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Schizophrenia in Children and Adolescents
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Book description

The earlier in life schizophrenia manifests itself, the poorer the long-term prognosis, and although it is very difficult to diagnose in the young, early treatment is now thought to improve outcome. Recent research also suggests that early onset schizophrenia has developmental precursors, making it difficult to distinguish from a number of other developmental disorders. In this timely book, an international team of psychiatrists, psychotherapists and psychologists give an up-to-date review of the latest findings in the diagnosis and treatment of schizophrenia in children and adolescents to give a comprehensive account of the current state of knowledge and the therapeutic options available to clinicians. They examine the disorder from developmental and clinical perspectives, with a focus on diagnosis, etiology, therapy and rehabilitation. This book is essential reading for all mental health professionals who treat young people with schizophrenia.

Reviews

‘There is a truly international list of expert contributors from Europe, the UK and the United States. The book is a solid gold resource for adolescent psychiatrists in particular and the multidisciplinary teams in inpatient units and other clinics where children and adolescents with psychosis are assessed and treated … This book will take its place as a major guide to practitioners in its important area of work for the next few years.’

Source: Journal of Child Psychology and Psychiatry

‘This is an excellent and very readable and absorbing book, which highlights how far the field has come in terms of understanding child and adolescent schizophrenia.’

Source: Psychological Medicine

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Contents

  • 1 - Childhood psychosis and schizophrenia: a historical review
    pp 1-23
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    Summary

    This chapter reviews the literature relating to schizophrenia in children and adolescents up to the 1970s. The historical study of schizophrenia highlights the remarkable degree of fluidity that has characterized its definition and diagnostic criteria and the special problems in relation to the existence and features of the disorder in children. There is conclusive evidence that children and young people were admitted alongside adult patients to private and public asylums. This practice continued into the twentieth century, until separate facilities were provided for juveniles, predominantly after the Second World War. A few authors described children displaying symptoms resembling premorbid characteristic of the early stages of schizophrenia. Multiple factors and morbid processes have been implicated in the causation of dementia praecox, schizophrenia and childhood psychosis. Treatment approaches have been remarkably diverse, often associated with evanescent, idiosyncratic etiological hypotheses and, generally, lacking evaluative research and controlled studies.
  • 2 - Definition and classification
    pp 24-42
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    Summary

    Hermann Emminghaus was the first to introduce a developmental perspective into child psychiatry, with special focus on psychoses. This chapter describes the general criteria for the classification of psychotic disorders in children and adolescents. In childhood and adolescence, however, age and developmental stage play a very important role in the classification of schizophrenia. The chapter discusses the psychotic disorders in childhood and adolescence and their relation to schizophrenia. Bettes and Walker found a strong effect of age on the manifestation of positive and negative symptoms. Positive symptoms increased linearly with age, while negative symptoms occurred most frequently in early childhood and late adolescence. About 50% of children and adolescents with schizophrenia show an uncharacteristic symptomatology in their premorbid personality. The chapter explains the classification of schizophrenia and other psychotic disorders according to International Classification of Diseases (ICD)-10 and Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV.
  • 3 - Epidemiology of early onset schizophrenia
    pp 43-59
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    Summary

    This chapter reviews what limited evidence there is in respect of epidemiology of early onset schizophrenia. Early onset schizophrenia will be subdivided into "very early onset schizophrenia" and "adolescent onset schizophrenia". Rare instances of autism and schizophrenia do occur, and it appears that individuals diagnosed with early onset schizophrenia quite often have some marked autistic symptoms in their premorbid history. Medical syndromes and epilepsy are sometimes associated with Asperger syndrome, but at a considerably lower rate than in classic childhood autism. Disruption of normal language development sometimes co-occurs with the appearance of epileptogenic discharge on the EEG (particularly during sleep). This group of disorders is often referred to as Landau-Kleffner syndrome. There have been few epidemiological studies specifically of adolescent onset schizophrenia. Most of the data on the epidemiology of schizophrenia in the adolescent age group derive from studies that include only a small subgroup of adolescents and young adults.
  • 4 - Childhood schizophrenia: developmental aspects
    pp 60-81
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    Summary

    Deficits observed in children with schizophrenia include problems with illogical thinking and loosening of associations similar in many ways to the difficulties observed in adolescents and adults with the disorder. This chapter reviews the developmental aspects of childhood schizophrenia relative to onset, clinical features, and of the disorder. In childhood schizophrenia auditory hallucinations are most consistently reported, in approximately 80% of cases. Particularly in younger children, hallucinations are more fluid and less complex than those usually observed in adults with the disorder. The frequency of delusions begins to increase markedly in adolescence with the increase in schizophrenia. While schizophrenia can occur at any level of cognitive ability several studies have suggested a relation between schizophrenia and lower levels of intellectual ability. Various disruptive behaviors suggestive of conduct or oppositional disorders may be observed particularly in the prodromal stage of the disorder.
  • 5 - Diagnosis and differential diagnosis
    pp 82-118
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    Summary

    This chapter reviews the historical development of the construct of schizophrenia as applied to both adults and children. It presents some of the basic tools of clinical epidemiology which can help to quantify diagnostic certainty in children and adolescents. The chapter compares diagnostic and statistical manual of mental disorders (DSM)-IV and International classification of diseases (ICD)-10 diagnostic criteria, and examines the implications for their different diagnostic thresholds when applied to children and adolescents. It considers the use of assessment instruments, in particular the potential for using symptom rating scales to improve diagnostic accuracy. The chapter provides the evidence for the validity of adult diagnostic criteria in children and adolescents. It considers how the pattern of premorbid and psychotic symptoms differs between childhood onset and adult onset schizophrenia. The chapter describes the process of differential diagnosis psychotic symptoms in children and adolescents, and discusses the potential for prevention and early diagnosis.
  • 6 - Genetic aspects
    pp 119-134
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    Summary

    Most genetic research to date concerns adult subjects with schizophrenia, and there is a relative dearth of information regarding the genetics of the childhood onset disorder. This chapter draws on evidence from adults as well as from the small amount of literature pertaining specifically to children. An earlier onset of schizophrenia might result from an increased genetic load or a more potent environmental insult, and would therefore be expected to result in increased familiality. Adoption studies allow the separation of the effects of genes and family environment. There are three commonly used methods such as: adoptee study, adoptee's family study and cross-fostering study. Various genetic mechanisms have been offered as explanations of the similarity between relatives in liability to schizophrenia. Alternative modes of inheritance may involve many genes of small effect, with or without an environmental effect.
  • 7 - Neurobehavioral perspective
    pp 135-167
  • View abstract

    Summary

    The neurobehavioral approach attempts to identify the central nervous system (CNS) substrates of a variety of psychiatric/behavioral disorders. This chapter summarizes three complementary sets of data that help elucidate the nature of neurobehavioral impairments in schizophrenia. The first set of data comes from studies that retrospectively characterize the development and course of neurobehavioral impairments in schizophrenic children. These studies reveal that there are certain neurobehavioral impairments in these children prior to the onset of psychotic symptoms. The second set of data comes from a series of cross-sectional studies examining cognitive/neuropsychological functioning using behavioral and psychophysiological methods. Thirdly, the chapter summarizes studies designed to identify aspects of brain structure and function underlying the neurobehavioral impairments found in schizophrenic children. Finally, the chapter attempts to integrate cross-sectional and longitudinal analyses of the nature and evolution of neuro-behavioral impairments in schizophrenic children within a neuro-developmental framework.
  • 8 - Psychosocial factors: the social context of child and adolescent onset schizophrenia
    pp 168-191
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    Summary

    This chapter focuses on psychosocial factors in child and adolescent onset schizophrenia with the goal of highlighting promising psychosocial treatment strategies. It deals with psychosocial functioning and developmental progressions of schizophrenia in adolescence. The chapter reviews the treatment strategies for schizophrenia in adolescents. Despite the dearth of controlled treatment trials for adolescents suffering from schizophrenia, accumulating clinical and research data highlight some major issues with respect to the treatment of schizophrenia in adolescent. Three primary psychosocial intervention approaches investigated for adults with schizophrenia include (i) individual psychotherapy, (ii) family-focused interventions, and (iii) skills building strategies. There is an urgent need for additional research to clarify optimal treatment strategies for adolescents with schizophrenia. The chapter turns to the implications of current knowledge for the psychosocial treatment of adolescents with schizophrenia, and concludes by offering suggestions regarding future directions for clinical research and treatment.
  • 9 - Treatment and rehabilitation
    pp 192-267
  • View abstract

    Summary

    This chapter describes a comprehensive treatment and rehabilitation program, which has been developed over a period of 20 years in the department of child and adolescent psychiatry of the Philipps-University of Marburg. Neuroleptic (antipsychotic) agents can be classified according to three main principles: chemical structure, receptor binding profile and clinical profile. Receptor binding profile of the most important neuroleptic (antipsychotic) compounds, can be subdivided into the three groups: typical high-potency neuroleptics, typical moderate and low-potency neuroleptics, and atypical neuroleptics covering five relatively newly developed compounds. The main indications for atypical neuroleptics are the acute and maintenance treatment of schizophrenic disorders with an emphasis on the treatment of refractory and chronic schizophrenic disorders. Neuroleptic-induced extrapyramidal side effects are a special problem in the treatment of children and adolescents with schizophrenia for several reasons.
  • 10 - Course and prognosis
    pp 268-297
  • View abstract

    Summary

    Developmental characteristics are most important in considering schizophrenia in children and adolescents. In considering course and prognosis, it is worthwhile to consider the available adult studies because there are more data. Considering the dearth of data on outcome and course in children and adolescents, and assuming that the disorder is basically the same in children and adults, then qualified but heuristic extrapolations may be made. Data will be organized within four main descriptive concepts: (i) premorbid adjustment; (ii) onset; (iii) course; and (iv) outcome. Within these four broad chronological categories, variables affecting course and outcome will be delineated and results of studies examined within these parameters. Suicide does appear to be a significant outcome in child and adolescents, though attempted suicide seems much more of a risk. Adult studies have shown that schizophrenia can be diagnosed reliably in national settings of varying cultures and religion and degree of industrial development.

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