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4, 1994
Children With
Schizophrenia: Diagnosis,
Phenomenology, and
Pharmacotherapy
Abstract
This article presents data on the
diagnosis and phenomenology of
schizophrenia in 16 hospitalized
children, ages 5.5 to 11.75 years.
These 16 subjects are the first to
complete an ongoing doubleblind, placebo-controlled study
of haloperidol in children with
schizophrenia diagnosed by
DSM-III-R criteria. We describe
the pharmacologic treatment response of this subsample and
compare our diagnostic, phenomenologic, and treatment findings
with those of other investigators.
Our results show that children
under age 12 can be diagnosed
with schizophrenia by the same
criteria used for adults, that they
show comparable clinical symptoms, and that on haloperidol
they show improvement in target
psychotic symptoms, at least in a
short-term inpatient setting.
Schizophrenia Bulletin, 20(4):
713-725, 1994.
Childhood-onset schizophrenia is a
rare disorder, estimated to occur
50 times less frequently than
adult-onset schizophrenia (Karno
and Norquist 1989). Its rarity, in
combination with changes over the
years in nomenclature and diagnostic criteria for schizophrenia as
it presents in childhood, has led to
a paucity of data about children
who meet currently recognized criteria (Beitchman 1985; Campbell et
al. 1991). On the Bellevue Hospital
Center's Children's Psychiatric Inpatient Unit, three studies have examined hospitalized children with
schizophrenia who met DSM-III
(American Psychiatric Association
1980) (Green et al. 1984; Green
and Padron-Gaylor 1986) and,
more recently, DSM-III-R (Ameri-
SCHIZOPHRENIA BULLETIN
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715
SCHIZOPHRENIA BULLETIN
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diagnosis of schizophrenia by
DSM-III-R criteria, with severity
of illness necessitating inpatient
hospitalization and warranting
pharmacotherapy. With these criteria, the most commonly reported
active schizophrenic symptoms
were auditory hallucinations and
delusions, which were experienced
by all 16 subjects. Associated visual hallucinations occurred in 11
(69%), and tactile hallucinations occurred in 4 (25%). Thought disorder was shown by 13 (81%), as
was inappropriate affect.
Previous studies of children with
schizophrenia also have reported
auditory hallucinations as common.
In a sample of 33 children with
late-onset psychosis, ages 7-13
years, 81.8 percent reported auditory hallucinations (Kolvin 1971a,
1971b; Kolvin et al. 1971a, 1971b,
1971c, 1971rf, 1971e). In two studies
using DSMIII criteria for schizophrenic disorder, auditory hallucinations were reported by 79.2 percent of 24 children, ages 6.7-11
(Green et al. 1984); in 16 other
children, ages 5.7-12.6, the rate
24
6.7-11.11
Werry
et al. 1991
30
Current
study
16
DSM-III
7-17
DSM-III-R
5.5-11.75
DSM-III-R
NR
79.2
37.0
8.3
54.2
NR
100
NR
57
53
13
13
47
57
NR
13
100
100
69
25
100
81
81
17
Note.NR = not reported; DSM-III and DSM-III-R = Diagnostic and Statistical Manual of
Mental Disorders (American Psychiatric Association 1980, 1987).
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SCHIZOPHRENIA BULLETIN
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Table 2.
Author(s)
CA1
Diagnosis
Drug(s)
Daily dose,
mg (mg/kg)
Response
75
13-18
Acute schizophrenia
or exacerbation
Loxapine
Haloperidol
25-200, M = 87.5
2-16, M = 9.8
Naruse et
al. (1982)
4 (of 87)
3-16
Psychosis (mainly
child schizophrenia)
Haloperidol
Pimozide
0.75-3.00
1.0-4.0
Spencer et
al. (1992)
16
5.50-11.75
(M = 8.89)
Schizophrenia
Haloperidol
(DSM-III-R)
Both drugs
superior to
placebo
Open/retrospective studies
Debray et
al. (1972)
"Infantile defect
schizophrenia"
Pimozide
2.0-6.0, M = 3
PangalilaRatulangi
(1973)
8 (of 10)
Schizophrenia or
schizophrenia-like
symptomatology
Pimozide
1.0-2.0
7 improved on
drug
9-14
Realmuto et 21
al. (1984)
Thiothixene
4.8-42.6, M =
16.2 (0.3)
Thioridazine 91-228, M = 178
(3.3)
Siefen and 21
Remschmidt
12 subjects
< 18 years
(M = 18.1)
Clozapine
Marked improvement or
remission in 11
(1986)
254-700, M =
352
Wore.M = mean; DSM-III and DSM-III-R = Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association 1980,
1987); ICD-9 = International Classification of Diseases (World Health Organization 1978).
'CA = Chronological age in years.
Age range for a subsample of 11 psychotic children and not only for the 2 with schizophrenia
SCHIZOPHRENIA BULLETIN
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mg/d
Mean
mg/kg/d
Mean
Conduct disorder
Campbell et al. (1982)
Campbell et al. (1984)
5
20
4-16
1-6
9.2
2.95
0.12-0.76
0.04-0.21
0.096
Schizophrenia
Spencer et al. (1992)
16
0.5-3.5
1.92
0.02-0.12
0.057
Autism
Campbell (1978)
Anderson et al. (1984)
Anderson et al. (1989)
20
40
45
0.5-4.01
1-3
0.25-4.00
1.65
1.11
0.844
0.019-0.217
0.016-0.184
0.05
0.047
Table 4.
721
Mean
mg/kg/d
Mean
Conduct disorder
(Campbell et al. 1984)
1.0-6.0
2.95
0.04-0.21
0.096
Schizophrenia
(Spencer et al. 1992)
0.5-3.5
1.92
0.02-0.12
0.057
0.25-4.0
0.844
0.016-0.184
0.047
Autism
(Anderson et al. (1989)
Baseline Placebo
Total sample, n = 16
Marked, n = 12
Mild/Moderate, n = 4
BPRS-C total
pathology
score3
45.56
41.11
43.80
53.82
40.92
33.50
51.75
47.26
36.10
CGI severity
of illness4
5.24
4.11
4.25
5.34
4.00
2.79
5.32
4.34
3.10
CGI global
improvement5
3.45
2.22
2.25
3.35
2.26
1.26
3.37
2.58
1.51
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SCHIZOPHRENIA BULLETIN
Table 6. Haloperidol response, as rated on the Global Clinical Judgments consensus ratings
and demographic variables in 16 children with schizophrenia, mean (range)
Global Clinical Judgments consensus ratings
Mild/Moderate
n = 4
Chronological Age (CA)
Full Scale IQ
7.56
(6.83-8.08)
Marked
n=12
9.29
Total sample
n = 16
(5.50-11.75)
8.86
(5.50-11.75)
Verbal IQ1
73.25 (65-83)
75
(62-88)
81.25 (60-123)
82.92 (66-114)
80.93 (60-123)
80.93 (62-114)
Performance IQ1
74
(60-81)
83.25 (55-114)
80.94 (55-128)
4.5
(3-5)
(1.5-9.0)
4.88
(1.5-9.0)
CA at onset of schizophrenia
5.88
(5-7)
8.34
(5-10.5)
7.7
(5-10.5)
(6-8)
8.92
(5-11)
8.44
(5-11)
IO = Intelligence quotient on Wechsler Intelligence Scale for Children-Revised (Wechsler 1974) or Wechsler Preschool and Primary Scale of
Intelligence (Wechsler 1967).
2
At the time when the child was accepted to the present study
Table 7. Haloperidol response, as rated on the Global Clinical Judgments consensus ratings
and 8 selected CPRS items in 16 children with schizophrenia, mean
Global Clinical Judgments consensus ratings
CPRS 1
items
Mild/Moderate, n = 4
Baseline Placebo
Marked, n .
= 12
Total sample, n = 16
Suspicious
affect
1.12
1.00
1.25
2.47
1.65
1.17
2.14
1.58
1.19
Blunted affect
1.65
1.33
1.25
2.83
2.53
1.58
2.54
2.29
1.50
Ideas of
reference
1.44
1.33
1.00
2.62
2.28
1.36
2.33
2.09
1.27
Persecutory
2.04
1.22
1.00
3.99
3.54
1.58
3.50
3.08
1.43
Other thinking
disorders
5.01
2.00
3.75
2.79
1.86
1.83
3.34
1.73
2.31
Delusions
3.88
3.67
3.92
4.28
3.31
2.11
4.17
3.36
2.56
Hallucinations
4.04
3.56
2.83
4.61
2.93
1.36
4.47
3.06
1.73
Peculiar
fantasies
3.08
2.00
3.92
4.18
2.86
2.36
3.90
2.74
2.75
723
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SCHIZOPHRENIA BULLETIN
725
Acknowledgments
This research was supported in
part by USPHS grants MH-00763
to Dr. Spencer and MH-40177 to
Dr. Campbell from the National
Institute of Mental Health. The authors thank the New York City
Health and Hospitals Corporation
and Bellevue Hospital Center for
their cooperation, Ms. Camille
Petty, R.N., and the Nursing Staff
of the Bellevue Hospital Center
Children's Psychiatric Inpatient
Unit for their assistance, and
McNeil Pharmaceutical for supplying haloperidol and matching
placebo tablets.
The Authors
Elizabeth Kay Spencer, M.D., is
Research Assistant Professor of
Psychiatry and Magda Campbell,
M.D., is Professor of Psychiatry,
Department of Psychiatry, New
York University School of Medicine, New York, NY.