A 6-year-old girl is brought to the clinic for evaluation of "strange behavior." Her parents have noticed that she seems to have conversations with herself when no one else is there, especially when she is alone in her room. In addition, when the girl dropped a plate at dinner, she said that "Mudsie did it" and that Mudsie was a friend who went to school with her. She states, "Mudsie is my invisible friend who is a bit clumsy, but I am teaching her to go slowly so that she gets better." The patient has no chronic medical conditions and has reached all her developmental milestones on time. Her maternal aunt was recently diagnosed with bipolar disorder. The patient has friends at school and gets along well with her 2 older siblings. She plays basketball, although she worries that she is not a good player because she drops the ball often. On mental status examination, the patient is friendly, cooperative, and responds appropriately to questions. She says that she can see and hear Mudsie but reports no other auditory or visual hallucinations. At one point in the interview, she looks over her shoulder and says, "Shhh, Mudsie, not now." Her parents are concerned that her behavior is abnormal and will interfere with her ability to make real friends. Which of the following is the most appropriate response?
Having an imaginary friend is most common in children age 3-6 but can be seen throughout school-age years. Although parents may become concerned when children report imaginary friends or when these relationships persist, this stage of development is considered healthy and normal. It aids a child's creativity and helps the child to navigate social relationships as a form of rehearsal. There is no evidence that imaginary friends negatively impact real friendships (Choice B).
Other normal creative behaviors in this age group include pretend play, dress-up, and storytelling with fanciful details.
(Choice C) A child may use imaginary friends to master anxiety and develop competence (eg, this child teaching her friend to be less clumsy) in a developmentally appropriate fashion. This girl has friends, gets along with her siblings, and interacts well with the physician. There is no indication of an anxiety disorder, and therapy is not necessary.
(Choice D) This child's behavior is normal for her age, and she shows no other signs concerning for psychosis (eg, disorganized behavior/speech, social isolation, regression of milestones). Psychiatric referral would be appropriate for an older child or adolescent with auditory or visual hallucinations.
(Choice E) Although this child may be using "Mudsie" as a way to master anxiety, imaginary friends play many roles (eg, companionship, social rehearsal). It is premature to suggest that the imaginary friend will not be needed when the girl becomes more confident in her basketball skills.
Educational objective:
Normal creative and healthy behaviors for young children include imaginary friends, pretend play, and storytelling with fanciful details.