"A preadolescent girl’s experience of hearing instrumental music without an external source, despite normal hearing and no psychosis, is prompting a re-evaluation of how the brain generates phantom sounds, particularly in younger populations."
This striking case from Thailand, detailed in the Journal of Developmental & Behavioral Pediatrics, presents a significant deviation from the typical profile of musical hallucinations. Traditionally understood as a phenomenon more prevalent in older adults and often linked to hearing loss or psychiatric conditions, this young girl’s experience, characterized by clear instrumental melodies appearing at specific times and resolving with medication, highlights the complexity and under-researched nature of these auditory experiences in children. The absence of hearing impairment or psychosis in her case is particularly noteworthy, suggesting that the brain mechanisms responsible for generating these internal soundscapes may be broader and more varied than previously understood.
Musical hallucinations, the subjective perception of music or melodies without any external auditory stimulus, have historically been a subject of fascination and clinical inquiry. While the phenomenon itself is not new, with the earliest recorded case dating back to 1846, a comprehensive understanding of its prevalence and underlying causes remains elusive. A 2024 review published in the World Journal of Psychiatry, which analyzed 294 reported cases, revealed that the average age of individuals experiencing musical hallucinations was nearly 68 years, with a notable overrepresentation of women. This extensive review categorized potential causes into eight groups, with psychiatric conditions accounting for the largest share (85 cases), followed closely by hearing impairment (77 cases). Intriguingly, Attention Deficit Hyperactivity Disorder (ADHD) was identified in only two cases, both involving adult men, underscoring the rarity of its association with this symptom. The review also cautioned against the erroneous diagnosis of psychosis in individuals experiencing musical hallucinations, emphasizing that a significant portion of these patients had no underlying mental illness.
The rarity of musical hallucinations in children further amplifies the significance of the Thai girl’s case. Clinicians reported fewer than 50 pediatric cases documented globally, and it is particularly uncommon in children who do not exhibit hearing loss or signs of psychosis. This makes her experience, which occurred for approximately a week and involved instrumental music perceived in both ears, a valuable data point for expanding our understanding of auditory perception and neurological function in this age group. The absence of lyrics in the music, its predictable timing, and the distress it caused her are all characteristic features that distinguish it from other auditory phenomena.
One of the most influential explanations for musical hallucinations emerged from a 2014 study published in the journal Cortex by researchers at Newcastle University and University College London. This groundbreaking research focused on Sylvia, a 69-year-old musician with perfect pitch whose auditory experiences began after a sudden, significant hearing loss. Using functional magnetic resonance imaging (fMRI), the team observed heightened activity in the auditory cortex and associated areas of her brain. They proposed a "predictive coding" model, suggesting that the brain constantly anticipates incoming auditory information and compares it with sensory input from the ears. In individuals with hearing loss, the weakened auditory signal may allow these internal predictions to become dominant, manifesting as phantom music. This model explained why external music could temporarily suppress Sylvia’s hallucinations: a stronger, more reliable auditory signal from the environment would override the brain’s internal predictions. William Sedley, a co-author of the study, articulated this as processes "running away with themselves to cause hallucinations."
Adding a rare first-person perspective, neurologist Bruce H. Dobkin of UCLA published a 2025 account of his own musical hallucinations following a cochlear implant for progressive hearing loss. His experience, which began with a men’s choir singing the "Star-Spangled Banner" on a loop, provided further anecdotal evidence for the link between auditory system changes and phantom music. Dobkin’s detailed description, which included the progression of his hallucinations from familiar songs to nonsense lyrics, offered valuable insights into the subjective nature of these experiences and their potential association with the brain’s attempt to compensate for diminished auditory input. He noted that his hallucinations coincided with deafness resulting from cochlear implant electrode placement, reinforcing the connection to changes in the auditory pathway.
However, the Thai girl’s case diverged significantly from these established patterns. Her hearing tests confirmed normal auditory function in both ears, and an electroencephalogram (EEG) conducted during the episodes revealed no signs of seizure activity. Crucially, she had no history of psychotic illness. Her diagnosis of ADHD, established at age five, and her treatment with methylphenidate, a common stimulant medication, were noted but not directly implicated as the cause of the hallucinations in the case report. Clinicians also observed frequent eye blinking, indicative of simple motor tics, which co-occurred with the musical experiences. Despite interventions such as limiting media exposure and employing behavioral techniques, the music persisted. The turning point came with the prescription of a low dose of the antipsychotic risperidone. Within three weeks, both the musical hallucinations and the tics resolved completely, and she remained symptom-free at a three-month follow-up.
The resolution of her symptoms with risperidone, an antipsychotic medication, raises intriguing questions. While not a direct indicator of psychosis, antipsychotics can modulate neurotransmitter systems that play a role in sensory processing and perception, potentially influencing the brain circuits involved in generating these auditory phenomena. The case report explicitly stated that the music was not attributed to her stimulant medication, leaving the exact etiology of her hallucinations open to speculation. The report did not aim to test the predictive model developed in cases of hearing loss, leaving an open question about whether the same brain machinery can malfunction in a child with unimpaired hearing.
The authors of the case report emphasized its diagnostic significance: recognizing that musical hallucinations can be structured, non-psychotic experiences is crucial for clinicians to avoid misdiagnosing children. The presence of tics alongside the hallucinations also adds another layer of complexity, as the resolution of both symptoms with risperidone suggests a potential underlying neurological link or a shared modulatory pathway. The limited duration of follow-up to three months means that the long-term implications and recurrence potential remain unknown.
It is vital to acknowledge the limitations inherent in a single case report. This particular instance cannot definitively establish the frequency of musical hallucinations in children with ADHD, nor can it definitively pinpoint the cause of this specific girl’s episodes or predict the efficacy of risperidone for other children. The concurrent resolution of tics and hallucinations also leaves room for interpretation regarding their interconnectedness.
Despite these limitations, the broader research landscape, including studies like the one on Sylvia and the firsthand account from Dr. Dobkin, points towards a unifying concept: the brain is not a passive receiver of sound but an active constructor of auditory experiences. This active construction process, while essential for perception, can, under certain circumstances, lead to the generation of internal sounds that are not externally present.
For parents who observe their child reporting phantom music, voices, or other sounds, the recommendation is clear: consult a pediatrician or prescribing physician. Prompt hearing and neurological evaluations are essential to understand the underlying cause. It is equally important for families to refrain from altering or discontinuing ADHD medication without explicit medical guidance, as abrupt changes can have significant consequences for the child’s well-being and management of their condition. The Thai girl’s case, while unique, serves as a potent reminder of the brain’s remarkable capacity for generating internal realities and the ongoing need for research to unravel the complexities of these phenomena, especially in pediatric populations.
