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New NICE guidance on psychosis and schizophrenia in children and young people

London, UK (January 23, 2013) – New NICE guidance stresses that signs of psychosis and schizophrenia in children and young people need to be identified early to help ensure they receive the treatment and care they need to live with the condition. NICE, the healthcare guidance body, has today (23 January) published a new clinical guideline on the recognition and management of psychosis and schizophrenia in children and young people up to the age of 18.

Professor Mark Baker, Director of the Centre for Clinical Practice at NICE, said: "Psychosis is used to describe a group of severe mental health disorders which disrupt a person’s perception, thoughts, emotions and behaviour through delusions and hallucinations. The most common form is schizophrenia – over a lifetime, about 1 in 100 people will develop schizophrenia, but it is most likely to start between the ages of 15 and 35 years. This is the first NICE clinical guideline to focus on the recognition and management of psychosis and schizophrenia specifically in children and young people. The guideline includes a number of recommendations to support healthcare professionals to accurately diagnose psychosis and schizophrenia in children and young people and offer them treatment options that are best suited to them."

Professor Chris Hollis, Professor of Child and Adolescent Psychiatry, University of Nottingham and Chair of the Guideline Development Group said: "Schizophrenia is a serious mental illness that can be extremely debilitating and have lasting effects even when treated, especially if the onset is during childhood. The symptoms are enormously distressing for both the child and their family or carers. However, there are effective treatment options available and spotting the signs of the disorder early can help ensure the young person and their family receives the treatment and support they need to live with the condition."

Professor Tim Kendall, Director of the National Collaborating Centre for Mental Health, which developed the guideline for NICE; Medical Director/Consultant Adult Psychiatrist, Sheffield Health and Social Care NHS Foundation Trust said: "There are some groups of young people who are especially prone to breaking down into a psychosis; and when they seek help, we can now say that antipsychotics should not be given to them. Instead, CBT for the family and the individual has the greatest chance of preventing high risk young people from converting to psychosis. We are also much clearer about the place of antipsychotics in the treatment of psychosis and schizophrenia: these drugs have quite severe side effects and need to be used with caution, especially in the young as the side effects can be especially severe. This guideline has really improved our confidence in what we should and shouldn’t do."

Dr David Shiers, GP who advises the National Audit of Schizophrenia (The Royal College of Psychiatrists), and member of the Guideline Development Group said: "The effect of psychosis and schizophrenia on a child cannot be underestimated. Nor can the heavy burden placed on their parents and carers. As well as recommendation of effective treatments and care, the guidance also places a strong emphasis on ensuring children and their families or carers have all the information and support they need, encouraging practitioners to consider the impact of the diagnosis and treatment; in particular this needs psychiatrists and general practitioners to work collaboratively and to be clear about their respective roles and responsibilities."

Recommendations include:

• Referral from primary care for possible psychosis: When a child or young person experiences transient or attenuated psychotic symptoms or other experiences suggestive of possible psychosis, refer for assessment without delay to a specialist mental health service such as CAMHS or an early intervention in psychosis service (14 years or over).
• Treatment options for symptoms not sufficient for a diagnosis of psychosis or schizophrenia: When transient or attenuated psychotic symptoms or other mental state changes associated with distress, impairment or help-seeking behaviour are not sufficient for a diagnosis of psychosis or schizophrenia: consider individual cognitive behavioural therapy (CBT) with or without family intervention and offer treatments recommended in NICE guidance for children and young people with any of the anxiety disorders, depression, emerging personality disorder or substance misuse.
• Do not offer antipsychotic medication: for psychotic symptoms or mental state changes that are not sufficient for a diagnosis of psychosis or schizophrenia, or with the aim of decreasing the risk of psychosis.
• Referral from primary care in first episode psychosis: Urgently refer all children and young people with a first presentation of sustained psychotic symptoms (lasting 4 weeks or more) to a specialist mental health service, either CAMHS (up to 17 years) or an early intervention in psychosis service (14 years or over), which includes a consultant psychiatrist with training in child and adolescent mental health
• Treatment of subsequent acute episodes of psychosis or schizophrenia: For children and young people with an acute exacerbation or recurrence of psychosis or schizophrenia offer oral antipsychotic medication in conjunction with psychological interventions (family intervention with individual CBT).
• Before referral for hospital care, think about the impact on the child or young person and their parents, carers and other family members, especially when the inpatient unit is a long way from where they live. Consider alternative care within the community wherever possible. If hospital admission is unavoidable, provide support for parents or carers when the child or young person is admitted.
• Education, employment and occupational activities for children and young people with psychosis and schizophrenia: For children and young people of compulsory school age, liaise with the child or young person’s school and educational authority, subject to consent, to ensure that ongoing education is provided.

The final published guidance will be available on the NICE website from 23 January, 2013.

Notes to Editors

About the guidance

1. The final guidance will be available on the NICE website from 23 January 2013: http://guidance.nice.org.uk/CG155/Guidance

2. 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 up to the age of 18 with psychosis or schizophrenia, including child and adolescent mental health services (CAMHS) and early intervention in psychosis services.

3. 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 10-18 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.

4. 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.

About NICE

5. The National Institute for Health and Clinical Excellence (NICE) is the independent organisation responsible for providing national guidance and standards on the promotion of good health and the prevention and treatment of ill health

6. NICE produces guidance in three areas of health:

• public health – guidance on the promotion of good health and the prevention of ill health for those working in the NHS, local authorities and the wider public and voluntary sector
• health technologies -guidance on the use of new and existing medicines, treatments, medical technologies (including devices and diagnostics) and procedures within the NHS
• clinical practice – guidance on the appropriate treatment and care of people with specific diseases and conditions within the NHS.
• social care – the Health and Social Care Act (2012) sets out a new responsibility for NICE to develop guidance and quality standards for social care. To reflect this new role, from 1 April 2013 NICE will be called the National Institute for Health and Care Excellence (NICE) and it will become a Non-Departmental Public Body.

7. NICE produces standards for patient care:

• quality standards – these describe high-priority areas for quality improvement in a defined care or service area
• Quality and Outcomes Framework – NICE develops the clinical and health improvement indicators in the QOF, the Department of Health scheme which rewards GPs for how well they care for patients
• CCG Outcomes Indicator Set (formerly known as COF) – NICE develops the potential clinical health improvement indicators to ensure quality of care for patients and communities served by the clinical commissioning groups (CCGs)

8. NICE provides advice and support on putting NICE guidance and standards into practice through its implementation programme, and it collates and accredits high quality health guidance, research and information to help health professionals deliver the best patient care through NHS Evidence.

This page was last updated: 21 January 2013

National Institute for Health and Clinical Excellence (NICE), 23.01.2013 (tB).