Functional symptoms

Functional symptoms are physical symptoms without an obvious physical cause. They can also be called Medically Unexplained Symptoms or Somatic Symptom Disorder. This page from Great Ormond Street Hospital (GOSH) explains about functional symptoms in children and young people and how they can be managed.Everyone can have physical symptoms such as painful or uncomfortable feelings inside the body. Usually they get better on their own, and if they do not, we might ask the doctor about them.

Often a reason for them can be found, but sometimes it cannot, even after the doctor has done a range of tests. If the symptoms continue and get in the way of everyday life we call these Functional Symptoms (FS) or Medically Unexplained Symptoms (MUS).

Functional symptoms are common – one in four children have them – and almost everyone has experienced unexplained physical symptoms such as dizziness, headaches, or tummy aches. It can be frustrating not to know the cause. However, these ‘medically unexplained symptoms’ can be understood better over time.

Most of us have been taught to think of our minds and bodies as separate things. For example, if we have a tummy ache, we may automatically assume that we have caught a tummy bug. It may be surprising to hear that it is equally likely that the tummy ache is due to worry or anxiety rather than a bug.

When people are upset or nervous, our bodies respond in different ways. Many people get headaches or ulcers, while other people might feel dizzy. Each of our bodies has a unique way of showing us how we feel and when we are in need of extra support.

Functional symptoms often occur at times of stress or distress. During stressful situations our bodies might react in different ways. Some common stressful events may include

• Starting a new school
• Being bullied
• Difficulties at school (for example exams, friendship problems)
• Changes in your family (for example loss of a loved one or someone moving away)

Some children with functional symptoms have additional mental health problems. It is important to detect and diagnose these alongside functional symptoms as they may have their own effective interventions or treatments.

They might include anxiety or depression or other difficulties such as Autism Spectrum Disorder and Attention Deficit Hyperactivity Disorder. Sometimes we never work out which came first – the physical symptoms or, for example, the anxiety. In reality it doesn’t matter too much. Both the physical symptoms and the mental health symptoms need treatment and sometimes it is the same treatment for both as the mind and body work closely together.

Many children and families begin their journey by feeling very frustrated because the tests that doctors carry out do not always show why their symptoms are there.

Even though doctors might not be able to find a physical cause for functional symptoms, there are ways to work out why someone is having them. Often a number of issues and stresses come together at the same time, which can then show up as a physical symptom, such as pain or dizziness.

It might take a lot of thinking to work out what is going on – everyone will need to work together like detectives to work out what is causing the issue or stress. This might include paediatricians, neurologists, psychologists, psychiatrists and school staff. One or more of these professionals need to work together in order to recognise and diagnose functional symptoms.

Once professionals have an idea of what might be causing the functional symptoms, they can start planning with you how to deal with them.

We would recommend that your child is assessed by a team who knows about functional symptoms such as a mental health (CAMHS) team or similar who will be able to generate tailored recommendations for your child.

However, there may be steps that you can try at home and at school to help your child get started on the road to a full recovery. You and your child’s GP can begin by identifying some lifestyle changes and goals.

Your child’s school also needs to understand how best to help your child when they experience functional symptoms. Health professionals might contact them to provide advice. It’s vital that the teachers also understand what functional symptoms are.

Generally a mix of different factors will play a part in the symptoms starting, continuing and getting better. These are likely to include biological (physical body), psychological (thoughts and feelings) and social aspects (friends, family and life circumstances) factors.

It can be useful to divide these factors into four groups: predisposing, precipitating, perpetuating and protective, as follows:

These are what makes a child more likely to get functional symptoms at some point.

Examples of predisposing factors include:

• Someone else in the family having functional symptoms – there is evidence that both genetics and family beliefs play a part in developing functional symptoms.
• Being an anxious or perfectionist kind of person.
• Long-standing stress, where our bodies are on constant high alert waiting for something to happen. For example, living with a family member with a long term health condition or living in dangerous circumstances.
• Other neurological or developmental difficulties, such as Autism Spectrum Disorder, Attention Deficit Hyperactivity Disorder (ADHD), learning difficulties, can increase the likelihood of developing functional symptoms.

Autism can make social communication and understanding friendships difficult, especially in teenage years when this becomes more complicated. It is also difficult for people with autism to understand and identify their emotions, and instead they may express emotions in a physical way.

ADHD can also mean that a young person may miss social cues or respond impulsively, and this can lead to difficulties with friends, as well as criticism from teachers.

Learning difficulties that are not recognised can lead to confusion and a sense of underachievement.

These are what set off or trigger the child’s functional symptoms.

Examples of precipitating factors include:

• Physical injury, infection or illness, where for example, pain may continue long after the injury has healed. 
• Distressing life events, such as parents splitting up or moving to a new area or experiencing loss of someone special.
• Confusing results and opinions from health professionals trying to find the cause of functional symptoms.

These are what keeps someone’s functional symptoms going.

Examples of perpetuating factors include:

• Reinforcing responses to symptoms such as talking a lot about them or using them as a source of comfort or reassurance.
• Stopping playing a full part in school life or normal everyday family activities.
• Having lots of medical examinations and tests that might not be needed (because this can make someone feel even more uncertain and worried).
• Having treatment for the physical symptoms rather than both physical and psychological – this separates the mind and body even further.

These work against the predisposing, precipitating and perpetuating factors to help protect against developing more severe symptoms and may help make them better.

Examples of protective factors include:

• Good understanding of symptoms and the stressors that might be causing them.
• Good social resources like supportive friends, school and family.
• Parenting that is kind and supportive, with family members working together ‘on the same page’, providing clear boundaries and consistent responses.
• Avoiding responses and actions that may reinforce the symptoms, for instance, allowing a child to avoid household chores in case it hurts.
• Support from school to address emotional, social and academic development.
• Getting quick and effective help for any mental health difficulties that go with the symptoms. 

Most children's functional symptoms can get better very quickly and may not need any specialist support at all. For others this journey might take a little longer.

It is common for children with functional symptoms to become more and more restricted by their symptoms over time. First of all, they might have to take time off school or do less around the house. They might stop seeing friends, avoid going to shops at busy times or stop using public transport for fear of having unpleasant symptoms.

For some, the symptoms become so disabling that they don’t leave home at all. We know that the more life becomes restricted in this way, the more distressed the child and their family becomes. This can lead to worsening of, or further symptoms. It can become a vicious cycle – but this can be broken!

There are things that everyone in the family, including your child, can do to improve functional symptoms:

• Reduce time spent thinking and talking about physical symptoms – if possible, replace this with other quality time, one-to-one, or as a family.
• Once doctors have told you that your child’s symptoms are functional, try to avoid further medical consultations and investigations. We know this is likely to make you all feel worse and for your child’s symptoms to last longer.
• Of course, if something completely different arises then discuss this with your GP. It is often possible to have a variety of different functional symptoms, so keep this in mind during this discussion.
• Tell your family members, your child’s school and friends about the symptoms, but remember to let them know not to make too much of a fuss over them!
• Gradually encourage your child to resume more activities, such as walking to the shop alone, going out with their friends, starting swimming again, even at times when they have the symptoms.
• Plan regular fun activities, such as taking a walk in the park, going for a swim, seeing friends and make sure they happen even when they have symptoms.
• Keep lines of communication open with your child. Make time for your child to open up about how they are feeling. Give your child time if they need it; some people find it hard to explain how they feel, and they may need for you to model this for them (for example, saying that you feel sad, anxious, excited or happy). If they struggle to talk about their feelings, try to think of non-verbal ways to help them describe their feelings.
• Help your child to stay healthy. This includes eating a balanced and varied diet, getting fresh air and exercise and getting enough sleep each night. Have a look at our sleep hygiene information sheet for ideas.

When we focus our attention on our body this can make everything feel bigger or worse! Most of the time we are unaware of the thousands of sensations in our bodies every minute.

Yet as soon as something feels wrong, and we focus on it, we feel the sensations more, and sometimes we can start to interpret sensations as symptoms.

The reactions of others (whether it’s reassurance or calling an ambulance) can unconsciously lead to this experience being repeated.

Changing this habit this can take a bit of time, and getting the balance between offering a supportive comment and reacting in a way that will reinforce your child’s behaviour, can be tricky to get right.

A very common issue is the tendency to do too much too quickly. On one day, your child may feel really motivated to recover and do a lot of activity. This may leave them feeling exhausted for the next few days and completely demotivated with regards to their recovery.

This pattern of increased activity followed by sudden reduction of activity is called ‘boom and bust’. This is really common when people have a goal and want to achieve it quickly such as going to the gym every day when determined to lose weight!

To overcome this, you need to support your child to think about gradually increasing their amount of activity. You may notice that their symptoms increase as they increase their activity level and they might have concerns that they are causing damage to their body or making things worse.

It is important to remember that over time, their body has got so used to not working in a certain way that any increase in activity level may create unusual experiences in the body. They are not causing damage; they are retraining their brain to help their body move in the way it did previously. With time, their body will recover from these difficulties, but it may be a bumpy ride to get there.

Most children make a full recovery from their symptoms, no matter how bad their symptoms might be at the start.

Some children may require treatment to get better. Although children with functional symptoms are usually first seen by family doctors (GP) and paediatricians (specialist children’s doctors), the successful treatments are usually provided by psychologists and psychiatrists.

This type of treatment can be accessed via your local community Child and Adolescent Mental Health Team (CAMHS) who will meet with you and your child to work out what support is needed. In some cases, they may ask a more specialist team to help.

Some children may also benefit from psychological support such as Cognitive Behavioural Therapy (CBT). This has been shown to reduce the frequency and intensity of physical symptoms. It can also help to identify new ways of coping and managing difficult emotions.

Some children may also benefit from medication for anxiety or depression. The doctors working with your child will always think about this carefully and discuss it with you.

We know that psychological treatment can be very effective. It can make symptoms reduce and happen less often, or make it easier for the child to get on with their normal life despite the symptoms.

In other words, although some of the child’s symptoms may carry on after treatment, importantly the symptoms no longer get in the way of their lives.

• Your child’s functional symptoms are real – not ‘made-up’ or ‘in the head’
• Sometimes several issues or stressors may come together to bring about the physical symptoms.
• Sometimes a ‘reason’ for symptoms is never found – they go away as mysteriously as they arrived.
• Most of the time young people with functional symptoms will recover completely.