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So were we talking about her father or the alligator? Obviously both, but in conquering the alligator, Ella had come to grips with her father’s behavior.


It’s worth noting that over time, the family system had changed: Ella’s mother had benefited as much as her daughter from the relaxation and healthy coping skills I’d taught them. The treatment had helped her recognize her own struggle with anxiety and depression, and she’d come to see how this struggle had affected Ella’s functioning. Thus, she asked her doctor to prescribe an SSRI antidepressant, and was demonstrating more nurturing behavior toward Ella. She’d become a safety advocate for Ella and herself, and as a result, Ella trusted her to be in charge and protect her.

During our final session, I complimented Ella on her hard work and progress and said to her mother, “She’s doing well in school. She can sit still and pay attention. She has no more nightmares and is sleeping in her own bed.”

At this point, Ella interrupted quietly and said, “Dr. Pat, I’m not as afraid of the alligator anymore either. My dad got out of jail, but I can’t see him until he gets better with his anger.”

This case had a good outcome, but I wonder what would have happened if the school’s diagnosis of ADHD had guided Ella’s treatment. We need to be mindful of the possibility of trauma when a child presents with symptoms of ADHD. Child abuse, neglect, and domestic violence occur in all types of families, and we have to do a better job asking the right questions and digging deeper—for the sake of children like Ella.

Case Commentary

By Martha Straus

The differential diagnosis of young children can be challenging even for the most trained and attentive clinician. After all, a five year old has a fairly limited repertoire for communicating distress. Plus, as Pat Pernicano wisely notes in her compelling case study, oppositional behavior, sleep issues, irritability, tantrums, bossiness, and hyperactivity could all be symptoms of a single,or comorbid diagnosis, including ADHD. These same behaviors, however, might also describe a five year old going through a tough patch—a normative, and perhaps transient, response to developmental or environmental stressors. Compounding the issue is the fact that traumatic experiences are more common in communities with fewer resources to treat it, so trauma is inevitably underdiagnosed.

The gold standard for making an ADHD diagnosis includes collecting as many data points as possible, such as a solid developmental history, interviews, assessment, play evaluation, observations, rating scales, and other reports. Such a comprehensive diagnostic assessment makes tremendous sense, and it would assist in sifting out the underlying stressors for young children who are challenging and challenged in those sit-and-be-quiet kindergartens. But it’s hugely expensive. Few children have the benefit of the skilled, costly, and time-consuming protocol that Pernicano describes and so deftly pursues.

I wonder what might be different if schools and physicians did understand the way that trauma can show up as inattention? Would these kids then get competent evaluations? Would classrooms accommodate their special needs for compassionate support and predictable activity? Would they get to go to play therapy?

In terms of play therapy, I particularly admire the combination of directive and nondirective techniques in Pernicano’s intervention. She’s able to make a strong and useful alliance with the mother while engaging in thoughtful dyadic play therapy. This approach has the wonderful advantage of modeling and practicing supportive parenting techniques, relaxation strategies, and coregulation. Ella’s mother was then better able to guide her within the healing metaphors of play and set safe limits for both of them.

Pat Pernicano, PhD, is a licensed psychologist in Louisville, Kentucky. She teaches part-time at Spalding University and treats children and families in Clarksville, Indiana. Her most recent book was Using Trauma-Focused Therapy Stories: Interventions for Therapists, Children, and Their Caregivers. Contact:

Martha Straus, PhD, a professor in the Department of Clinical Psychology at Antioch University New England, is the author of No-Talk Therapy for Children and Adolescents and Adolescent Girls in Crisis: Intervention and Hope. Contact:

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