CHILDHOOD Definitions Paranoid ideation differs from paranoid (2 CE HOURS) Schizophrenia is thought to be the most in that the ideas are held with less conviction common form of child, adolescent, and adult than with the patient who is delusional. Learning objectives . Symptoms often include delusions, Extrapyramidal side effects (EPS) are the !! To understand the history of childhood thought disorders, as well as auditory, visual, and various movement disorders such as tardive schizophrenia and psychosis. other types of , and . dyskinesia suffered as a result of taking !! To understand the significant definitions Delusions are unshakable beliefs that hold no antagonists, usually related to childhood schizophrenia and or little basis in reality. For example, people (neuroleptic) drugs, which are often used to psychosis including (but not limited to): with psychosis might strongly believe that control psychosis, especially schizophrenia. schizophrenia, delusions, hallucinations, and the government is plotting to harm them, that The best known EPS is thought disorders. they are being spied on through the radio or (involuntary, irregular muscle movements, !! To understand the components of screening television, that they have special “super” power; usually in the face). Other common EPS include: and diagnosis for childhood schizophrenia or that evil forces are trying to kill them. ■■ (often observed as the inability and psychosis. A is when a person’s thinking to remain seated due to motor restlessness !! To understand the diagnostic criteria for is confused. A person with a thought disorder or due to a sensation of muscular quivering. childhood schizophrenia and psychosis. may be hard to understand. Their ideas will often It is a side effect of many neuroleptic !! To understand the differences in symptoms be disorganized, but it is more than just ordinary ). between children/adolescents and adults. confusion. ■■ (muscular spasms of neck). !! To understand the prevention of childhood ■■ Oculogyric crisis, (muscular spasms of schizophrenia and psychosis. Hallucinations are when someone sees, hears, tongue, or jaw; more frequent in children). !! To understand the inherent difficulties smells, or feels something that does not really ■■ Drug-induced parkinsonism – which in treating childhood schizophrenia and exist. The most common form of includes (muscle stiffness, shuffling gait, psychosis. is auditory in nature. Persons with auditory drooling, tremor; less frequent in children !! To understand the outcomes related to hallucinations often report hearing voices. In and adolescents, more frequently observed in childhood schizophrenia and psychosis. some cases those voices will tell a person to do adults and the elderly). !! To understand the current research into a specific act. This type of childhood schizophrenia and psychosis. is called a command auditory hallucination. A dopamine antagonist is a drug which blocks The person with schizophrenia who experiences dopamine receptors. Introduction hallucinations will often believe that the Positive symptoms are abnormal thoughts The existence of childhood psychoses has hallucinations are totally real. Patients with and perceptions such as disordered thinking, been noted, discussed, and at times dismissed hallucinations may act strangely. For example, delusions, and hallucinations. for over one hundred years. In 1867 Henry they may talk or laugh to themselves as if Maudsley, a British , wrote in his conversing with somebody that the clinician Negative symptoms are loss, or decrease, of textbook, Physiology and Pathology of Mind, a can’t see. When the client responds to the normal functions often evidenced by blunted work entitled “Insanity of Early Life.” Kanner hallucinations it is said they are responding to , impaired attention, , and later noted that Maudsley was dismissed by his internal stimuli. anhedonia. contemporaries for acknowledging the existence The second most common hallucination is visual Avolition is a psychological state characterized of “insanity” in childhood. Much of the early in nature. The person who experiences visual by general lack of desire, motivation, and literature regarding childhood psychosis reveals hallucinations may see people who don’t exist persistence. Avolition is commonly seen in conflicting points of view, definitions, and or, in some cases, may see relatives, long dead patients with schizophrenia. Persons suffering classifications that kept changing over time. and buried. Children with visual hallucinations from avolition may not start or complete any Today, childhood schizophrenia and psychosis may report seeing mythological creatures such major tasks. are well established disorders (Tengan and Maia, as monsters and dragons. In rare cases, patients Anhedonia is the inability to experience 2004).Childhood schizophrenia is a severe and with psychosis may experience olfactory or most often persistent that is pleasure from normally pleasurable life events tactile hallucinations, although these are seldom such as eating, exercise, playing and other forms characterized by a loss of contact with reality, observed in children. changes in personality, and moderate to severe of social interaction. difficulty with social functioning. Tolbert (1996) Psychosis is a thought disorder where the Blocking is the disruption of thought evidenced provides an inventory of symptoms frequently person is unable to distinguish reality from by an interruption or momentary disruption of seen in children with psychosis: fantasy because of impaired reality testing. The speech. The individual appears to be trying to ■■ Auditory hallucinations. boundary between non-psychotic and psychotic remember what he or she was thinking or saying. ■■ Confused thinking. ideation and perception is not clearly delineated Loosening of associations is a disorder of ■■ Confusion of television with reality. in the literature. thinking and speech in which ideas shift from ■■ Diminished interest. Paranoia is often characterized by delusions one subject to another with remote or no ■■ Disinheriting. involving: apparent reasons. ■■ Extreme moodiness. ■■ Guardedness. ■■ Ideas that others are ‘out to get them’. ■■ Hyperalertness. is a behavioral condition ■■ Inability to distinguish dreams from reality. ■■ Hypersensitivity. characterized by a lack of variation in patterns of ■■ Odd and/or eccentric behavior. ■■ Jealousy. thought, motion and speech; by repetition of said ■■ Severe problems making and keeping ■■ Persecution. patterns; or both. friends. ■■ Suspiciousness. ■■ Speech disturbances. Screening and diagnosis Paranoid ideation evidences itself as patients ■■ Stereotypy. Screening ■■ Visual hallucination. being convinced that other people are: A complete screening and diagnostic workup for ■■ Vivid and bizarre thoughts and ideas. ■■ Thinking “bad thoughts” about them. ■■ That they are being followed. childhood schizophrenia will include some or all ■■ That they are the object of any number of of the following: dark conspiracies. ■■ A complete history including: Elite Page 1 □□ Medical. attenuated form (e.g., odd beliefs, unusual disruptive behavior disorders. Hearing a voice □□ Social. perceptual experiences). suggesting was most often associated □□ Family history. ■■ Schizoaffective and with . The clinician must strive ■■ Interviews with child, parents, guardians, exclusion: and to understand the context and content of the and other caregivers to assess possible Mood Disorder With Psychotic Features hallucinations when diagnosing a young child. psychotic symptoms, changes in behavior have been ruled out because either (1) As stated above, in childhood, and most and the possibility of other psychiatric no Major Depressive, Manic, or Mixed especially during adolescence, the affective problems. Episodes have occurred concurrently with symptoms of schizophrenia can sometimes ■■ Tests to assess cognitive skills and functional the active-phase symptoms; or (2) if mood be mistaken for age appropriate moodiness or abilities in daily life. episodes have occurred during active-phase oppositional behavior. It is worth noting that ■■ A review of school records and/or other input symptoms, their total duration has been brief in children and adolescents, hearing voices is from school personnel. relative to the duration of the active and not always a sign of schizophrenia, but may be ■■ Various lab tests may be indicated: residual periods. due in part to anxiety, , depression, family □□ Toxicology screens may be needed if ■■ Substance/general medical condition dynamics, or cultural issues. is suggested. exclusion: The disturbance is not due to the □□ Liver function studies, copper, and direct physiological effects of a substance Differences in symptoms between ceruloplasmin are part of the workup for (e.g., a drug of abuse, a ) or a children/adolescents and adults Wilson disease. general medical condition. All three major classificatory/diagnostic systems □□ Obtain porphobilinogen for porphyria. ■■ Relationship to a pervasive developmental (ICD-9, ICD-10 and DSM-IV-TR) have no □□ HIV titers may be needed. disorder: If there is a history of special criteria for children and recommend the □□ Brain-imaging tests such as MRI or Autistic Disorder or another Pervasive use of adult criteria in children (Reddy et al, CT scan can be used to rule out other , the additional 1993). This approach to diagnosis assumes that medical conditions. diagnosis of Schizophrenia is made only if there is a similarity between schizophrenia seen prominent delusions or hallucinations are in adults and that seen in children. There is a Diagnostic Criteria also present for at least a month (or less if general paucity of evidence in the clinical and At present, the criteria used to diagnose successfully treated). (direct quotation from research data to support this assertion. Similar schizophrenia in adults can also be used to Diagnostic and Statistical Manual of Mental clinical presentations of schizophrenia may diagnose schizophrenia in children: Disorders, Fourth Edition, Text Revision exist in both childhood and adulthood. Other ■■ Characteristic symptoms: Two (or more) of (2000). differences such as in the etiology, course and the following, each present for a significant prognosis may (and often) exist and should not portion of time during a 1-month period (or Issues related to assessment of children be overlooked (Beitchman, 1985). less if successfully treated): Very young children, regardless of their mental □□ Delusions. status, have unclear boundaries and are often The early age of onset and the complexities of □□ Hallucinations. unable to verbally describe their experiences, dealing with children presents multiple special □□ Disorganized speech (e.g., frequent thoughts, and emotions. Clinicians may have to considerations in regard to: derailment or incoherence). use play therapy as an assessment technique to ■■ Assessment. □□ Grossly disorganized or catatonic ferret out symptoms related to this diagnosis. It ■■ Diagnosis. behavior. should be noted that young children are concrete ■■ Educational needs. □□ Negative symptoms, i.e., affective in thought and have limited social experiences ■■ Emotional development. flattening, alogia, or avolition Note: Only (Piaget, 1962). Young children often possess a ■■ Family education. one criterion A symptom is required if private language or use private speech or talk ■■ Family training. delusions are bizarre or hallucinations to themselves aloud. According to Piaget, the ■■ Need for basic living skills training. consist of a voice keeping up a running immature child does not differentiate between ■■ Need for vocational training. commentary on the person’s behavior words or symbols and what words represent. ■■ Psychiatric Treatment. or thoughts, or two or more voices Fantasy and imaginative play emerge by the ■■ Psychological Treatment. conversing with each other. second year and continue for 3 to 4 years until ■■ Social development. ■■ Social/occupational dysfunction: For the child becomes more interested in peer games. Symptoms, beliefs, thoughts, and behaviors of a significant portion of the time since Animism (the attribution of life to objects that children and adolescents with schizophrenia the onset of the disturbance, one or more are not alive) is common due in normal child may not be the same as adults with this illness. major areas of functioning such as work, development. Even as the child gets older and The following symptoms and behaviors can interpersonal relations, or self-care are toward concrete operations (ages 5-7), the issue (and often) occur in children or adolescents with markedly below the level achieved prior to of creativity may come into play. The clinician schizophrenia: the onset (or when the onset is in childhood assessing the child must keep in mind the normal ■■ Confusing television and dreams from or adolescence, failure to achieve expected developmental processes when attempting to reality. level of interpersonal, academic, or diagnosis the presence of schizophrenia in a ■■ Decline in personal hygiene. occupational achievement). young child. ■■ Difficulty relating to peers, and keeping ■■ Duration: Continuous signs of the It is important to note that non-psychotic friends. disturbance persist for at least 6 months. hallucinations may be present in children. ■■ Disorganized or confused thinking. This 6-month period must include at least 1 Wilking and Paoli (1966) describe 42 children ■■ Disorganized, odd, or eccentric behavior. month of symptoms (or less if successfully with non-psychotic hallucinations. They found ■■ Disorganized, odd, or eccentric speech. treated) that meet Criterion A (i.e., active- a pattern of developmental difficulties, social ■■ Excessive mobility with no purpose. phase symptoms) and may include periods and emotional deprivation, and parents whose ■■ Extreme moodiness. of prodromal or residual symptoms. During own pathologies promoted a breakdown in the ■■ Holding untrue beliefs (delusions). these prodromal or residual periods, the child’s sense of reality. Edelsohn et al (2003) ■■ Ideas that people are out to get them or signs of the disturbance may be manifested indicates that non-psychotic hallucinations are talking about them (paranoia). by only negative symptoms or two or more not rare in presentation. In his study, auditory ■■ Inability to initiate plans. symptoms listed in Criterion A present in an hallucinations were most often associated with ■■ Inappropriate emotional expression. ■■ Minimal verbal communication. Page 2 Elite ■■ Physical immobility. and urine drug screens or hair analysis for illicit is seldom observed before the age of five. ■■ Seeing things and hearing voices which are drugs should be undertaken. Pre-morbid functioning is often marked by not real (hallucinations). difficulties with attention, conduct, inhibition, Recent studies report that children and ■■ Severe anxiety and fearfulness. withdrawal and emotional sensitivity. Eighty adolescents treated with oral, inhaled, and ■■ Unusual or bizarre thoughts and ideas. percent of children with the disorder exhibit intravenous corticosteroids may experience ■■ Withdrawal and increased isolation. difficulties with auditory hallucinations. adverse psychological side effects, including Fifty percent have reported difficulties with It has been noted that the behavior of children psychotic symptoms. Apparently, these can occur delusional beliefs. Research has also shown a with schizophrenia may change slowly over at any point during treatment. male predominance for childhood schizophrenia time, as opposed to some adults whose behavior with a reported male-to-female ratio averaging and thought processes may seemingly change Etiology 1.5-2:1. in a very short period of time (days or weeks). The cause of childhood onset schizophrenia, as For example, children who used to enjoy well as adult schizophrenia remains unknown. Mortality relationships with siblings, family members, The American Academy of Child and Adolescent It has been demonstrated that there is an and playmates may become increasingly shy or reports that current research suggests increased risk of death from suicide for persons withdrawn and seem to be in their own world. a combination of factors that may be responsible with schizophrenia. In several large studies of Sometimes youngsters will begin to verbalize for the development of psychotic symptoms in childhood-onset schizophrenia, the mortality strange fears and ideas. They may begin to cling children: rate from suicide was 5-11 percent. More than to parents or caregivers and say things that do ■■ Brain changes. one half of children with schizophrenia have not make sense to others. Interestingly, these ■■ Biochemical factors. persistent severe impairment in social skills early symptoms and problems may first be ■■ Genetic factors. and limitations in academic and occupational noticed by the child’s school teachers. ■■ Environmental factors. achievement. Other researchers suggest that problems in early Differential diagnosis brain development may be the cause of the Onset Some of schizophrenia illness. Certain areas of the brain that are rich As stated previously, the diagnostic criterion for may overlap with those of other , in the neurotransmitter dopamine seem to be childhood onset schizophrenia is the same as physical health, or developmental disorders. affected most often in all types of schizophrenia. for adults, except that symptoms appear prior These can include: to age 13 (average age at onset of 9), instead of ■■ spectrum disorders (including In another study using MRI on early-onset in the late teens or early 20s for many adults. asperger’s). schizophrenic patients to determine regional As previously noted, schizophrenia in adult ■■ . brain gray-matter abnormalities it was shown populations often begins with an acute episode. ■■ Borderline . that early-onset schizophrenic patients do have With children and adolescents it often emerges ■■ Cognitive deficits. brain differences compared with the controls. more gradually, over a period of months or years. ■■ Delusional disorders. It was observed that schizophrenic patients had a significant decrease in regional gray matter ■■ Medical disorders that affect the brain. Treatment ■■ Obsessive-compulsive disorder. when compared with the controls in several areas At present, schizophrenia (of any type) is ■■ Porphyria, acute. of the brain. Compared with control patients, believed to be a life-long disease that can be ■■ Post-traumatic stress disorder. preliminary results showed the presence of treated, controlled and curtailed, generally ■■ Rett Syndrome (a childhood brain abnormalities in temporolimbic areas in through the use of medication. There is no neurodevelopmental disorder). patients with early-onset schizophrenia. These known cure for schizophrenia. ■■ Schizoaffective disorder, (a disorder with abnormalities are similar to those seen in adult symptoms of both schizophrenia along with schizophrenia. The organization, Living with Childhood-Onset a mood disorder. Several studies (psychological, pharmacologic, Schizophrenia reports that the regular support ■■ Severe anxiety disorders. and ) of childhood-onset systems available to children will often have ■■ Severe major depression with psychotic schizophrenia have suggested dysfunction little or no experience dealing with any form features. in the prefrontal cortex and limbic systems of childhood psychosis, and that few families ■■ Substance abuse disorders (particularly of the brain. The neurotransmitter dopamine have the emotional, financial, and time resources cocaine and methamphetamine which are has been identified in the pathophysiology of needed to deal with this devastating long-term rare in children). schizophrenia. Drugs that increase dopaminergic illness. ■■ Wilson Disease. activity are thought to induce psychosis. Other Untreated psychosis is most often associated Psychotic disorders secondary to an underlying neurotransmitters also may be involved in the with longer and more difficult recovery and can physical illness are extremely rare in children development of schizophrenia. Serotonin may lead to significantly increased family distress, but need to be considered in the context of a be one of those neurotransmitters. The newer substance abuse /dependence, other mental comprehensive evaluation. A formal physical drugs are known to have health issues such as depression, and increased examination, including a comprehensive significant effects on serotonin in the brain. risk of suicide. neurological assessment, is essential, but often The role of genetics has long been established Proper early diagnosis and treatment is thought overlooked by practitioners. as one of the causes of childhood schizophrenia. to reduce the need for repeated psychiatric As stated above, the potential differential The risk of schizophrenia rises from 1 percent hospitalizations and may promote a more diagnosis is extensive and can include many for a child in a family with no history of the complete recovery. Standard treatments for general medical conditions in addition to primary illness, to 10 percent if a first degree relative has childhood onset schizophrenia most often psychiatric disorders including: it, to 50 percent if an identical twin is diagnosed consists of: ■■ Cerebral tumor. with the disorder. ■■ Low-dose, anti-psychotic medications. ■■ Epilepsies. ■■ Ongoing age-appropriate patient education. ■■ Neurodegenerative disorders. Incidence ■■ Family education. Psychosis in children is fairly rare with a ■■ Social skills training. Clark (2001), notes that Organic psychotic diagnosis of schizophrenia in only approximately ■■ Basic living skills training. disorder secondary to substance misuse is 1 in 10,000 to 40,000 minors, compared to ■■ Psychotherapy for the child, parents, and frequently suspected in the adolescent age group, approximately 1 in 100 in adults. The disease other caregivers. Elite Page 3 ■■ Cognitive remediation (primarily for movements. These and other side effects from Outcomes improving memory and attention). “typical” antipsychotic medication often results Outcome studies of childhood psychoses are ■■ Long-term support. in poor adherence to medication regimens. limited and have been criticized by some ■■ Psychiatric hospitalizations (as needed). In some cases, these side effects of these researchers as somewhat selective in nature. ■■ Residential care (for difficult or unresponsive medications have led to nonreversible or life- Nearly every study reveals that the majority of cases). threatening conditions. cases have poor outcomes, which was worse Newer (atypical) medications generally more Second generation antipsychotic medications in the childhood-onset than in adolescent- effectively treat psychotic symptoms without the (also known as atypical or novel) include: onset cases. Childhood-onset cases are often side effects more common with older (typical) ■■ Aripiprazole (Abilify). fraught with recurrent acute episodes, repeated anti-psychotic medications. Children and ■■ Clozapine (Clozaril). psychiatric hospitalizations, and markedly adolescents symptoms of psychosis are often ■■ Olanzapine (Zyprexa). impaired social functioning. Some studies encouraged to maintain their daily routines as ■■ Quetiapine (Seroquel). indicate that premorbid characteristics such much as possible. Some level of recovery is also ■■ Risperidone (Risperdal). as shyness, introversion, social withdrawal improved when the family itself is accepting, ■■ Ziprasidone (Geodon). and cognitive decline have been linked with non-confrontational, stable, and supportive. poor prognosis in early-onset schizophrenia Second generation antipsychotic medications (Remschmidt, 2000). There is ample evidence that stress can make the tend to have fewer side effects. In adults there symptoms of psychosis worse. is an observed lower incidence of tardive Prevention dyskinesia (TD) with the newer drugs and it is Medications No known interventions have been proven to thought that the same may hold true for children Medications that assist children manage their prevent the development of childhood onset and adolescents. TD results in involuntary psychotic symptoms have improved significantly schizophrenia / child psychosis at the time of this movements of your mouth, lips, tongue and other in the past ten to fifteen years. Antipsychotic paper. The National Institutes of Mental Health parts of the body. Other possible side effects medications are especially effective in reducing (NIMH) is attempting to identify children and of the older medications include interactions or eliminating hallucinations and delusions. adolescents at risk for developing schizophrenia with other medications, risk of seizures, and The newer generation (atypical) , with the aim of investigating whether treatment reductions of the white blood count. such as olanzapine and clozapine, can also with the atypical antipsychotic olanzapine help improve motivation and emotional could prevent, reduce, or slow the onset of this Psychotherapy disease. Because there are environmental factors expressiveness in some patients while lowering In cases of childhood schizophrenia and the likelihood of producing disorders of that clearly appear to influence the surfacing of psychosis, psychotherapy for the client, the schizophrenia, lowering the risk for genetically movement, including tardive dyskinesia. client’s family, and other caregivers will often Conversely, even with these newer (atypical) vulnerable individuals should theoretically be focus on coping strategies, problem-solving possible. medications, side effects remain, including skills, awareness of psychotic symptoms, as well excess weight gain that can increase risk of as issues related to anti-psychotic medication Studies and future treatment other health problems such as diabetes and heart compliance. There is no evidence to suggest disease. The Child Psychiatry Branch of the National that psychotherapy alone is a substitute for Institute of Mental Health is currently First generation antipsychotic medications medication. conducting research on childhood schizophrenia. include (but not limited to): Tarrier (2005), reports that schizophrenia and NIMH is currently recruiting children to better ■■ Chlorpromazine (Thorazine). other psychotic disorders were once thought understand: ■■ Fluphenazine (Prolixin). to be untreatable by psychological treatments. ■■ Importance of treatment. ■■ Haloperidol (Haldol). There is accumulating evidence that cognitive ■■ Diagnosis. ■■ Loxapine (Loxapac). behavior therapy (CBT) can result in significant ■■ Genetic basis for this disorder. ■■ Thioridazine (Mellaril). clinical benefit to these patients. ■■ Thiothixene (Navane). NIMH is interested in studying children who ■■ Trifluoperazine (Stelazine). are responders as well as non-responders to Psychiatric hospitalization current treatment modalities. The children and A child with schizophrenia may require one or Difficulties with treatment their families will be brought to the NIH Clinical several episodes of psychiatric hospitalization Child onset schizophrenia is frequently resistant Center at the expense of NIMH for an intensive to achieve sufficient stability to function at to medications, especially with first generation diagnostic evaluation and, when appropriate, home and in the community. Most often, (typical) antipsychotics. Of the more than 10 trials of new treatments. these hospitalizations occur as a reaction to typical antipsychotics currently available for use acute episodes of the illness where the child The Criteria for the study is as follows: in the U.S. only a few (haloperidol, loxapine, has become unmanageable or dangerous at ■■ Boys and girls 6-18 years old. thioridazine, thiothixene) have any data home. The hospitalization ensures safety while ■■ Onset of psychotic symptoms before the 13th concerning efficacy on children. the client’s medication regimen is adjusted birthday. The results of several studies indicate that a to minimize symptoms of the disorder while ■■ IQ above 70 (pre-psychotic). large number of young patients (15-45 percent monitoring for side effects related to anti- ■■ Compliant family. depending on the medication prescribed) psychotic medications. Benefits of participating in the study include: show little or no improvement while taking While hospitalized, the client will most often be ■■ Evaluation by a team which has seen more the medication. These studies also showed a treated by a multi-disciplinary team consisting psychotic children than almost any other high percentage of serious side effects. This of one or more , , research facility in the country. leads some researchers to suggest that children counselors, social workers, and psychiatric ■■ Recommendations by our psychiatrists, are at higher risk for developing these side nurses. While one of the goals of the team is to social worker, nurses, teachers, occupational effects than adults are. Common side effects return the child to the natural home environment, and recreational therapists for future of typical antipsychotics include sedation and this may not be possible in all cases. In some treatment. extrapyramidal side effect (EPS), which are instances the child must be referred to a mid ■■ All treatment is free; housing and characterized by motor deficits including loss of or long-term residential facility for further transportation are provided to those living at postural reflexes, bradykinesia (abnormally slow treatment and stabilization. a distance. movement), tremor, rigidity, and involuntary Page 4 Elite ■■ Opportunities for a drug-free washout of the adverse symptoms of this disease. 19. Remschmidt, H. (2001) Schizophrenia in children and trial for children who participate in our Newer atypical antipsychotics, with fewer adolescents. Retireved from Cambridge University. Web site: http://assets.cambridge.org/97805217/94282/ medication trial. extrapyramidal side effects and generally sample/9780521794282ws.pdf increased efficacy have benefited many 20. Tarrier, N. (2005) Cognitive Behaviour Therapy for Conclusion individuals who had been unresponsive to Schizophrenia – A Review of Development, Evidence and Implementation. Psychotherapy and Psychosomatics The existence of childhood schizophrenia and traditional typical antipsychotics. 74:136-144 psychosis has been discussed in professional 21. Tengan, S.K. and Maia, A.K. (2004) Functional psychosis circles for over one hundred years. Childhood Bibliography in Childhood and Adolescence. J. Pediatr. (Rio de J.), Vol. schizophrenia is a severe, debilitating, and 1. Baeza I, Salgado-Pineda P, Romero S, et al. 80, No. 2, Suppl. O. Neuromorphological abnormalities in early onset 22. Tolbert, H.A. (1996) Psychoses in Children and most often persistent mental disorder that is schizophrenia. Program and abstracts of the American Adolescents: A Review. Journal of Clinical Psychiatry, 57 characterized by a loss of contact with reality, Academy of Child and Adolescent Psychiatry 50th (Suppl. 3). changes in thinking, changes in personality, Annual Meeting; October 14-19, 2003; Miami, Florida. 23. Wilking VN, Paoli C: The hallucinatory experience: and moderate to severe difficulty with social Abstract A47. an attempt at a psychodynamic classification and 2. Beitchman, J.M. (1985) Childhood Schizophrenia : ‘A reconsideration of its diagnostic significance. J Am Acad functioning. review and comparison with Adult-onset Schizophrenia’. Child Psychiatry 1966; 5:431-440. Psychiatric Clinics of North America, 8, 793-814. Childhood schizophrenia is fairly rare in children: findings from a psychiatric emergency service. children. Psychosis in children is fairly rare Ann NY Acad Sci 2003; 1008:261-264. with a diagnosis of schizophrenia in only 3. Clark, A.F. (2001) Proposed treatment for adolescent approximately 1 in 10,000 to 40,000 minors, psychosis. 1: Schizophrenia and Schizophrenia-like psychoses. Advances in Psychiatric Treatment, 7, 16-23. compared to approximately 1 in 100 in adults. 4. Department of Health and Human Services – National The disease is seldom observed before the age Institutes of Health (2005) Schizophrenia: Childhood- of five. Onset Schizophrenia. Retrieved July 14, 2007, from MedicineNet.com Web site: http://www.medicinenet.com/ The symptoms and behavior of children and script/main/art.asp?articlekey=41427 adolescents with schizophrenia may differ 5. Department of Health and Human Services – National Institutes of Health (2003) Facts About Childhood Onset from that of adults with this illness. Some of Schizophrenia: An Update from the National Institute of the symptoms and behaviors that can occur Mental Health. Retrieved July 30, 2007 from University (Final examination questions on next page) in children or adolescents with schizophrenia of Virginia Health System. Web site: http://www. include auditory hallucinations, confused healthsystem.virginia.edu/internet/psychiatric/PDFs/ Schizophrenia/NIMHChildOnset.pdf thinking, ideas that others are ‘out to get them’, 6. Dunn, D. (2006) Schizophrenia and Other Psychoses. inability to distinguish dreams from reality, odd Retrieved August 1, 2007 from emedicine.com. Web site: and/or eccentric behavior, visual hallucinations, http://www.emedicine.com/ped/topic2057.htm 7. Edelsohn GA, Rabinovich H, Portnoy R: Hallucinations and vivid and bizarre thoughts and ideas. in nonpsychotic The onset of schizophrenia in children tends 8. Hollis, C. (2000) Adult Outcomes of Child – and Adolescent-Onset Schizophrenia: Diagnostic Stability and to be more gradual than for adults. Parents Predictive Validity. Am J Psychiatry 157:1652-1659. and caregivers may not notice that the child’s 9. Hollis, C. (2003) Developmental precursors of child – and behavior has changed slowly over time. Children adolescent-onset schizophrenia and affective psychoses: diagnostic specificity and continuity with symptom who used to enjoy relationships with playmates dimensions. The British Journal of Psychiatry 182: 37-44. may become more shy or withdrawn and seem 10. Kanner, L. (1971) Childhood psychosis: a historical to withdraw in to their own world. Many overview. Retrieved July 14, 2007 from neurodiversity. children with this diagnosis may start to cling com. Web site: http://neurodiversity.com/library_ kanner_1971a.html to parents and other caregivers. Some may say 11. Lambert, L. (2001) Identification and management things which do not make sense or appear to be of Schizophrenia in childhood. Journal of Child and responding to internal stimuli. Adolescent Psychiatric Nursing, Apr-Jun 2001. 12. Living with Childhood-Onset Schizophrenia (2004). There are inherent difficulties in diagnosing Living with childhood-onset schizophrenia. Retrieved schizophrenia in a child. Very young children, July 26, 2007 from Living with Childhood-Onset Schizophrenia. Web site: http://www.childhood- regardless of their mental status, have unclear schizophrenia.org/ boundaries and are often unable to verbally 13. Mayo Foundation for Medical Education and Research describe their experiences, thoughts, and (2006) Childhood Schizophrenia. Retrieved July 23, 2007 from CNN.com. Web site: http://www.cnn.com/HEALTH/ emotions. The clinician assessing the child library/ DS/00868.html must keep in mind the normal developmental 14. Mayo Foundation for Medical Education and Research processes when attempting to diagnosis the (2007) Schizophrenia. Retrieved from revolutionhealth. presence of schizophrenia in a young child. Web site: http://www.revolutionhealth.com/conditions/ mental-behavioral-health/schizophrenia/schizophrenia?se Children with schizophrenia require ction=section_05 15. Merck and Co., Inc. (2005) Childhood Schizophrenia. comprehensive treatment. A combination of Retrieved August 3, 2007 from The Merck Manuals medication, individual therapy, family therapy, Online Medical Library. Web site: http://www.merck.com/ patient education, and other adjunctive therapies mmpe/sec19/ch300/ch300c.html is often needed. can 16. NARSAD – The Mental Health Research Association (2007) Childhood Schizophrenia Retrieved August 10, be helpful for many of the symptoms and 2007 from NARSAD. Web site: http://www.narsad.org/dc/ problems associated with schizophrenia. Due childhood_disorders/schizophrenia.html to undesirable side effects these medications 17. Piaget, J. (1962). Comments on Vygotsky’s critical remarks concerning the language and thought of the require careful monitoring by the child’s child, and the judgement and reasoning of the child. In psychiatrist. L.S. Vygotsky (Ed.), Thought and language (pp. 1-14). Cambridge, MA: Massachusetts Institute of Technology Schizophrenia is a life-long disease that can be Press. treated and controlled. At present there is no 18. Remschmidt, H. (2000) Early-onset schizophrenia: cure for schizophrenia, but new medications History of the concept and recent studies. Indian Journal have been developed that can manage many of Behavioural Sciences, 10 (2) and 11 (1), 11-22.

Elite Page 5 CHILDHOOD SCHIZOPHRENIA Final Examination Choose the best answer for each question and then proceed to www.elitecme.com to complete your final examination.

1. The risk of schizophrenia rises from 1 percent for a child in a family with no history of the illness to: a. 10 percent if a first degree relative has the disorder. b. 20 percent if a first degree relative has the disorder. c. 30 percent if a first degree relative has the disorder. d. 40 percent if a first degree relative has the disorder.

2. Which of the following statements regarding Schizophrenia is true? a. Schizophrenia is a short-term disease. b. Schizophrenia can never be controlled. c. Schizophrenia can be cured. d. Schizophrenia is a life-long disease that can be controlled.

3. Standard treatments for childhood onset schizophrenia most often consists of? a. Low-dose, anti-phychotic medications. b. Ongoing age-appropriate patient education. c. Family education. d. All of the above.

4. Childhood schizophrenia is seldom observed before the age of? a. Five. b. Seven. c. Nine. d. Ten.

5. Childhood schizophrenia is fairly rare, with a diagnosis of schizophrenia in minors of approximately only: a. 1 in 20,000. b. 1 in 30,000. c. 1 in 40,000. d. 1 in 50,000.

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