Identification and management of Schizophrenia in childhood

Journal of Child and Adolescent Psychiatric Nursing, Apr-Jun 2001 by Lambert, Louise T

TOPIC. The identification and management of schizophrenia in childhood.

PURPOSE. To provide an overview of what is currently known about childhood schizophrenia.

SOURCES. Published literature and personal observations and experiences.

CONCLUSIONS. Early identification and treatment of childhood schizophrenia are critical, and more research and education on the part of all mental health professionals are needed in order to identify, provide treatment, and/or make referrals for children with this serious mental disorder.

Search terms: Childhood schizophrenia, developmental delays, neurobiological changes, psychoeducation, psychosis

Most nurse generalists are familiar with the diagnosis of schizophrenia in adulthood, through exposure during basic nursing education or through their work experiences. Nurses who work with children and adolescents in a mental health setting may have been involved with the assessment and treatment of a child diagnosed with schizophrenia. The clinical nurse specialist in child and adolescent psychiatric mental health nursing will likely have identified and treated a client with childhood schizophrenia in an inpatient or outpatient setting. The purpose of this article is to provide an overview of what is known about schizophrenia in childhood.

Incidence Prognosis

Schizophrenia is rarely seen in childhood (Remschmidt, Schultz, Martin, Warnke, & Trott, 1994), especially before the age of 12. It is less than one sixteenth as common as the adult-onset type (Harvard, 1997). According to Tolbert (1996), 1 in 10,000 children will develop the disorder. It occurs most often in late adolescence but can strike young children. When this is the case, about 50% of these children will experience serious neuropsychiatric symptoms (Taylor, 1998). Asarnow, Thompson, and Goldstein (1994) found that 61% of children with early onset childhood schizophrenia maintained the same diagnosis throughout adolescence and young adulthood. The Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association [APA], 1994) (DSM-IV) points out the poorer prognosis for early onset schizophrenia. The earlier age of onset has been correlated with high social disability (Eggers & Bunk, 1997). Eggers and Bunk found that no gender differences exist between sexes in average age of onset.

Signs and Symptoms

Young schizophrenic children can and do experience psychosis, which often is preceded by behavioral problems, developmental lags, and "soft" neurological signs. There may be language and motor delays well before the development of actual psychosis. About 30% of these children will demonstrate symptoms of pervasive developmental disorder such as posturing, rocking, and arm flapping, and may present as anxious, confused, or disruptive (Harvard, 1997). Children with schizophrenia fail to develop normal interpersonal relationships and problem-solving skills. They do not develop judgment, abstract reasoning, or age-appropriate self-care. There is an alteration in cognitive development, even though there is no intellectual impairment, causing the child to be unable to actualize knowledge (Taylor, 1998).

Studies of childhood schizophrenics prior to the onset of their illness often show a different physical appearance and a negative affect compared to siblings and peers (Litter & Walker, 1993). Social and cognitive development either regresses or does not occur and generally is not regained.

Although children with schizophrenia have hallucinations, diagnosis before preadolescence is sometimes difficult due to the, child's inability to provide details. One study done by the National Institute of Mental Health (NIMH) (Spencer & Campbell, 1994), however, reported that children between the ages of 5.5 and 11.75 had shared their auditory hallucinations in very specific terms. The hallucinations are usually auditory and persecutory or command in nature. Visual hallucinations also may be present (Werry, 1992). Delusions tend to reflect the day-today life of the child and exhibit themes of monsters, ghosts, or animals (Russell, 1994). Formal thought disorder and disruption of speech is seen more often in older children but is difficult to assess and identify in the younger, immature child (Caplan, 1994). While the actual course of a schizophrenic illness for a given child cannot be predicted, the development of the psychosis is usually gradual, without any abrupt onset or sudden break as is common in an adolescent or an adult (Russell). This slow insidious onset of symptoms, known as the "prodromal phase" (APA, 1994), appears early in the child's development and increases in intensity over time.

Etiology

Research has replicated that schizophrenia is related to neurological damage. The brain structure in childhood schizophrenia (Alaghband-Rad, Hamburger, Giedd, Frazier, & Rapoport, 1997) and molecular functioning of those who have schizophrenia is very different from normals in control groups (Andreasan, 1994; Austrian, 1995; Torrey, Bowler, Taylor, & Gottesman, 1994). Longitudinal studies show evidence of progressive ventricular enlargement in people with early onset schizophrenia (Jacobsen & Rapoport, 1998). According to Gordon et al. (1994), children with schizophrenia also have measurable differences in glucose metabolism. In addition, both children and adults with schizophrenia show irregular autonon-tic nervous system arousal and problems with visual tracking of moving objects. While it is not known what causes these neurobiological changes, there is growing evidence that the illness could be passed genetically or through a neurovirus occurring in the second trimester of pregnancy. Twin studies also suggest a genetic childhood schizophrenia link (Torrey et al., 1995).