Psychotic symptoms such as hallucinations and delusions can be the result of a primary psychiatric disorder. However, they may also be the manifestation of various underlying somatic diseases. Rapid diagnosis and treatment are crucial to the outcome of the prognosis. A common evidence-based diagnostic approach during the initial phase has yet to be established, but a comprehensive medical evaluation may detect treatable causes. This review presents several potential diagnostic considerations for children and adolescents with psychotic symptoms based on novel systematic reviews and guidelines.