Schizophrenia in Children

Schizophrenia is a major psychiatric illness that — while it is more common in adults — also affects children and adolescents. The disease is called “early-onset” schizophrenia when it occurs before the age of 18.

Schizophrenia can cause:

• visual hallucinations of people and objects that are not actually there
• auditory hallucinations of voices, music or other sounds that are not real
• delusions of threats that have no basis in reality
• severe difficulty making friends and maintaining relationships
• impaired speech and other communication skills
• inappropriate and damaging behavior

Though we are still learning the specifics of how schizophrenia affects the brain, it is believed that the disease may be linked to:

• a below-normal amount of gray matter — cell material that transmits sensory and movement messages throughout the central nervous system–in the brain's temporal lobe (the part of the brain's cerebral cortex that is responsible for hearing) and frontal lobe (the front portion of the brain's cerebral hemisphere, responsible for processing emotions, retaining memories, making decisions and measuring social responses)
• related loss of gray matter in the parietal lobe (part of the brain that processes information from the senses, makes mathematical calculations and controls how we handle objects)

In summary, schizophrenia:

• has no known, exact cause
• often appears to be inherited, passing down from generation to generation
• affects boys slightly more often than girls when it develops in childhood
• affects men and women equally when it develops in adolescence and adulthood
• has no known cure, but can be managed well when caught early and treated with effective therapy, medications and support

Causes

What causes schizophrenia?

There is no known, exact cause for schizophrenia, but the disease is believed to be linked to the following factors:

Genetics

While there is no single known cause for schizophrenia, experts believe that the disease has a strong genetic component — specifically, an inherited chemical imbalance in the brain.

A combination of genes passed down by both parents can lead to schizophrenia: If a parent has the disorder, a child has an estimated 10 to 15 percent chance of developing it; if a sibling is schizophrenic, a child has an estimated 7 to 8 percent chance of developing the disease. The risk significantly increases if more than one family member has the disease.

Environmental stresses during pregnancy

Though data is not conclusive, some experts believe a child’s schizophrenia may be linked to certain environmental factors that affect the mother during pregnancy, such as:

• drug or alcohol use
• exposure to particular hormonal or chemical agents
• exposure to certain viruses or infections
• extreme stress
• poor nutritional health

Signs and symptoms

What are the early warning signs of schizophrenia?

The behavioral changes caused by schizophrenia can be difficult to identify in the earliest stages of the disease. Symptoms may emerge slowly, develop over time or occur suddenly, as though “out of the blue.”

The following list of possible warning signs for schizophrenia is not definitive. Many of these symptoms may be caused by a condition other than schizophrenia; some will occur in children who do not have any disorder. However, it’s important to take note of any of these behaviors in your child as soon as they arise — especially if you have a family history of schizophrenia — and, if the behaviors persist, to contact a mental health professional as soon as possible.

Possible early warning signs in infants

• abnormal listlessness or extensive periods of inactivity
• overly relaxed or “floppy” arms or legs
• unnaturally still, flat posture when lying down
• unusual sensitivity to bright lights or rapid movements

Possible early warning signs in toddlers

• chronic high fevers
• fixation on repeating behaviors, even play, according to a specific regimen
• persistent state of distraction, anxiety or distress
• pronounced and sustained fear of certain events, situations or objects (note: while nearly all children experience specific fears as a normal developmental stage, children with early-onset schizophrenia tend to experience an extreme degree of fear that does not subside)
• weak and slumping posture

Possible early warning signs in school-aged children

• auditory hallucinations (the perception of sounds that others do not hear); most often, these hallucinations manifest as loud noises, whispers or collective murmuring

• claims that someone or something is “in my head” or “telling me to do things”

• extreme sensitivity to sounds and lights

• frequent self-talk (note: while many children will go through phases of having an “imaginary friend” or occasionally talking to themselves, children with possible early-onset schizophrenia spend the majority of their time conversing and laughing with themselves while shutting out real people and surroundings)

• tendency to be very “closed off” from others

• visual hallucinations (seeing things that are not actually there); common examples include streaks or swirls of light or flashing patches of darkness

Possible early warning signs in adolescents and teens

• a persistently vacant facial expression (known as “blank affect”)

• awkward, contorted or unusual movements of the face, limbs or body

• complaints and suspicions of threats, plots or conspiracies (for example, “someone has been sent to spy on me”)

• dwelling excessively on perceived slights, failures or past disappointments

• extreme irritability or angry outbursts that are unprovoked or disproportionate to the situation

• extreme or unwarranted resentment and accusations against others (“I know my parents have been stealing from me”)

• inability to follow a single train of thought

• inability to read nonverbal “cues” (failing to understand and respond appropriately to other people’s tone of voice, facial expressions or body language)

• inappropriate behavior and responses to social situations (for example, laughing out loud during a sad moment)

• incoherent speech

• irrational thinking, including:

  • assignment of “special meaning” to events and objects with no personal significance (for example, watching a famous person on television and believing they are conveying a secret message with their words or gestures)

  • assumption of extravagant religious, political or other authority (“I am God”)

  • belief that another person or entity is controlling one's body, thoughts or movements

  • belief that an evil force, spirit or entity has “possessed” the body or mind

• lapses in personal hygiene practices

• long periods of staring without blinking or difficulty focusing on objects

• rapidly fluctuating moods

• seeing or hearing things that others do not

• sudden, painful sensitivity to light and noise

• sudden, significant changes in sleep patterns — either inability to fall or stay asleep (insomnia), or excessive sleepiness and listlessness (called catatonia)

• talking aloud to oneself, often repeating or rehearsing conversations with others (real or imaginary)

• tendency to rapidly shift topics during a single conversation

• use of “nonsense” or made-up words

• withdrawal from friendships and activities

It is important to note that, in the case of all of the above warning signs, a child or adolescent with schizophrenia is not aware that these behaviors pose a problem. A schizophrenic child does not have a sense of becoming ill or that something is wrong. The gravity of the situation is only apparent to outside observers.

What symptoms do people with schizophrenia develop as the disease progresses?

As the disease progresses, people with schizophrenia display symptoms that are grouped into four categories: positive symptoms, negative symptoms, disorganized speech and disorganized or catatonic behavior.

Positive symptoms

Positive symptoms of schizophrenia involve the onset and acquisition of certain feelings, traits, and behaviors. These can include:

• beliefs that someone, or something, poses a threat or is causing some type of harm (for example, a sense of being followed by a person or group)

• confused thinking (for example, confusing what is happening on television with what is occurring in reality)

• hallucinations (seeing, hearing or feeling things that are not real; for example, hearing voices giving commands or seeing people, animals or objects that are not really there)

• delusions (ideas, situations or threats that seem real but are not actually based in reality; for example, believing a surveillance device has been installed in the body, home or car). Children with schizophrenia tend to experience hallucinations, but not delusions, until they reach early adulthood.

• problems distinguishing dreams from reality

• regressive behavior (for example, an older child suddenly acting like a much younger child and clinging to parents)

• severe anxiety

• severe changes in behavior (for example, becoming noticeably withdrawn)

• suddenly struggling with schoolwork; inability to comprehend material that was previously familiar

• vivid, detailed and bizarre thoughts and ideas

Negative symptoms

Negative symptoms of schizophrenia involve the lack or loss of certain capabilities and traits, such as:

• failure to demonstrate appropriate emotional responses (for example, laughing during a somber event or an upsetting conversation)

• inability to sustain existing friendships and relationships

• lack of emotional expression when speaking or interacting with others (having what is known as a “blank affect” on the face or failing to make eye contact)

• severe difficulty making friends

Disorganized speech

Schizophrenia often causes spoken and written communication that is garbled, nonsensical or otherwise impossible for others to follow. Examples of this disorganized speech may include:

• using words and sentences that do not fit together
• inventing words or terms that make no sense to others
• inability to stay “on track” in a conversation

Disorganized or catatonic behavior

Schizophrenia may lead to impaired behaviors that have a drastic impact on daily functions and activities. These disorganized or catatonic behaviors include:

• engaging in inappropriate activities or speech (for example, making obscene gestures or comments in public)

• extreme moodiness and irritability

• failure to dress in accordance with the weather (for example, wearing layers of heavy clothing on a sweltering summer day)

• failure to practice personal hygiene (for example, not bathing or brushing teeth)

• suddenly becoming confused or agitated, followed by sitting and staring in place as though “frozen” (this is called a catatonic state)

Your child may be diagnosed with schizophrenia if these symptoms are present for a period of at least one month.

FAQ

Q: Is schizophrenia common in adults? In children?
A: According to the Society for Neuroscience, about one in 100 adults has schizophrenia. The disease is considerably rarer in children; roughly one in 40,000 people under the age of 18 are diagnosed with the disease.

Q: What are the major similarities and differences between schizophrenia in adults and childhood-onset schizophrenia?
A: As is the case for adults with schizophrenia, children who are schizophrenic are also likely to:

• display limited or impaired emotional responses
• fail to practice adequate personal hygiene or other aspects of self-care (such as dressing weather-appropriately)
• have great difficulty in day-to-day functioning
• “live in their heads,” closing themselves off from other people and their surroundings
• suffer from hallucinations (both visual and auditory) or delusions (impressions or perceptions of situations that are not real)
• struggle to make and maintain friendships

Unlike adults with schizophrenia, children with the disease tend to:

• experience a gradual appearance and progression of symptoms, as opposed to a sudden and severe onset
• display difficulty meeting age-appropriate developmental milestones in motor skills, memory and reasoning and speech and language before developing symptoms of schizophrenia

Q: Can I prevent my child from developing schizophrenia?
A: While there is no way to prevent schizophrenia, a close look at your family history and careful observation of your child’s behavior can help predict the likelihood of him developing the disease. The earlier you seek treatment, the better chance you have to improve your child’s quality of life.

If you suspect your child is displaying symptoms of schizophrenia, the most important step you can take is scheduling an immediate professional evaluation. Request an appointment at Children's today.

Q: Do people with schizophrenia really have multiple personalities?
A: Although this is a common misconception about schizophrenia, it’s not true. What many people refer to as “multiple personality disorder” is altogether different and is now known as dissociative identity disorder.

A schizophrenic person does not experience memory “blackouts” and alternate identities. Instead, an individual with schizophrenia experiences a separation from reality that is characterized by:

• visual and auditory hallucinations
• false and irrational ideas and perceptions
• impaired or incoherent thinking and speech
• problems initiating and maintaining relationships
• difficulty processing social cues and non-verbal communication
• inability to recognize and adhere to appropriate social behaviors or personal hygiene practices
• oversensitivity to external stimulation, such as sounds and lights
• withdrawal from the outside world 

Q: Is it possible my child has bipolar disorder, not schizophrenia?
A: There are certain similarities between early-onset schizophrenia and pediatric bipolar disorder, particularly in the shared tendency to erupt in sudden and often unpredictable emotional outbursts.

The differentiating factor is what triggers these episodes: A child with bipolar disorder will become angry or inconsolable in response to a specific event or action). A child with early schizophrenia, by contrast, will have outbursts seemingly “out of nowhere,” with no obvious cause. In these cases, schizophrenic children are usually reacting to an overwhelming onslaught of sensation, such as sudden, unbearable sensitivity to noise in a room. They may also be frustrated by a sudden inability to communicate, think clearly or even stand or walk properly.

Q: What is the “black label warning” I keep hearing about when it comes to certain psychiatric medications?
A: Since 2004, the U.S. Food and Drug Administration has placed a black warning label on antidepressant medications. The warning label states, in part:

“Antidepressants increased the risk of suicidal thinking and behavior (suicidality) in short-term studies in children and adolescents with Major Depressive Disorder (MDD) and other psychiatric disorders. Anyone considering the use of [Drug Name] or any other antidepressant in a child or adolescent must balance this risk with the clinical need. Patients who are started on therapy should be observed closely for clinical worsening, suicidality, or unusual changes in behavior.”

Your clinician will carefully go over the specifics of any medication prescribed for your child’s schizophrenia, as well as any potential side effects you should watch for. Our team has years of experience in managing the use of psychiatric medications in children of all ages and with a wide variety of conditions. We will closely monitor your child for any sign of a negative response to the medication, and are always here to answer your questions and address any concerns you may have.

Q: What is the long-term outlook for my child?
A: If schizophrenia is detected and treated early, and if medications and therapies are successful, the disease has an excellent treatment rate. Lifelong monitoring by a qualified health professional is a must for anyone diagnosed with schizophrenia.

While there is no cure, children and adolescents with the disease can achieve normal — and even extraordinary — milestones at school, at work and in their personal lives. With proper treatment, many children with schizophrenia are able to go to college, hold jobs and have families as adults.

The following factors are critical in successfully treating schizophrenia:

• building a foundation of family and school awareness and support
• remaining under a clinician’s care for therapeutic treatment and regular monitoring
• seeking professional treatment as soon as symptoms emerge
• taking prescribed medications exactly as directed and for as long as directed (often long-term or throughout the lifetime)

Your treating clinician can give you specific information about your child’s condition, symptoms, and recommended treatment plan.

How do we diagnose schizophrenia?

A mental health clinician (typically a child and adolescent psychiatrist) will make the diagnosis following a comprehensive evaluation with you and your child. During the assessment, we’ll ask you to describe your child’s symptoms and provide an overview of your child’s family history, medical history, school life, and social interactions.

Typically, a child is diagnosed with schizophrenia if he or she:

• displays positive or negative symptoms for a period of at least one month
• is experiencing a worsening decrease in the ability to function on a day-to-day basis

If my child is diagnosed with schizophrenia, what happens next?

Your clinician will explain the particulars of schizophrenia, including its possible causes and effects and long-term repercussions. Specifically, you will be given a thorough overview of your child's individual symptoms and prognosis.

The next step is developing a mutually agreed-upon treatment plan — incorporating psychotherapy, medication, and school and community support — that works for you, your child, and your family.

You and your child (if old enough) will always have the opportunity to ask questions. Throughout the duration of treatment, you will be encouraged to bring up any and all concerns, worries, and fears so that the clinical team can provide the information and support you need.

How do we treat schizophrenia?

Schizophrenia is a major psychiatric illness that calls for careful, often complex, and lifelong treatment. A combination of therapies is usually necessary to effectively manage the disease.

Since there is no known cure for schizophrenia, treatment is aimed at reducing the severity of the disorder's impact on early life and helping the child manage symptoms. Treatment is most successful when symptoms are addressed early on.

As one of the largest pediatric psychiatric services in New England, Boston Children's has an experienced team of expert psychiatrists, psychologists, and social workers ready to help you, your child, and your family cope. Your clinician will prescribe treatment methods that may include medication, psychotherapy, specialized educational or activity programs, and support groups.

Medication

The use of medications (also called psychopharmacology) is essential in treating schizophrenia. The most commonly prescribed schizophrenia drugs are neuroleptics, or antipsychotic medications. These drugs act against the symptoms of schizophrenia, but cannot cure the disease itself.

Neuroleptics:

• are primarily used to treat the pervasive, intrusive, and disturbing thoughts caused by schizophrenia
• are designed to minimize the severity of hallucinations and delusions
• must be taken exactly as prescribed
• may require adjustments of dosage or type over time to maintain their effectiveness

Traditionally prescribed neuroleptics include:

• Stelazine (Trifluoperazine)
• Flupenthixol (Fluanxol)
• Loxapine (Loxapac, Loxitane)
• Perphenazine (Etrafon, Trilafon)
• Chlorpromazine (Thorazine)
• Haldol (Haloperidol)
• Prolixin (Fluphenazine Decanoate, Modecate, Permitil)

Newer and less commonly prescribed medications that have proven effective in treating symptoms of schizophrenia include:

• Aripiprazole (Abilify)
• Clozaril (clozapine)
• Geodon (ziprasidone)
• Risperdal (resperidone)
• Seroquel (Quetiapine)
• Zyprexa (olanzapine)

We have a specialized Psychopharmacology Program whose team members work with other Department of Psychiatry and Behavioral Sciences clinicians — and with parents and family members — to determine the best medications for each child, incorporate the medication regimen into the child's overall treatment plan, and monitor the effectiveness of the drugs over the long term.

Learn more about psychiatric medications for children and adolescents.

Psychotherapy

Psychotherapy — also known as “talk therapy” — is the cornerstone of psychiatric treatment at Boston Children's.

Through sessions with a psychiatrist or psychologist, your child can better:

• understand the symptoms of schizophrenia and how to manage them
• vocalize feelings of anxiety, fear, sadness, and anger associated with having a chronic psychiatric condition
• develop coping skills for the challenges of daily life
• deal with the stigma of mental illness
• explain schizophrenia to questioning family members and friends
• learn new ways to maintain healthy relationships with parents, siblings, teachers, and peers
• recognize the importance of adhering to a treatment plan, as well as setting goals and looking forward to the benefits of proper treatment

Treatment for schizophrenia will often include not only individual therapy for your child, but also family therapy for you and other loved ones, so that you have the information, support system, and other tools you need to become an active participant in your child's care.

Specialized educational and/or structured activity programs

Children and adolescents with schizophrenia may reap significant benefits from specialized programs offered at schools, in medical centers, or in the community. Examples of these programs might include:

• customized, smaller classroom settings, with educators who have specialized training in teaching children and adolescents with psychiatric disorders
• social skills training to:
  • develop healthy personal interaction techniques (such as maintaining good eye contact and determining fitting topics of conversation)
  • create a checklist for good hygiene
  • learn how to manage everyday tasks like balancing a checkbook or preparing a meal
• vocational training to help young adults find jobs and volunteer opportunities
• speech and language therapy to improve verbal and written communication

Your clinician can refer you to the educational and activity programs in your area that are best suited to address your child's needs.

Support groups

Schizophrenia support groups for children and families can be tremendously helpful. These groups meet at medical centers, schools, or community centers, and some even meet online or by phone. These resources can provide:

• a “safe place” to share personal experiences and simply “vent” when necessary
• a way to share tips and coping strategies with others facing the same challenges
• a network for identifying and recommending local resources

Your treatment team can recommend patient, parent, sibling, and family support groups that focus on living with schizophrenia.

Coping and support

The journey you, your child, and your family will undertake in treating schizophrenia can be emotionally, physically, and mentally exhausting.

In addition to the information provided here, Children's offers the following resources for support and guidance:

• The Advocating Success for Kids (ASK) Program provides multidisciplinary evaluation, referral and advocacy services for children under age 14 who are experiencing behavioral, emotional, learning or developmental problems, either at home or at school. ASK works with children who receive their primary care either at Boston's Bowdoin Street Community Health Center, Boston Children's at Martha Eliot, or Joseph M. Smith Community Health Center, or at Children's Primary Care Center. For more information about ASK, please call 617-355-4690.

• The Hale Family Center for Families is dedicated to helping families locate the information and resources they need to better understand their child's particular condition and take part in their care. All patients, families, and health professionals are welcome to use the center's services at no extra cost. The center is open Monday through Friday from 8 a.m. to 7 p.m., and on Saturdays from 9 a.m. to 1 p.m. Please call 617-355-6279 for more information.

• The Department of Spiritual Care (chaplaincy) is a source of spiritual support for parents and family members. Our program includes nearly a dozen clergy members — representing Episcopal, Jewish, Lutheran, Muslim, Roman Catholic, Unitarian, and United Church of Christ traditions — who will listen to you, pray with you, and help you observe your own faith practices during your child's treatment.

• The Experience Journal was designed by psychiatrist-in-chief David DeMaso, MD, and members of his team. This online collection features thoughts, reflections, and advice from kids and caregivers dealing not only with physical illnesses like asthma and diabetes, but also with such mental health conditions as ADHD and depression.

Visit our patient resources page for all the information you need about:

• getting to Boston Children's
• finding accommodations
• navigating the hospital experience

Helpful links

Please note that neither Boston Children's Hospital nor the Department of Psychiatry and Behavioral Sciences unreservedly endorses all of the information found at the sites listed below. These links are provided as a resource.

Helpful links for parents

• 20/20 Presents: Stories of children with schizophrenia
• About Early-Onset Schizophrenia (National Alliance on Mental Illness)
• National Alliance for Research on Schizophrenia and Depression
• Schizophrenia-Parents' Support Group at Yahoo Groups

Helpful links for teens

• CopeCareDeal
• Neuroscience for Kids – Schizophrenia
• TeenMoods Community
• ULifeline

Helpful links for younger children

• The Storm in My Brain (Adobe Acrobat is required to view and download)

Children’s Hospital Boston is at the forefront of basic science and clinical research, and our psychiatric research program is one of the most accomplished and innovative in the nation. We are constantly making discoveries that may lead to new ways of preventing, diagnosing and treating schizophrenia and other mental disorders. 

Some of Children’s recent research breakthroughs with exciting possibilities for the treatment of schizophrenia include:

Exploring the role of brain white matter in schizophrenia

A team led by Gabriel Corfas, PhD, researcher in Children's Department of Neurology and Department of Otolaryngology and Communication Enhancement, has uncovered the best evidence to date to suggest that defects in the brain’s white matter—tissues responsible for channeling communications throughout the nervous system—are a major contributor to schizophrenia. This raises the possibility of diagnosing the disease earlier and perhaps developing preventive treatments.

Understanding the brain's “master switch”

Children’s neuroscientists have identified the first known "master switch" in brain cells. This switch, called Npas4, orchestrates the formation and maintenance of inhibitory synapses, which are essential for proper brain function. Npas4 regulates more than 200 genes that act in various ways to calm “overexcited” cells, restoring the balance that is believed to go awry in schizophrenia and other neurologic disorders, such as autism and epilepsy.