198 Chapter 24
of serious side effects (for example, agranulocytosis). It is because of
these side effects that clozapine should only be used when first-line drugs
have failed.
Resolution of positive symptoms is often followed by a recovery phase
of several months during which residual negative symptoms partially or
fully resolve. As in the case of adult-onset schizophrenia, it is only a small
minority who recover completely and have no further episodes. Contin-
uing medication is likely to be needed. Family work will need to address
coming to terms with what is often a devastating life-long illness; reducing
the young person’s exposure to criticism, hostility and other negative
emotion may play a part in avoiding relapses. CBT to reduce the impact
of residual positive symptoms may be worthwhile but trials in this age
group are lacking. Affected individuals may also need special schooling,
social skills training, and phased transfer to adult community psychiatric
services. Particularly after second and subsequent episodes, recovery is
often incomplete and social functioning may gradually deteriorate.
Prognosis
Early onset generally carries a worse prognosis than adult onset. The best
predictors of poor long-term outcome are premorbid social and cognitive
impairments, a prolonged first psychotic episode, negative symptoms at
onset, and a prolonged period without treatment. Is prognosis improved
by detecting and treating first episodes of psychosis more rapidly? Unfor-
tunately, there is little evidence that early intervention teams do lead to
a long-term improvement in outcome. Perhaps delayed treatment is not
damaging in itself – simply a marker for the insidious onset and negative
symptoms that confer a worse prognosis even with rapid treatment.
Subject review
Hollis C. (2008) Schizophrenia and allied disorders.In: Rutter Met al.
(eds)Rutter’s Child and Adolescent Psychiatry, 5th edn. Wiley-Blackwell,
Chichester, pp. 737–758.
Further reading
Asarnow JRet al. (2004) Childhood-onset schizophrenia: clinical and
treatment issues.Journal of Child Psychology and Psychiatry 45 , 180–194.
Boeing Let al.(2007) Adolescent-onset psychosis: prevalence, needs and
service provision.British Journal of Psychiatry 190 , 18–26.