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

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Overview     Throughout centuries medical mysteries have been solved, and many childhood disorders have been unveiled. Children with disorders are no longer deemed as possessed, but are diagnosed with known medical disorders. In past centuries children were seen as miniature adults who were responsible for their own well-being. Much has changed since then our society now embraces the fact that children have a need for nurture and guidance, and parenthood is now a joy with many responsibilities. Imagine being the parent of a 3-year-old child who is experiencing developmental delays, such as language disorders, motor impairment, and developmental speech disturbances. The most common diagnoses derived from these symptoms is autism; it is important for parents to continue to track their child’s development because some symptoms may very well be early signs of a more serious disorder.          When making mental health diagnoses the developmental stage of the child must be considered (National Institute of Mental Health [NIMH], 2003). Prior to age seven it is rare to receive a diagnosis of early-onset (childhood-onset) schizophrenia. It is important to be familiar with normal developmental stages at different ages. At three years old a child may have an imaginary friend and may engage in conversations and play with them, however, it is abnormal for a seven year old to experience social withdrawal, delusions, hallucinations and other symptoms of psychosis. When these symptoms do occur for at least one month, a child would be diagnosed with childhood-onset schizophrenia under the DSM-IV-TR criteria (Mash & Wolfe, 2002). A few other comorbid symptoms and disorders are found in are depression, Attention Deficit Hyperactive Disorder (ADHD), conduct problems and suicidal tendencies.            Mash and Wolfe (2002) define schizophrenia as a mental illness that is expressed by abnormal thinking, feeling and unusual behavior. However, childhood-onset schizophrenia is a more severe form than adult-onset schizophrenia. Onset in childhood occurs gradually rather than suddenly and has a profound negative impact on the child’s social and academic competence (Mash & Wolfe, 2002). Misdiagnosis is common in young children, because psychosis occurs after other impairments (i.e., language disorders) are apparent. Autism is the most frequent diagnosis in young children, who are actually suffering from the beginning stage of schizophrenia. Some distinct criteria that identify children with schizophrenia from those with autism are: later onset (7 years or older), less frequent impairment in intellect, as well as, less severe social and language deficits. Also as the child with schizophrenia ages, experiences of hallucinations (disturbances in perception, things are seen, heard, and sensed that are not truly present), delusions (disturbances in thinking), strong misrepresentations of reality, and periods of relapse (periods of improvement followed by terrifying thought disorders, displayed by illogical jumping from one idea to another) and remission occur (Mash & Wolfe, 2002).             Early-onset is very rare, prevalence has varied in different sources from 1 in 10,000 to 1 in 40,000 children who are affected by this illness; the most commonly reported statistic is 1 in 10,000. One unfortunate finding is that onset before age ten is correlated with worse prognosis (Eggers & Bunk, 1997). In Asarnow’s (1988) study of children who are at risk it was reported that children of schizophrenic parents were often described as schizoid, that is they exhibited characteristics of schizophrenia. For example children were emotionally flat, socially withdrawn, distractible, and negativistic. Also the development of neuromotor impairments during middle childhood suggests development of schizophrenia during adolescence, and is more common in children that have parents with schizophrenia (Asarnow, 1988). Some attributes of the family environment that have been associated with increased risk are family communication deviance (deviance from the norm, lack of communication, negative communication, yelling, fighting etc.), poor parenting styles, and disturbances or trouble in the family environment.             Furthermore Jacobsen and Rapport (1998) found that in addition to greater severity, childhood-onset schizophrenia could possibly be related to greater heritability. After psychosis onset deterioration may occur in intellect and brain morphology changes may progress (Jacobsen & Rapoport, 1998). One important finding that has been consistent in studies is that childhood-onset is correlated with a significant increased risk for premorbid impairments such as, social, motor, and language impairments (i.e., production and comprehension). A neurodevelopmental model of schizophrenia has been proposed of genetic vulnerability and early neurodevelopmental insults result in impaired connections between a few brain regions (Mash & Wolfe, 2002). Also, Mash and Wolfe (2002) reported that the performance of children with schizophrenia on information-processing tasks is disrupted, more than other children, when the amount of information to be processed is increased. Statistics             Jacobsen and Rapport (1998) list some potential risk factors and their findings as follows: (1) there were no significant differences in score of obstetrical complications, between well siblings and those with childhood-onset schizophrenia; (2) a significant correlation between onset of psychosis and menstruation in females was found, with psychosis occurring more often after initial menses; (3) and an increased number of neurological dysfunction (i.e., movement disorders, poor sensory integration, and impaired coordination) was found in children with schizophrenia when matched with healthy children. Mash and Wolfe (2002) report that childhood-onset occurs earlier in boys (2-4 years) and is approximately twice as common in boys than in girls. This gender difference is not apparent in adolescence through adulthood. Asarnow, Tompson, and Goldstein’s (1994) study showed several different outcomes following treatment as follows: 56% showed function improvement, and 44% showed little improvement or deterioration throughout its course in a 2-7 year follow-up. No information was available in regards to cross-cultural and socioeconomic status (SES) patterns for children. Characteristics             Onset usually occurs between the ages of 6 through 11-years-old. Children who meet the DSM-IV criteria have characteristics of infantile autism, other childhood-onset pervasive developmental disorders, hallucinations (mainly auditory), delusions and thought disorder (i.e., broken sentences, irrational sentence structure). Asarnow et al., (1994) found that 90% of children who met DSM-III criteria presented clear hallucinations, 5% had possible hallucinations with clear delusions, and the remaining 5% also had possible hallucinations with definite thought disorder. Hallucinations are more often auditory than visual.             In addition, children who experience early-onset have no interest in social relationships, which is clear by withdrawal from peers in school and play, and often withdrawal from family members. Thought disorder is manifested in language, it is exhibited by loose associations, illogicality, and incoherent speech (Baltaxe & Simmons, 1995). Baltaxe and Simmons (1995) note that thought disorder in persons with schizophrenia are seen as impairments in communication, specifically a dysfunction in the speaker-hearer role relationship.             Mash and Wolfe (2002) mentioned that children with schizophrenia also have difficulty sleeping, paying attention, doing schoolwork and have inappropriate and/or flat emotions (i.e., these children may laugh at sad events). Kumra, Shaw, Merka, Nakayama, and Augustin (2001) emphasize thought disorders in children with schizophrenia as impairment in their ability to process and organize their thoughts and to reason adequately with the listener. Classroom issues             There is a lack of research on the impact that childhood schizophrenia has on the classroom. However, from the information of other sources it can be concluded that issues in education will occur when children have language disorders, poor motor skills, and attention deficits, are socially withdrawn, suffer depression, psychotic episodes and other symptoms that are characteristic of children with schizophrenia. It is common for these children to be placed in special education and a classroom that provides the least restrictive learning environment (education of students with disabilities in a class with students without disabilities to the maximum extent that is appropriate). Prior to onset of psychosis it is more likely that full inclusion is possible for a large percentage of the day. Abu-Akel, Caplan Guthrie, & Komo (2000) found that children with schizophrenia lack in the usage of transitional words and phrases that connect the content of one sentence to other sentences that follow. This makes it difficult to follow the speech of a child with schizophrenia, and may therefore merit the placement of the child in speech therapy or services outside the classroom. Abu-Akel et al., (2000) reported that the natural development of speech functions required to construct socially appropriate conversations might be impaired by childhood-onset schizophrenia. With this known clearly there will be problems in the classroom.             Moreover, the onset of psychosis can cause the classroom to become chaotic, distractible, and potentially dangerous. In Eggers, Bunk, and Krause’s (2000) study Table I provides a list of categories of premorbid behavioral peculiarities, a few of which are suicidal ideation (thoughts of suicide), bizarre behavior (fickle), paranoia (belief that people are teasing and laughing them), compulsion, anxiety, hallucinations and delusions can be added to this list. Careful consideration of the classroom environment is critical when proposing inclusion. In a classroom with children who are schizophrenic and suffer paranoia chaos is merely inevitable particularly if medication is being administered too much, too little, or not at all. This potentially hostile environment places all children at risk for harm. Treatment             The most common treatment for children with schizophrenia has been medication, mainly antipsychotics, which help reduce hallucinations and delusions (NIMH, 2003). Motivation and emotional expressiveness may be improved by the newer generation atypical antipsychotics (i.e., olanzapine and clozapine). Asarnow, Tompson, and McGrath (2004) found that various pharmacological and psychosocial treatment plans are used in clinical settings with children suffering form schizophrenia. The American Academy of Child and Adolescent Psychiatry established guidelines for practice, which emphasize antipsychotics medication in combination with psychoeducational, psychotherapeutic, social, and educational support programs (Asarnow et al., 2004).             Kumra (2000) states that when developing a treatment plan for children issues including current clinical status, level of cognitive functioning, the child’s developmental stage, and the severity of the illness, should be considered. Furthermore, the development of a treatment plan should be a collaborative effort consisting of a school teacher, a social worker, a psychiatrist, a clinical nurse specialist, an occupational therapist, and a neuropsychologist. Although the newer generation of antipsychotics has shown possible superiority on a number of measures, long-term clinical and functional impact remains uncertain; and weight gain has been shown to be a significant side effect (Kumra, 2000).             Some other treatment programs that are part of what Kumra (2000) calls the maintenance stage are psychoeducational training programs, social skills training and individual and family counseling. The objective of the psychoeducational training program is to improve attitudes toward treatment, reduce fear of side effects, and increase confidence in the treating physician and the prescribed medication (Kumra, 2000). The goal of social skills training is to teach acceptance, coping, and adjustment in social situations. Individual and family counseling offers another pillar of support for those affected by the child’s early-onset schizophrenia not limited to the child his or herself.             In conclusion, although childhood-onset schizophrenia is very rare, much attention must be given to this illness. Rather considering becoming first time parents, or third time parents always remember to be aware of family history, be knowledgeable of normal child development (so that abnormal development is clear), and to monitor child’s development. After entering the school system it is important that a partnership is established and maintained between parents, the school and teachers, so that any discrepancies, or congruence in behaviors between home and school are noted. Try not to overanalyze or underanalyze any potential developmental delays. Always seek professional assistance prior to making any self-diagnosis. One final note to make is that whether your child has child-onset schizophrenia or is a normal developing, healthy child, the most effective treatment is love and care for your child.

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