This Neuroscience Grand Rounds session, led by Yasaman Movahedi and Deanna Aghbashian, explores psychosis in adolescence through both clinical and neurocognitive lenses, emphasizing early recognition and multidisciplinary management. Early-onset psychosis is associated with significant cognitive impairments, including deficits in memory, attention and executive functioning that can impact academic performance, social development and long-term outcomes.
The session highlights key presenting symptoms, the psychosocial and neurocognitive effects of disease, and the role of integrated care teams, including psychology and neuropsychology in diagnosis and treatment. Clinicians will gain insight into evidence-based interventions and practical strategies to support early identification and coordinated care across inpatient and outpatient settings.
Learning Objectives:
Define early onset psychotic disorders and recognize presenting signs and symptoms in adolescence that may impact assessment and treatment.
Describe the potential psychosocial and neurocognitive impacts of early-onset psychosis and opportunities for roles of psychology and neuropsychology in multidisciplinary collaboration.
Identify evidence-based interventions and clinical resources available to medical providers for managing early-onset psychosis across inpatient and outpatient settings.
And Deanna here with us today. Yasmin Movahedi is a pediatric psychology intern here at Phoenix Children's. She's currently a doctoral candidate at Palo Alto University where she specializes in pediatric behavioral integrated healthcare. Yasmin is passionate about supporting children and adolescents facing mental health challenges. She takes a child-centered approach to therapy and incorporates evidence-based interventions to help youth and their families make meaningful progress to their therapeutic goals. We're really excited to have her here with us today. And Deanna Agbashian is a PhD doctoral candidate at Loma Linda University. She has a specialization in pediatric neuropsychology. She is currently completing her pediatric neuropsychology internship here with us at Phoenix Children's. Her clinical training has also included neuropsychology placements at University of California, Irving and Children's Hospital Los Angeles, where she worked with medically complex pediatric populations. And her research focuses on the neural mechanisms underlying social cognition in youth with early onset psychosis and autism, with an additional focus on the effects of childhood trauma and early onset psychosis. Her broader clinical and research interests center on applying neuropsychological principles to understand brain behavior relationships in pediatric medical populations and improving functional outcomes through interdisciplinary. Prior to her pursuing doctoral training, she practiced as a licensed clinical social worker, providing trauma informed psychotherapy and crisis assessment to adolescents and adults. And today they are both going to be here talking about psychosis and adolescence and really helping us understand the clinical and neurological perspectives, neurocognitive perspectives of that. So welcome, and we are excited to hear your presentation. Thank you so much. I appreciate it. I think one, sorry about our issues. We seem to have them every day, um, every Monday, but thank you so much for being here. Um, this Monday morning, um, like Doctor Phelps said, I'm Deanna and this is Yasmin. We are the interns, um, with neuropsychology and psychology. And today we're gonna be talking about, um, early onset psychosis and kind of what that looks like. Um, so it seems like we're having just a little bit of trouble, um, getting our slides up. Just be another minute or two. I'm so sorry. Deanna, is there anything I can do to help you? Oh, perfect. Thanks. OK. I'm sharing my screen, but if it um logs me out of Zoom, that's why. OK. So, So today, we are going to be talking about early-onset psychosis, kind of look at the signs and symptoms as well as talk about the psychosocial and neurocognitive impacts that we see with early onset psychosis, and then identify some of the evidence-based interventions and resources um that are available to medical providers. Um, to begin, we wanted to define adolescence as this presentation focuses on psychosis and the adolescent population. So adolescence is this like period of time, period of rapid neurodevelopment, particularly in systems supporting social cognition and evaluating and executive functioning. At the same time, the social demands increase, identity formation, peer relationships, and independence. This creates like this mismatch developing systems under uh increasing pressure. As a result, vulnerabilities become more visible, and this is also the peak for onset of psychotic disorders. Psychosis involves a loss of reality, um, affecting perception, thinking, and behavior. Uh, some core symptoms include delusions, hallucinations, uh, disorganizations. Importantly, these are often preceded by more subtle changes. Um, such as like withdrawal, cognitive, uh, difficulty, functional decline, which are all crucial for early identification. Early, we also want to define early onset psychosis, and that's when psychotic disorders begin before the age of 18 and within the 1st 2 years of the course of onset. So psychotic disorders are classified as severe mental illnesses. So according to the DSM-5TR this category includes schizophrenia, schizoaffective disorder, schizophrenic disorder, um, brief psychotic disorder, delusional disorder, and substance-induced psychotic disorder, and psychotic disorder due to other medical conditions. These disorders are primarily differentiated by duration, symptom pattern, and etiology. Um, so briefly going over each one, schizophrenia is the most common pedia is the most common, um, primary pediatric, uh, primary psychotic disorder, and it's usually characterized by chronic symptoms, um, chronic symptoms that may include delusions, hallucinations, disorganized, um, thinking, negative symptoms, and functional decline. Presentations also vary by person to person. We have brief psychotic disorder. Brief psychotic disorder really involves this like sudden onset of psychotic symptoms. It usually lasts from one day, but um one day but less than one month. Um, and the eventual like return to baseline functioning. Symptoms for that disorder include like delusions, hallucinations, disorganized speech, um, And grossly disorganized behavior. Schizophrenic disorder presents with symptoms similar to schizophrenia, but lasts between 1 to 6 months. Uh, individuals may experience delusions, hallucinations, again, that disorganized speech and behavior, and negative symptoms, often with impaired, uh, functioning and insight. Uh, delusional disorder is characterized by, uh, one or more persistent delusions lasting at least one month, um, without prominent hallucinations or marked functional, uh, functional impairment outside of the delusional belief. We have schizoaffreective disorder, uh, which includes both psychotic symptoms and mood episodes, so which could either be major depressive or manic, and that diagnosis requires a period of psychosis in the absence of mood, um, mood symptoms, in addition to overlapping mood and psychotic features. We have psychotic disorder due to another medical condition, and this occurs when psychotic symptoms are directly attributed due to like an underlying ill medical illness. So what that medical illness could look like, could be like neuro neurological injury, autoimmune conditions, and other systematic disorders. Lastly, we have a substance-induced psychotic disorder that involves hallucinations or delusions that develop during or shortly after substance use or withdrawal. So, overall, what we're trying to say is psychotic disorders exist on a spectrum with overlapping features, but differing trajectories, durations, and underlying causes. So talking about early onset psychosis, clinically, symptoms fall into either positive and either into positive and negative domains. So what do positive symptoms look like? Positive symptoms are added experiences such as hallucinations, um, delusions, or disorganizations. And then when we're talking about negative symptoms, we're really reflecting on a loss of function. So what that really looks like is In an individual could be like reduced motivation, emotional expression, and social engagement. So, importantly, distinguishing between primary psychotic form, um, form from medical causes is critical. For example, research suggests that visual hallucinations or abnormal vital signs may suggest an underlying medical condition. And so while we often describe psychosis kind of in those terms of those positive and negative symptoms, Sometimes that distinction can be pretty superficial, and we kind of wanna frame today as This perspective of like what's underlying cognitive and neural systems, and like how are they producing these, the symptoms that we're seeing. And so from that perspective, uh, psychosis is best understood as a neurodevelopmental disorder. Of course, there is some um kind of uh fighting within the community, in the research community, if this is a neurodevelopmental disorder, if there's something else. However, um, for today's topic, we will be talking about it from a neurodevelopmental lens. So then, rather than the, the diagnosis beginning when you first diagnose or when we're first seeing symp symptoms, we're actually um seeing that it reflects more of a process of unfolding over many years. So long before the symptoms emerge, we do see some subtle differences in cognition, um, in social functioning, and just overall development. So by the time a patient presents with their first episode of psychosis, we're we're often observing kind of the endpoint of a much longer trajectory. And while there is some strong evidence to support this model, um, we also see that, uh, not everyone agrees with it, as well as we see some pre-morbid cognitive vulnerabilities, developmental abnormalities, and then a progressive decline across the lifespan. So. And so here we are looking at the different phases of um early onset psychosis. So, like I said, long before the symptoms emerge, we do see some subtle differences. And so first, we do see kind of that pre-morbid stage where we might not be seeing any um symptoms at all, or there might just be some like sub-diagnostic Uh, peculiarities that we're seeing. And then we have what we call clinical high risk for psychosis, and these are individuals that might have um a genetic disposal, or they might be under kind of like a brief psychotic disorder. And so we'll see some of that um functional decline, and then if there is that genetic risk, that does kind of increase their chances of going to the prodrome, which is where we're seeing some worsening symptoms and functioning, some emerging paranoia, we might be seeing some perceptual changes. And then from there, if there isn't any uh intervention, they can go into their first episode of psychosis, and this is a full threshold of symptoms. So this is where they're getting their actual um diagnosis here. So you're seeing all of the symptoms that Yasmin had talked about earlier. And we're also seeing some clear functional impairment. So we kind of see overall, psychosis kind of reflects the accumulation of kind of this developmental risk where it eventually crosses over a threshold when the symptoms emerge. So some of the risk factors that we see are genetic, so having a family history of a psychotic disorder is one of the strongest predictors. However, we do see that there is about a 50% discordance in identical twins, with one having a psychotic disorder and the other one not. So kind of genetic genetics doesn't tell us the full story. We also see that there are other variables that do kind of increase the risk of um kind of meeting that criteria for a psychotic disorder as As someone ages, and this is kind of some early biological factors, and the suggestion is that this is disruptions kind of in the brain development, um, kind of in utero. So even, uh, some prematurity, low birth weight, any birth complications, um, low APAR scores are all risk factors, as well as, uh, maternal substance use in utero. Uh, and then we also have some environmental risk factors. So urban living, so living within a big city, um, immigration status also had a higher risk factor. And then we also see that in the northern hemisphere, uh, winter and spring birth is associated with a higher risk of early onset psychosis. And then finally, kind of that, uh, higher paternal age is also a risk factor. And psychosocial, uh, having instances of trauma, especially in childhood, is, uh, kind of increases that risk, as well as it is dose-dependent. So the more childhood trauma that you experience, the more likely, um, you are if you have kind of some of these predispositions to kind of develop a psychotic disorder and those psychotic features, as well as, uh, substance use. I know that there is some growing emerging research kind of in cannabis use, and they are finding that Um, specific, like, adolescents using cannabis, kind of. In that like 12 to 15 range, the more that they're using, the higher that risk becomes. So what are some of the mechanisms that kind of lead to um early onset psychosis? So at the neurobiological level, there are several mechanisms that are thought to drive this process. Um, one is abnormal synaptic pruning during adolescence, um, and then also kind of the Brain maturation from like in utero into adolescence isn't quite um on the same trajectory as we would typically see um in a typically developing adolescent. But with the synaptic pruning, um, we're seeing that there's an excessive elimination of neural connections. Uh, especially in the prefrontal and temporal regions, and this is thought that it might, uh, disrupt efficient brain functioning. And we also see that uh EOP is associated with age-related progressive, like structural changes just in the total gray matter volume and frontal gray matter volume, uh, as well as with the thickness in those regions as well. When I've seen an accelerated cortical thinning, um, when we see that inverted view of what we would expect the brain to mature. Throughout adolescence and young adulthood, it is um accelerated, so we do see some more deficits kind of in their functioning. And then also from a functional standpoint, there is some disc uh connectivity across brain networks. So kind of with that volume loss in the cortical thinning, also the different regions in the brain aren't talking to each other as well. And so there, those networks aren't working together. If you're thinking like the triple uh mode network, those ones don't have as great uh of an integration in someone who has early onset psychosis. And then when we, sorry, when we look at the neurochemical changes, we do see that uh dopamine is one of the biggest um neurochemical disruptions that we see and that is associated with positive symptoms, while glutamate, um, is, uh, associated with some of our cognitive dysfunctions and then our GABA. Then we see some inhibitory deficits. So again, things that we'll see in kind of the prefrontal cortex. And then overall, uh, within psychosis, there is this theory about the disrupted excitatory and inhibitory balance between kind of that GABA and that glutamate. And then with that, um, there is the kind of researchers finding the pathophysiology that underlies this neurodevelopmental and neuropsychiatric disorders is kind of due, um, and associated with the EI imbalance. And so, what does all of this mean? You know, um, People that have, uh, early onset psychosis, they do have a lot of functional impacts, um, and we do find that the younger that they are, The, like the greater these impacts are. So while we're talking about early onset psychosis, which is kind of in that adolescent range, very early onset psychosis, which is pretty rare, but it's still is something that uh might come across in um in your medical room, is kind of childhood onset. And the younger you are, the more severe these symptoms are gonna be. So you're gonna see more severe negative symptoms. You're gonna be seeing more um pre-morbid deficits. You might see some higher autistic traits, and so often that differential can be difficult to determine when they're much younger. Is this an autism spectrum disorder or is something happening, um, that this is actually kind of that pre-morbid, um, Functioning for someone with a psychotic disorder. And the younger that they are, the more um Like they're resistant to treatment, and this is all forms of treatment, um, medication, uh, psychotherapy, all of those. You will also see some Uh, psychosocial impacts as well. So people that have psychosis, it, it is a high burden on the families. They do have to kind of work a lot with the individual and making sure that they're not going through an acute phase, and then also that impacts their relationships, which can increase their social rejection and overall causes them to have a lack of social support. Which just overall will just decrease their overall, uh, like functioning and their, their outcomes. So, I'm gonna pause just a little bit and we're going to talk specifically about uh early onset psychosis, social cognition, and childhood trauma. So we see here that childhood trauma is a significant risk factor for developing psychosis, and we know that more severe trauma leads to worse symptoms. And we see that in early onset psychosis, social cognition, and childhood trauma, some of the same brain regions are implicated. So in social cognition, that's kind of what they call the social brain or those main regions as well as uh glutamate dysfunction, we might be seeing some deficits in social cognition. Well, in early onset psychosis, we're also seeing some really similar changes in um in kind of brain structure. This is all looking at structure. It's not looking at functional connectivity between any of these regions. Um, let's go to the next one. And so what my Uh, what my dissertation looked at is it explored the association between neuroanatomical and neurometabolytic aberrations in the brain that underlie cognition in, uh, youth with early onset psychosis. And then I also looked at the moderating effect of childhood trauma experiences on this association, and generally, uh, just what we're seeing here in those group differences. Uh, youth with early onset psychosis had a significant more exposure to childhood trauma. And they also had decreased social cognition. And so it might look um on the SRS2, that social responsiveness, uh, and this is actually the higher your scores are, the worse your functioning is. So you see there is a pretty big difference between our early onset psychosis and our typically developing youth. And this is pretty in line with what we're seeing just in uh other research. Now, specifically when we're looking at the moderation, I'm just gonna focus on a few of them cause I did do a very big analysis. But when we're just looking at the percuneus and the prefrontal cortex thickness, we did see that trauma did moderate that relationship. That increased uh precuneus and PFC thickness was associated with an increase in social cognition. And this is an increase in both uh social responsiveness and the tacit, which is kind of our perspective taking and our theory of mind task. And the way that this is written out, I know I just told you before that social responsiveness is a The higher the scores are, the worse it is. But the way that I'm actually reading this is that uh the higher they're actually improving on their social responsiveness. So if you look You know, at the graph on the left. Yeah, uh, you can see that. As uh perkus thickness increased, the scores went down, and that's because, uh, it actually improved the stronger and the thicker, um, those regions were. And so really what we're seeing is that while childhood trauma does strengthen the relationship between sickness and um social cognition, We're also seeing that having a thicker, um, like PFC and percuneus might actually be, um, kind of compensatory, so that it, uh, they can actually improve because they're maintaining, um, kind of the integrity of their brain. And we do see that the effect is stronger for those with more trauma experiences. So the more trauma you have, and you still have that preserved thickness, you can still make um some good understanding of social cognition, both in that social responsiveness, so how you're interacting in relationships and that theory of mind, so being able to take perspective on what other people are thinking. And so now, I will pivot again to talk about the neuropsychological profile, and of the domains that are generally impacted in uh early onset psychosis, as well as you see that these are impacted. In uh adults with uh psychosis as well. So, The one that's impacted the most is kind of that executive functioning piece, which makes sense because that is linked to uh the PFC kind of dysfunction. And so these are difficulties of planning, um, stopping themselves from doing things, being able to be flexible in the way that they're thinking, and this is associated with poor functional outcomes. You'll see more negative symptoms, and you'll see some more rigid rigidity here as well. And then we're going to jump over to working memory and attention. So working memory is just kind of the information that we can hold in our mind and manipulate it. So, along with attention, if you're not paying attention, you're not able to take in that information, and then you're, you're gonna have a difficult time just knowing what someone's told you, being in a doctor's office, and they're telling you, OK, these are The, um, the treatments that we're gonna do, kind of being able to hold that in their mind or remember like, OK, I need to take my meds at this time is going to be difficult for them. And this goes along with attention, uh, so kind of that sustained attention, as well as being able to filter irrelevant stimuli. And so you can see that this is often associated with some of those positive um symptoms as well. So having someone, like having auditory hallucinations, it's going to be more difficult for them to actually filter some of that stimuli out, as well as just what's going on around them. Everything will look like it's salient. And so this can uh impact their thinking. They might be more disorganized when you're talking to them. You might see reduced abilities to problem solve, as well as um impairs their communication. And then, like we just talked about social cognition, social cognition is, is, uh, greatly impacted, and you see that with emotion recognition, theory of mind, just that perspective taking and social reasoning. And then their overall emotional regulation, and so that will just impact kind of their daily relationships. And some neuropsychological assessment considerations. Um, when you are going to give a referral for someone that might be, uh, like in an acute, uh, psychosis, it's not generally a good time for us to do, uh, those assessments because we can't get a good baseline. Um, so we also won't have, uh, the patient's ability to be able to concentrate and to actually understand their instructions and provide their best effort. So really, we won't have a good idea of what their strengths and weaknesses are across their cognitive profile. Also, um, when giving referrals, substance use is something that should be considered. So if you know that a patient is currently abusing substances, we do, um, find that it is best to conduct our neuropsych evaluation when they're early in remission, um, just so we're not getting some of those confounding, um, impacts, especially on like processing speed if they're taking any, um, illicit drugs or illicit substances. And now, jump to uh treatment. So, oh, oops, I'm sorry, that wasn't supposed to be there. But there are 4 broad categories. It's the pharmacological, which is kind of the second generation of antipsychotics. We see a response rate about 60 to 80%, and then as you all know, there's some side effects, um, as well as some difficulties with adherence. Cognitive cognitive remediation, um, this targets cognitive deficits, and this is actually giving them like specific ways of, um, problem solving and doing different games and different activities to kind of rebuild those cognitive skills. And then neurostimulation, uh, kind of TMS is one, and I know, um, that DBS might eventually be kind of a possibility for, for neuropsychiatric disorders, but right now, TMS is kind of um Like number one. And then psychosocial interventions, I will actually pass over to Yasmine so she can go over those. Uh, so I'm gonna, just like Diana said, I'm going to be talking about the psych the psychological interventions and support options for psychosis. Uh, therapies for psychotic disorders include a variety of psychotherapeutic approaches that focuses on like the emotional, the social, and behavioral changes. Um, therapies can take Take form, it can take several forms and each has its own benefits. So for example, individual therapy focuses on the person's personal experiences, their emotions, their goals. It allows individuals to better understand their symptoms and work through their like specific needs. Whereas a group therapy really foc on the other hand, it provides this like sense of social support. It allows individuals to share experiences with others and really help them develop the coping skills in a more interactive setting. So overall, these therapies help individuals like recognize and manage triggers, improve their quality of life, build resilience and coping skills, coping strategies. Um, they're also important for addressing other mental health conditions that they may occur, that may occur alongside psychosis and for improving social skills. One of, um, so talking about these therapies, one evidence-based approach is cognitive behavioral therapy, especially cognitive behavioral therapy for psychosis. This really helps patients understand how their symptoms and behaviors are connected. It's especially useful for managing symptoms like hallucinations or distressing beliefs. Another key part of treatment is family support and education, so families are taught about psychosis and learn how to communicate and problem solve together, and then when families are informed and involved, that really helps support for better recovery. We also have support programs which help address like underlying conditions like substance use that Deanna mentions. It provides like social support, social, social work and community support. So overall, psychosis what we want to get from this slide is treatment for psychosis is not just a one approach. It's a combination of therapies, um, social supports, support systems, and sometimes hospitalizations. All of these different variables really work together to support recovery. We also wanted to compare inpatient versus outpatient interventions for psychosis. So starting with inpatient care, this really takes place in a hospital setting, um, and research suggests mainly used for individuals experiencing acute or severe symptoms. The delivery is more intense, sessions are typically short, they're flexible and individualized. Uh, therapy is also built into the daily routine on the unit. In terms of interventions in the inpatient, patients may receive CBT adapted for acute symptoms alongside psychoeducation and coping skills training, and the main goal here in inpatient is really stabilization. And what stabilization really looks like is reducing severe symptoms like hallucinations, agitations, lowering that distress, um, and helping the patient gain some, some sort of insight. It's also preparing them for um transition into inpatient and outpatient care. So overall, inpatient looks at short term, focuses on stabilization and not full full recovery. On the other hand, we have outpatient care that could happen in the community, it could happen outside of the inpatient facility, which focuses really on long-term recovery. Um, the structure can still be pretty intense, especially in programs like intensive outpatient programs where patients really attend multiple sessions per week, not just once. Um, outpatient care, just like inpatient care uses a multidisciplinary approach like combining therapies and social support. Interventions like inpatient include like CBT. It could also include like group therapy, skills training, along with uh support for daily functioning. So the goal here really is the goal is a little bit different here where the focus is on reducing symptoms over time. Improving overall functioning, um, helping individuals maintain like engagement and treatment. It also acts as a bridge after hospitalization to like support patients as they transition back to daily life. So the takeaway here is, um, from the slide is really inpatient care focuses on stabilization while outpatient care really focuses on recovery and long-term management. So the role of a psychologist, um, psychologists play a central role, a central role across the settings. 1st, 1st, we, they might provide CBT like we talked about in the previous slide, um, assess cognitive functioning, they might guide interventions that target real-world outcomes. Importantly, they're part of a multidisciplinary system, so working with psychiatry and families and schools to really support that recovery. Um, I also wanted to highlight distraction techniques that are also used here. They're short, they're focused on intervention, focused interventions that can also really be used for acute episodes. So these activities really help redirect attention from distressing hallucinations or delusions and can be implemented across inpatient as well as outpatient settings. Um, because they're practical and easy to apply, they're particularly useful for maybe like The patient in the moment. So the key goals of these interventions are really with CBT and these distraction techniques are really to reduce distress associated with hallucinations and delusions and improve insight and coping strategies, as well as bridge that care from inpatient stabilization to ongoing outpatient recovery. Um, Deanna and I also wanted to highlight some resources and programs focused on psychosis and early interventions. Um, providers can use these as well to learn really a lot more about psychotic disorders, or they can use these resources to really share them directly with patients and families. So, the first part, um, The first, uh, column is really based on psychosis-focused resources, and looking across different resources, we found that these were the most, um, talked about in various sites. So the first one is the National Institute of Mental Health or NIMH and NAMI's Early Psychosis Program. This really provides like This website really provides education, research updates, and support for individuals, um, so individuals experiencing psychosis, especially early onset psychosis that we talked about. Uh, next is UCLA's CAPS program that offers really specialized assessment and early treatment for young people showing early signs of psychosis as well. Next, we had UCI, the LEAPS program, which really focuses on research and preventative studies aimed at like better understanding and reducing the risk of developing long-term psychosis. Um, next we have OnT Track and New York, which provides, uh, both educational resources as well as recovery-focused support for patients, families, and as well as clinicians. So this first group of resources really focused on helping ensure that individuals experiencing psychosis and as well as their families have access to the most up to-date education, as well as different support systems they could look at, as well as early intervention services. The second Uh, the second group, um, is crisis resources. So for crisis situations, providers, providers should really inform patients and families that immediate help is available if they're not able to access them quickly. So one is, as always, the call 911, go to the nearest emergency department, such as like Phoenix Children's Hospital, Nexus crisis text line, like text home, um, or you could text 741-741. The National Suicide and Crisis Lifeline, call or text 988, and as well as local resources such as Maricopa's County County Crisis Line served by Mercy Care, and then PCH also has internal procedures for managing safety concerns, which really looks at Which the 3 that, the 2 that we found that were pretty significant and related to psychosis is adults with safety concerns, emergency department procedure, and as well as addressing non-patient safety concerns on the medical floors, standard operating um procedures. So all these crises resources and procedures really help individuals experience psychosis, um, experiencing psychosis and their families access support, guidance, and urgent care when needed. One thing that we did wanna highlight is kind of this coordinated specialty care. Um, really the gold standard for early psychosis treatment is to integrate multiple modalities. So from the medical side, um, taking care of that piece with the medications and kind of that acute phase, the psychologist being able to give some of more of those psychosocial interventions, which are also very important, kind of for recovery and for gaining kind of back that functional um abilities. And then neuropsychology for kind of being able to track some of these changes and some of those cognition changes that we might be seeing kind of in this course that could um last for a long time because what we do find is especially in early onset psychosis, the earlier that we're able to um intervene and not have kind of this period where they're not giving, getting any services, Um, is really important to kind of their trajectory and kind of their prognosis. So the earlier that we can get in and And kind of assist and intervene through all of these different um specialties, just kind of leads to better outcomes, especially for our kids who, the younger you are, the worse your outcomes are. We want to make sure that early intervention is key, and that we're intervening as soon as we're, we're noticing things. So even if you're not sure, but there's some questions like, oh, This, this could be autism, this could be psychosis, kind of um reaching out to consult with maybe some of the, the psychology colleagues and then as needed, kind of the neuropsych as well. Um, same as you. So thank you all so much. I do apologize again for uh how late we started, but hopefully we got um through everything and if there's any questions, please uh let us know. Yeah, and these are the references we mainly used as well if there's more questions or that wasn't answered or something you'd like to delve deep more on. It looks like Dr. Crewer has a hand raised. Dr. Crewer, you can unmute and ask your question. Thanks. Yeah, great presentation, guys. I, I was curious, um, so I'm, I'm one of the neurologists, uh, on staff at Phoenix Children's. I, I was curious, uh, you mentioned CBT as being one of the important elements of, uh, you know, the, the interdisciplinary treatment for these patients, and I, I was curious to what extent, uh, when CBT is employed, does it focus on having the patients recognize their own psychotic symptoms, um, and, and then if, if so, uh. What are the usual uh approaches used in in CBT to then have that individual uh deal with those, those symptoms? Yeah. Um, so CBT, that's a really great question. Thank you. What it really targets, it's like for CBTP, so it's cognitive behavioral therapy for psychosis. It's the specialized form of CBT that's adapted for like hallucinations, delusions, or paranoia. And what it really targets is hearing voices like the auditory hallucinations, delusional beliefs, paranoia, suspiciousness, distress from unusual experiences, um, negative symptoms, so like that withdrawal or low motivation, and how CBTP works, uh, um, in regards to what research suggests is instead of arguing with the patient of like, that's not real, CBTP really helps examine. Um, the evidence for beliefs, it helps reduce distress from voices, and it really helps develop alternative explanations, improve coping strategies, and test beliefs with behavioral experiments. So if there's like that belief of, oh well, people are like watching me through cameras, CBTP CBTP's approach may be, well, let's explore when that's happening. Let's look for um confirming or disconfirming evidence. Let's try experiments, like let's, I don't know, let's change your routine, and let's, what it does is really reduce anxiety and conviction over time. Um. So what it really does is focuses on like the stress reduction, not forcing on, not forcing belief change, um, and it's usually the structured weekly sessions that occur between like 12 to 24, how many other sessions that are needed. Does that kind of answer the question? Yeah, that was great. Thank you so much. Of course, thank you. Is there anything you wanna add? Uh, I do, I do wanna say like with CBT, uh, for psychosis. This isn't always something that you're gonna be able to fully implement when someone's in a cute face. Um, Within their delusions or having um like hallucinations, you might not be able to go through like step by step, but there are different techniques that you can use, especially if you have a good relationship with uh your patient. So kind of building that trust is foundational for any work with someone with a psychotic disorder, and also, um, we approach this kind of as like a collaboration. And looking at how, like, They think and feel, and helping them to reframe it in a way that makes sense for them, and not imposing our own uh beliefs or like our own understandings to it, but helping them to develop a more adaptive way of kind of conceptualizing what they're going through. And it does work um when they are kind of on medication and they're in kind of in a like a stable place. Thank you. So any other questions? That was excellent. Mrs. Kara Lewis, thank you both for being here. We appreciate you. Um, what is the youngest age you can do sort of this type of CBT? Obviously, I know you talked about young onset conditions and very young onset conditions, but How, how young can they be or in terms of their cognitive ability to do the CBT? I think um, I don't know if I've ever seen an age specifically for CBT, um, for psychosis, but I do know they do have to have a certain level of cognitive like functioning and understanding, so being able to kind of reality test and kind of work through things. Is this real? Is this not real? Um, so, Probably more of like the older child would be like more beneficial than like a younger kid. Yeah, so kind of like the range of like 10 to 24. The other thing I might add to that is, of course, we're, we're thinking about children who um have those cognitive capabilities, and so if you have somebody who's experiencing developmental delays, that might not be the most appropriate, um, therapeutic approach. And for those that are a little bit more lower um functioning, uh, like in their cognition, that it is gonna be more family-based and community-based interventions and working with families on how to intervene and kind of how to keep their child safe. Yeah, there's multiple approaches to this is what we're trying to get at. Any other questions? OK. Well, Yasmin and Diana, it was wonderful to have you. We learned a lot. Um, thank you for everyone for attending. We appreciate your time. Thank you, everyone, everyone.
