Very early onset schizophrenia: distinctiveness and characteristics

Very early onset schizophrenia or childhood schizophrenia is a rare and usually severe form of schizophrenia with onset of psychosis by age 12. It is estimated that schizophrenia affects less than 1 in 10,000 children aged 2-12 years old.

It is thought that childhood-onset schizophrenia is similar to adolescence- and adult-onset schizophrenia. DSM-IV and ICD-10 criteria for schizophrenia apply to all ages.

In the past, there was an argument whether there is a continuum between schizophrenia and autism. Today, most agree that they are two distinct disorders. In favor of the continuum is the presence of symptoms of Pervasive Developmental Disorder (PDD NOS) prior to very early onset schizophrenia, with social disabilities being the most prevalent feature.

Researchers tend to disagree with the definition of schizophrenia. Their disagreement has not to do with the severe core disturbance, as manifested by the characteristic symptoms with a great change in function, but rather where the limits are drawn. In other words, if less typical cases can be included in this diagnostic category.

As far as the developmental approach of the disorder is considered, there are developmental prodromal and premorbid symptoms related to the onset of childhood schizophrenia, such as birth complications, soft neurological signs, developmental disorders of speech and/or language, transient symptoms of pervasive developmental disorders, learning problems, school adjustment and social function problems, poor attention, hyperactivity and lower IQ score.

Symptomatology and neurobiological findings are dependent on each patient's stage of development. The child's cognitive maturity plays the most important role in the onset of certain symptoms.

Childhood schizophrenia has an extremely severe course, worse than the course of adolescence- or adult-onset schizophrenia.

Diagnosis of schizophrenia in children demands great attention and familiarization of clinical doctors with the disorder given that the mere application of criteria often leads to wrong diagnoses. Developmental factors should be taken into consideration when understanding and diagnosing "psychosis" and, consequently, schizophrenia in children.

During an extended study on childhood-onset schizophrenia, which began in 1990, and was conducted by the US National Institute of Mental Health (NIMH), it was found that almost 30% of patients included in the study as schizophrenics, presented with complex developmental disorders and brief periods of psychotic symptoms. These young patients did not meet DSM-IV criteria for schizophrenia. The researchers suggested this group of children with atypical psychosis to be labeled as "multidimensionally impaired- MDI". Taking the view that this disorder falls under schizophrenia spectrum disorders, they described the following characteristics: poor ability to discern fact from fiction, almost daily periods of emotional instability, reduced interpersonal skills despite their will to relate to their peers, cognitive deficits and absence of a typical thought disorder.

On the other hand, a research team from the Yale University described a syndrome in Autism Spectrum Disorders, which was named Multiple Complex Developmental Disorder (MCDD). For this disorder, which resembles MDI to a certain degree, they suggested the following criteria: difficulty in regulating mood and stress, difficulty in social interaction and thought disorders. Psychotic thought and primitive stress were the most prevalent symptoms distinguishing children with MCDD from children with autism.

Treatment of children calls for a comprehensive therapeutic plan. Coping with learning difficulties, social skills training and family psychoeducation are therapeutic interventions equally important to drug therapy.

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