Organic or psychosomatic? Facilitating inquiry with children and parents.

CASE Eric (12 years old, 6th grade) saw a new pediatrician with concern about fatigue and intermittent abdominal pain for the past 2 to 3 months. His mother observed that he appeared more tired and that the “whites of his eyes are more cloudy” than usual. He continued to be active, however, and reported that he played basketball and football without any problems. He slept 8 hours each night without a problem either initiating or maintaining sleep. When asked about the abdominal pain, Eric reported that it was usually in the left upper quadrant, more noticeable after running, and subsided after 1 to 2 minutes of rest. He denied any physical trauma, constipation, hematochezia, joint symptoms, fever, night sweats, or weight loss. His mother inquired about whether he could have hepatitis because a family friend, who was at their home cleaning the garage, had been diagnosed with hepatitis. However, she stated that neither she nor her son had any casual or intimate contact with this person and that he was in the garage for only a few hours. Eric and his mother lived alone. For several years, he saw his father only occasionally. Eric was struggling academically in school this year; his grades changed from A’s and B’s down to C’s and D’s. He had not changed schools and denied any problems getting along with either peers or teachers. When the pediatrician asked why Eric’s grades changed, his mother reported that she thinks it is because he is missing a lot of school and not keeping up with his homework. She reported that recently he missed 1 to 2 days weekly because “he is too tired” in the morning. Intrigued by the constellation of symptoms and concerns, the pediatrician asked Eric’s mother to wait in her office while she examined the patient. The physical examination was normal, and further questioning of the patient without a parent in the room did not elicit information to explain his school problems other than his insistence that he is often tired. Leaving the patient to dress, the pediatrician returned to her office. She asked the mother if there was anything that she wanted to share that she was uncomfortable discussing with her son in the room. At this point, the mother appeared anxious and disclosed that she was diagnosed with hepatitis C a few months ago. She stated that she felt well but was terrified that she gave the infection to her son, because they shared a glass immediately after she had undergone dental work and may have had “blood in my mouth.” Eric’s mother stated that she was so troubled after this event that she stopped any form of physical contact with her son including kissing, hugging, or snuggling as they watched television together for fear that she would pass the infection to him. The pediatrician spent considerable time explaining the usual mode of transmission of hepatitis C and the unlikelihood that her son could have contracted the disease from her with the contact described. In addition, she pointed out that the mother’s complete withdrawal from her son may be contributing to his apprehension about being away from her when it is time to go to school. Arrangements were made to perform baseline laboratory tests and hepatitis markers, and an appointment for a repeat visit was scheduled. After a few days, the pediatrician contacted Eric’s mother with a report of the normal laboratory results. When asked, the mother said that she has given Eric an occasional hug since the office visit. Two months later, the patient returned for a wellchild examination. His mother informed the pediatrician that their relationship was back to normal, that his energy level was returning to normal, and that he had missed only 1 day of school. In addition, his grades were improving, and he no longer complained of abdominal pain.