Scattered Minds: The Origins and Healing of Attention Deficit Disorder

by Gabor Maté MD

The first nine months or so of extrauterine life seem to have been intended by nature as the second part of gestation.

During this period, the security of the womb must be provided by the parenting environment.

For the second nine months of gestation, nature does provide a near-substitute for the direct umbilical connection: breast-feeding. Apart from its irreplaceable nutritional value and the immune protection it gives the infant, breast-feeding serves as a transitional stage from unbroken physical attachment to complete separation from the mother’s body.

No doubt the decline of breast-feeding, particularly accelerated in North America, has contributed to the emotional insecurities so prevalent in industrialized countries. Even more than breast-feeding, healthy brain development requires emotional security and warmth in the infant’s environment.

calm and consistent emotional milieu throughout infancy is an essential requirement for the wiring of the neurophysiological circuits of self-regulation. When interfered with, as it often is in our society, brain development is adversely affected. ADD is one of the possible consequences.

Almost all the adults minimize the effects of the trauma they had experienced. They

When people first mention violence they experienced in the family home, it is not unusual for them to do so with a smile. They use dismissive phrases they would never employ if they were describing the same events happening to someone else, particularly to any small child they know.

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.

Families in which sexual abuse is likely to occur are families that are psychologically stressful to grow up in from the moment of birth. So it’s not that sexual abuse later in childhood causes ADD, but that the psychological atmosphere that later will make abuse possible is already present in infancy.

It has been suggested that, in general, hyperactive kids are the ones most likely to get abused. Even if that were so, the abusive inclination of the parent is not caused by the child’s ADD. On the contrary—as with sexual abuse—ADD is more likely to arise in a family where physical mistreatment is a possibility, whether expressed or only latent.

Many people said that their families had moved a lot in their childhoods, which may very well reflect some ADD tendencies in their parents.

“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.”

Since a child cannot possibly be up to the task of taking care of a self-destructive adult, one given such responsibility inevitably develops a profound sense of inadequacy.

ADD children are far more likely than other children to have parents who have suffered major depression, about 30 percent compared with 6 percent.[3] That figure would be even higher, I believe, were it to include the many people whose depression never reaches a diagnosed clinical state but who live their lives in the grip of low moods and irritability that seem normal to them.

I have often seen patients who do not know just how down their moods had been until medications or some other mode of therapy lifts the weight of depression from their shoulders.

Stressed or depressed mothers are found to be more short-tempered, more controlling and more angry with their children. Depression, particularly in the mother, also evokes an aggressive response from many a young child, quite probably due to the child’s rage at what she unconsciously interprets as the emotional withdrawal of the mother.

Parents of ADD children, in other words, seem to be relatively alienated from their own families of origin. They do not see their brothers, sisters, mothers and fathers as often as others tend to. When they do see their families, the interaction tends not to be satisfactory. ADD children are less likely to have the comfort and support that only loving grandparents can give.

my mother’s violence you find another box, which contains my grandfather’s violence, and inside that box (I suspect but do not know) you would find another box with some such black secret energy—stories within stories, receding in time.”

shape them. The family as an institution has been

The Vancouver psychologist Gordon Neufeld calls anxiety “an attachment alarm.” Its role in the survival of the human infant and child is to signal when our attachment relationships, which we are absolutely dependent on, are threatened. It is useful, unless it becomes a chronic state.

hyperactivity expresses anxiety, lethargy and underarousal express shame. Shame, like anxiety, is an attachment emotion. “Whenever someone becomes significant to us, whenever another’s caring, respect or valuing matters, the possibility for generating shame emerges,” writes the psychologist Gershen Kaufman.[2]

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. Past the toddler phase, there will be many times the child’s behavior may trigger an angry response from the parent, the ADD child more than the average. Some parents are able to express anger without making the child feel cut off emotionally. They convey disapproval without rejection. Other parents, especially those with self-regulation problems of their own, may react with open or choked rage, punishing coldness or dejected withdrawal that signals defeat and disappointment. These were the anger responses my children experienced from me. Each time this happens, shame is evoked in the child, especially as the parent usually believes—and makes the child believe—that whatever his (the parent’s) reaction is, the child is ...

The adult or child with attention deficit disorder may frequently offend people or break a promise or be late somewhere. Given his inattentiveness and difficulties reading nonverbal social messages, he treads on toes—in both senses of that phrase.

John Ratey has aptly observed that “I’m sorry” is the most common phrase in the vocabulary of attention deficit disorder.

In ADD, hyperactivity and a low-arousal state have become entrenched, inappropriate to the individual’s age or to events in the immediate present. They are triggered too easily, and once triggered, they tend to go out of control.

Like so much else about attention deficit disorder, hyperactivity, lethargy and shame are closely connected with the neurological memories of the distant, stressed or distracted caregiver. There will be a sense of discomfort as soon as the mind becomes aware of itself, because such awareness immediately triggers responses encoded with the infant’s distress at feeling emotionally alone.

When it cannot do so, there is intense unease—or the aversion to one’s own mind, which we call boredom.

People often ask if one can “grow out” of attention deficit disorder—a good question, for healing is a matter of growth. And the answer is yes. It is not curing that ADD children need: they need to be helped to grow.

The adult with attention deficit disorder needs also to gain a deeper understanding of herself, to undertake the task we will later describe as self-parenting.

the wiring and chemistry of the brain are not rigidly set by heredity, neither are they unalterably fixed in early childhood. The challenge of healing later in life is identical to looking at causation in infancy. What conditions promote development? What conditions hinder it?

Most encouraging was Dr. Diamond’s finding that even the brains of animals deprived before birth, or deliberately damaged in infancy, were able to compensate by structural changes in response to enriched living conditions.

Early in life, plasticity, the responsiveness of the human brain to changing conditions, is so great that infants who suffer damage to one side of their brain about the time of birth, even if they lose an entire hemisphere, may compensate for the deficit.[2]

As we know, in ADD the cortex does not exercise firm enough control over the arousal and emotion-generating centers in the lower brain areas. Dr. Benes points out that important linkages between the cortex and these emotional centers continue to mature “as late as the sixth decade. . . . [This] suggests that human behavior may

It is no small challenge to promote the neurophysiological and emotional development of either a child or an adult with ADD, but it is far from impossible, as we shall see.

It is an atmosphere which simply demonstrates I care; not I care for you if you behave thus and so.”[8]

Ways have to be found to let the child know that certain behaviors are unacceptable, without making the child herself feel not accepted.

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.

Let’s replay that scene with a slightly different emphasis. The parent decides that being at school on time is not a question of life or death. There are natural consequences for a child who is chronically late, so it’s not a lesson he has to drive home to her this very morning. Without that sense of urgency, the father no longer sees the situation as a power struggle to be won at all costs. Not allowing his frustration to get in the way, the parent can maintain his empathy with the child. From this change of attitude a change of technique automatically follows. He firmly but gently reminds her about the passing of time but does not allow himself to become hooked and filled with anger—it is, after all, the child’s problem.

What the parents are teaching the child is that her well-being and security are more important to them than behavioral goals, and that conflicts between people do not have to end in emotional estrangement.

parent that the child does not at all want. If parents learn to anticipate the child’s impulsive expressions of negative emotion and are not threatened by them, the cycle of escalating anger or rejection can be broken.

Many of the traits thought to be caused by attention deficit disorder are, I am convinced, not the expressions of the specific neurophysiological impairments associated with ADD but of low self-esteem.

In the ADD child, low self-esteem is manifested not just by the self-putdowns he may utter, such as “I’m dumb.” Above all, it is apparent in the perfectionism and in the dejection and discouragement he experiences when he fails at a task or loses in a game. Nor can he accept not being in the right.

Where do self-judgment and lack of self-respect originate?

That people do judge themselves so harshly reflects low self-esteem, not low achievement. Self-esteem, we must realize, is the quality of self-respect that is evident in a person’s emotional life and behavior.

There are some adults with attention deficit disorder who exhibit great self-confidence in specific areas of functioning and are high achievers according to social standards. Many others are low achievers who bring little confidence to any field of endeavor. What they share is low self-esteem.

The diary is typical of attention deficit disorder in its format, written on dogeared scraps of paper filed in no particular order, months and years separating individual entries. It is typical, too, in the deep dissatisfaction with the self it reveals:

I have not achieved enough in life. I feel that my abilities exceed my attainments. I feel I could do more. . . . I vegetate, my ambitions like rotting weeds around me. I want to paint. I want to study languages: French, German, Spanish. . . . What else? I want to exercise. I want to meditate. I want to read. I want to see people. I want to take in more culture. I want to sleep enough. I don’t want to watch junk television any more. I want an end to the binge cramming of food into myself every evening. . . . I want to live!*

What are some of the markers of low self-esteem, besides consciously harsh self-judgment? As mentioned above, an inflated, grandiose view of oneself—frequently seen in politicians, for example. Craving the good opinion of others. Frustration with failure. A tendency to blame oneself excessively when things go wrong, or, on the other hand, an insistence on blaming others: in other words, the propensity to blame someone. Mistreating those who are weaker or subordinate, or accepting mistreatment without resistance. Argumentativeness—having to be in the right or, obversely, assuming that one is always in the wrong. Trying to impose one’s opinion on others or, on the contrary, being afraid to say what one thinks for fear of being judged.

Other traits of low self-esteem are an overwrought sense of responsibility for other people in relationships and, as we will discuss shortly, an inability to say no. The need to achieve in order to feel good about oneself. How one treats one’s body and psyche speaks volumes about one’s self-esteem: abusing body or soul with harmful chemicals, behaviors, work overload, lack of personal time and space all denote poor self-regard.

Self-esteem based on achievement has been called contingent self-esteem or acquired self-esteem. Unlike contingent self-esteem, true self-esteem has nothing to do with a self-evaluation on the basis of achievement or the lack of it. A person truly comfortable in his own skin doesn’t say, “I am a worthy human being because I can do such and such,” but says, “I am a worthy human being whether or not I can do such and such.”