Our last newsletter introduced the issue of recognizing and responding to psychotic symptomatology in primary care pediatrics and noted the potential pivotal role that early recognition plays in offering opportunity to refer for treatment, in both the short term and with an eye to the potential lifelong consequences for afflicted individuals. Today’s focus will provide some guidance on how a pediatric practitioner can screen for, interview and to identify a youngster at high risk for developing or already exhibiting signs of a schizophrenic (or other psychotic) disorder and then make appropriate referrals to obtain specialty care.
For most folks the words psychotic and or schizophrenic bring to mind the idea of a floridly disruptive, agitated, and disorganized individual who is experiencing persistent auditory hallucinations, bizarre thinking, delusional belief system(s), and a break down in their capacity to interact appropriately with others—all core features of a schizophrenic illness. The more typical course of an evolving schizophrenic disorder, however, is more subtle with gradual onset of the prodromal symptoms of social withdrawal, subtle cognitive declines (decreased concentration, disorganized thinking), and social and functional impairments including irritability, suspiciousness, a decline in functioning.
With recognition of these early signs and symptoms, a primary care provider can contribute to the more formal multidisciplinary diagnostic phase of intervention in three important ways, by.
- Considering the differential diagnoses that may be underlying the youth’s clinical presentation: Is this schizophrenia, or is it a substance-induced psychosis, a psychosis associated with severe depression or mania, an atypical presentation of another psychiatric condition (such as severe PTSD), or a symptom of an identifiable organic (metabolic or neurologic) disorder?
- Conducting a comprehensive physical exam and obtaining relevant laboratory studies, to include CBC, CMP, TSH, electrolytes, ceruloplasmin, ANA, ESR, VDRL, HIV, B12, folate, U/A and urine toxicology—these to rule out organic etiologies and to establish baseline levels to allow for prompt medication treatment when indicated.
- Encouraging the patient and family to seek evaluation and services from child/adolescent psychiatrist or a multidisciplinary behavioral program.
Interviewing the Patient: Interviewing an individual with suspected psychotic features can at times be challenging, but when feasible, doing so can aid in clarifying a diagnosis and is important in ruling out acute risk considerations and interventions. Minimally, it is important to explore whether the individual is a potential danger to themselves or others and inquiry as to whether they are having thoughts of hurting themselves or others and/or if they are hearing auditory hallucinations of a derogatory nature or which entail commands to act in a dangerous manner. Likewise, a history of significant impulsivity or agitation should be noted. If present, further risk assessment is warranted and may entail referral to an urgent care or other emergency service.
As with any patient experiencing distress or dysfunction, an empathic approach that acknowledges the youth’s distress and communicates your interest in learning more about their condition is most helpful. Learning about the time of onset of symptoms, their impact, and how the patient is coping are good initial steps. Inquiry as to issues of trauma, abuse, bullying and substance abuse should be made. Exploring for and learning about the presence or absence of overt symptoms of psychosis, such as hallucinations and delusional thinking, can feel awkward but prefacing the content inquiry with a statement to the effect that “Sometimes when people are having difficulties, they may hear or see things differently than usual. So, I am wondering if you have experienced times when you hear voices or find yourself thinking about things in an unusual way?”
Involving the Family: Engaging the family is also critical as they can provide important information as to the youth’s developmental history and baseline profile prior to symptom onset; the timeline of symptom progression and impact on functioning; the family history of mental health and substance use problems; and, the presence or absence of major life stressors.
- If, as discussed above, high risk features are clearly present a referral to a psychiatric emergency setting will be appropriate. If these concerns are less overt, a referral to the Rady’s Behavioral Urgent Care clinic might be considered—a call to the program to discuss the referral concerns would be advisable. (858) 966-5484
- If there are no imminent risk issues, referral to a child psychiatrist, another qualified behavioral health specialist who works collaboratively with a psychiatrist, or a multidisciplinary clinic program would be appropriate
- SmartCare can be a resource to assist parents in making the recommended connection to care. The SmartCare Family Support line is (858) 956-5900.
- Long term treatment resources
- Who they work with: insured and uninsured adolescents and young adults ages 10 to 25
- What they do: 12 to 18 months of interdisciplinary treatment involving multiple therapy modalities, including psychotherapy, group therapy, occupational therapy, education and employment support, peer support, and much more
- When to refer: if there is possible risk of first episode psychosis or psychotic-like symptoms present in your patient, you can refer them to Kickstart for an initial consultation and evaluation. They will determine if your patient is eligible for their services, as well as conduct assessments for psychosis risk. Their focus is on early intervention and prevention of psychosis, so early referral to this program is paramount for a patient to utilize their resources
- How to refer: there is a referral form on the Kickstart website that can be completed by the clinician, patient, and parent, and submitted to Kickstart in-person or via mail or fax. Phone (619) 481-3790 858 966-5484
- 2. CARE Program
- Who they work with: insured adolescents and young adults experiencing psychotic-like symptoms or first episode psychosis
- What they do: clinical services include collaborative care with patients and their families to create a unique treatment plan that best addresses patient needs. This could include medication management, psychotherapy, group therapy, intensive outpatient care, peer support, and inpatient care. Patients ages 12 to 35 can also enroll in research studies conducted at CARE.
- When to refer: if your patient is insured and presents with first episode psychosis or psychosis-related symptoms, they can be referred to CARE for further evaluation and assessment. They will collaborate to determine the level of care necessary and create a treatment plan to address the patient’s needs.
- How to refer: contact CARE as (619) 543-7745 or email: firstname.lastname@example.org
CARE Program | UC San Diego Department of Psychiatry. (n.d.). UC San Diego School of Medicine. Retrieved December 5, 2021, from https://medschool.ucsd.edu:443/som/psychiatry/research/CARE/pages/default.aspx
Hua, L. L. (2021). Collaborative Care in the Identification and Management of Psychosis in Adolescents and Young Adults. Pediatrics, 147(6). https://doi.org/10.1542/peds.2021-051486
Kickstart San Diego | Mental Health Prevention and Early Intervention. (n.d.). Kickstart San Diego. Retrieved December 5, 2021, from https://www.kickstartsd.org
Thanks to Sheridan Chappelle of the UC San Diego School of Medicine, Class of 2024 under the guidance and supervision of Desiree Shapiro, M.D., Associate Clinical Professor of Psychiatry University of California, San Diego Department of Psychiatry – Division of Child and Adolescent Psychiatry, Medical Director, UC San Diego Child and Adolescent Psychiatry Inclusive Excellence Program