The Future of Psychiatry is Neurodevelopmental
Michael Fitzgerald traces the recent development of, and problems with, the diagnosis of neurodevelopmental disorders.Mar 23, 2018
Neurodevelopmental disorders include learning disability, autism, ADHD, specific learning disorders, developmental coordination disorder, tic disorder, stereotypic movement disorder and now many researchers regard schizophrenia and bipolar as also being on the neurodevelopmental spectrum as well. As Michael Owen and Michael O’Donovan (2017) point out, there is a gradient of decreasing neurodevelopmental impairment from intellectual disability, autism, ADHD, schizophrenia and bipolar disorder. They also identify that, “recent genomic studies have identified large numbers of specific risk DNA changes and offer a direct and robust test of the predictions of the neurodevelopmental continuum model and gradient hypothesis”.
The importance for learning disability that recent research supports, is in “the view that schizophrenia is a disorder, whose origins lie in disturbance of brain development, but also that it shares genetic risk and pathogenic mechanisms with the early onset neurodevelopmental disorders, (intellectual disability, autism and ADHD)”. They also note that, “these disorders lie on a gradient of severity, implying that they differ to some extent quantitively as well as qualitatively”. Most psychiatrists and psychologists working with psychiatry and learning disability, and more severe disorders, will now be functioning largely as neurodevelopmental psychiatrists and psychologists.
The tragic history of psychiatry and psychology of blaming the parents with causing the autism, the refrigerator mother and the schizophrenogenic mother hopefully has largely passed. Unfortunately, John Bowlby has to be included in this group as he said autism was due to “inappropriate mothering”, in Volume 2 of Attachment and Loss. This blaming of the mother has not entirely passed, and mothers often interpret parenting classes as meaning that they caused the child’s problem due to faulty parenting. It’s critical in parenting classes and therapy, that it is emphasised that the parents are not the cause of the child’s problems when they have neurodevelopmental disorders. In my view, over 95% of parents are good enough. A small group suffer from drug addiction, alcoholism and serious mental disorders, which interfere with their parenting.
One of the great problems that we have in psychiatry and psychology with the neurodevelopmental disorders is that we have no biomarkers. All the neurodevelopmental disorders have a tendency to overlap and so, what we have in psychology and psychiatry is spectrums of one kind or another. Indeed, it’s clear now that we have overlapping spectrums and some of the aetiological genetic factors have genetic abnormalities, all of a similar kind occurring in a variety of disorders.
Thomas Insel (2015) states that we have what he calls “connectopathies”, meaning we have problems with brain circuitry connections. The goal to give us more solid diagnosis is to do what the National Institute of Mental Health is trying to do with psychiatric disorders – that is collecting “genomic, cellular, imaging and behavioural information on a large number of people”. The goal of the Research Domain Criteria is to define diagnosis, “as scientists have done with cancer”. New research will be cross-diagnostic. The aim will be to have biomarkers to help us with diagnosis. At the present time, the so-called, “lumpers”, who see a broad spectrum of disorder have clearly won, in terms of clinical diagnosis. Nevertheless, within the next fifty years it is likely that the, “splitters”, will have their successes with new biomarkers and diagnosis based on imaging, genetics etc.
One of the major problems in Ireland is in the diagnosis of autism. Unfortunately, often narrow, out-of-date concepts of autism are being used, which are missing over three-quarters of people with autism. The Centres for Disease Control in 2016 put the prevalence of autism at 1 in 68. I believe this is correct. The National Institute for Health & Clinical Excellence Guidelines for Autism, emphasise that there is no instrument that is a “gold standard”, and that the diagnosis is fundamentally a clinical diagnosis by an expert psychiatrist or psychologist in autism. Patients often come to me, telling me that their child is, “ADI-R negative”, with tears in their eyes, when the parents themselves, the school and everybody who knows the child knows that the child has autism.
Professor Dorothy Bishop from the University of Cambridge states that, “the main problem with the Autism Diagnostic Interview – R is not just the financial cost, (though that is certainly prohibitive), but also the cost in time; time for training, time for administration and time for scoring and consensus coding”. She goes on to indicate that, “if it could be shown that there were real benefits in accuracy of diagnosis from adopting this lengthy procedure, then I’d be happy to say okay”, but suggests that, “the originators of this instrument have never demonstrated that you actually need such a long process; it is really more an article of faith with them” (Feinstein, 2010). Feinstein also highlights that at the International Meeting for Autism Research, researchers, “lambasted the tool (ADI-R) for missing many cases of autism”, and that “this instrument was an expensive and ineffective instrument”.
Hopefully in the future, people will follow the National Institute for Clinical Excellence and use the clinical diagnosis by an expert psychiatrist or psychologist as the “gold standard”, insofar as we can have any gold standard today before the formal development of biomarkers.
Insel T. (2015): A different way of thinking. New Scientist, 22nd August, page 5.
Feinstein A. (2010): A history of autism. Chichester: Wiley Blackwell.
Bowlby J. (1980): Attachment and Loss, Volume 2. London: The Tavistock Institute of Human Relations.
Owen M. O’Donovan M. (2017): Schizophrenia and the neurodevelopmental continuum: The evidence from genomics. World Psychiatry. 16: 3, 227-235.
Professor Michael Fitzgerald was First Professor of Clinical Psychiatry at Trinity College Dublin, Ireland.
Michael specialises in Autism, Asperger’s syndrome, ADHD and child behaviour problems, having worked in the autism field since 1973, with a particular interest in creativity and mental health issues.
He has written, co-written, edited and co-edited over 24 books on this specialist subjects and has many peer reviewed publications.