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The author suggests that a multifaceted approach is optimal in the assessment of children who meet criteria for AD/HD. The diagnosis of AD/HD is often discounted by psychoanalysts because it is purely descriptive and behavioral, but it can be understood in psychoanalytic terms as a disturbance in ego functioning, namely in the synthetic, integrative function. The impact of this disturbance on development and its reverberation with dynamics, both intrapsychic and familial, create complex and highly individualized clinical presentations that evolve as development proceeds. Psychoanalytically informed evaluation and treatment recommendations are optimal, because enlightened psychoanalysts can integrate the multiple contributions to the clinical picture and craft an appropriate and balanced approach to help the child and the family toward progressive development. Such an approach may include medication, parent counseling, remediation, and psychoanalytic psychotherapy or psychoanalysis.
Karen Gilmore, M.D. is Associate Director, Head of Child Division, and Training and Supervising Analyst, Columbia University Center for Psychoanalytic Training and Research.
There is an incongruity …between the analyst's therapeutic thinking, which is metapsychological, i.e., directed toward the dynamic, economic, genetic, and structural aspects of psychic functioning, and his thinking as a diagnostician, which proceeds on the basis of concepts and categories which are descriptive. The difference between these viewpoints is so fundamental that it has caused many analysts to withdraw their interest altogether from diagnostic assessment as from an area which is neither essential nor very significant for their field of work, and has caused some others to regard all their patients' abnormalities as mere variations of the many vagaries and complexities of human behavior…. If symptoms are viewed merely as manifest phenomena, dealing with them remains arid so far as analytic interest is concerned. If the clinician is alerted to see opening up behind these the whole range of possible derivations, causations, and developmental affiliations, the field becomes fascinating, and scrutinizing a child's symptomatology becomes a truly analytic task.
Besides, so far as work with children is concerned, diagnostic assessment is more than a mere intellectual exercise for the clinician. It is, in fact, the only true guide to the choice of therapeutic method.
—A. Freud, 1970