Clinically Significant Neuroimaging Findings Among Pediatric Patients Presenting to the Emergency Department With Symptoms of Psychosis: A Multicenter Retrospective Study

Jennifer A Hoffmann^{1

2}, Tapan K Parikh³, Doug Lorenz⁴, Michael P Goldman⁵, Emily M Powers⁵, Shilpa J Patel⁶, Ilana S Lavina⁶, Theodore W Heyming⁷, Jasmin T England⁷, Mohsen Saidinejad⁸, Ilene Claudius⁹, Pallavi Ghosh¹⁰, Daniel J Shapiro¹¹, Tricia B Swan¹², Kamali L Bouvay¹³, Eileen Murtagh Kurowski¹⁴, Nadine M Smith¹⁵, Justin R Davis¹⁶, Alexander B Moxam¹⁷, Eli J Muhrer¹⁸, Rohit P Shenoi¹⁹, Elyse N Portillo²⁰, Ron L Kaplan²¹, Neil G Uspal²², Robert M Lapus²³, Andrea T Vo²⁴, Daniel B Fenster²⁵, Danielle B Barrocas²⁶, Deborah R Liu²⁷, Pradip P Chaudhari²⁷, Rachel Cafferty²⁸, Stephen B Freedman²⁹, Jerri A Rose³⁰, Megan F Evers³⁰, Ashley M Metcalf³¹, Fareed Saleh^{31

32}, Jennifer Dunnick³³, Raymond D Pitetti³³, Yashas R Nathani³⁴, Muhammad Waseem³⁵, Todd A Florin¹; Pediatric Emergency Medicine Collaborative Research Committee (PEMCRC) Psychosis Study Group

Affiliations

¹ Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA.
² Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.
³ Pritzker Department of Psychiatry and Behavioral Health, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA.
⁴ Department of Bioinformatics and Biostatistics, School of Public Health and Information Sciences, University of Louisville, Louisville, Kentucky, USA.
⁵ Yale University School of Medicine, New Haven, Connecticut, USA.
⁶ Division of Emergency Medicine, Children's National Hospital, Washington, DC, USA.
⁷ Department of Emergency Medicine, Children's Hospital of Orange County, Orange, California, USA.
⁸ The Lundquist Institute for Biomedical Innovation at Harbor UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, California, USA.
⁹ Harbor-UCLA, David Geffen School of Medicine at UCLA, Los Angeles, California, USA.
¹⁰ Children's Healthcare of Atlanta, Atlanta, GA, USA.
¹¹ Division of Pediatric Emergency Medicine, University of California, San Francisco, CA, USA.
¹² AdventHealth Ocala, Ocala, Florida, USA.
¹³ TriHealth Group Health Pediatrics and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.
¹⁴ Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.
¹⁵ Advocare Marlton Pediatrics, Marlton, NJ, USA.
¹⁶ Department of Pediatrics, University of Mississippi Medical Center, Jackson, Mississippi, USA.
¹⁷ Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, USA.
¹⁸ Charlie Health, Bozeman, MT, USA.
¹⁹ Division of Emergency Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA.
²⁰ Division of Pediatric Emergency Medicine, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA.
²¹ Department of Pediatrics, Division of Emergency Medicine, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, Washington, USA.
²² Seattle Children's Hospital, University of Washington School of Medicine, Seattle, Washington, USA.
²³ McGovern Medical School at UTHealth Houston, Houston, Texas, USA.
²⁴ Texas Children's Hospital, Houston, TX, USA.
²⁵ Department of Emergency Medicine, Columbia University Irving Medical Center, New York, New York, USA.
²⁶ Columbia University Irving Medical Center, New York, New York, USA.
²⁷ Children's Hospital Los Angeles, Keck School of Medicine at University of Southern California, Los Angeles, California, USA.
²⁸ Department of Pediatrics, Section of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA.
²⁹ Departments of Pediatrics and Emergency Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
³⁰ University Hospitals-Rainbow Babies & Children's Hospital, Case Western Reserve School of Medicine, Cleveland, Ohio, USA.
³¹ Rady Children's Hospital San Diego, San Diego, California, USA.
³² Department of Pediatrics, University of California-San Diego, San Diego, California, USA.
³³ Department of Pediatrics, Division of Pediatric Emergency Medicine, Duke University Hospital, Durham, NC, USA.
³⁴ Cook Children's Medical Center, Forth Worth, TX, USA.
³⁵ Lincoln Medical Center, Bronx, New York, USA.

PMID: 41025829
PMCID: PMC12517762
DOI: 10.1111/acem.70155

Clinically Significant Neuroimaging Findings Among Pediatric Patients Presenting to the Emergency Department With Symptoms of Psychosis: A Multicenter Retrospective Study

Jennifer A Hoffmann et al. Acad Emerg Med. 2025.

. 2025 Sep 30:10.1111/acem.70155.

doi: 10.1111/acem.70155. Online ahead of print.

Authors

Affiliations

¹ Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA.
² Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.
³ Pritzker Department of Psychiatry and Behavioral Health, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA.
⁴ Department of Bioinformatics and Biostatistics, School of Public Health and Information Sciences, University of Louisville, Louisville, Kentucky, USA.
⁵ Yale University School of Medicine, New Haven, Connecticut, USA.
⁶ Division of Emergency Medicine, Children's National Hospital, Washington, DC, USA.
⁷ Department of Emergency Medicine, Children's Hospital of Orange County, Orange, California, USA.
⁸ The Lundquist Institute for Biomedical Innovation at Harbor UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, California, USA.
⁹ Harbor-UCLA, David Geffen School of Medicine at UCLA, Los Angeles, California, USA.
¹⁰ Children's Healthcare of Atlanta, Atlanta, GA, USA.
¹¹ Division of Pediatric Emergency Medicine, University of California, San Francisco, CA, USA.
¹² AdventHealth Ocala, Ocala, Florida, USA.
¹³ TriHealth Group Health Pediatrics and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.
¹⁴ Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.
¹⁵ Advocare Marlton Pediatrics, Marlton, NJ, USA.
¹⁶ Department of Pediatrics, University of Mississippi Medical Center, Jackson, Mississippi, USA.
¹⁷ Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, USA.
¹⁸ Charlie Health, Bozeman, MT, USA.
¹⁹ Division of Emergency Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA.
²⁰ Division of Pediatric Emergency Medicine, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA.
²¹ Department of Pediatrics, Division of Emergency Medicine, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, Washington, USA.
²² Seattle Children's Hospital, University of Washington School of Medicine, Seattle, Washington, USA.
²³ McGovern Medical School at UTHealth Houston, Houston, Texas, USA.
²⁴ Texas Children's Hospital, Houston, TX, USA.
²⁵ Department of Emergency Medicine, Columbia University Irving Medical Center, New York, New York, USA.
²⁶ Columbia University Irving Medical Center, New York, New York, USA.
²⁷ Children's Hospital Los Angeles, Keck School of Medicine at University of Southern California, Los Angeles, California, USA.
²⁸ Department of Pediatrics, Section of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA.
²⁹ Departments of Pediatrics and Emergency Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
³⁰ University Hospitals-Rainbow Babies & Children's Hospital, Case Western Reserve School of Medicine, Cleveland, Ohio, USA.
³¹ Rady Children's Hospital San Diego, San Diego, California, USA.
³² Department of Pediatrics, University of California-San Diego, San Diego, California, USA.
³³ Department of Pediatrics, Division of Pediatric Emergency Medicine, Duke University Hospital, Durham, NC, USA.
³⁴ Cook Children's Medical Center, Forth Worth, TX, USA.
³⁵ Lincoln Medical Center, Bronx, New York, USA.

PMID: 41025829
PMCID: PMC12517762
DOI: 10.1111/acem.70155

Abstract

Background: The clinical utility of diagnostic neuroimaging for pediatric patients presenting to the emergency department (ED) for psychosis remains unclear. We sought to estimate the prevalence of and characteristics associated with clinically significant neuroimaging findings among pediatric patients presenting to the ED with symptoms of psychosis who had neuroimaging performed.

Methods: This retrospective cross-sectional study included visits by patients 5 to < 18 years old presenting with symptoms of psychosis to 28 EDs affiliated with the Pediatric Emergency Medicine Collaborative Research Committee from 2016 to 2019 and had neuroimaging performed. We estimated the rate of clinically significant neuroimaging findings, defined as those resulting in further testing, treatment, or medical admission, overall and by imaging modality. Multivariable logistic regression models examined presenting features associated with clinically significant findings.

Results: Clinically significant neuroimaging findings were identified in 5.4% (95% CI 4.2%, 6.9%) of 1118 ED visits (54% male, median [IQR] 14 [11-16] years old). Clinically significant findings occurred in 4.9% (34/699) of head computed tomography scans and 7.5% (45/604) of brain magnetic resonance imaging studies (p = 0.07). In a model that imputed missing data, no presenting features were associated with clinically significant neuroimaging findings. In a model that treated missing documentation as absence of the clinical feature, the adjusted odds of clinically significant neuroimaging findings were lower among ED visits by patients with suspected alcohol or substance use (aOR 0.38, 95% CI 0.16, 0.87).

Conclusion: Among pediatric patients presenting to the ED with symptoms of psychosis who had neuroimaging obtained, approximately 1 in 20 had clinically significant findings. Suspected alcohol or substance use was associated with lower odds of clinically significant neuroimaging findings, although this finding was not consistent across modeling approaches. Prospective studies are needed to definitively evaluate the utility of neuroimaging among children and adolescents presenting to the ED with symptoms of psychosis.

PubMed Disclaimer

Conflict of interest statement

TKP reports direct/indirect research funding for industry sponsored clinical trials from Alkermes, AbbVie, MindMed, Compass Pathways, Karuna Therapeutics, Cerevel, LB pharmaceuticals, Lyndra Therapeutics, Merck, Neurocrine Biosciences, Intra-Cellular Therapies, and Teva.

Figures

**Figure 1.. Flow Diagram for Case Inclusion/Exclusion**
ED: Emergency department

**Figure 2.. Factors Associated with Clinically Significant Neuroimaging among Children and Adolescents Presenting to the Emergency Department with Psychosis**
In the first model, imputation was used to handle missing data. In the second model, missing values (with no documentation of the clinical finding within clinician notes) were treated as absent. Neurological signs or symptoms included: headache, seizure, amnesia, weakness, sensory, vision change, gait change, meningismus, and/or focal neurologic deficit.

**Figure 3.**
Factors Associated with Clinically Significant Neuroimaging among Children and Adolescents Presenting to the Emergency Department with First-Episode Psychosis In the first model, imputation was used to handle missing data. In the second model, missing values (with no documentation of the clinical finding within clinician notes) were treated as absent. Neurological signs or symptoms included: headache, seizure, amnesia, weakness, sensory, vision change, gait change, meningismus, and/or focal neurologic deficit. ED: Emergency department.

See this image and copyright information in PMC

References

1. McClellan J Psychosis in Children and Adolescents. J Am Acad Child Adolesc Psychiatry. 2018;57(5):308–12. - PubMed
1. World Health Organization World Health Report, Chapter 2: Burden of Mental and Behavioural Disorders. 2001.
1. Cutler GJ, Rodean J, Zima BT, et al. Trends in Pediatric Emergency Department Visits for Mental Health Conditions and Disposition by Presence of a Psychiatric Unit. Acad Pediatr 2019;19(8):948–55. - PMC - PubMed
1. Hoffmann JA, Carter CP, Olsen CS, et al. Pediatric mental health emergency department visits from 2017 to 2022: A multicenter study. Academic emergency medicine 2024; - PubMed
1. Algon S, Yi J, Calkins ME, Kohler C, Borgmann-Winter KE. Evaluation and treatment of children and adolescents with psychotic symptoms. Curr Psychiatry Rep. 2012;14(2):101–10. - PMC - PubMed

Grants and funding

LinkOut - more resources

Full Text Sources

Save citation to file

Email citation

Add to Collections

Add to My Bibliography

Your saved search

Create a file for external citation management software

Your RSS Feed

Clinically Significant Neuroimaging Findings Among Pediatric Patients Presenting to the Emergency Department With Symptoms of Psychosis: A Multicenter Retrospective Study

Affiliations

Clinically Significant Neuroimaging Findings Among Pediatric Patients Presenting to the Emergency Department With Symptoms of Psychosis: A Multicenter Retrospective Study

Authors

Affiliations

Abstract

Conflict of interest statement

Figures

References

Grants and funding

LinkOut - more resources

Full Text Sources