Better theory-of-mind skills in children hearing voices mitigate the risk of secondary delusion formation

Objective: To examine the social cognitive vulnerabilities mediating delusion formation in children presenting with hallucinatory experiences. Method: A sample of 259 12- and 13-year-old children, from a baseline case-control sample of children with and without auditory hallucinations (AH), were re-assessed after 5 years for presence of AH. Presence of delusions and theory of mind (ToM) were also assessed, to examine the hypothesized moderating role of ToM in delusion formation in children hearing voices. Results: In children with AH at age 7-8 and/or 12-13 years, the risk of delusion formation was significantly higher (P interaction = 0.027) in those with lower ToM skills (OR = 4.3, 95% CI 1.9-9.9, P = 0.000), compared to those with higher ToM skills (OR 1.6, 95% CI 0.7-3.7, P = 0.26), independently from secondary school level. Conclusion: The results suggest that better mentalizing abilities confer protection against delusion formation in children experiencing perceptual anomalies, not reducible to general cognitive ability.