[Posted on 17 December, 2020 by Geir Øgrim]
In 1993 I left my job in school psychology and started to work in child- and adolescent psychiatry. Last autumn we celebrated 50 years of child psychiatry in the county of Østfold, Norway. My mind started to wander – what has happened during these years, and what will happen in the future? Because it is much easier to describe the past than to predict the future, I will start with the past.
As a school psychologist I had an interest in developmental disorders, learning disabilities and MBD – “minimal brain dysfunction”. In the early nineties I discovered to my surprise that some doctors and psychologists from child- and adolescent psychiatry were interested in developmental disorders, not only in psychoanalysis. They even applied for a neuropsychologist, and I swapped to child psychiatry.
How was that? I was met with respect, even when I announced that I was not interested in learning play therapy. When I introduced tests and rating scales this was a bit strange to my colleagues. Clinical observations and psychodynamic interpretations of the observed behaviour were the basis for diagnostic conclusions and case formulations. In fact, the diagnostic system was very different from DSM-5. Broadly speaking there were three categories: psychosis, neurosis and borderline. The methods and the professional perspectives have changed, but there were some qualities of yesterday’s child psychiatry that deserve respect. Some of the clinical descriptions impressed me, and the focus on respectful therapeutic relations with the children sometimes really improved their lives.
Although the prevailing theory about the causes of child pathology was maltreatment, under-stimulation and “cold mothers”, there was a growing interest in congenital vulnerability: MBD (ADHD), autism, mental retardation, learning disabilities, and later OCD and Tourette syndrome as well.
The history of psychology, also influencing child psychiatry, is filled with “schools”, with quite different approaches to treatment. Historically three major approaches can be highlighted: Psychodynamic therapies, behaviour therapies and medication. In addition, one should also mention the many schools of family therapy.
Ideological controversies between different treatment approaches have diminished during the last decades. One reason is perhaps that the professional world has accepted the principle of evidence-based practice – more or less. It also seems that the “schools” are more willing to include elements from other theoretical systems than they used to do. Communication strategies are included in parent management training, and family therapists acknowledge that ADHD, autism, Tourette or OCD heavily impact family life. The legitimate place of medications in child-and adolescent psychiatry is widely accepted, also by non-medical professionals.
Has child psychiatry moved from conflict to harmony? No, the gene-environment controversies are still with us – sometimes in polarised terms like “trauma vs. genes” – instead of asking how these factors may interact.
Diagnoses in the future
The present diagnostic systems are based on separable categories and behaviour symptoms. We know this is not the optimal description of reality. Future diagnostic systems may still need headlines like autism and ADHD, but for treatment purposes each patient should be described by strengths and difficulties on relevant dimensions such as inhibition, rigidity, working memory, emotion regulation etc.
The neurobiological origins of developmental disorders are well documented, and the details of the brain mechanisms involved are described with increasing precision. Despite this no direct or indirect measures of brain mechanisms are currently needed to diagnose developmental disorders. Future revisions of DSM and ICD should require that behavioural symptoms are supported or supplemented by biomarkers from objective tests, genetics, EEG, fMRI or other neuroimaging methods. Inclusion of such biomarkers may also give rise to subtypes that are more related to prognoses and treatment options than the present subtypes.
Treatments in the future
At a physiological level brain-function can be described as a dance involving chemistry and electricity. In psychiatry medical treatments have mainly involved chemistry, i.e. medication. Although significant and clinically meaningful effects are documented in numerous studies, such treatments do not help everyone. A more brain-based diagnostic system as described above may lead to improvements, but there are probably limits to the medication approach. For most disorders, a multimodal treatment approach is recommended, underscoring the limitations of medication alone.
Nootropics (“cognitive enhancing drugs”/”smart drugs”) have been studied extensively during the last decade. This research may lead to new treatment approaches for neurodevelopmental disorders.
Gene therapy for developmental disorders may not be science fiction. There are definitely some challenging ethical aspects here: “Your child has a genetic disposition for autism (or ADHD or OCD or…), but we can change this by gene-therapy”. Is this what we want?
The “electricity approach” also has a history in psychiatry. Modified versions of the highly disputed electroconvulsive therapy (ECT) is still used for treatment of severe depressions. Deep brain stimulation is sometimes used in severe cases of Tourette. Other, modern approaches, such as tDCS (transcranial direct current stimulation), with no serious side-effects, may eventually prove to be viable treatments. EEG neurofeedback (NF), learning to self-regulate electric brain activity (EEG) to improve function, has been around for several decades. In studies documenting clinical gains it has been difficult to separate the influence of general factors such as therapeutic relations and hope from the feedback itself. NF is a designation of different time-consuming methods. For whom is a specific NF-method working, and can some of the training take place at home? Such questions need to be answered to make NF a fully viable future treatment.
The number of evidence-based psychosocial and pedagogical treatments is increasing, and hopefully will continue to increase. Linking such approaches to the individual’s neurocognitive profile and brain-function will be in line with the principles of “personalised medicine”.
What else will happen in the future? Completely automatised testing and examinations? Digital social training? Online therapies? The future is here already.
Not commented on in this blog
Child- and adolescent psychiatry includes much more than neurodevelopmental disorders. Regrettably children will continue to experience neglect, trauma, abuse, under-stimulation, bullying, dysfunctional families with and without substance abuse etc., regardless of inborn vulnerability. Crises will happen and young people will need help to manage such events, sometimes from specialised psychiatry.
P.S. The only thing we know about the future is that we do not know anything about the future.