Schizophrenia Bulletin Advance Access published April 30, 2016

Schizophrenia Bulletin
doi:10.1093/schbul/sbw042

Academic Performance in Children of Mothers With Schizophrenia and Other

Severe Mental Illness, and Risk for Subsequent Development of Psychosis:
APopulation-BasedStudy

1
Telethon Kids Institute, University of Western Australia, Perth, Australia; 2Neuropsychiatric Epidemiology Research Unit, School
of Psychiatry and Clinical Neurosciences, University of Western Australia, Perth, Australia; 3School of Psychiatry and Clinical
Neurosciences, University of Western Australia, Perth, Australia; 4Clinical Research Centre, North Metropolitan Health Service Mental
Health, Perth, Australia; 5Centre for Clinical Research in Neuropsychiatry, School of Psychiatry and Clinical Neurosciences, University
of Western Australia, Perth, Australia

*To whom correspondence should be addressed; Telethon Kids Institute, University of Western Australia, 100 Roberts Rd, Subiaco,
Perth 6008, Australia; tel: +61-8-9489-7772, e-mail: Ashleigh.Lin@telethonkids.org.au

Objective: We examined the academic performance

at age 12 years of children of mothers diagnosed with
schizophrenia or other severe mental illness using a large
whole-population birth cohort born in Western Australia.
We investigated the association between academic performance and the subsequent development of psychotic
illness. Method: The sample comprised 3169 children of
mothers with severe mental illness (schizophrenia, bipolar disorder, unipolar major depression, delusional disorder or other psychoses; ICD-9 codes 295298), and
88 353 children of comparison mothers without known
psychiatric morbidity. Academic performance of children
was indexed on a mandatory state-wide test of reading,
spelling, writing and numeracy. Results: A larger proportion of children (43.1%) of mothers with severe mental
illness performed below the acceptable standard than
the reference group (30.3%; children of mothers with no
known severe mental illness). After adjusting for covariates, children of mothers with any severe mental illness
were more likely than the reference group to perform
below-benchmark on all domains except reading. For
all children, poor spelling was associated with the later
development of psychosis, but particularly for those
at familial risk for severe mental illness (hazard ratio
[HR]=1.81; 95% CI for HR=1.21, 2.72). Conclusions:
Children of mothers with a severe mental illness are at
increased risk for sub-standard academic achievement
at age 12 years, placing these children at disadvantage
for the transition to secondary school. For children with
familial risk for severe mental illness, very poor spelling
skills at age 12years may be an indicator of risk for later
psychotic disorder.

Key words: academic performance/psychosis/

schizophrenia/psychiatric disorder/at-risk/genetic risk/
familial risk/linked data/population/neurocognition
Introduction
Neurocognition is impaired in a substantial proportion
of people with schizophrenia and its component functions have been proposed as endophenotypes for the
disorder. According to a neurodevelopmental model of
schizophrenia1,2 and the criteria for an endophenotype,3
similar cognitive impairments are likely to be present in
the first-degree relatives of individuals with schizophrenia
who do not develop the illness, as well as in the probands
themselves before the psychosis onset. Extant evidence
supports these hypotheses. Compared with the children
of healthy parents, offspring of individuals with schizophrenia show poorer cognitive performance (see Niemi
etal4 and Agnew-Blais and Seidman5 for review). Reduced
cognitive ability throughout childhood and adolescence
is also a robust finding in individuals who later develop
schizophrenic illness (see Welham etal6 for review).
Population-based cohorts provide the opportunity to
investigate genetic and environmental risk factors for
schizophrenia and other severe mental illnesses on a
large, unbiased scale. Scholastic performance, as indexed
by school attainment assessments, is a plausible proxy
for cognitive ability. Notwithstanding its limitations, performance at school is likely to reflect, at least in part, a
young persons cognitive capacity. For example, it has
been shown that cognitive ability at age 11 years correlated .83 with results from national school examinations.7

The Author 2016. Published by Oxford University Press on behalf of the Maryland Psychiatric Research Center.
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AshleighLin*,1, PatsyDi Prinzio2, DeidraYoung2, PeterJacoby1, AndrewWhitehouse1, FlavieWaters3,4,

AssenJablensky5, and Vera A.Morgan2,5

A. Lin etal

Methods
Study Population
The electronic e-Cohort has been constructed by record
linkage across Western Australian administrative health
and social services registers. It includes all the children
born in Western Australia between 1980 and 2001 to
mothers with a diagnosis of schizophrenia or other severe
mental illness who had inpatient hospital admission or
ambulatory/outpatient contact recorded on the Hospital
Morbidity Data System and Mental Health Information
System between 1966 and 2001. The inclusion of mothers
with other nonorganic psychotic disorders in addition to
schizophrenia allows for investigation of the specificity
of findings across the psychosis spectrum. The e-Cohort
also comprises a comparison sample of all the children
born in Western Australia over the same period whose
mothers had no record of contact with mental health
services. There are 15 486 children born to 7508 case
mothers with severe mental illness and 452 459 children
born to 239 365 comparison mothers in the e-Cohort (see
Morgan et al20 for full description). The present study
consists of all children in the e-Cohort with academic
performance data in Year 7 (3169 case children and 88
353 comparison children). Children were followed up for
mental health outcomes to June 30, 2011, when their ages
ranged from 14 to 23years.
Case Definition and Diagnosis
To accommodate changes in diagnostic classification over
time, ICD-8 and ICD-10 codes were mapped to ICD-9
diagnoses to classify psychiatric morbidity for severe
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mental illnesses. These codes were schizophrenia (295.x),

bipolar disorder (296.0 and 296.25), unipolar (major)
depression (296.1, 296.6, 296.8 and 296.9) and any nonorganic psychosis (295.x, 296.x, 297.x and 298.x). The
research team has developed algorithms for determining
the diagnosis of individuals with multiple records.21 The
concurrent validity of register diagnoses of schizophrenia and affective psychoses have been evaluated against
an independent sample assessed using a semi-structured
diagnostic interview22 with sensitivity of 0.92 and specificity of 0.88 for schizophrenia and 0.80 and 0.90 respectively for affective psychoses.21 For offspring only, we
used a lifetime ever diagnosis of a psychotic disorder
within these ICD-9 ranges.
Record Linkage to Academic Performance
To examine the academic performance of children in
the e-Cohort, their records were linked to the Western
Australian Department of Education registry which
provides data on the Western Australian Literacy and
Numeracy Assessment (WALNA). WALNA is a curricular-based assessment administered annually to all students in the state of Western Australia in school grades
3 (age 8), 5 (age 10), and 7 (age 12). The test consists
of multiple choice, short answer and open-ended questions which measure skills in 4 academic domains: reading, writing, spelling, and numeracy. All WALNA tests
are scored using the Western Australian Measuring
Standards in Education Scale, allowing comparisons
to be made within test domains over time (eg, grade 3
numeracy and grade 5 numeracy), but not across test
domains (eg, grade 3 numeracy and grade 3 reading).
Higher scores indicate better performance. Benchmark
levels are agreed standards of performance determined
by educators throughout Australia to represent the minimum performance in each year necessary to make adequate educational progress. We investigated readiness for
secondary school by examining WALNA performance at
Year 7, approximately age 12.
Parental and Birth Information
Data were collected from the Midwives Notification
System, which includes mandatory, prospectively collected data on all infants born in Western Australia at
20 weeks gestation or weighing at least 400g, including
home births. Core data included maternal age, maternal
marital status, babys gestational age and weight, pregnancy complications (eg, pre-eclampsia, placenta praevia, abruption), labor and delivery complications (eg,
cephalopelvic disproportion, prolapsed cord, fetal distress) and early neonatal intervention and outcome (eg,
intubation, 5-minute Apgar score). The McNeil-Sjstrm
Scale for Obstetric Complications23 scoring was used,
where complications at severity level 4 or higher indicate

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The few studies that have examined the scholastic performance of the children of parents with schizophrenia
have demonstrated that those children show poorer scholastic performance810 and have lower teacher ratings,11
than the offspring of unaffected parents. The literature on
school performance and the later development of schizophrenia is large but inconsistent: some population-based
studies have reported poorer school performance prior to
schizophrenia onset,1215 others have not.1618 Overall, a
meta-analyses19 showed no significant effect for poor academic performance in individuals 16years of age or older
who subsequently developed schizophrenia.
Using data from linked records on children of mothers
with and without severe mental illness in a populationbased birth cohort in Western Australia,20 we aimed to:
(1) investigate academic performance at age 12years of
children of mothers diagnosed with schizophrenia, relative to the performance of children of mothers with other
severe mental illness and mothers with no known mental
illness; and (2) clarify the association between academic
performance at age 12years and subsequent development
of psychosis.

Academic Performance in Children of Mothers With Schizophrenia

adversity sufficient to be potentially harmful or relevant

to anomalous central nervous system development. We
created binary indicators for complications during: (1)
pregnancy; (2) labor or delivery; and (3) the neonatal
period, including birth defects.
Demographic Information

Statistical Analyses
Analyses were conducted in SPSS (version 21)and Stata
(version 13). We examined school performance belowbenchmark in Year 7 (approximately 12 years of age).
Below-benchmark performance in any academic domain
was noted first, followed by below-benchmark performance in specific academic domains.
Academic Performance Predicted by Mothers
PsychiatricStatus
Generalized linear models were conducted, using robust
standard errors to adjust for clustering of children within
mothers. Below-benchmark performance (compared to at
or above benchmark performance) were modeled as the
dependent variables and mothers psychiatric status was
the primary predictor of interest. First, we examined children of mothers with any severe mental illness, compared
with children of mothers with no known mental illness as
the reference group. Maternal diagnosis was then entered

Academic Performance and the Development of

Psychotic Disorder in Children
Time-to-event Cox regression analyses were employed
to investigate whether below-benchmark performance in
Year 7 was a predictor of subsequent psychotic illness
in the children. Any recorded psychotic disorder was
defined as an event. Time was calculated from WALNA
test date to date of first admission for psychosis, date
of death, or date of data extraction (whichever came
first). The same blocking method as above was used to
adjust for covariates. Robust standard errors were used
to account for clustering of individuals within mothers.
To ensure that poor academic performance was not the
effect of prodromal disturbances or psychosis onset,
children with a recorded onset of psychosis before or
within a year of WALNA testing were excluded from
analyses (n=56).
To investigate the contribution of maternal psychiatric
status to the association between academic performance
and the development of psychosis, analyses were repeated
with maternal psychiatric status as an additional covariate. Finally, time-to-event analyses were repeated again
stratified by maternal psychiatric status (children with
mothers with, vs without, severe mental illness).
All Cox regression analyses were checked to ensure the
assumptions of proportionality was met. Multiple diagnostic checks were employed to ensure any collinearity
between covariates did not adversely impact the estimation of parameters of key interest.
Results
In this sample, 3169 children had mothers with a severe
mental illness (schizophrenia = 320; bipolar disorder=766; unipolar (major) depression=1760; delusional
disorder or other psychoses=323). The sample also comprised 88 353 children with a mother with no known mental illness. By the time of data extraction, 998 children
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Socioeconomic status was determined using a censusderived area-level measure linked to the mothers residence at the time of the childs birth: the Australian
Bureau of Statistics (ABS) Socio-Economic Indexes For
Areas.24 We used the Index of Relative Socioeconomic
Disadvantage. For most cases, the smallest spatial unit
(the census collection district) was used to determine
level of disadvantage; postcode was used only where this
was not available. Index values were transformed into
quintiles. Geographical remoteness of the mothers residence at time of childs birth was determined using an
ABS census-derived area-level measure, the Australian
Standard Geographic Classification-Remoteness Area.25
Remoteness categories (major city, inner and outer
regional, remote and very remote) are based on the road
distance of a location from the nearest population centre, taking into account population size. Mothers and
offspring were classified as Indigenous if they reported
being Aboriginal or Torres Strait Islander in any of
the linked registers. Language other than English was
recorded from the Department of Education database.
Paternal age at birth of child was obtained from the Birth
Registration Records and paternal psychiatric status was
obtained from the Mental Health Information System.
Details of the data linkage sources, process and reliability
are available for this cohort20 and for the data linkage system in Western Australia more generally.26,27

as the primary predictor (schizophrenia, bipolar disorder,

unipolar (major) depression, delusional disorder or other
psychoses) and compared to the referencegroup.
Covariates were entered in blocks as follows: in model
1, calendar year and age at testing; in model 2, sociodemographic variables (gender at birth, English as a
second language, socioeconomic status at birth, remoteness at birth, Indigenous status) were added; in model
3, obstetric complications (gestational age, McNeilSjostrom obstetric complication scores during pregnancy,
labor/delivery, neonatal period) were further added; and
in model 4, other parental information (maternal marital status at birth of child, maternal age at birth of child,
paternal age at birth of child, paternal psychiatric status)
was inserted. Detailed demographic data for this sample
are presented in supplementary table1.

A. Lin etal

had developed a psychotic disorder; of these, 125 had a

mother with severe mental illness. The mean age of children at data extraction was 20.07years (SD=1.45). The
mean age at psychosis onset was 16.77years (SD=2.35).
When children with psychosis onset before or within
1year of WALNA testing were excluded, the mean age at
psychosis onset was 17.11years (SD=1.93).
Academic Performance Predicted by Mothers
PsychiatricStatus

Fig.1. Proportion of children with below-benchmark performance at Year 7 by mothers psychiatric status.
Table1. ORs for Below-Benchmark Academic Performance in Year 7 for Offspring of Mothers With Severe Mental Illnesses

Mother with any

severe mental illness
Mother with no
known mental illness

Any Domain,
N=91 023

Numeracy,
N=89 308

Spelling,
N=88 623

Reading,
N=88 981

Writing,
N=87 981

OR (95%
CI for OR)

OR (95%
CI for OR)

OR (95%
CI for OR)

OR (95%
CI for OR)

OR (95%
CI for OR)

1.33 (1.22, 1.44)

1.19 (1.08, 1.32)

1.26 (1.15, 1.38)

1.08 (0.97, 1.21)

1.22 (1.09, 1.37)

Reference

Reference

Reference

Reference

Reference

Note: The fully adjusted models are adjusted for calendar year of test, age at testing, gender, Indigenous status, English as a second
language, socioeconomic status, remoteness, gestational age, obstetric complications during pregnancy, during labor or delivery, during
the neonatal period, maternal age at birth, paternal age at birth, maternal marital status and paternal psychiatric status. ORs are shown
with 95% CIs for the OR for each academic domain. Robust standard errors were used to account for clustering of children within
mothers.

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Figure 1 shows the proportion of children performing below-benchmark by maternal psychiatric status.
Ahigher proportion (43.1%) of children of mothers with
severe mental illness performed below-benchmark on
any domain than the reference group (30.3%; children of
mothers with no known mental illness). The highest proportion of children with below-benchmark performance
were those with mothers with schizophrenia (49.7%), followed by children of mothers with delusional disorder or
other psychoses (49.5%), then children of mothers with
unipolar (major) depression (42.9%), and finally children

of mothers with bipolar disorder (38.3%). This pattern

held across academic domains.
OR with 95% CI for the full adjusted models predicting the academic performance of children of mothers
with severe mental illness are presented in table1 (statistics
for each adjusted model are presented as supplementary
table 2). After adjustments, children of mothers with any
severe mental illness were more likely than the reference
group to perform below-benchmark on all domains except
reading. Fully adjusted models by mothers diagnosis are
presented in table2 (statistics for each adjusted model are
presented as supplementary table3). Children of mothers
with schizophrenia were more likely than the reference group
to perform below-benchmark on any one of the domains
(OR=1.38; 95% CI for OR=1.071.79), and specifically
on spelling (OR=1.45; 95% CI for OR=1.101.91). After
adjustments, children of mothers with unipolar (major)
depression were more likely to perform below-benchmark
on all domains except reading. Children of mothers with
bipolar disorder or delusional disorder or other psychoses were more likely than the reference group to perform
below-benchmark on any one of the domains. Confidence

Academic Performance in Children of Mothers With Schizophrenia

intervals overlapped for the children of mothers with the different serious mental illnesses, suggesting no significant difference in academic performance between children exposed
to mothers with different psychotic disorders (table2).
Academic Performance and the Development of
Psychotic Disorder in Children
After adjusting for covariates, the development of a psychotic disorder in children was significantly associated

with below-benchmark performance on spelling (hazard ratio [HR]=1.20; 95% CI for HR=1.021.40; see
table3). Spelling remained a significant predictor of the
development of psychotic illness when maternal psychiatric status was entered as a covariate (HR=1.18; 95%
CI for HR = 1.011.38). When time-to-event analyses
were repeated with stratification by children of mothers
with and without severe mental illness, spelling remained
as a significant predictor of the development of psychosis in children of mothers with severe mental illness only

Mother with schizophrenia

Mother with bipolar disorder
Mother with unipolar (major) depression
Mother with delusional disorder or
other psychosis
Mother with no known mental illness

Any Domain,
N=91 023

Numeracy,
N=89 308

Spelling,
N=88 623

Reading,
N=88 981

Writing,
N=87 981

OR (95%
CI for OR)

OR (95%
CI for OR)

OR (95%
CI for OR)

OR (95%
CI for OR)

OR (95%
CI for OR)

1.38 (1.07, 1.79)

1.20 (1.02, 1.41)
1.36 (1.22, 1.52)
1.41 (1.10, 1.81)

1.25 (0.94, 1.66)

1.17 (0.95, 1.42)
1.22 (1.07, 1.39)
1.06 (0.78, 1.45)

1.45 (1.10, 1.91)

1.10 (0.90, 1.33)
1.30 (1.15, 1.46)
1.23 (0.93, 1.64)

1.16 (0.85, 1.58)

1.00 (0.79, 1.27)
1.13 (0.97, 1.31)
0.99 (0.71, 1.37)

1.11 (0.80, 1.55)

0.93 (0.73, 1.18)
1.40 (1.21, 1.62)
1.13 (0.80, 1.60)

Reference

Reference

Reference

Reference

Reference

Note: The fully adjusted models are adjusted for calendar year of test, age at testing, gender, Indigenous status, English as a second
language, socioeconomic status, remoteness, gestational age, obstetric complications during pregnancy, during labor or delivery, during
the neonatal period, maternal age at birth, paternal age at birth, maternal marital status and paternal psychiatric status. ORs are shown
with 95% CIs for the OR for each academic domain. Robust standard errors were used to account for clustering of children within
mothers.

Table3. Hazard Ratios for Fully Adjusted Models of the Development of Psychotic Disorder in Children for the Full Sample, and by
Mothers Psychiatric Status

Full Sample

Full Sample
(Including Mothers
Psychiatric Status)a

Children of
Mothers With
Severe Psychiatric
Disorder

Children of
Mothers With no
Known Psychiatric
Disorder

Any domain
below benchmark

N
HR (95% CI for HR)

90 962
1.14 (0.99, 1.31)

90 962
1.12 (0.97, 1.29)

3142
1.41 (0.96, 2.07)

87 820
1.08 (0.93, 1.25)

Numeracy
below benchmark

N
HR (95% CI for HR)

89 251
1.10 (0.92, 1.31)

89 251
1.08 (0.91, 1.29)

3049
1.31 (0.70, 1.82)

86 202
1.07 (0.89, 1.30)

Spelling below
benchmark

N
HR (95% CI for HR)

88 565
1.20 (1.02, 1.40)

88 565
1.18 (1.01, 1.38)

3014
1.81 (1.21, 2.72)

85 551
1.09 (0.92, 1.30)

Reading below
benchmark

N
HR (95% CI for HR)

88 921
1.08 (0.88, 1.32)

88 921
1.07 (0.88, 1.32)

3035
1.26 (0.74, 2.15)

85 886
1.04 (0.83, 1.30)

Writing below
benchmark

N
HR (95% CI for HR)

87 922
1.15 (0.94, 1.41)

87 922
1.13 (0.93, 1.39)

2960
0.83 (0.48, 1.45)

84 962
1.19 (0.96, 1.48)

Note: The fully adjusted models are adjusted for calendar year of test, age at testing, gender, Indigenous status, English as a second
language, socioeconomic status, remoteness, gestational age, obstetric complications during pregnancy, during labor or delivery, during
the neonatal period, maternal age at birth, paternal age at birth, maternal marital status and paternal psychiatric status. Hazard ratios
(HR) are shown with 95% CIs for the HR for each academic domain. Robust standard error was used to account for clustering of
children within mothers.
a
Maternal psychiatric status entered as an additional adjustment.

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Table2. ORs for Below-Benchmark Performance in Year 7 for Offspring of Mothers With Schizophrenia, Bipolar Disorder, Unipolar
(Major) Depression, and Delusional Disorder or Other Psychosis

A. Lin etal

(HR = 1.81; 95% CI for HR = 1.212.72). Children of

mothers with no known severe mental illness who went
on to develop psychosis did not show poorer academic
performance (HR=1.09; 95% CI for HR=0.921.30).
HR with 95% CI for each adjusted model are presented
as supplementary table3.
Discussion

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In this population-based cohort, we investigated academic performance in the offspring at age 12 years of
mothers with schizophrenia or other severe mental illness. Our findings confirm that children of mothers with
a severe mental illness are more likely to perform below
the acceptable standard on academic achievement tests
at this age. After adjustments for potential confounders,
children of mothers with schizophrenia were also more
likely to perform below expectation in any academic
domain. Sub-standard spelling at age 12 was associated
with the development of psychotic disorder, but only in
children of mothers with severe mental illness.
Children of mothers with a severe mental illness were
more likely to perform below-benchmark than the offspring of mothers with no known mental illness across
all academic domains, except reading. The proportion of
children performing below-benchmark (shown in figure1)
was greatest for those with mothers with schizophrenia,
followed by children of mothers with delusional disorder
and other psychoses, children of mothers with depression
and finally children of mothers with bipolar disorder.
After adjustments, children of mothers with schizophrenia were more likely than children of comparison mothers to perform below-benchmark in spelling. This finding
is partly consistent with previous results, including 2
population-based studies which demonstrated poorer
school performance (indexed by a summed score across
academic domains) at age 1516years in children of parents with schizophrenia.8,9 We show that poor academic
achievement is evident at an even earlier age. This is in
line with findings of poor scholastic performance from a
small group of children aged 1011years at familial risk
for schizophrenia,10 as well as with literature on cognitive
deficits in children of individuals with schizophrenia.4
We also investigated the relative risk for poor performance in the children of mothers with other severe mental
illness. After adjustment for covariates, children of mothers with unipolar (major) depression showed higher risk
for poor performance across all domains with the exception of reading. This effect was not evident in children of
mothers with bipolar disorder or delusional disorder and
other psychoses, although they did show reduced performance in at least 1 domain. The confidence intervals
for performance overlapped between children of mothers with the various severe mental illnesses. This suggests
that, at age 12, there are distinct deviations in performance between children at familial risk for severe mental

illness and comparison children, but no significant differences in academic performance between children exposed
to mothers with different psychotic disorders.
In this cohort, the development of any psychotic disorder was associated with below-benchmark performance
in the spelling domain after adjusting for potential confounding factors. The hazard ratio was relatively small
(HR=1.20). While some population-based studies and
a meta-analysis19 have shown no significant association
between poor academic performance and later schizophrenia,16,18,28 others have. Data from the British 1946
birth cohort showed that poor performance on mathematics, verbal and non-verbal tests at age 15 years predicted later schizophrenia.14 Similarly, in 2 large Swedish
cohorts, the development of psychosis was strongly associated with poor performance at age 1516years across
academic domains.12,13 MacCabe and colleagues12 found
that performance greater than 2 SDs below the mean was
associated with a 4-fold increase in risk for schizophrenia
or schizoaffective disorder, and a 3-fold increased risk for
other psychoses.
There are several possible explanations for the discrepancies in these findings. One reason may be that the individuals in our cohort who developed psychotic illness are
diagnostically more heterogeneous than other samples
and include individuals with schizophrenia, affective and
other psychoses. Affective and other psychotic disorders appear to be less strongly associated with impaired
school performance28 and premorbid cognitive ability
than schizophrenia,2931 although this is not always the
case.13,32,33
A second possibility is that we adjusted for a wide
range of socio-demographic variables, multiple indices of obstetric complications, and family factors in an
attempt to partial out specific associations between academic performance and psychotic disorder. Although our
unadjusted odds ratios were still smaller than those of
MacCabe and colleagues,12 they employed a more stringent cut-off for poor performance (<2 SD below the
mean), which might increase the hazard ratio. Dickson
et al19 also suggest the heterogeneity in findings may
reflect different educational systems and methods for
measuring academic achievement.
A third and more likely explanation for our findings
is that the poor scholastic performance in those who
develop psychosis may only occur (or reach a detectable
magnitude) in later adolescence. Almost all findings of
an association between poor school performance and
later schizophrenia are from youth aged 1516years.1215
Studies examining younger children generally found no
association; Cannon etal,18 Ang and Tan34 and Ullman
etal28,34 did not find a significant association between academic performance at ages 11,12 and 1314 respectively,
and subsequent schizophrenia. Further support for this
explanation comes from the school records of 70 patients
with schizophrenia15 showing that school performance in

Academic Performance in Children of Mothers With Schizophrenia

Linking multiple registers allowed us to adjust for a large

number of socio-demographic, obstetric and familyrelated variables known to be associated with severe illness, academic performance, and cognitive ability. Our
ascertainment of cases is likely to be valid, given that
the psychiatric register covers all public and private providers of in-patient mental health services, and public
out-patient and community services. We were not able
to capture mental illness diagnosed by general practitioners or private psychiatrists/psychologists, which may
have attenuated the findings. It is also possible that some
mothers may have been diagnosed with a severe mental
illness after data extraction, or diagnosed in another state
or country. Given the age range of the children at data
extraction, it is likely that some would still develop a psychotic disorder in the course oftime.
An important consideration is that academic achievement as indexed by population-based examinations is not
synonymous with psychometric assessment of intellectual or other cognitive abilities. Performance is likely to be
influenced by motivation at time of testing, school attendance and engagement, all of which could be affected
by growing up with a mother with severe mental illness.
Moreover, specific cognitive reduction, such as attention,
memory and cognitive flexibility, in the absence of global
intellectual impairment, are likely to impact the ability of
the child to perform school tests successfully. Despite this
limitation, it is appropriate to assume that academic performance below the acceptable standard largely reflects
impaired cognitive ability, especially given the existing
evidence of robust associations between neurocognitive
test performance, genetic risk for schizophrenia, and the
later development of the disorder. Finally, the psychiatric status of fathers was not included in the definition of
risk, although we did covary for paternal psychiatric status in analyses. We ascertained the paternity of 99.7% of
the cohort; however, missing paternity data was highest
for offspring of mothers with schizophrenia.
In conclusion, this study demonstrates that children of
mothers with severe mental illness are at increased risk
of poor academic performance at age 12 that is below
the acceptable standard, placing these children at disadvantage as they make the transition to secondary school.
Within this group, very poor spelling skills appear to be
associated with the later development of psychosis. The
findings suggest that targeted intervention to enhance the
academic skills of children of mothers with severe mental
illness needs to be considered. Moreover, poor spelling
skills, in combination with familial risk, may be an indicator of particular vulnerability for psychotic illness, and
care monitoring of these children could be warranted.44
Indeed, it has been argued that waiting for the onset
of positive psychotic symptoms in identifying risk for
schizophrenia is misguided.35 Existing approaches that
focus on these symptoms, eg, the ultra/clinical high risk
and psychotic-like experiences strategies, may already
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grades 4 and 8 were not significantly associated with the

development of schizophrenia, but performance in grade
11 was. Importantly, Fuller and colleagues15 showed that
language (which included spelling) was the only academic
domain in which there was a significant decline in scores
over time. Jones et al14 also demonstrated a trend for
poorer academic performance to be more strongly associated with schizophrenia with increasing age. Kahn and
Keefe35 suggest that this deterioration in cognitive ability
may be the earliest manifestation of schizophrenia.
This explanation is consistent with the evidence for an
association between poor cognition and schizophrenia,
as consistently demonstrated in military conscript studies
(assessment at age 1618 y),36,37 and the findings that a
decline in cognitive ability from the early adolescent years
to age 18 was associated with later schizophrenia and
other psychoses38 Such evidence would support a developmental lag hypothesis,39 whereby children who later
develop schizophrenia are acquiring new skills at a slower
rate than their healthy peers. Reichenberg and colleagues40
showed that in individuals who developed schizophreniaspectrum disorders deficits in verbal and visual concept
acquisition were evident early in childhood and remained
stable, while impairments in attention, processing speed
and working memory developed later. This is consistent
with our finding of below-benchmark spelling, but not
numeracy, at age 12 in those who subsequently developed
psychosis.
The association between poor spelling skills and psychotic illness was only evident in children of mothers
with severe mental illness. It may be that psychotic illness in the context of familial risk is associated with more
neurodevelopmental underpinnings than psychosis in the
absence of familial risk. Seidman and colleagues41 demonstrated that individuals at familial risk for psychosis
who later developed psychotic illness themselves showed
lower IQ and verbal ability at age 7 than those who developed psychosis but did not have a family history of risk.
Environmental influences are also likely to play a major
role in the cognitive development and school performance of children of mothers with severe mental illness.42
We adjusted for sociodemographic and family variables
available in the databases, but numerous other environmental factors associated with both school performance
and psychosis could not be accounted for. These include
school absences, the home learning environment, socioeconomic status later in life, trauma, parental level of
education and social isolation, as well as environmental
insults during pregnancy for which relevant data (eg,
maternal nutrition and smoking) were not available. It is
also necessary to consider the effect of cumulative risks
(including genetic risk) on school performance and cognitive development of children.43
The strength of this study is the large data set of over
90 000 children, 3169 of whom had a mother with severe
mental illness and 320 a mother with schizophrenia.

A. Lin etal

be intervening too late in the disease process to alter the

course of schizophrenia.45 Because poor academic performance in later adolescence represents one of the most
consistently reported risks for schizophrenia, following
young people over time to detect poor and deteriorating
academic performance and/or cognitive function may be
an effective risk identification strategy.35
Supplementary Material
Supplementary material is available at http://schizophreniabulletin.oxfordjournals.org.

This work was supported by funding from National

Health and Medical Research Council (NHMRC) project
grants 1002259, 458702, 303235, March of Dimes grants
#12-FY07-224, #12-FY04-48 and a Stanley Foundation
Grant. A.L. is supported by an NHMRC Early Career
Fellowship (#1072593).
Acknowledgments
We thank the Data Linkage Branch of the WA
Department of Health for linkage, extraction and client support services aspects of data provision. We also
thank the custodians of the WA Department of Health
Inpatient and Mental Health Data Collections, the WA
Midwives Notification System, the WA Department of
Education WALNA collection and the WA Registry of
Births, Deaths and Marriages for the provision of data.
The authors have no conflicts of interest to declare.
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