Childhood-Onset Schizophrenia Prevention
The problem of schizophrenia remains one of the most important psychosomatic problems in the modern psychiatry and requires more multidisciplinary research. Schizophrenia is a brain disorder, which manifests in abnormal mental functions and behavior. Schizophrenia is characterized by the severe psychotic symptoms, such as various forms of nonsense (false beliefs), hallucinations (false perception), frustration of thinking, extremely disorganized behavior, a catatonia (motor dysfunctions: from over excitation to a full immovability), the extremely inadequate or poor emotional reactions (flat affect), and also considerable deteriorations or social functioning violations. Childhood-onset schizophrenia (COS) is similar to regular schizophrenia, however it appears at early age. It is one of the most severe forms of schizophrenia, but is not an independent disease. At present, the psychosis, which begins in children up to 10 year old, is defined as COS. Moreover, the psychosis is divided into the subgroups according to the age of a child accepted in pediatrics, such as the early childhood – until 3 years old, pre-preschool age – from 3 to 5 years and preschool – from 5 to 7 years (Addington & Rapoport, Bartlett). The given research paper describes the prevalence rates and risk factors of COS, its diagnostic criteria, clinical characteristics, as well as prevention of the disease.
COS Prevalence Rates
According to Bartlett, the prevalence rates variate in different regions of the globe. The COS prevalence rates, extremely rarely found among children up to 12, increase in teenage years and reach its critical point at the age of 20-25:
- The prevalence of COS makes from 0.14 to 1.0 cases per 10 000 children;
- Schizophrenia occurs among the adults 100 times more often than among children;
- COS at earlier age (2-4 years) in boys happens twice more often than in girls. However, the specified distinctions between genders disappear at teenage years (Bartlett).
The general risk of the disease is 0.4 – 0.6% (4-6 cases per 1000 people). Boys and girls get sick equally, however, the prevalence of the disease in boys is explained by the general biological vulnerability of males to the neurological disorders, or different etiology (origin) of the processes in boys and girls. In adulthood, schizophrenia is met more often among the representatives of the lowest social and economic segments of the population. The symptoms in children with COS occur in the representatives of various cultures, ethnos and racial groups (Naguy & Al-Mutairi).
COS Risk Factors
The biological conditions, family, social and cultural factors as well as drug use and alcoholism are among the risk factors of COS. At the early stage of the neuronal development, including during pregnancy, the causal factors can increase the risk of the future development of the disease. In this regard, the COS risk is dependent on a birth season, indicating that the disorder is more often observed in children born in winter and spring. Moreover, the prenatal infections increase risk, thus confirming the direct connection of the disease with the developmental disorders.
Childhood-onset schizophrenia is a hereditary (familial) disease. However, the fact that not both monogerminal twins become sick in all schizophrenia cases says that not only genetic factors affect the probability of the development of schizophrenia in children. The non-genetic factors, including infections, toxins, trauma and stress during prenatal and post-natal development, also play a role in causing schizophrenia, apparently, having more mediated impact on the neurologic development (Bartlett; Starling & Feijo).
The modern views on the causes of COS are based on the vulnerability stress model, which focuses on the role of the interaction between a child’s predisposition and stressful and protective factors. The predisposition factors include a genetic risk, defects of the central nervous system, lack of the conditions necessary for training or pathological forms of family relations. The events increasing the probability of schizophrenic episodes, such as a death of a close relative, or sources of a chronic stress, such as ill-treatment of a child in a family, belong to stressors. The protective factors include the conditions reducing the probability of schizophrenic episodes in children belonging to a risk group. These factors include a highly developed intelligence, social skills or a favorable situation in a family (Addington & Rapoport).
The vulnerability stress model emphasizes the role of the neuropathology in developing schizophrenia at early age. Moreover, it is confirmed by the data, which proves that psychotic symptoms expressed in motor and cognitive deficiencies and disorders of a social interaction are found in babies and children earlier than the psychosomatic symptoms, expressed in the motor and cognitive deficits and violations of the social interconnections. The neuropsychological researchers testify that attention and information processing deficiency found in the adults with schizophrenia are characteristic for the children with COS. Moreover, the record of the brain activity during the performance of such tasks testifies to the existence of the limited ability to process cognitively the information (Starling & Feijo).
There is a strong influence of the genetic factors on the COS probability, which even exceeds the probability of a disease at mature age. In particular, the quantity of COS cases among the relatives of sick children approximately twice exceeds the number of the cases affecting the relatives of the adults sick with schizophrenia. This data in general confirms that COS is the most severe form of schizophrenia (Addington & Rapoport).
Among the social factors, there is a stable correlation between the COS risk and the urbanization degree. The social factors include a low social status, including poverty, migration caused by social disparities, racial discrimination, problematic families, a high level of unemployment and bad living conditions. The mockeries and injuring experiences in the childhood also promote the future development of schizophrenia. The parental education does not pose a risk of COS, but the broken relationship characterized by a lack of support can make its contribution. In addition, loneliness is one of the social factors of COS (Naguy & Al-Mutairi).
COS occurs in all cultural, social and economic classes. There is a larger number of children with schizophrenia in lower social and economic sectors of society. This fact is explained by the downward drift hypothesis, according to which sick people either move to the lower classes, or cannot get into the higher due to the disease. The stresses endured by the representatives of the lower class are the factors promoting the development of schizophrenia. Thus, that social stresses have an impact on the development of COS (Naguy & Al-Mutairi).
Immigration, industrialization and tolerance to abnormal behavior existing in certain sectors of society have an impact on the etiology of schizophrenia. The high prevalence of COS among recent immigrants can cause the change of the cultural features, which, being a stressful factor contributes to the development of the disease. In addition, the spread of schizophrenia in the developing countries is caused by the interaction with more advanced equipment and culture. Some types of culture can be more or less prone to schizophrenia depending on how a patient mentally perceives stress, what his role is or what social protection system is, and how complex social communications are. Schizophrenia has more favorable forecast in less developed nations.
COS and drug addiction are connected, and do not allow to trace the relationships of cause and effect with ease. There is an evidence that certain drugs are capable to cause the disease in some teenagers or to provoke the next attack. Amphetamines and alcohol stimulate the emission of dopamine, and the excess of a dopaminergic activity causes the psychotic symptomatology in schizophrenia. In addition, the excessive use of hallucinogenic and excitants can provoke COS (Starling & Feijo).
COS Diagnostic Criteria and Clinical Characteristics
The initial stages of COS can be manifested in a child’s inability to concentrate his/her attention, a sleep disorder, difficulty to study and avoidance of communication. The development of disease can be characterized by the incoherent speech; besides, a child can start seeing or hearing what people around cannot. After the progressing periods, may appear severest recurrence characterized by the incoherent thinking when a child starts jumping from one thought to another one without any logical communication. During the psychotic phases of COS, children can be convinced that they possess superhuman abilities or that some people constantly watch them. During a psychotic attack, a patient can start behaving in an unpredictable way, sometimes tending to aggression or a suicide (Naguy & Al-Mutairi).
The clinical manifestations of the disease at the age of 1- 3 are mainly presented by the monotonous excitement, circle walking, impulsiveness, unmotivated laughter and tears, run in the uncertain direction, etc. At late preschool age, the thinking disorders in the form of the nonsense-like imagination can appear. After the age of 12, schizophrenia is characterized with hallucinatory and crazy manifestations, though these symptoms can appear at the earlier age. The most severe form of COS is characterized by the alternation of the periods of motive excitement and immobility with the disintegration of the speech (a catatonic form). At teenage years, the hebephrenic form of the disorder is characterized by emotional emasculation, silliness, ridiculous “clownish” behavior and incoherent speech (Starling & Feijo).
The lack of emotions when voice and look do not change in the situations assuming the emotional response is another manifestation of COS. The events, which force a healthy person to laugh or cry, do not cause any reaction in children with COS. The defective intelligence, characteristic to children, whose schizophrenic process arose at the stages of the formation of informative abilities during the first years of life, is the most severe complication of COS.
The signs of the disorder should be observed continuously, for at least 6 months. In addition, after the emergence of the frustration signs in a child such symptoms as an essential lowering of the level of functioning in one or several areas, or inability to achieve the expected level of results in the interpersonal, educational or professional sphere are observed. The explanation of the observed disorders with mood, schizoaffective disorder, the use of any preparations or chemicals, and the general state of health should be excluded. In the presence of the diagnosis of autism or other severe diseases caused by developmental disorders, the additional diagnosis of schizophrenia can be made only if nonsense or hallucinations continue to occur for a month.
The use of the general diagnostic criteria of schizophrenia for children and adults facilitates the comparison of COS and the schizophrenia at mature age and allows defining the cases in which the continuous course of disease throughout the entire period of individual development takes place. However, schizophrenia can be revealed differently depending on age. In particular, nonsense, hallucinations and formal thinking disorders occur extremely rarely and, thus, are unable to diagnose the disease up to the age of 7 (Starling & Feijo).
The rejection of age distinctions when using the diagnostic criteria of schizophrenia can lead to the incorrect diagnosis of COS in children. However, the full form of disease does not develop until a more mature age. The other factors connected with the individual development can also matter, when making the diagnosis of schizophrenia. In particular, it is sometimes difficult to draw the line between such pathological symptoms as the nonsense and usual imaginations caused by the phantasies characteristic to many young children. In addition, it is necessary to consider the fact that unlike adults, young children do not feel discomfort and disorganizing character of the psychotic symptoms. Therefore, if they emerge at early stages of development, children may not distinguish them from the normal experiences.
The modern prevention of mental diseases includes the concepts of primary and secondary prevention. The primary prevention of children’s schizophrenia as an endogenous disease is quite problematic. Nevertheless, the modern data on the genetic risk of COS allow giving the relevant advice on the prevention or interruption of pregnancy. Another prerequisite of the COS primary prevention includes the data of many children’s psychiatrists on the frequency of exogenous harm in the early anamnesis of the COS patients (pre-natal, perinatal and early post-natal harm). Therefore, the measures connected with health protection of pregnant women, obstetric aid improvement, and also strengthening of the health of newborns and children of early age can be conditionally related to the primary prevention of COS (Naguy & Al-Mutairi).
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The COS’s psychogenesis includes the dependence of this disease on the surrounding microsocial environment, emotional deprivation, common accommodation with COS patients, etc. The measures directed on the improvement of environment and the prevention of the psychologically difficult and stressful situations are related to the COS secondary prevention (DeVylder).
At present, there are no reliable markers capable to predict the development of schizophrenia. However, there are the researches estimating the possibility of the future diagnosis through the combination of genetic factors and the psychosis-like experiences. The children belonging to the high-risk group, which assumes the existence of the transit or the self-checked psychotic experiences against the family history of schizophrenia, are diagnosed with COS within a year with the probability of 20-40% chance. Various methods of psychotherapy and medicines are capable to reduce the COS development among the children of a high-risk group (Naguy & Al-Mutairi).
The diagnosis of COS is an area of scientific knowledge much discussed in the middle 20th century. The given research paper showed that the symptoms of the subsequent development of schizophrenia can be revealed at early stages of a child’s development. The process started in the first critical period leads to the profound changes in the ontogenesis of a child.
Thus, the development of COS depends on the nature of interaction of the enduring psychobiological vulnerabilities, environmental and biological stressors, protective factors caused by the nature of a child’s development and favorable family conditions. Despite the genetic predisposition to schizophrenia, the probability of the schizophrenic episodes is high only when a person is also exposed to rather strong influence of the stressful factors, and has no sufficient resources to resist the disease.