I chose to be a paediatrician.
I chose it because I love children — I love their warm hugs, their cute giggles, and their stubborn determination to get better.
What I also love about paediatrics is the sheer detective work that happens behind the scenes. You see, our patients are usually unable to give accurate (if any) history.
You can’t ask a baby where it hurts. Good luck asking a toddler how she fell from the monkey bars. Nor can a newborn tell you why they’re crying.
Oftentimes, we doctors can explain their symptoms — a virus, reflux, or constipation. But I’ve found many a time where even the most senior doctors are left scratching their heads, perplexed and frustrated.
When our current knowledge of physiology isn’t equipped with the vocabulary to explain certain symptoms.
Somatisation
Somatisation refers to the experience of physical symptoms in the absence of abnormal findings in physical or laboratory investigations.
It currently affects 25% of children under 16 years old, with 10% of all children having their lives significantly impacted by these symptoms.
Symptoms may vary from simple headache and tummy pain to more concerning manifestations of fainting, vomiting, and seizures.
What makes somatisation difficult to diagnose and even harder to treat is that the causes are understood to be psychological. They are believed to stem from unconscious negative emotions instead of physiological causes, thus requiring input from many different teams to overcome.
Somatisation is a diagnosis of exclusion — so often, patients will have met several health professionals and undergone a barrage of tests to be told, “Everything has come back negative. We still can’t explain it.”
I’m going to share three such cases.
Note: details have been altered to preserve patient anonymity
Case I: The Boy Who Ate Tissue
I met G in the clinic.
It was one of his bi-annual checkups as he has an inherited blood disorder. But with early diagnosis and preventative treatment, he was doing well. He was excelling at school — being 8 years old, he was now accustomed to primary school life.
When all the routine questions were asked, he was told that we were happy with his progress and was advised to continue with his current treatment.
“We’ll see you in 6 months.”
“But wait, there is one other thing,” G’s mum said.
Mum and son exchanged uncomfortable stares as if deciding whether what came after should be shared.
“G likes to eat tissue paper, and this habit is getting worse.”
Later came a story that medical school never prepared me for.
G has been secretly eating tissue paper since he was six years old. What started as a harmless childish curiosity has morphed into a worrying addiction.
So much so, G’s mum has started to lock the tissue paper in a cupboard for fear that two rolls of toilet paper go missing in a single day. G had even resorted to eating toilet paper at his friend’s house during playdates.
While this secret side of him is publicly revealed, G looks at the floor.
When asked why he does it, he says, “I like the texture and taste. I can’t help myself. I know it’s wrong.”
My medical brain thinks of the harm this habit could cause. In my head, I was already listing the blood tests that I needed to order for G. But getting him to stop — that’s where I draw a blank.
It was only much later, when a few targeted questions seemed to crack the code.
“His dad and I broke up when this all started,” G’s mum later divulged. “His dad isn’t the best at keeping his promises — he doesn’t call or visit when he says he would.”
Without G knowing it, his body had expressed the pain he could not. His body yearned for control and predictability.
To retreat from a chaotic family environment, he hid where he found safety.
Case II: The Girl Who Wets The Bed
I met H a few years ago.
Part of my job as a paediatrician is overseeing the health and well-being of children in foster care. Early childhood adversity affects physical and mental health in children, and life outcomes when these are not addressed early are not favourable.
H was 12 years old and had been living in her current foster placement for a few years since being removed from her parents’ care due to severe neglect and abuse.
“How have you been feeling in yourself, H?” I asked.
She shrugged her shoulders and nonchalantly said, “Fine.”
However, her foster mum disagreed.
“There was an incident at school several weeks ago. She had a physical fight over a bag of crisps with my daughter. But we talked about it and we have ironed it out.”
“Please tell me more.”
H had monthly supervised meetings with her biological mum.
H doesn’t want to attend these meetings, but it is court-mandated. H’s foster family is going on holiday abroad soon, and H’s biological parents have not permitted H to go.
H has been stoic about the situation, but H’s foster mum knows she is having a hard time processing this news with the holiday quickly approaching.
This had all boiled over with a physical fight between H and her foster sister.
On the surface, it was a simple misunderstanding over a packet of crisps. But deep down, it is feelings of injustice that H has harboured for a long time, compounded by the fact that there is a court hearing in a few months, which will finalise her custody. She doesn’t want to leave her foster family, but there is a threatening possibility that that could happen.
So after the fight, H had started to wet the bed again.
This has unfortunately been a long-standing issue. Many investigations have been done to rule out a physical cause. But everything came back negative.
“It feels it is definitely stress-related because it always worsens nearer her court hearings.”
We all agree that H would benefit from psychological help, and I refer her back to her previous psychological team. But with the NHS squeezed for resources amongst budget cuts, I am not hopeful that she would get the help she needs.
Case III: The Girl Who Rubs Her Ears
Among all three stories, this is the story that I know best. Because this story is my own.
All my life, I had a nervous habit — I would massage my ears when I felt stressed or anxious.
My mum told me the story of how it started. Before I was an ear-rubber, I was a thumb-sucker.
Not wanting me to develop crooked teeth, my mum had gradually taught me to replace one soothing technique with another. She taught me to massage my ear during bedtime. And her plan had worked!
So much so, the habit had persisted into adulthood.
It was partly involuntary — I wouldn’t notice I was doing it until I did it. Being in a public environment wasn’t a deterrent, and it was so persistent that I felt uncomfortable wearing earrings.
I had my ears pierced at seven, but by the time I was a pre-teen, I had stopped wearing earrings altogether. Even when I started wearing the headscarf and fourteen, I had learnt to maneuver the fabric away for easy access to my ears.
The habit was most noticeable during exam season, in stressful situations at work, but most when my grandfather died.
In many ways, it felt like I was milking the pain away through my ears.
I am 34 years old now, and four years ago, I became a mother.
I had a stormy postpartum period filled with anxiety and fear — a lot of which pushed me to finally start therapy. Four years of on-and-off therapy had unlocked a lot of unprocessed grief, false beliefs, and difficult emotions buried deep down.
It has been painful work, but the most meaningful things usually are.
I hadn’t realised how my coping mechanisms very much mirrored that of my patients, until quite recently. And one day, everything clicked.
I can explain the tingling sensation in my fingertips before an emotional breakdown. The nausea in my chest when I was nervous. The eczema flare in my legs when I lacked sleep.
The body manifests what the mind can’t (or won’t) digest.
Helping Children Heal
Emotional pain is expressed through physical symptoms when a person doesn’t have the vocabulary or skills to communicate them in any other way.
Not surprisingly, poor emotional awareness is a predictor of somatisation in children.
To help children overcome their symptoms, it takes a lot of work and input from multiple teams (ie, doctors, psychologists, educators, parents, social workers, etc).
However, there are things that parents can do to help children process difficult emotions to prevent somatisation or reduce their effects:
Role-modelling good emotional awareness
Encouraging discussions around difficult emotions
Normalising discussions on how the body processes painful feelings
Fostering secure and safe attachments between parent and child
Giving sufficient time, attention, and care to the child in everyday situations, not only when a problem arises
I didn’t realise how invasive parental traits are passed down to their kids until I witnessed my own toddler rubbing his ears too before bed. He must have observed my habit and copied it unconsciously. But unlike me, he would pull his ears until they were raw and bleeding.
We would wake up every morning to another pillowcase covered in red. And despite trying different creams and recurrent warnings, nothing worked.
Until one day, he just stopped.
It wasn’t by miracle nor did it happen by chance.
It was a result of undoing many lifelong learned habits and crippling beliefs.
He stopped when his mother stopped.
I was sitting with my husband the other day when I said:
“Hey, I can’t remember the last time I rubbed my ears. I think it must be about a year ago now. Have you noticed it too?”
He nodded and smiled.
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