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3. Stressful physical or emotional childhood experiences as ADHD cause

3. Stressful physical or emotional childhood experiences as ADHD cause

3.1. Stressful physical childhood experiences as (co-)cause of ADHD

3.1.1. Bottle feeding increases, breastfeeding decreases ADHD risk

Infants who were not breastfed showed increased ADHD risk as children, whereas children who were not breastfed as infants showed decreased ADHD risk.123

The risk of ADHD decreases with the duration of breastfeeding.45

It is unclear what influence breastfeeding or the food itself has on this. It is known that bisphenol A increases the risk of ADHD. In 2007, bisphenol A was still contained much more frequently in baby bottles than in 2011, which could explain why a study found a fivefold increased ADHD risk in children fed by bottles in 2007, but no risk increase in children fed by bottles in 2011.6

Breast milk contains many substances that are essential for the development of babies, such as polyunsaturated fatty acids.3

In addition, breastfeeding involves physical affection for the child.

3.1.2. Screaming children

3.1.2.1. Factors that increase the risk of crying children

If the parents are heavy smokers, or if the mother smokes during pregnancy, the risk for a crying child increases by 30 to 150% (quite a few studies); the largest study on this (n = 5845) cites a 69% increased risk.7
In addition, there are several other possible causes that should be systematically excluded.8

3.1.2.2. Risk increase for ADHD in crying children

Writing babies have a significantly increased risk of ADHD.910 Another study reported an 11.8 times higher risk of developing hyperactivity at 8 to 10 years of age (plus 1181%), behavioral problems and negative emotional orientation were reported twice as often as in non-affected individuals.11

Details

Given a usual prevalence of 5 to 10% for ADHD (all subtypes), an 11.8-fold increase in risk would mean that 60 to 100% of all crying children will develop an ADHD form.
In addition, studies report that (former) crying children at 3.5 years of age are more likely to have behavioral problems according to their mothers, but do not have problems with attention span, behavioral regulation, and sociability.12 Cry babies cause significant stress to their parents. 5.6% of all crying children bring their parents to the point of abuse and neglect, including significant bodily harm (shaking, hitting).7

This proves the significant stress experienced by the affected baby over and above the actual cause that causes it to cry. A self-reinforcing system develops: stress of the child causes crying, this causes stress in the parents, which in turn increases the child’s stress.

Yelling is not currently considered a separate first symptom of ADHD.

3.1.3. Feeding problems with infants

Feeding problems in infants correlate with ADHD in adolescence and adulthood.10

3.1.4. Infant sleep problems

Infant sleep problems correlate with ADHD in adolescence and adulthood.10

3.1.5. Subependymal pseudocysts in neonates

Subependymal pseudocysts in newborns increase the risk for ADHD and autism.13

3.1.6. Valproic acid in neonates

Studies in mice suggest that valproate administration to neonates may cause permanent damage similar to that caused by ASA and, in some cases, ADHD.14

3.1.7. Antibiotic administration in the first years of life

Antibiotic administration in the second year of life increased the risk for ADHD by 20% to 33% and for sleep problems by 24% to 50% in a very large study.15
One small study found more frequent behavioral difficulties and depressive symptoms in 3 1/2-year-old children who received antibiotics in the first year of life.16 Two other studies found no increased risks of mental disorders with antibiotic administration in the first 1 17 to 218 years of life.

3.1.8. Surgical procedures under anesthesia

Children who experienced a single surgical procedure under anesthesia at age 5 years and younger were 37% more likely to take ADHD medications at later ages.19 The authors of this large study discuss an increased vulnerability of affected individuals to neurotoxic substances (anesthetics).
A cohort study in Taiwan found no increased ADHD risk from anesthetics in the first 3 years of life.20

It may be open to what extent the likelihood of surgical intervention under anesthesia is already influenced by the increased probability of accidents in ADHD sufferers. See Consequences of ADHD.
Another hour found a 37% increase in ADHD risk with a single anesthesia on the occasion of surgery up to 5 years of age, and a 75% increase with multiple anesthesia.21 Another study came to similar conclusions.22

Another study found significantly increased ADHD rates among 10- to 16-year-olds who had received surgery for a congenital heart defect as young children.23

3.1.9. Neurodermatitis / atopic eczema in childhood

Neurodermatitis / atopic eczema in childhood correlates with an increased risk of ADHD.24

3.1.10. Antihistamines in the first years of life

A large cohort study found that taking antihistamines (especially first-generation antihistamines) in the first years of life significantly increased the risk of ADHD later in life. Disturbance of REM sleep, which secondarily impaired brain maturation, was suggested as a possible cause.25

3.1.11. Passive smoking - Smoking persons in the environment in the first years of life

Nicotine exposure in children is associated with increased ADHD.5 Children with ADHD were twice as likely to have smokers in the family as non-affected children in one study.26
In the case of passive smoking, a connection to certain MAO-A gene variants is mentioned, which cause a lower serotonin degradation.27

In children, a linear association was shown between salivary cotinine (a nicotine breakdown product) and hyperactivity and behavior problems. This association remained significant after adjusting for family poverty, parental education, ADHD history, hostility, depression, caregiver IQ, and obstetric complications, and even after excluding children of mothers who had smoked during pregnancy. This indicates that exposure to nicotine in the early years of life alone may increase hyperactivity and behavior problems.28

3.1.12. Childhood air pollution

A large cohort study found a statistically significant association between nitrogen oxides and particulate matter (<2.5 pm) in childhood and the development of ADHD.29 A smaller cohort study confirmed this for particulate matter but not for nitrogen dioxide.30 Another cohort study found a 40% to 78% increased risk of ADHD from exposure to PM2.5 in the first to third year of life. Risk was associated with PM2.5 >16 μg/m3 and increased sharply with PM2.5 > 50 μg/m3. No sex-dependent association was found.31
In another study, the ADHD risk increased by 38% for each increase of 10 μg/m3 nitrogen oxide and by 51% for each increase of 5 μg/m3 particulate matter PM2.5. When both factors were considered together, the influence of nitrogen oxide predominated. Age and sex of the affected persons as well as educational level and income of the parents were excluded. A meta-study of 28 reports found similar results in the majority of reports.32 Nitrogen oxides already influence glutamatergic, opioidergic cholinergic and dopaminergic neurotransmission in the brain at non-toxic doses.33
Another metastudy of 12 studies found a correlation between particulate matter and ADHD in children in 9 of them.34

In rats, inhaled printer particles led to 5-fold increases in dopamine levels in one study, although these likely resulted from increased synthesis rather than decreased degradation.35.

3.1.13. Less green growth in the surroundings of the kindergarten / school

A very comprehensive study of nearly 60,000 children (4.4% of whom had an ADHD diagnosis) between the ages of 2 and 17 in 93 kindergartens/schools in Northeast China found a strong negative correlation of the amount of greenery (amount of plant life) in the kindergarten/school environment of children with AD(HHD). The less greenery there was, the higher the ADHD rate.36 A Canadian cohort study,30 a larger study from New Zealand37 and a smaller study of children in Barcelona38 came to similar conclusions.

The conclusions drawn from this are discussed controversially by the authors of the Chinese study:

  • It is conceivable that green has a very general calming effect. Since man was a nomad until 10,000 years ago, a green environment encoded the calming signal of food over millions of years. At that time, humans could not survive for long in regions without green. This corresponds to the biophilia hypothesis.39
  • Green reduces noise. Increased background street noise levels correlate with increased behavioral and sleep problems.40 Noise, however, was not a risk factor in the Canadian cohort study.30
  • Green serves as a filter for air pollutants and thus reduces fine dust and nitrogen oxides. Fine dust like nitrogen oxides are discussed as ADHD risk factors (see there).
  • Studies on whether people in green regions do more sports / exercise more than people in less green (urban) environments do not come to clear results.41
    Exercise is a significant factor in preventing/ reducing ADHD symptoms.
  • Poorer immune regulation may show adverse effects on brain development and behavior. Failure of immune regulation correlates with reduced exposure to macroorganisms and microorganisms. Green can enrich the microbial inputs from the environment that induce immune regulation.42

A very large Danish cohort study also concluded that fewer green plants in the home environment correlated with up to a 20% increased risk of ADHD.43

3.1.14. Growing up in urban environment

Children who grew up in a rural environment from the age of 3 had a one-third reduced risk of ADHD, according to a cohort study.44 The lower the proportion of vegetation in the environment, the higher the ADHD risk.

Another study suggests similar results.45

3.2. Stressful psychological childhood experiences as (co-)cause of ADHD

Traumatic experiences, but also stressful experiences below the threshold of trauma, are risk factors for ADHD. Social risk factors increase the risk of ADHD.46
Massive maternal stress in the early years of childhood causes significant epigenetic changes in the children’s DNA.47

3.2.1. Lack of attachment behavior of the mother/parent in the (first) years of childhood

A lack of secure attachment of the child to the mother, like social and emotional deprivation, has extensive negative effects on the child’s mental health even in later years of life.48

The security of the infant’s attachment to the mother or central caregiver determines the level of the stress hormone cortisol in the babies’ brains.

Disorganized attachment behavior is a risk element for ADHD.49 Attachment disorders of children in the first years of life lead to an activation of the DRD4 gene, which is also frequently involved in ADHD, if there is a corresponding genetic disposition.50 Lack of patience of parents was mentioned as a risk factor for ADHD,5 whereas impatience is a symptom of ADHD and can therefore also be an expression of genetic transmission.

Massive maternal stress in the early years of childhood causes significant epigenetic changes in the children’s DNA.47

Already poor parenting behavior is a psychosocial risk factor for ADHD.51

  • Inconsistency in education
  • Missing rules
  • Frequent criticism and punishment
  • Cold, distant, uncharitable manner

Details

How much time parents can spend with their children is not the decisive factor. It is much more important that children can absolutely rely on being accepted, welcomed, loved in every situation and especially when they misbehave. This does not mean that children are allowed to do everything they want. A good, warm parenting behavior is able to consistently limit inappropriate behavior, and they do so by evaluating an undesirable behavior without at the same time devaluing the child’s person as a whole (your behavior is not okay, you are okay). A lack of rules (and even worse: rules that only sometimes apply) are hardly bearable for children because they take away all security. The question of a mandatory “parenting license” is the subject of legal and ethical discussions.51

Numbers

10.5 million households in Germany have dogs.52(Stand 2014)
8.1 million families in Germany have underage children (as of 2014).
A Google search for parenting course OR parenting courses finds 169,000 results. (20.10.2015)
A Google search for dog training school finds 1,240,000 results. (20.10.2015)

Borderline, which typically results from intensely stressful attachment disorders to attachment figures in early childhood (first 2 years) due to physical, sexual, or psychological maltreatment, has significant comorbidity of ADHD.53

3.2.2. Psychological problems of parents

Psychological problems of the parents increase the ADHD risk for the children.54

  • Antisocial personality disorder of the father55
    A parent’s antisocial disorder is a huge (and usually violent) risk
  • Alcohol problems with father56
  • Depressive symptoms57
  • Bipolar disorder in parent doubles ADHD risk58
  • Depression of parent increases ADHD risk by 2/358

Parental psychological problems could act as an environmental influence and/or a genetic influence.

3.2.3. Stress of the mother in childhood

Stress experienced by the mother of 5 - 13 year old boys with ADHD tended to increase their ADHD symptomatology 12 months later and significantly worsened the children’s quality of life.59

3.2.4. Incomplete families

Single parent families increase the risk for ADHD.5655

Single parents naturally have a higher risk of not being able to give their children sufficient loving care and security. There are very well single parents who can do this very well. The decisive factor is not the amount of time that (part-time/working) parents can spend (less) with their children, but whether the children have the constant and secure feeling of being accepted and loved at all times, just as they are.

ADHD sufferers experience more frequent breakups in their relationships (even in adulthood) than non-affected individuals.

3.2.5. Family instability, constant quarrels between parents

A high level of stress in the primary family increases the risk of ADHD.5655

Family conflicts and ADHD

Chronic family conflict, decreased family cohesion, and confrontation with parental psychopathology (especially maternal) are found more frequently in families with ADHD sufferers compared to control families.”60
The risk for children to develop ADHD (odds ratio) increases with the level of psychosocial stress (Rutter Indicator, RI). For an RI of 1, the odds ratio is 7; for an RI of 4, it is 41.7 (68). Odds ratios > 1 indicate increased risk.61

Follow-up studies do not find complete persistence even during childhood and adolescence and confirm a frequent coincidence with family problems and parental problems.62 Conversely, high family cohesion and social support has a protective effect against ADHD.63

3.2.6. Young parents

Children whose mother does not have ADHD have a 14% increased risk of ADHD if one parent is younger than 20 years.
Children whose mother has ADHD have a 92% increased risk of ADHD if one parent is younger than 20.64 Another study also reports that younger fathers are more likely to have children with ADHD than older fathers.65

In one larger study, nearly 2 in 3 young mothers reported at least one mental health problem. Nearly 40% had more than one. Young mothers were two to four times more likely to have an anxiety disorder (generalized anxiety disorder, separation anxiety disorder, social phobia, and specific phobia), attention-deficit/hyperactivity disorder, oppositional defiant disorder, or conduct disorder than older comparison mothers or women aged 15-17 years, and two to four times more likely to have more than one psychiatric problem.66

3.2.7. Low socioeconomic status of the family of origin

Children from “lower class” families have an increased correlation with ADHD6755 57 and are more likely to receive ADH)S medications.68
Children from lower strata have about twice the risk of ADHD as children from higher strata (using a 3-layer model).69

Similarly, crowded living conditions increase children’s ADHD risk.55 Poor family finances correlated with a 2.12-fold increase in ADHD risk at kindergarten age in the United States.70

Details

The overall prevalence of ADHD in children and adolescents was found to be 2.2% in the 2007 Bella study71 (which we consider too low). A Bella sub-study with n= 2500 subjects between 7 and 17 years72 names the prevalence in parent assessment at around 5%. Both representations confirm a strong discrepancy of the prevalence according to social classes. According to the 2007 Bella study, the middle class is burdened with the average prevalence, while the lower social class has a prevalence of 3.9%, four times higher than the upper class.73 The Bella sub-study reports a prevalence of ADHD in the lower social stratum (at 7.2%) approximately 2.3 times higher than in the upper stratum at 2.8% (for 3 strata).72
Low parental income correlated with a 2.3% increased risk of ADHD in children in a cohort study in Denmark.74 Children of parents who were unemployed and had a low income and a low level of education were found to have a 4.9% increased ADHD risk. The fact that this pattern is not limited to ADHD, but is found identically in other mental disorders, e.g., anxiety, depression, or social behavior disorders, is considered by us to be strong evidence in support of the hypothesis of stress as a cause of the development of mental disorders. These other mental disorders, like ADHD, are also based on a multigenetic disposition (see 2.1.3. and 2.1.4.), which are epigenetically manifested by stress exposure in early childhood.757677

Gene candidates and early childhood stress as causes of other mental disorders

Interestingly, in one study, families with a high socioeconomic status did not benefit from behavioral therapy in addition to drug treatment. Only families with low socioeconomic status benefited more from a combination therapy of drug treatment and behavioral therapy than from drug treatment alone.78

We suspect that it is not so much socioeconomic status or the size of the home itself that are relevant factors, but that these circumstances unfortunately often correlate with inappropriate parenting practices and parents’ own problems (the latter of which may influence parents’ socioeconomic status on the one hand and be heritable on the other).

Parents of ADHD children showed elevated levels of cognitive weakness (IQ, reading tasks, verbal fluency), the highest stress scores of all parent groups compared, the most ADHD symptoms, and poor reading performance.79

In addition, there are indications that (with regard to ADHD-affected children) environment-centered psychotherapies (interventions in the family, with parents, in kindergarten or in school) are more effective than patient-centered behavioral therapies. In some cases, patient-centered behavioral therapies have been denied efficacy.80 This is likely to be particularly true for younger children (up to 6 or 8 years of age).
This may suggest that in children, external factors are a significant cause of AD(HHD).

Among college students, poorer financial resources also appear to correlate with increased ADHD symptomatology.81 There was no correlation with (self-induced) student debt.

A genetically predicted SD lower socioeconomic status causally predicted a 5.3-fold ADHD risk, whereas conversely ADHD causally caused socioeconomic status only very slightly. A genetically predicted one SD higher family income causally predicted a 65% lower ADHD risk. Again, the inverse effect was small.82

3.2.8. Low level of education of parents

Low parental education increases ADHD risk in children.56
Children of parents with low educational attainment had higher ADHD symptoms and a nearly doubled risk of severe ADHD symptoms. The association was independent of genetic and family environmental factors. The transfer of this model to depression was weaker and could be fully explained by common genetic factors.83
Lower levels of maternal education are reported to correlate with increased screen use by children, which in turn correlates with behavior problems.84
Low parental education correlated with a 3.5% increased risk of ADHD in children in a cohort study in Denmark.74 Children of parents who were unemployed and had low income and education levels were found to have a 4.9% increased ADHD risk.

Genetically predicted SD higher educational attainment causally predicted 70% lower ADHD risk.82

3.2.9. Unemployment of parents

Parental unemployment correlated with a 2.1% increased risk of ADHD in children in a cohort study in Denmark.74 Children of parents who were unemployed and had low income and education levels were found to have a 4.9% increased risk of ADHD.

3.2.10. Reduced ability of parents to reflect on their parenting role

Lower parental reflective functioning correlated with ADHD in children.57 Parental Reflective Functioning is defined as the ability of parents to reflect on their own and their child’s internal mental experiences.

3.2.10. Growing up in the home

Children who were prenatally exposed to multiple drug use by their mothers and who subsequently grew up in residential care were found to have a 3-fold risk of ADHD between the ages of 17 and 22.85

3.2.11. Growing up in adoption

A study of Chinese adopted girls found an ADHD rate of 16.7 %, which is about three times the usual prevalence.86 Whether this is a consequence of the adoption or a consequence of the problems of the birth parents, which were then also the cause of the adoption, is an open question. There are indications that the latter factor is influential.

3.2.12. Growing up in dysfunctional neighborhood

Children who grow up in a dysfunctional neighborhood/dysfunctional urban environment are at increased risk for ADHD. Interestingly, this seems to be less the case for black children.87

Higher neighborhood poverty correlated with higher parent-reported ADHD and lower parent-reported medication use in bivariate analysis. Poverty no longer correlated with ADHD in multivariate analysis, but medication use still correlated negatively with ADHD.88

3.2.13. Relatively earlier enrollment in school / older classmates

The youngest children enrolled in a class have a 30% increased risk of ADHD compared to the oldest children enrolled in a class. A study of more than 400,000 children in the U.S. showed that in states where a fixed age on Sept. 1 determines enrollment, the youngest children in a class are at risk of AD(H)S. September determines school enrollment, of children born in August, i.e., who reached school age immediately before the cutoff date, 0.85% had an ADHD diagnosis and 0.52% were receiving ADHD medication, while of children born in September, i.e., who were on average 11 months older, only 0.63% had an ADHD diagnosis and 0.4% were receiving ADHD medication. In states where enrollment was not fixed by age at a cutoff date, those born in August still had a slightly higher ADHD rate compared with those 11 months older, but the difference was no longer 0.21 percentage points but 0.08 percentage points.89
Similarly, a meta-analysis of three Brazilian cohort studies involving 8 million participants and 164,000 ADHD sufferers found that those children in a class who were among the 4 months youngest had a 34% increased risk of ADHD.90 Similar results were obtained in another study of 1 042 106 English children aged 4 to 15 years.91 The risk of depression and intellectual impairment increased in parallel with that of ADHD.
Another study with n = 8,092 Danish children found that delaying (pre-)school entry by one year dramatically reduced inattention/hyperactivity in the following year (effect size = -0.73). The effect was found primarily in girls and persisted into the age of 11 years.92
Another study of n = 418,396 Danish children found that the age of children within a school grade had no effect on (more frequent / less frequent) ADHD medication. The authors attributed this to, among other things, low ADHD prevalence, clear diagnostic criteria, and high requirements for prescribing ADHD medication in Denmark, and referred to studies in countries with high ADHD prevalence where differences were found.93

The results of the study are partly consistent with the fact that, according to a study in Canada, successful ice hockey players were disproportionately likely to be among the older children in a class. The same was seen among Belgium’s soccer players, where the date of birth of the particularly successful players was for a long time primarily in August and September, because the cut-off date for age determination for player selection in a year group was August 1. After this cutoff date was moved to January 1, the most successful players most often had birthdays in January and February. Another study confirmed this “relative age effect” across Europe.94
The effect is likely to be due, on the one hand, to the selection criteria. However, this could only explain the differences in athletes that may result from different support. However, the parallel to ADHD suggests that there might be an effect of the developmental leverage of the opportunity/risk genes at the same time.

How these differences are explained in relation to ADHD is unclear.

One hypothesis in this regard is that younger children would be pathologized at an above-average rate by the assessing teachers because of their naturally more immature behavior.95

Another hypothesis interprets behavioral problems less as a social consequence of the relatively young age within a class than as an absolute consequence of early school entry in general. In this study, however, no difference was found for ADHD.96 In our view, it also suggests that younger children are more likely to be enrolled in school too early than older children. It remains to be seen how large this influence is on ADHD.

Our hypothesis on this is that being among the youngest (and thus the weakest) in a class could also represent a psychological stressor. That low social rank is a significant stressor is well known. Studies on whether or to what extent this influences ADHD diagnoses in school children are not yet known to us.

3.2.14. Early massive stress experiences

Early childhood stress and chronic stress may be involved in the development of ADHD.97 20% to 50% of all children who experience early childhood trauma develop clinical ADHD symptoms.979899

See in detail Trauma as a cause of ADHD

3.2.15. Stressful experiences in childhood and early adolescence cause persistent ADHD in adulthood

A study of stress levels in children with ADHD found that severe stress levels in childhood and adolescence were associated with severe ADHD-HI or ADHD-I progression into adulthood, whereas children with mild stress levels in childhood and adolescence often showed remitting ADHD (ADHD-HI as well as ADHD-I).100

3.2.16. Early television consumption

Early television viewing at ages 1 and 3 correlates with attention problems at age 7.101

It must be questioned whether high television consumption by children at an early age is a causal cause of attention problems or whether parents with a poor capacity for attention due to their own psychological problems frequently leave children to their own devices and park them in front of the television. In the latter case, television consumption could also be merely a correlation and not necessarily a causal cause of ADHD. For there are - as will be described below - countless studies that prove that an affectionate, warm and secure attachment style can prevent ADHD even in the presence of a genetic disposition.
So, while it is assured that intensive parental attention is a good protection against ADHD, no studies are known on this side that television deprivation avoids ADHD.
The fact that intensive TV consumption as a substitute for personal attention correlates with a lack of personal attention is the more conclusive link from this side’s point of view. That consumption of television and Internet with content unsuitable for the age group can cause further damage is also likely to be certain.

3.2.17. Amount of media consumption does not cause ADHD, media consumption addiction correlates with ADHD

The amount of social media use has no influence on ADHD. Only media consumption addiction is associated with increased ADHD levels.102 Nevertheless, increased screen consumption seems to be able to impair attention in children.103

It has also been reported that screen use of more than 4 hours can cause “virtual autism” in children under 6 years of age. However, this regresses after the screen consumption is reduced.104


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