Cognitive-behavioural treatment of functional neurological symptoms (conversion disorder) in children and adolescents: A case series

Evaluation of a psychoeducation group for children presenting with functional tic-like behaviours

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.

Applying an Established Exposure Response Prevention Protocol for Young People With Tourette Syndrome in an Intensive, Group Format: A Feasibility Study

BACKGROUND

The motor and vocal tics that characterise Tourette syndrome are stigmatizing and impact on quality of life. Behavioural interventions such as Exposure Response Prevention or Comprehensive Behavioural Interventions for Tics are first line treatment for Tourette syndrome, but availability is limited. This study is the first to explore the impact of an established manualised Exposure Response Prevention treatment protocol, developed for individual therapy, but here uniquely delivered intensively, to a group.

METHODS

A naturalistic study comprised of a consecutive series of children (N = 20), aged 8-16 years (M = 12, SD = 2.17) were offered Exposure Response Prevention in one of two groups, delivered in series within a specialist clinic. Young people received the equivalent of 12 sessions (matching the manualised individual protocol).

RESULTS

The YGTSS and Giles de la Tourette Syndrome Quality of Life Scale for Children and Adolescents (Satisfaction Scale) showed significant improvement following treatment with moderate to large effect sizes. Thirty-five percent of children demonstrated a reliable improvement on the YGTSS Global Tic Severity score.

CONCLUSIONS

These data suggest an established Exposure Response Prevention protocol can be delivered in an intensive, group setting with a positive clinical outcome. Replication in a randomized controlled trial is an important next step.

Scoping review and expert-based consensus recommendations for assessment and management of psychogenic non-epileptic (functional) seizures (PNES) in children: A report from the Pediatric Psychiatric Issues Task Force of the International League Against Epilepsy

Limited guidance exists regarding the assessment and management of psychogenic non-epileptic seizures (PNES) in children. Our aim was to develop consensus-based recommendations to fill this gap. The members of the International League Against Epilepsy (ILAE) Task Force on Pediatric Psychiatric Issues conducted a scoping review adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-SR) standards. This was supplemented with a Delphi process sent to pediatric PNES experts. Consensus was defined as ≥80% agreement. The systematic search identified 77 studies, the majority (55%) of which were retrospective (only one randomized clinical trial). The primary means of PNES identification was video electroencephalography (vEEG) in 84% of studies. Better outcome was associated with access to counseling/psychological intervention. Children with PNES have more frequent psychiatric disorders than controls. The Delphi resulted in 22 recommendations: Assessment-There was consensus on the importance of (1) taking a comprehensive developmental history; (2) obtaining a description of the events; (3) asking about potential stressors; (4) the need to use vEEG if available parent, self, and school reports and video recordings can contribute to a "probable" diagnosis; and (5) that invasive provocation techniques or deceit should not be employed. Management-There was consensus about the (1) need for a professional with expertise in epilepsy to remain involved for a period after PNES diagnosis; (2) provision of appropriate educational materials to the child and caregivers; and (3) that the decision on treatment modality for PNES in children should consider the child's age, cognitive ability, and family factors. Comorbidities-There was consensus that all children with PNES should be screened for mental health and neurodevelopmental difficulties. Recommendations to facilitate the assessment and management of PNES in children were developed. Future directions to fill knowledge gaps were proposed.

[Conversion disorder, caring for body, mind]

Conversion disorder is a psychiatric disorder whose clinic and management lie at the crossroads between body and mind. It challenges healthcare professionals in terms of diagnosis, further investigation, referral and care. A number of questions arise, such as how caregivers perceive the relationship between body and mind, the place of the psychiatric hypothesis among the initial diagnostic hypotheses, and the temporality of care.

Asserting a Functional Neurological Symptom Disorder with a Complementary Diagnostic Approach: A Brief Report

INTRODUCTION

Functional neurological symptom disorder (FNSD) is a common diagnosis among adolescents. However, we feel it is a difficult diagnosis to assess because of the diversity of its clinical manifestations, the rapid changes in its nosography over the years, and its common imbrication with established somatic diagnoses. We would like to illustrate this hypothesis through a case presentation and the original diagnostic process that emerged from it.

METHODS

We chose to present our diagnosis approach through the case of an 11-year-old boy who showed a progressive loss of motor and sensory function to the point of total dependency, and then suddenly switched between this state and a "normal" physical presentation, while deliriously claiming to be an angel.

RESULTS

All possible infectious, autoimmune, metabolic, and toxic disorders were ruled out. After the successive therapeutic failures of antidepressants and neuroleptics, FNSD was diagnosed.

CONCLUSION

The DSM-5-TR classification was insufficient to explain the full clinical picture and a complementary approach (biblical, psychoanalytical, and historical) was used to analyze the cause of this atypical presentation.

Treatment Provided in Children and Adolescents with Functional Seizures-A Danish Nationwide Cohort

BACKGROUND

Functional seizures (FS) are episodes of paroxysmal involuntary movements and altered consciousness without the typical changes in the electroencephalography as with epilepsy. A multidisciplinary approach is the golden standard in the treatment of FS. This study examined the cross-sectoral collaboration and treatment modalities provided to children and adolescents after a diagnosis of FS.

METHOD

A Danish nationwide cohort, consisting of 334 children and adolescents, aged 5-17 years, with a validated diagnosis of FS during the period 2004-2014 was studied. Medical record data were collected from diagnosing hospital departments. Management and treatment modalities from the time of diagnosis up to three months after diagnosis were explored.

RESULTS

The most used treatment modalities were psychoeducation (n = 289, 86.5%) and follow-up in outpatient care (n = 192, 70.6%). A cross-sectoral collaboration was initiated for a third of cases (n = 98, 29.3%). The most commonly provided treatment combination consisted of psychoeducation, follow-up in outpatient care and psychotherapy; however, only a few patients received this specific combination (n = 14, 4.2%).

CONCLUSIONS

The treatment applied was individualized and consisted of varying use of treatment modalities. Initiatives to curate clinical guidelines and implement a multidisciplinary treatment approach should be further explored to improve treatment for this young group of patients.

Functional Neurological Disorder-Old Problem New Perspective

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.

Treatment of Pediatric Functional Neurological Symptom Disorder: A Review of the State of the Literature

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.

Psychiatric and personality factors in pediatric functional seizures: A prospective case-control study

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: Mean_age=15.4, Interquartile Range_age=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.

Diagnosis and Initial Treatment of Functional Movement Disorders in Children

Functional movement disorders (FMD) are complex neurobehavioral disorders that can be a significant source of disability for both children and their caregivers. While FMD in the adult population is better characterized, the aim of this paper is to review the pertinent clinical and historical features, diagnostic criteria, and multi-disciplinary management of FMD in the pediatric population. We highlight recent trends in pediatric FMD, including the increase in functional tic-like behaviors that has been observed during the COVID-19 pandemic.

Case report: Advice for schools on managing functional tic-like behaviours

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.

[Multidisciplinary care of an adolescent with somatic disorders]

Theo's clinical observation illustrates the management of a 14-year-old adolescent with unexplained somatic symptoms. His symptoms can be integrated into what the classification of mental illnesses calls a somatic symptom disorder, with a depressive comorbidity. The description of the care pathway shows the gradual acceptance of psychological suffering by the adolescent and his parents in a service where different professionals are involved, with sufficient time for a good therapeutic alliance to be built.

The effectiveness of psychological interventions for children and adolescents with non-epileptic seizures

BACKGROUND

This article systematically reviews the literature on the effectiveness of psychological interventions for non-epileptic seizures (NES) in children and adolescents.

METHODS

Embase, Medline and PsycINFO were searched to December 2020, for articles published in English, which used an objective measure to evaluate the outcome of a psychological intervention for NES. Further studies were identified from reference lists and experts in the field were contacted for unpublished studies.

RESULTS

Twelve studies met inclusion criteria. Of these, four were set up with the primary aim of evaluating an intervention of which two used a control group, two were prospective outcome studies and eight looked at retrospective clinical data. Two studies evaluated a single treatment modality, the others multiple treatment components. Overall, psychoeducation, and top-down psychotherapy, such as cognitive therapies, were the most frequent interventions, with recent studies describing body-oriented (bottom-up) approaches. Analysis across all studies identified a range of additional intervention components which included assessment and/or treatment for co-morbidities, liaison with school and support for parents, highlighting the importance of individualised treatment packages.

CONCLUSIONS

There is a paucity of studies specifically evaluating interventions for NES. Though a range of approaches have been described in managing this patient group, with generally positive outcomes, it is not possible to conclude from the available literature that one treatment approach is superior to another, though the information may be helpful in developing management guidelines.

["Somatic symptom disorders" in adolescence. A systematic review of the recent literature]

OBJECTIVES

Body expression of mental disorders is common in adolescence. Only two literature reviews over the last five years have been identified about somatoform disorders in children., The present article provides a systematic review of articles in English, which concern "Somatic Symptom and Related Disorders" according to the DSM-5 (Diagnostic and Statistical Manual - 5th Edition) among adolescents.

METHODS

The article search was made on Medline, Psychinfo, Google Scholar, BiomedCentral, Central and tripdatabase (for grey literature) according to PRISMA criteria and with the items "somatoform disorders" or "somatic symptom disorders". An age filter was applied for "adolescents", and a selection was done from the last five years. All articles concerning adolescents (often associated with children) were initially included, except for articles concerning eating disorders, dysmorphic disorders or adult population. Comments, editorials, opinion or descriptive articles were also excluded. The authors then carried out an analysis of the main topics, themes and questions covered in the selected publications and presented a descriptive synthesis.

RESULTS

A total of seventy-seven publications were included in the analysis, from three hundred and seventy-two publications. First, the terms used to refer to these "somatic symptom disorders" were varied, such as "somatization", "somatic complaints/symptoms", "functional disorder", "unexplained symptoms" and "somatoform disorders". Then, studies related just to adolescents were limited: most of studies included children and adolescents in their methodologies; and some of them questioned somatic symptoms from a developmental perspective. Case reports were the most represented articles among all medical specialties, with clinical descriptions about "functional neurological symptom disorder", "factitious disorder" and "somatic symptom disorder" with a medical disease, among children and adolescents. We sometimes observed a controversial borderline between psychological and somatic disorders. Various explanatory models appeared, especially the trauma path; familial and social environment was also pointed out, with a possible peer group effect; neurocognitive theories were finally described. The literature highlights the effectiveness of psychosocial therapies (especially the cognitive-behavioral therapy) and the importance of multidisciplinary management. Finally, a few studies with a qualitative methodology are represented.

CONCLUSIONS

Only nine articles included "somatic symptom disorder" in their titles, despite a terminology valued by many authors (compared to "somatoform disorders" from the DSM-IV). The heterogeneity of terminologies, case reports and explanatory models witness a lack of connexions between medical specialties. This could explain in part the wandering of adolescents and their families in the health care system. It could also contribute to the delay before diagnosis, especially when neurological symptoms exist, and a late referral for psychiatric consultation. Further studies are needed to understand difficulties to use a clinical pathway among medical specialties, when the benefit of amultidisciplinary approach seems to be unanimous.

Psychogenic non-epileptic seizures in children

Psychogenic Non-Epileptic Seizures (PNES) are a relatively common condition in children. While their clinical presentation resembles epileptic seizures, the underlying cause for PNES involves a multitude of bio-psychosocial factors. Patients may be misdiagnosed with epilepsy and subjected to unnecessary treatments, often delaying the diagnosis for years. A strong understanding of its symptomatology is essential for diagnosis of PNES. Successful management depends on effective teamwork that involves the neurologist as well as mental health professionals. This paper reviews the various aspects of PNES in children with emphasis on the clinical presentation, diagnosis as well as the underlying psychological basis and treatment.

Characteristics and outcomes of children with dissociative (conversion) disorders in western China: a retrospective study

BACKGROUND

Dissociative (conversion) disorder in children is a complex biopsychosocial disorder with high rates of medical and psychiatric comorbidities. We sought to identify the characteristics and outcomes of children with dissociative (conversion) disorders in western China.

METHODS

We conducted a retrospective cohort study of 66 children admitted with dissociative (conversion) disorders from January 2017 to July 2019, and analyzed their clinical characteristics, socio-cultural environmental variables, and personality and psychiatric/psychological characteristics. Binary logistic regression was used to analyze the variables associated with clinical efficacy.

RESULTS

Of these 66 patients, 38 (57.6%) were male and 28 (42.4%) were female, 46 (69.7%) had an antecedent stressor, 30 (45.5%) were left-behind adolescents, and 16 (24.2%) were from single-parent families. In addition, 30 patients (45.5%) were not close to their parents, 38 patients (59.4%) had an introverted personality, and 34 (53.1%) had unstable emotions. Thirteen families (19.7%) were uncooperative with the treatment. Patients who had cormorbid anxiety or depression exhibited significantly lower cognitive ability (P < 0.01). Logistic regression found that better treatment outcomes were positively associated with having a close relationship with parents, parental cooperation with treatment, and having a father with a lower level of education (i.e., less than junior college or higher).

CONCLUSIONS

The characteristics and outcomes of children with dissociative (conversion) disorders are related to socio-cultural environmental variables and psychiatric/psychological factors. Timely recognition and effective treatment of dissociative (conversion) disorders are important.

Measuring functional recovery in somatic symptom and related disorders: a scoping review

OBJECTIVE

Somatic symptom and related disorders (SSRDs) are prevalent, heterogenous conditions that have the potential to profoundly affect normative function in children and adolescents. Yet there is little understanding of pathways to recovery. This study aimed to systematically scope how functional recovery has been measured in children and adolescents with SSRD .

DESIGN

Scoping review of primary studies.

METHOD

Medline (Ovid) and PsychInfo were systematically searched for publications from January 1998 to April 2019. Primary studies in English that reported functional outcomes of children and adolescents with SSRD were included. Case reports and population studies were excluded. Within the tools and clinician notes, the core domains of functional outcome were identified.

RESULTS

Sixteen studies were identified that used 11 different functional outcome tools. The domains assessed within these functional outcome tools, together with the domains noted by clinicians, included physical and mental health symptoms, as well as school attendance and academic outcomes, recreational participation, impact on family and service utilisation. There was no evidence of a preferred outcome measure as only two of the tools were used in more than one study.

CONCLUSIONS

The variability of tools and domains used to measure functional recovery in children and adolescents with SSRD suggests lack of conceptual agreement about what constitutes functional recovery. Continued focus on symptom measurement or mental health comorbidities risks limiting research to single types of disorder (eg, functional neurological disability) or interventions, which threatens a much needed wider research agenda around appropriate treatment, including of complex and persistent disorders.

Functional neurological movements in children: Management with a psychological approach

AIM

To develop a cognitive behavioural treatment (CBT) approach that included novel attention training components to support symptom management in children with a primary diagnosis of Functional Movement Disorder (FMD).

METHOD

Eighteen children (9 male and 9 female) with a mean age of 13 years (sd = 2.46, range 10-18 years) were assessed and completed CBT with novel attention training components. Treatment outcomes were measured using the Child Global Assessment Scale (CGAS) which was administered at baseline and post-treatment.

RESULTS

Scores on the CGAS improved significantly post-treatment (p < 0.001) with all participants showing significant change in functioning on the basis of the Reliable Change Index (RCI), with clinically significant change across classification boundaries.

INTERPRETATION

This case series provides support for the use of CBT with attention training components for the management of FMD. Larger trials are necessary to identify which individual treatment components are most effective and to better understand and quantify response to treatment. Future clinical treatment studies would benefit from the inclusion of objective measures of interoception and attentional focus.

Epilepsy

Epilepsy is considered a disease characterized by an underlying predisposition to seizures as well as neurobiologic, cognitive, psychologic, and social consequences. It is the most frequent chronic neurologic condition of childhood, affecting 0.5%-1% of children worldwide. It comprises a variety of disorders with many different etiologies, consequently affecting management and outcome. Although the great majority of children have epilepsies that are self-limited and have a good prognosis, it is nevertheless very well recognized that epileptic activity (be it seizures or interictal discharges) can be particularly deleterious to the developing brain acting as a disruptor to normal developmental function. Indeed, epilepsy and neurocognitive and behavioral disorders very frequently coexist, and it can be challenging to understand if there is causality or if they are all the reflection of the underlying brain disorder. Hence, accurate phenotypic and etiologic diagnosis is of utmost importance as it will not only guide decision making with regard to choice of treatment but also enable management of expectations concerning outcome. The current chapter aims to provide a general overview of the fast evolving and vast field of childhood epilepsy from its definition and epidemiology, to its diagnostic challenges, management, and outcome.

Long-term outcomes of functional neurological disorder in children

OBJECTIVES

To establish the incidence and long-term outcomes (up to 21 years) of children presenting to a University hospital paediatric neurology service with symptoms due to functional neurological disorder (FND) with particular reference to occurrence of FND or similar symptoms in adulthood.

METHODS

Retrospective chart review to determine characteristics of the original paediatric FND presentation plus record-linkage with providers of Child and Adolescent Mental Health Services. Chart review of adult medical records for documentation of functional symptoms in adulthood.

RESULTS

124 individuals (56% female) met entry criteria. The most common presentations were seizures (18%), sensory loss (18%) and motor symptoms (16%). Frequency gradually increased with age of onset with an incidence in paediatric neurological services of 6 per 100 000 children under 16. In up to 21 years' follow-up (median 8.3 years), 114/124 attained their 16th birthdays by the study census date and were thus eligible for inclusion in an analysis of symptom persistence/recurrence in adulthood. 26/114 (23%) showed evidence of FND in adulthood of sufficient significance to be recorded in medical records.

CONCLUSION

Paediatric FND is commoner than previous estimates. Even in this selected population of children reaching specialist paediatric neurology services, a high long-term remission rate is observed.