What is childhood schizophrenia?
The condition is defined as schizophrenia that starts in children younger than 13 years of age (and usually older than 7). Apart from age of onset and severity, it is much the same as adult schizophrenia.
This article will focus on the symptoms, diagnosis, and treatment of childhood schizophrenia. To learn more about schizophrenia in general, including the possible causes of schizophrenia, please visit the Medical News Today page on schizophrenia.
Childhood schizophrenia versus autism
Childhood schizophrenia is a rare condition.
It was not until 1980 that childhood schizophrenia became understood as a separate diagnosis - before that time, children who today would be diagnosed with autism, which is a type of 'pervasive developmental disorder,' were grouped under the diagnosis of schizophrenia.
The confusion persists today. Because of its rarity, and because the paranoid symptoms often present as hostile and oppositional behaviors, children with schizophrenia may falsely be diagnosed with conduct disorder.
The confusion is understandable given that family, genetic, and imaging findings show similarities between autism and childhood schizophrenia.
Early descriptions that were used to classify autism included "atypical and withdrawn behavior," "failure to develop identity separate from the mother's," and "general unevenness, gross immaturity, and inadequacy in development." See below how symptoms of childhood schizophrenia compare with these descriptions of autism.
The video below, produced by the Child Mind Institute, a non-profit organization, shows a leading expert on childhood schizophrenia talking about how the symptoms appear and the distressing effects they can produce.
Prof. Rochelle Caplan describes how it is a slow-onset disorder in most cases. She explains how the experience can be "very scary" for the child at onset, and how the parents may notice this as anxiety.
It is frightening for the child, Prof. Caplan explains, because the hallucinations or delusions can be threatening; also, children understand from the age of about 5 that it is not normal to hear, for example, external voices that are not there, and that are not experienced by other people.
Childhood versus adult schizophrenia
The hallmark of schizophrenia in any person is psychosis - schizophrenia is a psychotic illness. This means a loss of contact with reality because of hallucinations and delusions - the so-called positive symptoms of schizophrenia.
Two other Medical News Today pages give detailed information on psychosis symptoms and schizophrenia, so here we will concentrate on the main differences between adult onset and childhood schizophrenia.
Before psychosis appears in people with schizophrenia, there is often a phase leading up to it called premorbid or prodromal. This phase is more pronounced in children than in adults.
In childhood schizophrenia, the premorbid developmental impairments include:
- language impairments
- motor (movement) effects
- social deficits
In over half of children who go on to develop childhood schizophrenia, this phase is found to have started from the first months of life.
Compared with the usual onset of schizophrenia in adolescence or adulthood, this suggests there is a more severe and earlier disruption of brain development when schizophrenia appears in 7-13-year-olds.
Hallucinations, as with adult cases, are usually auditory in childhood schizophrenia (hearing external voices that do not exist); visual and tactile (touch) hallucinations are rarer. The type of delusion is slightly different in childhood schizophrenia - the bizarre false beliefs are usually related to childhood themes and are less complex than those experienced by adolescents and adults.
The cognitive and motivational impairments observed in schizophrenia (also called negative symptoms) are more obvious in the very early-onset disorder. These include impairments in emotional expression, social interaction, and volition (the will to make decisions).
"Flat or inappropriate affect" is the main impairment - a loss of ability to express or recognize emotions.
In studies, flat affect in schizophrenia can be measured as reduced facial expressions during social interactions, emotional films, and cartoons, and an inability to recognize faces. The patients themselves lack insight into these deficits, reporting normal emotional experiences.
All children with very early-onset schizophrenia show an obvious decline in functioning. Their social and functional problems and their symptoms are similar to those in adults but more severe.
The American Academy of Child and Adolescent Psychiatry has provided a list of example symptoms typical of childhood schizophrenia in its fact sheet for families about the disorder; they include:
- Odd and eccentric behavior and/or speech (so-called disorganized and disordered symptoms).
- Confusing television and dreams for reality (an example of psychosis).
- Extreme moodiness.
- Severe anxiety (due to fear of threatening hallucinations or delusions).
- Difficulty relating to and keeping friends.
- Withdrawing and becoming increasingly isolated.
- Worsening personal grooming (problems with bathing).
Early-onset schizophrenia is when a child aged 13 to 18 experiences hallucinations, delusions, and cognitive impairment associated with schizophrenia.
Very early onset schizophrenia is the pediatric equivalent, used when symptoms affect a child under the age of 13 years. It is thought to affect 1 in 30,000 children.
One case study has suggested that children may start experiencing unusual perceptions from as young as 3 months or earlier.
The Diagnostic and Statistical Manual (DSM) does not distinguish between adult, early-onset, and very early-onset schizophrenia, but there are some differences. A child who develops symptoms from a very early age is more likely to have severe symptoms as an adult.
The challenge with very early-onset schizophrenia is making a firm diagnosis by differentiating it from other disorders, including:
Diagnosing childhood schizophrenia can be challenging.
- Affective disorders (mood disorders, both depression and bipolar disorder) that display psychotic symptoms.
- Pervasive developmental disorders (such as autism).
- Severe personality disorders.
As described above, there is both overlap and confusion between autism and childhood schizophrenia. The negative symptoms seen in youngsters with schizophrenia are similar to those seen in autistic spectrum disorders, namely:
- social withdrawal
- communication impairment
- poor eye contact
Another difficulty in diagnosing childhood schizophrenia is how rare it is, along with the fact that hallucinations, which are not uncommon in other childhood psychiatric illnesses, cannot be used alone to make the diagnosis.
As with adult schizophrenia, there is no single diagnostic test for the disorder in children, and it relies on the elimination of other conditions and disorders that could explain the symptoms.
The criteria for reaching a diagnosis of schizophrenia are the same, albeit perhaps more challenging, as they are for adults. Learn more about questions for patients and family to help diagnose psychosis.
As with psychotic illness in adults, the treatment in children is the same - the positive symptoms of hallucination and delusion (the psychosis) are treated with drugs called antipsychotics. These help to control symptoms of hallucination, delusion, and disorganized thinking.
The difference in treating children with schizophrenia is that older antipsychotics (also referred to as "typical" antipsychotic medications) tend not to be as effective as they are in adults with schizophrenia.
Therefore, newer "atypical" antipsychotics are used: risperidone (branded Risperdal in the U.S.) and olanzapine (Zyprexa), while clozapine (Clozaril, FazaClo, Zaponex, or Clopine) is another atypical option in cases that fail to respond to the first-line drugs.
The newer drugs, however, particularly when used in children, can produce side effects, including weight gain and glucose intolerance, even though the medications are well tolerated by patients.
Other antipsychotic drugs used in schizophrenia include haloperidol (Haldol) and chlorpromazine (Promapar or Thorazine).
However, antipsychotic treatments do not cure schizophrenia; drugs will need to be taken for life to help manage symptoms and prevent psychosis. Similarly, there are no preventive measures available to stop a child getting schizophrenia in the first place.
Learn more about pharmacological treatment with antipsychotics.
Families in the caring role
Childhood schizophrenia will obviously involve people caring for the child - even more than the disorder in adolescents and young adults.
In the past, however, families were irrationally blamed for the development of schizophrenia in children and might have been excluded from care. These ideas have since been replaced by recommendations that there should be family engagement whenever possible since it is often critical to the recovery process.
A variety of psychosocial and educational interventions also support children with schizophrenia, to help with socialization, communication, and behavior - similar to the help given to children with developmental disorders.