Pediatric schizophrenia

Pediatric schizophrenia (also known as childhood schizophrenia, childhood-onset schizophrenia, and early-onset schizophrenia)^[1] is a type of mental disorder that is characterized by degeneration of thinking, motor, and emotional processes in children and adolescents under the age of 18. The disease presents symptoms such as auditory and visual hallucinations, strange thoughts or feelings, and abnormal behavior, profoundly impacting the child’s ability to function and sustain normal interpersonal relationships. Schizophrenia is especially rare in children under the ages of 7–8 years old.^[2] About 50% of young children diagnosed with schizophrenia experience severe neuropsychiatric symptoms.^[3] Diagnostic criteria are similar to that of adult schizophrenia. Diagnosis is based on behavior observed by caretakers and, in some cases depending on age, self reports.

Schizophrenia has no definite cause; however, certain risk factors such as family history seem to correlate. There is no known cure, but childhood schizophrenia is controllable with the help of behavioral therapies and medications.

History

Schizophrenia is a disorder of the brain that is expressed in abnormal mental functions and disturbed behavior. Schizophrenia disorders are rare, especially in children. Only about 4% of total cases of schizophrenia occur in children fifteen and under, and only 0.1–1% occur in children under the age of ten.^[4] People have been and still are reluctant to diagnose schizophrenia early on, primarily due to the stigma attached to it.^[2]

Until the late nineteenth century, children were often diagnosed as suffering from psychosis like schizophrenia, but instead were said to suffer from "pubescent" or "developmental" insanity. Through the 1950s, childhood psychosis began to become more and more common, and psychiatrists began to take a deeper look into the issue.^[4]

By the 1960s, "childhood schizophrenia" became known as a "heterogeneous mixture" of different diseases, such as autism, symbiotic psychosis, and dementia infantilis. Childhood schizophrenia was not directly added to the DSM until 1980, when it was added to the DSM-III, which set forth diagnostic criteria similar to that of adult schizophrenia.^[4]

Signs and symptoms

The signs and symptoms of childhood schizophrenia are nearly the same as adult-onset schizophrenia. Some of the earliest signs that a young child may develop schizophrenia are lags in language and motor development. Some children engage in activities such as flapping the arms or rocking, and may appear anxious, confused, or disruptive on a regular basis. Children may experience symptoms such as hallucinations, but these are often difficult to differentiate from just normal imagination or child play. It is often difficult for children to describe their hallucinations or delusions, making early-onset schizophrenia especially difficult to diagnose in the earliest stages. The cognitive abilities of children with schizophrenia may also often be lacking, with 20% of patients showing borderline or full mental retardation.^[5]

Very early-onset schizophrenia refers to onset before the age of thirteen. The prodromal phase, which precedes psychotic symptoms, is characterized by deterioration in school performance, social withdrawal, disorganized or unusual behavior, a decreased ability to perform daily activities, a deterioration in self-care skills, bizarre hygiene and eating behaviors, changes in affect, a lack of impulse control, hostility and aggression, and lethargy.^[5]

As with adult schizophrenia, symptoms of early-onset schizophrenia can be classified as "positive" or "negative" symptoms. "Positive symptoms" are symptoms present in the child, but absent in healthy children; negative symptoms are those absent in the child, but present in healthy children.

Positive symptoms

The positive symptoms of early-onset schizophrenia are:

• Hallucinations
• Delusions
• Disorganized speech
• Disorganized or catatonic behavior

Most research has concluded that auditory hallucinations are the most common positive symptom in children. A child’s auditory hallucinations may include voices that are conversing with each other or voices that are speaking directly to the children themselves. Many children with auditory hallucinations believe that if they do not listen to the voices, the voices will harm them or someone else. Tactile and visual hallucinations seem relatively rare. Delusions are reported in more than half of children with schizophrenia, but they are usually less complex than those of adults.^[6]

Some children with schizophrenia also report feeling as if an outside force is controlling them or manipulating them in some way.

Negative symptoms

The negative symptoms of early-onset schizophrenia are:

• Flattened affect
• Anergia (lack of energy)
• Alogia (complete lack of speech)
• Avolition (lack of motivation)
• Social withdrawal
• Apathy (general or complete lack of all forms of emotion)

Diagnosis

Diagnosis is based on reports by parents or caretakers, teachers, school officials, and others close to the child. For an accurate diagnosis, the symptoms must be present and persistent for at least six months.^[7] The diagnosis of schizophrenia was often given to children who by today’s standards would be diagnosed as having of autism or pervasive developmental disorder. This may be because the onset of schizophrenia is gradual, with symptoms relating developmental difficulties or abnormalities appearing before psychotic symptoms. In the early approaches to diagnosing schizophrenia, categories were set to help distinguish a difference between childhood and adult schizophrenia. Current studies, however, show that the same criteria can be used to diagnose both children and adults. Diagnosis of children remains more challenging.^[8]

Boys are twice as likely to be diagnosed with childhood schizophrenia.^[9] Disease onset, however, is at the same age in both boys and girls.^[9]

Criteria

In the United States, the DSM-IV TR sets forth the standards for schizophrenia, with slight modifications for the early-onset type:^[10]

• At least two active-phase symptoms, lasting for at least one month:
  • Delusions
  • Hallucinations
  • Disorganized speech (for example, incoherence or frequent derailment)
  • "Grossly disorganized" or catatonic behavior
  • Negative symptoms
• If the delusions are bizarre or if hallucinations consist of running commentary about the person or two or more conversing voices, the following criteria may be ignored
• Failure to achieve expected level of interpersonal, academic, or occupational achievement
• Continuous signs of the disturbance persist for at least 6 months
  • At least one month of active-phase symptoms (or less if treated)
  • Periods of prodromal or residual symptoms, which may present only negative symptoms or attenuated forms of positive symptoms
• Both schizoaffective disorder and psychotic mood disorders have been ruled out
• The disturbance is not due to another medical condition or a substance (such as a drug of abuse or medication)
• "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)"

Diagnostic examinations

A professional who believes a child has schizophrenia usually conducts a series of tests to rule out other causes of behavior, and pinpoint a diagnosis. Three different types of exams are performed: physical, laboratory, and psychological.

Physical

Physical exams usually cover the basic assessments, including but not limited to; height, weight, blood pressure, and checking all vital signs to make sure the child is healthy.^[11]

Laboratory

Laboratory tests include electroencephalogram EEG screening and brain imaging scans. Blood tests are used to rule out alcohol or drug effects, and thyroid hormone levels are tested to rule out hyper- or hypothyroidism.^[11]

Psychological

A psychologist or psychiatrist talks to a child about their thoughts, feelings, and behavior patterns. They also inquire about the severity of the symptoms, and the effects they have on the child's daily life. They may also discuss thoughts of suicide or self-harm in these one-on-one sessions. School records may be requested and questionnaires are used to assess anxiety and mood. All are evaluated on an age-appropriate level.^[11]

Etiology

The causes of schizophrenia are largely unknown. Certain signs present in very young toddlers and children may predict schizophrenia later in life. "Premorbid developmental impairments including language, motor and social deficits, are more frequent and more pronounced in earlier- than in later-onset forms of schizophrenia. This pandysmaturation is reported from the first months of life in more than half of the children who develop childhood-onset schizophrenia, and it suggests a more severe and early disruption of brain development compared with the adolescent- and adult-onset disorder".^[5] Generally, the earlier the onset of the symptoms, the more severe and pervasive the disorder. Premorbid abnormalities and developmental delays are the earliest signs of a child developing schizophrenia. Research has tied schizophrenia to neurological damage. The molecular functioning of individuals with schizophrenia is extremely different from those of normal functioning. Studies have shown that children with this disorder may have progressive ventricular hypertrophy as well as differences in glucose metabolism. Children and adults with schizophrenia also show differences in autonomic nervous system arousal as well as problems with tracking moving objects. There is some evidence that shows that schizophrenia has a strong genetic component or may be the result of a neurovirus occurring in the second trimester of pregnancy. Another theory on the cause of schizophrenia is that children develop pathological symptoms as the result of anxiety, hypersensitivity, and social detachment. "The child who becomes schizophrenic has been sensitized to the negative characteristics of a parent and incorporates these feelings into his or her own distorted self-image".^[3] A different psychosocial theory says that a person succumbs to schizophrenia when under stress. "The stressors include the neurological dysfunction of schizophrenia and the resulting increase in dopamine activity in the mesolimbic dopamine system, and the psychobiological, environmental, and interpersonal stressors".^[3] Yet another theory about the causes of schizophrenia says that communication within the family makes children victims of conflicting messages, which leads to schizophrenic symptoms. This family communication theory has been largely disregarded due to new insight and research on the causes of the disorder.

Treatment

Childhood schizophrenia is a chronic disorder and children with schizophrenia require long-term treatment. Since researchers have yet to detect an exact cause for schizophrenia, medication is aimed to treat and maintain the symptoms associated with the disorder.^[12]

Medications

Most medications used for childhood schizophrenia are the same as the ones used for adult schizophrenia, with antipsychotics being the most prevalent.^[13] However, many antipsychotics have not been approved for use in children.^[12][14] The National Institute of Mental Health also warns that since the medications are FDA-approved for adult use, doctors are able to administer the medication on an "off-label use" basis.

Antipsychotics have serious side effects and require careful monitoring and management.^[13] Long-term antipsychotic treatment can cause a shrinkage of the brain.^[15]

Psychotherapy

Psychotherapy consists of techniques for treating mental health and some psychotic disorders. It helps patients understand what helps them feel positive or anxious, as well as accepting their strengths and weaknesses. On an individual basis, the patient learns about their disorder and learns to cope with persistent symptoms. Patients who receive the psychotherapy on a regular basis are "more likely to keep taking their medication, and they are less likely to relapse or be hospitalized."^[12] Long term studies of schizophrenia patients show that they do not need to use antipsychotics.^{[16][17][18][19]} Psychotherapy also helps the patient surmount the negative connotation associated with schizophrenia.

Prognosis

The primary area that children with schizophrenia must adapt to is their social surroundings. It has been found, however, that early-onset schizophrenia carried a more severe prognosis than later-onset schizophrenia. Regardless of treatment, children diagnosed with schizophrenia at an early age suffer diminished social skills, such as educational and vocational abilities.^[20] A study also found social disability in the group with onset before age twelve is significantly greater than those 13-18 at age of onset.^[21] Psychotherapy helps those with schizophrenia understand the disorder and learn to thrive socially with it ^[22] The stages of development as defined by Erik Erikson would increase the need for psychotherapy as well as family therapy.^[22] The parents here can increase their bond with the child and possibly increase the chance of recovery. Children with schizophrenia may never be rid of their symptoms completely, but treatments are in place to assist with coping.

The following statistics were gathered from E. Torrey in "Surviving Schizophrenia":

After 10 years, of the people diagnosed with schizophrenia: 25% Completely Recover; 25% Much Improved, relatively independent; 25% Improved, but require extensive support networks; 15% Hospitalization, unimproved; 10% Dead (Mostly Suicide)

After 30 years, of the people diagnosed with schizophrenia: 25% Completely Recover; 35% Much Improved, relatively independent; 15% Improved but require extensive support network; 10% Hospitalized, unimproved; 15% Dead (Mostly Suicide).^[23]

Prevention

Research efforts are focusing on prevention in identifying early signs from relatives with associated disorders similar with schizophrenia and those with prenatal and birth complications. Prevention has been an ongoing challenge because early signs of the disorder are similar to those of other disorders. Also, some of the schizophrenic related symptoms are often found in children without schizophrenia or any other diagnosable disorder.^[2] Some symptoms that may be looked at are early language delays, early motor development delays and school problems.^[24]

References