(Dis-)connections. The Treatment of an 11 Year Old Boy

by Philippe Grisar on April 2, 2011

Many cases of child psychosis present symptoms that fit the DSM IV criteria for ADHD (Attention Deficit Hyperactivity Disorder). Tim, an 11 year old boy, had been diagnosed as such. At home he was woven into the social discourse and nobody found his behaviour problematic. At school, certain problems came to the fore, and he was restless, talkative and ‘noisy’.

 

Tim’s fidgeting and verbal alertness were his way of keeping on his “costume of neurosis” [i]. What kept Tim “connected”, were his habits, rules, relentless chatting, ‘hyperkinetic provocation’ and at some moments pestering others and protesting a lot. These signs of débranchement [ii] held the psychotic triggering at bay. [iii]

 

Near the end of the first term of his last year in primary school his anxiety becomes unbearable. Just before Christmas he has a severe anxiety attack: he feels limp, thinks he is losing his memory and the control of his body.

 

At the beginning of January the mother phones me for an urgent first consultation for Tim. Before I meet him, an anti-psychotic drug has diminished the major symptoms, yet his fears remain. He has severe anxiety attacks after taking Ritalin, she tells me. I give them an appointment for the following morning. Before the end of the same day, the mother phones me again because the anxiety keeps haunting him, despite his taking an anxiolytic drug. I ask him via his mother to write down whatever he is afraid of, as a preparation to our first session the next morning. A couple of hours later the phone rings again: he can’t stop writing. I tell him via his mother that it is now enough and that he can stop writing, thanking him for his effort.

 

His anxiety is still there the following morning but not so overwhelming anymore. His mother tells me that he is a little better but that the anxiety still comes and goes. She shows me his writings: an endless series of sentences starting with ‘I’m afraid of’. I read his writings silently and ask him how he feels now. He answers that he is better but that he is afraid of becoming the victim of some physical change, illness or accident. Tim and his mother enlighten me on this series of fears: a kitchen knife, that their car could explode; that the food might be poisoned, etc.

 

Tim is the second of four children. His father is a well known doctor. He is acquainted with the psychiatrist who prescribed the Ritalin and confirmed the diagnosis of ADHD that the school suspected. His younger brother is diagnosed as autistic. His sisters seem to be fine.

 

I ask him about his past. Anxiety, and being different seem to be the main threads, but not alarmingly so. Everything seemed ‘normal’, until his behaviour and his demands became too much to handle at school. Ritalin worked well, the teachers said.

Then he questions me about his anxiety. He feels he might lose control and stab his brother with a kitchen knife or change into a “mongoloid” like the children he sees in the shopping mall – as if it was infectious. How is that possible?

I tell him his anxiety is real and that I believe his fears are genuine. At this stage I don’t agree with the reassurances of his mother, who tells him that he will never do the things he fears he could do. In contrast, I show some doubt about his fears becoming reality, and ask him if he is aggressive. He shakes his head. Then I explain that trisomy 21 is not contagious. He agrees.

 

In the following weeks we talk about his current life and his anxiety. He tells me his family is not worried and he feels safe, but at school they don’t understand him. Most of the time he feels distracted by the others and then he, and not the others, are reprimanded for it. All his life he has been afraid of potentially life threatening events. Once he heard his name being called out, but no one was present… During our talks he confides in me, saying that he has seen Casino Royal (a James Bond film). The sex in it, he says, aroused him and made him feel insecure. This is when his anxiety attacks began.

 

A few weeks later Tim feels terrorised by the idea of Global Warming. He tells me that he has seen The Day After Tomorrow (a disaster movie). This is a film where the destruction of the world actually comes to pass, like a ‘Weltuntergangskatastrophe’. He tells me that he is now on the look out, and that he checks the papers and on television for news about the phenomenon. I tell him it must have been an exciting film, but that I heard on the television that it is impossible that Global Warming could cause a sudden disaster. Tim agrees and starts to give arguments to prove his fear wrong. The fear still comes and goes, he says.

 

The anxiety abates slowly and shifts to complaints about school. He thinks it unfair that the other boys distract him and that he is blamed for it. However, he admits that his “classmates regard him as popular and funny”. The teacher has allocated a place to him that is away from the others. At home he never learns his lessons by himself. “My mother helps me”, he says.

 

His restlessness seems to be a way to present himself, as if he is constantly trying to fend off the intrusion of the Other. He gives me the impression that his body is like an ill-fitting coat, too large and too small at the same time, like a tool he doesn’t quite know how to use. How could he constitute himself?

 

Bereft of adequate signifiers, he cannot but repeat himself in complaints and small talk and then fall silent and restless. So I suggest that he draws something, but he has no inspiration at all. I put a paper on the table and say that we could alternately draw a line, until he has the inspiration to make something out of the shapes that form. Each time he draws a line, I mirror his line and he approves. When he can make out a shape, he either colours it in or completes it. Most shapes are abstract or become monsters. Drawing makes talking easier. It sort of weaves a network of drawn lines and spoken words. Sometimes he draws all by himself and the result is always a bit chaotic. He shows me his drawings and I offer to pin them on the board.

 

Two weeks before the summer holidays he tells me a dream: he and his friends are in the garden and he wants to reset the clock before global warming turns into a catastrophe. 2012 may never come. But the water comes anyway and he has to put up barriers and deep ditches to stop the water. Then there is a conflict with others. It is like a conflict after the disaster, a struggle to survive.

He remembers having seen a hurricane when he was in Mexico on holiday. I point out, with a wink, that he survived it. After this, his unrest goes away.

 

In the following session, he brings his exam results of the final year in elementary school. They are rather good and he is proud of it. He doesn’t know which school to go to next year, but he is going to visit some schools to make a choice. He will probably go to a boarding school.

He feels fine and asks me to make a collage with him. He wants to cut paper into shapes. Then he asks for glue and starts to stick all the shapes on another piece of paper. This paper becomes covered with ill-fitting paper shapes of various designs. It is as if he does this same procedure with himself: all the organs are more or less glued onto his body, leaving some space in between. This collage was not for show, I had to keep it in my folder.

After the collage, his interest in drawing is gone. He prefers to play Four in a Row during our talks, and I agree. The rules of this game are clear.

 

The hyperactivity and the associated ‘social clumsiness’ were the first phenomena, signs of dis-connection. Ritalin, and the film Casino Royal may have pushed his anxiety through the defences that his body and his behaviour provided for him.

As there was no established discourse to support him, Tim had to constitute himself by himself [ iv]. I think that the position of the analyst, as critical observer or secretary, served as a guide in an unknown territory that we both travelled through. The ‘guide’ put a question mark on the side of the intrusive, but the secretary never touched his delusional work. This special space for talking, commentating, drawing and in the end gluing, supported his work of weaving a body for himself, a some-body. At the end, he finds a way to ‘connect’, and a way of wearing the coat of his costume of neurosis.

 

Note:  This text was presented in London on Saturday 2nd April,2010 at the 9th conference of the New Lacanian School: ‘How Psychoanalysis Works’. Published 1) Translated by Catherine Massol as ‘(Dé-)Branchement dans la psychose, traitement d’un enfant de onze ans’, in Mental: Revue internationale de psychanalyse, vol 26:”Comment la psychanalyse opère”, June 2011, pp. 97-100. 2) p67-72 of The Psychoanalytical Notebooks Vol 23:”Our Orientation”, Oct 2011, Section: Clinical practice with children

 



 


[i] Deffieux J-P. Un cas pas si rare, in « La conversation d’Arcachon », Agalma. Le Seuil. 1997, p. 13.

[ii] Miller, J-A., Ouverture, in « La conversation d’Arcachon », Agalma. Le Seuil. 1997, p. 163.

[iii] I would like to compare his position to being woven into a social fabric.  His work was creating a delusional construction of elementary phenomena (as an auto-therapeutic solution). The others at school had become some kind of persecutor. This construction had become necessary to counter the more schizophrenic invasions of his anxiety.

[1v] Lacan, J.L’ Étourdit, in « Autres écrits », Éditions du Seuil, Paris, 2001, p. 474.  Cormac Gallagher’s English translation, published at www.LacaninIreland.com and available here.