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Psychosis and schizophrenia: recognition and management of psychosis and schizophrenia in children and young people

National Institute for Health and Care Excellence

Key priorities for implementation

  • The following recommendations have been identified as priorities for implementation

Referral from primary care for possible psychosis

  • When a child or young person experiences transient or attenuated psychotic symptoms or other experiences suggestive of possible psychosis, refer for assessment without delay to a specialist mental health service such as CAMHS or an early intervention in psychosis service (14 years or over)
  • Treatment options for symptoms not sufficient for a diagnosis of psychosis or schizophrenia
  • When transient or attenuated psychotic symptoms or other mental state changes associated with distress, impairment or help-seeking behaviour are not sufficient for a diagnosis of psychosis or schizophrenia:
    • consider individual cognitive behavioural therapy (CBT) with or without family intervention, and
    • offer treatments recommended in NICE guidance for children and young people with any of the anxiety disorders, depression, emerging personality disorder or substance misuse
  • Do not offer antipsychotic medication:
    • for psychotic symptoms or mental state changes that are not sufficient for a diagnosis of psychosis or schizophrenia, or
    • with the aim of decreasing the risk of psychosis

Referral from primary care for first episode psychosis

  • Urgently refer all children and young people with a first presentation of sustained psychotic symptoms (lasting 4 weeks or more) to a specialist mental health service, either CAMHS (up to 17 years) or an early intervention in psychosis service (14 years or over), which includes a consultant psychiatrist with training in child and adolescent mental health

Treatment options for first episode psychosis

  • If the child or young person and their parents or carers wish to try psychological interventions (family intervention with individual CBT) alone without antipsychotic medication, advise that psychological interventions are more effective when delivered in conjunction with antipsychotic medication. If the child or young person and their parents or carers still wish to try psychological interventions alone, then offer family intervention with individual CBT. Agree a time limit (1 month or less) for reviewing treatment options, including introducing antipsychotic medication. Continue to monitor symptoms, level of distress, impairment and level of functioning, including educational engagement and achievement, regularly

How to use oral antipsychotic medication

  • Before starting antipsychotic medication, undertake and record the following baseline investigations:
    • weight and height (both plotted on a growth chart)
    • waist and hip circumference
    • pulse and blood pressure
    • fasting blood glucose, glycosylated haemoglobin (HbA1c), blood lipid profile and
    • prolactin levels
    • assessment of any movement disorders
    • assessment of nutritional status, diet and level of physical activity
  • Monitor and record the following regularly and systematically throughout treatment, but especially during titration:
    • efficacy, including changes in symptoms and behaviour
    • side effects of treatment, taking into account overlap between certain side effects and clinical features of schizophrenia (for example, the overlap between akathisia and agitation or anxiety)
    • the emergence of movement disorders
    • weight, weekly for the first 6 weeks, then at 12 weeks and then every 6 months (plotted on a growth chart)
    • height every 6 months (plotted on a growth chart)
    • waist and hip circumference every 6 months (plotted on a percentile chart)
    • pulse and blood pressure (plotted on a percentile chart) at 12 weeks and then every 6 months
    • fasting blood glucose, HbA1c, blood lipid and prolactin levels at 12 weeks and then every 6 months
    • adherence
    • physical health
  • The secondary care team should maintain responsibility for monitoring physical health and the effects of antipsychotic medication in children and young people for at least the first 12 months or until their condition has stabilised. Thereafter, the responsibility for this monitoring may be transferred to primary care under shared care arrangements

Treatment of subsequent acute episodes of psychosis or schizophrenia

  • Offer family intervention to all families of children and young people with psychosis or schizophrenia, particularly for preventing and reducing relapse. This can be started either during the acute phase or later, including in inpatient settings
  • Before referral for hospital care, think about the impact on the child or young person and their parents, carers and other family members, especially when the inpatient unit is a long way from where they live. Consider alternative care within the community wherever possible. If hospital admission is unavoidable, provide support for parents or carers when the child or young person is admitted

Education, employment and occupational activities for children and young people with psychosis and schizophrenia

  • For children and young people of compulsory school age, liaise with the child or young person’s school and educational authority, subject to consent, to ensure that ongoing education is provided

full guideline available from…
National Institute for Health and Care Excellence, Level 1A, City Tower, Piccadilly Plaza, Manchester, M1 4BT
guidance.nice.org.uk/CG155

National Institute for Health and Care Excellence. Psychosis and schizophrenia in children and young people: recognition and management. January 2013

First included: Feb 13.

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