Originally published in the The Theraplay® Institute Newsletter of Winter 1999/2000

THERAPLAY FOR CHILDREN WITH ADHD

David Myrow, Ph.D.

Private Practice, West Seneca, New York

The life of overactive children is surprisingly predictable. They spend much of the day receiving negative feedback. “Derek, stop pulling Allison’s braids.” “Juanita, how many times do I have to tell you to stay in your seat?” “Simon, put away all of your other things and get out your mathematics homework.” And so forth. Somehow, these children have “trained” most of the adults they encounter to give them negative feedback, which increases the frequency of the behaviors.

Often these children are given the diagnosis by pediatricians and school personnel of Attention Deficit Hyperactivity Disorder (ADHD). They frequently are given additional diagnoses, especially Oppositional-Defiant Disorder and Conduct Disorder. Children who are described as ADHD also frequently meet the criteria for having learning disabilities. Perhaps the most troubling issue in categorizing children as ADHD is that the underlying causes of the behaviors are so varied. Children who are depressed, anxious, preoccupied, or neurologically impaired all may have trouble with attending, may be distractible, may be constantly in motion, and may behave aggressively toward peers. It is important to understand the underlying causes if treatment is to be successful.

There is evidence that some children come into the world with faster engines, lower thresholds for frustration and irritability, or inadequate self-regulating mechanisms. These biologically-driven tendencies can play a significant role in developing patterns of overactive and negative attention-seeking behavior. It is likely, however, that some children develop these patterns as a result of a mismatch between the activity level of the child and the parent (as described in “Matches”). Other children become overactive in response to anxiety provoking circumstances in their lives.

It is important to note that some children are too active for almost any adult to tolerate without learning some special strategies (and sometimes also getting a break from the child!). And sometimes medication needs to be used, even in the short term, to help slow down the child enough to help interrupt the pattern of negative feedback.

In attempting to understand a child’s overactive behavior, the Theraplay therapist pays particular attention to attachment issues. Many children who have trouble attending to tasks often have emotional needs that do not get met. A child who avoids eye contact, repeatedly bothers other children or adults, and engages in off-task behavior keeps others at a distance. Others -- parents, teachers, and peers -- avoid him. Yet this child repeats these behaviors much of the day. It is as if he were hungry but refuses food. By avoiding closeness with others, he is unable to feel “filled up” emotionally. So wherever the attention problem begins -- be it a neurological condition, a mismatch in tempo with a parent, anxiety, an attachment breach, etc. -- one issue that often needs to be resolved is that of the child’s being able to enjoy emotional closeness with people. Part of the therapeutic task will be to help the child regulate himself so that he does not push others away, and so that he gives others a chance to get close.

Theraplay with children exhibiting ADHD-like behavior seeks to promote self-control and the internalization of rules and structure, so that the child learns to modulate his own behavior. In Theraplay with these children, the therapist varies the pace of the session and introduces activities that enhance impulse control and the ability to delay gratification. This structured play improves self-esteem and helps develop the social skills necessary for success in school and peer relationships.

The format for Theraplay usually includes having the parents watch (simultaneously or by viewing videotapes) the therapist play with the child. After the relationship between the child and the therapist is established, and after the child has begun to increase her capacity for modulation of behavior, the parents join in for part of the child’s session. Sometimes, siblings, or even peers (in the school setting), are also brought in to help generalize the skills. The Theraplay therapist aims to increase the child’s capacity to enjoy emotional closeness with others, thereby decreasing the need for negative attention. Most of the time, and with parents’ permission, the therapist also reaches out to include school personnel in the overall plan; having consistent structure and support at home and at school increases the likelihood of success.

As an example, let us consider Bob -- who, for the sake of confidentiality, is actually a composite of several children who were diagnosed by pediatricians and school personnel as meeting the criteria for ADHD. This seven year old was described by parents as being aggressive toward other children in his second grade class. He sometimes refused to follow directions and would roam the classroom when he was supposed to be working at his desk or with other children in a small group. At home, he sometimes wandered off on his bicycle, ignoring requests to come home. His parents were devoted to Bob and his younger sister, but felt quite frustrated at his off-task, oppositional behavior. He was described as having been wiggly from birth, and often resistant to cuddling.

The therapist observed in the initial evaluation that Bob tended to avoid eye contact and to ignore directions from his parents. His dad often gave in to Bob when he refused a request. Mom would get angry when Bob refused requests, but sometimes made a sarcastic remark rather than set a firm limit. On a few occasions in which she attempted to set a limit, Bob changed the subject and left Mom frustrated. Bob seemed to be going at a faster pace than either parent. He was wiggly in his seat, and sometimes got up to walk around.

The therapist helped establish several goals with Bob’s parents: Seek eye contact and physical contact with Bob; re-direct him so that he completes tasks and remains involved in interactions; set clear, firm limits and follow up on them; and enjoy emotional closeness with Bob whenever possible. The therapist worked with Bob’s teacher to set up similar goals in the classroom and to arrange a scheme to reinforce his on-task behavior. The teacher was especially encouraged to seek eye contact with Bob and to give him a (literal) pat on the back frequently.

In the playroom, the therapist worked to keep Bob emotionally close, to have fun, and to help Bob practice regulating his own behavior. The therapist stayed in charge at all times. He required Bob to follow the rules in games, and also invited Bob to enjoy being taken care of. They thumb wrestled; Bob was challenged to see how many big and small bites he could take from a donut; and the therapist challenged Bob to see how far he could jump from a table into the therapist’s arms. After five sessions, each of which the parents viewed via videotape under the guidance of the therapist, the parents were invited into the Theraplay room for a part of the session with their son. They practiced setting the limits and keeping Bob engaged.

After 15 sessions, the teacher and parents all reported significant improvements in Bob’s behavior. He continued to need support to stay on task, but accepted redirection better. He showed more interest and pride in his work. He approached his teacher with on-task questions. Eye contact was better. He laughed and smiled more. Bob was starting to make friends.

In summary, the Theraplay therapist utilized the assessment of the parent-child relationship as well as Bob’s individual behavior in formulating the treatment plan. His avoidance of closeness with others was addressed directly in the play sessions, both individually and, later, with his parents. His parents were included in the treatment plan from the beginning, and they were invited to see him in different ways, which revealed his inner struggles as well as his unsuccessful strategies to get closer with others. Bob’s teacher was also engaged in the effort, and she was invited to view him in some different ways, which freed her to work more actively to engage him. Bob was able to get closer to others, to modulate his off-task behavior more, and to actively seek out other people in more appropriate ways.