Paeds · mental-behavioural-and-psychosomatic
Early-onset psychosis and mania
Also known as Childhood-onset schizophrenia and paediatric bipolar disorder · First-episode psychosis in young people · Early-onset mania and bipolar I disorder in youth · Clinical high risk and attenuated psychosis syndrome · Psychotic and manic presentations in adolescents
A fellowship approach to the child or adolescent presenting with psychotic or manic symptoms: recognising the gate, telling psychosis from mania and from mimics, excluding organic disease, screening suicide risk, and delivering evidence-based pharmacotherapy — risperidone and aripiprazole for early-onset schizophrenia, second-generation antipsychotics for paediatric mania — with active metabolic monitoring and early specialist referral, across ANZ, UK, US and Canada.
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Target exams
Red flags
- Active suicidal ideation with plan, intent or access to means, or recent attempt — exit the routine pathway the same day
- Acute behavioural disturbance with agitation, aggression or risk to self or others — needs a safety pathway and de-escalation
- Organic red flags: acute onset, fluctuating consciousness, fever, headache, focal neurology, seizures — exclude encephalitis, autoimmune disease, tumour or infection before any psychiatric label
- Catatonia, negativism, mutism, posturing or refusal of food and drink — a medical and psychiatric emergency
- Substance-induced psychosis that fails to resolve after a period of abstinence — reassess for a primary psychotic disorder
- Rapid mood cycling, severe insomnia with boundless energy, or command hallucinations — high suicide and misdiagnosis risk
Life stages
Care settings
Clinical exam formats
Board mappings
- General and Community Paediatrics
- Behavioural and developmental paediatrics — recognising serious mental illness and referring early
- Learning Goal 11 — Behaviour, development and mental health: recognise psychosis and mania and coordinate care
- Learning Goal 19 — Adolescent and young adult medicine: assess acute mental-state change and risk
- Renewed curriculum — Learning goal 7: serious behavioural and mental-health presentations including psychosis
- Behavioural Paediatrics and Mental Health
- Growth, Development and Behaviour
- Written Exam: differential of the psychotic or manic adolescent, organic exclusion and first-line pharmacotherapy
- Long Cases — early-onset psychosis or bipolar disorder with school decline and family conflict
- Short Cases — distinguishing primary psychosis from substance-induced and organic mimics
- Communication stations — explaining a serious mental-health diagnosis, treatment and monitoring to a young person and family
- Level 2 — Behavioural, emotional and mental health: recognises psychosis and mania and refers urgently
- Level 3 — Adolescent health: coordinates care of first-episode psychosis with specialist services
- General Paediatrics: excludes organic disease and screens suicide risk before a psychiatric label
- Foundation of Practice (FOP) — early-onset psychosis and mania, red flags and mimics
- Applied Knowledge in Practice (AKP) — diagnosis and pharmacotherapy of paediatric psychosis and bipolar disorder
- TAS — dopamine model, duration of untreated psychosis and adolescent mental health
- History and Communication — mental-state examination, collateral history and risk assessment
- Communication — counselling on antipsychotic treatment and metabolic monitoring
- Clinical — long case on the adolescent with new psychotic symptoms and declining function
- General Pediatrics Content Outline — Domain 5: Mental and Behavioral Health — psychosis and bipolar disorder
- General Pediatrics Content Outline — Domain 3: Adolescent Care — acute mental-state change
- General Pediatrics EPA 3: Recognising serious mental illness and coordinating specialist care
- Patient Care 1: acute mental-state assessment including suicide and organic-exclusion screens
- Medical Knowledge 2: pharmacotherapy of early-onset psychosis and paediatric mania
- Systems-Based Practice 4: coordination with child and adolescent mental-health services and school
- Medical Expert — early-onset psychosis and mania; organic exclusion and first-line treatment
- Development, Behaviour and Mental Health (10–15%) — psychotic and bipolar presentations
- Pediatrics: Foundations EPA — adolescent care including acute mental-health assessment
- Collaborator — linking young people to early-intervention psychosis services
Overview & Definition
A 15-year-old boy is brought to the emergency department after telling his mother that classmates have implanted a chip in his head. He has not slept for four nights. His mother thinks it is "just cannabis and stress." On examination he is terrified, guarded, and hears a voice telling him to run. The chip is not the diagnosis. The story is a gate — and whether anyone walks him through it correctly will shape the next decade of his life. [5] [2]
Early-onset psychosis describes a psychotic illness beginning before 18 years — a loss of reality testing shown by delusions, hallucinations and disorganised thinking. Early-onset mania describes a distinct episodic state of elevated or irritable mood with increased energy, racing thoughts and decreased sleep, the hallmark of paediatric bipolar I disorder. Both are rare compared with adult-onset illness, but both are serious, treatable, and easy to miss. [2]
The fellowship-level point is load-bearing: these are clinical problems, never character flaws or parenting failures. A young person in psychosis or mania is unwell, at risk, and needs the same systematic approach as any acutely deteriorating patient — assess, exclude dangerous mimics, and treat early. Waiting, blaming, or reassuring without an assessment wastes the window when treatment works best. [4] [3]
Core sequence for the psychotic or manic young person
- 1
Assess
Mental-state examination, mood, psychosis, substance use, trauma, family history; collateral from family and school.
- 2
Exclude danger
Suicide risk with plan, intent, means; organic disease — infection, encephalitis, autoimmune, thyroid, tox screen, neuroimaging if indicated.
- 3
Distinguish
Place on three axes: psychosis spectrum, bipolar spectrum, mimic — and grade severity.
- 4
Refer early
Urgent specialist child and adolescent mental-health referral; early-intervention psychosis pathway where available.
- 5
Treat
Antipsychotic for psychosis; second-generation antipsychotic ± mood stabiliser for mania; psychoeducation and family involvement.
- 6
Monitor
Metabolic monitoring at baseline, 4–6 weeks, 12 weeks, then 6-monthly; suicide-risk review at every contact.
References12ShowHide
- [1]Sikich L, Frazier JA, McClellan J, et al. Double-blind comparison of first- and second-generation antipsychotics in early-onset schizophrenia and schizo-affective disorder: findings from the Treatment of Early-Onset Schizophrenia Spectrum Disorders (TEOSS) study. American Journal of Psychiatry, 2008.PMID 18794207
- [2]McClellan J, Stock S Practice parameter for the assessment and treatment of children and adolescents with schizophrenia. Journal of the American Academy of Child and Adolescent Psychiatry, 2013.PMID 23972700
- [3]Cannon TD, Cadenhead K, Cornblatt B, Woods SW, Addington J, Walker E, Seidman LJ, Perkins D, Tsuang M, McGlashan T, Heinssen R Prediction of psychosis in youth at high clinical risk: a multisite longitudinal study in North America. Archives of General Psychiatry, 2008.PMID 18180426
- [4]Penttilä M, Jääskeläinen E, Hirvonen N, Isohanni M, Miettunen J Duration of untreated psychosis as predictor of long-term outcome in schizophrenia: systematic review and meta-analysis. British Journal of Psychiatry, 2014.PMID 25252316
- [5]Moore TH, Zammit S, Lingford-Hughes A, Barnes TR, Jones PB, Burke M, Lewis G Cannabis use and risk of psychotic or affective mental health outcomes: a systematic review. Lancet, 2007.PMID 17662880
- [6]Arseneault L, Cannon M, Poulton R, Murray R, Caspi A, Moffitt TE Cannabis use in adolescence and risk for adult psychosis: longitudinal prospective study. BMJ, 2002.PMID 12446537
- [7]Delbello MP, Kowatch RA, Adler CM, Stanford KE, Welge JA, Barzman DH, Nelson E, Strakowski SM A double-blind randomized pilot study comparing quetiapine and divalproex for adolescent mania. Journal of the American Academy of Child and Adolescent Psychiatry, 2006.PMID 16540815
- [8]Wagner KD, Kowatch RA, Emslie GJ, et al. A double-blind, randomized, placebo-controlled trial of oxcarbazepine in the treatment of bipolar disorder in children and adolescents. American Journal of Psychiatry, 2006.PMID 16816222
- [9]Tohen M, Kryzhanovskaya L, Carlson G, et al. Olanzapine versus placebo in the treatment of adolescents with bipolar mania. American Journal of Psychiatry, 2007.PMID 17898346
- [10]Haas M, Delbello MP, Pandina G, Kushner S, Van Hove I, Augustyns I, Quiroz J, Kusumakar V Risperidone for the treatment of acute mania in children and adolescents with bipolar disorder: a randomized, double-blind, placebo-controlled study. Bipolar Disorders, 2009.PMID 19839994
- [11]Geller B, Luby JL, Joshi P, et al. A randomized controlled trial of risperidone, lithium, or divalproex sodium for initial treatment of bipolar I disorder, manic or mixed phase, in children and adolescents. Archives of General Psychiatry, 2012.PMID 22213771
- [12]Findling RL, Correll CU, Nyilas M, Forbes RA, McQuade RD, Jin N, Ivanova S, Mankoski R, Carlson GA Aripiprazole for the treatment of pediatric bipolar I disorder: a 30-week, randomized, placebo-controlled study. Bipolar Disorders, 2013.PMID 23437959