9 Child and adolescent psychiatry9.7 Disorders in childhood and adolescence
9.7.3 Psychosis in children and adolescents
5 min read1 figure
Written by Resident Doctor Committee · Published
Definitions and age of onset
Very early onset (childhood-onset) schizophrenia begins with psychotic symptoms before 13 years, and early-onset schizophrenia begins before 18 years.
These terms describe age at onset, not separate diagnoses, and adult criteria apply, read in the light of development.
The International Classification of Diseases, 11th revision (ICD-11), requires characteristic symptoms for at least one month.
Epidemiology and risk
Schizophrenia is almost unknown before 10 years, its incidence climbs through adolescence, and most onsets before 18 fall at 15 years or later.
Psychotic-like experiences are far more common than psychotic disorder and often resolve, so voices in a child need developmental, emotional, sleep, substance and medical causes explored.
Disorganised thinking in a prepubertal child is far more often part of a neurodevelopmental disorder than of schizophrenia; with restricted, repetitive behaviour it points to autism spectrum disorder.
Earlier onset carries greater familial and neurodevelopmental loading, and frequent high-potency cannabis use is associated with psychotic disorder.
Clinical features
Feature | Frequency in childhood-onset schizophrenia |
|---|---|
Auditory hallucinations | About 95%, the most common |
Visual hallucinations | About 80% |
Delusions | About 60% |
Negative symptoms are more prominent than in adult-onset illness, as part of a more severe neurodevelopmental profile.
Hallucinations, negative symptoms and disorganisation are frequent, but catatonic signs are uncommon.
Cognitive difficulties, depression, anxiety and suicidal thinking may coexist.
Course and prognosis
Schizophrenia beginning before 18 responds less well to treatment than adult-onset schizophrenia.
Adolescent-onset schizophrenia usually runs a relapsing course, improving on treatment and then returning in acute episodes over many years rather than remitting for good.
Among psychoses beginning in childhood or adolescence, schizophrenia has the least favourable long-term outcome, through insidious onset, negative symptoms, disrupted development and frequent relapse.
Predictor | Effect on outcome |
|---|---|
Longer duration of untreated psychosis | Poorer; the consistent and modifiable predictor |
Insight, sex | Less consistent, and not modifiable in the same way |
Acute onset | Better |
Affective features | Better |
Differential diagnosis
Condition | What marks it out |
|---|---|
Early-onset schizophrenia | Sustained first-rank symptoms (third-person voices, thought insertion) after a prodrome of withdrawal and falling school performance; flat affect; no mood episode |
Schizotypal disorder | An enduring pattern, not an episode: eccentric dress, vague speech, magical thinking, ideas of reference held with doubt; lasts years (ICD-11: at least two) |
Acute and transient psychotic disorder | Abrupt psychosis within days in a previously well young person; content and mood change hour to hour; full recovery within weeks |
Substance-induced psychotic disorder | Begins during heavy use of a substance such as a stimulant, with formication and skin picking; clears within days of stopping |
Bipolar I disorder with psychotic features | Psychosis confined to a manic episode and congruent with its mood; full recovery between episodes |
Schizoaffective disorder (ICD-11) | Full mood episode and schizophrenia requirements met together for at least a month |
Autism | Social differences and restricted behaviour from the developmental baseline; the two can coexist, so look for new psychotic symptoms |
Obsessive-compulsive disorder | Obsessions and compulsions, sometimes with poor insight |
Trauma and dissociation | Voices and hypervigilance in a trauma context; voice content alone does not decide |
Epilepsy | Brief, stereotyped perceptual events with changes in awareness and automatisms |
Schizoaffective disorder is told from bipolar disorder with psychotic features because its psychosis also persists outside the mood episode.
Organic causes
Acute onset, confusion, seizures, catatonia, focal signs, regression or very young age raise concern about a medical cause.
Cause | Features alongside psychosis |
|---|---|
Delirium | Acute change, fluctuating attention, systemic or neurological findings |
Anti-NMDA (N-methyl-D-aspartate) receptor encephalitis | Subacute change, seizures, dyskinesia, autonomic disturbance, reduced consciousness |
Wilson's disease | Movement disorder, liver abnormalities, Kayser-Fleischer rings |
Niemann-Pick disease type C | Regression, vertical gaze palsy, splenomegaly |
22q11.2 deletion | Palatal and cardiac anomalies, hypocalcaemia; about a quarter develop schizophrenia spectrum illness |
Imaging is guided by findings: electroencephalography for suspected seizures, magnetic resonance imaging for neurological or atypical features, and no routine structural imaging in every first episode.
At-risk mental state
Most young people with an at-risk mental state do not progress to psychosis.
They are offered individual cognitive behavioural therapy (CBT), with or without family intervention, and treatment of any coexisting disorder.
Antipsychotic or other drug prophylaxis is not offered to prevent transition.
First-episode treatment
National Institute for Health and Care Excellence (NICE) first-line treatment is an oral antipsychotic, started low and titrated, with a tolerable metabolic profile, plus family intervention and individual CBT from the outset.
Family intervention runs to at least 10 sessions over 3 to 12 months, and CBT to at least 16 planned sessions.
If a young person declines medication, offer psychological treatment and review within a month.
NICE advises against rapid neuroleptisation (an antipsychotic loading dose) in under-18s, but allows brief overlap of two antipsychotics during a switch.
Young people are especially prone to weight gain, metabolic effects, dystonia, sedation and raised prolactin; olanzapine carries substantial weight risk and risperidone raises prolactin.
Aripiprazole is licensed for schizophrenia from 15 years and lurasidone from 13 years.
Monitoring
Inpatient admission by itself calls for a baseline electrocardiogram before an antipsychotic starts, as do product requirements and cardiovascular history or findings.
Weight is plotted on a growth chart weekly for six weeks, at 12 weeks, then six-monthly.
Pulse, blood pressure, glucose or glycated haemoglobin, lipids and prolactin are checked at baseline, at 12 weeks, then six-monthly.
Treatment resistance and clozapine
An antipsychotic given below its effective dose has not had an adequate trial, so titrate to the target dose before switching, augmenting or moving to clozapine.
Before calling the illness resistant, review the diagnosis, adherence, dose and duration, psychological treatment, substance use and physical illness.
Clozapine is offered after two adequate sequential antipsychotic trials of 6 to 8 weeks each, at least one second-generation, with adherence assured.
A first-generation antipsychotic need not be tried before clozapine.
Below 16 years, UK product information does not establish clozapine's safety and efficacy, so prescribing it is a specialist off-label decision.