Scattered Minds: The Origins and Healing of Attention Deficit Disorder

by Gabor Maté MD

you’re stuck in the middle of heavy traffic at an intersection; the engine has stalled and you are trying your best to get moving. Everyone is yelling and honking angrily at you, but no one offers to help. Perhaps no one knows how to.

Dexedrine,

ADD has much to do with pain, present in every one of the adults and children who have come to me for assessment. The deep emotional hurt they carry is telegraphed by the downcast, averted eyes, the rapid, discontinuous flow of speech, the tense body postures, the tapping feet and fidgety hands and by the nervous, self-deprecating humor. “Every aspect of my life hurts,” a thirty-seven-year-old man told me during his second visit to my office. People express surprise when after a brief exchange I seem to be able to sense their pain and grasp their confused and conflicted history of emotions. “I’m speaking about myself,” I tell them.

At times I have wished that the “experts” and media pundits who deny the existence of attention deficit disorder could meet only a few of the severely affected adults who have sought my help. These men and women, in their thirties, forties and fifties, have never been able to maintain any sort of a long-term job or profession. They cannot easily enter meaningful, committed relationships, let alone stay in one. Some have never been able to read a book from cover to cover, some cannot even sit through a movie. Their moods fly back and forth from lethargy and dejection to agitation. The creative talents they have been blessed with have not been pursued. They are intensely frustrated at what they perceive as their failures. Their self-esteem is lost in some deep well. Most often they are firm in the conviction that their problems are the result of a basic, incorrigible flaw in their personalities.

The strangely dissonant imagery tells also of a troubled soul who found reality harsh—so harsh that the mind had to be fragmented in order to fragment the pain.

What can be immobilizingly difficult is to arouse the brain’s motivational apparatus in the absence of personal interest.

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.

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. Like father, like son. At the age of eight or nine, my son said to me, “I always think I should be doing something, but I don’t know what it is.” The oldest person to whom I have prescribed a stimulant was an eighty-five-year-old woman who, on taking Ritalin, was able to sit still more than fifteen minutes for the very first time in her life.

On the other hand, when there is something one wants, neither patience nor procrastination exist. One has to do it, get it, have it, experience it, immediately.

“I am a person of permanent potential,” one patient said.

“I have never finished a thought in my life,” one young man lamented.

“It’s as if I was from Mars and everyone else was from Earth,” one forty-year-old woman said.

At social events, I tend to gravitate to the periphery, conscious of a feeling that somehow I cannot enter into the spirit of things. I observe people talking to each other, people I may know quite well, acutely aware that I have nothing to say to anyone. Social conversation has always been a mystery to me. I have at times looked at people engaged in animated discussion and wished that I was invisible so that I could overhear them—not to eavesdrop but to find out once and for all exactly what there is to talk about. My patients with ADD tell me much the same thing about their experience. “I don’t know how to make small talk, or I’m afraid of saying something stupid,” a twenty-six-year-old woman said. And the truth is, when the ADD adult does join conversations, she often finds herself bored by the minute attention others devote to subjects that to her seem to skim only the surface.

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I do not myself accept ADD as a disorder in the medicalized sense, ADD is not an illness, although some influential authorities have called it that. It is an impairment, like, for example, a visual impairment in the absence of any disease.

There is in ADD an inherited predisposition, but that’s very far from saying there is a genetic predetermination. A predetermination dictates that something will inevitably happen. A predisposition only makes it more likely that it may happen, depending on circumstances. The actual outcome is influenced by many other factors.

A hallmark of a conflictual marriage is that husband and wife are angry and dissatisfied with one another. While the atmosphere of conflictual relationships is intensely negative much of the time, it is usually punctuated by periods of equally intense, sometimes very passionate closeness. . . . Conflict can have an addictive quality: It is both a familiar scene and a poignant reminder of how involved two people are with one another. People do not want conflict, but they have not found an alternative way of interacting.

Environment does not cause ADD any more than genes cause ADD. What happens is that if certain genetic material meets a certain environment, ADD may result. Without that genetic material, no ADD. Without that environment, no ADD. The formative environment is the family of origin.

There was never any question of a lack of love in our home. But love felt by the parent does not automatically translate into loving experienced by the child. The atmosphere in our home was often one of open or suppressed emotional conflict between the parents, mutually disappointed expectations and profound anxieties we were not even aware of.

It was virtually impossible for me to say no to any request for help, no matter what the cost to my personal life. In honoring this overwrought sense of responsibility toward others, I neglected my responsibility toward the only people for whom I really was indispensable. This feeling of duty toward the whole world is not limited to ADD but is typical of it. No one with ADD is without it.

Young children cannot possibly understand the motives of adults. It means little to a young child that the parent feels love for him if that parent keeps disappearing at almost any time. The child experiences a sense of abandonment, a subliminal knowledge that there are things in the world much more important to the parent than he, the child, that he is not worthy of the parent’s attention. He begins to feel, at first unconsciously, that there must be something wrong with him. He also begins to work too hard to get his needs met: demanding contact, acting out or trying to please the parent to gain approval and attention.

There are things I wish I had not done during my children’s early years, but mostly I regret what I did not do: give my children the gift of a mindful, secure and reliable parental presence. I wish I had known how to allow myself to relax, to release myself from the compulsions driving me and to fully enjoy the wonderful little persons they were.

couples choose each other with an unerring instinct for finding the very person who will exactly match their own level of unconscious anxieties and mirror their own dysfunctions, and who will trigger for them all their unresolved emotional pain. This was certainly mutually true for us. Second, judgment or blaming is not the point. Understanding is.

I believe that it is in these stresses experienced by the parents in spite of their will to do the best for their children that the environmental roots of attention deficit are to be found.

Forgetting to Remember the Future ADD is not a problem of knowing what to do; it is a problem of doing what you know.

The ADD mind is afflicted by a sort of time illiteracy, or what Dr. Russell Barkley has called “time blindness.” One is either hopelessly short of time, dashing about like a deaf bat, or else acts as if blessed with the gift of eternity. It’s as if one’s time sense never developed past a stage other people leave behind in early childhood.

It is not until the age of seven or so, Jean Piaget found, that children begin to have a full understanding of time as a continuous flow.

The guiding assumption of the adult with attention deficit disorder, like that of the small child, seems to be that only the present exists and needs to be taken into account. He lives as if his actions had no implications for the future, no effects on future needs, relationships or responsibilities. The short-term goal is invariably chosen over the long-term, with the exception of activities or projects capable of arousing the sluggish motivation-reward nexus in the brain. The present impulse dominates. It has been aptly said that people with ADD forget to remember the future. In the moment of action or decision making, ADD adults are no more mindful of consequences than a young child.

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. Self-regulation implies that someone can direct attention where she chooses, can control impulses and can be consciously mindful and in charge of what her body is doing. Like time literacy, self-regulation is also a distinct task of development in human life, achieved gradually from young childhood through adolescence and adulthood. We are born with no capacity whatsoever to self-regulate emotion or action.

we may speak of an underdevelopment of emotional intelligence.

“being able to motivate oneself and persist in the face of frustrations; to control impulse and to delay gratification; to regulate one’s moods and keep distress from swamping the ability to think. . . ”[2] We have only to place a negative qualifier before the “being able” in that sentence, as in “not being able,” and we arrive at a succinct description of the ADD personality.

We all have experiences as parents that we are ashamed of and wish we could erase. Such scenes always represent failures of self-regulation and impulse control. What happens during these times is that the brain centers where the deepest emotions of fear or rage are generated simply overwhelm the higher centers meant to govern them—as they normally would in a small child.

Our initial response to a stimulus, whether anxiety producing or pleasurable, is unconscious. It comes not from the cortex but from lower brain centers where emotions originate. The cortex has a split second to decide whether to give permission to the impulse or to cancel it.[4]

What conditions are needed for human physiological and psychological maturation? What conditions would inhibit or interfere with that growth process? Instead of asking why a disorder or illness develops, we ask why a fully self-motivated and self-regulated human personality does not.

The answer to underdevelopment is development, and for development the appropriate conditions must exist. No matter how efficiently they are able to arouse the higher brain centers, medications offer only a partial solution to the problems posed by ADD. We may not be able to prescribe development directly, but we can promote an environment that makes development possible. Fortunately, as we will see when we come to the chapters on the healing process in ADD, neurological and psychological maturation can take place at any time during the life cycle, even in late adulthood.

Studies do show that if parents or siblings have ADD, a child in that family will have a greatly increased statistical risk for having ADD as well.

The family atmosphere in which the child spends the early formative years has a major impact on brain development. It is obvious that brain/mind problems such as ADD are far more likely to develop in families where the parents are struggling with dysfunction or psychological problems of their own.

Dr. Greenspan observes that the same combination of biological traits—the very same pattern of reactivity—can come to embody many positive human qualities, or may serve as the basis of highly disturbed characteristics. “Whether these features become talents or problems depends, in short, on how the child’s nature is nurtured,” he writes.[5] The critical difference is the environments in which children are reared.

Many variables will influence the particular environment a child experiences. Birth order, for one, automatically places siblings in dissimilar situations. The older sibling has to suffer the pain of seeing parental love and attention directed toward an intruder. The younger sibling may need to learn survival in an environment that harbors a stronger, potentially hostile rival, and never comes to know either the special status or the burden of being an only child. The full weight of unconscious parental expectations is far more likely to fall on the firstborn.

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 hidden factor of great importance is a parent’s unconscious attitude toward a child: what, or whom, on the deepest level, the child represents for the parents; the degree to which the parents see themselves in the child; the needs parents may have that they subliminally hope the child will meet.

To the infant and toddler, the world reveals itself in the image of the parent: in eye contact, intensity of glance, body language, tone of voice and, above all, in the day-to-day joy or emotional fatigue exhibited in the presence of the child.

It may be said that no two children have exactly the same parents, in that the parenting they each receive may vary in highly significant ways. Whatever the hopes, wishes or intentions of the parent, the child does not experience the parent directly: the child experiences the parenting.

If a mother has eight children, there are eight mothers. This is not simply because of the fact that the mother was different in her attributes to each of the eight. If she could have been the same with each. . . each child would have had his or her own mother seen through individual eyes.

If the decibel count in that kitchen had been measured when the father first instructed his daughter to hurry, it would not have registered at levels most people would define as yelling. The daughter’s reaction, however, is genuine. She picks up, senses, experiences the tension in the father’s voice, the edge of controlled impatience and frustration. That is what is translated in her brain as “yelling.” She is feeling exactly the same fear and outrage as another child would if shouted at in an angry manner. It is a matter of sensitivity, of the degree of reactivity to the environment. This child is emotionally hypersensitive.

People with ADD are hypersensitive. That is not a fault or a weakness of theirs, it is how they were born. It is their inborn temperament. That, primarily, is what is hereditary about ADD. Genetic inheritance by itself cannot account for the presence of ADD features in people, but heredity can make it far more likely that these features will emerge in a given individual, depending on circumstances. It is sensitivity, not a disorder, that is transmitted through heredity. In most cases, ADD is caused by the impact of the environment on particularly sensitive infants.

Although the flare-up of allergies can certainly aggravate ADD symptoms, the one does not cause the other. They both are expressions of the same underlying inborn trait: sensitivity. Since emotionally hypersensitive reactions are no less physiological than the body’s allergic responses to physical substances, we may say truthfully that people with ADD have emotional allergies.

Some hypersensitive children, feeling physical pain or discomfort, will express what to others may seem an excessive and exaggerated distress. They are accused of malingering or playacting or of looking for attention. In fact, there is no dissimulation in their behavior around pain or discomfort, only, in a phrase of Friedrich Nietzsche’s, “a refined susceptibility to pain.” Sensitivity is affected by emotional states.

Like hypersensitive instruments, sensitive children register and record even minute changes in their emotional environment. It is not a matter of choice for them; their nervous systems react. It is as if they had invisible antennae projecting in every direction, picking up and conducting into their bodies and their minds the psychic emanations around them. They may have no conscious knowledge of this, any more than an instrument is consciously aware of what measurements it is registering.

My wife and I learned to recognize our daughter’s moods and behaviors as real-time, instantaneous computer printouts of the psychological atmosphere in our home. If we wanted to know how we were doing as individuals or as a couple, we needed only check the facial expressions and emotional responses of our daughter.

Their child’s body is a barometer for the stresses on the whole family system, his symptoms the markings on a minutely calibrated instrument.