Schizophrenia in Children and Adolescents

Schizophrenia is the presence of hallucinations and delusions causing considerable psychosocial dysfunction and lasting 6 months.

(See also Schizophrenia in adults.)

Onset of schizophrenia is typically from mid-adolescence to the mid-30s, with a peak age of onset in the 20s. Features in adolescents and young adults are similar. Schizophrenia in prepubertal children (childhood-onset schizophrenia), in which symptoms similar to those of the adolescent/young adult-onset form develop before age 13, is extremely rare (1).

Although the first episode usually occurs in young adults, some contributory neurodevelopmental events and experiences occur earlier (eg, during the perinatal period).

These perinatal risk factors include the following:

• Genetic disorders (particularly those that increase risk of childhood onset)

• Exposure to certain drugs or substances (eg, cannabis) during a vulnerable period

• Prenatal undernutrition

• Labor complications, hypoxia, perinatal infection, placental abruption or insufficiency

• Childhood brain injury

Other risk factors, which occur later (eg, illicit drug use later in adolescence), may then trigger the onset of schizophrenia.

Manifestations of childhood-onset schizophrenia are usually similar to those in adolescents and adults, but delusions and visual hallucinations (which may be more common among children) may be less elaborate. Additional characteristics also help distinguish childhood-onset schizophrenia from the adolescent/young adult form (1):

• More severe symptoms

• A strong family history

• Increased prevalence of genetic abnormalities, developmental abnormalities (eg, pervasive developmental disorder, intellectual disability), and motor abnormalities

• Increased prevalence of premorbid social difficulties

• Insidious onset

• Cognitive deterioration

• Neuroanatomic changes (progressive loss of cortical gray matter volume, increase in ventricular volume)

Sudden-onset psychosis in young children should always be treated as a medical emergency with a thorough medical assessment to search for a physiologic cause of the mental status change; these causes include (2) the following:

• Therapeutic drugs (eg, stimulants, corticosteroids, anticholinergics)

• Recreational drugs (eg, cannabis)

• Central nervous system (CNS) disorders, including infection (viral, bacterial, parasitic), tumors, demyelinating diseases, injury, seizures, or migraines

• Autoimmune disorders (eg, anti-NMDA [N-methyl-d-aspartate] receptor encephalitis [3], SLE)

• Endocrinopathies (eg, hyperthyroidism, hypocortisolemia)

• Sleep disorders

• Metabolic disorders (porphyria, Wilson disease, GM2 gangliosidosis)

• Lysosomal storage diseases

• Nutritional deficiencies (magnesium and vitamins A, D, B1, B3, B12)

• Chromosomal abnormalities (22.11q, XXY, XO, fragile X, Prader-Willi, Fahr's Dis)

• COVID-19 (4–7)

Recent research indicates that there is an increased risk of developing certain psychotic disorders (namely, bipolar disorder and schizophrenia) among adolescents who use cannabis products containing tetrahydrocannabinol (THC; 8). This increased risk is not explained by genetic factors. There is concern that the legalization of marijuana may give adolescents (and their parents) a false sense of security about the safety of this common illicit drug.

There are several reports of psychoses in adolescents with symptomatic (6, 7 ) and asymptomatic (5, 4 ) COVID-19 infections as well as increased rates of admissions to psychiatric units for psychosis in youths without COVID infections (9).

Treatment of schizophrenia in children and adolescents is complex, with variable outcomes, and referral to a child and adolescent psychiatrist is strongly recommended.