Child and adolescent onset schizophrenia
Schizophrenia is one of the most devastating psychiatric disorders to affect children and adolescents. Although extremely rare before the age of 10, the incidence of schizophrenia rises steadily through adolescence to reach its peak in early adult life.
An accumulating body of evidence now supports the view that schizophrenia in childhood and adolescence shows continuity with the adult form of the disorder at the levels of symptoms, clinical course and underlying neurobiology. Like other disorders of presumed multifactorial origin (e.g. juvenile rheumatoid arthritis and diabetes), the early onset form of schizophrenia appears to lie at the extreme end of a continuum of disease severity and genetic liability.
This section focuses on the similarities and differences, from both a clinical and neurobiological perspective, between child and adolescent onset schizophrenia and the adult form of the disorder. Special attention will be given to the following topics.
First, the historical development of the concept of schizophrenia in children and adolescents. Secondly, the clinical issues relating to the recognition, differential diagnosis and management of child and adolescent onset schizophrenia. Thirdly, the evidence from clinical and neurobiological studies for continuity between the childhood and adult onset forms of the disorder. Fourthly, the possible mechanisms and timing of events in brain development that may be responsible for the onset of schizophrenia in children and adolescents.
Evolution of the concept of schizophrenia in childhood and adolescence
Both Kraepelin and Bleuler believed that schizophrenia presented in a similar form, albeit more rarely, during childhood and adolescence. Kraepelin (1919) found that 3.5% of cases of dementia praecox began before the age of 10, with a further 2.7% arising between the ages of 10 and 15. Kraepelin also remarked that these childhood onset cases frequently had an insidious onset. Bleuler (1911/1950) suggested that about 5% of cases of schizophrenia had their onset prior to age 15. De Sanctis (1906) described a group of young children who exhibited catatonia, stereotopies, negativism, echolalia and emotional bluntening. De Sanctis viewed this condition as an early onset form of Kraepelin’s dementia praecox, and coined the term ‘dementia praecoccissima’. The twentieth century saw a shifting debate about how best to categorize schizophrenia in childhood.
The expansion and contraction of the concept of schizophrenia in childhood closely mirrored a similar debate concerning the boundaries of the adult form of the disorder. It also echoed the debate about how best to conceptualize and define depression in childhood, with the idea of age-specific symptomatology (developmental heterotypy) competing with the idea of applying unmodified adult diagnostic criteria to children (developmental homotypy).
During the first third of the twentieth century the views of Kraepelin, Bleuler and De Sanctis held sway. During this period, schizophrenia in children and adults was seen as essentially the same disorder with a broadly similar clinical presentation. In the 1930s, however, coinciding with the emergence of child psychiatry as a separate discipline, an alternative ‘unitary’ view of childhood psychoses was proposed which conflated the present day concepts of autism, schizophrenia, schizotypal and borderline personality disorder (Potter 1933; Fish & Rivito 1979).
This broad definition of ‘childhood schizophrenia’ dominated the second third of the twentieth century. From the mid-1930s until the 1970s the concepts of autism and childhood schizophrenia were synonymous, with autism and other developmental disorders viewed as early manifestations of adult schizophrenia. This perspective was endorsed by DSM-II and ICD-8 which grouped all childhood onset psychoses, including autism, under a separate category of ‘childhood schizophrenia’.
The ‘unitary’ view of childhood psychoses was challenged in the 1970s, following the landmark studies of Kolvin (1971) and Rutter (1972) who demonstrated that autism and childhood onset schizophrenia could be distinguished in terms of age at onset, phenomenology and family history. This led to the differentiation of adult-type schizophrenia with childhood onset from autism. Hence, in the last third of the twentieth century, the pendulum swung back to the view that schizophrenia in children and adolescents should be defined using unmodified adult diagnostic criteria (developmental homotypy). This view was endorsed by DSM-III (American Psychiatric Association 1980) and ICD-9 (World Health Organization 1978), and has been maintained in DSM-IV (American Psychiatric Association 1994) and ICD-10 ( World Health Organization 1992), with the removal of the separate category of ‘childhood schizophrenia’ and the application of the same diagnostic criteria at all ages.
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