An adolescent presents to a pediatrician for a routine visit. When asked about hobbies, the patient says he enjoys writing fantasy stories. He discloses that he hears the voices of the characters he writes about and prefers conversing with them rather than spending time with others. He denies any distress from his conversations with the characters. Although his grades are good, he does not enjoy school. He has no close friends and has a history of being bullied in school. His mother reports a history of social awkwardness and restricted interests.
Pediatricians may be the first point of contact for youths reporting psychotic-like experiences. Ideally, pediatricians would refer these patients to psychiatric care immediately. However, due to the shortage of child and adolescent psychiatrists, they may need to make an initial assessment to determine the appropriate level of care.
A new AAP clinical report from the Committee on Adolescence provides guidance for the general pediatrician — with case vignettes — on how to assess, evaluate and treat patients who present with psychotic symptoms in collaboration with child and adolescent psychiatrists. The report, Collaborative Care in the Identification and Management of Psychosis in Adolescents and Young Adults, is available at https://doi.org/10.1542/peds.2021-051486 and will be published in the June issue of Pediatrics.
Symptoms, prevalence
Psychotic disorders are characterized by delusions, hallucinations, disorganized thinking, disorganized behavior and negative symptoms.
A systematic review of the literature showed a median of 17% of 9- to 12-year-olds and 7.5% of 13- to 18-year-olds reported experiencing auditory hallucinations. Most of these youths do not develop primary psychotic disorders, although those who experience hallucinations are more likely to have or develop psychiatric disorders.
Individuals characterized as at clinical high risk experience attenuated psychotic symptoms and may have subtle changes in their thinking and behaviors that differ from baseline functioning. They often experience a higher level of distress from these symptoms. Patients at clinical high risk also have a higher likelihood of transitioning to overt psychotic symptoms and eventually to a primary psychotic disorder.
Evaluation
When patients present with psychotic-like or overt psychotic symptoms, a thorough history of presenting illness and mental status exam should be conducted.
Pediatricians should screen for suicidal ideation, since patients presenting with psychotic symptoms are at higher risk of suicidal ideation/attempts. Care should be taken not to pathologize what could be imaginary friends, cultural beliefs or trauma.
Obtaining laboratory values and performing a thorough physical (including neurological) examination can be helpful.
Differential diagnoses include primary psychotic disorders, mood disorders, anxiety, trauma, substance use disorders, personality disorders, intellectual disability, autism spectrum disorder and somatic illnesses. Consultation with child and adolescent psychiatrists where clinically appropriate can be helpful; child psychiatry telephone access lines also can assist clinicians in areas where there is decreased access to specialty care.
Treatment
Treatment includes psychosocial treatments, such as cognitive behavioral therapy and family-focused interventions, and pharmacotherapy to treat the underlying psychiatric illness manifesting in psychotic symptoms. Evidence-based interventions for first-episode psychosis consist of coordinated specialty care, with individualized resilience training, family education program, supported education and employment, and shared decision-making regarding medication treatment (when necessary).
Although a patient should not be diagnosed prematurely with a primary psychotic disorder, reduction of the duration of untreated psychosis (time between first psychotic episode and treatment) can improve outcomes.
Guidance for pediatricians
- Assess for history of trauma, substance use and developmental delays in patients presenting with psychotic-like or frank psychotic symptoms.
- Consult with child psychiatrists when possible to facilitate referrals to specialists, according to symptom severity.
- Screen for suicidal thoughts.
- Use child psychiatry access programs when necessary and available; encourage funding for expansion of these programs.
The pediatrician in the vignette performs reality testing by asking the patient if he is really hearing the voices or if it could be his imagination. The patient states that although these fantasy characters seem real, he can distinguish actual conversations with others from the imagined conversations he experiences in his head.
Given the patient’s history of impaired social interactions and restricted interests, the pediatrician recommends evaluation for autism and genetic testing. He determines a referral for mental health services is unnecessary at this time.
Dr. Hua, lead author of the report, is the liaison from the American Academy of Child & Adolescent Psychiatry to the AAP Committee on Adolescence.
