Psychotherapy and Pharmacotherapy Treatment Outcome Research in Pediatric Populations

Reviewed treatment interventions for pediatric populations involving the combination of pharmacotherapy or psychotherapy or either treatment employed alone. The literature revealed a dearth of psychotherapy and pharmacotherapy outcome studies, with the exception of investigations of children diagnosed with attention-deficit hyperactivity disorder (ADHD). Issues pertaining to design, including sample selection, treatment integrity and comparability, and placebo controls also are reviewed. A potpourri of other issues are noted including parental attitudes toward the use of medication versus psychotherapy, treatment adherence, and patient/provider relationship. For children diagnosed with ADHD, the use of stimulant medication appears to be superior to psychotherapy employed alone in managing the behavior of these children as well as their classroom functioning. Recommendations are made for multimodal trials that examine the combined and individual use of pharmacotherapies and psychotherapies for various developmental and psychiatric disorders that occur in childhood and adolescence. Future studies also need to address the durable effects of these treatment options.     

Increased associated movements: influence of attention deficits and movement difficulties

This study was designed to examine whether increased associated movements (AMs) reflect motor difficulties or the symptoms associated with attention disorders. Four groups of male children (N=51) aged 6-8 years participated: Group 1 consisted of 13 children diagnosed with developmental coordination disorder (DCD); Group 2 consisted of 13 children diagnosed with attention deficit hyperactivity disorder (ADHD); Group 3 consisted of 10 children diagnosed with co-occurring DCD and ADHD, and Group 4 was a control sample of 15 children, with no known movement or attention difficulties. Various AM tasks were selected from established assessments and previous research to measure AM severity. The results supported the hypothesis that increased severity of AMs reflect movement difficulties with children in the DCD and DCD/ADHD groups displaying significantly more AMs than children in the ADHD and control groups (p<.001). No differences were found between the ADHD only and control groups (p=.67) or the DCD and DCD/ADHD groups (p=.81) suggesting that AM severity is not influenced by the neurodevelopmental symptoms associated with ADHD.     

PDD Symptoms in ADHD,an Independent Familial Trait?

The aims of this study were to investigate whether subtle PDD symptoms in the context of ADHD are transmitted in families independent of ADHD, and whether PDD symptom familiality is influenced by gender and age. The sample consisted of 256 sibling pairs with at least one child with ADHD and 147 healthy controls, aged 5–19 years. Children who fulfilled criteria for autistic disorder were excluded. The Children’s Social Behavior Questionnaire (CSBQ) was used to assess PDD symptoms. Probands, siblings, and controls were compared using analyses of variance. Sibling correlations were calculated for CSBQ scores after controlling for IQ, ADHD, and comorbid anxiety. In addition, we calculated cross-sibling cross-trait correlations. Both children with ADHD and their siblings had higher PDD levels than healthy controls. The sibling correlation was 0.28 for the CSBQ total scale, with the CSBQ stereotyped behavior subscale showing the strongest sibling correlation (r = 0.35). Sibling correlations remained similar in strength after controlling for IQ and ADHD, and were not confounded by comorbid anxiety. Sibling correlations were higher in female than in male probands. The social subscale showed stronger sibling correlations in elder than in younger sibling pairs. Cross-sibling cross-trait correlations for PDD and ADHD were weak and not-significant. The results confirm that children with ADHD have high levels of PDD symptoms, and further suggest that the familiality of subtle PDD symptoms in the context of ADHD is largely independent from ADHD familiality.     

Towards an understanding of unique and shared pathways in the psychopathophysiology of ADHD

Most attention deficit hyperactivity disorder (ADHD) research has compared cases with unaffected controls. This has led to many associations, but uncertainties about their specificity to ADHD in contrast with other disorders. We present a selective review of research, comparing ADHD with other disorders in neuropsychological, neurobiological and genetic correlates. So far, a specific pathophysiological pathway has not been identified. ADHD is probably not specifically associated with executive function deficits. It is possible, but not yet established, that ADHD symptoms may be more specifically associated with motivational abnormalities, motor organization and time perception. Recent findings indicating common genetic liabilities of ADHD and other conditions raise questions about diagnostic boundaries. In future research, the delineation of the pathophysiological mechanisms of ADHD needs to match cognitive, imaging and genetic techniques to the challenge of defining more homogenous clinical groups; multi-site collaborative projects are needed.     

When Equality Justifies Women's Subjection: Luce Irigaray's Critique of Equality and the Fathers' Rights Movement

The “fathers' rights” movement represents policies that undermine women's reproductive autonomy as furthering the cause of gender equality. Khader argues that this movement exploits two general weaknesses of equality claims identified by Luce Irigaray. She shows that Irigaray criticizes equality claims for their appeal to a genderneutral universal subject and for their acceptance of our existing symbolic repertoire. This article examines how the plaintiffs' rhetoric in two contemporary “fathers' rights” court cases takes advantage of these weaknesses.     

Interrelationships between Reading Disability and Attention-Deficit/Hyperactivity Disorder

Evidence from a number of investigations suggests a considerable overlap between reading disability (RD) and attention deficit-hyperactivity disorder (ADHD). We investigate the relationship between RD and ADHD in a cohort of 186 children 7.5–9.5 years of age, recruited explicitly to address classification and definitional issues in these disorders. Using multivariate methods, we examine the hypothesis that RD and ADHD represent separate diagnostic entities that frequently co-occur in the same individual. The results suggest that RD is characterized by deficits within the language system, in particular a subcomponent within that system, phonological processing; in contrast, such linguistic deficits are not characteristic of ADHD unless ADHD is associated with RD. When children with both RD and ADHD are examined, both the linguistic deficits associated with RD and the behavioral characteristics associated with ADHD are apparent, but these deficits are not synergistic. We conclude that RD and ADHD represent separate disorders that frequently co-occur.     

Symbolic play and language development

Symbolic play and language are known to be highly interrelated, but the developmental process involved in this relationship is not clear. Three hypothetical paths were postulated to explore how play and language drive each other: (1) direct paths, whereby initiation of basic forms in symbolic action or babbling, will be directly related to all later emerging language and motor outputs; (2) an indirect interactive path, whereby basic forms in symbolic action will be associated with more complex forms in symbolic play, as well as with babbling, and babbling mediates the relationship between symbolic play and speech; and (3) a dual path, whereby basic forms in symbolic play will be associated with basic forms of language, and complex forms of symbolic play will be associated with complex forms of language. We micro-coded 288 symbolic vignettes gathered during a yearlong prospective bi-weekly examination (N = 14; from 6 to 18 months of age). Results showed that the age of initiation of single-object symbolic play correlates strongly with the age of initiation of later-emerging symbolic and vocal outputs; its frequency at initiation is correlated with frequency at initiation of babbling, later-emerging speech, and multi-object play in initiation. Results support the notion that a single-object play relates to the development of other symbolic forms via a direct relationship and an indirect relationship, rather than a dual-path hypothesis.     

Social interactional behaviors and symbolic play competence as predictors of language development and their associations with maternal attention-directing strategies

Children’s early social interactional behaviors and symbolic play competence were studied at 14 months in a sample of 111 mother-infant pairs. The categories of social interactional behaviors, joint visual attention, socially coordinated and object oriented interactions were assessed via observations of mother-infant joint play. An index of symbolic play was derived from the child’s solitary play, which was assessed independently. We examined both the interrelations of these two types of early language predictors, and their relation to children’s language skills and maternal attention-directing strategies. Measures of children’s language comprehension and production were obtained using the MacArthur Communicative Development Inventories at 14 months, and Reynell Developmental Language Scales at 18 and 30 months. We found that at 14 months, social interactional behaviors and symbolic play competence were not statistically significantly related to each other. In line with our hypotheses, social interactional skills were associated more strongly with language production, and symbolic play competence more strongly with language comprehension. Maternal attention-directing strategies were strongly related to both children’s social interactional behaviors and symbolic play competence. Our findings indicated that maternal strategies that expanded the infant’s level of functioning were more effective in stimulating the children’s language development than were the other types of strategies.     

Impediments to the development of attachment

The function of the mother's reverie, as described by Bion, is viewed as a psychological parallel, following birth, to the physical function of the placenta.

Clinical material from psychotherapy with a 3 1/2-year-old girl illustrates that, as long as she maintained the delusion of being attached to her mother's body by a physical placenta, she was hindered from learning to experience herself as a separate individual and from developing normal feelings of attachment and grief over loss.

She was referred soon after her parents' separation when she showed a lack of reaction to the loss of her father. The material suggests that at the time of separation from her father she regressed to an earlier stage where there had already been a failure to work through infantile separation and individuation from her mother

The material reveals stages of her emergence from an illusory state of union, into one in which she could increasingly tolerate her separate existence. There followed an enrichment of her psychological means of communication through the use of imagination and symbolic play. She also became more receptive to her therapist's communications and could increasingly use psychological support to share and face inner pain.     

阅读障碍与注意缺陷多动障碍儿童的语言加工和反应抑制

阅读障碍与注意缺陷多动障碍(ADHD)高度共病,以往研究结果显示两种障碍在语言加工、执行功能等领域的缺陷既相似又不同。本研究采用语音意识测验、快速命名测验、语素意识测验和停止信号任务,以及阅读广度测验,分别考察四组被试（阅读障碍组、ADHD组、双重障碍组、正常控制组）的基础语言加工、反应抑制和言语工作记忆能力,结果发现：阅读障碍组和双重障碍组在语言加工任务上的成绩均显著差于ADHD组和正常组;ADHD组和双重障碍组在停止信号任务上的成绩显著差于阅读障碍组和正常组;所有障碍组在阅读广度测验上的成绩显著差于正常组。表明阅读障碍的特异性缺陷体现在语言加工过程上,而注意缺陷多动障碍的特异性缺陷体现在反应抑制上。这对于今后单一障碍的研究及临床诊断和干预具有重要的参考价值。     

Maternal Symptoms of Attention-Deficit/Hyperactivity Disorder and Maternal Language: Implications for Infant Language Development

The relationship between maternal ADHD symptoms and maternal language was examined in a community sample of 50 mothers of infants age 3–12 months. It was hypothesized that higher maternal symptoms of ADHD would be related to lower quality of maternal language use. Recordings of mothers’ speech were coded for complexity and elaboration of speech and vocabulary diversity during an interview with an adult and during mother–infant play interactions in the home. Hierarchical regression analysis revealed that maternal ADHD symptoms were significantly related to mothers’ lower mean length of utterances during the interview and during mother–infant play interactions. Maternal ADHD symptoms were not related to maternal vocabulary use in either of these situations. Our findings suggest that mothers with higher ADHD symptoms may display exiguous language behaviors when interacting with their infants and with adults. In addition, findings suggest one reason why current parent-management programs for children with ADHD, which are verbally based and rely heavily on the parent’s communication skills, are relatively ineffective when ADHD may be present in the parent.     

Working at the frontier and the use of the analyst: Reflections on analytic survival2

Certain connotations of ‘working at the frontier’ for the practicing psychoanalyst and for psychoanalysis are discussed in terms of movement along spatial and temporal dimensions. I then selectively highlight three currently significant frontier areas: moving between psychoanalysis and psychotherapy; psychoanalysis under conditions of terror and social traumatization; and the pursuit of the definitive as against the elusive subject. I suggest ‘the use of the analyst’ as the theme that underlies and epitomizes analytic presence and activity at these frontiers. Psychoanalysts are ‘used’ in innumerable ways, but especially by surviving the destructiveness‐deliberate and unconscious, real and symbolic‐aimed at them. The psychoanalytic presence at these frontiers fashions and reaffirms its unique, life‐embracing stance out of chaotic formlessness.     

Emotions,narrative and change

There is a wide agreement that emotions are central to the evaluation and understanding of change processes in psychotherapy. Unfortunately, most of the debate on the role of emotions has been influenced by the reductionist view of ‘psychophysiological symbolism’ (Averill 1996). We defend the position that, in order to understand their role in psychotherapy fully, we need to move in the direction of a more complex view of emotions. This paper presents a view of emotionsas social constructed phenomena operating via language and narrative. We present research suggesting that these narratives may be an essential process for understanding psychological disorders, how these disorders are developed and, finally, how they can be changed.     

The Preoedipal Development of the Critical Superego and Its Manifestations in Psychoanalytic Group Psychotherapy

Alexithymia is a psychic dysfunction in which symbolic thinking and fantasy are reduced, somatization is common, feelings are poorly communicated, empathy is impaired, and intimate interpersonal relations are difficult to maintain. Individuals with significant alexithymia may have a variety of psychiatric disorders but their psychotherapy should always be informed by an awareness of their alexithymia. This paper reviews the concept and details the most efficient means of psychotherapy for alexithymic patients. Ideal treatment for such patients maximizes their opportunities to learn while protecting their self-esteem and minimizing nonproductive stress. Such treatment involves concurrent individual and group psychotherapy. Clinical material is presented and specific therapeutic maneuvers are explored.     

Concurrent and Longitudinal Relationships Between Development in Graphic,Language and Symbolic Play Domains from the Fourth to the Fifth Year

This research investigated the developing inter‐relationships between language, graphic symbolism and symbolic play both concurrently and longitudinally from the fourth to the fifth year of childhood. Sixty children (n = 60) aged between 3 and 4 years completed multiple assessments of language and assessments of graphic symbolism, symbolic play and non‐verbal intelligence. A year later, 31 children (n = 31) were re‐tested using the same assessments. The findings revealed that skills within each symbolic domain were inter‐related during the fourth year, appearing to develop in a domain‐general type fashion based upon a common underlying symbolic mechanism. However, between the fourth and the fifth years, only language had predictive validity, suggesting a shift towards the verbal mediation of symbolic play and graphic symbolism as language becomes progressively internalized (Vygotsky, 1962, 1978). Copyright © 2012 John Wiley & Sons, Ltd.     

The molecular basis of cognitive deficits in pervasive developmental disorders

Persons with pervasive developmental disorders (PDD) exhibit a range of cognitive deficits that hamper their quality of life, including difficulties involving communication, sociability, and perspective-taking. In recent years, a variety of studies in mice that model genetic syndromes with a high risk of PDD have provided insights into the underlying molecular mechanisms associated with these disorders. What is less appreciated is how the molecular anomalies affect neuronal and circuit function to give rise to the cognitive deficits associated with PDD. In this review, we describe genetic mutations that cause PDD and discuss how they alter fundamental social and cognitive processes. We then describe efforts to correct cognitive impairments associated with these disorders and identify areas of further inquiry in the search for molecular targets for therapeutics for PDD.     

Symbolic play performance and early language development

The object-substitution symbolic play abilities of young children at three early language levels (i.e., MLU Stage Pre I, Early Stage I, and Late Stage I) were compared. In addition, the relationship between early language performance and object-substitution symbolic play was investigated. Results support the view that symbolic play performance is related to early language development, and in particular to the beginnings of combinational language (i.e., early syntax). Children at the combinatorial level of language development demonstrated significantly more representational ability than children at the single-word level.     

Sandplay in Jungian analysis: matter and symbolic integration

Jung described a way of thinking, tied to sensations and feelings, that is a thought connected to the body. Again in The Archetypes and the Collective Unconscious, Jung (1954) speaks of the symbol as a 'live body', corpus et anima. If the mind cannot credit itself with the discomfort that manifests through the body, this is a sign of a separation between mind and body. A consequence of all this is the literalization of the discomfort which makes it impossible to have a symbolic dimension. Therapy activates a process in which the patient can move from a stage of separation to a possible connection between mind and body, resulting in changes in the level of communication and of awareness. The mind opens itself to symbolization and the body becomes a field for a common language. From our reflections we have come to ascertain that we can speak of analysis only when an imaginary space is achieved, an intermediate space between the patient and the analyst, a space that is created from the intertwining of the symbolic capability of the patient with that of the analyst. Focusing our attention on the use of sandplay in analytic therapy, we know that one puts in the sand box objects that are marks of our psyche, visible traits that contain actions, corporeal movements and feelings. When one focuses on the overall representation built, one can go beyond the literal image and the analyst, keeping alive the image through his symbolic capability, opens the possibility of a dialogue with the symbolic dimension. The imagination as a symbolic thought is the humus that allows the analyst to maintain the intermediate symbolic level open by activating a symbolic process within the dialectic of the analysis.     

Personality Traits Elucidate Sex Differences in Attention-Deficit/Hyperactivity Disorder Comorbidity During Early Childhood

Attention-Deficit/Hyperactivity Disorder (ADHD) is highly comorbid with other childhood disorders, and there are striking sex differences in this comorbidity, particularly during early childhood. For example, boys with ADHD are more likely to exhibit comorbid disruptive behavior and neurodevelopmental disorders, compared to girls, during early childhood. Yet, explanations for these well-established sex differences remain in short supply. The current study evaluated the novel hypothesis that personality traits may serve as intermediate phenotypes that help explain sex differences in common ADHD comorbidity profiles during early childhood. Study participants were 109 children between the ages of 3 and 6 and their primary caregivers and teachers/daycare providers, recruited from the community and over-recruited for ADHD-related problems. Primary caregivers completed the Child Behavior Checklist, and teachers/daycare providers completed the Teacher Report Form as a measure of child behavior problems. Examiners completed the California Q-Sort as a measure of child personality traits. Moderated mediation analyses suggested that personality traits explain associations between ADHD and oppositional-defiance, aggression, and language problems in a sex-specific manner. While high neuroticism mediated associations between ADHD and oppositional-defiance in girls, disagreeableness mediated associations between ADHD and aggression and low conscientiousness mediated associations between ADHD and neurodevelopmental language problems in boys. Sex differences in trait-psychopathology associations may help explain sex differences in comorbidity profiles with possible implications for child assessment and personalized early intervention.     

The conceptual distinction between projective identification (Klein) and container-contained (Bion)

This paper describes the use of play in the psychotherapy of a latency child from a severely traumatised background. It considers the meaning of play in relation to the role of the psychotherapist and to psychotherapeutic technique and explores its functions in terms of the child's development. The paper documents the psychotherapist's learning experience about the difficulty of trying to make the ‘right’ interpretations and her consequent realisation of the intrinsic value of play in psychotherapy. In considering these themes, the author explores how, by placing interpretation secondary to play, the therapy enabled the development of the child's creativity and self-agency, facilitating a movement from primarily paranoid–schizoid defences towards the beginnings of a depressive position.