Childhood-Onset Schizophrenia Treatment & Management

Updated: Mar 25, 2019
  • Author: Marshal E Ash, DO; Chief Editor: Caroly Pataki, MD  more...
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Treatment

Approach Considerations

Acute inpatient care is necessary for persons with behaviors dangerous to self or others. The child with schizophrenia who is severely impaired may need day treatment programs or hospitalization until the child is stabilized and not considered a danger to self or others.

Pharmacotherapy is essential in the treatment of individuals with childhood-onset psychosis. Electroconvulsive therapy (ECT) has also been used adjunctively in rare cases.

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Medical Care

Pharmacotherapy

The first-line agents are neuroleptics. Newer atypical antipsychotic agents are generally chosen as the initial medications of choice.

Repeating assessment for medication adverse effects using standard measures is essential. The abnormal involuntary movement scale (AIMS) is one such standard measure. Possibly one third of children on antipsychotics develop withdrawal dyskinesias.

Recommendations for monitoring adults on atypical antipsychotics include checking the following:

  • Weight at baseline; 4, 8, and 12 weeks; and then quarterly

  • Blood pressure at baseline, 12 weeks, and annually

  • Fasting plasma glucose level at baseline, 12 weeks, and annually

  • Fasting lipid profile at baseline, 12 weeks, and every 5 years

Similar recommendations regarding atypical antipsychotics are not yet available for children and adolescents, but careful monitoring of weight, blood pressure, and glucose and lipids levels seems warranted. Correll et al. examined the cardiometabolic effects of olanzapine, quetiapine, risperidone, and aripiprazole in a 12-week trial of children and adolescents who had mood disorders, psychotic disorders, or disruptive-behavior disorders. Significant weight gain was seen with each of these medications, with olanzapine and quetiapine causing the most weight gain. In addition, olanzapine and quetiapine significantly increased total cholesterol and triglycerides. Risperidone also significantly increased triglycerides. As a result of these findings, the authors concluded that cardiometabolic monitoring occur biannually after the first 3 months of treatment. [89]

Interestingly, a 24-month study found differences in side effects between medications (particularly higher BMI in olanzapine and neurological side effects in risperdal) at the six-month follow up that were no longer significant at 12 and 24 months. [90] And while antipsychotics have been found to increase risk of metabolic syndrome, one study found the increased risk for metabolic syndrome in patients with first episode of psychosis existed even before initiation of antipsychotics. Patients 12–17 years old with psychosis had larger waist circumferences, higher cholesterol, and higher low-density lipoprotein. A diagnosis of schizophrenia was associated with higher CGI-severity scores and blood lipids. Again, these findings all existed before antipsychotic medication exposure. [91]

Many second-generation antipsychotics have been approved by the FDA in recent years for adolescents to treat schizophrenia including aripiprazole, lurasidone, olanzapine, quetiapine, paliperidone, and risperidone.

The second-generation antipsychotics iloperidone (Fanapt), asenapine (Saphris), cariprazine (Vraylar), and ziprasidone (Geodon) are approved for adult-onset schizophrenia, but not yet for pediatric patients. [92]

Ultra–high-risk intervention studies are exploring the use of antidepressants. [93]

A systematic review of data from 11 studies of antipsychotics (aripiprazole, haloperidol, molidone, olanzapine, paliperidone, quetiapine, risperidone, ziprasidone) on early-onset schizophrenia symptoms found only haloperidol, olanzapine, and risperidone had statistically significant positive effect on positive symptoms of PANSS scores at six-week follow-up compared to placebo. [94]

A retrospective cohort study of patients with early-onset schizophrenia diagnosed with comorbid mood or emotional disregulation disorders or comorbid cognitive impairment found treatment with atypical antipsychotic monotherapy was associated with less use of acute psychiatric services over time compared to treatment with multiple atypical antipsychotics or a single atypical antipsychotic plus an antidepressant or psychostimulant. Treatment with a single atypical antipsychotic plus a mood stabilizer did, though, show increased/stronger association. [95]

Transcranial magnetic stimulation

A case series in France suggested transcranial magnetic stimulaiton (TMS) may be therapeutic in the treatment of early-onset refractory auditory hallucinations in patients with childhood-onset schizophrenia. The patients in this study found benefit lasting one month after treatment. [96]

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Psychosocial Management

The child with schizophrenia requires multimodal care. This should include social skills training, a supportive environment, and a structured individualized special education program. A history of involvement with early education programs has been associated with greater response not only to social interventions but also to antipsychotics. [97]

Supportive psychotherapy is used to encourage reality testing and to help the child monitor for warning symptoms of impending relapse.

Cognitive behavioral therapy has been used successfully in adults with schizophrenia and may help improve coping with schizophrenia and monitoring of beliefs and attributions.

Cognitive remediation therapy in addition to treatment-as-usual in patients with early-onset schizophrenia was found to significantly improve verbal memory, executive function, daily living and adaptive functioning, and improvements in family burden. The findings of this study suggest there is still room for cognitive improvements even after being optimized on psychopharmacotherapy. [98]

Psychoeducational group interventions over 9 months focused on problem-solving strategies in the form of parallel parent and child groups led to significantly greater improvement in PANSS general scores and fewer emergency department visits compared to the non-structured interventions. No differences were found in hospitalization rates between the two groups. [99]

If a patient has known or suspected substance abuse, the patient should be referred to a substance abuse treatment program.

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Diet

Typical and atypical antipsychotic medications may stimulate the appetite. Low-calorie snacks and limitation of total intake at meals may help prevent excess weight gain. Weight and body mass index (BMI) should be monitored in all patients on atypical antipsychotics.

In a randomized, double-blind, placebo-controlled trial to study the preventive effect of omega-3 polyunsaturated fatty acids (PUFAs) in adolescents and young adults with subthreshold psychosis, Amminger et al a difference of 22.6% between the treatment group and the placebo group in the cumulative risk of progression to full-threshold psychosis. [100]

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Consultations

Due to the pervasive problems of the child with schizophrenia, a team approach is needed. Involve nursing, speech and language therapy, and occupational and physical therapy. A case manager may facilitate care.

A psychologist is an essential part of the evaluation and treatment team. Because of the expected cognitive impairments, the mental health clinician should obtain intelligence quotient (IQ) and achievement testing for adequate educational planning. Projective tests, such as the Rorschach or the Thematic Apperception Test, may be helpful in eliciting additional information. However, their reliability and validity are not superior to a competent interview.

A child neurologist and geneticist may be needed to help evaluate for possible organic etiologies.

Children taking chlorpromazine and thioridazine should be checked for retinopathy and lenticular changes by an ophthalmologist.

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Long-Term Monitoring

The frequency of regular outpatient visits is determined by the presence of continuing symptoms. Many children with schizophrenia have a residual phase with predominantly negative symptoms that can be socially disabling.

During residual phase or remission, monitor the child with schizophrenia for recurrence of positive symptoms (eg, hallucinations, delusions) that may signal a relapse or worsening of negative symptoms.

Monitor for any new symptoms or episodes of mania. Approximately 15–20% of children with an initial diagnosis of schizophrenia may be found later to have bipolar disorder, schizoaffective disorder, or one of the disorders listed in the differential diagnosis.

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Prevention

Treatment before the emergence of psychosis is under investigation.

In very preliminary work, first-degree relatives of patients with schizophrenia who had suggestive symptoms and neuropsychologic deficits received risperidone with a subsequent reduction in suggestive symptoms and improvement in attention and working memory. [101]

In a randomized controlled trial that compared risperidone and cognitive behavior therapy with intervention for symptoms in individuals at very high risk for schizophrenia, fewer people in the active treatment group progressed to a first episode of psychosis. [102]

This preliminary finding raises the possibility that children with prodromal symptoms of schizophrenia can be treated before the emergence of psychosis. Further study is required before such therapy can be recommended.

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