Psychosis is the clinical term used when an individual loses touch with reality.  In adolescents, psychosis can be caused by many different factors, ranging from substance abuse to the onset of a serious mental health disorder.

The unusual and often bizarre behaviors associated with psychosis can be particularly frightening and confusing for any parent to observe in their child, let alone know how to handle.  This brief guide is designed to help you identify the signs and determine the best course of action if you suspect your teen is becoming psychotic or experiencing a full-blown psychotic episode.

Adolescent Psychosis Statistics

• Every year in the U.S., approximately 100,000 adolescents and young adults will experience their first psychotic break
• The first episodes typically occur between the ages of 15 and 25
• 1 in 20 adults with schizophrenia report their first psychotic symptoms appeared prior to age 15
• Although psychotic disorders can develop in childhood, their prevalence greatly increases during adolescence
• Of those with prodromal (early, sometimes milder) psychotic symptoms, an estimated 1 out of 3 will proceed to develop psychosis
• Suicide is the leading cause of premature death in individuals with schizophrenia, with approximately 4 out of 10 with the disorder making at least one attempt

Looking for and Recognizing the Signs of Psychosis in Teens

While many parents have at least some familiarity with common symptoms of depression, anxiety, or ADHD, psychosis can catch even the most sophisticated and savvy parent off guard.

Understanding what to watch for and how to recognize symptoms of psychosis are the first – and perhaps the most critical – steps you can take as a parent.  This is because early intervention may significantly lessen the long-term impact.  One of the most important things to remember is this:

• Look for and pay close attention to any changes from your teen’s normal personality or behavior, particularly odd or unusual changes.

For example, if your teen is normally outgoing and articulate, increased isolation and slowed or stilted speech could be early indicators of psychosis.

With psychosis, your teen’s behavior will become increasingly bizarre, reflecting the chaos and confusion going on inside his or her mind.

Signs to watch for may include the following:

• Feeling increasingly uneasy or paranoid around other people
• Personality changes
• Odd or bizarre behaviors or ideas
• Decrease in emotional expression
• Confusion
• Grandiose thoughts or behavior (e.g. feeling and acting invincible or powerful)
• Withdrawing from family and friends
• Difficulty concentrating or organizing one’s thoughts
• Decline in hygiene and personal appearance
• Changes in eating or sleeping habits
• A sense that nothing is real
• Decreased interest in normal activities
• Decline in academic performance
• Low energy or motivation
• Strange perceptual experiences, such as seeing or hearing things that aren’t actually there (illusions or hallucinations)
• Unusual, slowed, or rigid movements or postures
• Anxiety
• Difficulties with social interactions
• Agitation
• Mood swings
• Self-mutilation or other forms of self-harm*
• Suicidal thoughts or behavior*
• Homicidal thoughts or behavior*
• Delusions (fixed beliefs not based in reality)

*Self-harm, suicidal thoughts or behaviors, and homicidal thoughts or behaviors should always be taken very seriously and never ignored, even if no other symptoms are present. 

It’s not uncommon for teens to occasionally exhibit some of the symptoms listed above, particularly when they’re under a lot of stress or feeling blue.  However, if several of the symptoms start to gradually appear simultaneously, or if your teen suddenly starts acting bizarrely, assume it’s serious and don’t wait to take action.

One of the most serious mistakes you can make as a parent is to assume your child is just “going through a phase” – attributing unusual behaviors or personality changes to a temporary “adolescent identity crisis” or play for attention.  It can be difficult for any parent to accept the possibility their child is using drugs or, even worse, developing a very serious psychiatric disorder.

Knowing the First Steps to Take

If you believe your teen is exhibiting signs of psychosis, the first steps to take towards handling the situation are to:

1. Sit down and talk to your child. Try to get a sense of what’s going on in his or her mind – and stay calm if your teen’s response reinforces your worst fears.

Ask your teen if there’s something bothering him or her – but don’t force the issue.  Keep in mind, if your teen is experiencing paranoia (which is common with psychosis), he or she will be reluctant to tell you anything.

2. Set up an appointment for an evaluation as soon as possible. Your family doctor or pediatrician can be a good place to start.  He or she can do an initial examination and preliminary diagnosis, use lab tests to determine if a substance (e.g. recreational drugs) or medical condition (e.g. an electrolyte imbalance) may be causing the symptoms, and prescribe short-term medication until you can get your child to a psychiatrist or other mental health professional.  Your family doctor should be able to give you a referral or recommendation to a psychiatrist, or, if your child’s symptoms warrant acute treatment, facilitate admission to the hospital.

With psychotic symptoms, it’s usually best to have your teen evaluated by a psychiatrist as soon as possible – especially if substance abuse or a medical cause has been ruled out.  It’s preferable to find one who specializes in treating children and adolescents.  A psychiatrist:

• has the specialized training and experience to identify and understand the complex aspects of adolescent psychosis
• understands the vulnerabilities and nuances of the developing adolescent brain
• is well-versed in psychiatric medications, particularly those approved for treating adolescent psychosis
• can provide ongoing medication management if needed (which is often the case with psychotic disorders like schizophrenia)

3. Get your child into treatment.** Once your child has been evaluated and a diagnosis has been determined, the next step is to get your child into the appropriate type of treatment.  The type and course of treatment will largely depend on the underlying cause of the psychosis.

If the psychosis is due to a psychiatric disorder (e.g. schizophrenia, bipolar disorder, or severe depression), treatment may include:

• Medication – Psychotic disorders generally require ongoing medication to help manage the symptoms. A small number of antipsychotic medications, such as Risperdal and Zyprexa, have been FDA-approved to treat adolescent psychosis. Although antipsychotic medications have a long list of potential side effects, the benefits usually far outweigh the risks.
• Talk Therapy – Regular individual therapy sessions with a psychologist, psychiatrist, or other mental health professional can help your child manage and navigate the tricky landscape of living with a serious psychiatric disorder that includes psychotic symptoms.
• Family Therapy – This can help you and other family members better understand and support your teen.
• Social Skills Training – Many individuals with psychotic disorders often struggle with social interactions and appropriate behavior in public settings. Social skills training can be particularly beneficial for them. 

If your teen’s psychosis is due to substance abuse or an underlying medical condition, treatment will need to focus primarily on those specific issues (e.g. drug rehab or medical treatment).  Talk therapy can address related emotional issues and enhance coping skills.  Family therapy can also be very beneficial.

**It should be noted that, if your child’s symptoms are severe – regardless of the underlying cause – inpatient treatment may be necessary for safety and stabilization.  Your child will be evaluated in the hospital and treatment recommendations will be made prior to discharge.

Supporting and Encouraging Your Child

Figuring out how to best support and encourage your teen can be particularly bewildering – and seem counterintuitive at times – when it comes to psychosis.  With psychosis, it’s important to remember the following:

1. It isn’t a sign of weakness
2. It can be very frightening and confusing for your child
3. It can’t be “overcome” by sheer determination
4. It may be the beginning of a lifelong and particularly challenging mental health disorder

Several things you can do to help your child include:

• Make it a point to educate yourself about the different types and causes of psychosis in teens
• Keep stress at home to a minimum as much as possible, as stress can worsen symptoms
• Make yourself available (and willing) to listen and let your child know you’re there for him or her
• Respect your child’s experience, even though you may not be able to understand it; don’t minimize, shame, scold, or ridicule
• Don’t attempt to argue or reason when your child says bizarre things; just listen
• If your child doesn’t like or refuses to take medication, especially due to unpleasant side effects (which are common), work with his or her doctor or therapist to explore other options or learn how to handle the resistance – a power struggle will just make things worse
• Avoid nagging or lecturing your child, especially if substance use was involved. Instead, strive for open communication and make a genuine effort to understand your child’s feelings and choices
• Don’t try to talk your child out of his or her experiences (e.g. delusional beliefs – no matter how far-fetched or bizarre) or hallucinations. Work with your child’s therapist for guidance on how to best respond
• Strive to remain calm even when you’re feeling scare or frustrated
• Respect your child’s privacy by keeping things on a need-to-know basis with friends, neighbors, and acquaintances
• Check in with your child periodically (without hovering) to see how he or she is doing, and to see if there is anything helpful you can do
• During bouts of agitation or anxiety, ask your child what would help him or her feel calmer. Your child’s suggestions may seem bizarre to you but work well for him or her.

What to Do When Things Escalate

Psychosis in adolescents can be extremely unpredictable and even dangerous, regardless of the underlying cause.  While some teens will respond well to treatment and begin to improve relatively quickly, others may become progressively or suddenly worse.

Medication, which is frequently indicated for psychosis, doesn’t always work – or work well enough – and often involves some trial and error.  This can be frustrating for both you and your child.

It’s not uncommon for individuals with psychosis to stop taking their medication due to paranoia or unpleasant side effects.  Command hallucinations (voices telling them to do something specific, like kill themselves), hopelessness and despair, or co-occurring depression may also cause them to become actively suicidal.

If things do escalate – for example, your child’s psychosis worsens, he or she becomes manic, or your child becomes a danger to himself or others – seek help immediately.

• Contact your child’s treatment provider
• Take your child to the nearest hospital emergency room (if you can do so safely)
• Call 911
• Enlist the help of a close family member or friend for assistance and support

When Individual Therapy isn’t Enough

With psychotic disorders, individual therapy and medication often aren’t sufficient to keep your child safe and stable on an ongoing basis.  If your child is:

• Refusing or frequently going off his medication
• Threatening or attempting to harm himself or others
• Putting himself in harm’s way
• Unable to function at all or without frequent assistance

then it’s time to consider a more intensive level of treatment.  This may involve:

• Intensive outpatient treatment (IOP) / Psychiatric day treatment / Partial hospitalization
• Residential treatment
• Inpatient psychiatric treatment

Intensive outpatient treatment (sometimes called psychiatric day treatment or partial hospitalization) can vary in terms of the amount of time spent and how often (e.g. 2 to 5 days) your child is required to go.  These programs are the next step up from regular outpatient treatment (i.e. an hour of therapy once or twice a week).

Residential treatment involves having your teen stay 24/7 at non-hospital treatment facility. Residential programs specialize in treating adolescents with serious psychiatric disorders.  Treatment typically lasts from 28 to 180 days, depending on your teen’s disorder and its severity.

Inpatient psychiatric treatment is the highest and most intensive level of treatment for adolescents and requires admitting your child to a secure adolescent psychiatric hospital inpatient unit.  Treatment may last for a few days to a few weeks, and medical staff is on hand to monitor patients 24/7. Inpatient treatment is particularly beneficial for adolescents who are too impaired to function,  need to be stabilized on medication, or are a danger to themselves or others.

Each of these higher levels of treatment typically provides frequent – sometimes even daily – visits with a psychiatrist and daily therapy (often both group and individual, and a combination of different types, such as psychotherapy, art therapy, occupational therapy, etc.).

Taking Care of Yourself

While psychosis due to substance abuse can easily become a lengthy ordeal, especially if your child frequently relapses, a psychotic disorder such as schizophrenia can mean a very long road ahead.  The inevitable challenges can take quite a toll on your emotional, mental, and physical health.  That’s why it’s so important to get the support you need and take good care of yourself.

Support can come in many forms including:

• Online support groups
• Close family and friends
• Local support groups (e.g. your local NAMI – National Alliance on Mental Illness – chapter)
• Therapy

Self-care can include making sure you:

• Get sufficient sleep
• Make time for yourself
• Learn to effectively manage your stress, e.g. with regular exercise, yoga, meditation, etc.

Dealing with psychosis will probably be one of the most difficult things your teen will ever face.  He or she will be looking to you for guidance, support, encouragement, and hope.  Taking good care of yourself will help ensure that you’ll be there to support and encourage your child.