National Alliance on Mental Illness
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Early Onset Schizophrenia
What is schizophrenia?
Schizophrenia is a major psychiatric illness. Symptoms usually begin in late adolescence or early adulthood. Numerous studies have found that about one in every 100 people around the world has the disorder. However, schizophrenia with an onset in adolescence (prior to age 18) is less common and an onset of the disorder in childhood (before age 13) is exceedingly rare. It is thought that at most one in every 100 adults with schizophrenia develops it in childhood.
Symptoms and Diagnosis
In both adults and children, the symptoms of schizophrenia can be divided into two broad categories—positive symptoms and negative symptoms.
Schizophrenia is diagnosed by the presence of two of the symptoms described above. For a diagnosis of schizophrenia, two of these symptoms must be present for at least six months and must be accompanied by increased difficulty in daily living in areas such as school, friendships and self-care.
Hallucinations or delusions in a child should lead to an evaluation by a mental health professional who has experience working with children and adolescents living with mental health disorders. A diagnosis of schizophrenia is made through an interview with the child and parents using information obtained from them and from school personnel.
Difficulties in diagnosing schizophrenia
Many of the symptoms seen in people with schizophrenia are also found in people with depression, bipolar disorder or other illnesses. As a result, studies have found that misdiagnosis is common. This is particularly true with children and adolescents. As such, it is extremely important to rule out other diagnoses such as depression, bipolar disorder and substance use before making a diagnosis of schizophrenia.
An additional difficulty in making a diagnosis in children and adolescents relates to the fact that hallucinations are surprisingly common and, in fact, are most often seen in children and adolescents with diagnoses other than schizophrenia. In a large study at the National Institutes of Health, the great majority of those previously diagnosed with schizophrenia did not receive that diagnosis following careful evaluation. In many children with other conditions, the nature of the hallucinations is different. While hallucinations in people with schizophrenia are often pervasive when not well treated, many children with other conditions such as mood disorders and dissociative disorders report auditory hallucinations when they are under stress. These hallucinations tend to be brief and very intermittent (lasting for only a few minutes). Also, children are very susceptible to leading questions and therefore should be asked about symptoms in a neutral fashion (i.e., not "Do you hear voices?").
Children with pervasive developmental disorders (autism, Asperger’s disorder, or an unspecified pervasive developmental disorder) often have social difficulties, disorganized behavior and language impairments. These developmental disorders can be confused with a diagnosis of schizophrenia.
Prognosis of early onset schizophrenia
The outcome for children with schizophrenia varies greatly and some individuals function well with medication. Earlier onset is often associated with a poorer outcome when it interferes with attending school and completing an education. However, because children typically live at home with the combined social environments of family and school, symptoms are often recognized early. This fact is significant because recent studies have suggested that earlier treatment may reduce the decline in functioning and long-term impairments commonly associated with schizophrenia. Therefore, accurate and early intervention and diagnosis are critical.
Treatment for schizophrenia
Treatment for schizophrenia includes biological, educational and social interventions. Medication is the cornerstone of the treatment of schizophrenia, but should be viewed as a means to facilitate psychological and social interventions. Treatment with only medication is not as effective as medication therapy combined with other forms of treatment.
The medications used to treat schizophrenia are termed "anti-psychotics" or "neuroleptics". The following second generation antipsychotics are FDA approved for early onset schizophrenia in youth ages 13-17: Rispiridone (Resperidol), aripipazole (Abilify), quetiapine (Seroquel) and Olanzapine (Zyprexa). Although these medications are often effective, they have been associated with significant side effects, including weight gain, increased cholesterol and the risk of diabetes. These side effects need to be regularly monitored and weighed against their effectiveness to treat symptoms of schizophrenia. Body image issues are often an issue to youth which compounds the concerns related to these side effects.
It is also important that associated symptoms be recognized and treated appropriately. For example, individuals with schizophrenia who develop depression or anxiety should be treated for these symptoms.
Children and adolescents with schizophrenia often need adjustments to their educational programs. Typically this would include smaller classrooms with teachers who are experienced with children and adolescents with psychiatric disorders. Their academic work may also need to be modified in order to accommodate problems sometimes associated with schizophrenia such as reduced concentration and attention.
Social difficulties are commonly seen with early onset schizophrenia. These include difficulty making and keeping friends, difficulty with interpersonal interactions and low frustration tolerance. Activities to develop social skills are integral to the treatment of schizophrenia. In addition, family therapy and education about schizophrenia may help family members to cope with the child’s illness.
Reviewed by Ken Duckworth, M.D. July 2010