Ruling out organic disease is only the beginning of evaluating and treating recurrent abdominal pain (RAP), In many cases, the more challenging task is helping the child return to normal functioning. Children with RAP often have a history of school absence associated with their abdominal symptoms. Parents may be reluctant to push the child to go to school if he or she has abdominal pain.
The goal of this article is to help physicians identify psychosocial factors that contribute to school absence and design simple interventions that help children return to school. These guidelines draw on clinical experience, theory, and empirical research to identify the psychosocial aspects of RAR1'5
USEFUL QUESTIONS FOR IDENTIFYING OBSTACLES TO SCHOOLATTENDANCE
Identification of obstacles to school attendance should begin early in the course of the medical evaluation, when establishing rapport with the child. It is most informative to learn about a child's thoughts and feelings directly from the child. Children not accustomed to speaking for themselves may turn to their parents for the answers to questions directed to them. By continuing to talk to the child and minimizing eye contact with parents, it is usually possible to engage in conversation with the child while parents listen. Children will speak more openly if the pediatrician is seated eye-to-eye with them, requiring either that the pediatrician squat or that the child be seated in an elevated position, such as on the exam table.
Discussions concerning school should begin with simple, non-threatening, informational questions directed to the child, such as inquiring about grade level or the teacher's name. It is generally not very informative to ask if the child likes school. Even children with significant school concerns usually deny problems and report that they like school. Nonetheless, evidence of school difficulties may be elicited indirectly (Sidebar 1, see page 130).
Questions that ask the child to make comparisons are particularly useful. These include questions about favorite and least favorite subjects, grade levels, teachers, and schools. Answers to these questions may provide leads regarding obstacles to school attendance. For example, if a child says he liked last year's teacher better than this year's teacher, subsequent questions about the differences between the two teachers may reveal a belief that the current teacher is "mean," does not like the child, or assigns too much homework. The pediatrician can then explore these Stressors further and help the family identify potential solutions.
Some children who had a good adjustment to school before their illness worry about their return. To elicit their concerns, the pediatrician might ask, for example, what it will be like to go back to school, if there is a lot of make-up work, and what classmates and the teacher will say about the absence. If the medical regimen requires a special diet, medication, or frequent trips to the bathroom, it is important to talk about how these will be managed at school.
COMMON OBSTACLES TO SCHOOL ATTENDANCE
Many children are overwhelmed by the extent of make-up work that confronts them as they return to school. They may worry that they simply cannot do that much work, that it will consume all of their free time for the indefinite future, or that they have missed so much class time that they will not understand the work. Once such concerns are brought into the open, they can be addressed with a structured plan.
Children will find make-up work more manageable if it is broken into small components, with a schedule that emphasizes steady progress rather than final products. For example, children who do not believe that they can write a four-page book report may agree that they can work on the report for half an hour a day, particulariy if a parent is available to help.
Some parents push their children to work more than the scheduled amount of time. This may result in a setback, so the clinician should emphasize that children must stop at the end of each scheduled work period. In some cases, it may be necessary for parents to contact the school to find out exactly what make-up work is required, negotiate a reasonable timeline for completion of the work, and request a reduction in work if it seems unnecessarily burdensome.
Explainations to Teachers and Peers
Some children worry that teachers or peers will ask why they have been absent from school. The medical tests showed that medically nothing was wrong, so what can they say when asked about their illness? In some cases, a teacher or peer has previously suggested that the child was faking illness to stay home from school. These children need assistance preparing a response that will help them save face. It may be enough to tell children that they can respond, 'The doctor said I have a problem with my stomach, but it's getting better." If school officials have implied that the illness is not real and have pressured the child about attendance, a letter from the pediatrician to the school may legitimize the illness and relieve pressure (Sidebar 2, see page 131).
Many children are reluctant to use the bathrooms at their schools. This presents particular problems for children with functional gastrointestinal disorders, who may need to use the bathroom frequently for symptom relief. Children avoid school bathrooms for a variety of reasons, including lack of privacy because doors on the toilet stalls have been removed, cannot be latched, or do not fully hide the occupant from view. Poor sanitation in the bathrooms and lack of toilet paper may also be concerns. In addition, fear that classmates will know they are defecating by the sound or smell, or that using the bathroom will take too long and they will be reprimanded for being late to class, makes many children reluctant to use the school bathroom.
It is helpful for the pediatrician to write a letter to the school indicating that, for health reasons, the child should be allowed to leave the classroom whenever necessary to use the bathroom (Sidebar 2, see page 131). This puts the timing of bathroom use under the child's control, thereby reducing anxiety about accidents and allowing the child to use the bathroom at times when other children may not be present. When the condition of the school bathroom is the primary problem, parents can be encouraged to contact school officials about improving sanitation or increasing privacy. Children who have never used a public bathroom may learn to do so in stages, beginning with bathrooms at the homes of friends and relatives and proceeding to bathrooms at a mall, restaurant, or public building. The parent can make this challenge appealing to the child by keeping a record and giving the child periodic rewards for using the bathroom in a new setting.
Relationship With a Teacher or Peers
In talking with patients with RAP, it is common to hear mat this year's teacher is not as nice as last year's teacher. A common scenario involves a sensitive child who has always had warm, nurturing teachers, but this year has a more matterof-fact, businesslike teacher. In some cases, the teacher has a reputation for harshness, but more often it appears that the child has misinterpreted the teacher's matter-of-fact manner as disapproval. Sorting this out may require that the parent meet with the teacher, school counselor, or principal to get another perspective. Sometimes the problem is alleviated through a teacher's extra effort to make the child feel special. In other cases, the child must be helped to understand and cope with the teacher's unfamiliar style. A change of teacher should be recommended only as a last resort, as this tends to reinforce children's belief that they cannot cope and to create additional Stressors associated with changing classrooms.
Some children can readily identify a particular classmate who teases them. Other children may report that they have no friends at school. Again, sorting out the extent to which the child's perception matches reality may require that the parent meet with the teacher, school counselor, or principal to get another perspective and to work together on a solution.
Fear of a Pain Episode at School
Some children are fearful that they will have a pain episode at school and be unable to manage it. They tend to have poor skills for coping with pain, and at times may exhibit such exaggerated distress that they are rushed to the emergency room. Their distress arises from a habit of focusing their attention on even minor physical sensations and becoming fearful that these sensations will increase in intensity. Fear, in turn, magnifies the noxious sensory experience. These children are caught in a vicious cycle of anticipation of pain, increased anxiety, and physiological arousal, lowered pain threshold, and increased distress.1,6
One of the pediatrician's primary goals in working with these children is to help them learn that they can cope with pain. It is best that their initial return to school be for a limited period of time, perhaps 1 or 2 hours a day (see section on Setting up a Star Chart to Encourage School Attendance, page 134, and Sidebar 4, page 133). Most children will agree that they can manage being at school for a very short period of time, even if they experience pain. This abbreviated attendance will help build their confidence so that they can survive a pain episode at school.
The pediatrician and family should agree on a plan regarding what the child should do if he or she experiences pain during time at school. In general, it is counter-productive for children to call home or leave school early when they experience a pain episode, as this will reinforce their pain complaint and passive coping. Instead, school personnel should be asked to allow the child to lie down and rest for a while in the main office, until the child feels well enough to return to class or it is time to leave school. If necessary, the child might also be referred to another professional for training in pain management strategies such as relaxation and distraction techniques.
In the course of the clinical interview, the pediatrician may learn a child has a history of academic difficulty in one or more classes. Further inquiry should be directed at discovering the extent to which the child's poor performance might be due to a learning problem, attention problems, failure to complete assignments, or placement in a class that is too advanced. The parent may need to contact the school for more information and for help devising a plan of action that might include tutoring, educational testing, assistance with organizational skills, or provision of special education services. Most states have policies requiring public schools to provide free educational testing under certain circumstances.
Test or Performance Anxiety
Parents or children sometimes report the child's symptoms are worse before a test, athletic event, or other competitive activity. If the focus of anxiety is fairly circumscribed, the child may benefit from simple coping strategies that can be suggested in the pediatrician's office. Strategies that involve redirecting children's thoughts and images so that these enhance radier than undermine their success are particularly useful.
One of these strategies is to be a good coach. Children and their parents generally agree that good coaches inspire confidence with statements such as "I know you can do it!" and "Get in there and give it your best!" Children with performance anxiety, in contrast, often are not good coaches for themselves. They are likely to think to themselves, "What if I fail?" and "I don't know if I can do it." The pediatrician and parents can help children become aware of the "what ifs" and negative statements they make to themselves, and substitute these with good coaching, such as saying to themselves, "I know I can do it." and "I'm going to do my best."
In some cases, test anxiety is just one aspect of anxiety that extends to many domains of the child's life. These children should be referred to a child psychologist or other mental health professional.
Separation anxiety includes a constellation of symptoms that often are associated with RAP. Indeed, one of the symptom criteria for a diagnosis of separation anxiety disorder is "repeated complaints of physical symptoms (such as headaches, abdominal pain, nausea, or vomiting) when separation from major attachment figures occurs or is anticipated."7 These physical symptoms tend to occur in the morning on school days, are less likely on weekends when the child will not be separated from the parent, and may recur on Sunday evenings in anticipation of going to school on Monday. Additional symptoms of separation anxiety are listed in S idebar 3.
In the clinical interview, evidence of separation anxiety may be found both in the timing of pain episodes before school and in the child's bedtime routine. Children with RAP and separation anxiety often sleep with a parent, ostensibly in case of a pain episode. In addition, parents often report that the child wants to be with one or both of them throughout the day. Similarly, parents may be reluctant to be apart from the child because of the possibility that a pain episode will occur and the child will need them.
Children with separation anxiety typically are quite dependent on their parents who, in turn, may seem overly protective of them. During the office visit, the pediatrician may observe that the child and parent sit very close together, for example, with the child on the parent's lap and the parent stroking the child. It may seem as if the parent actually experiences the child's pain. Some parents use language that reflects this enmeshment, as in, "We had a bad tummy ache yesterday." Both parent and child tend to view the pain as so severe that school attendance is impossible. The parent's mission is to protect the child from pain by finding a cure.
In the case of RAP, however, a complete cure may be difficult to achieve; many children continue to experience episodes of pain at least occasionally, regardless of the treatment. Therefore, children must learn to cope with pain while simultaneously undergoing various medical or dietary treatments so that pain impact on their lives is minimized. Parents are likely to agree that coping with pain is an important life skill that they use with some frequency (eg, going to work despite a headache). The pediatrician must convince them that one of their tasks as parents is to teach their children this skill. Parents can do this by supporting their children's efforts to attend school for at least part of the day in spite of pain.
Children can be asked to estimate how long they could manage being at school if they went to school the next day. A wise policy is to limit the first day back at school to whatever amount of time allows the child and parent to feel confident of success. The goal is to break the cycle of fear of separation from their parents. In many cases, the initial return to school is successful if it is limited to half a day. hi other cases, the most that children can manage without uncontrollable crying might be 5 minutes at school with the parent remaining present. These more severe cases of separation anxiety should be referred to a behavior specialist. The pediatrician might manage !ess severe cases of RAP with separation anxiety, making a referral if significant progress does not occur within a couple of weeks.
A gradual return to school is most successful if the child's school attendance is reinforced. The mechanics of setting up a reinforcement program are discussed in the section on Setting up a Star Chart to Encourage School Attendance (see page 134) and Sidebar 4.
Family Reinforcement of Sick-role Behavior
During the course of an illness, children may learn that staying home from school has advantages.8 For example, they may be excused from tests, sporting events, or other activities involving evaluation of their performance. Of course, one cannox assume that all children value being excused from a test or other activity; it is only a relief for children who fear failure.
In addition to relief from activities, children may receive special attention or privileges because of their symptoms. For example, an absent parent may visit more often when the child is sick, the child may be allowed to lay on the couch and watch television all day, schoolwork may be completed by means of a homebound program that results in bevtei grades, and so on. Thus, social consequences may reinforce children's symptoms and other sick-role behavior.
In the clinical interview, the pediatrician should get a detailed account of how parents decide whether their child should stay home from school and how the child spends the day when not at school. The role of activity avoidance may be difficult to uncover because children sometimes report liking an activity that their illness allows them to avoid. Usually, it is not that children are lying about whether they like the activity, but rather that they are ambivalent and do not understand their conflicting emotions.
Parents of children with RAP may need guidelines to help them decide when their children should stay home from schtH)! and what activities should be allowed on those days. Some pediatricians tell parents that school absence requires a body temperature of 101° or higher and additional symptoms other than pain. Parents who let their children stay home for minor symptoms may benefit from hearing that even children with major chronic illnesses attend school, and that it is important for all children to learn to cope with the minor physical symptoms that are a part of life.
As a general rule, parents of children with RAP can be told, "If the child is too sick to go to school, then the child is too sick to play." The child should stay in bed throughout the day, without toys or television. Schoolbooks may be allowed. If the child begins to feel better, he or she should return to school, even if there is only an hour left in the school day.
In some cases, the pediatrician may learn of significant psychopathology, family dysfunction, or Ufe Stressors that have contributed to the etiology or maintenance of a child's symptoms. Such problems generally call for immediate referral to a mental health professional.
SETTING UP A STAR CHARTTO ENCOURAGE SCHOOL ATTENDANCE
Some children will readily return to school following a medical evaluation that reveals no organic disease. Others will return once they have a plan for dealing with specific problems addressed above, such as make-up work. Finally, some children who have completely lost confidence in their ability to attend school will become distressed at the mere mention of their return to school. These children usually have several obstacles to school attendance, including some degree of separation anxiety. If they are required to return to school the day after their medical evaluation, chances are great they will have a severe pain episode that prevents school attendance. If they go to school in the morning, they are likely to develop pain during the day and come home early, thereby further convincing themselves and their parents that they cannot attend school. For these children, a gradual return to school is most effective.
The first step in helping children make a gradual return to school is identifying and addressing any obstacles to attendance, such as inadequate time to use the school bathroom. Next, the pediatrician should consult with the child and parent to identify a manageable goal for initial school attendance. Start by suggesting half a day and, if the reaction from child or parent indicates this will be difficult, decrease the time to as little as necessary for the child and parent to feel confident the child will succeed on the first day back to school.
A behavior reinforcement program, or "star chart," can be used to track and reward children's progress in attending school. An effective behavior reinforcement program must take into account the characteristics of the individual child and family. It is not possible to design a single program to reinforce school attendance that works for every child. However, the principles common to a successful program are illustrated in this hypothetical example.
Example of a Program to Reinforce School Attendance
In our example, Ashley is an 8-yearold girl who has missed several weeks of school because of Functional abdominal pain. The clinical interview revealed the primary obstacles to Ashley's attendance were separation anxiety and the fear that she would fail because she was so far behind in her schoolwoik.
In our discussion of her return to school, Ashley doubted that she could attend school for half a day, so we agreed that she would attend for only 2 hours on each of the first few days back at school. We sketched a star chart on a piece of paper, dividing the 2 hours into four periods of one-half hour each. Ashley would receive a star for each half hour at school. After she earned a certain number of stars, she would be able to exchange them for a small prize.
We had previously determined that Ashley liked inexpensive hair ribbons, so together we decided that she would use her stars to earn hak ribbons. Her mother agreed to purchase several of these so they would be on hand to give to Ashley on the days that she earned them. Ashley's mother also agreed to ask the grandmother not to give Ashley any new hair ribbons for a while, so that Ashley's only means of obtaining them would be by attending school.
Ashley's father agreed to help Ashley make a star chart on the computer that could be displayed on the refrigerator in the kitchen. This display was to remind the parents to keep track of Ashley's attendance, deliver her rewards on time, and verbally praise her for her progress. In addition to a rough sketch of the chart, the family left the clinic with a packet of stars and a letter to the school explaining the plan for a gradual return to school (Sidebar 2, see page 131).
The reward schedule was set up so that Ashley needed six stars to receive a hair ribbon. She could earn four stars on the first day of attendance. Thus, at the end of the first day, she was motivated to attend school the second day in order to earn the two additional stars needed for a hair ribbon. At the end of the second day, she had a total of eight stars. She redeemed six stars for a hair ribbon and had two remaining stars of the six required for another hair ribbon. Thus, she knew that if she attended school on the third day, she would have enough stars for another hair ribbon by the end of third day.
In cases of separation anxiety, separation of the child from one parent is often more difficult than separation from the other parent. Ashley's mother had said that it "tore her up" to drop Ashley off at school when Ashley had a stomach ache. In addition, Ashley was more likely to cry when separating from her mother than from her father. Therefore, Ashley's father was recruited to drive her to school for a few weeks.
At the end of the first week back at school, Ashley had regained some of her confidence about attending school. In addition to the reward system, the naturally occurring positive consequences associated with school (eg, seeing her friends) had begun to reinforce her school attendance. Nonetheless, she was sometimes tearful in the morning before school. Therefore, when we revised the schedule for the second week, we added a bonus star for not crying in the morning. In the second week, she attended school for 4 hours a day, received a star for each hour of attendance, and received a hair ribbon for six stars. Recognizing that school attendance is especially difficult on Monday after the weekend at home, we began the revised schedule of longer attendance on a Tuesday.
The revised schedule for the third week set the goal as full days of school attendance. Ashley received a star for attending school in the morning and a star for attending school in the afternoon. Ashley had begun to lose interest in hair ribbons, so we changed the reward to a menu of activities that she could choose from (eg, playing a board game with her parents, stopping for ice cream on the way home from school, a small toy). Three stars could be redeemed for one of these activity rewards. Note that as we increased the time period required for a star, we decreased the number of stars needed for a reward. In addition, if Ashley attended school for 5 days in a row, she would receive a special, bigger reward - going to a movie on the weekend.
In the subsequent weeks, the stars were discontinued, but each week that she attended 5 days of school, Ashley received a special privilege on the weekend. Finally, we set a long-term goal of attending school every day for 4 weeks in a row, and Ashley's parents promised that she could have several friends spend the night when she met that goal. That overnight party also served as a celebration of Ashley's success, at which time the program was discontinued.
This example illustrates several guidelines that can be followed in designing an individualized program to reinforce school attendance (Sidebar 4, see page 133). The initial goal for school attendance should be quite easy. It is important to achieve immediate success, however small, to break the cycle of repeated failure and help both children and parents gain confidence in themselves.
Rewards should be within the family budget and should be given to children immediately after they are earned. Rewards may be small prizes, special activities, or stars that can be redeemed for prizes or activities. The pediatrician should provide the family with a draft of the star chart that includes a written record of the amount of time needed to earn a star, and the number of stars required for a special prize or activity. It should not be possible for children to obtain the particular rewards by means other than the program. New rewards should be created as children lose interest in the current rewards. In addition to school attendance, related goals (eg, not crying in the morning) can be incorporated into the program and rewarded with bonus points. Parents should verbally praise children in addition to giving rewards.
Initially, children should be rewarded very brief periods of school atten(eg, a star for each half-hour). Later, the rewards should be given for longer periods of attendance. Both parents should be involved in the program. If a child has particular difficulty separating from one parent at the school door, then it may be helpful for the other parent to take the child to school for a while in order to break this pattern. The program should be reviewed and revised regularly to reflect new goals, which requires a weekly telephone call or office appointment with the pediatrician. Once children are attending school regularly, long-term goals should be set to help maintain attendance.
WHEN TO REFER TO A BEHAVIOR SPECIALIST
Before implementing behavioral interventions such as those described here, the pediatrician should solicit the parents' agreement that they will accept a referral to a behavior specialist if these interventions fail to show results within a specified time period, usually 2 to 3 weeks. It can be counter-productive to continue an intervention longer than 3 weeks without significant progress, as children and parents may become more convinced of the severity of the pain condition, the child's inability to cope, and the physician's ineffectiveness.
Common reasons a simple clinicbased intervention may not improve school attendance significantly include parents who are unwilling or unable to implement the plan, a physician who does not have adequate time or training to assist in the design and implementation of an effective plan, psychosocial or medical problems that are more complex than originally thought, and additional significant Stressors that are uncovered.
HOW TO REFER TO A BEHAVIOR SPECIALIST
Parents are most likely to accept a referral to a behavioral specialist if the pediatrician knows the specialist and can make a personal recommendation. An established working relationship with such a specialist also facilitates treatment coordination. Pediatricians should identify one or more child psychologists, family therapists, social workers, or other professionals in their community who will receive referrals and will provide the pediatrician with feedback. School counselors also can be a resource.
Some health care providers are reluctant to discuss the potential influence of psychosocial factors on children's symptoms, for fear of offending the parents. In fact, however, research has shown the mothers of approximately half of the children referred to a medical clinic for evaluation of RAP endorsed psychosocial causes for their children's pain in an interview conducted prior to the clinic visit.9 Sidebar 5 (see page 134) shows the percentage of mothers who endorsed each of various causes for their children's abdominal pain. Note that although 50% endorsed that being "nervous, worried, or tense" contributed to their child's pain, only 12% endorsed "having personal or emotional problems" as a contributing factor. This finding highlights the importance of using the parent's own terminology to avoid stigma and miscommunication in discussing mental health issues.
Another common misconception is that parents will not accept referrals for psychological or behavioral interventions. In fact, the critical issue in presenting such referrals may be the terminology used by the pediatrician. Our data showed that despite the fact that approximately half of the mothers of patients with RAP agreed that "knowing how to relax" and "less stress" would reduce their children's pain episodes, only 18% agreed that "counseling" would be helpful (Sidebar 5, see page 134).9 Of course, the goals of counseling often include relaxation training and stress reduction. It is likely that a referral for counseling would be more acceptable if it were presented as a referral for the specific aspects of counseling that the parents value.
The majority of mothers of children with RAP believe that both physical and psychosocial causes contribute to their children's pain, and that both medical and behavioral interventions will help to alleviate the pain.9 Thus, mothers' perceptions of RAP suggest that they welcome a biopsychosocial approach to evaluation and treatment. By working together with parents, school staff, and other professionals, the pediatrician can help children with RAP make the adjustment back to school and other regular activities.
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7. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC: APA; 1994.
8. Walker LS, Claar RL. Garber J. Social consequences of children's pain: when do they encourage symptom maintenance? J Pediatr Psychol. 2002;27<8>:689-698.
9. Claar RL, Walker LS. Maternal attributions for Ute causes and remedies of their children's abdominal pain. J Pediatr Psychol. I99924<4):345-354.