The Effectiveness of Mentalization-Based Treatment on Empathy among children with Attention Deficit- Hyperactivity Disorder

Attention Deficit-Hyperactivity Disorder (ADHD) is one of the developmental neurological disorders, which is associated with significant disorders in developmental, cognitive, emotional, and educational issues. Mentalization-based therapy enhances the ability of ADHD children to empathize by increasing the reflective function of one’s own and others’ mentalizing capacity and improve the ability to see through the perspective-taking and understanding of one’s own and others' feelings under the influence of ego functions reinforcement. From the theory of ego psychology and object-relations approach, Attention-Deficit Hyperactivity Disorder (ADHD) is a disorder in ego functions (executive functions, inability to regulate emotions, problem-solving, etc.) and the development of a coherent senseof self in relation to others. These children have serious problems in interpersonal relationships, and failure and the dyad of frustration and anger are characteristic of their relationships (1). According to Fonagyet al. (1996), mentalization is a psychological process that facilitates explicit and implicit meaningful interpretation of one's own and others' actions, desires, thoughts, and intentions(2, 3). Mentalization is the result of secure attachment and relationship with the early caregivers. Metallization-Based Therapy (MBT) was originally developed by Bateman and Fonagy for adult patients with borderline personality disorder in the 1990s; but in recent years, this treatment has been used for a wide range of disorders, including childhood disorders. Its purpose is to improve the mentalization skills (understanding of the inner world, point of view and feelings, and one's own desiresand others’ intentions or theory of mind) in the child and the parent. The present study aimed to test the effectiveness of this treatment on the empathic function of children with ADHD, considering there are some deficits in empathic functionsduring developmental lines of such children.

The present study is an experimental study of a one-factor design with three groups of Repeated Measures. The study sample consisted of 60 children (30 girls and 30 boys) with school-age ADHD (6- to 12-year-old) who were selected by targeted sampling. These children first received an initial diagnosis by a psychiatrist and then were assessed by psychologists for entry and exit criteria using the K-SADS-PL DSM-5 diagnostic interview form. The participants’ parents completed EQ-SQ questionnaire in three stages (pre-test, post-test, and follow-up), describing their child. Participating children were randomly assigned to three intervention groups including pharmacotherapy with methylphenidate, MBT-C, and combined method. The interventions lasted for 36 sessions and a follow-up session was held again three months after the end of the treatment. To analyze the data, Repeated Measures ANOVA and Bonferroni Post Hoc tests were used. All participants signed an informed consent form for ethical considerations.

MANOVA results showed that in the intergroup effect test between the three interventions (pharmacotherapy, MBT-C, combined method), there was a significant difference (P <0.001) in the empathy variable. The result of the intragroup effect test was also significant (P <0.001). In addition, the results of the Post Hoc test in  efficacycomparisons for the two-way between the three interventions showed that mentalization-based therapy and combined method were significantly different from the pharmacotherapy group; And its effectiveness in improving empathy in children with ADHD was confirmed. There was no significant difference in effectiveness between MBT-C group and combined method (P > 0.05).

The results confirm that mentalization-based therapy increases the level of empathy in children with ADHD. Mentalization-based therapy is a process-oriented therapy that uses plays to enhance mentalization and introspection, trying to teach and improve the reflective function, thinking, and mentalization capacity of children's mentalization and empathetic companionship and curiosity about the relationship with the child's inner experiences by the parents. Thus, MBT-C can be an effective intervention to improve empathy capacity in children with ADHD by focusing on the interaction of the inner and outer worlds and the regulation of emotions and interpersonal relationships.Data analysis of the present study showed that mentalization-based therapy was effective on empathy in children with ADHD and there was a significant difference between the three interventions of combinedintervention, MBT-C, and pharmacotherapy with methylphenidate in the empathy variable. And combinedintervention and MBT-C were more effective than pharmacotherapy on empathy in children with ADHD. Midgley et al. (2013) stated that the goal of Mentalization-Based Treatment for children (MBT-C) plants the seeds of curiosity and genuine empathy that create an atmosphere full of "emotional oxygen" for both the child and the parents so that they can face the pleasures and experience the challenges of life during the therapy(4). Taylor (2012) also utters that simple mentalization efforts such as support and empathy are effective in treating cases where there is high arousal in children (such as the emotional experiences seen in children with ADHD) (5).Given that mentalization-based treatment seeks to improve children's capacity for reflective functions, thinking, and mentalization, as well as educating reflective functions and practiceempathetic companionship and curiosity about the child's inner experiences to parents, it increases the effectiveness of treatment for ADHD children. Mentalization-based treatmentby use of play builds a powerful medium (for both the child and the parent and therapist) to explore relationships, to learn about the world of feelings, and to discover a psychological voice for oneself as a child. From a mentalization perspective, play is a form of social learning, as all kinds of experiences in daily life are rehearsed, changed, and completed, and integrated into the child's behavioral repertoire through this medium.