Childhood-Onset

Schizophrenia
Alison Lessard, Andrea Janzen, Jayla Schmidt and
Vicki Pederson
Presentation Overview
What do you Know?
Historical Context
What is Childhood Onset Schizophrenia
Diagnostic Criteria
Epidemiology
Theoretical Framework
Etiology
Comorbidity
Interventions
What did you Learn?
What Do You Know About
Schizophrenia?
1. Schizophrenia is more common in males than females.
2. Childhood-onset diagnostic criteria is the same as adult-onset.
3. People diagnosed with schizophrenia are violent.
4. People with schizophrenia have dual or multiple personalities.
5. Childhood-onset schizophrenia is very rare.
6. Medication can cure or eliminate symptoms of childhood-onset
schizophrenia.
7. Autism can lead to childhood-onset schizophrenia
8. Drugs used to treat childhood-onset schizophrenia have serious side effects.
9. Childhood-onset schizophrenia is a genetic disorder
10. Children with childhood-onset schizophrenia may also suffer from severe
separation anxiety.


Video Clip
Meet Jani



Historical Context
- 20th century has seen major changes in the criteria used to diagnose
schizophrenia in childhood.
-Cases of childhood psychosis, without organic brain disease, have been
reported for the last 200 years
- Early 1900's children were diagnosed using standards similar to those applied
to adult patients with only the most severe cases being diagnosed
- 1930's began to question whether or not children expressed schizophrenia
differently than adults and the term "child schizophrenia" was coined.
-This term was a broad term used to cover many disorders that, by today's
criteria, would include autistic disorder, pervasive developmental disorder,
mental retardation, and childhood-onset schizophrenia
-Late 1940's and 1950's many children exhibiting impairments were given the
diagnosis of schizophrenia but by current DSM-IV criteria would only meet
questionable borderline or no psychotic symptoms.

Historical Context cont.
- Bender's (1956) idea of schizophrenia would include mutism, mental
retardation as well as those with complex speech problems.
- Kolvin, Ounsted, Humphrey & McNay (1971) conducted a study which
contributed to a major shift in the conceptualization of schizophrenia in
children and the term "childhood schizophrenia" seemed to have outlived it
usefulness.
-With the development of DSM-III (1980) we see the diagnostic criteria return
to the pre-1930's approach of using the adult criteria to diagnosis
schizophrenia which is when the term Childhood-onset Schizophrenia
(COS) came into existence.
What is
Childhood
Onset
Schizophrenia?
Childhood-onset Schizophrenia
(COS)
Schizophrenia is a psychotic disorder
"Psychotic" refers to a specific grouping of symptoms:
o delusions
o prominent hallucinations
o disorganized speech
o disorganized or catatonic behaviour
Key features of schizophrenia are a combination of
positive and negative characteristic symptoms for a
significant portion of a 1 month period over a 6 month
period
Currently, children with COS are diagnosed using the
same criteria that is used for adults
Positive/Negative
Symptoms
- Positive symptoms reflect an excess or distortion of
normal functions (Criteria A1-A4)
- Represented by two distinct dimensions:
o psychotic dimension (delusions, hallucinations)
o disorganized dimension (speech, behaviours)
- Negative symptoms reflect reductions or loss of normal
functions (Criteria A5)
o flat affect
o alogia (disruption of thought and lack speech)
o avolition (inability to initiation goal-directed
behaviour)


Delusions (A1)
- Erroneous belief from a misinterpretation of perceptions or
experiences
- Delusions may often center around a common theme (persecutory,
referential, somatic, religious, grandiose)
- Persecutory delusions are most common (being spied on, tricked,
followed, torrented or ridiculed)
-Referential delusions (believe that certain gestures, comments,
passages from books, newspapers, songs or other environmental
cues are directed specifically at the individual)
- Delusions are very real and even when presented with contradictory
evidence, there is zero chance the idea is false

Nonbizarre vs. bizarre delusions
Non Bizarre delusion - the strong belief in something
that is possible but has no evidence to support it (ie. a
person's false belief they are being followed)

Bizarre delusion - the strong belief is clearly impossible
and not being drawn from an ordinary life experience (ie.
someone has removed one's organs and replaced them
with someone else's without any scars or wounds)
**If bizarre delusions are present, this alone fulfills
Criterion A
Hallucinations (A2)
- Perceptions in a conscious and awake state in the absence of
external stimuli which have qualities of real perception, in
that they are vivid, substantial, and located in external
objective space.
- May occur in any sensory modality (auditory, visual, olfactory,
sense of tastes, tactile) with auditory being most common
- Certain types of audio hallucinations (ie. 2 or more voices
having a conversation with each other or voices keeping a
running commentary on the person's thoughts or behaviours)
are considered to be a unique characteristic of schizophrenia.
**If these two types of hallucinations are present, this alone
fulfills Criteria A

DSM IV - Diagnostic
Criterion for Schizophrenia

DSM - IV Criteria cont.

DSM - IV Criteria con't.

Subtypes within Schizophrenia
Paranoid Type - preoccupation with delusions or
hallucinations
Disorganized Type - prominence of:
o disorganized speech
o disorganized behaviour
o flat/inappropriate affect
Catatonic Type - immobility seen with really rigid or
limp body or excessive motor activity that appears
purposeless
-resistant to being moved; unresponsive or mutism
-particular movements; bizarre posturing


Subtypes within Schizophrenia

-echolalia (echoing others, phrase or sounds)
-echopraxia (meaningless repetition or limitation of
movements)
Undifferentiated Type - doesn't meet previous 4
types but meets criterion A symptoms
Residual Type - only stipulated when there has been
at least 1 episode of schizophrenia but currently the
individual is without prominent positive psychotic
symptoms ( delusions, hallucinations, disorganized
speech/behaviour)
DSM-V Proposed Criteria
A. Characteristic symptoms: Two (or more) of the following, each present for a significant portion of
time during a 1-month period (or less if successfully treated). At least one of these should include
1-3
1. Delusions
2. Hallucinations
3. Disorganized speech
4. Grossly abnormal psychomotor behavior, such as catatonia
5. Negative symptoms, i.e., restricted affect or avolition/asociality
Note: deletion of
Only one Criterion A symptom is required if delusions are bizarre or hallucinations consist of a voice
keeping up a running commentary on the persons thoughts, or two or more voices conversing
with each other.

B. 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 are markedly below the level achieved prior to the onset (or when the onset is in childhood or
adolescence, failure to achieve expected level of interpersonal, academic, or occupational
achievement).



DSM-V Proposed Criteria
C. Duration: Continuous signs of the disturbance persist for at least 6 months. This 6-month period
must include at least 1 month of symptoms (or less if successfully treated) that meet Criterion A
(i.e., active-phase symptoms) and may include periods of prodromal or residual symptoms. During
these prodromal/residual periods, the signs of the disturbance may be manifested by only
negative symptoms or two or more symptoms listed in Criterion A present in an attenuated form
(e.g., odd beliefs, unusual perceptual experiences).
D. Schizoaffective and Mood Disorder exclusion: Schizoaffective Disorder and Mood Disorder With
Psychotic Features have been ruled out because either (1) no Major Depressive or Manic
Episodes have occurred concurrently with the active phase symptoms; or (2) if mood episodes
have occurred during active-phase symptoms, their total duration has been brief relative to the
duration of the active and residual periods.
E. Substance/general medical condition exclusion: The disturbance is not due to the direct
physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical
condition.
F. Relationship to a Pervasive Developmental Disorder: If there is a history of Autistic Disorder,
another Pervasive Developmental Disorder, or other communication disorder of childhood onset,
the additional diagnosis of Schizophrenia is made only if prominent delusions or hallucinations are
also present for at least a month (or less if successfully treated).
** Deletion of all Subtypes
Does anyone see any difficulties in identifying
delusions in children?


delusions completely ignore clear contradictory
evidence; the person is absolutely convinced
their delusion is real
Diagnostic Issues of Childhood-Onset
Schizophrenia(COS)
DSM-IV criteria for schizophrenia is similar across ages.
There is no separate diagnostic criteria for children.
DSM-IV does mention certain differences in childhood-
onset however these may make it more difficult to
diagnose COS
Hallucinations, delusions and thought disorders are
rare in children under the age of 7 years.
Diagnostic criteria does not take development into
account, which could result in some children being
excluded.
Distinguishing between a young child's imagination and
delusions can be difficult
Diagnostic Issues of Childhood-Onset
(COS)
Language and cognitive development can make it difficult for children to
accurately describe their symptoms.

Children are less likely to be able to distinguish psychotic symptoms from
normal experience and not report symptoms to their parents

Disorganized speech and behavior are common features of other childhood
disorders.

Many children who are screened for COS are taking medication for other
illnesses such as depression, bipolar disorder or anxiety this can affect
accuracy of diagnosis of COS.

Rarity of diagnosis in children has resulted in limited data


Jani-Video Clip
Two steps forward, One step back


What are the
patterns,
causes and
effects of COS?
Epidemiology of COS
Prevalence:
Childhood-onset typically occurs before age 12
very rare in young children - tentative estimates are 1 in 40,000.
childhood-onset 50 times less prevalent than adult-onset
Gender Differences:
majority of males diagnosed with childhood-onset - some estimates as high
as 5:1
ratio differences are more even in adolescence
Socioeconomic Factors
no clear evidence of socioeconomic factors in childhood-onset
schizophrenia
Culture
similar incidence rates across cultures and countries

Epidemiology of COS
Genetics
higher rate (up to 45%) of schizophrenia spectrum disorders in first degree
relatives of children with COS.

family history of other psychiatric illnesses present.

Additional Factors
majority of COS patients (50%-60%) have deficits in language
(expression/comprehension), motor (coordination/delayed milestones)
and social functioning (withdrawal/aloofness).

such deficits appeared years prior to onset of psychosis and could be
vulnerability factors for COS



Epidemiology of COS
childhood-onset patients were more likely than adult-onset to have PDD-
like symptoms such as hand flapping, echolalia and lack of response prior
to onset of psychosis.

some studies suggest COS patients have dysfunction in frontal-temporal
lobes.

individuals diagnosed with COS have lower IQ scores than later onset
types of schizophrenia. Decline in IQ scores seen after onset of psychosis.

Theoretical Framework
Vulnerability-Stress Model

o Joint contribution of genetics and stressful life
events

o Lacks specificity, thus it is heuristic

o 3 central constructs:
Vulnerability Factors
Stressors
Protective Factors
Vulnerability Factors
Both constitutional and environmental
vulnerability factors
o Genetic Factors
o CNS Damage
o Inadequate learning opportunities
o Exposure to deviant family communication patterns

Some may be more specific to COS, some
may be more general risk factors for
psychiatric disorders
Stressors
Hypothesized to lead to an increased
likelihood of a schizophrenic episode

o Major life events

o Chronic stressors, strain, and hassles
Protective Factors
Characteristics
o Intelligence
o Social Support
o Social competence
o Healthy family communication

Very hard to identify

"true" protective factors and strategies
Theoretical Models
Hypothesis vary in describing the way
vulnerability factors, stressors, and
protective factors interact

o Transactional Models emphasize Person x
Environment interactions over time
Etiology
Cause of schizophrenia is still unknown

COS etiology must address the fact that
children suffering from schizophrenia is
atypical to the larger group
4 Major Hypothesis
COS represents a particularly severe and chronic form
of the illness, with early onset reflecting a more severe
biological predisposition
COS represent a different illness
Early onset is associated with the presence of
potentiating factors, such as severe psychosocial and/or
biological factors
COS has no particular etiological significance - it
represents cases at the early end of the age-of-onset
distribution
Biological Factors
Support for view that schizophrenia is a
primary brain disease

However....

o There is no unitary brain lesion found in all patients

o Brain lesions found in some patients are not unique
or specific to schizophrenia
Neurodevelopmental Model

Adult-onset schizophrenia


COS in relation to this hypothesis
Dopamine Hypothesis
Supported by several sources of evidence for
adults
Supported by efficacy of phenothiazines and
related drugs in controlling symptoms
However....
Dopaminergic mechanisms are complex with
multiple hypotheses
o Dopamine Hyperfunction
o Imbalance
o Variety of dysfunctions
Evidence of Biological
Factors
Family studies and Genetic Factors

Chromosomal Anomalies

Brain Imaging Studies

Magnetic Resonance Spectroscopy

Neurocognitive Studies
Environmental Stressors
Data suggests COS is a familial disorder
However...
o Twin studies are less than 100%, indicating non-
genetic factors also influence the likelihood of
developing this disorder

Pregnancy and Birth Complication

Psychosocial Stress
Comorbidity
Common Comorbid
Diagnoses

Attention Deficit Hyperactivity Disorder
Oppositional Defiant Disorder
Depression
Anxiety Disorders
Eating Disorders
Speech and Language Disorders
Autism Spectrum Disorder
How can we
treat children
and youth with
COS?
Considerations
Current clinical status
Cognitive ability
Developmental stage
Severity of illness
Caregiver support
Not "curable" but treatable
Treatment can include:
o Medication
o Education
o Family Counselling
o Hospitalization and regular follow up
o Residential and Rehabilitation programs
o Peer Support groups

Medication
Generally referred to as antipsychotics or
neuroleptics

Standard Medications include:
o Thorazine
o Mellaril
o Proloxin
o Haldol

Side Effects called extrapyramidal symptoms:
o Include akinesia, akathisia and tardive dyskinesia

Medication
Atypical Antipsychotics:
o do not have the same chemical profiles as standard
medications
o seem to work in a different way than standard medications
o cause fewer side effects than standard medications, helping
patients to stabilize
Include:
o Risperidone
o Clozapine
o Olanzapine
o Quetiapine




Side Effects:
o weight gain and associated
health concerns
Psychosocial Interventions
Cognitive Behavioural Therapy (CBT)
o Links are established between thoughts, feelings,
and actions in a collaborative and accepting
atmosphere

Social Skills Training
o Communication and socialization
o Independent living skills
o Generalization of skills
o Dealing with conflict

Classroom Considerations
Structure and routine
Clear rules and consequences
Visuals
Chunking and making connections
Positive behaviour support
Organization
Video Clip- Jani
Looking forward


What Did You Learn About
Schizophrenia?
1. Schizophrenia is more common in males than females.
2. Childhood-onset diagnostic criteria is the same as adult-onset.
3. People diagnosed with schizophrenia are violent.
4. People with schizophrenia have dual or multiple personalities.
5. Childhood-onset schizophrenia is very rare.
6. Medication can cure or eliminate COS.
7. Autism can lead to COS.
8. Drugs used to treat COS have side effects.
9. Childhood-onset schizophrenia is a genetic disorder
10. Children with COS may also suffer from severe Separation Anxiety



References
American Psychiatric Association, (2002). Diagnostic and statistical manual
of mental disorders (4th ed., text rev.). Washington, DC: Author.
American Psychiatric Association, (n.d.). Diagnostic and statistical manual of
mental disorders (5th ed., proposal). Retrieved from: http://dwm5.org.
Biswas, P. (2008). Neurobiology of childhood-onset schizophrenia. Journal of
Indian Association for Child & Adolescent Mental Health, 4(3), 55-61
de Jager, W., Foster, K.A., Swartz, L. (2006). The clinical presentation of
childhood-onset schizophrenia: A literature review. South African Journal
of Psychology, 36(2), 299-318
Gochman, P., Miller, R., & Rapoport, J. L. (2011). Childhood-onset
schizophrenia: The challenge of diagnosis. Current Psychiatry Reports,
13(5), 321-322. doi: 10.1007/s11920-011-0212-4
Gonthier, M. & Lyon, M.A. (2004). Childhood-onset schizophrenia: An
overview. Psychology in the School, 41(7), 803-811. doi:10.1002/pits.20013



References
Kumra, S. (2000). The diagnoses and treatment of children and adolescents
with schizophrenia. Child and Adolescent Psychiatric Clinics of North
America, 9(1), 183-199.
Rosenbaum Asarnow, J., & Asarnow, R. J. (2003). Childhood-onset
Schizophrenia. In E. J. Mash & R. A. Barkley (Eds), Child
psychopathology (2nd ed., pp. 455-485). New York: Guilford.
Schizophrenia Society of Canada (2005). Learning About Schizophrenia: Rays
of Hope. Ontario: Author.
Tiffin, P.A. (2007). Managing psychotic illness in young people: A practical
overview. Child And Adolescent Mental Health. 12(4). 173-186.
doi:10.1111/j.1475-3588.2006.00418.