What is an effective way to ask kids about hallucinations?

[Ψ-117]

For me, one of the most challenging aspects of conducting a mental status examination on a young child is determining whether or not they are having hallucinations. I imagine I can safely assume that most of the time these kids are not psychotic. It's pretty rare to see true psychosis in children. But it seems that half the time when I ask kids if they have any hallucinations, they say yes.

I usually ask something like, "Do you hear or see things that aren't really there?" Alternate questions might be "Do you hear or see things that aren't real?" or "Do you hear or see things that other people can't?" Sometimes a child's positive endorsement of these symptoms may be a desire to please the interviewer by answering in the affirmative, but I'm sure that most of the time they don't quite understand the question. On the other hand, I have had some kids provide specific examples of their hallucinations, such as zombies. Often their symptoms can be quickly dismissed by asking the parents if they have ever thought their child might be hallucinating. Sometimes I can rephrase things for the child to help them better understand the question, after which they then deny hallucinations. Other times, however, it seems that some kids still don't understand what is being asked.

Anyone here know of an effective method for asking about hallucinations in young children?

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[splik]

Don't. Just Don't.



Psychotic like symptoms are not uncommon in children but they do not typically represent the presence of a psychotic illness. For example children who are traumatized, sexually abused, or bullied are more likely to report psychotic like symptoms. In the Dunedin cohort study, almost half of those who met criteria for schizophreniform disorder at 25 had psychotic-like symptoms by the age of 11. Anomalous experiences may be a harbinger of later psychosis but may be seen in mood disorder, PTSD, emerging personality disorder, dissociative disorders, other trauma related disorders, autistic spectrum disorders, and intellectual disability. The child's imaginary world is quite different from a psychotic illness.

True early-onset psychosis does not need such crude questioning to reveal itself. The mental status examination with a premium on observation is key. Children with true psychosis have quite frank disorganization of speech or thought, flattened, incongruent or bizarre affect, frank visual hallucinations all of which will be obvious to the observer. Dysmorphic features, minor physical anomalies (simian crease, low-set ears, tongue furrows, hypertelorism), and soft neurological signs (stereoagnosis, dysgraphesthesia, dysdiadokokinesis, impaired Luria 3-step command, primitive reflexes) may be present.

 

[milesed]

"Don't ask"? Are you kidding?

Yes, you should ask. The problem isn't how you ask, it's how you deal with the answers. It's true that real psychosis is rare in younger kids, but I see first breaks a lot and simply not asking would prevent treatment. Many are keeping it quiet and just appear shy in the first meeting. They often do not look obviously psychotic and I don't know what splik is getting at with the dysmorphic features list. Most psychotic kids I see have none.

I also see many who endorse AVh, but do not have true psychotic sxs. I agree it's often traumatized or very anxious kids in this group. Family history may help as well. I ask the typical questions-
When does it happen? Most psychotic kids have it occur everywhere.
What is it you hear or see? May help distinguish from their own thoughts or reliving trauma.
Try not to lead them with your questioning.
At the end of the interview, I sometimes am not sure myself and may wait on meds, but go ahead with labs, etc.

 

[PistolPete]

Agree that true psychosis is extremely rare in children and quite rare in teens under the age of 15. The vast majority of first breaks that I've seen have happened in those above 15 years old (excluding substances of course).

So the question now becomes: how do you ask? How do you refine your questions?
For example: do you distinguish AH from inside their head (their thoughts) vs outside their head (true psychosis)? Content of the AH? Running commentary?

 

[masterofmonkeys]

Don't. Just Don't.



Psychotic like symptoms are not uncommon in children but they do not typically represent the presence of a psychotic illness. For example children who are traumatized, sexually abused, or bullied are more likely to report psychotic like symptoms. In the Dunedin cohort study, almost half of those who met criteria for schizophreniform disorder at 25 had psychotic-like symptoms by the age of 11. Anomalous experiences may be a harbinger of later psychosis but may be seen in mood disorder, PTSD, emerging personality disorder, dissociative disorders, other trauma related disorders, autistic spectrum disorders, and intellectual disability. The child's imaginary world is quite different from a psychotic illness.

True early-onset psychosis does not need such crude questioning to reveal itself. The mental status examination with a premium on observation is key. Children with true psychosis have quite frank disorganization of speech or thought, flattened, incongruent or bizarre affect, frank visual hallucinations all of which will be obvious to the observer. Dysmorphic features, minor physical anomalies (simian crease, low-set ears, tongue furrows, hypertelorism), and soft neurological signs (stereoagnosis, dysgraphesthesia, dysdiadokokinesis, impaired Luria 3-step command, primitive reflexes) may be present.

Pretty much this

 

[smalltownpsych]

Don't. Just Don't.

"Don't ask"? Are you kidding?

So I tend to agree with Splik's sentiment, but I often feel the pressure to go along with the latter and then I am in a bit of a quandary as to how to address the endorsement of AH or VH that i don't feel are truly a manifestation of a psychotic disorder. I actually had this come up twice yesterday so this is a very real issue. The easiest thing is to just refer to a child psychiatrist and kick the liability can to them when they see this kid in two months, but that isn't always the best option for a number of reasons. Anyway, would appreciate more discussion about this.

 

[milesed]

I assumed those posting (including OP) were in child psyc. If you don't ask about psychotic sxs, you automatically fail the oral child/adol boards just like general psyc. It's just like asking about SI, HI- minimum standard of care.

 

[hamstergang]

If you don't ask about psychotic sxs, you automatically fail the oral child/adol boards just like general psyc.

Oral boards don't exist anymore.

The real question is how to ask about psychosis in a way that yields useful answers. "Do you hear voices?" is certainly not it, so what is it?

 

[birchswing]

There was a girl I knew in fifth grade who moved into the area and was bullied because of the sort of outrageous claims she made and wouldn't back down from. She said that cartoons were real and that she had seen them. And people asked her if she meant the people who dress up as characters at Disney World, and she insisted she saw the actual cartoons from TV but in real life. This got her teased quite a bit. I moved away after that so not sure what happened to her. Does that sound like something a child would say who is hallucinating?

 

[MLT2MT2DO]

There was a girl I knew in fifth grade who moved into the area and was bullied because of the sort of outrageous claims she made and wouldn't back down from. She said that cartoons were real and that she had seen them. And people asked her if she meant the people who dress up as characters at Disney World, and she insisted she saw the actual cartoons from TV but in real life. This got her teased quite a bit. I moved away after that so not sure what happened to her. Does that sound like something a child would say who is hallucinating?

1st year so I've had minimal interaction with children. But that simply just sounds like a little girls imagination attempting to build a defense mechanism.

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[Ψ-117]

I appreciate everyone's responses. I feel the same way about simply not asking kids if they hallucinate (due to the low yield and high false positive rate), but I also agree that screening for psychotic symptoms is a standard part of the MSE. The difficult thing for me is finding an efficient way of performing said screening. I was hoping someone in the SDN community would have some simple way of asking "Do you hallucinate?" that a child can understand. For the sake of comparison, I never ask kids if they have anxiety because they don't know what it is. Instead I ask them if they get nervous or worry a lot.

I also see many who endorse AVh, but do not have true psychotic sxs. I agree it's often traumatized or very anxious kids in this group. Family history may help as well. I ask the typical questions-
When does it happen? Most psychotic kids have it occur everywhere.
What is it you hear or see? May help distinguish from their own thoughts or reliving trauma.
Try not to lead them with your questioning.

This is helpful and thank you for your insight.

 

[DD214_DOC]

You do the same thing you would with an adult, except you also consider the reported symptoms in the context of where the child is at developmentally. Psychosis is more than just AH or VH, so you ask about the other stuff as well. You also remember that things such as, "good me", and, "bad me", or a, "bad person who tells me to misbehave" isn't psychosis but stuff you can see at certain levels of development. If a kid tells me he, "sees things", I always ask for lots of details. If the VH can be described, has a backstory, and been given a name, it's probably not a VH.

If a functional kid who is making and keeping friends, doing well in school, and doesn't seem too concerned about anything doesn't mention VH/AH until asked, I don't get too worried about it. It's the ones who seem ok at first and report they're doing well despite failing their classes, who after 10 minutes of being pushed talk about receiving special messages to hurt other people through their iPod sent down from the Ethereal Collective in the SpaceSky, you need to worry about.

You also remember that, "Imaginary Friend =/= VH and therefore PSYCHOSIS". I once got a consult from a PA in the ER for that. I really wish I was making that up. I still can't believe it happened.

 

[Merovinge]

I think a reason why this question is difficult is that in CAP there is not just a few common/best ways to ask screening questions. One would need to know the chronological age, developmental age, and family beliefs to even begin to have a list of screening questions. We expect a much higher false positive rate on the questions and as Hooahdoc mentioned, asking lots of questions to determine if it is developmentally appropriate. In the few cases of childhood onset schizophrenia that I have seen, all had either AH/VH and they were similar in reports to what I heard from first break psychosis in adults. In all cases there were other signs of schizophrenia, including bizarre beliefs that were not family syntonic, social withdrawal, frank delusions, subacute deterioration in hygiene or other age appropriate normative functions.

A big mistake is to just ask, then not take into account developmental age. I have seen so many autistic children who providers/parents/schools have thought were schizophrenic.