Psychosocial and family interventions The rationale for psychosocial family interventions follows from the association between high EE and the risk of relapse in schizophrenia (Leff & Vaughn 1985; Dixon & Lehman 1995). The overall aim is to prevent relapse (secondary prevention) and improve the patient’s level of functioning by modifying the family atmosphere. Lam (1991) conducted a systematic review of published trials of psychoeducation and more intensive family interventions in schizophrenia and drew the following conclusions. First, education packages on their own increase knowledge about the illness but do not reduce the risk of relapse. Secondly, more intensive family intervention studies with high EE relatives have shown a reduction in relapse rates linked to a lowering of EE.  Thirdly,  family interventions tend to be costly and time-consuming with most clinical trials employing highly skilled research teams.  Whether these interventions can be transferred into routine clinical practice is uncertain. Fourthly, interventions have focused on the reduction of EE in ‘high-risk’ families. Whether low EE families would also benefit from these interventions is less clear. This is particularly relevant to the families of children and adolescents with schizophrenia as, on average, these parents express lower levels of criticism and hostility than parents of adult onset patients (J.R. Asarnow et al. 1994). Hence, routine family interventions aiming to reduce high EE may be well-intentioned but misguided in their focus. Cognitive - behaviour therapy In adult patients, cognitive therapy has been used to reduce the impact of treatment-resistant positive symptoms (Tarrier et al. 1993). Cognitive - behaviour therapy (CBT) has been shown to be effective in treating negative as well as positive symptoms in schizophrenia resistant to standard antipsychotic drugs, with efficacy sustained over 9 months of follow-up (Sensky et al. 2000). Whether CBT is equally effective with younger patients, or those with predominant negative symptoms, remains to be established. Cognitive remediation Cognitive remediation is a relatively new psychological treatment which aims to arrest or reverse the cognitive impairments in attention, concentration and working memory seen in schizophrenia (Hayes &  McGrath 2000;  Wykes et al.  2000).  The results of an early controlled trial in adults are promising, with gains found in the areas of memory and social functioning (Wykes et al. 2000). The relatively greater severity of cognitive impairments in child and adolescent patients suggests that early remediation strategies may be particularly important in these younger patients. Helpful advice can also be offered to parents, teachers and professionals, such as breaking down information and tasks into small manageable parts to reduce demands on working memory and speed of processing. Organization of treatment services It is a paradox that patients with very early onset schizophrenia have the most severe form of the disorder yet they often receive inadequate and poorly co-ordinated services. One reason for this state of affairs may be that the core responsibility for schizophrenia is seen to lie within adult psychiatric services. In the UK, community-based child and adolescent mental health services (CAMHS) provide the first-line assessment and care for child and young adolescent psychoses, with only about half of these cases referred to specialist inpatient units (Slaveska et al. 1998). While inpatient admission is often unnecessary, generic CAMHS services are usually not well placed to provide a comprehensive assessment and treatment service for very early onset psychoses. First, the very low population prevalence of psychosis reduces the predictive value of diagnosis outside specialist centres.  Secondly,  community-based services often lack familiarity with newer therapies for psychoses including atypical antipsychotics. One possible model would be to establish specialist regional very early onset psychosis teams serving a population of about 5 million,  akin to specialist cancer centres.  These expert teams would be primarily outpatient-based but with access to inpatient facilities if required.  Hence,  the focus would be quite different from the more traditional general purpose adolescent inpatient unit. The teams could offer early diagnostic assessments for children and younger adolescents with suspected psychotic disorders and set up treatment plans in collaboration with more local child and adult psychiatric services. Ideally, these teams would be linked to a university academic centre with an interest in psychosis research and treatment evaluation.