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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&section=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&section=Facts+for+Familieshttp://aacap.org/page.ww?name=Schizophrenia+in+Children&section=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&section=Facts+for+Families