At first, when I heard that the director of the National Institute of Mental Health (NIMH) was in favor of the burgeoning idea of a “growth chart for the mind,” I was concerned. Don’t kids who are too fat or too thin already feel stigmatized? What about kids who are at 5% for height — or 105% for that matter? Who is to say what is “normal” for the developing mind? Besides, as a parent, I can’t help but wonder whether it isn’t “normal” for kids to be “psychotic”?
But when I delved into it a little more, I learned that Thomas Insel, M.D., believes in such growth charts because they can help clinicians identify — and, most importantly, intervene in — children at risk for schizophrenia.
All of the experts say repeatedly that with children, exhibiting psychotic “symptoms” does not mean they have a psychotic disorder. Many of these symptoms, as parents learn pretty quickly, are actually developmentally normal. While it may be reassuring to know that your child who has conversations with an imaginary friend is normal, this is also the phenomenon that makes diagnosis of psychosis in children so difficult. In fact, the experts — child psychiatrists and child psychologists — are the only ones who can actually distinguish between normal and abnormal behavior, and this is usually done based on the child’s age.
I was surprised to learn that even clinical experts have a hard time interviewing children about possible psychotic experiences, because questions about hallucinations and other psychotic experiences tend to result in a high rate of false-positives. In other words, children, who don’t know anything about psychotic phenomena, may come across as abnormal because they don’t understand the questions. This is why behavioral observations can be more fruitful.
Parents are rightfully concerned about unnecessary use of antipsychotics — as it is, there has been quite an increase in the use of these medications in children. However, many of the prescriptions of antipsychotics for children are for attention-deficit hyperactivity disorder (ADHD), not for psychosis. When prescribed for psychosis, I am not concerned about the use being “unnecessary” — far from it. With ADHD, I am not so sure.
In the incredibly difficult decisions parents and caregivers have to make, it’s important that there be trust between the family and the clinician. Medications come with side effects, but untreated psychosis is dangerous, life-threatening, and incapacitating. No parent wants to have his or her child hospitalized, or have the child’s life as an adult left unfulfilled because of illness.
So a chart that can signal problems early on — perhaps before medications are necessary — is something to support.
Growth and genetics
Schizophrenia in children is rare before age 13, but it increases during adolescence. It is related to growth, and to genetics. There is no reason to wait until symptoms are obvious, and there are lots of reasons not to wait.
The growth chart all parents are familiar with is the low-tech graph of the “normal” ranges for height, weight, and head circumference. It helps pediatricians tell when there is a problem. It’s pretty useful for such a simple tool — for example, even for a child in the normal range but who moves from the 80th percentile at age 6 to the 20th percentile at age 8, there could be a problem.
However, it’s much more difficult to develop a tool that measures cognitive and emotional development. If there were a map that showed the development of brain functions, it might help care providers find out what children are at risk for psychosis, according to a paper published last year in JAMA Psychiatry, which attracted Dr. Insel’s attention — in part because the NIMH funded the study.
The paper, by Ruben C. Gur, Ph.D., and colleagues, involved the creation of neurocognitive age growth charts that are developed by calculating predicted age based on performance. When neurocognitive age is younger than chronological age, there is a problem.
The children were part of a cohort of 50,000 children who were seen for general pediatric services, not psychiatric services. The study found that youth with psychotic symptoms were more likely to have neurocognitive delays.
“Just as children with diabetes veer from the normal growth trajectory in a pediatrician’s growth chart, children and adolescents in the psychosis spectrum group had a lower predicted age relative to typically developing children, with a developmental lag observed especially in tests of complex cognition and social cognition,” Dr. Insel wrote in a blog last year when the paper was published. “The delay ranged from 6 to 18 months and was present as early as age 8.”
The study wasn’t perfect — it was cross-sectional, not longitudinal, making it difficult to pin down the trajectory of growth, wrote Dr. Insel, adding that a one-hour test can’t test for all cognitive domains.
Still, the study showed that such a map — a growth chart of the mind — is possible. Furthermore, the tool is freely available to researchers at https://penncnp.med.upenn.edu/request.pl.
Dr. Insel hopes that the field uses this test to help develop normative data, as has been done for height, weight, and head circumference.
No parent wants to be told their child might have a psychosis. But there is a prolonged phase of subthreshold clinical symptoms before a diagnosis is made. Wouldn’t it be better to have a clinician stage an intervention before these symptoms manifest themselves overtly?
The NIMH is continuing to support such work. While prevention of schizophrenia is not yet on anyone’s radar — nobody knows what causes it — there are steps that can be taken by clinicians and parents to help.
For the study, see Gur RC, Calkins ME, Satterthwaite TD, et al. Neurocognitive growth charting in psychosis spectrum youths. JAMA Psychiatry 2014 April; 71(4):366–374. doi: 10.1001/jamapsychiatry.2013.4190.