IACAPAP Textbook of Child and Adolescent Mental Health

OTHER DISORDERS

Chapter

H.5

SCHIZOPHRENIA AND OTHERPSYCHOTIC DISORDERS OF EARLY
ONSETJean Starling & Isabelle Feijo

Jean Starling FRANZCP,
MPHChild and adolescent
psychiatrist, Director, Walker
Unit, Concord Centre for Mental
Health, Sydney, and seniorclinical lecturer, Discipline of
Psychiatry, Sydney Medical
School, University of Sydney,
Sydney, Australia
Conflict of interest: none
declaredIsabelle Feijo FRANZCP
Psychiatrist, Walker Unit,
Concord Centre for Mental
Health, Sydney, Australia
and specialist in child andadolescent psychiatry andpsychotherapy, Swiss Medical
Association
Conflict of interest: none
declaredJacksonPollock;
untitled.

Acknowledgement: thanks to
Polly Kwan who vetted theCantonese websites

This publication is intended for professionals training or practising in mental health and not for the general public. The opinions
expressed are those of the authors and do not necessarily represent the views of the Editor or IACAPAP. This publication seeks todescribe the best treatments and practices based on the scientific evidence available at the time of writing as evaluated by the authorsand may change as a result of new research. Readers need to apply this knowledge to patients in accordance with the guidelines andlaws of their country of practice. Some medications may not be available in some countries and readers should consult the specific drug
information since not all dosages and unwanted effects are mentioned. Organizations, publications and websites are cited or linked toillustrate issues or as a source of further information. This does not mean that authors, the Editor or IACAPAP endorse their content or
recommendations, which should be critically assessed by the reader. Websites may also change or cease to exist.
©IACAPAP 2012. This is an open-access publication under the Creative Commons Attribution Non-commercial License. Use,
distribution and reproduction in any medium are allowed without prior permission provided the original work is properly cited andthe use is non-commercial. Send comments about this book or chapter to jmreyATbigpond.net.au
Suggested citation: Starling J, Feijo I. Schizophrenia and other psychotic disorders of early onset. In Rey JM (ed), IACAPAP
e-Textbook of Child and Adolescent Mental Health. Geneva: International Association for Child and Adolescent Psychiatry and Allied
Professions 2012.

Schizophrenia H.5

1

IACAPAP Textbook of Child and Adolescent Mental HealthP

sychotic disorders are associated with impairment in emotional, cognitiveand social functioning, potentially leading to long term disability. Thereis also an increased risk of suicide and harm to others, particularly whenacutely unwell. Early and expert treatment is crucial, with optimal results obtainedwith prompt referral to psychiatric services and intensive treatment by a mental
health team, including a psychiatrist, in the acute phase of the illness. Furthermore,these disorders are highly stigmatized in most cultures, making treatment andintegration into the community difficult.
Psychotic symptoms in children
Schizophrenia is an extremely rare condition in prepubertal children;
psychotic symptoms in this age group need careful evaluation and may be due tomany other disorders. This section discusses the presentations of these symptoms
in children.
Childhood onset schizophrenia, where children’s symptoms meet criteria forschizophrenia and where symptoms start before the age of 13, is a very rare disorderwith a prevalence of less than 1/10,000 (Asarnow et al, 2004). The latest information
about childhood onset schizophrenia comes from large research cohorts such as theChildhood-onset Schizophrenia Study at the NIMH (Rapoport & Inoff-Germain,2000). These studies drew from a wide geographical area and had strict exclusion
criteria. Information from these cohorts suggests that childhood onset schizophrenia
is a severe form of the late adolescent/early adult onset disorder. Findings fromthese cohorts include more premorbid impairment than seen in those with later
onset, with an increased prevalence of cytogenetic (Addington & Rapoport, 2009)and developmental abnormalities including pervasive developmental disorders
and mental retardation (Rapoport et al, 2009). Premorbid social difficulties, motor
abnormalities and a family history of schizophrenia were more common than incontrols. The onset of the illness was often insidious with cognitive deterioration(Bedwell et al, 1999) and neuroanatomical changes (Arango et al, 2008) occurring
Terms used in this chapter•

Psychotic (symptoms) is a word used to describe situations when perceptions,thoughts or emotions are disordered so severely that contact is lost with external
reality. The two most common mental illnesses where psychotic symptoms are a
predominant feature are schizophrenia and bipolar disorder. Psychotic symptoms
include:− Hallucinations (false sensory perceptions in the absence of external
stimuli). Auditory hallucinations (“hearing voices”) are the most common but
visual hallucinations are also seen in children and teenagers with psychosis.
− Delusions (strongly held beliefs, not shared by other members of thecommunity, arising from an incorrect interpretation of external reality,
incompatible with a person’s social or religious background).

•Positive symptoms describe an excess or distortion of normal functions (such as
hallucinations or delusions).

•

Negative symptoms is used to describe a reduction or loss of normal functioning(for example loss of normal emotional reactivity or impaired cognitive functioning)•

Prodrome is the period of time before the onset of psychotic symptoms where
functioning is impaired.

•

Acute psychosis is the period of time when hallucinations and/or delusions are
predominant and behavior is often disturbed.

Schizophrenia H.5

2

IACAPAP Textbook of Child and Adolescent Mental Healthearly in the illness. However, few children with psychotic symptoms fulfill
diagnostic criteria for childhood onset schizophrenia and by the time diagnostic
criteria are met they are chronically ill, with significant disability.
Other psychotic disorders presenting in childhood include bipolar disorder(discussed in Chapter E.2). However, most children who present with psychotic
symptoms do not have schizophrenia or bipolar disorder. They are more likely
to show transient auditory hallucinations as well as mood or anxiety symptoms
with associated distress. At first presentation these children often meet diagnostic
criteria for depression, post-traumatic stress disorder (PTSD), anxiety or behavior
disorders but not for any of the psychotic disorders. Many have a long history ofdevelopmental, behavioral and emotional problems and may display a confusing
mix of symptoms. There are very few studies following up such children to see
if they go on to develop schizophrenia but the available evidence is summarized
below.
Auditory hallucinations are not uncommon in non-psychotic children
attending child psychiatry services (Dhossche et al, 2002). While most appear
to recover, a subgroup of those with hallucinations develops a psychotic illness.
In a clinic sample of 90 children it was found that half of the 15% who reported
hallucinations initially were hallucination free at 12 months, while a third had
ongoing symptoms and came close to meeting criteria for either schizophrenia or
bipolar disorder (Askenazy et al, 2007). Sixty percent of a sample of 80 children
with auditory hallucinations reported no hallucinations three years later but 16%
had developed delusions (Escher et al, 2002). Hallucinations were more likely
to persist in those with diagnoses of anxiety, depression or dissociative disorder.
Other risk factors were behavior problems, negative symptoms and more frequent
auditory hallucinations or hallucinations with negative content (Escher et al,2004). Children and adolescents with PTSD are also more likely to report auditory
hallucinations (Scott et al, 2007a). Children in community samples report
auditory hallucinations relatively often, two studies reporting a rate of 8% (McGeeet al, 2000; Scott et al, 2006). Hallucinations were more likely in children with
anxiety, depression, family dysfunction and inattention or hyperactivity. When thecohort reported by McGee and colleagues was followed up 15 years later, at theage of 26, a quarter of those with psychotic symptoms at age 11 met criteria forschizophreniform disorder (Poulton et al, 2000).
In summary, the differential diagnosis of psychotic symptoms in childhood
can be difficult and a longitudinal perspective is essential. It may be more useful
to describe “diagnostic hypotheses” rather than a specific diagnosis, especially at
first presentation (Lee et al, 2003). While the majority of children with isolated
psychotic symptoms will not go on to develop schizophrenia, schizophrenia or
bipolar disorder will develop in a significant minority either within one to two
years of hallucinations first appearing or they will remain comparatively well inadolescence but develop schizophrenia as an adult.

Click on the picture to accessa video clip in which ayoung woman describes her
psychotic symptoms that had
started during her childhood(7:31).

Click on the picture to heara university student talkabout psychosis and what it
is like to go through an early
detection service (9:59).

Psychotic symptoms in adolescence
Psychotic disorders of all types increase in prevalence during adolescence, toa prevalence of one in 500 among 18 year olds. Retrospectively, about one thirdof adults with psychotic disorders report that their illness started before the age of
20 and the lifetime prevalence of all psychotic disorders in the adult population

Schizophrenia H.5

3

IACAPAP Textbook of Child and Adolescent Mental Health

Table H.5.1

Diagnostic criteria for schizophrenia

1. Two or more of the following present for at least a month:•Hallucinations•
Delusions•
Disordered thoughts and speech (speech can be incoherent or greatly reduced)•
Severely disorganized behavior (including catatonia, or severe motor slowing)•
Negative symptoms
2. Deterioration in social, educational or work functioning
3. Duration of illness of at least six months, including the prodrome, if present (if duration I
less than six months, it is labeled schizophreniform psychosis)
4. Not due to another mental illness such as a mood disorder, or a medical condition.

is 2%-3% (Kendler et al, 1996). While some adolescents with psychosis comefrom similar high risk groups to those with childhood onset schizophrenia, themajority had previously normal functioning. In this group the typical illness course
starts with a prodrome, with nonspecific symptoms including low mood, anxiety,cognitive and functional deterioration.
The risk factors for schizophrenia in adolescents and young adults arewell described. These include a schizotypal personality, sub-threshold psychotic
symptoms (such as brief, indistinct auditory hallucinations), functional decline
and a family history of schizophrenia (Owens & Johnstone, 2006; Yung et al,2004). Combinations of these symptoms have been described as the “ultra highrisk” mental state. The likelihood of transition to psychosis with these risk factors
was thought to be high, but recent studies suggest that, in help-seeking young
people, the risk decreases from 40% to 16% (Yung et al, 2008). Poor functioning
at presentation, low-grade psychotic symptoms, depression and a long duration of
prodromal symptoms make transition to psychosis more likely.
Currently, the debate in the adolescent-onset group is at what stage to treat
the psychotic symptoms. Trials of antipsychotic medication have been shown to
reduce the transition from the “ultra-high risk” state to a psychotic disorder, but
as the risk of transition to psychosis drops in the clinic cohorts, the risk of using
antipsychotic medication in adolescents who are unlikely to later develop psychosis
becomes less acceptable (Yung et al, 2007).

ETIOLOGY

Click on the picture to heara young man describing his
struggle with schizophrenia
and its treatment (8:13).

The pathophysiology of schizophrenia or any of the other psychotic disorders
is still unclear. All psychotic disorders have a genetic vulnerability but there is noclear single gene implicated in causation. Recent research reports multiple genes
associated with the development of schizophrenia, but most have a small effect.
Most of these genes are nonspecific and some genes linked to schizophrenia arealso linked to autism and bipolar disorder. There are also multiple other organicand psychosocial risk factors. A summary of risk factors and their associated odds
ratios can be seen in Figure H.5.1. Additional risk factors include being male or an
immigrant. Children, and to a lesser extent teenagers, with psychosis are likely tohave more risk factors than those with a later age of onset.
When talking to young people and their families, the most easily understood

Schizophrenia H.5

4

IACAPAP Textbook of Child and Adolescent Mental Health

Figure H.5.1 Comparison of a selected set of relatively well-established risk factors forschizophrenia, focusing mainly on pre- and ante-natal factors.

CNS: central nervous system; depr: depression; Rh: Rhesus. Source: Sullivan PF. The genetics of schizophrenia.

model for the etiology of schizophrenia is the stress/vulnerability model. Risk
factors (or vulnerabilities) for the development of schizophrenia include:• Family history of psychosis, particularly in first degree relatives• Personality in the schizotypal, schizoid or paranoid spectrum, and• Being an older teenager or a young adult.
Factors that may precipitate a psychotic episode include organic factors
such as illicit or medical drug use, a severe physical illness, trauma or otherpsychological stress such as starting a more difficult course of study.

SYMPTOMS OF PSYCHOSIS
Positive symptoms••

Hallucinations, most commonly auditory hallucinations or hearing
voices. Visual hallucinations are more common in children than in
adults (up to 50% in some cohorts)
Delusions, generally persecutory or grandiose in nature

Negative symptoms••••

Reduced motivation
Flat or blunted affectSocial withdrawal
Impaired cognitive performance in domains such as attention,
concentration, memory and planning.

These negative and cognitive symptoms best predict long term outcome andmay precede the onset of hallucinations or delusions by many months. In additionchanges in mood, anxiety and levels of agitation are common.

Schizophrenia H.5

5

IACAPAP Textbook of Child and Adolescent Mental Health

The two most common psychotic disorders are schizophrenia and bipolar
disorder. Table H.5.1 summarizes the criteria for the diagnosis of schizophrenia.
The prominent symptoms are hallucinations and/or delusions. People who are
given a diagnosis of schizophreniform disorder have the same symptoms as thosewith schizophrenia but for less than six months. In both conditions there is also
associated disturbed behavior and deterioration in functioning, including school
performance and social functioning. In bipolar disorder, a distinct period ofmood symptoms is the predominant feature, with mania (at least one episodeof severely elevated mood affecting all areas of functioning including sleep andcognition for a period of at least seven days) being the most prominent. Delusions
and hallucinations in psychotic bipolar disorder tend to be grandiose if the patientis manic and depressive (e.g., of guilt, ruin, worthlessness) in psychotic depression.
The initial episodes of a bipolar disorder are often depressive, so diagnosis is notclear until after the young person has a manic episode (see Chapter E.2). The
diagnosis of both schizophrenia and psychotic mood disorders have poor reliability
at first presentation, with low agreement between clinicians and diagnostic
instability over time.

Click on the picture to heara description of psychotic
phenomena she had as ateenager in a person withbipolar disorder (3:06)

COURSE AND OUTCOME
A good outcome in early onset psychosis includes not only the resolutionof acute psychotic symptoms such as hallucinations and delusions, but also
a reduction in negative symptoms and a return to education and friendshipnetworks. A rapid recovery is more likely with early treatment, a more acute onset
and an illness with fewer negative symptoms. Early onset is associated with apoorer prognosis, particularly childhood onset (Hollis, 2000), although those with
illness onset prior to the age of 18 tend to have a worse outcome than those withadult onset (Schimmelmann et al, 2007). Male gender, ongoing substance use,
pervasive developmental disorder, poor premorbid function and insidious onset
are also associated with poorer outcomes.
Early treatment, not only reduces the severity of the first episode, but also
helps prevent relapse. While recovery may be good after the first episode − about
20% of young people with schizophrenia will have only one episode − a relapse is
not only extremely disruptive to educational, vocational and personal development
but may also be less responsive to treatment. Active follow up after recovery
from the first episode, including a clear plan to monitor for early warning signs(subtle signs of deterioration in mental state), as well as continuing antipsychotic
medication for twelve months after recovery will reduce the risk.

PSYCHOSIS IN SPECIFIC GROUPS
Developmentally disabled
Young people with developmental disability, in particular pervasive
developmental disorders, have an increased risk of psychosis but are also more
likely to be wrongly diagnosed as psychotic. Pervasive developmental disorders, also
called autistic spectrum disorders, are discussed in Chapter C.2. These disorders
manifest themselves with deficits in social interaction, impaired verbal andnonverbal communication, restricted and idiosyncratic interests, and stereotyped
behaviors. Because the core deficits in pervasive developmental disorders lead todifficulties in social interaction, repetitive or other unusual behaviors, and odd

Schizophrenia H.5

6

IACAPAP Textbook of Child and Adolescent Mental Healthpreoccupations, it can be difficult to differentiate between these symptoms andother psychiatric disorders. Behaviors or cognitions associated with pervasive
developmental disorders may appear similar to those of disorders such as anxiety,obsessive-compulsive disorder or even schizophrenia. The broad phenotypes seen
more commonly in relatives of children with autism, such as delayed language,
poor social functioning and executive control deficits are also risk factors forschizophrenia (Losh et al, 2008), suggesting some common causative factors.
There is so much overlap of symptoms between pervasive developmental
disorders and psychosis that before the 1970s, the term childhood psychosis was
widely used to refer to both childhood-onset schizophrenia and autism. Much of
the later work in this area, such as the seminal studies by Kolvin (Kolvin, 1971),
concentrated on identifying the differences between autism and schizophreni,
including age at onset and differing outcomes. During the past two decades,
the core syndromes of pervasive developmental disorders and childhood-onset
schizophrenia have been clearly delineated and research has focused on theidentification of comorbid psychosis and other mental illnesses in the pervasive
developmental disorder population.
In clinical practice, the main difficulty is making a differential diagnosis in ayoung person with pervasive developmental disorders and either increasingly odd
behaviors or a decline in functioning (Starling & Dossetor, 2009). It is important
to consider beliefs and behaviors in a developmental context, particularly in young
people with intellectual impairment. In this population, anxiety or depression
can also manifest with unusual behaviors. Psychosis should not be diagnosed
in individuals with pervasive developmental disorders without the presence of
hallucinations or delusions, as disturbed behavior alone is not sufficient.
Young people with a history of trauma
Rates of psychotic disorders are significantly increased in adults with ahistory of childhood sexual abuse (Cutajar et al, 2010). A history of psychologicaltrauma or maltreatment also increases the risk of transition from prodromal
symptoms to a psychotic disorder in young adults (Bechdolf et al, 2010b). Thereis less evidence of a link between trauma and psychosis in children and teenagers,
but traumatized young people are more likely to report hallucinations, sometimes
as a symptom of post-traumatic stress disorder (Shevlin et al, 2007).There is somedebate about whether auditory hallucinations reported by young people with achildhood history of trauma are different from those without a history of abuse.
Some studies found that hallucinations directly related to the trauma experience
were more likely, while others found no difference in symptoms (Scott et al,
2007b).
A history of childhood trauma also increases the risk of aggression, self-harm,suicide attempts and substance abuse in patients with psychosis (Hainsworth et al,2011). Clinically this means that young people with psychosis and a traumaticbackground are likely to be more difficult to treat and potentially more dangerous
to themselves and others. They are also more likely to live away from their families
or have less family support. It is important to be aware of the reasons for the
disturbed behavior and also provide treatment for the trauma symptoms as well as
for the psychotic disorder.

Schizophrenia H.5

7

IACAPAP Textbook of Child and Adolescent Mental Health

Substance use
The relationship between drug use and early psychosis is complex. There isgood evidence that early cannabis use increases the risk of psychosis in later life,
with some young people being more vulnerable than others. Research from a New
Zealand cohort suggests that there is a tenfold increase in the risk of psychosis
with cannabis use in people with a functional polymorphism of the catechol-Omethyltransferase (COMT) gene − associated with the production of dopamine in
the brain − suggesting a gene-environment interaction (Caspi et al, 2005). Druguse, particularly cannabis, psychostimulants and hallucinogens can precipitate a
psychotic episode, reduce response to treatment and increase the risk of relapse after
recovery. Cannabis use can worsen cognitive deterioration. Acute drug intoxication
can also mimic psychosis, although symptoms generally last only hours or days.
Symptoms lasting days to weeks suggest either severe ongoing substance abuse ora psychotic illness (Volkow, 2009).
Illicit drugs may also be used to self-medicate distress in the prodromal stageof schizophrenia so, the psychotic illness predate the substance abuse, but ongoinguse makes hallucinations and delusions less likely to respond to medication.
Strategies for helping teenagers with psychosis and substance use are detailed on
the EPPIC website.

ASSESSMENT
The goal of the initial assessment of a young person presenting with a
psychotic disorder is not just to make a diagnosis but also to develop rapportand set the stage for the ongoing treatment of a frequently chronic illness. While
going slowly and cautiously at this stage can be seen as wasting time, forcibly
treating without adequate discussion, education and understanding of the patientand family, can lead to later avoidance of services and relapse or recurrence of theillness.
Individual assessment
Obtaining a history of psychotic symptoms can be difficult. Young people
often avoid discussing such symptoms because they are frightened of being seen
as “crazy”. They need to be given the choice as to whether they would prefer to be
seen alone or with the support of a trusted adult, often a parent − although seeing
young people by themselves for a short period is always necessary, e.g. to assess
suicidality. Starting the interview with a discussion of more neutral topics suchas family, school, hobbies and friendships helps to build rapport and assemble
a picture of their general functioning. The interviewer can then move on to ask
about specific worries or concerns and explore those in more detail.

Click on the picture to accessan overview of the early
identification, assessment
and treatment of psychosis
by ORYGEN Youth Health

Asking about symptoms of anxiety and depressed or elevated mood is
crucial, as is discussing thoughts of self-harm or suicide. Finally there needs to be
specific enquiries about psychotic symptoms, where it is important to be neutral
but direct, for example saying “I am going to ask you some questions that seem
really strange but are important to help me understand what is happening with yourthoughts”. It may take several interviews to fully elicit symptoms; it can be difficult
for confused young people to put the chaos of their thoughts into words. Examplesof questions to use for a comprehensive assessment of psychotic symptoms are
given in Table H.5.2.

Schizophrenia H.5

8

IACAPAP Textbook of Child and Adolescent Mental Health

Table H.5.2

A mental state assessment for psychotic symptoms
Interview questions

Appearance
and behavior
Insight

Mood:depressed

Mood:
elevatedThought form

Observation at interview

Rationale for questions
Unusual behavior or dress should be
described and if possible understoodduring the interview−−

Could you tell me why you have come to see me?
Do you think there is anything that you need help
with?

If they understand that they are unwelland if they see the need for treatment,cooperation is more likely

−
−
−
−
−

Have you been feeling depressed or down recently?
Have you lost interest in things you usually enjoy?
Have you had problems sleeping?
Have you had thoughts of hurting yourself?
If yes to any of the above, ask also about eating,agitation, concentration, thoughts of guilt or
hopelessness and suicidal ideas or plans

Checking for a current and pasthistory of depression and risk of selfharm or suicide−

Have you ever had a period of time where you werefeeling so good, excited or hyper that you felt out ofcontrol, or did worrying things?
If yes ask for more details

A period of elevated mood may be amanifestation of bipolar disorder−

Observation of speech flow and thinking at interview−

Thought disorder is often seen inpsychosis and the type will help
with diagnosis. Thought disorder iswhere thoughts are poorly connected.
Speech can be also rushed in bipolar
disorder or slowed in depression.

Did you ever hear things that other people couldn’tsuch as noises or people’s voices?
If yes, what did you hear and how often?
If voices, did they comment on what you were thinking
or doing?
How many voices did you hear? Were they talking toeach other?
Did you have visions or see things that other people
couldn’t? (ask for details)
Also ask about tactile,olfactory and gustatory
abnormalities

These questions seek to elicit core
psychotic symptoms. As hallucinations
become more complex (more often,
say more things, more than one voice)a psychotic disorder is more likely.

Thought
content :delusionsStart with “I would like to ask you about unusualexperiences people sometimes have”− Has it ever seemed that people were talking about
you or taking special notice of you?
− Have you ever received special messages from theTV, radio, or other things around you?
− What about anyone trying to give you a hard time or
hurt you?
− Have you ever felt that you were especially importantor could do things that others could not?
− If yes to any, get further details

As delusions become more complex(e.g., not just people looking at me but
having an elaborate plan to hurt me)a psychotic disorder is more likely.
Paranoid delusions are most likely inschizophrenia spectrum disorders,and grandiose delusions in bipolar
disorder.

Cognitivefunctioning

Ask about current and past functioning at school including
concentration, motivation, ability to learn and academic
gradesPremorbid cognitive functioning
affects prognosis, while deterioration
is not only seen in psychotic disorders
but also in depression.

Perceptual
abnormalities:
hallucinations

−
−
−
−
−

Schizophrenia H.5

9

IACAPAP Textbook of Child and Adolescent Mental HealthA discussion of the rules of confidentiality is also important. While ateenager’s thoughts or feelings should be kept confidential, if they talk about
harming themselves or others there is often a duty of disclosure for safety reasons.
Similarly a history of past sexual or physical abuse may also require disclosure to
the relevant authorities, depending on the laws of the country they live in.
It is important to remember that it is rare for a psychotic disorder to exist in
isolation. Common co-morbidities include substance misuse (ask about tobacco,cannabis and stimulants), anxiety, depression, behavior disorders, a history of
trauma or developmental disorders.
Other assessments
Parents can provide a developmental history including pregnancy (viral
infections, maternal drug or alcohol use, other complications) birth trauma(such as emergency caesarian section, hemorrhage or hypoxia) or developmental
abnormalities, and can also describe symptoms that the young person is reluctant
to talk about or even unaware of. Siblings often have important information to add,
particularly about interactions and social functioning. Past or family psychiatrichistory can be an important pointer for diagnosis.
Corroborative information from schools, about academic and social
functioning, health services and other care agencies will also be needed for an
accurate assessment not just of mental state but also of current and previous levelsof functioning.

DIFFERENTIAL DIAGNOSISThe first consideration is to decide if the reported symptoms are truly the
manifestation of a psychotic illness or due to another disorder. For example adepressed teenager may describe hearing a voice saying that they are useless, but
are actually talking about their own thoughts, or an anxious adolescent may see
shadows by their bed and be convinced that burglars have broken into the house.
Symptoms may also appear related to a psychosis but do not meet full
diagnostic criteria. Many individuals with schizophrenia have a prodrome,with disturbances in mood, thoughts and behavior and some deterioration infunctioning. However, these symptoms are non-specific and can have other causes,
such as an adjustment disorder or depression. Research has also identified psychoticlike experiences − bizarre beliefs, persecutory ideas and magical thinking. All these
symptoms except magical thinking increase the risk of later developing psychosis(Yung et al, 2006).
Even if it is clear that the young person meets criteria for a psychotic
disorder, it can be difficult to make a specific (e.g., whether schizophrenia or
bipolar) diagnosis early. Many diagnoses made at first presentation are found to
be incorrect later (McGorry et al, 1995). Thus, some experts prefer to use theterm early onset psychosis because it reflects this diagnostic uncertainty and provides
more treatment flexibility. If there is a definite psychotic illness, early treatment is
crucial, irrespective of its nature (e.g., schizophrenia, mood disorder). The longer
the duration of untreated psychosis the more difficult the symptoms are to treat
and the greater the risk of long term disability (Leeson et al, 2011). It is also

Schizophrenia H.5

10

IACAPAP Textbook of Child and Adolescent Mental Health

Table H.5.3

Investigations recommended at baseline assessment for early onset psychosis

Investigation

Rationale

Full blood count••Detection of pre-existing hematological disorders such as anemia
Monitoring side effects of mood stabilizers•

Exclusion of pre-existing abnormalities (rare, but polydipsia can be seenin psychosis).
Monitoring for medication side effects (some antipsychotics andantidepressants can cause hypernatremia, mood stabilizers can impair
liver function)

Urea, electrolytes, liver function
tests

•

•

Detection of insulin resistance or lipid abnormalities. Initial and six
monthly monitoring as most antipsychotics can cause weight gain andinsulin resistance•Thyroid abnormalities can cause mood elevation or depression and are aside effect of lithium treatment•

Abnormalities a rare cause of psychosis•

Exclusion of pre-treatment hyperprolactinemia (e.g., due to pituitary
tumor).

•

To monitor possible antipsychotic induced hyperprolactinemia,

Brain imaging (Computerized
Axial Tomography, CAT;
Magnetic Resonance Imaging,
MRI)

•
•

Exclusion of preexisting neuroanatomical lesions (injuries, malignancy)
MRI preferable because of higher resolution image and less radiation
exposure but noise and claustrophobia may not be tolerated by patient

EEG•

Exclusion of a seizure disorder

Urine drug screen•

To rule out recent drug use or identify illicit drugs taken recently

Fasting glucose, cholesterol andtriglycerides
Thyroid function
Calcium levels
Prolactin

important not to miss depression or elevated mood and so to misdiagnose a mooddisorder as schizophrenia.
Other differential diagnoses include pervasive developmental disorders,
PTSD with flashbacks, delirium and drug intoxication or drug induced psychosis,
as discussed earlier. Finally, it is important to exclude possible organic disordersthat can be confused with psychosis such as delirium, neurological disorders andother medical conditions such as thyrotoxicosis or Vitamin B12 deficiency, by aphysical examination and physical investigations as detailed below.
Investigations
Investigations are detailed in Table H.5.3. They are not only performed to
exclude treatable organic causes for psychosis but also as a baseline to monitor,
prevent and manage side effects of treatment. A full physical examinationis also essential, with particular emphasis on developmental or neurologicalabnormalities. Weight, height, waist measurement, blood pressure and pulse need
to be recorded initially and monitored regularly. There are acute autoimmune or
inflammatory illnesses that can mimic psychosis, especially when onset is acute(symptoms in these cases could be of delirium). Appropriate pediatric or othermedical consultations may be required.

Schizophrenia H.5

11

IACAPAP Textbook of Child and Adolescent Mental Health

MANAGEMENT
Least coercive treatment
Assessment should always consider risk, both to the young person and toothers. Ideally assessment and treatment should occur while patients remain athome with their family, but an admission to hospital may be needed if:•

There are concerns about high risk of suicide•

There is risk aggression to others (e.g., because of delusional beliefs)•

The patient is at serious risk of exploitation by others while unwell•

The young person is homeless•Carers are exhausted. For example when teenagers have required roundthe clock supervision for days and their family can no longer manage
this•

There are physical symptoms such as fluctuating levels of consciousness
that require urgent medical investigation.

Taking into account the risk, the option least restrictive of patient’s liberty
should generally be used. If the risk is high, admission may need to be involuntary
if the consent of either the young person or their family cannot be obtained, or
there is concern that the young person is not well enough to make rational decisions
about treatment. The laws about involuntary hospitalization vary according tocountry, but many only allow treatment against an individual’s wishes if there isserious danger to themselves or others. Click here to see an example of legislation
for involuntary hospitalization.
While it is possible to admit a child under the age of sixteen with theirparents’ consent (in many countries individuals have the capacity to give consent
to treatment at 16 years of age, see Chapter A.1), it is also important to respect thechild’s rights, including the right to have their views about treatment considered
and to be protected from violence (protection from being hurt physically andmentally by caregivers). This means that, even if young people are admitted against
their will, every effort should be made to discuss their treatment with them, taketheir preferences into account wherever possible and to keep the use of coercive
practices such as restraint to an absolute minimum.
Summary of management
Biological
Antipsychotic medication is essential for the treatment of psychosis. Most
treatments are extrapolated from the results of adult studies. Studies in children
include one small randomized controlled trial (RCT) showing haloperidol to besuperior to placebo (Spencer & Campbell, 1994), and a small RCT (21 cases)
showing that clozapine was superior to haloperidol (Kumra et al, 1996). Studies
in adolescents show similar efficacy to adults for olanzapine, risperidone andhaloperidol, but with differing side effect profiles and a non-significant trend forolanzapine and risperidone to be more effective (Gothelf et al, 2003; Sikich et al,2008). These findings are similar to those in adult treatment trials.

Schizophrenia H.5

12

Sedation

++
++
+
+++
+++
++

Extra
pyramidal
side effects

++
+
++
+
+

+++

Dose
(mg)

1-6mg

200-800mg

10-30mg

5-20mg50-300mg

1-10mgRisperidone

Quetiapine

Schizophrenia H.5

Aripiprazole

Olanzapine

Chlorpromazine

Haloperidol

+

++

+++

+

++

++

Weight
gain

+

++

+

+

+++

Prolactin

+

++

+

+

+

++

Posturalhypotension

Very significant
weight gain
Sedation.
Not recommended
long term•

Weight gain, sedation
Severe extra
pyramidal side effects
including stiffness andagitation

•
•

•
•

Initial agitation

Initial sedation, often
settles••

Galactorrhea,
Sedation••

Potential
disadvantages

Common side effects of selected antipsychotic medications used in early onset psychosis

Medication

Table H.5.4

Less sedating, strong
antipsychotic effects

Sedating and calming
when acutely unwell

Sedating and calming
when acutely unwell

Sedation, weight gain andelevated prolactin are rare

Useful for psychosis withmood disorders or anxiety

Most data comes fromuse in adolescents(including in autism)

Comments

IACAPAP Textbook of Child and Adolescent Mental Health13

IACAPAP Textbook of Child and Adolescent Mental Health

PychologicalInterventions include psychoeducation and cognitive behavioral therapy.
Again, the evidence is from adult and late adolescent cohorts, with multiple trials
showing benefit from these therapies (Bechdolf et al, 2010a).
SocialThese therapies include family interventions and social skills training andagain show benefit in multiple adult trials (Addington et al, 2005; 2010).
Pharmacotherapy
Acute sedation
If there is acutely disturbed behavior or imminent danger, emergency
sedation may be needed. Rapidly acting oral medication such as lorazepam (1mg2mg), risperidone (0.5mg-1mg) or olanzapine (2.5mg to 5mg) are preferred. Oralwafers are absorbed more quickly and also dissolve in the mouth so are difficult
to spit out. If oral medication is refused, intramuscular lorazepam (1mg-2mg)
or haloperidol (2.5mg-5mg) are recommended. Intramuscular sedation usuallyrequires physical restraint and is very distressing for the child and family. It is
important to use the least coercive method of sedation not only to respect young
person’s rights, but also because the first experience of mental health treatment
can be very aversive and make the difference between ongoing compliance or
avoidance of further treatment.
Ongoing management of medication
If no emergency treatment is needed, medication decisions in early psychosis
aim to control psychotic symptoms and manage associated impairments assummarized in Figure H.5.1 (for management of psychotic depression and manic
episodes see Chapters E.1 and E.2 respectively). An antipsychotic is used to treat
hallucinations and delusions. In psychotic depression an antidepressant is added.
When there is mania a mood stabilizer may be more appropriate. Table H.5.4
summarizes side effects of the most commonly used antipsychotic medications. It
is recommended to start low and go slow with doses of antipsychotic medication.
This is to avoid side effects and maximize adherence to treatment. (For a detailed,evidence based summary of treatment algorithms, the use of specific medications
and side effects please see Taylor, 2012).
A second generation (atypical) antipsychotic is recommended as first line
treatment if possible because of marginally better treatment outcomes in acute
psychosis and the lower risk of movement disorder, particularly tardive dyskinesia,
as demonstrated in individual RCTs and meta analyses (Davis et al, 2003; Leucht
et al, 2009). However, second generation antipsychotics are expensive, so it may
be necessary to use a first generation antipsychotic such as haloperidol, which isstill highly effective (Schooler et al, 2005), although has more side effects thanrisperidone, for example.
When there is no response to antipsychotic medication after two weeks, a
medication review is needed – some response in positive psychotic symptoms is
usually seen by that time. If the maximum tolerable dose of a particular medication
has been reached without effect a choice needs to be made about either changing
medication or augmentation with another medication class (Figure H.5.1). Failure

Schizophrenia H.5

14

IACAPAP Textbook of Child and Adolescent Mental Health

Figure H.5.1 Simple flow chart for the treatment of an acute
psychotic episodePsychosis(hallucinations or delusions)

Antipsychotics(Risperidone, 0.5mg to 4mg,
as tolerated or to symptom
remission)

Poor responseat an adequate dose
for long enoughGood response:
continue withmedication

Psychotic symptoms
predominate

Mood symptoms
also present

Change to anotherantipsychotic:• quetiapine
100-800mg or• aripiprazole
10-30mg

Depression
predominates:
add an SSRI

Fluctuating mood:
add a moodstabiliser

Click on the picture to accessa metabolic monitoringalgorithm for young people
prescribed antipsychotic
medication

Schizophrenia H.5

15

IACAPAP Textbook of Child and Adolescent Mental Healthto respond to two or more antipsychotics for an adequate length of time and at
adequate doses should prompt referral to a specialist service for consideration of
clozapine.
Long term antipsychotic use increases the risk of obesity, type twodiabetes and cardiovascular disease. It is crucial to monitor height, weight andwaist measurement at the start of prescribing, and then at one, three, and thensix monthly intervals, with intervention as needed (see metabolic monitoringalgorithm in side box).
Clozapine for treatment resistant schizophrenia

Click on the picture to access
Get Help Early (Ontario
Working Group on Early
Intervention in Psychosis,
Canada). It includes stories
and artwork.

Clozapine is an atypical antipsychotic that is extremely effective inschizophrenia; it should be used if there is a poor response to two otherantipsychotic agents, each given at adequate doses for at least a four week trial. It
is not recommended except for treatment resistant cases because of the risk of life
threatening side effects and therefore the need for close monitoring. The minimum
frequency of monitoring is weekly white blood cell counts for the first 18 weeks,with caution being used when neutrophils fall below 2 per 109/Litre. Clozapine
should be ceased at a neutrophil count of 1.5 per 109/Litre. Many health services
require registration of patients on clozapine so that these monitoring requirements
are met before clozapine is dispensed. An example of the monitoring requirements
can be found here.

Life threatening

Table H.5.5

Severe and common side effects of clozapine and their management

Side effectSigns and symptoms

Agranulocytosis or
neutropenia••

Falling white cell count
Infections

Cardiomyopathy

•
•
•
•

Tachycardia
Fever
Fatigue
Chest pain

Other common side effects

Sedation
Hypersalivation
Constipation
Other cardiovasculareffects
Weight gain

Schizophrenia H.5•••

Weekly white cell counts as per clozapine
protocols, regular temperature and healthchecks.
Stop clozapine if low neutrophils•

ECG prior to starting clozapine, monitoring
temperature and heart rate, troponin levels
if available.
Stop clozapine if it occurs•

Give most of dose at night•

Dribbling, especially at night•

Small doses of hyoscine•

Remember to ask patients
about this•High fibre diet••

Hypotension
Tachycardia.

•

Monitor if minor, if significant refer tocardiologist•

Can be severe (10kg and
more)

•
•

Monitor weight and waist measurement
Diet management•••

Stop for a day
Reduce dose
Use anticonvulsant••

Reduce fluids at bed time
Change dose regime

SeizuresBed wetting

Monitoring and treatment•

Seen in 1 in 5, possible
worse on teenagers

16IACAPAP Textbook of Child and Adolescent Mental Health

Other common side effects are detailed in Table H.5.5, but this list is by nomeans complete. It is recommended that clozapine be prescribed only by specialists
who are aware of the side effects and able to manage the risks appropriately.
Other interventions
There is good evidence of effectiveness for several other therapies in thetreatment of early psychosis. All have been shown to reduce the risk of relapse and,most importantly, help young people and their families feel more in control of
their symptoms and their treatment.
Psychoeducation
Psychoeducation is a structured way of providing information about
psychotic disorders and their treatment for both young people and their families.
There are manualised programs available and evidence that psychoeducation
reduces the rate of relapse in early psychosis (Xia et al, 2011).
The ingredients of effective psychoeducation include:•••

Providing information about the illness and treatment options
Offering a forum for the young persons to discuss their illness andconcerns
Involving family members in the education process, whether with theirchildren or in parent groups.

If successful, the rate of relapse is reduced by increased adherence tomedication, reduction in maladaptive behaviors such as substance misuse, andearly recognition of symptom return or deterioration. Coping skills and problem
solving training can also be part of the education program (Xia et al, 2011).
While face to face psychoeducation programs are useful they may not be
available in remote or rural areas or may not be run at convenient times. Web
based resources are also an excellent way of obtaining information and becoming
part of a supportive network.
Cognitive behavioral therapy (CBT)
Some young people find CBT helpful in understanding and managing their
symptoms. The goals of CBT vary depending on the symptoms of concern, but
can include coping strategies for psychotic experiences and managing low mood.
Directly addressing the psychotic symptoms is most effective in the recovery rather
than the acute phase of the illness. However, CBT is also useful for managing
residual symptoms such as hallucinations that persist despite antipsychotic
treatment. Strategies include:•••

Click on the picture toaccess the Cognitively
Oriented Psychotherapy
for First-Episode Psychosis(COPE) manual.

Exploring and challenging delusional beliefs
Finding coping strategies to minimize the impact of hallucinations
Managing feelings of hopelessness and low mood using similar
techniques to those used in CBT for depression.

Working with families
As well as providing support, initial work with families involves a
psychoeducational approach, providing information about the illnesses and how it
affects thoughts and behaviors. Problem solving skills and communication strategies
help families deal with difficult situations and reduce distress in the household. This

Schizophrenia H.5

17

IACAPAP Textbook of Child and Adolescent Mental Healthreduces the risk of relapse, as well as preventing family estrangement (Addington
et al, 2005).
Maintenance medication and management of side effects
Use of antipsychotic medication is recommended for at least 12 months
after symptom remission to reduce relapse. Careful monitoring and managementof side effects is essential. Weight gain and associated metabolic abnormalities are
the most frequent, but sedation and cognitive slowing can also cause distress. Thereis some evidence from meta-analyses – of adult treatment trials – that the second
generation antipsychotics are more effective at preventing relapse than the first
generation ones (Alvarez-Jimenez et al, 2011). Six monthly monitoring is requiredfor:• Involuntary movements (the recommended scale is the AIMS –Abnormal Involuntary Movement Scale)• Weight, waist measurement, pulse rate and blood pressure• Fasting glucose and lipids.
Movement disorders, including Parkinsonism and akathisia, are lesscommon with second generation antipsychotics. If these occur, try small dosesof an anticholinergic drug, for example benztropine 0.5mg a day. Reducing thedose of antipsychotic is often more effective. Tardive dyskinesia, a rare, chronic
movement disorder, is often first seen as small movements in the face, togue or
fingers. Early identification is important as tardive dyskinesia may persist after
medication is ceased. The most commonly used mood stabilizers (in particularlithium carbonate, sodium valproate and carbamazapine) are teratogenic and thisneeds to be discussed with sexually active adolescents. The use of lithium requires
clear instructions about the need to avoid dehydration and have regular lithium
levels and thyroid function tests to monitor for possible toxicity (see Chapter E.2).
Prevention of relapse
The first step to relapse prevention is to develop an individual plan to detect
warning signs such as difficulty sleeping, increased anxiety or the first signs that
hallucinations or delusions are reappearing. If medication is being slowly reduced,
recurrence of any symptom suggests that a return to the higher effective dose isrequired, or to resume previously effective medication if it had been stopped.
Ongoing monitoring by mental health professionals during this time is essential.
There are few studies examining relapse rates in children and adolescents but one
study on first episode psychosis found a 17% relapse rate when medication was
stopped after 12 months (Gaebel et al, 2011). As with the first episode, the earliera relapse is treated the better the recovery. Relapses can also cause further cognitiveand social deterioration.
Services for early psychosis
While schools, general practitioners, pediatricians and other health careproviders often identify young people at risk of psychosis, once early psychosis is
identified it is essential that mental health services be involved if at all possible.
In Australia these services include child and adolescent mental health services−
community based teams who treat young people up to the age of 18 and youth
mental health services, for ages 12-25. All these services use a case management
model, with a case manager (mental health professional) and consultation with a

Schizophrenia H.5

Click on the picture to viewa 25 minute documentary on
schizophrenia. This website,which has information forpatients and families, issponsored by Janssen
Pharmaceuticals

18

IACAPAP Textbook of Child and Adolescent Mental Healthpsychiatrist as needed. Some services also provide assertive case management (a more
intensive case management used for difficult to treat patients, with active follow up
including home visits), drug and alcohol services, general health and sexual healthservices or help with financial management, housing and employment.
Specialized services in remote or rural areas are few or non-existent. Local
family doctors provide most of the care with support from a mental health worker,
often a nurse. Internet resources listed can be useful both to guide treatment andto provide education for young people and their families.

RECOVERY, RETURN TO EDUCATION ANDOUTCOME
It is important to be both optimistic and honest when talking to young
people and their families. They need to know that, while acute psychotic
symptoms almost always remit within days to weeks, negative symptoms such as
poor motivation, concentration and cognitive slowing may continue for many
months, particularly in the case of schizophrenia. While the majority of symptoms
improve in the first six months of treatment, improvement can continue for up to
two years. Schizophrenia spectrum disorders tend to have the slowest response, thehighest rate of residual deficits and a lifelong risk of relapse of up to 90%. A better
prognosis is more likely with a rapid onset of psychotic symptoms, prominentmood symptoms, good social and educational functioning prior to the illness anda rapid response to treatment.
Returning to school may be difficult because of negative symptoms,
cognitive difficulties or the amount of time missed, including explaining absences
to others. Options depend on what local health and education services are locallyavailable. Meeting with the young persons’ school and negotiating part-timeattendance is desirable. Where school counselors or similar are available, theirinvolvement is crucial. Some countries offer education programs with smallerclasses and staff trained to manage young people with psychological disorders.
For those who have reached school-leaving age, institutions that deliver vocational
training my provide support for these patients. Partial hospitalization (e.g., day
programs) or work preparation programs may be needed for those whose recovery
is slower. Additional evidence-based interventions such as social skills training or
cognitive remediation strategies may also be useful (Poletti et al, 2010; Addington
et al, 2010).
Incomplete recovery
Some young people with schizophrenia do not fully respond to treatment
and have ongoing positive or negative symptoms. Reasons for incomplete recovery
include:••Factors in the young person, including adherence to treatment.
Compliance may be poor because of lack of insight into their illness,concern about side effects such as weight gain or extra pyramidal
symptoms. Comorbid disorders such as drug and alcohol abuse, ahistory of trauma or a pervasive developmental disorder make psychosis
harder to treat
Illness factors. Some young people have a more severe form of the illness
with a long prodrome and prominent negative symptoms, which

Schizophrenia H.5

Click on the picture to view aclip about early intervention
and treatment from the US
Maine Medical Centre’s
PEIR Program. Other
useful websites are theone from the International
Early Psychosis Association(IEPA), a network for people
involved in the study andtreatment of early psychosis,
and the Early Psychosis
Prevention and Intervention
Centre (EPPIC) website.
This Australian website hasa wide range of information
about the identification andtreatment of early psychosis.
Mental Health professionals
can register with the siteand log on for forums andeducation sessions.
As well as many of thewebsites already mentioned
the Schizophrenia Fellowshipand Arafmi are twoAustralian non-governmentorganizations that provide
support and information forfamily members and others
who care for people withmental illness.

19

IACAPAP Textbook of Child and Adolescent Mental Health•takes longer to respond to treatment, or may never
respond completely
Treatment factors. Poor response is more likely if
the first experience of treatment was coercive or
patients do not have active follow up. Ongoing stressat school or in their family (e.g., high expressed
emotion) make relapse more likely. Psychologicaltreatments such as CBT or family therapy help toprevent relapse by teaching strategies to manage
early symptoms and reduce and mange stress.

Support for family and other carers
Caring for young persons with a chronic mental
illness can be exhausting for their families. As well as family
psychoeducation, informative websites and support groups canhelp families and carers feel less alone.

SUMMARY AND CONCLUSIONS
Psychotic symptoms in children and adolescents can be
confusing and difficult to assess in the early stages. However,
early symptoms, such as functional decline or hallucinations,should be taken seriously. While many symptoms remit with time, early symptoms
are associated with an increased risk of schizophrenia spectrum disorders in adultlife. There is also good evidence that early treatment reduces the morbidity andmortality associated with this group of severe mental illnesses.

Resources in languages other than English
There is a wealth of resources available on the Internet, some examples are given below.
•
•
•
•
•

•

Many international resources are indexed at schizophrenia.com
The Quebec Early Psychosis Program (AQPPEP) has a site in French
The Swiss Early Intervention site has interactive information in German, French andEnglishP3 Programa de Prevención de Psicosis is a Spanish site with resources in Spain
Chinese sites (Cantonese) include the Hong Kong Early Psychosis Intervention Society;
EASY, an animated website for people aged 15-25 with information about psychosis, selfassessment, news, and where to get help; and Radio-I-Care, an online radio broadcast
with a range of topics on mental illness, intervention, and how to live with psychosis.
The pharmaceutical company Astra Zeneca funds an educational site about psychosisand bipolar disorders in several languages (German, Russian, Turkish and English).

Schizophrenia H.5

Encouraged by Henri
Laborit, a French surgeon
and researcher, the French
pharmaceutical company
Rhône-Poulenc synthesizedchlorpromazine in 1950.
The first systematic studyof chorpromazine’s effecton Schizophrenia, which
included 38 patients, waspublished by the French
psychiatrists Jean Delayand Pierre Deniker in 1952.
Jean Delay created the word
"psychopharmacology",
propposed the definition ofneuroleptic drugs (literally,"substances that take thenerves") and together with
Deniker established the firstclassification of psychotropic
drugs. Chorpromazine is stillin clinical use today.
Photo: Delay (left) andDeniker20

IACAPAP Textbook of Child and Adolescent Mental Health

REFERENCES
Addington AM, Rapoport JL (2009). The genetics of childhoodonset schizophrenia: when madness strikes the
prepubescent. Current Psychiatry Reports, 11:156-161.
Addington J, Mccleery A, Addington D (2005). Three-year
outcome of family work in an early psychosis program.
Schizophrenia Research, 79:107-116.
Addington J, Piskulic D, Marshall C (2010). Psychosocial
treatments for schizophrenia. Current Directions in
Psychological Science, 19:260-263.
Alvarez-Jimenez M, Parker AG, Hetrick SE et al (2011).
Preventing the second episode: a systematic review andmeta-analysis of psychosocial and pharmacologicaltrials in first-episode psychosis. Schizophrenia Bulletin,
37:619-630.
Arango C, Moreno C, Martinez S et al (2008). Longitudinal
brain changes in early-onset psychosis. Schizophrenia
Bulletin, 34:341-353.
Asarnow JR, Tompson MC, Mcgrath EP (2004). Childhoodonset schizophrenia: clinical and treatment issues.
Journal of Child Psychology & Psychiatry, 45:180-194.
Askenazy FL, Lestideau K, Meynadier A et al (2007). Auditory
hallucinations in pre-pubertal children. A one-year
follow-up, preliminary findings. European Child &Adolescent Psychiatry, 16:411-415.
Bechdolf A, Knost B, Nelson B et al (2010a). Randomized
comparison of group cognitive behaviour therapy
and group psychoeducation in acute patients withschizophrenia: effects on subjective quality of life.
Australian & New Zealand Journal of Psychiatry,
44:144-50.
Bechdolf A, Thompson A, Nelson B et al (2010b). Experience of
trauma and conversion to psychosis in an ultra highrisk (prodromal) group. Acta Psychiatrica Scandinavica,
121:377-384.
Bedwell JS, Keller B, Smith AK et al (1999). Why does
postpsychotic IQ decline in childhood-onset
schizophrenia? American Journal of Psychiatry,156:1996-1997.
Caspi A, Moffitt TE, Cannon M et al (2005). Moderationof the effect of adolescent-onset cannabis use on
adult psychosis by a functional polymorphism inthe catechol-O-methyltransferase gene: longitudinalevidence of a gene x environment interaction.
Biological Psychiatry, 57:1117-1127.
Cutajar MC, Mullen PE, Ogloff JRP et al (2010). Schizophrenia
and other psychotic disorders in a cohort of sexually
abused children. Archives of general psychiatry, 67:1114-1119.
Davis JM, Chen N, Glick ID (2003). A meta-analysis of theefficacy of second-generation antipsychotics. Archivesof General Psychiatry, 60:553-564.
Dhossche D, Ferdinand R, Van Der Ende J et al (2002).
Diagnostic outcome of self-reported hallucinations
in a community sample of adolescents. Psychological
Medicine, 32:619-627.

Schizophrenia H.5

Escher S, Morris M, Buiks A et al (2004). Determinants ofoutcome in the pathways through care for children
hearing voices. International Journal of Social Welfare,
13:208-222.
Escher S, Romme M, Buiks A et al (2002). Independent courseof childhood auditory hallucinations: A sequential
3-year follow-up study. British Journal of Psychiatry,
181(supp43):s10-s18.
Gaebel W, Riesbeck M, Wolwer W et al (2011). Relapse
prevention in first-episode schizophrenia−maintenancevs intermittent drug treatment with prodromebased early intervention: results of a randomized
controlled trial within the German Research Network
on Schizophrenia. The Journal of clinical psychiatry,
72;205-218.
Gothelf D, Apter A, Reidman J et al (2003). Olanzapine,
risperidone and haloperidol in the treatment ofadolescent patients with schizophrenia. Journal of
Neural Transmission, 110:545-560.
Hainsworth C, Starling J, Brand F et al (2011). Trauma andpsychotic symptoms: Data from a pediatric mental
health inpatient unit. Journal of Traumatic Stress,
24:491-494.
Hollis C (2000). Adult outcomes of child- and adolescent-onset
schizophrenia: diagnostic stability and predictive
validity. American Journal of Psychiatry, 157:16521659.
Kendler KS, Gallagher TJ, Abelson JM et al (1996). Lifetime
prevalence, demographic risk factors, and diagnostic
validity of nonaffective psychosis as assessed in a
US community sample. The National Comorbidity
Survey. Archives of General Psychiatry, 53:1022-1031.
Kolvin I (1971). Studies in the childhood psychoses. I.
Diagnostic criteria and classification. British Journal of
Psychiatry, 118: 381-384.
Kumra S, Frazier JA, Jacobsen LK et al (1996). Childhood-onset
schizophrenia. A double-blind clozapine-haloperidol
comparison. Archives of General Psychiatry, 53:10901097.
Lee P, Moss S, Friedlander R et al (2003). Early-onset
schizophrenia in children with mental retardation:
Diagnostic reliability and stability of clinical features.
Journal of the American Academy of Child & Adolescent
Psychiatry, 42:162-169.
Leeson VC, Sharma P, Harrison M et al (2011). IQ trajectory,
cognitive reserve, and clinical outcome following afirst episode of psychosis: a 3-year longitudinal study.
Schizophrenia Bulletin, 37:768-777.
Leucht S, Corves C, Arbter D et al (2009). Second-generation
versus first-generation antipsychotic drugs forschizophrenia: a meta-analysis. Lancet, 373:31-41.
Losh M, Sullivan PF, Trembath D et al (2008). Current
developments in the genetics of autism: fromphenome to genome. Journal of Neuropathology &Experimental Neurology, 67:829-837.

21

IACAPAP Textbook of Child and Adolescent Mental Health

McGee R, Williams S, Poulton R (2000). Hallucinations
in nonpsychotic children. Journal of the American
Academy of Child & Adolescent Psychiatry, 39:12-13.

Scott JG, Nurcombe B, Sheridan J et al (2007b). Hallucinationsin adolescents with post-traumatic stress disorder andpsychotic disorder. Australasian Psychiatry, 15:44-48.

McGorry PD, Mcfarlane C, Patton GC et al (1995). The
prevalence of prodromal features of schizophrenia inadolescence: a preliminary survey. Acta Psychiatrica
Scandinavica, 92:241-249.

Shevlin M, Dorahy MJ, Adamson G (2007). Trauma andPsychosis: An Analysis of the National Comorbidity
Survey. The American Journal of Psychiatry, 164:166169.

Owens DGC, Johnstone EC (2006). Precursors and prodromata
of schizophrenia: findings from the Edinburgh High
Risk Study and their literature context. Psychological
Medicine, 36:1501-1514.

Sikich L, Frazier JA, Mcclellan J et al (2008). Doubleblind comparison of first- and second-generation
antipsychotics in early-onset schizophrenia andschizoaffective disorder: Findings from the Treatmentof Early-Onset Schizophrenia Spectrum disorders(TEOSS) study. The American Journal of Psychiatry,
165:1420-1431.

Poletti S, Anselmetti S, Bechi M et al (2010). Computeraided neurocognitive remediation in schizophrenia:
durability of rehabilitation outcomes in a follow-up
study. Neuropsychological Rehabilitation, 20:659-674.
Poulton R, Caspi A, Moffitt TE et al (2000). Children's
self-reported psychotic symptoms and adultschizophreniform disorder: A 15-year longitudinal
study. Archives of General Psychiatry, 57:1053-1058.

Spencer EK, Campbell M (1994). Children with schizophrenia:
diagnosis, phenomenology, and pharmacotherapy.
Schizophrenia Bulletin, 20:713-725.
Starling J, Dossetor D (2009). Pervasive developmental disorders
and psychosis. Current Psychiatry Reports, 11:190-196.

Rapoport J, Chavez A, Greenstein D et al (2009). Autism
spectrum disorders and childhood-onset
schizophrenia: Clinical and biological contributions toa relation revisited. Journal of the American Academy ofChild & Adolescent Psychiatry, 48:10-18.

Taylor D, Paton C, Kapur S (2012). Prescribing Guidelines in
Psychiatry. Oxford:Wiley Blackwell.

Rapoport JL, Inoff-Germain G (2000). Update on childhoodonset schizophrenia. Current Psychiatry Reports, 2:410415.

Xia J, Merinder BL, Belgamwar MR (2011). Psychoeducation
for schizophrenia. Cochrane Database of Systematic
Reviews. DOI: 10.1002/14651858.CD002831.pub2

Schimmelmann BG, Conus P, Cotton S et al (2007). Pretreatment, baseline, and outcome differences
between early-onset and adult-onset psychosis in an
epidemiological cohort of 636 first-episode patients.
Schizophrenia Research, 95:1-8.
Schooler N, Rabinowitz J, Davidson M (2005). Risperidone
and haloperidol in first-episode psychosis: a longterm randomized trial. American Journal of Psychiatry,
162:947-953.
Scott J, Chant D, Andrews G et al (2007a). Association between
trauma exposure and delusional experiences in a large
community- based sample. British Journal of Psychiatry,
190:339-334.
Scott J, Chant D, Andrews G et al (2006). Psychotic-likeexperiences in the general community: the correlatesof CIDI psychosis screen items in an Australiansample. Psychological Medicine, 36:231-238.

Schizophrenia H.5

Volkow ND (2009). Substance use disorders in schizophrenia:
clinical implications of comorbidity. Schizophrenia
Bulletin, 35:469-472.

Yung AR, Buckby JA, Cotton SM et al (2006). Psychotic-likeexperiences in nonpsychotic help-seekers: associations
with distress, depression, and disability. Schizophrenia
Bulletin, 32:352-359.
Yung AR, Nelson B, Stanford C et al (2008). Validation of"prodromal" criteria to detect individuals at ultrahigh risk of psychosis: 2 year follow-up. Schizophrenia
Research, 105, 10-17.
Yung AR, Phillips LJ, Yuen HP et al (2004). Risk factors forpsychosis in an ultra high-risk group: Psychopathology
and clinical features. Schizophrenia Research, 67:131142.
Yung AR, Yuen HP, Berger G et al (2007). Declining transition
rate in ultra high risk (prodromal) services: dilution or
reduction of risk? Schizophrenia Bulletin, 33:673-681.

22