Dr. Danielle Dick, welcome to Heart of the Matter. It’s wonderful to meet you. And this book you’ve written is fascinating. I found myself reading it both as somebody in recovery identifying, “Oh, I was one of those kids.” The anxious one who self-medicated. And then I also found myself reading it as a mom of two boys who are both very different, wondering if I see anything that can help me.
But it’s interesting. You say on your website, “DNA doesn’t just code for brown or blue eyes. It influences the way we move in the world.” Our DNA, tell me how it does that.
Yes. Well, thank you so much for having me here. I find one of the biggest misconceptions about genetics, and I think it’s partly because it’s the way we learn genetics in high school, which is punnet squares and how you’re going to have brown eyes, blue eyes. But our genetics influences the way our brains are wired. And that shapes almost all aspects of our lives. And very often, we don’t talk about those subtle but major ways that our DNA code, the luck of the draw when it comes to the genes that we inherit, impact the way that we see the world, the way that we think about the world, the things we choose to do, the things we enjoy, what environments are a good fit for us or not. And so, I both study the genetics of substance use disorders, but in order to do that, really it involves going way back in time with really how we’re born and how our DNA has coded our brains, and how that starts influencing our outcomes from the very beginning.
You talk about three categories of kids, people who might be prone to substance use disorder. Talk me through them, because one of those, kids who externalize things, and then it’s kids who internalize things, and then the third is the drug or alcohol response, our body’s response to it. What’s the first one, externalizing?
Yes. So we talk about there being multiple ways that our genes can influence substance use outcomes, and those are the three big genetically influenced pathways. So externalizing is an umbrella term that we use in psychology that is really about how we interact with the external world. And so these are behaviors that are related to how our brains essentially process rewards and consequences. And some of us have brains that are highly attuned to what is right in front of us and what excites us. And this can show up in things that we call impulsivity or sensation seeking or risk-taking.
And so what we know is that that is a strong genetically influenced temperamental style that shows up early in life. So those are the little kids who are highly approachable to strangers. They’re more extroverted as they’re growing up. They’re more risk-taking. They’re also more likely to have ADHD, to have conduct problems. Because as teenagers, they’re kind of pushing the edge of the envelope trying different things. And then we also know that that can manifest as substance use problems, because they’re more likely to like experimenting, like trying new things, and often find those substances rewarding. They like the environments that substance use often happens in. And so, that can be one of the genetically influenced pathways related to substance use problems.
Do those kids not have fear? Do they just like pushing to the edge of the envelope? What is that?
So the fear piece gets at the second genetically influenced pathway, which is sometimes called internalizing. So this is how what’s going on in our head shapes our internal emotions and feelings. And that shows up in things like anxiety, depression, fear. And so that is actually a somewhat related, because emotion regulation and behavior regulation can be correlated with one another, they can relate to one another. But the emotional part, the anxiety, the depression, the fear, that actually is a more indirect pathway to substance use, meaning that if someone doesn’t learn effective coping skills to manage those things, that alcohol and other drugs can be used as a coping strategy, and that can lead to substance use problems.
And though these are related pathways, they’re also distinct. Because one is about how brains are wired toward reward, toward sensation seeking, toward impulsivity. And the other one is how our brains are wired toward anxiety, fear. And of course, all of us are combinations of both of those things. And so sometimes actually, the anxiety piece can keep things a little bit in check if one is high on impulsivity. In other cases, when people carry multiple genetically influenced risk factors, so maybe they’re highly impulsive, but they are also higher on depression, that essentially might make them even more likely to develop substance use problems because they’re carrying multiple types of risk factors.
I wrote in my book that I felt like I was born anxious. Was I right?
In a sense, absolutely. Yes. And so, while we talk about DNA is not destiny, our DNA does influence the way our brains are wired.
It’s powerful.
It’s very powerful. And I think as parents and really as people in general, we don’t pay enough attention to that. We don’t really give genetics the credit it deserves for how much it impacts our lives. And so, as you were saying, you felt like, “I was born anxious.”
Well, you were born with a brain that was wired more toward that. Some of us are more predisposed toward anxiety sensitivity. Other people, they run right up to strangers, they’re not afraid to try anything. And in the same way that we can look around and see how different we all are on the outside, we know that, we take it for granted. At the same time, we then often assume the way other people’s brains work is just like the way our brains work, because that’s the only way we know of being in the world. But in fact, our brains are all just as different on the inside as the differences that we can see between people on the outside. And so yes, everyone’s born with their own unique wiring that influences how their brain works.
So on the whole nature versus nurture debate, you’re saying there is a powerful nature component, but that also nurture plays a huge role. You’re not doomed to… I mean, I hear this all the time, people talking about, “My father was an alcoholic, my grandfather was an alcoholic, my uncle was an alcoholic, my mother was an alcoholic. It’s a genetic thing, and that’s why I’m an alcoholic.” You can’t chuck it all up to your DNA or to your genetic family pool.
Absolutely. And so, the way that we help people conceptualize this, and this is with full credit to a dear friend who is really the world’s leading psychiatric genetic counselor, and they talk about, “We all have a mental health jar.”
So if you imagine one of those clear Mason jars, and imagine that when your jar is full, that’s when someone is actively experiencing some kind of illness, a substance use disorder, depression, clinical anxiety, something of that sort. Now what can go in that jar to fill it up to get it full? Well, imagine we all are born with some marbles at the bottom of that jar and those marbles are genetic predispositions. Some people are lucky and they just have a few marbles at the bottom of their jar that put them at risk. Other people are unlucky, and their jar might be three quarters of the way full. They’re carrying some of these genes that influence through the impulsivity pathways, through the anxiety pathways, maybe even through some of the pathways we haven’t really discussed, but that are about how your body specifically responds to a drug.
We’re going to get to that.
Yes. But nobody is born with a jar that is full. Nobody is born with an alcohol use disorder, for example. And so the other thing that can go into that jar to fill it up is environmental risk factors. And those could be things like trauma. They could be things like having lots of peers who are using substances and encouraging you to use substances. And so, it’s always this combination of genetics plus environment that influences whether or not someone actively is experiencing an illness. And everybody is going to have their own unique combination. You might have lower genetic risk but experience a lot of environmental traumas or risk factors, and that can lead to someone experiencing a substance use disorder. On the other hand, if you have a lot of genetic risk, the families that you were talking about that we encounter so frequently, then it doesn’t take as many environmental risk factors before someone is experiencing problems.
All right. So before we get to what parents can do, let’s tackle the third category, which is your body’s response to drugs or alcohol.
Yes. I actually find-
Everybody doesn’t respond the same way?
Everybody responds somewhat differently to alcohol and other drugs. And this is why some people, for example, will try opioids, it makes them feel nauseous, and they think, “How do people ever get addicted to this?”
Right.
Other people try opioids and think, “This is the best feeling I’ve ever had.”
With alcohol, there are genes involved in alcohol metabolism. Some people flush bright red, or it makes them feel nauseous because their bodies don’t break down alcohol as well. And it turns out that’s highly protective when you feel sick every time you drink just tiny amounts.
You’re not going to drink.
Yeah. You don’t tend to drink a lot, exactly. So there are genes that influence how our bodies respond to drugs and how much we like the feeling that that drug gives us. And we think of those as kind of drug specific genetic influences.
And one of the biggest misconceptions I think is that when I talk about genetic influences on alcohol and other substance use disorder, I increasingly find that people now will say, “Oh, yes, I understand that it’s genetically influenced, and some people are more likely to develop problems than others.”
But I find most people are thinking about this third substance specific pathway, that they’re thinking, “Some people, if they drink alcohol or try a particular drug, their bodies are much more likely to become addicted to it.”
Is that true?
No. While there is some truth to this idea that how our bodies respond to a drug influences the likelihood of developing problems, and for opioids especially, there’s some thought that that might play an outsized role. But for most substance use disorders, most genetic risk is through those first two pathways that we talked about. Most genetic risk is about how our brains are wired toward reward sensitivity, how it shows up as impulsivity, and being really excited about the things that are right in front of us. And the other one is through this pathway related to anxiety, sensitivity, and depressive proneness.
So what can parents do? Because I found myself as a parent doing this when I was reading through your book and your research, identifying each of my two sons. “Oh, that’s this son, that’s that son.”
One of my sons feels like he was also born anxious. He couldn’t sleep in his own room when he was a toddler. I would have to sit in his room until he was sound asleep and if he woke up in the night, he would come into our room. School drop off in preschool was torturous, because it was just such an awful, awful thing.
Yeah.
So I found myself looking and reading and thinking, “Oh, that’s this son, that’s that son. Oh, I recognize that.”
What can a parent do once you recognize your child in one of these two buckets?
So I too found myself of the irony raising the high risk child that I study when I was a parent. And it was the first time that I really started paying attention to what was out in the mainstream media and popular press when it came to child behavior. And what I realized is, we talk so little about genetic influences. And I think that’s because as parents we think, “Well, I can’t do anything about genes. And so why do I care about my kids’ genetics? I’m the one who’s in the trenches trying to figure out how to get school drop off to work.”
And I think that that is such a huge mistake, because despite the fact that some people think, “Oh, I don’t want to know about genetics because that’s telling me what kind of problems I’m destined to have.”
Right.
As we talked about it, on the contrary. One of the things that I think is so exciting and empowering about the advances we’ve made in genetics is that because we now understand something about how our genes influence some of these outcomes that we worry about in our kids, for example, are they going to be one of the ones to develop substance use problems? By understanding these genetic predispositions show up in other ways early in development, it is actually a really positive, powerful thing from a prevention standpoint. Because being a risk-taker, being impulsive is not necessarily a bad thing, because that same disposition that might eventually lead a teenager to be experimenting with alcohol or other drugs can be channeled into other outlets. And you can help kids learn strategies to manage that.
And similarly, children who are more anxious, more fearful, there are strategies that we know, effective ways, to help kids learn to manage their anxiety. And when we put those in place earlier in development, there’s a much higher likelihood of better outcomes, and we reduce the chances that they’ll ever go on to, for example, develop substance use problems.
If you teach a child how to manage his or her anxiety when he or she is young, they won’t be turning to drugs or alcohol later to self-soothe, because in that second bucket, the internalizing bucket, the bucket I found myself in, I had no tools to manage my own anxiety. And that’s why I eventually turned to alcohol, because it did help calm it. So it’s key to recognize early on that your child is suffering from this kind of thing, and to address it and help them with it years before they might turn to a substance to soothe it.
Absolutely. And this is what I think is so exciting about some of the new possibilities we have for prevention and for early intervention. And so, as one example, most substance use prevention programming that kids get in schools, at best, it’s harm reduction. It’s helping them learn about substances and ways to manage peer pressure. And those things are very important. But a lot of schools use programs for which there’s no good evidence that it actually works or helps reduce substances.
Like what?
Well, DARE historically. And scare tactics. And we know now that kids don’t respond to those in terms of reducing future substance use. They tend to be not very effective, well-meaning, and sometimes very good in raising awareness about substances and the problems that they can cause, but they don’t actually translate into kids making healthier choices.
And so for example, we’ve been working on programs to help kids learn about some of these characteristics in themselves. We developed a new prevention program called, All About You. And we don’t sell it as substance use prevention. We sell it as, learn about yourself to get the most out of your life. And the whole idea is that by understanding the way that our brains are wired, and for our kids to start to recognize this early on, and then see how that is shaping the choices that they’re making on a day-to-day basis, and which things are getting them closer to their long-term goals and what they really want out of life, and which things maybe in the moment are the things that they lean toward, their crutches or things that they might do, but that don’t actually get them closer to what they really care about.
We know that by understanding and starting to learn about those patterns, that’s when you can develop some self-awareness and you can then, with other skills and strategies, start to think about, “Okay, how do I use these parts of myself as my secret strengths to reach the things I want out of life?”
How do these kids learn this stuff about themselves?
Well, the same way that researchers figure these things out about kids. So there are short surveys that kids can take that we’ve administered to tens of thousands of kids in these longitudinal studies to look at how kids develop and grow and who develop substance use problems. And we know what are the early risk factors. And they’re the kind of things we were just talking about. And none of them are characteristics that destine kids to have problems.
And my father was a fighter pilot, and my brother is a fighter pilot, my son’s father is a fighter pilot. It’s no surprise that he is a impulsive, risk-taking child. And being a fighter pilot, you can think of as one way to channel in a productive way that risk-taking disposition. And so, we kid around that risk-taker is yes, more likely to be the child who is doing keg stands or other kinds of risky things that as parents we worry about once substances come into the equation, but there’s other ways to channel that disposition.
And the earlier you can help kids get involved in some of those other outlets and recognize this can be a great thing. It might also get you in trouble if, for example, the kids that have ADHD and have trouble focusing on one thing or staying in their seat. So we’re going to work on reducing potential problems and accentuating the positive outcomes and strengths that can come along with this.
So you’re saying that from an early age, parents should have conversations with their kids about their DNA, their genetic prototype, so to speak. That if they’re an externalizing type kid to say, “Listen, this is a huge plus for you and a strength for you, but let’s manage it and just keep in mind…”
I mean, I guess what do you say? What do you say to your child if they’re in that first or second bucket? Because the third bucket clearly is the response that’s after they’ve started using. So at what age do we say something and what do we say?
So Elizabeth, I always say it’s never too early to start having those conversations.
Okay. What? Third grade, fourth grade?
Even younger. Because you know when you have a toddler and a small child, you will know, do I have the child that is the impulsive one dangling from the top of the playground equipment? Or do I have the child that is the one that’s on the ground looking up at that child going, “That does not look like a good idea.”
And you’re the parent that’s encouraging them, “It’s okay, let’s just swing on the swing or let’s go…” And so you know, is your child one of the more risk-takers or is your child one of the higher on anxiety?
And one of the greatest gifts I think we can give our children as parents is to help them feel comfortable in their own brains and in their own shoes, and recognize that who they are is a special, wonderful gift. And so, by that I mean I, for example, am a much more extroverted, love to be around people kind of person. And my son was also higher on anxiety when he was young. And so on Saturday mornings I would plan get togethers that I was imagining would be really fun for us. And so we’d be sitting there having our cereal and I’d say, “Guess what? Today we’re going to go to the park and we’re going to meet up with so-and-so and so-and-so, their child and their child.”
And next thing I know he would throw down the spoon or slam the cereal off the table and be like, “I’m not going.”
And then our natural reaction as a parent is to be like, “That’s not appropriate, that’s not okay. You don’t throw your cereal on the ground.” Now you’re responding to the behavior.
And he digs in and you don’t have to have a PhD to realize this is going nowhere good. It’s not heading to a fun day at the park together. And what I realized when I stepped back was my child was a more anxious individual. And he didn’t have the natural skills to just blend right in with a bunch of different kids he didn’t know in a place he wasn’t familiar with. And I was doing the equivalent of throwing him into the deep end of the pool. It seemed like fun to me when I was little. You could throw me into that. And it was also creating, as he got older, the situation where it felt like, “Why can’t I do this thing that is expected of me? What’s wrong with me that I can’t just go blend in with all the other kids?”
And so that’s what I mean by being aware of our kids and their dispositions. I realized, “Oh, this is what’s going on. His little,” at that time, “toddler brain couldn’t say, ‘I’m nervous to go to the park with all these children I don’t know.'”
It’s interesting though, you’re describing something that I’ve actually observed with one of my sons, too, which is a mixture of the two buckets.
Yes.
He’s a risk-taker. He loves to do daring things, but he’s also an anxious child.
Yes.
It’s not just one or the other. You can be both.
Exactly. So we’re all complex people, and we have risk or not across multiple dimensions. And in fact, we have found that we can literally now calculate based on someone’s DNA what their genetic risk level is across these dimensions. And as you would expect, when you carry genetic risk across more of these dimensions, the likelihood that an individual is going to develop substance use problems goes up with each risk factor that someone is carrying.
But again, back to the not destiny. And so the anxiety piece, one, you can learn skills. And I did work with him, and he is still not the child who necessarily wants to be dancing on tables at a party, but-
That’s a good thing.
… he can perfectly, pleasantly mingle with other adults and those kind of things, even if it might not be his favorite thing. So we can both help them learn skills to manage that, but there is also this. When we recognize the way our kids’ brains are wired, we can also help them learn to love that about themselves and not feel lesser. And you can imagine the kids who are more impulsive, and you see this a lot with ADHD and whatnot, they’re constantly getting negative reinforcement. They’re getting negative feedback. It’s the “Sit down, pay attention.”
“Calm down. Pay attention.”
Yes, et cetera.
“Be quiet,” yeah.
And with the anxiety piece, too, it can be like, “What’s wrong? It’s not a big deal. Just go play with the other kids.”
And so, when we recognize these are the way our kids are wired, we can help them learn skills to either keep impulsivity in check or to, for example, be more comfortable moving in the world with others they don’t know or whatnot. But we’re probably not going to completely change who they are. I think for parents, that’s an important thing for us to remember.
All right, I have two last questions. The first is how much of what our DNA code is, how much of that is hereditary?
So all of our DNA is inherited from our parents.
So 100% of it is hereditary.
100%, yes.
Okay. Next question. If you have a child, because we’re talking almost exclusively on recognizing early on what genetic type our child might be, and then how to react/treat/raise that child with the awareness of prevention years down the road of any issues with substance use disorder. What should a parent do with a child who’s already in that struggle? If a child has already become either addicted or is already using drugs or alcohol in a way that’s unhealthy or dangerous or addictive, how can knowing or recognizing what your child’s type is help in treatment of a problem that’s already begun?
I’m so glad that you asked that, Elizabeth, because it isn’t just the case that once someone has a problem, okay, now we have to treat this problem. And so, genetics doesn’t matter anymore.
You treat it the same way, in other words.
Well, what I hope we will do better of in the future is recognizing that people develop substance use disorders through these different pathways. And so, understanding if the person in treatment or your loved one has developed an alcohol or other drug disorder via temperamental traits that are related to impulsivity, that are related to anxiety, or maybe that are related to actually the way that that drug makes them feel through these different pathways, though there’s many commonalities associated with treatment and having supportive family members and et cetera, are very important across the board, knowing what that disposition is is going to be important for creating recovery plans that can be sustained.
Because if you are that more impulsive risk-taking, highly sociable, for example, person, you can’t just remove what was that individual’s outlets for that disposition, which might have been related to alcohol, other drugs, friends who are using alcohol and other drugs.
Right.
If you remove that, you’ve created a void. And so that disposition could show up in other risky ways. Now, so for example, gambling, heavy online gaming, pornography, risky sex. And so by thinking about, “Okay, so this disposition still exists, how are we going to channel it? If you’re not using alcohol and other drugs, how are you going to channel it in ways that still make life feel exciting and meaningful?”
Right.
Or if you’re someone who’s more anxious, then okay, we can’t just treat the substance use. We actually now need to have skills in place so that there’s other ways to address and manage that anxiety, to manage hard situations that come up, and not slip back into using alcohol or other drugs to self-medicate. So those are a couple ways that I think even among some individuals who are in treatment, being mindful about what are the pathways that led to the problems is key for thinking about how do you create sustained recovery as well?
Yeah, that’s a real issue. Every parent wants to help their child, but you’re making the point that recognizing what your child’s DNA type might be, genetic code might be, can help you design treatment in the way that has the best chance to succeed.
It seems obvious that somebody who’s abusing alcohol or drugs to self-soothe over their own anxiety, it seems obvious that, okay, we need to teach that person how to manage their anxiety so that they don’t feel like they need to pick up a substance to soothe themselves. But you’re saying it also means that the person who picked up drugs or alcohol because they wanted the rush, that you need to figure out another way for them to get the rush.
Exactly, yes. And I think that unfortunately some of current state results from how we have treated substance use disorders historically, which is separate, different from psychiatry, from other mental health treatment and behavioral health. And so, sometimes substance use disorder treatment has been isolated by itself, whereas of course we’re all whole individuals. And so, many times people are using alcohol, but also other drugs but are also struggling with depression or anxiety or ADHD or you name it. And so, really I think there’s a movement toward recognizing, we need to think about each individual and what are the unique risk and protective factors that they’re carrying?
Yeah.
But that’s still something that we’re continuing to work to try to improve in the substance use disorder treatment field.
Well, it’s fascinating research. It’s important to emphasize something you’ve repeated over and over in this podcast, which is that genetics is not destiny. It doesn’t mean you’re doomed to be an addict or an alcoholic, but it is incredibly helpful for parents when they’re struggling with their kids to recognize that they may be reacting to certain things in a certain way, not because they’re choosing to be difficult or because I failed as a parent somehow to teach them properly. It’s the way they were born into this world. And I know that despite the fact that I suffered from anxiety, many times I was impatient or I hope I didn’t show up, but I felt impatient with my own child’s anxiety. Even though I know exactly that… So it’s really, really fascinating research.
The book is called, The Child Code, Dr. Danielle Dick. And I think it’s a must read for any parent hoping to… You don’t have to be worried about substance use disorder. This is a great way to understand how your child is and what makes your child tick. Thank you so much for coming on Heart of the Matter. Really appreciate it.
Thank you so much for having me. It’s been a joy.