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Adolescents’ selfie-taking and selfie-editing: A revision of the photo manipulation scale and a moderated mediation model

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• Published: 10 April 2021
• Volume 42 , pages 3460–3476, ( 2023 )

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• Francesca Gioia 1 ,
• Siân McLean 2 ,
• Mark D. Griffiths 3 &
• Valentina Boursier   ORCID: orcid.org/0000-0003-0899-8090 1  

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‘Selfie practices’ (e.g., editing, filtering, sharing) have become adolescents’ daily behaviors. The increasing centrality of online visual self-presentation might increase adolescents’ appearance-related concerns, problematic monitoring, and photo manipulation (PM). However, few studies focused on body image control in photos (BICP) and PM, and no studies evaluated the influence of selfie-expectancies on photo-taking and photo-editing. Consequently, two studies were conducted. Study1 psychometrically evaluated the PM scale ( N  = 1353). Study2 evaluated the mediating role of BICP and the moderating role of gender in the relationship between selfie-expectancies and PM ( N  = 453). The revised PM scale showed good psychometric properties. BICP mediated the relationship between selfie-expectancies and PM and being male significantly affected the relationship between the variables. Implications for adolescents’ appearance-related issues are discussed.

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Introduction

In contemporary society, web-based communication via social networking sites (SNSs) represents a widespread daily activity, especially among adolescents and young adults (e.g., Boursier & Manna, 2018a , 2018b ; D’Arienzo et al., 2019 ; Gioia & Boursier, 2019b ; Kırcaburun et al., 2019 ; Kuss & Griffiths, 2017 ). In early 2021, there were more than 4.2 billion active social media users (We Are Social, 2021 ) and teenagers comprised a high percentage of this total. More specifically, high proportions of adolescents aged 13 to 14 years (79%) and 15 to 17 years (84%) had active social media profiles (Mascheroni & Ólafsson, 2018 ) suggesting that social media is pivotal in adolescents’ social interactions and leisure activities (Bryant & Bryant, 2005 ; Musetti et al., 2020 ). A key feature of the online platforms favored by adolescents is the highly visual nature of the interactions those platforms afford. According to recent findings, SNSs appear to promote increasing amounts of digital visual content (Feltman & Szymanski, 2018 ), transforming contemporary everyday life to a “more photographic” life (d'Aloia & Parisi, 2016 ; p. 3) in which editing, filtering, posting, sharing, tagging, and commenting have become natural daily behaviors (d'Aloia & Parisi, 2016 ; Fox & Vendemia, 2016 ). In this regard, selfie-taking and selfie-sharing constitute two of the most popular activities carried out on SNSs (Balakrishnan & Griffiths, 2018 ; Diefenbach & Christoforakos, 2017 ; Fox & Vendemia, 2016 ; Katz & Crocker, 2015 ; McLean et al., 2019 ; Sung et al., 2016 ), and their use might be defined as a “way of being” (Griffiths & Kuss, 2017 , p.1).

The “selfie” has been defined as self-taken photograph, typically taken with smartphones or webcams and shared on social media (Oxford Dictionary, 2013 ) and specific selfie-related activities as selfie-taking and -posting have been described as gendered processes (Albury, 2015 ) in which traditionally females showed higher engagement (Boursier & Manna, 2018b ; Boursier et al., 2020c ; Chae, 2017 ; Dhir et al., 2016 ; Nguyen, 2014 ; Qiu et al., 2015 ; Sorokowska et al., 2016 ). However, both males and females seemed to utilize selfies for self-presentation purposes (Dutta et al., 2016 ; Guo et al., 2018 ; Katz & Crocker, 2015 ) and the inclusion of both boys and girls, has been defined crucial (McLean et al., 2019 ). Overall, the taking and sharing photos by individuals may appear to be straightforward and innocuous activities, selfie behavior represents a nuanced, complex, and multidimensional phenomenon reflecting selfies intentional creation, and comprises multiple actions including taking (such as preparation and posing), modifying (such as editing and filtering), and posting onto SNSs (McLean et al., 2019 ). This phenomenon requires further research (Boursier & Manna, 2018b ; Bruno et al., 2018 ; McLean et al., 2019 ) to more fully understand the possible risks and opportunities related to selfie behavior (e.g., Boursier et al., 2020a ; Boursier et al., 2020c ; Boursier & Manna, 2018b ; Diefenbach & Christoforakos, 2017 ; McLean et al., 2019 ). Concerning the opportunities offered by selfie-taking and selfie-sharing, some studies have shown that these activities appear to (i) provide new material for creative works, allowing creators to manage emotions (Bruno et al., 2018 ; Diefenbach & Christoforakos, 2017 ), (ii) improve individuals’ self-esteem and mood due to “likes” and positive feedback received from others (Reich et al., 2018 ; Toma, 2013 ), (iii) enhance self-confidence and self-attractiveness (Boursier & Manna, 2018b ; Grogan et al., 2018 ), and (iv) contribute to relationship construction (Chua & Chang, 2016 ; Sorokowska et al., 2016 ; Taylor et al., 2017 ). Other studies have found that selfie-taking and selfie-sharing represent habitual behaviors that help pass the time, facilitated by needs to belong, document, archive, retain special moments, and be creative (Bij de Vaate et al., 2018 ; Etgar & Amichai-Hamburger, 2017 ; Sung et al., 2016 ). Additionally, empirical findings have highlighted the value of selfies as a medium for self and identity exploration, allowing self-study and self-observation among young individuals (Diefenbach & Christoforakos, 2017 ; Rutledge, 2013 ). However, highly appearance-focused self-presentation, which appears to be a crucial element in selfie-presentation, may also afford risks, particularly in relation to young individuals’ body image (Boursier & Manna, 2018b ; Boursier et al., 2020a , 2020c ; Chae, 2017 ; Bij de Vaate et al., 2018 ; Diefenbach & Christoforakos, 2017 ; Lowe-Calverley & Grieve, 2018 ; Lyu, 2016 ; McLean et al., 2019 ; Yau & Reich, 2019 ), including selfie-related problematic behaviors (Balakrishnan & Griffiths, 2018 ; Griffiths & Balakrishnan, 2018 ; Monacis et al., 2020 ).

Body image typically plays a pivotal role in adolescent development and wellbeing and, during adolescence, boys and girls are typically required to face with physical changes, “new” body mentalization, and identity construction processes (de Vries et al., 2016 ; Franchina & Lo Coco, 2018 ; Markey, 2010 ; Rudd & Lennon, 2000 ). In this regard, social media might represent ideal places for adolescents’ identity construction and exploration processes (Kuss & Griffiths, 2017 ; Pelosi et al., 2014 ), and selfies might represent a medium for self-exploration, promoting self-study, and self-observation (Diefenbach & Christoforakos, 2017 ; Rutledge, 2013 ). Nevertheless, the increasing centrality of photos and visual self-presentation on SNSs may enhance young people’s appearance-related concerns and potentially problematic monitoring of their own body image and photos (Fox & Vendemia, 2016 ; Perloff, 2014 ). In this regard, the self-objectification theory (Fredrickson & Roberts, 1997 ; McKinley & Hyde, 1996 ), seems to offer a useful framework through which specific selfie behaviors and the risks imparted by those behaviors have been examined. Indeed, this perspective highlighted individuals’ tendency to experience and consider the body as an object assuming an observer’s point of view. Therefore, how the body appears represents something to control in order to meet socio-cultural internalized body ideals and avoid negative judgements. In this perspective, a positive association between levels of self-objectification and selfie activities has been previously stated, including selfie-posting among adolescent girls (Meier & Gray, 2014 ; Zheng et al., 2019 ), and selfie-editing among both early adult women (Bell et al., 2018 ; Veldhuis et al., 2020 ; Cohen et al., 2018 ), and young adult men (Fox & Rooney, 2015 ). Furthermore, in prospective analyses among adolescent boys and girls, reciprocal relationships between selfie behaviors and self-objectification have been observed whereby selfie-viewing and selfie-editing predicted increases in self-objectification and baseline levels of self-objectification were also found to predict increases in selfie viewing, editing, and posting (Boursier et al., 2020c ; Wang et al., 2019 ). As Diefenbach and Christoforakos ( 2017 ) stated, the self-camera might act as a mirror, or form of monitoring reflective of self-objectification, leading to an over-controlled self-presentation on SNSs that begins when taking a photo. According to previous studies (Boursier & Manna, 2019 ; Bij de Vaate et al., 2018 ; McLean et al., 2015 ; Pelosi et al., 2014 ), photo investment and control over body image in pictures represent adolescents’ and emerging adults’ attempt to manage concerns about their own self-portrait quality and how they portray themselves, following specific strategies in taking and choosing selfies before sharing online. It is likely that disembodied, asynchronous, and often, anonymous SNS environments allow individuals to present their best and ideal self on SNSs through photo-based activities, including editing, leading to some individuals problematically overinvest in their online body image (Boursier & Manna, 2018b ; Casale & Fioravanti, 2017 ; Cohen et al., 2018 ; Bij de Vaate et al., 2018 ; Fox & Rooney, 2015 ; Fox & Vendemia, 2016 ; Lonergan et al., 2019 ; McLean et al., 2015 ; Zhao et al., 2008 ). As Chen et al. ( 2019 ) noted, SNSs provide endless opportunities for individuals to share their own best self (often digitally modified and edited) to others, which may alter their perception of beauty and authenticity (Diefenbach & Christoforakos, 2017 ; Rajanala et al., 2018 ).

Previous studies have defined photo manipulation as the alteration and enhancement of selfies and photos through editing programs, computer software, or smartphone apps, before sharing on social media (Chae, 2017 ; McLean et al., 2015 ). Similar to photo investment, selfie-editing also appears to be related to individuals’ virtual makeovers, fulfilling their desire to create an ideal online self-presentation (Chae, 2017 ; Lowe-Calverley & Grieve, 2018 ). In this regard, females have been found active in manipulating photos and using photographic filters, more than male peers (Chae, 2017 ; Dhir et al., 2016 ; McLean et al., 2015 , 2019 ; Mingoia et al., 2019 ). Differently, according to Mascheroni et al. ( 2015 ), both male and female adolescents reported commonly editing their pictures (such as smoothing out skin, making body parts smaller or bigger, adding interactive filters), in order to convey an ideal appearance, gain an ideal form of online self-presentation, and receive positive feedback (such as ‘likes’ or comments) (Boursier & Manna, 2018b ; Chae, 2017 ; Chua & Chang, 2016 ; Nelson, 2013 ; Rajanala et al., 2018 ). In this regard, according to McLean et al. ( 2019 ), digital manipulation of photos and their posting on social media might generate social comparison with an ideal, but unrealistic, own and peers’ online self-presentation, especially among adolescents. However, as Bij de Vaate et al. ( 2018 ) noted, scholarly research tends to focus on selfie-posting behavior, whereas very few studies have explored selfie practices emphasizing photo investment, manipulation, and underlined motivations as possible predictors (Bij de Vaate et al., 2018 ; Chae, 2017 ; Dhir et al., 2016 ; McLean et al., 2015 , 2019 ). Indeed, personal expectancies (in particular positive outcome expectancies) have been identified as pivotal influence factors in individuals’ decisions and behaviors (Dermen & Cooper, 1994 ; Patrick & Maggs, 2009 ; Reich et al., 2010 ), and likely expectancies would have a role in influencing decisions and behaviors related to the multidimensional nature of taking, modifying, and posting selfies. However, to date, few studies have explored motives and expectancies underlying selfie practice during adolescence (i.e., Boursier & Manna, 2018b ; Bij de Vaate et al., 2018 ). An exception is the study by Boursier and Manna ( 2018b ) who developed a measure to facilitate exploration of adolescents’ motives and expectancies underlying selfie practice. They identified three kinds of selfie-related expectancies: positive (i.e., self-presentation, self-promotion, self-confidence, and self-attractiveness), negative (i.e., lack of control of own photos, privacy concerns, web exposure, and the possible effects on significant relationships), and neutral expectancies (i.e., selfie-making as a daily activity). Although few studies have examined motives among adolescents, some research has explored motives underlying selfie practices in other populations. This research has recognized entertainment, communication, and special moment retention as the main motivations for selfie-posting among emerging and young adults and among parents (Boursier et al., 2020c ; Bij de Vaate et al., 2018 ; Sung et al., 2016 ). Nevertheless, further research is needed.

In summary, previous studies confirm that selfie practice is a widespread daily activity and the increased social media use for sharing personal photos make adolescent body image an extremely contemporary issue (Boursier & Manna, 2019 ; Franchina & Lo Coco, 2018 ; Pelosi et al., 2014 ). Moreover, gender-related differences in selfie practices have been found, showing a traditionally higher engagement in selfie-taking, selfie-posting, and selfie-editing by girls compared with boys. Overall, selfie behavior appears to be a complex phenomenon that comprises not only selfie-sharing on social media but also taking and editing personal photos following specific control and manipulation strategies. However, according to the aforementioned literature, few studies have explored expectations underlying selfie-taking and selfie-editing as predictive factors of these behaviors. Therefore, in light of the popularity of selfie-taking and posting, as well as a new appreciation of the ease with which selfies may be edited and manipulated, the present paper comprises two related studies. The first study reports the adaptation, validation, and psychometric evaluation of the Photo Manipulation Scale (McLean et al., 2015 ) among an Italian adolescent sample. The second study aimed at evaluating the main and indirect effects of expectancies underlying selfie practice and appearance management in photos on adolescents’ photo manipulation while exploring the moderating role of gender in a mediation model. It has been hypothesized that selfie-related expectancies might positively cross-sectionally predict adolescents’ body appearance control and selfie-management (such as selfie-editing) before sharing online. Moreover, it was expected that gender would affect the relationship between selfie expectancies and photo manipulation.

The first study tested the psychometric properties of the Italian version of the 10-item Photo Manipulation Scale (PMS; McLean et al., 2015 ) among a large sample of Italian adolescent boys and girls. McLean et al. ( 2015 ) defined photo manipulation as the alteration of photo elements (easily available using editing programs or apps), prior to sharing online. According to Mascheroni et al. ( 2015 ) both boys and girls commonly report editing their own photos (for example, smoothing out skin, making body parts smaller or bigger, adding filters such as a crown of flowers or puppy ears), before sharing on social networking sites, to convey an ideal appearance and achieve an ideal form of online self-presentation, and to receive positive feedback (such as ‘likes’ and supportive comments) (Boursier & Manna, 2018b ; Chae, 2017 ; Chua & Chang, 2016 ; Nelson, 2013 ; Rajanala et al., 2018 ). Translation of the measure and subsequent investigation of its psychometric properties will facilitate further research on the antecedents and consequences of photo manipulation, such as appearance monitoring, body concerns and dissatisfaction, self-esteem, self-promotion, and social comparison (e.g., Ahadzadeh et al., 2017 ; Chae, 2017 ; Chen et al., 2019 ; Diefenbach & Christoforakos, 2017 ; Lyu, 2016 ; McLean et al., 2019 ). Therefore, the aim of the first study was to evaluate the factor structure of a revised version of PMS (McLean et al., 2015 ) among a sample of Italian adolescents.

Participants and Procedure

A total of 1353 adolescents were recruited from six Italian high schools. The school principals and parents were informed of the nature of the research and the measures used in generating the data, and they gave their consent for their children to participate. General information about the aim of the study was also announced in class. Participation was voluntary, confidentiality was assured, and all participants were informed that they could withdraw from the study at any time. All students agreed to participate and completed the survey questionnaires in a classroom setting via their smartphones, while researchers and teachers supervised the survey completion. The study was approved by the research team’s University Research Ethics Committees and was conducted in accordance with the ethical guidelines for psychological research by the Italian Psychological Association.

Participants’ reported their gender and age. They were then asked to complete the Italian version of the Photo Manipulation Scale (McLean et al., 2015 ). The scale comprises 10 items rated on a five-point-Likert scale, from 1 ( Never ) to 5 ( Always ) and evaluates how often adolescents manipulate and edit photos of themselves prior to sharing on SNSs (for example, “ How often do you make yourself look skinnier? ”, “ How often do you adjust the light/darkness of the photo? ”). Due to the increasing use of interactive filters among teenagers, in the present study, an extra item was added (“ How often do you use interactive filters [e.g., puppy ears, crown of flowers, etc.]? ”). Two independent researchers translated the original 10-item PMS and then, in order to minimize the risk of linguistic distortions, it was back-translated (adding the new item concerning the use of interactive filters) into English by a professional English-speaking translator (Van de Vijver & Poortinga, 2004 ). The final Italian version of PMS did not show meaningful differences from the original English version. In the present study, the 11-item revised PMS was used.

Statistical Analysis

The suitability of the data for factor analysis was tested with the Kayser–Meyer–Olkin (KMO) measure of sampling adequacy and Bartlett’s test of sphericity. Later, the exploratory factor analysis (EFA) was conducted, and the factor structure based on EFA was confirmed through confirmatory factor analysis (CFA) with independent samples. The two samples were obtained on two different occasions of data collection. The first involved 653 adolescents (Sample 1) to perform an initial EFA on the original 11-item PMS. In the second, 700 participants (Sample 2) were recruited to conduct the CFA. Due to items’ deviation from the normal distribution, in all structural equation modeling analysis, maximum likelihood estimation robust to non-normality (MLR) in Mplus 8 was used (Muthén & Muthén, 2012 ). To evaluate the overall model fit, several indexes were used: the comparative fit index (CFI) and the Tucker-Lewis Fit Index (TLI), for which values higher than 0.90 are desired (Bentler, 1990 ); root mean square error approximation (RMSEA) for which values smaller than 0.08 are desired (Browne & Cudeck, 1993 ); and the standardized root mean square residuals (SRMR) for which value below 0.08 is considered a good fit (Kline, 2015 ). To evaluate the internal consistency of the scale, both Cronbach’s α and Spearman-Brown coefficients were computed.

Descriptive Statistics

Sample 1 ( N  = 653) comprised 361 girls (55.3%) and 292 boys (44.7%) with a mean age of 16.4 years (SD = 3.06 years). Sample 2 ( N  = 700) comprised 351 girls (50.1%) and 349 boys (49.9%) with a mean age of 16.1 years (SD = 1.52 years).

Exploratory Factor Analysis

According to the KMO criterion, sampling adequacy was very good (KMO = 0.87). Bartlett’s test of sphericity showed that the correlation matrix was suitable for factor analysis (χ 2  = 2272.63, df = 55, p  < 0.001). In Sample 1 ( N  = 653), the EFA was performed with MLR estimator and goemin oblique rotation to evaluate the factor structure of the 11 items. The acceptability of the factor solution was based on goodness of fit index, the interpretability of the solution, and salient factor loadings (.30). Firstly, according to the mono-factorial structure of the original Selfie Manipulation Scale (McLean et al., 2015 ), one-factor solution has been tested. However, the obtained fit was inadequate. Similarly, the two-factor solution provided an inadequate fit. Thus, a three-factor solution has been tested, providing the first adequate fit to the data, MLRχ 2 (25) = 38.368, p  = .04; CFI = .99; TLI = .98; RMSEA = .03, 90% confidence interval (C.I.) [.005–.046]; SRMR = .02 (Table 1 ). Factor loadings are presented in Table 2 . For the further development of this scale, items were selected according to the following criteria. First, items that had factor loadings lower than 0.30 were excluded. Second, items with salient cross-loadings of greater than 0.30 on two or more factors were excluded from further analyses. The three excluded items are in highlighted in italics in Table 2 . As a result of the aforementioned criteria, Items 1, 3, and 8 of the original 11 items were subsequently removed from the final revised PMS.

Confirmatory Factor Analysis

Based on the previous EFA, a three-factor solution was tested with CFA on Sample 2 ( N  = 700). This model provided a good fit to the data (MLRχ 2 [17] = 72.771, p  < .001; CFI = .95; TLI = .91; RMSEA = .068, 90% C.I. [.053–.085]; SRMR = .045) (Fig.  1 ). The first factor comprised three items concerning the use of filters to modify or adjust the overall look of the photo (e.g., colors, brightness, contrast, etc.). This first factor was named photo filter use . The second factor comprised three items concerning body image modification. These items referred to making specific parts of the body look larger or smaller and making body shape skinnier or larger. This second factor was named body image manipulation . The third factor was named facial image manipulation and comprised two items concerning digitally correcting skin imperfections improving facial image. A second-order CFA has been tested where a second-order dimension labeled photo manipulation loaded on the three first-order dimensions. This model showed a very good fit, MLRχ 2 [17] = 72.770, CFI = .95; TLI = .91; RMSEA = .068, 90% C.I. [.053–.085]; SRMR = .045). Loadings of the second-order dimension on the first-order dimensions ranged between .60 and 1.02. The revised eight-item PMS showed good Cronbach’s α value (.80), lower but comparable to the Cronbach’s α value (.85) in the original study of McLean et al. ( 2015 ). The Cronbach’s α values for PMS subscales were .67 ( photo filter use ), .75 ( body image manipulation ) .74 ( facial image manipulation ). Moreover, due to the changed length of the scale, the Spearman-Brown coefficients for the PMS and the two-item facial image manipulation subscale were tested, showing a good reliability (.78 and .75, respectively). Means, standard deviations, and bivariate correlations among factors of the eight-item PMS are shown in Table 3 .

First order three-factors model and second order factor tested with confirmatory factor analysis. Note. Errors associated three latent variables are not showed in order to improve figure readability. *** p  < .001

Brief Discussion

The three-factor model of the eight-item PMS provided a good fit to the data (Table 1 ) and all items loaded significantly on their respective latent factors (Fig. 1 ). The PMS showed a good internal consistency and a good reliability despite the shorter length of the scale compared to the original PMS (McLean et al., 2015 ). Furthermore, the factors of the 8-item PMS (photo filter use, body image modification, and facial image manipulation) significantly and positively correlated with one another. A second-order dimension loaded on the three first-order dimensions indicating that a global score of photo manipulation might be reliably computed and used. Finally, the eight-item PMS showed an optimal Cronbach’s α, indicating a good internal consistency reliability of the instrument.

Despite the popularity of selfie-related activities on social media, especially among young people, scientific interest appears limited to selfie-posting, demonstrating a lack of attention to photo manipulation and its predictors (e.g., Bij de Vaate et al., 2018 ; Chae, 2017 ; Dhir et al., 2016 ; McLean et al., 2015 , 2019 ). Bij de Vaate et al. ( 2018 ) showed that prior to sharing self-portrays online, specific steps can occur. First, individuals might have specific motives (such as peer pressures, entertainment, habitual passing of time, and social interactions) and preoccupations (such as looking at, tagging, sharing, and commenting friends’ visual content) concerning selfie-taking. Second, after taking several photos, selfie-makers might strategically select the perceived best photo they would like to share on social media. Thirdly, individuals might apply filters and/or manipulate the photos and, finally, they will post the selfie(s). The second and third steps may be undertaken to achieve specific motives and in response to particular preoccupations. Moreover, other studies have examined gender-related differences in selfie investment and manipulation, showing that female adolescents are more active in selfie-taking and selfie-posting, and manipulating photos and using photographic filters more than male adolescent SNS users (Dhir et al., 2016 ; McLean et al., 2019 ). However, despite previous studies suggesting that motivations and expectancies play a pivotal role in determining young people’s general behaviors and specific selfie-related activities (Boursier et al., 2020c ; Dermen & Cooper, 1994 ; Patrick & Maggs, 2009 ; Reich et al., 2010 ), no previous studies have evaluated the possible predictive role of boys’ and girls’ selfie-expectancies (Boursier & Manna, 2018b ) concerning body image control and manipulation in photos, prior to sharing them online. Therefore, the second study tested a moderated mediation model, and evaluated the main and indirect effects of teens’ selfie-expectancies and selfie appearance management on photo manipulation and the moderating role of gender in this mediation model. It was expected that selfie-expectancies would be positively associated with photo manipulation and that this relationship would be mediated by selfie appearance management such that higher selfie expectancies would be associated with greater selfie appearance management, which would, in turn, be associated with greater frequency of manipulation of photos. In relation to gender moderation, it was expected that female gender would moderate the relationship between selfie expectancies and photo manipulation. This mediation and moderation models are presented in Figs.  2 and 3 .

The proposed mediation model

Conceptual model of the moderated mediation relationship. Note: Gender should moderate the relationship between adolescents’ selfie-expectancies and photo manipulation

A total of 453 adolescents from four different Italian high schools (47% males; mean age = 16.1 years, SD = 1.46) participated in a survey study. General information about the aim of the study, nature of the research, and the measures to be used in generating the data were provided to school principals, parents, and students who gave their consent. Adolescents’ participation was voluntary, confidentiality was assured, and all participants were informed that they could withdraw from the study at any time. All students agreed to participate and completed the survey questionnaires in a classroom setting via their smartphones, supervised by teachers and researchers. No course credits or remunerative rewards were given for participation. The study was approved by the research team’s University Research Ethics Committees and was conducted in accordance with the ethical guidelines for psychological research by the Italian Psychological Association.

Selfie-Expectancies Scale (SES)

The SES (Boursier & Manna, 2018b ) evaluates positive and negative expectancies concerning selfie-behavior. The scale comprises 23 items corresponding to seven different factors: relational worries (e.g., “How much selfie-taking might damage your reputation?” ), web-related anxieties (e.g., “How much selfie-taking might worry you because your photos/identity could be stolen?” ), sexual desire (e.g., “How much selfie-taking improves your sexual fantasies?” ), ordinary practice (e.g., “How much selfie-taking is a habit?” ), self-confidence (e.g., “How much selfie-taking improves your self-esteem?” ), self-presentation (e.g., “How much selfie-taking is a way to show to the others the best part of you?” ), and generalized risks (e.g., “How much selfie-taking might cause you problems in the future?” ). Each item is answered on a five-point Likert scale ranging from 1 ( totally disagree ) to 5 ( totally agree ). In the present study, the Cronbach’s α values for each SES subscale ranged from .65 to .87, comparable with the values (ranged from .60 and .86) reported in the original study (Boursier & Manna, 2018b ).

Body Image Control in Photos-Revised (BICP-R)

The original Body Image Control in Photos scale (Pelosi et al., 2014 ) was a 27-item scale, rated on a five-point-Likert scale from 1 ( Never ) to 5 ( Always ) and assesses adolescents’ photo management and control online and offline. Boursier and Manna ( 2019 ) revised and reduced the length of the original instrument. The short version comprises 16 items corresponding to five different factors: selfie-related factors (e.g., “ I prefer my image as it appears in self-portraits, because I know how to make it look better ”), privacy filter behaviors (e.g. “ I use privacy filters in order to show photos in which I appear more attractive only to certain people ”), positive body image factors (e.g., “I post those photos which I hope will receive praise for my appearance” ), sexual attraction factors (e.g., “ I have posted provocative photos on Facebook, in order to attract attention to myself ”), and negative body image factors (e.g., “ I feel awkward if I notice that someone has posted photos that show my body’s defects ”). In order to improve the interpretability, the name of BICP-R factors was modified compared to the previous version of the scale (Boursier & Manna, 2019 ). In the present study, the Cronbach’s α value for the scale was good (.81) and Cronbach’s α values for each BICP-R subscale ranged from .62 to .76, like the values (ranged from .65 and .77) of Boursier and Manna’s ( 2019 ) study. There, Boursier and Manna ( 2019 ) also established a cut-off score for identifying individuals who problematically control their body image in photos and identified four categories: occasional (scores of 0–24), habitual (scores of 25–50), at-risk (scores of 51–55), and problematic (scores higher than 55).

Photo Manipulation Scale-Revised (PMS-R)

The PMS, revised to an eight-item scale and validated in study 1 (original English version, McLean et al., 2015 ), was used in this second study to assess the frequency of photo manipulation. The global score of photo manipulation has been computed and used. According to the internal consistency values showed in Study 1 (.80) and in the original study of McLean et al. ( 2015 ) (.85), the Cronbach’s α value for the PMS-R was good (.79).

All statistical analyses were performed using the Statistical Package for Social Sciences SPSS (Version 23 for Windows). Firstly, skewness and kurtosis were calculated revealing that normality was met for all the study variables. Secondly, means, standard deviations of the variables, and confidence interval of means (CI: 95%) estimated with 1000 bootstrap samples were assessed. Independent t -tests were used to detect gender differences. The effect sizes of the differences were evaluated with Cohen’s d . Furthermore, bivariate Pearson’s correlations have been tested to evaluate the strength of association between among variables. Later, a mediation analysis was conducted by using Model 4 of Hayes’s ( 2017 ) Process Macro for SPSS with 1000 bias-corrected bootstrap samples to test the mediating effect of body image control in photos between adolescents’ selfie expectancies and photo manipulation. Finally, a moderated mediation model was examined using the Process Macro (Hayes, 2017 ), applying Model 5 with 1000 bias-corrected bootstrap samples. In this model, the moderating role of gender on the mediation model was tested, specifically on the direct relationship between adolescents’ selfie-expectancies and photo manipulation. According to Preacher et al. ( 2007 ), a moderating effect is demonstrated by the significant interaction of the independent variable and the moderator variable with the bootstrapped confidence intervals not containing zero.

Descriptive Statistics, Inferential Statistics, and Bivariate Correlations

Descriptive analyses and gender differences are reported in Table 4 . Statistically significant differences between boys’ and girls’ scores were found. Girls reported higher mean scores than boys for SES web-related anxieties, BICP privacy filter behaviors, BICP positive body image factors, BICP negative body image factors, BICP total score, and PM photo filters use. Effect sizes were small. In contrast, boys showed higher mean scores than girls for SES relational worries, SES sexual desire, SES generalized risks, SES total score, and PMS body image manipulation. Effect sizes were small to moderate. In terms of BICP descriptive cut-off categories, 9.3% of the sample occasionally controlled their own body image in photos, 77.5% habitually controlled it, 7.1% controlled it in a risky way, and 6.2% controlled it in a problematic way. More specifically, a higher percentage of girls had risky control over own body image in photos than boys (girls 7.5% vs. boys’ 6.6%; p  < .01), while a higher percentage of boys had higher problematic control over their bodily appearance in photos than girls (boys 7.5% vs. girls’ 5%; p  < .01).

Bivariate correlations between all variables are shown in Table 5 . Significant positive correlations were observed between selfie expectancy, body image control in photos, and photo manipulation subscales and total variables. In addition, significant positive correlations were observed between subscales of each assessment measure. Positive correlations of large effect size were observed among boys between selfie expectancy variables self-confidence and self-presentation and body image control in photo variables selfie-related factors and privacy filters, and the photo manipulation factor, filter use. In addition, the self-confidence selfie expectancy variable was correlated at large effect size with the negative body image factor from the body control in photos scale and use of facial manipulation from the photo manipulation scale. A similar pattern of significant associations was observed between these variables for girls. However, they did not reach a large effect size.

Mediation Analysis

The proposed mediation model (Fig.  2 ) was tested. As showed in Table 6 , selfie-expectancies had a significant direct effect on body image control in photos (a: β = .580; SE = .042; t = 13.728; p  < .001) and photo manipulation (c: β = .353; SE = .048; t  = 7.316; p  < .001). Moreover, body image control in photos had a significant direct effect on photo manipulation (b: β = .412; SE = .045; t  = 9.126; p  < .001). Finally, the total effect of selfie-expectancies on photo manipulation was significant (c’: β = .591; SE = .044; t  = 13.436; p  < .001) and the bias-corrected bootstrapping mediation test indicated that selfie-expectancies predicted photo manipulation via body image control in photos (a*b: β = .239; SE = .039; Bootstrap 95% CI [.166, .316]; p  < .001). The Sobel test showed that this model was significant (Z = 7.586; SE = .032; p  < .001) and it explained 39.7% of the total variance of photo manipulation.

Moderated Mediation Analysis

The moderated mediation test was conducted on the previously significant mediational model (Hayes, 2017 ) to examine whether gender moderated the mediation model, specifically the relationship between adolescents’ selfie-expectancies and photo manipulation (Fig.  3 ). Gender added to the model (girls coded as 1 and boys coded as 2) negatively directly predicted photo manipulation (β = −1.081; SE = .195; t  = −5.54; p  < .001) and the interaction between selfie-expectancies and gender showed a significant moderating effect on the association between adolescents’ selfie-expectancies and photo manipulation (β = .471; SE = .08; t  = 5.893; p  < .001). The 1000 bias-corrected bootstrapped estimates showed a significant indirect effect of selfie-expectancies on photo manipulation via body image control in photos (β = .219; SE = .039; Bootstrap 95% CI [.15, .308]) and for conditional direct effects of selfie-expectancies on photo manipulation bootstrapping estimates confirmed the significant gender effect on the relationship between the variables. More specifically, being female had no significant direct effect on the relationship between selfie-expectancies and photo manipulation (β = .108; SE = .063; t  = 1.715; p  = .09; Bootstrap 95% CI [−.016, .231]), while being male had a significant and positive direct effect on the relationship between the variables (β = .579; SE = .062; t  = 9.380; p  < .001; Bootstrap 95% CI [.458, .700]). The simple slopes representing the relationship between gender and photo manipulation scores at −1SD, mean, and + 1SD values of selfie-expectancies are shown in Fig.  4 . This shows that for girls, there was not a significant relationship between selfie expectancies and photo-manipulation, whereas, for boys, higher selfie expectancies were associated with greater levels of photo manipulation. The overall model was significant (R 2  = .441; SE = .305; F (4,448)  = 88.345; p  < .001).

Simple slopes of selfie-expectancies scores and photo manipulation. Note: Straight lines indicate significant effects of the predictor on photo manipulation scores

In this second study, a moderated mediation model was cross-sectionally tested in which body image control in photos mediated the association between expectancies underlying selfie behavior and photo manipulation, and gender moderated this relationship in a sample of Italian adolescents. Concerning the gender-related differences, selfie-expectancies, body image control in photos, and photo manipulation mean scores highlighted significant differences between male and female adolescents. Furthermore, the correlational study showed a significant and positive co-occurrence among variables, especially in male sample. The tested mediation model suggested that selfie-expectancies were both directly and indirectly (via body image control in photos) positively associated with photo manipulation among boys and girls. It is possible that greater expectations that taking selfies will bring particular outcomes might promote investment in photo-related activities and monitoring, consequently prompting the use of photo manipulation and editing strategies, especially among male adolescents. Indeed, surprisingly, the moderated mediation model showed that being female had no significant direct effect on the relationship between selfie-expectancies and photo manipulation. On the contrary, being male had a significant and positive direct effect on the relationship between the variables, such that for boys, but not girls, higher selfie expectancies were associated with greater levels of photo manipulation. For girls, the level of photo manipulation was relatively consistent across different levels of selfie expectancies.

General Discussion and Conclusions

The present studies contribute to the understudied research field concerning factors associated with photo investment and manipulation. The psychometric properties of a photo manipulation instrument and a moderated mediation model were tested among a specific sample of 13 to 19-years old Italian boys and girls. In the first study, factor structure, validity, and reliability of a revised version of Photo Manipulation Scale (PMS) (McLean et al., 2015 ) were evaluated. The original version of the English scale was modified by adding an item concerning the use of interactive filters (such as a crown of flowers and puppy ears), widely used among teenagers (Rajanala et al., 2018 ). Following EFA and removal of three items from the original scale, CFA suggested that a three-factor solution provided the best fit to the data. The three emerging first order-factors were named: (i) photo filter use (usage of filters that modify or adjust the overall look of the photo); (ii) body image manipulation (editing specific parts of the body look larger or smaller, skinnier or larger); and (iii) facial image manipulation (digitally smoothing out skin imperfections to improve facial appearance). The resulting eight-item revised PMS showed good internal consistency and reliability, confirming the revised PMS to be a reliable instrument to evaluate photo manipulation strategies among Italian adolescents.

In the second study, gender differences between selfie expectancies, body image control in photos, and photo manipulation were tested, and correlations between variables were examined. In addition, selfie expectancies and body image control in photos were examined as direct and indirect cross-sectional predictors of photo manipulation using the revised PMS and tested in a moderated mediation model. Gender-related differences in mean scores for selfie-expectancies were found. Consistent with previous research (Boursier & Manna, 2018b ; Boursier et al., 2020c ), relative to boys, girls appeared more worried about the risk that unknown individuals could steal or retouch their selfies, and about ‘losing control’ over their personal visual content, whereas boys (more than girls) expected that selfie practices might increase excitement and sexual fantasies and feelings. Interestingly, and in contrast to Boursier and Manna ( 2018b ), in which the relational worries selfie expectancies factor did not show a significant gender difference and generalized risks factor mean score was higher among girls, in the present study both mean scores were higher among boys compared to girls. Therefore, despite (or due to) the crucial role of sexuality in males’ selfie-related experiences, they showed higher mean scores than girls in negative expectancies underlying selfie practice. With regard to body image control in photos, previous studies (Boursier et al., 2020b ; Boursier & Manna, 2019 ; Gioia et al., 2020 ) highlighted a main condition of risk among girls in self-portrayal control online and offline. In the present study, despite female participants being more engaged in managing positive and negative images to promote their best self-presentation, boys reported greater problematic control over their appearance in photos than did girls. Finally, gender-related differences were found in photo manipulation scores. Girls used photo filters to improve the overall look of the photos more frequently than boys, whereas boys, more than girls, manipulated their body image making specific parts of the body look larger, smaller, or skinnier. It is likely that boys’ greater risky control on their appearance in photos is related to their higher manipulation of body image in photos prior to their sharing on SNS. In addition to these descriptive findings, the correlation analysis confirmed that body image control in photos and photo manipulation significantly and positively co-occurred, especially in boys.

The tested mediation model demonstrated that selfie-expectancies were both directly and indirectly (via body image control in photos) positively associated with photo manipulation. Previous studies have shown the influence of expectations on decisions and risky behaviors such as drinking alcohol, sexual activities, sexting, and problematic Internet use (Boursier & Manna, 2018b ; Brand et al., 2014 ; Dermen & Cooper, 1994 ; Dir et al., 2013 ; Turel & Serenko, 2012 ). Similarly, the expectancies underlying selfie practice appeared to predict the (over)investment in photo-related activities and monitoring, in order to share an ideal appearance when posting self-images on SNS, consistent with previous research (Bij de Vaate et al., 2018 ; Fox & Rooney, 2015 ; Fox & Vendemia, 2016 ; Lonergan et al., 2019 ; McLean et al., 2015 ). Furthermore, the control over body image in photos appeared as another significant predictor of teens’ photo manipulation. As noted by Bij de Vaate et al. ( 2018 ), this suggests that being engaged in thoughtful strategies to take the best photo to share online goes hand-in-hand with photo manipulation. In fact, body image control in photos positively mediated the relationship between selfie-expectancies and photo-editing. It is possible that expectations underlying selfie practice promote a possible excessive interest and commitment to a self-presentation that portrays an ideal appearance, and together these factors lead to greater photo manipulation before sharing online.

Recently, McLean et al. ( 2019 ) expressed the need to include boys as well as girls in research concerning selfie behavior. Consequently, in the present study, the participation of both males and females allowed the exploration of the influence of gender upon selfie practices. Indeed, the role of gender as a moderator might help to better explain the predictive role of selfie expectancies in photo manipulation. Contrary to several previous findings that found a female predominance in selfie-related activities and photo-editing strategies (Bij de Vaate et al., 2018 ; Dhir et al., 2016 ; McLean et al., 2015 ; Mingoia et al., 2019 ; Terán et al., 2019 ), the present findings showed that being male had a significant and positive direct effect on the relationship between selfie-expectancies and photo manipulation while being female did not influence the association between these variables. It is likely that males’ expectations concerning selfie-taking and selfie-sharing (mainly negative or related to the sexual component of the selfies) directly predicted their photo-editing strategies, especially to manipulate their own body image. Moreover, the predictive role of selfie-expectancies increased due to the mediating role of the control over body image in photos. A possible interpretation of the current findings could be that girls engage in a consistent level of photo manipulation regardless of their selfie expectancies and body image control in photo behaviors, whereas for boys, photo manipulation may occur only under circumstances where they are more highly concerned about the outcomes of their selfie behaviors, such as presenting an ideal appearance. Consistent with this explanation, boys are increasingly becoming concerned about and involved in body image-related activities (Gioia et al., 2020 ; Vandenbosch & Eggermont, 2013 ) in online and disembodied environments that allow individuals to edit and often problematically overinvest in their online appearance (Boursier & Manna, 2018b ; Casale & Fioravanti, 2017 ; Cohen et al., 2018 ; Bij de Vaate et al., 2018 ; Fox & Rooney, 2015 ; Fox & Vendemia, 2016 ; Lonergan et al., 2019 ; McLean et al., 2015 ; Zhao et al., 2008 ). It is likely that overinvestment and reiteration of photo manipulation and editing activities might lead to a problematic selfie-sharing on social media. Furthermore, concerning self-objectification, the relationship between this kind of experiences and social media use might be bidirectional. Indeed, as some recent studies highlighted (Boursier et al., 2020b , 2020c ; Gioia et al., 2020 ; Veldhuis et al., 2020 ), social media use and specifically visual content sharing might lead especially young people to strengthen self-objectification processes allowing them to manage personal images online (Bell et al., 2018 ; Fardouly et al., 2015 , 2017 ; Veldhuis et al., 2020 ), and engaging in potentially problematic social media use and body image-related activities (selfie enganement). In this regard, especially during adolescence, boys and girls are engaged in “new” body mentalization and identity construction processes, and the sharing of the own body images on social media assumes greater and increasing relevance (Boursier & Manna, 2019 ; Franchina & Lo Coco, 2018 ; Pelosi et al., 2014 ). Overall, it is likely that the relationship between social media and body image might be mutually reinforcing. Young people who are particularly concerned about their own body image might be more engaged in social media activities that focus on appearance and, at the same time, social media use and corresponding activities might exacerbate individuals’ body image concerns due to the constant peer-to-peer comparison (Chen et al., 2019 ; Perloff, 2014 ; Webb et al., 2017 ).

Practice Implications

Interestingly, the present findings have many practical implications. The widespread use of social media platforms makes the body image-related issues extremely contemporary. In this regard, these findings might enhance the psychologists’ and clinicians’ attention toward teenagers’ digital self-images on social media (King, 2016 ), helping them to better counsel adolescents about the integration and mentalization of a changing body. In this regard, the association between online body image-related issues and self-objectification experiences deserves clinicians and health workers attention suggesting a focus on the outcomes and mechanisms that underlie selfie practices (Veldhuis et al., 2020 ), thus supporting the adolescents’ identity construction processes and making them aware of the risk of digitally modified body standards internalization. Finally, the present findings might also help in planning and developing intervention and school-based programs, addressed not only to girls but also to boys who are increasingly becoming involved in and concerned about online appearance-related activities (Vandenbosch & Eggermont, 2013 ). In this regard, media literacy programs might be useful tools to educate teenagers about own real body image, about culturally and peer-to-peer promoted body standards, and about their selfie-sharing on social media (Fardouly et al., 2015 ; McLean et al., 2016 ).

Limitations and Future Directions

The novel findings of the present study provide evidence of the constant evolution of the social media landscape, with many platforms being replaced by new ones which are increasingly focused on visual content, especially among adolescents (Gioia & Boursier, 2019a ; Feltman & Szymanski, 2018 ). Therefore, further research concerning selfie behavior, consisting of selfie-taking with its strategies, selfie-editing and manipulation, and selfie-sharing, are needed. In addition, further research to examine the consequences of engaging in photo manipulation are needed to determine the extent to which this enhanced focus on appearance contributes to the emergence of other problems, such as body dissatisfaction.

Some limitations of the present studies need to be addressed when interpreting the findings. First, the studies used a self-report method, and its potential biases are well-known. Second, the samples came from a specific Italian geographic area and the results of both studies might not be representative of other contexts or cultures. Third, the cross-sectional nature of the study precludes the ability to formally evaluate the causality of the variables involved in the present study. Furthermore, although the sample was roughly gender-balanced, the first study did not explore the validity of the revised eight-item PMS across male and female groups. Finally, the present studies only explored a small number of variables in relation to the complex phenomenon of selfie-behavior. Other aspects should be explored alongside the variables investigated here. For example, photo manipulation and editing could be explored in association with self-objectification experiences, body image-related issues, and other online creative or problematic activities. Nevertheless, the present studies’ findings provided some novel and previously unreported issues. They demonstrated the good psychometric properties of the revised PMS, providing an appropriate instrument to assess adolescents’ photo manipulation strategies. Moreover, the findings showed a strong association between expectancies underlying selfie practice and more or less problematic strategies concerning body image monitoring and manipulation. More specifically, and unexpectedly, the present findings provided novel and unreported gender differences that highlight modifications concerning appearance-related issues and online activities carried out by both boys and girls.

Data Availability

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

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The authors thank the schools, teachers, and adolescents who participated in the research. The authors also thank Dr. Federica Coppola for her help in collecting data and Dr. Concetta Esposito for her help in mediation model analysis.

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Exploration of virtual body-representation in adolescence: the role of age and sex in avatar customization

• Daniela Villani 1 ,
• Elena Gatti 2 ,
• Stefano Triberti 1 ,
• Emanuela Confalonieri 2 &
• Giuseppe Riva 1 , 3  

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The malleable nature of the self led researchers to investigate the meaning of virtual identity by exploring virtual self-representation through avatars and its association with users’ identity. The present study aims to investigate the changes in virtual body-representation in adolescence related to age levels and sex and the association with adolescents’ self-esteem and body esteem. Anthropometric features, body esteem and self-esteem were used to assess adolescents’ body image and identity. The scoring code of the “Drawing Me” graphical test was used to evaluate the avatars. The sample is composed of 63 adolescents of different ages—early, middle and late adolescence—balanced by sex. Results show that the creation of a digital avatar changes with age and is partially associated with adolescents’ perceptions in terms of body esteem and self-esteem. Moreover, the creation of avatars occurs differently for boys, who enrich their avatars with many sexual features, than for girls, who prefer to detail their avatars’ clothing to enrich them. Critical reflections and implications for psychological interventions that may use avatars to investigate adolescents’ identity in integration with other tools will be discussed.

Each individual has personal beliefs and selfconceptions—good self, bad self, not-me self, ideal self, possible self, ought self—that can be made accessible at a given moment (Markus 1977 ). Any of these selfconceptions can be activated at any particular time due to a host of factors that become salient in a social situation. The term “malleable self” (Markus and Kunda 1986 ) allows us to capture this dynamic, multidimensional conceptualization of identity (Oyserman 2004 ). Other theories (Butler 1990 ) challenge the concept of identity itself, implying that some aspects usually conceived as stable and predetermined features of a person, such as for example gender, are on the contrary constituted through action, discourse and behavior (“performative” identity).

In any case, the malleable nature of the self is germane to virtual self-representation in virtual environments (VEs), including Massively Multiplayer Online Role-Playing Games (e.g. World of Warcraft, Everquest) and Virtual Worlds (e.g., Second Life) where individuals can play with their identities. Within these VEs, users can transform and customize several attributes of their avatar, such as ethnicity, gender, body shape, face and clothes (Jin 2012 ). The possibilities for creating and customizing an avatar may range from a relatively basic icon—such as a two-dimensional character comprising pre-set elements chosen by the user (Vasalou et al. 2008 ), as in some social networking platforms (e.g., Yahoo Answers)—to a totally customizable avatar as found in three-dimensional virtual worlds (e.g., Second Life). The proliferation of virtual worlds, which have been described as laboratories for the construction of identities (Turkle 1997 ), has come hand in hand with an increase in attention toward these metamorphic avatars and the perception that one’s digital body is the desired rendition of one’s self (Comello 2009 ; Williams 2007 ; Yee and Bailenson 2007 ). The chance to experiment with various aspects of one’s personality and body image in VEs, by expressing or modifying various physical and psychological dimensions, has led researchers to investigate the meaning of virtual self-representation in order to better understand its association with users’ identity (Hoffner 2008 ; Williams et al. 2011 ). Also, if we consider the point of view of performative conception of identity, the virtual worlds can be seen as opportunities to enact performances that retroactively constitute one’s self conception. For instance, Cover ( 2012 ) has observed that social networking profiles (that include avatars) are tools to develop identity as a narrative in line with cultural demands.

The relationship existing between the creation and customization of a digital avatar and the identity of its user constitutes an open debate in the literature. On the one hand, some researchers recognize a substantial discrepancy between the individual’s actual self and his or her avatar (Trepte et al. 2009 ; Trepte and Reinecke 2010 ). When people migrate from the real world to an avatar-based virtual world, they may perceive a discrepancy between the actual self and the virtual self (i.e., virtual self-discrepancy) in virtual identity construction (Jin 2012 ; Ramirez and Wang 2008 ). Inspired by Higgins et al. ( 1985 ), ‘‘virtual self-discrepancy’’ can be conceptually defined as “the degree to which a user’s virtual identity represented in the form of an avatar in the virtual environment deviates from the user’s actual identity in the real world” (Jin 2012 , p 2161). The construct of virtual self-discrepancy has been associated with users’ dissatisfaction with real life (Alsaker and Kroger 2006 ) and users’ intention to gain better mastery of the virtual world (Anderson et al. 2004 ). On the other hand, some researchers maintain that an avatar customized by an individual is substantially an extension of his or her self (Ata et al. 2011 ; Beasley and Standley 2002 ; Bell and Dittmar 2011 ), in that the avatar can be considered an expression of the individual’s actual identity (Bernasconi 2009 ; Bessiere et al. 2007 ). This coherence between individuals and their avatars have been found both related to personality, mental states, self-esteem and interests (Fong and Mar 2015 ; Kafai et al. 2010 ; Park and Henley 2007 ; Dunn and Guadagno 2012 ) and to behaviors exhibited within the virtual environment (Bessiere et al. 2007 ; McCreery et al. 2012 ). According to this perspective, avatars could express individuals “true selves” even if they live difficult situations or they are marginalized in the real world (Williams et al. 2011 ).

What emerges is that embodying an avatar is a recursive identity process and the fluidity of virtual self-representation encourages new interpretations of identity (Fox and Ahn 2013 ). This is particularly worthy of attention as virtual worlds become more popular among children and adolescents and appearance can play an important role in the ways avatars are used to communicate or express the self in a virtual world. Thus, those who are involved in the identity development process are called to show their bodies online, whether in a direct, indirect or virtual way. Furthermore, adolescents seem more likely than adults to identify themselves with their avatars and to develop emotional attachments toward them (Blinka 2008 ). As a consequence, there is growing attention about the relationship between the development of identity and virtual self-representation in adolescence (Klimmt et al. 2010 ; Milani et al. 2014 ).

We believe that investigating adolescents’ virtual self-representation represents an important challenge to take on for at least two reasons. First, avatar assessment allows to capture identity aspects in an unobtrusive way. Second, there is evidence that the ways in which users present themselves as avatars shape the behaviors of both users and perceivers (Nowak and Rauh 2005 ). This issue has important implications since users can portray themselves in a multitude of fashions. Self-presentations can affect online interactions between individuals in a manner that increases the risk of online sexual advances. Thus, monitoring avatar is important to protect young people, and especially girls, from risks related to excessive expression of their sexuality online and consequent online victimization (Noll et al. 2009 ).

In a recent study, Villani et al. ( 2012 ) found a promising method to analyze virtual body representation and compared it with body drawing. Results indicated that the adolescents put more sexual body, facial and clothing features in their avatars than in their drawings. More, girls included more sexual characteristics than boys, such as breast or hips and make up details. Although authors found that through the avatar it is possible to investigate important aspects of body representation, it is critical to consider that body representation changes through adolescence (Verstuyf et al. 2014 ). Recent studies (Confalonieri 2011 ; Gatti et al. 2014 ) show that there is a relationship among physical changes through puberty, psychological development and body representation; adolescents who are satisfied with their own bodies and faces represent themselves with a greater number of secondary sexual characteristics, many body details and coherent body shape and proportions. For this reason, a multidimensional analysis of avatar aimed at exploring differences among age phases and its association with adolescents’ body image and identity is needed.

Many studies agree that the most important individual factors influencing sense of identity in adolescence are age and sex (Holmqvist and Frisen 2012 ; Weichold and Fasche 2010 ; Ata et al. 2011 ; Gatti et al. 2014 ). Regarding age, body representation and body esteem change at different ages (early, middle and late adolescence) (Verstuyf et al. 2014 ) according to adolescents’ physical development (puberty). It seems that early adolescents are more satisfied with both their physical appearance and their weight and have higher levels of self-esteem than middle adolescents (Ciuluvica et al. 2010 ). Literature about late adolescence shows conflicting results: in case of coherence between adolescents’ body image and self-perception, adolescents increase satisfaction with their bodies; otherwise, adolescents could show internalized or externalized problems (Weichold and Fasche 2010 ). The research has shown that also avatar creation is sensitive to age differences. For example, Martey et al. ( 2013 ) found that appearance of participant avatars is a significant predictor of their age. Specifically, old users tend to customize avatar with more traditional appearance, such as representing themselves as something they perceived as accurate to their offline appearance (Reed and Fitzpatrick 2008 ). Younger players, that are players under thirty-5 years-old, are more likely to experiment their appearances. Nevertheless, these studies have been focused on adult age and, to our knowledge, there is still no research investigating changes in avatar customization depending on different phases of adolescence. For this reason, also this aspect constitutes an interesting aim to analyze in the present study.

Regarding sex, females appear more worried about their body appearance and more dissatisfied with their weight and they report lower self-esteem than males (Shea and Pritchard 2007 ; Bell and Dittmar 2011 ). This difference between girls and boys could be emphasized by the centrality of appearance in the female gender role, typical of western cultures. Avatars have been already considered an interesting field of research for what regards the representation of sex differences. For example, as shown by Beasley and Standley ( 2002 ), there is considerable gender role stereotyping in video games that still promotes unequal representations of gender characteristics, with male characters over-represented than female ones, and female characters often represented with unrealistic bodies and sexually-revealing clothing. Actually, this aspect is only indirectly related to the topic discussed here, in that research on gender role stereotyping in video games does not relate to avatars only, but also to non-playable characters. However, it may be important to consider that some adolescents can be influenced in their customization preferences by media-conveyed stereotypes. Indeed, adolescents are characterized by an intense exploration of all the components necessary for identity development (Burgess et al. 2007 ); these components include vocational and interpersonal roles. In a recursive way, literature highlights a strong link between exposure to gender roles depicted in the media, including videogames, and the attitudes towards gender roles in the everyday life (Kolbe and LaVoie 1982 ; Anderson et al. 2004 ). Therefore, analyzing whether there are differences in how male and female adolescents virtually-represent themselves represents a critical goal even for future studies aimed to understand what specific gender behaviors users may learn from playing with their avatars.

Starting from these premises the main goal of this study is to explore changes in virtual self-representation in adolescence. Specifically, we are interested in verifying these two principal hypotheses:

There are differences between adolescents’ virtual representations (avatars) according to their age levels and sex. In particular, according to the literature, we expect that (1) late adolescents will include a higher number of secondary sexual characteristics when creating their avatars than will early adolescents and that (2) adolescent females will create avatars with more sexual details compared to adolescent males.

Adolescents’ virtual representations are associated with their identity (body image and self-esteem). Specifically, we expect that adolescents characterized by low self-esteem and low body satisfaction will create avatars with less detail and poor sexual characterization.

Furthermore, we wondered if adolescents perceived a discrepancy between the actual self and the virtual self in avatar construction (RQ1).

In order to address these hypotheses and the last research question, we adopted a research approach involving early, medium and late adolescents who created and customized avatars to represent themselves. Avatars have been codified in their features basing on the “Drawing Me” method, that has been already used in this field (Villani et al. 2012 ). Moreover, the participants provided anthropometric measures, self-esteem, body-esteem data, and their opinion on self-avatar discrepancy filling in validated or ad-hoc questionnaires.

Participants

The sample included 63 adolescents between 11 and 19 years of age (M = 14.70; SD = 2.5) who completed all study measures. Following previous literature stating that body representation and body esteem change at different ages (early, middle and late adolescence) according to adolescents’ physical development (Blos 1967 ; Finlay et al. 2002 ; McCabe and Ricciardelli 2005 ; Gatti et al. 2014 ; Verstuyf et al. 2014 ), the sample included three age levels: 26 early adolescents aged 11–13 (M = 11.92; SD = .2), 15 middle adolescents aged 14–16 (M = 15.33; SD = .5) and 22 late adolescents aged 17–19 (M = 17.55; SD = .7). Participants were also balanced by sex (males = 29; females = 34).

Even though age and gender are the two principal factors in adolescents’ body perceptions investigated in this study, other individual variables, such as the body mass index (BMI), could also influence one’s perception and body representation (Jones and Crawford 2005 ; Fenton et al. 2010 ). Thus, we selected adolescents with normal range of BMI to avoid pathologies that could affect their body image and, consequently, their avatar creation.

Early adolescents were recruited in a secondary school, while middle and late adolescents were recruited in a high school, from the metropolitan area of Milan, Northern Italy. Participants came from different classes within these two schools. They had Italian backgrounds and came from upper-middle socioeconomic classes.

Ethical approval was gained through the University research ethics committee, which required informed consent from each participant’s parents.

Procedure and measures

Psychological assessment procedures and data collection of anthropometric clinical features (weight, height, and BMI) were performed by the researchers.

The administration of instruments took two sessions: during a class period, the adolescents completed questionnaires (first session); then, in a small group setting, they created their own avatars (second session). Finally, the participants answered two items about avatar self-discrepancy. Researchers monitored all processes and ensured that the students completed the questionnaires by themselves and in a silent and private context. Each student was free to drop out of the research any time and to express to the researchers any doubts or uncomfortable feelings. Details about the instruments we used are reported below.

Regarding adolescents’ body image and identity, we assessed:

Anthropometric features BMI was used to estimate a healthy body weight based on a person’s height. It is the most widely used diagnostic index to identify weight problems, usually to estimate whether individuals are underweight, overweight, or obese. The formula universally used is kg/m 2 . We just checked the BMI distribution to exclude outliers.

Body esteem The Body Esteem Scale (BES, Mendelson et al. 2001 ; Italian version by Confalonieri et al. 2008 ) consists of 14 items, and respondents indicate their degrees of agreement on a five-point Likert scale ranging from 0 (never) to 4 (always). Seven negative items are reverse-scored. The scale measures three factors: attribution (the evaluation attributed to others about one’s body and appearance), weight (satisfaction with one’s weight), and appearance (general feeling about one’s appearance). For these data, the three subscales had an adequate reliability (attribution: alpha = .68; weight: alpha = .84; appearance: alpha = .76).

Self - esteem The Rosenberg Self-Esteem Scale (Rosenberg 1965 ; Italian version by Prezza et al. 1997 ) is the most widely used measure of global self-esteem and has been determined to be valid and reliable among students (Rosenberg 1989 ). Responses to the 10 items are rated on a four-point Likert scale (strongly disagree to strongly agree), yielding scores between 10 and 40. The scale measures three factors: self - esteem (global self-worth), self - deprecation (criticism about self) and self - respect (praise of self), showing a high internal consistency (Cronbach’s alpha = .84) and a good test–retest correlation (r = .76).

Regarding avatar design, different studies showed that avatar creation/customization is strongly influenced by the cultural aspects of the virtual world in which the avatar is expected to be used (Ducheneaut et al. 2009 ; Triberti and Argenton 2013 ). To control this aspect and to avoid differences related to virtual contexts in which avatars would be used (e.g. a videogame or a social network), we decided to use appropriate software to allow participants to create their own avatars. According to the instruction of the “Drawing Me” Test (for details see the avatar scoring paragraph) adolescents were instructed as follows: “Please try to depict yourself by drawing the way you would want to present yourself to a person who was interested in you but did not know you. You are free to represent yourself in the most appropriate way, trying to communicate to the other person who you are and what your characteristics are”.

Avatar creation Avatars were created by the participants using the free online software Meez ( www.meez.com ), which allows the user to choose several aspects related to the prototypic figure, such as gender, as well as more specific details, such as height, body shape, clothes and environment.

Avatar scoring To evaluate the virtual avatar, we used the scoring code of the “Drawing Me” graphical test. The Drawing Me test, originally created for assessing body image perception of adults (Witkin et al. 1962 ) and then adapted in Italian and rearranged for adolescents (Confalonieri 2011 ) aims at identifying, through a graphic representation what adolescents think about their body in terms of perceptions, attributions, satisfaction, or self-perceived integration of body districts. The use of this test is consistent with a good deal of research literature that suggests the utility of incorporating drawings into assessment practices. The drawing method, in fact, offers the opportunity to obtain qualitative information that may not be easily retrieved through conventional paper-and-pencil verbal tests and, as such, may broaden the range of available information (Matto 2006 ). Concerning avatar, the efficacy of the Drawing Me Test in analyzing the virtual body representation has been already tested (Villani et al. 2012 ). Although we recognize that other avatar coding schemes exist, we consider it as the most appropriate to investigate virtual body representation of adolescents (Confalonieri 2011 ; Gatti et al. 2014 ; Villani et al. 2012 ).

Specifically, for avatar scoring we considered two scales: level of detail and level of sexual characterization. Each scale is structured in three different subscales scored from 1 to 3, assessing the quantity of specific characteristics. In other words, the focus is not on the characteristics resembling or not some arbitrary quality standard (e.g., beard of one type or another; heavy or light make up; etc.), but on how many of sexual characteristics are actually present in the avatars (see Table 1 ).

After the training period, three blinded independent examiners rated every avatar. The accordance between judges, measured by Cohen’s K coefficient, was .84.

Avatar Self - Discrepancy As a final measure, two items on a five-point Likert scale measured the avatar self-discrepancy (“How similar is your avatar to how you would like to be?”) and the avatar self-coherence (“How much is your avatar like you?”).

Before analyzing adolescents’ differences in avatar creation and the association with their identity, we checked the BMI distribution to eventually exclude participants with weight problems but we did not find outliers. BMI increased through adolescence and revealed a normal growth of the sample (Bernasconi 2009 ).

Descriptive data from body esteem, self-esteem and BMI by age and sex are reported in Table  2 .

Differences between adolescents’ virtual representations (avatars) according to their sex and age

Since the scoring of avatar coding was carried out on an ordinal scale, it was not possible to use parametric statistics. Thus, to examine statistically the relationship between age, sex and adolescents’ virtual representations, firstly we tested a series of log-linear models. As the interaction effects between the three variables were not significant, we used not parametric tests to analyze the effects of age (Kruskal–Wallis test) and sex (Mann–Whitney test) on avatar coding (descriptive data are presented in Table  3 ).

Concerning age differences, the scores of details related to facial features (χ2 = 10.685, df = 2, p < .01, η2 = .175) significantly changed. Specifically, late (U = 168.000, p < .005, η2 = .174) and middle (U = 122.500, p < .05, η2 = .124) adolescents gained higher scores than early adolescents and represented themselves with more facial details (e.g., they include eyelashes, eyebrows, or lips). No other significant differences were found related to body (χ2 = 4.713, df = 2, p = .095) and clothing (χ2 = 4.904, df = 2, p = .086) details.

Furthermore, we found significant differences related to body sexual characterization (χ2 = 6.950, df = 2, p < .05, η2 = .116) and face sexual characterization (χ2 = 6.675, df = 2, p < .05, η2 = .109). Also in this case, the sexual characterization both of body and facial features increased with the age of adolescents: late adolescents represented themselves with more sexual features (U = 179.000, p < .05, η2 = .110) (e.g., facial hair for boys and makeup for girls) and with more secondary sexual characteristics that indicated their gender (U = 165.000, p < .05, η2 = .159) than early adolescents. No significant differences were found related to clothing sexual characterization (χ2 = 4.000, df = 2, p = .118).

Below are examples of adolescents’ avatars according to their age level (Fig.  1 shows female changes and Fig.  2 shows male changes).

Early, middle and late female adolescents’ avatars

Early, middle and late male adolescents’ avatars

Concerning sex, we found significant differences in clothing details (U = 349.500, p < .05, η2 = .082), but no differences in facial (U = 452.000, p = .654) and body (U = 398.000, p = .265) details. Furthermore, facial sexual characterization (U = 185.000, p < .01, η2 = .373) and sexual total scale (U = 330.500, p < .05, η2 = .073) changed between male and females. Specifically, females tended to create avatars with much more clothing and ornamentation than males, whereas the males added more sexual features on their face, body and clothes than females.

Figure  3 shows a female’s avatar wearing flower in the hair and male’s avatar with beard.

Male and female adolescents’ avatars

Relationship between adolescents’ virtual representations and their body image and self-esteem

We conducted Spearman’s Rho correlations between the self-report measures (BES, RSE) and virtual representation (avatar coding) including all participants. The matrix of correlations is represented in Table  4 .

Body esteem and self-esteem appear to be partially related to avatar creation. Specifically, the appearance (BES subscale) is positively correlated with avatar body details and total details. Thus, adolescents with a good general feeling about their appearance represent themselves by including all body parts visible, a large number of facial features and of garments and accessories. The evaluation attributed to others about one’ body and appearance (attribution) and the satisfaction with one’s weight (weight) are not associated with avatar creation.

Furthermore, the self-respect (RSE subscale) is positively correlated with avatar facial sexual and total sexual characteristics. Thus, adolescents that pride themselves created avatar with a great number of secondary sexual features. The global self-worth (self-esteem) and the criticism about self (self-deprecation) are not associated with avatar creation.

Adolescents’ virtual-self discrepancy

We conducted a repeated measure ANOVA to compare the answers to avatar self-coherence (“How much is your avatar like you?”) with the answers to self-avatar discrepancy (“How similar is your avatar to who you would like to be?”). We found no significant differences between them (F (1,54)  = 1106; p = .298): the participants answered that the avatars were equally similar to both their own real selves and their ideal selves.

Furthermore, we performed a correlation analysis between the avatar-self coherence and avatar-self discrepancy questions, finding a significant positive relation between the two: ρ = .454, p = .001. It appears that no avatar-self discrepancy can be found among the sample, as the participants evaluated their own avatars as equally similar to their own real selves and their ideal selves.

Finally, we performed a correlation analysis between the avatar-self discrepancy and self-esteem, but we did not find significant correlations (self-deprecation: ρ = .168, p = .219; self-respect: ρ = .129, p = .347; self-esteem: ρ = .244, p = .072).

The present research aims to test the effectiveness of a multidimensional assessment of avatar in adolescence. To reach this goal we combined quantitative and qualitative measures to obtain a whole picture of virtual body image representation in adolescence. Adolescence is a period of life characterized by many important physical and psychological changes that may influence the identity development (Harter 2003 ; Alsaker and Flammer 2006 ; Smolak and Stein 2010 ; Fenton et al. 2010 ; Confalonieri and Gatti 2011 ). Since many studies have shown that the most important individual factors influencing the sense of identity in adolescence are age and sex (Holmqvist and Frisen 2012 ; Weichold and Fasche 2010 ; Ata et al. 2011 ; Gatti et al. 2014 ), and these factors are related also to avatar appearance in adult samples (Martey et al. 2013 ; Reed and Fitzpatrick 2008 ; Beasley and Standley 2002 ), we first investigated whether these factors influence the adolescent virtual self-representation.

Our first hypothesis has been confirmed. Results show that the creation of a digital avatar changes according to age level. Specifically, the more adolescents grow, the more they show, enriching the virtual representations of themselves with facial details and with facial and body sexual features. The results confirm that, during the transition from childhood to adulthood, the mental representation of one’s own body becomes more precise and accurate, including more details and sexual features. Probably, adolescents accurately depict changes in their real world bodies or personal style that also occurred with age, as previously showed in adult population (Reed and Fitzpatrick 2008 ). The detailed representation of secondary sexual features indicates that the body becomes more “personalized”. This “personalized” body is very important for reaching a body identity that will be integrated into a global identity at the end of adolescence (Alsaker and Kroger 2006 ; Bucchianeri et al. 2013 ).

Moreover, the creation of avatars occurs differently for boys than for girls. Males enrich their avatars with many sexual features (face, body and clothes) that underline their sex, whereas females prefer to detail their avatars’ clothes and enrich them with jewelry and objects. Concerning the gendered nature of the clothes we have to consider that the free online software used is probably influenced by socio-cultural aspects that have restricted the choice opportunities. Perhaps we found differences only in clothing details for this reason. Thus, clothing might be one opportunity for young women to explore and publicly present their sexuality (Gleeson and Frith 2004 ). Indeed, this permits to reconsider the contribution of performative identity theories (Butler 1990 ; Cover 2012 ; David et al. 2006 ): both the acts of males adding sexual body features and those of females adding jewelry and objects constitute identity performances, that are, repeated acts devoted to the construction of identity. In other words, avatar details and sexual characterization can be seen as a way in which an adolescent’s gender become intelligible through particular actions in the virtual world, as well as “girling” allow adolescents become identified and recognized as girls in the real world (Butler 2004 ; Nayak and Kehily 2006 ). This aspect should be carefully considered by future studies focusing on self-presentation online. In fact, previous research has found that there are some risks related to female hyper-sexualized representation online. Adolescent girls’ tendency to create sexually provocative avatars to represent themselves was tied to Internet victimization (Noll et al. 2009 ), in that girls who prefer provocative avatars (in terms of body and clothes) have been found more likely to receive online sexual advances.

As we considered avatar as the virtual representation of the adolescents’ actual identity, we would like to verify also the association between virtual self-representation and their body esteem and self-esteem. Our second hypothesis has been partially confirmed. We found some associations between the characteristics of the avatars and adolescents’ perceptions in terms of body esteem and self-esteem. It emerged that those with a positive feeling about their appearance tended to add more facial, body and clothes details to their own avatars. The satisfaction with one’s weight and the evaluation attributed to others about one’ body and appearance are not associated with avatar creation, which features range from limited list of options. Probably, the drawing method allows obtaining more information related to adolescents body esteem than avatar creation. Moreover, those with more self-respect created avatar with a great number of secondary sexual features. These correlations reinforce the link between physical and psychological development and highlight the important role of body changes in influencing body esteem, self-perception and self-worth (Alsaker and Kroger 2006 ).

Regarding our research question, we investigated whether the avatars created by the adolescents could be considered subjective representations of how they think they actually are (“real” selves”) real selves or how they desire to be in their imagination or in the future (“ideal selves”). To answer to this question, we analyzed avatar-self coherence versus avatar-self discrepancy in the context of our sample. Surprisingly, the results showed that the adolescents considered their avatars to be equally similar to both their real and ideal selves. In this sense, the adolescents of our sample seem to be characterized by an advanced level of self-construction, since their ideal selves appear not dissimilar from their real ones, if not substantially overlapping. This interpretation is confirmed by the significant positive correlation between the avatar-self coherence and avatar-self discrepancy questions.

To better understand this result, which is part of the debate on the relationship between the creation and customization of a digital avatar and the identity of its user, we have to consider two critical factors. First, adolescents characterized by high levels of self-esteem and a coherent body image constituted our sample. Thus far, avatar-self discrepancy has been primarily investigated in adults. A few studies have focused on adolescents, but their participants were characterized by specific pathologies, like online gaming addiction (Wan and Chiou 2006 ; Smahel et al. 2008 ) or a poor level of psychological well-being (Bessiere et al. 2007 ). Self-discrepancy theory suggests that psychological well-being is closely related to a person’s actual self (“me as I am”) versus his or her ideal self (“me as I would like to be”). People with larger real–ideal self-discrepancies thus have higher depression and lower self-esteem. Moretti and Higgins ( 1990 ) found the actual—ideal self-discrepancy to predict significant variance in self-esteem but this effect was only found when an idiographic, rather than a nomothetic, self-discrepancy measure was used. Even if we did not find significant correlations between avatar-self discrepancy and self-esteem, we can not exclude an effect due to the measure we have used.

Second, we have to consider that the adolescents in our sample created their avatars without a context of use. Different virtual worlds are characterized by the support they offer to specific activities that can bring out specific aspects of the user’s identity (McCreery et al. 2012 ). Moreover, the creation/customization of avatars by videogame players is strongly influenced by the cultural aspects of the virtual world in which the avatar is expected to be used (Ducheneaut et al. 2009 ; Triberti and Argenton 2013 ). Last but not least, users’ personal preferences and communicative intentions may influence natural avatar creation; for example, one may prefer a cartoon-like design trying to be funny, or a monstrous appearance in order to intimidate others (Triberti and Argenton 2013 ). For this reason, we used an avatar creation/customization program in order to invite participants to simply represent themselves through avatars, without the intention of later guiding them into an online videogame or a social networking platform. By doing so, we ensured that the avatar creation by the participants was related to self-expression only, and not to the possible intentions of a player who expects to enter a virtual world containing social relationships and cultural features. We think that if a user is asked to digitally re-create his or her identity with the purpose of communicating with others, he or she could be driven to modify it according to a desired rendition of the self. In contrast, according to our research, when an avatar-creation program is used to create an avatar that is not expected to be used elsewhere, the result can be considered more as an indication of how the real self of the user is constructed and perceived. It’s important to consider that the experimental manipulation allowed to focus on the specific phenomenon of virtual self representation but could have reduced the overall ecological validity of the study. Thus, this result may be considered with caution as it is not representative of any natural situation in which avatars are created by computer users.

Conclusions

To conclude, by extending previous results of Villani et al. ( 2012 ), which explored body representation in adolescence through the use of avatars, this study shows that, in a balanced sample characterized by high levels of self-esteem and a coherent body image, avatar creation becomes more detailed as adolescents’ age levels increase. More, virtual body representation is partially associated with body image and self-esteem. Data are promising and confirm the importance of analyzing avatar in a multidimensional way and integrating both quantitative and qualitative measures to obtain a whole picture of virtual body image representation in adolescence. Specifically, future qualitative measures are encouraged to use scales name coherent with the content investigated and to identify continuous variables in order to allow powerful statistical analyses. Given the proliferation of virtual worlds and social networks among adolescents, the present research might offer a particularly promising window into the comprehension of the psychological correlates of virtual self-representation of adolescents, in terms of what they express and say about themselves through the customization of digital figures. Other future challenges for research regard the elaboration of proper tools and/or experimental settings to investigate the other factors that may mediate the relationship between self representation and avatar creation, such as personal preferences/intentions, cultural characteristics of the virtual world, and type of avatar among others. For instance, literature (Sanford et al. 2015 ; Schwind et al. 2015 ) argues that people may not like avatars with a cartoon-like design, and this could be systematically related to age, with older subjects preferring realistic virtual figures.

On the one hand, implications of the present study for the “natural context” of virtual worlds and gaming should be considered with caution: indeed, in the present study avatar creation was manipulated with specific guidelines for the participants, in order to focus their customization effort on self-representation. Nevertheless, we should consider that adolescents who create/customize avatars to interact or play online could not have intention of represent themselves. Furthermore, the use of a coding scheme based on avatars’ features quantity could represent a limitation of the study. Although this method has already been used in the literature with satisfying results (Villani et al. 2012 ), it may be considered controversial, and the recourse to more objective and repeatable coding methods would be preferable for future studies.

On the other hand, the present study offers implications for both psychologists and educators who would make use of avatar creation/customization independently of the virtual worlds context in which they are typically expected to be used. In order to generate preventive measures to help adolescents through their developmental task, professionals can support adolescents to reflect upon their own self-perception in using avatar creation/customization. In conjunction with other proper instruments, the use of avatars can be a resource to promote adolescents’ self-knowledge, body esteem and self-esteem and, at the same time, to help them in identifying the possible influences of gender stereotypes along with the risks of internet victimization. Reinforcing skills such as self-esteem and the abilities to withstand social comparisons with peers and to accept the outcomes of bodily change could help adolescents to face the process of their pubertal development with better preparation and a greater ability to reach a satisfactory image of their own adult body. These processes could be enhanced by avatar designers careful in proposing avatar features that promotes online victimization prevention. Future researches are encouraged to investigate virtual body representation through avatar in adolescence with longitudinal studies, and to consider also specific clinical sample to understand if the avatar creation could be usefully integrated within therapeutic or educational treatments.

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DV conceived the study, participated in its design and coordination, performed the statistical analyses and drafted the manuscript. EG participated in the design of the study and coordination and helped to draft the manuscript. ST participated in the design of the study and performed the statistical analysis. EC participated in the design of the study and revised the manuscript critically for important intellectual content. GR participated in the design of the study and revised the manuscript critically for important intellectual content. All authors read and approved the final manuscript.

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Villani, D., Gatti, E., Triberti, S. et al. Exploration of virtual body-representation in adolescence: the role of age and sex in avatar customization. SpringerPlus 5 , 740 (2016). https://doi.org/10.1186/s40064-016-2520-y

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15 Effective Visual Presentation Tips To Wow Your Audience

By Krystle Wong , Sep 28, 2023

So, you’re gearing up for that big presentation and you want it to be more than just another snooze-fest with slides. You want it to be engaging, memorable and downright impressive. 

Well, you’ve come to the right place — I’ve got some slick tips on how to create a visual presentation that’ll take your presentation game up a notch. 

Packed with presentation templates that are easily customizable, keep reading this blog post to learn the secret sauce behind crafting presentations that captivate, inform and remain etched in the memory of your audience.

Click to jump ahead:

What is a visual presentation & why is it important?

15 effective tips to make your visual presentations more engaging, 6 major types of visual presentation you should know , what are some common mistakes to avoid in visual presentations, visual presentation faqs, 5 steps to create a visual presentation with venngage.

A visual presentation is a communication method that utilizes visual elements such as images, graphics, charts, slides and other visual aids to convey information, ideas or messages to an audience. 

Visual presentations aim to enhance comprehension engagement and the overall impact of the message through the strategic use of visuals. People remember what they see, making your point last longer in their heads. 

Without further ado, let’s jump right into some great visual presentation examples that would do a great job in keeping your audience interested and getting your point across.

In today’s fast-paced world, where information is constantly bombarding our senses, creating engaging visual presentations has never been more crucial. To help you design a presentation that’ll leave a lasting impression, I’ve compiled these examples of visual presentations that will elevate your game.

1. Use the rule of thirds for layout

Ever heard of the rule of thirds? It’s a presentation layout trick that can instantly up your slide game. Imagine dividing your slide into a 3×3 grid and then placing your text and visuals at the intersection points or along the lines. This simple tweak creates a balanced and seriously pleasing layout that’ll draw everyone’s eyes.

2. Get creative with visual metaphors

Got a complex idea to explain? Skip the jargon and use visual metaphors. Throw in images that symbolize your point – for example, using a road map to show your journey towards a goal or using metaphors to represent answer choices or progress indicators in an interactive quiz or poll.

3. Visualize your data with charts and graphs

The right data visualization tools not only make content more appealing but also aid comprehension and retention. Choosing the right visual presentation for your data is all about finding a good match. 

For ordinal data, where things have a clear order, consider using ordered bar charts or dot plots. When it comes to nominal data, where categories are on an equal footing, stick with the classics like bar charts, pie charts or simple frequency tables. And for interval-ratio data, where there’s a meaningful order, go for histograms, line graphs, scatterplots or box plots to help your data shine.

In an increasingly visual world, effective visual communication is a valuable skill for conveying messages. Here’s a guide on how to use visual communication to engage your audience while avoiding information overload.

4. Employ the power of contrast

Want your important stuff to pop? That’s where contrast comes in. Mix things up with contrasting colors, fonts or shapes. It’s like highlighting your key points with a neon marker – an instant attention grabber.

5. Tell a visual story

Structure your slides like a storybook and create a visual narrative by arranging your slides in a way that tells a story. Each slide should flow into the next, creating a visual narrative that keeps your audience hooked till the very end.

Icons and images are essential for adding visual appeal and clarity to your presentation. Venngage provides a vast library of icons and images, allowing you to choose visuals that resonate with your audience and complement your message. 

6. Show the “before and after” magic

Want to drive home the impact of your message or solution? Whip out the “before and after” technique. Show the current state (before) and the desired state (after) in a visual way. It’s like showing a makeover transformation, but for your ideas.

7. Add fun with visual quizzes and polls

To break the monotony and see if your audience is still with you, throw in some quick quizzes or polls. It’s like a mini-game break in your presentation — your audience gets involved and it makes your presentation way more dynamic and memorable.

8. End with a powerful visual punch

Your presentation closing should be a showstopper. Think a stunning clip art that wraps up your message with a visual bow, a killer quote that lingers in minds or a call to action that gets hearts racing.

9. Engage with storytelling through data

Use storytelling magic to bring your data to life. Don’t just throw numbers at your audience—explain what they mean, why they matter and add a bit of human touch. Turn those stats into relatable tales and watch your audience’s eyes light up with understanding.

10. Use visuals wisely

Your visuals are the secret sauce of a great presentation. Cherry-pick high-quality images, graphics, charts and videos that not only look good but also align with your message’s vibe. Each visual should have a purpose – they’re not just there for decoration. 

11. Utilize visual hierarchy

Employ design principles like contrast, alignment and proximity to make your key info stand out. Play around with fonts, colors and placement to make sure your audience can’t miss the important stuff.

12. Engage with multimedia

Static slides are so last year. Give your presentation some sizzle by tossing in multimedia elements. Think short video clips, animations, or a touch of sound when it makes sense, including an animated logo . But remember, these are sidekicks, not the main act, so use them smartly.

13. Interact with your audience

Turn your presentation into a two-way street. Start your presentation by encouraging your audience to join in with thought-provoking questions, quick polls or using interactive tools. Get them chatting and watch your presentation come alive.

When it comes to delivering a group presentation, it’s important to have everyone on the team on the same page. Venngage’s real-time collaboration tools enable you and your team to work together seamlessly, regardless of geographical locations. Collaborators can provide input, make edits and offer suggestions in real time. 

14. Incorporate stories and examples

Weave in relatable stories, personal anecdotes or real-life examples to illustrate your points. It’s like adding a dash of spice to your content – it becomes more memorable and relatable.

15. Nail that delivery

Don’t just stand there and recite facts like a robot — be a confident and engaging presenter. Lock eyes with your audience, mix up your tone and pace and use some gestures to drive your points home. Practice and brush up your presentation skills until you’ve got it down pat for a persuasive presentation that flows like a pro.

Venngage offers a wide selection of professionally designed presentation templates, each tailored for different purposes and styles. By choosing a template that aligns with your content and goals, you can create a visually cohesive and polished presentation that captivates your audience.

Looking for more presentation ideas ? Why not try using a presentation software that will take your presentations to the next level with a combination of user-friendly interfaces, stunning visuals, collaboration features and innovative functionalities that will take your presentations to the next level. 

Visual presentations come in various formats, each uniquely suited to convey information and engage audiences effectively. Here are six major types of visual presentations that you should be familiar with:

1. Slideshows or PowerPoint presentations

Slideshows are one of the most common forms of visual presentations. They typically consist of a series of slides containing text, images, charts, graphs and other visual elements. Slideshows are used for various purposes, including business presentations, educational lectures and conference talks.

2. Infographics

Infographics are visual representations of information, data or knowledge. They combine text, images and graphics to convey complex concepts or data in a concise and visually appealing manner. Infographics are often used in marketing, reporting and educational materials.

Don’t worry, they are also super easy to create thanks to Venngage’s fully customizable infographics templates that are professionally designed to bring your information to life. Be sure to try it out for your next visual presentation!

3. Video presentation

Videos are your dynamic storytellers. Whether it’s pre-recorded or happening in real-time, videos are the showstoppers. You can have interviews, demos, animations or even your own mini-documentary. Video presentations are highly engaging and can be shared in both in-person and virtual presentations .

4. Charts and graphs

Charts and graphs are visual representations of data that make it easier to understand and analyze numerical information. Common types include bar charts, line graphs, pie charts and scatterplots. They are commonly used in scientific research, business reports and academic presentations.

Effective data visualizations are crucial for simplifying complex information and Venngage has got you covered. Venngage’s tools enable you to create engaging charts, graphs,and infographics that enhance audience understanding and retention, leaving a lasting impression in your presentation.

5. Interactive presentations

Interactive presentations involve audience participation and engagement. These can include interactive polls, quizzes, games and multimedia elements that allow the audience to actively participate in the presentation. Interactive presentations are often used in workshops, training sessions and webinars.

Venngage’s interactive presentation tools enable you to create immersive experiences that leave a lasting impact and enhance audience retention. By incorporating features like clickable elements, quizzes and embedded multimedia, you can captivate your audience’s attention and encourage active participation.

6. Poster presentations

Poster presentations are the stars of the academic and research scene. They consist of a large poster that includes text, images and graphics to communicate research findings or project details and are usually used at conferences and exhibitions. For more poster ideas, browse through Venngage’s gallery of poster templates to inspire your next presentation.

Different visual presentations aside, different presentation methods also serve a unique purpose, tailored to specific objectives and audiences. Find out which type of presentation works best for the message you are sending across to better capture attention, maintain interest and leave a lasting impression. 

To make a good presentation , it’s crucial to be aware of common mistakes and how to avoid them. Without further ado, let’s explore some of these pitfalls along with valuable insights on how to sidestep them.

Overloading slides with text

Text heavy slides can be like trying to swallow a whole sandwich in one bite – overwhelming and unappetizing. Instead, opt for concise sentences and bullet points to keep your slides simple. Visuals can help convey your message in a more engaging way.

Using low-quality visuals

Grainy images and pixelated charts are the equivalent of a scratchy vinyl record at a DJ party. High-resolution visuals are your ticket to professionalism. Ensure that the images, charts and graphics you use are clear, relevant and sharp.

Choosing the right visuals for presentations is important. To find great visuals for your visual presentation, Browse Venngage’s extensive library of high-quality stock photos. These images can help you convey your message effectively, evoke emotions and create a visually pleasing narrative. 

Ignoring design consistency

Imagine a book with every chapter in a different font and color – it’s a visual mess. Consistency in fonts, colors and formatting throughout your presentation is key to a polished and professional look.

Reading directly from slides

Reading your slides word-for-word is like inviting your audience to a one-person audiobook session. Slides should complement your speech, not replace it. Use them as visual aids, offering key points and visuals to support your narrative.

Lack of visual hierarchy

Neglecting visual hierarchy is like trying to find Waldo in a crowd of clones. Use size, color and positioning to emphasize what’s most important. Guide your audience’s attention to key points so they don’t miss the forest for the trees.

Ignoring accessibility

Accessibility isn’t an option these days; it’s a must. Forgetting alt text for images, color contrast and closed captions for videos can exclude individuals with disabilities from understanding your presentation. 

Relying too heavily on animation

While animations can add pizzazz and draw attention, overdoing it can overshadow your message. Use animations sparingly and with purpose to enhance, not detract from your content.

Using jargon and complex language

Keep it simple. Use plain language and explain terms when needed. You want your message to resonate, not leave people scratching their heads.

Not testing interactive elements

Interactive elements can be the life of your whole presentation, but not testing them beforehand is like jumping into a pool without checking if there’s water. Ensure that all interactive features, from live polls to multimedia content, work seamlessly. A smooth experience keeps your audience engaged and avoids those awkward technical hiccups.

Presenting complex data and information in a clear and visually appealing way has never been easier with Venngage. Build professional-looking designs with our free visual chart slide templates for your next presentation.

What software or tools can I use to create visual presentations?

You can use various software and tools to create visual presentations, including Microsoft PowerPoint, Google Slides, Adobe Illustrator, Canva, Prezi and Venngage, among others.

What is the difference between a visual presentation and a written report?

The main difference between a visual presentation and a written report is the medium of communication. Visual presentations rely on visuals, such as slides, charts and images to convey information quickly, while written reports use text to provide detailed information in a linear format.

How do I effectively communicate data through visual presentations?

To effectively communicate data through visual presentations, simplify complex data into easily digestible charts and graphs, use clear labels and titles and ensure that your visuals support the key messages you want to convey.

Are there any accessibility considerations for visual presentations?

Accessibility considerations for visual presentations include providing alt text for images, ensuring good color contrast, using readable fonts and providing transcripts or captions for multimedia content to make the presentation inclusive.

Most design tools today make accessibility hard but Venngage’s Accessibility Design Tool comes with accessibility features baked in, including accessible-friendly and inclusive icons.

How do I choose the right visuals for my presentation?

Choose visuals that align with your content and message. Use charts for data, images for illustrating concepts, icons for emphasis and color to evoke emotions or convey themes.

What is the role of storytelling in visual presentations?

Storytelling plays a crucial role in visual presentations by providing a narrative structure that engages the audience, helps them relate to the content and makes the information more memorable.

How can I adapt my visual presentations for online or virtual audiences?

To adapt visual presentations for online or virtual audiences, focus on concise content, use engaging visuals, ensure clear audio, encourage audience interaction through chat or polls and rehearse for a smooth online delivery.

What is the role of data visualization in visual presentations?

Data visualization in visual presentations simplifies complex data by using charts, graphs and diagrams, making it easier for the audience to understand and interpret information.

How do I choose the right color scheme and fonts for my visual presentation?

Choose a color scheme that aligns with your content and brand and select fonts that are readable and appropriate for the message you want to convey.

How can I measure the effectiveness of my visual presentation?

Measure the effectiveness of your visual presentation by collecting feedback from the audience, tracking engagement metrics (e.g., click-through rates for online presentations) and evaluating whether the presentation achieved its intended objectives.

Ultimately, creating a memorable visual presentation isn’t just about throwing together pretty slides. It’s about mastering the art of making your message stick, captivating your audience and leaving a mark.

Lucky for you, Venngage simplifies the process of creating great presentations, empowering you to concentrate on delivering a compelling message. Follow the 5 simple steps below to make your entire presentation visually appealing and impactful:

1. Sign up and log In: Log in to your Venngage account or sign up for free and gain access to Venngage’s templates and design tools.

2. Choose a template: Browse through Venngage’s presentation template library and select one that best suits your presentation’s purpose and style. Venngage offers a variety of pre-designed templates for different types of visual presentations, including infographics, reports, posters and more.

3. Edit and customize your template: Replace the placeholder text, image and graphics with your own content and customize the colors, fonts and visual elements to align with your presentation’s theme or your organization’s branding.

4. Add visual elements: Venngage offers a wide range of visual elements, such as icons, illustrations, charts, graphs and images, that you can easily add to your presentation with the user-friendly drag-and-drop editor.

5. Save and export your presentation: Export your presentation in a format that suits your needs and then share it with your audience via email, social media or by embedding it on your website or blog .

So, as you gear up for your next presentation, whether it’s for business, education or pure creative expression, don’t forget to keep these visual presentation ideas in your back pocket.

Feel free to experiment and fine-tune your approach and let your passion and expertise shine through in your presentation. With practice, you’ll not only build presentations but also leave a lasting impact on your audience – one slide at a time.

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Introduction

Epidemiology, classification and definitions, core symptoms, hallucinations, disorganized thinking, disorganized behavior, negative symptoms, risk factors for conversion to primary psychotic disorder, psychotic-like symptoms presenting in youth, benign hallucinations, imaginary friends, cultural and religious considerations and bereavement, intellectual disability, etiology of psychotic symptoms and disorders, neuroanatomical abnormalities, neurotransmitters, genetic factors, environmental exposure, substance use, evaluation of patients with psychotic-like symptoms, interviewing patients with psychotic symptoms, physical examination, laboratory and imaging studies, when to refer to specialty care or ed, other psychosocial interventions, medications, adverse effects of antipsychotic medications and recommended monitoring, avoiding misdiagnosis and unnecessary treatment, resources for pediatricians, conclusions, advice for pediatricians, appendix 1: case vignettes, lead author, committee on adolescence, 2019–2020, past committee member, collaborative care in the identification and management of psychosis in adolescents and young adults.

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

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Liwei L. Hua , Elizabeth M. Alderman , Richard J. Chung , Laura K. Grubb , Janet Lee , Makia E. Powers , Krishna K. Upadhya , Stephenie B. Wallace; COMMITTEE ON ADOLESCENCE, Collaborative Care in the Identification and Management of Psychosis in Adolescents and Young Adults. Pediatrics June 2021; 147 (6): e2021051486. 10.1542/peds.2021-051486

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Pediatricians are often the first physicians to encounter adolescents and young adults presenting with psychotic symptoms. Although pediatricians would ideally be able to refer these patients immediately into psychiatric care, the shortage of child and adolescent psychiatry services may sometimes require pediatricians to make an initial assessment or continue care after recommendations are made by a specialist. Knowing how to identify and further evaluate these symptoms in pediatric patients and how to collaborate with and refer to specialty care is critical in helping to minimize the duration of untreated psychosis and to optimize outcomes. Because not all patients presenting with psychotic-like symptoms will convert to a psychotic disorder, pediatricians should avoid prematurely assigning a diagnosis when possible. Other contributing factors, such as co-occurring substance abuse or trauma, should also be considered. This clinical report describes psychotic and psychotic-like symptoms in the pediatric age group as well as etiology, risk factors, and recommendations for pediatricians, who may be among the first health care providers to identify youth at risk.

Psychosis is defined as impairment in thought and behavior so severe that the ability to distinguish reality from nonreality is lost. Psychotic symptoms include delusions, fixed and false beliefs, and hallucinations or false sensory perceptions. 1   Although these symptoms do not necessarily portend a primary psychotic disorder, there is a strong association with the presence or future development of other psychiatric disorders. 2 , 3   Primary mood or anxiety disorders with concurrent psychotic symptoms often indicate a more severe form of mood or anxiety disorder, such as bipolar disorder, with psychotic features and imply more impaired functioning. 4 – 6  

Pediatricians in the medical home may be the first point of contact for adolescents who report psychotic-like symptoms, which may be attributable in part to the ease of access to pediatricians and/or to a shortage of child and adolescent psychiatrists. 7   Therefore, pediatricians should be familiar and comfortable with asking additional questions when patients present with vague or overt psychotic symptoms, to determine the appropriate level of care (eg, close monitoring with specialty mental health consultation with psychiatrist, psychologist, or psychotherapist, or urgent emergency department [ED] evaluation). Management decisions will depend on the severity of the psychotic-like symptoms, how deeply entrenched the beliefs are (level of insight), level of distress, functional impact, and safety of the individual and others.

This clinical report aims to provide pediatricians with a framework for identification, initial assessment, and mental health referral and consultation for youth presenting with psychotic-like symptoms. This report strongly encourages collaboration between pediatricians and mental health specialists to determine the best course of treatment of patients presenting with psychotic-like experiences or psychosis.

Each year, approximately 100 000 adolescents and young adults in the United States experience a first-episode psychosis (FEP). 8 , 9   Estimates of the prevalence of early-onset schizophrenia (onset prior to 18 years of age) is approximately 0.5%, whereas the prevalence of schizophrenia in general is believed to be about 1%. 1   In the United States, childhood-onset schizophrenia (onset prior to 13 years of age), with a more severe course and worse prognosis, is rarer, with an estimated prevalence of approximately 0.04%. 1  

In general, the peak onset of psychotic disorders occurs between 15 and 25 years of age. 8   Researchers in a large study of FEP found approximately 18% of adults with schizophrenia experienced their first episode before 18 years of age (53.4% male). 10   In another study, researchers found 11% to 19% of a first-episode schizophrenia sample and 23% to 35% of a clinical high-risk syndrome sample reported onset of attenuated psychotic symptoms in childhood (manifesting at 13 years or younger). 11   Patients who are at clinical high risk (CHR) demonstrate nonspecific and attenuated psychotic symptoms, with subtle changes in cognition, behavior, and affect that are different from their previous baseline functioning. Patients at CHR may also have a history of social isolation or withdrawal as well as odd or suspicious behavior. Family and friends may be the first to notice these symptoms, but eventually individuals themselves may begin to experience distress as well. Patients at CHR have higher likelihood of transitioning to overt psychotic symptoms, such as auditory hallucinations and/or delusions. 12   Increased level of distress experienced with the psychotic symptom or psychotic-like experience appears to differentiate CHR status from non-CHR status, which leads to more help seeking. 13  

The prodrome is the phase before a full psychotic episode but can only be defined retrospectively after a psychotic disorder has developed. Studies indicate that the prodromal period may be an important time for early intervention. 14   The duration of untreated psychosis (DUP) is defined as the period between first presentation of psychotic symptoms and treatment. The median DUP was approximately 74 weeks from a sample of patients (15–40 years of age) in community mental health centers. 15   Individuals with shorter DUP appear to have better response to treatment and better overall prognosis, thus emphasizing the need for early identification and intervention. 15  

The key features defining psychotic disorders are delusions, hallucinations, disorganized thinking (speech), grossly disorganized or abnormal motor behavior (including catatonia), and negative symptoms. See the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) 1   section on schizophrenia spectrum and other psychotic disorders diagnoses for specific diagnoses and criteria.

Delusions are fixed, false beliefs. 1   Even if evidence is shown to the contrary of the belief, the belief remains unchanged. See Table 1 for common themes of delusions.

Common Themes of Delusions

The DSM-5 generally classifies delusions as bizarre or nonbizarre. 1   Thought withdrawal, the belief that one’s thoughts are being or have been removed; thought insertion, the belief that an outside force has placed thoughts in one’s head; and delusions of control, the belief that an outside force is controlling one’s body, are all categorized as bizarre delusions. Nonbizarre delusions are those that could be plausible, such as the belief that one is being monitored by the police or FBI or that one’s phone has been hacked by another person, despite a lack of evidence.

The DSM-5 defines hallucinations as vivid perception-like experiences occurring in the absence of any external stimuli. 1   Auditory hallucinations are the most common, although visual, tactile, gustatory, and olfactory hallucinations also occur. Patients report most auditory hallucinations as voices that may be familiar or unfamiliar and are distinct from one’s own thoughts. Hallucinations occurring when one is falling asleep (hypnagogic) or waking up (hypnopompic) are considered normal in the general population. Hallucinations occur more commonly in youth than delusions, and auditory hallucinations are more common than other sensory hallucinations.

Providers may assess for disorganized thinking by observing the patient’s speech. Jumping from topic to topic may be indicative of derailment or loose associations; inability to answer a question in a goal-directed manner or answering a question that was not asked may reflect tangential thinking. A speech pattern so disorganized that it may not be understood by others is known as incoherence or “word salad” (random words or phrases that are strung together in sentence form but do not make sense). 1  

The DSM-5 defines grossly disorganized or abnormal motor behavior as difficulty in performing goal-directed behavior, affecting functioning. Catatonia is decreased reactivity to the environment, and it may consist of a range of behaviors from negativism (not following directions) to mutism and stupor (not responding verbally or with appropriate motor responses, respectively) to catatonic excitement (purposeless and excessive motor movement). Catatonia may also include repeated stereotyped movements, echolalia, posturing, or grimacing. Catatonia is more likely to be associated with schizophrenia but can also be found with other psychiatric disorders or medical conditions, including autism spectrum disorder (ASD). 1  

Negative symptoms consist of diminished emotional expression, avolition (lack of motivation), alogia (poverty of speech), anhedonia (inability to experience pleasure), and asociality (reduced desire or motivation to form relationships). 1 , 16  

The North American Prodrome Longitudinal Study (NAPLS), a consortium of 8 research centers, aimed to study CHR populations and determine mechanisms of conversion to psychosis to predict conversion in a high-risk population with an age range of participants from 12 to 35 years. In a 2.5-year follow-up, risk of conversion from CHR to full psychotic disorder was 35%, whereas approximately one-third remitted and one-third continued to demonstrate attenuated positive symptoms with poorer overall functioning. 17 , 18   Once an individual receives a schizophrenia spectrum diagnosis, prognosis is generally poor unless they receive appropriate treatment. Researchers in 1 study using the Multi-Payer Claims Database demonstrated 12-month mortality after initial diagnosis was 1968 per 100 000 compared with the general population, in which it is 89 per 100 000 people. 19   The authors also found teenagers and young adults in whom psychotic disorder is diagnosed have about a 24-times greater 12-month mortality rate than their peers, suggesting that during the year after diagnosis, it is crucial to optimize outcomes by increasing monitoring with regular follow-up and early intervention. 19   An analysis of the database found it did not report cause of death, leaving the authors to speculate that the reason for death might have included suicide or substance use–related accidents. 19  

NAPLS described variables contributing uniquely to psychosis prediction to be genetic risk for schizophrenia with recent worsening of functioning, greater impairment in social functioning, history of substance use, increased levels of suspiciousness or paranoia, and increased levels of unusual thought content. 18   In NAPLS, 92% of the CHR sample had at least 1 positive symptom, the most common of which was unusual thought content and perceptual abnormalities, followed by suspiciousness. Eighty-two percent of subjects endorsed at least 1 negative symptom, of which avolition and poor occupational functioning were the most common, and 44% demonstrated 3 or more negative symptoms. Disorganized communication occurred infrequently and grandiosity less. 15   Greater levels of unusual thought content and suspiciousness, greater decline in social functioning, greater prodromal symptom severity, lower verbal learning and memory performance, more delayed processing speed, and younger age at symptom onset contributed to increased risk of conversion from CHR status to psychosis. 20   Social dysfunction in early adolescence is of particular significance in conversion to psychosis in CHR individuals. 21  

Many children and adolescents report psychotic-like experiences, but most do not go on to develop true psychotic illness. 22 , 23   Clinically significant psychosis usually involves mental status and behavioral changes and usually imparts a high level of distress. However, data suggest that psychotic-like experiences in childhood and adolescence can be associated with development of other psychiatric disorders in the future, and strong symptomatology in childhood may be associated with increased likelihood of psychotic disorder as adults. 24  

Youth who report psychotic symptoms also have a higher likelihood of experiencing current mental health difficulties than those who do not; however, psychotic-like symptoms that present during childhood and/or adolescence frequently resolve. Jardri et al 25   reported that hallucinations are common in children and may not signify psychiatric pathology; however, persistence of hallucinations into adolescence increases risk of developing psychosis five- to sixfold. In a study of adolescents with hallucinations, half reported no symptoms after 1 year. 26   Similarly, researchers in the Philadelphia Neurodevelopmental Cohort, a 2-year prospective follow-up study, reported 51% persistence or worsening of psychotic symptoms after 2 years. 27  

In youth presenting with delusions or hallucinations, mood disorders should be considered; although pediatric bipolar disorder is rare, early-onset schizophrenia is even rarer. 28   Ulloa et al 29   reported approximately 10% of youth ( n = 2031) seen in a pediatric mood and anxiety disorders clinic had psychotic symptoms. Of the 10% reporting psychotic symptoms, 62% of patients had a diagnosis of a depressive disorder, 24% had a diagnosis of bipolar disorder, and 14% had a diagnosis of schizophrenia.

In a general population of youth, hallucinations were more prevalent than delusions. 30   Youth report auditory hallucinations, often with commands and comments, more commonly than conversing voices. Visual and tactile hallucinations may occur with auditory hallucinations. True hallucinations occur when one is fully awake; they are vivid and evoke a response. 30   Delusions may occur but are vague and are usually related to the hallucinations. Symptoms that are specific to a certain situation (such as occurring only at nighttime or only when the individual is angry), overly detailed, and not associated with disorganized thoughts or behaviors are less likely to be indicative of a true psychotic disorder as well. 22  

Adolescents report fewer hallucinations than children do. Kelleher et al 31   found that a median of 17% of 9- to 12-year-olds and a median of 7.5% of 13- to 18-year-olds report auditory hallucinations. An increase in lifetime history of psychiatric disorders also correlated with an increased reporting of hallucinations. Those reporting psychotic-like symptoms were more likely to have a mental health disorder, including anxiety and mood disorder, at the time of presentation and even more likely over the course of their lifetimes. In a mental health clinic sample, Kelleher et al 32 , 33   found that patients presenting with psychotic experiences were more likely to have multiple psychiatric disorders and socio-occupational difficulties as well as a higher risk for suicidal behavior. A meta-analysis of 10 prospective cohort studies published between 2013 and 2017 found patients who reported psychotic experiences had twofold increased odds of later suicidal ideation, threefold increased odds of later suicide attempt, and fourfold increased odds of subsequent death by suicide. 34  

In a 15-year longitudinal study that followed individuals from 11 to 26 years of age, more than 40% of patients in whom schizophreniform disorder was diagnosed in early adulthood had disclosed symptoms at younger age. Of those who reported the most severe psychotic-like symptoms in preadolescence, approximately 25% had a diagnosis of schizophreniform disorder in early adulthood, and 70% experienced at least 1 of the following: hallucinations, delusions, disorganized speech, catatonia, or anhedonia. Almost all experienced poor occupational or social functioning. 2   When followed out to 38 years of age, those who had reported psychotic symptoms at a young age were at increased likelihood of having a diagnosis of schizophrenia and posttraumatic stress disorder and were also more likely to have attempted suicide. Very few had no psychiatric diagnosis at all. 24  

Youth reporting psychotic symptoms appear to have worse global functioning. 35   Approximately 75% of youth reported that the psychotic-like experiences were distressing to them. 35   Other studies reported those with FEP have significantly slower processing speed; processing speed also predicts social functioning 1 year later. 36   Patients with adolescent-onset psychosis did not demonstrate improvements in processing speed as they aged, which negatively affects functional outcomes. These findings support the idea that adolescent-onset psychosis is associated with a disruption in adolescent brain development, such as myelination. 36   In a study examining a CHR population, comparing those who developed psychosis during the course of the study versus those who did not, authors found only people with psychosis had impaired cognition, with specific impairments in processing speed, verbal memory, sustained attention, and executive functioning. This finding suggests cognitive deficits exist before manifestation of psychotic symptoms. Carrión et al 37   reported that these deficits persist but do not worsen over the course of the illness.

Although there is overlap, the risks and manifestations of psychotic-like symptoms in youth are heterogeneous. Other presentations that can be confused and/or associated with psychotic-like symptoms are described below. See Appendix 1 for sample case scenarios of psychotic and psychotic-like presentations that may occur in the pediatric ambulatory setting.

Some adolescents may mention hearing their name called with no other concerning symptoms. The Washington University in St Louis Kiddie Schedule for Affective Disorders and Schizophrenia, which assesses for hallucinations that are benign or pathologic, defines these as “benign hallucinations,” because they do not impair functioning, are nonthreatening in content, and occur infrequently. 38   Pathologic hallucinations, such as a voice telling one to harm oneself or others, do impair functioning. 38   A recent review of “healthy voice-hearer” literature found there appeared to be a continuum of voice hearing from healthy controls (no auditory hallucinations) to “healthy voice-hearers” (low frequency, low distress) to “clinical voice-hearers” (high frequency, high distress). 39   Although healthy voice hearers seem to be at higher risk of transitioning to mental health disorders, only a minority end up transitioning. 39  

Illusions are distinct from hallucinations but warrant mention. Illusions are defined as a misperception and/or misinterpretation of an actual stimulus, such as seeing a rope on the ground and thinking it is a snake for an instant, whereas hallucinations consist of perceiving something that is not actually there. 1   Illusions are not necessarily pathologic and can be experienced by people with no psychiatric disorders. In a white noise speech illusion study (hearing speech when only white noise was being played) in adults, there was no association of white noise speech illusion with psychosis in a nonclinical population. 40  

Imaginary friends, which could also be called “hallucination-like phenomenon,” are reported in 28% to 65% of children 5 to 12 years of age, and up to 65% of children 7 years of age and younger have imaginary companions. 25 , 41   There is scarce literature on imaginary companions and association with psychotic symptoms. An imaginary companion could be invisible or embodied by a doll or stuffed animal. 42   Imaginary companions during childhood are normative and are thought to help with development of appropriate social interactions and emotional regulation. 42   Children can identify that imaginary companions are not real. 42   Youth are usually able to make imaginary friends go away, unlike hallucinations. 30   Because of concerns for prognosis and relevance to future mental health disorders, a longitudinal study of “high-risk” middle school students 11 to 14 years of age with imaginary companions, described by their teachers as having the most “problem behaviors” (as assessed by the Child Behavior Checklist 4–18) in school, was performed. The researchers found that although these children had the most behavioral issues and the least social acceptance, they were not at higher risk for any psychiatric disorders and seemed to have greater positive adjustment. 43  

It is important for pediatricians to consider cultural issues or family background when asking about psychotic-like symptoms, because some symptoms that sound pathologic may be normal cultural or developmental responses. For example, if a youth describing a presence or shadow in their room at night comes from a family that believes strongly in spirits or ghosts, such an experience may not reflect an actual visual hallucination. During bereavement and mourning, youth may report auditory or visual hallucinations of the deceased person. 44 – 47   In these situations, the individual’s degree of distress can be helpful in determining the pediatrician’s next step. When symptoms are described as comforting or neutral, they are less likely to be an indication of a psychotic disorder. Distress would indicate something more problematic, and referral to a psychotherapist would be recommended.

People with intellectual disability (ID) may report psychotic-like symptoms, and pediatricians and developmental and behavioral pediatricians can assist with providing a differential diagnosis for youth with ID and ASD and help coordinate a plan of care related to special educational needs and therapies. Providers may consider using a neurodevelopmental framework to assess psychotic-like symptoms. Symptoms suggestive of psychosis in this population could instead reflect self-talk, imaginary friends, or fantasies, depending on an individual’s developmental level. 47   Stressful experiences, such as the loss of a loved one, may trigger or exacerbate psychotic-like symptoms. 47   When assessing adolescents or young adults with ID, it is important to determine if they understand the questions being asked to ensure a valid assessment. Individuals with intellectual limitations and delayed emotional development may feel pressured to answer a question a certain way to please the interviewer or blame negative behaviors on voices in their head to avoid getting in trouble. 44  

Co-occurring mental disorder and ID in youth is common and often persists through the life span. 48   Relative to children and adolescents without ID, the rate of co-occurrence of mental disorders in youth with ID is 3 to 4 times greater.

Core features of ASD consist of social communication and social interaction deficits as well as restricted interests, stereotyped or repetitive behaviors, and sensory sensitivities. Some of these symptoms may overlap with those occurring in schizophrenia spectrum disorders (SSDs). In addition, a number of individuals with ASD may experience transient hallucinations and engage in vivid fantasies, which may be mistaken for true psychotic symptoms. Although there is a level of co-occurrence of ASD and SSDs, one must be careful to distinguish the overlapping symptoms before giving both diagnoses. 49   Common genetic regions and brain regions may contribute to the comorbidity of ASD and SSDs. 50  

Co-occurring ASD and SSD should be considered when perceptual abnormalities and beliefs or behaviors are noted to be different from those at baseline, especially with associated change in functioning. 50   Thorough developmental, medical, and psychiatric history, as well as any other useful collateral information, is important when assessing for co-occurring conditions. In addition, genetic testing should be considered if not already completed. Clinicians should also monitor for catatonia.

In addition to serving as a risk factor for psychotic disorder, trauma can result in posttraumatic symptoms that can be mistaken for psychotic symptoms. For instance, flashbacks can be mistaken for visual and/or auditory hallucinations, and hypervigilance or hyperarousal can be mistaken for paranoid delusions. Withdrawal and avoidance could be mistaken for negative symptoms. 51   Assessment to determine if symptoms are psychotic-like or truly psychotic in nature may need to take place over time to determine the most appropriate course of treatment.

Dissociative episodes can also be associated with trauma and may serve as a protective mechanism to mentally or emotionally escape physical trauma. Dissociation is a detachment from reality, whereas psychosis is a loss of reality. Although the two are distinct, some researchers hypothesize that dissociation may mediate the relationship between traumatic life events and the development of attenuated positive psychotic symptoms. 52  

Schizophrenia is a heterogeneous disorder, but disruptions in brain connectivity and synaptic functioning likely underlie the development of schizophrenia. 53   These disruptions appear to occur first in neural circuits involved in referencing occurrences by time, place, and saliency, potentially resulting in an inability to recognize that certain thoughts have been self-generated, which could eventually contribute to loss of reality testing. Axonal pathology, such as disruption in myelination, may also be involved. 53   Excessive synaptic pruning may also be a factor, possibly associated with the immune system, namely upregulation of complement genes and activation of microglia. 54  

Scientists have found abnormalities in brain structure, likely progressive, including bilateral enlargement of lateral ventricles and volume decreases in the frontal lobe, hippocampus, and thalamus. 55 , 56   Rapoport et al 57   demonstrated reduced frontal and temporal gray matter volume compared with healthy controls. People with childhood-onset schizophrenia seem to lose more gray matter in the cortex than do children who report brief psychotic episodes. 57   Those with early-onset schizophrenia also show significant gray matter volume decrease and decrease in cortical folding. 55 , 58  

Schizophrenia is primarily associated with dopamine dysfunction, with increased dopamine synthesis and release leading to psychosis; however, multiple other neurotransmitters and pathways are believed to be involved. 59 , 60   Olney and Farber found that animals given N -methyl-D-aspartate receptor antagonists develop neurotoxic changes similar to those observed in brains of patients with schizophrenia. 61   Administration of agents that increase glutamate, such as phencyclidine or ketamine, increase the likelihood of psychotic symptoms. 62   Serotonin antagonism, as found in some second-generation antipsychotic medications, appears to provide some benefit for extrapyramidal symptoms and for mood symptoms associated with schizophrenia. 63   Serotonergic antagonists also show promise for treatment of negative and cognitive symptoms of schizophrenia. 60 , 63 , 64   The muscarinic cholinergic system may play a role in schizophrenia, because blockade of acetylcholine receptors can result in psychotic symptomatology. 60 , 65   In addition, alterations in the γ-aminobutyric acid neurotransmitter system may also have a role in schizophrenia. 60   Abnormalities in these neurotransmitter systems form the basis for pharmacologic treatment of psychotic disorders and/or schizophrenia.

Family, twin, and adoption studies indicate genetic involvement in schizophrenia. The risk of developing schizophrenia is 5 to 20 times higher in first-degree relatives of patients with schizophrenia. 55 , 66   Concordance rates are 40% to 60% between monozygotic twins and 5% to 15% in dizygotic twins and other siblings. 55 , 66   A number of genomic disorders resulting from duplication or deletion of genetic material have been associated with ID, ASD, and schizophrenia. See Table 2 for a list of medical illnesses for which symptoms can include psychosis. 67 – 69  

Medical Causes Associated With Psychotic Episodes

Sources: refs 30 , 44 , 67 , 111 , 115 . ACTH, adrenocorticotropic hormone; BMP, basic metabolic panel; CBC, complete blood cell count; CMV, cytomegalovirus; CRH, corticotropin-releasing hormone; ELISA, enzyme-linked immunosorbent assay; HPV, human papillomavirus; HSV, herpes simplex virus; IgG, immunoglobulin G; PCR; polymerase chain reaction; PTH, parathyroid hormone; TB, tuberculosis.

Environmental exposure can cause direct neurologic damage or may mediate risk of future development of psychosis with new mutations or epigenetic effects. 55   Environmental exposures include exposure in utero, like maternal starvation, obesity, or infection (such as Toxoplasma gondii ); obstetric complications (such as hypoxia, pregnancy bleeding, preeclampsia); substance exposure (marijuana, tobacco, alcohol); and advanced paternal age. 55 , 70 – 73   The effect of in utero stressors on the development of a psychotic disorder and other psychiatric disorders may be mediated by inflammation, although substances are believed to have negative effects on brain development, neurotransmitters, and cognition. 73 – 75   Substances that have been most studied are tobacco, alcohol, and marijuana, all of which have been associated with later development of psychosis in offspring exposed in utero. 75 – 77  

Childhood trauma experienced from 0 to 17 years of age, including emotional neglect, physical abuse, sexual abuse, emotional abuse, domestic violence, or bullying, increase the odds of psychotic experiences at 18 years or older. 78   Exposure to more than 1 type of trauma or experience of repeated trauma over multiple age periods further increase the odds of psychotic experiences. 78   Evidence suggests adverse childhood experiences can interact with genetic risk factors to contribute to the development of psychotic disorders or other psychiatric disorders. In a recent review of trauma and stressful life events in a population at high risk for psychosis, up to 80% of adolescents and young adults reported a history of childhood trauma, including bullying. 79   In adolescents and young adults with history of trauma, the overall odds of experiencing psychotic symptoms or developing a psychotic disorder range between 2.8 and 11.5. 80   A large-scale twin study in England and Wales with mental health assessments performed at 11 and 16 years of age found that bullying resulted in anxiety, mood, and conduct problems, and paranoid thoughts and cognitive disorganization persisted for 5 years. 81   Sexual trauma has the highest risk of conversion to psychosis, followed by physical trauma (eg, abuse, bullying, neglect). 79   Researchers in studies of people with CHR and FEP found both groups showed higher rates of suicide attempts and hospitalizations and generally demonstrated poorer functioning. 79   In the CHR population, there is a higher likelihood of comorbid posttraumatic stress disorder as compared with the healthy control population.

Some longitudinal studies found traumatic life experiences may predict the development of psychotic symptoms. 80 – 82   People presenting with psychosis who have a history of trauma have increased severity of psychotic symptoms, more frequent hospitalizations, increased number of comorbid disorders, more cognitive deficits, and increased treatment resistance. 80   In a longitudinal cohort study of a CHR population, researchers found a positive association between sexual abuse in childhood and conversion to a psychotic disorder. 83   Therefore, for patients who report a history of trauma, including physical or sexual abuse or bullying, providers may consider inquiring about any experience of psychotic symptoms.

History of trauma is associated with increased risk for future development of borderline personality disorder. 84   Borderline personality disorder can also present with psychotic-like experiences and/or psychotic symptoms and dissociative episodes. In a European study of adolescents 15 to 18 years of age, those with full threshold borderline personality disorder were more likely to experience psychotic symptoms; these symptoms predicted severity of borderline personality disorder. 85   Auditory and visual hallucinations, paranoia, and thought problems, like strange thoughts and confusion, were common and presented early in the course of the disorder. Another study suggested that borderline traits mediate the relationship between history of trauma and psychotic-like experiences in the context of high stress. 86  

The ingestion or use of multiple illicit substances, such as hallucinogens and stimulants, can result in psychotic experiences, although no causal link has been established. In a study of help-seeking youth, those at risk for developing a psychotic disorder had higher rates of tobacco, alcohol, and cannabis use than those individuals who were not. 87   In a study of 404 participants from the Recovery After an Initial Schizophrenia Episode–Early Treatment Program (RAISE-ETP), up to half of adolescents and young adults with FEP reported use of alcohol or cannabis within the month before starting treatment. 88   In addition, about half of this population also reported use of tobacco at the time of enrollment in RAISE-ETP. Authors found that cigarette smoking was associated with reports of more psychiatric symptoms and poorer functioning, more missed pills, and decreased quality of life. Use of alcohol was associated with decreased adherence to medication regimen, and cannabis use was related to increased severity of illness and positive symptoms of schizophrenia. 88   Other meta-analyses of observational and longitudinal studies have demonstrated that daily tobacco use is associated with increased psychosis risk as well as earlier age when psychotic symptoms begin; researchers in these studies concluded that a causal link between tobacco smoking and development of psychosis should be considered and that further studies should be performed. 89 – 91  

Most studies suggest a consistent association between marijuana use in adolescence and development of psychosis, and persistent use after an initial psychotic episode is associated with poorer prognoses. 92 – 94   There is also evidence suggesting earlier age at first marijuana use correlates with earlier age at onset of psychotic symptoms, regardless of whether or when marijuana users discontinued use; therefore, cannabis use is a preventable risk factor in psychosis. 93 , 95 , 96   There remains controversy over the level of risk for development of psychosis attributed to the use of cannabis and the level to which cannabis use can precipitate people without genetic predisposition to psychosis into illness. 92   One recent multisite study in Europe and Brazil demonstrated daily cannabis use and use of high-potency cannabis were the strongest independent predictors of having a psychotic disorder. 97   The odds of having a psychotic disorder for individuals using cannabis daily was 3.2 times higher than for those who never used cannabis (“never-users”). The odds of having a psychotic disorder in those who used high-potency cannabis versus never-users was 1.6 times higher. Because of the multiple sites and knowledge of incidence rates of psychotic disorders at those sites, researchers of this study were able to demonstrate that the association between use of cannabis and risk of psychosis varies by location depending on how and what kind of cannabis is used in that region. The authors report that in regions where cannabis is used daily and where high-potency cannabis tends to be used more frequently, there are more cases of psychotic disorders. 97   Synthetic cannabinoids (K2, spice) can also induce psychotic symptoms. 98   Routine urine toxicology screens do not screen for synthetic cannabinoids. 99  

In a study in Denmark following patients with substance-induced psychosis, researchers found that more than 30% converted to bipolar disorder or primary psychotic disorder. In the case of cannabis-induced psychosis, almost half converted. Approximately half of those patients who transitioned to schizophrenia did so within 2 years of diagnosis. A Scottish longitudinal study reported a 15.5-year cumulative hazard rate of 17.3% for diagnosis of schizophrenia after an initial hospital admission with substance-induced psychotic disorder (including cannabis, stimulants, and alcohol). Approximately half of these patients transitioned to schizophrenia within 2 years (80% by 5 years). These studies suggest that follow-up of patients in whom substance-induced psychosis is initially diagnosed could benefit from follow-up of 2 to 5 years to optimize early intervention and mitigate negative outcomes. 100 , 101  

Perhaps of particular relevance to pediatricians, because they may be more likely to prescribe stimulants for children with attention-deficit/hyperactivity disorder (ADHD), researchers of a recent study using data from 2 commercial insurance claims databases compared the diagnosis of new-onset psychosis in adolescents and young adults with a diagnosis of ADHD treated with either a methylphenidate or amphetamine formulation. Although both classes of stimulants increase overall dopamine, amphetamines potently increase dopamine release from neurons (similar to neurotransmission in a primary psychotic disorder), whereas methylphenidates inhibit dopamine transport, thereby decreasing reuptake of dopamine into the presynaptic terminal. 102   In this large-scale study of adolescents and young adults with stimulant prescriptions, researchers determined that 0.1% in the methylphenidate group and 0.2% in the amphetamine group required treatment of stimulant-induced psychosis. On the basis of this study, authors determined that approximately 1 in 660 patients with ADHD who are treated with a stimulant will develop a new-onset psychosis. 102   Analyses of data from the US Food and Drug Administration (FDA) and case reports demonstrated that stimulant-induced psychotic symptoms generally did not last long and often resolved with cessation of stimulant alone. 103   Cathinones (bath salts) fall under the category of stimulants and can also induce psychosis. Cathinones do not show up on routine urine drug screens. 99  

These data indicate that substance use increases vulnerability for those who are at risk for developing psychotic symptoms.

The presentation of adolescents and young adults with psychotic-like symptoms can be varied, and a wide differential diagnosis should be considered, including psychiatric disorders, physical illness, and intoxication (see Tables 2 and 3 ). Pediatricians may initially encounter a patient presenting with vague feelings that something is wrong or “off,” with a correlating drop in grades and/or work performance or increased isolation, which may be attributable to suspicions and mistrust of others. Patients may also present with decrease in hygiene and/or self-care, difficulty communicating or confused speech, and new-onset difficulty in concentrating. Additionally, adolescents may present with difficulty separating fantasy from reality. Early-onset schizophrenia can also present with cognitive delays. One of these symptoms merits consideration of referral to a mental health specialist for further evaluation and monitoring and therapy (eg, cognitive behavioral therapy [CBT]), and multiple symptoms warrant referral to a child and adolescent psychiatrist and a therapist. Collaboration with developmental and behavioral pediatricians should also be considered, especially in the context of ID and ASD. If symptoms are more overtly psychotic and could potentially lead to unsafe behavior with possible suicidal or homicidal ideation, pediatricians should arrange for immediate safety evaluation in a mental health facility or ED with resources to stabilize and evaluate children and adolescents with mental health problems.

Nonschizophrenia Spectrum Psychiatric Conditions Associated With Psychotic Episodes in Children and Adolescents

Sources: refs 44 and 67 .

Screening for psychosis with validated screens, such as the Prodromal Questionnaire–Brief, the PRIME early psychosis screen, and the Youth Psychosis At-Risk Questionnaire, can be helpful to screen for psychotic symptoms regularly because they are relatively short and have high specificity. Other longer screens are mostly used in research settings, such as the Structured Interview for Prodromal Symptoms (SIPS), the gold standard for psychosis risk, and the Comprehensive Assessment of At-Risk Mental States (CAARMS), both of which are labor-intensive and require special training by the administrator of the screen. 104 , 105  

In the case of an adolescent presenting with an acute psychotic break, additional concerns may be relevant, and there should be consultation with a child and adolescent psychiatrist if available. Although the below recommendations and suggestions for interviewing and examination of the patient remain important, pediatricians will also likely have more concern for trauma or signs of intoxication or withdrawal. There may also be more concern for agitation. Early signs of agitation include restlessness, irritability, and inappropriate or aggressive behaviors, which could require pharmacologic interventions, such as an antipsychotic (haloperidol is often used) and/or a benzodiazepine, such as lorazepam. It is best to offer these medications orally to allow the patient to feel that he or she has some control in the situation. 106   Because of safety concerns, these patients may ultimately be admitted to psychiatric inpatient units. If other physical or medical issues are discovered and the adolescent must be hospitalized in a pediatric unit, consultation with a psychiatrist may be helpful to manage agitation.

Pediatricians should interview patients in a quiet and private setting, with as few distractions as possible. Parents and guardians may be able to provide more information and a better time line than the patient, depending on the patient’s mental status. Attempting to construct a time line of symptom progression is also useful and includes asking about recent stressors or possible precipitating or exacerbating events, such as trauma in the form of physical or sexual abuse, bullying, or the loss of a loved one (or anniversary of such a loss). 55  

Although it is essential to gather history from parents or guardians, it is also important to talk alone with the adolescent. Careful attention to and documentation of the mental status of the adolescent is necessary (such as his or her presentation and hygiene, engagement, response to internal stimuli). When asking about possible psychotic symptoms, it is important for providers to normalize the symptoms if possible. Asking when these symptoms occur (when one is stressed or depressed, at night when one is alone) and how often they occur (randomly, only in stressful situations, constantly) is also helpful. In addition to asking about specific symptoms, it is helpful and important to ask reality-testing questions (testing how valid the patient’s beliefs are and trying to differentiate the patient’s internal experience from that of real life), which indicate how entrenched the belief is. If patients report hearing voices of others talking about them but feel that the voices could actually be their own thoughts or that there could be other explanations for the feeling that they are being watched, this would be less acutely concerning. Other important information including medical history (birth history, including age of parents, and developmental history); family psychiatric history; history of abuse or other trauma, including bullying; and history of substance use can shed light on possible risk factors and etiology. Although understanding of current symptoms is critical, it is also important to assess premorbid functioning to understand the patient’s degree of change from baseline.

Pediatricians also may consider gathering collateral information from teachers, counselors, or coaches, with consent, after the initial interview to gain different perspectives on the adolescent’s behavior and functioning. For example, if parents notice increased isolation and withdrawal as well as refusal to engage in regular hygiene, but the teacher states that grades continue to be good and the adolescent continues to engage in appropriate social interactions with peers (who also do not shower regularly), this might be less concerning for a prodromal presentation. See Appendix 2 for example questions.

Patients presenting with psychotic symptoms are at greater risk for suicide; therefore, it is critical to inquire about thoughts of self-harm or suicidal ideation, passive or active, with or without plan or intent. The Ask Suicide Screening Questions screening tool is helpful in determining the presence of suicidal thinking, and the Columbia-Suicide Severity Rating Scale can be used to determine the level of risk. 107 , 108   Patients may report command hallucinations telling them to hurt or kill themselves or others; derogatory hallucinations, such as voices that say negative things about them or put them down; or persecutory or religious delusions in which they could report feeling threatened by others or “the devil.” If there are concerns for safety to self or others, it is important for providers to refer immediately to the ED for evaluation and to ensure safe transportation. Other concerning symptoms that warrant referral to the ED include severe impairment in functioning, such as lack of self-care (eg, severe weight loss because of worry that the food is being poisoned) or complete isolation (eg, refusal to leave the room or home because of a belief that others will place thoughts in their heads). If there are no acute safety concerns but symptoms seem to be fully psychotic rather than attenuated, the patient is unable to come up with alternative explanations to delusions, the patient appears to be in distress, and/or functioning is affected, the pediatrician should refer the patient to a child and adolescent psychiatrist.

When a patient presents with psychotic-like symptoms, providers should perform a thorough physical examination with a detailed neurologic examination to exclude medical etiologies. Focal neurologic findings may warrant urgent consultation with neurology and may require additional evaluation such as EEG and brain imaging. Hallucinations that are primarily gustatory or olfactory can be suggestive of organic causes, such as seizure disorder or tumor, 109   although a more recent study suggests tactile, olfactory, and gustatory hallucinations are actually common in primary psychotic disorders and not necessarily indicative of organic brain disease. 110   Authors also found an association of tactile, olfactory, and gustatory hallucinations with earlier age of onset with psychosis. 110   Hallucinations associated with headaches warrant referral to a neurologist as well. 44  

Pediatricians may consider the following laboratory tests: complete blood cell count, comprehensive metabolic panel (including glucose, serum urea nitrogen/creatinine, liver function tests), thyroid-stimulating hormone, calcium and phosphorus, ceruloplasmin (to evaluate for Wilson disease), antinuclear antibodies, erythrocyte sedimentation rate, syphilis screening, HIV screening, vitamin B 12 and folate concentrations, and urinalysis and urine toxicology. 111   Testing levels of heavy metals may also be considered if clinically indicated. Testing for copy number variants in patients with psychosis may be considered when there is suspicion for a genetic syndrome. 112   See Table 2 for a list of medical illnesses, the symptoms of which can include psychosis, and recommended testing. 67 – 69  

There is limited evidence supporting imaging studies for patients who do not present with associated focal neurologic signs, although it may be helpful in those with a history of head trauma. 30   Patients with positive antinuclear antibody titers should be referred to pediatric rheumatology, and neuroimaging studies should be performed for evaluation of possible lupus cerebritis. 113   The American College of Radiology appropriateness criteria of evidence-based imaging guidelines for specific clinical presentations suggest that MRI or a computed tomographic scan may be appropriate initially in new-onset psychosis but that the yield of brain imaging for psychosis onset was low unless there was an evident neurologic deficit. 114  

There is also insufficient evidence to routinely perform EEG. However, in a patient presenting with FEP who has a history of a seizure disorder, EEG may rule out the possibility of ictal or interictal psychosis. 111 , 115   Some studies support prognostic, rather than diagnostic, implications of EEG, with abnormal EEG findings reflecting poorer prognosis. 116  

As noted previously, if attenuated symptoms worsen or become fully psychotic, pediatricians should refer patients for psychiatric care. If there are any concerns for safety, such as suicidal thoughts, self-harming thoughts or behaviors, or homicidal ideations because of suspicion of others, the pediatrician should immediately refer the patient to the ED or other mental health facility with means to evaluate and stabilize the patient or summon an ambulance for emergency transport to the ED depending on acuity of safety concerns. Although providers should maintain confidentiality for many mental health care concerns, in the event of concerns for danger, such as suicidal or homicidal ideation, abuse, or disorganization that is so severe that basic functioning is lost (such as not eating, drinking, or sleeping), providers must breach confidentiality to protect the minor patient and others from harm and document that they are doing so. If a patient reports symptoms that are not potentially dangerous and do not seem to affect functioning, these can be kept confidential between the patient and the treating physician and documented in a confidential section of the electronic medical record if available. The physician is advised to use his or her clinical judgment with regard to confidentiality and may encourage the patient to discuss these issues with the parent or guardian (even offering to be present during the discussion to lend support). In the case of a young adult, over 18 years, who has capacity and who presents with a parent or guardian, the clinician is able and encouraged to gather collateral information; however, the clinician cannot share confidential information with the family unless the patient asks him or her to do so. If a patient is considered a danger to self or others or is not able to conduct basic activities of daily living because of the severity of symptoms and needs to be psychiatrically hospitalized, the parent or guardian cannot be told unless the patient asks specifically that this be done or the parent has guardianship.

If a patient is at imminent risk to the safety of himself or herself or others or deemed unsafe or unwilling to engage in care, emergency medical services or police transport is advised, and referral communication to the ED is recommended. Some states have special procedures to mandate transfer, as well as documents that may accompany patients to indicate the pediatrician’s assessment that the patient needs emergency evaluation. Providing this documentation to the guardian who takes the patient to the ED may improve the likelihood of psychiatric hospitalization. States have varying legal requirements for involuntary evaluation and/or treatment of patients, and pediatricians are advised to consult their state department of health Web sites to determine the relevant mental health laws of their state. Although collaboration with a psychiatrist on appropriateness of transfer would be ideal, this is not always possible given the shortage of child psychiatrists. Therefore, in acute situations in which safety is a concern, a pediatrician should feel justified in sending a patient directly to the ED with the guardian if guardian is cognizant of the urgency of the situation and will take the patient to the ED or call 911 to transport the patient. See Fig 1 for consideration of monitoring, breaking confidentiality, and transport to ED for emergency evaluation.

Basic algorithm to determine next steps when a patient presents with psychotic-like symptoms.

Pediatricians may be the first providers to assess and identify psychotic-like symptoms. Because visits to the pediatrician may decrease in adolescence, pediatricians should be vigilant in assessing for mental health concerns and changes in functioning or unusual beliefs. 117   Because adolescence can be a difficult time for youth and parents alike, addressing stressors at home and in the environment can be beneficial for all adolescents, including those manifesting psychotic-like symptoms. Recommendations to spend more time in familiar settings among family members and/or close friends can be helpful. Helping the patient to obtain educational or career supports and appropriate psychiatric care earlier may decrease DUP and improve outcomes. In a study of patients presenting with psychotic symptoms associated with a nonpsychotic primary disorder, enhancement of coping skills was associated with improved outcomes. 5  

NAPLS provides a relatively new concept of “clinical staging” for psychotic disorders that may help determine treatment at different levels of presentation and symptom manifestation. Patients presenting with less severe symptoms and/or risk factors receive psychosocial treatments initially, and individuals with increased severity of symptoms and/or more risk factors receive pharmacotherapy in addition to psychosocial treatments. 118   Once a pediatrician identifies psychotic symptoms in an adolescent, it is likely that a referral to a mental health provider will result. Below are the current treatment modalities for psychotic disorders.

CBT is an evidence-based treatment of patients presenting with psychotic-like symptoms. CBT aims to lower distress and disability through working with delusions, hallucinations, and negative symptoms, using the “ABC method” (activating event leading to an automatic thought, which in turn affects affect and behavior). CBT aims to derive alternative explanations for the patient’s psychotic symptoms that are acceptable to the patient and the therapist and to decrease the patient’s distress from the symptom(s). 119 , 120   In a systematic review and meta-analysis, researchers found CBT lowered the risk of progression to psychosis at 6, 12, and 18 to 24 months and decreased symptoms at 12 months. 121   Authors of a more recent meta-analysis found that CBT resulted in a trend toward significant reduction of attenuated psychotic symptoms at 12 months. 122   In the Dutch Early Detection Intervention Evaluation Trial, authors studied people at “ultrahigh risk” of psychosis who received CBT in addition to routine care compared with a control group with routine care only. CBT plus routine care demonstrated averted transition to psychosis and reduced costs. 123   In addition, the National Institute for Health and Care Excellence recommends CBT with or without family therapy for patients presenting with attenuated psychotic symptoms. 124  

CBT in early psychosis has also revealed some benefit as a stand-alone treatment of psychosis, although most studies have been conducted with CBT in combination with antipsychotic medication treatment. CBT may be more acceptable to patients because of its lower side effect profile and decreased stigma; in addition, discontinuation of CBT is less common than discontinuation of treatment with antipsychotic medications. 125 – 127  

Aside from CBT, family-focused interventions, social skills training, supported education and employment, and healthy lifestyle training are early interventions that can be helpful for CHR patients. 128   Family interventions include family psychoeducation and improving communication between family members. In a meta-analysis, family therapy was found to show a nonsignificant trend toward decreasing attenuated psychotic symptoms at 6 months. 122   Because impairment in social skills can be associated with difficulty making friends, bullying, and poor occupational functioning, social skills training can involve role playing as well as practicing specific social skills to improve interpersonal skills. 128   CHR youth may be at higher risk for academic difficulties, so they may benefit from special education services, such as a 504 or individualized education program. Increased resources and appropriate accommodations can help these youth feel successful. In addition, supported employment can be helpful for patients at CHR, who may have trouble finding and maintaining jobs. Healthy lifestyle interventions include emphasis on proper nutrition, physical activity, getting enough sleep, managing stress, and not engaging in behaviors like smoking, substance use, and risky sexual practices. 128  

The Schizophrenia Patient Outcomes Research Team psychosocial treatment recommendations, which report evidence-based psychosocial treatments for people with schizophrenia, include assertive community treatment, supported employment, skills training, CBT, token economy interventions (positive reinforcement for target behaviors), family-based services, psychosocial interventions for alcohol and substance use disorders, and psychosocial intervention for weight management. 129   Correll et al 130   reported that early intervention services were superior to treatment as usual in FEP.

Initiating medication for the treatment of psychotic symptoms is generally out of the scope of pediatricians. However, limited access to mental health specialists may necessitate prescribing in some circumstances, ideally with consultation from a child and adolescent psychiatrist or developmental-behavioral pediatrician.

Several antipsychotic medications may alleviate psychotic symptoms if the symptoms are caused by a primary psychotic disorder (see Tables 4 and 5 ), although it is important to mention that ziprasidone and asenapine failed to separate from placebo in treatment of adolescents with schizophrenia. 131 , 132   When selecting an antipsychotic medication, those with FDA approval should be considered first. Other factors that may help guide the choice of treatment include side effect profile, patient and family preference, cost, insurance coverage, and availability of the medication. 133  

Commonly Used Antipsychotic Medications and Adverse Effects

Sources: 151 and 152 . TD, tardive dyskinesia.

Second-Generation Antipsychotic Medications: FDA Approval and Dose Ranges for Adolescents With Schizophrenia

Sources: 153 and 154 . BID, twice a day.

If psychotic symptoms are caused by another psychiatric disorder, the primary disorder (such as depression, bipolar disorder, or anxiety) should be treated first, unless the psychotic symptoms are so severe that brief treatment with an antipsychotic medication concurrently with a medication to treat the primary disorder should be considered. Given the adverse effects associated with antipsychotic medications, great care and consideration are advised before prescribing these medications.

With regard to dosing, the mantra is to “start low, and go slow,” always monitoring for adverse effects. Generally, lower doses should be effective in patients with FEP. 111   A meta-analysis and pooled data from 7 randomized controlled trials indicate an observable response usually within 2 weeks and that the initial improvement (in 2 weeks) is greater than in the subsequent 2 weeks. 134 , 135   See Table 4 for a list of antipsychotic medications and side effects and Table 5 for dose ranges and FDA approval for children and adolescents.

There have been trials comparing efficacy of first-generation and second-generation antipsychotic medications, including the Clinical Antipsychotic Trials of Intervention Effectiveness and European First Episode Schizophrenia Trial. Researchers in these studies did not find significant differences among efficacy of these antipsychotics but did find different side effect profiles, which influenced time to discontinuation. 136 , 137  

There are 2 main treatment studies of adolescents and young adults with schizophrenia. Researchers in the Treatment of Early-Onset Schizophrenia Symptoms (TEOSS) study compared the efficacy of first-generation or atypical (second generation) antipsychotic medications on early-onset schizophrenia and schizoaffective disorder because providers were prescribing more atypical antipsychotics because of better efficacy and tolerability, although there was no clear evidence of this. 138 , 139   The study included patients between 8 and 19 years of age receiving risperidone, olanzapine (both atypical antipsychotics), or molindone (first-generation antipsychotic). The 3 medications had similar efficacy (50% treatment response), but adverse effect profiles differed. 138   Molindone was associated with akathisia, an inner feeling of restlessness that compels people to be in motion; olanzapine and risperidone were associated with weight gain and metabolic changes. Risperidone also caused increase of prolactin levels. 138  

The National Institute of Mental Health Recovery After Initial Schizophrenia Episode (RA1SE) study of participants 15 to 25 or 30 years of age aimed to develop and implement integrated treatment protocols in FEP. The treatment program is NAVIGATE, named as such to support and guide patients and their families through the experience of FEP toward recovery. 140   NAVIGATE is a team-based comprehensive, multidisciplinary treatment program designed for implementation in community mental health facilities. Treatment interventions include individualized medication treatment (shared decision-making), family education program, individual resiliency training, and supported education and employment. 141 , 142   Coordinated specialty care with these components is now considered evidence-based care in treatment of early-onset psychosis and is tightly coordinated with primary medical care to optimize both mental and physical health. In a comparison of NAVIGATE and usual community care, NAVIGATE participants continued treatment of longer periods of time, had more improvement in symptoms and quality of life, and were more involved in school and work over a period of 2 years. 141   Patients also had fewer adverse effects and were less depressed. 143   Patients with shorter DUP seemed to benefit more from NAVIGATE than those with longer DUP. 141  

The pediatrician may be asked to evaluate a patient with medical symptoms that could be related to antipsychotic medication. Moreover, because of geographic limitations and cost concerns, families may rely on the pediatrician in the medical home to work collaboratively with the psychiatrist to monitor for certain side effects of antipsychotic medications. Adverse effects of antipsychotic medications include extrapyramidal symptoms, weight gain, impaired glucose metabolism, increased lipid concentrations, increased prolactin concentrations (leading to menstruation irregularities and galactorrhea), increased QTc interval, and sedation. Extrapyramidal symptoms include bradykinesia (decreased movement), akathisia, tremor, muscle rigidity, dystonia (intermittent or sustained muscle contractions), and tardive dyskinesia (involuntary and repetitive athetoid or choreiform movements of the body, lasting at least a few weeks). 144 , 145   Tardive dyskinesia can develop in association with the use of a neuroleptic medication for at least a few months and can persist beyond 4 to 8 weeks 1   (see Table 4 ).

The American Academy of Child and Adolescent Psychiatry practice parameter provides guidelines on metabolic monitoring for pediatric patients receiving antipsychotics, as second-generation antipsychotics are more likely to increase risk of metabolic syndrome, with increased waist circumference and blood pressure as well as hypertriglyceridemia, hyperglycemia, and low high-density lipoprotein (“good cholesterol”) concentration. 144 , 146 , 147   The guideline recommends baseline measurement of BMI, waist circumference, fasting blood glucose concentration, hemoglobin A1c, and fasting lipid concentrations. Additionally, monitoring includes BMI and waist circumference monthly for the first 3 months, at 6 months, and then yearly, unless there is a change in medication dose (in which case more frequent measurements should be made until dose stabilization). The guidance recommends measuring fasting glucose concentration, lipid concentrations, and hemoglobin A1c at 3 months and then yearly. 146 , 147   Providers may consider more frequent monitoring of children and adolescents.

Neuroleptic malignant syndrome (NMS) is a rare but life-threatening adverse effect of treatment with antipsychotic medications caused by excessive dopamine blockade. Symptoms include “lead-pipe” muscle rigidity, fever, autonomic dysfunction, and altered mental status. NMS is mostly likely to occur within hours to days of taking the medication, with the most common laboratory finding of elevated creatine concentrations of 1000 μg/L. 148   Initial management of NMS includes cessation of the causative drug and supportive medical care. Severe NMS may require treatment with bromocriptine mesylate, which is a dopamine agonist, and dantrolene sodium, a muscle relaxant. 148   If pediatricians detect potential NMS symptoms, it is important that the patient receive immediate assessment and treatment, because it is a potentially fatal emergency. 149  

Encountering a patient with psychotic-like or frank psychotic symptoms may be unsettling to pediatricians, who may have limited experience with mental health disorders. Psychotic-like symptoms can be frightening and debilitating, often fueling the pressure to treat with medication. Although data have shown an improved prognosis for shorter DUP, these data do not suggest that all psychotic symptoms should be treated with antipsychotic medication.

Pediatricians should proceed cautiously and thoughtfully with their evaluation, keeping a broad differential diagnosis in mind and attending to possible safety concerns. Because presentation of psychotic-like or frank psychotic symptoms can be complex, consultation with a child psychiatrist is generally warranted to avoid misdiagnosis and unnecessary treatment with antipsychotic medications. Additionally, we advise caution before making a diagnosis of unspecified psychotic disorder or any other psychotic disorder because these diagnoses often persist and may unnecessarily stigmatize patients.

Because of the shortage of child psychiatrists, there are resources within states that allow “live, real-time” consultations with child and adolescent psychiatrists in the area. Programs across the nation consisting of telephone or video consultations with a range of mental health providers are excellent resources that can guide diagnosis and treatment. These programs are free to primary care physicians, sometimes only within a certain geographic area, and are often funded by the state department of health. 150   Pediatricians can generally call the number for the program and undergo an orientation before beginning use of the telephone consult and, in some cases, telepsychiatry or physical consultation services. Some programs are open only to patients with medical assistance (Medicaid). Other programs not only offer consultation services but also offer training programs or continuing medical education opportunities to primary care physicians on the assessment and management of mental health issues. In some programs, if phone consultations are insufficient, pediatricians can schedule in-person evaluations within a few days of the phone consultation, which may be especially helpful to those practicing in remote or more rural areas where there are few to no child psychiatric providers. Other helpful resources for pediatricians are listed in Appendix 3. The resources include a link for coding recommendations, including new collaborative care codes used in the Psychiatric Collaborative Care Model, with a primary treating practitioner collaborating with a behavioral health care manager and a psychiatric consultant.

Psychotic symptoms can be frightening and confusing for patients, caregivers, and providers. Pediatric providers are unique in that they may be the first providers to observe attenuated psychotic symptoms or the first providers parents and guardians turn to if they observe such symptoms in their children. Understanding risk factors and symptoms to evaluate in patients who present with attenuated or psychotic symptoms is helpful in the evaluation of these youth and direct intervention, treatment, and referral, as early intervention can improve prognosis and level of functioning.

In patients who present with psychotic-like or full psychotic symptoms, follow-up questions to better characterize the patient’s presentation and disposition are helpful.

In patients presenting with psychotic-like experiences, pediatricians should evaluate for history of trauma, including sexual, physical, or emotional abuse, neglect, and bullying; substance use; and developmental delays.

Clinical interview, comprehensive physical examination including neurologic examination, laboratory studies, and imaging (when clinically indicated) may be helpful in determining an underlying cause of psychotic symptoms.

Pediatricians should facilitate referrals to specialists (therapist, psychologist, or child and adolescent psychiatrist or general psychiatrist) according to severity of symptoms. Consultation with psychiatry, if available, can be helpful in ensuring that the appropriate referrals are made. For those with ID or ASD, referral to a developmental-behavioral pediatrician should be considered as well. The medical home model can be helpful in coordinating care and supporting the patient and family as they navigate the mental health system.

Screening for suicidal thoughts is an essential component of the evaluation process because psychosis is associated with increased suicidal ideation; if there are suicidal thoughts or thoughts to hurt others, the patient should be transported immediately to the ED for evaluation. Severe decrease in functioning, such as inability to care for or feed oneself, may also warrant ED evaluation.

The time between presentation of attenuated psychotic symptoms and full-blown psychosis is a critical time for monitoring and early intervention. Collaboration with psychiatry can assist in the determination of whether monitoring or referral to another provider would be appropriate. Although care to avoid premature diagnosis of a psychotic disorder is important, evidence shows that minimizing the DUP mitigates symptoms and improves prognosis.

Researchers have found that multidisciplinary coordinated specialty care consisting of medication treatment (where indicated), family education, individual resiliency training, and supported education and employment is beneficial in FEP. Patients should be referred to such resources where available, and continued funding and expansion of such programs should be supported.

When starting antipsychotic medication, “start low and go slow” and provide regular monitoring for adverse effects. Pediatricians would generally not be expected to initiate antipsychotic medications. However, in some circumstances (eg, severe symptoms that do not meet inpatient criteria in the setting of limited access to mental health care), it may be appropriate for the pediatrician to start or manage a medication while awaiting subspecialty care, ideally with ongoing consultation with a child psychiatrist.

In some states, free, state-funded services with telephone, and sometimes in-person, consultations with child and adolescent psychiatrists are available. These programs can be helpful in supporting pediatricians to extend their mental health expertise and should be used where available. Expansion of these programs and continued funding support for them are encouraged.

Primary Psychotic Disorder

A 14-year-old patient presented with derogatory auditory hallucinations as well as visual hallucinations of eyes watching him. He had a history of declining grades, social relationships, and self-care. He described a recent visit to the ED after smoking cannabis that he believed may have been laced with something. He believed that he died or fell into a coma after that experience and that nothing is real now. When asked if there could be any other possible explanation, the patient replied that it could be aliens. The patient admitted that he was terrified by these thoughts and contemplated suicide, although part of him believed that he would not actually die if he tried to kill himself, because nothing was real. Because of the patient’s level of distress, delusions, and loss of reality testing, he was believed to be in real danger of harm to himself and/or others. He was transported to the ED for further evaluation and safety assessment.

Mood Disorder With Psychotic Features

A 15-year-old, high-achieving patient presented with delusions and auditory hallucinations that peers were talking about her. She believed that her parents were poisoning her food and telling peers about her weaknesses and vulnerabilities to use them against her. Her parents reported that she had been staying up late doing homework and sleeping only 1 to 2 hours a night, with associated racing thoughts, pressured speech, poor concentration, and inability to complete the many tasks she started. Because of the paranoid delusions and effect on her functioning, the patient was transferred to the ED. As part of the evaluation, no suicidal or homicidal ideations were noted, and the parents believed that they could ensure her safety. The patient was discharged from the hospital and referred to a child and adolescent psychiatrist, who ultimately diagnosed the patient with bipolar disorder, type I, severe with psychotic features, most recent episode manic. She was started on an atypical antipsychotic medication initially because of the severity of psychotic symptoms, as a mood stabilizer was slowly titrated to therapeutic level. She also began therapy. When the psychotic symptoms resolved, she returned to school and did well. At that time, her provider slowly discontinued the antipsychotic medication, and she remained on a mood stabilizer. She graduated from high school and went on to college.

A 16-year-old presented with hallucinations of people talking about her and making derogatory comments. She had previously done well but was now unwilling to leave her home because of severe anxiety attacks. The patient was referred to a child and adolescent psychiatrist as well as a psychotherapist. She eventually received a diagnosis of social anxiety disorder and was treated with a selective serotonin reuptake inhibitor (SSRI). She was able to return to school, and social relationships gradually resumed. After a period of stability, the patient returned to her pediatrician to manage her medication but continued to see a therapist.

Obsessive-Compulsive Disorder

A 17-year-old patient presented with intrusive sexual thoughts about her father and friends and worried that people and objects were dirty if they accidentally rubbed against her genitalia. She also expressed fears that she was homosexual when she thought another girl was attractive and would perseverate on this belief for hours to anyone who would listen at home. The patient was devoutly Catholic and feared that having these thoughts meant she was evil and deserved to die, although the thought of doing harm to herself was frightening to her. She began to pray multiple times a day to rid herself of these thoughts. Her pediatrician referred her to a psychologist, who referred her to a psychiatrist while continuing to work with her in therapy. With a combination of intensive CBT and an SSRI, the patient was able to overcome the obsessive thoughts and compulsions. Although she would sometimes still have them, she was able to tell herself that her mind was playing “tricks” on her and challenge these thoughts. She ultimately returned to her pediatrician for management of the SSRI and continued to have “booster” CBT sessions with the psychologist as needed.

A 14-year-old patient presented with auditory hallucinations consisting of multiple characters in a fantasy world he had created from a young age. He would often isolate himself to immerse himself in this fantasy world, which he preferred to “real life.” He had endured years of bullying and had no friends but was able to maintain good grades at school. The parents reported poor peer relationships and better social interactions with adults and younger children. He was obese, which correlated with multiple trials of antipsychotic medications, all of which had been stopped because of reported lack of efficacy. Because of concerns about impaired social interactions and restricted interests, the pediatrician referred the patient to a developmental-behavioral pediatrician for evaluation. After a thorough evaluation, the patient received a diagnosis of ASD. Genetic testing was completed and the result was negative. The developmental pediatrician recommended slow discontinuation of the antipsychotic medication because it became clear that the fantasy characters were a manifestation of ASD and caused no distress; in fact, they served as a coping mechanism against the challenges of real life. He began to participate in psychotherapy and a social skills group. Insight into his diagnosis and improved social interactions developed over time.

A 13-year-old patient reported in a childlike sing-song voice that her mood was happy but that she would often see a shadow figure at night and sometimes visions of a little girl who wanted to give her flowers. She stated that her parents had been telling her she should pray whenever these figures would come, which she would always do. She had an individualized education plan, and past neuropsychological testing indicated low IQ. The pediatrician recommended follow-up in 2 weeks to determine if the visual hallucinations or perceptions were distressing to the patient and whether the symptoms warranted a referral to a mental health specialist. At the 2-week follow-up, the patient began stating that these figures were becoming increasingly frightening, causing trouble sleeping, school refusal, and mood changes. The pediatrician referred her to a child psychiatrist for further assessment. Although the psychiatrist felt strongly that ID and possibly ASD were playing a large role in the patient’s presentation, the child’s report of distress and subsequent reports of hearing “terrifying” screaming while in school indicated need for medication initiation.

Cultural and Family Beliefs

A 15-year-old patient in treatment for ADHD for several years suddenly confessed to seeing ghosts in his room and feeling them touch him at times. He reported that these ghosts terrified him, so he had taken to wearing crosses, which he believed protected him. When the pediatrician asked if he had told anyone about these ghosts, he reported he had told his mother and father, both of whom also see ghosts. He stated that the ghosts were worse in his parents’ home, although he also felt the presence of different ghosts at his aunt’s home. Grades continued to be average, and he continued to have appropriate social interactions with peers at school. The provider routinely asked about these ghosts, as well as the patient’s functioning, at every follow-up visit but ultimately determined the patient’s reports to be associated with family beliefs or superstitions and provided no additional medications or referrals.

A 16-year-old female adolescent confidentially told her adolescent medicine provider that she had been sexually assaulted at a party about a month ago and that since then, she was “paranoid” whenever she went out that someone was going to hurt her. If it was dark when she returned home from a school activity or work, she would constantly think that she was hearing footsteps behind her and seeing shadowy figures following her. The pediatrician asked about how she was doing at school, and the patient replied that although her concentration was decreased because of anxiety and flashbacks, she was maintaining good grades and was still managing to function at work. The pediatrician suggested seeing a therapist about the trauma that had occurred but held off on referral to a psychiatrist; he also increased frequency of follow-up visits for a few months, during which he monitored the status of the flashbacks and hyperarousal. With the help of the therapist, who used a combination of trauma-focused CBT and dialectical behavioral therapy techniques to treat the patient, these symptoms steadily decreased without need for medication.

Adverse Effect to Medication

A 7-year-old child with a history of ADHD, combined type, returned to his pediatrician’s office 2 weeks after starting a stimulant medication to help with school functioning. The parents expressed concern that the child reported seeing faces and feeling like insects were crawling on his skin. Knowing that psychotic symptoms were a rare adverse effect of stimulant treatment, the pediatrician stopped the medication. Symptoms quickly resolved.

Temporal Lobe Epilepsy

A 19-year-old young adult with no psychiatric history presented with delusions of being dirty and thinking she could not clean herself or rid herself of a foul stench. She also reported the taste of peppermint. Because of the olfactory and gustatory hallucinations, a computed tomographic scan of the head and an EEG were performed. The EEG revealed abnormal brain wave activity, and the pediatrician referred the patient to a neurologist.

Examples of Questions to Ask When Interviewing Adolescents About Psychotic-Like Experiences

Helpful Resources on Mental Health Disorders

Clinical reports from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal (AAP) and external reviewers. However, clinical reports from the American Academy of Pediatrics may not reflect the views of the liaisons or the organizations or government agencies that they represent.

Dr Hua conceptualized, wrote, and revised the manuscript, considering input from all reviewers and the Board of Directors, approved the final manuscript as submitted, and takes responsibility for the final publication.

The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

All clinical reports from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.

This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.

FUNDING: No external funding.

attention-deficit/hyperactivity disorder

autism spectrum disorder

cognitive behavioral therapy

clinical high risk

Diagnostic and Statistical Manual of Mental Disorders , Fifth Edition

duration of untreated psychosis

emergency department

US Food and Drug Administration

first-episode psychosis

intellectual disability

North American Prodrome Longitudinal Study

neuroleptic malignant syndrome

selective serotonin reuptake inhibitor

Liwei L. Hua, MD, PhD

Elizabeth M. Alderman, MD, FSAHM, FAAP, Chairperson

Richard J. Chung, MD, FAAP

Laura K. Grubb, MD, MPH, FAAP

Janet Lee, MD, FAAP

Makia E. Powers, MD, MPH, FAAP

Krishna K. Upadhya, MD, FAAP

Stephenie B. Wallace, MD, MSPH, FAAP

Cora C. Breuner, MD, MPH, FAAP, Former Chairperson

Liwei L. Hua, MD, PhD – American Academy of Child and Adolescent Psychiatry

Ellie Vyver, MD – Canadian Pediatric Society

Anne-Maria Amies, MD – American College of Obstetricians and Gynecologists

Seema Menon, MD – North American Society of Pediatric and Adolescent Gynecology

Lauren B. Zapata, PhD, MSPH – Centers for Disease Control and Prevention

Karen Smith

James Baumberger, MPP

Competing Interests

Letter to the editor: addressing the impact of the affordable care act (aca) on children and young people's wellbeing: a focus on mental health care in juvenile detention facilities.

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• Arch Dis Child
• v.92(2); 2007 Feb

Neurological disorders presenting mainly in adolescence

The aim of this review is to discuss some of the neurological diseases that present mainly in the adolescent period. The article focuses on the usual presentation and course of the more common, and some uncommon, epilepsies, neuromuscular disorders, neurodegenerative disorders, inflammatory disorders of the central nervous system and some other, miscellaneous conditions. The article ends with a very brief and general discussion about management issues in this age group.

Recent medical publications, including two from the National Health Service, 1 , 2 have focused on adolescent health issues, and specifically the transition from paediatric to adult services. A recent review in Archives of Disease in Childhood outlined some of the major issues at this time of life, and highlighted the important differences between traditional paediatric practice and adolescent medicine. 3 The Oxford dictionary defines adolescence as the process of developing from a child to an adult, and the word itself is derived from the Latin word adolescere, meaning to come to maturity. The age at which a child enters and completes adolescence is therefore difficult to characterise and depends on many variables including sex, health, sociocultural values and economic factors. For the purposes of this review, adolescence will refer to children aged ⩾12 years.

The aim of this review is to describe the common and many of the less common neurological disorders that may have an onset or are present in adolescence; it is not possible to provide a comprehensive and detailed account of all the neurological disorders that may present in the teenage years—for example, head injury, brain tumour, stroke or Guillain–Barré syndrome, partly because these conditions may present throughout childhood, including adolescence. It is also not within the remit of this review to discuss in detail either the diagnostic process or the management of these disorders.

Normal neurodevelopment in adolescence

Adolescents show significant neuropsychological progress in the years leading up to adulthood, although this may lack the dramatic effect of a toddlers taking their first steps or uttering their first words. 4 Structurally, the brain continues to increase in total volume until the age of approximately 14 years. A longitudinal magnetic resonance imaging (MRI) study showed that the total white matter volume continues to increase into the early 20s, frontal and parietal grey matter volume peaks at approximately 14 years of age before declining, and the grey matter in the occipital and temporal lobes continues to increase until 20 years of age. 5 The decrease in frontal grey matter volume is probably due to massive synaptic loss during this period; data from primate models have estimated that up to 30 000 synapses may be lost per second over the entire cortex, particularly from the frontal regions. Although the precise reason for this is unknown, it is speculated that the brain is developing on the basis of experience and pertinent environmental needs—the “use it or lose it” theory. Finally, there seems to be much more focal activation of the brain in adolescence compared with early childhood, with a marked increase in the degree to which each hemisphere can process information independently.

Neurological disorders

Epilepsy is the most common neurological disorder of adolescence. 6 , 7 Epilepsy may have an onset at this time or pre‐existing epilepsy may continue to remit or deteriorate. Accurate history taking is crucial to the diagnosis. As teenagers usually attend clinic with parents who have not witnessed the paroxysmal events, it may be necessary to talk to their friends and schoolteachers to obtain useful, and even diagnostic, information. Investigations are used to classify epilepsy syndromes in order to guide treatment and inform on prognosis and to identify any underlying cause. There are some important epilepsy syndromes commonly present in adolescence.

• Juvenile myoclonic epilepsy

The most common epilepsy syndrome presenting in adolescence is juvenile myoclonic epilepsy (JME). 8 The syndrome is characterised by myoclonic seizures (typically on awakening, but also at other times) in all patients, generalised tonic–clonic seizures (GTCS) in approximately 90% and brief absence seizures in approximately 60% of patients. Presentation is typically with a tonic–clonic seizure, often on wakening after a late night or sleep deprivation (common at this age). Another frequent presentation is when the child/teenager has been playing on a video game, often late at night and in a dark room, indicating probable photosensitivity, a commonly observed phenomenon in this syndrome, occurring in 40% and possibly up to 80% 9 of patients and with a female predominance. It is important to ask the teenager presenting with a first GTCS about it and, if necessary, mime the myoclonic and absence seizures, which may not be recognised as seizures by either the teenagers or their friends and carers. Seizures are usually well controlled with appropriate drugs (usually sodium valproate) in up to 90% of patients; it is relatively common that some teenagers will be prescribed carbamazepine, which, although it controls the tonic–clonic seizures, usually exacerbates the myoclonic and absence seizures. This again emphasises the need to always ask about “jerks”, “twitches” and “blank periods” when initially assessing these teenagers. Seizure recurrence rate after drug withdrawal is high in JME, with approximately 80% of patients relapsing, even after a 2–3‐year period of seizure freedom.

• Juvenile absence epilepsy

Juvenile absence epilepsy (JAE) is another idiopathic generalised epilepsy that may present in adolescence, usually between 10 and 13 years of age. 10 The absence seizures tend to occur every day, but not as frequently as those in childhood‐onset absence epilepsy (CAE). In addition, the absences in JAE are more prolonged, last for 30–40 s or even for over a minute and are usually accompanied by more purposeful automatisms; in addition, speech may not be completely lost. This has often resulted in an initial (wrong) diagnosis of complex partial seizures and the prescription of carbamazepine, which exacerbates the absences and may even precipitate absence status. The electroencephalogram (EEG) shows spike and slow wave activity, but, in contrast with CAE, typically at a higher frequency (3.5–4 Hz) and with a bifrontal accentuation. At least 80% of patients have GTCS and 20% have occasional myoclonic seizures. Seizure control tends to be more difficult than in CAE, but can still be achieved in approximately 60% of patients. Unfortunately, spontaneous remission occurs in <50% and, although seizures may be life‐long, the absences tend to become less frequent by the third or fourth decade.

Epilepsy with generalised tonic–clonic seizures on awakening

Epilepsy with generalised tonic–clonic seizures on awakening is the other recognised and relatively common idiopathic generalised epilepsy to occur in adolescence, with a peak age of onset in the mid‐teens, often around puberty. 11 Individuals usually present with a GTCS invariably occurring at or within 2 h of waking from sleep (nocturnal or diurnal sleep). There is an overlap between this syndrome and JME, JAE and CAE; predictably therefore, some patients with epilepsy with generalised tonic–clonic seizures on awakening have been reported to have juvenile‐type absence and myoclonic seizures. Seizure control is relatively easy.

• Isolated partial seizures of adolescence

Isolated partial seizures of adolescence (also occasionally known as benign focal seizures of adolescence) is a rare and idiopathic seizure susceptibility syndrome with a peak age of onset at 13–15 years of age. 12 It presents with a single or cluster of focal onset seizures (usually no more than 2–5), often occurring over a period of no more than 36 h. Seizure manifestations include motor (often with a “Jacksonian march”, suggesting a frontal origin for the seizures), somatosensory and visual manifestations, but without auditory, olfactory or gustatory symptoms. Approximately 50% of patients will experience a secondarily GTCS. Neuroimaging with MRI is normal, and treatment is not usually required as most patients have only a single seizure or a cluster of seizures over a finite period.

Symptomatic focal epilepsies

Symptomatic focal epilepsies may also present in the mid‐to‐late teenage years. Characteristically, the initial seizures often occur during sleep or on waking, when the partial onset of the seizures may not have been witnessed. Neuroimaging (with MRI) should be undertaken in these teenagers unless the electroclinical features are entirely consistent with benign focal seizures of adolescence. In addition, children with mesial temporal epilepsy may also present at this age with obvious complex partial and secondary GTCS. They may have previously experienced complex febrile seizures with or without subsequent simple and complex partial seizures in mid‐childhood that may not have been recognised. 13 , 14

Late‐onset childhood occipital epilepsy

Late‐onset childhood occipital epilepsy (also known as Gastaut syndrome) is a relatively uncommon and presumed idiopathic (possibly genetic) epilepsy syndrome with a peak age of onset at 9 years, but which may present up to the age of 15 or 16 years. 15 Seizure manifestations are typically visual, with either simple (elementary) hallucinations or blindness, or both, lasting typically for 1–5 min. The simple hallucinations may progress into more complex visual hallucinations and may terminate in either a hemi‐convulsion or a generalised tonic–clonic convulsion. Importantly, consciousness may be lost without any accompanying tonic–clonic movements, which may occasionally make episodes difficult to differentiate from vasovagal syncope. Deviation of the eyes with or without ipsilateral deviation of the head is the most common motor symptom and occurs during or after the visual hallucinations. Postictal headache occurs in approximately 50% of patients and is often associated with nausea and vomiting. The interictal EEG typically shows occipital spike discharges that are usually (but not invariably) bilateral; occasionally these may only be seen in a sleeping record, and rarely the EEG may be normal. Neuroimaging is normal; however, in view of the relative rarity of this epilepsy syndrome, and because occipital spikes on EEG are not specific to this syndrome, there should be a low threshold for undertaking cerebral MRI. The visual seizures occur often and although the hemi‐seizures and generalised tonic–clonic seizures may occur infrequently, epilepsy drugs are always considered and usually prescribed (sodium valproate or carbamazepine). Spontaneous remission is reported to occur in approximately 60% of patients, usually within 4 years from onset.

Progressive myoclonic epilepsies

These are a rare group of both sporadic and genetic epilepsies, which may either have an onset or deteriorate in adolescence. 16 The key feature is that they may initially present as and follow an early course that is typical of an idiopathic generalised (or less likely focal), epilepsy and specifically JME. This is well illustrated by Lafora disease, an autosomal recessive disorder which presents in the early teens with seizures, usually myoclonic, clonic and focal, and often with predominant occipital paroxysms on the EEG. A relentless cognitive decline with associated development of extrapyramidal signs ensues after a delay of months to years. Clues to the possibility of an underlying PME include the fact that seizure control in PME is nearly always poor (and considerably worse than that seen in the idiopathic generalised epilepsies) and, importantly, additional features invariably develop, including cognitive stagnation and dementia, ataxia, non‐epileptic (action) myoclonus, pyramidal and extrapyramidal dysfunction (usually chorea), and visual failure. These additional features, together with the age at which they develop, depend on the specific PME (table 1). It is relatively common for the additional features of cognitive stagnation, ataxia, chorea and myoclonus to be initially ascribed to the side effects of epilepsy drugs, substance misuse, non‐concordance with drugs or persisting seizure activity, thereby leading to a considerable delay in diagnosis of the specific PME.

• Epilepsy with tonic–clonic seizures on awakening
• Symptomatic partial epilepsy (eg, mesial temporal epilepsy)
• Late onset childhood occipital epilepsy
• Idiopathic photosensitive occipital epilepsy
• -  Unverricht–Lundborg disease
• -  Lafora disease
• -  Juvenile neuronal ceroid lipofuscinosis
• -  Neimann–Pick disease type C
• -  Myoclonic epilepsy with ragged red fibres on muscle biopsy
• -  Sialidosis type 1
• -  Juvenile Huntington's disease
• -  Subacute sclerosing panencephalitis

Neurodegenerative disorders

• Diabetes insipidus, diabetes mellitus, optic atrophy and deafness (DIDMOAD)
• GM1 gangliosidosis
• Juvenile Huntington's disease
• Metachromatic leucodystrophy
• Mitochondrial cytopathies
• Juvenile neuronal ceroid lipofuscinosis
• Adrenoleucodystrophy

Variant Creutzfeldt–Jakob disease

Wilson's disease, neuromuscular disorders, becker muscular dystrophy, facio‐scapulo‐humeral dystrophy, myotonic dystrophy.

• Juvenile (autoimmune) myasthenia
• Hereditary motor and sensory neuropathy type Ia

Metabolic myopathies

Inflammatory disorders, multiple sclerosis.

• Acute disseminated encephalomyelitis
• Transverse myelitis

Neurodegenerative disorders, although individually rare, are collectively an important group of disorders to consider at this age. Regression, whether cognitive, motor or a mixture of both, poses a specific diagnostic challenge. The first question that must be dealt with in the adolescent presenting with an apparent loss of skills is whether this reflects a genuine neurodegenerative disorder or a pseudoregression due to some other aetiology. The first symptoms of a neurodegenerative disorder may be a change in personality or a declining school performance, or often a combination of both. The change from a primary school, single classroom environment to the secondary school with large varied classrooms as well as the increasing academic and organisational demands can often unmask pre‐existing static difficulties.

In a child with pre‐existing neurological difficulties it can be difficult to differentiate between a plateauing of skills, a pseudoregression (important as the cause may be reversible) and real onset of a neurodegenerative condition. In these situations, it is vital to consider the validity of the original diagnosis. The progressive myoclonic epilepsies are an excellent example of this problem, as discussed above. Other examples of this particular problem include the child with erroneously diagnosed “diplegic cerebral palsy” who has in fact a genetic disorder such as dopa‐responsive dystonia 17 or idiopathic torsion dystonia, hereditary spastic paraplegia or pantothenate kinase‐associated neurodegeneration (PKAN). Causes of pseudoregression include depression, which is becoming increasingly recognised (and often overlooked) in teenagers, and other non‐neurological conditions including acquired hypothyroidism and substance misuse. Poorly controlled and subtle epileptic seizures or frequent spike and wave activity on the EEG represent other potentially treatable causes of pseudoregression.

If it becomes clear that the adolescent does have an acquired neurodegenerative disorder, it may be helpful to consider such conditions in terms of:

• whether it appears to be a multi‐system disorder;
• whether the symptoms suggest mainly a peripheral or a central nervous system disorder (in addition, there are many rare disorders where both may be involved); and
• whether the grey or white matter is predominantly involved if it exclusively or predominantly involves the CNS.

Grey matter disorders more typically present with seizures (often myoclonic), a change in behaviour/personality and dementia. Symptoms more suggestive of a white matter disorder include focal neurological deficits, spasticity, and visual symptoms and signs. However, there may be considerable overlap. Data on disorders with progressive intellectual and neurological decline have been collected since 1997 and reported recently. 18 In this rare group of confirmed progressive intellectual and neurological decline disorders, the more common ones either diagnosed or occurring in adolescence included:

• diabetes insipidus, diabetes mellitus, optic atrophy and deafness (DIDMOAD)
• G M 1 gangliosidosis
• juvenile Huntington's disease
• metachromatic leucodystrophy
• mitochondrial cytopathies
• juvenile neuronal ceroid lipofuscinosis
• subacute sclerosing panencephalitis
• adrenoleucodystrophy
• variant Creutzfeldt–Jakob disease
• Wilson disease

Subacute sclerosing panencephalitis (SSPE)

In the UK, SSPE is rare (four patients (aged 11–15 years) have been diagnosed in the past 15 years at Alder Hey), but this condition is likely to increase in the next 10–15 years, with the reduced uptake of measles immunisation in the second year of life. The onset is usually insidious, often with a decline in school performance (poor concentration and short‐term memory) and behavioural disturbances, which may be initially ascribed to psychological problems or depression. Rare presentations include visual failure and frequent atypical absences, occasionally with myoclonic seizures. Progression varies from child to child, but characteristically includes clumsiness, myoclonic and tonic–clonic seizures. Over the ensuing weeks, months or years, dysphagia, dysarthria, involuntary movements and cortical visual impairment develop, eventually leading to coma and death. The EEG is characteristic (often suggesting the diagnosis) and shows very high‐amplitude and periodic triphasic slow wave complexes; diagnosis is confirmed by finding an increased anti‐measles antibody titre in the cerebrospinal fluid.

Variant Creutzfeldt–Jakob disease is important, although fortunately its incidence would not seem to be as high as predicted when first identified a decade ago. 19 , 20 , 21 The vast majority of paediatric cases have either had an onset around, or have presented after, 12 years of age. The most common presentation is with psychiatric symptoms (depression, anxiety or social withdrawal); cognitive involvement occurs early, but may be masked and initially overlooked because of the psychiatric symptoms. Sensory symptoms (paraesthesiae/painful dysaesthesiae) usually develop within 6 months of the onset, followed by ataxia and involuntary movements, typically dystonia, chorea and myoclonus. The EEG does not show the characteristic periodic paroxysms seen in sporadic Creutzfeldt–Jakob disease, but brain MRI usually shows symmetrical high signal in the posterior thalamic (pulvinar) regions. Death occurs usually at a median of 14–18 months from disease onset.

In children with Wilson's disease (hepatolenticular degeneration), presentation after 10 or 12 years of age is typically neurological although this may initially be subtle and limited to a single symptom (eg, dysarthria or gait disturbance). Psychiatric features ranging from behavioural disturbance to a paranoid psychosis may precede any neurological manifestations in up to 20% of patients. Neurological deterioration occurs in the late teenage years with worsening dysarthria, dystonia, a fixed pseudosmile, tremor, postural abnormalities and rigidity; dementia is a later complication and epilepsy is uncommon. The Kayser–Fleisher ring, an orange–brown discolouration at the limbus of the cornea, will be seen in most teenagers with neurological symptoms and, although usually visible with an ophthalmoscope, are far better visualised on slit‐lamp examination. Diagnosis can be confirmed by low serum caeruloplasmin and copper levels and high 24‐h urinary copper excretion; the defective gene is on chromosome 13q. The diagnosis of Wilson's disease is important as it is one of the very few treatable neurodegenerative disorders.

Friedreich's ataxia

The most common progressive disorder affecting primarily motor function in adolescence is Friedrich's ataxia, an autosomal recessive disorder. 22 It has a mean age at onset of 11–12 years (range 4–16 years) and presentation is usually with clumsiness, ataxia and dysarthria; these children may initially be diagnosed as having dyspraxia. Presentation in the teenage years may also be with pes cavus, or less commonly with scoliosis or cardiomyopathy. The ataxia is relentlessly progressive, but the rate of progression varies between (and occasionally within) families. Ambulation is lost between 6 and 10 years after onset. A hypertrophic cardiomyopathy is very common and may be shown early in the course of the disease by echocardiography in asymptomatic individuals. Muscle stretch/deep tendon reflexes are absent and plantar responses are extensor. Diagnosis is confirmed by finding the mutation of the frataxin gene on chromosome 9q, which is present in approximately 90% of affected individuals. Vitamin E‐responsive ataxia may present with a very similar clinical phenotype although the cardiomyopathy is rare; the Friedrich's ataxia mutation is negative and the ataxia improves with high‐dose vitamin E supplementation.

Pantothenate kinase–associated neurodegeneration

PKAN (previously known as Hallervorden–Spatz disease) is a rare autosomal recessive disorder that usually presents after 10–12 years of age with extrapyramidal dysfunction as manifest by rigidity (not spasticity), dystonia and, subsequently, choreoathetosis and dementia. 23 A pigmentary retinopathy is commonly found. Initial diagnoses in these young teenagers include cerebral palsy, dyspraxia and suspicion of substance abuse. The reported pathognomic brain MRI feature (the eye of the tiger sign) is not always seen in affected individuals, even with progressive neurological symptoms and signs, and may also disappear during the course of the disease. 24 Identification of the mutation encoding the enzyme pantothenate kinase 2 in approximately 60% of patients has allowed a more accurate diagnosis, but its absence does not preclude a diagnosis of PKAN.

Idiopathic torsion dystonia

Children with idiopathic torsion dystonia usually present between 7 and 12 years of age, but occasionally later. In most cases (80%), the disorder is inherited in an autosomal dominant pattern (but with incomplete penetrance) and present with bilateral (although occasionally asymmetric) lower limb dystonia and an abnormal, frequently bizarre gait that usually becomes more generalised to involve the upper limbs, neck and bulbar muscles. Initial diagnoses in these children may include cerebral palsy and a functional disorder. Generalisation is less probable if the initial presentation is in the upper limbs or trunk. The generalised form tends to progress relatively slowly over 5–10 (or more) years. Neuroimaging is normal and DNA analysis may show the presence of the DYT1 gene on chromosome 9q34 in about 60% of individuals.

Adolescents with recent‐onset neuromuscular disorders tend to have specific problems, usually related to self‐help skills and activities of daily living (eg, the teenage girl with facio‐scapulo‐humeral dystrophy or myasthenia who can no longer lift her arms or whose arms fatigue rapidly when brushing her hair). 25 This contrasts with younger children who more typically present with gross motor developmental delay, stumbling or an inability to keep up with their peer group. Although most neuromuscular disorders in adolescence present with weakness or muscle cramps or both, a number of rarer, and predominantly metabolic muscle disorders may present with fatigue.

Most of the neuromuscular disorders involving the muscle or peripheral nerve are inherited (often in an autosomal dominant pattern), and show clinical variation within a family. It is therefore important to always examine the child's biological parents and siblings in detail (including, where appropriate, undressed), as this may be important in identifying a specific neuromuscular disorder. In the authors' experience, this is particularly true for myotonic dystrophy, facio‐scapulo‐humeral dystrophy, hereditary motor and sensory neuropathy (HMSN) type Ia, and central core disease—all of which are typically inherited in an autosomal dominant pattern. Diagnosis is confirmed by neurophysiological investigations (nerve conduction studies, electromyography), muscle biopsy, DNA and other analyses (eg, positive anti‐acetylcholine receptor antibodies in juvenile auto‐immune myasthenia), depending on the specific disorder.

In general, progressive proximal muscle weakness in childhood is usually caused by a myopathy. Included in this group are the dystrophies and the inflammatory, endocrine and metabolic myopathies.

Patients with Duchenne muscular dystrophy always present in the first decade of life, whereas in Becker muscular dystrophy the onset is usually after 5 years of age, but also at any time in childhood or even in early adult life. Boys with Becker muscular dystrophy usually have a history of poor sporting activities and quite severe muscle pains after even moderate exercise, often leading to an initial referral to an orthopaedic surgeon or rheumatologist—with a consequent delay in diagnosis. Marked calf pseudo‐hypertrophy is common, and, as with the muscle pains, tends to be more marked than in Duchenne muscular dystrophy. The creatine phosphokinase level is always raised (>10–20 times normal) and echocardiography may show cardiac involvement in the absence of cardiac symptoms.

Facio‐scapulo‐humeral dystrophy is an autosomal dominant dystrophy presenting in late childhood or early adolescence with progressive facial weakness, scapular winging and weakness of muscles in the shoulder girdle leading to difficulties in raising the arms. Disease progression is variable, with periods of apparent arrest. Many patients do not become disabled and their life expectancy is normal, whereas others become wheelchair dependent in adult life.

Myasthenia gravis

Myasthenia gravis in adolescents (predominantly in females) is usually an autoimmune disease that presents in a similar fashion as the adult disease. Ptosis and diplopia are usually the initial presenting features, but weakness may become more generalised. Affected individuals may only have increasing fatigue as the day progresses. A considerable minority may present acutely over hours or days (often precipitated by an intercurrent illness or infection) in a myasthenic crisis with severe bulbar and respiratory difficulties, which is a medical emergency. The course tends to be slowly progressive.

The onset of symptoms in myotonic dystrophy is usually in adolescence or early adult life, although symptomatic myotonia (abnormal muscle relaxation after contraction) may be seen in childhood. Presenting features include muscle weakness, particularly of the face and distal limb muscles, and the teenager may already have been diagnosed with diabetes mellitus. Often, a background of mild to moderate learning difficulties is observed, which together with the presence of motor difficulties may lead to an initial diagnosis of dyspraxia. The affected parent in childhood/teenager‐onset myotonic dystrophy is typically the father, in contrast with the congenital form, where the affected parent is the mother. The course is slowly progressive, with severe weakness in the hands and feet in adult life.

Peripheral neuropathies

Most peripheral neuropathies in childhood and adolescence are hereditary; the most important exception is acute inflammatory demyelinating polyradiculoneuropathy (Guillain–Barré syndrome), which commonly presents between 11 and 15 years of age. Of the inherited neuropathies, HMSN type Ia and type II tend to be the most common and usually have a peak incidence in the second decade of life. HMSN type Ia is commonly inherited in an autosomal dominant manner. Weakness begins in the anterior tibial compartment and causes foot drop, pes cavus deformities and, eventually, clawing of the toes. Sensory disturbance may be found on formal examination, but is rarely clinically significant. Muscle stretch reflexes are typically absent at the ankles, but may be reduced or absent elsewhere, depending on the person's age. Symptom progression is slow and significant disability does not develop until middle adult life. Acquired neuropathies are most commonly seen in hospital, particularly in oncology patients receiving antineoplastic drugs and undergoing intensive care (critical illness neuropathy or myopathy).

A number of rare metabolic muscle disorders may also present in adolescence. Carnitine‐palmitoyl transferase type II (CPT‐2) has an onset in late childhood/adolescence and usually presents with myalgia, fatigability during or after exercise, and myoglobinuria after sustained aerobic exercise. 26 Respiratory muscles may be involved and fatal rhabdomyolysis has been reported rarely. There is no residual weakness after individual episodes, but repeated episodes over years may lead to a permanent, although mild, myopathy. The CPT‐2 concentration can be measured to confirm the diagnosis. Patients with CPT‐2 are at risk of malignant hyperthermia syndrome and must be counselled accordingly. Very‐long‐chain acyl coenzyme A dehydrogenase deficiency also usually presents after the age of 10 years with severe pain and myoglobinuria on exercise. The other important genetic metabolic myopathy is that seen in the mitochondrial cytopathies, 27 a multi‐organ group of conditions that can present at any age (commonly in childhood and early adult life) and with any symptoms, depending on the predominant organs involved. A predominant myopathic or neuropathic presentation is seen in myoclonic epilepsy and ragged red fibres (MERRF) (on muscle biopsy), and neurogenic atrophy ataxia and retinitis pigmentosa (NARP), respectively. Diagnosis of both myoclonic epilepsy and ragged red fibres and neurogenic atrophy, ataxia and retinitis pigmentosa may be made by finding the specific mutation on blood DNA analysis, although these mutations may be negative and diagnosis will subsequently be made on muscle biopsy (through histological analysis or finding the specific mutation on muscle DNA).

Inflammatory disorders of the central nervous system in adolescence

Multiple sclerosis occurring in the early to late teenage years is reported to represent between 3.6% and 4.4% of all cases of multiple sclerosis, although the figure may be higher with improved diagnostic techniques, including MRI scanners of greater magnetic strength, and an increased awareness that multiple sclerosis can occur in childhood. It is more common in females, particularly after puberty, and follows a relapsing and remitting course in approximately 60% of patients as in adults. The symptoms and signs of childhood multiple sclerosis are similar to those in adults, with visual involvement (optic neuritis or an internuclear ophthalmoplegia) or sensorimotor disturbances representing the most common manifestations. 28 , 29

Miscellaneous

Isolated location‐specific episodes of demyelination are relatively common in adolescents and include optic neuritis, transverse myelitis and rarely neuromyelitis optica (Devic disease). Acute disseminated encephalomyelitis (ADEM), usually a post‐infectious or, rarely, postvaccination disorder, can also present in adolescence and tends to be a monophasic illness; it is probably the most common demyelinating disorder in children. The presentation of ADEM is more often with an encephalopathic illness than with multiple sclerosis. The MRI changes in multiple sclerosis and ADEM may be similar, although characteristically are more widespread and dramatic in ADEM. However, relapses may occur although the risk is unclear; one recent case series suggested a risk of 57%. 29 Debate continues as to whether such relapses should be labelled as polyphasic ADEM or simply multiple sclerosis. 30

The diagnosis of both multiple sclerosis and ADEM is made on the basis of the child's presenting symptoms and signs and MRI findings. Importantly, multiple sclerosis should never be diagnosed after a single episode of demyelination. Cerebrospinal fluid analysis is important in both confirming the diagnosis, particularly in multiple sclerosis, with the finding of oligoclonal bands (which may also be present in ADEM and some disorders which involve the breakdown of the blood‐cerebrospinal fluid barrier), and excluding other causes including infections and some malignancies.

It is beyond the scope of this review to discuss the approach to an adolescent in general. However, certain points are worth emphasising. The diagnosis of any neurological disorder at this crucial time in development can have profound effects on the patient, particularly in terms of trying to achieve independence from their carers, making career choices, self‐esteem, and on establishing and maintaining peer relationships. Discussions on diagnoses demand understanding and sensitivity. The diagnosis of paroxysmal disorders usually relies on witness accounts of the event, and teenagers may find the relaying of such accounts by family members or friends embarrassing or even distressing. Involving adolescents in treatment decisions is also important, and giving choices and finding solutions around potential problems are often helpful approaches. Young people often respond better to facts and information rather than opinions and advice. There remains significant debate regarding the most appropriate approach to managing the transitional period; the two most common approaches include developing a formal specialty of adolescent medicine or developing a shared hand‐over service that is supervised jointly by both paediatric and adult specialists (eg, in epilepsy, neuromuscular disorders and neurodisability).

The considerable overlap between child and adult neurological practice in terms of disease presentation and management should not disguise the fact that adolescent neurology requires a specific approach to the patient. The clinician has to:

• be aware of the range of neurological disorders that may present at this age;
• be aware of the fact that the initial presentation of a neurological disorder may be with behavioural (including psychiatric) or cognitive features, or both;
• be open to reviewing and, if necessary, revising the original diagnosis if the subsequent course of the disorder is atypical or unusual and the response to treatment is unexpected or suboptimal;
• consider the possibility of depression or substance misuse in teenagers who present with what seems to be regression;
• appreciate the complex psychosocial changes at this time of life, the dynamic biological environment and the effect that a chronic disorder may have on the patient (eg, epilepsy 31 ); and
• seek appropriate specialist (neurological or psychiatric) advice sooner rather than later.

Abbreviations

ADEM - acute disseminated encephalomyelitis

CAE - childhood‐onset absence epilepsy

CPT‐2 - carnitine‐palmitoyl transferase type II

EEG - electroencephalogram

GTCS - generalised tonic–clonic seizures

HMSN - hereditary motor and sensory neuropathy

JAE - juvenile absence epilepsy

JME - juvenile myoclonic epilepsy

MRI - magnetic resonance imaging

PKAN - panthotenate kinase‐associated neurodegeneration

PME - progressive myoclonic epilepsy

Competing interests: None.