CLINICAL PRESENTATION

Children may present to their pediatrician or the hospital with symptoms such as weakness, difficulty walking, pseudoseizures, sensory abnormalities or pain. The presentation may have a cultural basis. For example, individuals in Pakistan often presented with "unresponsiveness," while those in Southern Africa demonstrated an agitated dementia (13). Table 20B.1 lists the more common symptoms.

In most cases, the symptoms are of acute onset and appear overnight. In younger children, this is often preceded by a seemingly minor injury or illness. Children who may not demonstrate concern for their impairment are called "la belle indifference." However, this is not specific for the diagnosis of conversion disorder. "La belle indifference," which is often reported in the adult population, is not as prevalent in the pediatric population and children are often very concerned about their symptoms. There are also a significant number of children who have associated symptoms of an anxiety disorder or major depression.

Risk factors for conversion disorder have been well reported in the literature and include a rigid obsessional personality trait (14), anxiety state or depression (15), and previous sexual abuse (16). Environmental risk factors include domestic stress, perceived parental rejection, poor communication within the family, unresolved grief (17), difficulty with peer relations and unhappiness at

TABLE 20B.1 COMMON PRESENTING SYMPTOMS OF CONVERSION DISORDER

school and/or academic failure (18). These children are often very intelligent, high achievers, and set very high personal expectations.

The diagnosis should be made after a detailed history and physical examination with appropriate testing as needed. Exam findings which are incongruous with neuroanatomic function support the diagnosis of conversion disorder. On physical examination, for example, normal reflexes may be noted in a flaccid limb. The gait disturbances do not correlate with a known organic disorder. Despite symptoms of balance impairments, weakness, or blindness, the individual does not collide with objects or sustain an injury. The sensory loss is not in a dermatomal or stocking-glove pattern. Diplopia does not resolve with covering one eye or is present in all directions. There may be periods of normal function or inconsistencies in function. It should also be remembered that a conversion disorder can be present with a confirmed neurologic condition; they are not mutually exclusive. Practitioners should try to avoid an extensive medical workup. However, Moene et al. noted that 11% of adult patients were later diagnosed with an organic disorder and the incidence of an incorrect diagnosis of conversion disorder has been reported in 4% to 6% of patients (19).

TREATMENT

In many cases, the physician may be able to simply give reassurance that the symptoms will resolve quickly and parents should downplay or ignore the symptoms. It is very beneficial to explain the diagnosis to parents so that they do not inadvertently reinforce the symptoms. However, giving the diagnosis to the child is often counterproductive as children feel that others think they are making up the symptoms or crazy. Instead, it is helpful to tell the child that testing reveals that the nerves and muscles are normal, but the communication to and from the brain is not working well; mind-body concept. This communication can be restored and symptoms can resolve. A referral for counseling is helpful in teaching children coping techniques for stress and if there are associated symptoms of anxiety or depression, a referral to psychiatry for further treatment is indicated (20).

When reassurance and education are not enough, there are two different treatment approaches; psychiatric intervention and physical rehabilitation. Symptoms such as pseudoseizures, syncope, and blindness, for example, are difficult to treat with physical rehabilitation and a psychiatric program is preferred. Psychiatric programs typically involve psychotherapy, hypnosis, counseling, and medication. The length of treatment is significantly longer than the physical rehabilitation approach and it may take years before symptoms improve and/or resolve. A more in-depth discussion of the psychiatric approach to treating conversion disorder is beyond the scope of this chapter and the reader is referred to the psychiatric literature.

If the conversion disorder has a physical manifestation such as a gait abnormality, for example, a structured rehabilitation program may be beneficial. However, parents must accept the diagnosis and agree to the program prior to initiation for the best results. The treatment team may include PT, occupational therapy, recreational therapy, school, psychology, psychiatry, and physiatry. Treatment is aimed at a systematic reacquisition of skills to meet the expected functional outcome; walking normally, for example. Speed demonstrated the effectiveness of a behavioral management approach (21) in a comprehensive program when used in conjunction with PT in the adult population (22). The behavioral approach uses positive reinforcement of healthy behaviors or functions and ignores those behaviors which are maladaptive. When the individual is not in therapy, he or she is instructed to rest so that the symptoms (eg, abnormal gait pattern) are not reinforced. In children, the program is kept very structured and children receive positive reinforcement only when they have achieved the individual goals set for them on their goal mountain (Figure 20B.1). Every goal mountain is individualized to sets steps to correct the physical abnormality, reinforce the mind-body concept of control, and reflect something of interest to the child.

Symptoms are largely ignored and children may not progress up the goal mountain until the goal is performed correctly on a set number of consecutive therapies. The goals should be achieved in the specified sequential order so that increased individual independence is achieved as skills are attained. Children are referred back to their goal mountain daily with praise for each achievement. The use of physical modalities such as biofeedback may be helpful in establishing the mind-body connection. In addition to PT and occupational therapy, children receive daily counseling with a psychologist to evaluate stressors and learn coping techniques. When children are not in therapy, they

FIGURE 20B.1 This goal mountain outlines the expected functional progress and steps to attaining functional independence for a boy with interests in baseball and swimming.

are instructed to rest or complete schoolwork. Parents also participate in counseling for education regarding the disorder and how to address any regression once children return home. Oftentimes, children require ongoing counseling after discharge from the rehabilitation program.

Potential reinforcers of the sick role must also be carefully evaluated and removed at the beginning of the program. For example, gifts for being in the hospital or increased visits from friends and family are discouraged. If gifts are brought in, they should be associated with the achievement of specific goals. Cell phone privileges and access to the Internet should be curtailed as these communications may either positively reinforce the sick role or may be a stressor. Families may also be a source of stress and limitation of visitation initially may be helpful with eventual reintegration as the child progresses and learns better coping strategies.

If the child is not progressing with the behavioral approach, a double bind should be considered. Teasell and Shapiro describe this as a strategic behavioral intervention in which the child is told that lack of progress "proves" a psychological cause for their symptoms. They reported improvements in several patients with long-standing symptoms using this approach (23).

In a review of the literature, Fitzgerald et al. found limited and poor quality evidence to establish efficacy for PT in the treatment of conversion disorder in children because most studies were observational, included PT as a component of a larger treatment regimen, and did not have control groups or well-defined outcome measures (24). The commonly used modalities in these studies included contracture management, electrotherapy, biofeedback, hydrotherapy, strength training, and behavioral programs. The study indicated the need for further research to provide an evidence base for treatment, but did not demonstrate that PT was ineffective or inappropriate for the treatment of this disorder.

With early recognition, recovery is usually within a few days or weeks and 85% to 97% of children will have a full recovery (13). Table 20B.2 lists the positive and negative prognostic factors for children with conversion disorder.

TABLE 20B.2 PROGNOSTIC FACTORS FOR CHILDREN WITH CONVERSION DISORDER