Clinical Features and Outcome of Child and Adolescent Schizophrenia

Abstract

Subjects admitted 12 months or more previously to two child and adolescent psychiatric units in New Zealand and the United States with a diagnosis of non-organic, nonautistic psychosis, were contacted and those who received a DSM-III-R diagnosis of schizophrenia were studied (n = 33 [New Zealand] and n = 24 [United States]). Premorbid and first-episode data were obtained from the admission record using global clinical measures of moderate reliability, outcome diagnosis and status by interviews, and professional and family reports. Mean ages at onset were 13.9 (New Zealand) and 15.6 (United States). Premorbid and clinical features resembled those in adult schizophrenia, though there were probable quantitative differences. At outcome (mean interval = 4 years) few subjects were symptom-free or independent, and mean global assessment of functioning had fallen from 55 to 40. Outcome was much worse in schizophrenia than bipolar disorder. Despite a 59 percent attrition rate and higher rates of initial misdiagnosis in the United States, and some demographic differences, New Zealand and United States samples resembled each other clinically and in outcome. Initial misdiagnosis of bipolar disorder as schizophrenia was not due to minimizing mood symptoms, which were common in both disorders. Within this age range (mostly 11-17), age at onset had only minor effects. Outcome was best predicted by premorbid personality.

First-Episode Psychosis: A Comparative Review of Diagnostic Evolution and Predictive Variables in Adolescents versus Adults

“…Studies that correlated an earlier onset with a better outcome (3,29) may have been partly explained by a difficulty in separating age from female sex, which may actually be the better prognostic factor (29). Neither the adolescent (3)(4)(5)14,19,29) nor adult (30-34) literature, however, could demonstrate a significant correlation between younger age of onset and poorer outcome or specific diagnosis, despite the traditional belief that earlier onset implies more severe psychopathology.…”

“…Studies have suggested that a younger age of onset is correlated with greater diagnostic instability (5,20,21,25,26), particularly for BAD. One study correlated younger age with poorer outcome (27), although the schizophrenia literature suggests that this may be a function of insidious onset (ocurring over more than 4 weeks) rather than a function of age itself (28).…”

“…The main results on this variable come from Werry and others, who report a 35% to 50% homotypic family history in BAD adolescents, compared with positive family histories for both schizophrenia and mood disorders in adolescents with schizophrenia (significant in 3, trend in 4). A strong family history of each illness was also correlated with early onset in BAD (14) and schizophrenia (5). Only 1 adult study in schizophrenia considered family history, reporting that heredity was not an important factor for outcome (34).…”

“…Substance use constitutes an important confounding variable that is often underestimated or unaccounted for (by making it an exclusion criterion), despite its impact on diagnosis, presentation, and evolution. In the adolescent literature, comorbid substance abuse was simply reported as a frequency, without comment on its correlation to diagnosis or outcome (4,5,18,20,29). In the adult literature, a history of substance use was correlated with a younger age of psychosis onset (39), lower GAF in schizophrenia (31), increased risk for suicide (irrespective of diagnosis) (36), and a follow-up diagnosis of BAD (40).…”

The use of Clozapine in Adolescents: A Case Report

“…However, longitudinal assessment is needed to ensure accuracy of diagnosis in all such cases. 23 As our child mental health services increase, we are likely to see more children with early-onset treatment-resistant schizophrenia. It is hoped that this report will add to the current body of knowledge and encourage clinicians in this part of the world to use clozapine for the benefit of our child patients.…”