Schizoaffective Disorder in Children and Adolescents

There are two types of schizoaffective disorder:

• Bipolar type- A manic episode (persistently elevated, expansive, or irritable mood) is part of the schizophrenic presentation. Major depressive episodes may also occur.
• Depressive type- A major depressive episode (depressed mood, loss of interest or pleasure) is part of the schizophrenic presentation.

The disorder may occur in a variety of temporal patterns. The following is a typical pattern: An individual may have pronounced auditory hallucinations and persecutory delusions for at least 2 months before the onset of a major depressive episode. The psychotic symptoms and the full major depressive episode are then present for at least 3 months. Then, the individual recovers completely from the major depressive episode, but the psychotic symptoms persist for at least another month before they disappear.

The symptoms and behavior of children and adolescents with schizoaffective disorder may be different from those of adults with this illness. The following symptoms and behaviors can occur in children or adolescents with schizoaffective disorder:

• Hallucinations – seeing or hearing things not seen or heard by others
• Delusions – fixed beliefs that are held regardless of evidence to the contrary
• Disorganized thinking – lack of continuity in speech, answers unrelated to questions
• Major Depressive Episode – sadness, feeling of worthlessness and emptiness, diminished interest in activities, insomnia or hypersomnia
• Bipolar Episode – inflated self-esteem, decreased need for sleep, distractibility, increase in goal-directed activity, a patient may experience euphoria, racing thoughts, engagement in risky behavior
• Changes in weight or appetite
• Suicidal thoughts or attempts

Schizoaffective disorder affects approximately 0.3% of adults. Onset of schizoaffective disorder typically occurs in early adulthood, although onset can occur anywhere from adolescence to late in life.

Schizoaffective disorder in youth is extremely rare. There are no current estimates of children and adolescents with schizoaffective disorder. Schizoaffective disorder, bipolar type may be more common in young adults, whereas schizoaffective disorder, depressive type, may be more common in older adults. The diagnosis of schizoaffective disorder is made using the same diagnostic criteria as those used for adults.

Youth with schizoaffective disorder present with the same severity of psychotic symptoms and functional impairment as those with schizophrenia. Common premorbid difficulties include social withdrawal and isolation, disruptive behavior disorders, academic difficulties, speech and language problems, although these problems are also often present in children who do not go on to develop schizophrenia.

There is little to no information in the literature on the etiology, risk factors and prognosis of children and adolescents with schizoaffective disorder. There is however, more research available on children and adolescents who have been diagnosed with early-onset schizophrenia. Early-onset schizophrenia is the diagnosis of schizophrenia prior to 18 years old.

Children and adolescents with schizophrenia are frequently marked by deficits in cognitive impairment such as deficits in attention or vigilance, memory, and executive functioning. A generalized or global impairment (e.g., subaverage IQ) is also common in this population. Approximately 10-20% of children with schizophrenia have a full-scale IQ of 70 or below.

Because schizophrenia in youth often has an insidious onset, the gradual development of psychotic symptoms in a child with premorbid language delays and social withdrawal can be difficult to recognize. Children may experience less elaborate delusions and hallucinations than adults. Visual hallucinations are more common in children with schizophrenia and should be distinguished from normal fantasy play. Symptoms such as disorganized speech and behavior, which are typically present in schizophrenia, also occur in many other disorders of childhood onset (e.g., autism spectrum disorder and attention-deficit hyperactivity disorder).

Family, twin, and adoption studies support a strong genetic component for schizophrenia. The lifetime risk of developing the illness is 5–20 times higher in first-degree relatives when compared to the general population. Risk factors that include paternal age and in utero exposure to maternal famine have also been hypothesized to contribute to the development of schizophrenia. Early childhood trauma has also been associated with childhood psychotic symptoms. Children who experienced maltreatment by an adult or bullying by peers were found to be at a higher risk for psychotic disorders later in life. Schizophrenia peaks at the age of 15 and this is one of the reasons why many authors see puberty as a risk factor for schizophrenia. Neurobiological changes that occur during the puberty and adolescence can influence more frequent occurrence of schizophrenia during this period of life. These neurobiological changes include progressive ventricular enlargement, reduction in total brain and thalamus volume, changes in temporal lobe structures, and reductions in frontal metabolism, volume reduction of the associative cortex and hippocampus, synaptic elimination during adolescent development of the prefrontal cortex, diminishing of cerebral plasticity, and changes in neurotransmission.

The following treatment guidelines for Schizoaffective Disorder are based on the adult population.

First Line Treatments

• Family Psychoeducation & Support: helps improve family functioning, problem solving and communication skills, and decrease relapse rates.
• Cognitive Behavior Therapy: includes social skills training, problem-solving strategies and self-help skills.
• Atypical Antipsychotic + Mood Stabilizer: thought to help by decreasing the amount of dopamine in the brain and reduce mood instability.
• Specific first-line atypical antipsychotics include:
• Risperidone
• Aripiprazole
• Olanzapine
• Quetiapine
• Specific first-line mood stabilizers include:
• Lithium
• Valproic Acid

Second Line Treatments

In cases of nonresponse to first-line treatment, adjunctive treatments to be used in conjunction with antipsychotic medications with reasonable evidence of efficacy include:

• Antidepressants (depression, negative symptoms)

• Benzodiazepines (anxiety, insomnia, akathisia)

• Antiepileptics such as Topirimate

Third Line Treatments

When patients do not respond adequately to the first- and second-line treatments described above, other strategies might include:

• Alternative antipsychotic agent, Clozapine

Additional Treatments to Consider

Preliminary evidence suggests that the following strategies, while not a substitute for better validated treatments described above, might be considered.

• Electroconvulsive Therapy (ECT)
• Omega-3 Fatty Acid Supplements