Psychological evaluation of clinical disturbance in children at risk for psychopathology

Offspring of Parents with Schizophrenia: A Systematic Review of Developmental Features Across Childhood

A significant body of longitudinal research has followed the offspring of parents with schizophrenia. This article presents a systematic review of 46 separate papers presenting the results of 18 longitudinal studies that have followed children who are at familial high risk of developing psychotic disorders. The studies suggest that these children do show distinct developmental patterns characterized by higher rates of obstetric complication, neurodevelopmental features such as motor and cognitive deficits, and distinctive social behavior. This review summarizes those findings according to child developmental stages. Twelve of the studies followed offspring into adulthood and examined psychiatric diagnoses. From 15% to 40% of children at familial high risk developed psychotic disorders in adulthood. Many also received other psychiatric diagnoses such as mood or anxiety disorders. This combination of results suggests that offspring of parents with schizophrenia are at high risk not just for schizophrenia but, more broadly, for poor developmental and general mental health outcomes. The clinical implications of the findings are discussed, as are new prognostic strategies and potential programs for selective prevention.

Specificity of familial transmission of schizophrenia psychosis spectrum and affective psychoses in the New England family study's high-risk design

CONTEXT

There is a long history of research on the familial transmission of schizophrenia and other psychoses. However, few studies have investigated the specificity of the transmission of schizophrenia-psychosis spectrum (SPS) disorders and affective psychoses (APs) or observed high-risk offspring into mid-adulthood.

OBJECTIVES

To investigate the transmission of psychoses from parents to their offspring and the specificity of transmission across psychosis subtypes.

DESIGN

High-risk follow-up study.

SETTING

New England Family Study's High-Risk Study, with population-based community sampling from Boston, Massachusetts, and Providence, Rhode Island.

PARTICIPANTS

A total of 203 high-risk offspring of 159 parents with diagnoses of psychoses (SPS and AP) and 147 control offspring of 114 control parents.

MAIN OUTCOME MEASURES

Systematically assessed research DSM-IV psychiatric diagnoses for adult offspring.

RESULTS

Compared with those of control parents, offspring of parents with SPS had a significant, almost 6-fold elevated risk of SPS disorders and a nonsignificant doubling of risk for AP. Offspring of parents with AP had a significant 14-fold elevated risk for AP compared with offspring of controls; for SPS disorders, the risk doubled but was not significant.

CONCLUSION

Having a parent with psychosis significantly increased the risk for psychosis among offspring and demonstrated specificity for the transmission of SPS disorders and APs within families.

Childhood developmental abnormalities in schizophrenia: evidence from high-risk studies

According to cohort studies, individuals who develop schizophrenia in adulthood show developmental abnormalities in childhood. These include delays in attainment of speech and motor milestones, problems in social adjustment, and poorer academic and cognitive performance. Another method of investigating developmental abnormalities associated with schizophrenia is the high-risk (HR) method, which follows up longitudinally the development of children at high risk for schizophrenia. Most HR studies have investigated children who have a parent with schizophrenia. This review summarizes findings concerning childhood and adolescent development from 16 HR studies and compares them with findings from cohort, conscript, and family studies. We specifically addressed two questions: (1) Does the development of HR children differ from that of control children? (2) Which developmental factors, if any, predict the development of schizophrenia-spectrum disorders in adulthood? While the answer to the first question is affirmative, there may be other mechanisms involved in addition to having a parent with schizophrenia. Factors which appear to predict schizophrenia include problems in motor and neurological development, deficits in attention and verbal short-term memory, poor social competence, positive formal thought disorder-like symptoms, higher scores on psychosis-related scales in the MMPI, and severe instability of early rearing environment.

The neuropsychology and neuroanatomy of bipolar affective disorder: a critical review

Bearden CE, Hoffman KM, Cannon TD. The neuropsychology and neuroanatomy of bipolar affective disorder: a critical review. Bipolar Disord 2001: 3: 106 150. C Munksgaard, 2001

OBJECTIVES

To present a comprehensive review of the existing neuropsychological and neuroimaging literature on bipolar affective disorder. This review critically evaluates two common conceptions regarding the neuropsychology of bipolar disorder: 1) that, in contrast to schizophrenia, bipolar affective disorder is not associated with general cognitive impairment independent of illness episodes, and 2) relative right hemisphere (RH) dysfunction is implicated in bipolar illness patients, supported by reports of relatively greater impairment in visuospatial functioning, lateralization abnormalities, and mania secondary to RH lesions.

METHODS

The major computerized databases (Medline and PSYCInfo) were consulted in order to conduct a comprehensive, integrated review of the literature on the neuropsychology and neuroanatomy of bipolar disorder. Articles meeting specified criteria were included in this review.

RESULTS

In a critical evaluation of the above notions, this paper determines that: 1) while there is little evidence for selective RH dysfunction, significant cognitive impairment may be present in bipolar illness, particularly in a subgroup of chronic, elderly or multiple-episode patients, suggesting a possible toxic disease process, and 2) the underlying functional correlate of these cognitive deficits may be white matter lesions ('signal hyperintensities') in the frontal lobes and basal ganglia, regions critical for executive function, attention, speeded information processing, learning and memory, and affect regulation. While this hypothesized neural correlate of cognitive impairment in bipolar disorder is speculative, preliminary functional neuroimaging evidence supports the notion of frontal and subcortical hypometabolism in bipolar illness.

CONCLUSIONS

The etiology of the structural brain abnormalities commonly seen in bipolar illness, and their corresponding functional deficits, remains unknown. It is possible that neurodevelopmental anomalies may play a role, and it remains to be determined whether there is also some pathophysiological progression that occurs with repeated illness episodes. More research is needed on first-episode patients, relatives of bipolar probands, and within prospective longitudinal paradigms in order to isolate disease-specific impairments and genetic markers of neurocognitive function in bipolar disorder.

fMRI during affect discrimination in bipolar affective disorder

OBJECTIVE

It has been hypothesized that disturbances in affect may represent distinct etiologic factors for bipolar affective disorder. The neural mechanisms mediating affective processes and their relationship to brain development and the pathophysiology of bipolar affective disorder remain to be clarified. Recent advances in neuroimaging techniques have made possible the non-invasive examination of specific brain regions during cortical challenge paradigms. This study reports findings based on fMRI data acquired during fearful and happy affect recognition paradigms in patients with bipolar affective disorder and in healthy adult subjects.

METHODS

Prior to the scan, subjects were instructed to view the stimuli and to identify the type of facial expression presented. Echo planar scanning was performed on a 1.5 Tesla scanner which had been retrofitted with a whole body echo planar coil, using a head coil.

RESULTS

The data indicate that in adult subjects with bipolar affective disorder, there is a reduction in dorsolateral prefrontal cortex activation and an increase in amygdalar activation in response to fearful facial affect. In a healthy comparison group, signal intensity changes were not found in these regions. In addition, although the patients with bipolar affective disorder completed the task demands, they demonstrated an impaired ability to correctly identify fearful facial affect but not the happy facial affect displayed.

CONCLUSION

These findings are consistent with the hypothesis that in some patients with bipolar affective disorder, there may be a reduction of frontal cortical function which may be associated with affective as well as attentional processing deficits.

Children of disturbed parents: the interface between research and intervention

This paper provides a review of high-risk studies and preventive interventions with children who have an increased likelihood of developing psychopathology because they are the offspring of emotionally disturbed parents. The research implications for preventive interventions are summarized in terms of selection of participants, goals for prevention, intervention methods, and intervention research methodology. Next, several preventive intervention programs are reviewed and evaluated for their responsiveness to the research literature. The review revealed that, despite theoretical and methodological diversity in the research literature, the findings provide many suggestions for the design of preventive interventions. On the other hand, intervention programs were most often found to have not used research findings in program design. This review concludes with suggestions for needed research and guidelines for future preventive interventions.

A review of research relevant to custody and access disputes

With the high rate of marriage breakdown, increasing numbers of children are becoming the subjects of custody and access disputes. The Courts are looking to the services of psychiatrists in these matters. They value our expert opinion on the least detrimental available alternative for the child. This paper reviews available research data which are relevant to psychiatric testimony on the determination of exclusive custody, joint custody and access. It is concluded that there is emerging an objective body of data which can buttress psychiatric opinion in these matters, but that a number of the principles which have guided the Courts to date, have not been thoroughly researched.

Rorschach Developmental Level in the offspring of patients with schizophrenia and manic-depressive illness

The Developmental Level (DL) score was assessed from Rorschach inkblot tests of 305 children. Children were either the offspring of one schizophrenic, one manic-depressive, one physically ill, or of two normal parents. Socioeconomic status, age, and intelligence were treated as covariates. Children of one schizophrenic parent had lower DL scores than children in the other three groups.

A retrospective analysis of the TATs of children at risk who subsequently broke down

A retrospective evaluation of stories told to three Thematic Apperception Test (TAT) cards by children at risk isolated six characteristics that were associated with functioning six to 10 years later. The characteristics included lack of individual initiative, denial of mother-child relationships, denial of negative outcomes, and lack of autonomy. The TATs of children at risk (due to one parent's hospitalization for a psychotic illness) who subsequently suffered major decompensation themselves (requiring hospitalization or intensive outpatient therapy) could be discriminated from those of children at risk with apparently normal development. The TAT characteristics were independent of the level of adjustment at the time the TATs were administered, not related to the child's IQ, socioeconomic status, race, or other family characteristics, and moderately negatively correlated with story length.