attention-deficit/hyperactivity disorder (adhd) represents adaptation to defective neurotransmission – an adaptation seldom with benefit. the resulting behavioural style not only increases vulnerability to adverse experiences, but also creates a context in which encountering adversity is more likely. furthermore, the fact that adhd is a highly heritable condition increases the probability of a child with a compromised neurobiological disposition being raised by caregivers with suboptimal resources

Sandberg, S

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UCL Discovery

The biopsychosocial context of ADHDSeija SandbergDepartment of Mental Health Sciences, Royal Free and University CollegeLondon Medical School, London W1W 7EY, United Kingdom.s.sandberg@ucl.ac.ukAbstract: Attention-deficit/hyperactivity  disorder  (ADHD)  representsadaptation to defective neurotransmission – an adaptation seldom withbenefit. The resulting behavioural style not only increases vulnerability toadverse experiences, but also creates a context in which encountering ad-versity is more likely. Furthermore, the fact that ADHD is a highly heri-table condition increases the probability of a child with a compromisedneurobiological disposition being raised by caregivers with suboptimal re-sources.The target article is, to my knowledge, the first serious attempt topresent a unified theory expanding from the biology of brain neu-rochemistry to continuously evolving interaction between a childwith attention-deficit/hyperactivity disorder (ADHD) and his orher social environment. It is also noteworthy that the first author,Sagvolden, is a renowned scientist in murine research.At the basis of the dynamic developmental theory, put forwardby Sagvolden et al., is a model of dysfunctional dopamine systemsin the brain. Three hypofunctioning dopamine system branchesand their behavioural consequences, representing the core symp-toms of ADHD, are outlined. These compromised properties re-sult from a combination of intrinsic (genetic) and extrinsic (e.g.,drugs and toxins) influences on the developing brain. The alteredneurobiological disposition gives rise to two main behavioural pro-cesses causing ADHD: altered reinforcement of novel behaviourand deficient extinction of previously reinforced behaviour. Ac-cording to the theory, ADHD symptoms are a product of a dy-namic process of the individual’s adaptation to defective neuro-transmission.The authors have construed a coherent account spanning frombiochemistry, via behaviour, to a reciprocal interplay between theaffected child and his/her biosocial environment. The theory pre-dicts that ADHD behaviour results from, and is continuouslymodified by, the dynamic context of individual predispositions andinterpersonal surroundings well into adulthood. And in the case ofmany adults, the individual predispositions come to form the in-terpersonal surroundings of another individual – their child.The individual predispositions are primarily guided by genes.However, the interplay also starts early – going back (at least) tothe intrauterine life (Grossman et al. 2003; Schneider et al. 1998).By the time the child’s behaviour reaches the level of abnormalityqualifying for ADHD, years of active interaction have taken place.And yet, as Sagvolden et al. note, not all children presenting withthe core symptoms of ADHD get identified as maladjusted. Thisis because the environment has been unusually insightful andsupportive in guiding the child’s excessive and disorganised activ-ity into constructive creativity. The individual ADHD symptomsat different times in a person’s life vary and are influenced by fac-tors exerting either a positive or negative effect. In other words,the environment can either protect from maladjustment, or pre-dispose to it.Crucial here is the caregiver’s ability to adjust the environmentto the child’s needs for optimal development of adaptive skills. Theresulting behavioural style, in turn, determines the long-term con-sequences of the early interactions. The theory predicts that achild with ADHD finds it hard learning how to match their be-haviour to the demands of a given situation. Consequently, therewill be few chances for the child to be rewarded for compliant be-haviour. Instead, the resulting chaotic behavioural style will onlymagnify the negative interactions with carers. For optimal up-bringing, the caregivers have to adapt to the child’s special needsby taking into account the implications of the underlying deficitsand adjust their expectations and demands accordingly. As the au-thors spell out, “a child with ADHD requires exceptional parent-ing skills” (sect. 4.2, para. 3).Commentary/Sagvolden et al.: A dynamic developmental theory of attention-deficit/hyperactivity disorder (ADHD)BEHAVIORAL AND BRAIN SCIENCES (2005) 28:3 441In real life, however, there are too few such resourceful parentsto go around; and their availability to children suffering from theproblems of ADHD is even more restricted. This is because aboutone in five of these parents themselves have ADHD, some withadded complications of depression, personality disorder, learningdisability, or substance abuse. Parents with such problems of theirown will have even greater difficulty coping with their child’s spe-cial needs (Lesesne et al. 2003). A child with ADHD growing upin these circumstances is at high risk for additional emotional andbehaviour problems, with their likelihood further increased by lowsocial class, parental psychopathology, and family conflict (Bie-derman et al. 2002b; Minde et al. 2003).To elucidate the risk mechanisms involved, the authors juxta-pose predictions from their theory with those of the coerciontheory of antisocial behaviour disorder by Patterson (1982). Ac-cording to Patterson, child non-compliance develops through acircular process of negative reinforcement between child andparent. Sagvolden et al. argue that such coercive child behaviour,once established, is especially hard to extinguish in children withADHD (and in their often ADHD parents).Because it is a highly familial disorder, ADHD also means thatthe same parents provide the genes and the environment. ParentalADHD, as a result of its core symptoms and/or comorbidities, isassociated  with  disruptive  family  environment  and  suboptimalparenting practices that often are resistant to modification (Chro-nis et al. 2004; Sonuga-Barke et al. 2002). ADHD in fathers, forexample, predicts higher levels of family disruption as a conse-quence of parental desertion and custodial sentences for impul-sive behaviour (Minde et al. 2003). The already demanding tasksof childrearing place a parent with ADHD at considerable disad-vantage: Maintaining patience and emotional responsiveness to-wards the child, providing attentive supervision, and organisingdomestic duties and childcare frequently present the parent withan unmanageable challenge. Also, extrapolating from the pro-posed theory, a parent with ADHD will find it hard to emotion-ally disengage amidst a child’s temper tantrum, but will easily endup contributing to its escalation, instead.These parenting styles bear resemblance to those observed instudies of depressed mothers. For example, a recent longitudinalstudy involving detailed observations of the interaction betweenpostnatally depressed mothers and their infants revealed a strik-ing pattern of “coercive caretaking” – a phenomenon hardly everseen in mothers who were not depressed (Murray et al. 1996).This pattern of early interaction had long-lasting connections, pre-dicting disruptive behaviour at least to age 8 (Morrell & Murray2003). Thus, there is a particular reason to pay attention to ADHDin girls in whom the problems are often overlooked until teenageyears, or entirely missed. Compared with boys with similar levelsof ADHD, girls are at a higher risk for anxiety, depression, andpoor psychosocial functioning (Rucklidge & Tannock 2001). If ig-nored, these problems are likely to continue into adulthood andwill determine the future style of parenting – of children proba-bly sharing the mother’s ADHD genes.It seems fit to conclude by agreeing with Sagvolden et al. in that“ADHD...   i s   a   case where functions of the central nervous sys-tem occasionally exceed the limits of normal variation and adap-tation” (sect. 3, para. 3) – and add environmental accommodation.Commentary/Sagvolden et al.: A dynamic developmental theory of attention-deficit/hyperactivity disorder (ADHD)442 BEHAVIORAL AND BRAIN SCIENCES (2005) 28:3

The biopsychosocial context of ADHD.

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