ADHD - Prevention and screening - What parents can do

ADHD is triggered by certain genetic constellations or by early childhood stress, which epigenetically activates certain gene constellations. Epigenetics means that, for example, the (de)methylation of genes alters their function. 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 heritable. 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 level required for ADHD to manifest, therefore, does not require the intensity of psychological, physical, or sexual abuse, but rather a relatively mild (but persistent) stress level may be sufficient.

The sensitivity of children with ADHD risk genes means that these children can already be permanently damaged by 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 ⇒ Parents’ attachment style to child particularly important in chance/risk genes.

It has been proven that prevention programs for parents can positively influence the ADHD of their affected children,¹ even if this does not help all children, which is also likely to be related to differing genetic exposure.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 is true regardless of ADHD, but especially true there: a negative parenting style is an independent risk factor for ADHD.³ Secure attachment can help prevent ADHD, especially in children who have a good ability to regulate their behavioral inhibition.⁴⁵
In positive terms, this means understanding which parenting styles and values are particularly good at protecting and supporting children.

Further, 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 research on parenting behaviors and child responses
  • 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
• 3. Defer for kindergarten / nursery and school
• 4. Selection of kindergarten / nursery
• 5. Avoidance of stresses and toxins
  • 5.1. Avoid stress and anxiety during pregnancy
  • 5.2. Avoid toxins during pregnancy
• 6. Avoidance and reduction of stress
• 7. Enriched Environment
• 8. Breastfeeding instead of bottle feeding
• 9. Maternal vitamin D2 and D3 during pregnancy
• 10. Administration of probiotics in the first months of life?

1. Attachment styles¶

An attachment style describes the way a person interacts with their counterpart in social relationships.
A distinction is made between 4 attachment styles:

• Secure
• Unsafe-avoiding
• Insecure-ambivalent
• Disorganized

Parents very often pass on their own attachment patterns to their children. Mothers 75%, fathers 65%.⁶
Knowledge about the importance of attachment behavior could significantly reduce the rate of passed-on insecure attachment. Special courses are offered for this purpose.⁷

The 4 attachment styles describe a gradual deeper and more serious disturbance of the attachment ability. Any stage away from a secure attachment style is an element of risk for mental disorders such as ADHD. The further the attachment style is from a secure attachment, the greater the risk.
Disorganized attachment behavior is a particularly strong risk element of ADHD.⁹. Attachment disorders of children in the first years of life lead to the activation of the DRD4 gene, which is also typical for ADHD, if there is a corresponding genetic disposition.¹⁰

1.1. Secure attachment style (B attachment)¶

The secure attachment style is also called autonomous attachment.

• Prevalence in Germany: approx. 60%¹¹
• Parental sensitivity
  • Prompt perception of the child’s signals
  • Correct interpretation of the child’s signals
  • Appropriate and timely response thereto
• Show children with secure attachment
  • Behavior
    • Great confidence in the availability of the attachment figure
      • Trust that the attachment figure will not abandon the child or respond incorrectly
      • Bonding person = safe haven
    • In separation situation
      • Children cry
      • Show their negative feelings clearly
      • Partially accept comfort of a strange woman (helper belonging to the test)
    • When the attachment figure returns
      • Child shows joy
      • Child seeks closeness and contact
      • Turns to other things again shortly afterwards
  • Correlating character traits
    • Positive correlation with¹²
      • Novelty seeking
      • Reward dependence
        • Tendency to respond markedly 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 dialogue and meet with others
    • Negative correlation with ¹²
      • Harm avoidance
        • Temperament of damage avoidance:
          • Worries about expectation of others
          • Fears uncertainty
          • Shy with strangers
          • Quickly tired.
    • A secure attachment style is least affected by Rejection Sensitivity, an insecure-avoidant (dismissing) attachment style showed more and an insecure-ambivalent (preoccupied) attachment style showed the most ADHD symptoms¹³
  • Stress is shown appropriately
    • Acclimatization to daycare sometimes takes 3 weeks, which is healthy⁶
• Adults with secure attachment:
  • Can speak freely and in a coherent flow of language in the interview about their experiences of attachment, loss, and grief with their parents and significant others.¹⁴
  • Response of securely attached mother to social interaction with child:
    • Increased oxytocin level¹⁵
    • Greater activation of the brain’s reward regions¹⁵
      • Nucleus accumbens (ventral striatum)
      • Hypothalamus
      • Pituitary
  • Response to Acute Stress (TSST)¹⁶
    • Relatively low subjective stress
    • Moderate response of the HPA axis (ACTH and cortisol)
    • High oxytocin response

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

Also called insecure-distant. English: Dismissive

• Germany: approx. 20 - 25⁶
• Children with insecure-avoidant attachment:
  • Lack of confidence in availability of attachment figure
    • Lack of confidence that the attachment figure will not abandon child or react incorrectly
    • Expectation: own wishes / needs will meet with rejection
  • Behavior:
    • Relationship avoidance to avoid or control the unpleasant experience of being rejected
    • In separation situation:
      • Children do not show their negative feelings
      • Do not cry
      • Seem outwardly unimpressed
        • No anxious signs
        • No annoying signs
        • Play on
      • Seek comfort from strange woman (helper belonging to the test) more clearly than securely bound children
      • Neurophysiological stress responses
        • Cortisol level elevated due to situation
        • Cortisol stress response higher than in securely bound children
        • Accelerated heartbeat
    • Upon return of the attachment figure:
      • Binding person is ignored
      • Child shows no joy
      • Look for closeness rather to other woman (helper belonging to the test) than to own attachment figure
    • Higher vulnerability to mental disorders⁶
    • Stress is not shown
      • Familiarization in kindergarten / crèche goes much too fast (sometimes in 3 days)⁶
  • Correlating character traits:
    • Negative correlation with¹²
      • Novelty seeking
• Adults with insecure-avoidant attachment:
  • Reaction of insecurely-avoidantly attached mother to social interaction with child causes
    • Not increased oxytocin level¹⁵
    • Stronger activation of the insular cortex in the cerebrum¹⁵
  • Assign little importance to interpersonal relationships and emotional bonds. They describe the relationship with their parents in a very idealized way, without being able to clarify this through concrete experiences.¹⁴
  • Greater ADHD symptomatology than a secure attachment style, less ADHD symptomatology than an insecure-entangled (preoccupied) attachment style¹³
  • Response to Acute Stress (TSST)¹⁶
    • Moderate subjectively perceived stress
    • Increased response of the HPA axis (cortisol and ACTH)
    • Moderate oxytocin response
    • Increased stress response to social conflict,¹⁷ which varies by stress phenotype¹⁸

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

Also called insecure-entangled attachment style.

• Germany: approx. 10 - 15⁶
• Bonding person does not react reliably, comprehensibly and predictably for child
  • Frequent alternation between sensitive and dismissive behavior
  • Behavior of the attachment figure can only be predicted with difficulty
  • Child must always worry about attachment
  • Child constantly evaluates mood of attachment figure to predict responses
• Effect:
  • Curiosity behavior and exploratory behavior restricted
  • In separation situation:
    • Children react fearfully
      • Fear unfamiliar situation
    • Show extreme load
    • Strange woman (test assistant) is feared as much as space itself
    • Stress even before attachment figure leaves
      as no positive outcome of the unknown situation is expected
• Correlating character traits:
  • Positive correlation with¹²
    • Harm avoidance
    • Novelty seeking
  • Negative correlation with¹²
    • Self-directedness
• Adults with insecure-ambivalent attachment:
  • Show in the interview, through a lengthy, often contradictory history and description of their multiple relationships, how emotionally entangled they still are with, for example, their parents and other relationship figures into adulthood.¹⁴
• More severe ADHD symptomatology than an insecure-ambivalent attachment style, much more severe ADHD symptomatology than a secure attachment style.¹³
• Response to Acute Stress (TSST)¹⁶
  • Moderate level of subjective perceived stress
  • Moderate HPA response (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 - 10⁶
• Bonding person reacts completely unpredictably for child
  • Threat and bonding person at the same time
  • Double bind for child not resolvable
  • E.g. traumatized attachment figures
    • Trauma reactions (fear of the attachment figure) not explainable for children
• Children with disorganized attachment:
  • Behavior:
    • In separation situation
      • Children react unexpectedly and unpredictably
      • No clear pattern of behavior
        Can occur, depending on the child:
        • Stereotypes
          • Go round in circles
        • Movement abnormalities
          • Unfinished / incomplete movement patterns
          • Freezing of movements / facial expressions for 30 seconds or longer
        • Fear reactions
          • Anxious facial expression
          • Raised shoulders, retracted head
          • Frozen movements
        • Crying for attachment figure
        • Mix of the A and C type strategies
        • Show extreme load
      • Strange woman (test assistant) is feared as much as space itself
      • Stress even before attachment figure leaves
        as no positive outcome of the unknown situation is expected
    • When the attachment figure returns
      • Bonding person may be ignored even though cried out for when separated
• Adults with disorganized attachment
  • When they report unprocessed losses and abusive experiences, they sometimes speak in a disjointed, disorganized manner, have thought breaks, confuse reality and fantasy. Dissociative states may occur, as well as pseudo-absence. Eye and feeling contact with interlocutor is lost for seconds to minutes. This incoherent style of speech, which always occurs when talking about unprocessed trauma (maltreatment, abuse, violence, loss, accident, natural disaster) is an expression of a disorganized representation of unprocessed traumatic experiences and could also be considered PTSD.¹⁴
  • More frequent development of borderline in adolescence¹⁹
  • Response to Acute Stress (TSST)¹⁶
    • High subjective stress perception
    • Flattened response of the HPA axis (ACTH and cortisol)
    • Medium oxytocin response

1.5. Further research on parenting behaviors and child responses¶

An unsupportive (cold, disinterested, dismissive) parenting style to children’s negative emotions caused them to have a flattened cortisol stress response and increased negative emotions.²⁰

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. There were 2.3 traumatic life events cited.²¹ Another study also found a strong correlation between insecure attachment style and ADHD.²² 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, quality of the parent-child relationship, or perceived parental competence.²³
Another study did not find any correlation, but was based on self-reports by those affected.²⁴ In our opinion, it is questionable whether children can adequately assess the security of their attachment to their parents themselves. Children are not likely to have a benchmark for this (during childhood). Otherwise, it would be inexplicable that children form an - albeit dysfunctional - attachment even to abusive parents. In our view, the psychological injuries of an insecure attachment arise precisely from the dissonance of a subjectively perceived attachment to the objectively existing attachment. If a person is aware that the attachment figure is wrong in his or her values, injuries by this attachment figure are less harmful.

There are statistically significant, albeit small in magnitude, associations between childhood attachment styles and salivary cortisol responses to acute stress in adulthood^{2526 27 28} and between attachment behaviors in adulthood and salivary cortisol responses in relationship conflict situations.²⁹²⁸

According to attachment theory, impulsivity, restlessness, negative attention seeking, hyperactivity, and lower concentration are presented as defensive reactions of a child with insecure attachment.
Mothers of children with ADHD were portrayed as having³⁰

• More direct
• Repulsive
• Less rewarding
• Intrusive (appropriate self-regulation of arousal states becomes more difficult)
• Tendency to interrupt the actions of the child
• Rigid boundaries in family interactions
• Unclear boundaries in family interactions
• Seductive or transgressive behavior

2. Educational goals and values¶

The first and most important criterion is: heat.
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 palpable warmth.
Warmth is perceptible to the child as an ever-existing affection for the child’s inner being that is palpable even in the face of misbehavior.
The more parental warmth 5-year-olds received, the lower their ADHD risk was at age 9.³¹

One example is to comfort a child when he or she is not feeling well - even if, for example, the reason he or she is not feeling well is that he or she has a cold because yesterday he or she ignored the reminder to put on a jacket.

2.2. Security¶

Security is a result: The child has the absolute certainty that he is accepted with all his facets (whether these please the parents or not) and is accepted. This does not mean that the child is allowed to do and leave everything that comes to mind. Parents have the task of imparting values to children. However, this imparting of values, standards, behaviors must correctly take place 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 his emotions - he knows that he is accepted with his emotions. A securely attached child will need a much longer time 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 insecure-avoidant child does not show it.

2.3. Clarity¶

Clarity is a setting of standards that is calculable, predictable and comprehensible (plausible, i.e. never arbitrary) for the child. Rules must never be arbitrary. Rules must also apply to the person who sets 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. There must be no uncertainty arising from apparent arbitrariness.
The validity of rules must not depend on the mood of the day or the whim of the caregiver.

The announcement that it’s time to go to bed at eight should not be fought through hard at times and completely ignored at others, depending on the mood of the parent. It’s not about the minute, it’s about the principle. A parent who sometimes lets loose a thunderbolt 5 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, thus loses the right to demand compliance with the rule from the child. Of course, the right to educate continues to exist. But if something is not important enough to be observed 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 thus destroys the child’s trust in the values set - the child becomes disoriented.

Clear rules are a helpful parenting style even when ADHD is present.³²

In particular, intermittent interventions must be avoided. Educational interventions that are made only sometimes - rules that are not applied consistently but only sporadically - perhaps every other day - reinforce the undesirable behavior instead of reducing it.³³

2.4. Respect¶

Respect is an acknowledgement that the child, even if it cannot even speak yet, has its own needs and values that are subjectively justified. They are subjectively justified even if they are contrary to the parent who raises them.

By their very nature, subjective justification does not mean that they are also objectively reasonable.

Respect, therefore, does not mean placing the child’s values above one’s own or acknowledging them when they are not appropriate. Respect means not devaluing the child’s own values (even if they are “wrong”), but gently, warmly, patiently and at the same time consistently communicating to the child what the right standard is.
The point is to accept the child’s perception as given (and not as evil) in order to teach him the “better” values with sovereign composure.

If the child is “wrong,” in the vast majority of cases it is the result of how adults treat them. Whoever accuses children of evil, probably walks through the world with the basic attitude that all people are evil.

Children can quickly distinguish well between soft and hard times - that is, 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, granting (as far as possible, autonomous) room for maneuver. This is also helpful in ADHD.³²

Positive role modeling of desired behavior is, on the one hand, a very natural pattern for teaching children desired behavior. At the same time, it conveys a form of respect by showing the child that what is desired of him is also performed by himself. Positive role modeling is at the same time a helpful behavioral pattern in the education of ADHD-affected children.³²

2.5. Positive reinforcement instead of punishment¶

Punishments are fundamentally much less suitable for deepening a behavior to be learned than positive reinforcement. This also applies to ADHD.³²

3. Defer for kindergarten / nursery and school¶

Children who are among the youngest in their class have an increased risk of ADHD by around 30%. This phenomenon is found worldwide - with the exception of Denmark.
The background to this is probably that in Denmark, children who are developmentally delayed in the opinion of their parents can be deferred from school without any problems.
It should therefore be worthwhile for children at risk to insist that the school enrollment date be moved back.

See more at Relatively early school enrollment as ADHD risk.

4. Selection of kindergarten / nursery¶

The selection of the right kindergarten is of particular importance. It is much more important than the selection of the “right” school later on, where the elementary school is also more important than the following one.

In the selection process, less emphasis should be placed on particular educational content, but much (and very much) more on how the educators interact with the children. The imparting of knowledge becomes important at the earliest from school age. In the toddler age, an emotionally warm and affectionate upbringing is much more important. It creates the security with which the children can develop their abilities themselves 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 cognitively cold. A good nursery, a good kindergarten can be recognized quite simply by the fact that the children move around there in a relaxed manner and feel comfortable, that there is a lot of cuddling, cuddling and cuddling. Wonderfully illuminating on this: Becker-Stoll: “Sign off immediately!” When does outside care harm the child? What characterizes a sensitive educator?“.³⁴

5. Avoidance of stresses and toxins¶

5.1. Avoid stress and anxiety during pregnancy¶

During pregnancy and lactation mothers should avoid:

• Stress
  • The permanently elevated level of cortisol (and other stress hormones) during prolonged stress in the mother permanently damages the stress systems of the unborn child. While short-term stress (short-term cortisol exposure) is countered by protective mechanisms of the placenta, these protective mechanisms can no longer protect against long-term cortisol exposure due to chronic stress.
  • Persistent anxiety, depression and other psychological stresses of the mother cause such states of stress

Likewise, chronic stress is extremely harmful to young children up to age 3. Another particularly vulnerable age is middle adolescence (around 13 to 15 years).

See more at ⇒ Prenatal stressors as ADHD environmental causes In the section ⇒ Environmental factors as causes of ADHD in the section ⇒ Emergence.

5.2. Avoid toxins during pregnancy¶

Furthermore, they should avoid coming into contact with the following substances at all costs:

• Alcohol
• Nicotine
• Other drugs
• Risky drugs
  e.g.
  • Paracetamol
  • Benzodiazepines
  • Β-2-adrenaline receptor agonists
  • Cortisol (e.g. as a drug)
• Bisphenol A (BPA)
  • BPA is still used in many everyday products, such as:
    Plastic bottles, plastic toys, thermal paper, tin can linings, epoxy resin floor coatings, and more
  • BPA acts like a hormone and damages the HPA axis of the unborn, 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 listing can be found at ⇒ Prenatal stressors as ADHD environmental causes In the section ⇒ Environmental factors as causes of ADHD in the chapter ⇒ Emergence.

6. Avoidance and reduction of stress¶

Pets (especially medium 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 is also true in the education of children with ADHD.³²

7. Enriched Environment¶

“Environmental enrichment” is defined in terms of laboratory rodents as “a method of creating a more stimulating environment compared to the baseline.”
Multiple studies in rodents suggest that animals at increased risk (genetically or environmentally) for ADHD are less likely to develop ADHD or lower ADHD symptoms when kept in an enriched environment.³⁵ Although such studies, by their nature, cannot be easily extrapolated to humans, this is consistent with 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.

See more at ⇒ Bottle feeding increases, breastfeeding decreases ADHD risk In the article ⇒ Environmental factors as a cause of ADHD in the chapter ⇒ Emergence.

9. Maternal vitamin D2 and D3 during pregnancy¶

A good level of vitamin D2 and D3 in the mother until birth has a preventive character in relation to ADHD.³⁶

Plenty of daylight, which causes vitamin D3 formation, seems to be able to counteract ADHD in children.
One study shows that ADHD in the U.S. is most prevalent in the darker East, while the lighter West has lower ADHD rates.³⁷

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 13 years of age, while 17% in the placebo group received an ICD 10 diagnosis of ADHD or ASD.³⁸
Although this report is very optimistic, it should not be considered robust (as is always the case in science) until it has been replicated multiple times. Until then, the treatment should be considered experimental.