Schizophrenia in children and adolescents

Is it possible to explain the fact that schizophrenia in children can appear at a fairly early age? It is even more difficult to determine the disease in a timely manner - as a rule, most parents are not sufficiently aware of this issue, and they do not go to the doctors at the first adverse signs. What is the result: children, for whom it is extremely important to start appropriate treatment, do not receive the necessary and timely medical care. And the disease, meanwhile, is progressing. [1]

Perhaps this material will convey the necessary information to parents: after all, it would be useful to know the initial suspicious signs of childhood schizophrenia, as well as the principles of first aid for the mentally ill.

Mental illness in children

In children, mental disorders and schizophrenia occur on almost the same scale as in adults, only they manifest themselves in their own way. For example, if in an adult a depressive state is accompanied by apathy and depression, then in a small patient it will be manifested by irascibility and irritability. [2], [3]

For childhood, such well-known mental pathologies are characteristic:

• Anxiety disorders - post-traumatic stress disorder, obsessive-compulsive disorder, social phobia, generalized anxiety disorder.
• Attention deficit hyperactivity disorder, which is accompanied by difficulty concentrating, increased activity and impulsive behavior.
• autistic disorders. [4]
• stressful conditions. [5]
• Eating disorders - anorexia, bulimia, psychogenic overeating.
• Mood disorders - arrogance, self-abasement, bipolar affective disorder. [6], 
• Schizophrenia, accompanied by a loss of contact with the real world.

In different situations, psychopathology in children can be temporary or permanent.

Does schizophrenia occur in children?

Indeed, schizophrenia can occur at any age, and even in children. However, detecting pathology in a baby is much more difficult than in an adult. The clinical signs of schizophrenia at different age stages are different, they are difficult to describe and identify.

The diagnosis of schizophrenia in children should only be made by a qualified psychiatrist with experience in pediatrics with mentally ill children. [7]

Schizophrenia in children is diagnosed predominantly in late adolescence, or during puberty (for example, after 12 years). Early detection of the disorder—before a specified age—is rare but likely. There are cases of detection of the disease in children aged 2-3 years.

In general, experts distinguish the following age periods of childhood schizophrenia:

• early age schizophrenia (in children under 3 years old);
• preschool schizophrenia (in children from 3 to 6 years old);
• schizophrenia of school age (in children 7-14 years old).

Epidemiology

If we talk about the incidence of schizophrenia in children, the disease is relatively rarely recorded before the age of 12. Starting from adolescence, the incidence increases sharply: the critical age (the peak of pathology development) is considered to be 20-24 years. [8]

Childhood schizophrenia is common and can be approximately 0.14-1 case per 10,000 children.

Schizophrenia is 100 times less common in children than in adults.

Boys are at the greatest risk of early development of schizophrenia. If we consider adolescence, then the risks for boys and girls are the same.

Causes of the schizophrenia in children

For both adult and childhood schizophrenia, there is no proven generally accepted pathogenetic mechanism of development, so the causes are quite general.

• hereditary predisposition. The risk of schizophrenia in children is much higher if the ancestors of the first and second line showed explicit or indirect signs of psychopathology. [9]
• Late pregnancy. There is an increased risk of mental disorders in children born to older mothers (over 36 years old).
• Father's age (association of father's age at conception with the risk of developing schizophrenia). [10], [11]
• Difficult conditions in which the patient lives. Tensions in the family, alcoholism of parents, lack of money, loss of loved ones, constant stress - all these factors contribute to the development of schizophrenia in children.
• Severe infectious and inflammatory diseases in a woman during childbearing (for example, prenatal influenza). [12], 
• Obstetric events and complications during pregnancy. [13], [14]
• Severe beriberi, general exhaustion in a woman during the periods of conception and bearing a baby.
• Early addictions.

Risk factors

More than a century ago, scientists suggested that the development of schizophrenia in children does not depend on external causes. To date, experts have recognized that, most likely, we are talking about a combination of the factor of unfavorable heredity  [15]and the negative influence of the external environment: a small child can be exposed to such an influence both in the prenatal and perinatal periods.

The early development of schizophrenia in children may be due to a violation of the formation of the nervous system during a woman's pregnancy, or in early childhood. At the same time, neurodegenerative disorders in brain tissues are not rejected. [16]

Cases of familial incidence of schizophrenia are represented mainly by the genetic component. At the moment, multiple representatives of genes are already known that can provoke the development of schizophrenia in childhood. Such genes are involved in the formation of the nervous system, the formation of brain structures and neurotransmitter mechanisms. [17]

Given the above, we can distinguish the following risk factors for the onset of schizophrenia in children:

• hereditary predisposition;
• the conditions in which the infant lived and was brought up in early childhood;
• neurobiological problems, psychological and social factors.

Pathogenesis

A clear pathogenetic picture of the development of schizophrenia in children still does not exist. There are theories and assumptions - for example, according to one of them, the disease develops as a result of local cerebral hypoxia at critical stages of migration and formation of nerve cells. With the help of computed tomography and magnetic resonance imaging, as well as multiple post-mortem studies, specialists were able to detect several important changes in the structure and functionality of the brain: [18]

• the lateral ventricles and the third ventricle are dilated against the background of atrophic processes in the cortex and expansion of the sulci;
• the volumes of the prefrontal zone of the right hemisphere, amygdala, hippocampus and thalamus are reduced;
• the asymmetry of the posterior superior temporal gyri is broken;
• metabolic processes in the nerve cells of the visual tubercles and prefrontal zone decreases.

Separate experiments made it possible to detect an increasing decrease in the volume of the cerebral hemispheres. Pathological changes in the cytoarchitectonics of the brain were determined, namely, a mismatch in the size, orientation and density of the nerve structures of the prefrontal zone and the hippocampus, a decrease in the density of nerve cells in the second layer and an increase in the density of pyramidal neurons in the fifth cortical layer. If we take into account all these changes, then we can single out such a cause of schizophrenia in children as damage to the cortico-striatothalamic circuits: this entails a change in the filtration of sensory information and the functioning of short-term memory. [19]

Despite the fact that full-fledged diagnosable schizophrenia develops closer to adolescence, individual pathological disorders (for example, cognitive and emotional) can be noticed even in early childhood. [20]

Symptoms of the schizophrenia in children

In early age periods and before reaching school age, the symptomatic manifestations of schizophrenia in children have certain features that reflect the natural imperfection of nervous activity. First of all, catatonic disorders are detected - for example, sudden paroxysmal excitement against the background of causeless laughter or tears, aimless swinging left and right or walking in a circle, striving into uncertainty (often - to a dead end). [21]

With age, when the baby already clearly expresses his thoughts, with schizophrenia, one can observe such violations as stupid fantasizing with an abundance of implausible and unrealistic images. Moreover, such fantasies are almost entirely present in all children's conversations, forming the pathology of delusional fantasizing. Often there are hallucinations: the baby can talk about incomprehensible voices inside the head, about someone who wants to harm or offend him.

Sometimes a patient with schizophrenia complains about ordinary everyday objects or situations, which, in his words, are endowed with a terrifying essence, and such complaints are associated with real and intense fear. Of course, it is quite difficult for parents to identify the early symptoms of childhood schizophrenia from standard and numerous fantasies. [22]

In psychiatric reference literature, one can often find descriptions of individual signs and abnormalities that parents should pay attention to.

The first signs may look like this:

• Symptoms of paranoia - the baby complains that everyone around has conspired against him. Everything that does not correspond to his desires is interpreted as an attempt to humiliate and insult, to which the patient responds with aggression and active opposition.
• Hallucinations (verbal, visual).
• Ignoring personal hygiene, outright slovenliness, refusal to wash, cut hair, etc.
• Systematic unfounded fears, fantasies about certain creatures visiting children day and night, talking to them, inclining them to fulfill any requirements.
• Loss of interest in previously favorite games and activities, refusal to communicate with friends and family, withdrawal into oneself.
• Emotionally extreme manifestations, radically opposite emotions, alternating without definite intervals. The little patient cries and immediately laughs, may accompany all this with delusional fantasies and excessive clowning.
• Children's speech does not concentrate on any one topic, the conversation can be suddenly interrupted, or transferred to another topic, and then to a third one, and so on. Sometimes the baby just falls silent, as if listening to himself.
• Chaotic thinking, lack of direction of thoughts, throwing from side to side.
• A haunting desire to harm, whether to oneself or others. During negative emotional manifestations, the patient can beat toys, furniture, damage property, etc. And for him it seems quite funny.

The behavior of a child with schizophrenia in senior school age is characterized by an aggravation of delusional hallucinatory manifestations. Becomes characteristic of excessive foolishness, absurdity in behavior, pretense, a tendency to seem younger than one's age.

The features of schizophrenia in children most often make it possible to determine the disease already closer to adolescence, when noticeable deviations are found in the form of emotional inhibition, general detachment from the environment, poor school performance, craving for bad habits and addictions. As the transitional period from childhood to adolescence approaches, pronounced deviations in general development, including intellectual development, are revealed.

Schizophrenia in young children, in young children from 2 to 6 years old, is characterized by reduced activity, increasing indifference to everything. Gradually, there is a desire for isolation and protection from the outside world: the baby becomes secretive, uncommunicative, preferring loneliness to noisy and crowded companies. For schizophrenia, monotonous repetitions are typical: the patient can monotonously shift toys for hours, perform one or a couple of movements, make the same strokes with pencils.

In addition, schizophrenia in preschool children is manifested by impulsive behavior, emotional imbalance, groundless whims or laughter. There is a distorted perception of reality, disorders of the quality of thought processes. The delirium of relationships or persecution, the replacement of loved ones is quite pronounced. With age, the thought process becomes incoherent, and thoughts become unstable, chaotic and fragmentary.

Physical activity also suffers. Violations are manifested in excessive sharpness of movements, a change in posture, and the face is completely deprived of emotionality and takes on the form of a “mask”. [23]

Features of the course of schizophrenia in children

Schizophrenia in children can begin at an early age, almost simultaneously with the onset of mental development. This affects the formation of such features of the flow:

• the clinical picture is very often "erased", because the painful symptoms do not "hold out" to the known adult symptoms. For example, in young children, schizophrenia is manifested by the inadequacy of the reaction to uncomfortable situations, indifference to surrounding close people;
• children with schizophrenia fantasize suspiciously for a long time, talk on strange topics, sometimes gravitate towards asociality, can leave home, use alcohol and drugs;
• the development of children with schizophrenia is uneven: advances are interspersed with deviations from the norm (for example, the child could not learn to walk for a long time, but he began to speak early).

It is very important to pay attention to such features, as this allows you to understand the subtleties of the mechanism of development of schizophrenia in children. [24]

Forms

Schizophrenia in children can occur in one of several existing forms:

• paroxysmal (progredient) form, characterized by recurring attacks with certain remission intervals, increasing adverse symptoms;
• continuously flowing, or sluggish schizophrenia in children, which has a malignant constant course;
• recurrent form, which is characterized by a periodic paroxysmal course.

If we consider the classification according to symptoms and signs, then schizophrenia in children can be of the following types:

• Simple schizophrenia, with the absence of delusional and hallucinatory states, with the presence of volitional disorders, depression of motivation, mental flattening and emotional stinginess. This type of disease is most susceptible to therapy.
• The hebephrenic type is characterized by emotional pretentiousness, a tendency to clowning and antics. In addition, the patient vividly protests against everything, becomes impulsive and even aggressive (including himself). Education is not “given” to these children, in any form. If timely treatment is not followed, such patients begin to pose a threat to others.
• Catatonic schizophrenia in children is manifested by pretentiousness of body position, posturing. The patient can sway for a long time in the same way, wave his arms, shout or pronounce one word or phrase. At the same time, he refuses to communicate with loved ones, can repeat certain sounds or facial expressions.

Separately, specialists distinguish congenital schizophrenia in children. This is a chronic mental disorder, which is accompanied by the above unusual children's reactions to the environment, people and events. This term of congenital disease is rarely used in medicine. The fact is that this diagnosis is quite difficult, since it is almost impossible to determine most of the disorders in a newborn and infant, until his psyche is finally formed. Usually, at the stage of early development, doctors are unable to answer the question of whether schizophrenia is congenital or the formation of the pathology occurred later. [25]

Complications and consequences

With schizophrenia in children, there is a likelihood of developing such consequences and complications:

• loss of the possibility of social adaptation and interaction with others;
• general disorders of brain functions;
• neuroleptic extrapyramidal syndromes, as a result of long-term use of neuroleptics.

With timely treatment and constant monitoring by specialists, some adverse symptoms may remain in children:

• violations of coordination;
• lethargy, low energy level;
• communicative insufficiency, vagueness of thoughts and speech;
• behavioral disorders;
• attention deficits, impaired concentration, distractibility. [26]

Diagnostics of the schizophrenia in children

Diagnosis of schizophrenia in children is carried out by a psychiatrist,  [27] who, if a problem is suspected, usually takes the following actions:

• talks with parents, finds out the duration and nature of suspicious symptoms, asks about background diseases, assesses the degree of hereditary predisposition;
• talks with a sick baby, asks questions, evaluates his reaction, emotional manifestations, behavior;
• determines the degree of intelligence, the quality of attention and features of thinking.

The psychodiagnostic test for schizophrenia in children includes several methods at once:

• Schulte tables;
• correction test;
• method of eliminating the superfluous;
• method of exclusion and comparison of concepts;
• association test;
• Ravenna test.

These tests are not specific for the diagnosis of schizophrenia, but they help to detect some deviations in the patient's mental activity. True, they can only be used in relation to older children and adolescents. 

EEG in schizophrenia in a child also does not provide specific data, but most often the study allows you to detect:

• fast low-amplitude activity;
• disorganized rapid activity;
• lack of α-rhythm;
• high-amplitude β-activity;
• dysrhythmia;
• "peak-wave" complex;
• generalized slow wave activity.

In patients with schizophrenia, a change in the bioelectrical brain activity is detected quite often. It is not always pronounced, but can also be used as a marker of the risk of developing the disease.

Emission computed tomography (SPECT) has expanded understanding of the physiological functioning of the intact brain and can detect perfusion defects in the cerebral cortex in patients with childhood onset schizophrenia. [28]

Differential diagnosis

Differential diagnosis in children should distinguish and identify schizophrenia from early childhood autism, a schizotypal personality disorder. [29], [30]

Childhood schizophrenia and autism are distinguished by the absence of delusional symptoms, hallucinations, aggravated heredity, alternation of relapses with remissions, withdrawal from society (in return, there is a delay in social development).

Schizotypal personality disorder is usually suspected in the continuous sluggish course of schizophrenia in children. In such a situation, the presence or absence of hallucinations, delusional states, and pronounced mental disorders are considered to be the basic distinguishing features.

Epilepsy in children should also be differentiated from schizophrenia - the symptoms of temporal lobe epilepsy are especially similar, in which personality disorders, mood and anxiety disorders are observed. Children may have significant behavioral problems, often become socially isolated, emotionally unstable and dependent.

Oligophrenia is another pathology that requires differential diagnosis with early onset schizophrenia. In contrast to oligophrenia, in children with schizophrenia, developmental inhibition is partial, dissociated, and the symptom complex is manifested by autism, morbid fantasies, and catatonic symptoms.

Treatment of the schizophrenia in children

Therapy in the detection of schizophrenia in children is prescribed only with the use of integrated approaches and activities. [31] It usually consists of the following methods:

• psychotherapeutic impact.

Conversations with a psychologist, stimulation of emotional and sensual manifestations help the child reach a new level and get rid of many internal "locks" and experiences. During a psychotherapeutic session, a patient with schizophrenia himself can delve into his own state, feel his mood, sensations, and analyze behavior. The psychotherapist gives impetus to the emergence of reactions to standard and non-standard situations, to overcoming barriers that are difficult for the patient.

• Medical treatment.

The drug regimen for schizophrenia in children may include stimulants, antidepressants, antipsychotics,  [32]or anti-anxiety medications.

The most effective therapeutic option is selected separately in each specific situation. Perhaps, with a mild course of schizophrenia in children, the use of psychotherapeutic sessions will be sufficient, and in some cases, combined drug treatment will be shown.

Experts note that treatment is more effective in the acute period of the disease.

What should parents do after a diagnosis of schizophrenia in children? The first thing that should not be forgotten is the full support of a sick person. In any situation, parents should not give vent to their own negative feelings, demonstrate their helplessness or disappointment. To accept the baby and try to help him is an important decision that can change the course of the pathological process in a positive direction.

It is necessary to consult a doctor - perhaps not even with one or two specialists. We need to look for ways to try not to dwell on the situation, to spend time positively with a schizophrenic patient, to learn how to manage stress. In almost all clinics of this direction, there are support groups and family counseling courses. Any parent should first of all understand their baby and try to help him as much as possible.

Is there a cure for schizophrenia in children? Yes, it is treated, but such treatment requires both an integrated approach on the part of doctors and boundless love and patience on the part of parents. In mild and moderate cases, therapy is directed to the prevention of exacerbations, the possibility of returning to normal life. At the end of treatment, the child should be under the periodic supervision of psychiatrists, systematically visit the psychotherapy room.

What medications can a doctor prescribe

In the malignant continuous course of schizophrenia in children, antipsychotics are prescribed  [33],  [34]which are distinguished by a pronounced antipsychotic effect - for example:

• Chlorpromazine - prescribed to children, starting from the age of one. Enter intramuscularly or intravenously. The doctor determines the dosage and regimen of therapy individually, depending on the indications and the patient's condition. Prolonged use can lead to the development of neuroleptic syndrome.
• Levomepromazine (Tisercin) is prescribed to children from 12 years of age, at an average daily dosage of 25 mg. Possible side effects: postural hypotension, tachycardia, neuroleptic malignant syndrome.
• Clozapine - is used not earlier than adolescence (preferably after 16 years), in the lowest possible individual dosage. Side effects: weight gain, drowsiness, tachycardia, hypertension, postural hypotension. [35], [36]

Anticholinergic drugs are used to prevent the development of adverse neuroleptic consequences while taking antipsychotics:

• Trihexyphenidyl - prescribed to children from 5 years of age, in the maximum daily dose of not more than 40 mg. During treatment, hypersalivation, dry mucous membranes are possible. Cancellation of drug is made gradually.
• Biperiden - for schizophrenia in children is used in individually set dosages - orally, intravenously or intramuscularly. Possible side effects: fatigue, dizziness, disturbance of accommodation, dyspepsia, drug dependence.

During the treatment of uncomplicated schizophrenia in children, stimulant and atypical antipsychotics are used:

• Trifluoperazine (Triftazin) - is prescribed in individually selected dosages, carefully weighing the positive and negative aspects of the use of the drug. Side symptoms can be dystonic extrapyramidal reactions, pseudoparkinsonism, akinetic-rigid phenomena.
• Perphenazine - is used to treat children from 12 years old, in individual dosages. Internal administration of the drug may be accompanied by dyspepsia, hypersensitivity reactions, extrapyramidal disorders.
• Risperidone - is used mainly from the age of 15, starting with 2 mg per day, with subsequent dosage adjustment. Experience with younger children is limited.

With the continuous course of the paranoid schizoid form, it is possible to use neuroleptic drugs with anti-delusional properties (Perphenazine, Haloperidol). If hallucinatory delirium predominates, then emphasis is placed on Perphenazine or Trifluoperazine. [37]

In the later stages of schizophrenia in children, fluphenazine is added.

Febrile schizophrenia requires the use of infusion treatment in the form of infusions of a 10% glucose-insulin-potassium mixture, saline solutions, potassium, calcium and magnesium preparations. To prevent cerebral edema, osmotic diuretics are used intravenously, against the background of Diazepam or hexenal anesthesia. 

Prevention

Since the clear causes of schizophrenia in children are still unknown, heredity plays a significant role in the development of pathology. It turns out that many children are born with a predisposition to the disease. It is not a fact that a child will definitely develop schizophrenia, so it is important to start the prevention of this disorder in a timely manner. And it is better to do this immediately from the moment the baby is born. What are preventive actions?

• Provide a small patient with normal child-parent relationships, a calm environment in the family, with the exception of stress and conflict situations.
• To educate the baby in a simple, accessible and understandable adequate framework for him, adhere to the daily routine.
• Avoid the formation of children's fears, talk more often, explain and encourage, in no case use a "command" tone and do not punish.
• Develop emotionality in the baby, involve them in social communication, accustom them to the team.
• Do not be shy to seek help from specialists if necessary.

Forecast

It is impossible to determine the prognosis of schizophrenia in children if the situation is assessed only by the initial signs of the disease. The specialist must separate favorable and unfavorable symptoms, and only then determine the severity of the pathology. A good prognosis can be assumed if schizophrenia began its development late, its onset was abrupt, and the symptoms were pronounced. Additional positive aspects are the simplicity of the personality structure, good adaptive and social signs, and a high probability of psychoreactive development of schizophrenic waves. [38]

It is noted that girls have a better prognosis than boys.

Indicators of an unfavorable prognosis are:

• delayed and latent onset of schizophrenia;
• the presence of only basic signs of the disease;
• the presence of schizoid and other premorbid personality disorders;
• dilated cerebral ventricles on CT scan;
• developing addictions.

It is worth noting that schizophrenia in children proceeds not only according to certain pathological patterns, but largely depends on the social atmosphere and environment, with the ability to change under the influence of drug therapy. [39] According to statistics, with age, recovery occurs in about 20% of children, and a pronounced improvement is noted in 45% of patients.