Childhood-Onset Schizophrenia: An Update

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A child's stage of development must be taken into account when considering a diagnosis of mental illness. Behaviors that are normal at one age may not be at another. Rarely, a healthy young child may report strange experiences-such as hearing voices-that would be considered abnormal at a later age. Clinicians look for a more persistent pattern of such behaviors. Parents may have reason for concern if a child of 7 years or older often hears voices saying derogatory things about him or her, or voices conversing with one another, talks to himself or herself, stares at scary things-snakes, spiders, shadows-that are not really there, and shows no interest in friendships. Such behaviors could be signs of schizophrenia , a chronic and disabling form of mental illness.

Fortunately, schizophrenia is rare in children, affecting only about 1 in 40,000, compared to 1 in 100 in adults. The average age of onset is 18 in men and 25 in women. Ranking among the top 10 causes of disability worldwide, schizophrenia, at any age, exacts a heavy toll on patients and their families. Children with schizophrenia experience difficulty in managing everyday life. They share with their adult counterparts psychotic symptoms (hallucinations, delusions), social withdrawal, flattened emotions, increased risk of suicide and loss of social and personal care skills. They may also share some symptoms with-and be mistaken for-children who suffer from autism or other pervasive developmental disabilities, which affect about 1 in 500 children. Although they tend to be harder to treat and have a worse prognosis than adult-onset schizophrenia patients, researchers are finding that many children with schizophrenia can be helped by the new generation of antipsychotic medications.

Symptoms and Diagnosis

While schizophrenia sometimes begins as an acute psychotic episode in young adults, it emerges gradually in children, often preceded by developmental disturbances, such as lags in motor and speech/language development. Such problems tend to be associated with more pronounced brain abnormalities. The diagnostic criteria are the same as for adults, except that symptoms appear prior to age 12, instead of in the late teens or early 20s. Children with schizophrenia often see or hear things that do not really exist, and harbor paranoid and bizarre beliefs. For example, they may think people are plotting against them or can read their minds. Other symptoms of the disorder include problems paying attention, impaired memory and reasoning, speech impairments, inappropriate or flattened expression of emotion, poor social skills, and depressed mood. Such children may laugh at a sad event, make poor eye contact, and show little body language or facial expression.

Misdiagnosis of schizophrenia in children is all too common. It is distinguished from autism by the persistence of hallucinations and delusions for at least 6 months, and a later age of onset-7 years or older. Autism is usually diagnosed by age 3. Schizophrenia is also distinguished from a type of brief psychosis sometimes seen in affective, personality, and dissociative disorders in children. Adolescents with bipolar disorder sometimes have acute onset of manic episodes that may be mistaken for schizophrenia. Children who have been victims of abuse may sometimes claim to hear voices of-or see visions of-the abuser. Symptoms of schizophrenia characteristically pervade the child's life, and are not limited to just certain situations, such as at school. If children show any interest in friendships, even if they fail at maintaining them, it is unlikely that they have schizophrenia.

Treatment

Treatments that help young patients manage their illness have improved significantly in recent decades. As in adults, antipsychotic medications are especially helpful in reducing hallucinations and delusions. The newer generation "atypical" antipsychotics, such as olanzapine and clozapine, may also help improve motivation and emotional expressiveness in some patients. They also have a lower likelihood of producing disorders of movement, including tardive dyskinesia, than the other antipsychotic drugs such as haloperidol. However, even with these newer medications, there are side effects, including excess weight gain that can increase risk of other health problems. The NIMH (National Institute of Mental Health) is conducting research studies to improve treatments (www.clinicaltrials.gov). Children with schizophrenia and their families can also benefit from supportive counseling, psychotherapies, and social skills training aimed at helping them cope with the illness. They likely require special education and/or other accommodations to succeed in the classroom.