Sara Who Suffered From ADHD

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Attachment-based family treatment of a girl with an ADHD-diagnosis


This is an extremely detailed case study of a 6-year-old girl “Sara” diagnosed with ADHD. Sara being diagnosed with ADHD was highly uncooperative and on-edge. Her family was asked if they would like to use a new medium of therapy to better Sara’s condition and upon agreeing received the playful attachment-based intervention – Theraplay. Before the intervention of this therapy, Sara was uncooperative, edgy, and stubborn and her parents were naturally, exhausted, they could not understand how to regulate their child, who had developed symptoms of relational trauma. This article includes a theoretical background based on interventions discussing attachment and the polyvagal theory. Assessments both before and after the treatment were initiated are included and there is also included a detailed description of the parents and the therapists’ experiences and subjective viewpoints during and after treatment based on interviews in the last and ending phases of the therapy. This article also elaborates that how an unwilling and disobedient (as most children diagnosed with ADHD are) child-like Sara improved her behavior over time upon the initiation of Theraplay. The parents said during interviews that they experienced behavioral problems with Sara right from the start. For the first five years of her life, Sara was constantly dissatisfied with strong body tensions. As an infant, she slept very little. And during the short periods that she did sleep, she woke up screaming. Her screams rang in her parents’ ears. After this treatment was introduced, her hyperactivity decreased, the self-esteem of the parents and the child increased, her ability to mentalize and focus increased, as the parents grew confident in their roles, they improved the quality and the amount of mental security they provided to their child which in turn, aided her psychological development. The results of the treatment were analyzed theoretically and showed how the child’s relational trauma behavior decreased and how her attachment behavior improved. Through feelings of safety, social engagement, guidance, and playfulness the stress levels of the parents were reduced and their mentalizing ability became stronger. The study shows the importance of giving parents and the child new emotional experiences and of being together to help parents in developing a deeper, better, stabilized, and objective understanding of their child and the problems they go through. Theraplay has previously been successful in treating internalized problems but this case study illustrates how this therapeutic technique can be successful in treating children with ADHD. The therapists felt that in this case, the technique helped spark the parents’ empathy and understanding of their child. Through this playful technique, the whole family was able to grow as a unit. The relationship with the parents improved drastically and as everyone knows that is a big milestone in treating children with ADHD. The parents shared their feelings and received helpful support in return, they learned how to better manage and understand their child who was going through a problem. Another important aspect was sharing the difficult parts and how that was also hard on the child but only strengthened their alliance. The development clearly progressed from preverbal to verbal thanks to this technique. To be able to mentalize and understand Sara, the parents first needed to be mentalized themselves. And this Theraplay greatly helped bridge the differences between the child and the parents. The relationship with the parents is a key factor in any child’s life but with children diagnosed with ADHD, it is integrally essential and plays a very important role in the treatment as well. This therapeutic technique targeted family relationships and achieved great results.


The study showed that attachment-based treatment was helpful for a child with ADHD and relational trauma. The need for early interventions was highlighted. If the family had received such help during Sara’s first years, perhaps they would have been able to understand their child better and much of the suffering both of the child and of the parents could have been avoided. Theraplay helped the family to come closer. This study also includes all viewpoints, those of parents and of the child. Relating to both, ADHD and relational trauma. The development followed a rather intersubjective spiral, it went from listening and observing to emotional and active participation, from reacting bodily to stress responses to emotionally reflecting on their own inner being and on their child’s. Using mentalization and harboring, the therapist regulated the parent’s emotions and supported the parents’ implicit processes to increase their reflection and self-awareness abilities. This case study proves the importance of emotional regulation and of family participation in the treatment of an ADHD child.

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As is often the case with ADHD diagnosis and treatment, this therapeutic route and the treatment was perhaps too long. If this treatment plan of “Theraplay” is to be adopted for the treatment of ADHD children, perhaps the parents and the child would both get frustrated and abandon the treatment. And since the period of the treatment was so extensive, it cannot be said with utmost certainty that the positive results were truly the doing of the treatment or “Theraplay” or simply the consequence of the maturity on the part of the child that initiated such a positive behavior. It is hard to pinpoint what in the development is the result of the treatment and what is the result of biological maturity. Since the treatment is based on one case the results cannot be generalized.


Since Sara suffered from night terrors and was extremely fidgety, perhaps some medications should have been administered that could monitor and calm her behavior. Her educational needs were not highlighted. For children with ADHD, educational interventions are extremely important, individual school support, such as school environment and behavioral supports perhaps, should have been initiated to boost her self-esteem and confidence. Moreover, for her behavioral problems, only Theraplay was considered, some Cognitive Behavior Therapies could have perhaps, produced better and faster results.


The study shows the importance of working therapeutically with parents, to give parents and children new experiences of being together. A great deal is required of the parents of a child with ADHD. The parents in the case described difficulties to meet the child’s emotional needs, the basis for developing secure attachment relationships. It raises the question if ADHD is a risk factor for attachment disorder which would indicate underdiagnosis of relational trauma. The existence of attachment disorders in children with ADHD could be high and this question needs to be further examined. The study shows the importance of interaction assessments of the parents’ implicit, ability to meet the child’s basic emotional needs. Explicit descriptions do not help us find the fundamental problems, which is a prerequisite for optimal interventions based on the individual family’s needs. The case study showed that complex cases can be helped by playful attachment-based treatment but there remains a need for further research on this topic.  


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