Childhood Psychosis

1. Childhood Psychosis Danica Adolfsson M. Clinical Psychology CQU Wellness Centre

2. Childhood psychosis • Prevalence is rare in children and youth (1/1000) • Childhood psychosis refers to children under 12 years old who experience psychotic symptoms described in the DSM-IV-TR as; disorganisation or gross disturbance of thought form or speech, thought content, or behaviour, or extreme negativism. Hallucinations and delusions are usually thought to establish the diagnosis of psychosis only if other organic medical or neurological conditions can be ruled out. • Psychotic symptoms may be experienced within the context of a range of disorders (Schizophrenia, Schizotypal Personality Disorder, Schizo-affective disorder, Psychosis Not Otherwise Specified (PNOS), depression, bi-polar and severe anxiety). • Psychotic symptoms experienced in the context of Childhood-onset Schizophrenia (COS) contains the most prevalent research.

3. Childhood psychosis: DIAGNOSIS • The DSM-IV-TR diagnostic criteria for child, adolescent and adult experiences of schizophrenia do not differ except that the additional feature given to those with childhood/adolescent-onset is the failure to achieve expected level of interpersonal, academic or occupational achievement. • Accurate diagnosis of childhood psychosis requires careful assessment: • The fantasy worlds that children often create, the issues of their developing cognition and language (which may be impacted by retardation in some cases) make it difficult to distinguish between typical and atypical development.

4. Childhood psychosis: DIAGNOSIS • Accurate diagnosis of childhood psychosis requires careful assessment: • Other non-psychotic but intense and repetitive symptoms such as obsessions in OCD, perseverative thoughts related to developmental disorders and disorganisation related to AD/HD need to be distinguished from psychotic symptoms. • Hand flapping, perseverative smelling and touching-symptoms typically seen in children with Pervasive Developmental Disorders are also seen in children with COS. Children with COS are also seen to have attentional problems, distractibility and other disinhibitions of executive functioning typical of children with AD/HD.

5. Childhood psychosis: onset and outcomes • Insidious course and onset of psychosis prior to 12yrs is a predictor of poor outcome in functioning (e.g. cognitive, social, occupational, educational etc.). • Premorbid impairments in COS have been reported as more severe compared to the impairments individuals with Adult Onset Schizophrenia (AOS) experienced as children, especially in language development. In a study conducted by Remschmidt (2005, as cited in Kumperscak, 2011), full and partial remission of psychotic symptoms were seen to be less likely in those with Early Onset Schizophrenia (EOS) compared to AOS. • Greater severity of both positive and negative symptoms in acute episodes of childhood psychosis, lower cognitive functioning and premorbid dysfunction in language, motor development and social relatedness are factors that may contribute to poorer outcome.

6. Childhood psychosis: onset and outcomes • Girls seem to have somewhat better prognosis, both because they seem to be less vulnerable to the early-onset than boys, and because they seem to be less affected by the illness (Kumperscak, 2011). • In an Australian study, those diagnosed with EOS (<18yrs) reported superior functioning in global, social and communicational areas and reported less positive symptoms compared to AOS at 7.4 years follow up(Amminger, 2011).

7. Childhood psychosis: Associated Features • Pre-pubertal children with psychosis seen to have less systematic delusions (delusions organised around a common theme) and lower prevalence of catatonic symptoms, but seen to exhibit hallucinations, disordered thought processes and flattened affect (Courvoisie, 2001). • Children with psychotic symptoms are more likely to: engage in more anti-social, inattentive and hyperactive behaviours, experience anxiety and depressive symptoms and engage in self harm (Polanczyk, Moffitt & Arseneault, 2010).

8. Childhood psychosis: Associated features • Neurodevelopmental delays: • Children with COS show abnormal or delayed development e.g. gross and fine motor delays, hypotenia, poor coordination, sensory integration difficulties and language difficulties. • High incidence of language disorders in children with COS. Those with delayed receptive or expressive language have been seen to catch up with peers, but still show some deficits in linguistic capacity (Asarnow, 1999; Asarnow, Brown, & Strandburg, 1995; Karatekin, & Asarnow, 1998).

9. Childhood schizophrenia: Associated features • Neurocognitive delays: • Children with COS appear to have lower IQ scores compared to non COS population • Deficits seen in both verbal and spatial memory in children with COS. • Deficits seen in learning, attention and abstraction in children with COS and PNOS. • Learning disabilities and language disorders are also present in those with Bi-Polar Affective Disorder.

10. Childhood schizophrenia: Associated features • Physiological markers: • Children with COS seen to have larger lateral ventricular volumes and smaller cerebral volumes compared to control subjects. Strong association between smaller cerebral volume and negative symptoms has been reported. • Over time, subjects with COS have exhibited reductions of volumes in the globuspallidus (regulation of voluntary movement), caudate (learning), right temporal lobe (interpretation of the meaning of visual stimuli), left hippocampus (information consolidation and memory), posterior superior temporal gyrus (PSTG- auditory processing)(Rapoport, Geid & Jacobsen, 1997; El-Sayed et. al., 2010). • Unlike AOS, brain aberrations in COS are first seen in the parietal lobe (visuo-spatial and associated thinking) and progress later to the frontal lobe (in AOS aberrations are firstand more often seen in the frontal lobes).

11. Childhood schizophrenia: Associated features • White and grey matter loss • White and grey matter loss is progressive and occurs at an early stage of COS. • COS has been associated with early parietal grey matter loss and later temporal and frontal grey matter reductions. These grey matter reductions are seen to be greater than those reductions similarly seen in AOS. • Abnormalities in white-matter language-related pathways have been found which may reflect language deficits in COS. • Myelin dysfunction- There may be a delay or decrease in the myelination process in COS due to increased levels of radial diffusivity (water is easily diffused into the sheath, i.e. sheath is weak) in the myelin sheath compared to controls (Clark et. al, 2012).

12. Average rate of grey matter loss over time in those with EOS.

13. Childhood schizophrenia associated features • Smooth pursuit eye tracking movements: • Ability to track a slowly moving object at a steady pace. • Those with COS and AOS have exhibited impaired function of smooth pursuit eye tracking movements compared to controls. This impairment has implications for sensory processing of motor signals and prediction of movement. • Children with COS and disturbed smooth pursuit eye tracking tended to have parents with disturbed eye tracking movements. (Jacobsen et. al, 1996; Levy, Sereno, Gooding, & O’Driscoll, 2010)

14. Etiology and risk factors of childhood psychosis • Genetics: • Copy Number variations (CNVs): Are alterations in DNA, causing there to be an abnormal number of copies of DNA sections (i.e. a component may be deleted or duplicated). Deletions at the 22q11.2 section of DNA is a well accepted genetic subtype of schizophrenia. • A number of CNVs have been examined as possible predictors of schizophrenia, no one alone has been conclusive as a predictor of schizophrenia.

15. Etiology and risk factors of childhood psychosis • Family and Twin studies: • Families of children with COS indicate that first-degree relatives and other relatives have similar neurocognitive difficulties. 30% of non-psychotic parents of children with COS showed neurocognitive impairments. • Higher correlations of psychotic symptoms in children between monozygotic twins compared with dizygotic twins, similar to patterns in adults with psychosis • Children with psychosis symptoms are more likely than children w/out psychosis symptoms to have mothers who have a psychosis spectrum disorder

16. Etiology and risk factors of childhood psychosis • Environmental risk factors: • Urban area • Disadvantaged family • Parent-child relationship: • Studies suggest that children with psychotic symptoms tend to have parents who exhibit more negative expressed emotion. • Stress and trauma: • Maltreatment and abuse • Chaotic household • Birth complications: • Perinatal complications and lower birth weights more commonly seen in children with psychotic symptoms compared to controls. • (Husted, Ahmed, Chow, Brzustowicz, & Bassett, 2010; Polanczyk, Moffitt, & Arseneault, 2010)

17. Etiology and risk factors of childhood psychosis • Models of psychosis: • Neurodevelopmental model: Psychosis seen to be caused by impairment in brain development that occurs in the context of genetic vulnerability. • Dimensional model: Emphasises that every individual sits on a spectrum according to their degree of schizotypy symptomology e. g. those with full blown psychosis are represented at an extreme end of the spectrum. This model is similar to the neurodevelopmental model in that progression of symptoms to a clinical disorder is not inevitable but dependent on an interplay between inherited susceptibility and environmental factors.

18. Treatment • Treatment must be age appropriate, clear and without any questions that could be misunderstood or confusing. • Clinicians act as advocates with the parents for their patients with schools and other social agencies to ensure that these children and adolescents can continue with their education and that their specials needs are recognized. • Important that the therapist is calm and relaxed, using short and understandable questions, talking slowly and understandably. Unclear question formulations and irony, must be avoided because they can additionally confuse and excite the patient.

19. Treatment • Psychotic patients can clinically present as: • Acute psychotic, excited and/or physically aggressive: involves vivid hallucinations and illusions without any reality or impulse control and without disease insight. • Socially withdrawn: adolescents with peculiar ideas and interests, diminished school achievements, in whom psychotic symptoms are present but hardly fulfill the needed diagnostic criteria for any psychotic disorder. • Because of the complex nature of early-onset psychosis, pharmacological and psycho-social therapies are often combined as treatment.

20. Treatment • Medical: • Typical anti-psychotic medication: Haloperidol has been trialed in several studies (not recent)- seen to reduce symptoms of psychosis however accompanied by side effects. • A-typical anti-psychotic medication: Considered standard treatment for children with COS. Risperidone, clozapine, quetiapine, aripiprazole, olanzapine, and ziprasidone usually given to children, not completely absent of side-effects (e.g. weight gain, >cholesterol), however pose less risk than typical anti-psychotics. All have been seen to reduce both positive and negative symptoms to varying extent, however trials included small samples and were conducted over relatively short time periods (Mattai, Hill, & Lenroot, 2010). • Often, the use of antipsychotic medications in addition to the use of antidepressants (mirtazapine, citalopram) or mood stabilizers (lithium, carbamazepine) is indicated in functional psychosis.

21. Treatment • Psychologicalbased treatments: • Family based approaches: • Intervention involves improving family functioning, problem solving, communication and relapse prevention. • Psycho-education for parent and child is important in order to recognise a relapse on time, to prevent preterm drug reduction or cessation, and to strengthen the compliance (Kumperscak, 2011). • Family based therapy and social skills training combined have been found to reduce both the positive and negative symptoms of Early-onset Schizophrenia (EOS) compared to standard treatment methods (Hall & Bean, 2008).

22. Treatment • Emotion Management Therapy: Aims to help those with psychotic symptoms regulate emotions, handle emotional stress of psychosis, develop stress coping skills. • Cognitive Enhancement Therapy (CET): Designed as a recovery phase intervention, aims to develop and enhance mental capacities participants work at recovery through structured group and computer exercises. In a 2yr follow up study conducted by Eack, Greenwald and Hogarty (2009) which involved 58 subjects with EOS/Schizo-Affective Disorder, CET was shown to moderately enhance neurocognitive function. • Rehabilitation: Aims to slowly rehabilitate patients who have suffered psychosis into normal life, step by step focusing energy on developing social, occupational, cognitive and problem solving skills as well as coping strategies. Hospitalisation in severe cases may be necessary for a period of time.

23. Summary • COS is rare and viewed as a severe form of schizophrenia which occurs during a key period in brain development. • COS is pervasive, affecting numerous areas in a persons life such as their cognitive, physical, emotional, social, educational and behavioural function. • Careful diagnosis is important as psychotic and non-psychotic symptoms of developmental disorders, mood disorders and schizotypal disorders can overlap. • The neurodevelopmental model incorporates genetic, environmental and neurological factors as means of explaining the development of childhood psychosis. • A-typical anti-psychotic medication is usually prescribed to alleviate the positive symptoms of psychosis. Family based therapy and other psycho-social approaches are advocated as effective strategies to maintain and regain previous levels of functioning after episodes of psychosis.

24. References (by section) • Childhood psychosis general information: • Brown, J. L., & Bagley, D. A. . (2012). Psychosis in Children and Adolescents. In L. Miller (Ed.), Psychiatric Research Institute (pp. 1-32). Arkansas: Division of Medical Services, Arkansas Department of Human Services. • Courvoisie, H., Labellarte, M. J., & Riddle, M. A. (2001). Psychosis in children: diagnosis and treatment. Clinical Neuroscience, 3(2), 79-92. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3181648/pdf/DialoguesClinNeurosci-3-79.pdf • Polanczyk, G., Moffitt, T. E., & Arseneault, L. (2010). Etiological and clinical features of childhood psychotic symptoms: Results from a birth cohort. Archives of General Psychiatry, 67(4), 328-338. doi: 10.1001/archgenpsychiatry.2010.14 • Diagnosis: • American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). doi:10.1176/appi.books.9780890423349 • Courvoisie, H., Labellarte, M. J., & Riddle, M. A. (2001). Psychosis in children: diagnosis and treatment. Clinical Neuroscience, 3(2), 79-92. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3181648/pdf/DialoguesClinNeurosci-3-79.pdf • Onset and Outcomes: • Amminger, G. P., Henry, L. P., Harrigan, S. M., Harris, M. G., Alvarez-Jimenez, M., Herrman, H., & McGorry, P. D. (2011). Outcome in early-onset schizophrenia revisited: findings from the Early Psychosis Prevention and Intervention Centre long-term follow-up study. Schizophrenia Research, 131(1-3), 112-119. doi: 10.1016/j.schres.2011.06.009 • Courvoisie, H, Labellarte, M. J., & Riddle, M. A. (2001). Psychosis in children: diagnosis and treatment. Clinical Neuroscience, 3(2), 79-92. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3181648/pdf/DialoguesClinNeurosci-3-79.pdf • Kumperscak, H. G. (2011). Childhood and Adolescent Schizophrenia and Other Early-Onset Psychoses, Psychiatric Disorders - Trends and Developments, Dr. Toru Uehara (Ed.), Intech, Europe. Available from: http://www.intechopen.com/books/psychiatric-disorders-trends-and- developments/childhood-and-adolescent-schizophrenia-and-other-early-onset-psychoses

25. References (by section) • Associated features: • Asarnow, R. F. (1999). Neurocognitive impairments in schizophrenia: a piece of the epigenetic puzzle. European Child Adolescent Psychiatry. 8, 5-8. • Asarnow, R. .F, Brown, W, Strandburg, R. (1995). Children with a schizophrenic disorder: neurobehavioral studies. European Archive of Psychiatry Clinical Neuroscience, 245, 70-79. • Biswas, P. (2008). Neurobiology of Childhood-Onset Schizophrenia. Journal of Indian Association for Child and Adolescent Mental Health, 4(3), 55-61. • Clark, K. Narr, K. L., O'Neill, J. Levitt, J., Siddarth, P., Phillips, O. & Caplan, R. (2012). White matter integrity, language, and childhood onset schizophrenia. Schizophrenia Research, 138(2–3), 150-156. Available from: http://dx.doi.org/10.1016/j.schres.2012.02.016 • El-Sayed, M., Steen, R. G., Poe, M. D., Bethea, T. C., Gerig, G., Lieberman, J., & Sikich, L. (2010). Brain volumes in psychotic youth with schizophrenia and mood disorders. Journal of Pschiatry and Neuroscience, 35(4), 229-236. doi: 10.1503/jpn.090051 • Gogtay, N., Sporn, A., Clasen, L. S., Nugent, T. F., Greenstein, D., Nicolson, R., Rapoport, J. L. (2004). Comparison of Progressive Cortical Gray Matter Loss in Childhood-Onset Schizophrenia With That in Childhood-Onset Atypical Psychoses. Archives of General Psychiatry, 61(1), 17-22. doi: 10.1001/archpsyc.61.1.17 • Karatekin, C, Asarnow, R. F. (1998). Working memory in childhood-onset schizophrenia and attention-deficit/hyperactivity disorder. Psychiatry Res. 80, 165-176.

26. References (by section) • Associated features continued: • Jacobsen, L. K., Hong, W. L., Hommer, D. W., Hamburger, S. D., Castellanos, F. X., Frazier, J. A., & Rapoport, J. L. (1996). Smooth pursuit eye movements in childhood-onset schizophrenia: Comparison with attention-deficit hyperactivity disorder and normal controls. Biological Psychiatry, 40(11), 1144-1154. Available from: http://dx.doi.org/10.1016/S0006-3223(95)00630-3 • Levy, D. L., Sereno, A. B., Gooding, D. C., & O’Driscoll, G. A. (2010). Eye Tracking Dysfunction in Schizophrenia: Characterization and Pathophysiology. Current Topics in Behavioural Neuroscience, 4, 311-347. • Narr, K. C., O'Neill, K. L., Levitt, J., Siddarth, J., Owen, P. P., & Rochelle, C. (2012). White matter integrity, language, and childhood onset schizophrenia. Schizophrenia Research, 138(2–3), 150-156. Available from: http://dx.doi.org/10.1016/j.schres.2012.02.016 • Polanczyk, G., Moffitt, T. E., & Arseneault, L. (2010). Etiological and clinical features of childhood psychotic symptoms: Results from a birth cohort. Archives of General Psychiatry, 67(4), 328-338. doi: 10.1001/archgenpsychiatry.2010.14 • Rapoport, J. L, Giedd, J.,& Jacobsen, L. K. (1997). Childhood-onset schizophrenia: progressive ventricular enlargement during adolescence on MRI brain rescan. Arch Gen Psychiatry, 54, 897-903. • Sporn, A., Greenstein, D., Gogtay, N., Sailer, F., Hommer, D.W., Rawlings, R., & Rapoport, J. L. (2005). Childhood-onset schizophrenia: smooth pursuit eye-tracking dysfunction in family members. Schizophrenia Research, 73(2–3), 243-252. Available from: http://dx.doi.org/10.1016/j.schres.2004.07.020 • Thompson, P. M, Vidal, C, & Giedd, J. N. . (2001) Mapping adolescent brain change reveals dynamic wave of accelerated gray matter loss in very early-onset schizophrenia. ProcNatlAcadSci, 98(20),1650-11655.

27. References (by section) • Etiology and risk factors • Biswas, P. (2008). Neurobiology of Childhood-Onset Schizophrenia. Journal of Indian Association for Child and Adolescent Mental Health, 4(3), 55-61. • Broome, M. R., Woolley, J. B., Tabraham, P., Johns, L. C., Bramon, E., Murray, G. K., Murray, R. M. (2005). What causes the onset of psychosis? Schizophrenia Research, 79(1), 23-34. Available from: http://dx.doi.org/10.1016/j.schres.2005.02.007 • Hay, D. A, Martin, N. G., Foley, D., Treloar, S.A., Kirk, K. M., & Heath, A. C. (2001).Phenotypic and genetic analyses of a short measure of psychosis-proneness in a large-scale Australian twin study. Twin Res, 4(1), 30-40. • Husted, J. A., Ahmed, R., Chow, E. W. C., Brzustowicz, L. M., & Bassett, A. S. (2010). Childhood trauma and genetic factors in familial schizophrenia associated with the NOS1AP gene. Schizophrenia Research, 121(1–3), 187-192. Available from:http://dx.doi.org/10.1016/j.schres.2010.05.021 • Polanczyk, G., Moffitt, T. E., & Arseneault, L. (2010). Etiological and clinical features of childhood psychotic symptoms: Results from a birth cohort. Archives of General Psychiatry, 67(4), 328-338. doi: 10.1001/archgenpsychiatry.2010.14 • Sagar, A., Bishop, J. R., Tessman, D. C., Guter, S., Martin, C. L., & Cook, E. H. (2013). Co-occurrence of autism, childhood psychosis, and intellectual disability associated with a de novo 3q29 microdeletion. American Journal of Medical Genetics. Part A, 161(4), 845. Available from: www.ncbi.nlm.nih.gov/pubmed/23443968 • Tam, G. W., Redon, R., Grant, S. G., & Carter, N. P. (2009). Review: The Role of DNA Copy Number Variation in Schizophrenia. Biological Psychiatry, 66, 1005-1012. doi: 10.1016/j.biopsych.2009.07.027

28. References (by section) • Treatment: • Aramjit, T. , & Joshi-Kenneth, E. T. (2002). Psychosis in childhood and its management. Neuro-psychopharmacology: The Fifth Generation of Progress, 45, 613-624. • Chung, Y. C., Yoon, K. S., Park, T. W., Yang, J. C., & Oh, K. Y. (2013). Group Cognitive-Behavioral Therapy for Early Psychosis. Cognitive Therapy & Research, 37(2), 403-411. doi: 10.1007/s10608-012-9460-9 • Eack, S. M,, Greenwald, D. P., Hogarty, S. S., (2009). Cognitive enhancement therapy for early-course schizophrenia: effects of a two-year randomized controlled trial. Psychiatry Services, 6, 1468–1476. • Hall, S., & Bean, R. (2008). Family Therapy and Childhood-Onset Schizophrenia: Pursuing Clinical and Bio/Psycho/Social Competence. Contemporary Family Therapy: An International Journal, 30(2), 61-74. doi: 10.1007/s10591-008-9061-7 • Hodel, B., Brenner, H. D., Merlo, M. C., & Teuber, J. F. (1998). Emotional management therapy in early psychosis. British Journal of Psychiatry, 172(33), 128-133. • Kumperscak, H. G. (2011). Childhood and Adolescent Schizophrenia and Other Early-Onset Psychoses, Psychiatric Disorders - Trends and Developments, Dr. Toru Uehara (Ed.), Intech, Europe. Available from: http://www.intechopen.com/books/psychiatric-disorders-trends-and- developments/childhood-and-adolescent-schizophrenia-and-other-early-onset-psychoses • Mattai, A. K., Hill, J. L., & Lenroot, R. K. (2010). Treatment of early-onset Schizophrenia. Current Opinion in Psychiatry, 23(4), 304-310. • Sadock, B. J. & Sadock, V.A. (Eds.) (2007). Kaplan and Sadock's Synopsis of Psychiatry: Behavioral Sciences, Clinical Psychiatry, Williams & Wilkins, Baltimore, USA