Caring for teens and young adults with psychotic symptoms

For many teenagers and young adults with psychotic symptoms, pediatricians are frequently the first clinician to encounter them. In an ideal world, they would be immediately referred to psychiatric care, but the lack of options in some areas mean that pediatricians may have to make the initial assessment or continue care after assessment by a specialist. A report in Pediatrics offered tips to pediatricians to help teenagers and young adults who may be experiencing psychotic symptoms.¹

There are a number of common symptoms that a pediatrician may see when initially diagnosing a patient with a psychosis. One is delusions, which may be classified as bizarre, such as the belief that an outside force has put thoughts into the patient’s head, or non-bizarre, such as the patient is being monitored by the police, although no evidence suggests it is happening. Hallucinations are another common symptom, with auditory hallucinations being the most common. Some patients may have disorganized thinking, which can be assessed by listening to the patient’s speech and can include the inability to answer a question or speaking incoherently. There may also be disorganized behavior, including catatonia.

Tips in this report include:

• Use follow-up questions to better characterize the presentation and disposition of patients who have psychotic-like or full psychotic symptoms.
• Evaluate for history of trauma, including sexual, physical, or emotional abuse, neglect, and bullying; substance use; and developmental delays.
• Determine the cause of symptoms using a variety of tools such as clinical interview, comprehensive physical examination including neurologic examination, laboratory studies, and imaging.
• Refer to a specialist based on the severity of the patient’s symptoms. A consult with psychiatry could help ensure appropriate referrals are done and a developmental-behavioral pediatricians should also be considered for patients who have an intellectual disability or autism spectrum disorder.
• Screen for suicidality and arrange transport of patients who either have suicidal thoughts or thoughts of hurting others to the emergency department immediately.
• Refer patients to multidisciplinary coordinate specialty care when it’s available.
• Use the “start low and go slow” approach for the initiation of antipsychotic medication and monitor for adverse effects. Although not typical, some pediatricians may need to start antipsychotics, either because of severe symptoms or limited access to appropriate behavioral care.
• Be aware of free, state-funded services that include telephone or in-person consultations with child and adolescent psychiatrists.

Reference

1. Hua L, Committee on adolescence. Collaborative care in the identification and management of psychosis in adolescents and young adults. Pediatrics. May 24, 2021. Epub ahead of print. doi:10.1542/peds.2021-051486