Imaginary friends are common in early childhood and are usually a normal feature of cognitive and emotional development. For clinicians, the key challenge is distinguishing typical imaginative play from patterns that may signal emotional distress or neurodevelopmental concerns that require further assessment.

An imaginary friend is a fictional character that a person, most often a child, creates mentally and interacts with as if the character were real. Talking with invisible dragons, having tea with invented heroes, or sharing secrets with companions only the child can see are part of normal development and do not usually indicate a psychological disorder. This phenomenon typically fades with age and cognitive maturation.

Research suggests that up to 65% of children have had an imaginary friend by age 7, according to landmark studies by Marjorie Taylor, PhD, and Stephanie Carlson, PhD, originally published in Developmental Psychology. Among imaginary friends still active at age 7, 67% were invisible, while 33% were personified objects, such as stuffed animals with distinct personalities. The studies showed that having an imaginary friend is a common and normative activity and is positively associated with better emotional understanding and an enhanced ability to take others’ perspectives.

“Imaginary friends appear as a natural part of the development of symbolic play and imagination,” said Tania Ruiz, a psychopedagogue specializing in learning and educational psychology and a therapeutic coordinator at Anda CONMiGO, a Spanish network of multidisciplinary centers caring for children and adolescents with neurodevelopmental and learning disorders.

“They are most frequent between ages 3 and 7, a period marked by intense creativity, during which the distinction between fantasy and reality is still under construction.”

Imaginary friends can take many forms, including people, animals, animated objects, or fantastical beings. “Beyond appearance, what matters is the function they serve,” Ruiz explained. “Some provide protection, others act as play companions, and others embody aspects of the child, such as bravery or strength. Through these figures, children organize their inner world and rehearse the management of needs, desires, and conflicts.”

From an emotional perspective, imaginary friends allow children to express fear, anger, sadness, or unmet desires that they may struggle to communicate directly. They function as a tool for making sense of emotions and practicing coping strategies. Cognitively, this type of play stimulates language development, narrative skills, planning, cognitive flexibility, and symbolic thinking. By creating stories, dialogues, and scenarios, children exercise executive functions and problem-solving abilities.

Imaginative Play or Clinical Concern?

“Concern arises when play becomes rigid; the child does not tolerate questioning or modifying the imaginary friend; the content is persistently violent; the presence of the friend causes distress, isolation, or fear; or when it coexists with other warning signs involving language, social interaction, or behavior,” Ruiz cautioned.

Most children with imaginary friends fall within typical developmental limits. In some cases, however, imaginary friends may be associated with:

• Difficulty regulating emotions (such as intense fears and anxiety) or managing sleep problems
• Significant stressors or life changes, including parental separation, the birth of a sibling, or a change of school
• Challenges with social interaction or language
• Behavioral problems, when the child uses the imaginary friend to justify actions or avoid responsibility

In such situations, the imaginary friend is not the cause of the difficulty but rather a potential indicator that the child is attempting to cope with an experience that is difficult to manage.

Attention-Deficit/Hyperactivity Disorder (ADHD) and Autism Spectrum Disorder

In ADHD, imaginary friends may serve as a space for creative expression and internal play and are not inherently concerning. In some cases, they may intersect with impulsivity or with difficulty distinguishing imagined events from those that actually occurred. These issues are typically addressed through psychoeducation and interventions focused on emotional regulation.

In autism spectrum disorder, the situation differs. Many children have difficulty developing complex symbolic play, making elaborate imaginary friends less common. When they do appear, it is important to determine whether the behavior reflects functional symbolic play or stems from restricted interests, rigid routines, or literal thinking that the child transforms into a constant “presence.” In all cases, imaginary friends are never interpreted in isolation but rather within the context of the child’s overall developmental profile.

Therapeutic Approach

When play involving an imaginary friend reflects intense fears, internal conflict, issues of control, or anxiety, the therapeutic goal is not to eliminate the character but to understand its function and support what the child is expressing through it.

“In therapy sessions, clinicians observe what the imaginary friend represents — protection, authority, fear, or companionship — and identify emotional themes that emerge repeatedly, such as abandonment, frustration, or insecurity,” Ruiz explained. “From there, symbolic resources are introduced, including new characters, alternative stories, or different endings, to help the child process these experiences. At the same time, the therapist puts words to what is happening in the play to support emotional identification and organization.”

This work is always carried out in coordination with the family. Parents are informed about the role of the imaginary friend and given guidance on how to support the child without reinforcing fears or invalidating imagination. When clear warning signs emerge, such as extreme rigidity, distress, interference with daily functioning, or persistent confusion between fantasy and reality, a more comprehensive evaluation and coordinated intervention with mental health services is recommended.

This story was translated from El Médico Interactivo, part of the Medscape Professional Network.