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ADHD is triggered by certain genetic constellations or by early childhood stress, which activates certain gene constellations epigenetically. Epigenetics means, for example, that the function of genes is altered by (de)methylation. For example, the production of a neurotransmitter or the sensitivity of a receptor can be permanently increased or decreased.
The genetic disposition for ADHD is highly hereditary. If there are ancestors with ADHD in the child’s family, this significantly increases the likelihood that the child will also have a corresponding genetic disposition for ADHD.
Children with a genetic predisposition to ADHD are often particularly sensitive.
The early childhood stress exposure required for the manifestation of ADHD therefore does not require the intensity of psychological, physical or sexual abuse, but a relatively mild (but lasting) stress exposure may be sufficient.
The sensitivity of children with ADHD risk genes means that these children can suffer lasting and permanent damage from stresses that do not affect other children. Several of the ADHD risk genes are also opportunity genes. If children with these genes receive special support, they develop better than children without these genes who receive the same support.
More on this at ⇒ Attachment style of parents to child particularly important for opportunity/risk genes.
There is evidence that prevention programs for parents can have a positive influence on the ADHD of their children with ADHD,1 even if this does not help all children, which may also be related to different genetic backgrounds.2
What can parents do to protect their children from ADHD?
First of all, parents should understand the influence that attachment styles have on their children’s physical and mental health and resilience. This applies independently of ADHD, but especially in this case: a negative parenting style is an independent risk factor for ADHD.3 A positive parenting style, especially on the part of the father, can counteract ADHD - especially in sensitive children.4 Likewise, secure attachment can help prevent ADHD, especially in children who have a good ability to regulate their behavioral inhibition.56 Parental engagement weakens the association between prenatal maternal stress and ADHD symptoms of attention-deficit/hyperactivity disorder in girls.7
In positive terms, this means understanding which parenting styles and values protect and support children particularly well.
Furthermore, certain stresses and contact with various substances should be avoided.
An attachment style describes the way in which a person deals with their counterpart in social relationships.
A distinction is made between 4 attachment styles:
Safe
Insecure-avoiding
Uncertain-ambivalent
Disorganized
Parents very often pass on their own attachment patterns to their children. Mothers to 75%, fathers to 65%.8
Knowledge about the importance of attachment behavior could significantly reduce the rate of insecure attachments being passed on. Special courses are offered for this purpose.9
One study found specific stress responses of cortisol, ACTH and oxytocin in people with early traumas - depending on the attachment pattern that now exists.10
Against the background of our research findings that cortisol responses differ according to personality type and the realization that a strong oversupply or undersupply of neurotransmitters and hormones can cause a down- or upregulation of receptor systems, it is questionable whether the following binding pattern-specific stress responses can be assigned in such a detailed, clear and stable manner, or whether they could also be transitional stages to other stress responses. What is certain, however, is that any deviation from an average endocrine stress response, regardless of its direction (excessive or flattened), is a sign of an unhealthy stress load and an imbalance in the stress systems.
The 4 attachment styles describe a progressively deeper and more serious Disorder of Attachment. Any increment that deviates from a secure attachment style is a risk element for mental disorders such as ADHD. The further the attachment style is from secure attachment, the greater the risk.
Disorganized attachment behavior is a particularly strong risk element of ADHD.11. Attachment disorders in children in the first years of life lead to the activation of the DRD4 gene, which is also typical of ADHD, if there is a corresponding genetic disposition.12
Stronger activation of the insular cortex in the cerebrum17
Attach little importance to interpersonal relationships and emotional bonds. They describe the relationship with their parents in a very idealized way, without being able to illustrate this with concrete experiences.16
Stronger ADHD symptoms than a secure attachment style, lower ADHD symptoms than a preoccupied attachment style15
Show in the interview through a lengthy, often contradictory story and description of their diverse relationships how emotionally entangled they still are with their parents and other relationship persons, for example, until adulthood.16
Stronger ADHD symptomatology than an insecure-ambivalent attachment style, much stronger ADHD symptomatology than a secure attachment style.15
Attachment person reacts completely unpredictably for the child
Both threat and attachment figure
Double bind for child cannot be dissolved
E.g. traumatized attachment figures
Trauma reactions (fear of the attachment figure) cannot be explained for children
Children with disorganized attachment:
Behavior:
In a separation situation
Children react unexpectedly and unpredictably
No clear pattern of behavior
May occur, depending on the child:
Stereotypes
Turn in circles
Movement abnormalities
Unfinished / incomplete movement patterns
Freezing of movements / facial expressions for 30 seconds or longer
Anxiety reactions
Anxious facial expression
Raised shoulders, retracted head
Frozen movements
Crying for attachment figure
Mix of A- and C-type strategies
Show extreme stress
A strange woman (test assistant) is just as feared as space itself
Stress even before the attachment figure leaves
as no positive outcome of the unknown situation is expected
On the return of the attachment figure
Attachment person can be ignored, even though they cried for her when they were separated
Adults with disorganized attachment
When they talk about unprocessed losses and experiences of abuse, they sometimes speak incoherently, disorganized, have interrupted thoughts, confuse reality and fantasy. Dissociative states and pseudo-absence may occur. Visual and tactile contact with the other person is lost for seconds to minutes. This incoherent style of speech, which always occurs when unprocessed trauma is discussed (maltreatment, abuse, violence, loss, accident, natural disaster), is an expression of a disorganized representation of unprocessed traumatic experiences and could also be considered PTSD.16
More frequent development of borderline in adolescence21
Flattened response of the HPA axis (ACTH and cortisol)
Medium oxytocin response
1.5. Further studies on parental behavior and children’s reactions¶
A non-supportive (cold, disinterested, dismissive) parenting style in response to the children’s negative emotions resulted in a flattened cortisol stress response and increased negative emotions.22
One study reported 29% secure and 71% insecure attachment in boys with ADHD, with the insecure-ambivalent attachment style predominating. 2.3 traumatic life events were mentioned.23 Another study also found a strong correlation between insecure attachment style and ADHD.24 Another study found more ambivalent and disorganized attachment representations in children with ADHD. Avoidant attachment style was not more common. The results were independent of comorbid ODD, parents’ educational level, the quality of the parent-child relationship or perceived parental competence.25 Another study also found problems in the attachment of people with ADHD to their parents.26
Another study found no connection, but was based on self-reports by the people with ADHD.27 In our opinion, it is questionable whether children can adequately assess the security of their attachment to their parents themselves. Children are unlikely to have a benchmark for this (during childhood). Otherwise, it would be inexplicable that children develop an - albeit dysfunctional - bond even with abusive parents. In our view, the psychological injuries of an insecure attachment arise precisely from the dissonance between a subjectively perceived attachment and the objectively existing attachment. If a person is aware that the attachment figure is wrong in their values, injuries caused by this attachment figure are less damaging.
However, it should be taken into account that in ADHD the symptom of rejection sensitivity causes the subjective feeling of a lack of attachment, so that interviews with people with ADHD do not allow any direct conclusions to be drawn about the actual attachment behavior of the parents.
There are statistically significant, albeit small, correlations between childhood attachment styles and salivary cortisol responses to acute stress in adulthood28293031 and between attachment behavior in adulthood and salivary cortisol responses in relationship conflict situations.3231
According to attachment theory, impulsivity, restlessness, negative attention seeking, hyperactivity and reduced concentration are presented as defensive reactions of a child with an insecure attachment.
Mothers of children with ADHD were portrayed as33
More directive
More repellent
Less rewarding
More intrusive (appropriate self-regulation of arousal states is made more difficult)
Tendency to interrupt the child’s actions
Rigid boundaries in family interactions
Unclear boundaries in family interactions
Seductive or transgressive behavior
Negative parenting styles are linked to ADHD symptoms in childhood and adolescence34
From the parents’ perspective, the variable “criticism - rejection” is the most important explanation for attention difficulties, anxiety and emotional regulation.
From a child’s perspective
the strict parenting style is the most important variable in explaining hyperactivity and emotional regulation.
a warm communication style was significant in predicting lower difficulties in emotion regulation.
The first and most important criterion is: warmth.
The second and equally important criterion is safety.
The third criterion is clarity. Clarity in the sense of foreseeable consequences, of understandable, sensible, comprehensible rules that also apply consistently - for the child as well as for the parents.
The fourth criterion is: respect.
Unconditional and always perceptible warmth.
Warmth is perceptible to the child as an ever-present affection for the child’s inner being that can be felt even in the event of misbehavior.
The more parental warmth 5-year-olds received, the lower their ADHD risk was at age 9.3536
One example is to comfort a child when they are not feeling well - even if they are not feeling well because they have a cold, for example, because they ignored the reminder to put on a jacket yesterday.
Security is a result: the child has the absolute certainty that it is accepted and accepted with all its facets (whether the parents like them or not). This does not mean that the child is allowed to do whatever it wants. Parents have the task of teaching children values. However, this teaching of values, standards and behavior must be done correctly in such a way that the child is simultaneously taught that its perception is correct, that it does not feel or perceive “wrongly” and that the values apply.
A child who feels secure is not afraid to show their emotions - they know that their emotions will be accepted. A securely attached child will take much longer to settle into kindergarten than an insecurely avoidantly attached child who is supposedly easy to care for after just a few days in kindergarten. Supposedly because the stress reaction is the same for all children - only the insecurely-avoidantly attached child does not show this.
Clarity means setting standards that are predictable, foreseeable and comprehensible (plausible, i.e. never arbitrary) for the child. Rules must never be arbitrary. Rules must also apply to those who set them. This does not mean bedtimes, but values. 100% is not required. Exceptions are human - but they must be plausibly justified and they must be so rare that the fundamental validity of the rules is clear. Uncertainty must not arise from apparent arbitrariness.
The validity of rules must not depend on the mood of the day or the mood of the caregiver.
The announcement that it’s eight o’clock for bedtime should not be fought over or completely ignored, depending on the mood of the parent. It’s not about the minute, it’s about the principle. A parent who sometimes lets out a thunderstorm five minutes after the time and sometimes (for no particular reason) looks at the clock for the first time three quarters of an hour after the time, loses the right to demand that the child adheres to the rule. Of course, the parenting right still exists. But if something is not important enough to be adhered to when the parent does not feel like it, then “it” is (justifiably) not considered so important from the child’s point of view that non-compliance actually creates danger. Ultimately, the parent destroys the child’s trust in the set values - the child becomes disoriented.
Clear rules are also a helpful parenting style if ADHD is present.37
In particular, intermittent interventions must be avoided. Educational measures that are only sometimes applied - rules that are not applied consistently, but only occasionally - perhaps every other day - reinforce the undesirable behavior instead of reducing it.38
Respect means recognizing that the child, even if it cannot yet speak, has its own needs and values that are subjectively justified. They are subjectively justified, even if they contradict the parent raising the child.
Subjective justification does not necessarily mean that they are objectively appropriate.
Respect therefore does not mean placing the child’s values above your own or recognizing them if they are not appropriate. Respect means not devaluing the child’s own values (even if they are “wrong”), but gently, warmly, persistently and at the same time consistently communicating to the child what the right standard is.
It is important to accept the child’s perception as a given (and not as evil) in order to convey the “better” values to him or her with sovereign composure.
If the child is “wrong”, this is in the vast majority of cases the result of how adults treat them. Anyone who accuses children of being bad is probably going through the world with the basic attitude that all people are bad.
Example:
It’s time to go to bed. Announcing to a child who is still playing, “It’s eight o’clock now, you’re going to bed”, without any warning or announcement, without the child being able to mentally prepare for the desired or required action, is disrespectful. Imagine this: You are sitting contentedly in the living room reading your favorite newspaper. Suddenly your partner comes into the room and says: “Please take out the trash, now, right away. No, not after the article - now!!!!” How would you feel if no particular reason was apparent? Rightly so: treated disrespectfully. It goes without saying that you have the right to at least finish reading the newspaper article you are reading.
This is even more true for children, who have much less of a sense of time and planning than adults.
It costs nothing to tell your child 20 minutes before bedtime: “In 20 minutes it will be eight”. And ten minutes before again: “It’s ten minutes to bed”. A confident adult who trusts their child to do well will make the third announcement at eight, perhaps a little more clearly, and five past eight the fourth, even clearer or already strict (possibly even ten past eight the fifth and last, but that is a question of parenting style) A wise parent has already planned for one or two overdrafts. These will not always be needed, and when they are, they are a simple way of avoiding a lot of stressful arguments. Not only for the child, but also for the parents.
The important thing for the child is that it can adjust to this. It is respected that they can and may be just as absorbed in something as an adult in their newspaper article or something else. It is also important that there is a (friendly and warm, but clearly practiced) consequence to such an announcement, namely that the child goes to bed at the announced time.
A parent who is annoyed when a child is not on their way to bed a few minutes after eight in response to such an announcement should ask themselves: how sure am I of myself? Am I afraid of not being respected?
Children can quickly distinguish between soft and hard times - that the bus won’t wait if you’re late, while the toothbrush is still in the bathroom five minutes later.
But why should you keep telling a child that they have to go to bed at eight, because they know that?
Children don’t have as good a sense of time as adults. The reverse is also true: the parent already knows a quarter of an hour in advance that it is about to be eight. And it is the parents’ job to lovingly show their children the right way, not the child’s job to anticipate and perfectly adapt the parent’s educational guidelines.
Another example is to criticize the child’s misbehaviour, but not the child as a whole. Anyone who does something wrong needs feedback that the behavior is not okay. Anyone who questions the whole person when they misbehave is behaving disrespectfully.
Respect includes, among other things, giving the child room to maneuver (as independently as possible). This is also helpful for ADHD.37
On the one hand, setting a positive example of the desired behavior (role model) is a completely natural way of teaching children the desired behavior. At the same time, it conveys a form of respect by showing the child that what is desired of him or her is also provided by the child. Positive role modeling is also a helpful behavior when raising children with ADHD.37
2.5. Positive reinforcement instead of punishment¶
Punishment is generally much less suitable for reinforcing a behavior to be learned than positive reinforcement. This also applies to ADHD.37
Children who are among the youngest in their class have an increased risk of ADHD by around 30%. This phenomenon can be found worldwide - with the exception of Denmark.
The background to this is probably the fact that in Denmark children who, in the opinion of their parents, are developmentally delayed can be deferred from starting school quite easily.
It should therefore be worthwhile for children at risk to insist that the school start date be postponed.
Choosing the right kindergarten is of particular importance. It is far more important than choosing the “right” school later on, although elementary school is also more important than the following one.
When making a selection, less emphasis should be placed on specific educational content and much (much) more on how the educators interact with the children. Imparting knowledge only becomes important from school age at the earliest. In infancy, an emotionally warm and affectionate upbringing is much more important. It creates the security with which the children can develop their own skills in later years so that they can then absorb knowledge.
The best educational concept, the most committed development goal is of no use if it is taught to the children in a cognitively cold way. A good crèche, a good kindergarten can be easily recognized by the fact that the children are relaxed and feel comfortable there, that there is a lot of cuddling, cuddling and cuddling. Wonderfully illuminating on this: Becker-Stoll: “Sign out immediately!” When does external care harm the child? What characterizes a sensitive educator?“.40
Mothers should avoid it during pregnancy and breastfeeding:
Stress
The permanently elevated level of cortisol (and other stress hormones) caused by prolonged maternal stress permanently damages the unborn child’s stress systems. While short-term stress (short-term exposure to cortisol) is absorbed by the placenta’s protective mechanisms, these protective mechanisms can no longer protect against long-term exposure to cortisol due to chronic stress.
Persistent anxiety, depression and other psychological stress in the mother cause such stressful conditions
Chronic stress is also extremely harmful for young children up to the age of 3. Another particularly vulnerable age is middle adolescence (approx. 13 to 15 years).
You should also avoid coming into contact with the following substances at all costs:
Alcohol
Nicotine
Other drugs
Risky medications
e.g.
Paracetamol
Benzodiazepines
Β-2-adrenaline receptor agonists
Cortisol (e.g. as medication)
Bisphenol A (BPA)
BPA is still used in many everyday products, e.g:
Plastic bottles, plastic toys, thermal paper, tin can linings, floor coatings made of epoxy resin and much more
BPA acts like a hormone and damages the HPA axis of the unborn child, newborn and child
Even the smallest amounts contribute to the development of diabetes mellitus, obesity, thyroid disorders, developmental disorders, infertility, etc.
Pets (especially medium-sized and large dogs) are therapeutically effective and support the avoidance of stress and stress reduction and help with the automation of rules (feeding, grooming, walking). This applies to parents as well as children - with and without ADHD.37
“Environmental enrichment” in relation to laboratory rodents is defined as “a method of creating a more stimulating environment compared to the initial situation”.
Multiple studies on rodents indicate that animals with an increased risk of ADHD (genetic or environmental) are less likely to develop ADHD or fewer ADHD symptoms if they are kept in an enriched environment.41 Even if such studies cannot simply be transferred to humans, this is consistent with the empirical experience that rich experiences for children promote stable emotional development.
Enriched environment influences the dopaminergic structures of the brain
Mice reared in an enriched environment show
altered mRNA expression for proteins involved in cell proliferation, cell survival and signal transduction, particularly in the striatum42
reduced activating and rewarding effect of stimulants such as cocaine, whose primary mechanism of action is based on the dopamine transporter44
Enriched environment here: larger cages with several toys that were changed once a week
altered gene expression in the striatum and a lower cocaine-induced dopamine level in the striatum4442
However, not all studies on environmental enrichment have shown a benefit, e.g. in mice used as ASD model animals:
Shank3-KO mice showed no improvement in ASD-typical behavior on enriched environment, but rather increased anxiety-like behavior and lower motor performance45
Neuroligin-3 R451C mice reacted with increased aggression.46
Several reports suggest that prolonged breastfeeding of infants reduces the risk of ADHD and other disorders. In addition to the supply of a variety of nutrients in breast milk, the physical contact provided is a decisive factor
Children with ADHD were 1.51 times more likely to be exclusively breastfed for less than 3 months and 52% less likely to be exclusively breastfed for more than 3 months (meta-analysis of k = 11 studies)47
Not breastfeeding increased the risk of ADHD by 3.71 times (OR = 3.71). Children with ADHD had a significantly (2.44 months) shorter duration of breastfeeding (SMD: Hedges’ g = - 0.36)(meta-analysis of k = 11 studies). 47
In a small Lebanese correlational study (n = 119), breastfeeding reduced the risk of ADHD by 74% (OR = 0.263).48
A good level of vitamin D3 in the mother up to birth has a preventive effect on ADHD.49
Plenty of daylight, which produces vitamin D3, appears to counteract ADHD in children. A study shows that ADHD in the USA occurs mainly in the darker East, while the lighter West has lower ADHD rates.50 This requires children to spend enough time in the sun, especially from infancy, avoiding too much clothing and avoiding the constant use of sunscreen. Children who are only exposed to the sun with sun cream with a high sun protection factor cannot produce sufficient D3 and therefore have an increased risk of brain development disorders. The optimal time to stay in the sun without protection is about half the time after the first redness appears.
10. Administration of probiotics in the first months of life?¶
A single study found that of 75 children who received a probiotic (Lactobacillus rhamnosus GG, ATCC 53103) from 0 to 6 months of age, none developed ADHD or ASD by age 13, while in the placebo group 17% received an ADHD or ASD diagnosis according to ICD 10.51
Even if this report is very optimistic, it should not be considered reliable (as is always the case in science) until it has been replicated several times. Until then, the treatment should be considered experimental.
