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Hallucinations in Children and Youth: Information for Primary Care

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Sommaire : Children/youth may present in primary care with hallucinations. This does not necessarily mean a psychotic illness such as schizophrenia. Primary care professionals play an invaluable role by ruling out medical causes, and referring to mental health services as appropriate. Early identification can mean close monitoring and appropriate interventions, which can then reduce later risk of developing psychosis or other problems.
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Epidemiology

  • 2.8% of adults report hallucinations below age 21
  • 8-21% of 11-yo children report hallucinations; most of these (i.e. 2/3) have no DSM-IV diagnosis at the time, nonetheless, self-report of psychotic symptoms predicts increased risk of later psychotic disorder (Poulton, 2000).

Definition of Hallucinations

  • False auditory, visual, gustatory, tactile, or olfactory perception not associated with real external stimuli. 

DDx of Hallucinations in Children/Youth

  • Medical causes
    • Electrolyte disturbances
    • Metabolic disorders
    • Severe infections / fever
    • Neurologic causes such as
      • Hypnagogic and hypnopompic hallucinations: Visual hallucinations that occur before falling asleep, or while waking up
      • Brain neoplasms
      • Seizures
      • Migraines
    • Medications
    • Stimulants; steroids; anticholinergics
  • Recreational drugs
    • LSD, cannabis, amphetamines, cocaine
    • Red flags for substance -induced hallucinations
      • Acute onset of hallucinations
      • Dilated pupils
      • Extreme agitation or drowsiness
      • Other signs of intoxication.
  • Normal development
    • Hallucinations in children are not uncommon, and can be part of normal development.
    • Imaginary friends: Many children will report having imaginary friends, which usually are characterized by coming and going as the child pleases, being pleasant, a source of comfort, i.e. not ego dystonic.
  • Reaction to stress or adversity
    • Children/youth with problems with past abuse, neglect, or problems with family attachments may report voices
  • Cultural
    • Children/youth from certain cultural backgrounds may report voices that are consistent with cultural norms, e.g. witches, ghosts, spiritualism
  • Internal dialogue
    • Children sometimes say that “the voice made me hit my brother”, when in fact it is their internal thoughts/feelings 
    • It may be hard for children to express their inner feelings (such as frustration, anger)
  • Normal bereavement
    • People may report seeing their loved one who is deceased, and usually perceived as comforting
  • Psychiatric DDx
    • Psychotic illness such as Schizophrenia, Schizophreniform disorders, First Episode Psychosis
      • Red flags
        • Delusions
        • Hallucinations
        • Loss of function
      • Classic / typical hallucinations would be:
        • Several voices making critical commentary
        • Command hallucinations telling patient to harm self/others
        • Scary hallucinations 
        • Bizarre hallucinations that have no basis in reality 
    • Major depression with psychotic features
      • Typically a voice that is ego-syntonic with the depression, e.g. a voice that says the person is worthless, and other negative content
    • Bipolar disorder
      • Typically grandiose hallucinations, such as a grandiose voices 
    • Flashbacks
      • Flashbacks in PTSD involve reliving past traumas, sometimes like a movie played in the person’s head

Physical Exam

  • Rule out medical causes

Investigations

  • There are no routine investigations, however, order investigations if medical causes suspected.

Treatment

  • If patient has prodrome for psychotic disorder, consider medication treatment
    • Red flags for prodrome (McGorry, 2003)
      • Recent decreased function
      • First-degree relative with psychotic disorder or schizotypal personality disorder
    • Medication options include
      • Risperidone
      • Olanzapine
         
  • If patient has major depressive disorder with psychotic features, consider adding antipsychotic medication in addition to antidepressant treatment
     
  • Consider referral to mental health professional for coping strategies
More...

Further reading for clinicians

References

  • Edelsohn GA, Rabinovich H, Portnoy R. Hallucinations in nonpsychotic children: findings from a psychiatric emergency service. Ann N Y Acad Sciences. 2003;1008:261-264.
  • Kotsopoulos S, Konigsberg J, Cote A, et al. Hallucinatory experiences in nonpsychotic children. J Am Acad Child Adolesc Psychiatry. 1987;26:375-380
  • McGorry PD, Yung AR, Phillips LJ. The “close-in” or ultra high-risk model: a safe and effective strategy for research and clinical intervention in prepsychotic mental disorder. Schizophr Bull. 2003;29(4):771-790.
  • Poulton R, Caspi A, Moffitt TE, et al. Children’s self reported psychotic symptoms and adult schizophreniform disorder: a 15-year longitudinal study. Arch Gen Psychiatry. 2000;57:1053-1058.
  • Schreier HA. Hallucinations in nonpsychotic children: more common than we think? J Am Acad Child Adolesc Psychiatry. 1999;38(5):623-625.

About this Document

Written by members of the eMentalHealth.ca/PrimaryCare team which includes members of the Department of Psychiatry and Family Medicine at the University of Ottawa. Reviewed by members of the Family Medicine Program at the University of Ottawa, including Dr's Farad Motamedi; Mireille St-Jean; Eric Wooltorton.

Disclaimer

Information in this pamphlet is offered ‘as is' and is meant only to provide general information that supplements, but does not replace the information from a health professional. Always contact a qualified health professional for further information in your specific situation or circumstance.

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Affichée le : Feb 20, 2015
Date de la dernière modification : Nov 27, 2015

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