Attention Deficit Hyperactivity Disorder

Integration of Cognitive, Neuropsychological, and Psychodynamic Perspectives in Psychotherapy

Francine Conway, Francine Conway

• Publisher: Routledge
• Year: 2015
• ISBN:
  9781317671626
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy
• Index: Psychology

For many researchers, clinicians, teachers, patients, and family members, the discourse on ADHD has been occurring in silos. Traditional ADHD camps are organized primarily in terms of neurological and cognitive perspectives and to a lesser extent psychoanalytic/psychodynamic perspectives. Those with an interest in ADHD have not been able to obtain a comprehensive understanding of the disorder and consequently have been restricted in psychotherapy treatment options. This book argues for the integration of the three perspectives on ADHD.

Drawing on the expertise of an international range of contributors, thevolume addresses questions from a psychoanalytic vantage point which have considerable meaning in clinical work with children who have ADHD. They examine the role of trauma and attachment problems as both a possible antecedent to ADHD, and as an outgrowth of ADHD which predisposes the child to limitations in emotion regulation, social adversity, an even maltreatment. Several questions pertinent to psychodynamic treatment and relevant case studies are discussed including: a) the viability of psychoanalysis/psychodynamic treatment for ADHD children b) the impact of early traumatic experience on the child's specific weaknesses in attention, over-reactivity and dysregulation c) contributions of problems in object relations and regressive defences to ADHD symptoms d) and the importance of other intrapsychic issues.

This book was originally published as a special issue of the Journal of Infant, Child and Adolescent Psychotherapy.

Introduction: Attention Deficit Hyperactivity Disorder in Children and the Psychoanalytic Process

James McCarthy, Ph.D.
Francine Conway, Ph.D.

“The child can use the analyst as a new love object, an auxiliary ego, a new object of identification, or an object of externalizing inner conflicts and the splitting of ambivalence” (Sandler, Kennedy, and Tyson, 1980, p. 107).

This statement made by Anna Freud reflects Freud’s belief that the emergence of psychopathology is influenced by multiple factors, including an underlying neurobiological vulnerability, that complicate the ubiquity of unconscious conflicts throughout the stages of personality development. In calling attention to the analyst’s divergent roles with a child, she also cautioned against the danger of maintaining a developmental orientation to psychopathology which is unidimensional by commenting, “I criticize above all the lack of data to support the concept of the unempathic mother as the pathogenic agent” (Anna Freud, 1983, p. 385).

Anna Freud’s recommendation that the analyst can become both an active presence in children’s lives and a new object in their inner world remains a cornerstone of contemporary psychodynamic treatment approaches. Her identification of the analyst as a potential, auxiliary ego for the child whose aim is to promote ego development underlies the principles of child psychotherapy. If the therapeutic process is understood as an emotional experience involving unconscious communication that fosters comprehensive ego development in the child and psychological growth in the family, then a psychoanalytic orientation is not in any way mutually exclusive with cognitive-behavioral and psychopharmacological efforts at symptom reduction.

Two essential goals of psychoanalytic psychotherapy with children and adolescents consist of establishing a therapeutic alliance that broadens and deepens the child’s emotional communication and formulating interventions which address the child’s particular developmental immaturities and adjustment problems. The contradictions inherent in simultaneously discerning unconscious emotional communication while using techniques designed to address specific problems and impairments in functioning requires a willingness to integrate therapeutic approaches (Lewis, 1997). Some degree of comfort with the ambiguity inherent in these contradictory goals is an essential aspect of a having a psychoanalytic orientation. Defining the purpose of the psychoanalytic process as the overall facilitation of emotional, cognitive, and adaptive functioning, sets the stage for integrative treatment with children who have Attention Deficit Hyperactivity Disorder (ADHD), especially since studies have established that children and adolescents with ADHD usually have a variety of emotional and behavioral problems.

The articles in this monograph illustrate the relevance of an integrative approach to the child with ADHD within a psychoanalytic framework. To begin, Dr. Zabarenko calls attention to the contributions of psychoanalysis, neuroscience, and cognitive approaches to understanding ADHD. Arguing for the formation of a “team approach” of these three perspectives, she encourages analysts and researchers to adopt the tools provided by each and explore ways in which the three perspectives are intercorrelated. To respond to Dr. Zabarenko’s challenge, one must have some working knowledge of the contributions of neuropsychology. Drs. Gopin and Healey offers a review of a variety of theoretical models formulated to account for the heterogeneous array of cognitive and behavioral deficiencies that characterize individuals with ADHD. In their article, a review of the recent literature on the neural and neurocognitive determinants of ADHD is presented, and the importance of conceptualizing the disorder within a developmental framework is emphasized.

The authors of the articles in this issue invite the reader to maintain an attitude of openness about the multiplicity of etiological causes, the complexities of trauma, and the importance of difficulties in affect regulation commonly found in children with marked ADHD. The authors stress the value of psychoanalytic theories for illuminating the ego impairments and the obstacles to the negotiation of developmental opportunities experienced by a great many of these children and youth. Even though problems in attention and concentration are widespread in children and adolescents with many types of psychopathology, such as Early Onset Schizophrenia and acute, pediatric Bipolar illness, the papers generally refer to children who have severe, long standing deficits in concentration, sustained attention, and impulsiveness that interfere with their daily functioning and which can’t be accounted for solely on the basis of a discreet trauma or a severe psychiatric disorder.

An integrative, psychoanalytic understanding of the therapeutic process is informed by developmental psychopathology research studies that delineate interacting systems impeding healthy maturation in groups of high risk children. Little is known about the mechanisms by which attentional deficits compound problems in attachment and emotion regulation resulting in part from either trauma, or from a genetic predisposition to emotional dysregulation (Cicchettii, Ackerman, and Izard, 1995; Shields and Cicchetti, 1998). Barkley (2010) believes that emotion dysregulation is a primary, fundamental component of ADHD, which contributes as much to the compromised functioning as do deficient problem solving skills and executive function deficits. Investigations of comorbidity in children with ADHD often highlight their heterogeneity and the 40–50 percent rates of co-occurrence of ADHD with disruptive behavior disorders. Implicit in these research considerations is the interplay among executive function deficits, cognitive weaknesses in social and emotional information processing, and problems with self-regulation. For example, Crawford, Kaplan, and Dewey (2006) report that a higher number of co-existing disorders in children with ADHD correlates with worse performance on tests of memory and visual-motor skills, as well as worse problems in everyday functioning. Beginning with the 1936 publication of The Ego and the Id, psychoanalytic writers have discussed only some of the developmental issues corresponding to these research questions under the rubric of cognitive maturation and abnormalities in the development of the ego.

From a psychoanalytic vantage point, the articles address five related questions which have considerable meaning in clinical work with children who have ADHD. First, is psychoanalysis a viable option for treatment of ADHD children? Dr. Leuzinger-Bohleber, on the basis of clinical experience results of the Frankfurt Prevention Study and the EVA Study, offers psychoanalysis as an alternative to psychostimulant only treatments. A discussion of short case studies illustrated through seven psychodynamic subgroups of children with ADHD is presented.

Second, has the role of trauma and attachment problems been fully explored as both a possible antecedent to ADHD, and as an outgrowth of ADHD which predisposes the child to limitations in emotion regulation, social adversity, an even maltreatment? Third, to what extent has the impact of early traumatic experience contributed to the child’s specific weaknesses in attention and in curtailing overreactivity and dysregulation in an age-appropriate manner? Dr. Szymanski and colleagues address this question by calling attention to the strong relationship between trauma and ADHD. Dr. Conway and colleagues discuss this issue of differential diagnosis of ADHD by focusing on the prevalence of chronic stressors, even traumatic events, in the lives of ADHD children. The National Child Traumatic Network has taken up the issue of complex trauma in children. The term “complex trauma” describes the “experience of multiple, chronic and prolonged, developmentally adverse traumatic events, most often of an interpersonal nature (e.g., sexual or physical abuse, war, community violence) and early-life onset” (van der Kolk, p. 403). It is likely that many children with ADHD are emotionally dysregulated due to their experience of chronic traumatic life events resulting in what the authors term “attachment trauma.” Both Drs. Szymanski and Conway call attention to the need for those providing psychotherapy treatments to also consider the impact of trauma on the child’s ability to pay attention and concentrate. Dr. Jones gives a case illustration of metallization based therapy and introduces the idea of a more active technique, linking metallization base therapy and Ferenczi’s lost practice.

Fourth, have underlying problems in object relations and a conflict related reliance on regressive defenses contributed to poor attention and to poor self-control? Dr. Salomonsson’s discusses his model, which combines Ego Psychology and Object Relations perspectives to explore the nature of the internal object of the ADHD child, an object which the child may experience as closed and rejecting. He presents the case of a six-and-a-half year old boy and offers a psychoanalytic interpretation of selected treatment interventions.

Finally, how have the patterns of emotional and cognitive deficits and the unconscious conflicts become evident in the child’s transference configurations, in addition to the family transactions? Three case presentations address this point. Dr. Gensler’s discussion of a contextual, psycho-dynamic approach to the therapy of a seventh grade boy with attention problems addresses this issue. Neuropsychological and psychoanalytic concepts that are relevant to attention are reviewed followed by a comprehensive discussion of the treatment of that case. A summary of the case demonstrates a contextual, psychodynamic approach to the therapy of children with attention problems. Dr. Seitler presents a case regarding the treatment of an ADHD boy, which posits that ADHD is typically related to a form of agitated depression and amenable to psychodynamic treatment. The final case presented by Cione and colleagues discusses a psychodynamic approach to play therapy in working with a six-year-old boy. This article describes the effective, two-year psychodynamic treatment of an African American boy with ADHD using psychodynamic techniques related to emotion regulation.

Although ADHD is generally thought of as a chronic and persistent neurological, behavioral, and developmental disorder, the work presented in this monograph makes a strong argument for psychodynamic or psychoanalytic treatment of ADHD. It is our hope that this issue will begin to resolve the ongoing debate about the relevance of psychodynamic or psychoanalytic-oriented psychotherapy for the treatment of ADHD individuals. This issue will have accomplished its goal if there is a subtle shift in the context through which we understand ADHD. Most would agree that a central issue among individuals diagnosed with ADHD is the difficulty these individuals experience in regulating their emotions and controlling their impulses. Psychoanalytic views on the process of the development of self-regulatory abilities in the child are crucial in understanding how the child’s interpersonal interactions support or impinge on emotion regulation functioning.

References

Barkley, R. (2010), Why emotional impulsiveness should be a central feature of ADHD? The ADHD Report, 18: 1–5.

Cicchetti, D., Ackerman, B. P., & Izard, C. E. (1995), Emotions and emotion regulation in developmental psychopathology. Development and Psychopathology, 7: 1–10.

Cione, G., Coleburn, L. A., Fertuck, E. A., & Fraenkel, P. (2011, this issue). Psychodynamic play therapy with a six-year-old African American boy diagnosed with ADHD. Journal of Infant, Child, and Adolescent Psychotherapy, 10, 129–141.

Conway, F., Oster, M., & Szymanski, K. (2011, this issue). ADHD and complex trauma: A descriptive study of hospitalized children in an urban psychiatric hospital. Journal of Infant, Child, and Adolescent Psychotherapy, 10, 59–71.

Crawford, S. G., Kaplan, B. J., & Dewey, D. (2006), Effects of coexisting disorders on cognition and behavior in children with ADHD. Journal of Attention Disorders, 10: 192–9.

Freud, A. (1936), The Ego and the Mechanisms of Defense. London: Hogarth Press.

Freud, A. (1983), Problems of pathogenesis. Psychoanalytic Study of the Child, 38: 383–8.

Gensler, D. (2011, this issue). Trouble paying attention. Journal of Infant, Child, and Adolescent Psychotherapy, 10, 102–114.

Gopin, C. B. & Healey, D. M. (2011, this issue). The neural and neurocognitive determinants of ADHD. Journal of Infant, Child, and Adolescent Psychotherapy, 10, 13–31.

Jones, B. (2011, this issue). The reality-sampling deficit and ADHD: Indication for an active technique. Journal of Infant, Child, and Adolescent Psychotherapy, 10, 72–85.

Leuzinger-Bohleber, M., Laezer, L., Pfenning, N., Fischmann, T., Wolff, A., & Conway, F. (2011, this issue). Psychoanalytic treatment of ADHD children in the frame of two extraclinical studies: The Frankfurt Prevention study and the EVA study. Journal of Infant, Child, and Adolescent Psychotherapy, 10, 32–50.

Lewis, O. (1997), Integrated psychodynamic psychotherapy with children. Child and Adolescent Clinics of North America, 6: 53–68.

Salomonsson, B. (2011, this issue). Psychoanalytic conceptualizations of the internal object in an ADHD child. Journal of Infant, Child, and Adolescent Psychotherapy, 10, 86–101.

Sandler, J., Kennedy, H., & Tyson, R. (1980), The Technique of Child Analysis: Discussions with Anna Freud. Cambridge, MA: Harvard University Press.

Seitler, B. N. (2011, this issue). Is ADHD a real neurological disorder or collection of psychosocial symptomatic behaviors? Implications for treatment in the case of Randall E. Journal of Infant, child, and Adolescent Psychotherapy, 10, 115–128.

Shields, A. & Cicchetti, D. (1998), Reactive aggression among maltreated children: The contributions of attention and emotion dysregulation. Journal of Clinical Child Psychology, 27: 381–95.

Szymanski, K., Sapanski, L., Conway, F. (2011, this issue). Trauma and ADHD—Association or diagnostic confusion? A clinical perspective. Journal of Infant, Child, and Adolescent Psychotherapy, 10, 51–58.

van der Kolk, B. A. (2005). Developmental trauma disorder: Toward a rational diagnosis for children with complex trauma histories. Psychiatric Annals, 35, 401–408.

Zabarenko, L. (2011, this issue). ADHD via psychoanalysis, neuroscience, and cognitive psychology: Why haven’t we fielded a team? Journal of Infant, Child, and Adolescent Psychotherapy, 10, 5–12.

ADHD via Psychoanalysis, Neuroscience, and Cognitive Psychology: Why Haven’t We Fielded a Team?

Lucy Zabarenko, Ph.D.

Believing that the best approach to treating and understanding ADHD is a team formed from representatives of neuroscience, psychoanalysis, and cognitive psychology, in this article I begin by investigating why such a team has not been forged. A brief review of the literature in each field illustrates what each discipline might reasonably contribute to our knowledge about the syndrome. Suggestions are then presented about processing the data from such a team emphasizing the advantages of models using iterative multivariate statistics.

Introduction

Compared to the courtly style of dealing with structural change in the healing professions, there is something appealing about the dispatch with which players are shuffled and shelved in professional sports. If a quarterback makes two fatal errors or misses an opportunity for a pass, he is benched. If a pitcher allows three hits, he may be relieved or get a chance to call for a bunt. If skaters dazzle with the precision of their school figures, they might still prevail even if their freestyle lacks pizzazz. Yet Attention Deficit Hyperactivity Disorder (ADHD), one of the most prevalent neuropsychiatric disorders and arguably one whose management causes some of the highest levels of misery to patients and their families, resists solutions and has somehow not evoked the team approach—a strategy which has a good track record.

In this essay I will assemble data about th...

Table of contents

• Cover
• Title
• Copyright
• Contents
• Citation Information
• Notes on Contributors
• 1. Introduction: Attention Deficit Hyperactivity Disorder in Children and the Psychoanalytic Process
• 2. ADHD via Psychoanalysis, Neuroscience, and Cognitive Psychology: Why Haven’t We Fielded a Team?
• 3. The Neural and Neurocognitive Determinants of ADHD
• 4. Psychoanalytic Treatment of ADHD Children in the Frame of Two Extraclinical Studies: The Frankfurt Prevention Study and the EVA Study
• 5. Trauma and ADHD – Association or Diagnostic Confusion? A Clinical Perspective
• 6. ADHD and Complex Trauma: A Descriptive Study of Hospitalized Children in an Urban Psychiatric Hospital
• 7. The Reality-Sampling Deficit and ADHD: Indication for an Active Technique
• 8. Psychoanalytic Conceptualizations of the Internal Object in an ADHD Child
• 9. Trouble Paying Attention
• 10. Is ADHD a Real Neurological Disorder or Collection of Psychosocial Symptomatic Behaviors? Implications for Treatment in the Case of Randall E.
• 11. Psychodynamic Play Therapy With a Six-Year-Old African American Boy Diagnosed With ADHD
• Index