Conversion Disorder in Australian Pediatric Practice

KASIA KOZLOWSKA, F.R.A.N.Z.C.P., KENNETH P. NUNN, F.R.A.N.Z.C.P.,

DONNA ROSE, MA, ANNE MORRIS, F.R.A.C.P., ROBERT A. OUVRIER, M.D.,
AND JOHN VARGHESE, F.RA.N.Z.C.P.

ABSTRACT
Objectives: To describe the incidence and clinical features of children presenting to Australian child health specialists with
conversion disorder. Method: Active, national surveillance of conversion disorder in children younger than 16 years of age
during 2002 and 2003. Results: A total of 194 children were reported on. The average age was 11.8 years; 23% were
younger than 10 years of age. Presentations were complex, with 55% presenting with multiple conversion symptoms. The
most common presentations were disturbance of voluntary motorfunction (64%), sensory symptoms (24%), pseudoseizure
(23%), and respiratory problems (14%). Hospital admission was required for 70%, with an average stay of 10.2 days.
Antecedent stressors were also reported in 62% and a history of mental health concerns in 42%, with 14% of children taking
psychotropic medications for comorbid anxiety or depression. The incidence of conversion disorder in Australian specialist
child health practice is estimated to be between 2.3 and 4.2/100,000. Conclusions: Conversion disorder is associated with
a significant burden for the child, family, and the health system. This study emphasizes the comorbidity with anxiety,
depression, and symptoms of pain and fatigue. It also highlights the potential impact of "commonplace" stressors such
as family conflict and children's loss of attachment figures. J. Am. Acad. ChildAdolesc. Psychiatry,2007;46(1):68-75.
Key Words: conversion disorder, somatoform disorder, dissociative disorder, epidemiology.

Conversion disorder refers to a disturbance of body
function characterized by neurological sensory or motor
symptoms in which known medical explanations do not
explain or fail to account for the severity of the patient's
impairment (American Psychiatric Association, 2000).
Accepted July 17,2006
Dr. Kozlowska and Ms. Rose are with the Department of P.-cholagical
Medicine, The Children Hospital at Westmead, Sydney, Australia; Profemor
Nunn is with Nexus, John Hunter Hospital Newcastle, Australia;Dr.Morris
andPrfessorOuvrierare with the DepartmentofPaediatricsand ChildHealth,
The ChildrenHospitalat Westmeadand Universit ofSydney;andDr.Varghese
is with the Child and Family Therapy Unit, Royal Children's Hopitai
Brisbane,Australia.
The authors acknowledge the contribution of all child health specialists
contributing to the surveillance of uncommon childhood diseases though the
AustralianPaediatricSurveillance Unit andjohn Camilleri,Dr.Diane Gray,
andDr.Duc Van. Particularthanks go to Dr.Padraic Grattan-Smithforhis
many thoughtful comments. They gratefully acknowledgeftndingforthis study
from the NSW CentreforMental Health, NSWHealth.
Correspondence to Dr. Kasia Kozlowska, Department of PycholAgical
Medicine, The ChildrenHospital at Westmeaad Locked Bag 4001, Westmea4i
2145, NSW Australia, e-maiL Kasiak@chw.edu.au.
0890-8567I07/4601-0068©2006 by the American Academy of Child
and Adolescent Psychiatry.
DOI: 10.1097101.chi.0000242235.83140.lf
Conversion symptoms include medically unexplained
motor weakness, loss of other sensory function such as
touch, sight, and hearing, and nonepileptic seizures
(also known as pseudoseizures). Symptoms are experi-
enced by patients as involuntary and vary in severity
from mild, transitory somatic concerns to chronic func-
tional impairment. The diagnosis of a conversion
disorder requires that symptoms be associated with
significant distress or disability (American Psychiatric
Association, 2000). Conversion disorder does not
include the broader array of nonspecific unexplained
medical symptoms such as fatigue or nausea, although
these may be seen as comorbid features. Patients who
presentwith medically unexplained pain alone may meet
criteria for the diagnosis of somatoform pain disorder.
The etiology of conversion disorder has long been
the topic of debate (Kozlowska, 2005). Contemporary
functional imaging studies suggest that some conver-
sion symptoms can be viewed as reflecting errors in how
emotional information is processed by the brain (Black
et al., 2004; Kozlowska, 2005; Mailis-Gagnon et al.,
2003; Roelofs and Spinhoven, in press). Management
strategies depend on the type and severity of symptoms

68 J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 46:1, JANUARY 2007


and the ability of health' providers to address the
putative underlying/maintaining psychogenic factors.
Conversion disorder is well recognized and described
in adolescents and adults (Akagi and House, 2001;
Fink et al., 2004; Lieb et al., 2000). Lieb and colleagues
found somatoform pain disorder and conversion
disorder to be the most common of the somato-
form disorders, with the 12-month prevalence identi-
fied as 0.9% and 0.2%, respeciively, in a large cohort of
German young people ages 14 to 24 years. Incident
cases were not distinguished. All somatoform disorders
were more common in females and associated with high
levels of comorbid psychiatric symptomatology, func-
tional disability, and a high rate of use of medical
services. Globus hystericus (sensation of-having a lump
in the throat) was the most frequently reported
conversion symptom. The Lieb et al. study employed
robust methods that are frequently emphasized in
mental health epidemiology, including the use of a
structured diagnostic interview. However, the use of
structured clinical diagnostic interview to collect retro-
spective self-reported conversion symptoms without
access to the medical opinion that is required to exclude
organic explanations for the conversion symptoms'is a
significant limitation of this work.
Studies of conversion disorder in young children are
limited to case reports and case series in children as
young as 4 years of age (Grattan-Smith et al., 1988;
Kotagal et al., 2002; Kramer et al., 1995; Lancman
et al., 1994; Rock, 1971). High rates of comorbid
mood and anxiety disorders are reported (Grattan-
Smith et al., 1988; Pehlivanturk and Unal, 2000;
Wyllie et al., 1999). Significant life events, including
sexual and physical abuse or significant family stressors,
are also frequently described in this population
(Grattan-Smith et al., 1988; Lancman et al., 1994;
Pehlivanturk and Unal, 2000; Seltzer, 1985; Srinath
et al., 1993; Wylie et al., 1999). A retrospective medical
records audit at an Australian pediatric teaching hos-
pital identified 52 cases of children diagnosed with
conversion disorder during a 10-year period (Grattan-
Smith et al., 1988). The most common presentation
was abnormal gait (69%). However, 62% of children
presented with multiple symptoms. Children were
"heavily investigated," and 25% of the sample had
lengthy admissions, with an average stay of 31 days.
In contrast to adult practice, in which chronic
symptoms are thought to be the norm (Ljungberg,
J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 46:1, JANUARY 2007
CONVERSION DISORDER IN AUSTRALIAN CHILDREN
1957; Sheehan, 2002), childhood conversion disorder is
believed to be associated with a good outcome (Leary,
2003; Turgay, 1990; Wyllie et al., 1991). Nevertheless,
children presenting to tertiary health services can
experience severe, disabling symptoms and their treat-
ment can be difficult, protracted, and costly. Pehlivanturk
and Unal (2002) found that of their series of forty 9- to
14-year-olds, 15% failed to recover from their conversion
symptoms and 35% were eligible for a DSM-IVdiagnosis
of mood or anxiety disorder 4 years after diagnosis.
The clinical experience of the authors suggested that
conversion disorder is a low-incidence but high-impact
condition of childhood that is of greater importance to
pediatric and consultation liaison psychiatry practice
than the limited literature has indicated. The objectives
of this study-were to gain national data on the incidence
of conversion disorder in Australian children seen by
child health specialists and to describe the pattern and
severity of illness, associated psychosocial features, and
use of medical resources.
Basic descriptive, epidemiological research is crucial
to informing policy on resource allocation for service
provision and prevention policy. However, the applica-
tion of epidemiological methods to the investigation of
mental health conditions in young children involves
significant methodological challenges, including lim.i-
ted availability of age/developmentally appropriate
diagnostic assessment interviews for young children
and difficulties associated with the integration of
multiple sources of information from family, child,
and clinician. The study of conversion disorder is
complicated further by the need for additional evidence
such as medical examination and investigations, to rule
out organic explanations. We therefore elected to use a
surveillance methodology that has been successfully,
used in the investigation of the epidemiology of
uncommon infectious diseases (Elliott et al., 2004), as
well as health concerns such as of dementia in
childhood (Nunn et al., 2002) and Munchausen
syndrome by proxy (McClure et al., 1996).
METHOD
Contributors to the Australian Paediatric Surveillance
Unit (APSU)
In the Australian health. care system, children who experience
significant impairment secondary to unexplained neurological
symptoms come to the attention of health care providers via two
69
KOZLOWSKA ET AL.
pathways: hospital emergency departments or referral from general
medical (family) practice to specialist pediatric practice. Cases of
conversion disorder were therefore ascertained through the APSU,
with voluntary reporting by child health specialists. The APSU is a
unit of the Division of Paediatrics and Child Health, Royal
Australasian College of Physicians, and its role is to facilitate
national, active surveillance of uncommon but high-impact diseases
of childhood, including infectious and vaccine-preventable diseases,
genetic disorders, childhood injuries, and mental health concerns.
The APSU is one of 14 national pediatric surveillance units using a
model of surveillance developed by the British Paediatric
Surveillance Unit (INoPSU, 2003).
Contributors to APSU surveillance are fellows of the Division of
Paediatrics and Child Health, Royal Australasian College of
Physicians (93%) and other child health specialists including child
and adolescent psychiatrists (3%). Participation in APSU surveil-
lance among pediatricians in clinical practice in Australia is 94%.
The participation of child and adolescent psychiatrists is more
limited to those working in general pediatric health settings. In
2003, 1,050 clinicians from Australia's six states and two mainland
territories participated in the monthly surveillance of 14 conditions,
including conversion disorder, with an overall response rate of 96%
(APSU, 2005). The geographical distribution of APSU clinicians
parallels the distribution of the Australian population of children,
except in the two least populous states/territories (Tasmania and the
Northern Territory), where access to specialist health services is
more limited.
Reporting Criteria
Inclusion criteria were children younger than 16 years of age seen
by child health specialists during the previous month, with a newly
diagnosed episode of conversion disorder. Conversion disorder was
defined as the presence of one or more symptoms and/or signs
affecting voluntary motor or sensory function that could not be
explained by a neurological or other general medical condition,
according to the clinical judgment of the treating pediatrician after
physical examination and appropriate investigations. Consistent
with DSM criteria for disorder, the study criteria also required
that the symptoms and/or signs caused significant distress and/or
impairment in daily activities such as self-care, school, play, and
family activities.
Exclusion criteria were children with symptoms that were
intentionally produced or precipitated by substance use or with
symptoms limited to pain (somatoform pain disorder), fatigue
(chronic fatigue syndrome), or sexual dysfunction. Also excluded
were children with symptoms that were better accounted for by
another mental disorder or symptoms that occurred exclusively
during the course of somatization disorder. Although DSM-IV-TR
appears to allow a diagnosis of conversion disorder if the symptom
"warrants medical evaluation" (American Psychiatric Association,
2000, p. 498 E) children were excluded from this study if no
impairment was reported by the treating clinician. This criterion
ensures a reasonable operational distinction between conversion
symptoms and the DSM-JV-TR definition of disorder.
Surveillance Method
Before the commencement of the study, all of the APSU clini-
cians received reporting information consistent with DSM-IV-TR
criteria for conversion disorder. This included a description and
examples of common presentations such as pseudoseizure, motor or
70
sensory loss, and other symptoms. On a monthly basis, clinicians
were mailed or E-mailed a report card listing conditions currently
being studied through the APSU. Clinicians reporting cases of
conversion disorder were then sent a detailed questionnaire seeking
de-identified demographic and clinical information including the
nature and duration of presenting symptoms, investigations,
hospital admissions and other treatments, recent stressful events
identified, and history of other medical or mental illness in the child
and his or her immediate family.
The case questionnaire required clinicians to identify presenting
symptoms and to specify which investigations had been used to
exclude organic disease in the course of their routine clinical
practice. Clinicians were not required to apply neurological grading
systems because this is not a requirement of DSM-IV-TR criteria,
nor were clinicians required to follow a standardized investigation
pathway because exclusion of conversion disorder requires appro-
priate investigation as dictated by symptom presentation and good
clinical practice. These requirements are consistent with recom-
mended clinical practice, which does not encourage unnecessary
tests that can function to reinforce abnormal illness behavior and
demands for unnecessary and costly investigations (Leary, 2003;
Pilowsky, 1969).
RESULTS
Surveillance Reports
Three hundred ten reports of conversion disorder
were made to the APSU during the 2-year surveillance
period (Fig. 1). Completed questionnaires were
received for 267 (86%), resulting in 194 cases of
conversion disorder consistent with the study criteria.
Three children presented twice with new episodes of
conversion disorder during the 2-year study period.
Most cases were reported by general pediatricians/
pediatric subspecialists, 13% of cases were reported by
both pediatricians and child and adolescent psychia-
trists, and 30% were reported by child and adolescent
psychiatrists only. Of the latter, all indicated that the
child had been reviewed by a pediatrician.
Total reports 2002-2003 = 310
1
Clinical data obtained = 267 (86%)
-. 26 duplicates
.............. 47 errors
f18 cases >16 years
L28 not meet case criteria
Conversion disorder = 194
Fig. 1 Surveillance data summary, 2002-2003.
J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 46:1, JANUARY 2007

Fig'. 2 The interrelationship between the principal conversion disorder
symptom dusters, pain, and fatigue.
Case Characteristics
For the 194 confirmed cases, the average age at
diagnosis was 11.8 years (SD 2.7 years, range 3.1-15.9
years), 23% of cases were younger than 10 years of age.
Although most (77%) of the children were diagnosed
with their first episode conversion disorder, 44 Lhildren
(23%) had experienced previous episodes. Consistent
with the adult literature, most of the confirmed cases
were females (n = 138, 71%). However, there were
proportionally fewer females in the younger age group:
57% of the children younger than 10 years of age
and 76% of children 10 to 16 years old were female
(x 2 = 6.16, df= L,p < .05).
Population Estimates
In 2003, the population of Australia's children
younger than 16 years of age was 4.25 million. In this
study, the annual incidence of conversion disorder in
children younger than 16 years of age, diagnosed by
Australian child health specialists, was 2.3/100,000
(95% confidence interval [CI] 2.0-2.6/100,000). The
reported incidence of conversion disorder in children
younger than 10 years of age, seen in specialist child
health practice, was lower at 0.8/100,000 (95% CI
0.6-1.1/100,000).
The state of New South Wales (NSW) is the most
populous of Australia's six states and two mainland
territories. NSW is home to one third of Australia's
children younger than 16 years of age and 38% of
APSU's reporting clinicians and is serviced by three
pediatric teaching hospitals. Of the 194 confirmed cases
of conversion disorder identified by this study, 119
(61%) resided in NSW. The annual incidence of
conversion in children younger than 16 years of age,
J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 46:1, JANUARY 2007
CONVERSION DISORDER IN AUSTRALIAN CHILDREN
seen in specialist child health practice in NSW was
4.2/100,000 (95% CI 3.5-5.0/100,000).
Presentation and Diagnosis
For most of the children with conversion. disorder,
the clinical picture and associated contextual factors
were complex. Fifty-five percent of children presented
with more than one conversion symptom, and almost
one third presented with three or more conversion
symptoms. The most common presentation was a
disturbance of voluntary motor function (64% of all
cases). This included children with motor weakness
(n = 75), limb paralysis (n = 28), abnormal gait (n = 73),
abnormal movement (n 32), or difficulties with
speech or swallowing (n = 8). There were 46 (24%)
children with at least one sensory symptom, including
paresthesia/anesthesia (n = 23) and vision (n = 24) or
hearing difficulties (n = 5). Other common presenta-
tions were pseudoseizures (23% of all cases) and
respiratory problems (14% of all cases). More than
one fourth of children presented with symptoms from
more than one of the four principal symptom clusters
(Fig. 2). Symptoms of pain (56%) or fatigue (34%)
were also commonly reported alongside conversion
symptoms. There was only one age-related difference in
rates of presentation for the major symptom clusters:
pseudoseizures were seen in 11% of the children
younger than 10 years of age and in 26% of children 10
to 16 years of age (X2 = 4.1, df= 1,p < .05).
The time between symptom onset and diagnosis
ranged from less than 1 week to more than 2 years
(Fig. 3).
27% 27% 0 Subsequent episode
50 M r0First episode
40 -
a30 "I
AO1
"u20:
10-
0o 1 , - 11,1. .. 1-,- .- 1 - 111- 11
<1 week 1-4 weeks 1-6 months 6-12 months >12 months
Duration of symptoms
Fig. 3 Duration of symptoms before diagnosis in children diagnosed with
first and subsequent episodes of conversion disorder.
71
KOZLOWSKA ET AL.
Mental Health
Past or concurrent mental health concerns were
reported for 82 cases (42%). The most commonly
reported mental health concerns were anxiety (n = 45),
depression (n = 31), and previous episodes of con-
version disorder (n = 42). Unfortunately, the study
questionnaire did not differentiate history of psychiatric
illness from concurrent symptoms. However, psycho-
tropic medications were prescribed for 28 (14%) of
cases for a comorbid mental health concern, with
antidepressants being most frequently used.
Clinicians reported a family history of mental illness
in 30% (n = 58) of cases; maternal depression (n = 20)
and anxiety (n = 13) were the most commonly reported
concerns.
Antecedents
In this study, at least one antecedent life event or
stressor was identified for 62% of cases during routine
clinical interview. Two or more significant events or
stresses were recorded for 34% of cases. Family
separation and loss (including recent death of a loved
one and separation from a parent) and family conflict
(ranging from verbal conflict and physical violence to
one child witnessing the attempted murder of a family
member) were the most commonly reported antecedent
events (Fig. 4).
Separation/loss
Family conflict/violence
School/learning stressors
Recent child health issue
Recent family health issue
Bullying
Sexual assault
S7%
Other
0 10
Fig. 4 Antecedent stressors reported by clinicians.
72
Health Service Use
Health service use was high. Children saw an average
of two medical specialists (range 1-5) around the time
of diagnosis. Allied health therapists were involved in
the care of 82 cases (42%). Most cases (78%) were also
seen by or referred to a psychiatrist and/or psychologist
around the time of diagnosis. Most children had
multiple medical investigations including blood tests
(60%), EEG (30%), respiratory/sleep studies (9%), and
videotelemetry (9%), and 104 children (54%) had a
large range of other investigations. Imaging studies
(MRI and/or CT scanning) were conducted in 47% of
children. Admission to hospital was required by 135
(70%) children for an average of 10.2 days (median 6.0
days, SD 12.3, range 1-90 days). Admission to hospital
was more common in children younger than 10 years of
age (55%) than for children 10 to 16 years of age (32%;
x2 = 6.1, df= 1, p < .05), although there was no
significant difference in the duration of admission
between age groups.
It is notable that health service use, including hospi-
talization and number of clinicians involved in care, did
not decline with the diagnosis of subsequent episodes of
conversion disorder. Indeed, there was a trend toward
the duration of hospital admission to be greater for
children with subsequent episodes (mean 13.4 days, SD
16.0 days; first episode duration of hospitalization,
mean 9.3 days, SD 11.9 days,p = .056).
-34%
-20%
14%
8%
6%
20 30 40 50 60 70
Frequency (n)
J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 46:1, JANUARY 2007

DISCUSSION
This study describes the largest series of young
children suffering from conversion disorder. Presenta-
tions of children and adolescents are often complex,
with multiple conversion symptoms and/or comorbid
pain, fatigue, anxiety, and depression. Because of the
ascertainment method used, this study identified
children toward the complex/severe end of the spec-
trum of conversion disorder. However, the clinical
presentation of children was consistent with the
findings of smaller case series of children (Grattan-
Smith et al., 1988; Kotagal et al., 2002; Kramer et al.,
1995) and older age groups (Akagi and House, 2001;
Lieb et al., 2000).
One in 10 Australian child health specialists saw at
least one child with conversion disorder during the
2-year study period. In common with many epidemio-
logical studies, the incidence figures reported are likely
to be an underestimate. There are no clear demographic
or service explanations for the observed differences in
regional reporting rates because the APSU's monthly
surveillance response rate was consistently excellent
across the three eastern seaboard states (96%-97%)
during the study period. However, because most of the
study investigators are based in NSW, it is possible that
clinician awareness of the reporting criteria for the
disorder and/or compliance with the research was raised
through collegial networks in that state. It is tlierefore
likely that the NSW incidence of 4.2/100,000 (95% CI
3.5-5.0/100,000) is a better estimate of the incidence
of conversion disorder in Australian children seen in
specialist pediatric practice.
Health service use was high. Children presenting
with conversion symptoms had multiple investigations
and more than two thirds of children were admitted to
the hospital. These findings demonstrate that although
conversion disorder is not common in children, they
place considerable demands on consulting time and
diagnostic resources and can represent significant
burden of care for families, physicians, and the medical
system.
The association between conversion disorder and
adverse life events and strong negative emotions has
been noted since the 19th century (Carter, 1853).
Recent stressful life events were frequently documented
by clinicians in their case reports. Although it is not
possible to draw conclusions about the association
J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 46:1, JANUARY 2007
CONVERSION DISORDER IN AUSTRALIAN CHILDREN
between antecedent events and conversion disorder
using this methodology, it is worthwhile noting that
unlike early literature that emphasized an association
between conversion disorder and traumatic events such
as sexual abuse, this and other studies (Grattan-Smith
et al., 1988; Lancman et al., 1994; Seltzer, 1985;
Srinath et al., 1993; Wyllie et al., 1999) highlight the
potential impact of more commonplace stressors such as
family conflict and loss of/separation from attachment
figures on whom children rely for care, comfort, and
protection. One possible interpretation is that signifi-
cant disruptions in the family system are as frightening
and traumatic to the vulnerable child, manifesting
somatic and psychological symptoms of distress.,
Limitations
The use of the APSU method in child mental health
research has both strengths and weaknesses. The
principal strength of the APSU and indeed pediatric
surveillance units throughout the world is the excellent
uptake of and response to voluntary, active reporting by
child health specialists. Although in the Australian
health care system, children impaired by conversion
disorder are generally seen by pediatric specialists, some
incident cases of pediatric conversion disorder may
have been managed by general practitioners or health
specialists such as adult psychiatrists who do not
participate in APSU surveillanc6. This number is likely
to be small.
Although case reporting criteria were provided to all
contributors to the APSU, a standardized assessment
protocol was not used to guide the diagnosis and
exclude differential diagnoses. The use of standardized,
clinical diagnostic interviews with prospective cases
often improves diagnostic certainty. However, their
application to our age group and disorder of interest is
debatable. The somatoform disorders are a diagnostic
category for which the gold standard clinician assess-
ment/diagnosis is difficult to proxy with structured
clinical diagnostic interviews. The criteria require
physical, examination and appropriate investigation by
a qualified medical practitioner or corroboration from
medical records. The weakness of our methodology is
that it does not allow for the appraisal of variation in the
reporting clinicians' clinical skills or practice. However,
this concern is mitigated in a number of ways: all
contributors to the APSU have specialist qualifications,
73
KOZLOWSKA ET AL.
suggesting a baseline level of competence; study subjects
were heavily investigated; and it is well documented
that modern imaging technologies have largely over-
come previous findings that organic illnesses were being
misdiagnosed as conversion disorder (Crimlisk et al.,
1998; Goodyer, 1981).
Clinical Implications
The commonly held belief that young children may
be precluded from manifesting conversion symptoms
because of a lack of necessary social or cognitive skills
(Taylor, 1986) needs to be reconsidered. Although
uncommon, children as young as 3 years old present in
pediatric and child and adolescent psychiatry practice
with conversion disorder. Up to one third of these
children experience symptoms and associated impair-
ment for more than 6 months before diagnosis.
Furthermore, the presentations are often complicated
by anxiety, depression, or significant disruptions to the
family system. Vigilance with regard to sexual abuse
and other forms of maltreatment remains a core clinical
responsibility. However, recognition of comorbid
mental health concerns and distress within the child
and family system facilitates early diagnosis and helps
unravel the precipitating and/or maintaining factors for
childhood conversion disorder.
The substantial overlap between somatoform pain
and conversion disorder observed in this and other
studies (Fishbain et al., 1991; Mailis et al., 2001)
suggests that this nosological division may be artificial.
This is consistent with advances in psychophysiology
that suggest that the processing of pain and other
somatosensory information is interdependent and
interacts with the function of motor structures (Craig,
2001; Mailis-Gagnon et al., .2003; Vuilleumier et al.,
2001). Comorbidity of conversion disorder with
symptoms of unexplained fatigue presents a similar
nosological dilemma. However, debate surrounding the
differentiation of conversion disorder, somatoform pain
disorder, and the symptom of fatigue is embedded in a
wider debate about the description, classification, and
treatment of the somatoform disorders (Creed and
Barsky, 2004; Rief and Sharpe, 2004). This debate
cannot be resolved until the specific mechanisms that
underlie conversion symptoms are elucidated. In the
meantime, it is apparent that pain and/or fatigue are
commonly experienced in children and young people
74
with conversion disorder and play an important role in
determining the young person's level of impairment
and the family's decision to seek medical attention.
Finally, this study design did not enable the
monitoring of the course of illness, use of treatment
pathways, relapse rates, family burden of care, or a
thorough exposition of antecedent and maintaining
psychosocial conditions. These are important avenues
for further research and assessment of clinical outcomes.
A better understanding of the course of illness and
use of medical services over time will inform the
allocation of resources to a population of children whose
burden of illness and health service use can be high.
Disclosure: The authorshave no financialrelationships to disclose.
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Sleep-Disordered Breathing, Behavior, and Cognition in Children Before and After Adenotonsillectomy Ronald D. Chervin, MD,
MS, Deborah L. Ruzicka, RN, PhD, Bruno J. Giordani, PhD, Robert A. Weatherly, MD, James E. Dillon, MD, Elise K. Hodges, PhD,
Carole L. Marcus, MBBCh, Kenneth E. Guire, MS

Objectives: Most children with sleep-disordered breathing (SDB) have mild-to-moderate forms, for which neurobehavioral complications
are believed to be the most important adverse outcomes. To improve understanding of this morbidity, its long-term response to
adenotonsillectomy, and its relationship to polysomnographic measures, we studied a series of children before and after clinically
indicated adenotonsillectomy or unrelated surgical care. Methods: We recorded sleep and assessed behavioral, cognitive, and psychiatric
morbidity in 105 children 5.0 to 12.9 years old: 78 were scheduled for clinically indicated adenotonsillectomy, usually for suspected
SDB, and 27 for unrelated surgical care. One year later, we repeated all assessments in 100 of these children. Results: Subjects who had an
adenotonsillectomy, in comparison to controls, were more hyperactive on well-validated parent rating scales, inattentive on cognitive
testing, sleepy on the Multiple Sleep Latency Test, and likely to have attention-deficit/hyperactivity disorder (as defined by the Diagnostic
and StatisticalManualofMentalDisorders,FourthEdition) as judged by a child psychiatrist. In contrast, 1 year later, the 2 groups showed
no significant differences in the same measures. Subjects who had an adenotonsillectomy had improved sdbstantially in all measures, and
control subjects improved in none. However, polysomnographic assessment of baseline SDB and its subsequent amelioration did not
dearly predict either baseline neurobehavioral morbidity or improvement in any area other than sleepiness. Conclusions: Children
scheduled for adenotonsillectomy often have mild-to-moderate SDB and significant neurobehavioral morbidity, including hyperactivity,
inattenti6n, attention-deficit/hyperactivity disorder, and excessive daytime sleepiness, all ofwhich tend to improve by 1 year after surgery.
However, the lack of better correspondence between SDB measures and neurobehavioral outcomes suggests the need for better measures
or improved understanding of underlying causal mechanisms. Pediatriýs 2006;1 17:e769-e778.

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J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 46:1, JANUARY 2007
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TITLE: Conversion Disorder in Australian Pediatric Practice

SOURCE: Journal of the American Academy of Child and
Adolescent Psychiatry 46 no1 Ja 2007
PAGE(S): 68-75
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