Identification and treatment of individuals with childhood-onset and early-onset schizophrenia.

Approximately 8 % of patients with schizophrenia are diagnosed before age 18, and 18 % experience their first symptoms before age 18. This narrative review explores the management of patients with early-onset schizophrenia (EOS) and childhood-onset schizophrenia (COS) from diagnosis to their transition to adult care settings. Early diagnosis of schizophrenia in children and adolescents is essential for improving outcomes, but delays are common due to overlapping of symptoms with developmental phenomena and other psychiatric conditions, including substance use, and lack of clinicians' awareness. Once diagnosed, antipsychotic treatment is key, with specific second-generation agents generally being preferred due to better tolerability and their broader efficacy evidence-base in youth. Dosing should be carefully individualized, considering age-related differences in drug metabolism and side effect liability. Clinicians must be vigilant in detecting early non-response and consider switching or dose escalation when appropriate. Since early age of illness onset is a consistent risk factor for treatment-resistant schizophrenia (TRS), clinicians need to be competent in diagnosing TRS and using clozapine. Since COS and EOS are associated with cognitive deficits and impaired functioning, psychosocial interventions should be considered to improve overall functioning and quality of life. Good long-term outcomes depend on continuous treatment engagement, and successful transitioning from pediatric to adult care requires careful planning, early preparation, and collaboration between pediatric and adult clinicians. Targeting functional outcomes and quality of life in addition to symptom remission can improve overall patient well-being. Comprehensive evaluations, age-specific assessments, and targeted interventions are needed to address the unique challenges of EOS and COS.

Comparison of clinical characteristics and treatment efficacy in childhood-onset schizophrenia and adolescent-onset schizophrenia in mainland China: A retrospective study.

AIM: The comparative study of childhood-onset schizophrenia (COS) and adolescent-onset schizophrenia (AOS) is scarce. This study aimed to examine the differences in clinical presentations and treatment efficacy between COS and AOS and further analyse the factors affecting the efficacy of early-onset schizophrenia (EOS). METHODS: A total of 582 electronic medical records of inpatients with EOS (216 COS and 366 AOS inpatients) between 2012 and 2019 were retrospectively analysed. The positive and negative syndrome scale (PANSS) was used to assess psychotic symptoms. Logistic regression analysis was performed to analyse the predictors of efficacy. RESULTS: The mean age of onset of EOS was 12.87 ± 2.19 years. The importance of better diagnosing COS appeared in a longer illness course, more frequently insidious onset, less frequent delusions, more severe negative symptoms and bizarre behaviours than AOS. Besides, COS had more frequent visual hallucinations and impulsive behaviours than AOS. After hospitalization, the improvement rate of psychotic symptoms in COS and AOS were 38.3% and 47.8%, respectively. The difference of efficacy between the two groups was statistically significant. Days of hospitalization, age of onset, presence of flat affect, PANSS total and negative score at admission were predictors of treatment efficacy in EOS individuals. CONCLUSIONS: COS inpatients suffer more obvious negative symptoms, bizarre behaviours, visual hallucinations and impulsive behaviours and worse efficacy than AOS inpatients. The severity of negative symptoms and age of onset seem the most noteworthy predictors of efficacy. These findings highlight the importance of early detection and early intervention.

Duelo y psicosis en niños: cuando también se pierde el sentido de realidad / Mourning and psychosis in children: when the sense of reality is lost too / Dol i psicosi en nens: quan també es perd el sentit de realitat

En los últimos años se ha estudiado ampliamente la relación entre los traumas vividos en la infancia y el desarrollo de psicosis en la vida adulta. Este artículo se centra en el momento del trauma en tiempo presente, concretamente en las consecuencias que pue­de suponer para un niño la muerte de su cuidador principal. Se describen las relaciones entre el trauma actual y el desarrollo de sintomatología psicótica temprana. Y se concluye la importancia de tener en cuenta este tipo de evento vital en la evaluación y tratamiento en niños

Lately, the relationship between child­hood trauma and the development of psychosis in adult life has been extensively studied. This article focuses on the moment of trauma in the present, specifically on the consequences that the death of a primary caregiver can have on a child. The relationships between current trauma and the development of early psychotic symptoms are described. This type of trauma must be taken into account while evaluating and treating children

En els darrers anys s'ha estudiat àmpliament la relació entre els traumes viscuts a la infància I el desenvolupament de psicosi a la vida adulta. Aquest article se centra en el moment del trauma en temps present, concretament en les conseqüències que pot suposar per a un nen la mort del seu cuidador principal. Es descriuen les relacions entre el trauma actual I el desenvolupament de simptomatologia psicòtica en l'avaluació I tractament en nens

Clinical Characteristics and Predictors of Outcome of Schizophrenia-Spectrum Psychosis in Children and Adolescents: A Systematic Review.

OBJECTIVE: Treatment of early-onset schizophrenia spectrum psychosis (EOS) is hampered by limited data on clinical presentation and illness course. We aimed to systematically review the clinical characteristics, diagnostic trajectories, and predictors of illness severity and outcomes of EOS. METHODS: We conducted a systematic PubMed, PsycINFO, and Embase literature review including studies published from January 1, 1990 to August 8, 2014 of EOS patients with 1) ≥50% nonaffective psychosis cases; 2) mean age of subjects <19 years; 3) clinical samples recruited through mental health services; 4) cross-sectional or prospective design; 5) ≥20 participants at baseline; 6) standardized/validated diagnostic instruments; and 7) quantitative psychotic symptom frequency or severity data. Exploratory analyses assessed associations among relevant clinical variables. RESULTS: Across 35 studies covering 28 independent samples (n = 1506, age = 15.6 years, age at illness onset = 14.5 years, males = 62.3%, schizophrenia-spectrum disorders = 89.0%), the most frequent psychotic symptoms were auditory hallucinations (81.9%), delusions (77.5%; mainly persecutory [48.5%], referential [35.1%], and grandiose [25.5%]), thought disorder (65.5%), bizarre/disorganized behavior (52.8%), and flat or blunted affect/negative symptoms (52.3%/50.4%). Mean baseline Positive and Negative Syndrome Scale (PANSS)-total, positive, and negative symptom scores were 84.5 ± 10.9, 19.3 ± 4.4 and 20.8 ± 2.9. Mean baseline Clinical Global Impressions-Severity and Children's Global Assessment Scale/Global Assessment of Functioning (CGAS/GAF) scores were 5.0 ± 0.7 and 35.5 ± 9.1. Comorbidity was frequent, particularly posttraumatic stress disorder (34.3%), attention-deficit/hyperactivity and/or disruptive behavior disorders (33.5%), and substance abuse/dependence (32.0%). Longer duration of untreated psychosis (DUP) predicted less CGAS/GAF improvement (p < 0.0001), and poor premorbid adjustment and a diagnosis of schizophrenia predicted less PANSS negative symptom improvement (p = 0.0048) at follow-up. Five studies directly comparing early-onset with adult-onset psychosis found longer DUP in EOP samples (18.7 ± 6.2 vs. 5.4 ± 3.1 months, p = 0.0027). CONCLUSIONS: EOS patients suffer substantial impairment from significant levels of positive and negative symptoms. Although symptoms and functioning improve significantly over time, pre-/and comorbid conditions are frequent, and longer DUP and poorer premorbid adjustment is associated with poorer illness outcome.

Transcranial Direct Current Stimulation in Child and Adolescent Psychiatry.

OBJECTIVES: Transcranial direct current stimulation (tDCS) is a noninvasive brain stimulation technique that consists of applying a weak electric current over the scalp to modulate cortical excitability. tDCS has been extensively investigated in adults with psychiatric disorders. The aim of this study was to review the current literature regarding the use of tDCS in children and adolescents with psychiatric disorders. METHODS: We searched MEDLINE and EMBASE databases for studies evaluating the safety and efficacy of tDCS in children and adolescents from age 0 to 18 years with psychiatric disorders. RESULTS: We found six studies that evaluated patients with different psychiatric disorders, with diverse study designs and stimulation parameters, including three small randomized clinical trials (RCTs), one evaluating childhood-onset schizophrenia, one RCT with patients with autism spectrum disorders (ASD), and one study in attention-deficit/hyperactivity disorder (ADHD); three open-label studies, two evaluating patients with ASD, and one study of feasibility of the technique in children and adolescents with language disorders and diverse psychiatric disorders, including ASD, intellectual disability, and ADHD. We also found three studies of dosage considerations in the general pediatric population. The technique was well tolerated, with no reports of serious side effects. CONCLUSION: Preliminary research suggests that tDCS may be well tolerated and safe for children and adolescents with psychiatric and neurodevelopmental disorders. Nevertheless, because the literature regarding tDCS in child and adolescent psychiatry is scarce and there exist limited numbers of randomized controlled trials, it is not possible to draw definite conclusions. Future studies should investigate the technique with regard to specific psychiatric conditions in comparison with standard treatments. In addition, long-term efficacy and safety should be monitored.

[Childhood-onset schizophrenia].

Childhood-onset schizophrenia has been clinically studied and is believed to be on a continuum with adult-onset schizophrenia. However, childhood-onset schizophrenia is more difficult to diagnose than it is in adults, since children are in a developmental state. This article reviewed the literature regarding childhood-onset schizophrenia. This article discusses the clinical features, development until manifestation, possibility of early diagnosis, and treatment. Early intervention may improve the prognosis of psychotic disorders such as schizophrenia. However, early intervention of childhood-onset schizophrenia requires case histories with accurate descriptions of the development of the disease until its onset.

Treatments in context: transcranial direct current brain stimulation as a potential treatment in pediatric psychosis.

Childhood-onset schizophrenia is a chronic, severe form of schizophrenia, and is typically treatment resistant. Even after optimized pharmacotherapy, a majority (over 70%) of these pediatric patients present lasting psychotic symptoms and impaired cognition, necessitating the need for novel treatment modalities. Recent work in transcranial magnetic stimulation suggests moderate efficacy in symptom reduction in adult patients with schizophrenia; however, the transcranial magnetic stimulation treatment is cumbersome for this severely ill population. Transcranial direct current stimulation may provide a safe and effective adjuvant treatment for continued residual symptoms of schizophrenia.

Tolerability of transcranial direct current stimulation in childhood-onset schizophrenia.

BACKGROUND: In recent years, transcranial direct current stimulation (tDCS) has been used to study and treat many neuropsychiatric conditions. However, information regarding its tolerability in the pediatric population is lacking. OBJECTIVE: This study aims to investigate the tolerability aspects of tDCS in the childhood-onset schizophrenia (COS) population. METHODS: Twelve participants with COS completed this inpatient study. Participants were assigned to one of two groups: bilateral anodal dorsolateral prefrontal cortex (DLPFC) stimulation (n = 8) or bilateral cathodal superior temporal gyrus (STG) stimulation (n = 5). Patients received either 2 mA of active treatment or sham treatment (with possibility of open active treatment) for 20 minutes, for a total of 10 sessions (2 weeks). RESULTS: tDCS was well tolerated in the COS population with no serious adverse events occurring during the study. CONCLUSIONS: This is the first study to demonstrate that a 20-minute duration of 2 mA of bilateral anodal and bilateral cathodal DC polarization to the DLPFC and STG was well tolerated in a pediatric population.

Schizophrenia and related disorders in children and adolescents.

This paper reviews the concept and recent studies on childhood and adolescent psychoses with special reference to schizophrenia. After a short historical introduction, the definition, classification, and epidemiology of child- and adolescent-onset psychoses are described, pointing out that some early-onset psychotic states seem to be related to schizophrenia (such as infantile catatonia) and others not (such as desintegrative disorder). The frequency of childhood schizophrenia is less than 1 in 10,000 children, but there is a remarkable increase in frequency between 13 and 18 years of age. Currently, schizophrenia is diagnosed according to ICD-10 and DSM-IV criteria. The differential diagnosis includes autism, desintegrative disorder, multiplex complex developmental disorder (MCDD) respectively multiple developmental impairment (MDI), affective psychoses, Asperger syndrome, drug-induced psychosis and psychotic states caused by organic disorders. With regard to etiology, there is strong evidence for the importance of genetic factors and for neurointegrative deficits preceding the onset of the disorder. Treatment is based upon a multimodal approach including antipsychotic medication (mainly by atypical neuroleptics), psychotherapeutic measures, family-oriented measures, and specific measures of rehabilitation applied in about 30% of the patients after completion of inpatient treatment. The long-term course of childhood- and adolescent-onset schizophrenia is worse than in adulthood schizophrenia, and the patients with manifestation of the disorder below the age of 14 have a very poor prognosis.

Childhood-onset schizotypal disorder: a follow-up study and comparison with childhood-onset schizophrenia.

OBJECTIVE: This paper presents results from the UCLA Follow-Up Study of Childhood-Onset Schizophrenia (SZ) Spectrum Disorders. METHOD: We assessed 12 children with schizotypal personality disorder (SPD) and 18 children with schizophrenia 1-7 years following initial project intake. RESULTS: There was significant continuity between SZ spectrum disorders in childhood and adolescence. Although not all children who presented initially with SZ spectrum disorders continued to meet criteria for SZ spectrum disorder as they progressed through the follow-up period, rates of SZ spectrum disorders ranged from 75% to 92% across the 3 follow-up years for children initially presenting with SPD, and from 78% to 89% for children initially presenting with SZ. CONCLUSION: The most common clinical outcome for children with SPD was continuing SPD, supporting the hypothesis of continuity between childhood and later SPD. However, 25% of the SPD sample developed more severe SZ spectrum disorders (schizophrenia or schizoaffective disorder), also supporting the hypothesis that SPD represents a risk or precursor state for more severe SZ spectrum disorders.

Childhood-onset schizophrenia: premorbid and prodromal diagnostic and treatment histories.

OBJECTIVE: There is increasing interest in the possible relationship between the early diagnosis and treatment of schizophrenia during adolescence and improved long-term outcome. This study reviews the premorbid and prodromal diagnostic and treatment histories for childhood-onset schizophrenia, to assess whether early identification and treatment is possible in this school-age group. METHOD: Parents of 17 children with childhood-onset schizophrenia or schizoaffective disorder were questioned retrospectively regarding symptoms, exposure to mental health professionals, diagnoses, and treatments. RESULTS: Initial presenting symptoms clustered around violent aggression and school problems. Age of first recognized psychotic symptoms ranged from 2 to 11 years, followed 2.0+/-2.0 years later by a diagnosis of schizophrenia. Prior to a schizophrenia diagnosis, these children were exposed to stimulants, antidepressants, lower-dose typical neuroleptics, mood stabilizers, alternative treatments, and individual and family therapy. CONCLUSION: Early diagnosis of childhood-onset schizophrenia is met with caution in the psychological and medical community. These children received many diagnoses before schizophrenia or schizoaffective disorder was diagnosed. A diagnosis of schizophrenia or schizoaffective disorder and utilization of effective atypical neuroleptic treatment was delayed until evaluation by a child and adolescent psychiatrist. Obstacles to early identification and treatment are discussed.

Treatment of schizophrenia in childhood and adolescence.

This paper reviews the management of schizophrenia occurring during childhood and adolescence. It considers the clinical features of the disorder particular to its early onset before providing a practical framework for assessment and treatment based upon a critical review of the available literature. A multi-modal approach to treatment encompassing the individual and their family is adopted with the roles of pharmacological, psychological, and environmental interventions all considered. The place of the newer "atypical" antipsychotic agents and the likelihood that they will soon become the first-line drugs of choice is particularly discussed.

Childhood and adolescent psychosis: a review of the past 10 years.

OBJECTIVE: Developmental aspects of psychosis are reviewed and related to the more frequent psychotic conditions in children and adolescents. METHOD: The review of the recent literature focuses on developmental aspects of psychotic phenomena, i.e., hallucinations, delusions, and thought disorder. RESULTS: While the applicability of much early work on this topic is limited, more recent work suggests that psychotic conditions are observed in childhood and increase in frequency during adolescence. CONCLUSIONS: Developmental factors in the expression of psychosis are relevant to the diagnosis and treatment of such conditions.

Psychoses in children and adolescents: a review.

The differential diagnosis of psychoses in children and adolescents encompasses a wide range of disorders. The interpretation of psychotic symptoms in these patients must consider age, developmental level, symptomatology, and etiology for an appropriate DSM-IV diagnosis. Previous classifications of psychoses provided little information about the underlying processes or possible treatment. Clinical experience suggests that psychotic manifestations in young patients are influenced by developmental stage and that eliciting target symptoms from a young patient necessitates using and understanding the youth's language. Proper patient assessment demands interviews with family and collaborative sources, as well as endocrine, metabolic, neurologic, infectious, and toxicologic laboratory evaluations. Treatment involves interventions aimed at all spheres of life. The prognosis and outcome are generally poor in early-onset psychoses and are complicated by comorbidities.

Speech and language disorders in children and adolescents with schizophrenia.

This study examines communication characteristics and specific language deficits in 47 children and adolescents diagnosed with early-onset schizophrenia using DSM-III-R criteria. All had been referred for speech and language services because of apparent communication problems. Standardized tests and formal measures were used to identify impairment in discrete areas of communication, including pragmatics, receptive and expressive vocabulary and syntax, abstract language, auditory processing, and speech production. Results showed that these discrete areas were variably involved, with pragmatics, prosody, auditory processing, and abstract language having the greatest involvement. The communication deficits identified in the early-onset group closely resembled the phenomenology reported in studies of the communication characteristics of adults with schizophrenia. This comparison thus lends further support to the presence of the same disorder as seen in adults. The roles of gender, mental retardation, and seizure disorders are also discussed as additional risk factors in the development of communication problems and schizophrenia.

[Child and adolescent psychiatric emergencies]. / Kinder- und jugendpsychiatrische Notfälle.

Guided by the most important clinical categories, child and adolescent psychiatric disorders are described that may manifest as emergency cases. The kind of intervention and treatment modalities that are effective are documented. Drug treatment is of special importance in emergency cases.