Because such abilities are already observed and assessed, to an extent, as part of a child's schooling, there is potential for the development of predictors and the identification of targets for psychological intervention. Studies examining the ability of teachers and other educational professionals, in day-to-day contact with adolescents, to predict future sufferers of schizophrenia do show some statistical power, but this is at the cost of many false positives and even more false negatives (Isohanni, et al., 2004) unless restricted to high-risk populations (Kravariti, Dazzan, Fearon, & Murray, 2003). One possible exception was the study by Davidson et al. (1999) linking the Israeli Draft Board Registry with the National Psychiatric Hospitalization Case Registry. Adolescent boys, aged 16 to 17 years, underwent preinduction assessments to determine suitability for military service. Those admitted to a psychiatric hospital with schizophrenia 4 to 10 years later were matched with control individuals from their school class at the time of original assessment. Identified predictors for schizophrenia in the male adolescents included deficits in social and intellectual functioning and organizational activity. The predictive model derived by the authors had 75% sensitivity, 100% specificity, and a positive predictive value of 72%. However, as highlighted in a commentary by Jones and van Os (2000), the predictive power of this model was achieved by excluding from the sample those school classes without individuals who later became schizophrenic.

So far the best prediction has come not from teachers but from a psychiatric interview. In the Dunedin study (Poulton et al., 2000), 11-year-old children were asked about experiences of quasi-psychotic symptoms. The questions were as follows:

Those who answered positively to one of the five questions or possibly positively to two were 16 times more likely to develop a schizophrenia-like psychosis by age 26 years. Teachers or school nursing staff could be advised of the value of such questions. However, little work aiming at primary prevention (i.e., preventing progression from premorbid abnormalities to prodrome) is in progress.

Falloon initiated an early intervention for “prodromal” symptoms in adolescents and adults, in the form of the Buckingham project, a “shared care model” between primary and secondary care (using low doses of medication, interventions designed to reduce stress, psychoeducation, and follow-up for 2 years after the symptoms had occurred). He claimed that this reduced the annual incidence of first-episode psychosis from 7.4 per 100,000/year, as measured by the same group in 1989, to 0.75 per 100,000/year during the 4-year study period (Falloon, Kydd, Coverdale, & Laidlaw, 1996).

Unfortunately, adolescents developing schizo-phrenia suffer the same delays as their older counterparts, often not receiving diagnosis or treatment for a prolonged period. Consequently, a number of projects have been developed to reduce this unnecessary period of untreated psychosis.

Projects such as the Personal Assessment and Crisis Evaluation (PACE) clinic in Melbourne, Australia, and the early Treatment and Intervention in Psychosis (TIPs) project in Norway aim at secondary prevention (i.e., preventing progression from prodrome into syndrome) in adolescents and adults. Such programs are motivated by the belief that the chronicity of schizophrenia may develop in the early stages of the illness and that long-term outcomes may be linked to the duration of untreated psychosis, or DUP that is, the time period between onset of symptoms and initiation of treatment. However, the latter hypothesis remains theoretical. Norman and Malla (2001) reviewed the concept of DUP and while they confirmed that there was evidence to suggest a relationship between DUP and the ease with which first remission of symptoms is achieved, they could not find evidence to support a link with disease progression. Although the concept of DUP focuses on initiation of pharmacological treatment, de Haan, Linszen, Lenoir, de Win, and Gorsira (2003) suggest that delay in initiating intensive psychosocial treatment may have similar implications for outcome, particularly in relation to negative symptoms at follow-up.

The TIPS project is a prospective clinical trial that started in Norway in 1997, comparing an experimental sector with two other control sectors (age range 15 to 65 years). The experimental sector developed a system for early detection and also established a comprehensive information, service, and education program aimed at both the general public and professionals involved in health care and education (Johannessen et al., 2001). In the 2 years after the initiation of the TIPs project, mean DUP decreased from 1.5 years to 0.5 years.

The PACE was established in Melbourne, Australia, in 1994; the aim was to evaluate the prodromal phase, develop interventions that prevent further deterioration and maximize function, and set up a clinical service to identify and engage young people experiencing potential early psychosis. Preliminary results, which are further discussed in Cognitive Behavior Therapy, below, show that early intervention in the prodrome can at least delay onset of first-episode psychosis.

It seems likely that the wider-ranging public and educative measures occurring in the TIPS project and PACE clinic are vital to any health service initiatives or collaboration, especially in view of adolescents' poor primary care attendance. It is important to note, however, that while a number of the early-intervention services cover the adolescent age range, their goal

is actually to intervene in an early stage of the disorder rather than to specifically target those who develop schizophrenia in adolescence.

Cognitive behavior therapy (CBT) addresses problems in the here-and-now by targeting dysfunctional thoughts and behaviors within a collaborative therapeutic relationship. Efficacy of CBT and acceptability by those with disorders such as depression and anxiety have been demonstrated (Beck, Sokol, Clark, Berchick, & Wright, 1992; Kovacs, Rush, Beck, & Hollon, 1981). In support of the growing (but relatively underevaluated) practice of CBT in adults with schizophrenia, Rector and Beck (2002) suggest that since the inferential errors and faulty logic in hallucinations and delusions are similar to those seen in other disorders, CBT should also work in schizophrenia. They describe CBT for psychosis as an active, structured therapy, usually of 6 to 9 months duration, given individually.

Unfortunately, we could not find any reports of the use of definitive CBT in specifically adolescent individuals. However, data are beginning to accumulate from the early-intervention programs, reporting on the use of CBT in early-onset psychosis. McGorry et al. (2002) conducted a randomized controlled trial (RCT) with 14-to 30-year-olds at the Early Psychosis Prevention and Intervention Centre, Melbourne, which is associated with the PACE clinic discussed earlier. This study compared interventions designed to reduce the risk of progression to first-episode psychosis, in a clinical sample aged 14 to 30 years, termed ultra-high risk (first-degree family history of schizophrenia and subthreshold symptoms). The interventions comprised a needs-based intervention and a specific preventive intervention (low-dose risperidone and CBT) for 6 months with assessments at baseline and 6 and 12 months, using a defined threshold outcome rather than a formal diagnosis of schizophrenia. Ten of 28 in the needs-based intervention versus 3 of the 31 in the specific intervention had reached the defined outcome by the end of treatment; however, there was no significant difference at 6-month follow-up. When the data were assessed, taking into account drug adherence, a significant difference was found between the fully adherent specific intervention group and the needs-based group. It seemed that the specific intervention delayed onset.

Dickerson (2000) reviewed all studies investigating CBT for schizophrenia in adult populations (although age data are not supplied) between 1990 and 1999. She examined the available data for seven different CBT approaches, some focusing on acute psychosis, others on persisting positive symptoms. Her conclusion was that there were some CBT strategies that reduced positive symptomatology, especially in individuals with clearly defined symptoms that they themselves viewed as problematic. The most beneficial outcome appeared to be in reducing conviction in and distress about delusions; there was little evidence to suggest that CBT was efficacious in negative symptoms or social functioning. The overall superiority of CBT was reduced when the control condition was matched for therapist input.

Even more disappointing, a Cochrane meta-analysis of CBT in schizophrenia (Cormac, Jones, & Campbell, 2002) found no evidence that CBT, in addition to standard care, reduces the relapse and readmission rate in the short or longer term (1 year) any more than standard care alone. Moreover, there was no overall difference between CBT and supportive psychotherapy, with respect to relapse rate or improvements in mental state.

Pilling et al. (2002) conducted a systematic review of RCTs of CBT (and family interventions, social skills training, and cognitive remediation). The trials reviewed compared CBT with supportive therapies and standard care in predominantly chronic psychosis. There was no evidence for increased effectiveness of CBT during treat

ment, although CBT showed a clear advantage over the comparison treatment at follow-up when measured continuously in terms of “important improvement.” This superiority persisted for up to 18 months after treatment. Furthermore, CBT groups had lower dropout rates. It was not possible to identify any particular responder characteristics or the optimum frequency or length of treatment.

Although the Study of Cognitive Reality Alignment Therapy in Early Schizophrenia (SoCRATES; Lewis et al., 2002) was conducted among individuals with an average age of 27, it is one of the more relevant adult studies to this discussion because the patients recruited were in the early phases of their illness. The RCT compared CBT with routine care, supportive counseling and routine care, and routine care alone, all for 5 weeks duration only, in individuals suffering their first or second episode of schizophrenia. Use of CBT showed only transient advantages over the other two intervention conditions in speeding remission from acute symptoms in this group of individuals.

In summary, the adult literature suggests that, although CBT might have some beneficial effects, questions such as defining the length of treatment required, which patients would benefit, and at which stages in their illness it should be implemented still remain unanswered. Until these questions are answered in adult populations, it would be foolish to commence large trials in adolescent individuals, especially without adequately defined aims. This caution should not prevent CBT techniques from being borrowed in part in the development of specific interventions targeted at the special needs of adolescents with schizophrenia.

Deficits in cognitive function such as working memory, attention, and executive functioning are core features of schizophrenia. Cognitive remediation therapy (CRT) aims to teach people thinking skills. More specifically, it uses material that is not personal to the individual and targets the specific domains affected in schizophrenia. Cognitive remediation therapy can be character ized into three generic approaches (Bellack & Brown, 2001):

The assessment of efficacy of CRT has again been hampered by methodological constraints, in particular, the heterogeneity of intervention packages used and then inappropriately compared. Wykes et al. (2001) have made attempts to reduce this phenomenon by describing a typology for classification of methods.

Very little evaluative work has been published in the area of interpersonal therapy (IPT) since the 3-year trial conducted by Hogarty et al. (1997). Although this study was aimed at reducing the “late relapse” observed to occur in the second year after psychotherapeutic intervention, and was conducted in a mixed adult and adolescent cohort (16 to 55 years old), it warrants discussion because its conclusions seem particularly pertinent to the adolescent population. This study examined relapse and noncompliance in outpatients with schizophrenia and schizoaffective disorder in two concurrent trials. One trial concerned individuals who resided with their families who were randomly assigned to personal therapy, family therapy, personal therapy and family therapy, or supportive therapy; the other trial studied those individuals who lived alone who were randomly assigned to either personal or supportive therapy.

Personal therapy occurred in three stages, and although it focused on internal, personal responses to stress, and not the regulation of external triggers, it did not use symbolic interpretation or analysis of unconscious factors. It aimed more specifically to identify and manage the “affect dysregulation” that might mediate relapse or inappropriate behavior. All patients were on the minimum effective dose of medication. The overall rate of relapse over the 3-year period was 29% over all groups, which was lower than expected. For individuals residing with their family, the group receiving personal therapy relapsed less than the other groups, although this was only significant for family intervention. For individuals living alone, personal therapy significantly increased relapse rates, compared to those for supportive treatment, even though the latter was particularly rich in its provisions. The authors suggested that the group living away from their family may not have reached a stable independence; they may have been too distracted to prioritize the therapy or the intervention itself may have overloaded them. Perhaps this conclusion should serve as a more global caution: full assessment of levels of independence and subjective perceptions of stability may be required before initiating any form of psychotherapy.

Social skills training is a structured educative program that involves modeling, role-play, and reinforcement (Bellack & Mueser, 1993). It is based on the hope that the improved social skills generalize to real-life situations and might even improve symptomatology and reduce relapse. These interventions are targeted at the profound impairments in social functioning that characterize schizophrenia and affect life in the workplace, family, and wider community. There are three forms of social skills training as detailed by Bellack and Mueser (1993): the basic model, the social problem-solving model, and the cognitive remediation model (considered in the previous section).

The basic model involves breaking down complex social interactions into smaller elements. The patients are therefore taught the steps and then the combined elements by means of role-play and areas such as self-care, medication management, and conversation are targeted. Bustillo, Lauriello, Horan, and Keith (2001) reviewed reports from 1996 to 2001 and found that the basic model was repeatedly efficacious in improving social skills and that this effect continued for up to 12 months. However, there was not much to suggest that this treatment affected overall social performance. Evidence from studies of the