Behavior that persists

For several weeks in December, I worked with an adolescent medicine doctor who was like magic. Watching him massage our spectacularly manipulative patients into compliance was like watching someone fit a greased elephant into a cigar box. His motto was, as he told me repeatedly, “Every behavior that persists is being rewarded on some level.”

We had a patient for a time, an 11-year old girl I’ll call Precious. Precious had previously been diagnosed with lupus, a chronic and very real illness, but had been admitted this time for abdominal pain. Shortly after her admission (and her extensive workup), it became clear that her acute symptoms were what we politely call “inorganic”–meaning, they originated in her mind and not in a localized disease process.

Precious had been hospitalized many times before. She knew what worried doctors, and early on, she made damn sure we worried about her, often through disingenuous means along the lines of faking abnormal vital signs and abnormal urine output. Dr. Magic ignored these bids for attention and instead began to educate Precious about coping with her functional abdominal pain. At this point, she began refusing to eat, drink, or even sit up, saying these things caused her too much pain.

She was good. Even Dr. Magic felt challenged. 

“She really, really wants to be in the hospital,” her nurse said. Dr. Magic agreed. He thought that, while some of her pain might be real (as in a somatization disorder), some of it might also be made up (as in the very different factitious disorder)–and all of it originated in her head. There was a clear reward for acting sick: Christmastime in a children’s hospital means loads of activities, attention, and toys. She’d only get these things if she remained admitted as an inpatient, and she’d remain admitted if she remained sick. 

You don’t have to be pubertal to understand the logic, and yet I still had no idea how to get her to act as well as she was.

What we needed to do, Dr. Magic said, was to realign the axis of behavior and reward around something we could actually give or take away. We then needed to use that thing to stop rewarding her bad behavior–acting sick–and start rewarding good behavior–coping with her pain, whether real or not. 

From the day of her admission, Precious’ room had been filled with the artwork she loved to create, along with piles of distractions provided by her doting family and by the hospital, itself. Now, Dr. Magic took me into her room, where we took down the drawings and hauled out sacks of games and toys. He explained to Precious how things would work: she could eat and walk and, little by little, earn her stuff back. Or she could lie in bed and be hungry and bored. 

In other words, Christmastime in the hospital wouldn’t be fun unless she demonstrated coping skills. And the second she demonstrated coping skills, she’d go home. It was an ingenious trap.

She knew it, too. I was on call that night, and late into the evening, I could hear her sitting in her bed and screaming in frustration. Dr. Magic popped in after an evening meeting. “This is a good sign,” he said, then disappeared in a puff of smoke.

The next morning, I woke her while listening to her chest. “How are you feeling?” I asked. “It hurts to swallow,” she said, “but it’s something I think I can cope with. Can I go home?”

Yes, she could.

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7 Comments on “Behavior that persists”

  1. EGM Says:

    That had to have been Dr. _.
    We’ve got a Dr. Magic at my new institution, too. I call him Your Magesty. He’s f’ing incredible. I can’t stand adolescents, but I love learning from the docs who are great at working with them!
    Happy New Year, Dr. Signout!

  2. Sara Says:

    What a guy! I can only hope that I have such insightful mentors when I finally make it to residency.

    P.S. – I really enjoy your writing. :)


  3. How does a child fake abnormal vital signs and urine output?

  4. signout Says:

    By breathing fast and dumping out urine she was supposed to be saving.

  5. Awesome Mom Says:

    Where were her parents in all this? Why were they not involved in this situation?

  6. signout Says:

    Mom was involved–too involved. Part of Precious’ problem was that at home, complaining about her symptoms resulted in far more than treatment–it resulted in reward, such as days out of school, toys, attention, and lots of special services. The plan described above grew out of a meeting with Precious’ mother, during which she admitted that Precious was out of control and was running the household. She consented to the intervention I describe.

    Parents do not want to appear as though they don’t love their children. But in children with chronic illnesses, the best way to demonstrate parental love is to treat symptoms while teaching–and rewarding–coping. Although this is easier said than done, I think many parents accomplish it, anyway.

  7. Jude Says:

    You were extremely fortunate to have had a rolemodel such as your Dr. Magic – so many paediatricians find adolescents too trying to understand. It’s much easier to deal with the hard facts of pathology than psychology.

    I’ve seen so many children – pre and post pubescence – manipulating healthcare professionals and their families and it is easy to get sucked into their behaviour, or to dismiss it as being too complex and time consuming to deal with effectively.

    However, faking / exaggerating illness is a symptom of something real, even if it is ultimately supra-tentorial. The child who is ‘sick’ because they feel marginalised in their family because of a sibling’s chronic illness and the time and attention that demands; the child who is ‘sick’ because they perceive it as a way of keeping their parents from divorcing. However, don’t forget the parents who end up colluding in their child’s ‘illness’ as it makes them important in some way – a sort of quasi Munchausen’s by proxy – all very challenging and requiring experienced, objective and patient healthcare professionals to identify, understand and manage the difficulties that are intrinsic to these situations.


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