Peter, an 11-year old boy is referred to the school guidance counselor for declining grades. However, Peter presents with brief self-limited hallucination and persecutory ideation with a gradual deterioration in overall functioning. The potential for development of childhood-onset schizophrenia is expressed. Peter fits the profile of a child at ultra high-risk of developing psychosis raising the question as how to manage and possibly treat him. A literature review is conducted to evaluate the evidence that treatment at this stage can avert psychosis. It is determined to start with the randomized, controlled trials as the evidence with the least bias. There is good evidence that low-dose anti-psychotics and cognitive therapy may reduce the intensity of his symptoms. However, it is decided that medication is not the best choice and a decision is made to monitor Peter’s mental state closely. National Institute of Mental Health (NIMH) studies suggest that clozapine is superior to haloperidol for patients like Peter. Attention to psychosocial factors that may contribute to his lack of response to treatment is important, especially the level of expressed emotion within the family. Behavioral family therapy is often highly effective in reducing the level of expressed emotion and in adult-onset schizophrenia. The treatment with the clozapine is chosen. Peter has an excellent response, however with a wide range of side effects. These side effects were found to be manageable. Such a severe and complex disorder as childhood schizophrenia is well served by an approach based on evidence with the least bias. Even with complex treatment issues, such as Peter’s, a multidisciplinary team approach matching optimal pharmacotherapy with attention to educational needs and the family environment is a highly effective intervention. Table, figure, references