Increased psychotic symptoms in childhood and adolescence: better diagnosis or new risk factors?

Psychotic symptoms, such as hallucinations, disorganised speech, compromised psychomotor abilities and delusions, are common in childhood and adolescence (American Psychiatric Association, 2013; Kelleher et al., 2012). Indeed, according to a systematic review and meta-analysis of population-based studies, the median prevalence of these symptoms is 17% in children aged 9-12 and 7.5% in adolescent aged 13-18 (Kelleher et al., 2012), while in the general population the lifetime prevalence ranges between 5.8% and 12.5% (Linscott and van Os, 2013; Nuevo et al., 2012; McGrath et al., 2015).


In this regard, it is important to specify that the definition of “psychotic symptoms” refers to a manifestation of cognitive or perceptual dysfunction and does not correspond to that of “psychotic disorders”, i.e. conditions in which psychotic symptoms meet specific diagnostic criteria (Lieberman et al., 2018). The median global prevalence of psychotic disorders is 4.6 per 1000 persons (Moreno-Kustner et al., 2018). Notably, it has been reported that subclinical psychotic experiences are transitory in nearly 80% of individuals and only a small proportion (7.4%) develops into real psychotic disorders (Linscott and van Os, 2013).


With regards to assessment of psychotic symptoms, the differential diagnosis is complicated by the variety of possible causes (e.g. stressors, trauma - such as sexual abuse in childhood - or diseases like brain tumours (Staal et al., 2017; Mittal et al., 2010; McGrath et al., 2017) and by the interplay between genetic, environmental and physical factors (Staal et al., 2017). Due to this complexity, a direct causal relationship between an underlying pathology and psychotic symptoms cannot always be determined (Staal et al., 2017).
Therefore, while it is important in each case of childhood psychotic symptoms to evaluate critical somatic aspects suggestive of primary physical illness, there is no need to submit the child to a profusion of superfluous diagnostic tests (Stall et al., 2017). Yet, as finding balance is essential but challenging, it is important to provide clinicians with an adequate diagnostic algorithm that is able to guide them through the decision-making process using an evidence-based approach (Stall et al., 2017). Moreover, such a tool may help to reduce both healthcare costs and the burden imposed by the disease on children and their families (Stall et al., 2017).


References

  • American Psychiatric Association. Diagnostic and statistical manual of mental disorders, fifth edition (DSM-5). Philadelphia, PA: American Psychiatric Association; 2013.
  • Kelleher I, Connor D, Clarke MC, Devlin N, Harley M, Cannon M. 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.
    Lieberman JA. Psychotic disorders. N Engl J Med 2018;379:270-280.
  • Linscott RJ, van Os J. 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;43:1133-1149.
  • McGrath JJ, Saha S, Al-Hamzawi A, Alonso J, Bromet EJ, Bruffaerts R, et al. Psychotic experiences in the general population: a cross-national analysis based on 31,261 respondents from 18 countries. JAMA Psychiatry 2015;72(7):697-705.
  • McGrath JJ, McLaughlin KA, Saha S, Aguilar-Gaxiola S, Al-Hamzawi A, Alonso J, et al. The association between childhood adversities and subsequent first onset of psychotic experiences: a cross-national analysis of 23,998 respondents from 17 countries. Psychol Med 2017;47(7):1230-1245 (freely available from PubMed).
  • Mittal VA, Karlsgodt K, Zinberg J, Cannon TD, Bearden CE. Identification and treatment of a pineal region tumor in an adolescent with prodromal psychotic symptoms. Am J Psychiatry 2010;167(9):1033-1037 (freely available from PubMed).
  • Moreno-Kustner B, Martín C, Pastor L. Prevalence of psychotic disorders and its association with methodological issues. A systematic review and meta-analyses. PLoS ONE 2018;13(4):e0195687 (freely available from PubMed).
  • Nuevo R, Chatterji S, Verdes E, Naidoo N, Arango C, Ayuso-Mateos JL. The continuum of psychotic symptoms in the general population: a cross-national study. Schizophr Bull 2012;38(3):475-485 (freely available from PubMed).