The Functional Neurologic Disorder (FND) in Children
That Has Been on the Rise Since October 7
Dr. Emmanuel Kornitzer

Translated from https://healthy.walla.co.il/item/3662054

May 5, 2024

The child complains of pain and weakness, but the tests show no disease? They may have Functional Neurologic Disorder (FND), a syndrome in which physical problems occur following a mental health event. Against the background of the tense situation [in Israel], there has recently been an increase in diagnoses of this type.

FND is a well-known phenomenon among adults and youngsters, some of whom come to us for treatment at The ALYN Pediatric and Adolescent Rehabilitation Hospital.

Functional Neurologic Disorder is a condition that mimics a neurological disease but without any injury to the brain, spinal cord, or nerves. Instead, it is a state of emotional or mental stress that causes symptoms resembling a neurological disorder. Various symptoms may appear, such as weakness, paralysis of limb(s), sensory disturbances, sudden blindness, tremors, seizures, and more. As a result, there is severe impairment of daily functioning, such as an inability to walk and perform basic functions like dressing, bathing, and eating independently. The phenomenon occurs in pre-adolescent children (8-10), with a higher prevalence in adolescence, and the degree of severity of functional decline varies from child to child.

The cause of this phenomenon, as mentioned, is a state of emotional or mental stress that manifests through physical symptoms. During the COVID-19 restrictions, many people were in a state of stress, and in Israel, as in the rest of the world, there was an increase in mental health issues and referrals to mental health systems, according to reports by the Ministry of Health. Similarly, an increase has been observed in FND cases since October 7.

To diagnose this phenomenon, it is first necessary to rule out neurological or other organic diseases that can cause these symptoms. It is important to see a doctor and undergo tests, including blood tests and occasionally imaging (CT or MRI). Often, after the tests come back normal and the doctor diagnoses FND, it is still difficult for the family to accept that there is no organic (physical) disease despite the neurological symptoms. Families move from one hospital to another and from doctor to doctor to continue searching for an organic diagnosis. The problem is that as time passes, the symptoms become more fixed. Additionally, the medical system and the patient's environment may sometimes convey disbelief or even accusations of pretense to the teenager. This, of course, is not the case: these children do not pretend or lie—physically, they really feel paralyzed or have a movement disorder.

Since the events of October 7, there has been a further increase in the number of people dealing with FND. Recently, a child was hospitalized with us who experienced a stressful encounter (firsthand) with a courier who came to his home. His parents asked him not to open the door, but the messenger insisted. The boy opened the door, holding a knife behind his back. That stressful experience, against the background of the security situation in Israel, deeply affected him. Within a day of the incident, the boy felt weakness in his legs and developed an inability to bear weight on them, and since then he has not been able to walk without support.

Stressful situations that cause FND can also happen due to experiences such as a difficult parental divorce or a serious illness of a close family member. Such stressful situations also occur at school. An example of this is a boy with complete paralysis of the lower extremities who was referred to us after undergoing a comprehensive initial examination in a hospital and ruling out neurological disease. During psychological treatment that the boy received with us, it was found that he had been bullied at school.

Another condition that can cause FND is one-time or ongoing sexual abuse. Unfortunately, these cases are not uncommon among children and adolescents.

However, it is important to note that this usually does not happen because of a single, sudden event, but rather different and ongoing stressors of varying intensities that cause the child to develop FND.

To this day, we do not fully understand why the phenomenon occurs in one teenager and not in another, given the same significant stress. It may be related to personality structure, background anxiety, and even characteristics of physical sensitivity.

Above all, it is important to understand that there are successful treatments for this phenomenon. Sometimes emotional therapy (e.g., cognitive behavioral therapy) or psychiatric therapy (e.g., when accompanied by significant anxiety or depression) is sufficient. Usually, and especially when the functional impairment is significant, there is a great advantage in being treated by a professional team who take care of both body and mind. At ALYN, we have been treating these cases for years through multi-disciplinary teamwork that includes physiotherapists, occupational therapists, psychologists, doctors, and, if necessary, psychiatrists.

In conclusion, the current situation in Israel is causing an increase in cases of FND. It is important to understand that functional neurological disorders are real conditions and are not "imaginary." Youngsters suffering from FND often undergo lengthy and unnecessary medical diagnostic evaluations, or alternatively, many times the child is not believed and even suspected of "pretending" or "making it up" (especially if the symptoms are inconsistent or changing)—which exacerbates the phenomenon due to lack of treatment, as well as causing additional significant emotional damage to the child. These disorders result in prolonged absences from school and often social distancing. The goal of the treatment is to return the child to full and normal functioning within their family, school, and activities as soon as possible.

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The author is the Director of the Pediatric Rehabilitation and Day Hospitalization Departments at ALYN Hospital and part of the Clinic for CRPS and Functional Somatic Disorders