As briefly mentioned in the overview to this treatment guide, the underlying psychopathology of children with PNES, conversion disorder, involves displacement of the tension associated with negative emotions, such as anxiety, anger, fear, frustration, and demoralization onto physical symptoms. Why certain children develop conversion disorder with epilepsy-like symptoms rather than other physical symptoms remains unclear [1, 2]. However, current psychodynamic theories on pediatric PNES and evidence for triggers (see review in [3]) and risk factors [4]) shed light on ways the disorder might develop.

From the research perspective, triggers for pediatric PNES include learning difficulties; social problems; parent marital discord; family dysfunction; unrealistic expectations by the child or the parents for the child to excel at school, sports, or extracurricular activities; bullying and other forms of psychological abuse; and rarely physical or sexual abuse [5–9]. But not every child who experiences these trigger factors develops PNES. Two independent risk factors differentiate children with PNES from their siblings, a somatopsychiatric factor and an adversity factor [10]. In other words, children with medical problems, excessive use of medical services, fearful response to physical sensations, and psychiatric diagnoses—the somatopsychiatric factors—are at risk for PNES. Bullying associated with emotional problems, psychiatric diagnoses, and treatment with psychiatric drugs—the adversity factors—also increase the vulnerability for PNES.

From the psychodynamic perspective, children who develop PNES and other conversion disorders [11] appear to use avoidance when faced with situations that trigger negative emotions (fear, anger, frustration, anxiety, or sadness). In addition to not confronting and/or problem-solving the situation that triggers these negative feelings, these children are often unaware of or deny experiencing negative emotions. Thus, they are avoidant on both the functional and emotional levels. In some cases, the children have language difficulties with impaired use and/or retrieval of words to describe their emotions (alexithymia) (see review in Reilly et al. [3]) and/or difficulty using sentences to formulate [12] their feelings and thoughts, particularly those involving abstract concepts. As a result, and given their use of avoidance, they do not tune into their negative emotions and/or verbally express or talk about their problems and the associated emotions.

In other cases, the children have intact language skills. However, when they verbalize and express their difficulties or problems to their parents and ask for their help, the parents pay no or little attention to the children’s complaints. In some cases, parents misinterpret, scold, criticize, or verbally abuse the children for their difficulties and avoidant behavior. These responses cause the children to back off, not share their difficulties with their parents, and continue to avoid dealing with the problems at hand.

The children’s unexpressed negative emotions accumulate when the problem situation(s) does(do) not go away and/or gets(get) worse due to the children’s avoidance. Repeat exposure to the problem situation(s) and the lack of problem-solving triggers(s) the children’s anxiety, as well as negative responses by others, which, in turn, make the children more fearful. Mounting of their unexpressed negative feelings on the one hand and the practical results of not problem-solving on the other hand result in these children feeling there is no way out. Taylor [13] used the term predicament to describe this situation, which leads to displacement of the growing tension and mounting unresolved problems into physical symptoms.

Because of the attention these children get due to the seizure-like episodes, they are excused from meeting demands in the school, home, and social environment and/or from dealing with other potential stressors or triggers of their condition. Increased attention by parents and others to the child’s “seizures,” together with continued avoidance of dealing with ongoing problems, difficulties, and/or challenges, is called secondary attention. This inevitable phenomenon reinforces recurrence of the episodes which then take on a life of their own. The more they recur, the more attention the child gets and the more difficult it is for the child to cope with the ongoing problems. Antiseizure medications, also known as antiepileptic drugs (AEDs), can have adverse effects, including fatigue and irritability that further impair the children’s ability to problem-solve and reinforce this vicious cycle. In terms of family functioning, the child’s symptoms might overwhelm the parents in their efforts to deal with the child’s illness and their own ongoing life stressors, such as family discord.

From the behavioral perspective, how parents respond when their child reports physical symptoms acts as positive or negative emotional reinforcers. As such, they can influence how much their child complains about aches, pains, and not feeling well. The wide range of parental responses includes a lack of response, a neutral concerned response, or an excessive anxious response for the child to receive immediate medical attention. In some families, parents only pay attention to their children when they are sick or have physical complaints. Children whose parents are overly anxious when their children have somatic complaints and children of parents who pay attention to them only when they are ill are at high risk for somatization and conversion disorder [14, 15].

Confirmation of PNES is based on two essential components. The first component is a prolonged video-EEG (vEEG) in which the child has seizure-like episodes without EEG evidence for ongoing epileptic activity. The second component is that the child meets criteria for a conversion disorder or, more rarely, a dissociation disorder, based on a comprehensive psychiatric evaluation. This treatment guide focuses on treatment of children with PNES who have a conversion disorder. Table 2.1 lists the DSM-5 diagnostic criteria for this disorder [16].