Functional symptoms in children may be much more common than previously believed

neuropsychological assessment and followup, and directing intervention to targeted domains. However, this technology also brings about challenges regarding compatibility of appbased screening tools over different operating systems and updates, language of instruction used in the apps, cultural sensitivity of the test items, useability, training of practitioners implementing the technology within their clinical practice, security of the devices, and cost and supply of the hardware and software. Additional challenges arise concerning patient confidentiality when a database is used to record and monitor performance over time. Whilst the opportunities for touchscreen technology in screening basic cognitive, sensory, and motor abilities in pediatric patients are high, so are the challenges. Clinicians need to partner with technology developers to cocreate feasible solutions to these challenges to ensure touchscreen technology becomes a valuable, reliable, and valid resource that will enhance the efficiency and effectiveness of service provision within clinical neuropsychology units worldwide.

neuropsychological assessment and follow-up, and directing intervention to targeted domains.
However, this technology also brings about challenges regarding compatibility of app-based screening tools over different operating systems and updates, language of instruction used in the apps, cultural sensitivity of the test items, useability, training of practitioners implementing the technology within their clinical practice, security of the devices, and cost and supply of the hardware and software. Additional challenges arise concerning patient confidentiality when a database is used to record and monitor performance over time. Whilst the opportunities for touchscreen technology in screening basic cognitive, sensory, and motor abilities in pediatric patients are high, so are the challenges. Clinicians need to partner with technology developers to co-create feasible solutions to these challenges to ensure touchscreen technology becomes a valuable, reliable, and valid resource that will enhance the efficiency and effectiveness of service provision within clinical neuropsychology units worldwide.

DATA AVA I L A BI L I T Y S TAT E M E N T Not required.
ORC I D Nicola J. Pitchford https://orcid.org/0000-0001-5193-8371 How common is functional neurological disorder (FND) in children, and how long do children suffer from FND symptoms? These questions should frame the ways we provide clinical services for children, where we focus research investments, and how we train the next generation of clinicians. Simply put, we should match our efforts to the size of the problem. However, accurately assessing FND in children is difficult: many clinicians receive no training in diagnosing FND and historically, medicine's 'hidden curriculum' imposed substantial stigma on individuals with FND. This stigma carries into systemic surveillance methods, such as automated screening of diagnostic codes. Pediatric neurologists who document the diagnosis of FND fail to apply FND-related ICD-10 codes in 77% of cases. 1 Yong et al. 2 have quantified the magnitude and impact of pediatric FND using an active, prospective surveillance approach -they identified cases through weekly emails to child-focused clinicians for 3 years, and followed those children for up to 40 months. They found that FND is substantially more common than previously measured (incidence of 18.3/100 000). This suggests that pediatric FND is 21-fold more common than pediatric multiple sclerosis, 3 and 8.8-fold more common than pediatric stroke. 4 FND symptoms were more persistent than in prior studies, with 79% having ongoing symptoms at last follow-up. Several factors impact the accuracy of incidence measures. Importantly, Yong et al. studied a population in which all pediatric care was provided through a single hospital system, reducing the number of cases missed due to presentation elsewhere. This likely increased accuracy relative to regions where care is fragmented across multiple health systems. However, they did not include emergency and general medical providers in their surveillance regimen, inevitably leading to an undercount of pediatric FND. Their use of an active, case-seeking methodology likely bypassed some difficulties in discussing and documenting the FND diagnosis, such as the fear of increasing stigma for the patient or inciting criticism of the clinician. 1 However, other causes of underdiagnosis -utilizing higher diagnostic thresholds for FND, the perception that FND misdiagnoses are penalized, or the outdated belief that FND is a diagnosis of exclusion 1 -may have led clinicians to underreport in the present study. Their ascertainment method required that physicians opt-in to report FND cases. Readers who have ever been too busy to reply to automated alerts (in this case, 156 weekly emails) will recognize that this method likely led to an undercount of pediatric FND.

R E F E R E NC E S
One experimental factor likely inflated the incidence of FND, at least temporarily. The final year of the study coincided with the COVID-19 pandemic, with significant communitylevel increases in social isolation, anxiety, and depression -all factors shown to increase the risk of FND. A marked increase in tic-like functional movement disorders emerged during this interval, 5 possibly resulting from social contagion. The degree to which FND incidence and phenotype changed during the COVID era is not detailed in the study. Given that the incidence estimates in this study were substantially higher than prior measures of pediatric FND, we must question which factors are most relevant in our own practices: the drivers of undercount or overcount? My anecdotal experience suggests that FND is among the most common reasons to seek pediatric neurological care; this higher incidence rings true. Yong et al. made numerous methodological choices that increased the accuracy of their measures. Future studies may improve on their methods by including cases that never reach neurologists or psychiatrists, by offsetting both the pragmatic and stigma-derived sources of undercount, and by distinguishing the impacts of populationlevel stressors from baseline rates of pediatric FND.

DATA AVA I L A BI L I T Y S TAT E M E N T Not required
ORC I D Jeff L. Waugh https://orcid.org/0000-0001-7526-1342