Scattered: How Attention Deficit Disorder Originates and What You Can Do About It

The following article has been published with kind permission
Lew Mills, PhD, MFT, a Bay Area psychotherapist working with Attention Deficit
in Adults.

Book Review: Scattered: How Attention Deficit Disorder Originates and What You Can Do About It

by Gabor Maté, MD, 1999

Another book claiming that ADHD is caused by environmental
factors? Sure. And ADHD can be cured in a few weeks with the latest
snake-oil treatment.

Those of us who have been around that loop a few times will be
forgiven for being suspicious of a book that once again seems to
argue against the given wisdom that ADHD is fundamentally a
neurobiological disorder, with a large genetic component.

But Maté’s book does not fall simply into either side of
the nature/nurture dichotomy. It does allow that there is a
genetically determined “sensitivity” inherent in ADHD. It also
insists that there are environmental factors which play a large role
in how ADHD eventually plays out in the individual. The value of the
book is in how it elaborates the intricate interplay of “nature” and
“nurture” factors.

To choose just one instance of this argument, Maté
describes a familiar feature of ADHD, which he calls “counterwill.”
It is sometimes predictable that if you ask an ADHD person to do
something, they will be vexingly compelled to do the opposite. Their
will seems to run the other way from whatever direction they are
being pointed. This is the basis of the overlap of ADHD with
“oppositional-defiant disorder.”

It appears to us that an ADHD person is being “too willful.” But
in fact, it reflects an absence of a well integrated self and “will”
as well as an environmental experience of being overrun by someone
else’s will.

The elaboration of that argument is more complex, but it assumes
that qualities of the experience of having an ADHD biology can lead
to predictable developmental consequences if certain environmental
factors are present. In the case of counterwill, if the ADHD child’s
attention errors are consistently met by controlling behavior from an
adult, the ADHD child will learn to counteract the overriding of
their fragile will by being “strong-willed” in the opposite

The child’s goal is not the specific willful behavior that
results, but it is rather the assertion of an independent will. The
child may not even know what they want until they are asked to do one
particular thing. Then it is completely clear to them that they want
to do the opposite. This increases the ADHD child’s feeling of
autonomy, (even though it is in reality the most slavish reactivity
to other people). Counterwill is desperately required, in order to
not feel the complete dissolution of their own will.

So this has a clear environmental component, even as it also stems
in part from the difficulty that the ADHD child has in constituting
their own sense of self-direction and self-control. Presumably, if
raised in ideal conditions, ADHD children would not develop
counterwill . Hence, counterwill is not a part of the “biology” of
ADHD. However, given the predictable negative and controlling
reactions of imperfect adults to the frustrations of “cat-herding” an
ADHD child, counterwill is likely to develop in the ADHD child with
some frequency. The overwhelmed adult, by increasingly controlling
the behavior of the ADHD child, unintentionally creates the
oppositional behavior that makes their task so much more difficult.
Biology interacts with a predictable environment to reach an unhappy
but common result.

More broadly, the theme that runs underneath the greater part of
the book is that stress amongst parents (or primary care-givers) is
fundamental to the development of ADHD. This stress leaves the
parents unable to sufficiently pay attention to the emotional needs
of the child, which in turn leads to a disturbed attachment process
that Maté sees as characteristic of ADHD children. Maté
asserts that the genetic predisposition to ADHD is based on an
oversensitivity to these stresses in the parents. Only the
combination of stressed, emotionally unavailable parents and the
genetic oversensitivity will lead to ADHD.

Maté does not argue, as some others might, that ADHD causes
the parenting problems in the first place. He claims that the
parenting problems exacerbate the ADHD issues that the child comes to
physiologically. But it would make sense to extend his argument that
environment and genetics interact continuously. Those of us who have
been there know: not only do parents affect the ADHD child, but the
ADHD child profoundly influences the parent.

Personally, I feel that the “nurture” case is overstated in
Maté’s book, even though the general thrust makes sense. The
overemphasis on attachment issues in ADHD neglects that many other
independent disorders include disturbances in attachment. Attachment
issues are probably not the defining characteristic of ADHD.

I also think that Maté underplays the significance of
medications in treatment. Even though he acknowledges the sometimes
dramatic improvements that medication can make, he tends to see the
disorder primarily as psychological. Hence psychological treatments
take precedence over biological ones. The therapeutic effect of
“unconditional positive regard” is considered “first line” treatment,
with medication as an adjunct. In my experience, the medication can
have such a profound effect, that it makes little sense to not try
this first. Of course I also agree that the psychological
consequences of ADHD need to be addressed for substantial improvement
to occur.

Of course, the main danger of describing ADHD psychologically is
that it is interpreted as a problem that should be surmounted purely
psychologically. There are people who will blame themselves forever
for just “not trying hard enough” rather than face a real
physiological difficulty that they can treat physiologically.

Maté does not put it together entirely psychologically, but
I remain nervous about that risk. I do not think that anyone is
served well if we categorically fall back to blaming parents and
schools for not adapting to ADHD children better. We have had to work
hard to get past the “psychologizing” of ADHD as the product of a
“too fast culture” or relaxed parenting standards and so on. The task
is not to throw out the insights of a physiological explanation, but
to expand it by looking at the interplay of the given, genetic nature
and the environmental nurture where it plays out.


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