Provided by the National Institute of Mental Health
A child's stage of development must be taken into account when
considering a diagnosis of mental illness.1 Behaviors that are normal at one age
may not be at another. Rarely, a healthy young child may report strange
experiences—such as hearing voices—that would be considered abnormal at a later
age. Clinicians look for a more persistent pattern of such behaviors. Parents
may have reason for concern if a child of 7 years or older often hears voices
saying derogatory things about him or her, or voices conversing with one
another, talks to himself or herself, stares at scary things—snakes, spiders,
shadows—that are not really there, and shows no interest in friendships. Such
behaviors could be signs of schizophrenia, a chronic and disabling form of
mental illness.2
Fortunately, schizophrenia is rare in children, affecting only about 1 in
40,000,3 compared to 1 in 100 in adults. The average age of onset is 18 in men
and 25 in women. Ranking among the top 10 causes of disability worldwide,4
schizophrenia, at any age, exacts a heavy toll on patients and their families.
Children with schizophrenia experience difficulty in managing everyday life.
They share with their adult counterparts psychotic symptoms (hallucinations,
delusions), social withdrawal, flattened emotions, increased risk of suicide and
loss of social and personal care skills. They may also share some symptoms
with—and be mistaken for—children who suffer from autism or other pervasive
developmental disabilities, which affect about 1 in 500 children. Although they
tend to be harder to treat and have a worse prognosis than adult-onset
schizophrenia patients, researchers are finding that many children with
schizophrenia can be helped by the new generation of antipsychotic medications.5
Symptoms and Diagnosis
While schizophrenia sometimes begins as an acute psychotic episode in young
adults, it emerges gradually in children, often preceded by developmental
disturbances, such as lags in motor and speech/language development. Such
problems tend to be associated with more pronounced brain abnormalities. The
diagnostic criteria are the same as for adults, except that symptoms appear
prior to age 12, instead of in the late teens or early 20s.6 Children with
schizophrenia often see or hear things that do not really exist, and harbor
paranoid and bizarre beliefs. For example, they may think people are plotting
against them or can read their minds. Other symptoms of the disorder include
problems paying attention, impaired memory and reasoning, speech impairments,
inappropriate or flattened expression of emotion, poor social skills, and
depressed mood. Such children may laugh at a sad event, make poor eye contact,
and show little body language or facial expression.
Misdiagnosis of schizophrenia in children is all too common. It is distinguished
from autism by the persistence of hallucinations and delusions for at least 6
months, and a later age of onset—7 years or older. Autism is usually diagnosed
by age 3.7 Schizophrenia is also distinguished from a type of brief psychosis
sometimes seen in affective, personality, and dissociative disorders in
children. Adolescents with bipolar disorder sometimes have acute onset of manic
episodes that may be mistaken for schizophrenia. Children who have been victims
of abuse may sometimes claim to hear voices of—or see visions of—the abuser.
Symptoms of schizophrenia characteristically pervade the child's life, and are
not limited to just certain situations, such as at school. If children show any
interest in friendships, even if they fail at maintaining them, it is unlikely
that they have schizophrenia.
Treatment
Treatments that help young patients manage their illness have improved
significantly in recent decades. As in adults, antipsychotic medications are
especially helpful in reducing hallucinations and delusions. The newer
generation "atypical" antipsychotics, such as olanzapine and clozapine, may also
help improve motivation and emotional expressiveness in some patients. They also
have a lower likelihood of producing disorders of movement, including tardive
dyskinesia, than the other antipsychotic drugs such as haloperidol. However,
even with these newer medications, there are side effects, including excess
weight gain that can increase risk of other health problems. The NIMH is
conducting research studies to improve treatments (www.clinicaltrials.gov).
Children with schizophrenia and their families can also benefit from supportive
counseling, psychotherapies, and social skills training aimed at helping them
cope with the illness. They likely require special education and/or other
accommodations to succeed in the classroom.
Causes
Although it is unclear whether schizophrenia has a single or multiple underlying
causes, evidence suggests that it is a neurodevelopmental disease likely
involving a genetic predisposition, a prenatal insult to the developing brain,
and stressful life events. The role of genetics has long been established; the
risk of schizophrenia rises from 1 percent with no family history of the
illness, to 10 percent if a first degree relative has it, to 50 percent if an
identical twin has it. Prenatal insults may include viral infections, such as
maternal influenza in the second trimester, starvation, lack of oxygen at birth,
and untreated blood type incompatibility. Studies find that children share with
adults many of the same abnormal brain structural, physiological, and
neuropsychological features associated with schizophrenia.6 The children seem to
have more severe cases than adults, with more pronounced neurological
abnormalities. This makes childhood-onset schizophrenia potentially one of the
clearest windows available for research into a still obscure illness process.
For example, unlike most adult-onset patients, children who become psychotic
prior to puberty show conspicuous evidence of progressively abnormal brain
development. In the first longitudinal brain imaging study of adolescents,8
magnetic resonance imaging (MRI) scans revealed fluid filled cavities in the
middle of the brain enlarging abnormally between ages 14 and 18 in teens with
early-onset schizophrenia, suggesting a shrinkage in brain tissue volume.9 These
children lost four times as much gray matter, neurons and their branchlike
extensions, in their frontal lobes as normally occurs in teens. This gray matter
loss engulfs the brain in a progressive wave from back to front over 5 years,
beginning in rear structures involved in attention and perception, eventually
spreading to frontal areas responsible for organizing, planning, and other
"executive" functions impaired in schizophrenia.10 Since losses in the rear
areas are influenced mostly by environmental factors, the researchers suggest
that some non-genetic trigger contributes to the onset and initial progression
of the illness. The final loss pattern is consistent with that seen in adult
schizophrenia. Adult-onset patients' brains may have undergone similar changes
when they were teens that went unnoticed because symptoms had not yet emerged,
suggest the researchers.
In addition to studies of brain structural abnormalities, researchers are also
examining a group of measures associated with genetic risk for schizophrenia.
Early-onset cases of illness have recently proven crucial in the discovery of
genes linked to other genetically complex disorders like breast cancer,
Alzheimer's, and Crohn's diseases.3 Hence, children with schizophrenia and their
families may play an important role in deciphering schizophrenia's molecular
roots. Evidence suggests that the rate of genetically-linked abnormalities is
twice as high in children as in adults with the illness. Similarly,
schizophrenia spectrum disorders, thought to be genetically related to
schizophrenia, are about twice as prevalent among first-degree relatives of
childhood-onset patients. In one recent study, a third of the families of
individuals with childhood onset schizophrenia had at least one first-degree
relative with a diagnosis of schizophrenia, or schizotypal or paranoid
personality disorder.11 This profile of psychiatric illness is remarkably
similar to that seen in parents of adult-onset patients, adding to the
likelihood that both forms share common genetic roots. Other anomalies
associated with adult schizophrenia, such as abnormal eye movements, are also
more common in families of children with the illness.
Families of children with schizophrenia who are interested in participating in
research are encouraged to fill out the NIMH Childhood-Onset Schizophrenia
Survey, to help determine eligibility for studies.
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For More Information
Please visit the following link for more information about organizations that
focus on schizophrenia.
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REFERENCES
1US DHHS. Children and mental health (Chapter 3). In: Mental health: a report of
the Surgeon General. Rockville, MD: U.S. Department of Health and Human
Services, Substance Abuse and Mental Health Services Administration, Center for
Mental Health Services, National Institutes of Health, National Institute of
Mental Health, 1999; 123-220. http://www.surgeongeneral.gov/library/
mentalhealth/chapter3/sec1.html
2NIMH Schizophrenia publications.
3Nicolson R, Rapoport JL. Childhood onset schizophrenia: rare but worth
studying. Biological Psychiatry, 1999; 46: 1418-28.
4World Health Organization. The World health report 2001—mental health: new
understanding, new hope. Geneva: World Health Organization, 2001.
5 American Academy of Child and Adolescent Psychiatry. Practice parameters for
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10Thompson P, Vidal C, Giedd JN, Gochman P, Blumenthal J, Nicolson R, Toga AW,
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11 Asarnow RF, Nuechterlein KH, Fogelson D, Subotnik KL, Payne DA, Russell AT,
Asamen J, Kuppinger H, Kendler KS. Schizophrenia and schizophrenia-spectrum
personality disorders in the first-degree relatives of children with
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58(6): 581-8.
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