Assessing Youth with Psychotic Experiences: A Phenomenological Approach

Key points

Perceptual disturbances

Perceptual disturbances in a child may represent normal development, an SSD, or another primary mental health disorder¹¹ and thus require nuanced interpretation. Start with open-ended questioning to avoid leading the child, then proceed to more direct, detail-oriented questions for each sensory domain: hearing, vision, smell, taste, and touch. Ask about the full range of anomalous perceptual experiences, illusions, and hallucinations, as well as associated symptoms (Box 1).

Perceptual

Thought disturbances

Thought disturbances are another common presenting symptom. These disturbances can consist of abnormalities of content, such as delusions, or of form, such as disorganized speech. Delusions are beliefs that are fixed, not culturally normative, and inflexible to change despite conflicting evidence, and can present in a variety of themes, such as persecutory, referential, influence, somatic, religious, and grandiose. The assessment of thought content should start with open-ended curiosity about

Behavioral disturbances

Disorganized behavior may manifest as an inability to sustain goal-directed behavior (such as self-care), or bizarre, nonpurposeful, nonsensical, or unpredictable acts. Clinicians must first attempt to understand the child’s thought process and content before attempting to understand the behavior. For instance, a behavior may be clearly nonsensical, bizarre, or unpredictable in its origin; or it may be a logical reaction to illogical thinking. For instance, a teenager who begins to cover up her

Affective symptoms

Anxiety and mood disorders are common in children, with more than 8% of children between the ages of 6 and 17 years carrying a diagnosis, and rates have been increasing over time.³⁷ Affective and anxiety symptoms and PEs co-occur, and there is a bidirectionality of experience: psychotic disorders can present initially with mood or anxiety symptoms; mood and anxiety disorders can cause PEs; and youth that go on to develop psychotic disorders can have comorbid, distinct anxiety, and mood

Cognitive dysfunction

Cognitive dysfunction is increasingly recognized as a core feature of SSDs,⁴³ and the presence of cognitive impairments is correlated with poor long-term functional outcomes.44, 45, 46 Epidemiologic studies have consistently shown that cognitive impairments precede the development of frank psychotic symptoms in youth who subsequently develop psychotic disorders.47, 48

Cognitive deficits in schizophrenia are heterogeneous, ranging from discrete to global, but cognitive functioning can be up to 2

Motor symptoms

Motor symptoms are commonly observed and assessed in the context of neuroleptic treatment, but motor abnormalities can exist in antipsychotic-naive individuals with schizophrenia, including youth. Phenomenologically, abnormal motor functioning can be described in terms of increased activity (restlessness, excitement, tremors, agitation, motor impulsiveness, tics, choreiform movements, and so forth) or decreased activity (psychomotor retardation, poverty of movement, stupor, motor blocking,

Formulation and differential diagnosis

Once the clinician has gathered the relevant history and the developmental timeline of a child’s symptomatic evolution, this information should be coherently synthesized into a diagnostic formulation. Even in child and adolescent mental health, in which comorbidity is often the rule rather than the exception, diagnostic parsimony should be attempted. At times, determining a diagnosis is straightforward, but, often, information is lacking, significant discrepancies in the history exist, or the

Treatment planning

Once a clinician has determined the causal nature of a child’s symptoms, or a leading hypothesis has been developed, a comprehensive treatment plan should be created. Elements can include psychoeducation (for the patient and family), additional medical evaluations or testing, psychotherapy (individual, group, family), school/employment accommodations, rehabilitative interventions, and psychopharmacology.

First, clinicians should summarize their findings with the patient and caregivers to provide

Summary

PEs may be part of normal development or indicate a wide range of mental disorder. Using a systematic, domain-based, phenomenological approach to assessing psychotic symptoms in youth facilitates the gathering of the nuanced clinical information necessary to understand a child’s specific experience. Mapping this information onto a narrative timeline, while understanding the evolution and developmental context of PEs, is essential in making an accurate diagnostic formulation and appropriate