Auditory hallucinations in youth
van Slobbe-Maijer, Kim
DOI:
10.33612/diss.94597038
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Publication date:
2019
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van Slobbe-Maijer, K. (2019). Auditory hallucinations in youth: occurrence, clinical significance and
intervention strategies. Rijksuniversiteit Groningen. https://doi.org/10.33612/diss.94597038
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Hallucinations in children and
adolescents: an updated review
and practical recommendations for
clinicians
Kim Maijer Andrea Raballo Mark Hayward Aikaterini Rammou Charles Fernyhough James G. Scott Monica E. Calkins Ann Shinn Martin Debbané Laura A. Steenhuis Renaud Jardri Daniel H. Wolf
Ian Kelleher Agna A. Bartels-Velthuis
ABSTRACT
Hallucinations in children and adolescents are now known to occur on a continuum from healthy to psychopathology-related phenomena. Although hallucinations in young populations are mostly transient, they can cause substantial distress. Despite hallucinations being widely investigated, research so far has had limited implications for clinical practice. The present paper has three main aims: (1) to review research findings since 2014 (when the last major review of the area was published); (2) to present assessment tools validated to measure hallucinations in children and adolescents; and (3) to discuss therapeutic strategies and clinical issues. We conclude by presenting a tailored care model for clinicians, and outline future challenges for research.
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GENERAL INTRODUCTION
Hallucinations (“erroneous percepts in the absence of identifiable stimuli”4) have been widely investigated in both adult and younger populations, and new insights continue to emerge, both from studies on hallucinations (especially auditory hallucinations) in particular, as well as from complementary research on broader psychotic experiences (PE). Though hallucinations and related PE were traditionally conceptualized as intrinsic manifestations of psychotic disorders, the increasingly accepted framework is that such phenomena reflect broader trait-like phenotypes occurring on a continuum11, 12. The continuum of hallucinatory experiences in children and adolescents can be interpreted as resembling the distribution found in adults, with healthy children and adolescents at one end and those experiencing more clinically significant psychopathological syndromes at the other4, 13, 14, 24, 92, 98, 99.
Superficial commonalities between hallucinations in adults and young people should not, however, be allowed to obscure significant differences that may obtain between them. One key issue is hallucination prevalence. A previous systematic review on the prevalence of PE revealed higher rates in children (17%, age 9–12 years) than in adolescents (7.5%, age 13–18 years)43—although a recent meta-analysis100 of auditory hallucinations prevalence did not find such an age-group difference (12.7% in children and 12.4% in adolescents). Furthermore, prevalence rates of auditory hallucinations in adults (5.8%) and the elderly (4.5%) were found to be significantly lower than in younger populations100. This is consistent with studies showing a mostly transient course of hallucinations in children and adolescents19-21, 24, suggesting they are frequently self-limiting and can possibly be part of typical development100.
Another important issue is that hallucinations may have differing significances depending on what state of the life course they are associated with. Several studies have demonstrated that hallucinations occurring in adolescence are more indicative of psychopathology than hallucinations experienced during childhood28, 76, 92. However, despite being less indicative, childhood hallucinations can still cause distress and impaired functioning, and may, therefore, warrant clinical attention24, 92, 101. Unfortunately, research on hallucinations in children and adolescents has had limited impact on clinical practice, primarily due to the lack of consistent definitions, differences in assessment methods, and phenomenological complexity2. For example, in their meta-analysis of auditory hallucinations prevalence, Maijer et al.100 identified 26 study samples that had used 11 different questionnaires. Such methodological variability is likely to confound the accurate reporting of hallucinations across studies of community populations.
In 2014, Jardri and colleagues4 synthesized research results on childhood and adolescent hallucinations as part of the International Consortium on Hallucination Research (ICHR) working group and provided practical recommendations for future research. The present article has three main aims: (1) to outline new research that has since emerged since 2014; (2) to present assessment tools used to investigate hallucinations in children and adolescents; and (3) to discuss therapeutic strategies and clinical issues.
Before presenting our review, we consider some important issues about definitions. Our working definition of “hallucination” is “a sensory experience in which a person can see, hear, smell, taste, or feel something that is not there”.
Hallucinations are reported in children as young as five years old, and the terms “early onset hallucinations” and “very early onset hallucinations” have used to refer to hallucinatory experiences occurring in young children16, 92. Although these terms might imply relevance for clinical outcomes, research findings are somewhat contradictory. For example, it is unclear what early or very early age of hallucination onset suggests about clinical course. Childhood hallucinations are reported as mostly transient21, 24 and become increasingly associated with psychopathology during later adolescence28, 76, 92. Additionally, adult voice-hearers without need for care or distress have a significantly younger age of hallucination onset compared to voice-hearers with the need for care102. At the same time, hallucinations present at 11 years of age was shown to increase the risk for the development of later schizophreniform disorder26. So, although there might be an indication that older adolescents with onset of hallucinations are more likely to experience or develop psychopathology, it is unclear if there is an age threshold above which the presence of hallucinations significantly increases the risk for later psychopathology. Because of the current lack of consistent nosological substantiation of the terms ‘very early onset’ and ‘early onset’ hallucinations, we propose to define these terms in correspondence to neurodevelopmental age categories43, 100: ‘very early’ (or ‘childhood’) for ages <13 years and ‘early’ (or ‘adolescent’) for ages 13-18.
A second issue is the extent to which hallucinations are persistent. The 11-year cohort study by Bartels-Velthuis et al.20 showed an overall 6.2% persistence rate from age 7-8 to age 18-19, with a decreasing persistence trend with increasing age (23.5% from age 7-8 to age 12-13 vs. 18.2% from age 12-13 to age 18-19). Since hallucinatory experiences are by definition state phenomena (in the sense of typically unfolding over a discrete period of time), their temporal persistence is plausibly an index of psychopathological significance. Indeed, the degree of persistence of hallucinations over time may be an important predictor of transition to a clinically significant disorder4, 18. For example, persistence of hallucinations was shown to be associated with an increased risk for psychotic and
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non-psychotic psychopathology20, 103, 104, as well as drug abuse and suicide attempts104,and need for mental health care105. Nevertheless, as these studies show, hallucinations and other subthreshold positive symptoms exhibit varying trajectories, and children and adolescents with transient symptoms still have worse outcome measures and reduced quality of life at follow-up than typically developing peers106. In addition, studies have measured persistence of hallucinations across a range of durations (eg, 1.6 to 8.4 years103, 6 years105, and 11 years20), and there is no clear consensus on how long hallucinations should be present for them to be considered “persistent”.
We performed a search for relevant studies published from January 2014 (the preparation date of Jardri et al.’s4 review) until July 12, 2017 in PubMed using the following search terms: ((infant[Title/Abstract] OR infancy[Title/Abstract] OR child*[Title/Abstract] pediatric[Title/Abstract] OR paediatric[Title/Abstract] OR adolescen*[Title/Abstract]) AND hallucinat*[Title/Abstract]). The search retrieved 216 articles. Screening titles, excluding case reports and specific somatic disorder related hallucinations, resulted in 57 eligible articles. These articles were used according to relevance and scope of the present paper. Also, relevant papers published after July 12, 2017 were incorporated. Although we emphasize post-2014 articles in the current article, we also, for the sake of giving the fullest picture of the current state of research, discuss their congruence (or otherwise) with earlier literature.
Research findings since 2014
Since the 2014 publication4, new research specifically regarding hallucinations in youth has been scarce. There is accumulating evidence suggesting an impaired global functioning of youth with auditory verbal hallucinations (AVHs), even when compared to adolescents with mental disorders (but without hallucinations)22, 23. With regard to high and heterogenic (co)morbidity rates, a recent study in help-seeking children and adolescents with auditory hallucinations confirmed that the occurrence of hallucinations is associated with the full range of psychotic, affective, anxiety, autistic, behavioral, personality and trauma disorders as well as cognitive impairments and parent-parent and/or parent-child interaction problems; and the majority of the sample (53%) was classified with two or more DSM diagnoses92.
Suicidality
Accumulating evidence, from both general population and clinical samples, demonstrates a strong relationship between hallucinations in children and adolescents and comorbid suicidality with increased risk of suicide attempts107, 108. Moreover, hallucinations predict incident suicidal behavior in the short term (at 3-month109 and 12-month109, 110
follow-up), in the medium term (when followed from childhood into adolescence105, 111) and in the longer term (when followed from childhood and adolescence into adulthood104, 112, 113). The relationship between hallucinations and suicidal behavior cannot be simply explained by co-occurring psychopathology. Research has demonstrated that individuals with psychopathology and hallucinations have an increased risk of suicidal behavior over and above that which would be associated with psychopathology alone31, 109. A number of factors may contribute to the increased risk of suicidality associated with hallucinations, including direct causation (ie, command hallucinations), but also the distress caused by hallucinatory experiences in general, as well as shared risk factors, such as mental disorders (where hallucinations and suicidality may be regarded as markers of psychopathological severity), substance use and environmental (ie, trauma and stressful life events) and psychological (ie, self-esteem and emotional regulation) factors resulting in indirect pathways114.
Neuroimaging
We found only one post-2014 study specifically providing some insight in hallucinations in youth through neuroimaging studies. Amico and colleagues115 studied 20 young people (aged 13-16 years) with AVH and 20 controls; for the AVH group they found anomalies in functional connectivity directly and indirectly involving the Default Mode Network (DMN), the Salience Network and Central Executive Network, as well as neural networks involving both primary and secondary auditory cortical regions. These findings were in line with previous work from Jardri and colleagues116, showing that hallucinatory experiences emerge from a spontaneous DMN withdrawal.
Psychological factors
Specific psychological models of the mechanisms involved in the onset and maintenance of hallucinations have been examined. However, evidence for these models in children and adolescents is sparse. The cognitive model for positive symptoms of psychosis by Garety and colleagues117 asserts that higher hallucination severity is associated with higher levels of emotional disturbance, cognitive biases, and negative life events. This has also been found in children and adolescents118. Cognitive biases such as jumping to conclusions119, less positive schematic beliefs about self/others120, and metacognitive beliefs121 are all associated with hallucinations in young populations. Metacognitive beliefs121 were also shown to be associated with unusual perceptions in adolescents from the general population, but more studies are needed to test the metacognitive model for hallucination proneness122. More recently, social cognitive mechanisms such as impairments in theory-of-mind or mentalizing have been proposed as potentially key in the emergence of hallucinations in children and adolescents123, 124. For example, Clemmensen et al.123 found paranoid delusions but not hallucinations to be associated
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with hyper-theory-of-mind. However, Pignon and colleagues16 did find deficits intheory-of-mind skills in children with hallucinations. Perhaps the difference in age (and thus developmental stage) between these two studies can explain these different findings. The identification of psychological mechanisms that are associated with the emergence and persistence of hallucinations in children and adolescents may inform indicated preventative strategies in the future125.
Social and cultural factors
Trauma and negative life events are known to be associated with hallucinations in a bidirectional dose-response relationship126-128. Trauma is also associated with the persistence of hallucinations20. However, the majority of children and adolescents experiencing maltreatment do not develop hallucinations126 and not every child or adolescent with hallucinations has experienced negative life events90. However, these studies do suggest that children exposed to current or past traumatic event(s) are more vulnerable to the presence and potentially the persistence of voices. Moreover, discontinuation of negative life events predicts discontinuation of hallucinations127, providing an opportunity for targeted intervention strategies, such as programs against bullying.
Hallucinations are typically understood differently when comparing European and African samples129. However, there are sparse studies of cultural factors in hallucinations involving children and adolescents. Adriaanse et al.66 examined the prevalence and impact of PE in a large community sample of ethnic minority and majority youth in the Netherlands. They found that minority children had a two- to threefold higher prevalence of PE with high impact compared to Dutch peers. In addition, religious beliefs and/or experiences may also influence prevalence estimates. For example, one study found that moderately religious adolescents were more likely to report and develop hallucinations than non-religious adolescents130. It was speculated that religious rituals and activities could have been adopted as a method of appraisal of or coping with their hallucinations. These findings point to the need to assess ethnic and cultural context when constructing intervention strategies for young people.
Gene and environment factors
There is limited evidence available from studies of genetic and environmental influences on hallucinations in children and adolescents. Zavos et al.131 reported that out of all types of PE, heritability was lowest for hallucinations. Nevertheless, in their twin study, both extreme/frequent and milder/less frequent PE in adolescents were influenced by the same genetic and environmental factors. A genomic wide association study from Pain et al.132
showed that PLEs show genetic overlap with psychiatric diagnoses. The results of these two studies support the continuum hypothesis.
Assessment tools
The subjective and stigmatized nature of hallucinatory experiences and an expectation of a negative response from others may act as barriers to the disclosure of hallucinations133. Furthermore, clinicians may lack confidence in talking about hallucinatory experiences6. When disclosure does occur and is appropriately responded to, there are few psychometric tools for hallucinations that are suited to the cognitive and literacy levels of children and adolescents4. In addition, assessment tools for hallucinations need to be directed at children and adolescents themselves, as parents are not always aware of their children’s experiences, and may report lower levels of symptoms19, 24, 134. There are a number of instruments that more broadly assess PEs during childhood and adolescence (see Table
1)39, 57, 61, 68, 104, 105, 135-163. However, these measurements commonly assess the presence of
hallucinations in the auditory domain only, using just a single item (e.g. “Have you ever heard voices or sounds that no one else can hear”)16, 107. Merely assessing the presence of hallucinations may be useful, but does not incorporate specific characteristics and qualities of hallucinations. For the purpose of this review, the focus will be on outlining (new) instruments specifically designed to assess the phenomenology of hallucinations in youth.
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Ta b le 1 . I ns tr um en ts t ha t a ss es s f or t he p re se nc e of h al lu ci na ti on s i n c hi ld re n a nd a do le sc en ts a In st ru m ent A ut h o rs P ro p er ti es V al id it y i n c h il d re n /a d o le sc en ts b H al luc in at io n ite m (s ) In st ru m en ts t h a t c o m p re h en si ve ly e va lu a te f o r a b ro a d r a n g e o f p sy ch ia tr ic d is o rd er s a n d /o r s y m p to m s i n c h il d re n a n d a d o le sc en ts C A PA A ng ol d e t a l., 19 95 Se m i-st ru ct ur ed d ia gn os ti c i nt er vi ew f or ag es 9 -18 . b “D o y ou e ve r h ea r t hi ng s t ha t o th er p eo pl e c an ’t h ea r? O r s ee t hi ng s t ha t o th er p eo pl e c an ’t s ee ? D o y ou e ve r n ot ic e s m el ls o r t as te s t ha t o th er p eo pl e d on ’t? ” DI SC Sh aff er e t a l., 200 0 Se m i-st ru ct ur ed d ia gn os ti c i nt er vi ew f or ag es 6 -18 . b YC H 56 . “ In t he l as t y ea r, h av e y ou e ve r s ee n s om et hi ng o r s om eo ne th at o th er p eo pl e w ho w er e p re se nt c ou ld n ot s ee , t ha t i s h ad a vi si on w he n y ou w er e c om pl et el y a w ak e? ” YC H 57 . “ In t he l as t y ea r, h av e y ou h ea rd t hi ng s o th er p eo pl e c ou ld no t h ea r, s uc h a s a v oi ce ?” K-SA D S K au fm an e t al ., 1 99 7 Se m i-st ru ct ur ed d ia gn os ti c i nt er vi ew f or ag es 6 -18 . b “H as t he re e ve r b ee n a t im e w he n y ou h ea rd v oi ce s t ha t o th er pe op le c ou ld n ot h ea r? . .. D id y ou e ve r h ea r m us ic w hi ch o th er pe op le c ou ld n ot ?” “H as t he re e ve r b ee n a t im e w he n y ou s aw t hi ng s l ik e pe op le o r fi gu re s t ha t o th er p eo pl e c ou ld n ot s ee ?” “H as t he re e ve r b ee n a t im e w he n y ou s m el le d t hi ng s t ha t o th er pe op le c ou ld n ot s m el l o r f el t t hi ng s t ha t w er e n ot t he re ?” In st ru m en ts t h a t s cr ee n f o r a b ro a d r a n g e o f p sy ch ia tr ic d is o rd er s a n d /o r s y m p to m s i n c h il d re n a n d a d o le sc en ts BA SC R ey no ld s & K amp hau s, 20 0 4 C om m erc ia lly -a va il ab le (www . pea rs on cl in ic al .c om ) c om pr eh en si ve sc re en in g s ys te m f or m ea su ri ng b eh av io ra l an d e m ot io na l s tr en gt hs a nd w ea kn es se s in c hi ld re n a nd a do le sc en ts i n p re sc ho ol th ro ug h h ig h s ch oo l; s ys te m c on si st s o f a t ea ch er r at in g s ca le a nd a p ar en t r at in g sc al e i n a dd it io n t o a 1 76 -i te m s el f-re po rt fo rm ; i te m s 1 -6 9 o n s el f-re po rt f or m a re ra te d t ru e ( T ) o r f al se ( F ), w hi le i te m s 70 -1 76 a re r at ed n ev er ( N ), s om et im es ( S) , of te n ( O ), o r a lm os t a lw ay s ( A ). T he ‘ at yp ic al it y’ s ca le o f B A SC -2 , c on si st in g o f 9 i te m s t ha t a ss es s s ym pt om s s im il ar t o t ho se id en ti fie d by ps yc ho si s ri sk sc re en er s (o dd be ha vi or s, de lu si on al t ho ug ht s, p ar an oi a, a nd h al lu ci na ti on s) , w as v al id at ed a ga in st t he S IP S i n 7 0 h el p-se ek in g yo ut h a ge s 1 2-22 ; s en si ti vi ty 6 5% , s pe ci fic it y 8 7% , PP V 8 0% , N P V 7 6% (T ho m ps on e t a l. 2 01 5). 62 . “ So m et im es , w he n I ’m a lo ne , I h ea r m y n am e. ” 12 2. “ I h ea r v oi ce s i n m y h ea d t ha t n o o ne e ls e c an h ea r.” 13 0. “ I s ee w ei rd t hi ng s. ” 16 0. “ I h ea r t hi ng s t ha t o th er s c an no t h ea r.”Ta b le 1 . ( C on ti nue d) In st ru m ent A ut h o rs P ro p er ti es V al id it y i n c h il d re n /a d o le sc en ts b H al luc in at io n ite m (s ) Y SR A ch en ba ch , 19 91 W id el y u se d 1 12 -i te m s el f-re po rt qu es ti on na ir e, d er iv ed f ro m t he C hi ld B eh av io r C he ck li st ( C B C L) ; r at ed o n a 3 -p oi nt L ik er t s ca le ( ‘0 = no t t ru e, ’ ‘1 = so m ew ha t o r s om et im es t ru e, ’ ‘ 2= ve ry tr ue o r o ft en t ru e’ ). In a b ir th c oh or t o f 3 ,8 01 i nd iv id ua ls b or n i n A us tr al ia b et w ee n 1 98 1-19 84 a nd e nr ol le d i n t he M at er -U ni ve rs it y S tu dy o f P re gn an cy a nd i ts O ut co m es ( M U SP ), h ig he r Y SR s co re s a t a ge 1 4 w er e as so ci at ed w it h i nc re as ed r is k o f s cr ee ni ng p os it iv e fo r n on -a ff ec ti ve p sy ch os is ( SP -N A P) o n t he C ID I (W H O , 1 99 2) a t a ge 2 1, i n m al es . + A H o n t he Y SR a t ag e 1 4 s ho w ed a 5 .1 -f ol d o dd s ( 95 % C I 2 .2 -1 1. 8) i n m al es a nd a 2 .3 -f ol d o dd s ( 95 % C I 1 .0 -5 .1 ) i n f em al es of b ec om in g S P-N A P a t 2 1. + V H o n t he Y SR a t a ge 1 4 w as a ss oc ia te d w it h a 2 .9 -f ol d o dd s ( 95 % C I 1 .1 -7 .5) of b ec om in g S P-N A P a t 2 1( W el ha m e t a l. 2 0 0 9). In di vi du al s f ro m t he M U SP b ir th c oh or t s tu dy ( 25 0 w ho r ep or te d Y SR h al lu ci na ti on s o nl y a t a ge 1 4, 8 3 w ho r ep or te d Y SR h al lu ci na ti on s a t b ot h 1 4 a nd 2 1 ye ar s, a nd 3 21 w ho d id n ot e nd or se h al lu ci na ti on s at e it he r 1 4 o r 2 1) w er e a ss es se d a ga in a t a ge 3 0 -3 3; ha llu ci na ti on s a t a ge 1 4 a lo ne n ot a ss oc ia te d w it h an y m en ta l d is or de r i n a du lt ho od v s. h al lu ci na ti on s en do rs ed a t b ot h 1 4 a nd 2 1 y ea rs h ad i nc re as ed od ds o f b ei ng d ia gn os ed w it h a p sy ch ot ic d is or de r, a s ub st an ce u se d is or de r, a nd l if et im e s ui ci de at te m pt s( C on ne ll e t a l. 2 01 6). T he “ th ou gh t p ro bl em s” s ub sc al e o f t he Y SR (9 i te m s, i nc lu di ng A H a nd V H ) w as a ls o u se d to p ro sp ec ti ve ly t ra ck d iff er en t t ra je ct or ie s o f su bc li ni ca l p sy ch ot ic e xp er ie nc es a m on g a do le sc en ts in t he g en er al D ut ch p op ul at io n p ar ti ci pa ti ng i n th e T R ac ki ng A do le sc en ts ’ I nd iv id ua l L iv es S ur ve y (T R A IL S) (W ig m an e t a l. 2 01 1). 40 . “ I h ea r s ou nd s o r v oi ce s t ha t o th er p eo pl e t hi nk a re n’ t t he re .” 70 . “ I s ee t hi ng s t ha t o th er p eo pl e t hi nk a re n’ t t he re .”
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Ta b le 1 . ( C on ti nue d) In st ru m ent A ut h o rs P ro p er ti es V al id it y i n c h il d re n /a d o le sc en ts b H al luc in at io n ite m (s ) In st ru m en ts t h a t c o m p re h en si ve ly e va lu a te f o r p sy ch o si s o r p sy ch o si s-li k e e xp er ie n ce s i n c h il d re n a n d a d o le sc en ts C A A R M S Yu ng e t a l., 20 05 C om pr eh en si ve d ia gn os ti c i nt er vi ew a nd ra ti ng s ys te m t o a ss es s p sy ch os is r is k. b “D o y ou h av e v is io ns , o r s ee t hi ng s t ha t m ay n ot r ea lly b e t he re ? D o yo u e ve r s ee t hi ng s t ha t o th er s c an ’t, o r d on ’t s ee m t o? ... ” “D o y ou e ve r h ea r t hi ng s t ha t m ay n ot r ea lly b e th er e? D o y ou ev er h ea r t hi ng s t ha t o th er p eo pl e s ee m n ot t o ( su ch a s s ou nd s o r vo ic es )? ... ” “D o y ou e ve r s m el l t hi ng s t ha t o th er p eo pl e d on ’t n ot ic e? ... ” “D o y ou e ve r g et a ny o dd t as te s i n y ou r m ou th ?. ..” “D o y ou e ve r g et s tr an ge f ee li ng s o n, o r j us t b en ea th , y ou r s ki n? ... ” “H av e y ou n ot ic ed a ny c ha ng e i n y ou r b od il y s en sa ti on s, s uc h a s in cr ea se d, o r r ed uc ed i nt en si ty ? O r u nu su al b od il y s en sa ti on s s uc h as p ul li ng f ee li ng s, a ch es , b ur ni ng , n um bn es s, v ib ra ti on s? ” SI P S M il le r e t a l., 20 03 St ru ct ur ed i nt er vi ew t o d ia gn os e t he ps yc ho si s p ro dr om e; c on si st s o f t he Sc al e o f P ro dr om al S ym pt om s ( SO P S) , Sc hi zo ty pa l P er so na lit y D is or de r C he ck li st , fa m il y h is to ry q ue st io nn ai re , a nd g lo ba l as se ss m en t o f f un ct io ni ng ( G A F ). b A ud it or y: 3. “ D o y ou e ve r h ea r u nu su al s ou nd s l ik e b an gi ng , c lic ki ng , h is si ng cl ap pi ng , o r r in gi ng i n y ou r e ar s? ” 4. “ D o y ou e ve r t hi nk y ou h ea r s ou nd s a nd t he n r ea li ze t ha t t he re i s pr ob ab ly n ot hi ng t he re ?” 5. “ D o y ou e ve r h ea r y ou r o w n t ho ug ht s a s i f t he y a re b ei ng s po ke n ou ts id e y ou r h ea d? ” 6. “ D o y ou e ve r h ea r a v oi ce t ha t o th er s d on ’t s ee m t o o r c an ’t he ar ?” V is ua l: 3. “ H av e y ou e ve r s ee n u nu su al t hi ng s l ik e fl as he s, fl am es , v ag ue fig ur es o r s ha do w s o ut o f t he c or ne r o f y ou r e ye ?” 4. “ D o y ou e ve r t hi nk y ou s ee p eo pl e, a ni m al s, o r t hi ng s, b ut t he n re al iz e t he y m ay n ot r ea lly b e t he re ?” 5. “ D o y ou e ve r s ee t hi ng s t ha t o th er s c an ’t o r d on ’t s ee m t o s ee ?” So m at ic: 1. “ H av e y ou n ot ic ed a ny u nu su al b od il y s en sa ti on s su ch a s t in gl in g, p ul li ng , p re ss ur e, a ch es , b ur ni ng , c ol d, n um bn es s, vi br at io ns , e le ct ri ci ty , o r p ai n? ” O lfa ct or y a nd G us ta to ry : 1. “ D o y ou e ve r s m al l o r t as te t hi ng s t ha t o th er p eo pl e do n’ t n ot ic e? ”Ta b le 1 . ( C on ti nue d) In st ru m ent A ut h o rs P ro p er ti es V al id it y i n c h il d re n /a d o le sc en ts b H al luc in at io n ite m (s ) In st ru m en ts t h a t s cr ee n f o r p sy ch o si s o r p sy ch o si s-li k e e xp er ie n ce s i n c h il d re n a n d a d o le sc en ts A P SS K el le he r & C an no n, 2 01 1 7-it em s el f-re po rt q ue st io nn ai re ( 4 it em s f ro m D IS C (S ha ff er e t a l. 2 0 0 0) pl us a dd it io na l q ue st io ns o n v is ua l ha llu ci na ti on s, d el us io ns o f c on tr ol , a nd gr an di os it y) ; i nc lu de s 3 -c ho ic e r es po ns e (‘ Ye s, d efi ni te ly ’= 1 p oi nt , ‘ M ay be ’= 0. 5 p oi nt , ‘N o, n ev er ’= 0 p oi nt ). V al id at ed a ga in st t he K -S A D S i n 3 34 a do le sc en ts ag es 1 1-13 i n t he s ch oo l s et ti ng i n D ub li n, I re la nd ; PP V 1 0 0% a nd N P V 8 8. 4% f or a ny p sy ch ot ic -l ik e ex pe ri en ce s ( PP V 7 1. 4% , N P V 9 0. 4% f or A H ) (K el le he r & C an no n, 2 01 1). 4. “ H av e y ou e ve r h ea rd v oi ce s o r s ou nd s t ha t n o o ne e ls e c an he ar ?” 6. “ H av e y ou e ve r s ee n t hi ng s t ha t o th er s c an no t s ee ?” C A PE -4 2 St ef an is e t al ., 2 0 02 42 -i te m s el f-re po rt q ue st io nn ai re m od ifi ed fr om P D I-16 (P et er s e t a l. 2 0 0 4) ; i nc lu de s 4-ch oi ce r es po ns e ( ‘n ev er ,’ ‘ so m et im es ,’ ‘o ft en ,’ ‘ ne ar ly a lw ay s’ ); f or a ny r es po ns e ot he r t ha n ‘ ne ve r,’ r es po nd en t i s i ns tr uc te d to i nd ic at e d eg re e o f d is tr es s c au se d b y t he ex per ien ce . V al id at ed a ga in st t he C A A R M S i n 1 65 h el p-se ek in g y ou th a ge s 1 3-24 ; P P V 6 5% , N P V 6 3% f or fu ll q ue st io nn ai re ( cu t-off o f 3 .2 i n t he p os it iv e di m en si on s ub sc al e s ho w ed s en si ti vi ty 6 7% , sp ec ifi ci ty 7 3% , P P V 7 2% , N P V 6 8% ; c ut -o ff o f 2 .8 sh ow ed s en si ti vi ty 8 3% , s pe ci fic it y 4 9% , P P V 6 3% , N P V 7 4% )( M os sa he b e t a l. 2 01 2). 30 . “ D o y ou e ve r h ea r y ou r o w n t ho ug ht s b ei ng e ch oe d b ac k t o yo u? ” 33 . “ D o y ou e ve r h ea r v oi ce s w he n y ou a re a lo ne ?” 34 . “ D o y ou e ve r h ea r v oi ce s t al ki ng t o e ac h o th er w he n y ou a re alon e? ” 42 . “ D o y ou e ve r s ee o bj ec ts , p eo pl e, o r a ni m al s t ha t o th er p eo pl e ca nn ot s ee ?” D A W B A-P E -S G un de rs en e t al ., 2 018 10 s el f-re po rt i te m s o n p sy ch ot ic ex pe ri en ce s ( PE) , o r ‘ st ra ng e e xp er ie nc es th at a re s ur pr is in gl y c om m on ’; P E se ct io n i s e m be dd ed w it hi n t he D A W B A , a c om pr eh en si ve o nl in e q ue st io nn ai re ad m in is te re d t o p ar en ts , c hi ld re n ( ag es 1 1+ ), an d t ea ch er s ( PE i te m s a ns w er ed o nl y b y th e c hi ld ); r at ed o n a 3 -p oi nt L ik er t s ca le (‘0 = no ,’ ‘ 1= a l it tl e, ’ ‘ 2= a l ot ’). V al id at ed a ga in st 2 2 K -S A D S p sy ch os is i te m s in 1 ,5 71 c hi ld re n a ge s 1 1-12 p ar ti ci pa ti ng i n a lo ng it ud in al b ir th c oh or t s tu dy i n C op en ha ge n, D en m ar k ( C op en ha ge n C hi ld C oh or t 2 0 0 0) ; se ns it iv it y 7 4% , s pe ci fic it y 7 7% , P P V 2 7% , N P V 96 % (G un de rs en e t a l. 2 018 ). T 1. “ A nt ho ny s ee s v is io ns . H e s ee s p eo pl e, a ni m al s o r o th er t hi ng s th at s ee m u nr ea l t o h im b ut t ha t c an ’t b e s ee n b y o th er p eo pl e e ve n if t he y a re t he re a t t he t im e. D o y ou e ve r s ee v is io ns ?” T2 . “ B il l h ea rs s pe ci al v oi ce s i ns id e h is h ea d. F or e xa m pl e, h e he ar s s tr an ge v oi ce s t al ki ng t o h im o r a bo ut h im . D o y ou e ve r h ea r sp ec ia l v oi ce s i ns id e y ou r h ea d? ” T3 . “ C ha rl es h ea rs s pe ci al v oi ce s c om in g o ut o f t he a ir w he n t he re is d efi ni te ly n o o ne a ro un d. T hi s i s n ot j us t h im i m ag in in g t ha t h e ha s h ea rd s om eo ne c al li ng h is n am e ( w hi ch i s e xt re m el y c om m on ). H e h ea rs m uc h m or e t ha n t hi s: c on ve rs at io ns a bo ut h im se lf o r pe op le t al ki ng a l ot t o h im . D o y ou e ve r h ea r s pe ci al v oi ce s f ro m out si de y ou rs el f? ”
5
Ta b le 1 . ( C on ti nue d) In st ru m ent A ut h o rs P ro p er ti es V al id it y i n c h il d re n /a d o le sc en ts b H al luc in at io n ite m (s ) HQ c Po se y & L os ch , 1 98 3; Pe ar so n e t al ., 2 0 0 8 14 -i te m s el f-re po rt q ue st io nn ai re ( ve rs io n m od ifi ed f or a do le sc en ts b y P ea rs on e t al (P ea rs on e t a l. 2 0 0 8) c on ta in s 1 2 i te m s - v oi ce o f G od a nd d ri vi ng -r el at ed i te m s ex cl ud ed ); b in ar y r es po ns e ( ye s/ no ). M od ifi ed v er si on w as u se d t o a ss es s h al lu ci na to ry ex pe ri en ce s i n a n on -c li ni ca l s am pl e o f 2 50 ad ol es ce nt s i n t he U K a ge s 1 4-15 ( co m pa re d t o a n on -cl in ic al a du lt s am pl e) (P ea rs on e t a l. 2 0 0 8). 1. “ So m et im es I h av e t ho ug ht I h ea rd p eo pl e s ay m y n am e… li ke in a s to re w he n y ou w al k p as t s om e p eo pl e y ou d on ’t k no w … H as so m et hi ng l ik e t hi s e ve r h ap pe ne d t o y ou ?” 5. “ W he n I w as l it tl e, I h ad a n i m ag in ar y p la ym at e, I r em em be r th at I r ea lly t ho ug ht I h ea rd h er v oi ce w he n w e ta lk ed … a ) D id y ou h av e a n i m ag in ar y p la ym at e? b ) D id y ou h ea r h is /h er v oi ce a lo ud ?” 6. “ E ve ry n ow a nd t he n— no t r ea l o ft en — I t hi nk I h ea r m y n am e o n th e r ad io . H ap pe ne d t o y ou ?” 7. “ So m et im es w he n I ’m i n t he h ou se a ll a lo ne , I h ea r a v oi ce c al l m y n am e… I g ue ss I k in d o f k no w t ha t i t r ea lly i sn ’t s om eb od y a nd it ’s r ea lly m e… bu t i t d oe s s ou nd l ik e a r ea l v oi ce . H ap pe ne d t o yo u? ” 8. “ L as t s um m er I w as h an gi ng u p c lo th es i n t he b ac ky ar d. Su dd en ly I h ea rd m y [ hu sb an d] c al l m y n am e f ro m i ns id e t he ho us e. H e s ou nd ed l ik e so m et hi ng w as w ro ng a nd w as l ou d a nd cl ea r. I r an i n… bu t h e w as o ut i n t he g ar ag e a nd h ad n’ t c al le d a t al l… .T hi s o r s om et hi ng s im il ar h ap pe n t o y ou ?” 9. “ I’ ve h ea rd t he d oo rb el l o r t he p ho ne r in g w he n i t d id n’ t. H ap pe n to y ou ?” 10 . “ I h ea r m y t ho ug ht s a lo ud . H ap pe n t o y ou ?” 11 . “ I h av e h ea rd G od’ s v oi ce … no t t ha t h e m ad e m e k no w i n m y he ar t… bu t a s a r ea l v oi ce . H ap pe n t o y ou ?” 12 . “ W he n I a m d ri vi ng i n m y c ar … pa rt ic ul ar ly w he n I ’m t ir ed or w or ri ed … I h ea r m y o w n v oi ce f ro m t he b ac ks ea t… us ua lly s oo th in g… S im il ar t hi ng s h ap pe n t o y ou ?” 13 . “ I d ri ve a l ot a t n ig ht … . S om et im es l at e a t n ig ht , w he n I ’m t ir ed , I h ea r s ou nd s i n t he b ac ks ea t l ik e p eo pl e t al ki ng … j us t a w or d h er e an d t he re … A ny th in g s im il ar h ap pe n t o y ou ?” 14 . “ A lm os t e ve ry m or ni ng … I h av e a p le as an t c on ve rs at io n w it h m y de ad g ra nd m ot he r. I t al k t o h er a nd q ui te r eg ul ar ly h ea r h er v oi ce ac tu al ly a lo ud . A ny th in g s im il ar h ap pe n t o y ou ?”Ta b le 1 . ( C on ti nue d) In st ru m ent A ut h o rs P ro p er ti es V al id it y i n c h il d re n /a d o le sc en ts b H al luc in at io n ite m (s ) L H SH -R L au na y & Sl ad e 1 98 1; B en ta ll & Sl ad e, 1 98 5 12 -i te m s el f-re po rt q ue st io nn ai re ; r ev is ed ve rs io n b y B en ta ll & S la de 20 r at ed o n a 5-po in t L ik er t s ca le ( ‘0 = ce rt ai nl y d oe s n ot ap pl y t o y ou ,’ ‘ 1= po ss ib ly d oe s n ot a pp ly t o yo u, ’ ‘ 2= yo u’ re u ns ur e, ’ ‘ 3= po ss ib ly a pp lie s to y ou ,’ ‘ 4= ce rt ai nl y a pp lie s t o y ou ’). It em s # 7 a nd 1 2 w er e u se d t o a ss es s f or A V H i n a p op ul at io n-ba se d s am pl e o f 9 ,6 46 N or w eg ia n ad ol es ce nt s a ge s 1 6-19 (K om pu s e t a l. 2 01 5). 2. “ In m y d ay dr ea m s I c an h ea r t he s ou nd o f a t un e a lm os t a s cl ea rl y a s i f I w er e a ct ua lly l is te ni ng t o i t.” 5. “ T he s ou nd s I h ea r i n m y d ay dr ea m s a re u su al ly c le ar a nd di st in ct .” 7. “ I o ft en h ea r a v oi ce s pe ak in g m y t ho ug ht s a lo ud .” 8. “ In t he p as t I h av e h ad t he e xp er ie nc e o f h ea ri ng a p er so n’ s v oi ce an d t he n f ou nd t ha t n o o ne w as t he re .” 9. “ O n o cc as io ns I h av e se en a p er so n’ s f ac e i n f ro nt o f m e w he n n o on e w as i n f ac t t he re .” 10 . “ I h av e h ea rd t he v oi ce o f t he d ev il .” 11 . “ In t he p as t I h av e h ea rd t he v oi ce o f G od s pe ak in g t o m e. ” 12 . “ I h av e b ee n t ro ub le d b y h ea ri ng v oi ce s i n m y h ea d. ” PL E Q -C L au re ns e t al ., 2 01 2 9-it em s el f-re po rt q ue st io nn ai re ( 5 i te m s ad ap te d f ro m D IS C (S ha ff er e t a l. 2 0 0 0) pl us 4 a dd it io na l i te m s) ; i nc lu de s 3 -c ho ic e re sp on se ( ‘0 = no t t ru e, ’ ‘ 1= so m ew ha t t ru e, ’ ‘2 = ce rt ai nl y t ru e’ ). Fa ct or a na ly ti c m et ho ds w er e u se d t o d et er m in e th e l at en t s tr uc tu re o f p sy ch os is -l ik e e xp er ie nc es in 7 ,9 66 c hi ld re n a ge s 9 -1 1 r ec ru it ed f ro m 7 3 pr im ar y s ch oo ls i n t he g re at er L on do n a re a; t he t w o ha llu ci na ti on i te m s w er e m os t a bl e t o d is cr im in at e a l at en t p sy ch ot ic -l ik e c on st ru ct f ro m d im en si on s re pr es en ti ng i nt er na li zi ng a nd e xt er na li zi ng pr ob le m s( L au re ns e t a l. 2 01 2). 4. “ H av e y ou e ve r h ea rd v oi ce s t ha t o th er p eo pl e c ou ld n ot h ea r? ” 9. “ H av e y ou e ve r s ee n s om et hi ng o r s om eo ne t ha t o th er p eo pl e co ul d n ot s ee ?”
5
Ta b le 1 . ( C on ti nue d) In st ru m ent A ut h o rs P ro p er ti es V al id it y i n c h il d re n /a d o le sc en ts b H al luc in at io n ite m (s ) PL IK Si H or w oo d e t al ., 2 0 0 8 Se m i-st ru ct ur ed i nt er vi ew w it h 1 2 ‘ co re ’ it em s [ 7 i te m s f ro m D IS C (S ha ff er e t a l. 20 0 0) + 5 i te m s f ro m S C A N (W in g e t a l. 19 90 )] c ov er in g 3 d om ai ns o f p os it iv e ps yc ho ti c s ym pt om s ( ha llu ci na ti on s, de lu si on s, b iz ar re s ym pt om s) ; i nc lu de s 3-ch oi ce r es po ns e [ ‘y es ’ ( Y ), ‘ no ’ ( N ), ‘m ay be ’ ( M )] a nd a dd it io na l o pt io ns f or ‘r ef us ed’ ( R ) a nd ‘ do n’ t k no w ’ ( D K ); i f c hi ld an sw er s ‘ ye s’ o r ‘ m ay be ,’ i nt er vi ew er u se s su pp le m en ta ry q ue st io ns t o p ro be ( e. g. , it em s H 2-H 11 , H 18 -H 19 ). I nt er vi ew er i s al so p ro m pt ed t o a sk i f t he s pe ci fic i te m in q ue st io n o nl y e ve r h ap pe ne d w he n fa ll in g a sl ee p o r w ak in g u p, w he n i ll w it h a h ig h t em pe ra tu re , w he n d ri nk in g al co ho l, o r w hi le u si ng d ru gs ( ca nn ab is , am ph et am in es /s pe ed , g lu e, o th er s, o r n ot ap pl ic abl e) . In 6 ,4 55 c hi ld re n, m ea n a ge 1 2. 9 y ea rs ( ra ng e 1 1. 4-14 .3 ), f ro m t he A vo n L on gi tu di na l S tu dy o f P ar en ts an d C hi ld re n ( A L SP AC ) b ir th c oh or t i n t he U K , PP V ’s w he n c om pa ri ng s el f-re po rt w it h t he fi na l in te rv ie w er r at in gs , w er e p oo r ( 3-50 % ) f or a ll i te m s ex ce pt A H ( 71 % )( H or w oo d e t a l. 2 0 0 8). A ud it or y: H 1. “ Si nc e y ou r 1 2t h b ir th da y h av e y ou e ve r h ea rd v oi ce s t ha t o th er pe op le c an ’t h ea r? ” H 2. “ W ha t d id y ou h ea r? W ha t k in ds o f t hi ng s d id y ou h ea r? W ha t di d y ou t hi nk i t w as ? D id y ou t hi nk i t w as y ou r i m ag in at io n o r r ea l? W as i t l ik e a t ho ug ht o r m or e l ik e a v oi ce ?” H 3. “ H ow o ft en h av e t he se v oi ce s h ap pe ne d t o y ou s in ce y ou r 1 2t h bi rt hd ay ?” H 4. “ T he v oi ce s t ha t y ou h av e h ea rd , w he re d id t he y c om e f ro m ? Fr om i ns id e y ou r h ea d? W as i t y ou r t ho ug ht s y ou h ea rd ? C ou ld ot he r p eo pl e h ea r t he v oi ce s? ” H 5. “ Fr om o ut si de y ou r h ea d, t hr ou gh y ou r e ar s? D id i t s ou nd a s cl ea r a s m y v oi ce d oe s t al ki ng t o y ou r ig ht n ow ?” H 6. “ D o t he vo ic es t al k d ir ec tl y t o y ou o r t el l y ou t hi ng s? ” H 7. “ D o t he se v oi ce s t el l y ou a ny th in g? ( w ha t? ) ( G oo d o r b ad ?) H av e t he y e ve r t ol d y ou t o h ur t y ou rs el f o r k il l y ou rs el f? H av e t he y ev er t ol d y ou t o h ur t o r k il l s om eo ne e ls e? W ho ? H ow ?” H 8. “ D o y ou h ea r v oi ce s t ha t t al k a bo ut w ha t y ou ’r e d oi ng ? O r fe el in g? O r t hi nk in g? ” H 9. “ D o y ou e ve r h ea r 2 o r m or e v oi ce s ( th at o th er s c ou ld n’ t h ea r) ta lk in g t o e ac h o th er ? O r a bo ut y ou ? H 10 . “ H av e th er e b ee n o th er n oi se s o r v oi ce s y ou h av e h ea rd t ha t yo u h av e n ot t ol d m e a bo ut ? [ R at e h er e s po ra di c ( si ng le w or d) ha lluc in at io ns .]” H 11 . “ O r e le m en ta ry h al lu ci na ti on s ( no is es s uc h a s b an gs o r be lls )?” V is ua l: H 17 . “ Si nc e y ou r 1 2t h b ir th da y h av e y ou e ve r s ee n s om et hi ng o r so m eo ne t ha t o th er p eo pl e c ou ld n’ t s ee ?” H 18 . “ D id i t s ee r ea l? C an y ou g iv e m e a n e xa m pl e? ” H 19 . “ H ow o ft en h as t hi s o cc ur re d s in ce y ou r 1 2t h b ir th da y? ”Ta b le 1 . ( C on ti nue d) In st ru m ent A ut h o rs P ro p er ti es V al id it y i n c h il d re n /a d o le sc en ts b H al luc in at io n ite m (s ) PR IM E -R M il le r e t a l., 20 0 4 12 -i te m s el f-re po rt q ue st io nn ai re d ev el op ed by t he a ut ho rs o f t he S IP S; a sk s a bo ut ex pe ri en ce s w it hi n t he y ea r; r at ed o n a 7-po in t L ik er t s ca le ( ‘0 = de fin it el y d is ag re e, ’ ‘1 = so m ew ha t d is ag re e, ’ ‘ 2= sl ig ht ly d is ag re e, ’ ‘3 = no t s ur e, ’ ‘4= sl ig ht ly a gr ee ,’ ‘ 5= so m ew ha t ag re e, ’ ‘ 6= de fin it el y a gr ee ’). V al id it y o f J ap an es e v er si on te st ed i n 52 8 p sy ch ia tr ic ou tp at ie nt s a ge s 1 6-30 ; i n t he 1 15 p at ie nt s w ho co m pl et ed b ot h P R IM E -R a nd S IP S, s en si ti vi ty w as 1 0 0% , s pe ci fic it y 7 4% , P P V 4 3% , N P V 10 0% (K ob ay as hi e t a l. 2 0 0 8). V al id it y a ls o t es te d u si ng t he S IP S i n 4 9 i nd iv id ua ls ag es 1 2-22 a cc es si ng m en ta l h ea lt h s er vi ce s i n t he U S; u si ng a c ut off o f ≥ 2, s en si ti vi ty 8 0% , s pe ci fic it y 48 % , P P V 5 2% , N P V 7 8% )( K li ne e t a l. 2 01 2). A c ul tu ra lly m od ifi ed ( m PR IM E) v er si on s ho w ed le ss r ob us t v al id it y m ea su re s i n a n on -c li ni ca l sa m pl e o f 2 ,7 58 K en ya n y ou th a ge s 1 4-29 ; i n t he 18 2 in di vi du al s w ho c om pl et ed b ot h t he m PR IM E a nd SI P S, s en si ti vi ty w as 4 0% , s pe ci fic it y 6 5% , P P V 1 2% , N P V 9 0% (O w os o e t a l. 2 01 4). 10 . “ I h av e h ad t he e xp er ie nc e o f h ea ri ng f ai nt o r c le ar s ou nd s o f pe op le o r a p er so n m um bl in g o r t al ki ng w he n t he re i s n o o ne n ea r m e.” 11 . “ I t hi nk t ha t I m ay h ea r m y o w n t ho ug ht s b ei ng s ai d o ut l ou d. ” P Q -B L oe w y e t a l., 20 0 8 21 -i te m ( br ie f v er si on ) s el f-re po rt qu es ti on na ir e; a sk s a bo ut e xp er ie nc es w it hi n t he p as t m on th ; b in ar y r es po ns e (y es /n o) ; i f a ns w er i s ‘ ye s, ’ r es po nd en t is a sk ed t o i nd ic at e h ow p ro bl em at ic t he ex pe ri en ce i s. V al id at ed a ga in st t he S IP S i n 1 41 i nd iv id ua ls a ge s 12 -3 5 r ef er re d t o o ne o f t w o p ro dr om al r es ea rc h cl in ic s i n t he U S ( C al if .); c ut off o f ≥ 3 d em on st ra te d se ns it iv it y 8 9% , s pe ci fic it y 5 8% , P P V 9 3% , N P V 46 % (L oe w y e t a l. 2 01 1). V al id it y a ls o t es te d u si ng t he S IP S a s g ol d s ta nd ar d in 4 9 i nd iv id ua ls a ge s 1 2-22 a cc es si ng m en ta l h ea lt h se rv ic es i n t he U S ( M ar yl an d) ; c ut off o f ≥ 6 s ho w ed se ns it iv it y 9 5% , s pe ci fic it y 2 8% , P P V 4 8% , N P V 89% 2(K li ne e t a l. 2 01 2). 2. “ H av e y ou h ea rd u nu su al s ou nd s l ik e b an gi ng , c lic ki ng , h is si ng , cl ap pi ng o r r in gi ng i n y ou r e ar s? ” 9. “ D o y ou s om et im es g et s tr an ge f ee li ng s o n o r j us t b en ea th y ou r sk in , l ik e b ug s c ra w li ng ?” 17 . “ A re y ou r t ho ug ht s s om et im es s o s tr on g t ha t y ou c an a lm os t he ar t he m ?” 19 . “ H av e y ou s ee n u nu su al t hi ng s l ik es fl as he s, fl am es , b li nd in g lig ht , o r g eo m et ri c f or m s? ” 20 . “ H av e y ou s ee n t hi ng s t ha t o th er p eo pl e c an ’t s ee o r d on ’t s ee m to s ee ?”
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Ta b le 1 . ( C on ti nue d) In st ru m ent A ut h o rs P ro p er ti es V al id it y i n c h il d re n /a d o le sc en ts b H al luc in at io n ite m (s ) P Q -1 6 Is in g e t a l., 201 2 16 -i te m s el f-re po rt q ue st io nn ai re ; b in ar y re sp on se ( tr ue /f al se ); i f a ns w er i s ‘ tr ue ,’ re sp on de nt i s a sk ed t o i nd ic at e h ow m uc h di st re ss h e/ sh e e xp er ie nc es o n a 4 -p oi nt sc al e ( ‘0 = N o, ’ ‘ 1= M ild ,’ ‘ 2= M od er at e, ’ ‘3 = Se ve re ’). V al id at ed i n 3 ,6 71 h el p-se ek in g D ut ch a du lt s a ge s 18 -3 5 31; I ta li an ve rs io n (i P Q -1 6) va lid at ed ag ai ns t t he C A A R M S i n 7 2 h el p-se ek in g a do le sc en ts a ge s 1 3-17 re fe rr ed t o c hi ld a nd a do le sc en t n eu ro ps yc hi at ry se rv ic es; s en si ti vi ty 7 7% , s pe ci fic it y 5 4% , P P V 7 2% , N P V 6 0% 32. 3. “ I s om et im es s m el l o r t as te t hi ng s t ha t o th er p eo pl e c an ’t s m el l or t as te .” 4. “ I o ft en h ea r u nu su al s ou nd s l ik e b an gi ng , c lic ki ng , h is si ng , cl ap pi ng , o r r in gi ng i n m y e ar s. ” 6. “ W he n I l oo k a t a p er so n, o r l oo k a t m ys el f i n a m ir ro r, I h av e se en t he f ac e c ha ng e r ig ht b ef or e m y e ye s. ” 8. “ I h av e s ee n t hi ng s t ha t o th er p eo pl e a pp ar en tl y c an ’t s ee .” 9. “ My t ho ug ht s a re s om et im es s o s tr on g t ha t I c an a lm os t h ea r th em .” 13 . “ I h av e h ea rd th in gs o th er p eo pl e c an ’t h ea r l ik e v oi ce s o f p eo pl e w hi sp er in g o r t al ki ng .” SPE Q R on al d e t a l., 201 4 63 -i te m s el f- a nd p ar en t-re po rt qu es ti on na ir e c om pr is ed o f s ix p sy ch os is su bs ca le s; t he 9 i te m s i n t he h al lu ci na ti on su bs ca le w er e s el ec te d f ro m t he C A P S 34 a nd ra te d o n a 6 -p oi nt L ik er t s ca le ( ‘0 = no t a t al l,’ ‘ 1= ra re ly ,’ ‘ 2= on ce a m on th ,’ ‘ 3= on ce a w ee k, ’ ‘4= se ve ra l t im es a w ee k, ’ ‘ 5= da il y’ ). V al id it y a ss es se d v ia a gr ee m en t w it h t he P L IK Si in a pp ro x. 5 ,0 0 0 1 6-ye ar -o ld t w in s b or n i n t he U K ( an d t he ir p ar en ts ); c or re la ti on b et w ee n S PE Q an d P L IK Si f or h al lu ci na ti on s w as r = 0. 60 , p < 0. 0 01 (R on al d e t a l. 2 01 4). “H ea r s ou nd s o r m us ic t ha t p eo pl e n ea r y ou d on ’t h ea r? ” “S ee t hi ng s t ha t o th er p eo pl e c an no t? ” “F ee l t ha t s om eo ne i s t ou ch in g y ou , b ut w he n y ou l oo k n ob od y i s th er e? ” “H ea r n oi se s o r s ou nd s w he n t he re i s n ot hi ng a bo ut t o e xp la in th em? ” “D et ec t s m el ls w hi ch d on ’t s ee m t o c om e f ro m y ou r s ur ro un di ng s? ” “S ee s ha pe s, l ig ht s, o r c ol or s e ve n t ho ug h t he re i s n ot hi ng r ea lly th er e? ” “N ot ic e s m el ls o r o do rs t ha t p eo pl e n ex t t o y ou s ee m u na w ar e o f? ” “E xp er ie nc e u nu su al b ur ni ng s en sa ti on s o r o th er s tr an ge f ee li ng s in o r o n y ou r b od y t ha t c an ’t b e e xp la in ed ?” “H ea r v oi ce s c om m en ti ng o n w ha t y ou ’r e t hi nk in g o r d oi ng ?” Y-PAR Q-B O rd e t a l., 20 0 4 28 -i te m ( br ie f v er si on ) s el f-re po rt qu es ti on na ir e, b as ed o n t he C A A R M S; in cl ud es 3 -c ho ic e r es po ns e ( ‘Y ’= ye s, ‘ N ’= no , ‘U ’= un de ci de d). V al id at ed a ga in st t he S IP S i n 4 9 i nd iv id ua ls a ge s 12 -2 2 a cc es si ng m en ta l h ea lt h s er vi ce s i n t he U S; us in g a c ut off o f ≥ 1 1, s en si ti vi ty w as 6 5% , s pe ci fic it y 76 % , P P V 6 5% , N P V 7 6% (K li ne e t a l. 2 01 2). 12 . “ D o y ou e ve r h ea r t he v oi ce o f s om eo ne t al ki ng t ha t o th er pe op le c an no t h ea r? ” 15 . “ H av e y ou n ot ic ed a ny u nu su al b od il y s en sa ti on s s uc h a s ti ng li ng , p ul li ng , p re ss ur e, b ur ni ng , c ol d, v ib ra ti on s, d ri ll in g, te ar in g, o r e le ct ri ci ty ?” 19 . “ D o y ou e ve r h ea r s ou nd s t ha t a re n ot t he re ?” 22 . “ D o y ou s ee t hi ng s t ha t o th er s c an ’t o r d on ’t s ee ?” 24 . “ D o y ou g et s tr an ge f ee li ng s o n o r j us t b en ea th y ou r s ki n? ”Table 1. (Continued)
Note: AH, auditory hallucinations; AVH, auditory verbal hallucinations; APSS, Adolescent Psychotic Symptom
Screener; BASC, Behavior Assessment System for Children; CAARMS, Comprehensive Assessment of the At-Risk Mental State; CAPA, Child and Adolescent Psychiatric Assessment; CAPE, Community Assessment of Psychic Experiences; CAPS, Cardiff Anomalous Perceptions Scale; CIDI, Composite International Diagnostic Interview; DAWBA-PE-S, The Development and Well Being Assessment, Self-Reported Psychotic Experiences; DISC, Diagnostic Interview Schedule for Children; K-SADS, Kiddie Schedule for Affective Disorders and Schizophrenia for School Aged Children; HQ, Hallucination Questionnaire; LHSH-R, Launay-Slade Hallucination Scale, Revised; NPV, negative predictive power; PDI-16, Peters Delusions Inventory, 16 Item; PPV, positive predictive value; PLEQ-C, Psychotic-Like Experiences Questionnaire for Children; PLIKSi, Interview for Psychosis-Like Symptoms; PQ-16, Prodromal Questionnaire, 16 Item; PQ-B, Prodromal Questionnaire, Brief; PRIME-R, PRIME Screen, Revised; SCAN, Schedules for Clinical Assessment in Neuropsychiatry; SIPS, Structured Interview for Psychosis Risk Syndromes; SPEQ, Specific Psychotic Experiences Questionnaire; Y-PARQ-B, Youth Psychosis At-Risk Questionnaire, Brief; YSR, Youth Self Report.
aOnly instruments available in English are listed, all references can be found in the reference list of the thesis. bValidation measures in children and adolescents are described only for screening instruments.
cHypnagogic and hypnopompic hallucination items in the Hallucination Questionnaire (items 2-4) not listed.
Since the 2014 paper4, two themes relating to the assessment of hallucinations have emerged. First, the introduction of developmentally appropriate methods of assessment that are suitable and comfortable for a younger generation. Second, the use of a structured, systematic and comprehensive approach to the assessment of hallucinations in youth. See Table 2 for an overview of the most recently developed instruments, in line with these themes.
Regarding theme 1, it is important to acknowledge that the current generation of children and adolescents are increasingly using digital platforms. The MHASC164 (Multisensory Hallucinations Scale for Children) was specifically developed with this in mind and assesses quantitative and phenomenological features of hallucinations in all modalities. This app utilizes common game-based aesthetics and codes to increase engagement and motivation of children and adolescents during the assessment, using a simple, intuitive and playful interface with developmentally appropriate language165. The MHASC app was designed for use in community populations of children and adolescents. Recognizing that potential harm can come from labeling the experienced phenomena as mental illness, the developers emphasize that MHASC is not a diagnostic tool but more a quantitative and phenomenological measure. The MHASC app is currently being validated and will be made freely available on common App Stores in multiple languages.
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Table 2. Instruments that assess for phenomenological features of hallucinations in youth Instrument Age group Modalities Benefits Drawbacks
MHASC Very early &
early onset
5 sensory modalities explored + cross modal experiences (auditory, visual, somatosensory, gustatory, olfactory) Attractive layout (game-based app) Systematic and comprehensive Validation ongoing
SOCRATES Very early &
early onset 1 sensory modality explored (auditory) Systematic and comprehensive Requires clinical skills and presence of interviewer Not validated
AVHRS-Q Early onset 1 sensory modality
explored (auditory)
Quick assessment Systematic and comprehensive Validated
Not suitable for very early onset hallucinations
Note: MHASC, Multisensory Hallucinations Scale for Children; AVHRS-Q, Auditory Vocal
Hallucination Rating Scale Questionnaire; SOCRATES, Assessment of Perceptual Abnormalities and Unusual Thought Content.
The SOCRATES assessment of perceptual abnormalities and unusual thought content, similarly, provides a structured and comprehensive approach to assess specific characteristics of hallucinations (auditory and others), for use in children and adolescents in both clinical and research environments166. It has been developed with the aim of providing a method that is standardized, systematic and comprehensive, facilitating the assessment of changes over time and the comparison of phenomena across studies and centers.
For the assessment of specific characteristics and severity of AVH in pediatric populations, the Auditory Vocal Hallucination Rating Scale93, 167 (AVHRS) can be used.
In adolescent (and adult) populations (aged from 12 years), the AVHRS-Q(uestionnaire) has been developed as a self-report version of the AVHRS94. The AVHRS-Q can be delivered online, providing a brief (on average taking 6 min) and comprehensive assessment of AVH. The AVHRS-Q has been used in the second follow-up of a large Dutch cohort study on auditory verbal hallucinations in 18-19 year old adolescents20, and is currently being validated.
To conclude, the MHASC, the SOCRATES and the AVHRS-Q assessment are all suitable for the assessment of characteristics and phenomenology of AVH in youth and are outlined in Table 2. All of these instruments are primarily developed for research purposes, although they can also be applied in clinical practice to help clinicians to standardize their assessment of hallucinations. New digital technologies and other methods have presented new opportunities for both research and clinical practice, in order to better reach, study, assess and if necessary treat children and adolescents with hallucinations.
Therapeutic strategies and clinical issues
Children and adolescents may seek help for hallucinations, presenting themselves to community health services, general practitioners, outpatient clinics and emergency services7, 92, 168, 169, and a number of treatment options are available.
Targeted psychoeducation and psychotherapy
Kapur and colleagues7 investigated the experience of children and adolescents with hallucinations and their parents when engaging in mental health services. These young voice hearers reported feeling lost, not listened to, and found it difficult to obtain useful information. Parents sought a holistic approach (including counselling, peer groups, meditation, drug information sharing and alternative educational opportunities), whereas the children and adolescents preferred a more normalizing and destigmatizing approach. In line with the need for a more holistic approach, psychological interventions with a transdiagnostic and symptom-specific focus are deemed more acceptable by both clinicians and children and adolescents3, 7. Also, Jardri and colleagues4 emphasized an urgent need for psychotherapeutic interventions specifically developed for children and adolescents. Furthermore, Ruffell and colleagues33 conclude that targeted cognitive behavioral therapy (CBT) for PE in children and adolescents is recommended to improve clinical outcome. Currently, such tailored interventions are being developed. In the UK, hallucinations are one target of the Coping with Unusual ExperienceS for children (age <12 years) (CUES) (ISRCTN 13766770) and Coping with Unusual ExperienceS for 12-18 year olds (CUES+)170 (ISRCTN 21802136) studies that are evaluating CBT-informed interventions for children and adolescents with PE. In the Netherlands, Maijer and colleagues92 (see their supplementary material for more information) developed Stronger Than Your Voices (STYV), which is a form of CBT developed at an outpatient clinic for children and adolescents suffering from hallucinations that can be applied regardless of age or possible underlying (psychiatric) disorder. STYV is currently being assessed within a feasibility study.
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The relation-based therapies for hallucinations that are being developed for adultsmight also be useful for young people (eg, relating therapy171), given their emphasis on responding in more adaptive ways to difficult relationships (irrespective of the seen [social] or unseen [auditory hallucination] nature of the relational other). This focus on relationships addresses the aforementioned need for therapy to incorporate holistic and normalizing approaches.
Medication
Medication does not play a primary role in the treatment of hallucinations. When hallucinations are present in children and adolescents in the context of an established psychotic disorder, treatment with antipsychotic medication can be considered, following treatment guidelines34. However, the presence of distressing hallucinations does not always justify the diagnosis of a psychotic disorder and thus warrants restraint in prescribing antipsychotic medication92, 172. Incidentally, for example when hallucinations are a symptom or signal of decompensation of underlying conditions (such as an autism spectrum disorder or borderline personality disorder), antipsychotic medication can be considered as a (temporary and supplementary) intervention, according to related (inter) national guidelines and treatment protocols.
Other interventions
Other hallucination-focused interventions for children and adolescents include repeated transcranial magnetic stimulation (rTMS) as an add-on to therapy for persistent hallucinations. Although no new research on rTMS specifically for hallucinations in children and adolescents has emerged since 20144, earlier findings highlight the potential beneficial effects of low-frequency rTMS on reducing early-onset treatment-resistant hallucinations. There remains a need for large controlled trials to test its efficacy, which may aid in determining optimized stimulation parameters and evaluate its long-term therapeutic effect.
The use of virtual reality and avatars in the treatment of several dimensions of psychotic symptoms is promising173, 174, although there is still limited research, which is only restricted to adults at this time. In addition to digital assessment tools, online and virtual treatment strategies might be specifically appealing to children and adolescents and should be explored in future research.
Clinical application
When screening for hallucinations, it is important to note the potential barriers to disclosure133 and the possibility that parents may not always be aware of the presence and/or significance of children’s hallucinations19, 24, 134. Moreover, children from young
ages have the capacity to report on their hallucinatory experiences16, 24, 92, 100 and the age-appropriate questionnaires (albeit mostly regarding auditory hallucinations) described above can be used to facilitate these conversations in both community and clinical settings.
Attention has been drawn to the needs of children and adolescents actually seeking help for hallucinations, as the duration and severity of their complaints are often substantial, and there can be a variety of (severe) comorbid psychopathology92. Help-seeking children and adolescents and their parents are in need of information and targeted help to address hallucinations, preferably through a holistic and de-stigmatizing approach7, 92. The rise of easily accessible community services (such as Headspace in Australia, Heads Together in the United Kingdom, and @Ease in the Netherlands) might support such an approach and perhaps diminish the gap between the duration of complaints and referral to appropriate care. These community services could fulfill the need for easily accessible ways to gain information and/or to screen whether there is an indication for referring to mental health care facilities.
When encountering children and adolescents seeking help for hallucinations, clinicians should initially adopt a “curious-but-cautious” attitude, seeking to learn more about the hallucinatory experience and its psychosocial and psychopathological context. A holistic perspective can maximize engagement at this stage and the provision of psychoeducation about hallucinations, especially within the framework of the continuum model, may be helpful. If the clinician identifies that hallucinations are present, underlying causative factors and/or (psycho)pathology should first be targeted before considering hallucination-specific interventions. The experience of the clinicians working at the specialized outpatient clinic for youth with AVH at the UMC Utrecht suggests that in many cases, hallucinations subsequently decrease or even diminish when underlying causative factors (such as psychiatric [co-]morbidity) can be adequately targeted92. However, if (still) indicated and/or requested, the age-appropriate psychotherapeutic interventions described above are being developed to target the hallucinations. To provide knowledge and information on hallucinations, the psychoeducation section of such treatment protocols might be used for children and their parents before (or without) applying a whole treatment protocol. When hallucinations are present in the context of a psychotic disorder and/or previous steps were not sufficient, antipsychotic medication can be considered. A stepwise guide for clinicians is given in figure 1. In addition, as hallucinations are strongly associated with suicidal behavior, it is critical to perform suicide risk assessment in young people reporting hallucinations.
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Figure 1. Guide for clinicians: stepwise approach to hallucinations in youth
1. Manage expectations
Explain that although hallucinations are the primary reason to seek help, a broad view on the child’s/ adolescent’s development and possible (mental health) difficulties is needed to understand the clinical impact and relevance of the hallucinations
2. Assessment of general health
a. Perform a comprehensive mental health assessment including all DSM domains and possible problems on the domains of family (e.g. issues regarding interpersonal relations and/or (mental) health), social relations (e.g. bullying) and education (e.g. impairment of cognitive performances) while involving important caregiver(s) for hetero-anamnestic information b. Explore possible somatic complaints
c. Use additional assessment(s) if indicated, such as neuropsychological testing, specific diagnostic interviews and/or somatic investigations such as a blood test (e.g. when a genetic syndrome is suspected)
3. Assessment of hallucination characteristics
The use of a questionnaire such as the AVHRS or SOCRATES is not only helpful to structurally explore the characteristics of (auditory) hallucinations and to better understand their burden, but also to relieve anxiety and de-stigmatize talking about these experiences.
4. Place the hallucinatory experiences in an explanatory model
With the information gathered in step 2 and 3, work out whether the hallucinations should be understood as a possibly benign, developmental phenomenon or that they may be a symptom of (developing) (mental) health issues
5. Provide psycho-education to child/adolescent and caregiver(s)
Regardless of a possible benign and/or developmental origin, all children/adolescents and their caregiver(s) should receive and understand both up-to-date information on hallucinations in general (possibly using psycho-education sections of specific psychotherapeutic interventions) and a personalized explanatory model on their experience of hallucinations
6. Interventions
a. In case of (expected) benign and/or developmental hallucinations, step 5 is often sufficient b. Hallucinations as a signal or symptom of (mental) health issues
Interventions should primarily and firstly focus on these underlying conditions following their specific guidelines/treatment protocol. For example, in case of ADHD or depression first treat these disorders or in case of cognitive impairment first adjust school level
c. Hallucinations that persist in causing distress (despite step 6b) or when underlying conditions are unclear (or for any reason cannot be treated)
Use age-appropriate psychotherapeutic interventions such as CUES or STYV 7. Antipsychotic medication
Hallucinations per se are not an indication for the use of antipsychotic medication. When hallucinations are a symptom of psychotic disorder, but also when hallucinations are a symptom or signal of decompensation of underlying conditions (such as an autism spectrum disorder or borderline personality disorder) antipsychotic medication can be considered according to related guidelines/ treatment protocol (e.g. see NICE).
Note: AVHRS = Auditory Vocal Hallucination Rating Scale; CUES = Coping with Unusual ExperienceS; STYV =Stronger Than Your Voices; NICE = National Institute for health and Care Excellence.
