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Barak S, Landa J, Eisenstein E, Gerner M, Ravid Vulkan T, Neeman-Verblun E, Silberg T. Agreement and disagreement in pediatric functional neurological symptom disorders: Comparing patient reported outcome measures (PROMs) and clinician assessments. Comput Struct Biotechnol J 2024; 24:350-361. [PMID: 38741721 PMCID: PMC11089279 DOI: 10.1016/j.csbj.2024.04.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 04/17/2024] [Accepted: 04/18/2024] [Indexed: 05/16/2024] Open
Abstract
Youth with functional neurological symptom disorder (FNSD) often perceive themselves as having limited capabilities, which may not align with clinical evaluations. This study assessed the disparities between clinician evaluations and patient-reported outcome measures (PROMs) regarding pain, motor function, and learning difficulties in youth with FNSD. Sixty-two youths with FNSD participated in this study, all of whom reported experiencing pain, motor problems, and/or learning difficulties. Clinicians also assessed these domains, resulting in a two-by-two categorization matrix: (1) agreement: child and clinician report "problems"; (2) agreement: child and clinician report "no problems"; (3) disagreement: child reports "problems" while the clinician does not; and (4) disagreement: clinician reports "problems" while the child does not. Agreement/disagreement differences were analyzed. No significant differences in prevalence were observed between the evaluators regarding pain (clinician-85%, child-88%), motor (clinician-98%, child-95%), or learning problems (clinician-69%, child-61%). More than 80% of the children and clinicians report pain and motor disorders. Instances in which children and clinicians reported learning problems (40.3%) exceeded cases in which both reported no problems (9.6%) or only the child reported problems (20.9%). Overall, the agreement between pain and motor function assessments was high (>90%), whereas that concerning learning difficulties was moderate (49.9%). Disagreement in pain/motor assessments was minimal (<5%), whereas for learning difficulties, disagreement rates were high (>20%). In conclusion, a significant concordance exists between PROMs and clinician assessments of pain and motor problems. However, the higher frequency of disagreements regarding learning difficulties emphasizes the importance of incorporating patient and clinician evaluations in pediatric FNSD treatment.
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Affiliation(s)
- S. Barak
- Department of Nursing, Faculty of Health Sciences, Ariel University, Ariel, Israel
- Department of Pediatric Rehabilitation, The Chaim Sheba Medical Center, The Edmond and Lily Safra Children's Hospital, Ramat-Gan 5262000, Israel
| | - J. Landa
- Department of Pediatric Rehabilitation, The Chaim Sheba Medical Center, The Edmond and Lily Safra Children's Hospital, Ramat-Gan 5262000, Israel
- The Sackler School of Medicine, Tel Aviv University, Tel Aviv 39040, Israel
| | - E. Eisenstein
- Department of Pediatric Rehabilitation, The Chaim Sheba Medical Center, The Edmond and Lily Safra Children's Hospital, Ramat-Gan 5262000, Israel
| | - M. Gerner
- Department of Pediatric Rehabilitation, The Chaim Sheba Medical Center, The Edmond and Lily Safra Children's Hospital, Ramat-Gan 5262000, Israel
| | - T. Ravid Vulkan
- Department of Pediatric Rehabilitation, The Chaim Sheba Medical Center, The Edmond and Lily Safra Children's Hospital, Ramat-Gan 5262000, Israel
| | - E. Neeman-Verblun
- Department of Pediatric Rehabilitation, The Chaim Sheba Medical Center, The Edmond and Lily Safra Children's Hospital, Ramat-Gan 5262000, Israel
| | - T. Silberg
- Department of Pediatric Rehabilitation, The Chaim Sheba Medical Center, The Edmond and Lily Safra Children's Hospital, Ramat-Gan 5262000, Israel
- Department of Psychology, Bar-Ilan University, Ramat-Gan 5290002, Israel
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2
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Duncan M, Pearman Z, Harrold K, Warren A, Evans S, McAllister E, Heyman I, Shavel-Jessop S, Murphy T, Liang H. Evaluation of a psychoeducation group for children presenting with functional tic-like behaviours. Clin Child Psychol Psychiatry 2024; 29:1011-1025. [PMID: 38476087 DOI: 10.1177/13591045241237829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/14/2024]
Abstract
We describe the implementation and evaluation of an online psychoeducation group for young people experiencing functional tic-like behaviours (FTLBs) - a type of functional neurological disorder (FND). Across six groups, 50 participants completed pre- and post-group goal-based outcomes (GBOs) and 36 participants completed service-user feedback, which gathered qualitative and quantitative data about participants experiences of the group. Young people and their parents reported significant improvement in their GBOs following the group and increased knowledge and confidence in managing FTLBs. The findings highlight that virtual psychoeducation group intervention is an acceptable and effective first step in treatment of young people with FTLBs. We discuss implications for future intervention development.
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Affiliation(s)
- Morvwen Duncan
- The Tic Service, Great Ormond Street Hospital for Children, UK
| | - Zoe Pearman
- The Tic Service, Great Ormond Street Hospital for Children, UK
| | - Katie Harrold
- The Tic Service, Great Ormond Street Hospital for Children, UK
| | - Amy Warren
- The Tic Service, Great Ormond Street Hospital for Children, UK
| | - Sacha Evans
- The Tic Service, Great Ormond Street Hospital for Children, UK
| | - Eve McAllister
- The Tic Service, Great Ormond Street Hospital for Children, UK
| | | | | | - Tara Murphy
- The Tic Service, Great Ormond Street Hospital for Children, UK
| | - Holan Liang
- The Tic Service, Great Ormond Street Hospital for Children, UK
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3
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Scheurich JA, Klaas KM, Sim LA, Weiss KE, Case HF, Harbeck-Weber C. Characteristics and outcomes of youth with functional seizures attending intensive interdisciplinary pain treatment. Epilepsy Behav 2024; 153:109689. [PMID: 38447301 DOI: 10.1016/j.yebeh.2024.109689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 02/05/2024] [Accepted: 02/10/2024] [Indexed: 03/08/2024]
Abstract
Functional seizures (FS) can be debilitating and negatively impact quality of life. Yet intervention research for FS is limited, especially for youth. This study examined clinical characteristics and outcomes of youth with FS (13-23 years) presenting to a pediatric intensive interdisciplinary pain treatment (IIPT) program in the midwestern United States. Sixty youth (mean age = 16.5 years; 83.3 % female) met inclusion criteria. At intake, comorbid chronic pain, somatic symptoms, autonomic dysfunction, eating and weight disturbances, and mental health concerns were common. Despite this high symptom burden, youth with FS reported significant improvements in functioning measured with the Functional Disability Inventory, t(53) = 9.80, p <.001, d = 1.32; depression measured with the Center for Epidemiological Studies - Depression Scale for Children, t(53) = 6.76, p <.001, d = 0.91; anxiety measured with the Spence Children's Anxiety Scale, t(53) = 3.97, p < .001, d = 0.53; and catastrophizing measured with the Pain Catastrophizing Scale for Children, t(53) = 6.44, p <.001, d = 0.86, following completion of the program, suggesting that IIPT may be an effective treatment option for highly disabled and emotionally distressed youth with FS. Future research is needed to continue to refine best practices for youth with FS to reduce suffering and improve outcomes.
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Affiliation(s)
- Jennifer A Scheurich
- Department of Psychiatry & Psychology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA; Department of Pediatrics, Children's Mercy Kansas City, 2401 Gillham Road, Kansas City, MO 64108, USA; University of Missouri-Kansas City School of Medicine, 2411 Holmes St, Kansas City, MO 64108, USA.
| | - Kelsey M Klaas
- Department of Pediatric & Adolescent Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
| | - Leslie A Sim
- Department of Psychiatry & Psychology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
| | - Karen E Weiss
- Department of Psychiatry & Psychology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
| | - Hannah F Case
- Department of Otolaryngology, Texas Tech University Health Sciences Center, 3601 4th Street STOP 8315, Lubbock, TX 79430, USA.
| | - Cynthia Harbeck-Weber
- Department of Psychiatry & Psychology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
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4
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Garcia A. Pediatric Functional Neurologic Disorders. Pediatr Clin North Am 2023; 70:589-601. [PMID: 37121644 DOI: 10.1016/j.pcl.2023.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
Functional neurologic disorders are common in the pediatric population. Recently, there has been a renewed focus on functional neurologic disorders, leading to improvements in diagnosis and management. This review focuses on updates in clinical presentation, diagnosis, pathophysiology (including neuroimaging), and treatment of functional neurologic disorders in the pediatric population.
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Affiliation(s)
- Angela Garcia
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, Suite 1200, Pittsburgh, PA 15201, USA.
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5
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Stager L, Mueller C, Morriss S, Szaflarski JP, Fobian AD. Sense of control, selective attention, cognitive inhibition, and psychosocial outcomes after Retraining and Control Therapy (ReACT) in pediatric functional seizures. Epilepsy Behav 2023; 142:109143. [PMID: 36872138 PMCID: PMC10164678 DOI: 10.1016/j.yebeh.2023.109143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 02/02/2023] [Accepted: 02/12/2023] [Indexed: 03/07/2023]
Abstract
BACKGROUND Differences in sense of control, cognitive inhibition, and selective attention in pediatric functional seizures (FS) versus matched controls implicate these as potential novel treatment targets. Retraining and Control Therapy (ReACT), which targets these factors, has been shown in a randomized controlled trial to be effective in improving pediatric FS with 82% of patients having complete symptom remission at 60 days following treatment. However, post-intervention data on sense of control, cognitive inhibition, and selective attention are not yet available. In this study, we assess changes in these and other psychosocial factors after ReACT. METHODS Children with FS (N = 14, Mage = 15.00, 64.3% female, 64.3% White) completed 8 weeks of ReACT and reported FS frequency at pre and post-1 (7 days before and after ReACT). At pre, post-1, and post-2 (60 days after ReACT), all 14 children completed the Pediatric Quality of Life Inventory Generic Core Scales, Behavior Assessment System (BASC2), and Children's Somatic Symptoms Inventory-24 (CSSI-24), and 8 children completed a modified Stroop task with seizure symptoms condition in which participants are presented with a word and respond to the ink color (e.g., "unconscious" in red) to assess selective attention and cognitive inhibition. At pre and post-1, ten children completed the magic and turbulence task (MAT) which assesses sense of control via 3 conditions (magic, lag, turbulence). In this computer-based task, participants attempt to catch falling X's while avoiding falling O's while their control over the task is manipulated in different ways. ANCOVAs controlling for change in FS from pre- to post-1 compared Stroop reaction time (RT) across all time points and MAT conditions between pre and post-1. Correlations assessed the relationships between changes in Stroop and MAT performance and change in FS from pre- to post-1. Paired samples t-tests assessed changes in quality of life (QOL), somatic symptoms, and mood pre to post-2. RESULTS Awareness that control was manipulated in the turbulence condition of the MAT increased at post-1 vs. pre- (p = 0.02, η2 = 0.57). This change correlated with a reduction in FS frequency after ReACT (r = 0.84, p < 0.01). Reaction time significantly improved for the seizure symptoms Stroop condition at post-2 compared to pre- (p = 0.02, η2 = 0.50), while the congruent and incongruent conditions were not different across time points. Quality of life was significantly improved at post-2, but the improvement was not significant when controlling for change in FS. Somatic symptom measures were significantly lower at post-2 vs. pre (BASC2: t(12) = 2.25, p = 0.04; CSSI-24: t(11) = 4.17, p < 0.01). No differences were observed regarding mood. CONCLUSION Sense of control improved after ReACT, and this improvement was proportional to a decrease in FS, suggesting this as a possible mechanism by which ReACT treats pediatric FS. Selective attention and cognitive inhibition were significantly increased 60 days after ReACT. The lack of improvement in QOL after controlling for change in FS suggests QOL changes may be mediated by decreases in FS. ReACT also improved general somatic symptoms independent of FS changes.
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Affiliation(s)
- Lindsay Stager
- University of Alabama at Birmingham, Department of Psychology, United States
| | - Christina Mueller
- University of Alabama at Birmingham, Department of Neurology, United States
| | - Skylar Morriss
- University of Alabama at Birmingham, Department of Psychology, United States
| | - Jerzy P Szaflarski
- University of Alabama at Birmingham, Department of Neurology, United States; University of Alabama at Birmingham, Departments Neurosurgery and Neurobiology and the UAB Epilepsy Center, United States
| | - Aaron D Fobian
- University of Alabama at Birmingham, Department of Psychiatry and Behavioral Neurobiology, United States.
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6
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Perjoc RS, Roza E, Vladacenco OA, Teleanu DM, Neacsu R, Teleanu RI. Functional Neurological Disorder-Old Problem New Perspective. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:1099. [PMID: 36673871 PMCID: PMC9859618 DOI: 10.3390/ijerph20021099] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Revised: 12/29/2022] [Accepted: 01/04/2023] [Indexed: 06/17/2023]
Abstract
Functional neurological disorder (FND) is a common issue in the pediatric population. The concept and our understanding of functional neurological disorders have changed over the past years, and new etiologic models and treatment plans have been explored. Knowledge about FND in the pediatric population, however, is lacking. The aim of this review is to provide an update on pediatric functional neurological disorder. We conducted a literature search of PubMed and SCOPUS databases and reviewed a total of 85 articles to gain insight into the current understanding of FND etiology, diagnosis, treatment, and prognosis in children and adolescents. Functional and high resolution MRI revealed abnormal connectivity and structural changes in patients with functional symptoms. The diagnostic criteria no longer require the presence of a psychological factor and instead focus on a rule-in diagnosis. Treatment of FND includes a clear communication of the diagnosis and the support of a multidisciplinary team. Although FND typically has a poor prognosis, better outcomes appear to have been achieved in children and young adults. We conclude that pediatric functional neurological disorder is a prevalent pathology and that this patient population has additional specific needs compared to the adult population.
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Affiliation(s)
- Radu-Stefan Perjoc
- “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania
- “Dr. Victor Gomoiu” Children’s Hospital, 022102 Bucharest, Romania
| | - Eugenia Roza
- “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania
- “Dr. Victor Gomoiu” Children’s Hospital, 022102 Bucharest, Romania
| | - Oana Aurelia Vladacenco
- “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania
- “Dr. Victor Gomoiu” Children’s Hospital, 022102 Bucharest, Romania
| | - Daniel Mihai Teleanu
- “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Emergency University Hospital, 050098 Bucharest, Romania
| | - Roxana Neacsu
- “Dr. Victor Gomoiu” Children’s Hospital, 022102 Bucharest, Romania
| | - Raluca Ioana Teleanu
- “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania
- “Dr. Victor Gomoiu” Children’s Hospital, 022102 Bucharest, Romania
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7
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Owen T, Silva J, Grose C, Bailey A, Robinson S, Anderson S, Ludlow A, Sharp S, Toghill L, Hedderly T. Case report: Advice for schools on managing functional tic-like behaviours. Front Psychiatry 2022; 13:1001459. [PMID: 36545035 PMCID: PMC9760715 DOI: 10.3389/fpsyt.2022.1001459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Accepted: 11/21/2022] [Indexed: 12/08/2022] Open
Abstract
There has been an increase in the occurrence of sudden onset functional tic-like behaviours in adolescents during the COVID-19 pandemic, which has had a significant impact on the affected individual's ability to engage with education. The aim of this article is to generate discussion and inform practice within schools with regard to the management of functional tic-like behaviours. An advice sheet for schools has been produced based on clinical expertise and experience of consulting with schools around the management within education settings. Case examples are presented highlighting the importance and impact of these strategies. We also highlight the need for further evaluation of the effectiveness of the advice sheet in collaboration with schools and families.
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Affiliation(s)
- Tamsin Owen
- Tics and Neurodevelopmental Movements Service (TANDeM), Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Juliana Silva
- Tics and Neurodevelopmental Movements Service (TANDeM), Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
- Department of Psychology, University of East Anglia, Norwich, United Kingdom
| | - Claire Grose
- Tics and Neurodevelopmental Movements Service (TANDeM), Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Alice Bailey
- Tics and Neurodevelopmental Movements Service (TANDeM), Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Sally Robinson
- North East London Foundation Trust, London, United Kingdom
| | | | - Amanda Ludlow
- Department of Psychology, University of Hertfordshire, Hatfield, United Kingdom
| | | | | | - Tammy Hedderly
- Tics and Neurodevelopmental Movements Service (TANDeM), Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
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8
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Baidoo L. Functional neurologic disorder (FND) in pediatrics: A clinical review with discussion of FND in the era of COVID-19. Nurse Pract 2022; 47:42-47. [PMID: 36165973 DOI: 10.1097/01.npr.0000873532.17436.85] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Functional neurologic disorder is a complex disorder of truly experienced neurologic symptoms without evidence of underlying neurologic disease. This clinical review focuses on the pediatric population and includes the impacts of the COVID-19 pandemic. Clinician knowledge and early identification can substantially improve patient outcomes.
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Affiliation(s)
- Lauren Baidoo
- Lauren Baidoo is an advanced practice nurse in the Department of Neurology at Ann & Robert H. Lurie Children's Hospital of Chicago in Chicago, Ill
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9
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Rajabalee N, Kozlowska K, Lee SY, Savage B, Hawkes C, Siciliano D, Porges SW, Pick S, Torbey S. Neuromodulation Using Computer-Altered Music to Treat a Ten-Year-Old Child Unresponsive to Standard Interventions for Functional Neurological Disorder. Harv Rev Psychiatry 2022; 30:303-316. [PMID: 35616609 PMCID: PMC9470039 DOI: 10.1097/hrp.0000000000000341] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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10
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Stager L, Morriss S, McKibben L, Grant M, Szaflarski JP, Fobian AD. Sense of control, selective attention and cognitive inhibition in pediatric functional seizures: A prospective case-control study. Seizure 2022; 98:79-86. [PMID: 35430472 PMCID: PMC9081274 DOI: 10.1016/j.seizure.2022.03.021] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Revised: 03/28/2022] [Accepted: 03/29/2022] [Indexed: 11/21/2022] Open
Abstract
PURPOSE To date, laboratory-based experimental behavioral methods have not been used to identify factors associated with pediatric functional seizures (FS), leaving a critical gap for effective treatment development. METHODS Children ages 13-18 with video-EEG-confirmed FS were matched to controls (MCs) based on income, sex, race, and age. A modified Stroop task which included a condition requiring participants to report the ink colors in which seizure symptom words were written (e.g., "shaking" in blue) measured selective attention and cognitive inhibition through response time. The magic and turbulence task assessed sense of control in three conditions (magic, lag, turbulence). Children with FS were asked to report premonitory symptoms predicting FS. RESULTS Participants included 26 children with FS and 26 MCs (Meanage=15.2, 74% female, 59% white). On Stroop, children with FS had a slower reaction time (Mean=1193.83) than MCs (Mean=949.26, p = 0.022) for seizure symptom words. Children with FS had significantly poorer sense of control in the turbulence condition of the magic and turbulence task (Mean=-3.99, SD=8.83) than MCs (Mean=-11.51, SD=7.87; t(20)=-2.61, p =0.017). Children with FS (Mean=-1.80, SD=6.54) also had significantly poorer sense of control in the magic condition than MCs (Mean=-5.57, SD=6.01; p =0.028). Ninety-eight percent of patients endorsed premonitory symptoms. CONCLUSION Compared with MCs, children with FS have (1) poorer selective attention and cognitive inhibition when presented with seizure-related information and (2) lower sense of control (i.e. poorer awareness that their control was manipulated). Premonitory symptoms were common. Sense of control, selective attention, and inhibition may be novel treatment targets for FS intervention.
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Affiliation(s)
- Lindsay Stager
- Department of Psychology, University of Alabama at Birmingham, United States
| | - Skylar Morriss
- Department of Psychology, University of Alabama at Birmingham, United States
| | - Lauren McKibben
- Department of Psychiatry and Behavioral Neurobiology, University of Alabama at Birmingham, United States; Department of Anesthesiology, University of North Carolina, Chapel Hill, United States
| | - Merida Grant
- Department of Psychiatry and Behavioral Neurobiology, University of Alabama at Birmingham, United States
| | - Jerzy P Szaflarski
- Departments of Neurology, Neurosurgery and Neurobiology and the UAB Epilepsy Center, University of Alabama at Birmingham, United States
| | - Aaron D Fobian
- Department of Psychiatry and Behavioral Neurobiology, University of Alabama at Birmingham, United States.
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11
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West E, Shah U. Diagnosis of Functional Weakness and Functional Gait Disorders in Children and Adolescents. Semin Pediatr Neurol 2022; 41:100955. [PMID: 35450671 DOI: 10.1016/j.spen.2022.100955] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 02/08/2022] [Accepted: 02/19/2022] [Indexed: 11/15/2022]
Abstract
Functional neurological disorder is neurological dysfunction not primarily explained by pathophysiologic or structural abnormalities and can present in children and adolescents with limb weakness, gait abnormality, non-epileptic seizures or sensory changes. In this review article we focus primarily on the diagnosis of functional limb weakness and functional gait disorders, and how to differentiate functional neurological disorders from structural or pathologic neurological presentations of weakness or gait disturbance. Detailed history and attentive observation of a patient outside of the formal neurological examination can be pertinent to identifying inconsistency and incongruency in keeping with functional neurological presentations. Understanding of structural and physiologic neurological pathology is required to identify non-anatomical and non-pathological features consistent with a diagnosis of functional neurological disorder. Diagnosis is made on recognition of positive clinical features of a functional disorder on examination and is not based primarily on exclusion of a pathologic neurological disorder. Specific tests can be performed to elicit pathognomonic findings supportive of a diagnosis of functional limb weakness and gait disorders.
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Affiliation(s)
- Ellen West
- Department of Neurosciences, Queensland Childrens Hospital, Brisbane, Queensland, Australia
| | - Ubaid Shah
- Department of Neurosciences, Queensland Childrens Hospital, Brisbane, Queensland, Australia; The University of Queensland, Brisbane, Queensland, Australia.
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12
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Pierce ME, Albert DVF. Delivering the Diagnosis: A Practical Approach to a Patient With a Functional Neurological Disorder. Semin Pediatr Neurol 2022; 41:100948. [PMID: 35450673 DOI: 10.1016/j.spen.2021.100948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 11/24/2021] [Accepted: 11/25/2021] [Indexed: 10/19/2022]
Abstract
Functional Neurological Disorders are a common and debilitating group of diseases that have been the subject of stigma and confusion across medical history. It is well-documented that prognosis and even possible resolution of symptoms are linked to successful delivery of the diagnosis by the clinician, and correct understanding of diagnosis by the patient. In the following article, we delineate the nature of these disorders and provide an overview to assist providers successfully navigate the communication of these diagnoses to patients and families.
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Affiliation(s)
- Mark E Pierce
- Department of Neurology, The Ohio State University Wexner Medical Center, Columbus, OH.
| | - Dara V F Albert
- Department of Pediatrics, Division of Neurology, Nationwide Children's Hospital, Columbus, OH
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13
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Paleari V, Nisticò V, Nardocci N, Canevini MP, Priori A, Gambini O, Zorzi G, Demartini B. Socio-demographic characteristics and psychopathological assessment in a sample of 13 paediatric patients with functional neurological disorders: A preliminary report. Clin Child Psychol Psychiatry 2022; 27:492-503. [PMID: 34743581 DOI: 10.1177/13591045211055084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This observational study aims to characterize, from a socio-demographic and psychopathological perspective, a sample of children with Functional Neurological Disorders (FND). Thirteen paediatric patients (below 18 years old) with FND and their parents completed a battery of anamnestic and neuropsychological tests, assessing socio-demographic status, cognitive level, behavioural and emotional issues, depression, anxiety, alexithymic traits and dissociative symptoms. Five patients presented movement disorders (tremor, myoclonus and gait disorder), three patients psychogenic non-epileptic seizures and five patients sensitivity disturbances (pain, anaesthesia and paraesthesia). Cognitive profile was normal in 11 patients; academic performance was good in nine patients, but three had a diagnosis of Specific Learning Difficulty or Attention Deficit Hyperactivity Disorder. Precipitating events occurred in 11 patients. At the self-report questionnaires, mean scores close to the clinical cut off were documented with respect to affective and somatic problems. At the parent-report questionnaires, clinically significant mean scores were observed in the subscales assessing anxious-depressive symptoms and somatic complaints. We speculate that paediatric FND patients, although acknowledging the relevance of somatic symptoms, have difficulties in recognizing internal emotional states (that, instead, are easily recognized by their parents). The case of one FND patient was described. These preliminary data might help identifying different clinical phenotypes of paediatric FND.
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Affiliation(s)
- Vittoria Paleari
- Dipartimento di Scienze Della Salute, Università Degli Studi di Milano, Milano, Italy.,U.O. Neuropsichiatria Infantile Fondazione IRCCS, 9328Istituto Neurologico Carlo Besta, Milano, Italia
| | - Veronica Nisticò
- Dipartimento di Scienze Della Salute, Università Degli Studi di Milano, Milano, Italy.,"Aldo Ravelli" Research Center for Neurotechnology and Experimental Brain Therapeutics, Università Degli Studi di Milano, Milano, Italy
| | - Nardo Nardocci
- U.O. Neuropsichiatria Infantile Fondazione IRCCS, 9328Istituto Neurologico Carlo Besta, Milano, Italia
| | - Maria Paola Canevini
- U.O. Neuropsichiatria Infantile ASST Santi Paolo e Carlo, Presidio San Paolo, Milano, Italy
| | - Alberto Priori
- Dipartimento di Scienze Della Salute, Università Degli Studi di Milano, Milano, Italy.,"Aldo Ravelli" Research Center for Neurotechnology and Experimental Brain Therapeutics, Università Degli Studi di Milano, Milano, Italy.,III Clinica Neurologica, ASST Santi Paolo e Carlo, Presidio San Paolo, Milano, Italy
| | - Orsola Gambini
- Dipartimento di Scienze Della Salute, Università Degli Studi di Milano, Milano, Italy.,"Aldo Ravelli" Research Center for Neurotechnology and Experimental Brain Therapeutics, Università Degli Studi di Milano, Milano, Italy.,Unità di Psichiatria 52, ASST Santi Paolo e Carlo, Presidio San Paolo, Milano, Italy
| | - Giovanna Zorzi
- U.O. Neuropsichiatria Infantile Fondazione IRCCS, 9328Istituto Neurologico Carlo Besta, Milano, Italia
| | - Benedetta Demartini
- Dipartimento di Scienze Della Salute, Università Degli Studi di Milano, Milano, Italy.,"Aldo Ravelli" Research Center for Neurotechnology and Experimental Brain Therapeutics, Università Degli Studi di Milano, Milano, Italy.,Unità di Psichiatria 52, ASST Santi Paolo e Carlo, Presidio San Paolo, Milano, Italy
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14
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Elliott L, Carberry C. Treatment of Pediatric Functional Neurological Symptom Disorder: A Review of the State of the Literature. Semin Pediatr Neurol 2022; 41:100952. [PMID: 35450669 DOI: 10.1016/j.spen.2022.100952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Revised: 01/11/2022] [Accepted: 01/11/2022] [Indexed: 11/26/2022]
Abstract
Functional Neurological Symptom Disorder (FNSD), or experiencing neurological symptoms incompatible with either a neurological condition or a medical condition, is a common condition presenting in children and adolescents. It is associated with impairment in quality of life for patients and their families and represents a significant burden to the healthcare system. There is currently limited research available regarding effective treatment of pediatric FNSD. Currently, only one RCT exists studying effective treatment of FNSD in children and adolescents, and it is limited to one sub-type of FNSD and only examined cognitive behavioral therapy compared to supportive therapy. Despite this, almost all published research supports good prognosis for pediatric FNSD with all studies reporting improvement either in FNSD symptoms or in the quality of life and functioning of patients with FNSD. The most support was found for the use of cognitive behavioral therapy either as a stand-alone treatment or in the context of interdisciplinary treatment. Future research should focus on increasing the rigor of research, including expanding RCTs to include additional sub-types of FNSD and comparing across various treatment modalities.
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Affiliation(s)
- Lindsey Elliott
- Department of Psychiatry and Behavioral Sciences, Univeristy of Texas at Austin, Austin, TX.
| | - Caroline Carberry
- Department of Educational Psychology, University of Texas at Austin, Austin, TX
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15
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Stager L, Morriss S, Szaflarski JP, Fobian AD. Psychiatric and personality factors in pediatric functional seizures: A prospective case-control study. Seizure 2022; 98:105-112. [PMID: 35462300 PMCID: PMC9081249 DOI: 10.1016/j.seizure.2022.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Revised: 04/08/2022] [Accepted: 04/12/2022] [Indexed: 10/18/2022] Open
Abstract
PURPOSE This study assessed psychiatric and personality characteristics in relation to pediatric functional seizures (FS). METHODS In a 1:1 prospectively matched-control study design, children with documented FS (confirmed via video EEG; ages 13-18) were matched to controls (MCs) on income, sex, race, and age. Primary outcomes were Behavior Assessment System for Children, Second Edition (BASC-2) and Millon Adolescent Clinical Inventory (MACI). Secondary measures included questionnaires assessing trauma, somatization, body awareness and quality of life (QOL). T-tests investigated differences between groups on T-scores. Due to lack of significant outcomes, an experimental analysis was conducted assessing differences in number of clinically elevated BASC-2 and MACI scores between groups. Binary logistic regressions determined the influences of clinically elevated scores on likelihood participants have FS. T-tests assessed differences on secondary measures. RESULTS Participants included 84 children, 42 with FS and 42 MCs (Children with FS: Meanage=15.4, Interquartile Rangeage=3; 73.5% female; 59.5% white). Children with FS had greater parent-reported somatization (t(23)=5.67, p<0.001) on BASC-2, greater somatization on CSSI-24 (t(35)=6.83, p<0.001), and poorer QOL (t(41)=-6.22; p<0.001) than MCs. There were no differences in clinically elevated BASC-2 or MACI scores compared to MCs and clinically elevated scores did not influence likelihood participants have FS. CONCLUSIONS Children with FS had greater somatization and poorer QOL but similar rates of psychiatric symptoms, trauma, and maladaptive personality traits compared to MCs. Psychiatric or personality factors did not predict likelihood of FS. Explanations of pediatric FS should consider novel contributors to FS rather than relying solely on a psychiatric etiology.
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16
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Treatment Approaches for Functional Neurological Disorders in Children. Curr Treat Options Neurol 2022; 24:77-97. [PMID: 35370394 PMCID: PMC8958484 DOI: 10.1007/s11940-022-00708-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/09/2021] [Indexed: 12/18/2022]
Abstract
Abstract
Purpose of Review
Functional neurological disorder (FND) is a multi-network brain disorder that encompasses a broad range of neurological symptoms. FND is common in pediatric practice. It places substantial strains on children, families, and health care systems. Treatment begins at assessment, which requires the following: the medical task of making the diagnosis, the interpersonal task of engaging the child and family so that they feel heard and respected, the communication task of communicating and explaining the diagnosis, and the logistical task of organizing treatment.
Recent Findings
Over the past decade, three treatment approaches—Retraining and Control Therapy (ReACT), other cognitive-behavioral therapies, and multidisciplinary rehabilitation—have been evaluated in the USA, Canada, and Australia. Of children treated in such programs, 63 − 95% showed full resolution of FND symptoms. The common thread across the programs is their biopsychosocial approach—consideration of biological, psychological, relational, and school-related factors that contribute to the child’s clinical presentation.
Summary
Current research strongly supports a biopsychosocial approach to pediatric FND and provides a foundation for a stepped approach to treatment. Stepped care is initially tailored to the needs of the individual child (and family) based on the pattern and severity of FND presentation. The level of care and type of intervention may then be adjusted to consider the child’s response, over time, to treatment or treatment combinations. Future research is needed to confirm effective treatment targets, to inform the development of stepped care, and to improve methodologies that can assess the efficacy of stepped-care interventions.
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17
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Wiggins A, Raniti M, Gaafar D, Court A, Sawyer SM. Pediatric Somatic Symptom and Related Disorders: Parent Acceptance Influences Recovery. J Pediatr 2022; 241:109-114. [PMID: 34624318 DOI: 10.1016/j.jpeds.2021.09.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Revised: 08/30/2021] [Accepted: 09/29/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVES To assess how clinicians discuss the diagnosis of somatic symptom and related disorders (SSRDs) in patients admitted to a children's hospital and explore the effect of parent and patient acceptance of the diagnosis on recovery. STUDY DESIGN In this cross-sectional study, we reviewed the electronic medical records of pediatric admissions diagnosed with SSRD over 18 months. All diagnostic discussions with patients and families were analysed to identify concepts used by clinicians within these discussions and the extent of parent and patient acceptance of the diagnosis. Recovery status up to 12 months after diagnosis was also identified. Acceptance and recovery were categorized as "full," "partial," or "none." RESULTS Ninety-five of 123 (77.2%) patients (median age 14.3 years, range 7.3-18.3) had at least 1 diagnostic discussion recorded. Clinical explanations within the diagnostic discussion spanned a variety of concepts, with the most common being a description of somatization (62%). Full parent acceptance of the diagnosis of SSRD was more likely when discussions involved two parents (P = .002). Full acceptance of the diagnosis by at least 1 parent was associated with complete functional recovery in their children (OR 8.94, 95% CI 2.24, 35.9, P = .002). In contrast, there was no significant association between full acceptance by patients and their recovery. CONCLUSION The influence of parent acceptance of the diagnosis of SSRD reinforces the importance of therapeutic engagement with families, as well as with children and adolescents.
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Affiliation(s)
- Aaron Wiggins
- Department of Mental Health, Royal Children's Hospital, Victoria, Australia.
| | - Monika Raniti
- Murdoch Children's Research Institute, Victoria, Australia; Department of Pediatrics, The University of Melbourne, Victoria, Australia; Center for Adolescent Health, Royal Children's Hospital, Victoria, Australia
| | - Duaa Gaafar
- Department of Mental Health, Royal Children's Hospital, Victoria, Australia; Center for Adolescent Health, Royal Children's Hospital, Victoria, Australia
| | - Andrew Court
- Department of Mental Health, Royal Children's Hospital, Victoria, Australia
| | - Susan M Sawyer
- Murdoch Children's Research Institute, Victoria, Australia; Department of Pediatrics, The University of Melbourne, Victoria, Australia; Center for Adolescent Health, Royal Children's Hospital, Victoria, Australia; Department of Adolescent Medicine, Royal Children's Hospital, Victoria, Australia
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18
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Barak S, Silberg T, Gerner M, Eisenstein E, Bardach CA, Yissar T, Landa J. Functional neurological symptom disorder: Preliminary findings of factors associated with walking ability post integrative pediatric rehabilitation. J Pediatr Rehabil Med 2022; 15:433-446. [PMID: 36031917 DOI: 10.3233/prm-210107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
PURPOSE The current study's aims were to (1) examine long-distance walking ability (6-minute walking test [6MWT]) and walking hemodynamic responses (i.e., heart rate) among youth with functional neurological symptom disorder (FNSD) before and after an integrative pediatric rehabilitation (IPR) program; and (2) explore factors predicting improvement in walking ability. METHODS Thirty-one youth with FNSD participating in an IPR program were recruited. The IPR program was activated biweekly in an ambulatory format. Study measures included the 6MWT, hemodynamic characteristics, rate of perceived exertion (RPE), pain-intensity perception, and Child's Somatization Inventory-24 (CSI-24). All measures were conducted upon admission to the IPR and discharge. RESULTS Findings indicated a significant increase in 6MWT distance, as well as decreases in heart rate, RPE, and pain-intensity perception from admission to discharge. At admission, CSI-24 and pain intensity predicted 6MWT distance (adjusted R2 = 0.68). Pain intensity predicted discharge 6MWT distance (adjusted R2 = 0.18). Initial 6MWT predicted changes in 6MWT distance from admission to discharge (adjusted R2 = 0.33). CONCLUSION Using an integrative rehabilitation approach increases walking distance and decreases pain-related symptoms in youth with FNSD, emphasizing the need for collaboration between physical therapists and pediatric psychologists. Moreover, changes in walking ability may increase participation and thus should be the focus of IPR.
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Affiliation(s)
- Sharon Barak
- Department of Nursing, College of Health Sciences, Ariel University, Ariel, Israel.,Pediatric Rehabilitation, The Edmond and Lily Safra Children's Hospital, The Chaim Sheba Medical Center, Ramat-Gan, Israel
| | - Tamar Silberg
- Pediatric Rehabilitation, The Edmond and Lily Safra Children's Hospital, The Chaim Sheba Medical Center, Ramat-Gan, Israel.,Department of Psychology, Bar-Ilan University, Ramat-Gan, Israel
| | - Maya Gerner
- Pediatric Rehabilitation, The Edmond and Lily Safra Children's Hospital, The Chaim Sheba Medical Center, Ramat-Gan, Israel
| | - Etzyona Eisenstein
- Pediatric Rehabilitation, The Edmond and Lily Safra Children's Hospital, The Chaim Sheba Medical Center, Ramat-Gan, Israel
| | - Chen Arzoni Bardach
- Pediatric Rehabilitation, The Edmond and Lily Safra Children's Hospital, The Chaim Sheba Medical Center, Ramat-Gan, Israel
| | - Tamar Yissar
- Pediatric Rehabilitation, The Edmond and Lily Safra Children's Hospital, The Chaim Sheba Medical Center, Ramat-Gan, Israel
| | - Jana Landa
- Pediatric Rehabilitation, The Edmond and Lily Safra Children's Hospital, The Chaim Sheba Medical Center, Ramat-Gan, Israel.,The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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Demirci OO, Sagaltici E. Eye movement desensitization and reprocessing treatment in functional neurological symptom disorder with psychogenic nonepileptic seizures: A study of two cases. Clin Child Psychol Psychiatry 2021; 26:1196-1207. [PMID: 34353136 DOI: 10.1177/13591045211037276] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Patients with functional neurological symptom disorder (FND) have many diverse symptoms including psychogenic nonepileptic seizures (PNES), positive movements such as tremor, dystonia, or gait abnormalities, loss of motor function such as leg or arm paresis, and loss of sensory functions, such as blindness, deafness, or loss of feeling in the limbs. Eye movement desensitization and reprocessing (EMDR) is a therapy method that includes some techniques arising from psychodynamic, cognitive, and behavioral approaches. EMDR is known as a proven psychotherapeutic approach in post-traumatic stress disorder, but there are also numerous studies reporting its efficacy in other psychiatric disorders and trauma-associated symptoms, in patients with comorbid psychiatric disorders. This article presents the outcome of EMDR treatment of two patients' cases, a 13-year-old female and a 16-year-old male, who were diagnosed as FND with PNES, according to the DSM-5 diagnostic criteria. In both cases, there was a significant decrease in Adolescent Dissociative Experiences Scale scores and no pseudo seizures were found, even at the sixth-month follow-up visits. These case studies suggest that EMDR can be an effective method in the long-term treatment of FND with PNES and a useful alternative to other treatment methods.
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Affiliation(s)
- Onur O Demirci
- Department of Psychology, 270726Istanbul Gelisim University, Istanbul, Turkey
| | - Eser Sagaltici
- Department of Psychiatry, 162307Bagcilar Training and Research Hospital, Istanbul, Turkey
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20
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Interdisciplinarity and Integration: An Introduction to the Special Issue on Psychopathology in Medical Settings. J Clin Psychol Med Settings 2020; 28:1-5. [PMID: 33219478 PMCID: PMC7678582 DOI: 10.1007/s10880-020-09752-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/07/2020] [Indexed: 10/28/2022]
Abstract
As the world views, incredulously, the calamitous consequences of the COVID-19 pandemic, the inseparable connections between body and mind become more and more apparent, even for the heretics (i.e., biological determinists). Such realizations also bolster the understanding of the close link between medical conditions and psychopathology. Launched prior to the COVID-19 epidemic, this special issue sets out to illuminate the prevalence, course, etiology, and responses to a myriad of psychopathological conditions in medical conditions. The 13 articles in this special issue address a variety of medical conditions (chronic illness and chronic pain, Pica, cancer, acute delirium, factitious disorders, functional neurological symptoms, sleep disorders, fetal conditions), mental disorders (depression, anxiety, suicidality, eating disorders, personality disorders, PTSD), medical settings (primary care vs. specialty clinics), and developmental levels (children, adolescents, and adults). The overarching theme emanating from reading these articles is that clinical-health psychology, or clinical psychology in medical settings, is an ever-needed field of inquiry, epitomizing interdisciplinarity and science/practice integration.
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