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

Context

This guideline is concerned with the recognition and management of psychosis and schizophrenia in children and young people up to the age of 18. The term 'psychosis' is used in this guideline to refer to the group of psychotic disorders that includes schizophrenia, schizoaffective disorder, schizophreniform disorder and delusional disorder. This guideline also addresses those children and young people considered clinically to be at high risk or prodromal for psychosis and schizophrenia. The recognition, treatment and management of affective psychoses (such as bipolar disorder or unipolar psychotic depression) are covered by other NICE guidelines.

Psychosis and the specific diagnosis of schizophrenia in children and young people represent a major psychiatric disorder, or cluster of disorders that alters a person's perception, thoughts, mood and behaviour. The symptoms of psychosis are usually divided into 'positive symptoms', including hallucinations (perception in the absence of any stimulus) and delusions (fixed or falsely held beliefs), and 'negative symptoms' (such as emotional apathy, lack of drive, poverty of speech, social withdrawal and self‑neglect). Children and young people who develop psychosis will have their own unique combination of symptoms and experiences, the precise pattern of which will be influenced by their circumstances and stage of development.

Psychosis and schizophrenia are commonly preceded by a so‑called prodromal period, lasting up to 12 months, in which the child or young person's behaviour and experience are altered. Relatives may become aware of these changes first. Changes include the emergence of transient and/or attenuated psychotic symptoms, such as hallucinations and/or delusions with associated impaired functioning. More subtly, the child or young person may become socially withdrawn or suspicious, with alterations in expressed feeling. It is important to note that most children and young people with transient or attenuated psychotic symptoms do not go on to develop psychosis or schizophrenia, although those with such symptoms do appear to be at higher risk than other children and young people of developing psychosis and schizophrenia up to 10 years after onset of symptoms.

The prevalence of psychotic disorders in children aged between 5 and 18 years has been estimated to be 0.4% (the figure across all ages and populations in the UK is 0.7%). Schizophrenia accounts for 24.5% of all psychiatric admissions in young people aged 10 to 18 years (the overall admission rate is 0.46 per 1000 for this age range), with an exponential rise across the adolescent years. The rise in incidence increases most from age 15 onwards.

There is a worse prognosis for psychosis and schizophrenia when onset is in childhood or adolescence. The symptoms and experience of psychosis and schizophrenia are often distressing and the effects of the illness are pervasive. Although about one‑fifth of children and young people with schizophrenia have a good outcome with only mild impairment, one‑third have severe impairment that needs intensive social and psychiatric support. Psychosis and schizophrenia can have a major detrimental effect on children and young people's personal, social, educational and occupational functioning, placing a heavy burden on them and their parents and carers.

Although the mainstay of treatment for psychosis and schizophrenia has been antipsychotic medication, there is limited evidence of its efficacy in children and young people. There are also concerns that children and young people are more sensitive than adults to the potential adverse effects of antipsychotics, including weight gain, metabolic effects and movement disorders. A number of psychological interventions, including family intervention, cognitive behavioural therapy (CBT) and arts therapies, have been used but evidence of efficacy is currently unavailable in children and young people and provision of these therapies for children and young people and for adults is variable.

This guideline covers the care provided by primary, community, secondary, tertiary and other health and social care professionals who have direct contact with, and make decisions concerning, the care of children and young people with psychosis or schizophrenia, including child and adolescent mental health services (CAMHS) and early intervention in psychosis services.

Early intervention in psychosis services provide people aged 14 to 35 years with a more intensive therapeutic service than traditional community services. They are designed to intervene early, and deliver support and evidence‑based interventions in a 'normalising' environment for the first 3 years after onset of psychosis.

There is geographical variation in the configuration and integration of CAMHS and early intervention in psychosis services, and in the provision and integration of other services for children and young people with psychosis and schizophrenia, including education, employment and rehabilitation, and social services. In particular, provision for the needs of 16- and 17‑year‑olds with psychosis and schizophrenia can be fragmented and inadequate and they can experience difficulties in gaining access to appropriate accommodation and vocational or occupational support and rehabilitation.

A number of recommendations in this guideline have been adapted from recommendations in other NICE clinical guidelines. Where this occurred, the guideline committee was careful to preserve the meaning and intent of the original recommendation. Changes to wording or structure were made in order to fit the recommendations into this guideline. In all cases, the original source of any adapted recommendation is indicated.

The guideline incorporates NICE's technology appraisal guidance on aripiprazole for the treatment of schizophrenia in people aged 15 to 17 years.