Scattered Minds: The Origins and Healing of Attention Deficit Disorder

by Gabor Maté

A few people with ADD have extraordinary mechanical skills and are able to dismantle and assemble complex objects, pieces of machinery and the like almost intuitively.

the person with ADD loses track by the time his informant is halfway through her first sentence. Fortunately, he has perfected the art of nodding. Ashamed to admit his lack of comprehension and knowing the futility of asking for clarifications that he would grasp with no greater success, he gives a masterful impersonation of one who understands.

Active attention, the mind fully engaged and the brain performing work, is mustered only in special circumstances of high motivation. Active attention is a capacity the ADD brain lacks whenever organized work must be done, or when attention needs to be directed toward something of low interest.

A facility for focusing when one is interested in something does not rule out ADD, but to be able to focus, the person with ADD needs a much higher level of motivation than do other people.

ADD is situational: in the same individual its expression may vary greatly from one circumstance to another. There are certain classes, for example, in which the ADD child may perform remarkably well, while in others she is scattered, unproductive and perhaps disruptive. Teachers may conclude that the child is willfully deciding when or when not to buckle down and work diligently. Many children with ADD are subjected to overt disapproval and public shaming in the classroom for behaviors they do not consciously choose. These children are not purposively inattentive or disobedient. There are emotional and neurophysiological forces at play that do the actual deciding for them.

Not once in high school or university did I begin an assignment or essay before the eve of the day it was due.

Many are recognizable by their compulsive joking, their pressured, rapid-fire speech, by their seemingly random and aimless hopping from one topic to the next and by their inability to express an idea without exhausting the English vocabulary. “I have never finished a thought in my life,” one young man lamented. Men and women with ADD have about them an almost palpable intensity that other people respond to with unease and instinctive withdrawal.

but mostly I regret what I did not do: give my children the gift of a mindful, secure and reliable parental presence.

IT IS NOT that I wish to be late. I do not imagine for a moment that I will be late. I may have to be somewhere, miles away, at 9:00 a.m., but as long as it is not yet nine, I fully believe I have time enough.

narrow genetic explanations for ADD and every other condition of the mind do have their attractions. They are easy to grasp, socially conservative and psychologically soothing. They raise no uncomfortable questions about how a society and culture might erode the health of its members, or about how life in a family may have affected a person’s physiology or emotional makeup.

Infants, particularly sensitive infants, intuit the difference between a parent’s real psychological states and her attempts to soothe and protect the infant by means of feigned emotional expressions. A loving parent who is feeling depressed or anxious may try to hide that fact from the infant, but the effort is futile. In fact, it is much easier to fool an adult with forced emotion than a baby.

Each time we scream at someone in traffic, we are telling a story from the earliest part of our life.

The deficiencies and imbalances of brain chemicals are as much effect as cause. They are greatly influenced by emotional experiences. Some experiences deplete the supply of neurotransmitters; other experiences enhance them.

acrimony,

Among the recurrent themes blighting the childhoods of adults I have seen with severe cases of ADD are family strife and divorce; adoption, depression—especially in the mother; violence—especially from the father; alcoholism; and sexual abuse.

Only people abused in their youth will go on to abuse their own children—and they will do so almost inevitably unless they have recognized the facts of their own childhood histories and have taken up the task of healing.

“There are two possibilities why your memories of childhood are so hazy,” I suggest to people. “Either nothing happened worth remembering, or too much happened that may be hurtful for you to recall.” As we shall see in a later chapter, human beings can tune out entire periods of their lives that were characterized by emotional pain.

In the language of psychology, mental absence, tuning out, is an example of a mind state known as dissociation.1 It is employed in clinical psychiatry to refer to specific syndromes such as multiple personality disorder, but I use the term in its general sense. Dissociation, including the tuning-out of ADD, originates in a defensive need—it is a form of psychological defense.

The original purpose of dissociation is to separate conscious awareness from some emotional pain we are experiencing, to dis-associate one from the other. We may think of dissociation as a psychological anesthetic.

Dissociation is a nature-given emergency survival technique. It is not meant for everyday use but is to be employed in the rare circumstance when to feel pain threatens survival more than not to feel pain. Since tuning out can be perilous even as it protects, only under certain dire conditions will nature allow us to use it as defense. The first condition is severe distress. One does not have to tune out the hurt of a stubbed toe. The second condition is helplessness. If help is available, it is safer to feel the pain and scream for assistance than to tune it out.

Once in place, a defense mechanism such as tuning out takes on a life of its own. Little or nothing of a distressing nature need be there in the immediate environment for it to happen. It becomes, as it were, the “default” setting in the cerebral apparatus of awareness: unless some other special switch is turned on, tuned out will be the state that the brain automatically returns to. Because tuning out is based on deeply entrenched neurological responses, their later activation requires very little stimulus.

Nobody is born with “attention.” Like language or locomotion, being attentive is a skill we acquire. As with all other skills, the conditions necessary for the development of attention have to be present.

Attention and emotional security remain intertwined throughout childhood. What looks like a deficit of attention may be a preoccupation with something important to the child but hidden to the observing adult: the child’s emotional anxieties. The classroom behavior of ADD children, to give a common example, is frequently said to be disruptive. They seem to have more interest in interacting with their peers than in the material the teacher would have them study—which may simply mean that they are obsessed with trying to get their relationship needs met.

The nagging hunger for emotional contact explains the oft-observed “paradox” that many children with ADD are capable of focused work in the presence of an adult who is keeping them company and paying attention to them. This is no paradox at all, if we see the opposing roles of anxiety and attachment in influencing attention: attachment promotes attention, anxiety undermines it. When the child is not concerned with seeking emotional contact, his prefrontal cortex is freed to allocate attention to the task at hand, illustrating that what we call attention deficit disorder is not a fixed, unalterable physiological state; it’s a physiological state, yes, but not fixed and unalterable. The warmth and satisfaction of positive contact with the adult is often just as good as a psychostimulant in supplying the child’s prefrontal cortex with dopamine.

Shame becomes excessive if the parent’s signaling of disapproval is overly strong, or if the parent does not move to reestablish warm emotional contact with the child immediately—what Gershen Kaufman calls “restoring the interpersonal bridge.” Chronic stress experienced by the parent has the effect of breaking that bridge. The small child does not have a large store of insight for interpreting the parent’s moods and facial expressions: they either invite contact or forbid it. When the parent is distracted or withdrawn, the older infant or toddler experiences shame. Shame postures are observed in infants in response to nothing more than the parent breaking eye contact. The demeanor of the infants of depressed mothers is one of inactivity and the averted gaze.

John Ratey has aptly observed that “I’m sorry” is the most common phrase in the vocabulary of attention deficit disorder. What strikes me immediately when I meet new ADD patients is how often they apologize.

They apologize when I ask them to speak louder, when they cannot easily answer a question, when I interrupt their flow of speech to ask for more information, when I tell them that we will wind up the session in a few minutes as time is running out. People ask forgiveness for being in my office in the first place. Their opening words may be an apology: “I am sorry to be taking up your time. I am sure there are many people waiting to see you who need help a lot more than I do.” Of course, they also apologize if they think they have too serious a problem: “I’m sorry, I know it’s difficult to help me. You couldn’t have imagined you would be dealing with such a basket case.” These expressions of remorse, where no offense was committed, communicate a deep sense of shame. If the words did not betray shame, it could still be recognizable in the averted eyes.

A requirement of healing, becoming whole, is circuitry in the brain that can carry different messages and a different, nonhelpless image of the self. There is strong evidence that such circuits can develop at any time in life, as can neural pathways to help the cortex to do its job of inhibition and regulation.

Our immediate objective of getting the child to obey or to perform this or that task may need to be sacrificed. On the other hand, tactics needed to achieve short-term behavior goals may have to involve the weakening of the attachment. Especially in the beginning, the parent will be confronting those options regularly. The unfortunate “time-out” technique of disciplining is an archetypical example of how opting for the short-term goal can harm attachment and therefore be ruinous to the long-term objective. In “time out” the small child is sent to his room or otherwise banished from contact with the parent for varying periods of time, and is supposed thereby to learn the difference between good and bad behavior. That is not what they learn. Time out requires raising as a threat the worst nightmare a young child can have—being cut off from the parent. Whatever the parent intends, the message received by the child is If you do not do as I want you to do, if you displease me, I am quite ready to sever the relationship with you. I only want you around on my terms. Time out may achieve its immediate goal, especially with a young child already anxious about his attachment with the parent and thus inclined to please. The effect, however, is to increase the child’s anxiety and, deep down, the child’s rage as well. Anxiety will diminish the child’s capacity to develop self-regulation.

She feels accepted even with her faults. The attachment relationship is maintained, and further room has been cleared for development. Eventually, the question of punctuality will resolve itself. The world will teach her the necessary lessons, if she is helped to become open to learning.

Children with ADD may be highly susceptible to the negative aspects of their environment, but the other side of the coin is that they are equally responsive to positive changes.

We think that children act, whereas what they mostly do is react. Parents who realize this acquire a powerful tool. By noticing their own responses to the child, rather than fixating on the child’s responses to them, they free up tremendous energy for growth. “If parents shift their focus off the child and become more responsible for their own actions, the child will automatically (perhaps after testing whether the parents really mean it) assume more responsibility for himself,”

“If parents focus on being responsible for themselves and respecting boundaries in relating to their children, the children will automatically grow towards being responsible for themselves.”

Self-regulation in this context has nothing to do with “controlling one’s temper.” What we call “temper” is only an automatic anxiety response. It is the reaction of a person who cannot tolerate the feeling of anxiety. Self-regulation is not the absence of anxiety, at least not in the very beginning, but a person’s ability to tolerate her own anxiety.

We may believe we have a perfect idea of why they act as they do, when in reality our beliefs reflect no more than our own anxieties. Whenever we ascribe a motive to the other person, as in “you are doing this because…,” we discard curiosity and immobilize compassion. The person who knows has nothing to learn, has given up on learning. “In the beginner’s mind there are many possibilities, in the expert’s mind there are few,” said the Zen master Shunryu Suzuki. It is good to be aware that we are beginners as we approach the ADD child.

In our interactions with children, intentional thinking gets in the way of seeing the child for who he really is. Worse, the judgments we deliver on our children become the self-judgments they will carry into adult life. “I was a bad kid,” or “I was always trying to cause some trouble” frequently express the way adults with ADD recall themselves as children. The child sooner or later comes to see himself, as much as he may protest against it, through the negative opinion of the parent.

laziness and the procrastination are not immutable traits of a person but expressions of his relationship with the world, beginning with the family of origin.

A strong defense is there only because there is threat, and the child is threatened only because a strong sense of his own self has not developed sufficiently. So the root of the problem is that rather than being too powerful, the inner core of self, the true will, is stunted. This is why the various epithets such as stubborn, willful and so on indicate not a strong will but the lack of one. An emotionally self-confident person does not have to adopt an oppositional stance automatically. She may resist others’ attempts to control her, but she will not do so rigidly and defensively. If she opposes something, it is from a strong sense of what her true preferences are, not a knee-jerk reflex. A child not driven by counterwill does not automatically experience any advice, any expression of the parent’s opinion, as an attempt at control.

Encourage self-discipline instead of controlling the child Too often parents confuse discipline or good parenting with control. They are supported in this misbelief by their relatives and neighbors, or by voices in the media, who say that the only problem with the behavior of ADD children is that parents are too lax with their discipline, too weak to control their son or daughter. If that were true, children treated harshly should be the best behaved and should grow up into the best citizens. As a survey of the population of any foster home or prison would show, the contrary is true. The issue is not how to control the child but how best to promote the child’s development.

The problem is that our parenting styles and teaching methods in many cases fail to support the child’s natural drive for discovery and mastery. Encouraging development to unfold is based on the knowledge that nature has its own positive agenda for the child: it has given the child, every child, all the potential and capacities required for full maturation. Attempting to motivate from the outside betrays a lack of faith in the child and in nature. It reflects the anxiety of the parent, not the limitations of the child. It’s unfortunate but true that while we may not be able to transplant genuine motivation into our children, we are altogether too successful when it comes to sowing in them the seeds of our own anxiety. A child who must meet only parental expectations will likely acquire a chronic sense of incompetence as she fails over and over again to live up to them.

True motivation is knowing that I do what I do not because someone else wants me to do it, or because I believe someone will respect or like me for doing it, not because some inner voice tells me I “should” do it, and not because I am asserting my independence by defying someone who forbade me to do it. What I do satisfies me, regardless of what others may think.

The rationale for the rule needs to be clearly articulated, so that the rule itself rather than the parent’s will is seen as authoritative.

Language supports freedom, including freedom from one’s own impulses.

parents can avoid painful scenes if they learn to respect the motive instead of fixating on the outcome.

Actions have their own consequences in the world; we don’t need to create them.

Punishments are designed to control behavior rather than to encourage learning and development in the child. They are, according to all the relevant research, bound to backfire. They sabotage learning from consequences and hinder the ability to take responsibility. Punishments substitute the parent’s feelings and judgments for the lessons taught by reality.

Parents may worry that if they support the child’s autonomy, she may grow up to be selfish, unmindful of others. It is a common fear, but unfounded. It is based on the completely erroneous view that children are wild creatures needing to be tamed by any means necessary. The process of becoming connected with other people and learning appropriate human interactions, of developing into a social creature, is called socialization. Children don’t have to be trained into socialization. Because it is a fundamental human drive, we naturally develop connectedness and compassion if our own basic needs have been respected. Socialization is at the apex of a pyramid. The base is formed by secure attachment and autonomy.

Who are we trying to teach must precede what are we trying to teach as a fundamental consideration.

A person becomes open to respecting the boundaries of others when her own rights and boundaries are respected.

ADD adults are convinced that their low self-esteem is a fair reflection of how poorly they have done in life only because they do not understand that their very first failure—their inability to win the full and unconditional acceptance of the adult world—was not their failure at all.