Functional Dissociative Seizures in Children: From Diagnostic Dilemma to an Integrated, Inclusive Model of Care

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Diagnosis also requires assessment of developmental history, learning and neurodevelopment, mood and anxiety, family context, school functioning, bullying, trauma, recent loss, and major life changes.A specific psychological trigger is common but not required.2,3 Diagnosis a n D ManageMentThe diagnostic and management approach is summarized in Table 1.• Functional dissociative seizures and epilepsy can coexist; confirmation of one must not automatically exclude the other.• Management begins with a clear, nonjudgmental explanation shared by neurology and mental health teams: the diagnosis is known, the symptoms are genuine, and recovery is possible.• Treatment combines a multidisciplinar y approach: psychoeducation, individualized psychological therapy, management of comorbidities and stressors, family participation, school reintegration, and restoration of normal activity. CliniCal overviewFunctional/dissociative seizures (FDS), previously termed psychogenic nonepileptic seizures (PNES), are paroxysmal episodes of altered movement, sensation, awareness, responsiveness, perception, or behavior that resemble epileptic seizures but are not generated by epileptic ictal discharges.The events are real and involuntary.Delayed recognition can expose children to unnecessary antiseizure medication, repeated emergency visits and investigations, school absence, restricted activity, and escalating family anxiety.The International League Against Epilepsy (ILAE) term FDS avoids defining the condition only by what it is not and reduces the implication that symptoms are fabricated or purely psychological. 1 The current pathophysiology model integrates brain-network functioning with attention, emotion, memory, arousal, prior experience, development, and environmental context.FDS should therefore be diagnosed positively, using characteristic history and semiology, rather than solely after excluding every disease.A careful description should document onset, duration, evolution, motor pattern, eye state, responsiveness, fluctuation, triggers, recovery, injury, and whether events are stereotyped.Eyewitness accounts and smartphone videos are useful.When available, video-electroencephalography (video-EEG) capture of the child's habitual event, showing typical clinical behavior without an epileptic ictal correlate, provides the highest diagnostic certainty.If video-EEG is unavailable, graded certainty may be based on clinician-witnessed events, reliable video, semiology, and appropriate EEG data. 2 Rigid semiology labels may be less useful than describing the event using a three-dimensional axis: motor activity, responsiveness, and change over time.Events may be nonmotor or hypermotor, with preserved or impaired responsiveness, and may fluctuate or transition during a single episode.