The COVID pandemic has left many of people in quarantine and/or isolated from friends, family, loved ones and, for some, ourselves. This article will provide reflections on the influence of the pandemic on various components of our psychology and faith.

On an intellectual level, it might be easy for an individual with COVID (or a similar life-threatening disorder) to understand they have a serious illness that might cause death. Yet, mandated isolation or even quarantine may be difficult to conceive, especially for those who are seemingly healthy. Quarantine can foster strong feelings dehumanization and helplessness.

The essence of feeling dehumanized is amplified if one is unable to receive proper 

, their problems are minimized, or they reacted to as if they are a threat. This could feel like a punishment, and without a clear understanding of the reason for punishment. One could struggle with feeling guilty over past deeds either conscious or not. One would ultimately struggle with feelings of panic, an alarm signal that their body is being threatened. In this state, one might easily feel dissociated or disconnected from their body, loved ones, and life itself.

For many in isolation, they believe they are in quarantine. This sends a message to their body that they are dangerous and infectious. It is important, therefore, that we accurately use the terms, since the words we use and how we think shape our being and responses. Can you imagine the mind of a person that is quarantined who does not have the virus? It can be puzzling, frustrating, and add to the anxiousness and uncertainties.

Here are a few brief interactions demonstrating intense anxiety, uncertainty, and confusion.

I don’t want to go around people. I don’t want to infect anyone and have that on my conscience.

I'm staying away from people now. I don’t know who is who. I don’t want to catch anything.

As I’m listening to you, it appears you are imagining catching more than the virus. Is that true?

 Well, I didn’t think of it that way consciously until you pointed it out, but I guess so.

 It appears that you feel the danger of others will enter inside you and infect you whether it be COVID or not?

Some patients who experience mental agony and uncertainty turn to their religious beliefs to help cope with the COVID pandemic. They may look to passages in the scripture or a faith leader for 

. The stories in religious teachings and their symbolism may help patients better make sense of their world and their experiences, which may help patients address the anxieties, fears, and guilt.

For instance, we can look to the Genesis narrative of the Fall of Adam and Eve. In the text, Adam and Eve did not see their environment or God as a threat to their life before they ate from the Tree of Good and Evil. Indeed, they were isolated from any threat to their body and mind.

After they ate from the Tree of Good and Evil, they were “quarantined,” in other words, not allowed in the Garden of Eden until they repented and were healed spiritually, bodily, and mentally. Their behavior changed. They covered themselves with fig leaves. During that time, they were not very close to each other, and they were distant from God. After being quarantined, they continued to struggle, and so goes the essence of the story as the Fall of Man.

What does this passage reveal about one’s environment, where they live, learn, heal, work, play, and pray? What if that environment makes them feel the need to quarantine or isolate themselves from God and others? This is no longer the Garden of Eden, and one’s body is not protected, which makes our minds vulnerable. In turn, greater vulnerability to one’s body weakens one’s ability to defend ourselves from infections and other physical insults. Yet, how one frames their experience will influence how they respond. And the nature of one’s body will influence their ability to frame their experiences.

Bodily compromises lead to mental compromise as expressed in susceptibility to thoughts of doubt, fear, panic, and the like. The 

 has caused us to feel unsafe not only in our homes, schools, workplaces, and recreational and religious spaces but also our minds and souls.

Nonetheless, concerns about the COVID-19 virus are legitimate. We can help people understand that their mind’s processes using representations or symbols, such as those in the scripture. The virus might symbolize danger, feelings of being alien (or seeing others as aliens), among other meanings.

As we continue to live in this COVID world, it is important to ask patients, when we are using the word 

, from what are we quarantining? This discussion can help patients put the fears, 

 is Co-founder of The Southern Renaissance and Group 6:22.

Videos

For some patients, quarantine and isolation may generate feelings of uncertainty. It is important to use accurate terminology, since the words we use and how we think shape our being and responses.

Psychological and Spiritual Reflections on the COVID-19 Pandemic

Looking Back to Look Forward
This MONTH in PSYCHIATRY

The First International Congress on Infantile Psychiatry took place in July 1937, in Paris, France, as part of the International Exposition of Paris. Organized by leading French psychiatrist Dr Georges Heuyer, the Congress attracted participants from more than 20 countries, including Hungary, Austria, Belgium, Germany, England, Portugal, Italy, Spain, and Switzerland as well as from places further afield, including the United States, Canada, Brazil, and Egypt.

 The international success of the meeting attested to the vibrancy of a field that was itself barely beyond its infancy.

Interestingly, the first 45 volumes of the 

(1844-1889) did not include a single article on 

by British psychiatrist Henry Maudsley, FRCP, was the first major work to include a chapter on “The insanity of early life.” Dr John Langdon Down’s 

On Some of the Mental Affections of Childhood and Youth 

of 1887 pioneered the study of children’s intellectual disabilities. In 1899, the term 

 (in French) was first used as a subtitle in Dr Marcel Manheimer’s monograph 

 Then, the early decades of the 20th century witnessed a growing interest in childhood, thanks to the child guidance movement in the US and England, the rise of therapeutic pedagogy in Germany and Austria, and various social reform initiatives directed at solving the problems of “troublesome” children in the schools and juvenile delinquency.

At first, most psychiatrists saw children’s mental difficulties as early manifestations of adult conditions. In 1911, Swiss psychiatrist Eugen Bleuler, MD, published his influential work on the schizophrenias, the conditions that Emil Kraepelin, MD, had included under 

Bleuler believed that schizophrenia was rare in childhood, but 4% of the cases he knew had an onset in children younger than 15 years.

Other conditions seemed to affect even infants. During the first decade of the 20th century, Italian psychiatrist Dr Sancte de Sanctis postulated the existence of a dementia praecocissima, which appeared in infants around two years of age. The Viennese psychologist and educator Theodor Heller, PhD, coined the term dementia infantilis for a condition that also afflicted young children.

 By the time Johns Hopkins University psychiatrist Leo Kanner, MD, published his 1935 

 textbook, the first of its kind in the English language; the volume ran more than 500 pages.

In Paris, delegates from many countries debated all sorts of children’s behavior maladjustments in 4 sections: general psychiatry, school psychiatry, forensic psychiatry, and discussions. Psychiatrists deliberated the significance of their contributions for pedagogues and for pediatricians, conscious that claiming legitimacy to treat a child’s mind required some negotiation.

 Swiss psychiatrist Jakob Lutz and French-American Louise Despert, MD, presented their work on childhood schizophrenia. Their subsequent publications listed numerous studies from colleagues in different countries about children who would later have various diagnoses ofschizophrenia or autism. This would become a lively area of research in the following decades.

The committee that organized the congress also created an international organization: the International Association for Child Psychiatry and Allied Professions. Swiss psychiatrist Moritz Tramer, MD, was elected permanent Secretary. The journal 

 that he had started in 1934 became the official publication of the organization.

 Excited about the field’s promising future, the delegates planned for the Second International Congress of Child Psychiatry to be held in Leipzig, Germany in 1941. World War II interfered, and the next congress would not take place until 1948 in London.

The war divided many of the newly self-defined child psychiatrists politically and intellectually, and it also destroyed their ability to communicate with each other. Thus, the war had tremendous consequences for the field. It also had a far-reaching impact on the mental health of many children, which became a major focus of research in the postwar period.

is is Professor of History of Science, Institute for the History and Philosophy of Science and Technology, University of Toronto. She reports no conflicts of interest concerning the subject matter of this article.

1. Premier Congrès international de psychiatrie infantile, Paris, 24 juillet au 1er août 1937; 4 volumes. Lille: S.I.L.I.C. imprimerie; 1937.

2. Kanner L. Childhood psychosis: a historical overview.

1971;15:14-19. On the start of child psychiatry in the United States, see: Schowalter JE. 

A history of child and adolescent psychiatry in the United States

On Some of the Mental Affections of Childhood and Youth. 

5. Manheimer M. Les Troubles Mentaux de L’Enfance: Précis de Psychiátrie Infantile. Paris: Société d’Éditions Scientifiques; 1899.

Taming the Troublesome Child: American Families, Child Guidance, and the Limits of Psychiatric Authority. 

Cambridge, Mass: Harvard University Press; 1999.

7. Bleuler E. Dementia praecox oder Gruppe der Schizophrenien. Leipzig: Franz Deuticke; 1911, see: Kaplan RM. The name “schizophrenia” is heard worldwide. 

8. Parry-Jones W. Annotation: the history of child and adolescent psychiatry: its present day relevance. 

9. Vicedo M, Ilerbaig J. Leo Kanner’s call for a pediatric-psychiatric alliance. 

10. Schleimer K. The history of IACAPAPA: The International Association for Childe and Adolescent Psychiatry and Allied Professions. https://iacapap.org/content/uploads/History_of_IACAPAP-75-YEARS.pdf. ❒

Articles

Solving the problems of “troublesome” children throughout the ages.

The First International Congress on Infantile Psychiatry

This conversation was inspired by a clinical encounter during an intern’s inpatient psychiatry rotation after which she posed the question, “Was that racist?” An attending psychiatrist offers reflections on her own training experience and continued challenges navigating a marginalized racial identity in psychiatry.

“Was that racist?” As two black female psychiatrists, our professional and personal development have been punctuated by this question too many times to count. We invite you to our dialogue as an early career psychiatrist and resident psychiatrist as we outline a few of these most notable junctures of racism and our personhood. This conversation was inspired by a clinical encounter during Dr Uyanwune’s intern year inpatient psychiatry rotation after which Dr. Uyanwune posed the question, “Was that racist?” As an attending psychiatrist, Dr Isom offers reflections on her own training experience and continued challenges navigating a marginalized racial identity in psychiatry.

The question rang out seemingly accompanied by a haunting echo when I first heard it from you. I thought to myself that I had asked myself this question numerous times. The answer always lay in the body. I knew I needed to explain the body-based reactions that clue those with darker skin into the realities of a racialized existence. I wanted to say, “Trust your gut!” These were important signals throughout residency. The quickening of the breath. Goosebumps on the arm. Fluttering in the chest. The body sending alarm signals meant to communicate that you, they, we, are not quite right in this moment. Something is awry.

You asked, “Was that racist?” I offered a simple “Yes,” first because it is the most important thing to say. My reply was loaded with memories, pain, and anger as I too had felt and flinched at the experience of interpersonal racism. Did you notice anything in your body during that moment on the wards? Have you felt those clues before?

Sad to say, I have felt similar feelings and asked myself the same question. However, for me, it wasn’t until I moved from my home country Nigeria and lived in Europe (Holland, specifically) at the age of 11 that I was confronted with those physical sensations more often than not. At the time, my question wasn't, “Was that racist?” Instead, I constantly felt like 

I was focused primarily on myself and what I thought I was repeatedly doing wrong on a daily basis that resulted in differential treatment amongst my peers. It wasn't until a few years later that I was able to process these experiences, and as I look back now, when I ask, “Was that racist?”, the answer is, “Yes.”

Let your trainees know they can come to you with difficult racialized experiences. And when they do, listen. This applies to any psychiatrist confronting racism, not just those in training. We could use your support at all levels.

 It is a fascinating thing, racial ethnic identity development. It is a different journey for all of us, so individualized. I remember when I was 10 or 11 and on a family trip to Walmart. I had been told by my parents I was black and the world was going to treat me differently. However, I hadn’t quite experienced the shock of it until I turned the corner in the store and came face to face with an older white woman pushing her cart. She was accompanied by her husband. She nearly spat at me, “Stupid N*****r,” before rushing past me with her husband, who stood silent, as if I were non-existent.

That is when I knew, you can feel it in the body; it’s so visceral. I was terrified. That moment was a reality check that racism had no regard for the innocence of my youth. I still cry at the memory especially when thinking about the possibility of my toddler daughter being exposed to a similar encounter at some point.

Wow, I’m sorry you had to experience that, especially at that age. After I moved from Holland where I attended a predominantly white school, I went to college in Toronto, Canada, and found myself surrounded by black and brown bodies. In Holland, I didn’t feel comfortable telling my white friends about my racialized experiences. However, in Toronto, I felt more validated amongst my friends. It was a more comfortable space where I wasn’t gaslighted but rather affirmed whenever I spoke about these difficult and traumatic experiences. This allowed me to be more vocal about the discrimination I experienced on an almost daily basis.

 I had the same experience at my historically black college. It was transformative. Wouldn’t it be wonderful to have that kind of mirroring experience anywhere we go such as residency and life in general? To be validated, affirmed, and supported in general but also to have support when processing our experiences of racism? Knowing that that isn’t always the outcome has led me to be more silent in spaces where a validating response is less likely.

The dangers of projection are always around us. We take steps to not appear angry or aggressive which saps our opportunities to assert our humanity. It is nearly surreal that we have to take extra steps to avoid rocking the boat by erasing our own experiences for the comfort of others. Black Lives Matter, right?

Yes! As a trainee in medicine, it would be healthier to feel comfortable sharing these experiences on rounds with my attendings. Instead, I have found most of the time when discussing difficult patient encounters, my attendings fail to see through a racial lens when working with black and brown residents. Rather, they often put up a defense at the mention of racial dynamics, and this hinders further discussion and subsequently deters me from mentioning future experiences with them. They don’t seem to understand that they are undermining patient care.

 That white fragility is something powerful, isn’t it? With the overwhelming majority of attendings and administrators being white in our training program, it was a concept I remember having to learn quickly. You can never quite tell, particularly early in training, how much your lived experience will be honored. As an attending, I am still navigating spaces where my racialized experience cannot be discussed openly for fear of discussing what seems to be taboo in medicine.

It is interesting to see white people and others purchasing books on white culture now out of interest. I bought the books years ago for my own survival. I needed to read about white culture to be safe and successful. Beyond those who are black, this is an essential lesson for all those who identify as persons of color.

If you could offer one piece of advice to those responsible for trainees and working alongside any psychiatric colleague, what would you say?

To attendings and supervisors, I would say, read and educate yourself on these issues and topics. It is difficult and uncomfortable work that needs to be done. Let your trainees know they can come to you with difficult racialized experiences. And when they do, listen. This applies to any psychiatrist confronting racism, not just those in training. We could use your support at all levels. Foster a liberated space that allows them to speak their truth to power.

Believe them. Validate them. Affirm them. Lastly, practice calling out injustices and inappropriate behaviors when you see and hear them.

 I echo your suggestions and invite those in the field to examine their racial identity and own the responsibilities that come along with it, for our patients and for our specialty. The cost of silence on racism in medicine must become prohibitive. The time is now.

 is a PGY-2 Resident in the Department of Psychiatry, Yale School of Medicine. 

is an Attending Psychiatrist, Codman Square Health Center and Boston Medical Center.

An early career psychiatrist and resident psychiatrist reflect on their racialized experiences in predominantly white spaces and the impact on their lives.

The Cost of Silence on Racism: A Dialogue

Child and adolescent psychiatrist Abhijit Ramanujam, MD, discusses clinically relevant issues in childhood schizophrenia. Dr Ramanujam is Regional Director of 

Laurie Martin (LEM): How common is schizophrenia in children under the age of 18?

 The worldwide prevalence of early onset schizophrenia,that is symptoms prior to the age of 18yrs is estimated to be about 0.5% of the population,whereas childhood onset or very early onset schizophrenia which begins prior to the age of 13, has been estimated to be around 0.04% in the United States.Much less is known about the prevalence of childhood onset schizophrenia internationally.

LEM: Is there an age in which a child is too young to consider a diagnosis of schizophrenia? What do we know about early detection of schizophrenia and how soon can it be diagnosed?

 Although there is no official age considered too young for a diagnosis of schizophrenia, we have to keep in mind that childhood-onset schizophrenia that starts before aged 13 years is extremely rare.

Whenever a child is suspected of having schizophrenia, the clinical assessment should include a thorough personal, medication, psychosocial and family history as well as physical examination, neurological work-up, laboratory evaluation, and collateral information from family and schools.

In terms of diagnosis, DSM-5 diagnostic criteria for schizophrenia in childhood and adolescence are the same as those used for adult disorders. They include the presence of significant positive and negative symptoms during a 1-month period (such as delusions or hallucinations, disorganized speech, catatonic behavior, and negative symptoms such as lack of motivation and lack of socialization). Disturbance of functioning in 1 or more major areas and continued signs of disturbance for at least 6 months, as well as the exclusion of other psychiatric or medical diagnoses.

Although the diagnostic criteria used in children are the same as those for adults, there are some key differences in clinical presentation:

• Usually hallucinations are much more common than delusions in youth with schizophrenia as compared to adults. The most common hallucinations are auditory with comments or commands. These are often accompanied by visual and tactile hallucinations.

• Although hallucinations are more common, they are least likely to reported. Many youths may not disclose auditory hallucinations since they are scared that the voices may harm them.There may also be delusions associated with it such as "The voices tell me that they will kill me if I talk about them to anyone."

• Children and adolescents are more likely to exhibit negative symptoms such as being socially aloof or having a flat affect which can sometimes be mistaken for depression or lack of motivation for plain laziness as I have actually heard some of the parents describe it.

• Cognitive decline, in particular verbal memory, attention, and concentration, is significantly affected. Delay in language, motor, and social development, and delay or deviation in developmental milestones may be pronounced as well in childhood-onset schizophrenia; although these delays are not diagnostic, they are commonly observed.

LEM: What are the most commonly confused causes of schizophrenia-like behaviors?

 There are many other disorders that can be confused with schizophrenia-like behaviors.

The most common one I see is PTSD. PTSD symptoms can include flashbacks which some patients may describe as auditory hallucinations. Hypervigilance and flashbacks together can often be misinterpreted as paranoia and hallucinations. However, you will notice less disorganized thinking and usually symptoms begin after a traumatic event.

Another area is autism spectrum disorders. Misdiagnosis of autism spectrum disorders as a psychotic disorder also occurs very commonly. Common features such as impairment in social communication can be misinterpreted as negative symptoms of psychosis. Stereotyped use of language seen in autism can be confused with disorganized speech.

It is very important to obtain a thorough developmental history and a baseline thought processes which helps distinguish these 2 diagnoses.

Some patients may have a comorbid diagnosis of autism spectrum disorder and schizophrenia. In these cases, you will see a new onset delusion or hallucination lasting longer than 1 month. Disordered or delusional thinking will be distinctly different from the baseline. We usually notice a significant deterioration of social and general functioning with comorbid diagnoses. I sometimes noticed this in children who have been through multiple foster homes. A baseline thought process is difficult to establish in this case since past history is not readily available. These children are more likely to be wrongly diagnosed as having a disorganized thinking process as opposed to a social communication issue.

Schizoaffective disorder can be a difficult one to differentiate since a psychotic syndrome continues to evolve as a child progresses through the developmental process. Again, a thorough longitudinal symptom assessment would help distinguish the 2.

Major depressive disorders with psychotic features or bipolar disorder with psychosis should also be considered very carefully. Usually in depression with psychotic features, the psychosis is generally seen when the depressive disorder has significantly worsened. Guilt dominates in depressive psychosis. In case of bipolar disorder with psychotic features, you generally see psychosis during severe episodes of mood and not during lucid intervals.

Another area that is very important to remember is that in very young children before the age of 6, anxiety can itself present as hallucinations. Many children with symptoms of anxiety report, "Someone called my name;" they may also report visual hallucinations such as "Mama, I see a shadow every night passing by." Most of these children are healthy and nonpsychotic.

Anxiety-related visual hallucinations are very common in preschool children. Usually in the history, you will notice that there will be a precipitating event such as watching a scary movie or video game that triggered such reactions. Whereas in early-onset schizophrenia, you will notice a decline in cognitive function, attention, and concentration, as well as the presence of negative symptoms which indicate psychosis.

Sometimes, substance-induced psychosis that is secondary to steroid use can present very similarly to a primary psychotic disorder. Urine toxicology screens are very important. It is also important to remember that many of the newer recreational drugs may not be detected in current screens; hence a thorough history will help us distinguish between the 2.

In case of delirium, look for waxing and waning of symptoms or evidence of ingestion of substance or any other metabolic abnormalities, since these are usually seen in delirium and not a psychotic illness.

Other medical conditions may also mimic psychotic symptoms. Those include:

• Autoimmune disorder, such as systemic lupus erythematosus

• Metabolic disorder, such as Wilson disease

I am only mentioning the positive pertinent factors in each of the following 3 cases for the sake of brevity. All names and identifying factors have been changed. This is for clinical purposes only.

Case presentation 1: Oppositional or something else?

PR is a 17-year-old boy who initially brought in by his father with chief complaints of “very oppositional, up to something, secretive, and angry.”

The father appeared remorseful due to his "busy schedule" for the last 3 to 4 years. His being away also coincided with a gradual deterioration of his son.

PR refused to talk other than state, "I hate them" [my parents].

Neuropsychological tests, detailed medical examinations, laboratory tests, and a urine drug screen came back negative; the clinical picture became clearer as we obtained collateral information.

The mother described her son demonstrated bizarre behavior. She also hesitatingly disclosed family psychiatric issues (many relatives with schizophrenia), which was initially minimized. “It is a taboo and we do not talk about it,” she said.

His siblings disclosed they are fearful of him "Since he stays up all night and talks to himself. He does not seem like our brother anymore."

School reported he was growing increasingly isolative and suspicious of other kids. His grades kept falling. Teachers also responded behavior that was indicative of PR being internally preoccupied.

The approach of the parents changed from “the boy just needs good disciplining” to a gradual understanding and compliance with the treatment plan.

I will discuss the treatment plan further below. But before that I would like to say that PR is doing much better than he was 3 years ago.

Case presentation 2: “The adopted boy who was ‘psychotic.’”

A was adopted at age 3 and was brought in for an evaluation by his adoptive mother at age 9. The adoptive mother insisted he was “psychotic” and fearful of ingesting food because he thought his mother had poisoned it.

On examination, the boy was found to have significant anxiety, ADHD symptoms, and social communication disorder.

His fear of contamination was misinterpreted as paranoia and delusional. He had also watched a “cold cases” forensic science documentary along with his brother a few months ago which was the precipitating factor. Further information revealed he had a family history of anxiety disorder but no family history of schizophrenia.

Case presentation 3: “My daughter is hearing voices.”

SK is a 7-year-old girl who was brought in for auditory hallucinations. A detailed history revealed a traumatic past (she had witnessed domestic violence). Although currently she lives in a safe environment, she continued to experience flashbacks in the form of auditory hallucinations. There was no family history of psychotic disorders.

After 6 months of cognitive behavioral therapy and trauma-related behavioral therapy, the patient is doing significantly better.

LEM: What are some of the common therapeutic approaches in the treatment of childhood schizophrenia?

In this stage, medications are aimed at delaying or stopping progression to psychotic disorder amongst children who are considered high risk or those that have prodromal symptoms, such as disorganized behavior, paranoia or suspicion, or any unusual thought content that is below the threshold of a full-blown psychotic disorder.

Several medications have been tested in clinical trials. Trials of omega-3 fatty acids have shown mixed results. However, although clinical trials are mixed given the positive potential effects as well as the limited adverse effects of omega-3 fatty acids make it a good choice to consider.

Selective serotonin reuptake inhibitor antidepressants have been shown to be helpful in two naturalistic studies but have not been tested in a clinical trial. Initiating SSRIs along with omega-3 fatty acids is a grade 2 recommendation which basically means this is a suggestion, but clinicians could choose a reasonable alternative.

Clinical trials have not found antipsychotics to be efficacious in terms of delaying or preventing progression to psychosis.

Antipsychotics are first-line treatment for confirmed schizophrenia. Several randomized trials have shown that antipsychotics reduce positive symptoms of schizophrenia, such as hallucinations and delusions. Antipsychotics eliminate or reduce the symptoms to a tolerable level in about 70% of the patients with schizophrenia.

Negative symptoms of schizophrenia, such as diminished emotional expression or lack of motivation is a little more difficult to treat.

We generally follow the age guidelines from the indications approved by the FDA in the United States which were based on the age of enrollees in the efficacy trials of antipsychotics in children with schizophrenia. These medications are aripiprazole, lurasidone, olanzapine, paliperidone, quetiapine, risperidone, 

, and the first-generation agents, chlorpromazine, haloperidol, and perphenazine.

The current recommendation is to start with a second-generation antipsychotic with lower sedation and fewer problems with metabolic syndrome.

Clinical trials have not consistently found any one antipsychotic more effective than the others except clozapine, but due to adverse effects, it is reserved for use in treatment-resistant schizophrenia.

Hence, clinicians can select 1 amongst the above medications, based on patient age and medication adverse effect profile.

LEM: Can you talk about cardiometabolic risks or any other risks of treatment with antipsychotics, and do they outweigh clinical benefits?

The adverse effect profiles of individual antipsychotic drugs vary widely. Children and adolescents compared with adults are at a high risk of many of the adverse effects associated with antipsychotic use

Common adverse effects associated with second-generation antipsychotics include weight gain and related metabolic effects, sedation, anticholinergic symptoms, elevated prolactin levels and extrapyramidal symptoms, cardiac effects, and sexual dysfunction.

Many of these drugs increase appetite and alter metabolic control. Children who are more vulnerable to these adverse effects are those with pre-existing conditions, such as obesity, diabetes, or elevated cholesterol. Clozapine and olanzapine carry significantly higher risk than other antipsychotics, whereas lurasidone and to an extent aripiprazole are associated with the lowest risk.

Clinicians should conduct routine short and long-term monitoring of weight, waist circumference, blood pressure, fasting glucose, and lipid profile of patients taking any of the antipsychotic drugs. For patients in whom weight gain is a concern, we tend to prescribe lurasidone. Whenever possible, we tend to avoid medication such as olanzapine which has a higher rate of metabolic abnormality.

Tardive dyskinesia is characterized by involuntary movements of the mouth, tongue, face, extremities, or trunk (including lip-smacking, tongue, and jaw movements, and facial grimacing). The symptoms are often initially mild; however, they can progress and become disfiguring or disabling. Tardive dyskinesia risk increases with age, time of exposure to medications, and prior development of extrapyramidal symptoms (EPS).

 is less common in youth compared with adult and older adult populations—0.4% versus 6.8%.

The risk of tardive dyskinesia in children appears to be the greatest with first-generation antipsychotics with minimal or no risk seen with second-generation antipsychotics.

 Clozapine has not shown to cause tardive dyskinesia. Patients on these medications should be formally assessed for tardive dyskinesia at least annually. Older adults should be assessed every 6 months.

Nausea and sedation are common adverse effects of antipsychotic treatment in all patients, but they often remit over time and should not be considered a reason to terminate treatment. As mentioned earlier although no one antipsychotic is better than the other, for patients with prominent insomnia we tend to use quetiapine.

Clinicians should routinely assess for fall risks in vulnerable population, given that many of these medications cause sedation as well as orthostatic hypotension. Anticholinergic effect, such as constipation, dry mouth, blurry vision, and urinary retention are fairly common. In the case of clozapine sialorrhea rather than dry mouth is common.

 Second-generation antipsychotics have reduced incidence of akathisia, rigidity, bradykinesia, dysphagia, tremor, and acute dystonic reactions that constitute EPS. Among the second-generation antipsychotics, risperidone carries the highest risk, especially at doses greater than 4 mg/day; elevated risk is also noted with aripiprazole, asenapine, and lurasidone. Quetiapine and clozapine are preferred agents in patients with high risk for EPS. Patients on second-generation agents should be asked about restlessness, slow movements, shaking, and rigidity at baseline and weekly during dose increases.

We usually start with a second-generation antipsychotics because of their lower rates of extrapyramidal symptoms and tardive dyskinesia compared with the first-generation antipsychotics.

Prolactin elevation can occur in both men and women. Accordingly, patients may experience gynecomastia, galacturia, menstrual disturbance sexual dysfunction and infertility. Risperidone and paliperidone are more strongly associated with elevated prolactin. Olanzapine and aripiprazole, clozapine and quetiapine show little or no change in prolactin levels.

Patients on risperidone and paliperidone should be asked about changes in sexual function and abnormal lactation at each visit for 12-week and annually thereafter. A serum prolactin level is indicated if the patient develops signs of sexual dysfunction or galacturia.

Sexual adverse effects that cause dysfunction in all phases of sexual activity are quite common. It seems to be highest on patients who are prescribed risperidone and least amount patients were on aripiprazole. Clinicians are encouraged to ask about sexual functioning initially and at least annually thereafter.

QT prolongation can happen with many of the medications. A corrected QT interval greater than 500 or an increase in QT of 60 or more during antipsychotic treatment indicates significant risk. Ziprasidone appears to have a somewhat greater risk of QT prolongation. Olanzapine and risperidone have been associated with mild QT prolongation but neither carries a specific caution on this issue. Lurasidone and Abilify are the least likely to cause cardiac arrhythmias.

Routine monitoring of ECG with antipsychotics is not usually required in patients without cardiac risk factors. Rarely, cases of myocarditis and cardiomyopathy have been reported with quetiapine, Risperdal, and ziprasidone.

Orthostatic hypotension is frequently observed with clozapine, quetiapine, iloperidone, and paliperidone. This is somewhat less so with olanzapine, risperidone, and ziprasidone. It very rarely occurs with aripiprazole. The symptoms are generally benign and self-limiting but, in some cases, may necessitate a slowing in the rate of dose titration. Seizures have been associated with several second-generation antipsychotics and is dose dependent. Clozapine carries the 

 among the second-generation antipsychotics.

Some of the less common adverse effects include 

, cardiomyopathies, and cataracts. The use of antipsychotics in children should always be started with extreme caution at a low dose and titrated slowly.

LEM: Are there family or genetic factors to consider? What about trauma, sexual abuse, or domestic violence? Do these factors have any effect on children’s propensity to develop early-onset psychosis or psychotic symptoms?

 In terms of predisposing factors, genetic vulnerability, environmental factors, obstetric complications, trauma, social adversities, and substance use can all contribute to the risk for acquiring a primary psychotic disorder. Studies have shown the presence of a substance use disorder and co-occurring psychotic symptoms indicate an increased risk for developing a primary psychotic disorder.

Cannabis in particular has the potential to cause psychotic symptoms, although the studies are limited. However, the body of evidence is consistently increasing.

The birth cohort study of patients with schizophrenia reported an association between hypoxia during birth complications and early onset schizophrenia but not of adult-onset schizophrenia. Prematurity was found in 17% of early-onset psychosis in a schizophrenia spectrum disorder study.

Two large systematic studies demonstrate that 30% to 50% of patients with childhood onset schizophrenia had premorbid features of autism or had comorbid diagnoses of pervasive developmental disorders.

 However, youth with early-onset schizophrenia frequently showed greater premorbid deficits in attention, learning, and socialization compared with their counterparts with adult-onset schizophrenia.

A meta-analysis reported strong evidence that childhood adversity was associated with an increased risk for psychosis in adults, although psychotic symptoms may also be present in PTSD.

 Twin studies suggest that childhood-onset of schizophrenia may have a substantial genetic component.

 A number of psychiatric disorders occur in higher frequency amongst first-degree relatives of children with schizophrenia.

For example, bipolar disorder prevalence is 6% in first degree relatives versus 2.4% in the general population. The same can be said for schizophrenia spectrum disorder: 10% in first-degree relatives versus 3.5% in general population. Anxiety disorders prevalence is 15% in first degree relatives versus 7.3% in the general population.

LEM: Is it too early to talk about long-acting injectable antipsychotic agents, or LAI, treatments?

 In terms of long-acting injectable antipsychotics, they have not been sufficiently studied in younger children to recommend their use.

LEM: From a child’s perspective, how do we build a daily routine of taking oral medications? What can one expect when there is a patient stops treatment abruptly?

 I strongly recommended a multimodal instead of medication-alone approach for a better outcome. First psychoeducation is key and is best provided early in treatment and frequently reviewed, provide children and their parents or guardian information about the illness, medications, and other interventions. It is highly useful to integrate family members and educate them to better support youth.

There are a few variables in terms of our approach based on the clinical presentation of the patient.

For patients with schizophrenia who have had a recent psychotic episode and have significant ongoing contact with family members, we recommend patients and family members receive a family intervention for at least 6 to 9 months. During family intervention, patient's family members receive education about the nature course treatment of schizophrenia.

It also involves correcting the erroneous notion that poor parenting was the cause of schizophrenia. Many parents are left to wonder what they could have done wrong to cause the illness and need help transitioning from the guilt and blame to acceptance and support.

Many times, family members may perceive the negative symptoms of schizophrenia, such as lack of motivation and asociality, as laziness. Furthermore, the clinician should teach early warning signs and explain the importance of medication adherence.

2. If the patient has had multiple relapses of schizophrenia and reside in a particularly stressful family environment, a more intensive problem-solving family therapy has been developed. 

In these cases, we identify and correct overly hostile and critical parent-patient interaction. Sometimes stressful family dynamics can be mitigated by finding outside rehabilitative activities or supported employment for the patient.

3. For individuals who experience persistent delusions or hallucinations despite adequate trials of antipsychotic medication, we recommend adjunctive treatment with cognitive-behavioral therapy over medication alone (

Podcasts

Although the diagnostic criteria used in children are the same as adults, there are some key differences in clinical presentation of psychotic features. More in this podcast about childhood schizophrenia.

The Realities of Childhood Schizophrenia

Katharine Phillips, MD, Professor of Psychiatry, DeWitt Wallace Senior Scholar, at 

; and Attending Psychiatrist at New York-Presbyterian Hospital, shares some thoughts about coping during this pandemic. "It is an unprecedented and very stressful time for our patients and perhaps also for us," she says. 

In this video, she discusses some unique coping and stress management skills that may alleviate some of the distress. In addition to optimizing their medications, psychiatrists can help patients call upon what they've learned in the therapy, such as cognitive restructuring, or cognitive behavioral therapy. Dr Phillips is a member of the 

Katharine Phillips, MD, shares key insights on coping.

Coping Skills for Patients

Orthorexia nervosa (or pathologically “healthy” eating) is distinct from anorexia nervosa, bulimia, and avoidant/restrictive food intake disorder. There are high-risk populations for ON, such as athletes and others who are focused on being healthy However, most of those individuals will only experience social impairment. On the other hand, individuals who view food as medicine are at increased risk for life-threatening medical complications and even death.

In this video, we interview Thomas R. Dunn, PhD, author of a recent CME for 

. Dr Dunn is Professor, School of Psychological Sciences, University of Northern Colorado, Greeley, CO; and Staff Psychologist, Denver Health Medical Center; Dr Hawkins is Chief Executive Officer and Licensed Psychologist, Center for Change, Orem, UT.

Transcript edited for brevity and clarity. For the entire interview, please watch the video. -Ed

About 20 or 30 years ago there was a physician out here in Colorado who recognized that people were very passionate about the quality of food that they were eating, and they were going out of their way to try to find the freshest, most nutritious foods they could.

On the surface this sounds very reasonable, but we want to be careful about what kinds of foods we eat. One of the things he noticed was that there were people who were getting too carried away with this quest to be as healthy as possible. So he developed or coined this term called orthorexia, which is a sort of a straight or rigid diet. Over the years, European researchers especially have been studying this notion that there are people who seem to get pathological about their healthful eating.

So, most of us are aware of anorexia nervosa, a condition where people are worried about being fat; in the case of orthorexia, we are worried about being unhealthy. And so, there's a tipping point. There seem to be people who are overly thoughtful about their diet, when it gets to the point where they restrict to the point of not getting their nutrition. They may start off being vegetarian, then they're vegan, then they're raw, and then they restrict what they can eat. 

There are individuals that have rigid eating habits that have become problematic for them, in their social circles. For example, I dealt with a young woman who was flabbergasted that her fiance would break up with her. After they were engaged, her future mother and father-in-law were coming to celebrate, and they decided to go out to dinner. Sharing meals is a central way of celebrating. He told her, "Please don't be weird about the food," and she got into an argument with the waitress over the croutons. It was this pattern of interacting over diet, that was really disruptive in this case to her social life.

Although weight loss may be a favorable feature of healthful diets, "clean eating" can be taken to extremes. In this video, we interview Thomas R. Dunn, PhD, author of a recent CME for Psychiatric Times. Orthorexia Nervosa. 

Psychological and Spiritual Reflections on the COVID-19 Pandemic

The First International Congress on Infantile Psychiatry

The Cost of Silence on Racism: A Dialogue

The Realities of Childhood Schizophrenia

Coping Skills for Patients

Clean Eating to the Extreme

The Many Histories of Biological Psychiatry: Anne Harrington, DPhil

Specialized Brain Training Relieves Phantom Pain

Traumas, Adversities, and Psychosis: Investigating Practical Implications

Has the Playing Field Been Leveled?