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Introduction

Treating children and adolescents with FND

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Basic psychological guidelines

Integrated assessment

A comprehensive assessment of the child's psychological functioning is important, including:

  • Assessment of current psychological state (triggers and maintaining factors FND)

  • Assessing associated psychological symptoms and/or psychological disorders and planning appropriate treatment for them

  • Medical history

  • A broader assessment of risk factors, which, in addition to the risk of self-harm and suicide, also includes risk factors relating to physical disability and school absenteeism

  • Child psychological development

  • The immediate, short and long-term emotional, behavioural and social consequences of FND

Use of appropriate language

It is important to take into account the child's developmental stage and the ability to gain insight into their own mental processes. It is precisely because of certain age limits that the use of language based on the mind-body connection is recommended and the use of language that refers only to psychological constructs is discouraged. The use of simple visual tools that the child understands and that well represent his or her subjective psychological experience is recommended.  

Understanding FND in the context of the biopsychosocial model

It is crucial to explore and take into account the wider range of social factors that influence and amplify psychological and neurobiological factors. Social factors relate mainly to the school and family context. 

Some factors to explore:

  • School absenteeism

  • Cognitive problems

  • Learning difficulties

  • Peer pressure and bullying

  • Ineffective coping strategies

  • The pressure of high expectations

  • Family functioning in general

  • Family problems

  • Parental reactions to the child's condition

  • Wider social functioning

    Basic treatment procedure

    1. Making a positive diagnosis FND

    2. Biopsychosocial formulation and referral to specific specialists

    3. Family involvement (joint search for factors contributing to the maintenance of the disorder)

    4. Multidisciplinary treatment plan

    5. Planning to cope with relapses and building psychological resilience

Advice before mutidisciplinary treatment

  • All (neurological) examinations were performed and a diagnosis of FND was made.

  • The diagnosis of FND is adequately explained to the child/young person and parents. A general description of the treatment is also provided.

  • Making sure the child/young person and parents understand and accept the diagnosis of FND.

  • If the child/young person and parents do not understand and/or accept the diagnosis of FND, we will arrange another neurological examination and/or potentially refer the patient and family to a clinical psychologist to help with acceptance of the diagnosis.

Common psychological processes encountered in the treatment of children and adolescents with FND and their families

( ©Kasia Kozlowska and Blanche Savage, 2021)

    • Excessive attention to symptoms, increasing their severity and intensity, and subjective pain

    • Catastrophic interpretation of symptoms leading to worsening symptoms

    • Catastrophic self-related thoughts 

    • Catastrophic thoughts about external events (e.g. climate crisis)

    • Low internal locus of control over symptoms

    • Low locus of control over events or expectations relating to school and family situation

    • Negative expectations about treatment, amplified by catastrophic symptom interpretation and low locus of perceived internal control (nocebo effect)

    • Self-critical rumination (e.g. the child blames himself for not trying hard enough in therapies, so the symptoms got worse)

    • Perfectionism, associated with feelings of sadness and disappointment

    • Obsessive thinking that may relate to FND symptoms

    • Negative focus on the future and difficulty keeping attention on the present moment

    • Suppression of negative thoughts (avoidant cognition)

    • Feelings of excessive responsibility, either related to the school environment or to family roles

    • Chronic concerns

    • Feelings of sadness, anger, guilt and hopelessness about the state of your health

    • Suppression of emotions (dissociation)

    • Inability to recognise and monitor physical states (e.g. arousal levels)

    • Inability to ask for help

    • Fear and avoidance of certain activities

    • Inability to communicate openly with parents about distress and concerns

    • Unresolved grief, trauma or difficult experience

    • Increased feelings of stress due to inadequate parental support

    • Intrusive thoughts/feelings about an unpleasant event

Psychological assessment

  • A family genogram, which helps to create a gestalt view of family patterns and relationships (along with a medical history).

  • The child's developmental history (from conception to the present), as it helps to understand the sequence of key life events (positive/negative) and the context within which FND symptoms developed.

  • The child's response to key life events.

    • How did the child physically react to them? (Changes in sleep, appetite, onset of certain symptoms, stress)

    • Has the child shown behavioural responses to stress (e.g. school absenteeism, social isolation, etc.)?

  • How do stress levels, anxiety and changes in well-being change over time?

    Tracking the development of functional symptoms over time and their association with key life events.

Some general interventions

( Kozlowska et al., 2023)

    • Interventions related to sleep problems

    • Teaching children/adolescents to recognise states in the body (mindfulness techniques, drawing the feelings they experienced during a stressful experience)

    • Learning strategies to calm the central nervous system (breathing, mindfulness techniques, etc.) Developing the ability to distinguish between high and low levels of arousal

    • Bottom-up mindfulness, somatic or biofeedback interventions

    • 'Top-down' cognitive interventions (only when a lower level of arousal is present)

    • Learning to identify stressors

    • Use of medication if the child's arousal level is too high and cannot otherwise be reduced

    • Kozlowska, K., Chudleigh, C., Savage, B., Hawkes, C., Scher, S., and Nunn, K. P. (2023). Evidence-based mind-body interventions for children and adolescents with functional neurological disorder. Harvard Review of Psychiatry, 31(2), 60-82.

    • Kozlowska, K., Sawchuk, T., Waugh, J. L., Helgeland, H., Baker, J., Scher, S., and Fobian, A. D. (2021). Changing the culture of care for children and adolescents with functional neurological disorder. Epilepsy & behavior reports, 16, 100486.

    • Kozlowska, K., and Mohammad, S. (2023). Functional Neurological Disorder in Children and Adolescents. In Symptom-Based Approach to Pediatric Neurology (pp. 699-724). Cham: Springer International Publishing.

    • Vassilopoulos, A., Mohammad, S., Dure, L., Kozlowska, K., and Fobian, A. D. (2022). Treatment approaches for functional neurological disorders in children. Current Treatment Options in Neurology, 24(2), 77-97.

    • Savage, B., Chudleigh, C., Hawkes, C., Scher, S., and Kozlowska, K. (2022). Treatment of functional seizures in children and adolescents: a mind-body manual for health professionals. Australian Academic Press.