Child psychiatrist Hilgo Bruining: ‘Some children may need more freedom’

Hilgo Bruining (49) is a child psychiatrist, but he started 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 those children also becoming mentally exhausted and often having such a tired head that they could no longer study.” Conversely, he noted that children without congenital disease could experience the most horrible things – accidents, cancer – without mental breakdown. . “

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 disorders. Not by chance, 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 inadequate 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 in his home in Amsterdam-Noord, two days after his inaugural lecture. The table is filled with gifts, the packer brings several gifts during the conversation. Bruining says he learned from his father – a pediatrician specializing in pediatric diabetes – that medication is “a game of guard”. Be sharp and precise. To take nothing for granted. When he trained as a child psychiatrist at 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, banged their heads against the wall all day in a dark room or gifted children who actually functioned well except in social contact – everyone has autism spectrum disorders. What was the use of it? I also found it strange that the diagnosis decided what to do and prescribe, not the child’s individual problems and circumstances. “

Everyone on Ritalin.

“And if it worked, or seemed to work, the diagnosis was confirmed. At that time” – around 2005 – “we concentrated mainly on genetics in research, it thought we would solve the puzzle, and genetic mutations that actually interfere were found. the social development, but did your children have anything to do with the offer? It did not lead to new treatments.We noticed that the stimulus treatment was different in children with an autism spectrum disorder and I wondered if this could not be made more tangible and if one could examine this for each individual child. “

As long as you leave a child with autism alone, you say, there is not much to worry about.

“The problem lies mainly in the interaction with the surroundings, which is perceived as too intense and too complicated, sometimes even as frightening. It triggers something in the children that prevents them from learning or behaving socially. How did it happen?”

Children with severe developmental disabilities are insufficiently helped

The brain, Bruining says, is not “blank paper” filled with information from birth. The largest part of the brain, 95 percent, is occupied with spontaneous activity that controls the organs and enables mental functions: 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 must 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 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 it can go wrong?

“Everything can go wrong in the entire development, but it is essential to switch from construction to function. A crucial moment is shortly before birth, when a sharp and sharp drop 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 be created 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 disorders in the development of the brain can have the same effect: a child who learns to react less well to the environment. ”

And why are there other ailments 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 autistic problems had febrile seizures? neurologists do not see it 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 whole metabolism, which often also affects the brain. One 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 as a complex system that organizes itself in a balance between order and chaos. Nature is full of such systems – the weather, 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 stimulus balance. “What I see a lot in the doctor’s office: a child who is too tired to do anything. It gets easily irritated, there are concentration and sleep problems, far too much.”

If a child does not have other conditions, then does it not have autism or ADHD?

“In mild cases, that’s actually the question. I see them a lot, the children without language or speech delays or motor skills at a young age, without a strained family history, without other ailments. In that case, there is actually no reason to assume, You must then dare to tell the parents that stimulus sensitivity can also be a psychological phenomenon, part of the personality. A child can simply be a little more sensitive, more sensitive and therefore often more artistic. If it also has a little dyslexia and is in a competitive school, then it may have symptoms similar to those of autism or ADHD.If you want to treat that child, then you are doing it wrong in two ways.The treatment will not help and you neglect this child’s needs It can have a catastrophic effect. ”The stimulants” – Ritalin and similar drugs – side effects. Sometimes antipsychotics are added against the angry moods, neurochemically the counterpart to the stimuli, one mixes the brain completely together. You turn a psychiatric patient into a child who is not. ”

Can you objectively diagnose a developmental disorder such as autism or ADHD?

“Together with the youth care, we have set up N = Du Videncenter at Emma Børnehospital for the purpose. We do not take a diagnosis as our starting point, but examine how each individual child has developed and what the problems are in everyday life. We examine with an EEG, an electroencephalogram, whether these are associated with a disturbed stimulus treatment. If so, then the next question, of course, is what causes it. It may 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 severe disorders. “

You give children with stimulus-defective medication that act on the chloride concentration.

“Bumetanide, actually a water pill that lowers blood pressure and can also lower the chloride concentration in brain cells. These are subtle effects, but we see children for whom the world suddenly opens up. They could just be a little more careful. They have less angry moods. Or less intense. “

So the stimulus balance can still be adjusted after birth by mimicking that choride shift?

“Partly. The chance that it helps decreases with age. You can also use other means to improve the stimulus balance. I dare say that in some children an auxiliary dog ​​has an effect on the stimulus treatment. It is still kitchen table psychology, but I think: less stress for the child, a less tired brain. ”

Can postpartum stress cause a brain development disorder?

“I think so, biologically speaking. If you expose mice to violent 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 shutdowns† Do not waste energy on out-of-balance networks. ”

In your inaugural lecture, you said that children’s brains can be overloaded by games, social media, and pressure to perform.

“For many children it may not matter, for some children it may be good, for other children it is too difficult. My point is that all of these factors are now not included in the diagnosis. In the mild cases, there will certainly be overdiagnosis, but there also appears to be a real increase in autistiform stimulus treatment without severe allergies or epilepsy or other explanatory factors. And it would not surprise me if the world children grow up in plays a role in that. ”

Also?

“Then it often becomes child psychiatry. The child is unmanageable, the parents are desperate and the school demands that the child be given medication. I do not care about the blame, that’s how the system works. Schools must meet standards, children must adhere to them. What is the message of these children’s behaviors? You need to think about that. If they do not have a developmental delay, what will help? Does not give pills or diagnoses, but this is how it often goes. They suppress the unrest and then the conclusion is: you see, it’s ADHD after all. We do a lot of damage with that. ”

And what is the message about the behavior of those children?

“That certain children may need more physical and mental freedom. That one 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. ”

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