- Breathing: Have the child breathe in for three seconds, hold their breath for three seconds, and then breathe out for three seconds. For younger children, the very act of focusing on this activity will ground them to the moment. For older children and teens, there might be more instruction like having the child focus on how the breath feels coming in, holding it in their lungs, and finally blowing out through their nose or mouth.
- Seeing the world: Ask the child to spend a minute looking around the room while being silent with the goal of finding things in the room that have never been noticed before. After one minute, the child should be asked to share the most interesting thing that they see now but have not noticed before.
- Feeling objects: Provide the child with an object or series of objects and ask them to spend a minute just noticing what the object feels like in their hand. Guiding them to attend to the texture, temperature, size, shape, etc. Afterwards, ask the child to share what they noticed.
- Listening: Ring a bell or other chime-like noise that provides a long trailing sound. Ask the child to indicate when they can no longer hear the sound. After the ringing ends, ask the child to listen to any other sound they hear for the next minute.
- Emotional acceptance: Young children tend to be more “in the moment” than most when it comes to emotional experience. When a child is expressing an emotion, rather than tell them “You’re okay,” validate their emotional experience and let them know it is okay to be angry, sad, etc. Then follow with asking your child how their body feels when they are in this emotional state. This process can help children to be more in touch with their bodies and begin to recognize how their emotions feel in their body to create greater emotional awareness.
- Headspace.com – https://www.headspace.com/headspace-meditation-app
- Calm.com – https://www.calm.com
- Mindful.org – https://www.mindful.org/meditation/mindfulness-getting-started
By: Stephanie Monaghan-Blout, Psy.D.
Pediatric Neuropsychologist
Emerging Psychosis: When to Worry about Your Teen’s Thinking
Teenagers are famous for incidents of bad judgment and poorly considered decisions; it is one of the rites of passage for parents and children to have had at least one “What were you thinking?” discussion before the teen leaves the family nest for college or employment. These events are often memorable, however, because they tend to be outliers, occurring simultaneously with instances of relatively accurate appraisals of situations and relatively adequate problem-solving as they navigate the expectations of school, family, friends, and community.
Some parents must confront a separate set of ongoing concerns about their child’s thinking that effect their assessment of the world and themselves. In this article, I will talk about the nature of psychosis, describe the changes leading up to an episode of psychosis and outline emerging models of treatment which aim to prevent the first acute episode or at least delay onset of the episode as much as possible. These findings emphasize the critical importance of early identification and treatment of symptoms to prevent or reduce future impairment.
The Nature of Psychosis
Psychosis refers to a condition in which a person has lost contact with reality and is unable to distinguish what is real and what is not. Psychotic symptoms include what are called “positive” (what is present) and “negative” (what is absent) symptoms.
- Positive symptoms include: abnormalities of thinking in both content as well as form; the former refers to distortions of reality such as hallucinations or delusions, and the latter refers to disorganization of thinking and bizarre behavior.
- Negative symptoms refer to the reduction of emotional response (“blunted” or incongruous affect), apathy and loss of motivation, social withdrawal, impaired attention, reduced speech and movement, loss of enjoyment in life (“anhedonia”).
Researchers have also identified subtle cognitive impairments that include:
- Deficits in processing speed
- Executive function
- Sustained attention/vigilance
- Working memory
- Verbal learning and memory
- Reasoning and problem solving
- Verbal comprehension
- Social cognition
The impact of these issues can result in severe functional deficits across a range of domains such as work, school, and relationships.
Psychosis is now thought to be a neurodevelopmental disorder, meaning that it is thought to be related to abnormalities in brain development that become apparent as the brain matures in adolescence. Psychosis is thus a condition that emerges gradually as the underlying dysfunction comes to the fore. It is also thought to be a neurodegenerative disorder, meaning that the disease causes physical changes to the brain that results in impaired functioning. These changes include, on average, slightly larger lateral ventricle and slightly less cerebral gray matter for people at the first psychotic break compared to controls. From a behavioral perspective, researchers have found that the longer people live with an untreated psychosis, the more likely they are to experience functional impairments, have a poor response to psychiatric medications, and experience a poor quality of life. These alarming findings have prompted researchers and clinicians to research the period of time before the first psychotic break, referred to as the prodromal period, where symptoms start to emerge, in an effort to discover a way to divert or slow this process.
The Prodromal Period
The prodromal period is a time when “subclinical”, or milder symptoms of psychosis begin to appear. This period can vary in length from a few weeks to a few years. During this period, the adolescent or young adult may experience mild disturbances in perception, cognition, language, motor function, willpower, initiative, level of energy, and stress tolerance. These are differentiated from frank psychosis by lower levels of intensity, frequency or duration. The teen may complain of nonspecific clinical symptoms such as depression, anxiety, social isolation, and/or difficulties with school. They then may start to occasionally experience positive symptoms that are brief in duration and moderate in intensity. These events may become more serious over time, although they don’t happen often, last for only a few minutes to hours, and the person still retains some insight as to the unusual nature of the phenomena. However, this situation changes as the person comes closer to the initial psychotic break, signaled by the emergence of unusual thoughts, perceptual abnormalities, and disordered speech.
Risk and Resource
Who is most likely to move from the prodromal period to frank psychosis? Factors most predictive of this transition include people with a family history of psychosis and a recent deterioration of functioning, a history of substance abuse, and higher levels of unusual thoughts and social impairments. Other mediating factors include poor functioning, lengthy time period of symptoms, elevated levels of depression or other comorbid conditions, and reduced attention.
What factors appear to ameliorate risk of descending into psychosis? Risk/protective factors include higher premorbid cognitive skills and social skills and lack of a history of substance abuse.
How and When to Intervene
The information provided here about emerging psychosis underlines the critical importance of early intervention to address the serious and pervasive impact on functioning. Professionals who treat people at risk of psychosis are now beginning to use a clinical staging of treatment, meaning treatments should be tailored to the client’s needs, starting with safer and simpler interventions for the prodromal stages and increasingly intensive and aggressive treatment for people who are already contending with psychosis. This requires starting with what appears to be most problematic at the time for the person. For some people, this means treating the comorbid psychiatric conditions. For those who are experiencing difficulties with attention/executive function or reporting elevated levels of unusual symptoms, it may mean starting the person on an atypical antipsychotic. The use of targeted psychosocial interventions such as cognitive behavioral therapy, social skills training, and family therapy have all been found to be associated with reduced or delayed transition to first episode psychosis.
Where to Go for Help
Living in the Boston area, we are fortunate to have a wealth of resources in our hospitals and training sites that are engaged in cutting edge research and intervention to address the needs of young people who are contending with emerging psychosis. These include Beth Israel-Deaconess Hospital’s Center for Early Detection and Response to Risk (CEDAR) and the Prevention and Recovery in Early Psychosis (PREP) jointly run by the Beth Israel-Deaconess and Massachusetts Mental Health Center. Also, Cambridge Health Alliance offers the Recovery in Shared Experiences (RISE) program for the treatment of first episodes of psychosis.
Neuropsychological testing, augmented by psychological testing can be a useful tool to learn more about cognitive and emotional functioning. However, this is best undertaken as part of a comprehensive program of intervention.
Articles used for this blog:
- Larson, M, Walker, E, and Compton, M (2010) Early Signs, diagnosis, and therapeutics of the prodromal phase of schizophrenia and related psychotic disorders, Expert Review of Neurotherapy. Aug. 10 (8), 1347-1359. https://www.nimh.nih.gov/health/topics/schizophrenia/raise/what-is-psychosis.shtml
- NPR Your Health Podcast (2014) Halting Schizophrenia Before It Starts
- Miller, Brian Negative Symptoms in Schizophrenia; The Importance of Identification and Treatment, Psychiatric Times, March 2017
About the Author:
Formerly an adolescent and family therapist, Dr. Stephanie Monaghan-Blout is a senior clinician who joined NESCA at its inception in 2007. Dr. Monaghan-Blout specializes in the assessment of clients with complex learning and emotional issues. She is proficient in the administration of psychological (projective) tests, as well as in neuropsychological testing. Her responsibilities at NESCA also include acting as Clinical Coordinator, overseeing psycho-educational and therapeutic services. She has a particular interest in working with adopted children and their families, as well as those impacted by traumatic experiences.
To book a consultation with Dr. Monaghan-Blout or one of our many other expert neuropsychologists, complete NESCA’s online intake form.
Neuropsychology & Education Services for Children & Adolescents (NESCA) is a pediatric neuropsychology practice and integrative treatment center with offices in Newton, Massachusetts, Plainville, Massachusetts, and Londonderry, New Hampshire, serving clients from preschool through young adulthood and their families. For more information, please email info@nesca-newton.com or call 617-658-9800.
By: Ann Helmus, Ph.D.
NESCA Founder/Director
NESCA was founded on the idea that a thorough evaluation reflecting careful analysis of information gathered from history, observations, and testing data is crucial in formulating a comprehensive, individualized plan for supporting a child to realize their potential. Increasingly, NESCA is expanding its intervention services, which allows for a higher level of integration between the evaluator and treater. Clearly recognizing the benefit of psychopharmacological intervention for many children and adolescents, at NESCA, we focus on the powerful benefits of many non-medication approaches.
Our experience, supported by research, is that significant improvements in functioning result from psychoeducation, direct teaching of strategies to parents and students, and intervention at the physical level. Psychoeducation refers to the process of educating clients and their parents about the nature of challenges such as anxiety or ADHD. Beyond gaining a thorough understanding of the challenges faced by a client, parents, teachers, and students need strategies for managing problematic symptoms and behaviors. Teaching and helping parents and students practice these strategies often yields huge changes in functioning. Finally, the mind and body are interconnected and intervening at the physical level is often more straight-forward for many of our clients, leading to impressive changes in cognitive and emotional functioning.
NESCA offers the following therapeutic interventions:
Cognitive Behavioral Therapy (CBT):
CBT is an evidence-based therapy that focuses on identifying and changing thoughts patterns and behaviors that are interfering with functioning. Of note, we have a therapist who is highly experienced in psychotherapeutic intervention with children and adolescents who are on the autism spectrum, including the use of the Sidekicks app developed by the Affinity Project.
Acceptance and Commitment Therapy (ACT):
ACT uses approaches such as mindfulness and behavioral change strategies to help clients increase flexibility and reach goals.
Many children require more frequent meetings in order to master the strategies that are being taught for behavioral/emotional regulation or social functioning. NESCA’s intensive out-patient therapy programs generally involve three weekly sessions of direct service for the child followed by brief parent guidance meetings.
NESCA offers a group for school-age children with ADHD and their parents. Children meet in one group while their parents meet concurrently in another group, both led by experienced psychologists. Starting in 2018, NESCA will be offering drama-based therapy groups based on the Spotlight model developed at the Northeast Arc and researched by the Social Competence and Treatment Lab at Stony Brook University.
This intensive program was developed to address school refusal through both home-based and center-based psychotherapy, parent guidance and school consultation.
Community Based Skills Coaching:
Many clients struggle to generalize strategies that they have learned in therapy to daily living. NESCA has highly skilled coaches that work with adolescents and young adults in the community to practice skills and strategies.
Postsecondary Transition Planning:
Adolescents with developmental challenges, learning disabilities, and psychiatric issues often need support in planning for “life after high school”. Our veteran transition specialists work with adolescents and their parents to identify strengths, formulate realistic goals and a plan for reaching goals over their high school years.
Individual or small group interventions in our yoga studio to build self-awareness and the ability to use breath and movement to address symptoms of anxiety and enhance attention.
These ancient treatments can be highly effective for treating anxiety, ADHD, and other childhood conditions.
About the Author:
NESCA Founder/Director Ann Helmus, Ph.D. is a licensed clinical neuropsychologist who has been practicing for almost 20 years. In 1996, she jointly founded the Children’s Evaluation Center (CEC) in Newton, Massachusetts, serving as co-director there for almost ten years. During that time, CEC emerged as a leading regional center for the diagnosis and remediation of both learning disabilities and Autism Spectrum Disorders.
In September of 2007, Dr. Helmus established NESCA (Neuropsychology & Education Services for Children & Adolescents), a client and family-centered group of seasoned neuropsychologists and allied staff, many of whom she trained, striving to create and refine innovative clinical protocols and dedicated to setting new standards of care in the field.
Dr. Helmus specializes in the evaluation of children with learning disabilities, attention and executive function deficits and primary neurological disorders. In addition to assessing children, she also provides consultation and training to both public and private school systems. She frequently makes presentations to groups of parents, particularly on the topics of non-verbal learning disability and executive functioning.
To book a consultation with Dr. Helmus or one of our many other expert neuropsychologists, complete NESCA’s online intake form.
Neuropsychology & Education Services for Children & Adolescents (NESCA) is a pediatric neuropsychology practice and integrative treatment center with offices in Newton, Massachusetts, Plainville, Massachusetts, and Londonderry, New Hampshire, serving clients from preschool through young adulthood and their families. For more information, please email info@nesca-newton.com or call 617-658-9800.
Connect with Us