Childhood-Onset Schizophrenia Clinical Presentation

Updated: Mar 25, 2019
  • Author: Marshal E Ash, DO; Chief Editor: Caroly Pataki, MD  more...
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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 a study of child/adolescent patients in South Carolina diagnosed with schizophrenia spectrum disorder, patients diagnosed with schizophrenia were commonly also diagnosed with speech/language/educational disabilities, MR/ID, PDD/ASD, CD/ODD, ADHD. [68] 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. [69]

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. [70]

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 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. [71] True hallucinations are usually vivid but not detailed, usually elicit a response from the child, and occur when the child is fully awake. [72] Delusions are present in approximately 60% of patients. Delusions and thought disorders were most predictive of true non-affective psychosis in childhood-onset schizophrenia via a UK study. [56]

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. [73, 74, 75] Adolescents with early-onset schizophrenia displayed deficits in Theory of Mind assessment and executive function compared to adolescents without early-onset schizophrenia. [76] 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. [77]

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. [78]

When studying siblings of patients diagnosed with childhood-onset schizophrenia, siblings displayed cognitive skill learning deficits compared to the healthy control group. When given the WPT (weather prediction test, an assessment of learning probabilistic associations), siblings of patients with childhood-onset schizophrenia performed worse than the control group after both 50 trials and 800 trials. The authors of that study suggested “that a behavioral impairment in probabilistic classification learning in healthy, unaffected siblings mirrors the deficits seen in patients and thus may reflect genetic liability for the disease.” [79]

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 medications, nonprescribed medications, and drugs of abuse 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. [80]


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. [81]

The most common abnormalities in individuals with adult schizophrenia are "soft signs," including incoordination, persistence of developmental reflexes, and impaired ocular pursuit movements. Neurological soft signs were found in adolescents with schizophrenia as well. [82]

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. [83]