Childhood Onset Schizophrenia

(((I am currently studying for a licensure exam & completing an internship.  This blog post is intended as a study exercise.  In it, I review information from papers I’ve written on childhood onset schizophrenia. It is not intended as a substitute for mental health counseling or diagnosis…)))

COS is characterized by an onset of psychosis prior to the age of thirteen (Khurana, et al, 2007). According to the DSM-5 Manual the characteristics of schizophrenia are identical in children and adults (American Psychiatric Association, 2013). However, while childhood-onset schizophrenia has a similar set of symptoms, its psychopathology is unique.   For this reason, it is much more difficult to diagnose. Hallucinations and delusions are often confused with fantasy play and difficult to distinguish from childish, idiosyncratic thinking (American Psychiatric Association, 2013; Khurana, et al, 2007). Disorganized cognition is often confused with autism or ADHD, and negative symptoms are frequently confused with bipolar disorder or developmental delay (Khurana, et al, 2007; Orvaschel, et al, 2001). Adding to this complexity is the fact that the onset of COS is gradual. Premorbid symptoms, such as minor neurological deficits, motor delays and social withdrawal are difficult to attribute to a clear cause for this reason (Khurana, et al, 2007).

Diagnostic Criteria

Criterion A for Schizophrenia requires the presence of delusions, hallucinations, and disorganized speech for at least one month (American Psychiatric Association, 2013).   Other criterion, include diminished functioning and continuous signs of disturbance for six months, including residual and prodromal periods (American Psychiatric Association, 2013). Due to the temporally specific criteria, longitudinal observation is critical for accurate diagnosis. Morrison’s (2014) diagnostic tree for psychosis suggests first ruling out medical diagnosis as an underlying cause for psychotic symptoms. Addressing neurocognitive deficits then requires considering developmental disorders or psychosis as an explanation (Morrison, 2014). The timing psychotic and depressive symptoms can then help differentiate a bipolar disorder and a psychotic disorder (Morrison, 2014). Finally, observing the length of time psychotic symptoms can be helpful when differentiating between the psychotic disorders (Morrison, 2014).

While the essential characteristics of schizophrenia are identical in children, developmental considerations make it more difficult to diagnose (American Psychiatric Association, 2013; Orvashel, et al, 2001). For example, hallucinations and delusions are often less complex, and need to be differentiated from imaginative and fantasy play (American Psychiatric Association, 2013; Orvashel, et al, 2001). Additionally, the DSM-5 manual cautions against attributing disorganized speech and thought to schizophrenia in children without first considering more common issues (American Psychiatric Association, 2013).  In order to account for these developmental differences, adjustments must be made to the process of diagnosis. For example, collaborative information from significant adults in the child’s life, are essential when assessing symptoms associated with this disorder (Patterson, et al, 2009). Additionally, a systems perspective can be helpful when considering the impact of the family situation on presenting symptomatology (Patterson, et al, 2009). Orvashel, et al, (2001) state that treatments must also be adapted to a child’s developmental needs. For example, psychosocial treatment methods can help address the effects of interpersonal relationship issues on adjustment and progression of schizophrenia (Orvashel, et al, 2001).   Additionally, these treatment methods might be helpful for child’s family who is trying to cope with the complex symptoms associated with this disorder (Orvashel, et al, 2001)

Assessment Considerations

Longtudinal Observation of Symptoms

The core issue of COS is an impaired reality testing ability, which produces many of the positive symptoms it is known for (Orvaschel, et al, 2001). As a severe form of schizophrenia with a guarded prognosis, COS is difficult diagnose without an understanding of childhood development and schizophrenic psychopathology.   The logic underlying this DSM-5 diagnosis is phenomenological and no clear cause has yet been determined (Velligan & Alphs, 2013). Instead, COS is a byproduct of an interaction between environmental stressors (i.e. dysfunctional family environments) with individual vulnerabilities (i.e. brain abnormality), (Patterson, et al, 2009).   Consequently, a judicious and longitudinal assessment of symptoms is critical which includes information from multiple sources (the school system, the family, and the child). Thorough medical and neuropsychological assessments are also important to rule out this as a cause for symptoms of psychosis.

Developmentally Appropriate Assessment

Assessment of COS requires an array of collaborative information and developmental considerations. Due to developmental deficits, young children will have difficulty verbalizing abstract verbal concepts. As a result, adjustments must be made throughout the assessment process (Orvaschel, et al, 2001). Caution should be taken when assessing delusions and hallucinations (Orvaschel, et al, 2001). Delusions tend to exceed the imaginative thinking common in child.   Instead they involve fixed and erroneous beliefs that are frequently terrifying, compelling suffers to engage in irrational behavior (Khurana, et al, 2007).   Additionally, while phobic hallucinations are common in anxiety-related disorders during childhood, the majority of children reporting hallucinations do not have COS (Khurana, et al, 2009; Orvashel, et al, 2001). Play therapy techniques can provide effective solutions to assessing disordered thinking. For example, one resource for this paper described a “Formal Thought Disorder Story Game” (Orvashel, et al, 2001, p419), as a useful assessment of this symptom. Negative symptomatology, (including blunted affect, anhedonia, lack of motivation, and depression) should also be monitored. Several resources for this article stated that suicide ideology is especially common in COS suffers (Khurana, et al, 2007; Velligan & Alphs, 2013

A Systems Perspective

Before concluding this paper, I feel it is important to briefly mention the importance of a System’s Perspective. Common in Marriage & Family Therapy, this theoretical viewpoint sees cause as a circular, rather than linear concept (Patterson, et al, 2007). Utilizing this perspective, a therapist is forced to ask how multiple systems affect the child’s presenting symptomatology (Patterson, et al, 2007).   How does the home environment affect the child? How are the school systems and child’s peer relationships, affecting their academic achievements? Asking questions such as these will require a strong collaborative relationship with the parents and the child so that all information can be gathered.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author
Greenstein, D., Kataria, R., Gochman, P., Dasgupta, A., Malley, J. D., Rapoport, J., & Gogtay. (2014). Looking for childhood-onset schizophrenia: Diagnostic algorithms for classifying children and adolescents with psychosis. Journal of child and adolescent psychopharmacology, 24(7), 366-373.
Khurana, A. (2007). Childhood-onset schizophrenia: Diagnostic and treatment challenges. Psychiatric times, 24(2), 33.
Morrison, J. (2014). Diagnosis made easier: Principles and techniques for mental health clinicians, 2nd ed. New York: Guilford Press.
Orvaschel, H., Faust, J., & Hersen, M. (Eds.). (2001). Handbook of conceptualization and treatment of child psychopathology. Oxford, UL: Elsevier LTD.
Patterson, J., Williams, L, Edwards, T., Chamow, L. & Grauf-Grounds, C. (2009). Essential Skills in Family Therapy: From the First Interview to Termination. New York: Guilford Press.
Velligan, D.I, & Alphs, L.D. (2013). Negative symptoms in schizophrenia: The importance of identification and treatment. Psychiatric Times, 30(5), 24-26.

 

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