Scattered Minds: The Origins and Healing of Attention Deficit Disorder

by Gabor Maté MD

I do not see it as a fixed, inherited brain disorder but as a physiological consequence of life in a particular environment, in a particular culture. In many ways one can grow out of it, at any age. The first step is to discard the illness model, along with any notion that medications can offer more than a partial, stopgap response.

As long ago as 1934, an article in The New England Journal of Medicine identified a distressing quality to some people’s lives, which the authors called “organic drivenness.” I, for one, have rarely had a moment’s relaxation without the immediate and troubling feeling that I ought to be doing something else instead.

The common theme on all days, good or bad, is a gnawing sense of having missed out on something important in life.

There is a popular discomfort with any condition of the mind perceived as “abnormal.” But what if illness is not a separate category, if there is no line of distinction between the “healthy” and the “nonhealthy,” if the “abnormality” is just a greater concentration in an individual of disturbed brain processes found in everyone? Then perhaps there are no fixed, immutable brain disorders, and we could all be vulnerable to mental breakdowns or malfunctions under the pressure of stressful circumstances. We could all go crazy. Maybe we already have.

Heredity does make an important contribution, but far less than usually assumed. At the same time, it would serve no purpose to set up the false opposition of environment to genetic inheritance. No such split exists in nature, or in the mind of any serious scientist. If in this book I emphasize environment, I do so to focus attention on an area that most books on the subject neglect and none explore in nearly enough detail. Such neglect frequently leads to crippling deficiencies in what people are offered by way of treatment.

The major impairments of ADD—the distractibility, the hyperactivity and the poor impulse control—reflect, each in its particular way, a lack of self-regulation.

One way to understand ADD neurologically is as a lack of inhibition, a chronic underactivity of the prefrontal cortex.

Hence the efficacy of stimulant medications: they arouse the inhibitory function. They wake up the cop, alert the underdeveloped and underactive circuitry of the prefrontal cortex.

Even without world wars, revolutions and emigration, siblings growing up in the same home almost never share the same environment. More accurately, brothers and sisters share some environments—usually the less important ones—but they rarely share the one single environment that has the most powerful impact on personality formation. They may live in the same house, eat the same kinds of food, partake in many of the same activities. These are environments of secondary importance. Of all environments, the one that most profoundly shapes the human personality is the invisible one: the emotional atmosphere in which the child lives during the critical early years of brain development. The invisible environment has little to do with parenting philosophies or parenting style. It is a matter of intangibles, foremost among them being the parents’ relationship with each other and their emotional balance as individuals. These, too, can vary significantly from the birth of one child to the arrival of another. Psychological tension in the parents’ lives during the child’s infancy is, I am convinced, a major and universal influence on the subsequent emergence of ADD.

A 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.

Because the formation of the child’s brain circuits is influenced by the mother’s emotional states, I believe that ADD originates in stresses that affect the mothering parent’s emotional interactions with the infant. They cause the disrupted electrical and chemical circuitry of ADD. Attachment and attunement, two crucial aspects of the infant-parent relationship, are the determining factors.

Maternal depression is associated with diminished infant attention spans. Summarizing a number of British studies, Dale F. Hay, a researcher at the University of Cambridge, suggests “that the experience of the mother’s depression in the first months of life may disrupt naturally occurring social processes that entrain and regulate the infant’s developing capacities for attention.”[3]

This sharing of emotional spaces is called attunement.[5] Emotional stress on the mother interferes with infant brain development because it tends to interfere with the attunement contact. Attunement is necessary for the normal development of the brain pathways and neurochemical apparatus of attention and emotional self-regulation. It is a finely calibrated process requiring that the parent remain herself in a relatively nonstressed, non-anxious, nondepressed state of mind. Its clearest expression is the rapturous mutual gaze infant and mother direct at each other, locked in a private and special emotional realm, from which, at that moment, the rest of the world is as completely excluded as from the womb.

Attunement is the quintessential component of a larger process, called attachment.[7] Attachment is simply our need to be close to somebody. It represents the absolute need of the utterly and helplessly vulnerable human infant for secure closeness with at least one nourishing, protective and constantly available parenting figure. Essential for survival, the drive for attachment is part of the very nature of warm-blooded animals in infancy, especially of mammals.

Most parents extend to their children some mixture of loving and hurtful behavior, of wise parenting and unskillful, clumsy parenting. The proportions vary from family to family, from parent to parent. Those ADD children whose needs for warm parental contact are most frustrated grow up to be adults with the most severe cases of ADD.

Nature’s goal for human growth is for the eventual maturation of a self-motivated, self-regulated and self-reliant adult. The infant lacks these attributes. We may say that the natural agenda is really the transformation of regulation from dependence on another individual to independence, from external regulation to internal regulation.

it is not that a disorder develops, but that certain important brain circuits do not develop. Interference with the conditions required for the healthy development of the prefrontal cortex, I believe, accounts for virtually all cases of ADD.

the aversion to one’s own mind, which we call boredom.

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. “Thus,” she writes, “we must not give up on people who begin life under unfavorable conditions. Environmental enrichment has the potential to enhance their brain development too, depending on the degree or severity of the insult.”

Science tells us that not even in rodents can the link between emotions and mental organization be ignored. In her Berkeley laboratory, Dr. Marian Cleeves Diamond found improvements in the problem-solving capacity of rats treated with tender loving care corresponding with the growth of richer connections in their cortex. “Thus, it is important to stimulate the portion of the brain that initiates emotional expression,” Dr. Cleeves Diamond writes. “Satisfying emotional needs is essential at any age.”[7]

A few weeks, perhaps longer, but once the attachment relationship does become consistently fixed as the fundamental value, parents will be amazed and gratified how rapidly their child responds with cooperative behavior. Even more surprising to them will be that their rigid rules and their expectations become less important as they learn to place their emotional bonds with their child above everything else.

What matters above all is not the technique, but the degree of parental self-regulation. The fundamental issue is not how to parent, but who is parenting? By this I don’t mean which parent, the mother or the father, but the state of mind of the adults as they respond to the child.

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.

Just as with unconditional acceptance, the child should not have to work for attention either by destructive acts or by look-at-me behaviors, or by “good boy, good girl” compliance. The hunger is eased by the parent’s seizing every possible opportunity to devote positive attention to the child precisely when the child has not demanded it. “We have to satiate the child with attention, stuff her full of it until it’s coming out her ears,” says the developmental psychologist Gordon Neufeld. Once the attention hunger is alleviated, the “just-looking-for-attention” behaviors will lessen.

Like a psychological immune system, counterwill functions to keep out anything that does not originate within the child herself.

The importance of the attachment relationship has been the underlying theme of this book.

The issue is not how to control the child but how best to promote the child’s development. By the time it becomes an urgent matter of control, as with aggressive or destructive behaviors, the relationship with the parents is usually in tatters and the counterwill dynamic has grown immense. One prevents having to control by maintaining the relationship and defusing counterwill.

Not surprisingly, one of the most frequently asked questions by parents of children with attention deficit disorder is, “How can I motivate my child?” The answer, if we understand the dynamic of counterwill discussed in the previous chapter, is that you can’t. More exactly, you may succeed in activating the child temporarily with a threat or with the promise of immediate reward but at the expense of the child’s self-motivation in the long run.

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.

The fear of intimacy is also a fear of the loss of self. There is the well-known paradox that the person with ADD craves real human contact, feels like an outsider and wishes to belong—but at the same time is reclusive, often preferring his own company to that of others. The paradox is due to his oscillating back and forth between two fears: the anxiety of loneliness and abandonment, and, opposing that, a parallel sense of danger that if he commits to a relationship, he will be overwhelmed, swallowed up.

The unsolved problem is how to be oneself in contact with other people.

“People gravitate toward their emotional mirror images,” Michael Kerr points out.[5] It is well recognized now that people will form relationships with others exactly at the same level of psychological development and self-acceptance as their own. “People tend to sort themselves by levels of emotional development for many purposes, not just marriage,” writes Stanley Greenspan, “because those functioning at different levels are practically speaking different languages. . . People widely separated developmentally in fact have very little to talk about.”[6] What we might call the law of equal development holds true even if the partners themselves buy into the mythology that one of them is more emotionally mature than the other.

The therapist must be able to extend to the client the attitude Carl Rogers called unconditional positive regard. “When a person is encouraged to get in touch with and express his deepest feelings,” writes the British psychiatrist and psychoanalyst Anthony Storr, “in the secure knowledge that he will not be rejected, criticized, nor expected to be different, some kind of rearrangement or sorting-out process often occurs within the mind which brings with it a sense of peace; a sense that the depths of the well of truth have really been reached.”[2]

Time is scattered like sunlight through a sieve.

self-understanding and self-acceptance are the first responsibility of the adult who wants to foster his own growth, which really is no different from what any parent owes a child.

All addictions are anesthetics. They separate us from the distress in our consciousness. We throw off our familiar and tired consciousness to assume another mind state we find more comfortable, at least temporarily. Desperate to be out of our mind and unaware, we surrender to the addiction, to be lulled into a walking sleep.

The compulsion beckons; the addict runs to serve it. Gradually, in each orgy of buying, I felt myself shrinking into a ghost of myself, full of self-contempt and apologetic for my existence.

The harder these people work to compensate for their deficient biochemistry through their respective addictions, the more they perpetuate the emotional emptiness that only the ownership of their problem and the recognition of its causes in past and present will begin to fill.

As Grass writes, we are far away from our griefs, which are the truest parts of ourselves. There is no path toward oneself that leads away from the pain.

The irony is that the energy ADD adults expend on their attempts at sameness is wasted, as is the anxiety parents generate over their child’s differentness. The world is much more ready to accept someone who is different and comfortable with it than someone desperately seeking to conform by denying himself. It’s the self-rejection others react against, much more than the differentness. So the solution for the adult is not to “fit in,” but to accept his inability to conform. The child’s uniqueness has to first find a welcome in the heart of the parent.

We don’t do our children any favors when we try to protect them from experiencing sadness or failure. What we really want for them when they feel sad is to be able to endure disappointment and hurt feelings, not to hide behind defenses, angry acting-out and driven behavior in order to avoid emotional distress. Not, in other words, for them to become ADD adults. It takes a lot of loving to help a child accept sadness, to know that it can be endured, that sadness, like all other mind states, is evanescent. It will pass.