By David Joel Miller
What do were really know about who gets ADHD and why?
Developmental Psychopathology is the discipline that studies why one person gets a mental illness and another does not. This discipline also looks at how a disorder develops over the life time. Developmental psychopathology has a lot to tell us about who gets ADHD and why.
The picture, when it comes to ADHD and most other disorders is not as clear as we would wish. With all the people currently taking meds for ADHD you would think that professionals would know what ADHD was and what was causing it.
Both of these questions are fuzzy.
Developmental psychopathology tells us that there are two primary ways of behaving. Some people internalize and hold it all in. They are prone to depression and anxiety.
Other people externalize and let it all out. They are likely to get in trouble, get labeled oppositional defiant, conduct disordered or even anti-social.
People with ADHD may internalize, externalize or do both.
What we call ADHD is in essence three different problems and those problems can occur in multiple combinations. First the three problems and then the possible causes.
1. Impulsivity – poor behavioral inhibition is the defining characteristic.
Poor impulse control is prominent feature of most children. It also affects many adults both with and without ADHD. So if you find it hard to control your impulses you are at risk of getting an ADHD diagnosis.
This makes ADHD hard to differentiate from bad behavior or criminal behavior for that matter. Some have argued that most people in prison are there because they have ADHD. I find that hard to believe.
But when we see the way addicts and alcoholics struggle to not drink and use, then that feature of loss of behavioral control seems to fit a lot of socially unacceptable behavior.
Impulsivity looks a lot like acting out or externalizing behavior.
Paying attention, in my view, is a skill that people can learn or improve. We believe, partly based on the existence of the ADHD diagnosis, that there are some people who have difficulty focusing their attention when they try to do that.
Impulsive people have more difficulty sustain their attention because they keep getting distracted by other things that catch their attention.
Inattention or impaired ability to sustain attention is a characteristic of internalizing disorders. When you are depressed you can’t pay attention. Neither can the anxious person. So professionals need to be very careful to not call depression or anxiety by the wrong name – ADHD.
This is a problematic criteria some of the time. What is hyper or excessive activity is in the eye of the beholder. The child who will not sit still in class looks hyperactive, when they are in class. The child who sits quietly in their seat looks normal.
But put these two children out on the soccer field and the child that sits down and watches rather than plays looks under active and the child that runs after the ball for long periods of time, they become the star player.
Increase the amount of exercise and the child that is hyperactive may calm down and sit still. This running to cure ADHD is the precise opposite of the fall-behind-in-your-work and you lose your recess approach.
All three of these factors, poor inhibition of impulses, inattention and hyperactivity can occur in varying amounts and combinations in any one person. This makes us wonder about causes of ADHD.
Is there one cause of ADHD or many?
A number of things have been identified as risk factors for ADHD.
There are also ADHD protective factors.
1. Genetics play a role in who gets ADHD.
Up to 75% of the risk of getting ADHD can be accounted for by various genetic factors. Wish this explained something. There are at least 7 different genetic mutations affecting two different neurotransmitter systems that increase the risk. This 7 genes in all the possible combinations results in up to 5,000 different combinations of genes that may increase the risk. But this risk factor does not guarantee you get ADHD and there are other risk and protective factors.
These genes are not specific to ADHD so they may be causing other mental illness and these illnesses may be risks for ADHD.
2. Environment, especially parenting, is a risk factor that may explained the other 25% of ADHD.
For most people parents provide both genetics and environment which makes it hard to disentangle the effects of the two.
One thing we find that helps solve this puzzle is that if a parent has two of the symptoms of ADHD, say dad has ADHD and is inattentive and impulsive, there is a high chance that his son will not only have ADHD, but will also be inattentive and impulsive.
The children of parents that have ADHD have a high incidence of the same form of ADHD the parent had.
Things would be simpler if people had one and only one disorder. But most people with ADHD have two, three or more.
Almost half of all children with ADHD also have a diagnosis of Anxiety disorder. This complicates treatment for children with ADHD. In adults one thing we are told to recommend to our clients is to reduce their intake of caffeine and other stimulants, like amphetamine. But for kids with ADHD and anxiety disorder the treatment is to put them on a prescribed amphetamine.
I find this confusing. If it makes you wonder, talk with your prescribing psychiatrist about your or your child’s meds. (Yes there are non-stimulant ADHD meds but they do not get prescribed all that often.) Side effects of prescribed medications can look like a mental illness. If you have confusion, depression or anxiety and are taking prescribed medication discuss your emotional problems with your doctor and see if your meds could be causing some of your symptoms.
A second disorder that coexists with childhood ADHD is a substance use or abuse disorder. Occasionally the ADHD child is doing drugs but a lot of the time it is mom that is on drugs and this increases the risk of the child having ADHD even if mom does not start drugs until after the child is born. Yes having a mother who is using increases childhood ADHD.
Having a depressed or anxious mother also is a risk factor for developing ADHD.
There have been even more studies on dad than mom in the ADHD area. If dad had any acting out problems as a child there is at high risk that the child, boy or girl, will also act out and get in trouble at school and with the law.
We do know that the ability to pay attention develops over time and that there are ways to increase your ability to pay attention other than taking meds. It also appears that the brain circuits that control attention also overlap those for emotional regulation. More on these topics in posts to come.
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Did that help explain ADHD and its possible causes?