It has been observed that children with auditory hallucinations (AH) may develop secondary delusional ideation, which is thought to increase the risk of need for care and patient status. Little is known about the cognitive vulnerabilities mediating delusion formation in children experiencing perceptual anomalies like AH. The ability to correctly interpret another person's intentions or emotions, referred to as mentalizing ability or ‘theory of mind’ (ToM), is shown to be impaired in children with psychotic symptoms and to be associated with delusional ideation in individuals at risk. A direct link between mentalizing ability and delusions is suggested by their presentation as alterations in social inference.

To examine the cognitive vulnerabilities mediating delusion formation in children presenting with AH.

In a sample of 259 12- and 13-year-old children, AH, delusional experiences (’mind reading’,’paranoid ideas’ and’receiving media messages’) and theory of mind (ToM) were assessed, in order to examine the hypothesized moderating role of ToM in delusion formation.

The risk of delusion formation was significantly higher in AH children with lower ToM skills (OR = 2.9, 95% CI 1.3–6.4, P = 0.008), compared to AH children with higher ToM skills (OR = 1.7, 95% CI 0.9–3.4, P = 0.11).

Our results suggest that better mentalizing abilities confer protection against developing full-blown psychosis in children experiencing perceptual anomalies.