ADHD - Prevention and Early Intervention - What Parents Can Do

Author: Ulrich Brennecke
Review 09/2024: Waldemar Zdero, M.A. in Psychology

ADHD is triggered by certain genetic configurations or by early childhood stress, which epigenetically activates specific genetic configurations. Epigenetics refers to the process by which, for example, the (de)methylation of genes alters their function. For example, this can permanently increase or decrease the production of a neurotransmitter or the sensitivity of a receptor.

The genetic predisposition to ADHD is highly heritable. If there are relatives in the child’s family who have ADHD, this significantly increases the likelihood that the child also has a corresponding genetic predisposition to ADHD.

Children with a genetic predisposition to ADHD are often particularly sensitive.
The early childhood stress required for ADHD to develop does not, therefore, need to be as intense as psychological, physical, or sexual abuse; even relatively mild (but persistent) stress may be sufficient.

The heightened sensitivity of children with ADHD risk genes means that these children can suffer lasting and permanent harm from stressors that do not affect other children. Many 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 level of support.
For more information, visit ⇒ Parental attachment style is particularly important when it comes to genes associated with opportunities and risks.

There is evidence that prevention programs for parents can have a positive impact on children with ADHD¹, even though this does not help all children—a fact that is likely related to differences in genetic predisposition.²

What can parents do to protect their children from ADHD?

First, parents should understand the impact that attachment styles have on their children’s physical and mental health and resilience. This applies regardless of ADHD and has been demonstrated by studies on ADHD: A negative parenting style is an independent risk factor for ADHD.³ A positive parenting style, particularly on the part of the father, can counteract ADHD—especially in sensitive children.⁴ Likewise, a secure attachment can help prevent ADHD, particularly in children who have a good ability to regulate their behavioral inhibition.⁵⁶ Parental involvement weakens the association between prenatal maternal stress and ADHD symptoms in girls.⁷
Parenting training can improve the quality of the parent-child bond.⁸

Put positively, this means understanding which parenting styles and values are particularly effective in protecting and supporting children.

In addition, certain types of physical strain and contact with various substances should be avoided.

1. Attachment Styles¶

An attachment style describes the way a person interacts with others in social relationships.
There are four distinct attachment styles:

• Certainly
• Uncertain-avoidant
• Uncertain-ambivalent
• Disorganized

Parents very often pass on their own attachment styles to their children. This is true for 75% of mothers and 65% of fathers.⁹
Understanding the importance of attachment behavior could significantly reduce the rate of insecure attachments being passed on. Special courses are offered for this purpose.¹⁰

The four attachment styles describe a progressive, increasingly severe impairment of the ability to form attachments. Each increment that deviates from a secure attachment style is a risk factor for mental disorders such as ADHD.
Of course, parents—like everyone else—aren’t 100% consistent. Recognizing that this is a natural part of life and is acceptable—without accepting it as a permanent state—can be a positive experience for children and help them avoid an excessive drive for perfection. (“Losing your balance from time to time is part of living a balanced life.” Elizabeth Gilbert: Eat, Pray, Love.)
However, the further the attachment style is from a secure attachment overall, the greater the risk.
Disorganized attachment behavior is a particularly strong risk factor for ADHD.¹². Attachment disorders in children during the first years of life, when combined with a corresponding genetic predisposition, lead to the activation of the DRD4 gene, which is also characteristic of ADHD.¹³

1.1. Secure attachment style (B-attachment)¶

The secure attachment style is also known as autonomous attachment.

• Prevalence in Germany: approx. 60%¹⁴
• Parental Sensitivity
  • Prompt recognition of the child’s cues
  • Correct interpretation of a child’s cues
  • An appropriate and timely response to this
• Show children with secure attachments
  • Behavior
    • Great confidence in the availability of the primary caregiver
      • Confidence that the primary caregiver will not abandon the child or react inappropriately
      • Attachment figure = safe haven
    • Appropriate Behavior During a Breakup
      • Children cry
      • Clearly express their negative feelings
      • Sometimes accept comfort from a woman they don’t know (a helper participating in the test)
    • Upon the return of the primary caregiver
      • Child Shows Joy
      • A child seeks closeness and contact
      • Shortly afterward, turns his attention back to other things (= trust in his primary caregiver)
  • Correlated traits
    • Positive correlation with¹⁵
      • Enjoyment of constantly new things/games/ideas (“novelty seeking”)
      • Reward dependence
        • A tendency to respond strongly to reward cues, particularly verbal cues of social recognition, social support, and mood.
      • Cooperativeness
        • Willingness to cooperate, willingness to help
        • Social acceptance, empathy, compassion
      • Self-transcendence
        • Ability to engage in dialogue and interact with others
    • Negative correlation with¹⁵
      • Harm Avoidance
        • Is worried about what others expect
        • Fears uncertainty
        • Shy around strangers
        • Gets tired quickly.
    • A secure attachment style is the least affected by rejection sensitivity¹⁶
  • Stress is portrayed realistically
    • The adjustment period at daycare can sometimes take 3 weeks, which is actually healthy⁹
• Adults with secure attachments:
  • Are able to speak freely and coherently during an interview about their experiences of attachment, loss, and grief with their parents and significant others.¹⁷
  • When there is a secure bond between mother and child
    • Oxytocin levels rise during social interaction with the child¹⁸
    • The brain’s reward regions are activated more strongly:¹⁸
      • Nucleus accumbens (ventral striatum)
      • Hypothalamus
      • Pituitary gland
  • Acute Stress Response (TSST) in Securely Attached Individuals:¹⁹
    • Relatively low levels of subjective stress
    • Moderate response of the HPA axis (ACTH and cortisol)
    • Strong oxytocin response

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

Also known as “insecure-distant.” English: Dismissive

• Germany: approx. 20–25%⁹
• Children with an anxious-avoidant attachment style:
  • Lack of confidence in the availability of the primary caregiver
    • A lack of confidence that the attachment figure will be reliably present and respond appropriately (the child is worried about being abandoned)
    • Expectations: One’s own wishes and needs will be rejected
  • Behavior:
    • Avoiding relationships in order to avoid or control the unpleasant experience of being rejected
    • In a separation situation:
      • Children don’t show their negative feelings
      • Don’t cry
      • Appear unimpressed on the surface
        • No signs of fear
        • No troubling signs
        • Continue playing
      • A child seeks comfort from a stranger (a research assistant involved in the test) more clearly than children who are securely attached
      • Neurophysiological stress responses
        • Cortisol levels elevated due to the situation
        • Cortisol stress response higher than in securely attached children
        • Rapid heartbeat
    • When the primary caregiver returns:
      • The primary caregiver is being ignored
      • The child shows no joy
      • Child seeks closeness more with a stranger (a research assistant involved in the test) than with his or her own primary caregiver
    • Greater vulnerability to mental disorders⁹
    • Stress is not shown
      • The adjustment period at preschool or daycare goes by way too fast (sometimes in just 3 days)⁹
  • Correlated traits:
    • Negative correlation with¹⁵
      • Novelty Seeking
• Adults with an anxious-avoidant attachment style:
  • The reaction of an insecure-avoidant attached mother to social interaction with her child results in
    • No elevated oxytocin levels¹⁸
    • Greater activation of the insular cortex in the cerebrum¹⁸
  • They attach little importance to interpersonal relationships and emotional bonds. They describe their relationship with their parents in a highly idealized way, without being able to illustrate this with specific experiences.¹⁷
  • More severe ADHD symptoms than a secure attachment style; less severe ADHD symptoms than an insecure-preoccupied attachment style¹⁶
  • Acute Stress Response (TSST):¹⁹
    • Moderate subjectively perceived stress
    • Increased response of the HPA axis (cortisol and ACTH)
    • Moderate oxytocin response
    • An increased stress response to social conflicts,²⁰ which varies depending on the stress phenotype²¹

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

Also known as the anxious-avoidant attachment style. English: preoccupied.

• Germany: approx. 10–15%⁹
• The primary caregiver’s behavior toward the child is unreliable, incomprehensible, and unpredictable
  • Frequent shifts between sensitive and dismissive behavior
  • It is difficult to predict the behavior of the primary caregiver
  • A child must always worry about forming attachments
  • The child constantly observes and assesses the caregiver’s mood in order to anticipate reactions
• Effect:
  • Curiosity and exploration behaviors are restricted
  • In a separation situation:
    • Children react with fear
      • Fear unfamiliar situations
    • Indicate extreme stress
    • A stranger (test assistant) is just as feared as the room itself
    • Stress Even Before the Caregiver Leaves
      since a positive outcome of the unknown situation is not expected
• Correlated traits:
  • Positive correlation with¹⁵
    • Harm avoidance
    • Novelty Seeking
  • Negative correlation with¹⁵
    • Self-directedness
• Adults with an insecure-ambivalent attachment style:
  • In the interview, through a long-winded, often contradictory account and description of their complex relationships, they reveal just how emotionally entangled they still are—even into adulthood—with their parents and other significant others.¹⁷
• More severe ADHD symptoms than an insecure-ambivalent attachment style; much more severe ADHD symptoms than a secure attachment style.¹⁶
• Acute Stress Response (TSST):¹⁹
  • A moderate level of subjectively perceived stress
  • Moderate HPA response (cortisol, ACTH)
  • Relatively low oxytocin response

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

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

• Germany: approx. 5–10%⁹
• The child’s primary caregiver reacts in a way that is completely unpredictable to the child
  • Both a threat and a primary caregiver
  • Child Unable to Resolve Double-Bind
  • E.g., traumatized caregivers
    • Trauma reactions (fear of the attachment figure) are difficult for children to understand
• Children with disorganized attachment:
  • Behavior:
    • In a separation
      • Children react in unexpected and unpredictable ways
      • No clear pattern of behavior
        Depending on the child, the following may occur:
        • Stereotypes
          • Spin in a circle
        • Movement abnormalities
          • Unfinished / incomplete movement patterns
          • Freezing of movements / facial expressions for 30 seconds or longer
        • Anxiety reactions
          • A fearful expression
          • Shoulders hunched, head bowed
          • Frozen movements
        • Crying for a caregiver
        • A combination of Type A and Type C strategies
        • Indicate extreme stress
      • A stranger (test assistant) is just as feared as the room itself
      • Stress Even Before the Caregiver Leaves
        since a positive outcome of the unknown situation is not expected
    • Upon the return of the primary caregiver
      • The attachment figure can be ignored, even though the child cried out for them when separated
• Adults with disorganized attachment
  • When they talk about unresolved losses and experiences of abuse, they sometimes speak incoherently, in a disorganized manner, have breaks in their train of thought, and confuse reality with fantasy. Dissociative states may occur, as well as pseudo-absences. Eye contact and emotional connection with the conversation partner are lost for seconds to minutes. This incoherent style of speech, which always occurs when the unprocessed trauma is discussed (mistreatment, abuse, violence, loss, accident, natural disaster), is an expression of a disorganized representation of the unprocessed traumatic experiences and could also be considered PTSD.¹⁷
  • More Frequent Development of Borderline Personality Disorder in Adolescence²²
  • Response to Acute Stress (TSST)¹⁹
    • High subjective perception of stress
    • Blunted response of the HPA axis (ACTH and cortisol)
    • Moderate oxytocin response

1.5. Further Studies on Parental Behavior and Children’s Reactions¶

A non-supportive (cold, disinterested, dismissive) parenting style in response to children’s negative emotions resulted in a blunted cortisol stress response and increased negative emotions in the children.²³

The association between maternal ADHD and parental parenting stress was fully mediated statistically by maternal depression.²⁴

1.6. Attachment Styles and ADHD¶

A study reports that 29% of boys with ADHD have a secure attachment style and 71% have an insecure attachment style, with the insecure-ambivalent attachment style being the most common. An average of 2.3 traumatic life events were reported.²⁵ Another study also found a strong correlation between insecure attachment styles and ADHD.²⁶ A different 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, parental educational level, the quality of the parent-child relationship, or perceived parental competence.²⁷ Another study also found attachment problems between people with ADHD and their parents.²⁸
Another study found no correlation, though it was based on self-reports from people with ADHD.²⁹ In our view, it is questionable whether children are capable of adequately assessing the security of their attachment to their parents on their own. Children likely do not yet have a point of reference for this (during childhood). Otherwise, it would be impossible to explain why children form an attachment—albeit a dysfunctional one—even to abusive parents. In our view, the psychological harm resulting from an insecure attachment arises precisely from the dissonance between a subjectively perceived attachment and the objectively existing one. If a person is aware that the attachment figure is wrong in their values, the harm caused by that attachment figure is less damaging.

However, it should be noted that in ADHD, the symptom of rejection sensitivity causes a subjective feeling of a lack of attachment, so surveys of people with ADHD do not allow for direct conclusions about the parents’ actual attachment behavior.

There are statistically significant, albeit modest, associations between childhood attachment styles and salivary cortisol responses to acute stress in adulthood^{3031 32 33} as well as between attachment behavior in adulthood and salivary cortisol responses in situations of relationship conflict.³⁴³³

According to attachment theory, impulsivity, restlessness, negative attention-seeking, hyperactivity, and poor concentration are seen as defensive reactions in a child with an insecure attachment.
Mothers of children with ADHD were portrayed as³⁵

• More directive
• More dismissive
• Less rewarding
• More intrusive (making it more difficult to regulate arousal levels appropriately)
• Tendency to interrupt the child’s actions
• Rigid Boundaries in Family Interactions
• Unclear Boundaries in Family Interactions
• Seductive or inappropriate behavior

Negative parenting styles are associated with ADHD symptoms in childhood and adolescence.³⁶
From the parents’ perspective, the “criticism–rejection” variable is the most important factor explaining attention difficulties, anxiety, and emotional regulation.
From a child’s perspective, it was

• a strict parenting style is the most important variable in explaining hyperactivity and emotional regulation.
• A warm communication style is a significant predictor of fewer difficulties with emotion regulation.

2. Educational Goals and Values¶

There are helpful parenting guidelines that can also be useful when dealing with ADHD.³⁷

We consider the following to be particularly valuable:
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 predictable consistency, of rules that are understandable, sensible, and transparent—and that are applied consistently—for the child as well as for the parents.
The fourth criterion is: respect.

2.1. Heat¶

Unconditional and always palpable warmth.
To a child, warmth is perceived as a constant affection for the child’s inner being—one that is felt even when the child misbehaves.
One example is comforting a child when he or she isn’t feeling well—even if the reason he or she isn’t feeling well is, for example, because he or she has a cold or because he or she ignored the reminder yesterday to put on a jacket.

The more parental warmth 5-year-olds received, the lower their risk of ADHD was at age 9.³⁸³⁹
Similarly, low levels of warmth from either the father or mother (to an equal extent) toward 30-month-old infants were associated with an increased likelihood of an ADHD diagnosis in elementary school (from the father: +107%, from the mother: +102%).⁴⁰
ADHD, including subclinical ADHD in children, was associated with less warm parental behavior.⁴¹

Reduced emotional availability on the part of the mother correlated with increased ADHD symptoms in the child, with lower scores on the “Non-Hostility” subscale being particularly associated with ADHD symptoms.⁴²

2.2. Safety¶

Security is a result: The child has the absolute certainty that he or she is accepted and embraced in all his or her facets (whether the parents like them or not). This does not mean that the child is allowed to do whatever comes to mind. Parents have the responsibility to instill values in their children. However, this process of instilling values, standards, and behaviors must be done in such a way that the child simultaneously understands that their perception is valid, that they are not “wrong” in how they feel or perceive things, and that these values are valid.

A child who feels secure is less hesitant to show their emotions—they know they will be accepted just as they are. A securely attached child is more likely to need a longer-than-average adjustment period to kindergarten than an insecure-avoidant child, who—supposedly because they’re easy to care for—gets along just fine after only a few days in kindergarten. I say “supposedly” because the stress response is the same in all children—it’s just that the child with an insecure-avoidant attachment does not show it.

2.3. Clarity¶

Clarity means setting standards that are predictable, foreseeable, and understandable (plausible) for the child. Rules must never be arbitrary. Rules must also apply to the person who sets them. This does not refer to bedtime, but to values. 100% compliance is not required. Exceptions are human—but they must be justified in a plausible way, and they must be so rare that the fundamental validity of the rules is unambiguous. There must be no uncertainty arising from apparent arbitrariness.
The enforcement of rules must not depend on the caregiver’s daily condition or mood.

The rule that bedtime is at eight shouldn’t be strictly enforced one moment and completely ignored the next, depending on the parent’s mood. It’s not about the exact minute; it’s about the principle. A parent who is unpredictable—sometimes launching into a tirade five minutes past the appointed time and other times (for no particular reason) not glancing at the clock until three-quarters of an hour later—loses a significant amount of credibility when it comes to demanding that the child follow the rule. If such inconsistencies aren’t isolated incidents but a systematic part of how the situation is handled, children definitely pick up on it, even if they don’t always consciously process it.
Of course, the right to discipline remains. However, the more a rule is subject to arbitrariness or the parent’s whims, the more it conveys the message that following the rule cannot be that important—and that failing to follow it does not actually pose any danger. Ultimately, the parent or guardian undermines the child’s trust in the established values—leaving the child feeling disoriented.
The other extreme would be following rules for the sake of the rules themselves. This implies that rules do not have a purpose that arises from the matter at hand, but rather that their justification stems solely from the authority of the one who sets them. This devalues rules. Respect is not something that can be enforced through rules. Every person can only earn respect; it cannot be enforced. Enforced respect is always hollow.

Clear rules are also a helpful parenting approach for children with ADHD.⁴³

In particular, intermittent interventions must be avoided. Disciplinary measures that are taken only occasionally—rules that are not applied consistently but only sporadically—perhaps every other day or every third day—reinforce the undesirable behavior rather than reducing it.⁴⁴

Unpredictable or inconsistent rules or signals from parents or caregivers are another cause of early childhood stress. An increased prevalence correlates with a higher likelihood of a mental health diagnosis (ADHD, anxiety, depression, externalizing problems, sleep disorders) or a physical health diagnosis (obesity, abdominal pain, asthma, headaches). Including unpredictable or contradictory rules or signals in stress screening can help explain risks for depression, obesity, and sleep disorders that have been overlooked by previous screening methods.⁴⁵

2.4. Respect¶

Respect means recognizing that even though a child cannot yet speak, it has its own needs and values that are subjectively valid. They are subjectively valid even if they go against the wishes of the parent raising the child.

By definition, being subjectively justified does not mean that they are also objectively appropriate.

Respect, therefore, does not mean placing the child’s values above your own or accepting them when they are inappropriate. Respect means not dismissing the child’s own values (even if they are “wrong”), but rather gently, warmly, and persistently—while remaining consistent—helping the child understand what the correct standard is.
The key is to accept the child’s perception as a given (and not as something bad) in order to instill “better” values in the child with confident composure.

If a child is “bad,” in the vast majority of cases, it is the result of how adults treat them. Anyone who assumes the worst of children probably goes through life with the basic belief that all people are bad.

Low levels of attention and acceptance toward 30-month-old infants on the part of either the father or mother (to the same extent) were associated with an increased likelihood of an ADHD diagnosis in elementary school (on the father’s side: +97%, from the mother’s side: +47%).⁴⁰
A high degree of neglect and restrictions imposed on 30-month-old infants by either the father or the mother (to the same extent) resulted in an increased likelihood of an ADHD diagnosis during elementary school (by the father: +109%, from the mother’s side +106%).⁴⁰

Children quickly learn to distinguish between flexible and strict rules—that is, the bus won’t wait if you’re late, while your toothbrush will still be in the bathroom five minutes later.

Respect involves, among other things, allowing people the freedom to act (as independently as possible). This is also helpful for those with ADHD.⁴³

Demonstrating the desired behavior (role modeling) is, on the one hand, a very natural way to teach children how to behave. At the same time, it conveys a sense of respect by showing the child that the adult also practices what is expected of the child. Setting a positive example is also a helpful approach when raising children with ADHD.⁴³

2.5. Time Together¶

Low levels of outdoor and social activities with 30-month-old infants on the part of either the father or mother (to the same extent) were associated with an increased likelihood of an ADHD diagnosis in elementary school (on the father’s side: +74%, on the mother’s side: +60%).⁴⁰

2.6. Communication Style¶

A parenting communication style focused on emotions as well as on solutions was associated with significantly lower levels of emotional dysregulation in children than a non-supportive communication style.⁴⁶

2.7. Positive reinforcement instead of punishment¶

In general, punishment is far less effective than positive reinforcement at reinforcing a behavior that needs to be learned. This also applies to ADHD.⁴³

One hypothesis suggests that ADHD behaviors are a functional expression of delay aversion—a strong motivational disposition to avoid or escape negative emotional states caused by delay. The hypothesis is that the strength of this disposition, although neurobiologically rooted, is exacerbated by early negative social interactions during waiting-related encounters.
A longitudinal study of n = 112 preschool children and their parents from London, UK, and Hong Kong observed the children’s performance, behavior, and emotional reactions, as well as their parents’ reactions during a Parent-Child Delay Frustration Task (PC-DeFT) and two control tasks without a waiting period. Teachers assessed the children’s ADHD-related behaviors and their aversion to delays at the start of the study and at the follow-up (12–18 months later).
At the start of the study, the children’s maladaptive performance correlated with negative parental reactions during the PC-DeFT and with teachers’ ratings of ADHD and delay aversion. Negative parental reactions during the PC-DeFT at the start of the study predicted an increase in teacher-rated ADHD behaviors at the follow-up, but similar associations were not observed for parental reactions at baseline in the non-waiting tasks. The increase in ADHD symptoms in children associated with negative parental reactions at the start of the study was statistically mediated by delay aversion. These long-term effects were consistent across the samples from the United Kingdom and Hong Kong.
The authors conclude that parents’ negative reactions to preschoolers’ attempts to cope with delays are associated with an increase in ADHD-related behaviors over time and with an increase in delay aversion.⁴⁷

Children from a school with a punitive disciplinary style lied much more frequently and developed the skills needed to lie several years earlier.⁴⁸

2.9. Parents’ Self-Confidence¶

High levels of self-confidence among parents are associated with more positive parenting, particularly when the child exhibits challenging behaviors due to a mental health condition.⁴⁹

2.10. Preventing and Reducing Stress¶

Pets (especially medium- and large-sized dogs) have therapeutic benefits; they help prevent and reduce stress and aid in establishing routines (feeding, grooming, walking). This applies to parents as well as children—with or without ADHD.⁴³

2.11. Enriched Environment - Fostering Rich Experiences¶

“Environmental enrichment” is defined, in the context of laboratory rodents, as “a method of creating an environment that is more stimulating than the baseline condition.”
Numerous studies on rodents suggest that animals—whether or not they have an increased risk of ADHD (due to genetic or environmental factors)—are less likely to develop ADHD or exhibit fewer ADHD symptoms when they grow up in an enriched environment.⁵⁰⁵¹ Although such studies cannot, by their very nature, be easily extrapolated to humans, this finding is consistent with the empirical observation that a rich range of experiences promotes stable emotional development in children.

2.12. Fostering Positive Childhood Experiences¶

Positive childhood experiences significantly reduced the risk of suicide among individuals with ADHD and ASD.
ADHD (d = 0.45) is the psychiatric condition with the highest risk of suicide after depression (d = 0.90). (Meta-analysis, k = 58, n = 626,486,590)⁵⁸

Positive childhood experiences include supportive and nurturing experiences and relationships during childhood:⁵⁹

• the ability to talk with family members about feelings
• the feeling of being supported by one’s family during difficult times
• Enjoyment of participating in community traditions
• the sense of belonging in high school
• the feeling of being supported by friends
• having at least two adults outside the family who show genuine interest
• the feeling of being cared for and protected by an adult at home

Among adults, the likelihood of depression and/or poor mental health was

• 72% lower for those with 6 to 7 positive childhood experiences than for those with 0 to 2 positive childhood experiences
• 50% lower for those with 3 to 5 positive childhood experiences than for those with 0 to 2 positive childhood experiences

2.13. Reservations for Preschool/Daycare and School¶

Children who are among the youngest in their class have a roughly 30% higher risk of ADHD. This phenomenon is observed worldwide—with the exception of Denmark.
The reason for this is likely that in Denmark, children whom their parents believe to be developmentally delayed can be deferred from starting school with relative ease.
For at-risk children, it should therefore be worthwhile to insist on postponing the start of school.

For more information, see Relatively Early School Enrollment as a Risk Factor for ADHD And Month of Birth Influences ADHD Risk

2.14. Choosing a Preschool or Daycare¶

Choosing the right preschool is of particular importance. It is far more important than choosing the “right” school later on—although, even in that case, elementary school is more important than the schools that follow.

When making a choice, less emphasis should be placed on specific educational content, and much (indeed, far more) on how the educators interact with the children. The transmission of knowledge becomes important only once children reach school age, at the earliest. In early childhood, an emotionally warm and attentive upbringing is far more important. It creates the sense of security that allows children to develop their own abilities in later years, enabling them to then absorb knowledge.

Even the best educational approach and the most dedicated developmental goals are useless if they are taught to children in a cold, impersonal way. A good daycare center or preschool is quite easy to recognize by the fact that the children move about freely and feel at ease there, and that there is plenty of cuddling, hugging, and affection. A wonderfully enlightening read on this topic: Becker-Stoll: “Withdraw Your Child Immediately!” When Does Childcare Harm a Child? What Defines a Sensitive Educator?”.⁶⁰

3. Avoiding Stress and Toxins¶

3.1. Avoiding Stress and Anxiety During Pregnancy (+72% to +100%; with 5HTTLPR +800%)¶

During pregnancy and while breastfeeding, mothers should avoid:

• Stress
  • Persistently elevated levels of cortisol (and other stress hormones) in the mother during prolonged stress cause permanent damage to the stress response systems of the unborn child. While short-term stress (short-term cortisol exposure) is mitigated by the placenta’s protective mechanisms, these mechanisms can no longer provide protection against long-term cortisol exposure resulting from chronic stress.
  • Persistent anxiety, depression, and other psychological distress in the mother can lead to such stressful conditions

Chronic stress is also extremely harmful to toddlers up to age 3. Another particularly vulnerable age group is early adolescence (approximately ages 13 to 15).

For more information, visit ⇒ Prenatal Stressors as Environmental Causes of ADHD In the section ⇒ Environmental factors as causes of ADHD in the chapter ⇒ Development.

3.2. Avoid toxins during pregnancy and breastfeeding (up to +778%)¶

Furthermore, mothers should definitely avoid coming into contact with the following substances (incomplete list):

• Alcohol (+778%)
• Nicotine
  • Maternal nicotine use during pregnancy (+58% to +378%)
  • Nicotine use by a parent before conception (+259%)
• Other drugs (up to +200%)
• High-risk medications
  e.g.,
  • Paracetamol (+37% to +250%, controversial)
  • Cortisol (e.g., as a medication)
  • SSRI (0% to +63%)
  • Β-2-adrenoreceptor agonists (+30%)
  • Pregabalin (+29%)
  • Antibiotics during pregnancy (+14%)
  • Antiepileptic drugs: Valproate during pregnancy (+12%)
• Lead
  • Water from old water pipes
• Polycyclic aromatic hydrocarbons (PAH) (+99 to 157%)
• Polychlorinated biphenyls / Polychlorinated biphenyl ethers (+23%)
  • Bisphenol A (BPA) is still used in many everyday products, such as:
    Plastic bottles, plastic toys, thermal paper, can liners, epoxy resin floor coatings, and much more
  • BPA acts like a hormone and damages the HPA axis in fetuses, newborns, and children
  • Even the smallest amounts contribute to the development of diabetes mellitus, obesity, thyroid disorders, developmental disorders, infertility, etc.
• Pyrethroids
  • 1st Generation: Allethrin
  • Second-generation pyrethroids: fenvalerate, permethrin
  • Fourth-generation pyrethroids include: bifenthrin, cypermethrin, cyfluthrin, deltamethrin, flucythrinate, and prallethrin
  • The pyrethroid deltamethrin can pass from a woman’s skin into her breast milk via her bloodstream.⁶¹
  • Brand names of products containing deltamethrin: Butox, Decis, Deltamax, Deltatic, K-Obiol, K-Othrine, Latroxin Delta, Prevendog, Scalibor, Scatto⁶²
  • Included in
    • Insect Poisons (Mosquitoes, Malaria-Prevention Nets, Bed Bugs, Head Lice, Pubic Lice, and Clothing Lice, Scabies Mites / Scabies)
    • Plant protection products
    • Sprays and shampoos to treat ticks, fleas, and sand flies in dogs
    • Grains (residues—up to 2 mg/kg are permitted in Switzerland)
    • Aircraft Cabins (Disinfection of Air and Surfaces, Including During Flight)⁶³
      • Extent of the consequences unclear
      • Pyrethrins
        • Cabin air: 50 to 80 μg/m³ possible; 0.05 μg/m³ after 1 hour
        • Surface contacts: 150–300 μg
      • D-Phenothrin (less toxic) is required in some countries for the disinsection of landing aircraft
        • 20 to 57 μg/m³ possible; after 1 hour, 0.1 to 0.7 μg/m³
        • MAK value: 5 mg/m³
• Chlorpyrifos (pesticide)

Exposure to pesticides can also occur during agricultural use (application in fields).

Take special care with plant protection products or insecticides indoors, as these do not break down when exposed to sunlight and cannot be removed through air circulation.
After being outdoors, do not wear the same clothes indoors; change immediately and wash them; do not leave them lying around the house.

A more complete list can be found at ⇒ Prenatal Stressors as Environmental Causes of ADHD In the section ⇒ Environmental Factors as Causes of ADHD in the chapter ⇒ Development.

3.3. Avoiding Infections During Pregnancy¶

Bacterial and viral infections in the mother during pregnancy increase the risk of ADHD in her children.
Maternal fever during pregnancy (+31% to +164%)

For more information, see Prenatal Stressors as Environmental Causes of ADHD In the chapter “ : Origins”.

3.4. Avoid elevated or decreased thyroxine levels during pregnancy (up to +310%)¶

Elevated or decreased thyroxine levels can nearly quadruple the risk of ADHD.
For more information, see Prenatal Stressors as Environmental Causes of ADHD In the chapter “ : Origins”.

3.5. Preventing Anemia in Mothers During Pregnancy (+31%)¶

Maternal anemia during pregnancy increased the risk of ADHD in the child by 31%.
For more information, see Prenatal Stressors as Environmental Causes of ADHD In the chapter “ : Origins”.

3.6. ADHD Medications During Pregnancy¶

Among n = 11,075 pregnancies, the use of ADHD medications was associated with a higher risk of preterm birth:⁶⁴

• during early pregnancy
  • by 29% for 2 or more prescriptions
  • 8% for 1 prescription
  • by 1% for every 30 days of cumulative ADHD medication use
• during late pregnancy
  • by 15% with each dose of ADHD medication
  • by 7% for every 30 days of cumulative ADHD medication use

4. Positive Living Conditions¶

4.1. A Balanced Diet During Pregnancy¶

There is evidence that a high-fat diet during pregnancy increases the risk of impulsivity, while a low-protein diet increased the risk of inattention.⁶⁵

Seafood consumption within the recommended limits during pregnancy may be associated with better social-emotional, behavioral, and overall developmental outcomes in children, as well as possibly some aspects of cognitive development.⁶⁶

4.2. Vaginal Birth Instead of a C-Section¶

The fetus has a sterile intestinal tract. A newborn, however, depends on a healthy gut flora. During a vaginal birth, the baby naturally acquires the foundation for a healthy gut flora. This is not the case with a cesarean section. In this scenario, the baby acquires a microbiome similar to that found on the skin, along with an increased risk of hospital-acquired infections.
Initial studies report the successful transfer of the mother’s microbiome via fecal transplantation using the mother’s (cleaned) stool.⁶⁷ This is likely to contribute not only to the prevention of ADHD, but also—and even more so—to the prevention of ASD, which correlates even more strongly with microbiome imbalances.
If you have a C-section, breastfeeding is therefore especially important during the first three months (see below).

For more information, see The Gut-Brain Axis and ADHD In the chapter on Causes.

4.3. Vitamin D3 During Pregnancy and Early Childhood¶

Maintaining good vitamin D3 levels in the mother through pregnancy has a preventive effect with regard to ADHD.⁶⁸

Plenty of daylight, which promotes vitamin D3 production, appears to help counteract ADHD in children. A study shows that ADHD in the U.S. occurs primarily in the darker eastern regions, while the brighter western regions have lower rates of ADHD.⁶⁹ This requires children to spend sufficient time outdoors—especially during infancy—while avoiding excessive clothing and the constant use of sunscreen. Children who go out in the sun exclusively with high-SPF sunscreen cannot produce sufficient vitamin D3 and are therefore at increased risk of brain development disorders. The optimal duration for unprotected sun exposure is about half the time it takes for the first signs of redness to appear.

4.4. Breastfeeding Instead of Bottle-Feeding¶

Several reports suggest that extended breastfeeding reduces the risk of ADHD and other disorders in infants. In addition to the wide range of nutrients provided by breast milk, the physical contact involved is a key factor.

Children with ADHD were 1.51 times more likely to have been exclusively breastfed for less than 3 months and 52% less likely to have been exclusively breastfed for more than 3 months (meta-analysis of k = 11 studies).⁷⁰

Not breastfeeding increased the risk of ADHD by a factor of 3.71 (OR = 3.71). Children with ADHD had a significantly shorter (2.44 months) duration of breastfeeding (SMD: Hedges’ g = −0.36) (meta-analysis of k = 11 studies). ⁷⁰

In a small Lebanese correlation study (n = 119), breastfeeding reduced the risk of ADHD by 74% (OR = 0.263).⁷¹

Breastfeeding not only provides the infant with nutrients, but also helps the infant develop a healthy gut flora. While formula may also contain nutrients, it barely provides the infant with natural gut flora. If breastfeeding is not an option for health reasons, probiotics could be a viable alternative (see below).

For more information, visit ⇒ Bottle-feeding increases, breastfeeding decreases the risk of ADHD In the article ⇒ Environmental factors as a cause of ADHD in the chapter ⇒ Development.

4.5. Seafood as a Food Source¶

A diet for children and adolescents that includes the recommended amounts of fish and seafood showed benefits for cognitive development in 5 of 18 short-term RCTs and in 5 of 9 long-term cohort studies. (Meta-analysis, n = 27)⁷² No effects on social behavior or behavioral symptoms were found.

5. Early and Preventive Treatment Options¶

5.1. Should Probiotics Be Given in the First Months of Life?¶

One 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 the age of 13, whereas 17% of the placebo group received a diagnosis of ADHD or ASD according to ICD-10.⁷³
Even though this report is very encouraging, it should (as is always the case in science) not be considered reliable until it has been replicated multiple times. Until then, the treatment should be regarded as experimental.

5.2. Training of Non-Integrated Primitive Reflexes¶

Babies develop primitive reflexes that support the development of higher-level skills. These primitive reflexes are usually integrated as the child continues to develop (replaced by more advanced patterns of behavior). Children in whom (certain) primitive reflexes persist show an increased risk of motor and physical symptoms, including ADHD—
The integration of primitive reflexes can be trained and helps prevent motor and cognitive problems that can lead to ADHD.
For more information, see Persistent Tonic Neck Reflexes in the article “ : Motor Symptoms of ADHD” In the chapter “ : Symptoms”