“It depends.”

That’s my response (and that of most of my clinician-scientist colleagues who participated in the MTA study) to Paul Tough’s recent commentary. For context, from 1990-2000 I served as Associate Director for Child & Adolescent Research at the National Institute of Mental Health (NIMH), and was the NIMH scientist responsible for initiating and leading my colleagues in this landmark study. Tough’s ultimate conclusions were sensible: impairment and functioning in children and adult with ADHD depends on the setting and context in which they are asked to perform.

But the set-up was misleading, and presented readers with long-recognized false dichotomy — as if ADHD is either biologic or not, inborn or environmental, medical or psychological. In fact, ADHD, like many of our chronic health conditions – allergic asthma, essential hypertension, adult onset diabetes, chronic obstructive pulmonary disease and arthritis, is both. Any of these conditions can be helped or hindered based on our behaviors, such as exercise, diet, sleep (including changing daily habits), or our choices of which environments, positive or negative, to which we expose our bodies and brains — salt, fats, refined carbohydrates, physical rehabilitation, pollution or pollen-laden environments, etc. Many of the so-called “biologic” illnesses noted above can be partially and sometimes fully improved based on this array of factors — partly biologic, partly genetic, and obviously environmental.

So why should we be surprised that a child’s ADHD symptoms may be worse in some settings, but apparently less of a problem in other settings? Or why some children with significant ADHD may find that early difficulties become more manageable when as an adult, they can pick environments or niches that are more naturally stimulating or to their liking? None of these eventualities mitigate against the merits of a carefully considered diagnosis at an earlier point of life, when that individual was experiencing significant problems with critical life tasks. Doesn’t that also apply for asthma, hypertension, and diabetes? — if we can make choices that change or even eliminate the impact of these conditions on our lives, does that mean they were not real?

So the article does an initial disservice to children, families, and adult adults with ADHD to the extent that misleads readers, and implicitly asks them to accept what is in fact a false dichotomy — one that belies a lack of understanding of the complexity of factors that underpin modern concepts of causation for many of our illnesses — and how our lifestyles and environments can affect our health outcomes. One harmful by-product of this faulty either-or assumption – either biologic or not – is that by implying that ADHD is not “a real disorder,” then somehow parents or naïve doctors must be to blame — or that schools are “the problem”, that social media and screen time are at fault, etc. Might all of these factors be important to consider when understanding the difficulties in a given child? Certainly. If addressed, could they improve a given child’s or adult’s presentation? Perhaps. It depends.

Sincerely,

Dr. Peter S. Jensen, M.D.

Board Chair and Founder, The Resource for Advancing Children’s Mental Health (The REACH Institute), and previously Associate Director for Child & Adolescent Mental Disorders Research, National Institute of Mental Health