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Psychodramatic group psychotherapy as a parental intervention in attention deficit hyperactivity disorder: A preliminary study
The Arts in Psychotherapy 41 (2014) 233–239
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The Arts in Psychotherapy
Psychodramatic group psychotherapy as a parental intervention in attention deficit hyperactivity disorder: A preliminary study Pınar Vural, M.D. a,∗ , Cengiz Akkaya, M.D. b , Ilker Küc¸ükparlak, M.D. c , Ilker Ercan, PhD. d , Nevin Eracar, PhD. e a
Department of Child and Adolescent Psychiatry, Faculty of Medicine, Uludag University, Bursa, Turkey Department of Psychiatry, Faculty of Medicine, Uludag University, Bursa, Turkey c Izzet Baysal Mental Health Hospital, Bolu, Turkey d Department of Biostatistics, Faculty of Medicine, Uludag University, Bursa, Turkey e Faculty of Education, Marmara University, Istanbul, Turkey b
a r t i c l e
i n f o
Article history: Available online 12 March 2014 Keywords: ADHD Mother–child interaction Child psychiatry Parenting
a b s t r a c t It is already known that clinical attention deficit hyperactivity disorder (ADHD) is affected by some negative parenting variables. The aim of this study was to investigate the effects of psychodramatic group psychotherapy (PGP) on parenting variables. The study group included seven mothers whose children had been diagnosed with ADHD and were attending a special education and rehabilitation center. Twelve PGP sessions, one per week, were conducted with these mothers. Participants’ statements were recorded at each session, and these statements were evaluated to indicate basic parental variables, namely: parental psychopathology, negative parental cognitions, negative parental attitudes, family functionality–marital conflict, and parental stress. The statistical study revealed that statements indicating parental psychopathology and negative parental attitudes showed a statistically significant negative correlation with time. Qualitative data indicate mothers stigmatization, self-stigmatization and harsh punishment toward the children. Parental psychopathology and negative parental attitudes are two parental factors that are known to have a negative impact on the clinical status of ADHD, and PGP might be effective in improving these two factors. © 2014 Elsevier Ltd. All rights reserved.
Introduction Attention deficit hyperactivity disorder (ADHD) is one of the most frequent pediatric disorders; its symptoms (including inattention, hyperactivity, and impulsivity) appear before age seven (American Psychiatric Association, 2000). It has a worldwide prevalence of 5–8% and a national prevalence of 8.1% Turkey (Biederman, Newcorn, & Sprich, 1991; DiScala, Lescohier, Barthel, & Li, 1998; Ersan, Do˘gan, Do˘gan, & Sümer, 2004). It has been found that children with ADHD are prone to psychical injuries, including bicycle accidents, head trauma, or injuries to multiple body regions, as well as psychiatric comorbidity such as specific learning disabilities, conduct disorders, and mood and anxiety disorders (Biederman et al., 1991; DiScala et al., 1998). It is also well known that ADHD affects many aspects of the child’s life, exacerbating academic
∗ Corresponding author at: Uludag Universitesi Tip Fakultesi Cocuk ve Ergen Psikiyatri Klinigi, 16059 Bursa, Turkey. E-mail address: [email protected] (P. Vural). http://dx.doi.org/10.1016/j.aip.2014.02.004 0197-4556/© 2014 Elsevier Ltd. All rights reserved.
difficulties and social problems that persist into adulthood in as many as 30–60% of cases. Such individuals might experience problems like being fired from jobs, more frequent divorce, and a significantly increased risk of and drug and substance use (Johnston & Mash, 2001; Harpin, 2005). For these reasons, ADHD should be discussed comprehensively. Genetic factors have an important role in ADHD etiology. Family, twin, and adoption studies have shown that it is highly heritable (Stergiakouli & Thapar, 2010). However, considering that monozygotic concordance rates of ADHD do not approach 100%, and up to 50% of children with ADHD do not show the biological abnormalities that are assumed to be inherited. Johnston and Mash (2001) have indicated that environmental factors can also cause a predisposition to this disorder. Researchers have observed that familial risk factors may increase and maintain the symptoms of ADHD; however, a responsive and sensitive family environment provides an opportunity for the child to develop self-regulation skills, and might help in reducing or even eliminating the symptoms of ADHD, even for children with a genetic predisposition to this disorder.
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A literature review reveals that the basic parenting variables that are known to be associated with the clinical course of ADHD have been researched in relation to major topics including parental psychopathology, negative parental cognitions (NPC), negative parental attitudes (NPA), family functionality–marital conflict (FF–MC), and parental stress (Chronis, Chacko, Fabiano, Wymbs, & Pelham, 2004; Modesto-Lowe, Danforth, & Brooks, 2008; Wells et al., 2000). Parental psychopathology There are numerous findings for depressive symptoms of parents of children with ADHD (Chronis et al., 2004). These parents have increased rates of anxiety disorders, stimulant/cocaine dependence, drinking problems, and childhood ADHD relative to parents of children without ADHD (Chronis, Lahey, Pelham, Kipp, Baumann, & Lee, 2003; Tzang, Chang, & Liu, 2009). Regarding the genetic nature of the disorder, it is not surprising that up to 25% of children with ADHD will have a parent suffering from ADHD (Faraone & Biederman, 1997). It has also been reported that parenttraining programs might not be effective on child ADHD when mothers display substantial levels of ADHD symptoms (SonugaBarke, Daley, & Thompson, 2002). Parent psychopathology might be considered as a factor that could worsen child outcomes, as it is known that parents with psychiatric disorders spend less time with and show less affection to their children, provide poorer supervision, use harsher punishments, inconsistently reinforce rules, and argue with partners about child management issues (Cunningham, 2007). Negative parental cognition Johnston and Freeman (1997) reported that parents of children with ADHD evaluated inattentive-overactive and oppositional defiant behaviors as more internally caused, less controllable by the child, and more stable; furthermore, they had more negative reactions to such behaviors. It has also been indicated that parents of children with ADHD may have trouble accepting the diagnosis of ADHD, have dilemmas regarding that the behaviors of the child may have resulted from a normal developmental period, have concerns about the reliability of medication, worry that the treatment may change the personality of their children, blame themselves for the status of their children, and be anxious about the inhibitory effects of the drugs on the learning ability of their children or the addiction risk of treatment (Charach, Skyba, Cook, & Antle, 2006). Negative parental attitudes Cross-cultural studies have emphasized that parents of children with ADHD have much more parental stress, and as a result, their parenting patterns are characterized by more controlling, disapproving, overreacting, dissatisfied, criticizing, strict, interfering, inconsistent, and less rewarding attitudes. It is also reported that they are more insensitive to the requirements of their children and use psychical discipline methods more frequently. It is claimed that poor parental skills may exacerbate children’s self-control deficits and contribute to the development of additional disruptive disorders that worsen ADHD outcomes (Modesto-Lowe et al., 2008). Family functionality and marital conflict Several studies have indicated that parents of youth diagnosed with ADHD in childhood were more likely to divorce and had a shorter latency to divorce than parents of children without ADHD. These findings might be associated with the fact that children’s destructive behaviors increase the marital stress of the parents
(Barkley, Fischer, Edelbrock, & Smallish, 1990; Wymbs et al., 2008). The severity of disruptive child behavior (e.g., oppositional defiant disorder/conduct disorder) increases the risk of marital dissolution. It is already known that ADHD may contribute to the deterioration of family functions. It has been emphasized that this deterioration might be associated with the increased housing expenses of families and substantial healthcare and work loss costs (Barkley et al., 1990; Modesto-Lowe et al., 2008). Marital conflicts trigger anxiety in children. There are sectional studies revealing the biological signs (electrodermal responses, cortisol levels, and sleep quality and duration) of this anxiety. This effect is believed to be mediated by emotional insecurity (El-Sheikh, Buckhalt, Mark Cummings, & Keller, 2007). In addition to this, it has been found that destructive marital conflict is negatively related to children’s emotional security and prosocial behavior, as assessed by parent and teacher ratings (McCoy, Cummings, & Davies, 2009). These findings indicate a reciprocal interaction between family functioning and the clinical course of ADHD. Parental stress It is well known that children with ADHD are less compliant with their parents, sustain their compliance for shorter time periods, are less likely to remain on task, and display more negative behaviors, leading their parents to be vulnerable to more parental stress (Wells et al., 2000). Psychodrama is a method for exploring psychological and social problems by having participants enact the relevant events in their lives (taking roles) instead of simply talking about them (Blatner, 2000). It may be defined as a way of practicing living without being punished for making mistakes. As the personal representation of truth by the protagonist can be eye-opening for someone else watching, J.L. Moreno, who founded psychodrama in Vienna in the early 1900s, described it as a scientific exploration of truth through dramatic method (Tauvon et al., 1998). Spontaneity and creativity are necessary for being able to take roles and interact, so a standard psychodrama session begins with a warm-up stage to stimulate spontaneity. After warming up, two of the many techniques that can be used in the action stage are role reversal and doubling. Role reversal occurs when the protagonist of the drama switches roles and positions with a person playing another role on the stage. This technique helps people to develop empathy, a deeper understanding of the situation, and gain insight. Doubling is when one of the group members acts as the protagonist’s auxiliary ego and expresses his or her unexpressed thoughts and feelings. Sessions end after the sharing stage, where group members share their feelings about the scene and past experiences related to it (Garcia, 2010). Methods Participants Samples were collected via an announcement at a special education and rehabilitation center affiliated with The Institution of Social Services and Child Protection. Mothers with children who had been diagnosed as ADHD, were between 6 and 11 years old, and were primary school 1st to 5th class students were included. Among these, seven consecutive volunteers were accepted for the study. Diagnostic evaluation was carried out by one of the authors, who is a child and adolescent psychiatrist, considering the criteria for attention deficit and disruptive behavior disorders in DSM IV. The DSM IV based Disruptive Behavior Disorders Screening and Rating Scale (DBD-STS), which has been found to have validity and
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reliability in Turkish, was applied in order to support the diagnosis (Durukan et al., 2008). Mothers of children with clinically diagnosed mental retardation or other chronic disorders, mothers under psychiatric medication, or illiterate mothers were not accepted for the study. Other disruptive behavior disorders (DBD) accompanied with ADHD were not considered as an exclusion criterion. Before the beginning of the study, each mother was informed about the group study and each was required to give written approval.
Table 1 Samples of attendants’ statements assessed as parenting variables affecting clinical adhd. Parental psychopathology
NPC NPA
FF–MC
Procedure Psychodramatic group psychotherapy (PGP) was carried out with mothers of children with ADHD started in December of 2007. It continued weekly for 12 weeks and each session was 120 min long. The PGP aimed revealing basic parenteral variables that are known to be associated with the clinical course of ADHD, participants gaining insight and improving coping skills over these points. In this study, classical techniques of psychodrama were utilized. Since psychodrama is inherently spontaneous, it was impossible to structure the sessions strictly, and themes to be handled in sessions were determined considering the group’s requirements each week. Each session started with feedback from the last session and ended with group members talking about the group study of that day. Psychodramatic techniques, session aims and participants responses are presented in Appendix A. Sessions were managed by a drama therapist educated in a national psychodrama institution and an assistant therapist, under the supervision of a certified trainer. PGP process The first session started with therapist and co-therapists introducing themselves, followed by a short introduction to psychodrama and basic rules. The introduction proceeded through the PGP process in occasion. Instruction to the attendants for imagination over themselves was made, and the attendants were matched as pairs randomly. Each one of the pairs introduces her to other uninterrupted for 5 min. Then this meeting is replayed with two chairs and role reversal techniques. There were two group plays over a scenario including a child with ADHD in the second session. Role feedbacks and sharing stage revealed significant burden, anger, impatience and overexpectations about the children. The therapist encouraged the group for their sincereness. Another important theme of sharing stage was fathers carrying less burden. As the second session bringed out self blame, the third one was structured for aiming self representations to hold the group. In that session the attendants select objects representing themselves and detailed the reasons for their selection mostly revealed negative self representations (listed in Appendix A). Despite the negativity of self representations, signals of better coping, psychological wellness and reduced anger and corporal punishment within the PGP process were spotted at the sharing stage. Attendants shared their ideas about the useful properties of that special object in order to support each other. The fourth session was held by imagination of major life events in order to remind attendants other roles than being a mother of a child with ADHD and positive life events to install hope. Mothers one of major challenge appeared to be their childrens education. A group play over a scenario with a class including a student with ADHD was played in the fifth session. It was followed by a protagonist play over an attendants actual problem with her child’s teacher. Attendant who played protagonist gained insight over how her self-stigmatization broke down communication with the
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Parental stress
I have suspended all of my relationships. I have isolated myself. I am looking forward to being left alone and crying My child is careless and irresponsible. It must feel good for him to be carefree I feel frustrated and hit my daughter when she struggles with her homework. I am concerned with this situation because I have realized that I do not feel any regret When I ask him to stop playing, he does not obey. Then his father gets angry at me and we argue What will happen to him when I am dead? That is the main source of my anxiety
NPC: negative parental cognition, NPA: negative parental attitudes, FF–MC: family functionality–marital conflict.
teacher during the feed back of the role reversals. Group play of a cruise revealed social roles in the sixth session. Non-verbal expression of specific emotions was studied in the seventh session. Both sessions were supportive about the burden of motherhood. The eighth session was conducted with a protagonist play over an actual neighbor visit, which revealed the burden of stigmatization of being a mother of a child with ADHD. The neighbors comments about the child’s being undisciplined and questioning the existence of the ADHD phenomenon hurt the mother and urge her questioning her motherhood. Other attendants shared their opinions about the ADHD concept in a supportive manner. Charts symbolizing attendants own lives were drawn at the ninth session. The sharing revealed their insensitivity to own psychological needs. The tenth session was conducted with a protagonist play of an argument between the child with ADHD and his sibling. Attendants own sibling rivalry was revealed during the sharing stage. In the eleventh session imagination of a place felt relaxed was instructed regarding having next to the last session. Attendants again focused their own psychological needs. The last session was held with process analysis, participants verbalizing wishes for each other, which in turn instilled hope and improved self confidence. Data analysis Notes taken during the sessions were assessed independently by two investigators, who were drama therapists, one of whom was blind to hypothesis. Statements of attendants at the sharing stage were evaluated regarding whether they were indicating basic parental variables under the titles of parental psychopathology, NPC, NPA, FF–MC, and parental stress, which are known to be associated with clinical ADHD. Each statement was collected to generate a score of that title for the session. In consequence of independent assessments by two investigators, mutually agreed feedbacks were included in the statistical study as data. Statements which were not mutually agreed on were not included in the statistical study. For instance, one of the participants’ responses, “I have suspended all of my relationships. I have isolated myself. I am looking forward to being left alone and crying”, was evaluated as a sample of parental psychopathology by both of the investigators and included in the statistical study. Other samples of group participants’ statements are included in Table 1. Relations between variables in our study were analyzed with the Pearson correlation coefficient. The significance was determined as p < 0.05 in statistical comparison. The SPSS 16.0 program was used for statistical analyses.
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Table 2 Analysis of relation between time and parental variables. Time
Parental psychopathology NPC NPA FF–MC Parental stress
r
p
−0.710 – −0.697 – –
0.010* 0.341 0.012* 0.569 0.774
NPC: negative parental cognition, NPA: negative parental attitudes, FF–MC: family functionality–marital conflict. * Statically significant result.
Results Quantitative data The ADHD cases consisted of seven children, six male and one female. According to DSM IV, two of the cases were diagnosed as predominantly inattentive type, one was predominantly hyperactive impulsive type, and four were combined type. Five of the cases had comorbid oppositional defiant disorder (ODD). The children were between 8 and 12 years old. Attendant mothers were between 30 and 38 years old. All of them were primary school graduates, except for one who was a high school graduate. All of the mothers were unemployed after analyzing the relations between the time variable and parental psychopathology, NPC, NPA, FF–MC, and parental stress, only an inversely proportional highly significant relation of time with parental psychopathology and NPA was detected (Table 2). Qualitative findings The PGP process revealed that attendants social environment was suspicious about the existence of diagnostic entity of ADHD and insisted that the children’s misbehavior was a result of being poor disciplined. Most of the mothers were influenced by this thought, thus excessive amounts of self-stigmatization was observed in mothers. Many of the mothers assessed their children’s misbehavior as a result of their lack of nurturing capabilities, which in turn resulted with adopting harsher punishment methods. This probably yielded with higher levels of misbehavior of the children and desperateness of the mothers. During the PGP process mothers noticed the universality of their problems, gained empathy with their children and communication skills with their children and social environment. The PGP process instilled hope and self-confidence to them. Thus, starting from the third session signals of better coping, psychological wellness and reduced anger and corporal punishment within the PGP process were shared incrementally by the attendants. Discussion The main target of this study was to investigate the availability of PGP as a parental intervention method to normalize the interaction of mothers with their children with ADHD. Stigmatization and self-stigmatization processes, harsh punishment to the children, and burden of motherhood were major themes observed through the PGP process. One study from Turkey revealed levels of misinterpretation and stigma on ADHD did not differ on parents with or without a child with ADHD (Karabekiro˘glu et al., 2009). The same study indicated that 1/3 of the information was misinterpreting and half of them were enhancing the stigmatization on printed media. Those findings might point how social stigmatization raised self-stigmatization. Another study
from Turkey aiming to explore the long-term socialization goals of Turkish mothers revealed that low-educated mothers emphasized the importance of relatedness and obedience more than higheducated mothers; and high-educated mothers stressed autonomy and self-enhancement as desirable characteristics more than low-educated mothers did (Yagmurlu, Citlak, Dost, & Leyendecker, 2009). The attendants of our study were low educated and childrens misbehavior might demoralize them more deeply for falling far from their goals for their children. Many of the attendants adopted harsher punishment methods with desperateness, and this probably yielded with higher levels of misbehavior of the children and burden of the mothers. Maybe most importantly Günay and Bener (2011) revealed that 35% of the women in their sample from capital city of Turkey, Ankara perceived that child nurturing and discipline are primarily mothers responsibility. This ratio was significantly higher in women with lower education, lower income and without employment. As our attendants were less educated, had short monthly income, and unemployed, their statements in this direction would be quite predictable. In fact mothers gained awareness about their husbands relatively quite less burden through the PGP process. One of the findings of our quantitative work is that the feedbacks of parents regarding their own psychopathology reduce over time. It has been indicated that parents of children with combinedtype ADHD in particular show more depressive symptoms (Chronis et al., 2004). Durukan et al. (2008) also revealed higher depression and anxiety levels in mothers of children with ADHD. In a prospective study, it has been detected that depression in mothers of hyperactive children is predictive for higher levels of childhood aggression (Shin & Stein, 2008). It has also been shown that depression in mothers of children with ADHD – just like in mothers of other children – is predictive for corporal punishment, and corporal punishment in fact increases the aggressive behavior of children (Stormont-Spurgin & Zentall, 1995). In another study, it has been determined that depression of mothers and children’s feelings of inferiority and inadequacy, which cause deficiency in interpersonal relationships, are related to aggression in children with ADHD (Connolly & Vance, 2010). The finding that depression in mothers is predictive of the development of comorbid behavior disorders in children with ADHD might be interpreted in this context (Chronis et al., 2007). Therefore, the relation between parental psychopathology and ADHD might be mediated by the reduction of parental skills (Cunningham, 2007). Gerdes et al. (2007) stated that mothers who are depressive, having an external locus of control, and with less self-esteem, may evaluate themselves as being insufficient when it comes to coping with the usual difficulties of being the parent of a child with ADHD. These mothers consider that they have insufficient influence on the behaviors of their children, so they are apt to have lax parental styles. These cognitions may mediate between NPA and psychopathologies like depression. The Pelham et al. (1997) study might be found rather provoking when it comes to rethinking the causality between NPA and children with ADHD. In this study, parents were randomly assigned to interact with child actors who role played deviant children with externalizing behavior disorders, as well as normal children. The parents who interacted with problematic actors reported that they felt more inadequate, hostile, anxious, and depressed. After the study, these parents were supplied with alcohol if they wanted, and the parents who interacted with problematic children consumed significantly more alcohol. These findings have been interpreted as child’s externalization problems may directly decrease the selfesteem of parents. Another finding in our study is that the feedbacks of parents regarding NPA reduce over time. There are a few studies which suggest a relationship between NPA and ADHD. In a prospective
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study on 191 children who were followed from birth to 11 years old, caring variables of mothers were assessed twice, when the children were 6 and 42 months old. It was found that intrusive caregiving at 6 months of age and overstimulating caregiving at 42 months of age were predictive of hyperactivity at the age of 11 (Carlson, Jacobvitz, & Sroufe, 1995). The results of parental intervention on the child are also interesting. It has been detected that behavioral parental therapy is efficient when it comes to attention deficit and hyperactive-impulsive symptoms as well as social problems and violating behaviors in children (Huang et al., 2009). These findings indicate that parenting methods might interfere with the clinical course of ADHD. It is suggested that the self-regulatory deficits of children with ADHD may cause their parents to adopt more controlling and negative attitudes to compensate for the children’s deficits (Cunningham, 2007). On the other hand, Chronis et al. (2004), has emphasized the reciprocal nature of the interaction in the findings about the parenting characteristics of mothers of children with ADHD differing from others from very early periods of the children’s life, and parent intervention programs ameliorating not only children’s behavior problems, but also core symptoms of ADHD, including attention deficit and hyperactivity-impulsivity. The main finding of our research is that feedbacks of parents regarding their own psychopathology and NPA reduce in time over three months of PGP. Quantitative analysis suggested that mothers psychopathology resulted from mainly the burden of stigmatization and self-stigmatization processes, and NPA was a result of both mothers burden and stigmatization. We cannot proceed to a deeper analysis due to the similarity of participants’ socio-demographic variables. Both parental psychopathology and NPA might worsen ADHD outcomes according to the existing data from the field. Although there have been some studies in the ADHD literature in which psychodrama techniques like role playing have been used, this is the first study of PGP with parents of children with ADHD as far as we know. It appears that parental variables and clinical ADHD may show a very complicated and sometimes reciprocal interaction. Considering the nature of this interaction, opinions to the effect that family interventions in ADHD should not be restricted to parent training and should deal with parental psychopathology and stress have been gaining importance day by day (Chronis et al., 2003; Modesto-Lowe et al., 2008). Chronis et al. (2004) emphasized that each family may have different needs because of the complicated structure of this interaction, and therefore individualized
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behavioral parent training programs might be more useful. Consequently, it seems that psychodrama might fulfill all of these requirements due to its applicability for both psycho-educational and therapeutic purposes, giving the opportunity for each individual to study his/her actual problems and due to its tendency to elicit the study of interpersonal relationships (Blatner, 2000). In order to examine the relation of children with ADHD with their parents and the influence of parents on the clinical course of ADHD, various methods can be used, such as analysis of in-depth interviews (Peters & Jackson, 2009) analysis of video recordings of the child–parent interaction at home (Bor, Sanders, & MarkieDadds, 2002) or in the laboratory setting (Johnston & Jassy, 2007), sociometric analysis of children playing with their peers under their parents’ supervision in the laboratory setting (Mikami, Jack, Emeh, & Stephens, 2010) and applying scales after interaction with child actors role playing externalization problems (Pelham et al., 1997), in addition to standard procedures applied with structured scales. We have adopted an alternative method of analyzing participants’ feedbacks and classifying them into major parenting variables that interfere with clinical ADHD. There are numerous limitations in this study. The limited number of attendants can be considered the most important among these. Nevertheless, it is recommended that the number of attendants should be between 7 and 10 for the efficiency of the group therapy (Cohen & Rice, 2005). Another limitation is that participants could be evaluated for only a three-month period; long-term follow-up could not be performed. Furthermore, the results should be assessed carefully, since they were obtained only from the analysis of participants’ feedbacks. Although it is an important restriction that a scale-based evaluation was not carried out for mothers in our study, the efficiency of PGP could be evaluated better in this way, since it would prevent the awareness of mothers and any impact on spontaneity before the sessions. A control group was not available due to our methodology, which was based on the analysis of participants’ statements during sessions. Another limitation is that the possible effects of mothers’ PGP process on the clinical course of their children’s ADHD were not explored. Despite all of these limitations, to the best of our knowledge this is the first study investigating PGP in parents of children with ADHD. Comprehensive research is needed to evaluate the effect of PGP on parents of children with ADHD more clearly. Appendix A. Table A1.
Table A1 Psychodramatic techniques, Therapeutic goals and Group members responses in the Sessions. Sessions
Technique
Therapeutic goals
Group members responses
1
Introduction to psychodrama, paired matching, role reversal, two chairs, group sharing
2
Group play about a scenario including a child with ADHD, role feed back and sharing
Gaining insight about communication skills, to develop empathy skills, to build group cohesion, to introduce basic psychodrama techniques Developing empathy with their children and other figures of the family, gaining insight about feelings and actions in interacting with their children
3
Selecting an object in the room to symbolize themselves, doubling
Recognizing the difficulties in understanding the instructions, thus remembering their own attention problems through childhood by two members Recognizing their anger, impatience and overexpectations about the children, unresponsiveness about childrens’ needs; noting that father role carries relatively less burden A whiteboard eraser with two opposite sides soft and hard, a seashell with a smooth inner and rough outer surface; a stone which is hard; a flute which is noisy; an old tree model which suffered from many storms and still lonely; another stone which is durable and calm; a button which is tied and connects two sides. a Stigmatization of the child with ADHD and self-stigmatization of motherhood of the child with ADHD
Revealing self representations, interventions on negative self representations, revealing the relationship between these representations and family relations
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Table A1 (Continued ) Sessions
Technique
Therapeutic goals
Group members responses
4
Imagination of a happy and a sad moment, sharing
Remembering major life events including the childbirth and accidents, family conflicts, corporal punishment
5
Group play of a class with a child with ADHD, role feedback and sharing Protagonist play of a child’s homework problems, doubling, role reversal Protagonist play of a members dialog with her child’s teacher, role reversal, role feedback and sharing Group play of a cruise, role feedback and sharing
Indicating the existence of positive life events despite negative others, improving self efficacy by offering solutions to other members, revealing the universality of the negative feelings Developing empathy with the child, gaining awareness about their relationship with the teachers
Gaining awareness about problem solving abilities and social roles
Burden of raising a child with ADHD, depressive complaints, guilt, self-stigmatization, social exclusion Burden of motherhood, interaction between emotions of the self and the child
6
7
Expressing emotions non-verbally, sharing
8
Protagonist play of a home visit from a neighbor, role reversal, soliloquy Drawing a chart symbolizing their lives; a circle with proportions for themselves and other members of the family
9
10
11 12
a
Protagonist play of a nervous breakdown while trying to intervene an argument between siblings, role reversal, sharing Imagination of a place where they feel relaxed and comfortable, sharing Process analysis, having each participant to make a wish for each other, holding hands to create a circle and shake hands for farewell
Understanding others emotions comprehensively, gaining insight about own emotions Analyzing stigmatization processes, enhancing coping skills for stigmatization Focusing over their own psychological status
Focusing over their communicating styles
Relaxation (considering having the next to the last session) Instil hope
Difficulties of being teacher of a child with ADHD, social exclusion of the child, self-stigmatization of mothers
Gaining patience about the child’s misbehavior, inventing new solutions for specific problems Revealing how less space left for themselves in daily living, father’s less responsibility for the children, burden of motherhood of a child with ADHD Revealing their own impulsive, aggressive and punishing reactions to frustrating life events, their own sibling rivalry Need for loneliness and space Progress over gaining empathy, enhancing coping skills, self-confidence
Participants own descriptions of the objects.
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The Arts in Psychotherapy
Psychodramatic group psychotherapy as a parental intervention in attention deficit hyperactivity disorder: A preliminary study Pınar Vural, M.D. a,∗ , Cengiz Akkaya, M.D. b , Ilker Küc¸ükparlak, M.D. c , Ilker Ercan, PhD. d , Nevin Eracar, PhD. e a
Department of Child and Adolescent Psychiatry, Faculty of Medicine, Uludag University, Bursa, Turkey Department of Psychiatry, Faculty of Medicine, Uludag University, Bursa, Turkey c Izzet Baysal Mental Health Hospital, Bolu, Turkey d Department of Biostatistics, Faculty of Medicine, Uludag University, Bursa, Turkey e Faculty of Education, Marmara University, Istanbul, Turkey b
a r t i c l e
i n f o
Article history: Available online 12 March 2014 Keywords: ADHD Mother–child interaction Child psychiatry Parenting
a b s t r a c t It is already known that clinical attention deficit hyperactivity disorder (ADHD) is affected by some negative parenting variables. The aim of this study was to investigate the effects of psychodramatic group psychotherapy (PGP) on parenting variables. The study group included seven mothers whose children had been diagnosed with ADHD and were attending a special education and rehabilitation center. Twelve PGP sessions, one per week, were conducted with these mothers. Participants’ statements were recorded at each session, and these statements were evaluated to indicate basic parental variables, namely: parental psychopathology, negative parental cognitions, negative parental attitudes, family functionality–marital conflict, and parental stress. The statistical study revealed that statements indicating parental psychopathology and negative parental attitudes showed a statistically significant negative correlation with time. Qualitative data indicate mothers stigmatization, self-stigmatization and harsh punishment toward the children. Parental psychopathology and negative parental attitudes are two parental factors that are known to have a negative impact on the clinical status of ADHD, and PGP might be effective in improving these two factors. © 2014 Elsevier Ltd. All rights reserved.
Introduction Attention deficit hyperactivity disorder (ADHD) is one of the most frequent pediatric disorders; its symptoms (including inattention, hyperactivity, and impulsivity) appear before age seven (American Psychiatric Association, 2000). It has a worldwide prevalence of 5–8% and a national prevalence of 8.1% Turkey (Biederman, Newcorn, & Sprich, 1991; DiScala, Lescohier, Barthel, & Li, 1998; Ersan, Do˘gan, Do˘gan, & Sümer, 2004). It has been found that children with ADHD are prone to psychical injuries, including bicycle accidents, head trauma, or injuries to multiple body regions, as well as psychiatric comorbidity such as specific learning disabilities, conduct disorders, and mood and anxiety disorders (Biederman et al., 1991; DiScala et al., 1998). It is also well known that ADHD affects many aspects of the child’s life, exacerbating academic
∗ Corresponding author at: Uludag Universitesi Tip Fakultesi Cocuk ve Ergen Psikiyatri Klinigi, 16059 Bursa, Turkey. E-mail address: [email protected] (P. Vural). http://dx.doi.org/10.1016/j.aip.2014.02.004 0197-4556/© 2014 Elsevier Ltd. All rights reserved.
difficulties and social problems that persist into adulthood in as many as 30–60% of cases. Such individuals might experience problems like being fired from jobs, more frequent divorce, and a significantly increased risk of and drug and substance use (Johnston & Mash, 2001; Harpin, 2005). For these reasons, ADHD should be discussed comprehensively. Genetic factors have an important role in ADHD etiology. Family, twin, and adoption studies have shown that it is highly heritable (Stergiakouli & Thapar, 2010). However, considering that monozygotic concordance rates of ADHD do not approach 100%, and up to 50% of children with ADHD do not show the biological abnormalities that are assumed to be inherited. Johnston and Mash (2001) have indicated that environmental factors can also cause a predisposition to this disorder. Researchers have observed that familial risk factors may increase and maintain the symptoms of ADHD; however, a responsive and sensitive family environment provides an opportunity for the child to develop self-regulation skills, and might help in reducing or even eliminating the symptoms of ADHD, even for children with a genetic predisposition to this disorder.
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A literature review reveals that the basic parenting variables that are known to be associated with the clinical course of ADHD have been researched in relation to major topics including parental psychopathology, negative parental cognitions (NPC), negative parental attitudes (NPA), family functionality–marital conflict (FF–MC), and parental stress (Chronis, Chacko, Fabiano, Wymbs, & Pelham, 2004; Modesto-Lowe, Danforth, & Brooks, 2008; Wells et al., 2000). Parental psychopathology There are numerous findings for depressive symptoms of parents of children with ADHD (Chronis et al., 2004). These parents have increased rates of anxiety disorders, stimulant/cocaine dependence, drinking problems, and childhood ADHD relative to parents of children without ADHD (Chronis, Lahey, Pelham, Kipp, Baumann, & Lee, 2003; Tzang, Chang, & Liu, 2009). Regarding the genetic nature of the disorder, it is not surprising that up to 25% of children with ADHD will have a parent suffering from ADHD (Faraone & Biederman, 1997). It has also been reported that parenttraining programs might not be effective on child ADHD when mothers display substantial levels of ADHD symptoms (SonugaBarke, Daley, & Thompson, 2002). Parent psychopathology might be considered as a factor that could worsen child outcomes, as it is known that parents with psychiatric disorders spend less time with and show less affection to their children, provide poorer supervision, use harsher punishments, inconsistently reinforce rules, and argue with partners about child management issues (Cunningham, 2007). Negative parental cognition Johnston and Freeman (1997) reported that parents of children with ADHD evaluated inattentive-overactive and oppositional defiant behaviors as more internally caused, less controllable by the child, and more stable; furthermore, they had more negative reactions to such behaviors. It has also been indicated that parents of children with ADHD may have trouble accepting the diagnosis of ADHD, have dilemmas regarding that the behaviors of the child may have resulted from a normal developmental period, have concerns about the reliability of medication, worry that the treatment may change the personality of their children, blame themselves for the status of their children, and be anxious about the inhibitory effects of the drugs on the learning ability of their children or the addiction risk of treatment (Charach, Skyba, Cook, & Antle, 2006). Negative parental attitudes Cross-cultural studies have emphasized that parents of children with ADHD have much more parental stress, and as a result, their parenting patterns are characterized by more controlling, disapproving, overreacting, dissatisfied, criticizing, strict, interfering, inconsistent, and less rewarding attitudes. It is also reported that they are more insensitive to the requirements of their children and use psychical discipline methods more frequently. It is claimed that poor parental skills may exacerbate children’s self-control deficits and contribute to the development of additional disruptive disorders that worsen ADHD outcomes (Modesto-Lowe et al., 2008). Family functionality and marital conflict Several studies have indicated that parents of youth diagnosed with ADHD in childhood were more likely to divorce and had a shorter latency to divorce than parents of children without ADHD. These findings might be associated with the fact that children’s destructive behaviors increase the marital stress of the parents
(Barkley, Fischer, Edelbrock, & Smallish, 1990; Wymbs et al., 2008). The severity of disruptive child behavior (e.g., oppositional defiant disorder/conduct disorder) increases the risk of marital dissolution. It is already known that ADHD may contribute to the deterioration of family functions. It has been emphasized that this deterioration might be associated with the increased housing expenses of families and substantial healthcare and work loss costs (Barkley et al., 1990; Modesto-Lowe et al., 2008). Marital conflicts trigger anxiety in children. There are sectional studies revealing the biological signs (electrodermal responses, cortisol levels, and sleep quality and duration) of this anxiety. This effect is believed to be mediated by emotional insecurity (El-Sheikh, Buckhalt, Mark Cummings, & Keller, 2007). In addition to this, it has been found that destructive marital conflict is negatively related to children’s emotional security and prosocial behavior, as assessed by parent and teacher ratings (McCoy, Cummings, & Davies, 2009). These findings indicate a reciprocal interaction between family functioning and the clinical course of ADHD. Parental stress It is well known that children with ADHD are less compliant with their parents, sustain their compliance for shorter time periods, are less likely to remain on task, and display more negative behaviors, leading their parents to be vulnerable to more parental stress (Wells et al., 2000). Psychodrama is a method for exploring psychological and social problems by having participants enact the relevant events in their lives (taking roles) instead of simply talking about them (Blatner, 2000). It may be defined as a way of practicing living without being punished for making mistakes. As the personal representation of truth by the protagonist can be eye-opening for someone else watching, J.L. Moreno, who founded psychodrama in Vienna in the early 1900s, described it as a scientific exploration of truth through dramatic method (Tauvon et al., 1998). Spontaneity and creativity are necessary for being able to take roles and interact, so a standard psychodrama session begins with a warm-up stage to stimulate spontaneity. After warming up, two of the many techniques that can be used in the action stage are role reversal and doubling. Role reversal occurs when the protagonist of the drama switches roles and positions with a person playing another role on the stage. This technique helps people to develop empathy, a deeper understanding of the situation, and gain insight. Doubling is when one of the group members acts as the protagonist’s auxiliary ego and expresses his or her unexpressed thoughts and feelings. Sessions end after the sharing stage, where group members share their feelings about the scene and past experiences related to it (Garcia, 2010). Methods Participants Samples were collected via an announcement at a special education and rehabilitation center affiliated with The Institution of Social Services and Child Protection. Mothers with children who had been diagnosed as ADHD, were between 6 and 11 years old, and were primary school 1st to 5th class students were included. Among these, seven consecutive volunteers were accepted for the study. Diagnostic evaluation was carried out by one of the authors, who is a child and adolescent psychiatrist, considering the criteria for attention deficit and disruptive behavior disorders in DSM IV. The DSM IV based Disruptive Behavior Disorders Screening and Rating Scale (DBD-STS), which has been found to have validity and
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reliability in Turkish, was applied in order to support the diagnosis (Durukan et al., 2008). Mothers of children with clinically diagnosed mental retardation or other chronic disorders, mothers under psychiatric medication, or illiterate mothers were not accepted for the study. Other disruptive behavior disorders (DBD) accompanied with ADHD were not considered as an exclusion criterion. Before the beginning of the study, each mother was informed about the group study and each was required to give written approval.
Table 1 Samples of attendants’ statements assessed as parenting variables affecting clinical adhd. Parental psychopathology
NPC NPA
FF–MC
Procedure Psychodramatic group psychotherapy (PGP) was carried out with mothers of children with ADHD started in December of 2007. It continued weekly for 12 weeks and each session was 120 min long. The PGP aimed revealing basic parenteral variables that are known to be associated with the clinical course of ADHD, participants gaining insight and improving coping skills over these points. In this study, classical techniques of psychodrama were utilized. Since psychodrama is inherently spontaneous, it was impossible to structure the sessions strictly, and themes to be handled in sessions were determined considering the group’s requirements each week. Each session started with feedback from the last session and ended with group members talking about the group study of that day. Psychodramatic techniques, session aims and participants responses are presented in Appendix A. Sessions were managed by a drama therapist educated in a national psychodrama institution and an assistant therapist, under the supervision of a certified trainer. PGP process The first session started with therapist and co-therapists introducing themselves, followed by a short introduction to psychodrama and basic rules. The introduction proceeded through the PGP process in occasion. Instruction to the attendants for imagination over themselves was made, and the attendants were matched as pairs randomly. Each one of the pairs introduces her to other uninterrupted for 5 min. Then this meeting is replayed with two chairs and role reversal techniques. There were two group plays over a scenario including a child with ADHD in the second session. Role feedbacks and sharing stage revealed significant burden, anger, impatience and overexpectations about the children. The therapist encouraged the group for their sincereness. Another important theme of sharing stage was fathers carrying less burden. As the second session bringed out self blame, the third one was structured for aiming self representations to hold the group. In that session the attendants select objects representing themselves and detailed the reasons for their selection mostly revealed negative self representations (listed in Appendix A). Despite the negativity of self representations, signals of better coping, psychological wellness and reduced anger and corporal punishment within the PGP process were spotted at the sharing stage. Attendants shared their ideas about the useful properties of that special object in order to support each other. The fourth session was held by imagination of major life events in order to remind attendants other roles than being a mother of a child with ADHD and positive life events to install hope. Mothers one of major challenge appeared to be their childrens education. A group play over a scenario with a class including a student with ADHD was played in the fifth session. It was followed by a protagonist play over an attendants actual problem with her child’s teacher. Attendant who played protagonist gained insight over how her self-stigmatization broke down communication with the
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Parental stress
I have suspended all of my relationships. I have isolated myself. I am looking forward to being left alone and crying My child is careless and irresponsible. It must feel good for him to be carefree I feel frustrated and hit my daughter when she struggles with her homework. I am concerned with this situation because I have realized that I do not feel any regret When I ask him to stop playing, he does not obey. Then his father gets angry at me and we argue What will happen to him when I am dead? That is the main source of my anxiety
NPC: negative parental cognition, NPA: negative parental attitudes, FF–MC: family functionality–marital conflict.
teacher during the feed back of the role reversals. Group play of a cruise revealed social roles in the sixth session. Non-verbal expression of specific emotions was studied in the seventh session. Both sessions were supportive about the burden of motherhood. The eighth session was conducted with a protagonist play over an actual neighbor visit, which revealed the burden of stigmatization of being a mother of a child with ADHD. The neighbors comments about the child’s being undisciplined and questioning the existence of the ADHD phenomenon hurt the mother and urge her questioning her motherhood. Other attendants shared their opinions about the ADHD concept in a supportive manner. Charts symbolizing attendants own lives were drawn at the ninth session. The sharing revealed their insensitivity to own psychological needs. The tenth session was conducted with a protagonist play of an argument between the child with ADHD and his sibling. Attendants own sibling rivalry was revealed during the sharing stage. In the eleventh session imagination of a place felt relaxed was instructed regarding having next to the last session. Attendants again focused their own psychological needs. The last session was held with process analysis, participants verbalizing wishes for each other, which in turn instilled hope and improved self confidence. Data analysis Notes taken during the sessions were assessed independently by two investigators, who were drama therapists, one of whom was blind to hypothesis. Statements of attendants at the sharing stage were evaluated regarding whether they were indicating basic parental variables under the titles of parental psychopathology, NPC, NPA, FF–MC, and parental stress, which are known to be associated with clinical ADHD. Each statement was collected to generate a score of that title for the session. In consequence of independent assessments by two investigators, mutually agreed feedbacks were included in the statistical study as data. Statements which were not mutually agreed on were not included in the statistical study. For instance, one of the participants’ responses, “I have suspended all of my relationships. I have isolated myself. I am looking forward to being left alone and crying”, was evaluated as a sample of parental psychopathology by both of the investigators and included in the statistical study. Other samples of group participants’ statements are included in Table 1. Relations between variables in our study were analyzed with the Pearson correlation coefficient. The significance was determined as p < 0.05 in statistical comparison. The SPSS 16.0 program was used for statistical analyses.
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Table 2 Analysis of relation between time and parental variables. Time
Parental psychopathology NPC NPA FF–MC Parental stress
r
p
−0.710 – −0.697 – –
0.010* 0.341 0.012* 0.569 0.774
NPC: negative parental cognition, NPA: negative parental attitudes, FF–MC: family functionality–marital conflict. * Statically significant result.
Results Quantitative data The ADHD cases consisted of seven children, six male and one female. According to DSM IV, two of the cases were diagnosed as predominantly inattentive type, one was predominantly hyperactive impulsive type, and four were combined type. Five of the cases had comorbid oppositional defiant disorder (ODD). The children were between 8 and 12 years old. Attendant mothers were between 30 and 38 years old. All of them were primary school graduates, except for one who was a high school graduate. All of the mothers were unemployed after analyzing the relations between the time variable and parental psychopathology, NPC, NPA, FF–MC, and parental stress, only an inversely proportional highly significant relation of time with parental psychopathology and NPA was detected (Table 2). Qualitative findings The PGP process revealed that attendants social environment was suspicious about the existence of diagnostic entity of ADHD and insisted that the children’s misbehavior was a result of being poor disciplined. Most of the mothers were influenced by this thought, thus excessive amounts of self-stigmatization was observed in mothers. Many of the mothers assessed their children’s misbehavior as a result of their lack of nurturing capabilities, which in turn resulted with adopting harsher punishment methods. This probably yielded with higher levels of misbehavior of the children and desperateness of the mothers. During the PGP process mothers noticed the universality of their problems, gained empathy with their children and communication skills with their children and social environment. The PGP process instilled hope and self-confidence to them. Thus, starting from the third session signals of better coping, psychological wellness and reduced anger and corporal punishment within the PGP process were shared incrementally by the attendants. Discussion The main target of this study was to investigate the availability of PGP as a parental intervention method to normalize the interaction of mothers with their children with ADHD. Stigmatization and self-stigmatization processes, harsh punishment to the children, and burden of motherhood were major themes observed through the PGP process. One study from Turkey revealed levels of misinterpretation and stigma on ADHD did not differ on parents with or without a child with ADHD (Karabekiro˘glu et al., 2009). The same study indicated that 1/3 of the information was misinterpreting and half of them were enhancing the stigmatization on printed media. Those findings might point how social stigmatization raised self-stigmatization. Another study
from Turkey aiming to explore the long-term socialization goals of Turkish mothers revealed that low-educated mothers emphasized the importance of relatedness and obedience more than higheducated mothers; and high-educated mothers stressed autonomy and self-enhancement as desirable characteristics more than low-educated mothers did (Yagmurlu, Citlak, Dost, & Leyendecker, 2009). The attendants of our study were low educated and childrens misbehavior might demoralize them more deeply for falling far from their goals for their children. Many of the attendants adopted harsher punishment methods with desperateness, and this probably yielded with higher levels of misbehavior of the children and burden of the mothers. Maybe most importantly Günay and Bener (2011) revealed that 35% of the women in their sample from capital city of Turkey, Ankara perceived that child nurturing and discipline are primarily mothers responsibility. This ratio was significantly higher in women with lower education, lower income and without employment. As our attendants were less educated, had short monthly income, and unemployed, their statements in this direction would be quite predictable. In fact mothers gained awareness about their husbands relatively quite less burden through the PGP process. One of the findings of our quantitative work is that the feedbacks of parents regarding their own psychopathology reduce over time. It has been indicated that parents of children with combinedtype ADHD in particular show more depressive symptoms (Chronis et al., 2004). Durukan et al. (2008) also revealed higher depression and anxiety levels in mothers of children with ADHD. In a prospective study, it has been detected that depression in mothers of hyperactive children is predictive for higher levels of childhood aggression (Shin & Stein, 2008). It has also been shown that depression in mothers of children with ADHD – just like in mothers of other children – is predictive for corporal punishment, and corporal punishment in fact increases the aggressive behavior of children (Stormont-Spurgin & Zentall, 1995). In another study, it has been determined that depression of mothers and children’s feelings of inferiority and inadequacy, which cause deficiency in interpersonal relationships, are related to aggression in children with ADHD (Connolly & Vance, 2010). The finding that depression in mothers is predictive of the development of comorbid behavior disorders in children with ADHD might be interpreted in this context (Chronis et al., 2007). Therefore, the relation between parental psychopathology and ADHD might be mediated by the reduction of parental skills (Cunningham, 2007). Gerdes et al. (2007) stated that mothers who are depressive, having an external locus of control, and with less self-esteem, may evaluate themselves as being insufficient when it comes to coping with the usual difficulties of being the parent of a child with ADHD. These mothers consider that they have insufficient influence on the behaviors of their children, so they are apt to have lax parental styles. These cognitions may mediate between NPA and psychopathologies like depression. The Pelham et al. (1997) study might be found rather provoking when it comes to rethinking the causality between NPA and children with ADHD. In this study, parents were randomly assigned to interact with child actors who role played deviant children with externalizing behavior disorders, as well as normal children. The parents who interacted with problematic actors reported that they felt more inadequate, hostile, anxious, and depressed. After the study, these parents were supplied with alcohol if they wanted, and the parents who interacted with problematic children consumed significantly more alcohol. These findings have been interpreted as child’s externalization problems may directly decrease the selfesteem of parents. Another finding in our study is that the feedbacks of parents regarding NPA reduce over time. There are a few studies which suggest a relationship between NPA and ADHD. In a prospective
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study on 191 children who were followed from birth to 11 years old, caring variables of mothers were assessed twice, when the children were 6 and 42 months old. It was found that intrusive caregiving at 6 months of age and overstimulating caregiving at 42 months of age were predictive of hyperactivity at the age of 11 (Carlson, Jacobvitz, & Sroufe, 1995). The results of parental intervention on the child are also interesting. It has been detected that behavioral parental therapy is efficient when it comes to attention deficit and hyperactive-impulsive symptoms as well as social problems and violating behaviors in children (Huang et al., 2009). These findings indicate that parenting methods might interfere with the clinical course of ADHD. It is suggested that the self-regulatory deficits of children with ADHD may cause their parents to adopt more controlling and negative attitudes to compensate for the children’s deficits (Cunningham, 2007). On the other hand, Chronis et al. (2004), has emphasized the reciprocal nature of the interaction in the findings about the parenting characteristics of mothers of children with ADHD differing from others from very early periods of the children’s life, and parent intervention programs ameliorating not only children’s behavior problems, but also core symptoms of ADHD, including attention deficit and hyperactivity-impulsivity. The main finding of our research is that feedbacks of parents regarding their own psychopathology and NPA reduce in time over three months of PGP. Quantitative analysis suggested that mothers psychopathology resulted from mainly the burden of stigmatization and self-stigmatization processes, and NPA was a result of both mothers burden and stigmatization. We cannot proceed to a deeper analysis due to the similarity of participants’ socio-demographic variables. Both parental psychopathology and NPA might worsen ADHD outcomes according to the existing data from the field. Although there have been some studies in the ADHD literature in which psychodrama techniques like role playing have been used, this is the first study of PGP with parents of children with ADHD as far as we know. It appears that parental variables and clinical ADHD may show a very complicated and sometimes reciprocal interaction. Considering the nature of this interaction, opinions to the effect that family interventions in ADHD should not be restricted to parent training and should deal with parental psychopathology and stress have been gaining importance day by day (Chronis et al., 2003; Modesto-Lowe et al., 2008). Chronis et al. (2004) emphasized that each family may have different needs because of the complicated structure of this interaction, and therefore individualized
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behavioral parent training programs might be more useful. Consequently, it seems that psychodrama might fulfill all of these requirements due to its applicability for both psycho-educational and therapeutic purposes, giving the opportunity for each individual to study his/her actual problems and due to its tendency to elicit the study of interpersonal relationships (Blatner, 2000). In order to examine the relation of children with ADHD with their parents and the influence of parents on the clinical course of ADHD, various methods can be used, such as analysis of in-depth interviews (Peters & Jackson, 2009) analysis of video recordings of the child–parent interaction at home (Bor, Sanders, & MarkieDadds, 2002) or in the laboratory setting (Johnston & Jassy, 2007), sociometric analysis of children playing with their peers under their parents’ supervision in the laboratory setting (Mikami, Jack, Emeh, & Stephens, 2010) and applying scales after interaction with child actors role playing externalization problems (Pelham et al., 1997), in addition to standard procedures applied with structured scales. We have adopted an alternative method of analyzing participants’ feedbacks and classifying them into major parenting variables that interfere with clinical ADHD. There are numerous limitations in this study. The limited number of attendants can be considered the most important among these. Nevertheless, it is recommended that the number of attendants should be between 7 and 10 for the efficiency of the group therapy (Cohen & Rice, 2005). Another limitation is that participants could be evaluated for only a three-month period; long-term follow-up could not be performed. Furthermore, the results should be assessed carefully, since they were obtained only from the analysis of participants’ feedbacks. Although it is an important restriction that a scale-based evaluation was not carried out for mothers in our study, the efficiency of PGP could be evaluated better in this way, since it would prevent the awareness of mothers and any impact on spontaneity before the sessions. A control group was not available due to our methodology, which was based on the analysis of participants’ statements during sessions. Another limitation is that the possible effects of mothers’ PGP process on the clinical course of their children’s ADHD were not explored. Despite all of these limitations, to the best of our knowledge this is the first study investigating PGP in parents of children with ADHD. Comprehensive research is needed to evaluate the effect of PGP on parents of children with ADHD more clearly. Appendix A. Table A1.
Table A1 Psychodramatic techniques, Therapeutic goals and Group members responses in the Sessions. Sessions
Technique
Therapeutic goals
Group members responses
1
Introduction to psychodrama, paired matching, role reversal, two chairs, group sharing
2
Group play about a scenario including a child with ADHD, role feed back and sharing
Gaining insight about communication skills, to develop empathy skills, to build group cohesion, to introduce basic psychodrama techniques Developing empathy with their children and other figures of the family, gaining insight about feelings and actions in interacting with their children
3
Selecting an object in the room to symbolize themselves, doubling
Recognizing the difficulties in understanding the instructions, thus remembering their own attention problems through childhood by two members Recognizing their anger, impatience and overexpectations about the children, unresponsiveness about childrens’ needs; noting that father role carries relatively less burden A whiteboard eraser with two opposite sides soft and hard, a seashell with a smooth inner and rough outer surface; a stone which is hard; a flute which is noisy; an old tree model which suffered from many storms and still lonely; another stone which is durable and calm; a button which is tied and connects two sides. a Stigmatization of the child with ADHD and self-stigmatization of motherhood of the child with ADHD
Revealing self representations, interventions on negative self representations, revealing the relationship between these representations and family relations
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P. Vural et al. / The Arts in Psychotherapy 41 (2014) 233–239
Table A1 (Continued ) Sessions
Technique
Therapeutic goals
Group members responses
4
Imagination of a happy and a sad moment, sharing
Remembering major life events including the childbirth and accidents, family conflicts, corporal punishment
5
Group play of a class with a child with ADHD, role feedback and sharing Protagonist play of a child’s homework problems, doubling, role reversal Protagonist play of a members dialog with her child’s teacher, role reversal, role feedback and sharing Group play of a cruise, role feedback and sharing
Indicating the existence of positive life events despite negative others, improving self efficacy by offering solutions to other members, revealing the universality of the negative feelings Developing empathy with the child, gaining awareness about their relationship with the teachers
Gaining awareness about problem solving abilities and social roles
Burden of raising a child with ADHD, depressive complaints, guilt, self-stigmatization, social exclusion Burden of motherhood, interaction between emotions of the self and the child
6
7
Expressing emotions non-verbally, sharing
8
Protagonist play of a home visit from a neighbor, role reversal, soliloquy Drawing a chart symbolizing their lives; a circle with proportions for themselves and other members of the family
9
10
11 12
a
Protagonist play of a nervous breakdown while trying to intervene an argument between siblings, role reversal, sharing Imagination of a place where they feel relaxed and comfortable, sharing Process analysis, having each participant to make a wish for each other, holding hands to create a circle and shake hands for farewell
Understanding others emotions comprehensively, gaining insight about own emotions Analyzing stigmatization processes, enhancing coping skills for stigmatization Focusing over their own psychological status
Focusing over their communicating styles
Relaxation (considering having the next to the last session) Instil hope
Difficulties of being teacher of a child with ADHD, social exclusion of the child, self-stigmatization of mothers
Gaining patience about the child’s misbehavior, inventing new solutions for specific problems Revealing how less space left for themselves in daily living, father’s less responsibility for the children, burden of motherhood of a child with ADHD Revealing their own impulsive, aggressive and punishing reactions to frustrating life events, their own sibling rivalry Need for loneliness and space Progress over gaining empathy, enhancing coping skills, self-confidence
Participants own descriptions of the objects.
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