Association for child psychology and psychiatry occasional papers
Third, it may be used skilfully to remove any inappropriate secondary gains that are occurring. Elizabeth's somatoform pain disorder meant she was not at school but could spend hours in her grandparents' heated swimming pool. Instituting 20 minutes of complete rest every hour, in a darkened room with no distraction, introduced change to this comfortable regime, which was not producing recovery.
Reduction in rest periods was made contingent on coping better with other activities, e. The approach to management of these difficulties is no different from that for any other young person; the difficulty is usually in establishing the extent of the problem and of helping the young person and family recognise its relevance in aiding recovery from the symptomatic presentation.
The approach to peer group interaction problems will depend on the young person and his or her pre-existing skills, and may be individual using cognitive—behavioural didactic social skills or problem-solving techniques or through group processes. Liaison with education professionals is essential. The importance of a systemic perspective in somatising disorders has already been emphasised: there is obvious potential for difficulties consequent upon the involvement of numerous individuals and groups with different beliefs and practices.
There is a role for a systemic practitioner in helping these family and professional systems to work together successfully for the benefit of the young person; a medical background may increase the power to convene relevant meetings. Systemic work may also be undertaken within the more limited arena of the day or in-patient psychiatric unit, or with paediatric and CAMHS staff working together.
More specific tasks may also be undertaken with the family: psycho-educational work to introduce a carefully paced rehabilitation and explain the nature of the illness and its treatment Chalder, ; exploration of family illness beliefs and alternatives; helping parents to manage physical symptoms and other kinds of behaviour; enabling recovering children to negotiate differently and more directly with their parents. However, evidence of the utility of systemic approaches, used either as an adjunct to other interventions or alone, is lacking and research will be hard to undertake.
Management of factitious disorders follows the same principles as for any other somatising presentation, but special care should be taken to engage the parents, lest they become extremely punitive when the factitious nature of the symptom becomes apparent. Unfortunately, young people whose factitious presentations are severe and intractable are more likely to come from families in which problems with open and trusting relationships are also evident, making work with all the family difficult.
In circumstances where physical, sexual and emotional abuse and attachment disorder have constituted a part of the aetiology, where there are many other psychological symptoms, including conduct problems and self-harm, where parents themselves have somatisation disorders or there is other major social dysfunction, management is rarely able to take place in the organised way described for most families. The child may be in a substitute family or there may be major difficulties in engaging parents if relationships remain ambivalent or negative.
If possible, the principles and practice of management described above should be employed. But in some cases damage limitation may have to be the main objective: responding to crises and periods of emotional distress with an intervention relevant to the mood disorder or self-harming phase, or helping to find an appropriate educational or substitute home environment.
Preventing unnecessary medical interventions is important for young people with severe disruption of social circumstances and relationships; even this may be difficult if the young person is moved to a different part of the country.
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Some of the most severe difficulties, in terms of their impact on the patient's lifestyle, may be included here, and it is this that justifies efforts at indirect work. The first is to support the professionals already involved and enable them to provide limited interventions, for example by advising on sleep hygiene and the prescription of antidepressants, or supporting the work of a paediatric play worker or practice counsellor who is able to spend time with the young person.
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The purpose is not to encourage delivery of interventions by those without appropriate training but to monitor the situation, to work on principles of management in key areas and to provide an opportunity for the development of trust in an accepting, emotionally congruent and sympathetic professional. This person can also encourage the family to consider engagement with CAMHS for more intensive and appropriate treatment in the future. Another aspect of this supportive liaison role is to help the paediatrician and others to retain the psychosomatic formulation in mind, rather than seeing a puzzling physical problem.
Naturally, a chronic, severe and untreated problem is unlikely to make a quick recovery, but without help the urge to reinvestigate without good reason may become overwhelming. Box 4. Liaison roles of the child and adolescent mental health services in the management of problem families. Support Advise and enable professionals to make optimum interventions and keep psychosomatic formulation in mind. Containment Help professionals prevent unnecessary investigations and treatment. Prevention of avoidable impairment Overview effect on the patient of the disorder and the family's response to it.
The second role is to help the paediatrician to contain the situation, to prevent harm from unnecessary investigations and unproven or superfluous treatments. Some families repeatedly seek new specialists and interventions, and professionals, including the GP, may need help to resist pressure to make referrals for yet more opinions.
The exception to this reluctance to endorse further referral should be the involvement of pain clinics. It is important that children and families are not prevented from receiving necessary advice from experts but, in principle, such experts should be approached by the first specialist for second opinions where necessary, rather by the family, who may involve professionals not fully informed about the background and previous investigations.
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The third role is to keep under review the extent to which the somatising disorder and the family's management may be causing avoidable impairment to the young person's development, considered in the broadest sense in terms of physical, emotional, social and educational milestones. The intensity of the parents' drive for an invalid lifestyle or surgical interventions for their child may occasionally be so extreme that professionals consider invoking child protection legislation, in which case a meeting of all relevant professionals with local authority social workers is appropriate.
The range of disorders described in this paper is wide and the treatment interventions equally broad in variety.
Although there is a wealth of clinical studies from the s onwards, they are often from selected secondary and tertiary paediatric populations, and the earlier ones do not meet modern levels of precision in categorisation and measurement. The categorisations and measurements of symptoms and outcomes used in the earlier epidemiological studies are also relatively unsophisticated.
We do not know what proportion of the children received any form of treatment intervention. Hence, it is not surprising that it is difficult to make robust predictions of outcome of the somatising disorders at different ages and that the literature appears to give inconsistent results. This problem is compounded by the existence of a group of sufferers and families who appear to seek out practitioners predicting continued invalidity as the outcome and who find it difficult to engage with active treatment approaches.
Nevertheless, despite the longstanding and severe nature of many of the disorders, there are substantial gains to be made from mental health treatments in relieving physical symptoms, improving management and reducing handicap and in remediating functional impairment in terms of lifestyle, independence and relationships.
Although engagement remains the single most important determining factor, those who work closely with paediatricians and others in this area are able to maximise such opportunities. This is an argument for early involvement of specialist expertise in dealing with the more handicapping disorders: chronic dissociative and somatoform disorders and chronic fatigue.
Outcomes may be considered in relation to the future risk of a psychiatric disorders or symptoms, b continuing unexplained physical symptoms and c more widespread somatoform problems. This is the case even when psychiatric symptoms were not apparently present in childhood.
We do not yet know which young people will, as they develop, acquire the ability to express emotional distress through verbal means and whether as one suspects they differ from those who continue to present somatising disorders, either with or without other psychological symptoms. The results of different studies and also outcomes in boys and girls are inconsistent, reinforcing the need for more research and greater specificity in the comparisons made.
There are also conflicting results in longitudinal clinical studies that examine whether children continue to experience the same physical symptoms when they grow up, but there are clearly many continuities in vulnerabilities to certain physical symptom constellations. Papers examining outcomes for specific disorders are becoming more common but still often relate to specialist services rather than diagnostic groups.
Adjustment disorders characterised by physical and emotional symptoms are by definition short-lived, as are transient dissociative reactions. In general, these disorders show poor continuity with adult presentations. The picture for more chronic dissociative disorders is less strightforward.
More long-lasting dissociative disorders are often associated with ongoing difficulties in areas such as school and peer relationships Wynick et al Factitious disorders often have a similar clinical course: the index episode usually resolves completely, but the underlying difficulties remain and are associated with other psychiatric presentations later. The long-term outcomes of well-defined somatoform disorders in childhood and adolescence are rarely reported, although symptom-specific groups e.
A typical study Murray et al describes recovery times following diagnosis itself sometimes more than 2 years after symptom onset of between 0 and weeks median 7 weeks , but Clinically, any of the long-lasting severe somatoform disorders may show continuities into adulthood.
This is consistent with the results of studies of adults with somatoform disorders that suggest that many begin in adolescence or even earlier. The late onset of hypochondriasis, barely represented within child and adolescent populations, has been commented upon above. Chronic fatigue is a better researched area for both treatment and outcome, with studies of adults, adolescents and children providing information about positive factors for recovery: engagement with psychiatric services Vereker, , clear physical precipitants of the illness, onset at the start of a new school year, ongoing immunological abnormalities, better maternal health and socio-economic status Rangel et al In a relatively small study persistent symptoms were predicted by strong maternal belief at the outset in a physical cause for the illness and by personality difficulties and disorder in the adolescents Rangel et al Most series with children and adolescents are small and highly selected, but typically, two-thirds of sufferers make a good recovery.
With the exception of the burgeoning literature on chronic fatigue, somatising disorders remain one of the most neglected areas in child and adolescent psychiatry. Recognition of these disorders and their responsiveness to vigorous treatment are a continuing major problem. The challenges continue once recognition has occurred: a non-pejorative terminology is needed, to be shared with paediatricians; existing categorisation systems must be reviewed to take account of child development; and treatment research using rigorous definitions must approach the strength level of randomised controlled trials.
More theoretical research on mechanisms of somatisation and more longitudinal studies with robust measures of symptom and function are also urgently required. Nevertheless, the wealth of clinical material in the literature remains a strength of this area, and the development of collaborations between centres and between disciplines to achieve a better evidence base forms an exciting prospect for future research and treatment of these handicapping disorders. In the management of somatoform disorders in adolescents: a increasing emotional recognition and expression through non-verbal and verbal techniques is often helpful.
Regarding severe somatoform disorders and chronic fatigue syndrome in childhood and adolescence: a the prognosis is well established. Long-standing multiple pains in children and adolescents: a are not associated with increased rates depression and anxiety in the long term. As regards factitious disorders: a the presenting fabrication usually resolves. Loading article Login Alert.
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