Functional neurological disorder is a common reason for a child to arrive in the emergency department, and this narrative review argues that the usual approach — investigate, find nothing, imply the problem is therefore not real — is both wrong and harmful. Gaps in clinician education delay the diagnosis; the delay generates unnecessary tests and interventions, which cost money and sometimes hurt the child.
The central recommendation is a diagnostic one. Functional neurological disorder should be made as a positive diagnosis using rule-in signs, not as a diagnosis of exclusion resting on negative tests. That is a real change in reasoning: it means a clinician who elicits the characteristic signs can name the condition on the day rather than after a battery of imaging, and it means a normal scan is not the evidence base for the diagnosis. The review also covers triage, outpatient referral routes and the recurring difficult scenarios.
The second recommendation matters as much as the first. Tell the child and family promptly, clearly, and in a way that validates the symptoms as real and involuntary. A diagnosis delivered as 'we found nothing' is heard as disbelief, and predictably brings the family back through the emergency department; one delivered as a named condition with a mechanism and a referral is the beginning of treatment. Be clear this is a narrative review offering practical guidance rather than a trial: the recommendations rest on clinical expertise and existing literature, not on outcomes measured against usual care.
- Learn and use the rule-in signs for your commonest presentations — functional weakness, tremor and seizures each have their own
- Do not order imaging in order to make this diagnosis; order it only if a red flag warrants it
- Name the condition to the family on the day, and say the symptoms are real and involuntary
- Agree the outpatient referral before discharge — paediatric neurology, psychology or a joint clinic where one exists
- Recognise the evidence grade: this is expert narrative guidance, not comparative trial evidence
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