Early Signs of Psychosis in Teenagers: What the Risk Is and What to Do Next

Creator: Ryan S. Sultan, MD
Published: 2026-11-12

By Ryan S. Sultan, MD
Psychiatrist · Columbia University Irving Medical Center
Published November 12, 2026 · 6-minute read

Psychotic-like experiences are common in childhood and adolescence, and most of them pass. Across 19 population studies, the median prevalence of psychotic symptoms was 17% among children aged 9 to 12 and 7.5% among adolescents aged 13 to 18.¹ In a review covering children and adults, the experiences remitted over time for about 80% of those who reported them, and 7.4% went on to a psychotic disorder.²

Some young people meet research criteria for "clinical high risk for psychosis." In a 2021 meta-analysis of 130 studies and 9,222 people, 25% developed psychosis within 3 years, so most had not by that point.³ These are group figures, and they can't say what will happen to one teenager.

What "clinical high risk" means

The term describes people who present with potentially prodromal symptoms. Inclusion requires one or more of the following:⁴

Attenuated psychotic symptoms, meaning psychotic symptoms that are below the threshold in severity or duration^{4, 5}
A brief, limited, intermittent psychotic episode
Trait vulnerability plus a marked decline in psychosocial functioning
Unspecified prodromal symptoms

Researchers also describe "basic symptoms": disturbances the person notices in perception, thought processing, language, and attention, with insight into them intact.⁴ In the North American Prodrome Longitudinal Study, higher levels of unusual thought content and suspiciousness and a greater decline in social functioning each contributed to individual risk.⁶

The DSM-5 work group recommended including attenuated psychosis syndrome in the appendix (Section 3) of DSM-5 as a condition for further study. It reported that the diagnosis was reliable in academic and research settings and less so in community settings.⁵

How often high risk becomes psychosis

Share of people at clinical high risk who developed psychosis
Follow-up	2012 meta-analysis (27 studies, 2,502 people)	2021 meta-analysis (130 studies, 9,222 people)
6 months	18%	9%
1 year	22%	15%
2 years	29%	19%
3 years	36%	25%

Sources: Fusar-Poli et al., 2012, and Salazar de Pablo et al., 2021.^{7, 3} The two columns come from separate meta-analyses.

The 2021 analysis also reported 27% at 4 years and 28% beyond 4 years.³ The 2012 authors, writing before the later analysis, noted that "some recent work suggests that the risk of transition may be declining," and publication year was one of the factors that influenced transition risk in their analysis.⁷

Participants were young adults on average: the mean age in the 2021 analysis was 20.3 years.³ European guidance from 2015 reported lower conversion rates in children and adolescents.⁸

What happens to those who don't develop psychosis

In a meta-analysis of 773 people who met high-risk criteria, 73% did not convert to psychosis over 2 years, and about 46% of those fully remitted from their baseline attenuated symptoms.⁹ In a North American cohort, 214 participants (71%) had not made the transition over 2.5 years. At least one attenuated positive symptom was still present for 43% at 1 year and 41% at 2 years, and social and role functioning remained poorer than in comparison subjects.¹⁰

A 2022 meta-analysis of 28 studies and 2,756 people concluded that clinical outcomes improve in those who don't transition, and that less than half remit over time.¹¹ In a 2020 review of people at clinical high risk as a whole, 41% had a depressive disorder and 15% had an anxiety disorder.¹²

The risk calculator is a research tool

A risk calculator was built from 596 high-risk participants followed for up to 2 years. The 2-year probability of conversion to psychosis was 16%, and the model's concordance index was 0.71.⁶

The authors wrote that the calculator can be validly applied only to patients who screen positive on a structured interview that requires training to administer, and that its most immediate uses will be in research. They added that the tool would not be usable if a prodromal risk syndrome has not been diagnosed.⁶

What the prevention trials show

A 2018 network meta-analysis of 16 studies and 2,035 patients found no evidence that any one intervention was superior to the others in preventing transition at 6 and 12 months.¹³ A 2025 meta-analysis limited to children and adolescents (24 studies, 1,319 participants) found that interventions improved positive symptoms, negative symptoms, total symptoms, and functioning compared with no intervention or placebo, with no effect on transition to psychosis or depressive symptoms.¹⁴

The 2020 review concluded that, because the uncertainty is high, needs-based and psychological interventions should still be offered.¹²

Does fish oil prevent psychosis?

The early result didn't hold up. In a 2010 single-center trial of 81 people, 2 of 41 (4.9%) in the omega-3 group and 11 of 40 (27.5%) in the placebo group had transitioned to a psychotic disorder by 12 months.¹⁵ In a larger trial of 304 participants (mean age 19.1 years), the 12-month transition rates were 11.5% with omega-3 and 11.2% in the control group, and the authors wrote that the trial "clearly failed to replicate the findings of the original single-center trial."¹⁶

The UK guideline advises against antipsychotics for prevention

The United Kingdom's NICE guideline on psychosis and schizophrenia in children and young people (recommendation 1.2.6, dated 2013) says: "Do not offer antipsychotic medication" either "for psychotic symptoms or mental state changes that are not sufficient for a diagnosis of psychosis or schizophrenia" or "with the aim of decreasing the risk of psychosis."¹⁷

The same guideline recommends referral for specialist assessment without delay, regular monitoring of symptoms and functioning for up to 3 years when a clear diagnosis can't be made, consideration of individual cognitive behavioral therapy with or without family intervention, and treatment of anxiety, depression, or substance misuse.¹⁷ Any change to a medication a teenager already takes is a decision to make with the prescriber.

When a teenager needs a prompt evaluation

A teenager with hallucinations, a marked drop in functioning, or thoughts of self-harm needs a prompt psychiatric evaluation. An immediate risk of harm to the teenager or to someone else is an emergency. In the 2020 review, suicidal ideation was reported in 66% of people at clinical high risk and self-harm in 49%, and 27% used cannabis.¹² I've written separately about drug-induced psychosis and schizophrenia and about treatment once psychosis is diagnosed.

Limitations of the evidence

This evidence has limitations. First, the transition figures come from samples with a mean age near 20, and heterogeneity between studies was high. Second, setting the 2012 figures beside the 2021 figures compares two separate meta-analyses. Nevertheless, the findings agree on several points: most people at clinical high risk had not developed psychosis within 3 years, many still had symptoms, and the UK guideline recommends assessment and monitoring and advises against preventive antipsychotics.

Frequently asked questions

How common are psychotic-like experiences in children and teenagers?

Across 19 population studies, the median prevalence of psychotic symptoms was 17% among children aged 9 to 12 and 7.5% among adolescents aged 13 to 18. In a review covering children and adults, the experiences remitted over time for about 80% of those who reported them, and 7.4% went on to a psychotic disorder.^{1, 2}

Will my teenager develop schizophrenia if they are at clinical high risk for psychosis?

The studies give group figures and can't say what will happen to one teenager. In a 2021 meta-analysis of 9,222 people at clinical high risk with a mean age of 20.3 years, 15% developed psychosis at 1 year and 25% within 3 years, so most had not by that point. A teenager with hallucinations, a marked drop in functioning, or thoughts of self-harm needs a prompt psychiatric evaluation, and an immediate risk of harm is an emergency.³

Is attenuated psychosis syndrome a DSM-5 diagnosis?

Does fish oil prevent psychosis?

The early result didn't hold up. A 2010 trial of 81 people found fewer transitions with omega-3 (4.9% versus 27.5% at 12 months). A larger trial of 304 participants found 12-month transition rates of 11.5% with omega-3 and 11.2% in the control group, and its authors wrote that it failed to replicate the earlier trial.^{15, 16}

Should a teenager take an antipsychotic to prevent psychosis?

The UK NICE guideline for children and young people says not to offer antipsychotic medication with the aim of decreasing the risk of psychosis. It recommends specialist assessment without delay and, when a clear diagnosis can't be made, monitoring for up to 3 years. Any change to a medication a teenager already takes is a decision to make with the prescriber.¹⁷

In a crisis: call or text 988, or go to the nearest emergency department. A first episode of psychosis belongs in a hospital-based or coordinated specialty care program.

I start and manage clozapine in an outpatient practice in Chelsea, Manhattan. Details are on the schizophrenia care in NYC page. Clozapine should not be stopped, skipped, or restarted without the prescriber. This page is general information and does not replace an evaluation.