OH! That’s a completely different thing entirely. Command hallucinations are very powerful and can be dangerous, and escalate quicker than other hallucinations from what I understand. They typically involve commands to do things like hurt others or themselves. My daughter gets those occasionally but it’s infrequent currently. And right now she’s still able to distinguish right and wrong so she fights against the violent ones. Somehow, despite all of this, that’s a line she doesn’t or won’t cross very easily (thank goodness!)
Has he been making any verbal statements lately? Showing signs of loss of control? Been violent to inanimate objects? Having rages or irrational behaviors you can’t talk him out of? Do you have a safe room in your house? Somewhere that either he can be locked or you and your sons can be for safety? Do you have a safety plan for you and the other kids? How old are the twins? What kind of family support do you have?
I can only tell you what I’ve done to determine when we’re in a “crisis” that needs intervention, and when it’s just a bad day. Maybe that will help you (be warned, it’s a lot of daily monitoring and note taking).
I would monitor and track his symptoms to determine if there’s an increase in symptoms. For me, I give a score for each day based on symptoms. Some symptoms are allowed to be numbered individually (i.e. how many hallucinations she has in a day, how many times she hears voices, how many times she discusses killing herself or wanting to die) and others are just a single score of 1 (i.e. sad or down, afraid). I total those up and it helps me to see when her symptoms are worse. I have 25 symptoms I track for her based on the DSM’s diagnostic criteria for her disorders (I use an Excel spreadsheet - easier to visually track that way). A score below 10 is acceptable but anything approaching 20 is close to crisis. Our highest score was an 18 out of 25 and we admitted her the next day. This last time it was a 16 of 25 but she was very suicidal. If she talks about suicide or wanting to die two days in a row, we consider that a mental health crisis and work to admit her again. You’ll have to build your own methods for judging the behavior and symptoms based on your child. I also keep a log of activities, situations, etc.
She comes to me and describes her hallucinations and other events so I can record them. Be warned - that may break your heart more than anything else once you open that door but it gives a really clear channel of communication. I’ve slowly but surely built her trust up to the point where I’m a nonjudgemental confidante. She still has times when she doesn’t trust me or has paranoia but I’m still able to work through it with her by finding ways to back the stress down for her. It’s very time-consuming.
For my daughter, she will tell me things she will tell no one else, even and especially doctors, because she’s learned not to trust them (IVs, admissions, etc) and fears them on an instinctive level. They, unfortunately, have collectively added to her paranoia so she now believes they will hurt her, not help her. In addition, she lacks insight and many times after an episode she forgets she even has one.
Autistic twins plus a schizophrenic son? My heart goes out to you - that’s a daily feat of mental strength the likes of which I cannot imagine. I have two mentally disabled children myself and no day is a cake walk. Most days though, I wouldn’t trade it for anything. They make me a better person than I ever would be otherwise. Hang in there and try to remember to take it one day at a time!