Download CHILDHOOD SCHIZOPHRENIA

CHILDHOOD SCHIZOPHRENIA
(2 CE HOURS)
Learning objectives
!! To understand the history of childhood
schizophrenia and psychosis.
!! To understand the significant definitions
related to childhood schizophrenia and
psychosis including (but not limited to):
schizophrenia, delusions, hallucinations, and
thought disorders.
!! To understand the components of screening
and diagnosis for childhood schizophrenia
and psychosis.
!! To understand the diagnostic criteria for
childhood schizophrenia and psychosis.
!! To understand the differences in symptoms
between children/adolescents and adults.
!! To understand the prevention of childhood
schizophrenia and psychosis.
!! To understand the inherent difficulties
in treating childhood schizophrenia and
psychosis.
!! To understand the outcomes related to
childhood schizophrenia and psychosis.
!! To understand the current research into
childhood schizophrenia and psychosis.
Introduction
The existence of childhood psychoses has
been noted, discussed, and at times dismissed
for over one hundred years. In 1867 Henry
Maudsley, a British psychiatrist, wrote in his
textbook, Physiology and Pathology of Mind, a
work entitled “Insanity of Early Life.” Kanner
later noted that Maudsley was dismissed by his
contemporaries for acknowledging the existence
of “insanity” in childhood. Much of the early
literature regarding childhood psychosis reveals
conflicting points of view, definitions, and
classifications that kept changing over time.
Today, childhood schizophrenia and psychosis
are well established disorders (Tengan and Maia,
2004).Childhood schizophrenia is a severe and
most often persistent mental disorder that is
characterized by a loss of contact with reality,
changes in personality, and moderate to severe
difficulty with social functioning. Tolbert (1996)
provides an inventory of symptoms frequently
seen in children with psychosis:
■■ Auditory hallucinations.
■■ Confused thinking.
■■ Confusion of television with reality.
■■ Diminished interest.
■■ Disinheriting.
■■ Extreme moodiness.
■■ Ideas that others are ‘out to get them’.
■■ Inability to distinguish dreams from reality.
■■ Odd and/or eccentric behavior.
■■ Severe problems making and keeping
friends.
■■ Speech disturbances.
■■ Stereotypy.
■■ Visual hallucination.
■■ Vivid and bizarre thoughts and ideas.
Definitions
Schizophrenia is thought to be the most
common form of child, adolescent, and adult
psychosis. Symptoms often include delusions,
thought disorders, as well as auditory, visual, and
other types of hallucinations, and paranoia.
Delusions are unshakable beliefs that hold no
or little basis in reality. For example, people
with psychosis might strongly believe that
the government is plotting to harm them, that
they are being spied on through the radio or
television, that they have special “super” power;
or that evil forces are trying to kill them.
A thought disorder is when a person’s thinking
is confused. A person with a thought disorder
may be hard to understand. Their ideas will often
be disorganized, but it is more than just ordinary
confusion.
Hallucinations are when someone sees, hears,
smells, or feels something that does not really
exist. The most common form of hallucination
is auditory in nature. Persons with auditory
hallucinations often report hearing voices. In
some cases those voices will tell a person to do
a specific act. This type of auditory hallucination
is called a command auditory hallucination.
The person with schizophrenia who experiences
hallucinations will often believe that the
hallucinations are totally real. Patients with
hallucinations may act strangely. For example,
they may talk or laugh to themselves as if
conversing with somebody that the clinician
can’t see. When the client responds to the
hallucinations it is said they are responding to
internal stimuli.
Paranoid ideation differs from paranoid delusions
in that the ideas are held with less conviction
than with the patient who is delusional.
Extrapyramidal side effects (EPS) are the
various movement disorders such as tardive
dyskinesia suffered as a result of taking
dopamine antagonists, usually antipsychotic
(neuroleptic) drugs, which are often used to
control psychosis, especially schizophrenia.
The best known EPS is tardive dyskinesia
(involuntary, irregular muscle movements,
usually in the face). Other common EPS include:
■■ Akathisia (often observed as the inability
to remain seated due to motor restlessness
or due to a sensation of muscular quivering.
It is a side effect of many neuroleptic
medications).
■■ Dystonia (muscular spasms of neck).
■■ Oculogyric crisis, (muscular spasms of
tongue, or jaw; more frequent in children).
■■ Drug-induced parkinsonism – which
includes (muscle stiffness, shuffling gait,
drooling, tremor; less frequent in children
and adolescents, more frequently observed in
adults and the elderly).
A dopamine antagonist is a drug which blocks
dopamine receptors.
Positive symptoms are abnormal thoughts
and perceptions such as disordered thinking,
delusions, and hallucinations.
Negative symptoms are loss, or decrease, of
normal functions often evidenced by blunted
affect, impaired attention, avolition, and
anhedonia.
The second most common hallucination is visual
in nature. The person who experiences visual
hallucinations may see people who don’t exist
or, in some cases, may see relatives, long dead
and buried. Children with visual hallucinations
may report seeing mythological creatures such
as monsters and dragons. In rare cases, patients
with psychosis may experience olfactory or
tactile hallucinations, although these are seldom
observed in children.
Avolition is a psychological state characterized
by general lack of desire, motivation, and
persistence. Avolition is commonly seen in
patients with schizophrenia. Persons suffering
from avolition may not start or complete any
major tasks.
Psychosis is a thought disorder where the
person is unable to distinguish reality from
fantasy because of impaired reality testing. The
boundary between non-psychotic and psychotic
ideation and perception is not clearly delineated
in the literature.
Blocking is the disruption of thought evidenced
by an interruption or momentary disruption of
speech. The individual appears to be trying to
remember what he or she was thinking or saying.
Paranoia is often characterized by delusions
involving:
■■ Guardedness.
■■ Hyperalertness.
■■ Hypersensitivity.
■■ Jealousy.
■■ Persecution.
■■ Suspiciousness.
Paranoid ideation evidences itself as patients
being convinced that other people are:
■■ Thinking “bad thoughts” about them.
■■ That they are being followed.
■■ That they are the object of any number of
dark conspiracies.
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Anhedonia is the inability to experience
pleasure from normally pleasurable life events
such as eating, exercise, playing and other forms
of social interaction.
Loosening of associations is a disorder of
thinking and speech in which ideas shift from
one subject to another with remote or no
apparent reasons.
Stereotypy is a behavioral condition
characterized by a lack of variation in patterns of
thought, motion and speech; by repetition of said
patterns; or both.
Screening and diagnosis
Screening
A complete screening and diagnostic workup for
childhood schizophrenia will include some or all
of the following:
■■ A complete history including:
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■■
■■
■■
■■
□□ Medical.
□□ Social.
□□ Family history.
Interviews with child, parents, guardians,
and other caregivers to assess possible
psychotic symptoms, changes in behavior
and the possibility of other psychiatric
problems.
Tests to assess cognitive skills and functional
abilities in daily life.
A review of school records and/or other input
from school personnel.
Various lab tests may be indicated:
□□ Toxicology screens may be needed if
substance abuse is suggested.
□□ Liver function studies, copper, and
ceruloplasmin are part of the workup for
Wilson disease.
□□ Obtain porphobilinogen for porphyria.
□□ HIV titers may be needed.
□□ Brain-imaging tests such as MRI or
CT scan can be used to rule out other
medical conditions.
Diagnostic Criteria
At present, the criteria used to diagnose
schizophrenia in adults can also be used to
diagnose schizophrenia in children:
■■ Characteristic symptoms: Two (or more) of
the following, each present for a significant
portion of time during a 1-month period (or
less if successfully treated):
□□ Delusions.
□□ Hallucinations.
□□ Disorganized speech (e.g., frequent
derailment or incoherence).
□□ Grossly disorganized or catatonic
behavior.
□□ Negative symptoms, i.e., affective
flattening, alogia, or avolition Note: Only
one criterion A symptom is required if
delusions are bizarre or hallucinations
consist of a voice keeping up a running
commentary on the person’s behavior
or thoughts, or two or more voices
conversing with each other.
■■ Social/occupational dysfunction: For
a significant portion of the time since
the onset of the disturbance, one or more
major areas of functioning such as work,
interpersonal relations, or self-care are
markedly below the level achieved prior to
the onset (or when the onset is in childhood
or adolescence, failure to achieve expected
level of interpersonal, academic, or
occupational achievement).
■■ Duration: Continuous signs of the
disturbance persist for at least 6 months.
This 6-month period must include at least 1
month of symptoms (or less if successfully
treated) that meet Criterion A (i.e., activephase symptoms) and may include periods
of prodromal or residual symptoms. During
these prodromal or residual periods, the
signs of the disturbance may be manifested
by only negative symptoms or two or more
symptoms listed in Criterion A present in an
attenuated form (e.g., odd beliefs, unusual
perceptual experiences).
■■ Schizoaffective and mood disorder
exclusion: Schizoaffective Disorder and
Mood Disorder With Psychotic Features
have been ruled out because either (1)
no Major Depressive, Manic, or Mixed
Episodes have occurred concurrently with
the active-phase symptoms; or (2) if mood
episodes have occurred during active-phase
symptoms, their total duration has been brief
relative to the duration of the active and
residual periods.
■■ Substance/general medical condition
exclusion: The disturbance is not due to the
direct physiological effects of a substance
(e.g., a drug of abuse, a medication) or a
general medical condition.
■■ Relationship to a pervasive developmental
disorder: If there is a history of
Autistic Disorder or another Pervasive
Developmental Disorder, the additional
diagnosis of Schizophrenia is made only if
prominent delusions or hallucinations are
also present for at least a month (or less if
successfully treated). (direct quotation from
Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition, Text Revision
(2000).
Issues related to assessment of children
Very young children, regardless of their mental
status, have unclear boundaries and are often
unable to verbally describe their experiences,
thoughts, and emotions. Clinicians may have to
use play therapy as an assessment technique to
ferret out symptoms related to this diagnosis. It
should be noted that young children are concrete
in thought and have limited social experiences
(Piaget, 1962). Young children often possess a
private language or use private speech or talk
to themselves aloud. According to Piaget, the
immature child does not differentiate between
words or symbols and what words represent.
Fantasy and imaginative play emerge by the
second year and continue for 3 to 4 years until
the child becomes more interested in peer games.
Animism (the attribution of life to objects that
are not alive) is common due in normal child
development. Even as the child gets older and
toward concrete operations (ages 5-7), the issue
of creativity may come into play. The clinician
assessing the child must keep in mind the normal
developmental processes when attempting to
diagnosis the presence of schizophrenia in a
young child.
It is important to note that non-psychotic
hallucinations may be present in children.
Wilking and Paoli (1966) describe 42 children
with non-psychotic hallucinations. They found
a pattern of developmental difficulties, social
and emotional deprivation, and parents whose
own pathologies promoted a breakdown in the
child’s sense of reality. Edelsohn et al (2003)
indicates that non-psychotic hallucinations are
not rare in presentation. In his study, auditory
hallucinations were most often associated with
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disruptive behavior disorders. Hearing a voice
suggesting suicide was most often associated
with depression. The clinician must strive
to understand the context and content of the
hallucinations when diagnosing a young child.
As stated above, in childhood, and most
especially during adolescence, the affective
symptoms of schizophrenia can sometimes
be mistaken for age appropriate moodiness or
oppositional behavior. It is worth noting that
in children and adolescents, hearing voices is
not always a sign of schizophrenia, but may be
due in part to anxiety, stress, depression, family
dynamics, or cultural issues.
Differences in symptoms between
children/adolescents and adults
All three major classificatory/diagnostic systems
(ICD-9, ICD-10 and DSM-IV-TR) have no
special criteria for children and recommend the
use of adult criteria in children (Reddy et al,
1993). This approach to diagnosis assumes that
there is a similarity between schizophrenia seen
in adults and that seen in children. There is a
general paucity of evidence in the clinical and
research data to support this assertion. Similar
clinical presentations of schizophrenia may
exist in both childhood and adulthood. Other
differences such as in the etiology, course and
prognosis may (and often) exist and should not
be overlooked (Beitchman, 1985).
The early age of onset and the complexities of
dealing with children presents multiple special
considerations in regard to:
■■ Assessment.
■■ Diagnosis.
■■ Educational needs.
■■ Emotional development.
■■ Family education.
■■ Family training.
■■ Need for basic living skills training.
■■ Need for vocational training.
■■ Psychiatric Treatment.
■■ Psychological Treatment.
■■ Social development.
Symptoms, beliefs, thoughts, and behaviors of
children and adolescents with schizophrenia
may not be the same as adults with this illness.
The following symptoms and behaviors can
(and often) occur in children or adolescents with
schizophrenia:
■■ Confusing television and dreams from
reality.
■■ Decline in personal hygiene.
■■ Difficulty relating to peers, and keeping
friends.
■■ Disorganized or confused thinking.
■■ Disorganized, odd, or eccentric behavior.
■■ Disorganized, odd, or eccentric speech.
■■ Excessive mobility with no purpose.
■■ Extreme moodiness.
■■ Holding untrue beliefs (delusions).
■■ Ideas that people are out to get them or
talking about them (paranoia).
■■ Inability to initiate plans.
■■ Inappropriate emotional expression.
■■ Minimal verbal communication.
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■■ Physical immobility.
■■ Seeing things and hearing voices which are
not real (hallucinations).
■■ Severe anxiety and fearfulness.
■■ Unusual or bizarre thoughts and ideas.
■■ Withdrawal and increased isolation.
It has been noted that the behavior of children
with schizophrenia may change slowly over
time, as opposed to some adults whose behavior
and thought processes may seemingly change
in a very short period of time (days or weeks).
For example, children who used to enjoy
relationships with siblings, family members,
and playmates may become increasingly shy or
withdrawn and seem to be in their own world.
Sometimes youngsters will begin to verbalize
strange fears and ideas. They may begin to cling
to parents or caregivers and say things that do
not make sense to others. Interestingly, these
early symptoms and problems may first be
noticed by the child’s school teachers.
Differential diagnosis
Some signs and symptoms of schizophrenia
may overlap with those of other mental health,
physical health, or developmental disorders.
These can include:
■■ Autism spectrum disorders (including
asperger’s).
■■ Bipolar disorder.
■■ Borderline personality disorder.
■■ Cognitive deficits.
■■ Delusional disorders.
■■ Medical disorders that affect the brain.
■■ Obsessive-compulsive disorder.
■■ Porphyria, acute.
■■ Post-traumatic stress disorder.
■■ Rett Syndrome (a childhood
neurodevelopmental disorder).
■■ Schizoaffective disorder, (a disorder with
symptoms of both schizophrenia along with
a mood disorder.
■■ Severe anxiety disorders.
■■ Severe major depression with psychotic
features.
■■ Substance abuse disorders (particularly
cocaine and methamphetamine which are
rare in children).
■■ Wilson Disease.
Psychotic disorders secondary to an underlying
physical illness are extremely rare in children
but need to be considered in the context of a
comprehensive evaluation. A formal physical
examination, including a comprehensive
neurological assessment, is essential, but often
overlooked by practitioners.
As stated above, the potential differential
diagnosis is extensive and can include many
general medical conditions in addition to primary
psychiatric disorders including:
■■ Cerebral tumor.
■■ Epilepsies.
■■ Neurodegenerative disorders.
Clark (2001), notes that Organic psychotic
disorder secondary to substance misuse is
frequently suspected in the adolescent age group,
and urine drug screens or hair analysis for illicit
drugs should be undertaken.
Recent studies report that children and
adolescents treated with oral, inhaled, and
intravenous corticosteroids may experience
adverse psychological side effects, including
psychotic symptoms. Apparently, these can occur
at any point during treatment.
Etiology
The cause of childhood onset schizophrenia, as
well as adult schizophrenia remains unknown.
The American Academy of Child and Adolescent
Psychiatry reports that current research suggests
a combination of factors that may be responsible
for the development of psychotic symptoms in
children:
■■ Brain changes.
■■ Biochemical factors.
■■ Genetic factors.
■■ Environmental factors.
Other researchers suggest that problems in early
brain development may be the cause of the
illness. Certain areas of the brain that are rich
in the neurotransmitter dopamine seem to be
affected most often in all types of schizophrenia.
In another study using MRI on early-onset
schizophrenic patients to determine regional
brain gray-matter abnormalities it was shown
that early-onset schizophrenic patients do have
brain differences compared with the controls.
It was observed that schizophrenic patients had
a significant decrease in regional gray matter
when compared with the controls in several areas
of the brain. Compared with control patients,
preliminary results showed the presence of
brain abnormalities in temporolimbic areas in
patients with early-onset schizophrenia. These
abnormalities are similar to those seen in adult
schizophrenia.
Several studies (psychological, pharmacologic,
and neuroimaging) of childhood-onset
schizophrenia have suggested dysfunction
in the prefrontal cortex and limbic systems
of the brain. The neurotransmitter dopamine
has been identified in the pathophysiology of
schizophrenia. Drugs that increase dopaminergic
activity are thought to induce psychosis. Other
neurotransmitters also may be involved in the
development of schizophrenia. Serotonin may
be one of those neurotransmitters. The newer
atypical antipsychotic drugs are known to have
significant effects on serotonin in the brain.
The role of genetics has long been established
as one of the causes of childhood schizophrenia.
The risk of schizophrenia rises from 1 percent
for a child in a family with no history of the
illness, to 10 percent if a first degree relative has
it, to 50 percent if an identical twin is diagnosed
with the disorder.
Incidence
Psychosis in children is fairly rare with a
diagnosis of schizophrenia in only approximately
1 in 10,000 to 40,000 minors, compared to
approximately 1 in 100 in adults. The disease
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is seldom observed before the age of five.
Pre-morbid functioning is often marked by
difficulties with attention, conduct, inhibition,
withdrawal and emotional sensitivity. Eighty
percent of children with the disorder exhibit
difficulties with auditory hallucinations.
Fifty percent have reported difficulties with
delusional beliefs. Research has also shown a
male predominance for childhood schizophrenia
with a reported male-to-female ratio averaging
1.5-2:1.
Mortality
It has been demonstrated that there is an
increased risk of death from suicide for persons
with schizophrenia. In several large studies of
childhood-onset schizophrenia, the mortality
rate from suicide was 5-11 percent. More than
one half of children with schizophrenia have
persistent severe impairment in social skills
and limitations in academic and occupational
achievement.
Onset
As stated previously, the diagnostic criterion for
childhood onset schizophrenia is the same as
for adults, except that symptoms appear prior
to age 13 (average age at onset of 9), instead of
in the late teens or early 20s for many adults.
As previously noted, schizophrenia in adult
populations often begins with an acute episode.
With children and adolescents it often emerges
more gradually, over a period of months or years.
Treatment
At present, schizophrenia (of any type) is
believed to be a life-long disease that can be
treated, controlled and curtailed, generally
through the use of medication. There is no
known cure for schizophrenia.
The organization, Living with Childhood-Onset
Schizophrenia reports that the regular support
systems available to children will often have
little or no experience dealing with any form
of childhood psychosis, and that few families
have the emotional, financial, and time resources
needed to deal with this devastating long-term
illness.
Untreated psychosis is most often associated
with longer and more difficult recovery and can
lead to significantly increased family distress,
substance abuse /dependence, other mental
health issues such as depression, and increased
risk of suicide.
Proper early diagnosis and treatment is thought
to reduce the need for repeated psychiatric
hospitalizations and may promote a more
complete recovery. Standard treatments for
childhood onset schizophrenia most often
consists of:
■■ Low-dose, anti-psychotic medications.
■■ Ongoing age-appropriate patient education.
■■ Family education.
■■ Social skills training.
■■ Basic living skills training.
■■ Psychotherapy for the child, parents, and
other caregivers.
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■■ Cognitive remediation (primarily for
improving memory and attention).
■■ Long-term support.
■■ Psychiatric hospitalizations (as needed).
■■ Residential care (for difficult or unresponsive
cases).
movements. These and other side effects from
“typical” antipsychotic medication often results
in poor adherence to medication regimens.
In some cases, these side effects of these
medications have led to nonreversible or lifethreatening conditions.
Newer (atypical) medications generally more
effectively treat psychotic symptoms without the
side effects more common with older (typical)
anti-psychotic medications. Children and
adolescents symptoms of psychosis are often
encouraged to maintain their daily routines as
much as possible. Some level of recovery is also
improved when the family itself is accepting,
non-confrontational, stable, and supportive.
There is ample evidence that stress can make the
symptoms of psychosis worse.
Second generation antipsychotic medications
(also known as atypical or novel) include:
■■ Aripiprazole (Abilify).
■■ Clozapine (Clozaril).
■■ Olanzapine (Zyprexa).
■■ Quetiapine (Seroquel).
■■ Risperidone (Risperdal).
■■ Ziprasidone (Geodon).
Medications
Second generation antipsychotic medications
tend to have fewer side effects. In adults there
is an observed lower incidence of tardive
dyskinesia (TD) with the newer drugs and it is
thought that the same may hold true for children
and adolescents. TD results in involuntary
movements of your mouth, lips, tongue and other
parts of the body. Other possible side effects
of the older medications include interactions
with other medications, risk of seizures, and
reductions of the white blood count.
Medications that assist children manage their
psychotic symptoms have improved significantly
in the past ten to fifteen years. Antipsychotic
medications are especially effective in reducing
or eliminating hallucinations and delusions.
The newer generation (atypical) antipsychotics,
such as olanzapine and clozapine, can also
help improve motivation and emotional
expressiveness in some patients while lowering
the likelihood of producing disorders of
movement, including tardive dyskinesia.
Conversely, even with these newer (atypical)
medications, side effects remain, including
excess weight gain that can increase risk of
other health problems such as diabetes and heart
disease.
Psychotherapy
First generation antipsychotic medications
include (but not limited to):
■■ Chlorpromazine (Thorazine).
■■ Fluphenazine (Prolixin).
■■ Haloperidol (Haldol).
■■ Loxapine (Loxapac).
■■ Thioridazine (Mellaril).
■■ Thiothixene (Navane).
■■ Trifluoperazine (Stelazine).
Tarrier (2005), reports that schizophrenia and
other psychotic disorders were once thought
to be untreatable by psychological treatments.
There is accumulating evidence that cognitive
behavior therapy (CBT) can result in significant
clinical benefit to these patients.
Difficulties with treatment
Child onset schizophrenia is frequently resistant
to medications, especially with first generation
(typical) antipsychotics. Of the more than 10
typical antipsychotics currently available for use
in the U.S. only a few (haloperidol, loxapine,
thioridazine, thiothixene) have any data
concerning efficacy on children.
The results of several studies indicate that a
large number of young patients (15-45 percent
depending on the medication prescribed)
show little or no improvement while taking
the medication. These studies also showed a
high percentage of serious side effects. This
leads some researchers to suggest that children
are at higher risk for developing these side
effects than adults are. Common side effects
of typical antipsychotics include sedation and
extrapyramidal side effect (EPS), which are
characterized by motor deficits including loss of
postural reflexes, bradykinesia (abnormally slow
movement), tremor, rigidity, and involuntary
In cases of childhood schizophrenia and
psychosis, psychotherapy for the client, the
client’s family, and other caregivers will often
focus on coping strategies, problem-solving
skills, awareness of psychotic symptoms, as well
as issues related to anti-psychotic medication
compliance. There is no evidence to suggest
that psychotherapy alone is a substitute for
medication.
Psychiatric hospitalization
A child with schizophrenia may require one or
several episodes of psychiatric hospitalization
to achieve sufficient stability to function at
home and in the community. Most often,
these hospitalizations occur as a reaction to
acute episodes of the illness where the child
has become unmanageable or dangerous at
home. The hospitalization ensures safety while
the client’s medication regimen is adjusted
to minimize symptoms of the disorder while
monitoring for side effects related to antipsychotic medications.
While hospitalized, the client will most often be
treated by a multi-disciplinary team consisting
of one or more psychiatrists, psychologists,
counselors, social workers, and psychiatric
nurses. While one of the goals of the team is to
return the child to the natural home environment,
this may not be possible in all cases. In some
instances the child must be referred to a mid
or long-term residential facility for further
treatment and stabilization.
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Outcomes
Outcome studies of childhood psychoses are
limited and have been criticized by some
researchers as somewhat selective in nature.
Nearly every study reveals that the majority of
cases have poor outcomes, which was worse
in the childhood-onset than in adolescentonset cases. Childhood-onset cases are often
fraught with recurrent acute episodes, repeated
psychiatric hospitalizations, and markedly
impaired social functioning. Some studies
indicate that premorbid characteristics such
as shyness, introversion, social withdrawal
and cognitive decline have been linked with
poor prognosis in early-onset schizophrenia
(Remschmidt, 2000).
Prevention
No known interventions have been proven to
prevent the development of childhood onset
schizophrenia / child psychosis at the time of this
paper. The National Institutes of Mental Health
(NIMH) is attempting to identify children and
adolescents at risk for developing schizophrenia
with the aim of investigating whether treatment
with the atypical antipsychotic olanzapine
could prevent, reduce, or slow the onset of this
disease. Because there are environmental factors
that clearly appear to influence the surfacing of
schizophrenia, lowering the risk for genetically
vulnerable individuals should theoretically be
possible.
Studies and future treatment
The Child Psychiatry Branch of the National
Institute of Mental Health is currently
conducting research on childhood schizophrenia.
NIMH is currently recruiting children to better
understand:
■■ Importance of treatment.
■■ Diagnosis.
■■ Genetic basis for this disorder.
NIMH is interested in studying children who
are responders as well as non-responders to
current treatment modalities. The children and
their families will be brought to the NIH Clinical
Center at the expense of NIMH for an intensive
diagnostic evaluation and, when appropriate,
trials of new treatments.
The Criteria for the study is as follows:
■■ Boys and girls 6-18 years old.
■■ Onset of psychotic symptoms before the 13th
birthday.
■■ IQ above 70 (pre-psychotic).
■■ Compliant family.
Benefits of participating in the study include:
■■ Evaluation by a team which has seen more
psychotic children than almost any other
research facility in the country.
■■ Recommendations by our psychiatrists,
social worker, nurses, teachers, occupational
and recreational therapists for future
treatment.
■■ All treatment is free; housing and
transportation are provided to those living at
a distance.
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■■ Opportunities for a drug-free washout
trial for children who participate in our
medication trial.
Conclusion
The existence of childhood schizophrenia and
psychosis has been discussed in professional
circles for over one hundred years. Childhood
schizophrenia is a severe, debilitating, and
most often persistent mental disorder that is
characterized by a loss of contact with reality,
changes in thinking, changes in personality,
and moderate to severe difficulty with social
functioning.
Childhood schizophrenia is fairly rare in
children. Psychosis in children is fairly rare
with a diagnosis of schizophrenia in only
approximately 1 in 10,000 to 40,000 minors,
compared to approximately 1 in 100 in adults.
The disease is seldom observed before the age
of five.
The symptoms and behavior of children and
adolescents with schizophrenia may differ
from that of adults with this illness. Some of
the symptoms and behaviors that can occur
in children or adolescents with schizophrenia
include auditory hallucinations, confused
thinking, ideas that others are ‘out to get them’,
inability to distinguish dreams from reality, odd
and/or eccentric behavior, visual hallucinations,
and vivid and bizarre thoughts and ideas.
The onset of schizophrenia in children tends
to be more gradual than for adults. Parents
and caregivers may not notice that the child’s
behavior has changed slowly over time. Children
who used to enjoy relationships with playmates
may become more shy or withdrawn and seem
to withdraw in to their own world. Many
children with this diagnosis may start to cling
to parents and other caregivers. Some may say
things which do not make sense or appear to be
responding to internal stimuli.
There are inherent difficulties in diagnosing
schizophrenia in a child. Very young children,
regardless of their mental status, have unclear
boundaries and are often unable to verbally
describe their experiences, thoughts, and
emotions. The clinician assessing the child
must keep in mind the normal developmental
processes when attempting to diagnosis the
presence of schizophrenia in a young child.
Children with schizophrenia require
comprehensive treatment. A combination of
medication, individual therapy, family therapy,
patient education, and other adjunctive therapies
is often needed. Psychiatric medication can
be helpful for many of the symptoms and
problems associated with schizophrenia. Due
to undesirable side effects these medications
require careful monitoring by the child’s
psychiatrist.
Schizophrenia is a life-long disease that can be
treated and controlled. At present there is no
cure for schizophrenia, but new medications
have been developed that can manage many
of the adverse symptoms of this disease.
Newer atypical antipsychotics, with fewer
extrapyramidal side effects and generally
increased efficacy have benefited many
individuals who had been unresponsive to
traditional typical antipsychotics.
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(Final examination questions on next page)
Page 5
CHILDHOOD SCHIZOPHRENIA
Final Examination
Choose the best answer for each question
and then proceed to www.elitecme.com to
complete your final examination.
1. The risk of schizophrenia rises from 1
percent for a child in a family with no
history of the illness to:
a. 10 percent if a first degree relative has
the disorder.
b. 20 percent if a first degree relative has
the disorder.
c. 30 percent if a first degree relative has
the disorder.
d. 40 percent if a first degree relative has
the disorder.
2. Which of the following statements
regarding Schizophrenia is true?
a. Schizophrenia is a short-term disease.
b. Schizophrenia can never be controlled.
c. Schizophrenia can be cured.
d. Schizophrenia is a life-long disease that
can be controlled.
3. Standard treatments for childhood onset
schizophrenia most often consists of?
a. Low-dose, anti-phychotic medications.
b. Ongoing age-appropriate patient
education.
c. Family education.
d. All of the above.
4. Childhood schizophrenia is seldom
observed before the age of?
a. Five.
b. Seven.
c. Nine.
d. Ten.
5. Childhood schizophrenia is fairly rare, with
a diagnosis of schizophrenia in minors of
approximately only?
a. 1 in 20,000.
b. 1 in 30,000.
c. 1 in 40,000.
d. 1 in 50,000.
PYTX02CS12
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