Psychosis in children: diagnosis and treatment

Abstract

The diagnosis of childhood psychosis raises a host of unresolved problems, despite the Diagnostic and Statistical Manual Of Mental Disorders, 4th edition, Text Revision (DSM-IV-TR) giving identical symptoms and definitions for children, adolescents, and adults. The fantasy lives of children, and issues of developing language and cognition (including retardation), all impair diagnostic accuracy, particularly when differentiating between childhood-onset schizophrenia (COS) (≤12 years), bipolar affective disorder, major depressive disorder, and even obsessive-compulsive disorder and attention-deficit/hyperactivity disorder: the catch-all classification, psychosis not otherwise specified (PNOS), is always available for conundra that prove unsolvable. Typical if nonpathognomonic features include neurocognitive difficulties. Multiple screening instruments and specialized versions of semistructured diagnostic interviews are available. Although smooth-pursuit eye-tracking movements may prove a genetic marker for COS, etiologies are likely to be oligogenetic rather than related to a single gene. No specific biological markers or neuroimages have been identified. As such, psychoses may be indicative of a more general pattern of brain dysfunction. Drug treatments are largely based on the adult literature because of a dearth of controlled data below age 18. There are still no rigorous studies of psychosocial treatments and psychotherapy specific to childhood psychosis.

Differentiating Childhood-Onset Schizophrenia From Other Childhood Disorders

“…Children with COS may not experience resolution of their negative symptoms, while children with MDD with psychotic features will most likely experience improvement of mood symptoms. Additionally, the decreased energy seen in COS compared to the psychomotor retardation of depression present another challenge in the complex diagnostic process [ 20 ]. Finally, it is important to consider that comorbidity is high in schizophrenia, with an estimated 50% rate of comorbid depression [ 21 ].…”

A study of symptom profile and diagnostic break up of psychotic illness among children and adolescents in a tertiary care hospital

“…The symptom classification was based on the categorisation of psychotic symptoms into positive symptoms (including hallucinations and delusions, negative symptoms (such as emotional apathy, lack of drive, poverty of speech, social withdrawal and self-neglect), disorganisation symptoms (speech and behaviour) and catatonic symptoms. We subdivided the positive symptoms into perception and thought disturbances, disorganised symptoms into behavioural subgroup, negative symptoms with additional category for self-neglect and non-specific symptoms which can be seen in prodrome into emotional and academic clusters [9,10].…”

Treatment resistant psychosis in children and adolescents and clozapine: Nuances

“…The phrase "childhood-onset psychosis (COP)" was initially subsumed under the description of pervasive developmental disorder (PDD). In the DSM-V or ICD-11, the symptomatology and stated definitions/criteria of psychotic illnesses remain the same for children, adolescents, and adults (1,2). Imaginative play and fantasy are frequent in young children and early teens.…”

“…Imaginative play and fantasy are frequent in young children and early teens. Children's imaginations and fantasy lives, combined with language and cognitive development stages, influence diagnostic accuracy, particularly when distinguishing between Childhood-Onset Schizophrenia (COS), Mood Disorders such as Bipolar Affective disorder (BPAD) or Major Depressive disorder (MDD), obsessive-compulsive disorder (OCD), and Attention-Deficit/Hyperactivity Disorders (ADHD) (1). The term "Psychosis Not Otherwise Specified (PNOS)" has been used to fill diagnostic gaps in instances with an ambiguous presentation.…”

“…But these symptoms are not exclusive to psychosis; they can also be found in trauma, seizure disorders, and other medical illnesses as well as other psychiatric condition of mood disorder and dissociative disorders. A normal child with a busy imagined life can misinterpret thoughts as real events and insist vehemently that a thought or dream occurred (1), which may the criteria for hallucination and delusion, posing diagnostic challenge.…”