Objective: To characterize the differential diagnosis of functional movement disorders in children

Background: While movement disorders with known neurological etiologies may merit interventions with greater than minimal risk, movements without apparent neurological pathologies may require restraint. When evaluating children with movements, clinicians may be challenged by the need to distinguish movement disorders with identified neuropathology from movements without apparent pathophysiology including (A) genuine symptoms and signs (functional movement disorders) [1-4] and (B) symptoms and signs fabricated by a caregiver (Munchausen syndrome by proxy) [5] or a child (malingering) [6].

Method: A five-year-old prepubertal African-American girl was shot in her left thorax and left arm at the distance of two feet accidentally by a stranger. After a delay of four hours she taken to the emergency room for admission for a thoracotomy. She experienced repeated nightmares about being followed and killed by strangers [3].

Four years later she began to experience poor vision after being punched in the eye by a girl at school. A day before her ninth birthday, her mother took her to the emergency room with a chief complaint of “I can’t see” for the preceding day [3].

Results: The patient shook hands with the examiners and maintained eye contact with them. She said that she could neither see nor hear. She responded to questions in a noisy emergency room. She correctly identified objects [3]. 

Subsequently she presented at the emergency room with mouth twisting to the right, shaking, and frothing followed by confusion and sleepiness leading to treatment with 100 mg phenobarbital by mouth twice daily [3].

Family history.

Her mother aged 24 years was treated with phenobarbital for a convulsive seize disorder since age 13. After a religious experience she suddenly discontinued the medications for a year without seizures [4].

Conclusion: The differential diagnosis of movements in children can challenge clinicians in emergency rooms. Obtaining a comprehensive history is key to develop an optimal treatment plan [6]. Identifying family members with similar functional movement disorders facilitates the diagnosis. Physical, sexual, and psychological abuse must be ruled out. 

If the accompanying persons fabricate symptoms for a child, clinicians may institute procedures with serious risks and adverse effects. Munchausen syndrome by proxy [5] and other child abuse must be ruled out.

References: 1. American Psychiatric Association. Diagnostic and statistical manual of mental disorders (DSM-5®). 5th ed. Washington, DC: American Psychiatric Pub; 2013. https://doi:10.1176/appi.books.9780890425596. 2. Mayo Foundation for Medical Education and Research (MFMER). Functional neurologic disorders/conversion disorder. 2021. Available online: https://www.mayoclinic.org/diseases-conditions/conversion-disorder/symptoms-causes/syc-20355197 (accessed 9 March 2021). 3. Brašić JR. Conversion disorder in childhood. German Journal of Psychiatry. 2002; 5 (2): 54-61. 4. Brasic JR. Is stalking preventable? Med Hypotheses. 2005; 64 (4): 878-879. PMID: 15694710 https://doi.org/10.1016/j.mehy.2004.11.010 5. Abeln B, Love R. An overview of Munchausen syndrome and Munchausen syndrome by proxy. Nurs Clin N Am. 2018; 53: 375-384. https://doi.org/10.1016/j.cnur.2018.04.005. 6. Elshourbagy T, Mousa A, Mohamed M, Brasic J. Differentiation of zaghrouta, ululation to express joy in the Middle East, from movement disorders and other conditions. Int J Health Life Sci. 2021; 7(1):e106655. https://doi.org/10.5812/ijhls.106655

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