Early-Onset Schizophrenia (EOS)

Early-Onset Schizophrenia (EOS)

• This is a rare form of schizophrenia
• It begins in childhood/adolescence, before age 18
• Very early-onset schizophrenia starts before age 13
• Earlier diagnosis tends to mean worse prognosis

Symptoms and Impact

• Phenotypically, EOS follows the same path as adult schizophrenia
• It is often more severe and developmentally disruptive
• Early-onset symptomology tends to be more severe
• It causes neurodevelopmental deficits, keeping children out of school, sometimes needing hospitalization

Genetic and Prevalence Factors

• It has a greater family or genetic component
• The prevalence is 1 in 10,000 children
• Very early-onset schizophrenia is 1 in 40,000 children
• Higher prevalence in males, who tend to have more negative symptoms like anhedonia, lack of energy, and depression
• Gender differences tend to stabilize after adolescence

Early Warning Signs and Diagnosis

• The early warning signs can be similar to depression, easy to misdiagnose
• The more a patient is studied, the more apparent the psychosis becomes
• A strong family history of the disorder is crucial
• Inheritability can be up to 80% as opposed to the 50-60% for adults

Related Disorders

• First-degree relatives may have schizophrenia spectrum or mood disorders
• Relatives may have schizoaffective or bipolar disorder
• Patients may also resemble someone with autism

Developmental History and Prodromal Phase

• Social history is important
• Delayed motor development can be seen, like delays in crawling and walking
• There are delays in responsiveness and the ability to read emotions
• There may be artistic traits and social isolation

Pregnancy factors

• Complications during pregnancy may increase the risk
• Hypoxia
• Maternal infections
• Prematurity
• Low birth weight
• Environmental stressors like trauma, neglect, adverse experiences, and high-express emotions (HEE) at home

Symptom Presentation

• This correlates to adult presentations
• Hallucinations are often auditory

Hallucinations

• Command auditory hallucinations are more worrisome
• These might compel patients to do something they normally would not
• A key is to discern what the auditory hallucinations are saying
• Young children may not decipher between internal thoughts and voices and may not be full-on hallucinations
• Negative comments and conversational hallucinations can occur
• Hallucinations can be negative, positive, or offer positive affirmations

Command Hallucinations

• They range from hurting someone else to self-harm
• Delusions are often present and can be bizarre and referential

Additional Symptoms

• Disorganized speech could be incoherent or involve derailment
• Negative symptoms include affective flattening, abolition, and alogia
• Cognitive impairment in attention, working memory, and executive functioning
• Developmental signs: social awkwardness, isolation, difficulty with abstract thinking
• Lack of age-appropriate peer relationships, and attraction to adults or parents can occur

DSM Diagnosis Criteria

• Requires two or more symptoms for over one month
• Continuous signs for about half a year
• Symptoms can vary but must be present for the last six months
• There must be functional impairment

Symptom Criteria

• One symptom must be delusions, hallucinations, or disorganized speech
• Other symptoms encompass negative symptoms or grossly disorganized/catatonic behavior
• A diagnosis can be made even without negative symptoms if only positive symptoms are present

Further Testing

• A full psychiatric and developmental history, talking to family/caregivers, and a family psychiatric history can be helpful
• Brain MRI to rule out anything structural
• Neuropsychological testing is important
• Autism testing (using ADOS) to rule out autism

Co-morbidity of Autism

• Autism may have an earlier onset
• It could include a language/communication issue in infancy
• Autistic children won't respond to you and won't read a lot of emotions
• There aren't hallucinations
• Autism can overlap, but there wouldn't be psychotic features

Differential Diagnosis

• Bipolar with psychosis
• Prominent mood symptoms such as depression
• Episodic psychosis could be related to trauma or PTSD for example

Substance-Induced Psychosis

• A toxicology screen would usually be preformed
• This is a time-limited condition
• This reverses upon the body metabolizing a drug

Grief Psychosis

• Grief, psychotic disorder: psychotic symptoms will last less than a month and then return to baseline
• This is related to a lot of emotional distress

Prognosis Indicators

• The earlier the onset, the worse it is
• Prominent negative symptoms are a negative indicator
• More depression, lack of speech, or lack of motivation indicate the possibility of a worse prognosis
• Strong family connection and a family history of schizophrenia is an indicator
• Poor premorbid functioning is a sign indicator
• A longer prodromal time and cognitive/developmental impairments all can indicate worse prognosis

Treatment Factors

• Lack of insight and poor treatment adherence will reduce the effectiveness of all treatment
• Acute onset and prominent positive symptoms correlate to a better outcome
• The later the diagnosis, the better the outcome
• A supportive family structure is also benificial
• Derailment due to negative influences in the house and a family’s lack of belief in treatment could derail treatment
• A good response to anti-psychotics can be a good prognostic sign
• Preserving cognitive function can also be a good sign
• Cognitive function shows an ability to develop better coping mechanisms

Treatment of Psychosis

• Psychosis must be treated first when it comes to therapy and group activities
• Patients won't engage in therapy if they can't sit still enough
• Atypicals can be used as a first-generation treatment

Medication Considerations

• First-generation medications should not be overly recommended due to the potential for tardive dyskinesia
• Atypicals include Risperidone, Abilify, Olanzapine, and Metiapine
• Monitoring for metabolic stuff (weight gain, prolactin elevations, etc.)
• Metformin and Topamax are to curb appetite
• Olanzapine for treatment-resistant cases

S-Waivers for SUD

• Barriers to treatment may be lowered to deal with substance abuse treatments
• DEA renewals will likely include the S-waiver
• Clozarel is having registration requirements removed
• Low doses and slow increase is the way to go with medicines
• Psychosocial components can be in place for years

Therapy types

• CBT is widely practiced
• Individual therapy for reality testing can be used
• Social skills training is important
• Family therapy to help regulate stress, emotion, and HEE's
• Supportive counseling and education helps with course and prognosis
• Schizophrenia is a lifelong disorder
• Meds to manage the disease are needed and breaking bad news about that is key

Education

• Educational support includes IEPs, which stand for individualized education plans
• IEPs are more specific and significant than 504 plans, and are transferred with the patient

Medications

• It must be remembered children and adolescents are in continuous brain development

Dosing

• Neurodevelopmental, biological, and mental age should be considered
• Medications can impact the brains reaction
• Legalities and the risk of medications
• Effects on brains when they are young need to be considered

Metabolism

• The synapses are still forming in children
  • It could change how they metabolize
• It could change the way they deal with medications in the future
• Children may metabolize faster than adults due to liver enzyme activity, so medications may need to be taken more frequently due to half-life

Body Composition

• Body composition changes in young ages
• Be aware changes have an impact
• Younger kids tend to be chunkier
• It will be easier to move up the dosage one the patient is closer to adulthood

Height and Weigh

• Dosing changes based on height and weight
• Children can be more sensitive to height or weight
• They are more worried about weight gain and sedation

Cardiac Histories

• One needs to look into Cardiac Histories
• Also eating disorders must be a factor considered

Anxiety and Stimulants

• If someone has anxiety, avoid stimulants
• Stimulants increase dopamine and norepinephrine
• Monitor height, weight, heart rate, and blood pressure

Non-Stimulants

• Tamoxetine (Stratera), biopsy, Intuniv, and Clonidine can be used
• Norepinephrine inhibitors are the usual medication recommendation
• Daily medication
• Work on dopamine and norepinephrine levels
• Tamoxetine has a black box warning like an antidepressant
• SNRI's can have overlapping medication affects
• Guaposine and Clonidine are outputs to adrenergic agonists
• They can help with hyperactivity
• They can help with impulsivity

Behavioral Modifications

• Extra time to act before getting in trouble with a decision

Low vitals

• Avoid guanidine or clonidine
• They are used for ADHD and Sedative medication

Other Medications

• SSRI's or EU's are medication to consider for:
  • Anxiety disorders
  • Depression
  • OCD

FDA approval

• Testing has to be ethical for pregnant woman
• Experiment or treatment
• Fluoxetine FDA approved for medication of depression (in kids)
• Other options for children under 25 for suicidal thoughts
• Antipsychotics used for irritability
• For autism
• Mood stabilizers and aggression with disruptive disorders

Other Drugs

• Side effects are metabolic symptoms
• Weight gain or sedation should be watched out for
• Mood stabilizers are drugs such as lithium and vaproic acid
• Other options than ones the FDA approved
• lithium is FDA approved
• Lithium has harsh side effects
• Vapric acid are tremors
• Weight gain are common issues with cognitive dueling
• There are different medications needed based on different tolerances

Anti-Anxieties

• Anti-Anxieties can help if used safely
• Benzos are not widely used for the people because of the risk involved
• Addiction
• Cognitive development
• Synapses are still forming so don't impact with bad medication
• Medication is only for short time due to affecting teens
• Used with the okay
• ADHD can be seen again and is the reviewed first line
• Non students would be shutera and guapaxine and clonodine

Other disorders

• ASD the anti-psychotics are approved
• Risperdoll
• Irritability

Obsessive Activities

• People on the spectrum are OCD like behaviors
• They have compulsive activities
• Can see in the DDI population
• High perspective for breeding likes
• High dose of ssris
• Repetitive behaviors cause the thoughts

Repetitive behaviors

• Perservate one something for long time to remember or repeat activities
• SSRI's will be prescribed long term
• Not always the best result but makes bareable
• Benzos kids will freak out and help with anxiety going to school from panic of not going

Anxiety people

• Tend to be safe once over there issues tend to be good once they get past over the initial step
• Use to get them into school building then they can freeze the issue with stuff.
• Everything boils down to knowing each medication on every level from its uses or effects with the people and body with each disorder that can present.
• The main thing there looking for is repetitive behaviors in the thoughts