Acute medical workup for new-onset psychosis in children and adolescents: A retrospective cohort

No consensus exists about which medical testing is indicated for youth with new-onset psychotic symptoms. We conducted a chart review of youths aged 7-21 years who were medically hospitalized for workup of new-onset psychotic symptoms from January 2017 through September 2020 in a free-standing children's hospital. The sample included 131 patients. At discharge, 129 (98.5%; 95% confidence interval [CI]: 94.5-99.8) were diagnosed with a primary psychiatric condition, 1 was diagnosed with levetiracetam-induced psychosis, and 1 with seronegative autoimmune encephalitis. Notably, 33 (25.2%; 95% CI: 18.0-33.5) had incidental findings unrelated to psychosis, 14 (10.7%; 95% CI: 6.0-17.3) had findings that required medical intervention but did not explain the psychosis, 12 (9.2%; 95% CI: 4.8-15.5) had a positive urine drug screen, and 4 (3.1%; 95% CI: 0.8-7.6) had a neurological exam consistent with conversion disorder. In conclusion, extensive medical testing in the acute setting for psychosis had a low yield for identifying medical etiologies of new-onset psychotic symptoms.

Of Triggers, Tigers, and Tactics: Managing Emotional Dysregulation

The frustration of defining, understanding, and addressing irritability in child psychiatry and the difficulties that children with emotion dysregulation face on a daily basis can be seen as parallel processes. We know that irritability is one of the most common reasons for which children are referred for evaluation.¹ We also know that the stakes are extremely high, with persistent irritability associated with suicidality.² Despite this, we do not have a readily available nosological paradigm. Our current clinical approach remains muddled by outbursts' transdiagnostic nature. We find ourselves listing things such as posttraumatic stress disorder, disruptive mood dysregulation disorder, attention-deficit/hyperactivity disorder, anxiety, and depressive disorders in the chart, but feeling that we have not fully captured the unique neurobiological and subjective essence of a child's irritability syndrome.³ Furthermore, despite extensive research, we lack accessible diagnostic tools or effective treatment protocols to implement on a community-wide basis. So, we (JC, CU) think we have every right to be irritable as we experience frustrative non-reward (thinking and focusing on this issue with blocked goal attainment) and face existential threat (desperately wanting children and families to enjoy better developmental trajectories, and wanting it now!).⁴.

Dysregulation and Suicide in Children and Adolescents

Suicide rates continue to rise among children and adolescents; suicide is the second leading cause of death in the United States. Although research studies have identified factors associated with suicide risks for youths, none distinguishes those who have suicidal ideation from those who most likely will make an attempt or die by suicide. Most studies focus on psychiatric diagnoses associated with suicide risks. Recent studies suggest that cross-cutting symptom profiles may be a stronger predictor of risks for suicide than diagnosis. This article provides an overview of emotional dysregulation as it relates to suicidal ideation, intent, and behaviors for youth.

The Affective Reactivity Index: a concise irritability scale for clinical and research settings

BACKGROUND

Irritable mood has recently become a matter of intense scientific interest. Here, we present data from two samples, one from the United States and the other from the United Kingdom, demonstrating the clinical and research utility of the parent- and self-report forms of the Affective Reactivity Index (ARI), a concise dimensional measure of irritability.

METHODS

The US sample (n = 218) consisted of children and adolescents recruited at the National Institute of Mental Health meeting criteria for bipolar disorder (BD, n = 39), severe mood dysregulation (SMD, n = 67), children at family risk for BD (n = 35), or were healthy volunteers (n = 77). The UK sample (n = 88) was comprised of children from a generic mental health setting and healthy volunteers from primary and secondary schools.

RESULTS

Parent- and self-report scales of the ARI showed excellent internal consistencies and formed a single factor in the two samples. In the US sample, the ARI showed a gradation with irritability significantly increasing from healthy volunteers through to SMD. Irritability was significantly higher in SMD than in BD by parent-report, but this did not reach significance by self-report. In the UK sample, parent-rated irritability was differentially related to emotional problems.

CONCLUSIONS

Irritability can be measured using a concise instrument both in a highly specialized US, as well as a general UK child mental health setting.