More than half of patients attending a pediatric gastroenterology clinic met symptom-based criteria for a functional gastrointestinal disorder. Knowing how to relieve the physical and emotional suffering in children and families without disease is a necessity for every clinician. The purpose of this chapter is to offer conceptual groundwork and concrete suggestions for recognizing and managing patients with functional gastrointestinal disorders.
Biomedical Model
The dominant model for understanding disease has been the biomedical model. The biomedical model makes two assumptions: (1) any symptom can be traced back to a single cause, and (2) every symptom is either “organic,” meaning there is identifiable, objectively defined pathophysiology, or “functional,” meaning without objectively defined pathophysiology. This dualistic approach implicitly places “organic disease” in high esteem. Functional disorders are considered less serious, psychological, or without etiology or treatment. The biomedical model works for a broken bone or a kidney stone, but not so well when there are chronic problems such as headaches, abdominal pain, or chronic fatigue.
What are the Defining Characteristics of Functional Disorders?
Symptoms of disease are caused by tissue damage, which causes organ malfunction. By contrast, functional symptoms are caused by events that are among the repertoire of responses inherent in disease-free organs. This definition of “functional” purposely avoids the implication of psychological origins, because symptoms may be caused by factors that are not psychological. Moreover, “psychogenic” is often interpreted as “psychopathologic” and offends patients by implying that functional symptoms are caused by wrong thoughts and are not real. Some parents may interpret a psychological diagnosis in their child as blame directed toward them for being bad parents.
Children with functional disorders may have biomarkers that provide insight into the pathophysiology behind the symptoms. Eighty percent to 100% of children with irritable bowel syndrome have rectal hypersensitivity, an exaggerated perception to rectal distension. Rectal hypersensitivity is a biomarker for irritable bowel syndrome, an abnormality in pain physiology that is not present in healthy children or in children with disease. A biomarker has been defined as a “characteristic that is objectively measured and evaluated as an indicator of normal biologic processes, pathogenic processes, or pharmacologic responses to a therapeutic intervention.” Another example of a biomarker occurs in functional diarrhea. There was no postprandial pattern of random intermittent variable amplitude contractions, but instead there was a pattern of repeated phase 3 episodes of the fasting migrating motor complex. Thus, in several pediatric functional disorders so far, investigators discovered biomarkers for functional disorders.
An example of a functional symptom is the runner’s leg cramp. It is caused by fatigue-induced spasm in a healthy muscle. The pain may be severe, but it does not result from disease or delusion. Diagnostic tests, other than observation, and treatments, other than rest, are unnecessary.
There are negative consequences of failure to recognize functional conditions. There are also therapeutic opportunities afforded by recognition of the functional component of illness. The following case vignette exemplifies what can happen if a functional illness is ignored.
A 17-year-old young woman noted the insidious onset of crampy abdominal pain and loose stools without blood during her first semester in pre-medical education in a city far away from home. Mid-semester she was upset by a separation initiated by a high school boyfriend. She skipped breakfast and lunch to avoid having to interrupt her classes to use the rest room. She lost weight. Her physician ordered screening laboratory tests and a gastrointestinal (GI) consult. Results of inflammatory bowel disease and celiac serologies and screening labs were normal. The consultant performed upper and lower endoscopy and 24-hour pHmetry; all results were normal. She complained of sharp pains under the ribcage after meals, and the frequency and severity of the abdominal pain worsened. She was unable to return to class because of worsening pain intensity. Her physician ordered a surgical consult. The surgeon ordered a hepatobiliary iminodiacetic acid (HIDA) scan. The ejection fraction was 33% (adult normal 35% to 90%). The gastroenterologist performed an endoscopic retrograde pancreatogram and cholecystogram that showed no dilation and no stones. The surgeon removed the gallbladder. The patient had prolonged pain after surgery and was discharged with nasojejunal tube feedings, narcotics for abdominal pain, and polyethylene glycol for constipation. She remained out of school for many months, disabled by pain and unable to eat.
This case involved a previously healthy adolescent with irritable bowel syndrome (IBS) and unrecognized comorbid anxiety and depression due to several adolescent environmental stressors. Her physicians and family approached the problem from the biomedical point of view, with the presumption that illness must have an organic etiology. A clinician trained in the biopsychosocial model would have recognized and treated IBS as well as the concurrent stress and physiologic responses to it. Instead, this patient underwent extensive testing for diseases to explain her symptoms. Each negative test result reinforced the parents’ worries that something important was being missed. The patient focused on her mystery disease and was oblivious to the emotional impact of separations from family and ex-boyfriend, and failure to adapt to college. The clinician, family, and patient were upset and frustrated by the failure to find organic pathology to explain the “daily vomiting and abdominal discomfort.” Finally, a surgeon removed her gallbladder, which caused more pain. A psychiatric consultant found no eating or thought disorder and criticized the gastroenterologists for requesting the consultation, stating that the request might have been motivated by the physicians’ failure to find what was wrong. The patient, family, and clinicians inadvertently co-created disability by considering only organic etiologies and avoiding consideration of the patient’s stressful experiences and functional, physiologic responses to stress, namely, IBS and functional dyspepsia.
This adolescent’s illness fell into the gap between conventional medicine and conventional mental health. Opinion was shared by clinicians and family that a disease was to blame for the patient’s symptoms. The psychiatrist found no evidence of psychiatric disease. The surgeon believed the HIDA scan was abnormal, resulting in a diagnosis of biliary dyskinesia, although there are no normal values for children. Maladaptive thinking was compounded by the patient’s passive coping style and the effects of narcotics on digestive physiology. Physicians and family viewed psychosocial factors as separate from, and less important than, medical disease.
Biopsychosocial Model
The biopsychosocial model, proposed by Engel in 1977, is an alternative to the biomedical model. In the biopsychosocial model, the goal is to understand and treat illness , the patient’s subjective sense of suffering, rather than confining the diagnostic effort to no more than finding disease. Physicians who engage the biopsychosocial model recognize that symptoms may develop from several different influences, not just disease. Symptoms may stem from normal development (for example, infant regurgitation), psychiatric disease (examples include somatic symptom disorder, conversion disorder, factitious disorder imposed on another), impact of culture and society (for example, a man with chest pain ignores the signals because he carries no health insurance), and functional disorders, in which symptoms are real, but there is no easily discerned disease. Examples include tension headache, fibromyalgia, IBS, and functional dyspepsia. Several influences may converge to form a clinical syndrome. For example, Crohn’s disease may occur together with IBS, so that the patient may experience intolerable abdominal pain and diarrhea even when Crohn’s disease is in remission. Rumination syndrome (a functional disorder) may coexist with social anxiety (a psychiatric disorder), resulting in a person who cannot leave the house because of “vomiting.”
Rather than reducing a cluster of symptoms to a single pathophysiology (reductionism), the biopsychosocial model expands the potential for understanding a problem from simultaneously interacting systems at subcellular, cellular, tissue, organ, interpersonal, and environmental levels. For example, an event such as changing schools may be a psychological stress that in turn alters cellular immunity and disease susceptibility, or change at a subcellular level, such as hepatitis C infection, may influence organ function, the person, the family, and society. Psychosocial and biomedical factors share and interactive relationship in the clinical expression of illness and disease.
Early Learning: Developmental Aspects of Functional Gastrointestinal Disorders
To understand many of the pediatric functional disorders, it is necessary to consider the child’s point of view. For example, neonates are born with reflexes that ensure defecation. About the time that other neonatal reflexes disappear, so do the reflexes for defecation. As a consequence, the 6- to 8-week-old infant must learn to defecate by contracting the abdominal muscles to increase intraabdominal pressure, while relaxing the sphincter and pelvic floor muscles. In a few healthy infants, learning to coordinate two muscle groups simultaneously does not come easily. These infants may scream for 20 minutes or more to increase intraabdominal pressure. Finally, they relax their pelvic floors simultaneously with a Valsalva maneuver and defecate. This clinical presentation is called functional dyschezia .
The infant who perceives pain with passing a large hard stool will learn to avoid defecation. Next, anticipation of pain with the urge to defecate results in an inability to relax the pelvic floor. The maladaptive response to fear of painful defecation, contracting of the pelvic floor with the perceived need to defecate, becomes internalized and results in functional constipation . For about the first 5 years of life, functional constipation persists unless adults ensure that the child experiences painless defecation. When asked in language that they understand, toddlers and preschool children endorse that they are afraid of hard, painful stool. School-aged children use denial to defend themselves against those who would like to help them. Their feigned nonchalance and apparent indifference occur because they are ashamed and unaware of the cause or natural history of functional constipation. They state that they do not feel the urge to defecate. Careful observation contradicts the child’s explanation for refusing to defecate. Each day the child has episodes of stiffening the legs, facial expression turning blank or grimacing, and complaining of a bellyache. These episodes last about 90 seconds. These behaviors are external manifestations of the child’s perception of high-amplitude propagating colonic contractions, signaling that it is time to defecate. Unfortunately, the child with functional constipation interprets the discomfort from the stretching of the rectal wall as abdominal pain rather than an urge to defecate. At this age, educating the children and parents about functional constipation and motivating behavior change in the child are keys to successful resolution.
Functional symptoms during childhood sometimes accompany normal development (e.g., infant regurgitation), or they may arise from maladaptive behavioral responses to internal or external stimuli (e.g., in functional constipation, fecal retention is a behavioral consequence of painful defecation). The expression of a functional GI disorder depends on an individual’s autonomic, affective, and intellectual development, as well as on concomitant organic and psychological disturbances.
For example, infant regurgitation is a problem for months during the first year. Functional diarrhea affects infants and toddlers, but the outcome is unknown because stools are no longer checked after the child is toilet trained. Through the first years of life, children cannot accurately report symptoms such as nausea or pain. The infant and preschool child cannot discriminate between emotional and physical distress. With our current limitations, irritable bowel syndrome and functional dyspepsia are diagnosed only after the child becomes a reliable reporter for pain in the early school years.
First Visit
A clinician with a biopsychosocial approach recognizes that a majority of clinic patients will have functional disorders. In functional disorders, few diagnostic tests are necessary or desirable. The clinician must be prepared to diagnose and treat functional disorders by communicating the relevant information to a patient and parents who are receptive. Therefore, developing a therapeutic alliance is most important during the initial stages of the diagnostic interview.
Depending on the age and experience of the child, the doctor’s white coat may be a nocebo, the antonym for placebo. Toddlers fear the white coat because of negative past associations with gagging sticks and needle pokes. Adolescents may despise the white coat because it is a symbol of authority. The white coat may be a barrier to effective communication. If the family is already in the examination room, it is appropriate to knock and then open the door slowly. Take a moment to scan the room, and smile when you introduce yourself. Then go around the room shaking hands to acknowledge each individual, including siblings. If you acknowledge siblings early and often, they will be less competitive for their parent’s attention during the interview.
There are three goals for the interview: (1) develop a therapeutic alliance with the family, (2) obtain a history and perform a physical examination, and (3) communicate information and initiate a treatment plan. The interviewer sits and listens as the child or parent narrates the chief complaint and history. The interviewer does not interrupt. The parent expects to be interrupted and begins with a high-pressure stream of details. Pressured speech is a measure of the historian’s anxiety. Pressured speech gradually fades to normal, and eventually the historian stops talking. Next, the clinician repeats the salient features of the narrative, to prove that he was listening. At this point, the patient and family are pleasantly surprised that the doctor listened without interruption and remembered the story.
In the early phase of the interview, the clinician asks open-ended questions. The clinician usually knows at this point whether he is working with organic disease or a functional disorder, because the history included signs and symptoms of disease or not. (See Table 7-1 for signs and symptoms of disease.) If the patient has not volunteered the information, the clinician should ask. If “red flags” are absent, then the clinician asks questions that focus on the functional disorders. “Are you saying that 3 or 4 days a week for the past 2 months you had bellyaches that felt better after defecation, and the stool came out too hard, and it felt like you could not get it all out? Then you have irritable bowel syndrome.” “Are you telling me that you get bellyaches after every meal? You feel bloated and nauseated? Why, you have dyspepsia! We can begin treating it today as functional dyspepsia because 85% of adolescents with dyspepsia have no endoscopic disease. Alternatively, we can scope and be sure about the cause for symptoms. Which style would be better for you?”
| Disease | Unhelpful Signs and Symptoms | FGID |
|---|---|---|
| Blood in emesis or stool | Waking with abdominal pain | Pain at the umbilicus |
| Fevers | Pain is only symptom | |
| Weight loss | Pain lasts <10 min | |
| Waking with diarrhea |
Effective Reassurance
Effective reassurance includes several components. First, the clinician develops rapport with the patient and caretakers by being attentive and empathetic. The second component requires an answer to the four questions that concern most parents: (1) What is wrong? It is cyclic vomiting. (2) Is it dangerous? No. (3) Will it go away? Probably, but we do not know when. (4) What can we do about it? First, we educate you all about cyclic vomiting. Then we describe the drugs we use to prevent episodes and the drugs we use to treat episodes, and weigh the risks and benefits of all the management possibilities. The third component for effective reassurance is a promise of continuing availability.
The following case vignette exemplifies how recognition of functional symptoms can help in clinical management.
A bright 9-year-old girl was brought for evaluation for recurrent abdominal pain that had caused her to miss 3 weeks of school. Her symptoms became disabling sometime after the onset of her mother’s untreated episode of anxious depression. The child expressed worries about her parents’ safety when they traveled. She insisted on sleeping on the couch nearer to her parents’ bedroom, rather than in her own room. At the time of the consultation, the mother stated that she was sure there was an organic cause for her daughter’s abdominal pain. Moreover, she was certain that the pains were severe because of the child’s stoic behavior after an accidental fracture of her forearm in the past. (“She has a high pain threshold, so when she actually complains, I know she’s really hurting!”). The mother said she was told by previous physicians that none of many diagnostic procedures found anything physically wrong. A mental health assessment was suggested. The mother said she did not have much faith in psychologists and could not see the purpose of such a recommendation. (Doing so would have made her feel as though she was abandoning her role as protector of her child’s health and concurring with the insulting implication that her daughter was faking illness.)
In fact, this child had a real illness. It did not involve disease, but it had three identifiable elements: (1) a functional disorder, functional abdominal pain, prevalent in girls her age; (2) separation anxiety ; and (3) somatizing, that is, symptoms associated with emotional distress and disability. The diagnosis offered to the mother was functional abdominal pain syndrome. The clinician described the child’s condition, including its high prevalence in healthy schoolchildren, and explained that the symptoms were due to heightened activation of healthy sensory and motor nerves in the gastrointestinal tract. Like a runner’s leg cramp or a swimmer’s shiver after a cold dip, functional symptoms are part of how the healthy body works. Although her child’s pains could be severe at times, they neither resulted from nor caused disease. The functional nature of her child’s pains explained why diagnostic tests for diseases had been unrevealing. Skillful communication, which addressed the worries and concerns elicited from the mother during the history, permitted her and the clinician to avoid the “physical-versus-emotional” controversy. She was relieved to learn that her daughter’s pains, although sometimes severe, were not dangerous. She abandoned her insistence on more invasive, stressful diagnostic tests. The doctor’s unhurried, painstaking efforts at obtaining an extended history and her gentle but thorough physical examination convinced the mother that her daughter’s symptoms were being taken seriously. Making use of their rapport, the physician then reflected, in a nonjudgmental, concerned manner, on all of the emotional stress they had suffered as a family and how any normal child might have reacted to it with anxiousness. At that point, the mother was ready to hear the doctor’s thoughts about emotional issues. She was also ready to shift her concerns away from the hidden malignancy that she feared was causing her child’s pains, toward concern about the developmental damage accruing as a result of missed school. Once reassured, she became ready to place the expectation on her child to return to school, even though her daughter still had some complaints. The change in the mother’s attitude did not “cure” her child’s anxiety, but the mother’s new confidence in her daughter’s health ended the vicious cycle of symptoms and fear that dominated their relationship. The physician made herself available to the parents, the child, and the school nurse to support efforts at getting her back into school.
In this case, the concept of functional disorders was used to avoid adversarial interaction in which the parent could, at first, only accept an organic diagnosis. The physician recognized the child’s anxiety and its possible causes. The concept of functional disorders allowed the physician to avoid having to make the choice of either ordering more diagnostic tests (against her better judgment) in order to preserve the doctor–patient relationship, at least temporarily, or stating what was unacceptable to the mother, thereby breaking off the relationship and any opportunities for further help.
Acceptance of the nondangerous nature of a child’s abdominal symptoms and the unwavering support of the physician, enabled the mother to place an expectation on her daughter to do what she had to do, namely, return to school. This is a stressful juncture at which the mother, on one hand, is made to feel heartless by increasing displays of suffering by her child on hearing that she will go to school and, on the other hand, recognition that her child’s use of genuine abdominal pain for psychological gain was leading to abnormal codependency and invalidism. Proof of the effectiveness of management was that the magnitude of pain issue diminished within a few days and excessive school absences ceased.
When a child becomes dependent on the uncritically accepting, comforting nearness of the parent, and the parent is unable to bear the guilt created by the accusatory tantrums of her child, the parent–child relationship becomes inimical to normal development of both. The clinician who succeeds in managing the functional disorder complicated by anxiety-induced somatizing and helps remove the patient’s “need to be sick” has accomplished a triumph of clinical management.
Biomedical Versus Biopsychosocial Models
The majority of clinicians likely include elements of both the biomedical and biopsychosocial models in their practice. It can be argued, however, that all illnesses, organic and functional, are best managed within the framework of the biopsychosocial rather than the biomedical model of practice.
The biomedical and biopsychosocial models of practice share the same goals, namely, improving patients’ well-being. However, the scope of what is considered to be impairment and the extent to which the clinician considers the origin and remedies to that impairment differ. The biomedical model limits the role of the physician to the diagnosis and treatment of disease and assumes that doing so restores well-being. The biopsychosocial model expands the meaning of the goal and the clinical process by which it is achieved. Illness is defined as the patient’s subjective sense of suffering. The goal of management is to identify the patient’s disease as well as other factors contributing to suffering. The biopsychosocial model includes an analysis of the relationship and contributions of each factor in the patient’s illness. Such was not done in the case of the 17-year-old pre-medical student but was attempted with some success with the 9-year-old girl with abdominal pain and school absence.
A schematic summary by which the biomedical and biopsychosocial models can be contrasted is presented in Figure 7-1 . The large circle represents illness . The six smaller circles within it represent six constituent categories, one or more of which may contribute to a patient’s illness. Category one represents disease . This category is the principal focus of the biomedical model. Category two represents psychological disorders , that is, behavior or psychological syndrome or pattern causing distress and disability. Excluded from this category are normal emotional responses to stressful events such as grief at the loss of a loved one. The third category represents functional symptoms , such as IBS. The fourth category represents somatizing , the prominence of body symptoms associated with emotional distress and impairment. The fifth category represents symptoms that are manifestations of normal development and are neither organic nor functional, but prompt patients to seek medical evaluation (e.g., adolescent gynecomastia). The sixth circle represents failure in the relationship between the patient and society , such as no access to treatment. This scheme helps the clinician explore areas of illness that are often neglected in the biomedical model of care.
Treatment
Once the clinician is sure that the problem meets symptom-based diagnostic criteria, it is helpful to read aloud to the family the criteria from the Rome III classification. Reading from a Rome III document is a strong argument for parents who are not convinced by the clinician’s words alone. Next, it is helpful to provide the patient with a plausible explanation for the problem. Following the education piece, there may or may not be a need for further treatment. Effective reassurance may be all that is needed in many situations. To reinforce the educational lessons, and to assist one parent with describing the disorder to other family members, it is a good idea to hand a parent a pamphlet about the disorder obtained from the International Foundation for Functional Gastrointestinal Disorders at www.IFFGD.org .
Chronic abdominal pain is the most common chief complaint in pediatric gastroenterology clinics. Chronic pain is often caused by a sensitization of primary visceral afferent nerves to pressure and stretch (primary hyperalgesia), and amplification of pain messages in central nervous system (CNS) nonspecific arousal systems (secondary hyperalgesia). Chronic pain is associated with alterations in physiologic and anatomic brain regions. Treatment of chronic neuropathic pain may focus on the CNS and/or afferent neurons from the hollow viscus. Pain perception occurs in the brain cortex. It is influenced by past experiences, catastrophization, and expectations for pain as well as afferent signals. Catastrophization, the belief that symptoms can only worsen and that the patient is helpless, further activates autonomic arousal. Similarly, an external locus of control, the belief that the suffering can be reduced only from outside sources, interferes with coping and amplifies arousal. Chronic pain treatment may involve psychotherapy or drugs. A randomized, controlled trial comparing a tricyclic antidepressant to cognitive behavioral therapy (CBT) in adults proved that drugs and CBT were equivalent in short-term relief of chronic pain from IBS, and both were better than time spent on IBS education. Psychotherapy and hypnosis have the advantage of effects that last long after the treatment period compared to drug effects that last only as long as treatment continues. Drugs have the advantage of not requiring a psychotherapist, in a world in which mental health professionals may not be readily available. Evidence for drug efficacy in children with pain in functional gastrointestinal disorder (FGID) is limited.
Although evidence exists about how food, infection, inflammation, permeability, and the microbiome all contribute to triggering symptoms, pain or nausea associated functional gastrointestinal disorders respond better to treatments targeting the CNS than targets outside the brain. Trials of hypnosis, CBT, and citalopram (Celexa) in children were more successful than cisapride, tegaserod, famotidine, or rifaximin for chronic abdominal pain.
Several classes of drugs have effects on either afferent nerves and/or central arousal systems. The tricyclic antidepressants have been helpful in treating many forms of chronic neuropathic pain. In addition, amitriptyline is effective in suppressing episodes of cyclic vomiting syndrome or abdominal migraine and preventing migraine headaches. Two recent controlled trials yielded equivocal results with amitriptyline in children with IBS. Both trials used low doses of amitriptyline, a factor that may have been the cause of the response not different from placebo. Alternatively, an exceptional placebo response of 80% may reflect the biopsychosocial approach of the investigators, who provided effective reassurance and an expectation that the medicine would be effective.
Approach to the Child or Adolescent with Pain-Associated Disability Syndrome
The term pain-associated disability syndrome (PADS) describes a downward spiral of increasing disability and pain (or other symptom, such as nausea) for which acute pain treatments do not eliminate pain or disability—the inability to engage in activities of daily life. PADS pain may be caused by tissue pathology, but it is more often associated with one or more functional gastrointestinal disorders. The suffering seems out of proportion to objective evidence of disease. PADS is limited to preteens and teens. It is associated with a passive coping style, and nearly always with a sleep disorder. PADS patients have overt or undiagnosed cognitive or emotional stressors that must be addressed to relieve underlying autonomic arousal.
PADS patients fall into a gap between biomedical medicine and conventional mental health, as central and enteric nervous systems interact. Pain activates nonspecific CNS arousal. Pain memories create an expectation for more pain; catastrophization and a maladaptive coping style are associated with patients who feel helpless to control their pain, and hopeless about symptom reduction. Symptoms are inversely proportional to the patient’s perception of his or her own academic or social competence. Although brief interventions may improve symptoms, no patient stays better without the family understanding the diagnosis and participating in treatment.
If the patient and family accept the diagnosis, treatment is partially or totally successful in relieving suffering and returning the patient to normal daily activities. A multidisciplinary, biopsychosocial team approach is optimal, because clinicians, patient, and family must communicate frequently and honestly. The burden of healing shifts from a medical model, in which the patient is passive and the clinicians test and treat, to a rehabilitation model, in which the patient is responsible for learning to help herself, with clinicians as guides. The team is usually led by a physician and a child health psychologist. Other team members may include a physical therapist, dietitian, occupational therapist or child life specialist, teacher, and family therapist. We have the patient and family sign a contract on the first day, promising to participate in all treatment to the best of their ability. Next, we make a schedule designed to fill every day with activities to prevent the patient from ruminating about troubles, but instead exercise body and mind so that there is fatigue by day’s end, facilitating restful sleep. The physician prescribes medicine to ensure restful sleep: amitriptyline, mirtazapine (7.5 mg dose), or eszopiclone. The physician may add other chronic pain medications, such as gabapentin or clonidine. The psychologist finds one or more forms of relaxation that the patient enjoys, such as relaxation breathing, yoga, hypnosis, guided imagery, or biofeedback games.
The psychologist applies CBT to introduce the patient to an active coping style and problem solving. The family asks why a psychological treatment is used to treat abdominal pain. It is helpful for them if the clinician explains that the pain is not under the patient’s control, because pain is coming from pain nerve signals that arise from pressure or stretching of the gastrointestinal tract walls and amplified by arousal centers deep in the brain. The brain modulates many body activities that are not under conscious control, such as pain, blood pressure, pulse, and respirations. However, with training, the thinking part of the brain can learn to control these. “Take respirations: please hold your breath! Now the thinking part of the brain is controlling your respirations, overriding the unconscious control. OK. Breathe again.” With CBT, catastrophic, negative thoughts are replaced by hope for successful treatment. Passive behaviors are replaced by active coping. The physical therapist provides an exercise program enjoyable for the patient, guaranteed for success each day, such as walking the mall or running with the family dog. The occupational therapist may work on massage to put good feelings into the brain. Music therapy, Child Life services, and homework add to a full day of activities.
If the psychologist diagnoses a comorbid psychological disorder amenable to drug therapy, such as panic disorder, anxiety disorder, depression, or attention deficit/hyperactivity disorder, there may be cause to add psychotropic medications. The team physician may prescribe psychotropic drugs and/or ask for a psychiatry consultant to assist. We explain to the patient and family that psychotropic drugs reduce suffering to help the patient focus on learning the skill set she will need to avoid a recurrence, and that we plan to taper the drugs as soon as the patient acquires confidence in the necessary skills.
The PADS patient misses school for 2 months or more because of symptoms and repeated hospitalizations. Returning to school often requires that a treatment team member advise the school about PADS and the patient’s impending return. Sometimes it is best to begin with just a few hours a day, for the patient’s favorite subjects. As with daily exercise, the idea is to choose incremental steps with expectations for success.
PADS has not been described in adults or in young children. There must be some developmental vulnerability to PADS, perhaps related to the identity uncertainty and confusion that is the developmental focus at that age.
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