Christel Middeldorp (50) has a twelve-year-old son who loves Harry Potter, so in her inaugural speech recently – she has been appointed professor of family psychiatry at Amsterdam UMC – she took the early years of Harry Potter and Tom Riddle, alias Lord Voldemort, as example to explain what her research is about. That's how, she said, she lured her son to the university auditorium. His mother in a toga, like the teachers of Hogwarts School of Witchcraft and Wizardry, also nice.
Why many children who are neglected or abused develop a mental disorder, but not all children – that is what interests Christel Middeldorp. She believes that her profession should pay more attention to children who end up well despite their traumas, and why that happens. In her inaugural lecture she mentioned the emotionally extremely neglected children in Romanian orphanages under the dictator Ceausescu. After his demise, at the end of 1989, a number of them were adopted by English families who gave them as much love as possible. In adulthood, 80 percent appeared to have psychological complaints. But not 20 percent.
Harry Potter had a rocky childhood. He grew up with his aunt, who treated him like a Cinderella. Sleeping in a cupboard under the stairs while his cousin was spoiled, that job. At Hogwarts, where he goes when he is eleven, he finds out that his parents did not die in an accident, as he had always been told, but were murdered by Voldemort. Harry's mother had been able to save her son, a baby, just before her death. And Tom Riddle slash Voldemort? Also a bad boy. His mother, a nasty and evil woman, died an hour after his birth. His father had already disappeared by then. Tom Riddle grew up in an orphanage, where he became an annoying and aggressive boy. “Two children with similar traumas,” says Christel Middeldorp a few weeks after her inaugural lecture in a Hilversum lunchroom, not far from her home. “Yet one develops into a psychopath and the other into a hero.”
You used them as an example to emphasize the influence of genes.
“Yes, because it is too easy to say that someone became a psychopath because of his bad childhood. That is more nuanced. You are never solely defined by the circumstances you are exposed to in your life. It's also the genes. The interplay of genes and environment determines your vulnerability to psychological complaints. It is both and. In the consultation room I like to use the model of a jug. You start life with a genetic predisposition that makes your risk for a certain outcome high or low. If the can is already quite full when you are born, then a single adverse event is sometimes enough to push you over the limit. And vice versa. If the jug is almost empty, a lot of bad things have to happen before you develop a mental illness.”
The share of genes in one condition is greater than in the other.
“For anxiety and depression it is the lowest, 40 percent. For behavioral problems and ADHD, the heritability is estimated at 80 percent. This does not mean that a child of a parent with ADHD will also develop ADHD in 80 percent of cases. It's about opportunities. That 80 percent only says something about the explanation of differences between people.”
Your genetic predisposition, you say, is not only related to the environment in which you grow up, but also influences it.
“Look at children with behavioral problems or ADHD. They receive more negative reactions than children who usually do what they are asked. Anxious children are more likely to have parents who are protective. Then you may think: this protective attitude creates anxious children. But anxious children also evoke this protective attitude themselves. So yes, if you have a genetic predisposition to psychological complaints, you have a greater chance of an environment that is unfavorable for your development. Misery is related to misery.”
That is why you should also look at the parents of a child with psychological complaints?
“You must be aware in the consultation room that psychological complaints are the result of many factors, whereby cause and effect are often no longer distinguishable. So yes, if a child has complaints, also look at the family. And if an adult has psychological complaints, also look at the children. It seems obvious, but in practice it hardly happens.”
In your inaugural lecture you talked about the connection between depression in the mother during pregnancy and psychological complaints in the child later.
“This connection has often been demonstrated, but a large study in the general population in Norway has shown that the complaints in the child do not arise because the effect of the mother's depression during pregnancy lags for so long. If you look at all family factors, depressive complaints in the child later appear to only be directly related to depression in the mother at that time. And even then, most of the depression in the child is explained by genetic predisposition.”
What does that mean for the treatment?
“The mother's depression later is of course related to the depression during her pregnancy. If treatment of that depression prevents the mother from becoming depressed again later, you prevent the risk of depression in the child. Although you can never completely eliminate this, given the genetic makeup of the child. The same goes for child abuse. The psychological complaints in children are only partly caused by the child abuse itself. Here too there is a connection with the child's genetic predisposition to psychological complaints, and probably also with other unfavorable environmental factors, such as poverty. Tom Riddle has neither his genes nor his environment. He ends up as a psychopath. He could also have become depressed, but apparently externalizing is more in keeping with his gene package.”
And Harry Potter?
“He does have his genetic package. And at Hogwarts he is the headmaster's favorite, while Tom Riddle is viewed with suspicion from the start. Just as negativity begets negativity, positivity begets positivity.”
You advocate taking DNA samples from every child who is examined.
“The more data you have, the better you can predict what the course will be. Are the complaints one-off? Are they going to repeat themselves? You also need to map the environment, DNA alone will never be enough. But with this you can identify the group with the highest risk profile and offer better treatment.”
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