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ELECTRONIC ARTICLE:
John V. Campo, Carlo Di Lorenzo, Laurel Chiappetta, Jeff Bridge, D. Kathleen Colborn, J. Carlton Gartner Jr, Paul Gaffney, Samuel Kocoshis, and David Brent
Adult Outcomes of Pediatric Recurrent Abdominal Pain: Do They Just Grow Out of It?
Pediatrics 2001; 108: e1 [Abstract] [Full text] [PDF]
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[Read P3R] What is an adequate work-up before referral?
Harold Vann   (2 July 2001)
[Read P3R] Response to Dr. Vann
John V Campo   (2 July 2001)

What is an adequate work-up before referral? 2 July 2001
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Harold Vann,
Retired Pediatrician

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Re: What is an adequate work-up before referral?

hvann{at}aol.com Harold Vann

Since recurrent abdominal pain is a frequent symptom in childhood is there an outcomes studied protocol for an adequate work-up before consultation with a psychiatrist or psychologist?

Response to Dr. Vann 2 July 2001
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John V Campo
University of Pittsburgh School of Medicine

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Re: Response to Dr. Vann

campojv{at}msx.upmc.edu John V Campo

Dear Dr. Vann:

Thank you for your question. Unfortunately, there is no simple answer as to when the medical work-up should be considered complete, and I suspect that pediatricians would not be likely to agree completely on what would constitute a reasonable “boilerplate” medical assessment for pediatric recurrent abdominal pain (RAP). The facts of each case must be evaluated individually, and it may be impossible to absolutely and definitively rule-out unrecognized disease in many children with ostensibly unexplained RAP. The clinician must strive for a balance between the importance of minimizing professional anxiety about unrecognized physical disease, family anxiety, the risks of medical tests and procedures, and cost. In general, unless the professional is reasonably comfortable that a serious physical disease has not been missed and is able to communicate this conviction to the patient and family, it will be difficult to provide credible reassurance to the patient and family that physical disease has not been overlooked.1 Unnecessary medical tests and treatments can be dangerous in and of themselves, and have the potential to communicate physician uncertainty and thus generate unnecessary patient and family anxieties. A functional diagnosis should not be made by excluding physical disease alone, but the clinician should look for “clues” or positive findings, with the more prominent being contiguity of the symptom with psychosocial stressors, the presence of a diagnosable psychiatric disorder, association of the symptom with psychological gain for the child, existence of a model for the symptom within the child’s immediate environment, and responsiveness of the symptom to placebo, suggestion, or psychological treatment.2-5 Such “clues” are certainly not definitive. A constellation of “clues” taken together is most persuasive, but do not exclude the possibility that physical disease may be present. The clinician should certainly perform a focused psychiatric interview with the child and parent, and ask relevant questions about persistent fears, worries, and depressive symptoms.

Sincerely,

John V. Campo, M.D.

References: 1. Campo, J.V., Fritz, G. (In press). A management model for pediatric somatization. Psychosomatics. 2. Goodyer, I. M., & Taylor, D.C.: Hysteria. Arch Dis Child 1985; 60:680-681. 3. Dubowitz, V., & Hersov, L.: Management of children with non-organic (hysterical) disorders of motor function. Dev Med Child Neurol 1976; 18:358-368. 4. Friedman, S. B.: Conversion symptoms in adolescents. Pediatric Clinics of North America 1973; 20:873-882. 5. Campo, J. V., & Garber, J.: Somatization. In R. T. Ammerman & J. V. Campo (Eds.), Handbook of Pediatric Psychology and Psychiatry (Vol. 1). Boston: Allyn & Bacon, 1998, pp. 137-161.