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Key Features

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Essentials of Diagnosis
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  • Delusional thoughts

  • Disorganized speech (rambling or illogical speech patterns)

  • Disorganized or bizarre behavior

  • Hallucinations (auditory, visual, tactile, olfactory)

  • Paranoia, ideas of reference

  • Negative symptoms (ie, flat affect, avolition, alogia)

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General Considerations
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  • The incidence of schizophrenia is about 1 per 10,000 per year

  • Onset of schizophrenia is typically between the middle to late teenage and early 30s

  • Symptoms usually begin after puberty, although a full "psychotic break" may not occur until the young adult years

  • Childhood onset (before puberty) of psychotic symptoms due to schizophrenia is uncommon and usually indicates a more severe form of the spectrum of schizophrenic disorders

  • Childhood-onset schizophrenia is more likely to be found in boys

  • Schizophrenia has a strong genetic component

  • Other psychotic disorders that may be encountered in childhood or adolescence include schizoaffective disorder and psychosis not otherwise specified (psychosis NOS)

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Clinical Findings

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  • Children and adolescents display many of the symptoms of adult schizophrenia

  • Hallucinations or delusions, bizarre and morbid thought content, and rambling and illogical speech are typical

  • Affected individuals tend to withdraw into an internal world of fantasy and may then equate fantasy with external reality

  • They generally have difficulty with schoolwork and with family and peer relationships

  • Adolescents may have a prodromal period of depression prior to the onset of psychotic symptoms

  • Most patients with childhood-onset schizophrenia have had nonspecific psychiatric symptoms or symptoms of delayed development for months or years prior to the onset of their overtly psychotic symptoms

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Diagnosis

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  • Obtaining a family history of mental illness is critical when assessing children and adolescents with psychotic symptoms

  • Psychological testing, particularly the use of projective measures, is often helpful in identifying or ruling out psychotic thought processes

  • Psychotic symptoms in children younger than age 8 years must be differentiated from manifestations of normal vivid fantasy life or abuse-related symptoms

  • Children with psychotic disorders often have learning and attention disabilities in addition to disorganized thoughts, delusions, and hallucinations

  • In psychotic adolescents, mania is differentiated by high levels of energy, excitement, and irritability

  • Any child or adolescent exhibiting new psychotic symptoms requires a medical evaluation that includes

    • Physical and neurologic examinations (including consideration of magnetic resonance imaging and electroencephalogram)

    • Drug screening

    • Metabolic screening for endocrinopathies

    • Wilson disease

    • Delirium

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Treatment

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  • The treatment of childhood and adolescent schizophrenia focuses on four main areas

    • Decreasing active psychotic symptoms

    • Supporting development of social and cognitive skills

    • Reducing the risk of relapse of psychotic symptoms

    • Providing support and education to parents and family members

  • A special school or day treatment environment may be necessary, depending on the child's or adolescent's ability to tolerate the school day and classroom activities

  • Support for the family emphasizes the importance of clear, focused communication and an emotionally calm climate in preventing recurrences of overtly psychotic symptoms

  • Antipsychotic medications (neuroleptics)

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