Functional neurological disorders in children and young people
Article first published online: 13 DEC 2012
© The Authors. Developmental Medicine & Child Neurology © 2012 Mac Keith Press
Developmental Medicine & Child Neurology
Volume 55, Issue 1, pages 3–4, January 2013
How to Cite
Ramesh, V. (2013), Functional neurological disorders in children and young people. Developmental Medicine & Child Neurology, 55: 3–4. doi: 10.1111/dmcn.12058
- Issue published online: 13 DEC 2012
- Article first published online: 13 DEC 2012
Neurology and psychiatry are closely intertwined, nowhere more so than in the realm of non-organic functional disorders of the nervous system, which constitute 2–10% of patients seen in paediatric clinics. Often the patient has seen several doctors – none committing to a firm diagnosis of non-organic disorder despite suspicions. Parents are often reluctant to consider psychological factors, or to seek help from child and adolescent mental health professionals because of a perceived stigma and possible self-blame.
Freud viewed hysterical symptoms as the transformation of inner psychological conflict into physical symptoms by displacement. Current psychiatric terminology distinguishes two types of disorder (DSM IV-TR) previously labelled ‘hysteria’: somatoform and dissociative. The former includes conversion, somatization, pain disorders, hypochondriasis, and body dysmorphic disorders. The latter includes dissociative amnesia and fugue. Often there is comorbid mood and anxiety disorder[1-3] and discussion of their origins may prove a fruitful line of enquiry. The presence of high levels of childhood trauma retrospectively reported by adult sufferers has led some to view these disorders as a post-traumatic response, especially among genetically predisposed individuals.
Functional neurological disorders are usually seen in adolescents (twofold more common in females) and occur across a range of cognitive ability. Symptoms may follow minor illness, injury, and in rare instances, abuse.[1, 2, 4] Presenting symptoms and signs include non-epileptic seizures (often on a background of mild epilepsy), paralysis, gait disorders, complex pain syndromes, bizarre sensory and visual disturbances, and chronic fatigue.
Affected patients have often stopped attending school, losing both educational opportunity and the social stimulation provided by peers. This inevitably causes functional deterioration, social isolation, and subsequent reintegration challenges. Patients may derive subtle and not so subtle secondary gains; e.g. getting parental attention and not having to face up to a challenging situation. However, malingering is rare.
Clinical examination is normal or inconsistently abnormal. Careful medical and nursing observation over time often highlights incongruities. Neurological disorders that rarely present with psychiatric features (e.g. Wilson disease, systemic lupus erythematosus, NMDA receptor antibody mediated encephalitis) need exclusion. Usually, investigations are normal or show minor ambiguities. Physical illness specialists must conduct thorough investigations quickly and draw a line under them in order not to over-medicalize and entrench the problem.
Engagement with patient and family in a non-judgemental, empathetic way is helpful. The doctor should acknowledge that there is a problem, despite not having found a physical cause to explain it. The diagnosis must be explained in an honest, logical, and inoffensive manner. A positive emphasis is placed on the apparently baffling normality of tests, indicating no damage to the hardware of the nervous system, but a temporary and reversible malfunction in its software. The doctor states to the young person the need for a balance of physical and emotional well-being to function as a ‘whole’. The family are counselled to shift focus from causation to treatment.
The patient and family are best served by a multidisciplinary team including paediatric neurologists and experienced nursing, physiotherapy, and adolescent mental health professionals, providing a consistent coordinated care plan to improve function using physical and psychological strategies. The value of child mental health colleagues can be compared with ‘motivators’ used by sports celebrities. Comorbid depression or anxiety is treated. Cognitive behavioural therapy is often employed in the context of an overall rehabilitation philosophy. Care is taken to deal with the patient primarily on a one-to-one basis and allow for symptom resolution with dignity and without loss of face.
It is known from adult literature that without timely resolution the problem becomes chronic with severe personal and economic consequences. In one paediatric series only 56% of patients were ‘cured’ on follow-up over 7½ years.
The patient journey through the healthcare system is well defined for physical illness, unlike for functional disorders. I have run a successful joint clinic for over a decade (with a consultant child and adolescent psychiatrist) in a multidisciplinary format for young people with functional disorders, with excellent audited outcomes. We believe it to be a rewarding, mutually beneficial, and reassuring partnership in an often frustrating area, not least because, unlike disorders paediatric neurologists diagnose, this one is eminently treatable. The value of such a combined care model has been demonstrated previously.