Recognition and management of psychosis in children

Deakin J, Lennox B. Psychotic symptoms in young people warrant urgent referral. Practitioner. 2013 Mar;257(1759):25-8, 3.

“There is a worse prognosis for psychosis and schizophrenia when onset is in childhood or adolescence. However, outcomes are improved with early detection and treatment. Psychotic symptoms can be associated with a variety of disorders including schizophrenia, schizoaffective disorder, drug-induced psychosis, personality disorder, epilepsy and autistic spectrum disorder. Positive symptoms include hallucinations and delusions. Negative symptoms include apathy, lack of drive, poverty of speech, social withdrawal and self-neglect. The DSM IV criteria for schizophrenia include two or more of the following: hallucinations, delusions, disorganised speech, grossly disorganised or catatonic behaviour and negative symptoms. Adults may raise concerns about social withdrawal, bizarre ideas, a change in behaviour or a decline in achievement. Most children and young people with psychotic symptoms will not go on to develop psychosis or schizophrenia. Direct enquiry may be needed to elicit suspected unusual beliefs or hallucinations. To distinguish unusual ideas from delusions the ideas should be tested for fixity. For example by asking: ‘Are you sure? Could there be another explanation?’ Mood and anxiety symptoms should be explored. The assessment should include a developmental history with particular attention to premorbid functioning. Failure to make expected progress whether personal, social or academic is significant. Better outcomes in terms of symptoms and social function are associated with a shorter duration of untreated psychosis. The detection of psychotic symptoms in primary care therefore warrants an urgent referral to secondary care mental health services for assessment and treatment.”

Full-text for Children’s and Emory users.


Kendall T, et al. Recognition and management of psychosis and schizophrenia in children and young people: summary of NICE guidance. BMJ. 2013 Jan 23;346:f150.

“Assessment and diagnosis of psychosis and schizophrenia in children and young people can be challenging because it has to take into account developmental factors and potential differential diagnoses and comorbid conditions, which differ from those in adults. The NICE guideline aims to reduce delayed recognition and increase accurate diagnosis and early uptake of evidence based treatments by supporting rapid referral of children and young people with suspected psychosis from primary care to a consultant psychiatrist with training in child and adolescent mental health (through either child and adolescent mental health services (CAMHS) or an early intervention in psychosis service).”

NICE Guideline: Psychosis and schizophrenia in children and young people

Full-text for Children’s and Emory users.


Algon S, et al. Evaluation and treatment of children and adolescents with psychotic symptoms. Curr Psychiatry Rep. 2012 Apr;14(2):101-10.

“At initial onset of psychotic symptoms, a general evaluation for medical disorders is warranted, including toxicology for recreational drugs, complete blood count, basic metabolic panel, and thyroid function tests. Where history or signs upon physical or neurological examination suggest a medical disorder, further testing should be considered (eg, comprehensive metabolic panel, antinuclear antibody, HIV, B12, RPR, serum calcium/phosphorus, copper/ceruloplasmin and heavy metal levels, and genetic testing) [33, 34]. Screening for metabolic disorders, storage diseases, infectious diseases, and autoimmune encephalopathies may also be considered under consultation with health care providers with specific expertise in these areas. In cases of persistent psychosis or cases with suspected neurological conditions, evaluation with MRI is recommended. Although of low yield in larger cohorts of individuals with first-onset psychosis [35, 36], brain imaging should be considered before rendering the diagnosis of severe mental illness [37]. The diagnostic utility of obtaining electroencephalograms in patients with psychosis is limited and should be guided by index of suspicion for seizures [37].”

Free full-text. 


Reimherr JP, McClellan JM. Diagnostic challenges in children and adolescents with psychotic disorders. J Clin Psychiatry. 2004;65 Suppl 6:5-11.

“The diagnosis of psychotic disorders in children and adolescents is often complex and challenging. The symptomatic overlap between different psychotic conditions and other emotional, behavioral, and developmental disorders has led to high rates of misdiagnosis, especially at time of onset. The clinical expression and progression of diagnosable disorders are affected by maturational processes. Thus, psychotic illnesses in pediatric patients may vary from adult presentations because of developmental factors. Establishing a specific diagnosis is difficult when the differential diagnosis comprises disorders that share common symptoms and are frequently comorbid. The clinical assessment depends as much on input from parents and teachers as from the patients themselves, and there may be conflict between these different perceptions. This article reviews recent research and current concepts relating to diagnostic challenges in pediatric psychiatry.”

Full-text for Emory users.


More PubMed results on psychosis in children.

Created 08/08/13; updated 12/03/15. 

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