Childhood onset schizophrenia
CHILDHOOD ONSET SCHIZOPHRENIA
CHILDHOOD ONSET SCHIZOPHRENIA DEFINITION
Childhood schizophrenia is a severe brain disorder in which children interpret reality abnormally. Schizophrenia involves a range of problems with thinking (cognitive), behavior or emotions. Schizophrenia may result in some combination of hallucinations, delusions, and disordered thinking and behavior. Signs and symptoms may vary, but they reflect an impaired ability to function.
Childhood schizophrenia is essentially the same as schizophrenia in adults, but it occurs early in life and has a profound impact on a child’s behavior and development. With childhood schizophrenia, the early age of onset presents special challenges for diagnosis, treatment, educational needs, and emotional and social development.
Schizophrenia requires lifelong treatment. Identifying and starting treatment for childhood schizophrenia as early as possible may significantly improve your child’s long-term outcome.
CHILDHOOD ONSET SCHIZOPHRENIA CAUSES
Although it’s unclear whether schizophrenia has a single or multiple underlying causes, evidence suggests that it is a neurodevelopmental disease likely involving a genetic predisposition, a prenatal insult to the developing brain and stressful life events. The role of genetics has long been established; the risk of schizophrenia rises from 1 percent with no family history of the illness, to 10 percent if a first degree relative has it, to 50 percent if an identical twin has it. Prenatal insults may include viral infections, such as maternal influenza in the second trimester, starvation, lack of oxygen at birth, and untreated blood type incompatibility. Studies find that children share with adults many of the same abnormal brain structural, physiological and neuropsychological features associated with schizophrenia. The children seem to have more severe cases than adults, with more pronounced neurological abnormalities. This makes childhood onset schizophrenia potentially one of the clearest windows available for research into a still obscure illness process.
For example, unlike most adult-onset patients, children who become psychotic prior to puberty show conspicuous evidence of progressively abnormal brain development. In the first longitudinal brain imaging study of adolescents, magnetic resonance imaging (MRI) scans revealed fluid filled cavities in the middle of the brain enlarging abnormally between ages 14 and 18 in teens with early onset schizophrenia, suggesting a shrinkage in brain tissue volume. These children lost four times as much gray matter, neurons and their branch-like extensions, in their frontal lobes as normally occurs in teens. This gray matter loss engulfs the brain in a progressive wave from back to front over 5 years, beginning in rear structures involved in attention and perception, eventually spreading to frontal areas responsible for organizing, planning, and other “executive” functions impaired in schizophrenia. Since losses in the rear areas are influenced mostly by environmental factors, the researchers suggest that some non
genetic trigger contributes to the onset and initial progression of the illness. The final loss pattern is consistent with that seen in adult schizophrenia. Adult-onset patients’ brains may have undergone similar changes when they were teens that went unnoticed because symptoms had not yet emerged, suggest the researchers.
In addition to studies of brain structural abnormalities, researchers are also examining a group of measures associated with genetic risk for schizophrenia. Early onset cases of illness have recently proven crucial in the discovery of genes linked to other genetically complex disorders like breast cancer, Alzheimer’s and Crohn’s diseases. Hence, children with schizophrenia and their families may play an important role in deciphering schizophrenia’s molecular roots. Evidence suggests that the rate of genetically-linked abnormalities is twice as high in children as in adults with the illness. Similarly, schizophrenia spectrum disorders, thought to be genetically-related to schizophrenia, are about twice as prevalent among first-degree relatives of childhood onset patients. In one recent study, a third of the families of individuals with childhood onset schizophrenia had at least one first-degree relative with a diagnosis of schizophrenia, or schizotypal or paranoid personality disorder. This profile of psychiatric illness is remarkably similar to that seen in parents of adult onset patients, adding to the likelihood that both forms share common genetic roots. Other anomalies associated with adult schizophrenia, such as abnormal eye movements, are also more common in families of children with the illness.
CHILDHOOD ONSET SCHIZOPHRENIA PATHOPHYSIOLOGY
Early onset schizophrenia (with onset before adulthood) represents a rarer and possibly more severe form of the disorder which has received particular attention in the last two decades. Current evidence strongly suggest continuity with adult onset schizophrenia, with phenomenological, cognitive, genetic and neuroimaging data pointing towards similar neurobiological correlates and clinical deficits but worse long term outcome. Future research in early onset cases is likely to increase further our insight into the neurodevelopmental origins of schizophrenia and the complex gene-environment interactions affecting its emergence.
CHILDHOOD ONSET SCHIZOPHRENIA SYMPTOMS
The video below, produced by the Child Mind Institute, a nonprofit organization, shows a leading expert on childhood schizophrenia talking about how the symptoms appear and the distressing effects they can produce.
It is frightening for the child, Prof. Caplan explains, because hallucinations or delusions are threatening and also because children understand from the age of about five years that it is not normal to hear, for example, external voices or smells that are not there, and that are not experienced by other people.
CHILDHOOD ONSET SCHIZOPHRENIA DIAGNOSIS
While schizophrenia sometimes begins as an acute psychotic episode in young adults, it emerges gradually in children, often preceded by developmental disturbances, such as lags in motor and speech/language development. Such problems tend to be associated with more pronounced brain abnormalities. The diagnostic criteria are the same as for adults, except that symptoms appear prior to age 12, instead of in the late teens or early 20s. Children with schizophrenia often see or hear things that don’t really exist, and harbor paranoid and bizarre beliefs. For example, they may think people are plotting against them or can read their minds. Other symptoms of the disorder include problems paying attention, impaired memory and reasoning, speech impairments, inappropriate, or flattened, expression of emotion, poor social skills, and depressed mood. Such children may laugh at a sad event, make poor eye contact, and show little body language or facial expression.
Misdiagnosis of schizophrenia in children is all too common. It is distinguished from autism by the persistence of hallucinations and delusions for at least 6 months, and a later age of onset—7 years or older. Autism is usually diagnosed by age 3.7 Schizophrenia is also distinguished from a type of brief psychosis sometimes seen in affective, personality and dissociative disorders in children. Adolescents with bipolar disorder sometimes have acute onset of manic episodes that may be mistaken for schizophrenia. Children who have been victims of abuse may sometimes claim to hear voices of—or see visions of—the abuser. Symptoms characteristically pervade the child’s life, and are not limited to just certain situations, such as at school. If children show any interest in friendships, even if they fail at maintaining them, it’s unlikely that they have schizophrenia.
CHILDHOOD ONSET SCHIZOPHRENIA TREATMENT
Schizophrenia in children requires lifelong treatment, even during periods when symptoms seem to go away. Treatment is a particular challenge for children with schizophrenia.
Childhood schizophrenia treatment is usually guided by a child psychiatrist. The team may include, for example, your:
- Pediatrician or family doctor
- Psychiatrist, psychologist or other therapist
- Psychiatric nurse
- Social worker
- Family members
Main Treatment Options
The main treatments for childhood schizophrenia are:
- Individual and family therapy
- Social and academic skills training
Medications For Childhood Schizophrenia
Antipsychotic medications are at the heart of treatment for schizophrenia in children. Most of the medications used in children are the same as those used for adults with schizophrenia. Antipsychotic medications are often effective at managing symptoms such as delusions, hallucinations, loss of motivation and lack of emotion.
It can take several weeks after starting a medication to notice an improvement in symptoms. In general, the goal of treatment with antipsychotic medications is to effectively control signs and symptoms at the lowest possible dosage. Your child’s doctor may try combinations, different medications or different dosages over time. Other medications also may help, such as antidepressants or anti-anxiety medications.
Newer, second-generation medications (atypical antipsychotics) are usually tried first in children because they have fewer side effects compared with older antipsychotics. However, they can cause weight gain, high blood sugar and high cholesterol. Examples of antipsychotics approved by the Food and Drug Administration (FDA) to treat childhood schizophrenia in children age 13 and older include:
- Aripiprazole (Abilify)
- Olanzapine (Zyprexa)
- Quetiapine (Seroquel)
- Risperidone (Risperdal)
First-generation medications (typical antipsychotics), approved by the FDA to treat schizophrenia in children age 13 and older, are usually equally as effective as second-generation antipsychotics in controlling delusions and hallucinations. However, they may have frequent and potentially significant neurological side effects, including the possibility of developing a movement disorder (tardive dyskinesia) that may or may not be reversible.
Because of the increased risk of serious side effects with first-generation antipsychotics, they often aren’t recommended for use in children until other options have been tried without success. Examples of these medications include:
- Haloperidol (Haldol)
Medication Side Effects And Risks
All antipsychotic medications have side effects and possible health risks, some life-threatening. Side effects in children and teenagers may not be the same as those in adults, and sometimes they may be more serious. Children, especially very young children, may not have the capacity to understand or communicate about medication problems.
Talk to your child’s doctor about possible side effects and how to manage them. Be alert for problems in your child, and report side effects to the doctor as soon as possible. The doctor may be able to adjust the dosage or change medications and limit side effects.
Also, antipsychotic medications can have dangerous interactions with other substances. Tell your child’s doctor about all medications and over-the-counter products your child takes, including vitamins, minerals and herbal supplements.
In addition to medication, psychotherapy (talk therapy) is important. Psychotherapy may include:
- Individual therapy. Psychotherapy with a skilled mental health provider can help your child learn ways to cope with the stress and daily life challenges brought on by schizophrenia. Therapy can help reduce symptoms and help your child make friends and succeed at school. Learning about schizophrenia can help your child understand the condition, cope with symptoms and stick to a treatment plan. There are many types of psychotherapy, such as cognitive behavioral therapy.
- Family therapy. Your child and your family may benefit from therapy that provides support and education to families. Involved, caring family members who understand childhood schizophrenia can be extremely helpful to children living with this condition. Family therapy can also help you and your family improve communication, work out conflicts and cope with stress related to your child’s condition.
Social And Academic Skills Training
Training in social and academic skills is an important part of treatment for childhood schizophrenia. Children with schizophrenia often have troubled relationships and school problems. They may have difficulty carrying out normal daily tasks, such as bathing or dressing. Treatment plans that include building skills in these areas can help your child function at age-appropriate levels when possible.
During crisis periods or times of severe symptoms, hospitalization may be necessary. This can help ensure your child’s safety and make sure that he or she is getting proper nutrition, sleep and hygiene. Sometimes the hospital setting is the safest and best way to get symptoms under control quickly. Partial hospitalization and residential care may be options, but severe symptoms are usually stabilized in the hospital before moving to these levels of care.