Unexplained physical complaints are common in children and form the basis for childhood somatization (the manifestation of distress through somatic symptoms) and somatoform disorders. Emotional symptoms and anxiety disorders are often comorbid with both unexplained physical symptoms and somatoform disorders. Risk factors include stress sensibility and probably biologic vulnerability in the child, mood and somatization disorders in the family, parental overinvolvement, and possibly limited psychological “mindedness” in relation to physical symptoms. The best evidence of efficacy is for family behavioral cognitive treatments, but for especially severe cases a multidisciplinary, carefully coordinated approach has been found to be clinically helpful.
Physical complaints tend not to feature prominently in the everyday work of child and adolescent psychiatrists or child and youth mental health clinics. These problems are more likely to be referred to the local pediatric clinic. As a result, expertise in the assessment and management of the psychiatric aspects of such problems varies considerably and can be limited. An exception are psychiatric pediatric liaison teams as they deal primarily with problems at the interface between physical and mental health problems, which include medically unexplained symptoms. Nevertheless, family engagement in assessment and treatment can be problematic even for specialist liaison teams.
Whether children and families engage with and benefit from psychiatric services depends to a large extent on whether families appreciate the link between physical and psychiatric symptoms, and wish to work on the comorbid psychopathology such as anxiety disorders or on the contributing psychosocial problems such as family disruption or school difficulties. Benefit may also depend on the joint expertise of pediatric and child and adolescent mental health teams in attending to these types of problems.
Definitions and general clinical issues
Physical complaints or somatic symptoms are common in children and adolescents, and the majority will have a physiologic explanation rather than one deriving from a diagnosable medical illness. Nevertheless, they often lead to pediatric visits. General population surveys show that young people report a mean of 2 somatic symptoms being present “a lot” in the 2 weeks before assessment; the most common being headaches, low energy, sore muscles, nausea and upset stomach, back pains, and stomach pains. Many of these symptoms will be mild but for a minority they will be recurrent and impairing. About 1 in 10 children report recurrent impairing aches and pains, and a comparable number have distressing somatic symptoms or are regarded by their parents as “sickly.”
The way complaints are managed relies on how they are understood; if parents or young people see them as a likely expression of medical illness, they will either visit their doctor or handle the problem themselves using their personal medical knowledge and experience. On the other hand, they may be of the opinion that the symptoms are temporary and unlikely to indicate illness, such as when a child’s abdominal symptoms are linked to certain foods “not agreeing” with them. Alternatively, they can have a psychological or social explanation, for example, symptoms exacerbated by stress such as worries about school, the child complaining in order to be comforted and to avoid going to school, or a particularly feared lesson. Common and effective parental reactions to dealing with symptoms thought to be psychosocially influenced are to “play down” the importance of the symptom so that the child learns to cope, or to comfort the child and try to find the cause of the distress.
There are times, however, when symptoms become marked and persistent, remain unexplained after pediatric examination, and cause considerable distress and impairment. There may also be indications of ongoing stress or associated psychiatric symptoms; however, these are not always obvious and parents and doctors may be at a loss to explain the severity and impairment. A psychiatric opinion is helpful to assist with differential diagnosis and confirm or exclude the presence of somatization, or of a somatoform disorder or another primary or comorbid psychiatric disorder amenable to psychiatric intervention. It is also helpful to identify psychosocial factors likely to be playing a part in symptom maintenance even when a definite psychiatric disorder is not present, and in medically informed psychosocial rehabilitation.
Somatization and Somatoform Disorders
For many children coming into contact with medical services with unexplained physical complaints, there will be evidence of somatization. This term describes a constellation of clinical and behavioral features indicating a tendency to experience and communicate distress through somatic symptoms unaccounted for by pathologic findings, and for these symptoms nevertheless to be attributed to physical illness, thus leading the patient to seek medical help. Somatization is a crucial feature of several ICD-10 ( International Classification of Diseases , tenth revision) and DSM-IV ( Diagnostic and Statistical Manual of Mental Disorders , fourth edition) somatoform disorders of which the most commonly seen in children and adolescents are persistent somatoform pain disorder, dissociative/conversion disorder, and—even though not part of DSM-IV and referred to as “neurasthenia” in ICD-10—chronic fatigue syndrome (CFS). Mental factors are assumed to have major significance as either precipitating or maintenance influences in these disorders.
Unexplained physical complaints become a clinical problem when, in addition to severe, recurrent, and impairing, they lead to repeated medical contacts with expectations of medical treatment. It is common by that stage for parents and children to hold the belief that there is some medical problem their doctor may be missing; this leads on the one hand to excessive special investigations determined more by the principle of not leaving any stone unturned than by sound clinical indication, and on the other to a reluctance to seek or accept a referral for psychiatric evaluation. Rejection of psychiatric assessment by children and parents can be intense to the extent that it seems unreasonable to others.
Psychological “Mindedness” and Related Dilemmas
The intensity is partly related to the fear that a physical illness will be missed, but probably also to a lack of psychological “mindedness,” with difficulty acknowledging that psychological and physical symptoms may be closely interconnected, and a concomitant reluctance to consider that the child and family may be able to gain control over them. This reluctance is sometimes a result of frustrated efforts to manage the complaints at early stages in their presentation, and is also likely to be connected to impairment being a central feature of severe functional somatic symptoms.
Impairment often involves withdrawal and avoidance of everyday responsibilities and stresses. Many children severely affected with unexplained medical complaints and somatoform disorders are in stressful situations they find difficult to manage or seek support for on a day-to-day basis. In this context illness represents a double-edged sword; while it is an unpleasant distressing physical experience it is also an escape or way out of these stresses. The withdrawal is, however, only legitimate and acceptable if the negative experience of illness and its physical nature are acknowledged by others, thus assuming that the child is at the mercy of a “force majeure,” and therefore unable to resist. A markedly affected child will often seemingly “hold on” to the illness and oppose expectations from others that he or she may have some control over the impairment. Children might challenge families and doctors when asked to contribute actively to the rehabilitation process, or simply display passive noncooperation. These children might feel too weak to resist the symptoms, or be too frightened to face the prospect of returning to everyday life and those very stressors the symptoms are helping to avoid. It is not uncommon, therefore, for some children to angrily state that the doctor or rehabilitation staff do not “believe” the symptoms because otherwise they would not be expected to do anything strenuous or demanding.
Assessment and Management
Because of the nature of these problems, assessment and treatment need to take due note of both the physical and psychosocial contributory and maintaining factors. The best approach is one using a biopsychosocial framework whereby problems are not regarded as either physical or mental, but rather whereby the relative contribution of biologic, psychological, and social factors is considered. The view that physical symptoms are wholly medically explained and therefore within the exclusive domain of the pediatrician, or alternatively are wholly medically unexplained and by implication are not within the pediatrician’s domain but rather within the domain of psychiatric teams, does not correspond to clinical experience. A medical disorder may trigger or underlie medical symptoms which then become unexplained not in themselves but rather in terms of their severity or the impairment caused. For example, excessive lower limb weakness may follow a bone fracture and subsequent immobilization, or pseudoseizures may manifest in a child with epilepsy. In practice, pediatricians often recognize that psychosocial issues can influence pediatric problems, whether with or without an organic substrate, as demonstrated in other articles in this issue. Understanding unexplained medical problems and their management at the pediatric clinic therefore needs to take into account the triggering of physical problems or other stressors, as well as psychosocial problems that may play a part in their maintenance. A particular complicating, and not uncommon, factor in clinical practice is when the attending clinician suspects psychological issues are playing a part, as in somatization or somatoform disorders, but this is at odds with the child’s and parental attitudes and views about the nature of the problem and who is the best professional to help. Engaging and working with the family to achieve a common view will thus be a requirement before effective treatment can be undertaken.
Previous reviews
Several reports have reviewed the literature on unexplained physical complaints, and somatization and somatoform disorders as they manifest in children and young people. This article reviews first the main conclusions from these reviews and then considers new findings that have helped illuminate their nature and management.
The clinical picture, frequency and epidemiology, etiologic factors, and treatment of unexplained physical complaints have been reviewed comprehensively. An early review of child psychiatric symptoms with somatic presentations highlighted that the nosologic validity and boundaries of somatoform disorders, as described in DSM-IV and ICD-10 classification systems, were still comparatively untested in children. Nevertheless, there was converging evidence that functional or likely medically unexplained physical complaints were common and present in about 1 in 10 children in the general population. These symptoms often involved recurrent abdominal pains or headaches, and there was a female predominance. Concurrent psychopathology was present in excess in affected children (between one-third to one-half) and usually consisted of emotional (anxiety of depressive) disorders, disruptive problems being a considerably less common association.
Specific child personality features were noted with several affected children who were described in clinical reports as conscientious or obsessional, sensitive, insecure, and anxious; high academic expectations were also noted. An excess of stressful events commonly involving school activity but also sometimes physical illness were reported, as was illness triggering symptom onset. Family influences were thought to be important; more specifically, family health problems, preoccupation with illness, and in some cases parents appearing anxiously sensitized to the experience of physical symptoms and seeking reassurance from medical services. For a small number of families profound family disorganization and sexual abuse were relevant. Clinicians described high levels of enmeshment between family members and parental overprotection. The emerging picture was one of children with vulnerable personality features who developed functional somatic symptoms following traumatic (physical or psychosocial) events.
The review of the topic by Campo and Fritsch was generally in line with these observations and conclusions. This review addressed a variety of unexplained physical symptoms, not just abdominal pains and headaches but also limb pains and aching muscles (“growing pains”), although they noted that pseudoneurologic symptoms are comparatively rare in community samples. Campo and Fritsch highlighted that presentations are often multi-symptomatic and that—in contrast with the frequency of functional symptoms—somatoform disorder presentations are rare in childhood. The excess of unnecessary and potentially dangerous and costly medical investigations and treatments to which these children are exposed, alongside the excessive use of health care services, was emphasized.
A further summary review considered tentative findings about possible biologic substrates for unexplained physical complaints; for example, altered colonic motility, enhanced gastrointestinal sensitivity, and possible inflammatory changes in children with functional gastrointestinal symptoms. Evidence was starting to emerge that parental reinforcement of symptoms and discouragement of coping were likely to be factors contributing to symptom maintenance, and that the effect of external stressors on the emergence of physical symptoms might be mediated by low levels of social competence.
A recent article has outlined some of the reasons for studying unexplained medical symptoms in children separately from adults, including the observation that the presenting symptoms tend to be specific to childhood and therefore questionnaires designed for adults are not appropriate, and the importance of gathering parental reports especially for preadolescents. Recent research has confirmed the presence of unexplained medical symptoms in young preschool children, and their association with anxiety symptoms in the child and distress in the parents. More unexplained somatic symptoms are reported by older than younger girls, and there is congruence generally between symptom reporting, illness attitudes conducive to somatization, and low academic attainment.
This review mentioned an unusual syndrome linked to somatization in children called “pervasive refusal” whereby children and adolescents present with profound and pervasive withdrawal, including refusal to eat, drink, talk, walk, and engage in any form of self-care. Although the nosology of this syndrome has not been established, it appears to be an extreme and serious manifestation of somatoform and other stress disorders. The review also noted factitious presentations in childhood, whereby parents fabricate childhood illness or children themselves cause damage to wounds or scratch corneas, as problems related to childhood somatization, although the active part played by young people or their parents in symptom production is at variance with the traditional assumption that in somatization and somatoform disorders unconscious mechanisms determine symptom production.
Previous reviews
Several reports have reviewed the literature on unexplained physical complaints, and somatization and somatoform disorders as they manifest in children and young people. This article reviews first the main conclusions from these reviews and then considers new findings that have helped illuminate their nature and management.
The clinical picture, frequency and epidemiology, etiologic factors, and treatment of unexplained physical complaints have been reviewed comprehensively. An early review of child psychiatric symptoms with somatic presentations highlighted that the nosologic validity and boundaries of somatoform disorders, as described in DSM-IV and ICD-10 classification systems, were still comparatively untested in children. Nevertheless, there was converging evidence that functional or likely medically unexplained physical complaints were common and present in about 1 in 10 children in the general population. These symptoms often involved recurrent abdominal pains or headaches, and there was a female predominance. Concurrent psychopathology was present in excess in affected children (between one-third to one-half) and usually consisted of emotional (anxiety of depressive) disorders, disruptive problems being a considerably less common association.
Specific child personality features were noted with several affected children who were described in clinical reports as conscientious or obsessional, sensitive, insecure, and anxious; high academic expectations were also noted. An excess of stressful events commonly involving school activity but also sometimes physical illness were reported, as was illness triggering symptom onset. Family influences were thought to be important; more specifically, family health problems, preoccupation with illness, and in some cases parents appearing anxiously sensitized to the experience of physical symptoms and seeking reassurance from medical services. For a small number of families profound family disorganization and sexual abuse were relevant. Clinicians described high levels of enmeshment between family members and parental overprotection. The emerging picture was one of children with vulnerable personality features who developed functional somatic symptoms following traumatic (physical or psychosocial) events.
The review of the topic by Campo and Fritsch was generally in line with these observations and conclusions. This review addressed a variety of unexplained physical symptoms, not just abdominal pains and headaches but also limb pains and aching muscles (“growing pains”), although they noted that pseudoneurologic symptoms are comparatively rare in community samples. Campo and Fritsch highlighted that presentations are often multi-symptomatic and that—in contrast with the frequency of functional symptoms—somatoform disorder presentations are rare in childhood. The excess of unnecessary and potentially dangerous and costly medical investigations and treatments to which these children are exposed, alongside the excessive use of health care services, was emphasized.
A further summary review considered tentative findings about possible biologic substrates for unexplained physical complaints; for example, altered colonic motility, enhanced gastrointestinal sensitivity, and possible inflammatory changes in children with functional gastrointestinal symptoms. Evidence was starting to emerge that parental reinforcement of symptoms and discouragement of coping were likely to be factors contributing to symptom maintenance, and that the effect of external stressors on the emergence of physical symptoms might be mediated by low levels of social competence.
A recent article has outlined some of the reasons for studying unexplained medical symptoms in children separately from adults, including the observation that the presenting symptoms tend to be specific to childhood and therefore questionnaires designed for adults are not appropriate, and the importance of gathering parental reports especially for preadolescents. Recent research has confirmed the presence of unexplained medical symptoms in young preschool children, and their association with anxiety symptoms in the child and distress in the parents. More unexplained somatic symptoms are reported by older than younger girls, and there is congruence generally between symptom reporting, illness attitudes conducive to somatization, and low academic attainment.
This review mentioned an unusual syndrome linked to somatization in children called “pervasive refusal” whereby children and adolescents present with profound and pervasive withdrawal, including refusal to eat, drink, talk, walk, and engage in any form of self-care. Although the nosology of this syndrome has not been established, it appears to be an extreme and serious manifestation of somatoform and other stress disorders. The review also noted factitious presentations in childhood, whereby parents fabricate childhood illness or children themselves cause damage to wounds or scratch corneas, as problems related to childhood somatization, although the active part played by young people or their parents in symptom production is at variance with the traditional assumption that in somatization and somatoform disorders unconscious mechanisms determine symptom production.
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