Q. My son is 9 years old. His mother and I are divorced and we have not seen her in three or four years. I have been told by some doctors that my son has spina bifida, and others has said that he has some sort of myopathy. My son has complained of being exceptionally tired at times, of headaches, and having muscle fatigue.

I'm really not looking for answers from you, but a pathway to follow in getting my son the help that he needs. Between my parents and myself, we have tried many different paths such as support groups for children of divorce to doctors in Indianapolis and St Louis. My son needs help, but I just don't where to turn next.

A. This does sound like a problem that needs careful professional assessment and treatment. I can't comment directly on the physical problems you mention, except to say that either your son has spina bifida (a defect in the spinal cord) or he does not--it should not be hard to determine, given a careful neurological evaluation.

The same goes for the myopathy, fatigue, and headaches. I would suggest that seeing a pediatric neurologist and a pediatric rheumatologist at a major academic medical center would be the most useful initial paths for these problems.

The issue of his anxiety symptoms is perhaps more complex. It is not hard to imagine that a child who has experienced mysterious physical problems that set him apart from his peers, on top of the virtual loss of his mother, would be prone to anxiety, dread, or panic. (I can't rule out some underlying medical or neurological explanation for these symptoms, of course, and that is another reason for the evaluations I suggested above). Assuming these panic and phobic symptoms are psychologically-based, there may be substantial benefits from a combined program of cognitive-behavioral therapy (CBT) and a medication trial.

CBT involves helping the child learn new ways of thinking himself out of anxiety, and new behaviors to substitute for maladaptive ones. A child psychologist with special training in CBT would be one way to pursue this; a child psychiatrist with a cognitive-behavioral orientation would also be fine, and could prescribe medication as well. (Though it is not my preference, many mental health professionals might suggest a more psychodynamically-oriented or experiential form of therapy, emphasizing the exploration of unconscious feelings and repressed emotions).

Medications called SSRIs (such as Prozac or Zoloft) might be useful for some of the symptoms you describe, though these agents are not without some risks; e.g., side effects such as sedation or gastrointestinal distress. Thus, some child psychiatrists might first try CBT, then consider adding a medication if your son were not responding adequately. I realize you may already have seen doctors who have tried one or more of these approaches, without success.

If that's the case, I would try to have your son seen at a specialty clinic at a major teaching institution, such as Washington University Medical Center in St. Louis. A reasonable evaluation sequence might be: 1. pediatric neurologist; 2. pediatric rheumatologist; and 3. pediatric psychiatrist or psychologist. I do hope you find some help for your son--good luck!

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September 2002

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