Predisposing factors
Precipitating factors
Maintaining factors
Family
Child
Current family relationship difficulties
Genetic component
Anxiety, depression
Family model of serious illness
Physiological vulnerability
Life stresses
Current parental anxiety and somatisation
Verbal communication about emotional issues limited
Physical illness
School problems
Conditional caretaking
Peer group problems
High achievement orientation
Suspicious attitude to medical expertise
Academic problems
Conflict avoidance
Parental history of somatoform illness, anxiety, or depression
Cognitive limitations
Benefits of sick role
Problems with boundary setting for children
Low self-esteem
Child
Parent
Temperamental factors, including sensitive, conscientiousness, emotional labiality, vulnerability, + worthlessness
Life crises
Earlier emotional abuse
Low IQ
Social-relating difficulties
Physical illness
13.5 Burden
Children with somatoform disorders tend to present repeatedly to doctors because their presenting symptoms are physical and families tend to attribute the symptoms to medical, not psychological causes. The medical help-seeking behaviour that accompanies the symptoms often leads to various unnecessary painful medical investigations and treatments before their psychological nature is identified. These investigations tend to reinforce the belief in the child and family that there is an underlying physical cause Domenech-Llaberia et al. (2004). All of this can result in a huge burden on patients in terms of time, money, and effort as well as wastage of resources. Children often miss school to attend multiple appointments, and parents may need to take time off work to care for their child and take them to appointments. Further, it may result in parents having decreased leisure time, having to take time off work and subsequent financial implications. Families may need to reorganize themselves in their activities of daily living to accommodate caring for the sick child, which may increase overall family stress.
13.6 Assessment
Steps involved in assessment
1.
Ascertaining the child and parents’ views of the illness is important since most of them have come after meeting several doctors. Many parents may still be pursuing organic causes; therefore, it is important to address all the physical symptoms, find out what medical disorders have been excluded, explore possible physiological explanations, and be aware of the possibility for physical and psychological causes to coexist.
2.
Psychiatric assessment should include developmental and psychiatric history and mental state examination.
3.
Psychometric assessments may be helpful in determining the child’s cognitive level, and any disparity between child’s educational expectations and actual abilities, school history, and family functioning is assessed.
4.
Engaging the family early in the assessment process, explain the formulation to them and engage them in therapy. The intervention module is an adaptation of the work done previously (De Shazer (1985); Gureje et al. (1997); Knapp et al. (2006); Keiling et al. (2011); Kozlowska et al. (2007); Lieb et al. (2000); Pehlivanturk and Unal (2002) and Robins et al. (2005)).
13.7 Intervention
13.7.1 Integrated Eclectic Intervention Module for Children with Somatoform Disorder and Their Parents
Outline of Module
Number of sessions: 6
Frequency of sessions: 2 per week
Duration of each session: 50–60 min
Setting: Hospital
Type of session: Individual sessions or with parents
Who delivers: Clinical psychologist
13.7.2 Instructions for Therapists
Use this module as a guide. It presents the fundamental areas you should focus on during the sessions. The content worked on in each session should be integrated and build upon in subsequent sessions. Become familiar with the module and use it based on each child/adolescent’s particular symptoms, circumstances, and your own personal style. The psychiatrist is consulted for any comorbid condition.
Session 1: Preintervention assessment and Psychoeducation
Participant: Child and parent
Objective of the session
Understand the child’s problem
Increase child’s and parent’s understanding of somatoform disorders
Form a rapport with child and parent.
Duration: 60–90 min
Tasks
(i)
Semi-structured interview
(ii)
Preintervention study measures (child and parent)
(iii)
Psychoeducation
(iv)
Providing reassurance, support, reattribution
(v)
Functional analysis.
Homework: ABC charting
13.7.3 Task (I) Semi-structured Interview
The therapist should administer the semi-structured interview Performa and generate information from the child on the following areas: School, Academics, Teachers, Peer group, Family, Parents, Siblings
The therapist starts the session by asking the child, “What is your name, age? What class do you study in?”
The therapist inquires from the parents about their relation with child, their family setup, support, and any family stress. “Do you have a joint family or do you live with your parents, any stress the family is currently undergoing?”
13.7.4 Task (II) Preintervention Study Measures (Child)
The therapist instructs the child and tells the child, “This is a list of 35 items assessing bodily difficulties you experienced in the last 2 weeks. You have to tell me how much you were bothered by each symptom rating from 0 which means not at all, 1 Some-what, 2 Often, 3 Quite a lot, 4 a whole lot.”
The child is given some time to complete the Childhood Somatization Inventory. Any queries are simultaneously answered.
Following which the child is given the Coping Scale for Children and Youth. The therapist explains to the child, “During problems, how much do you make use of the following methods. You have to tick the option that you find most appropriate.”
The Children’s Global Assessment of Functioning was filled by the therapist, in consultation with the parent, by rating the child’s most impaired level of general functioning for the specified time period by selecting the lowest level which describes his/her functioning on a hypothetical continuum of health illness.
13.7.5 Task (II) Preintervention Study Measures (Mother)
The mother is given the DASS and asked to fill the questionnaire, “Please read each statement and circle a number 0, 1, 2, or 3 which indicates how much the statement applied to you over the past week. There are no right or wrong answers. Do not spent too much time on any statement.”
Then, she is given the coping checklist to complete, “This is a list of commonly used methods of handling stress and reducing stress. You have to answer yes if it applies to you and no if it doesn’t.”
Following which the GAF is administered.
The therapist starting at the top level evaluates each range by asking “Is your symptom severity OR level of functioning worse than what is indicated in the range description? Keep moving down the scale until the range that best matches your symptom severity OR the level of functioning is reached, whichever is worse.”
13.7.6 Task (III) Psychoeducation
The therapist can use the following information for psychoeducating the parents.
The parents are psychoeducated by telling them, “Your child may sometimes respond to stressful or painful experiences with somatic symptoms without having a serious medical illness. Although these symptoms are referred to as psychological, but it does not mean that the child is mentally handicapped. The child is not intentionally producing these symptoms and is not malingering.”
Predisposing factors
It is further explained to them, “Both personal and factors based on context may predispose children to developing somatic complaints. Genetic, physiological vulnerability to a particular somatic condition, a high level of suggestibility, difficult temperament and low self-esteem may predispose children to somatoform disorders. A family culture that is illness-oriented may predispose children and adolescents to develop somatic problems through a process in which the children observe that sick-role behaviours of other family members elicit excessive care and distress is communicated through somatic complaints.”
Precipitating factors
The therapist explains the role of precipitating factors, “Biological factors such as personal illness or injury or illness, injury in a family member, major stressful life events, such as bereavement or abuse, and a build-up of small stressors may also precipitate somatoform disorders.”
Maintaining factors
The therapist further educates the parents by telling them, “Somatic complaints may be maintained by the belief that they are un-controllable. Also, it permits the child to avoid anxiety-provoking issues which would have to be faced if the symptoms were resolved. Poor coping strategies and cognitive distortions involving catastrophizing about the symptoms may contribute, by increasing autonomic arousal and reducing the efficiency of the immune system. Family, school, peer-group and health-care may give the child secondary gains associated with the sick role. Poor coping strategies of parents, high levels of stress and limited support to family may compromise their resourcefulness in managing their children’s difficulties.”
13.7.7 Task (IV) Reassurance, Support
The therapist reassures and gains the parents’ confidence by telling them, “The child would be followed until full recovery and even later to make sure that no possible organic cause is overlooked.”
The child is told, “You will get fine soon and we completely understand your problem and it can be overcome.”
13.7.8 Task (V) Functional Analysis
The therapist explains to the parent, “You need to record information regularly about the child’s symptoms, the circumstances surrounding its occurrence and treatment adherence. The Intensity of the symptoms will be rated from 0 to 10, with 0 not present being and 10 being maximum intensity, frequency counts i.e. the number of times the child reports of symptoms during the day and how long do they last.”
For child’s age <10, parents will record.
For child’s age ≥10, the child records.
The following chart is used for recording:
Day/date/time | Intensity 0–10 | Antecedents | Behaviour | Consequences | Duration |
|---|---|---|---|---|---|
. |
The child and parents are asked whether they have any further questions and they are told to come for the next session.
Session 2: Symptom management
Participant: Child and parent
Objective of the session
Engage parents in active management of symptoms
Encourage child to take control of symptoms by teaching cognitive and behavioural skills.
Duration: 50–60 min
Tasks
(i)
Review charting
(ii)
Teach parents to limit secondary gains from sick behaviour
(iii)
Activity scheduling
(iv)
Teach child symptom control using relaxation, distraction, and cognitive restructuring.
Homework: Practice relaxation, chart self-statements
(i)
Review charting
(ii)
The therapist must review before beginning the next session. Revise the previous session and the homework assignment. Ask child and parent whether they have any questions from the previous session.
13.7.9 Task (I) Review Charting
The therapist must review before beginning the next session. Revise the previous session and the homework assignment. Ask child and parent whether they have any questions from the previous session.
13.7.10 Task (II) Help Parent Limit Child’s Secondary Gains from Sick Behaviour
The therapist educates the parent about the removal of reinforcement for symptomatic behaviour by explaining to them that, “You might be reinforcing illness behaviour in your child by giving excessive attention to the child whenever he displays illness behaviours. You should try and limit giving too much attention to your child, limit frequent visits from visitors, phone calls, gifts, recreational privileges whenever the child displays symptomatic behaviour. You are advised to ignore non-verbal illness behaviours and use children’s complaints about symptoms as an opportunity to prompt them to use symptom-management skills.”
The therapist educates the parent about reinforcement of well behaviours by explaining to them that, “When the child does not display any symptomatic behaviour for sometime (define based on the kind of symptoms) and engages in positive productive activities you have to praise the child, allow them to watch TV, give food of their choice, let them engage in other recreational activities.”
Breathing exercises
The therapist starts by telling the advantages of breathing exercises to the child.
“Relaxation exercises have advantages and some of them are:
It helps us in taking more oxygen in our brain. The more oxygen reaches our brain, the more alert we feel. It helps us to bring our mind to here and now and helps us see the situations more objectively and then work on it.
Our mind may be full of thoughts that prevent us from seeing the true nature of problem. Therefore, through relaxation our mind becomes clear.”
The therapist sits on a chair and demonstrates the instructions before asking the child to follow them. Once the child starts practicing the breathing exercise, the therapist should ensure that the child keeps their eyes closed during the session and check whether the child is doing it correctly.
Additionally, they should be instructed that, “The exercises can be done as many times as possible and remember to give a gap of about 1 h for eating a meal before and after the breathing exercises.”Related posts:
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