Clinical profile, conversion rate, and suicidal thinking and behaviour in children and adolescents at ultra-high risk for psychosis: a theoretical perspective

  • Maria Pontillo | Child and Adolescence Neuropsychiatry Unit, Department of Neuroscience, Children Hospital Bambino Gesù, Rome, Italy.
  • Maria Cristina Tata Child and Adolescence Neuropsychiatry Unit, Department of Neuroscience, Children Hospital Bambino Gesù, Rome, Italy.
  • Roberto Averna Child and Adolescence Neuropsychiatry Unit, Department of Neuroscience, Children Hospital Bambino Gesù, Rome, Italy.
  • Prisca Gargiullo Child and Adolescence Neuropsychiatry Unit, Department of Neuroscience, Children Hospital Bambino Gesù, Rome, Italy.
  • Silvia Guerrera Child and Adolescence Neuropsychiatry Unit, Department of Neuroscience, Children Hospital Bambino Gesù, Rome, Italy.
  • Stefano Vicari Child and Adolescence Neuropsychiatry Unit, Department of Neuroscience, Children Hospital Bambino Gesù, Rome; Institute of Psychiatry, Fondazione Policlinico Universitario A. Gemelli, Catholic University, Rome, Italy.


Over the past years there has been substantial growing interest in the prodromes of psychosis to identify individuals at risk for psychosis prior to their first psychotic episode. Researchers have proposed criteria to detect young adults at Ultra-High Risk (UHR) for psychosis, and these criteria have also been applied to children and adolescents, though few clinical studies have examined this population. This theoretical perspective presents some of the crucial issues in the assessment and treatment of UHR children and adolescents: the presence of a specific clinical profile (i.e., different to that of healthy controls and UHR young adults), the predictive value of UHR criteria, and the presence and clinical significance of suicidal thinking and behaviour. In UHR children and adolescents, like UHR young adults, the presence of Attenuated Psychotic Symptoms (APS) is the most frequently reported inclusion criterion at baseline, with a prevalence of approximately 89–100%. In addition, there are frequently non-psychotic comorbid diagnoses of depressive and anxiety disorders. In contrast to the UHR adult population, UHR children and adolescents demonstrate a lower conversion rate to frank psychosis, most likely due to their high rate of APS. Finally, UHR adolescents report a high prevalence of suicidal ideation and self-injurious behaviour (67.5%), as well as a significantly greater frequency of attempted suicide, relative to adolescents with frank psychosis. On this basis, UHR children and adolescents report a clinical complexity that should be carefully monitored and considered for specific and targeted therapeutic interventions to be planned and developed



PlumX Metrics


Download data is not yet available.


Albert, U., Tomassi, S., Maina, G., & Tosato, S. (2018). Prevalence of non-psychotic disorders in ultra-high risk individuals and transition to psychosis: A systematic review. Psychiatry Research, 270, 1-12. doi: 10.1016/j.psychres.2018.09.028. DOI:

Armando, M., Pontillo, M., De Crescenzo, F., Mazzone, L., Monducci, E., Lo Cascio, N., Santonastaso, O., Pucciarini, M.L., Vicari, S., Schimmelmann, B.G., & Schultze-Lutter, F. (2015). Twelve-month psychosis-predictive value of the ultra-high risk criteria in children and adolescents. Schizophrenia Research, 169(1-3), 186-192. doi: 10.1016/j.schres.2015.10.033. DOI:

Bang, M., Park, J.Y., Kim, K.R., Lee, S.Y., Song, Y.Y., Kang, J.I., Lee, E., & An, S.K. (2017). Suicidal ideation in individuals at ultra-high risk for psychosis and its association with suspiciousness independent of depression. Early Intervention in Psychiatry, 13(3), 539-545. doi: 10.1111/eip.12517. DOI:

Bromet, E.J., Nock, M.K., Saha, S., Lim, C.C.W., Aguilar-Gaxiola, S., Al-Hamzawi, A., Alonso, J., Borges, G., Bruffaerts, R., Degenhardt, L., de Girolamo, G., de Jonge, P., Florescu, S., Gureje, O., Haro, J.M., He, Y., Hu, C., Karam, E.G., Kovess-Masfety, V., Lee, S., Lepine, J.P., Mneimneh, Z., Navarro-Mateu, F., Ojagbemi, A., Posada-Villa, J., Sampson, N.A., Scott, K.M., Stagnaro, J.C., Viana, M.C., Xavier, M., Kessler, R.C., McGrath, J.J.; & World Health Organization World Mental Health Survey Collaborators. (2017). Association Between Psychotic Experiences and Subsequent Suicidal Thoughts and Behaviors: A Cross-National Analysis From the World Health Organization World Mental Health Surveys. JAMA Psychiatry, 74(11), 1136-1144. doi:10.1001/jamapsychiatry.2017.2647. DOI:

Byrne, R., & Morrison, A.P. (2010). Young people at risk of psychosis: a user-led exploration of interpersonal relationships and communication of psychological difficulties. Early Intervention in Psychiatry, 4(2), 162-8. doi:10.1111/j.1751-7893.2010.00171.x. DOI:

Challis, S., Nielssen, O., Harris, A., & Large, M. (2013). Systematic meta-analysis of the risk factors for deliberate self-harm before and after treatment for first-episode psychosis. Acta Psychiatrica Scandinavica, 127(6), 442-54. doi: 10.1111/acps.12074. DOI:

Cornblatt, B.A., Lencz, T., Smith, C.W., Olsen, R., Auther, A.M., Nakayama, E., Lesser, M.L., Tai, J.Y., Shah, M.R., Foley, C.A., Kane, J.M., & Correll, C.U. (2007). Can antidepressants be used to treat the schizophrenia prodrome? Results of a prospective, naturalistic treatment study of adolescents. Journal of Clinical Psychiatry, 68(4), 546-57. DOI: 10.4088/jcp.v68n0410. DOI:

Dolz, M., Tor, J., De la Serna, E., Pardo, M., Muñoz-Samons, D., Rodríguez-Pascual, M., Puig, O., Sugranyes, G., Usall, J., Sánchez-Gistau, V., & Baeza, I. (2019). Characterization of children and adolescents with psychosis risk syndrome: The Children and Adolescents Psychosis Risk Syndrome (CAPRIS) study. Early Intervention in Psychiatry, 13(5), 1062-1072. doi: 10.1111/eip.12728. DOI:

Fusar-Poli, P., Bonoldi, I., Yung, A.R., Borgwardt, S., Kempton, M.J., Valmaggia, L., Barale, F., Caverzasi, E., & McGuire, P. (2012). Predicting psychosis: meta-analysis of transition outcomes in individuals at high clinical risk. Archives Of General Psychiatry, 69, 220-9. doi: 10.1001/archgenpsychiatry.2011.1472. DOI:

Fusar-Poli, P., Cappucciati, M., Borgwardt, S., Woods, S.W., Addington, J., Nelson, B., Nieman, D.H., Stahl, D.R., Rutigliano, G., Riecher-Rössler, A., Simon, A.E., Mizuno, M., Lee, T.Y., Kwon, J.S., Lam, M.M., Perez, J., Keri, S., Amminger, P., Metzler, S., Kawohl, W., Rössler, W., Lee, J., Labad, J., Ziermans, T., An, S.K., Liu, C.C., Woodberry, K.A., Braham, A., Corcoran, C., McGorry, P., Yung, A.R., & McGuire, P.K. (2016). Heterogeneity of Psychosis Risk Within Individuals at Clinical High Risk: A Meta-analytical Stratification. JAMA Psychiatry. 73(2), 113-20. doi: 10.1001/jamapsychiatry.2015.2324. DOI:

Fusar-Poli, P., Nelson, B., Valmaggia, L., Yung, A., & McGuire, P. (2014). Comorbid depressive and anxiety disorders in 509 individuals with an at-risk mental state: impact on psychopathology and transition to psychosis. Schizophrenia Bullettin, 40, 120–131. doi: 10.1093/schbul/sbs136. DOI:

Häfner, H., Maurer, K., Ruhrmann, S., Bechdolf, A., Klosterkötter, J., Wagner, M., Maier, W., Bottlender, R., Möller, H.J., Gaebel, W., & Wölwer, W. (2004). Early detection and secondary prevention of psychosis: facts and visions. European Archives of Psychiatry and Clinical Neuroscience, 254, 117–128. DOI: 10.1007/s00406-004-0508-z. DOI:

Kelleher, I., Murtagh, A., Molloy, C., Roddy, S., Clarke, M.C., Harley, M., & Cannon, M. (2012). Identification and characterization of prodromal risk syndromes in young adolescents in the community: a population-based clinical interview study. Schizophrenia Bullettin, 38(2), 239-46. doi: 10.1093/schbul/sbr164. DOI:

Lam, M., Abdul Rashid, N.A., Lee, S.A., Lim, J., Foussias, G., Fervaha, G., Ruhrman, S., Remington, G., & Lee, J. (2015). Baseline social amotivation predicts 1-year functioning in UHR subjects: A validation and prospective investigation. European Neuropsychopharmacology, 25(12), 2187-96. doi:10.1016/j.euroneuro.2015.10.007 DOI:

Lencz, T., Smith, C.W., Auther, A., Correll, C.U., & Cornblatt, B. (2004). Nonspecific and attenuated negative symptoms in patients at clinical high-risk for schizophrenia. Schizophrenia Research, 68(1), 37-48. DOI: 10.1016/S0920-9964(03)00214-7 DOI:

Lindgren, M., Manninen, M., Kalska, H., Mustonen, U., Laajasalo, T., Moilanen, K., Huttunen, M., Cannon, T.D., Suvisaari, J., & Therman, S. (2014). Predicting psychosis in a general adolescent psychiatric sample. Schizophrenia Research, 158, 1–6. doi: 10.1016/j.schres.2014.06.028. DOI:

McGlashan, T.H. (2008). Structured Interview for Prodromal Syndromes (SIPS). Yale University, New Haven.

McGorry, P.D., Hickie, I.B., Yung, A.R., Pantelis, C., & Jackson, H.J. (2006). Clinical staging of psychiatric disorders: a heuristic framework for choosing earlier, safer and more effective interventions. Australian and New Zealand Journal of Psychiatry, 40, 616–622. DOI: 10.1080/j.1440-1614.2006.01860.x DOI:

McHugh, M.J., McGorry, P.D., Yuen, H.P., Hickie, I.B., Thompson, A., de Haan, L., Mossaheb, N., Smesny, S., Lin, A., Markulev, C., Schloegelhofer, M., Wood, S.J., Nieman, D., Hartmann, J.A., Nordentoft, M., Schäfer, M., Amminger, G.P., Yung, A., & Nelson, B. (2018). The Ultra-High-Risk for psychosis groups: Evidence to maintain the status quo. Schizophrenia Research, 195, 543-548. doi: 10.1016/j.schres.2017.09.003. DOI:

Nelson, B., Yuen, K., & Yung, A.R. (2011). Ultra high risk (UHR) for psychosis criteria: are there different levels of risk for transition to psychosis? Schizophrenia Research, 125(1), 62-8. doi: 10.1016/j.schres.2010.10.017. DOI:

Pancheri, P., Brugnoli, R., Carilli, L., Delle Chiaie, R., Marconi, P.L., & Petrucci, R.M. (1995). Valutazione dimensionale della sintomatologia schizofrenica. Validazione della versione italiana della scala per la valutazione dei sintomi positivi e negativi (PANSS). Italian Journal of Psychopathology, 1, 60–75.

Pelizza, L., Azzali, S., Garlassi, S., Paterlini, F., Scazza, I., Chiri, L.R., Pupo, S., & Raballo, A. (2018). Adolescents at ultra-high risk of psychosis in Italian neuropsychiatry services: prevalence, psychopathology and transition rate. European Child & Adolescent Psychiatry, 27(6), 725-737. doi: 10.1007/s00787-017-1070-3. DOI:

Pelizza, L., Poletti, M., Azzali, S., Paterlini, F., Garlassi, S., Scazza, I., Chiri, L.R., Pupo, S., & Raballo, A. (2019). Suicidal Thinking and Behavior in Adolescents at Ultra-High Risk of Psychosis: A Two-year Longitudinal Study. Suicide and Life-Threatening Behavior, 49(6), 1637-1652. doi: 10.1111/sltb.12549. DOI:

Piskulic, D., Addington, J., Cadenhead, K.S., Cannon, T.D., Cornblatt, B.A., Heinssen, R., Perkins, D.O., Seidman, L.J., Tsuang, M.T., Walker, E.F., Woods, S.W., & McGlashan, T.H. (2012). Negative symptoms in individuals at clinical high risk of psychosis. Psychiatry Research, 196(2-3), 220-4. DOI:10.1016/j.psychres.2012.02.018 DOI:

Poletti, M., Pelizza, L., Azzali, S., Paterlini, F., Garlassi, S., Scazza, I., Chiri, L.R., Gebhardt, E., Pupo, S., & Andrea, R. (2019). Clinical high risk for psychosis in childhood and adolescence: findings from the 2-year follow-up of the ReARMS project. European Child & Adolescent Psychiatry, 28(7), 957-971. doi: 10.1007/s00787-018-1262-5. DOI:

Pompili, M., Serafini, G., Innamorati, M., Lester, D., Shrivastava, A., Girardi, P., & Nordentoft, M. (2011). Suicide risk in first episode psychosis: a selective review of the current literature. Schizophrenia Research, 129(1), 1-11. doi: 10.1016/j.schres.2011.03.008. DOI:

Raballo, A., Semrov, E., Bonner, Y., & Simmons, M.B. (2013). Traduzione e adattamento italiano della CAARMS (the Comprehensive Assessment of At-Risk Mental States). Centro Stampa della Regione Emilia-Romagna, Bologna.

Ribolsi, M., Lin, A., Wardenaar, K.J., Pontillo, M., Mazzone, L., Vicari, S., & Armando, M. (2017). Clinical presentation of Attenuated Psychosis Syndrome in children and adolescents: Is there an age effect? Psychiatry Research, 252, 169-174. doi: 10.1016/j.psychres.2017.02.050. DOI:

Salokangas, R.K., Ruhrmann, S., von Reventlow, H.G., Heinimaa, M., Svirskis, T., From, T., Luutonen, S., Juckel, G., Linszen, D., Dingemans, P., Birchwood, M., Patterson, P., Schultze-Lutter, F., Klosterkötter, J; & EPOS group. (2012). Axis I diagnoses and transition to psychosis in clinical high-risk patients EPOS project: prospective follow-up of 245 clinical high-risk outpatients in four countries. Schizophrenia Research, 138 (2–3), 192–197. doi: 10.1016/j.schres.2012.03.008. DOI:

Schimmelmann, B.G., Michel, C., Martz-Irngartinger, A., Linder, C., & Schultze-Lutter, F. (2015). Age matters in the prevalence and clinical significance of ultra-high-risk for psychosis symptoms and criteria in the general population: Findings from the BEAR and BEARS-kid studies. World Psychiatry, 14(2), 189-97. doi: 10.1002/wps.20216. DOI:

Schimmelmann, B.G., Walger, P., & Schultze-Lutter, F. (2013). The significance of at-risk symptoms for psychosis in children and adolescents. The Canadian Journal of Psychiatry, 58(1), 32-40. doi: 10.1177/070674371305800107. DOI:

Schultze-Lutter, F., Michel, C., Schmidt, S.J., Schimmelmann, B.G., Maric, N.P., Salokangas, R.K., Riecher-Rössler, A., van der Gaag, M., Nordentoft, M., Raballo, A., Meneghelli, A., Marshall, M., Morrison, A., Ruhrmann, S., & Klosterkötter J. (2015). EPA guidance on the early detection of clinical high risk states of psychoses. European Psychiatry, 30(3), 405-16. doi: 10.1016/j.eurpsy.2015.01.010. DOI:

Taylor, P.J., Hutton, P., & Wood, L. (2015). Are people at risk of psychosis also at risk of suicide and self-harm? A systematic review and meta-analysis. Psychological Medicine, 45(5):911-26. doi: 10.1017/S0033291714002074. DOI:

Tiffin, P.A., & Welsh, P. (2013). Practitioner review: schizophrenia spectrum disorders and the at-risk mental state for psychosis in children and adolescents--evidence-based management approaches. Journal of Child Psychology and Psychiatry, 54(11), 1155-75. doi: 10.1111/jcpp.12136. DOI:

Tor, J., Dolz, M., Sintes, A., Muñoz, D., Pardo, M., de la Serna, E., Puig, O., Sugranyes, G., & Baeza, I. (2018). Clinical high risk for psychosis in children and adolescents: a systematic review. European Child & Adolescent Psychiatry, 27(6), 683-700. doi: 10.1007/s00787-017-1046-3. DOI:

Trotman, H. D., Holtzman, C. W., Walker, E. F., Addington, J. M., Bearden, C. E., Cadenhead, K. S., Cannon, T.D., Cornblatt, B.A., Heinssen, R.K., Mathalon, D.H., Tsuang, M.T., Perkins, D.O., Seidman, L.J., Woods, S.W., McGlashan, T. H. (2014). Stress exposure and sensitivity in the clinical high-risk syndrome: Initial findings from the North American Prodrome longitudinal study (NAPLS). Schizophrenia Research, 160(1–3), 104–109. DOI:

Upthegrove, R., Birchwood, M., Ross, K., Brunett, K., McCollum, R., & Jones, L. (2010). The evolution of depression and suicidality in first episode psychosis. Acta Psychiatrica Scandinavica 122, 211–218. DOI: 10.1111/j.1600-0447.2009.01506.x DOI:

Velthorst, E., Nieman, D.H., Becker, H.E., van de Fliert, R., Dingemans, P.M., Klaassen, R., de Haan, L., van Amelsvoort, T., Linszen, D.H. (2009). Baseline differences in clinical symptomatology between ultra high risk subjects with and without a transition to psychosis. Schizophrenia Research, 109(1-3), 60-5. doi: 10.1016/j.schres.2009.02.002 DOI:

Velthorst, E., Nieman, D.H., Linszen, D., Becker, H., de Haan, L., Dingemans, P.M., Birchwood, M., Patterson, P., Salokangas, R.K., Heinimaa, M., Heinz, A., Juckel, G., von Reventlow, H.G., French, P., Stevens, H., Schultze-Lutter, F., Klosterkotter, J., & Ruhrmann, S. (2010). Disability in people clinically at high risk of psychosis. British Journal of Psychiatry, 197, 278–284. DOI: 10.1192/bjp.bp.109.075036 DOI:

Welsh, P., & Tiffin, P.A. (2014). The 'at-risk mental state' for psychosis in adolescents: clinical presentation, transition and remission. Child Psychiatry & Human Development, 45(1), 90-8. doi: 10.1007/s10578-013-0380-z. DOI:

Werbeloff, N., Drukker, M., Dohrenwend, B.P., Levav, I., Yoffe, R., van Os, J., Davidson, M., & Weiser, M. (2012). Self-reported attenuated psychotic symptoms as forerunners of severe mental disorders later in life. Archives Of General Psychiatry, 69(5), 467-75. doi:10.1001/archgenpsychiatry.2011.1580. DOI:

Yung, A.R., & McGorry, P.D. (1996). The prodromal phase of first-episode psychosis: past and current conceptualizations. Schizophrenia Bullettin, 22(2), 353-70. DOI: 10.1093/schbul/22.2.353 DOI:

Yung, A.R., Yuen, H.P., McGorry, P.D., Phillips, L.J., Kelly, D., Dell'Olio, M., Francey, S.M., Cosgrave, E.M., Killackey, E., Stanford, C., Godfrey, K., & Buckby, J. (2005). Mapping the onset of psychosis: the Comprehensive Assessment of At-Risk Mental States. Australian and New Zealand Journal of Psychiatry, 39(11-12), 964-71. DOI: 10.1080/j.1440-1614.2005.01714.x DOI:

Ziermans, T., de Wit, S., Schothorst, P., Sprong, M., van Engeland, H., Kahn, R., & Durston, S. (2014). Neurocognitive and clinical predictors of long-term outcome in adolescents at ultra-high risk for psychosis: a 6-year follow-up. PLoS One, 9(4), e93994. doi: 10.1371/journal.pone.0093994. DOI:

Ziermans, T.B., Schothorst, P.F., Sprong, M., & van Engeland, H. (2011). Transition and remission in adolescents at ultra-high risk for psychosis. Schizophrenia Research, 126, 58–64. doi: 10.1016/j.schres.2010.10.022. DOI:

Special Section: Clinical high risk for mental illness
Ultra High Risk, psychosis, children and adolescents, suicidality
  • Abstract views: 444

  • PDF: 215
  • HTML: 0
How to Cite
Pontillo, M., Tata, M. C., Averna, R., Gargiullo, P., Guerrera, S., & Vicari, S. (2020). Clinical profile, conversion rate, and suicidal thinking and behaviour in children and adolescents at ultra-high risk for psychosis: a theoretical perspective. Research in Psychotherapy: Psychopathology, Process and Outcome, 23(1).