Kasia Kozlowska

• The University of Sydney

Each field’s intellectual and behavioral standards, including its ethical standards, come to be embodied, over time, in each trainee through the process of professional education and clinical training. This chapter examines the social processes by which newcomers, initially outsiders, become part of a professional community. What we see is that the...

In this chapter we introduce the themes of the book. We highlight the challenges of addressing ethical problems of one kind or another as they arise throughout the clinician’s workday. We introduce the reader to some of the distinctions and concepts that we’ve used in our earlier writings and that are explored in much more detail in this book. The...

We have just looked at the role of informal ethical discourse and the touchstone questions in responding to discrepant experiences (Chapter 8). In this chapter we look at the role of informal ethical discourse and a parallel set of concrete clinical questions in determining the course of prospective action. In such situations we need to identify ou...

By the time students enter professional school in health care, they have developed their own distinctive ways of thinking, feeling, acting, and communicating and interacting with others. They have also had long previous experience with roles and role-playing that helps set the stage for their understanding of what is required in their future roles...

The touchstones for learning, which arise at the interface of affect and intellect, mark our encounters with the unexpected. This experience of discrepancy then leads us to ask what has happened, and why? How do we deal with the discrepancy? In this sense our action frameworks, as discussed in Chapter 6, have a fundamental, dual role in clinical ex...

The touchstone questions—the last step of the touchstone process—play a central role in informal ethical discourse, clinical decision-making, and health professionals’ communication with other health professionals and with patients and families. As we will see, the touchstone questions engage the whole person, and it is as whole persons that clinic...

Moral development begins in childhood and continues into adolescence and adulthood, and through each clinician’s professional life. Elements of ongoing moral experience—fairness, autonomy, truthfulness, trust, doing good/avoiding harm, solidarity, and moral judgment—are part of the essential background of knowledge, experience, and informal ethical...

The shared, lived experience of individuals within a professional community generates the local moral processes that shape and maintain the community, its values, and its commitments. This chapter explores three different conceptions of communities in which shared processes shape the lives and values of community members: interpretive communities (...

This chapter highlights the challenges involved in nurturing the clinician’s voice, and it also includes some attention to sources of professional dysfunction. We introduce the action cycle as a way of understanding the sequence that begins with one’s baseline experience, moves through the touchstone process, and then proceeds to judgment, action,...

As an alternative to the “standard mode” of clinical ethics, with its typical emphasis on formal ethical reasoning (often including ethical principles) and other forms of “top-down” analysis, we suggest that clinical ethics is better understood in terms of socio-institutional processes. It is just such processes that are at work in Stanley Fish’s i...

In this chapter we look at how clinical skills develop over time, at the diversity of skills to be learned, and at the inherently social and interactive character of the learning process. Learning to identify when something has “gone wrong”—that is, to identify discrepancies from what was expected—is a crucial element of this process of learning cl...

At the outset of their health care education, all students already possess sophisticated, well-developed action frameworks that enable them to think about ends, means, and the need for ongoing adjustments. These frameworks are supported by capacities and skills that include the following: moral capacities; cognitive, perceptual, and affective capac...

We begin this concluding chapter by explaining just what we mean by revitalizing health care ethics. We see clinical ethics as embodied in clinicians and as maintained through the socio-institutional processes of the interpretive communities that define each particular field of health care. We stress the importance of respecting and building upon t...

From the early years of this century, many Western countries adopted the “Dutch Protocol” as a new medical pathway for treating children and adolescents with childhood-onset gender dysphoria. On this approach, gonadotrophin-releasing hormone agonists (GnRHa) were used to suppress puberty, followed by cross-sex hormones (testosterone or oestrogen)....

Introduction: Functional neurological disorder (FND) is a neuropsychiatric disorder that manifests in a broad array of functional motor, sensory, or cognitive symptoms, which arise from complex interactions between brain, mind, body, and context. Children with FND make up 10%-20% of presentations to neurology services in children's hospitals and u...

Robust evidence from adult samples indicates that neurocognitive dysfunction is a hallmark of many mental illnesses, contributing to the loss of daily function and quality of life that these illnesses cause. However, it is still unclear whether neurocognitive deficits associated with mental illnesses begin to manifest well before adulthood or impac...

Objectives In vivo magnetic resonance spectroscopy (MRS) was used to investigate neurometabolic homeostasis in children with functional neurological disorder (FND) in three regions of interest: supplementary motor area (SMA), anterior default mode network (aDMN), and posterior default mode network (dDMN). Metabolites assessed included N-acetyl aspa...

Over the last decades, theoretical perspectives in the interdisciplinary field of the affective sciences have proliferated rather than converged due to differing assumptions about what human affective phenomena are and how they work. These metaphysical and mechanistic assumptions, shaped by academic context and values, have dictated affective const...

Previous studies suggest that subjective distress in children with functional neurological disorder (FND) is associated with stress-system dysregulation and modulates aberrant changes in neural networks. The current study documents illness-promoting psychological processes in 76 children with FND (60 girls and 16 boys, aged 10.00−17.08 years) admit...

Learning objectives: • Develop and implement treatment plans for children and adolescents with functional neurological disorder (FND)• Outline a plan to increase awareness and standardize the care for patients with FND using evidence-based interventions. Abstract: Functional neurological disorder (FND) in children and adolescents involves the bi...

This prospective case-cohort study examines the developmental pathway choices of 79 young people (13.25–23.75 years old; 33 biological males and 46 biological females) referred to a tertiary care hospital’s Department of Psychological Medicine (December 2013–November 2018, at ages 8.42–15.92 years) for diagnostic assessment for gender dysphoria (GD...

Functional neurological (conversion) disorders (FNDs) in children are neuropsychiatric disorders involving complex interactions between the brain, mind, body, and context—the lived experience of the child and the family. The last two decades have seen important advances in our understanding, diagnosis, assessment, and treatment of FNDs in children....

This treatment manual stems from a program developed by the mind-body team at The Children’s Hospital at Westmead, a tertiary care paediatric hospital in New South Wales, Australia. The team’s Mind-Body Program, organised as part of a consultation-liaison psychiatry service within the Department of Psychological Medicine, works with young people wh...

Background: The emergence of acute-onset functional neurological symptoms, the focus of this study, is one of three stress responses related to immunisation. This case-control study documents the experience of 61 young people with past or current functional neurological disorder (FND) in relation to the COVID-19 vaccination program in Australia....

Background: Between 2019 and 2022, there was a marked rise in adolescents/young adults seeking urgent help for functional tic-like behaviours (FTLB). Given the global scale of this phenomenon, pooling cases in an international registry is needed to better characterize this spectrum and facilitate future longitudinal observation. Methods: An inte...

Objectives Previous studies with adults suggest that aberrant communication between neural networks underpins functional neurological disorder (FND). The current study adopts a data-driven approach to investigate the extent that functional resting-state networks are disrupted in a pediatric mixed-FND cohort. Methods 31 children with mixed FND and...

We present here a unifying framework for affective phenomena: the Human Affectome. By synthesizing a large body of literature, we have converged on definitions that disambiguate the commonly used terms—affect, feeling, emotion, and mood. Based on this definitional foundation, and under the premise that affective states reflect allostatic concerns,...

Introduction: Since exposure to potentially traumatic events during childhood and adolescence has been shown to be very common, its screening is very important. Our aim was to develop a self-assessment checklist to perform screening of potentially traumatic events in childhood and adolescence. Methods: The development of the Checklist of Potential...

Purpose of Review Functional neurological disorder (FND) is a multi-network brain disorder that encompasses a broad range of neurological symptoms. FND is common in pediatric practice. It places substantial strains on children, families, and health care systems. Treatment begins at assessment, which requires the following: the medical task of makin...

Objective Stress system dysregulation is considered to have an important role in the aetiology of paediatric functional neurological (conversion) disorder. This study examined salivary cortisol and α-amylase awakening responses in children with functional neurological disorder to determine activation patterns of the hypothalamic–pituitary–adrenal a...

Aim: To report the prevalence and clinical characteristics of children with rapid onset functional tic-like behaviours during the COVID-19 pandemic. Methods: Single centre, retrospective cohort study of children (<18 years) referred to the tic clinic from January 2018 to July 2021. We calculate the prevalence of newly diagnosed functional tics,...

Treatment of children (including adolescents) with functional movement disorder involves a biopsychosocial (holistic) approach. In a well-conducted medical assessment for FND, the pediatric neurologist establishes a good therapeutic alliance, makes a positive diagnosis of functional neurological disorder (FND), provides a clear explanation, and dir...

Gender dysphoria, characterised by distress associated with an incongruence between an individual's assigned and experienced gender, is encountered in 1%-2% of children and adolescents. Recent findings suggest neurodevelopmental disorders (NDDs), including Autism, are frequently reported among youth with Gender Dysphoria. This study aims to explore...

Children and adolescents with functional neurological (conversion) disorder (FND) present with symptoms of impaired motor and sensory function. FND involves complex interactions between the brain, mind, body, and lived experience of the child. The gold standard for treatment is therefore a holistic, biopsychosocial approach with multimodal interven...

Amongst the most important conditions in the differential diagnosis of epilepsy is the one that manifests as paroxysmal of altered behaviour, awareness, sensation or sense of bodily control in ways that often resemble epileptic seizures, but without the abnormal excessive or synchronous electrical activity in the brain that defines these. Despite t...

Asylum-seeking children presenting in the shutdown state have been the subject of much discussion and controversy—on both government and medical system levels—in Australia and in Sweden. In this article, we conceptualize the shutdown state as an evolutionary response to extreme threat. We adopt a neuroscience approach to present five plausible mode...

As members of a multidisciplinary team of professionals who treat children and adolescents with functional neurological (conversion) disorder (FND), we highlight the pressing need to develop an FND-informed culture of care that takes into account recent advances in our understanding of this group of patients. Stories of clinical encounters in healt...

Patients with epilepsy have their authorisation to drive restricted under detailed guidelines, but the rules for those with non-epileptic seizures are far less clear. We surveyed specialist clinicians in Australia and found little agreement as to whether such guidelines existed for non-epileptic seizures or what they might be. A number of possible...

The human, as a biological system, is an open system embedded within larger systems —including the family, culture, and socio-political environment. In this context, a patient with functional seizures (FS) is embedded in relationships, educational/professional institutions, culture, and society. Both connection to these broader systems and the qual...

Functional neurological disorder (FND) is a prevalent, disabling and costly condition at the neurology–psychiatry intersection. After being marginalised in the late 20th century, there has been renewed interest in this field. In this article, we review advances that have occurred over the past decade (2011–2020) across diagnosis, mechanisms, aetiol...

Functional neurological (conversion) disorder (FND) was of great interest to early clinical neuroscience leaders. During the 20th century, neurology and psychiatry grew apart - leaving FND a borderland condition. Fortunately, a renaissance has occurred in the last two decades, fostered by increased recognition that FND is prevalent and diagnosed us...

This prospective study examines the clinical characteristics of children ( n = 79; 8.42–15.92 years old; 33 biological males and 46 biological females) presenting to a newly established, multidisciplinary Gender Service in New South Wales, Australia, and the challenges faced by the clinicians providing clinical services to these patients and their...

The current study examines patterns of attachment/self-protective strategies and rates of unresolved loss/trauma in children and adolescents presenting to a multidisciplinary gender service. Fifty-seven children and adolescents (8.42–15.92 years; 24 birth-assigned males and 33 birth-assigned females) presenting with gender dysphoria participated in...

“This book, at the intersection of mind-body medicine, is a must-read … The authors have done a masterful job of linking together emerging cutting-edge biology with case-based discussions and practical treatment suggestions to aid the development of a mind-body program. Functional disorders are common in pediatrics, and this book is a major advance...

In this chapter we continue our exploration of the neurobiology of functional somatic symptoms by considering the role of the brain. The brain plays a key role in regulation, in coordinating the stress response, and in helping the child adapt to the circumstances of living over time. Every component of the body stress system—the HPA axis, autonomic...

In this chapter we outline the key principles that are built into the structure of our Mind-Body Program and into the interventions we undertake with any particular child. The principles are especially useful in the following circumstances: in assessing a referral for treating functional somatic symptoms; in setting up the multidisciplinary team ar...

Cognitive and other psychological processes on the mind level of operations are amenable to conscious manipulation, and they provide a therapeutic window for change. These psychological processes can have a powerful top-down effect, with the capacity to contribute to the child’s efforts to regulate her stress system, her body more generally, and he...

In this chapter we continue our exploration of the neurobiology of functional somatic symptoms by considering the skeletomotor system. When the stress system activates, the skeletomotor system activates in tandem, to prepare the body for protective action. And when protective action is no longer necessary, the skeletomotor system typically deactiva...

In this chapter we continue our exploration of the neurobiology of functional somatic symptoms by considering the role of the hypothalamic-pituitary-adrenal (HPA) axis. It is a complicated system that helps to regulate energy, and that affects cell function and gene expression, throughout the body. In addition to playing a fundamental role in body...

This chapter introduces the reader to the stress-system model for functional somatic symptoms through the personal journey of the first author. The stress-system model provides clinicians with a framework for thinking about the neurobiology of functional somatic symptoms and for explaining them to children and their families. The components of the...

Children are born into a family and shaped by the relationships, interactions, beliefs, stories, and experiences within the family system. In this way, the health of the family and the health of the child are closely interconnected, and interventions with children presenting with functional somatic symptoms must always involve the family. All the i...

The paediatrician has a central role as a gatekeeper both in diagnosing functional somatic symptoms and in directing the child and family onto a path toward health and well-being. In addition to determining that the child’s symptoms are not caused by a disease process, the paediatrician provides the child and family with a positive diagnosis that s...

We begin our exploration of the neurobiology of functional somatic symptoms with the circadian clock because every organ, tissue, and cell in our body has a circadian rhythm—and all components of the stress system are regulated by the circadian clock. The integrity of the circadian clock is important in health and dis-ease, and is often dysregulate...

In this chapter we continue our exploration of the neurobiology of functional somatic symptoms by considering the autonomic nervous system. In response to stress, the autonomic system activates into defensive mode to prepare the body for protective action. And when protective action is no longer necessary, the system typically deactivates. But if t...

Functional somatic symptoms involving the gut are common in children and adolescents. The human gut has a close symbiotic relationship with the microorganisms that live inside it. When this relationship is going well, the microbiota—the community of organisms that live inside the gut—and the gut work together to break down food to provide both the...

In this chapter we continue our exploration of the neurobiology of functional somatic symptoms by considering the mind level of brain operations. Consciousness—the state of being aware, especially (for our purposes) of something within oneself—adds another dimension to the neurobiological systems that regulate body state. Among the objects of consc...

In this brief conclusion we take a step back and reflect on the continuing need for health professionals and health care systems to develop a more holistic (systemic), mind-body approach to diagnosing and managing functional somatic symptoms in children and adolescents. And as we have seen, specialized multidisciplinary, multimodal programs are nec...

In this chapter we continue our exploration of the neurobiology of functional somatic symptoms by considering the role of the immune-inflammatory system. This system functions like a watchdog that is gifted with prescience. It holds memory for past threats to the physical or psychological well-being of the child. It activates—into defensive mode—in...

The clinical encounter with the mental health clinician—or multidisciplinary team—typically begins in the family assessment interview, where engagement and rapport building between the clinician and the family take place through a series of therapeutic processes. First comes the process of generating a narrative. The child or adolescent and family...

This chapter sets the scene for the rest of the book. Across time and across cultures, functional somatic symptoms have presented under many different guises, been given many different names, and been conceptualized in many different ways. Theories and speculation have therefore abounded, but without any firm scientific foundation. It is only very...

From the perspective of the stress-system model, the treatment of functional somatic symptoms involves a system-level approach. The factors that contribute to stress-system dysregulation and the emergence of functional somatic symptoms operate, both proximally and over longer periods, on different system levels: body, mind, attachment and family re...

Aim Children and adolescents with functional neurological disorder (FND) present with physical impairment and mental health comorbidities. Specialist physiotherapy programs for treating FND have been developed over the last two decades. This article reports outcome data from three cohorts of children treated with a multidisciplinary rehabilitation...

Functional neurological (conversion) disorder (FND) is a prevalent and disabling condition at the intersection of neurology and psychiatry. Advances have been made in elucidating an emerging pathophysiology for motor FND, as well as in identifying evidenced-based physiotherapy and psychotherapy treatments. Despite these gains, important elements of...

Objectives Psychogenic non-epileptic seizures (PNES) have been hypothesized to emerge in the context of neural networks instability. To explore this hypothesis in children, we applied a graph theory approach to examine connectivity in neural networks in the resting-state EEG in 35 children with PNES, 31 children with other functional neurological s...

Children with functional neurological disorder (FND) present with motor and sensory neurological symptoms that impair health and physical functioning and that create an ongoing clinical burden for caregivers and hospitals worldwide. Treatment programs for these children involve a multidisciplinary approach with physical therapy as a fundamental com...

Objectives This International League Against Epilepsy (ILAE) Report: (a) summarizes the literature about “driving and psychogenic nonepileptic seizures (PNES)”; (b) presents the views of international experts; and (c) proposes an approach to assessing the ability of persons with PNES (PwPNES) to drive. Methods Phase 1: Systematic literature review...

Objectives We aimed to identify existing outcome measures for functional neurological disorder (FND), to inform the development of recommendations and to guide future research on FND outcomes. Methods A systematic review was conducted to identify existing FND-specific outcome measures and the most common measurement domains and measures in previou...

The development and selection of optimal outcome measures is increasingly recognized as a key component of evidence-based medicine, particularly the need for the development of a standardized set of measures for use in clinical trials. This process is particularly complex for functional neurological disorder (FND) for several reasons. FND can prese...

Accumulating evidence indicates that psychological and neurophysiological processes interconnect and interact to activate the body’s stress system and to trigger and maintain functional somatic symptoms. This study used the Early Life Stress Questionnaire, Depression Anxiety Stress Scales and biological markers (heart rate, heart rate variability,...

The role of peripheral physiology in the experience of emotion has been debated since the 19th century following the seminal proposal by William James that somatic responses to stimuli determine subjective emotion. Subsequent views have integrated forebrain’s ability to initiate, represent and simulate such physiological events. Modern affective ne...

There is accumulating evidence that patients with functional neurological symptom disorder (FND) show activation of multiple components of the stress system—the hypothalamic–pituitary–adrenal axis, autonomic nervous system, and brain regions involved in arousal- and emotion-processing. This study aims to examine whether the immune-inflammatory comp...

Objective To estimate the paediatrician-diagnosed incidence of chronic fatigue syndrome (CFS) in Australia, and describe demographic and clinical features, as well as approaches to diagnosis and management. Methods The Australian Paediatric Surveillance Unit facilitates monthly national surveillance of uncommon conditions seen by paediatricians. D...

In this article, we present the first in depth linguistic study of human feelings. While there has been substantial research on incorporating some affective categories into linguistic analysis (e.g. sentiment, and to a lesser extent, emotion), the more diverse category of human feelings has thus far not been investigated. We surveyed the extensive...

Functional somatic symptoms (FSS) emerge when the stress system is activated in response to physical or emotional stress that is either chronic or especially intense. In such cases, the heightened state of physiological arousal and motor activation can be measured through biological markers. Our team have integrated the use of biological markers of...

In this chapter we continue the exploration of ethics as embedded in thought, emotion, and action. We begin by discussing two cases, one of which presents a sharp conflict, one of which does not, and both of which use the goal-directed, concrete language of clinical medicine as the health professionals work out their differences, the challenges pre...

What to teach? How to teach it? These are the central questions for teaching professional ethics to trainees in health care, as they are for teaching any students in any subject in any field. The answers we present here and in the coming chapters build upon the criticisms of bioethics from sociology, history, and anthropology, as discussed briefly...

This chapter weaves together the various themes presented in earlier chapters: ethics and the self; informal versus formal ethical discourse; fast and slow thinking; the embeddedness of informal ethical discourse in the various interpretive communities of health care; the need to rely on, and use, informal ethical discourse in teaching health care...

Unlike what happens in the classroom, where discussions can end in conflict, with agreement nowhere in sight, ethical problems in clinical health care require that decisions be made. Some form of closure is required in order to move forward. And closure can be elusive indeed. In this chapter we look at efforts to achieve closure through the use of...

In this chapter we introduce the themes of the book and present our overall approach to clinical ethics for health professionals. Of special note is our assumption that the social sciences—especially history, sociology, and anthropology/psychology—can do much to enrich how health professionals think about clinical ethics. We also provide an overvie...

The bioethics movement, originating in the United States but then expanding to become a worldwide phenomenon, generated a conception of ethical reasoning that is oriented toward ethical (and legal) rights—and also, more abstractly, toward ethical principles. These modes of reasoning, though useful and even powerful tools for trained philosophers an...

Presenting a full formal curriculum for teaching ethics to health professionals is obviously far beyond the scope of this single chapter. But what we can do here is discuss a range of teaching formats—core lecture course, discussion classes, and observational and participatory activities—that can be used in any field of health care, along with an e...

In this chapter we focus specifically on teaching health care ethics in clinical settings rather than the classroom, through formal courses. The clinical opportunities are diverse, often ad hoc, and usually connected up with current clinical cases. We also discuss the use of formal clinical modules and the role of mentoring as ways of enriching and...

In this chapter we begin the process of rebuilding clinical ethics in health care—from the ground up. Clinical ethics, like all ethics, has its foundation in the self—in a full conception of the person whose thoughts, emotions, and actions must be understood as an integrated whole. It is from that foundation that one can then start building, for al...

This book has its origins in the work of the first author (SS) as a researcher, teacher, and consultant in the 1980s. During that period, the growing interest in bioethics was coupled with a growing distrust of doctors and the medical profession. To capture that particular historical period and how the first author’s views about ethics and health c...

The bioethics movement did not arise and expand in a vacuum. As discussed in this chapter, advances within medicine were creating a need for ethical issues to be identified and addressed. Major new work in philosophy suggested that philosophically trained “bioethicists” could uniquely contribute to ethics in medicine. The growing momentum of the co...

The goal of this open access book is to develop an approach to clinical health care ethics that is more accessible to, and usable by, health professionals than the now-dominant approaches that focus, for example, on the application of ethical principles. The book elaborates the view that health professionals have the emotional and intellectual reso...