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The school psychologist's primer on early onset schizophrenia: a review of research regarding epidemiology, etiology, assessment, and treatment.

Early Onset Schizophrenia (EOS, onset of symptoms prior to age 18 years) is the diagnostic classification, identifying children and adolescents experiencing delusions (having beliefs not based on reality), hallucinations (seeing or hearing things that do not exist), disorganized or incoherent speech, grossly disorganized or catatonic behavior or negative symptoms such as lack of emotion (see American Psychiatric Association [APA], 2000 for a list of full diagnostic criteria). Of special significance to school psychologists is the finding that schizophrenia is associated with, among others, impaired language, motor and social skills as well as creative thought (Andreasen, 2000; Nicolson et al., 2000). Given that these skills and abilities are crucial to effective school functioning, it is imperative that school psychologists are familiar with EOS and able to provide effective support services, in an educational context, to students struggling with this disorder. Moreover, school psychologists who are able to identify EOS are better suited to facilitate early intervention and to offer insight regarding academic planning based on the needs of the student which can have a profound and positive effect on developmental trajectories (Li, Pearrow & Jimerson, 2010). This is best accomplished through collaboration with educators, parents and other professionals to provide an optimal learning environment for the student and to address EOS from a developmental psychopathology perspective.

Among the most pervasive and debilitating of childhood psychopathologies is early onset schizophrenia (EOS). Given that EOS is typically identified during the school-age years, school psychologists are in a unique position to identify symptoms and provide the necessary support services. Thus, the purpose of this primer is to provide school psychologists and other educational professionals with relevant and contemporary information related to preventative, assessment and treatment strategies for students with EOS as well as to provide current etiological and epidemiological information.

Developmental Psychopathology Perspective

The developmental psychopathology perspective provides a conceptual framework for understanding specific psychopathologies in relation to normal developmental trajectories. Addressing psychopathology from this perspective allows for the examination of disordered behavior from multiple viewpoints and across differing domains, thus helping to illuminate the course of disordered behavior, which may help to increase adaptive success (Wicks-Nelson & Israel, 1997). In the transactional-ecological developmental model, development of any process (be it physiological or psychological) is influenced by way of the dynamic and reciprocal interactions with the individual's life context over time (Sameroff, 2009). The behavioral manifestations of a child at any point in time are the result of the transactions between the individual, his/her external experiences, and his/her genetic makeup (Sameroff, 2009). This developmental psychopathology perspective takes into account factors related to sociocultural, biogenetic, personality, family systems, and behavioral domains as well as the interactions between these factors over time (McGorry, 2011). When applied specifically to schizophrenia, a developmental psychopathology perspective may offer added insight and, ideally, allow professionals to consider important factors that might otherwise be overlooked. Additionally, added insight may be gained that informs the development of preventative measures and support strategies. Other considerations accounted for by a developmental psychopathology perspective may include diagnostic difficulties resulting from younger children's lack of expressive language skills and cognitive abilities resulting in the child's inability to adequately describe his or her experiences or, for example, differentiate between delusions and typical childhood imaginative fantasies (Mash & Barkley, 2003).

Epidemiology

Lifetime prevalence of schizophrenia in the general population is approximately 1% (Mueser & McGurk, 2004). While the onset of most cases of schizophrenia occurs during late adolescence and early adulthood (i.e., typically between ages 16 and 35; Asarnow, Thompson, & McGrath, 2004), EOS is relatively rare. It has been estimated that one child in 10,000 can be expected to develop some form of schizophrenic disorder; the rate decreases to approximately one in 40,000 with childhood onset schizophrenia (COS, onset prior to age 12 years; Asarnow & Asarnow, 2003; Nicolson & Rapoport, 1999; Remscmidt, 2002). During late adolescence, however, the number of new cases significantly increases reaching an approximate prevalence of 1%. More specifically, the rate of adolescent schizophrenic disorders increases between 13 and 17 years of age, typically during the middle and high school years (Dunn & Loth, 2012; Remschmidt, 2002). Given this sharp increase in EOS during late adolescence, school psychologists and educational professionals must be prepared to identify the signs and symptoms.

Schizophrenia research, not limited to early onset, reveals that males (a) suffer a psychotic episode at an earlier age, (b) show greater evidence of cognitive impairment, (c) evidence more neurological abnormalities, and (d) are more likely to have a more severe course of illness than women (American Academy of Child and Adolescent Psychiatry, 2001; Murray, Jones, Susser, van Os, & Cannon, 2003). Cases of schizophrenia are found more frequently in lower socioeconomic status (SES) populations (Kirkbride, Barker et al., 2008; Kirkbride, Boydell et al., 2008; Munk-Jorgensen & Mortensen, 1992). This association could be interpreted in a number of ways. For example, a person's low SES could be a result of the challenges the disorder brings to occupational functioning, or the stress of poverty could increase the risk for manifesting symptoms (Li, Pearrow, & Jimerson, 2010). Studies examining the relationship between SES and EOS have yielded equivocal findings (Asarnow & Asarnow, 2003). Higher incidence and prevalence of AOS may exist among certain ethnic/racial minority groups (Fearon et al., 2006; Kirkbride, Barker et al., 2008; Keith, Reiger, & Rae, 1991). However, findings indicating higher prevalence in African Americans, for example, may be confounded by the relationship between SES and prevalence of the illness.

Adult Outcomes Associated with EOS

Poorer outcomes are associated with EOS compared with adult-onset schizophrenia (AOS). Cases with early onset showed greater levels of impairment in social functioning when compared with adult-onset cases in a follow-up study with 97 individuals with EOS (Schmidt et al., 1995). A significantly higher percentage of patients with EOS (19%) compared with the general population (3%) did not graduate from high school as reported in a study by Reichert, Kreiker, Mehler-Wex, and Warnke (2008). The literature indicates better overall outcomes, including higher level of psychosocial functioning and periods of improvement, associated with AOS in comparison with EOS (Li, Pearrow, Jimerson, 2010). Improvement in long-term functional outcomes in people with EOS and AOS appear to be more effective with early detection and specialized treatment (Amminger, Henry, Harrigan, 2011).

Etiology

Definitive causes of schizophrenia, and EOS, remain unknown. Current evidence supports a developmental psychopathology model, wherein multiple factors play a role in the development of this illness. These include genetic vulnerabilities as well as neurobiological and environmental factors (Table 1 includes a brief description of core elements of a multifaceted model). Regarding children and adolescents, there may be interplay between genetic vulnerability, neurobiological, and environmental factors that put these youth at risk for developing schizophrenia (Uhlhaas, 2011; Weinberger & Harrison, 2011). Neurobiological etiologies involve genetically rooted deviations in brain structure and chemistry. Environmental stressors include complications in pregnancy and birth, as well as psychosocial stressors such as trauma and stigma. The following section presents a brief overview of these biological and environmental stressors include models. For an extensive discussion of etiologies, the reader is referred to Li, Pearrow, and Jimerson (2010).

Neurobiological Factors

Brain structure. Neuroanatomical abnormalities have been revealed among patients with EOS (e.g. Lawrie, McIntosh, Hall, Owens, & Johnstone, 2008). Examples of such abnormalities are volume reduction in multiple brain regions such as the hippocampus, thalamus, and frontal lobe (Rapoport et al. 2005; Thompson et al. 2001; Mehler and Warnke 2002; Rapoport et al. 1997). Deficits in the parietal lobe have also been more pronounced in EOS and COS cases (Burke, Androutsos, Jogia, Byrne, & Frangou, 2008; Vidal et al. 2006). Abnormalities in the parietal cortices "may be associated with the inability to differentiate between self-produced and externally generated behavior, which is the hallmark of psychosis" (Li, Pearrow, & Jimerson, 2010, p. 18). Gray matter loss could be responsible for cognitive impairments and the prefrontal cortex is a promising predictor of later psychosis (Wood et al. 2003). Cases of schizophrenia comprise "a unique cohort with an onset before puberty and associated initially with profound structural abnormalities within the parietal and frontal regions and later incorporating temporal regions post adolescence" (Gogtay, Vyas, Testa, Wood, & Pantelis, 2011, p. 509).

Brain chemistry. The dopamine hypothesis posits that this neurotransmitter is involved in the pathogenesis of schizophrenia. Recent findings have enriched and modified the original hypothesis of the 1970s, which focused on excessive transmission at dopamine receptors. Current understandings of this hypothesis include the interaction of environmental factors discussed below contributing to dopamine dysfunction. In addition, dopamine is more appropriately linked with psychosis, namely the positive symptoms of schizophrenia (Howes & Kapur, 2009).

Genetic factors. There exists strong evidence presented in family, twin, and adoption studies to support the inheritability of schizophrenia. For example, a child has an approximately 40% chance of developing schizophrenia if both parents have the illness. The chances drop to 12% if only one parent has the illness (Miller & Mason, 2002). Craddock, O'Donovan, and Owen (2006) estimate the general heritability of schizophrenia to be approximately 80-85%. Researchers have proposed genetic alterations, such as the gain or loss of DNA chunks called copy-number variations (CNVs), to be responsible for schizophrenia (Lupski, 2008; Walker, Kestler, Bollini, & Hochman, 2004). Rather than resulting from a single genetic locus or even small number of genes, the literature suggests multiple genes acting in concert, or various individual genes acting independently, play a role in the heritable vulnerability of schizophrenia (Walker et al. 2004).

The role of genetics in the development of EOS appears to be especially strong. Parents of youth with EOS have higher rates of schizophrenia spectrum disorders than parents of individuals with AOS (Margari et al., 2008; Nicolson et al., 2003). Identical twins of patients with schizophrenia have a 50% chance of developing the illness; 10-15% of fraternal twins may develop schizophrenia if their twin has it. The observation that these concordance rates are substantially less than 100% suggest non-genetic factors also play a role in the development of schizophrenia (Li et al., 2010).

Environmental Factors

Prenatal risks. The literature suggests elevated risk for later development of schizophrenia, regardless of age at onset, is associated with prenatal exposures to toxins, such as lead, and infections, such as rubella, (Li et al., 2010; Opler et al., 2008; Brown, 2006; Brown et al. 2004). Findings suggest a relationship between maternal bacterial infection in pregnancy and offspring risk of schizophrenia, with stronger effect for earlier onset (Hunter, Kisley, McCarthy, Freedman & Ross, 2011). Virus exposure during pregnancy may increase the likelihood of schizophrenia pathogenesis in individuals with genetically high risk (Li et al., 2010). Of importance to note, Thapar and Rutter (2009) caution against assuming causation with regard to prenatal risk factors for subsequent psychopathology. The reported associations may be spurious because of inherited confounders. Thus, school psychologists and other practitioners need to be aware that "[r]educing the risk of a specific outcome will only be effective if there is a true causal relationship with the prenatal factor" (Thapar & Rutter, 2009, p. 101).

Perinatal risk. Increased risk for schizophrenia, regardless of age at onset, has been linked with several perinatal factors (Murray et al. 2004; Clarke et al. 2006). Findings indicate general nutritional deprivation and lack of specific micronutrients may be risk factors (Opler & Susser, 2005). Body mass index and low birthweight are also associated with this disease (Li, Pearrow, Jimerson, 2010). Labor delivery complications (LDCs) have been associated with increased risk of EOS (Verdoux et al., 1997), but they have low predictive value for the development of schizophrenia (Lewis & Levitt, 2002). McNeil and colleagues (2009) found a link between unwanted pregnancy in interaction with genetic risk for psychosis and increased risk of schizophrenia-spectrum disorders. More research is needed to determine potential mediators for this association.

Postnatal risk. Evidence suggests the risk of schizophrenia varies according to season of birth, place of birth, and migrant status (McGrath 2007). It has been proposed that pre- and postnatal Vitamin D deficiency may explain these associations (McGrath, Burne, Feron, Mackay-Sim, & Eyles, 2010; Cantor-Graae, & Selten, 2005; McGrath, et al., 2004). Dalman et al. (2008) report a weak association between viral central nervous system infections during childhood and subsequent development of schizophrenia spectrum disorders.

Trauma. The literature suggests negative life events and traumatic experiences are associated the risk for psychosis and schizophrenia. Child abuse, specifically, has been identified as a possible causal factor for psychosis and schizophrenia manifested as hallucinations in the forms of voices commenting and command hallucinations (Read, Van Os, Morrison, & Ross, 2005). It is important to note that the studies reviewed by Read and colleagues yielded correlational findings that are insufficient to confirm a causal relationship between child abuse and psychosis. Child abuse is related to early age of onset and more positive symptoms (Li, Pearrow, Jimerson, 2010). A study by Frazier et al. (2007) involving over 100 children with schizophrenia spectrum disorders revealed "13% had a history of physical abuse, 10% sexual abuse, 14% neglect, and 20% witnessed trauma in the past" (p. 982).

Stigma. It is not uncommon for people with schizophrenia to experience stigma as a result of negative social interactions associated with their diagnosis. However, such "structural discrimination and social adversity" may also serve as a causal factor of the illness (Li et al., 2010, p. 17). Negative social interactions may result from early manifestations of psychosis (e.g. paranoid reactions or odd speech) during the prodromal stage (Van Zelst, 2009). The related stigma increases the person's risk of transitioning to schizophrenia or other psychotic disorder for which the person is vulnerable.

ASSESSMENT

Possible Challenges to Identification of EOS

Because schizophrenia is relatively rare in children, most school psychologists may not have been exposed to EOS, which can make identification of the disorder challenging. Further diagnostic complications may arise given that approximately two-thirds of children experiencing EOS also meet the criteria for other mental disorders (House, 1999) including oppositional conduct disorder (31%) and atypical depression/dysthymic disorder (37%) (Asarnow & Asarnow, 2003). This comorbidity can produce a masking effect, making detection of the disorder more difficult. For these reasons, among others, school psychologists and other educational professionals must be keenly aware of the etiological course and warning signs associated with EOS.

Importance of Early Detection

The detection of EOS in children is crucial for a number of reasons. To begin with, students with EOS face numerous challenges at school such as behaviors that can interfere with school success, including cognitive deficits resulting in difficulty paying attention, memory and retention difficulties, speech and language problems and developmental delays. Other challenges can include social skills deficits, which can foster poor peer relationships, and behavioral problems resulting in discipline referrals, suspensions, expulsions and ultimately drop out. Moreover, low achievement and drop out are associated with poorer outcomes in adult life (Li, et al., 2010). From a more legalistic viewpoint, federal legislation mandates that students with disabilities receive a free and appropriate public education (FAPE). Qualified students are those who have a mental or physical impairment that substantially limits a major life activity, for instance learning. Thus, depending upon the severity of symptoms and their effect on functioning in the school setting, students may, or may not, qualify for special services. Therefore, in cases in which a student is manifesting signs of EOS, or is diagnosed with EOS, and it is adversely affecting school functioning, an assessment for special education services eligibility should be administered.

Listed above are a number of reasons explaining how school psychologists may be able to identify the manifestations and warning signs associated with EOS. Being familiar and knowledgeable about these indicators will allow for the provision of needed support services for students with EOS and will allow school psychologists to make crucial assessment decisions and to provide valuable input for tailoring educational plans.

Screening and assessment tools. The use of screening instruments is a time-efficient strategy to identify individuals with an increased risk of developing schizophrenia and in need of more intensive evaluation. Listed below are four prominent screening instruments. Although they share adequate test-retest reliability, high convergent validity, and high inter-correlations, they do not adequately distinguish between measures of depression, anxiety, and attention deficit disorders (Chang, Golembo, Maeda, Tsuji & Schiffman, 2008; Hafner & Maurer, 2006; Olsen & Rosenbaum, 2006). The screening tools include the Youth Psychosis At Risk Questionnaire (Y-PARQ; Ord et al., 2004), the PROD-screen (Heinimaa et al., 2003), SIPS screen (Miller, Cicchetti, Markovich, McGlashan, & Woods, 2004), and Prodromal Questionnaire (PQ; Loewy & Cannon, 2008). To date these screening instruments are still being validated and are not systematically used in the general population--though there is the potential for their use in community-based settings. For a more comprehensive list of prospective screening tools relevant to the prodromal stage of schizophrenia the reader is referred to Li, Pearrow, and Jimerson (2010).

Pearrow, Li, and Jimerson (2012) emphasize that one particularly salient dimension that school mental health professionals should carefully watch for in students who are experiencing schizophrenia symptoms is marked deterioration of social and role functioning, such as progressive social withdrawal and decline of school grades, poor self care, and neurocognitive decline (such as attention, memory, information processing speed). In many instances, these students may have been receiving special education services before being diagnosed as having schizophrenia due to language delays, motor abnormalities, emotional disturbances, learning disabilities, and attention-related difficulties (Nicolson, Lenane, Singaracharlu, & Rapoport, 2000). Indeed, cognitive dysfunction has been regarded as a hallmark feature of schizophrenia (the prototypical primary psychotic disorder) from the time of its earliest conceptualizations.

In summary, early indicators of psychoses can help school psychologists determine when to refer a student for outside services more suited to address serious mental health issues such as schizophrenia. Nevertheless, it is important for school psychologists to monitor students already diagnosed with EOS to ensure they are provided the necessary support services.

DIAGNOSTIC ASSESSMENT

Diagnostic Criteria

Diagnosing schizophrenia is usually done based on criteria found in the DSM-IV-TR (APA, 2000). Currently, the criteria necessary for receiving a diagnosis of schizophrenia are identical for children and adults .The 5 subtypes of schizophrenia are briefly described below, for full diagnostic criteria as well different dimensions of schizophrenia, see the DSM-IV-TR (APA, 2000).

* Paranoid-type schizophrenia is characterized by delusions and auditory hallucinations.

* Disorganized-type schizophrenia is characterized by speech and behavior that are disorganized or difficult to understand, and flattening or inappropriate emotions.

* Catatonic-type schizophrenia is characterized by disturbances of movement (e.g., grossly disorganized or immobility).

* Undifferentiated-type schizophrenia is characterized by some symptoms seen in the other subtypes of schizophrenia, but not enough of any one of them to define it as another particular type of schizophrenia.

* Residual-type schizophrenia is characterized by a past history of at least one episode of schizophrenia, but the person currently has no positive symptoms (delusions, hallucinations, disorganized speech or behavior).

Associated features. Features associated with the latter stages of the prodromal phase, and prior to receiving a diagnosis of EOS, may include social phobia, obsessive-compulsive behavior, and academic decline as well as poor sleeping patterns and a loss of interest in eating. Other abnormalities may include motor difficulties, an early sign of neurodevelopmental problems associated with schizophrenia. Grimacing, posturing, unusual mannerisms, and ritualistic or stereotypical behavior have also been reported in individuals with EOS (APA, 2000). Seiferth et al. (2009) reported deficits in recognizing, assessing, and experiencing emotions, as well as the processing of emotional facial expressions in individuals experiencing EOS. For more information on symptom onset, developmental course, associated features, age specific features, gender related features and differential diagnosis see Li et al. (2010).

Developmental, Health, and Family History

Pre-, peri- and postnatal risk factors. Crucial to the diagnosis of EOS is a developmental, health and family history. The obtaining of this information can be done through interviews with the child and family members. Included in the interviews should be questions pertaining to pre-, peri-, and postnatal history.

Developmental milestones. History of developmental milestones should also be addressed and are a critical component of assessment. Research results have suggested that language impairment is more extant in EOS than in other psychiatric illnesses in youth, and more pervasive in males compared to females (Hollis, 1995). Vourdas et al., (2003) found that youth with EOS had more reading and spelling difficulties compared to a normal control group.

Medical and diagnostic history. During initial stages of evaluation, conducting a thorough medical and diagnostic history can be very informative. In line with a developmental psychopathology approach, both allow for a continuum of history as opposed to information at a single given point in time (i.e., at the time of the interview). Special attention should be paid to past or present symptoms commonly found to coexist with schizophrenia including anxiety, depression, panic disorder, posttraumatic stress disorder, obsessive-compulsive disorder, and substance abuse (Buckley, Miller, Lehrer, & Castle, 2009). Knowing the history and time of onset of these symptoms can help to illuminate the idiosyncrasies of a particular child's disorder thus allowing professionals to conduct a more informed assessment.

Indirect Assessment

Using rating scales and clinical interviews to obtain information about a child constitutes indirect assessment. Typically, individuals significant to the child's well being (e.g., parents, teachers, guardians), and in many cases the child being assessed, complete rating scales based on their experience with, and observations of, the child. Additionally, interviews with the child and significant others can be used to assess for warning signs and symptoms of EOS. Interviews can be formal and standardized or informal. Rating scales and interviews should both be used as necessary components of a quality and ethical assessment to detect prodromal signs and present symptoms of EOS. Both of these methods allow for the attainment of objective information, likely missed if only the child is used to acquire assessment information, and both facilitate the use of environmental and psychosocial information, which are integral components of the developmental psychopathology perspective. The Behavior Assessment System for Children-II (BASC-II; Reynolds & Kamphaus, 2004) and The Schedule for Affective Disorders and Schizophrenia for School-Age Children--Present and Lifetime Version (K-SADS-PL; Kaufman et al., 1997; Kaufman, Birmaher, Brent, Rao, & Ryan, 1996) are examples of indirect assessment instruments, the former exemplifying a rating scale and the latter a clinical interview, that can be used by school psychologists to assess for early warning signs and symptoms of EOS. For a more exhaustive list of indirect assessment instruments see Li et al. (2010).

Direct Assessment

The observation of targeted overt behaviors, while they are occurring, is termed direct assessment (Li, 2004). Motoric movements, speech, facial expressions, tone of voice and presentation are examples of overt behaviors that can be observed directly. Given that EOS is often accompanied by maladaptive overt behaviors, direct assessment can help to identify key diagnostic elements exhibited by a child. A key element of direct observation is the use of an independent person to perform the observation. Best results are usually obtained when the individual being observed is unaware that the observation is taking place. Due to the lack of standardized observation instruments, school psychologists are usually limited to clinical observations to acquire direct assessment information. The observations of parents and teachers, who are with the children in different settings and for extended amounts of time each day, can provide valuable insights into the nuances and/or major variation in a child's daily behavior as well. These types of insights, spanning time and environmental settings, are key developmental aspects of a comprehensive diagnostic assessment.

Psychoeducational Assessment

Because significant differences exist between diagnostic (i.e., DSM IV-TR; APA, 2000) and educational eligibility (i.e., Individuals with Disabilities Education Improvement Act, 2004) criteria, school psychologist should carry out their own psychoeducational assessments to develop a profile of a student's functioning in the school setting. Social, behavioral and academic performance should be assessed to help form a basis from which to derive educational, treatment, intervention, progress monitoring, Section 504, and support plans.

Testing Considerations, Accommodations, and Modifications

When assessing children in the prodromal stage or diagnosed with EOS, a number of considerations should be attended to including current and past levels of functioning, developmental level, schizophrenia subtype (i.e., paranoid, catatonic, disorganized, undifferentiated, or residual), and current stage of the illness (i.e., active, recovery, residual). These considerations will help to determine if attained scores and performance levels are true indicators of the child's abilities or products of impaired functioning or still other factors such as current medications. Moreover, school psychologists should be vigilant of changes in the child during testing such as radical shifts in behavior, increases in overt behaviors, or bizarre response patterns. School psychologists can adjust or make modifications to testing protocol based on the prevalence of behaviors that might adversely affect test performance and scores. Regardless of the difficulties encountered while testing a child with signs of prodromal functioning, or diagnosed with EOS, school psychologists should do their best to adhere to and preserve standardization procedures in order to maintain the integrity of testing practices and outcomes. Finding the balance between flexibility and testing fidelity can be very difficult, so school psychologists must do their best to adhere to established assessment standards and carefully consider the results in a situational context and on a case-by-case basis.

Communication with caregivers and medical providers. Prior to conducting a psychoeducational assessment, school psychologists should consult with physicians and/or other medical personnel under whose care the child may be. These individuals can provide valuable information such as medications being taken and their possible side-effects. For example, confounding symptoms and medication side-effects, like pronounced weight-gain (Armenteros & Davies, 2006; Mattai, Hill, & Lenroot, 2010) could interfere with accurate assessment. Consultation with these caregivers can also provide information about subtype of the illness, phase of the illness, and any other extenuating circumstances needing consideration. Being informed of such information can help ensure that the child is in the appropriate state to undergo a psychoeducational evaluation that will reflect true levels of functioning.

Important too is appropriate communication with the caregivers of the child being assessed. Discussing the nature, parameters, purpose and intent of assessment, within reasonable bounds, will likely decrease any extant discomfort or reservations and help to demystify the assessment process. Additionally parents should be notified about the outcomes of the assessment in a timely and understandable manner. By drawing on the expert knowledge of medical personnel and the intimate knowledge of caregivers, school psychologists will be better able to plan for necessary assessment modifications or postponements, thus increasing the likelihood of administering an effective and accurate assessment.

Specific Psychoeducational Assessment Practices

Behavioral observations. A psychoeducational assessment for a student with EOS has multiple components. Once the examiner has obtained the preliminary information described above, behavioral observations in various settings and at various times are necessary to gain a clear picture of functional impairments and to better understand the dynamics of the child's EOS (Kodish & McClellan, 2007; Wozniak, White & Schulz, 2005). Of great importance is the identification of academic and social strengths and deficits unique to the child. Observations of the student may reveal the situations that are most problematic for the student and thus inform intervention and treatment.

Interviews. Interviews with the child, caregivers, teachers and other key figures in the child's life, are another way to gain insight into the child's functioning and to corroborate information already obtained through observations of the child. School psychologists should pay special attention to discrepancies between interviewees regarding functioning of the child as this may reveal differential functioning based on situation or setting. The school nurse should also be interviewed to ascertain any physical and/or mental health information of which s/he may be aware. Typically, school nurses are responsible for managing student pharmacological regimens during school hours and can provide related information to the school psychologist.

Cumulative file review. A comprehensive review of student cumulative records can provide a window into past student functioning spanning multiple ages and grade levels. From a developmental psychopathology perspective, cumulative files offer a wealth of information and are a literal "hard copy" of a student's developmental course and the age of onset of specific developmental milestones. It goes without saying that, from a developmental psychopathology perspective, a thorough file review is among the most important sources of information. It also constitutes a great place to begin gathering data for the assessment of a student with EOS.

Psychoeducational testing. A number of psychoeducational test instruments are available to help complete an assessment of students with EOS. These instruments are designed to assess the current state of student functioning in a number of salient developmental categories. A typical psychoeducational evaluation of a student with EOS may consist of, but is not limited to, formal assessments of cognitive, academic/developmental, language, and emotional functioning as well as adaptive behavior. School psychologists should work in collaboration with other school personnel including a speech/language pathologist and, when available, an occupational therapist to complete a comprehensive psychoeducational assessment. Often, if a student with EOS is being assessed and is already receiving support services, a special education teacher will also be a member of the assessment team. Comprehensive review of the numerous psychoeducational test instruments available is beyond the scope of this manuscript, the reader is referred to Li et al. (2010) for a well-developed discussion highlighting some of the more salient contemporary test instruments.

TREATMENT

The treatment of EOS requires a comprehensive integrative approach that includes both psychopharmacological and psychosocial interventions. It is important to include developmentally appropriate interventions that take into account cognitive, social and behavioral functioning. The management of EOS is reflective of that offered to adults with increased emphasis on family and developmental factors. Due to the gradual nature of developing symptoms, referrals for treatment of children may be delayed, allowing for the development of more severe symptoms of the disorder (Li et al., 2010). Even with treatment, the extended prognosis of individuals with EOS is disheartening. Several years after the implementation of a treatment plan, approximately 70% of individuals continue to experience symptoms of schizophrenia. The quality of outcomes decreases as the length of time the individual experienced psychosis before receiving treatment increases (Asarnow, Tompson & McGrath, 2004). Given this relationship, creating a treatment plan followed by expedited treatment, keeping in mind developmental history, previous experience with mental health services, and desired developmental outcomes, is imperative. Advantages of receiving treatment for schizophrenia may include: (a) a remediation of symptoms, (b) hope induced by the prospect of a better outcome and possibility of living a functional life, (c) a decrease in long term morbidity and chronicity, and (d) an increase in the potential for optimal response and outcome (Bryden, Carrey & Kutcher, 2001).

The most advantageous treatment for EOS is one characterized by global and all-encompassing applications (Sikich, 2005). Additionally, treatment strategies tailored specifically to the child receiving treatment increase the likelihood of compliance and follow-through, thus increasing the chances of achieving treatment aims (Findling & Schulz, 2005).

School-Based Treatment Considerations

Pearrow, Li, and Jimerson (2012) offer an extensive discussion of the behavior and classroom management of children and adolescents with schizophrenia. Factors needing consideration when designing school-based treatment strategies for EOS include consideration of the child's developmental levels as well as factors that define the dynamics of the illness (Li et al., 2010; Pearrow, Li, & Jimerson, 2012). The early and severe nature of EOS warrants special consideration of the developmental level of the child because distinguishing diagnoses and matching treatment with impairment can be challenging (Bryden et al., 2001). Put another way, the stage of development in which the child is at the time of treatment may warrant the selection of a certain treatment modality, usually matched with a specific impairment. Additionally, treatment must be matched with the developmental level of the child while allowing for the continuation of normative expansion in developmental domains such as psychosocial functioning. To further illustrate the importance of matching developmental level with treatment, cognitive behavioral therapy (CBT) may not be appropriate for younger children with EOS because their cognitive abilities are still in the nascent stage of development making the grasping of quintessential CBT concepts extremely difficult or impossible (Asarnow et al., 2004).

Another developmental psychopathology consideration includes family dynamics. The early nature of the disorder dictates that the family occupies the primary role in treatment. Treatment components, therefore, must be sensitive to the established family system and allow for the child to function within that system. Even more so than in the treatment of adults with schizophrenia, family therapy is important for young children because parents are usually the primary caregivers. Family therapy typically addresses the possible progression of EOS and ways in which the family can cope with its impact on the child's development.

Evidence-Based Treatments

Pharmacological interventions. Presented here is a brief overview of findings related to psychopharmacological treatments of EOS and adult schizophrenia. Brown et al., (2008) highlighted the almost complete lack of clinical trials and controlled studies examining children and adolescents with EOS as well as the lack of studies focusing solely on the effects of pharmacological treatment of schizophrenia spectrum disorders. Also emphasized was the lack of psychopharmacological studies focusing on long-term outcomes instead of acute symptoms as well as the paucity of psychopharmacological studies of EOS including children less than 13 years of age.

While these points are well taken, psychopharmacological treatment is the prevailing method for treating schizophrenia and has been shown to reduce positive symptoms and relapse rates in adults (Lehman et al., 2004; Table 2 provides a summary of common antipsychotic medications, some of which may be prescribed to youth with EOS). Moreover, psychopharmacological treatment of schizophrenia targets psychotic symptoms during the acute phase, the prevention of relapse during the recovery and residual phases, and adverse side effects (Remschmidt & Theisen, 2005). Also, while improved outcomes on the positive symptoms of EOS have been demonstrated, similar outcomes pertaining to negative outcomes are nonexistent. Although the role of school psychologists is not to administer medications, they can play an important role in monitoring effectiveness and side effects of medications for EOS in the early stages of treatment.

Psychosocial interventions. Used in concert with pharmacological treatment, several psychosocial interventions have produced desirable effects related to relapse rate, symptoms, and social impairments in adults with schizophrenia (Drury, Birchwood & Cochrane, 2000; Garety, Fowler & Kuipers, 2000; Garety & Freeman, 1999; Hogarty & Ulrich, 1998; Lehman et al., 2004; Pinto, La Pia, Mennella, Giorgio & DeSimone, 1999). By targeting the stabilization and maintenance phases of schizophrenia, psychosocial interventions complement pharmacological treatments. However, as with psychopharmacological treatments, there exists a dearth of studies concentrating on psychosocial treatments of EOS (Dulmus & Smyth, 2000; Haugaard, 2004). What followsis a brief overview of recommended psychosocial interventions.

Cognitive-behavioral therapy. When employed to treat schizophrenia, Cognitive Behavioral Therapy (CBT) focuses on the thoughts, emotions and behaviors associated with symptoms of schizophrenia. Also addressed are triggers, consequences, and responses to symptoms. CBT interventions address the identification of target symptoms, coping strategies, affect regulation, interpretations of reality, and recognition of stress (Asarnow et al., 2004; Lehman et al., 2004; Penn et al., 2004). CBT is most beneficial for those experiencing persistent pharmacotherapy resistant symptoms except for those in the acute phase of schizophrenia (Dickerson, 2000).

The goal of CBT is well suited for school psychologists. When used to address EOS, CBT facilitates active collaboration between the child and therapist, which fosters the establishment of a supportive therapeutic relationship and a shared understanding of the illness. This, in turn, facilitates psychoeducational treatment for the child, which includes, among others, learning about the specific nature of the illness, the importance of treatment compliance, treatment options, and relapse prevention Dilk & Bond, 1996). By combining CBT with other evidence-based treatments, for instance Supportive Therapy (Penn et al., 2004) and Personal Therapy (Hogarty, 2002), the psychoeducational components of CBT are complemented by focusing on the therapeutic alliance, providing support and advice, making efforts to minimize stress, building skills to increase personal competence at self regulation, and developing self awareness pertaining to affective, cognitive and behavioral states. Ongoing maintenance of a supportive therapeutic relationship can help the child to deal with daily stress resulting from the social and academic challenges of school, which illustrates one way that school psychologists can support children with EOS. As with adult CBT, the objectives of treating EOS must be customized to meet the needs of the individual being treated.

Skills training. Skills training that focuses on developing basic skills, the development of which are often disrupted by EOS, is an important component of treating the illness. Providing training in communication, social, and daily life skills is an integral part of the early treatment of children with EOS (American Academy of Child and Adolescent Psychiatry, 2001; Asarnow et al., 2004; Gonthier & Lyon, 2004).

Family interventions. When treating a child with EOS, family participation and involvement are extremely important because the individual is likely to reside with their family and depend upon them to support and access treatment. Family participation in treatment of EOS yields positive outcomes such as improved family problem solving and enhanced psychosocial functioning (Doane, Goldstein, Miklowitz & Falloon, 1986; Hogarty, 2002). Given these findings in adult and child populations, it appears that for any treatment to be effective in reducing symptoms of EOS, it must include a family treatment component. Family therapy should target the reduction of environmental stressors so as to reduce the chances of relapse (Clark & Lewis, 1998) and should last at least 9 months, the length at which more positive outcomes are demonstrated when compared to those lasting less than 6 months (Pitschel-Walz, Leucht, Bauml, Kissling & Engel, 2001).

Psychoeducational interventions in the school setting. There exist three psychosocial interventions that have exceptionally strong applicability to the school setting. Supported employment and education employs individualized job development, ongoing job support, and integration of vocational and mental health services (Lehman et al., 2004). Applying this intervention to the lives of youths involves affecting modifications to address educational and social development in the school environment.

Token economy interventions have demonstrated efficacy within the context of controlled environments where clear expectations and consequences for behaviors have been established (Lehman et al., 2004). Poor social skills and relationship difficulties are commonly associated with EOS and other psychopathologies in children; token economy systems may increase skill acquisition (Spence, 2003). Additional research is needed to assess the specific benefits of using token economy systems with children with EOS.

School-wide interventions have been implemented to address the causes of stigma and discrimination both of which can have profound implications for developing youth as they struggle with mental illness. An evaluation of one program addressing stigma and discrimination, administered to over 1,500 middle school students in the United States, precipitated significant improvement in knowledge and attitudes relative to mental illness (Watson et al., 2004). Interventions such as this, that address social development in a school setting, can help reduce stress for those experiencing EOS and/or other mental disorders.

INTERNET RESOURCES FOR PROFESSIONALS

Given the seriousness of early onset schizophrenia in children, early identification and intervention are very important. There are numerous online resources available to children, parents, and school psychologists to assist in the identification, treatment, and support of children with early onset schizophrenia, however, it is often difficult to identify quality materials. The information described below, includes support at the individual, family, and community level, as well as links to additional resources. For an extended list of internet resources the reader is referred to Li, Pearrow, & Jimerson (2010).

National Institute of Mental Health (http://www.nimh.nih.gov/health/topics/schizophrenia/index.shtml)

This website provides current research on the topic of Childhood Onset Schizophrenia. Through easy-to-read publications and fact sheets this site provides general information about the disorder, including assessment, treatment, and help finding services. A variety of resources offered here will be useful to a wide array of persons, including people with schizophrenia, their family members, researchers, as well as professionals.

MedlinePlus--Schizophrenia (http://www.nlm.nih.gov/medlineplus/schizophrenia.html)

This website shares the most up-to-date information and research on schizophrenia with various links to sites from reputable national agencies, including information related specifically to schizophrenia in children. Here you can gain access to medical journal articles through the research database MEDLINE. Additionally, this site offers fact-sheets, information about drugs, an illustrated medical encyclopedia, and patient tutorials.

Schizophrenia.com--Information, Support, and Education (http://www.schizophrenia.com/index.php)

This site is a non-profit web community dedicated to the education and support of those impacted by schizophrenia. Although this site is not specific to early-onset schizophrenia, information is provided related to this specific subgroup of individuals. Links and information on this site include basic information about the disorder (e.g., definition, risk factors, prognosis, treatment) as well as newsblogs, discussion groups, chat rooms, links to articles (based in newspapers and scientific journals), a newsletter, and even links to international discussion groups.

North American Society for Childhood Onset Schizophrenia (http://www.nascos.org/Home/)

This site was developed by the North American Society for Childhood Onset Schizophrenia for the purpose of helping families and professionals share information and resources. Basic information specific to COS is provided for the general public. Access to the site's Knowledge Base is available for anyone interested in becoming a member of the site. It contains updated information on research and resources for parents and family members. Links to other schizophrenia-related sites are also provided.

National Alliance on Mental Health (http://www.nami.org/Content/ContentGroups/Helpline1/Early_Onset_Schizophrenia.htm)

This user-friendly website provides information about fighting stigma, EOS, symptoms, diagnosis and related difficulties, typical prognosis, common methods of treatment, medications, and a brief overview of current research being conducted on EOS. It seems to be most geared toward families suspecting or living with affected children.

The American Academy of Child and Adolescent Psychiatry (http://www.aacap.org/cs/root/facts_for_families/schizophrenia_in_children)

This site provides a brief primer for families interested in understanding schizophrenia in children. It presents common symptoms and early warning signs of COS. To help families with the challenge of distinguishing other common diagnoses that may co-occur or precipitate a diagnosis of COS, the website offers links to other psychiatric disorders such as bipolar disorder and autism.

The American Psychological Association (http://www.apa.org/topics/topicschiz.html)

This page is dedicated to schizophrenia in general, not EOS or COS specifically. It includes information and links to journals, books, other websites, and fact sheets that apply to children and their families.

Psychiatric Times (http://www.psychiatrictimes.com/schizophrenia)

The Psychiatric Times website includes access to medical news as well as research reviews, practice guidelines, and clinical trials. These and other resources provide information on the etiology, epidemiology, assessment, and treatment of schizophrenia including COS. Authored by medical professionals, this website includes information regarding differential diagnosis and comorbid diagnoses--rarely found on other sites.

CONCLUSIONS

This manuscript provides a brief overview of the contemporary understandings of schizophrenia with early and childhood onset. The central aim herein has been to bring science to practice and succinctly highlight key considerations for school psychologists and other educational professionals. Although cases of early and childhood onset schizophrenia are rare, the associated effects are among the most pervasive and debilitating of all childhood psychopathologies (Li, Pearrow, & Jimerson, 2010). The information presented in this manuscript offers important knowledge and resources to prepare school psychologists and other educational professionals to identify and address the needs of students with EOS.

No single, definitive cause of schizophrenia or EOS has been identified; instead the literature supports a multifaceted etiological model consisting of environmental, genetic, and neurobiological factors. A developmental psychopathology perspective offers great utility for understanding schizophrenia in general and EOS in particular. Poor long-term outcomes are generally associated with EOS and available evidence suggests outcomes are worse than those associated with adult onset schizophrenia. Therefore, knowledge of early warning signs and specialized treatment can help school psychologists improve the developmental trajectory of students with EOS by allowing for earlier and more effective efforts at primary and secondary prevention.

In addition, knowing the early indicators of psychoses can help school psychologists determine when to refer a student for outside services more suited to address serious mental health issues such as schizophrenia. Moreover, it is important for school psychologists to monitor and support students already diagnosed with EOS to ensure they are provided the necessary support services in the school context.

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Rafael J. C. Hernandez, W. Jeremy Rime, and Shane R. Jimerson

University of California, Santa Barbara

Correspondence about this article may be sent to Shane R. Jimerson, University of California-Santa Barbara, CCSP 2113 ED, Santa Barbara, CA 93106-9490. Email: jimerson@education.ucsb.edu

Rafael J. C. Hernandez, M.A., is a doctoral student at the University of California, Santa Barbara.

W. Jeremy Rime, M.A., is a doctoral student at the University of California, Santa Barbara.

Shane R. Jimerson, PhD, is a Professor of School Psychology at the University of California, Santa Barbara. He is the Co-Editor of the Developmental Psychopathology at School book series published by Springer Science.
TABLE 1. Etiological Factors of Schizophrenia

Risk Genes
      Neuregulin, Dysbindin, D-amino acid oxidase,
      Catechol-O-methyltransferase, Proline dehydrogenase, Reelin,
      serotonin type 2a receptor, dopamine D3 receptor

Early Insults: Pre, peri, and postnatal risks
      Viral Infections: herpes simplex, influenza, rubella
      Toxins: Lead, alpha-aminolevulinic acid
      Obstetric: Mother hypertention, loss of husband while being
      pregnant, malnutrition
      Delivery complications

Other Environmental Factors
      Vitamin D deficiency, winter birth, high latitude, inner city
      residence, drug use, natural disasters

Trauma
      Stigma; emotional, physical, sexual, and psychological abuse;
      neglect; bullying, loss of a beloved one

Brain Abnormality
      Reduction in whole brain and hippocampal volume, low volume of
      total cortical gray matter, high volumes of white matter,
      ventricular, and basal ganglia; larger superior temporal gyri
      relative to brain size; lack of normal right-greater-than left
      hippocampal asymmetry; larger ventricles, smaller temporal
      lobes, reduced metabolism in frontal lobe, significant reduction
      of mid sagittal thalamus

Adapted from Li, Pearrow, & Jimerson (2010). Copyright 2010 by
Springer. Reprinted with permission of the publisher.

TABLE 2. Antipsychotic Medications, Generic and Brand Names and
Typical Tablet Dosage

                  Generic Name       Brand Name   Tablet dosage range

Atypical          Risperidone        Risperdal    1-3 mg
                  Olanzapine         Zyprexa      2.5-10 mg
                  Clozapine          Clozaril     25-100 mg
                  Quetiapine         Seroquel     25-200 mg
                  Ziprasidone        Geodon       20-60 mg
                  Aripiprazole       Abilify      5-15 mg

High Potency      Haloperidol        Haldol       0.5-20 mg
Typical           Pimozide           Orap         2 mg
                  Fluphenazine       Prolixin     2.5-10 mg

Medium Potency    Trifluoperazine    Stelazine    1-10 mg
Typical           Perphenazine       Trilafon     2-16 mg
                  Thiothixene        Navane       2-20 mg
                  Loxapine           Loxitane     5-50 mg

Low Potency       Molindone          Moban        5-100 mg
Typical           Mesoridazine       Serentil     10-100 mg
                  Thioridazine       Mellaril     10-200 mg
                  Chlorpromazine     Thorazine    10-200 mg

Adapted from Wilens (1999) and Li, Pearrow, & Jimerson (2010).
Copyright 2010 by Springer. Reprinted with permission of the
publisher.
COPYRIGHT 2013 California Association of School Psychologists
No portion of this article can be reproduced without the express written permission from the copyright holder.
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Author:Hernandez, Rafael J.C.; Rime, W. Jeremy; Jimerson, Shane R.
Publication:Contemporary School Psychology
Article Type:Disease/Disorder overview
Date:Jan 1, 2013
Words:10935
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