Hallucinations in Children: Diagnostic and Treatment Strategies; Consider Developmental, Medical, and Other Causes to Identify Nonpsychotic Hallucinations

Article excerpt

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, page 54).

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 imag es stored in memory).

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-TV-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)

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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.

Differential diagnosis

Table 1 lists possible causes of hallucination in children. (6), (10-13) Hallucinations during childhood can occur in the context of several psychiatric disorders, including:

Table 1

Possible causes of hallucinations in children and adolescents

Normal development

Nonpsychotic psychopathoiogy

Psychosocial adversity

Psychotic illness

Stress

Family dysfunction

Deprivation

Developmental difficulties

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

Source: References 6, 10-13

* schizophrenia

* schizophreniform disorders

* mood disorders with psychotic features (Table 2). (14)

Table 2

Content of hallucinations may point to their cause

Schizophrenia or other  May hear several voices making a critical
psychotic disorders     commentary Command hallucinations telling
                        patients to harm themselves or others
                        Bizarre voices like 'a computer in my head'
                        or aliens Voices of someone familiar or a
                        'relative' Visual hallucinations of devils,
                        scary faces, space creatures, and skeletons

Depressive disorders    Usually a single voice speaking from outside
                        the patient's head with derogatory or
                        suicidal content

Bipolar disorder        Usually involves grandiose ideas about
                        power, worth, knowledge, family, or
                        relationship

Bereavement             Usually a transient (visual or auditory)
                        perception of the deceased person

Posttraumatic stress    Transient visual hallucinations, usually
disorder                with phobic content

Source: Reference 11

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. …