early childhood schizophrenia symptom and treatment
TRANSCRIPT
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EARLY CHILDHOOD SCHIZOPHRENIA SYMPTOM AND
TREATMENT
CREATED BY:
NADIA ALWAINY
030.08.171
FACULTY OF MEDICINE
TRISAKTI UNIVERSITY
JAKARTA
2012
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PREFACE
First of all, the writer wants to thank God for all of His never ending blessings, and
because of Him, the writer can finish this paper. Second of all, the writer wants to thank dr.
Nuryani as her consultant and advisor, who gave the subject of Early Childhood
Schizophrenia Symptom and Treatment, and for her time and attention. Then the writer wants
to thank her parents, her sisters, and her amazing friends who support until the very end so
the writer can call this paper, finished.
Early Childhood Schizophrenia Symptom and Treatment is created for her final
assignments of English subject in Medical Faculty of Trisakti and in a hope that this will be a
helpful source for people who read it. Moreover, by reading this paper, the writer hopes
readers would raise more awareness to prevent further complication of the disease.
Deepest apologies for there are still many grammatical errors since this was made
during a learning process and the writer expects advice and critics to improve the quality of
this paper.
(Nadia Alwainy)
November 2012
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ABSTRACT
Childhood onset schizophrenia is a type of mental disorder that is characterized by
degeneration of thinking, motor, and emotional processes in children and young adults under
the age of 18. The disease is illustrated by symptoms such as auditory and visual
hallucinations, strange thoughts/feelings, and abnormal behavior therefore profoundly
impacting the childs ability to function and sustain normal interpersonal relationships.
Schizophrenia is especially rare in children under the ages of 78 years old. About 50% of
young children diagnosed with schizophrenia will experience severe neuropsychiatric
symptoms. Diagnostic criteria are similar to that of adult schizophrenia, however there are
differentiating characteristics between the two. Diagnosis is based on observed behavior by
caretakers and in some cases depending on age, self reports. It is important to note that
diagnosis can only be made by a psychiatrist or licensed psychologist. There is no known
cure, but childhood schizophrenia is controllable with the help of the proper fusion of
behavioral therapies and medications.
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TABLE OF CONTENTS
Preface 1
Abstract 2
Table of Contents 3
Chapter 1 (Introduction) 4
Chapter 2 (Discussion) 5
Chapter 3 (Conclusion) 13
References 14
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I. INTRODUCTIONIn this paper, we will discuss about schizophrenia symptoms in childhood and the
treatment. Schizophrenia is a serious psychiatric illness that causes strange thinking, strange
feelings, and unusual behavior. It is uncommon in children and hard to recognize in its early
phases. The cause of schizophrenia is not known. Current research suggests a combination of
brain changes, biochemical causes, and genetic and environmental factors. Early diagnosis
and medical treatment are important. Schizophrenia is a life-long disease that can be
controlled but not cured. Diagnosis and treatment has been an ongoing challenge because
early sign of the disorder or similar to those of other disorder. Also, some of the
schizophrenic treatments (medication or drugs) have a lot of side effect.
I hope this paper can be useful for medical students, clinicians, and other people who
read it to build awareness of how important it is to acknowledge the early symptom of
schizophrenia, shown in the abnormalities in children behavior. Some symptoms that may be
looked at are early language delays, early motor development delays, and school problems.
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II. DISCUSSIONChildhood schizophrenia (also known as early-onset schizophrenia) is Schizophrenia
is a major psychiatric illness. Symptoms usually begin in late adolescence or early adulthood.
Numerous studies have found that about one in every 100 people around the world has the
disorder. However, schizophrenia with an onset in adolescence (prior to age 18) is less
common and an onset of the disorder in childhood (before age 13) is exceedingly rare. It is
thought that at most one in every 100 adults with schizophrenia develops it in childhood. (7)
A small minority of patients manifest schizophrenia in childhood. Such children may
at first present diagnostic problems, particularly with differentiation from mental retardation
and autistic disorder. Recent studies have established that the diagnosis of childhood
schizophrenia may be based on the same symptom used for adult schizophrenia. Its onset
usually insidious, its course tends to be chronic, and the prognosis is mostly unfavorable.(4)
A.
Symptom
Children and adolescent display many of the symptoms of adult schizophrenia.
Hallucination or delusions, bizarre and morbid thought content, and rambling and illogical
speech are typical. Affected individuals tend to withdraw into an internal world of fantasy
and may equate fantasy with external reality. They generally have difficulty with schoolwork
and with peer relationships. Adolescents may have a prodromal period of depression prior to
the onset psychotic symptoms. The majority patients with childhood onset schizophrenia
have had nonspecific psychiatric symptoms or symptoms delayed development for months or
years prior to the onset of their overtly psychotic symptoms.(3)
The symptoms of schizophrenia can be classified into separate groups- positive and
negative symptoms. Positive symptoms are those symptoms that are "added on" to how a
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child typically thinks and feels. Negative symptoms are things that are absent in a childs
actions or thoughts compared to a child who does not have the disorder.
Positive Symptoms of Early-Onset Schizophrenia:
Hallucinations Delusions Disorganized Speech Disorganized or catatonic behavior
Negative Symptoms of Early-Onset Schizophrenia:
Flattened affect (mood) Anergia (lack of energy) Alogia (complete lack of speech) Avolition (lack of motivation) Social withdrawal
Most research has concluded that auditory hallucinations are the most common
positive symptom in children. Tactile and visual hallucinations seem to be relatively rare.
Delusions are reported in more than half of children with schizophrenia but they are usually
less complex than those of adults. In general, active psychotic symptoms, such as auditory
hallucinations and delusions, are apparent and prompt hospitalization, while negative
symptoms, such as blunted affect and withdrawal, are less likely to attract attention. A
childs 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, that the voices will harm the
child or someone else. Some children with schizophrenia also report feeling as if an outside
force is controlling them or manipulating them in some way.
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The behavior of children with schizophrenia may change slowly over time. For
example, children who used to enjoy relationships with others may start to become more shy
or withdrawn and seem to be in their own world. Sometimes youngsters will begin talking
about strange fears and ideas. They may start to say things that do not make sense. These
early symptoms and problems may first be noticed by the child's school teachers. (5)
Children with these symptoms must have a complete evaluation. Parents should ask
their family physician or pediatrician to refer them to a child and adolescent psychiatrist, who
is specifically trained and skilled at evaluating, diagnosing, and treating children with
schizophrenia.(5)
A.1 Diagnosis
Diagnosis is based on reports by parents/caretakers, teachers, school officials and
others close to the child. If any abnormalities in behavior are present, psychiatrists or other
professionals in the mental health fields do a further assessment. TheDiagnostic and
Statistical Manual of Mental Disorders,version DSM-IV is the standardized manual used in
the United States to diagnose mental disorders.
The DSM-IV-TR diagnostic criteria include course specifiers (i.e., prognosis) that
offer clinicians several options and describe actual clinical situations (Table 1-1). The
presence of hallucinations or delusions is not necessary for diagnosis of schizophrenia when
patient exhibits two of the symptoms listed as symptoms 1 through 5 in criterion A in Table
1-1 (e.g, disorganized speech). Criterion B requires that impaired functioning, although not
deteriorations, be present during the active phase of the illness. Symptoms must persist for at
least 6 months, and a diagnosis of schizoaffective disorder or mood disorder must be absent.
(4)
http://en.wikipedia.org/wiki/Diagnostic_and_Statistical_Manual_of_Mental_Disordershttp://en.wikipedia.org/wiki/Diagnostic_and_Statistical_Manual_of_Mental_Disordershttp://en.wikipedia.org/wiki/Diagnostic_and_Statistical_Manual_of_Mental_Disordershttp://en.wikipedia.org/wiki/Diagnostic_and_Statistical_Manual_of_Mental_Disordershttp://en.wikipedia.org/wiki/Diagnostic_and_Statistical_Manual_of_Mental_Disordershttp://en.wikipedia.org/wiki/Diagnostic_and_Statistical_Manual_of_Mental_Disorders -
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Table 1-1
DSM-IV-TR Diagnostic Criteria for Schizophrenia
A Characteristic Symptoms:two (or more) of the following, each present for a
significant portion of time during 1-month period (or less if successfully treated) :
(1) delusion thoughts
(2) hallucinations (auditory, tactile, visual, olfactory)
(3) disorganized speech (frequent derailment or incoherence)
(4) grossly disorganized or bizzare behavior
(5) negative symptoms (flat affect, avolition, or alogia)
note : only one criterion A symptom is required if delusions are bizzare or hallucinations
consist of a voice keeping p a running commentary on the person's behaviour or
thoughts, or two or more voices conversing with each other.
B Social/occupational dysfunction: for a significant portion of the time since the onset ofdisturbance, one or more major areas of functioning such as work, interpersonal
relations, or self-care are markedly below the level achived prior to the onset (or when
the onset is in childhood or adolescence, failure to achive expected level of
interpersonel, academic, or occupattonal achivement).
C Duration : Continous signs of the disturbance persist for at least 6 month. This 6 month
period must include at least 1 month symptoms (or less if succesfully treated) that meet
criterion A (active phase-symptoms) and may include periods of prodromal or residual
symptoms. during this prodormal residual periods, the sign of the disturbance may be
manifested by only negative symptoms or two or more symptom listed in criterion A
present in an attenuated form.D Schizoaffective and mood disorder exclusion: schizoaffective and mood disorder with
psychotic features have been ruled out because either (1) no major depresive, manic, or
mixed have occurred concurrently with the active-phase symptoms; or (2) if mood
episodes have occured during active-phase symptom, their total duration have been brief
relative to the duration of the active and residual periods.
E Substance/general medical condition exclusion: the disturbance is not due to the
direct physiological effects of a substance (e.g., a drug abuse, a medication) or general
medical condition.
F Relationship to a pervasive developmental disorder: if there is a history of autistic
diorder or another pervasive developmental diorder, the additional diagnosis of
schizophrenia is made only if prominent delusion or hallucination are also present for at
least a month(or less if successfully treated)
B. TreatmentThe treatment of childhood and adolescent schizophrenia focuses on four main areas:
(1)Decreasing active psychotic symptoms,
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(2)Supporting development of social and cognitive skills,(3)Reducing the risk relapse of psychotic symptoms, and(4)Providing support education to parents and family members.
Antipsychotic medications (neuroleptics) are the primary psychopharmacologic
intervention. In addition, a supportive, reality-oriented focus in relationship cans help to
reduce hallucination, delusions, and frightening thoughts. A special school or day treatment
environment may be necessary depending on the childs or adolescents ability to tolerate the
school day and classroom activities. Support for the family emphasizes the importance of
clear, focused communication and an emotionally calm climate in preventing recurrences of
overtly psychotic symptoms.(3)
B.1 Pharmacologic Management
Neuoleptic medications (usually referred to as antipsychotics in thiscontext) often
reduce the intensity of positive symptoms but do not necessarily shorten the episode. Many
adolescent psychiatrists choose newer atypical antipsychotics such as olanzapine or
risperidone as firstline treatment in preference to traditional typical antipsychotics such as
haloperidol or chlorpromazine.(2)(Table B-1).
Table B-1 -- Antipsychotic indications for schizophrenia (1)
FDA Indication
for Adults
FDA Indication for
Adolescents 1317 Years
Positive-Controlled Trials
in Pediatric Population
First-Generation Antipsychotics (typical)
Haloperidol
Perphenazine
Chlorpromazine
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FDA Indication
for Adults
FDA Indication for
Adolescents 1317 Years
Positive-Controlled Trials
in Pediatric Population
Loxapine
Thioridazine
Thiothixene
Second-Generation Antipsychotics (atypical)
Risperidone
Olanzapine
Quetiapine
Aripiprazole
Ziprasidone
Asenapine
Paliperidone
Clozapine
Iloperidone
Abbreviation:FDA, Food and Drug Administration.
Head-to-head comparisons of typicals and atypicals suggest that they are roughly
equally effective as far as reducing psychotic features are concerned, differing mainly in their
adverse effects: typicals are more linked to extrapyramidal side effects (for example,
Parkinsonian symptoms) and atypicals to rapid weight gain and its metabolic complications.
(Table B-2). Clozapine is a special atypical that may be successful when other typical and
atypical antipsychotic have failed patients on Clozapine need regular blood monitoring to
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reduce the risk of serious side effects (for example, agranulocytosis). It is because of these
side effects that clozapine should only be used when first-line drugs have failed. (2)
Table B-2 : Side effects of antipsychotic medications
(1)
Side Effects First-Generation
Antipsychotics
Second-Generation Antipsychotics
Haloperidol Perphenazine Risperidone Olanzapine Quetiapine Aripiprazole Ziprasidone Paliperidone Clozapine
Acute
Parkinson
Syndrome
++++++ ++++ ++++ ++ - ++ ++ ++++ -
Akathisia ++++++ ++++ ++ ++ ++ ++++ +++ ++ ++
Diabetes
Mellitus
++ ++ ++ ++++++ ++++ + + ++ +++++
Diabetes
Insipidus
- - - - - - - - +
Lipid
Levels
+ ++ ++ ++++ +++ + + ++ ++++
Neutropenia + + + + + + + + ++++
Orthostatic
hypotension
+ ++ ++ ++++ ++++ + - ++ ++++++
Prolactin
level
++++ ++++ ++++++ +++ - - ++ +++++ -
Prolactin
level
- - - - - ++++ - - -
QT
interval
+ ++ ++ + ++ + ++++ ++ ++
Sedation + ++ ++ ++++ ++++ + + ++ ++++++
Seizures + + + + + + + + ++++
Tardive
Dyskinesia
++++ ++++ + + + + + + -
Withdrawal
Dyskinesia
++++ +++ ++ + + ++++ ++ ++ ++
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Side Effects First-Generation
Antipsychotics
Second-Generation Antipsychotics
Haloperidol Perphenazine Risperidone Olanzapine Quetiapine Aripiprazole Ziprasidone Paliperidone Clozapine
Weight
Gain
++ ++++ ++++ ++++++ ++++ ++ ++ +++ ++++++
Abbreviations:, decreased; , increased; -, none; + to ++++, mild to severe.
Resolution of positive symptoms is often followed by a recovery phase of several
months during which residual negative symptoms partially or fully resolve. As in the case of
adult-onset schizophrenia, it is only a small minority who recover completely and have no
further episodes. Continuing medication is likely to be needed. Family work will need to
address coming to terms with what is often a devastating life-long illness; reducing the young
persons exposure to criticism, hostility and other negative emotion may play a part in
avoiding relapses. CBT (Community Based Therapy) to reduce the impact of residual
positive symptoms may be worthwhile but trials in this age group are lacking. Affected
individuals may also need special schooling, social skills training, and phased transfer to
adult community psychiatric services. Particularly after second and subsequent episodes,
recovery is often incomplete and social functioning may gradually deteriorate. (2)
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III. CONCLUSIONEarly diagnosis and treatment in childhood schizophrenia is important. It has been
found, however, that early-onset schizophrenia carried a more severe prognosis than later-
onset schizophrenia. Regardless of treatment, children diagnosed with schizophrenia at an
early age suffer diminished social skills, such as educational and vocational abilities. . The
primary area that children with schizophrenia must adapt to is their social surroundings. A
study also found social disability in the group with onset before age twelve is significantly
greater than those 13-18 at age of onset. Psychotherapy is used in order to assist those with
schizophrenia understand their disorder and learn to thrive socially with it. The stages of
development would increase the need for psychotherapy as well as family therapy. The
parents here can increase their bond with the child and possibly increase the chance of
recovery. Pharmacologic management in early-onset schizophrenia is also important to
decrease active psychotic symptoms and reduce the risk relapse of psychotic symptom.
Children with schizophrenia may never be rid of their symptoms completely, but treatments
are in place to assist with coping.
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REFERANCE
1. Carlisle L. Psychopharmacology of schizophrenia in children and adolescent. The pediatricsclinics of North America 2011; 58(1):205
2. Goodman R, Scott S. Child and adolescent psychiatry. Wiley-Blackwell 2012; 24: 193-1973. Hay W W, Levin M J, Sondheimer J M. Current diagnosis & treatment pediatrics.
McGraw-Hill Inc 2009; 6: 186.
4. Sadock B J, Sadock V A, Mitchell C W. Kaplan & Sadocks concise textbook ofclinical psychiatry. Lippincott Williams & Wilkins 2008; 10: 156-177.
5. American Academy of Child and Adolescent Psychiatry. Schizophrenia in children. Avalaibleat :
http://aacap.org/page.ww?name=Schizophrenia+in+Children§ion=Facts+for+Families .
Accessed November 24, 2012
6. Mental Health of America. Schizophrenia in children. Available at :http://www.nmha.org/index.cfm?objectId=C7DF8F81-1372-4D20-C84C5539FAB14576
Accessed November 24, 2012
7. National Alliance on Mental Illness. Early onset schizophrenia. Available at :http://www.nami.org/Content/ContentGroups/Helpline1/Early_Onset_Schizophrenia.htm .
Accessed November 24,2012
http://aacap.org/page.ww?name=Schizophrenia+in+Children§ion=Facts+for+Familieshttp://aacap.org/page.ww?name=Schizophrenia+in+Children§ion=Facts+for+Familieshttp://www.nmha.org/index.cfm?objectId=C7DF8F81-1372-4D20-C84C5539FAB14576http://www.nmha.org/index.cfm?objectId=C7DF8F81-1372-4D20-C84C5539FAB14576http://www.nami.org/Content/ContentGroups/Helpline1/Early_Onset_Schizophrenia.htm%20.%20Accessed%20November%2024http://www.nami.org/Content/ContentGroups/Helpline1/Early_Onset_Schizophrenia.htm%20.%20Accessed%20November%2024http://www.nami.org/Content/ContentGroups/Helpline1/Early_Onset_Schizophrenia.htm%20.%20Accessed%20November%2024http://www.nami.org/Content/ContentGroups/Helpline1/Early_Onset_Schizophrenia.htm%20.%20Accessed%20November%2024http://www.nmha.org/index.cfm?objectId=C7DF8F81-1372-4D20-C84C5539FAB14576http://aacap.org/page.ww?name=Schizophrenia+in+Children§ion=Facts+for+Families