e International Journal of

Int J Psychoanal (2010) 91:395398 doi: 10.1111/j.1745-8315.2010.00260.x

Panel Report Convergences and divergences in treatments of so-called ADHD children1

rgin, Marianne Leuzinger-Bohleber, Moderators Dieter Bu Alan Sugarman, Reporter
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Marianne Leuzinger-Bohleber introduced the panel by noting the increasing interest in ADHD, particularly from a psychoanalytic perspective. Several reasons for this were postulated. One was the recent dialogue between psychoanalysis and contemporary neurobiology that promises to expand the ability to understand and treat psychopathology that has some neurobiological contributor. Others involve new developments from within psychoanalysis. For example, infant attachment and memory research have fostered alternative models and therapeutic techniques to treat early disturbances of affect regulation, symbolization, and mentalization all central dysfunctions in ADHD. The last reason for the growing discussion about ADHD in psychoanalytic circles was thought to be an effort by self-critical psychoanalysts to respond to competition with other treatment modalities, most prominently, cognitive-behavioral and psychopharmacological ones. She emphasized that psychoanalytic concepts offer the possibility of shedding light on the complex and multiple determinants of ADHD, thereby allowing for more differentiated diagnoses and treatment strategies that accept the likelihood of different psychodynamic subgroupings of children who might all receive the same descriptive diagnosis of ADHD. Dieter Brgin expanded on this introduction, emphasizing the symptom triad of ADHD: (1) attentional problems; (2) overactivity; and (3) poor impulse control. Each of the mental functions underlying these symptoms is dependent on the quality of the relationship between the infant and caretaker. Thus one can assume that a child with longstanding disturbances in these three functions had difficulty finding adequate help in developing them. ADHD children often have histories reflecting disturbances in infantile development, impaired attachment, and other ego disruptions. Early object loss and or psychic conflict are also often found in their histories. However, the multitude of factors prohibits generalizations about etiology or pathogenesis. This analytic understanding of the symptom triad was said to manifest itself in the analytic process in a variety of ways. Intrapsychic conflict
1 Panel held at the 46th Congress of the International Psychoanalytical Association, Chicago, USA, 29 July 2009. Panellists: Birgit Grtner (Germany), Luise Lzer (Germany), Bjrn Salomonsson (Sweden). Discussant: Alan Sugarman (USA).

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manifested in the self-representation or in the central self-object-affect relation (insufficient containing holding function) was one such manifestation. Others include impairment in self-regulation and inconsistent symbolization capacity. Brgin suggested that the capacity to use the analytic dialogue and to present internal experiences figuratively and in a narrative should be used as prognostic indicators for psychoanalytic treatment. Analyzing such patients requires the analyst to translate action into language and to use his own psyche to transform the patients intrapsychic processes into helpful interventions. Such work necessitates continuous adjustment to the childs inconsistent ego functions and fragile self -esteem. In an attempt to answer those who devalue the utility of a psychoanalytic approach with these children, Luise Lzer presented findings from an ongoing empirical study comparing the outcomes of psychoanalytic and cognitive-behavioral treatments of children with hyperkinetic and conduct disorders. The study compared children between 5 and 12 years old who were either untreated, treated with parental counseling and low frequency psychiatric treatment, treated with behavioral pharmacological treatments, or manualized long-term psychoanalytic treatment. The children treated with psychoanalysis came from an outpatient service or psychoanalysts in private practice. The other two treatment groups came from a clinic. The untreated control group involved matched pairs. 62 children treated with psychoanalytic therapy seemed to derive more benefit than children treated with other modalities, according to initial findings. Birgit Grtner then provided some clinical information about the children in the study including vignettes about their psychoanalytic treatment. She reported that children in the study had a noteworthy degree of traumatic experiences involving loss, separation, and uprooting in their histories. Boys with such factors in their histories tended to have difficult relationships with their fathers. These traumas then have a variety of intrapsychic consequences that distort subsequent development. One such child, a 7 year-old boy, lost his father and social community when his mother found out about the fathers extramarital affair and moved with the boy to a different city and forbade contact with the father. In addition to the typical ADHD symptoms, the boy regularly had aggressive outbreaks toward girls at school. The therapist understood his anger to be related to oedipal conflicts exacerbated by not having a father to temper his incestual longings for his mother. Thus, he was initially relieved when his mother moved in with another man. Grtner noted that, in addition to the traumas experienced by each of the patients she described, their parents had all been psychologically burdened in ways that made them ineffective as adults and restricted their holding function. The parents tended to be quite narcissistic and deeply insecure. Mothers, in particular, appeared needy and reinforced their sons symbiotic tie to them. Each of the boys she discussed failed to separate from their dyadic tie to their mother and engage a triadic relationship with both of their parents. This failure undermined the development of a stable masculine identity. She concluded that this psychodynamic constellation represented one typical object relational pathway to ADHD symptoms.
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Bjrn Salomonsson concluded the presentations with an extended vignette of a four-times-weekly analysis of a 10 year-old boy with ADHD who was also being prescribed Strattera. The case report emphasized the boys difficulty with affect regulation, its dynamic meaning, and its technical management. Like the parents described by Grtner, this boys parents were notably ineffective as adults. Indeed, Salomonsson described them as seeming like overgrown teenagers unable to accept structure and discipline. The boys analysis was characterized by violent responses to interpretations of affect that the analyst understood to indicate an internal object rejecting him instead of helping him. Recently the parents had requested a change to a once-weekly session with the boy and another weekly parental session. The analyst discussed it with the boy and agreed to the change for fear the parents would terminate the treatment unilaterally if he did not agree. A session following the change was presented to illustrate the boys difficulty with discussing affects in the sessions. Salomonsson then elaborated on his understanding of the tendency of ADHD patients to become violent in the context of trying to discuss their affects. He gave an example of the patient attacking him after he interpreted that the man in the boys drawing looked lonely, an attempt to address the affects he assumed motivated the ADHD symptoms. The analyst understood the attack to mean that the boy had experienced the interpretation as akin to a dangerous concrete object that must be physically fended off. The analyst, in that moment, represented a bad un-containing external object thrusting interpretation-things at him. ADHD children like this one show a semiotic fragility (Salomonsson, 2006) wherein words become confused with things. Bion (1954) was mentioned to have said that the capacity to form word symbols requires the ability to grasp whole objects and to have abandoned the paranoidschizoid position. ADHD patients like the one described have difficulty moving freely between linguistic and more primordial demarcating signifiers (Rosolato, 1985). For these reasons, it is important that the analyst interpret to ADHD children only after assessing the patients semiotic fragility and internal object in the moment. It is important to address his troubled feelings and his view of the analyst as container. Alan Sugarman discussed the various presentations beginning with his appreciation of the research efforts by the Frankfurt Hyperactivity Study Group to provide empirical, quantitative data to supplement the idiographic data offered by practicing psychoanalysts. He then offered a way to understand the pathogenesis and treatment of ADHD children based on developmental research by Fonagy and his colleagues as well as Linda Mayes and Donald Cohen at the Yale Child Study Center. His model emphasizes that psychopathology arises from mental functions not working optimally. The defining problems of ADHD children involve inadequate concentration, attention, and motor control. In addition, his clinical experience is that they usually have impaired affect regulation, narcissistic regulation, and self and object constancy. These functional impairments are due either to active inhibition or failure to develop fully because of either very early conflict, trauma, or constitutional limitations, or the intrusion disruption coloring by conflicted content on otherwise adequately developed functions. He
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reminded the audience that Dieter Brgin (Sugarman, 2006) had suggested that ADHD children are born with constitutional hypersensitivities that are exacerbated by misattuned and unempathic parents. Psychoanalytic treatment of these patients involves the analyst creating an analytic frame into which the patient externalizes his disrupted functions in the transference, observes his mind in action, notes its disrupted functions as they occur, grapples with understanding the reasons for this, and gains a sense of conscious mastery of his mind and a comprehensive sense of himself-as-agent. Salomonssons case was then discussed from this perspective. The patients semiotic fragility was thought to indicate an inability to distinguish mental representations from reality. The violent attacks were seen as an attempt to regulate with action the anxiety that the patient could not regulate with his mind and words. This is a common problem with ADHD patients. The panel ended with active discussion from the audience that raised questions about treatment of these patients, including the place of medication in psychoanalytic therapy with them. All agreed that it is impossible to describe one etiological pathway for all these children. The advantage of a psychoanalytically oriented treatment is its ability to consider multiple determinants.
References
Bion WR (1954). Notes on the theory of schizophrenia. Int J Psychoanal 35:11318. ments de linterpre tation. Paris: Gallimard. Rosolato G (1985). Ele Salomonsson B (2006). The impact of words on children with ADHD and DAMP. Consequences for psychoanalytic technique. Int J Psychoanal 87:102947. Sugarman A (2006). Panel report of trauma and ADHD. Int J Psychoanal 87:23741.

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