Edited by Shane R. Jimerson, Ph.D.
Contributed to by the Graduate Students in the Counseling, Clinical,
and School Psychology Program at the University of California, Santa Barbara.
Ongoing design and publication of this site is completed by Shane R. Jimerson, Jeff R. Klein and Angela D. Whipple. Please forward comments regarding this site to Shane R. Jimerson. This page was last updated 1.11.02. © 2002
Symptoms
Epidemiology
Etiology
Assessment
Treatment
Authors
Shane R. Jimerson, Jeff Hayden & Don Risdall
University of California, Santa Barbara
Childhood-Onset Schizophrenia
Schizophrenia is a debilitating disease. It’s
prevalence rates range between .5 and 1% of the population. Its chronic,
debilitating effects on the development of the individuals has significant
social, financial effects around the world. When schizophrenia strikes
a young child, the effect is tremendous. Schizophrenia will stunt
and/or alter the normal development of the child in all domains. Without
early, effective interventions, schizophrenia will impede the individual’s
ability to proceed through the normal developmental stages wherein they
acquire many of the life skills necessary for optimal adult functioning.
Despite the policy of the World Health Organization (WHO) stating that
children should not be placed in adult wards of any kind many children
and adolescents diagnosed with this disorder are receiving services in
adult psychiatric facilities (Werry, 1992, 1996). To date, relatively little
empirical research has been done exclusively examining the prevalence or
treatment of this serious disorder. Prior to the DSM-III (American
Psychiatric Association, 1980), the diagnosis of childhood schizophrenia
encompassed
almost all severe mental disturbances of childhood. Thus, most
studies on childhood schizophrenia done prior to 1980 actually consisted
of very heterogeneous samples and included such pervasive developmental
disorders as autism and other psychotic conditions (Remschmidt, Schulz,
Martin, Warnke, & Trott, 1994; Volkmar, 1996; Werry, 1996).
Most knowledge about schizophrenia comes from
studies conducted with adults. Despite nosological similarities between
adult- and childhood-onset schizophrenia, the age and developmental stage
of the individuals with the disorder influence the way they experience
and react to it. Children, adolescents, and adults encounter different
biological vulnerabilities and psychosocial stressors within a particular
environmental context that affect their clinical presentation, course,
and responsiveness to various treatment options (Asarnow, Asarnow, Hornstein,
& Russell, 1991). Preliminary research findings also suggest
that childhood-onset schizophrenia may be a more severe form of the disorder
and children with this disorder may be more genetically homogeneous (Asarnow,
Asarnow, Hornstein, & Russell, 1991; Asarnow, 1994). Thus, the
study of childhood-onset schizophrenia can be informative in delineating
the etiological pathways of this disorder. Given the psychobiological
consequences and socioeconomic effects of this severe disorder, it is important
that mental health professionals increase their understanding of it through
continuous research and intervention.
DSM-IV Diagnostic Criteria for Schizophrenia
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):
(1) delusions
(2) hallucinations
(3) disorganized speech (e.g., frequent derailment or incoherence)
(4) grossly disorganized or catatonic behavior
(5) negative symptoms, i.e., affective flattening, alogia, or
avolition
Note: Only one Criterion A symptom is required if delusions are bizarre or hallucinations consist of a voice keeping up a running commentary on the person's behavior or 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).
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 or 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, Manic, or Mixed 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 effect 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 or another Pervasive Developmental Disorder, 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).
Classification of longitudinal course (can be applied only after at
least 1 year has elapsed since the initial onset of active-phase symptoms):
Episodic With Interepisode Residual Symptoms (episodes are defined by the
reemergence of prominent psychotic symptoms); also specify if: With
Prominent Negative Symptoms Episodic With No Interepisode Residual
Symptoms Continuous (prominent psychotic symptoms are present throughout
the period of observation); also specify if: With Prominent Negative
Symptoms Single Episode In Partial Remission; also specify if: With
Prominent
Negative Symptoms
Single Episode In Full Remission
Other or Unspecified Pattern
Source. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed., pp. 285-286). Washington, DC: Author.
EPIDEMIOLOGY
The estimated prevalence rates of adult-onset
schizophrenia range between .5 and 1% of the entire population, with onset
generally occurring during young adulthood. Childhood-onset schizophrenia,
being much rarer than the adult-onset disorder, has an estimated prevalence
rate of about .14 in 1,000 in children below the age of 15 (Eggers &
Bunk, 1997). This extremely low prevalence rate may reflect, in part, difficulty
in defining the phenomenology of childhood-onset schizophrenia due to young
children’s limitations in describing their symptoms as well as researchers’
difficulty in distinguishing those symptoms from normal childhood experiences
(Russell, 1994).
Based on structured diagnostic interviews,
Kendler et al. (1996) estimated the 6-month and lifetime prevalence rate
of .7%. There is some indication that the incidence of schizophrenia has
declined over the years and Stoll et al. (1993) suggested the newer classification
and assessment methods outlined in the diagnostic manuals of the American
Psychological Association (DSM classification system) appear to be pushing
the prevalence rate under 1%. Estimates from the World Health Organization
place the annual incidence rate at .22 out of 1000 (Bromet et al, 1995)
and the DSM-IV (1994) vary the rate from .2% to 2%.
Schizophrenia’s chronic, debilitating effects
on the development of individuals have significant social and financial
effects around the world. When schizophrenia strikes a young child, the
effect is tremendous. Schizophrenia will stunt and/or alter the normal
development of the child in all domains. Without early, effective interventions,
schizophrenia will impede the individual's ability to proceed through the
normal developmental stages wherein one acquires many of the life skills
necessary for optimal adult functioning. Despite the policy of the
World Health Organization (WHO) stating that children should not be placed
in adult wards of any kind many children and adolescents diagnosed with
this disorder are receiving services in adult psychiatric facilities (Werry,
1992, 1996). To date, relatively little empirical research has been done
exclusively examining the prevalence or treatment of this serious disorder.
Prior to the DSM-III (American Psychiatric Association, 1980), the diagnosis
of childhood schizophrenia encompassed almost all severe mental disturbances
of childhood. Thus, most studies on childhood schizophrenia done
prior to 1980 actually consisted of very heterogeneous samples and included
such pervasive developmental disorders as autism and other psychotic conditions
(Remschmidt, Schulz, Martin, Warnke, & Trott, 1994; Volkmar, 1996;
Werry, 1996).
Most knowledge about schizophrenia comes from
studies conducted with adults. However, this may be changing. For example,
currently the NIMH is conducting a study of 50 children (30 boys
and 20 girls) who were carefully screened and who have shown the full DSM-IV
diagnostic criteria for schizophrenia (Lott, 1999). Their mean age of diagnosis
was 10 years, with the youngest child in the group showing onset of the
disorder at 7 years. Despite nosological similarities between adult- and
childhood-onset schizophrenia, the age and developmental stage of the individuals
with the disorder influence the way they experience and react to it.
Children, adolescents, and adults encounter different biological vulnerabilities
and psychosocial stressors within a particular environmental context that
affect their clinical presentation, course, and responsiveness to various
treatment options (Asarnow, Asarnow, Hornstein, & Russell, 1991).
Preliminary research findings also suggest that childhood-onset schizophrenia
may be a more severe form of the disorder. That is, according to Judith
Rapoport from the National Institute of Mental Health (NIMH), early-onset
schizophrenia may now be viewed on a continuum with adult-onset schizophrenia
rather than as a distinctively different disease as was previously believed
(Lott, 1999). Thus [delete and] children with this disorder may be more
genetically homogeneous (Asarnow, Asarnow, Hornstein, & Russell, 1991;
Asarnow, 1994) and the study of childhood-onset schizophrenia can be informative
in delineating the etiological pathways of this disorder. Given the
psychobiological consequences and socioeconomic effects of this severe
disorder, it is important that mental health professionals increase their
understanding of it through continuous research and intervention.
The available research findings vary on the
gender and age of onset. For instance, a Symposium on childhood-onset schizophrenia
conducted by the European Child & Adolescent Psychiatry association
(Eggers et al., 1999) indicated that there were no gender differences in
age of first psychiatric symptoms and no significant difference in age
at first psychotic symptom. However, the prevalence rates were reported
to be earlier in females than in males. Previous findings indicate that
males, on average, 1) suffer a psychotic episode at an earlier age, 2)
show greater evidence of cognitive impairment, 3) evidence more neurological
abnormalities, and 4) are more likely to have a more severe course of illness.
Studies indicate that childhood onset of the
disorder is clinically and neurobiologically continuous with adult onset.
Phenomenological, neuropsychological, and neurobiological studies have
shown strong similarities between child and adult onset in attention, memory,
and executive functions (Goldberg and Gold, 1995; Asarnow RF et al 1994).
Despite these similarities, the effect of these deficiencies on the developing
individual could have far reaching implications for the child. A review
of individuals clinically treated for schizophrenia indicate those with
the onset before age 13 had shown significantly more pre-morbid language
delays and difficulties than those with later onset (Hollis 1995). Similarly,
a study done at the National Institute of Mental-Health (NIMH) showed that
patients with very early onset schizophrenia, on average (50% or greater),
experienced language, motor, and social abnormalities years before the
onset of psychotic symptoms (Nicolson & Rapoport, 1999).
Schizophrenia with an earlier age of onset
and a more chronic (as opposed to sudden) course is more likely to remain
a persistent and recurrent psychological impairment. Therefore, adolescents
diagnosed with schizophrenia tend to have a less favorable outcome than
those diagnosed during adulthood and are more likely to suffer lingering
symptoms (25%) or require residential care (50%).
Research has shown an imbalance in the incidence
rate among the social classes. One such study (Eaton et al., 1988) indicated
that there is a 3 to 1 relationship of onset between the lowest and highest
classes. There are two commonly suggested hypotheses explaining this phenomenon.
One relates the occurrence to negative environmental factors, such as poor
fetal nutrition (Wahlbeck, Forsén, Osmond, Barker, & Eriksson,
2001), and the second explanation is if an individual experiencing risk
factors of the disorder falls short of social and occupational expectations,
he/she experiences a higher risk for onset (Bromet and Fenning, 1999).
I. ETIOLOGY
Schizophrenia has been identified as a disease of the brain. Several risk factors have been linked to its onset, many of which are the foundations in the various models that attempt to identify the origins and course. These models include the genetic or biological, viral/ immunological, psychosocial, and transactional. Investigations of contributing factors focus on demographic, genetic, and environmental aspects. Additionally, studies examining the interaction of genetic, psychological, and psychosocial factors has demonstrated that genes alone are not likely sufficient for the development of schizophrenia (Portin & Alanen, 1997). Various models have sought to define etiological factors and describe how an individual may come to experience the symptoms characteristic of schizophrenia. While other models have been offered, below are described the most recent and currently cited etiological models:
Genetic/ Biological Model
In general, twin studies have found a concordance
rate of 40-50% in monozygotic twins and 4-10% in dizygotic twins (McGuffin,
Asherson, Owen, & Farmer, 1994). In one study of monozygotic
twins (Jones and Cannon 1998), findings suggest that if one of the siblings
is impaired the other has a 50% risk for developing the disorder regardless
of being reared in the same environment. In other risk studies, Gottesman
and Shields (1982) found that the risk of onset for a child is 46.3% if
both parents have schizophrenia. The percentage drops to 12.8% if
only one parent is affected and 5.6% if a first generation relative has
experienced the disorder. Similarly, Gooding & Iacono (1995) found
that individuals with one parent diagnosed with schizophrenia have a 10%
chance of developing the disorder. The risk increases to over 40%
when both parents are affected with schizophrenia. Neuropsychological deficits
such as impairments in attention and information processing, reaction time,
eye tracking, event-related potentials, and changes in sleep patterns also
support schizophrenia as a biological disorder (Asarnow, 1994; Asarnow
& Asarnow, 1996). Nevertheless, its diverse features suggest
that various biological, psychosocial, and environmental factors may interact
in unique ways in each individual, leading to etiological heterogeneity.
Empirical evidence has also shown support
for the Feinberg hypothesis (Keshavan et al., 1994), which postulates an
abnormality in synaptic pruning (i.e., loss of neural elements) during
postnatal development. Individuals with childhood-onset schizophrenia
showed an excessive cortical pruning in prefrontal limbic/striatal circuits
in schizophrenia. These abnormal reductions in cortical synapse density
during adolescence may account for the changes in neuroanatomy, sleep patterns,
dopamine and glutamate activities. More systematic studies are necessary
to clarify the causal role of hyperpruning in schizophrenia.
Based on the diathesis-stress multifactorial
model, McGuffin (1994) and his colleagues postulated that "non-genetic"
factors, i.e. random changes in gene expression or structure, are the first
“hit” in this "two-hit" hypothesis, while random environmental events may
trigger the second "hit" in predisposed individuals. These random genetic
changes include somatic mutation, unstable DNA sequences, genomic imprinting,
and X inactivation and are believed to contribute to the discordance between
MZ twins. Although the hypothesis of random non-transmissible changes
in gene expression and structure can possibly explain the variance in schizophrenia,
it has not been empirically tested. The article presents a succinct
argument for genetic changes due to environmental events as the cause of
schizophrenia; nevertheless, empirical support is lacking.
A difference in the age of onset between males
and females has also been identified. The onset in males generally, is
before females. Hafner et al. (1998) conducted an epidemiological study
that indicated a later onset for females until the onset of menopause.
They suggest that an "estrogen effect" inhibits onset for females.
Infective/ Immunological Model
According to this model, schizophrenia is caused
by an infection, mainly viral, of the central nervous system (CNS) or by
autoantibodies against CNS tissues. Geographic variation (urban vs.
rural) and gender differences may reflect differences in the exposure to
pathogenic infectious agents. A season-of-birth effect (born between
later winter and early spring) is noted (Kirch, 1993). Persons born during
these times have a greater likelihood of experiencing ventricular enlargement,
which is a predisposition to schizophrenia and a 10% greater chance of
developing the disorder (Gooding & Iacono, 1995). Furthermore,
a greater percentage of individuals have schizophrenia if exposed to influenza
during the second trimester of gestation than those exposed during the
first and third trimesters. Various markers of immune activation
and multiple autoantibodies are noted in schizophrenia (Waltrip II et al.,
1997).
Foster (1999) explores the possibility that
schizophrenia is mainly an allergic reaction to latex. His investigation
neither supported hypothesis nor any alternative hypothesis.
Kirch (1993) presents variations of the infectious-autoimmune
hypothesis including active infection, disruptions of CNS functions by
viral proteins, reactivation of latent virus, integration of retrovirus
into the host DNA, and autoimmunity. However, research has failed
to identify a specific infectious agent or autoantibody that can explain
the development of schizophrenia. The possible involvement of multiple
viruses, variations in affected genes, and the differences in clinical
features of schizophrenia support etiological heterogeneity and the complex
interactions among genetic and environmental factors.
Davis & Phelps (1995) suggest that the
concordance for schizophrenia in monozygotic twins can be accounted for
by shared prenatal viral infection. Depending on the time of twinning,
MZ twins may have various placentation arrangements and chorion types,
which determine whether fetal circulation is shared or separated.
Using handedness as a marker of placentation status, the concordance for
psychosis was compared between two types of MZ twins: dichorionic monozygotic
(DC-MZ) and monochorionic monozygotic (MC-MZ). 60% of the MC-MZ twins
were concordant for psychosis, whereas only 32.1% of the DC-MZ twins were
concordant. Although this finding supports the hypothesis of shared viral
infection as the etiology of schizophrenia, it must be interpreted with
caution because handedness concordance is only an indirect indicator of
placentation status. Direct examination of shared prenatal environment
in the etiology of schizophrenia is necessary, especially in light of the
increased rate of prenatal and perinatal complications found in individuals
with schizophrenia (Nicolson, Lenane, Hamburger, Fernandez, Bedwell, &
Rapaport, 2000).
Psychosocial Model
Research has shown an imbalance in the incidence
rate among social classes. One such study (Eaton et al., 1988) indicated
that there is a 3 to 1 ratio of onset between the lowest and highest classes.
The psychosocial model suggests that psychosocial stressors, such as disturbed
parents, life events, financial distress, and inadequate home environment,
are risk factors that increase individuals' vulnerability in developing
schizophrenia (Asarnow, 1994; Asarnow & Asarnow, 1996). Among many
social factors, communication deviance (CD), or "a confusing, unclear communication
style that leads to a disruption in the focus of attention" (Asarnow, Asarnow,
Hornstein, & Russell, 1991, p. 114) was widely studied in its association
with schizophrenia.
Parents of schizophrenic and schizotypal children
were found to have significantly higher rates of communication deviance
(CD), as measured by the Thematic Apperception Test, than the parents of
depressive and dysthymic children (Asarnow et al 1988) . Moreover,
children diagnosed with schizophrenia spectrum disorders who were in high
CD families had the lowest Children's Global Adjustment Scale scores and
the poorest WISC-R performance scores. The similar results
between children with childhood schizophrenia and schizotypal disorders
suggest that these disorders may be related. However, CD is not specific
to schizophrenia spectrum disorders; it is only a correlate for general
psychopathology. Additionally, it may be the case that CD is an effect
rather than a cause of psychopathology in these families (McFarlane &
Lukens, 1994).
Social factors can enhance or diminish the
risk for schizophrenia in predisposed individuals. There are two commonly
suggested hypotheses explaining the imbalance of diagnosis in social class.
One relates the occurrence to negative environmental factors inhibiting
normal development. Second, if an individual experiencing risk factors
of the disorder falls short of social and occupational expectations, he/she
experiences a higher risk for onset (Bromet & Fenning 1999).
Research has generally supported the social
selection model, which asserts that the social status (socioeconomic, marital)
of individuals with schizophrenia is the consequence, rather than the cause,
of their disorder and it is not specific to schizophrenia (Weyerer 1984).
Furthermore, the evidence of stable and even distribution of schizophrenia
across various cultures and countries supports the notion that genetic
vulnerability, not social stress, is dominant in the etiology of schizophrenia.
However, these hypotheses are of ongoing debate (North, Pollio, Smith &
Spitznagel, 1998).
Transactional Model
The transactional model includes aspects of
the above theories and, taking into account the view of developmental psychopathologists,
views schizophrenia as being the ultimate outcome or result of dynamic
interchanges or transactions between an individual and his or her environment.
In this model, the etiology of schizophrenia is characterized by multiple
sources and is thus etiologically heterogeneous (Gooding & Iacona,
1995). Prenatal malnutrition, brain injury, and influenza have all
been identified as strong risk factors for the onset of schizophrenia (Bromet
& Fenning, 1999). In addition, Andreasen (1999) suggests that the causal
factors are due to multiple "hits" of a combination of inherited genetic
factors and non-genetic factors that inhibit brain development and functioning.
These "hits" may include obstetrical complications, viral agents and winter
births and these in turn influence and are influenced by more transient
challenges or stressors such as family environment and situational difficulties.
In turn, there may be protective factors which reduce risk among those
at-risk individuals such as intelligence and social support (Asarnow &
Asarnow, 1996). This model represents an enhanced diathesis-stress
framework and seeks to unite the disparate theories regarding the developmental
etiology of schizophrenia.
Asarnow & Asarnow (1996) put schizophrenia
into historical context by describing the changes in its diagnostic criteria.
Various etiological models (biological, neurodevelopmental, psychosocial)
are prefaced with epidemiological information in order for the readers
to appreciate the significant impact of this disorder on child development.
The vulnerability-stress model is detailed in a transactional framework
to account for the effects of genetic factors, environmental stressors,
and psychosocial stress in the development of schizophrenia. Gooding &
Iacono (1995) provide a very comprehensive review of neurobiological and
psychosocial factors in schizophrenia that is evident at various stages
of child development. Information related to comorbidity and various
empirical methods in studying schizophrenia are discussed. The chapter
is written in a transactional perspective that accounts for the confluence
and dynamics between individuals and their environment.
High-risk studies have been somewhat effective
in examining these gene-environment dynamics. Such studies, for example,
have shown that having a mother with schizophrenia increases an individual’s
risk for childhood-onset schizophrenia (Olin & Mednick, 1996). In addition
to genetically predisposing their children to this disease, schizophrenia,
mothers with schizophrenia have been found to provide a poorer environment
with less stimulation and emotional involvement for their children. This
sub-optimal environment may lead to behavior on the part of the child that
is stressful for the mother which increases her poor parenting and so on.
II. DEVELOPMENTAL PERSPECTIVE
The developmental perspective considers the
transactions between the individual and his/her environment across the
life span. It acknowledges and appreciates both transient and enduring
changes within the life space of individuals, which can influence the etiology,
diagnosis, onset, course, features, and prognosis of pathology. For
example, a child may not formally meet the diagnostic criteria for schizophrenia
due to developmental immaturity to manifest positive symptoms. Therefore,
it is important to account for developmental changes in the study of childhood-onset
schizophrenia.
Depending on the developmental phase of the child,
the signs for schizophrenia differ. During infancy, risks for schizophrenia
may be indicated by pandevelopmental retardation, which includes underactivity,
language abnormalities or delays, hypotonia, and lack of social responsiveness
(Gooding & Iacono, 1995). During early childhood when social
bonding becomes more prevalent and emotional expression becomes more sophisticated
in normal children, schizophrenic children may show inappropriate clinging,
extreme mood liability, and rage reactions. As these children move
into middle childhood and adolescence, neurological and cognitive deficits
may become more apparent as they face greater social and cognitive demands
at school as well as maturational changes in their physiology and chemistry.
Formal thought disorder and flat or inappropriate affect may emerge (Asarnow,
Asarnow, Hornstein, & Russell,1991). These shifts in clinical
features are accompanied by numerous neurophysiological changes within
the individual as a result of the dynamic interaction between the individual
and the environment over time. Thus, the developmental perspective
allows researchers to examine the dynamics and variations of the individual
in a comprehensive way.
Murray and Fearon (1999) present a "trajectory of increasing deviance"
explanation of this model. They suggest that an individual experiencing
an anxious personality and cognitive difficulties with an underlying abnormality
of neural networks risks increasing academic and social difficulties. Resulting
difficulties could lead to social adversity or drug use (attributable risk
factors of onset) and eventually onset of schizophrenia.
I. ASSESSMENT
Assessment of childhood-onset schizophrenia
is essential to differentiating the disorder from a pervasive developmental
disorder. Prior to the third edition of the Diagnostic and Statistical
Manual of Mental Disorders (DSM-III; American Psychiatric Association,
1980), children that were diagnosed with schizophrenia included those with
a heterogeneous group of developmental disorders (Asarnow & Asarnow,
1996). DSM-III introduced specific criteria for making diagnostic determinations
(which are essentially the same criteria that are used for adults; Nicolson,
Lenane, Hamburger, Fernandez, Bedwell, & Rapoport, 2000). This format
lent itself to the development of structured interview instruments (e.g.,
Diagnostic Interview for Children and Adolescents) that yielded yes or
no answers regarding the presence or absence of specific diagnostic criteria
(Achenbach, 1998).
In its current state the diagnosis of the
disorder is difficult and controversial. In fact, it is often misdiagnosed
by clinicians due to its rarity, unspecified criteria for diagnosis in
children, and overlap with other childhood psychiatric conditions (Knowlton,
1995). The following factors have been identified as possible aids in the
diagnosis but do not confirm it: developmental background, genetic and
family history, current stress factors for the affected individual, level
of functioning prior to illness, course of illness, and response to therapy.
Additionally CT scans of the head, or more recently magnetic resonance
imaging (Eliez & Reiss, 2000), may reveal enlarged ventricles in the
brain, however these are not routinely done (Lott, 1999). These factors
have all been linked to risk factors of the disorder. (http://health.yahoo.com/health/Diseases_and_Conditions/Disease_Feed_Data/Schizophrenia/,
2000). It may be particularly important to look at pre-morbid development
as, in an ongoing NIMH study, nearly all of the children with childhood-onset
schizophrenia had demonstrated some neurodevelopmental abnormalities well
before the onset of psychosis (Lott, 1999).
Since publication of the fourth edition of
the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American
Psychiatric Association, 1994), few studies have been conducted regarding
the diagnosis of childhood-onset schizophrenia. A review of the literature
produced few articles specifically related to the topic of assessments
and diagnosis of schizophrenia. Kaufman et al. (1997) investigated the
most widely used diagnostic tool, the Schedule for Affective Disorders
and Schizophrenia for School-Age Children-Present and Lifetime Version
(K-SADS-PL). The K-SADS-PL is an interview instrument that surveys the
existence of both past and current symptoms in children. Once information
is collected, the K-SADS-PL generates diagnoses according to DSM-IV criteria.
According to Kaufman et al. (1997), the K-SADS-PL is a highly reliable
instrument. A follow-up study (Ambrosini, 2000) of various versions of
the instrument (including the K-SADS-PL) outlined the historical development,
reliability, validity, administrative characteristics, and uses of the
K-SADS. Findings suggest that the K-SADS is a useful tool for assessing
the current, past, and lifetime diagnostic status in children and adolescents.
"It has the potential to further aid in the validation of psychiatric disorders"
(Ambrosini, 2000, p. ??)."
Another relatively recent report focused on
an instrument that has traditionally assessed symptom severity in adult
psychiatric populations. The Positive and Negative Syndrome Scale (PANSS)
assesses a wide variety of symptoms associated with psychotic disorders.
In 1994, this instrument was modified for use with children (Fields, Grochowski,
Lindenmayer, Kay, Grosz, Hyman, & Alexander, 1994). In their
report, they demonstrated that their efforts have resulted in a valid and
reliable instrument that can successfully differentiate individuals with
schizophrenia from those with other psychotic disorders.
II. DEVELOPMENTAL PERSPECTIVE
Diagnosing the cardinal features of schizophrenia
(e.g., hallucinations, and delusions) is extremely difficult prior to the
age of seven. Asarnow notes that using the same criteria to assess both
adults and children "may mask developmental trends" (Asarnow & Asarnow,
1996). The difficulty in making accurate diagnoses is highlighted in a
report by Jacobsen and Rapoport (1998). In a detailed screening of children
referred to the National Institute of Mental Health (NIMH) with a diagnosis
of schizophrenia, only 38 out of 168 cases reviewed met all criteria for
schizophrenia.
It is especially important for diagnosticians to consider a child's
development when assessing the presence or absence of the diagnostic criteria
for schizophrenia. While observing an adult talking incessantly to him
or herself may indicate hallucinations, a similar observation with a child
may merely be an indication that the child was engaged in imaginative play,
particularly if the child was young (e.g., 5 years old). The same would
be true for an imaginary friend – that is, it would be typical for a child,
but unusual for an adult. As can be seen, taking the developmental level
of the individual into consideration is necessary in making the distinction
between "typical" and "atypical."
The importance of an early diagnosis is noted by Bedwell and colleagues
(1999). In a study conducted with 31 children having childhood-onset schizophrenia
between the ages of 6 and 18 to determine if a postpsychotic decline in
full-scale IQ during adolescence was due to a dementing process or a failure
to acquire new skills, the authors concluded that decline in full scale
IQ in patients with childhood-onset of the disorder was due to an inability
to acquire new information and skills.
III. OPTIMAL ASSESSMENT STRATEGY
Given the difficulties noted above and the
report by Jacobsen and Rapoport (1998), it is clear that no single instrument
has been very successful at assessing the diagnosis or symptoms of schizophrenia
in children across raters. To assess the diagnosis, symptoms, and accompanying
sequelae of childhood-onset schizophrenia, one study used seven separate
instruments as well as in-depth reviews of psychiatric history, and psychological
and school reports (Alaghband-Rad, Hamburger, Giedd, Frazier, & Rapoport,
1997). This highlights the need to take a comprehensive view when assessing
the diagnosis and symptoms of childhood-onset schizophrenia.
Another study (Davidson et al., 1999) investigated
whether subtle behavioral and intellectual abnormalities can predict vulnerability
for schizophrenia before the first psychotic manifestation. This study
looked at 509 patients identified in the National Psychiatric Hospitalization
Registry (16-17 year-old males) compared to a matched sample of non-patients.
The study showed that healthy male adolescents who were later hospitalized
for schizophrenia had significantly lower test scores on all measures than
adolescents not reported to the National Psychiatric Registry. It was determined
that the strongest predictors for schizophrenia were deficits in social
functioning, organizational ability, and intellectual functioning.
A more recent strategy has been the attempt to identify pre-morbid
indicators of schizophrenia such as family psychiatric history, obstetric
complications, neurological abnormalities, early separation and institutionalization,
and family functioning in children at high risk for development of the
disorder (Olin & Mednick, 1996). The advantage of this assessment strategy
is the ability to target individuals for primary prevention.
Transactional models fit the strategy of taking
comprehensive views of the individual. The transactional model most closely
associated with schizophrenia is the vulnerability-stress model. As Asarnow
and Asarnow (1996) describe, the vulnerability-stress model "...emphasizes
the joint contribution of genetic predisposition and stressful life events
to the development and recurrence of schizophrenia" (p. ??). It appears
that without accepting such a model, identification and understanding of
schizophrenia will likely be incomplete.
IV. ASSESSMENT REFERENCES
Diagnostic Interview for Children and Adolescents (DICA)
Achenbach, T., 1998 Reich, W., 2000
Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present
and Lifetime Version (K-SADS-PL). Kaufman, J. et al., 1997Ambrosini, P.
J., 2000
Positive and Negative Syndrome Scale (PANSS) Fields, J. H., Grochowski,
S., Lindenmayer, J. P., Kay, S.R., Grosz, D, Hyman, R.B., & Alexander,
G., 1994
I. TREATMENT
Treatment refers to those methods employed to attempt to alleviate the symptoms associated with a given disorder. Currently, the most widely used and most effective treatment for schizophrenia is the administration of antipsychotic medication along with various forms of psychosocial interventions and education such as skills training and family therapy (American Psychiatric Association, 1997). When dealing with childhood onset of the disorder, Clark & Lewis (1998) suggested a similar multi modal approach, one that includes pharmacotherapies, cognitive strategies, family interventions, and environmental manipulations.
II. PHARMACOLOGICAL TREATMENT
Most of the evidence of drug treatments for COS has been taken from studies of adults (Clark & Lewis, 1998; Campbell & Cueva, 1995). However, various neuroleptics, similar to those prescribed for adult-onset schizophrenia, have been used in the treatment of childhood-onset schizophrenia. These include such conventional antipsychotic medications as phenothiazines, butyrophenones, thioxanthenes, dibenzoxazepines, and dihydroindolones, which block dopamine D2 receptors in the mesolimbic system (Dixon, Lehman, & Levine, 1995). Anedotal reports generally suggest that they are less effective in children than in adults with schizophrenia and have such side effects as tardive dyskinesia, rigid posture, and motor restlessness (Gordon, et. al., 1994; Wicks-Nelson & Israel, 1997). Recently, an atypical antipsychotic drug, clozapine, has shown some promise in the treatment of childhood-onset schizophrenia. It interacts complexly with both serotonin and dopamine and alleviates both positive and negative symptoms. It has a different set of possible side effects, however, including fatigue, orthostatic hypotension, constipation, sialorrhoea, and agranulocytosis (Turetz, Mozes, Toren, Chernarzan, Yoran-Hegesh, Mester, Wittenberg, Tyano, & Weizman, 1997). A recent open label study of another new antipsychotic, olanzapine, has demonstrated effects similar to those seen with clozapine (Kumra, Jacobsen, Lenane, Frazier, Smith, Bedwell, Lee, Malanga & Hamburger, 1998). This finding is significant because agranulocytosis has not been reported with olanzapine monotherapy. Due to the dearth of controlled studies, the efficacy of these neuroleptics is yet to be determined empirically.
III. DEVELOPMENTAL PERSPECTIVE
Despite evidence indicating that childhood-onset
schizophrenia is similar to the adult-onset type in many ways, the unique
developmental challenges of children and adolescents can affect the quality,
quantity, frequency, intensity, and significance of various schizophrenic
symptoms. For example, Remschmidt & Schulz (1995) indicated that there
might be differences between adult and children neurotransmitters-receptor
sensitivities. Therefore, therapists and researchers must be sensitive
to relevant developmental features in their design of treatment. Since
research on childhood-onset schizophrenia did not begin until the last
decade, treatments were mostly borrowed from our knowledge of adult-onset
schizophrenia. While COS and AOS have many commonalities, a plan
of treatment must take into consideration children's distinct biological
composition and psychosocial experiences.
Pharmacological treatments have traditionally
used the same medications as those prescribed among adults. Additionally,
psychosocial treatments have followed the adult models and mainly focused
on rehabilitation and management of the disorder. Despite the widespread
use of these treatment approaches, controlled treatment efficacy studies
are lacking. Researchers are only beginning to refine their methodology
in determining the optimal dosage and in understanding the biochemical
reactions among children and adolescents. Treatments must account for patients'
developmental context, which includes neurobiological and cognitive maturity,
psychosocial skill acquisition, and available social networks. The
involvement of the family may be particularly important among young patients.
Family intervention treatments have been noted as effective and useful
in treatment of adult onset schizophrenia (American Psychiatric Association,
1997; Frances et, al 1996). In childhood-onset schizophrenia, the
application of family interventions has been suggested (Clark & Lewis
1998) because of the increased communication and support provided. Research
in support of family interventions of childhood-onset schizophrenia has
been scarce. At any rate, without developmental considerations, treatments
cannot achieve their desired effectiveness, and the disorder can further
disrupt children's overall growth. Individual psychological therapies have
also been employed with adults. These would include social skills training,
cognitive behavioral approaches, and vocational rehabilitation (Clark &
Lewis 1998). Clark & Lewis (1998) suggest the application of similar
techniques to children. These would include questions of existential (meaning
and identity), bereavement (loss of health, opportunity, and the future),
and psychoeducational (knowledge of the illness and treatment options)
issues.
IV. OPTIMAL TREATMENT
The optimal treatment for schizophrenia,
according to Remschmidt & Martin (2000), should integrate five specific
components into a comprehensive treatment plan: (1) pharmacologic treatment
of acute psychosis; (2) pharmacologic prevention of relapse; (3) psychotherapy;
(4) family intervention; and (5) rehabilitative measures.
While there is a scarity of data addressing
psychopharmacologic treatment for children (Dulmus & Smyth, 2000),
current studies suggest the use of standard antipsychotics such as haloperidol
(Haldol) or fluphenazine (Prolixin), or newer antipsychotics such as risperdone
(Risperdal) or clozapine (Clozaril) may be most effective. However, most
individuals will require several trials to find the medication or combination
of medications which best suits their needs. Once psychotic symptoms have
been controlled, medication must be maintained to reduce the risk of relapse
(Dulmus & Smyth, 2000).
Psychotherapy, in the form of social skills
training, for example, is a necessary component for the optimal treatment
of COS (Dulmus & Smyth, 2000). Although no controlled studies of psychotherapeutic
treatment for COS have been reported in the literature, it has been shown
to be successful with individuals with AOS and would seem to be especially
needed for COS patients as they may not acquire the necessary social skills
due to their illness. In studies with adults, social skills training has
been shown to improve loudness, fluency, affect, eye contact, assertiveness,
grooming and hygiene, self management, coping, conversational skills, participation
in activities, and social adjustment. It has also been shown to decrease
relapses.
Family interventions in the form of psychosocial
education, behavioral problem solving, support for individuals and families,
and ongoing crisis management has also been shown to be effective in preventing
relapse. Used in conjunction with antipsychotic medication, a treatment
that includes an educational and supportive family therapy appears to be
most effective means for meeting the needs of individuals diagnosed with
schizophrenia. Dulmus & Smyth (2000) recommend a three-part family
intervention plan which includes (1) education addressing the etiology,
symptoms, course, and management of the illness; (2) training in problem
solving; and (3) training in communication skills.
While not currently addressed in the treatment
of COS, rehabilitation is needed for many sufferers of COS subsequent to
the abatement of their acute symptoms. In a 12-year follow-up study of
96 patients treated for early-onset schizophrenia, 57% were found to be
somewhat impaired with respect to their educational and occupational goals
and 75% were financially dependent on either their parents or public assistance
(Lay, Blanz, Hartmann, & Schmidt, 2000).
V. IN SUMMARY
Childhood schizophrenia is a complex
and difficult disorder. Although there appears to be a strong genetic and
biological link to the development of schizophrenia, there also appear
to be multiple factors that contribute to the ultimate development of schizophrenic
symptoms. The diverse features of schizophrenia suggest that the disorder
has multiple etiologies and various biological, psychosocial, and environmental
factors interact in dynamic ways, creating an interplay of vulnerabilities
and challenges which can lead to the development of the disorder (Gooding,
D. C., & Iacono, W. G. ,1995). Explanations for the disorder appear
to fit a transactional model rather than a single “cause.”
The disorder itself can be devastating to
individuals and families when it manifests itself at any age. However,
childhood-onset schizophrenia may represent a more severe variant of later
onset adult schizophrenia and may have a more severe and lifelong course
as well. Sparse empirical evidence is available for the assessment and
treatment of childhood-onset schizophrenia. This is most likely due to
the relative rarity (.14 in 1000) of the disorder in children. However,
current treatments focus on antipsychotic medication in conjunction with
supportive family interventions and psychosocial education.
The developmental perspective considers the transactions between an
individual and his or her environment across the life span. This perspective
allows for an examination of the dynamics and variations of a disorder
in a comprehensive way. From a developmental perspective, it can be difficult
to distinguish childhood schizophrenia from normal developmental fantasy,
and a diagnosis of childhood schizophrenia prior to age seven is rare.
VI. WEBSITES
Top 10 Websites
(1) Internet Mental Health (IMH: www.mentalhealth.com)
http://www.mentalhealth.com/book/p40-sc01.html#Head_6
This is a comprehensive site that could be of the utmost help to families
concerned with schizophrenia. It covers everything from the stigma of schizophrenia
to crisis intervention to handling the patient’s return to home. Although
it is not specific to childhood-onset schizophrenia, it should be helpful
to any family coping with the devastating effects of schizophrenia.
(2) The Schizophrenia Home Page – A Not-for-Profit Information, Support,
and Information Center
http://www.schizophrenia.com/research/research.html
I particularly like this site because of the different languages available
(English, French, and Spanish). Another appeal of this site is the fact
that it has information for laypeople as well as professionals. In fact,
this site has a little something for everyone, including parents, offspring,
spouses, and siblings of people with schizophrenia.
(3) Schizophrenics Anonymous, The National Schizophrenia Association
http://www.sanonymous.org/
I picked this website as one of the top 10 because of its usefulness
to people with schizophrenia. Reading about a program that is run by people
like themselves will provide people with hope where they may otherwise
feel hopeless. I can imagine that it would increase people’s self-efficacy
to believe that they could somehow affect the outcome of their disease.
(4) National Institute of Mental Health
http://www.nimh.nih.gov/
Parents who are interested in having their children participate in
clinical trials will find this a useful site. It would be especially useful
for parents who are frustrated because they may not be getting help through
traditional treatment. It would allow them to participate in trials with
the most current treatments available.
(5) The Merck Manual of Diagnosis and Therapy
http://www.merck.com/pubs/mmanual/section19/chapter274/274b.htm
Even though this site is sponsored by a pharmaceutical company, it
is helpful in that it distinguishes between symptoms of different childhood
disorders. This is particularly important for parents struggling with diagnostic
problems. It also provides treatment information for each disorder.
(6) NAMI – The Nation’s Voice on Mental Illness
http://www.nami.org/youth/skzphrn.htm
This may be my favorite site for the reasons I stated previously, namely
the kids’ newsletter. There really don’t seem to be many sites that are
directed towards children who need/want information about schizophrenia.
This newsletter is for families and, as long as they gear it towards children
(or at least make it so that the parents can explain it to them), it should
be very useful.
(7) Schizophrenia - Questions And Answers National Institute of Mental
Health
http://www.hoptechno.com/book39.htm
Again, this is a good all-purpose site that has a broad range of issues
concerning schizophrenia. It addresses schizophrenia in general and then
specifically childhood-onset schizophrenia. I particularly liked the way
it addressed the heritability issue of schizophrenia and whether or not
the parents are at fault.
(8) WWW.Health-Center.com
This site is loaded with information about all sorts of childhood disorders.
It has a search function and when I entered “schizophrenia,” it returned
more than 50 pages including genetics, treatment, and facts and fiction
about schizophrenia.
(9) The Schizophrenia and Other Psychotic Disorders Home Page
http://www.mhsource.com/schizophrenia/index.html
This site is primarily for healthcare professionals. I think it is
a good one because it offers a lot of different information. There are
links to clinical research, outcomes, case studies, solutions for treatment
teams, and even multimedia information. Although this is a site for professionals,
it also has a link for patient and caregiver support.
(10) National Schizophrenia Fellowship: Your guide to severe mental
illness
http://www.nsf.org.uk/
This is an excellent site with many useful links. The subtitle of this
page is “for everyone who wants to know more, from carers and users to
professionals.” Although I’m not really sure what they mean by “users,”
anyone who is interested in schizophrenia could be helped by this site.
The fastfind feature is especially nice. When I put in “childhood onset,”
it gave me 9 references.
Other Websites of Interest
The Doctors Guide To The Internet
http://www.pslgroup.com/SCHIZOPHR.HTM
Site contains medical news and alerts, general schizophrenia information,
and discussion and newsgroups. The site also provides current research
findings in cause, treatment and other medical news related to schizophrenia.
WWW.Health-Center.com
Health-Center.com is reported as a physician-owned company and is "dedicated
to delivering high quality interactive health experience via the Internet."
A large portion of the site is dedicated to schizophrenia (http://site.health-center.com/brain/schizophrenia/default.htm)
The site is very complete in that it answers questions of what schizophrenia
is by including facts and fictions of the disorder. It looks at the possible
risk factors such genetics, brain chemistry and brain imaging, its symptoms
and complications to the individual and family, dealing with the disorder,
its progression and treatments of the disorder. The treatment section gives
a description of several effective medications with possible side affects.
The site gives a good oversight to the disorder.
Schizophrenia - Questions And Answers National Institute of Mental Health
http://www.hoptechno.com/book39.htm
This site presents questions that are important to anyone who wants
to learn about schizophrenia. Examples include, "What is it?", and " Can
Children Be Schizophrenic?". The answers are provided by some of the leading
authorities in the field. An excellent site to visit if you want to learn
about schizophrenia.
Mayo Clinic: Schizophrenia
http://www.mayohealth.org/mayo/9801/htm/schizophrenia.htm
This site provides a brief report on what is known about schizophrenia.
It includes descriptions of positive and negative symptoms, and important
distinctions (e.g., it's not multiple personality). It briefly describes
treatment resistance and highlights some of the new antipsychotic drugs
now on the market. Finally, the site provides useful links to other important
mental health sites.
Internet Mental Health (IMH: www.mentalhealth.com)
http://www.mentalhealth.com/book/p40-sc01.html#Head_6
This site is truly a handbook! It covers topics from "What is schizophenia"
to "Research findings of interest". The site includes specific "chapters"
on diagnosis and assessment of positive and negative symptoms. This site
should provide answers to most of the most common questions regarding schizophrenia.
http://www.mentalhealth.com/book/p40-sc01.html#Head_8
Part of the IMH site, this section provides a brief history of the
diagnosis as identified in the revisions of the Diagnostic and Statistical
Manual of Mental Disorders. Also provides advocacy information and a brief
description of the process of diagnosis. The information would be useful
because it gives a non-technical introduction to the assessment process.
http://www.hoptechno.com/book39.htm
Another section of the IMH site provides a preliminary online diagnosis
questionnaire. The visitor is cautioned that accurate psychiatric diagnosis
requires a full physical examination and a full diagnostic interview conducted
by a mental health professional "who is fully trained in mental health
diagnosis, and who has sufficient knowledge of medicine to recognize when
the symptoms of a mental disorder are due to physical causes." And that
"This program is an aid to diagnosis and is not a substitute for expert
clinical judgment by a licensed mental health professional." The program
asks for responses to a series of questions concerning delusions, hallucinations,
and emotional expression.
http://www.mentalhealth.com/dx/fdx-ps01.html
The Prodromal Phase of First-episode Psychosis: Past and Current Conceptualizations
This section of the site is a an article originally printed in the
Schizophrenia Bulletin (Schizophrenia Bulletin, 22(2): 353-370, 1996) and
suggests that the initial prodrome (the prepsychotic period preceding the
first onset of a psychotic illness) "in psychosis is potentially important
for early intervention, identification of biological markers, and understanding
the process of becoming psychotic." The article proposes the hybrid/interactive
model of pre psychosis. Also advises the need for a more systematic evaluation
of the prodromal phase in first-episode psychosis.
The Schizophrenia and Other Psychotic Disorders Home Page
(http://www.mhsource.com/schizophrenia/index.html)
Site includes practical information for healthcare professionals. The
visitor is presented with links to clinical research information, patient
outcomes, case studies, solutions for treatment teams, and general epidemiological
information. This general information link The following: frequently
asked questions about schizophrenia, NAMI consumer and family guide to
schizophrenia treatment, National Alliance for the Mentally Ill (NAMI)
schizophrenia resources, NAMI Self-education: living with schizophrenia,
schizophrenia (CAMI's Journal(California Alliance for the Mentally Ill),
schizophrenia (NIMH), schizophrenia in children, a schizophrenia fact sheet
and resources to promote the understanding schizophrenia.
Schizophrenia: The Rationale for Early Detection and Intervention
- Schizophrenia.com
http://www.schizophrenia.com/news/earlydet.html
This site reports the urging of Orna Guralnik, Psy.D. for early detection
and intervention of schizophrenia. Early detection and intervention improves
prognosis, and in the case of children, lessens the developmental impact
of schizophrenia. An important site to review to appreciate the issues
involved with this important topic.
Neurobiological Disorders in Children and Adolescents
The Schizophrenia Home Page – A Not-for-Profit Information, Support,
and Information Center
http://www.schizophrenia.com/research/research.html
Includes discussion and chat areas in English, French, and Spanish
for, e.g., parents and siblings of people with schizophrenia. Also includes
basic schizophrenia information, including sections on causes, diagnoses,
medications, success stories, support groups, managing depression and preventing
suicide. Although this site appears to be primarily targeted towards lay
people, it also has a section for in-depth schizophrenia information for
researchers and professionals.
Childhood Onset Schizophrenia
http://ac.marywood.edu/thaler/www/
This site has areas for Definition, History, Diagnosis, Statistics,
Causes, Outcomes, Treatment, Family Support, and Links. Although the information
on this website is general in scope, it appears to be fairly up-to-date.
The page author, Tiffany Thaler, provides an e-mail address at Marywood
University but otherwise fails to identify herself or her credentials for
posting such a site.
Schizophrenics Anonymous, The National Schizophrenia Association
http://www.sanonymous.org/
This is the website for Schizophrenics Anonymous, a self-help organization
based on the concept of programs such as Alcoholics Anonymous. The site
details their “6-steps for recovery.” As they say in their mission statement,
their purpose is “To educate the public at-large about schizophrenia-related
disorders, foster the development and maintenance of support groups for
those affected and their loved ones, provide an information clearinghouse/network
for persons seeking assistance, provide early detection and the availability
of adequate on-going treatment interventions, and to promote research regarding
the understanding and treatment of schizophrenia.”
National Institute of Mental Health
http://www.nimh.nih.gov/
While this website is not specific to childhood-onset schizophrenia,
it has a section, Clinical Trials, where you enter the disorder in which
you are interested to find out if there are currently clinical research
studies for which NIMH is recruiting. Another useful function of this website
is the Publications section where “researchers, mental health and health
care practitioners, patients, and the general public” can order material
on a variety of mental disorders (some of which are published in Spanish).
Seems to be a good source of reliable information.
The Merck Manual of Diagnosis and Therapy
http://www.merck.com/pubs/mmanual/section19/chapter274/274b.htm
What I particularly liked about this site was the differentiation between
Autism, Childhood-Onset Pervasive Developmental Disorder, Childhood Disintegrative
Disorder, and Childhood Schizophrenia. From reading postings on other websites,
it appears that diagnosticians often have difficulty, according to parents,
in differentiating between some of these disorders which often present
with similar symptoms. However, since Merck is a pharmaceutial company,
I would need to feel sure of their objectivity in approaching treatment
options.
National Schizophrenia Fellowship: Your guide to severe mental illness
http://www.nsf.org.uk/
On this site, if you click on “fastfind” in the bottom left-hand corner,
you are taken to a search page where you can enter schizophrenia or childhood-onset
schizophrenia. The ensuing display features 219 references on a variety
of subjects related to both adult- and childhood-onset schizophrenia. Although
this organization is based in England, there are references here that would
be helpful to anyone interested in diagnosis, treatment, or support.
The Experience of Schizophrenia: Ian Chovil’s Homepage
http://www.chovil.com/index.html#2
This is the website of a 46-year-old Canadian man with schizophrenia.
I found this to be a very interesting and informative site. The author
not only tells his personal story but also has pages devoted to medication
and family and social support as well as charts and graphs illustrating
the relative prevalence, symptoms, and prognosis of schizophrenia.
Medline Plus Health Information (A service of the National Library of
Medicine)
http://www.nlm.nih.gov/medlineplus/schizophrenia.html
This is an NIH (National Institutes of Health) website which contains
many links to information about schizophrenia. It is extremely well maintained
with up-to-date links including articles publications of 2/9/01 and 2/14/01.
Other links can be found to NIMH (National Institutes of Mental Health),
National Mental Health Association, and World Fellowship for Schizophrenia
and Allied Disorders, including their pamphlet entitled “Schizophrenia:
First Warning Signs.”
NAMI – The Nation’s Voice on Mental Illness
http://www.nami.org/youth/skzphrn.htm
This particular website focuses on child and adolescent mental illnesses
of all kinds. It covers such areas as Support, Education, Advocacy, and
Research. What I like best about this site is the newsletter for kids,
“Because Kids Grow Up: NAMI News – for families touched by childhood-onset
brain disorders (mental illnesses) and professionals who care.” It appears
to be a great resource for parents and children. In the current issue,
in fact, there was an article on COS.
Online Clinic -- Childhood Schizophrenia: Prevalence, Treatment, &
Educational Management
http://www.online-clinic.com/Disorders/childhood_schizophrenia.html
This is a site maintained by Larry Burd, PhD., of the North Dakota
School of Medicine. Dr. Burd is the Director of the North Dakota Fetal
Alcohol Syndrome Center and the Director of the Division of Developmental
Epidemiology for the School of Medicine in the Departments of Neuroscience
and Pediatrics. This site provides information on Dr. Burd's research,
referral of patients, seminars, and ordering of materials
What distinguishes autism from schizophrenia?
http://www.unl.edu/tcweb/pharm/class96/con.cka.autism.schizo.dif.html
This is a 1-page site that differentiates symptoms of autism and childhood-onset
schizophrenia. Although it is a simple site, it addresses an important
concern of parents who may be worried about something being wrong with
their child.
Mental Health Links -- Schizophrenia
http://virtualsocialwork.co.uk/links/mental/meschiz.htm
This website has a list of links to other sites about schizophrenia.
Although it is not specific to childhood-onset schizophrenia, it is a good
resource to direct people interested in the general topic.
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