Course and prognosis of childhood schizophrenia

Young children with psychotic symptoms and risk for suicidal thoughts and behaviors: a research note

Objective

Suicidal thoughts and behaviors (STBs) are prevalent among youth with psychotic disorders (PD) relative to the general population. Recent research now suggests that STBs may present during the prodromal phase of the disease, or the clinical high risk (CHR) state. While this knowledge is important for the development of suicide prevention strategies in adolescent and adult populations, it remains unclear whether risk for suicide extends to children with or at risk for psychosis. The current study is an extension of previous work assessing STBs in youth across the psychosis continuum. We examine STBs in 37 CHR and PD children ages 7–13 years old, and further explore the prodromal symptom correlates of STB severity among CHR children.

Results

CHR and PD children endorsed STBs with a frequency and severity similar to what is observed in older CHR and PD populations. A number of children had never previously vocalized their suicidal plans or intent. Among CHR children, Social Anhedonia and Odd Behavior or Appearance were significantly correlated with STB severity. These findings underscore the importance of screening for STBs even in young children presenting with psychotic symptoms.

Suicidal behaviors in children and adolescents with psychotic disorders

Suicide is the leading cause of premature death in individuals with psychotic disorders. Risk for onset of suicidal behaviors tends to begin in adolescence, remaining high into young adulthood. The present study aims to evaluate the interplay of early onset psychosis and suicide risk by examining suicidal behaviors (ideation, planning, and attempts) in children and adolescents with psychotic disorders (PD) compared to typically developing peers (TD). Twenty five youths were recruited and were diagnostically evaluated for psychosis. We found that the PD children exhibited significantly higher levels of suicidal behaviors than TD children, even when parsed into individual at-risk behaviors.

A Review of Childhood-Onset Schizophrenia

Schizophrenia is a neurodevelopmental disorder with a multifactorial etiology. Pediatric schizophrenia consists of early-onset schizophrenia (onset prior to age 18 years) and childhood-onset schizophrenia (onset prior to age 13 years). Adolescence has been established as a critical period for neuronal pruning; hence, with earlier the onset of symptoms, there may be disruption in the normal process of neuronal development, causing impairments with memory, abstract thinking, and emotion regulation. Although the lifetime prevalence of schizophrenia is 1% in the general population, the incidence of pediatric schizophrenia is rare. Therefore, it is important to effectively evaluate the cause of any psychosis of a child or an adolescent. An accurate history and physical, including a detailed neurological examination, are vitally important, as are pertinent laboratory and imaging tests to rule out the many alternative differential diagnoses that also present with psychotic symptoms. The antipsychotics continue to be significantly more effective than placebo in treating pediatric schizophrenia in combination with psychotherapy, as evidenced by the recent Recover After an Initial Schizophrenia Episode (RAISE) study. However, further study is still needed to better understand causality, improve assessment, and develop a definitive treatment algorithm.

School Psychology and Infantile Autism

This paper presents an overview of infantile autism which includes theories of aetiology, definition of the condition, overlapping conditions, assessment procedures and prognosis. A model treatment that can be implemented by school psychologists is also presented.

Incidence and 12-month outcome of childhood non-affective psychoses: British national surveillance study

The schizophrenias are uncommon before the age of 14 but incidence/prevalence figures are lacking. The 1-year incidence, clinical features and short-term outcomes in childhood-onset schizophrenia spectrum disorder were evaluated via the Child and Adolescent Psychiatry Surveillance System. Fifteen children with a provisional diagnosis were reported. Outcome data were obtained for 12 individuals, 8 of whom met the diagnostic criteria, equating to an estimated incidence of 0.21/100 000 (95% CI 0.08-0.34). Delusions and thought disorder were a more consistent predictor of 'caseness' than hallucinations. Illness outcomes at 1 year were generally poor. Childhood-onset schizophrenia appears to be a rare but serious disorder.

Practice parameter for the assessment and treatment of children and adolescents with schizophrenia

This Practice Parameter reviews the literature on the assessment and treatment of children and adolescents with schizophrenia. Early-onset schizophrenia is diagnosed using the same criteria as in adults and appears to be continuous with the adult form of the disorder. Clinical standards suggest that effective treatment includes antipsychotic medications combined with psychoeducational, psychotherapeutic, and educational interventions. Since this Practice Parameter was last published in 2001, several controlled trials of atypical antipsychotic agents for early-onset schizophrenia have been conducted. However, studies suggest that many youth with early-onset schizophrenia do not respond adequately to available agents and are vulnerable to adverse events, particularly metabolic side effects. Further research is needed to develop more effective and safer treatments.

A systematic review of the long-term outcome of early onset schizophrenia

BACKGROUND

The current review analyzes the long-term outcome and prognosis of early onset schizophrenia based on previously published studies in 1980.

METHODS

A systematic search of articles published in the English-language literature after 1980 identified a total of 21 studies, which included 716 patients who were either suffering from early onset schizophrenia (EOS) or both EOS and other psychotic disorders (MIX). The authors of the current review scored the outcome as either "good," "moderate," or "poor." The mean age of onset in these studies was <18 years.

RESULTS

In general, the outcome in studies with EOS is worse than the outcome in MIX studies. Only 15.4% of the patients in EOS studies versus 19.6% of the patients in MIX studies experienced a "good" outcome. In contrast, 24.5% of the patients in EOS studies versus 33.6% in MIX studies experienced a "moderate" outcome, and 60.1% in EOS studies versus 46.8% in MIX studies experienced a "poor" outcome. The authors identified various significant effects on outcome. In EOS, the findings were significantly affected by sample attrition, indicating that in studies with a high dropout rate, fewer patients experienced a "moderate" outcome, and more patients experienced a "poor" outcome; however, the effect sizes were small. Furthermore, the effects were also small and more favourable for specific functioning measures, as opposed to more global measures, small to moderate in terms of worse outcomes for follow-up periods >10 years, small to moderate for more unfavourable outcomes in males, and small to large for worse outcomes in studies including patients diagnosed before 1970.

CONCLUSIONS

In contrast to the adult manifestation, the early manifestation of schizophrenia in childhood and adolescence still carries a particularly poor prognosis. According to these aggregated data analyses, longer follow-up periods, male sex, and patients having been diagnosed before 1970 contribute predominantly to the rather poor course of EOS.

Neurobiology and phenotypic expression in early onset schizophrenia

AIM

Early-onset schizophrenia (onset before adulthood) is a rare and severe form of the disorder that shows phenotypic and neurobiological continuity with adult-onset schizophrenia. Here, we provide a synthesis of keynote findings in this enriched population to understand better the neurobiology and pathophysiology of early-onset schizophrenia.

METHODS

A synthetic and integrative approach is applied to review studies stemming from epidemiology, phenomenology, cognition, genetics and neuroimaging data. We provide conclusions and future directions of research on early-onset schizophrenia.

RESULTS

Childhood and adolescent-onset schizophrenia is associated with severe clinical course, greater rates of premorbid abnormalities, poor psychosocial functioning and increased severity of brain abnormalities. Early-onset cases show similar neurobiological correlates and phenotypic deficits to adult-onset schizophrenia, but show worse long-term psychopathological outcome. Emerging technological advances have provided important insights into the genomic architecture of early-onset schizophrenia, suggesting that some genetic variations may occur more frequently and at a higher rate in young-onset than adult-onset cases.

CONCLUSIONS

Clinical, cognitive, genetic and imaging data suggest increased severity in early-onset schizophrenia. Studying younger-onset cases can provide useful insights into the neurobiological mechanisms of schizophrenia and the complexity of gene-environment interactions leading to the emergence of this debilitating disorder.

Psychopharmacology of schizophrenia in children and adolescents

The past 5 five years have seen major advances in the diagnosis and treatment of schizophrenia in children and adolescents. This article, reviews the clinical and diagnostic characteristics of schizophrenia in youth with an eye toward recent findings. This article also provides a more extensive review and update of the psychopharmacology of early-onset schizophrenia.

A comparative pilot study of second-generation antipsychotics in children and adolescents with schizophrenia-spectrum disorders

OBJECTIVE

There is a limited evidence base to guide treatment of children and adolescents with nonaffective psychoses because few comparative studies of first-line second-generation antipsychotics (SGAs) have been undertaken. To plan the design of a subsequent randomized controlled trial (RCT), the authors conducted this pilot study to demonstrate the feasibility of the treatment and measurement protocols.

METHOD

Thirty children and adolescents (20 males, 10 females), ages 10-18 years, who met unmodified Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) criteria for a schizophrenia-spectrum disorder (schizophrenia, schizoaffective, schizophreniform, psychotic disorder not otherwise specified) were randomized to receive 12 weeks of open-label, flexibly dosed treatment with either risperidone (mean [standard deviation, SD] dose = 3.4 mg [1.5]), olanzapine (mean [SD] dose = 14.0 mg [4.6]) or quetiapine (mean [SD] dose = 611 mg [253.4]).

RESULTS

Twenty one (70%) of 30 subjects completed the study. There was no overall statistically significant difference with regard to reduction in Positive and Negative Syndrome Scale (PANSS) total scores in treatment efficacy observed (F((2,24)) = 3.13, p = 0.06). However, the possibility of a large differential treatment effect with regard to change in PANSS total scores favoring risperidone relative to quetiapine (risperidone vs. quetiapine, d = 1.10 [95% confidence interval, CI, 0.09-2.01]) was suggested by the point estimate.

CONCLUSIONS

These preliminary data, viewed together with the extant literature, suggest that a future larger RCT with only two treatment arms may be warranted to establish whether there is a clinically significant differential treatment effect between risperidone and quetiapine for children and adolescents with nonaffective psychoses. Additional challenges and considerations for mounting a larger RCT are explored.

Efficacy and tolerability of second-generation antipsychotics in children and adolescents with schizophrenia

Early-onset schizophrenia-spectrum (EOSS) disorders (onset of psychotic symptoms before 18 years of age) represent a severe variant associated with significant chronic functional impairment and poor response to antipsychotic treatment. All drugs with proven antipsychotic effects block dopamine D(2) receptors to some degree. The ongoing development of the dopamine and other neurotransmitter receptor systems during childhood and adolescence may affect clinical response and susceptibility to side effects in youth. A literature search was conducted of clinical trials of antipsychotics in children and adolescents with EOSS disorders between 1980 and 2007 from the Medline database, reference lists, and conference proceedings. Trials were limited to double-blind studies of duration of 4 or more weeks that included 15 or more patients. Ten clinical trials were identified. Antipsychotic medications were consistently found to reduce the severity of psychotic symptoms in children and adolescents when compared with placebo. The superiority of clozapine has been now demonstrated relative to haloperidol, standard-dose olanzapine, and "high-dose" olanzapine for EOSS disorders. However, limited comparative data are available regarding whether there are differences among the remaining second-generation antipsychotics (SGAs) in clinical effectiveness. The available data from short-term studies suggest that youth might be more sensitive than adults to developing antipsychotic-related adverse side effects (eg, extrapyramidal side effects, sedation, prolactin elevation, weight gain). In addition, preliminary data suggest that SGA use can lead to the development of diabetes in some youth, a disease which itself carries with it significant morbidity and mortality. Such a substantial risk points to the urgent need to develop therapeutic strategies to prevent and/or mitigate weight gain and diabetes early in the course of treatment in this population.

Treatment of early-onset schizophrenia spectrum disorders (TEOSS): demographic and clinical characteristics

OBJECTIVE

We examined baseline demographic and clinical profiles of youths enrolled from 2001 to 2006 in the publicly funded multicenter, randomized controlled trial Treatment of Early-Onset Schizophrenia Spectrum Disorders.

METHOD

Youths (8-19 years) with schizophrenia (SZ) and schizoaffective disorder were recruited at four academic sites. Diagnosis was made via structured and clinical interviews. Assessments of psychiatric symptoms and social and global functioning were included.

RESULTS

A total of 119 youths were enrolled. The mean age at illness onset was 11.1 +/- 3.5 years. Patients with SZ and schizoaffective disorder had similar ratings on the Positive and Negative Symptom Scale, Brief Psychiatric Rating Scale for Children, and Clinical Global Impression-Severity Scale. The overall level of functioning was similar in the two groups. A comparison to published reports of adults with SZ indicates that these youths may have more severe symptoms based on results of the Positive and Negative Symptom Scale.

CONCLUSIONS

This is one of the largest samples of youths with SZ spectrum disorders studied to date and the largest assessment of youths with schizoaffective disorder. High rates of symptoms and general psychopathology were noted. There was a substantial degree of social and functional impairment. The symptom profiles are consistent with, but more severe than, those reported in the adult literature.

Antipsychotics in early onset Schizophrenia: Systematic review and meta-analysis

BACKGROUND

To develop an evidence base for using antipsychotic medications for schizophrenia in children and adolescents.

METHOD

Data sources were identified in PsychINFO (1872-2003), MEDLINE (1966-2003), and articles in reference lists. Study selection criteria: (1) treatment with antipsychotics; (2) ages were between 5 and 18 years; (3) sample diagnosed with schizophrenia; (4) prospective design; (5) rating instruments used. Fifteen studies met inclusion criteria and were rated. Study quality was independently rated.

RESULTS

Average response rate among 8 studies employing atypicals was 55.7% compared to 72.3% among 13 studies employing typicals. The difference was statistically different at the trend level (z = 1.65, P < 0.10). The effect size on a continuous measure was 0.36 in favor of typicals. When study quality was included in the model, the effect of medication type remained unchanged. Average weight gain in patients treated with typicals was 1.4 Kg. compared to 4.5 Kg for those treated with atypicals. Sedation was more common among those on atypicals. The rate of extrapyramidal side effects was similar among the two groups

CONCLUSIONS

Antipsychotic medications seem effective for schizophrenia treatment in children and adolescents. Typicals appear to be more effective and cause less weight gain than atypicals. However, more rigorous clinical trials are necessary.

Treatment-refractory schizophrenia in children and adolescents: an update on clozapine and other pharmacologic interventions

Treatment-refractory early-onset schizophrenia is a rare but severe form of the disorder associated with poor premorbid function and long-term disability. The currently available evidence suggests that clozapine remains the most efficacious treatment for the amelioration of both positive and negative symptoms of the disorder and problematic aggressive behaviors. Clozapine use in children and adolescents, however, is limited by its association with hematologic adverse events and an increased frequency of seizure activity. Further studies are needed to examine the usefulness of antipsychotic combinations and of augmentation therapies to antipsychotic medications in order to treat persistent residual psychotic symptoms in children and adolescents who have schizophrenia and who have not responded to several sequential trials of antipsychotic monotherapy.

Saccadic eye movement task identifies cognitive deficits in children with schizophrenia, but not in unaffected child relatives

BACKGROUND

The delayed oculomotor response (DOR) task requires response inhibition followed by movement of gaze towards a known spatial location without a current stimulus. Abnormalities in response inhibition and in the spatial accuracy of the eye movement are found in individuals with schizophrenia and in many of their relatives, supporting the use of these saccadic abnormalities as endophenotypes in genetic studies. It is unknown whether school-age children, either with psychosis or as relatives of a schizophrenic proband, can be included.

METHOD

One hundred eighty-seven children, ages 5.8-16.0 years - 45 children with childhood-onset schizophrenia, 64 children with a first-degree relative with schizophrenia, and 84 typically developing children - completed DOR tasks with 1 and 3 second delays.

RESULTS

Children with childhood-onset schizophrenia demonstrated impaired response inhibition and impaired spatial accuracy compared to both relatives and typicals; however, relatives and typicals did not differ from each other.

CONCLUSIONS

Children with childhood-onset schizophrenia have saccadic abnormalities similar to those found in adults with schizophrenia, supporting the continuity of executive function deficits in childhood-onset with adolescent and adult-onset schizophrenia. However, saccadic tasks are not sensitive to genetic risk in non-psychotic children and 6-15-year-old children should not be included in genetic studies utilizing this endophenotype.

A esquizofrenia ao longo da infância

As pesquisas sobre os grupos “de alto risco” (filhos de pais esquizofrênicos), assim como os estudos prospectivos na população geral, mostram que os futuros esquizofrênicos apresentam, comparativamente aos sujeitos-controle, atrasos do desenvolvimento psicomotor, déficits cognitivos e algumas particularidades comportamentais. Tais dados parecem confirmar a idéia segundo a qual a esquizofrenia corresponderia a um distúrbio neurodesenvolvimental cuja expressão varia ao longo da vida. As especificidades clínicas e evolutivas dos raros casos de esquizofrenia iniciando-se na infância levam alguns autores a pensar que se trataria de uma entidade específica e cujo pertencimento ao “espectro autista” necessita ainda ser estudado.

Phenomenology of childhood psychosis: findings from a large sample of psychiatrically referred youth

Our objective was to evaluate the scope and clinical correlates of psychotic phenomena in psychiatrically referred children and adolescents. Subjects were 1657 psychiatrically referred youth (mean age = 10.9 years) evaluated from 1991 to 2002. DSM-III-R diagnoses were obtained through maternal report by using the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Epidemiologic Version. Childhood-onset psychosis was defined by the presence of delusions or hallucinations. Childhood-onset psychosis was identified in 8% of psychiatrically referred youth. It was associated with a chronic course and high levels of impairment. Comorbidity with disruptive, mood, and anxiety disorders was very severe, with only one of the 132 identified youth with psychosis not having at least one comorbidity. In conclusion, childhood-onset psychosis in referred youth is common and highly morbid. It remains an important topic of research deserving full clinical and scientific attention.

Premorbid functioning in early-onset psychotic disorders

OBJECTIVE

To examine the premorbid characteristics of youths with early-onset psychotic disorders.

METHOD

Subjects with early-onset psychotic disorders received an extensive diagnostic evaluation upon entry into the study, including a historic review of premorbid functioning using the Premorbid Adjustment Scale.

RESULTS

Youths with schizophrenia (n = 27), bipolar disorder (n = 22), and psychosis not otherwise specified (NOS) (n = 20) were included. High rates of premorbid behavioral problems and academic difficulties were noted across all subjects. Youths with schizophrenia had higher rates of premorbid social withdrawal and global impairment. They also tended to have fewer friends. The psychosis NOS group had significantly higher rates of abuse histories and posttraumatic stress disorder.

CONCLUSIONS

Premorbid abnormalities are common features of early-onset psychotic disorders. The social withdrawal and peer problems specific to youths with schizophrenia likely represent early manifestations of negative symptoms. The abuse histories in the psychosis NOS group may explain the atypical nature of their reported psychotic symptoms, which in many cases are likely posttraumatic phenomena.

Early-onset schizophrenia in children with mental retardation: diagnostic reliability and stability of clinical features

OBJECTIVES

To investigate the presentation of early-onset schizophrenia in children with mental retardation (MR) and the stability of clinical features over time.

METHOD

A purpose-designed assessment protocol was developed based on best-practice recommendations in the research literature. Diagnostic reliability, investigated in a group of 20 children with MR, was found to be very good (kappa = 0.87). Using this protocol, the clinical service identified 10 children with an initial diagnosis of schizophrenia. This group was then reassessed 2 years later.

RESULTS

At the end of 2 years, 8 of the 10 children with schizophrenia still warranted this diagnosis. However, there was considerable instability in relation to certain diagnostic criteria, notably delusions and visual hallucinations. In all cases some improvements in severity were seen at follow-up. However, the eight whose schizophrenia was confirmed at follow-up showed major deterioration in cognitive level.

CONCLUSIONS

It is possible to make reliable diagnoses of early-onset schizophrenia in people with MR, provided the assessment system is carefully structured and pays attention to all the important sources of information. However, symptoms should be reviewed frequently, particularly those that cannot be substantiated by patient interview.

Childhood-onset schizophrenia: premorbid and prodromal diagnostic and treatment histories

OBJECTIVE

There is increasing interest in the possible relationship between the early diagnosis and treatment of schizophrenia during adolescence and improved long-term outcome. This study reviews the premorbid and prodromal diagnostic and treatment histories for childhood-onset schizophrenia, to assess whether early identification and treatment is possible in this school-age group.

METHOD

Parents of 17 children with childhood-onset schizophrenia or schizoaffective disorder were questioned retrospectively regarding symptoms, exposure to mental health professionals, diagnoses, and treatments.

RESULTS

Initial presenting symptoms clustered around violent aggression and school problems. Age of first recognized psychotic symptoms ranged from 2 to 11 years, followed 2.0+/-2.0 years later by a diagnosis of schizophrenia. Prior to a schizophrenia diagnosis, these children were exposed to stimulants, antidepressants, lower-dose typical neuroleptics, mood stabilizers, alternative treatments, and individual and family therapy.

CONCLUSION

Early diagnosis of childhood-onset schizophrenia is met with caution in the psychological and medical community. These children received many diagnoses before schizophrenia or schizoaffective disorder was diagnosed. A diagnosis of schizophrenia or schizoaffective disorder and utilization of effective atypical neuroleptic treatment was delayed until evaluation by a child and adolescent psychiatrist. Obstacles to early identification and treatment are discussed.

[Early childhood psychosis versus early childhood autism? Differential diagnosis based on one week observation in an inpatient setting]

We report on the case of a 4-year old child suffering for the past six months from a lingering psychotic development. Several months of outpatient observation did not permit a clear differential diagnosis of either childhood autism or an early psychosis. During a one-week inpatient stay at our hospital recurring productive-psychotic episodes were observed that finally led to the exclusion of the diagnosis of "childhood autism" (ICD-10 F 84.0 (Dilling et al., 1993)) and to the diagnosis of "other disintegrative childhood disorder" (ICD-10: F 84.3 (Dilling et al., 1993)).

Practice parameter for the assessment and treatment of children and adolescents with schizophrenia. American Academy of Child and Adolescent Psychiatry

This practice parameter reviews the literature on the assessment and treatment of children and adolescents with schizophrenia. Recommendations are based on the limited research available, the adult literature, and clinical experience. Early-onset schizophrenia is diagnosed using the same criteria as in adults, and it appears to be continuous with the adult form of the disorder. Noted characteristics of youth with schizophrenia include predominance in males, high rates of premorbid abnormalities, and often poor outcome. Differential diagnosis includes psychotic mood disorders, developmental disorders, organic conditions, and nonpsychotic emotional/behavioral disorders. Treatment strategies incorporate antipsychotic medications with psychoeducational, psychotherapeutic, and social and educational support programs. The advent of atypical antipsychotic agents has enhanced the potential for effective treatment.

Psychosis in a pediatric mood and anxiety disorders clinic: phenomenology and correlates

OBJECTIVES

To examine the demographics and phenomenology of psychosis in a sample of children and adolescents referred to a mood and anxiety disorders clinic.

METHOD

Patients (N = 2,031) were assessed with the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present Episode version and classified as definite, probable, or nonpsychotic. Clinical and demographic characteristics of the groups were compared,and symptoms of psychosis were analyzed using factor analysis.

RESULTS

Definite psychotic symptoms were seen in approximately 90 (4.5%) patients: 80% of these reported hallucinations (mainly auditory), 22% delusions, and 3.3% thought disorder. Of the patients with definite psychotic symptoms, 24% had bipolar disorder, 41% had major depression, 21% had subsyndromal depression, and 14% had schizophrenia spectrum disorders (schizophrenia and schizoaffective disorders). Factor analysis of the definite psychotic symptoms yielded 4 factors: hallucinations, thought disorder, delusions, and manic thought disorder. Psychotic patients had a higher frequency of comorbid disorders and suicidal ideation than nonpsychotic patients.

CONCLUSIONS

Outpatient youngsters with mood disorders frequently present with psychotic symptoms, in particular auditory hallucinations. These patients commonly have comorbid psychiatric disorders and suicidal ideation.

Schizophrenia with onset before the age of eleven: clinical characteristics of onset and course

This study reports on the long-term course of 11 patients (6 girls, 5 boys) with childhood onset schizophrenia (COS, age at onset < 10 years). Patients were examined twice (mean follow-up period 38 years after onset). The premorbid development is assessed in terms of the Modified Premorbid Adjustment Scale (M-PAS) and additionally described by distinct psychopathological categories. The psychopathology at the onset of psychosis and at the second follow-up examination was assessed by categorical application of the Positive and Negative Syndrome Scale (PANSS). The outcome was rated with the Disability Assessment Score (DAS). The course of psychotic episodes and intervals between them is presented according to DSM-IV subtype classifications. Ten of 11 patients presented premorbid developmental peculiarities that were not adequately covered by the M-PAS subscales. Whereas in the 4 patients with acute onset of psychosis the positive PANSS-type was predominant, in the 7 patients with an insidious onset the negative PANSS-type prevailed. The nature of the diagnostic subtypes varied markedly across the course of the illness. In case of a continuous predominant catatonic symptomatology the outcome was poor. Detailed case descriptions help to illuminate the heterogeneous psychopathology of COS. Various temporary premorbid behavioral peculiarities were precursors of COS. A differentiation between premorbid and prodromal signs proved to be arbitrary. Our results contradict the assumption that COS is characterized only by a negative symptomatology.

Symptom dimensions in the course of childhood-onset schizophrenia

The symptom dimensions of childhood-onset schizophrenia (COS) are described by focussing on the clinical features of 44 patients at onset of illness during the first episode and at follow-up investigation 42 years after onset. All subjects were re-diagnosed according to DSM IV. The symptomatology was evaluated with the Positive and Negative Symptom Scale (PANSS) at onset and at follow-up. Two principal component factor analyses with varimax-rotation were applied to the complete items set of the PANSS. The frequencies of positive, negative, and global symptoms were compared longitudinally in an ANOVA-repeated measures design. The factor analysis revealed 5 orthogonal symptom dimensions (factors) at onset of psychosis: Cognition, social withdrawal, antisocial behaviour, excitement, and reality distortion. At follow-up a five-factor solution was found, too, but different dimensions emerged: a positive, negative, excitement, cognitive, and anxiety/depression component which fits to the 5-factor model of White et al. (1997). The first psychotic episode of EOS is accompanied with more unspecific symptoms such as social withdrawal and antisocial behavior. In the later stages of (COS) the structure of symptom dimensions changes to that known from adult-onset schizophrenia (AOS). The results indicate that COS and AOS are comparable nosological entities and that more than 3 dimensions are required to describe the relevant clinical symptom structure. Positive and global symptoms decreased significantly during the course of illness. The frequencies of negative symptoms did not change which demonstrates their disabling impact.

The ESSEN study of childhood-onset schizophrenia: selected results

INTRODUCTION

We present the results of a 42 year long-term follow-up of 44 patients (19 males, 25 females) with childhood-onset schizophrenia (COS, age at onset: 7-14 years) who could be traced for a second follow-up examination 27 years after the first follow-up.

METHOD

Data from interviews, clinical records, premorbid and social disability assessments were evaluated for statistical analyses. The symptomatology observed during the whole course of illness was rediagnosed by DSM-IV criteria.

RESULTS

The paranoid, catatonic, and schizoaffectives subtypes appeared most frequently. There have been no gender differences in age of first psychiatric symptoms (AFS), AFPS, and age of first hospitalization. Kaplan-Meier's survival-analysis carried out for AFPS with sex as the grouping factor revealed that the cumulative prevalence appears to be earlier in females (between 7 and 15 years) than in males (between 10 and 18 years). Of the 44 patients 50 % had a continuing severe course. Patients with onset before 12 years of age were characterized by a chronic/insidious onset, marked premorbid abnormalities, and by a poorer remission. Premorbid features of social withdrawal and reluctance indicated a risk for social disability within the later course.

CONCLUSION

COS, as a rare but severe variant of schizophrenia, frequently develops from premorbid social maladaptation to an insidious onset but is subsequently followed by a transition to a course and outcome not distinguishable from that of adult-onset schizophrenia.

Early-onset psychotic disorders: course and outcome over a 2-year period

OBJECTIVE

To examine the course and outcome of early-onset psychotic disorders.

METHOD

These are data from a longitudinal, prospective study of youths with psychotic disorders. Standardized diagnostic and symptom rating measures were used.

RESULTS

Fifty-five subjects with the following disorders have been recruited: schizophrenia (n = 18), bipolar disorder (n = 15), psychosis not otherwise specified (n = 15), schizoaffective disorder (n = 6), and organic psychosis (n = 1). Follow-up assessments were obtained on 42 subjects at year 1 and 31 subjects at year 2. Youths with schizophrenia had more chronic global dysfunction, whereas subjects with bipolar disorder overall had better functioning, with a cyclical course of illness. However, according to results of a regression model, premorbid functioning and ratings of negative symptoms, but not diagnosis, significantly predicted the highest level of functioning over years 1 and 2.

CONCLUSIONS

Course and level of functioning differentiated bipolar disorder from schizophrenia. However, premorbid functioning and ratings of negative symptoms were the best predictors of functioning over the follow-up period. These findings are consistent with the adult literature, and they further support that psychotic illnesses in young people are continuous with the adult-onset forms.

Frontal lobe of children with schizophrenia spectrum disorders: a proton magnetic resonance spectroscopic study

BACKGROUND

Schizophrenia is commonly considered a neurodevelopmental disorder. Our aim was to determine whether the proton magnetic resonance spectroscopic (1H-MRS) changes seen in adults with schizophrenia are displayed in children at risk for developing schizophrenia.

METHODS

Children with symptoms of schizophrenia-spectrum disorders (n = 16; mean age = 132 months) and a comparison group (n = 12; mean age 130 months) took part in a 1H-MRS study of the left frontal lobe. Areas of peaks from N-acetylaspartate (NAA), choline (Cho), and creatine (Cre) were determined and ratios of NAA/Cre and Cho/Cre calculated and compared between groups.

RESULTS

The mean ratio of NAA/Cre was significantly lower in schizophrenia-spectrum subjects than the comparison group (1.67 vs. 1.92; p < .05). Medication status did not affect results in schizophrenia-spectrum subjects.

CONCLUSIONS

Our findings suggest that the metabolic changes associated with adult schizophrenia are observed in children with some or all of the symptoms of schizophrenia, supporting a neurodevelopmental theory for schizophrenia.

Practice parameters for the assessment and treatment of children and adolescents with schizophrenia. American Academy of Child and Adolescent Psychiatry

These practice parameters review the literature on children and adolescents with schizophrenia. Because this literature is sparse, information is also drawn from research with adults. Clinical features in youth with schizophrenia include predominance in males, high rate of premorbid abnormalities, increased family history of schizophrenia, and often poor outcome. Diagnostic issues include the overlap, and therefore potential for misdiagnosis, between the first presenting symptoms of schizophrenia and those of psychotic mood disorders, developmental disorders, organic conditions, and other nonpsychotic emotional/behavioral disorders. Treatment should include using antipsychotic medications in conjunction with psychoeducational, psychotherapeutic, and social and educational support programs. These parameters were previously published in J. Am. Acad. Child Adolesc. Psychiatry, 1994, 33:616-635.

Risperidone in adolescents with schizophrenia: an open pilot study

OBJECTIVE

To assess critically the short-term efficacy and safety of risperidone in adolescents with schizophrenia.

METHOD

Subjects were adolescents who were attending a research day hospital as outpatients and who had received a diagnosis of schizophrenia. This was an open pilot study; after a 2-week washout period during which all psychotropic medications were gradually discontinued, subjects were treated with risperidone for 6 weeks. Dosage was regulated individually over a period of 3 weeks; starting dose was 2.0 mg/day followed by 1.0-mg increments every 2 days; maximum dose was not to exceed 10 mg/day. The main outcome measures included the Positive and Negative Syndrome Scale of Schizophrenia, the Brief Psychiatric Rating Scale, and the Clinical Global Impression.

RESULTS

Ten adolescents between 11 and 18 years of age were enrolled in the study. Risperidone produced clinically and statistically significant improvement on the Positive and Negative Syndrome Scale for Schizophrenia. Brief Psychiatric Rating Scale, and Clinical Global Impression at doses ranging from 4.0 mg/day to 10.0 mg/day (mean = 6.6). There were no major adverse reactions associated with risperidone use.

CONCLUSIONS

Risperidone appears to have been effective and well tolerated in this sample of adolescents with schizophrenia.

A 22- to 25-year follow-up study of former child psychiatric patients: a register-based investigation of the course of psychiatric disorder and mortality in 546 Danish child psychiatric patients

A total of 546 children and adolescents, aged 5 to 15 years, who were admitted as in-patients to psychiatric hospitals throughout Denmark between 1970 and 1973, were followed up with regard to later readmissions and mortality. Approximately one-third of the sample had at least one readmission after the age of 18 years; there was no significant difference between male and female subjects. Probands with three selected diagnoses, namely childhood neurosis, conduct disorder and maladjustment reactions, did have a significantly greater general risk of readmission to psychiatric hospital in adulthood than the background population. In total, 24 probands (22 male, and 2 female subjects) died during the study period. Eight subjects had committed suicide. The standard mortality rate was significantly increased.

Long-term stability of diagnosis and symptom dimensions in a systematic sample of patients with onset of schizophrenia in childhood and early adolescence. II: Postnegative distinction and childhood predictors of adult outcome

BACKGROUND

The aim of this study was to verify the presence and stability across life of the positive/negative distinction in early-onset schizophrenia (EO-SZ) through a longitudinal factor analysis of the schizophrenic dimensions, and to identify the factors predicting several indices of long-term outcome for EO-SZ.

METHOD

Forty children consecutively referred for DSM-III-R schizophrenia (SZ) in a specific catchment area comprised the sample.

RESULTS

Across a 14.8-year follow-up, longitudinal factor analysis identified two separate factors corresponding to the positive and negative symptom dimensions. We also observed that: the GAS rated over the last three years of adult illness and the severity of negative symptoms during the stabilised interepisode intervals in adulthood were the indices of adult outcome that were most easily predicted; and the best childhood predictors of adult outcome were premorbid functioning and severity of positive and negative symptoms during acute episodes.

CONCLUSIONS

The presence of premorbid non-psychotic behaviour disturbances (NPBD) and premorbid developmental problems was not related to severity of outcome, in contrast to the former variables.

Schizophrenia with childhood and adolescent onset--a nationwide register-based study

The aim of this study was to determine the frequency, demographic characteristics and course of children and adolescents admitted with a diagnosis of schizophrenia before the age of 18 years. The paper describes 312 patients from Denmark who were given a diagnosis of schizophrenia during the period between 1970 and 1993. Schizophrenia with a childhood onset was extremely rare. Only four children under the age of 13 years and 28 children under the age of 15 years had received such a diagnosis. The study showed that a number of adolescents who were diagnosed with schizophrenia at their first admission were not given the same diagnosis at later admissions in adulthood. The most common diagnoses in this group of apparently misdiagnosed cases were personality disorders, primarily borderline and antisocial personality disorder.

Relationships between mental disorders in childhood and adulthood

Research findings on continuities and discontinuities in psychopathology between childhood and adult life are reviewed with respect to major depressive disorders, anxiety states, obsessional conditions, anorexia nervosa, conduct disorders, hyperkinetic disorders, autism, specific developmental disorders of language and schizophrenia. The findings are used to consider both the conceptual issues and possible mediating mechanisms.

Epidemiology of early-onset schizophrenia

A total of 232 (84%) first episodes of schizophrenia from our epidemiologically defined ABC sample (Age, Beginning and Course) were retrospectively assessed with regard to the onset and early course of the disorder. In a follow-up study a representative subgroup (n = 133) was prospectively examined in five cross sections over 3 years from first admission on. Population-based incidence rates for 5-year age groups comprising a range of < 10 - < 60 years were calculated on the basis of two definitions of onset: first sign of disorder and first psychotic symptom. In 40% of adult patients who had been admitted with a first schizophrenic episode after age 20 years the prodromal phase, in 11% the psychotic prephase, began before that age. This demonstrates that schizophrenia often begins in an age period in which the social and cognitive development and brain maturation are still unfinished. Early-onset schizophrenias (< or = 20 years) were compared with a medium-onset group (21 - < 35 years) and a late-onset group (35 - < 60 years) with regard to age and type of onset, early symptom-related course, social development and social course. The number of schizophrenia-specific positive and negative syndromes in early-onset schizophrenia is comparable to that of higher age groups. However, neurotic syndromes, emotional disorders and conduct disorders are most frequent in younger patients, especially in young men. Paranoid syndromes seem to prevail in late-onset schizophrenia, whereas less differentiated positive syndromes, such as delusional mood, are more frequent in the youngest age group. An earlier onset of schizophrenia has more severe social consequences than onset in adults, because it interrupts the cognitive and social development at an earlier stage. The worse social course of schizophrenia in men compared with women cannot be related to a more severe symptomatology, but to the earlier age at onset and the impairment or stagnation of social ascent at an earlier stage of social and cognitive development. Social disability in the sense of an adaptation to the expectations of the social environment, as well as symptomatology during the further course of schizophrenia, show no major differences between the genders nor between the age groups.

Adolescent onset psychosis. A clinical and outcome study

58 psychotic adolescents between the ages of 12 and 17 diagnosed according to RDC criteria were matched with psychiatric comparisons and followed-up using a two stage design. Information upon the group as a whole was obtained using death records, criminal records and data from the Oxford Record Linkage System. A sub-sample of 21 matched pairs were interviewed using the Schedule for Affective Disorders and Schizophrenia--Life time version (SADS-L) and the Adult Personality Functioning Assessment (APFA). The outcome of adolescent schizophrenia was poor with 78% continuously ill and socially handicapped. Outcome was better for bipolar disorders and schizo-affective disorders and similar to psychiatric comparisons.

Practice parameters for the assessment and treatment of children and adolescents with schizophrenia. American Academy of Child and Adolescent Psychiatry

These practice parameters review the literature on children and adolescents with schizophrenia. Because this literature is sparse, information is also drawn from research with adults. Clinical features in youth with schizophrenia include predominance in males, high rate of premorbid abnormalities, increased family history of schizophrenia, and often poor outcome. Diagnostic issues include the overlap, and therefore potential for misdiagnosis, between the first presenting symptoms of schizophrenia and those of psychotic mood disorders, developmental disorders, organic conditions, and other nonpsychotic emotional/behavioral disorders. Treatment should include using antipsychotic medications in conjunction with psychoeducational, psychotherapeutic, and social and educational support programs.

Thought disorder in childhood

OBJECTIVE

This paper delineates the evolution of the concept of thought disorder and presents a developmental/neurobehavioral theory of the main components of formal thought disorder in childhood-onset schizophrenia.

METHOD

A review of past and recent clinical, cognitive, and linguistic studies of thought disorder in childhood-onset schizophrenia presents the main features and changes in the thought disorder concept.

RESULTS

The review emphasizes that, in the past, this term was used to describe a variety of clinical manifestations in a heterogenous group of children because of the lack of distinction between childhood schizophrenia and infantile autism. The studies that have been conducted during the past 15 years, however, have demonstrated well-defined clinical components of thought disorder and their cognitive/information processing, linguistic/pragmatic, and biological correlates.

CONCLUSIONS

A functional conceptualization of formal thought disorder in childhood-onset schizophrenia is presented in light of the theoretical and clinical implications of the reviewed studies.

Psychotic disorders diagnosed in adolescence. Outcome at age 30 years

Fifty-five cases who had been diagnosed in adolescence as suffering from a psychotic condition while attending a child or adult psychiatric clinic were compared with age-, sex- and school-matched cases with respect to various outcome measures at age 30 years. Overall, the outcome for young people who need psychiatric care for psychotic conditions in adolescence appears to be gloomy with respect to psychosocial adjustment. There were clear differences in outcome depending on specific psychosis diagnosis category at the time of original diagnosis. Females tended to have better outcome than males, but differences were small and not conclusive in this respect.

Conceptualizing "borderline syndrome of childhood" and "childhood schizophrenia" as a developmental disorder

OBJECTIVE

This is the first attempt to define and validate criteria for an early onset, chronic syndrome of disturbances in affect modulation, social relatedness, and thinking. This study formulates and tests five hypotheses that follow from conceptualizing this syndrome as a developmental disorder. The advantages of viewing this syndrome as a developmental disorder are discussed and compared with alternative formulations such as childhood schizophrenia or borderline syndrome of childhood.

METHOD

An inpatient cohort (26 boys, 4 girls) was ascertained using specific, defined criteria. Using standardized measures on retrospective chart reviews, these subjects were compared with two different inpatient samples: one diagnosed with dysthymic disorder, the other with conduct disorder.

RESULTS

The criteria readily distinguished between developmentally disordered children and comparison groups. Findings also supported the hypotheses in the predicted directions; index subjects had earlier onset of symptoms, poorer social and overall adjustment, longer hospitalizations, and poorer outcomes.

CONCLUSIONS

Findings support the validity of this developmental concept for a multiple complex developmental disorder and give preliminary, "first-cut" validity to these specified criteria.

A follow-up study of early onset psychosis: comparison between outcome diagnoses of schizophrenia, mood disorders, and personality disorders

This study examined the outcome of youth previously diagnosed with psychotic disorders at a public-sector tertiary care hospital. Of 95 children and adolescents retrospectively identified, follow-up information (mean interval 3.9 years) was obtained on 24 subjects with an outcome diagnosis of schizophrenia, 9 with psychotic mood disorders, 5 with personality disorders (antisocial or borderline), and 1 with schizo-affective disorder. The schizophrenic group was more often odd premorbidly and functioned worse at outcome, while the mood-disordered group had a shorter follow-up period and was more often anxious or dysthymic premorbidly. The personality-disordered group resembled the schizophrenics in their degree of impairment and chronicity. All three groups had high rates of family disruption, low SES, substance abuse, and chronicity, and were similar in their degree of premorbid impairment, length of prodrome, age of onset, initial diagnosis, and family psychiatric history. Misdiagnosis at onset was quite common and highlights the need for systematic longitudinal assessment of early onset psychotic disorders.

Child and adolescent (early onset) schizophrenia: a review in light of DSM-III-R

Early onset schizophrenia (EOS) is defined as that beginning in childhood or adolescence (under 16 or 17). Studies of EOS are infrequent, and comparative adult figures not always available, but tentative conclusions may be drawn. EOS is more common in males; symptomatology is often undifferentiated; frequencies of homotypic family disorder, premorbid schizotypal personality, and neurodevelopmental abnormalities high; outcome poor but only slightly worse than in adults; response to psychotropic drug treatment probably similar though not properly tested; and confusion with psychotic bipolar disorder particularly common. Onset before language is developed presents special diagnostic difficulties. There are a few reports of autistic children developing schizophrenia but this requires replication. Differences from adult schizophrenia are more marked when onset is in childhood than in adolescence but all are quantitative rather than qualitative suggesting that the disorders are the same and that there should be no separate category for children or adolescents.