Commentary on Forrest: Attention Deficit/Hyperactivity Disorder, Networks and Introjection

“ … ADHD is too important to keep out of the analytic field…”, Forrest (2021:51) rightly says. Indeed, there is a need for group analytic conceptualizations of neurodevelopmental disorders. Attention Deficit/Hyperactivity Disorder (ADHD) has been neglected in Group Analysis. Forrest is correct in pointing this out and his contribution is certainly valuable. After reading his article again, I felt that it needed further clarification.

I.

In his discussion, Forrest focuses mainly on attention. He neglects hyperactivity and impulsivity. That is problematic, since ADHD is characterized by three core symptoms: inattention, hyperactivity and impulsivity. According to the APA (2013), hyperactivity and impulsivity manifest in fidgeting, difficulties remaining seated, running around when it is inappropriate to do so, inability to engage in activities quietly, often being on the go or acting as if being driven by a motor, talking excessively, blurting out answers before the question has been asked, difficulty waiting one’s turn and interrupting others.

Moreover, ADHD should be grounded in theoretical frameworks which consider the distinct aspects of attention alongside their neurobiological substrates. Attention is not one system (Hommel et al., 2019). This is only partly acknowledged in Forrest’s discussion. The CFP is involved in switching and sustained attention facilitated by the DMN network. Forrest does not consider all forms of attention. Attention comprises selective attention (focus on a single stimulus while filtering out background noise), divided attention (ability to switch between different tasks), sustained attention (concentrating for a certain period of time) and focused attention (attending to one topic only).

In his conceptualization, selective and focused attention seem to be missing. This is problematic, because they may have additional neural correlates (e.g. parietal cortices, frontal eye fields, pulvinar nuclei, superior colliculi) (see Posner et al., 2019).

Furthermore, one part of the brain network (e.g. frontal cortex) must be viewed in interaction with other networks (e.g. thalamus, hippocampus). Otherwise we cannot conceptualize a person holistically.

Interestingly, Forrest discusses how society regulates the use of the body by punishment or scapegoating. In my experience, teachers tend to punish disruptive (hyperactive or impulsive) and not inattentive children, who merely sit in the classroom and daydream. Furthermore, boys are more hyperactive than girls, whose minds often wander into a fantasy world. Both teachers and parents penalize boys, because they are the ones who tend to create havoc. Gender differences and their implications for introjection and projection are not explored by Forrest.

II.

Even though he highlights the risk of adopting a radical position (towards ADHD), in his conclusion, Forrest then states that a radically social view would be the most valid perspective. He seems to contradict himself. In the discussion, the suggests that we need both radical and orthodox positions.

III.

Of course, social and relational processes are important, as Forrest rightly says. But they also affect development before a child is born. How a mother relates to her not yet born infant, as well as the environmental, psychological and social reactions she experiences, all impact on the embryo’s development in uterus. So the social gets inside, even before the child is even born, which Foulkes was aware of.

Unfortunately, we do not exactly know how these ‘in uterus effects’ influence the development of ADHD. But what we do know is that the environment can shape our genes, which is the field of epigenetics (Francis, 2011). Maybe a combined group analytic (Forrest’s ideas) and socio-evolutionary approach, which identifies the contexts (e.g. capitalist societies), that give rise to expectations with regards to how children must behave, as well as factors related to life adversity (e.g. scapegoating, punishment), which cause psychopathological alterations (ADHD) through epigenetic mechanisms (e.g. DNA methylation, histone modification), would be another way forward? Changing the social conditions that induce epigenetic changes, could perhaps become a group analytic focus.

IV.

Neonates do indeed have different temperaments at birth. The interplay between epigenetics and the modification of temperament by the social environment is an interesting area. While this is beyond the scope of Forrest’s article, it nevertheless seems important to explore how the extracellular environment of neonates is influenced by their environment (e.g. social interaction).

Acknowledging the importance of biopsychosocial factors, Forrest suggests that ADHD itself develops in the relational matrix. Nonetheless, he seems to prioritise the “constitutional component brought by the child” (p. 57), because he refers to them as “substantial”. However, social interactions have a profound impact on neurotransmitters and hormones. This indicates that constitutional factors are directly created through an interplay of the environment and neuronal networks due to the plasticity of the brain. So viewing constitutional factors as the cause of ADHD is too simplistic. I am not suggesting that Forrest is unaware of this complexity. By attributing a “substantial” effect to constitutional (innate) aspects, he seems to perhaps unintentionally echo a societal discourse, which blames the child.

This is surprising since he uses the word “construct” in the abstract of his article. A logical conclusion would have been that ADHD is a socially constructed diagnosis. Forrest does not reach this conclusion. In other words, he describes the development of the diagnosis of ADHD, but misses something crucial.

Traditionally, diagnostic systems (DSM/ICD) have conceptualized mental disorders as discrete categories, which qualitatively differ from normality. Nevertheless, converging behavioural, neurocognitive and genetic evidence supports a dimensional model of ADHD. It posits continuity of symptoms and underlying causes. Thus, ADHD could be regarded as an extreme expression of a normal variation in the population. Not only would this be more in line with Group Analysis, but it would also open up new avenues to treat ADHD in the group. And a focus on symptoms would become redundant.

V.

In the current article, Forrest suggests a group analytic formulation of ADHD. Whether or not we refer to conceptualizations as ‘formulations’, a term used in psychology, is not merely a matter of semantics. It indicates that there are no sharp boundaries between Group Analysis and psychology. This also applies to neuroscience. After all, Foulkes was an advocate of neurology and his concept of the matrix is linked to neuroscience. So when Forrest discusses how neuroscience could be of value to Group Analysis, let us not forget that Foulkes did suggest that we should have some knowledge of neurology. It leaves us with a dilemma. So when Forrest indicates that group analysts need to adopt a neurobiological perspective, it begs the question how psychotherapists should acquire this knowledge. It is an issue that concerns the wider group analytic community and the training committee.

VI.

Group Analysis has much to offer in the emerging discourse on social interactional neuroscience, Forrest suggests. What exactly can Group Analysis offer? Affective neuroscience (e.g. Panksepp, 1998) already views human beings as social, so Forrest’s “radically social view of human persons” (p. 62) is nothing new for those neuroscientists. Considering also that psychoanalysis has been contributing to neuroscience for many years, Forrest needs to spell out very clearly what new contributions Group Analysis can make.

  Moreover, explanations alone are insufficient, if they do not simultaneously offer solutions to the difficulties that individuals with ADHD face.

VII.

Forrest refers to critics of ADHD and post-industrialism. What exactly must change in a capitalist society, if we want to accommodate children with ADHD?

He mentions Elias and clearly understands how crucial societal processes are. But Forrest does not go a step further, i.e. examining the social matrix of ADHD, and suggesting that Group Analysis could ‘intervene’ at a socio-political level by setting up large groups, conducting research, or by offering a societal analysis.

VIII.

Forrest writes about the limits of our method, suggesting that increased work on social interactional neuroscience and a better understanding of neural networks could enable us to make sense of those limits in a more cogent way. I find myself agreeing and disagreeing with him. He seems to uncritically embrace neuroscience. There is a danger that group analysts could enthusiastically accept neuroscientific findings as authoritative and settled. Neuroscience could become the new dogma or ideology.

While neuroscience can inform our understanding of psychological disturbance in certain areas of the brain, it also has its limits. Identifying changes in blood flow through a fMRI only tells us that a particular region of the brain is active. We must bear this in mind and not regard neuroscience as the panacea, which will solve all ‘ADHD related problems’, that we encounter in terms of theory, method and technique.

Neuroscience cannot provide irrefutable evidence for every aspect of the underlying pathology of neurodevelopmental disorders. The same holds true for social interactional neuroscience, which studies what brains do in relationships (see Peyton, 2023).

Furthermore, many neuroscientists have been criticized for assuming that brain and mind are the same (Lieff, 2013). Which brain structure or neuronal region do represent our mind? Can cells and molecules tell us what the mind is? Having read some relevant literature, I do not get the impression that this is the case, despite Panksepp’s (1998) term ‘BrainMind’, which refers to the social emotionality of our brain, and is comparable to Foulkes’ foundation matrix. Panksepp’s unity between brain and mind seems to differ from how many people view the mind. Perhaps Foulkes’ (1964) suggestion that our mind consisted of proceeding events, which are moving, offers a better explanation than molecular science?

Be this as it may, neuroscience is useful. Knowing that the prefrontal cortex is not optimally functioning in ADHD, allows us to adapt our techniques so that we can address the consequences of this dysfunction.

IX.

Forrest proposes that ADHD is amenable to a realistic, group analytic understanding, even if group analysis would not be the method of treatment. I would concur that it is not the method of treatment, because CBT is (see Liu et al., 2023).

It is also true that neurodevelopmental disorders do not simply disappear in adulthood, even though the elderly are less likely to be hyperactive, because they no longer have this surplus of energy that characterizes hyperactivity.

If group analytic theory enables exploration of ADHD, and Forrest has shown that this is the case, then group analytic technique may not be as limited as some may think. Groups analysts are trained to select the right mix of members, contain anxiety, work with transferences/countertransference and focus on the therapeutic relationship. All these are important when conducting groups for people with ADHD. And so is the therapeutic alliance, which is still a key factor to successful therapeutic outcome across treatment modalities and symptoms (Bourke et al., 2021).

Considering that a modified form of Group Analysis has shown good results with difficult patient groups, I am perhaps more optimistic than Forrest what Group Analysis could ‘achieve’ when treating adults with ADHD. My optimism is also based on experience, because I conducted a group for such adults (see Vosmer, 2015). Social interaction enabled my group members to feel less isolated. They stopped to depend so much on others in their daily lives. Admittedly, they were taking medication and I had modified the group analytic approach. Drawing on the extant ADHD literature (e.g. Hesslinger et al. 2002, Virta et al. 2008) and the group analytic treatment literature (see Volbak), I devised a 12-week group programme, which combined group analytic principles with mindfulness, CBT and psychoeducation. The 90-minute long sessions consisted of a structured part, followed by a free-floating discussion. Group analytic thinking was applied to group processes and to discussions with the co-conductor, who was not a group analyst. Although impulsivity, a hallmark of ADHD, is often considered an exclusion criterium for psychodynamic group therapy, integration of techniques from other psychotherapies might decrease impulsivity, as discussions in my homogenous group indicated.

Some time ago, I proposed that Group Analysis could be useful for all kinds of disturbances, because people have a desire to communicate, irrespective of what diagnoses they have been given. Like Forrest, it was my hope that other group analysts would conduct groups for (adults) with ADHD and write about them. Alas, I have not seen any article in Group Analysis.

X.

It is great that Forrest has disrupted our avoidant culture when it comes to ‘neuro disorders’. While my article predominantly focused on treatment, Forrest’s emphasis is theoretical. ADHD in children is a disturbance of introjective and projective processes at a psychological level, he proposes. He highlights a mismatch between the child and society, which prevents introjection. The environment does not provide the child with what s/he needs in order to adequately regulate her/his attention and physical movement.

Equally interesting, but not mentioned by Forrest, is that ADHD diagnoses have increased in Western cultures, particularly the USA. Is ADHD a culturally specific, a ‘Western Disorder’? Unfortunately, Forrest does not explore this. He seems to describe only vertical projections, where society projects into the child, disowning reciprocity (p. 58). But what about horizontal projections between the subsystems (families, school groups)? Do their projections entail pathogenic processes, i.e. epigenetic and associated neuronal dynamics?

XI.

When applying the location of disturbance, Forrest wonders whether disturbance could be found in an overly active DMN, or in an underdeveloped CFP network control, or outside the brain itself (p. 55). The disturbance could be in all of these, in my opinion. Each could be involved to a varying degree.

Is Forrest right in saying that Group Analysis has much to offer to perceptions about ADHD? Probably, because cognition is to a large extent a group activity (Sloman et al., 2021).

References

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Virta M, Vedenpää A, Grönroos N, Chydenius E et al. (2008) Adults With ADHD. Benefit From Cognitive-Behaviorally Oriented Group Rehabilitation. A Study of 29 Participants.  Journal of Attention Disorders. 12(3): 218-226.

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