Does Childhood Matter?

It sure felt like it.

News Update 1: Cyclone Alfred hovered off the coast of Brisbane for several days and crossed on Saturday night, tearing off rooves and toppling trees over power lines. A quarter million people will have no power for days. We’re in the foothills, about 40km from the coast, so the winds here weren’t as strong, no trees down in our area, and we’re on solar power so we had it pretty easy. Yesterday, Sunday, we had 360mm of rain (26.5”) in 24hrs, except it was probably more as the rain gauge overflowed. The nearby paddocks along the flats look like rivers. It could always be worse, and it will be worse. Since the current crop of politicians have decided to bequeath to our grandchildren a rapidly warming globe, cyclones will be more frequent, more intense and reach further from the equator. Just thought I’d throw that in.

News Update 2: The news from Texas is that two people have died in a measles outbreak. These are the first deaths from measles in the US in ten years (population about 325million). Both victims were unimmunised. A 6yo child came from the county with the lowest rate of immunisation in the country, and many other cases have been reported from the region. This video has all the figures and info (despite the renowned Prof. Peter Hotez’s bad hair day). The new secretary of health, Mr RF Kennedy Jr, who is implacably opposed to mass immunisation, said the department is providing Vitamin A and ambulance rides to anybody who wants them. The adult who died had made the decision not to be immunised. The child who died didn’t have any say in it.

Albert Einstein reputedly said: “The difference between stupidity and intelligence is that intelligence has limits.”

*****

Talking of stupidity, I am still struggling to digest the claim by a well-known professor that failed biological models of mental disorder are still models, so I mustn’t say there are no biomedical models of mental disorder. You could say that this is just another academic cat fight (except I’m not an academic, as they are quick to point out) but it has real world consequences. If it’s true that mental disorder is “just” biological, and can be fully investigated and understood by the normal techniques of laboratory biosciences, then there’s no point in getting hot and bothered over childhood abuse and neglect, poverty, wars, and so on. So is it true? From the psychiatric point of view, does childhood matter? In answering that question, there are several themes, theoretical and practical, that need to be pursued, even though most haven’t been.

Starting with the theoretical ideas to be examined, there are two distinct approaches, the psychological and the biological, each of which could be true or false. We end up with four separate lines of enquiry: Biological – true or false; Psychological – true or false. Those who want to argue that mental disorder is a biological thing, as did the former director of the US NIMH, Dr Thomas Insel [1], must show a direct connection between biology and mental life. However, they must also show that a psychological cause for mental disorder is impossible, which seems absurd – and it is. On the other hand, people who want to show mental disorder is psychological must provide a formal model of the mind and show how it can go wrong. They should also show why it’s not biology but that flows from the model of mind, so it’s an easier task.

For the category of biology, and Dr Insel notwithstanding, it is the case that no psychiatrist, no psychologist, no neuroscientist nor even a scatty philosopher has ever shown any pathway by which the mind can be understood as a pure brain function. This is their first step. When it’s put that way, it doesn’t even make sense. It’s like the fabled Mr Buckley, a resident of Sydney in the 1860s or so. According to legend, he decided he was going to walk to China from Sydney. He found financial backers and set about buying horse and cart, provisions and so on, and suitably-equipped for his journey, he set off. All he lacked was an atlas. He had all the physical paraphernalia for a successful expedition, but he didn’t have a mental plan on how to reach his goal. Of course, he was never seen again but he lives on in the expression: “You’ve got Buckley’s chance, mate,” meaning: “Your plan can’t possibly succeed.” First rule of any scientific project: before you invest a penny, make sure you have a plan or map, better known as a model, to test your idea. If you don’t have a plan or map or model, then regardless of what you think you’re doing, where you’re doing it or with what, it ain’t science. End of discussion.

Second category: can we make a case that mental disorder is a psychological phenomenon? That is, could mental disorder have a mental cause in the presence of a healthy brain? In the biological approach, bad mental events are always and only caused by bad brain events (“chemical imbalance”) but the psychological model says only that the cause of any mental event is a prior mental event, as in:

“I look at the clock and think about eating so I decide to walk to the kitchen.”

“I suffer grief because I believe I have lost something important.”

“I feel anxious today because I believe something bad will happen tomorrow.”

“I can’t watch the news these days, I get so angry at all the stupid people.”

In each case, Mental Event A directly causes Mental Event B, in the strict sense of causation. To make sense of this, I need a formal theory of mind. To account for mental disorder, I need a model of mind that shows how, within a healthy brain, mental functions can malfunction as pure mental events. Preferably, the theory of mind should show how mind and body interact but it’s not essential. All this is now available, including mind-body interaction [2].

Next, we look at the practicality of the chosen pathway. Fact: biological psychiatry has totally dominated the research agenda for at least 75 years. Dr Insel said that in his 13 years as director of NIMH (2002-15), he disbursed some US$20billion for basic biological research. It’s probably another $20billion since then, giving a world total since 1950 of something like $100billion in today’s money. Surprisingly, he admitted it hadn’t done a damned thing for all the people labouring under the burden of mental disorder [3]. It hadn’t produced any remotely convincing results, and it hadn’t improved their lives one iota. I say surprisingly because one of the hallmarks of biological psychiatrists is an eternal optimism that one fine day, the key to mental disorder will fall out of a test tube and humanity will enter a new golden age (unspoken: and the researchers will become rich beyond the fever dreams of Musk).

So the worthy Dr Insel, who got his start in psychiatry by studying rodents, has learned the hard way the same lesson as Mr Buckley’s eager financial backers: if you’re going to shell out money on an idea, just check the details first, otherwise you’ll probably meet the same sticky end as old Buckley (probably as lunch on his first day for the excitable bull sharks of the Hawkesbury River, just north of Sydney). Before he gave them a penny, Insel should have asked his eager supplicants, sorry, distinguished academic researchers, to provide a formal reductionist model of mental disorder. That way he could have saved a lot of money and time. So far, biological psychiatry’s score is pretty dismal: no theory or model, and no evidence.

When it comes to evidence for the psychological causation of mental disorder, we’re on much stronger ground. Even though mainstream psychiatry doesn’t have anything like an integrative model of mind and body, and even though proving that one psychological event causes another is fiendishly difficult, and despite all the prejudice and fairy stories, there is a growing body of evidence that adverse events can lead to mental disorder. As an example of prejudice, look no further than the military. Until just recently, it was firmly believed that war would make a man of you – if it didn’t kill you, of course. Even into the 1970s, generals and politicians believed that soldiers who broke down during war had pre-existing “weak characters,” and their terrible experiences only exposed what was already there. This is plain nonsense but it was gospel among those who had never had any trouble in their lives. Fortunately, that’s now gone, replaced by the idea that psychologically-traumatic events can produce severe, long-term mental disorders in previously well-adjusted personalities. Those of us who have studied individuals very closely, which is much more difficult than it sounds, have never had the slightest doubt that adverse life experiences, both as children and as adults, can produce severe, lasting mental disorder with all its complications. All that is lacking is a causative model.

As for evidence, in all fields of science, there are two approaches: you can either study lots of cases superficially, or study a few in depth. In psychiatry, we have distant, epidemiological studies, usually based in registers, which get all the research money and close, individual studies, which get none. Epidemiologists are slowly starting to show that the relationship between adverse childhood experiences (known to cognoscenti as ACE) such as childhood abuse and neglect (CAN) is causative and not coincidental. The problem is that psychiatrists who believe the biological thing won’t read individual studies, but three recent papers provide the sort of evidence that can’t easily be dismissed.

The first, from Sweden in 2017 [4], asked how children who had been placed in out of home care (OHC) fared in the long term. Swedish welfare services keep very detailed registers, plus they have a homogeneous population who don’t move around a lot, plus sophisticated epidemiologists with lots of computers, so extracting these sorts of figures isn’t difficult for them. They started with all people born in Stockholm in 1953, of whom a surprising 9% had experience of OHC. By mid-life, they were not doing as well as children who had been raised by their parents throughout. The 7% who were placed due to their parents’ problems were struggling:

… cohort members with the experience of OHC had substantially lower educational attainment as well as more experiences of means-tested social assistance recipiency, unemployment, and mental health problems in midlife, compared to their same-aged peers.

Although this says nothing about what happened to the children, it’s clear that a troubled start in life has repercussions that echo down through the years, very often for life. The trouble is that the input statistics are crude. Some children are hugely relieved to be offered another home while some children, removed from hopeless parents, are desperate to go back, even if to “rescue” one or both of them. Others are more frightened of failing in a new, pleasant environment than they are of enduring a bad but familiar home. This is the sort of detail that can only be gained from a study in depth of small numbers of subjects. Registry studies are too “coarse-grained” to yield precise information.

Next, a psychological survey from 2024 studied childhood maltreatment, defined as “physical, sexual, or emotional abuse; emotional or physical neglect; and domestic violence before the age of 18 years” [6, pE2]. They briefly reviewed the literature, which finds maltreatment accounts for up to 30% of adult mental disorder. Their own study concluded: “childhood maltreatment accounts for 21% to 41% of common mental health conditions in Australia …” On a population basis (not individual), their figures were: suicide bids: 41%; self-harm 39%; drugs 32%; alcohol abuse 27%; depression 24% and anxiety 21%. Because these disorders start young, the burden if disability is very high.

Finally, a project based in the long-term NSW Child Development Study [6], which has over 90,000 cases, looked at the cumulative incidence of mental disorders in children who had come to the attention of Child Protective Services before age ten. The authors began by noting that various surveys “…show an approximate 50% increase in mental disorders among young people over the past two decades.” This is despite funding increases of about 3.5% per annum, meaning outcomes are going south as the costs head north. As a registry study, they couldn’t look at the cause of the referrals, only at the outcomes, which ranged from “no action,” to “at risk,” to “exposed to risk,” and finally to those placed in care out of home.

They reached two conclusions. First, the worse the outcome, the greater the risk of getting a psychiatric diagnosis. This is predictable: mental disorder is “dose-related” to adverse experiences, meaning the more crap the child cops in life, the worse life will be. Repeated adverse experiences will generally cause earlier onset of worse mental disorders than a single episode. For all children known to CPS before ten, the risk of later mental disorder is about 20%. However, children who had to be removed from their parents showed up to ten times greater incidence of major mental disorder than the others in the study, and they were already worse off than children who were never referred.

Second, the longer they were followed, the more likely they were to develop mental disorders. That is, they don’t all develop problems only at the time of the abuse. Some do but, for many others, it takes time to show. Just because a child is coping fairly well at 14 doesn’t mean they’re out of the woods. The wheels can still fall off, especially if something else goes wrong, even something that wouldn’t worry a normal child. Early damage sits there, quietly festering away in the darkness until one day, it bursts out.

These authors also felt that the information in the departmental files was coarse and probably underestimated the actual effects of childhood adverse experiences. They closed with the polite recommendation that child protection services need to be “at the forefront of mental illness prevention.” Oh dear, that won’t do at all. We can’t divert money away from drugs, ECT, TCMS, hospitals and security wards just to go and talk to children, can we? The point surely is that even if expenditure on child and adolescent mental health services is going up by 3.6% per year, it’s not going to the right place. It’s going to the same black hole into which Insel poured his department’s $20billion and it vanished without a trace. It’s not enough to say we have lots of nurses chasing children at schools to give them their drugs, what we need is people talking to them to find out what’s going wrong. And that’s not easy.

This is where the in-depth studies come into their own. It’s normal to ask adults: “What do you think caused your mental disorder?” Now this doesn’t mean some brisk, brusque chick with a clipboard handing out questionnaires with “7 questions on anxiety” to a roomful of people and then telling them to fill in why they think they’re mental. That doesn’t work. Most men and plenty of women don’t want to talk about their unhappy childhoods. Even though they know that’s where the problem started, they want to gloss over it, as in this case:

Mr AB had been involved in mental health services for the 25 years since he turned 18. He was diagnosed “schizoaffective” and had been detained a number of times over the years, with a long list of drugs in various doses. He had been unable to work for years and his marriage was barely holding together. When first seen, he was hostile to seeing “yet another f..g useless shrink.” When told I intended to take his history, he became angry, shouting that it was all in the f..g file if I knew how to read. He was told I hadn’t read his file and didn’t intend to. I wanted him to tell his story as I didn’t trust the file. Startled, he sat back and began answering the long list of questions, except those regarding his early life: “It was shit,” he snorted. “You don’t wanna know about it.” After reassessment, he agreed to a slow reduction in his drugs (large doses of lithium, quetiapine, valproate and several others), adding that the only thing they had done for him was to gain 50kg and wreck his sex life. Review of his files later showed no detail at all on his early life.

After about six weeks, his childhood again came up. This time, very slowly and in obvious distress, he revealed that life on their small farmlet on a dead-end road on the outskirts of the city had been appalling. All four children had been subject to grotesque physical, sexual and emotional abuse by both parents. Barely able to speak, he recounted that at about 13, he had become increasingly angry about being involved and one day started punching his mother. His father came in with a loaded rifle, pointed at him and threatened to shoot him. At 16, after a particularly sickening incident, he ran away and never saw them again. He was a very capable worker but gradually his life fell apart. At 18, he was detained in a mental hospital after a brawl with police and embarked on his career as a “nut case.”

Following this catharsis, he started to make good progress. Over a number of years, he was able to discontinue the drugs, lost a great deal of weight and returned to the workforce.

During the first interview, I had asked him the standard question of whether welfare were ever involved with his family. Of course, they were not, they never are. Yes, in those days in rural areas, the services weren’t very good. Yes, the parents would have lied to the welfare officers and no, welfare wouldn’t have pushed the issue. Schools didn’t have welfare workers so it probably wasn’t going to be otherwise for those children – but it isn’t much better now. Some years ago, I became concerned about a heavy-drinking woman with three girls under 12 who had moved in with a man I knew to be a heavy user of drugs and porn. At her visits, the mother let slip that she knew about his “porn addiction” but she felt she could trust him to look after the girls when she went to work at night. After another visit, I rang child welfare to notify them that I had concerns (we have mandatory notification here). A few weeks later, they emailed to say they had rung the mother three times but she didn’t pick up her phone so they had closed the case.

The mental health dollar for child and adolescent services is spent on drugs, case conferences, welfare hearings, psychometry, impersonal hospitals, brain scans, and so on. The research money and the academic interest goes on huge surveys of vastly complex government data bases, more conferences, drug research, transcranial direct current brain stimulation and the like, when what is really needed is readily-accessible staff on the ground whom sufferers can trust, because trust is what separates humans from robots.

The problem becomes self-reinforcing. Psychiatrists who believe mental disorder is biological don’t put any effort into probing the patient’s early life experiences, so they don’t get the crucial information. Needless to say, patients don’t feel they can trust them so they volunteer nothing. The psychiatrist prescribes drugs but when the patient doesn’t get any better, or gets worse, as Mr AB did, the psychiatrist doesn’t ask: “Is there something I’m missing about this case? Some vital clue I’ve missed?” because they don’t believe there are vital clues. And they never say, “Seems I’m not helping you, perhaps you’d better see somebody else.”

If perchance the psychiatrist has read some of the papers above and accepts that adverse life events can produce mental disorder, it’s still seen as “biological.” Somehow, they have no idea how, life events trigger changes in brain chemistry that can only be rectified by drugs. When that doesn’t work, they don’t question themselves, because their “biomedical model” (the one they haven’t written) can’t be wrong, so they simply pile on the drugs. And the patient’s life gets worse, and worse. Thus, the incidence of mental disorder in the community goes up and up, the total expenditure goes up and up, and the outcomes get worse and worse. As Kingsley Amis said, “More means worse.” All for lack of a model of mental disorder.

Will biological psychiatry ever work? “You’ve got Buckley’s chance, mate.”

*****

References;

1. Insel TR, Cuthbert BN, Garvey M, et al (2010). Research Domain Criteria (RDoC): toward a new classification framework for research on mental disorders. Commentary. American Journal of Psychiatry, 167: 748-751.

2. McLaren N (2021): Natural Dualism and Mental Disorder: The biocognitive model for psychiatry. London, Routledge. Amazon.

3. Rogers A (2017). Star Neuroscientist Tom Insel Leaves the Google-Spawned Verily for ... a Startup? Wired Science May 11 2017.

4. Brännström L et al (2017). Children Placed In Out-of-Home Care as Midlife Adults: Are They Still Disadvantaged or Have They Caught Up With Their Peers? Child Maltreatment 22(3) 205-214 DOI: 10.1177/1077559517701855

5. Grummit L et al (2024). Burden of Mental Disorders and Suicide Attributable to Childhood Maltreatment JAMA Psychiatry. doi:10.1001/jamapsychiatry.2024.0804

6. Green M et al (2025). Cumulative incidence of adolescent mental disorders following childhood maltreatment: An Australian longitudinal population cohort study. Australian & New Zealand Journal of Psychiatry 59(3) 197–201. DOI: 10.1177/00048674241307150

*****

The whole of this material is copyright but can be quoted or retransmitted provided the author is acknowledged.