Evidence-Based Reviews

Hallucinations in children: Diagnostic and treatment strategies

Current Psychiatry. 2010 October;9(10):53-56

References

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12. Kotsopoulos S, Konigsberg J, Cote A, et al. Hallucinatory experiences in nonpsychotic children. J Am Acad Child Adolesc Psychiatry. 1987;26:375-380.

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15. Famularo R, Kinscherff R, Fenton T. Psychiatric diagnosis of maltreated children: preliminary findings. J Am Acad Child Adolesc Psychiatry. 1992;31:863-867.

16. Putnam FW, Peterson G. Further validation of the child dissociative checklist. Dissociation. 1994;7:204-211.

17. Kaufman J, Birmaher B, Clayton S, et al. Case study: trauma-related hallucinations. J Am Acad Child Adolesc Psychiatry. 1997;36(11):1602-1605.

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19. Kerbeshian J, Burd L. Are schizophreniform symptoms present in attenuated form in children with Tourette Disorder and other developmental disorders? Can J Psychiatry. 1987;32(2):123-135.

20. Pao M, Lohman C, Gracey D, et al. Visual, tactile, and phobic hallucinations: recognition and management in the emergency department. Pediatr Emerg Care. 2004;20:30-34.

21. Edelsohn GA. Hallucinations in children and adolescents: considerations in the emergency setting. Am J Psychiatry. 2006;163(5):781-785.

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Table 4

Diagnostic considerations when assessing a hallucinating child

General:
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 origin
Schizophrenia is rare before age 11
In pervasive developmental disorders, schizophrenia is diagnosed only if prominent delusions and hallucinations are present for at least 1 month
Hallucinations are not uncommon in major depressive disorder but may be associated with higher risk of bipolar disorder
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
Source:References 25-28

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:

Clinical Point

A diagnosis of psychotic disorder NOS should be avoided when hallucinations occur in nonpsychotic children

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

Treatment

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

Assessment scales for early identification of psychosis have limitations because most are not standardized for use in children age <14. To assess symptoms and predict future psychosis in children consider using:

Scale of Prodromal Symptoms
Structured Interview for Prodromal Symptoms
Comprehensive Assessment of At-Risk Mental States
Bonn Scale for the Assessment of Basic Symptoms.

A hallucinating child may be considered prodromal if he or she has:

30% drop in Global Assessment Functioning score in the past month
a first-degree relative with affective or nonaffective psychotic disorder or schizotypal personality disorder.³¹

Antipsychotics. When treating children, use antipsychotics with caution and consider short- and long-term risks and benefits. Early treatment is indicated when hallucinations are among a patient’s psychotic symptoms; however, antipsychotic use for children in the prodromal phase lacks consensus. McGlashan et al³² showed that in 60 high-risk patients (mean age 16), olanzapine, 5 to 15 mg/d, reduced conversion to psychosis by 50% over 6 months. McGorry et al³³ observed that in 59 ultra-high risk patients (mean age 20), adding low-dose risperidone (1 to 2 mg/d) and cognitive-behavioral therapy (CBT) was superior to case management and supportive psychotherapy in preventing psychosis after 6 months of treatment, but this difference was not maintained at 6 months of follow-up.

Clinical Point

Early treatment is indicated when hallucinations are among a patient’s psychotic symptoms; antipsychotic use lacks consensus

CBT slows progression to psychosis in ultra-high risk patients and reduces positive symptoms more specifically than it improves emotional dysfunction.³⁴ CBT for psychosis is based on the concept that auditory hallucinations have an underlying personalized meaning or cognitive schema.³⁵ The initial goal of treatment is to engage the child and understand:

What do the hallucinations mean to the patient?
How did they start?
Can the child start or stop them?
What does the patient think they are?

Clinical Point

CBT slows progression to psychosis in ultra-high risk patients and reduces positive symptoms

The clinician then strives to help the child identify alternative explanations for these hallucinations and develop coping strategies.³⁶ “Normalizing” the voices helps the child attribute these voices to a less anxiety-provoking cause.³⁷ Consider suggesting common reasons for the hallucinations, such as:

lack of sleep
isolation
dehydration
extreme stress
strong thoughts (obsessions)
fever and illness
lack of food
drugs and alcohol.

If your patient learns that any of these reasons could explain the hallucinations, he or she may start to have a less delusional understanding of them. Suggest that the voices are “real” only if your patient believes it.