A 14-year-old girl is referred to your pediatric clinic by her primary care physician for evaluation of chronic abdominal pain and excessive worries about school performance. The abdominal pain has been present for 8 months, described as a dull, periumbilical ache that occurs almost daily, worse on school mornings, and improves on weekends and holidays. She has seen a pediatric gastroenterologist; all investigations (CBC, ESR, CRP, celiac serology, abdominal ultrasound, stool studies) are normal. She has missed 25 days of school in the past 6 months. Her mother reports that she is a "perfectionist" who spends 3-4 hours nightly on homework, repeatedly erasing and rewriting assignments. She is tearful at the thought of returning to school after a break. She has no fever, weight loss, vomiting, or diarrhea. On examination, she is well-appearing, but there is mild diffuse abdominal tenderness without guarding or rebound. She is anxious, avoids eye contact, and fidgets during the interview. Her mother asks: "What is wrong with my daughter? We've done so many tests and they're all normal. Is this all in her head?"
Task for the candidate: You are the pediatrician. Perform a psychosocial assessment. Discuss your approach, including the differential diagnosis (anxiety disorders, somatic symptom disorder, school refusal), the use of screening tools (Pediatric Symptom Checklist, HEADSS interview), the importance of separate interview with the adolescent, the role of functional abdominal pain, and the management plan (cognitive-behavioral therapy, school reintegration plan, pharmacotherapy if indicated). The examiner will observe your response and ask follow-up questions.
💡 Examiner instruction (interactive): This is a case of somatic symptom disorder (functional abdominal pain) with comorbid anxiety (generalized anxiety disorder or school refusal). The candidate must recognize that abdominal pain is likely a somatic manifestation of underlying psychologic distress. The approach should include: (1) reassure the family that the pain is real (not "all in her head") but is likely related to stress; (2) perform a HEADSS interview (Home, Education, Activities, Drugs, Sexuality, Suicide/Depression) with the adolescent separately; (3) use standardized screening tools (Pediatric Symptom Checklist [PSC], SCARED for anxiety, PHQ-9 for depression); (4) rule out red flags for organic disease (weight loss, night waking, vomiting, rectal bleeding, abnormal labs); (5) develop a biopsychosocial formulation; (6) treat with CBT (for anxiety and pain) and SSRI (fluoxetine or sertraline) if moderate-severe anxiety; (7) develop a school reintegration plan (gradual return, 504 plan/IEP if needed).
🔍 Examiner Questions (interactive) – Click to reveal model answers
❓ Q1 (Examiner): “What is the differential diagnosis for chronic abdominal pain in an adolescent with normal organic workup? What are the red flags for organic disease?”
✅ Candidate's answer:
• Functional (non-organic) causes (most likely):
- Functional abdominal pain (FAP) / Functional abdominal pain syndrome (FAPS).
- Abdominal migraine (paroxysmal periumbilical pain with pallor/nausea).
- Irritable bowel syndrome (IBS) – associated with altered bowel habits.
- Somatic symptom disorder (pain with disproportionate thoughts/feelings/behaviors).
- Anxiety disorders (generalized anxiety, separation anxiety, school refusal).
- Depressive disorder.
• Organic causes to rule out (red flags):
- Red flags: Weight loss, fever, night waking, vomiting (especially bilious/hematemesis), bloody stools, nocturnal diarrhea, oral ulcers, arthritis, rash, family history of IBD/celiac, abnormal labs (elevated ESR/CRP, anemia, low albumin).
- Specific diagnoses: Inflammatory bowel disease (Crohn, UC), celiac disease, peptic ulcer disease, chronic constipation, pancreatitis, cholelithiasis, renal stones, endometriosis (adolescent females), abdominal epilepsy.
• This patient’s normal workup and lack of red flags strongly suggests a functional/biopsychosocial etiology.
❓ Q2 (Examiner): “Describe the HEADSS psychosocial interview. How would you apply it to this 14-year-old girl?”
✅ Candidate's answer:
• HEADSS stands for:Home, Education, Activities, Drugs, Sexuality, Suicide/Depression.
• Application to this patient (conducted separately from parent):
- Home: “How do you get along with your parents? Any conflicts, divorce, domestic violence?” – Assess family stressors.
- Education: “How are you doing in school? What are your grades? Do you feel pressure to perform? Have you been bullied?” – Excessive worry about school performance suggests academic anxiety.
- Activities: “What do you do for fun? Do you have friends? What do you do together?” – Social isolation may exacerbate anxiety.
- Drugs: “Have you ever tried alcohol, cigarettes, or drugs?” – Rule out substance use.
- Sexuality: “Are you in a relationship? Any concerns about your body, sexual activity?” – Assess body image, sexual health.
- Suicide/Depression: “Everyone feels sad or angry sometimes. How about you? Have you ever felt so sad you wished you were not alive?” – Screen for depression/suicidality.
• This patient likely has high academic pressure, possible peer conflicts, and anxiety symptoms.
❓ Q3 (Examiner): “What psychosocial screening instruments can be used in primary care to identify mental health problems in adolescents? Which would you use here?”
✅ Candidate's answer:
• Broad-band (general) screening tools:
- Pediatric Symptom Checklist (PSC-17 or PSC-35) – parent and youth versions; screens for internalizing (anxiety/depression), externalizing (behavior), and attention problems. Well-validated, free, easy to use.
- Strengths and Difficulties Questionnaire (SDQ) – similar to PSC.
• Narrow-band (focus on specific symptoms):
- Screen for Child Anxiety Related Emotional Disorders (SCARED) – 41 items, parent and child; screens for panic, GAD, separation anxiety, social anxiety, school avoidance.
- Generalized Anxiety Disorder-7 (GAD-7) – quick (7 items) for older adolescents.
- Patient Health Questionnaire-9 (PHQ-9) – for depression.
- PHQ-15 – for somatic symptoms.
• For this patient: PSC-17 (quick internalizing screen) + SCARED (anxiety) + PHQ-9 (depression) + ask about suicidal ideation.
• Action: If scores above clinical cutoffs, refer to mental health specialist or manage in primary care with CBT/SSRI.
❓ Q4 (Examiner): “Why is it important to interview the adolescent separately from the parent? What confidentiality issues should you address?”
✅ Candidate's answer:
• Reasons for separate interview:
- Adolescents are more likely to disclose sensitive information (substance use, sexual activity, bullying, self-harm, suicidal thoughts) without a parent present.
- Parents may not be aware of internalizing symptoms (anxiety, depression) – adolescents are often better reporters of their own emotional state.
- Builds trust and rapport with the adolescent, who is the primary patient.
- Allows assessment of family dynamics and parental functioning.
• Confidentiality and limits (must state at the beginning):
- “Everything you tell me is confidential, unless you tell me that you are going to harm yourself, harm someone else, or someone is harming you. In that case, I will need to involve your parents or other adults to keep you safe.”
- “I will also need to share important information with your parents to help coordinate your care, but I will let you know what I plan to share.”
- “You can ask me not to share certain things, but I will tell you if I cannot keep that secret.”
- Encourage the adolescent to share their concerns with parents, but respect their autonomy.
❓ Q5 (Examiner): “What are the DSM-5 criteria for somatic symptom disorder (SSD)? How does it differ from functional abdominal pain?”
✅ Candidate's answer:
• DSM-5 criteria for SSD (all must be met):
1️⃣ One or more somatic symptoms that are distressing or disrupt daily life (e.g., abdominal pain).
2️⃣ Excessive thoughts, feelings, or behaviors related to the somatic symptoms, manifested by at least one of: (a) disproportionate and persistent thoughts about seriousness of symptoms; (b) persistent high level of anxiety about health/symptoms; (c) excessive time/energy devoted to symptoms or health concerns.
3️⃣ Although any one symptom may not be continuously present, the state of being symptomatic is persistent (typically >6 months).
• Difference between SSD and functional abdominal pain (FAP):
- FAP (Rome IV criteria): Episodic or continuous abdominal pain without evidence of organic disease, but does NOT require excessive health-related thoughts/anxiety. FAP is a symptom-based diagnosis (functional gastrointestinal disorder).
- SSD: Requires the psychologic component (excessive thoughts, anxiety, behaviors). SSD can be diagnosed even if there is an underlying organic disease (but symptoms are disproportionate).
- In practice, many children with FAP meet criteria for SSD if they have significant anxiety about the pain.
- This patient’s excessive worries about school performance and absences suggest SSD.
❓ Q6 (Examiner): “List the ‘red flag’ signs and symptoms that would prompt further investigation for organic causes of abdominal pain in a child or adolescent.”
✅ Candidate's answer:
• Systemic red flags:
- Unexplained fever.
- Unintentional weight loss (or failure to gain weight).
- Night waking due to pain (distinguishes functional from organic).
- Fatigue, malaise.
- Oral ulcers, arthritis, rash (suggest IBD or autoimmune disease).
- Family history of IBD, celiac disease, peptic ulcer disease.
• Gastrointestinal red flags:
- Vomiting (especially bilious, hematemesis, or projectile).
- Diarrhea (nocturnal, bloody, or with mucus).
- Constipation (chronic, refractory).
- Rectal bleeding, melena.
- Dysphagia, odynophagia.
- Localized tenderness or mass on examination.
- Perianal disease (fissures, fistulas, skin tags – suggest Crohn).
• Laboratory red flags:
- Anemia, thrombocytosis, elevated ESR/CRP, hypoalbuminemia, abnormal LFTs, elevated celiac serology.
- This patient has none of these – reassuring.
❓ Q7 (Examiner): “This patient has missed 25 days of school. What is school refusal? What are the common causes and management strategies?”
✅ Candidate's answer:
• School refusal (school avoidance): Child’s refusal to attend school or difficulty remaining in school for the entire day, associated with emotional distress (anxiety, fear, depression).
• Common causes:
1️⃣ Separation anxiety disorder (younger children).
2️⃣ Social anxiety disorder (fear of peers, performance).
3️⃣ Generalized anxiety disorder (excessive worry about school performance, tests, social judgment).
4️⃣ Somatic symptom disorder (abdominal pain, headaches on school mornings).
5️⃣ Depression (lack of motivation, social withdrawal).
6️⃣ Bullying or victimization (physical, verbal, cyber).
7️⃣ Academic difficulties (learning disabilities, ADHD).
• Management strategies:
1️⃣ Gradual, planned school reintegration – not immediate full-day return; start with partial day or specific classes.
2️⃣ Collaboration with school – guidance counselor, school psychologist, 504 plan or IEP (if learning disability).
3️⃣ Treat underlying psychiatric disorder – CBT for anxiety, SSRI for anxiety/depression.
4️⃣ Parent training – reinforce school attendance, avoid secondary gain (allowing child to stay home for pleasant activities).
5️⃣ Address bullying or academic supports.
• Avoid prolonged home schooling unless there is a medical contraindication.
❓ Q8 (Examiner): “What is a biopsychosocial formulation? Provide a formulation for this patient using the 4 Ps (predisposing, precipitating, perpetuating, protective factors).”
✅ Candidate's answer:
• Biopsychosocial formulation: A comprehensive assessment integrating biologic, psychologic, and social factors that contribute to the patient’s presentation.
• For this patient (4 Ps):
- Predisposing factors: Perfectionistic temperament, family history of anxiety (mother described as anxious? – ask), possible genetic vulnerability to anxiety.
- Precipitating factors: Transition to high school, increased academic demands, tests, social pressures, possible conflict with peers/teachers.
- Perpetuating factors: School absences → falling behind → increased anxiety → more absences (vicious cycle). Parental accommodation (letting child stay home). Somatic symptoms reinforced by attention from parents/doctors.
- Protective factors: Intact family, motivated to improve, no substance use, no suicidality, good cognitive ability, supportive mother (although anxious).
• Strengths: No red flags for organic disease, willing to engage in treatment.
❓ Q9 (Examiner): “What are the evidence-based treatments for anxiety disorders in adolescents? What would you recommend for this patient?”
✅ Candidate's answer:
• First-line psychotherapy:Cognitive-Behavioral Therapy (CBT) – specifically for anxiety. Components include:
- Psychoeducation about anxiety and somatic symptoms.
- Identifying and challenging anxious thoughts (cognitive restructuring).
- Relaxation techniques (deep breathing, progressive muscle relaxation).
- Gradual exposure to feared situations (school, tests).
- Relapse prevention.
• First-line pharmacotherapy (if moderate-severe or poor response to CBT alone):
- Selective serotonin reuptake inhibitors (SSRIs) – fluoxetine, sertraline, escitalopram.
- Fluoxetine is FDA-approved for OCD and depression, often used off-label for GAD/social anxiety.
- Sertraline is also commonly used.
- Start low, go slow (e.g., sertraline 25 mg daily, titrate to 50-100 mg).
- Monitor for side effects (nausea, insomnia, activation, suicidal ideation – black box warning).
• For this patient: Start with CBT (8-12 sessions). If no improvement or severe anxiety, add SSRI (sertraline or fluoxetine).
• Also address school reintegration and family support.
❓ Q10 (Examiner): “What are the FDA-approved medications for pediatric anxiety disorders? What monitoring is required when starting an SSRI?”
✅ Candidate's answer:
• FDA-approved medications for pediatric anxiety:
- Duloxetine (SNRI) – approved for GAD in children ≥7 years.
- Fluoxetine, sertraline, fluvoxamine – approved for OCD (but commonly used off-label for anxiety).
- Escitalopram – approved for depression, not anxiety, but used off-label.
- No SSRI is FDA-approved for pediatric anxiety except duloxetine for GAD (and OCD meds).
• Monitoring when starting SSRI:
1️⃣ Baseline and follow-up (2-4 weeks, then 8-12 weeks):
- Suicidal ideation (black box warning – ask directly, "Do you have thoughts of hurting yourself?").
- Behavioral activation (increased energy, agitation, impulsivity – more common in children).
- Side effects: nausea, diarrhea, headache, insomnia/somnolence, dry mouth, decreased appetite.
- Sexual side effects (adolescents – decreased libido, anorgasmia).
2️⃣ ECG – not routinely required unless cardiac symptoms or other risk factors (but consider if prolonged QT known).
3️⃣ Educate family: Benefit may take 4-6 weeks; do not stop abruptly; monitor for worsening anxiety or mood changes.
4️⃣ If suicidal ideation emerges, discontinue and refer to emergency mental health services.
❓ Q11 (Examiner): “How would you manage functional abdominal pain (FAP) in this adolescent? What pharmacologic treatments are available for FAP?”
✅ Candidate's answer:
• Non-pharmacologic (first-line):
1️⃣ Reassurance and validation: "The pain is real, but it is not dangerous. It is caused by stress and anxiety affecting the gut (brain-gut axis)."
2️⃣ CBT – teaches coping strategies, relaxation, and reframing pain.
3️⃣ Gut-directed hypnotherapy – evidence supports its use in pediatric FAP.
4️⃣ Dietary modifications – avoid trigger foods, high-fiber diet, adequate hydration (not curative but may reduce symptoms).
5️⃣ School reintegration plan – prevents chronic absenteeism.
• Pharmacologic (second-line, for moderate-severe symptoms):
- Cyproheptadine (antihistamine/serotonin antagonist) – may reduce pain in FAP and abdominal migraine (dose: 0.25-0.5 mg/kg/day).
- Amitriptyline (low dose) – tricyclic antidepressant, 10-25 mg at bedtime – modulates visceral pain. Requires ECG (QT prolongation risk).
- SSRIs (if comorbid anxiety/depression) – reduce pain via central modulation.
- Peppermint oil – may reduce IBS symptoms.
• Avoid opioids – absolutely contraindicated in FAP.
❓ Q12 (Examiner): “Which patients with anxiety/somatic symptoms can be managed in primary care, and which should be referred to a mental health specialist?”
✅ Candidate's answer:
• Manage in primary care (mild to moderate, uncomplicated):
- Mild anxiety with minimal functional impairment (still attending school, participating in activities).
- No suicidal ideation or self-harm.
- No comorbid substance use, psychosis, or bipolar disorder.
- Family supportive and engaged.
- Pediatrician comfortable prescribing SSRIs and monitoring side effects.
- Can provide brief CBT techniques or refer to self-help resources (e.g., anxiety workbooks, online CBT programs).
• Refer to mental health specialist (child psychiatrist, psychologist):
- Moderate to severe anxiety with significant functional impairment (school refusal, social isolation).
- Suicidal ideation, self-harm, or suicide attempt.
- Complex comorbidity (depression, OCD, eating disorder, substance use, psychosis).
- Poor response to first-line SSRI after adequate trial.
- Family dysfunction or caregiver mental illness interfering with treatment.
- Need for specialized psychotherapy (e.g., trauma-focused CBT, DBT).
- This patient (moderate-severe school refusal, 25 absences) should be referred to a child psychiatrist or psychologist for CBT + possible SSRI.
❓ Q13 (Examiner): “The mother asks, ‘Is this all in her head? We did all the tests and they’re normal.’ How do you respond?”
✅ Candidate's structured answer:
• “Thank you for sharing your frustration. I understand you have done many tests and they are all normal. That is actually reassuring – it tells us there is no dangerous disease like cancer, IBD, or infection.”
• “The pain is NOT ‘all in her head.’ The pain is real. What we believe is happening is that stress and anxiety are affecting her gut – there is a direct connection between the brain and the intestines called the brain-gut axis. When a person is anxious, the gut can become more sensitive and can cramp or ache.”
• “Your daughter’s excessive worry about school performance is likely the source of her stress. The abdominal pain is her body’s way of reacting to that stress. This is called functional abdominal pain or somatic symptom disorder.”
• “The good news is that this condition is treatable. Treatment focuses on reducing anxiety and stress, not on finding more medical tests. We can use therapy (CBT) and sometimes medication (SSRIs) to help her.”
• “We will also work with the school to help her return gradually. You are not alone – we will help you and your daughter through this.”
❓ Q14 (Examiner): “What is the prognosis for adolescents with functional abdominal pain and anxiety? Are there any long-term sequelae?”
✅ Candidate's answer:
• Prognosis is generally good with appropriate treatment.
• Short-term: 50-70% of children with FAP improve within 1-2 years with non-pharmacologic interventions.
• Long-term outcomes (if untreated or inadequately treated):
- Persistence of abdominal pain into adulthood (20-40% continue to have symptoms).
- Increased risk of anxiety disorders, depression, and functional gastrointestinal disorders (IBS) in adulthood.
- Chronic school absenteeism → academic underachievement, social isolation.
- Unnecessary medical procedures and healthcare utilization.
- Protective factors: Early intervention, CBT, family support, successful school reintegration.
• With CBT and SSRI (if needed), most adolescents achieve significant symptom reduction and return to normal functioning.
🗣️ Examiner's probing / high-yield points (Psychosocial Assessment):
• "What is the HEADSS interview?" → Home, Education, Activities, Drugs, Sexuality, Suicide/Depression.
• "What is the most important red flag for organic abdominal pain?" → Night waking (pain wakes child from sleep).
• "What is the first-line psychotherapy for anxiety?" → CBT.
• "What is the first-line medication for anxiety in adolescents?" → SSRI (fluoxetine, sertraline).
• "What is the difference between functional abdominal pain and somatic symptom disorder?" → SSD requires excessive health-related thoughts/anxiety; FAP does not.
• "What is the Pediatric Symptom Checklist (PSC)?" → 17/35-item parent/youth screen for psychosocial problems.
• "What is school refusal?" → Anxiety-based school avoidance, not truancy.
• "What is the black box warning for SSRIs?" → Increased risk of suicidal ideation in young adults (monitor closely).
📘 Psychosocial Assessment – Core Revision for TOACS
🔍 Initial Approach Rule out organic disease (red flags: night waking, weight loss, fever, vomiting, blood). If normal workup, consider functional/biopsychosocial causes. Validate pain (real, not "all in head") while explaining brain-gut axis.
📋 Psychosocial Interview HEADSS (Home, Education, Activities, Drugs, Sexuality, Suicide/Depression). Conduct adolescent separately from parent. State confidentiality limits (harm to self/others, abuse).
🩺 Screening Tools PSC (Pediatric Symptom Checklist) – broad-band. SCARED (anxiety), PHQ-9 (depression), GAD-7. Use to quantify severity and monitor response.
💊 Treatment CBT (first-line for anxiety/FAP). SSRI (fluoxetine, sertraline) for moderate-severe anxiety. School reintegration plan. Cyproheptadine or low-dose amitriptyline for pain (second-line).
📈 Prognosis & Referral Good prognosis with early treatment. Refer to mental health specialist if severe impairment, suicidality, poor response to treatment, or complex comorbidity.
⭐ High-yield pearls for TOACS (Psychosocial Assessment):
• Always rule out red flags before diagnosing functional disorder.
• HEADSS interview with adolescent separately is essential (confidentiality limits must be stated).
• Pediatric Symptom Checklist (PSC) is a quick, validated screen.
• CBT is first-line for anxiety and functional abdominal pain.
• SSRIs (fluoxetine, sertraline) are first-line for moderate-severe anxiety (black box warning for suicidality).
• School refusal requires gradual reintegration, not immediate full-day return.
• Night waking is a red flag – suggests organic cause.
🗣️ Candidate's role-play & examiner feedback
💬 To the candidate (role‑play): You will be asked the 14 questions from the Examiner Q&A tab. This station tests the systematic psychosocial assessment of an adolescent with chronic abdominal pain and excessive worries about school performance. Key steps: (1) rule out organic causes (red flags), (2) perform HEADSS interview separately, (3) use screening tools (PSC, SCARED, PHQ-9), (4) diagnose functional abdominal pain/somatic symptom disorder with comorbid anxiety, (5) develop biopsychosocial formulation, (6) treat with CBT + SSRI (if moderate-severe), (7) create school reintegration plan, and (8) provide empathetic, validating counseling to the mother. Demonstrate a non-judgmental, biopsychosocial approach.
✅ Recommends CBT as first-line psychotherapy for anxiety and pain
✅ Prescribes SSRI (fluoxetine or sertraline) for moderate-severe anxiety (if indicated)
✅ Creates school reintegration plan (gradual return, 504 plan/IEP as needed)
✅ Counsels mother validatingly (pain is real, not "all in her head")
✅ Knows when to refer to mental health specialist (severe impairment, suicidality, poor response)
📚 Key references: Nelson Textbook of Pediatrics 22e (Chapter 32 – Psychosocial Assessment and Psychiatric Diagnostic Evaluation), DSM-5 criteria for Somatic Symptom Disorder and Generalized Anxiety Disorder, AAP guidelines for mental health screening in primary care, CPSP protocols for adolescent psychosocial assessment.