Childhood onset schizophrenia—before the age of 12—is extremely uncommon. (The youngest patient I ever saw with diagnosed schizophrenia was a five-year-old girl named Deborah, who thought she had a baby caught in her throat.) The earlier the disorder shows itself, the more severe it will be. It is during adolescence, most commonly at about age 18, that schizophrenia is most often diagnosed. That’s when a child is most likely to have his first break from reality. The break is usually dramatic, and it can sometimes be quite sudden. I’ve spoken to parents who describe their child as perfectly normal one day and totally off the wall and out of control the next. (These are the parents who usually show up in the emergency room.) It’s more common, however, to see a gradual decline in a child’s behavior before the first big break, some early signs that trouble is on the way.
Children later diagnosed with schizophrenia fall into two broad categories. The first group is the childhood asocials; these are the withdrawn kids, the ones whose behavior has always been strange. “He never seemed quite right” and “She was always a little off are descriptions we commonly hear from the families of these children. There is a great deal of evidence to suggest that those families are correct in their not-very-scientific assessment. Some years ago an experiment was conducted with the home movies of the families of children who were eventually diagnosed with schizophrenia. In each case the families had more than one child, but only one of the kids had schizophrenia. With 100 percent accuracy the mental health professionals who viewed those old home movies could pick out the child with schizophrenia when he was only five or six years old. There was nothing specific about their findings. There was simply the sense that there was something “not quite normal” about the child in question, in the way he interacted with the other kids or with the camera. These youngsters are often aloof, not interested in socializing.
Not all children demonstrate those early signs of more serious disorders to come. The other basic group of people with schizophrenia is made up of kids who seem perfectly “normal” right up until the break. I myself had a childhood friend who belongs in this category. Mike had everything going for him; he was valedictorian of our class, all-city tennis champion, and Mr. Popularity. His life seemed absolutely perfect until the September he went off to an Ivy League college, at age 18. Three weeks later he had his first break with reality; he was convinced that his room was under surveillance and that he was being monitored 24 hours a day by Martians. He was eventually diagnosed with schizophrenia.
THE SYMPTOMS
Schizophrenia in children may be hard to recognize in its early stages. The child suffering from schizophrenia may have delusions, fixed beliefs that other people don’t have. He may have hallucinations, hearing things that others don’t hear and seeing things that others don’t see. He may have difficulty distinguishing dreams from reality. He’ll have vivid and bizarre thoughts and ideas. He’ll be moody, exhibit strange behavior, and withdraw from social interactions. Often he’ll think that people are out to “get” him. He’ll confuse television with real life, and he’ll have problems making and keeping friends. To meet the official definition of schizophrenia the symptoms must persist for a period of six months. (If the symptoms have not been present for six months, we make an initial diagnosis of schizophreniform disorder. The treatment for this disorder is the same as that followed for schizophrenia.)
The delusions associated with schizophrenia may take many forms. I’ve talked to a 15-year-old boy who thought that David Letterman was talking directly to him every night; another teenage boy who was so convinced that his parents were trying to poison him that he stopped eating; an 11-year-old girl who thought that her parents had been taken over by aliens; a 16-year-old girl who sat in the TV room of the hospital and watched her favorite soap opera, Another World, completely convinced that the show was being performed just for her; and a 17-year-old who thinks that it’s his face on the dollar bill. I treated an 18-year-old teenage boy who believed the government was beaming poisonous rays down on his head that were making him bald and deaf. One day during a session with him I scratched my head, and he shouted, “I knew it! You’re in on it!” It turns out that head-scratching was a sign that I was part of the government’s plot against him.
All of these unfortunate children and adolescents have one important characteristic in common: they are living in a world of their own creation, and they believe in it totally, regardless of the efforts of others to bring them back to reality. The voices they hear become as real to them, and as important to them, as anything in the real world. For example, nothing anyone could do or say would persuade Miranda that rats are not living in her stomach. We seriously considered giving her the X rays she asked for in the emergency room but decided against it. It would be pointless to show her an X ray of her stomach—without rats, of course. She would simply say that the rats had moved to her knee or that we had given her someone else’s X rays by mistake. Reasoning or arguing with kids suffering from these kinds of delusions—saying, for example, “Don’t you see? This just doesn’t make sense”—is fruitless at best.
Adolescents with schizophrenia at times exhibit bizarre and inappropriate behavior. One 16-year-old I talked to about his delusions (he thought that the FBI was following him) couldn’t stop smiling and giggling as we talked. He seemed to be having a wonderful time.
People with schizophrenia have an explanation for everything, no matter how strange. One little girl, just starting the second grade, came to us because she heard voices that wouldn’t stop. She used to walk around with her hands covering her ears, crying, “Make them stop! Make the voices stop! I can’t stand it anymore.” After a few weeks of Haldol the voices finally did stop, and she told us so. “Where did the voices go?” we asked her. “They went shopping,” she replied.
There are two kinds of symptoms associated with schizophrenia: positive and negative. The positive symptoms (called positive not because they’re good but because they involve excessive distortion of normal function) include the delusions and hallucinations, which are relatively easy to identify. A 16-year-old girl who thinks she’s a rock star whose video runs on MTV every night at midnight exhibits a positive symptom. The most common of the negative symptoms (negative because they involve loss of normal function) is withdrawal, demonstrated in kids who pull back from the world. These kids seem flat and distant; they don’t initiate or respond to conversations; they’re detached but not really depressed. Positive symptoms are easier to treat than negative symptoms. We can give medication to an adolescent and make his hallucinations and delusions go away. What we can’t do quite so easily, even with medication, is motivate kids who sit in their rooms all day and watch television while the world passes them by.
Some of the symptoms we see in examining schizophrenia may seriously endanger a child. One of the saddest cases I’ve come across was that of a seven-year-old boy who was admitted to our unit with severe burns on his abdomen. The little boy had been burning himself with his father’s cigarette lighter. When we asked him why he did it, he said, without blinking an eye, that the voices told him he had to.
THE DIAGNOSIS
It is not particularly difficult to identify a symptom of psychosis, but identifying the symptom is not enough. To make a proper diagnosis—to find out precisely what is wrong with a child or an adolescent—we have to know more about the company that symptom keeps. Symptoms of psychosis may have many causes, including drug abuse and extreme stress. A psychotic symptom is like a headache. It can be caused by an allergy or a simple infection. Or it can be the result of something considerably worse. Kids, especially teenagers, may be guarded or even deceptive about their symptoms, and this complicates the process of making a diagnosis even further.
In the early stages of this disorder, just after the first or perhaps the second episode, it can still be quite difficult to pinpoint the problem. As the disease progresses, the symptom picture usually becomes a lot clearer, and we can be more precise. Bipolar disor
der (Chapter 15), major depressive disorder (Chapter 14), pervasive developmental disorder (Chapter 19), and obsessive compulsive disorder (Chapter 8) are just some of the diseases that must be ruled out. Because of the serious and complicated nature of schizophrenia, it is crucial that a correct diagnosis be made, ideally by a child and adolescent psychiatrist with experience in dealing with severely ill youngsters.
In examining a child or an adolescent who shows symptoms associated with schizophrenia (especially delusions and hallucinations) we have to rule out some of the other disorders that have similar symptoms. Psychotic symptoms can be categorized as mood congruent or mood incongruent. Quite simply, the mood congruent symptoms make a little more sense than the mood incongruent ones, because they correspond to the mood of the patient. For instance, if the youngster has depression with psychotic symptoms, his delusions or hallucinations will have a tone that is consistent with being depressed. For example, he’ll think he has a terminal illness and is going to die. If he hears voices, they’ll say something along the lines of, “You’re no good. You’ve never been good. You never will be good. You must be punished.” If an adolescent is manic, his mood congruent symptoms will echo that mood, telling him that he’s a world-famous sports hero or a millionaire with superpowers. On the other hand, adolescents with schizophrenia will have symptoms that are mood incongruent; they have no relationship to their mood or to reality.
Someone with bipolar disorder will have flight of ideas in his speech; he moves quickly from idea to idea, but there will be a connection between those ideas, however tenuous. The ideas of someone with schizophrenia are completely disjointed, characterized by “looseness of associations.” The conversation of someone with schizophrenia in its most extreme form is incomprehensible; we call it “word salad.” Words just come spilling out, and no one can understand them. More often than not, the patient isn’t even aware that he’s not making sense.
People who have schizophrenia are usually frightened and confused. I’ve examined kids who heard voices and had imaginary companions but weren’t afraid of them or impaired by them. One boy I remember in particular, five years old, was able to exercise full control over his invisible friends. They did exactly what he told them to do. Another kid, this one age seven, had voices who helped him with his homework. He said to me: “Oh, I like this voice. He gives me the answers on my test.” It’s developmentally normal for kids to hear voices and have imaginary playmates. Neither of these children was diagnosed with schizophrenia.
Adolescents with schizophrenia do not have that control over the voices, and they don’t like them. They’re the kids who say, “The voice is telling me to do something I don’t want to do. If I don’t do it, it’s going to make me do something even worse.” They are deluded, but their fear is very real. Often they’re afraid to eat, to sleep, or to walk down the street. They have belief systems that are personal and often painful. They’re tortured by their symptoms. Children and adolescents with schizophrenia are often in great pain.
A diagnosis of schizophrenia is not easy for a physician to give or for a parent to hear, and no one is inclined to use the term lightly. A correct diagnosis is essential. One of the most significant criteria for a diagnosis of schizophrenia is “deterioration with no return to baseline,” which means that even with treatment, the patient’s condition is unlikely to get better over time. In fact, as time goes on and the number of episodes increases, a youngster’s level of function may become lower. In the case of childhood onset schizophrenia a child will probably fail to reach the expected developmental milestones. Adolescence is a critical period for the acquisition of vocational skills. New learning is difficult for young people with schizophrenia. An adolescent who used to be able to drive a car before the “break” will most likely be able to drive again; however, an adolescent who didn’t learn to drive before the illness will find the new task very difficult indeed.
One set of parents I know refused even to say the word schizophrenia. They insisted on calling what was wrong with their son “an anxiety disorder” or “a psychotic problem.” At 16 their son Rick had his first psychotic episode when he was away at summer camp. He thought that people were out to get him, that his food was being poisoned, that his camp counselor was interested in having sex with him. Rick became increasingly agitated at camp, and his parents were finally summoned to take him home. Rick’s diagnosis was schizophrenia, and he started taking Haldol right away. It took his parents nearly a year to use the correct word.
I can’t really blame those parents for their reluctance to acknowledge that their boy had schizophrenia. There’s no way around the fact that schizophrenia is an extremely distressing diagnosis. Still, for all the pain and disappointment the news may bring, the sooner the diagnosis is made, the sooner the treatment can begin.
THE BRAIN CHEMISTRY
There’s no doubt about it: schizophrenia is the result of a malfunction in the brain. However, what causes the brain to malfunction is still a largely unanswered question. According to the most recent studies, there are many underlying influences of schizophrenia, some of them genetic and some environmental.
We know quite a bit about the genetic influences associated with schizophrenia. For example, we know that the first-degree relatives—offspring and siblings—of people with schizophrenia have 10 times greater likelihood of developing the disorder themselves. We also know that the concordance rate of schizophrenia in identical twins is 50 percent, as opposed to 10 percent in fraternal twins. (Among identical twins reared apart from each other in separate families, the concordance rate is still extremely strong.) Other research shows that when a mother with schizophrenia adopted a child who was not genetically predisposed to the disorder, the child did not develop schizophrenia, no matter how crazy or disturbed the adoptive mother was.
Obviously, this disorder has a strong biological component, but just as obviously, schizophrenia is not always passed on from generation to generation. Plenty of cases are sporadic, and many theories have been advanced to explain them. Some say it’s caused by a virus. Others say it must be the result of a genetic mutation or a neurodevelopmental delay. Evidence for the genetic mutation theory is supported by the fact that adults with schizophrenia do not reproduce as often as the general population, yet the prevalence of the disorder remains constant.
We have benefited a good deal from knowing something about what the brain of an adult with schizophrenia looks like. Brain scans—both CAT scans and MRIs—of adult patients show that the brain of someone with schizophrenia looks different from that of a “normal” adult. There are several differences, but the most telling are the enlarged cerebral ventricles and the diminished activity of the prefrontal cortex in the brains of people who have schizophrenia and the fact that the overall brain volume of adults with schizophrenia is 8 percent smaller than that of normal adults. There are studies in progress now that will tell us more about the brains of children and adolescents with schizophrenia, but early findings suggest that the same kinds of brain discrepancies will be found.
These days the most widely held theory about what causes the psychotic symptoms of schizophrenia is too much dopamine in the brain. One of the facts supporting this case is that drugs that increase the brain’s level of dopamine, such as cocaine and amphetamines, may bring on psychosis; certainly they can mimic some of the psychotic symptoms. Another reason to take this theory seriously is the fact that all the medications that reduce the symptoms of schizophrenia have some effect on the dopamine system. As usual, nothing is simple about this area of research, however. The drugs that seem to work best—especially Risperdal—affect other neurotransmitters as well, especially serotonin.
THE TREATMENT
Treatment for schizophrenia should ideally include family support and education, social skills training and other behavioral therapy, vocational rehabilitation, and, eventually, supervised housing, all of which will make the adolescent with schizophrenia and his family more comfortable an
d better able to cope with this serious illness. But before any of these efforts can be put into motion, the first and most effective line of treatment is medication. The only treatment that has any marked effect on the symptoms associated with this disorder is medicine.
The drugs traditionally prescribed for the treatment of schizophrenia are the neuroleptics, which are divided into two categories: high-potency neuroleptics, such as Haldol and Prolixin; and low-potency neuroleptics, of which the most commonly prescribed are Thorazine and Mellaril. The medicines are equally effective in the treatment of the symptoms of schizophrenia, but they have different side effects. The low-potency neuroleptics may cause low blood pressure, dry mouth, blurred vision, lethargy, constipation, and weight gain. The side effects of the high-potency neuroleptics sometimes cause “pseudo-Parkinsonism,” restlessness, weight gain, and acute dystonic reactions (muscle spasms). Dystonic reactions may be frightening to patients and family members, but they are easily reversed with an injection of the antihistamine Benadryl.
The most disturbing side effect associated with long-term use of neuroleptics is tardive dyskinesia, in which various parts of the body—especially the tongue, the facial muscles, and the arms and legs—wriggle and writhe involuntarily. Tardive dyskinesia ranges from very mild to quite severe. The most serious concern about tardive dyskinesia is that it can be permanent. The other side effects associated with the neuroleptics will disappear quite quickly if the medication is stopped. Tardive dyskinesia doesn’t always go away even if the drug is discontinued. The more neuroleptic medication the adolescent takes over time, the greater is his risk of developing tardive dyskinesia. However, if the medication is stopped too soon—because of the patient’s noncompliance, for example—the likelihood of a return of the psychotic symptoms increases. This often means that the adolescent will need larger doses for each new episode, which in turn increases his chances of developing tardive dyskinesia.
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