ADHD - Prevention and screening - What parents can do

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.

• 1. Attachment styles
  • 1.1. Secure attachment style (B attachment)
  • 1.2. Insecure-avoidant attachment style (A-attachment)
  • 1.3. Insecure-ambivalent attachment style (C-attachment)
  • 1.4. Disorganized / disoriented attachment style (D attachment)
  • 1.5. Further studies on parental behavior and children’s reactions
  • 1.6. Attachment styles and ADHD
• 2. Educational goals and values
  • 2.1. Heat
  • 2.2. Security
  • 2.3. Clarity
  • 2.4. Respect
  • 2.5. Positive reinforcement instead of punishment
  • 2.6. Parents’ self-confidence
• 3. Deferral for kindergarten / crèche and school
• 4. Selection of kindergarten / crèche
• 5. Avoidance of pollution and toxins
  • 5.1. Avoid stress and anxiety during pregnancy
  • 5.2. Avoid toxins during pregnancy
• 6. Avoiding and reducing stress
• 7. Enriched Environment
• 8. Breastfeeding instead of bottle feeding
• 9. Vitamin D3 in pregnancy and early childhood
• 10. Administration of probiotics in the first months of life?

1. Attachment styles¶

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

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

1.1. Secure attachment style (B attachment)¶

The secure attachment style is also called autonomous attachment.

• Prevalence in Germany: approx. 60 %¹³
• Parental sensitivity
  • Prompt perception of the child’s signals
  • Correct interpretation of the child’s signals
  • Appropriate and timely response to this
• Show children with secure attachment
  • Behavior
    • Great confidence in the availability of the attachment figure
      • Trust that the attachment figure will not let the child down or react incorrectly
      • Attachment person = safe haven
    • Appropriate behavior in separation situations
      • Children cry
      • Show their negative feelings clearly
      • Accept partial comfort from a strange woman (helper belonging to the test)
    • On the return of the attachment figure
      • Child shows joy
      • Child seeks closeness and contact
      • Turns to other things again shortly afterwards (= trust in attachment figure)
  • Correlating traits
    • Positive correlation with¹⁴
      • Enjoying new things/games/ideas (“novelty seeking”)
      • Reward dependence
        • Tendency to respond clearly to reward signals, especially verbal signals of social recognition, social support and mood.
      • Cooperativeness
        • Willingness to cooperate, helpfulness
        • Social acceptance, empathy, compassion
      • Self-transcendence
        • Ability to engage in dialog and encounter with others
    • Negative correlation with¹⁴
      • Harm avoidance
        • Worries about the expectations of others
        • Fears uncertainty
        • Shy towards strangers
        • Quickly tired.
    • A secure attachment style is least affected by rejection sensitivity¹⁵
  • Stress is shown appropriately
    • Acclimatization in daycare sometimes takes 3 weeks, which is healthy⁸
• Adults with secure attachment:
  • Can speak freely and coherently in the interview about their experiences of attachment, loss and grief with their parents and significant others.¹⁶
  • With a secure bond between mother and child
    • Increases oxytocin levels during social interaction with the child¹⁷
    • The reward regions of the brain are more strongly activated¹⁷
      • Nucleus accumbens (ventral striatum)
      • Hypothalamus
      • Pituitary gland
  • Response to acute stress (TSST) with secure attachment¹⁸
    • Relatively low subjective stress
    • Moderate reaction of the HPA axis (ACTH and cortisol)
    • High oxytocin response

1.2. Insecure-avoidant attachment style (A-attachment)¶

Also called insecure-distanced. English: Dismissive

• Germany: approx. 20 - 25 %⁸
• Children with insecure-avoidant attachment:
  • Lack of confidence in the availability of the attachment figure
    • Lack of trust that the attachment figure will be there reliably and react correctly (child is worried about being let down)
    • Expectations: own wishes / needs will be met with rejection
  • Behavior:
    • Relationship avoidance in order to avoid or control the unpleasant experience of being rejected
    • In a separation situation:
      • Children do not show their negative feelings
      • Do not cry
      • Seem outwardly unimpressed
        • No anxious signs
        • No annoying signs
        • Play on
      • Child seeks comfort from a strange woman (helper belonging to the test) more clearly than securely attached children
      • Neurophysiological stress reactions
        • Cortisol levels increased due to the situation
        • Cortisol stress response higher than in securely attached children
        • Accelerated heartbeat
    • When the attachment figure returns:
      • Attachment person is ignored
      • Child shows no joy
      • Child seeks closeness to another woman (the helper in the test) rather than to their own attachment figure
    • Higher vulnerability to mental disorders⁸
    • Stress is not shown
      • Acclimatization to kindergarten / crèche happens far too quickly (sometimes in 3 days)⁸
  • Correlating character traits:
    • Negative correlation with¹⁴
      • Novelty seeking
• Adults with insecure-avoidant attachment:
  • Reaction of insecurely-avoidantly attached mother to social interaction with child causes
    • Not elevated oxytocin levels¹⁷
    • 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
  • Response to acute stress (TSST)¹⁸
    • Moderate subjectively perceived stress
    • Increased reaction of the HPA axis (cortisol and ACTH)
    • Moderate oxytocin reaction
    • Increased stress response to social conflicts,¹⁹ which varies depending on the stress phenotype²⁰

1.3. Insecure-ambivalent attachment style (C-attachment)¶

Also called insecure-entangled attachment style. English: prooccupied.

• Germany: approx. 10 - 15 %⁸
• Attachment person reacts unreliably, incomprehensibly, unpredictably for the child
  • Frequent change between sensitive and dismissive behavior
  • Behavior of the attachment figure is difficult to predict
  • Child must always worry about attachment
  • Child constantly observes/checks the attachment figure’s mood in order to predict reactions
• Effect:
  • Curiosity and exploratory behavior restricted
  • In a separation situation:
    • Children react anxiously
      • Fear unfamiliar situation
    • Show extreme stress
    • A strange woman (test assistant) is feared just as much as space itself
    • Stress even before the attachment figure leaves
      as no positive outcome of the unknown situation is expected
• Correlating character traits:
  • Positive correlation with¹⁴
    • Harm avoidance
    • Novelty seeking
  • Negative correlation with¹⁴
    • Self-directedness
• Adults with insecure-ambivalent attachment:
  • 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
• Response to acute stress (TSST)¹⁸
  • Moderate level of subjectively perceived stress
  • Moderate HPA reaction (cortisol, ACTH)
  • Relatively low oxytocin response

1.4. Disorganized / disoriented attachment style (D attachment)¶

Also called ambivalent-avoidant (A-/C-attachment style) or unstable-avoidant.

• Germany: approx. 5 - 10 %⁸
• 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
  • Response to acute stress (TSST)¹⁸
    • High subjective perception of stress
    • 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

1.6. Attachment styles and ADHD¶

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 adulthood^{2829 30 31} 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.

2. Educational goals and values¶

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.

2.1. Heat¶

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.

2.2. Security¶

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.

2.3. Clarity¶

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

2.4. Respect¶

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.

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.

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

2.6. Parents’ self-confidence¶

Good parental self-confidence correlates with more positive parenting, especially when the child’s behavior is stressful due to mental impairment.³⁹

3. Deferral for kindergarten / crèche and school¶

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.

More on this at Relatively early school enrollment as a risk for ADHD And Month of birth influences ADHD risk

4. Selection of kindergarten / crèche¶

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

5. Avoidance of pollution and toxins¶

5.1. Avoid stress and anxiety during pregnancy¶

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).

More on this at ⇒ Prenatal stressors as ADHD environmental causes In the section ⇒ Environmental factors as a cause of ADHD in the chapter ⇒ Emergence.

5.2. Avoid toxins during pregnancy¶

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.
• Lead
• Chlorpyrifos (plant protection product)

A more complete list can be found at ⇒ Prenatal stressors as ADHD environmental causes In the section ⇒ Environmental factors as a cause of ADHD in the chapter ⇒ Emergence.

6. Avoiding and reducing stress¶

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

7. Enriched Environment¶

“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.

8. Breastfeeding instead of bottle feeding¶

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

Find out more at ⇒ Bottle feeding increases, breastfeeding reduces ADHD risk In the article ⇒ Environmental factors as a cause of ADHD in the chapter ⇒ Development.

9. Vitamin D3 in pregnancy and early childhood¶

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.