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Childhood Schizophrenia

Schizophrenia of Childhood

Childhood schizophrenia is a form of schizophrenia that targets children younger than 12.


Presentation

Patients with childhood schizophrenia exhibit similar clinical symptoms as adults with the disorder, but they are less prone to elaborate delusions or visual hallucinations. Some important features can differentiate the two different types of schizophrenia. These include a more extensive family history of the disease, an insidious onset, more prominent deterioration of cognitive functioning, symptoms that are in general more severe, presence of various genetic and developmental abnormalities including motor disability as well as mental dysfunction, and organic cerebral changes such as increases in the volume of the ventricles and loss of cortical gray matter.

Schizophrenia is diagnosed by identifying a collection of symptoms. No single symptom is uniquely associated with the disease. First rank symptoms that were described in 1959 by Kurt Schneider are considered important in the establishment of the diagnosis. They include hallucinations, delusions, thought insertion or withdrawal and auditory hallucinations characterized by a running commentary over the behavior of the patient.

Furthermore, hallucinations characteristic of the disorder are somatic in nature. They tend to refer to various sensations in many body organs but with no attributable organic cause. Delusions usually manifest in beliefs that an external authority has the capacity to insert or remove particular thoughts from the mind of the patient.

Symptoms in schizophrenia can be further classified into positive or negative. Positive symptoms generally refer to behavior that is an excess of what is generally considered normal. These include the first rank symptoms defined by Schneider, in addition to disorganized thought, speech and behavior. Speech abnormalities are a hallmark of the disease, and they principally manifest with looseness of association, in which the patient falsely creates relationships between unrelated semantic concepts. Tangentiality is another feature of the disease, and it describes a patient's tendency to stray off from a present topic into a completely different one without any logical coherence. Patients may also talk in a "word salad", whereby the speech has almost a complete lack of logical and semantic coherence. In addition to thought and speech processes, behavior can also be disorganized in the sense that the patient is unable to accomplish goal-oriented tasks such as the preparation of meals or taking care of their daily needs. Patients may also exhibit increased agitation in the form of cursing or loud shouting, dress inadequately or perform sexual acts in public.

Negative symptoms, on the other hand, represent an absence of behavior that is expected to be common in normal individuals. Several negative symptoms are critical in the establishment of the diagnosis and are generally associated with greater social and emotional dysfunction. A deficiency in processing and exhibiting emotions is termed affective flattening and is very characteristic of the disease. In addition, patients may display poor speech content and show a complete absence of motivation to perform tasks. Negative symptoms are usually harder to identify for psychiatrists than positive ones.

Pediatric Disorder
  • This pediatric disorder is characterized by the onset of this disease before the age of thirteen. In general, earlier onset of this mental illness is more severe than later first occurrences.[schizlife.com]
Abnormal Eye Movement
  • Other anomalies associated with adult schizophrenia, such as abnormal eye movements, are also more common in families of children with the illness.[schizophrenia.com]
Auditory Hallucination
  • Among the actual psychotic symptoms seen in childhood schizophrenia auditory hallucinations are the most common. They are often presented in relatively simple form of akoasms (auditory hallucinations, such as noise, shots, knocks, etc.).[en.wikipedia.org]
  • Children with schizophrenia often hear voices and other noises that other people do not hear (auditory hallucinations ). They also firmly believe something is true even when there is proof that it is false ( delusion ).[cigna.com]
Visual Hallucination
  • Patients with childhood schizophrenia exhibit similar clinical symptoms as adults with the disorder, but they are less prone to elaborate delusions or visual hallucinations.[symptoma.com]
  • Among the 35 children in the UCLA study, 80 percent presented with auditory hallucinations, 74 percent with flat or inappropriate affect, 63 percent with delusions, 40 percent with formal thought disorder, and 37 percent with visual hallucinations.[academic.oup.com]
  • Hallucinations – An obvious sign is if the child experiences auditory hallucinations (e.g. hearing voices in their head ) and/or experiences visual hallucinations (e.g. sees things that aren’t really there).[mentalhealthdaily.com]
  • Tactile and visual hallucinations seem relatively rare.[en.wikipedia.org]
  • hallucinations Later signs and symptoms As children with schizophrenia age, more typical signs and symptoms of the disorder begin to appear.[mayoclinic.com]
Withdrawn
  • The patients' premorbid personality also seems to be of great importance: A poor prognosis can be found in patients who were cognitively impaired, shy, introverted, and withdrawn before the beginning of their psychotic state.[doi.org]
  • Often children show their signs gradually, such a child may become shy or withdrawn. These signs are often first noticed by teachers. Children may begin talking about odd fears or ideas.[schizophrenia.com]
  • When the teen presents with a depressed or withdrawn mood, a physician will refer to psychotherapy and/or counseling.[factbasedhealth.com]
  • Children who used to enjoy relationships with others may become more shy or withdrawn and seem to be in their own world. Treatment Early diagnosis and medical treatment are important.[psychotherapyclinicokc.com]
  • Early descriptions that were used to classify autism included "atypical and withdrawn behavior," "failure to develop identity separate from the mother's," and "general unevenness, gross immaturity, and inadequacy in development."[medicalnewstoday.com]
Paranoid Ideation
  • Negative schemata about the self and others and paranoid ideation in at-risk states and those with persisting positive symptoms . Early Intervention in Psychiatry, Vol. 12, Issue. 6, p. 1157. CrossRef Google Scholar Saglier, Christophe 2018.[bjp.rcpsych.org]
  • No difference was appreciated in rates of suicidal behavior between children versus adolescents with a psychotic disorder. [60] Violence is also a potential problem, particularly for the adolescent with paranoid ideation.[emedicine.medscape.com]

Workup

Diagnosis of schizophrenia is established clinically although laboratory tests are usually administered to rule out other causes of the symptoms.

In cases where substance abuse is suspected, a urine toxicology screen may be necessary. Wilson disease can also sometimes present with severe psychotic episodes and is usually diagnosed with liver function tests and an assessment of copper and ceruloplasmin serum levels. Other necessary tests may include VDRL (Venereal Disease Research Laboratory) for syphilis, HIV (Human Immunodeficiency Virus) testing, porphobilinogen for porphyria and a screen for heavy metals. Some children may also exhibit mental retardation as well as abnormal physical features. In these cases, it is recommended to perform a genetic assessment and a karyotype that may reveal the 22q11 deletion syndrome or 5q chromosomal mutation [10].

Imaging with MRI or CT is usually routinely performed for patients with a first episode of psychosis. MRI is the preferred modality although CT is an acceptable substitute, in case MRI is not available. Imaging may show an enlargement of the ventricles, as well as losses in gray matter. These findings, however, are not sufficient to diagnose the disease. MRI may also identify other conditions that can manifest similarly to schizophrenia. Leukodystrophy is generally associated with demyelination and neuronal ceroid lipofuscinosis with atrophy.

Patients who exhibit symptoms in an episodic fashion may be investigated with electroencephalography (EEG). Furthermore, treatment with clozapine necessitates an EEG because of an elevated risk of seizure occurrences.

Pathological analyses are usually restricted on postmortem tissue, most frequently for research studies. They have shown decreased hippocampal volume, although no gliosis has been identified. The presence of gliosis generally indicates the presence of an ongoing inflammatory process. Most pathological analyses have been performed on tissue from adult onset schizophrenia.

The mental status examination is the most important tool in the armory of the psychiatrist to diagnose schizophrenia. It generally follows a structured or a semi-structured form, especially during the first assessment. It should be also utilized to monitor symptoms of the patients during later visits. Standardized psychological approaches have been devised to assess particular elements of the disease. These include the brief psychiatric rating scale (BPRS), the Kiddie Schedule for Affective Disorders and Schizophrenia (K-SADS) and the Positive and Negative Syndrome Scale (PANSS) [11]. More symptoms can sometimes be detected with the help of the Rorschach test and the Thematic Apperception Test. Extensive psychological tests are sometimes necessary when devising adequate treatment plans.

Gliosis
  • They have shown decreased hippocampal volume, although no gliosis has been identified. The presence of gliosis generally indicates the presence of an ongoing inflammatory process.[symptoma.com]

Treatment

Treatment of childhood schizophrenia consists mainly of pharmacotherapy and psychosocial management. The mainstay of medical treatment is with antipsychotics. The initial drugs that are employed are the atypical neuroleptics. Benzodiazepines are sometimes used to calm an agitated child and decrease anxiety. Agitation and anxiety can be particularly prominent in psychosis.

Children with schizophrenia open link may also undergo training in social skills. Supportive and cognitive behavioral therapy can also be used to improve coping strategies and help the child identify coming relapses.

Prognosis

Childhood schizophrenia is generally characterized by a worse prognosis than schizophrenia with an onset in adulthood. Children with the disorder eventually become less independent in adulthood are less likely to be employed and have fewer academic achievements and social relationships. Patients who develop schizophrenia generally fare worse than those with a more acute onset. They are also less likely to respond to medication.

Patients with schizophrenia have a more elevated risk of committing suicide. Studies indicate that suicide risk is 5 to 11% in patients with childhood schizophrenia. Around 50% will have significant social impairment, manifested in both academic and occupational status. 10% of all adults with schizophrenia will commit suicide.

Adolescents affected by schizophrenia are also likely to display violent behavior, as well as impulsivity that could result in injury, substance dependence and abuse and the acquirement of sexually transmitted diseases.

Etiology

The etiological factors underlying schizophrenia remain unknown but both genetic and environmental factors are thought to be involved. In particular, genetic predispositions, prenatal factors and future stressful occurrences are thought to ultimately result in neurodevelopmental abnormalities leading to the disease. Genetic involvement has long been suspected as can be evidenced by an increase in the risk of having the disease when it is present in first-degree relatives or identical twin siblings. Indeed, risk increases from 1 to 10% in first-degree relatives and to 50% in case of an identical twin of a patient with the disease. Prenatal factors that are likely to contribute include infections in the second trimester with influenza, blood type incompatibility between mother and fetus that went untreated, malnutrition and deficiency in oxygen at birth.

Genes that were associated with childhood schizophrenia have been also linked to a wide range of diseases including Alzheimer's disease, Crohn disease and breast cancer [4]. Children with schizophrenia also tend to have more frequent genetic abnormalities than adults with schizophrenia. In addition, the disease is associated with a genetic predisposition for schizophrenia in close family members. One study found that up to a third of families of children with schizophrenia have first-degree relatives with paranoid personality disorder, schizotypal personality disorder or schizophrenia. These rates are extremely close to what is generally observed in the adult form of the disease, indicating that both forms may have similar underlying etiology [5]. Families of children with schizophrenia tend to also have more common abnormalities in eye movements.

Epidemiology

Childhood schizophrenia is a very rare disease with prevalence estimated at around 1 case in every 10,000 individuals in the United States. Prevalence increases remarkably with late onset, and approaches 1% for the form of the condition that starts in late adolescence or early childhood.

Prevalence of schizophrenia is almost uniform internationally, with slight increases in more urban environments. Nonetheless, rates in underdeveloped countries are still unknown. Schizophrenia is also more common in men relative to women with an approximate ratio of 2:1.

Studies on childhood schizophrenia have not yet revealed whether the condition is more or less prevalent among men or women or among specific ethnic groups. Nonetheless, the AESOP (Aetiology and Ethnicity in Schizophrenia and Other Psychoses Study) study in 2006 revealed that psychotic disorders tend to occur more commonly among black and minority ethnic groups [6].

Childhood schizophrenia tends to have a worse prognosis than the adult type and is associated with a very insidious presentation. On the other hand, adult-type schizophrenia with an onset in adolescents may have an acute or insidious presentation. Early onset schizophrenia is generally associated with worse outcomes.

Sex distribution
Age distribution

Pathophysiology

Children and adults with schizophrenia share many of the neural, physiological and neuropsychological characteristics of the disease, although children tend to have more severe manifestations. Childhood schizophrenia also opens interesting research avenues for broader investigations into the disease process of schizophrenia as a whole. Studies indicate that children with schizophrenia have more conspicuous abnormalities in brain development relative to patients who display their first psychotic episodes after puberty. Structural magnetic resonance imaging of the brain in adolescents between the ages of 14 to 18 has shown significant enlargements of the ventricles, implying an associated decrease in the volume of overall brain cells [7] [8]. Brain tissue loss was so severe, that it was estimated that adolescents with schizophrenia had already lost almost 4 times the amount of brain tissue in the frontal lobes compared to normal subjects. Brain loss does not occur haphazardly, but rather in a predictable pattern that begins in the occipital and parietal cortices, in areas known to be involved in perception and attention, and further spreads frontally, involving areas of the brain responsible for executive functions such as planning and organization [9]. Tissue shrinkage in the parietal cortex has been mostly associated with environmental factors, indicating that the trigger for the disease is most likely to be caused by the environment. On the other hand, the pattern of brain matter loss in the frontal cortex is more similar to what is observed in adult schizophrenia patients. Nonetheless, researchers suggest that even adult subjects with schizophrenia may have already undergone a similar process during their adolescence but, because of the absence of accompanying symptoms, it may not have been detected.

Prevention

Currently there are no preventive measures for childhood schizophrenia, although ongoing research may yield interesting findings [12] [13].

Summary

Childhood schizophrenia is a particular form of schizophrenia that affects children younger than 12 [1] [2]. The etiological factors underlying the disease are still not completely elucidated, but it is thought that a combination of genetic predisposition, prenatal insults and environmental stress are responsible. Patients usually present with positive and negative symptoms that are typical of the disease seen in adults, although delusional beliefs and visual hallucinations are less prominent [3]. Treatment is with atypical antipsychotics as well as supportive and cognitive behavioral therapy. Childhood schizophrenia generally has a worse prognosis than adult schizophrenia.

Patient Information

Childhood schizophrenia is a form of schizophrenia that develops in children younger than 12. Schizophrenia is a debilitating psychiatric disorder that manifests with a multitude of symptoms that include hallucinations, delusional beliefs, disorganized speech and behavior as well as cognitive decline. Diagnosis is usually clinical, although the physician may perform laboratory tests to rule out other causes. Childhood schizophrenia is treated with a combination of medications and therapy. It generally has a worse prognosis than adult onset schizophrenia.

References

Article

  1. Baribeau DA, Anagnostou E. A comparison of neuroimaging findings in childhood onset schizophrenia and autism spectrum disorder: a review of the literature. Front Psychiatry. 2013 Dec 20;4:175.
  2. Clemmensen L, Vernal DL, Steinhausen HC. A systematic review of the long-term outcome of early onset schizophrenia. BMC Psychiatry. 2012 Sep 19;12:150. 
  3. Lambert LT. Identification and management of schizophrenia in childhood. J Child Adolesc Psychiatr Nurs. 2001 Apr-Jun;14(2):73-80.
  4. Nicolson R, Rapoport JL. Childhood onset schizophrenia: rare but worth studying. Biological Psychiatry, 1999; 46: 1418-28.
  5. Asarnow RF, Nuechterlein KH, Fogelson D, et al. Schizophrenia and schizophrenia-spectrum personality disorders in the first-degree relatives of children with schizophrenia: the UCLA family study. Archives of General Psychiatry, 2001; 58(6): 581-8.
  6. Kirkbride JB, Fearon P, Morgan C, et al. Heterogeneity in incidence rates of schizophrenia and other psychotic syndromes: findings from the 3-center AeSOP study. Arch Gen Psychiatry. 2006 Mar; 63(3):250-8. 
  7. Rapoport JL, Giedd JN, Blumenthal J, et at. Progressive cortical change during adolescence in childhood-onset schizophrenia. A longitudinal magnetic resonance imaging study. Arch Gen Psychiatry. 1999 Jul;56(7):649-54.
  8. Thompson P, Vidal C, Giedd JN, et al. Mapping adolescent brain change reveals dynamic wave of accelerated gray matter loss in very early-onset schizophrenia. Proceedings of the National Academy of Sciences, 2001; 98(20): 11650-5.
  9. Giedd JN, Blumenthal J, Jeffries NO, et al. Brain development during childhood and adolescence: a longitudinal MRI study. Nature Neuroscience, 1999; 2(10): 861-3.
  10. Amminger GP, Schäfer MR, Papageorgiou K, et al. Long-chain omega-3 fatty acids for indicated prevention of psychotic disorders: a randomized, placebo-controlled trial. Arch Gen Psychiatry. 2010 Feb; 67(2):146-54. 
  11. Caplan R, Guthrie D, Fish B, Tanguay PE, David-Lando G. The Kiddie Formal Thought Disorder Rating Scale: clinical assessment, reliability, and validity. J Am Acad Child Adolesc Psychiatry. 1989 May; 28(3):408-16.
  12. Grcevich SJ, Findling RL, Rowane WA, Friedman L, Schulz SC. Risperidone in the treatment of children and adolescents with schizophrenia: a retrospective study. J Child Adolesc Psychopharmacol. 1996 Winter. 6(4):251-7. 
  13. McGorry PD, Yung AR, Phillips LJ, et al. Randomized controlled trial of interventions designed to reduce the risk of progression to first-episode psychosis in a clinical sample with subthreshold symptoms. Arch Gen Psychiatry. 2002 Oct; 59(10):921-8.

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Last updated: 2019-07-11 20:44