Attention and Attunement

The diagnosis of ADHD (Attention Deficit and Hyperactivity Disorder) is the “hot button” diagnosis in the world of child and adolescent psychiatry and psychology. Labeling children so young has become controversial and many question the use of stimulants as treatment. It has been noted that more methylphenidate and other psycho-stimulants are being consumed by children in the United States than in any other country even though any evidence of long term benefits are lacking. In September 2010, a study was released that stated there was a genetic link to ADHD. The study was performed by a professor from Cardiff University and she hoped the finding would help dispel the myths that ADHD is caused by “bad parenting or high-sugar diets”. I am very skeptical of the idea of genetics as the sole cause of any illness. The truth is that the connection between illness and genetics is often over-exaggerated and 86% of the time the initial genetic links are often found to be overstated when larger studies are conducted. Maybe poorly attuned parenting or excessive sugar lead contribute to these genes to be expressed? Some articles online have used the circular argument that there is no proof that dysfunctional family dynamics have any role on the development of ADHD, but I just do not buy into that. MyADHD.com says, “While parents of children with ADHD are likely to give more negative commands to their ADHD child and less positive attention, this may be due to the fact that ADHD children are often non-compliant and, therefore, parents are more likely to be more negative in their interaction with them.” That clearly sounds like poor attunement and maybe the prognosis for a diagnosis of ADHD could be improved by focusing on the attachment status and interactions of the child and parents.

I have read differing views of the geneticism debate. Steven Pinker argues against the idea encompassed by the “tabula rasa” model of the social sciences in his book, The Blank Slate. He explains that human nature is shaped by varying psychological adaptations and warns of inappropriate or excessive guilt placed on parents because it is assumed emotional difficulties in their children to be entirely environmentally caused. Oliver James, child developmental psychologist, has been an outspoken critic about the ideology that mental disorders are caused primarily by genetics. He cites The Human Genome Project, which was completed in 2001, revealed that, to the shock of the geneticists, that human beings only have about 25,000 genes and specific gene patterns for the most common mental illnesses could not be found (eg. depression, anxiety). His viewpoint can be summarized with an excerpt from his book They F*** You Up : “Yes, genes do establish a basic repertoire of traits in nearly all humans, but the subtle differences between us in their expression are largely determined by our upbringing. We got where we are today, the only species on earth able to survive in all ecosystems, by being born pliably plastic to our particular family.” Most researchers would agree that it is extremely unlikely that there are specific genes are solely responsible for mental illness and that you should “accept your fate” in terms of your genetics. As with most psychological disorders, the factors that cause the development of ADHD are complex . Our children develop within an interactive biological and experiential model. The way we parent are children and the environment we provide is important along with taking into account genetic predisposition. (Note: I am not in any way implying it is “your fault” if your child is having difficulties, including a diagnosis of ADHD. It is easy to take the credit when are children are doing “well” by societal standards and blame “disorders of the brain”, instead of looking inward at family dynamics, when our children are struggling. This is not about blame, shame, or guilt. We need to be empowered with knowledge about parenting practices and be open to forgiving ourselves when we make mistakes. We have the choice to change how we are interacting with our children. Our children have the gift of resilience. By changing how we interact with our children we can alter the prognosis of psychological disorders.)

How can our parenting alter the expression of these specific genes? As parents can we temper the development of ADHD or difficulties with attention? I think the resounding answer is “yes” and we can do this by providing our children with secure attachment. We can do this by being “good enough” parents, as coined by Winnicott. I was thinking about the connection between insecure/disorganized attachment and ADHD after working with several children in the last month with both disruptive externalizing behaviors, a diagnosis of ADHD, and family dysfunction that set the stage for the development of insecure/disorganized attachment. I decided to see if any research had been completed that supported my hunch. I found some studies that you can read by clicking the links below:

Disorganized Attachment and Inhibitory Capacity: Predicting Externalizing Problem Behaviors

Disorganized Attachment Representation and Atypical Parenting in Young School Age Children with Externalizing Disorder

Attachment Representation in Mothers of Children with Attention Deficit Hyperactivity Disorder

ADHD is described as having three core symptoms: inattention, hyperactivity, and impulsivity. Disorganized attachment leads to difficulties with the regulation of emotions, social communication, and academic reasoning. I found the last study the most interesting. The abstract states, “Considering the results of clinical attachment studies we formulated the following hypothesis: the prevalence of maternal insecure and unresolved attachment representations increases with the degree of severity of children’s ADHD symptoms. Therefore it is highest in mothers of children with ADHD who are treated clinically (group A). It is expressed less strongly in mothers of children with ADHD symptoms without need for clinical treatment (group B). In a control group of mothers who children have no ADHD diagnosis (group C), there is the lowest prevalence of insecure and disorganized attachment representations.” The attachment status was assessed using the Adult Attachment Projective and increased clinical involvement for treatment of ADHD was correlated with an increase in insecure and unresolved attachment of the mothers. Insecure attachment comes from a lack of attunement with our caregivers during infancy and toddlerhood. Without resolving our childhood “hurts” we are very likely to pass our insecure attachment status on to our children. Daniel Siegal MD has a book he co-authored with Mary Hartzell M. Ed. titled Parenting from the Inside Out that covers this topic in depth. Is this perhaps why ADHD is four times more likely to be diagnosed when a family member has been diagnosed as well? Low dopamine has also been indicated as a causal factor in the development of ADHD. Due to lack of attunement are the “seeking” systems, which involves the mesolimbic and mesocortical dopamine pathways, in these children’s brains underdeveloped? Neuroscience research by Jaak Panksepp shows that "emotionality is modified by cortical injury" and ongoing levels of stress during infancy and childhood can alter amygdala function. What are some ways we can be more attuned to our children? How can we evoke more emotional resonance and harmony when we interact with our children?

I have been reading The Mindful Brain by Daniel Siegal MD and have found myself repeating his acronym for mindfulness, COAL, frequently throughout challenging parts of my day, whether at work with clients on the crisis unit or handling a difficult moment with Genevieve. COAL stands for curiosity, openness, acceptance, and love. Studies have shown that by applying mindfulness techniques you can improve your capacity to regulate your emotions, improve patterns of thinking, and combat emotional dysfunction. Preliminary research on those who practice mindfulness techniques shows that actual changes take place in the brain. The thought is that these techniques promote neural plasticity. Mindful awareness is a form of inner attunement to self that promotes both psychological and physical health. When we care for ourselves we are more capable of having empathy for the emotional states of our children. How can you approach the challenges of parenting with curiosity, openness, acceptance and love? What are some ways to become more attuned to the emotional states of our children?

1) We express our attunement to our children through verbal and non-verbal interactions. They need to feel safe and secure and receive affection and love. We can express that we understand their needs by the way we hold, feed, bathe, and diaper them. We can express verbally and through the intonation of our voice that we tolerate their feelings and allow them to be comfortable with their emotions.

2) With older verbal children, listen with attention when they tell you how they feel. When you offer your attention you model the practice of focusing. Attempt to find out what unmet needs they are trying to express and what feelings they are experiencing. Help them to put words to their feelings. Verbalize and validate their point of view.

3) Accept them unconditionally and be genuine during your interactions. Listen more and say less.

"Self-Soothing" and Scaffolding

The “self soothing” debate makes me think back to of the “old days” of psychology – when the behaviorists had full reign in the 1940s and 1950s. The names B.F. Skinner and John Watson probably ring a bell if you took Psychology 101 in college. The movement was driven by the idea that psychology can be simplified to behaviors and that you should not concern yourself with discussions about human consciousness or emotions. The idea that holding and cuddling your baby will “spoil” them or cause undesired dependence is an ideological remnant of this era of psychology. This myth continues to be passed along in our culture and unfortunately through some parenting literature written by so-called “experts” who do not have training in child development, psychology, or affective neuroscience. I believe most parents now know, as it is supported with science, that you cannot “spoil” a baby through affection. Regardless, there is still cultural pressure to create independence before children are developmentally mature through methods that advocate non-response to your child’s cries. If you stop responding to your child’s cries regularly and consistently they will stop attempting to communicate their needs to you. I define "response" as providing your presence and not necessarily trying "fix it" or terminate your child's emotions. You can learn more about this concept by reading about the work of Aletha Solter PhD, a developmental psychologist, and through the Resources for Infant Educators (RIE) philosophy created by Magda Gerber. The state of no longer reaching out for needs to be met is labeled “learned helplessness”. It is interesting to note that two of John Watson’s children later committed suicide as adults. They likely had much difficulty functioning as adults due to lack of affection and attunement during their formative years.

I do agree that self-soothing is a learned skill to some degree, but the brain pathways and “wiring” have to be in place. Humans come out of the womb very neurologically immature and pathways for soothing are not developed. In other words, by soothing your infant you develop the pathways for them to later soothe themselves. Young infants require external soothing by parents to maintain emotional homeostasis and cope with the stress of transitions. I often work on “self-soothing” techniques with clients suffering from debilitating depression and/or anxiety. These clients often have history of emotional and/or physical neglect. This neglect is not always as severe as you would imagine. For example, the insidious effects of chronic invalidation by parents or other caregivers. They are lacking some or all of the essential “wiring” that nurturing parents provide through their responsiveness to crying and distress.

This brings up the topic of scaffolding! Jerome Bruner, a cognitive psychologist, introduced this theory in the 1950s. He mostly spoke about the term scaffolding in relation language acquisition, but the theory can be applied to many developmental skills. Scaffolding is defined as a teaching strategy that limits complexities and then gradually removes those limits as learners gain the knowledge, skills, and confidence to cope and complete the task independently. A scaffold is described as a temporary framework that is put up for support and gradually diminished as the child is able to take on the task independently. How does this apply to the idea of “self-soothing”? How can you be open to and support your child efforts to soothe and calm themselves?

Soothing is a dance between each parent and child dyad. I do not believe there is a finite timeline for when a child “should” be able to self-soothe or not. Each child is an individual with its own temperament. Each parent has his or her own threshold for crying and amount of sleep required for daily functioning. I bed shared and nursed Genevieve back to sleep every one to three hours for the first eleven months of her life. (Disclaimer: This is my experience and the sleeping arrangement that I chose for my family and I am not implying that this is the only acceptable way or that this arrangement would be ideal for your family. I encourage families to be creative with their sleeping arrangements if they are not getting enough sleep while providing for their child nighttime needs. I think the best sleeping arrangement is one where the mother feels reasonably rested and the child can have their attachment and belongings needs met.) And yes, I did this while working full-time twelve-hour shifts on a crisis unit from the time she was four months old. I chose and accepted this arrangement. I attempted to limit some nursing sessions during the night when she was around ten months old. I remained present and observed her crying. Through the tone of her cry and body language she communicated to me clearly that she still needed the comfort of nursing throughout the night. One month later, I noticed she would often fall asleep next to me without nursing, but while having her back patted, at the beginning of the night. So I started trying to pat her during the night for every other nursing session. She would often arch her back and become angry initially, but I would tell her, “I know this is hard for you, but you can fall back to sleep without nursing. Sleepy sleep.” Often times she is asleep in five to ten minutes. I have now moved on from patting her back to just being present next to her as she falls asleep. I effectively used scaffolding to assist Genevieve in learning to fall asleep without nursing by soothing her to the point where she is almost asleep and then letting her take over from there. I believe in her ability to soothe herself while supported by my calming presence. I view her as capable within the confines of her developmental age. I have found this process to be very gentle and effective. Sleep deprivation is one of the biggest challenges of parenting and balance between baby’s need for comfort and mother’s need for sleep is always a priority.