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Childhood-Onset Schizophrenia: The Severity of Premorbid Course
Childhood-Onset Schizophrenia: The Severity of Premorbid Course
ABSTRACT
Objective: To review the premorbid histories of 23 children meeting DSM-II/-R criteria for schizophrenia with onset
before age 12 years and to compare these with childhood data of later-onset schizophrenics. Method: Premorbid
features up to 1 year before onset of first psychotic symptoms were rated from hospital and clinic records, clinical
interviews, rating scales, and tests. Results: In keeping with previous studies, specific developmental disabilities and
transient early symptoms of autism, particularly motor stereotypies, were common. Comparison with the childhood of
later-onset schizophrenics showed greater delay in language development, and more premorbid speech and language
disorders, learning disorders, and disruptive behavior disorders. (Sixty percent had received or were estimated to meet
criteria for one or more clinical diagnoses.) Conclusions: Childhood-onset schizophrenia may represent a more malig-
nant form of the disorder, although selection and ascertainment bias cannot be ruled out. The presence of prepsychotic
language difficulties focuses attention on the importance of early temporal and frontal lobe development; early transient
motor stereotypies suggest developmental basal ganglia abnormalities and extend previous findings seen in the child-
hood of later-onset patients. J. Am. Acad. Child Ado/esc. Psychialry, 1995,34,10:1273-1283. Key Words: childhood-
onset schizophrenia, premorbid, prodrome, prepsychotic.
op mc nra l delays an d poor er soc ial adj us tme nt th an T he clinical and neurob iolo gical character iza tio n of
controls; in general, th ese features we re m ore ap pa rent ch ild hood- onse t schizo p h ren ic pat ients is on going at
in males. th e N ational Institute of Mental H ealth (NIMH) (Fra-
The st udy of childhood-onset sch izo phren ia rep re- zier er al., 1994; Gordon et al., 1994; McKenna
sen ts a unique app roach to the neurod evelopmental et al., 1994a ,b) . In th e present study, the prep sych otic
understanding of th e d isorder. Very early on set cases development of th is sam ple of 23 chi ld ren and adoles-
ma y rep resent a m ore h omogen eou s or m ore severely cents me eting DSM -III-R criter ia for schizophren ia,
affected gro up, th at received a " bigger do se" of a with onse t of first psychotic sym ptoms by or before
hypo th et ical etiolog ical age nt suc h as early brain insult. age 12 years, was exam ined . The pr esent rep ort is of
Alt ern at ively, a relati vely beni gn p rem orbid course thi s gro u p's prem orbid dev elo pme ntal course in relatio n
wo uld foc us interest mo re on facto rs respo nsi ble for to othe r stud ies of ch ild ho od-o nse t sch izophren ia and
acti vation of the di so rd er, e.g. , pr ecocious pu bertal to studies of childhood abnorm aliti es seen in patients
devel opment, in whi ch an identical diso rder and co u rse with later-onset sch izoph ren ia.
is manifest ed but sim ply initiated at an earlier po int
in time. METHOD
Only a sma ll number of repo rts on ch ild hood -o nset
sch izoph ren ia d escribe even briefly the pr epsych otic
SUBJECTS
and /or p rodromal co urse. These are su m marized in
T he premorb id and prodromal histo ries of 23 children (15 boys
T abl e I . and 8 girls) diagnosed using DSM -fll-R criteria for schizophrenia
As see n, Kolvin et a!. (19 7 1) exa mi ned the p rem orb id (American Psychiatric Associa tio n, 1987) are th e subject of this
period of 33 sch izoph ren ic child ren whose illnesses stud y. W hen seen at the N IM H , they had a mean age of 14 years
(range, 10 through 19). Patients had been recruit ed natio nally
developed before age 15 years, finding behavioral abn or- throu gh an no un cements to profession al and patient ad voc acy
malities in 87(Yo and m ajor milestone delays in 49% groups. T he advertisem ent s sought referrals of children meeting
o f cases. Kydd and Werry ( 1982) d escribed 15 ch ildre n DSM-lIf-Rcriteria for schizophrenia with o nset of psychot ic symp-
tom s prior to or by age 12 years. Early history from preschoo l
in who m schizo ph renia developed befo re age 16 years, and kindergart en had to suppo rt an estima ted no rmal intelligence.
for who m o nset was rated as insidious in onl y fou r. More th an 350 charts were reviewed, from which 98 subjects and
Prodromal depressive sym pto ms pr ed ated th e onset of their families were screened in person and 28 were diagnosed as
sch izo p h ren ic. T wenty-t hr ee of the se patient s have partici pated in
schizo ph ren ia by a period of 1 month to 2 years in
the study to date. More com plete descrip tions of this o ngoing
th ese chi ld ren. Asarn ow and Ben-Meir ( 198 8) repo rte d stu dy are available elsewhere (Go rdo n ct al., 1994; McKenna
poorer p remorbid ad ju stm ent and mo re insi d ious o nset er aI., 1994a,b).
At th e NIMH , all partic ipants und erwent a com prehensive
in children with schi zo phrenia spectrum disorders co m-
screening process inclu ding clinical int erview by two child psychia-
pared with children who had depressive disorders. trists and structu red int erviews with the Schedule for Affective
Green and co lleagues ( 1984) examined 24 children in Disorders and Sch izophreni a for School-Age C hild ren-E pidem io-
logic Version (K-SADS -E) (O rvaschel er al., 1980); selected portions
who m sch izo ph renia developed befo re th ey were 12
of the Diag nostic In terview for C hildren and Ado lescents-Parent
years of age, and an enlarged sam ple of 38 cases (Green Versio n (DICA-P) and C hild Version (DICA-C) for disrup tive
et al., 1992 ), and th ey found insidi ous onse t to be the behavior disorder s, substance abuse, and child psychosis (H erjanic
and Ca mpbell, 1977); th e Prcmo rbid Adj ustme nt Scale (PAS)
rul e. W atkins and co lleag ues (19 88) , in the mo st carefu l
(Ca nno n-Spoo r er al., 1982); and the Auti sm D iagnostic Inte rview-
stu dy to date, of 18 schizo ph renic chi ldren, all psych oti c R (Lord , 1991 ).
by age 10 , found severe language deficits and delayed
motor development in 72%. Thi rt y-n ine percent of RATING OF PREMORBID AND PRODROME PERIODS
the sample had met criter ia for in fantile autism before Two psychiatrists (l.A, K.M.) independently reviewed the pre-
the on set of sch izo phre n ia, with m or e disturbance in mo rbid and prodromal histo ries of th e 23 patients usin g all available
past records, includin g charts from previou s hospitals and clinics,
ma les. Ru ssell and co lleagues ( 1989) , in a separate clinical and structured psych iatric interviews at the NIMH , and
study fro m th e same cen ter, found th at 9 (26%) of all available tests. T he records reviewed and nu mber availab le for
3 5 ch ild ren with sch izophren ia had exh ibited clear each measure are shown in Table 2. As expecte d, hospital/clinical
evaluation s varied co nsiderably.
sym pto ms of pervasive developmental d isorder (P O D), Raters were instructed to rate only those sym pto ms fo r which
altho ugh non e had met full cr iter ia. dea r behaviora l descript io ns existed in th e records. In case of
TABLE 1
Studies of Premorbid History of Childhood-Onset Schizophrenics
Age at Onset Findings
Study Sample Method of Psychosis Premorbid Prodrome
Kolvin et al., 197 I 33 Unstructured < 15 yr (10 29 (87%) "odd or un- Insidious onset in 29 (87%)
interview were < 12 usual"; 16 (49%) any
yr) major milestone delay
(mainly speech delay:
15 [46%]); 2 (6%)
echolalia
Kydd & Werry, 1982 15 (8 M/7 F) Chart review <16 yr Insidious onset in 4 (26%)
Green ct al., 1984, 24 (15 M/9 F), CBCL and <12 yr Insidious onset in 29 (87%)
1992 expanded to chart review
38 (26 M/
12 F)
Asarnow & Ben-Meir, 31 (I I M/6 F K-SADS and <13 yr Very poor scores on PAS, Insidious onset in 16 (52%),
1988 schizophrenic, interview means (± SD): schizo- chronic course in
10 M/4 F (DSM-III) phrenics, 4.11 (1.0); less 14 (45°/<,)
schizo typal) premorbid sociability,
much more disturbed
than depressive contrast
group (p < .000 I);
FSIQ = 89.7 (11.99);
VIQ = 92.2 (14.3):
PIQ = 87.2 (10.5)
Watkins et al., 1988 18 (13 M/5 F) DSM-lll and <12 yr 39% infantile autism; 17%
CBCL PDD NOS; 72% severe
language deficits; 72%
developmental motor
abnormalities
Russell et al., 1989 35 (24 Mill F) Semistructured < 12 yr ADHD features, 14 (40%); Behavioral disturbance in
interview conduct disorder, 30 (86%)
(DSM-IIl) 6 (17%); PDD features,
9 (26%); none met full
criteria
Note: Higher PAS scores reflect greater impairment (maximum = 6). Insidious = slow, continuous decline. CBCL = Child Behavior
Checklist; PAS = Premorbid Adjustment Scale; K-SADS = Schedule for Affective Disorders and Schizophrenia for School-Age Children;
FSIQ = Full Scale IQ; VIQ = Verbal IQ; PIQ = Performance IQ: PDD = pervasive developmental disorder; NOS = not otherwise
specified; ADHD = attention-deficit hyperactivity disorder.
discrepancies, "positive" clear symptoms took precedence over ently. Interrarer reliability was then checked periodically throughout
negative statements, and symptoms recorded at the time they were the remainder of assessment. Interrarer reliability was calculated
observed took precedence over recollection. using the K statistic if ratings were on a categorical scale or intraclass
Prodrome was defined as any new symptoms during the I-year correlation coefficients (ICCs) if on a continuous scale (Bartko
period before the onset of first psychotic symptoms. All childhood and Carpenter, 1976; Flciss, 198 I). Agreement on the following
years before that were considered the premorbid period, the focus variables was excellent: speech (K = .81), attention-deficit hyperactiv-
of this study. All measures were not available for every subject, ity disorder (ADHD) (K = .80), motor development (K = .80),
and a combination of data from available sources (psychological PDD symptoms (K = 1.0), sociability (ICC = .96), peer relationships
tests, hospital records, school records, parents' reports, interview (ICC = .98), interests (ICC = .89), scholastic performance (ICC =
notes) were used, usually giving most weight to positive statements. .93), and adaptation to school (ICC = 1.0). Agreement on language,
Because of the varied amount and quality of information, a diagnosis
type of onset, and prodrome was fair to good: language (K = .64),
of absent/probable/definite was used in denoting the presence or
type of onset (K = .4 I), impulsivity (K .44), and prodrome
absence of characteristics.
(K = .55).
Two reasons may explain the higher K for speech than for
Establishment of Interrater Reliability language. Speech disorders were diagnosed if a significant degree
After five practice chart reviews, reliability between the two of stuttering, articulation problems, or dysfluencies were described
psychiatrists was assessed on 10 subsequent charts rated independ- in the records or clinical interviews. These are somewhat easier to
TABLE 2
Basis for Ratings of Prodromal Behavioral Status for 23 Childhood-Onset Schizophrenics
Data Source/Number Available
Speech &
Psychiatric School Language Hospital Parent
Measure/Diagnosis Testing Reports Evaluation Records Interview D!CA AD! PAS K-SADS
IQ 7 16
Developmental
milestones 20 21 22
Specific develop-
mental disorders 21 7 20 23 23
Disruptive behavior
disorders 21 20 23 23
Pervasive develop-
men tal disorders 21 20 23 22
Social development 21 23 23 22 23
Prodrome 21 20 23 23
Note: Type of onset (acute, subacute or insidious) was rated on the basis of all available charts, records, and past interviews. DICA =
Diagnostic Interview for Children and Adolescents; ADI = Autism Diagnostic Interview; PAS = Premorbid Adjustment Scale; K-SADS =
Schedule for Affective Disorders and Schizophrenia for School-Age Children.
specify and code than the results of the language testing, which Thus, for this study, only the childhood section was used. There
included some contradictory findings and discrepant test results is a 7-point scale for each item (0 through 6 = normal-severely
which were not simple to interpret. impaired); individual items were social withdrawal (as defined by
avoidance of social interaction and social contexts, i.e., a reduction
PREMORBID PERIOD in the rate of interpersonal interaction), peer relationships, interests,
scholastic performance, and school adaptation. Finally, an overall
PAS score was generated by adding the scores for each item and
Developmental Milestones dividing this sum by the number of items rated. Premorbid
Developmental milestones were examined through the Autism impulsivity was rated separately using items in the DleA, which
Diagnostic Interview, medical, and educational records and other reflect items 4, 5, and 12 of criterion A from the DSM-III-R
parental reports. Where sources conflicted, data were rated as ADHD criteria. These were difficulty awaiting turn in games or
missing. The Denver Developmental Screening Test (Frankenburg, group situations, blurting out answers to questions before they
1969) was used to determine developmental milestones (below had been completed, and not listening to what is being said to
l Oth percentile was considered a significant delay). him or her. A -i-poinr scale was used representing 3, 2, 1, or no
items endorsed.
Premorbid IQ
Test scores were available for seven patients; for cases where Specific Developmental Disorders
more than one premorbid IQ test was available, the highest score Speech and Language Disorders. Psychological reports, school
was used. Where repeated IQ scores and/or other indices of records, and medical records were examined by two psychiatrists to
cognitive level were available, the data were scrutinized for evidence determine the presence or absence of language disorders, including
of intellectual deterioration. In other cases intelligence estimates expressive, receptive, or speech and articulation disorders. Full
were based on school performance using the scale developed by DSM-III-R criteria were required for "definite" diagnosis. For those
Kydd and Werry (1982): level 1 and 2 = above average intelligence, with definite diagnoses, the following IQ and language tests were
level 3 = average, level 4 to 7 = below average. available: Verbal subscale ofWISC (seven cases), Token Tests for
Children (two cases), Clinical Evaluation of Language Fundamen-
Social Development tals-Revised (three cases), Experience One Word Picture Vocabulary
Premorbid social functioning, assessed using the PAS, was based Test (two cases), Peabody Picture Vocabulary Test-Revised (five
on information from the patient, the patient's family, and previous cases), Structured Clinical Interview for DSM-III-R (one case),
records. In the PAS, "prernorbid" is defined as the period ending Developmental Sentence Analysis (one case), Carrow Receptive
6 months before evidence of overt psychosis. It has four sections Language Test (one case), Test of Language Development (one
(childhood, up to 11 years), early adolescence (12 through 15 case), Test for Auditory Comprehension of Language-Revised (one
years), late adolescence (16 through 18 years), and adulthood (19 case), Bankson Language Screening (one case), Boston Naming
years and older). Norms are provided for each age group from a (one case), One Word Receptive Picture Vocabulary Test (one
large normarive database but only for total score, and without case), Test of Problem Solving (one case), and Language Screening
standard deviations. The appropriate premorbid life periods are Test (one case). Cases had a mean number of 3.5 tests (range, 1
rated using this scale regardless of the present age of the subject. through 5).
Motor Ski lls Disorder. Cri terion A of DSM-IIl- R develop ment al RESULTS
co ordi na tio n d isor der was used :"The person's performan ce in daily
acriviries req uiri ng m ot o r coordination is marked ly below the T he premorbid and prod romal histories of 23 pa-
expected level, given th e person 's chro no logical age an d int ellect ual
tient s (males: n = 15, mean = 14. 5 ± 1.5; females:
capac ity . T his may be man ifested by ma rke d del ays in achieving
mo to r mil eston es, d rop pin g th ings, clu msiness, poor perform an ce n = 8, mean = 13.9 ± 1.8) with a mean age on
in sports , or poor handw riti ng." Reports by pa rents or reach ers of adm ission of 14.3 (± 1.8) years (range, 10 to 19 years)
suc h prob lems were take n as diagnostic. are summarized in T able 3. T he gro up had considera ble
Academic Skills Disorders. T hree school record ite ms were exam-
ined : repe titio n of a grade before o nset of psych oti c sym ptoms, premorbid develop mental delay and psychop ath ology,
p laceme nt in a specia l ed ucation class or assign me nt to specia l in keeping with other reports of premorbid develop -
classes, and any test-based reports of specific learn ing disabilities ment in childhoo d schizop h renia .
such as readin g, ar ithmetic, etc .
Statistical Analysis
Premorbid Pervasive Developmental Disorders
Selected parts of the Autism Diagnostic Interview (commun ica- Chi-square, Student's t test, or paired t test were
tio n, soc ial development and play, int erests and behaviors) and all used to compare groups or child/adult-onset studies
availab le charts 'and records were exam ine d. C hildren with a histo ry
of PO D sym pto ms were classified by whe the r they met th e full
differences, depending on th e distribution of th e vari-
DSM- IlI-R criteria for PO D (t hree criteria) or met two of the ables. Spearman or Pearson correlations were used to
th ree DSM-IIl-R crit er ia for POD. Those meeting one criteria for examine the relation ships amo ng variables.
POD m ost typ ically exhib ited stereo typy, echo lalia, or Rapping.
Developmental Milestones
Disruptive Behavior Disorders
ADHD. Medical, psychological, and school records were exam- Delays, as repo rted retros pectively, were seen for
ined as well as scor es for D IC A-P. T he di agnosis of AD HD was one quarter to one half of the subjects. There were
mad e using DSM -IlI-R criteria (Ame rica n Psych iat ric Associa-
more delays for crawling in males (t = 10.0 , P = .04).
tion, 1987).
Conduct D isorder. Pare nt and Child DI CA sections on disrup tive Delays were most striking for language development,
behavior d isord ers were exami ned and teachers' comments were since 9 (43%) of th e 2 1 for who m dat a were available
recorded whe n available: C h ild ren were co nsidered to have had had had prominent delay; th e mean age of first sente nce
co nduct disorder features if any th ree of th e DSM -IlI-R co nd uct
disor der criteria were m et up to 1 year befo re the o nset of
was 26 .5 months (±7.4) , which is significantly delayed
psych oti c sym pto m s. compared with the adult cases in Jones and cowo rkers'
(1994) repo rt (t = 6.30 , P < .000 1), alth ough it is
PRODROME
not clear whether we had the exact comparable data.
Sym p to ms during th e yea r before o nset of psychotic symptoms Early developmental delays in talking had no significant
were evalua ted using th e p rodrome section of the K-SAD S w ith
respect to withdrawal, school pe rfor ma nce , markedly peculiar be- relationship to IQ as obtained for 17 subj ects on
havior , impaired hygiene, blunted or ina pprop riate affect, vagu e/ admission to the NIMH (r = - .25, P = not signifi-
digressive speech or pov erty of speech, odd or magical thinking, cant [NS]).
od d perceptual experiences, and marked lack of initiative. C ha rts
were also reviewed to evaluate oppositional or negativistic beh avior
Premorbid IQ
versus socia l wi thdrawal or inhibitio n.
T he mean prepsychotic Full Scale IQ score, available
TYPE OF ONSET
for only seven pat ient s, was 87.7 (25.4), wit h a range
T ype of o nset was classified by the two rating psych iatr ists as
of 64 to 134, which correspo nds to borderlin e to low-
subacut e (6 months or less between change from baseline, i.e.,
in itial no nspec ific sym p toms to first psychotic symp to ms) or insid i- normal range of IQ and is significantly lower than
ous (more th an 6 m onths between change fro m baseline to first Offord's (1974) report (X 2 = N S, P < .000 1). T he
p sych otic sy m p to m s) , Co urse of ill" ess wa s ra te d as epi sodi c if
m ean sco res on the Ve rba l a nd Performance su bs ca les
charac terist ic psycho tic sym pto ms (such as delusions, hallucinat ions,
or for ma l th ou ght disorder) had ever occ urred in discrete ep isode s were 86.83 (29.1) and 93.42 (19.0), respectively. For
lastin g 6 months or lon ger. th e 16 cases witho ut premorbid IQ tests, school per-
form ance-based inte lligence estimate s showed low-n or-
ADULT STUDIES
mal IQ as a rule. For those who had both pre- and
All available stu dies of the childhood o f adul t schi zop h ren ics
postp sychot ic IQ test ing, multiple test ing between
w ith at least so mewhat compa rab le measures were selected . Me thod-
ologica lly, these varied co nsiderably and no ne had pr ecisely compa- high est prem orb id IQ and NIMH IQ revealed no
rable ch ild hoo d beh avioral measures. consistent cognitive decline. (Prepsychotic mean = 87.7
[25.4], postpsychotic mean = 83.7 [17.3], paired t= .77, infantile autism, one (4%) had met two of three, and
P = .48.) Further assessment of pre- and postpsychotic four (17%) had met one of three criteria for infantile
language tests for seven subjects, with particular atten- autism (Table 3). Of great interest were the transient
tion to reading or vocabulary subscales, also did not motor features of POD, namely hand flapping (5 cases),
suggest significant cognitive decline. head banging (1 case), and hand flicking (1 case).
Children with any features of POD were more likely
Social Development
to be male (X 2 = 7.2, P < .01), to have insidious onset
The mean overall total PAS score was 2.33 ± 1.60. (X 2 = 8.6, P = .003), and to have more developmental
The total norm for this age group is 0.23. motor delays (X 2 = 6.8, P = .03). Thus, as expected,
The mean for impulsivity was 0.86 ± 1.17 and children without a history of autism or autistic features
there were no sex differences (p = NS). Approximately were less abnormal premorbidly.
half the sample had significant impulsivity (see below
and Table 3), and approximately half were relatively Disruptive Behavior Disorders
withdrawn and asocial. Seven (30%) patients were considered to have had
Specific Developmental Disorders definite AOHO and two (9%) had met criteria for
conduct disorder.
Speech and Language Disorders. Ten (43%) patients
had definite and two (9%) had probable histories of Type of Onset/Prodrome
articulation disorders. All 12 cases had articulation
delays (failure to use developmentally expected speech As reported in other childhood studies, insidious
sounds), and stuttering was recorded for two. Using onset was most frequent; 15 patients (62%) had insidi-
DSM-III-R criteria, expressive, receptive, or mixed re- ous onset of psychosis, whereas in 8 (35%) the onset
ceptive/expressive language disorders were found in was subacute. Only one (possible) case was rated as
eight patients (33%). Of these, three had mixed re- episodic in course.
ceptive/expressive, four expressive, and one receptive A variety of prodromal symptoms were indicated
language disorders. In addition, two patients had proba- by the K-SAOS. Scores from the prodrome section of
ble language disorders. Comparison with a large pro- the K-SAOS (a dichotomous scale) for 17 subjects
spective study of the childhood of a community-based were as follows: withdrawal, 65%; impaired school
adult sample Oanes et al., 1994) showed a significant performance, 65%; markedly peculiar behavior, 59%;
delay in spoken language for our group (t = 6.3, P impaired hygiene, 29%; blunted/inappropriate affect,
< .0001). 71 %; vague/poverty of speech, 47%; odd/magical
Motor Skills Disorder. Using criterion A of the DSM- thinking, 35%; odd perceptual experience, 35%; and
III-R, coordination disorder, significant symptoms were marked lack of initiative, 53%.
recorded for six cases (27%), while two (9%) had The change in behavior indicated by previous clinical
probable histories of motor disorder. All had signifi- records during the prodrome (that is, during the year
cantly delayed motor milestones. Two had difficulty prior to the onset of psychotic symptoms) similarly
with handwriting, one had poor performance in sports, showed 10 (43%) patients to have exhibited opposi-
and one was identified as very clumsy. tional or negativistic behavior. Social withdrawal or
Academic Skills Disorders. Twelve patients (52%) had inhibition was also recorded in 10 (43%) patients. In
repeated at least one grade before the onset of psychotic 3 (13%) there had been no change.
symptoms, which was not significantly different from
Summary of Childhood Findings for NIMH Sample
Offord's (1974) report. Fifteen cases (65%) had had
placement in special education classes, and specific In general, as seen in Table 3 the present sample
learning disabilities had been diagnosed in seven (30%) showed quantitative and qualitative abnormalities simi-
patients: reading for three (13%) and arithmetic for lar to those in previous reports on very early onset
four (17%). schizophrenia (no statistical differences were found
by X2 analysis). Delayed milestones were prominent,
Pervasive Developmental Disorders
particularly for language. In agreement with other
Nine (36%) patients had had at least some feature pediatric studies, transient early symptoms of POD
of POD: three (13%) patients met full criteria for had been common.
TABLE 3
Premorbid Developmental Milestones, Developmental Disorders, and Psychiatric Disorders for 23 Childhood-Onset Schizophrenics
Age Reached Milestone Percent with Delay
Age at First: Mean (SO) Range (>95% on DDST) Comments
Speech disorders 10 (43) 2 (9) 12 (52) Comparable to Kolvin et al. (I 971), who
found 46% (16/33) (X' = NS)
Language disorders 8 (35) 2 (9) 10 (43) 72% reported by Watkins et al. (1988)
(X' = NS)
Motor coordination disorder 6 (27) 2 (9) 8 (36) 72% reported by Watkins er al. (1988)
(X' = NS)
Specific learning disability 7 (30) No data given in other studies
Reading 3 (13)
Arithmetic 4 (17)
Repeating a grade 12 (52) 12 (52)
Special educational 15 (65) 15 (65)
placement
Psychiatric Definite
Disorder No. (%) Probable Comments
Note: DDSI' = Denver Developmental Screening Test; NS = not significant; ADHD = attention-deficit hyperactivity disorder; POD =
pervasive developmental disorder.
"Ten (43%) had at least one definite premorbid developmental disorder.
Comparison with Childhood of Adult-Onset For example, the lack of cognitive deterioration seen
Schizophrenics in our sample is similar to findings in adult-onset
schizophrenia (Goldberg and Weinberger, 1988).
Table 4 shows a highly condensed summary of
childhood studies of later-onset schizophrenia with In general, girls had better premorbid histories than
comparison to the present study. boys and less insidious onset, consistent with findings
The present data would indicate a more severe in adults. However, unlike reports in adults, there were
premorbid course for childhood-onset cases. Most in- no statistical differences between girls and boys on
teresting is how this is true for only some measures. social maladjustment as measured by the PAS and
TABLE 4
Child hood Status of Adult-Onset Schizophrenics
Co m pa rison with Premorbid
H istory for N IM H
C h ild hoo d-O nset Schizophrenics
Study Sam ple Me thods Findings (n = 23)
O fford, 1974 116 (51 MI65 F) Schoo l records Rep eating a grade 32%; mean Repeating a grade 52% (Xl =
FSIQ = 92.65 N S); mean FSIQ = 87.7
(p < .000l)
Wan & Luben- 54 (27 M/27 F) School records M ean IQ = 102.86. M ales: em o- No sex differences for impulsiv-
sky, 1976 (age 15-34) tionall y unstable in grades i ry (Xl = N S); special class:
7-12; fema les: introverted, 65% (selective difficulties with
crno rio nally u nst able and pas- math and read ing)
sive in kindergarten-grade 6
(earlier than expect ed); learn -
ing difficu lties based on grad es
(especia lly ma th)
W alker & Lew- 5 Siblings Home movies from C ompared ro nonpsychotic sib- N o home mov ies availabl e; mile-
inc, 1990 (4 M Il F) infancy and lings: poor eye contact, less sto ne delays compatible; tran -
(age 17-24 ) child hood positive affect. poorer fine and sient PDD motor may be
gross motor coordination , less similar ph enomena
inte rpersonal responsiveness
Walker er al., 25 Sibl ings Home mo vies from G reater negat ive affecr than sib- N o sex differences for opposi-
1993 (25 M/7 F) infancy and lings, especially for fem ales tion al or negativistic behavior
(mea n agc: childhood (Xl = N S)
34 ::!: 6.27)
Jones et al., 1994 30 (20 Mil 0 F) Pro spective data Late mi lestones (walking and W alkin g 13.1 (t = N S); talk ing
from British talkin g with d ifference s in 26.5 (t = 6.30; P < .000 1)
1946 birth co- means 1.2 months):
hort (N = 5.362) walkin g (mea n) = 14.7 mo;
ralking (mean) = 15.5 rn a
Done cr al., 1994 33 (20 M/ 13 F) Prospective data Age 7: more social maladjust- N o gender differences for with -
from Brit ish ment than controls (p < .0 1); dr awal (Xl = NS ); o nly moder-
1958 cohort male: overreaction > ate withdrawal prob lem s for
(N = 15,398 underreaction group
in 1965) (F = 3.2, P = .02) (F = 12.1,
P < .001)
Note : N IM H = N ational Institute of Mental Health; FSIQ = Full Scale IQ; PDD = pervasive developmental disor der; N S = not
significant.
ratings of wit hdrawn/oppositional behaviors. In con- Ben-Meir (1988) , our data indi cate significant premor-
trast to reports on adults, three reports of childhood- bid social maladjustment in this population compared
onset schizophrenia (including this study) find a with at least first-episode adults (e.g., Lieberman er al.,
substant ial minority of cases to have had at least one 1992), altho ugh PAS scores are not directly comparable
symptom of PDD, although none met criteria for across studies.
PDD at the time of the study. Such observation was
not noted for any adult-onset studies. Furthermore,
DISCUSSION
the majority of childhood cases appear to have had
insidious onset, without episodic course , in contrast These findings support and extend previous reports
to first-episode adult cases (Lieberman et al., 1993). on the preps ychotic development of very early onset
Although we did not find the same severe premorbid schizophrenia. A more chronic course, more typically
poor adjustment using the PAS as did Asarnow and insidious onse t, more severe abnormalities in language
and motor development, and a high proportion of sample may be an exaggerated form of the transient
clinically significant premorbid psychiatric disorders abnormalities described by Fish (1984; Fish et al.,
appear more characteristic of childhood-onset cases. 1992) for high-risk infants who later became schizo-
Evidence of disruptive behavior disorders in 43% of phrenic and by Walker et al. (1994a,b) based on home
children, school performance problems and learning movies. It is tempting to speculate that our early-onset
disabilities in almost 50%, language difficulties in about cases suffered more severe early brain insult so that
50%, and mean IQ in the borderline to low-average these transient disturbances were more striking and
range are consistent with other studies. came to clinical attention. Alternatively, the retrospec-
The comparison with adult-onset schizophrenia (Ta- tive nature of the adult studies may have obscured
ble 4) is of interest. Where quantification is available, such early history, while the present study used parent
particularly for the prospective studies of Jones et al. interviews and the Autism Diagnostic Interview to
(1994) and Done et al. (1994), the findings indicate obtain such data more systematically than is likely in
greater premorbid abnormalities in childhood-onset most studies of later-onset cases. Diagnostically, it is
schizophrenia, most notable for delays and abnormalit- clear that early transient "POD" should not preclude
ies in speech and language development, for specific a later diagnosis of childhood-onset schizophrenia.
learning disabilities and disruptive behavior disorders. A number of methodological limitations make these
Only a minority of our cases were not a focus of conclusions tentative. Because of the rarity of schizo-
clinical concern before the onset of psychosis. This, phrenia in childhood, these patients were recruited by
together with the chronicity and severity of childhood national search and, in fact, more than 100 children
cases (Gordon et al., 1994), indicates that childhood- referred as schizophrenic were seen in person to identity
onset schizophrenia may be a more malignant form these 23 cases. Thus we cannot evaluate the selection
of the disorder. However, selection and ascertainment bias inherent in this study. Because these cases were
biases together with our small sample make these referred for participation in an inpatient trial of cloza-
conclusions tentative. pine offered to nonresponders to typical neuroleptics
The somewhat focused areas of greater severity such (Frazier et al., 1994), only more severe cases would
as language abnormalities may be indicators of left have been referred. Just as important, retrospective
brain dysfunction, appearing earlier in development studies of later-onset schizophrenia either did not or
(David, 1994; McGuire et al., 1993; Watkins et al., could not obtain the detailed childhood records avail-
1988). We did not, however, have sufficient informa- able for very early onset cases. It is unclear, therefore,
tion to further characterize the pattern of preschizo- whether the increased rate in childhood cases reflects
phrenia language difficulties. Clinically premorbid ascertainment and/or recording bias. In spite of this,
patterns of language development may be of great our findings agree with those of previous reports from
predictive value for later psychosis. Diagnostic evalua- groups that were not carrying out extensive inpatient
tion of childhood schizophrenics should attempt careful evaluation or drug treatment (Russell et al., 1989;
characterization of underlying speech and language Watkins et al., 1988), indicating similar high chronicity
abnormalities. and high rate of premorbid disorders when compared
A particularly intriguing finding, consistent across to later-onset subjects.
three of six studies, is that symptoms of POD occur In conclusion, as expected, patients with childhood-
premorbidly in childhood-onset schizophrenia (Russell onset schizophrenia have a more disturbed premorbid
et al., 1989; Watkins et al., 1988). The possible conti- history as a group, particularly as evidenced by the
nuity between schizophrenia and autism has been a presence of speech and language disorders. The major
matter of controversy in the past (Cantor et al., 1982; findings, however, highlight the similarity in develop-
Petty et al., 1984), but in general the two are well mental pattern for childhood and later-onset disorder.
established as distinct disorders (Volkmar et al., 1988; Ongoing neurobiological studies including quantitative
Volkmar and Cohen, 1991). The present findings raise magnetic resonance imaging will seek evidence of more
the possibility that at least some transient forms of severe CNS alteration or evidence of precocious brain
POD features may reflect a more severe early brain development for these unexplained vety early onset
insult, and in fact the motor abnormalities seen in our cases.
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Watkins JM, Asarnow RF, Tanguay PE (1988), Symptom development Weinberger DR, Berman KF, Zec RF (1986), Physiologic dysfunction of'
in childhood onset schizophrenia. J Child Psychol Psychi{ltly29:865-878 dorsolateral prefrontal cortex in schizophrenia: regional cerebral blood
Watt NF (1972), Longitudinal changes in the social behavior of children Row evidence, Arch Gen Psychially 43: 114-124
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