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 detect the disease in time - as a rule, most parents are not sufficiently aware of this issue, and they do not contact doctors at the first unfavorable signs. The result is that children who are in need of appropriate treatment do not receive the necessary and timely medical care. In the meantime, the disease progresses. [1]

Perhaps this material will bring the necessary information to parents: after all, it is not unreasonable to know the initial suspicious signs of childhood schizophrenia, as well as the principles of first aid to the mentally ill.

Mental illness in children

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

Childhood is characterized by such well-known psychiatric pathologies:

• Anxiety states - post-traumatic stress disorder, obsessive compulsive neurosis, sociophobia, 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-deprecation, bipolar affective disorder. [6],
• Schizophrenia, accompanied by a loss of connection to the real world.

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

Does schizophrenia happen in children?

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

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

Schizophrenia in children is predominantly diagnosed in older adolescence or during puberty (e.g., after age 12). Early detection of the disorder - before this age - is rare but likely. There are cases of the disorder being detected in children aged 2-3 years.

In general, experts distinguish such age periods of pediatric schizophrenia:

• Early-onset schizophrenia (in children younger than 3 years of age);
• Preschool schizophrenia (in children three to six years old);
• School-age schizophrenia (in children 7-14 years old).

Epidemiology

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

Pediatric schizophrenia is common and may be approximately 0.14 to 1 case per 10,000 children.

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

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

Causes of the schizophrenia in children

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

• Hereditary predisposition. The risk of schizophrenia in children is much higher if first- and second-line ancestors showed overt 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 of age).
• Father's age (association of father's age at conception with risk of schizophrenia). [10], [11]
• Difficult conditions in which the patient lives. Tense relations 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 disease in a woman while carrying a baby (e.g., prenatal influenza). [12],
• Obstetric events and complications during pregnancy. [13], [14]
• Severe avitaminosis, general exhaustion in a woman during the periods of conception and carrying the baby.
• 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. To date, experts have recognized that, most likely, it is 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 influence both in the prenatal and perinatal period.

The early development of schizophrenia in children may be due to a disturbance in the formation of the nervous system during a woman's pregnancy or in early childhood. Neurodegenerative disorders in brain tissue are not excluded. [16]

The familial incidence of schizophrenia is predominantly genetic. At the moment, multiple representatives of genes that can provoke the development of schizophrenia in childhood are already known. Such genes are involved in the process of formation of the nervous system, formation of brain structures and neurotransmitter mechanisms. [17]

Taking into account the above, it is possible to distinguish such risk factors for the appearance of schizophrenia in children:

• hereditary predisposition;
• The conditions in which the infant lived and was raised in early childhood;
• Neurobiological issues, 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 due to local cerebral hypoxia at critical stages of migration and formation of nerve cells. With the help of computer and magnetic resonance imaging, as well as multiple pathological and anatomical studies, experts have managed to discover several important changes in the structure and functionality of the brain: [18]

• lateral ventricles and the third ventricle are dilated against the background of atrophic processes in the cortex and furrow dilation;
• volumes of the prefrontal zone of the right hemisphere, amygdala, hippocampus and optic tubercles are reduced;
• the asymmetry of the posterior superior temporal gyrus is disrupted;
• metabolic processes in the nerve cells of the optic 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 identified, namely, a discrepancy in the size, orientation, and density of 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. If we take into account all these changes, we can identify such a cause of schizophrenia in children as damage to the cortico-striatothalamic circuits: this entails changes in the filtering of sensory information and the work of short-term memory. [19]

Although fully diagnosable schizophrenia develops closer to adolescence, individual pathological disturbances (e.g., cognitive and emotional) can be seen in early childhood. [20]

Symptoms of the schizophrenia in children

In early age and before 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 seizure-like agitation on the background of gratuitous laughter or tears, aimless swaying to the left-right or walking in circles, striving in uncertainty (often - in a dead end). [21]

With age, when the child already clearly expresses his thoughts, in schizophrenia one can observe such disorders as silly 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 also hallucinations: the baby can talk about incomprehensible voices inside the head, about someone who wants to harm him or offend him.

Sometimes the schizophrenic patient complains about ordinary everyday objects or situations that he or she says have 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 the standard and numerous fantasies. [22]

Psychiatric reference literature often describes individual signs and abnormalities that parents should look out for.

The first signs may look like this:

• Symptoms of paranoia - the child complains that everyone around him is conspiring 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 confrontation.
• Hallucinations (verbal, visual).
• Ignoring personal hygiene, outright slovenliness, refusal to wash, cut hair, etc.
• Systematic unfounded fears, fantasies about some 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 himself.
• Emotional extreme manifestations, radically opposite emotions, alternating without definite intervals. The young patient cries and laughs at the same time, may accompany all this with delusional fantasies and excessive clowning.
• Children's speech is not concentrated on any one topic, the conversation may be suddenly interrupted, or transferred to another topic, and then to a third and so on. Sometimes the baby just goes silent, as if listening to himself.
• Chaotic thinking, lack of direction of thoughts, tossing from side to side.
• A haunting desire to do harm - no matter if it is to themselves or to someone else. During negative emotional manifestations, the patient may hit toys, furniture, damage property, etc. The patient may be quite amused by this. The patient may hit toys, furniture, damage property, etc. During negative emotional manifestations.

Behavior of a child with schizophrenia in high school age is characterized by aggravation of delusional-hallucinatory manifestations. It becomes characteristic of excessive foolishness, ridiculous behavior, pretension, tendency to appear younger than his age.

The peculiarities of schizophrenia in children most often allow to determine the disease closer to adolescence, when noticeable deviations in the form of emotional inhibition, general detachment from the environment, unsatisfactory performance in school, craving for bad habits and addictions are detected. As the transition 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 is characterized by reduced activity, increasing indifference to everything. Gradually there is a desire for isolation and isolation from the outside world: the baby becomes secretive, unsociable, preferring solitude to noisy and crowded companies. Monotonous repetitions are typical of schizophrenia: the patient can monotonously spend hours shifting toys, performing one or a couple of movements, making identical strokes with pencils.

In addition, schizophrenia in preschool children is manifested by impulsive behavior, emotional instability, groundless caprices or laughter. There is a distorted perception of reality, disorders of the quality of thought processes. Delusions of relationships or persecution, replacement of loved ones are quite strongly expressed. With age, the thought process becomes incoherent, and thoughts become unstable, chaotic and fragmented.

Motor activity also suffers. Disorders are manifested in excessive abruptness of movements, changes in posture, and the face is completely devoid of emotionality and acquires 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 maturation. This affects the formation of such features of the course:

• the clinical picture is very often "erased", as the painful symptoms do not "reach" the known adult symptoms. For example, in young children schizophrenia is manifested by inadequate reaction to uncomfortable situations, indifference to surrounding loved ones;
• children with schizophrenia have long and suspicious fantasies, speculate on strange topics, sometimes gravitate to antisocial behavior, may leave home, use alcoholic beverages and drugs;
• The development of children with schizophrenia is uneven: advancements are interspersed 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 it 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:

• seizure-like (progredient) form, characterized by recurrent attacks with definite remission intervals, increasing adverse symptomatology;
• Continuous, or lethargic schizophrenia in children, which has a malignant persistent course;
• recurrent form, which is characterized by a periodic attack-like course.

If we consider the classification by symptoms and signs, schizophrenia in children comes in these types:

• Simple schizophrenia, lacking delusions and hallucinatory states, with the presence of volitional disturbances, depressed motivation, thought flattening, and emotional stinginess. This type of illness is most amenable to therapy.
• The hebephrenic type is characterized by emotional pretentiousness, a tendency to clowning and clowning. In addition, the patient strongly protests against everything, becomes impulsive and even aggressive (including to himself). Learning these children are not "given", in any form. If not followed by timely treatment, such patients begin to pose a threat to others.
• Catatonic schizophrenia in children is manifested by flamboyance of body posture, posturing. The patient may sway, wave his hands, shout or utter a single word or phrase for long periods of time. At the same time, he refuses to communicate with loved ones, may repeat certain sounds or elements of facial expressions.

Specialists separately distinguish congenital schizophrenia in children. It is a chronic mental disorder that is accompanied by the above-mentioned unusual childhood reactions to the environment, people and events. Such a term of congenital disease in medicine is rarely used. The fact is that making this diagnosis is quite difficult, since it is practically impossible to determine most of the disorders in a newborn and breastfed infant, until his psyche is not finally formed. Usually at the stage of early development, doctors are unable to answer the question of whether schizophrenia is congenital or whether the formation of pathology occurred later. [25]

Complications and consequences

In schizophrenia in children, there is a possibility of developing these effects and complications:

• loss of social adaptation and interaction with others;
• general brain dysfunctions;
• Neuroleptic extrapyramidal syndromes as a result of long-term neuroleptic use.

With timely treatment and ongoing specialist supervision, some unfavorable symptoms may remain in children:

• coordination problems;
• lethargy, low energy levels;
• communication deficits, unclear thoughts and speech;
• behavioral disorders;
• Attention deficits, concentration disorders, distractibility. [26]

Diagnostics of the schizophrenia in children

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

• Interviews the parents, ascertains the duration and nature of suspicious symptoms, inquires about background illnesses, and assesses the degree of hereditary predisposition;
• Talks with the sick baby, asks questions, assesses his or her reactions, emotional displays, and behavior;
• determines the degree of intelligence, the quality of attention and the characteristics of thinking.

Psychodiagnostic test for schizophrenia in children includes several techniques at once:

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

These tests are not specific for the diagnosis of schizophrenia, but they can help detect some abnormalities in the patient's thinking. However, they can only be used in older children and adolescents.

EEG in schizophrenia in a child also does not provide specific data, but more often than not, the study can detect:

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

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

Emission computed tomography (SPECT) has expanded the understanding of the physiologic functioning of the intact brain and can identify cortical perfusion defects in patients with schizophrenia developed in childhood. [28]

Differential diagnosis

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

Child schizophrenia and autism differ in the absence of delusional symptoms, hallucinations, aggravated heredity, interspersing of relapses with remissions, and withdrawal from society (instead, there is a delay in social development).

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

Epilepsy in children should also be differentiated from schizophrenia - the symptoms of temporal lobe epilepsy are particularly similar, with personality, mood and anxiety disorders. 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 signs.

Treatment of the schizophrenia in children

Therapy for schizophrenia in children is prescribed only with the use of complex approaches and measures. [31] It usually consists of such techniques:

• Psychotherapeutic impact.

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

• Medication treatment.

The drug therapy regimen for schizophrenia in children may include taking stimulants, antidepressants, antipsychotic [32] or sedative medications.

The most effective therapeutic option is selected separately in each specific situation. Psychotherapeutic sessions may be sufficient for mild schizophrenia in children, and in some cases a combination of medications may be indicated.

Specialists 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 the sick person. In any situation, parents should not give vent to their own negative feelings, show their helplessness or frustration. Accept the child and try to help him - an important decision that can change the course of the pathological process in a positive way.

You need to consult with a doctor - perhaps even more than one or two specialists. You need to look for ways to try not to dwell on the situation, to spend time with the schizophrenic patient in a positive way, and to learn to manage stress. Almost all clinics of this kind have support groups and family counseling courses. Any parent should first of all understand their child and try to help them as much as possible.

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

What medicines your doctor can prescribe

In the malignant uninterrupted course of schizophrenia in children, neuroleptics are prescribed, [33], [34] which are characterized by a pronounced antipsychotic action - for example:

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

To prevent the development of adverse neuroleptic effects while taking neuroleptics, cholinolytic drugs are used:

• Trihexyphenidyl - administered to children from 5 years of age, in the maximum daily dose not exceeding 40 mg. During treatment, hypersalivation, dry mucous membranes are possible. The drug is canceled gradually.
• Biperiden - in schizophrenia in children is used in individually prescribed dosages - orally, intravenously or intramuscularly. Probable side effects: fatigue, dizziness, impaired accommodation, dyspepsia, drug dependence.

Stimulant and atypical neuroleptics are used in the treatment of uncomplicated schizophrenia in children:

• Trifluoperazine (Triftazine) - prescribed in individually selected dosages, carefully weighing the positive and negative aspects of the drug. Side symptoms may include dystonic extrapyramidal reactions, pseudoparkinsonism, akinetic-rigid phenomena.
• Perphenazine - used for the treatment of children from 12 years of age, in individual doses. Internal administration of the drug may be accompanied by dyspepsia, hypersensitivity reactions, extrapyramidal disorders.
• Risperidone - used predominantly from the age of 15 years, starting at 2 mg daily, with subsequent dosage adjustments. Experience of use in younger children is limited.

In the continuous course of the paranoid schizoid form, neuroleptic drugs with antidelusional properties (Perphenazine, Haloperidol) may be used. If hallucinatory delirium predominates, Perphenazine or Trifluoperazine is emphasized. [37]

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

Febrile schizophrenia requires the use of infusion treatment 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 Diazepam or hexenal anesthesia.

Prevention

Since the clear causes of schizophrenia in children are still unknown, heredity plays an important 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 schizophrenia in a child will develop necessarily, so it is important to start the prevention of this disorder in time. And it is better to do this directly from the moment of birth of the baby. What are the preventive actions?

• Provide the young patient with normal child-parent relations, a calm family environment, with the exclusion of stress and conflict situations.
• Raise your toddler in simple, accessible and understandable adequate frameworks, adhere to the daily regimen.
• Avoid creating children's fears, talk more often, explain and encourage, never use an "orderly" tone and do not punish.
• To develop emotionality in the baby, to attract them to social communication, to accustom them to the collective.
• Do not hesitate to seek professional help when necessary.

Forecast

It is impossible to determine the prognosis of schizophrenia in children, if you assess the situation 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 sharp, and the symptomatology - pronounced. Additional positive points are the uncomplicated personality structure, good adaptive and social signs, 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:

• the delayed and latent onset of schizophrenia;
• the presence of only basic signs of disease;
• The presence of schizoid and other premorbid personality disorders;
• dilated cerebral ventricles on the 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 possibility of changing under the influence of drug therapy. [39] According to statistics, with age, recovery occurs in about 20% of children, and pronounced improvement is noted in 45% of patients.