CLINICAL HANDBOOK OF SCHIZOPHRENIA

482 VI. SPECIAL POPULATIONS AND PROBLEMSPrior to the onset of psychotic symptoms, children may present with nonspecificsymptoms suggestive of pervasive development disorder, learning disabilities, oppositionalbehavior/violent aggression, and attentional dysfunction. Regarding the latter, becausehigh doses of stimulant medications have been shown to induce psychotic symptomsin normal individuals, and low doses can induce psychotogenic symptoms inindividuals susceptible to psychosis, physicians should be extremely cautious when prescribingthese medications for children with attentional deficits who may also be vulnerableto psychosis. Premorbid abnormalities, similar to those noted earlier, have beenobserved in patients with adult-onset schizophrenia. However, the rate of language impairmentsand transient, autistic-like symptoms appears higher in children and adolescentswith schizophrenia relative to their adult counterparts, potentially suggesting thata more disturbed neurodevelopmental course is associated with an earlier onset ofschizophrenia.The few studies to examine the phenomenology of COS using DSM-III (AmericanPsychiatric Association, 1980) criteria have supported a hypothesis of phenomenologicalcontinuity with later-onset schizophrenia. Schizophrenia in children is frequently insidiousrather than acute in onset, and the most common psychotic features reported bypatients are developmentally appropriate auditory hallucinations and delusions. Thepresence of formal thought disorder, however, is more variable and depends on the sample,and there is little agreement on how to describe the disorganized speech patterns ofchildren with schizophrenia, because terms such as illogicality, loose associations,tangentiality, and speech poverty have been used very differently by different clinicians.Medication status at time of assessment is important to note, because both psychotic andaffective symptoms may be masked by the administration of psychotropic medications,and patients may not experience a relapse of their symptomatology immediately after discontinuationof their medications. Additionally, collateral data, such as reports fromother specialists consulted (e.g., school reports, previous neuropsychological test data,speech and language evaluations, and neurological and genetics consultations), should beobtained. To prevent misdiagnosis, each child or adolescent with a diagnosis of schizophreniashould be followed closely for several years, and a medication-free period, if feasible,should be considered to help clarify diagnosis.There is a requirement in DSM-IV-TR that the signs of a psychotic disturbance mustbe present for at least 6 months, with at least 1 month of active-phase psychotic symptoms(fewer, if successfully treated). The 6-month duration may include periods ofprodromal or residual symptoms. In community settings there is typically a lag of approximately2 years from the time that psychotic symptoms first manifest to the time thatchildren and adolescents with schizophrenia first present for psychiatric treatment.Objective evidence of deterioration in function for a child might include a need for psychiatrichospitalization or day treatment, as well as worsening grades in school and/orplacement in special education classes due to behavior problems.In terms of differential diagnosis, it should be stressed that hallucinations and delusionsare commonly observed in patients with affective psychoses and pervasive developmentaldisorders, and the prevalence of these disorders is far more common than COSfrom an epidemiological perspective. A number of children with pervasive developmentaldisorders report psychotic symptoms; however, this group typically does not exhibitmarked deterioration in social or school functioning for a sufficient amount of time coincidentwith the onset of psychotic symptoms to warrant an additional diagnosis ofschizophrenia. Psychosis due to a general medical condition, medication, or illicit druguse should always be ruled out with a careful history, physical examination, and appro-