Functional neurological symptom disorders in a pediatric emergency room: diagnostic accuracy, features, and outcome
Claudio M de Gusmão1, Réjean M Guerriero2, Miya Elizabeth Bernson-Leung2
1Department of Neurology, Boston Children's Hospital, Boston, Massachusetts; Department of Neurology, Pediatric Movement Disorders Clinic, Massachusetts General Hospital, Boston Massachusetts.
Insights
Pediatric trainees accurately diagnose functional neurological symptom disorders (FNSD) in emergency settings. While prognosis is good, FNSD causes significant school and work absences, highlighting the need for early recognition.
Area of Science:
- Pediatric Neurology
- Child Psychiatry
- Emergency Medicine
Background:
- Functional neurological symptom disorders (FNSD) are common in pediatric emergency care.
- Limited data exists on pediatric FNSD epidemiology and outcomes.
Purpose of the Study:
- Assess diagnostic accuracy of trainee first impressions for FNSD in pediatric ER.
- Describe presentation, demographics, socioeconomic impact, and outcomes of pediatric FNSD.
- Evaluate parental satisfaction with care.
Main Methods:
- Retrospective review of psychiatry consultations for pediatric FNSD.
- Prospective collection of children presenting with suspected FNSD over 3 months.
- Structured telephone interviews 3-6 months post-discharge to assess outcomes.
Main Results:
- Trainees demonstrated high diagnostic accuracy (93-94%).
- Mixed sensory-motor symptoms were most common; stressors were typically not severe.
- Significant impact on school days (22.4) and parental workdays (8.3) reported.
- 78% of children were symptom-free at follow-up.
Conclusions:
- Trainee clinical impression is reliable for diagnosing pediatric FNSD.
- Favorable prognosis exists, but substantial socioeconomic burden is noted.
- Improved recognition and communication can reduce disability and healthcare costs.
Background:
In children, functional neurological symptom disorders are frequently the basis for presentation for emergency care. Pediatric epidemiological and outcome data remain scarce.
Objective:
Assess diagnostic accuracy of trainee's first impression in our pediatric emergency room; describe manner of presentation, demographic data, socioeconomic impact, and clinical outcomes, including parental satisfaction.
Methods:
(1) More than 1 year, psychiatry consultations for neurology patients with a functional neurological symptom disorder were retrospectively reviewed. (2) For 3 months, all children whose emergency room presentation suggested the diagnosis were prospectively collected. (3) Three to six months after prospective collection, families completed a structured telephone interview on outcome measures.
Results:
Twenty-seven patients were retrospectively assessed; 31 patients were prospectively collected. Trainees' accurately predicted the diagnosis in 93% (retrospective) and 94% (prospective) cohorts. Mixed presentations were most common (usually sensory-motor changes, e.g. weakness and/or paresthesias). Associated stressors were mundane and ubiquitous, rarely severe. Families were substantially affected, reporting mean symptom duration 7.4 (standard error of the mean ± 1.33) weeks, missing 22.4 (standard error of the mean ± 5.47) days of school, and 8.3 (standard error of the mean ± 2.88) of parental workdays (prospective cohort). At follow-up, 78% were symptom free. Parental dissatisfaction was rare, attributed to poor rapport and/or insufficient information conveyed.
Conclusions:
Trainees' clinical impression was accurate in predicting a later diagnosis of functional neurological symptom disorder. Extraordinary life stressors are not required to trigger the disorder in children. Although prognosis is favorable, families incur substantial economic burden and negative educational impact. Improving recognition and appropriately communicating the diagnosis may speed access to treatment and potentially reduce the disability and cost of this disorder.
