Hallucinations in children: Diagnostic and treatment strategies
Consider developmental, medical, and other causes to identify nonpsychotic hallucinations
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Hallucinations in children are of grave concern to parents and clinicians, but aren’t necessarily a symptom of mental illness. In adults, hallucinations usually are linked to serious psychopathology; however, in children they are not uncommon and may be part of normal development (Box).
A hallucination is a false auditory, visual, gustatory, tactile, or olfactory perception not associated with real external stimuli.1 It must be differentiated from similar phenomenon such as illusions (misperception of actual stimuli), elaborate fantasies, imaginary companions, and eidetic images (visual images stored in memory).
In children, hallucinations are not always a sign of psychosis
Although hallucinations frequently are considered synonymous with psychotic disorders, in children this rare. Neurobiologic studies (fMRI) of adults show activation of Broca’s area (left inferior frontal gyrus) seconds before patients perceive auditory verbal hallucinations, which suggests that auditory hallucinations may be misidentified self-talk.a,b According to Piaget,c children age <7 may have difficulty distinguishing between events occurring while dreaming and awake. He further theorized that nonpathologic hallucinations could become pathologic when combined with trauma such as abuse. Straussd suggested that psychosis might lie on a continuum with normal phenomenon. In a case series, Wilking and Paulie described how developmental difficulties, deprivation, sociocultural conditions, and family relationships could contribute to impaired reality testing.
Imaginary friends or companions are common among all children. Children who have imaginary friends are more likely to report hearing “voices.”f Imaginary friends:
- appear, function, and disappear at the wish of the child
- pose no threat and often are a source of comfort
- often can be described in detail
- are not ego-dystonic.g
Also, children with imaginary friends will not show evidence of a thought disorder.
a. Shergill SS, Brammer MJ, Amaro E, et al. Temporal course of auditory hallucinations. Br J Psychiatry. 2004;185:516-517.
b. Shergill SS, Brammer JJ, Williams SC, et al. Mapping auditory hallucinations in schizophrenia; using functional magnetic resonance imaging. Arch Gen Psychiatry. 2000;57;1033-1038.
c. Piaget J. The child’s conception of the world. London, United Kingdom: Routledge and Kegan Paul; 1929.
d. Strauss JS. Hallucinations and delusions as points on continua function. Rating scale evidence. Arch Gen Psychiatry. 1969;21:581-586.
e. Wilking VN, Paoli C. The hallucinatory experience: an attempt at a psychodynamic classification and reconsideration of its diagnostic significance. J Am Acad Child Psychiatry. 1966;5:431-440.
f. Pearson D, Burrow A, FitzGerald C, et al. Auditory hallucinations in normal child populations. Pers Individ Dif. 2001;31:401-407.
g. Lewis M. Child and adolescent psychiatry: a comprehensive textbook. 3rd ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2002.
Common, yet a cause for concern
Epidemiologic studies show 2.8% of adults report hallucinations before age 21.2 Nonpsychotic children as young as age 5 have reported hallucinations.3 Hallucinatory phenomenon may be present in 8% to 21% of all 11-year-old children; two-thirds of these patients have no DSM-IV-TR diagnosis.4,5 However, 1 evaluation of 62 nonpsychotic hallucinating children treated in a psychiatric emergency department (ED):
- 34% had depression
- 22% had attention-deficit/hyperactivity disorder (ADHD)
- 21% had disruptive behavior disorders
- 23% had other diagnoses.6
Studies suggest that children who have hallucinations but no other psychotic symptoms have a better long-term prognosis than those with additional psychotic symptoms.7 A 17-year longitudinal study of children with hallucinations and concurrent emotional and conduct problems found:
- up to 50% of patients still experience hallucinations at age 30
- hallucinations did not significantly predict clinical outcome at age 30
- childhood hallucinations did not increase the risk for psychosis, depression, organic brain disorder, or other psychiatric illnesses.7
In a study of children with psychosis and disruptive disorders, at 2- to 8-years follow-up 50% met criteria for major depressive disorder, bipolar disorder, or schizophreniform disorders.8 In a 15-year longitudinal study of 11-year-olds, self-reported psychotic symptoms—such as delusional beliefs and hallucinatory experiences—predicted a high risk of schizophreniform disorder at age 26.9 These studies suggest that experiencing significant disruptions in thoughts and perceptions during childhood may be related to later development of prominent mood and thought disorders.
They can also manifest as comorbid or associated symptoms of disorders not commonly associated with hallucinations, such as ADHD, disruptive disorders, anxiety disorders, and prodromal clinical states. Medications, substance use, and organic and metabolic disorders also must be considered in the differential diagnosis (Table 3).
Hallucinations may occur in low-functioning or anxious children, in the context of psychosocial adversity or abuse, and during bereavement of a deceased parent when the surviving parent is emotionally unavailable.11-13,15-17 Rule out hypnagogic and hypnopompic hallucinations, which are predominantly visual hallucinations that occur immediately before falling asleep and during the transition from sleep to wakefulness, respectively.18 Rarely, a child who has had hallucinations for some time may learn to complain of them when he or she is not hallucinating in order to obtain a primary or secondary gain, such as getting attention from caregivers.
Little is known about psychosis and hallucinations in preschoolers (age ≤5); therefore, their language use may help assessment. Because of cognitive immaturity, children often use illogical thinking and loose association and may describe their thoughts as “voices.” This is common in children with language disorders—and sometimes in healthy patients—who may talk about voices because they cannot describe their own thoughts.
Children with ADHD and/or oppositional defiant disorder often are impulsive and show poor judgment and may blame voices for telling them to do bad things. These “hallucinations” may represent internal thoughts battling with the child’s conscience.6 Auditory and visual hallucinations have been reported in children with Tourette syndrome, especially when associated with ADHD or obsessive-compulsive disorder.19
Medical causes. Electrolyte disturbances, metabolic disorders, fever, and serious infections are common nonpsychiatric causes of hallucinations.20 Brain neoplasm—particularly in visual association areas, the temporal lobe, or portions of the optic nerve or retina—also may produce hallucinations, which can be complex with full images.21
Medications such as steroids and anticholinergics may cause hallucinations. Case studies report visual and tactile hallucinations with methylphenidate therapy that resolve after discontinuing the medication.22 Illicit substances, including cannabis, lysergic acid diethylamide (LSD), cocaine, amphetamines, 3,4-methylenedioxymeth-amphetamine (ecstasy), opiates, and barbiturates, can induce hallucinations.
Suspect substance-induced hallucinations if your patient shows:
- acute onset of hallucinations
- dilated pupils
- extreme agitation or drowsiness
- other signs of intoxication.
Hallucinations caused by seizure disorders are rare but can be somatosensory, visual (occipital lobe focus), auditory, olfactory (uncinate, complex partial), or gustatory. The hallucinations may be unformed (flashing lights or rushing noises) or formed (images, spoken words, or music) and could be part of the aura arising from the temporal lobe (dreamlike, flashbacks). Command hallucinations are rare and adult and pediatric patients usually sense they are not real.23
Migraines occur in approximately 5% of prepubertal children and often are comorbid with affective and anxiety disorders.24 Hallucinations associated with migraine commonly are visual, but gustatory, olfactory, and auditory hallucinations also can occur, with or without headaches.3 Any hallucination associated with headaches should be investigated neurologically. Other diagnostic aspects of hallucinations to consider while interviewing children are listed in Table 4.25-28
Possible causes of hallucinations in children and adolescents
Sociocultural interaction (immigration)
Poorly differentiated male and female family roles
Presence or absence of different mother figures
Cultural factors (witches, ghosts, spiritualism)
Hallucination of deceased parent, when unresolved mourning persists in the surviving parent
Content of hallucinations may point to their cause
Schizophrenia or other psychotic disorders
May hear several voices making a critical commentary
Usually a single voice speaking from outside the patient’s head with derogatory or suicidal content
Usually involves grandiose ideas about power, worth, knowledge, family, or relationship
Usually a transient (visual or auditory) perception of the deceased person
Posttraumatic stress disorder
Transient visual hallucinations, usually with phobic content
Source: Reference 11
Hallucinations in young patients: Differential diagnoses
Psychiatric disorders that are usually defined by psychotic features, including:
Psychiatric disorders that commonly do not include hallucinations but in which hallucinations can occur as comorbid or associated symptoms, such as:
Prodromal and at-risk clinical states of psychiatric disorders (psychotic and mood disorders)
Medications (steroids, anticholinergics, stimulants)
Drug intoxication and abuse
Organic or nonpsychiatric disorders
Diagnostic considerations when assessing a hallucinating child
Hallucinations are a symptom, not a diagnosis
They can have a developmental, neurologic, metabolic, or psychiatric basis
Visual, gustatory, and olfactory hallucinations suggest a medical- or substance-related
Schizophrenia is rare before age 11
In pervasive developmental disorders, schizophrenia is diagnosed only if prominent
Hallucinations are not uncommon in major depressive disorder but may be
During interviewing, remember that children:
are highly suggestible
may answer questions in the affirmative to get attention or to please the interviewer
may not fully or partially understand what is being asked
may blame their misbehavior on voices to escape punishment
may not distinguish between night terrors and illusions
Psychotic disorder not otherwise specified
(NOS) in children often is overused and misused. One reason could be that DSM-IV-TR does not have a category for hallucinations in nonpsychotic children or for children who are at risk for psychosis. However, recommendations regarding the diagnosis of psychotic disorder NOS note it:
- may be used if uncertainty persists after ruling out all other diagnoses
- should be avoided when hallucinations occur in nonpsychotic children
- should not be used longitudinally if a clinician later determines a specific disorder accounts for the hallucinations.29
Addressing underlying medical or psychiatric illness, including substance use, is primary. Some adolescents or children may think that cannabis use is relatively benign. Discuss the risks of cannabis use in an age-appropriate manner.
In the ED. Children or adolescents who present with hallucinations in the ED should undergo a thorough evaluation that explores the differential diagnoses. Suggestions for evaluating patients in this setting appear in Table 5.21
Prodromal or at-risk children. There is no consensus on how early to initiate treatment for children in the prodromal stages of psychosis. Early identification and treatment is imperative because duration of untreated psychosis (DUP) is a primary predictor of treatment response in first-admission patients, and longer DUP corresponds to poorer prognosis in children.30