CHILDHOOD SCHIZOPHRENIA

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Oculogyric crisis, (muscular spasms of tongue, or jaw; more frequent in children). Drug-induced parkinsonism – which includes (muscle stiffness, shuffling gait,.

CHAPTER

CHILDHOOD SCHIZOPHRENIA (2 CE HOURS)

By Kathryn Brohl, MA, LMFT

Learning objectives

!! To understand the history of childhood schizophrenia and psychosis. !! To understand the significant definitions related to childhood schizophrenia and psychosis including (but not limited to): schizophrenia, delusions, hallucinations, and thought disorders. !! To understand the components of screening and diagnosis for childhood schizophrenia and psychosis. !! To understand the diagnostic criteria for childhood schizophrenia and psychosis. !! To understand the differences in symptoms between children / adolescents and adults !! To understand the prevention of childhood schizophrenia and psychosis. !! To understand the inherent difficulties in treating childhood schizophrenia and psychosis. !! To understand the outcomes related to childhood schizophrenia and psychosis. !! To understand the current research into childhood schizophrenia and psychosis.

Introduction

The existence of childhood psychoses has been noted, discussed, and at times dismissed for over one hundred years. In 1867 Henry Maudsley, a British psychiatrist, wrote in his textbook, Physiology and Pathology of Mind, a work entitled “Insanity of Early Life.” Kanner later noted that Maudsley was dismissed by his contemporaries for acknowledging the existence of “insanity” in childhood. Much of the early literature regarding childhood psychosis reveals conflicting points of view, definitions, and classifications that kept changing over time. Today, childhood schizophrenia and psychosis are well established disorders (Tengan and Maia, 2004).Childhood schizophrenia is a severe and most often persistent mental disorder that is characterized by a loss of contact with reality, changes in personality, and moderate to severe difficulty with social functioning. Tolbert (1996) provides an inventory of symptoms frequently seen in children with psychosis:  Auditory hallucinations.  Confused thinking.  Confusion of television with reality.  Diminished interest.  Disinheriting.  Extreme moodiness.  Ideas that others are ‘out to get them’.  Inability to distinguish dreams from reality.  Odd and/or eccentric behavior.  Severe problems making and keeping friends.  Speech disturbances.  Stereotypy.  Visual hallucination.  Vivid and bizarre thoughts and ideas.

Definitions

Schizophrenia is thought to be the most common form of child, adolescent, and adult psychosis. Symptoms often include delusions, thought disorders, as well as auditory, visual, and other types of hallucinations, and paranoia. Delusions are unshakable beliefs that hold no or little basis in reality. For example, people with psychosis might strongly believe that the government is plotting to harm them, that they are being spied on through the radio or television, that they have special “super” power; or that evil forces are trying to kill them. A thought disorder is when a person’s thinking is confused. A person with a thought disorder may be hard to understand. Their ideas will often be disorganized, but it is more than just ordinary confusion. Hallucinations are when someone sees, hears, smells, or feels something that does not really exist. The most common form of hallucination is auditory in nature. Persons with auditory hallucinations often report hearing voices. In some cases those voices will tell a person to do a specific act. This type of auditory hallucination is called a command auditory hallucination. The person with schizophrenia who experiences hallucinations will often believe that the hallucinations are totally real. Patients with hallucinations may act strangely. For example, they may talk or laugh to themselves as if conversing with somebody that the clinician can’t see. When the client responds to the hallucinations it is said they are responding to internal stimuli.

Paranoid ideation differs from paranoid delusions in that the ideas are held with less conviction than with the patient who is delusional. Extrapyramidal side effects (EPS) are the various movement disorders such as tardive dyskinesia suffered as a result of taking dopamine antagonists, usually antipsychotic (neuroleptic) drugs, which are often used to control psychosis, especially schizophrenia. The best known EPS is tardive dyskinesia (involuntary, irregular muscle movements, usually in the face). Other common EPS include:  Akathisia (often observed as the inability to remain seated due to motor restlessness or due to a sensation of muscular quivering. It is a side effect of many neuroleptic medications).  Dystonia (muscular spasms of neck).  Oculogyric crisis, (muscular spasms of tongue, or jaw; more frequent in children).  Drug-induced parkinsonism – which includes (muscle stiffness, shuffling gait, drooling, tremor; less frequent in children and adolescents, more frequently observed in adults and the elderly). A dopamine antagonist is a drug which blocks dopamine receptors. Positive symptoms are abnormal thoughts and perceptions such as disordered thinking, delusions, and hallucinations. Negative symptoms are loss, or decrease, of normal functions often evidenced by blunted affect, impaired attention, avolition, and anhedonia.

The second most common hallucination is visual in nature. The person who experiences visual hallucinations may see people who don’t exist or, in some cases, may see relatives, long dead and buried. Children with visual hallucinations may report seeing mythological creatures such as monsters and dragons. In rare cases, patients with psychosis may experience olfactory or tactile hallucinations, although these are seldom observed in children.

Avolition is a psychological state characterized by general lack of desire, motivation, and persistence. Avolition is commonly seen in patients with schizophrenia. Persons suffering from avolition may not start or complete any major tasks.

Psychosis is a thought disorder where the person is unable to distinguish reality from fantasy because of impaired reality testing. The boundary between non-psychotic and psychotic ideation and perception is not clearly delineated in the literature.

Blocking is the disruption of thought evidenced by an interruption or momentary disruption of speech. The individual appears to be trying to remember what he or she was thinking or saying.

Paranoia is often characterized by delusions involving:  Guardedness.  Hyperalertness.  Hypersensitivity.  Jealousy.  Persecution.  Suspiciousness. Paranoid ideation evidences itself as patients being convinced that other people are:  Thinking “bad thoughts” about them.  That they are being followed.  That they are the object of any number of dark conspiracies.

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Anhedonia is the inability to experience pleasure from normally pleasurable life events such as eating, exercise, playing and other forms of social interaction.

Loosening of associations is a disorder of thinking and speech in which ideas shift from one subject to another with remote or no apparent reasons. Stereotypy is a behavioral condition characterized by a lack of variation in patterns of thought, motion and speech; by repetition of said patterns; or both.

Screening and diagnosis Screening

A complete screening and diagnostic workup for childhood schizophrenia will include some or all of the following:  A complete history including: Page 1



  

ŠŠ Medical. ŠŠ Social. ŠŠ Family history. Interviews with child, parents, guardians, and other caregivers to assess possible psychotic symptoms, changes in behavior and the possibility of other psychiatric problems. Tests to assess cognitive skills and functional abilities in daily life. A review of school records and/or other input from school personnel. Various lab tests may be indicated: ŠŠ Toxicology screens may be needed if substance abuse is suggested. ŠŠ Liver function studies, copper, and ceruloplasmin are part of the workup for Wilson disease. ŠŠ Obtain porphobilinogen for porphyria. ŠŠ HIV titers may be needed. ŠŠ Brain-imaging tests such as MRI or CT scan can be used to rule out other medical conditions.

Diagnostic Criteria

At present, the criteria used to diagnose schizophrenia in adults can also be used to diagnose schizophrenia in children: A. Characteristic symptoms: Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated): 1. Delusions. 2. Hallucinations. 3. Disorganized speech (e.g., frequent derailment or incoherence). 4. Grossly disorganized or catatonic behavior. 5. Negative symptoms, i.e., affective flattening, alogia, or avolition Note: Only one criterion A symptom is required if delusions are bizarre or hallucinations consist of a voice keeping up a running commentary on the person’s behavior or thoughts, or two or more voices conversing with each other. B. Social/occupational dysfunction: For a significant portion of the time since the onset of the disturbance, one or more major areas of functioning such as work, interpersonal relations, or self-care are markedly below the level achieved prior to the onset (or when the onset is in childhood or adolescence, failure to achieve expected level of interpersonal, academic, or occupational achievement). C. Duration: Continuous signs of the disturbance persist for at least 6 months. This 6-month period must include at least 1 month of symptoms (or less if successfully treated) that meet Criterion A (i.e., active-phase symptoms) and may include periods of prodromal or residual symptoms. During these prodromal or residual periods, the signs of the disturbance may be manifested by only negative symptoms or two or more symptoms listed in Criterion A present in an attenuated form (e.g., odd beliefs, unusual perceptual experiences). D. Schizoaffective and mood disorder exclusion:

Schizoaffective Disorder and Mood Disorder With Psychotic Features have been ruled out because either (1) no Major Depressive, Manic, or Mixed Episodes have occurred concurrently with the active-phase symptoms; or (2) if mood episodes have occurred during active-phase symptoms, their total duration has been brief relative to the duration of the active and residual periods. E. Substance/general medical condition exclusion: The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition. F. Relationship to a pervasive developmental disorder: 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). (direct quotation from Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (2000).

Issues related to assessment of children

Very young children, regardless of their mental status, have unclear boundaries and are often unable to verbally describe their experiences, thoughts, and emotions. Clinicians may have to use play therapy as an assessment technique to ferret out symptoms related to this diagnosis. It should be noted that young children are concrete in thought and have limited social experiences (Piaget, 1962). Young children often possess a private language or use private speech or talk to themselves aloud. According to Piaget, the immature child does not differentiate between words or symbols and what words represent. Fantasy and imaginative play emerge by the second year and continue for 3 to 4 years until the child becomes more interested in peer games. Animism (the attribution of life to objects that are not alive) is common due in normal child development. Even as the child gets older and toward concrete operations (ages 5-7), the issue of creativity may come into play. The clinician assessing the child must keep in mind the normal developmental processes when attempting to diagnosis the presence of schizophrenia in a young child. It is important to note that non-psychotic hallucinations may be present in children. Wilking and Paoli (1966) describe 42 children with non-psychotic hallucinations. They found a pattern of developmental difficulties, social and emotional deprivation, and parents whose own pathologies promoted a breakdown in the child’s sense of reality. Edelsohn et al (2003) indicates that non-psychotic hallucinations are not rare in presentation. In his study, auditory hallucinations were most often associated with disruptive behavior disorders. Hearing a voice suggesting suicide was most often associated with depression. The clinician must strive to understand the context and content of the hallucinations when diagnosing a young child.

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As stated above, in childhood, and most especially during adolescence, the affective symptoms of schizophrenia can sometimes be mistaken for age appropriate moodiness or oppositional behavior. It is worth noting that in children and adolescents, hearing voices is not always a sign of schizophrenia, but may be due in part to anxiety, stress, depression, family dynamics, or cultural issues.

Differences in symptoms between children/adolescents and adults

All three major classificatory/diagnostic systems (ICD-9, ICD-10 and DSM-IV-TR) have no special criteria for children and recommend the use of adult criteria in children (Reddy et al, 1993). This approach to diagnosis assumes that there is a similarity between schizophrenia seen in adults and that seen in children. There is a general paucity of evidence in the clinical and research data to support this assertion. Similar clinical presentations of schizophrenia may exist in both childhood and adulthood. Other differences such as in the etiology, course and prognosis may (and often) exist and should not be overlooked (Beitchman, 1985). The early age of onset and the complexities of dealing with children presents multiple special considerations in regard to:  Assessment.  Diagnosis.  Educational needs.  Emotional development.  Family education.  Family training.  Need for basic living skills training.  Need for vocational training.  Psychiatric Treatment.  Psychological Treatment.  Social development. Symptoms, beliefs, thoughts, and behaviors of children and adolescents with schizophrenia may not be the same as adults with this illness. The following symptoms and behaviors can (and often) occur in children or adolescents with schizophrenia:  Confusing television and dreams from reality.  Decline in personal hygiene.  Difficulty relating to peers, and keeping friends.  Disorganized or confused thinking.  Disorganized, odd, or eccentric behavior.  Disorganized, odd, or eccentric speech.  Excessive mobility with no purpose.  Extreme moodiness.  Holding untrue beliefs (delusions).  Ideas that people are out to get them or talking about them (paranoia).  Inability to initiate plans.  Inappropriate emotional expression.  Minimal verbal communication.  Physical immobility.  Seeing things and hearing voices which are not real (hallucinations).  Severe anxiety and fearfulness.  Unusual or bizarre thoughts and ideas.  Withdrawal and increased isolation. Elite CME

It has been noted that the behavior of children with schizophrenia may change slowly over time, as opposed to some adults whose behavior and thought processes may seemingly change in a very short period of time (days or weeks). For example, children who used to enjoy relationships with siblings, family members, and playmates may become increasingly shy or withdrawn and seem to be in their own world. Sometimes youngsters will begin to verbalize strange fears and ideas. They may begin to cling to parents or caregivers and say things that do not make sense to others. Interestingly, these early symptoms and problems may first be noticed by the child’s school teachers.

Differential diagnosis

Some signs and symptoms of schizophrenia may overlap with those of other mental health, physical health, or developmental disorders. These can include:  Autism spectrum disorders (including asperger’s).  Bipolar disorder.  Borderline personality disorder.  Cognitive deficits.  Delusional disorders.  Medical disorders that affect the brain.  Obsessive-compulsive disorder.  Porphyria, acute.  Post-traumatic stress disorder.  Rett Syndrome (a childhood neurodevelopmental disorder).  Schizoaffective disorder, (a disorder with symptoms of both schizophrenia along with a mood disorder.  Severe anxiety disorders.  Severe major depression with psychotic features.  Substance abuse disorders (particularly cocaine and methamphetamine which are rare in children).  Wilson Disease. Psychotic disorders secondary to an underlying physical illness are extremely rare in children but need to be considered in the context of a comprehensive evaluation. A formal physical examination, including a comprehensive neurological assessment, is essential, but often overlooked by practitioners. As stated above, the potential differential diagnosis is extensive and can include many general medical conditions in addition to primary psychiatric disorders including:  Cerebral tumor.  Epilepsies.  Neurodegenerative disorders. Clark (2001), notes that Organic psychotic disorder secondary to substance misuse is frequently suspected in the adolescent age group, and urine drug screens or hair analysis for illicit drugs should be undertaken. Recent studies report that children and adolescents treated with oral, inhaled, and intravenous corticosteroids may experience adverse psychological side effects, including

psychotic symptoms. Apparently, these can occur at any point during treatment.

Etiology

Research has also shown a male predominance for childhood schizophrenia with a reported male-to-female ratio averaging 1.5-2:1.

The cause of childhood onset schizophrenia, as well as adult schizophrenia remains unknown. The American Academy of Child and Adolescent Psychiatry reports that current research suggests a combination of factors that may be responsible for the development of psychotic symptoms in children:  Brain changes.  Biochemical factors.  Genetic factors.  Environmental factors.

Mortality

Other researchers suggest that problems in early brain development may be the cause of the illness. Certain areas of the brain that are rich in the neurotransmitter dopamine seem to be affected most often in all types of schizophrenia.

As stated previously, the diagnostic criterion for childhood onset schizophrenia is the same as for adults, except that symptoms appear prior to age 13 (average age at onset of 9), instead of in the late teens or early 20s for many adults. As previously noted, schizophrenia in adult populations often begins with an acute episode. With children and adolescents it often emerges more gradually, over a period of months or years.

In another study using MRI on early-onset schizophrenic patients to determine regional brain gray-matter abnormalities it was shown that early-onset schizophrenic patients do have brain differences compared with the controls. It was observed that schizophrenic patients had a significant decrease in regional gray matter when compared with the controls in several areas of the brain. Compared with control patients, preliminary results showed the presence of brain abnormalities in temporolimbic areas in patients with early-onset schizophrenia. These abnormalities are similar to those seen in adult schizophrenia. Several studies (psychological, pharmacologic, and neuroimaging) of childhood-onset schizophrenia have suggested dysfunction in the prefrontal cortex and limbic systems of the brain. The neurotransmitter dopamine has been identified in the pathophysiology of schizophrenia. Drugs that increase dopaminergic activity are thought to induce psychosis. Other neurotransmitters also may be involved in the development of schizophrenia. Serotonin may be one of those neurotransmitters. The newer atypical antipsychotic drugs are known to have significant effects on serotonin in the brain. The role of genetics has long been established as one of the causes of childhood schizophrenia. The risk of schizophrenia rises from 1 percent for a child in a family with no history of the illness, to 10 percent if a first degree relative has it, to 50 percent if an identical twin is diagnosed with the disorder.

Incidence

Psychosis in children is fairly rare with a diagnosis of schizophrenia in only approximately 1 in 10,000 to 40,000 minors, compared to approximately 1 in 100 in adults. The disease is seldom observed before the age of five. Premorbid functioning is often marked by difficulties with attention, conduct, inhibition, withdrawal and emotional sensitivity. Eighty percent of children with the disorder exhibit difficulties with auditory hallucinations. Fifty percent have reported difficulties with delusional beliefs.

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It has been demonstrated that there is an increased risk of death from suicide for persons with schizophrenia. In several large studies of childhood-onset schizophrenia, the mortality rate from suicide was 5-11 percent. More than one half of children with schizophrenia have persistent severe impairment in social skills and limitations in academic and occupational achievement.

Onset

Treatment

At present, schizophrenia (of any type) is believed to be a life-long disease that can be treated, controlled and curtailed, generally through the use of medication. There is no known cure for schizophrenia. The organization, Living with Childhood-Onset Schizophrenia reports that the regular support systems available to children will often have little or no experience dealing with any form of childhood psychosis, and that few families have the emotional, financial, and time resources needed to deal with this devastating long-term illness. Untreated psychosis is most often associated with longer and more difficult recovery and can lead to significantly increased family distress, substance abuse /dependence, other mental health issues such as depression, and increased risk of suicide. Proper early diagnosis and treatment is thought to reduce the need for repeated psychiatric hospitalizations and may promote a more complete recovery. Standard treatments for childhood onset schizophrenia most often consists of:  Low-dose, anti-psychotic medications.  Ongoing age-appropriate patient education.  Family education.  Social skills training.  Basic living skills training.  Psychotherapy for the child, parents, and other caregivers.  Cognitive remediation (primarily for improving memory and attention).  Long-term support.  Psychiatric hospitalizations (as needed).  Residential care (for difficult or unresponsive cases). Newer (atypical) medications generally more effectively treat psychotic symptoms without the side effects more common with older (typical) Page 3

anti-psychotic medications. Children and adolescents symptoms of psychosis are often encouraged to maintain their daily routines as much as possible. Some level of recovery is also improved when the family itself is accepting, non-confrontational, stable, and supportive. There is ample evidence that stress can make the symptoms of psychosis worse.

Medications

Medications that assist children manage their psychotic symptoms have improved significantly in the past ten to fifteen years. Antipsychotic medications are especially effective in reducing or eliminating hallucinations and delusions. The newer generation (atypical) antipsychotics, such as olanzapine and clozapine, can also help improve motivation and emotional expressiveness in some patients while lowering the likelihood of producing disorders of movement, including tardive dyskinesia. Conversely, even with these newer (atypical) medications, side effects remain, including excess weight gain that can increase risk of other health problems such as diabetes and heart disease. First generation antipsychotic medications include (but not limited to):  Chlorpromazine (Thorazine).  Fluphenazine (Prolixin).  Haloperidol (Haldol).  Loxapine (Loxapac).  Thioridazine (Mellaril).  Thiothixene (Navane).  Trifluoperazine (Stelazine).

Difficulties with treatment

Child onset schizophrenia is frequently resistant to medications, especially with first generation (typical) antipsychotics. Of the more than 10 typical antipsychotics currently available for use in the U.S. only a few (haloperidol, loxapine, thioridazine, thiothixene) have any data concerning efficacy on children. The results of several studies indicate that a large number of young patients (15-45 percent depending on the medication prescribed) show little or no improvement while taking the medication. These studies also showed a high percentage of serious side effects. This leads some researchers to suggest that children are at higher risk for developing these side effects than adults are. Common side effects of typical antipsychotics include sedation and extrapyramidal side effect (EPS), which are characterized by motor deficits including loss of postural reflexes, bradykinesia (abnormally slow movement), tremor, rigidity, and involuntary movements. These and other side effects from “typical” antipsychotic medication often results in poor adherence to medication regimens. In some cases, these side effects of these medications have led to nonreversible or lifethreatening conditions. Second generation antipsychotic medications (also known as atypical or novel) include:  Aripiprazole (Abilify).  Clozapine (Clozaril).

   

Olanzapine (Zyprexa). Quetiapine (Seroquel). Risperidone (Risperdal). Ziprasidone (Geodon).

Second generation antipsychotic medications tend to have fewer side effects. In adults there is an observed lower incidence of tardive dyskinesia (TD) with the newer drugs and it is thought that the same may hold true for children and adolescents. TD results in involuntary movements of your mouth, lips, tongue and other parts of the body. Other possible side effects of the older medications include interactions with other medications, risk of seizures, and reductions of the white blood count.

Psychotherapy

In cases of childhood schizophrenia and psychosis, psychotherapy for the client, the client’s family, and other caregivers will often focus on coping strategies, problem-solving skills, awareness of psychotic symptoms, as well as issues related to anti-psychotic medication compliance. There is no evidence to suggest that psychotherapy alone is a substitute for medication. Tarrier (2005), reports that schizophrenia and other psychotic disorders were once thought to be untreatable by psychological treatments. There is accumulating evidence that cognitive behavior therapy (CBT) can result in significant clinical benefit to these patients.

Psychiatric hospitalization

A child with schizophrenia may require one or several episodes of psychiatric hospitalization to achieve sufficient stability to function at home and in the community. Most often, these hospitalizations occur as a reaction to acute episodes of the illness where the child has become unmanageable or dangerous at home. The hospitalization ensures safety while the client’s medication regimen is adjusted to minimize symptoms of the disorder while monitoring for side effects related to antipsychotic medications.

indicate that premorbid characteristics such as shyness, introversion, social withdrawal and cognitive decline have been linked with poor prognosis in early-onset schizophrenia (Remschmidt, 2000).

Prevention

No known interventions have been proven to prevent the development of childhood onset schizophrenia / child psychosis at the time of this paper. The National Institutes of Mental Health (NIMH) is attempting to identify children and adolescents at risk for developing schizophrenia with the aim of investigating whether treatment with the atypical antipsychotic olanzapine could prevent, reduce, or slow the onset of this disease. Because there are environmental factors that clearly appear to influence the surfacing of schizophrenia, lowering the risk for genetically vulnerable individuals should theoretically be possible.

Studies and future treatment

The Child Psychiatry Branch of the National Institute of Mental Health is currently conducting research on childhood schizophrenia. NIMH is currently recruiting children to better understand:  Importance of treatment.  Diagnosis.  Genetic basis for this disorder. NIMH is interested in studying children who are responders as well as non-responders to current treatment modalities. The children and their families will be brought to the NIH Clinical Center at the expense of NIMH for an intensive diagnostic evaluation and, when appropriate, trials of new treatments. The Criteria for the study is as follows:  Boys and girls 6-18 years old.  Onset of psychotic symptoms before the 13th birthday.  IQ above 70 (pre-psychotic).  Compliant family.

While hospitalized, the client will most often be treated by a multi-disciplinary team consisting of one or more psychiatrists, psychologists, counselors, social workers, and psychiatric nurses. While one of the goals of the team is to return the child to the natural home environment, this may not be possible in all cases. In some instances the child must be referred to a mid or long-term residential facility for further treatment and stabilization.

Benefits of participating in the study include:  Evaluation by a team which has seen more psychotic children than almost any other research facility in the country.  Recommendations by our psychiatrists, social worker, nurses, teachers, occupational and recreational therapists for future treatment.  All treatment is free; housing and transportation are provided to those living at a distance.  Opportunities for a drug-free washout trial for children who participate in our medication trial.

Outcomes

Conclusion

Outcome studies of childhood psychoses are limited and have been criticized by some researchers as somewhat selective in nature. Nearly every study reveals that the majority of cases have poor outcomes, which was worse in the childhood-onset than in adolescentonset cases. Childhood-onset cases are often fraught with recurrent acute episodes, repeated psychiatric hospitalizations, and markedly impaired social functioning. Some studies

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The existence of childhood schizophrenia and psychosis has been discussed in professional circles for over one hundred years. Childhood schizophrenia is a severe, debilitating, and most often persistent mental disorder that is characterized by a loss of contact with reality, changes in thinking, changes in personality, and moderate to severe difficulty with social functioning. Elite CME

Childhood schizophrenia is fairly rare in children. Psychosis in children is fairly rare with a diagnosis of schizophrenia in only approximately 1 in 10,000 to 40,000 minors, compared to approximately 1 in 100 in adults. The disease is seldom observed before the age of five. The symptoms and behavior of children and adolescents with schizophrenia may differ from that of adults with this illness. Some of the symptoms and behaviors that can occur in children or adolescents with schizophrenia include auditory hallucinations, confused thinking, ideas that others are ‘out to get them’, inability to distinguish dreams from reality, odd and/or eccentric behavior, visual hallucinations, and vivid and bizarre thoughts and ideas. The onset of schizophrenia in children tends to be more gradual than for adults. Parents and caregivers may not notice that the child’s behavior has changed slowly over time. Children who used to enjoy relationships with playmates may become more shy or withdrawn and seem to withdraw in to their own world. Many children with this diagnosis may start to cling to parents and other caregivers. Some may say things which do not make sense or appear to be responding to internal stimuli. There are inherent difficulties in diagnosing schizophrenia in a child. Very young children, regardless of their mental status, have unclear boundaries and are often unable to verbally describe their experiences, thoughts, and emotions. The clinician assessing the child must keep in mind the normal developmental processes when attempting to diagnosis the presence of schizophrenia in a young child. Children with schizophrenia require comprehensive treatment. A combination of medication, individual therapy, family therapy, patient education, and other adjunctive therapies is often needed. Psychiatric medication can be helpful for many of the symptoms and problems associated with schizophrenia. Due to undesirable side effects these medications require careful monitoring by the child’s psychiatrist. Schizophrenia is a life-long disease that can be treated and controlled. At present there is no cure for schizophrenia, but new medications have been developed that can manage many of the adverse symptoms of this disease. Newer atypical antipsychotics, with fewer extrapyramidal side effects and generally increased efficacy have benefited many individuals who had been unresponsive to traditional typical antipsychotics. Bibliography ŠŠBaeza I, Salgado-Pineda P, Romero S, et al. Neuromorphological abnormalities in early onset schizophrenia. Program and abstracts of the American Academy of Child and Adolescent Psychiatry 50th Annual Meeting; October 14-19, 2003; Miami, Florida. Abstract A47. ŠŠBeitchman, J.M. (1985) Childhood Schizophrenia : ‘A review and comparison with Adult-onset Schizophrenia’. Psychiatric Clinics of North America, 8, 793-814. children: findings from a psychiatric emergency service. Ann NY Acad Sci 2003; 1008:261-264. ŠŠClark, A.F. (2001) Proposed treatment for adolescent psychosis. 1: Schizophrenia and Schizophrenia-like psychoses. Advances in Psychiatric Treatment, 7, 16-23. ŠŠDepartment of Health and Human Services – National Institutes of Health (2005) Schizophrenia: Childhood-Onset Schizophrenia. Retrieved July 14, 2007, from MedicineNet.com Web site: http://www.medicinenet.com/script/main/art. asp?articlekey=41427 ŠŠDepartment of Health and Human Services – National Institutes of Health (2003) Facts About Childhood Onset Schizophrenia: An Update from the National Institute of Mental Health. Retrieved July 30, 2007 from University of Virginia Health System. Web site: http://www.healthsystem.virginia.edu/internet/psychiatric/PDFs/ Schizophrenia/NIMHChildOnset.pdf

ŠŠDunn, D. (2006) Schizophrenia and Other Psychoses. Retrieved August 1, 2007 from emedicine.com. Web site: http://www.emedicine.com/ped/topic2057.htm ŠŠEdelsohn GA, Rabinovich H, Portnoy R: Hallucinations in nonpsychotic ŠŠHollis, C. (2000) Adult Outcomes of Child – and Adolescent-Onset Schizophrenia: Diagnostic Stability and Predictive Validity. Am J Psychiatry 157:1652-1659. ŠŠHollis, C. (2003) Developmental precursors of child – and adolescent-onset schizophrenia and affective psychoses: diagnostic specificity and continuity with symptom dimensions. The British Journal of Psychiatry 182: 37-44. ŠŠ•Kanner, L. (1971) Childhood psychosis: a historical overview. Retrieved July 14, 2007 from neurodiversity.com. Web site: http://neurodiversity.com/library_kanner_1971a. html ŠŠ•Lambert, L. (2001) Identification and management of Schizophrenia in childhood. Journal of Child and Adolescent Psychiatric Nursing, Apr-Jun 2001. ŠŠ•Living with Childhood-Onset Schizophrenia (2004). Living with childhoodonset schizophrenia. Retrieved July 26, 2007 from Living with Childhood-Onset Schizophrenia. Web site: http://www.childhood-schizophrenia.org/ ŠŠMayo Foundation for Medical Education and Research (2006) Childhood Schizophrenia. Retrieved July 23, 2007 from CNN.com. Web site: http://www.cnn.com/ HEALTH/library/ DS/00868.html ŠŠMayo Foundation for Medical Education and Research (2007) Schizophrenia. Retrieved from revolutionhealth. Web site: http://www.revolutionhealth.com/conditions/mentalbehavioral-health/schizophrenia/schizophrenia?section=section_05 ŠŠMerck and Co., Inc. (2005) Childhood Schizophrenia. Retrieved August 3, 2007 from The Merck Manuals Online Medical Library. Web site: http://www.merck.com/mmpe/ sec19/ch300/ch300c.html ŠŠNARSAD – The Mental Health Research Association (2007) Childhood Schizophrenia Retrieved August 10, 2007 from NARSAD. Web site: http://www.narsad.org/dc/ childhood_disorders/schizophrenia.html ŠŠPiaget, J. (1962). Comments on Vygotsky’s critical remarks concerning the language and thought of the child, and the judgement and reasoning of the child. In L.S. Vygotsky (Ed.), Thought and language (pp. 1-14). Cambridge, MA: Massachusetts Institute of Technology Press. ŠŠRemschmidt, H. (2000) Early-onset schizophrenia: History of the concept and recent studies. Indian Journal of Behavioural Sciences, 10 (2) and 11 (1), 11-22. ŠŠRemschmidt, H. (2001) Schizophrenia in children and adolescents. Retireved from Cambridge University. Web site: http://assets.cambridge.org/97805217/94282/ sample/9780521794282ws.pdf ŠŠTarrier, N. (2005) Cognitive Behaviour Therapy for Schizophrenia – A Review of Development, Evidence and Implementation. Psychotherapy and Psychosomatics 74:136-144 ŠŠTengan, S.K. and Maia, A.K. (2004) Functional psychosis in Childhood and Adolescence. J. Pediatr. (Rio de J.), Vol. 80, No. 2, Suppl. O. ŠŠTolbert, H.A. (1996) Psychoses in Children and Adolescents: A Review. Journal of Clinical Psychiatry, 57 (Suppl. 3). ŠŠWilking VN, Paoli C: The hallucinatory experience: an attempt at a psychodynamic classification and reconsideration of its diagnostic significance. J Am Acad Child Psychiatry 1966; 5:431-440.

5. Schizophrenia is a life-long disease that can be controlled but not cured. True False 6. Untreated psychosis is most often associated with longer and more difficult recovery and can lead to significantly increased family distress. True False 7. Medications that assist children in managing their psychotic symptoms have not improved significantly in the past ten to fifteen years. True False 8. Second generation antipsychotic medications (also known as atypical or novel) include Aripiprazole, Clozapine, Olanzapine, Quetiapine, Risperidone and Ziprasidone. True False 9. Schizophrenia is believed to be very common in children.

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Final Examination Questions Choose the best answer for questions 1 through 10 and then proceed to www.elitecme.com to complete your final examination.

True False 10. Children with schizophrenia rarely need comprehensive treatment. True False

1. Childhood schizophrenia is a mild disorder generally treated by pediatricians. True False 2. The most common form of hallucination is auditory in nature. True False 3. Psychosis is a disorder of thought where the person is unable to distinguish reality from fantasy because of impaired ability to test reality. True False 4. Certain areas of the brain that are rich in the neurotransmitter dopamine seem to be affected most often in all types of schizophrenia. True False

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