University of Groningen Auditory hallucinations in youth van Slobbe-Maijer, Kim

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Auditory hallucinations in youth

van Slobbe-Maijer, Kim

DOI:

10.33612/diss.94597038

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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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Chapter 4 Clinical signifi cance of auditory

hallucinations in youth: comparison

between a general population and a

help-seeking sample

Kim Maijer Laura A. Steenhuis Rosa Lotgering Saskia J.M.C. Palmen Iris E.C. Sommer Agna A. Bartels-Velthuis

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Dear editors,

During childhood and adolescence, AVH are mostly transient, pointing towards a possible benign or developmental nature. However, in some children and adolescents, AVH can lead to substantial suffering, are associated with significant behavioral problems, and may last for a longer period, even into adulthood19, 20, 24_{. When children and adolescents actually}

seek help for AVH, they represent a group with a high level of suffering, a reduced level of functioning and severe and/or comorbid psychopathology. In addition, time to treatment is substantial92_{. The present study aims to identify to what extent adolescents (aged 12-13}

years) experiencing AVH in the general population might be in need for clinical care. In addition, we explored whether these adolescents could have been identified at earlier age (7-8 years) and how they function at age 18-19 years.

We compared two independent, previously described samples: a clinical sample of a help-seeking population (HSP) (originating from a naturalistic study with anonymized data of n=207 youngsters, aged 8-18 years)92_{and a general population (GP) sample (originating}

from a case-control sample, followed in three waves: (i) baseline (T0; n=694 [n=347 with AVH], age 7/8 years); (ii) 5-year follow-up (T1; n=337 [n=55 with AVH], age 12/13 years) and (iii) 11-year follow-up (T2; n=293 [n=15 with AVH], age 18/19 years)19, 20, 24_.

For the HSP-sample and the T0 and T1-GP samples, AVH were assessed with the Auditory Vocal Hallucination Rating Scale (AVHRS)93_{. An AVH severity index was composed}

conform previous analyses24_{. For the T2-GP sample, AVH was assessed with the}

AVHRS-Q(uestionnaire)94_{. Parents of both the HSP and GP (T0 and T1) samples completed}

the Child Behavior Checklist (CBCL)80_{to assess problem behavior. Both total scores}

and internalizing, externalizing and eight syndrome scales were calculated (scoring normal=0, subclinical=1, clinical=2). Participants of the T2-GP sample completed the Community Assessment of Psychic Experience (CAPE)95_{, covering frequency and distress}

of positive, negative and depressive experiences, and the Depression, Anxiety and Stress Scale (DASS-21)96_{assessing symptoms of anxiety, depression and stress. The T2}

GP-sample was also assessed on social functioning with the Groningen Questionnaire about Social Behavior (GSVG-45)97_.

Analyses comprised (1) Comparison of the HSP- and T1 GP-samples, (2) Creating a ‘need for care’ measure by combining ‘AVH-severity’ and ‘CBCL-total’ z-scores, using means and standard deviations of the HSP sample, (3) Identifying adolescents with ‘need for care’ status in T1 GP-sample using the combined z-score with a threshold of ≥-1 (as adolescents below this threshold did not require clinical care but, for example, only reassurance, see92_{), (4) Comparison ‘need for care’ and ‘no need for care’ AVH adolescents}

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51 Clinical significance of auditory hallucinations in youth

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at T1 as well as retrospectively at T0 and prospectively at T2 follow-up. Analyses were performed using IBM SPSS Statistics version 23.0 (descriptives, z-scores, t-tests and chi-square tests).

Mean age and gender of the HSP (12.3 years, SD 2.8, 40.2% males) and GP (12.8 years, SD 0.8, 35.8% males) samples did not differ significantly. The HSP-sample scored significantly higher on both AVH severity (HSP mean 6.86 (SD 2.40); GP mean 2.84; (SD1.98)) and CBCL total score (HSP mean 59.21 (SD 25.60); GP mean 30.34 (SD24.27)) (see Supplementary table 1). Combined z-scores could be calculated for 62 (57.9%) cases of the HSP-sample due to missing data on either AVH-severity (17 missings (15.9%)) and/or CBCL total (37 missings (34.6%)) scores. There were no significant differences in AVH-severity for CBCL completers and non-completers (t(71.991)=71.991, p=0.132) or in CBCL-total between AVH completers and non-completers (t(68) = 0.839, p=0.404). In the HSP-sample, combined z-scores ranged from -2.16 to 1.27. In the T1 GP-sample, the combined z-scores ranged from -2.35 to 0.21.

Thirteen (23.6%) adolescents from the T1 GP-sample met the predefined ‘need for care’ criterion (see Table 1). Of these 13 adolescents with ‘need for care’ status at T1, nine already heard voices at T0, indicating that 69.2% of these adolescents had persistent AVH. Retrospectively, children with ‘need for care’ at T1, scored significantly higher on CBCL total and several subscales, but not on AVH-severity at age 7-8 years (T0) (see Supplementary Table 2). At T2, seven (of the thirteen) young adults with ‘need for care’ status at T1 could be assessed. Two of these seven young adults with ‘need for care’ status at T1 had persistent voices. At T2, those with ‘need for care’ at T1 reported significantly more depressive symptoms and higher distress (CAPE) and had significantly lower social functioning in their education (GSVG-45), compared to those without ‘need for care’ at T1 (see Supplementary Table 3).

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Ta b le C om pa ri so n ‘ N ee d f or C ar e’ v er su s ‘ N o N ee d f or C ar e’ s ub gr ou ps w it hi n G P T 1 s am pl e N ee d f or C ar e & A V H N o N ee d f or C ar e & A V H S ta ti st ic s N (% ) M ea n ( S D) N M ea n ( S D) T-te st ( d f) C h i-sq u ar e (d f) S ig . A ge ( ye ar s) 13 13 .0 0 (0 .6 5) 42 13 .0 0 (0 .6 33 ) 1. 31 4 ( 53 ) 0. 19 4 G end er (m ale ) 6 ( 46 .2 ) 18 ( 42 .9 ) 0. 20 6 ( 53 ) 0. 83 8 AV H s ev er it y i nd ex 13 4. 0 0 ( 2. 22 ) 42 2. 0 0 (1 .6 18 ) -3 .7 82 ( 53 ) <. 0 01 C B C L T ot al s co re 13 60 .0 0 (2 3. 64 3) 40 19 .0 0 (1 4. 07 4) -7 .5 64 ( 51 ) <. 0 01 C B C L R an ge ( N c lin ic al ) a T ot al c 11 ( 84 .6 ) 2.0 0 (0. 59 9) 2 (4 .8) 0.0 0 (0. 54 3) 33 .9 90 ( 2) <. 00 1 I nt er na liz in g b 10 ( 76 .9 ) 2. 0 0 (0 .7 68 ) 4 ( 9. 5) 0.0 0 (0.6 66 ) 23 .2 70 ( 2) <. 00 1 E xt er na liz in g c 7 ( 53 .8 ) 2. 0 0 (0 .7 68 ) 2 (4 .8) 0.0 0 (0. 46 3) 30 .0 26 ( 2) <. 00 1 S oc ia l w it hd ra w al b 1 ( 7. 7) 0.0 0 (0. 55 5) 0 (0 .0) 0.0 0 (0. 15 6) 3. 49 9 ( 2) 0. 17 4 S om at ic c om pl ai nt s b 6 ( 46 .2 ) 1. 0 0 ( 0. 95 4) 2 (4 .8) 0.0 0 (0. 49 5) 15 .21 0 ( 2) <. 0 01 A nx iou s/ de pr es se d b 4 ( 30 .8 ) 0.0 0 (0. 927 ) 1 ( 2. 4) 0. 0 0 ( 0. 40 0) 10 .85 4 ( 2) .0 04 S oc ia l p ro bl em b 3 ( 23 .1 ) 1. 0 0 (0 .8 32 ) 3 ( 7. 1) 0.0 0 (0. 52 7) 17. 44 4 (2 ) <. 0 01 T hou gh t p ro bl em s c 4 ( 30 .8 ) 0.0 0 (0. 927 ) 1 ( 2. 4) 0.0 0 (0.3 79 ) 11 .4 79 ( 2) .0 03 A tt en ti on p ro bl em s c 6 ( 46 .2 ) 1. 0 0 ( 0. 95 4) 0 (0 .0) 0. 0 0 (0 .0 0) 28 .9 91 ( 2) <. 00 1 R ul e-br ea ki ng b eh av io r b 3 ( 23 .1 ) 0.0 0 (0. 87 7) 2 (4 .8) 0.0 0 (0. 43 6) 3. 89 1 ( 1) 0. 04 9 A gg re ss iv e b eh av io r c 3 ( 23 .1 ) 0.0 0 (0. 87 7) 0 (0 .0) 0.0 0 (0. 15 8) 10 .7 97 (2 ) 0. 00 5 ato ta l ‘ ne ed f or c ar e’ N = 1 3 & t ot al ‘ no n ee d f or c ar e’ N = 4 2 bto ta l ‘ no n ee d f or c ar e’ N = 4 1 cto ta l ‘ no n ee d f or c ar e’ N = 40

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By comparing a HSP-sample with a GP-sample of adolescents with AVH, we could provide the estimation that nearly a quarter of adolescents with AVH in the general population might actually be in need of clinical care. From as early as 7 and 8 years of age, these children stood out from their peers with regard to problem behavior, but not necessarily to AVH severity. This information is helpful in understanding the clinical significance of AVH in youth in the general population. To specify, clinicians should be aware that approximately one in four adolescent voice hearers might need clinical care. Also, caregivers should always perform a broad clinical assessment when encountering children and adolescents with AVH. Our data suggest that, even from young age, AVH can be regarded as a signal of a vulnerable population, which may be in need of care for a broader spectrum of problems than AVH alone. Future research regarding AVH in youth might profit from explicitly implementing a broader assessment of distress and need for care, to better understand the origin of their suffering, with the aim of developing tailored support.

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S up p le me n ta ry t ab le 1 . C om pa ri so n G en er al P op ul at io n ( G P) a nd H el p-Se ek in g P op ul at io n ( H SP ) s am pl e GP H SP S ta ti st ic s N % M ea n ( S D) N % M ea n ( S D) T-te st ( d f) C h i-sq u ar e (d f) S ig . A ge ( ye ar s) 55 ( 33 .9 5) 12 .82 ( 0. 64 ) 10 7 ( 66 .0 5) 12 .3 1 ( 2. 82 ) -1 .7 8 .18 9 G end er (m ale ) 24 ( 35 .82 ) 43 ( 40 .1 9) 0. 17 8 ( 1) .6 73 AV H s ev er it y i nd ex 55 ( 37 .9 3) 2. 84 ( 1. 98 ) 90 ( 62 .0 7) 6. 86 ( 2. 40 ) 10 .4 46 ( 14 3) <. 00 1 C B C L T ot al s co re 30.3 4 (2 4. 27 ) 59 .21 ( 25 .6 0) 6. 33 4 ( 121 ) <. 00 1 C B C L R an ge ( N c lin ic al ) T ot al 13 ( 24 .5 3) 0.62 (0. 86 ) 53 ( 75 .7 1) 1. 60 (0 .7 5) 33 .6 12 ( 2) <. 00 1 I nt er na liz in g 14 (2 7. 45 ) 0.6 9 (0. 87 ) 50 ( 71 .4 3) 1. 56 (0 .7 5) 28 .1 78 ( 2) <. 00 1 E xt er na liz in g 9 ( 16 .9 8) 0. 43 (0 .7 7) 26 ( 37 .1 4) 0. 83 (0. 95 ) 6. 12 9 ( 2) .04 7 W it hd ra w n/ de pr es se d 1 ( 1. 85 ) 0.0 6 (0.3 0) 42 (6 0. 0 0) 1.3 0 (0. 91 ) 55 .6 19 ( 2) <. 00 1 S om at ic c om pl ai nt s 8 ( 14 .8 1) 0.3 9 (0. 74 ) 22 ( 31 .4 3) 0. 74 (0 .9 1) 5. 26 1 ( 2) .0 72 A nx iou s/ de pr es se d 5 ( 9. 26 ) 0. 28 ( 0. 63 ) 7 ( 10 .0 0) 0. 23 (0.62 ) 2. 34 6 ( 2) .3 0 9 S oc ia l p ro bl em s 6 ( 11 .1 1) 0.3 0 (0.6 6) 32 ( 45 .7 1) 0.9 7 (0 .9 8) 17. 29 5 (2 ) <. 00 1 T hou gh t p ro bl em s 5 ( 9. 43 ) 0. 26 (0.6 6) 63 ( 91 .3 0) 1. 88 ( 0. 40 ) 87 .2 20 ( 2) <. 00 1 A tt en ti on p ro bl em s 6 ( 11 .3 2) 0. 26 (0.6 6) 6 ( 8. 57 ) 0.3 1 (0.6 3) 3. 87 6 ( 2) .1 44 R ul e-br ea ki ng b eh av io r 5 ( 9. 26 ) 0. 19 (0. 59 ) 11 ( 15 .7 1) 0. 43 (0 .7 5) 8. 36 5 ( 2) .0 15 A gg re ss iv e b eh av io r 3 ( 5. 66 ) 0. 15 (0. 50 ) 8 ( 11 .4 3) 0.3 6 (0.6 8) 4. 71 5 (2 ) .0 95

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S up p le me n ta ry t ab le 2 . C om pa ri so n of t he ‘ N ee d f or C ar e a t T 1’ s ub gr ou p v er su s t he r es t of A V H s am pl e w it hi n G P B as el in e s am pl e N ee d f or c ar e a t T 1 + A V H R es t o f A V H s amp le S ta ti st ic s N (% ) M ea n ( S D) N M ea n ( S D) T-te st ( d f) C h i-sq u ar e (d f) S ig . A ge ( ye ar s) 9 7. 8 (0.3 ) 338 8.0 (0. 5) 1. 52 5 ( 34 5) .1 28 G end er (m ale ) 4 ( 44 .4 ) 17 1 ( 50 .6 ) -. 36 3 ( 34 5) .7 17 AV H s ev er it y i nd ex 9 1. 67 (1. 12 ) 338 1. 84 ( 1. 51 ) .3 41 ( 34 5) .7 33 C B C L T ot al s co re 6 45 .6 7( 25 .0 2) 201 23 .9 6( 18 .9 1) -2 .7 46 ( 20 5) .0 07 C B C L R an ge ( N c lin ic al ) 1 T ot al 3 ( 50 ) 1. 0 0 (1 .0 95 ) 33 ( 16 .7 ) 0. 42 (0 .7 58 ) 4. 80 7 ( 2) .0 90 I nt er na liz in g 3 ( 50 ) 1. 0 0 (1 .0 95 ) 39 ( 19 .4 ) 0. 48 (0 .8 0) 3. 61 ( 2) .16 4 E xt er na liz in g 3 ( 50 ) 1. 17 ( 0. 98 3) 26 ( 12 .9 ) 0. 36 (0 .7 02 ) 7. 37 3 (2 ) .0 25 W it hd ra w n/ de pr es se d 0 (0) 0. 0 0 (0 .0 0) 4 ( 1. 99 ) 0.0 8 (0.3 43 ) .4 14 ( 2) .81 3 S om at ic c om pl ai nt s 1 ( 16 .7 ) 0. 50 (0. 83 7) 9 (4 .4 8) 0. 15 (0. 47 ) 3. 01 8 ( 2) .2 21 A nx iou s/ de pr es se d 2 1 ( 16 .7 ) 0. 50 (0. 83 7) 16 ( 8. 0) 0. 21 (0. 57 2) 2. 29 4 ( 2) .3 18 S oc ia l p ro bl em 0 (0) 0. 0 0 (0 .0) 3 ( 1. 49 ) 0.0 5 (0. 27 8) .21 6 ( 2) .89 8 T hou gh t p ro bl em s 3 1 ( 25 ) 0. 50 (1 .0 ) 11 ( 5. 53 ) 0. 15 (0. 48 6) 2. 76 6 (2 ) .2 51 A tt en ti on p ro bl em s 1 ( 16 .7 ) 0.6 7 (0. 81 6) 8 ( 3. 98 ) 0. 14 (0. 44 8) 9. 65 8 ( 2) .0 08 R ul e-br ea ki ng b eh av io r 2 ( 33 .3 ) 0. 83 (0 .9 83 ) 10 ( 4. 97 ) 0. 16 (0. 48 8) 9. 96 9 ( 2) .0 07 A gg re ss iv e b eh av io r 2 ( 33 .3 ) 0. 83 (0 .9 83 ) 11 ( 5. 47 ) 0. 14 (0. 48 4) 10 .9 14 ( 2) .0 04 1: t ot al ‘ ne ed f or c ar e’ N = 6 & t ot al ‘ no n ee d f or c ar e’ N = 20 1; 2: t ot al ‘ no n ee d f or c ar e’ l N = 20 0; 3: t ot al ‘ ne ed f or c ar e’ N = 4 & t ot al ‘ no n ee d f or c ar e’ N =1 99

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Supplementary table 3

. Comparison ‘Need for Care’ versus ‘No Need for Care’ subgroups within GP T2 sample

A V H + N ee d f or C ar e T 1 (N = 7) A V H + N o N ee d f or C ar e T 1 (N = 26 ) S ta ti st ic s N (% ) M ea n ( S D) N M ea n ( S D) C h i-sq u ar e (d f) T-te st ( d f) S ig . A ge ( ye ar s) 7 18 .7 8 ( 0. 28 ) 26 18 .9 2 (0.3 6) 0. 928 ( 31 ) .3 60 G end er (m ale ) 2 ( 28 .6 ) 9 ( 34 .6 ) 0. 91 ( 1) .10 0 C A PE f re qu en cy Po si ti ve 7 9. 29 ( 9. 98 ) 25 4. 80 ( 5. 03 ) -1 .1 49 ( 6. 87 4) .28 9 Ne ga ti ve 7 11 .8 6 ( 6. 57 ) 25 8. 16 ( 4. 31 ) -1 .7 85 ( 30 ) .0 84 D epr es si ve 7 8. 43 ( 4. 65 ) 25 4. 76 ( 3. 40 ) -2 .3 31 ( 30 ) .0 27 C A PE d is tr es s Po si ti ve 7 7. 43 ( 7. 28 ) 22 3. 32 ( 4. 0 9) -1 .4 56 ( 7. 24 8) .18 7 Ne ga ti ve 7 12 .4 3 (7 .7 2) 25 7. 24 ( 4. 37 ) -1 .70 3 ( 7. 11 1) .1 32 D epr es si ve 7 9. 29 ( 5. 41 ) 24 5. 42 ( 4. 05 ) -2 .0 62 ( 30 ) .04 8 DA SS D epr es sion 7 10 .2 9 (7 .0 6) 25 6. 80 ( 5. 75 ) -1 .3 51 ( 30 ) .18 7 A nx ie ty 7 10 .2 9 (10 .10 ) 25 6. 24 ( 6. 25 ) -1 .3 16 ( 30 ) .19 8 St re ss 7 11 .1 4 ( 7. 65 ) 25 8. 56 ( 5. 87 ) -0 .9 63 ( 30 ) .3 43 So ci al F un ct ion in g To ta l S co re 7 3. 01 ( 0. 49 ) 25 3. 25 (0 .4 2) 1. 30 1 ( 30 ) 0. 203 Pa re nt s 7 3. 0 0 (1 .0 1) 25 3. 28 (0 .7 2) 0. 68 4 ( 7. 78 3) 0. 51 4 R om an ti c R el at io ns 3 3. 0 0 ( 0. 87 ) 11 3.6 7 (0.3 4) 1. 31 0 ( 2. 16 7) 0.3 12 F ri en ds /a cq ua in s 7 3. 40 ( 0. 61 ) 25 3.3 4 (0. 52 ) -0 .2 43 ( 30 ) 0. 80 9 Sc ho ol 7 2. 40 ( 0. 60 ) 22 3. 20 ( 0. 45 ) 3. 76 3 ( 27 ) 0. 00 1 W or k 5 3. 12 (0 .7 7) 18 3. 22 (0. 58 ) 0.3 27 (2 1) 0. 74 7 H ou se ho ld c ho re s 2 3. 60 (0 .0 0) 14 3.3 0 (0. 48 ) -0 .8 66 ( 14 ) 0. 401 H ob bie s 7 3. 0 0 ( 0. 41 ) 25 3. 12 ( 0. 67 ) 0. 589 (1 6. 041 ) 0. 56 4

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