It is important to thoroughly assess for other causes for the hallucinations before considering a psychotic disorder because primary psychotic disorders are very rare in children. It is important to conduct a thorough clinical history and physical exam, and to consider basic labs and/or brain imaging if there are other signs of a medical or neurological process. Medical causes for hallucinations include: seizures, brain tumors (particularly in the visual association areas, temporal lobes and area around the optic nerve and retina), thyroid disease, electrolyte imbalances and adrenal disorders.

Medications that can commonly cause hallucinations include steroids, anticholinergics, and stimulants. It is important to consider the possibility of illegal drug use, including marijuana, even in very young children, who may have either taken the drug on purpose or ingested it accidentally. Visual, olfactory and gustatory hallucinations in children may suggest a medication or substance-related cause. It is important to rule out hypnagogic hallucinations, which occur immediately before falling asleep and hypnopompic hallucinations, which occur during the transition from sleep to wakefulness, both of which are normal phenomena.

True hallucinations in children are more likely to be a part of a non-psychotic psychiatric disorder than a primary psychotic disorder. Hallucinations can occur in children with non-psychotic psychiatric disorders, like depression, anxiety, and disruptive disorders. Hallucinations are not uncommon in depression in children but may suggest a higher risk for developing bipolar disorder. It is common for grieving children to hear “voices” from recently deceased loved ones. It’s important to remember that children who have experienced trauma can experience hallucinations as part of the trauma reaction. Hallucinations are common in children with developmental delays, including autism spectrum disorder. Children with language disorders may talk about “voices” because they cannot describe their own thoughts. In these situations, it can be helpful to ask a child if s/he is experiencing the voice inside of outside his/her head.

After ruling out the above, one can consider a primary psychotic disorder. It is important to assess for other psychotic symptoms (like disorganized speech, bizarre behavior, delusions, paranoia) as well as negative symptoms of psychosis (apathy, amotivation, and decline in functioning) before assuming a primary psychotic disorder, because a diagnosis of a primary psychotic disorder should not be made based on hallucinations alone.

In conclusion, while the report of hallucinations in children is worrisome, it is unlikely that it represents a psychotic disorder. It is important to conduct a thorough history to determine the underlying cause of the reported symptom.

Most people who experience a traumatic event, however, do not develop PTSD, so it is important to be aware of the risk factors for someone to develop PTSD after a traumatizing event. There is a genetic susceptibility to developing PTSD. PTSD shares genetic variance with other anxiety disorders like panic disorder and generalized anxiety disorder. PTSD also shares genetic variance with substance abuse disorders. People who experience an interpersonal assault are more likely to develop PTSD compared to people who experience a non-assault based trauma. PTSD is commonly seen in patients with military experience but can also be seen as a result of sexual assault, physical abuse, and domestic violence, in children and adults. PTSD is more commonly seen in situations where someone is exposed to a repeated trauma rather than a single trauma.

People with smaller hippocampi (the part of the limbic system that plays a role in both memory and inhibitory control) are more likely to develop PTSD after a traumatic event.  The hippocampus is an area of the brain with high numbers of gluco-corticoid receptors, glucocorticoids being part of the physiologic response to stress.  In PTSD, there is an over-activation of the Hypothalamic-Pituitary-Adrenal (HPA) axis which results in an increase in the fight or flight response. This contributes to the symptoms that are seen in PTSD, including hyper-vigilance, avoidance of triggers, nightmares, intrusive flashbacks, experiencing distress with reminders of the trauma, sleep disturbance, irritability, anger outbursts, and exaggerated startle response. Children experiencing PTSD will display it in their play and might also exhibit aggression, regression in their development and hyperactivity and impulsivity.

Patients with PTSD are at higher risk for suicidal ideation and suicide. They are at higher risk for other mental health concerns like other anxiety disorders and major depression. They are at higher risk for substance abuse problems, in large part in an effort to “self-medicate”.

The mainstay of treatment for PTSD is therapy (individual and group) and medication if needed. Trauma focused CBT is an evidence-based therapy practice used for PTSD. Additionally some patients find EMDR (eye movement desensitization and reprocessing) helpful for their symptoms. The SSRIs and other antidepressants can be useful for the depressive and anxiety symptoms of PTSD. Additionally medications like Prazosin can be used adjunctively for nightmares and sleep disturbance. Benzodiazepines are not particularly helpful for PTSD and therefore are not generally a recommended treatment.

It is our hope that this primer on PTSD is helpful for primary care providers to be able to screen for PTSD appropriately and refer for a more thorough assessment as needed.

More work is necessary to examine the potential neurobiological mechanisms underlying this association. Emerging studies in neuroimaging and genetic research are starting to provide some clues. Neuroimaging studies have shown that irregularities in dopaminergic neurotransmission and prefrontal cortex dysfunction have been found in both ADHD and PTSD, leading to the possibility that abnormalities in specific neural circuits in ADHD may increase the vulnerability for both ADHD and PTSD. Genome-wide data has found substantial shared common genetic variation between these two disorders, and they also have some common specific genetic risk factors. Further research is needed to understand the clinical significance of these findings.

So what does all this mean clinically in a primary care setting? Awareness of this comorbidity between ADHD and PTSD alerts clinicians treating patients with one disorder to screen for the other.  Additionally, the association between symptoms also suggests that PTSD symptoms can exacerbate ADHD symptoms and vice versa. Patients with PTSD can develop an acquired ADHD-like syndrome, which includes reports of inattention, disorganization, and forgetfulness. This is related to the work showing that chronic uncontrollable stress impairs working memory and prefrontal cortex function. Awareness of this link also alerts prescribers to be aware of the possible side effects of stimulant medications used to treat ADHD symptoms on the anxiety and trauma symptoms of PTSD. Clinical experience supports the idea that in children with both PTSD and ADHD, the alpha-agonists can be helpful for both symptoms.