Download Child and Adolescent Psychopathology

Childhood
Schizophrenia
Chapter 21
Robert F. Asarnow
HISTORICAL BACKGROUND AND
TERMINOLOGICAL AND CONCEPTUAL ISSUES
 1930s: The construct of childhood schizophrenia
included children who today would receive DSM-IV
diagnoses of autistic disorder, pervasive
developmental disorders (PDDs), schizophrenia, or
disintegrative psychosis.
 1960s & 1970s: Children with schizophrenia had
hallucinations, delusions, and formal thought disorder.
 DSM-III, DSM-III R and DSM-IV: Diagnostic criteria for
schizophrenia in children was identical to those used
for adults, with minor allowances made for how specific
symptoms may be manifested in childhood.
DIAGNOSTIC ISSUES AND DSMIV CRITERIA
 The DSM-IV states that the essential symptoms of
schizophrenia are “delusions, hallucinations,
disorganized speech, grossly disorganized or
catatonic behavior, and negative symptoms” (American
Psychiatric Association, 1994, p. 285).
 Taking child development into account, important
to differentiate common childhood phenomena
such as imaginary friends, magical thinking, and
hypnagogic experiences from true delusions and
hallucinations.
DIFFERENTIAL DIAGNOSTIC
ISSUES
 Making a differential diagnosis involving schizophrenia
in children requires ruling out the following psychiatric
conditions:
 Mood disorders, schizoaffective disorder, PDDs,
communication disorders, obsessive compulsive disorder,
posttraumatic stress disorder, dissociative disorders, and
medical conditions such as seizure disorders, brain tumors,
and substance abuse.
 Prevalence
 Very rare resulted in considerable uncertainty about its
prevalence.
 Prior to 12 years of age the prevalence rate of such true COS
is fewer than 1 in 10,000 (Burd & Kerbeshian, 1987).
DEVELOPMENTAL PROGRESSION AND
THE PRODROMAL PHASE
 Outcome
 In general, outcomes in children with schizophrenia are
generally worse than when onset is in adulthood (Remschmidt
& Theisen, 2005).
 Sex Differences
 Excess of boys to girls when onset of schizophrenia is
prior to 12 years of age.
 Nearly equal when onset of schizophrenia is after age 12.
 Comorbidity
 Most common comorbid diagnoses in children are
conduct/oppositional behaviors and atypical depression
or dysthymic disorder.
OVERLAP BETWEEN AUTISM
AND COS
 Considerable body of biological research pointing to
overlap between autism and COS.
 “It appears that in autism there is acceleration or
excess of early postnatal brain development (1–3
years), whereas in COS there is exaggeration of the
brain maturation process of childhood and early
adolescence (10–16 years). While autism and COS
have been distinguished at the level of clinical
symptoms, since DSM III the results of genetic and
brain imaging studies indicate that there is overlap in
the neurobiological substrates for these disorders”
(Rapoport et al., 2009, p.14).
RISK FACTORS
 Population-Based Studies
 First-degree relatives of patients with adult-onset of schizophrenia is
greater
 Familial aggregation of schizotypal personality disorder
 Concordance rates for schizophrenia are 55.8% among monozygotic
twins and 13.5% among dizygotic twins
 Specific Genes
 Linkage studies: Susceptibility genes have been identified including
dysbindin, neuregulin-1, DISC1, G72, and the alpha 7 nictotinic
receptor subunit
 Cytogenetic Abnormalities
 “Rare structural variants”
 Endophenotypes
 Abnormalities in smooth pursuit eye-movements, neurocognitive
functioning, brain structure, brain electrical activity, and autonomic
activity
RISK FACTORS
 Conclusions Regarding Genetic Findings
 High phenotypic variation presents challenges in mapping the pathways
from gene to disorder
 Little known about the normal function of putative susceptibility genes for
schizophrenia or how they may affect processes related to the
development of schizophrenia
 Drug Abuse
 Adolescents with a genetic predisposition for schizophrenia are more
likely to develop psychotic symptoms and/or show a greater psychotic
response to cannabis, amphetamines, cocaine, and psychomimetic
drugs
 Obstetric Complications
 Development of schizophrenia in adult life was doubled in people with a
history of obstetric complications
 Parent and Family Characteristics
 Dysfunctional family-rearing environments
 Maladaptive parent communication patterns
RISK FACTORS
 Brain Structure
 9.2% reduction in total brain volume
 Progressive loss of brain tissue starting from the back of
the brain and spreading forward
 Neurocognition
 Presence of cognitive impairments is the most robust
finding when schizophrenia patients are compared to
healthy controls
 Neural Networks in Schizophrenia
 COS patients show the same general pattern of
neuroanatomic and cognitive findings as patients with
adult onset of schizophrenia
TREATMENT
 Same antipsychotic medications that are used to
treat adults with schizophrenia are used to treat
children and adolescents with schizophrenia
 Because of serious side effects clozapine is
usually used only when patients have not
responded to other antipsychotic treatments.
THEORETICAL SYNTHESIS AND
FUTURE DIRECTIONS
 COS may represent a severe, highly genetic, and
biologically homogeneous form of schizophrenia in
which the biological substrate is more clearly
discernible than in adult-onset schizophrenia.
 This framework sets the stage for challenging
questions:
 What causes a small number of children to develop
schizophrenia very early in life?
 What triggers the onset of psychotic symptoms?