Childhood-onset schizophrenia differs from adult-onset schizophrenia and schizophrenia that is first manifested in individuals in adolescence. Adolescent-onset schizophrenia occurs before the age of 17 years, and childhood-onset schizophrenia is delineated as emerging prior to the age of 12 years. Schizophrenia, generally, is characterized by positive and negative symptoms.
Childhood schizophrenia profoundly impacts a child’s thoughts, memory, senses, behaviors and overall development. Disruptions in relationships and disorganized thinking are common. Children may exhibit harmful or unusual behaviors and are at increased risk of injuries or other illnesses.
Though childhood schizophrenia shares some similar symptoms with later-onset forms, like hallucinations and delusions, it also involves developmental delays, regressions and deficits.
Due to its differences from adult schizophrenia, assessing and accurately diagnosing childhood schizophrenia can be challenging. Careful evaluation using standardized diagnostic interviews and symptom rating scales is necessary. With early detection and intervention, the course and outcomes for this devastating illness may be improved.
Symptoms and Causes of Childhood Schizophrenia: An Overview
The symptoms that emerge with the onset of schizophrenia in childhood and adolescence are generally the same as those that appear with adult schizophrenia. Positive symptoms, specifically, include those that can be represented by behaviors that are added to the normal presentation of an individual, and negative symptoms comprise those behaviors that are deficits with regard to normal behavior. Positive symptoms include, but are not limited to, delusions and hallucinations, as well as symptoms of a formal thought disorder, including rapid or pressured speech. Negative symptoms include flat affect, or diminished emotional expression, poor hygiene, a lack of motivation and poverty of speech.
Children suspected as having schizophrenia may have difficulty in differentiating dreams from reality, and they may confuse television with reality. They may have vivid and bizarre thoughts and ideas. They may demonstrate severe moodiness, regression to earlier stages of development, and they may have difficult peer relationships.
Initial Signs:
The early signs of schizophrenia arising in childhood may first appear as general developmental and social delays or regressions. Children and teens who go on to develop schizophrenia often have difficulties with focus and attention, such as trouble listening or difficulties completing tasks. Impaired social skills like poor eye contact and lack of interest in peers is common.
Academic performance frequently suffers, with children struggling to meet milestones in reading, writing, and math. Regressions in self-care abilities, like problems consistently brushing teeth or getting dressed, may be observed.
Emotional control issues can manifest as frequent temper tantrums, laughing or crying for no clear reason, or emotional reactions that seem disconnected from the situation. Speech and language delays or abnormalities like repetition of words or phrases (echolalia) are also often present.
These generalized delays and regressions tend to arise before the more overt psychotic symptoms of schizophrenia appear.
Causes of Schizophrenia
Childhood schizophrenia doesn’t have a single cause. There are multiple factors that may play a role in its development:
- Brain development issues before birth - Abnormalities in brain development during pregnancy may contribute. This could involve problems with neuron migration and synaptic pruning.
- Pregnancy complications - Malnutrition, viral infections, placental insufficiency and other issues during pregnancy have been linked to increased risk.
- Birth complications - Oxygen deprivation and trauma during birth may play a role.
- Loss of brain connections - There is a progressive loss of connectivity between different areas of the brain as schizophrenia develops.
- Chemical imbalances - Imbalances in neurotransmitters like dopamine and glutamate may lead to the symptoms of schizophrenia.
So while a single cause is not known, it seems that a combination of genetic vulnerabilities, brain development issues, and environmental factors may interact to produce childhood schizophrenia in those predisposed. More research is still needed on the root causes.
Prevention and Early Signs
Prior to making a formal diagnosis of schizophrenia, the clinician should rule out disorders such as autism, bipolar disorder and patterns of behavior or the lack of them that can be asserted to be indicative of developmental delays. Parents of a child who may be schizophrenic should be concerned about deviant behavior in their child. However, they should resist the tendency to pathologize their child by interpreting the child’s behavior as outside of what may be expected in children with ordinary problems.
Distinguishing Childhood-Onset from Adolescent-Onset Schizophrenia
There are specific ways that distinguish childhood-onset schizophrenia from adolescent-onset schizophrenia. The earliest indications of schizophrenia in children include delays in language development, late locomotion, such as walking and crawling, and other abnormal behaviors, such as rocking, although one can see that such behaviors are not sufficient to diagnose the child as schizophrenic. Other more serious signs of schizophrenia include hearing voices that speak negatively to the child, or auditory hallucinations, voices talking about him, including delusions of reference, and being frightened by visions of things that are not actually there, such as visual hallucinations. These symptoms, generally, may represent issues of concern to the parents of a child or adolescent who may be schizophrenic. Nevertheless, the parent or the clinician should be hesitant to exaggerate the severity of odd behaviors: a child may simply have a creative and colorful imagination, as opposed to schizophrenia.
Diagnosis: Criteria in Children and Adolescents
The diagnostic criteria used to address the problems of schizophrenia in children and adolescents are similar to that used for adults, but there are some differences. In adolescents, schizophrenic symptoms may include: withdrawal from family and peers, a diminished academic performance, problems with sleeping, irritability or depression, lack of motivation and odd behavior. Again, these types of behavior may reflect relatively normal behavior in an adolescent who is adjusting to roles implicit in maturational development. The schizophrenic adolescent, as compared with an adult, is less likely to manifest delusions, but is more likely to have visual hallucinations.
Diagnostic challenges:
- Hallucinations and delusions are common in healthy children, making it difficult to identify pathological psychosis requiring intervention.
- Many medical and psychiatric conditions like epilepsy, depression, or autism can produce symptoms mimicking psychosis. These must be ruled out before diagnosing schizophrenia.
- Symptoms must persist for at least 6 months to confirm schizophrenia, delaying formal diagnosis.
- Young children often lack insight into their experiences and have trouble describing symptoms accurately. This hampers diagnosis.
- Symptoms like social withdrawal, poor concentration, or sleep issues overlap with other childhood disorders.
Overall, clinicians must be very cautious and thorough when evaluating potential childhood schizophrenia, given the diagnostic complexities. Longitudinal observation, input from multiple sources, and ruling out alternate causes is essential to confirm a schizophrenia diagnosis in children.
Caution in Diagnosis and Treatment
As indicated, the parent and the clinician should be very careful before attributing diagnostic labels to their child. Diagnoses often lead to the prescription of medication, and, while medication may be the method of choice for treating psychiatric disorders, the use of medication may not be the first choice in treatment of odd behaviors that appear to represent the possibility of schizophrenia in childhood and adolescence.
Treatment Approaches
Due to the complexity and severity of childhood schizophrenia, a comprehensive treatment approach is recommended:
- Medication - After thorough evaluation, antipsychotic medications may be prescribed. However, side effects and developmental impacts must be closely monitored, especially in young children.
- Psychotherapy - Individual and family therapy provides education, coping skills, and support. Cognitive behavioral therapy is often used to manage symptoms.
- Social Skills Training - Improving social skills and peer interactions is important for development. Social skills groups and coaching can help.
- Hospitalization - During acute psychotic episodes, hospitalization may be required to stabilize symptoms and ensure safety.
- Educational Assistance - Children with schizophrenia often require special education services and accommodations to address learning challenges.
- Family Counseling - Helping parents and siblings understand schizophrenia and adapt home life is crucial. Regular family therapy aids coping.
While antipsychotic medication may eventually be needed, non-pharmacological approaches should be tried first when possible. With a tailored, multimodal plan combining education, psychotherapy, and medication only as needed, outcomes can be optimized. However, each child must be treated as an individual.
Side Effects of Medications
When antipsychotic medications are used to treat childhood schizophrenia, the potential side effects must be carefully weighed against the benefits. Children are especially vulnerable to adverse effects given their developing bodies and brains. Several concerning side effects warrant close monitoring:
- Weight Gain - Many antipsychotics cause rapid and excessive weight gain. Obesity can emerge quickly, leading to lifelong health complications. Diet, exercise, and behavioral plans may help mitigate weight gain.
- Metabolic Issues - Antipsychotics increase risks of high cholesterol, triglycerides, and blood glucose. Metabolic panels should be regularly checked for any abnormalities indicating diabetes or cardiovascular risks.
- Hormonal Changes - Disruptions in growth hormone, prolactin, and other hormones can occur. This may impact development, especially during puberty. Endocrine function should be assessed.
- Movement Disorders - Abnormal motor symptoms like tremors, spasms, and restlessness can appear. Dose reductions may alleviate these.
- Sedation - Excessive sleepiness and fatigue are common with antipsychotics. This worsens attention and learning. Lower doses can reduce sedation.
- Heart Problems - Some antipsychotics affect electrical conduction in the heart, prolonging QT interval. This requires ECG monitoring to watch for arrhythmias.
By carefully selecting medications and dosing, regularly monitoring side effects, and implementing preventative measures, adverse effects can be minimized. However, risks must be balanced with benefits when treating vulnerable children with antipsychotic medications.
Provider Assessment Tools for Diagnosis
One way of determining a diagnosis of schizophrenia is the use of assessment tools in an effort to satisfactorily address the characteristics residing in the schizophrenic presentation. Psychometric tests for child schizophrenia do not exist, so the diagnostic tools primarily rely on the self-report of the youth and her parents and the interviewing of a youth and her parents when there exists the suggestion of a schizophrenic diagnosis in a child or an adolescent. Such assessment tools include the following: The Structured Clinical Interview for the purpose of obtaining a DSM-IV diagnosis. (SCID; First, Spitzer, Gibbon & Williams, 1992.); The Brief Psychiatric Rating Scale, (BPRS; Overall & Gorman, 1962.); The Positive and Negative Syndrome Scale (PANSS; Kay, Opler & Fitzbein, 1987.); The Scale for Assessment of Positive Symptoms and The Scale for Assessment of Negative Symptoms, (Andreasen, 1982)
The Structured Clinical Interview, (SCID), allows the clinician to delineate a diagnosis through interview of the client and her parents. The information derived by the clinician includes the following: family history of psychiatric problems, developmental history, academic performance, past treatment, chief complaint, past psychiatric history of the client, substance abuse problems, history of hospitalizations, medications tried and used, medical history, and diagnoses that have been ruled out, as well as an assessment of overall functioning. This information should enable a clinician to render a diagnosis. As indicated by research, ( Lobbertael, Leurgans & Artz, 2010), this type of interview allows for moderate to excellent inter-rater reliability, or agreement regarding derivation of diagnoses by clinicians. This means that the clinician using the SCID will demonstrate reliability in terms of accuracy in diagnostic formulations.
The Brief Psychiatric Rating Scale, (BPRS), is another instrument that is used to determine a diagnosis of schizophrenia in children and adolescents. This assessment instrument, like the SCID, relies on an interview of a client and her parents. This instrument determines the manifestation of symptoms of schizophrenia or other psychotic disorders. Symptoms assessed include hostility, suspiciousness, hallucinations and grandiosity, all of which can be seen in an individual diagnosed with schizophrenia. Clearly, the BPRS is useful in deriving a diagnosis of schizophrenia.
The Positive and Negative Symptom Scale, (PANSS), also targets the severity of positive symptoms and negative symptoms. As indicated, positive symptoms include delusions and hallucinations, for example, and negative symptoms include social withdrawal, flat affect or diminished emotion in terms of facial expression, and confused or odd speech. This scale delineates not only the existence of positive and negative symptoms, it allows for an assessment of the severity of these symptoms, and, as a matter of course, it will render a diagnosis of schizophrenia or the dismissal of such a diagnosis.
The Scale for Assessment of Positive Symptoms, (SAPS), and the Scale for Assessment of Negative Symptoms, (SANS), were both developed by Andreasen, (1982) as instruments that utilize interview techniques. The SAPS assesses for the presence of positive symptoms, such as hallucinations, delusions and bizarre behavior. The SANS assesses negative symptoms, such as flat affect, poverty of speech, poor grooming and hygiene, loss of interest in formerly pleasurable activities, poor relationships with peers and friends and deficits in attention.
Outlook and Treatment Options
Overall, it should be noted that there clearly exist some concerns in diagnosing children and adolescents with the serious psychotic disorder of schizophrenia. However, there are reliable assessment instruments by which a clinician may render the determination of a schizophrenic diagnosis. Parents who are concerned about what may seem to be the abnormal behavior of their child should be able to go to a clinician who will be able to make such a diagnosis and rule out other diagnoses. Ultimately, that is the point at which efficacious treatment of schizophrenia in children and adolescents may begin.
Living With Childhood Schizophrenia
Parenting a child with schizophrenia can be very demanding. Ongoing communication with teachers, counselors, and other care providers is essential to monitor the child’s behaviors and progress. Implementing educational accommodations and therapy techniques consistently across home and school is key.
Parents must also make sure to take care of themselves, as the stresses of having a child with severe mental illness can take a toll. Support groups for parents and families impacted by childhood schizophrenia can provide invaluable connections, advice, and understanding.
With compassion, patience and care, parents can optimize their child’s development despite the challenges of schizophrenia. Early intervention, family support, tailored treatment, and regular monitoring together offer the best chance at positive long-term outcomes.
While childhood schizophrenia is a devastating diagnosis, the prognosis can be hopeful with comprehensive, individualized management.
References:
- AndreasenNC. Negative symptoms in schizophrenia. Definition and reliability Arch Gen Psychiatry. 1982 Jul;39(7):784-8.
- AndreasenNC. The Scale for the Assessment of Positive Symptoms (SAPS. Iowa City, IA: The University of Iowa; 1984.
- Spitzer RL, Williams JB, Gibbon M, First MB: The Structured Clinical Interview for DSM-III-R (SCID). I: History, rationale, and description. Arch Gen Psychiatry 1992 Aug; 49(8):624-9.
- Kay SR, Fiszbein A, Opler LA (1987). “The positive and negative syndrome scale (PANSS) for schizophrenia.”. Schizophr Bull 13 (2): 261–76.
- Lobbertael, J., Leurgans, M., & Artz. Inter-rater reliability of the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID I) and Axis II Disorders (SCID II) Journal: Clinical Psychology & Psychotherapy - CLIN PSYCHOL PSYCHOTHER , 2010.
- Overall JE, Gorham DR (1962). The brief psychiatric rating scale. Psychological Reports 1962 vol. 10, pp799-812.
This is an update to the original post "Assessing Schizophrenia in Children and Adolescents" published on Aug 4, 2014.
