Treat schizophrenia even if your teenager refuses

Treat schizophrenia as you would any other serious medical illness in your teenager

"My 18yr son is aggressive, hearing voices, and not sleeping."

"Since the last two months he is not attending college. He talks to himself in his room and is not going out with his friends."

"He feels he is being tracked through the TV and yesterday assaulted his mother when she put it on."

"We tried taking him to our doctor but he refuses saying there is nothing wrong with him."

This is a common introduction to the more severely ill teenagers presenting at Pathfinder Clinic.

Why teenagers with schizophrenia refuse to see a psychiatrist 

Teenagers refuse to see a psychiatrist for illness related and personal reasons

Illness related factors

Schizophrenia is a brain disease. Your teenager has difficulties recognising his own symptoms. In schizophrenia there are changes in brain structure, chemistry and functioning. The individual is unable to recognise the problems in thinking, and perception. They hear voices threatening harm to themselves and their families. The  same voices command them not to see the doctor. Reality is distorted and they are unable to correct it through feedback from others. Your teenager perceives this distorted internal image of the world as the real one. They attribute their problems to the external environment. Technically this is termed as a lack of insight. The disease process prevents them from seeing these distortions as an illness. Because of the illness they refuse to see the doctor or take medications.

Personal reasons

Many adolescents refuse or drop out of treatment due to stigma of mental illness. They have high levels of self-stigma. They believe that schizophrenia is a result of a laziness, weakness or incompetence. This belief is reinforced by parents, society and friends who give advice like

"You really need to get your act together"

or

"You better snap out of it or people will think you’re crazy."

So in their mind your adolescent rationalises the problems as being outside themselves

 – "You won’t let me do what I want and now you are trying to label me as crazy, you need therapy, you go to the doctor."

Taking medication is seen as an acknowledgement of their own failure. To the teenager denial of illness and rejection of medical care appears more acceptable.

Parents

Parents of an adolescent with schizophrenia are working through their own public stigma. They may see schizophrenia as occurring due to faulty parenting and lack of control. They struggle against the stereotype of their son or daughter as incompetent and requiring supervision. They mistakenly fear they will need to protect the teenager from being labelled and shunned socially. In their mind going to the doctor will accelerate the stigmatising process. So the symptoms are ignored or controlled to the greatest extent possible. This may include keeping the teenager out of school or college for months until the exams are due. When the illness makes life unbearable at home they seek medical help. This is often in an atmosphere of shame and a sense of failure. Many families are unable to overcome these prejudices. They delay treatment for decades until they realise there may be no one to care for their son or daughter when they are gone.

The advisers and 'well wishers' of teenagers and their families are a third set of influencers whose lack of specific knowledge can reinforce self-stigma. Statements like

"Send him to us for a few weeks and he’ll be OK"

and

"Avoid ‘psychiatric’ medications because they are addictive"

or

"Medicines will cause permanent damage"

add further obstacles to the path to standard and adequate treatment.

When the adolescent is functioning well on the medication these misinformed 'well wishers' are the ones who advise

"What do you need the medicine for? I can see nothing wrong with you"

and set the stage for relapse and refusal to meet with the doctor when the illness relapses

 – "Chacha said there is nothing wrong with me, why are you trying to label me?"

What to do?

Refusing help for schizophrenia is not an option.

• We have already seen what can be done to get a reluctant patient to see the psychiatrist. 
• However, for schizophrenia, more urgent measures may be required.  Involuntary admission to a mental health facility for initiation of treatment may be needed. This is especially so when the adolescent is violent, suicidal, using addictive substances, or repeatedly missing from home. Involuntary admission helps in the same way that it helps get your adolescent admitted to hospital if they had dengue fever even if they did not want it. There are provisions in the Mental Health Act to ensure this is done in safety with respect for your adolescent’s rights. After they receive treatment and brain function returns to normal they will thank you. For they will be relieved from the terrors of reality distortions and desperation of suicide thoughts. 
• Once treatment is initiated ensure they take medications every day as prescribed. Don’t take on any other responsibility regarding the medication. Leave that as a dialogue between your teenager and their psychiatrist. Just make sure it continues to happen.

Why teenagers with schizophrenia must get treatment even if  they don't want it

Brain cell death

Schizophrenia is associated with death of brain cells and shrinking of brain volume. The longer the duration of untreated symptoms the greater the toxic “dose” of delusions and hallucinations delivered to the developing adolescent brain. Delusions and hallucinations are merely the tip of the iceberg – underlying brain changes have already set in. When treatments are delayed for more than a week the illness becomes even more severe and impairing. The person is less likely to recover, and is at greater risk for addiction to cannabis and other substances. These negative changes related to delay persist even after a year when treatment is finally started.

Academic impact

Schizophrenia symptoms make it difficult for the teenager to attend school or college. There is difficulty focusing. In the earliest stages there is an accelerated deterioration in academic performance. This usually takes place in late adolescence. Research suggests this may be a marker for schizophrenia onset. Deteriorating academic performance is seen even before social or other symptoms to appear. Unfortunately this is the very stage of life at which academic performance is critical and shapes career choices for adult employment. Many formerly brilliant students are anguished when they are suddenly struggling to even pass their exams. In fact studies have shown schizophrenia is more likely to affect those who excel at academics, making it all the more devastating. Missing or failing in board exams has an adverse impact that timely treatment can obviate.

References

1. Compton MT, Gordon TL, Weiss PS, Walker EF. The "doses" of initial, untreated hallucinations and delusions: a proof-of-concept study of enhanced predictors of first-episode symptomatology and functioning relative to duration of untreated psychosis. J Clin Psychiatry. 2011 Nov;72(11):1487-93. doi: 10.4088/JCP.09m05841yel. Epub 2011 Jan 11.
2. Fung KM, Tsang HW, Corrigan PW. Self-stigma of people with schizophrenia as predictor of their adherence to psychosocial treatment. Psychiatr Rehabil J. 2008 Fall;32(2):95-104. doi: 10.2975/32.2.2008.95.104.
3. Guo X, Li J, Wei Q, Fan X, Kennedy DN, Shen Y, Chen H, Zhao J. Duration of untreated psychosis is associated with temporal and occipitotemporal gray matter volume decrease in treatment naïve schizophrenia. PLoS One. 2013 Dec 31;8(12):e83679. doi: 10.1371/journal.pone.0083679. eCollection 2013.
4. Harrigan SM, McGorry PD, Krstev H. Does treatment delay in first-episode psychosis really matter? Psychol Med. 2003 Jan;33(1):97-110.
5. Karlsson JL. Psychosis and academic performance. Br J Psychiatry. 2004 Apr;184:327-9.
6. Strauss GP1, Allen DN, Miski P, Buchanan RW, Kirkpatrick B, Carpenter WT Jr. Differential patterns of premorbid social and academic deterioration in deficit and nondeficit schizophrenia. Schizophr Res. 2012 Mar;135(1-3):134-8. doi: 10.1016/j.schres.2011.11.007. Epub 2011 Nov 29.
7. Penttilä M, Jääskeläinen E, Haapea M, Tanskanen P, Veijola J, Ridler K, Murray GK, Barnes A, Jones PB, Isohanni M, Koponen H, Miettunen J. Association between duration of untreated psychosis and brain morphology in schizophrenia within the Northern Finland 1966 Birth Cohort.Schizophr Res. 2010 Nov;123(2-3):145-52. doi: 10.1016/j.schres.2010.08.016. Epub 2010 Sep 15.

Want more references? View my collection, "Teenagers with schizophrenia need treatment even if they don't want it" from PubMed

Mental Health and Academic Performance in Children

10yr window to treat mental health problems affecting academic performance

Mental health & academic performance

Mental health has a direct impact on academic performance in children. Neglected childhood psychiatric disorders like ADHD and Learning Disorders adversely affect the child’s academic performance and educational attainment. Poor educational outcomes affect the child’s health, employment, and status as an adult. This is especially so for psychiatric conditions that are seen at 7 years and persist beyond 16 years of age.

Mental health disorders in children have a greater impact on academic performance than chronic physical illness. The presence of a single mental condition results in morel board exams failures and backlogs. This association is more than for chronic illnesses of the neurological, lung, heart, or digestive systems. Physical impairments are not associated with exam failures. More than half the teenagers who fail to complete their secondary education have a diagnosable psychiatric disorder. Mental health problems in childhood impede academic performance as the student is unable to take advantage of learning opportunities at school and at home.

Poor academic performance may be a marker for mental health problems in childhood. We screened secondary school students performing poorly at academics for mental health disorders. 2/3 of these children had at least one mental health disability. ADHD and Depression were the most common mental health disorders in this population. One third of the children had more than one mental health disorder. Our study showed that screening children who had poor academic performance would help in the early identification of treatable psychiatric disorders. This in turn would improve academic performance and subsequent adult outcomes.

Mental health problems in children negatively impact physical health, employment and social status as they grow into adults. These adverse health, employment and social status outcomes are especially seen in those children with psychiatric disorders at age 7 that persist to age 16. There is a large window of opportunity between ages 7 to 16 during which psychiatric disorders can be addressed to prevent adverse outcomes in adulthood.

Mental health problems in childhood have a higher impact on academic performance than chronic physical conditions. Psychiatric disorders account for a large chunk of school failures in children. Poor academic performance in children may be a marker for the presence of undetected mental health problems. Treatment of childhood disorders like ADHD improves academic performance. There is a decade window between the ages of 7 and 16 years to prevent adverse impacts on physical health, employment and social status by treatment of mental health problems that are resulting in poor academic performance.

References

1. Case, Anne, Angela Fertig, and Christina Paxson. "The lasting impact of childhood health and circumstance." Journal of Health Economics 24.2 (2005): 365-389. 
2. Stoep VA, Weiss NS, Kuo ES, Cheney D, Cohen P. What Proportion of Failure to Complete Secondary School in the US Population Is Attributable to Adolescent Psychiatric Disorder? Journal of Behavioral Health Services & Research, 2003, 30(1), 119-124.
3. Neville Misquitta, Sayyara Ansari. Prevalence of ADHD, Depression and Dysgraphia in School Children. 15th IACAPAP. New Delhi. 30-Oct-2002

ADHD treatment improves academic performance

ADHD treatment improves academic performance

ADHD medication enhances academic performance when started early. ADHD drug treatment improves reading ability in children with Attention Deficit Hyperactivity Disorder (ADHD) and Dyslexia. New research shows that drug treatment of ADHD also improves maths ability especially when started early - at least by the 4th standard. Children starting treatment a year or two later show progressively greater declines in academic performance.

ADHD is characterised by inattention and hyperactive-impulsive behaviour. Parents who bring their children to the clinic are focused only on issues arising from the child's hyperactivity. Impairments due to inattention are not immediately apparent in the pre-school years. Depending on the severity of ADHD, inattention is unmasked when the child enters academic life in primary school or during the transitions to middle school, high school, and college. At each  of these stages an increasing demand is placed on the cognitive faculty of attention which the child's brain is not capable of meeting.

Children with ADHD fail to absorb formative academic concepts in primary school. However, rote learning or tutoring by the parents helps the child clear these initial stages. It is only later when the cognitive load exceeds the child's capacity to concentrate that academic problems become manifest. By this time the child's academic progress has already taken a downward trajectory. Reversing this trend and repairing the negative impact on the child's self-esteem entails considerably more effort, time and sustenance at these later stages. The earlier treatment for ADHD is initiated, the better.

Inattention in ADHD is due  to altered brain proteins. These are involved in modulation of the neurochemical - dopamine. This results in reduced dopamine in the synapse (fluid filled space that transmits information from one brain cell to another).  Altered dopamine modulation in the frontal lobe of the brain makes the child impulsive and distractible. ADHD medications act on dopamine and noradrenaline receptors to keep each dopamine molecule longer in the synaptic cleft. Dopamine is then available to stimulate the receptors for longer.

Parental concerns regarding side-effects of ADHD drug treatment on the developing child are largely unfounded. There is now evidence that shows long-term treatment with therapeutic doses of ADHD medication does not affect the developing brain or other standard measures of growth. ADHD drug treatment also does not increase the risk for addiction. As with any other medication side effects can arise at the start of treatment. Adherence to the review schedule will help monitor and mitigate these. All medication is prescribed after carefully weighing the risks and benefits. In the case of ADHD the risks are poor academic functioning and subsequent narrowing of career options at best, to dropping out or expulsion from school and subsequent delinquency at the worst. The benefits of treatment are highlighted in the  report card shown above.

Drug treatment of ADHD enhances academic performance and learning by reducing the inattention and hyperactivity of ADHD. The child with ADHD has attentional and impulse control issues. Inattention and hyperactivity interfere with classroom learning. The earlier ADHD treatment is started the better the outcome in terms of academic achievement. Many children have experienced these benefits.

References

1. Kathryn E Gill, Peter J Pierre, James Daunais, Allyson J Bennett, Susan Martelle, H Donald Gage, James M Swanson, Michael A Nader and Linda J Porrino. Chronic Treatment with Extended Release Methylphenidate Does Not Alter Dopamine Systems or Increase Vulnerability for Cocaine Self-Administration: A Study in Nonhuman Primates. Neuropsychopharmacology , (18 July 2012) | doi:10.1038/npp.2012.117
2. Penny Corkum, Melissa McGonnell and Russell Schachar. Factors affecting academic achievement in children with ADHD. Journal of Applied Research on Learning. Vol. 3, Article 9, 2010.
3. Zoëga, et al. A Population-Based Study of Stimulant Drug Treatment of ADHD and Academic Progress in Children. Pediatrics 2012;130:2011-3493

Learning Disability - academic underachievement

Impaired spelling and arithmetic in Standard 3 boy with Learning Disorder

Learning Disorder (LD) is characterised by impaired acquisition of academic skills. This impairment in scholastic skills is not due to intellectual disability, physical disorders, emotional disturbances, or environmental, cultural, or economic disadvantage.

There is a gap between ability and application. The child may know what is asked, is able to explain it verbally, but is unable to put it down in writing. Learning Disorder could affect any of the three scholastic Rs – Reading, wRiting or aRithmetic.

Types of Learning Disability

1. Dyslexia – is the commonest learning disability (80%). It is marked by impairment of the ability to recognize and understand written words.
2. Dyscalculia – problems with doing math, understanding time, using money.
3. Dysgraphia – problems with handwriting, spelling.
4. Dyspraxia – problems with hand-eye coordination and balance, difficulties with fine motor skills.

Signs and Symptoms

Most children with a Learning Disability are not diagnosed until they are in Standard 2-3 or 7-8 years of age. Remarks like ‘can do better’ or ‘handwriting needs to improve’ are often the first warning signs to appear in the report card. Many of these children would have been the stars of their nursery or kindergarten class. The transition to assessment of written output in primary school is what unmasks the disorder. The aware teacher is able to help the parents understand and put the parents on the path to remedial teaching.

Parents should watch out for

• Reading may be slow or there is repeated rereading or skipping of an entire section. In the lower classes the child learns to memorise and reproduce entire chapters. Later the child is unable to hold the increasing amounts of material in memory, grades plummet, and confused parents are left searching for answers.
• Problems in copying from the blackboard or a book. This is a frequent complaint of the teacher. Classwork is left incomplete. The child tries to copy from their partner and is punished for distracting the class.
• Poor handwriting or drawing – their exercise books are messy, with frequent scratching out and erasing. This is especially so when the child writes on blank paper. It is also a reason why the child performs poorly in exams – they just cannot write quickly enough. They run out of time before they reach the last few questions.
• Other signs in more severe conditions
• Reversing numbers and letters while reading or writing - For example, confusing ‘b’ and ‘d’
• Mixing the order of letters or numbers. Writing ‘twon’ instead of ‘town’.
• Skipping letters in spelling. The child says ‘grass’ but writes ‘gas’.
• Forgetting words they know well.
• Weakness in mathematics.

Conquering Learning Disorder

• Approach a centre undertaking diagnosis of learning disabilities.
• A complete history of the child’s birth, milestones, health and academic record
• Physical exam to exclude problems related to vision and hearing
• Psychometry - to demonstrate specific academic problems that are not associated intellectual disability
• Psychiatric assessment - to address associated anxiety, phobias and depression that arise out of repeated academic failures.
• Psychiatric assessment - to exclude or address Attention Deficit Hyperactivity Disorder (ADHD) a common comorbidity. 15-40% of children with ADHD also have dyslexia.
• Remedial teaching is essential to overcome learning problems 

Drug treatment for dyslexia?

There is a growing body of research to show that at least in children who have both ADHD and dyslexia there are significant improvements in reading ability with ADHD medication. These improvements in reading ability are not related merely to improvements in attention. The brain systems responsible for therapeutic improvement in children with ADHD + dyslexia are probably different from those in children with ADHD alone. The finding that selective areas of working memory can be enhanced by these medications is important, as poor working memory function appears to be a mental constraint on academic learning.

References

1. Schulte-Körne G. The Prevention, Diagnosis, and Treatment of Dyslexia. Dtsch Arztebl Int. 2010 Oct;107(41):718-26; quiz 27. Epub 2010 Oct 15
2. Sumner CR, Gathercole S, Greenbaum M, Rubin R, Williams D, Hollandbeck M, Wietecha L. Atomoxetine for the treatment of attention-deficit/hyperactivity disorder (ADHD) in children with ADHD and dyslexia. Child Adolesc Psychiatry Ment Health. 2009 Dec 15;3:40..