Long-term psychoanalytic treatment of ADHD and ODD children: The Frankfurt ADHD and ODD Effectiveness Study

Leuzinger-Bohleber, M. (2010): Psychoanalytic preventions/interventions and playing “rough-and-tumble” games: Alternatives to medical treatments of children suffering from ADHD. International Journal of Applied Psychoanalytic Studies, 7, 332-338.

Leuzinger-Bohleber, M., Canestri, J., & Target, M. (Eds.). (2010). Early Development and its Disturbances: Clinical, Conceptual and Empirical Research on ADHD and Other Psychopathologies and its Epistemological Reflections. London: Karnac Books.

Läzer, K.L. (2015). Effectiveness of psychoanalytic psychotherapy and behavioral therapy treatment in children with attention deficit hyperactivity disorder and oppositional defiant disorder. Journal of Infant, Child and Adolescent Psychotherapy 14(2): 111-128, DOI: 10.1080/15289168.2015.1014991.

The Frankfurt ADHD and ODD Effectiveness Study was conducted between 2005 and 2013 at the Sigmund-Freud-Institut in cooperation with the Anna-Freud-Institut and the child and adolescent psychiatry unit at the university hospital Frankfurt/Main. The research was supported by the German Association of Psychoanalytic Child- and Adolescent Psycho­therapists (VAKJP e. V.); the LOEWE initiative by the state of Hessen, Germany; Zinnkann Foundation; Research Advisory Board of the International Psychoanalytical Association, and the Sigmund-Freud-Institut.

Background

A broader discourse on attention deficit hyperactivity disorder (ADHD) among psycho­analysts started in 2002 with the publication of a special issue of Psychoanalytic Inquiry, claiming that, until relatively recently, a number of practitioners on both sides of the debate from within and outside the psychoanalysis profession had discouraged the use of psychoanalytic treatment for patients with ADHD. Since then psychoanalysts have begun to share their clinical experience of treating ADHD children in several clinical case studies, thus providing psychoanalytic concepts for the understanding and treatment of the triad of inattention, impulsivity and hyperactivity. However, evidence based controlled studies for long term psychoanalytically informed therapies with ADHD children have hardly been performed until now.

Objective

The study explores the effectiveness of long-term psychoanalytic treatment without medication and compares it with behavioral/ medication treatment of ADHD and/or oppositional deviant disorder (ODD) diagnosed children in publicly funded outpatient clinics. It was assumed that psychoanalytic psychotherapy without medication would be at least as effective in reducing the recurrence of the ADHD symptoms among children as a combination of behavioral treatment and medication.

Method

Seventy-three children with DSM-IV diagnosis of ADHD and/or ODD participated in a controlled trial with a naturalistic observational design. The primary outcome was symptom reduction 38 months after the pre-treatment assessment using the diagnostic system for mental disorders in children and adolescents (DISYPS-KJ). Secondary outcomes were significantly lower scores for Conners Parent Scale (CPRS) and Conners Teacher Rating Scale (CTRS), Child Behavior Checklist (CBCL), and Teacher Report Form (TRF) scores.

Treatment

Psychoanalytic treatment consisted of twice weekly therapy sessions of 50 minutes with the child and bi-weekly sessions of 50 minutes with parents provided by psychoanalysts in private practice. The treatment length varied from child to child. In average, the psycho­analytic treatment lasted 25.9 months (SD = 9.62). The manual by A. Staufenberg was developed during the Frankfurt Prevention Study between and was accepted and implemented by all psychoanalysts participating in the study.

Behavioral/medication treatment. Children attended either a manualized six-week concentration-training program or they attended a manualized two week anti-aggression training program. A parent-training program accompanied both programs. Additionally, children were prescribed methylphenidate, if needed, by a psychiatrist. In total, 63.3% of the children were medicated for a time period of 29.6 months on average (SD = 15.89).

Results

Fifty-four children (74.0%) completed the follow-up 38 months on average after the baseline. Both treatment groups demonstrated significant symptom reduction, with no significant differences in effectiveness between the two groups. Teacher ratings as well as parent ratings showed a significant decline over time on the ADHD index scores, on oppositional behavior and hyperactivity/impulsivity levels and on internalizing and externalizing problem scores. Both groups demonstrated similar main effects of time. There were no significant interactions between group and time. The findings support the hypothesis that psychoanalytic psychotherapy without medication is as effective as behavioral therapy and/or medication treatment.

Evaluation

While it is the first study of its kind, the study has limitations. First, the sample size is relatively small. Second, pertaining to the naturalistic design, one weakness is the resulting heterogeneity, which is evident both within and between the groups. This heterogeneity led to a biased sample in certain areas. The strength of the study is the naturalistic design. Psychotherapies were investigated as they were realized in the offices and institutions of ‘real’ psychotherapists with ‘real’ patients in Frankfurt nowadays associated with a high external validity of the findings. The study has scientifically followed severely disadvantaged children with a diagnosis of ADHD and/or ODD and their families over the course of a long-term psychoanalytical therapy and compared them in a naturalistic setting to a comparative group providing already well-validated behavioral/medication treatment. In this respect, the study is pioneer work.

Clinical Trial Registration

DRKS-ID:  DRKS00003356 http://apps.who.int/trialsearch/trial.aspx?trialid=DRKS00003356

Contact

Prof. Katrin Luise Läzer

Email: laezer@sigmund-freud-institut.de

Prof. Dr, Marianne Leuzinger-Bohleber

Email: m.leuzinger-bohleber@sigmund-freud-institut.de