Schizophreniform psychosis of childhood: Therapeutic considerations

Schizophreniform Psychosis of Childhood: therapeutic Considerations Eva P. Lester

and Catherine

LaRoche

T

HE TWO CENTRAL QUESTIONS about childhood schizophrenia-- the psychobiologic unity of its various clinical forms and the relationship between childhood and adult schizophrenia-remain unanswered. In this paper, we will focus on the late type of childhood schizophrenia, described in the GAP classification’ as schizophreniform psychosis. Five cases seen over a period of time will be discussed in an attempt to sharpen the definition of this syndrome and also to contrast it with the earlier forms of childhood psychosis. In addition, the treutment and outcomeof the five cases will be discussed. Recently Rutter,2,” Churchill,-’ Halpern” and others proposed that autism is J central language disorder or a central disorder of cognition resulting in impairment in the comprehension of language and its utilization for social communication. They sharply separate autism that starts no later than age 30 months from schizophrenia starting at age 7 or 8 years. In Rutter’s words, “autism has nothing to do with schizophrenia.“z This position is contradicted by a mass of clinical data that points to the existence of overlapping forms.“-” Furthermore, accumulating evidence seems to support a link between autism and the schizophrenic illnesses, Recent publications underline the fact that the language disorder of autistic children, although of fundamental importance in the shaping of the clinical picture, itself rests on a more basic defect,“*“‘,” This defect lies in the very foundation of behavior; the stimulus-res~nse process. Thus, according to Ornitz”.” and others, faulty modulation and inadequate homeostatic regulation of sensory input is considered to be the primary defect in autism. This perceptual inconstancy is implicated in the failure of the autistic child’s attention and in his difficulty to select and respond to stimuli appropriately. Thus, in the area of language learning-the most complex of al1 learning in early life--the selecting, coding, and patterning of auditory input is impaired. The auditory perceptual field of the child becomes chaotic, and he cannot distinguish and recognize words or combinations 01 phonemes through the mass of stimuli impinging upon him. Since one of the essential features of language is “the sequencing of auditory percepts into meaningful patterns for the purpose of communication,” the afflicted child will show severe retardation in his language development. Besides the difficulty in selecting and integrating sensory input, the autistic child cannot readily transfer information from one sensory modality to another, or along the various levels of neurocircuits. This is what Halpern” has termed the failure of symbolic transformation. From the Royal Victoria Hospital. Montreal and the Department of P.vFchiarry. McGill 1’niver.yit.v. Montrral. Quebec, Canada. Eva P. Lester, M.D.: Direcror, Chifd and Adole.~ren~ Service, Royal Victoria H~~.~pi~a[,and .4ssociare Professor, Deparrmennr of Psychiatry, McCilI University. Montreal; Catherine LaRoche, M.D.: Staff Child Psychiatrist. Child and Adolescent Service, Royal Victoria Hospiral. Monrreal, Quebec, Canada. Address reprint requests to Eva P. Lesrer, M.D.. Department of P.ywhiatr?. McGill L’niwrsiry. Montreal, Quebec, Canada.

Comprehensive Psychiatry. Vol. 19, No. 2 (March/April). 1978

1 53

154

LESTER AND LA ROCHE

The dysfunctions in the stimulus response process described above are very similar to those found in all forms of schizophrenia. 13.14In later forms and in adult life, the resulting symptomatology is different from the symptomatology of autism mainly because of differences in the timing of decompensation. Shakow,‘” in a comprehensive overview of the research in schizophrenia during the last 30 years (juvenile and adult types), concludes that the only consistent findings in schizophrenic patients are those relating to basic impairments in perception, and states that such impairments may explain the salient symptomatology of the illness. The differences among individuals and subtypes may be explained by experiential events in the lives of patients and differences in their individual endowment. The schizophreniform psychosis of childhood has a late onset and is characterized by symptomatology that distinguishes it from both the autistic syndromes and the more classic types of childhood schizophrenia. The study of this disturbance has been greatly handicapped by the existence of multiple definitions and the lack of agreement among clinicians about its exact nature.‘” This lack of agreement seems to be the result of differences in methods of defining and classifying rather than in the cases observed.‘“-‘X Thus, what seems to be basically the same syndrome has been labeled, for example, pseudoneurotic type childhood schizophrenia (Lauretta Bender), pseudoneurotic schizophrenia (Kestenberg), type 3 regressive psychosis (Mahler), and episodic regressive psychosis (Szurek).‘” (In the last lo-15 years, several excellent papers have appeared in the literature on the nature and treatment of “borderline children.“‘g-‘” This body of work, originating from a number of psychoanalytic centers, represents the most systematic exploration of these nonautistic and not typically schizophrenic types of severe disturbances in childhood. However, since clinical description is often only a peripheral interest with most of these writers, and dynamic and metapsychologic issues take precedence over issues of etiology and epidemiology in their writings, the integration of the “borderline syndrome” within the broad concept of schizophrenia has not been established in their work. Even the term “borderline” becomes ambiguous at times.“,‘” In some writings it retains the usual connotation of a syndrome bordering on psychosis, while in others it has a restricted psychoanalytic definition; the disorder is conceived as a fundamental impairment in object relations and the term borderline means that the child remains on the border between object cathexis and primary identification.“) On purely descriptive grounds, the most frequently discussed characteristics of those disturbances that may be called schizophreniform are grouped as follows: (I) Excessive pervasive anxiety, unrelated or poorly related to current or past experiential events; phobias, ritualistic behavior, and obsessive-compulsive symptoms; unprovoked (and not easily controlled), sudden and disorganizing outbursts of temper. (2) Uneven development, with precocities and seeming arrest or deceleration of growth, resulting in a scatter in function; the most typical example is a child with high intelligence coupled with poor judgment and poor reality testing. Besides uneveness, one observes shifts in the rate of development as well as marked regressions and loss of acquired skills. (3) Excessive fantasy activity as one of the cardinal symptoms. This fantasy, bizarre and persevering, is at times referred to as delusional thinking. Parenthetically, we would like to pose the question whether before the age of I I-13, i.e., before the final stage of cognitive growth is reached and deductive, hypothetic thought is possible, the child is able to develop true delusional thinking. In other words, until the child develops the ability for metathinking, which is the ability

CHILDHOOD

SCHIZOPHRENIFORM

of thinking

about

are delusions fantasies

thought,

how can we be sure that

--pathologic

forms

of thought

the abnormal

over which

products

of the child’s

the child has no control

thought

and not simple

used by the child to release his anxiety?

(4) The object adults.

155

PSYCHOSIS

relations

in particular

susptcion ofother

of these children.

the mother,

Overdependency

is coupled

with

and clinging

behavior

fear of peers, aloofness,

towards

social withdrawal,

the and

children.

Although there seems to be agreement that clinically the illness becomes apparent between 5 and 7 years, there is no consensus as to whether this is the actual onset of an illness until then latent or whether this is simply a major exacerbation of an ongoing process precipitated by the stress of going to school. The five cases to be described represent a small sample, but because they were seen over a long period of time, they may offer the opportunity for valid observations. CASES Three

boys and two girls between

lives of the children was the reason

were not totally

for the referral.

cases both parents

free of abnormality,

All

there was a positive

family

were intact, history

grandfather

The symptomatology

education.

amount

of anxiety

and unpredictable

was the most regressed. struck

was analogous

was functioning there

and in four of the

all of whom were reported poorly.

In three case*

was good reason

to that described

outbursts

of temper.

in this paper.

Four of the children

A girl of 7 and an only child,

to suspect

The one child

All children

presented

without

inordinate

clinical

she was passive. infantile.

signs o/

avoiding

most

all stress in her life. It was the teacher

as a shreld against

uninvolvement

the earl!

schizophrenic.

shifts.

by her total

families,

had siblings,

and in another

and regressive

tasks of her age. and using both parents the child.

professional

but one of the families

of the five children

in development

referred

came from

might have been an ambulatory

uneveness

to us. Although

it was clear that a sudden change in behavior

Four patients

of schizophrenia,

showed anxiety

five children

had postgraduate

to be doing well. All families that the paternal

the ages of 6 and 9 years were referred

in the class and her failing

despite

who

above avrragc

ability. All

children

stunted

were overdependent

sense of self contrasted

children

showed

socially:

none had any friends.

Two

children

impairment organic

precocious showed

of spatial

memory

with

skills.

and individuation

their All

a third

This particular for spatial

superior

children

signs of neurobiolopic

organization);

brain involvement.

had a phenomenal

language

minor

on the adult

sharply

did poorly

involvement

child showed marked child,

was delayed.

intellectual

functioning

In two children,

development. in school.

(mild

both academically

motor

hand “flapping”

in the very-superior

thn

f-our of the tint

dyscoordination. hut no other

and milc sign of

range of intelligence.

relations.

TREATMENT

As in the cases reported by Jordan and Prugh,‘” the five children responded well to weekly individual psychotherapy sessions over a long period of time (I4 2X months). Regular sessions with the parents served a secondary role of helping to provide a holding situation for the child and to integrate the child’s rapid changes within the family. Ongoing school consultations were useful in implementing and consolidating therapeutic aims. Kemp, Harrison, and Finch2” describe three overlapping stages in the psychotherapeutic treatment of psychotic children: (1) breaking through the autistic barrier to establish contact, (2) developing ego functions, and (3) dealing with intrapsychic and interpersonal conflicts. In the treatment of our cases, overlapping stages are also discernible, but they do not correspond exactly to those described by Kemp, Harrison, and Finch.‘” In our opinion, comparing the course of treatment of autistic children, as outlined by Kemp, Harrison, and Finch,” and

156

LESTER AND

LA ROCHE

the treatment of the five cases described above may be useful for the further differentiation of the two syndromes. The first stage, for example, that of establishing contact and a working relationship, was greatly accelerated by the five children’s readiness to attach to the adult. The child’s quick attachment to the therapist was used to cue in on his intense disorganizing anxiety and to create a more structured predictable environment than the neurotic child may require, yet one that provides room for selfexpression and autonomy. The regularity, predictability, and consistency of the sessions themselves lent order and stability to the child’s confused and frightening world. The following case demonstrates how quickly this kind of child relates and responds to the adult therapist, who is viewed as an ally: B.R., an alert, intense, 6-year-old boy was referred for extensive aggressive fantasies, unpredictable explosive tantrums, and very poor peer relationships since the onset of school. Preschool history was marked by precocious language and intellectual development and a close attachment to his mother. In the first session, he involved himself quickly with the examiner, demonstrating considerable ability to communicate both verbally and through play, in spite of an extremely high level of anxiety. In this first interview, a discussion of everyday problems with peers suddenly gave way to agitated talk of monsters and madmen accompanied by mounting panic and rapid alternation of identification with the victim and aggressor. Caught up in this state, reality testing and an appropriate sense of identity seemed completely lost. Surprisingly, within a few months, this boy had formed a strong positive relationship with the therapist, accompanied by such a dramatic symptom improvement it was difficult to detect traces of the psychotic behavior that had been so clear in earlier sessions, This high level of functioning, though, was quite unstable and closely tied to environmental stresses and supports.

Once the relationship is established, the scope of the “second stage”““‘in our cases becomes large. These patients, in contrast to the autistic child who needs to establish and maintain primary ego operations (language-perceptual constancy, time space concepts, etc.) come to the treatment with a large repertoire of behaviors and a considerable network of object relationships, albeit some only in fantasy. The goals of the therapy at this stage are multiform: help the child select, discriminate, and organize extero and proprioceptive stimuli and then move to appropriate behavior: distinguish between the self and non-self and establish ego boundaries to ward off fusion with objects and loss of sense of self; discriminate between inner and outer reality, between fantasy and actuality, and sharpen reality testing. The following vignette illustrates this process: E. M., an immature, inhibited ‘I-year-old girl was referred for psychiatric care following the onset of marked regressive trends including social withdrawal and academic failure since entering school. During the first 5 months of therapy, she displayed mostly her wish to remain regressed, to be fed, to be messy, unorganized, and undisciplined. In her drawings and playing with toy animals or human figures, she repeatedly constructed simple scenes of two figures lying upon each other or eating up one another. It became clear that interpretation alone was not sufficient to induce changes in this patient. Structuring of the sessions and limit setting at home and at school were indicated. Structuring of the sessions involved not only interpretation of the child’s behavior, but also direct action in demonstrating self-non-self boundaries, in delineating reality, and in encouraging the child to reach further than gratification of her immediate needs. Additional structure within sessions included such interventions as encouraging the child to sit on a chair instead of lying on the floor, to complete a drawing instead of scribbling, and to wait for the end of the session to eat her sweets instead of swallowing them up as she entered the room. Her regressive tendency in the face of frustration due to inadequate ego skills was interpreted many times. The results

CHILDHOOD

SCHIZOPHRENIFORM

were immediately

obvious

play became more complex

PSYCHOSIS

in several

157

areas of the child’s

and diverse

and included

functioning;

for example,

her dreams

and

more material.

The child’s clinging and overdependence often exists alongside an excessive need to control, especially in the early stages of therapy. When playing out fantasies, the child may relegate the therapist to a restricted minor assistant’s role. The wish of the child to take charge is not challenged, but viewed as an expression of budding autonomy as well as a need to avert object fusion. Once allowed to participate within the play, the therapist can gradually enlarge her role and in a gentle way direct and structure the material. An important aspect of the work is the identification and development of the child’s natural strengths and shifting their use toward more adaptive. integrative. and reality-oriented, rather than constrictive and defensive, behavior. From dealing with issues arising in play, the therapist gradually moves the child to face ongoing problems, with peers, school, and family. The next case illustrates these last points: From linguistic child’s pleasure

the beginning skills, ability

Rachel,

through

an extremely

the composition

to use words was not discouraged.

but provided

and writing.

of treatment,

communicated

a way of dealing

the therapist

tegrate

experience

trusted

external

many

and this part of the therapist

fears.

In the process.

was then gradually

girl with

of poems

and anxiety.

of the child’s

and show her new ways of coping.

reality

7-year-old

It was. in fact. labeled

with inner confusion

was able to allay

anxious and telling

a gift,

superior

and stories.

The

which not only gave

Using mutual

storytelling

to help her clarify the therapist internalired

and in-

became

a

by the child.

Throughout the treatment, the therapist maintains a stable, anxiety-free relationship in which the continuous warm and positive communications to the child enhance the breaking down of pathologic denial and projection of anxiety and the substitution by sublimation or repression. In general, easing the crippling anxiety, is a major therapeutic aim, in order to free the ego from burdensome, defensive operations so that growth and restructuring may proceed faster. This. and tht: child’s strong attachment to the therapist, reflecting partly a splitting off of any negative feelings, determine the existence of a predominantly poaitivt: transference during most of the treatment. work (interpretation 01‘ As treatment progresses, “stage three”“’ therapeutic intersystemic conflict) may become necessary, but in our opinion, emphasis or neurotic conflict should not at any stage become the predominant element ol‘ treatment. The thrust of the therapy should remain the promotion of the self as a structuring and organizing system. Jordan and Prugh’” characterize their psychotherapy with schizophreniform children as ego-supportive. Our approach is more than this. It combines supportive maneuvers with some interpretation of internalized conflict, but also active stimulation for progression and mastery. It further differs from the approach of child analysts who consider therapeutic education or modified analytic treatment as only the preliminary phase aimed at making up for interactional failure and at stimulating ego growth;2’ this phase is seen to be just a prerequisite to traditional child analysis. In our experience, once a state of adequate functioning is achieved. treatment may be terminated. The children usually withdraw or lose interest as the need to emotionally invest in peers and peer activities emerges very strongly. The danger here is to confuse this wish for autonomy and individuation as a manifestation of an emerging negative transference necessitating further treat-

158

LESTER AND

LA ROCHE

ment. It is our thesis that the spontaneous move on the part of the child to break away from therapy at this point should be respected and treatment discontinued, even if it is to be resumed at a later date. We view the child’s wish for autonomy as a normal need to exercise new functions and newly acquired skills. Another vignette illustrates this phase of the therapy: After about a year of psychotherapy, J. M. stopped bringing to sessions the maps and favorite fantasies of foreign countries, famous kings, and composers that had filled many hours. He moved to the topic of World War II, with particular interest in war planes. This was the first interest that was shared with his brother. At the same time, J. M. announced that he didn’t care much about coming to see the therapist because he was bored. In the next few months, his play became much more aggressive and outer-directed. He talked of war planes and the kinds of executions that might befit his enemies (classmates or teachers). He expressed a lot of anger towards his mother. In the 14th month, J. M. set the date for termination. He lost interest in the sessions as he moved more and more to peers and peer activities. His games became somewhat benign. He reported no nightmares and his general apprehension had subsided.

In a recent discussion of the developmental issues of the latency-aged child, Anthony” reminded us of Sullivan’s astute observations that one phase of development may be therapeutic for another. It is our thesis that the naturally observed shifts occurring in the second period of the latency phase (from 8 years on)-namely an overall smoother functioning, a decreased awareness of suffering and readiness to accept help, a consolidation of defenses, a greater involvement of the ego in outer reality, and a cognitive shift allowing greater ordering of the world-are important changes that may help prepare the child to tackle the turmoil of adolescence. It is hypothesized here that an ongoing therapeutic relationship that perpetuates a strong involvement and dependence on an adult may seriously compromise the child’s need to repress disturbing fantasies and affects in order to direct attention to the accomplishment of industry, a very essential step in ego growth. To summarize, the five cases were seen in individual psychotherapy for periods of time varying from 14 to 28 months. All our children showed remission with lessening of the anxiety, disinterest in fantasy, and improved peer relations. All cases had some form of follow-up, ranging from regular monthly visits for 6 months to 6 years of brief communications over the phone. Improvement was maintained during the follow-up period. Our oldest child, who is now 15 years old, is doing well despite severe stress in the family. Our findings confirm what has been reported by several other investigators, namely that these children respond well to individual treatment.2” According to Jordan and Prugh,‘” who had a well-documented sample of 22 cases, if untreated, these children show progressive severe deterioration. Their experience and the results from these five cases indicate that with proper treatment, the process of deterioration is arrested. However, the long-range prognosis is still uncertain. At this point, one may quote Lauretta Bender,“O who, refuting the optimism of recent reports about the treatment of these cases, said not long ago : It appears to be almost necessary to spend a lifetime in following early recognized cases of childhood schizophrenia to confirm that schizophrenic children, whether they start as autistic or symbiotic, psychotic in childhood or at puberty, pseudopsychopathic or pseudoneurotic in adolescence, run a life course of schizophrenia.

CHILDHOOD

SCHIZOPHRENIFOR~

PSYCHOSIS

1 5’3

No one questions Bender’s authority on the subject, but it is still possible that refining our methods of definition for the subtypes of the disease and then making our specific therapeutic tools work for these subtypes may considerably brighten the outlook for a significant number of children. REFERENCES 1. Group

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