178 Chapter 21
Natural history
The great majority of children and adolescents grow out of RAP; very few
turn out to have missed organic disorders. In a proportion, it may be a
precursor of the irritable bowel syndrome in adulthood.
Treatment
The family need convincing medical reassurance based on an appropriate
assessment. It is often helpful to involve the affected individual and
his or her family in systematic monitoring and recording of symptoms,
antecedents and consequences is often helpful; this may make the rela-
tionship with psychosocial stressors clearer to all concerned. The child or
adolescent can be taught techniques to control symptoms: guided imagery,
self-hypnosis, or relaxation techniques. The affected individual should
be encouraged to resume normal activities despite any residual pain;
parents need to reinforce these activities through praise and attention,
simultaneously reducing the extent to which symptoms are rewarded
by extra attention. Using these approaches, pain usually disappears or
becomes easier to live with if it persists or recurs.
Chronic fatigue syndrome (CFS)
Best known in adults, CFS does also occur in children and adolescents,
affecting between 0.4 and 2 children and adolescents per thousand,
according to one British study. CFS is usually defined on the basis of
disabling physical fatigue of over six months duration that is unexplained
by primary physical or psychiatric causes. It is often accompanied by
mental fatigue and by other physical symptoms, without a demonstrable
organic basis. Low mood is common, with the family considering this to
be a consequence rather than a cause of the CFS. This low mood is not
often associated with self-blame or feelings of worthlessness; a depressive
disorder is only diagnosable in roughly a third of cases. As for adult CFS,
the evidence for an organic aetiology is weak and inconsistent, but absence
of proof is not proof of absence.
This is a disorder where a debate between doctor and family about the
relative importance of physical and psychological factors is particularly
likely to generate heat rather than light. It is best to remain agnostic, to
refuse to be drawn into debates that cannot be resolved on the basis of
current evidence, and to get on with treatment. It is helpful to motivate
the affected individual and the family to beat the problem by harnessing
the ‘power of positive thinking’ and graded rehabilitation approaches.
Working with the family, it is usually possible to get the child or adolescent
to do a bit more every day, with a graded return to normal physical
activities, leisure pursuits and school. It is worth emphasising that these
cognitive-behavioural approaches do help, but that their success does not
prove that the disorder was ‘all in the mind’ in the first place.