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Preschool identification of and intervention for psychiatric symptoms has the potential for lifelong benefits. However, preschool identification of thought disorder, a symptom associated with long term risk for social and cognitive dysfunction, has received little attention with previous work limited to examining preschoolers with severe emotional and behavioral dysregulation. Using story-stem methodology, 12 children with ADHD and 12 children without ADHD, ages 4.0–6.0 years were evaluated for thought disorder. Thought disorder was reliably assessed (Cronbach’s alpha = .958). Children with ADHD were significantly more likely than children without ADHD to exhibit thought disorder (75% vs 25%; Fischer’s Exact Test = .0391). Thought disorder can be reliably assessed in preschool children and is present in preschool children with psychiatric illness including preschool children with ADHD. Thought disorder may be identifiable in preschool years across a broad range of psychiatric illnesses and thus may be an appropriate target of intervention.
The mental health field has demonstrated an increasing interest in indicated prevention; specifically the idea that early detection and treatment of symptoms not only improves acute function but prevents or limits the longer-term adverse impacts of chronic symptom expression. However, for this approach to be tested and, when appropriate, utilized, early detection of symptoms is critical. There are ongoing efforts to characterize preschool presentation of a variety of symptoms including attentional dysfunction, mood instability, and anxiety (1–10). However, preschool presentation of thought disorder, a symptom with high impairment potential, has received little attention.
Thought disorder is defined as “unusual or dysfunctional ways of thinking,” and can consist of a variety of symptoms including loose associations and bizarre or illogical thinking (11, 12). Thought disorder is an important symptom because it can cause dysfunction in several aspects of functioning (13). Thought disorder is correlated with poor executive functioning (14) and trouble with theory of mind which helps in social functioning especially with perspective taking (15).
Thought disorder is often present in psychotic disorders but can also be present in other disorders such as autism, epilepsy, schizotypal personality disorder, ADHD and in maltreated children (16–25). Methodology to assess thought disorder is available as young as 7 years of age; however, thought disorder has received little attention in preschool populations.
Recently, we have developed a process for identifying thought disorder in preschool children which involves the use of story stems (26). In preschoolers, thought disorder can manifest as bizarreness or violence outside of the initial content of a story stem or having props in a story come to life and act on their own accord. Story Stem paradigms can elicit violent themes in preschoolers with a history of violence or violence exposure; however, that violence tends to be expressed within the context of the story-line; the expression of violent themes unrelated to the story are thought to be more reflective of thought disorder. Similarly, while the purpose of Story Stem paradigms including props is for children to use (“play”) with the props, the embodiment of the prop with an independent identity whose actions are only tangentially or even unrelated to the initial story theme is unusual in other populations and felt to be evidence of thought disorder (26). Preschool children exhibiting symptoms of severe mood and behavioral dysregulation, which may now fall under the Diagnostic and Statistical Manuals, Fifth Edition (DSM 5)(27) category of Disruptive Mood Dysregulation Disorder (DMDD) commonly exhibit thought disorder, with 80% being identified as having thought disorder as compared to 9% of healthy comparison children (26). In children ages 7 and older, thought disorder is present not only in children with severe psychiatric illnesses, but also is present in a broader range of psychopathology including ADHD (28). This study seeks to determine if the same is true in preschool children: Is thought disorder associated with preschool ADHD?
This study recruited twelve children (9 female), ages 4.0–6.0 years old, with attention deficit/hyperactivity disorder, as confirmed via a structured diagnostic evaluation by an experienced clinician (as discussed below). Participants were recruited by a mental health consult service imbedded in a primary care pediatrics clinic at the Children’s Hospital Colorado. Exclusion criteria for a projected IQ < 70 (as discussed below) or parent reported major medical/neurological disorder, severe language disorder, and a history of physical or sexual abuse. A group of 12 (8 female) typically-developing children ages 4.0–6.0 were recruited from the same clinic using advertisements. Exclusion criteria for the typically developing group included the same criteria as the attention disorders group plus any DSM IV TR Axis I diagnosis as assessed using a structured instrument and family history of major psychiatric disorder including schizophrenia, bipolar disorder, schizoaffective disorder, major depressive disorder, generalized anxiety disorder, and obsessive compulsive disorder in a first or second degree relative as determined by parent report. One child was excluded from the typically developing group due to diagnosis of anxiety. Four additional children were excluded (2 with ADHD and 2 from the comparison group) because either they did not complete the required parent and child visits (n=2) or, during participation, the thought disorder assessment was incorrectly administered (n=2).
All participants were accompanied to the visit by a parent. Parents provided consent for their child, as monitored by a local Institutional Review Board. Parents were offered an honorarium for their participation. Table 1 contains demographic information for the study sample.
The vocabulary and block design sections of the Wechsler Preschool and Primary Scale of Intelligence (WPPSI-III or IV(29, 30)), completed by trained research assistants blind to group membership, served as a proxy for IQ to screen out intellectual disability or severe language disorder. The vocabulary and block design subtests are used as a proxy for full-scale IQ as they correlate at 0.84 and 0.85, respectively, with full-scale IQ (31). Results are summarized in Table 1.
Using the Preschool Age Psychiatric Assessment (PAPA) (1), participants were evaluated by a trained clinician through parent reported symptoms. Each symptom was given a score of 0 meaning not present, 2 or 3 meaning present and to indicate severity. The reliability of the PAPA has been previously assessed in children down to age 2 years with test-retest correlations from 0.56–0.89 for the DSM-IV syndrome scale scores (32). A section was added to the PAPA administration designed to assess for symptoms of DMDD (Appendix 1). Diagnostic categories can be found in Table 1.
Children participated in story completion of four stories, three that are adapted from the MacArthur Story Stem Battery (33) and one story from the Family Story Task (FAST) (34). In each story, the child is provided with characters and small props related to the story, such as a cooking pot and tiny, non-sharp pretend knife, or small non-sharp saw or hypodermic needle made with stickers and a paperclip. The child is given the beginning of the story and asked what happens next. After a practice story, with guidance from the examiner to elaborate using narration and motions of the props, no prompts are given after the story stem unless the main problem is not addressed by the participant. Story Scripts for the birthday party story and “Spilled juice” story can be found in (35). The Band-Aid Story can be found in (34). Please see Appendices 2 and 3 for the “Saw” and “Vaccination” stories, as these were unique stories created for this study based on guidelines from (35). The childrens’ responses to the story stems stories were videorecorded for later scoring by a blinded coder.
The scoring method used to rate thought disorder was developed to address prevalent themes in stories found in prior work (26). These themes included bizarreness or violence outside of the original story stem and props coming to life and acting on their own accord. Recordings were blind coded by a trained rater (AH), blind to subject group membership. 50% of videorecordings were re-rated by another trained blind coder (KK), also blind to subject group membership.
Thought disorder was frequently present in preschool children. Examples are presented in Table 2. Each subject was assessed in four stories; each story was scored for presence/absence of bizarreness/violence outside the context of the story and props coming to life (8 possible data points per child). Thought disorder was identified in at least one child for each of the four stories utilized (Table 3). Reliability was high across all data points (Cronbach’s alpha = .984) and when determining whether each child had evidence of thought disorder in at least one story stem (Cronbach’s alpha = .958). One point on one story differed between the two coders. With the one disagreement the primary rater scoring was used.
Seventy-five percent (n=9) of preschoolers with signs of attention disorders versus 25% of typically developing preschoolers demonstrated bizarreness or violence outside of the original story stem in at least one story (Fisher’s exact test = .0391).
Thought disorder is present in some preschool aged-children and is reliably detectible. This is consistent with the previous reports (26), providing additional support to the hypothesis that thought disorder can be reliably detected in preschool children using story stems.
The proposed criteria for classifying a story stem response as thought disorder is that the response includes either violence outside of the initial content of a story stem or having props in a story come to life and act on their own accord. The inclusion of an either-or criterion was based on previous work with a group of severely psychiatrically ill preschoolers where some children demonstrated one or the other type of response, but not both. In this study, having responses include having props in a story come to life and act on their own accord was uncommon and did not occur in the absence of violence outside the initial content of a story stem. Given the small sample sizes in both this and previous work, it is unclear whether a true difference in frequency of having props come to life is present; however, this should be investigated as a potential marker of either diagnostic specificity or illness severity.
The primary goal was to assess whether, in preschoolers, thought disorder is associated with ADHD. Thought disorder was three times more likely in children with ADHD than in a typically developing comparison group, suggesting that, as is true in older children, thought disorder extends to a broader range of preschooler psychopathology including ADHD.
ADHD rarely presents in isolation and 50% of the children in this study with ADHD also presented with comorbidity. This high rate of comorbidity is consistent with studies of older children with ADHD and thought disorder, which had rates of comorbidity as high as 95% (28). In this study, particularly in the context of the small sample size, we cannot rule out that thought disorder may be related to the other psychiatric comorbidities. However, in the ADHD group, the likelihood of thought disorder was similar for preschoolers with (five of six) and without (four of six) psychiatric comorbidity, suggesting an association with ADHD.
Both the clinically referred and typically developing sample was largely female which, particularly when combined with the small sample size, prevented examination of gender as a contributing factor. However, previous studies have been weighted toward male samples (65%) (26), suggesting thought disorder presents in both genders.
Meeting criteria for any DSM-IV Axis 1 psychiatric disorder was an exclusionary criterion for the typically developing comparison group, yet twenty-five percent 25% of the typically developing group also demonstrated thought disorder. This was unanticipated and higher than previously reported. Additional factors not assessed, such as home environment or violence exposure insufficient to elicit post-traumatic disorder symptoms, may have contributed to thought disorder in control children. However, given the recruitment of ADHD and comparison subjects from the same population, these factors are likely equally distributed across groups and thus do not detract from the identified relationship to an ADHD diagnosis. With the small sample size, it may also represent a random deviation from population based values. It is unclear whether thought disorder in the healthy comparison group is a transient phenomenon of little clinical significance or reflective of subclinical symptoms that may predict increased risk for later illness. Longitudinal work will be necessary to address this issue.
Thought disorder is a symptom common to several psychiatric diagnoses that can cause dysfunction. This study extends the finding that thought disorder can be reliably identified in preschool children and that it is more common in children with ADHD. While thought disorder has been clearly defined in older populations, in preschool children using story-completion themes of violence or bizarreness and props coming to life and acting on their own seems to be reliably detectable across sexes, severe mood and behavioral dysregulation, and also ADHD. At this point thought disorder is demonstrated in some typically developing children but it is unclear if this is a precursor to psychopathology. With the increased interest in recognizing psychiatric illness and it’s precursors as early as possible, it is important to look at symptoms that are detectable in the preschool years and may be a target for intervention. Thought disorder may be an etiological factor in later development of social and cognitive dysfunction.
We would like to thank JoAnn Robinson for her valued consultation on study design and data analysis, Cathy Danuser for help with recruitment and Kimberly Mulhauser, Michelle Six, Jose Baron, and Meredith Tittler for their strong effort in data collection. We also thank the preschoolers and their families for generously donating their time to take part in this study.
This publication was funded, in part, by NIH grant 5R01MH101295, the American Psychiatric Institute on Research and Education (APIRE)/Janssen Resident Psychiatric Research Scholars, and by the American Academy of Child and Adolescent Psychiatry (AACAP) Pilot Research Award for Attention Disorders and/or Learning Disabilities for Junior Faculty and Child and Adolescent Psychiatry Residents supported by the Elaine Schlosser Lewis Fund. The manuscript’s contents are the responsibility of the authors and they do not necessarily reflect the official views of AACAP or the Elaine Schlosser Lewis Fund.
Story Theme: Sharp Object
Props: wood, saw
Characters: C1, C2, D, M
E: Mom is working in the garden. Robert/Rose and Michael/Michelle are playing in the backyard and watching Dad make them a new play house. They have been so excited about helping Dad build their new house so they can play in it. Dad is using a sharp saw to cut the wood.
D: “Girls/boys, I have to go next talk to mom in the garden, but I’ll be right back. Stay off the wood and don’t touch the tools while I am gone, okay?”
E: Show me and tell me what happens next.
Issue Prompt 1: What did the kids do while Dad was gone?
Issue Prompt 2: Then what did Dad say when he returned?
Remove: wood, saw, C2
Story Theme: Sharp Object
Props: Table, Needle
Characters: C1, D, M, Nurse
E: Robert/Rose goes to the doctor’s office with his/her mother and father to get a vaccination, the kind of good shot that prevents illness. When Robert/Rose gets to the office, he/she sees the nurse and the hypodermic needle on the table.
N: It’s time to give the shot.
E: Show me and tell me what happens next.
Prompt: What about Robert’s/Rose’s shot?
If no clear ending is presented:
Is this a good place to end your story? OR How does the story end?
Remove: Table, needle, nurse