Formation of delusional ideation in adolescents hearing voices: a prospective study

Previous work suggests that auditory hallucinations in children and adolescents occur frequently in the absence of psychotic illness, although a number of such children go on to develop more severe psychotic symptomatology and need for care. We examined prospectively what factors are associated with formation of delusions in adolescents who are hearing voices. Eighty adolescents (mean age 12.9 years, SD = 3.1) who reported hearing voices were examined at baseline and followed-up three times over a period of 3 years. Fifty percent were receiving professional care, but 50% were not in need of care. Baseline measurement of voice appraisals, attributions, psychopathology, global functioning, dissociation, stressful life events, coping mechanisms, and receipt of professional care were used as predictors of delusion formation, measured as a score of 6 or greater on the extended BPRS items: "suspiciousness," "unusual thought content" and "grandiosity." Thirteen children (16%) displayed evidence of delusional ideation over at least one of the three follow-up periods, of which seven (9%) de novo. Adjusting for presence of baseline delusional ideation, delusion formation over the follow-up period was associated with baseline voice appraisals and attributions such as tone of the voice (hazard ratio voice "variably friendly and hostile" compared to "always friendly": HR = 6.8, 95% CI: 1.1, 41.0), perceived location of the voice (outside vs. inside head: HR = 2.9, 95% CI: 1.0, 8.7), and whether the voice resembled that of a parent (HR = 3.5, 95% CI: 1.0, 12.0); baseline BPRS anxiety/depression (HR = 6.4, 95% CI: 1.9, 21.4), baseline BPRS disorganization (HR = 5.0, 95% CI: 0.98, 26.1) and the baseline amount of reported recent stressful life events (HR continuous life events score: 1.8, 95% CI: 1.0, 3.3). In addition, in older children, the perceived influence of the voices on emotions and behavior was strongly associated with delusion formation (HR = 5.1, 95% CI: 1.0, 25.9). Delusion formation in children hearing voices may be responsive to triggering events and facilitated by feelings of anxiety/depression. The results also highlight the role of attributions associated with external sources, authority figures, perceived influence or "power" over the person, as well as emotional appraisal processes and cognitive disorganization.