Posted tagged ‘mental illness’

Should children hear voices in their heads?

July 11, 2016

The Pediatric Insider

© 2016 Roy Benaroch, MD

Missy wrote in: “My daughter casually mentioned last night that there is a person who is mean. I asked her more about it this morning and she says this person in her head tells her to say bad things. She says it sometimes scares her. She is 5 1/2 and is very imaginative. Mental illness does run in both sides of the family. How serious should we take this? What can we do? My daughter is funny, brilliant, and the sweetest child I have ever known. What can we do to help her?”

“Hearing voices” is common in children. A study of 3780 grade-school children in The Netherlands in 2009 found that over the course of a year, 9% of children reported hearing voices in their heads. Most of them weren’t bothered by it, though about 15% of them reported that the voices were troubling or disruptive. In a later study, the same authors found that most of these children (75%) said that the voices stopped within 5 years. So these voices are not usually a problem, and typically go away on their own.

Still, since Missy’s daughter is bothered by the voices, and they’re telling her to say “bad things,” I think a little more exploring is a good idea. I’d encourage the family to use these voices as a starting point to talk about what’s troubling her daughter, and (more importantly) what she can do about it. After all, for everyone, there’s always something that’s a problem. The goal isn’t to eliminate your child’s concerns or worries, but rather to teach them how to deal with them.

I’d start by telling the child that a lot of kids hear these things, or that Mommy used to hear them, too. (If that’s true – you might have to ask grandma.) How do the voices make you feel? Can the voices really make you do anything? What can you do if you don’t want to do the thing the voices say? Help your child understand that bad thoughts happen to everyone – but she doesn’t actually have to listen to them, and that she has the power to say to the voice, “No.” (Keep in mind that little kids are very concrete thinkers, and they are used to listening and obeying “rules”, and doing what they’re told. You may have to give her explicit permission, this time, to “disobey” the voice, and not feel badly about that.)

Ask her, “What is the voice telling you to do?” The answer might help both of you learn about what kinds of things are on your child’s mind. If the voice says “Push my little sister,” you could say, “I’ll bet sometimes you feel a little mad at your sister, and that’s OK. You can think those things, and that doesn’t make you bad.”

“Why” questions can sometimes be helpful, especially as kids grow a little older. “Why do you think a voice is telling you to steal candy?” Can open up a way to talk about the kinds of conflicting feelings that everyone has. On the one hand, you want the candy, because it tastes good; on the other hand, you know it’s not good for your teeth. These are tough dilemmas, for all of us, thinking things at the same time that contradict each other. Kids can start to understand how internal conflicts make all of us feel uncomfortable.

If the voices continue bothering a child, or seem to be contributing to behavior problems, the next step would be to get a referral to a mental health professional, typically a psychologist experienced with children. Ask your child’s doctor for references in your community.

While many children hear internal voices, it’s uncommon for teens and adults to continue to hear these (most of us perceive that our “internal monologue” is actually part of our own minds, and not projected from somewhere else.) As children mature into adults, continued thoughts “from outside”, especially if they’re “command thoughts” that tell you to do something, can be a sign of more-serious trouble. Other warning flags to look for include disturbances in mood or interactions with other people, hostility or paranoia, a lack of outward emotions, or unusual sleeping habits. While “hearing voices” isn’t especially worrisome in a child, seek additional help if this happens in teens or adults, especially when accompanied by other problems.

You're sort of confusing me, so, uh, begone... or, uh, y'know, however I get rid of you guys.

Is the FDA’s antidepressant warning killing people?

October 27, 2014

The Pediatric Insider

© 2014 Roy Benaroch, MD

In 2004, the FDA launched a program to “strengthen safeguards for children treated with antidepressant medication.” Among other steps, they started requiring manufacturers of several kinds of antidepressants to include a warning in their product labeling, a so-called “black box,” that explicitly and loudly proclaimed a risk for children taking these medications. The warning said that children taking these medications were at an increased risk of suicidal thoughts and behaviors. Later, the black box warning was expanded to include young adults. The warning was required to be added to the labeling of medications including Prozac, Zoloft, Celexa, Wellbutrin, and several other medications.

What prompted this action was an observation from studies of children taking these medications that in the weeks after starting them, there seemed to be increased thoughts of suicide. Not suicide attempts, and not deaths from suicide (there were actually no suicide deaths at all among the study groups), but self-reported thoughts about suicide.

Now, depression is a serious illness—and suicide is a very serious consequence of depression. People with major depression have about a 15% cumulative lifetime risk of death by suicide, so this is a very significant and serious problem not to be taken lightly. We know that people with depression often think of suicide, and are at grave risk for attempting suicide—is it possible that anti-depressant medications actually make this risk worse?

A June, 2014 study from The British Medical Journal has looked at the consequences of the FDA’s decision (and the ensuing broad media coverage.) Researchers examined data from a total of 2.5 million teens and young adults from 11 health care plans in the United States. After the warning, the use of these medications dropped by about 24-31% (depending on age grouping.) This was accompanied by an increase in the rate of suicide attempts, by 22-34%. The rate of deaths from suicide did not change at all—just the rate of attempted suicides.

So, no, the FDA’s warning, based on this study, didn’t increase actual deaths. But it did increase suicide attempts, which likely means it increased the rate and severity and consequences of depression. It certainly hasn’t done any good. The warning has scared many families and doctors away from one mode of therapy for depression. Antidepressant medications aren’t perfect—they do have important side effects, and they don’t always work, and they’re certainly not for everyone with symptoms of depression—but they can be one important part of the treatment of some depressed adolescents. It’s a shame that this misguided “black box warning” is doing more harm than good.

Depression in the family

December 15, 2011

The Pediatric Insider

© 2011 Roy Benaroch, MD

Beth posted, “As someone who has battled clinical depression since childhood, and whose husband has many of the same issues, I’m very curious about the risks my children face in this area. How much more likely are they to suffer from depression?”

Depression, as well as other mental illnesses, do run in families. The population risk of major depression—that is, the risk that someone will have depression at least once during their life—is probably about 5-10%. Add in the risk of an anxiety disorder, and you’ve probably got a lifetime risk in the 10-15% range. With one parent with problems with anxiety or depression, the risk for their children is about doubled, to 20-30%; with both parents, it’s somewhat higher than that (I couldn’t find an exact number.) So you’re right to be concerned about the risk in your kids.

We do know that there is more than genetics at work, though. Depression and anxiety are also influenced by environmental factors, including early childhood trauma, and exposure to parents and other loved ones with mental illness. If you and your husband are being successfully treated for depression,  it should reduce your own children’s risk—because they’re being raised by parents without symptoms (or with reduced symptoms) of mental illness.

The diagnosis of depression and anxiety disorders in children may be more difficult because kids do not necessarily have the same symptoms. While adults have anhedonia (lack of joy), children will more typically have irritability or chronic unexplained pain, trouble sleeping, or trouble with peers and in school.

If you’re worried about symptoms of mental illness in your kids, please bring them to your pediatrician. Be open about your own history of these problems. That can help the doctor come up with the best diagnosis. Though your kids are at elevated risk, that’s not to say that they’ll definitely—or even probably—have problems like these.