Hilgo Bruining (49) is a child psychiatrist, but he started out as a pediatrician and at the time it surprised him how little attention was paid to the brains of children with a congenital chronic disease. “For example, in children with cystic fibrosis,” he says, “everything was focused on limiting the damage to the lungs. Not much was done about the fact that those children also became mentally exhausted and often had such a tired head that they could no longer study.” Conversely, he noticed that children without congenital disease could experience the most terrible things—accidents, cancer—without mental breakdown. Bruining: “That brought me to the question of what resilience looks like neurobiologically and why one child can have more than another.”
He recently became a professor at the Amsterdam UMC, specializing in neurobiological developmental disorders – autism, ADHD – and in his speech at the acceptance of his chair he said that children with such a disorder almost always have other disorders. Epilepsy, migraine, allergies, inflammation, abdominal pain, metabolic diseases. No coincidence, he said. These disorders are related to each other, perhaps they have the same cause.
He also said that children with severe developmental disabilities receive insufficient support, while children with mild behavioral problems are often diagnosed too easily and treated too much. In the 1970s, 1 in 1,000 children was diagnosed with Autism Spectrum Disorder, now 1 in 50 to 100. The numbers are higher for ADHD.
We talk about it at his home in Amsterdam-Noord, two days after his inaugural lecture. The table is full of gifts, the parcel deliverer brings more gifts during the conversation. Bruining says he learned from his father – a pediatrician who specializes in pediatric diabetes – that medicine is “a game of watch”. Be sharp and precise. Taking nothing for granted. When he was training to be a child psychiatrist at the UMC Utrecht, he was surprised that children with behavioral and learning problems were all so different and yet received the same diagnosis. “Whether it was gifted children who, due to their hypersensitivity to stimuli, were banging their heads against the wall all day long in a dark room or gifted children who actually functioned well except in social contact – all have autism spectrum disorder. What was the use of that? I also found it strange that the diagnosis determined what to do and prescribe, not the individual problems and circumstances of the child.”
All on the Ritalin.
“And if it worked, or seemed to work, the diagnosis was confirmed. At that time” – around 2005 – “we mainly focused on genetics in the research, we thought that would solve the puzzle, and indeed genetic mutations were found that disrupt social development, but did your children have something to do with that? offer? It did not lead to new treatments. We noticed that the stimulus processing was different in children with an autism spectrum disorder and I wondered whether this could not be made more tangible and whether you could investigate this for each child.”
As long as you leave a child with autism alone, you say, there is little to worry about.
“The problem lies mainly in the interaction with the environment, which is experienced as too intense and too complicated, sometimes even as frightening. It triggers something in those kids that prevents them from learning or behaving socially. How did that happen?”
Children with severe developmental disabilities are insufficiently helped
The brain, Bruining says, is not “blank paper” that is filled with information from birth. The largest part of the brain, 95 percent, is occupied by spontaneous activity that directs the organs and makes mental functions possible: thinking and doing, the emotional experience. Before birth, the structure of that entire system is constructed—100 billion neurons, each in contact with tens of thousands of other neurons—and after birth it has to begin to interact with the environment. “From that moment on,” says Bruining, “the neurons must also be able to inhibit. If the brain were to let all the stimuli through, it would be chaos. The stimulus balance must be installed around birth, so that the right amount of information can flow to the right place in the brain at the right time.”
And that’s where things can go wrong?
“Anything can go wrong in the entire development, but that switch from construction to functioning is essential. A defining moment is shortly before birth, when a strong and abrupt decrease in the concentration of chloride in the neurons occurs and inhibition becomes possible. The oxytocin released during delivery also lowers the chloride. This chloride shift is characteristic of most animal species. It is one of the best-proven concepts in neurobiology and it teaches us that this stimulus balance must also arise at the right time, so that a child is able to learn to process stimuli after birth.”
Why could that shift fail?
“Genetic predisposition, premature birth, smoking, alcohol, chronic maternal stress, trauma – it all seems to be the cause of a brain that does not inhibit enough. So you see that different types of disturbances in the development of the brain can have the same effect: a child that learns to respond less well to the environment.”
And why are there other disorders as well?
“Yes, how come. What is nature trying to tell us if developmental disorders in the brain are almost always associated with it? Why is there such a clear overlap between autism and epilepsy? And why have so many children with autistiform problems had a febrile seizure? Neurologists don’t see it that way yet, but I think it must be related. And then the metabolic disorders. In children with such a disorder, a genetic abnormality can disrupt the entire metabolism, often affecting the brain as well. You can reason with all these disorders that the balance in the body is disturbed and the effect of this can be seen everywhere.”
Children with mild behavioral problems are often diagnosed too easily and treated too much
Following the example of the Danish theoretical physicist Per Bak and the Amsterdam neurophysicist Klaus Linkenkaer-Hansen, Hilgo Bruining considers the brain a complex system that organizes itself in a balance between order and chaos. Nature is full of such systems – the weather, flocks of starlings, genetics, oceans – and Per Bak proved in 1987 that they are governed by universal laws. And they all have their own mechanisms for keeping the balance. “Brain activity,” says Bruining, “takes a lot of energy, 20 to 30 percent of what is available, at rest, and when illness or stress or a busy environment places more demands on the brain and requires more energy , this can be at the expense of the stimulus balance. What I see a lot in the doctor’s office: a child who is too tired to do anything. It is easily irritated, there are concentration and sleeping problems, everything is too much.”
If a child has no other conditions, does he not have autism or ADHD?
“In mild cases, that is indeed the question. I see them a lot, the children without delays in language or speech or motor skills at a young age, without a burdened family history, without other disorders. There is actually no reason to assume that there is a developmental disorder. You must then dare to say to parents that stimulus sensitivity can also be a psychological phenomenon, part of the personality. A child can simply be a bit more sensitive, more touchy, and therefore often more artistic. If it also has some dyslexia and is in a competitive school, then it may have symptoms similar to those of autism or ADHD. If you’re going to treat that kid then you’re doing it wrong in two ways. The treatment is not going to help and you are neglecting this child’s needs. That can have a disastrous effect. The stimulants” – Ritalin and similar drugs – “do not work, and strangely enough, even more stimulants, or other types, are given, and in those cases often lead to serious side effects. Sometimes antipsychotics are added against the angry moods, neurochemically the counterpart of the stimulants, you completely mix up the brain. You make a psychiatric patient of a child who is not.”
Can you objectively diagnose a developmental disorder such as autism or ADHD?
“We have set up the N=You Knowledge Center at Emma Children’s Hospital for this purpose, together with youth care. We do not start from a diagnosis, but investigate how each child has developed and what the problems are in daily life. We investigate with an EEG, an electroencephalogram, whether these are associated with a disturbed stimulus processing. If so, then the next question is, of course, what causes that. It could be in the metabolism or there is a genetic mutation of the signal transmission in the brain. We see the latter in about 30 percent of children with serious disorders.”
You give children with a stimulus defect medicines that work on the chloride concentration.
“Bumetanide, actually a water pill that lowers blood pressure and can also lower the chloride concentration in brain cells. They are subtle effects, but we see children for whom the world suddenly opens. They could just be a little more careful. They have less angry moods. Or less intense.”
So the stimulus balance can still be set after birth by imitating that choride shift?
“Partially. The chance of it helping decreases with age. You can also use other means to improve the stimulus balance. I dare to say that in some children an assistance dog has an effect on the stimulus processing. It is still kitchen table psychology, but I think: less stress for the child, a less tired brain.”
Can stress after birth cause a brain development disorder?
“I think so, biologically speaking. If you expose mice to severe stress, you will see disturbances in the stimulus balance. The brain has relatively few ways to respond. Usually it is: something is not going well here, I need certain areas downshutten† Don’t waste energy on networks that are out of balance.”
In your inaugural lecture you said that children’s brains may be overloaded by gaming, social media and pressure to perform.
“For many children that may not matter, for some children it may be good, for other children it is too taxing. My point is that all these factors are now not included in the diagnosis. In the mild cases there will certainly be overdiagnosis, but there also seems to be a real increase in autistiform stimulus processing without severe allergies or epilepsy or other explanatory factors. And it wouldn’t surprise me if the world children grow up in plays a role in that.”
And then?
“Then it often becomes child psychiatry. The child is unmanageable, parents are distraught and the school demands that the child be given medication. I don’t care about blame, that’s how the system works. Schools have to meet standards, children have to go along with them. What is the message of the behavior of those children? You have to think about that. If they don’t have a developmental disability, what will help? Not giving pills or diagnoses, but that’s how it often goes. They suppress the unrest and then the conclusion is: you see, it is ADHD after all. We do a lot of damage with that.”
And what is the message of those children’s behavior?
“That certain children may need more physical and mental freedom. That you should move more with their temperament and not put them in a rigid education system. And if the behavior stems from pedagogical neglect, then you have to do something about it.”