Pediatric schizophrenia

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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[edit]

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[edit]

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[edit]

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[edit]

The negative symptoms of early-onset schizophrenia are:

Diagnosis[edit]

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[when?] 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[edit]

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[edit]

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[edit]

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[edit]

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[edit]

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[edit]

Causes largely unknown.

Treatment[edit]

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[edit]

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[edit]

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 some may not need to use antipsychotic medications continuously throughout their lives.[16][17][18][19] Psychotherapy also helps the patient surmount the negative connotation associated with schizophrenia.

Prognosis[edit]

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[edit]

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[edit]

  1. ^ Nordqvist, Christian (17 June 2010). "What Is Childhood Schizophrenia? What Causes Childhood Schizophrenia?". Medical News Today. Retrieved 13 January 2011. 
  2. ^ a b c Wicks-Nelson, Allen C.; Israel (2009). "Pervasive developmental disorders and schizophrenia". In Jewell, L. Abnormal child and adolescent psychology. Upper Saddle River, NJ: Prentice Hall Higher Education. pp. 327–359. ISBN 9780132359788. 
  3. ^ Lambert, LT (April–June 2001). "Identification and management of schizophrenia in childhood". Journal of Child and Adolescent Psychiatric Nursing 14 (2): 73–80. doi:10.1111/j.1744-6171.2001.tb00295.x. PMID 11883626. 
  4. ^ a b c Remschmidt, H. E.; Schulz, E.; Martin, M.; Warnke, A.; Trott, G. (1994). "Childhood Onset Schizophrenia: History of the Concept and Recent Studies". Schizophrenia Bulletin 20 (4): 727–745. doi:10.1093/schbul/20.4.727. PMID 7701279. 
  5. ^ a b Masi, G.; Mucci, M.; Pari, C. (2006). "Children with schizophrenia: Clinical picture and pharmacological treatment". CNS Drugs 20 (10): 841–66. doi:10.2165/00023210-200620100-00005. PMID 16999454. 
  6. ^ Spencer, EK; Campbell, M (1994). "Children with schizophrenia: diagnosis, phenomenology, and pharmacotherapy". Schizophrenia bulletin 20 (4): 713–25. doi:10.1093/schbul/20.4.713. PMID 7701278. 
  7. ^ Mash, J.E.; Wolfe, A.D. (2009). Abnormal Child Psychology (4th ed.). Belmont, CA: Cengage Learning. ISBN 9780495506270. [page needed]
  8. ^ Bender, Lauretta (1953). "Childhood Schizophrenia". Psychiatric Quarterly 27 (1): 663–681. doi:10.1007/BF01562517. 
  9. ^ a b Gonthier, Misty; Lyon, Mark A. (22 July 2004). "Childhood-Onset Schizophrenia: An Overview". Psychology in the Schools 41 (7): 803–811. doi:10.1002/pits.20013. 
  10. ^ Diagnostic and statistical manual of mental disorders (IV-TR ed.). American Psychiatric Association. 1994.  quoted in "Schizophrenia". BehaveNet. Retrieved 9 May 2013. 
  11. ^ a b c "Childhood schizophrenia: Tests and diagnosis". 17 December 2010. 
  12. ^ a b c National Institute of Mental Health. "How is schizophrenia treated?". 
  13. ^ a b 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. 
  14. ^ "Tables of FDA-Approved Indications for First- and Second-Generation Antipsychotics". Retrieved 9 May 2013. 
  15. ^ Long-term antipsychotic treatment and brain volumes: a longitudinal study of first-episode schizophrenia.Arch Gen Psychiatry. 2011 Feb;68(2):128-37. doi: 10.1001/archgenpsychiatry.2010.199.
  16. ^ Harrow, M; Jobe, TH (May 2007). "Factors involved in outcome and recovery in schizophrenia patients not on antipsychotic medications: a 15-year multifollow-up study.". The Journal of nervous and mental disease 195 (5): 406–14. PMID 17502806. 
  17. ^ Harrow, M; Jobe, TH; Faull, RN (Oct 2012). "Do all schizophrenia patients need antipsychotic treatment continuously throughout their lifetime? A 20-year longitudinal study.". Psychological medicine 42 (10): 2145–55. PMID 22340278. 
  18. ^ Fenton, WS; McGlashan, TH (Oct 1987). "Sustained remission in drug-free schizophrenic patients.". The American journal of psychiatry 144 (10): 1306–9. PMID 2889376. 
  19. ^ Insel, Thomas. "Antipsychotics: Taking the Long View". National Institute of Mental Health. Retrieved 25 February 2014. 
  20. ^ 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.
  21. ^ 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.
  22. ^ a b 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.
  23. ^ Torrey E. F.(2006). Surviving Schizophrenia: A Manual for Families, Patients, and Providers (5th Edition) . Publisher: Quill; 5th edition (April 1, 2006) ISBN 0-06-084259-8
  24. ^ Mayo Foundation for Medical Education and Research (2011). http://www.mayoclinic.com/health/childhood-schizophrenia/DS00868