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Childhood schizophreniaBy Mayo Clinic staff
Original Article: http://www.mayoclinic.com/health/childhood-schizophrenia/DS00868
Childhood schizophrenia is one of several types of schizophrenia, a chronic mental illness in which a person loses touch with reality (psychosis). Childhood schizophrenia is essentially the same as schizophrenia in adults, but it occurs early in life — sometimes even before the teen years — and has a profound impact on a child's behavior.
Childhood schizophrenia includes hallucinations; delusions; irrational behavior and thinking; and problems carrying out routine daily tasks, such as bathing. With childhood schizophrenia, the early age of onset presents special challenges for diagnosis, treatment, educational needs, and emotional and social development.
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, such as rocking or arm flapping
Some of these signs and symptoms are also common in children with pervasive developmental disorders, such as autism. In fact, ruling out these developmental disorders is one of the first steps in diagnosing childhood schizophrenia.
Later signs and symptoms
As children with schizophrenia age, more typical signs and symptoms of the disorder begin to appear, including:
- Seeing or hearing things that don't exist (hallucinations), especially voices
- Having beliefs not based on reality (delusions)
- Lack of emotion
- Emotions inappropriate for the situation
- Social withdrawal
- Poor school performance
- Decreased ability to practice self-care
- Strange eating rituals
- Incoherent speech
- Illogical thinking
Symptoms may be difficult to interpret
When childhood schizophrenia begins very early in life, symptoms may build up gradually. The early signs and symptoms may be so vague that you can't quite decide what's wrong, or you may attribute them to a developmental phase.
As time goes on, the symptoms may become more severe and more noticeable to family, friends and school officials. Eventually, your child may develop the symptoms of psychosis, including hallucinations, delusions and difficulty with organizing his or her thoughts. As thoughts become more disorganized, there's often a "break from reality." This phase of childhood schizophrenia is often the most distressing to children and their families and frequently results 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 may lead to stigmatizing labels. Yet, treatment at the first sign of a problem may help in the long run.
If you notice that your child has stopped meeting daily expectations, such as bathing or dressing, no longer wants to socialize, is slipping in academic performance, has violent or aggressive behavior, or has other signs and symptoms of a possible mental health disorder, seek medical advice. These general signs and symptoms don't necessarily mean a 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.
If your child has a change in thinking, such as developing hallucinations, disorganized thinking patterns or distortions in reality, seek medical care as soon as possible, as these symptoms should be addressed right away. Your child's teacher or other school personnel also may bring to your attention changes in your child's behavior.
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, though, 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 while in the womb
- Poor nutrition while in the womb
- Stressful life circumstances
- Older paternal age
- Taking psychoactive drugs during adolescence
Signs and symptoms of schizophrenia typically develop between the teenage years and the mid-30s. Early-onset schizophrenia occurs in children younger than age 17. Very early-onset schizophrenia occurs in children younger than age 13.
Left untreated, childhood schizophrenia can result in severe emotional, behavioral, health, and even legal and financial problems. Complications that childhood schizophrenia may cause or be associated with include:
- Suicidal thoughts and behavior
- Self-destructive behavior
- Abuse of alcohol, drugs or prescription medications
- Inability to perform daily activities, such as bathing or dressing
- Declining school performance
- Inability to attend school
- Inability to live independently
- Withdrawal from friends and family
- Behavior problems, including fighting, damaging property and stealing
- Health problems from antipsychotic medications
Preparing for your appointment
You're likely to start by first having your child see his or her pediatrician or family doctor. In some cases when you call to set up an appointment, 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. Start by getting prepared for a scheduled medical or psychiatric appointment. Think about your child's needs and goals, and review your child's symptoms and medical history. Before the appointment:
- Write down any symptoms you've noticed, including when these symptoms began and how they've changed over time. Try to have specific examples ready.
- Write down key personal information, including any major stresses or recent life changes that may be affecting your child.
- List any other medical conditions, including mental health problems, with which your child has been diagnosed.
- Take a list of all medications, as well as any vitamins or supplements, that your child takes.
Questions to ask
Write down a list of questions to ask. These questions may include:
- What is likely causing my child's symptoms or condition?
- Other than the most likely cause, what are other possible causes for my child's symptoms or condition?
- What kinds of tests does my child need?
- Is my child's condition likely temporary or chronic?
- 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 take home with me? What websites do you recommend visiting?
In addition to the questions that you've prepared to ask your doctor, don't hesitate to ask questions anytime you don't understand something being discussed.
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 vitamins and supplements, does your child take?
Tests and diagnosis
If your doctor or mental health provider believes your child may have childhood schizophrenia or another mental illness, he or she typically runs a series of medical and psychological tests and exams. These can help pinpoint a diagnosis, rule out other problems that could be causing your child's symptoms and check for any related complications.
These exams and tests generally include:
- Physical exam. This may include measuring height and weight; checking vital signs, such as heart rate, blood pressure and temperature; listening to your child's heart and lungs; and examining the abdomen.
- Laboratory tests. These may include a complete blood count (CBC), screening for alcohol and drugs, and a check of your child's thyroid function. Other tests that may be ordered to check for other medical problems may include magnetic resonance imaging (MRI) 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. A doctor or mental health provider will talk to you and your child about his or her thoughts, feelings and behavior patterns. He or she will ask about symptoms, including when they started, how severe they are, how they affect daily life and whether your child has had similar episodes in the past. The doctor may also talk to your child about any thoughts of suicide, self-harm or harming others.
Your child may be evaluated to check his or her ability to think and function at an age-appropriate level. Your doctor may also request to review school records. And your child may be asked to complete psychological questionnaires to help examine his or her mood, anxiety and possible psychotic symptoms.
A difficult and possibly long 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, bipolar disorder or substance abuse. Also, doctors often don't want to rush a diagnosis of such a serious condition. A child psychiatrist may want to monitor your child for six months or more.
During that time, your child's psychiatrist will monitor your child's behaviors, perceptions and thinking patterns. For example, the psychiatrist will want to know whether problems occur at home or at school, or whether they occur in all environments. In some cases, a psychiatrist may recommend starting treatment with medications even before an official diagnosis is made. This is especially important when symptoms of aggression or self-injury have occurred. Some of the medications can be very helpful in limiting these types of behavior and restoring a sense of normalcy to your child's behavior.
Diagnostic criteria for childhood schizophrenia
To be diagnosed with childhood schizophrenia, your child must meet certain symptom criteria spelled out in the Diagnostic and Statistical Manual of Mental Disorders (DSM). This manual is published by the American Psychiatric Association and 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, rather than schizophrenia. As thinking and behavior patterns and symptoms become more clear 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 and include:
- Presence of at least two of these: delusions, hallucinations, disorganized speech, disorganized or catatonic behavior, lack of emotion, social withdrawal, inability to carry out routine daily tasks such as dressing and bathing
- Failure to achieve the expected level of academic, social or work performance
- Signs last for at least six months
- Other mental health disorders have been ruled out
Treatments and drugs
Childhood schizophrenia is a chronic condition, lasting through adulthood. Because of this, schizophrenia in children requires lifelong treatment, even during periods when symptoms seem to have subsided. Treatment is similar for all types of schizophrenia, but is a particular challenge for children with schizophrenia.
Childhood schizophrenia treatment is usually guided by a psychiatrist skilled in treating schizophrenia in children. But because the condition can affect so many areas of your child's life, other professionals may be on the treatment team too. The treatment team can help make sure that your child is getting all of the treatment he or she needs and that care is coordinated among all of his or her care providers.
The team involved in treatment of childhood schizophrenia may include your:
- Pediatrician or family doctor
- Case worker
- Psychiatric nurse
- Social worker
- Family members
Main treatment options
The main treatments for childhood schizophrenia are:
- Individual and family psychotherapy
- Social and academic skills training
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 to treat adults with schizophrenia. While most of those medications haven't been specifically approved to treat children — mainly because they haven't been thoroughly tested in children — they can be used off-label in children. Off-label use is a common and legal practice of using a medication to treat a condition or age group not specifically listed on its prescribing label as an approved use.
Because of the possibility of serious side effects, make sure you understand all the pros and cons of antipsychotic medication use in children.
Second-generation antipsychotics (atypical antipsychotics)
A class of antipsychotic medications called atypical antipsychotic medications are usually tried first in children because they have fewer side effects. The Food and Drug Administration has approved only two second-generation antipsychotics to treat childhood schizophrenia in children ages 13 to 17:
- Risperidone (Risperdal)
- Aripiprazole (Abilify)
Atypical antipsychotic medications are often effective at managing such symptoms as hallucinations, delusions, loss of motivation and lack of emotion. Serious side effects can include weight gain, diabetes and high cholesterol and, more rarely, movement disorders.
First-generation antipsychotics (conventional, or typical, antipsychotics)
These antipsychotic medications are usually equally as effective as second-generation antipsychotics in controlling delusions and hallucinations. Conventional antipsychotics, however, may have more serious neurological side effects. Risks include the possibility of developing a movement disorder (tardive dyskinesia) that causes involuntary movements of the face, tongue, limbs and hands. Although the conventional and atypical antipsychotics both share this risk, the conventional agents are more likely to result in movement disorders, especially if they are taken over a long period of time.
Typical antipsychotics, especially generic versions, are often cheaper than second-generation antipsychotics. However, their risk of serious side effects means they often aren't recommended for use in children until other options have been tried without success.
Medication side effects and risks
All antipsychotic medications have side effects and possible health risks, some life-threatening. Side effects in children and adolescents 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.
Be sure to talk to your child's doctors about all of the possible side effects and about routine checks for health problems while he or she takes these medications. Also, be alert for problems in your child, and report side effects to the doctor as soon as possible. By spotting medication problems early, your child's doctor may be able to adjust the dosage or change medications and limit side effects. Your child's doctors also can help all of you learn to manage side effects appropriately.
Also, antipsychotic medications can have dangerous interactions with other substances. Tell your child's doctors about all medications and over-the-counter substances he or she takes, including vitamins, minerals and herbal supplements.
Psychotherapy for childhood schizophrenia
Although medications are a key childhood schizophrenia treatment, psychotherapy also 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 can help your child make friends and succeed at school. Learning about childhood schizophrenia can help your child understand his or her condition, cope with symptoms, and stick to a treatment plan. There are many types of psychotherapy that may be useful, such as cognitive behavioral therapy.
- Family therapy. Both 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 communicate better with each other, work out conflicts and cope with stress related to your child's condition.
Social and academic skills training for childhood schizophrenia
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 skill-building in these areas can help your child function at age-appropriate levels when possible.
Hospitalization for childhood schizophrenia
During crisis periods or times of severe symptoms, hospitalization may be necessary. This can help ensure your child's safety and that of others, and make sure that he or she is getting proper nutrition, sleep and hygiene. Getting symptoms under control quickly is very important in childhood schizophrenia, and sometimes the hospital setting is the safest and best way to do this. Partial hospitalization and residential care also may be options, but symptoms are usually more stabilized before moving to these levels of care.
Lifestyle and home remedies
Childhood schizophrenia isn't an illness that you or your child can treat on your own. But you can do some things for your family and your child that will build on the professional treatment plan:
- Take medications as directed. Try to make sure that your child takes medications exactly 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 for treatment is.
- Pay attention to warning signs. You and your child may have identified things that may trigger his or her schizophrenia symptoms, cause a relapse or prevent your child from carrying out daily activities. Make a plan so that you know what to do if symptoms return. Contact your child's doctor or therapist if you notice any changes in symptoms. Addressing schizophrenia symptoms early can prevent a situation from worsening.
- Make exercise and healthy eating a priority. Medications used to treat schizophrenia are associated with an increased risk of obesity and high blood cholesterol in children. Work with your child's doctor to make a nutrition and exercise plan for your child that will help manage weight and benefit your child's heart health.
- Avoid drugs, tobacco and alcohol. Alcohol and illegal drugs can worsen schizophrenia symptoms. Make sure your child isn't using drugs and alcohol. If necessary, get appropriate treatment for a substance abuse problem.
- 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 or supplements. These can interact with schizophrenia medications.
Coping and support
Coping with an illness as serious as 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. Here are some ways to cope with childhood schizophrenia:
- Learn about childhood schizophrenia. Education about the condition 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. Recovery from childhood schizophrenia is an ongoing process. Stay motivated as a family by keeping recovery goals in mind. As a family, you're responsible for managing the illness and working toward goals.
- Find healthy outlets. Explore healthy ways your whole family can channel energy or frustration, such as hobbies, exercise and recreational activities.
- Structure your time. Plan your day and activities. Try to stay organized. You may find it helpful to make a list of daily tasks.
- 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.
There's no sure way to prevent childhood schizophrenia. But evidence shows that some signs of schizophrenia may be present as early as infancy. Early identification and treatment may help get symptoms under control before serious complications develop. Avoiding treatment delays may help improve the long-term outlook. Early treatment is also crucial in helping limit psychotic episodes, which can be extremely frightening to a child and his or her parents.
Signs and symptoms during infancy or early childhood years that may warrant further evaluation include:
- Early language delays
- Early motor development delays
- School problems
Getting early treatment — and sticking with it — can help reduce or prevent worsening schizophrenia symptoms.
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