Symptomatic Presentation and Initial Treatment for Schizophrenia in Children and Adolescents

Christoph U. Correll, MD

Department of Psychiatry, The Zucker Hillside Hospital, Glen Oaks, and the Department of Psychiatry and Behavioral Sciences, Albert Einstein College of Medicine of Yeshiva University, Bronx, NY

Schizophrenia in children is characterized as either early-onset (beginning at ages 13 to 18 years) or very-early-onset (occurring before 13 years of age).1 Very-early-onset schizophrenia is rare, and affects approximately twice as many boys as girls; in adolescence, the risk of schizophrenia steadily increases and the rates equalize between the sexes.1

The criteria for schizophrenia include both positive and negative symptoms that persist over time. Positive symptoms include delusions, hallucinations, and disorganized speech or behavior, while negative symptoms are deficits such as affective flattening, alogia, and anhedonia.2 Significant social or occupational or academic dysfunction is another diagnostic criterion for schizophrenia. Childhood-onset schizophrenia is associated with greater cognitive impairment, increased negative symptoms, and more severe social consequences than adult-onset schizophrenia.3–5

Course of Childhood-Onset Schizophrenia

In the premorbid stage, children with schizophrenia tend to have deficits in cognitive measures such as executive functioning and sustained attention4; high rates of behavioral problems, social withdrawal, and academic difficulties6; and impairments in speech, language, and motor skills.7 Childhood-onset schizophrenia is associated with a greater reduction of gray matter brain volume than that seen in adult-onset schizophrenia.8 This gray matter loss has been correlated with symptom severity and impairments in cognitive functioning over time and may account for the increased impairment in early-onset schizophrenia versus adult-onset schizophrenia. Children under the age of 13 years generally have a more insidious onset of symptoms (ie, lasting ≥ 1 year), while adolescents have both acute and insidious types of onset.1

In the onset phase of schizophrenia, the prodromal stage, patients experience a worsening of premorbid abnormalities or a marked change from baseline functioning. The acute phase is dominated by positive symptoms and deterioration in functioning and may last 1 to 6 months, or longer if treatment response is slow.1 Response to acute-phase treatment is followed by the recovery phase, in which patients may experience residual, primarily negative, symptoms. Positive symptoms may not return for several months, but patients will cycle between acute and recovery stages, and chronic impairment may result from persistent residual symptoms. Eventually, patients will experience less severe acute psychotic breaks, but their overall functioning will be decreased compared with their premorbid functioning. These stages typically are the same in adult-onset schizophrenia, but patients with early-onset schizophrenia tend to have a more chronic course and worse functional outcomes than patients with later onset (AV 1).9 Premorbid functioning and IQ are the best predictors of outcome for children and adolescents with schizophrenia.10

Diagnostic Difficulties

Differentiating childhood-onset schizophrenia from mood or other psychiatric disorders is difficult, and, therefore, misdiagnosis is common.10 For instance, hallucinations may be difficult to differentiate from intense, internal preoccupations due to anxiety or from obsessions that border on delusional thoughts in obsessive-compulsive disorder. A history of significant trauma can lead to severe anxiety and psychotic-like experiences in children. Even developmentally appropriate imagination can sometimes be hard to differentiate from psychotic symptoms such as basic auditory hallucinations, which are the most common positive symptom in children with schizophrenia.11 This is particularly true in younger patients, who may misremember events or attribute their actions to some outside control (eg, “the devil told me to do this”).


Children with pervasive developmental disorders can be illogical and irrational in their behaviors or disorganized in their behavior or speech. Aggression and hostility, frequent symptoms in childhood presentations, can span across multiple disorders, and determining whether the hostility is associated with psychosis can be difficult. Depressive symptoms are also difficult to differentiate from negative symptoms in children. In addition, both clinician bias against a diagnosis considered to be stigmatizing and clinician inexperience with early-onset psychotic symptoms can delay diagnosis or lead to ineffective or inappropriately delayed treatment.

Certain clinical features can help to differentiate schizophrenia from affective or other psychotic disorders. In a prospective study12 comparing symptom structures of early-onset schizophrenia, bipolar disorder, and psychosis NOS, negative symptoms were predictive of a diagnosis of schizophrenia, while behavioral problems and dysphoria were common to all 3 disorders. Premorbid developmental impairments have been found in more than 80% of patients with early-onset schizophrenia
(AV 2),7 and, along with an insidious onset of symptoms, can help to differentiate schizophrenia from bipolar disorder.11 A personal history of ADHD, a family history of bipolar disorder, and the presence of an anxiety disorder are indicative of bipolar disorder.11,13 A diagnosis of psychotic disorder NOS in childhood is not a reliable predictor of a psychotic disorder outcome because many patients instead go on to develop mood, personality, or obsessive-compulsive disorders.14

Initial Treatment

Treatment should include pharmacotherapy for both the positive and negative symptoms of schizophrenia and for any comorbid conditions (eg, substance abuse or developmental problems). Antipsychotics, including atypical antipsychotics, have proven efficacy in children and adolescents for both acute treatment of psychosis and as maintenance treatment to decrease the risk of relapse.15 Pediatric patients, however, are at greater risk than adults for certain adverse effects and should be monitored closely. (For additional information, see the J Clin Psychlopedia activity “Safety and Tolerability of Antipsychotic Treatment for Young Patients With Schizophrenia.”)

Individual or group therapy and age-appropriate psychosocial interventions addressing problem solving, communication skills, and psychosocial functioning are also recommended for children and adolescents with schizophrenia. Additionally, support and treatment education for the family are recommended, and many patients will need community support programs, special educational services, and day treatment or partial hospitalization programs.1

For Clinical Use


  • Be aware that schizophrenia occurring before the age of 13 years usually has an insidious onset, while schizophrenia occurring in adolescence may have either an acute or insidious onset
  • Become familiar with symptoms that may be indicative of schizophrenia in children, such as negative symptoms and premorbid developmental abnormalities
  • Devise a comprehensive treatment plan that includes both pharmacotherapy and psychosocial interventions



ADHD = attention-deficit/hyperactivity disorder
NOS = not otherwise specified

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