Patient Presentation
An 8-year-old male came to clinic for the first time with his mother for his health maintenance visit. They raised no concerns until discussing school. They noted that he was getting some extra help with reading and also some therapy that was going to stop over the summer break. The school therapy occurred weekly and was for hearing voices. The boy described a single, female, human voice without a name that just talked or made sounds. The voice says his name and does not tell him to do particular things. There are no other sounds such as ringing, humming, etc. It has been occurring for over a year and continues to bother him as it is continuing to occur, but not because it is escalating in frequency, duration, intensity, or content. The voice occurs throughout the day and in any location. It does not specifically occur when he is going to sleep or awakening. He does not know the duration of the episodes and the mother isn’t sure either as he doesn’t seem to act differently. She will intermittently ask him about them or he will tell her it is occurring. He is described as being a quieter child but is well-liked at school and has friends at home and school that he plays with. The mother denies substance abuse, physical or emotional abuse and no bullying. There were no obvious traumatic events in the child’s history. There is stimulant medication in the household for a sibling but there was no missing medication. Similarly, there were some alcoholic beverages but none that were obviously missing. The family history revealed some mental illness in uncles, aunts, and cousins on the paternal family side, but the mother does not know what it is or how it is being treated.

The past medical history shows no specific developmental concerns other than the reading issue. There was no history of seizures, abnormal staring spells, abnormal or erratic behavior, unusual or neurological infections and no specific travel history. Limited electronic medical records revealed that hearing voices was noted the previous year and his doctor discussed him with psychiatry who felt that therapy would be indicated and that they would be willing to see him. An appointment with psychiatry was not made by the family. The review of systems is also negative including headache, and he reportedly had no problems with sleeping.

The pertinent physical exam showed growth patterns that were tracking from the previous year at the 25%. His vital signs were normal. His skin, thyroid and neurological examinations were normal as was the rest of his exam. His speech was normal in content and production for his age. While describing the voice his face looked disturbed to the pediatrician, and this emotion was only noted in relation to talking about the voices and not other aspects of the history.

The diagnosis of a healthy appearing male who continued to have what appeared to be auditory hallucinations. The school therapy was reportedly helping but would end soon. The pediatrician couldn’t unveil any other psychosis-type symptoms, nor specific mood or personality disorder symptoms. Substance abuse was unlikely as the cause as was a migraine, or an infectious disease cause. The pediatrician thought that this likely was more benign, but because the hallucinations continued to be frequent and were causing some distress to the patient, felt that psychiatric evaluation was needed. Before ending the appointment the safety plan in place was reviewed and the pediatrician recommended that the mother find out more about the paternal family’s mental health history. Psychiatry was contacted the next day and made an appointment in 2 months. The clinic social worker was going to contact the school to see what options there were for continued therapy over the summertime.

Discussion
Auditory hallucinations are “…the experience of complex auditory perceptions in the absence of expected external sensory stimuli.” They are not under the patient’s control. They are not illusions (i.e. actual sensory inputs occurring that are misrepresented or distorted), delusions (i.e. wrong beliefs or thoughts that continue to be held even when contradictory evidence is presented or can be logically reasoned) nor are normal changes that occur when falling asleep or awakening (hypnogogic and hypnopompic hallucination). They are also not due to overactive childhood imaginations which are under the patient’s control. Auditory hallucinations are less common than visual hallucinations and often can occur together. Auditory hallucinations can occur as a symptoms of psychotic and mood disorders, as well as conduct disorders. Medical causes tend to be acute usually in the context of an altered level of consciousness such as a fever, encephalitis or toxin including substance abuse or overdose. Episodic causes include temporal lobe epilepsy, migraine and sleep disorders. A review can be found here.

Learning Point
Auditory hallucinations are linked to psychotic disorders. However, psychotic disorders are less common in younger patients, although symptoms can emerge in younger children. Schizophrenia and bipolar disorder have peak onset in later teen and early adult ages. There is “…evidence that hallucinations – especially when simple and occasional – are common in children in general population samples and reported by just short of 1 in 10 children and young people.” In these samples many are benign and transient. Making a correct diagnosis can be difficult because of the child’s age, and their verbal and cognitive/developmental abilities. Treatment includes treating an underlying medical condition or psychiatric disorder and if a psychosis diagnosis is made, then antipsychotic medications may be used. Safety planning should also be done with the patient and family.

Characteristics of auditory hallucinations that are clinically significant includes:

• Have multiple voices, voices that talk among themselves, voices that talk to the patient
• Occur frequently or impair the patient
• Are distressing to the patient
• Are a symptom of a potential underlying medical disorder
• Are a symptom of a potential psychotic disorder including bipolar or severe depression or schizophrenic spectrum

Characteristics of a potential psychotic state in a child or youth includes:

• Consciousness is clear. Patient is oriented to surroundings, time, and space
• Hallucinations and delusions
• Socially withdrawn
• Bizarre behavior including talking or responding to invisible objects or people
• Language is abnormal. Production can be minimal or patient can be mute. It may be repetitive or incoherent.
• Inappropriate emotional response – excessive emotional response (i.e. excessively giggling) or laughing over a serious matter
• Activity changes – often hypoactivity but may be hyperactivity

Questions for Further Discussion
1. What are common toxidromes? A review can be found here
2. How common is bipolar disorder? A review can be found here
3. What should be considered when “medically clearing” a psychiatric patient? A review can be found here

Related Cases

Disease: Auditory Hallucination | Psychotic Disorders | Teen Mental Health | Child Mental Health

Symptom/Presentation: Mental Status Changes

Specialty: 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 these topics: Psychotic Disorders, Teen Mental Health and https://medlineplus.gov/childmentalhealth.html”>Child Mental Health.

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.

Miller EE, Grosberg BM, Crystal SC, Robbins MS. Auditory hallucinations associated with migraine: Case series and literature review. Cephalgia. 2015;35(10):923-30. doi:10.1177/0333102414563088

Garralda ME. Fifteen minute consultation on children ‘hearing voices’: when to worry and when to refer. Arch Dis Child Educ Pract Ed. 2015;100(5):233-237. doi:10.1136/archdischild-2014-307853

McClellan J. Psychosis in Children and Adolescents. Journal of the American Academy of Child & Adolescent Psychiatry. 2018;57(5):308-312. doi:10.1016/j.jaac.2018.01.021

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa