A 9-year-old girl is brought to the office by her mother for assessment of "bad stomach aches." The patient has missed 5 days of school in the past few weeks due to intermittent abdominal pain that is "achy all over" and worse in the morning. She has not had associated nausea, vomiting, diarrhea, or constipation. Her appetite is poor. The mother reports that her daughter used to be talkative and outgoing, but now she declines invitations to play at friends' houses and instead takes naps after school. The patient has been distracted in class lately and less engaged in group activities. Her father lost his job 3 months ago and has been home more often since then. The mother says, "Things have been difficult financially. It doesn't help that her father has started drinking again." When interviewed, the patient is withdrawn and makes poor eye contact. When asked if she feels depressed, she says, "Everything will be better when no one has to take care of me anymore." She avoids answering further questions. The patient has no significant medical history. Vital signs and physical examination, including abdominal examination, are normal. Which of the following is the most appropriate next step in the management of this patient?

Question

A 9-year-old girl is brought to the office by her mother for assessment of "bad stomach aches."  The patient has missed 5 days of school in the past few weeks due to intermittent abdominal pain that is "achy all over" and worse in the morning.  She has not had associated nausea, vomiting, diarrhea, or constipation.  Her appetite is poor.  The mother reports that her daughter used to be talkative and outgoing, but now she declines invitations to play at friends' houses and instead takes naps after school.  The patient has been distracted in class lately and less engaged in group activities.  Her father lost his job 3 months ago and has been home more often since then.  The mother says, "Things have been difficult financially.  It doesn't help that her father has started drinking again."  When interviewed, the patient is withdrawn and makes poor eye contact.  When asked if she feels depressed, she says, "Everything will be better when no one has to take care of me anymore."  She avoids answering further questions.  The patient has no significant medical history.  Vital signs and physical examination, including abdominal examination, are normal.  Which of the following is the most appropriate next step in the management of this patient?

Quizplus · Accepted Answer

This patient's social withdrawal, poor appetite, impaired concentration, and sleeping during the day are concerning for depression. As seen in this patient, childhood depression is often associated with somatic symptoms such as stomach aches and headaches because children often have difficulty recognizing or discussing their emotions. Any child with a change in behavior in the context of family stress and parental substance use should be assessed for child abuse. This girl's avoidance of answering most questions is worrisome. In addition, her refusal to directly answer whether she is depressed, saying that "everything will be better when no one has to take care of me anymore," is particularly concerning for possible suicidal ideation. The most appropriate next step is to obtain an emergency psychiatric assessment that can assist in determining if psychiatric hospitalization is necessary. Considerations for inpatient care include suicidal ideation, poor psychosocial support, and lack of psychiatric follow-up (as an outpatient). This patient has poor psychosocial support with ongoing familial stressors and no current psychiatric care. She should not be sent home until further evaluation of her safety takes place. (Choices A and B) Contacting the patient's school and arranging for an in-home social work assessment can be helpful in understanding the case factors involved and making appropriate recommendations for treatment and support that involve both the school and family. However, information from the school may be insufficient to rule out suicidality or abuse, and the child should not be sent home until her safety is established. (Choices C and D) Checking a comprehensive metabolic panel and obtaining an ultrasound are appropriate if there is concern for medical causes of abdominal pain (eg, localized pain or guarding, rebound on examination). However, these are unlikely to be helpful in a patient with nonspecific aches and a normal physical examination. In addition, the results of these tests take time, and suicidality and safety are immediate concerns. (Choices F and G) Antidepressants and/or psychotherapy (individual, family) are appropriate treatments for pediatric depression. However, an assessment of suicide risk and a determination of the appropriate level of care should take place first. Educational objective: In children and adolescents with depression, considerations for inpatient treatment include suicidal ideation, poor psychosocial support, and lack of psychiatric follow-up. Any child who has possible thoughts of suicide must undergo emergency assessment for safety. References: Suicide in childhood: a literatura review. (http://www.ncbi.nlm.nih.gov/pubmed/28954160)

A 9-Year-Old Girl Is Brought to the Office by Her