Abnormal Child Psychology - Childhood-Onset Schizophrenia

Schizophrenia

• Considered one of the most debilitating disorders.
• Involves cognitive and emotional dysfunction.
• Interferes with functioning in a variety of contexts (social, vocational, etc.).
• Typically, there is not a complete restoration of functioning.

Epidemiology

• Affects about 1% of the population.
• Almost equally distributed between males and females, unless early onset occurs, which is more common in males (4:1 ratio).
• Typically, onset occurs in late adolescence/early adulthood.
• Found in most cultures and races.
• Higher prevalence in populations of/with:
  • Ethnic minorities
  • Low SES (socioeconomic status)
• "Early-onset schizophrenia" refers to schizophrenia occurring before the age of 18 years.
• "Childhood-onset schizophrenia" is onset prior to age 13 years (rare), approximately 0.04% of children.

Childhood-Onset Schizophrenia (COS)

• Precursors and Comorbidities:
  • Gradual onset.
  • Almost 95% have a history of behavioral, social, and psychiatric disturbances before the onset of psychosis.
  • Developmental precursors: speech and language problems, problems in motor development, movement abnormalities, social impairment, unusual thought content, suspicion/paranoia, substance abuse, and genetic risk with recent deterioration in function.
  • Other symptoms/disorders: anxiety and depression, ADHD, conduct problems, movement abnormalities, suicidal tendencies.
  • 70% meet criteria for another diagnosis (commonly mood disorder or ODD/CD).
• Phases:
  • 95% experience a prodrome phase prior to the onset of positive symptoms, marked by functional decline affecting academic and social functioning and ADLs (activities of daily living).
  • The prodromal phase is followed by an acute phase with positive symptoms.
  • Recovery phase primarily involves negative symptoms and may still have positive symptoms.
  • Residual phase involves complete resolution of positive symptoms for an extended period.

DSM-5 Criteria

• Two or more of the following, each present for a significant portion of the time during a one-month period (or less if treated successfully). One must be 1, 2, or 3:
  1. Delusions
  2. Hallucinations
  3. Disorganized speech (such as frequent derailment or incoherence)
  4. Grossly disorganized or catatonic behavior
  5. Negative symptoms (such as affective flattening, alogia, or avolition)
• Social/Occupational Dysfunction: For a significant portion of the time since the onset of the disturbance, one or more major areas of functioning such as work, interpersonal relations, or self-care is markedly below the level achieved prior to the onset.
• Duration: Continuous signs of the disturbance persist for at least six months.
• Not attributable to another medical or psychiatric condition.

Childhood-Onset Schizophrenia (cont.)

• Compared to autism, COS has:
  • Later age of onset
  • Less intellectual impairment
  • Less severe social and language deficits
  • Hallucinations and delusions
  • Periods of remission and relapse
• Compared to adult-onset:
  • Lower intellectual functioning
  • Lower premorbid functioning
• Higher rates of negative symptoms are poor prognostic indicators.
• Higher unemployment rates and greater social deficits.
• Less likely to live independently.

Categories of Symptoms

• Positive
• Disorganized
• Negative

Positive Symptoms

• The addition of abnormal experiences/behaviors.
• Hallucinations
• Delusions
• Experienced by 50-70% of people with schizophrenia.

Childhood Onset Schizophrenia

• Not every child with psychotic symptoms has schizophrenia.
• Can be common with mood disorders, trauma, substance use.
• Rule out medical causes.
• Developmentally normal behaviors may include having an imaginary friend.
• Hallucinations can be part of normal development or can be associated with nonpsychotic psychopathology, psychosocial adversity, or a physical illness.

Negative Symptoms

• The absence of typical behaviors or expression.
• Deficits in social, emotional, and motivational functioning.
• Maybe harder to recognize than positive symptoms.
• Tend to be more stable than positive symptoms.
• Associated with worse prognosis.

Negative Symptoms (Examples)

• Avolition: Inability or lack of energy to engage in routine and/or goal-directed activities.
• Anhedonia: Inability to feel pleasure; lack of interest/enjoyment in activities or relationships.
• Alogia: Lack of meaningful speech: poverty of speech or poverty of content of speech.
• Asociality: Social withdrawal, poor social skills, few friends, little interest in being with other people.
• Flat Affect: Flat affect refers only to outward expression, not necessarily internal experience.

Disorganized Symptoms

• Thought Disturbance:
  • Disorganized Speech:
    • Derailment/loose associations
    • Perseveration
    • Clanging/Word Salad
      • Example: "I have to go to the store, the floor is more, and I want to explore the door."
      • Example: "The rain falls, the train calls, and the pain stalls."
• Behavioral Disturbances:
  • Catatonia:
    • Immobility & muscular rigidity
    • Agitation, e.g., repetitious movements
    • Stuporous State
      • Reduced responsiveness, patients seem unaware of surroundings, but afterwards can often report what happened.
  • Inappropriate Affect
    • Incongruent
    • Laughing/crying inappropriately

Cognitive Deficits

• Major determinant of quality of life – but not technically a DSM symptom.
• Potentially more so than severity of positive and negative symptoms.
• Cognitive functions affected:
  • Attention
  • Working memory
  • Episodic memory
  • Executive functioning

Genetics

• The lifetime prevalence rate for schizophrenia is around 1%.
• Relatives of individuals with schizophrenia are at a significantly higher risk for schizophrenia.
• As genetic similarity increases between two people, the risk that they will both have schizophrenia increases.
• Concordance is related to severity; more severe cases are more likely inherited.

Congenital Factors

• Pregnancy and birth complications:
  • Mothers of people who develop schizophrenia were more likely to have experienced problems before and during birth.
  • Reduced supply of oxygen during delivery?
• Viral infections and season of birth:
  • People with schizophrenia are more likely to have been born during the winter months.
  • It is possible that they had more viral infections during winter months, but this hypothesis has not received direct support.
  • Viral damage to the fetal brain.
  • Schizophrenia rates are higher when the mother had the flu in the second trimester of pregnancy.

Causes: Dopamine Hypothesis

• Excess in Dopamine?
• Medications that block dopamine rapidly -but symptom relief takes several weeks.
• To be effective, antipsychotics must reduce dopamine activity to below normal levels.
• Side effects-Tardive dyskinesia is a movement disorder characterized by involuntary repetitive movements, particularly of the face, tongue, and limbs.
• Cognitive Impairments.

Childhood-Onset Schizophrenia (cont.) - Causes

• Current views are based on a vulnerability-stress model that emphasizes the interplay among vulnerability, stress, and protective factors.
• Neurodevelopmental model: a genetic vulnerability and early neurodevelopmental insults result in impaired connections between many brain regions that include the prefrontal cortex and parts of the limbic system.
• Biological factors: strong genetic contribution in COS with heritability estimates around 80%.
• CNS dysfunction and improvements with medication suggest it is a disorder of the brain.

Childhood-Onset Schizophrenia (cont.) - Treatment

• Current treatments emphasize the use of antipsychotic medications combined with psychotherapy plus social and educational support programs.
• Medications (e.g., risperidone) help control psychotic symptoms by blocking dopamine transmission.
  • Adverse effects (which can be serious) reduce adherence to treatment and require constant monitoring.
• Psychosocial treatments: family intervention, social skills training, cognitive behavior therapy, and educational support.

Presentation/Duration

• Generally chronic.
• Moderate-to-severe impairment from diagnosis to death.
• Mayo Clinic: "Rule of Fourths"
  • 25% chronic or deteriorating course
  • 25% some reduction but still need support
  • 25% significant symptom reduction
  • 25% improve completely
• Slightly less than average life expectancy.
• The typical course is relatively stable functioning with discreet periods of exacerbation.
• 5% of patients with childhood-onset lose their life to suicide or as a direct result of dangerous behaviors during psychosis.

Treatment of COS

• COS is a chronic disorder with a poor long-term prognosis.
• Pharmacological treatments, particularly antipsychotic medications, may be used to help control psychotic symptoms.
• Psychosocial treatments, such as social skills training, family intervention, and educational supports are also important.

Psychosocial Treatment

• Cognitive Behavioral Therapy (CBT)
  • Recognize and challenge delusional beliefs.
  • Recognize and challenge expectations associated with negative symptoms.
    • e.g., "Nothing will make me feel better so why bother?"
• Cognitive Enhancement Therapy (CET)
  • Cognitive remediation
  • Improve attention, memory, problem-solving, and other cognitive-based symptoms.

Psychosocial Treatment

• Case manager helps coordinate treatments and provides support.
• Help navigating life, such as managing everyday activities, transportation, etc.
• Helps broker access to available services.
• Case Management
• Institutional programs
• Hospitalization (at least two to three weeks) is often indicated for acute psychosis.