Caroly Pataki, MD

As a consequence of its premorbid impairments, insidious onset, and relative treatment resistance, childhood-onset schizophrenia (COS) presents clinicians with a number of diagnostic dilemmas and treatment challenges. COS occurs in fewer than 1 in 10,000 children

 and fewer than 1% of patients with schizophrenia receive this diagnosis in childhood.

 The ages and rates at onset are similar in boys and girls.

Characterized by the onset of psychosis before the age of 13 years, COS is typically preceded by behavioral and cognitive symptoms that overlap with features of autism spectrum disorders, affective and disruptive behavior disorders, and speech and language disorders.

 Premorbid and comorbid psychiatric disorders make the diagnosis of COS a challenge and its treatment complicated. Persons with COS appear to have the poorest outcome among those in whom schizophrenia is diagnosed,

 so early detection of and intervention for COS may be important to maximize the impact of treatment for children and their families.


Children in whom schizophrenia develops commonly show aberrant social and cognitive development in the very early stages, before the onset of psychosis. Precursors of COS include high rates of soft neurologic signs (minor neurologic abnormalities that are not associated with a specific neurologic disorder), significant delays in language and motor development, and social withdrawal.

 identifies behavioral precursors of COS and common premorbid childhood psychiatric disorders.

The lack of a well-defined period of normal development in children with COS may obscure the delineation of illness onset, making accurate diagnosis more difficult. Compared with adolescent- and adult-onset schizophrenia, the rates of insidious onset in COS are considerably higher, 71%

 compared with about 61% in adolescent and adult cases.

Clinical assessment and differential diagnosis


COS is 50 times less likely to occur than adolescent-onset schizophrenia.

 The diagnosis of COS requires the presence of persistent hallucinations or delusions, disorganized speech and behavior (positive symptoms), and/or lack of developmentally appropriate affect and goal-directed behaviors (negative symptoms) for at least 1 month, and enduring impairment for at least 6 months. The current criteria in 

for the diagnosis of COS are identical to those for a diagnosis of schizophrenia in adults with only one modification, namely, a child's failure to achieve an expected level of interpersonal, academic, or occupational achievement, which may replace a deterioration in function. There is no minimum age requirement for COS, and therefore, it can be diagnosed in very young children who meet the above criteria. However, it is rarely diagnosed before preschool age.

Optimal strategies for assessing and diagnosing COS include a structured or semistructured interview with the child and parent, in addition to a clinical interview and observation. A well-accepted semistructured interview is the Schedule for Affective Disorders and Schizophrenia–Present and Lifetime Versions.

Because of the frequent preexisting thought and language dysfunction, COS is often more challenging to diagnose than schizophrenia in adolescents. For example, delusions or hallucinations may not be easily distinguished from the odd and idiosyncratic thinking in developmental disorders. In addition, a child's report of auditory hallucinations is frequently not pathognomonic of schizophrenia, since most children who report hallucinations do not have schizophrenia and many do not have psychotic disorders

-these hallucinations may simply be hypnagogic or hypnopompic.

Delusions in childhood exceed exaggerated magic beliefs, and these “fixed false beliefs” are often frightening and may drive a child to take an irrational action in an attempt to counteract them. For example, a child with a delusion that a sibling has AIDS and is trying to infect him or her might seek to “protect” himself or herself by wearing boots in the shower and hiding from the sibling at home. Similar counteractive protective behaviors may be observed in children with obsessive-compulsive disorder; however, delusions are often more bizarre than obsessions, and in general, delusional children do not believe that the danger diminishes as a result of their own responses (ie, compulsive rituals do not neutralize the fears).

True psychotic symptoms must be differentiated from children's reports of psychotic-like phenomena surrounding the idiosyncratic thinking and perceptions associated with pervasive developmental disorders (PDD), psychotic-like symptoms that may arise in children with posttraumatic stress syndrome, or anxiety-related transient “phobic” hallucinations. Psychotic symptoms in adolescents, compared with those of young children, are often more clearly described because of the increased developmental abilities of teens to articulate their inner experiences, which helps make the diagnosis of schizophrenia more clear-cut.

The comorbidity and overlap between PDD and COS sometimes makes these 2 disorders difficult to distinguish. Children with PDD may have more idiosyncratic, poorly formulated, peculiar thoughts that may shift or evolve over time. Like children with COS, children with PDD may also have odd beliefs-for example, that they are able to communicate with valued inanimate objects. Phobic hallucinations usually occur in the context of anxiety, such as a child “seeing” a frightening face in the window when it is dark, but which may not trouble the child during the day when the anxiety is muted.

Children with COS often fail to acquire the necessary social skills to fit in with same-age peers and frequently end up isolated. Significant rejection from peers, isolation from sports and other social activities, and generalized confusion and fear may emerge and permeate daily life.


The relationship of COS to PDD has been of interest given their frequent coexistence. In a sample of children with COS, 34% had pervasive developmental symptomatology and 60% met criteria for a speech and/or language disorder.

 found that 25% of children with COS had a lifetime diagnosis of PDD and those with comorbid PDD did not differ from the COS-only group in age at COS onset, cognitive performance, neuropsychological measures, or overall long-term outcome.

In a recent review of COS and childhood-onset schizoaffective disorder, 99% of those with either disorder were found to have at least 1 comorbid diagnosis: 84% had attention-deficit/hyperactivity disorder (ADHD), 43% had oppositional defiant disorder, 30% had depression, and 25% had separation anxiety disorder.

 have been found to be comorbid with schizophrenia. Many comorbid disorders of COS, such as PDD, ADHD, and speech and language disorders, have their onset before COS.


Treatment strategies focus on alleviating positive and negative symptoms, reducing long-term morbidity, and preventing relapse. Clinical experience supports a combination of psychopharmacologic and psychosocial interventions to address the treatment needs in COS.


The available studies, as well as anecdotal clinical experience, suggest that response to antipsychotics in children with COS is less robust than in adolescents or adults with schizophrenia. Current pharmacologic research for COS is focused on identifying antipsychotic agents that provide optimal efficacy without significant adverse events. Atypical antipsychotics, including risperidone, olanzapine, and clozapine, have been shown in randomized clinical trials and open trials to be efficacious in the treatment of COS

; however, significant adverse effects, including weight gain, extrapyramidal adverse effects, and metabolic abnormalities, have occurred. 

 summarizes several recent psychopharmacologic trials for COS.

The superiority of clozapine over typical and atypical antipsychotics was shown in 2 randomized clinical trials for the treatment of COS; however, the use of clozapine was associated with serious adverse events such as tachycardia, hypertension, cardiac and lipid abnormalities, agranulocytosis, seizures, and nocturnal enuresis.

In a 1-year open-label trial of olanzapine for the treatment of COS, positive symptoms improved after 6 weeks and negative symptoms showed improvement after 1 year of treatment.

 Adverse effects included increased appetite and weight gain,

 GI symptoms, headaches, agitation, liver function abnormalities, and sustained tachycardia.

Pharmacologic treatment for COS remains an area of active research with 2 large ongoing multisite trials. The Early Onset Schizophrenia Study is investigating newer atypical antipsychotic agents. Preliminary open-label data suggest that ziprasidone was beneficial in approximately 13 of the 40 patients with COS after 12 weeks of treatment, with a mean final dosage of 118 mg/d. In over 1 year of this study, 50% of patients gained weight but no significant ECG changes occurred. The preliminary data suggest that ziprasidone may be useful in the treatment of COS.

 Another ongoing double-blind trial (Treatment of Early Onset Schizophrenia Spectrum Disorders) compares molindone, risperidone, and olanzapine.


Psychosocial interventions address social, family, and peer relationship distress and developmental sequelae associated with COS.

 Social skills training is geared toward improving the patient's strategies for dealing with conflict and avoidance, enhancing communication within the family, and improving socialization and vocational skills. Psychoeducation helps the patient and his family understand the illness, the treatment options, and the prognosis for developing strategies to cope with the symptoms.

 Family psychoeducation and cognitive-behavioral therapy have been shown to reduce relapse in adolescents and adults with schizophrenia,

 and it is conceivable that a similar gain may occur in patients with COS.


Outcome studies ranging from several years to up to 42 years after diagnosis of COS indicate that the long-term functioning of patients with COS is poor compared with that of patients who have adolescent- or adult-onset schizophrenia.

 In general, the earlier the onset of COS, the poorer the prognosis. Variables indicative of better prognoses among children with COS are higher premorbid intelligence, more positive than negative symptoms of schizophrenia, and cooperation of family in treatment.

 Outcome variables in COS are detailed in 

Follow-up data indicate that close to two thirds of children with onset of schizophrenia between the ages of 6 and 14 years will be chronically ill.

 While outcomes are most grave for children with onset of illness before 13 years of age, findings from long-term outcome studies of adolescents with schizophrenia indicate that the illness has a negative impact on their academic success.

 For example, compared with the general population, adolescents with schizophrenia are about one third as likely to graduate from secondary school.

With respect to occupational functioning, the findings from a 3-year outcome study of schizophrenia in children and adolescents showed that fewer than one fifth were able to function in academic or work settings at the level of same-age peers in the general population.

 Long-term follow-up of individuals with COS and adolescent-onset schizophrenia over 6 to 40 years indicates that significant impairment persists into adulthood; only 7% of the sample were able to maintain a stable relationship, and 59% were unmarried and living alone. Although 73% had some form of employment, 27% were unable to work.

 Clearly, the burden of schizophrenia lingers over the years.

While COS and adolescent-onset schizophrenia are the same disorder, their relationship is highlighted by a poorer prognosis in youth who meet diagnostic criteria before age 14 years.

 Children with COS are at significantly increased risk for having bor-derline intellectual function or mild mental retardation,

 and they are more likely to have speech and language disorders

 compared with those who have adolescent-onset schizophrenia.

Given the challenge of finding successful multimodal interventions for COS, available psychopharmacologic agents have shown some evidence of effectiveness, although all are still limited by serious adverse effects. Future investigations of combined psychosocial and pharmacologic treatments are needed to provide a broader range of effective interventions to improve long-term function of patients with COS.

Dr Khurana and Dr Aminzadeh are first-year child and adolescent psychiatry fellows at the Los Angeles County–University of Southern California (USC) Child and Adolescent Psychiatry Fellowship Program. Dr Bostic is director of school psychiatry at Massachusetts General Hospital in Boston and McLean Hospital in Belmont, Mass. Dr Pataki is director of residency training in child psychiatry at the USC Keck School of Medicine in Los Angeles.

Dr Khurana and Dr Aminzadeh report that they have no conflicts of interest concerning the subject matter of this article. Dr Bostic has received grant support and/or honoraria from Abbott, Forest, GlaxoSmithKline, Eli Lilly, and Pfizer; he is on the speakers' bureau for Forest and a consultant for GlaxoSmithKline. Dr Pataki has received research support from Eli Lilly, Pfizer, Novartis, and Shire.


Clozapine (Clozaril)
Haloperidol (Haldol)
Molindone (Moban)
Olanzapine (Zyprexa)
Risperidone (Risperdal)
Ziprasidone (Geodon)

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Articles

Persons with childhood-onset schizophrenia appear to have the poorest outcome among those in whom schizophrenia is diagnosed.

Childhood-Onset Schizophrenia: Diagnostic and Treatment Challenges

Adolescents of every generation reject their parents' icons as they seek out and empower their own. These icons fall along a continuum, from mainstream hero figures--usually tolerable to parents and the adult generation, such as Kelly Clarkson, Beyoncé, and Usher--to the antiheroes at the other end, such as Marilyn Manson, Courtney Love, Eminem, Dennis Rodman, and perhaps even fictional video game characters such as Hitman and the protagonist CJ in 

 These antiheroes seem deliberately provocative, assailing almost every social convention of the adult generation, and parents often fear they are leading youth astray.

 Indeed, identification with some youth subcultures (eg, goth) may be associated with increased risk of self-harm.

Yet every generation repeats this pattern, elevating their own rebel leaders while dismissing their parents' icons. All along the spectrum, icons resonate with important themes inherent to adolescent development and provide clinical opportunities to engage both adolescents struggling with individuation and parents seeking skills to facilitate this process despite feeling stymied by their adolescents.

Whether Eminem in the 2000s, Marilyn Manson in the 1990s, Alice Cooper in the 1970s, or Elvis Presley or James Dean in the 1950s, antiheroes possess similar characteristics (

), and these characteristics amplify important developmental challenges faced by the adolescent. Moreover, these antiheroes challenge the adolescent's parents, who are contending with their own developmental hurdles imposed by the adolescent's separation/individuation process.

The appeal of antiheroes coincides with 2 intertwined developmental tasks that are important in adolescence. First, adolescents must separate enough from parents to identify their own interests and to construct an identity. Second, adolescents must be able to connect to other peers as they separate from parents. This is not a linear process, and the adolescent intermittently rejects and then approaches parents for support during times when the adolescent experiences a failure or is ostracized by his or her peer group. The adolescent may be harsh and critical of his parents at one moment, fearing dependency and making an effort to separate, yet expect parents to be compassionate the next moment, when the adolescent feels shunned or neglected by even a subgroup of peers.

The phenomenon of adolescent antihero admiration can thus be viewed as a developmentally important part of an adolescent's psychological growth toward individuation. Inclusion of temporary identifications, even with outrageous figures, by adolescents is part of their process of deriving a cohesive sense of self.

 Adolescents who struggle with feelings of alienation may be more prone to try on an antihero identity among their explorations. Even this phase may ultimately strengthen their final identity, since adolescents may distill antihero traits to manage their own fears of being outcast as they strive for autonomy.

Both heroes and antiheroes may provide an identity way station, facilitating separation from parents and offering the adolescent identifiable means (clothes, music, specific interests) to be recognized by like-minded others, which helps adolescents identify potential peer connections. In the effort to connect with similar peers, and to distance from dissimilar peers, adolescents exaggerate differences among peer groups, including their musical preferences.

 However, the personas tried on by the adolescent often wear poorly and may be abandoned relatively quickly, particularly if they do not lead to useful connections to peers.

Antiheroes may particularly appeal to adolescents who, sensitive to their own flaws, see the antihero as similarly flawed and shunned by adults. These adolescents also hope to find the ability to flourish without depending on adults. Few have suggested that the appeal of Alice Cooper, Courtney Love, or Marilyn Manson was primarily based on their vocal abilities. What antiheroes do possess, beyond outrageous behavior, are uniqueness, creativity, and cour-age, which predominate over traits such as perfect pitch or physical strength. In addition, they may help adolescents view their own flaws as acceptable or even heroic badges of honor.

Adolescents often imitate the antihero, even in appearance, as they try to fashion themselves into a figure similarly powerful to stand against authority figures, despite lacking attributes or talents recognized by mainstream culture. Looking the part may be the most effective means by which adolescents can demonstrate their need to play out the fantasy of emerging victorious. Antihero identities adopted by adolescents are almost invariably temporary holding identities, as the adolescent figures out that portraying the stage persona of the antihero does not work in real life as fantasized.

J, a 15-year-old boy with depressive disorder and a propensity for fighting in school, excitedly directed his therapist to a Web site featuring a famous and somewhat disreputable sports figure physically attacking a commentator who was ridiculing the player on national television. The patient stressed that many of his friends felt strongly that this video gave credence to the argument that physical assault was a necessary and justifiable response to verbal insults. As the video progresses, the sports figure leaps across the interview table and attacks the broadcaster before he is pulled out of the fight by station attendants.

The patient noted that many of his friends saw this scene as an example of how one can be pushed toward violence as the only response to ongoing insults and therefore justified his own continual pugilism in school and in the neighborhood. The therapist identified with the patient, noting that it felt good to see the broadcaster deftly "handled" by the professional ballplayer. However, both the therapist and patient also wondered whether the player and the broadcaster were following a kind of unwritten script that, in the end, made the player seem potentially even more foolish than expected. After all, it was obvious, barring some unknown martial arts expertise on the part of the broadcaster, that the athlete could easily overcome this adversary and that his response was therefore particularly uncreative and predictable. A quick Google search revealed that the incident had left the athlete in a state of media infamy, and the patient wondered whether it would have been even more effective for the player to simply have walked off the set, leaving the puerile broadcaster alone with his mockery.

While adolescents are seeking autonomy, parents may become fearful that their offspring may be irreparably harmed by exposure to antiheroes.

 Indeed, violent imagery in the media may negatively influence the development of adolescent attitudes such as empathy.

 The expansion of mass media and the decrease in censorship provide adolescents more exposure to more extreme images,

 desensitizing them to previously unspeakable behaviors.

Antiheroes have been implicated in promoting negative, self-destructive adolescent behaviors and, at the extreme, adolescent tragedies such as teen suicides.

 While a small fraction of severely psychiatrically ill adolescents imitate the potentially violent antics of antihero personas, the vast majority of adolescents can distinguish these staged acts from real lifestyles.

Antihero imitation may become an acceptable part of adolescent culture for healthy adolescents, but when is it a sign of maladaptive behavior? Signs of potentially worrisome adolescent antihero worship occur when it results in alienation, isolation, or humiliation rather than serving as a form of connection. Furthermore, when imitation is coupled with expressions of any self-injurious behavior or violence toward self or others, this signals the need for intervention.

T, a 14-year-old girl, described in outpatient therapy how she felt alienated by peers after dying her hair black, wearing black nail polish, and changing her cell phone ringtone to a rap song. She complained that peers she had known since elementary school stopped talking to her. In therapy, T began showing her therapist her MySpace profile as well as those of boyfriends, including one whose profile included pictures of marijuana leaves. T's profile included photos of multiple friends, some in sexually provocative positions.

The therapist examined not only T's profile but others' profiles on MySpace, as well, as T and the therapist imagined what the "real person" was like who put up various profiles. They soon recognized that T's sexually provocative material made some boys expect that she would "put out," which put her in uncomfortable situations, including other girls talking badly about her. T recognized that she wished others would think she was "hot" so that she might become more popular among peers, and she could not think of other ways to attract their attention or respect. Although she had relatively little insight into the reasons behind her music choices, she thought others would think she was "mature" and "hip-hop," which would elevate her over other girls. T's fears of being neglected, as well as her choice of ways to attract attention, became a focus of therapy. While she dyed her hair multiple other colors to imitate the female singer Pink during the course of treatment, connections between feeling "not special" and then taking such actions led T to recognize her overwhelming impulses to do anything to avoid loneliness. As T examined the consequences of such acts, she realized that she often did not obtain what she wanted. She began articulating her feelings to others during the times when she felt lonely and needy of attention.

Clinical opportunities with adolescents and their parents

As shown in these case illustrations, antiheroes may be useful clinically as a vehicle for addressing adolescent struggles with separation and identity development. Specifically, antiheroes may provide an additional window to the soul of the adolescent. Based on the adolescent's passion for what the antihero represents, discussions of antiheroes may serve as a projection device for clinicians and parents. Antiheroes may also facilitate discussion of complex issues, since the adolescent describes reactions to the antihero that in reality reflect the adolescent's own worries and concerns.

While the adolescent may experience anxiety caused by separation/individuation fears, parents may also feel anxious in that they fear losing control over their child, fear criticism from other parents, and perhaps most important, fear their child will abandon their values and instead emulate the antihero du jour. The adult's familiar psychological defense system may be challenged in these circumstances. Parental regression to authoritarianism or denial manifesting as avoidance or neglect may emerge, causing the parents to overlook the underlying needs of the separating adolescent. Even small tensions may become too much to bear when both the adolescent and parent cannot harness their own anxieties, and then both may rely on more primitive defenses that undermine efforts toward constructive negotiation. While disconnection and avoidance of anxiety-provoking interactions occur, perhaps facilitating adolescent separation, this scenario does not allow parents to model or provide the adolescent with useful responses to employ as coping skills.

The clinical opportunity available amid these parent-adolescent conflicts is to examine optimal coping skills to navigate this complicated separation/individuation process with parents and adolescents. The adolescent's interests in icons, even antiheroes, provide important channels of communication and cues. If these are recognized in a developmental context, adults can attune and assist the adolescent in separating while minimizing their own distress. Clinical opportunities for both adolescents and parents are outlined in 

Negative impacts of the antihero on the adolescent, based on observed behavior or suspicion of impending harm to the adolescent or others, warrant attention by the clinician. The function served by the antihero can inform the clinician as to which interventions are most likely to benefit the patient and family members. Functional assessments usually involve the identification of the settings or context in which the adolescent's troublesome behaviors occur.

 In addition, functional assessments examine the antecedents leading to the inappropriate behavior and the consequences of these behaviors.

For example, an adolescent may frighten parents and teachers by dressing like a particular icon. This behavior may occur only at school, or everywhere, and may have emerged after the adolescent was not accepted for a sports team or school musical group, or simply following rejection by peers. The consequences of this behavior may include formation of bonds with similar peers, expanding a group of accepting peers, and the added pressures of increased conflicts with parents that the new peers may bring.

For some adolescents, role-modeling an antihero may serve as a behavior that emerges in response to disappointed or disapproving adults and peers. Moreover, the antihero remains available to the adolescent through the media for ongoing direction about what to wear and how to act. Yet the adolescent can never fully identify with the antihero, so this costume can ultimately be discarded; that is, since the adolescent did not create this persona, it resides with the antihero when the adolescent is ready to abandon it. What is harder for the adolescent to abandon is the circle of peers who may similarly be identified by their interest in an antihero.

Ultimately, antiheroes and what they represent suffer the fate of other antithetical ideas in society: they become somehow assimilated into the current adolescent culture. To continue as antiheroes, these characters have to rebel against their socially acknowledged role. This does not mean antiheroes necessarily sell out, but instead that antiheroes provoke a response from mainstream society, which most often adjusts to them. To this end, it is helpful to remind parents that the values of antiheroes are reflections of the prevailing culture as much as they are reactions to the values of the prevailing culture. Every era has its heroes and villains, and most past villains are eventually understood in the context of more mainstream ideals.

Adolescents often need help in negotiating the sometimes turbulent trail toward adulthood. Adults can be an invaluable support to adolescents by preparing (beyond protecting) them to contend with the media barrage to which they are currently exposed. Adults can promote understanding of adolescent developmental issues through thoughtful examination of adolescent choices in music, media, and pop culture icons--including antiheroes. Adults who deal with adolescents may set goals to model tolerance of adolescents' individual choices while setting guidelines for behavior that demonstrate the basic values that are important to adults and to successful societal integration. Media pop culture icons and antiheroes present clinicians and adults with the opportunity to work through critical developmental challenges with adolescents by using sometimes distressing images to address struggles leading to individuation and autonomy.

Dr Bostic is director of school psychiatry at Massachusetts General Hospital in Boston and McLean Hospital, Belmont, Mass. Dr Pataki is director of residency training in child psychiatry at the University of Southern California Keck School of Medicine, Los Angeles. Dr Rho is a child psychiatry fellow at Cambridge Hospital, Mass. Dr Schlozman is associate director of residency training in child psychiatry at Massachusetts General Hospital and McLean Hospital. Dr Martin is director of the child psychiatry inpatient service at Yale-New Haven Hospital, Conn.

Dr Bostic has received grant support and/or honoraria from Abbott, Forest, GlaxoSmithKline, Eli Lilly, and Pfizer. Dr Pataki has received research support from Eli Lilly, Pfizer, Novartis, and Shire. Drs Rho, Schlozman, and Martin have no financial relationships to disclose.

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 Stack S, Gundlach J, Reeves JL. The heavy metal subculture and suicide. 

Adolescents reject their parents’ icons and seek out and empower their own. Antiheroes seem deliberately provocative, assailing almost every social convention of the adult generation, and parents often fear they are leading youth astray.

Caroly Pataki, MD

Articles

Childhood-Onset Schizophrenia: Diagnostic and Treatment Challenges

Rebels Without a Cause? Adolescents and Their Antiheroes