Childhood Schizophrenia

Childhood schizophrenia is a very rare condition but it is an illness with high rates of psychosocial impairment, with a poorer prognosis compared to the adult onset form.

Schizophrenia before the age of 17 is known as early-onset schizophrenia. If it occurs before the age of 13, it is termed very early-onset schizophrenia. Very early-onset schizophrenia is rare, and it is estimated that its prevalence is 1:30,000. The incidence increases with adolescenc to 1 in 1000. Schizophrenia will have the same devastating effect on children as it will have on adults. It can impair psychosocial and occupational functioning and interfere with schooling, interpersonal relationships, disrupt families and lead to significant reliance on family and social services for support.

Boys are more affected than girls, and also get affected at a younger age than girls. It is thought that the hormone oestrogen has a protective effect on brain development and therefore girls are more protected. Schizophrenia is rarely diagnosed before the age of 5 years.

The symptoms of childhood schizoprenia usually emerge slowly over months to years. Occasionally the symptoms emerge suddenly in a previosuly well functioning child. The risk and causal factors are the same as for adult schizophrenia. The children who eventual meet criteria for childhood schizophrenia often have a history of poor social functioning and poor academic achievement despite normal intelligence, and delayed motor and language milestones. Early diagnosis is difficult and most will invariably have been diagnosed with other disorders such as ADD, learning disability, developmental delay, autism, OCD, anxiety and depression before the schizophrenia becomes more overt.

Both early-onset and very early-onset schizophrenia are diagnosed using the same DSM-IV criteria as for adult schizophrenia. This would be the presence of hallucinations, delusions, or thought disorder, with a functional decline over at least 6 months. In retrospect, it might be noticed that the patient was going through the prodromal period. This would have recognised by a change in behaviour, becoming socially withdrawn, behaving oddly, or there may have a period of depression.

The symptoms are similar as in adult schizophrenia. Auditory hallucinations will also commnly occur in children. They may hear several voices making critical derogatory comments, or commands to kill or harm themselves or others. The voices may be bizarre, described as an alien or computer, or it may be that of a relative. The visual hallucinations can be every frightening. Children describe seeing skeletons, creatures, and devils.

Delusions occur with increased frequency as the child gets older. They can be persecutory, grandiose and religious. Disordered thinking and speech are common symptoms. Their style of speaking is often characterised by decreased attempts to correct their speech or to make themselves understood, through repetition, more detail and revision.

It must be remembered that the content of hallucinations and delusions will be age-specific. eg a young age will have animal and monster themes, while an older child may have themes of the occult, or being pursued by alien or government agencies.

Childhood schizophrenia is sometimes difficult to differentiate from other childhood-onset illnesses. These include autistic spectrum disorders, affective (manic or depressive) disorders, schizotypal personality disorder, epilepsy, and psychosis related to medical disorders or illicit drugs. 10% of children will also report non-psychotic hallucinations and delusions.

The DSM-IV differentiates 5 types of schizophrenia: paranoid, disorganised, residual, undifferentiated and catatonic.

Treatment of childhood schizophrenia will require the use of both medication and psychology therapies, taking into account the developmental stage of the child and the family dynamics. Schooling is vital to any child and appropriate educational support will have to be provided as well.

Psychological therapy
It has been shown that adults with schizoprenia will benefit from psychosocial interventions (cognitive behavioural therapy, social skills, cognitive remediation, and family intervention). There are few studies that have systematically examined the benefits of psychosocial inteventions in childhood schizophrenia. One study found benefit in using cognitive enhancement therapy in a small sample of patients with early-onset schizohrenia. So the potential for benefit does exist, but this will differ on the psychological maturation of the child. The decision to offer therapy will ultimately depend on the resources available, and opinion following a psychological assessment of the child.

Basic but effective psychotherapy should include psychoeducation for the child, family members and significant others. The school might have to be involved if there are significant symptoms related to the schizophrenia or significant imtellectual impairments.

Antipsychotic drugs
The mainstay of treatment will always be antipsychotic drugs, the same ones used in adult onset schizophrenia.

Typical antipsychotic drugs have been shown to be effective in childhood schizophrenia. The last study was done in 1992 which showed haloperidol to be more effective than placebo. This was however accompanied by a high rate of side effects such as extra-pyramidal side effects, sedation, and raised prolactin. There was also concern that children may be more sensitive to the development of EPS than adults.

Currently atypical antipsychotics are considered first line treatment for childhood schizophrenia and adolescent schizophrenia. This is due to the decreased risk of movement side effects viz: extra-pyramidal side effects and late onset tardive dyskinesia. The atypical antispychotics used in schizophrenia in children include risperidone, olanzapine, quetiapine, aripiprazole and zyprasidone. Only risperidone and aripiprazole have US Food and Drug Administration (FDA) approval for the treatment of early-onset schizophrenia, but all these atypical antipsychotics are used as treatment.

Atypical agents are as effective in reducing psychotic symptoms compared to typical antipsychotics. There is a reduced burden of extra-pyramidal side effects and tardive dyskinesia but the one major draw back has been weight gain and metabolic side effects, diabetes and raised cholesterol. This is compounded by the fact that children and adolescents seem to be more sensitive than adults to the weight gaining effects of the antipsychotic drugs. Other side effects include prolactin elevation, akathisia and sedation.

In an extensive review of the use of atypicals in childhood and adolescence, it was found that olanzapine was associated with the most weight gain. Aripiprazole, quetipaine and riperidone were associated with intermediate weight gain, and zyprasidone was associated with the least weight gain.

Clozapine remains the treatment of choice for treatment resistant schizophrenia, and also has lower risks of extra-pyramidal side effects and tardive dyskinesia. The haemotological side effects of low white cells or bone marrow failure remains.

Ultimately, the type and number of medications that the patient is on, will be a result of a careful consideration of the adverse effects of the drugs versus any benefits provided, bearing in mind that there also varying individual responses to drugs.



References
Curr Opin Psych 2010, 23:304310
Eur Psychiatry. 2011 Feb 2
Synopsis in Psychiatry 9th ed
CNS Drugs. 2007;21(12):1035-8
Drugs. 2011 Jan 22;71(2):179-208


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