Forschungsfeld 1

Frankfurt ADHD and ODD Effectiveness Study

Project:
Frankfurt ADHD and ODD Effectiveness Study
Which children do benefit from psychoanalytic or behavioral/medical treatment most? A naturalistic, controlled ongoing study – brief description
 

Although research has been conducted in the pharmacological and behavioural treatment of attention deficit/ hyperactivity disorder (ADHD) over the past decade, the empirical evidence for the differential effectiveness of psychoanalytic treatment has not yet been sufficiently studied. Between 2003 and 2006 the Sigmund-Freud-Institute, in cooperation with the Institute for Psychoanalytic Treatments of Children and Adolescents, conducted the Frankfurt Prevention Study (FPS). The FPS demonstrated that a two-year psychoanalytic (non-psychopharmacological) prevention and intervention program in Kindergarten resulted in a statistically significant decrease in ADHD symptoms, such as aggressive and impulsive behavior (Leuzinger-Bohleber et al. 2006, 2006a, 2007, Staufenberg 2011).

Recognizing the FPS-indicated benefits of psychoanalytic treatment for ADHD children, and the opportunity to deepen established research in collaboration with child analysts in Frankfurt, the Frankfurt ADHD and ODD Effectiveness Study was initiated in 2006.

 

Recruitment of research subjects, research sample and controls

a) Participants
In the Frankfurt ADHD Effectiveness Study, 102 children with ADHD or ODD participated  in different treatments: Psychoanalytic treatment: N = 34, mean age = 7.21, SD = 1.91; cognitive-behavioral/medical treatment N =24, mean age = 8.52, SD = 1.70 ; standard treatment N = 27, mean age = 8.75, SD = 1.68; untreated control group N =17, mean age = 6.29, SD = 0.470.

Participants met ICD-10 criteria (International Classification of Diseases, WHO, 2010) for ADHD (F90.1 Hyperkinetic disorder associated with conduct disorder; F90.0 Disturbance of activity and attention) or for ODD (F 91.3 Oppositional defiant disorder) as determined by parent interviews and teacher reports, using the Diagnostic System for Mental Disorders in Children and Adolescents (DISYPS-KJ, Döpfner & Lehmkuhl 2003), and using child assessment instruments.

All patients’ files were reviewed independently by two licensed psychologists (M.L.B and B.G). Furthermore, the diagnostic process was controlled for the psychoanalytic treatment group and for the behavioral/medial treatment group, using two independent researchers (I.W. and A.C.) who completed the DISYPS-KP checklist during each parent interview. Thereby, an interrater reliability = .97 was assured.  Exclusion criteria included autistic behavior and mood disorders, anxiety disorders, pervasive developmental disorders (< 75 IQ) and schizophrenia. Data collection began in 2006 and continued for nearly four years.

b) Design, research sample and controls
The effectiveness of long-term psychoanalytic treatment in children with ADHD or ODD children was investigated using a prospective, controlled design. The children, meeting the ICD-10 criteria for ADHD or ODD, were allocated, according to their first contact, to the intervention group (psychoanalytic treatment) or to one of the control groups (a. behavioral/medical treatment, b. standard treatment, c. untreated control group). This means that if parents first consulted a psychoanalyst or the psychoanalytic outpatient clinic, the child was assigned to the psychoanalytic treatment group.

Psychoanalytic treatment. In accordance with the manual for psychoanalytic treatment (Staufenberg, 2011), psychoanalytic treatment was conducted by a psychoanalyst in private practice. Usually, children in psychoanalytic treatment saw the therapist twice a week, for  2 years on average. Parents saw the therapist once in two weeks.

Control group a) behavioral/medical treatment. Children within the behavioral/medical treatment group attended either a six-week attention and concentration training program (Marburger Konzentrationstraining, Krowatschek, Albrecht & Kowatschek, 1990) meeting once a week for two hours, accompanied by a parent training program, or they attended a two-week anti-aggression training program that took place in the hospital, daily from 8 AM to 7 PM (Anti-Aggression training, Grasmann & Stadler, 2008). At the beginning, children in the behavioral/medical treatment group were examined and diagnosed by a psychiatrist and medicated accordingly, if needed.

Control group b) Treatment As Usual (TAU). This treatment refers to a low-frequency child psychiatric treatment that includes parent counseling and optional medication, ergotherapy, social training and parents’ management-training.

Control group c) untreated control group. The untreated control group was selected from the untreated control group of the Frankfurt Prevention study.

c) Procedure
Participants within the psychoanalytic treatment group were screened after completing the probatory sessions with the analyst. The children and parents were then invited to the Sigmund-Freud-Institute, for further assessment. Consequently, each child who had met the criteria for ADHD or ODD (as described above) was recruited for psychoanalytic treatment. The same procedure was applied to recruitment for behavioral/medical treatment and for standard treatment. In each family, parents and child were invited to the Sigmund-Freud-Institute for assessment at three measurement thresholds: pre-measurement, post-measurement and follow-up measurement, one year after finishing treatment. Furthermore, parents, children and teachers were asked to complete questionnaires semi-annually.


Ethical safeguards, instruments and estimated end of data collecting

a) Ethical safeguards
All regulations in the Declarations of Helsinki, Hong Kong and their subsequent modifications have been adhered to in the Frankfurt ADHD Effectiveness Study. Every family has received information in regard to initial evaluation, criteria of acceptance, forms of treatment, audio taped recordings, and the examinations taking place during and after the treatment. Prior to the use of data towards the study protocol, all participating patients  signed an informed consent form after receiving extended informational briefings. Each patient was advised of the right, at any time and without further explanation or disadvantage, to terminate his/her participation in the study, with the possibility of continued individual treatment guaranteed by the cooperating institutions. The approval of the local ethics commissions (of the State of Hessen) were received.

b) Outcome instruments
Diagnostic System for Mental Disorders in Children and Adolescents (DISYPS-KP, Döpfner & Lehmkuhl, 2003). The DISYPS-KP – Diagnostic System for mental Disorders in Children and Adolescents – consists of different types of data: a parental questionnaire (that can be used as a structured parent interview), a teacher questionnaire and a self-reporting questionnaire (for children aged 11-18). The clinical assessment is performed by clinicians and psychological professionals using the DISYPS-KP checklists for ADHD and ODD which are related to the stipulated in  DSM-IV and ICD-10.

Conners Teacher Rating Scale. The Conners Teacher Rating Scale (CTRS-S) (Conners, 2001) includes four subscales: Hyperactivity, Attention Deficit, Conduct-Problem, and ADHD-Index. The CTRS-S has been found to be sensitive to changes in children with ADHD before and after (medical) treatment in the general school-age population (e.g., Pearson et al., 2003).
Conners Parent Rating Scale. The Conners Parent Rating Scale (CPRS-S) (Conners, 2001) includes four subscales: Hyperactivity, Attention Deficit, Conduct-Problem, ADHD-Index. The CTRS-S has been found to be sensitive to changes in children with ADHD before and after (medical) treatment in the general school-age population (e.g., Pearson et al., 2003).

c) Further instruments
Children were examined by use of different questionnaires and psychological tests.  Intelligence was assessed using the Culture Fair Test, CFT-20R (Weiß, 2008). The child’s behavior during examination was reported by the observation questionnaire “behavior during examination” (VWU, Döpfner, Schurmann & Frölich 1998). Using the “d2 Test of attention” (Brickenkamp & Zillmer, 1998), we obtained a consistent and valid measure of visual scanning accuracy and speed. Furthermore, we applied the projective “Schweinchen-Schwarzfuss Test” as a psychoanalytically proven instrument for children. This narrative story stem test, including 17 cards with black and white drawings, features a little pig with a black foot as the main character (Corman, 1995). The test was tape recorded and transcribed, permitting the researchers to consider the inner psychic states and fantasies of the child.
Moreover, the Inventory for the Assessment of the Quality of Life in Children and Adolescents, ILK (Mattejat, 2006) was completed by children as well as by parents and therapists. The ILK addresses seven different areas of life such as school, family and friendship, and provides the opportunity to compare the different perspectives. 
Regarding the assessment of children with ADHD and ODD, comorbidity is an important issue (e.g. Biederman et al., 2010, Germano et al., 2010). In order to further assess the children’s comorbidity, parents and teachers were requested to complete the Child Behavior Checklist and the Teacher Report Form, respectively (Achenbach, 1991, Arbeitsgruppe Deutsche Child Behavior Checklist 1998).
Primary data included a questionnaire of behavior that provides information about the first years of life, personal disease history, and family history (Englert, Jungmann, Lam, Wienand & Poustka, 1998).

d) Estimated end of data collection
Due to the long term psychoanalytic treatment and a follow-up measurement one year after the end of treatment, data collection will probably be completed in December 2012.

 

Literature

Achenbach, T. M. (1991). Integrative Guide to the 1991 CBCL/4-18, YSR, and TRF Profiles. Burlington, VT: University of Vermont, Department of Psychology.

Adam, C./ Döpfner, M./ Lehmkuhl, G. (2002): Der Verlauf von Aufmerksamkeitsdefizit-/ Hyperaktivitätsstörung (ADHS) im Jugend- und Erwachsenenalter. In: Kindheit und Entwicklung, Jg. 11, H. 2: 73–81.

Arbeitsgruppe Deutsche Child Behavior Checklist (1998): Elternfragebogen über das Verhalten von Kindern und Jugendlichen; deutsche Bearbeitung der Child Behavior Checklist (CBCL/4-18). Einführung und Anleitung zur Handauswertung. 2. Auflage mit deutschen Normen, bearbeitet von M. Döpfner, J. Plück, S. Bölte, K. Lenz, P. Melchers & K. Heim. Köln: Arbeitsgruppe Kinder-, Jugend- und Familiendiagnostik.

Arbeitsgruppe Deutsche Child Behavior Checklist (1993): Lehrerfragebogen über das Verhalten von Kindern und Jugendlichen; deutsche Bearbeitung der Teacher’s Report Form (TRF) der Child Behavior Checklist. Einführung und Anleitung zur Handauswertung, bearbeitet von M. Döpfner & P. Melchers. Köln: Arbeitsgruppe Kinder-, Jugend- und Familiendiagnostik.

Barkley, R. (1997). AD/HD and the Nature of Self-control. New York: Guilford Press.

Biederman J, Petty CR, Clarke A, Lomedico A, Faraone SV. Predictors of persistent ADHD: An 11-year follow-up study. J Psychiatr Res. 2010 Jul 23. [Epub ahead of print] PubMed PMID: 20656298.

Brickenkamp, R. & Zillmer, E. (1998). The d2 Test of Attention. (1st US ed.). Seattle, WA: Hogrefe & Huber Publishers.

Conners, C. K. (2001). Conners’ Rating Scales- Revised. Technical Manual. Instruments for use with Children and Adolescents. New York, Toronto: Multi-Health Systems Inc.

Corman, L. (2006): Der Schwarzfuß-Test. Grundlagen, Durchführung, Deutung und Auswertung. 3. Auflage. Basel: Ernst Reinhardt Verlag.

Döpfner, M., Schürmann, S., Frölich, J.: Therapieprogramm für Kinder mit hyperkinetischem und oppositionellem Problemverhalten THOP: Materialien für die klinische Praxis. Weinheim: Beltz, 1998.

Döpfner, M. & Lehmkuhl, G. (2003). Diagnostik-System für psychische Störungen im Kindes- und Jugendalter nach ICD-10 und DSM-IV (DISYPS-KJ). 2. korr. und erg. Auflage. Bern: Verlag Hans Huber.

Englert, E./ Jungmann, J./ Lam, L./ Wienand, F./ Poustka, F. (1998): Basisdokumentation Kinder- und Jugendpsychiatrie (BADO) im Auftrag der Kommission Qualitätssicherung DGKJP/BAG/BKJPP.

Germano E, Gagliano A, Curatolo P. Comorbidity of ADHD and dyslexia. Dev Neuropsychol. 2010 Sep;35(5):475-93. PubMed PMID: 20721770.

Gilmore, K. (2002). ‘Diagnosis, dynamics, and development: Considerations in the psychoanalytic assessment of children with AD/HD’. Psychoanalytic Inquiry, 22: 372–391.

Grasmann, D. &  Stadler, C. (2008). Verhaltenstherapeutisches Intensivtraining zur Reduktion von Aggression. Multimodales Programm für Kinder, Jugendliche und Eltern. Wien, New York: Springer.

Laezer, K. L./ Gaertner, B./ Brand, T./ Leuzinger-Bohleber, M. (2009): Hyperaktive Kinder - eine Herausforderung für die Kinderpsychotherapie. Erster Bericht aus einer laufenden Therapiewirksamkeitsstudie. In: Analytische Kinder- und Jugendlichen-Psychotherapie, Jg. XL., H. 4, S. 557–594.

Laezer, K. L., Gaertner, B., Werner, I., Weisenburger and  Leuzinger-Bohleber, M. (2010): Therapievergleichsstudie von psychoanalytischen und kognitiv-verhaltenstherapeutisch/medikamentösen Behandlungen von hyperaktiven Kindern. Poster presented at the Joseph Sandler Research Conference, February, 2010.

Lehmkuhl, G., and Döpfner, M. (2006). ‘Die Bedeutung multimodaler Therapieansätze bei Kindern mit Aufmerksamkeitsdefizit- / Hyperkativitätsstörungen’. In: Leuzinger-Bohleber, M., Brandl, Y., and Hüther, G. (eds). ADHS – Frühprävention statt Medikalisierung: Theorie, Forschung, Kontroversen. Göttingen: Vandenhoeck & Ruprecht. pp. 118–133.

Leuzinger-Bohleber, M., and Pfeifer, R. (2002). ‘Remembering a depressive primary object? Psychoanalysis and Embodied Cognitive Science: A dialogue on memory’. International Journal of Psychoanalysis, 83: 3–33.

Leuzinger-Bohleber, M., Dreher, A. U., and Canestri, J. (eds). (2003). Pluralism and Unity? Methods of Research in Psychoanalysis. London: IPA.
Leuzinger-Bohleber, M., and Pfeifer, R. (2006a). ‘Recollecting the past in the present: Memory in the dialogue between psychoanalysis and cognitive science’. In: Mancia, M. (ed.). Psychoanalyis and Neuroscience. Milano: Springer. pp. 63-95.

Leuzinger-Bohleber, M., Brandl, Y., and Hüther, G. (eds) (2006). ADHS – Frühprävention statt Medikalisierung: Theorie, Forschung, Kontroversen. Göttingen: Vandenhoeck & Ruprecht.

Leuzinger-Bohleber, M., Brandl, Y., Hau, S., Aulbach, L., Caruso, B., Einert, K.-M., Glindemann, O., Göppel, G., Hermann, P., Hesse, P., Heumann, J., Karaca, G., König, J., Lendle, J., Rüger, B., Schwenk, A., Staufenberg, A., Steuber, S., Uhl, Ch., Vogel, J., Waldung, Ch., Wolff, L., and Hüther, G. (2006). ‘Die Frankfurter Präventionsstudie. Zur psychischen und psychosozialen Integration von verhaltensauffälligen Kindern (insbesondere ADHS) im Kindergartenalter – ein Arbeitsbericht’. In: Leuzinger-Bohleber, M., Brandl, Y., and Hüther, G. (eds). ADHS – Frühprävention statt Medikalisierung: Theorie, Forschung, Kontroversen. Göttingen: Vandenhoeck & Ruprecht. pp. 238–269.

Leuzinger-Bohleber, M., Staufenberg, A., and Fischmann, T. (2007). ‘ADHS – Indikation für psychoanalytische Behandlungen? Einige klinische, konzeptuelle und empirische Überlegungen ausgehend von der Frankfurter Präventionsstudie’. Praxis der Kidnerpsychologie und Kinderpsychiatrie, 56: 356–385.

Krowatschek, D., Albrecht, S. & Krowatschek, G. (2004). Marburger Konzentrationstraining (MTK) für Schulkinder. Verlag Modernes Lernen. Borgmann Media.

Mattejat, F. & Remschmidt, H. (2006). Inventar zur Erfassung der Lebensqualität bei Kindern und Jugendlichen(ILK). Ratingbogen für Kinder, Jugendliche und Eltern. Bern: Verlag Hans Huber, Hogrefe AG.

Pearson D. A., Santos C. W., Roache J. D., Casat C. D., Loveland K. A., Lachar D., Lane D. M., Faria L. P., Cleveland L.A. (2003). Treatment effects of methylphenidate on behavioral adjustment in children with mental retardation and ADHD. In: J Am Acad Child Adolesc Psychiatry. Feb;42(2):209-16.

Staufenberg, A. (2011). Psychoanalytische Behandlungen von hyperaktiven Kindern. Eine Katamnesestudie, Frankfurt: Brandes u. Apsel
Weiß, R. (2006). Grundintelligenztest Skala 2 (CFT 20-R) Göttingen: Hogrefe-Verlag.

Zabarenko, L. M. (2002). ‘AD/HD, Psychoanalysis and neuroscience: A survey of recent findings and their applications’. Psychoanalytic Inquiry, 22: 412–432. 
 

Contact

Principal investigators

Katrin Luise Laezer,  PhD
University Kassel, Faculty of Human Science (FB 01)
Institute for Psychoanalysis
Sigmund-Freud-Institut
Beethovenplatz 1-3
D-60325 Frankfurt am Main, Germany
Laezer@sigmund-freud-institut.de

Marianne Leuzinger-Bohleber, Prof. PhD
Director of the Sigmund-Freud-Institute in cooperation with
University Kassel, Faculty of Human Science (FB 01)
Institute for Psychoanalysis
Sigmund-Freud-Institut
Beethovenplatz 1-3
D-60325 Frankfurt am Main, Germany
Tel: +49 (0)69 971204-147
Fax +49 (0)69 971204-150
M.Leuzinger-Bohleber@sigmund-freud-institut.de


Co-Prinicipal Investigators:

Birgit Gaertner, Prof. PhD
Fachhochschule Frankfurt am Main, University of Applied Science
Nibelungenplatz 1
60318 Frankfurt am Main, Germany
Tel: +49 (0)69 15330
Fax: +49 (0)69 1533-240
Gaertner@fb4.fh-frankfurt.de

Angelika Wolff
Former Chair of the
Institute für Analytical Child and Adolescent Therapies
Privat practice:
Eppsteiner Str. 38
60323 Frankfurt am Main, Germany
Tel: +49 (0)69 728590
angelika.wolff@ikjp.de