The Significance of At-Risk Symptoms for Psychosis in Children and Adolescents

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1 CanJPsychiatry 2013;58(1):32 40 In Review The Significance of At-Risk Symptoms for Psychosis in Children and Adolescents Benno Graf Schimmelmann, MD 1 ; Petra Walger, MD 2 ; Frauke Schultze-Lutter, PhD 3 1 Professor and Medical Director, University Hospital of Child and Adolescent Psychiatry, University of Bern, Bern, Switzerland. Correspondence: University Hospital of Child and Adolescent Psychiatry, Bolligenstrasse 111, 3000 Bern 60, Switzerland; bschimme@aol.com. 2 Consultant, Department of Child and Adolescent Psychiatry, University of Cologne, Germany. 3 Senior Psychologist, Department of Research, University Hospital of Child and Adolescent Psychiatry, University of Bern, Bern, Switzerland. Key Words: prodrome, schizophrenia, adolescence, early diagnosis, early intervention, psychosis Received and accepted September The early detection and treatment of people at risk for psychosis is currently regarded as a promising strategy in fighting the devastating consequences of psychotic disorders. Currently, the 2 most broadly used sets of at-risk criteria, that is, ultra-high risk (UHR) and basic symptom criteria, were developed mainly in adult samples. We review the data regarding the presence and relevance of at-risk symptoms for psychosis in children and adolescents. The few existing studies suggest that attenuated psychotic symptoms (APS) and brief limited intermittent psychotic symptoms (BLIPS) do have some clinical relevance in young adolescents from the general population. Nevertheless, their differentiation from atypical psychotic symptoms or an emerging schizotypal personality disorder, as well as their stability and predictive accuracy for psychosis, are still unclear. Further, standard interviews for UHR criteria do not define a minimum age for the assessment of APS and BLIPS or guidelines as to when and how to include information from parents. APS and basic symptoms may be predictive of conversion to psychosis in help-seeking young adolescents. Nevertheless, the rate and timing, and thus the required observation time, need further study. Moreover, no study has yet addressed the issue of how to treat children and adolescents presenting with at-risk symptoms and criteria. Further research is urgently needed to examine if current at-risk criteria and approaches have to be tailored to the special needs of children and adolescents. A preliminary rationale for how to deal with at-risk symptoms for psychosis in clinical practice is provided. W W W La signification des symptômes à risque de psychose chez les enfants et les adolescents La détection et le traitement précoces des personnes à risque de psychose sont actuellement réputés constituer une stratégie prometteuse pour combattre les conséquences désastreuses des troubles psychotiques. À l heure actuelle, les 2 ensembles les plus utilisés de critères à risque, c est-à-dire, le risque ultra-élevé (RUE) et les critères des symptômes de base, ont été développés principalement pour des échantillons adultes. Nous examinons les données au regard de la présence et de la pertinence des symptômes à risque de psychose chez les enfants et les adolescents. Les quelques études existantes suggèrent que les symptômes psychotiques atténués (SPA) et les symptômes psychotiques brefs, limités et intermittents (BLIPS) ont une certaine pertinence clinique chez les jeunes adolescents de la population générale. Néanmoins, leur différenciation des symptômes psychotiques atypiques ou d un trouble de la personnalité schizotypique naissant, ainsi que leur stabilité et leur exactitude à prédire la psychose sont encore indéfinies. De plus, les entrevues standards pour les critères RUE ne fixent pas d âge minimum pour l évaluation des SPA et des BLIPS, ni n offrent de guides sur le moment et la manière d inclure l information des parents. Les SPA et les symptômes de base peuvent prédire une conversion à la psychose chez les jeunes adolescents qui recherchent de l aide. Néanmoins, le taux et la chronologie, et donc le temps d observation requis, nécessitent plus de recherche. En outre, aucune étude n a encore abordé la question de la façon de traiter des enfants et des adolescents qui présentent des symptômes et des critères à risque. Il faut de toute urgence plus de recherche pour examiner si les critères à risque et les approches actuelles doivent être adaptés aux besoins spéciaux des enfants et adolescents. Un exposé préliminaire de la façon de traiter les symptômes à risque de psychose dans la pratique clinique est présenté. 32 W La Revue canadienne de psychiatrie, vol 58, no 1, janvier 2013

2 The Significance of At-Risk Symptoms for Psychosis in Children and Adolescents Four of the 6 leading causes of the years lived with disability are due to neuropsychiatric disorders 1 of them is schizophrenia, which is also among the disorders with the highest economic impact. 1 The devastating consequences may even be aggravated when the disorder has an early onset before the age of 18. Compared with AOP, people with EOP more frequently display adverse prognostic criteria, for example, more pronounced neurodevelopmental deficits, 2 lower premorbid adjustment, 3 more negative symptoms at the onset of psychosis, 4 and more severe cognitive impairments. 5 Also, treatment of EOP is complicated by a higher rate of antipsychotic side effects, such as extrapyramidal motor symptoms 6 and weight gain. 7 In line with these findings, several authors of follow-up studies of EOP alone 8,9 concluded that people with EOP were having worse outcome, compared with those with AOP. However, 2 independent studies from the EPPIC in Melbourne, Australia, comparing the course and outcome of EOP and AOP, recently reported a similar shortterm and even better long-term outcome of EOP, compared with AOP (onset range between 14 and 30 years). 10,11 One possible explanation for the similar, or even better, functional outcome in the EOP group in these 2 studies is that maintenance of one s school career and support in achieving adolescent developmental milestones have been highly promoted by the EPPIC therapeutic model for those under the age of ,12 Besides age-appropriate, efficient treatment concepts and facilities, a promising strategy to improve outcome in psychotic disorders is to detect the disorder in its early stages. Assuming that early detection and early treatment of the manifest psychotic disorder attenuates its devastating consequences, one approach is to reduce the DUP. 13,14 Notably, adolescents with EOP are at risk of experiencing Abbreviations AD AOP APS BLIPS BSABS antidepressant adult-onset psychosis attenuated psychotic symptoms brief limited intermittent psychotic symptoms Bonn Scale for the Assessment of Basic Symptoms CAARMS Comprehensive Assessment of At Risk Mental States COGDIS Cognitive Disturbances COPER Cognitive Perceptive Basic Symptoms DSM Diagnostic and Statistical Manual of Mental Disorders DUP duration of untreated psychosis EOP early onset psychosis EPPIC Early Psychosis Prevention and Intervention Center SIPS Structured Interview for Prodromal Syndromes SPD schizotypal personality disorder SPI-CY Schizophrenia Proneness Instrument Child and Youth version UHR ultra-high risk Highlights Research into the early detection of psychosis has predominantly been carried out in adults and older adolescents, with little consideration of possible special requirements in children and younger adolescents; hence neither the rates and timing of conversion to psychosis and other disorders in children and younger adolescents fulfilling current at-risk criteria are clear nor the clinical relevance of, and treatment options for, at-risk symptoms in help-seeking or general population samples of this age group. Children and adolescents at-risk symptoms should be assessed together with comorbid psychiatric syndromes and disorders, as well as psychosocial and neuropsychological functioning; however, owing to the current lack of knowledge in this age group, risk of conversion to psychosis should not be communicated to children and adolescents and their families, or it should be done very carefully. More benign treatment options that increase resilience, such as stress reduction, cognitive-behavioural therapy, social skills training, healthy lifestyle, no alcohol and (or) illicit drugs, and sleep hygiene, as well as targeted treatment of comorbid psychiatric syndromes, including ADs, may be preferrable to cognitive therapy, which focuses only on APS and BLIPS, and to antipsychotic treatment, owing to the higher risk of side effects in children and adolescents. longer treatment delays than people with AOP. 3,11 There are several potential explanations for this finding: positive symptoms in EOP may be easily overlooked, 3 especially if parents and primary care providers assume that the adolescents symptoms are the expression of some sort of adolescent crisis. 11 Additionally, comorbid conditions, such as substance abuse, and depressive and anxiety syndromes, may mask the emergence of a psychotic disorder. Further, the general and mental health network (not only pediatricians, general physicians, and school psychologists but also child and adolescent psychiatrists) may not be sufficiently aware and trained to appropriately and regularly assess psychotic symptomatology in adolescents. 11 Finally, it is possible that EOP is associated with a greater frequency of an insidious onset illness trajectory. 11 Thus children and adolescents with psychotic disorders need specific early detection strategies to reduce the DUP. The second early detection approach is to detect early signs of the emerging disorder before sustained psychotic symptoms occur. This approach is based on findings of retrospective studies 15,16 indicating that psychotic disorders are commonly preceded by a prodromal phase of several years. While a prodrome may include rather nonspecific symptoms and can only safely be diagnosed in retrospective studies, research during the last 15 years has led to 2 rather specific sets of at-risk criteria for psychotic disorders, the UHR criteria and the basic symptom criteria (Tables 1 and 2). The presence of one of these criteria is associated with about a 20% risk of conversion to psychosis in help-seeking adults (including some older adolescents) in the following The Canadian Journal of Psychiatry, Vol 58, No 1, January 2013 W 33

3 In Review Table 1 UHR criteria according to the SIPS APS Any 1 of the following symptoms with a score of 3 to 5: Unusual thought content and (or) delusional ideas (P1) a Suspiciousness and (or) persecutory ideas (P2) a Grandiose ideas (P3) a Perceptual abnormalities and (or) hallucinations (P4) a Disorganized communication (P5) a Symptoms have begun or worsened in quality in the past year Symptoms occur at least once within 1 week for the last month Symptoms not better explained by another DSM-IV disorder BLIPS Any 1 of the following frank psychotic symptoms with a score of 6: Unusual thought content and (or) delusional ideas (P1) a Suspiciousness and (or) persecutory ideas (P2) a Grandiosity (P3) a Perceptual abnormalities and (or) hallucinations (P4) a Disorganized communication (P5) a Symptoms have begun in the past 3 months Symptoms occur currently at least several minutes per day at least once per month Symptoms not better explained by another DSM-IV disorder Genetic risk plus recent deterioration a Item number of the SIPS At least 1 first-degree relative with history of any nonaffective or affective psychosis, or SPD in the patient according to SIPS criteria Substantial functional deterioration in the past year (defined as a drop in the Global Assessment of Functioning score of at least 30% during the last month, compared with the patient s highest score in the previous 12 months) year. 17 The UHR criteria of an imminent risk include APS, BLIPS, and a combination of a genetic risk factor and a recent persistent significant decline in functioning. 18 However, depending on the centre, the assessment scale, and (or) the time of their assessment, the exact definition of UHR criteria and conversion rates vary considerably between studies. 19,20 Moreover, the basic symptom criteria, COPER and COGDIS, are partially overlapping, but delineate risk of potentially different imminence and specificity sensitivity ratio Nevertheless, both sets of at-risk criteria were developed solely 21 or predominately in adult samples (age 16 and older). 18 Therefore, early detection and treatment of people with first signs of the emerging disorder, which is currently regarded as one promising strategy in fighting the devastating consequences of psychosis, 1 may face different or additional challenges in children and adolescents, compared with adults. As the first incidence peak of psychotic disorders is around age 21, 25 many patients prodrome will start in adolescence or even childhood; and clinicians do encounter at-risk symptoms in children and adolescents. However, they generally have no, or only a very limited, evidence base and are thus unsecure how to name and how to treat these symptoms appropriately. As a consequence, these children and adolescents may either be overlooked or labelled as pre-psychotic, prodromal, or at risk, even without carrying out specialized assessments; further they may either be 34 W La Revue canadienne de psychiatrie, vol 58, no 1, janvier 2013 over- or undertreated with ADs, antipsychotics, or other psychotropics. This situation is aggravated because at-risk research in mostly adult samples has led to the proposal to include an attenuated psychosis syndrome based on the APS criterion of the UHR criteria (Table 1) in Section III of DSM Thus it is important to review the evidence on the significance of at-risk symptoms in children and adolescents and to provide a preliminary rationale of how to deal with these symptoms in clinical practice before attenuated psychosis syndrome will be included among the main diagnostic criteria. The Significance of At-Risk Criteria in the Child and Adolescent General Population Most recently, Kelleher et a1 27 provided data on the prevalence of APS and BLIPS according to the SIPS criteria but assessed with the Kiddie Schedule for Affective Disorders and Schizophrenia, Present and Lifetime version, in the general population of 212 pupils, age 11 to 13 years. Among the total sample, 8.1% (n = 19) reported any APS or BLIPS at-risk criterion (7.7% APS, 3.5% BLIPS) according to the SIPS (Table 1). Slightly more males than females fulfilled at least 1 of these 2 criteria. Further, 7.7% met UHR criteria according to the CAARMS, which has an extended onset criterion. 20 However, when including the 30% decrease in social functioning criterion recently

4 The Significance of At-Risk Symptoms for Psychosis in Children and Adolescents Table 2 Basic symptom criteria according to the SPI-CY Risk criterion, COPER At least any 1 of the following 10 basic symptoms with a SPI-CY score of 3 or more within the past 3 months: Decreased ability to discriminate between ideas and perception, fantasy and true memories (B1) a Unstable ideas of reference (B2) a Visual perception disturbances (B3, 01) a Acoustic perception disturbances (B4.2, B5) a Derealization (B7) a Thought interference (D9) a Thought pressure (D10) a Disturbance of receptive speech (D11) a Thought perseveration (D14) a Thought blockages (D15; from age 13 onward) a First occurrence, independent of frequency, 12 or more months ago High-risk criterion, COGDIS At least any 2 of the following 9 basic symptoms with a SPI-CY score of 3 or more within the past 3 months: Unstable ideas of reference (B2) a Disturbances of abstract thinking (D7; from age 13 onward) a Inability to divide attention (D8) a Thought interference (D9) a Thought pressure (D10) a Disturbance of receptive speech (D11) a Disturbance of expressive speech (D12) a Thought blockages (D15; from age 13 onward) a Captivation of attention by details of the visual field (02) a a Item number of the SPI-CY Adapted from Schultze-Lutter et al 39 added as a criterion to the APS and BLIPS definitions according to the CAARMS 20 only 0.9% (n = 2) of the children met UHR criteria. Notably, 89% of children with any APS reported distress caused by them. 27 Thus about 6.9% in this adolescent population fulfilled both APS and the distress criterion of the proposed DSM-5 Section III antenuated psychosis syndrome. Further, 63% of children with APS or BLIPS met criteria for at least 1 past or present Axis I diagnosis (mainly of a present disorder: depressive disorders 37%, anxiety disorders 32%, and behavioural disorders 21%). Children with APS or BLIPS demonstrated poorer psychosocial functioning according to the children s global assessment scale (derived from the Global Assessment of Functioning), compared with those who did not fulfil APS or BLIPS criteria. 27 From this study, though not fully representative and in need for replication, it appears that APS and BLIPS although generated and validated in mainly adult samples may have some clinical relevance in children and young adolescents from the general population, although the studied age segment only spans 3 years. Nevertheless, the stability and predictive accuracy for psychotic disorders still needs to be studied in follow-up assessments. Data about the prevalence of basic symptom criteria in adolescents from the general population is also rather preliminary. Meng et a1 28 assessed basic symptoms according to the BSABS in 99 adolescents from the general population of Basel, Switzerland, age 14 to 20 years (mean 16.7, SD 1.2). Re-analysis of these data revealed an estimated prevalence of COGDIS at 3.1% and COPER at 8.0%. 29 However, these estimates were derived from BSABS ratings and thus only based on the presence but not frequency or duration of symptoms; therefore, the minimum duration and (or) frequency requirements of COPER and COGDIS (Table 2) might not have been met by a proportion of these adolescents. Therefore, these rates may actually overestimate the true prevalence of basic symptom criteria in adolescents. The Significance of Psychotic Symptoms in the Child and Adolescent General Population In the Dunedin birth cohort study, 30 psychotic symptoms at age 11 (2 out of 5 psychotic symptoms rated likely or one symptom rated definitely by a psychiatrist) predicted the emergence of a schizophreniform disorder at age 26 (OR 16.4, 95% CI 3.9 to 67.8). Further, a surprisingly high percentage (42%) of people with a schizophreniform The Canadian Journal of Psychiatry, Vol 58, No 1, January 2013 W 35

5 In Review Table 3 Comparison of symptoms included in the APS criterion according to SIPS and DSM-IV SPD 34 SPD APS a Ideas of reference Ideas of reference are part of both unusual thought content and (or) delusional ideas (P1) b and suspiciousness and (or) persecutory ideas (P2) b Odd beliefs or magical thinking Unusual thought content and (or) delusional ideas (P1) b Grandiose ideas (P3) b Suspiciousness or paranoid ideation Suspiciousness and (or) persecutory ideas (P2) b Unusual perceptual experiences Perceptual abnormalities and (or) hallucinations (P4) b Odd thinking and speech Disorganized communication (P5) b Inappropriate or constricted affect Odd, eccentric or peculiar behaviour or appearance Lack of close friends or confidants other than first-degree relatives Excessive, persistent social anxiety associated with paranoid fears rather than negative judgments about self Beginning by early adulthood and present in various contexts c First appearance within past year or current rating higher than 12 months ago, and present 1 or more per week in past month a In the SIPS, criteria of an SPD only require the presence of symptoms for more than 1 year in various contexts. b Item number of the SIPS c Defined by a score of 3 to 5 on the listed SIPS positive (P) items disorder or schizophrenia at age 26 already had psychotic symptoms (of unclear persistence and severity) at age 11, which did not justify an EOP diagnosis at that time. 30 In contrast to this study, 2 more recent studies emphasized the atypical nature of psychotic symptoms in childhood as well as their high remission rates and low predictive use for later psychotic disorders. Bartels-Velthuis et al 32 reported auditory hallucinations in 9% of 3870 children, age 7 to 8 years. Notably, auditory hallucinations were slightly more prevalent, yet less severe, in the rural population of children, and only 15% of these children had comorbid clinically relevant behavioural problems and distress. The persistence of these hallucinations during 5 years was 24% in the 337 children who were followed up 33 ; and 9% of the re-examined 12- to 13-year-old children newly developed auditory hallucinations. Predictors of persistence of symptoms were worse school performance, behavioural problems, external attributions of hallucinations, and hearing more than one voice. 33 Similarly, Hlastala and McClellan 31 reported high remission rates (50%) and no conversion to a psychotic disorder within 2 years in a small sample of 20 children and adolescents (age 7 to 18) with atypical psychotic symptoms. Compared with 27 adolescents with EOP, psychotic symptoms in non-eop youth were defined as atypical if they were fleeting, atypical in nature (for example, highly detailed, suggestible, or their content related to past traumatic experiences), context specific (for example, present only when the young person was angry or while negotiating for some particular need to be met), likely to result in secondary gain from the illness, and were not accompanied by disorganized speech. 31 Although some differences in the above findings may be due to methodological issues, such as different interviews and 36 W La Revue canadienne de psychiatrie, vol 58, no 1, janvier 2013 not strictly operationalized criteria for atypical psychotic symptoms, the conflicting results still indicate that it is far from clear whether (atypical) psychotic symptoms in childhood if they do not justify a formal psychotic diagnosis predict later psychotic disorder, how they should be distinguished from APS and BLIPS, and how they should be treated. Conceptual and Assessment Issues The unclear role and definition of atypical psychotic symptoms in children and adolescents has already created doubts that APS and BLIPS criteria, when assessed with the SIPS (Table 1) or the CAARMS, can simply be transferred to children and young adolescents. Nevertheless, these are not the only conceptual issues and data creating doubts in this respect: APS definitions overlap with positive symptom phenomena of SPD, such as magical thinking, unusual perceptual experiences, or odd thinking and speech (Table 3). The SIPS differentiates between SPD and APS by applying detailed time criteria (Table 1): overlapping symptoms must be new or clearly progressive within the last 12 months. However, in the context of SPD, these positive symptoms are thought to emerge in adolescence. 34 Therefore, incipient SPD features and APS may be difficult to distinguish in adolescence. The other symptoms of SPD, such as social anxiety, no close friends, and restricted affect (Table 3), may also not be sufficient for distinguishing APS from SPD because they are also well-known (unspecific) precursors of psychoses and are likely to accompany APS. 35 Whether this conceptual problem is of clinical relevance remains to be studied because the presence of SPD is also associated with conversion to psychosis (to a similar degree or even higher than that associated with APS). 36,37

6 The Significance of At-Risk Symptoms for Psychosis in Children and Adolescents Another problem is that neither SIPS nor CAARMS define a minimum age for the assessment of APS. For example, magical or odd thinking is common in children, and part of their normal development in the preoperational stage (age 2 to 7). 38 Assessment of Basic Symptoms in Children and Adolescents For basic symptoms, the SPI-CY 39 is the only instrument in the field of early detection of psychosis, so far, especially designed for use in children and adolescents. It considers the following conceptual assumptions and data 29 : based on earlier experiences with BSABS assessments in children, most SPI-CY items are thought to be applicable to children age 8 and older, because a child should be able to consider experiences and relationships from different points of view from this age onward. A certain command of social perspective taking is necessary to ensure that the child is sufficiently capable of self-reflection that only enables the detection of basic symptoms as self-experienced aberrations from the child s normal mode of experience. For the assumed lack of a sufficiently mature command of social perspective taking, using the SPI-CY with much younger children is probably not reliable. Further, starting at about 13 years of age, the child or adolescent will also have acquired self-reflective abilities and higher-level metacognitive processes 37 that only allow the assessment of some basic symptoms, such as thought blockage and disturbances of abstract thinking, which are part of the basic symptom criteria (Table 2), or autopsychic depersonalization and decreased spontaneity. Therefore, these items are only considered to be appropriately assessable in adolescents of roughly age 13 and older. Further, the SPI-CY emphasizes the differentiation between basic symptoms and symptoms inherent to other child and adolescent psychiatric disorders and allows the inclusion of parents reports where considered appropriate, although keeping its focus on the self-perception of the patient. With this, the SPI-CY, which will have to be further validated in prospective studies, is currently the only early detection instrument especially designed for use in children and adolescents. So far, the criteria of COPER and COGDIS have remained unchanged. 40 Conversion Rates to Psychosis in Children and Adolescents Fulfilling At-Risk Criteria Very little is known about the predictive use of at-risk criteria in children and adolescents. While quite a few studies included a certain number of adolescents (age less than 18 years), only 2 studies assessed conversion rates exclusively in children and adolescents to date. A naturalistic intervention study with a variable 2- to 88-month follow-up of 48 adolescents 12 to 18 years old (few subjects were up to 22 years old) with APS according to the SIPS, indicated a more insidious onset of frank psychoses, that is, a longer interval between study intake and conversion than reported from adult or mixed samples. 44 Among the 12 patients (25%) with a conversion to psychosis, only 3 (6.3%) converted within the first year. Six (12.5%) developed psychosis in the second year, 2 (4.2%) in the third year, and 1 (2.1%) even only after 5.5 years. The authors concluded that a longer observation time may be required for adolescents with APS. A second, more recent study, by Ziermans et a1, 45 assessed the predictive use of UHR criteria and COGDIS in 58 adolescents (age 12 to 18) during 2 years. The conversion rate was lower (16% within 2 years), but the timing was comparable to that of adults; that is, most adolescents converted within the first year. All 9 converters had APS at baseline, and 7 out of 9 adolescents also fulfilled the COGDIS criterion. In 50% of at-risk adolescents, the UHR criteria remitted, and 35% still fulfilled UHR criteria at 2-year follow-up. Although these studies assessed only adolescents but no children below age 12, they provide the first evidence that APS and COGDIS may be predictive of conversion to psychosis in this age group. Nevertheless, the timing, and thus the required observation time in children and adolescents and the transferability of risk staging models generated in adult samples, 41 remains to be shown in future studies. Moreover, no studies have yet addressed the issue of how to treat children and adolescents presenting with at-risk symptoms and criteria. Another strategy, using extended SIPS BLIPS criteria (Table 1) and targeting the early detection of schizophrenia spectrum psychosis, and not just any psychosis, was used by Correll et al. 46,47 In a naturalistic study of 29 adolescents (age 12 to 22) followed during 6 months (mean 22.8 months, SD 19.4), 27% (n = 7) developed schizophrenia or schizoaffective disorder, 34.6% had a mood disorder (with or without psychotic symptoms), 11.5% a personality disorder, and 7.7% an obsessive compulsive disorder. Only 38.4% improved (having negative APS only or no positive and no negative symptoms). These data suggest heterogeneous outcomes of children and adolescents with BLIPS, psychosis not otherwise specified, or brief psychotic disorder, the latter 2 commonly used diagnostic entities in children and adolescents with psychotic symptoms. 48 Clinical Implications In summary, research in early detection and intervention of psychosis has predominantly been carried out in adults and older adolescents, with little consideration of possible special requirements in children and younger adolescents. Hence the rates and timing of conversion to psychosis in children and younger adolescents fulfilling current at-risk criteria are unclear. 17 However, results of 2 recent studies, by Cornblatt et a1 44 and Ziermans et a1, 45 suggest that current at-risk criteria may indeed be predictive of conversion to psychosis in young help-seeking adolescents. Figure 1 displays the potential implications of the prevalence rates and clinical significance of at-risk criteria in the general population. The interesting study by Kelleher et a1 27 provided initial evidence that APS and BLIPS may have clinical relevance in young adolescents of the general The Canadian Journal of Psychiatry, Vol 58, No 1, January 2013 W 37

7 In Review Figure 1 Epidemiology of at-risk criteria in children and adolescents: potential implications At-risk criteria in GPS Common Rare Nonpredictive of conversion to psychosis Predictive of conversion to psychosis Not clinically relevant Clinically relevant Revise criteria Consider encouragement for help seeking and treatment in GPS GPS = general population sample Adapted from Schimmelmann 52 population because many were distressed by their symptoms, and many suffered from other lifetime Axis I diagnoses. However, prevalence rates of psychosis risk criteria that were more than twice the lifetime incidence of psychosis 49 caution against indiscriminate encouraging of help seeking for APS and BLIPS in the general population. However, if the decline in social functioning criterion of the CAARMS is added, the prevalence of 0.9% is much lower, but may be too insensitive. At least, this study implies that young adolescents of a certain age segment experience APS and BLIPS and that those with APA or BLIPS commonly have other Axis I diagnoses and (or) suffer from these symptoms. While it would be premature to encourage help seeking and subsequent treatment in children and adolescents with atrisk symptoms in the general population, mental health professionals should be aware of these psychopathological phenomena in help-seeking patients presenting with other common psychiatric disorders of young adolescence; for example, depression, anxiety, and behavioural disorders. From our clinical experience in early detection services that assess help-seeking children and adolescents with at-risk symptoms, we conclude that these youngsters do suffer from these symptoms; more often than not they have functional impairment; that youth and their caregivers value the competent assessment of at-risk phenomena as well as of potential comorbid psychiatric syndromes and neuropsychological impairments; and that they are interested in focusing on them in the treatment 38 W La Revue canadienne de psychiatrie, vol 58, no 1, janvier 2013 process, independent of any conversion risk to psychosis. For example, in some children as young as age 8, the detection of APS comorbid, or causally related, to obsessive symptoms had fundamental consequences for their psychotherapeutic treatment. Likewise, the detailed assessment of cognitive and perceptive basic symptoms can guide the diagnostic distinction between dissociative or borderline and potential at-risk-for-psychosis phenomena by providing a deeper understanding of the underlying psychopathology. Obviously, based on today s sparse evidence, risk of conversion to psychosis should not be communicated to children and young adolescents fulfilling at-risk criteria and to their parents, or at least it should be done very carefully. This risk, especially in children, may only exist after a certain persistence of symptoms. However, the availability of a child and adolescent psychiatrist with special training and sufficient experience in the assessment of at-risk symptoms for psychosis in this age group will be most welcome by each regional mental health system. This will also prevent an unjustified and potentially stigmatizing pseudo-diagnosis of pre-psychotic or prodromal in these patients, which thereby cautions against the premature use of antipsychotics. The higher risk of antipsychotic side effects in this age group and a high risk of distress related to these side effects interfering with development and daily living 50,51 justifies the recommendation to use other, lower-risk treatment options first, such as supportive and family therapy,

8 The Significance of At-Risk Symptoms for Psychosis in Children and Adolescents cognitive-behavioural therapy, social skills training, healthy lifestyle, sleep hygiene, stress reduction, and if indicated ADs or other targeted treatments of psychiatric syndromes or disorders. It is recommended that adult and child and adolescent psychiatrists and (or) psychologists work together in a team and that research on the clinical significance and predictive accuracy of current at-risk criteria and on potential treatment options in younger age groups is pursued. Acknowledgements The authors declare they have no conflict of interest related to this work. The Canadian Psychiatric Association proudly supports the In Review series by providing an honorarium to the authors. References 1. World Health Organization (WHO). Prevention of mental disorders. Geneva (CH): WHO; Asarnow JR, Tompson M, Woo S, et al. 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