Assessment of Psychotic Features in Children and Adolescents

The evaluation of psychotic symptoms in children and adolescents is straightforward when the psychotic features are the presenting problem or are mentioned as one of the presenting problems. What child psychiatrists need to do in these cases is expand on the presenting complaint and explore other psychotic features or associated psychiatric conditions.

In children in whom psychosis is not identified as the presenting problem, a good area to explore is nighttime behaviors preceding sleep. For a number of children and adolescents, nighttime is an anxiety- and fear-producing time.

A good opening question is, How do you sleep at night? If the child says that he or she has problems falling asleep, the examiner can ask whether there is something that keeps him or her from sleeping. The child may begin to talk about scary things that happen at night. A systematic review of night fears may reveal psychotic symptoms:

This inquiry is followed by the exploration of delusional features, mainly paranoia:

In my experience, paranoid ideation is generally more enduring than perceptual disturbances.

Some children are scared of closets, believing that someone or something is in the closet (a monster, Freddie Kruger, or the like). Other children are afraid of windows, believing that somebody might come in through the window at night to either do something bad to them or to take them away. Some children are afraid of the space underneath the bed: they think someone may be hiding there. The bathroom is another place that elicits a variety of fears. Some children are scared to go to the bathroom, even during the day.

Depending on the clinical presentation, that is, complex partial symptomatology (temporal lobe epilepsy), the examiner may ask, Do you ever smell things that others do not? Do you ever experience weird tastes in your mouth? Do you ever experience any sense of estrangement? Do you ever feel the world looks weird to you? Can you predict the future?

Psychotic features are relatively common in mood disorders, eating disorders, substance use disorders, and in neurodevelopmental disorders, mainly 22qll genetic syndromes. Examiners need to consider the rare condition of very early onset schizophrenia in preadolescents, and in children in middle or late adolescence, early onset schizophrenia, which is not rare.

In manic cases, the examiner must explore grandiose delusions, such as these:

At times, the discovery of psychosis requires additional exploratory means. Trisha, an 8-year-old Caucasian, was evaluated for a suicidal verbalization: she told the school counselor that she had a plan to kill herself with a knife. She also had difficulties controlling her anger; she threw frequent tantrums, slammed doors, screamed frequently, and voiced that nobody liked her. The biological mother had five children; the oldest child and a 13-year-old girl were still living with her. Trisha’s maternal grandmother was raising Trisha and two of her siblings; the biological mother saw them only sporadically. The grandmother suspected a great deal of neglect and even sexual abuse.

Trisha had been retained in first grade. A cognitive assessment nine months before the psychiatric evaluation revealed that Trisha had borderline intellectual abilities. She was reading at a kinder level, and her scores in spelling and arithmetic were at a first-grade level. The biological mother had a history of drug abuse and had been in jail five times. Trisha looked regressed and childish and sometimes she laughed inappropriately.

During the Mental Status Examination, Trisha endorsed hearing steps at night and having a feeling that people were watching her. She also endorsed homicidal ideation, and her grandmother reported that she frequently threatened to kill or hurt others with a gun. There were no guns at home, but she made hand gestures as if she were shooting a gun.

When she was asked to draw, following the guidelines sketched in Psychiatric Interview of Children and Adolescents (see biography), she evidenced signs of psychotic thinking and preoccupation: “Bloody Mary” appeared in all the drawings. When the examiner, for instance, asked her to draw a person, she drew herself with Bloody Mary at her side. In another drawing, she is walking with her brother to the house. He has Bloody Mary eyes. The drawings put a light on the extensive paranoid symptomatology that had not been appreciated by the verbal exploration.

When she was asked to explain the drawing, she mentioned that Bloody Mary was around her most of the time. This alerted the examiner to the presence of psychotic, paranoid thinking, which the patient had not explicitly endorsed.

A word of caution about evaluating psychosis in preadolescents and late preschoolers: I have witnessed the strongest denial and rationalizations and defensiveness in the parents of these subjects. Parents justify that their children’s endorsement of these symptoms is due to recently watched movies, TV shows, video games, or the like; some parents normalized those abnormal experiences or have accepted false reassurance from others, even experts, that the child will grow out of these symptoms, that these problems will go away, or the like. Even worse, some parents believe that the child has some supernatural abilities. Other parents state that the child’s endorsement of the psychotic exploration is due to the suggestive questioning by the interviewer (leading questioning).

To avoid this rationalization, I recommend the following strategy: Ask the parents(s) to assist in the evaluation by posing a number of questions: Please ask Jimmy if he is scared at night. Ask Jimmy if he hears weird noises, scary sounds. Does he hear voices talking to him when nobody is around? And so on. When the child endorses unusual experiences, perceptual disturbances, or paranoid feelings, it is harder for a parent to deny or explain away what the child asserted. ■