attention deficit

The Real “Attention Deficit”: Ritalin, Hand Grenades, Good Medicine

In the many years that I have been studying childhood neglect, I have often been struck by how many clients, particularly men, come in toting a diagnosis of ADD or ADHD. To them, and also their frequently impatient or frustrated loved ones, it seems accurate, with their loose or sluggish focus, perhaps forgetfulness, failure of agency, and disorganized brains. Never fond of diagnostic labels nor a fan of amphetamine drugs, I have remained skeptical and curious. What is really going on here?  

I know early on in my anecdotal scavenging, I coined a trilogy of neglect symptoms I came to call “the Three P’s” of neglect, primarily showing up in the interpersonal domain, but not exclusively. The P’s are passivity, procrastination, and paralysis. For many, it seemed to fit and stick. I have held on to the paradigm as I sought more information as well as developmental and neuroscience underpinnings for my “theory.” 

I hypothesized that, given that the infant brain develops in resonation with the brain of the primary caretaker (usually, at least at first, the mother), if that little brain is reaching to resonate with a brain that is depressed, terrified, angry or most of all absent, it fails to develop and learn to regulate in a consistent, calm and essentially safe and healthful way. What does happen when there is no one there to resonate to, or not nearly enough resonation? Well, we certainly have the extreme example of the Romanian orphans, who appear nearly catatonic. But what about the more “garden variety” that we are more likely to encounter in our offices? That has been my question for many years.

I have heard many trauma stories about little kids panicked and terrified as they went to school each day, in dread of reading circles where each child had to read a passage. Some would count and calculate when or which segment would be theirs in the rotation so they could practice, or slide out to the bathroom to avoid it (and sometimes to vomit,) feeling such shame, confusion, and self-hatred about why it was so hard for them. 

Meanwhile, some got in trouble with their parents for poor grades; some were held back a grade or two, and many simply disappeared under the radar, invisible and unhelped, concluding that they were stupid in addition to feeling invisible and alone. Many, amazingly bright, found their own workaround strategies for reading. Others discovered a sport like rock climbing which takes incredible concentration, focus, and patience to train their brains. Still, others sank into a haze of drugs to get away from the whole thing. I have seen many iterations, all originally coming from neglect.

In the 1980’s it seemed that ADD and ADHD became the diagnosis du jour. Suddenly kids were being slapped with that label right and left. And they were met with a parade of amphetamine drugs. Oy vey! 

The first drug of choice I remember was Ritalin, which always somehow reminded me of the sinister and scary villain the Riddler on the Batman show. Suddenly it seemed we had a whole generation of children on speed, which gave me a Riddler-like chill, thinking of what this does to our gene pool, let alone providing a possible “gateway” to other, less manageable kinds of drug use. But it also seems there was little curiosity about what causes this problem, and if there was a way to move upstream in addressing it. Meanwhile, in many cases, the drugs were something of a nightmare for the kids, with sleep problems and other kinds of dysregulation causing plenty of conflict between parents and kids about taking their pills or not.

Empty space is suffocating and deathly, and it is truly like dying to many of these adult survivors. Boredom is a slow and mortal agony.

Hand Grenades

One thing I began to notice in some couples where at least one partner was a child of neglect was a little dynamic I came to call “hand grenades.” This was where one partner would lob a truly provocative, antagonistic, or triggering remark at the unsuspecting other. It was baffling because the rise they were likely to get was completely predictable and sure to incite a rageful or rejecting blast in reaction. I would hear about similar interactions where someone would similarly incite loud conflict at Thanksgiving dinner, for example. It was baffling until I began to study it more.

For the child of neglect, boredom and waiting feel lethal. Imagine an infant left alone too much, in a cavernous vacuum of empty space, waiting with uncertainty for someone arbitrarily to come – or not, learning quickly that hoping or crying was pointless. They had no impact. Empty space is suffocating and deathly, and it is truly like dying to many of these adult survivors. Boredom is a slow and mortal agony. Some of them discovered as young children that negative attention might be better than none at all, so by being somehow naughty or “bad” would garner some kind of reaction from the otherwise perhaps oblivious other, and interrupt the emptiness. As I continued to observe these little hand grenade scenarios, the variables seemed to coalesce: neglect, ADD, and hand grenades. Hmmm… 

I later learned from neuroscientist Ruth Lanius that often, in the under-stimulated, dysregulated brain of a traumatized person, only when under threat does the brain start firing and come alight. Only then does the person perhaps momentarily feel alive. I began to learn from some of these flamethrowers that they were simply bored. They were not trying to be mean; rather, they were trying to keep from dying. Certainly, a hard sell to the insulted partner, but it does, in fact, make sense.

So, who is tagged with a “disorder?” Where does the deficient attention reside?

Good Medicine

So, where does the real attention deficit reside? Perhaps in what that infant and child did and did not receive, the oceanic poverty of mirroring and care, the failure of resonance that makes the brain grow and develop and makes a child feel alive. As the child of neglect gets a little older, and slowly grows into a person, they continue to be unseen, unheard, not known, not understood, perhaps disappearing into quiet invisibility. Maybe as their learning disabilities or boredom go unnoticed as well, and their dysregulated brains continue to languish quietly alone, attention may become spotty, dulled, unreliable. 

So, who is tagged with a “disorder?” Where does the deficient attention reside? Perhaps first with the neglectful parent, and later in the unassuming child’s brain. Another expression of the intergenerational transmission of trauma perhaps? And how many generations will wind up on amphetamines?

If in fact attention deficit is really a euphemistic or medicalizing label for neglect, what might be a better remedy? Some of the most robust, copious, and well-replicated neurofeedback research we have has been with ADD and ADHD. But perhaps the best medicine is upstream: effective trauma healing that will enable resonant presence, reliable, loving, consistent attention – a new intergenerational transmission. We are not talking about perfect attunement! The attachment researchers remind us that the best of the “good enough” parents achieve the optimal rhythms of attachment and presence about 30% of the time, with the rest being the dance of rupture and repair. Perhaps we can strive for that 30%, and wean ourselves, detox ourselves from inattention and even speed!

Today’s song:

My book “Working with the Developmental Trauma of Childhood Neglect: Using Psychotherapy and Attachment Theory Techniques in Clinical Practice” was published on August 31st. It provides psychotherapists with a multidimensional view of childhood neglect and a practical roadmap for facilitating survivors’ healing.

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