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ADHD: Nurture Matters

A recent press release announced: “Children in Foster Care Three Times More Likely to Have ADHD Diagnosis.” A study found that 25% of children in foster care had been diagnosed with ADHD, more than triple the 7.14% of all children in Medicaid who were not in foster care.

The obvious question is why this occurs. Clearly, neglect, abuse, attachment disruptions and emotional upheavals correlate with ADHD symptoms in this population of children in foster homes. In other words, their environment contributed to their mental health condition; the etiology of their ADHD was not strictly biological. If the above mentioned statistics are not pure happenstance, the ways these children were (and were not) taken care of caused them to develop ADHD.

A follow-up question, then, is: Why is the first-line treatment in these and so many other children most often medication? Why are there not more and better-known and used psychologically-based treatments that focus on mitigating abuse and neglect, repairing attachment disruptions, and healing emotional wounds? The issue is not restricted to children diagnosed with ADHD. Recent research reveals that poor children on Medicaid are four times as likely to receive antipsychotic medication as are kids whose parents can afford private insurance:

Some experts say they are stunned by the disparity in prescribing patterns. But others say it reinforces previous indications, and their own experience, that children with diagnoses of mental or emotional problems in low-income families are more likely to be given drugs than receive family counseling or psychotherapy.1

This is not only a mental health issue; it’s a public health and a social justice issue as well.

In the context of neurochemistry, medicating ADHD makes perfect sense. Studies have shown that people with attention-deficit symptoms have, for example, low levels of the neurotransmitter dopamine. If you’re a psychiatrist, and you have a patient complaining that she can’t focus, and you can give her a pill (Ritalin or Adderall) that will increase her dopamine, which will stimulate the “reward center”2 in her brain and increase her motivation, wouldn’t you write the prescription? There are so many cases in which medication has reduced symptoms (only while the drug is active in the body) that it has become by far the most established treatment for ADHD.

One potential problem with the prescription of stimulant medication, in particular, is that a recent study suggests dopamine actually may not be the neuro-culprit.3 But the main problem with this medical approach is not in the neurochemical imbalances that the researchers and the prescribers are seeing plain as day in the data. The problem is that the data lacks environmental context, which turns out to be critically, and therefore clinically, relevant. A wealth of research over the past decade has been bringing into focus a much more complex and sensible picture: apparently—shockingly—what we do with our children permanently affects their mental health! In an editorial titled “‘It’s the environment stupid!’ On epigenetics, programming and plasticity in child mental health,” Edmund J.S. Sonuga-Barke writes:

we are seeing fascinating examples of the power of the environment to shape disorder expression and the neurobiological processes presumed to underpin it. Powerful new concepts are being applied to help explain the ways that environments influence gene expression4 (Mill & Petronis, 2008), program biological systems (Swanson & Wadhwa, 2008) and promote both functional and structural plasticity during brain development (Rapoport & Gogtay, 2008).5 [Emphases added.]

ADHD (and many other diagnoses not included in the scope of this post) is neuro-developmental. The brains—or, more accurately, the entire nervous systems—of children and adults with attentional symptoms have been shaped by their experiences, primarily in early childhood. In “A Developmental Investigation of Inattentiveness and Hyperactivity,” Carlson, Jacobvitz and Sroufe observe:

In early childhood, quality of caregiving more powerfully predicted distractibility, an early precursor of hyperactivity, than did early biological or temperament factors. Caregiving and contextual factors together with early distractibility significantly predicted hyperactivity in middle childhood.6

The mental health consequences of neglect and abuse—as well as parent-child misattunements in fundamentally loving families that simply have normal family problems—can turn out to be lifelong. (Just ask adult ADDers who are struggling to cope with midlife crises.) Can the damage be undone? The short answer is yes. Recent findings in the fields of neuroplasticity7 and somatic-based trauma treatment are demonstrating that permanent healing is possible for those with disrupted nervous systems. Some of us have taken this view all along. The “Nurtured Heart Approach,” developed by Howard Glasser, is a powerful, effective treatment for ADHD, which consists in, essentially, holding the child in “unconditional positive regard”:8 connecting with the child exclusively in love and admiration for who the child is, and disciplining in clear, short, non-punitive ways.

I, for my part, am overjoyed that scientific research is finally proving that we are not biological machines but rather that which we mean when we use the word human. Nevertheless, more research is needed in order to begin to shift the prevailing paradigm, a paradigm in which most people hearing of the Nurtured Heart Approach for the first time find the concept either impossible or ill advised or both.

I do not think prescribing medication for ADHD is bad. I do agree with many critics that medications for ADHD are grossly over-prescribed. If we are just patient and resilient enough ourselves to look more closely at the experiences of young ADDers who are jumping from desk to desk and twirling their hair while gazing at a flower in a jar, we will find that in most cases what they need in their lives is something other than a pill.

  1. “Poor Children Likelier to Get Antipsychotics”, New York Times, December 12, 2009, page A1 of the New York edition. 

  2. There is no “reward center” in the brain. This phrase is a metaphor. The brain is not a county fair; no kewpie dolls are handed out. The human brain is organic, and while we’re alive, it’s alive (and vice-versa). 

  3. “Imaging study shows dopamine dysfunction is not the main cause of Attention Deficit Hyperactivity Disorder (ADHD)” 

  4. It is still commonly thought among the college-educated that genes are to living organisms what programming code is to computer software. It is not so. There is an excellent discussion in Stephen Talbott’s Biology Worthy of Life. Here is an excerpt:

    Picture the situation concretely. Every bodily activity or condition presents its own requirements for gene expression. Whether you are running or sleeping, starving or feasting, getting aroused or calming down, suffering a flesh wound or recovering from pneumonia—in all cases the body and its different cells have specific, almost incomprehensibly complex and changing requirements for differential expression of thousands of genes. And one thing necessary for achieving this expression in all its fine detail is the properly choreographed performance of the chromosomes.

    This performance cannot be captured with an abstract code. Interacting with its surroundings, the chromosome belongs as much to a living activity as any other element in its cellular environment. [Emphasis added.]

  5. Journal of Child Psychology and Psychiatry 51:2 (2010), pp 113–115. 

  6. “A Developmental Investigation of Inattentiveness and Hyperactivity.” Child Development, 1995, 66, 37-54. 

  7. See, for example, Norman Doidge’s book, The Brain’s Way of Healing: Remarkable Discoveries and Recoveries from the Frontiers of Neuroplasticity

  8. The phrase is not Glasser’s; it is from the writings of psychologist Carl Rogers. 

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