Widening the Scope: Making Psychoanalysis More Central to Society
by N. Szajnberg, MD, Managing Editor
Last week, I gave Professor Marianne Leutzinger-Bohleber’s overview of psychoanalytic research approaches. This week, she speaks directly. It is a powerful voice.
Professor Leutzinger-Bohleber presents her preventive intervention controlled study with 1,000 children in Frankfurt primary schools. She demonstrates that a psychoanalytically-informed network of interventions decreases aggression and anxiety in children; in girls, the interventions also decreased hyperactivity. Those facts are then grounded in a more global, sophisticated perspective on this thing we call attention deficit hyperactivity disorder. First, she suggests that the primary feature of this disorder is lowered behavioral inhibition: this in turn adversely affects executive functions such as reflection, imagination, empathy and creativity. Further, she argues that “rough-and-tumble” play is necessary to develop frontal lobe executive functioning, citing not only human, but also ethological studies of play.
Please read and consider Professor Leutzinger-Bohleber’s successful study. Consider with your colleagues that this a model for what psychoanalytic institutes could do in their own communities that will both use our expertise, promote psychoanalytic research and widen the scope of our discipline.
Psychoanalytic Preventions/ Interventions and Playing “Rough-and-Tumble” Games: Alternatives to Medical Treatments of Children Suffering from ADHD?
MARIANNE LEUZINGER-BOHLEBER
Attention deficit/hyperactivity disorder (ADHD) is currently one of the most frequently diagnosed conditions in children and adolescents. According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM- IV) criteria, ADHD is diagnosed if four conditions are met. First, there must be either a persistent pattern of inattention or hyperactivity-impulsivity that occurs more frequently than is typical for the patient’s age. Second, some of the symptoms must have been present before the age of seven. Third, the symptoms must be observed in at least two settings, such as at home and at school or work. Finally, clear evi- dence is required of compromised social, academic, or occupational functioning. The estimated prevalence rate at the age of 6 to 18 years is between two and six percent. There also is a high comorbidity between ADHD and other psychopa- thologies such as depression (see, e.g. Bhardwaj & Goodyer, 2009, p. 178).
Medical treatment has continuously and dramatically increased since the 1990s. All over the world, 10 million children are now treated with amphet- amines after having been diagnosed with ADHD, a number that has increased dramatically. In Germany, 34 kg of methylphenidate were sold annually in drug stores in 1993; by 2009, this had risen to 1735 kg, an increase of 5103 percent (Bundesinstitut für Arzneimittel und Medizinprodukte, 2010).
At this time, a heated debate is taking place concerning the explanations and treatments for ADHD in children. The differing positions can be summa- rized as follows:
(1) ADHD is a primarily genetically determined illness of certain brain regions and functions that can be efficiently treated by medications like methyphenidate and amphetamines. Environmental factors may play an additional but not a primary role and should be measured “objectively” (as, e.g., the influence of smoking on the embryo and a possible vulnerability to ADHD due to this factor). Although the authors often talk about a “multimodal form of treatment,” medical treatment is at the heart of the interventions.
(2) ADHD is a complex pattern of behavior owing to multiple factors deter- mined by different individual, biographical (psychodynamic) determinants. Prenatal factors, social conditions of the childhood environment, problem- atic or even traumatic experiences within early relationships, and mismatch of temperament between the primary caregiver and the baby are all seen as influential, although genetic and biological factors (like temperament) also play an important role. Interventions or therapies are mainly focused on the individual biographical and social factors. It may be necessary to combine these therapies with medication as an emergency strategy, but medication should not be considered as a cure for the factors producing ADHD.
The debate concerning the different causes and treatments for ADHD was a primary reason the Sigmund-Freud-Institut in Frankfurt began the so-called Frankfurt Prevention Study (FPS), which it undertook in cooperation with the Institute for Psychoanalytic Treatments of Children and Adolescents in Frankfurt. The representative, cluster randomized FPS1 was carried out from September 2003 to September 2006. To be able to draw a representative sample of roughly n = 500 children in the prevention/intervention group and a control- comparison group of another n = 500 children, we had to perform a basic assess- ment in all public kindergartens in Frankfurt (114 kindergartens with approximately 4500 children). The main hypothesis of the study was that a two- year psychoanalytic (and non-psychopharmacological) prevention and inter- vention program would result in a statistically significant decrease in the number of children suffering from psychosocial disturbances (particularly aggressive con- flicts, frequently the main problem of ADHD children in social situations) in their first year of school (compared with the control group). The aim of the psychoanalytic prevention and intervention program was to strengthen the understanding of specific psychic and psychosocial situations of so-called “chil- dren at risk,” particularly those with problems concerning the regulation of affects, which often leads to aggressive conflicts with other children as well as to learning and attention difficulties.
Our program consisted of several components based on a psychoanalytic understanding of ADHD: (1) psychoanalytic supervision of the kindergarten teams; (2) strengthening the professional competence of teachers to understand and cope with these “difficult” children; (3) a weekly offering of psychoanalyti- cally-oriented educational programs for individual children or the children’s group, including a violence prevention program called FAUSTLOS (NO FISTS, a modification of the US program SECOND STEPS) developed by Cierpka and his group (see Cierpka & Schick, 2006); (4) psychoanalytic therapy (always including the parents) offered to children with severe psychopathologies (includ- ing ADHD), mostly in the kindergartens themselves; (5) consultations and educational courses for parents; and, finally, (6) intensive collaboration with medical doctors, child psychiatrists, mental health and welfare institutions and potential schools, if necessary (see also Leuzinger-Bohleber et al., in press; Laezer, in preparation).
As our study progressed, we obtained statistical results that support our main hypothesis: the level of aggression and anxiety of the children in the prevention group decreased significantly compared with the control group (interestingly, there was a statistically significant decrease of hyperactivity only in girls) (see Leuzinger-Bohleber et al., 2007, 2008a). From a psychoanalytic perspective, we identified a variety of psychodynamic backgrounds that culminate in ADHD syndrome according to DSM–IV: (a) known brain damage (due to organic trau- mata during birth, an accident, encephalitis, and so on); (b) early emotional neglect; (c) personal and family trauma (for example, in refugees’ families); (d) chronic under-stimulation of highly talented children in kindergarten; (e) a mismatch of the temperament of the child with their primary caregiver; (f) a mismatch of family culture with the cultural “rules” of the host country (for example, a Moroccan family living in Germany); (g) growing up with a chroni- cally depressed mother. In 17 single-case studies, psychoanalytical child therapy has proven highly successful, resulting in a sustaining, “good enough,” social integration, as well as good achievement in school (with follow-ups of up to four years at present). These children could only be treated in the kindergartens, as their parents would not have been able to see the therapists in their private offices. We also tried to motivate about 25 other parents whose children had serious conduct problems in the kindergartens to enter their children in therapy, but these parents were not willing to accept our offer of therapy.
To summarize, this large empirical and clinical study shows that in all of the children investigated, early disturbances of affect regulation led, in different and individual combinations, to behavior assigned an ADHD diagnosis. This is the major reason we argue that psychoanalysts, as experts in the complexity of early trauma and other developmental disorders and their treatments, should get involved in the public discussion of diagnosis and treatment for this group of children. Causation does not necessarily mean that treatment must be carried out in the same domain, but we need to take seriously a developmental model which can make sense of diverse aetiological pathways.
The core of psychoanalytic conceptualization has always been that a child’s symptoms are the product of complex unconscious and conscious factors: idio- graphic, biographical, und societal factors, on the one hand, and specific genetic, biological, and neurobiological determinants on the other hand. Therefore, we agree with many contemporary authors that psychoanalysis, both as a theory and as a treatment method, has a lot to offer in understanding children with ADHD and could even, once enriched by awareness of the biological determi- nants, be seen as a promising, non-medical treatment possibility for these chil- dren, offering intensive corrective emotional experiences to them (for example, Bürgin, 2005; Carney, 2002; Gilmore, 2002; Leuzinger-Bohleber, 2009; Rothstein, 2002; Sugarman, 2006; Zabarenko, 2002).
It can be assumed that even if certain genetic dispositions exist, specific early “embodied” interaction experiences in object relations have occurred that “trigger” the development of attention deficit and hyperactivity. These early pathological experiences, in turn, may only be modified or corrected perma- nently, in the sense of self-regulation of the infantile organism, by means of new “embodied” experiences and not by medication intended to adjust a particular malfunction in the brain. In other words, neurobiologically and psychically failed developments may largely be corrected or at least mitigated by suitable, adequate, “corrective” experiences in important relationships (with teachers, therapists, etc.) and the environment.
The work of Jaak Panksepp (1998), a leading neurobiologist and brain researcher into emotional development, supports our position concerning the treatment of ADHD children. In brief, recent brain-imaging data provided by Panksepp reveals that the major difference in the brains of individuals with ADHD is in the frontal areas. At the gross structural level, brains of children diagnosed with ADHD exhibit a five percent reduction of overall size. There are also some neurochemical differences (Soltano, 1998), but none of them is suf- ficiently large to permit us to conclude that the differences constitute a medically significant abnormality.
According to this view, the fundamental problem in ADHD is not a deficit in attention, but an abnormally low level of behavioral inhibition, a global func- tion that allows better reflection, imagination, empathy and creativity. These abilities promote behavioral flexibility, better foresight and a more mature regula- tion of behavior. If we accept the existence of a frontal lobe contribution to ADHD, we still must consider whether there are environmental or physical ways to improve such frontal lobe functions permanently (Panksepp, 1998, p. 93).
Medical treatment offers the “physical” possibilities. Without a doubt, short- term behavioral improvements occur with psychostimulants. The problem, as many studies show, is that there has been little evidence of long-term improve- ment. When medication is terminated, ADHD symptoms typically return, sug- gesting that the children are not learning to manage their lives better. Evidence for long-term improvements of cognitive functions and other abilities remains practically non-existent (for a summary of such work, see Barkley, 1997; Panksepp, 1998). Panksepp argues that the short-term benefits of the treatment with psy- chostimulants would be acceptable if they did not have any negative physical consequences (which have been argued to include a small decrease in the rate of physical growth; a relatively rare incidence of seizure, tics, mania, and delusional tendencies; and the controversial finding of a range of other difficulties when these children grow up, such as drug abuse).
Due to methodological problems, the long-term effects of treatment with psychostimulants can hardly be studied in human beings. Panksepp, therefore, relies on animal studies. There is some evidence from these studies that psycho- stimulants decrease, instead of increase, neural plasticity. “In general, dopami- nergic arousal, as can be achieved with psychostimulants, tends to reduce glutamate-mediated neural plasticity” (Panksepp, 1998, p. 95). Panksepp thus pleads for a different strategy in the treatment of ADHD children in our societ- ies: to create more possibilities for young children to develop the frontal lobe executive functions by playing and, in particular, by playing so-called rough-and- tumble games:
The urge to indulge in rough-and-tumble play is a birthright of the mammalian brain . . . Social play may be an experience-expectant, or preparatory, process that helps program higher brain areas that will be required later in life. Indeed “youth” may have evolved to give complex organisms time to play and thereby to exercise the natural skills they will need as adults. We already know that as the frontal lobes mature, frequency of play goes down … Might access to rough-and-tumble play promote frontal lobe maturation? (Panksepp, 1998, pp. 95–96)
To sum up, like many contemporary brain researchers, Panksepp postulates a user-dependent emergence of brain organic changes in hyperactivity and attention deficit. Particularly for children born with an impulsive temper and character (probably genetically determined), the possibility of engaging in active exploration of their environment and in rough-and-tumble play seems to be essential in order to develop frontal lobe executive functions. If, for various reasons, children do not have sufficient possibilities to engage in such explora- tion and play (due to their early object relations, traumatic experiences, or simply environmental factors such as the absence of a playground for small children) they may develop ADHD. Medication probably does not help to compensate for this deficit in the frontal lobe executive functions. Organic brain changes (just like psychological changes) can only take place “user- dependently,” that is, in new, playful, and explorative situations. They are par- ticularly effective if combined with intense, positive, emotional relationship experiences (see also Damasio, 1994, 2003; Dawirs et al., 1992; Doidge, 2007; Fuchs et al., 2010; Hüther, 2006; Moll et al., 2000; Leuzinger-Bohleber et al., 2008b; Leuzinger-Bohleber et al., 2010; Leuzinger-Bohleber et al., in press; Passolt, 2004).
In my view, medication should only be given after a careful neurological, psychiatric, and psychological investigation. It should be reserved for children in whom no psychotherapeutic or pedagogic intervention seems to be available or shows signs of being successful. This caution is consistent with many psychi- atric, neurological, and psychoanalytic authors who warn of early medical inter- ference with the growing brain. On the other side, of course, is the hope that pharmacological regulation of a neurochemical abnormality would allow more normal growth of brain and psychological capacity. Independent studies on the long-term effects of medication are urgently needed. In the meantime, great caution is appropriate.
Much more clinical and empirical research is needed on all aspects of this serious spectrum of disorders. Nevertheless, given the current state of affairs, we reach the following conclusion: taking into account neurobiological, (uncon- scious) biographical as well as societal factors, we are convinced that contempo- rary psychoanalysis – due to its richness of conceptualization and clinical experience – offers a unique perspective on the complexities of ADHD and thus provides a means to achieve adequate prevention in families as well as in public institutions. More than other psychotherapeutic approaches, psychoanalysis offers suitable “corrective” experiences in the therapeutic relationships with these children and thus the possibility to “correct” or at least mitigate the effects of failed early development. Psychoanalytic treatment should be considered one of the promising therapeutic choices for treating children with ADHD.
NOTE
1 The study was supported financially mainly by the Zinnkan Foundation, but also by the Research Advisory Board (RAB) of the International Psychoanalytic Association, the Hertie Foundation, and the Polytechnische Gesellschaft, Frankfurt.
For REFERENCES, See: Int. J. Appl. Psychoanal. Studies (2010) DOI: 10.1002/aps
Copyright © 2010 John Wiley & Sons, Ltd
Prof. Dr. Marianne Leuzinger-Bohleber Direktorin Sigmund-Freud-Institut Myliusstr. 20, 60323 Frankfurt a.M. Germany m.leuzinger-bohleber@sigmund-freud-institut.de
Int. J. Appl. Psychoanal. Studies (2010) DOI: 10.1002/aps