Childhood schizophrenia

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.

Early signs and symptoms

The earliest indications of childhood schizophrenia may include developmental problems, such as:

• Language delays
• Late or unusual crawling
• Late walking
• Other abnormal motor behaviors — for example, rocking or arm flapping

Some of these signs and symptoms are also common in children with pervasive developmental disorders, such as autism spectrum disorders. So ruling out these developmental disorders is one of the first steps in diagnosis.

Symptoms in teenagers

Schizophrenia symptoms in teenagers are similar to those in adults, but the condition may be harder to recognize. This may be in part because some of the early symptoms of schizophrenia in teenagers are common for typical development during teen years, such as:

• Withdrawal from friends and family
• A drop in performance at school
• Trouble sleeping
• Irritability or depressed mood
• Lack of motivation
• Strange behavior

Compared with adults, teens may be:

• Less likely to have delusions
• More likely to have visual hallucinations

Later signs and symptoms

As children with schizophrenia age, more typical signs and symptoms of the disorder begin to appear. Signs and symptoms may include:

• Hallucinations. Hallucinations can involve any of the senses, but these usually involve seeing or hearing things that don’t exist. Yet for the person with schizophrenia, they have the full force and impact of a normal experience.
• Delusions. These are false beliefs that are not based in reality. For example, you believe that you’re being harmed or harassed; certain gestures or comments are directed at you; you have exceptional ability or fame; another person is in love with you; a major catastrophe is about to occur; or your body is not functioning properly.
• Disorganized thinking (speech). Disorganized thinking is inferred from disorganized speech. Effective communication can be impaired, and answers to questions may be partially or completely unrelated. Rarely, speech may include putting together meaningless words that can’t be understood, sometimes known as word salad.
• Disorganized or abnormal motor behavior. This may show in a number of ways. Behavior is not focused on a goal, which makes it hard to perform tasks. Abnormal motor behavior can include resistance to instructions, inappropriate and bizarre posture, a complete lack of response, or useless and excessive movement (catatonia).
• Negative symptoms. This refers to lack of or reduced ability to function normally. For example, the person appears to lack emotion, such as not making eye contact, not changing facial expressions, or speaking without inflection. Also, the person may talk less, neglect personal hygiene, lose interest in everyday activities or socially withdraw.

Symptoms may be difficult to interpret

When childhood schizophrenia begins early in life, symptoms may build up gradually. The early signs and symptoms may be so vague that you can’t recognize what’s wrong, or you may attribute them to a developmental phase.

As time goes on, symptoms may become more severe and more noticeable. Eventually, your child may develop the symptoms of psychosis, including hallucinations, delusions and difficulty organizing thoughts. As thoughts become more disorganized, there’s often a “break from reality,” frequently resulting in hospitalization and treatment with medication.

When to see a doctor

It can be difficult to know how to handle vague behavioral changes in your child. You may be afraid of rushing to conclusions that label your child with a mental illness. But early treatment will likely help in the long run. Your child’s teacher or other school staff may alert you to changes in your child’s behavior.

Seek medical advice if your child:

• Has developmental delays compared with other siblings or peers
• Has stopped meeting daily expectations, such as bathing or dressing
• No longer wants to socialize
• Is slipping in academic performance
• Has strange eating rituals
• Shows excessive suspicion of others
• Shows a lack of emotion or shows emotions inappropriate for the situation
• Has strange ideas and fears
• Has violent or aggressive behavior or agitation

These general signs and symptoms don’t necessarily mean your child has childhood schizophrenia. They could indicate simply a phase or another condition, such as depression, an anxiety disorder or a medical illness that requires other types of evaluation.

Seek medical care as soon as possible if your child has a change in thinking, as these symptoms should be addressed right away. Signs and symptoms can include:

• Having beliefs not based on reality (delusions)
• Seeing or hearing things that don’t exist (hallucinations), especially voices
• Disorganized or illogical thinking
• Speech that doesn’t make sense

It’s not known what causes childhood schizophrenia, but it’s thought that it develops in the same way as adult schizophrenia does. It’s not clear why schizophrenia starts so early in life for some and not others.

Childhood schizophrenia and other forms of schizophrenia are brain disorders. Genetics and environment likely both play a role in causing schizophrenia.

Problems with certain naturally occurring brain chemicals called neurotransmitters may contribute to childhood schizophrenia. Imaging studies show differences in the brain structure of people with schizophrenia, but the significance of these changes isn’t clear.

Although the precise cause of schizophrenia isn’t known, certain factors seem to increase the risk of developing or triggering schizophrenia, including:

• Having a family history of schizophrenia
• Exposure to viruses, toxins or malnutrition while in the womb
• Abnormal activation of the immune system, such as from inflammation or autoimmune diseases
• Older age of the father
• Taking psychoactive drugs during teen years

Schizophrenia symptoms generally start in the late teens to the mid-30s. It’s uncommon for children to be diagnosed with schizophrenia. Early-onset schizophrenia occurs in children younger than age 17. Very early-onset schizophrenia in children younger than age 13 is rare.

Left untreated, childhood schizophrenia can result in severe emotional, behavioral and health problems. Complications associated with schizophrenia may occur in childhood or later, such as:

• Poor performance or inability to attend school or work
• Inability to perform daily activities, such as bathing or dressing
• Withdrawal from friends and family
• Suicide
• Self-injury
• Anxiety and phobias
• Depression
• Abuse of alcohol, drugs or prescription medications
• Poverty
• Homelessness
• Family conflicts
• Inability to live independently
• Health problems, including those associated with antipsychotic medications, smoking and poor lifestyle choices
• Being a victim of aggressive behavior
• Aggressive behavior

You’re likely to start by first having your child see his or her pediatrician or family doctor. In some cases, you may be referred immediately to a specialist, such as a pediatric psychiatrist or other mental health provider who specializes in child development.

In rare cases where safety is an issue, your child may require an emergency evaluation in the emergency room and possibly a hospital specializing in child and adolescent psychiatry.

What you can do

Being an active participant in your child’s care is critical. Before the appointment make a list of:

• Any symptoms you’ve noticed, including when these symptoms began and how they’ve changed over time — include specific examples
• Key personal information, including any major stresses or recent life changes that may be affecting your child
• Any other medical conditions, including mental health problems, that your child has
• All medications, vitamins, herbs or other supplements that your child takes, including the dosage

Questions to ask

Make a list of questions to ask the doctor, such as:

• What is likely causing my child’s symptoms or condition?
• What are other possible causes?
• What kinds of tests does my child need?
• Is my child’s condition likely temporary or long term?
• How will a diagnosis of childhood schizophrenia affect my child’s life?
• What’s the best treatment for my child?
• What specialists does my child need to see?
• Who else will be involved in the care of my child?
• Are there any brochures or other printed material that I can have? What websites do you recommend?

Don’t hesitate to ask questions anytime that you don’t understand something.

What to expect from your doctor

Your child’s doctor is likely to ask you and your child a number of questions. Anticipating some of these questions will help make the discussion productive. Your doctor may ask:

• When did symptoms first start?
• Have symptoms been continuous or occasional?
• How severe are the symptoms?
• What, if anything, seems to improve the symptoms?
• What, if anything, appears to worsen the symptoms?
• How do the symptoms affect your child’s daily life?
• Have any relatives had a mental illness?
• Has your child experienced any physical or emotional trauma?
• Do symptoms seem to be related to major changes or stressors within the family or social environment?
• Have any other medical symptoms, such as headaches, nausea, tremors or fevers, occurred around the same time that the symptoms started?
• What medications, including herbs, vitamins and other supplements, does your child take?

If schizophrenia is suspected, your child’s doctor typically asks about medical and psychiatric history, conducts a physical exam, and does medical and psychological screenings. Your doctor may also request to review school records. This process can help pinpoint a diagnosis and rule out other problems that could be causing your child’s symptoms.

The diagnostic process generally involves:

• Tests and screenings. These may include blood tests that help rule out conditions with similar symptoms and screening for alcohol and drugs. The doctor also may request imaging studies, such as magnetic resonance imaging (MRI) or computerized tomography (CT) scan of the head to look for abnormalities in the brain structure, or an electroencephalogram (EEG) to look for abnormalities in brain function, such as seizures.
• Psychological evaluation. This may include observing appearance and demeanor, asking about thoughts, feelings and behavior patterns, talking to your child about any thoughts of self-harm or harming others, evaluating ability to think and function at an age-appropriate level, and assessing mood, anxiety and possible psychotic symptoms.

Challenging process

The path to diagnosing childhood schizophrenia can sometimes be long and challenging. In part, this is because so many other conditions can have similar symptoms, such as depression or bipolar disorder. A child psychiatrist may want to monitor your child’s behaviors, perceptions and thinking patterns for six months or more.

For example, the psychiatrist will want to know whether problems occur only at home or at school, or everywhere. In some cases, a psychiatrist may recommend starting medications before an official diagnosis is made. This is especially important for symptoms of aggression or self-injury. Some medications can help limit these types of behavior and restore a sense of normalcy.

Diagnostic criteria

To be diagnosed with childhood schizophrenia, your child must meet certain criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American Psychiatric Association. This manual is used by mental health providers to diagnose mental conditions and by insurance companies to reimburse for treatment.

The psychiatrist may first diagnose your child with a nonspecific psychotic disorder. As thinking and behavior patterns and symptoms become clearer over time, a diagnosis of schizophrenia may be made if the criteria are met.

Diagnostic criteria for childhood schizophrenia are generally the same as for adult schizophrenia. This involves ruling out other mental health disorders and determining that symptoms aren’t due to substance abuse, medication or a medical condition.

A person must have at least two of the following signs and symptoms most of the time during a one-month period, with some level of disturbance being present over six months:

• Hallucinations
• Delusions
• Disorganized speech
• Disorganized behavior
• Catatonic behavior, which can range from a coma-like daze to bizarre, hyperactive behavior
• Negative symptoms, which relate to lack of or reduced ability to function normally

At least one of the symptoms must be hallucinations, delusions or disorganized speech.

The person shows a significant decrease in the ability to attend school, work or perform normal daily tasks most of the time.

Schizophrenia in children requires lifelong treatment, even during periods when symptoms seem to go away. Treatment is a particular challenge for children with schizophrenia.

Treatment team

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
• Pharmacist

Main treatment options

The main treatments for childhood schizophrenia are:

• Medications
• Individual and family therapy
• Social and academic skills training
• Hospitalization

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.

Second-generation antipsychotics

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 antipsychotics

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:

• Chlorpromazine
• Perphenazine
• 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.

Psychotherapy

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.

Hospitalization

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.

Although childhood schizophrenia requires professional treatment, here are ways to get the most out of the treatment plan:

• Take medications as directed. Try to make sure that your child takes medications as prescribed, even if he or she is feeling well and has no current symptoms. If medications are stopped or infrequently taken, the symptoms are likely to come back and your doctor will have a hard time knowing what the best and safest dose is.
• Check first before taking other medications. Contact the doctor who’s treating your child for schizophrenia before your child takes medications prescribed by another doctor or before taking any over-the-counter medications, vitamins, minerals, herbs or other supplements. These can interact with schizophrenia medications.
• Pay attention to warning signs. You and your child may have identified things that may trigger symptoms, cause a relapse or prevent your child from carrying out daily activities. Make a plan so you know what to do if symptoms return. Contact your child’s doctor or therapist if you notice any changes in symptoms to prevent the situation from worsening.
• Make physical activity and healthy eating a priority.Medications used to treat schizophrenia are associated with an increased risk of obesity and high cholesterol in children. Work with your child’s doctor to make a nutrition and physical activity plan for your child that will help manage weight and benefit heart health.
• Avoid drugs, tobacco and alcohol. Alcohol and illegal drugs can worsen schizophrenia symptoms. Make sure your child isn’t using drugs or alcohol. If necessary, get appropriate treatment for a substance abuse problem.

Coping with childhood schizophrenia can be challenging. Medications can have unwanted side effects, and you, your child and your whole family may feel angry or resentful about having to manage a condition that requires lifelong treatment. To help cope with childhood schizophrenia:

• Learn about the condition. Education about schizophrenia can empower you and your child and motivate him or her to stick to the treatment plan.
• Join a support group. Support groups for people with schizophrenia can help you reach out to other families facing similar challenges. You may want to seek out separate groups for you and for your child so that you each have a safe outlet.
• Get professional help. If you as a parent or guardian feel overwhelmed and distressed by your child’s condition, consider seeking professional help from a mental health provider.
• Stay focused on goals. Dealing with childhood schizophrenia is an ongoing process. Stay motivated as a family by keeping treatment goals in mind.
• Find healthy outlets. Explore healthy ways your whole family can channel energy or frustration, such as hobbies, exercise and recreational activities.
• Take time as individuals. Although managing childhood schizophrenia is a family affair, both children and parents need their own time to cope and unwind. Create opportunities for healthy alone time.

Early identification and treatment may help get symptoms of childhood schizophrenia under control before serious complications develop. Early treatment is also crucial in helping limit psychotic episodes, which can be extremely frightening to a child and his or her parents. Avoid treatment delays to help improve your child’s long-term outlook.

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