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Evaluating Psychosis in Children
Claudio Cepeda, MD
Clinical associate professor in the Department of Psychiatry at UT Health, San Antonio, TX
Dr. Cepeda has disclosed that he has no relevant financial or other interests in any commercial companies pertaining to this educational activity.
The author of the Concise Guide to the Psychiatric Interview of Children and Adolescents, as well as a clinician who has served both inpatient and outpatient pediatric populations for decades, Dr. Cepeda shares his interviewing tips on how to detect signs of psychosis in children.
CCPR: First of all, how common is psychosis in children?
Dr. Cepeda: It depends on what population you are talking about. It is quite uncommon among all kids who show up at a primary care provider’s office. But in a child psychiatric practice, about 3%–5% of children have psychosis, and among children needing hospitalization, the rates are much higher (Cepeda C, Psychotic Symptoms in Children and Adolescents. London: Routledge; 2013). It can be difficult to pick up on these symptoms—every so often in my practice, I evaluate a child formerly seen by a child psychiatrist, and it turns out the psychiatrist had missed psychotic symptoms that were present.
CCPR: And among children who present with psychosis, what are the most common causes?
Dr. Cepeda: About 70% of cases are due to a mood disorder, usually unipolar depression. About 20% are secondary to trauma, including physical and sexual abuse; 4%–5% may be drug related; and the rest are due to a primary thought disorder, such as schizophrenia (van Os J et al, Arch Gen Psychiatry 2001;58(7):663–668).
CCPR: How do you suggest we go about evaluating psychosis in kids?
Dr. Cepeda: There are two situations. In some cases, it is obvious, because children come in saying things like they are hearing voices, or they talk about feeling like someone is after them. But in other cases, the child does not present with obvious symptoms, and you have to ask specific questions.
CCPR: It’s not easy asking questions about psychosis, especially in younger kids who may not understand the concept of psychotic phenomena. How should we begin that conversation?
Dr. Cepeda: A good entrance into the topic is to explore night behavior. I ask, “Are you scared at night?” If the child says yes, I ask, “What are you scared of?” Children may say they hear weird sounds or scary noises, or say they see things in the dark. I’ll proceed from there, asking for more specifics like, “What kinds of noises do you hear?”
CCPR: So you are using “are you scared at night” as a kind of initial screening question.
Dr. Cepeda: Yes, but in many cases you have to be more thorough and systematic than simply asking screening questions. For example, kids may say that they don’t hear anything or see anything, but if I still suspect some kind of psychosis, I’ll go through a series of very specific questions. For example, I’ll ask, “Are you scared of the closet?” In my experience, the closet is a place many psychotic features center on. Kids see it as the hiding place of monsters, or of the devil. Another one is, “Are you scared of the windows?” Some kids think that people are going to come in through the window and hurt them or their family. Other kids will say they are scared of what’s under the bed.
CCPR: It sounds like asking about nighttime phenomena is important. But since so many kids have fears about monsters in the closet or under the bed, how do you tell if this signals psychosis?
Dr. Cepeda: Nighttime fear is just the starting point—it gets the conversation going. Then you dig deeper. For instance, if a kid without psychosis says Freddy Krueger’s in the closet and his parents assure him that no one is in there, he will eventually settle down and fall asleep. A psychotic child will not be able to fall asleep and will persist in his belief no matter how much reassurance he receives. Another important clue is if the child has these fears during the day or at school. The typical distractions of the day will push away scary thoughts for most children, but not for one who’s psychotic. That child will be obsessed. In addition, most kids might be afraid of the bogeyman, but they don’t feel they are being watched per se. Children with psychosis will often feel not only that they are being watched, but also that the scary entity is coming to get them. They have paranoid ideation. They might also hear voices—not just “you are ugly” or “nobody loves you,” but perhaps also command voices to injure or kill either themselves or others.
CCPR: So it goes beyond nighttime, and beyond an impersonal bogeyman?
Dr. Cepeda: Yes, but all of that said, in most kids, the psychosis is more active at night. It’s also not uncommon to feel that there is somebody watching them while they are showering—often with the fear that somebody on the other side of the shower curtain is going to harm them. Some people are surprised at the young ages some of these nighttime hallucinations can begin. In the literature, there are reports of psychosis in 3- or 4-year-olds (Beresford C et al, Clin Child Psychol Psychiatry 2016;10(3):429–439). I remember a 3 ½-year-old boy whose parents brought him in because they discovered that he kept knives under his pillow. When I asked him why, he said that he had them because he had seen the “gingle,” which was a word he had made up. He said he needed the knives to defend himself against the gingle that was coming to kill him and his family.
CCPR: Let’s assume that you ask children whether they are scared at night and they say no. Where might you go from there in the assessment?
Dr. Cepeda: I’ll ask some questions that are similar to what we would ask adults. I ask if they ever hear voices talking to them when there is nobody around. I’ll ask if they see things that are unreal, like monsters or ghosts. If there is a chance of epilepsy, I explore sensory hallucination: “Do you ever feel someone touching you? Do you smell things others don’t smell? Do you ever have a bad taste in your mouth?” It’s also important to explore paranoia specifically, not just give it passing notice. This is an area of the evaluation that is often missed even by child psychiatrists.
CCPR: So how do you catch this?
Dr. Cepeda: I recommend that you ask four questions. The first question is, “Do you ever feel like people say bad things about you?” This is frequently felt by kids in general, so a positive response is not strong evidence for psychosis. I’ll then ask, “Do you feel people watch you?” This gets more weight. I might hear, “That’s why I can’t sleep—because someone is watching me. Every time I go to the bathroom, I feel I’m being watched.” Ask where it happens, being sure to ask specifically if it happens at school. If children say they feel that they are being watched in the classroom, this increases my suspicion of actual psychosis. Again, if the fears occur during classroom activities, they must be pretty profound. Some kids ask to sit in the back of the room so no one can be watching them from behind.
CCPR: What are the last two questions you ask about paranoia?
Dr. Cepeda: The first of those two is, “Do you feel that you are being followed?” Many kids will say no initially, but they may not really understand what I’m talking about. So I’ll explain: “When you are walking, do you need to check to see if someone is behind you?” Many will say yes to that, and that gets a lot of weight in my assessment. Finally, I’ll ask, “Do you feel somebody is after you? That someone wants to do something bad to you?” I give the most significant weight to that answer because it says the most about a problem with perception.
CCPR: How do you evaluate kids who are very young, or who are not verbal?
Dr. Cepeda: For kids who lack verbal skills, or for those who are reticent to relate to strangers (as many 4- to 7-year-olds are), you can get the parent to ask the questions. That gives you the opportunity not only to observe how the child responds to the parent’s questions, but also to assess how aware the parents are to the presence of symptoms. The other thing I do in younger kids is ask them to create drawings. I start by asking them to draw anything they want. Kids with psychosis usually draw something unusual right away. Whereas a child without psychosis might draw something benign, like a house or a park, a child with psychosis might start by drawing a pistol or a knife. For the second drawing, I ask the child to draw somebody. Next, I ask for a drawing of the opposite sex, then I ask for a drawing of the child’s family doing something together. None of these drawings can diagnose psychosis, but they are useful for opening up communication and observing behavior.
CCPR: How do parents respond when they hear you asking these questions about psychosis?
Dr. Cepeda: There’s a paradox here. Parents bring their child in because the child has been telling them some of these disturbing things, things the parents know are not right and that the child is too preoccupied with. But when they recognize that the line of questioning is leading to psychosis, they sometimes become defensive. If a child claims to be afraid of monsters, the parents might say, “That’s just because he likes to watch scary movies” or, “She just saw a scary program on TV.” That’s another reason I might put the questioning into the parents’ hands—it can help to ground them in what’s going on.
CCPR: Is it always easy to distinguish a childhood fear or fantasy from an actual hallucination or paranoid delusion? Is it all houses and parks versus knives and pistols? Clearly, it’s easy enough if the child feels someone is after them and talking to them, and the child can’t be calmed down even during the day. But aren’t there sometimes gray areas?
Dr. Cepeda: You raise a good point. It’s not always easy to decide if the abnormal perception is psychosis or a normal fear. One of the indicators of psychosis is the intensity of affect—these kids will look really scared. It is not simply “interesting” for them. Another thing to ask, particularly if you are skeptical of the story, or if the parents are skeptical and think the child is exaggerating, is, “Are you telling me the truth?” If you put this question directly, many kids with actual psychosis will tell you immediately that they are.
CCPR: Do the types of psychotic symptoms provide clues to the underlying cause?
Dr. Cepeda: To a degree. In general, command hallucinations point you in the direction of a major depressive episode, or more rarely a bipolar depressed presentation. About 90% of the time, the voices of command hallucinations are telling children to kill themselves, and about 10% of the time they are being told to kill someone else (Buccheri R et al, Psychosoc Nurs Ment Health Serv 2007;45(9):46–54).
CCPR: How do you discuss medications with parents?
Dr. Cepeda: That’s an important question, especially because we are talking about antipsychotics, which are controversial treatments in children because of the significant side effects. I describe the more problematic side effects, which are mainly dystonia and weight gain. There are times when I feel strongly that a child could benefit from medications, and I do push for them. In my experience, parents will readily accept meds for problems such as command hallucinations or paranoia—especially when the paranoia causes behavior issues like bringing weapons to school to avenge a perceived misdeed. They also often accept meds when the child is not sleeping because of psychosis.
CCPR: Thank you for your time, Dr. Cepeda.
Child PsychiatryDr. Cepeda: It depends on what population you are talking about. It is quite uncommon among all kids who show up at a primary care provider’s office. But in a child psychiatric practice, about 3%–5% of children have psychosis, and among children needing hospitalization, the rates are much higher (Cepeda C, Psychotic Symptoms in Children and Adolescents. London: Routledge; 2013). It can be difficult to pick up on these symptoms—every so often in my practice, I evaluate a child formerly seen by a child psychiatrist, and it turns out the psychiatrist had missed psychotic symptoms that were present.
CCPR: And among children who present with psychosis, what are the most common causes?
Dr. Cepeda: About 70% of cases are due to a mood disorder, usually unipolar depression. About 20% are secondary to trauma, including physical and sexual abuse; 4%–5% may be drug related; and the rest are due to a primary thought disorder, such as schizophrenia (van Os J et al, Arch Gen Psychiatry 2001;58(7):663–668).
CCPR: How do you suggest we go about evaluating psychosis in kids?
Dr. Cepeda: There are two situations. In some cases, it is obvious, because children come in saying things like they are hearing voices, or they talk about feeling like someone is after them. But in other cases, the child does not present with obvious symptoms, and you have to ask specific questions.
CCPR: It’s not easy asking questions about psychosis, especially in younger kids who may not understand the concept of psychotic phenomena. How should we begin that conversation?
Dr. Cepeda: A good entrance into the topic is to explore night behavior. I ask, “Are you scared at night?” If the child says yes, I ask, “What are you scared of?” Children may say they hear weird sounds or scary noises, or say they see things in the dark. I’ll proceed from there, asking for more specifics like, “What kinds of noises do you hear?”
CCPR: So you are using “are you scared at night” as a kind of initial screening question.
Dr. Cepeda: Yes, but in many cases you have to be more thorough and systematic than simply asking screening questions. For example, kids may say that they don’t hear anything or see anything, but if I still suspect some kind of psychosis, I’ll go through a series of very specific questions. For example, I’ll ask, “Are you scared of the closet?” In my experience, the closet is a place many psychotic features center on. Kids see it as the hiding place of monsters, or of the devil. Another one is, “Are you scared of the windows?” Some kids think that people are going to come in through the window and hurt them or their family. Other kids will say they are scared of what’s under the bed.
CCPR: It sounds like asking about nighttime phenomena is important. But since so many kids have fears about monsters in the closet or under the bed, how do you tell if this signals psychosis?
Dr. Cepeda: Nighttime fear is just the starting point—it gets the conversation going. Then you dig deeper. For instance, if a kid without psychosis says Freddy Krueger’s in the closet and his parents assure him that no one is in there, he will eventually settle down and fall asleep. A psychotic child will not be able to fall asleep and will persist in his belief no matter how much reassurance he receives. Another important clue is if the child has these fears during the day or at school. The typical distractions of the day will push away scary thoughts for most children, but not for one who’s psychotic. That child will be obsessed. In addition, most kids might be afraid of the bogeyman, but they don’t feel they are being watched per se. Children with psychosis will often feel not only that they are being watched, but also that the scary entity is coming to get them. They have paranoid ideation. They might also hear voices—not just “you are ugly” or “nobody loves you,” but perhaps also command voices to injure or kill either themselves or others.
CCPR: So it goes beyond nighttime, and beyond an impersonal bogeyman?
Dr. Cepeda: Yes, but all of that said, in most kids, the psychosis is more active at night. It’s also not uncommon to feel that there is somebody watching them while they are showering—often with the fear that somebody on the other side of the shower curtain is going to harm them. Some people are surprised at the young ages some of these nighttime hallucinations can begin. In the literature, there are reports of psychosis in 3- or 4-year-olds (Beresford C et al, Clin Child Psychol Psychiatry 2016;10(3):429–439). I remember a 3 ½-year-old boy whose parents brought him in because they discovered that he kept knives under his pillow. When I asked him why, he said that he had them because he had seen the “gingle,” which was a word he had made up. He said he needed the knives to defend himself against the gingle that was coming to kill him and his family.
CCPR: Let’s assume that you ask children whether they are scared at night and they say no. Where might you go from there in the assessment?
Dr. Cepeda: I’ll ask some questions that are similar to what we would ask adults. I ask if they ever hear voices talking to them when there is nobody around. I’ll ask if they see things that are unreal, like monsters or ghosts. If there is a chance of epilepsy, I explore sensory hallucination: “Do you ever feel someone touching you? Do you smell things others don’t smell? Do you ever have a bad taste in your mouth?” It’s also important to explore paranoia specifically, not just give it passing notice. This is an area of the evaluation that is often missed even by child psychiatrists.
CCPR: So how do you catch this?
Dr. Cepeda: I recommend that you ask four questions. The first question is, “Do you ever feel like people say bad things about you?” This is frequently felt by kids in general, so a positive response is not strong evidence for psychosis. I’ll then ask, “Do you feel people watch you?” This gets more weight. I might hear, “That’s why I can’t sleep—because someone is watching me. Every time I go to the bathroom, I feel I’m being watched.” Ask where it happens, being sure to ask specifically if it happens at school. If children say they feel that they are being watched in the classroom, this increases my suspicion of actual psychosis. Again, if the fears occur during classroom activities, they must be pretty profound. Some kids ask to sit in the back of the room so no one can be watching them from behind.
CCPR: What are the last two questions you ask about paranoia?
Dr. Cepeda: The first of those two is, “Do you feel that you are being followed?” Many kids will say no initially, but they may not really understand what I’m talking about. So I’ll explain: “When you are walking, do you need to check to see if someone is behind you?” Many will say yes to that, and that gets a lot of weight in my assessment. Finally, I’ll ask, “Do you feel somebody is after you? That someone wants to do something bad to you?” I give the most significant weight to that answer because it says the most about a problem with perception.
CCPR: How do you evaluate kids who are very young, or who are not verbal?
Dr. Cepeda: For kids who lack verbal skills, or for those who are reticent to relate to strangers (as many 4- to 7-year-olds are), you can get the parent to ask the questions. That gives you the opportunity not only to observe how the child responds to the parent’s questions, but also to assess how aware the parents are to the presence of symptoms. The other thing I do in younger kids is ask them to create drawings. I start by asking them to draw anything they want. Kids with psychosis usually draw something unusual right away. Whereas a child without psychosis might draw something benign, like a house or a park, a child with psychosis might start by drawing a pistol or a knife. For the second drawing, I ask the child to draw somebody. Next, I ask for a drawing of the opposite sex, then I ask for a drawing of the child’s family doing something together. None of these drawings can diagnose psychosis, but they are useful for opening up communication and observing behavior.
CCPR: How do parents respond when they hear you asking these questions about psychosis?
Dr. Cepeda: There’s a paradox here. Parents bring their child in because the child has been telling them some of these disturbing things, things the parents know are not right and that the child is too preoccupied with. But when they recognize that the line of questioning is leading to psychosis, they sometimes become defensive. If a child claims to be afraid of monsters, the parents might say, “That’s just because he likes to watch scary movies” or, “She just saw a scary program on TV.” That’s another reason I might put the questioning into the parents’ hands—it can help to ground them in what’s going on.
CCPR: Is it always easy to distinguish a childhood fear or fantasy from an actual hallucination or paranoid delusion? Is it all houses and parks versus knives and pistols? Clearly, it’s easy enough if the child feels someone is after them and talking to them, and the child can’t be calmed down even during the day. But aren’t there sometimes gray areas?
Dr. Cepeda: You raise a good point. It’s not always easy to decide if the abnormal perception is psychosis or a normal fear. One of the indicators of psychosis is the intensity of affect—these kids will look really scared. It is not simply “interesting” for them. Another thing to ask, particularly if you are skeptical of the story, or if the parents are skeptical and think the child is exaggerating, is, “Are you telling me the truth?” If you put this question directly, many kids with actual psychosis will tell you immediately that they are.
CCPR: Do the types of psychotic symptoms provide clues to the underlying cause?
Dr. Cepeda: To a degree. In general, command hallucinations point you in the direction of a major depressive episode, or more rarely a bipolar depressed presentation. About 90% of the time, the voices of command hallucinations are telling children to kill themselves, and about 10% of the time they are being told to kill someone else (Buccheri R et al, Psychosoc Nurs Ment Health Serv 2007;45(9):46–54).
CCPR: How do you discuss medications with parents?
Dr. Cepeda: That’s an important question, especially because we are talking about antipsychotics, which are controversial treatments in children because of the significant side effects. I describe the more problematic side effects, which are mainly dystonia and weight gain. There are times when I feel strongly that a child could benefit from medications, and I do push for them. In my experience, parents will readily accept meds for problems such as command hallucinations or paranoia—especially when the paranoia causes behavior issues like bringing weapons to school to avenge a perceived misdeed. They also often accept meds when the child is not sleeping because of psychosis.
CCPR: Thank you for your time, Dr. Cepeda.
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