Summary of Czech Recommendations for the Diagnosis and Treatment of Schizophrenia in Children and Adolescents 2022
In June 2022, the Psychiatric Society of the Czech Medical Association JEP updated its recommendations for the diagnosis and treatment of schizophrenia in children and adolescents. This is the first online version, which will allow for faster implementation of new findings important for clinical practice and decision-making by state institutions. We bring you a summary of the key points of these recommendations.
Clinical Picture and Differential Diagnosis
In children and adolescents, the acute phase of schizophrenia develops after a prodromal period lasting from days to years. Patients may exhibit positive symptoms (delusions, hallucinations), negative symptoms (autism, ambivalence), disorganized behavior (disorganized speech, cognitive dysfunction, bizarre motor phenomena, affective dullness, loss of communication). Positive symptoms are typical in the acute phase, while negative symptoms prevail after six months. 75% of patients have neurodevelopmental disorders in the motor, speech, and social areas. Complex delusions are absent. Elementary auditory hallucinations, inappropriate affect, and deterioration of previous psychosocial functions are common.
In differential diagnosis, it is necessary to rule out schizoaffective disorders, schizotypal disorder, induced delusional disorder, depressive and bipolar affective disorders, pervasive developmental disorders, post-traumatic stress disorder, and obsessive-compulsive disorder.
Treatment
Early-onset schizophrenia is recommended to be treated with monotherapy using atypical antipsychotics (AP), and in cases of catatonic symptoms, electroconvulsive therapy. In most cases, hospitalization in a child psychiatry ward is necessary, possibly even without the patient's consent. In the first line, aripiprazole (2–30 mg/day in 2–3 doses), lurasidone (starting dose 37.5 mg; beware of the risk of extrapyramidal syndrome!), quetiapine (evaluated at dosing 25–800 mg/day), or risperidone (lower dosing 1–3 mg; with higher dosing /4–6 mg/ there is a significant increase in side effects!) is administered.
If an effect is achieved after 4–6 weeks, medication is continued and psychotherapy (education and cognitive-behavioral therapy) is added. If the drug dose's effect is not achieved, paliperidone (aged 12–17 years, the safe and well-tolerated dose was 1.5–12 mg/24 hours) or olanzapine (dosing 9.6 ± 5.4 mg/day; weight gain is common) is used as a second-choice medication.
The effects of treatment are reviewed again after 4–6 weeks. If unsuccessful, olanzapine or haloperidol as a third-choice medication (lower efficacy and more side effects than atypical neuroleptics, average evaluated dose 0.02–0.12 mg/kg/day) is recommended, after another 4-6 weeks clozapine as a fourth-choice medication (risk of epileptic seizures, neutropenia) or a combination of clozapine + aripiprazole (if clozapine alone was unsuccessful and in pharmacoresistant patients, augmentation with aripiprazole 5–15 mg). Lithium can be used from the age of 12 under standard conditions with the appropriate laboratory tests. Adequate levels range around 0.3–0.6 mmol/l.
Other Recommendations
Important aspects include the therapeutic relationship between patient and doctor, good and comprehensive cooperation with the family, detailed family education, monitoring of medication side effects, spontaneous changes in patient behavior (depressive states, suicidal tendencies, and attempts), and acute deterioration caused by medication interruption, etc. Differential diagnostic questions, especially bipolar or schizoaffective disorder, must still be considered.
It is advisable to gradually involve the patient in activities of interest, prepare an individual education plan at school in cooperation with the educational-psychological counseling center (PPP), and consider the illness when choosing a study and employment placement (preferably calm, more individual employment and study fields in the humanities). With adherence to these rules and good family cooperation, the prognosis can be surprisingly good in some cases.
Conclusion
Schizophrenia in children and adolescents represents a serious illness requiring long-term treatment. It demands timely diagnosis, treatment of prodromal symptoms with low-dose atypical AP, systematic use of the above APs, and sometimes antidepressant treatment. Monotherapy is preferred; controlled studies of combined therapeutic approaches are not available. Even in children and adolescents, depot AP can be used under the same indications as in adults. Patient compliance must undoubtedly be monitored, and it must be considered that most medications are prescribed off-label (informed consent of the patient or their legal representative is therefore required). The prognosis is favorable in a smaller number of patients than in adults.
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Source: Paclt I. Schizophrenia in Children and Adolescents. Recommended Procedures for Psychiatric Care. Psychiatric Society of the Czech Medical Association JEP, 2022. Available at: https://postupy-pece.psychiatrie.cz/images/pdf/15_Schizofrenie_u_deti-22.pdf
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