Early onset schizophrenia (EOS), with an onset prior to age 18, is an often debilitating disorder characterized by deficits in affect, cognition, and the ability to relate socially with others. This is a rare, but serious disorder, often associated with significant morbidity, chronicity, and psychosocial impairment.

The first important point is that psychosis and schizophrenia are not interchangeable. Psychosis is a general term referring to disordered processing of thoughts and impaired grasp of reality. As such, psychosis or psychotic-like symptoms can occur as a part of many psychiatric syndromes other than schizophrenia, including

Intermittent psychotic symptoms may be frequently observed in children ill enough to require psychiatric hospitalization for a number of disorders. The evaluation of psychotic symptoms in children is complicated as well, as childhood is a natural time for fantasy, imaginary friends, and other illogical thoughts. Differentiating an “overly rich imagination” from a thought disorder may occasionally be difficult. Illogical thinking, social isolation, and inappropriate affect may be seen in autistic disorder, but very early onset, developmental history, and clinical features of lack of social reciprocity as well as the lack of positive symptoms of schizophrenia (such as hallucinations) differentiate the two disorders. Brief psychotic symptoms may be seen during times of stress for a number of children with a variety of vulnerabilities. The symptoms may respond positively to environmental modifications to decrease stress. The take-home point: Evaluate every patient for psychotic symptoms, but don’t rush to a diagnosis of early onset schizophrenia.

In children with early onset schizophrenia (EOS), hallucinations, thought disorder, and flattened affect are the most consistent symptoms (Table 16.1). It is important to distinguish between psychotic thought processes and developmental delays or language disorders.

The types of schizophrenia include paranoid, disorganized, catatonic, undifferentiated, and residual. Schizophreniform disorder includes the same symptoms as schizophrenia, but the episode lasts between 1 and 6 months, whereas schizophrenia lasts for 6 months or more including the prodromal, active, and residual phases. Good prognostic features of schizophreniform disorder are rapid onset of psychotic symptoms,
confusion, good premorbid social and occupational functioning, and absence of blunted or flat affect.