Dear Dr Ash,

Our son recently got married to his long-term girlfriend and they’ve bought their first house in a lively part of Liverpool full of couples with young families. My husband and I are in our 60s and couldn’t be happier about this – he is our only child and we like his wife very much. Yet a dark cloud cast a shadow over everything last weekend when my daughter-in-law, in answer to a question I asked about what the maternity leave allowance was these days – calmly told me they had no intention of having children because (and I quote) “there’s no point, when climate change catastrophe is about to wipe us all out anyway.”

My husband and I are devastated. The prospect of an old age with no grandchildren is bad enough – but what will it be like living in a world full of young couples who have given up hope for the future?
Please help us find a silver lining.

Longing,
Liverpool

Being right, it turns out, matters far less than being happy

Dear Longing,

I read your letter this morning on a train into London under a heavy sky of undifferentiated grey. There seems to be a thin film of mud covering the outside of the train, the residue of unending days of dense, squalid rain. It’s hard to feel optimistic about lunch, let alone about the distant future of generations yet unborn. But in an effort to lift your mood and mine, I have been reminiscing about those halcyon days when I was a graduate student in London, living on a canal barge, finding reasons to amble past the British Museum in the mornings. And those perfect spring afternoons eating lunch on the grass in Queen Square with my colleagues, in front of the Victorian façade of the National Hospital for Neurology and Neurosurgery. I’m reminded in particular of my colleague Tali Sharot, and some fascinating work she was doing at the time on the neural mechanisms of optimism.

Sharot argued that most people had what she called an “optimism bias” – on average, across large populations, they tend to discount negative evidence and exaggerate positive evidence. In one of her studies, she and her team asked a group of young people to predict the likelihood that they personally would develop cancer in their lifetimes. Participants were given a moment to respond, then shown the true population-level lifetime cancer risk (around 30 per cent for that demographic group). They were then asked again what their personal cancer risk might be. Some were pessimistic, guessing that their risk was something like 40 per cent. Other were optimists, guessing something like ten per cent. On average both groups were wrong by the same amount, but when shown the true figure of 30 per cent the pessimists dramatically reduced their guesses to something like 31 per cent while the optimists barely nudged theirs upwards to figures around 14 per cent In other words, relatively good news had much more of an impact on people’s beliefs than relatively bad news. This lopsided inaccuracy is what Sharot calls an optimism bias.

In those golden afternoons in the park many years ago, Tali’s work made perfect sense. In the years since, as the zeitgeist has grown ever darker and world appears poised on the edge of moral, political and environmental collapse, it seems impossible to believe that the brain could really operate in this way. But after more a decade and hundreds more papers published by Sharot and others in the field, the evidence is quite convincing that it does, and the brain mechanisms involved may shed some light on your dilemma.

The optimism bias arises from two biologically distinct processes occurring in the brain’s inferior frontal lobes. The right inferior frontal lobe represents negative information about future events, while the left inferior frontal lobe represents positive information. In pessimists these two brain regions are active and well-coordinated, accurately representing both negative and positive information – research shows that people suffering from depression are, in fact, quite good at predicting future events. But in optimists, the right inferior frontal lobe shows reduced activity. Negative information about the future simply isn’t represented well, and therefore predictions about the future are inaccurate. But this impairment, what really amounts to a form of brain dysfunction in optimists, paradoxically improves life outcomes. Optimists experience just as many negative events as pessimists, but they tend to feel better about them and they move on quickly. They get sick less often, they recover from illness more quickly and ultimately they live longer. Being right, it turns out, matters far less than being happy.
Your son and daughter-in-law may be weighing up many reasons for and against having kids, and their predictions about climate change may only be a part of the story. But I encourage you to tune in to your own optimism bias. The world is wide and the future offers myriad unknown possibilities. If in the end your son chooses not to have children, you and your husband may enjoy other blessings that you have not yet anticipated.

Best wishes,
Dr Ash

Dear Dr Ash,

My best friend is the mother of a twelve-year-old son with behavioural issues – he’s a lovely kid, but has terrible tantrums and she and her partner find it almost impossible to ask him to do anything. He is disruptive at school, has a poor attendance record, and shouts and swears at both his parents, sometimes even lashing out physically. This is really taking its toll on their relationship and both my friend and her partner are unhappy and exhausted. My friend is now on anti-depressants and says that she and her partner argue all the time. After many weeks of waiting, they’ve finally been given an appointment with a child psychiatrist – their GP has been saying for years that he very likely has autism and/or ADHD. But now that a diagnosis is finally on the horizon, my friend is getting cold feet about it. She’s worried that giving him a label will make matters worse, sending the message that he’s different or defective and giving him yet another thing to struggle against. I’m worried that without a diagnosis she won’t get the help she needs for him – and that she’ll pay the price with her marriage and her own mental health. Can you help me to help her?

Worried,
Wolverhampton

Diagnosis can provide a framework of parenting and teaching strategies

Dear Worried,

I suspect your friends are on the horns of a dilemma created in no small part by the word “diagnosis” itself. Its ancient Greek roots are “dia”, which conveys a sense of moving through or across boundaries, and “gnosis” which implies a deep form of knowing. It gives us the idea that by moving across boundaries, by dividing and categorising, we come to a profound insight about the world itself. Diagnosis promises to lead us to something concrete and real, something probably made of molecules and genes and ideally a little nubbin of some sort that can be seen in a picture and fixed with a surgery.

In reality, a diagnosis tell us very little about the specifics of an underlying medical condition and even less about the truth of someone’s humanity. As a doctor I’m aware that no two patients are alike, no matter how similar their diagnostic labels might be. And I don’t mean this in a trivial sense, like we are all unique snowflakes and everyone is special. I mean that the particulars of any individual’s biology, the unique quirks of their anatomy and physiology, moulded by their life experiences, create a complex biological system that is unlike any other. That’s why doctors don’t imagine that grouping people into diagnostic categories leads to truth or even to deep insight. We use diagnosis only in a practical way, to convey a rough sketch of our ideas to other clinicians and to help select and coordinate treatment options. We shouldn’t believe in the truth of diagnosis, any more than we believe that atoms are really made of little coloured balls whizzing around each other; a diagnosis is a tool, a metaphor, but not an explanation.

That said, because of the way we structure medical care and social support, it can be an extremely effective tool. It sounds like your friend desperately needs help one way or another, and the most straightforward way to get that is with a diagnosis. In the cases of categories like autism and ADHD, the diagnosis can provide a framework of parenting and teaching strategies that may prove useful. It may enable the school to support the child and his family more effectively, with dedicated time and resources. And receiving a diagnosis is often a great relief to patients who are otherwise struggling to understand what is happening to them. If things for your friend are as bad as they sound, it is likely that the boy himself is frustrated and already feels something is wrong; I wonder if it isn’t harder for him to know he’s different but then be deprived of any language to express how. We are living at a moment when neurodiversity is increasingly recognised as a strength and I hope that any stigma attached to these diagnoses is rapidly fading. Ultimately, if we can hold diagnostic labels at arms length, we can take advantage of their practical value without succumbing to delusions about their truth.

Best wishes,
Dr Ash