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Amongst the most important conditions in the differential diagnosis of epilepsy is the one that manifests as paroxysms of altered behaviour, awareness, sensation or sense of bodily control in ways that often resemble epileptic seizures, but without the abnormal excessive or synchronous electrical activity in the brain that defines these. Despite this importance, there remains little agreement – and frequent debate – on what to call this condition, known inter alia as psychogenic non-epileptic seizures (PNES), dissociative seizures (DS), functional seizures (FS), non-epileptic attack disorder (NEAD), pseudoseizures, conversion disorder with seizures, and by many other labels besides. This choice of terminology is not merely academic – it affects patients’ response to and understanding of their diagnosis, and their ability to navigate health care systems.This paper summarises two recent discussions hosted by the American Epilepsy Society and Functional Neurological Disorders Society on the naming of this condition. These discussions are conceptualised as the initial step of an exploration of whether it might be possible to build consensus for a new diagnostic label.

Children with epilepsy experience adjustment and coping issues related to being diagnosed with a chronic illness. They are also at increased risk for comorbid attention problems, anxiety, and depression. Psychogenic non-epileptic seizures (PNES), events that involve symptoms that may appear to be seizures but do not have associated epileptic brain activity, often represent a diagnosis of conversion disorder. PNES are typically very impairing and require psychological treatment. This chapter will provide an overview of the cognitive-behavioral treatment approaches for youth with epilepsy and PNES and highlight the treatment components with a case example.

Objectives Pediatric psychogenic nonepileptic seizures (PNES) is a functional somatic symptom condition with significant health-care service burden. While both family and individual factors play an important role in the development and maintenance of PNES, little is known about what predicts urgent health-care use in families with children who have PNES. The aim of the current study was to explore whether child coping and parental bonding styles influence the decision to seek urgent medical care in these families. Methods Data were analyzed from youth of age 8-18 years, 47 with PNES, and their 25 sibling controls. Parents provided the number of youth emergency room visits and hospitalizations in the preceding year. Youth completed a questionnaire about their coping styles and a measure about their mothers' and fathers' bonding styles. Using a mixed model with family as a random effect, we regressed urgent health-care use on participant type (youth with PNES or sibling), parental bonding style, and youth coping style, controlling for number of child prescription medications. Results Higher urgent health-care use was associated with having PNES, coping via monitoring, and perceiving one's father to be rejecting and overprotective. Lower urgent health-care use was associated with coping via venting and with perceiving one's mother to be caring and overprotective. Conclusions This study provides preliminary empirical support for family-based clinical efforts to reduce child urgent health-care use by enhancing effective child coping skills and improving parental response to child impairment and distress in families with youth with PNES.

To help their child problem-solve, it is essential for parents to recognize and accept that the child has stressors. This can be challenging because the parents often are not psychologically minded, might be unaware of the child’s struggles, and/or do not know how to help the child problem-solve. They might misinterpret the child’s avoidance of problem solving as being lazy and think that the child’s request for help is a way to get attention or be manipulative. Your role in this process is to help the parents recognize and understand the difficulties and stressors the child faces, as well as to give the parents a framework for how to respond using the approaches presented in this chapter.

Adaptive problem-solving is clearly a challenge for children with PNES. This goal focuses on how the parents can help the child problem-solve adaptively. To do this, it includes the methods described for the child in Chap. 9 and how the parents can help the child operationalize them.

This guide devotes a whole section to the diagnosis of pediatric PNES because this process is challenging. In fact, the diagnosis is often missed, and the average time it takes for the diagnosis to be confirmed is 6 months to 3.5 years. The longer it takes to reach a diagnosis and begin treatment, the worse the outcome is. In this section, we describe the underlying psychopathology, risk factors, and triggers of pediatric PNES; the gold standard diagnosis; why it is difficult to make the diagnosis in children; red flags, suggesting a possible PNES diagnosis; and the techniques to overcome the challenges of diagnosing this disorder.

The ultimate therapy goal for a child with PNES is that the child acquires adaptive problem-solving skills. To do this, the child needs to be able to tune into negative emotions (anxiety, fear, anger, sadness) (Goal 1), identify the stressors and difficulties that trigger these feelings (Goal 2), and be aware of physical sensations that accompany stress (Goal 3) without using avoidance and channeling the negative emotions and stressors through the body (Goal 4). Although problem-solving is the ultimate goal, your work with the child on adaptive problem-solving starts from early in therapy.

Children with PNES have difficulty identifying stressors other than the physical symptoms that they experience. Early in treatment, these often are the only stressors that they and/or their parents acknowledge. Management of the child’s physical symptoms builds the rapport and trust in the therapist that is needed to help the child and parents explore the child’s other stressors. Identification of stressors should be part of each therapy session using the techniques described in this chapter.

Goals 1 and 2 provide techniques to help the child recognize negative emotions the child experiences and identify stressors, respectively. Goal 3 now focuses on how to assist the child to tune into and verbalize the negative affect associated with stressors.

The main objective of this goal is to improve the relationships between the parents and child. Communication within the family involves a dynamic interplay between the parents and child. This chapter guides you on how best to identify and understand communication breakdowns that occur between the parents and the child, their triggers, how they evolve, as well as what can be done to prevent and/or fix them.

Anxiety disorders and depression are common in youth with PNES. These disorders are frequently under-recognized and under-treated. They can appear before NES symptom onset and remain after PNES is diagnosed. Cognitive behavioral therapy (CBT) is an evidenced-based treatment for anxiety disorders and depression, disorders that are common in childhood and adolescence. This chapter describes the indications for CBT in the anxiety disorder and depression found in youth with PNES. It also includes an overview of the essential elements of CBT that have been demonstrated to have the strongest evidence for efficacy.

During the course of treatment, it often becomes apparent that the child’s NES and other physical symptoms are emotionally based. But the child is unaware of the link between the child’s negatively charged emotions or thoughts and these symptoms. As a result of therapy, the child begins to understand that stressful situations evoke negative emotions in most people and in the child. Once this is achieved, it is important to examine how stress and negative emotions are associated with the child’s NES episodes and other physical sensations.

Your work with the parents is an essential component of the therapy of children and adolescents with PNES. Goal 1 focuses on the importance of addressing the feelings the child’s episodes evoke in the parents and how they manage these emotions. This is the first step in helping them successfully apply the behavioral approach needed to mitigate the child’s episodes. This chapter includes techniques you can use to help the parents talk about their distress during the child’s episodes. Since these children often have multiple physical complaints, the parents must learn how to manage them. To do this, they need to be cognizant of the emotions they experience when the child complains of physical symptoms.

The final chapter of this treatment guide briefly reviews the main aspects of the diagnosis, feedback, as well as the short-term and long-term treatment techniques for pediatric PNES. The chapter concludes with practical suggestions to accelerate the transition to help you become an expert in the treatment of pediatric PNES.

Like children with other types of conversion symptoms, children with PNES use maladaptive coping strategies, in particular, avoidance to manage stressors. As they become better at controlling their episodes using the techniques presented in Chap. 4 and in Appendices D, E, G, H, I, J and K, the ultimate goal of therapy is to help these children identify, verbalize, and monitor their stressors as well as develop adaptive coping strategies. More specifically, they require help to first recognize, express, and monitor the emotional, familial, social, and academic experiences that evoke their anxiety and/or other negative emotions. They then need to understand the maladaptive nature of their coping skills and the relationship among their stressors, poor problem-solving, and their episodes, as well as other physical symptoms.

It is important to identify the family stressors as they might directly play a role in the child’s problems. Achieving this goal is not easy as parents might be unwilling to share their family problems with the therapist. This chapter guides you on how to sensitively achieve this goal from early on and throughout the child’s therapy.

Successful delivery of feedback on the diagnosis of PNES determines whether the parents and child will be open to accept that the child has a psychiatric not a neurological diagnosis. Their acceptance and understanding of the disorder are essential for them to agree to the treatment needed to stop the episodes, prevent their recurrence, reintegrate the child to school and normal life, as well as learn to cope and problem-solve in an adaptive rather than maladaptive manner through avoidance. This chapter focuses on potential pitfalls in giving the feedback about the diagnosis and treatment of PNES. They involve who gives the feedback and describes the treatment plan, how and when this is done, and the need for a follow-up appointment to determine how the parents and child processed the feedback information.

Objectives This study examined the risk factors for learning problems (LP) in pediatric psychogenic non-epileptic seizures (PNES) and their specificity by comparing psychopathology, medical, cognitive/linguistic/achievement, bullying history, and parent education variables between subjects with PNES with and without LP and between subjects with PNES and siblings with LP. Methods 55 subjects with PNES and 35 siblings, aged 8–18 years, underwent cognitive, linguistic, and achievement testing, and completed somatization and anxiety sensitivity questionnaires. A semi-structured psychiatric interview about the child was administered to each subject and parent. Child self-report and/or parent report provided information on the presence/absence of LP. Parents also provided each subject's medical, psychiatric, family, and bullying history information. Results Sixty percent (33/55) of the PNES and 49% (17/35) of the sibling subjects had LP. A multivariable logistic regression demonstrated that bullying and impaired formulation of a sentence using a stimulus picture and stimulus word were significantly associated with increased likelihood of LP in the PNES youth. In terms of the specificity of the LP risk factors, a similar analysis comparing LP in the youth with PNES and sibling groups identified anxiety disorder diagnoses and bullying as the significant risk factors associated with LP in the PNES youth. Conclusions These findings emphasize the need to assess youth with PNES for LP, particularly if they have experienced bullying, have linguistic deficits, and meet criteria for anxiety disorder diagnoses.

Purpose To examine the risk factors for internalizing (anxiety, depression) and posttraumatic stress (PTSD) disorders, somatization, and anxiety sensitivity (AS) in youth with psychogenic non-epileptic seizures (PNES). Methods 55 probands with PNES and 35 siblings, aged 8–18 years, underwent a psychiatric interview, cognitive and language testing, and completed somatization and AS questionnaires. Parents provided the subjects' medical, psychiatric, family, and adversity history information. Results The risk factors for the probands' internalizing disorders (girls, older age of PNES onset), somatization (older age, epilepsy), and anxiety sensitivity (girls, adversities) differed from their siblings. The risk factors in the siblings, however, were similar to the general pediatric population. Proband depression was unrelated to the study's risk variables while PTSD was significantly associated with female gender and lower Full Scale IQ. Conclusions Knowledge about the specificity of the risk factors for comorbid psychopathology in youth with PNES might facilitate their early identification and treatment.

Cognitive, psychiatric, psychosocial, and behavioral difficulties are common in youth with epilepsy. Collectively, these comorbidities can be referred to as mental health problems as they reflect brain and behavioral function. Detection and treatment of mental health problems remain an unmet need in epilepsy care that can impact epilepsy, psychosocial, scholastic, and quality-of-life outcomes. Given limited resources in everyday pediatric epilepsy practice, this targeted review provides a stratified plan and suggested tools for screening school-aged youth with epilepsy for the presence of mental health problems. Comanagement of epilepsy and associated comorbidities is a newer concept that may help address the complex, long-term needs of patients by using a multidisciplinary team approach and by engaging primary care providers.

1. Hema Patel, MD* 2. David W. Dunn, MD*† 3. Joan K. Austin, PhD, RN§ 4. Julia L. Doss, PsyD‡ 5. W. Curt LaFrance Jr, MD, MPH** 6. Sigita Plioplys, MD§§ 7. Rochelle Caplan, MD†† 1. *Section of Child Neurology, Department of Neurology, Indiana University School of Medicine, Indianapolis, IN. 2. †Section of Child Psychiatry, Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN. 3. §Indiana University School of Nursing, Indianapolis, IN. 4. ‡Minnesota Epilepsy Group, St. Paul, MN. 5. **Department of Neuropsychiatry and Behavioral Neurology, Brown Medical School, Rhode Island Hospital, Providence, RI. 6. §§Department of Psychiatry and Behavioral Sciences, Northwestern University's Feinberg School of Medicine, Chicago, IL. 7. ††Semel Institute for Neuroscience and Human Behavior, UCLA, Los Angeles, CA. After completing this article, readers should be able to: 1. Recognize the antecedent stressors associated with psychogenic nonepileptic seizures in children. 2. Identify pediatric nonepileptic seizures clinically. 3. Distinguish psychogenic nonepileptic seizures from epileptic seizures and other paroxysmal nonepileptic events. 4. Be aware of the comprehensive assessment needed to evaluate the child who has possible psychogenic nonepileptic seizures. 5. Become familiar with the management approaches used to treat psychogenic nonepileptic seizures in children. Nonepileptic seizures are episodic behavioral events that mimic epileptic seizures but are not associated with abnormal cortical electrical discharges. Psychogenic nonepileptic seizures (PNES) are related to an underlying psychological stressor or conflict and differ from other paroxysmal nonepileptic events. A variety of terms have been used in the literature to describe these events, including hysterical epilepsy, hysteroepilepsy, psychogenic seizures, pseudoepileptic seizures, pseudoseizures, and nonphysiologic or functional seizures. The term psychogenic nonepileptic seizure is preferred because it is nonpejorative and neutral, although there is continuing discussion regarding the most appropriate terminology. PNES are common. Although population data are limited, one report suggested a prevalence of 2 to 33 per 100,000, basing the estimate on an assumption that 10% to 20% of patients seen in an epilepsy center would be found to have PNES. (1) Reviewing video-electroencephalography (EEG) monitoring records, Patel and associates (2) and Wyllie and colleagues (3) found that 3.5% and 7% of children, respectively, seen in clinic for assessment of persistent seizures had PNES. PNES occur in both elementary-age children and in adolescents as well as in all age groups of adults. (2)(3)(4)(5)(6) A female preponderance has been …