Can the onset of psychosis be predicted in children and adolescents?
Psychosis is a mental health disorder that has a strong impact on the quality of life of those affected and their immediate environment. Currently, psychotic disorders, including schizophrenia, are among the leading causes of disability in the world. It is estimated that 3 in 100 people will experience a psychotic episode during their lifetime, but the onset of the disorder usually occurs in late adolescence or early adulthood, between the ages of 13 and 30.
For this reason, it is very important to be able to detect and identify early children and adolescents at higher risk of developing a psychotic disorder, in order to initiate an early therapeutic approach and minimize the impact on their quality of life.
What does it mean to be at risk of having a psychotic disorder?
There are some biological, personal, and environmental factors that make some people more likely to develop a psychotic disorder. Several characteristics have been identified that are associated with a higher risk of developing psychosis (Oliver et al., 2020; Radua et al., 2018):
- Clinical factors: Presence of attenuated psychotic symptoms and low functionality (clinical risk for psychosis).
- Environmental factors:
- Stress: Stressful life events, trauma, and other environmental stress-related factors have been shown to be risk factors for the development of psychosis.
- Consumption of toxic substances.
- Complications linked to the neurodevelopmental process: complications during the early stages of embryonic development (pregnancy); obstetric complications; maternal and paternal age; consumption of toxic substances during pregnancy; lower scores in cognitive functioning; and brain alterations observable with magnetic resonance imaging.
- Seasonality and place of birth: being born in an urban environment or in a specific season of the year (summer and winter) has been linked to a higher risk of developing schizophrenia.
- Conditions linked to ethnicity: certain ethnicities, such as the Black-Caribbean ethnicity of England, or belonging to a minority ethnic group are linked to a higher risk of having psychotic disorders.
- Genetic factors
- Relatives: Studies have been conducted with relatives of psychosis and twin studies. Currently, the evidence seems to suggest that having a first-degree relative with psychosis increases the risk of developing the disorder by up to 50% (Cannon et al., 2008).
- Candidate genes: So far, the evidence on possible genes linked to the etiology of schizophrenia or possible associated risk factors is not clear. Some of the genes that are suggested to be linked to schizophrenia are DISC1, DTNBP1, NRG1 DAOA or COMT, among others. However, their link with the disorder is still unclear and research is still needed to reach a conclusion (Hamilton, 2008).
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Based on scientific evidence of associated risk factors, clinical criteria have been developed to identify which people are at risk (Miller et al., 2003; Yung et al., 2008). One or more of these criteria must be met:
- Presenting positive psychotic symptoms (delusions, perceptual hallucinations or behavioral disorganization), which are presented in an attenuated manner, that is, milder. The person experiencing them doubts whether what they are perceiving or thinking is real, is really happening around them or is the result of their imagination.
- Presenting frank positive psychotic symptoms , which means that you do not doubt that what is happening is real, which spontaneously resolve without the need for the introduction of pharmacological treatment. The symptoms are short-lived, do not last more than a few days (maximum one week) and disappear spontaneously, without any treatment having been introduced. Often, the person who experiences it does not even go to a mental health service, since it is something that happens occasionally and disappears on its own.
- Having a first-degree relative with a diagnosis of psychotic disorder , and having a decrease in day-to-day functioning.
These diagnostic criteria are not currently a diagnostic category included in diagnostic manuals such as the DSM-5 or the ICD-11; they are still part of categories that deserve further research to be used by clinical health professionals.
Three out of ten people who are at risk of having psychosis will develop the disorder during the first three years after its identification.
But not all people who are at risk or who are at higher risk end up developing the disorder. It is currently known that three out of ten people detected at risk will develop a psychotic disorder within the first three years of their identification (Fusar-Poli et al., 2020; Salazar De Pablo et al., 2021).
Currently, of the risk factors mentioned, it has been observed that presenting more severe clinical symptoms is, for now, the factor most associated with developing psychosis. It is also noted that the more risk factors a person has, the greater the risk of developing the disorder, but there is still no knowledge of how these factors interact with each other, nor how the risk increases depending on which factors they are. For this reason, the scientific community continues to research in this line.
Why is it important to study the risk of developing a psychotic disorder in the adolescent population?
Studying the characteristics of the population at risk will allow us to make an early and accurate diagnosis and institute treatment as soon as possible, in order to avoid the onset of the disorder or delay its appearance for as long as possible. Being able to offer psychological support, emotional management tools and clinical monitoring adapted to each case not only helps prevent, but also improves the quality of life of young people and their families.
The introduction of early treatment has shown very good results in improving the clinical outcome of affected people, but no clear strategy for the prevention of these disorders can yet be concluded. For this reason, research continues , both in treatments and in risk and protective factors.
It is important to be able to detect and identify children and adolescents at higher risk of developing a psychotic disorder in order to initiate an early therapeutic approach and minimize its impact.
However, as in many other areas of science, psychosis, its treatment and prevention have been studied mainly in the adult population, although the first symptoms of a psychotic disorder can appear as early as adolescence. This is why it is key to study the risk of developing a psychotic disorder in children and adolescents (Solmi et al., 2022).
It is important to remember that the adolescent brain is a developing brain. This characteristic leads us to two fundamental questions in the specific study of this population: On the one hand, it is known that many mental disorders -such as psychosis- present themselves differently in children and adolescents. Scientific evidence suggests that psychosis, if it occurs during childhood or adolescence, has an insidious onset, that is, more gradual, and with a greater presence of so-called negative psychotic symptoms , such as apathy or social isolation, among others (Baeza et al., 2024). In addition, the impact it has on adolescence is great, since it is a period in which the brain is acquiring many of the skills required to face adult life (Arango, 2011).
Conduct research to improve the quality of life of people with psychosis
On the other hand, the fact that it is still a developing brain also makes it a brain with more plasticity and greater capacity to adapt to changes. This phenomenon is known as neuroplasticity , and can mean that treatments that are instituted at this time can be taken advantage of in a different way than an adult brain. This is also key in this case, since detecting a population that is still at risk and giving them tools that allow them to face what they are experiencing or will experience in the future can change the course of the disorder or even prevent it (Marín, 2016).
These two issues make it necessary to carry out studies focused on the child and adolescent population, in order to observe the specific characteristics in these age groups, not only in psychosis, but in all mental disorders.
Detecting the population that is still at risk and giving them tools that allow them to face what they are experiencing or will experience in the future can change the course of the disorder.
In the case of psychosis in particular, however, there is another reason that makes the study of the adolescent population at risk relevant. During adolescence , the brain undergoes a series of very important changes . One of them is neuronal pruning, where all the neuronal connections that had been created in the early stages of life but are no longer relevant for facing adulthood are destroyed. This process of destroying connections that are not useful to make room for new connections is believed to be altered in people who have a psychotic disorder (Cannon et al., 2015; Gomes et al., 2016). If we study people at risk who are at this specific time in brain development, it will allow us to understand how this disorder works from a biological point of view and see how these processes evolve in a brain at risk.
CAPRIS, a study by Sant Joan de Déu to prevent psychosis in childhood and adolescence
The Sant Joan de Déu Research Institute (IRSJD), in collaboration with the Hospital Clínic de Barcelona, has been studying for more than ten years how to prevent psychotic disorders in children and adolescents. In this line of research, it is carrying out the CAPRIS study (Child and Adolescent Psychosis RIsk Study), led by Dr. Montserrat Dolz, which aims to identify markers that allow increasing the predictive power of the clinical tools currently used, thus improving the detection of children and adolescents at higher risk of developing a psychotic disorder.
Before meeting criteria for a psychotic disorder, most people may experience a phase in which certain attenuated signs or specific characteristics occur. The CAPRIS project has so far collected data from approximately 200 children and adolescents between 10 and 17 years of age who meet the clinical risk criteria for developing psychosis. It also collects data from children and adolescents who do not present these symptoms, and who form part of the control group. This control group is matched by age and sex with people in the risk group, with the aim of being able to compare the two groups and to identify whether there are differences in clinical, neuropsychological, neuronal, biological and environmental factors . Likewise, these boys and girls are followed for a year and a half, to assess whether any of the people develop a psychotic disorder and, by comparing the group of people who develop psychosis with those who do not, it can be determined which of the factors mentioned may be more associated with the development of a first psychotic episode.
The treatment of psychotic disorders in adolescents
What are the main results obtained so far?
To date, the CAPRIS study has obtained important results, which have given rise to several scientific articles, including:
- The use of clinical risk criteria also in the child and adolescent population . The criteria have been shown to be useful in the child and adolescent population. It has been identified that 23% of participants at risk develop a psychotic disorder eighteen months after their detection. This implies that almost one in four people detected at risk makes a transition to a full-blown psychosis within a year and a half of follow-up (Dolz et al., 2024).
- The identification of a series of specific characteristics of boys and girls who are at clinical risk of psychosis. It has been observed that they are people who present mental health diagnoses (mainly depression and anxiety, among others) (Dolz et al., 2019; Rodríguez-Pascual et al., 2021; Vergara et al., 2023) and who have more stressful life experiences during the year prior to their identification (Muñoz-Samons et al., 2021). It has also been observed that they seem to have lower cognitive performance than the control group at the time they present symptoms (Tor et al., 2020).
- The identification of clinical markers of transition to psychosis. Currently, few and not very robust markers have been detected. However, it seems that the presence of attenuated positive symptoms, some characteristics of cognition and some environmental characteristics can identify which people will develop psychosis, but these are still not very robust results. (Dolz et al., 2024; Tor et al., 2018, 2023, 2025).
Future vision of the CAPRIS study
The research team of this study is currently focused on continuing to refine the risk criteria , but also on improving diagnostic tools for the detection of people at risk. In this sense, work is currently underway on the creation of a risk calculator (PREDICT-CAPRIS). This tool could be used in the future as a support for clinical diagnosis, to facilitate identification by mental health professionals. For now, it is a concept still under study.
On the other hand, a line is being initiated focused on the identification of protective factors and the validation of psychological treatments focused on resilience.
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