Approach Considerations

Laboratory studies are performed as part of an assessment for the differential diagnosis of schizophrenia. Toxicology screens may be needed if substance abuse is suggested. Liver function studies, copper, and ceruloplasmin are part of the workup for Wilson disease. Obtain porphobilinogen levels for porphyria. Human immunodeficiency virus (HIV) titers, Venereal Disease Research Laboratory (VDRL) testing, or heavy metal screening may also be needed.

If the child has intellectual disability or dysmorphic features, include a karyotype in the genetic assessment. One example is the 22q11 deletion syndrome, or velocardiofacial syndrome.^[84]Other preliminary reports suggest 5q involvement.

Other general medical conditions may contribute to psychotic symptoms. According to Giannitelli et al., the following things should cause clinicians to have an increased level of suspicion for general medical conditions:

“Several clinical and historical features appear to warrant an increased index of suspicion of organic factors: (1) Atypical aspects of the clinical history and course, including: (a) acute and/or very early onset; (b) onset apparently triggered by surgery, viral infection, or medications; (c) cognitive or developmental regression. (2) Atypical symptomatic features: (a) confusion; (b) catatonia (Consoli et al., 2012)^[85]; (c) rare and serious neurological adverse reactions to treatment. (3) Presence of co-occurring physical symptoms, for example: (a) suspicion of seizures; (b) malar rash; (c) gastro-intestinal signs; (d) dysmorphic features.”

Those authors suggest of a wide array of imaging and laboratory studies to pursue, based on the clinical and historical presentation; readers are encouraged to refer to that article for further information.^[86]

MRI or CT scanning

Neuroimaging with magnetic resonance imaging (MRI) or computed tomography (CT) scanning (if MRI is not available) should be part of the evaluation of new-onset psychosis. MRI helps to exclude certain organic causes of psychosis. Demyelination is observed in the child with leukodystrophy. Atrophy is observed in some children with neuronal ceroid lipofuscinosis. Ventricular enlargement and gray matter loss are consistent with, but not diagnostic of, childhood-onset schizophrenia.

EEG

Perform electroencephalography (EEG) if episodic symptoms or signs are present in the evaluation of a child with psychosis. In children who receive clozapine, obtain an EEG because of the increased risk of seizures associated with clozapine.

ECG

Obtain an electrocardiogram (ECG) before starting a low-potency antipsychotic as well as before starting medication and as part of follow-up care of a child who receives pimozide. Having a baseline ECG is important for patients with childhood-onset schizophrenia as some medications used to treat psychosis have the potential of prolonging the QTc and having a baseline measurement could be of benefit.

Histology

Neuropathologic studies are available for persons with later-onset schizophrenia but not for children with schizophrenia. Postmortem studies have demonstrated reduced volume of the hippocampus. Gliosis has not been found, suggesting that no active inflammatory process occurs.

Psychologic Testing

Initially, a baseline diagnostic framework is formed by the recommended Mental Status Examination. Structured or semistructured interviews are beneficial for the initial assessment and monitoring symptoms during follow-up care.

Other standard instruments include the following:

Kiddie Schedule for Affective Disorders and Schizophrenia (K-SADS)^[73]
Brief psychiatric rating scale (BPRS)
Positive and Negative Syndrome Scale (PANSS)

Projective tests, such as the Rorschach, may be helpful in eliciting further symptoms. The Thematic Apperception Test may also be helpful in eliciting additional information. However, diagnosis is confirmed by comprehensive clinical assessment. Psychologic testing of cognitive function is essential for treatment planning. The Stroop test, the Wisconsin Card Sorting Test, and the Mazes test all were found to significantly separate a group of patients diagnosed with early-onset schizophrenia from a control group based on executive functioning skills; a study published in the Scandinavian Journal of Psychology suggested the Stroop test was able to discriminate the best of the three.^[87]

The National Institute of Mental Health developed a scale and scoring algorithm clinicians can use to predict accurate diagnoses of childhood-onset schizophrenia. Higher levels of both positive and negative symptoms together with lower levels of depression indicate higher probability that a child has childhood-onset schizophrenia rather than another diagnosis with psychosis.^[88]

Treatment & Management

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Media Gallery

Childhood schizophrenia. Early and late gray matter deficits in schizophrenia. Areas of gray matter loss, shown in red and yellow, spread from back-to-front (right to left) over 5 years in composite MRI scan data from 12 teens with childhood-onset schizophrenia, beginning at age 14 (left). Red and yellow denotes areas of greater loss. Source: Paul Thompson, MD, UCLA, Laboratory of Neuroimaging. NIMH media file.
Childhood schizophrenia. Rate of gray matter loss. Composite MRI scan data showing areas of gray matter loss over 5 years, comparing 12 normal teens (left) and 12 teens with childhood-onset schizophrenia. Red and yellow denotes areas of greater loss. Front of brain is at left. Source: Paul Thompson, MD, UCLA, Laboratory of Neuroimaging. NIMH media file.

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Author

Marshal E Ash, DO Resident Physician, Department of Psychiatry, Wright State University, Boonshoft School of Medicine

Marshal E Ash, DO is a member of the following medical societies: American Psychiatric Association, Christian Medical and Dental Associations, Ohio Psychiatric Physicians Association

Disclosure: Nothing to disclose.

Coauthor(s)

Suzie C Nelson, MD, DFAACAP, FAPA Assistant Professor, Associate Training Director of Child and Adolescent Psychiatry Fellowship Program, Department of Psychiatry, Wright State University, Boonshoft School of Medicine; Child and Adolescent Psychiatrist, Director of Child Psychiatry Operations, Wright-Patterson Medical Center

Suzie C Nelson, MD, DFAACAP, FAPA is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, Christian Medical and Dental Associations

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Chief Editor

Caroly Pataki, MD Health Sciences Clinical Professor of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, David Geffen School of Medicine

Caroly Pataki, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, New York Academy of Sciences, Physicians for Social Responsibility

Disclosure: Nothing to disclose.

Additional Contributors

David W Dunn, MD Arthur B Richter Professor of Child Psychiatry, Professor of Child Neurology and Psychiatry, Departments of Neurology and Psychiatry, Director, Division of Child and Adolescent Psychiatry, Co-Director, Riley Child and Adolescent Psychiatry Clinics, Training Director, Child and Adolescent Psychiatry and Triple Board Program, Indiana University School of Medicine

David W Dunn, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, American Academy of Neurology, American Association of Directors of Psychiatric Residency Training, American Epilepsy Society, American Psychiatric Association, Child Neurology Society, International Child Neurology Association, International League Against Epilepsy, Tuberous Sclerosis Alliance

Disclosure: Honorarium for grant review committee for Department of Defense.

Annemarie K Loth, MD Child and Adolescent Psychiatry, St Louis Behavioral Medicine Institute

Annemarie K Loth, MD is a member of the following medical societies: American Psychiatric Association, Indiana Psychiatric Society

Disclosure: Nothing to disclose.

Acknowledgements

Angelo P Giardino, MD, PhD Clinical Associate Professor, Department of Pediatrics, Baylor College of Medicine; Medical Director, Texas Children's Health Plan, Inc

Angelo P Giardino, MD, PhD is a member of the following medical societies: Academic Pediatric Association, American Academy of Pediatrics, American Professional Society on the Abuse of Children, Harris County Medical Society, Helfer Society, and International Society for Prevention of Child Abuse and Neglect

Disclosure: Bayer Honoraria Review panel membership; Pfizer Grant/research funds Independent contractor; MedImmune Honoraria Review panel membership

Raj K Kalapatapu, MD Fellow, Addiction Psychiatry, Columbia University College of Physicians and Surgeons

Raj K Kalapatapu, MD is a member of the following medical societies: American Academy of Addiction Psychiatry, American Academy of Child and Adolescent Psychiatry, American Association for Geriatric Psychiatry, American Medical Association, and American Psychiatric Association

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.