[Is periodic psychosis in adolescence a disease of its own? The differential diagnosis of psychomotor psychoses in childhood and adolescence]

A historically orientated analysis of a disease that must be seen in connection with menstruation is made on the basis of literature on periodical psychoses in adolescence, which are described as nosologically separate disturbances. This relation turns out to be by no means obligatory, and this also applies to the homogeneity of the disease. Psychomotor disturbances of psychopathological importance are described by means of ideally typical cases of disease and presented with a differentiated diagnosis. Psychoses occurring during different periods in childhood and adolescence, do not show any sex-specific differences and no absolute dependence in accordance with the menstruation rhythm, but are mostly connected with a hereditary and also a perinatal strain in childhood. In their acute and long-term progress the psychomotoric disturbances allow a differentiated prognosis and therefore a therapeutic explanation. They can be classified in accordance with the Wernicke-Kleist-Leonhard classification schema as motility psychosis and periodic catatonia. With this in mind, the positive-negative dichotomy of schizophrenic disturbances in childhood and adolescence should be carefully reconsidered.

Psychoses in children and adolescents: a review

The differential diagnosis of psychoses in children and adolescents encompasses a wide range of disorders. The interpretation of psychotic symptoms in these patients must consider age, developmental level, symptomatology, and etiology for an appropriate DSM-IV diagnosis. Previous classifications of psychoses provided little information about the underlying processes or possible treatment. Clinical experience suggests that psychotic manifestations in young patients are influenced by developmental stage and that eliciting target symptoms from a young patient necessitates using and understanding the youth's language. Proper patient assessment demands interviews with family and collaborative sources, as well as endocrine, metabolic, neurologic, infectious, and toxicologic laboratory evaluations. Treatment involves interventions aimed at all spheres of life. The prognosis and outcome are generally poor in early-onset psychoses and are complicated by comorbidities.

Clinical features of childhood-onset schizophrenia with obsessive-compulsive symptoms during the prodromal phase

Thirty-nine patients with schizophrenia, diagnosed according to DSM-III-R, who were under 15 years of age, were studied in two groups; 16 subjects with obsessive-compulsive symptoms during the prodromal phase, and 23 with no obsessive-compulsive disorders. The group with obsessive-compulsive symptoms during the prodromal phase was characterized by a higher ratio of males, higher incidences of perinatal and brain computed tomography (CT) abnormalities, fewer hereditary factors, longer duration of the prodromal phase, and a higher incidence of insidious onset and negative symptoms compared with the group without such prodromal symptoms. Schizophrenic patients with obsessive-compulsive symptoms during the prodromal phase were clinically distinct from those without, which suggests the possibility of subtype categorization.

[Psychotherapeutic and sociotherapeutic aspects in schizophrenic psychoses in childhood and adolescence]

A critical review is given of modern psychotherapeutic and sociotherapeutic approaches used with children and adolescents with schizophrenic disorders. Therapeutic strategies are evaluated within the framework of emprical data on biological and psychosocial facets of schizophrenia. Major treatment goals are discussed that go beyond differences in psychotherapeutic methodology, e.g. attainment of biographical continuity, improvement of strategies for social interaction and conflict resolution, stabilization of self-structures, mastery of age-dependent developmental tasks and, finally, coordination of different therapeutic interventions. It is stressed that psychotherapy and sociotherapy are equally important in the treatment of children and adolescents with schizophrenia.

[Early manifestations of schizophrenic psychoses]

Schizophrenic disorders in childhood are rare. Only about 0.5 to 1% of all such disorders have their onset before age 9 and about 4% before age 14. In puberty and early adolescence, however, there is a marked increase in the frequency of such disorders. In childhood more boys seem to be affected, but during adolescence this difference seems to disappear. Possible etiological factors currently under discussion are genetic factors, neurointegrative deficits, attentional deficits, communication deficits and conspicuous premorbid features. With regard to the latter, the authors could show that positive and negative symptoms appear months or even years before the first manifestation of the disorder requiring inpatient treatment. From this perspective schizophrenic disorders in general and those with early onset in particular fit a dimensional model of illness better than a categorical one. In the development of preventive measures more attention to premorbid features is essential.

Plasma clozapine and haloperidol concentrations in adolescents with childhood-onset schizophrenia: association with response

BACKGROUND

Plasma clozapine and haloperidol concentrations were studied in adolescents being treated for childhood-onset schizophrenia.

METHOD

Eleven patients (9 boys, 2 girls; mean age = 14.1 +/- 2.1 years) received a 6-week blinded or open trial of clozapine. Five patients also received 6 weeks of blinded or open haloperidol. Doses were increased on an individual basis to a mean 6-week dose of 5.99 +/- 2.6 mg/kg/day for clozapine and 0.24 +/- 0.20 mg/kg/day for haloperidol. The Brief Psychiatric Rating Scale and Bunney Hamburg Rating Scale were completed weekly for each subject. Weekly blood samples were obtained during therapy and assayed by high performance liquid chromatography.

RESULTS

The mean clozapine level at Week 6 was 378.3 ng/mL and ranged from 77.5 to 1050 ng/mL. The mean Week 6 haloperidol level was 23.0 ng/mL (range, 6.2-44.3 ng/mL). The clozapine desmethyl and N-oxide metabolites achieved mean concentrations of 77% and 18%, respectively, of those of the parent compound. The mean ratio of haloperidol/reduced haloperidol was 4.48 (range, 0.76-8.76). Clozapine concentrations versus clinical benefit exhibited a consistent linear relationship among patients (correlation range, 0.26-0.96). Conversely, poor and inconsistent correlations between haloperidol concentrations and clinical effects were observed. No relationships were noted between clozapine or haloperidol dose and clinical effects.

CONCLUSION

Adolescents with schizophrenia produce a greater amount of desmethylclozapine than previously seen in adults. Plasma clozapine concentrations appear to be related in a linear fashion to clinical improvement.

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.

Clozapine in the treatment of a young adolescent with schizophrenia

Although recent reports have suggested that clozapine may be efficacious in the treatment of adolescents with schizophrenia, few studies have examined the use of clozapine in patients younger than 17 years of age. We describe highly successful trials of clozapine conducted in a 13-year-old girl and her cousin, both of whom developed severe symptoms of schizophrenia, which were refractory to neuroleptic medication, at the ages of 11 and 13 years, respectively. The pharmacology of and clinical experience with clozapine are reviewed.

Looking for childhood-onset schizophrenia: the first 71 cases screened

OBJECTIVE

To review psychiatric referrals to a study of childhood-onset schizophrenia.

METHOD

Children and adolescents (N = 71) and their parents selected from a total of 260 patients referred to the National Institute of Mental Health between 1990 and 1993, with onset of psychosis at or before age 12 years, were screened in person, using the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Epidemiologic Version, portions of the Diagnostic Interview for Children and Adolescents-Parent Version, and clinical interview. Best-estimate diagnoses using all sources of information were determined. Thought disorder was rated on a subset of subjects using standardized videotaped speech samples.

RESULTS

Interrater reliability (kappa) between two child psychiatrists for best-estimate primary diagnoses ranged from .65 to .81. Schizophrenia was diagnosed for 19 children who by history had had onset at or before age 12, but all were in puberty when interviewed. Affect disorders (N = 14) and Asperger's syndrome and pervasive developmental disorder not otherwise specified (N = 6) were also diagnosed. A large group of reliably identifiable children not completely described by any DSM-III-R category and provisionally called "multidimensionally impaired" (N = 21) with multiple language or learning disorders, mood lability, and transient psychotic symptoms was seen.

CONCLUSIONS

Childhood-onset schizophrenia is often misdiagnosed, perhaps is often misdiagnosed, perhaps because of the rarity of the disorder and the ambiguity in applying primary criteria. An array of developmental disturbances are seen with less pervasive childhood-onset psychotic symptoms.

An open trial of clozapine in 11 adolescents with childhood-onset schizophrenia

OBJECTIVE

To review the response of 11 adolescents with childhood-onset schizophrenia to a 6-week open clozapine trial.

METHOD

Eleven children meeting DSM-III-R criteria for schizophrenia had a 6-week open trial of clozapine (mean sixth week daily dose 370 mg). Behavioral ratings included the Brief Psychiatric Rating Scale and Children's Global Assessment Scale.

RESULTS

More than half showed marked improvement in Brief Psychiatric Rating Scale ratings by 6 weeks of clozapine therapy compared to admission drug rating and compared to a systematic 6-week trial of haloperidol.

CONCLUSIONS

This open trial indicates that clozapine may be a promising treatment for children and adolescents with schizophrenia who do not respond well to typical neuroleptics. A double-blind placebo-controlled study is ongoing.

Clozapine for early developmental delays with childhood-onset schizophrenia: protocol and 15-month outcome

This paper reports on the pharmacotherapy and long-term follow-up of a child treated with clozapine. It is one of the earliest American experiences with this agent in children to date. Clozapine was relatively effective and safe in this patient. Additional features of the case are the early social and developmental delays preceding schizophrenia, the response of symptoms of childhood-onset schizophrenia to clozapine, and the reduction in tardive dyskinesia symptoms while taking clozapine. Compared to recommendations for dosing adults, a slower rate of increasing clozapine doses was important for this child. For future reference, the protocol and consent form used for this course of treatment are included.

Family-expressed emotion, childhood-onset depression, and childhood-onset schizophrenia spectrum disorders: is expressed emotion a nonspecific correlate of child psychopathology or a specific risk factor for depression?

Expressed emotion (EE) was examined, using the brief Five Minute Speech Sample measure, in families of (1) children with depressive disorders, (2) children with schizophrenia spectrum disorders, and (3) normal controls screened for the absence of psychiatric disorder. Consistent with the hypothesis of some specificity in the association between EE and the form of child disorder, rates of EE were significantly higher among families of depressed children compared to families of normal controls and families of children with schizophrenia spectrum disorders. Within the depressed group, the presence of a comorbid disruptive behavior disorder was associated with high levels of critical EE, underscoring the need to attend to comorbid patterns and subtypes of EE in future research.

Assessing positive and negative symptoms in children and adolescents

OBJECTIVE

The purpose of this study was to test the reliability and validity of a new assessment instrument for positive and negative symptoms in severely disturbed children and adolescents (Kiddie-PANSS).

METHOD

The Positive and Negative Syndrome Scale for adult schizophrenia was modified through successive field trials on the basis of developmental characteristics of children and adolescents. The scale was then given to 34 inpatients (19 children, mean age = 9.35 years, and 15 adolescents, mean age = 14.33 years) with DSM-III-R diagnoses of schizophrenia, psychosis not otherwise specified, schizoaffective, affective, conduct, personality, and developmental disorders determined independently by child psychiatrists. All patients with schizophrenia were placed in the schizophrenic group, and all others were placed in a general inpatient group. The Kiddie-PANSS ratings were given by three trained child psychiatrists after a 30-35-minute structured interview. The Achenbach Child Behavior Checklist, the Scale for the Assessment of Positive Symptoms, and the Scale for the Assessment of Negative Symptoms were also administered in order to determine criterion-related association.

RESULTS

Intraclass correlation coefficients revealed that all subscales and total psychopathology were reliably assessed among raters. The Kiddie-PANSS and Scale for the Assessment of Positive Symptoms/Scale for the Assessment of Negative Symptoms correlated with one another, indicating criterion-related association. Differences on measures of positive, negative, and general psychopathology, as measured by the Kiddie-PANSS, between the patients with schizophrenia and the general inpatient group were highly significant.

CONCLUSIONS

The Kiddie-PANSS shows good interrater reliability and criterion-related validity. In a cohort of inpatient children and adolescents the scale successfully differentiated schizophrenic patients from nonschizophrenic patients.

Communication deficits in childhood schizophrenia spectrum disorders

This article examines the effects of age, cognition, and discourse skills on the clinical manifestations of formal thought disorder in 31 children with schizophrenia, 14 with schizotypal personality disorder (SPD), and 70 who were normal. The communication deficits of the 31 children with schizophrenia have three characteristics: illogical thinking, loose associations, and impaired discourse skills. Loose associations and illogical thinking reflect different aspects of impaired attention/information processing in children with schizophrenia. Only certain aspects of the discourse deficits of the children with schizophrenia are associated with the cognitive measures used in this study. The children with SPD have similar illogical thinking and loose associations scores but a narrower range of discourse deficits than the children with schizophrenia. Implications of the interaction between the clinical, cognitive, and discourse manifestations of the communication deficits of children with schizophrenia are discussed. The possible relationship between these manifestations and positive and negative symptoms of schizophrenia are also reviewed.

Children with schizophrenia: diagnosis, phenomenology, and pharmacotherapy

This article presents data on the diagnosis and phenomenology of schizophrenia in 16 hospitalized children, ages 5.5 to 11.75 years. These 16 subjects are the first to complete an ongoing double-blind, placebo-controlled study of haloperidol in children with schizophrenia diagnosed by DSM-III-R criteria. We describe the pharmacologic treatment response of this subsample and compare our diagnostic, phenomenologic, and treatment findings with those of other investigators. Our results show that children under age 12 can be diagnosed with schizophrenia by the same criteria used for adults, that they show comparable clinical symptoms, and that on haloperidol they show improvement in target psychotic symptoms, at least in a short-term inpatient setting.

The clinical presentation of childhood-onset schizophrenia

This review describes the symptomatic presentation of schizophrenia with onset in childhood. Phenomenologic data from an original sample of 35 children with onset before the age of 12, from the University of California, Los Angeles (UCLA) Childhood-Onset Schizophrenia Research Program, are presented and compared with similar data from two other major studies. Similarities and differences between childhood-onset and adult-onset forms of the disorder are discussed, with special emphasis on gender ratio and mode of onset. Among the 35 children in the UCLA study, 80 percent presented with auditory hallucinations, 74 percent with flat or inappropriate affect, 63 percent with delusions, 40 percent with formal thought disorder, and 37 percent with visual hallucinations. In the vast majority of cases onset was insidious. The mean age at onset of general psychiatric symptoms was estimated to be 4.6 years, the mean age at onset of psychotic symptoms was 6.9 years, and the mean age at diagnosis was 9.5 years. The phenomenology of the UCLA sample is compared with two other major studies of childhood-onset schizophrenia. The relative frequency of core symptoms, with the exception of thought disorder, was strikingly similar across the three studies, as was the mode of onset. The groups were also similar in age at diagnosis, gender ratio, and IQ. Limited comparisons with studies of first-onset schizophrenia in adults suggest basic similarities between schizophrenia with onset in childhood and adulthood. The qualitative nature of the symptoms reported is similar to that seen in adult cases with the expected developmental variations, for example, delusions are less complex in children and reflect childhood themes. Limited data from a cross-sectional assessment using DSM-III criteria indicate that the relative frequency of core symptoms may also be similar to that seen in adult cases. In contrast to previous reports, this review suggests that the high male to female ratio seen in childhood-onset cases represents a continuum with young adult cases, and gender ratio does not truly distinguish childhood-onset from (young) adult-onset forms of the disorder. Schizophrenia with onset before adolescence does seem to differ from later-onset cases in the very high rates of insidious as opposed to acute onset. The insidious onset may also help explain the clinical observation that in some children psychotic symptoms, particularly those of long duration, can be relatively ego-syntonic.

Clozapine treatment in very early onset schizophrenia

Very early onset schizophrenic patients only partially benefit from conventional antipsychotic treatment and are at increased risk for developing tardive dyskinesia (TD). Clozapine, which lacks extrapyramidal side effects including TD, has been proved effective for adult schizophrenic patients who are resistant to other neuroleptics. Clozapine, therefore, may offer an alternative treatment for these patients. The authors report four successful trials of clozapine in children aged 10 to 12 years old with schizophrenia, the youngest group reported on to date, who were unresponsive to conventional neuroleptic treatment.

Clinical features and outcome of child and adolescent schizophrenia

Subjects admitted 12 months or more previously to two child and adolescent psychiatric units in New Zealand and the United States with a diagnosis of non-organic, nonautistic psychosis, were contacted and those who received a DSM-III-R diagnosis of schizophrenia were studied (n = 33 [New Zealand] and n = 24 [United States]). Premorbid and first-episode data were obtained from the admission record using global clinical measures of moderate reliability, outcome diagnosis and status by interviews, and professional and family reports. Mean ages at onset were 13.9 (New Zealand) and 15.6 (United States). Premorbid and clinical features resembled those in adult schizophrenia, though there were probable quantitative differences. At outcome (mean interval = 4 years) few subjects were symptom-free or independent, and mean global assessment of functioning had fallen from 55 to 40. Outcome was much worse in schizophrenia than bipolar disorder. Despite a 59 percent attrition rate and higher rates of initial misdiagnosis in the United States, and some demographic differences, New Zealand and United States samples resembled each other clinically and in outcome. Initial misdiagnosis of bipolar disorder as schizophrenia was not due to minimizing mood symptoms, which were common in both disorders. Within this age range (mostly 11-17), age at onset had only minor effects. Outcome was best predicted by premorbid personality.

Childhood-onset schizophrenia: editors' introduction

Descriptions of various psychotic symptoms in children began to appear in the psychiatric literature at about the same time as descriptions of psychotic symptoms in adults. For example, Kraepelin estimated that at least 3.5 percent of his cases of dementia praecox had onsets before age 10. The construct of "childhood schizophrenia" initially emerged from attempts to classify a broad range of psychotic children. By the late 1940s and 1950s, the diagnosis of "childhood schizophrenia" was given to many disturbed children who today would be considered to have infantile autism and other developmental disabilities. In the early 1970s infantile autism and its variants was differentiated from schizophrenia of childhood onset. These changes were incorporated in DSM-III, which returned to the practice before 1930 of diagnosing schizophrenia in children using the same criteria as for adults, with minor allowances for differences in the manifestations of these symptoms during childhood. The studies presented in this issue of Schizophrenia Bulletin use DSM-III, DSM-III-R, or ICD-9 criteria for schizophrenia.

Cognitive/neuropsychological studies of children with a schizophrenic disorder

This article summarizes a series of cognitive/neuropsychological studies of children with schizophrenia. One set of studies, which surveyed a broad range of neuropsychological functions, revealed no evidence that children with schizophrenia are consistently impaired in sensory, perceptual, or language functions. Rather, the studies showed that children with schizophrenia performed poorly on tasks requiring sensory, perceptual, and language processing that made extensive demands on information-processing capacity. A second series of studies, which examined visual information processing by manipulating the processing demands of span of apprehension tasks, yielded similar findings. The key characteristic of tasks that elicit impaired performance in children with schizophrenia is that the task makes extensive demands on processing resources. This suggests that these children have limited information-processing capacity. Three hypotheses are proposed concerning the cognitive processes that are impaired in children with schizophrenia: (1) the cognitive processes that seem to be impaired in these children are part of a more general, hierarchically organized attention system; (2) the component processes of the system are subserved by different brain structures; and (3) the structures are part of a network that includes the frontal lobe and thalamus in interaction with the reticular activating system.

Childhood-onset schizophrenia: a followup study

This article is an overview of our studies of childhood-onset schizophrenia. Data are presented demonstrating that (1) the majority of the sample showed continuing schizophrenia as they progressed through adolescence; (2) there was considerable variability in outcome, defined by global adjustment scores, with 56 percent of the sample showing improvement in functioning during a 2- to 7-year followup period and the other 44 percent showing minimal improvement or a deteriorating course; (3) schizophrenia in childhood could be diagnosed by the same criteria used for adults and was associated with severe dysfunction; and (4) some intrafamilial attributes found to be associated with schizophrenia in adults were also associated with schizophrenia in children, but there were some differences in the family environmental correlates of childhood- and later-onset schizophrenia. These data are consistent with the hypothesis that childhood- and later-onset schizophrenia represent the same illness or illnesses. Additional research is needed, however, to clarify the etiologic and clinical significance of the atypical early onset in childhood cases.