Topic: Childhood Schizophrenia
Researched and written by:  Martina Miller
                                                I attest that the following report is a product of my own original work.

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Overview/Definition of Childhood Schizophrenia Childhood – onset schizophrenia is a disorder of the brain that is characterized by hallucinations, delusions, thought disturbances, disorganized behavior, inappropriate or flat affect, and significant impairment in functioning (Mash & Wolfe, 2002).  Childhood schizophrenia can be diagnosed with the same criteria as adult schizophrenia and it seems to be a more severe form than adults.  In the early phases, children may begin to lose sleep and have difficulty concentrating.  The child may start to avoid friends and stop doing well in school.   They may start to have delusions and hallucinations, believe they have powers or think they are being watched.  These children could become violent and have suicidal thoughts.  Childhood schizophrenia has a gradual onset with significant impairment in social and academic competence and the symptoms usually stay with them into adulthood (Mash & Wolfe, 2002).   Adolescents with mild schizophrenia tend to be anxious and tired.  They are more irritable than normal, and could be depressed and suicidal.  They show less empathy toward others.  Like childhood-onset schizophrenia, adolescent schizophrenia is better treated if it is discovered earlier and adolescents usually respond well to antipsychotic drugs (Bauer & Bauer, 1982). Many people confuse schizophrenia in children with autism.  There are, however, a few ways to tell the two apart.  With schizophrenia, the problem develops at a later age, there is less intellectual impairment, social and language deficits are not as severe, hallucinations and delusions are present as the child gets older, and there are more relapses and remissions (The National Institute of Mental Health, 2003).  Some disorders are commonly misdiagnosed as childhood onset schizophrenia.  Children having bi-polar disorder, autism, attention-deficit hyperactivity disorder, mental retardation, major depressive disorder, mood disorders, organic disorders, and obsessive-compulsive disorder often get this label (Werry, 1992).  The most common comorbid disorders are conduct/oppositional defiant disorder and major depression.        Statistics             Childhood schizophrenia is very rare in children under 12; it affects 1 in 40,000 children.  Usually it is not diagnosed before the age of 5, but if it is diagnosed before 5 then it usually occurs in males ages 2-4.  It occurs 100 times more frequently in adults. The prognosis is usually not good for children with schizophrenia.  In research done by Kydd and Werry (1982), they found that 40 percent of the cases in their study were in remission, which was good compared to previous research that only had a 20 percent result.  Childhood schizophrenia is twice as common in boys as it is in girls.  This difference seems to disappear in adolescence.  Research has shown that childhood schizophrenics come from less educated families and patients have a low-average to average range of intelligence (Yates, 2003).  There is little information about socioeconomic class, cultural patterns and childhood schizophrenia.  Eighty percent of children have auditory hallucinations and 50 percent have delusions.  The National Institute of Mental Health (2003), did research on 49 patients that did not respond to conventional therapy.  They found that 55 percent had language difficulties, 57 percent had motor abnormalities, 55 percent had social abnormalities, and 63.3 percent had either failed a grade or required placement in special education.  The participants’ families had high rates of personality disorders, 45 percent had at least one relative with a personality disorder.  Seventy-seven percent of the patients whose family members had a personality disorder had already been diagnosed with a language abnormality (Yates, 2003). Characteristics of Childhood Schizophrenia             For a diagnosis of childhood schizophrenia at least two or more of 5 characteristics must be met.  The first characteristic is delusions which are strong beliefs that somebody is after you, spying on you or following you when this is not true.  The second characteristic is hallucinations which are seeing, hearing, or sensing that things are there when they really are not, such as bugs are crawling on the wall, or the devil is telling you to kill someone.  A third characteristic is disorganized speech, which is talking about things that do not make sense or just saying words that do not go together.  An example would be saying “I am going to the fifth kingdom, only I’m allowed there and the spiders are coming with me.” The fourth characteristic is grossly disorganized or catatonic behavior, which is performing behaviors such as sitting still for hours at a time in the same position, this would be catatonic.  Disorganized behaviors would be taking all the puzzle pieces out of a box then putting them back in a hundred times.  The fifth characteristic is negative symptoms, like affective flattening, alogia, or avolition (Mash & Wolfe, 2002).  Affective flattening is when someone shows no emotions.  Alogia is when someone does not speak very much.  Avolition is when someone can not start or complete a job.  These characteristics need to be significantly taking over a child’s life for a month or more (American Psychiatric Association, 2000).              DeCesare, Pellegrino, & Yuhasz (No Date), said there are other characteristics that maybe associated with childhood schizophrenia.  Usually children with schizophrenia will have poor language abilities, poor coordination, poor or nonexistent social skills, and poor psychomotor and executive functioning.  There are different phases of schizophrenia, the first being the prodromal phase which occurs prior to developing acute psychotic symptoms.  This phase happens when the child starts to perform poorly on things at school and has no friends, and everything seems different and starts to go wrong.  The second phase is the acute phase which is when a child goes for treatment; this usually happens when psychotic symptoms are present and level of functioning goes down.  The third phase is the recovery phase which is marked by the active phase and psychotic symptoms are still present with confusion, disorganization, and/or dysphoria.  The fourth and last phase is the residual phase where positive psychotic symptoms are minimal, but negative ones are still there (DeCesare, Pellegrino, & Yuhasz, No Date).  Positive symptoms are a presence of unusual perceptions, thoughts, or behaviors, such as, delusions, hallucinations, disorganized thought or speech, and disorganized or catatonic behavior.  Negative symptoms involve the absence of behaviors, rather than the presence of behaviors, such as affective flattening, alogia, and avolition (Nolen-Hoeksema, 2004).             Other signs of childhood schizophrenia are low cognitive functioning, low socioeconomic class, immature thinking and behaving, low academic success, low social interactions, less likely to live independently as an adult, increased risk for substance abuse, increased suicide rates, increased anxiety, family problems, attention problems, and bizarre thoughts (DeCesare, Pellegrino, & Yuhasz, No Date). Childhood-Onset Schizophrenia in the Classroom/Treatment for the Classroom             Martin, England, Kaprowy, Kilgour, & Pilek, (1968) did a study with autistic children’s behavior in the classroom.  Children with autism and schizophrenia can show similar behaviors so the treatment for autism could also be effective with certain schizophrenic behaviors.  One child in their study was named Peter and he had a lot of tantrums which they believe were reinforced by attention from whoever was around him.  They did the therapy sessions at the Manitoba Training School.  The sessions were for 1 ½ hours in the morning and afternoon with each session having a 15 minute break.  They used the child’s breakfast and lunch as reinforcers.  In the first week the trainers conducted session in a small room with one trainer per child and arranged it so the children could not get up and leave easily.  They focused on reducing tantrum behavior, sitting quietly, teaching more words, and using a token system.  In the second week the session in the morning was still in the same room and the afternoon session was in a regular classroom.  They still had one trainer per child and tried to reduce the disturbance of moving to the regular classroom.  In the third week, to the sixth week, they moved the desks to look like a normal classroom and increased the number of children in the class to seven.  Also, the child had more trainers with him or her for certain tasks in the classroom.  In the seventh through twelfth weeks the children had to begin with sitting quietly in their classroom.  One trainer gave verbal training to seven children for 30 minutes.  Some of the children went to other rooms for 30 minute periods to learn matching, tracing, or copying.  The children who were left in the class were taught by one trainer on verbal skills and commands (Martin et al., 1968).              The researcher found with initial behavior problems, such as tantrums, by ignoring this behavior and eliminating the attention given, the tantrums were almost completely eliminated.  In order to use tokens as reinforcers, the researchers had to first pair a token with food, then they worked as reinforcers and when the child received five tokens they could cash them in for a piece of food.  Then they used the tokens to reinforce sitting quietly.  They received a token for sitting still for 15 seconds.  After several reinforced periods of time the seconds it took to get a token were increased.  By the end of three week most of the children would sit still and quietly in their seats (Martin et al., 1968).  Next they looked at the verbal training and they used something called fading.  Fading is basically teaching a child to respond to something and switching it so they respond to a different set of stimuli.  An example would be point to your nose and say nose enough times so the child says nose when you point to it.  Now start saying what is this and point to your nose, then say nose.  Keep doing this until the child can say nose when you ask what is this.  This procedure worked for most of the children and helped them gain a small naming vocabulary.  Next the researchers measured tracing and copying abilities.  In these procedures they taught the children to trace lines and figures and then copy them from a picture.  First, the researchers guided the child’s hand while tracing a shape.  Then eventually faded out holding the child’s hand.  After they traced the line correctly then were asked to trace a picture that had dotted lines.  This procedure was not as successful with all the children.  Some traced the lines and copied pictures and others did not.  Next they taught the children how to match two things that were alike.  They would show pictures of objects and ask the child to show them, one shoe then two shoes.  Two of the children acquired this skill, but the remaining children did not (Martin et al., 1968).  One thing that made this program effective was the reinforcement program they used.  Another thing they thought was effective was the control they had over the children’s food before breakfast.  After the end of this study, the researchers implemented the following changes, the breakfast and lunch were eventually eliminated as reinforcers and replaced with candy, chips, and popcorn.  Instead of using poker chips for tokens, they used stars, and the children began meeting as a group with a kindergarten teacher at the Manitoba School for a 1 ½ a day.  The researchers concluded that the children were not close to being able to be in a normal kindergarten class, but they could sit still and respond with only one teacher (Martin et al., 1968). Riester (1986) did research on how to teach the schizophrenic child.  He developed a questionnaire that he used to interview teachers.  Five questions were about behaviors shown by schizophrenic children and 1 question was about the teacher’s personal attributes.  The teachers chosen to answer these questions had worked with schizophrenic children and emotionally disturbed children for years and were considered experts.  Together they came up with a summary of the things they considered to work best with teaching the schizophrenic child (Riester, 1986).  These teachers found one of the most important things to be having a very clearly defined system and rules.  Intervention for impaired reality testing, in school, causes poorly oriented time and space and the children are unable to set limits and boundaries.  One suggestion they gave for this problem is to have clear rules and consequences, and to give the child a highly structured learning environment.  Another problem is children with schizophrenia have selective attention.  A way to increase selective attention is to put a student in a desk that is free of distractions, and divide longer assignments into shorter ones.  Another problem that schizophrenic children have in school is not having any friends or the ability to make them.  A way to help with this is to engage in frequent interactions to gain trust, and tell how friends interact with one another (Riester, 1986).    Having poor organization skills and not setting schedules occur often in children with schizophrenia.  To help this, they suggested putting up schedules in the class and keeping the classroom organized.   The last problem the teachers talked about was verbal and nonverbal behavior does not match the conversation and these children do not learn interpersonal skills.  Ways to improve this are to use positive reinforcement and model and teach appropriate behavior.  Riester (1986) concludes with saying these intervention strategies are not certain, but they do seem to be effective.  He believes that in the future students in college going for teaching should have a class on teaching the schizophrenic child.  Rangaswamy and Jalaludeen (1982) did research on treating schizophrenic children.  They developed a treatment program and used one child as a case study.  There were three goals in this program, the first being to improve emotional relationships with others. The second was to get rid of habit behaviors, behavior problems, and phobias.  The third was to improve his academic skills.  The researchers used eye contact training and imitation training.  The children were taught to share, to reduce habit disorders, and repetitive behaviors.  They treated phobias and improved their academic abilities using token reinforcers.  Finally the children were taught to manage their classroom problems.  It is important to include parents in training and teaching.  Nine months after treatment the child still maintained his achievements.  The researchers concluded that overall, his academic abilities improved dramatically (Rangaswamy & Jalaludeen, 1982). In Alaska, Konopasek (1984) did research on their only residential psychiatric facility for children.  At this place they have a school staff to teach the children when they are admitted.  They have a two teachers and an aide.  When the child is admitted the staff assesses their level of academic functioning and decides what classroom they will be in.  Konopasek (1984) says early signs of schizophrenia are deteriorating academic functioning and psychotic episodes.  When a child becomes psychotic a change in medicine is usually needed.  The children start school at the same time everyday and with the same teacher, and they follow the same schedule each day.  It is important for the teachers to be aware of the side-effect of the medicine.  Medicine could make the child appear tired or not interested.  Usually the child is interested and does not want to be tired, but the side effects cause them to be that way.  Teachers should conform to each individual student’s need to help with academic performance.  Another suggestion in the classroom is arranging the child’s desk to be free of distractions.  Children that are having delusions or hallucinations need support.  Not support for their delusions and hallucinations, but to know they are safe and help to see their thoughts and beliefs are not real.  Teachers need to know what their student’s hallucinations and delusions are and plan the lessons so they do not bring on these hallucinations or delusions.  These interventions are intended to be useful in general classroom and are not a prevention or cure. They are only intended to help assist with a child during a psychotic period (Konopasek, 1984). Medication has, in most cases, been the most successful in treating childhood schizophrenia, although there can be side-effects.  The most serious side effect is tardive dyskinesia, but it is usually rare and with children very rare.  Tardive dyskinesia seems to progress with age.  Most patients do well on medicine although it may take a while to find the right combination and dose level.  One problem with medication is some people are unwilling to take it (Werry, 1992).  Combining antipsychotic drugs with these behavior programs in school will turn out to be the best possible treatment for children with schizophrenia. In conclusion, the best programs for treating childhood schizophrenia in the classroom seem to be behavioral in nature.  They seem to share in common some sort of point or token system with positive reinforcement.  All of the programs also suggest clearly defining the rules in the classroom and what is expected from the child with the token system.  Another suggestion for treating schizophrenia is make sure to know how long the child has been experiencing it and how often the child has relapsed.  For childhood schizophrenia, an absolute in treatment is always medicine.  The stress and pain on the families of children with childhood schizophrenia is devastating.  There is still so much to learn about this very complex, rare disorder, therefore more research should be done in the future.

References

American Psychiatric Association, (2000). Diagnostic and Statistic Manual of Mental Health Disorders. Fourth Edition, Text Revision. Washington, D.C., American Psychiatric Association, 2000.

Bauer, W., & Bauer, J. L. (1982). Adolescent schizophrenia. Adolescence, 17(67), 685 – 693. 

DeCesare, S., Pellegrino, P., & Yuhasz, J. (No Date). Childhood-onset schizophrenia.  Retrieved on November 6, 2004 from http://ac.marywood.edu/pellegrino/www/COS.htm.

Konopasek, D. E. (1984). The efficacy of educational interventions for hospitalized schizophrenic children. Journal of Child and Adolescent Psychotherapy, 1(1), 30 – 33.

Kydd, R. R. & Werry, J. S. (1982). Schizophrenia in children under 16 years.  Journal of autism and developmental disorders, 12(4), 343 – 356.

Martin, G. L., England, G., Kaprowy, E., Kilgour, K., Pilek, V. (1968). Operant conditioning of kindergarten-class behavior in autistic children.  Behavior Res. & Therapy, 6, 281 – 294.

Mash, E. J., & Wolfe, D. A. (2002).  Autism and childhood-onset schizophrenia.  In Abnormal Child Psychology (2^nd ed., pp. 257 – 291). Belmont, CA: Thomson Wadsworth.

Nolen-Hoeksema, S. (2004).  Schizophrenia. In Abnormal Psychology. (3^rd ed., pp. 353 – 396). New York, NY: McGraw-Hill.

Rangaswamy, K., & Jalaludeen, A. (1982). A multifaced approach in the treatment of a case of childhood schizophrenia. Child Psychiatry Quarterly, 15(3), 83 – 90.

Reister, A. E., & Rash, J. D. (1986).  Teaching the schizophrenic child. The Pointer, 30(4), 14 – 20.

The National Institute of Mental Health (2003). Childhood-onset scizophrenia: An update from the NIMH. Retrieved on November 6, 2004 from http://www.nimh.nih.gov/publicat/schizkids.cfm.

Werry, J. S. (1992). Child and adolescent (early onset) schizophrenia: A review in light of DSM-III-R. Journal of Autism and Developmental Disorders, 22 (4), 601-624.

Yates, M. (2003). Childhood schizophrenia. Retrieved November 6, 2004 from http://www.childadvocate.net/childhood_schizophrenia_summary.htm.