A 6-Year-Old Girl Is Brought to the Clinic for Evaluation

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?

A) Having imaginary friends is normal at this age and may help with social relationships.
B) Having imaginary friends is normal; however, their presence can adversely affect the development of real friendships.
C) Having imaginary friends is often associated with mood disorders; starting cognitive-behavioral therapy should be considered.
D) Your daughter may be experiencing early signs of psychosis; she requires further evaluation.
E) Your daughter will likely no longer need her imaginary friend once she feels more confident playing basketball.