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Schizophrenia in Children and Adolescents

Adolescence is full of challenges. A young person may be unwilling to talk about their feelings or share much about what’s happening in their life. This is normal since all adolescents must separate from their parents and establish themselves as young adults. During this time, it may be difficult to see the early warning signs of a mental health condition like depression or even the early symptoms of a developing psychosis.

However, when a young person begins to hear angry voices that aren’t there or to strongly believe strange things you should seek help. An early professional evaluation and beginning treatment during a person’s first episode of psychosis can potentially improve how well they respond to treatment and have a positive effect on long term recovery.

What is schizophrenia?

Schizophrenia is a serious mental illness that has an impact in every area of a young person’s life. It is a complex condition that affects different people in different ways.

Some of the most common types of symptoms people with schizophrenia experience include:

  • Hallucinations. Hallucinations involve the misperception of things that are not really there. Hearing sounds or voices, auditory hallucinations, are the most common hallucinations. The voices are often threatening or critical. Young children may believe that toys or pets are talking. Teenagers might believe that people are talking about them or calling them names. Other types of hallucinations include seeing or smelling things that are not there. Hallucinations may be associated with other medical conditions.
  • Delusions. Delusions involve a fixed belief in something that is not true despite evidence that shows otherwise. A child might express ideas that don’t make sense or have fearful beliefs. A young person may believe that strangers know what they are thinking or that the television is sending them messages. Trying to argue or convince the person that they are mistaken or wrong will often be rejected and cause conflict or avoidance.
  • Changes in behavior. A young person may find it difficult to do everyday things like bathing, attending school or communicating. A young person may lose motivation and withdraw into themselves. Cognitive issues often appear early and will cause a decline in school performance. This along with withdrawal and isolation are often the first indications of psychosis.

Psychosis is a serious symptom and not a diagnosis by itself. When a person is experiencing psychosis he or she can’t tell what is real from what is not real. They may or may not know that their experience of reality is not shared by others.

How common is schizophrenia in children and adolescents?

Fortunately, schizophrenia is rare in children. According to the National Institute of Mental Health (NIMH) only 1 in 40,000 children experience the onset of symptoms before the age of 13. Because childhood onset is so unusual a comprehensive evaluation needs to rule out other causes of childhood psychosis before considering a diagnosis of childhood onset schizophrenia.

Far more common is the emergence of schizophrenia between the mid-teens and mid-twenties. Females typically develop the illness a few years later than males. However, symptoms are commonly seen during the late teen years for both. Schizophrenia impacts about 1 percent of the population around the world.   

Who is at risk and what are the warning signs?

The exact cause of schizophrenia is not known but there seems to be both genetic and environmental factors that contribute to its development.

There are several factors that seem to increase the risk a young person will develop schizophrenia, including:

  • A family history of schizophrenia or psychosis.
  • Exposure to viruses, toxins or malnutrition before birth.
  • Unusual immune system responses like inflammation or autoimmune diseases.
  • Having an older father.
  • Using marijuana or other psychoactive drugs, especially heavy, early use.
  • Traumatic head injuries appear to raise the risk of schizophrenia.

Clear warning signs that an adolescent may be developing schizophrenia are difficult to identify. However, when several of the following warning signs occur at the same time it is important to have your child evaluated by their physician or a mental health professional. Warning signs include:

  • Irritability, depression.
  • Trouble concentrating or thinking clearly.
  • Lack of energy or motivation.
  • Changes in sleeping, eating or self-care habits.
  • Trouble keeping up in school.
  • Spending a lot more time alone than usual.
  • Suspiciousness or feelings that people are talking about them.
  • Confused, strange or bizarre thinking.
  • Appearing internally distracted.

In children, the symptoms of schizophrenia may build up gradually and may not be specific. In teens, you may be unaware of many of the signs or think they’re just going through a phase. As time goes on, the early warning signs of schizophrenia may develop into symptoms becoming more severe and noticeable.

How is schizophrenia diagnosed?

Diagnosing schizophrenia in a young person can be a long and challenging process. Many other conditions like bipolar disorder or pervasive development disorders can have similar symptoms so getting a good evaluation is essential. Substance use can also make determining the correct diagnosis difficult.

To begin the process, your child’s doctor or psychiatrist will ask about medical and psychiatric history and may also conduct psychological testing. A physical exam and medical tests are also necessary to rule out other possible causes for the symptoms.

An evaluation includes an observation of appearance and behavior, talking about thoughts and feelings, asking about thoughts of harming self or others, evaluating thinking ability, age-appropriate behaviors, emotional wellness and possible psychotic symptoms.

A medical evaluation involves medical tests and screenings including blood tests to look for other conditions and imaging studies–MRI, CT, EEG–looking for abnormalities in brain structure and function. Unfortunately, there are no blood tests for this condition and imaging studies are not able to help with specific aspects of psychiatric diagnosis.

A young person must have at least two of the following symptoms the majority of the time during a 1-month period, and some level of difficulty present for over six months:

  • Delusions.
  • Hallucinations.
  • Disorganized speech–rambling, incoherent, nonsensical speech.
  • Disorganized or catatonic behavior–ranging from coma-like, posturing to bizarre, hyperactive behavior.
  • Lack of emotion or the inability to function normally.

At least one of the symptoms a young person experiences must be delusions, hallucinations or disorganized speech. In addition, a young person will have a difficult time meeting normal expectations in school, work or socially.

The National Institute of Mental Health provides free assessment and services to children and their families and also researches this condition in young children.

What type of treatment works for adolescents with schizophrenia?

A treatment plan is helpful in mapping out the different types of treatment and achieving the best outcome. It may be led by your child’s psychiatrist and include: your child’s pediatrician or family doctor, psychologist or therapist, psychiatric nurse, social worker, caretakers, teachers and pharmacist. The young person should be actively engaged in the plan, but this can be challenging at some stages. Overtime, the goal will be to have the young person manage the treatment plan.

Parents are essential team members. Your involvement is critical and will involve providing input, participating in treatment decisions and implementing the plan. Frequent two-way communication and feedback from parents and professionals allow for adjustments to the plan and keeps everything on track.

Medication. Psychiatric medication, including antipsychotic medication, is important in the treatment of schizophrenia in adolescents. Antipsychotics are often effective at managing serious symptoms like delusions and hallucinations. Some symptoms like lack of emotion or difficulty with relationships may improve more slowly. Cognitive symptoms and lack of motivation do not currently respond to available medications. Other types of medications, such as antidepressants or anti-anxiety medications may be important as well. Frequently, different combinations of medication at varying dosages are often needed to maximize improvements and control side effects.

Psychosocial treatments. Psychosocial treatments include individual and family therapies, psychoeducation, self-help and support groups. Cognitive behavioral therapy (CBT) is a successful form of individual therapy. It can help your child learn ways to cope with stress and life challenges. CBT can teach them about schizophrenia and how to manage symptoms.

Family therapy. Family and home life are significantly affected and family therapy can be very helpful by improving communication, working out conflicts and learning to cope with the stress associated with your child’s condition.

Family education and support. Family education and support are important. NAMI offers family education programs and support groups. NAMI Basics Education Program is designed for parents and caregivers of children and teens experiencing a mental health disorder. You can see if a program is available near you by contacting your local NAMI Affiliate.

Social and academic support services. Children with schizophrenia often have problems with relationships and difficulties at school. Sometimes even daily tasks are difficult. Skill building support services can help a young person develop age-appropriate skills and improve relationships.

An Individual Education Plan (IEP) developed by your child’s school can provide them with an academic environment that incorporates helpful training and skill development from specially trained teachers and support staff. Talking to your child’s counselor or school psychologist will help identify appropriate services and school options.

Hospitalization. It may be necessary to hospitalize a young person if they are experiencing a crisis or if their safety is at risk. Your child’s psychiatrist or doctor can arrange for an admission to an appropriate hospital which is often the best way to get symptoms quickly under control. This may be a difficult decision for a family, but it can be necessary.

A crisis plan can help anticipate risks and to plan for them in a positive and collaborative way. Talk with your doctor about how to help prevent a crisis. If you are concerned about suicide or the safety of another person, call 911. It is important when you call to be prepared with necessary information and to be sure everyone understands that it is a psychiatric emergency.

After being in the hospital, other levels of care–partial hospitalization, residential care–may be important until a young person is ready to return home.

Recovery After Initial Schizophrenia Episode (RAISE) is a multisite research project studying the different factors that improve a young person’s recovery in the early stages of schizophrenia.

What can I do to help my child and support their treatment?

Learning about psychosis and schizophrenia will help you understand what your young person is experiencing and trying to cope with. Talking to your young person’s mental health professionals will help you understand how the family can best support them and their treatment.

Living with schizophrenia is challenging. Some suggestions for ways to support your young person include:

  • Pay attention to triggers. You and your young person will need to become familiar with situations or things that trigger symptoms, cause a relapse or disrupt normal activities. It is always best to avoid triggers and the treatment team can offer helpful advice. Always contact the doctor or therapist if you believe changes in symptoms might lead to an emergency.
  • Take medications as prescribed. Many young people will question if they still need the medication when they have a period of improvement or are unhappy with some side effects. Stopping or changing medication usually results in a return of symptoms, often within days but sometime as long as weeks, and many times a doctor can make changes that will improve or eliminate side effects without compromising the treatment’s effectiveness.
  • Understanding Anosognosia. Anosognosia is the term used when a person with a psychiatric illness is unable to see that they are ill. It’s also known as “lack of insight” or “lack of awareness” and affects many people with schizophrenia. Anosognosia can make treatment challenging, but with good care some young adults learn to appreciate that they are able to manage their lives while having an illness.
  • Check first before taking any other medication. Check with the doctor prescribing your child’s medications before you give your young person any other prescription drugs, over-the-counter drugs, vitamins, supplements, etc. Drug interactions can be a serious problem.
  • Avoid using illegal drugs, alcohol or tobacco. These substances are known to worsen schizophrenia symptoms. Marijuana is a trigger for psychosis in many instances. If they develop a substance use disorder with schizophrenia, getting help for both is essential.
  • Stay healthy. For a young person living with schizophrenia staying active and eating well are very important. Many of the medications used in treatment cause weight gain and high cholesterol. Your child’s doctor or nutritionist can help you develop a plan for healthy lifestyle habits. Staying active is a key to improving lifelong health. Smoking is also a risk for health and is common in people who live with schizophrenia.

Reviewed by Ken Duckworth, M.D., May 2014


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