Participants will explore the prevalence of psychotic experiences among kids with mental health concerns and kids in the general population, discuss the differential diagnosis of psychotic symptoms in children and youth, examine the relationship between hallucinations and suicidal behavior in youth and review the appropriate psychiatric and medical workup for youth with psychotic experiences

1. When Children or
Teens Present With
Psychotic Symptoms
Stephen Grcevich, MD
Family Center by the Falls, Chagrin Falls OH
Associate Professor of Psychiatry, NEOMED
Presented at Stark MHAR Lunch and Learn
August 11, 2021

2. Learning Objectives:
• Explore the prevalence of psychotic experiences among
kids with mental health concerns and kids in the general
population
• Discuss the differential diagnosis of psychotic symptoms
in children and youth
• Examine the relationship between hallucinations and
suicidal behavior in youth.
• Review the appropriate psychiatric and medical workup
for youth with psychotic experiences

3. Question:
What is the approximate prevalence of psychotic
experiences among children and teens?
A. 0.5%
B. 2%
C. 5%
D. 10%
E. None of the above

4. Answer
• 9.8% of children,
teens in metanalysis
of 13 community
samples (n=29,517)
reported psychotic
experiences
Healy C et al. Psychological Medicine , Volume 49 , Issue 10 , July 2019 , pp. 1589 - 1599

5. Domains of Psychosis
Perceptual
disturbances
Thought
disturbances
Behavioral
disturbances
Affective
regulation
Cognitive
dysfunction
Motor
symptoms
Tyson JW, House EM, Donovan AL. Child Adolesc Psychiatric Clin N Am 29 (2020) 1-13

6. Considerations
in evaluating
children, teens
with psychotic
experiences
(PE)
• PE occur on a continuum
• More common in children and
adolescents
• Not necessarily indicative of
psychopathology
• May be a source of distress, even
if non-pathologic
• Often represent a non-specific sign
associated with increased risk of a
broad range of mental health
conditions
• Often associated with trauma

7. Relationship between psychotic
experiences and mental illness in kids
• 60-80% of teens reporting hallucinations met lifetime
criteria for Axis I disorder
• 30-43% had a current disorder
• Hallucinations seen in 40% of children with two disorders,
55% with three
• Rates are 20% and 35% in teens
• Kids with psychotic symptoms are…
• 6X more likely to have been abused
• 10X more likely to have seen domestic violence
• 10X more likely to be a victim of bullying

8. Longer term implications of
psychotic symptoms
• 1/3 had anxiety disorders, including PTSD
• 20% had major depression
• 11% had schizophrenia
Among 11-year-olds with auditory hallucinations, by age 26:
• Risk persisted for schizophrenia, PTSD, suicide attempts, anxiety
• Among those with most severe hallucinations, 23% had schizophrenia, 50%
had PTSD, substance abuse and suicide attempts
• Only one was free of mental illness
At age 38:
Poulton R et al. Arch Gen Psychiatry 2000;57(11):1053-58
Fisher HL et al. Psychol Med 2013;10:1-10

9. Teens with psychosis and
suicide…
Teens with psychosis are 10X more likely to
have had suicidal thoughts/behavior - 4X
more likely to engage in self-harm
86% with suicidal ideation had planned or
attempted suicide - 20X greater risk than
teens with suicidal ideation without psychosis
Kelleher I, Lynch F, Harley M et al. Arch Gen Psychiatry 2012;69(12):1277-1283

10. Evaluation of the child or teen
with psychotic symptoms
AACAP Practice Parameters on Schizophrenia, September 2013
Developmental
perspective is critical –
start with first sign of
any emotional,
behavioral,
developmental
difficulties
Standard psychiatric
assessment
procedures should be
followed
Interviews with parent,
child
Review of records,
historical information
Laboratory evaluation
and neuroimaging
useful in ruling out
general medical
conditions
Projective, personality
testing not definitive,
but may lend
information to support
diagnosis

11. Differences
in psychotic
symptoms
between
children and
adults
Sikich L. Child Adolesc
Psychiatric Clin N
Am;22(2013):655-673

12. Interviewing,
evaluation tips
• When possible, observe patient’s interactions
around peers
• Ask parents about child’s persistence in telling
obvious lies (possible sign of delusional
thinking)
• Ask kids if they’ve ever heard something but
can’t figure out who’s talking or notice that
others around you acted as if they didn’t hear
anything
• DON’T ask if they’ve had hallucinations or
heard voices
• Need to verify that the patient has understood
the questions

13. Tyson JW, House EM, Donovan AL. Child Adolesc Psychiatric Clin N Am 29 (2020) 1-13

14. Medical
conditions
that can
produce
psychotic
symptoms
• Migraines
• Medication-induced (stimulants)
• Illicit substances
• Cannabis often potentiates latent
psychosis
• Seizure disorders
• Malignancies
• Encephalitis
• Lupus
• Genetic syndromes
• 22q11 deletion syndrome most
important (velocardiofacial
syndrome)
• Down Syndrome
• Marfan Syndrome

15. Recommended medical workup
when psychosis is suspected
• Thorough pediatric and neurologic evaluation
• CBC, serum chemistry, TFT’s, urine toxicology
• Ceruloplasmin
• Mandatory if hepatomegaly, elevated LFTs, Kayser-
Fleischer rings present
• Neuroimaging studies (MRI) –preferably with
contrast
• Mandatory if neurologic symptoms present, history of
head trauma
• Microarray, karyotype
• If dysmorphology, intellectual disabilities, significant
cognitive decline, small or marfanoid stature present
Sikich L. Child Adolesc Psychiatric Clin N Am;22(2013):655-673

16. An important
caution…
Misdiagnosis is a
common problem-the
accuracy of the
diagnosis should be
reviewed periodically
as treatment
progresses

17. Pediatric prevalence
of schizophrenia
• Less than 3/100,000 prior to
age 10
• 13/100,000 between ages
10-14
• 200-550/100,000 between
ages 14-18
• 5% are symptomatic by age
14, 20-30% by age 18

18. Epidemiology of Early-Onset
Schizophrenia:
• Onset prior to age 13 is quite rare, increasing
sharply during adolescence
• Male/female ratio of 2:1 in EOS (function of
earlier age of onset-five years earlier in males
than females)
• Onset unrelated to hormonal changes
associated with puberty
• Only two cases in literature reported prior to
age 6
Frazier JA et al. Psychiatry Res. (1997) 70:1-7

19. Cognitive Delays in Early Onset
Schizophrenia
• Deficits in memory, executive functioning,
attention, and global impairments are generally
noted
• Premorbid problems with verbal reasoning,
working memory, attention, and processing
speed
• Cognitive decline typically occurs at the time of
onset of illness
• Once established, intellectual deficits appear to
be stable over time without continued
deterioration
AACAP Practice Parameters on Schizophrenia, September 2013

20. Neuroimaging Findings in Early
Onset Schizophrenia
Rapoport JL et al. Arch. General Psychiatry (1999) 56: 649-654
Increased ventricular size
Decrease in cortical gray matter volume during adolescence
Smaller total cerebral volumes
Frontal lobe dysfunction
Neuroimaging studies are not diagnostic of the disorder!

21. Special Issues in Diagnosis of
Early Onset Schizophrenia
• Reluctance to make diagnosis because of prognosis,
social stigma
• Diagnosis more difficult because…
• Younger patients more likely to present in prodromal
phase
• Some may lack communication skills to accurately
describe their inner thought process
• Initial diagnosis is notoriously inaccurate

22. What does a kid look before they
develop schizophrenia?
• Almost all are
diagnosed with ADHD
because of executive
functioning deficits
• Social withdrawal,
isolation
• Speech, language
issues common
• Often experience
insidious decline in
cognitive functioning

23. Summary
• Most kids who report hallucinations or
other psychotic symptoms don’t have
psychosis
• Psychotic symptoms are seen much
more commonly in kids who have
experienced trauma and neglect
• Reports of psychotic symptoms are
especially concerning in youth
reporting suicidal thinking or behavior
• Thorough medical and mental health
evaluation, ongoing consideration of
validity of psychotic disorder
diagnosis critical!

24. Tyson JW, House EM, Donovan AL. Child Adolesc Psychiatric Clin N Am 29 (2020) 1-13

25. Tyson JW, House EM, Donovan AL. Child Adolesc Psychiatric Clin N Am 29 (2020) 1-13

26. Tyson JW, House EM, Donovan AL. Child Adolesc Psychiatric Clin N Am 29 (2020) 1-13