Childhood schizophrenia (also known as childhood-onset schizophrenia and very early-onset schizophrenia) is similar in characteristics to schizophrenia that develops at a later age, with the major difference being an onset before the age of 13 years and a more challenging diagnosis. Schizophrenia is characterized by positive symptoms that can include hallucinations, delusions, and disorganized speech; negative symptoms, such as blunted affect, avolition, and apathy, and a number of cognitive impairments. Differential diagnosis is often problematic since several other neurodevelopmental disorders, including autism spectrum disorder, language disorder, and attention-deficit/hyperactivity disorder, also have signs and symptoms similar to childhood-onset schizophrenia.
The disorder is associated with symptoms like auditory and visual hallucinations, delusional thoughts or feelings, and abnormal behavior, profoundly impacting the child's ability to function and sustain normal interpersonal relationships. Delusions are often vague and less developed than those of adult-onset schizophrenia, which features more systematized delusions. Among the psychotic symptoms seen in childhood schizophrenia, non-verbal auditory hallucinations are the most common and often sound like shots, knocks, and bangs. Other symptoms can include irritability, searching for imaginary objects, low performance, and a higher rate of tactile hallucinations compared to adult-onset schizophrenia. It typically presents after the age of seven. About 50% of young children diagnosed with schizophrenia experience severe neuropsychiatric symptoms. Studies have demonstrated that diagnostic criteria are similar to those of adult-onset schizophrenia. Neither DSM-5 nor ICD-11 list "childhood schizophrenia" as a separate diagnosis. The diagnosis is based on a thorough history and psychiatric examination by a child psychiatrist, exclusion of medical causes of psychosis (often by extensive testing), observations by caregivers and schools, and, in some cases (depending on age), self-reports from pediatric patients.
Classification of mental disorders Diagnostic and Statistical Manual of Mental Disorders
Childhood schizophrenia was not directly added to the DSM until 1968, when it was added to the DSM-II, which set forth diagnostic criteria similar to that of adult schizophrenia. "Schizophrenia, childhood type" was a DSM-II diagnosis with diagnostic code 295.8, equivalent to "schizophrenic reaction, childhood type" (code 000-x28) in DSM-I (1952). "Schizophrenia, childhood type" was successfully removed from the DSM-III (1980), and in the Appendix C they wrote: "there is currently no way of predicting which children will develop Schizophrenia as adults". Instead of childhood schizophrenia they proposed to use of "infantile autism" (299.0x) and "childhood onset pervasive developmental disorder" (299.9x).
In the DSM-III-R (1987), DSM-IV (1994), DSM-IV-TR (2000), DSM-5 (2013) there is no "childhood schizophrenia". The rationale for this approach was that, since the clinical pictures of adult schizophrenia and childhood schizophrenia are identical, childhood schizophrenia should not be a separate disorder. However, the section in schizophrenia's Development and Course in DSM-5, includes references to childhood-onset schizophrenia.
International Classification of Diseases In the International Classification of Diseases 8th revision (ICD-8, 1967) there was a category (295.8) "Other" in the schizophrenia section (295). "Other" includes: atypical forms of schizophrenia, infantile autism, schizophrenia, childhood type, NOS (Not Otherwise Specified), schizophrenia of specified type not classifiable under 295.0–295.7, schizophreniform attack or psychosis.
Unspecified psychoses with origin specific to childhood (code 299.9) in the International Classification of Diseases 9th revision (ICD-9) includes "child psychosis NOS", "schizophrenia, childhood type NOS" and "schizophrenic syndrome of childhood NOS".
"Childhood type schizophrenia" available in the Soviet adopted version of the ICD-9 (code 299.91) and the Russian adopted version of the 10th revision ICD-10 (code F20.8xx3) and the U.S. adopted the 10th revision ICD-10 (code F20.9x6) classified "schizophrenia, unspecified".
Signs and symptoms
Schizophrenia is a mental disorder that is expressed in abnormal mental functions, a loss of one's sense of identity and self, a compromised perception of reality, and disturbed behavior.
The signs and symptoms of childhood schizophrenia are similar to those of adult-onset schizophrenia. Some of the earliest signs that a young child may develop schizophrenia are lags in language and motor development. Some children engage in activities such as flapping the arms or rocking, and may appear anxious, confused, or disruptive on a regular basis. Children may experience hallucinations, but these are often difficult to differentiate from just normal imagination or child play. Visual hallucinations are more commonly found in children than in adults. It is often difficult for children to describe their hallucinations or delusions, making very early-onset schizophrenia especially difficult to diagnose in the earliest stages. The cognitive abilities of children with schizophrenia may also often be lacking, with 20% of patients showing borderline or full intellectual disability.
Negative symptoms include apathy, avolition, alogia, anhedonia, asociality, and blunted emotional affect.
Apathy is an overall lack of interest or enjoyment, which relates to the negative symptom of blunted emotional affect. Blunted emotional affect includes a lack of facial expressions, lack of intonation while speaking, and little eye contact. If you are speaking to someone who has blunted emotional affect, it would be difficult to determine their feelings using their facial expressions and tone. Avolition is experienced when the child shows few goal-focused behaviors and choices, and a lack of interest in goal-related activities, including personal hygiene. Alogia can be seen when people use few words and lack fluency while speaking. Anhedonia relates to an inability to find pleasure in activities that one previously found enjoyable, as well as the inability to remember previous enjoyable memories. Asociality is a symptom seen when a person has no interest in socializing with others.
These negative symptoms can severely impact children's and adolescents' abilities to function in school and in other public settings.
Very early-onset schizophrenia refers to onset before the age of thirteen. The prodromal phase, which precedes psychotic symptoms, is characterized by deterioration in school performance, social withdrawal, disorganized or unusual behavior, a decreased ability to perform daily activities, a deterioration in self-care skills, bizarre hygiene and eating behaviors, changes in affect, a lack of impulse control, hostility and aggression, and lethargy.
Auditory hallucinations are the most common of the positive symptoms in children. Auditory hallucinations may include voices that are conversing with each other or voices that are speaking directly to the children themselves. Many children with auditory hallucinations believe that if they do not listen to the voices, the voices will harm them or someone else. Tactile and visual hallucinations seem relatively rare. Children often attribute the hallucinatory voices to a variety of beings, including family members or other people, evil forces ("the Devil", "a witch", "a spirit"), animals, characters from horror movies (Bloody Mary, Freddy Krueger) and less clearly recognizable sources ("bad things," "the whispers"). Delusions are reported in more than half of children with schizophrenia, but they are usually less complex than those of adults. Delusions are often connected with hallucinatory experiences. Command auditory hallucinations (also known as imperative hallucinations) were common and experienced by more than half of the group in a study at Bellevue Hospital Center's Children's Psychiatric Inpatient Unit. In this study, delusions were characterized as persecutory for the most part, but some children reported delusions of control. Many said they were being tortured by the beings causing their visual and auditory hallucinations; some thought disobeying their voices would cause them harm.
Some degree of thought disorder was observed in a test group of children at Bellevue Hospital. They displayed illogicality, tangentiality (a serious disturbance in the associative thought process), and loosening of associations.
Pathogenesis Several environmental factors, including perinatal complications and prenatal maternal infections may contribute to the etiology of schizophrenia. Prenatal rubella or influenza infections are associated with childhood-onset schizophrenia. Severity or frequency of prenatal infections may also contribute to earlier onset of symptoms by means of congenital brain malformations, reduction or impairment of cognitive function, and psychological disorders. It is believed that prenatal exposure to rubella modifies the developmental course during childhood, increasing the risk for childhood schizophrenia. Genetic predisposition is an important factor as well; familial mental illness is more frequently reported for childhood-onset schizophrenic patients. While it is hard to detect, there are relatives who are more-likely to be diagnosed with schizophrenia if they are children of individuals who have this disorder. "First degree relatives" are found to have the highest chance of being diagnosed with schizophrenia. Children of individuals with schizophrenia have a 8.2% chance of having schizophrenia while the general population is at an 0.86% chance of having this disorder. These results indicate that genes play a big role in one developing schizophrenia.
Genetic There is "considerable overlap" in the genetics of childhood-onset and adult-onset schizophrenia, but in childhood-onset schizophrenia there is a higher number of "rare allelic variants". There have been several genes indicated in children diagnosed with schizophrenia that include: neuregulin, dysbindin, D-amino acid oxidase, proline dehydrogenase, catechol-Omethyltransferase, and regulator of G protein signaling. There have also been findings of 5HT2A and dopamine D3 receptor. An important gene for adolescent-onset schizophrenia is the catechol-O-methyltransferase gene, a gene that regulates dopamine. Children with schizophrenia have an increase in genetic deletions or duplication mutations and some have a specific mutation called 22q11 deletion syndrome, which accounts for up to 2% of cases.
Neuroanatomical Neuroimaging studies have found differences between the medicated brains of individuals with schizophrenia, and the brains of those without, though research does not know the cause of the difference. In childhood-onset schizophrenia, there appears to be a more rapid loss of cerebral grey matter during adolescence. Studies have reported that adverse childhood experiences (ACEs) are the most preventable cause of the development of psychiatric disorders such as schizophrenia. ACEs have the potential to impact on the structure and function of the brain; structural changes revealed have been related to stress. Findings also report that different areas of the brain are affected by different types of maltreatment.
Diagnosis
The same criteria are used to diagnose children and adults. Diagnosis is based on reports by parents or caretakers, teachers, school officials, and others close to the child.