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Childhood-Onset Schizophrenia Clinical Presentation

  • Author: Annemarie K Loth, MD; Chief Editor: Caroly Pataki, MD  more...
Updated: Sep 03, 2014


Most children who develop schizophrenia have disturbances of behavior and cognition before the onset of characteristic symptoms of psychosis. Delays in speech and language and delays in acquisition of motor milestones are noted in approximately one half of these children. Children who develop schizophrenia have higher rates of impaired social skills and school achievement before presenting signs of schizophrenia. Approximately one third of the children develop symptoms of inattention, hyperactivity, aggression, or rage.

One half of these children have received previous diagnoses, including pervasive developmental disorders (PDDs), attention deficit hyperactivity disorder (ADHD), and internalizing disorders (eg, bipolar disorder, depression, anxiety disorders). In one study, psychotic symptoms appeared, on average, 2.5 years after the initial clinical presentation, and the diagnosis of schizophrenia was made a mean of 2 years after the onset of psychosis.

All of the characteristic symptoms of schizophrenia have been described in persons with childhood-onset schizophrenia. Ballageer et al found that bizarre behavior and negative symptoms were more common in individuals with adolescent-onset schizophrenia compared with those with onset during the adult years.[29]

Compared with adults with schizophrenia, children with schizophrenia have catatonia less often. Changes in affect are common, with blunting or inappropriate affect observed in approximately two thirds of children with schizophrenia. In addition, patients with childhood-onset schizophrenia suffer from significant sleep disturbances, which are highly related to symptom severity.[30]

Hallucinations and delusions

Hallucinations and delusions become more complex and elaborate with increasing age. Hallucinations (auditory more common than visual) are usually the presenting symptom and are reported by approximately 80% of children who receive the diagnosis of schizophrenia.

A recent study by David et al showed that 94.9% of patients who had documented childhood-onset schizophrenia had auditory hallucinations, 80.3% had visual hallucinations, 60.7% had somatic/tactile hallucinations, and 29.9% had olfactory hallucinations. Somatic/tactile and auditory hallucinations occurred almost exclusively in patients who also had visual hallucinations. Patients who had visual hallucinations had lower IQ scores, earlier age of onset, and more severe illness in comparison to patients who did not have visual hallucinations.[31]

Delusions are present in approximately 60% of patients.

Thought disorder and impaired cognition

Approximately one half of children with schizophrenia have a formal thought disorder, although assessment may be more difficult in children than in adults. Caplan and associates demonstrated that loose associations and illogical thinking can be documented reliably.[32, 33, 34] Poverty of speech was not documented. In one study of adolescents, speech samples were obtained from 105 subjects identified as being clinical high risk for a first episode of psychosis (CHR). CHR patients who subsequently experienced psychosis (CHR+) had an elevated rate of illogical thinking and poverty of content in their speech when compared with typically developing controls and CHR patients who did not have a psychotic episode.[35]

Cognitive functioning is often impaired at the onset of childhood schizophrenia. In most series of children with schizophrenia, the average full-scale intelligence quotients (IQs) have been in the 80s, with particular deficits in verbal comprehension, language, and short-term memory. Attention and executive functioning may be impaired. A subsequent decline in full-scale IQ appears to be due to failure to learn rather than to loss of function.

Gochman et al reported that long-term trajectory of IQ measures appears stable, and level cognitive functioning extends 13 years or longer after the onset of psychosis, despite chronic illness and concomitant, progressive loss of cortical gray matter.[36]

Substance abuse

Substance abuse occurs more frequently in individuals with psychosis than in the general population. Patients should be asked about their use of tobacco, alcohol, prescribed drugs, and nonprescribed drugs using a respectful and nonjudgmental approach. Details about the route of administration; quantity, frequency, duration, and pattern of use; and the duration of the current level of use should be elicited.[37]


Physical Examination

Abnormalities in the neurologic examination are observed in as many as one half of adults with new-onset schizophrenia. In one study, Karp et al found significantly more signs of neurologic dysfunction in adolescents with earlier-onset schizophrenia.[38]

The most common abnormalities in individuals with adult schizophrenia are "soft signs," including incoordination, persistence of developmental reflexes, and impaired ocular pursuit movements.

Adolescents with earlier-onset schizophrenia have persistence of primitive reflexes. Compared with a healthy control group, the number of primitive reflexes does not decrease with advancing age in adolescents with schizophrenia. Children with schizophrenia are commonly reported to have delayed motor development and impaired coordination.

Formal measurements of ocular smooth pursuit have demonstrated abnormalities in individuals with childhood-onset schizophrenia.

Research on handedness and schizophrenia has remained replete with inconsistencies.[39]

Contributor Information and Disclosures

Annemarie K Loth, MD Fellow in Child and Adolescent Psychiatry, Indiana University School of Medicine

Annemarie K Loth, MD is a member of the following medical societies: American Psychiatric Association, Indiana Psychiatric Society

Disclosure: Nothing to disclose.


David W Dunn, MD Program Director, Child and Adolescent Psychiatry, Professor, Departments of Psychiatry and Neurology, Indiana University School of Medicine

David W Dunn, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, American Academy of Neurology, American Epilepsy Society, American Psychiatric Association, Child Neurology Society

Disclosure: Received research grant from: Eli Lilly<br/>Honorarium for grant review committee for Department of Defense.

Chief Editor

Caroly Pataki, MD Health Sciences Clinical Professor of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, David Geffen School of Medicine

Caroly Pataki, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, New York Academy of Sciences, Physicians for Social Responsibility

Disclosure: Nothing to disclose.


Angelo P Giardino, MD, PhD Clinical Associate Professor, Department of Pediatrics, Baylor College of Medicine; Medical Director, Texas Children's Health Plan, Inc

Angelo P Giardino, MD, PhD is a member of the following medical societies: Academic Pediatric Association, American Academy of Pediatrics, American Professional Society on the Abuse of Children, Harris County Medical Society, Helfer Society, and International Society for Prevention of Child Abuse and Neglect

Disclosure: Bayer Honoraria Review panel membership; Pfizer Grant/research funds Independent contractor; MedImmune Honoraria Review panel membership

Raj K Kalapatapu, MD Fellow, Addiction Psychiatry, Columbia University College of Physicians and Surgeons

Raj K Kalapatapu, MD is a member of the following medical societies: American Academy of Addiction Psychiatry, American Academy of Child and Adolescent Psychiatry, American Association for Geriatric Psychiatry, American Medical Association, and American Psychiatric Association

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

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Childhood schizophrenia. Early and late gray matter deficits in schizophrenia. Areas of gray matter loss, shown in red and yellow, spread from back-to-front (right to left) over 5 years in composite MRI scan data from 12 teens with childhood-onset schizophrenia, beginning at age 14 (left). Red and yellow denotes areas of greater loss. Source: Paul Thompson, MD, UCLA, Laboratory of Neuroimaging. NIMH media file.
Childhood schizophrenia. Rate of gray matter loss. Composite MRI scan data showing areas of gray matter loss over 5 years, comparing 12 normal teens (left) and 12 teens with childhood-onset schizophrenia. Red and yellow denotes areas of greater loss. Front of brain is at left. Source: Paul Thompson, MD, UCLA, Laboratory of Neuroimaging. NIMH media file.
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