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Course of auditory vocal hallucinations in childhood: 5-year follow-up study

  • Agna A. Bartels-Velthuis (a1), Gerard van de Willige (a1), Jack A. Jenner (a1), Jim van Os (a2) and Durk Wiersma (a3)...
Abstract
Background

In a baseline study among 7- and 8-year-old children with auditory vocal hallucinations, only limited functional impact was observed.

Aims

To assess 5-year course and predictors of auditory vocal hallucinations, as well as 5-year incidence and its risk factors.

Method

A sample of 337 children, 12 and 13 years of age, were reassessed on auditory vocal hallucinations and associated symptoms after a mean follow-up period of 5.1 years.

Results

The 5-year persistence and incidence rates were 24% and 9% respectively, with more new cases arising in urban areas. Both persistent and incident auditory vocal hallucinations were associated with problem behaviour in the clinical range of psychopathology as measured with the Child Behavior Checklist, particularly at follow-up, as well as with other psychotic symptoms, particularly at baseline. Persistence was predicted by baseline auditory vocal hallucinations severity, particularly in terms of external attribution of voices and hearing multiple voices, and was associated with worse primary school test scores and lower secondary school level.

Conclusions

First onset of auditory vocal hallucinations in middle childhood is not uncommon and is associated with psychopathological and behavioural comorbidity. Similarly, persistence of auditory vocal hallucinations in childhood is not uncommon and is associated with psychopathological, behavioural and cognitive alterations.

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Copyright
Corresponding author
Agna A. Bartels-Velthuis, University Medical Center Groningen, University Center for Psychiatry, University of Groningen, PO Box 30.001 (CC72), 9700 RB Groningen, The Netherlands. Email: a.a.bartels@med.umcg.nl
Footnotes
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We thank the funding organisations: the ‘Stichting tot Steun VCVGZ’ (Foundation for Support, Christian Union for Care of Mentally Ill), the ‘Stichting Open Ankh’, the ‘Bensdorp Fund’, Maastricht University Medical Centre and the Rob Giel Research centre of the University of Groningen. The ‘Stichting tot Steun VCVGZ’, ‘Stichting Open Ankh’ and ‘Bensdorp Fund’ had no role in the study design, in the collection, analysis, and interpretation of data, in the writing of the report, or in the decision to submit the paper for publication.

Declaration of interest

None.

Footnotes
References
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Course of auditory vocal hallucinations in childhood: 5-year follow-up study

  • Agna A. Bartels-Velthuis (a1), Gerard van de Willige (a1), Jack A. Jenner (a1), Jim van Os (a2) and Durk Wiersma (a3)...
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eLetters

Follow-up and assessment of auditory vocal hallucinations: A few concerns and considerations

Raman D Pattanayak, Senior Research Associate
21 October 2011

We read with interest the paper1 on auditory vocal hallucinations in 12/13 years old children, which was a 5-year follow up of the earlier population-based assessment.2 We wish to emphasize a few points pertainingto study methods and interpretations, not previously dealt with in the discussion of findings.

First, the study assesses hallucination as a symptom, not necessarilythe result of a psychiatric disorder. Children may hear voices in several pediatric-onset illnesses, for example temporal epilepsy or migraine may lead to recurrent experience of hallucinations or a medication adverse effect e.g. steroids or even methylphenidate may lead to a transitory hallucinations.3,4 While the use of cannabis and other substances has beenexplored in the study, information on a known medical condition in these children may have been available with parents and not explored. Further, aword of caution is appropriate for the clinical implications of the study that it deals with a community-based sample of children and the findings may not necessarily be generalizable to a psychiatric clinical population.

Second, it appears from study methodology (as described in greater detail in earlier paper) that there was one screening question (In the past year, have you heard one or more voices that only you and no one elsecould hear?') followed by the administration of Auditory Vocal Hallucination Rating Scale (AVHRS). It raises some concerns as to whether an effort has been made to establish hallucinations somewhere between screening and rating of the phenomenon. It appears that all the children in follow-up study who screened positive on initial question were rated onAVHRS and the reported figures are reflective of possible hallucinatory experiences, rather than firmly established hallucinations. In the earlierpaper, a mention has been made that three items on AVHRS (number of voices, duration & frequency) could be informative to distinguish between real and illusory voices, however no elaboration is made on the threshold or cut-off for individual items or scale per se. It is, therefore, not clear how the rating scale or the individual items could separate true hallucinations from imaginations, illusions and pseudo hallucinations in the children.

Third, the AVRHS have not been validated for use in child population.The psychometric properties have been described for adult population, but requires testing in younger population. 2,5 There are several complexitiesand intricacies associated with assessment of hallucinatory experiences inchildren, and use of adult instruments may not be justifiable. The pilot testing was done on 25 children 'with hallucinations in a clinic setting',which may not have be enough or adequate to distinguish children with hallucinations from apparently healthy children.

Fourth, the items related to hypnagogic and hypnopompic hallucinations were dropped altogether from AVHRS for the study (reason cited as 'the answers on the item pertaining to hypnagogic and hypnopompicvoices were sometimes inconclusive' in pilot testing2). We think that the complete exclusion of any kind of questioning pertaining to relation of hallucinations with sleep is a major omission and could have provided useful information for part, if not whole of sample. Further, the responses of 12/13 year olds may have more definite and conclusive to compared to 7/8 years old, therefore these items may have been included inthe follow-up assessments.

Fifth, with regards to a large number of refusals to participate, there is a possibility of introduction of a bias in the studied sample. The authors have commented that the refusal do not appear to be due to psychiatric problems in children. We wish to stress on a possibility that the things may be the other way round. The parents of children with psychiatric symptoms may have more inclined to participate compared to parents of apparently healthy children, thereby contributing to the seemingly high 5-year incidence rates (9%).

Only one-fourth of parents appear to be aware or have knowledge of the 'voices' heard and reported by their child, which may be explored further. The study reports several interesting results and adds to a limited prior literature in the field. The findings, however, need to be replicated in future studies overcoming these limitations and performed insimilar settings as well as across cultures.

References:

1.Bartels-Velthuis AA, van de Willige G, Jenner JA, van Os J, Wiersma D. Course of auditory vocal hallucinations in childhood: 5-year follow-up study. British J Psychiatry 2011; 199: 296-3022.Bartels-Velthuis AA, Jenner JA, van de Willige G, van Os J, Wiersma D Prevalence and correlates of auditory vocal hallucinations in middle childhood. Br J Psychiatry 2010; 196: 41-6.3.Hallucinations in children: Diagnostic and Treatment strategies. Current Psychiatry 2010; 9: 53-614.Gross-Tsur V, Joseph A, Shalev RS: Hallucinations during methylphenidate therapy. Neurology 2004; 63: 753-7545.Bartels-Velthuis AA, Van de Willige G, Jenner JA, Wiersma D. Assessing Auditory Vocal Hallucinations: The Psychometric Evaluation of the AuditoryVocal Hallucination Rating Scale (AVHRS). University Medical Center Groningen, University Center for Psychiatry, University of Groningen, 2008.

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Conflict of interest: None declared

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