Is AD(H)D a Disorder?
ATTENTION DEFICIT DISORDER has been called the “flavour of the nineties.” Fueling scepticism about its actual prevalence is the fact that no feature of ADD is so unique that it cannot be found, to one degree or another, in any number of people among the non-ADD population. Lumping a group of personality characteristics together in a psychiatric manual does not automatically establish a pathology.
Dr Gabor Mate wrote in his book, Scattered Mind,“ADD should not be treated as a disorder in the medicalised sense. ADD is not an illness, but an impairment, e.g. a visual impairment in the absence of any disease.”
The question is, where do these impairments come from?
There are no definitive answers with our current state of scientific knowledge, even with the leap-and-bound understanding of brain science in the past decades. The popular view from virtually all the authors of popular books on the subject asserts that ADD is a heritable genetic disorder. With some notable exceptions, the genetic view also dominates much of the discussion within professional circles.
Nature and Nurture
There is in ADD an inherited predisposition, but that’s very far from saying there is a genetic predetermination. A predetermination dictates that something will inevitably happen. A predisposition only makes it more likely that it may happen, depending on circumstances. Many other factors influence the actual outcome.
Dr Gabor Mate believes that ADD can be better understood if we examine people’s lives, not only bits of DNA. Heredity does make a significant contribution, but far less than usually assumed. At the same time, it would serve no purpose to set up the false opposition of environment to genetic inheritance. No such split exists in nature or the mind of any serious scientist. It is not Nature VS Nurture; it is nature together with nurture.
Such neglect frequently leads to crippling deficiencies in what people are offered by way of treatment. There are many biological events involving the body and brain that are not directly programmed by heredity. The genetic blueprints for the architecture and the workings of the human brain develop in a process of interaction with the environment. ADD does reflect biological malfunctions in certain brain centres. Still, many of its features— including the underlying biology itself—are also inextricably connected to a person’s physical and emotional experiences in the world.
Genes can be activated or turned off by factors in the environment. In the Cree population of northwestern Ontario, for example, diabetes is found at a rate five times the Canadian national average, despite the traditionally low incidence of diabetes among native peoples. The genetic makeup of the Cree people cannot have changed in a few generations. The destruction of the Crees’ traditional physically active ways of life, the substitution of high-calorie diets for their previous low-fat, low-carbohydrate eating patterns and significantly increased stress levels are responsible for the alarming rise in diabetes rates. Although heredity is involved in diabetes, it cannot possibly account for the pandemic among Canada’s native peoples, or the rest of the North American population, for that matter. We will see that in similar ways changes in society are causing more and more children to be affected by attention deficit disorder
Case Study: Adopted Identical Twins
Studies do show that if parents or siblings have ADD, a child in that family will have a significantly increased statistical risk for having ADD as well. ADD is also found more commonly in people whose first-degree relatives are alcoholics or suffer from depression, anxiety, addiction, obsessive-compulsive disorder or Tourette’s syndrome. It may appear from such facts that this motley collection of related syndromes is largely hereditary—but to assume that would be like believing that if there are three generations of butchers or bakers or candlestick makers in a family, then meat cutting, baking and candle manufacturing must also be genetic.
The family atmosphere in which the child spends the early formative years has a major impact on brain development. It is obvious that brain/mind problems such as ADD are far more likely to develop in families where the parents are struggling with dysfunction or psychological problems of their own. It would be astonishing if children growing up in such unsettled environments did not develop some of the same problems. No genes need be involved at all for these conditions to run in families.
There has been an enduring misconception in psychological studies that comparing identical twins adopted by different families can separate out genetic effects from environmental ones. Because identical twins adopted by different parents are brought up under different circumstances, any similarities in personality traits are assumed to be due to the shared heredity; any differences in character are thought to be caused by differences of environment. This misbelief has heavily influenced the conventional understanding of attention deficit disorder. It has been shown, for example, that if one of the twin pair has ADD, there is a 50 to 60 percent likelihood that the other will have it as well. The technical term for this likelihood is concordance. Such a high degree of concordance is taken to prove a hereditary causation—but only if one ignores the most obvious question: since identical twins have exactly the same genes, why is the concordance not closer to 100 percent? Also ignored is a powerful environmental factor: the adoption itself.
A consistently available nurturing caregiver is a fundamental need of the human infant. Adoption means separation from the birth mother to whose body, voice, heartbeat and biorhythms a newborn is attuned by the time of birth. We cannot simply discount the devastating effect such separation may have on the impressionable nervous system of the infant. Not a few adoptions including a significant number of the adoptions examined in published studies— take place several months or longer after birth. Many adoptee infants must endure several changes of caregiver without any single, consistently reliable mothering figure to provide them with a constant, safe relationship. Given that emotional security is an absolute human need in infancy, it is astonishing that adoption is so often forgotten as a possibly crucial influence.
There is another environment that adopted twins have shared: nine months in the same uterus. Stress on the mother during pregnancy can unbalance the levels of hormones in her body, particularly of the stress hormone cortisol (cortisone). Both during and after intrauterine life, cortisol directly affects the developing nervous system. The vast majority of pregnancies ending in adoption occur in mothers under severe stress. They are often unwanted pregnancies, many in teenage girls facing enormous personal, family and social pressures. Infants—twins or single—who are adopted out are likely to have been exposed to high levels of stress hormones throughout the nine months of gestation, a negative influence on their developing brains even before birth.
For such reasons, we can expect all adopted children to be at unusually high risk for psychological problems in general, ADD in particular, without any recourse to genetic explanations. Such is the case. Any health professional working with ADD cases is struck by the large proportion of clients, children or adults, who were adopted in early childhood. A 1982 study found that “the rate of adoption among ADD patients in the clinical population was 8 to 16 times the prevalence of adopted children in the population at large.” If you have ADD, you have a far higher than average chance of having been adopted.
Our current world
We are living in a highly stressed world. Work stress, environmental stress, relationship stress and all kind of stress creep into our life and send our sympathetic nervous system (SNS) into overdrive. The overdrive state of SNS leads the body to secrete an excessive amount of cortisol, epinephrine and norepinephrine. The stress level is even higher during this unprecedented COVID-19 era that never seen before in the modern world that threatens life and livelihood.
Stress on the mother during pregnancy can unbalance the levels of hormones in her body, particularly of the stress hormone cortisol (cortisone). Both during and after intrauterine life, cortisol directly affects the developing fetus and infant nervous system.
Because of these high-stress level, we very likely see next generation to be at unusually high risk for psychological problems in general, ADD in particular, without any recourse to genetic explanations.
We need to recognise what stress can impact our next generation during their formative years (including the first nine months of gestation). The government, employer, society should provide support to pregnant mother to ease their stress level to protect our next generation immediately.
We also ought to educate the nation on stress management. Not just the typical 2 hours stress management talk but ingrain stress management into our work-driven lifestyle while keeping Singapore competitive advantage. The government should lead as an example and Private organisation to follow.
Survival mentality is vital to keep Singapore’s edge. It is pivotal to push ourself to achieve a greater height, over and again. Yet, a delicate balance between psychological health and achievement need to be maintained.
Special Credit to Gabor Mate MD “A Scattered Mind” for the most part of the content in this article