In 1986, a major effort was launched at the Child Mental Health Center of the I.K.A., a Child Psychiatry center handling 4500 new cases per year. The utilization of Systemic Consideration in Child Psychiatry. Main tool, family therapy. This project has already yielded remarkable results. However, in order to make use of some executives of the Center who had a different direction and to avoid one-sidedness, an additional topic was chosen for research, with an organic rationale par excellence. The Hyperkinetic Syndrome.

For the needs of this research, an extra file was created that included specific information related to the Syndrome and related to the history of the parents, the individual history of the child and the diagnostic criteria of DSM III.

The first major finding was that only 1 in 10 cases of hyperactivity reported by parents or teachers actually belonged to the category of ADHD. Many of these children actually had mental retardation, anxiety disorders, depression, special developmental disorders, reactive behavior, or were normal. For the children diagnosed with "Attention Deficit Hyperactivity Disorder" a strict protocol was created for the administration of Methylphenidate and the control of all those parameters and side effects mentioned in the literature.
A table was thus formed where the dosage of Methylphenydate, the child's height, weight, blood pressure and blood pressure, the findings of the regular blood test and data concerning the occurrence of insomnia, anorexia, nausea, vomiting and skin reactions were noted. Even in the regular communication, the information about the child's behavior was recorded. At the same time, the provision of information on the Syndrome, for the administration of medicines as well as counseling of the parents was foreseen.

But Christos, Velisarios, Vasilis, Lazaros and Giannis, children aged 6-11, faced difficulties that exceeded our records. Christos threw a stone at his classmate, who was making fun of him, breaking his head. Vassilis, in the second grade, having already changed schools four times, refused to go to school and his mother favored him staying at home. At Yannis' school, they called him by the name of a famous (Rochamis) criminal who, however, had many people who liked him...

At the same time, multiple problems were observed in the children's families. Parents were recorded breaking the rules of cooperation in the same way their children did at school. They were late or forgot their appointments, many times it was found that they lied or concealed facts or sometimes they were interrupted without warning, i.e. acting on impulse. Corporal punishment and the threat of institutionalizing the child were common means of punishment. Finally, the existence of many intense family conflicts and conflicts was evident.

But it was decided that the behavior disorder was a complication on the ground of the Central System, the global treatment of the problem within the framework of the family was proposed.

The family as an autonomous system has to fulfill a main goal which is the happiness of its members, i.e. the coverage of material and emotional needs. To accomplish its task, each family establishes rules that govern, on the one hand, the internal relations between the members and their subsystems, and on the other, the relations with the community. There is thus an unwritten regulation regarding overall and individual goals, boundaries between members, how decisions are made, what is allowed and what is prohibited.
The functional family is governed by rules that are as stable as possible in terms of values and goals and flexible in terms of how they are achieved. In contrast, dysfunctional families tend to be rigid or chaotic. Rigid people find it difficult to adapt to new data arising from the external environment or from the development of each member. Chaotics are characterized by confusion, tension and lack of any stability.

Everything is fluid and an action is sometimes considered objectionable and punished and sometimes goes unnoticed.

The harsh and highly competitive conditions that prevail in Western society push people to move at marginal rates. Returning home is intertwined with the expectation of a haven for rest. Having a child with ADHD is a source of constant tension and stress for the family that has to deal with the additional problems that arise. The child with Hyperactive Syndrome requires a constant vigilance of the parents. Hyperactivity itself increases the tension of parents who try to control it without succeeding. The abandonment of physical strength leads to an exhaustion of patience which is expressed by outbursts of anger, disproportionate to the specific occasion on the part of the child. Guilt follows fatally. In combination with hyperactivity, the impulsiveness of the child and mainly the absence of a sense of danger put the parent in a double bind. If he constantly runs after his child, he is considered overprotective and the cause of the child's lack of development. If left alone, he was considered an indifferent parent who neglects his child and therefore the cause of the accidents that will occur. It leads to despair and the consolidation of the perception that he is a bad parent. This position is also confirmed by his partner who, being in a corresponding psychological mood, looks for a way out and accuses him. It is to be expected that a daily dispute breaks out with constant recriminations about who is to blame. "It's your fault that you don't impose yourself on him" - "It's your fault that you're always absent and you've put everything on me" - "You're weak" - "You're unfair".

The end of the argument finds both of them exhausted and unhappy. The child perceives himself as the source of the conflict, with the result that the idea is reinforced that he is indeed a bad child, a tyrant.

Taking on the role of "scapegoat" in the family and then at school takes an emotional toll on the child with ADHD resulting in very low self-esteem, which entails a depressed state.
The isolation he experiences from other children in response to his difficulty to cooperate and to his years of employment in the same project confirm his poor quality.

The lack of duration in attention leads to the creation of learning gaps that cumulatively imply poor school performance, certainly unequal to his mental ability. The unfavorable reactions of school personnel to the characteristic behavior of the syndrome and the lowering of self-esteem due to the feeling of inadequacy can combine with the unfavorable comments of friends and make the school a place of unhappiness and frustration. This can then lead to the manifestation of antisocial behavior of self-defeating and self-punishment.

In this way, he takes on the role of the "evil" and demands, since he has difficulty in negotiating his participation, that he destroys the play of the other children in order to communicate with them even negatively and, knowing their rejection, he attacks first.

All this, of course, leads him to greater isolation from the other children and to a new dead-end vicious circle. The child's multiple problems at school and the difficulty of dealing with them will lead the teacher to call the parents to describe them. He will make reference to the learning domain, but will insist on behavioral issues. He will tell them about his fruitless efforts to include the child in the class group, but also about the obstacles that interfere with the education of the other children. In the end, he will suggest studying in a special class or getting help from a "Special Child Psychiatry Center". Parents will feel humiliated and once again angry and guilty at the same time. They will exert unbearable pressure to study they will order and threaten. They will sit down to read it in marathon exhausting efforts of several hours.

These efforts will be made in a climate of discomfort, frustration, anger, frustration, hopelessness and pressure for both the parent and the child. The situation naturally stabilizes with the parents and the child feeling unhappy.
Contact with the Medical Education Center is usually made when the family has despaired of their ability to deal with the problem. Parents approach with ambivalence. They wish and hope for the magical healing of the child and fear a new refutation. They also shudder at the indictment of the education they have practiced up to now. Usually in this phase one parent has withdrawn and the other has a closed close but at the same time rejecting relationship with the child.

When the child with Hyperactive Syndrome first comes to the Medical Education Center, he feels discontent and fear, unlike children of other categories. It has no individual demand and is therefore closed, fearful and suspicious. Many times he perceives his arrival as the price of his bad behavior.

The family therapist, coming into contact with the family, sets as his main goal the redefining (refraining) of the problem. It will reverse the identification of the child with his problem and focus on the relationships between family members. It will bypass the destructive and dead-end question of "who is to blame" and move them to the painful but creative question of "what is to blame and what can be done?".

The success of redefining the problem presupposes a positive connection – joining of the therapist with the family as a whole and with each member individually. It is necessary for the therapist and the family to find a common language, to create a relationship of trust that will allow them to build on this transaction.

The therapist has the responsibility of creating and maintaining a positive emotional climate where, along with the existence of stable rules, the child with Hyperactive Syndrome will be given the opportunity to relax. This atmosphere works both ways, since on the one hand it gives the opportunity to highlight the positive sides of the child and on the other hand it provides an indirect role model for the parents. During the session the issue of existing boundaries, roles and rules is raised. The issue of boundaries is crucial and at the same time the most pathological.

In particular, there is an excessive closure of the family to the community, which is expressed by the interruption of relations with relatives and the lack of friends. This attitude arises from the self-fulfilling prophecy that the child with his destructive behavior will expose the parents by canceling all attempts at fun or communication.

In contrast, there is an abolition of boundaries within the family with the main characteristic being enmeshment. Functional subsystems have been removed. There is no clear division between the generations, e.g. between parents and children. Neglect of the marital relationship is the norm. Going out for spousal entertainment is considered an unattainable luxury for the loss of which the child bears the brunt. (No one tolerates it because of their behavior).
However, assigning the responsibility of the course of the marital relationship to the child, imaginatively gives it an enormous power but with the identification of it as destructive.

The family's children subsystem is also not working. The slightest fuss and argument between the siblings is taken as a call for help to the parent who is acting as referee (anyone involved in sports knows that the referee ends up losing, or does this only happen in Greece?) and therefore the conflict becomes generalized.. This is one of the topics that the therapist will touch on in the "here and now" since something similar will certainly happen during the session that will give him the opportunity to capitalize on it.

The dissolution of functional subsystems enables the creation of other pathological ones, e.g. mother - child with Hyperkinetic Syndrome where there is a very close relationship but at the same time (it is a relationship of rejection) it includes tension, anger and rejection. Therefore, the necessity of redefining the boundaries between the members is raised and the openness of the family to the community is strengthened.

There is also the question of the existence of fixed rules. What is allowed and what is prohibited. The most common malfunction in this matter consists in the existence of too many prohibitions which are not enforced. Their establishment is based on the hope that something will be saved but leads to the exact opposite extreme where the child is promoted to despise the existence of rules. At some point, however, the parent, running out of patience, lashes out violently over something less important.

During the session, the existence of a few but stable rules, which should take into account the reality of the family members and whose violation will entail consequences, is supported.
Accordingly, the tasks that the therapist sets for the family are such that their realization is possible.

The most important part of therapy is done indirectly and non-verbally. It is the issue of low self-esteem of family members. Negotiating such painful issues could be disastrous if the therapist gets carried away and allows the exchange of blame. Families tend to attract the therapist to discuss only the negative aspects of the family, thereby reinforcing their negative self-esteem.
The therapist tends to reduce irrational worry and guilt and neutralize feelings of helplessness. That is why the therapist is intrusive and acts as an auxiliary ego, using his authority to reward their positive side. With this tactic it will allow family members to look at each other with trust and appreciation perhaps for the first time in years. This, of course, cannot be based on false compliments, nor on the reduction of real difficulties. It relies on the therapist's ability to appreciate other aspects of life. In this way, it helps them to set other parameters of their self-evaluation, e.g. the family usually dwells on the child's poor school performance and bad behavior.

The therapist is interested in the child's feelings of love during the parents' difficult moments. Therefore he breaks his negative identification as a "bad child", as a "tyrant" and defines him as "the child who is tyrannized by his difficulty, but who cares for others". So in this way it breaks the child's direction towards conduct disorder…

In closing, I would like to focus on the need to consider the Hyperactive Syndrome as a bio-psycho-social phenomenon that has its biological root expressed in the minor neurological disorders that require their regulation but which coexist with the child's intrapsychic conflicts resulting in low self-esteem and which lead to conduct disorder as a depressive equivalent and its social component which concerns the family mainly, but also the school. We believe that any one-sided approach cannot work and a holistic approach is required.

Dimitris Karagiannis
Symposium of the Child Psychiatry Society of Greece, May 1992