When a child or adolescent reports “I hear voices”, it naturally causes concern for parents and healthcare clinicians alike. The immediate question is “what is the cause”? This, followed by “what to do about it?”
An optimal approach to assessing “voices” in youth includes a culturally sensitive, trauma-informed, and family-centered philosophy. The metaphysical experience of hearing voices can be very commonplace, if not celebrated, in many cultures across the world. As a result, an intergenerational framework may exist in the lives of our patients that normalize ‘voices.’ It is critical to obtain collateral information from close family members about the family’s beliefs, in a manner that conveys cultural humility, as this information may significantly shift the interpretation of the child’s experience.
Other times, “voices” may represent a symptom of a mental health concern. Trauma, mood, and stress are the most common causes of these experiences outside of cultural explanations.
In these cases, the primary care clinician’s role is to provide further assessment (including consideration of potential organic causation—e.g., a seizure disorder or other neurologic condition) followed by guidance to appropriate behavioral health services when indicated. Particularly for the younger child, but also in general for adolescents, it is fortunate that it is more likely than not that hallucinatory symptoms are not due to a psychosis, such as bipolar disorder, schizophrenia or a substance exposure. Nonetheless, it is quite likely that there is some significant element of psychological distress in process and quite possibly a diagnosable disorder such as anxiety, depression, developmental delay or trauma occurring that should be addressed through supportive interventions such as therapy, social supports, and in some instances medication intervention.
Hallucinations can broadly be defined as “erroneous percepts in the absence of identifiable stimuli” (Jardri et al, 2014) or “a sensory experience in which a person can see, hear, smell, taste, or feel something that is not there” (Maijer et al., 2019). Hallucinations are, in fact, not quite so rare. In their recent review, Maijer et al reported that up to 12% of children and adolescents may report audio hallucinations, whereas close to 5% of adults and the elderly experience them. For younger children, these experiences are often transient and a part of typical normative development. However, the longer the experiences last, the more likely the child will develop psychopathologies of either a non-psychotic or a psychotic nature. In these cases, further attention and intervention is warranted along with a focus on risks as there is growing evidence of an association of hallucinations with suicidal ideation and attempts.
Our understanding of the causes of hallucination is expanding. It is now understood that in individuals with more severe hallucinations, there are higher rates of cognitive biases, such as a tendency to jump to conclusions, and negative self-schema. Children, and in particular those with Autism Spectrum Disorders, with deficits in theory-of-mind (the awareness of others’ thinking and feeling) have higher rates of hallucinations. There is a correlation between exposure traumatic events and hallucinations. Recent studies suggest removal of traumatic experiences can correlate with resolution of the symptom.
Maijer, et al, propose an approach to management of hallucinations which includes,
- Help families attain a broader view of the child’s overall well-being to more fully understand the significance of the symptom and establish the presence or absence of mental illness. (Primary Care Clinician)
- Perform a psychiatric assessment to include detailed evaluation of the symptoms and develop a differential diagnosis. (Mental Health Clinician)
- Explain symptoms to child and family once the above have been completed. (Mental Health Clinician and Primary Care Clinician)
- Arrange for Therapy and Psychopharmacology on case by case basis (Mental Health Clinicians)
Jardri R, BartelsVelthuis AA, Debbané M, et al. From phenomenology to neurophysiological understanding of hallucinations in children and adolescents. Schizophr Bull. 2014;40(suppl 4):S221–S232
Maijer, K., Hayward, M., Fernyhough, C., Calkins, M. E., Debbané, M., & Jardri, R. (2019). Hallucinations in Children and Adolescents : An Updated Review and Practical Recommendations for Clinicians, 45(1), 5–23. https://doi.org/10.1093/schbul/sby119