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Emergency department evaluation of acute onset psychosis in children

Kavita M Babu, MD
Edward W Boyer, MD, PhD
Section Editors
Stephen J Teach, MD, MPH
Gary R Fleisher, MD
Deputy Editor
James F Wiley, II, MD, MPH


New-onset psychosis in children and adolescents represents an uncommon and complex presenting complaint. Psychosis has been defined as a "disruption in thinking, accompanied by delusions or hallucinations" [1]. Delusions represent false, fixed beliefs that cannot be resolved through logical argument, while hallucinations are false perceptions that have no basis in external stimuli [1]. In contrast, delirium is marked by an altered sensorium with waxing and waning deficits in attention and concentration. Orientation and concentration are preserved with functional psychosis. However, the distinction between delirium and psychosis in pediatric patients can be difficult to establish, particularly in younger children. Despite these differences, hallucinations may actually represent a symptom of delirium, and separating psychosis and delirium acutely may be impossible.

The onset of psychosis is an important diagnostic element. Acute onset occurs more commonly with an underlying medical cause rather than psychiatric disease. Even patients with symptoms suggestive of a primary psychiatric diagnosis should undergo a medical evaluation to exclude possible reversible etiologies of psychosis.


The differential diagnosis of psychosis in children encompasses hypoglycemia, cerebral hypoxia, drug toxicity, medical illness, and psychiatric disease (table 1 and table 2).

Substrate deficiency

Hypoglycemia – Hypoglycemia is a rare, but important cause of psychosis and hallucinations [2,3]. All patients with alterations in mental status require immediate bedside capillary glucose testing. Rapid correction of blood sugar is critical to prevent seizures and persistent neurologic sequelae. Hypoglycemia with abrupt change in behavior may occur in children being treated for Type I and Type II diabetes; alternatively, hypoglycemia may result from ingestions (eg, ethanol, beta-blockers, and sulfonylureas) or from inborn errors of metabolism. (See "Approach to hypoglycemia in infants and children".)

Cerebral hypoxia – Inadequate brain oxygenation may lead to altered mental status with combative behavior. Thus, any condition that results in hypoxemia (eg, pulmonary insufficiency), insufficient oxygen carrying capacity of the blood (eg, severe anemia), or inadequate brain perfusion (eg, cardiac insufficiency) may result in an encephalopathy with psychotic features. These patients require emergent identification of the underlying cause of cerebral hypoxia and immediate interventions to restore brain oxygenation.

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Literature review current through: Nov 2017. | This topic last updated: Nov 20, 2017.
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  1. Davids K, Charney D, Coyle J Nemeroff C. Neuropsychopharmacology, Lippincott Williams & Wilkins, Philadelphia 2002.
  2. Brady WJ Jr, Duncan CW. Hypoglycemia masquerading as acute psychosis and acute cocaine intoxication. Am J Emerg Med 1999; 17:318.
  3. Hussain K, Mundy H, Aynsley-Green A, Champion M. A child presenting with disordered consciousness, hallucinations, screaming episodes and abdominal pain. Eur J Pediatr 2002; 161:127.
  4. Frampton A, Spinks J. Hyperthermia associated with central anticholinergic syndrome caused by a transdermal hyoscine patch in a child with cerebral palsy. Emerg Med J 2005; 22:678.
  5. Göpel C, Laufer C, Marcus A. Three cases of angel's trumpet tea-induced psychosis in adolescent substance abusers. Nord J Psychiatry 2002; 56:49.
  6. Soutullo CA, Cottingham EM, Keck PE Jr. Psychosis associated with pseudoephedrine and dextromethorphan. J Am Acad Child Adolesc Psychiatry 1999; 38:1471.
  7. Calello DP, Osterhoudt KC. Acute psychosis associated with therapeutic use of dextroamphetamine. Pediatrics 2004; 113:1466.
  8. Curran C, Byrappa N, McBride A. Stimulant psychosis: systematic review. Br J Psychiatry 2004; 185:196.
  9. Shannon M. Methylenedioxymethamphetamine (MDMA, "Ecstasy"). Pediatr Emerg Care 2000; 16:377.
  10. Farber NB. The NMDA receptor hypofunction model of psychosis. Ann N Y Acad Sci 2003; 1003:119.
  11. Shirley KW, Kothare S, Piatt JH Jr, Adirim TA. Intrathecal baclofen overdose and withdrawal. Pediatr Emerg Care 2006; 22:258.
  12. Tobias JD. Tolerance, withdrawal, and physical dependency after long-term sedation and analgesia of children in the pediatric intensive care unit. Crit Care Med 2000; 28:2122.
  13. Dawson KL, Carter ER. A steroid-induced acute psychosis in a child with asthma. Pediatr Pulmonol 1998; 26:362.
  14. Ingram DG, Hagemann TM. Promethazine treatment of steroid-induced psychosis in a child. Ann Pharmacother 2003; 37:1036.
  15. Duke T, Mai M. Meningitis or madness: a delicate balance. J Paediatr Child Health 1999; 35:319.
  16. Iannaccone R, Sue YJ, Avner JR. Suicidal psychosis secondary to isoniazid. Pediatr Emerg Care 2002; 18:25.
  17. Przybylo HJ, Przybylo JH, Todd Davis A, Coté CJ. Acute psychosis after anesthesia: the case for antibiomania. Paediatr Anaesth 2005; 15:703.
  18. Kanner AM, Dunn DW. Diagnosis and management of depression and psychosis in children and adolescents with epilepsy. J Child Neurol 2004; 19 Suppl 1:S65.
  19. Richards CF, Gurr DE. Psychosis. Emerg Med Clin North Am 2000; 18:253.
  20. Xavier M, Correa B, Coromina M, et al. Sudden psychotic episode probably due to meningoencephalitis and Chlamydia pneumoniae acute infection. Clin Pract Epidemiol Ment Health 2005; 1:15.
  21. Nguyen TH, Day NP, Ly VC, et al. Post-malaria neurological syndrome. Lancet 1996; 348:917.
  22. Thomas NH, Collins JE, Robb SA, Robinson RO. Mycoplasma pneumoniae infection and neurological disease. Arch Dis Child 1993; 69:573.
  23. Nissenkorn A, Moldavsky M, Lorberboym M, et al. Postictal psychosis in a child. J Child Neurol 1999; 14:818.
  24. Logsdail SJ, Toone BK. Post-ictal psychoses. A clinical and phenomenological description. Br J Psychiatry 1988; 152:246.
  25. Oner O, Unal O, Deda G. A case of psychosis with temporal lobe epilepsy: SPECT changes with treatment. Pediatr Neurol 2005; 32:197.
  26. Caplan R, Tanguay PE, Szekely AG. Subacute sclerosing panencephalitis presenting as childhood psychosis. J Am Acad Child Adolesc Psychiatry 1987; 26:440.
  27. Sedel F, Baumann N, Turpin JC, et al. Psychiatric manifestations revealing inborn errors of metabolism in adolescents and adults. J Inherit Metab Dis 2007; 30:631.
  28. Sit D, Rothschild AJ, Wisner KL. A review of postpartum psychosis. J Womens Health (Larchmt) 2006; 15:352.
  29. Majlesi N, Greller HA, McGuigan MA, et al. Thyroid storm after pediatric levothyroxine ingestion. Pediatrics 2010; 126:e470.
  30. Shabana M, Shalaby M, Alhumayed S, Alshehri A. Paediatric case report: primary antiphospholipid syndrome presented with non-thrombotic neurological picture psychosis; treat by antidepressants alone? Int J Rheum Dis 2009; 12:170.
  31. Reimherr JP, McClellan JM. Diagnostic challenges in children and adolescents with psychotic disorders. J Clin Psychiatry 2004; 65 Suppl 6:5.
  32. Chun TH, Sargent J, Hodas GR. Psychiatric emergencies. In: Textbook of Pediatric Emergency Medicine, 5th, Fleisher GR, Ludwig S, Henretig FM (Eds), Lippincott Williams & Wilkins, Philadelphia 2006. p.1820.
  33. Fisch N, Goldberg-Stern H, Kivity S, et al. A 9-year old boy with acute psychosis and non-convulsive status epilepticus. Eur Psychiatry 2011; 26:1716.
  34. Hilt RJ, Woodward TA. Agitation treatment for pediatric emergency patients. J Am Acad Child Adolesc Psychiatry 2008; 47:132.
  35. Dorfman DH, Kastner B. The use of restraint for pediatric psychiatric patients in emergency departments. Pediatr Emerg Care 2004; 20:151.
  36. Sorrentino A. Chemical restraints for the agitated, violent, or psychotic pediatric patient in the emergency department: controversies and recommendations. Curr Opin Pediatr 2004; 16:201.