Chapter 95. Childhood Schizophrenia

Schizophrenia in children is defined in the same way as for adolescents and adults, based on characteristic psychotic symptoms (ie, hallucinations, delusions, and symptoms of thought disorder) accompanied by deficits in adaptive functioning for at least 6 months.1 Historically, the term was used broadly and included children who had what we now know to be autism; schizophrenia and autism are now seen as being quite different.2 The concept of childhood psychosis is problematic, considering the marked developmental changes in children’s understanding of reality (see Table 95-1).

Although adolescent- and adult-onset schizophrenia is relatively common, childhood onset of the disorder is rare (2 in 10,000). As with adults, there may be a preponderance of lower socioeconomic status in affected children. Also as with adults, there are frequent associations with anxiety and mood disorders.3

Various lines of evidence suggest the importance of neurobiological factors in the pathogenesis of this syndrome. Neuropsychological studies reveal deficits in attention, short-term memory, and information processing. Abnormalities in smooth-pursuit eye movements (saccades) are frequent. Family studies (eg, of adopted children) suggest that rates of schizophrenia are substantially higher among children whose parents have the disorder.1 It had been proposed that psychological factors are important in the pathogenesis, but data supporting this notion are limited. However, stressful life experiences may be important in precipitating psychotic episodes in children. Exposure to pharmacological agents (eg, stimulants) may produce a schizophrenic-like psychosis. Changes in MRI studies include increased volume of the lateral ventricle and basal ganglia and decreased gray matter; it is possible that some of these changes may reflect long-term medication effects.4 Recent genetic studies have identified several microdeletions and copy number variations that appear to increase the risk for schizophrenia in adults.

Children who develop schizophrenia often demonstrate premorbid features such as problems with language development, attention, inhibition, withdrawal, and social oddity.3 Although studies of adults who develop schizophrenia suggest some childhood precursors of the condition, their applicability to childhood schizophrenia is limited.

This condition rarely manifests before 5 years of age. Three patterns of onset are noted: acute, insidious with gradual deterioration, and insidious onset with an acute exacerbation of disturbance. Males are more likely to have an earlier onset of the disorder. Children with schizophrenia exhibit similar problems with hallucinations, delusions, and thought process, although the content may reflect childhood concerns. Hallucinations are the most frequently reported symptom. Auditory hallucinations with persecutory content (eg, voices commenting about the child) are most common, whereas somatic and visual hallucinations are less frequent.5,6 Hallucinations and delusions typically are less detailed or less complicated in younger children. A formal thought disorder is difficult to assess, although rating instruments are available. Clinical features are summarized in eFigure 95.1.

The differential diagnosis of childhood schizophrenia includes mood and anxiety disorders (eg, obsessive compulsive disorder), seizure disorder, psychotic depression, mania, and conduct disorder. Mood and anxiety disorders often coexist with schizophrenia and may alter the clinical presentation. Occasionally, seizure disorders may present in ways suggestive of psychosis or schizophrenia. Childhood-onset schizophrenia should be differentiated from the mood disturbances that are seen in psychotic depression or mania. Sometimes, children with obsessive compulsive disorder may exhibit ideas that are difficult to distinguish from delusions; however, an affected child usually is cognizant of the irrational nature of such ideas. Children with conduct disorder may exhibit hallucinations. Hallucinations occasionally occur as an isolated symptom in preschool children, particularly with stress. In school-age children, psychotic symptoms are more worrisome and likely to be associated either with serious psychopathology or substance abuse.

The diagnosis of schizophrenia in children compared to adolescents is challenging. It requires a careful evaluation, with consideration of other factors such as substance abuse and seizure disorder.1,3 Some children present with complex symptoms, and the diagnosis is confirmed over time as the course becomes more clear. In clinical practice, delays in diagnosis often reflect both the technical difficulties that are inherent in diagnosing children and the reluctance to consider this disorder as a possibility.

Assessing a child for schizophrenia should include a detailed and comprehensive history, psychological or communicative evaluation, psychiatric examination, physical examination, toxicological screen, and neurological consultation if indicated. The presence of other developmental or psychiatric disorders should be noted. Psychological testing may be helpful diagnostically and may help in designing an intervention program. Several assessment instruments, such as the Kiddie Formal Thought Disorder Rating Scale,7 have been developed. Sometimes details of hallucinations or other psychotic phenomena are elicited through drawing or play (eFig. 95.2). The expertise of an experienced child and adolescent psychiatrist should be obtained.

Management of children with schizophrenia should build on specific patterns of strengths and weaknesses, with recognition of the stage of the illness (ie, presence of active psychotic symptoms). Usually an intensive, multimodal treatment program is indicated, which includes medications, individual psychotherapy, educational intervention, and family support. Inpatient treatment may be appropriate, particularly during the active psychotic phase and in cases where the diagnosis is unclear.1,3

Major tranquilizers (eg, phenothiazines) may diminish hallucinations and delusions. The atypical neuroleptics (eg, clozapine) are currently used to treat most symptoms of schizophrenia.8 Family interventions should be focused on supporting the child’s ongoing development and adaptation, and any associated problems in development or learning should be addressed.

Childhood-onset schizophrenia tends to follow an unremitting course with serious implications for the child’s learning and subsequent development. Additional difficulties arise with coexisting mood or anxiety disorders.1,8

Changes in the definition of childhood schizophrenia complicate the interpretation of previous research on its natural history. It does, however, appear that the outcome is generally poor, although occasionally some degree of remission is observed; in most cases, problems persist over time.9 Early onset (ie, before 10 years of age) is a negative prognostic sign. Anhedonia (lack of pleasure in activities) is usually less responsive to pharmacological intervention. Relatively positive outcome is related to acute onset, older age at onset, better premorbid adjustment, and well-differentiated symptoms.