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Childhood schizophrenia

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Pediatric schizophrenia (also known as childhood onset schizophrenia) [1] is a type of mental disorder that is characterized by degeneration of thinking, motor, and emotional processes in children and young adults under the age of 18. Patients are unable to distinguish between what is real and what is not; the disease is illustrated by symptoms such as auditory and visual hallucinations, strange thoughts/feelings, and abnormal behavior therefore 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 will experience severe neuropsychiatric symptoms. [3]. Diagnostic criteria are similar to that of adult schizophrenia, however there are differentiating characteristics between the two. Diagnosis is based on observed behavior by caretakers and in some cases depending on age, self reports. It is important to note that diagnosis can only be made by a psychiatrist and licensed psychologist. Schizophrenia has no definite cause, however, certain risk factors seem to correlate. Suggestions of causes combine multiple factors, not just one, that could contribute to the onset of the disease. Genetics play a large part in patients with schizophrenia, with higher rates found in children of schizophrenics. There is no known cure but childhood schizophrenia is controllable with the help of the proper fusion of behavioral therapies and medications.

History

Schizophrenic disorders are rare, especially in children. Only 4% of children fifteen and under are affected, and 0.1-1% is affected 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 [5]. Until the late nineteenth century, children were often not found to be suffering from psychosis like schizophrenia, but instead said to be suffering from “pubescent” or “developmental” insanity. Through the 1950’s, childhood psychosis began to become more and more common, and psychiatrists began to take a deeper look into the issue [6]. By the 1960’s, “childhood schizophrenia” became known as a “heterogeneous mixture” of different diseases, such as autism, symbiotic psychosis, dementia infantilis, etc. Childhood schizophrenia was not directly added to the DSM until 1980 in the DSM-III, which included similar diagnostic criteria as adult schizophrenia [7].


Signs and symptoms

Signs are physical states that others can see and observe while symptoms are something that a third party is unaware of but the patient describes. When children develop Schizophrenia very early in life, their signs seem to be a possible developmental phase and start off small and insignificant. As the disorder progresses, children will begin showing signs of psychosis and experiencing symptoms such as, but not limited to, delusions, hallucinations and disorganized thoughts. As the symptoms become more severe, a break from reality occurs and this is when medical attention is needed.[8]

Negative symptoms

The term “negative symptom” is used to describe a normal function that most people have which are not present in a schizophrenic patient. These symptoms include

  • Lack of motivation
  • Lack of emotion
  • Social withdrawal
  • Inability to take care of oneself
  • Poor school performance.[9]

Positive symptoms

As the counterpart to negative symptoms, positive symptoms are described as being present in a schizophrenic patient while not present in non-patients. These include:

  • Seeing or hearing things, especially voices, that do not exist (Hallucinations)
  • Having beliefs that are not based in reality (Delusions)
  • Having inappropriate emotions to certain situations
  • Being easily agitated
  • Illogical thinking and incoherent speech
  • Strange eating habits

Positive symptoms are usually easier to treat than negative symptoms and are easier to sustain a better quality of life.[8]

Diagnosis

Diagnosis is based on reports by parents/caretakers, teachers, school officials and others close to the child. If any abnormalities in behavior are present, psychiatrists or other professionals in the mental health fields do a further assessment. For an accurate diagnosis, the symptoms must be present and persistent for at least 6 months [10] . The label of schizophrenia was often given to children who by today’s standards would fall under a diagnosis of autism or Pervasive Developmental Disorder (PDD). This may be due to the fact that the onset of schizophrenia is gradual, and different symptoms including a history of behavioral, social, language and speech difficulties, abnormalities in motor development, and psychiatric disturbances that appear before the psychotic symptoms However, many symptoms have now been distinguished, which help aid in a proper diagnosis. This assessment allows the psychiatrist to either pinpoint the psychosis, or discover a cause for a different diagnosis. 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 with schizophrenia. Diagnosis is usually more challenging when it pertains to children rather than adults [11]

Criteria

The Diagnostic and Statistical Manual of Mental Disorders, version DSM-IV is the standardized manual used in the United States to diagnose mental disorders. The criteria used to diagnose the disorder is as follows: Two or more of the following symptoms present for a significant portion of time during a one-month period.

  • Delusions
  • Hallucinations
  • Disorganized speech
  • Disorganized behavior
  • Social dysfunction (interpersonal or academic achievement)

If the symptoms last for a six-month period, further assessments by medical professionals should be done.[12] The American Psychological Association notes that “if delusions are bizarre or if hallucinations consist of a running commentary about the person or two or more conversing voices, then only one of these symptoms is required to make the diagnosis.

Diagnostic examinations

If a professional believes that a child has schizophrenia, a series of tests are usually performed in order to rule out other causes of behavior and pinpoint a diagnosis. Three different types of tests are used; physical exam, laboratory and psychological.

Physical Exam

The 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. [13]

Laboratory

Physical exams alone cannot completely diagnose schizophrenia, but they do help rule out other diseases that can be causing the behavior. Doctors may run tests on the brain to see if any abnormalities exist, Cite error: A <ref> tag is missing the closing </ref> (see the help page). Some tests include electroencephalogram EEG screening and brain imaging scans. Blood tests are used to rule out alcohol or drug effects being a factor.

Psychological

A psychologist or psychiatrist will talk to a child about their thoughts, feelings, and behavior patterns. They will also inquire about the severity of the symptoms, and the effects they have on the child's daily life. Thoughts of suicide or self-harm may also be discussed in these one-on-one sessions. School records may be requested and questionnaires are used to assess anxiety and mood. All will be evaluated on an age appropriate level.[13]

Possible causes

Evidence suggests that there is a large hereditary component with schizophrenia. Research proposes that schizophrenia is caused by genetic vulnerability coupled with environmental stressors.

Environmental causes

Environmental causes will be described as any factor that is not genetic or hereditary (any macro-factor). Some possible environmental risk factors comprise of:

  • Disturbed family/ interpersonal problems
  • Being from a low-class household/poverty
  • Inadequate social resources

These alone do not cause schizophrenia. There needs to be some kind of genetic predisposition coupled with these factors.

Genetic causes

The link between genetics and schizophrenia is seemingly strong. Many believe that changes in neo-natal development cause the disorder while others believe it is hereditary, but neither have concrete support. If neither parent has the disorder there is a 1% chance that a child will develop it but the chances increase to 10% if one parent has schizophrenia. Possible genetic causes may be:

  • Family history of the disorder
  • Exposure to viruses in the womb
  • Prenatal malnutrition
  • Certain drugs
  • Stressful situation early in life

Treatment

Childhood schizophrenia is chronic and children with schizophrenia require permanent treatment.[9] Since researchers have yet to detect an exact cause for schizophrenia, medication is aimed to treat and maintain the symptoms associated with the disorder. [14] Treatment is the same for all forms of schizophrenia. However, because childhood is such a molding period, treatment can be a challenge.

Medications

Most medications used for childhood schizophrenia are the same as the ones used for adult schizophrenia, with antipsychotics being the most important step in treatment, with antipsychotics being the most important step in treatment to “control psychotic symptoms by blocking dopamine transmission at the D2 receptor” [15] The National Institute of Mental Health lists some antipsychotic drugs that may be used include but are not limited to

It is important to note that “although many medications are safe and effective, many of the above mentioned medications have not been studied or approved or approved” [16] for the use of children with schizophrenia. The National Institute of Mental Health also warns that since the medications are FDA approved, the doctors are able to administer the medication on an “off-label” basis, which means the child is able to receive the medication to help the patient, even though it is not used for schizophrenia specifically. More research is needed in the study of the effects on medication. The side effects of the medication have serious side-effects and need to be “carefully monitored and managed with changes in dose or type of medication as needed” [17]. The reason it is important to monitor the symptoms, especially during the first two weeks, is because children respond to the medications differently than adults. These side-effects include weight gain and motor dysfunction,

Psychotherapy

Psychotherapy consists 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.” [18] Psychotherapy also helps the patient surmount the negative connotation associated with schizophrenia.

Prospective Outlook

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 [19]. 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 [20]. Psychotherapy is used in order to assist those with schizophrenia understand their disorder and learn to thrive socially with it [21] The stages of development as defined by Erik Erikson would increase the need for psychotherapy as well as family therapy Cite error: The <ref> tag has too many names (see the help page)..

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 [22]. Some symptoms that may be looked at are early language delays, early motor development delays and school problems [23].

References

  1. ^ [1], Nordqvist, Christian (17 Jun 2010). "What Is Childhood Schizophrenia? What Causes Childhood Schizophrenia?". Medical News Today. Retrieved 13 Jan 2011.
  2. ^ Wicks-Nelson, R., Israel, A. C. (2009). Pervasive developmental disorders and schizophrenia. Jewell, L. (Eds), Abnormal child and adolescent psychology (327-359). Upper Saddle River, NJ: Pearson.,
  3. ^ Lambert, Louise T (Apri-Jun 2001). "Identification and management of Schizophrenia in childhood". Proquest.com. Retrieved 15 October 2011.
  4. ^ Remschmidt, H. E., Schulz, E., Martin, M., Warnke, A. & Trott, G. (1994). Childhood Onset Schizophrenia: Historyof the Concept and Recent Studies. Oxford Journals, 20(4).
  5. ^ Wicks-Nelson, R., Israel, A. C. (2009). Pervasive developmental disorders and schizophrenia. Jewell, L. (Eds), Abnormal child and adolescent psychology (327-359). Upper Saddle River, NJ: Pearson.
  6. ^ Remschmidt, H. E., Schulz, E., Martin, M., Warnke, A. & Trott, G. (1994). Childhood Onset Schizophrenia: Historyof the Concept and Recent Studies. Oxford Journals, 20(4).
  7. ^ Remschmidt, H. E., Schulz, E., Martin, M., Warnke, A. & Trott, G. (1994). Childhood Onset Schizophrenia: Historyof the Concept and Recent Studies. Oxford Journals, 20(4).
  8. ^ a b Segal, Robert; Smith, Melinda. "Understanding Schizophrenia: A GUIDE TO THE SIGNS, SYMPTOMS, AND CAUSES". HelpGuide.org. Retrieved 13 Jan 2011.
  9. ^ a b "Schizophrenia in children". American Academy of Child & Adolescent Psychiatry. Nov 2004. Retrieved 13 Jan 2011.
  10. ^ Mash,J.E., Wolfe,A.D. (2009). Abnormal Child Psychology (4th edition). Belmont, CA: Cengage Learning
  11. ^ Bender, Lauretta. "Childhood Schizophrenia". Psychiatric Quarterly. 27 (1): 663–681.
  12. ^ Diagnostic and statistical manual of mental disorders (4th ed.). American Psychiatric Association. 1994.
  13. ^ a b http://www.mayoclinic.com/health/childhood-schizophrenia/DS00868/DSECTION=tests-and-diagnosis
  14. ^ http://www.nimh.nih.gov/health/publications/schizophrenia/how-is-schizophrenia-treated.shtml
  15. ^ Tiffin, P.A. (2007). Managing psychotic illness in young people: A practical overview. Child And Adolescent Mental Health. 12(4). 173-186. Doi:10.1111/j.1475-3588.2006.00418.x. Retrieved from: EBSCOhost.
  16. ^ http://www.nimh.nih.gov/health/publications/schizophrenia/how-is-schizophrenia-treated.shtml
  17. ^ Tiffin, P.A. (2007). Managing psychotic illness in young people: A practical overview. Child And Adolescent Mental Health. 12(4). 173-186. Doi:10.1111/j.1475-3588.2006.00418.x. Retrieved from: EBSCOhost.
  18. ^ http://www.nimh.nih.gov/health/publications/schizophrenia/how-is-schizophrenia-treated.shtml
  19. ^ Lay, B., Blanz, B., Hartmann, M., & Schmidt, M. H. (2000). The psychosocial outcome of adolescent-onset schizophrenia: A 12-year followup. Schizophrenia Bulletin, 26(4), 801-816. Retrieved from EBSCOhost.
  20. ^ Eggers, C., & Bunk, D. (1997). The long-term course of childhood-onset schizophrenia: A 42-year followup. Schizophrenia Bulletin, 23(1), 105-117. Retrieved from EBSCOhost.
  21. ^ Bellak, L. (1958). Childhood schizophrenia and allied conditions. Benedict, P. K. (Eds), Schizophrenia: A review of the syndrome (555-693). New York, NK: Grune & Stratton.
  22. ^ Wicks-Nelson, R., Israel, A. C. (2009). Pervasive developmental disorders and schizophrenia. Jewell, L. (Eds), Abnormal child and adolescent psychology (327-359). Upper Saddle River, NJ: Pearson.
  23. ^ Mayo Foundation for Medical Education and Research (2011). http://www.mayoclinic.com/health/childhood-schizophrenia/DS00868
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