Childhood-Onset Schizophrenia
(3-5-15)
Madness, lunatics, and demonic possession
Psychosis referes to a group of severe mental disorders involving delusions, hallucinations, disorganized thinking, grossly disorganized or abnormal motor behavior, and negative symptoms
Kraepelin dementia praecox: dementia of adolescence
Bleuler the schizophreniasBleuler’s 4 A’s:
autism
affect
ambivalence
anhedonia
“childhood schizophrenia”
Bender
Kanner
Potter
Creak
Kolvin studied psychosis in children:
children with onset between 5 & 15 showed hallucinations, delusions, and formal thought disorder
children with onset before 3 showed autistic symptoms but not schizophrenic symptoms
Rutter showed that autistic children followed into adulthood did not show symptoms of schizophrenia
on the other hand: autism is not a protective factor for schizophrenia and comorbid occurrence has been reported in some individuals; the issue of any overlap between these two conditions beyond change association continues to be investigated. General conclusion: schizophrenia is rare is individuals with ASD, as it is rare in the general population
Schizophrenia
core symptoms:
Delusions
Hallucinations
Disorganized speech (looseness of associations)
Grossly disorganized or catatonic behavior
Negative symptoms: flat affect, alogia, avolition
Delusions, hallucinations, looseness of association, catatonic and agitated behavior are referred to as "positive symptoms" (behavior excesses; florid psychosis); the negative symptoms (behavior deficits; deficit syndrome) are both more subtle and possibly more serious in terms of long-term adjustment.
course: diagnosis requires a sustained course for at least 6 months
childhood onset cases usually show a more chronic and severe course
prevalence of onset of schizophrenia in childhood: rare
North Dakota data:
0.19 per 10,000 children between 2 & 12for contrast: prevalence in adult population (with usual onset between 15 and 20) is approximately 1%
sex ration: more Males than Females
(for contract: app. = in adolescence/adult onset cases)
cultural variation: very limited (based primarily on WHO adult data)associated deficits:
language, visual perception, and memory--only when extensive demands are made on processing capacity
visual-motor coordination & fine-motor speed
executive functionsrisk factors:
genetic risk
environmental stressors
prenatal viral infections (esp. 2nd trimester)
pregnancy & birth complications
psychosocial stressors
family conflict, poor communication, poor problem solving, high expressed emotion
schizotypal personality disorderprotective factors:
child factors
intellectual competence
social competence
environmental
social support
family problem solvingdifferential considerations:
onset pattern: insidious (process) vs. acute (reactive)
onset age:
premorbid adjustment:
post-episode state:
predominance of negative symptoms:
Childhood-Onset Schizophrenia (COS) (material from Kumra, Shaw, Merka, Nakayama, & Augustin, 2001)
Research supports the conclusion that childhood- and adult-onset schizophrenia represent the same disease process.
Childhood-onset schizophrenia (COS): onset of psychotic symptoms by age 12 years.
Similarities between adolescents with COS & adults with schizophrenia:
clinical presentation
Schizophrenia can be reliably diagnosed in children and adolescents using unmodified adult criteria (also Asarnow, Tompson, & McGrath, 2004)
neuropsychological test performance
cognitive deficits--attention
executive functioning
verbal recall
visuospatial abilities
fine motor skillssimilar cognitive impairment seen in relatives & offspring
Patients with COS appear to show a decline in FSIQ during adolescence, this does not appear to reflect deterioration but an inability to acquire new information & skills relative to healthy children
autonomic functioning
abnormalities in peripheral indicators of autonomic nervous system activity, such as skin conductance and heart rate, have been reported in both adult-onset and COS
smooth-pursuit eye movement
40-80% of patients with adult-onset schizophrenia have abnormalities in smooth-pursuit eye movements (SPEM). 30-50% of first-degree biological relatives show similar abnormalities, as well as children of parents with schizophrenia. Patients with COS and their first-degree relatives show similar eye-tracking abnormalities.
anatomic brain MRI & MRSI
structural magnetic resonance imaging (sMRI) studies have found similar abnormalities in adults and child-onset cases of schizophrenia:
deficit in cortical gray matter volume and enlargement of cortical sulcal and ventricular cerebrospinal fluid volumes.
evidence has also found small vermal size in adult onset and COS cases, suggesting abnormal cerebella function
however--"no sMRI abnormality has been consistently found in all affected individuals, and for each measure there is considerable overlap between patients and healthy control subjects." p. 925
Magnetic Resonance Spectroscopic Imaging (MRSI): new imaging technique that allows regional quantification of brain chemistry.
an MRSI study of patients with COS revealed decreased in brain chemistry ration of N-acetylaspartate (NAA) to creatin (CRE)--a putative marker of neuronal integrity--exclusively in the prefrontal cortex and hippocampus.Differences in childhood-onset schizophrenia:
more severe premorbid abnormalities
across studies, the rates of language impairment, transient autistic-like symptoms, and nonspecific symptoms appear higher in COS than in adult-onset patients
more cytogenetic abnormalities
microdeletions of chromosome 22q11 have been reported more frequently in COS (6.4%) than in adult-onset schizophrenia (2.0%) than in the general population (0.2%)
greater family histories
elevated rate of schizophrenic spectrum disorders (schizoaffective disorder & schizotypal & paranoid personality disorders) has been reported in studies of COS
Hypothesis: greater genetic vulnerability in COS, which may result in earlier symptom development
Postpsychotic IQ Decline in Childhood-Onset Schizophrenia
Bedwell, Keller, Smith, Hamburger, Kumra, & Rapoport (1999) investigated changes in IQ subtest results in a group of children and adolescents who had been diagnosed with schizophrenia prior to age 12 (COS). They concluded that the decline in Full Scale IQ observed over time with COS reflected primarily the inability to learn new information and abilities, and not dementia. They did report a significant correlation between decrease in hippocampal volume and smaller increases in raw scores on the Information subtest.
Adult outcome of youth diagnosed with COS
COS is predictive of schizophrenia or schizophrenia spectrum disorders in adulthood (Asarnow, Tompson, & McGrath, 2004)
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