The Age Spectrum of Schizophrenia: Early to Late Onset

• The onset of schizophrenia typically occurs from the late teens to the early 30s but can also occur in childhood, early adolescence, late adulthood, and very late adulthood
• Patients with childhood- and early-onset schizophrenia are often misdiagnosed due to symptom overlap with other childhood disorders
• Patients with late- and very late–onset schizophrenia-like psychosis may present milder positive symptoms compared with early-onset schizophrenia
• Improved awareness and diagnostic tools are essential for timely and effective diagnosis and intervention

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Schizophrenia affects approximately 24 million people worldwide,¹ with an incidence rate of approximately 0.45% in adults and approximately 0.05% in children globally.^1–4 Onset typically occurs from the late teens to the early 30s, occurring earlier in men (late teens to early 20s) compared with women (20s to early 30s).⁵ While early adulthood onset was once considered to be a central characteristic of the condition, onset times can vary widely, revealing a complex picture of demographic differences and heterogenous presentation at different ages of onset.^6,7

The onset of schizophrenia can be categorized by age as follows: childhood onset before 13, early onset between 13-17, adult onset at 18 and older, late onset between 40 and 60, and very late–onset schizophrenia-like psychosis at 60 and older.^8–10 In this article, we explore the varying ages of onset of schizophrenia and characterize the differences between these patient populations.

Schizophrenia is a devastating condition, especially when it presents in childhood or adolescence.² Childhood onset is remarkably rare but represents a more severe form of schizophrenia with more prominent pre-psychotic developmental disorders, brain abnormalities, and genetic risk factors.^2,8 Both childhood- and early-onset schizophrenia are often misdiagnosed and have worse outcomes compared with adult-onset schizophrenia, including more negative symptoms, increased premorbid deficits, higher levels of enuresis, higher levels of autistic traits, and a higher risk of treatment resistance.^4,11 Cognitive deficits in the same cognitive domains as those in adult-onset schizophrenia have been observed in both childhood- and early-onset schizophrenia, and there is evidence of more severe deficits in executive functions, processing speed, working memory, and verbal memory in comparison with adult-onset schizophrenia.^4,12

Distinguishing between adult-, childhood-, and early-onset schizophrenia is important, as childhood-onset schizophrenia is often characterized by a higher likelihood of speech, language, and/or educational disabilities and more severe intelligence deficits than early-onset schziophrenia.^2–4 Driver and colleagues found that these symptoms are evident in 67% of patients with childhood-onset schizophrenia.² In contrast, patients with early-onset schizophrenia tend to exhibit higher suicidality, more depressive symptoms, and a longer duration of untreated psychosis.¹¹ Furthermore, patients with childhood-onset schizophrenia are more likely to have an attention-deficit/hyperactivity disorder diagnosis, whereas patients with early-onset schizophrenia are more likely to have a diagnosis of schizophrenia or schizoaffective disorder, substance use disorder, or an organic brain disorder.³ There are conflicting data regarding differences in onset between male and female patients in childhood- and early-onset schizophrenia, but it is thought that male patients with early-onset schizophrenia may be more vulnerable to neurodevelopmental comorbidities, and early illness onset has been linked with a higher genetic predisposition in female patients.^3,4

Diagnosing childhood- and early-onset schizophrenia presents several challenges.⁴ Diagnoses are often delayed due to similarities with normal childhood fantasies, obsessive-compulsive disorder symptoms, autism spectrum disorders, and attention-deficit/hyperactivity disorder.⁴ Substance abuse in adolescents can further complicate diagnosis.⁴ Key risk factors for both childhood- and early-onset schizophrenia include an urban rearing environment, childhood trauma, migration and minority status, traumatic brain injury, and substance use.¹³ Clinical considerations that are important to note in childhood- and early-onset schizophrenia involve individualized antipsychotic dosing due to age-related differences in metabolism and side effects.⁴ Early-onset schizophrenia increases the risk of treatment-resistant schizophrenia (TRS), requiring expertise in diagnosing TRS and using clozapine.⁴ Psychosocial interventions are also important due to associated cognitive deficits and reduced quality of life.⁴

Hidden in the golden years: Uncovering schizophrenia’s late emergence

Although schizophrenia typically presents earlier in life, at least 20% of patients experience onset after the age of 40.⁶ Despite recommendations by Maglione and colleagues and Vahia and colleagues, based on data from several studies, late- and very late–onset schizophrenia-like psychosis are not included as subtypes in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition.^6,14,15 The study of late-onset schizophrenia began with Manfred Bleuler, and it has since been noted that while late-onset schizophrenia and onset before the age of 40 share similar symptom profiles, there are significant differences.¹⁵ Patients with late-onset schizophrenia tend to exhibit lower severity of positive symptoms and less affective flattening.^6,14,15 Cognitive impairment and cognitive deterioration are prevalent across all age groups, but impairments in executive functions are notably observed in those with late-onset schizophrenia.^9,16 Additionally, Fagerlund and colleagues found that there are more prominent cognitive symptoms, such as more severe deficits in working memory and verbal memory, in patients with early- or late-onset schizophrenia compared with patients with adult-onset schizophrenia.^4,12 Patients with late-onset schizophrenia are also more likely to experience visual, tactile, and olfactory hallucinations with running commentary.⁶ Patients with very late–onset schizophrenia-like psychosis, on the other hand, are less likely to experience negative symptoms and formal thought disorders compared with patients with late- or early-onset schizophrenia ¹⁵ but have a higher likelihood of impaired learning and retention.⁹ 

Diagnosing and treating late- and very late–onset schizophrenia-like psychosis involves specific clinical considerations.¹⁵ Late- and very late–onset schizophrenia-like psychosis are both more prevalent in female patients.^9,15 Key risk factors to note in patients with late-onset schizophrenia include psychosocial factors proximal to psychosis onset, such as unemployment and migration, as well as physical health problems.¹³ For patients with late- and very late–onset schizophrenia, a combination of pharmacological and psychosocial/behavioral management approaches is recommended.¹⁵ It is also important to note that approximately 60% of very late–onset schizophrenia-like psychosis cases are secondary psychosis caused by neurodegenerative diseases such as dementia.⁹ Therefore, distinguishing secondary psychosis from very late–onset schizophrenia-like psychosis is crucial.⁹ 

Bridging generations: Navigating schizophrenia across age groups

While schizophrenia traditionally manifests during early adulthood, its occurrence in children or elderly individuals poses a significant diagnostic challenge, with no explicit framework from clinical guidelines on the topic.^4,6 Identifying and accurately diagnosing schizophrenia in these patient populations is crucial yet complex due to overlapping symptoms with other developmental stages or age-related conditions.^4,9 This highlights the pressing need for improved diagnostic tools, enhanced clinician awareness, and collaborative care to ensure timely intervention and appropriate management.⁴

Further reading

Cite this article as The age spectrum of schizophrenia: Early to late onset. Connecting Psychiatry. Published June 2025. Accessed [month day, year]. [URL]

SC-US-77208

SC-CRP-17284

February 2025