A 5-year-old boy is brought to the office by his mother due to "concerning behavior." The patient's mother says that he is doing well and enjoying first grade, but for the past month she has noticed him talking to himself and insisting that he can see an angel. Earlier today he told his mother, "Angels can be nice or they can be angry, and if I speak too loudly the angel could sit on my sister's head." His mother reports no problems with the patient's appetite or sleep. She mentions that 6 weeks ago he fell off a balance beam during gymnastics class and says, "He bruised his arm but was okay otherwise. He's more cautious in class now but still seems to enjoy tumbling." The patient spends time with his cousins and siblings but tends to be shy around strangers. He tells the physician about his new toy car and a schoolteacher he likes. The patient has no prior medical conditions; family history is notable for a paternal uncle with schizophrenia. Vital signs are normal, and the patient's height and weight are tracking on the 60th percentile. Physical examination reveals no abnormalities. The patient turns to his left at one point and whispers something under his breath. He then looks at the physician and says, "Can't you see the angel? He's waving at you." Which of the following is the most likely diagnosis in this patient?
Having an imaginary friend, such as this child's invisible angel, is a developmentally appropriate aspect of childhood. An imaginary friend may be human, animal, or a fantasized figure and is common in the preschool and early school-aged years, decreasing in frequency after age 6. It is a form of creative play that can help a child explore new ideas and develop social competence through the rehearsal of social roles in a safe way. An imaginary friend can also provide comfort in times of distress or fear or give voice to a child's otherwise unacceptable thoughts and feelings.
A child's interaction with an imaginary friend can be quite vivid and include visual, auditory, and tactile components. There is no evidence that having an imaginary friend results in social or academic dysfunction; it may in fact contribute to the development of self-esteem by increasing creative, emotional, and relational skills.
(Choice A) Acute stress disorder is characterized by intrusive reexperiencing of a traumatic event together with symptoms of avoidance and hyperarousal. This child is more cautious at gymnastics, which is a natural response to a fall, but he is still attending and enjoying class. He does not have problems with sleep or concentration, which would indicate a state of hyperarousal.
(Choice B) An adjustment disorder is diagnosed when an emotional or behavioral response is out of proportion to a stressor and causes impairment. This child's invention of an imaginary friend is developmentally appropriate.
(Choice D) This child does not show the deficits in social interaction or repetitive behaviors seen in autism spectrum disorder.
(Choice E) In addition to hallucinations, early-onset psychosis would present with other psychotic symptoms such as delusions, confused speech, and/or behavior and negative symptoms (eg, lack of motivation, social withdrawal). Children with psychosis would be expected to have marked changes in functioning across multiple domains, including a decline in social interaction and academic performance. In contrast, this child does well in school, engages with family members, and interacts appropriately with the physician.
Educational objective:
Having imaginary friends is developmentally appropriate in preschool and school-aged children. It represents a form of creative play, aiding in the development of emotional and social competence, as well as providing comfort in times of distress.