Why does little Eric, suffering from ADHD, just not feel better although Dr. Stephanie Boßerhoff makes use of all treatment possibilities? The answer is as simple as it is disturbing.
A report from neuropediatrician Dr. Stephanie Boßerhoff, written down by Michael Lohmann
Eric (name changed) was five when he came to our sociopediatric centre and he was thirteen when the scales fell from our eyes: Suddenly, we understood why our normally effective therapy offer didn’t show much success for him.
In kindergarten, Eric was constantly fidgeting and teasing the other children. The sturdy boy with the pale face showed the typical symptoms of ADHD: restlessness, poor concentration, excessive impulsivity. When there was a fight, Eric was almost always part of it. “If you want your child to go to school next year, you should contact the sociopediatric center”, the director of the kindergarten told the parents. This is how Ms. Tietze and Eric came to me for a first consultation.
Ms. Tietze told me that Eric was pretty jittery, was he was a boy after all. “And all the other children keep teasing him. He only defends himself.”
“How does Eric behave at home?”
“Well, he can’t really sit still. He has ants in his pants – that can often be exhausting.”
“That is often exactly the problem: Children with ADHD don’t realize when they are provoking others”, I try to explain to her. “And that way, they don’t understand how the fight arises. They always feel like the other children started all this, I was only defending myself!”
“But they are bullying him anyways! That is a fact.”
While we are talking, Eric looks around in my office and inspects the toys in the play area. To me, he appears rather timid, even though he is constantly in movement. His clothes from a discounter give away that money is tight for the family. Eric’s dad is a warehouse worker and Ms. Tietze was a cashier at Aldi before her three children were born. There is no space for extra things.
“To examine more thoroughly how pronounced Eric’s ADHD symptoms are and at what stage of development he is, you have the possibility to stay in the clinic with Eric for a week. We would carry out different examinations and tests and would have a good basis to help your son.”
“Is it that bad that he has to stay in the clinic?”, Ms. Tietze asks worried.
“No, you don’t have to. But the stay could help us to quickly find the right therapy for Eric and we wouldn’t lose any time before he goes to school.”
“That does sound better!” Ms. Tietze promises to talk to her husband about it. A few days later, she tells me that her husband agreed with her.
In the clinic, not only the tests show Eric’s strong ADHD symptoms – we also get to experience them: The boy swirls around and cannot keep to the point. We see how hard it is for Ms. Tietze to set clear boundaries for him. She also tells me about her problems at home: “We live in the house of my husband’s parents. They think that I’m not able to bring up my children anyways and interfere in everything. Eric’s grandfather is the worst, the children are really scared of him.”
“Does he hit the children?”
“No, he doesn’t. But he would like to.”
“Ms. Tietze, you know that violence makes everything even worse. Especially with ADHD.”
“You don’t have to worry, my children are not getting hit.”
In the clinic, the nurses also have a good impression of Ms. Tietze. They are especially trained to watch the handling of mother and child. Of course they also notice when mothers mainly stay outside to smoke, stay on their phone the whole time and show little interest for their children. But for Ms. Tietze, we see that she is really trying hard for her son.
We inform Ms. Tietze about the symptoms and provide her with education strategies. It is most important to consequently set boundaries and to give positive encouragement. After all, children do more of what attracts attention, no matter if positive or negative. As ADHD children are so exhausting for their surroundings, they especially get attention when they provoke or are restless: “Let it be! Sit still now!” When they keep calm or make efforts to stay concentrated, the attachment figures are often so relieved that their attention goes somewhere else. Thus, the child learns: Now that I behave decently, nobody cares! So we try to teach the parents that they have to support their children especially when they show the behavior they wished for. To lead the energy to the positive things. Ms. Tietze also understands that.
As Eric’s IQ test shows normal results as well, nothing is in the way of his enrolment at primary school.
In order to support Eric additionally, we suggest drug therapy. “The drugs will help him to concentrate better but they don’t replace therapeutic assistance. Both is effective in particular in combination. Therefore, I suggest that we accompany Eric from now on.”
Ms. Tietze agrees and we determine another appointment to talk about how Eric is doing at school.
During the next appointments, it becomes clear that Eric’s transition to school went comparatively well. But then, teacher’s complaints multiply: Eric often has fights and can barely be kept under control.
I arrange an appointment with Ms. Tietze for the late Friday afternoon, so that her husband can come along this time. He is a stocky, sturdy man who seems to find the whole issue pretty annoying. “He is just a boy and real boys want to fight sometimes!”, he says. Then he tells me that he used to be like that in the past, too.
“I had a spaz in school sometimes and knocked over some chairs.”
The way I experience Mr. Tietze here, I can imagine very well that he used to suffer from ADHD. That way, we probably cleared up the genetic component, because ADHD is 80 percent genetically determined while the forms can be very different.
“Mr. Tietze, can you see yourself in your son’s behavior?”
“Yes, of course, I regularly had trouble at school.”
“But you surely want your son to have a good education?
“Yes, he is not stupid after all.”
“Exactly! And that’s why we all should try hard for him to live up to the demands at school.”
“Alright, so what can I do?”
I explain to Mr. Tietze how important it is that he as a father spends time with his son. “And always tell Eric when he did something well.”
Two years later, the Tietze family moves out of the grandparent’s house. Ms. Tietze is relieved and Eric’s change of school seems to do him good. Finally, the situation eases. But then, the old scheme repeats: fights, impudence, annoyed teachers. The school threatens to suspend him. There is one other treatment possibility that I suggest to the parents: “What I can offer is an eight-week stay in our day-care hospital. Eric would have an educator there who has a lot of experience dealing with ADHD children. They would only care for him and one other child.”
“And how should that help?”, Mr. Tietze asks.
“That is like a practice program. Eric could learn to control himself better under guidance, so that he doesn’t freak out because of every small matter.”
Ms. and Mr. Tietze agree and as Ms. Tietze has to get surgery after a slipped disc, Mr. Tietze comes to the consultations in the day-care hospitals in the following weeks. Eric’s educator tells me that Mr. Tietze is cooperating very well.
After the stay at the day-care hospital, Eric appears to be trying really hard to implement at school what he learned. However, after a few months, there are complaints again. Eric is 12 years old now and the Children and Family Court Advisory and Support Service had already been called in. They send a social and pedagogical family assistance to the family. “Somehow I always have the feeling that you cannot reach this boy”, the assistance tells me. I know this feeling. What is happening? Why does none of our measures show any perceptible effect?
I get the answers half a year later: Ms. Tietze tells me that her husband and her split up and she moved out with the children.
“He hit me and Eric regularly. Through all the years. And I always hoped that it would get better. Especially after we moved away from his parents. But nothing got better.”
“We have known each other for so long now. Why did you never tell me about this?”
“Because I hoped that we could deal with it on our own. I was also embarrassed.”
As is often the case, violence was the creeping hidden poison. As long as there weren’t any bruises or broken bones, violence isn’t visible. It’s typical that Eric never talked about it either. He didn’t show any signs whatsoever towards me, the nurses nor the educator in the day-care hospital. That’s typical as well, because the children do not that it isn’t okay when their parents hit them, but they love them anyways. They want to be loyal.
The consequences of domestic violence are devastating, especially for ADHD. The emotional situation of the affected person plays a big role for the development of the disease. Does he live in a loving environment or in a situation characterized by violence? Is he doing something that he likes or does he constantly feel under pressure? In our experience, every ADHD child that lives in a loving home environment can be treated successfully with our measures. By advising the parents and teachers, using behavioral therapy and drugs, we accomplish that the children and adolescents can cope at school and during leisure time as well as deal with their peer group. Eric received all this treatment as well and yet his problems didn’t cease. It got significantly better when his mother got separated from his father. He was able to concentrate better at school and there no more fights. We could even slowly reduce the drugs.
Eric’s story clearly illustrated the devastating consequences of domestic violence once again. And it also shows how difficult it can be to take a look behind the scenes. What can we do if there are no signs of external violence and nobody talks about it? Unfortunately, there are also cases where children talk about their problems but nobody believes them.
On our ward, there were three brothers between five and nine years. They were the horror of the whole house: The three raged about the hallways, destroyed toys and didn’t take orders from the nurses. It was so bad that the nurses said after a week: “Dear Ms. Boßerhoff, if you summon these boys again, we quit our job!” At the end of the week, I brought cake for the annoyed staff, which is why the dictum “cake week” developed. When it got bad again, it was called a “cake week”.
These three boys lived with their mother, the father had a prohibition of contact after repeated violence. However, during the emotional diagnosis, the boys told us that the father kept coming into the family and that they hit them. We held a helper’s conference and talked to the Children and Family Court Advisory and Support Service. The family assistance said: “The boys told me that as well, but I don’t believe them.” We couldn’t do anything, because the supervisory power was with the Children and Family Court Advisory and Support Service after all. Eight weeks later, we heart that one of the boys had set his brother’s bed on fire. Finally, the Children and Family Court Advisory and Support Service took action and took the children away from the family. The boy had to take such drastic measures! In retrospect, it got even clearer to me that the massive displays of behavioral problems of the boys on our ward was nothing but a cry for help. Our experience confirms that children who scream at an excessive level and are aggressive and oppositional, almost always experienced domestic violence – emotionally of physically.
In our hospital, we are increasingly confronted with cases of domestic violence. This is surely also due to the fact that poverty is increasing. Poverty and endangerment of the child’s welfare are closely connected, because poverty is one of the factors that encourage violence. The problem is that two thirds of the children that grow up under these conditions will ultimately end up in the same situation. Violence produces new violence.
As we are confronted with these cases every day in our clinic, we know how difficult it is especially for children from these precarious circumstances that kindergartens and schools have been closed for weeks due to Corona. We are worried that the cases of domestic violence will increase further.
Certainly, I became more sensitive due to these experiences. I cannot bear violence on television anymore. Crime series used to be no problem for me, but today I cannot watch these movies anymore, because my patients experienced something similar. My colleagues feel the same; we prefer watching something light on Sunday evenings.
This text is an excerpt from the book: Wenn eine Begenung alles verändert – Ärztinnen und Ärzte erzählen. (When an encounter changes everything – doctors talk about their experiences.) Doctors talk about encouters with patients that left their marks and discuss new treatment methods. ©atp Verlag, Cologne 2021.