Juvenile-Onset Schizophrenia

When I was being trained, two decades ago, my professors in Psychiatry made it plain that childhood schizophrenia was not only rare, as far as they were concerned, it didn't exist at all.  Today, we accept most of this, but also acknowledge perhaps that the signs, if not the full-blown syndrome, can be present fairly early in life. As with the dementias, the older the patient at onset, the more the patient has.  Early onset schizophrenia is associated with a worse outcome, all things being equal.  The opposite of that is to recognize, understand and respond to the condition as early in the progression as possible.  Schizophrenia, as with other mental disorders, is polymorphic, and so the task of recognition, understanding and treatment is perilous.

Structuring such a book is not a simple task.  The editors have done it this way:

Carlson, Naz and Bromet conducted a 7 year study in first-episode schizophrenia and discuss the diagnostic issues: namely, to be thorough is to create workable diagnostic considerations that will influence treatment and outcomes, dealing (in 33 pages) with the recognition and treatment side of the dilemmas above.  To fill in the blanks with regard to neurobiological issues, Keshavan from Pittsburgh embarks on presenting a unifying hypothesis that relies on the actions of the glutamatergic systems to bring together the sometimes conflicting models that now exist. Glutamate is the endogenous excitatory mechanism of the brain, opposed largely by GABA, the endogenous inhibitor of the brain.  Dopamine, the much quoted biogenic amine of schizophrenia research, is under tonic excitatory control of both NMDA and AMPA or kainite control (all glutamatergic neurons) with regard to the prefrontal cortex, with mesolimbic tonic inhibitory control also under glutamatergic regulation.  By now, the educated will have got his drift, and begin to see how regulating dopamine excitatory mechanisms in the prefrontal cortex and dopamine inhibitory mechanism in the mesolimbic area might relate to the novel, dopamine regulating antipsychotic drugs, this especially the range of "goldilocks" drugs so endearing to Stephen Stahl and other psychopharmacologists.  White and Nelson continue the neurobiology slant in the next chapter, covering neurobiological development during childhood and adolescence, taking a rather deprecating view that the system goes from being highly inefficient to highly efficient along the way. What they are referring to is of course the brain's development strategy which is to create a host of arborized neuronal tissue, and then embark on phases of pruning back in an "if-you-don't-use-it-you-lose-it" series of events going on into early adulthood. They begin with the neural tube of organogenesis, through myelination and gyrification, focusing finally on the prefrontal cortex, and they are done in 18 pages.

Picking up on the developmental theme, Frangou, Hadjulis and Murray (from England, as the names suggest, and from the Maudsley investigations), look at genetic risks, at perinatal events and environmental influences in the emergence of the disorder as a phenotype.  This will include drugs, psychomotor and language issue, family interactions, and finishing off with cognitive factors, amongst others such as life events.

Imaging studies and neurophysiological testing dominate the next few chapters.  Schultz, one of the editors, together with DeOreo and Lamm start off with a neuroimaging chapter, probing, as Thompson has done, the wave of destruction that seems to accompany this condition.

Wozniak, White and Schultz (same White, same Schultz as before) look at neuropsychological factors, namely intelligence, academic functioning, language, attention, executive functioning, learning and memory, visual perceptual skills and fine motor skills. The course of these deficits is examined.  Chapter 7 examines neurophysiology and the neurodevelopmental hypotheses, a very complex chapter in cognitive neuropsychological terms.  Walker, Kestler, Hochman and Bollini survey the indicators of risk signaling the onset of the disorder, with both biological and psychological antecedents being operative in the evolution of the condition.  Amminger (Austria), Leicester, Francey and McGorry (all from Australia) describe the prodromal period and the methodology of investigation of these symptoms, examining in some detail the many assessment tools available.  Prediction, age-specific characteristics, and intervention strategies are all discussed.  Again, reference is made to the putative role of glutamate.  Case studies are also given here, unusual for this book.

Gogtay now joins the better known Judith Rapoport, looking at other psychotic disorders, transient episodes being more common in childhood than is often recognized.  Drawing on NIMH data and the MDI group, with the neurobiological and neurophysiological study data, eye tracking, neuropsychological functioning, and brain imaging results are examined.  The conclusion is that psychotic phenomena are relatively common and rarely imply a diagnosis of schizophrenia.  The high levels of ADHD comorbidity, more reminiscent of early bipolar disorder, are a confounding factor here, as are other more nonspectrum psychological disorders on Axes I and II.

Chapter eleven begins the devotion of chapters to treatment, with Dass and McNamara as well as editor Findling adding their experience, and other research, into the atypicals, starting low and going slow, given these are not mature brains. The use of quetiapine, given its low side effect profile, is particularly encouraging.

An alternative and complementary approach is that of psychotherapy and school interventions, Sikich is a doctor with experience in the field. As with all of these chapters, there is included a table of the literature review.  The importance of engagement is emphasized, with a phased response in tune with the phases of the illness.  As promised in the title, CBT and CT are examined, as well as school interventions, where symptoms may be most apparent given the stressors there.

Ever since Palazzoli and the Milan School, group interventions have been put forward as having some efficacy, and chapter 13 with Harle and McClellan looking at family and group interventions.  The literature review is small.

At this point the book ends.  As an introduction to the subject, the book does well, and as a middle level trainer, even better. The issues are current, the research quoted looks to me to be pretty up to date, with the small lag that bedevils edited books barely apparent, and that is the price we pay for anthologies that group the experts together as opposed to researching such difficult issues ourselves.

What is emphasized all over again in such books is the need for awareness and vigilance in the primary care professionals, so that early diagnoses and intervention educated by neurobiological findings and a neurological paradigm can be optimized.  We know however that Schizophrenia is a little more obvious in a child than a bipolar or depressive episode, but despite this, a comprehensive approach is still lacking in most developed countries, and most helping professions are not well trained in recognizing such conditions in anyone, let alone children and adolescents. Worse, a comprehensible set of guidelines for helpers with regard to medication and other treatments is lacking, and this book will go some way to filling that gap.  If anything is missing, a more comprehensive chapter on drug-abuse issues would go down well, as well as a chapter on managing violence in this group.

© 2005 Roy Sugarman

Roy Sugarman, Ph.D., Conjoint Senior Lecturer in Psychiatry, University of New South Wales, Australia