Dr Soumitra Datta Hello, I’m Soumitra Datta,  Consultant Child Psychiatrist. Today we would   be talking on “Management of Psychosis in Children  and Adolescents.” This talk would be in two parts,   so go through it sequentially,  and hopefully, by the end of it,   your understanding of managing psychosis  in this age group would be somewhat better. I don’t have any conflict of interest to declare.  I was part of the Cochrane Schizophrenia Group,   the Cochrane Collaboration, for the last  several years and we would talk about   the reviews we have produced. That’s the  only conflict of interest I can talk of.   We will touch upon, you know, the presentation  of psychosis in children and adolescents,   the differential diagnosis in this  age group and what is the evidence   base for managing this group of children  who have developed psychosis? And how do   you wrap it all together when you apply this  evidence base to your daily clinical setting? Now, psychosis in a youth, you know, is  diagnosed based on a diagnostic criteria,   just like adults. So, children and adolescents may  have positive psychotic symptoms, like delusions,   hallucinations, they may have negative  symptoms, or they might have behaviours,   which are disorganised. We do need to  distinguish formal thought disorders   in this age group, with specific language  disorders, because children are growing,   and they acquire more than one language in their  lifespan. And, you know, while they’re learning,   they might, you know, sort of, express  certain ideas, which is different from adults. Misdiagnosis of psychosis in adolescents is  quite common. So, you have to be careful,   while making a diagnosis, and we  will talk about that a little bit.   Children who develop schizophrenia has – you  know, research has shown that they have premorbid   problems with, you know, verbal reasonings,  memory and attention span. And so, if you go   back and take history of those children you have  made a diagnosis of psychosis, you might be able   to spot things which were, sort of, warning  signs prior to the confirmatory diagnosis of   psychosis. There is also, typically, a cognitive  decline after the psychosis have stabilised. So,   there might be impact of the disease on their  overall functioning of the adolescent. However,   this is not routine. Many patients with  psychosis might do well with treatment. Now, how do you make a differential  diagnosis, which we are talking about? So,   you know, a neurotypical child may have overactive  imagination, they may have vivid fantasies and   that’s being a child. And the other thing, which  you have to consider, is that some adolescents   might be at a high-risk state. So, you know, if  there is a family history of psychosis, there is   a recent deterioration in the functioning, say  the school functioning, there might be paranoid   thoughts, some degree of social impairment.  However, these symptoms do not only, you know,   conform to the diagnosis of diagnos – psychosis,  or it might be that, you know, there are transient   symptoms or attenuated symptoms of psychosis.  So, this is what we call – is a high-risk state. Sometimes, and again, in adolescents, it’s not  uncommon for children who have juvenile-onset   obsessive compulsive disorder, and they may  have obsessional thinking related to symmetry,   or they may have an obsessive thought in  terms of something terrible will happen.   And Clinicians should be careful not to make  the mistake of labelling this as a, you know,   paranoid delusion. Autistic spectrum  conditions, lack of social reciprocity,   some idiosyncratic beliefs, these are again  – you know, they may have some similarities   with a young person developing psychosis.  However, in psychosis, usually there is an onset,   acute onset, or – you know, whereas in autistic  spectrum examination, it’s a longstanding pattern. You can have adolescents who develop bipolar  illnesses, mania, with psychosis, so florid   delusions, elaborate thoughts, rapid speech,  as opposed to, you know, paucity of speech,   and some children and adolescents might actually  develop psychosis, or even schizophrenia. So   that this could be – the onset could be  slow, insidious, or it could be, you know,   acute. There is usually a change in functioning  when a young person develops a psychotic illness. So, you know, to summarise, you have to go through  the entire spectrum of a neurotypical child,   to an anxiety disorder, like obsessive compulsive  disorder, somebody with a high-risk state,   or having developed psychosis, like mania and  schizophrenia. So, this is – these are the   differentials that you would need to consider  while managing a patient – a young person. Now, a mental high-risk state, if you see the  recent meta-analysis, it does shay – say that, you   know, “At five-year follow-up, one in six youth  diagnosed with at-risk mental state,” which the   authors say, “ARMS” had transitioned to psychosis,  but they did not find evidence that this   resk – risk was related to the ARMS diagnosis,  as opposed to just a sampling or a recruitment,   you know, strategy reflecting on the  results. So, you do need to be careful   while dealing with this very fragile  group of children and putting a label. Now, psychosis in children and adolescents, you  know, the other thing, which you need to consider,   is normal children can have hallucinations,  which are not part of a psychiatric syndrome.   A child may be bereaved or having grief,  they may have funeral hallucinations.   There could be acute and transient psychosis,  often related to a stress, which does not progress   to a lifelong psychotic condition. There might  be prodromal symptoms, which could be anxiety   symptoms, but later on, develops into psychosis,  so you need to follow-up the child over time. There could be, very rarely, actual childhood  onset schizophrenia. It’s very, very rare,   in the sense that one in 10,000 children  develop childhood onset schizophrenia,   which is very different from adult onset  schizophrenia, where the prevalence in 100. So,   you might be a Child Psychiatrist, practising  your entire life and not come across a   person with childhood onset schizophrenia. Now, in adolescents with psychosis,  the picture changes, because, you know,   one fifth of all adults with psychosis actually  have the onset of illness in their adolescence.   However, you need to, as I mentioned earlier,  be mindful of that this could be the first   episode of a psychotic bipolar disorder.  And also, you know, don’t misdiagnose   schizophrenia with other disorders, which  I have been talking about, like OCD. Now, in childhood onset schizophrenia,  so childhood means, you know,   less than 13-years-of-age, it’s not adequately  studied because it’s very rare, as I have been   mentioning. However, the diagnostic validity is  more or less established for, you know, below 13,   but below six it’s not very well established.  The framework which we use, as Psychiatrists,   is same as adults, like positive, negative and  cognitive decline. There are prodromal symptoms,   often, there could be an acute phase,  there could be a recovery phase,   or there would be residual symptoms. The outcomes,  you know, there could be some moderate to severe   impairment in some children. So, you need to  be, you know, educating the family and working   with the families, instilling them hope,  at the same time, being realistic about how   they need to engage with the Mental Health  Services for a considerable length of time. All children with suspected schizophrenia, if they  have these following features, should be evaluated   for a medical condition. You know, if there is,  sort of, a history of substance misuse, so, you   know, is this cannabis induced psychosis? Or, you  know, if there is a family history of an illness,   which presents with psychotic symptoms, or  if there is symptoms suggestive of PTSD,   with a history of trauma, abuse. So, these are  things, which you need to be mindful about. So, while you’re doing physical examination  of a child, if there is organic signs,   like focal neurological deficits, seizures,  you know, further evaluation, brain imaging,   etc., might be necessary. Referral to an  appropriate specialist, like a Neurologist,   when appropriate, should be done. History  of medical illnesses, as I mentioned, that,   you know, if there is a history of the man –  child having a medical illness, like porphyria,   which may have, you know, psychotic symptoms,  that needs to be looked into. If there is a   family history of similar illness, that again,  you know, that condition needs to be evaluated,   say Wilson’s disease, something like that.  But, you know, by and large, these are rare.   Be mindful that you do need to do a physical  examination for children and adolescents with   psychosis. It will not be causal, but at least  you would be treating the child in a holistic way. So, while we, you know, sort of, end the – this  part of our discussion, we do need to end with the   fact that, you know, antipsychotic medications are  the primary treatment for schizophrenia spectrum   disorders in children and adolescents.  However, we are treating a child here,   so we need to be, you know, treating the child  with the psychological and social components in   mind. Children, almost always, are in a family, so  engaging with the parents, getting their consent,   explaining what we are treating their children  for, allaying their anxieties. So, these would   go a long way in, sort of, engaging the family  and having a better outcome for the child. So, I would like to conclude that,  you know, diagnosis of psychosis needs   careful consideration of other differential  diagnosis. You need to have regular follow-up,   be open to emerging symptoms  and psychopathology, which   might happen over the course of your follow-up.  Psycho-educate and, you know, when appropriate,   you have to start medications, but engage  the child and the family together. Thank you.