Early Onset Psychosis in Children
Dr. Jack Krasuski and Dr. Alvin Lee Lewis meet after Dr. Lewis’s presentation at the Oasis 2019 Child and Adolescent Psychiatry Conference to discuss highlights of his talk about psychosis and related disorders in children.
Dr. Jack Krasuski: Dear colleague, hey, it’s Dr. Jack again. I’m here with Dr. Lee Lewis. Dr. Lewis, among many other things, you’re a specialist in psychosis and youth. You just got off the podium.
Dr. Alvin Lee Lewis: I did.
Dr. Jack Krasuski: After giving your presentation on psychosis. Wonderful feedback. Why don’t we spend a few minutes and give us some highlights. What would you really, number one, want to convey to our colleagues who may be struggling with patients with early onset or suspected psychosis? What would you tell them?
Three Types of Youth Psychosis
Dr. Alvin Lee Lewis: Right. There are three types of psychosis that I talk about in kids. That is what the lecture was about. The first is what I call easy psychosis. We all hope for those cases. Most psychosis in kids is not schizophrenia. Most psychosis in kids is from other psychiatric disorders, like depression, bipolar, trauma, PTSD [post traumatic stress disorder], or ASD – acute stress disorder, even medication side effects from things like stimulants, recent substance abuse in teenagers. Those things, they are predominately the new onset psychosis in kids, and are going to be from that realm.
Dr. Jack Krasuski: Not great to have that but certainly the prognosis is much better.
Dr. Alvin Lee Lewis: The prognosis is much better. The second type of psychosis that I talk about is classic psychosis. That’s when teenagers present with what looks more like an adult schizophrenia picture. They have decompensation of their cognitive function. It’s usually over a more insidious amount of time, six months, one year of a decline. They typically will have poor ADLs, attention to daily living. They won’t be taking care of themselves as well. Their affect might change, along with the classic positive symptoms of delusionality, paranoia, social isolation, ideas of reference. That’s the more classic psychosis, and in those cases, you probably want to treat them much like the literature states on adults: Known FDA approved neuroleptics/antipsychotics at the lowest dose possible and then treat the comorbidities as they present.
Then the third type of psychosis that I talk about is what I call “real life psychosis” which are the presentations that you get a lot of people that have numerous confounders of what could be contributing to their psychosis, like somebody that comes in that has depression, ADHD, PTSD, has been traumatized, maybe also has chronic marijuana or other substance use, all in this clinical picture. In those cases, assessment is so important, talking to as many people that know and work and exist with his patient as possible, having an extensive amount of time to be able to talk with this patient, garner their trust, build rapport with them, try to engage the community around them to provide support to turn this case into one that will have a better prognosis than what the clinical picture presents at onset.
Dr. Jack Krasuski: It sounds like the assessment could be an extended affair. I would get from you, like don’t rush to judgment, keep an open mind, give a provisional diagnosis, and then keep gathering information. Obviously, it’s the right thing to do, and then, at that point, look at the parents and give them a more definitive diagnosis.
Importance of Structure in the Recovery Process
Dr. Alvin Lee Lewis: Educate and work with the parents on a step-by-step basis through the process: Short term goals, psychoeducation, long-term goals. One thing that is very, very important is that even when the patient seems like they’re better, stick with them, because they’re more likely to regress, they’re more likely to relapse in those symptoms, so be with the patient and the family throughout the entire process of recovery, making sure they continue to get the social structure, the academic structure, and eventually the vocational structure that they need to continue striving and prevent a relapse of psychosis later on in life.
Dr. Jack Krasuski: I think it’s important to stress to the parents, to the whole family, that this is really likely to be a chronic condition. It’s not a sprint. It’s a lifelong marathon. It really is. Really, I think helping them, even with the grieving process. I have three kids. I could imagine if someone told me my kid was possibly a schizophrenic. It would be devastating for everyone, and I think helping the family through that, coming to terms.
Dr. Alvin Lee Lewis: Yea. It can be tough. I said this today. One of the things that I like to do with families and kids that have what look like to be a chronic psychotic process is to schedule a time whenever the kid’s at school to meet with the parents by themselves and have that conversation about, hey, this is what we’re looking at, this is what long term we should be looking at, let’s take some time right now to envision your son or daughter as an adult. What’s that going to look like? How can we prepare for that starting now as a teenager? How can we prepare for 10 years from now? What kind of support are they going to need? Vocationally? Familywise? Do they need to get in a system of more support? Are they isolated? Do they need to move towards more family members that could provide help and support or to a community that could provide that support? It’s good to take that time with the parents and encourage them to be a leader in their child’s care.
Dr. Jack Krasuski: One question that arises in my mind, so from the time of initial clinical contact, from the time of establishing perhaps a clear, more definitive diagnosis, there is a period of time there.
Dr. Alvin Lee Lewis: Right.
How to Discuss the Condition with Parents
Dr. Jack Krasuski: How would you recommend that we clinicians talk to the parents when you’re in that period of really not knowing yet what it’s going to turn out to be. How do you keep a balanced view, where it’s serious, but we don’t want to jump to conclusions?
Dr. Alvin Lee Lewis: The thing I always propose is that parents respect the authority of the doctor, but parents also respect the honesty of a doctor. These kids that have psychosis, I find myself very frequently, early on in the process with the parents, saying I don’t know exactly what’s going on yet.
Dr. Jack Krasuski: I like that.
Dr. Alvin Lee Lewis: But you know what. . .
Dr. Jack Krasuski: Because you don’t.
Dr. Alvin Lee Lewis: You don’t, yet. So if I were to come in and say, oh gosh, this isn’t that big of a deal, look at these positive prognostic factors, or gosh, we really need to worry about this because it looks so severe right out of the gate, I’ll say, you know what, we don’t know what it is yet, but as long as we keep working together, it’s going to make itself known. We will know. But while we’re learning, let’s take these steps to combat symptoms. So focus on the symptoms and not the diagnosis. What can we do right out of the gate to help out with hallucinations? What can we do to help out with delusions? What can we do to help out with the cognitive dulling? What can we do to help out to brighten the affect? What can we do to help out with social engagement? How can we get them more engaged socially with peers and with adults? Those things, rather than saying this is schizophrenia.
Dr. Jack Krasuski: I would add, obviously, making sure they’re safe because there’s a heightened suicide risk.
Dr. Alvin Lee Lewis: That’s true. That’s true. The lifetime prevalence of schizophrenia is about a 10% suicide risk. That’s very high, so constantly looking at the safety of the patient and the family structure, increased episodes of agitation, aggression, those types of things, self-aggression and aggression to others are definitely warning signs, constantly looking at that, reassessing that at every visit, also encouraging the patients to contact you if they notice a change. I always tell the parents all the time: Don’t write anything off as oh gosh, it’s just a bad day. If something really pops in your mind, you’re the parent, you know them better than anybody.
Dr. Jack Krasuski: Trust your gut.
Dr. Alvin Lee Lewis: Exactly. If something pops in and they’re like, oh gosh, they’ve never done this before, email me, give me a call.
Tips for Making an Accurate Assessment
Dr. Jack Krasuski: Yes. I like that. One last question I have. Do you have any tips for doing the assessment right? Because this is a difficult area and, as you mention in your second category, the classic psychosis, there is this downward path and sometimes those positive symptoms of delusions or hallucinations may actually not be present, or they may not be admitted to.
Dr. Alvin Lee Lewis: Right.
Dr. Jack Krasuski: They might be paranoid. The last thing they’re going to do is admit that they’re hearing voices. What tips do you have for the clinician who is like, I don’t know what’s going on? I did all the obvious things. What kind of advice would you have to really do the assessment from A to Z? Really complete here.
Dr. Alvin Lee Lewis: Sure. Whenever I was in medical school, we had this thing that we called the biopsychosocial model.
Dr. Jack Krasuski: It still exists.
Dr. Alvin Lee Lewis: Not as much as it should. I teach in medical schools and the biopsychosocial model has unfortunately gone to the wayside. But whenever I am addressing psychosis, in particular, I lean heavily on the biopsychosocial model for assessment.
Biological: Is there anything biological that is a clue here? Do they have neurological abnormalities? Do they have a changed or altered face that might be associated with a genetic condition? Do they have other physical symptoms? Gut-related symptoms? Neurological symptoms that might point you to something that might be biological?
Psychological: What’s their development phase? Where are they in their developmental spectrum? Are they under the age of 12 to where maybe they don’t understand the world yet? Are they older than that? Making determinations of their development based on not just information you get from them, but the benefit of treating children versus adults is most of the time they have a system around them. Don’t be lazy. Talk to the parents. Talk to the teachers. Talk to the caregivers. Talk to everybody, especially in situations like this.
Socially: How are they interacting with their peers? How are they interacting with adults? How are they interacting with their teachers? Are they interacting with the families? What are the changes that have occurred over the last little while that alarmed you? Get into the minutiae of that. Are there other explanations of why this could be happening in this particular child’s life that’s not psychosis?
If you work through all of that, get all that information, you can make a pretty good educated medical guess as to what’s going on.
Dr. Jack Krasuski: Dr. Lewis, even these few minutes with you right now have been very valuable for me. I thank you very much.
Dr. Alvin Lee Lewis: Thank you for having me.
Dr. Jack Krasuski: And being of this. Thank you.
Dr. Alvin Lee Lewis: Welcome to Charleston.
Dr. Jack Krasuski: Yes. Beautiful. I love it. Thank you, doctors. We’re signing off.