CLINICAL HANDBOOK OF SCHIZOPHRENIA

46. Children and Adolescents 485TREATMENT PRINCIPLESIn adult patients with schizophrenia, psychoeducational interventions aimed at improvingawareness of the illness and the need for medication, family function, problem solving,and communication skills have been shown to decrease relapse rates in conjunctionwith good pharmacological treatment. In adolescents with early prodromal features ofthe illness, some experts have argued that psychosocial and educational interventionsshould be the first line of treatment, because the natural history and diagnostic stabilityof these prodromal symptoms in adolescents has not been established.Similar to adults, children and adolescents with schizophrenia and related psychoticdisorders also appear to benefit from a combined treatment approach, including medicationand psychosocial interventions. The development of a treatment plan requires theconsideration of many issues, including current clinical status, cognitive level, developmentalstage, and severity of illness. Individual educational plans need to be developedfor each child in accordance with his or her specific needs, as assessed by a multidisciplinaryteam. The general principles of the care of children and adolescents with psychotic disordersinclude (1) establishing a supportive therapeutic relationship with the patient andfamily; (2) providing education to the patient and family as to the nature of the child’s illness,prognosis, and treatment, as well as how to recognize changes in mood, behavior, orthought processes that may be indicative of clinical deterioration, so that adequate treatmentcan be provided quickly; and (3) increasing understanding of and adaptation to thedisorder by helping patients cope with their environments by improving family relationshipsand communication skills, teaching personal safety, reviewing educational plans,advocating for special rehabilitative services, accessing appropriate medical care, and securingdisability income support when appropriate.Pharmacological TreatmentsSince 1996, there has been a substantial increase in the number of prescriptions forantipsychotic medications, predominantly for children with severe emotional disturbances.Although substantial, well-designed clinical trial data support the use of antipsychoticsin adult patients with schizophrenia, few studies have included pediatric patients(under age 18). Thus, most of the currently available evidence to support the use of thesemedications in children has been based on open-label studies in small groups of patientsand case reports, and should be considered preliminary. Therefore, the general lack ofcontrolled clinical trials and outcome data in children with schizophrenia spectrum disordershas precluded the development of evidence-based treatment guidelines. However,several multisite, industry-sponsored and National Institute of Mental Health (NIMH)–funded controlled trials of antipsychotic medications are currently under way, and the resultsshould be available shortly. Nevertheless, apart from differences in side effects anddosing, treatment efficacy appears to be similar in both adult and pediatric patients.Short-term efficacy has generally been measured by reductions in positive or negativesymptoms among treated patients during 4- to 8-week medication trials. An advantage isthat these studies clearly demonstrate how well a medication can reduce target symptoms;however, what remains less clear is whether short-term symptomatic improvementwill lead to improvements in functional outcome and prevention of future relapse.In assessing treatment effects and outcomes, there has been an increased push for cliniciansto incorporate standardized symptom and behavior rating scales with proven reliabilityand validity to measure the severity and frequency of target symptoms before