ADHD – A Psychodynamic Perspective by Damien McLellan
The Masters in Therapeutic Child Care Course at Carlow College presented its third national training event in the George Bernard Shaw Theatre at Visual in Carlow on April 8th 2013, offering a psychodynamic perspective on ADHD, subtitled “An Illness of our Time?”. Our first training event, Making All the Difference in 2009 was followed by Taking the Road Together in 2010. These occasions continued the theme begun at The Road Less Travelled conference in Kilkenny presented by St Bernards in 2000 to celebrate their 25th Anniversary as a child care centre and to share their journey thus far along the road to becoming a therapeutic community.
All of these events were intended to inspire and enable professionals to work with children and other service users according to mainly psychodynamic and therapeutic community principles. ADHD (Attention Deficit Hyperactivity Disorder) had often come up for consideration by many of us in professional practice situations and was something we knew we would have to address sooner than later. RTE broadcast the Prime Time programme on ADHD, A Cry for Help in November 2012 which seemed to give ADHD a worrying degree of uncritical clinical credibility. So we decided to offer a training day which we hoped would begin a conversation on the subject.
Peter Kieran, co-founder and tutor on the MATCC Course, introduced the proceedings, passing on President Michael D Higgins’ support for the symposium as a much needed discourse on the gulf between the humanistic approach and the medical model. Peter also shared the opinion expressed to us by Gordon Jeyes, CEO Designate of the Child and Family Support Agency, that coherence on this subject was important and often eludes Ireland.
I was the first of two speakers, the second being Dr Kevin McGrattan, a Senior Clinical and Paediatric Psychologist currently with CAMHS (Child and Adolescent Mental Health Services) in Limerick. My task was to present an overview of the situation before Kevin followed with a more clinical and detailed perspective. (Kevin’s presentation will be held over until the next edition of Curam. Editor.)
I began by expressing my view that in 30 years’ time we could be looking back on the current widespread medication of children with behavioural problems with the same shame and regret we now look back on the Magdalen Laundries and the institutional and recent clerical child abuse scandals. I offered five other serious current social care failures of this state that were highlighted recently by Carl O’Brien in the Irish Times.
There is a worldwide discussion taking place, particularly in Australia, the United States and the United Kingdom around the concern that the original diagnosis of ADHD as a pure form of organic damage is being uncritically expanded to describe children whose behavioural problems could be better understood as part of a complex but largely negative environmental experience.
To illustrate the situation in Ireland today statistics from the 2012 report from CAMHS were presented which indicated that the overwhelming majority of children now presenting with mental health problems from across all age ranges were predominantly described as having hyperkinetic or ADHD disorders. This would seem to be the basis of the medical orthodoxy that currently prevails in Ireland but what if it was not based on reality and the lived experiences of children?
I then recounted how when John Bowlby first proposed that children could be unhappy and disturbed by actual events in their real lives he was confronting the psychological orthodoxy that then prevailed which insisted that troubled children were only preoccupied with Oedipal and sexual fantasies. It took the films of James and Joyce Robertson, showing in harrowing detail the pain of children enduring and sometimes not psychologically surviving separation, to eventually convince the sceptics that attachment is a fundamental human need and that the instinct to achieve and sustain proximity is the most profound and universal human driver.
Donald Winnicott, one of the former sceptics but eventually accepting the compelling basis of Bowlby’s thesis, then wondered about the children who had never attached at all. He gave us the concept of the ‘facilitating environment’, the favourable circumstances which enable the infant to grow and flourish. This environment needed a ‘good enough’ primary carer who would allow the new-born baby to experience a continuity of the physical holding enjoyed in the womb without being exposed to unnecessary stress and impingement. Unless the baby is able to internalise this holding he will be unable to subsequently self-hold. Unless the baby is able to gradually see that his primary carer can be both good and bad, both perfect and sometimes disappointing, the baby will not arrive at what Melanie Klein called the depressive position, a mature and healthy acceptance that life can be both good and bad. The integrated child has psychologically integrated the good and bad mother as well as the good and bad sense of self.
Building on the work of Bowlby, Mary Ainsworth and Winnicott, Mary Main offered a fourth category of insecurely attached children, the disorganised insecurely attached child. This describes a child who has not integrated, not successfully negotiated Eric Erickson’s Trust v Mistrust developmental milestone and who has suffered considerable trauma and impingement on top of not having had a good enough start to life. These unfortunate circumstances are known as ‘the double whammy’. These children have no internal working models, are unable to contain or regulate feelings. So they impulsively and uncontrollably inflict them on the environment they believe has failed them.
Allan Schore has relatively recently constructed his neurological developmental theories on the foundations laid by Bowlby and Winnicott, arguing that attunement is the essential core of attachment and that children who have missed out on a good enough attachment experience have also been deprived of attunement. Attunement is when the infant experiences the full, exclusive and unconditional attention of the primary carer. During these times, Schore claims, the baby produces the chemical dopamine which is essential for the development of the neurological self-regulatory system. Without these shared experiences, the self-regulatory system does not develop. Furthermore, in double whammy scenarios, the infant, in order to survive stressful and dangerous situations, produces the stress chemical cortisol which has a corrosive effect on the self-regulatory system and on the development of dopamine.
I then proposed that in evolutionary terms our natural self-regulatory neurological systems evolved and worked well in primitive pastoral settings where mothers lived and worked alongside their babies, supported by a sophisticated extended family support network. However, when we reflect on the situation today for so many children growing up in families saturated with media stimulation but where there is not ‘good enough’ attention, let alone attunement, where very long periods of day-care is the norm for many infants as young as 6 months, where there is conflict and violence compounded by addiction and mental health issues, can we be so sure that all of the children being currently so widely diagnosed and medicated for ADHD behaviours are simply affected by a genetic neurological disorder?
Isn’t it more likely that these children present with attachment disorders due to the deficit of attachment and attunement in their early months and the stressful and dangerous conditions in which they struggle to survive? As Bowlby might have argued, couldn’t the cause for their distressed and distressing behaviour be better explained by the ‘not good enough’ environments they are struggling to survive in, rather than something ‘not good enough’ in them, as the medical model claims.
The psychodynamic treatment alternative presented in the Workshops
Kevin and I offered workshops in the afternoon but for me the highlight of the day was that three social care workers, Laura Healy and Padraig McCullogh from Don Bosco in Dublin and Ciaran Reddin from St Bernards in Fethard also offered workshops. They each presented on a child diagnosed with ADHD that they had worked closely with as a keyworker. They described how the children had begun by testing them, to see if they were safe and dependable, and then becoming very dependent on them. Knowing that their keyworkers were tuned into them, the children began to ask for early deficits and needs to be addressed by way of special treats or rituals exclusive to them. Gradually the children who had previously behaved impulsively and were a danger to themselves and others began to self-regulate and make significant improvements in their behaviors and their lives. These workshops were attended by many of the Carlow College students who must have been inspired by their peers and fellow professionals and the high and sophisticated quality of work that is possible to be undertaken in therapeutic settings.
Damien McLellan is a consultant psychotherapist who works directly with children and families and supports staff teams to work from a therapeutic perspective. He is course leader of the Masters in Therapeutic Child Care Course at Carlow College.