A 6-year-old female came to clinic for her health maintenance visit. She was reportedly developing normally and her first grade teacher had no concerns. Her mother asked, “She has an imaginary friend and I’m not sure how much I should give in to this idea. Most of it is just normal play like playing dolls, but she is demanding the little stuffed toy has to be buckled up in the car too, and gets really upset if the toy doesn’t come with us.”
The pertinent physical exam showed a normal female with growth parameters around 75% for height and weight. The examination was normal.
The diagnosis of a healthy female with an imaginary friend was made. The physician asked several more questions which confirmed normal play patterns with the toy, and did not reveal any concerns for the child’s mental health or development. He recommended to take a practical approach. “The imaginary friend is really normal for kids but they can stay around for a long time and can be very important to the children. I would let her lead the way but there are limits in the real world. For example, she can have the friend in her school backpack so it is available, and you even could put it in a small box which can be the friend’s car seat. Obviously the friend does not get their own real car seat in your car.” “You can also try to see if she can come up with her own creative ideas about whatever the issue is too. That can help her learn to negotiate in the real world. But let me know if she seems to be having more concerning mental health issues or the problems are escalating,” he counseled.
Paracosms are imaginary worlds or societies and is a creative activity in middle childhood. Storytelling and narrative activities are believed to help people “…to promote insight into behavior, contribute to empathy, help us find meaning in life events, and extend our experience beyond personal circumstance.” These narrative activities are public or private and based in real or fictional experiences. They can be communicated verbally or acted out and can focus on the character or the plot of the narrative. There is not a great deal of research on paracosms and much is asking adults to remember to their own childhoods where some type of paracosm is endorsed by about 40% of the individuals in the particular research group. In two studies of 8-12 year olds, there was a ~17% prevalence of a paracosm. Those with and without a paracosm did not differ in many ways, but those with a paracosm had more inhibitory control and had higher creativity scores especially in storytelling tasks and potentially in creative ways to make new friends.
Imaginary friends (IFs), invisible friends, imaginary companions, etc. are often a part of a paracosm and may “…facilitate the development of social competence, particularly with respect to the regulation of emotion and the acquisition of interpersonal skills useful in adulthood, such as cooperation and perspective taking.” There is no prototype for an IF. An IF “is a character, sometimes invisible and sometimes embodied in an object such as a stuffed animal or doll, which is animated by the child and treated as real.” IFs come in all forms, shapes, sizes, genders, appearances, and ages. Invisible IF can be based on real people or fictional characters or be entirely unique. The longevity of the IF also varies from short time periods, but also to months or years with consistency in the description of the IF. The child often will incorporate the IF into daily routines and their relevance and importance to the child commonly is persistent over long time periods.
IFs provide relational benefits and social supports to the child that is similar to what occurs with real best friends and these tend to be more egalitarian relationships. IFs that are personified objects may have hierarchies such as the child playing the role of parent to the object. Some children create idealized interactions while others have IFs who have difficult behaviors or even are imaginary enemies. Both positive and negative IFs are seen in typically developing children. IFs allow opportunities for creating, exploring and maintaining friendship and relational skills, practicing such skills, and coping with emotional difficulties and emotionally charged situations. They also are used to explore social situations and negotiate social roles that may be practical experiences in the real world.
The child’s IF and their relationship with the IF should be respected, but do not necessarily need to be catered to. For example, the child says that she and the IF are only going to have ice cream for breakfast. The parent can simply say, “Ok. We don’t have any ice cream. Here is your cereal this morning,” where the parent simply acknowledges but asserts their authority.
IFs overall are common in early and middle childhood. Paracosms appear to peak around age 9 years and wane by around age 12 years. In the two studies of 8-12 years old regarding paracosms, ~50% endorsed an IF. Having an IF was more common if the child also had a paracosm (~80%) than if they did not (~40%). IFs also occur across a wide range of cultures, but prevalence or incidence varies. One study of non-predominantly western industrialized countries with children 3-8 years old found overall 21% had an IF but had a range of 5-34% in children depending on the country studied.
Questions for Further Discussion
1. What symptoms might indicate that the child with the IF may need mental health services?
2. How is anxiety diagnosed in children?
3. How is depression diagnosed in children?
4. What are some of the benefits of play for children and adolescents?
- Disease: Imaginary Friend | Child Development | Child Mental Health
- Symptom/Presentation: Behavior Problems
- Specialty: General Pediatrics | Psychiatry and Psychology
- Age: School Ager
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for this topic: Child Development.
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
To view videos related to this topic check YouTube Videos.
Gleason TR. The psychological significance of play with imaginary companions in early childhood. Learn Behav. 2017;45(4):432-440. doi:10.3758/s13420-017-0284-z
Wigger JB. Invisible friends across four countries: Kenya, Malawi, Nepal and the Dominican Republic. Int J Psychol. 2018;53 Suppl 1:46-52. doi:10.1002/ijop.12423
Taylor M, Mottweiler CM, Aguiar NR, Naylor ER, Levernier JG. Paracosms: The Imaginary Worlds of Middle Childhood. Child Dev. 2020;91(1):e164-e178. doi:10.1111/cdev.13162
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa