Early-onset Schizophrenia is defined by an onset prior to adulthood, with an onset prior to 12 years of age being rare (Vyas et al., 2011). The Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association, 2013) identifies early onset as being associated with a worse prognosis. The DSM-5 further emphasizes that childhood schizophrenia is more difficult to diagnosis, where as compared to adults, “childhood delusions and hallucinations may be less elaborate” (p. 102), and visual hallucinations should be “distinguished from normal fantasy play” (p. 102). Furthermore, hallucinations are not uncommon in both healthy children and children with a psychiatric illness, yet often with childhood schizophrenia, hallucinations are multimodal (Driver, Gogtay, & Rapoport, 2013). Diagnostic criteria for schizophrenia are “age independent” (Stentebjerg-Olesen, Pagsberg, Fink-Jensen, Correll, & Jeppesen, 2016), which is supported by diagnostic stability throughout the lifespan.
Yet there is still ambiguity with differential diagnosis for early-onset schizophrenia. As noted by Stentebjerg-Olesen, Pagsberg, Fink-Jensen, Correll, and Jeppesen (2016) there is “considerable overlap in phenomenology between schizophrenia and affective symptomatology in children and adolescents with psychosis” (p. 411). As cited in Stentebjerg-Olesen et al. (2016), Weary (1992) and Masi et al. (2006) the most common diagnostic mistake is a “misclassification of a mood disorder as schizophrenia” (p. 411). Other diagnostic considerations extend to pervasive developmental disorders, severe personality disorders or traits, posttraumatic stress disorder (PTSD), generalized anxiety disorder, and obsessive-compulsive disorder (Driver et al., 2013). As such understanding the “developmentally sensitive descriptions of symptomatology, clinical characteristics, and outcome” may offer a clearer diagnostic picture for early-onset schizophrenia (Stentebjerg-Olesen et al., 2016, p. 411).
In a systematic review of studies from 1990 to 2014 of early-onset psychosis, Stentebjerg-Olesen et al. (2016) found that hallucinations were mainly auditory (81.9%) and delusions were mostly persecutory and of reference (77.5%). Formal thought disorder was found in 65% of the patients and 36% had disorganized speech or pressured speech. Negative symptoms were found in about half of the patients, and half of the group with negative symptoms experienced positive symptoms as well. Comorbidity was high at 32% for substance abuse and 33.5% for ADHD and disruptive behavioral disorders. Trauma is also thought to play a significant role in early-onset schizophrenia, with Stentebjerg-Olesen et al. (2016) finding a high level of comorbid PTSD (34%).
Stentebjerg-Olesen et al. (2016) found that “severity of positive symptoms at baseline, the severity and the persistence of negative symptoms, longer [duration of untreated psychosis], and poorer premorbid adjustment each predicted a worse outcome of illness” (p. 423). Longer duration of untreated psychosis and poorer premorbid adjustment were also associated with poorer outcomes. In short, patients with early-onset schizophrenia were found to have substantial impairment from positive and negative symptoms, disorganized behavior, and pre- and comorbid conditions and diagnoses. The authors note that the “high prevalence of negative and disorganized” symptoms “may mask the emergence of psychosis” and delay identification and treatment (p. 424).
Dannie S. Harris
WKPIC Doctoral Intern
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
Driver, D. I., Gogtay, N., & Rapoport, J. L. (2013). Childhood onset schizophrenia and early onset schizophrenia spectrum disorders. Child and Adolescent Psychiatric Clinics of North America, 22(4), 539-555.
Stentebjerg-Olesen, M., Pagsberg, A. K., Fink-Jensen, A., Correll, C. U., & Jeppesen, P. (2016). Clinical characteristics and predictors of outcome of schizophrenia-spectrum psychosis in children and adolescents: A systematic review. Journal of Child and Adolescent Psychopharmacology, 26(5), 410-427.
Vyas, N. S., Patel, N. H., & Puri, B. K. (2011). Neurobiology and phenotypic expression in early onset schizophrenia. Early Intervention in Psychiatry, 5, 3-14.