Hallucinations in children: Diagnostic and treatment strategies
Consider developmental, medical, and other causes to identify nonpsychotic hallucinations
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
Table 1
Possible causes of hallucinations in children and adolescents
| Normal development |
| Nonpsychotic psychopathology |
| 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 |
Table 2
Content of hallucinations may point to their cause
| Schizophrenia or other psychotic disorders | May hear several voices making a critical 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 disorder | Transient visual hallucinations, usually with phobic content |
| Source: Reference 11 | |
Table 3
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
|
Metabolic disorders
|
| Source: a. Schreier HA. Hallucinations in nonpsychotic children: more common than we think? J Am Acad Child Adolesc Psychiatry. 1999;38(5):623-625. b. Kotsopoulos S, Konigsberg J, Cote A, et al. Hallucinatory experiences in nonpsychotic children. J Am Acad Child Adolesc Psychiatry. 1987;26:375-380. c. Yates TT, Bannard JR. The “haunted” child: grief, hallucinations and family dynamics. J Am Acad Child Adolesc Psychiatry. 1988;27:573-581. d. Lewis M. Child and adolescent psychiatry: a comprehensive textbook. 3rd ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2002. e. 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. f. Edelsohn GA. Hallucinations in children and adolescents: considerations in the emergency setting. Am J Psychiatry. 2006;163(5):781-785. g. Sosland MD, Edelsohn GA. Hallucinations in children and adolescents. Curr Psychiatry Rep. 2005;7:180-188. |
