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

Scattered: How Attention Deficit Disorder Originates And What You Can Do About It Gabor Mate, M.D. New York: Dutton, Penguin Putnam Inc., 1999. 348 pages.

Although this book was first published in 1999 it remains currently available in a paperback edition and its history of being reprinted bears testimony to its ongoing sales. It is n interesting addition the ever increasing library of books on the subject. It is penned by a physician who at the time of writing had only recently determined that he was an example of adult ADHD and had apparently restructured much of his practice around the needs of ADHD clients, both young and old. The book presents the current trends towards the diagnosis of ADHD moving beyond children to adults and the apparent appeal that many feel to being so labelled.

The author treads a careful line by advocating the judicious use of medications while at the same time indicating the perils of over diagnosing the condition. He argues that whereas there may be a genetic predisposition toward ADHD, environmental factors can be equally important. Whereas the behaviours associated with it might be said to predetermine certain dispositions, the ability to address and respond to them remains pretty fairly within the domain of personal responsibility. This is a particularly important argument within the context of the popular narrative on the subject given that it seems that one of the attractions of receiving the diagnosis in the first place is the transfer of responsibility. Any explanation that involves genetic determinism supports this process. At the same time, it was Aristotle who argued over two thousand years ago that potential for existence must logically predate its actualization. In short, it can be argued that any human behaviour must involve the previous potential for such behaviour but it is another argument altogether to argue that any behaviour is genetically predetermined as this would undermine any pretence of free will and any attempt to introduce responsibility for actions with a moral context. In this sense, the use of “potential” is the grey zone in which environmental factors of the individual choice of response comes into play.

The identification of ADHD is based upon an assessment of behaviour that is both quantitative and qualitative and to a lesser or greater degree, subjective. As behaviours are attributable to subject, agent or author, they are not free floating in a realm of consciousness unconnected with the personality as a whole. Responsibility for behaviour can be minimized through arguments focusing upon (a) genetic determinism or (b) biological determinism. The former provides the argument that a person is the way he or she is as a result of being predetermined or preconfigured genetically to be the way they are. As such, freedom of choice and responsibility are removed in much the same way as saying that a person is tall. The latter corresponds to arguments where the biological components or substructure required for some level of functioning are not present. An example of this would be colour blindness.

When ADHD is presently applied as a diagnosis, it addresses dysfunction within a school or classroom context. Reports generated and language in and around whatever actions need to be taken to accommodate the condition invariably interchange the terms “disability” and “inability” in such a manner as to be mutually synonymous. The accommodations therefore are viewed as adjustments needed to be made in terms of environment, expectations or delivery. Inherent in this approach is the assumption that changes need to be initiated by those other than the students given that he or she is incapable of making the adjustments. The advantage of this presentation is to eliminate the responsibility for the dysfunction from the individual student and to a lesser extent the teachers, parents or family context where the latter are not responsible for causing the dysfunction but have an obligation to respond to it. In short, the outside world must adapt to the student because the student is presented as being incapable of adapting to circumstances as presently configured.

The arguments presented in Scattered complicate this discussion in that the author presents examples of developmental or experiential issues that can give rise to such behaviours. Within a therapeutic paradigm this would further entail that responses to circumstances giving rise to the development of behavioural patterns are subject to control by the individual if they are able to understand and process this through self-realization. As the author states:

“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 upon circumstances. The actual outcome is influenced by many other factors.”

As such, since behavioural tendencies are not hard wired then they may be subject to redirection or control by the individual and insofar as that is true they may be seen as being responsible for them.

However, it is important to note that whereas ADHD began as a diagnosis for school children, it has expanded to cover adults. In adult cases, the focus is not normally on the dysfunction in the context of school since that phase of life is over, but other behavioural dysfunctions attributable to it. You therefore end up with an adult, in this case the author of the book, who has been able to maneuver successfully through medical school and is obviously capable of more than average functioning in the skill sets regards as underdeveloped or not present in candidates for ADHD classification, being diagnosed as such. Given this, it becomes obvious that the impairments must present themselves in more ways than are normally encountered while viewing adolescent behaviour:

“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. For self-regulation to be possible, specific brain centres have to develop and grow connections with other nerve centres, and chemical pathways need to be established. Attention deficit disorder is a prime illustration of how the adult continues to struggle with the unsolved problems of childhood. She is held back precisely where the child did not develop, hampered in those areas where the infant or toddler got stuck during the course of development.”

And again:

“In his best-selling book Emotional Intelligence, Daniel Goldman, behavioural and brain sciences writer from The New York Times, defines this capacity of “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…” We have only to place a negative qualifier before “being able” in that sentence, as in “not being able,” and we arrive at a succinct description of the ADD personality.”

While discussing these issues in terms of the psycho-social or personal life experiences giving rise to behavioural tendencies, the author spares no expense in explaining the behaviour in terms of neurological terms. In furtherance of this, he constantly makes reference to the functioning of the brain as if it were a complex computer with circuits, wiring and interfaces and implicitly as if the brain was separable from the mind.

“That the infant/toddler mode is so often dominant in attention deficit disorder reflects incomplete development of pathways in the cerebral cortex, and between the cortex and lower areas of the brain.”

And again:

“In general, the functions of the right prefrontal cortex include impulse control, social-emotional intelligence and motivation. It also participates in the directing of attention. Human beings injured here, so called prefrontal patients, exhibit distractibility, poor regulation of impulses and other classic signs of ADD.”

As such there is implicit reductionism in that the mind or consciousness is reduced to “brain” and derivative from it. However analogies whereby the brain is likened to a computer tend by their very nature to be reductionist in character. Whereas in previous times the function of a human being were likened to a machine or a clockwork mechanism, we have now become computers. Ironically, the likening of a human being’s brain to a computer could just as readily be reversed to likening the computer to a human brain albeit a much simpler version. The former employs the logical form of “only just” inherent in reductionist thinking whereas the latter implies similarity but not identity.

It is however in the presentation of the brain as a thing with which I would take issue in that its growth is not merely an organic process in the same vein as the growth of a turnip. The growth of the brain may be regarded as being one and the same thing as experiential growth. This in turn is the result of conscious interactions between the individual and their environment. For this reason, if a child was placed into an induced coma and kept alive until adulthood, nobody would contend that upon being brought of this state that the subject would immediately demonstrate maturity of judgement and action. The point being that the growth of mind or brain is linked to consciousness and experience and is not merely a vegetative process as implied in the neurological examples provided.

However, I find that one of the more endearing characteristics of the book is the manner in which it presents itself as a voyage of self-discovery in which the author seems to have found answers to explain his own conflicts and life experiences by virtue of attributing a diagnosis that he or common practice has perhaps stretched to accommodate. For him, the diagnosis of ADHD explains some of his own behaviours in a manner that makes sense of them both respective of his strengths as well as his weaknesses. Indeed, this raises the larger issue of working from a “dysfunction” back to a causal agent that is assumed to exist at a cellular or biological level determining behaviour and accounting for the deficit(s). As such, ADHD is diagnosed in children based upon a perceived in ability to function with a specific context and the same may be said of numerous other diagnosed issues with their designated labels.

With adult ADHD as is the case with the author of this book, his diagnosis of ADHD makes sense of his “dysfunctions” as a husband, father and human being in general. The problem with this approach is the employment of “dysfunction” to explain behaviour that is less than perfect. That standard, I would argue, is not only irrational within the context of what it is to be a human being, but also implies a standard of human behaviour not obtainable on this side of the grave. For those who become preoccupied with the less than perfect standard, it is easy to lose track of the “better than” or “worse than” framework within which humanity resides. To focus on a model of perfect behaviour as if it was the norm of comparison is not only unrealistic but inherently distorts all that it touches.

The story goes of the patient suffering from a range of symptoms which when presented to various physicians results in no diagnosis. Eventually, the patient finds a specialist who provides a multi-syllabic term for that which is held responsible but also offers (a) that there is no cure (b) that there is no explanation as to the cause or origin and finally (c) that he symptoms may continue, get worse or inexplicably better. Other than the name that has been provided and the reassurance given to the patient, what actual knowledge has been added? Indeed, does naming anything provide understanding or power over what is referred to? Curiously, there is throughout mysticism and religious practices a magic associated with names whereby the practitioner gains power or control by virtue of being able to know them and call them out. It would appear that the same tendencies persist today in different manifestations.

Defining people in terms of what they are not, is a backwards way of approaching the study of human behaviour which should, if scientifically grounded in inductive reasoning, begin with a survey of what is, not what should be. Variations from a mean are a more realistic window into human behaviour than comparisons to a non-existent ideal. In the final analysis, I would argue that what is said about this in the context of adult ADHD is equally valid within a discussion of adolescent ADHD. The fact that somebody does not do very well at school is not a dysfunction per se but rather perhaps a lack of suitability of certain behaviours within a specific environment and having specific expectations. The assumption that there is something wrong with the person is a logical leap. The fact that somebody is not very good at something does not constitute a statement equal to saying that there is something wrong with a person. It does imply that the behaviours need to change to become more suitable to that environment whereby the changing of those behaviours resides as the responsibility of the individual to adjust in ways that will yield desired results. At present however, it is current practice to change the environment and expectations to the limitations imposed by the behaviour.