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 identify the disease in a timely manner – as a rule, most parents are not sufficiently informed on this issue, and they do not consult doctors at the first unfavorable signs. What is the result: children for whom it is extremely important to begin appropriate treatment do not receive the necessary and timely medical care. And the disease, meanwhile, progresses. [ 1 ]

Perhaps this material will convey the necessary information to parents: after all, it would not be superfluous 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

Children suffer from mental disorders and schizophrenia almost on the same scale as adults, but they manifest themselves in their own way. For example, if an adult's depressive state is accompanied by apathy and depression, then in a small patient it will manifest itself as irascibility and irritability. [ 2 ], [ 3 ]

The following well-known mental pathologies are typical for childhood:

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

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

Does schizophrenia occur in children?

Indeed, schizophrenia can occur at any age, even in children. However, it is much more difficult to detect pathology in a child than in an adult. Clinical signs of schizophrenia at different age stages differ, 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 mainly in late adolescence or during puberty (for example, after 12 years). Early detection of the disorder - before the specified age - is rare, but probable. 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-onset schizophrenia (in children under 3 years of age);
• preschool schizophrenia (in children from 3 to 6 years old);
• school-age schizophrenia (in children aged 7-14 years).

Epidemiology

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

Childhood schizophrenia is common and may account for approximately 0.14-1 case per 10,000 children.

Schizophrenia in children occurs 100 times less frequently than in adults.

Boys have the highest risk of developing schizophrenia early on. If we consider adolescence, then the risks for boys and girls are the same.

Causes 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 first- and second-line ancestors showed obvious 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).
• Paternal age (relationship between paternal age at conception and risk of developing schizophrenia). [ 10 ], [ 11 ]
• The difficult conditions in which the patient lives. Strained relationships 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 women during pregnancy (for example, prenatal flu). [ 12 ],
• Obstetric events and complications during pregnancy. [ 13 ], [ 14 ]
• Severe vitamin deficiencies, general exhaustion in women during periods of conception and bearing a child.
• Early drug addictions.

Risk factors

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

Early development of schizophrenia in children may be due to disruption of the development of the nervous system during pregnancy or in early childhood. At the same time, neurodegenerative disorders in brain tissue are not ruled out. [ 16 ]

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

Taking into account the above, we can identify the following risk factors for the development of schizophrenia in children:

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

Pathogenesis

There is still no clear pathogenetic picture of the development of schizophrenia in children. 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. Using computer and magnetic resonance imaging, as well as multiple pathological studies, specialists have managed 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 widening of the grooves;
• the volumes of the prefrontal zone of the right hemisphere, amygdala, hippocampus and thalamus are reduced;
• the asymmetry of the posterior superior temporal convolutions is disrupted;
• Metabolic processes in the nerve cells of the thalamus and prefrontal zone are reduced.

Individual experiments have revealed a progressive decrease in the volume of the cerebral hemispheres. Pathological changes in the cytoarchitecture of the brain have been identified – namely, a discrepancy in the size, orientation and density of the neural structures of the prefrontal zone and 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. Taking into account all of these changes, we can identify 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 work of short-term memory. [ 19 ]

Although full-blown diagnosable schizophrenia develops closer to adolescence, individual pathological disorders (for example, cognitive and emotional) can be noticed in early childhood. [ 20 ]

Symptoms schizophrenia in children

In early age periods and before reaching school age, 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 swaying left and right or walking in circles, striving for uncertainty (often - into a dead end). [ 21 ]

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

Sometimes a patient with schizophrenia complains about ordinary everyday objects or situations that, according to him, have a terrifying essence, and such complaints are associated with real and strong 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 deviations that parents should pay attention to.

The first signs may look like this:

• Symptoms of paranoia - the child complains that everyone around him has conspired against him. Anything that does not correspond to his wishes 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, obvious sloppiness, refusal to wash, get a haircut, etc.
• Systematic unfounded fears, fantasies about certain creatures visiting children day and night, talking to them, persuading them to fulfill certain demands.
• Loss of interest in previously favorite games and activities, refusal to communicate with friends and family, withdrawal into oneself.
• Emotional-extreme manifestations, radically opposite emotions, alternating without certain intervals. The little patient cries and then laughs, can accompany all this with delirious fantasies and excessive clowning.
• Children's speech does not focus on any one topic; the conversation can be suddenly interrupted, or transferred to another topic, and then to a third, and so on. Sometimes the baby simply falls silent, as if listening to himself.
• Chaotic thinking, lack of direction in thoughts, tossing from side to side.
• A persistent desire to harm - no matter if it is oneself or someone else. During negative emotional manifestations, the patient may beat toys, furniture, damage property, etc. Moreover, for him, this seems quite funny.

The behavior of a child with schizophrenia in senior school age is characterized by an aggravation of delusional-hallucinatory manifestations. Excessive silliness, absurdity in behavior, pretense, and a tendency to seem younger than their age become characteristic.

The characteristics of schizophrenia in children most often allow the disease to be identified closer to adolescence, when noticeable deviations are detected in the form of emotional inhibition, general detachment from the environment, poor performance at school, craving for bad habits and addictions. As the transition period from childhood to adolescence approaches, pronounced deviations in general development are detected, including in intellectual terms.

Schizophrenia in young children, in small children from 2 to 6 years old, is characterized by decreased activity, increasing indifference to everything. Gradually, a desire for isolation and isolation from the outside world appears: the child becomes secretive, uncommunicative, preferring solitude to noisy and crowded companies. Monotonous repetitions are typical for schizophrenia: the patient can monotonously move toys for hours, perform one or two movements, make the same strokes with pencils.

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

Motor activity also suffers. Disturbances manifest themselves in excessively abrupt movements, changes in posture, and the face completely loses its emotionality and takes on the appearance of a “mask”. [ 23 ]

Peculiarities 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 course:

• the clinical picture is often "erased" because the painful symptoms do not "reach" the known adult symptoms. For example, in young children, schizophrenia is manifested by an inadequate reaction to uncomfortable situations, indifference to the surrounding loved ones;
• Children with schizophrenia fantasize for a long time and suspiciously, discuss strange topics, sometimes tend to be asocial, may leave home, drink alcohol and use drugs;
• The development of children with schizophrenia occurs unevenly: advances alternate with deviations from the norm (for example, a child could not learn to walk for a long time, but began to speak early).

It is very important to pay attention to such features, as this allows us 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 (progressive) form, characterized by recurring attacks with certain remission intervals, increasing unfavorable symptoms;
• continuously progressing 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 by symptoms and signs, then schizophrenia in children is 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 clown and grimace. In addition, the patient strongly protests against everything, becomes impulsive and even aggressive (including towards himself). These children are not "given" to study, in any form. If timely treatment does not follow, such patients begin to pose a threat to others.
• Catatonic schizophrenia in children is manifested by eccentric body postures and posing. The patient may sway in the same way for a long time, wave his arms, shout or pronounce one word or phrase. At the same time, he refuses to communicate with loved ones, and may repeat certain sounds or elements of facial expressions.

Specialists separately distinguish congenital schizophrenia in children. This is a chronic mental disorder that is accompanied by the above-mentioned unusual childhood reactions to the environment, people and events. This term for a congenital disease is rarely used in medicine. The fact is that making this diagnosis is quite difficult, since it is almost impossible to determine most disorders in a newborn or infant until his or her psyche is fully formed. Usually, at the stage of early development, doctors are unable to answer the question of whether schizophrenia is congenital or whether the pathology developed later. [ 25 ]

Complications and consequences

In children with schizophrenia, there is a risk of developing the following consequences and complications:

• loss of the ability to socially adapt and interact with others;
• general disorders of brain functions;
• neuroleptic extrapyramidal syndromes as a result of long-term use of neuroleptics.

With timely initiation of treatment and constant monitoring by specialists, children may still experience some unfavorable symptoms:

• impaired coordination;
• lethargy, low energy level;
• communication impairment, confusion of thoughts and speech;
• behavioral disorders;
• attention deficits, impaired concentration, distractibility. [ 26 ]

Diagnostics schizophrenia in children

The 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 to the sick child, asks questions, evaluates his reaction, emotional manifestations, behavior;
• determines the level of intelligence, quality of attention and features of thinking.

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

• Schulte tables;
• proofreading;
• method of eliminating the unnecessary;
• method of elimination and comparison of concepts;
• association test;
• Ravenna test.

The tests listed are not specific for diagnosing schizophrenia, but they do help to detect some deviations in the patient's thinking. However, they can only be used with older children and adolescents.

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

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

In patients with schizophrenia, changes in bioelectric brain activity are found quite often. They are not always very pronounced, but can also be used as a marker of the risk of developing the disease.

Spinal emission computed tomography (SPECT) has increased our understanding of the physiological functioning of the intact brain and can identify cortical perfusion defects in patients with childhood-onset schizophrenia.[ 28 ]

Differential diagnosis

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

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

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

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 diagnostics with early-onset schizophrenia. Unlike oligophrenia, in children with schizophrenia, developmental inhibition is partial, dissociated, and the symptom complex is manifested by autism, morbid fantasies, and catatonic symptoms.

Treatment schizophrenia in children

Therapy for the detection of schizophrenia in children is prescribed only using complex approaches and measures. [ 31 ] It usually consists of the following methods:

• Psychotherapeutic influence.

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

• Drug treatment.

Drug therapy for schizophrenia in children may include stimulants, antidepressants, antipsychotics [ 32 ] or anti-anxiety medications.

The most effective therapeutic option is selected individually in each specific situation. Perhaps, in the case of mild schizophrenia in children, psychotherapeutic sessions will be sufficient, and in some cases, combined drug treatment will be indicated.

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

What should parents do after diagnosing schizophrenia in children? The first thing that should not be forgotten is the full support of the sick person. In any situation, parents should not give vent to their own negative feelings, demonstrate their helplessness or disappointment. Accepting the baby and trying 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 even more than one or two specialists. It is necessary to look for ways to try not to dwell on the situation, to spend time positively with a patient with schizophrenia, to learn to manage stress. Almost all clinics of this type have support groups and family counseling courses. Any parent should first of all understand their child and try to help him as much as possible.

Is schizophrenia treatable in children? Yes, it is, but such treatment requires both a comprehensive approach from doctors and boundless love and patience from parents. In mild and moderate cases, therapy is aimed at preventing exacerbations and the possibility of returning to normal life. After treatment, the child should be under periodic supervision of psychiatrists and systematically visit a psychotherapy office.

What medications can a doctor prescribe?

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

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

To prevent the development of adverse neuroleptic effects during the use of neuroleptics, anticholinergic drugs are used:

• Trihexyphenidyl - prescribed to children from 5 years of age, in a maximum daily dose of no more than 40 mg. During the treatment, hypersalivation and dry mucous membranes are possible. The drug is discontinued gradually.
• Biperiden - for schizophrenia in children is used in individually established dosages - orally, intravenously or intramuscularly. Possible side effects: fatigue, dizziness, accommodation disorder, dyspepsia, drug dependence.

During the treatment of uncomplicated schizophrenia in children, stimulating and atypical neuroleptics are used:

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

In the case of continuous paranoid schizoid form, it is possible to use neuroleptic drugs with anti-delusional properties (Perphenazine, Haloperidol). If hallucinatory delusions predominate, then the activation is done on Perphenazine or Trifluoperazine. [ 37 ]

In the late stages of schizophrenia in children, Fluphenazine is added.

Febrile schizophrenia requires the use of infusion therapy in the form of infusions of 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 exact causes of schizophrenia in children are still unknown, heredity plays a significant role in the development of the pathology. It turns out that many children are born with a predisposition to the disease. It is not a fact that schizophrenia will necessarily develop in a child, so it is important to begin 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 the preventive measures?

• Provide the little patient with normal parent-child relationships, a calm environment in the family, with the exclusion of stress and conflict situations.
• Raise your child within simple, accessible and understandable adequate frameworks, and adhere to a daily routine.
• Avoid developing children's fears, talk more often, explain and encourage, and never use a "commanding" tone or punish.
• Develop emotionality in children, involve them in social communication, and accustom them to being part of a group.
• Don't hesitate 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. A 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 to develop late, its onset was abrupt, and the symptoms were pronounced. Additional positive aspects include the simplicity of the personality structure, good adaptive and social characteristics, and a high probability of psychoreactive development of schizophrenic waves. [ 38 ]

It is noted that the prognosis for girls is better than for boys.

Indicators of an unfavorable prognosis are:

• delayed and latent onset of schizophrenia;
• presence of only basic signs of the disease;
• the presence of schizoid and other premorbid personality disorders;
• dilated cerebral ventricles according to CT results;
• developing dependencies.

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