How Childhood Schizophrenia Is Diagnosed

Childhood schizophrenia, also called childhood-onset schizophrenia (COS) or very early-onset schizophrenia, is a severe mental health disorder that is diagnosed in children under the age of 13. It is very rare, affecting less than 0.04% of children.

Childhood-onset schizophrenia is characterized by distorted thinking, altered perceptions, unusual behavior, and unusual use of language and words. It can severely affect a child's development and their ability to function on a daily basis.

What to Know About Childhood-onset Schizophrenia

Verywell / Brianna Gilmartin

Childhood schizophrenia is a difficult disorder to diagnose, partly because it is not well understood. The diagnosis requires the exclusion of other medical or mental health conditions that may have similar symptoms.

The gold standard for diagnosing childhood schizophrenia is using the American Psychiatric Association's criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

When Does Schizophrenia Usually Develop?

The symptoms of schizophrenia usually start in young adulthood, between late adolescence and the early 30s. Symptoms tend to emerge slightly sooner in men than in women. When the condition is diagnosed before the age of 18 but after age 13, it is referred to as early-onset schizophrenia (EOS). EOS is rare, with an estimated prevalence of 0.23%.

Professional Screenings

Schizophrenia typically develops slowly. The early warning signs usually start before the first severe episode (when hallucinations and delusions, called positive symptoms, are experienced for the first time).

If your child's doctor thinks your child may have schizophrenia, they will send them to a mental health provider, who will conduct a psychiatric evaluation and other tests.

Mental Health Evaluation

During an evaluation, a mental health practitioner will observe your child's appearance and demeanor. They will also ask your child about their thoughts, feelings, and behaviors, as well as get input from you about what you have observed. You will also discuss your family's medical history, particularly any mental health conditions.

A mental health professional will assess your child's ability to think and function at an age-appropriate level, as well as their mood, anxiety level, and possible psychotic symptoms.

The diagnostic criteria that are used to diagnose childhood schizophrenia are similar to those that are used to diagnose adults with schizophrenia.

According to the DSM-5, a diagnosis of schizophrenia requires two or more of the following symptoms to be exhibited for a significant portion of time during a six-month period.

  • Delusions
  • Hallucinations
  • Disorganized speech (frequently derails from their train of thought or is incoherent)
  • Grossly disorganized or catatonic behavior
  • Diminished emotional expression or avolition (negative symptoms)

The DSM-5 criteria state that at least one of the symptoms must be delusions, hallucinations, or disorganized speech.

Other criteria for the diagnosis of schizophrenia in the DSM-5 include:

  • Significant problems with and failure to achieve the expected levels of interpersonal, academic, or occupational functioning
  • Symptoms are not caused by the effects of substance use, medication, or a medical condition.

Ruling Out Other Conditions

The DSM-5 also requires a mental health practitioner to rule out schizoaffective disorder and depressive or bipolar disorder with psychotic features before making a diagnosis of schizophrenia.

If there is a history of autism spectrum disorder (ASD) or a communication disorder of childhood onset, schizophrenia can be diagnosed only if there are prominent delusions or hallucinations in addition to the other required symptoms of schizophrenia. These symptoms must have been present for at least one month (or less if the symptoms are successfully treated).

Childhood-Onset vs. Adult-Onset Schizophrenia

People who develop schizophrenia at a young age might be more likely to experience certain symptoms compared with people who develop it later in life.

Children might also be less likely to experience paranoid delusions (the belief that others are out to harm you) than people who develop schizophrenia at an older age.

Labs and Tests

A diagnosis of childhood schizophrenia requires the exclusion of other conditions. Certain tests can be performed to help make the correct diagnosis.

Physical Examination

A physical exam helps clinicians rule out medical conditions that might explain a child's symptoms. It also lets them assess the child for any health complications.

Imaging Studies

Differences in the brain structure and the central nervous system have been found to be associated with schizophrenia. Imaging studies to look for these changes and to rule out other neurological conditions might be performed.

Differential Diagnosis

A differential diagnosis is a crucial factor when diagnosing childhood schizophrenia. The presence of symptoms that are similar to those seen in other mental health conditions, the presence of comorbid conditions (where a child has more than one condition), and the early age at which children experience psychotic-like symptoms can all make it difficult to accurately diagnose childhood schizophrenia.

High rates of comorbidity have been found in children with schizophrenia—specifically, attention deficit hyperactivity disorder (ADHD) and affective disorders.

Three disorders overlap with and can be difficult to distinguish from childhood schizophrenia:

  • Mood disorders with psychotic features: These conditions can present with psychotic symptoms, which can be misdiagnosed as childhood schizophrenia. The DSM-5 specifically requires that a diagnosis of childhood schizophrenia is made only when schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out.
  • Autism spectrum disorder (ASD): Symptoms such as abnormal speech and flat affect (not expressing emotions, particularly the lack of facial expression) that are seen in ASD can be misdiagnosed as the negative symptoms of schizophrenia. If a child has ASD or a childhood-onset communication disorder, the DSM-5 requires the presence of prominent delusions or hallucinations in addition to the other required symptoms, that last for at least one month, before a diagnosis of schizophrenia is made.
  • Attention deficit hyperactivity disorder (ADHD): The attentional and behavioral symptoms of ADHD might be misdiagnosed as childhood schizophrenia.

There are also other more common mental health conditions that might be misdiagnosed as childhood schizophrenia:

Certain medical conditions can also be misdiagnosed as childhood schizophrenia:.

  • Seizure disorder
  • Anti-NMDA (N-methyl D-aspartate) receptor encephalitis
  • Herpes simplex encephalitis (HSE)
  • Lysosomal storage diseases
  • Neurodegenerative disorders
  • Central nervous system (CNS) tumors
  • Progressive organic CNS disorder (e.g., sclerosing panencephalitis)
  • Metabolic disorders
  • Chromosomal disorders (22q11 deletion syndrome)

Behaviors in Healthy Children

Some of the symptoms of childhood schizophrenia appear in healthy children. For example, having a vivid imagination and fantasies are typical parts of childhood.

However, they might be misunderstood to be hallucinations and taken as a symptom of schizophrenia. Similarly, children who have poor or underdeveloped language skills may be perceived as having the disorganized thought and speech patterns that are observed in schizophrenia.

Self/At-Home Testing

The only way to obtain an accurate assessment and diagnosis of childhood schizophrenia is to be evaluated by a trained mental health provider. However, parents and caregivers should be aware of the early warning signs to ensure they seek care as soon as possible.

Children often develop changes in behavior before the onset of schizophrenia. These changes in behavior are normally noticed when children start school at age 5 or 6. However, many families report that disruptive behavior began before their child started school.

These changes can manifest in a variety of different ways, including:

  • Introversion
  • Loneliness
  • Depression
  • Aggression
  • Suicidal ideation
  • Bizarre behavior

Behavioral difficulties can lead to children struggling in school—one of the most common issues reported in people diagnosed with schizophrenia at an early age.

The warning signs may start when a child is very young. People diagnosed with schizophrenia in childhood have more developmental difficulties than those diagnosed later in life.

Very early developmental warning signs include:

  • Delayed motor development (e.g., not walking until over 18 months old)
  • Delayed speech and/or language development (e.g., not speaking meaningful two- or three- word phrases until over 36 months old)
  • Impaired social development at an early age (e.g., not using gestures to communicate or failing to regulate facial expressions)

A Word From Verywell

Childhood schizophrenia is rare. Most behavioral changes or early warning signs associated with the condition will have other more common causes. However, if you are concerned about any behaviors or changes that your child is showing, it's important to talk with their doctor.

Your child can be referred to a mental health provider for a careful evaluation and tests that will rule out other causes for their symptoms. If a diagnosis of schizophrenia is made, you will be able to ensure they get the treatment that is best suited to them.

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