Voices in Tenth Grade: Diagnosing Early-Onset Schizophrenia in a 15-Year-Old and Choosing an Antipsychotic When the Trial Evidence Shows Equal Efficacy and Very Different Weight Gain
[Student Name]
University of Phoenix
PMH/505: Psychiatric Management Of Children And Adolescents
Week 7 Assignment
[Instructor Name]
[Date]
The patient is a composite written for a model paper.
Maya, 15, was an honor student until last year. Over six months, her grades fell, she stopped seeing friends and began spending most of her time in her room. Her parents found her talking to someone who was not there. She now describes two voices that comment on her actions and tell her she is being watched through the school's cameras. She has stopped eating school lunch, fearing it is poisoned. There is no substance use by her report or on urine testing. Her maternal uncle has schizophrenia. What follows describes the evaluation and plan.
Diagnostic Approach
The practice parameter written by McClellan and Stock (2013) for the national child psychiatry academy recommends that schizophrenia in youth be diagnosed with the same criteria used in adults, after an assessment that weighs bipolar or depressive illness with psychosis, drug-related psychosis, trauma, autism spectrum disorder and medical and neurological causes. They recommend antipsychotic medication as the primary treatment, combined with psychosocial interventions, with careful monitoring of side effects.
Ruling Out Other Causes
Maya's workup includes a physical and neurological examination, complete blood count, metabolic panel, thyroid function, a urine drug screen and, because of her new onset, brain MRI. All are normal. Mood disorder is considered: she has no manic episodes and her depressive symptoms, low energy and withdrawal, appear secondary to her psychosis. She has no history of trauma. Her prodrome of declining function over months, prominent hallucinations and delusions and family history support schizophrenia.
Diagnosis
Maya meets criteria for schizophrenia: delusions, hallucinations and negative symptoms, including social withdrawal and reduced motivation, with continuous signs of illness for more than six months and marked decline in functioning. Early-onset schizophrenia, beginning before 18, is associated with more severe developmental disruption and makes early, sustained treatment particularly important.
The voices were the symptom her parents noticed; the six months of quiet decline before them was the illness beginning.
What the Trial Showed
Sikich et al. (2008), in the Treatment of Early-Onset Schizophrenia Spectrum Disorders (TEOSS) study, randomly assigned 119 youths to molindone, olanzapine or risperidone and found no significant differences in response rates, 50%, 34% and 46%, respectively. Olanzapine and risperidone caused significantly more weight gain, and olanzapine caused the greatest weight gain and increases in cholesterol, LDL, insulin and liver enzymes. Molindone caused more akathisia. The authors questioned the near-exclusive use of second-generation antipsychotics in early-onset schizophrenia.
Weight and Metabolic Risk
Correll et al. (2009) followed youths starting antipsychotics for the first time and found that, after about 11 weeks, weight increased by 8.5 kg with olanzapine, 6.1 kg with quetiapine, 5.3 kg with risperidone and 4.4 kg with aripiprazole, compared with 0.2 kg in an untreated group. Olanzapine and quetiapine significantly increased cholesterol and triglycerides. Weight gain in adolescence can have lasting cardiometabolic consequences.
Choosing a Medication
With similar efficacy among antipsychotics and large differences in weight gain, the choice rests on side effects. Aripiprazole is FDA approved for schizophrenia in adolescents 13 to 17 and had the smallest weight gain among the agents studied by Correll et al. (2009). Maya starts aripiprazole at 2 mg daily, increasing to 10 mg over two weeks. Molindone is no longer marketed in the United States. Olanzapine is avoided because of its metabolic effects, and her family agrees after seeing the weight data side by side.
Monitoring
Baseline and follow-up measurements include weight, BMI percentile, waist circumference, blood pressure, fasting glucose, lipids and hemoglobin A1c at baseline, 12 weeks and then at least annually, with weight at every visit. Akathisia and other movement effects are assessed with standardized scales. If weight rises more than expected, lifestyle intervention is intensified, and metformin may be considered.
Explaining the Diagnosis to Maya
Maya is told her diagnosis in plain language, with emphasis on the fact that treatment helps and many young people return to school and friendships. She is skeptical that the voices are part of an illness, a common response. Rather than argue, I ask her to track whether the voices become quieter with medication, turning her doubt into an experiment she can observe.
Cannabis and Relapse
Maya does not use cannabis, but many of her classmates do. She learns that cannabis, especially high-potency products, can worsen psychosis and trigger relapse, and she agrees to avoid it. Her parents learn to talk about this without lecturing.
Family Psychoeducation
Maya's parents learn about schizophrenia, the importance of medication adherence, early warning signs of relapse and how to respond calmly to her beliefs without arguing about them. Family psychoeducation reduces relapse. Her parents also need support for their own grief and fear, particularly given the uncle's illness.
Negative Symptoms
Maya's withdrawal, flat expression and low motivation often respond less to medication than hallucinations do. Therapy targets small, concrete goals, such as one walk with her mother each day and one text to a friend each week, and her parents learn that these symptoms are part of the illness, not laziness.
Sleep
Her sleep had shifted to daytime. Restoring a regular schedule supports both mood and the effectiveness of treatment, and her parents help by keeping mornings structured.
School
Maya takes a medical leave from school and returns part time with a Section 504 plan or individualized education program, including reduced workload, a quiet testing room and a staff contact. Returning to school is central to her development and recovery.
Coordinated Specialty Care
Maya is referred to a coordinated specialty care program for first-episode psychosis, which brings together prescribing, individual therapy, family education, help returning to school or work and a case manager in one team. These programs improve engagement and outcomes for young people early in the illness.
Adherence
Adolescents with psychosis often stop medication, especially when side effects appear or when they feel better. Maya's parents supervise her daily dose at first. As she gains insight, responsibility shifts to her. Discussing side effects openly at each visit makes it more likely she will report problems rather than quietly stop.
Safety
Suicide risk is elevated in early psychosis, particularly as insight grows and young people grasp what the diagnosis means. Maya denies suicidal thoughts, but the risk is reassessed at each visit, and her parents are given crisis contacts and asked to secure medications at home.
If Aripiprazole Fails
If Maya does not respond to two adequate antipsychotic trials, clozapine is recommended for treatment-resistant schizophrenia in youth, with its required blood monitoring (McClellan & Stock, 2013).
Conclusion
Maya's gradual decline, hallucinations and delusions, family history and negative workup support early-onset schizophrenia. The TEOSS trial showed that antipsychotics were similarly effective but differed in weight and metabolic effects, and a cohort of youths starting antipsychotics documented substantial weight gain, least with aripiprazole. Her plan combines aripiprazole with metabolic monitoring, family education, school support and coordinated specialty care.
References
Correll, C. U., Manu, P., Olshanskiy, V., Napolitano, B., Kane, J. M., & Malhotra, A. K. (2009). Cardiometabolic risk of second-generation antipsychotic medications during first-time use in children and adolescents. JAMA, 302(16), 1765-1773. https://doi.org/10.1001/jama.2009.1549
McClellan, J., & Stock, S. (2013). Practice parameter for the assessment and treatment of children and adolescents with schizophrenia. Journal of the American Academy of Child and Adolescent Psychiatry, 52(9), 976-990. https://doi.org/10.1016/j.jaac.2013.02.008
Sikich, L., Frazier, J. A., McClellan, J., Findling, R. L., Vitiello, B., Ritz, L., Ambler, D., Puglia, M., Maloney, A. E., Michael, E., De Jong, S., Slifka, K., Noyes, N., Hlastala, S., Pierson, L., McNamara, N. K., Delporto-Bedoya, D., Anderson, R., Hamer, R. M., & Lieberman, J. A. (2008). Double-blind comparison of first- and second-generation antipsychotics in early-onset schizophrenia and schizoaffective disorder: Findings from the Treatment of Early-Onset Schizophrenia Spectrum Disorders (TEOSS) study. American Journal of Psychiatry, 165(11), 1420-1431. https://doi.org/10.1176/appi.ajp.2008.08050756
How this PMH 505 Week 7 example is structured
The PMH/505 Week 7 work usually covers eating disorders and early-onset psychosis. This paper addresses psychosis in an adolescent: careful diagnosis, a thorough medical workup, a medication chosen for its side effect profile when efficacy is similar and a recovery plan that includes family and school. Students search this week as PMH 505 Week 7, PMH505 Wk 7 or PMH/505 Wk 7; all three are the same assignment.
PMH/505 Week 7 questions, answered
What does PMH/505 Week 7 usually ask for?
Many sections ask students to assess and treat an adolescent with an eating disorder or with early-onset psychosis, attending to medical risk, family involvement and careful prescribing.
Do second-generation antipsychotics work better than older ones in early-onset schizophrenia?
In the TEOSS trial, risperidone and olanzapine were not more effective than molindone, a first-generation drug, and olanzapine caused the most weight gain and metabolic change.
How much weight do adolescents gain on antipsychotics?
In a cohort of youths starting antipsychotics for the first time, average gains over about 11 weeks ranged from 4.4 kg with aripiprazole to 8.5 kg with olanzapine.
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