Childhood psychosis

F09

CHILDHOOD PSYCHOSIS

DESCRIPTION

It is important to note that children who present with symptoms such as hallucinations, confusion and intensely aggressive or disturbed behaviour may not be psychotic or suffer from schizophrenia. Delirium should be the first diagnosis to consider, before a psychotic disorder is suspected. Failure to recognise a delirium may delay the diagnosis of the underlying medical condition or drug-related delirium and place the child at risk.

Delirium is a non-specific neuropsychiatric disorder which indicates global encephalopathic dysfunction in medically ill patients. The core features consist of attentional disturbances, an altered level of consciousness and diffuse cognitive deficits. It is fluctuating in nature and may present with perceptual disturbances, commonly visual hallucinations.

Any child presenting with an apparent psychosis is considered a medical emergency and should have a medical work-up before being referred to a psychiatrist. This should include FBC, U&E, LFT, TSH, drug screen, EEG and brain CT scan.

Sedate before transfer if behaviourally disturbed. Refer to Sedation of an acutely disturbed child or adolescent.

SCHIZOPHRENIA

F20.9

DESCRIPTION

Schizophrenia is a chronic psychotic disorder characterised by disturbances in thinking, perceptions, emotions and behaviour and is associated with significant functional impairment. Childhood and adolescent schizophrenia are rare.

  • Very Early Onset Schizophrenia (VEOS) is defined as the onset before age 13 years.
  • Early Onset Schizophrenia is defined as the onset before age 18 years.
  • Onset during childhood and adolescence confers a poorer prognosis for the illness, treatment refractoriness and significant impairment in functioning.
  • Similar diagnostic criteria for adults are used. However, in children, the delusions are not as bizarre or systematised as in adults. The clinical presentation in adolescents more closely resembles that in adults. The child or adolescent may not reach expected levels of interpersonal, academic or occupational functioning.

DIAGNOSTIC CRITERIA (DSM 5)

  • Two or more of the following symptoms need to be present for a significant portion of time during a 1-month period. At least one of these must be (1), (2) or (3):
    1. delusions
    2. hallucinations
    3. disorganised speech
    4. grossly disorganised or catatonic behaviour
    5. negative symptoms i.e. affective flattening or avolition
  • The level of functioning declines or there is failure to achieve expected levels of interpersonal, academic or occupational functioning.
  • The disturbance has lasted at least 6 months with a 1-month period of previously mentioned symptoms. Prodromal, attenuated or residual features may be included in the time period.
  • Exclude other psychiatric disorders, general medical conditions or effects of substances.

GENERAL AND SUPPORTIVE MEASURES

  • Supportive individual and family counseling is an important part of the comprehensive treatment plan.
  • The aim of individual counseling is to develop understanding of the illness, to improve coping strategies, to provide structure and limit regression.
  • Family interventions focus on psycho-education and facilitating acceptance of the diagnosis to ensure adequate compliance and support for the patient.
  • Educational issues include transitioning back into school after a psychotic episode and academic support.

MEDICATION TREATMENT

Pharmacotherapy is the first line treatment for psychosis in children and adolescents.

Acute phase treatment

Sedate before transfer. Refer to Sedation of an acutely disturbed child or adolescent .

If previously prescribed antipsychotic medication:

  • Re-initiate treatment, in consultation with a psychiatrist.

If no previous medication (while awaiting admission and in consultation with a psychiatrist)

  • Risperidone: oral.

5 – 12 years (under 50 kg):

  • Starting dose: 0.01 mg/kg/day.
  • Maintenance dose: 0, 02-0,04 mg/kg/day.

13 – 17 years:

  • Starting dose: 0.5 mg daily.
  • Maximum dose: 3 mg daily.
  • Use lowest effective dose to limit adverse long-term side effects and to facilitate adherence.
  • Increase dose by 0.25–0.5 mg daily every 1–2 weeks, depending on tolerability and age.
  • Refer if doses in excess of 3 mg are required.

Maintenance phase: (12–24 months)

  • Gradually lower the dose of risperidone from that needed to treat the acute psychotic phase to that needed to prevent relapse and to ensure adequate adherence.

REFERRAL

  • All children and adolescents for assessment and initial management.
  • Urgent: young children, individuals responding to command hallucinations or behaviourally-disturbed psychotic children or adolescents.