AA Bartels-Velthuis

BA Cornblatt

Benno G. Schimmelmann

BG Schimmelmann

C Arango

C Fleischhaker

F Schultze-Lutte

Frauke Schultze-Lutter

GP Amminger

H Meng

I Joa

I Kelleher

JR Jepsen

L Skalli

M Marshall

R Poulton

SA Hlastala

T McGlashan

TB Ziermans

WT Carpenter

English

Schimmelmann, Benno G

Schultze-Lutter, Frauke

Bern Open Repository and Information System (BORIS)

EDITORIALEarly detection and intervention of psychosis in childrenand adolescents: urgent need for studiesBenno G. Schimmelmann • Frauke Schultze-LutterPublished online: 18 April 2012 Springer-Verlag 2012Psychotic disorders, particularly of the schizophrenia-spectrum, are among the most severe mental diseases. Theycan lead to delays in the maturation of neuropsychologicalfunctions in affected children and adolescents and long-term neuropsychological deficits [1, 2] as well as signifi-cant impairments in psychosocial functioning [3]. Thismakes schizophrenia one of the six leading causes of yearslived with disability [4]. To fight the devastating conse-quences of psychotic disorders, two strategies have beenfollowed with great enthusiasm and hope over the last15 years.One strategy is to detect the disorder as early as possi-ble, i.e., to reduce the duration of untreated psychosis and,consequently, to adequately treat the disorder as soon aspossible with an early and specialized intervention. Nota-bly, it was assumed for a long time that an adolescent onsetof psychosis (before age 18, EOP) is associated with worseoutcomes compared to adult-onset psychosis (AOP; [5]).However, two recent studies comparing EOP (age 14–17)with AOP (age 18–30) did not support this assumption.They indicated that EOP when also treated in an earlypsychosis, prevention and intervention centre have similarshort-term [6] and similar or even better long-term out-comes [7]. Most recently, an independent comparativepopulation based study conducted in a different centreconfirmed these findings [8]. It still remains to be shownwhether specialized early detection and intervention indeedcauses the similar or even better outcomes of EOP. Despitethe face validity of early intervention, it is not yet clear forpatients with AOP that early intervention is superior totreatment-as-usual for patients with AOP. A recent Coch-rane review concluded that there is some support for thesuperior effectiveness of early intervention, but that furtherstudies are desirable, and that it is questionable whethergains are maintained [9]. Regarding early interventionstrategies, it is generally recommended that an earlyintervention service should be provided longer than 2 years[10] or, alternatively, new strategies should be developedto produce more sustainable effects of short-term intensiveearly intervention programs. For children and adolescentswith EOP, studies on the effectiveness of such programs orspecial needs within these programs are necessary. Whileinitial evidence suggests that early intervention works inadolescents [7], the duration of untreated psychosis wasfound to be clearly longer in adolescents than in adultsdespite early detection efforts [11, 12]. However, the rea-sons for this are not known. Potential reasons are: insuffi-cient knowledge about psychotic symptoms in therespective health care service (including child and ado-lescent psychiatry/psychology); a more insidious onset ofsymptoms; more negative symptoms; higher rates of refu-sal to seek help, and overlooking symptoms or misinter-preting them as adolescent crisis by parents and teachers.The second strategy to improve outcome of psychoticdisorders is to detect early signs of the emerging disorderbefore sustained psychotic symptoms occur. While a pro-drome may include rather unspecific symptoms and canonly safely be diagnosed in retrospect, research over thelast 15 years has brought about two rather specific sets ofat-risk criteria for psychotic disorders, the ultra-high riskcriteria (including attenuated psychotic symptoms, APS;brief limited intermittent symptoms, BLIPS) and the basicsymptom criteria (including cognitive–perceptive symp-toms, COPER; cognitive disturbances, COGDIS). Thepresence of one of these criteria is associated with an aboutB. G. Schimmelmann (&)  F. Schultze-LutterUniversity Hospital of Child and Adolescent Psychiatry,University of Bern, Bolligenstr. 110, 3000 Bern 60, Switzerlande-mail: bschimme@aol.com123Eur Child Adolesc Psychiatry (2012) 21:239–241DOI 10.1007/s00787-012-0271-z20 % risk of conversion to psychosis in help-seeking adultsin the following year [13]. This research, in mostly adultsamples, led to the proposal of an Attenuated PsychosisSyndrome for inclusion in DSM-5 [14]. In this journal,1 year ago, Arango [15] carefully weighed the risks andbenefits for children and adolescents of including theAttenuated Psychosis Syndrome in DSM-5, and made thepoint that APS must also be considered in developmentalterms. APS are not sufficiently validated in children andadolescents in terms of conversion to psychosis or diseasestatus at all. As the Attenuated Psychosis Syndromeincludes only one out of three UHR and none of the basicsymptom criteria, future research on the early detection ofpsychosis in children and adolescents must take a broaderperspective. The following questions should be addressed:1. Predictive validity of current at-risk criteria in chil-dren and adolescents: To date, only two rather smallstudies assessed conversion rates exclusively in chil-dren and adolescents. Cornblatt [16] (48, 12- to18-year-old, adolescents with attenuated psychoticsymptoms) reported that at-risk adolescents convertedto psychosis later than expected from studies of adults.However, Ziermans [17] (58, 12- to 18-year-old,adolescents with UHR criteria or COGDIS) reportedthat the conversion rate was slightly lower but notdelayed compared to adults (16 % in 2 years). Data onchildren below age 12 are not available.2. Assessment issues: Apart from the schizophreniaproneness instrument–child and youth version (SPI–CY; [18]) for the assessment of basic symptoms inchildren and adolescents (age 8–17), no age-adaptedtools for the assessment of the other at-risk criteria inchildren and adolescents exist. As most studies onadults included some adolescents (Cage 15), it isprobably safe to use current assessment tools in thisage group (e.g., SIPS [19] or CAARMS [20]);whereas, it is not known whether at-risk criteria arevalid in this age group. However, it is unclear (1) atwhat age children are able to provide reliable accountof at-risk symptoms, (2) when and how parentalreports should be considered, and (3) how a differentialdiagnosis to relevant child and adolescent psychiatricdisorders should be made (e.g., autism spectrumdisorders).3. Significance of at-risk symptoms in the general pop-ulation of children and adolescents: To date, it is notfully understood whether at-risk symptoms are socommon among children and adolescents that a validdistinction between ill and non-ill youngsters isdifficult [21]. This question came into focus withseveral studies in adults and children that report highrates of standardized lay person or self-report assessedpsychotic-like experiences in the general population[15]. However, only three studies addressed thisquestion to date in adults [22] and adolescents[3, 23] using appropriate clinical assessments of at-risk criteria. All the three studies found rather low ratesof APS or BLIPS in children (age 11–13; 0.9–8.1 %depending on UHR definition [23]) or adults (age16–40; 0–2 % [22]) as well as COPER (\3 %) andCOGDIS (\8.0 %) in adolescents [13]. Notably, inchildren and adolescents, 63 % of adolescents withAPS or BLIPS met criteria for at least one past orpresent axis-I diagnosis according to DSM-IV [23].They also had poorer psychosocial functioning thanthe control group. In the pilot-study on adults, similarfindings were reported [22]. These rather preliminaryfindings support the notion that current at-risk criteria,if carefully assessed, are less prevalent than expectedfrom studies on psychotic-like experiences and relatedto some impairment. Furthermore, the clinical rele-vance of (atypical) psychotic symptoms in childrenand their predictive validity for a psychotic disorder isstill not fully understood. While several studiesconfirm the transient and atypical nature of (atypical)psychotic symptoms in children with low conversionrates to psychotic disorders [24–26], the Dunedin birthcohort study reported that psychotic symptoms at age11 predicted the emergence of a schizophreniformdisorder at age 26, but also of an anxiety disorder [27].Regarding clinical implications, child and adolescentpsychiatry is far from having a sufficient evidence base forcreating appropriate strategies for the early detection andearly intervention in psychosis in this age group. However,regarding early intervention, initial evidence suggests thatadolescents (age 14–17) benefit from early interventionprograms to a degree that is comparable to the benefit ofyoung adults [6, 7]. Yet, age-appropriate early detectionstrategies may be necessary to reduce the duration ofuntreated psychosis in adolescents. The early detection ofpsychosis in the prodromal stage is difficult in both adultsand children/adolescents. However, the proposal of anAttenuated Psychosis Syndrome for inclusion in DSM-5reflects the fact that patients with APS indeed experiencedistress and significant impairment, so that treatment seemsjustified independent of conversion risk to psychosis.While the evidence is sparse, our experience is that thismay also be true in children and adolescents. They (andtheir parents or carers) suffer from at-risk symptoms,appreciate their competent assessment and are interested infocusing on them in the treatment process, independent ofconversion risk. The concern that an increased use ofantipsychotics in children and adolescents might follow theintroduction of a non-validated Attenuated Psychosis240 Eur Child Adolesc Psychiatry (2012) 21:239–241123Syndrome, voiced by Arango [15], may be true. However,the availability of a child and adolescent psychiatrist withspecial training and sufficient experience in the assessmentof at-risk symptoms in this age group will be most wel-comed in the mental health system. This would prevent anunjustified and potentially stigmatizing, yet commonlyencountered pseudo-diagnosis of ‘‘pre-psychotic’’ or‘‘prodromal’’ for these patients, and may thereby limitpremature or prolonged use of antipsychotics. To this, it isrecommended that adult and child and adolescent psychi-atrists work together in a team and that the clinical sig-nificance and predictive validity of current at-risk criteriain children and adolescents is further studied.References1. Jepsen JR, Fagerlund B, Pagsberg AK, Christensen AM, Nor-dentoft M, Mortensen EL (2010) Deficient maturation of aspectsof attention and executive functions in early onset schizophrenia.Eur Child Adolesc Psychiatry 19(10):773–7862. 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Early detection and intervention of psychosis in children and adolescents: urgent need for studies

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Early detection and intervention of psychosis in children and adolescents: urgent need for studies

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