From the moment he was handed to me in the delivery room, Alex, my firstborn, seemed not happy to be here. His eyes were bottomless, his expression grave. He spent his first three months writhing and screaming inconsolably, the word “colic” wholly insufficient to describe our collective suffering. It wasn’t until his brother, Sammy, arrived that I realized just how different Alex was compared with other babies. Sammy cried only when he was hungry or wet. He made easy eye contact and loved to be stroked, hugged and kissed—all the things Alex recoiled from as an infant.
Later, when I took Alex to playgroups, he crawled away from the other toddlers to do his own thing, so we quit going. It wasn’t that Alex appeared unhappy. He would sometimes sit and smile with satisfaction for no apparent reason. At age two and three, Alex attended a Montessori preschool. Although he enjoyed the hands-on activities, his teachers often commented that he usually ignored them as well as the other children. His first grade teacher thought he must be hard of hearing because he routinely ignored her directions, especially the daily reading and writing drills she assigned. In one of the first studies ever done with families afflicted with schizophrenia, the Edinburgh High Risk Study, Scottish mothers commonly described children who went on to develop the disorder as occupying a world of their own.
I had so often thought of Alex the same way.
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Alex first began to manifest the so-called negative symptoms of schizophrenia in puberty. These included a loss of motivation, social and emotional withdrawal, a disinterest in hygiene and dress, and trouble sleeping. The term “positive symptoms” refers to the more obvious behaviors we think of as “crazy”—hearing or seeing someone who is not there, for example, or holding fixed, illogical beliefs—and they would unfortunately come, too, a little later, as they are known to, right before the first psychotic break.
Knowledge of schizophrenia as a long-term disease process has existed since the early 20th century. The initial signs of this process—the impaired body sensations, reduced tolerance to stress, increased emotional reactivity and, especially, social deficits—“can appear more or less continuously between two months and 35 years prior to their progression to the first psychiatric symptoms,” wrote German researcher Joachim Klosterkötter of the University of Cologne in a 2001 essay.
Although much of the profession still focuses on the debilitating full-blown illness, paying attention to its origins and early stages provides the greatest chance of altering its course. In particular, adjusting a child’s environment is one important way of minimizing the impact of this serious mental illness. Parenting does not cause schizophrenia, at least not on its own, but that does not mean that parents and other adults are powerless to protect children from it.
Weighing the Chances
In an 1896 treatise German physician Emil Kraepelin observed that many of the children of his schizophrenic patients, especially those who would go on to develop the disease themselves, were “a little different in character and behavior from their peers—beginning in early childhood.” The accumulating evidence now backs up Kraepelin’s observation that a significant number of individuals later diagnosed with schizophrenia display some common and often peculiar traits and experiences as children or adolescents.
Knowing risk factors and warning signs can save many children from being diagnosed too late for the most effective treatment. With autism, for example, the American Academy of Pediatrics has issued guidelines for parents and physicians as a result of lobbying efforts by autism advocacy organizations. Parents are to watch for possible behavioral signs such as a baby avoiding eye contact, being slow to babble or experiencing sudden developmental regressions, and screening is recommended for infants as young as nine months. Parents and doctors can begin to think similarly about other childhood mental disorders, including schizophrenia.
The prevalence of schizophrenia in the general population is 1.1 percent, but if a parent has schizophrenia, the child has a 10 to 12 percent risk of developing it. She also has a 17.1 percent chance of developing a personality disorder in the same “spectrum” as schizophrenia, such as paranoid or schizoid personality disorder, compared with the background rate of 3 percent for these afflictions in youths, according to the U.S. Surgeon General. Her chances of an anxiety disorder are similarly raised—to 16 percent, from an average rate of 13 percent for children. The odds of having a conduct disorder also go up from 10 to 13 percent if a parent has schizophrenia. This same inherited liability can alternatively manifest as a learning disorder. Recent studies with “unaffected” children of a schizophrenic parent—meaning they are free of the disease’s symptoms—have established their higher risk for a retinal eye defect that can interfere with visual learning.
In addition, a well parent can pass on a risk for the disease without noticeably manifesting its symptoms. A carrier may have symptoms that are below the clinical threshold for a disorder. For example, a mother may display what psychologists call an idiosyncratic use of language, which is a low-level version of the “thought disorder” symptom that can occur in her adult child with psychosis. I discovered such a high-low symptom linkage between Alex and me. It arose when I would go “blank” midsentence, being briefly embarrassed by the words coming out of my mouth and scrambling to compensate with another clarifying sentence.
I trust you’re getting the picture that everything about your family’s medical and mental health history—including a relative’s weird habits, addictions and “moodiness,” any diagnosed medical or neurological condition, and unexplained accidents—can be relevant to your or your child’s mental health care today. Because so many of us don’t know our family mental health histories, we’re often thrust into the role of sleuths, connecting the dots among pieces of evidence to identify a vulnerability that may be lying in wait.
Very Early Signs
In one extraordinary family study from 1990, researchers at Emory University collected early home movies from families with a schizophrenic adult. The scientists easily identified the preschizophrenic kids from their siblings because of their flatter emotional states—they showed less joy or distress—and fewer coordinated movements. As the investigators suspected, the films depicted signs of schizophrenia decades before these children went on to develop it.
Recent studies have documented early psychotic symptoms in children as young as 12 and even five years of age. You may wonder, as I did, “Don’t all five-year-olds play pretend and have imaginary friends?” The answer is yes, they do. But, researchers say, trained mental health workers using reliable diagnostic interview tools can tell the difference between ordinary childhood fantasies and deeper signs of psychological trouble. None of the children participating in these studies were identified at the beginning as mentally disturbed, making the documentation of their lives and vulnerabilities a process of discovery for these researchers.
In one such study, the British Environmental Risk (E-Risk) Longitudinal Twin Study, 1,116 mothers with five-year-old twins participated in home-visit assessments. The 2,127 children in the group were evaluated first at age five and then followed to age 12 with 96 percent retention. In addition to the children’s mental health, interviewers assessed a wide range of factors in the child’s family, school and home that might contribute to a higher risk for psychosis.
Interviewers explored garden-variety symptoms of psychosis with questions such as “Do you ever hear or see things that other people can’t hear or see?” As it turns out, the vast majority of normal five-year-olds answer these queries as almost all normal 16- and 30-year-olds from a general population would, with a simple “no.” In the E-Risk study, 7.9 percent answered “yes,” putting them in the category of having a “probable” symptom of psychosis. Yet when researchers probed deeper, they determined that only 4.2 percent had a “definite” symptom of an auditory hallucination. To find out whether any of these children may have experienced a delusion, workers asked, “Have you ever thought you were being followed or spied on?” Here 2.5 percent had the probable symptom, but in the end only 15 children, or 0.7 percent, definitely displayed delusionary thinking.
Once signs of psychosis were confirmed in 125 children, researchers looked for common risk factors present in their lives. The most telling commonality was that all the 12-year-old children with current psychotic symptoms had had significantly more emotional, behavioral and educational problems at age five than did their asymptomatic peers. The most predictive problems, which tended to worsen with time, were antisociality and hyperactivity, but others were childhood depression and anxiety. The researchers acknowledged that these behaviors were not specific to schizophrenia and can occur in the context of other disorders, including ADHD, antisocial conduct, depression and anxiety.
One particular cause for alarm: these children with early psychotic symptoms were also more likely to have engaged in self-harm, which, according to their mothers, included cutting themselves with razors and beating their heads against the wall; one child even attempted a hanging. “Given the fact that children can conceal self-harm from parents, the association between psychotic symptoms and self-harm may be underestimated here,” the researchers wrote.
Although the vast majority of kids grow out of their early childhood emotional and behavioral challenges, an important minority do not get better on their own, researchers say. The children at highest risk are those living with others afflicted with serious mental health problems. In the E-Risk study, about twice as many of the affected 12-year-olds’ relatives had been admitted to psychiatric units, and 29 of these relatives had made suicide attempts.
Results from the longer-term, ongoing Dunedin Multidisciplinary Health and Development Study in New Zealand indicate that symptoms of psychosis at age 12 do, in fact, augur psychological problems later on. In this study, researchers assessed individuals born between April 1972 and March 1973 in Dunedin, starting at age three and again every two years thereafter. Psychiatric evaluations of 789 children revealed symptoms of early psychosis in 116, nearly 15 percent, who were not initially thought to be at high risk. The presence of such symptoms, the researchers found, was strongly predictive of personality disorders in young adulthood. Specifically, 42 percent of those who later developed either schizophrenia or a related personality disorder had reported experiencing a psychotic symptom, such as a hallucination, when they were interviewed at age 11. [For more on predicting psychosis, see “At Risk for Psychosis?” by Carrie Arnold; Scientific American Mind, September/October 2011.]
Although subtle signs in Alex manifested slowly in the course of his childhood, after he reached his 14th year, to say that all hell broke loose would be an understatement. I was, therefore, not surprised to later read national epidemiological data identifying 14 as the year by which half of all adult mental disorders begin, including anxiety disorders, bipolar disorder, depression, eating disorders, conduct and oppositional disorders, psychosis and schizophrenia. Scientists looking into this phenomenon attribute it to the tremendous growth spurt that begins in puberty when an adolescent’s brain, body and emotions are transformed as never before or ever again. This is also the age when the mental illnesses affecting boys and girls sharply diverge, with girls becoming suddenly more vulnerable to depression, whereas boys begin to populate clinics specializing in early psychosis.
Stemming Psychosis
Although most pubescent children sail through this normal maturational process, those at risk of becoming derailed by it need help. Negative risk factors for schizophrenia come in different forms. Many scientists believe that aspects of a person’s environment can activate the gene or genes that confer greater vulnerability to a disease such as schizophrenia. The bottom line is that a vulnerable young person can take only so many additional environmental insults before he reaches the point of no return.
How do we as individuals and parents work with known risk factors to prevent mental illness? We start where the scientific evidence is strongest. It is clear that a baby’s prenatal experience and the quality of parental care received during the first five years of life top the list of significant environmental risk factors. When a family has a history of mental illness, the research tells us that a high level of stress for a mother during the first trimester of pregnancy can raise a child’s risk for schizophrenia—as can obstetrical complications and a baby’s low birth weight.
There is now no doubt that physical abuse, bullying by peers and ingesting cannabis can do great damage to a genetically vulnerable prepubescent child. We understand that conduct problems in early childhood and adolescence can lead to antisocial adults and raise the risk for psychosis. Further, we know that where we live and the quality of schools can also change the odds. One big negative, for instance, is living in an urban environment. In the E-Risk study, for example, 65 percent of the affected children were city dwellers. Epidemiologists are not sure why: Are city residents more likely to develop serious mental illness because of urban social isolation, exposure to pathogens, stress or violence? Or do psychologically vulnerable people tend to migrate to cities?
Finally, we are very aware that the level of chaos in a household and the presence of untreated adult psychiatric problems can also negatively affect any child’s mental health—but particularly that of one carrying a higher genetic risk. On the other hand, growing up in a stable home with loving, supportive parents is the most powerful “neuroprotector” a child can have on her side.
If it sounds like I’m getting dangerously close to the historical tendency to blame parents for the psychological ills of a child, to a certain degree I am. I believe we’ve gone too far in the direction of blaming biochemistry and not taking responsibility for our own roles in shaping the health of our children’s brains. I’m advocating transparency and the taking of greater responsibility by everyone—parents, extended family members, mental health practitioners and our larger communities, including corporate health care and government-administered services—for the mental health of our children and future leaders. For grandparents, that may mean giving up an old family secret over which you still carry considerable shame. For parents, it means first becoming more educated about what factors contribute and detract from a child’s positive emotional growth.
In a 2009 report entitled Preventing Mental, Emotional, and Behavioral Disorders among Young People: Progress and Possibilities, the Institute of Medicine and the National Research Council assembled voluminous evidence to show that mental illness is preventable in children. Programs that teach parents effective parent-child emotional communication skills are among the most useful that have been tried. There were also robust positive results from interventions aimed at reducing substance abuse, conduct disorder, antisocial behavior, aggression and child abuse, as well as programs that help children struggling with depression after a divorce and efforts to reduce aggressive conduct in schools.
The issue of drug use is a particularly important one for parents to grapple with. According to the University of Michigan’s annual Monitoring the Future survey, marijuana use by American adolescents—especially eighth- and 10th-graders—was up in 2009 for the third year in a row, reversing a decline tracked since 1992. The age of first-time marijuana users is also dropping, and fewer teenagers believe there is a serious health risk associated with marijuana use. When Alex first started smoking pot, I did not view it as his biggest problem behavior. Far bigger, I thought, was the fact that he had not done his homework in recent memory. Yet as psychiatry professor Demian Rose of the University of California, San Francisco, told me, “the data are quite clear that heavy marijuana use increases the risk of developing chronic psychosis fivefold to 10-fold—even after young people stop using.”
A final note on school violence: in one study of 6,437 British 12-year-olds, researchers found that a child’s risk of psychotic symptoms was increased twofold if he had been bullied between the ages of eight and 10. If he had been more severely and more often victimized by his peers, the child’s risk of psychosis doubled or tripled.
In the past, our culture has quietly condoned bullying as a rite of passage by looking the other way. After a couple of decades filled with school shootings and other gruesome crimes committed by young people against their peers, this stand is no longer popular. Still, bullying continues. It has moved online and has become more prevalent among girls. If your child is being regularly teased, pushed, tripped, verbally harassed or ostracized at school or in the neighborhood or if he is being persecuted online through the misuse of social-networking Web sites, you must be your child’s first line of defense. Don’t wait. Act. The same goes if you witness another child being victimized in any of these ways.
Treating a child for the first signs of mental distress is the essence of early intervention and secondary prevention—the type used to stop an illness from getting worse. This treatment does not necessarily mean introducing a psychiatric medication. The earlier the symptoms are noticed, the less invasive or onerous the treatment tends to be. If medication is what it takes to stop the advance of a disease process in a child, however, any concerned parent should give it serious consideration and weigh the risks and benefits carefully. Most adult mental disorders begin in childhood or adolescence. Those that are treated before adulthood have the best outcomes—meaning a remission of symptoms. This is what we’re after.
This article was published in print as "A Mind in Danger."