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Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.

Early-onset psychosis and bipolar disorder

Psychiatry · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

RapidFull
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Behavioural crisis may conceal immediate medical or psychiatric danger

Command hallucinations, suicidal or violent intent, severe agitation, catatonia, rapidly fluctuating consciousness, delirium, intoxication, neurological signs or an inability to eat, drink or maintain basic safety requires urgent assessment rather than a routine diagnostic pathway.

Action: Secure a low-stimulation safe setting, assess ABCDE and glucose, obtain urgent senior paediatric, emergency and mental-health input, treat suspected intoxication or medical illness, and use the least restrictive lawful response. Do not leave the young person or family to manage an immediate risk while awaiting outpatient CAMHS or early-intervention review.

Synopsis

Recognise possible psychosis and episodic mania in children and adolescents, exclude medical and substance-related causes, secure timely specialist assessment, and deliver developmentally appropriate family-inclusive treatment with safe physical monitoring.

  • Possible psychosis includes hallucinations, delusional ideas, thought interference, disorganisation or functional decline, but developmental imagination, trauma phenomena, sleep transitions, substances and neurological illness can resemble it.
  • NICE advises referral without delay to CAMHS or an early-intervention service when a child or young person has transient or attenuated psychotic symptoms or other experiences suggestive of possible psychosis.
  • Sustained psychotic symptoms lasting four weeks or more warrant urgent specialist referral; do not wait for further deterioration or a complete primary-care diagnostic work-up.
  • Do not offer an antipsychotic merely for attenuated symptoms or to reduce future psychosis risk; offer indicated treatment for anxiety, depression, substance misuse or emerging personality difficulties while specialists monitor change.
  • For first-episode psychosis, NICE recommends oral antipsychotic medication together with family intervention and individual CBT, chosen collaboratively after discussing likely benefits and adverse effects.
  • Before antipsychotic treatment, record weight, height, waist and hip circumferences, pulse, blood pressure, fasting glucose or HbA1c, lipids, prolactin, movement findings, nutrition and activity; obtain ECG when NICE indications apply.
  • A bipolar diagnosis in young people requires specialist, prospective longitudinal assessment; episodic euphoria must be present for most of the day on most days for at least seven days when diagnosing mania.
  • Irritability alone is not a core diagnostic criterion for paediatric bipolar disorder, and depression plus a family history does not establish bipolar disorder.
  • Assess development, neurodivergence, trauma, culture, school, family, sleep and substances before attributing unusual communication or behaviour to psychosis or bipolar disorder.

    • Key red flags

    New confusion, fluctuating attention, fever, seizure, focal neurology, severe headache, movement disorder, autonomic instability or abrupt cognitive decline suggests an organic syndrome requiring urgent medical investigation.

    Command experiences, persecutory beliefs linked to action, weapons access, suicidal intent, severe self-neglect, dehydration, food refusal or inability to protect a dependent child requires same-day safety planning and escalation.

    Marked agitation, little or no sleep, disinhibition, grandiose risk-taking or psychotic behaviour may represent mania, intoxication or another acute state and should not be managed by telephone reassurance alone.

    Catatonic immobility, mutism, posturing, excitement or autonomic change is a medical and psychiatric emergency; antipsychotic treatment should not be improvised before expert review.

    Abuse, exploitation, trafficking, online coercion, substance supply or frightening experiences within the home may generate or shape symptoms and require a private safeguarding assessment.

    Investigation priorities

    01
    Developmental psychiatric interviewFirst step

    Define phenomenology, conviction, context, duration, mood linkage, functional change and the young person's explanation.

    Management branches

    Possible psychosisRefer without delay and preserve uncertainty

    Transient, attenuated or otherwise suggestive psychotic experiences occur without an immediate medical emergency.

    1. Assess phenomenology, development, function, sleep, mood, substances, suicide, violence, vulnerability, physical warning signs and safeguarding.
    2. Refer without delay to specialist CAMHS or an age-appropriate early-intervention service and provide a named urgent-return route.
    3. Treat established coexisting anxiety, depression or substance misuse, but do not use antipsychotic medication simply to prevent psychosis.

    Key medicines

    Aripiprazole for a bipolar I manic episode in an adolescentFor an adolescent aged 13 years or older with a moderate to severe bipolar I manic episode, give 2 mg orally once daily for 2 days using the 1 mg/mL oral solution, then 5 mg once daily for 2 days, then the recommended 10 mg once daily. Use for the minimum period needed for symptom control and no longer than 12 weeks. Doses above 10 mg daily are exceptional, require close monitoring and must not exceed 30 mg daily.Younger patients have higher adverse-effect risk. Discuss and monitor akathisia and other extrapyramidal effects, somnolence, fatigue, weight and metabolic change, cardiovascular status, impulse-control symptoms and CYP2D6 or CYP3A4 interactions. Higher doses have no demonstrated enhanced efficacy in this population and cause substantially more adverse effects.
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    Sources and review status6 sources · checked 27 Aug 2026 · clinical review pending+
    Sources

    Sources and review status

    National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.

    • NICE CG155 psychosis and schizophrenia in children and young peopleReferral, assessment, first-episode treatment, antipsychotic use and monitoring recommendations.
    • NICE CG185 bipolar disorder recommendationsAge-specific referral, longitudinal diagnosis and treatment principles for young people.
    • NICE QS80 psychosis and schizophrenia in children and young peopleQuality priorities for assessment, intervention and physical-health monitoring.
    • NHS psychosis overviewAccessible current UK description of symptoms, urgent help and causes.
    • NICE TA292 aripiprazole for adolescent bipolar I maniaLicensed age, indication and maximum twelve-week treatment recommendation.
    • Aripiprazole 5 mg tablets SmPCCurrent product-specific adolescent bipolar-mania initiation, target dose, duration and adverse-effect cautions.

    Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

    Authoring stateRapid draftClinical stateAwaiting reviewJurisdictionUnited Kingdom