childhood trauma and bipolarWe often discuss the stressors that play a role in triggering bipolar disorder in adults who have a genetic susceptibility to it, but what about stressors in childhood?

Results of a study published in the January 2011 edition of the American Journal of Psychiatry entitled “Childhood trauma and children’s emerging psychotic symptoms: A genetically sensitive longitudinal cohort study,” claim to show that childhood trauma from maltreatment and bullying is associated with children’s reports of psychotic symptoms.

While the report serves an important role in calling attention to the serious psychological and psychiatric damage that intentional abuse and bullying can cause, it also raises the question of what is and is not psychosis, especially in children.

Reviewing the Report’s Findings

The findings in this report seem to suggest that trauma in childhood is associated with higher rates of psychotic symptoms at age 12 years – specifically higher rates than in those who have not experienced such trauma. Interestingly the data also suggest a higher risk of psychotic symptoms is related to trauma events that are associated with intent to harm – abuse by an adult or bullying by a peer – as opposed to trauma that was accidental.

The findings also suggest that the more trauma is experienced, the higher the likelihood of psychosis – a “dose dependent” relationship between dose of trauma and likelihood of psychotic symptoms. Furthermore these higher risks of psychosis were not due to genetics, IQ, socioeconomic deprivation (i.e. poverty), or early psychiatric symptoms.

This is powerful data regarding a group of children followed from birth until age 12, which is one of the best ways to look at how children’s psychiatric problems evolve over time. And it adds even more fuel to the public health argument that being vigilant for abuse and bullying is one of the best ways to prevent psychiatric problems in children – leading to better outcomes for the child and family and lower costs to the community in the future.

Questioning the Definition of Psychosis in Children

My problem with this study is the definition of psychosis. It has always been difficult to be clear about what is and is not psychosis in children. Children have vivid fantasy lives, making it quite challenging to distinguish between childhood psychosis and fantasy.

There is also a long standing debate about the self-report of psychotic symptoms; for instance, when a child reports hearing voices, is that true psychosis or are they sorting out their own internal monologue and defining it as a voice? That is a developmentally difficult question to answer.

Often in adults with psychosis, they do not have insight into their psychosis. When they “hear a voice,” they believe it to be real, so they will often tell you, at least early in their illness, that they do not hear voices. When a child talks about angels following them home from school to guard them, is that a childlike religious belief or a true delusion?

Actively engaging with an angel, seeing the angel as controlling other people and events, and changing one’s own behavior in response to the angel are more characteristic of a hallucination or a delusion. But is just believing an angel is present psychosis? This is a tough call, especially in a child.

Diagnosing Psychosis in Children

In reading the article I was not convinced that I would have diagnosed so many of these children with psychotic symptoms. I tend to rely on more active, observable findings such as:

  • Disorganized and fractured thinking or speech.
  • Observable responses to voices.
  • Frank delusions about the world that are inconsistent with age and developmental level.

Childhood Psychosis Over-Diagnosed or Under-Diagnosed?

The percentage of children that these authors report as having a definite psychotic experience is close to 6% of the study population, which is a huge number of children. Many other studies would suggest a much lower frequency of psychosis in 12 year olds.

There tends to be something of a split in the professions: those who feel psychosis in children is under-diagnosed and more common than we think, and those who find it very rare. I tend to fall in the latter category, so this article goes against my assessments of the frequency of psychosis in children.

While the issue of childhood trauma and psychiatric symptoms is important, and this data suggests connections, I am not sure that the connection with psychosis is well supported yet.

Note: The writing of today’s post generated an interesting discussion about the definitions of “psychosis,” “delusions,” and “hallucinations.”

Tune in Friday for definitions and explanations of these terms.

Photo by Jeremy Weate, available under a Creative Commons attribution license.