The insidious onset of schizophrenia

The insidious onset of schizophrenia in children and adolescents

In this blog post, we will talk about the insidious onset of schizophrenia in children and adolescents.

You will read about diagnosis, symptoms and treatment of schizophrenia children and adolescents.

The insidious onset of schizophrenia

Schizophrenia is a chronic mental illness in which the affected person loses contact with reality.

Schizophrenia in children and adolescents has the same symptoms as in adults, except that the impact on the child’s behaviour is major.

Schizophrenia is found under the age of 12 in 1.5 – 4 / 10,000 children, and in adults in 0.7 – 7.1 / 1,000 adults.

There are approximately 10 million people with schizophrenia worldwide, and 2 million new cases are detected each year.

Schizophrenia in children and adolescents includes hallucinations, illusions, distorted behaviour and thinking, to which are added difficulties in performing daily tasks.

Aetiology and risk factors

An increase in the incidence of schizophrenia has been observed in children whose parents are schizophrenic, this being possible due to genetic involvement.

1A specific gene has been identified that carries the code for the production of a substance needed for the brain circuit, which is missing or in a smaller amount in patients with schizophrenia.

Also incriminated are obstetric complications, sex, puerperal development, certain chronic diseases such as focal epilepsy, cerebral dysfunction with movement disorders, poor sensory integration, impaired coordination, delay or failure to mature.

Risk factors

Although the exact cause of schizophrenia is unknown, it seems that there are certain factors that increase the risk of developing this disease such as:

• Hereditary history of schizophrenia;
• Viral infections during intrauterine life;
• Fetal hypotrophy;
• Stress conditions;
• The advanced age of the parents;
• Administration of psychoactive drugs to adolescents.

Schizophrenia with early-onset (schizophrenia) occurs before the age of 18, and schizophrenia with very early onset (very early-onset schizophrenia) occurs before the age of 13 years.

Symptoms

Schizophrenia with very early onset

Schizophrenia with very early onset or infantile schizophrenia itself has a slow progressive evolution starting with the age of 3-5 years –  but before 12 years.

The clinical picture is characterized by a normal previous psychic development associated with a satisfactory adaptation.

These children are calm, with intellectual concerns and the tendency to develop their knowledge especially in fields such as astronomy, geography, history.

Later, bizarre behaviour is installed insidiously, the interest of the game diminishes, they retreat into their environment. Mutism is also common.

The insidious onset may sometimes be associated with the appearance of a sibling in the family, the need for surgery or the presence of intercurrent somatic diseases.

A  clinical case has the following characteristics:

• The appearance of disorders regarding the relationship with the family, the environment;
• Installation of lack of interest associated with withdrawal, isolation;
• Stereotypical activity;
• Thinking disorders – usually there is a slowness of the ideational rhythm to which is added the decrease in school performance;
• Loss of the ability to differentiate the imaginary real;
• Delusional ideas usually set in after the age of 6 and show marked polymorphism;
• After the age of 10, the ideas of persecution, of poisoning are installed;
• The occurrence of perceptual disorders such as hallucinations are less common;
• Auditory or visual hallucinations may be present;
• Disorders of one’s own self-consciousness can occur – depersonalization-derealization phenomena (ideas of body transformation that are felt as fragmentation or as a transformation in an animal);
• Speech disorders such as mutism, echolalia, stereotypes are also installed;
• Speech is monotonous, artificial;
• Presence of disorders in the affective sphere – there is anxiety that is expressed through screams, gestural stereotypes;
• Fears and phobias are present, most of the time unjustified (eg: fear of dolls);
• Changes in the game – initially decrease the activity of the game, the game with other children, after which the game is autistic, the child playing alone.

Schizophrenia with early-onset

Schizophrenia with early-onset usually occurs during puberty and adolescence – at this age more common is the form with acute onset and remittent evolution.

Intermediate forms with the subacute onset and continuous evolution can also be identified.

The onset is most often caused by a somatic illness, but can also be triggered by mental trauma or surgery.

The onset symptomatology is represented by the appearance of unjustified fears, by absurd obsessions to which is added psychomotor agitation and incoherent delirium.

Also, the patient may present at the physical examination oscillating fever, sweating, constipation, diarrhoea, changes in heart rate and blood pressure, saburral tongue.

In these cases, the symptoms usually subside.

At the insidious onset, there are mental disorders such as derealization, depersonalization, emotional disorders or sometimes the adolescent is irascible, impulsive, with aggressive tendencies.

Excesses such as alcohol consumption, theft, vagrancy, sexual excesses may also be present.

These may be associated with the idea or suicide attempts.

The teenager ends up refusing to attend school, retires, no longer cares, no longer eats.

The clinical picture is usually similar to that of the adult, except that the symptoms are more variable, hallucinatory and delusional hot flashes can often be accompanied by disturbances of consciousness.

In the slowly progressive form, dissociative thinking disorders, depersonalization feelings, loss of identity appear.

The differential diagnosis for schizophrenia in children, in this case, is made with adult schizophrenia.

Diagnostic

The diagnosis of schizophrenia in children and adolescents is a thorough one because such a diagnosis is very severe, with marked consequences on the subsequent evolution.

The physical examination will include the measurement of height, weight, vital signs and temperature, to which is added the examination on devices and systems.

Paraclinical examinations will include:

• Screening tests for alcohol and drug use;
• Thyroid tests;
• MRI to identify brain abnormalities;
• Encephalogram to identify temporal epilepsy.
• Psychological tests – a psychiatrist will talk to the child about his thoughts and feelings. Parents will be asked how severe the symptoms are, how they affect their daily activities.

The child will also be evaluated in terms of thinking and the correspondence of its development with his age.

Also, questionnaires will be applied that will evolve the anxiety, the mental state and the presence or not of the psychotic symptoms.

The diagnosis of schizophrenia in children and adolescents is usually difficult due to the overlapping of symptoms with that of other pathologies such as:

• Depression;
• substance abuse;
• bipolar disorder.

Also, doctors often avoid rushing to make such a serious diagnosis.

The diagnosis for schizophrenia with very early onset is based on DSM IV criteriaong>:

A. Marked and sustained defect of social relations such as lack of emotional response, lack of empathy;

B. At least one of the three criteria:

1. Sudden and eccentric anxiety, exaggerated reactions to common events, unexplained moments of panic.

2. The reduced and inadequate effect, unexplained anger reactions, extreme lability of mood.

3. Opposition to the change of the environment or insistence on executing acts in the same manner.

4. Particular postures, movements of hands and fingers, walking on tiptoes, on heels.

5. Speech abnormalities, abnormal voice modulation, monotonous voice.

6. Hyper or hyposensitivity to sensory stimuli.

7. Self-mutilation.

C. The onset of the syndrome after 30 months and before 12 years.

D. Absence of delusional ideas and hallucinations proper and a marked loss of logistical associations.

Complications

Untreated, schizophrenia causes many complications such as:

• Depression;
• Suicidal thoughts or suicide attempts;
• Drug and alcohol abuse;
• Inability to take care of oneself: eating, getting dressed or taking a shower;
• Inability to go to school;
• Inability to be independent of an adult;
• Behavioural disorders;
• Decreased school performance.

Treatment

Child and adolescent schizophrenia is a chronic disease that persists throughout adulthood.

Treatment should be performed throughout life, even when the symptoms disappear.

The treatment is directed by a psychiatrist specialized in child psychiatry.

The stages covering pharmacological, individual treatment and psychotherapy, hospitalization in crises.

Pharmacological treatment

The medication used to treat childhood schizophrenia includes antipsychotic medication – they are similar to those used in adults;

Atypical or second-generation antipsychotics – used in children because they have fewer side effects – approved are Risperidone and Aripiprazole (Abilify).

Atypical antipsychotics are used especially to relieve symptoms such as hallucinations, loss of motivation, emotional flattening.

Side effects are represented by:

• Weight gain;
• Diabetes;
• hypercholesterolemia;
• Extrapyramidal symptoms.

Conventional or first-generation antipsychotics are as effective as second-generation antipsychotics in controlling hallucinations but have severe neurological side effects such as tardive dyskinesia manifested by involuntary movements of the face, eyelids, tongue, limbs.

Although both first-generation and second-generation are at risk for tardive dyskinesia, first-generation dyskinesia is more common.

Medication side effects

All antipsychotics have serious side effects with risks to health and even life. Side effects in children and adolescents do not coincide with those in adults.

Children and adolescents do not usually have the ability to understand and communicate about their medical problems (the occurrence of possible side effects).

Antipsychotics also interact with other medicines, so any new medicines must be checked for compatibility.

Psychotherapy

Psychotherapy is very important for the treatment of schizophrenia and includes:

Individual therapy that will educate the child how to adapt to stress and the challenges caused by the presence of the disease in everyday life.

Therapy can be beneficial for reducing symptoms and adapting the child to the social environment.

The psychotherapist will also explain what schizophrenia is, what the symptoms are and how to follow the treatment as correctly as possible.

Family therapy – involving family members in therapy can help improve communication between its members.

Hospitalization of a child with schizophrenia. The child will be hospitalized during crises, thus ensuring his safety, but also that of those around him.

Conclusions

In this blog post, we talked about the insidious onset of schizophrenia in children and adolescents.

You also read about diagnosis, symptoms and treatment of schizophrenia children and adolescents.

Schizophrenia is a chronic mental illness in which the affected person loses contact with reality.

Schizophrenia in children and adolescents has the same symptoms as in adults, except that the impact on the child’s behaviour is major.

The insidious onset may sometimes be associated with the appearance of a sibling in the family, the need for surgery or the presence of intercurrent somatic diseases.

If you have any questions, comments or recommendations, please feel free to leave a comment below. 

FAQ on the insidious onset

Further reading

Schizophrenia in Children and Adolescents (Cambridge Child and Adolescent Psychiatry), by Helmut Remschmidt 

Psychosis in Children and Adolescents: A Guide for Clinicians, An Issue of Child And Adolescent Psychiatric Clinics of North America, by Ellen House 

Psychosis and Schizophrenia in Children and Young People: The NICE Guideline on Recognition and Management (NICE Mental Health Guidelines) (NICE Guidelines), by National Collaborating Centre 

Me, Myself, and Them: A Firsthand Account of One Young Person’s Experience with Schizophrenia (Adolescent Mental Health Initiative), by Kurt Snyder

References

Asarnow JR, Thompson MC, McGrath E. Annotation: childhood-onset schizophrenia: clinical and treatment issues. J Child Psychol Psychiatry 2004 Feb; 45(2): 180–94

Eggers C, Bunk D. The long-term course of childhood-onset schizophrenia: a 42-year follow-up. Schizophr Bull 1997; 23(1): 105–17

Masi, G., Liboni, F. Management of Schizophrenia in Children and Adolescents. Drugs 71, 179–208 (2011).

Werry JS, McClellan J, Chard L. Early-onset schizophrenia, bipolar and schizoaffective disorders: a clinical follow-up study. J Am Acad Child Adolesc Psychiatry 1991 May; 30(3): 457–65