Psychotic Symptoms in Children and Adolescents

Assessment, Differential Diagnosis, and Treatment, 1st

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 Table of Contents

Preface vii
Acknowledgments ix

Chapter 1 Overview of Psychotic Symptoms in Childhood 1

Chapter 2 Psychiatric Assessment 25
Chapter 3 Examination of Other Psychotic Symptoms 51
Chapter 4 Examination of Mood and Afect 83
Chapter 5 Aids in the Diagnostic Process 93
Chapter 6 Diferential Diagnosis of Psychotic Disorders:
Medical Conditions Associated with Psychosis 117
Chapter 7 Diferential Diagnosis of Psychotic Disorders:
Psychiatric Disorders Associated with Psychosis 153
Chapter 8 Etiology and Pathogenesis 203
Chapter 9 Psychosocial Interventions for Chronic Psychoses 237
Chapter 10 Psychopharmacological Treatment: Considerations
in the Clinical Use of Antipsychotic Medications 273
Chapter 11 Mood Stabilizing Medications in the Treatment
of Psychotic Disorders of Children and Adolescents,
Other Treatments, and Alternative Treatments 313
Chapter 12 Overview of Atypical Antipsychotics 331
Chapter 13 Side Efects of Mood Stabilizers and
Atypical Antipsychotics 359
Chapter 14 Treatment of Atypical Side Efects 419

v
vi Contents

Appendix A Drug Interactions 443

Appendix B Conventional or Classic Antipsychotics 447

Notes 457
References 489
Index 525

he author has received consultation fees from Lilly, AstraZeneca, Bristol-Myers

Squibb, and Pizer Pharmaceuticals, but does not have any inancial ailiation
to any of these companies or to any other pharmaceutical manufacturer.
 Preface

Psychosis in childhood is not rare. Actually, psychosis is a rather common

phenomenon in severe psychiatric conditions. Although psychotic features
may go unrecognized for a long time, quite oten these features are inluential
if not determinative of maladaptive behaviors. Psychotic symptoms may be
reliably identiied with simple questions. Identifying psychotic features is rather
simple. Deliberate engagement and systematic and nonleading questioning are
the main diagnostic skills that examiners should apply in this area.
Psychiatric examination places a great deal of attention on the nature of
the clinical communication and on the detailed analysis of issues related to the
presenting symptoms.
he author has extensive experience in dealing with moderate to severe
child and adolescent psychopathology, and has developed a simple and sys-
tematic method of inquiry to explore these symptoms.
On one occasion, the author made a presentation on psychotic disorders
in children and adolescents. One member of the audience objected to the
presenter’s recommendation for a methodic and systematic exploration of
perceptual disorders and delusional symptoms. he objecting psychiatrist
asserted that exploring psychotic symptoms in the manner recommended by
the author would be very time consuming. To this, the author retorted that
to not explore psychotic features in a systematic fashion was a risky practice
psychiatrists could not aford. he author reminded the audience that a com-
prehensive and systematic examination is the most cost-efective intervention
that a physician can ofer to his or her patients.
Some physicians and some child and adolescent clinicians feel mystiied by
the process of evaluating psychotic behavior. It should not be so. Children give
reliable responses to an interviewer’s questions about subjective experiences.
Rarely, parents know about the child’s psychotic experiences, and usually they
are skeptical about the existence of psychotic features in their children. For this
reason, in very small children, the author conducts the evaluation of psychotic
experiences in the parents’ presence and, as indicated in the text, the author
engages parents in the diagnostic enquiry.

vii
viii Preface

All the cited cases were seen by the author at the Southwest Mental Health
Center (SMHC).1
his book is preeminently a clinical text, mostly descriptive. It will be
useful to child psychiatrists and child psychologists, to adolescent and general
psychiatrists, and to the great variety of mental health professionals (nurses,
clinical social workers, special education specialists, and other clinicians) who
specialize in the child and adolescent ield.
he author agrees with experts who maintain that psychosis in childhood is
consequential. Psychotic experiences can certainly submerge, leaving no trace.
On the other hand, a signiicant number of psychotic experiences endure, and
they either become organizing psychopathological cores, or they aggravate
other comorbid psychiatric conditions.
Chapters 1, 2, 3, 4, 6, 7, and 9 are readily accessible to nonmedical readers;
the rest of the book is rather technical and requires some medical or biological
background. No matter what the reader’s background may be, the chapters on
the use of medication with children (chapters 10, 11, 12), and the ones that
overview medication side efects (chapter 13) and the treatment of medication
side efects (chapter 14), will beneit any reader involved in the process of as-
sessing and treating children and adolescents.
In contemporary psychiatry, biochemical issues at the subcellular levels
are the order of the day. he author overviews the most relevant aspects of
biological psychiatry that he considers fundamental in clinical practice. It is
hoped that the technical aspects of the book do not become too overbearing
to nonmedical readers.
he author is sympathetic with international readers who may want to
pursue some of the cited references. About 15% of the bibliography relates
to Continuing Medical Education (CME) literature that may be inaccessible
in foreign countries. In the same vein, another 15% of references are found
in new clinical publications that have limited international distribution. he
CME presentations were chosen among other things for the relevance of the
topics, the clarity of the expositions, the didactic aspects of the programs, the
reputation of the faculty, and/or the visual aspects of the programs including
graphs and tables.
 Acknowledgments

he late Otto Will, M.D., a superb Sullivanian psychotherapist of schizophrenia

in the 1970s, used to say that his best teachers were his patients. I do agree with
him; we owe a great deal to the people we serve. Each child and each family
leave teachings and memories that contribute to our expertise and personal
growth. I want to express my gratitude to the multiple children and parents I
have had the privilege to treat.
I was invited to organize a conference on Psychosis in Childhood at the
Annual Meeting of the Puerto Rico Academy of Psychiatry in 2001. he idea for
this book germinated during the preparation for that conference. I am grateful
to Jose Manuel Pou, M.D., for such an invitation.
If the best git of love is the provision of time, I want to express my im-
mense gratitude to so many persons who in one way or another contributed
to the culmination of this book. I appreciate and recognize that without the
collaboration of so many persons this book might not have reached a successful
conclusion. It is likely that my recollection would betray me in remembering
many persons who to greater or lesser degree have contributed to making this
endeavor a success. hat risk notwithstanding, I take such a risk and give public
recognition to a number of persons who assisted me in a signiicant way in the
preparation, content, and readability of the text. Nonetheless, I take sole and
complete responsibility for the quality of the content.
If being lucky is to have a good wife and a good boss, I am very lucky in-
deed. I am particularly grateful to my “boss,” Graham Rogeness, M.D., for the
moral, logistic, and intellectual support of this project. As Medical Director of
the Southwest Mental Health Center (SMHC) and President of the Southwest
Psychiatric Physicians (SPP), to which I belong, he allowed our busy secretarial
staf to assist me in many practical aspects of the preparation of the manuscript.
In the same vein, I am very grateful to Fred Hines, CEO of SMHC at San Anto-
nio, for his support of this efort, and for the staf and logistic support provided
during the last four years.
Special gratitude is due to Sheila Ortiz, Director of Operations, for the inter-
est she demonstrated in this project, and for the time she spent proofreading a
number of chapters. I want to express many thanks to the SPP secretarial staf,

ix
x Acknowledgments

and to Diana Gonzales, in particular, for her ongoing assistance throughout

the evolution and completion of the book.
As was the case with my irst book, he Concise Guide to the Psychiatric
Interview of Children and Adolescents (APA, 2000), I am immensely indebted
to Marie Beyer, LPC, for the enthusiasm that she demonstrated for the new
book and for her generosity in spending uncountable time reading and cor-
recting drats and making suggestions regarding the clarity and readability of
the text.
I am very thankful to my SPP colleagues for their professional support
and for sharing and discussing a number of vignettes presented in the text.
Geof Gentry, Ph.D., Vice President of Clinical Services and Rick Edwards,
LPC, Director of Inpatient Services, at the SMHC, gave helpful suggestions to
improve the quality of chapter 9.
Cynthia Mascarenas, PharmD, MS, BCPP, Clinical Assistant Professor,
University of Texas College of Pharmacy at Austin and University of Texas
Health Science Center at San Antonio, provided input in the psychopharma-
cological book chapters.
Upon acquaintance with preliminary drats of the book, Herb Reich, Senior
Editor, gave strong support to me, and strove to carry the drat to publication. I
am most grateful to him for his editorial assistance and for ironing out the pub-
lication contract; his ongoing support for this book is greatly appreciated.
David Booth and Quint Taylor, Director of Information Technology and
Network Administrator, respectively, at the SMHC, ofered ongoing computer
expertise. On more than one occasion, David and Quint helped me to get
of a “computer jam.” David assisted in the technical aspects of digitizing the
drawings and algorithms, and both Dave and Quint were always available and
ofered assistance on a variety of computer and information processing issues.
I want to express my special gratitude to both of them.
Early in the development of the book, Lisa Gustafson, LMSW, former
Director of Admission SMHC, read drats of the irst two chapters and gave
valuable suggestions.
I disrupted the retirement of my good friend, Gonzalo Mesa, by asking him
to assist me in the correlation and completeness of the bibliography, a tedious
job. I thank Dr. Mesa for his meticulous job.
Many Child Fellows and General Psychiatric Residents from the Depart-
ment of Psychiatry, University of Texas Training Program at San Antonio,
assisted me with multiple bibliographic searches. Former General Psychiatric
Residents Ricardo Salazar, M.D. and Ashley Chen, M.D., as well as former Fel-
lows in Child and Adolescent Psychiatry Jennifer Herron, M.D., Annita Mikita,
M.D., Soad Michelsen, M.D. (now a member of SPP), James Brown, M.D.,
Henry Polk, M.D., and Melissa Watson, M.D., assisted me in this endeavor.
In the same vein I am thankful to Juan Zavala, M.D., Tracy Schillerstrom,
M.D., Ilianai Torres-Roca, and Lucille Gotanco, M.D., Fellows in Child and
 Acknowledgments xi

Adolescent Psychiatry at the University of Texas Health Science Center at

San Antonio (UTHSCSA) for assisting me in the same area. Dr. Schillerstrom
also gave a number of suggestions regarding the clarity of chapters 5 and 6.
Special thanks to Peta Clarckson, M.D., former Child Fellow, for her interest,
eagerness, and diligence in procuring bibliographic references. Many senior
medical students who elected to rotate at the SMHC also assisted me in ob-
taining bibliographic references. Equally, I express gratitude to Jody Gonzalez,
Ph.D., a faculty member at UTHSCSA, for her contribution with important
bibliographic references.
My deepest appreciation goes to the staf of EvS Communications for the
meticulous job done with the correction of the manuscript and for the enhance-
ment they provided to the readibility of the text.
I am most thankful to David Guadarrama, R.Ph., John Gaston, Chris Rios
and Bryan E. Vacek, Alex Camacho and Ana Pechenik, and Bill Simmons,
pharmaceutical representatives from Lilly, Jenssen, Astro-Zeneca, Bristol-
Myers/Otsuka Pharmaceuticals, and Pizer, respectively. hey provided me
with scientiic information when requested and facilitated contact with the
regional scientiic representatives. I want to express my deepest appreciation
to each one of them.
Last but not least, I am grateful to my wife Rosalba’s unswerving support
for the new book; her support is laudable considering her state of ill health.
In spite of her delicate health and decreasing energies, she has been excited
about this endeavor no matter how much time it has taken away from family
and marital life.
 CHAPTER 1

Overview of Psychotic
Symptoms in Childhood

his chapter will review the following propositions:

• Psychotic symptoms are rather common in clinical practice.

• Psychotic symptoms are common in severe psychiatric disturbances.
• Most of the psychotic features in children and adolescents are associated
with afective disorders.
• he great majority of psychotic symptoms of children and adolescents
respond to appropriate treatment.
• here are a number of barriers that examiners need to overcome to objectify
psychotic disorders.
• Psychotic symptoms in childhood may represent incipient signs of serious
psychiatric disorders or may foreshadow serious future psychopathology.
• Otentimes, psychotic symptoms are not apparent; clinicians need to ex-
plore their presence systematically in all patients.
• Serious psychotic disorders may continue into adulthood.
• Psychotic symptoms are seldom trivial. hey need close monitoring

THE CONCEPT OF PSYCHOSIS

he concept of psychosis has diferent levels of explanation. As a symptom, psy-

chosis has traditionally referred to the presence of hallucinations and delusions;
as a disorder, and applying the DSM-IV-TR (APA, 2000) deinition of mental
disorder, the term psychotic disorder refers to a signiicant clinical behavioral
and psychological pattern or syndrome that occurs in an individual and that
is associated with distress and disability (impairment in one or more impor-
tant areas of functioning, or developmental progression), or with a signiicant
increased risk of death (suicide), sufering pain (due to distressing symptoms),
disability, or an important loss of freedom due to fear or misinterpretation
of reality, secondary to abnormal perception, paranoia, or thought disorder,

1
2 Psychotic Symptoms in Children and Adolescents

among others (DSM-IV-TR, 2000, p. xxxi). he Dorland’s Illustrated Medical

Dictionary (1994) gives a very succinct deinition of illness: “a condition marked
by pronounced deviation from the normal healthy state.” he subheading of
“Mental Illness” refers the reader to the concept of disorder (p. 819), and the
term is deined as a “derangement or abnormality of function; a morbid physi-
cal or mental state” (p. 492). his short deinition of illness agrees with the
explanatory deinition of disorder obtained from the DSM-IV-TR described
above. he concept of psychiatric disorder is customarily used to describe what
is informally designated as mental illness.
Psychotic symptoms may emerge in isolation from other disturbances, be
coterminous with other disturbances (frequently afective disturbances), or
be a substantial component of a major psychotic disorder. Isolated psychotic
symptoms, not associated with other psychiatric symptoms, are of no clinical
concern because they do not interfere with adaptive functioning. Psychotic
symptoms may be secondary to substance abuse or may be associated with other
psychiatric disorders, such as mood disorders, anxiety disorders, and others.
he DSM-IV-TR established that psychotic symptoms represent an element
of severity of the mood or anxiety syndromes, but they become indispensable,
prominent, and incapacitating symptoms in patients with severe primary psy-
chotic disorders (so-called “functional” psychotic disorders).
hought disorder and negative symptoms are also cardinal associated
symptoms of severe psychotic disorders (schizophrenic spectrum disorders).
Bipolar disorder, in its moderate and severe presentations, may be associated
with signiicant psychotic features. At times, it is diicult to diferentiate one
category of disorder from the other. Formerly, there was a rigid separation be-
tween the so-called thought disorders (schizophrenic disorders) and the mood
disorders (unipolar and bipolar disorders), the belief being that certain forms
of thought disorder were exclusive of the schizophrenias. Although, this belief
is now considered inaccurate, the distinction between thought disorders and
mood disorders is still maintained. However, the boundaries of these disorders
are not as distinct and speciic as was previously postulated (see chapter 8).
In recent years, a number of accompanying deicits such as disorganized
behavior, cognitive deicits, and a variety of neuropsychological deicits have
been recognized, and added to the deinition of severe psychotic disorders.
In the study of psychosis in childhood and adolescence, the dimension of
development needs to be considered. A severe psychosis in childhood causes
developmental deviations, impairs the acquisition of adaptive skills, and handi-
caps the child in a multiplicity of adaptive domains: neuromotor, cognitive,
learning, interpersonal, social–adaptive, and subjective functioning.
here is a growing consensus regarding the progression and continuity
of the symptomatology (illness/disorder) from childhood to adulthood for
a number of psychotic disorders. here is also an increasing recognition that
severe, chronic, and progressive psychotic disorders have a neurobiological
 Overview of Psychotic Symptoms in Childhood 3

substrate, and that genetic, neurodevelopmental, neurodegenerative, and neu-

rochemical factors, as well as adverse environmental conditions, contribute to
the expression (onset and maintenance) of the disorder. Most of these issues
will be discussed in chapter 8.

RISKS FACTORS FOR PSYCHOTIC DISORDERS

Multiple risks factors have been considered in the development of psychotic

disorders. hese include: changes in mental status, such as depression or
anxiety; subjective complaints, impaired cognitive, emotional, motor, and
automatic functioning; changes in bodily sensations and in external percep-
tion; low tolerance for normal stress; drug and alcohol usage; neurocognitive
impairment; obstetric complications; and delays in milestones achievement.
Possible trait markers include neurological abnormalities and poor premor-
bid adjustment (Phillips et al., 2002, p. 261). Patients at risk for psychotic
disorders have some positive neurological indings; however, the nature of the
neurological abnormalities is unclear. Curiously, patients with larger (though
still within the normal range) let hippocampal volumes at intake were more
likely to develop a psychotic episode in the subsequent 12-month period.
Furthermore, comparison of the MRIs of patients who underwent a psychotic
episode with MRIs at intake revealed neurological structural changes in the
let insula cortex and in the let posteriomedial temporal structures, including
the hippocampus and posterior hippocampus gyrus during the transition to
psychosis (Phillips et al., 2002).

PREVALENCE OF PSYCHOTIC SYMPTOMS

Psychotic symptoms are not uncommon experiences in the lives of children;

they are not uncommon indings in clinical practice, either. Psychotic features
occur more frequently in children than originally thought. Severe psychotic
disorders are uncommon in childhood. his proposition is supported by Reim-
herr and McClellan (2004), who asserted that “Although, psychotic illnesses
are relatively rare in youths, especially younger children, these disorders are
not uncommon in clinical settings and must be considered in the evaluation
of every individual patient” (p. 10). Although psychotic symptoms are rather
common in clinical practice, this is not so in regard to the frequency or preva-
lence of psychotic disorders.
In clinical populations, the prevalence of psychotic symptoms in children
and adolescents has been reported as 4 and 8%, respectively. Psychosis becomes
more prevalent with increasing age (Birmaher, 2003, p. 257).
In community samples, prevalence of psychosis (psychotic symptoms) in
4 Psychotic Symptoms in Children and Adolescents

children and adolescents has been estimated to be about 1%. Auditory hallucina-
tions (about 8%) are the most frequent psychotic symptoms. Delusional beliefs
in children are less complex than those in adolescents, and their frequency is
estimated at about 4% (Ulloa et al., 2000).
In epidemiological studies in adults, 3 to 5% of the subjects report psychotic
symptoms before age 21. In a cohort of 2,031 children aged 5 to 21, evaluated
at a mood and anxiety disorder clinic, 4.5% of the evaluated children had a
deinite psychosis (deined as having the presence of a deinite hallucination
and a deinite delusion), and 4.7% had probable psychosis (deined as having
the presence of a suspected or likely hallucination, or a suspected or likely
delusion). For patients with deinite psychotic symptoms, 41% had a major
depressive disorder; 24% were diagnosed with bipolar disorder; and 21% were
diagnosed as depressive disorder not fulilling criteria for major depressive
disorder. In 14% of the cases, patients received a schizophreniform spectrum
disorder diagnosis: four patients had schizophrenia, and nine patients had
schizoafective disorder. Patients with anxiety and disruptive disorders who
presented with deinite psychotic symptoms always had a comorbid mood
disorder (Ulloa et al., 2000, p. 339).
Mood disorders were the most frequent conditions associated with psy-
chosis. hese observations are in line with prevalence community studies in
general populations; for instance, in a representative sample of 7,076 subjects
(aged 18 to 64 years), psychoticlike symptoms were strongly associated with
psychotic disorders (van Os, Hanssen, Bijl, & Volleberg, 2001, p. 667).
Among the psychotic symptoms, hallucinations were the most prevalent
symptoms in 80% of patients (73.6% endorsed auditory command hallucina-
tions), followed by delusions (22%) and thought disorder (3.3%). hought
disorder was only present (or perhaps only recognized) in adolescents. Hallu-
cinations perceived as coming from outside of the head were more common in
adolescents than in children. he frequency of other perceptual disturbances in
psychotic children was as follows: 38.5% visual hallucinations, 26.2% olfactory
hallucinations, and 9.9% tactile hallucinations. Delusions of reference were the
most common type of delusions: delusions that people “could read my mind,”
“could know my own thoughts,” or that other people “could hear my thoughts”
were less common (Van Os et al., 2001). Usually, these delusional symptoms
are rare and only present in severe psychotic disorders, and when present, they
are more common in middle to late adolescence and beyond.

REASONS PSYCHOSIS IS UNDERDIAGNOSED IN CHILDREN

AND ADOLESCENTS

Clinicians have hesitated to explore perceptual abnormalities or delusional

thinking in childhood. Some clinicians feel mystiied when they explore
 Overview of Psychotic Symptoms in Childhood 5

psychosis in children. his contributes to the high rate of misdiagnosis and

underdiagnosis of psychotic disorders in childhood.
Problems with misdiagnosis probably relect clinicians’ reluctance to con-
sider this diagnosis, a lack of familiarity with clinical presentations of psychosis
in childhood, or idiosyncratic practices; it is also true that many cases are dif-
icult to characterize until enough time has passed for the disturbing process
to provide a clear pattern of the unfolding illness. he use of standardized
diagnostic practices, adherence to diagnostic criteria, and systematic symptom
exploration improve accuracy.
Children typically do not share their disordered perceptual experiences or
delusional beliefs with parents or other trusted adults. For children, psychotic
features belong to the realm of private or secret experiences that are seldom
divulged to signiicant others. Frequently, parents only become aware of the
presence of psychotic symptoms when the child starts displaying abnormal
behaviors.
Older children and adolescents who develop a psychotic illness oten have
some recognition that something is wrong with their thinking, perception, or
behavior; they feel frightened due to a feeling of confusion in their sense of
reality. Perceptual disturbances and paranoid feelings further limit a patient’s
willingness to discuss symptoms with caretakers or providers because the in-
dividual has a penumbra of awareness of his or her abnormal experiences.
Some parents normalize psychotic experiences or expect that “children will
grow out” of them. his idea may be reinforced by professionals; sometimes
pediatricians and even mental health professionals support these naïve expec-
tations and give parents false reassurances. Parents are oten told that these
unusual experiences are trivial and temporary. Sadly, this contributes to delays
in identiication and treatment of early presentations of psychotic symptoms.
Even psychiatrists may miss the symptoms underlying psychosis as they focus
on presenting behavioral manifestations such as aggression or suicide (Semper
& McClellan, 2003, p. 682).
As an example of how parents are misguided or falsely reassured, Schaf-
fer and Ross (2002) describe initial experiences of parents of schizophrenic
children with professionals:

Once the psychotic symptoms began, the common predominant theme was frus-
tration with the lack of a clear and inite diagnosis at an earlier stage of develop-
ment. Consistently, they reported telling pediatricians and school psychologists
that something was “seriously wrong.” Of those [parents] who recognized psychotic
symptoms early, three (out of 17) were explicitly told by a medical professional
that “schizophrenia does not exist in children.” Eight families (out of 17) specii-
cally stated that they questioned schizophrenia as a possible cause of the child’s
symptoms but were told by more than one mental health or medical professional
that psychotic symptoms in childhood are not necessarily schizophrenia, and, since
the diagnosis could not be made, antipsychotic medications were not indicated.
6 Psychotic Symptoms in Children and Adolescents

One mother quoted a psychologist as having told her: “Let’s make friends with the
voices.” his confusion over the meaning of psychotic symptoms was associated
with a mean two-year delay in diagnosis, and the trial and failure of alternative
treatment plans. Speciically, many trials of mood stabilizers occurred during
this period, as did trials of alternative treatments. In all cases, once the diagnosis
of schizophrenia was determined and antipsychotic medications were used, a
signiicant change was seen in baseline symptoms. (p. 543)

Psychotic symptoms are baling for children and parents. Children with
psychotic symptoms experience a lack of understanding and support from
signiicant others when they reveal disturbing perceptions or beliefs; as a conse-
quence, they learn to keep abnormal experiences to themselves, increasing, then,
their fear and sense of alienation. It is not uncommon to hear from disturbed
children that they have sufered from psychotic experiences for a long time, even
years, or that the psychotic experiences began in early childhood. It is when the
child no longer feels able to control the psychotic inluence that the psychosis
becomes manifested in unmistakably abnormal or bizarre behaviors.
Some parents become defensive when they become aware that their
children are experiencing psychotic symptoms. Others attribute an ominous
connotation to psychotic symptoms, not knowing that most of the psychotic
symptoms are amenable to appropriate interventions.
Psychotic symptoms in their ofspring oten confront parents with their
own disturbed sense of reality. Not infrequently, psychotic symptoms in children
trigger in the parents painful memories of their own developmental experi-
ences: these symptoms remind parents of their own unusual experiences, of
psychotic parents or relatives, or of other disturbing events in their past. It is not
unusual, when a child endorses psychotic features, that other family members
may endorse psychotic symptoms as well.
Psychotic symptoms should be taken seriously and clinicians need to alert
parents to take appropriate steps to prevent the disturbed child from acting
out his or her psychotic beliefs. When dealing with psychotic symptoms, the
irst priority for parents should be to guarantee the safety of the child and that
of siblings and caretakers. his is particularly true when the child experiences
auditory command hallucinations telling the child to either kill others or to
kill himself. A child misguided by distorted beliefs may also pose a serious risk
to others when he believes that he needs to defend himself against a falsely
perceived persecutor or external danger.
Psychotic symptoms do not occur in isolation; therefore, psychotic symp-
toms in the context of an otherwise normal mental status examination warrant
skepticism (Reimherr & McClelland, 2004, p. 6). Relevant psychotic symptoms
impair the child’s adaptive capacity in a variety of areas.
 Overview of Psychotic Symptoms in Childhood 7

TABLE 1.1 Risk factors of psychotic disorders

• Homicidal behavior
• Suicidal behavior
• Terroristic behavior
• Impulsive/self-defeating behaviors
• Alcohol and drug abuse
• Gang participation/antisocial behavior
• Unwanted pregnancies/STDs
• Poor compliance and relapse risk
• School diiculties
• Social and vocational problems
• Self-neglect
• Victimization

RISKS ASSOCIATED WITH PSYCHOTIC SYMPTOMS

Psychotic patients, especially those who are paranoid, have an increased po-
tential for violent and homicidal behaviors. hese risks need to be explored
and monitored systematically.

Homicidal Behavior

he risk is higher if the patient has history of aggressive/violent behaviors, or

if he or she has already planned or has taken steps to do personal harm. he
Tarasof decision places a burden of disclosure and creates conidentiality chal-
lenges for clinicians and physicians; the speciic rules of disclosure vary from
state to state. he physician needs to be familiar with the obligations to warn
potential victims in the state where he or she practices.
Here is an example of a psychotic adolescent with strong homicidal feelings:

Crissy, a 15-year-old white teenager, was evaluated because she threatened to hurt
herself and the family. She had never received a psychiatric evaluation before, in
spite of extensive behavioral diiculties and ongoing psychological distress.
he patient reported feeling suicidal for at least a couple of years and en-
dorsed a history of multiple suicidal attempts. She disclosed strong and enduring
homicidal thoughts against her stepfather. She had been close to stabbing him
with a butcher knife and harbored the plan of “cutting his balls during his sleep.”
She said she would put the “balls” in his mouth for him to choke. She claimed that
he had sexually abused her for a number of years, subjecting her to a variety of
sexual acts except vaginal intercourse. Crissy stated that she had told her mother
about this but her mother had not done anything about it. She reported that she
was aware that her stepfather was abusive to her mother, and that the family had
been in a shelter for battered women the year before.