By Jerry Morris, PsyD, MsPharm, MBA

MB (Marc Braman, MD, MPH):
Okay, so what I’m hearing is that the direct cause, or I guess the direct physiology for ADD is that these parts in the top and the front of the brain aren’t developed enough, and these are the parts of the brain that put the person in control, that allow them to regulate their responses, their thoughts, to be able to adapt to what’s going on around them. Is that correct?

JM (Jerry Morris, PsyD, MsPharm, MBA):
That’s exactly correct, and that they are maturing at a different rate than other children. But that if we implement the right kind of exercises and interventions, they can catch up, their brain can grow.

Okay. So, essentially, their brain is growing slower than would be ideal. To get even deeper than that, why is their brain growing more slowly than normal, or that is most functional? Are there causes below this leading to this brain slowed development?

Exactly. This is what’s called the multi-pathway or multi-etiology concept of emotional disorders. We now know that it takes a lot of variables coming together to create an emotional disorder or a different brain. And so, it can be in vivo gestation problems or stressors. It can be physical illnesses that become stressors in the early infant’s life. It can become the family environment and stressors in the infant’s life. Or, it can become a combination of those things. So that, we know that the brain grows and even a good cattle rancher takes real good care of its new heifers and steers, and nutritionally, environmentally, in terms of stress, they don’t let dogs come and run them. They know this, that in formative years, stress and the environment plays a huge developmental director on brain and organ growth.

So, if we wanted to have a map of what ideal treatment would look like, what percent of that map is medication, what percent is a psychologist or therapist, what percent is school or family? Can you give us a map picture with what percentages, roughly speaking?

Sure. And it depends on whether you have severe form of attention deficit disorder and you have to do immediate control — which is the role of medications. And obviously, neurons grow slow and the brain resists neuron growth, otherwise we’d be like a clown with a different face everyday. So, if the behavior is so severely disruptive or risky, we’ve got to move in with medications that can knock off 10% or 15% of the lack of inhibition, of the lack of flexibility, and the lack of interpersonal skills, and to begin to gain control. Now, on the longer range, over a two to three-year period, then we can implement the behavioral controls. So, the percentage depends on the severity of the symptoms and the disorder.

It also depends on, of course, the family. In many of these families, they have differential developmental levels and they have more stress, or chaos, or communication problems, so that that’s continuing to exacerbate. So, to give you a hard and fast rule, we can’t —  depending on the individual case. Some places you’d need to do most of the work, or even 50% of the work with the family members in the family environment. In other cases, you do the early 50% of the work with medications, and in other cases, you would get them involved in all of the positive institutions and positive relationships that will do these repeated exercises in flexibility, in inhibition, and in relational skill development that grows those neurons. So, the question is individualized to the family in the case.

Certainly, because that make a lot of sense. An average run-of-the-mill, attention deficit disorder, how often and for how long is someone seeing a therapist?

Attention-deficit/hyperactivity disorder is characterized by a delay in cortical maturation. Shaw P, Eckstrand K, Sharp W, Blumenthal J, Lerch JP, Greenstein D, Clasen L,  Evans A, Giedd J, Rapoport JL. (2007). Proc Natl Acad Sci USA. Dec 4;104(49):19649-54. Epub 2007 Nov 16.

From Neuroscience: Seven Principles of a Brain-Based Psychotherapy. Kandel ER, Schwartz, JH, & Jessell, TM. Principles of Neural Science. 2001 McGraw-Hill. New York. Psychotherapy: Theory, Research, Practice, Training 1997 Copyright 2005 by the Educational Publishing Foundation 2005;42,(3):374–383.

A new intellectual framework for psychiatry. Kandel E.R. Am J Psychi. 1998; 155, 457–469.

Attention Deficit Hyperactivity Disorder:  Effectiveness of Treatment in At-Risk Preschoolers; Long-Term Effectiveness in All Ages:  and Variability in Prevalence, Diagnosis, and Treatment  (2011).  Agency for Healthcare Research and Quality U.S. Department of Health and Human Services 540 Gaither Road Rockville, MD 20850 Contract No. MME2202 290-02-0020. AHRQ Publication No. 12-EHC003-EF.

Jerry Morris, PsyD, MSPharm, MBA

Dr. Morris is former President and current Executive Director of the American Board of Medical Psychology. He has owned and operated mental health hospitals and community centers and has run residency-training programs. He has managed clinical programs that treat lifestyle related diseases and is a member of the American College of Lifestyle Medicine.

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