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

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

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

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

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

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

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

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

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

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

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

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

 

© 2005 Roy Sugarman

 

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

Categories: ChildhoodDisorders, Psychology