Psychiatry Case Challenge: A 9-Year-Old With Suicidal Behavior

James Robert Brasic, MD, MPH


January 25, 2022

This child presented with a psychosis manifested by auditory hallucinations and delusions that the devil was telling him to kill himself. After a few days of hospitalization and treatment with 5 mg molindone, a dopamine receptor-blocking drug (orally twice daily), the auditory and visual hallucinations and thoughts of killing himself and others subsided. The length of time experiencing these symptoms and the resolution of the symptoms by treatment with antipsychotic medication in the therapeutic milieu of an inpatient child psychiatric unit merited the diagnosis of brief reactive psychosis for this child. If these symptoms and signs had persisted for longer, then a diagnosis of schizophrenia would have been more likely but is not supported at this point.

Schizophrenia is a lifelong, severe mental illness characterized by marked abnormalities in thinking and behavior. Family history of schizophrenia is significant as well. Although schizophrenia usually has an onset in late adolescence or young adulthood, it may occur in children. Schizophrenia presents with positive, negative, and cognitive symptoms. Some symptoms of schizophrenia include the following[19]:

  • Hallucinations

  • Sensory perceptions without environmental stimuli

  • Delusions

  • Fixed false beliefs

  • Thought disorders

  • Abnormal thought processes

  • Movement disorders

  • Unwanted adventitious motions

  • Flat affect

  • Diminished emotional expression in tone of voice

  • Diminished pleasure in life

  • Diminished ability to start and complete tasks

  • Diminished speaking

  • Problems with executive function

  • Diminished attention

  • Problems with working memory

A key point in the evaluation and the treatment of a child is the assessment of the risk for harm to self and to others. This child repeatedly assaulted others. He made severe acts to injure himself. He repeatedly reported hearing the voices of devils telling him to kill himself. Suicidal and homicidal reports must be taken seriously even when reported by children who may have limited resources to carry out successful suicidal and homicidal plans.

Children can kill others and themselves. The expression by a patient of the intention to execute a plan to kill himself or herself or others is grounds for the involuntary hospitalization of the patient. Suicidal and homicidal threats from children, adolescents, and adults must be taken seriously, as the adage holds "better safe than sorry." Hospitalization is mandatory for patients with suicidal or homicidal ideation.


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