Welcome to my blog, which speaks to parents, professionals who work with children, and policy makers. Through stories from my behavioral pediatrics practice (with details changed to protect privacy) I will show how contemporary research in child development can be applied to support parents in their efforts to facilitate their children’s healthy emotional development. I will address factors that converge to obstruct such support. These include limited access to quality mental health care, influences of a powerful health insurance industry and intensive marketing efforts by the pharmaceutical industry.

Thursday, August 30, 2012

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

7 comments:

  1. "Current research at the intersection of genetics, neuroscience and developmental psychology reveals a complex ongoing interaction between biology and environment."

    More wishful thinking on your part, than the evidence would suggest. Claudia, as much as we'd LIKE to understand the biology of behavior, the fact is we haven't the foggiest idea what "biological vulnerability" means.

    You prove this point with the running 9-month old. Calling his behavior abnormal reveals nothing about his brain, and everything about our culture biases

    ReplyDelete
  2. Hi Rob

    Thanks for your comment. I understand what you are saying about cultural bias regarding "normal" activity level. What I mean by biological vulnerabilities is traits that appear to reside in the child from birth. This would include such things as a baby who is not cuddly or who has intense reactions to sounds, or has difficulty transitioning from awake to asleep. Nurses often identify these babies in the newborn nursery as standing out from the other babies. When a child develops motor skills in advance of cognitive development, this can be seen as a biological vulnerabiity analogous to language delay when a child's capacity to communicate lags behing his cognitive development.

    ReplyDelete
  3. And your point is well taken as well, Claudia. I want to underscore that calling a trait "biological" ought to remain in quotation marks until such time as we can identify what biology we are referring to. Otherwise, we commit another fallacy: the fallacy of biological reductionism. To repeat, the fallacy is a fallacy because we assume a biological entity without actually producing one.

    ReplyDelete
  4. Unless we're talking about souls here, which is outside the realm of science, ALL human behavior and all brain activity is "biological." It's not reductionistic to say that.

    The question is what behavior patterns are or are not due to a physical brain abnormality, or are instead the reactions of a healthy brain to a problematic environment.

    Hard to absolutely "prove" one way or another given our current understanding of neuroarchitecture, but I don't think that level of proof is required to discuss the evidence for and against and make a reasonable guess. No one knew what germs were when the plague wiped out half of Europe, but they sure knew it wasn't the workings of a healthy body. Seems they were right.

    ReplyDelete
  5. Claudia and David, the germ theorists were right, but they were not proved right until Koch proved them right. Claudia, you will appreciate that a likely counter-example are the attention-deficits. Do we continue to hold out hope that biological correlates will be found? Or will we wait for the diagnosis to fall into the bin next to hysteria, homosexuality and masturbational insanity?

    ReplyDelete
  6. The bin sounds like a good idea. However, we would still have children who have what I am calling biological vulnerabilities such as sensitivity to sensory input or difficulty with state regulation. In another culture where kids are less bombarded with sensory input, or Kindergarten was less structured, these might not be a problem. However, in our society, I think it is important to validate parents' experience of children, as well as the child's experience, and support them in thier efforts to mamage these vulnerabilities. If we could do this without a diagnostic label it would be ideal.

    ReplyDelete
  7. May I suggest that if you do in fact hope to follow the guidance implicitly found in the phrase "embrace complexity" that you - as a professional care provider - can multi-track your response to parents such as those you describe.

    Put another way, multi-factorial problems require multifaceted responses. In the case of the family described herein, disaggregating the familial, marital, developmental and behavioral issues that you recount, you can undertake (or urge the parents to approve) cognitive testing of the child should he/she endorse the diagnostic criteria for ADHD in your office. Once the results are in-hand, a course of treatment can be more accurately and reliably implemented - should the data indicate ADHD or another disorder.

    As you know, the testing conducted sans medication. In this way, you and the parents will be working from a common understanding and an objective set of results. Of course, some parents and even some clinicians harbor pre-existing doubts about the efficacy of cognitive testing and may therefore torpedo even the most genuine efforts on behalf of the child in concord with the data.

    I would also suggest that the controlled use of stimulant medication is among the most well understood psychopharmacological tool that clinicians can use in service of their patients. The body of knowledge upon which you and any other clinician can draw on is over 100 years deep.

    That said, it seems only sensible to approach the problem of issue disaggregation, diagnosis and differentiation on mutually reinforcing, parallel tracks.

    ReplyDelete