SEÇÃO LIVRE

 

Emotional development of children with Attention Deficit Hyperactivity Disorder

 

Desenvolvimento emocional de crianças com Transtorno de Déficit de Atenção / Hiperatividade

 

Desarrollo emocional de niños con Trastorno de Déficit de Atención / Hiperactividad

 

 

Ana Paula Mucha Tonetto^I; Fernanda Kimie Tavares Mishima-Gomes^II; Valeria Barbieri^III

^IDoutoranda pelo Programa de Pós-Graduação em Psicologia da Faculdade de Filosofia, Ciências e Letras de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil. anapaulamtonetto@gmail.com
^IIDoutora pelo Programa de Pós-Graduação em Psicologia da Faculdade de Filosofia, Ciências e Letras de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil. ferkimie@yahoo.com.br
^IIIProfessora Associada do Departamento de Psicologia da Faculdade de Filosofia, Ciências e Letras de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil. valeriab@ffclrp.usp.br

 

 

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ABSTRACT

Attention Deficit Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder that manifests itself in childhood and can accompany the individual in adult life. The child with such diagnosis presents a clinically significant decline in social and academic functioning. This study aimed to understand the emotional development of children diagnosed with ADHD, as comprehending the experiences of these children helps in understanding the emergence and persistence of this condition. This was a clinical-qualitative study, using Winnicottian psychoanalysis as a theoretical reference. The methodological strategy used was the "transferential narratives" and the children's apperception test - animal figures (CAT-A) was employed as mediator in the communication during the interview. The participants were four children diagnosed with ADHD under psychiatric and medication support for the disorder. The children revealed that attention-deficit and hyperactivity behavior arose as a deficiency in receiving the "holding", resulting in weakening and disregard for the creative gesture that promotes and sustains the emotional bond with the world. In these conditions, the ability to experience transitionality, to play, and for symbolization cannot develop. It is important to understand the emotional development of the children considering the possibilities of intervention and therapeutic help for them and their families.

Keywords: attention deficit disorder with hyperactivity; psychoanalysis; child.

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RESUMO

O Transtorno de Déficit de Atenção / Hiperatividade (TDAH) é uma desordem do neurodesenvolvimento que surge na infância e pode permanecer na vida adulta. A criança com esse diagnóstico apresenta prejuízo clinicamente significativo no funcionamento social e acadêmico. Esta pesquisa tencionou compreender o desenvolvimento emocional de crianças diagnosticadas com TDAH, pois conhecer as experiências dessas crianças auxilia na compreensão do surgimento e manutenção desse quadro. Trata-se de um estudo clínico-qualitativo, empregando a psicanálise winnicottiana como referencial teórico. A estratégia metodológica utilizada foi a das "narrativas transferenciais" e o teste de apercepção temática infantil - figuras de animais (CAT-A), empregado como mediador da comunicação na entrevista. Participaram quatro crianças diagnosticadas com TDAH em acompanhamento psiquiátrico e medicamentoso para o transtorno. As crianças revelaram que os comportamentos desatentos e hiperativos surgem como uma deficiência no recebimento do "holding", tendo como resultado um enfraquecimento e a desconsideração do gesto criativo que promove e sustenta o vínculo emocional com o mundo. Nessas condições, a capacidade para vivenciar a transicionalidade, para o brincar e para a simbolização não podem se desenvolver. É importante entender o desenvolvimento emocional das crianças pensando nas possibilidades de intervenção e auxílio terapêutico a elas e suas famílias.

Palavras-chave: transtorno de déficit de atenção com hiperatividade; psicanálise; criança.

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RESUMEN

El Trastorno de Déficit de Atención / Hiperactividad (TDAH) es un trastorno del neurodesarrollo que surge en la infancia y puede permanecer en la vida adulta. El niño con ese diagnóstico presenta un perjuicio clínicamente significativo en el funcionamiento social y académico. Esta investigación intentó comprender el desarrollo emocional de niños diagnosticados con TDAH, pues conocer las experiencias de esos niños auxilia en la comprensión del surgimiento y mantenimiento de ese cuadro. Se trata de un estudio clínico-cualitativo, empleando el psicoanálisis Winnicottiana como referencial teórico. La estrategia metodológica utilizada fue la de las "narrativas transferenciales" y la prueba de apercepción temática infantil - figuras de animales (CAT-A), empleado como mediador de la comunicación en la entrevista. Participaron cuatro niños diagnosticados con TDAH bajo seguimiento psiquiátrico y con medicamentos para el trastorno. Los niños revelaron que los comportamientos desatentos e hiperactivos surgen como una deficiencia en la recepción del "holding", que resulta en un debilitamiento y la negligencia del gesto creativo que promueve y sustenta el vínculo emocional con el mundo. En esas condiciones, la capacidad para vivir la transicionalidad, el juego y la simbolización no pueden desarrollarse. Entender el desarrollo emocional de los niños ayuda a pensar en las posibilidades de intervención y ayuda terapéutica para ellas y sus familias.

Palabras clave: trastorno de déficit de atención con hiperactividad; psicoanálisis; niño.

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Introduction

Attention Deficit Hyperactivity Disorder (ADHD) is currently one of the most debated topics when it comes to behavioral and school difficulties. This term is used to define a neurobiological disorder that arises in childhood and can accompany the individual throughout their life. Approximately 67% of cases detected in childhood remain in adult life. Estimates assume that inheritance of the disorder is close to 80% (Silva, 2005; Kappel, 2016).

Attention Deficit Hyperactivity Disorder is considered a complex disorder and its etiology is not well described, with several proposed causal hypotheses. Evidence suggests that environmental and genetic factors are associated with increased susceptibility of the individual to ADHD. Environmental factors are usually related to the family and socioeconomic context. Other factors affect specific brain processes, including fetal exposure to alcohol, maternal smoking and low birth weight, which can affect the attention and motivation processes (Dumas, 2011; Hora, Silva, Ramos, Pontes & Nobre, 2015). Fernandes et al. (2017) pointed out that children diagnosed with ADHD present a delay in motor performance when compared to what is expected for the age group.

The symptoms must, necessarily, cause some kind of difficulty or impediment to the accomplishment of tasks and impairments in relationships. Hyperactive and impulsive children often put themselves in danger and are at increased risk of accidents (Dumas, 2011).

One of the earliest literary references to individuals with attention, hyperactivity and impulsivity disorders is found in Shakespeare, who alluded to a "malady of attention" allegedly acquired by King Henry VII. In children, hyperactivity was first described in 1845 in a Russian poem called "Fidgety Philip", written by the physician Heinrich Hoffman. In this poem, Philip's symptoms increase, alternating between the inability to stand still, squirming and laughing, and swinging back and forth in his chair until he inevitably falls (Mash & Barkley 2003; Martins et al. 2014).

Population studies suggest that ADHD appears in the majority of cultures, in about 5% of children and 2.5% of adults (APA, 2014). Prevalence rates are quite variable, however, it is believed that 8 to 12% of children in the world have ADHD. Americans are the most affected, approximately 9.5%, that is, 5.4 million children and adolescents aged 4 to 17 years had ADHD in 2007 (Polanczyk, 2008). According to data from the Brazilian Attention Deficit Association (Associação Brasileira de Déficit de Atenção - ABDA), between 3% and 5% of Brazilian children suffer from ADHD; among these children, 60% to 85% continue to present the disorder in adolescence (Cheida & Monteiro, 2014). The incidence ratio between boys and girls ranges from 4:1 to 9:1. There is, however, no clear scientific explanation from any area of research to shed light on this greater vulnerability of males. What seems to happen is that boys are more often referred for treatment than girls because they also develop behavioral problems. Currently, the diagnosis of ADHD is a challenge because several diseases may present common warning signs and symptoms, such as dyslexia, intellectual deficiency or comorbidities such as oppositional defiant disorder, conduct disorder, bipolar disorder and depression (Machado et al., 2014; Alves, Neme & Cardia, 2015; Dias & Badin, 2015).

There are two main sets of diagnostic criteria for ADHD: one based on the International Classification of Mental and Behavioral Disorders, 10^th revision - ICD-10 (OMS, 1993), and the other on the criteria of the Diagnostic and Statistical Manual of Mental Disorders, 5^th edition - DSM-IV (APA, 2014). According to the ICD-10, the diagnosis of this disorder requires abnormal levels of hyperactivity, inattention and impulsivity for at least six months. The DSM-IV (APA, 2014) includes ADHD in the group of neurodevelopmental disorders, defined by harmful levels of inattention, disorganization and/or hyperactivity-impulsivity (Benczik, 2010). There are a number of questionnaires that employ the DSM-IV criteria, which are used for screening, for assessment of severity and frequency of symptoms and for monitoring the treatment, and can be answered by parents and/or teachers. Among them, the ADHD Rating Scale (Pappas, 2006) and the Conners Questionnaire (Conners, 1989) are the best known and used in Brazil, as well as the SNAP-IV, based on the DSM (Christiansen et al., 2012; Gonçalves et al., 2013).

The treatment of ADHD requires a broad and multidisciplinary approach. The most commonly used therapeutic approaches include education on the disorder for all who have contact with the child, such as family and teachers, use of medication for the child, and psychotherapeutic interventions with the child and the family. The treatment should be provided on an ongoing basis, considering and covering the different contexts and people with whom these children coexist. The use of pharmaceuticals is prescribed in most cases, these being first-line medications for the treatment of ADHD in school-age children, adolescents and adults (Desidério & Miyazaki, 2007; Mattos, Rohde & Polanczyk, 2012). For the pharmaceutical therapeutic care of ADHD, the main substance used worldwide is methylphenidate, a stimulant marketed since the 1950s in Switzerland (where it was synthesized) Germany and the United States. Due to its association with ADHD, its sales have increased, becoming the most consumed stimulant in the world. In the treatment of ADHD, it is sought to adapt the administration of the drug to periods of greater school, behavioral or social difficulties for the patient (Moreira et al., 2014). In Brazil, it has been sold since the 1990s. Brazilian production increased from 40kg in 2002 to 226kg in 2006. The use of methylphenidate between 2009 and 2011 in Brazil indicates that two million boxes were prescribed in 2011, with an increase of almost 30% in the period (ANVISA, 2012). The increase in sales of these drugs attracted collective attention to the possibility of excessive treatment (Itaborahy & Ortega, 2013).

Silva and Alvarenga (2013), when evaluating maternal parenting practices and childhood behavior in children diagnosed with ADHD, concluded that there was no evidence regarding the impact of these parenting practices on the emergence and maintenance of this disorder. They therefore support the hypothesis that parental behavior contributes to the emergence of comorbidities, but does not play a determining role in the onset or exacerbation of ADHD symptoms. Maia, Gama and Michalick-Triginelli (2012) investigated the relationship between Attention Deficit Hyperactivity Disorder, family dynamics and dysphonia, and found no statistically significant differences in parenting practices between groups of families with and without ADHD. Lien et al. (2015), in a study of more than 3,000 children with ADHD in Taiwan, also found no family predictors for the onset of ADHD; however, they found better treatment responses in cases where the child's family also received psychosocial support. In contrast, Gau and Chang (2013) observed a relationship between impairments in the mother-infant relationship and the onset of ADHD, especially when the mother had neurotic depressive symptoms. This conclusion is in agreement with the study by Cartwright et al. (2011), which indicated a difficulty in the emotional expression of the mothers of these children. Harvey, Metcalfe, Herbert and Fanton (2011) found an association between parental depression during the preschool years of the child and the manifestation of ADHD, confirming the findings of Takeda, Ambrosini, deBerardinis and Elia (2012), which linked parental psychopathology to an increased risk of developing ADHD in children.

Interactions between parents and children in families where at least one child has ADHD are characterized by more conflict, coercion and stress, although discipline may also be looser, unlike that observed in ordinary families (Benczik & Casella, 2015). However, much of the family conflict seems to stem from the child's ADHD and its impact on family functioning, rather than its etiological agent. Furthermore, Benczik (2010) stated that parents' behavior, their characteristics and their occupational pattern may also be related to these problematic interactions, and contribute to their occurrence. Assessing the relevance of the interaction between the family role and the pathology studied, coupled with the experiences of children with ADHD, this study aims to comprehend the emotional development of these children, in order to provide practical support for interventions and therapeutic care for these children and their families.

 

Method

This work is part of a master's dissertation entitled "The Maternal Experience and Development of the Self in Children with Attention Deficit Hyperactivity Disorder", developed from a qualitative research perspective. The theoretical framework employed was Winnicott's psychoanalysis and the transferential narratives methodological strategy (Aiello-Vaisberg, Machado, Ayouch, Caron & Beaune, 2009), in which the researchers make clinical presentations as an authoral report, which allows the reader the comprehension of the encounter as a whole. The clinical event is narrated with the countertransferential impressions of the researcher and their free associations. Later, these contents are associated to theoretical concepts, based on psychoanalysis. In this context, at the moment of clinical occurrence, a projective procedure was employed as a dialogical mediator. These procedures consist of a special form of dialogue, such as a "playful dialogue", in a kind of make-believe. Its rigor and scientificity are due to the dialogical situation which, combined with care related to the setting, is predominantly structured from the personality of the research participants (Aiello-Vaisberg, 1995). In this way, the projective techniques allow the comprehension and identification of characteristics of the individual interviewed, allowing for the creation of dialogue between the participant and the interviewer, stimulating new associations (Aiello-Vaisberg, 2004; Turato, 2008).

The dialogical mediator chosen was the Children's Apperception Test - animal form (CAT-A). The cards used were 1, 2, 3, 4 and 8, which evoke the following themes: orality and relationship with the mother figure, oedipal conflict, perception of the parental figures and relationship with authority, fraternal rivalry and perceptions considering the family dynamics. The use of these CAT-A cards as mediators of communication has proved to be an important facilitator of communication, as demonstrated by Barbieri (2011, 2015), Heck (2014) and Bomfim (2015), who used this mediator to understand the maternal experience in other contexts and also used Winnicottian theory for the data analysis.

Two meetings were held with each child: in the first, the research was explained to the child and the person responsible; in the second, the cards of the Children's Apperception Test - Animal Form (CAT-A) were used as communication mediators. Four boys participated in the study (all of the names used are fictitious, in order to preserve the participants' anonymity - see Table 1): Davi (7 years and 10 months), Pedro (10 years and 10 months), Vinicius (8 years and 8 months) and Marcos (9 years and 6 months). All were undergoing medical monitoring due to the diagnosis of ADHD. With the exception of Vinicius, who started treatment two months before, the other boys had been monitored for two years; despite using controlled medication, at the time of the meetings, without this having been previously agreed, the children were not medicated. Regarding the family members, three children lived with both parents and younger siblings, while Vinicius lived with his mother and had an older sister.

 

Results and Discussion

Case 1 - Davi: The child presented difficulties in the contact with the researcher, showing impatience and intense discouragement in the face of activities he considered difficult, believing that he was not able to do them (when seeing a figure he soon stated he did not know what to say, and had difficulty in telling stories; his answers were short and vague). When he realized he was capable of creating something, he was encouraged; however, when he failed, he wanted to give up again, showing insecurity and low self-esteem.

In telling the stories, Davi, with great difficulty, described the characters very poorly, without managing to develop a story with beginning, middle and end. The chick (card 1) ate along with other chicks and soon someone arrived who devoured them all ("Along came the rooster and ate them!"). There were indications that the first relationship of proximity and attachment (mother-child) was interrupted abruptly, without satisfaction. Faced with the anguish of experienced annihilation, the boy resorts to omnipotence as a defense (card 2), making the character he identified with win the tug of war easily against the other two weak bears (father-mother). The relationship with the immediate environment, i.e. the family, is experienced as a tug of war. To live with the parental figures, he sees himself as the strongest ("The little bear is the strongest... It will win!"), without having limits to his omnipotence.

Next, Davi indicates the other's difficulty in perceiving his needs and how much he needs to take care of everything by himself (card 3 - lion and mouse do not communicate), without being able to trust the environment. The characters are together in the scene, but apart in affection, united only by the television they watch. Even the moments that should be enjoyable are considered distressing: an outing (picnic) does not happen and the characters go to sleep (card 4). There is an interruption in the activity due to passivity and immobility. One more relationship is interrupted and each side remains attached to their own needs, without affective contact. The intolerance of the environment in relation to the needs of the child continues (card 8), located in a family that does not fulfill his needs, but only reprimands him (the monkey's grandmother is very angry with him). Again, the difficulty in establishing a bond shows up, the lack of acceptance and recognition of his "art", which is shunned, only leads him to shut himself up more inside himself (the little monkey does not want to change).

Case 2 - Pedro: The boy demonstrated not being able to create long stories and had poor vocabulary which made some answers difficult; however, he helped with the activity, wanted to participate, and was curious to see the sequence of the cards. At times he needed the objects to be named for him (such as the bib on card 1 and pipe on 3). The stories told show the lack of holding and gratification received by the child, both in terms of quality and quantity. In card 1, it was observed that gratification was obtained through a person outside the family environment, suggesting that the parents seem little able to fulfill the child's basic needs. This gratification that comes from outside is not yet fully enjoyed, the mother forbids its use, directing it is to be shared with the father ("The mother says that it is to be left for the father"). The force of the mother's presence follows in card 2, it is she who wins the tug of war; despite being accompanied by her son, the victory is hers alone. There is no affective involvement on the part of the child in the game, which seems to make little sense, arousing only dissociated reactions (the father, though he tried to win, is happy when he loses the game) or clichés (mother and son happy because they won).

The next story (card 3) ratifies the maternal presence as authority (she is the lion), and suggests that something wrong happened with the lion, who is pensive and silent, sad and depressed, with no reason why. There is mention of a possible maternal depression, the reasons for which the child cannot understand. Although there are two characters in the story, there is no relationship between them, and the mouse (the child) becomes impotent and unable to act faced with what happened to make the adult sad; the interaction does not take place. This situation distresses the child, who, with card 4, shows a certain eagerness to establish a close affective relationship with someone who can understand his childlike condition, to regress and relate through the game, the space of transitionality. He seems to have few opportunities to enjoy relaxation and play, and when this happens, it is mainly the figure of the father who provides such experience ("Because my mother does not go out, but my father goes out with me. He goes out with me and my brothers"). Playing with the mother, on the other hand, is seen as something distant and very unlikely to be reached.

Finally, in the last card, Pedro describes three generations of the family. He is able to establish a historical continuity for the family, in vertical terms (great-grandmother, grandmother, grandson) and how the transmission is made, that is, the socialization of the children. With this he makes an attempt to inscribe his place in the family, but curiously "skips" his mother. The family context is not harmonious, with "gossip" and reprimands to the grandson's behavior. Therefore, instead of constituting a cohesive and pleasant group to live with, the relationship between the members is marked by intrigue, reprimands and distrust. The scarcity of illusory experiences reflects in difficulties to consolidate the area of the transitional phenomena and even playing appears as something distant. The chances of enjoying these experiences with the parents are slim, especially with the mother. He seems to be powerless to help her, becoming irritated with this.

Case 3 - Vinicius: This kid showed an interest in participating in the activity; however, he was bothered when he felt difficulty. From the beginning of the contact, the fact that Vinicius seemed to be younger than he really was had an impact. Confirming this first impression, in the story about card 1, he conveyed the message that, in order to have secured the holding of the mother and the gratification she provides, it was necessary to be close to her ("Who is closer to the mother eats more..."). In this way and in this position, he can become stronger. In this sense, maternal love is guaranteed by the maintenance of a developmental condition inferior to that which he is capable of (he speaks like a baby), close to the symbiosis, which may be hindering the emotional development of the child.

After displaying the need to join the mother in a symbiotic movement, the rivalry appears between father and mother for the love and support of the child (card 2: "Three bears, one is going and the other is with the son pulling..."). On one hand, the capacity to take care of things is achieved in a certain way; on the other, the child's approach to the father for this assurance is opposed by the mother, a situation that may engender conflicting loyalties in the child. The figure of the sister is also important for stabilizing the capacity for transitionality. It is sought as a way to circumvent the maternal deficiency for playing and his attempts to prolong the earlier fusional bond, but also to assure the family relevance (or bond) through consanguinity ("I play a little with my sister... My blood sister" - alluding to the existence of the stepdaughter of the father). Unlike the father, the figure of the sister is not perceived by the mother as threatening and does not rouse her rivalry.

The previous theme that mobilized the child continues in card 3, regarding the effects caused in the mother by the closeness of the child to the father. Apparently, this condition triggers anger and persecution on the part of the mother; however, her fragility does not allow a real action ("And then he (the mouse) saw that (the lion) was watching him, and he tried to catch the mouse, but his 'backs' was broken"). The child's reaction at first is manic, the mouse laughs when the lion gets hurt ("The mouse laughed and the lion did not go to the hospital"), but there is an attempt to repair it, the lion was not hurt to the point of going to the hospital, showing the child's concern for his mother.

The difficulties in the family relationship continue in card 4, the capacity for transitionality is also the object of attention in the story, represented mainly in the character of the kangaroo "postman", which represents people in relationships, with the brotherly relationship and the bond with the father gaining importance. Again, the sister arises as essential to offer part of the holding to the child; she interrupts the trip to feed him and gratify him ("Three kangaroos. A baby who drank water, another who did not like to use a skipping rope and only liked to ride a bike and the biggest is a postman. The postman arrived and the girl came down, and this one here too (the kangaroo alone on the bicycle) to give water"). She also accepts the father's participation for the continuity of this function, when the kangaroo that represents her goes to play while the other is left in the care of the father ("This. There, she went to play with more kangaroos, and he went to drink water with the father") and later returns, both to continue this offer and to experience the transitional phenomena ("Then they went to deliver the parcels in the forest and then they went for a picnic").

The issues of socialization and protection are emphasized in the last card. There is a conflict between the desire of the child and that of the father experienced in the context of a relationship of protection of the parent for the child ("Four little monkeys. The father was telling his son to behave and the other two were gossiping. They said he messes about and has a lot of tantrums. Then the father saw that they were gossiping and got angry with them"). Thus, he relies on his father to defend him against the impositions of others and the narcissistic wounds they may cause; however, there is no excessive permissiveness, since the goal of socialization by the father persists. Vinicius understands the father's intention and acknowledges the protection he offers.

The emerging content of the dialogical mediators reveals that at the moment of his development, the child struggles with the task of cementing and consolidating his capacity for transitional experiences, amidst the demands of his parents who share his care, his mother's and his own fear of losing the love they devote to one another and also of revealing it to the father. He then resorts to the figure of the sister, who seems able to help him in this transit between absolute and relative dependence, putting him at a lesser risk of reproach. To be able to take advantage of these resources expressed in the care provided by the sister and by the father, without causing injuries and losses in the mother, seems to be what the child seeks.

Case 4 - Marcos: This child presented a great deal of difficulty in verbalization: he exchanged letters (g for c) and spoke like a younger child, with many mispronounced words. At times there was a gentleness in his voice; however, the impatience in remaining seated, still, paying attention, his stories being too short, and wanting to leave the room masked his friendlier side. In the contact with him there was an ambivalence about correcting him or not, being irritated or not. He said he did not want to make up stories, but then he continued. He behaved in an intrusive way and without boundaries, wanting to touch the cards that were on the table and not sitting in the chair, even when requested. Like the contact, his stories were short and hard to understand.

Right at the beginning (card 1) he indicated the ability of the parents to fulfill his needs: the father and the mother make food (milk pudding) that does not sustain him. Although there is a puppy who is more enthusiastic, the situation apparently does not promote rivalries of any kind, neither between the brothers, nor between him and one of the parents. The situation of dispute shows up in card 2, with colorful positive Oedipal experiences: he with his mother against his father, who is still stronger than both ("The little boy and the mother are in tug of war and this here is daddy (the bear that's alone)... It's strong, it is"). However, in the rest of the contact, the Oedipal experience does not appear as a pillar in the organization of the child's personality, which seems to be based on dynamics far more primitive than this.

Accordingly, it is in the report of card 3 that the "reactive" quality of the acceptance, on his behalf, of what the mother offers (breast-pudding) and his perception of her ability to fulfill his needs and desires is revealed. The story he invented about the lion and the rat that eat endlessly until they get sick shows, in fact, the voracious pursuit of gratification that is based on important experiences of deprivation ("The king of the jungle. He ate everything and got a big belly ache and that's the end!"). In this way, the difficulties presented by the boy are sustained in more primitive periods of the emotional development. At this moment, Marcos is distressed and his capacity for representation and symbolization begins to fail. Threatened by inner danger, he asks to return to his mother, hoping she will protect him. He asks to leave the room, but ends up staying. The persistence of these difficulties until the end of the meeting reveals that their nature is of a more structural order than specific to a theme. The playing, which was precarious from the start, deteriorates further. Therefore, it is with great difficulty that he persists in the task, but at the cost of a contamination of the following stories, losing the notion of the differences between the objects (cards).

There is some relief at seeing card 4, which refers to the relationship between siblings. He uses it to situate his condition from the contraposition between the two characters (siblings), which gives him some support in the process of integrating the personality ("Yes! And daddy stayed before... But all the others were traveling with them... The little one, the puppy (small kangaroo) has not got ears yet."). Apparently, he can only count on his brother for support in acquiring and sustaining integration capacity, since the father is absent and, when present, only opposes his relationship with his mother ("It's the brother who knows how to ride a bicycle, but the other does not know, the end.").

This preliminary achievement of integration is again shaken by card 8, where he reveals the cause of the deprivation he suffered: the death of his grandmother, a figure who offered him holding ("The grandma gorilla died!"). This death was noted, but not understood or expected ("I do not know, I just saw"). It was this experience of loss felt as atrocious that led to the voracity, picking lice and eating them ("One is talking and the other is picking lice and eating them... This is how the 'monkey' does it"), which the mother cannot understand ("The mother is angry because he is picking flees and eating them!"). In the degradation of symbolic capacity that happens then, Marcos becomes the monkey, imitating the animal ("Uh uh uh, ah, ah, ah"), which shows that this loss occurred at a time when he still did not have the developmental capacity that allowed him to differentiate between internal and external reality, that is, still in the absolute dependence stage of emotional development, when the grandmother tried to supply the previous lack of illusion in the experience with the mother. As a result, the loss seems to have triggered psychotic type distress.

Marcos shows he is a child who suffered and still suffers because of the deprivation of experiences of illusion, which makes the acceptance of disappointment and the possibility of joining the area of transitionality extremely painful. His hyperactivity seems to cover up unthinkable anxieties, in which the loss of the object becomes a threat of annihilation. The personality is pre-organized in a psychotic way and the suffering experienced is acute.

Synthesis of the narratives

The children generally spoke very little, used impoverished vocabulary and were often limited to the descriptions of the cards, indicating the difficulty they have in playing and fantasizing, due to the blockage in the creative process. This is sustained by specific emotional dynamics and by precariousness in the process of constitution of the self. These deficiencies seem to stem from a series of difficulties in the family relationships of these children and from the inability to fulfill their emotional needs. Therefore, in psychodynamic terms, all the children presented low self-esteem and insecurity facing the world and the challenges of emotional development. The roots of these characteristics seem to lie in a lack of holding received early in life, which in some cases may be partially repaired by other figures, the father or sister (case 3), the grandmother (case 4) or an undefined person who provided a "standardized" adaptation to the needs (case 2). This support, however, did not prevent the onset of emotional distress, although it seems to have played an important role in terms of lessening the seriousness of the psychopathology (cases 3 and 4), which, however, rapidly deteriorated upon its interruption (case 4).

In all cases, the narratives revealed that the oral gratification and illusion needs were only partially fulfilled, with the mothers having difficulty adapting to objects imaginatively created by their children. In this way, it was not possible for these children to establish a sense of continuity with the world, which cannot be creatively appropriated by them and seen as a pleasant place to live. A personal sense of existence cannot be constituted, and the sensation is that there is a difficult space to transpose between themselves and the world, resulting in withdrawal that can reach very serious levels (cases 1, 2 and 4). In these circumstances, due to the deprivation suffered, the children remain in a dependent relationship with their mothers, hoping to find the illusory provision that they lack, which is also encouraged by the mother. However, the extension of the period of symbiosis alters the quality of the bond to foster autonomy; therefore the child's difficulties persist.

The presence of this gap between himself and the world compromises the child's capacity for transitionality and make-believe, and thus for symbolization. Any attempt to get close is interpreted as invasion and fulfilling their demands as submission; hence, relationships are experienced as a "war of forces" between the child and the environment, which intensifies in situations where it is necessary to have limits imposed by an authority figure (cases 1, 2 and 4). This gap between the self and the other is further aggravated by the difficulties of relationships that exist in the family group, which is full of conflicts (cases 1, 2, 3 and 4) or, even worse, composed of people who are physically together, but do not relate to each other (cases 1 and 2). Thus, the real, genuine encounter cannot be established, and the child's creative gesture does not find the necessary resistance to be humanized, being lost in the vacuum or smothered, a situation that could compromise the personalization and development of a sense of corporeity. In this context of divergence, all the children reported difficulties in enjoying moments of pleasure and relaxation with the mother, seen as presenting limitations to relax and play. The failure of the mother to mold herself to the object and to the creative gesture of the child is understood by the child as the result of a possible depression of the mother, who is perceived as fragile and very susceptible to destabilization in the face of the aggressiveness directed towards her. The childhood aggression cannot then be humanized or controlled, and reparative capacities do not develop.

Considering this unfavorable picture of emotional development, in all cases the children still seem to seek a relationship capable of offering them the experiences of illusion and access to transitionality that they lack, and when they can obtain them, however scarce and insufficient, they try to help the mother to learn to play (cases 2 and 3). Unfortunately, as the mother is refractory to these efforts, the child develops a deep sense of impotence. The children's difficulties in achieving transitional experiences thus appear to be sustained by experiences of deprivation that they experience directly or indirectly through the direct loss of the people who offered them holding or by a deprivation suffered by the mother that degrades the emotional world and the bond with her child (cases 2, 3 and 4). The impact of these deprivations differs according to the level of emotional development the child has attained, and may lead to anguish of annihilation (cases 1 and 4) resulting from voracious attacks on the object as responses to the deprivation suffered, with attempts to repair them and with the fear of retaliation.

Faced with these emotional and family dynamics, the child remains paralyzed in a relationship of dependence with the mother, in a frustrated hope of finding the experience necessary to thaw the blocks to his emotional development. If, by chance, he is able to overcome this immobilization by seeking another object from the outside world that is able to help him in this overcoming, he will still have to face the resistance of a mother who does not tolerate being replaced (cases 1, 3 and 4) nor symbolized.

 

Conclusion

The results indicate that the children participating in this study revealed that the inattentive and hyperactive behaviors they present are related to a smothering and to a disregard of the creative gesture that promotes and sustains the emotional connection with the world. Thus, the bond with the world makes no sense to them, and the fulfillment of their demands is experienced as an invasion. In such conditions, the ability to experience transitionality, play and symbolization cannot develop. Although all the children continued to strive to find an object within or outside their family to repair the lack of holding received, success in this endeavor requires overcoming the resistances of the mothers, who demand the continuation of a bond of symbiotic dependence. Accordingly, the results of this study suggest that psychotherapeutic monitoring, for the mother and the family members and for the child, would be an ideal way to alleviate the child's symptoms, so that he can regain his creative capacity to act spontaneously in the world.

Regarding the research method, the CAT-A proved to be quite fertile as a dialogic mediator, and stresses the scope of this instrument as a facilitator of communication between interviewer and interviewee. The topicality of the Winnicottian theory and its relevance could also be observed. Although arisen from a different historical moment, Winnicott's ideas have proved to be an important resource for reflecting on current issues. This is the case of ADHD, a disorder that seems to be under construction, as it has undergone changes in its nomenclature. New studies are frequently published regarding the etiology, diagnosis and treatment of this disorder, with it currently being one of the best-known neurodevelopmental disorders in childhood, due to its high prevalence.

This study, which encompasses psychoanalysis and ADHD, highlights the importance of understanding the context in which the family is inserted in the emergence or maintenance of this disorder, provided that it goes beyond the mere consideration of the parenting styles and practices in its etiology, in order to emphasize the experience and the meaning of this emotional difficulty for each child and their family. Assuming that emotional development always occurs in a relational context, Winnicott's theory, which shares the same assumption, and was used as a theoretical framework, proved to be appropriate for the interpretation of the results, in collaboration with new studies that use the Winnicottian theory or other approaches to thinking about ADHD and other pathologies.

It is hoped that this work will be an incentive for the perception of how psychoanalysis can contribute to the comprehension and treatment of ADHD. Because this was a qualitative study that sought to comprehend the experience, the clinical event, the objective was not, therefore, to exhaust the possibilities of discussion. Thus, there is still much to be explored in view of the richness of the encounter with the participants of this study. For this reason, other studies, such as understanding ADHD in girls, in young people and in adults, can be conducted and may contribute.

 

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Recebido em 17 de maio de 2018
Aceito para publicação em 10 de setembro de 2018

 

 

Este artigo é um recorte da pesquisa de mestrado intitulada "A experiência materna e o desenvolvimento do Self de crianças com Transtorno de Déficit de Atenção/Hiperatividade", de Ana Paula Mucha, realizada em 2017 na Faculdade de Filosofia, Ciências e Letras de Ribeirão Preto, Universidade de São Paulo, com financiamento do CNPq (Conselho Nacional de Desenvolvimento Científico e Tecnológico).