The Riggs Blog

ADHD and the Vulnerability Paradigm: A cautionary tale

by Eric Plakun, MD, DLFAPA, FACPsych

Young girlDame Gillian Lynne is Broadway Royalty. She choreographed Cats and Phantom of the Opera, and at 88 is still dancing, but the story of the start of her career, told on NPR in a story on Weekend Edition Saturday, is a cautionary tale about the danger of viewing problems in psychiatry through the lens of vulnerability rather than plasticity. By the time Gillian was 7, her mother and her teachers were at their wits end with little “wriggle bottom,” who could not sit still and had no attention span. Worried she had a learning disability, though there was no such diagnosis as ADHD in the 1930s, Gillian’s mother took her to an astute doctor who noticed her eagerness to take things in even while she tried desperately to sit on her hands and stay still. After hearing mother’s concerns and observing Gillian’s squirming, the doctor told Gillian he and mother needed to speak privately, switched on the radio and walked out of the room with mother. The two, though, paused outside the door and watched as Gillian, set free, bounced all over the doctor’s office and furniture to the music. After a few minutes the doctor said to Gillian’s mother, “There’s nothing wrong with your daughter, she’s a dancer. Send her to dance school.” Gillian credits this astute clinician with the start of her career. What would happen today?

Many clinicians are trained in a vulnerability model of disease, looking for signs of an underlying problem that needs treatment. The same paradigm shapes most research. We look for genes that confer vulnerability to illness. Research on the serotonin transporter promoter gene suggests the vulnerability paradigm may be short sighted. Here certain alleles—a variant of the gene—are associated with a greater risk of depression in individuals who have experienced childhood adversity, like abuse. Clinicians and researchers have leapt on this as a potential example of a vulnerability gene—a gene that increases the risk of depression if environmental factors go wrong, as in abuse. What is often overlooked is the rest of the story. That is, those with this same variant of the gene have the least risk of depression if they have positive early experiences. The same variant of the serotonin transporter promoter gene that looks like it confers vulnerability in adverse conditions seems to confer an advantage in positive conditions. What looks like a “vulnerability” gene turns out to be a “plasticity” gene that may confer advantage or disadvantage depending on what kind of experiences a child finds in the world. A doctor stuck in the vulnerability paradigm who looked at Gillian might only see ADHD and put her on stimulants to quiet her restlessness. Fortunately, she found a doctor who, perhaps ahead of his time, knew that plasticity was a more hopeful and more useful model, and that what looked like a vulnerability could be a gift.

Credit for front page photo: Copyright: <a href='http://www.123rf.com/profile_evdoha'>evdoha / 123RF Stock Photo</a>

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