Medical evaluation of first presentation of psychotic symptoms in children and adolescents.

Introduction: Psychotic symptoms in children and adolescents may represent either normative developmental phenomena or severe psychiatric and medical conditions, requiring careful differential diagnosis. Methods: This retrospective study aimed to evaluate the medical workup of children and adolescents admitted for a first presentation of psychotic symptoms at a tertiary pediatric center over a 10-year period. The sample included 68 patients (mean age 13.7 ± 3.7 years) who underwent clinician-directed evaluations including physical exams, laboratory tests, toxicology screens, neuroimaging, and lumbar puncture when indicated. Results: Sixteen patients (23.5%) were diagnosed with substance-/medication-induced or medically-associated psychosis. In this cohort, younger age, very early onset psychosis (<13 years), and catatonia at first presentation were more frequently observed among patients with secondary etiologies, whereas documented prior subthreshold symptoms were more frequently documented among those diagnosed with primary psychiatric disorders. Most investigations did not identify a secondary cause, reflecting clinician-directed evaluation in routine practice; however, selected cases (e.g., autoimmune encephalitis, multiple sclerosis) illustrate the clinical importance of careful assessment when specific suspicion is present. Conclusion: These findings suggest that targeted medical evaluation may be useful in pediatric psychosis, particularly when clinical features raise suspicion for secondary etiologies, and may help inform clinical decision-making in tertiary pediatric settings.