176 Chapter 21
suggested risk and protective factors are certainly plausible, they derive
primarily from clinical impressions (a potentially fallible guide) rather than
from empirical studies.
External stressors
Both chronic adversities and acute life events can play a part. Abuse only
seems relevant in a small minority of cases; bullying and academic stresses
are probably more common contributors.
Approach to management
Children and adolescents with somatic symptoms have often been referred
to paediatricians in the first instance. An organic cause will not have been
found – a correct term is ‘medically unexplained symptoms’. Families
may be better able to accept a psychosomatic approach to assessment
and treatment when their family doctor and paediatrician have taken a
holistic approach from the outset, considering the interplay of biological
and psychological factors from the first assessment onwards. Involving
mental health professionals is then just a change in emphasis rather than
a complete switch of direction that carries the implicit message: ‘We have
completed our investigations and there is nothing really wrong with your
child, so you had better see the psychiatrists instead.’
The family need to hear from their doctor that the assessment so far
has ruled out the dreadful organic diseases that they were worried about
(tumours, ulcers, blockages, or whatever). This does not mean that the
symptoms are unimportant; it simply means that effective symptomatic
treatments can now be deployed without having to worry that there is
something more sinister in the background. This message, which helps
de-escalate anxious fixation on symptoms, is undermined if physical
investigations continue ‘just in case’.
There is little to gain and much to lose from trying to force the family
to be more psychologically minded than they want to be. If the family
continues to feel that physical factors are important, remember that they
may be right: current medical views on body and mind will probably seem
ridiculously primitive to future generations. It can be useful to emphasise
the value of ‘mind over matter’ and graded rehabilitation approaches.
Psychological and behavioural methods can work even when symptoms
have a physical cause, which is why these methods are used to help
children and adolescents cope with painful medical procedures or chronic
physical symptoms of known organic origin. It is often helpful to teach
techniques such as ‘self-hypnosis’ or relaxation therapy. These can make
affected individuals (and their parents) feel more in control of symptoms.
This is treatment for the present episode and prophylactic medicine for
the future too. The more psychologically minded families may agree from
the outset that psychological stresses could have played a part and need
to be explored further. Less psychologically minded families can find this
too challenging at the outset, but are sometimes more receptive when
‘mind over matter’ techniques have started to pay dividends. Children