Is mental illness simply a matter of a "chemical imbalance" or "bad gene"? Do we need to fix children's disordered brains or do we need to let kids be kids?
Over the past two decades, there has been a meteoric rise in the number of children - now estimated to be 1 in 6 - diagnosed and treated for a range of psychological disturbances including ADHD, autism, mood disorders, and learning disabilities. Explanations in the popular media tend to polarize around two viewpoints:
1) Childhood mental illnesses are caused by genetically influenced chemical imbalances in the brain. Magic bullet cures will come in the form of drugs that correct these imbalances in much the same way that insulin cures diabetes. Greater awareness and improved diagnostics have lead to the spike in incidence rates.
2) We need to let kids be kids. Children by definition are inattentive and moody, and we have to let them run and play, and stop pathologizing normal behaviors in order to drug them into silence for the convenience of quiet classrooms and orderly households.
The truth is, neither of these perspectives tell the whole story. Without question, some children are diagnosed unnecessarily because their behavior is inconvenient to the adult world. In All Work and No Play and Childhood Lost, I described pathogenic trends in American culture that undermine children's psychological health, such as developmentally insensitive school systems, the disappearance of creative play in early childhood, and screen technologies that immerse them in violent and sexualized worlds. When you place children in environments that undermine their development, inevitably, some will "not fit in", and they may find themselves labeled with ADHD, a learning disability, or a mood disorder.
At the same time, many children are struggling with very real symptoms ranging from impulsivity and learning challenges to panic and rage; they are not merely, "unique" "quirky" or "willful" and it is deeply frustrating and demoralizing to parents who are looking for help and guidance and who are judged as inadequate parents who "can't control their kids". It is not outrageous to suggest that a child's developing brain might be disordered in some way, just as any other organ in the body might be, and that the solutions lies in correcting that disorder.
So which is it? Do we need to fix children's disordered brains or do we need to let kids be kids? In other words, do solutions lie in fixing their biology or fixing their environments? Or as psychologists like to say, is this a problem of nature or nurture? My latest edited book: The Science and Pseudoscience of Children's Mental Health (Praeger, 2015) stipulates that we are asking the wrong question. Pitting Nature versus Nurture is an outmoded dichotomy that has been replaced in serious scientific circles by the science of Epigenetics; put simply, the understanding that environments, whether they be cellular or social, can activate or silence genes which in turn have a profound effect on brain development. In chapter 3 of Science and Pseudoscience, Neurobiologist Richard Francis provides an overview of the field of epigenetics:
How is it that our environment can affect our genes? That idea seems incongruous. This seeming incongruity reflects a basic misperception about how genes influence human development, a misperception popularized not only in the media, but by many geneticists as well. Recognizing the role of environment in regulating gene behavior unleashes enormous potential for understanding children's mental health and developing interventions ranging from diet to relationships, which in turn alter gene expression. The standard view - which focuses on identifying the "ADHD" gene or gene sequence, for example, with a view to intervening at the level of the gene, without any consideration of the role of environment - is shortsighted and fundamentally flawed.
DNA has come to be conceived as the instructor of development[.] … From an epigenetic perspective, genes are as much instructed as instructors. I have used the metaphor of a theatrical production to distinguish the executive gene view from that of an epigenetically informed view of genes as they function in the cell (microcosm) and development (macrocosm). From the perspective of the executive gene, DNA functions as the director of the theatrical production, proteins as the actors, and all other biochemicals as the stage hands. From an epigenetic perspective, in contrast, DNA, proteins, and everything else interact more as an ensemble cast.
The science of epigenetics has taught us that when we radically change children's environments from time spent outdoors to hours sitting in front of screens, from foods that grow in the ground to food that is processed in a laboratory from clean air, soil and water to air, soil and water that is saturated with tens of thousands of man made chemical toxicants - 1,000 of which have been targeted as neuro or brain toxins - that these environments powerfully impact gene expression, and brain development.
In a recent article written for the Lancet, internationally renowned environmental health experts Philip Landrigan and Phillipe Grandjean describe the chemical soup that our children are swimming in as causing nothing less than a global silent pandemic of neurodevelopmental toxicity. Rates of childhood illness have spiked dramatically in the last couple of decades. Everything from childhood cancers and asthma to learning disabilities and autism are on the rise. For example, in the 1970s, Autism was diagnosed in one in every 10,000 children. Today it is diagnosed in 1 in 63 children and in 1 in 42 boys. The human genome does not evolve quickly enough to explain these rapidly changing statistics, but we have changed children's environments radically and so we are obliged to consider the impact of these highly unnatural environments on genetic expression and the development of the exquisitely complex and fragile human brain from its embryonic beginnings until it is fully mature in late adolescence.
Furthermore, we cannot anchor our understanding of the interplay of genes and environments to the chemical imbalance theory. It has not stood the test of science. The field of psychiatry has itself rejected this theory. There is no compelling scientific evidence that depression, bipolar disorder, schizophrenia, anxiety, ADHD or Autism are caused by chemical imbalances. This may surprise and confuse you, because the chemical imbalance theory continues to be widely trumpeted in the media and by PCPs and psychiatrists who work directly with patients. And yet, as Robert Whitaker notes in chapter 2 of Science and Pseudoscience, leaders in the field of psychiatry are publicly renouncing the theory. Here are some quotes that he shares from three leading psychiatrists:
"[E]arlier notions of mental disorders as chemical imbalances are beginning to look antiquated."
Thomas Insel, Director National Institute of Mental Health, 2011
"Chemical imbalance is sort of last-century thinking … It's much more complicated than that. . . . It's really an outmoded way of thinking."
Joseph Coyle, Editor-in-Chief, Archives of General Psychiatry, 2012
"In the past 30 years, I don't believe I have ever heard a knowledgeable, well-trained psychiatrist make such a preposterous claim, except perhaps to mock it. … [T]he "chemical imbalance" image has been vigorously promoted by some pharmaceutical companies, often to the detriment of our patients' understanding. In truth, the "chemical imbalance" notion was always a kind of urban legend—never a theory seriously propounded by well-informed psychiatrists.
Ronald Pies, Editor-in-Chief Emeritus of Psychiatric Times, 2011
And so it seems that the commonly held belief about the cause of mental illness - the chemical imbalance in the brain - is fundamentally flawed.
If we look at the symptoms that drive the psychiatric diagnoses most commonly given to children, and adults for that matter, they are generally very broad and do not point to the source of the illness any more than a fever does. Lowering a fever can be of vital importance at the acute stage of an illness, but none of us believes that a steady diet of aspirin and cold compresses is in any sense a cure. The same is true of symptoms like hyperactivity, and inattention. Sometimes professional training actually serves to narrow rather than illuminate our understanding, and we stop seeing the obvious. For example, inattention and hyperactivity are generic states of mind that can have a multiplicity of causes: Poor diet, permissive parenting, hours in front of screen entertainments, an outsized imagination, being bullied, neglect or abuse. And research tells us that prenatal exposures to maternal stress hormones, cocaine or alcohol, and environmental pollutants can epigenetically lead to symptoms of inattention and hyperactivity. And yet, the belief that all children exhibiting hyperactivity or inattentiveness are suffering from the same well-understood genetically influenced brain disorder called ADHD, with objective diagnostic criteria and well established drug protocols, is widely held by parents and clinicians alike. I would argue that it is also more useful to call depression and psychosis symptoms rather than illnesses. To be clear, like fever, symptoms of depression and psychosis can be devastating and life threatening, at which time symptom relief becomes the top priority. But we need to move beyond the idea that everyone who is depressed, or psychotic or hyperactive has the same disease, any more than we would assume that everyone who has abdominal pain, or headache or fever does. In so doing, we can begin to address the underlying causes rather than just staunching the wound with a tourniquet.
In light of psychiatry's own disenchantment with the chemical imbalance theory, it is still legitimate to argue that while psychiatric drugs don't cure illnesses per se, they may provide much needed symptom relief, and because they are vetted by the FDA, they are safe to use. In fact however, the FDA only requires two clinical trials - designed and funded by the drug companies who make them - that show that the drug has a statistically greater effect than a placebo regardless of whether these statistical differences have any clinical significance and regardless of how many other clinical trials for the same drug fail to show a difference. Harvard University professor Irving Kirsch's review of the research on the efficacy of antidepressants[*] reveal that while the effect of antidepressants as compared with placebo are statistically significant, the difference is nonetheless so small, that it doesn't translate into a therapeutic improvement. Also, this statistical difference is attributable to the fact that antidepressants have a host of side effects unlike placebo pills. Therefore, most patients in these trials "break blind" meaning that they can guess whether they are on an actual medication or not, which affects their expectations. This doesn't rule out the possibility that some people experience symptom relief from their medication, and as long as they're informed about possible adverse effects, of course it's appropriate that they continue to use their medication. However, it's a different matter with children who cannot give consent.
Meanwhile, outstanding research from many scientific disciplines has led to deeper understanding of childhood psychological disturbance and paved the way for more effective treatments. But this science is conveniently placed in a box called "alternative medicine", which for many is a euphemism for junk science. The irony is that it is the chemical imbalance theory that represents junk science. How has psychiatry - with its history of insulin coma therapy, lobotomy, shock therapy and today, the wholesale treatment of millions of children with ineffectual and dangerous drugs for questionable diagnoses - become the gold standard against which other disciplines and treatment approaches are measured?
The belief in the "chemical imbalance" and the "bad gene" as the cause of children's mental illness lives on as a powerful cultural myth. It is stoked by the pharmaceutical industry which has identified children as a fertile market for its products, and by the health insurance industry seeking an easy and cheap solution to complex psychological issues with multifaceted causes. Personal, family and cultural factors, as well as more compelling biological explanations are swept under the rug if they don't result in increased drug sales and the promise of a quick fix. We might dismiss this as "business as usual" in corporate America if the stakes weren't so high. As I have described in my last three books, No Child Left Different, Bipolar Children, and Drugging Our Children, the drug cocktails that millions of children are consuming damage their developing brains and bodies while the real source of their suffering remains untreated. But this does not negate the value of scientific research.
The Science and Pseudoscience of Children's Mental Health exposes the myth of the chemical imbalance and the bad gene and introduces the science of epigenetics as a compelling conceptual framework for understanding the science of children's mental health. It presents research on the importance of high quality prenatal and early childhood care in fostering healthy brain development and mental health from a multidisciplinary, epigenetic perspective. Authors present research that sheds light on the impact of neurotoxicants such as heavy metals and pesticides, as well as the salutary effects of micronutrients. The underpinnings of autism spectrum disorder and concussion syndrome are explored from a functional neurology perspective, which views the brain as a complex, dynamic system with much greater plasticity than we have heretofore understood, opening the door to breakthroughs in diagnosis and treatment.
For evidence-based research on Attention Deficit Disorder with Hyperactivity, visit the GreenMedInfo.com Research Dashboard.
[*] SSRI antidepressants increase the availability of serotonin in the brain.