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Selected Readarounds in Child and Youth Care

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Psychosomatic illness and symptoms in children

Stanley Levenstein

Psycho-somatic illnesses (also known as psycho-physiological disorders) are certain conditions in which structural changes in the body are attributed mainly to emotional disturbance. Common examples of psycho-somatic illnesses in children are bronchial asthma and certain skin conditions such as neurodermatitis (hives) and eczema, while less common (but not rare) examples are diabetes and stomach ulcers. Psycho-somatic symptoms refer to complaints such as stomach pains, headaches, dizziness and tiredness which are attributable to emotional causes, but without any structural changes in the body tissues.

The emotional – physical link

How can emotional disturbances cause physical illnesses or complaints? The various organs of the body e.g. the skin, lungs and stomach and intestines, which are not under voluntary control, are especially sensitive to changes in the individual's emotional state. By "voluntary control" is meant the individual's ability to control the functioning of an organ or organ-system by an act of conscious will. Readers will know from their own experience that they are unable to control their own heart- (pulse) rate, but that they have been aware of their hearts beating faster after physical exertion or when experiencing intense anxiety. The same applies to other bodily activities such as sweating, blushing, and narrowing or widening of the pupils of the eyes. The reason for the lack of voluntary control over these activities is that the organs concerned receive their nerve supply from a part of the nervous system known as the "autonomic" nervous system which regulates all involuntary bodily functions. The autonomic nervous system is under the control of a part of the brain known as the hypothalamus which in turn is very sensitive to any changes (external or internal) that may affect the individual's emotional equilibrium. The autonomic nervous system is intended to help maintain the effective functioning of the body as a whole, but in cases of psycho-somatic illness, the nature of the stresses and the nervous responses to them produce a pathological reaction.

It is not only the autonomic nervous system which plays a part in the production of psycho-somatic disorders. Hormones such as cortisone, thyroid hormone and insulin which are produced by various glands in the body and secreted directly into the blood-stream, can and do play an important part in the development of psycho-somatic disorders. The glands, known as endocrine glands, which produce these hormones also receive their nerve supply from the autonomic nervous system and are therefore influenced by, and in turn influence, the individual's emotional state. The activity of the endocrine glands is also regulated by the hypothalamus which has been described as "the conductor of the endocrine orchestra".

It can thus be seen that there is the most intimate connection between the individual's emotional state (psycho) and the functioning of his/her body (soma). This inter-connectedness is so great that many people have argued that the term "psycho-somatic" is an artificial one, implying as it does a separation between the functioning of the psycho and the soma. In fact it is increasingly being shown that there is an interplay between psychic and somatic factors in virtually all "physical" illnesses and not only in "psycho-somatic" disorders. An example of this is the study of bereaved spouses in the United Kingdom where it was shown that the individuals concerned not only showed a higher incidence of emotional and "psychosomatic" disorders than controls, but also a markedly increased incidence of "physical" illnesses, such as arthritis, infections and cancer!

Coping with distress and loss

Perhaps the Bereavement Study would be an appropriate starting point from which to consider the problem of psycho-somatic disorders in children in residential care. In a sense all children in residential care could be regarded as bereaved, if not in the literal sense then certainly insofar as they have all experienced major losses of important parental and other figures in their lives. Furthermore, unlike adults, they have usually not yet been able to develop adaptive ways of coping with the considerable stresses in their lives, nor have they yet acquired the verbal skills to express their distress in words. Both these factors are likely to render the child in residential care more susceptible to psycho-somatic disorders as well as to illness in general.

Where does the child care worker fit into all this? Firstly, he/she needs to recognise physical ailments in the child in residential care as being, to a greater or lesser extent, a manifestation of the child's emotional suffering. Secondly, although the care worker may be aware that a child's physical complaints are largely of emotional origin, the child himself will not realise this. As mentioned earlier, the activities of the organs concerned are not under voluntary, or conscious, control. The child will therefore (usually) not be aware of the emotional origins of his/her physical symptoms. Thirdly, although a child's symptoms may be emotionally induced, this does not make them any less real. An attack of asthma precipitated by emotional causes can be just as severe as one due to allergic irritants, and a headache or stomachache is no less painful for the fact that it may be tension-related. It must be extremely vexing for a child clutching his stomach or head to be told that he is "imagining" the pain when he is painfully aware that this is not true.

Malingering

How does a care worker know whether a child is malingering or not? This question is perhaps an unfortunate one because of the pejorative connotations of the word "malingering". with its moralistically loaded undertones. I he child is thus seen as bad rather than sad. Objectively speaking, malingering suggests a conscious falsification of complaints as opposed to the predominantly unconscious origins of psycho-somatic illness. It may be difficult to assess to what extent, if any, somatic complaints are deliberately fabricated by a child. A more important consideration is what purpose is to be served by such an assessment. If the aim is to identify "malingerers" in order to expose them as liars and frauds, then the care worker will be embarking on an exercise which is not only futile but also counter-productive. Much more important questions for the care worker to consider are "if this child is malingering, why has he/she found it necessary to adopt this maladaptative way of dealing with his/her problems" and "how can I find ways to try to understand this child better and help him/her to cope more constructively with his/her problems?" This approach does not imply that malingering should be encouraged or reinforced by the care worker. It does, however, suggest that the care worker's suspicion that a child may be fabricating or exaggerating his/her complaints should not form the basis of a power struggle between the care worker and the child with the child's body as the arena for the contest. The outcome of such power struggles can only be a defeat for the care worker, the child, and their relationship, with the child who has been upbraided for "putting on an act" either feeling unjustly accused or else believing that he/she will have to try to be more convincing next time. In either case, any possible chance of helping the child with his/her problems will have been lost. On the other hand, if the care worker can indicate to the child that he/she is not unduly concerned about the severity of the child's complaints without adopting a critical or punitive attitude, the child may gradually come to the realisation that there might be better ways of coping with life's difficulties than producing physical symptoms. In cases of persistent suspected malingering, it may be necessary for the care worker to adopt quite a firm approach to the child and state clearly that the child will not be allowed to stay away from school, for example. However, even then the card worker's firmness should not turn into hostility, and at a later stage the opportunity should be created to discuss with the child the circumstances e.g. unhappiness at school, which gave rise to the malingering.

Medical advice

When should the care worker ask a doctor to see a child with possible psychosomatic complaints? As in the case of parents with their children, this will depend on the judgment (and anxiety level) of the care worker. The care worker has a responsibility to ensure that the child's health is not neglected (asthma attacks, for example, can be extremely dangerous and a doctor should always be contacted if the attacks do not respond to inhalers or other asthma medication). On the other hand, it would be very unwise to call the doctor every time a child complained of a stomach- or headache. The care worker has to steer a middle course which avoids any harm to the child's health as well as preventing the "medicalisation" of all the child's complaints. The latter situation could have the effect of reinforcing somatisation as the child discovers that every complaint is rewarded by special medical attention, and the even worse effect of convincing the child that he must be physically ill if he has to be seen so frequently by the doctor.

Of greater importance than the question of whether or when to ask for medical help is the co-operation between the care worker and the doctor. If the care worker is in doubt as to whether a child's symptoms are of physical rather than emotional origin, then the doctor is also likely to be uncertain. Doctors, because of their training which is heavily loaded towards physical rather than emotional problems, tend to be biased towards diagnosing organic (physical) rather than psychological causes for patients' symptoms. The care worker can be of great assistance to the doctor by providing him with essential information about the child's background, personality make-up, relationships with other children, school difficulties, etc. This input from the care worker may well prevent any unnecessary investigations and drug treatments being carried out by the doctor. The doctor in his turn can assist the care worker by advising her/him as to when medical intervention may be necessary with a particular child, and when not. The importance of the 'team approach' between care worker and doctor cannot be stressed highly enough: if they are not working together, the stage is set for splitting of care worker and doctor by the child e.g. "the doctor says my pains are due to worms, so you were talking nonsense when you asked me if I was upset about anything!", or "the doctor thinks there's something wrong with me and I've got to go for X-rays . Of course there will be times when such situations are unavoidable, but generally speaking, an overorganic approach by the doctor, unchecked by discussions with the care worker, can only be to the detriment of the child.

Children at risk

What children are more likely to develop psycho-somatic symptoms and/or illnesses? There has been much research and literature published on this topic. Only a few of the findings will be mentioned in this article.

Minuchin, in his study of Psycho-somatic Families, found that the families of children suffering from such illnesses e.g. anorexia nervosa, asthma, diabetes, were characterised by "enmeshment" (family members are overinvolved with one another and overresponsive), rigidity, and a marked inability to resolve conflicts. A psychosomatically ill child may help the parents to avoid facing the conflicts in their relationship by apparently focussing all their attention on the child. In other words, the child is unconsciously encouraged to remain sick in order to help the parents avoid having to face their mental problems. For the child this is preferable to the trauma of being exposed to his parents' marital problems coming into the open, so he continues to have psycho-somatic symptoms and the system is maintained. In other cases a psychosomatic illness or symptom may be used to maintain a dependent role in the family, while in others it may be an expression of frustrations, anger, or deprivation.

These findings have important implications for care workers. The setup in residential care is of course not identical to that of a nuclear family but there are important similarities. The individuals concerned form part of a system which in some cases may be "enmeshed" and rigid, with poor conflict resolution. Psycho-somatic illness in children in residential care could be a response to tensions among the children and/or staff members or a reaction to an overprotective (or insufficiently protective) care worker (the latter representing a parental figure in the eyes of the child). Other studies have focussed on the personalities of children with psycho-somatic illnesses. Asthmatic children, for example, showed heightened dependency on the mother, fearful concerns about rejection, suppression of resentment reactions, and ultimately efforts to control and regain the relationship. John Apley, a prominent British pediatrician, conducted a detailed study of 1 000 children with abdominal pains. In over 90 percent of cases, no organic (physical) cause for the pain could be found. Apart from the fact that children with organic causes for their pain (e.g. kidney infections) tended to experience their pain towards the sides of the abdomen rather than in the centre (around the navel), there were no reliable distinguishing features (e.g. severity, duration of pain, accompanying signs like fever, vomiting, or diarrhoea) between abdominal pain of physical and that of psycho-somatic origin.

The children with psycho-somatic abdominal pains (as compared with controls) were found to be highly strung, fussy, excitable, anxious, timid, or apprehensive. Most gave an impression of over-conscientiousness. as did also many of their parents. Often they were 'bad mixers', but aggressive behaviour was uncommon, and the children were described as 'indrawn' rather than 'outgoing'.

Another important finding from Apley's study was that in a large proportion of cases of psycho-somatic abdominal pain, a distinct time relationship between a causal precipitating factor and the onset of the abdominal pain could be established. The commonest causal precipitant was found to be stresses related to the school which the child was attending.

Management

Apley found that "informal psychotherapy" was effective in a large proportion of the cases of psycho-somatic abdominal pain he attended. This approach included allowing the child (and parents) to verbalise their fears about the child's pain (e.g. appendicitis, cancer), encouraging the child to "blow off steam" about topics which he/she felt strongly about including apparently irrelevant details about everyday life, at home and at school; and modifying harmful aspects of the child's environment.

What can the care worker do to help the child with psycho-somatic ailments? From what has been discussed thus far, it will be clear that in the first instance the care worker needs to observe children under her/his care closely. Is this a child who expresses his feelings easily, or is he inclined to "bottle up" a lot (and thus be more prone to psycho-somatic disorders)? Has this child been subject to any particular stresses recently, e.g school problems, separation from a friend, physical or sexual abuse? Having ascertained any precipitating factors, e.g. poor relationship with school teacher, the child should be encouraged to talk about his feelings about the matter (compare the "blowing off steam" which Apley referred to). The care worker should listen attentively and empathetically and not rush in with advice or admonitions. It is possible that the child may express anger towards the care worker – this should be regarded as a positive development as the child who is verbalising such feelings is less likely to express them with bodily symptoms. The care worker should therefore avoid reacting defensively to such criticisms whether or not he/she feels there is any substance to the child's allegations.

In cases where school difficulties exist, the care worker should make contact with the child's teacher and school principal. Much tact may be needed to avoid creating the impression that the teacher is being criticised or that the care worker is teaching her her job. The care worker can indicate that she wishes to assist the teacher by providing her with background information about the child and his progress. She can ask the teacher to assist her by offering suggestions as to how the child can be helped with schoolwork and why the child seems to be struggling. The teacher can also be asked about the child's relationships with other children at the school, etc. Approached in this kind of way, the teacher's attitude towards the child may change from a hostile to a more sympathetic one. As in the case with the medical attendant, the care worker's coordinating role may be pivotal. Having suggested some approaches to the child with psycho-somatic problems, it must be stated that the most important factor which will determine the care worker's success with these children is the relationship which she/he establishes with the child. It goes without saying (but nevertheless has to be said) that in the absence of a safe, trusting relationship, a child is unlikely to share his innermost fears and feelings with a care worker. In the case of children in residential care such relationships are particularly difficult to form as the children's previous experiences have considerably undermined their capacity for trust. Nevertheless, the care worker should persevere, and be prepared for self-examination as well as discussions with supportive colleagues in an attempt to improve her/his relationship with the children under her/his care as far as possible.

Conclusion

The problem of children with psychosomatic illness poses a special challenge to the care worker. While it is understandable that children in residential care are likely to be particularly prone to these illnesses, it remains true that illness is a maladaptive way of coping with stresses, and if allowed to progress can only have the effect of further disadvantaging already disadvantaged children (Apley is convinced, for example, that children with recurrent psychosomatic abdominal pains are at greatly increased risk of developing peptic ulcers in adult life). The care worker's difficult task is to help the child to find ways, other than illness, to cope with the many stresses he will have to contend with.

References

Apley, J. The Child with Abdominal Pains Blackwell, Oxford, 1959.

Minuchin. S., Rosman, B.C. and Baker, L. Psycho-somatic Families Harvard, Cambridge, 1978.

Parkes, C.M. Bereavement – Studies of Grief in Adult Life Tavistock, London, 1972.

Suinn, R.M. Fundamentals of Behaviour Pathology Wiley, New York, 1970. 

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