Cel de-al XXV-lea Congres SNPCAR

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24-27 septembrie 2025 – Brașov Hotel Kronwell

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Asist. Univ. Dr. Cojocaru Adriana – Președinte SNPCAR


Risk factors and resilience in children with high risk for psychosis

Autor: Adriana Cojocaru Andreea Șiclovan Luminiţa Ageu Daniela Părău Liliana Nussbaum Laura Nussbaum
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Resilience is a complex concept that can be defined as an ability to succesfuly adapt in front of a major stress or stressful life events [1]. Luthar and Zelazo ( 2003) advice us that is best to avoid using “resilience” as a personality trait, but as a process [2]. This quality is a dynamic process for adapting in stressful conditions. Resilience is not static, it is not a trait and it can be not be measured directly [3].

It has been discussed that the genetic polymorphisms associated with vulnerability to adverse environments may also be associated with greater responsivity to positive environments through therapeutic interventions [4].

Among the factors that influences the heterogeneity of resilience is genetic influences on environment susceptibility ( a form of geneenvironment interaction GxE) [5].

Risk factors that increase chances of mental disorder or maladaptive sisorder include: poverty, loss of a family member, maltreatment, attachment disorders other traumatic events. Also, there are nonpsycological factors such as prenatal and perinatal injuries, infectious agents, or other biological pahtogents that compromise healthy development [6].

There were studied six different predictors of child psychopathology: severe marital discord, low socioeconomic status, large family size, parental criminality, maternal mental illness and out of home placement. The presence of two risk factors, quadrupled negative effects on adjustment. This demonstrates that the association between cumulative risk and adjustment has direct implications for how resilient individuals are [5].

With the help of literature we have examined the relation between risk factors, resilience and the risk to develop a psychotic episode.

The psychosis prodrome offers a unique opportunity for identifying mechanism of psychosis onset and testing early intervention strategies. Prodrome in clinical medicine refers to the early symptoms and signs of illness preceding the charactetistic manifestations [6].

In children and adolescents with high risk for developing psychosis, there is a decline in: social and school functioning, changes in thinking, emotions
and perceptions, subclinical psychotic symptoms (short, limited, intermittent), social withdrawal, loss of interest and initiative [7].

CRITERIA FOR PRODROMAL SYNDROMES ACCORDING TO SIPS (STRUCTURED INTERVIEW FOR PRODROMAL SYNDROMES)[8]
1. The attenuated positive symptoms syndrome
1.1 The rate of moderate severity (3), moderately severe (4) or severe but not psychotic (5) at any of the 5 positive SIPS symptoms.
1.2 Symptoms appear above the severity level at a moderate frequency for at least once a week in the last month.
1.3 Symptoms must have started within the last year, or at present must meet at least one point more than 12 months before.
2. Genetic risk and deterioration syndrome
2.1 1st degree relative with psychosis or the patient to meet DSM criteria for schizotypal personality disorder.
2.2 30% decrease in GAF score compared to last year and present in the last month.
3. Short intermittent psychotic syndrome
3.1 Score of 6 on the psychosis intensity scale for any of the 5 positive symptoms in SIPS
3.2 Symptoms are present at least a few minutes a day with a frequency of at least once a month
3.3 The symptom must have reached psychotic intensity during the last 3 months.
3.4 Symptoms are not seriously disorganized or dangerous
3.5 Symptoms do not last more than one hour per day with an average frequency of 4 days per week over the course of a month.

Regarding the psychiatric and neurological premorbidities we mention: Anxiety disorders, Depression, Obsessive-compulsive disorder, ADHD, suicide attempt, Behavioral disorders, Eating disorders, Enuresis and ecoprezis, Eating disorders, Attachment disorders, Emotional disorders, Emotional disorders, of psychoactive substances, Epilepsy, Soft neurological disorders [9].

We reserve an important role for risk factors and protective factors to develop a first psychotic episode.

The risk factors for developing psychosis can be divided into environmental, family and individual risk factors.

Individual risk factors are: genetic predisposition, perinatal and postnatal injuries, developmental delay, cognitive deficit, disorganized attachment, difficult temperament, traumatic events, stress, lack of social and school skills, low self-esteem, physical and mental health problems, lack of recognition and management of emotions, poor self-regulation of behaviors, emotional, physical, sexual abuse, neglect.

Family risk factors can be: placement outside the family, abandonment, emigration, parents too young or unwanted child, parents with low self-esteem or maltreatment, parents with a somatic or mental disorder, parental crime, spousal violence, large families, loss to a family member through divorce or death, consumption of psychoactive substances or alcohol, parental difficulties associated with the school, lack of structured educational routine and inadequate penalties, financial and organizational problems, absence of professional activity or socioprofessional problems, hyper-protection of the child.

Environmental factors: biochemical, infectious agents, frequent change of environment, media, precarious socio-economic status, housing or school in disadvantaged neighborhoods, lack of an adequate educational model, inappropriate use of the internet, inadequate education models that consider normal neglect, maltreatment, neglect, lack of support network, surroundings with behavioral disorders and substance use, disharmonious relationships with colleagues and the school environment, including bullying [10].

These risk factors can alter the structure of the brain and may associate cognitive abnormalities associated with psychiatric disorders, so psychotic disorders are the final stage of abnormal neurodevelopmental disorders, which begin many years before the onset of the disease. This demonstrates the importance of identifying children and adolescents with an increased risk of developing psychosis and the fact that this can prevent the onset of the disorder through early therapeutic interventions.

At the opposite end, we divide the protective factors into: Individual, Family related, Environmental. These protective factors are of particular importance
in reducing the impact of risk factors, and one of these important protective factors in patients with a positive family history or with different risk factors for psychiatric disorders is resilience.

Individual protective factors are: good problem solving ability, good ability to self-control and anticipate events, adequate adaptation strategies, high self-esteem, absence of addictions, pregnancy and birth with physiological evolution, neuroplasticity, physical health, average intelligence or above, good temperament traits, secure attachment, social skills.

Family related protective factors: good parentchild and brother-brother relationship, with affection, understanding and trust, pleasant family atmosphere, traditional family, present and an effective extended family, lack of somatic family affections, care, proper education, expectations the potential of the child, the emotional and practical support of the child, good socio-economic and intellectual level of the family, religious beliefs, spiritual values, good management of the “crises”, the ability to request and seek help.

Environmental protective factors: present social support network that responds to the needs of the child (neighbors, teachers, friends), adequate social norms, surroundings with positive influences, good living environment and school environment, extracurricular activities, cultural, social, religious values
transmitted, good positive relationships with other adults outside the family, good models of development and consequently, attending a community, a school.

Resilient children and adolescents, during and after the “stressful” event, have good and lasting functioning despite vulnerabilities and a high degree of risk, do not show a decrease in their level of functioning and do not convert under the effect of stress. They restructure their cognitions, beliefs and behavior in order to adapt to the traumatic event and to withstand future trauma [10].

STANDARDIZED INSTRUMENTS
As standardized resilience measurement tools we can use: CD-RISC-Connor-Davidson Resilience Scale; CBCL for parents; Axis V of DSM-IV.

CD-RISC-CONNOR-DAVIDSON RESILIENCE SCALE is made up of 25 items, measures the ability to cope with stress and adversity, each item is evaluated on a 5-point scale (0-4), higher scores reflecting greater resistance. This scale identifies 5 factors behind resilience: personal competence, tolerance to negative effects as well as reinforcement to stressful effects, secure interpersonal relationships, increased performance and positive interpersonal relationships during childhood and adolescence [11].

PSYCHOSOCIAL INTERVENTIONS

Psychosocial interventions have the role of lowering risk factors and increasing resilience and prevention and intervention programs focused on resilience, aim: to develop competences with improving communication skills, to solve problems, to reduce the risk of substance abuse, to increase self esteem, stress management, assertiveness skills.

Psychosocial interventions are directly responsible for increasing the quality of life and act by decreasing the level of stress the person is subjected to, by increasing their ability to cope with different social situations and events with potential stress, providing the sick person with effective social support. They need to focus on the patient, family and common characteristics that are part of the process of understanding and increasing resilience.

There are recommended: Cognitive-behavioral therapy, Group therapy, Family therapy, Psychotherapy Art therapy, Zootherapy, Therapy through games, Strengths based therapy [12,13].


ASSISTED RESILIENCE

Assisted resilience may be primary (disorder prevention), secondary (early identification of the first manifestations, avoidance of symptom onset), or tertiary (preventing aggravation or recurrence of the disorder, reducing the duration and consequences of the disorder). This method of intervention identifies the resources existing in the community and uses them, is inspired by the “Strengths Based Intervention” and focuses on building resilience by pursuing the
development of strengths and abilities to prevent problems from occurring. It promotes health and well-being, focuses on positive emotions, thoughts and behaviors and thus increases the quality of life, enhances the support network, uses the strengths of children, teachers and the community in which they live and it develops personal skills [14].

OBJECTIVES OF THE INTERVENTIONS
Cultivating resilience (adapting to change and stressful events through healthy and adaptive methods) and promoting moral competence, developing cognitive skills, eliminating desirable behaviors and addictions, developing social and school skills, learning problem solving strategies, improving selfesteem, improving self-esteem promoting spirituality, culture and religion, developing self-determination and self-efficacy, learning to recognize one’s own and others’ emotions, expressing and controlling them, diminishing anxiety, impulsivity and aggression, improving interpersonal relationships and developing assertiveness, developing a future plan [15].

CONCLUSIONS
In conclusion, some children and adolescents naturally manage to be resilient, while others become vulnerable, needing the help of mental health professionals to restore the balance between “risk factors” and “protective factors” and gain resilience.

Resilience can be increased by the factors that influence it. It is important to know the risk and protective factors that help us in the interventions in the “ultra hight-risk” group. Thus we can prevent the emergence of psychoses in children and adolescents at high risk for mental disorders.

BIBLIOGRAPHY

1. Tyrone Donnon, Understanding relationship between resilience and bullying in adolescence, 2009
2. Luthar, Zelazo, Research on resilience: An integrative review, 2003
3. Julia Kim-Cohen, Resilience and developmental Psychopathology, Child and Adolescent Psychiatric Clinics of North America 16(2):271-83, May 2007
4. Anita Th apar, Daniel S. Pine, James F. Leckman et al. , Rutter’s Child and Adolescent Psychiatry, 6th Edition, 2015
5. Fisher HL, Cohen-Woods S, Hosang GM, et al. Stressful life events and the serotonin transporter gene (5-HTT) in recurrent clinical depression. J Aff ect Disord. 2012;136(12):189–193. doi:10.1016/j.jad.2011.09.016
6. Laura Nussbaum, Liliana Nussbaum , Managementul psihozelor la copil și adolescent, Editura Artpress, 2012
7. Woodberry, Kristen A et al. “Progress and Future Directions in Research on the Psychosis Prodrome: A Review for Clinicians.” Harvard review of psychiatry24.2 (2016): 87–103.
8. Addington J, Cadenhead KS, Cannon TD, et al. North American Prodrome Longitudinal Study: A Collaborative Multi
site Approach to Prodromal Schizophrenia Research. Schizophrenia Bulletin. 2007
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