Psychotic Symptoms and Disorders

As a pediatrician, you will not generally be asked to diagnosis and treat psychotic disorders.  However, psychotic disorders have a lifetime prevalence of about 3%.

The onset of symptoms of psychotic disorders begins in adolescence with diagnosis rates peaking in late adolescence and early adulthood. 

You have a critical role in the early identification of the psychosis prodrome, because early identification and intervention can help to preserve long-term functioning.

The Psychosis Prodrome

The presence of 1 or more of the following conditions increases risk of developing a psychotic disorder.  The presence of all 3 greatly increases the risk; these constitute the antecedent triad of psychosis risk.

  • speech or motor abnormality
  • social, emotional or behavioral problems
  • psychotic-like experiences

Early motor development

Children who go on to develop schizophrenia have

  • Later unsupported walking
  • Later unsupported standing
  • Later unsupported sitting
  • than did their peers, but no difference in 
    • Unsupported head control
    • Object grasping

Psychotic-like experiences

The prevalence of auditory hallucinations among 

  • children aged 9–12 years is 17%, 
  • adolescents is 7.5 %,
  • adults is 5–8 %. 

The persistence of psychotic-like experiences through puberty constitutes a high risk for a psychotic disorder. 

  • Of 9-12 year olds with psychotic-like experiences, 40.9% reported distress or functional impairment associated with these experiences, particularly those with the antecedent triad (68.1 %). 
  • 39% of children who reported PLEs at baseline continued to report these experiences in adolescence.
  • Persistent PLEs from childhood (9–11 years) were associated with internalizing and externalizing psychopathology in adolescence, as well as with schizophrenia (Laurens and Cullen 2016).

Asking children about psychotic-like experiences:

  • Some people believe that their thoughts can be read.  Have other people read your thoughts?
  • Have you ever believed that you were being sent special messages through the television?
  • Have you ever thought that you were being followed or spied upon?
  • Have you ever heard voices that other people could not hear?
  • Have you ever felt that you were unter the control of some special power?
  • Have you ever known what another person was thinking even though that person wasn't speaking?
  • Have you ever felt as though your body had been changed in some what that you could not understand?
  • Do you have any special powers that other people don't have?
  • Have you ever seen something or someone that other people could not see?

Symptoms of Social Withdrawal

  • Would rather be alone than with others
  • Refuses to talk
  • Secretive, keeps things to self
  • Too shy or timid
  • Stares blankly
  • Sulks a lot
  • Underactive, slow moving, or lacks energy
  • Unhappy, sad, or depressed
  • Withdrawn, doesn’t get involved with others

While the differential for social withdrawal includes depression, substance use, anxiety and traumatic experiences, essentially all psychotic episodes are preceded by social withdrawal (Cannon et al 2017).

Those who do not go on to develop psychosis are not false positives.

Prodromal symptoms and signs of psychosis are related to  

  • anxiety, depression, and substance use disorders
  • impairments in academic performance and occupational functioning
  • difficulties with interpersonal relationships 
  • decreased subjective quality of  life
  • suicide risk

The sooner in the prodrome you can intervene, the more likely you help preserve functioning.

This timeline, adapted from Thomas and Woods (2006), illustrates the level of functioning in individuals who will develop a psychotic disorder relative to average functioning (the straight line across the upper part of the graph).  There is baseline imairment in the premorbid period, an abrupt decline in functioning during the prodrome, and severe decline during the first episode.  DUP indicates "duration of untreated psychosis" and the longer the duration, the greater impact on functioning.  


Early recognition matters.

Meta-analysis of formal interventions lasting > 12 months for high risk patients:

  • The 1 year risk for transition from a prodromal stage to first episode psychosis was reduced, on average, by 54% (p < 0.001).
  • The effect of the interventions persisted: the risk of becoming psychotic over 24-48 months was reduced by 36% (p = 0.016) (Van der Gaag et al 2013).

Social skills training to prevent bullying and social exclusion

Children who already have some delay in cognitive, social, or motor development are at even higher risk for being bullied.

Bullying often results in social isolation and chronic stress.

A prospective study on >1,000 adolescents:

  • When exposure to bullying stopped over course of the study, the incidence of psychotic experiences decreased significantly 
  • Interventions that stop bullying can impact the expression of psychosis vulnerability (Sommer et al 2016).

Early interventions to prevent drug abuse

Drug abuse, especially when initiated in the early teens, is a risk factor for schizophrenia. 

Interventions for teens and their parents which improve family communication and rule-setting can reduce the rate of subsequent drug abuse.

Unknown the extent to which such interventions impact rates of conversion to schizophrenia, but if you see a child with risk factors for psychosis, messages around drug use should be clear. 

Exercise participation

Kids at risk for psychosis have lower rates of exercise participation than do their peers.

Low motivation and negative symptoms are factors that keep high risk patients from exercise.

Physical exercise may improve performance on different cognitive measures in patients with schizophrenia. Encouraging and rewarding exercise from an early age in high-risk patients may help protect cognition and slow rate of conversion.

How do you talk to kids and families about being at risk for psychosis?

Consider the risks and benefits of disclosure of your concerns.

Communicating information about increased risk may cause anxiety, but may be beneficial for the child and family: it may validate perceived social or cognitive problems or emerging psychotic experiences. 

Disclosure provides the opportunity to educate child and family about early-symptom recognition and lifestyle adjustments. 

More extensive discussions of ethical aspects of disclosing risk status may be found in Mittal et al, Bioethics, 2015.


Cannon, T. D., van Erp, T. G., Bearden, C. E., Loewy, R., Thompson, P., Toga, A. W., Huttunen, M. O., Keshavan, M. S., Seidman, L. J., & Tsuang, M. T. (2003). Early and late neurodevelopmental influences in the prodrome to schizophrenia: Contributions of genes, environment, and their interactions. In Schizophr Bull (Vol. 29, Issue 4, pp. 653–669).

Fusar-Poli, P., Borgwardt, S., Bechdolf, A., Addington, J., Riecher-Rössler, A., Schultze-Lutter, F., Keshavan, M., Wood, S., Ruhrmann, S., Seidman, L. J., Valmaggia, L., Cannon, T., Velthorst, E., De Haan, L., Cornblatt, B., Bonoldi, I., Birchwood, M., McGlashan, T., Carpenter, W., … Yung, A. (2013). The Psychosis High-Risk State. JAMA Psychiatry, 70(1), 107–120.

Laurens, K. R., & Cullen, A. E. (2016). Toward earlier identification and preventative intervention in schizophrenia: Evidence from the London Child Health and Development Study. Social Psychiatry and Psychiatric Epidemiology, 51, 475–491.

Mittal, V. A., Dean, D. J., Mittal, J., & Saks, E. R. (2015). Ethical, Legal, and Clinical Considerations when Disclosing a High-Risk Syndrome for Psychosis. Bioethics, 29(8), 543–556.

Sommer, I. E., Bearden, C. E., van Dellen, E., Breetvelt, E. J., Duijff, S. N., Maijer, K., van Amelsvoort, T., de Haan, L., Gur, R. E., Arango, C., Díaz-Caneja, C. M., Vinkers, C. H., & Vorstman, J. A. (2016). Early interventions in risk groups for schizophrenia: What are we waiting for? NPJ Schizophrenia, 2, 16003.

Thomas, L. E., & Woods, S. W. (2006). The schizophrenia prodrome: A developmentally informed review and update for psychopharmacologic treatment. In Child Adolesc Psychiatr Clin N Am (Vol. 15, Issue 1, pp. 109–133).

van der Gaag, M., Smit, F., Bechdolf, A., French, P., Linszen, D. H., Yung, A. R., McGorry, P., & Cuijpers, P. (2013). Preventing a first episode of psychosis: Meta-analysis of randomized controlled prevention trials of 12month and longer-term follow-ups. Schizophrenia Research, 149(1–3), 56–62.