Approach to New-Onset Psychosis in Pediatrics: A Review of Current Practice and an Interdisciplinary Consensus-Driven Clinical Pathway at a Single-Center Institution
Restricted accessReview articleFirst published online March, 2023
Approach to New-Onset Psychosis in Pediatrics: A Review of Current Practice and an Interdisciplinary Consensus-Driven Clinical Pathway at a Single-Center Institution
New-onset psychosis in the pediatric population poses many diagnostic challenges. Given the diversity of underlying causes, which fall under the purview of multiple medical specialties, a timely, targeted, yet thorough workup requires a systematic and coordinated approach. A committee of expert pediatric physicians from the divisions of emergency medicine, psychiatry, neurology, hospitalist medicine, and radiology convened to create and implement a novel clinical pathway and approach to the pediatric patient presenting with new-onset psychosis. Here we provide background and review the evidence supporting the investigations recommended in our pathway to screen for a comprehensive range of etiologies of pediatric psychosis.
KleinhausKHarlapSPerrinM, et al.Age, sex and first treatment of schizophrenia in a population cohort. J Psychiatr Res.2011;45(1):136–141.
3.
SchneiderCPapachristouEWimberleyT, et al.Clozapine use in childhood and adolescent schizophrenia: a nationwide population-based study. Eur Neuropsychopharmacol.2015;25(6):857–863.
4.
DriverDIGogtayNRapoportJL. Childhood onset schizophrenia and early onset schizophrenia spectrum disorders. Child Adolesc Psychiatr Clin N Am.2013;22(4):539–555. doi: 10.1016/j.chc.2013.04.001
5.
KelleherIConnorDClarkeMCDevlinNHarleyMCannonM. Prevalence of psychotic symptoms in childhood and adolescence: a systematic review and meta-analysis of population-based studies. Psychol Med.2012;42(9):1857–1863. doi: 10.1017/S0033291711002960
6.
LinscottRJvan OsJ. An updated and conservative systematic review and meta-analysis of epidemiological evidence on psychotic experiences in children and adults: on the pathway from proneness to persistence to dimensional expression across mental disorders. Psychol Med.2013;43(6):1133–1149.
7.
BenjaminSLauterbachMDStanislawskiAL. Congenital and acquired disorders presenting as psychosis in children and young adults. Child Adolesc Psychiatr Clin N Am.2013;22(4):581–608.
8.
ColemanMGillbergC. The schizophrenias. In: A Biological Approach to the Schizophrenia Spectrum Disorders. Springer; 1996.
9.
FreudenreichOCharles SchulzSGoffDC. Initial medical work-up of first-episode psychosis: a conceptual review. Early Interv Psychiatry.2009;3(1):10–18. doi:10.1111/j.1751-7893.2008.00105.x
10.
EndresDMatysikMFeigeB, et al.Diagnosing organic causes of schizophrenia spectrum disorders: findings from a one-year cohort of the Freiburg diagnostic protocol in psychosis (FDPP). Diagnostics (Basel).2020;10(9):691.
BonnotOKlünemannHHSedelFTordjmanSCohenDWalterfangM. Diagnostic and treatment implications of psychosis secondary to treatable metabolic disorders in adults: a systematic review. Orphanet J Rare Dis.2014;9(1):65.
13.
KranzlerHNKesterHMGerbino-RosenG, et al.Treatment-refractory schizophrenia in children and adolescents: an update on clozapine and other pharmacologic interventions. Child Adolesc Psychiatr Clin N Am.2006;15(1):135–159.
14.
KeepersGAFochtmannLJAnziaJM, et al.The American Psychiatric Association practice guideline for the treatment of patients with schizophrenia. Am J Psychiatry.2020;177(9):868–872.
15.
PollakTALennoxBRMüllerS, et al.Autoimmune psychosis: an international consensus on an approach to the diagnosis and management of psychosis of suspected autoimmune origin. Lancet Psychiatry.2020;7(1):93–108.
16.
TitulaerMJMcCrackenLGabilondoI, et al.Treatment and prognostic factors for long-term outcome in patients with anti-N-methyl-d-aspartate (NMDA) receptor encephalitis: a cohort study. Lancet Neurol.2013;12(2):157–165.
17.
MuhrerEMoxamADunnM, et al.Acute medical workup for new–onset psychosis in children and adolescents: a retrospective cohort. J Hosp Med. 2022;17(11):907-911.
18.
HoffmannLAJariusSPellkoferHL, et al.Anti-Ma and anti-Ta associated paraneoplastic neurological syndromes: 22 newly diagnosed patients and review of previous cases. J Neurol Neurosurg Psychiatry.2008;79(7):767–773.
19.
LeeSKLeeST. The laboratory diagnosis of autoimmune encephalitis. J Epilepsy Res.2016;6(2):45–52.
20.
DahmLOttCSteinerJ, et al.Seroprevalence of autoantibodies against brain antigens in health and disease. Ann Neurol.2014;76(1):82–94.
21.
RambergerMBstehGSchandaK, et al.NMDA Receptor antibodies. Neurol Neuroimmunol Neuroinflamm.2015;2(5):e141.
22.
PollakTAVincentAIyegbeC, et al.Relationship between serum NMDA receptor antibodies and response to antipsychotic treatment in first-episode psychosis. Biol Psychiatry.2021;90(1):9–15.
23.
WarrenNSwayneASiskindD, et al.Serum and CSF anti-NMDAR antibody testing in psychiatry. J Neuropsychiatry Clin Neurosci.2020;32(2):154–160.
24.
PollakTALennoxBR. Time for a change of practice: the real-world value of testing for neuronal autoantibodies in acute first-episode psychosis. BJPsych Open.2018;4(4):262–264.
25.
ScottJGGillisDRyanAE, et al.The prevalence and treatment outcomes of antineuronal antibody-positive patients admitted with first episode of psychosis. BJPsych Open.2018;4(2):69–74.
26.
YoshimuraBTakakiM. Anti-NMDA receptor antibody positivity and presentations without seizure, involuntary movement, hypoventilation, or tumor: a systematic review of the literature. J Neuropsychiatry Clin Neurosci.2017;29(3):267–274.
27.
Gresa-ArribasNTitulaerMJTorrentsA, et al.Diagnosis and significance of antibody titers in anti-NMDA receptor encephalitis, a retrospective study. Lancet Neurol.2014;13(2):167–177.
28.
GrausFTitulaerMJBaluR, et al.A clinical approach to diagnosis of autoimmune encephalitis. Lancet Neurol.2016;15(4):391–404.
29.
SkikicMArriolaJA. First episode psychosis medical workup. Child Adolesc Psychiatr Clin N Am.2020;29(1):15–28. doi:10.1016/j.chc.2019.08.010
30.
ManchandaRNormanRMallaA, et al.EEG Abnormalities and two year outcome in first episode psychosis. Acta Psychiatr Scand.2005;111(3):208–213.
31.
KayserMSTitulaerMJGresa-ArribasNDalmauJ. Frequency and characteristics of isolated psychiatric episodes in anti-NMDA receptor encephalitis. JAMA Neurol.2013;70(9):1133, 10.1001/jamaneurol.2013.3216.
32.
BrittonPNEastwoodKPatersonB, et al.Consensus guidelines for the investigation and management of encephalitis in adults and children in Australia and New Zealand. Intern Med J.2015;45(5):563–576.
33.
ClancyMJClarkeMCConnorDJCannonMCotterDR. The prevalence of psychosis in epilepsy; a systematic review and meta-analysis. BMC Psychiatry.2014;14(1):75.
34.
MorrowEMLafayetteJMBromfieldEBFricchioneG. Postictal psychosis: presymptomatic risk factors and the need for further investigation of genetics and pharmacotherapy. Ann Gen Psychiatry.2006;5(1):9.
35.
TarulliADevinskyOAlperK. Progression of postictal to interictal psychosis. Epilepsia.2001;42:1468–1471. doi: 10.1046/j.1528-1157.2001.10701.x
36.
TadokoroYOshimaTKanemotoK. Interictal psychoses in comparison with schizophrenia? A prospective study. Epilepsia.2007;0(0):070730094150003.
37.
JacobsonSJerrierH. EEG in delirium. Semin Clin Neuropsychiatry.2000;5(2):86–92. doi: 10.153/SCNP00500086
CellucciTVan MaterHGrausF, et al.Clinical approach to the diagnosis of autoimmune encephalitis in the pediatric patient. Neurol Neuroimmunol Neuroinflamm.2020;7(2):e663.
40.
ZulianiLNosadiniMGastaldiM, et al.Management of antibody-mediated autoimmune encephalitis in adults and children: literature review and consensus-based practical recommendations. Neurol Sci.2019;40(10):2017–2030.
41.
AbboudHProbascoJCIraniS, et al.Autoimmune encephalitis: proposed best practice recommendations for diagnosis and acute management. J Neurol Neurosurg Psychiatry.2021;92(7):757–768.
42.
OrdóñezAELuscherZGogtayN. Neuroimaging findings from childhood onset schizophrenia patients and their non-psychotic siblings. Schizophr Res.2016;173(3):124–131.
43.
StevensJRPrinceJBPragerLMSternTA. Psychotic disorders in children and adolescents: a primer on contemporary evaluation and management. Prim Care Companion CNS Disord.2014;16(2):PCC.13f01514.
44.
CunqueiroADurangoAFeinDMYeKScheinfeldMH. Diagnostic yield of head CT in pediatric emergency department patients with acute psychosis or hallucinations. Pediatr Radiol.2019;49(2):240–244.
45.
FalkenbergIBenettiSRaffinM, et al.Clinical utility of magnetic resonance imaging in first-episode psychosis. Br J Psychiatry.2017;211(4):231–237.
46.
ForbesMSteflerDVelakoulisD, et al.The clinical utility of structural neuroimaging in first-episode psychosis: a systematic review. Aust N Z J Psychiatry.2019;53(11):1093–1104.
47.
GibsonLMPaulLChappellFM, et al.Potentially serious incidental findings on brain and body magnetic resonance imaging of apparently asymptomatic adults: systematic review and meta-analysis. Br Med J.2018;363.
48.
GouletKDeschampsBEvoyFTrudelJF. Use of brain imaging (computed tomography and magnetic resonance imaging) in first-episode psychosis: review and retrospective study. Can J Psychiatry.2009;54(7):493–501.
49.
MooneyhamGCFerrafiatVStolteEFuchsDCCohenD. Developing consensus in the assessment and treatment pathways for autoimmune encephalitis in child and adolescent psychiatry. Front Psychiatry.2021;12:638901. doi: 10.3389/fpsyt.2021.638901. PMID: 33854451; PMCID: PMC8039450.
