Every day, in households across America, a mini-drama unfolds: A child utters the words, “I don’t feel good,” and a parent struggles to respond appropriately.
What at first seems pretty straight forward–a child says he’s ill–often turns out to be a fairly complex situation, especially if saying “I don’t feel good” is a frequent occurrence.
Although some kids rarely complain about feeling sick, there’s another group-about 10 to 15 percent of all children ages 5 to 12-who have chronic physical complaints that do not have a clear organic cause. Their complaints are vague and usually involve a triad of symptoms: stomachaches, headaches and limb pain. Many complain at least once a week about some kind of ache or pain for months. For parents of these kids, responding to “I don’t feel good” isn’t simple at all. The discomfort may or may not appear real, but the frequency of it (and sometimes the timing of it) seems suspect. Uppermost in these parents’ minds is this question: “Is my child faking it?”
The surprising answer in most cases, according to pediatricians and mental health experts, is probably not.
“Feigning illness, which is a conscious decision like putting the thermometer by the light bulb so it will register a fever, is not very common,” says Kathleen Kelley, associate professor of clinical psychiatry and pediatrics at the University of Chicago.
Neil Schechter, professor of pediatrics at the University of Connecticut and an expert on children’s pain, agrees. “Kids are usually describing symptoms they are genuinely experiencing,” he says. And, although parents of kids who complain a lot would like a definitive diagnosis of illness or a clean bill of health, the answer usually is not black and white.
“It’s not a simple either/or situation, either you have a real problem or you’re malingering,” he explains. “We should eliminate that dichotomy because it’s destructive.”
A better question is why they’re experiencing the symptom, not if.
One Friday morning, 12-year-old Ben told his mother that his stomach hurt so much he couldn’t go to school. Christine Fox says she was a little suspicious of his insistence on staying home, because during a previous illness he hadn’t resisted going to school. But Ben wasn’t a chronic complainer and so, although she wasn’t convinced he was really sick, she let him stay home.
“At first I thought, OK, what test does he have to take today? But he’s very responsible about school work, so I couldn’t imagine any homework or test that would prompt this groaning about his stomach,” Fox explains. “There was a dance after school that he had really wanted to go to, and I figured if he were willing to give that up, either he really was sick or there was a really good reason that he didn’t want to go to school.”
Ben never admitted it, but Fox later discovered that Ben had had a verbal fight with another child the day before and there was a threat that he’d be beaten up at school. While she was at work and Ben was at home, he experienced a total recovery.
Still, Fox doesn’t think the symptoms Ben described were fake.
“I think he had a real physical symptom. Just the idea of my not letting him stay home caused his stomach to ache,” Fox says. “If I had sent him to school, he would have been sick. You could see him working himself up.”
Although Ben’s ailment was an isolated incident, it reveals how crucial it is for parents to think about the whole child, not just the particular symptom the child is presenting. This is even more true for parents confronted with recurrent complaints. Often, kids who have pain are letting their bodies talk for them, says Kelley. “What they’re saying is, `This is tough, we’re not doing well,’ ” she explains. “The physical aspect is a reflection of how the whole person is doing.”
Joyce Kramer (who asked that her real name not be used) of Chicago’s North Side found that was just the case with her son Brian’s recurrent headaches. When he was in 3rd and 4th grade, he often called home from school saying his head hurt and he didn’t feel well. She’d take him home, but he never became ill. At the same time, it became clear he was having a hard time socially at school as well as some conflicts with his teachers. The headaches, Kramer is certain, were an expression of Brian’s problems at school.
“When your kid is not emotionally OK, it’s very hard to distinguish the symptoms from physical illness,” she says.
That’s why parents need to investigate chronic complaints from both the physical and the psychological perspective simultaneously. You don’t want to miss a serious illness, and some, such as appendicitis, can begin rather subtly. And the cause of some medical problems is elusive. It wasn’t until Roxanne Munch’s daughter became a mother herself that the family discovered the cause of the daughter’s chronic headaches, poor appetite and other symptoms as a child. Roxanne Munch’s grandson has a rare genetic disorder and her daughter is a carrier of the recessive gene that causes it. The symptoms she had as a child were a mild expression of that gene.
A trip to the pediatrician, then, is especially warranted to check out any pattern or new symptom.
“Parents need to be secure if they’re going to be firm,” says Kelley. “And many pediatricians are very savvy. Going to the pediatrician shows concern and may be reassuring to a child who has unconsciously focused on a particular physical sensation or problem.”
At the same time, parents need to think about school-related stresses, including class bullies, undiagnosed learning disabilities and attention problems, shifting friendship groups and difficult teacher-student relationships. For some kids, these stresses cause recurrent pain, which is alleviated when the stresses are resolved. Brian Kramer, now a 6th grader who manages the social and academic scene with greater ease, no longer has headaches that prompt him to call home from school.
Parents should consider their kids’ outside activities too. “Make sure the child isn’t so overcommitted and overstructured that there’s no other way to extricate himself than to be sick,” says Schechter.
How parents respond to recurrent physical complaints may determine their length as well as their severity. Experts say parents need to strike a delicate balance between recognizing and empathizing with the symptoms and not overly attending to them so the pain isn’t reinforced.
“If the child has recurrent symptoms that go away when he’s told that he doesn’t have to go to school, then the child can internalize that and always have a stomachache when he has to go to school,” explains Martin Stein, professor of pediatrics at the University of California at San Diego and president of the Society for Developmental and Behavioral Pediatrics. “If the parent feels the child is not too sick, the best approach is to have him go to school.”
As parents, we’re teaching our kids how to respond to illness in a healthy way, Stein says. “The nurturing, care and empathy they receive teaches them about an important social event in their lives: illness.”
The best response is to give a quick appreciation for the symptoms but have a positive attitude that doesn’t overemphasize the pain. Parents can say things like, “I know this really hurts, but walk around and let’s see how you’re doing” or “I’ll do everything I can to make you comfortable, but now you have to finish your homework.”
Kramer found that the more she attended to her son’s complaints, the sicker he acted. “Whenever he said he didn’t feel well, I immediately acted very concerned,” Kramer says. “But I found that only encouraged a non-illness.”
Kramer now is very low key in her response, but continues to observe her son’s behavior. “If he says he has a sore throat, I look in his throat and say I don’t see anything, even though I can’t identify a red throat,” she says. “Then I watch him. If he’s lively, joking around, eating OK, I figure that consciously or unconsciously he’s using the symptom for another purpose.”
That technique is a good one for chronic complainers, who can focus on how they’re not feeling well and so feel worse.
“It’s actually harder on the kid to let the symptoms grow that don’t need to be there or for an illness to become more debilitating,” Kelley says. “It decreases their ability to get out and function.”
If kids do stay home, it’s important not to reward them by making home too much fun. There shouldn’t be a lot of TV watching or video game playing, and kids should get their homework assignments from school and complete them. If there’s a miraculous recovery at the end of the day, the child should not be allowed to go out. And when they’re home in bed, parents should not be checking on them all the time. In as respectful a way as possible, parents should positively reinforce their child’s non-pain behavior.
At its extreme, kids with chronic complaints but no clear organic cause can develop what’s called conversion disorder, in which their body actually begins to look like it has a serious illness.
Conversion disorder often involves neurological symptoms, such as pseudo seizures, fainting or an inability to walk. “In these cases, the kid unconsciously, without meaning to, has symptoms that resolve a school-related or relationship-related problem,” explains Kathleen Kelley, associate professor of clinical psychiatry and pediatrics at the University of Chicago. It resolves the problem for them because they can’t do what they’re supposed to be doing and they don’t have to deal with the conflict.
“It’s easier to deal with a physical symptom than, say, choosing one parent over another when your parents are divorcing or dealing with abusive kids at school,” says Kelley.
These kids go through a battery of tests, MRIs, EEGs, blood work and more, only to have them come back normal. Helping them resolve their problems involves a team approach of psychiatric and rehabilitative intervention.
