By Alison Van Dyk
Hyperactivity in four year olds takes many forms. Usually the child who is problematic from the first day of school is identified as hyperactive. Some of the causes of hyperactivity in children are: Attention Deficit Hyperactivity Disorder (ADHD), Trauma or reaction to traumatic or violent events, Abandonment or Death of a parent, Oppositional Defiant Disorder, Learning Differences, etc. It could also be the result of a combination of the above. The following case describes an example of a child for whom Play Therapy and Sandplay was helpful in diagnosing and treating the cause of his hyperactivity. This child attended a preschool program that I am the director of for a school in the South Bronx, NY with a predominantly Hispanic population.
Jason was small for his age and very bright. He was three years 4 months at the beginning of the year. He had trouble settling down at circle time, could not stay with any one activity for any period of time and was constantly getting into trouble for his impulsive behavior, hitting other kids and getting into fights. He was not so much aggressive, as he was out of control and disruptive in class. This was his first group experience away from home. His father and mother had been separated for 1-12 years and he has a younger brother, age 2.
In talking to the parents separately for conferences, it became clear that Jason had witnessed domestic violence at an early age. His mother was open about the verbal and physical fights that she and her husband had had. He continued to have difficulty during the year when he visited his father and new partner.
In response to one of the nonverbal tests given to children in the beginning of the preschool program, the LADS or Levy-Wiedis Animal Drawing Story Test, Jason said: “Somebody was fighting with the kids and they gonna take him to jail”. That somebody was his father who created a volatile domestic scene wherever he lived. His father also had problems with the court around childcare payments and responsibility issues. Jason had witnessed the police being called to break up a fight while his parents were together and then again during visits to his father’s house. As if this was not enough for a four year old to deal with, Jason’s mother was in treatment for cancer and was in and out of the hospital that year. He was painfully aware of what death was and we had many conversations about Selina, the beautiful Hispanic singer from LA who was killed by a jealous employee. He told me that he and his mother cried when they saw that movie.
Most of the Play Therapy goals included helping him to nonverbally process his traumatic experiences, gain confidence in himself and learn to manage his behavior in terms of the class demands. Jason was able to use the therapy sessions including Art Therapy, Sandplay and Drama to process his feelings and learn to accept the limits that his parental situation dictated. In class however, he continued to show hyperactive behavior. He scored on the Burks Behavior Rating Scale: Very Significant for Poor Attention and high in Significant for Poor Impulse Control, Poor Reality Contact, and Poor Social Conformity. If we look at the behavior Jason was exhibiting, we might think that he had ADHD. Many psychiatrists and pediatricians might prescribe medications for a child like this. And of course I thought about a referral for an evaluation. However, there were too many psychological factors that were a result of Jason’s witnessing of family violence, the threat of abandonment by his father and fears around loosing his mother to cancer. All of this led me to think that Sandplay would be a treatment of choice to help Jason express his anxiety and worries in a safe and nurturing environment.
In subsequent Sandplay sessions, Jason worked on his father issues using Darth Vader as the dangerous Dad whom he has to call Mom for help with during two home visits. I have no doubt that Jason was terrified by his father’s aggressive behavior. However, he also loved his father and craved his attention. His new partner told Jason’s father that when their first baby was born, she didn’t want him to see his children from his first marriage. In April the baby was born and Jason’s father stopped the home visits. Eventually, as the reality of the final rejection by the father set in, Jason saw himself as the cause of the father’s rejection, a common reaction in young children. Jason drew this LADS picture in May.
The Animal of his story is the turtle to the left and to the right is a mouse, which he is feeding (green food). This drawing symbolizes his acceptance of the family dynamic and his need for protection from painful feelings. Parental abandonment is a very challenging experience for a child. To the right he feeds a mouse. He is transitioning from desperately wishing for a relationship with his father to wanting to take care of his mother. She is getting married over the summer and Jason is looking forward to a new stepfather. Notice that he has depicted his individuation in this drawing by the two creatures that are separate from the large open circle above. In his first drawing at the beginning of the year, the two red and blue circles are still inside or not quite fully free of the large circle, the image of mother, womb, etc. Now that he has accepted the finality of not seeing his father, Jason was more open to the new father he was about to have in his life. However he did have some other concerns that needed to be dealt with.
In some of his answers to questions on the LADS test, Jason says that the animal might be dead (with no one to take care of him) and that the animal worries about him “in the woods by myself”. He also states that the father does not like the animal. He needs help with his guilt that he may have actually caused the father’s rejection. He is also openly expressing his anxieties and lifting the burden that he has been carrying, a fear of a second abandonment due to his Mom’s illness. In class he shows improvement in his adjustment to the other children. In answer to the questions, the animal feels liked and accepted by others. He is still unsure of his academic abilities but his answers indicate that he sees himself as smart, happy and good, all improvements.
His Burks Behavior Rating Scale scores for the end of the year showed significant progress in some of the behaviors that therapy sought to address. Poor Attention went down (improved) from Very Significant to Not Significant, a drop of 15 points. The other scores were Poor Impulse Control which went up (worsened) 8 points and Excessive Aggression, which went up 5 points. Poor Anger Control stayed the same. Poor Social Conformity improved by 5 points and Reality Contact improved by 1 point.
Jason had made significant progress in dealing with his hyperactive behavior. With the help of Sandplay, he began to accept his feelings of loss and fears of abandonment. He learned how to control himself better is school and stay focused rather than going from activity to activity without completing any one thing. Jason still had to work on impulse control and aggression. This would take more time. Although he has some challenges ahead, it was decided that Jason was ready for kindergarten. This also means the end of therapy for children leaving the program. In this school system, if a child continues to exhibit problematic behavior, they are referred to the Board of Education Social Worker for further help.
The act of making a picture with toys or figures in the sand is a right brain, non-verbal activity. It is a communication skill that is developed during the process. Children learn to use it to think through problems and see their issues in a more reflective way. One feels the images and resonates with their meaning, regardless of the age of the maker. Sandplay also helps a child to increase their attention span. It helps a child look at where he is feeling hurt or sad and come to a resolution around those feelings. In Jason’s case, this allowed the energy that used to go into anxiety, to go into the important activity of learning and growing. Too much worry and anxiety is unhealthy for anyone, much less a four year old. The therapy program helped Jason to accept that his father had chosen not to see his children and to see that this had nothing to do with anything he had done. This also helped him to accept a new stepfather. His mother’s health improved and he was able to end the year at grade level academically.
Using Hyperactivity as a diagnosis for three to four year olds has many advantages. It allows the Play Therapist to evaluate the possible psychodynamic factors that may be the root cause of the problem rather than assuming that the problem has an organic cause like ADHD. It is also gives the child time to work through emotional problems and remove the blocks to learning. If the hyperactivity has not lessened after a year or two (preschool and kindergarten), then a complete evaluation is needed and medication may be necessary.
Play in the Sandbox of Life.