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Psychosis in childhood
PSYCHOSIS IN CHILDHOOD By G E O R G E
STROH*
Psychiatrist-in- Charge High Wick Hospital, St. Albans, Herts. CrImDHOOD Psychosis is a blanket term covering a variety of syndromes of severe mental illness occurring up to puberty. The vagueness of the concept prevents the making of a rigid classification which would be premature and unjustified. But, its very vagueness allows for a great many interpretations of what should be included under this term and leads to a great deal of confusion when discussing mtiology, symptoms, prognosis and treatment. It might be convenient to consider a nuclear form, the prototype, as it were, of childhood psychosis, where the diagnosis would be agreed upon by most workers in this field, ff one were to represent this nuclear type pictorially, it would occupy a small area only, but casting a large shadow around itself. This shadow would be the area of overlap with other types of disturbance in childhood. There would thus be an overlap between psychosis and neurosis, between psychosis and mental subnormality, between psychosis and those disturbances where a known physical cause is identifiable (epilepsy, brain damage, phenylketonuria), and an overlap between the group who can be classified as behaviour disorders, maladjustment or psychopathy. This border-line area would be huge. The nearer to the centre of this picture a child's condition could be placed, the nearer to the nuclear form he would be and the more he would approach the prototype of what may be called the schizophrenic syndrome. The further one moves to the periphery, the more psychotic features will merge with the clinical picture with which, in this area, the psychosis overlaps. It will be in these border-line areas often a matter of one's personal bias whether one includes a child under the diagnosis of, e.g. neurosis or psychosis, or, say, subnormality or psychosis. It is therefore very difficult to gauge the size of the problem of childhood psychosis in terms of numbers of children affected. To begin with, as far as I know, no study has been made that attempted to investigate the incidence. From my own experience, hazarding little more than what might be called an inspired guess, I would think that there are about 3,000 to 4,000 children in this country in whom a diagnosis of psychosis could confidently be made. By this I mean those severely disturbed children whose clinical picture is closely approaching the nuclear form. The problem will obviously be enormously increased, depending on how much of the surrounding overlap area we include under the heading of this syndrome. In practice, I should have thought it did not make much difference, for t h e moment, how much of the border-line areas we include *Based on a lecture delivered in the Joint Refresher Course of the M. & C.W. and S.H.S. Groups, April, 1962. 21
22
PUBLIC
HEALTH
VOL.
LXXVII
NO.
1
All these children would come under the heading of severely emotionally disturbed, and our knowledge of diagnosing, understanding or treating these children, and our facilities in dealing with them, are still grossly inadequate. It might be interesting to reflect why it should not have been until relatively recently that the existence of severe mental illness in childhood had become widely known. To begin with, child psychiatry itself is a relatively new outgrowth of general psychiatry. Then, cultural changes over the last 100 years and the influence of psychological theories (like those of Freud) have made us increasingly aware that the child is an individual with an understanding and inner life very much his own, and not just a diminutive form of the adult. There may also have been a reluctance, both by the medical profession and by lay people, to accept the disturbing and somehow unimaginable fact that there are children who are mad. Both the reluctance to accept the existonce of mental illness in children and the diagnostic confusion, have led to some difficulties in name-giving. Childhood psychosis, schizophrenic syndrome, infantile autism, the borderline concepts, atypical child, pseudo-neurosis, pseudo-psychopathy, etc., have become often analogous terms for a severely emotionally disturbed child. For the present, I shall refer to the nuclear form (or the schizophrenic syndrome) on one hand, and to the peripheral form on the other, including both forms under the heading childhood psychosis. The obvious disadvantage of using the term schizophrenia in childhood is that it borrows a term denoting a clinical syndrome in adult psychiatry, when it is by no means clear yet what in fact the link, if any, is between childhood "schizophrenia" and adult schizophrenia. Diagnosis of any clinical syndrome can be based on ~etiology, symptomatology, pathology, prognosis or any combination of these. The a:tiology of childhood psychosis is unknown. It is furthermore clear that we are not likely to find that there is one indispensable factor responsible for this syndrome or group of syndromes, but rather a variety of factors, many of them equally important. As a generalization, one could say that there does not seem to be any physical or psychological trauma that, by itself, could be made responsible for severe mental illness in children. Diagnosis based on pathology, i.e. ps may ultimately be the most useful one, but at present is too long-winded and uncertain to be of any practical value. It will therefore dearly be the descriptive approach to which we shall have to resort for making a diagnosis. SYMPTOMATOLOGY
None of the symptoms to be described, with the possible exception of one, are pathognomonic. Any one of them may appear in a number of other conditions, brain damage, neurosis, subnormality, etc. It is rather the constellation and the severity of the symptoms and their persistence which may produce the clinical picture of what might then be called psychosis in childhood,
PSYCHOSIS
IN
CHILDHOOD
23
Personal Relationships A typical psychotic child will be unable to make good contact with the adults or children in his environment. He could either be considered to be detached or withdrawn, or, as it has been called in the past, live in a world of his own, or his behaviour may be clinging, attempting to mould his body into that of an adult. T h i s " symbiotic "relationship, one assumes, is one which is to the mutual benefit, albeit neurotic or psychotic, of mother and child. It appears that in such children the extreme closeness between mother and child, which is a normal feature in child development for the first six months or so, has not given way to the development of individuality and independence in the child. Such symbiotic or empty clinging is difficult to describe in words, but can be felt most readily. The child may sit on one's lap or climb on to one's shoulders and yet one has not the feeling that any true emotional contact has been made. It is rather as if the child considers one as a piece of furniture to sit on, or a tree to climb on. The withdrawn, or so-called autistic child, remains apparently aloof from, and apparently unaware of, his environment. Though he may fleetingly look at one, there is neither interest nor concern in his look and he might walk past one as if he had not noticed one's presence. To a large extent, this lack of relationship can be modified by normal, affectionate care and attention and the reason for the extreme withdrawnness of some children may be that, for reasons other than the child's disturbance, contact with adults or children in his environment was not possible. I should make it quite clear here, as I will do later, that this does not imply that it is the fault of the parents if a child behaves in such severely disturbed manner, but rather that it is almost impossible for any parents to tolerate certain kinds of behaviour in their own children. It can sometimes be difficult to distinguish the empty clinging of the psychotic from the superficial, easy relationship of the institutionalized or deprived child but the deprived child, though he may wander from one adult to another, is clearly seeking attention, and the need for this is easily felt by the observer.
Speech Some disorder of speech is present in almost all psychotic children. The disturbance may be that a child has never acquired the ability to speak, or had begun to talk and then stopped, or speaks in an abnormal way. Abnormality of speech may basically be of two kinds : disturbed content of speech, or a disturbed manner of talking. The disturbed manner could be characterized by unusual inflection, either excessive or monotonous. The content might show disorder of thinking, bizarre fantasies, neologisms, echolalia. Such children can also show unusual fears of the spoken word which is addressed to them. Some quite harmless sounding words or sentences may cause extreme anxiety or provoke aggression.
24
PUBLIC
HEALTH
VOL.
LXXVII
NO.
1
Absence, or unusual development of speech, is often one of the first signs of abnormality that bring the child to the attention of the doctor. Although clearly there are many reasons for unusual or late speech development, the possibility must be considered that it might indicate severe emotional disturbance. This possibility must particularly be borne in mind if acquired speech, however rudimentary, has been lost or is not progressing satisfactorily. A differential diagnosis of developmental aphasia will always have to be considered in a non-talking child, but as so little is known of either condition, both as regards origin and treatment, thorough and prolonged investigation would be necessary in either case.
Perceptual Disturbance Perhaps the most common cause for referral for a child that later is diagnosed as suffering from psychosis, is apparent deficiency of hearing. In such children, as a rule, no physical abnormality can be found and although the possibility always exists that there is some undefined constitutional deficiency, the peripheral hearing apparatus is clearly normal. This type of behaviour can be classed under the heading of perceptual disturbance, namely a disordered function of one of the sensory modalities, without any evidence that the sensory apparatus itself is diseased. Perception can, for that purpose, be defined as those mechanisms or functions which are interposed between sensory input and the organism's response to it. It does include, therefore, the individual's psychic make-up and can be considered as an active selective process. A child suffering from what is considered auditory imperception or auditory avoidance will at times react to the spoken voice, at times not, and in many ways react as if he were either deaf or partially deaf, except that he may appear actively to avoid sound by turning his head or covering his ears. Visual avoidance would manifest itself by the child not looking at, or actively looking away from, a person or half or completely shutting his eyes. An example of this was shown by S. who, as a three-year old, blinded himself for three days by putting ointment in his eyes but who, throughout this period, walked and generally behaved the same as when he was able to see. It should not be understood that these children are in fact unaware of sound or visual stimulation, but rather that the external world is not meaningfully appreciated. Perceptual disturbance may also manifest itself by the prominence, or excessive use, of one or the other sensory modality, particularly touch and smell. Some children will appear to be still in the stage of an infant who likes to feel everything and comes to know objects by putting them to his mouth, some may even " l e a r n " about the environment by mouthing up and down furniture or walls. Others will sniff at their environment or put objects to their noses. Another feature which may fundamentally be caused by perceptual disturbance is the unusual use many of these children make of objects around them. Preoccupation with sameness has been ~ e s c d h ~ as one of the most
PSYCHOSIS
IN
CHILDHOOD
25
common behaviour patterns of psychotic children, e.g. the flicking of a stick or string, putting small objects into rows or piling them into heaps. One child known to us would, if left alone, interminably stroke his palms with leaves until they became sore and even bleeding. Another child would, with great skill and persistence, kick small objects along the floor incessantly, walking up and down. Such preoccupation with sameness will have to be distinguished both from similar play seen in the severely subnormal child, and in the ritualistic behaviour of the severely obsessional child. Whenever there is evidence that there is inadequate appreciation of the spoken word, one will attempt to distinguish between what has been described as auditory imperception and deficient hearing due to physical causes. In a large number of cases, however, the results of repeated and prolonged tests remain equivocal. Motility It is here that we may find the one behaviour pattern that is almost pathognomonic of psychosis : spinning of the body. The child turns round and round sometimes slowly, sometimes reaching an almost frenzied climax, but never showing any signs of giddiness. It is this absence of any apparent disequilibrium which distinguishes this activity from similar ones seen in normal children. In addition to spinning themselves, these children may spin round objects, plates or ashtrays for instance, and show extraordinary skill doing it. Head-banging and head-rolling are frequently seen and so is rocking, with the child kneeling or sitting, or standing up and moving the body back and forth. Movements, particularly of locomotion, can show a lack of fluidity, a clumsiness which is in contrast often to the rapidity with which they ear carried out. Some move in a careful, pigeon toed walk, others dart across the room from one wall to the other, one child in our experience wriggled his way like a worm from place to place though he was quite able to walk. The unusually good sense of balance of some children is probably due to their lack of appreciation of real danger. Some movements (rocking falls into this group) are done probably because they provide some sensory satisfaction, e.g. turning of the wrists, hand-flapping and finger-play. The child moves the fingers in front of his face, looking through them, perhaps finding pleasure in the light changes such movement produces in front of the eyes. It is the sort of play which is normal in the baby. This list of symptoms is by no means exhaustive, nor, it must be repeated, is any one, with the possible exception of spinning, in itself characteristic of childhood psychosis. The aim here is to focus attention on four areas of the child's behaviour, all equally important and all usually affected in the nuclear type of the disturbance. It must be admitted, though, that when we talk of disturbances of speech, motility, perception and emotional contact we talk of things of a different order. Abnormalities of speech and motility we can
26
PUBLIC
HEALTH
VOL.
LXXVII
NO.
1
directly observe, but when we discuss symptoms under the heading of disorders of perception and emotional contact we mix observational data with presumed causation. This in itself need not detract from the usefulness such a brief guide towards diagnosis may have.
DevelopmentalHistory Most of our information of the early development of the child that later becomes psychotic is retrospective. Thus most of the more subtle points are missed and many of the cruder ones over-emphasized. The parents may reiterate incidents with great clarity, incidents that may have stayed in their minds for a variety of reasons but which have little immediate relevance to the child's illness. On the other hand, important and relevant information is hidden by parents who feel uneasy and guilty, though their conscious intention is to give the fullest information. Most parents will say that the child has been normal up to a certain age, often about two years, that then progress was halted and from that time over-all deterioration set in. They noticed that the child stopped learning new words, that he stopped using the words he knew, or that his speech became increasingly unintelligible. His behaviour altogether became aimless and his play, if there was any, was not constructive. It is often difficult to be sure that indeed there was a period of normality followed by deterioration. The more one delves into the history, the more one finds that many of these apparently normal children revealed certain early abnormalities. The mother might s a y that he wasn't really a cuddly baby, particularly when she compared him with another child, that his " s p e e c h " didn't really amount to more than a few unclearly spoken words used mostly in imitation, and that he never showed any inclination to persistent or constructive play. If, however, the mother insists that indeed behavioural changes have occurred at a certain age, she may relate accidents, such as falling off a table or some emotional upset at home, as possibly responsible for the child's illness. It is in fact unusual that one can convince oneself that there was any physical or psychological trauma that can be made responsible for the deterioration. Meningitis or encephalitis can, of course, at any age cause permanent personality changes and in a few of the psychotic children there is a history of unexplained high fever of a few days duration, accompanied by high-pitched, inconsolable crying. Teething is often blamed for this but it may be that some of these febrile episodes are episodes of an encephalopathy. Although a thoroughly taken history will reduce the number of cases in which an undoubted change in the developmental progress of the child occurred, there are certainly some psychotic children in whom the early development must be considered normal. In some children it was quite clear to the parents from the beginning that their child was not normal, despite the absence of physical stigmata and although physical milestones are within normal limits. Such children take little
PSYCHOSIS
IN
CHILDHOOD
27
notice of the environment, they have no interest in simple toys such as rattles, they show no discrimination of faces and they are either excessively restless and noisy, or, more commonly, excessively quiet. Parents sometimes describe such a baby as extremely placid and good. There may also have been feeding difficulties, difficulties in sucking for the first few days and the child never put objects to his mouth or sucked his thumb as other infants do. Speech never developed beyond the babbling stage. The differential diagnosis from severe subnormality will be on the basis of the symptomatology and absence of physical stigmata. THE
PSYCHOTIC
CHILD
AND
HIS
FAMILY
There is no convincing evidence that childhood psychosis is genetically determined, and as such it is significantly different from adult schizophrenia. One of the most common misconceptions is that the child's disturbance is directly attributable either to mishandling by his parents, particularly mother, or to unsatisfactory conditions in his family. It is possible, though as yet unproven, that a subtle disturbance during the early mothering of the child may be a contributory factor to the illness, but so far investigation of the parents of psychotic children has not revealed that home conditions or the handling of the child are significantly different from that of parents of normal children. Disturbance of the subtle interchange in the mother-child union need not only be due to personality difficulties of the mother but could equally well, and primarily, be caused by the child's innate inability to provide the necessary stimulus for good mothering. It is in this area of family relationships that childhood psychosis becomes a problem of large proportions. There is probably no other disturbance in childhood which could produce such devastating effect on the family. The physical management alone tends to make the home child-centred. Mother, or possibly father, may be the only ones who dare, or are able, to look after the child, all activities of the parents have to be more and more restricted to allow for the care of the child. This interference with, and limitation of, the parents' own life arouses mixed feelings which increases their already often present feeling of guilt for having produced such a child. The time and energy spent on the young patient is often taken from the attention that would otherwise be given to husband or the other children. This can produce marital difficulties and add to the bewilderment of the siblings, who already find themselves puzzled and frightened by the unusual behaviour of their brother or sister. Neighbours complain or comment, grandparents or aunts and uncles criticise. Thus, when considering our relative ignorance of childhood psychosis and the impact the psychotic child has on his immediate and sometimes wider environment, it seems imperative that our attention should be focused on the investigation and treatment of this group of conditions. Facilities at present are pitifully inadequate for that purpose, and only the most intensive psychological care and exploration, coupled possibly with well integrated physical research, will help us to elucidate severe mental illness in childhood.
STROH*
Psychiatrist-in- Charge High Wick Hospital, St. Albans, Herts. CrImDHOOD Psychosis is a blanket term covering a variety of syndromes of severe mental illness occurring up to puberty. The vagueness of the concept prevents the making of a rigid classification which would be premature and unjustified. But, its very vagueness allows for a great many interpretations of what should be included under this term and leads to a great deal of confusion when discussing mtiology, symptoms, prognosis and treatment. It might be convenient to consider a nuclear form, the prototype, as it were, of childhood psychosis, where the diagnosis would be agreed upon by most workers in this field, ff one were to represent this nuclear type pictorially, it would occupy a small area only, but casting a large shadow around itself. This shadow would be the area of overlap with other types of disturbance in childhood. There would thus be an overlap between psychosis and neurosis, between psychosis and mental subnormality, between psychosis and those disturbances where a known physical cause is identifiable (epilepsy, brain damage, phenylketonuria), and an overlap between the group who can be classified as behaviour disorders, maladjustment or psychopathy. This border-line area would be huge. The nearer to the centre of this picture a child's condition could be placed, the nearer to the nuclear form he would be and the more he would approach the prototype of what may be called the schizophrenic syndrome. The further one moves to the periphery, the more psychotic features will merge with the clinical picture with which, in this area, the psychosis overlaps. It will be in these border-line areas often a matter of one's personal bias whether one includes a child under the diagnosis of, e.g. neurosis or psychosis, or, say, subnormality or psychosis. It is therefore very difficult to gauge the size of the problem of childhood psychosis in terms of numbers of children affected. To begin with, as far as I know, no study has been made that attempted to investigate the incidence. From my own experience, hazarding little more than what might be called an inspired guess, I would think that there are about 3,000 to 4,000 children in this country in whom a diagnosis of psychosis could confidently be made. By this I mean those severely disturbed children whose clinical picture is closely approaching the nuclear form. The problem will obviously be enormously increased, depending on how much of the surrounding overlap area we include under the heading of this syndrome. In practice, I should have thought it did not make much difference, for t h e moment, how much of the border-line areas we include *Based on a lecture delivered in the Joint Refresher Course of the M. & C.W. and S.H.S. Groups, April, 1962. 21
22
PUBLIC
HEALTH
VOL.
LXXVII
NO.
1
All these children would come under the heading of severely emotionally disturbed, and our knowledge of diagnosing, understanding or treating these children, and our facilities in dealing with them, are still grossly inadequate. It might be interesting to reflect why it should not have been until relatively recently that the existence of severe mental illness in childhood had become widely known. To begin with, child psychiatry itself is a relatively new outgrowth of general psychiatry. Then, cultural changes over the last 100 years and the influence of psychological theories (like those of Freud) have made us increasingly aware that the child is an individual with an understanding and inner life very much his own, and not just a diminutive form of the adult. There may also have been a reluctance, both by the medical profession and by lay people, to accept the disturbing and somehow unimaginable fact that there are children who are mad. Both the reluctance to accept the existonce of mental illness in children and the diagnostic confusion, have led to some difficulties in name-giving. Childhood psychosis, schizophrenic syndrome, infantile autism, the borderline concepts, atypical child, pseudo-neurosis, pseudo-psychopathy, etc., have become often analogous terms for a severely emotionally disturbed child. For the present, I shall refer to the nuclear form (or the schizophrenic syndrome) on one hand, and to the peripheral form on the other, including both forms under the heading childhood psychosis. The obvious disadvantage of using the term schizophrenia in childhood is that it borrows a term denoting a clinical syndrome in adult psychiatry, when it is by no means clear yet what in fact the link, if any, is between childhood "schizophrenia" and adult schizophrenia. Diagnosis of any clinical syndrome can be based on ~etiology, symptomatology, pathology, prognosis or any combination of these. The a:tiology of childhood psychosis is unknown. It is furthermore clear that we are not likely to find that there is one indispensable factor responsible for this syndrome or group of syndromes, but rather a variety of factors, many of them equally important. As a generalization, one could say that there does not seem to be any physical or psychological trauma that, by itself, could be made responsible for severe mental illness in children. Diagnosis based on pathology, i.e. ps may ultimately be the most useful one, but at present is too long-winded and uncertain to be of any practical value. It will therefore dearly be the descriptive approach to which we shall have to resort for making a diagnosis. SYMPTOMATOLOGY
None of the symptoms to be described, with the possible exception of one, are pathognomonic. Any one of them may appear in a number of other conditions, brain damage, neurosis, subnormality, etc. It is rather the constellation and the severity of the symptoms and their persistence which may produce the clinical picture of what might then be called psychosis in childhood,
PSYCHOSIS
IN
CHILDHOOD
23
Personal Relationships A typical psychotic child will be unable to make good contact with the adults or children in his environment. He could either be considered to be detached or withdrawn, or, as it has been called in the past, live in a world of his own, or his behaviour may be clinging, attempting to mould his body into that of an adult. T h i s " symbiotic "relationship, one assumes, is one which is to the mutual benefit, albeit neurotic or psychotic, of mother and child. It appears that in such children the extreme closeness between mother and child, which is a normal feature in child development for the first six months or so, has not given way to the development of individuality and independence in the child. Such symbiotic or empty clinging is difficult to describe in words, but can be felt most readily. The child may sit on one's lap or climb on to one's shoulders and yet one has not the feeling that any true emotional contact has been made. It is rather as if the child considers one as a piece of furniture to sit on, or a tree to climb on. The withdrawn, or so-called autistic child, remains apparently aloof from, and apparently unaware of, his environment. Though he may fleetingly look at one, there is neither interest nor concern in his look and he might walk past one as if he had not noticed one's presence. To a large extent, this lack of relationship can be modified by normal, affectionate care and attention and the reason for the extreme withdrawnness of some children may be that, for reasons other than the child's disturbance, contact with adults or children in his environment was not possible. I should make it quite clear here, as I will do later, that this does not imply that it is the fault of the parents if a child behaves in such severely disturbed manner, but rather that it is almost impossible for any parents to tolerate certain kinds of behaviour in their own children. It can sometimes be difficult to distinguish the empty clinging of the psychotic from the superficial, easy relationship of the institutionalized or deprived child but the deprived child, though he may wander from one adult to another, is clearly seeking attention, and the need for this is easily felt by the observer.
Speech Some disorder of speech is present in almost all psychotic children. The disturbance may be that a child has never acquired the ability to speak, or had begun to talk and then stopped, or speaks in an abnormal way. Abnormality of speech may basically be of two kinds : disturbed content of speech, or a disturbed manner of talking. The disturbed manner could be characterized by unusual inflection, either excessive or monotonous. The content might show disorder of thinking, bizarre fantasies, neologisms, echolalia. Such children can also show unusual fears of the spoken word which is addressed to them. Some quite harmless sounding words or sentences may cause extreme anxiety or provoke aggression.
24
PUBLIC
HEALTH
VOL.
LXXVII
NO.
1
Absence, or unusual development of speech, is often one of the first signs of abnormality that bring the child to the attention of the doctor. Although clearly there are many reasons for unusual or late speech development, the possibility must be considered that it might indicate severe emotional disturbance. This possibility must particularly be borne in mind if acquired speech, however rudimentary, has been lost or is not progressing satisfactorily. A differential diagnosis of developmental aphasia will always have to be considered in a non-talking child, but as so little is known of either condition, both as regards origin and treatment, thorough and prolonged investigation would be necessary in either case.
Perceptual Disturbance Perhaps the most common cause for referral for a child that later is diagnosed as suffering from psychosis, is apparent deficiency of hearing. In such children, as a rule, no physical abnormality can be found and although the possibility always exists that there is some undefined constitutional deficiency, the peripheral hearing apparatus is clearly normal. This type of behaviour can be classed under the heading of perceptual disturbance, namely a disordered function of one of the sensory modalities, without any evidence that the sensory apparatus itself is diseased. Perception can, for that purpose, be defined as those mechanisms or functions which are interposed between sensory input and the organism's response to it. It does include, therefore, the individual's psychic make-up and can be considered as an active selective process. A child suffering from what is considered auditory imperception or auditory avoidance will at times react to the spoken voice, at times not, and in many ways react as if he were either deaf or partially deaf, except that he may appear actively to avoid sound by turning his head or covering his ears. Visual avoidance would manifest itself by the child not looking at, or actively looking away from, a person or half or completely shutting his eyes. An example of this was shown by S. who, as a three-year old, blinded himself for three days by putting ointment in his eyes but who, throughout this period, walked and generally behaved the same as when he was able to see. It should not be understood that these children are in fact unaware of sound or visual stimulation, but rather that the external world is not meaningfully appreciated. Perceptual disturbance may also manifest itself by the prominence, or excessive use, of one or the other sensory modality, particularly touch and smell. Some children will appear to be still in the stage of an infant who likes to feel everything and comes to know objects by putting them to his mouth, some may even " l e a r n " about the environment by mouthing up and down furniture or walls. Others will sniff at their environment or put objects to their noses. Another feature which may fundamentally be caused by perceptual disturbance is the unusual use many of these children make of objects around them. Preoccupation with sameness has been ~ e s c d h ~ as one of the most
PSYCHOSIS
IN
CHILDHOOD
25
common behaviour patterns of psychotic children, e.g. the flicking of a stick or string, putting small objects into rows or piling them into heaps. One child known to us would, if left alone, interminably stroke his palms with leaves until they became sore and even bleeding. Another child would, with great skill and persistence, kick small objects along the floor incessantly, walking up and down. Such preoccupation with sameness will have to be distinguished both from similar play seen in the severely subnormal child, and in the ritualistic behaviour of the severely obsessional child. Whenever there is evidence that there is inadequate appreciation of the spoken word, one will attempt to distinguish between what has been described as auditory imperception and deficient hearing due to physical causes. In a large number of cases, however, the results of repeated and prolonged tests remain equivocal. Motility It is here that we may find the one behaviour pattern that is almost pathognomonic of psychosis : spinning of the body. The child turns round and round sometimes slowly, sometimes reaching an almost frenzied climax, but never showing any signs of giddiness. It is this absence of any apparent disequilibrium which distinguishes this activity from similar ones seen in normal children. In addition to spinning themselves, these children may spin round objects, plates or ashtrays for instance, and show extraordinary skill doing it. Head-banging and head-rolling are frequently seen and so is rocking, with the child kneeling or sitting, or standing up and moving the body back and forth. Movements, particularly of locomotion, can show a lack of fluidity, a clumsiness which is in contrast often to the rapidity with which they ear carried out. Some move in a careful, pigeon toed walk, others dart across the room from one wall to the other, one child in our experience wriggled his way like a worm from place to place though he was quite able to walk. The unusually good sense of balance of some children is probably due to their lack of appreciation of real danger. Some movements (rocking falls into this group) are done probably because they provide some sensory satisfaction, e.g. turning of the wrists, hand-flapping and finger-play. The child moves the fingers in front of his face, looking through them, perhaps finding pleasure in the light changes such movement produces in front of the eyes. It is the sort of play which is normal in the baby. This list of symptoms is by no means exhaustive, nor, it must be repeated, is any one, with the possible exception of spinning, in itself characteristic of childhood psychosis. The aim here is to focus attention on four areas of the child's behaviour, all equally important and all usually affected in the nuclear type of the disturbance. It must be admitted, though, that when we talk of disturbances of speech, motility, perception and emotional contact we talk of things of a different order. Abnormalities of speech and motility we can
26
PUBLIC
HEALTH
VOL.
LXXVII
NO.
1
directly observe, but when we discuss symptoms under the heading of disorders of perception and emotional contact we mix observational data with presumed causation. This in itself need not detract from the usefulness such a brief guide towards diagnosis may have.
DevelopmentalHistory Most of our information of the early development of the child that later becomes psychotic is retrospective. Thus most of the more subtle points are missed and many of the cruder ones over-emphasized. The parents may reiterate incidents with great clarity, incidents that may have stayed in their minds for a variety of reasons but which have little immediate relevance to the child's illness. On the other hand, important and relevant information is hidden by parents who feel uneasy and guilty, though their conscious intention is to give the fullest information. Most parents will say that the child has been normal up to a certain age, often about two years, that then progress was halted and from that time over-all deterioration set in. They noticed that the child stopped learning new words, that he stopped using the words he knew, or that his speech became increasingly unintelligible. His behaviour altogether became aimless and his play, if there was any, was not constructive. It is often difficult to be sure that indeed there was a period of normality followed by deterioration. The more one delves into the history, the more one finds that many of these apparently normal children revealed certain early abnormalities. The mother might s a y that he wasn't really a cuddly baby, particularly when she compared him with another child, that his " s p e e c h " didn't really amount to more than a few unclearly spoken words used mostly in imitation, and that he never showed any inclination to persistent or constructive play. If, however, the mother insists that indeed behavioural changes have occurred at a certain age, she may relate accidents, such as falling off a table or some emotional upset at home, as possibly responsible for the child's illness. It is in fact unusual that one can convince oneself that there was any physical or psychological trauma that can be made responsible for the deterioration. Meningitis or encephalitis can, of course, at any age cause permanent personality changes and in a few of the psychotic children there is a history of unexplained high fever of a few days duration, accompanied by high-pitched, inconsolable crying. Teething is often blamed for this but it may be that some of these febrile episodes are episodes of an encephalopathy. Although a thoroughly taken history will reduce the number of cases in which an undoubted change in the developmental progress of the child occurred, there are certainly some psychotic children in whom the early development must be considered normal. In some children it was quite clear to the parents from the beginning that their child was not normal, despite the absence of physical stigmata and although physical milestones are within normal limits. Such children take little
PSYCHOSIS
IN
CHILDHOOD
27
notice of the environment, they have no interest in simple toys such as rattles, they show no discrimination of faces and they are either excessively restless and noisy, or, more commonly, excessively quiet. Parents sometimes describe such a baby as extremely placid and good. There may also have been feeding difficulties, difficulties in sucking for the first few days and the child never put objects to his mouth or sucked his thumb as other infants do. Speech never developed beyond the babbling stage. The differential diagnosis from severe subnormality will be on the basis of the symptomatology and absence of physical stigmata. THE
PSYCHOTIC
CHILD
AND
HIS
FAMILY
There is no convincing evidence that childhood psychosis is genetically determined, and as such it is significantly different from adult schizophrenia. One of the most common misconceptions is that the child's disturbance is directly attributable either to mishandling by his parents, particularly mother, or to unsatisfactory conditions in his family. It is possible, though as yet unproven, that a subtle disturbance during the early mothering of the child may be a contributory factor to the illness, but so far investigation of the parents of psychotic children has not revealed that home conditions or the handling of the child are significantly different from that of parents of normal children. Disturbance of the subtle interchange in the mother-child union need not only be due to personality difficulties of the mother but could equally well, and primarily, be caused by the child's innate inability to provide the necessary stimulus for good mothering. It is in this area of family relationships that childhood psychosis becomes a problem of large proportions. There is probably no other disturbance in childhood which could produce such devastating effect on the family. The physical management alone tends to make the home child-centred. Mother, or possibly father, may be the only ones who dare, or are able, to look after the child, all activities of the parents have to be more and more restricted to allow for the care of the child. This interference with, and limitation of, the parents' own life arouses mixed feelings which increases their already often present feeling of guilt for having produced such a child. The time and energy spent on the young patient is often taken from the attention that would otherwise be given to husband or the other children. This can produce marital difficulties and add to the bewilderment of the siblings, who already find themselves puzzled and frightened by the unusual behaviour of their brother or sister. Neighbours complain or comment, grandparents or aunts and uncles criticise. Thus, when considering our relative ignorance of childhood psychosis and the impact the psychotic child has on his immediate and sometimes wider environment, it seems imperative that our attention should be focused on the investigation and treatment of this group of conditions. Facilities at present are pitifully inadequate for that purpose, and only the most intensive psychological care and exploration, coupled possibly with well integrated physical research, will help us to elucidate severe mental illness in childhood.