Monday, February 22, 2010

Diagnosis of Early-Onset Schizophrenia

From MedscapeCME Psychiatry & Mental Health

Linmarie Sikich, MD 02/10/2010

Although schizophrenia is generally thought of as an adult disorder, it can occur in children and adolescents.
Indeed, the majority of cases of schizophrenia emerge when patients are between 15 and 25 years of age.
Early-onset schizophrenia appears to have a worse prognosis than schizophrenia emerging during adult years.
Although families often seek medical advice pertaining to behavioral symptoms of the disorder or its prodrome, clinicians frequently fail to recognize the illness and misdiagnose it as a more prevalent childhood disorder such as attention-deficit/hyperactivity disorder or oppositional defiant disorder because of the nonspecificity of early symptoms and developmental differences in reporting psychotic phenomena.
In addition, differential diagnosis often depends on a longitudinal perspective of the disorder that may be lacking during early stages of treatment.
These difficulties often lead to prolonged periods without treatment or with inadequate treatment.

In addition, there may be cases in which clinicians suspect schizophrenia but are reluctant to diagnose it because of fears about stigmatizing the child or demoralizing the child and family.
However, affected individuals and their families often feel frustrated because the child is not responding to the treatments provided. Ineffective treatments may lead to hopelessness and problems with long-term treatment adherence.

Delays in effective treatment appear to lead to worse prognosis, with higher rates of treatment resistance and greater functional impairment.
Because reductions in the duration of untreated psychosis in adults with schizophrenia have been repeatedly demonstrated to improve outcomes, enhancing the ability of clinicians to recognize and diagnose early-onset schizophrenia spectrum disorders is expected to lead to better outcomes, improve the quality of life of affected individuals, and reduce the tremendous societal and personal costs associated with treatment-resistant illness.

This article will review the diagnostic criteria, prevalence, and typical course of early-onset schizophrenia spectrum disorders in children and adolescents and discuss typical developmental variations in the presentation of symptoms and specific approaches to eliciting symptoms in children and adolescents. The suggested workup, differential diagnosis, and frequent comorbidities will be reviewed. Vignettes will illustrate key points.

Diagnostic Criteria for Early-Onset Schizophrenia Spectrum Disorders
Schizophrenia and schizoaffective disorder are diagnosed using the same Diagnostic and Statistical Manual of Mental Disorders -- Fourth Edition (DSM-IV)[7] criteria in pediatric and adult populations.
These criteria require the presence of 2 or more "characteristic symptoms" including:

Positive psychotic symptoms, such as
Disorganized speech;
Grossly disorganized behavior or catatonia; or
Negative symptoms. These reflect the absence of behaviors that are present in healthy individuals and include
Poverty of speech;
Limited thought content;
Failure to make choices (avolition);
Reduced or absent facial expressions (flat affect); or
Poor attention to activities of daily living such as personal hygiene.

In addition, the diagnostic process must confirm social and occupational dysfunction and it must exclude mood disorders, substance abuse, and general medical conditions. If a primary diagnosis of autism spectrum disorder exists, the diagnosis of schizophrenia must include clear hallucinations or delusions.
Symptoms must persist for 6 months in DSM-IV criteria or 1 month in International Statistical Classification of Diseases and Related Health Problems -- Tenth Edition (ICD-10) criteria. However, both classification systems allow nonspecific prodromal and residual symptoms to be included in the duration of symptoms.
Schizophrenia also includes persistent neurocognitive impairments in executive function (particularly working memory, cognitive flexibility, and problem-solving), memory, and general cognition that are likely to be given greater prominence in DSM-V.[8-10]

Schizoaffective disorder is distinguished from schizophrenia by the presence of significant affective symptoms for a significant proportion of the time.
Many clinicians only include symptoms of mania, although depression is highly prevalent in schizophrenia.
The diagnostic criteria for depression and bipolar disorder are also consistent between pediatric and adult populations.
The criteria for obsessive-compulsive disorder (OCD) are largely the same in adults and children, although the obsessions and compulsions are not required to be egodystonic in youth, which may increase confusion with schizophrenia spectrum disorders.

In addition to these well-established diagnostic criteria, there is increasing awareness that some children suffer from severe psychiatric disturbances that often involve odd language and social behavior, distortions of reality in response to specific environmental events and unpredictable behaviors, but do not clearly meet criteria for diagnosis of schizophrenia.

Such children have been proposed to have a unique disorder that has been termed "Multidimensionally Impaired Disorder"or "Multiple Complex Developmental Disorder."
Both overlap with severe mood dysregulation, except that severe mood dysregulation specifically excludes any psychotic symptoms.
There have been limited follow-up studies of such children and these have yielded somewhat discrepant results. A National Institutes of Mental Health group led by Judith Rapoport evaluated 26 pediatric patients (mean age,11.6 ± 2.7 years) and found that half of subjects followed up at 2-8 years were diagnosed with psychosis NOS, 3%-12% had schizoaffective disorder, 38% had bipolar disorder, 12% had major depression, and 15% were symptom-free.[15] A European group found that 78% of children with multiple complex developmental disorder examined as adolescents had symptoms that appeared prodromal for schizophrenia although none had yet been diagnosed with a schizophrenia spectrum disorder.

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