Child therapy presents the unique opportunity for creativity amongst therapists and psychiatrists due to the limited knowledge children possess about the therapeutic process, emotions, medications, and a variety of other aspects of psychotherapy. It is a tremendous responsibility for a child’s therapist to utilize age-appropriate communication to educate a child regarding his or her diagnosis, possible treatment options, and how to be actively engaged during their own treatment. One area of communication with children that is especially important is providing a context for the interplay between psychotropic medication, psychotherapy, and the patient’s own involvement in clinical care.

When beginning psychotherapy with a patient, especially a child patient, one of the most important aspects of the initial conversation is to provide realistic expectations regarding what to expect from therapy. Similarly, when a psychiatrist is initially prescribing medication to a child, the psychiatrist will engage in a conversation with the child where they will most likely discuss 1) the rationale for prescribing the specific medication, 2) the expected dosage, 3) possible positive changes that might occur as a result of incorporating the medication into the treatment protocol, and 4) what side effects the patient should be cautious of when beginning the medication.

Although my role as a psychologist does not involve making critical decisions regarding medication, I, too, have a crucial role to play when one of my child patients begins medication. My role is twofold: I am not only an additional source of communication and feedback between the psychiatrist, patient, and family, but I can also serve as a tool to support medication compliance and adherence to the psychotropic treatment protocol.

Since joining the MGH Child/Adolescent Outpatient Psychiatry team nearly a year ago, I have had the tremendous opportunity to collaborate with truly talented and creative psychiatrists. As a result of these collaborations, I have grown in my ability to communicate with my patients regarding the importance of medication compliance and adherence, especially in the lives of children we see frequently in our clinic: those children who have been diagnosed with Attention Deficit Hyperactivity Disorder (ADHD).

According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5; American Psychiatric Association, 2013), 5% of children in the United States meet criteria for ADHD, and these children comprise a significant portion of the cases that many child psychologists work with in their clinics or private practices. ADHD consists of a variety of symptoms that impair executive functioning, such as distractibility, inattention, impulsivity, poor planning, poor organization, procrastination, and poor time management.

For children especially, these symptoms are often significantly detrimental to the ability to successfully navigate emotions and manage given responsibilities throughout the course of the day, such as academic tasks or following directions given by others. In addition to these symptoms impacting an individual’s attention during performance-based tasks, ADHD often has a negative impact on a child’s ability to maintain appropriate and healthy peer relationships (Strine et al., 2006) and children with this diagnosis are more likely to experience accidents and injuries due to their executive functioning challenges (Leibson, Katusic, Barbaresi, Ransom, & O’Brien, 2001). Emotionally, children with ADHD are at increased risk for aggression, depression, social isolation, and conduct concerns when compared to the general population, and ADHD medication has been shown to decrease the severity of these observed behaviors and emotions (Semrud-Clikeman, Pliszka, & Liotti, 2008).

According to the most recent best practices for ADHD report from the American Academy of Pediatrics’ Subcommittee on Attention-Deficit/Hyperactivity Disorder Steering Committee on Quality Improvement and Management (2011), these children will experience the best opportunity for positive change regarding their ADHD symptoms via a combination of behavioral psychotherapy and medication. Although this standard of care is well known within the psychiatric community, many children fail to receive or maintain both aspects of treatment, and therefore are susceptible to receiving suboptimal or less-than-ideal treatment for their ADHD symptoms.

According to recent research by Thiruchelvam, Charach, and Schachar (2001), children’s adherence to often-prescribed stimulant medication fell over the course of three years, with adherence reaching 81% at the end of year one, 67% at the end of year two, and 52% by the end of year three. This specific research also identified several factors that influenced whether a child would adhere to the prescribed medication protocol: Those who were younger or experiencing more significant distress were more likely to continue taking medication.

Although it is easy for me to promote psychotherapy to children impacted by ADHD, given my role as the orchestrator of that specific treatment modality, there is much that can be done to advocate to both the patient and the patient’s family to remain engaged and compliant with psychotropic medication and care. This is especially important given the complex beliefs and perceptions many parents often harbor about psychotropic medications and how it is often a difficult family decision to agree to administer drugs to child (Jackson & Peters, 2008).

And so, this is where superheroes comes into play…

While working with a particular patient this year, I was having difficulty teaching the patient 1) the importance of taking his medication for ADHD, and 2) the importance of recognizing when his medication had ceased working. It was important for both his treatment team and his parents to help him gain more insight into his executive functioning challenges in order to avoid unintended negative behavioral or emotional consequences and to further support him with self-initiating interventions.

While collaborating with this patient’s psychiatrist, I proposed the metaphor of Batman and Robin to help provide a language to speak about the relationship between the patient and his ADHD medication. In this metaphor, the patient is the superhero (because, honestly, everyone dreams of being a superhero), the ADHD medication is the sidekick, and the stressors of the day (e.g., homework, music practice, distracting classmates, etc.) are the villains. Written below is an example of how I might explain the metaphor to a child who recently began a medication regimen for ADHD:

Hey Billy, I spoke to Dr. Mickey Mouse last week and he told me that you began to take medication to give you a little extra support with paying attention and I think that is great. Although it is often difficult to remember to take your medication everyday or to understand how it works, I want to give you a quick story to help you remember how to take your medication and to recognize when your medication might be out of your system at the end of the day. Are you ready to hear it? Great.

So, imagine that you are Batman…how cool would that be!?! I want you to imagine yourself as Batman because Batman is a pretty talented dude: He is smart, respectful, strong, caring, and he has a ton of cool gadgets. Now, imagine that your ADHD medication is Robin, Batman’s sidekick. Robin is dependable, consistent, loyal, and is a great ally to Batman who has been able to save him from trouble many times in the past. Well, when you take your medication in the morning, it is almost like you are Batman and you call Robin in the morning to provide you back up to help clean up the mean streets of Gotham. But, in your case, you are not fighting criminals or doing anything like that. You and Robin are fighting to pay attention in class and be more mindful of your behavior.

Think about it this way: Can you think of some things that distract you in class or at home? Those distractions are like the villains that Batman and Robin fight in the comics and movies because they keep you from being successful or enjoying yourself. So, when you take your medication, you have backup to help you fight those villains and you do not have to spend as much energy fighting those villains on your own or get too frustrated when fighting them alone, like you might have been in the past. On days that you forget to take your medication, you can still fight those villains, but it will be harder and more difficult because you do not have Robin to rely on.

Another important thing to realize about Robin is that he does not get paid overtime, so he only works for about eight hours a day, just like most ADHD medications. So, when you take your medication in the morning, know that you will probably only be able to have Robin help you for about eight to nine hours a day before he goes home. When he goes home for the night, as he will every night, it will mean that you will need to recognize that he is unavailable and that you, Batman, will need to once again fight those villains on your own.

Using Batman and Robin might be a great way for you and your parents to communicate about your medication. Maybe your dad might say something like “Don’t forget to take Robin to school with you this morning,” or your mom might say “Billy, it seems like you’re having a little bit more difficulty paying attention, do you think that Robin might have gone home for the night already?” This way, we can talk about your medication in a cool code without having you worry about other people hearing your business. How does that sound to you?

This metaphor has been useful to help accomplish several goals, including promoting self-efficacy in the child, encouraging the child to be increasingly responsible for personal medication compliance, utilizing mindfulness and metacognition to recognize when the medication is no longer active in the child’s system, and being able to approach medication adherence in a fun and manageable way. This metaphor also provides the family with a cool way to talk about the ADHD medication that may help shield the child from the unfortunate potential of stigma when talking about the medication in more explicit terms (i.e., while in public). I have found this metaphor works well with most young children, given how popular superheroes and comic book mythology are in our society, and there are a variety of characters from which to choose if your patient has a gender preference, for example. Additionally, by identifying as a strong fictional character, the child may start to embody some of the positive traits of this individual and therefore grow in terms of self-esteem and tolerance for stress.

Metaphors like this one exist all around us and they are extremely useful in the implementation of psychotherapy to children, especially given how much of their learning occurs through fables, parables, and other types of narrative expressions. As clinicians, we have the opportunity to invest in our own creativity and the creativity of our patients to make therapy fun and help it come alive in the therapeutic space. And, more importantly, we should share these metaphors with our colleagues and the rest of the clinical community to help cultivate a common language we can all use to better reach the children and families we serve. So, go ahead and steal this metaphor and put it to good use.

If you have a great metaphor you would like to share, please post on Twitter and use the hashtag: #stealthismetaphor.

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Jonathan Jenkins, Psy.D.