EMDR therapy has eight phases: history taking (obtaining background information to identify suitability for EMDR and identify processing ‘targets’ from life events), preparation, assessment (access the target for EMDR processing by stimulating primary aspects of the memory), desensitisation (process experiences toward an adaptive resolution; i.e. no distress), installation (increasing connections to positive cognitive networks), body scan (complete processing of any residual disturbance associated with the target), closure (ensuring client stability at session completion and between sessions) and reassessment (ensuring maintenance of therapeutic outcomes and stability of the client) (Shapiro, 2014). Once processing is achieved, it is expected to lead to symptom resolution. Bilateral stimulation is used for processing. Eye movements are commonly used, and other forms of bilateral stimulation include tactile stimulation using tapping or buzzers/pulsars and auditory stimulation.
During my training, I was exposed to behavioural or neurodevelopmental pathways. In these pathways for children with behavioural problems or inattentiveness, tests such as the Conners were used to diagnose attention deficit hyperactivity disorder (ADHD) after screening of symptoms. Following diagnosis, if the patient wanted to trial or seemed to need to trial medication, this was done with stimulants being the first-line treatment. However, what we did not know very well was the story of their lives or the significance of the impact of their life stories on their current behaviour and functioning. Therefore, in my journey as a psychiatrist, I tried to know and understand the relationship between life experiences and the symptomatology of ADHD. In this article, I write about two cases involving young people where resolution of triggers from life experiences helped resolve ADHD symptoms and wean them off their stimulant medication.
There are varying views on the relationship between life experiences and ADHD. Walker et al. (2021) reported that compared with children with no adverse childhood experiences (ACEs), the odds of an attention deficit hyperactivity disorder (ADHD) diagnosis were 1.39, 1.92 and 2.72 times higher among children with one, two and three or more ACEs. Miodus et al. (2021) examined the relationship between childhood ADHD symptoms, lifetime trauma exposure and current posttraumatic stress disorder (PTSD) symptoms among a diverse group of 454 college students (equivalent to university in New Zealand). They found that college students with a childhood history of elevated ADHD symptoms reported significantly higher numbers of trauma exposure and PTSD symptoms (Miodus et al., 2021).
In her interview with Dr Paul Skirrow for the Journal of the New Zealand College of Clinical Psychologists, Dr Diana Kopua discussed her concerns with diagnosis and treatment of ADHD in Māori without considering historical injustices. She said, ‘Simply describing behaviours that focus on an individual struggling to conform within a society that does not reflect a Māori worldview is no longer acceptable. We have an opportunity to sit with these whanau and engage in conversations that stop them from thinking “they” are the problem’ (Kopua & Skirrow, 2023). The international paediatric community is now considering other models to understand physical symptoms and those of disorders such as ADHD. They sometimes use the framework of toxic stress to formulate to understand the diagnosis. A seminal publication by Shonkoff et al. (2012) and a recent article by Gilgoff et al. (2022) discussed this along with implementation of measures in clinical practice to mitigate pathology.
There have also been concerns about longer-term adverse effects of medication used for ADHD (Harris, 2023). The largest known longitudinal study on the effect of stimulant medication, the MTA Study, reported at the 6–8 year review that, ‘With one exception (math achievement), children still taking medication by 6 and 8 years fared no better than their non-medicated counterparts despite a 41% increase in the average total daily dose, failing to support continued medication treatment as salutary (at least, continued medication treatment as monitored by community practitioners)’ (Molina et al., 2009). Given these findings and varied opinions, it may be worth exploring non-medical ways of managing the symptoms of ADHD. It may also be worth addressing the impact of life experiences in those presenting with ADHD symptoms to determine if such an approach can help decrease the symptoms of ADHD, and thereby reduce the need for medication. EMDR therapy could play an important role as an effective non-medication tool to minimise medication use for ADHD and to help individuals wean off ADHD medications.
Survival is the most important function for a living organism. We learn by experience, and use this learning to adapt and survive. Our brain uses templates from past learning to ‘view’ the future. I tell my patients that our survival brain is like a ‘fire truck’ idling by the pavement. As soon as there is a 111 call, it takes off with flashing lights and screaming sirens. Sometimes, when the fire truck is used to getting too many 111 calls, it starts to err on the side of caution by misinterpreting other calls as 111 and activating. Medications help to dim the lights and quieten the sirens. EMDR therapy teaches the fire truck what is 111 and what is not. With this metaphor in mind, we will consider the stories of two young people.
Case Reports of Weaning off Stimulant Medication (Methylphenidate in Both Cases)[1]
Case 1: Nilesh: ‘My tummy hurts! I don’t want to take this medication!’
Nilesh (name changed), a 13-year-old Fijian Indian boy, was first referred to the Child and Adolescent Mental Health Service (CAMHS) at the age of 8 years. He was stood down from school for punching another student and not being remorseful. He was easily distracted and could not sit still. He did not engage with CAMHS and was discharged. He was re-referred 4 years later; this time he was stood down from school for aggression, and was to be allowed back ‘only if’ diagnosed with ADHD. Nilesh was also cutting himself, hitting his head on the wall, saying he wanted to kill himself and his mum and running away from his dad and step-mum’s home. He had multiple police call outs. He was diagnosed with ADHD (Conners strongly positive) and started on a long-acting form of methylphenidate (Concerta), which had been increased to 36+18 mg before I saw him. He complained of experiencing severe headaches and a sore stomach since starting Concerta.
Nilesh’s mum reported domestic violence throughout pregnancy and until she separated from Nilesh’s father when Nilesh was aged 3 years. She returned to work when he was 3 months old, leaving him in the care of babysitters. He went to day care when aged 2.5 years. His mum remarried when he was aged 7 years, but the marriage ended in 2 years. He attended multiple primaries and was bullied at school. He lived with his full time working mum and younger brother, and visited his dad and step-mum on weekends. Nilesh said he got ‘hidings’ from dad, and his step-mum said things like, ‘I hate you’, ‘you are mental’, ‘your mum doesn’t want you’, ‘your brother doesn’t want you’ and ‘nobody wants you’.
Nilesh stopped Concerta shortly before he started EMDR therapy because of the adverse effects. He had nine sessions of EMDR therapy over 8 months, of which four were by Zoom. Nilesh said he could not recall any memory that caused him disturbance or that triggered him. So, when he came to the session after incidents at school or home, particularly in the initial sessions, we used an EMDR technique called ‘Floatback’. This technique helps the client to make associations between present experiences and past events. Once the earliest event that elicited similar responses is identified, it is used as a ‘target’ for processing. The therapist asks questions such as, ‘What is your earliest memory of feeling this way?’ (https://emdrtherapyvolusia.com/wp-content/uploads/2016/12/Floatback_and_Float.pdf).
Once Nilesh had a fight with a boy at school who tried to sell a vape to his younger brother. Using Floatback, he identified a memory of when he had asked his father and stepmother what a vape was when he saw them selling these in their dairy. He said that his father and stepmother responded angrily, saying he would become a druggie and go to jail. It made him feel angry and think he was ‘a bad boy’. He said that he felt the anger ‘in my fists’. It seemed that the recent vape incident had been the trigger that made Nilesh re-live the earlier memory of the day he had asked his father and stepmother what a vape was. It made him feel like a bad boy and made him angry. This led to the fight. Once he processed this earlier memory using EMDR therapy, Nilesh was able to engage with the boy from school in a regulated way in a mutual reconciliation process organised by the school. Following this, when he found the boy trying to do the same thing again, he simply went and reported it to the teacher, rather than getting into a fight.
Another time, Nilesh went to a school camp and returned in an agitated state. Using Floatback, he recalled that the smell of the farm where the school camp had been was similar to the smell of the farm where he used to go with his father. He said that his father used to take him to a farm and, ‘He (father) used to tell me to do things that I didn’t want to do like cut the lamb and stuff’. It was scary ‘because it was still alive’; ‘It was screaming, other lambs were running away, its legs were moving like it was trying to run away after its head was cut off. I felt scared and disgusted’. He felt calmer after processing this memory.
Nilesh was usually very fidgety and got easily frustrated, especially when asked or expected to sit still. Using Floatback again, he recalled feeling restless, fidgety and frustrated when he and his brother visited their father and stepmother in the weekends and had to sit at the back of the dairy the whole day while the father and stepmother worked. He said, ‘Me and my brother always had to stay at the back of the shop quietly all day till they closed shop’. It also brought up memories of hidings from his father and negative things he had been told by his stepmother, as mentioned above. After processing these memories, he felt far more calm and less fidgety.
Nilesh had frequent fights with his younger brother and expressed a desire to be ‘mean’ to him. Floatback brought up memories of his brother and stepbrother being provided expensive gifts while instead of a much-desired scooter that he had asked for, he was given a cheap substitute. After processing this memory, he felt happier and became more loving toward his brother. A further problem was that his mum leaving home made Nilesh very upset. When she went to a concert, she had to text him pictures of herself to reassure him that she was safe. He also had difficulty falling asleep. Although he could not recall any particular earlier memory that made him fear for his mum’s safety, he disclosed nightmares of his mum being hit by a truck or drowning. Once this nightmare was processed using the EMDR standard protocol, Nilesh was able to be calm and relaxed when his mum left home without him. His sleep also improved. He spent the last two sessions focussing on residual fidgety body sensation. He was able to stay calm at the end of this and said, ‘I feel comfortable staying still’. At discharge, he asked his mum to get him a desk to do homework if she could not afford to buy him a new scooter.
Case 2: James (Multiple Diagnoses and on Multiple Medications)
James, a 17-year-old Pakeha boy, was diagnosed with speech and language delay when aged 3 years, ADHD when aged 5 years, and mild autism spectrum disorder/Aspergers disorder and global learning difficulties soon after. He started methylphenidate (in the form of Ritalin) when aged 5 years, switched to dexamphetamine (another stimulant medication) 6 months later and then to a different form of long-acting methylphenidate (Concerta), which was discontinued because it had an inadequate effect. He had a brief trial of atomoxetine (non-stimulant medication for ADHD) after which he was re-started on Ritalin LA (a long-acting form of Ritalin). Risperidone (an antipsychotic medication sometimes also used for behavioural problems) and oral clonidine (an ‘alpha2 agonist’ that modulates the sympathetic nervous system) twice daily were added for his anxiety and melatonin for sleep.
Born at term by vacuum suction, James had difficulty feeding and often woke crying. He started supplementary feeds at 1 week and was able to sleep through the night 2 weeks later. He went to day care from age 3 months when his mum returned to work. He changed day care centres after 6–9 months at the first centre. He was bullied at primary and intermediate school and at the beginning of high school. When he was aged 7 years, his mum suffered three heart attacks. James had a high level of behavioural problems. In Year 1, his teacher put him at a table away from others because he was disruptive. When aged 11 years, he smashed a school window and wrote on the toilets with permanent markers. He scrapped furniture with a butter knife, and stabbed cushions. He broke the microwave with his fist and slammed a glass door breaking it. He had ‘no idea of personal space’. He felt everyone hated him and started to say that he hates life and wished he was not alive.
I first saw James when he was aged 17 years following a significant meltdown when his mum asked him to clean the kitty litter tray. At this time, he was on oral clonidine 100 mcg twice daily, Ritalin LA 40 mg twice daily, risperidone 2 mg morning and at lunch and melatonin 3 mg at night. I switched him from oral clonidine to a clonidine 0.1 mg TTS weekly patch to avoid problematic ‘rebound’ of the sympathetic nervous system between oral clonidine doses. He did not have any major outbursts after this. My formulation was that past un-resolved traumatic stress, including the experience of his difficult birth, inability to feed, going to day care at 3 months of age, experiencing bullying at school and his mum’s heart attacks, were being triggered in the present, either being causative of or possibly significantly contributing to his current behaviours. After discussing this with James and his parents, he started EMDR therapy.
James had all his EMDR sessions in the sensory room sitting on a rocking chair, with a weighted blanket, to stay within his ‘window of tolerance’. He was supported in the room by either or both parents. I used reciprocal interactions such as throwing and catching a sensory ball in between sets of bi-lateral stimulation eye movements to keep him grounded when he seemed to dissociate. Using EMDR therapy, James first processed the meltdown that had happened just before he came under my care as it was overwhelming. He said, ‘My heart aches and my brain hurts’. After this, he processed his memories in chronological order, starting from the earliest that he could remember. This included memories of bullying and of his mother’s heart attacks.
Following processing the memories of mum’s heart attacks (i.e., how he woke up one morning and found both parents gone, then was told mum had had a heart attack and went to see her at the hospital), he was able to be calm and not get agitated when his mum and dad went for a holiday and when his mum had to go to a conference. It appeared that this memory had caused him to fear for his mum’s life, which made him feel agitated when she left home. He started to perform better at school after processing memories of having been bullied. As he improved, I began bringing down his medication, starting with Ritalin LA, then risperidone. Because he was still quite fidgety, he processed his body sensation of fidgetiness, just like Nilesh had done. As he did this, he said, ‘The buzzing is calming down’ and that his heart was beating slower. He continued processing his body sensation until there was ‘zero buzzing’. I asked, ‘When was the last time you felt zero buzzing?’ He answered, ‘Never’.
Because he continued to get irritable (although to a much lesser level) when asked to leave gaming to help with chores such as feeding the cats, we used the ‘Flashforward’ EMDR technique to process this. With Flashforward, we ask the client to identify a catastrophic future fear (which is highly unlikely to occur). This fear, including its various points of disturbance are then processed. James processed all the points of disturbance pertaining to stopping his gaming. Following this, he was able to come off his computer without significant agitation.
By end the of EMDR therapy, James was weaned off all his medication. He was able to pause gaming and feed the cats or plan this ahead without becoming upset. His dad commented, ‘We are hardly ever having shouts or fights’. James’ sleep had improved. He began to ‘listen in class’ and ask questions, something he had not done before. He became more socially aware and respectful of others’ personal space. He brought a large novel to one of his last sessions, sat on the floor quietly and began reading it while I conversed with his parents.
Discussion
Both Nilesh and James had histories of early childhood adversity. Neither had a ‘big T’ or ‘major’ trauma such a near-death experience, natural disasters, motor vehicle accidents or similar. Nilesh’s traumas would qualify as ACEs, as per the ACE study (Felitti et al., 1998). These traumas included physical violence, verbal and emotional abuse, domestic violence and parental separation. However, the sensation of fidgetiness appeared to link back to the time when he had to sit still for long hours at the back of the shop and not directly to his ACEs, although the ACEs are also likely to have contributed.
James’ adverse experiences included medical trauma of a vacuum suction birth, difficulty feeding soon after birth, going to day care at age 3 months (which may have disrupted attachment and decreased the ‘buffering’ of everyday stress), bullying at school and his mother having heart attacks. These experiences would not be usually considered as ACEs. However, both Nilesh and James were affected by their respective adverse past experiences, despite these experiences not meeting Criterion A for a diagnosis of PTSD (i.e. exposure to actual or threatened death, serious injury or sexual violence). Although James’ mother’s heart attacks would have fulfilled Criterion A for James (‘learning that the traumatic event(s) occurred to a parent or caregiving figure’), he did not appear to meet threshold for a diagnosis of PTSD after the event. I also wondered if this event of ‘losing’ his mother linked back to the time when he was 3 months old when his mother had to return to work when he went to daycare, making him ‘lose’ her in a way. Addressing the impact of these adverse experiences in the way they were stored in the clients’ brains and bodies offered symptom reduction of ADHD. The symptom reduction with EMDR therapy was sustained and exceeded the symptom reduction gained with stimulant medication.
As a psychiatrist in the public and private healthcare systems, I have had to creatively adapt consultation appointments to include medication review and EMDR therapy to maximise time efficiency. This combined medication-EMDR therapy strategy helped me to wean some of my patients off medication, including those with a diagnosis of ADHD, or be able to decrease their current use of medication.
Conclusion
EMDR therapy opens a world of possibilities for sustained healing that can either help people stay off medication or wean off medication. Further research on use of EMDR therapy to specifically decrease the frequency of prescribing stimulant medication for ADHD, or wean patients off stimulant medication is needed. The AIP model used to conceptualise the presenting problems in the context of the person’s life story makes us consider the impact of negative experiences in daily life on our nervous system. Sustained recovery using EMDR therapy, and when needed combining this with other strategies such as sensory-movement, relational, family work, can help decrease the burden on health services and the resulting impact on wider society by starting to ‘close the revolving door’ of relapse and re-presentations for mental disorders, including ADHD.
Written consent was obtained from the clients and their parent/legal guardians.