OVERVIEW: What every practitioner needs to know
Are you sure your patient has childhood psychosis? What are the typical findings for this disease?
The term childhood psychosis actually could refer to any one of a group of disorders that have common symptoms. It is important to differentiate between these disorders, however, because of differences in treatment, course, and prognosis.The common symptoms shared by these disorders can be hallucinations, delusions, disorganized thinking or formal thought disorder, affective disturbances, and impaired reality testing. After ruling out other causes for psychotic symptoms, the diagnosis of schizophrenia can be made if the symptoms have lasted longer than 6 months, and schizophreniform disorder can be diagnosed if symptoms have lasted less than 6 months. During that time there is a least a 1-month period (or less if successfully treated) of 2 or more or the following:
Grossly disorganized or catatonic behavior
Negative symptoms: affective flattening, alogia, or avolition.
Only one of these symptoms is required if delusions are bizarre or hallucinations consist of a voice keeping up a running commentary on the person’s behavior or thoughts, or there are two or more voices conversing with each other. The 6-month period must include at least 1 month of these symptoms and may include periods of prodromal or residual symptoms. The most common symptoms that come to clinical attention are hallucinations, delusions, thought disorder, and disorganized behavior. Before these symptoms become apparent, there is a prodromal phase in which there is some degree of functional deterioration that may go on for weeks or years.
The clinical presentation of childhood/adolescent schizophrenia is on a continuum with adult-onset schizophrenia, taking into account the child’s developmental stage. Negative symptoms, including affective flattening, anhedonia, alogia, and avolition often occur but can be more difficult to recognize in children and adolescents..Disorganized thinking or formal thought disorder can be part of the acute presentation of schizophrenia and can be associated with disorganized and bizarre behavior.
Patients may have difficulties at school and at home with activities of daily living because of cognitive deficits in attention, memory, and executive functioning that are frequently found in children and adolescents with schizophrenia. Inappropriate affect is one of the defining features of the disorganized type of schizophrenia. As in adult-onset schizophrenia, there are subtypes of schizophrenia: paranoid, disorganized, catatonic, undifferentiated, and residual type.
What other disease/condition shares some of these symptoms?
Other conditions that can cause psychotic symptoms include the following:
General medical conditions
Substance-induced psychotic disorder
Mood disorders, including bipolar disorder and major depressive disorder
Anxiety disorders, including obsessive compulsive disorder, posttraumatic stress disorder, and generalized anxiety disorder
Pervasive developmental disorders
Brief psychotic disorder
Shared psychotic disorder
Psychotic disorder not otherwise specified
Organic or general medical conditions that can cause psychotic symptoms are many and include the following:
Central nervous system lesions (brain tumors, head trauma, congenital malformations)
Metabolic disorders (endocrinopathies, Wilson disease)
Neurodegenerative disorders (Huntington chorea, lipid storage disorders)
Developmental disorders such as velocardiofacial syndrome
Toxic encephalopathies: substances of abuse (marijuana, alcohol, Ecstasy,
Salvia divinorum, phencyclidine, cocaine, amphetamines, hallucinogens, solvents) as well as some medications (corticosteroids, anticholinergic agents, and other toxins such as heavy metals (e.g., mercury)
Infectious diseases, including encephalitis, meningitis, HIV-related syndromes.
What caused this disease to develop at this time?
The cause of schizophrenia is not known, but research is ongoing to elucidate the relative roles of genetics, environment, and neurodevelopmental as well as psychosocial stressors.There is a 10%-15% risk of schizophrenia developing if one parent has it, compared with a 1% risk in the general population.The prevalence of childhood-onset schizophrenia, defined as onset before age 13 years, is 0.1% or less.There is evidence that schizophrenia in childhood has frequently been misdiagnosed and with careful follow-up, these children will end up with another diagnosis (see the many possible diagnoses for psychotic symptoms in childhood).
The prevalence increases during adolescence until it reaches adult levels of 1% during late adolescence.The peak ages of onset for the disorder are from 15-30 years of age.There is evidence that supports an interaction between a neurodevelopmental and a genetic/environmental component that leads to the development of childhood-onset schizophrenia.
The majority of patients with early-onset schizophrenia have been found to have premorbid abnormalities, including social withdrawal and isolation, speech and language problems, academic and disruptive behavioral problems, as well as developmental delays. It has been found that the premorbid functioning of patients with bipolar disorder can be a way to differentiate that group from patients with schizophrenia, for they do not tend to have premorbid abnormalities as listed above.
What laboratory studies should you request to help confirm the diagnosis? How should you interpret the results?
There are no confirmatory laboratory studies to diagnose schizophrenia. However, there are conditions that must be ruled out by laboratory studies, imaging studies, and other studies. Electroencephalography can rule out seizure disorder as a cause for psychotic symptoms other than schizophrenia. Urine toxicologic evaluation can rule out substance-induced pyschosis.
As part of the medical evaluation, laboratory tests to consider would include complete blood count, serum chemistry panels, thyroid function analysis, urinalysis, urine toxicologic studies, and chromosomal studies if there is evidence in the clinical presentation of a developmental syndrome. If the child is at risk, testing should be done for HIV.
Would imaging studies be helpful? If so, which ones?
Magnetic resonance imaging (MRI) can rule out certain organic causes for psychotic symptoms: brain tumor, congenital malformation, head trauma. If there is evidence of neurologic dysfunction or abnormal electroencephalographic or MRI results, a neurology consult is warranted.
Confirming the diagnosis
Most children with hallucinations are not schizophrenic but may have recurrent symptoms if they have a history of trauma because of dissociative disorder or posttraumatic stress disorder. Psychotic symptoms can also occur in other anxiety disorders in children, such as acute phobic reactions and obsessive complusive disorder. It is important to obtain a careful history, sometimes requiring multiple sources, to assess premorbid functioning, a possible decline in functioning, the presence of negative symptoms—including apathy, affective flattening, and alogia—a history of trauma, a family history of mental illness (present and past), and substance abuse/new medication treatment.
Presentation with psychotic symptoms, including some or all of the following: hallucinations, delusions, disorganized thoughts or behavior, impaired reality testing
A. Symptoms secondary to a medical cause. If not proceed to B.
B. Symptoms secondary to a mood disorder: rule out bipolar disorder, major depressive disorder with psychotic features or schizoaffective disorder. If not proceed to C.
C. No significant impairment in functioning with nonbizarre delusions: diagnosis of delusional disorder. If not proceed to D.
D. Psychotic symptoms lasting less than 1 month, diagnosis of brief psychotic disorder; if lasting more than 1 month and less than 6 months, diagnosis of schizophreniform disorder; if lasting more than 6 months, diagnosis of schizophrenia if full criteria are met, if not, diagnosis of psychotic disorder, NOS.;
;Rarely there is the development of delusions because of a close relationship with another person who has the same/similar delusion, diagnosis of shared psychotic disorder.
If you are able to confirm that the patient has childhood psychosis, what treatment should be initiated?
After the diagnosis of schizophrenia has been made and other causes for psychosis have been ruled out, intensive treatment should start immediately.The longer the child is experiencing psychotic symptoms, the more severe the developmental impact. It must be established whether it is safe for the child to be treated outside the hospital. If there are command hallucinations, suicidal ideation/behavior, or comorbid substance abuse, the patient requires inpatient treatment or immediate crisis intervention.
Antipsychotic medication is the treatment of choice.The target symptoms for the antipsychotic medication are hallucinations, delusions, agitation, aggression and overactivity. Full efficacy may take up to 10-12 weeks at a therapeutic dose.The first-line antipsychotic medications for schizophrenia in children and adolescents are risperidone, quetiapine, and aripiprazole. Risperidone is started at 0.5 mg once a day either morning or evening and is then increased by 0.5 mg not more frequently than once every 24 hours up to 3-4 mg a day, usually in divided doses, depending on the tolerability of side effects.
Quetiapine is started at 50 mg a day, usually given at bedtime or in the evening because of the frequency of sedation as a side effect. The dose can be increased to 100 mg on day 2, 200 mg on day 3, 300 mg on day 4, and 400 mg on day 5.The daily dose should be divided into 2-3 doses during the day.
If after adequate trials of two of these atypical antipsychotic medications, the patient has not responded, a typical antipsychotic agent or clozapine would be recommended. Long-term treatment should be comprehensive and include ongoing medication monitoring and a supportive/therapeutic educational placement including social skills training. Psychoeducational treatment to support the family and the patient can help with maintaining the child at home.
Comorbid conditions, such as substance abuse or depression, must be addressed if the patient is to do well. If there are safety concerns, the patient should be hospitalized until stabilized. At times this can lead to lengthy hospitalizations or even residential treatment. Schizophrenia is a chronic illness and most children, even with adequate treatment, more than 50% of patients remain significantly impaired.
What are the adverse effects associated with each treatment option?
Children and adolescents treated with atypical antipsychotic agents are at higher risk than most adults for the development of multiple adverse effects. They include sedation, extrapyramidal symptoms (although not akathisia), withdrawal dyskinesia, prolactin-related adverse effects (especially in postpubertal girls), weight gain, dyslipidemia, and suicidal ideation and behaviors.
There should be baseline blood work done as well as baseline height, weight, and body mass index (BMI) measurement. These indices should then be followed over time, as long as the patient is taking medication. The recommended assessments and frequency are as follows:
Personal and family history: at baseline and annually
Lifestyle monitoring: at every visit
Height, weight, BMI percentile/z score:at every visit
Somnolence/sedation: at every visit
Sexual symptoms/signs: at baseline, titration, then every 3 months
Blood pressure, pulse baseline: at titration, and every 6 months
Fasting glucose, lipids ± insulin determinations: at baseline, 3 months, then every 6 months
Liver function tests: at baseline, 3 months, then every 6 months
Extrapyramidal symptoms, akathisia: at baseline, titration, 3 months, then annually
Dyskinesia/tardive dyskinesia: at baseline, 3 months, then annually
Electrolyte determination, blood count, renal function: at baseline and annually (except with clozapine)
Prolactin levels: only when symptomatic
Electrocardiogram: if taking ziprasidone, during titration and at maximum dose
What are the possible outcomes of childhood psychosis?
Increasing evidence indicates that compared with later-onset schizophrenia, childhood-onset schizophrenia is associated with worse outcomes that may have to do with the negative impact of the illness on the rapidly developing brain. Onset before the age of 10 years is associated with a poor outcome. Outcome is best predicted by premorbid functioning and the severity of positive and negative symptoms during the acute phase.
There is a percentage of patients who have only one cycle of the illness: prodrome, acute phase, recovery phase. Twenty percent of patients may have complete remission. Insidious onset and onset before age 12 years have been associated with a poorer outcome and incomplete remission. Misdiagnosis of children and adolescents is a significant problem in the patient group referred for the treatment of schizophrenia. Hallucinations in childhood are not necessarily a sign of schizophrenia. Diagnostic clarification comes over time with careful follow-up.
What causes this disease and how frequent is it?
The development of schizophrenia has a significant genetic component as mentioned above. There is also a sharp rise in the incidence of schizophrenia with the onset of pubertal changes. Perinatal complications, disruption in fetal neural development, and changes in brain structure and size have been followed in the incidence of schizophrenia. Infants who are genetically at risk may display a neurointegrative defect described as pandysmaturation. The occurrence of developmental delays and premorbid abnormalities may represent the early manifestations of the disorder. An increased risk for the development of psychosis has been found in association with substance abuse, particularly amphetamine and marijuana use.
Other clinical manifestations that might help with diagnosis and management
Children with schizophrenia often have been found to have three characteristic communication deficits: illogical thinking, loose associations, and impaired discourse skills. Rates of incoherence are low. Personality disorders are sometimes confused with schizophrenia: borderline personality disorder, schizoid personality disorder, schizotypal personality disorder.
Rating instruments that are helpful for clarification of diagnosis and monitoring of treatment response include the following:
Schedule for Affective Disorders and Schizophrenia for School Age Children, present and lifetime version (PUBMED:9204677)
Children’s Global Assessment Scale (PUBMED:6639293)
Brief Psychiatric Rating Scale for Children (PUBMED:7111598)
Bunney-Hamburg Psychosis Rating Scale (PUBMED:14016854)
Scale for the Assessment of Positive Symptoms (Available at: http://www.movementdisorders.org/UserFiles/file/Long_SAPS_2000_publish(1).pdf)
Scale for the Assessment of Negative Symptoms (Sans) (Available at: http://www.movementdisorders.org/UserFiles/file/Long_SANS_2000_publish(1).pdf)
The Autism Screening Questionnaire (PUBMED:10789276) is useful in assessing comorbid pervasive developmental disorders.
What complications might you expect from the disease or treatment of the disease?
See above regarding possible side effects secondary to antipsychotic medication. The risk of suicide or accidental death resulting from behaviors caused by psychotic thinking appears to be at least 5%. Adults with schizophrenia have a suicide rate as high as 10%. They are also at increased risk for medical illness and mortality.
How can childhood psychosis be prevented?
There are no known preventive measures available.Treatment of premorbid symptoms has been attempted without significant success.
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- OVERVIEW: What every practitioner needs to know
- Are you sure your patient has childhood psychosis? What are the typical findings for this disease?
- What other disease/condition shares some of these symptoms?
- What caused this disease to develop at this time?
- What laboratory studies should you request to help confirm the diagnosis? How should you interpret the results?
- Would imaging studies be helpful? If so, which ones?
- Confirming the diagnosis
- If you are able to confirm that the patient has childhood psychosis, what treatment should be initiated?
- What are the adverse effects associated with each treatment option?
- What are the possible outcomes of childhood psychosis?
- What causes this disease and how frequent is it?
- Other clinical manifestations that might help with diagnosis and management
- What complications might you expect from the disease or treatment of the disease?
- How can childhood psychosis be prevented?