What Causes ADHD?

Culture Vs. Biology: What Really Causes ADHD?

Contrast and compare the controversial new theory that our fast-paced, stressed-out, consumer-driven lives cause ADHD with other scientific evidence to the contrary.

Person holding two puzzle pieces to the sky signifying finding the right specialist for your child with ADHD
Person holding two puzzle pieces to the sky signifying finding the right specialist for your child with ADHD

What Causes ADHD?

Most ADHD researchers point to genetics and heredity as deciding factors for who gets attention deficit and who doesn’t. But Michael Ruff, M.D., a clinical associate professor of pediatrics at Indiana University, believes DNA is just part of the story. He is convinced that at least some cases of ADHD are a byproduct of our fast-paced, stressed-out, consumer-driven lifestyles. Let’s compare other research and expert insights to Dr. Ruff’s controversial theory on what causes ADHD.

In a recent article in Clinical Pediatrics, Dr. Ruff called ADHD an ‘epidemic of modernity.’ What does that mean? Is it the only explanation for ADHD?

Dr. Ruff: “I’m talking about the cultural environment that prevails today — the modern way of life and its impact on the developing brain. Today’s children are immersed in a world of instant messaging and rapid-fire video games and TV shows. Today’s parents are rushing around and working so hard to earn money to buy more stuff that they have less time to spend with their kids.

“When kids get accustomed to such a rapid tempo, it’s hard for them to adjust to the comparatively slow pace of the classroom. They transfer the sense of urgency they’ve seen at home to their academic endeavors.”

Randy Kulman, Ph.D., founder and president of LearningWorks for Kids: “There is no question that playing video games affects the brain. In existing studies, neuroscientists have used functional magnetic resonance imaging (FMRIs) to see how video games can change the structure of the brain. And the results show that video games can actually improve brain-based skills and help kids with ADHD.

“Researchers Daphne Bavelier and Shawn Green have demonstrated that playing action-based video games can improve processing speed. Torkel Klingberg has shown that consistent use of adaptive video games improves working memory skills and alters brain structure.”

[Self-Test: Signs of Emotional Hyperarousal]

“Increases in grey matter in the right hippocampus, the cerebellum, and right prefrontal cortex were observed in a study of adults playing Super Mario Bros. Another study demonstrated that playing Tetris resulted in a larger cortex and increased brain efficiency.”

“StarCraft, an action game, can lead to improved brain flexibility and problem solving. Playing Rayman Raving Rabbids can improve reading in children ages 7 to 13. Brain-training video games change brain functioning and slow the degree of mental decay in the elderly. All of these findings are well documented.”

“However, just as with virtually anything else in the world, too much of a good thing is bad for you. If you drink too much juice, eat too much fruit, or spend too much of your time jogging, there will be negative effects. Helping your child to have a balance of physical, social, unstructured, creative, and digital play, is vital. With video games, playing between 60 to 90 minutes a day appears to benefit kids the most.”

There’s evidence that ADHD has a biological basis. Doesn’t that mean it’s hereditary?

Dr. Ruff: “Not entirely. The young brain is highly malleable. As it matures, some brain cells are continually making new connections with other brain cells, a process known as ‘arborizing,’ while others are being ‘pruned’ back. Arborizing and pruning determine how circuitry is wired in the prefrontal cortex, the region that is largely responsible for impulse control and the ability to concentrate. We’ve failed to acknowledge the extent to which environmental factors influence these processes.”

ADDitude editors: Available evidence suggests that ADHD is genetic — passed down from parent to child. It seems to “run in families,” at least in some families.

  • A child with ADHD is four times more likely to have a relative with ADHD.
  • At least one-third of all fathers who had ADHD in their youth have children who have ADHD.
  • The majority of identical twins share the ADHD trait.

A number of studies are now taking place in the U.S. and Europe to try to pinpoint the genes that lead to susceptibility for ADHD. Scientists are investigating many different genes that may play a role in developing ADHD, especially genes linked to the neurotransmitter dopamine. They believe it likely involves at least two genes, since ADHD is such a complex disorder.

There’s also evidence that toxins and pollution contribute to the development of ADHD, though more research is needed on these environmental factors.

[ADHD Is More Than Just Genes]

The role of environment in causing ADHD is an interesting theory, but is there evidence to support it?

Dr. Ruff: “There hasn’t been much research on the role of the environment in ADHD, but some studies are suggestive. In 2004, University of Washington researchers found that toddlers who watch lots of TV are more likely to develop attentional problems. For every hour watched per day, the risk rose by 10 percent.

“My group practice, in Jasper, Indiana, cares for more than 800 Amish families, who forbid TV and video games. We haven’t diagnosed a single child in this group with ADHD.”

“On the other hand, we care for several Amish families who have left the church and adopted a modern lifestyle, and we do see ADHD…in their kids. Obviously, the genes in these two groups are the same. What’s different is their environment.”

“There’s also some evidence to suggest that academic problems are rare in social and cultural groups that traditionally place a high value on education, hard work, and a tight-knit family structure. For example, a 1992 Scientific American study found that the children of Vietnamese refugees who settled in the U.S. did better in school and had fewer behavior problems than their native-born classmates. The researchers noted that the Vietnamese kids spent more time doing homework than did their peers, and that their parents emphasized obedience and celebrated learning as a pleasurable experience.”

ADDitude editors: While some environmental factors almost certainly do influence the development of ADHD, more than 1,800 studies have been conducted on the role of genetics in ADHD, creating strong evidence that ADHD is mostly genetic.

The genetic evidence for ADHD can be ignored, but not argued away. Studies of twins and families make it clear that genetic factors are the major causes of ADHD, says Russell Barkley, Ph.D., author of Taking Charge of Adult ADHD. In fact, an estimated 75 to 80 percent of variation in the severity of ADHD traits is the result of genetic factors. Some studies place this figure at over 90 percent.

How can parents reduce the likelihood that their children will develop severe ADHD?

Dr. Ruff: “I counsel parents to limit the amount of TV their kids watch. I urge them to read to their kids every day, starting at age one, and to play board games and encourage other activities that promote reflection and patience. I also urge parents to do more slow-paced, step-by-step activities with their children, like cooking and gardening. Carve out more quiet time, when you’re not so busy. Put down the cell phone, and stop multitasking.”

Edward Hallowell, M.D., practicing psychiatrist and founder of the Hallowell Center for Cognitive and Emotional Health: “We know enough about ADHD to offer science-based suggestions that can help reduce the likelihood of someone developing this condition.

He advises expectant mothers not to “indulge in alcohol, cigarettes, or illicit drugs, or mistreat yourself or your unborn child in any other way. And get good prenatal care. Poor health care [while expecting a child] brings the risk of developing ADHD.”

“Make sure you have excellent medical care during [your] delivery….Lack of oxygen at birth, trauma during birth, and infections acquired during delivery can cause ADHD.”

“Once you give birth or bring home your adopted child, rejoice. The exciting and momentous journey of parenthood begins. That being said, your enchanting infant requires a lot of work. You may be sleep- and time-deprived, and tempted to plant your [child] in front of the TV to keep him occupied. But don’t. Studies have shown that infants and toddlers who watch more than two hours of television a day are more likely to develop ADHD than other children.”

“As you turn off the TV, turn on human interaction. Social connectedness bolsters the skills that minimize ADHD’s impact. So have family meals often, read aloud together, play board games, go outside and shoot hoops or throw a Frisbee — play, play, play. Also make sure that your child’s school is friendly and encourages social interaction.”

“These are practical measures that can help reduce the likelihood of a child developing ADHD. Remember, too, that inheriting the genes that predispose toward this condition doesn’t guarantee getting it. It is not ADHD that is inherited, but rather the predisposition toward developing it. Simply by reducing your child’s electronic time while increasing interpersonal time, you reduce the likelihood that the genes for ADHD will be expressed as he grows older — even if they were inherited.”

“A final note: You may not be able to prevent your child from developing ADHD, and that’s just fine. I have ADHD, and two of my three kids have it as well. With proper interventions, ADHD need not be a liability. In fact, it can be a tremendous asset. While a person can learn the skills to compensate for its downside, no one can learn the gifts that so often accompany ADHD: creativity, warmth, sharp intuitive skills, high energy, originality, and a ‘special something’ that defies description.”

If a child already has ADHD, can a change in the environment help control symptoms?

Dr. Ruff: “The brain can relearn executive functions like planning and attention well into the fourth decade of life. Consistent discipline, less TV and video games, and an emphasis on exercise, seem to be key. Exercise promotes on-task behavior and helps relieve the ‘desk fatigue’ that makes it hard for kids to sit still in class.”

Colin Guare, a 24-year-old freelance writer and co-author of Smart But Scattered Teens: “If playing video games for hours guaranteed future success, I would be President by now.

“This isn’t the case, of course. Still, much of my mental dexterity and sharper executive function — brain-based skills required to execute tasks — can be chalked up to my hours spent in front of a screen. Gaming has helped me manage my ADHD-related shortcomings.”

ADDitude editors: Though parents will argue that video games are distracting, and an obstacle to learning, research suggests otherwise. In his book, What Video Games Have to Teach Us About Learning and Literacy, James Paul Gee, Ph.D., notes that what makes a game compelling is its ability to provide a coherent learning environment for players. Not only are some video games a learning experience, says Gee, but they also facilitate metacognition (problem solving). In other words, good games teach players good learning habits.

Several video games offer individuals with ADHD the chance to have fun and to polish their executive skills at the same time. Four popular, entertaining, mentally rewarding, and cool games for teens are: Portal and Portal 2, Starcraft and Starcraft II: Wings of Liberty, The Zelda Franchise, and Guitar Hero.”

Randy Kulman, Ph.D.: “Watch your child play Minecraft or other skill building games for a few minutes, and you’ll see that he plans, organizes, and problem-solves while engaged in a video game — skills we’d all like our ADHD kids to develop. Wouldn’t it be great if he could transfer those game-playing skills to everyday tasks? He can, with a little help from you. Use the following three steps to tap into the skill-building potential of video games:

  1. Help your child identify the thinking and problem-solving skills that are necessary to play the game.
  2. Encourage metacognition and reflection by talking about how these skills are used in the real world.
  3. Engage your child in activities that use these skills, and then talk with your child about how the skills connect to game play.”

Kulman recommends the games Bad Piggies, Roblox, and Minecraft to build these skills.

How about medication?

Dr. Ruff: “There’s no doubt that medication can help control symptoms of ADHD. However, it’s problematic when doctors and parents believe ADHD to be simply the result of a ‘chemical imbalance,’ while failing to consider that a ‘lifestyle imbalance’ may also be involved. Even if medication is part of your child’s treatment plan, you still need to get the TV out of his bedroom.”

ADDitude editors: There’s no disputing that a healthy lifestyle — nutrient-rich foods, lots of water, exercise, and less stress — is better for ADHD. However, according to a study published online in the Journal of Attention Disorders in 2016, just the opposite is happening — children with ADHD engage in fewer healthy lifestyle behaviors than do their peers without the condition. There’s definitely room for improvement.

[When ADHD Is All In the Family]

10 Related Links

  1. Yes it is! Genetics and environment the latter being more simple to treat/combat as far as myself is concerned. However , i have contemplating on between?, Conception to birth. When the environment takes toll on one on how early in a child’s development in the womb. That cannot be overlooked. Healthcentral.com gave myths and facts on the causes of adhd but by now just entering that saying on search engine it can be found most anywhere.

  2. I have no desire to contradict any of the conclusions reached by others about the causes of ADD/ADHD in general, or the causes of any one person’s symptoms in particular. However, my personal history is sure to be helpful for many others diagnosed with ADD/ADHD.

    During my time in public school (the 1950s and 60s), my condition was usually labelled “minimal brain damage.” I had to wait until age 49 before being diagnosed with ADD (up to that point being judged as a person “never living up to their potential”).

    Every possible test was done, physical and mental, to determine the cause of my symptoms, except for one. (Stay tuned.)

    I was diagnosed with “adult ADD” (a novel diagnosis at the time, as ADD was considered a problem only for children.) After 20 years of medication (the typical combo of Ritalin and Prozac), I received a second diagnosis, which (at the time) I considered unrelated to my ADD: I had Sleep Apnea. I was sent home with a CPAP machine and a bundle of information, including videos, which described my condition to a “T.” Much to my amazement, the symptoms of sleep apnea are virtually identical to those of ADD!

    After one month of nightly use of the CPAP machine, I felt no further need for the medications and have not taken them since. Most of the symptoms are gone, and I am living another life as a result.

    It’s been 5 years since I’ve been using the CPAP machine, and recent research I’ve done indicates that about 75% of those diagnosed with ADD “also” have sleep apnea. None of these studies venture to say that anyone has sleep apnea “instead of” ADD.

    From my experience and the results of recent studies, I have drawn two conclusions: first, every person (of any age) diagnosed with ADD should be tested for sleep apnea. Second (and more controversial), serious consideration should be given to the proposition that a preponderance of ADD symptoms are caused by sleep apnea.

    The controversy will arise primarily from the phenomena of “vested interest in error.” As Sinclair Lewis said, “It is difficult to get a man to understand something, when his salary depends upon his not understanding it!” Here we have a collection of symptoms with a label, ADD or ADHD, with no causes known to a certainty, and no cure–but with an entire community, culture and pharmaceutical industry profiting from its existence. In contrast, we have sleep apnea, a well-established physical condition with known causes, and a cure. There is immense profit potential in the treatment of symptoms with no cure available, and little profit potential in producing a cure: the ideal source of monetary and intellectual corruption.

    Perhaps someday there will be studies proving cause-and effect connections between ADD/ADHD and physical conditions other than sleep apnea ( or “minimal brain damage”), as opposed to mere correlations. So far, I have seen none. Anyone who has, please let us know. In the meantime, there are millions of people who are “not living up to their potential,” missing out on a cure and medicating themselves to alleviate symptoms while exposing themselves to the side effects of these medications.

    As always, it’s up to us to take charge of our own well-being.

    1. I have 2 dd’s diagnosed w/ ADHD who have recovered & are thriving now w/ mild Adhd.

      My 13 yr old rising 2e GT 7th Grader had breathing issues at birth, Speech delay & is Predominantly Inattentive. In her 3rd grade at school in class while volunteering I saw she was very pale & had dark circles so I got a Fitbit to chk her HR & oxygen levels during sleep. There were interruptions throughout the night. I was surprised since she always appeared to sink into deep sleep. A sleep study confirmed she had low oxygen levels & did not sleep thru night. We then visited ENT. He looked in her nose & throat & said he didn’t see any issues. I gave him the sleep study & he was surprised & said let’s do X-ray. The X-ray revealed very enlarged adenoids. Bam!!! We had adenoids removed. Dr. Said it may take 3 months for brain to work optimally once it has the oxygen it needs.

      My 12 yr old snored so it was obvious she had blockage somewhere. She had an X-ray & swollen adenoids as well just not as enlarged as her sister. We had her adenoids removed same day.

      My well respected pediatrician ignored the symptoms & never recommended having ENT X-ray to check for blockage nor did he recommend a sleep study. I was a novice & ended up going about the process of discovery the more expensive way. Should of had ENT X-ray 1st then sleep study would have been unnecessary. The catch though is as the ENT wasn’t going to order the X-ray until I showed him the sleep study confirming low oxygen levels & sleep interruptions.

      It’s been a journey & my now 7th Grader still masters Reading & Language. She is still however recovering academically in Maths so Summer Mathnasium has been our fun game style gap filler. She has characteristics of Dyscalculia. So a combination of obstacles kept being put in her way such as removing her RTI svc to see if she could hang, accelerated State Staar drill prep that caused a gap year in I believe 2012-2013 or 2013-14, enlarging adenoids causing low oxygen levels thus sleep deprivation.

  3. “February/March 2006”

    I am thankful that ADDitude.com has seen fit to tag an original publication date on at least these articles that came from specific magazine issues. Older dates don’t make the articles less useful, but having the date attached at least gives us some additional context to interpret what is written. It would be very good to see this expanded to everything else. Not having dates attached makes it appear you are hiding the fact that more of the information here is older vs not.

    Receiving an email dated today, though, with the same description of “latest science”, when the article is from 12 years ago?? This is not an appropriate way to sell it to us, in my opinion.

    Please don’t misrepresent the age of the information you are making available here. It does a great disservice to readers.

  4. ADHD has been described in the past as being an general “umbrella” medical diagnosis for some types of cognitive impairments that have no specific or apparent cause. Sometimes, ADHD symptoms may be caused by multiple medical/social factors that are hard to assess or discover.

    In addition to biology/heredity and social environment as possible causes of ADHD, it seems to me there may be a 3rd cause of ADHD that is not often discussed – traumatic brain injuries caused by sudden-impact accidents that may result in physical or psychological cognitive problems…

    I’ve read that soft-tissue injuries or accidents that cause a brain concussion can lead to possible ADHD symptoms. The reason may be that ADHD – which may affect human Executive Decision-making functions and/or Emotions – is related to the pre-Frontal Cortex area of the Brain that is located behind the Forehead and above the Eyebrow area. This forehead area of the Brain can also be damaged or impaired from frontal soft-tissue brain injuries caused by car accidents, contact sports, tumbling down stairs, falling off a House Roof, etc.

    As a result, I wonder if amateurs and professionals who participate in contact sports (especially US Football or European Rugby players with CTE injuries) tend to experience multiple brain concussions over an extended period of time that may result in ADHD symptoms.

    I wonder what medical studies or research statistics have been completed that may show a link between brain injuries caused by accidents and how this may be compared to ADHD symptoms. Supposedly ADHD medical studies have been running for the past 10+ years, so I am surprised there is little discussion about an ADHD extension to CTE injuries.

  5. So the article referenced by Dr. Ruff is 11 years old. I expect a little better out of ADDitude. Also I’m tired of articles that imply parents are to blame for ADHD. My husband and I tried our best to follow all best parenting practices to a T, but our daughter has ADHD. We did positive parenting, parent-child bonding, didn’t miss a well child visit, limited screen time, read daily, breastfed and gave proper nutrition, the works. I don’t think the right type of research is being done into causes. I read a several articles from Europe with a link between febrile seizure and ADHd; my daughter had a febrile seizure. Makes me wonder.

  6. It does seem like everyone has ADHD these days. And, I can see where the constant input from so many places could have an impact on anyone. And maybe it’s become somewhat of a catchall. My mother always said that my brother was hyperactive, but later he was diagnosed with ADHD. He was born in 1960.

    My dad always needed to be busy. He worked all week, and then found more to do on the weekends. I don’t think I ever saw him truly relaxed until he was ready to drop. My mother was very smart, but often distracted and very disorganized. I’m the oldest child in the family, and I was pretty active, too. But what I mostly remember was feeling like I was stupid. I had trouble in school, especially math. However, I loved art and always did well with that. Once I hit puberty, I recall being depressed a lot of the time, but I think it was mostly attributed to being a moody teenager.

    I have another brother who seems to have trouble relating to others. He’s even told me recently that he’s not good at picking up on facial cues. He’s always been awkward, but he’s certainly smart, and he also has had problems with depression.

    My husband was the one who pushed me towards seeing a therapist, and eventually I was diagnosed with ADHD. What really makes me aware of my family now is being with my husband for so many years. He’s very different in the way he handles life. He’s a lot more relaxed, and has much easier time of remembering things (including names!). I have to admit that being diagnosed was actually helpful for me. It gave me a completely different perspective on my own behavior.

    I guess my point is I have an entire family who grew up before computers, TV 24/7, and all the other distractions. We lived in the country, so lots of time spent outside. If it’s not hereditary for some of us, then I don’t know what caused it.

  7. My comment above of June 15, 2018 needs an update. In an unusual circumstance (an on-the-spot exam by a sleep apnea expert), I was given a CPAP machine without first going through the usual protocol of having an overnight sleep study first. The study was ordered by a VA physician, after he heard my story (and my opinion that I was misdiagnosed with ADD and spent 20 years taking medication that, had I been diagnosed with sleep apnea at the outset, I would never have been prescribed).

    When I awoke after the sleep study, I was informed that if I had met certain criteria, I would have been awakened and fitted with a CPAP machine. I did NOT meet those criteria. I have yet to get the analysis of the test, but I anticipate being told that “I do not suffer from sleep apnea,” and therefore don’t need the machine. (I will post again after I get the physician’s “verdict.”)

    So…assuming I anticipate the “verdict” correctly… If I don’t have sleep apnea, why was I diagnosed 20 years ago with ADD, a condition which presents symptoms virtually identical with sleep apnea? Was my life before diagnosis just a bad dream? Did my lifetime condition BD (Before Diagnosis) spontaneously go into remission, now that I approach my 73d birthday?

    I propose a more rational explanation for the (anticipated) results of my sleep study: the CPAP machine functioned (for the last 4 years) as a training device. Before the CPAP, I would sleep on my back as a preferred or dominant position, causing my airway to collapse and starting the apnea cycle: blocked airway, cessation of breathing, buildup of CO2, triggering of the autonomic system to produce a jolt of adrenalin sufficient to make me roll over but insufficient to arouse me from sleep, and an inevitable repetition of this cycle as many as 100 times a night, producing all the usual ADD/sleep apnea symptoms (as I propose, in my case, caused by the combined cumulative effects of all those jolts of adrenalin and lack of the proper amounts of deep, restorative sleep).

    The “training ” which I propose that the CPAP machine provided was this: whenever I would sleep on my back, closing off my airway, the CPAP machine would automatically increase its pressure to keep my airway open, as it is designed to do. At that maximum pressure, the face mask would leak, bringing me fully awake because of the airflow over my face, at which point I would reset the machine and roll over on one side. After 4 years of use, this machine “trained” me to sleep only on one side or the other, never on my back, even after I stopped using the machine. (Conveniently, in the context of this analysis, the week before the sleep study I unintentionally left the machine at home.)

    As I said above, I will report the official medical “verdict,” and the response(s) to my rhetorical questions above, in a subsequent post.

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