Getting Ahead of ADHD

Its full title is Getting Ahead of ADHD: What Next-Generation Science Says about Treatments That Work—and How You Can Make Them Work for Your Child. It came out from Guilford Press in August 2017. About three hundred pages.

Joel T. Nigg is a clinical psychologist and an active researcher in the ADHD field. He did his doctorate at UC Berkeley under Stephen Hinshaw. He is a professor of psychiatry, pediatrics and behavioral neuroscience at Oregon Health & Science University, where he also directs the psychology division and the ADHD program.

I did not see an updated edition on the publisher's site; the version I read is the 2017 edition.

I could not find a verified Turkish edition; I write it under its English title.

A researcher writing for parents

What sets this book apart from an ordinary parenting guide is that its author is someone who conducts research on ADHD.

Nigg writes to answer the questions parents run into on the internet: Is my child's ADHD from what they eat? Is it screens? Is it environmental pollution? Do natural treatments work? Which is exaggerated alarm and which is reasonable caution?

The book's tone comes from here too. It does not frighten, it does not talk down, it does not find any question silly. It takes each question, looks at what the research says, and at the end of each topic leaves the reader with resources to turn to.

While reading, the language did not always suit me; everything is told through "your child." But the questions are my questions too. As an adult with ADHD I lived the same debates for years through my own life.

The order of the nine chapters

The book consists of an introduction and nine chapters.

The first chapter builds the present understanding of ADHD. The second chapter is given to epigenetics. The third is nutrition, the fourth exercise and sleep. The fifth is technology, the sixth environmental chemicals. The seventh is adversity, stress and trauma. The eighth is conventional and alternative professional treatments. The last chapter brings it all together.

The order is deliberate. First the theoretical framework, then the areas a parent can influence alone, last expert support.

The question I kept in mind while reading

In every chapter of the book I asked myself the same question: is this an association or a cause?

Almost all the debates around ADHD revolve around this question. A study finds a link between a factor and ADHD symptoms; the next day the headlines write that the factor causes ADHD. The distance in between is usually lost.

One of the things that makes Nigg's book valuable is that it keeps reminding the reader of this distance. Once you have placed this question in your head, you keep asking it on your own at every new news item even after you finish the book.

Epigenetics: a magic word or a framework

The second chapter is the backbone of the book. Nigg presents epigenetics, that is, how genes are switched on and off by environmental influences, as a framework that moves past the nature-nurture debate.

The basic message is this: a child may inherit a genetic predisposition to ADHD, but how and to what extent that predisposition shows itself is also determined by other factors.

This framework gives the parent hope and leaves them something they can do. Areas like nutrition, sleep, exercise and stress reduction gain meaning.

Care is needed here. The epigenetic findings from human studies in ADHD are still at an early stage and mostly based on small samples. The 2019 review by Faraone and Larsson puts heritability at about 74 percent. Epigenetics shows that the environment matters, but it does not remove this high heritability. Nigg does not deny genetic predisposition either; even so, a chapter title like "the end of the nature-nurture debate" speaks with more certainty than the field has reached today.

The difference becomes clear when compared with Maté's Dağınık Zihinler (Scattered Minds). Maté puts the environment at the center as a cause. Nigg treats the environment as a factor that works on top of a strong genetic predisposition. The second reading fits today's data much better. If you are curious about the heritability side, you can look at the article is ADHD hereditary.

A framework that reduces guilt

While reading this book I often thought of the guilt that parents carry.

The mother or father of a child diagnosed with ADHD often asks the same question: what did I do wrong? The surroundings feed this question too. Too much screen time, wrong nutrition, not enough discipline.

Nigg's framework moves this question somewhere else. The predisposition is largely genetic; the parent did not choose it. But the parent has an influence over how this predisposition will show itself in daily life. This is a reading that removes the blame and leaves the responsibility. My reading went in this direction, and I cannot think of a healthier starting point for a parent.

Nutrition: the old debates

The third chapter enters the oldest and loudest debate around ADHD: food.

The chapter title promises to bring new clarity to old debates, and the book's general stance is kept here too: weighing each claim separately.

It is worth remembering where this debate stands today. That sugar does not affect children's behavior has been known since the 1995 meta-analysis by Wolraich and colleagues. There are studies showing that elimination diets may have an effect in a subgroup, but in blinded assessments the effect is seen to shrink. Omega-3 supplementation has an effect but a limited one.

So nutrition is not a treatment for ADHD on its own, but it may be a part of the whole. Nigg's balanced approach fits this picture. I covered the topic in detail in the article does diet work for ADHD.

Exercise, sleep and brain development

The fourth chapter brings two areas together and, I think, is one of the strongest chapters of the book.

On exercise, the research points to a moderate effect on ADHD symptoms. On sleep, the relationship runs both ways: ADHD disturbs sleep, and disturbed sleep makes ADHD symptoms worse.

For the adult reader this chapter has an extension. It is known that in a significant share of adults with ADHD, sleep time is chronically shifted late. Although the book speaks through children, what it says about the effect of sleep on attention applied directly to me.

This was the chapter that touched me most. The book explains sleep through the development and functioning of the brain, without turning it into a moral lesson.

Screens and chemicals

The fifth chapter is given to technology, and its title speaks of both the danger and the promise. I liked this balance. Screens on the one hand carry a debated effect on attention, and on the other offer supportive tools for people with ADHD.

In research there are studies reporting a relationship between screen use and ADHD symptoms, but causation cannot be said to have been shown, and the reverse direction is at least as plausible: children with ADHD may be drawn more to high-stimulation screens. I discussed the details in the article does screen time cause ADHD.

The sixth chapter is about environmental chemicals. The chapter title promises to separate alarm from reasonable caution, and given the fear the internet produces on this subject, this distinction is very valuable.

One example in this area shows how much care environmental risk debates demand. For a long time a strong association was reported between smoking during pregnancy and ADHD in the child. In studies comparing siblings, this association was seen to weaken considerably; a significant part of it seems to be explained by shared genetic and environmental differences between families. This does not mean smoking in pregnancy is harmless. It only reminds us of the distance between "there is an association" and "it causes."

Hardship, stress, trauma

The seventh chapter talks about creating a safe haven for a child with ADHD.

Nigg recognizes the relationship of adverse experiences and stress with ADHD symptoms, but does not put this in place of genetic predisposition. Reading this chapter, I saw that the place where I got stuck in Maté's book is handled more carefully here.

It needs to be remembered that children with ADHD are also more exposed to adverse experiences because of their symptoms themselves. The arrow works in both directions.

Professional help

The eighth chapter handles conventional and alternative treatments together.

The approach Nigg proposes is integrative: using medication together with lifestyle changes and other supportive methods. He stresses that a single solution does not suit everyone and that treatment should be adjusted to the person. The decision on medication is always made with a doctor.

On alternative treatments the book's stance is one of sifting. It aims to separate approaches that have no evidence, or may even be harmful, from real advances. This chapter is a good ground for evaluating the promises circulating about things like neurofeedback.

The parts that have aged

The book was written in 2017. Since then, many new studies have been published on screen use, nutrition and exercise. The general framework holds but the details need updating chapter by chapter.

The book was not written for adults. There is no special chapter on adult ADHD, on the distinctive presentation of ADHD in women, or on late diagnosis.

And one more thing: the effect sizes of lifestyle changes are mostly small or moderate. The book's hopeful tone may create the expectation in some parents that these changes can replace medication. Nigg does not claim this, but the reader needs to be careful not to fall into this misreading.

My recommendation to someone reading this book today is to use it as a map. The chapter titles show which questions are worth asking. When you get stuck on a question, looking at newer reviews on that topic lets you see where the picture the book drew in 2017 has changed. The book's most lasting contribution is anyway less the individual findings than that it teaches you how to weigh these questions.

What I took for myself as an adult reader

Suggestions written for children can be adapted to an adult too. What I noted for myself:

• Taking sleep as seriously as a component of treatment.
• Seeing movement not as a sports goal but as an everyday tool for attention.
• Letting go of guilt about screens and looking at which use scatters me and which supports me.
• With every new claim I read online about "what causes ADHD," first asking: association or cause?

For whom, and how

For the parent of a child newly diagnosed with ADHD who is lost among the contradictory information read online, I would recommend it first.

As an adult with ADHD I got a lot from it too, but you need to read it knowing that it is a parents' book.

I would not recommend it to someone who is looking for a medication-free solution and wants to get its approval from this book; the book does not give that approval, and if one tries to read it that way, it is misread.

You do not need to read it from start to finish. Read the first two chapters for the framework. Then go to the question that occupies your mind: food, sleep, screens or trauma. Each chapter is complete in itself.

The last chapter shows how these debates can be translated into the daily life of a family; if you want to put a plan on paper, you can start there.