Ritalin for all: the fallacy of simple answers

I've been thinking about the phrase, "the fallacy of simple answers," in preparation for writing about a new book I was asked to review, Pills are Not For Preschoolers (whose cover looks remarkably similar to my book, Keeping Your Child in Mind, that came out a year ago.).  Author Marilyn Wedge gives a clear and compelling argument for the use of family therapy in treatment of behaviorally symptomatic children. Unlike the title suggests, the book is not primarily about preschoolers, but offers multiple examples of her successful work with children ranging from preschool to adolescence.

She contrasts this approach with the current trend of solving complex problems with a prescription for medications. She writes:

What happens, then, if the child's symptoms are treated with medications-say Ritalin or Adderall for the hyperactivity or Zoloft for the depression? The hyperactive boy may indeed calm down and the depressed girl may well cheer up. But, as we will see, if the deeper family issues are not addressed and resolved, unanticipated consequences may emerge, sometimes months or even years later.

Prescribing medication in this way is an example of a simple answer. But I actually heard the above phrase in a completely different context.  I heard it from my father, with whom I am working on a new book about his experience growing up in Nazi Germany. He was telling me that the year of his birth, 1923, was the same year that Hitler was arrested for trying to overthrow the German government. Hitler spent the next year in prison writing Mein Kampf. My father described it as a time characterized by "the fallacy of simple answers." He expressed concern that in this current time of economic hardship, some politicians (particularly those speaking in Tampa this week) offer simple answers to complex problems.

My father was not saying that these politicians are Nazis, and I am not saying that our current approach to child behavior problems has any relation to Nazism. But the phrase resonated for me.  Looking to simple answers to complex problems can have unanticipated, and sometimes dangerous, consequences. In the case of Ritalin prescriptions, one of these is the current epidemic of stimulant abuse in high school.

Unfortunately Wedge's book is also an oversimplification in two important ways. First, many of her cases, while I'm sure they are honestly portrayed, come across as being way too easily resolved. Many of the families I treat in my behavioral pediatrics practice are dealing with serious trauma and loss.  Unlike the families Wedge describes, they have often been struggling with their child's behavior since infancy. Certainly not all families will find that six or seven visits will solve everything.

The biggest oversimplification, however,  is her presentation of the biology/environment, or nature/nurture issue in an either/or model that is not only oversimplified but also outdated. Current research at the intersection of genetics, neuroscience and developmental psychology reveals a complex ongoing interaction between biology and environment.

For example,  families who come to me with concerns about "ADHD" often describe a child who was not only very active in utero, but was also running by 9 months.  Clearly such a child has a biological vulnerability. But even here environmental influences may be at play. A 2006 study at Johns Hopkins showed an association between psychological distress in pregnancy and advanced motor development.

These children often have a family history of ADHD, suggesting a genetic influence. But parents who have themselves struggled with similar problems may bring intense emotional responses to their child's behavior. Genetics and environment are inextricably linked.

In addition, having a child with these challenges, even when they are biologically based, can lead to marital conflict, particularly if one or both parents share these traits. The stress in the household produced by this conflict may in turn exacerbate a child's "problem behavior," or what is more accurately referred to as "symptoms."

The hopeful part of this complexity is that this science tells us that by changing the environment, it is possible to change the biology. We can no longer think in simple dichotomies of drugs or therapy, biology or environment. Supporting relationships, family therapy being one approach, can actually change the brain.

My go-to phrase that I learned from my mentor and colleague Ed Tronick is "embrace complexity." When parents are given the space and time to tell their story to a non-judgemental listener, the multiple origins of their child's behavior, as exemplified by the above view of "ADHD", will become clear. In such an environment of reflection and understanding, a child's development, at the level of gene expression and biochemistry of the brain, can move in a healthy direction