Schizophrenia in children

Childhood schizophrenia also called “early-onset” schizophrenia when it occurs before the age of 18, is an uncommon but severe mental disorder (major psychiatric illness) in which children interpret reality abnormally. Schizophrenia involves a range of problems with thinking (cognitive), behavior or emotions. It may result in some combination of hallucinations, delusions, and extremely disordered thinking and behavior that impairs your child’s ability to function.

Childhood schizophrenia is essentially the same as schizophrenia in adults, but it occurs early in life and has a profound impact on a child’s behavior and development. With childhood schizophrenia, the early age of onset presents special challenges for diagnosis, treatment, education, and emotional and social development.

Schizophrenia can cause:

• visual hallucinations of people and objects that are not actually there
• auditory hallucinations of voices, music or other sounds that are not real
• delusions of threats that have no basis in reality
• severe difficulty making friends and maintaining relationships
• impaired speech and other communication skills
• inappropriate and damaging behavior

Though scientists are still learning the specifics of how schizophrenia affects the brain, it is believed that schizophrenia may be linked to:

• A below-normal amount of gray matter—cell material that transmits sensory and movement messages throughout the central nervous system–in the brain’s temporal lobe (the part of the brain’s cerebral cortex that is responsible for hearing) and frontal lobe (the front portion of the brain’s cerebral hemisphere, responsible for processing emotions, retaining memories, making decisions and measuring social responses)
• Related loss of gray matter in the parietal lobe (part of the brain that processes information from the senses, makes mathematical calculations and controls how we handle objects)

Schizophrenia is a major psychiatric illness that requires careful, often complex and lifelong treatment. Identifying and starting treatment for childhood schizophrenia as early as possible may significantly improve your child’s long-term outcome.

A combination of therapies is usually necessary to effectively manage childhood schizophrenia.

Since there is no known cure for schizophrenia,treatment is aimed at reducing the severity of schizophrenia’s impact on early life and helping the child manage symptoms. Treatment is most successful when symptoms are addressed early on.

Schizophrenia key points:

• has no known, exact cause
• often appears to be inherited, passing down from generation to generation
• affects boys slightly more often than girls when it develops in childhood
• affects men and women equally when it develops in adolescence and adulthood
• has no known cure, but can be managed well when caught early and treated with effective therapy, medications and support

What are the early warning signs of schizophrenia?

The behavioral changes caused by schizophrenia in children can be difficult to identify in the earliest stages of the disease. Symptoms may emerge slowly, develop over time or occur suddenly, as though “out of the blue.”

The following list of possible warning signs for schizophrenia is not definitive. Many of these symptoms may be caused by a condition other than schizophrenia; some will occur in children who do not have any disorder. However, it’s important to take note of any of these behaviors in your child as soon as they arise—especially if you have a family history of schizophrenia—and, if the behaviors persist, to contact a mental health professional as soon as possible. Typically a child and adolescent psychiatrist will make the diagnosis following a comprehensive evaluation with you and your child. During the assessment, a child and adolescent psychiatrist will ask you to describe your child’s symptoms and provide an overview of your child’s family history, medical history, school life and social interactions.

Typically, a child is diagnosed with schizophrenia if he or she:

• displays positive or negative symptoms for a period of at least one month
• is experiencing a worsening decrease in the ability to function on a day-to-day basis

Possible early warning signs in infants

• abnormal listlessness or extensive periods of inactivity
• overly relaxed or “floppy” arms or legs
• unnaturally still, flat posture when lying down
• unusual sensitivity to bright lights or rapid movements

Possible early warning signs in toddlers

• chronic high fevers
• fixation on repeating behaviors, even play, according to a specific regimen
• persistent state of distraction, anxiety or distress
• pronounced and sustained fear of certain events, situations or objects (note: while nearly all children experience specific fears as a normal developmental stage, children with early-onset schizophrenia tend to experience an extreme degree of fear that does not subside)
• weak and slumping posture

Possible early warning signs in school-aged children

• auditory hallucinations (the perception of sounds that others do not hear); most often, these hallucinations manifest as loud noises, whispers or collective murmuring
• claims that someone or something is “in my head” or “telling me to do things”
• extreme sensitivity to sounds and lights
• frequent self-talk (note: while many children will go through phases of having an “imaginary friend” or occasionally talking to themselves, children with possible early-onset schizophrenia spend the majority of their time conversing and laughing with themselves while shutting out real people and surroundings)
• tendency to be very “closed off” from others
• visual hallucinations (seeing things that are not actually there); common examples include streaks or swirls of light or flashing patches of darkness

Possible early warning signs in adolescents and teens

• a persistently vacant facial expression (known as “blank affect”)
• awkward, contorted or unusual movements of the face, limbs or body
• complaints and suspicions of threats, plots or conspiracies (for example, “someone has been sent to spy on me”)
• dwelling excessively on perceived slights, failures or past disappointments
• extreme irritability or angry outbursts that are unprovoked or disproportionate to the situation
• extreme or unwarranted resentment and accusations against others (“I know my parents have been stealing from me”)
• inability to follow a single train of thought
• inability to read nonverbal “cues” (failing to understand and respond appropriately to other people’s tone of voice, facial expressions or body language)
• inappropriate behavior and responses to social situations (for example, laughing out loud during a sad moment)
• incoherent speech
• irrational thinking, including:
  • assignment of “special meaning” to events and objects with no personal significance (for example, watching a famous person on television and believing they are conveying a secret message with their words or gestures)
  • assumption of extravagant religious, political or other authority (“I am God”)
  • belief that another person or entity is controlling one’s body, thoughts or movements
  • belief that an evil force, spirit or entity has “possessed” the body or mind
• lapses in personal hygiene practices
• long periods of staring without blinking or difficulty focusing on objects
• rapidly fluctuating moods
• seeing or hearing things that others do not
• sudden, painful sensitivity to light and noise
• sudden, significant changes in sleep patterns—either inability to fall or stay asleep (insomnia), or excessive sleepiness and listlessness (called catatonia)
• talking aloud to oneself, often repeating or rehearsing conversations with others (real or imaginary)
• tendency to rapidly shift topics during a single conversation
• use of “nonsense” or made-up words
• withdrawal from friendships and activities

It is important to note that, in the case of all of the above warning signs, a child or adolescent with schizophrenia is not aware that these behaviors pose a problem. A schizophrenic child does not have a sense of becoming ill or that something is wrong. The gravity of the situation is only apparent to outside observers.

What symptoms do people with schizophrenia develop as the disease progresses?

As the disease progresses, people with schizophrenia display symptoms that are grouped into four categories: positive symptoms, negative symptoms, disorganized speech and disorganized or catatonic behavior.

Positive symptoms

Positive symptoms of schizophrenia involve the onset and acquisition of certain feelings, traits, and behaviors. These can include:

• beliefs that someone, or something, poses a threat or is causing some type of harm (for example, a sense of being followed by a person or group)
• confused thinking (for example, confusing what is happening on television with what is occurring in reality)
• hallucinations (seeing, hearing or feeling things that are not real; for example, hearing voices giving commands or seeing people, animals or objects that are not really there)
• delusions (ideas, situations or threats that seem real but are not actually based in reality; for example, believing a surveillance device has been installed in the body, home or car). Children with schizophrenia tend to experience hallucinations, but not delusions, until they reach early adulthood.
• problems distinguishing dreams from reality
• regressive behavior (for example, an older child suddenly acting like a much younger child and clinging to parents)
• severe anxiety
• severe changes in behavior (for example, becoming noticeably withdrawn)
• suddenly struggling with schoolwork; inability to comprehend material that was previously familiar
• vivid, detailed and bizarre thoughts and ideas

Negative symptoms

Negative symptoms of schizophrenia involve the lack or loss of certain capabilities and traits, such as:

• failure to demonstrate appropriate emotional responses (for example, laughing during a somber event or an upsetting conversation)
• inability to sustain existing friendships and relationships
• lack of emotional expression when speaking or interacting with others (having what is known as a “blank affect” on the face or failing to make eye contact)
• severe difficulty making friends

Disorganized speech

Schizophrenia often causes spoken and written communication that is garbled, nonsensical or otherwise impossible for others to follow. Examples of this disorganized speech may include:

• using words and sentences that do not fit together
• inventing words or terms that make no sense to others
• inability to stay “on track” in a conversation

Disorganized or catatonic behavior

Schizophrenia may lead to impaired behaviors that have a drastic impact on daily functions and activities. These disorganized or catatonic behaviors include:

• engaging in inappropriate activities or speech (for example, making obscene gestures or comments in public)
• extreme moodiness and irritability
• failure to dress in accordance with the weather (for example, wearing layers of heavy clothing on a sweltering summer day)
• failure to practice personal hygiene (for example, not bathing or brushing teeth)
• suddenly becoming confused or agitated, followed by sitting and staring in place as though “frozen” (this is called a catatonic state)

Your child may be diagnosed with schizophrenia if these symptoms are present for a period of at least one month.

What are the major similarities and differences between schizophrenia in adults and childhood-onset schizophrenia?

As is the case for adults with schizophrenia, children who are schizophrenic are also likely to:

• display limited or impaired emotional responses
• fail to practice adequate personal hygiene or other aspects of self-care (such as dressing weather-appropriately)
• have great difficulty in day-to-day functioning
• “live in their heads,” closing themselves off from other people and their surroundings
• suffer from hallucinations (both visual and auditory) or delusions (impressions or perceptions of situations that are not real)
• struggle to make and maintain friendships

Unlike adults with schizophrenia, children with schizophrenia tend to:

• experience a gradual appearance and progression of symptoms, as opposed to a sudden and severe onset
• display difficulty meeting age-appropriate developmental milestones in motor skills, memory and reasoning and speech and language before developing symptoms of schizophrenia.

Do people with schizophrenia really have multiple personalities?

Although this is a common misconception about schizophrenia, it’s not true. What many people refer to as “multiple personality disorder” is altogether different and is now known as dissociative identity disorder.

A schizophrenic person does not experience memory “blackouts” and alternate identities. Instead, an individual with schizophrenia experiences a separation from reality that is characterized by:

• visual and auditory hallucinations
• false and irrational ideas and perceptions
• impaired or incoherent thinking and speech
• problems initiating and maintaining relationships
• difficulty processing social cues and non-verbal communication
• inability to recognize and adhere to appropriate social behaviors or personal hygiene practices
• oversensitivity to external stimulation, such as sounds and lights
• withdrawal from the outside world

Is it possible my child has bipolar disorder, not schizophrenia?

There are certain similarities between early-onset schizophrenia and pediatric bipolar disorder, particularly in the shared tendency to erupt in sudden and often unpredictable emotional outbursts.

The differentiating factor is what triggers these episodes: A child with bipolar disorder will become angry or inconsolable in response to a specific event or action). A child with early schizophrenia, by contrast, will have outbursts seemingly “out of nowhere,” with no obvious cause. In these cases, schizophrenic children are usually reacting to an overwhelming onslaught of sensation, such as sudden, unbearable sensitivity to noise in a room. They may also be frustrated by a sudden inability to communicate, think clearly or even stand or walk properly.

If my child is diagnosed with schizophrenia, what happens next?

Your clinician will explain the particulars of schizophrenia, including its possible causes and effects and long-term repercussions. Specifically, you will be given a thorough overview of your child’s individual symptoms and prognosis.

The next step is developing a mutually agreed-upon treatment plan—incorporating psychotherapy, medication and school and community support—that works for you, your child and your family.

You and your child (if old enough) will always have the opportunity to ask questions. Throughout the duration of treatment, you will be encouraged to bring up any and all concerns, worries and fears so that the clinical team can provide the information and support you need.

Helping someone who may have schizophrenia

Family and friends can help their loved ones with schizophrenia by helping them get treatment and encouraging them to stay in treatment. Supporting a loved one with schizophrenia can be hard. Being respectful, supportive, and kind without tolerating dangerous behavior is the best way to help someone with schizophrenia.

If you think someone you know may have symptoms of schizophrenia, talk to him or her about your concerns. Although you can’t force someone to seek professional help, you can offer encouragement and support and help your loved one find a qualified doctor or mental health professional.

If your loved one poses a danger to self or others or can’t provide his or her own food, clothing or shelter, you may need to call your local emergency number or other emergency responders for help so that your loved one can be evaluated by a mental health professional.

In some cases, emergency hospitalization may be needed. Laws on involuntary commitment for mental health treatment vary by state. You can contact community mental health agencies or police departments in your area for details.

Are people with schizophrenia violent?

Most people with schizophrenia are not violent; however, the risk of violence is greatest when schizophrenia is untreated. It is important to help a person with schizophrenia symptoms get treatment as quickly as possible. People with schizophrenia are much more likely to harm themselves than others.

If you suspect you or someone you know may be experiencing the symptoms of schizophrenia, see a doctor as soon as possible.

Childhood schizophrenia causes

It’s not known what causes childhood schizophrenia, but it’s thought that it develops in the same way as adult schizophrenia does. Researchers believe that a combination of genetics, brain chemistry and environment contributes to development of the disorder. It’s not clear why schizophrenia starts so early in life for some and not for others.

Problems with certain naturally occurring brain chemicals, including neurotransmitters called dopamine and glutamate, may contribute to schizophrenia. Neuroimaging studies show differences in the brain structure and central nervous system of people with schizophrenia. While researchers aren’t certain about the significance of these changes, they indicate that schizophrenia is a brain disease.

Genetics

While there is no single known cause for schizophrenia, experts believe that the disease has a strong genetic component—specifically, an inherited chemical imbalance in the brain.

A combination of genes passed down by both parents can lead to schizophrenia. If a parent has schizophrenia, a child has an estimated 10 to 15 percent chance of developing schizophrenia; if a sibling is schizophrenic, a child has an estimated 7 to 8 percent chance of developing schizophrenia. The risk significantly increases if more than one family member has schizophrenia.

Environmental stresses during pregnancy

Though data is not conclusive, some experts believe a child’s schizophrenia may be linked to certain environmental factors that affect the mother during pregnancy, such as:

• drug or alcohol use
• exposure to particular hormonal or chemical agents
• exposure to certain viruses or infections
• extreme stress
• poor nutritional health

Risk factors for schizophrenia in kids

Although the precise cause of schizophrenia isn’t known, certain factors seem to increase the risk of developing or triggering schizophrenia, including:

• Having a family history of schizophrenia
• Increased immune system activation, such as from inflammation or autoimmune diseases
• Older age of the father
• Some pregnancy and birth complications, such as malnutrition or exposure to toxins or viruses that may impact brain development
• Taking mind-altering (psychoactive or psychoactive) drugs during teen years.

Childhood schizophrenia prevention

While there is no way to prevent schizophrenia, a close look at your family history and careful observation of your child’s behavior can help predict the likelihood of him developing schizophrenia. The earlier you seek treatment, the better chance you have to improve your child’s quality of life. Early identification and treatment may help get symptoms of childhood schizophrenia under control before serious complications develop. Early treatment is also crucial in helping limit psychotic episodes, which can be extremely frightening to a child and his or her parents. Ongoing treatment can help improve your child’s long-term outlook.

If you suspect your child is displaying symptoms of schizophrenia, the most important step you can take is scheduling an immediate mental professional evaluation.

Childhood schizophrenia signs and symptoms

Schizophrenia involves a range of problems with thinking, behavior or emotions. Signs and symptoms may vary, but usually involve delusions, hallucinations or disorganized speech, and reflect an impaired ability to function. The effect can be disabling.

Schizophrenia symptoms generally start in the mid- to late 20s. It’s uncommon for children to be diagnosed with schizophrenia. Early-onset schizophrenia occurs before age 18. Very early-onset schizophrenia in children younger than age 13 is extremely rare.

Symptoms can vary in type and severity over time, with periods of worsening and remission of symptoms. Some symptoms may always be present. Schizophrenia can be difficult to recognize in the early phases.

Early signs and symptoms

The earliest indications of childhood schizophrenia may include developmental problems, such as:

• Language delays
• Late or unusual crawling
• Late walking
• Other abnormal motor behaviors — for example, rocking or arm flapping

Some of these signs and symptoms are also common in children with pervasive developmental disorders, such as autism spectrum disorder. So ruling out these developmental disorders is one of the first steps in diagnosis.

Symptoms in teenagers

Schizophrenia symptoms in teenagers are similar to those in adults, but the condition may be more difficult to recognize in this age group. This may be in part because some of the early symptoms of schizophrenia in teenagers are common for typical development during teen years, such as:

• Withdrawal from friends and family
• A drop in performance at school
• Trouble sleeping
• Irritability or depressed mood
• Lack of motivation
• Strange behavior
• Substance use

Compared with schizophrenia symptoms in adults, teens may be:

• Less likely to have delusions
• More likely to have visual hallucinations

Later signs and symptoms

As children with schizophrenia age, more typical signs and symptoms of the disorder begin to appear. Signs and symptoms may include:

• Delusions. These are false beliefs that are not based in reality. For example, you think that you’re being harmed or harassed; that certain gestures or comments are directed at you; that you have exceptional ability or fame; that another person is in love with you; or that a major catastrophe is about to occur. Delusions occur in most people with schizophrenia.
• Hallucinations. These usually involve seeing or hearing things that don’t exist. Yet for the person with schizophrenia, hallucinations have the full force and impact of a normal experience. Hallucinations can be in any of the senses, but hearing voices is the most common hallucination.
• Disorganized thinking. Disorganized thinking is inferred from disorganized speech. Effective communication can be impaired, and answers to questions may be partially or completely unrelated. Rarely, speech may include putting together meaningless words that can’t be understood, sometimes known as word salad.
• Extremely disorganized or abnormal motor behavior. This may show in several ways, from childlike silliness to unpredictable agitation. Behavior is not focused on a goal, which makes it hard to do tasks. Behavior can include resistance to instructions, inappropriate or bizarre posture, a complete lack of response, or useless and excessive movement.
• Negative symptoms. This refers to reduced or lack of ability to function normally. For example, the person may neglect personal hygiene or appear to lack emotion ― doesn’t make eye contact, doesn’t change facial expressions, speaks in a monotone, or doesn’t add hand or head movements that normally occur when speaking. Also, the person may have reduced ability to engage in activities, such as a loss of interest in everyday activities, social withdrawal or lack ability to experience pleasure.

Symptoms may be difficult to interpret

When childhood schizophrenia begins early in life, symptoms may build up gradually. The early signs and symptoms may be so vague that you can’t recognize what’s wrong, or you may attribute them to a developmental phase.

As time goes on, symptoms may become more severe and more noticeable. Eventually, your child may develop the symptoms of psychosis, including hallucinations, delusions and difficulty organizing thoughts. As thoughts become more disorganized, there’s often a “break from reality” (psychosis) frequently requiring hospitalization and treatment with medication.

Suicidal thoughts and behavior

Suicidal thoughts and behavior are common among people with schizophrenia. If you have a child or teen who is in danger of attempting suicide or has made a suicide attempt, make sure someone stays with him or her. Call your local emergency number immediately. Or if you think you can do so safely, take your child to the nearest hospital emergency room.

Childhood schizophrenia complications

Left untreated, childhood schizophrenia can result in severe emotional, behavioral and health problems. Complications associated with schizophrenia may occur in childhood or later, such as:

• Suicide, suicide attempts and thoughts of suicide
• Self-injury
• Anxiety disorders, panic disorders and obsessive-compulsive disorder (OCD)
• Depression
• Abuse of alcohol or other drugs, including tobacco
• Family conflicts
• Inability to live independently, attend school or work
• Social isolation
• Health and medical problems
• Being victimized
• Legal and financial problems, and homelessness
• Aggressive behavior, although uncommon

Childhood schizophrenia diagnosis

Diagnosis of childhood schizophrenia involves ruling out other mental health disorders and determining that symptoms aren’t due to substance abuse, medication or a medical condition. The process of diagnosis may involve:

• Physical exam. This may be done to help rule out other problems that could be causing symptoms and to check for any related complications.
• Tests and screenings. These may include tests that help rule out conditions with similar symptoms, and screening for alcohol and drugs. The doctor may also request imaging studies, such as an MRI or CT scan.
• Psychological evaluation. This includes observing appearance and demeanor, asking about thoughts, feelings and behavior patterns, including any thoughts of self-harm or harming others, evaluating ability to think and function at an age-appropriate level, and assessing mood, anxiety and possible psychotic symptoms. This also includes a discussion of family and personal history.
• Diagnostic criteria for schizophrenia. Your doctor or mental health professional may use the criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association. Diagnostic criteria for childhood schizophrenia are generally the same as for adult schizophrenia.

Typically a child and adolescent psychiatrist will make the diagnosis following a comprehensive evaluation with you and your child. During the assessment, a child and adolescent psychiatrist will ask you to describe your child’s symptoms and provide an overview of your child’s family history, medical history, school life and social interactions.

Typically, a child is diagnosed with schizophrenia if he or she:

• displays positive or negative symptoms for a period of at least one month
• is experiencing a worsening decrease in the ability to function on a day-to-day basis

Challenging process

The path to diagnosing childhood schizophrenia can sometimes be long and challenging. In part, this is because other conditions, such as depression or bipolar disorder, can have similar symptoms.

A child psychiatrist may want to monitor your child’s behaviors, perceptions and thinking patterns for six months or more. As thinking and behavior patterns and signs and symptoms become clearer over time, a diagnosis of schizophrenia may be made.

In some cases, a psychiatrist may recommend starting medications before an official diagnosis is made. This is especially important for symptoms of aggression or self-injury. Some medications can help limit these types of behavior and restore a sense of normalcy.

Diagnostic criteria for Schizophrenia

Criteria for schizophrenia include signs and symptoms of at least six months’ duration, including at least one month of active-phase positive and negative symptoms (Table 1) ¹⁾. Delusions, hallucinations, disorganized speech, and disorganized behavior are examples of positive symptoms. Negative symptoms include a decrease in the range and intensity of expressed emotions (i.e., affective flattening) and a diminished initiation of goal-directed activities (i.e., avolition).

Table 1. Diagnostic Criteria for Schizophrenia

A. Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated). At least one of these must be (1), (2), or (3):
	1. Delusions
	2. Hallucinations
	3. Disorganized speech (e.g., frequent derailment or incoherence)
	4. Grossly disorganized or catatonic behavior
	5. Negative symptoms (i.e., diminished emotional expression or avolition)
B. For a significant portion of the time since the onset of the disturbance, level of functioning in one or more major areas, such as work, interpersonal relations, or self-care, is markedly below the level achieved prior to the onset (or when the onset is in childhood or adolescence, there is failure to achieve expected level of interpersonal, academic, or occupational functioning)
C. Continuous signs of the disturbance persist for at least 6 months. This 6-month period must include at least 1 month of symptoms (or less if successfully treated) that meet Criterion A (i.e., active-phase symptoms) and may include periods of prodromal or residual symptoms. During these prodromal or residual periods, the signs of the disturbance may be manifested by only negative symptoms or by two or more symptoms listed in Criterion A present in an attenuated form (e.g., odd beliefs, unusual perceptual experiences)
D. Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out because either: (1) no major depressive or manic episodes have occurred concurrently with the active-phase symptoms, or (2) if mood episodes have occurred during active-phase symptoms, they have been present for a minority of the total duration of the active and residual periods of the illness
E. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition
F. If there is a history of autism spectrum disorder or a communication disorder of childhood onset, the additional diagnosis of schizophrenia is made only if prominent delusions or hallucinations, in addition to the other required symptoms of schizophrenia, are also present for at least 1 month (or less if successfully treated)

[Source ²⁾]

Child schizophrenia test

Early onset schizophrenia in children presents symptoms such as hallucinations, strange thoughts or feelings, and abnormal behavior that inhibit his/her ability to function and maintain relationships. Answer the questions below to see if your child or teenager may be suffering from schizophrenia.

Below is a list of questions that relate to life-experiences common among children and adolescents who have been diagnosed with schizophrenia.

1. Does your child claim to hear or see things that others cannot?
2. Does your child claim that others are controlling their thoughts and emotions?
3. Does your child struggle to keep up with daily living tasks such as showering, changing clothes, doing homework, etc.?
4. Does your child speak in a monotone voice or not make facial expressions that match their emotions?
5. Does your child respond to questions with unrelated or confusing responses?
6. Does your child ever claim to have powers that other people cannot understand or appreciate?
7. Does your child feel that they are being tracked, followed, or watched at home or outside?
8. Does your child have difficulty distinguishing fiction from reality?
9. Does your child have disorganized or abnormal motor behavior, such as strange posture or excessive movement of their body?
10. Does your child have developmental delays compared to their peers?

Childhood schizophrenia treatment

Schizophrenia in children requires lifelong treatment, even during periods when symptoms seem to go away. Treatment is a particular challenge for children with schizophrenia.

Treatment team

Childhood schizophrenia treatment is usually guided by a child psychiatrist experienced in treating schizophrenia. The team approach may be available in clinics with expertise in schizophrenia treatment. The team may include, for example, your:

• Psychiatrist, psychologist or other therapist
• Psychiatric nurse
• Social worker
• Family members
• Pharmacist
• Case manager to coordinate care

Main treatment options

The main treatments for childhood schizophrenia are:

• Medications
• Psychotherapy
• Life skills training
• Hospitalization

Medications

Most of the antipsychotics also called neuroleptics used in children are the same as those used for adults with schizophrenia. Antipsychotic drugs are often effective at managing symptoms such as delusions, hallucinations, loss of motivation and lack of emotion.

In general, the goal of treatment with antipsychotics is to effectively manage symptoms at the lowest possible dose. Over time, your child’s doctor may try combinations, different medications or different doses. Depending on the symptoms, other medications also may help, such as antidepressants or anti-anxiety drugs. It can take several weeks after starting a medication to notice an improvement in symptoms.

Antipsychotics (neuroleptics):

• are primarily used to treat the pervasive, intrusive, and disturbing thoughts caused by schizophrenia
• are designed to minimize the severity of hallucinations and delusions
• must be taken exactly as prescribed
• may require adjustments of dosage or type over time to maintain their effectiveness.

Traditionally prescribed neuroleptics include:

• Stelazine (Trifluoperazine)
• Flupenthixol (Fluanxol)
• Loxapine (Loxapac, Loxitane)
• Perphenazine (Etrafon, Trilafon)
• Chlorpromazine (Thorazine)
• Haldol (Haloperidol)
• Prolixin (Fluphenazine Decanoate, Modecate, Permitil)

Newer and less commonly prescribed medications that have proven effective in treating symptoms of schizophrenia include:

• Aripiprazole (Abilify)
• Clozaril (clozapine)
• Geodon (ziprasidone)
• Risperdal (resperidone)
• Seroquel (Quetiapine)
• Zyprexa (olanzapine)

Your child’s physician and other healthcare team members will work with parents and family members—to determine the best medications for your child, incorporate the medication regimen into the child’s overall treatment plan and monitor the effectiveness of the drugs over the long term.

Second-generation antipsychotics

Newer, second-generation medications are generally preferred because they have fewer side effects than do first-generation antipsychotics. However, they can cause weight gain, high blood sugar, high cholesterol and heart disease.

Examples of second-generation antipsychotics approved by the Food and Drug Administration (FDA) to treat schizophrenia in teenagers age 13 and older include:

• Aripiprazole (Abilify)
• Olanzapine (Zyprexa)
• Quetiapine (Seroquel)
• Risperidone (Risperdal)

Paliperidone (Invega) is FDA-approved for children 12 years of age and older.

First-generation antipsychotics

These first-generation medications are usually as effective as second-generation antipsychotics in controlling delusions and hallucinations. In addition to having side effects similar to those of second-generation antipsychotics, first-generation antipsychotics also may have frequent and potentially significant neurological side effects. These can include the possibility of developing a movement disorder (tardive dyskinesia) that may or may not be reversible.

Because of the increased risk of serious side effects with first-generation antipsychotics, they often aren’t recommended for use in children until other options have been tried without success.

Examples of first-generation antipsychotics approved by the FDA to treat schizophrenia in children and teens include:

• Chlorpromazine for children 13 and older
• Haloperidol for children 3 years and older
• Perphenazine for children 12 years and older

First-generation antipsychotics are often cheaper than second-generation antipsychotics, especially the generic versions, which can be an important consideration when long-term treatment is necessary.

Medication side effects and risks

All antipsychotic medications have side effects and possible health risks, some life-threatening. Side effects in children and teenagers may not be the same as those in adults, and sometimes they may be more serious. Children, especially very young children, may not have the capacity to understand or communicate about medication problems.

Talk to your child’s doctor about possible side effects and how to manage them. Be alert for problems in your child, and report side effects to the doctor as soon as possible. The doctor may be able to adjust the dose or change medications and limit side effects.

Also, antipsychotic medications can have dangerous interactions with other substances. Tell your child’s doctor about all medications and over-the-counter products your child takes, including vitamins, minerals and herbal supplements.

What is the “black label warning” I keep hearing about when it comes to certain psychiatric medications?

Since 2004, the U.S. Food and Drug Administration has placed a black warning label on antidepressant medications. The warning label states, in part:

“Antidepressants increased the risk of suicidal thinking and behavior (suicidality) in short-term studies in children and adolescents with Major Depressive Disorder (MDD) and other psychiatric disorders. Anyone considering the use of [Drug Name] or any other antidepressant in a child or adolescent must balance this risk with the clinical need. Patients who are started on therapy should be observed closely for clinical worsening, suicidality, or unusual changes in behavior.”

Your clinician will carefully go over the specifics of any medication prescribed for your child’s schizophrenia, as well as any potential side effects you should watch for. Our team has years of experience in managing the use of psychiatric medications in children of all ages and with a wide variety of conditions. We will closely monitor your child for any sign of a negative response to the medication, and are always here to answer your questions and address any concerns you may have.

Psychotherapy

In addition to medication, psychotherapy, sometimes called talk therapy, counseling, psychosocial therapy or, simply, therapy, can help manage symptoms and help you and your child cope with the disorder.

Psychotherapy is a general term for treating mental health problems by talking with a psychiatrist, psychologist or other mental health provider.

During psychotherapy, you learn about your condition and your moods, feelings, thoughts and behaviors. Psychotherapy helps you learn how to take control of your life and respond to challenging situations with healthy coping skills.

There are many types of psychotherapy, each with its own approach. The type of psychotherapy that’s right for you depends on your individual situation.

Psychotherapy may include:

• Individual therapy. Psychotherapy, such as cognitive behavioral therapy, with a skilled mental health professional can help your child learn ways to deal with the stress and daily life challenges brought on by schizophrenia. Therapy can help reduce symptoms and help your child make friends and succeed at school. Learning about schizophrenia can help your child understand the condition, cope with symptoms and stick to a treatment plan.
• Family therapy. Your child and your family may benefit from therapy that provides support and education to families. Involved, caring family members who understand childhood schizophrenia can be extremely helpful to children living with this condition. Family therapy can also help you and your family to improve communication, work out conflicts and cope with stress related to your child’s condition.

Life skills training

Treatment plans that include building life skills can help your child function at age-appropriate levels when possible. Skills training may include:

• Social and academic skills training. Training in social and academic skills is an important part of treatment for childhood schizophrenia. Children with schizophrenia often have troubled relationships and school problems. They may have difficulty carrying out normal daily tasks, such as bathing or dressing.
• Vocational rehabilitation and supported employment. This focuses on helping people with schizophrenia prepare for, find and keep jobs.

Specialized educational and/or structured activity programs

Children and adolescents with schizophrenia may reap significant benefits from specialized programs offered at schools, in medical centers or in the community. Examples of these programs might include:

• customized, smaller classroom settings, with educators who have specialized training in teaching children and adolescents with psychiatric disorders
• social skills training to:
  • develop healthy personal interaction techniques (such as maintaining good eye contact and determining fitting topics of conversation)
  • create a checklist for good hygiene
  • learn how to manage everyday tasks like balancing a checkbook or preparing a meal
• vocational training to help young adults find jobs and volunteer opportunities
• speech and language therapy to improve verbal and written communication

Hospitalization

During crisis periods or times of severe symptoms, hospitalization may be necessary. This can help ensure your child’s safety and make sure that he or she is getting proper nutrition, sleep and hygiene. Sometimes the hospital setting is the safest and best way to get symptoms under control quickly.

Partial hospitalization and residential care may be options, but severe symptoms are usually stabilized in the hospital before moving to these levels of care.

Lifestyle and home remedies

Although childhood schizophrenia requires professional treatment, it’s critical to be an active participant in your child’s care. Here are ways to get the most out of the treatment plan.

• Follow directions for medications. Try to make sure that your child takes medications as prescribed, even if he or she is feeling well and has no current symptoms. If medications are stopped or taken infrequently, the symptoms are likely to come back and your doctor will have a hard time knowing what the best and safest dose is.
• Check first before taking other medications. Contact the doctor who’s treating your child for schizophrenia before your child takes medications prescribed by another doctor or before taking any over-the-counter medications, vitamins, minerals, herbs or other supplements. These can interact with schizophrenia medications.
• Pay attention to warning signs. You and your child may have identified things that may trigger symptoms, cause a relapse or prevent your child from carrying out daily activities. Make a plan so that you know what to do if symptoms return. Contact your child’s doctor or therapist if you notice any changes in symptoms, to prevent the situation from worsening.
• Make physical activity and healthy eating a priority. Some medications for schizophrenia are associated with an increased risk of weight gain and high cholesterol in children. Work with your child’s doctor to make a nutrition and physical activity plan for your child that will help manage weight and benefit heart health.
• Avoid alcohol, street drugs and tobacco. Alcohol, street drugs and tobacco can worsen schizophrenia symptoms or interfere with antipsychotic medications. Talk to your child about avoiding drugs and alcohol and not smoking. If necessary, get appropriate treatment for a substance use problem.

Coping and support

Coping with childhood schizophrenia can be challenging. Medications can have unwanted side effects, and you, your child and your whole family may feel angry or resentful about having to manage a condition that requires lifelong treatment. To help cope with childhood schizophrenia:

• Learn about the condition. Education about schizophrenia can empower you and your child and motivate him or her to stick to the treatment plan. Education can help friends and family understand the condition and be more compassionate with your child.
• Join a support group. Support groups for people with schizophrenia can help you reach out to other families facing similar challenges. You may want to seek out separate groups for you and for your child so that you each have a safe outlet.
• Get professional help. If you as a parent or guardian feel overwhelmed and distressed by your child’s condition, consider seeking help from a mental health professional.
• Stay focused on goals. Dealing with childhood schizophrenia is an ongoing process. Stay motivated as a family by keeping treatment goals in mind.
• Find healthy outlets. Explore healthy ways your whole family can channel energy or frustration, such as hobbies, exercise and recreational activities.
• Take time as individuals. Although managing childhood schizophrenia is a family affair, both children and parents need their own time to cope and unwind. Create opportunities for healthy alone time.
• Begin future planning. Ask about social service assistance. Most individuals with schizophrenia require some form of daily living support. Many communities have programs to help people with schizophrenia with jobs, affordable housing, transportation, self-help groups, other daily activities and crisis situations. A case manager or someone on your child’s treatment team can help find resources.

Clinical course of schizophrenia

Patients with schizophrenia have a varied clinical course that may include remission, exacerbations, or a more persistent chronic illness. Among patients who remain ill despite therapy, some have a stable clinical course, whereas others experience worsening symptoms and functioning. Factors that predict the clinical course and prognosis of these patients are not understood, and there is no reliable way to predict outcomes. Approximately 20% of patients can be expected to have a positive outcome ³⁾.

Suicide is a concern when treating patients with schizophrenia. The risk of suicide is 13 times greater in persons diagnosed with schizophrenia compared with the general public, with a lifetime risk of about 5% ⁴⁾. Patients with auditory hallucinations, delusions, substance abuse, or a history of suicide attempts are at higher risk. Adequate treatment of schizophrenia and its comorbidities, along with diligent screening for risk factors, reduces the likelihood of suicide ⁵⁾. The overall mortality rate for patients with schizophrenia is two to three times higher than that of the general public ⁶⁾. Most deaths are related to an increased rate of cardiovascular and respiratory diseases, stroke, cancer, and thromboembolic events ⁷⁾.

In the past, schizophrenia was viewed as a disease with a poor prognosis. Currently, the disease course and response to treatment are marked by heterogeneity; differences in treatment response, disease course, and prognosis are to be expected ⁸⁾. Despite adequate treatment, one-third of patients will remain symptomatic. Although most patients need some form of support, most are able to live independently and actively participate in their lives ⁹⁾.

Prognosis of schizophrenia

If schizophrenia is detected and treated early, and if medications and therapies are successful, the disease has an excellent treatment rate. Lifelong monitoring by a qualified health professional is a must for anyone diagnosed with schizophrenia.

While there is no cure, children and adolescents with the disease can achieve normal—and even extraordinary—milestones at school, at work and in their personal lives. With proper treatment, many children with schizophrenia are able to go to college, hold jobs and have families as adults.

The following factors are critical in successfully treating schizophrenia:

• building a foundation of family and school awareness and support
• remaining under a clinician’s care for therapeutic treatment and regular monitoring
• seeking professional treatment as soon as symptoms emerge
• taking prescribed medications exactly as directed and for as long as directed (often long-term or throughout the lifetime)

Your treating clinician can give you specific information about your child’s condition, symptoms and recommended treatment plan.