Frosted Intellectuals: How Dr. Leo Kanner Constructed the Autistic Family

Dr. Leo Kanner, in his delineation of autism as a clinical entity, is also remembered for having created a powerful stereotype of parents of autistic children as highly educated, intelligent, and emotionally distant. As historians have come to understand that autism arose out of a preceding diagnosis, childhood schizophrenia, it has also become clear that the so-called "refrigerator mother" caricature arose out of the preceding notion of the cold "schizophrenogenic" mother. However, this does not explain Kanner's belief that parents (fathers as well as mothers) were highly educated and intelligent. This study is the first to compare Kanner's famous published case studies with case records of his patients in the Phipps Clinic at Johns Hopkins in order to discover how this stereotype was created. Contrary to his assertion in the published literature, Kanner did indeed see patients with autism whose parents who did not fit his stereotype, but he did not publish these cases. Kanner's stereotype of the "autistic parent" thus seems to have arisen through a process of confirmation bias. This continues to have ramifications to the present day, by linking autism in the popular mind to highly educated and professional parents, and by leading patients with nonstereotypical patients to go unrecognized.

Psychosis in a Patient with Davidoff-Dyke-Masson Syndrome

OBJECTIVES

To report the finding of psychosis in a patient with Davidoff-Dyke-Masson Syndrome.

METHOD

Case report.

CONCLUSIONS

Right-sided hemiatrophy may be an addition to the list of neuro-developmental and structural cerebral anomalies associated with psychotic disorders including schizophrenia.

Schedule for affective disorders and schizophrenia for school-age children (K-SADS-PL) for the assessment of preschool children--a preliminary psychometric study

OBJECTIVE

To assess the psychometrics of the schedule for affective disorders and schizophrenia for school-age children present and lifetime version (K-SADS-PL) in diagnosing DSM-IV psychiatric disorders and subsyndromal symptomatology in preschool children.

METHOD

Parents were interviewed about their children using the K-SADS-PL, and they completed the early childhood inventory-4 (ECI-4) and child behavior checklist for ages 1(1/2)-5 years (CBCL). Discriminant, divergent, and convergent validity of the K-SADS-PL were evaluated in 204 offspring ages 2-5 years old of parents from an ongoing study. Inter-rater reliability as well as predictive validity of intake diagnoses at second assessment approximately two years after intake were evaluated. Fourteen children were also assessed by the preschool age psychiatric assessment (PAPA).

RESULTS

Children who were diagnosed with oppositional defiant disorder, attention deficit hyperactivity disorder, anxiety, mood, or elimination disorders had significantly higher scores on the ECI-4 than children without these disorders. Significant correlations were found for all convergent CBCL scales. Divergent validity was acceptable for emotional disorders. Inter-rater kappa coefficients for all diagnoses were good. Above noted results were similar for children with at least one positive K-SADS-PL key screen symptom. A significantly higher percentage of children with an intake diagnosis had a diagnosis approximately two years after intake compared to those without an intake disorder. Overall, there was consistency between the PAPA and the K-SADS-PL.

CONCLUSIONS

Pending further testing, the K-SADS-PL may prove useful for the assessment of psychopathology in preschoolers.

Cortical brain development in schizophrenia: insights from neuroimaging studies in childhood-onset schizophrenia

Childhood-onset schizophrenia (COS; defined as onset by age 12 years) is rare, difficult to diagnose, and represents a severe and chronic phenotype of the adult-onset illness. A study of childhood-onset psychoses has been ongoing at the National Institute of Mental Health (NIMH) since 1990, where children with COS and severe atypical psychoses (provisionally labeled "multidimensionally impaired" or MDI by the NIMH team) are studied prospectively along with all first-degree relatives. COS subjects have robust cortical gray matter (GM) loss during adolescence, which appears to be an exaggeration of the normal cortical GM developmental pattern and eventually mimics the pattern seen in adult-onset cases as the children become young adults. These cortical GM changes in COS are diagnostically specific and seemingly unrelated to the effects of medications. Furthermore, the cortical GM loss is also shared by healthy full siblings of COS probands suggesting a genetic influence on the abnormal brain development.

Schizophrenic-like neurocognitive deficits in children and adolescents with 22q11 deletion syndrome

22q11.2 Deletion Syndrome (22q11DS) is the most common genetic microdeletion syndrome affecting humans. The syndrome is associated with general cognitive impairments and specific deficits in visual-spatial ability, non-verbal reasoning, and planning skills. 22q11DS is also associated with behavioral and psychiatric abnormalities, including a markedly elevated risk for schizophrenia. Research findings indicate that people with schizophrenia, as well as those identified as schizoptypic, show specific cognitive deficits in the areas of sustained attention, executive functioning, and verbal working memory. The present study examined such schizophrenic-like cognitive deficits in children and adolescents with 22q11DS (n = 26) and controls (n = 25) using a cross-sectional design. As hypothesized, 22q11DS participants exhibited deficits in intelligence, achievement, sustained attention, executive functioning, and verbal working memory compared to controls. Furthermore, deficits in attention and executive functioning were more pronounced in the 22q11DS sample relative to general cognitive impairment. These findings suggest that the same pattern of neuropsychological impairment seen in patients with schizophrenia is present in non-psychotic children identified as at-risk for the development of schizophrenia based on a known genetic risk marker.

IQ stabilization in childhood-onset schizophrenia

OBJECTIVE

To examine the long term IQ trajectory for childhood-onset schizophrenia (COS) in an expanded, prospective longitudinal study.

METHODS

Seventy children meeting DSM criteria for schizophrenia were tested at 2 year intervals with age appropriate Wechsler intelligence tests and repeated administration of information and comprehension WISC subtests even after age 18. For a subgroup with 31 patients, pre-NIH IQ test administrations were available including 18 pre-psychotic and 13 post-psychotic subjects. The pattern of IQ performance over time was determined using mixed model regression analysis.

RESULTS

No progressive cognitive decline was seen up to 13+ years post psychosis onset. For the subgroup of subjects with pre-illness scores, there had been an initial steep decline in IQ, from about 2 years prior to 1.7 years after onset of psychotic symptoms, as reported for adult patients.

CONCLUSIONS

The level long-term trajectory of IQ measures in COS appears stable, similar to that reported for adult onset patients. For COS, level cognitive functioning extends up to 13+ years post psychosis onset, in spite of chronic illness and concomitant, progressive loss of cortical gray matter.

Childhood-onset schizotypal disorder: a follow-up study and comparison with childhood-onset schizophrenia

OBJECTIVE

This paper presents results from the UCLA Follow-Up Study of Childhood-Onset Schizophrenia (SZ) Spectrum Disorders.

METHOD

We assessed 12 children with schizotypal personality disorder (SPD) and 18 children with schizophrenia 1-7 years following initial project intake.

RESULTS

There was significant continuity between SZ spectrum disorders in childhood and adolescence. Although not all children who presented initially with SZ spectrum disorders continued to meet criteria for SZ spectrum disorder as they progressed through the follow-up period, rates of SZ spectrum disorders ranged from 75% to 92% across the 3 follow-up years for children initially presenting with SPD, and from 78% to 89% for children initially presenting with SZ.

CONCLUSION

The most common clinical outcome for children with SPD was continuing SPD, supporting the hypothesis of continuity between childhood and later SPD. However, 25% of the SPD sample developed more severe SZ spectrum disorders (schizophrenia or schizoaffective disorder), also supporting the hypothesis that SPD represents a risk or precursor state for more severe SZ spectrum disorders.

Annotation: childhood-onset schizophrenia: clinical and treatment issues

BACKGROUND

In the past 10 years, there has been increased research on childhood-onset schizophrenia and clear advances have been achieved.

METHOD

This annotation reviews the recent clinical and treatment literature on childhood-onset schizophrenia.

RESULTS

There is now strong evidence that the syndrome of childhood-onset schizophrenia exists and there are several similarities between childhood- and later-onset schizophrenia. Schizophrenia in youth can be reliably diagnosed using the same criteria employed with adults, and childhood-onset schizophrenia is predictive of schizophrenia or schizophrenia spectrum disorders in adulthood. Data is accumulating to guide pharmacological treatment strategies, and practice parameters have been developed to guide clinical care.

CONCLUSIONS

Despite significant advances, there remains an urgent need for additional research on treatment and service delivery strategies. Promising work with adults highlights the importance of attending to psychosocial as well as pharmacologic treatment strategies, and the potential value of preventive interventions.

Childhood antecedents of schizophrenia: developmental sequencing and specificity of problem behavior

Childhood antecedents of schizophrenia were explored for 148 boys seen in child guidance clinics prior to the onset of adolescent or adult disorders. Those most disturbed in childhood were more likely to be preschizophrenic, and their disturbed behavior was relatively specific to that grouping. Childhood problems with motor coordination and attention were associated with impulsive, inappropriate behavior which led to peer rejection followed by increasing seclusiveness. Clinical grouping of the most disturbed boys produced composite descriptions for four groups.

Gender differences in schizophrenia

Sex differences in schizophrenia can be caused by the disease process itself, by genetic and hormonal differences, by differences in the maturation and morphology of the brain and in age- and gender-specific behavioural patterns. These hypotheses will be tested on the major results reported in the literature as well as on different levels (epidemiology, risk factors, animal experiments, a controlled clinical study) on data from the ABC Schizophrenia Study. Symptomatology, lifetime risk and symptom-related course of illness-the latter without consideration of age-show no gender differences. However, until menopause illness onset is delayed and severity of illness is reduced by oestrogen on the level of gene expression and transmitter functioning. Oestrogen has an antagonistic effect on the-familial or exogenous-predisposition to illness. As a result, the age distribution of onset and the severity of first-episode illness in young men and post-menopausal women differ from the normal. First intervention trials with oestrogen substitution of neuroleptic therapy have demonstrated antipsychotic effects. The poorer social course of schizophrenia in men than in premenopausal women is accounted for by men's lower level of social development at illness onset and the subsequent impediment of their further development. Men's socially adverse illness behaviour, too, is a contributing factor. Scarcity of the knowledge of differences in the development, morphology and functioning of the male and female brain does not yet allow any definitive conclusions about gender differences in schizophrenia.

"Real world" atypical antipsychotic prescribing practices in public child and adolescent inpatient settings

This article examines the factors that influence antipsychotic use among youth treated in public inpatient facilities. By combining data from 11 focus groups, a survey of 43 researchers and clinicians, and a chart review of 100 closed patient charts, we investigated the interplay between physicians' and staff members' perceptions of problems related to antipsychotic prescribing, their beliefs concerning optimal approaches, their actual recorded prescribing behaviors, and the discrepancies between their beliefs and their recorded practices. We discovered that antipsychotics are prescribed broadly to treat a variety of conditions, including nonpsychotic disorders among children in public inpatient facilities. Despite overall expert consensus regarding "best practices," physicians described systemic obstacles that prevent the application of these practices, and our data confirmed that best practices are not always followed. Future research should be done with this patient population and should investigate the factors that influence antipsychotic use among inpatient youth.

[Prodromal symptoms of schizophrenics syndrome in children and adolescent]

This presentation concentrates on modality and frequency analysis of prodromal schizophrenic symptoms of the children and adolescent. A sample (n-50) of children between 8 and 19 years was tested by structural interview. There were observed the signs resembling following symptoms: negative symptoms (74%), anxiety disorders (42%) and obsessive-compulsive disorders (20%).

Neurocognitive impairments in nonpsychotic parents of children with schizophrenia and attention-deficit/hyperactivity disorder: the University of California, Los Angeles Family Study

BACKGROUND

We tested the hypotheses that certain neurocognitive impairments index genetic liability to schizophrenia and that childhood-onset schizophrenia (COS) is a variant of adult-onset schizophrenia (AOS) by determining whether parents of COS probands show the types of neurocognitive impairments found in relatives of AOS probands.

METHODS

Parents of COS probands (n = 79) were compared with parents of attention-deficit/hyperactivity disorder (ADHD; n = 190) and community control (CC; n = 115) probands on 3 neurocognitive tasks shown in previous research to detect impairments in patients with AOS and ADHD and in the relatives of patients with AOS. Parents with a diagnosis of psychosis were excluded from the study.

RESULTS

On the Degraded Stimulus-Continuous Performance Test and the Trail-Making Test B-Adolescent Version, the parents of COS probands performed significantly worse than the parents of CC and ADHD probands, who did not differ significantly from each other. On the Span of Apprehension, we found no significant group differences. Using rigorous cutoffs, a combination of scores on the 3 neurocognitive tests identified 16 (20%) of the mothers and fathers of COS probands compared with 0% of the mothers and fathers of CC probands. There was diagnostic specificity of the neurocognitive impairments. A combination of neurocognitive scores identified 6 (12%) of the mothers of COS probands vs 0% of the mothers of ADHD probands. A cutoff that identified 2 (2%) of the fathers of ADHD probands classified 5 (17%) of the fathers of COS probands. We found no significant differences in neurocognitive functions between the parents of ADHD and CC probands.

CONCLUSIONS

The aggregation of neurocognitive impairments in the parents of COS probands provides further evidence of etiologic continuity between COS and AOS. A substantial subgroup of parents of COS probands had a worse neurocognitive performance than that of any of the parents of ADHD and CC probands. Receiver operating characteristic curves showed that when rigorous cutoffs define neurocognitive impairments, the combination of scores on certain neurocognitive tasks produced a level of diagnostic accuracy in the parents of COS probands that is sufficient for use in genetic linkage studies.

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.

Clozapine impact on clinical outcomes and aggression in severely ill adolescents with childhood-onset schizophrenia

OBJECTIVE

To evaluate the impact of clozapine on aggressive behaviour and clinical outcomes in children and adolescents with schizophrenia or schizoaffective disorder.

METHODS

We reviewed the charts of 6 children and adolescents who were admitted consecutively to a long-term care facility for clinical outcomes, including seclusion and restraints incidents prior to and during clozapine treatment. We also present a representative case history.

RESULTS

We noted clinically significant improvements in social interaction and decreases in the number of violent episodes and homicidal or suicidal thoughts. The global assessment of functioning (GAF) scores improved significantly. Weight gain was significant.

CONCLUSIONS

These cases illustrate the benefits of clozapine treatment in refractory childhood-onset schizophrenia. Outcomes are similar to those described in adults. Even though open data limit conclusions from this study, it is pertinent that there was a clinically significant improvement in aggressive behaviours. This may be particularly important for improved morale of patients, their families, and treating staff. It may also be helpful in discharge to a less restrictive environment.

Childhood-onset schizophrenia: research update

This review is a research update of recent literature related to childhood-onset schizophrenia (onset of psychotic symptoms by age 12 years). This subgroup of patients has attracted considerable research interest because patients with a childhood onset may represent a more homogeneous patient population in which to search for risk or etiologic factors. We examine data indicating that childhood-onset schizophrenia (COS) shares the same clinical and neurobiologic features as later-onset forms of the disorder. Compared with adults with schizophrenia, however, this subgroup of patients appears to have more severe premorbid neuro-developmental abnormalities, more cytogenetic anomalies, and potentially greater family histories of schizophrenia and associated spectrum disorders. While preliminary, these data indicate that a greater genetic vulnerability may be one of the underpinnings of COS. Future studies of this subgroup may provide important clues as to the genetic basis for schizophrenia and how gene products influence certain features of the disease, such as age of onset and mode of inheritance.

Identification and management of schizophrenia in childhood

TOPIC

The identification and management of schizophrenia in childhood.

PURPOSE

To provide an overview of what is currently known about childhood schizophrenia.

SOURCES

Published literature and personal observations and experiences.

CONCLUSIONS

Early identification and treatment of childhood schizophrenia are critical, and more research and education on the part of all mental health professionals are needed in order to identify, provide treatment, and/or make referrals for children with this serious mental disorder.

Speech and language disorders in children and adolescents with schizophrenia

This study examines communication characteristics and specific language deficits in 47 children and adolescents diagnosed with early-onset schizophrenia using DSM-III-R criteria. All had been referred for speech and language services because of apparent communication problems. Standardized tests and formal measures were used to identify impairment in discrete areas of communication, including pragmatics, receptive and expressive vocabulary and syntax, abstract language, auditory processing, and speech production. Results showed that these discrete areas were variably involved, with pragmatics, prosody, auditory processing, and abstract language having the greatest involvement. The communication deficits identified in the early-onset group closely resembled the phenomenology reported in studies of the communication characteristics of adults with schizophrenia. This comparison thus lends further support to the presence of the same disorder as seen in adults. The roles of gender, mental retardation, and seizure disorders are also discussed as additional risk factors in the development of communication problems and schizophrenia.

Cognitive brain potentials in children at risk for schizophrenia: preliminary findings

Event-related brain potentials were recorded to auditory stimuli from children at risk for schizophrenia and normal control children who were part of two independent samples being followed longitudinally. Subjects were required to detect (with a reaction time response) one of two infrequent events (either a pitch change or a missing stimulus), each of which occurred 17 percent of the time, and was embedded in a sequence of frequent events occurring 66 percent of the time. The event-related potential (ERP) elicited by both infrequent stimuli consisted of a positive-going wave peaking at 350 msec for the pitch change ERP (P350) and 400 msec for the missing stimulus ERP (P400) and a slow wave, which overlapped with and extended beyond the P350 and P400 potentials. When the eliciting event was relevant, these potentials were significantly larger than when it was irrelevant. When the waveforms by the highrisk (HR) subjects were compared to those produced by the normal control (NC) subjects, the HR subjects of both samples showed significantly less late positive amplitude (P350 and P400) than the NC subjects, but only when the eliciting event was relevant. This effect appeared to be independent of reaction time, as reaction time means and variances were quite similar between risk groups. Other possible explanations for this amplitude reduction were explored. Since late positive component amplitude reduction has been consistently reported to characterize the waveforms of adult schizophrenics, the reduction seen in children at genetic risk for schizophrenia may be a premorbid indicator for the development of the psychosis.

A 20-year study of an adolescent psychiatric clientele, with special reference to the age of onset

During a period of 20 years (1968-1988) all inpatients admitted for the first time to the adolescent psychiatric unit in Copenhagen (n = 841) were classified in accordance with social and psychiatric variables, to describe the clientele as a group and, furthermore, to investigate changes occurring during that period. The total clientele had a broad age range (12-21 years), with as many as 36% less than 15 years old. Eleven percent of the patients had attempted suicide before admission. Fifty-six percent of the total group were diagnosed as psychotic or as borderline cases. The patients came predominantly from lower social levels, and almost half the group had a child debut defined as symptoms that had resulted in referral for further investigation during childhood. Moreover, among the schizophrenic patients 35% had an early onset. The age of onset may have some clinical significance, as this item was related to several sociodemographic variables. Finally, an increase in the rate of psychoses and lower social class was recorded during the period.

A 10-year follow-up study of an adolescent psychiatric clientele and early predictors of readmission

Over a period of 20 years (from 1968 to 1988) all inpatients (n = 839) who were admitted for the first time to the adolescent psychiatric unit in Copenhagen were registered, and 40 social and psychiatric variables were recorded, to investigate early predictors of later readmission. Overall, 44.8% of the patients were readmitted within a certain observation period (range, 1.5-21.5 years). Among a subsample of 488 patients (58%) who could be followed up for more than 10 years after their first admission 26% became heavy users of psychiatric services, defined as long-term inpatients or revolving-door patients. Severe early diagnoses (schizophrenia and affective psychoses) were strongly associated with rapid relapses and frequent readmissions. A statistical estimate of the risk of later heavy use based on 12 independent variables is presented.

Childhood schizophrenia: responsiveness to questions during conversation

OBJECTIVES

This study characterized further the communicative deficits associated with childhood-onset schizophrenia. It examined the use of speech functions that involve responses to Yes/No and Wh- questions in children with schizophrenia and normal children during conversation. It also ascertained the relationship of these speech functions with cognition and thought disorder.

METHOD

Speech function variables, formal thought disorder, and cohesion were coded in 32 schizophrenic and 34 normal children, aged 5.6 to 12.4 years, from speech samples elicited with the Story Game.

RESULTS

The schizophrenic children were significantly more impaired in the use of speech functions than the normal children. Other than the association of a subset of the speech functions with distractibility and loose associations, the speech function measures were unrelated to cognitive and thought disorder measures.

CONCLUSIONS

Speech function analysis detects communication deficits not captured by thought disorder measures in children with schizophrenia.

Thought disorder in childhood schizophrenia: replication and update of concept

OBJECTIVES

To examine whether measures of thought disorder differentiated schizophrenic from normal children and to examine the relationship of these measures with developmental and cognitive factors.

METHOD

The speech samples of 88 schizophrenic and 190 normal children, aged 9 to 13 years, were coded with the Kiddie Formal Thought Disorder Rating Scale and Halliday and Hassan's analysis of cohesion.

RESULTS

Above and beyond differences in mental age, gender, and neuroleptic status, the patients had significantly more formal thought disorder (FTD) and cohesive deficits than the normal children matched by mental age. The younger schizophrenic and normal children had significantly more thought disorder than the older children with these diagnoses. Combined FTD and cohesion scores correctly identified 76% of schizophrenic and 88% of normal children with little variability across mental age. The thought disorder measures generated 2 independent components: FTD and cohesion.

CONCLUSIONS

Thought disorder measures that include both FTD and cohesion provide a quantitative diagnostic tool of childhood-onset schizophrenia.

Including children and adolescents with schizophrenia in medication-free research

OBJECTIVE

There has been an increasing focus on the ethical issues raised by studies requiring the withdrawal of effective medication in schizophrenic adults. This article examines the risks and benefits of a medication-free period for pediatric patients with treatment-refractory schizophrenia who are participating in an ongoing study.

METHOD

Between April 1993 and March 1998, 31 children and adolescents were admitted with a diagnosis of treatment-resistant, childhood-onset schizophrenia. Parental consent was obtained so that patients could participate in a medication-free research period. Patients were evaluated at screening, at the end of a 4-week washout, at the completion of a 6- to 8-week atypical neuroleptic trial, and at a 2- to 4-year follow-up.

RESULTS

At the completion of a 4-week drug-free period, seven patients (23%) were diagnosed with another disorder on the basis of data gained from the drug-free period and their lack of schizophrenic symptoms. Their revised diagnoses were posttraumatic stress disorder (N = 1), an atypical psychosis labeled "multidimensionally impaired" (N = 4), and personality disorder (N = 2). At follow-up, three of these patients remained free of neuroleptic therapy. For eight patients (26%), the washout was curtailed because of rapid and severe deterioration of their schizophrenic symptoms.

CONCLUSIONS

For children and adolescents with treatment-refractory schizophrenia, a medication-free period can be conducted safely for at least 4 weeks for inpatients. Such trials are useful on clinical grounds and for providing homogeneous patient groups for research. This study also highlights the necessity of having access to hospitalization to observe children and adolescents with psychotic symptoms while medication free.

[Atypical neuroleptics in the child and adolescent]

The FDA approval for clozapine in 1990 under several hematologic surveillance conditions has reactualized the debate on the use of atypical neuroleptics for adults with schizophrenia. The use of conventional neuroleptics in children and adolescents has always been a subject of controversy due to their side effects and the absence of controlled studies. The pharmacological action of clozapine and risperidone is mainly on D2 and 5HT. Since 1992 several studies concerning children and adolescents show the efficiency and the tolerance of the clozapine and risperidone in various disorders, especially in very early onset schizophrenia (VEOS). Controlled trials are necessary to confirm the data obtained in open studies.

Progressive reduction of temporal lobe structures in childhood-onset schizophrenia

OBJECTIVE

A previous cross-sectional study of brain morphology in childhood-onset schizophrenia indicated sparing of the temporal lobes from processes reducing total cerebral volume in this population. In the present study, subjects with childhood-onset schizophrenia and healthy subjects were rescanned at 2-year follow-up to determine whether this pattern of temporal lobe sparing persists with ongoing illness.

METHOD

Anatomic brain magnetic resonance imaging scans were acquired for 10 adolescent patients with average onset of schizophrenia at 10.4 years (SD = 1.7) and 17 healthy adolescents. Scans were obtained on initial admission and at 2-year follow-up by using identical equipment and measurement methodology.

RESULTS

Schizophrenic subjects showed significantly greater decreases than healthy subjects in right temporal lobe, bilateral superior temporal gyrus and posterior superior temporal gyrus, right anterior superior temporal gyrus, and left hippocampal volumes during the follow-up interval. Decline in right posterior superior temporal gyrus was associated with high total scores on the Scale for the Assessment of Positive Symptoms at baseline and at follow-up.

CONCLUSIONS

Progressive reduction of temporal lobe structures occurs with ongoing illness in childhood-onset schizophrenia.

[The 5 factor model of childhood schizophrenia]

Forty-four first-admission patients with childhood-onset schizophrenia (age at onset < or = 14 years) were examined retrospectively for 30 clinical symptoms using the Positive and Negative Syndrome Scale (PANSS; 15). A principal component analysis with varimax rotation was applied to the full item set of this scale and revealed five orthogonal independent symptom groups: cognition affect, social withdrawal, anti-social behavior, excitement, and reality distortion. In order to validate these psychopathological dimensions we analyzed the relation between the five factor scores and outcome variables (Disability Assessment Schedule, DAS-M; 13) several years after onset: Social withdrawal was correlated with poor outcome; reality distortion was related to good outcome (P < 0.01). A multivariate ANOVA identified group differences in the anti-social behavior factor between acute and insidious onset of illness and between boys and girls; patients with an acute onset scored significantly higher on the excitement factor than those with an insidious onset (P < 0.05). According to our results more than two dimensions are necessary to describe the psychopathology of childhood-onset schizophrenia, similar to adolescent- and adult-onset schizophrenia.

Brief report: association of sex chromosome anomalies with childhood-onset psychotic disorders

OBJECTIVE

An apparent excess of sex chromosome aneuploidies (XXY, XXX, and possibly XYY) has been reported in patients with adult-onset schizophrenia and with unspecified psychoses. This study describes the results of cytogenetic screening carried out for pediatric patients meeting DMS-III-R criteria for childhood-onset schizophrenia (COS) and a subgroup of patients with childhood-onset psychotic disorder not otherwise specified, provisionally labeled by the authors as multidimensionally impaired (MDI).

METHOD

From August 1990 to July 1997, karyotypes were determined for 66 neuroleptic-nonresponsive pediatric patients (28 MDI, 38 COS), referred to the National Institute of Mental Health for an inpatient treatment trial of clozapine.

RESULTS

Four (6.1%) of 66 patients (3 MDI, 1 COS) were found to have sex chromosome anomalies (mosaic 47,XXY; 47,XXY; 47,XYY; mosaic 45,XO, respectively), which is higher than the expected rate of 1 per 426 children or 2.34 per 1,000 in the general population (4/66 versus 1/426, chi 2 = 19.2, df = 1, p = .00001). All cases had been previously undiagnosed.

CONCLUSIONS

These findings lend support to a hypothesis that a loss of balance of gene products on the sex chromosomes may predispose affected individuals to susceptibility to additional genetic and environmental insults that result in childhood-onset psychotic disorders. Karyotyping of children with psychotic disorders should be routine.

Attention deficits in childhood-onset schizophrenia: reaction time studies

The hypothesis of continuity between childhood-onset and adult schizophrenia was tested by comparing the performance of 15 patients with childhood-onset schizophrenia and 52 age-matched controls on 2 reaction time paradigms that have been used to study adult schizophrenia. On simple reaction time to tones with regular and irregular preparatory intervals of 2, 4, and 8 s, patients showed greater effects of the length of the preparatory interval in the regular condition and greater effects of the preparatory interval (girls only) and the preceding preparatory interval in the irregular series. On simple reaction time to random lights and tones, patients were faster on ipsimodal sequences than cross-modal sequences compared with controls. Overall, patients were much slower than controls in both paradigms. The results suggest similar attention dysfunction as is found in adult schizophrenia and thus are consistent with the continuity hypothesis.

Autonomic nervous system markers of psychopathology in childhood-onset schizophrenia

BACKGROUND

Consistent abnormalities in peripheral indicators of autonomic activity, ie, skin conductance (SC) and heart rate (HR), have been reported in adult-onset schizophrenia. Herein, we use these markers to test the hypothesis of continuity between childhood-onset schizophrenia and adult-onset schizophrenia.

METHODS

Skin conductance and HR were recorded from 21 severely ill children and adolescents (mean age, 14.1 years) with childhood-onset (< or = 12 years) schizophrenia (patient group) and from 54 age-matched controls (control group) during a rest period, a series of innocuous tones, reaction time instructions, and a simple warned reaction time task.

RESULTS

During rest, patients had higher rates of spontaneous SC responses (SCRs) and HRs than controls, but their SC level was marginally lower and declined more slowly over time. Half of the patients, compared with 4% of the controls, failed to give SC-orienting responses to the first 2 tones. Patients who responded had impaired SCR magnitudes, and their habituation was more erratic than that of controls. The increase in SC level and SCR frequency at the onset of the task period was greatly attenuated in the patients, so that both variables were higher in controls. Patients had smaller SCRs and anticipatory HR responses to the reaction time stimuli. Skin conductance nonresponding was associated with negative and total symptoms, and spontaneous SCR frequency was associated with positive symptoms.

CONCLUSIONS

The findings show similar abnormalities in autonomic nervous system activity in childhood-onset schizophrenia to those found in adult chronic schizophrenia, thus supporting the hypothesis of continuity of the childhood and adult forms of the illness. Comparisons with data from other childhood disorders suggest that the combination of low-elicited SC activity with high levels of spontaneous SC activity may be specific to schizophrenia.

Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version (K-SADS-PL): initial reliability and validity data

OBJECTIVE

To describe the psychometric properties of the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime version (K-SADS-PL) interview, which surveys additional disorders not assessed in prior K-SADS, contains improved probes and anchor points, includes diagnosis-specific impairment ratings, generates DSM-III-R and DSM-IV diagnoses, and divides symptoms surveyed into a screening interview and five diagnostic supplements.

METHOD

Subjects were 55 psychiatric outpatients and 11 normal controls (aged 7 through 17 years). Both parents and children were used as informants. Concurrent validity of the screen criteria and the K-SADS-PL diagnoses was assessed against standard self-report scales. Interrater (n = 15) and test-retest (n = 20) reliability data were also collected (mean retest interval: 18 days; range: 2 to 36 days).

RESULTS

Rating scale data support the concurrent validity of screens and K-SADS-PL diagnoses. Interrater agreement in scoring screens and diagnoses was high (range: 93% to 100%). Test-retest reliability kappa coefficients were in the excellent range for present and/or lifetime diagnoses of major depression, any bipolar, generalized anxiety, conduct, and oppositional defiant disorder (.77 to 1.00) and in the good range for present diagnoses of posttraumatic stress disorder and attention-deficit hyperactivity disorder (.63 to .67).

CONCLUSION

Results suggest the K-SADS-PL generates reliable and valid child psychiatric diagnoses.

[Diagnostic and follow-up typological characteristics of early schizophrenia]

Schizophrenic psychoses with early onset (< or = 10) are very rare; they occur in approx. 0.5-1% of the total number of patients. Long-term research with sufficiently long observation periods may be able to answer the question whether there is a nosological continuity between early-onset schizophrenia and schizophrenic psychoses in adults. We report on the results of a study on 13 patients with onset at the age of 10 years or earlier (7 girls, 6 boys) with an average duration of illness of 36.1 years (SD = 10.2 years). 3 patients had deceased in the meantime, one patient could not be reached by mail. 9 of the original 13 patients could be examined during the second follow-up by the same interviewer (on the average 27 years after the first follow-up). In 5 children the onset was acute (less than one week), in 8 children insidious (more than 4 weeks). Among the 5 patients with acute onset of childhood psychoses the positive PANSS-type (60%) predominated, in the 8 patients with at first barely perceptible beginning, the negative PANSS-type (45%) prevailed. In respect of the diagnostic division into subcategories, we found a remarkably large variability: At the beginning the disorganised type, at the first follow-up the paranoid, and at the second follow-up the catatonic and the disorganised type were diagnosed most frequently by 4 independent raters. The evaluation of the whole course shows that the incidence of the paranoid type was most frequent. Clear positive-productive psychotic symptoms occurred very early in our patients, i.e. already at the age of 7 years. On the whole, 77% of the patients showed positive symptoms from the beginning of psychotic breakdown; more than half of them had hallucinations from the beginning. This is contrary of the current opinion that childhood-onset schizophrenia begins predominantly with negative symptoms. However, at the beginning of insidious courses, negative symptoms prevail. The prognosis for the 8 insidious courses on the whole was unfavourable (only one full remission, one partial remission, the rest poor or very poor remissions). No connection between the total diagnosis (subtype) and the remission grade was seen.

Childhood-onset schizophrenia: biological markers in relation to clinical characteristics

OBJECTIVE

The purpose of this study was to examine the relationships between clinical and neurobiological measures of childhood-onset schizophrenia. It was hypothesized that there would be a more striking pattern in the rare cases with very early onset than is seen in subjects with later onset.

METHOD

Premorbid, clinical, prenatal, perinatal, and magnetic resonance imaging brain measures were examined in 29 children and adolescents who met the DSM-III-R criteria for schizophrenia with onset before age 12. Specifically, gender, premorbid adjustment, and clinical symptoms were examined in relation to cerebral volume, ventricular volume, and maternal obstetrical complications.

RESULTS

Males were more likely to have had an insidious onset than females. There was a significant negative correlation between score on the Scale for the Assessment of Negative Symptoms and total cerebral volume.

CONCLUSIONS

These neurobiological associations support the continuity of early-onset schizophrenia with the later-onset disorder; the striking association between smaller cerebral volume and negative symptoms suggests a more homogeneous or more potent neurobiological basis for very early-onset schizophrenia.

The long-term course of childhood-onset schizophrenia: a 42-year followup

This article presents results of a 42-year long-term followup of 44 patients (19 males, 25 females) with childhood-onset schizophrenia. Age at onset ranged from 6 to 14 years (mean =11.8 years). The patients and their first-degree relatives were interviewed in 1994, 27 years after the first followup, by the same investigator with the Present-State Examination (PSE) and the Disability Assessment Schedule. The clinical records were analyzed with the Instrument for the Retrospective Assessment of Onset of Schizophrenia and with sections of the PSE. The cases were rediagnosed according to DSM-III-R, based on longitudinal data obtained between onset and the first hospital admission. Although cumulative prevalence is earlier in females than in males, no gender differences exist in average age at onset. An acute onset was significantly more frequent after 12 years of age. An early age at onset was correlated with high social disability scores. Of the patients, 25 percent were completely, 25 percent partially, and 50 percent were poorly remitted at the second followup. None of the patients with chronic onset remitted completely. The results are discussed with respect to epidemiology, gender differences, and etiological hypotheses of childhood schizophrenia.

Blink rate in childhood-onset schizophrenia: comparison with normal and attention-deficit hyperactivity disorder controls

Several lines of evidence have implicated central dopaminergic pathways in the modulation of blink rate. In the present study, blink rate during smooth pursuit was examined in 17 children with childhood-onset schizophrenia, on and off of clozapine, and compared to that of age-matched normal children and unmedicated children with attention-deficit hyperactivity disorder (ADHD). As has been observed in adolescent and adult schizophrenics, blink rate was significantly higher in schizophrenic children relative to normal and ADHD controls. Within the schizophrenic group, blink rate did not significantly change with the introduction of clozapine and was not related to clinical variables. Blink rate was positively correlated with deterioration in smooth pursuit in normal subjects.

Childhood-onset schizophrenia. A double-blind clozapine-haloperidol comparison

BACKGROUND

Childhood-onset schizophrenia is a rare but severe form of the disorder that is often treatment-refractory. In this study, the efficacy and adverse effects of clozapine and haloperidol were compared for children and adolescents with early-onset schizophrenia.

METHODS

Twenty-one patients (mean [+/-SD] age, 14.0 +/- 2.3 years) with onset of Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition-defined schizophrenia that began by age 12 years and who had been nonresponsive to typical neuroleptics participated in the study. Patients were randomized to a 6-week double-blind parallel comparison of clozapine (mean [+/-SD] final dose, 176 +/- 149 mg/d), or haloperidol, (16 +/- 8 mg/d).

RESULTS

Clozapine was superior to haloperidol on all measures of psychosis (P = .04-.002). Positive and negative symptoms of schizophrenia improved. However, neutropenia and seizures were major concerns. To date, one third of the group has discontinued using clozapine.

CONCLUSIONS

Clozapine has striking superiority for positive and negative symptoms in treatment-refractory childhood-onset schizophrenia. However, due to possibly increased toxic effects in this pediatric population, close monitoring for adverse events is essential.

Smooth pursuit eye movements in childhood-onset schizophrenia: comparison with attention-deficit hyperactivity disorder and normal controls

Abnormalities of the smooth pursuit eye movements of adults with schizophrenia have been well described. We examined smooth pursuit eye movements in schizophrenic children, contrasting them with normal and attention-deficit hyperactivity disorder (ADHD) subjects, to determine whether there is continuity of eye movement dysfunction between childhood- and adult-onset forms of schizophrenia. Seventeen schizophrenic children with onset of illness by age 12, 18 ADHD children, and 22 normal children were studied while engaged in a smooth pursuit eye tracking task. Eye tracking variables were compared across the three groups. Schizophrenic children exhibited significantly greater smooth pursuit impairments than either normal or ADHD subjects. Within the schizophrenic group, there were no significant relationships between eye tracking variables and clinical variables, or ventricular/brain ratio. Childhood-onset schizophrenia is associated with a similar pattern of smooth pursuit abnormalities to that seen in later-onset schizophrenia.

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.

Long-term stability of diagnosis and symptom dimensions in a systematic sample of patients with onset of schizophrenia in childhood and early adolescence. I: nosology, sex and age of onset

BACKGROUND

Little is known about the long-term outcome of schizophrenia that has its onset during childhood and early adolescence (early-onset schizophrenia, or EO-SZ). Whether or not EO-SZ is an aetiologically separate form of schizophrenia (SZ) is unresolved.

METHOD

The study was a 14.8-year follow-up, using methods such as systematic sampling, evaluation of possible non-respondent bias, consensus best-estimate diagnoses (DSM-III-R) made independently in childhood and adulthood, measures of positive and negative dimensions, of non-psychotic behaviour disturbances (NPBD) and of developmental problems before the appearance of SZ.

RESULTS

There was high stability of EO-SZ (n = 40) diagnoses (mean onset at 14.0 years) until adulthood (mean age at follow-up 28.8 years) but a lower stability of positive and negative schizophrenic dimensions. There was a poor outcome of EO-SZ, a strong over-representation of males but few gender differences, and no effect of age of onset on clinical features and outcome.

CONCLUSIONS

EO-SZ taken as a whole shows no qualitative differences to adult-onset SZ. However, a distinction through the onset of preschizophrenic developmental problems or NPBD might be a way to investigate heterogeneity within EO-SZ.

Case study: neuroleptic malignant syndrome without pyrexia

Fever is generally considered to be an essential feature of neuroleptic malignant syndrome (NMS). The authors present the case of a 12-year-old boy who had many features of NMS but did not have fever. This case emphasizes the importance of assessing the total clinical situation. It also supports the concept of neuroleptic-induced catatonia (NIC) and NMS as disorders on the same spectrum. A scoring system is offered as a guide to severity of NIC-NMS.

Childhood and adolescent psychosis: a review of the past 10 years

OBJECTIVE

Developmental aspects of psychosis are reviewed and related to the more frequent psychotic conditions in children and adolescents.

METHOD

The review of the recent literature focuses on developmental aspects of psychotic phenomena, i.e., hallucinations, delusions, and thought disorder.

RESULTS

While the applicability of much early work on this topic is limited, more recent work suggests that psychotic conditions are observed in childhood and increase in frequency during adolescence.

CONCLUSIONS

Developmental factors in the expression of psychosis are relevant to the diagnosis and treatment of such conditions.

Conversational repair in schizophrenic and normal children

OBJECTIVE

Children acquire the skills to monitor the adequacy of their spoken message and to self-initiate repair strategies that modify the message during early, middle, and late childhood. To characterize further the communication deficits of childhood-onset schizophrenia, this study compared self-initiated repair strategies in schizophrenic and normal children and their relationship with formal thought disorder, discourse deficits, and distractibility.

METHOD

Measures of self-initiated repair, formal thought disorder, and cohesion were coded in 32 schizophrenic and 47 normal children, aged 5.6 to 12.4 years, from speech samples elicited with the Story Game.

RESULTS

The schizophrenic children used some repair strategies (false starts, fillers, referential revision) more infrequently than the normal children. Within the schizophrenic group, the children who were receiving neuroleptic medication underutilized repair and had more discourse deficits than the unmedicated patients. Loose associations and distractibility were associated with increased use of false starts but not fillers.

CONCLUSIONS

In addition to formal thought disorder and discourse deficits, schizophrenic children underutilize self-initiated repair when presenting their thoughts to the listener, particularly if they are being treated with neuroleptics, a potential sign of increased clinical morbidity. Impoverished communication skills might reflect negative signs in childhood-onset schizophrenia.