Psychosis in children

Psychosis in children is rare and can be challenging to recognize and diagnose. However, recent research suggests a higher prevalence of childhood psychosis than previously thought. Psychosis can cause impairments in children’s social, academic, and daily functioning and can be treated with therapy, medication, and psychosocial interventions.

What is psychosis?

Psychosis is a condition that can cause abnormal thoughts, behavior, emotions, and perceptions. Psychosis can occur in the context of several mental health disorders, including psychotic disorders, such as schizophrenia, and other conditions, such as bipolar disorder, major depressive disorder, and trauma-related disorders ^[1].

Often, psychosis involves the presence of hallucinations and delusions. Someone experiencing hallucinations perceives something sensory that is not there. This can involve any of the five senses; sight, hearing, smell, taste, and touch, although typically hallucinations are visual or auditory. Someone experiencing delusions has firmly held beliefs that are not real ^[2].

Psychosis can also cause disorganized and disordered thoughts, behavior, and speech, as well as negative symptoms such as social withdrawal and blunted emotions ^[1][2].

Psychotic disorders commonly emerge in early adulthood, so it is less common for young children to experience psychotic symptoms. However, it is possible for psychosis to develop in children and adolescents. Additionally, evidence suggests that young people can experience prodromal symptoms, which are early warning signs of schizophrenia ^[3][4].

Signs and symptoms of psychosis in children

Signs of psychosis in children may vary depending on the individual and the cause of their symptoms. However, common symptoms of psychosis that are seen in children and adolescents may include ^[2][3][5]:

• Hallucinations, commonly auditory or visual
• Lack of verbal expression
• Lack of facial emotional expression
• Social withdrawal
• Difficulties with schoolwork
• Impaired cognitive functioning, such as memory and concentration
• Eccentric or bizarre behavior
• Emotional lability
• Agitation and restlessness
• Unusual or incoherent speech
• Not speaking very much or in a quiet voice
• Impulsive behavior
• Lack of insight and awareness of symptoms
• Unusual eye movements, such as significantly increased or decreased blinking
• Developmental delays
• Late crawling or walking
• Becoming confused often
• Telling parents they feel that they feel strange or something is wrong
• Difficulties making friends
• Unusual or odd ideas

What causes psychosis in children?

The occurrence of psychosis in children cannot be attributed to one cause and is likely due to several contributing factors, such as:

Genetics

As is the case with adult-onset schizophrenia, research also shows that psychosis in childhood has a significant genetic factor. Studies show that if a parent has developed schizophrenia in childhood or adolescence, there is a significantly increased risk of their child developing early-onset schizophrenia or other psychotic illness ^[4][6].

Environment

Stress and trauma are thought to increase the risk of psychotic symptoms developing in children. Although these factors cannot cause psychotic symptoms, they can trigger or worsen symptoms in at-risk children ^[4][5].

Pregnancy complications

Studies show that schizophrenia and other psychotic disorders may be linked to complications during pregnancy and childbirth, such as preterm delivery and exposure to infection or substances during pregnancy. This is also believed to be a risk factor for early-onset schizophrenia and psychosis ^[7].

Neurobiology

Studies have found that children with psychosis are likely to have reduced gray matter volume, suggesting that this is linked to psychotic symptoms. It is also believed that neurotransmitters influence the onset of psychotic symptoms. For example, the levels and activity of dopamine, glutamate, and serotonin are found to be abnormal in children with schizophrenia-related disorders ^[4][6].

Drugs

Substance use is believed to increase the risk of psychotic symptoms, including cocaine, amphetamines, ketamine, and hallucinogens ^[1][4].

In particular, the use of cannabis has been found to be associated with the development of psychosis. Although research into this link is conflicting, evidence suggests a significantly increased risk of psychosis in heavy cannabis users. Additionally, research shows that people with psychosis who use high quantities of cannabis experience more significant gray matter loss than those who don’t ^[4][8].

Medications

Many types of medications can cause or worsen symptoms of psychosis, including several mental health medications, steroids, antihistamines, antibiotics, and opioids. As such, some signs of psychosis in children may be linked to medicinal treatments instead of mental illness ^[4][9].

Illness and injury

Similarly, psychosis in children could be caused by several illnesses or injuries. Medical conditions that can cause symptoms of psychosis include traumatic head injuries, brain tumors, infections, malaria, and encephalitis ^[4][9].

Diagnosing psychosis in children

As there are many different potential causes of psychosis in children, clinicians must first determine the cause of the symptoms. It can be helpful to gather information about the family history of mental and physical health, as this can help to determine specific risk factors that can be tested first ^[6].

For example, psychotic symptoms can be caused by several medical conditions, medications, and substances, so it is necessary to rule these out. This may involve a blood test, EEG, MRI, and checking vital signs ^[2].

It is also possible for symptoms of other conditions to be mistaken for signs of psychosis. For example, attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorder (ASD), and obsessive-compulsive disorder (OCD) can present with symptoms that appear similar to psychosis, such as developmental delays, impaired social abilities, and eccentric or odd behaviors ^[6].

Furthermore, psychosis can be a symptom of various mental health conditions, including ^[4][6]:

• Schizophrenia
• Schizoaffective disorder
• Schizotypal disorder
• Schizophreniform disorder
• Bipolar disorder
• Major depressive disorder
• Trauma-related disorders
• Personality Disorders

As such, it is important to determine if psychotic symptoms occur alongside signs of other conditions, such as mania or depression, to help formulate a diagnosis.

Diagnosing a specific mental health condition will involve the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) ^[10], which outlines diagnostic criteria. For many disorders, the criteria are the same for children and adults and can cause difficulties in diagnosis when aiming to determine signs of psychosis compared to normal child behavior ^[6][11].

As such, it is often helpful for clinicians to interview parents or caregivers alongside children. This can help gather information about symptoms, such as when they started, how they have changed, and how they impact functioning. Parents can also provide information about developmental progress, family history, and any experiences of trauma or abuse ^[2][4].

The clinician may also use diagnostic tools such as questionnaires to help determine the presence of specific symptoms and conditions. The more information can be ascertained about the child and the presenting symptoms, the more apparent an appropriate diagnosis will be ^[4][6].

How to treat psychosis in children

Recognizing and treating signs of psychosis as early as possible can improve the outcome, potentially reducing symptom severity and the risk of further psychotic episodes. As such, implementing early intervention for childhood psychosis is essential ^[3].

Treatment will likely vary depending on the cause of the child’s psychotic symptoms. If a physical condition or illness has caused the symptoms, medical treatment will be implemented and may be augmented with antipsychotics ^[4].

Medication

If psychosis is deemed to be due to a psychotic illness, such as schizophrenia, the child may be prescribed an antipsychotic medication, such as risperidone or aripiprazole. Initially, they will be commenced on a very low dose, which will be gradually increased ^[3].

There is limited research into the effectiveness and safety of antipsychotics in children, so medicinal treatment is mainly based on adult research. However, some studies show that antipsychotics can be effective for young people with psychosis ^[6].

Studies also show that children and adolescents may be at increased risk of experiencing side effects, so the prescribing doctor will closely monitor the young person throughout their treatment. This will include regular checks on weight, physical well-being, and extrapyramidal symptoms (movement abnormalities) ^[4].

Therapy

Therapy can help the individual to manage their symptoms, improving self-esteem and distress tolerance ^[3].

Cognitive behavioral therapy may be advised, which can help the individual to evaluate their beliefs and perceptions and reduce harmful or dysfunctional behaviors. This can also provide the young person with tools and strategies to make sense of their environment and daily encounters without the confusion and agitation that their symptoms may cause ^[4].

They may also receive psychoeducation to help them understand their condition, symptoms, and treatment options. This can improve insight and medication compliance, improving treatment outcomes and functioning ^[4][5].

It may also be helpful to provide family therapy so that caregivers and others within the home can better understand their loved one’s condition and how best to support them ^[11].  

Psychosocial interventions

Children with psychosis may need support in managing at home and school, which might involve making accommodations to improve their environment. Parents and teachers can support the child by reducing their stress, simplifying the environment, and reducing stimulation. This can help to prevent or reduce agitation and confusion ^[5][6].

Additionally, it may be necessary to provide support with academic functioning and increasing social interactions to prevent withdrawal and isolation ^[3][4].

How common is psychosis in children?

Recent studies indicate that 9-25% of young people experience psychotic symptoms. This figure may vary depending on the inclusion criteria and the cause of the symptoms. However, while this figure is high, the likelihood of schizophrenia in children is rare. It is believed that schizophrenia occurs in only 1 in 10,000 children under the age of 13 ^[4][6].

With ongoing research, the understanding of psychosis in children will continue to develop, helping to improve the recognition and treatment of the conditions in which it occurs.