Decoding psyche and soma: a clinician’s treasure trove for treating somatic symptoms in children and their families
Treating somatic symptoms in children and adolescents
Williams SE, Zahka NE (2017). New York: Guilford Press, 273 pp. ISBN 978-1-4625-2952-0 (Hardcover: $35.00 USD; eBook: $35.00). Link
Reviewed by Bryan Carter, Kristie Schultz, and Elaine Gilbert
This is the third book to be published in The Guilford Child and Adolescent Practitioner Series (editors John Piacentini and John Walkup), and it readily lives up to expectations for providing the pediatric practitioner with the nuts-and-bolts techniques required for everyday clinical work with challenging clinical presentations. Pediatric psychologists Drs. Williams and Zahka are seasoned academic clinicians with Cincinnati Children’s Hospital Medical Center whose day-to-day experiences with youth presenting with functional disability associated with a wide range of somatic symptom conditions has led to their development of sound evidence-based interventions that are developmentally sensitive and innovative in their adaptation to addressing a myriad of family dynamic factors. They adopt a truly multidisciplinary perspective that guides the clinician through those key systems factors that must be navigated to maximize a positive outcome for the often-reluctant and difficult to engage patient and family. Being the sensitive clinicians they are, the authors stress the importance of empathy by continually making the reader aware of the confusing and frustrating path their patients have been on in arriving at a somatic symptoms diagnosis.
The book is organized into clear and concise sections starting with an exceptionally comprehensive view of what comprises somatic symptoms, while always maintaining an eye on helping the clinician understand these conditions in a language that is interpretable to patients and their families. Since referrals for somatic symptom conditions are most typically seen in a medical context, Williams and Zahka are clear in their insistence that the psychosocial services provider must work in close contact with physicians and other healthcare providers in assuring a thorough medical evaluation and differential diagnostic evaluation has been conducted before introducing the patient and family to the biopsychosocial model of somatic symptoms. This is followed by a clear physiological and cognitive behavioral explication of symptom continuation that informs the treatment approach. This section includes a practical overview of the manner in which somatic symptoms express themselves within (e.g. neurology, cardiology, gastroenterology) and across (e.g. pain, fatigue) multiple medical specialties and treatment settings. One of the strongest contributions in this section is the authors’ clinically useful presentation of the autonomic nervous system (ANS), its function and dysfunction in the context of somatic symptoms. The reader is provided with child-friendly depictions of how the ANS can go awry, leading to the confluence of pain, anxiety, and avoidance, all contributing to functional disability.
The second section of the book continues the authors’ sensitivity in approaching the conduct of assessment in a clinically relevant manner. Relying heavily on narrative in establishing rapport while educating the patient and family by thorough clinical interviewing, Williams and Zahka are masterful in their provision of sample clinician-patient/family dialogues that explicate the teasing out of clinical information that informs the treatment approach. There is also a more abbreviated discussion of the use of formal assessment measures of symptoms, impairment, stress and coping, etc., but they are pragmatic in recommending that the use of formal assessment tools should always be relevant, helpful, and “worth everyone’s time.” Indeed, an overemphasis on formal psychosocial assessment in the initial stage of clinical work with patients with somatic symptoms can be alienating and counter-therapeutic. Williams’ and Zahka’s skills as academic clinicians is on best display in their extension of the assessment leading into the process of educating the patient and family on the real world understanding of the biopsychosocial model at work in the patient’s somatic symptom presentation, functional disability and buy-in to intervention. The chapter on education is rich with interactive patient-clinician scripted dialogues that exemplify the process of motivating and leading the patient into understanding their symptoms and how lifestyle changes will play an increasing role in improving functioning and quality of life.
The third section on intervention reflects the comprehensive multidisciplinary and multidimensional treatment approach supported by the growing body of research on treating pediatric patients with chronic health conditions where somatic symptoms are primary or even secondary to a well-delineated clinical disorder. The authors begin with an emphasis on the role of physical activity and exercise in these patients who have often become inactive, deconditioned and socially isolated in response to their debilitating symptoms. This is followed by discussions of the important roles of sleep, nutrition, daily schedule and family relationships. Next, Williams and Zahka address work with the emotional and behavioral components to intervention including the development of a coping skills toolkit that involves relaxation (progressive muscle relaxation, diaphragmatic breathing, imagery, biofeedback), and distraction techniques (e.g. incorporating pleasant activities). This section concludes with an excellent overview of cognitive behavioral therapy interventions, again enhanced by concise illustrative patient-clinician dialogues.
Effective clinical work with pediatric patients with debilitating somatic symptom conditions necessitates close coordination and collaboration with a number of the systems in which these patients must function if improvement is to be obtained. Initially, perhaps no system is more important than the parents of the affected patient. Williams and Zahka deftly address what we like to refer to as the slippery slope that parents are on when their child is diagnosed with a health condition (i.e. the protective and highly supportive and nurturing approach appropriate for an acute and resolvable illness becoming problematic for a more protracted condition). They guide parents through strategies that improve parental modeling of coping, encouragement of their child gradually resuming more normal activities, better tolerance of distress in their child, improved balance of their attention between symptoms and functioning, and promotion of more positive coping in extra-family/community activities. This is then extended to the all-important matter of school attendance and performance, including the clinician actively advocating for the child receiving accommodations and resources to reduce the demands and stress of returning to school. From their experiences in working in a complex health care and academic medical setting, the authors complete this section with a thoughtful discussion of the various levels and forms of communicating and collaborating with other healthcare colleagues in order to assure coordinated care.
Finally, the appendix of the book could virtually stand alone as a patient workbook as it consists of reproducible forms and tools that illustrate and serve to enhance the rich clinical assessment and intervention narratives in the text. Well-illustrated and clear forms are provided depicting various aspects of the biopsychosocial model, assessment tools, and interventions which can be used both in-session and as homework tools.
Drs. Sara Williams and Nicole Zahka have provided the clinician reader of their book Treating somatic symptoms in children and adolescents with a comprehensive and thoroughly instructive state-of-the-art resource for treating pediatric patients with somatic symptom conditions. Their artful use of illustrative clinical dialogue feels almost as though one has attended a workshop with these masterful clinicians. Undoubtedly this resource will find an important and readily accessible place on the bookshelf for frequent reference in providing competent care to this growing patient population.
Cite as: Carter B, Schultz K, Gilbert E. Decoding psyche and soma: a clinician’s treasure trove for treating somatic symptoms in children and their families. Book review: Treating somatic symptoms in children and adolescents. Pediatric Pain Letter 2018;20(2):18-20. www.childpain.org/ppl