All children are psychotic

Psychosis is a misunderstood term. Journalists are always confusing it with psychopathy, just as they often still insist that a 'schizophrenic' is someone with a Jekyll-and-Hyde-style split personality. (I could blame T. S. Eliot for this, but that would require another post.) In newspaper-speak, calling someone psychotic seems to mean that they are especially nasty and especially cold-hearted, in the mould of Saddam Hussein or Abu Musab Al-Zarqawi (I once saw both described thus, within a page of each other, in a British Sunday newspaper). If I were one of the large number of people who suffer in silence from a psychotic disorder, I would feel angry and more than a little betrayed. The irony is that psychosis found favour as a term among those many clinicians and researchers who were tired of the deep-rooted misconceptions about schizophrenia, and who now find that their preferred term has become as semantically garbled as its predecessor. 

In fact, psychosis refers to a group of psychiatric disorders which involve some disturbed relation to reality. The hallmarks of psychosis are symptoms like hallucinations (the perception of entities that are not actually present) and delusions (irrational, unshakeable beliefs about how things are). Among patients who receive a diagnosis of schizophrenia, one of the most common such symptoms is auditory verbal hallucinations, or hearing voices when no one is speaking. There is good evidence that these experiences are not confined to those with psychiatric diagnoses. Although voice-hearing can be a distressing, frightening and debilitating experience, several recent surveys have shown that a sizeable minority of healthy people hear voices and live with them quite comfortably. It may be entrenched in our cultural understanding as a first sign of madness, but voice-hearing is a phenomenon that affects people right across the spectrum of sanity and insanity.

It may also be an experience that is particularly prevalent in childhood. Last month saw the appearance of our article on children's susceptibility to imaginary verbal experiences, and the culmination of some research conducted over a number of years in Australia, the UK and the US. The roots of our work lay in some classic studies with adult psychiatric patients. In the 1970s, an experiment by Mintz and Alpert showed that voice-hearing schizophrenia patients (when compared to non-voice-hearing patients) produced especially vivid auditory imagery in the absence of any relevant stimulation. In the 1990s, Feelgood and Rantzen found a similar pattern among healthy adults who scored highly on a measure of susceptibility to hallucinations. Their experiment involved playing college students a recording of white noise and asking them whether they could hear any words being spoken. The students who were more prone to hallucinations were more likely to report having heard voices speaking amidst the noise. As described in his popular book on the psychology of psychosis, Madness Explained, Richard Bentall has suggested that voice-hearing happens because hearers have a difficulty in distinguishing between real and imagined events. Under certain circumstances, the individuals affected become tricked into believing that an experience, like a voice, that they have imagined has actually been perceived from the outside. 

This is a mistake that is particularly likely to occur in childhood. Young children have rich imaginative lives, but they also have a rather weak understanding of the boundary between reality and fantasy. Asking children to decide whether an experience is internally or externally generated may therefore be a tall order. We wondered whether one indicator of children's susceptibility to such confusions might be their reporting of imaginary companions. Dating at least as far back as Julian Jaynes' classic (and controversial) study of the origins of consciousness, several observers have noted that engaging with an imaginary playmate bears similarities with the experience of hallucinations. In a 2001 article, a team from the Isle of Wight found that children (aged 9–11) who admitted having had an imaginary companion were more likely to report hearing words in a recording of a human voice which had been treated so that the language was unintelligible. In our own study, we made some improvements to methodology and found the same results in two younger samples of children (ages 4–8). Children who reported having an imaginary friend were more likely to say that they heard words being spoken in a recording of jumbled-up, meaningless speech sounds, and this relation could not be accounted for by any obvious factors like age, gender or IQ. 

There are several reasons why children might be susceptible to confusing an imagined experience with a real one. Although kids often show a good understanding of the distinction between fantasy and reality, they can give out rather mixed signals when asked whether their imaginary friends are real or not. My niece, Annabel, had an imaginary friend called Mr Plate, who liked eating peas but was very badly behaved. When I asked her whether Mr Plate was real, she was indignant. Of course he was only pretend; how could I possibly think otherwise? And yet when I asked her whether I, a reality-rooted adult, would be able to meet and talk to Mr Plate, she promised that this could be arranged. I think we can get too caught up on the question of whether children know the difference between what is real and what is not real. Much more fruitful, in my view, is to ask what children understand about their own mental experience. In the strange world of childhood, what is internal is also external. Thoughts bleed into reality, as what is objectively real gradually takes up residence in the world of the mental. Drawing the boundary of one's individual mind, as a hermetically sealed entity that is unknowable to others, is a childhood's work.  

One issue is that young children have a rather weak understanding of how thinking operates. Indeed, they probably do not start to think, in the sense of experiencing a predominantly verbal stream of consciousness, until they have had a chance to internalize the linguistic social dialogues that are going on around them. In Chapter 8 of The Baby in the Mirror, I look at the work of the great Soviet psychologist, L. S. Vygotsky, whose writings have transformed our understanding of how thinking develops in childhood. Vygotsky argued that the ongoing internal conversation we call 'thinking' develops when the child's social interactions become reconstructed internally, in their own private experience. The implications of this theory, such as that our thinking has the quality of a dialogue with ourselves, are profound. But one simple implication is that inner speech arrives in children's heads at a certain point in development, and therefore, for a time, will seem unfamiliar. It is possible that young children have these experiences of hearing internal voices engaging with each other in the dialogue of thought, but simply do not recognise them as thinking. Instead, they may attribute them to some external agency, such as an imaginary friend. 

This still leaves us with a paradox. Psychologists such as Marjorie Taylor and Stephanie Carlson have argued, on the basis of their own careful empirical studies, that engaging with imaginary companions is generally a 'good thing' for children's development. Some studies, for example, have shown that children with imaginary companions do better at tasks measuring social understanding and creativity. And yet our view of imaginary companions seems to depict such children as having a weaker grasp of how thinking works. The solution to the paradox may lie in the unexamined assumption that what may be a cause for concern in adulthood must also ring alarm bells when it occurs in childhood. A child's mind must be a strange place to be. Trying to project oneself imaginatively into these unfamiliar spheres of existence is exhilarating, but not always straightforward. 

I don't say much about imaginary companions in the book, because it covers a developmental period when pretend friends are not really yet in evidence. In fact, Athena's friends have been almost exclusively real ones. Her brother is much more of a fantasist. Isaac doesn't yet have a distinct, named imaginary companion, but he is always telling us about his 'other house', where there are pet lions and reindeer and pigs that keep breaking into the kitchen and making a terrible mess on the floor. 'Is your other house real,' I ask him, 'or only pretend?' He is adamant that it is as real as this one is. I ask him whether I might be able to go to his other house one day, and he says yes, although—and I detect a subtle attempt to protect his fantasy—it is a long way away and I would probably fall asleep on the way. 

So: all children are psychotic. There is some truth in the statement, if we accept that experiences that can be abnormal in adulthood can be perfectly typical in childhood. Young children's experiences have some similarities with the unusual perceptions and beliefs that both healthy adults and psychiatric patients report, and they may also share some common underlying cognitive mechanisms. One thing that's certain is that we need to use the term 'psychosis' properly, and concentrate on the specific experiences that we want it to refer to. If we are careful to do that, understanding the strange world of the young child could have benefits that extend far beyond the playground. 

(With apologies to Douglas Coupland for the title.)