Does antidepressant use during pregnancy cause autism, as a recently published study suggests? Using Family Systems Theory to answer this question will lead to a more nuanced answer than a traditional cause and effect conceptualization.
What is Autism?
A study authored by Anick Bérard, Ph.D. and others linking autism and antidepressant use during pregnancy was published this week in the Journal of the American Medical Association. (Bérard, A. 2015). Autism is a condition diagnosed in childhood and characterized by a spectrum of social, communication and behavioral deficits. (“Autism Spectrum”, 2015) The term autism was first used in the context of mental health in 1911 (“WebMD”) and first applied to children in the 1940s. (“A History”) It wasn’t until the 1980’s, however, that most lay people had heard of autism in children. Since that time, interest in autism has increased. A milder form of the condition, Asperger syndrome, also became a formal diagnosis in the 1990s.
There is a debate whether autism rates have been rising in recent years, or if the increase in diagnoses is attributable to improved rates of detection or other factors. Whichever the case, concern about this development syndrome is widespread. There is much public speculation about the causes of autism and Asperger syndrome.
What Causes Autism?
Autism is a constellation of symptoms that appears to have many potential causes, some known but most still poorly understood. Postulated causes of autism and autism spectrum disorders include: environmental toxins, genetics, disruptions in brain growth, premature birth, and infection. In 1988, physician Andrew Wakefield published a study linking childhood vaccinations with autism. In the years since it has been proven that Wakefield was paid by a law firm that wanted to sue the manufacturers of the vaccines, and that he falsified his data. Despite this, public opinion has been influenced by his findings. This has led to lowered vaccination rates and increases in childhood diseases like measles in the years since the publication of his discredited study. (Cohen, E., & Falco, M. 2011)
The current JAMA study is generating numerous definitive-sounding headlines intimating or stating outright that antidepressant use by women during pregnancy causes autism in children. There are, however, a smaller number of publications that question the significant of the study findings, the research methodology employed, and the motives of the study’s senior author, Anick Bérard, Ph.D.
Cause and Effect Thinking Versus Systems Thinking
A study making a claim that autism can be caused by antidepressant use in pregnancy is an example of cause and effect thinking.In cause and effect thinking, A causes B:
Leo spends all his time at work because his wife, Shawna, is needy and demanding.
Contrary to a cause and effect model, a systems theory view of Leo and Shawna’s relationship dynamic is more complex (Bowen, M. 1978):
Historically, Shawna had a very close relationship with her mother, who lived down the street from her and Leo. Since her mother’s death last year, Shawna has demanded more of Leo’s time. As a child and teen, Leo had maintained a fairly distant relationship with his mother, whom he perceived as emotional and clingy. Since his mother in law’s death, Leo is uncomfortable with Shawna’s heightened emotionality. He has begun to feel like he did around his mother, and he has found himself spending more time at his office. The more he works, the more upset Shawna becomes. The more needy and demanding she is, the more time Leo spends at work. It’s a vicious cycle.
Likewise, looking at the relationship between maternal depression, antidepressant use and childhood autism becomes more complicated when viewed through the lens of systems theory.
The connection between maternal depression and antidepressants as seen through a family systems theory lens would highlight the interplay between mother, infant, and other family members. All involved family members, including the extended family and the families of origin of both parents, would be included in the assessment. Environmental factors, nutrition, other illnesses and pathogens would all be considered as possible contributors to both maternal depression and childhood autism, which would then feed back into the system in a reciprocal fashion.
Autism is characterized by a range of possible deficits and varies greatly from patient to patient. Rather than attributing such a complicated disorder to one causal agent like antidepressant use during pregnancy, systems theory would more likely conceptualize autism as the result of a “perfect storm” of emotional, physical, environmental, familial, and societal factors. Even in conditions that are clearly caused by one identifiable agent, cause and effect thinking is not as useful as a systemic perspective. For example, exposure to the chicken pox virus may cause chicken pox (in some people-not everyone who is exposed will catch the virus), but the course of the illness varies from person to person. The severity of the chicken pox will be affected by many factors; age of onset, the health and nutrition of the person who catches the virus, the family vulnerability to chicken pox, the level of chronic anxiety in the family at the time of the infection, access to treatment, how caregivers and the patient think and feel about the illness, plus many other, unknown factors.
Anxiety About Autism
The perceived increase in the prevalence of autism and autism spectrum disorders, in combination with a lack of definitive knowledge about its cause(s) and how best to treat it have led to a high level of societal anxiety about the condition.The interplay between the media, unscrupulous “scientists”, and a frightened public has become a dysfunctional system of its own.
Questions to Consider When Evaluating a Study:
Using a systems theory lens to evaluate a study like this current one in JAMA will lead the reader to consider the following questions:
1. Who has conducted the study? Where are the authors getting their funding? Is there a potential conflict of interest?
2. Have other similar studies come to the same conclusions? Has this study been reproduced and validated by other studies?
3. What is meant, numerically, by claims like; increased risk, double the risk, etc. Double the risk may mean an increase from 1 child in 500 to 2 children in 500. The real numbers make a difference and this can be difficult to ascertain with a superficial reading of the study, or by reading articles that summarize the study.
4. Is the study size statistically significant? Is the study sample representative of the general population?
And most importantly:
5. Are the findings in this study, minus other corroborating evidence, compelling enough to prompt a change in lifestyle? Have the risks of making the change-the ways the system will be affected-been taken into account? (For example, the risk of discontinuing antidepressant therapy versus the risk of developing autism).
Snappy headlines and simple premises attract readers. This current study may, in time, be proven a valuable addition to the literature about autism. Or, like Andrew Wakefield’s deceptive research findings, it could just add to the confusion and misinformation about a serious childhood disorder. A shift from cause and effect thinking to systems thinking is a good step toward making an informed decision.
Auerbach, D. (2015, December 15). The Irresponsible Claim That Antidepressants During Pregnancy Cause Autism. Retrieved December 20, 2015, from http://www.slate.com/articles/health_and_science/medical_examiner/2015/12/antidepressants_in_pregnancy_probably_do_not_cause_autism.html
Autism Spectrum Disorder Fact Sheet. (n.d.). Retrieved December 20, 2015, from http://www.ninds.nih.gov/disorders/autism/detail_autism.htm last modified November 3, 2015
Bérard, A. (2015, December 14). Antidepressant Use During Pregnancy and the Risk of Autism. Retrieved December 20, 2015, from http://archpedi.jamanetwork.com/article.aspx?articleid=2476187&linkid=19568755#Discussion
Bowen, M. (1978). Family therapy in clinical practice. New York: J. Aronson.
Cohen, E., & Falco, M. (2011, January 5). Retracted autism study an 'elaborate fraud,' British journal finds. Retrieved December 20, 2015, from http://www.cnn.com/2011/HEALTH/01/05/autism.vaccines/index.html
A History of Autism. (n.d.). Retrieved December 20, 2015, from http://www.webmd.com/brain/autism/history-of-autism