Maybe it is just me. It probably is. It seems I must have taken a wrong turn in practicing psychiatry somewhere along the line.
Dr. Carl C. Bell
For whatever reason, I never truly saw and appreciated the seamlessness between the psychiatric problems children, adults, and the elderly have plaguing them. Of course, I always marveled at how a child who had honest-to-goodness autism could become a full-grown adult and have an adult psychiatrist diagnose that individual as having schizophrenia; why not an adult with autism? But that was the extent of my understanding of the seamlessness between childhood and adult diagnoses. Maybe it is because I was poorly trained and never bothered to get a childhood developmental from my adult psychiatric patients. When I would present a case to supervisors as an adult psychiatric resident, I recall never presenting a child developmental history as a part of the patient’s trajectory. It was as though since there was adult psychiatry and child psychiatry, then the disorders of adults and children should be separated as well.
I know many adult psychiatrists never ask their adult patients, “How old were you when you graduated high school?” although an answer of “I never graduated,” or I graduated at 19-20” should raise questions. When I was in community psychiatry residency, I had some training at the Institute for Juvenile Research (birthplace of child psychiatry), so I understood something about children and the problems they had. Of course, back then, child psychiatric diagnoses were not that good, but with the advent of the DSM-5, children’s psychiatric diagnoses became more precise. This was probably because of research and better epidemiologic data about the prevalence of the six major neurodevelopmental disorders (intellectual disability, attention-deficit/hyperactivity disorder, speech and language disorders, autism spectrum disorders, specific learning disorders, and motor disorders). Maybe I am too old to remember, but I don’t remember anyone with a serious focus on what happens to psychiatrically ill children when they grow up to be adults or what psychiatric problems adult psychiatric patients had when they were children.
In a brilliant article in the September issue of the American Journal of Psychiatry, Avshalom Caspi, PhD, and Terrie E. Moffitt, PhD, propose that there is a single dimension of psychopathology, or “p.”
The authors perceptively remind us that we characterize children’s psychopathology as internalizing and externalizing disorders (with a slight nod to psychotic disorders in children), but these features do not seem prominent or ubiquitous in adult psychiatry’s thinking about adult psychiatric patients. They do a great job at pointing out there is ample evidence of a great deal of comorbidity between “discrete” children’s and adults’ psychiatric disorders. We certainly learned this from the findings of the DSM-5’s Personality and Personality Disorders Work Group.
Their p suggests a common thread between various childhood psychiatric disorders and adult psychiatric disorders. Furthermore, Dr. Caspi’s and Dr. Moffitt’s assertion that longitudinal research identifying “poor childhood self-control” (a symptom of affect dysregulation) and poor executive functioning as a salient early developmental predictor of their p sounds a lot like fetal alcohol exposure to me (Fetal Alcohol Exposure Among African Americans). So does their declaration that individuals with higher levels of p have difficulty with attention, concentration, mental control, and visual-motor problems.
Maybe I have confirmational bias, as I have seen the common thread of fetal alcohol exposure run from childhood to adults, but many of my residents and students see it as well.
Accordingly, I think we have made mistakes in psychiatry when we ask (if we ask) the mother of our patients was she drinking when she was pregnant, and “Was the patient born low-birth weight and/or premature?” We should be asking – “When did you realize you were pregnant?” “Were you doing any social drinking before you knew you were pregnant?” Thus, we miss the common thread of fetal alcohol exposure in child and adult psychopathology.
I realize that a great many competing interests are trying to get our time and attention, and there is a lot to read and figure out. In our efforts to do no harm, do psychiatrists try to take their time to fully understand things before we act? Some aspects of our understanding seem to be “no brainers,” and the continuation of child neurodevelopmental disorders morphing into adult mental disorders should be obvious. But maybe we took a wrong turn – which is why it took me 45 years to figure out that fetal alcohol exposure in utero has a significant impact on adult psychiatric disorders.
Dr. Bell is staff psychiatrist at Jackson Park Hospital’s surgical-medical/psychiatric inpatient unit; clinical professor emeritus, department of psychiatry, University of Illinois at Chicago; former director of the Institute for Juvenile Research; and former president/CEO of the Community Mental Health Council, all in Chicago. He also serves as chair of psychiatry at Windsor University, St. Kitts.