Introduction

You might have often heard about people faking disease or mental illness, at times either subconsciously or to gain another’s sympathy. This disorder is clinically termed Munchausen's or factitious disorder and manifests itself as a personality disorder, usually as a result of childhood neglect or trauma. 

The opposite of this disorder, where one has a lack of awareness of their illness and disease, is termed anosognosia, the disorder rendering you blissfully unaware of pain. In this condition, an individual is unable to determine or fails to recognise the existence or extent of the disease that encompasses them. Usually, tending to affect individuals with neurological issues, such as schizophrenia or memory disorders like dementia. Denial of the illness does tend to be one of the main symptoms of a number of disorders; they show involvement of the central nervous system as well as the psychological processes of being in denial. This disorder tends to be more prevalent in the adult population, although it is now emerging to be present within the adolescent population as well. This article aims to give you an overview of anosognosia mainly focusing on its impact on children, highlighting the characteristic changes that separate it from the adult populations. Further, we delve into the neurobiological underpinnings and diagnostic criteria followed by management strategies. 

What is anosognosia?

Anosognosia, originating from the Greek words “nosos” meaning disease, and “gnosis” meaning knowledge, translates to the term implying a lack of knowledge or awareness about one's disease or condition. This condition was first highlighted by a French neurologist who was describing patients afflicted with paralysis of the left side of their body.¹ In most cases, it occurs across multiple disorders ranging from psychiatric to neurological. Often after damage to the right parietal lobe of the brain, usually during ischemic strokes.²

Figure 1. Labelled lobes of the brain. With the frontal lobe coloured yellow and the parietal lobe darker blue. Source: Shutterstock.

Although this condition can be traced to certain neurological disorders affecting the individual’s brain function and structure. Undergoing traumatic brain injury, stroke, dementia and Alzheimer's disease (to name a few conditions) could cause the onset of an individual’s inability to gauge their pain levels and other illnesses.

How is juvenile anosognosia different?

Juvenile anosognosia shares its similarities with adult-onset anosognosia for certain symptoms but may overall present differently as it begins at the developmental stage. Children with bipolar disorder, diabetes, ADHD or Asperger’s syndrome seem to react most commonly with symptoms relating to anosognosia. Tending to lash out in disbelief and denial at times - as unlike adults, adolescents may lack emotional and cognitive maturity - children being diagnosed with certain conditions understandably can potentially react in a more “aggressive” manner to cope with their lifelong diagnosis that seemingly has no direct cure but can only be managed with routine hospital visits. People who suffer from this condition are more likely to get arrested or become homeless.

Causes and effects of anosognosia in children

Anosognosia is a mental condition that resonates in the brain of the afflicted individual. The frontal and parietal lobes of the brain are the regions that are rudimentarily affected in afflicted adolescents. 

Frontal lobe dysfunction

Figure 2. Highlighted frontal lobe region of the human brain. Source: Shutterstock.

The frontal lobe in the brain is present in the front of the brain and controls your movement as well as thoughts and reactions.³ It helps take in the information around you, organise it and present an accurate image. Dysfunction in the frontal lobe can lead to a lack of awareness and improper functioning of this frontal lobe. 

• Emotional regulation: The frontal lobe affects the processing and emotional regulation of the individual. Dysfunction in the region can lead to rapid mood changes or emotional numbness making the afflicted individual unable to appropriately respond or perceive their own disorder’s symptoms or limitations.
• Impairment in self-reflection: Dysfunction in the frontal lobe can cause difficulties in appropriately introspecting upon oneself, reducing the capability of one to accurately gauge their emotional state. Self-assessment and self-awareness are compromised in anosognosia due to comorbid psychiatric or neurological conditions. 

Parietal lobe dysfunction

Figure 3. Highlighted parietal lobe of the human brain. Source: Adobe Stock.

The parietal lobe is present on the top of your head; it helps regulate sensory input, aiding in the perception of sensation, as well as in the processing of auditory and visual information. Dysfunction in the parietal lobe leads to:

• Issues in body perception: Colloquially known as body dysmorphia, paired with frontal lobe dysfunction; it could lead to the brain’s perception being skewed of one’s self-image. Changing the way the individual views their body and shape leads to inaccurate perceptions of themselves. This dysmorphia can add to a lack of sensory or motor awareness.
• Spatial unawareness: Dysregulation in the parietal lobe can lead to hemispatial neglect, where individuals have a difficult time perceiving their visio-spatial environment. Causing them to bump into objects around them due to a failure to recognise the distance between themselves and the object or surface around them.

Symptoms of juvenile anosognosia

Individuals, including adolescents, tend to have a tendency to not acknowledge or recognise the medical issue that they have. Since patients lack awareness of their own illnesses, it then correlates that the individual must be afflicted with some sort of mental or other health condition in order to experience the onset of anosognosia. Self-awareness is spread over a broad region of an individual’s brain and hence involves parts of both, the frontal as well as the parietal lobe. 

The symptoms of juvenile anosognosia can vary depending on the underlying cause and specific functions that are affected by the condition. Some of the common symptoms of this condition are:

• Unconcerned attitude: In their daily lives, children afflicted with this illness tend to display a lack of care and concern about the impairments that affect their lives, even when they experience significant hindrances and issues in academic performance and daily activities.
• Behavioural changes: An increase in impulsivity, irritability, and the prevalence of emotional numbness can tend to be a result of frustrated feelings from the difficulties in coping with their impairments, even when they are unaware of the underlying reasons for the behaviour.
• Social isolation: Children could have certain social difficulties due to their impaired awareness of their environment due to their inability to recognise their conditions. They tend to have difficulties maintaining relationships, isolate themselves, and inability to participate in group activities. 
• Motor impairments: Difficulty in carrying out their motor skills and lacking sensory awareness of the objects around them, constantly bumping into it and hurting themselves is quite common in due to parietal lobe dysfunction. This can further cause feelings of frustration and issues in cognitive functions. 
• Academic decline: Juvenile anosognosia can tend to lead to a decline in academic performance. The child might struggle in academic surroundings due to the inability to properly carry out tasks requiring attention, memory, or cognitive skills.

Diagnosis and treatment of juvenile anosognosia

For someone afflicted with anosognosia, especially someone who is an adolescent, this is quite a frustrating condition. The inaccurate perception of pain and other conditions seems real and convincing, causing them to perceive themselves with inaccuracy. These misinterpretations can cause them to get into conflicts with the adults around them and refuse treatment. A lack of insight can also cause them to stop taking their required medication and halt treatment, hence often being combined with mania or psychosis. The lack of insight can cause unsociable and reckless behaviour seeming to be quite frustrating and tedious on the people around them at times. 

The adults around the adolescent must be aware and sensitive to the behaviours around them.

When noticing a child presenting any of the above-mentioned symptoms to a concerning degree, the local GP or healthcare provider must be sought out for guidance. Traditional assessment methods to assess adults via clinical interviews and self-report questionnaires are not used since they may not be reliable for assessing children. Instead, a conglomeration of self-awareness is assessed using: 

• Performance-based tests, 
• Behavioural observations, and 
• Caregiver reports paired with speaking to the adolescent is opted for

Connectivity and brain activity between the afflicted regions are examined using brain scans. Looking for any disruptions between brain networks that could potentially affect social cognition and self and sensory perception.

Using further advanced techniques like fMRI scans or diffusion tensor imaging - measuring the white matter in the brain. Aiding in measuring the neural correlations to anosognosia in children with greater accuracy. For example, aberrant white matter connectivity in the prefrontal cortex and disrupted functional connectivity between the default mode network and salience network have been observed in children with anosognosia.

Management of anosognosia in children

Anosognosia in children has significant implications for clinical intervention as it is advised to reduce the progression of the illness. These intervention strategies for children could include social skills training, cognitive-behavioural and family therapy (CBT), and psychoeducation.

Psychoeducation is when children and their families are provided with information about the child's condition, deficits, and potential consequences. CBT techniques could help children develop metacognitive skills, improving their awareness of their own cognitive abilities and limitations. Social skills training can help children learn to recognise social cues and navigate social interactions more effectively. Family therapy may address parental attitudes and beliefs about the child's condition and promote supportive and empathic communication within the family.

Summary

Anosognosia in children is a condition that renders them insensitive and unaware of the pain around them. Usually comorbidity with other health or neurological conditions, it presents in the adolescent population followed by symptoms such as visuospatial unawareness, body dysmorphia, difficulties regulating emotion, the decline in social and academic performance and an increase in impulsivity and recklessness as a, coping mechanism. Clinical intervention is necessary as this arises due to dysregulation in the functioning of the frontal and parietal lobes of the brain. Increasing awareness of the children about their condition, encouraging them to not neglect their symptoms and their caregivers to be more aware and sympathetic toward them.