Assessing for psychotic symptoms in children?

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Agrippa2

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I was wondering if there were anyone could provide some tips when assessing for psychotic symptoms in children. The other day I saw a 7yo girl for her first med-check following her initial eval. CC was that the child was having tantrums, defiant behaviors, and seemed to be responding to internal stimuli. Apparently the doc thought that she had some psychotic symptoms too, specifically auditory hallucinations. She started the child on aripiprazole 2mg hs.

Since the last visit, the client apparently had less defiant and oppositional behavior and no more AH. My doc assessed this by asking "are you hearing anything in your head? Any strange voices?" She repeated some variation of this question 2 or 3 more times. The girl denied any symptoms. During other cases, I've seen her do the same thing when assessing kids for other things, ie. si/hi. Some have unfortunately answered yes after the 4th of 5th iteration.

I was hoping to learn some other methods to assess these younger school age kids. Can anyone suggest some tips? With older kids, I've been able to assess for perceptual abnormalities using similar methods I've used with adults. With young kids I sometimes like to have kids draw and if they provide some distressing/bizarre images, I will explore them. Any pearls of wisdom would be appreciated.

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What is your occupation and why is the kid your "client"? Who is your "doc"? Are you doing the "med check"? More than 5 years on sdn and only 3 postings?
 
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I was wondering if there were anyone could provide some tips when assessing for psychotic symptoms in children. The other day I saw a 7yo girl for her first med-check following her initial eval. CC was that the child was having tantrums, defiant behaviors, and seemed to be responding to internal stimuli. Apparently the doc thought that she had some psychotic symptoms too, specifically auditory hallucinations. She started the child on aripiprazole 2mg hs.

Since the last visit, the client apparently had less defiant and oppositional behavior and no more AH. My doc assessed this by asking "are you hearing anything in your head? Any strange voices?" She repeated some variation of this question 2 or 3 more times. The girl denied any symptoms. During other cases, I've seen her do the same thing when assessing kids for other things, ie. si/hi. Some have unfortunately answered yes after the 4th of 5th iteration.

I was hoping to learn some other methods to assess these younger school age kids. Can anyone suggest some tips? With older kids, I've been able to assess for perceptual abnormalities using similar methods I've used with adults. With young kids I sometimes like to have kids draw and if they provide some distressing/bizarre images, I will explore them. Any pearls of wisdom would be appreciated.
I'm not a doctor, but my hope is that a child presenting with these symptoms would see a psychologist for whatever clinical workups they have as well as imaging testing. Like I said, not a doctor, but if I had a child I wouldn't be content to treat with an antipsychotic at that age without psychological testing and something like an MRI.
 
What is your occupation and why is the kid your "client"? Who is your "doc"? Are you doing the "med check"? More than 5 years on sdn and only 3 postings?

Yeah, this is throwing up some red flags for me as well. If the 'Doc' that's being referred to is a supervisor, then I'd expect the OP to have said 'My supervisor assessed this..." Not 'My Doc...'
 
What is your occupation and why is the kid your "client"? Who is your "doc"? Are you doing the "med check"? More than 5 years on sdn and only 3 postings?
I didn't take it suspiciously. I assumed the OP was a PA. But then again I'm not a doctor. Or a PA.
 
I'm not a doctor, but my hope is that a child presenting with these symptoms would see a psychologist for whatever clinical workups they have as well as imaging testing. Like I said, not a doctor, but if I had a child I wouldn't be content to treat with an antipsychotic at that age without psychological testing and something like an MRI.
And an EEG!
Had a six year old patient once who was being diagnosed with psychosis by a school counselor because she "kept staring at things that weren't there" and acting confused. The counselor had unfortunately talked mom into going to her primary care doc, who "diagnosed" bipolar disorder and started her on lithium and risperidone for what we discovered was actually absence seizures.
 
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What is your occupation and why is the kid your "client"? Who is your "doc"? Are you doing the "med check"? More than 5 years on sdn and only 3 postings?

Sorry, I updated my profile. I believe I made this account 5+ years ago when I was considering going to medschool vs. NP route as a non-trad. I chose the NP route. As part of my clinical I'm currently in an OP CMHC supervised by both a PMHNP (psychiatric mental-health nurse practitioner) and a Child & Adolescent Psych.

I use client/patient interchangeably. By doc I'm referring to my supervising psychiatrist. On this particular visit, I was observing.

I'm not a doctor, but my hope is that a child presenting with these symptoms would see a psychologist for whatever clinical workups they have as well as imaging testing. Like I said, not a doctor, but if I had a child I wouldn't be content to treat with an antipsychotic at that age without psychological testing and something like an MRI.

Clients are (usually) assessed by a psychologist before referral to psychiatry in this setting. It's rare for me to see such a young patient with psychotic symptoms and I readily admit my lack of expertise.
 
Sorry, I updated my profile. I believe I made this account 5+ years ago when I was considering going to medschool vs. NP route as a non-trad. I chose the NP route. As part of my clinical I'm currently in an OP CMHC supervised by both a PMHNP (psychiatric mental-health nurse practitioner) and a Child & Adolescent Psych.

QUOTE]

So you completely write out the abbreviation PMHNP and then abbreviate the physician you work with.
 
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This is an interesting topic. I wish we could discuss it without worrying who the OP is. I will give my thoughts later after I get home and check one thing out.
 
This is an interesting topic. I wish we could discuss it without worrying who the OP is. I will give my thoughts later after I get home and check one thing out.

If the presentation was appropriate, I wouldn't have cared either.
It is important to know what knowledge base you are starting from before giving "pearls of wisdom" on this...
 
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Not a Doctor here either, but I find it a tad strange that the Psychiatrist you're working with is assessing auditory hallucinations by asking "are you hearing anything in your head?" As a patient who has periods of Psychosis (or at least Psychotic Fx) the question that is put to me is "are you hearing these voices internally or externally."

Apart from that the only other thing I will say is be careful not to start off with a presumption of diagnosis and then proceed to try and fit the child's symptoms to that. I'd also be wary of secondary gain (attention, sympathy etc) from the Parent's point of view.
 
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So you completely write out the abbreviation PMHNP and then abbreviate the physician you work with.
I wrote out pmhnp because you asked my occupation and I wasn't sure whether most people knew. I've enjoyed your posts Grover. I have no desire argue about whether I appropriately presented a case to you, the politics of nurse practitioners, or whatever else. I'm just trying to learn from wherever I can, including this forum.

How did the kid describe the auditory hallucinations when they were present?
I wasn't present during the initial eval, but I was able to review the eval. HPI noted that teachers noticed that she seemed to be talking to herself. When the teacher inquired who she was talking to, apparently she told them that she was talking to the voices in her head. Mother stated that since these teacher reports, shes also noticed shes been talking to herself. In the MSE, she noted command AH consisting of "voices telling me to hurt myself." No VH. No other pertinent negatives (paranoia, delusions, negative symptoms) were mentioned.
 
Not a Doctor here either, but I find it a tad strange that the Psychiatrist you're working with is assessing auditory hallucinations by asking "are you hearing anything in your head?" As a patient who has periods of Psychosis (or at least Psychotic Fx) the question that is put to me is "are you hearing these voices internally or externally."

Apart from that the only other thing I will say is be careful not to start off with a presumption of diagnosis and then proceed to try and fit the child's symptoms to that. I'd also be wary of secondary gain (attention, sympathy etc) from the Parent's point of view.

I agree. Some questions I use with older clients is "do you hear these voices like you hear my voice or do you hear it from inside your head?" My favorite is "is the voice louder in one ear vs your other ear?" That worked well in the ED. But with these kids, I thought her style of questions were due to her belief that these were more developmentally appropriate? I've also witnessed her asking things like "do you have any scary things in your head? Do you have any strange things in your head? Do you get scared? Is something bad going to happen to you?" These are for maybe...5-10yo pts? Secondary gain did come to mind. The mother was a bit strange and worked in healthcare. May have been some unhealthy enmeshment, but can't say with such a short visit.
 
voices and visions are not usually psychotic symptoms in children (or even in adults) so that is the first important point. it is not correct to call them psychotic symptoms. There is a large differential, from normal childhood experiences, dissociation, factitious disorder by proxy, PTSD, anxiety, intellectual disability, autism, substance abuse, idiom of distress, or is the kid just making it up entirely (not uncommon in severely disturbed conduct disorder). one should think of organic causes as well, but most children should not be having an extensive workup or needing MRIs etc. again a good history, mental status exam and collateral will usually give the diagnosis away. visual hallucinations are more common in childhood forms of schizophrenia than adult. but really what you are looking for in children if you are concerned about psychosis is disorganized thinking and behavior. If the child doesn't have significant disorganization they are very very unlikely to have a psychotic disorder, especially given the hebephrenic form of schizophrenia predominates in these early-onset presentations.
 
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With young kids I sometimes like to have kids draw and if they provide some distressing/bizarre images, I will explore them.

I have a rather colourful rendering of a figure that I drew around the age of 5, the description alongside it read "This is a rain spirit, they put dust on the dead bodies, the dead bodies grew into a love flower, it was a red flower from the blood." I was learning Greek and Roman Mythology/Classical studies from my older cousin at the time so I have a feeling I might have mixed up the Myth of Narcissus with the play by Sophocles, "The Antigone". I've always been wondered though what a Psychiatrist would make of that in this day and age, what sort of diagnosis I might, or might not end up with. (tangent).

I've also witnessed her asking things like "do you have any scary things in your head? Do you have any strange things in your head? Do you get scared? Is something bad going to happen to you?" These are for maybe...5-10yo pts?

This is where I could see a child's answers being inadvertently misinterpreted if the treating Physician in question had already formed a preset notion of diagnostic outcome. To give one example, in grade 3 Primary School (Australian school years from the 70s, so around the age of 6 or 7) we were told the story of "Sadako and the Thousand Paper Cranes", and taught how to fold the Origami Cranes. At that point I began compulsively making paper Cranes, to the detriment of nearly all other outside activities, because I'd become utterly terrified that people would die from Leukemia if I didn't make at least 1000 Cranes myself (terrified to the point of hysterics when the teacher had to forcibly stop me several days later). Now if you were a mental health worker who had already decided on a diagnosis along the spectrum of Psychotic disorders, I can imagine it would be very easy to fit something like that into the symptomology of the diagnosis you're already looking to give - compulsion becomes 'command hallucination', obsessive rumination with catastrophic thinking becomes 'fixed and bizarre delusion', and so on. That's where I think you'd need to be careful in regards to entering any diagnostic situation with preconceived ideas, or to allow yourself to be swayed by any potentially leading input from the parents. Of course as I said I'm not a Doctor so I'm just extrapolating from my own experiences.
 
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I'm not a doctor, but my hope is that a child presenting with these symptoms would see a psychologist for whatever clinical workups they have as well as imaging testing. Like I said, not a doctor, but if I had a child I wouldn't be content to treat with an antipsychotic at that age without psychological testing and something like an MRI.
Many parents and patients feel the way you do, that certain tests should be done for a certain diagnosis. But in reality, this is something we can empirically test. That is, does performing the MRI or psychological testing actually change our management enough to be cost effective (taking into account the monetary costs and the risks -- risks of the tests themselves plus risks of us later acting on false-positives). A full physical exam and history should be taken. An MRI and psychological testing should be done next only if indicated based on that physical exam and history. But if the history/exam are normal outside of the psychosis and associated symptoms, then they probably shouldn't be done.

No one would ask that we do a bone marrow biopsy in this case because it's more clear that it comes with a lot more risks than potential benefits here. An MRI is a closer decision, but still likely inappropriate.

the question that is put to me is "are you hearing these voices internally or externally."
I agree. Some questions I use with older clients is "do you hear these voices like you hear my voice or do you hear it from inside your head?" My favorite is "is the voice louder in one ear vs your other ear?"
People do like to ask this, "inside or outside the head?" question, but I've not seen any evidence that this helps to distinguish true psychosis from other experiences (in fact, the one study I've seen suggested that it does NOT help us distinguish).

What I think is helpful is to get the patient talking about the experience so that we can better understand it. If a true hallucination, then the patient will lack the reality testing that this is actually their own thoughts. However they hear it, it will seem like it's coming from someone else.
 
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I find this question useful mostly with DD patients who sometimes misinterpret inner critique/monologue with "voices." The follow up question is if the "voice" resembles anyone (mom, teacher, etc).


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People do like to ask this, "inside or outside the head?" question, but I've not seen any evidence that this helps to distinguish true psychosis from other experiences (in fact, the one study I've seen suggested that it does NOT help us distinguish).

What I think is helpful is to get the patient talking about the experience so that we can better understand it. If a true hallucination, then the patient will lack the reality testing that this is actually their own thoughts. However they hear it, it will seem like it's coming from someone else.

True and good point. I must admit I was simplifying things a tad, perhaps I should have indicated a bit more that an assessment for Psychotic symptoms doesn't usually just stop with a basic 'inside or outside' your head type question.
 
Psychosis could happen in children but it's on the order of one in thousands to even millions depending on the age. The younger the less likely.

The problem is misdiagnosis and that children are often times not reliable interviewees. One could, for example, ask if they have hallucinations and they might say yes not understanding what that word means. If asked "do you hear things that others don't, "they may say yes thinking that's what you want them to say and children are highly suggestible.

IMHO misdx is always bad but in a child it can lead to some very serious problems such as the child for years suffering from a continued misdiagnosis and unneeded meds for years if not even decades or the rest of their life. This is a serious problem, and a lot of docs have poor skills or even little interest in getting it right cause this takes time and patience.

While forensic psychiatry is not the field for this, there are plenty of forensic cases and studies showing that children often times answer not in a manner what they believe is true but what they believe the interviewer wants to hear.

I've seen too many psychiatrists so easily medicate a child based on so little. My wife specializes in DBT and one of her borderline PD clients told her something to the effect of, "my child always cried and caused me a lot of problems. Now I know she has bipolar disorder because a psychiatrist prescribed her Risperdal and now she's sleeping all the time. He told me she has bipolar disorder."

The child was 2 years old and I knew that doctor. He has a local reputation as a quack that gave everyone as much Xanax and Adderall as they wanted. He also tried to sell real estate to his patients with dependent personality disorder. His partner psychiatrist lost his license in Ohio for giving dozens of patients rectal examinations, and each time his partner got in trouble this guy defended the other in court.

My wife knew that guy was a quack and asked me if we could do anything. The only thing I could think of that she could do that wasnt' overstepping her boundaries was to tell the client to get a second opinion from someone actually board-certified in child psychiatry. This guy that prescribed Risperdal was not.
 
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(Child Adol psyc here)- It's still difficult for me to diagnose kids with psychosis at that age. It's very rare and the developmental issues that come into play make it a complex process that often unfolds over a series of visits. If OP is an ARNP, I'd have them seeing a child psyc until they are stable. It may be a bit out of your depth.
 
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If we are looking at a pure psychosis process, I look for disorganization/ bizarre behavior/ loss of reality testing/ bizarre delusions/ downward trend (obv much quicker than in adults). AH is common with mood disorders, but most of the time, it's patient's own thoughts. As someone mentioned, you can ask the internal vs. external question, but that is not diagnostic. I like to ask if the voice is familiar sounding, male/female, how many, tone of voice, how can you be sure it's not your own, etc etc. Try to nail it down pretty specific, then in subsequent visits, I ask similar questions to see if they stay consistent. VH are extremely uncommon and more likely due to underlying organic causes. I also like to check out their journals if they keep any. Better for teenagers than the young ones like your patient.
 
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I had a prepubescent child admitted with a diagnosis of MDD, severe with psychotic features. Not only did she not meet MDD criteria, but the "psychosis" was her seeing and hearing ghosts (she knew they were ghosts due to their white faces) and mummies (she knew they were mummies as they were wrapped in toilet paper). She said we couldn't see them as they'd go away whenever we looked where they were. o_O
 
I had a prepubescent child admitted with a diagnosis of MDD, severe with psychotic features. Not only did she not meet MDD criteria, but the "psychosis" was her seeing and hearing ghosts (she knew they were ghosts due to their white faces) and mummies (she knew they were mummies as they were wrapped in toilet paper). She said we couldn't see them as they'd go away whenever we looked where they were. o_O

:smack:
 
(Child Adol psyc here)- It's still difficult for me to diagnose kids with psychosis at that age. It's very rare and the developmental issues that come into play make it a complex process that often unfolds over a series of visits. If OP is an ARNP, I'd have them seeing a child psyc until they are stable. It may be a bit out of your depth.

I am a PMHNP student and am training under a Child & Adolescent Psychiatrist as part of my clinical component of my program. I would not feel comfortable treating this population without strong collaboration with a strong CAP.

Here's an update. We saw the child for a follow up visit. Her auditory hallucinations completely went away but she was still "defiant." However, she had not taken any Abilify. Medicaid had denied it as their step-therapy/formulary was not followed - ie. risperdol or another cheaper agent wasn't used first. She went home with some tenex instead for her...behavioral problems. Not trying to start any MD vs. NP wars. Some MDs/NPs are better than other MDs/NPs. My anecdote is not meant to reflect on any particular class of clinicians.
 
Glad it turned out better than it initially appeared.
 
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