps. Vis, a typical bout of SIH in a little girl:
C5: Annie, 7, was urgently ‘referred’ by her grandma. In her “very loud voice” Annie had screeched at her grandpa at a flee-market, accusing him of physically abusing her. “But he simply restrained her wrist and snapped at her for grabbing at a fragile display item.” A bystander, “a complete stranger who didn’t see the whole thing,” publicly reprimanded him. This unpleasant episode terribly embarrassed and distressed grandpa. Both grandparents wondered whether they should baby-sit anymore for their son and daughter-in-law. Of course, grandpa, an elderly retired cleric, still convalescing from a recent heart attack, could do without that sort of stress and was so advised. Listening to this story opened Pandora’s Box. Out it came that Annie’s mother was too lenient with her “only child” and had long vetoed all of father’s efforts at discipline. He, apparently to keep the peace, withdrew to the family’s edge. His job as a long-distance trucker helped him keep his distance. Grandma vaguely recounted that Annie had had “some problem with other children in the neighbourhood” involving the police. “She also is having trouble in school. Not long ago, she was put on something for ADHD.” Grandma disagreed with the doctor’s methods: “She’s a perfectly bright child. There’s nothing wrong with her brain.”
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DEVELOPMENT OF ANXIETY-HYPERACTIVITY
Does this seem like a complete confusion of nuclear, extended family and outside relationships? I asked the grandmother to phone the parents and convey my offer of help. Annie’s father (reportedly unenthusiastically) said he would try to persuade his wife to attend a 'nuclear' family meeting. Before seeing them, a hypothetical MSF-picture was running through my head. One must be careful of preconceived notions, but in this instance multiple split fields impinging upon Annie, the Identified Patient (IP), were born out.
During the assessment, Annie (the IP) squeezes between her mom (M) and dad (F) and wriggles restlessly. When they speak to each other she interrupts. Although on Ritalin, by ‘finger twitch test’ evidence (we'll see how it is done later) she most likely does not have neurological ADHD! Father, glancing at his wife, reveals that Annie is not his child. His own boy, the same age as Annie, visits biweekly. Annie’s mother tries to undercut her husband, but he passively wiggles out, so that she finds it impossible to pin him down. I encourage them both to talk about their differences vis a vis Annie, whose eyes almost pop out at the prospect. Struggling to override the adverse effects of Ritalin, she settles down.
The meeting was brief. Annie already appears less hyper – confirmed by all. Everything points to SIH. A call to the family doctor is encouraging. She does not really like the idea of prescribing Ritalin for Annie and is quite prepared to stop it if (focused) family intervention works. It may be tricky dealing with the teacher (T). Next session will include grandparents (GP). What’s up with the police (P)? The other child? Another SF:RS on top of all the rest?
BASIC DIAGNOSTIC POINTERS
In order to assess for induced hyperactivity we need to keep in mind three system levels while focusing on one at a time: 1) the ‘symptom’ is the hyperactive, distracted child, otherwise known as the IP, 2) the next level up is the immediate nuclear (or single parent) family with a possible split field triangle (SF:RS), and 3) beyond that is the extended family, more distant relatives and the child’s wider circle of social systems (school, agencies, sports and so on) that may reveal the presence of ‘spreading’ MSFs. This comprehensive approach is not a daunting task. But it takes some concentration. With practice it becomes quite natural for the diagnostician to hold it all up-front in the head while juggling focus.
Foremost, however, diagnosis and assessment of SIH requires an awareness that it actually exists as an entity. First, think of it! Then pause to consider that the child about to be prescribed that powerful stimulant drug could be a relayer trapped in a nasty social drama – not suffering true neuro-ADHD. Ask of yourself: Is the right answer really stimulant medication? Would you advise an insomniac to drink coffee at bedtime? Then try this useful little screening test:
THE FINGER-TWITCH TEST: viii The child is told that a game is to be played with the interviewer to see who can sit longer without moving hands or fingers. The hands hang between the knees. The interval between the beginning of the game and the twitch of a finger or hand is measured by stopwatch. (Slow athetoid movements or fine tremors are disregarded.) There is a significant difference between potential stimulant-drug-responders (true neurological ADHD) and non-responders (SIH and other non-organic varieties). Neuro-ADHD, shows a finger twitch much earlier (mean time 21 seconds) than SIH (mean time 38 seconds). If the child twitches early, start it on a trial of stimulant medication. And I would add: If the twitch is late, call in both parents for a specialized SF:RS interview.
Diagnosis should not be made merely by exclusion, but in a direct and positive sense. See the family together at least once. This is important, too, with separated/divorced parents. They should be exhorted to come in for the sake of their child. (It may not be easy or even possible in single parent families if a lone boy/girl friend lurks furtively in the background; a delinquent, deadbeat dad/mom can still be at one-corner-removed of an SF:RS-triangle!) Thirty minutes is enough time. Watch parent-child interactions closely. SIH-children, on guard at first, may nestle beside mother, relatively quiet and well-behaved. You may have to precipitate action. Casually, innocently, inquire about potentially taboo topics—bedtime, curfew, eating habits, allowance, clothing styles, forbidden movies or internet sites. Be assured, many of these things are potently relevant to all children, depending on age. Note if the parents try to avoid talking about them or conversely start arguing again. Then ask more pointed questions: Is there tale-bearing going on? If separated, is one parent probing the child about the doings of the other? If the child begins to wriggle, or better yet, moves to sit in-between the parents, and tries to distract or interrupt them, you could well have right in front of you an SF:RS-triangle in vivo.
Seek evidence of multiple split fields. Ask about relatives: over-indulgent grandparents, disaffected or busybody aunts/uncles. Are a little friend’s parents doing things differently and used as leverage by the child? In particular, find out about parent-school conflicts in which the child is likely to be enmeshed: punctuality, homework, differing educational philosophies, marks. When a child comes home complaining about a teacher, and parents automatically side with the child, the makings of a split field between teacher and parent, with child in the middle, are present. Go a step farther: If a number of social agencies is involved with the family, and the child is getting increasingly hyper, you can almost be certain there are unresolved differences, resentments. MSFs well could be operating. Draw a diagram for yourself showing the MSFs you suspect. It is unlikely that you will be able to confirm all possible split fields by direct observation, but a parent-grandparent-child session is not too hard to arrange and a parent-teacher-consultant conference is always desirable. In these 2 meetings you might find 3 SF:RSs.
Important: Any adult—parent, teacher, worker (right along with the IP child)—in the clutches of an SF:RS-MSF, although vaguely aware of its noxious effects, is oblivious to its existence as the prime cause. It takes a knowledgeable outsider to recognize SIH for what it is. The onus is on the professional to act: 1) directly to cure a family or 2) preemptively to stop SF:RS-MSF spread. Once pointed out, willing parents can correct a split field with fair ease. They don’t need personal psychoanalysis to sort it out!
