Kids with Psychosis and Hallucinations

Why do the kids see things?

When a child has a break from reality it can stem from multiple reasons: abuse, trauma, genetic, inorganic, intellectual disability, medical conditions…etc. but they all have one thing in common, there’s a source. Typically, psych treatment targets aggressive symptoms, and sometimes they may resolve if you treat the underline issues or scenarios that were just mentioned.

However, when a child is experiencing hallucinations and it’s no clear reason it’s like you’re going into uncharted waters. Schizophrenia rarely presents before the age of 15 and I’m going to assume a young child isn’t doing hardcore drugs or anything extreme but something isn’t right. Instead of sleeping at night or engaging, the child just flat out says, “I see demons”. For the sake of simplicity, I’m talking about children before puberty. After puberty, treatment is similar to adults.

The kid isn’t on medications, it’s the first time the parent heard this information, and according to all my references, this overall doesn’t happen. Maybe it’s a joke, the kid wants some attention, or the videogames are too explicit, but these thoughts and poor behavior have been persistent and getting worse.

How to Talk with Family?

As usual, assess for trauma or abuse any time there’s a change in behavior and at every visit. Plus, dealing with kids, you have to think differently. Bizarre behaviors and actions may also put a child at risk of being harmed despite nothing occurring prior. I’m saying this because if I put a 6y/o on antipsychotics, yes it’s for the psych symptoms but also because the parenting may get more extreme trying to deal with the kid.

Parents may think to put the kid in a closet or become emotionally abusive and threatening to get the child to act “normal”. Of course, suspected abuse must be reported but I educate about avoiding these questionable methods by telling the parents to NOT negatively react to a child being “weird” or “bizarre”. Educate about the necessity of letting the medication work because >90% of my kids who did have audible/visual hallucinations eventually stopped. Thus, it’s always a chance you’ll get a child that falls in the 10% or just keep having the hallucinations.

I let parents know what’s common and the likely prognosis so they won’t feel more distress or anger. For example, I would say many kids have huge imaginations but I agree anything scary can make the behaviors more difficult…let’s treat now before things continue to get worse, and hopefully, the child will grow out of it like the boogeyman or other common imaginations. Quick side note; be careful not to say Santa Claus is fake or other things that the child may think are still real to not cause more distress.  

Commend the family for getting help and I let them know, that medications don’t have to be forever but until the child can better control their mood and emotions, treatment can lessen these behaviors. Remember, we don’t have a clear psychosis or schizophrenia dx so target mood/emotions/behaviors i.e. anxiety, depression, ODD. Therefore, the treatment plan has to also somewhat include how to address these possible hallucinations or bizarre behaviors. The way you use language is key to getting the parents on board and on the same page.

What is the Treatment Plan?

Even though I don’t have a diagnosis for the hallucinations, they have to be prioritized. Psychosis is considered a complication of hallucinations and delusions, in which the patient will have to be hospitalized. Again, another discussion point with families as to why we have to use medications and can’t wait for a kid to just “grow out of it”… We don’t want a hospitalization if we can avoid it but we only have 20 minutes to figure everything out. Here are my go-to steps that usually help:

  1. Get a Genetic Test: nothing is worse than putting a child on medications that they’re not metabolizing or having major side effects from… I recently had a kid that only responded to ziprasidone, and is honestly doing better than ever. This was after many failures with previous prescribers so think about it medical people, if a child is having hallucinations the person is already in a rare category, which means that their genetics will more than likely also be complex. Don’t fight against genetic testing.
  2. Start Small with Standards: risperidone and aripiprazole are F.D.A. approved for children and target poor behaviors and they’re available in small doses. If they didn’t resolve the behaviors at that dose, trial higher dosages because at least you know the medication was tolerated before (if there was no adverse reaction).
  3. Target Sleep: we don’t want kids battling demons at night or at any time.  I discussed the importance of sleep and treatment. If my patient is having sleep issues and hearing voices, low-dose olanzapine is usually my go-to…If the child is on it for a few months (as in the psych symptoms are actually subsiding), I express to the parent about getting labs but I usually go over maintenance and side effects before prescribing or the parent feels like discontinuing the medication if the voices have stopped so it just depends on the situation.
  4. Assess the Learning R/O ADHD: how well is the child performing in school or in general? Remember knowledge is power and if the kid is having bizarre symptoms or is not capable of fully expressing themselves, their mood and behavior will get worse.
  5. Keep Everyone Safe: I tell parents truly child-proof the house: lock up sharp objects, weapons, things that are flammable, all ETOH/medications/marijuana or whatever drugs. Implement a safety plan such as the nearest ERs, crisis lines, emergency contacts..etc. I had one parent argue with me about how that’s too much and I simply responded how you can’t put a price on your safety and peace of mind but as a provider, you have to discuss safety measures.

What to do in F/U or if Things Get Worse?

I discuss worsening behaviors, which are usually severe violence and aggression but most literature doesn’t address psychotic behaviors. Overall, parents need to be aware that when things get more distressing, inpatient is the best option. However, it’s a difficult decision, you don’t want the kid to miss school, or be away from family, and most places don’t accept small children. The youngest I had was 7y/o but it took WEEKS to find placement. Nevertheless, to make this decision, the risks have to outweigh the benefits, which is mainly harm to self or others.

Once the child is out of the hospital or stabilized, continue to assess/treat the psych symptoms. Usually, the provider continues the discharge medications unless you have good reasons to change them i.e. allergic/adverse reactions.

Continue to focus on school or learning abilities. I sometimes tell parents that school may not be for everyone but we can focus on reading and writing or life skills such as self-care, hygiene, cleaning, and eventually cooking, driving, staying alone at home, etc.

With the f/up’s you are focusing on improving the quality of life and decreasing the psych symptoms. You should have a safety plan with all patients, but it’s not realistic. However, with people who are dealing with hallucinations, I usually try to prioritize a safety plan.

In Conclusion

Lastly, I want to mention make sure the collaborative physician is aware or you’re consulting with someone if the child is having increasingly bad hallucinations. It’s not common and the level of care can be overwhelming.

I asked my co-workers what they thought about this one incident because I’ve just never heard of a 6y/o having major hallucinations. Plus, the father said she was manipulative because she will say, “the voices told me not to do my homework” and the family overall had a lot of dysfunction. The psychiatrist I worked with said that level of manipulation was rare but the kid usually only heard voices when being asked something to do something. She was also having weight issues so we all agreed to lower her antipsychotics because the hallucinations weren’t too bad. She was okay for a few months but had a major episode and got hospitalized for threatening the family.

So as you can see all these extra factors can easily get overwhelming. She’s doing better but continues to struggle with hallucinations. So yes communicate with colleagues for assistance or until things are stable so you can have your own peace of mind.

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