ADHD: Not all complex problems have 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.  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.

Claudia M. Gold is a pediatrician who blogs at Child in Mind and is the author of Keeping Your Child in Mind.

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  • Cindy

    I read this article with mixed feelings. As the mother of a child with PDDNOS, ADHD and an anxiety disorder, I would do anything to help him with his “symptoms”. I agree that nothing in this is simple. But I argue that there are much stronger causes at play than home environment.

    I can tell you that he is the 10 year old middle child of a middle class family, both parents work, and there is stress, of course – any working family has it. But finances are steady, the home is more than comfortable, and there is much love. My son’s siblings are thriving. I am beginning to resent the finger pointing at assumed family dysfunction.
    The school requires that he be on medication and quite honestly it’s been the best thing that has had any lasting benefit for him, especially the anti depressants for overall stability and the stimulants for concentration in the classroom. If dysfunction is a culprit than I suggest it’s a societal dysfunction. I was originally anti medication and have tried everything from diet changes, martial arts, yoga and behavior therapy to help my child. I do agree that calm environments are beneficial (no one would argue with that for any human let alone one with sensory processing disorders). And the WORLD is not calm.
    My child’s disabilities stem from something much deeper than our family life. I was pregnant during the 9/11 attacks, did this alter my body chemistry at key developmental stages? Maybe, marginally – but a lot of other women were pregnant than too, some with direct ties to someone lost in the attack or in the ensuing war, and war has been around as long as man has existed. The schools are crowded – and over scheduled with not enough recess or physical education, is this the cause of our problems with ADHD? Perhaps it adds to the difficulties, but my child came out stressed by the world, he struggled from day one with sensory overload, and emotional regulation. I work full time to meet our family needs, does this reduced availability add to his problems? I ask all this, because there are plenty of “normal” families struggling with ADHD challenges, and we are all dealing with the same stress or dysfunction that has been around since the dawn of time.
    No matter what people feel about the medications, in order to function in today’s schools (and perhaps that is the key?) without being the kid more likely to drop out, fail academically or struggle with bullying or other behavior issues, the medications are the tried and true winners of helping us through. They are not given in a vacuum. They are part of a bigger support program including therapists, psychiatrists, social integration programs and more. If loving support systems were enough to fix things, we’d have “cured” my son a long time ago. There is a fundamental difference in his make up that makes him who he is. We can only hope to build the skills for him to manage in a way that is socially acceptable and where he can go on to live his life meaningfully.

  • DavidBehar

    If Hitler had been shot for treason instead of treated with subtlety, the world would have been better off. If the Jews and Communists had killed him, that would have been a simple answer. I like Saddam Hussein’s philosophy, “If there is a person, then there is a problem. If there is no person, then there is no problem.”
    There are many people who need to be killed to improve the world by their absence, including the entire hierarchy of the lawyer profession. I have advocated their mass arrest, trials for insurrection against the constitution, and summary executions. All social pathologies would end in a short time.

    Sometimes, the simple answer is best. For example, treat the ADHD and the complex family stressors and conflicts evaporate. The author is a biased advocate. She fails to disclose her economic interest in this failed treatment for ADHD. The advocacy of complexity is a form of bad faith, and rent seeking, a synonym for armed robbery.

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