What are the symptoms of schizophrenia in children?

Symptoms of Schizophrenia in Children

Children with schizophrenia present with auditory hallucinations (most common positive symptom), delusions related to childhood themes that are less complex than in adults, flat or inappropriate affect (the predominant negative symptom), disorganized speech, and marked deterioration in functioning below their previous developmental level. 1, 2

Core Psychotic Symptoms

Positive Symptoms:

• Auditory hallucinations are the most frequent positive symptom in childhood-onset schizophrenia, often presenting as elementary auditory experiences 2
• Visual and tactile hallucinations occur but are rarer than auditory hallucinations 2
• Delusions are present but less complex than in adolescents and adults, typically relating to childhood themes rather than elaborate systematic beliefs 2, 3
• Only one psychotic symptom is required for diagnosis if: delusions are bizarre, hallucinations include a voice providing running commentary on the child's behavior/thinking, or two or more voices converse with each other 1, 4

Negative Symptoms (Predominant):

• Flat or inappropriate affect is the most prominent negative symptom 2, 3
• Affective flattening and blunted emotional responses 1
• Paucity of thought or speech 1
• Social withdrawal and isolation 1, 3
• Anergia (lack of energy) 1

Disorganization:

• Formal thought disorder is common, manifesting as disorganized speech patterns 3
• Grossly disorganized or catatonic behavior 1, 4
• Tangentiality and circumferentiality in speech 1

Functional Deterioration (Required for Diagnosis)

A marked deterioration from previous functioning is present in all children with schizophrenia and represents a key diagnostic criterion 1, 2, 3:

• Failure to achieve age-appropriate levels of interpersonal development 1, 4
• Academic decline or failure to progress academically as expected 1
• Deterioration in self-care and daily functioning 1, 3
• Social isolation and withdrawal from peer relationships 1

Prodromal Phase Symptoms (Often Precede Overt Psychosis)

The onset is insidious in at least 75% of children, with prodromal symptoms appearing before full psychotic symptoms emerge 2, 3:

• Marked social isolation and withdrawal 1
• Deterioration in occupational/academic functioning 1
• Peculiar behaviors such as food hoarding and poor hygiene 1
• Odd beliefs or perceptions that don't meet full criteria for delusions 1
• Poverty of speech or speech content 1

Premorbid Developmental Impairments

Premorbid developmental abnormalities are more frequent and pronounced in childhood-onset schizophrenia compared to later-onset forms 2, 3:

• Language deficits present from early development 2, 3
• Motor developmental delays 2, 3
• Social deficits affecting peer relationships 2, 3
• This "pan-dysmaturation" is reported from the first months of life in more than half of children who develop childhood-onset schizophrenia 2

Duration Requirements

Symptoms must be present for at least 6 months total, including 1, 4:

• Active phase with overt psychotic symptoms lasting at least 1 month (or less if successfully treated) 1
• May include prodromal phase before active symptoms 1
• May include residual phase after active symptoms 1

Critical Diagnostic Pitfalls

Most children reporting hallucinations are not schizophrenic, highlighting the need for careful differential diagnosis 4, 5:

• True psychotic symptoms must be differentiated from psychotic-like phenomena due to developmental delays, trauma exposure, or overactive imagination 1, 5
• Approximately 10% of children from the community report nonpsychotic hallucinations or delusions 2
• Children with developmental speech and language disorders may be mistakenly diagnosed as thought disordered, but they lack other prerequisite schizophrenic symptoms such as hallucinations, delusions, or odd social relatedness 1
• Cultural or religious beliefs may be misinterpreted as psychotic symptoms when taken out of context 4, 5

Bipolar disorder with psychotic features is frequently misdiagnosed as schizophrenia in adolescents, as manic episodes in this age group often include schizophrenia-like symptoms at onset 1, 4, 6:

• Approximately 50% of adolescents with bipolar disorder are initially misdiagnosed as having schizophrenia 4, 5
• Systematic longitudinal reassessment over time is the only accurate method for distinguishing these disorders 1, 4

Pervasive developmental disorders (autism spectrum) must be distinguished by 1:

• The absence or transitory nature of true hallucinations and delusions in autism 1
• Earlier age of onset in autism (generally before age 5) versus schizophrenia (generally after age 5) 1
• Predominance of characteristic deviant language patterns and aberrant social relatedness in autism 1

Substance-induced psychosis, particularly from cannabis, must be ruled out before diagnosing schizophrenia 6:

• Cannabis use should be discontinued immediately and a 4-6 week observation period is recommended before making a definitive diagnosis 6
• A toxicology screen should be obtained to confirm substance use 6

Age-Specific Considerations

Very-early-onset schizophrenia (VEOS) is defined as onset before age 13 years, while early-onset schizophrenia (EOS) is defined as onset before age 18 years 1:

• VEOS is extremely rare with point prevalence <1/10,000 before age 12 3
• The incidence rises dramatically in adolescence, with prevalence estimated at 0.23% between ages 13-18 years 3
• The insidious onset, high rates of premorbid problems, and clinician hesitancy to diagnose schizophrenia in children usually delay recognition of the syndrome 2

Prognosis Indicators

An impaired outcome is reported in approximately 50-60% of children with schizophrenia 2, 3:

• Negative symptoms often persist even when positive symptoms improve with treatment 4
• Earlier age of illness onset is a consistent risk factor for treatment-resistant schizophrenia 7
• Cognitive deficits and impaired functioning are common 7