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 direction.

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 caregivers) 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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