Pediatric schizophrenia

Pediatric schizophrenia (also known as childhood schizophrenia, childhood-onset schizophrenia, and early-onset schizophrenia) is a type of mental disorder that is characterized by degeneration of thinking, motor, and emotional processes, with onset before age 18 (early onset) or before age 13 (very early onset).^[1][2] 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. It typically presents after the age of seven.^[1] About 50% of young children diagnosed with schizophrenia experience severe neuropsychiatric symptoms.^[3] Diagnostic criteria are similar to those 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.

Signs and symptoms

Schizophrenia is a psychiatric disorder that is expressed in abnormal mental functions and disturbed behavior.

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 intellectual disability.^[4]

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.^[4]

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.^[5]

Diagnosis

The same criteria are used to diagnose children and adults, but diagnosis of children is more challenging. Diagnosis is based on reports by parents or caretakers, teachers, school officials, and others close to the child.

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 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.^[6] Laboratory tests include electroencephalogram EEG screening and brain imaging scans. Blood tests are used to rule out alcohol or drug effects,^[6] and thyroid hormone levels are tested to rule out hyper- or hypothyroidism. 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.^[6] Some symptoms that may be looked at are early language delays, early motor development delays and school problems.^[6]

Cause

There is no known single cause or causes of schizophrenia, however, it is a heritable disorder.

Genetic

There is "considerable overlap" in the genetics of childhood-onset and adult-onset schizophrenia, but in childhood-onset schizophrenia there is a higher number of "rare allelic variants".^[7] An important gene for adolescent-onset schizophrenia is the catechol-O-methyltransferase gene, a gene that regulates dopamine.^[8] Children with schizophrenia have an increase in genetic deletions or duplication mutations and some have a specific mutation called 22q11 deletion syndrome, which accounts for up to 2% of cases.^[9][10]

Neuroanatomical

Neuroimaging studies have found differences between medicated schizophrenic brains and neurotypical brains, though research does not know the cause of the difference.^[11] In childhood-onset schizophrenia, there appears to be a faster reduction of gray matter.^[11]

Epidemiology

Schizophrenia disorders in children are rare.^[1] Boys are twice as likely to be diagnosed with childhood schizophrenia.^[12] People have been and still are reluctant to diagnose schizophrenia early on, primarily due to the stigma attached to it.^[13]

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.^[13]

Treatment

Current methods in treating early-onset schizophrenia follow a similar approach to the treatment of adult schizophrenia. Although modes of treatment in this population is largely understudied, the use of antipsychotic medication is commonly the first line of treatment in addressing symptoms. Recent literature has failed to determine if typical or atypical antipsychotics are most effective in reducing symptoms and improving outcomes.^[14] When weighing treatment options, it is necessary to consider the averse effects of various medications used to treat schizophrenia and the potential implications of these effects on development.^[15] A 2013 systematic review compared the efficacy of atypical antipsychotics versus typical antipsychotics for adolescents:

Prognosis

An early or very-early diagnosis of schizophrenia leads to a worse prognosis than other psychotic disorders.^[2] 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.

The grey matter in the cerebral cortex of the brain shrinks over time in people with schizophrenia; the question of whether antipsychotic medication exacerbates or causes this has been controversial. A 2015 meta-analysis found that there is a positive correlation between the cumulative amount of first generation antipsychotics taken by people with schizophrenia and the amount of grey matter loss, and a negative correlation with the cumulative amount of second-generation antipsychotics taken.^[17][18]

History

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.^[19]

By the 1960s, "childhood schizophrenia" became known as a "heterogeneous mixture" of different disorders, such as autism, symbiotic psychosis, and dementia infantilis. Childhood schizophrenia was not directly added to the DSM until 1968, when it was added to the DSM-II,^[20] which set forth diagnostic criteria similar to that of adult schizophrenia.^[19] “Schizophrenia, childhood type” was a DSM-II diagnosis with diagnostic code 295.8*.^[20] It's equivalent to “schizophrenic reaction, childhood type” (000-x28) in DSM-I (1952).^[20]

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.

References

Further reading

• Tiffin PA, Welsh P (2013). "Practitioner review: schizophrenia spectrum disorders and the at-risk mental state for psychosis in children and adolescents--evidence-based management approaches". J Child Psychol Psychiatry. 54 (11): 1155–75. PMID 24102356. doi:10.1111/jcpp.12136.