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Somatic complaints and symptoms of anxiety and depression in a school-based sample of preadolescents and early adolescents. functional impairment and implications for treatment

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Somatic complaints and symptoms of anxiety and depression in a school-based sample of preadolescents and early adolescents. functional impairment and implications for treatment

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This study examined the associations between somatization and specific somatic complaints on one hand, and symptoms of general anxiety, depression and types of anxiety symptoms (separation, generalized and social phobia symptoms) on the other. We also document the two-week prevalence of specific somatic complaints and investigate if there is a functional impairment in frequently complaining children. A cluster sampling procedure was used for this cross-sectional study with 1,514 randomly selected 4 th to 6 th grade pupils from Catalonia (Spain). Information about anxiety, depression and somatic symptoms was collected by means of self-report. Our results indicate that the most prevalent somatic symptoms were abdominal pain (11.2%) and headaches (10.1%). Through logistic regression analysis, positive significant associations were found between general anxiety, depression symptoms, separation and social phobia symptoms on one hand, and somatization on the other hand; and between separation anxiety symptoms and headaches, abdominal pain, leg pain, tiredness, and dizziness. Frequently complaining children have more impairment in their activity at home, school and in relationships with peers. Thus, there are relationships among somatization, symptoms of anxiety, and symptoms of depression. Increased functional impairment in children with somatic complaints highlights the importance of
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Articles Section
Somatic complaints, anxiety and depression in children and adolescents 191
Journal of Cognitive and Behavioral Psychotherapies,
Vol. 11, No. 2, September 2011, 191-208.
SOMATIC COMPLAINTS AND SYMPTOMS OF
ANXIETY AND DEPRESSION IN A SCHOOL-BASED
SAMPLE OF PREADOLESCENTS AND EARLY
ADOLESCENTS. FUNCTIONAL IMPAIRMENT AND
IMPLICATIONS FOR TREATMENT
Teodora C. ZOLOG*¹, Ma Claustre J. BALLABRIGA¹, Albert B.
MARTIN², Josefa C. SANS³, Carmen HERNANDEZ-MARTINEZ³,
Kelly R. ACOSTA¹, Eldemira DOMENECH-LLABERIA¹
¹Universitat Autònoma de Barcelona, Spain
²Universitat Autònoma de Barcelona, Spain
³Universitat Rovira i Virgili, Tarragona, Spain
Abstract
This study examined the associations between somatization and
specific somatic complaints on one hand, and symptoms of general
anxiety, depression and types of anxiety symptoms (separation,
generalized and social phobia symptoms) on the other. We also
document the two-week prevalence of specific somatic complaints
and investigate if there is a functional impairment in frequently
complaining children. A cluster sampling procedure was used for
this cross-sectional study with 1,514 randomly selected 4th to 6th
grade pupils from Catalonia (Spain). Information about anxiety,
depression and somatic symptoms was collected by means of self-
report. Our results indicate that the most prevalent somatic
symptoms were abdominal pain (11.2%) and headaches (10.1%).
Through logistic regression analysis, positive significant
associations were found between general anxiety, depression
symptoms, separation and social phobia symptoms on one hand, and
somatization on the other hand; and between separation anxiety
symptoms and headaches, abdominal pain, leg pain, tiredness, and
dizziness. Frequently complaining children have more impairment in
their activity at home, school and in relationships with peers. Thus,
there are relationships among somatization, symptoms of anxiety,
and symptoms of depression. Increased functional impairment in
children with somatic complaints highlights the importance of
* Correspondence concerning this article should be addressed to:
E-mail: dorazolog@gmail.com
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Teodora C. Zolog et al.
192
developing useful interventions. Cognitive-behavioral interventions
as well as family therapy are discussed.
Keywords: somatization, anxiety, depression, functional impairment
Introduction
Reports of physical symptoms presumed to be medically unexplained are
common in children and adolescents; about 10%-30% children and adolescents
are affected by somatic complaints (Campo & Fritsch, 1994). Medically
unexplained somatic symptoms constitute the core features of somatoform
disorders (DSM-IV, American Psychiatric Association, 1987; ICD-10, World
Health Organization, 1992) associated with marked functional impairment and
emotional and behavioral symptoms.
A number of studies have assessed the relationship between somatic
complaints and psychopathology in children and adolescents, above all the
relationship between somatic complaints and anxiety or depression, through
pediatric, psychiatric and community samples or with different methods. These
studies have shown that: 1) children and adolescents with frequent somatic
complaints are more likely to be diagnosed with anxiety and depression disorders
(e.g. Campo & Fritsch, 1994; Campo, Jansen-McWilliams, Comer, & Kelleher,
1999; Domenech-Llaberia, Jane, Canals et al., 2004; Jellesma, Rieffe, Terwogt,
& Kneepkens, 2006); 2) the frequency of somatic complaints tends to increase
with the severity of the anxiety and depression reports (e.g., Dhossche, Ferdinand,
Van der Ender, & Verhulst, 2001; Garber, Walker, & Zeman, 1991; Muris &
Meesters, 2004; Rauste-Von Wright & Von Wright, 1981; Walker & Green,
1989); 3) children and adolescents with anxiety or depression disorders have been
found to have more somatic complaints than children and adolescents without
anxiety disorders or with other psychiatric disorders (Egger, Angold, & Costello,
1998; Egger, Costello, Erkanli, & Angold, 1999).
Although it is well established that complaining children are at risk of
internalizing disorders, especially depression and anxiety disorders, there are few
studies that associate specific somatic complaints with types of anxiety symptoms
or disorders. There are inconsistent findings in this regard, with confusing
outcomes. For example, Egger et al. (1999) reported headaches, alone and with
stomach aches, associated with Generalized Anxiety Disorder (GAD), but neither
stomach aches nor headaches alone were associated with Separation Anxiety
Disorder (SAD), even though both headaches and stomach ache are specifically
mentioned in the DSM-IV criteria for SAD. They found only musculoskeletal
pain, with or without stomach ache, to be associated with SAD. Conversely,
Livingston, Taylor and Crawford (1988) indicated that abdominal pain and
palpitations are significantly more common among patients with SAD. Children
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Somatic complaints, anxiety and depression in children and adolescents 193
diagnosed with anxiety disorders reported more frequent somatic complaints
compared to children without anxiety disorders in the study by Hofflich, Hughes
and Kendall (2006), but in the same study somatic complaints did not differ
across the principal anxiety disorder groups of GAD, SAD or Social Phobia (SP).
Regarding SP, Beidel, Christ and Long (1991) found that this anxiety disorder
was associated with trembling, sweating and palpitations.
In addition to psychological problems, children and adolescents with
frequent somatic complaints suffer from accentuated functional impairment with
adverse consequences like social isolation, loss of peer relationships and
academic difficulties due to school absenteeism (Bernstein, Massie, Thuras et al.,
1997; Domenech-Llaberia et al., 2004; Roth-Isigkeit, Thyen, Stöven,
Schwarzenberger, & Schmucker 2005; Vila, Kramer, Hickey et al., 2009; Walker,
Garber, Smith, Van Slyke, & Greene, 2001). In the study by Vila et al. (2009),
47% of the sample (443/941) suffering from somatic complaints reported
impairments in their ability to concentrate, 41% (387/946) had reduced capacity
for enjoyment, 30% (278/939) were absent from school, and 24% (227/937) had
impairments in seeing friends. Roth-Isigkeit and colleagues (2005) found that the
prevalence of restrictions in daily activities varied among children and
adolescents with different pain locations; 51.1% of children and adolescents with
abdominal pain and 43.0% with headaches but only 19.4% with back pain
reported having been absent from school because of this.
Our principal aims are to: 1) document the two-week prevalence of
recurrent somatic complaints: headaches, abdominal pain, leg pains, tiredness and
dizziness; 2) examine the relationship between general anxiety, depression
symptoms and types of anxiety symptoms (generalized, separation and social
anxiety symptoms) on one hand, and frequent somatic complaints taken together
(somatization) and specific frequent somatic complaints (i.e., headaches,
abdominal pain, tiredness, leg pains and dizziness), on the other 3) investigate
whether there is functional impairment in frequently complaining preadolescents
and early adolescents compared to children who report fewer somatic complaints
(three or less than three somatic complaints) concerning school attendance, and in
their relationships with peers, at home and at school. Also we measure the risk of
being affected at home, at school and in their relationships with peers due to
somatic complaints. Focusing on only one dimension of child functioning,
generally school attendance, is one of the main limitations of existing research on
functional impairment in children and adolescents with somatic complaints. Our
study offers a comprehensive assessment of the impact of somatic complaints
across a variety of contexts (e.g., school, home, relationships with others). This
information on impact of somatic complaints is essential to develop cost-effective
treatment and high-quality care.
Consistent with previous research, we hypothesized that there are
significant positive associations between depression symptoms, general anxiety,
and somatization. Also, we hypothesized that there are significant positive
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Teodora C. Zolog et al.
194
associations between headaches, tiredness and somatic complaints in general
(somatization) on one hand, and generalized anxiety symptoms on the other hand;
we expected a significant positive relationships between headaches, abdominal
pain (gastrointestinal pain), leg pain and separation anxiety symptoms. Finally,
we hypothesized that there is significant functional impairment in frequently
complaining preadolescents and early adolescents due to somatic complaints
compared with children with fewer somatic complaints.
Method
Participants
This project is part of a large cross-sectional study, financed by the Fondo
de Investigación Sanitaria (FIS: 040978) and consists of two phases, only the first
of which is described here. Cluster sampling was conducted by randomly
selecting a set of 13 schools (7 state schools and 6 state-subsidized private
schools) from the total of 26 schools (17 state and 9 state-subsidized private
schools) and from all five representative areas of Reus (Catalonia, Spain), a
medium-sized town with 100,000 inhabitants.
One thousand five hundred and fourteen students participated,
representing 46.9% of the total number of children in the 4th to 6th grades
registered in all schools in Reus in the 2006/2007 academic year. The exclusion
criterion was the presence of the following diagnoses: pervasive developmental
disorder, mental retardation, schizophrenia and other psychotic disorders.
Findings considered indicative of explainable physical symptoms represented an
additional exclusionary criterion (for example abdominal pain or headaches
exclusively associated with menstruation in girls). From 1,514 questionnaires,
only 7 were eliminated because they were more than 50% incomplete. Children
with a chronic medical condition (asthma and more rarely diabetes or renal
failure) and children who were unable to read and understand Spanish or Catalan
were also excluded. The final sample consisted of 1450 preadolescents and early
adolescents, 690(47.6%) of whom were male and 760 (52.4%) female. A total of
31% of the children were from families with a low socio-economic status, 60.5%
from families with a medium socio-economic status and 8.5% from families with
a high socio-economic status. Table 1 shows the socio-demographic
characteristics of the whole sample.
Measures
The instruments used in the first stage of the research were:
A demographic questionnaire that asked children to report their age,
grade, gender, birth country (origin), information about family composition, and
the most important events that occurred in the last year of their lives.
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Somatic complaints, anxiety and depression in children and adolescents 19
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Table 1. Socio-demographic characteristics.
CATEGORY N (%)
GENDER Male
Female
690
760
47.6
52.4
8
9
10
11
12
13
AGE
MEAN
SD
8
335
474
490
137
6
10.29
0.95
0.6
23.2
32.9
34.0
8.9
0.4
SOCIO-ECONOMIC
STATUS
Low
Middle
High
449
876
125
31
60.5
8.5
RACE
Spanish
Latin American
European
African and Moroccan
Others
1262
94
30
39
25
87.6
6.5
2.1
2.7
1.1
Four Factor Index of Social Status (Hollingshead, 1975). This instrument
provided an index of socio-economic level according to four factors: marital
status, occupation, education, and retirement. The status score of a nuclear family
unit was calculated by multiplying the scale value for occupation by a weight of 5
and the scale value for education by a weight of 3 (the overall factor weights were
calculated with multiple regression equations). The resulting computed scores
ranged from 66 (high) to 8 (low).
The Child Depression Inventory (CDI; Kovacs, 1983; Monreal, 1988) is a
self-report inventory of depressive symptoms in children and adolescents. It is
comprised of 27 items. Each one of them has three possible responses. The child
must indicate the one that best describes his or her situation during the last two
weeks. The scores of the items range between 0 and 2, depending on the intensity
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Teodora C. Zolog et al.
196
of the symptom. In our study the Catalan version, developed by the Department of
Psychology at the Autonomous University of Barcelona, was used. The
psychometric properties are acceptable (Monreal, 1988).
The Somatic Questionnaire (Domenech-Llaberia et al., 2004) is a self-
report that looks at the presence and frequency (once, two or three times, over
three times) of five somatic complaints in the two weeks prior to assessment:
abdominal pain, headaches, leg pain, tiredness and dizziness. It also provided
information about the children’s chronic health problems where applicable. To
assess their functional impairment due to somatic complaints, respondents were
asked if they missed school as a consequence of somatic complaints and to relate
the extent to which any of the somatic symptoms affected, limited or restricted
their ability to engage in common daily activities at home, at school and in their
relationships with peers.
The Screen for Child Anxiety Related Emotional Disorders (SCARED,
Birmaher Khetarpal, Brent et al., 1997; Birmaher, Brent, Chiappetta et al., 1999)
was developed to screen for symptoms of some DSM-IV anxiety disorders,
namely generalized anxiety disorder, separation anxiety disorder, panic disorder
and social and school phobias. The 41-item version was used for this study.
Children were to indicate the frequency with which each symptom was
experienced on a 3 point scale: 0 (almost never), 1 (sometimes) and 2 (often). The
SCARED total anxiety (general anxiety) and subscale scores can be obtained by
summing across relevant items. In community samples of Spanish children and
adolescents (Domènech & Martinez, 2008; Vigil et al., 2009), good internal
consistency was obtained with a 0.83 global Cronbach’s alpha. The Cronbach’s
alphas obtained for each factor were: 0.44 for school avoidance, 0.67 for social
phobia, 0.68 for generalised anxiety and separation anxiety and 0.72 for panic
disorder. Test-retest reliability was 0.72. Concurrent validity was evaluated in
relation to the STAIC (Spielberger, 1973). This relationship is significantly
stronger with the STAIC-trait (0.58).
Procedure
Our research was approved by the Human Research Ethics Committee of
the Universitat Rovira i Virgili. This first stage of the research uses pupils as the
main informants. Data was collected between January and June of the 2006/2007
academic year. After written parental consent forms were received, trained
graduate research assistants administered the self-report measures to pupils in
groups during a regularly scheduled classroom period. Additionally, we were able
to review the questionnaires immediately after completion and address incomplete
questionnaires. All participants read a standardized set of instructions, advising
participants to read each item and select the answer that seemed most appropriate.
Special care was taken to explain and describe the questionnaire of somatic
complaints to the participants; taking into account that children could have
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Somatic complaints, anxiety and depression in children and adolescents 19
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difficulty understanding that emotions can be expressed physically, with the
intention of assuring the accuracy of the answers. Confidentiality was assured.
Data analysis
The data was entered into a Microsoft Access program created for this
study, which included comprehensive protection to guarantee the quality of the
information introduced (Granero, Domenech, & Bonillo, 2001). The data from
this program was then exported to SPSS.
Logistic regression models were used to determine the associations
between depression symptoms, general anxiety symptoms as predictor variables
and somatic complaints taken together (somatization) as an outcome variable.
Control variables were age, gender, socio-economic status and negative life
events.
In addition, we used logistic regression models to evaluate the
associations between types of anxiety symptoms (separation, generalized and
social phobia symptoms) as independent variables and specific somatic
complaints (headaches, abdominal pain, leg pains, tiredness and dizziness) and
somatic complaints taken together (somatization) as dependent variables. Control
variables were depression symptoms, age, gender, socio-economic status and
negative life events.
In order to enhance the clinical value of our study, we focused our
analysis only on preadolescents and early adolescents at risk for somatization
disorders, who reported four or more symptoms in the last two weeks
(Domenech-Llaberia et al., 2004; Garber, Walker, & Zeman 1991). In this regard,
specific somatic complaints (headaches, abdominal pain, leg pains, tiredness and
dizziness) and somatic complaints in general (somatization) were dichotomized
indicating the absence (Score 0) or presence (Score 1) of the frequent somatic
complaints (four or more complaints in the last 2 weeks). The criterion of four or
more symptoms was used to define children and adolescents with recurrent
somatic complaints, taking into account that previous studies had used the same
criterion in Spanish population and with the same instrument (see Domenech-
Llaberia et al., 2004).
All variables were introduced simultaneously into the equation through
the enter method. We removed from the analysis scales of anxiety (panic and
school avoidance scale) containing more than half the items referring to somatic
complaints.
We compared the group of frequently complaining children (with four or
more somatic complaints) with the group of children who reported fewer somatic
complaints (one, two or three times in the last two weeks), using the chi-square
test (χ2). From these groups were chosen only the children who reported being
affected at school, at home and in the relationships with peers due to somatic
complaints. We also used the odds ratio (OR) to measure the relationship between
frequently complaining children and children who reported three or less
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Teodora C. Zolog et al.
198
symptoms regarding the risk of being affected at home, at school and in their
relationships with peers due to somatic complaints. Furthermore, the t-test
established the number of days of school missed by frequent somatizers. A p
value of 0.05 or below was taken to indicate statistical significance.
Results
Prevalence
The proportion of children who reported symptoms on one occasion or
more was: 58.5% children with headaches, 52, 7% children with abdominal pain,
46.6% children with leg pains, and 29% children reporting tiredness. The least
frequent somatic complaint was dizziness with 28.3% preadolescents and early
adolescents complaining of it one or more times in the last two weeks of
evaluation. Restricting frequency to those who reported experiencing somatic
complaints four or more times, there were the following most frequent symptoms:
abdominal pain (11.2%), headaches (10.1%), and leg pains (9.9%). Dizziness was
the least frequent symptom, with 4.8% of the preadolescents and early adolescents
reporting dizziness four or more times in the period prior to evaluation. Two
hundred seventy nine preadolescents and early adolescents suffered from two or
more types of somatic symptoms in the two weeks prior to evaluation (19.2%).
Table 2. Frequency of somatic symptoms
Never
N (%)
Once
N (%)
Two
N (%)
Three
N (%)
>=Four
times
N (%)
Headaches 602
(41.5)
404
(27.9)
193
(13.3)
104
(7.2)
147
(10.1)
Abdominal pain 685
(47.3)
376
(25.9)
164
(11.3)
63
(4.3)
162
(11.2)
Leg pains 773
(53.4)
310
(21.4)
150
(10.3)
73
(5.0)
144
(9.9)
Tiredness 1030
(71.0)
194
(13.4)
97
(6.7)
37
(2.6)
92
(6.3)
Dizziness 1039
(71.7)
228
(15.7)
84
(5.8)
29
(2.0)
70
(4.8)
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Somatic complaints, anxiety and depression in children and adolescents 199
Associations with depression and anxiety symptoms
Logistic regression analysis (see Table 3) revealed the association
between depression, general anxiety symptoms and the presence/absence of
somatization. The analysis also revealed associations between types of anxiety
symptoms (separation, generalized and social phobia symptoms) and the
presence/absence of somatic complaints in general (somatization) or the
presence/absence of specific somatic symptoms (abdominal pain, headaches,
tiredness, leg pains and dizziness). Somatic complaints in general (somatization)
were associated significantly with symptoms of depression (CDI scale), general
anxiety, separation and social phobia symptoms. For each incremental increase in
depression symptoms, the probability of somatization disorder diagnosis was 1.08
times greater (p<0.001; IC%: 1.04 to 1.13). In the same way, for each incremental
increase in general anxiety and separation anxiety symptoms, the probability of a
somatization disorder diagnosis was 1.09 times greater (p<0. 001; IC%: 1.06 to
1.11) and 1.21 (p<0.001; IC%: 1.11 to 1.32) times greater respectively regarding
the relationship between somatization and separation anxiety symptoms. A
positive significant relationship was established between somatization and social
phobia symptoms (OR: 1.07; IC%:1.00 to 1.15; p<0.05).
Table 3. Associations between anxiety/depression symptoms and somatic complaints -
Odds Ratio (95% CI) - obtained by logistic regressions
Note: OR = Odds Ratio; CI. = Confidence Interval; p = significance value
* p < 0.05; ** p < 0.01; ***p < 0.001
Somatization Abdominal
pain
Headaches Tiredness Leg pains Dizziness
General
anxiety
1.09***
(1.06 to
1.11)
1.05***
(1.02 to
1.07)
1.04***
(1.02 to
1.07)
1.03*
(1.01 to
1.06)
1.05 ***
(1.03 to
1.08)
1.06***
(1.03 to
1.09)
Depression
1.08***
(1.04 to
1.13)
1.06***
(1.03 to
1.10)
1.08***
(1.04 to
1.12)
1.14***
(1.10 to
1.19)
1.09***
(1.05 to
1.12)
1.09***
(1.05 to
1.14)
Separation
anxiety
1.21***
(1.11 to
1.32)
1.13**
(1.04 to
1.21)
1.13**
(1.04 to
1.22)
1.15 **
(1.04 to
1.26)
1.16***
(1.07 to
1.26)
1.13*
(1.02 to
1.25)
Generalized
anxiety
1.00
(0.93 to
1.07)
0.98
(0.92 to
1.05)
0.99
(0.92 to
1.06)
0.95
(0.87 to
1.03)
0.94
(0.87 to
1.01)
0.98
(0.90 to
1.08)
Social
phobia
1.07*
(1.00 to
1.15)
1.01
(0.94 to
1.08)
0.99
(0.92 to
1.07)
1.00
(0.92 to
1.09)
1.04
(0.96 to
1.11)
1.00
(0.91 to
1.10)
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Teodora C. Zolog et al.
200
Only the separation subscale had significant associations with the
presence/absence of specific somatic complaints: the incremental increase in
separation anxiety symptoms determined an increased risk of recurrent abdominal
pain (OR= 1.13; p<0.01; IC%: 1.04 to 1.21), recurrent headaches (OR= 1.13;
p<0.01; IC%: 1.04 to 1.22), recurrent tiredness (OR=1.15; p<0.01; IC%: 1.04 to
1.26), recurrent leg pains (OR= 1.16; p<0.001; IC%: 1.07 to 1.26), and recurrent
dizziness ( OR=1.13; p<0.05; IC%: 1.02 to 1.25)
Functional impairment
Results regarding the functional impairment of frequently complaining
preadolescents and early adolescents are presented in Table 4. Therefore,
328(44.7%) children with recurrent somatic complaints reported missing school
due to their somatic complaints, compared to 126(24.3%) children with three or
less symptoms in the last two weeks who were absent from school (χ2 = 54.75,
with p< 0.001). Similarly, 323(44.1%) frequently complaining children were
affected at home due to somatization, compared to 112(21.6%) children with
three or less symptoms who reported being affected at home due to somatic
complaints (χ2 = 67.40, with p<0.001). 157(21.4) frequent somatizers were
affected in their relationships with peers due to somatic complaints compared
with 49(9.5%) children with three or less somatic complaints affected in their
relationships with peers(χ2 = 31.55; with p<0.001); and 247(33.7%) frequent
somatizers affected at school versus 80(15.4%) children with three or less
complaints in the last two weeks affected at school(χ2 = 52.37, with p< 0.001).
Table 4. Functional impairment in frequently versus less complaining children
Children's
restriction in daily
functioning
Children with
three or less
complaints
Children with
four or more
complaints
χ2
OR
(95% CI)
Absence from school 126(24.3) 328(44.7) 54.75 2.52 1.96 to 3.22
At school 80(15.4) 247(33.7) 52.37 2.78 2.09 to 3.69
At home 112(21.6) 323(44.1) 67.40 2.85 2.21 to 3.68
Relationships with peers 49(9.5) 157(21.4) 31.55 2.60 1.85 to 3.67
Note: χ2 = Pearson chi-square test; OR = Odds Ratio; CI. = Confidence Interval
All showed test are significant (p<0.05)
The likelihood of being affected at school, at home and in their
relationships with peers due to somatic complaints is 2.78 (95% CI: 2.09 to 3.69),
2.85 (95% CI: 2.21 to 3.68) and 2.60 (95% CI: 1.85 to 3.67) times greater
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Somatic complaints, anxiety and depression in children and adolescents 201
respectively for frequent somatizers versus children with three or less complaints.
In addition, frequently complaining children have a 2.52 (95% CI: 1.96 to 3.22)
times greater risk of being absent from school than children with fewer somatic
complaints.
Additional analysis was effectuated in order to establish the number of
days absent from school, using the t-test. Thus, frequently complaining pupils
missed school on average 1.04 (SD=1.41) days in the last two weeks compared
with children with three or less symptoms who missed on average 0.41 (SD=0.85)
days. This difference is statistically significant (M=0.63 days; SD=0.07; IC 95%
0.49 to 0.76, with t=9.03; p< 0.001).
Discussion and conclusions
Prevalence
Among the most prevalent somatic complaints were headaches with
58.5% of the complaining preadolescents and early adolescents reporting
headaches on at least one occasion and abdominal pain (52.7% of the
preadolescents and early adolescents complaining one, two, three or more times in
the last 2 weeks). Generally speaking, the overall prevalence rates of specific
somatic complaints fit in well with the studies that used preadolescents and
adolescents as participants, where the most prevalent somatic symptom was
headache (e.g., Dhossche et al., 2001; Egger et al., 1999; Roth-Isigkeit et al.,
2005; Vila et al., 2009). Indeed, from a developmental point of view, headaches
are more common in older children (see Beck, 2008). Restricting frequency to
those who reported four or more symptoms in the period prior to evaluation, the
most frequent symptom is abdominal pain (11.2%) followed by headaches
(10.1%).
On the other hand, our prevalence rates are comparable to the British
community study (Vila et al., 2009) or Ukrainian community sample (Litcher et
al., 2001) that had presented two-weeks prevalence of somatic complaints in
preadolescents and adolescents. But, it is necessary to stress that the estimates of
prevalence offered by the various epidemiological studies vary widely and
reliable epidemiological information is limited. This arises from the different
criteria used in establishing the prevalence, some studies using more stringent
criteria compared with the more open criteria used by others. For example, in the
study by Egger et al. (1999) headaches and stomach aches were considered as
present only if they lasted for at least 1 hour and occurred at least once a week
during the preceding 3 months. Therefore, taking into account frequency and
duration Egger et al. (1999) found that 2.8% children reported stomach aches.
However, in studies using self-reports and, thus relying mostly on patients’ recall,
without considering the duration and severity of pain as criteria, the estimated
rates were much higher. For example, Saps et al. (2009) found that weekly
abdominal pain was suffered by 38% children. It is possible that other factors
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Teodora C. Zolog et al.
202
influence the estimated rates; there are studies that report a continuing increase in
the prevalence rates of somatic complaints with decades (e.g., Just et al., 2003;
Santalahti, Aromaa, Sourander, Helenius, & Piha 2005).
Associations with depression and anxiety symptoms
We found the next significant associations: a positive significant
association was found between depression symptoms, general anxiety symptoms
and somatization. These findings are in line with almost all studies (e.g., Campo
et al., 1999; Dhossche et al., 2001; Jellesma et al., 2006; Muris & Meesters, 2004)
that reported somatic complaints in general (somatization) associated with
internalizing problems, including symptoms of depression and general anxiety.
With regard to the relationships between types of anxiety symptoms and
specific somatic complaints or somatic complaints in general (somatization) we
found few significant associations: separation anxiety symptoms were associated
with all somatic symptoms (headaches, abdominal pain, leg pains, tiredness,
dizziness and somatization): the increase in level of separation anxiety symptoms
determined the increased risk of suffering from recurrent headaches, abdominal
pain, leg pains, tiredness and dizziness. Few studies that examine relationships
between types of anxiety symptoms or disorders and specific somatic complaints
seem to find significant associations in this regard: there are studies that found
positive associations between somatic symptoms and SAD (e.g., Bernstein et al.,
1997; Livingston et al., 1988), and studies that found more symptoms of
musculoskeletal pains (with or without stomach ache) in children and adolescents
with SAD (e.g., Egger et al., 1999). In the study by Hofflich et al. (2006) children
with SAD reported many more symptoms than those listed in DSM-IV (racing
heart, feeling strange, restless, sick to their stomach, cold or sweaty). In our study
positive significant associations were established between separation anxiety
symptoms and headaches, but in the study by Egger et al. (1999) children with
SAD did not report headaches, although the presence of headaches or stomach
aches is included as one of the possible diagnostic criteria for SAD.
On the other hand, we hypothesized that there are positive significant
associations between generalized anxiety symptoms and headaches, tiredness or
somatic complaints in general (somatization), taking into account that the DSM-
IV criteria for GAD include the presence of at least one physical symptom. We
did not find any significant relationship between generalized anxiety symptoms
and somatization or specific somatic complaints. Nevertheless, the literature
regarding the associations between specific somatic complaints and GAD offers
mixed results. Egger et al. (1999) found relationships between GAD and
headaches (alone or with stomach aches) while Hofflich et al. (2006) found a
wide range of somatic symptoms differentiating children with GAD from non-
anxious children, like feeling shaky or jittery, strange, weird, or unreal,
experiencing chest pain, or their heart racing or skipping beats; symptoms not
specific to GAD. Along the same lines, Last (1991) stated that children with
Articles Section
Somatic complaints, anxiety and depression in children and adolescents 203
overanxious anxiety (the predecessor to GAD) were not different in their somatic
complaints compared to children with other anxiety disorders.
We found significant positive associations between social phobia
symptoms and somatization. The DSM-IV does not require somatic complaints
for a diagnosis of SP, even though inconsistent findings from literature have again
emerged: Beidel et al. (1991) found children with SP reporting more trembling,
sweating and heart palpitations; and in the study by Hofflich et al. (2006) children
with a diagnosis of SP (compared with non-anxious children) did report feeling
shaky or jittery, having sweaty hands.
Although not part of our objective, it should also be mentioned that our
results revealed positive significant associations between depression, general
anxiety symptoms and all specific somatic complaints (headaches, abdominal
pain, leg pain, tiredness and dizziness).
To sum up our findings, we found few significant associations between
types of anxiety symptoms and somatization or specific somatic complaints. Only
separation anxiety symptoms were associated positively with specific somatic
complaints, and somatization with symptoms of general anxiety, depression and
social phobia symptoms. Our results, added to the findings in the literature
support the following conclusion: somatic complaints in general (somatization)
may indicate the presence of general anxiety or depression and specific somatic
complaints do not necessarily point to particular types of anxiety symptoms. A
particular type of anxiety does not necessarily predict specific somatic
complaints. Nevertheless, there are several studies that found positive
relationships between gastrointestinal symptoms and separation anxiety. More
studies are needed to examine whether it is necessary to use somatic complaints
as a diagnostic criteria for specific anxiety disorders such as GAD or SAD.
Functional impairment
In our study, the results revealed the presence of a significant functional
impairment in frequently complaining pupils compared with children who
reported three or less somatic complaints in the period prior to evaluation. This
functional impairment was reported by pupils in the form of school attendance;
44.7% children with recurrent somatic complaints missed on average one day of
school in the two weeks prior to evaluation. This may indicate a great impact on
daily functioning; taking into account that missing school leads to a risk of social
isolation and academic difficulties. Along the same lines, Saps et al. (2009) found
that 33% of children and adolescents missed on average 2.3 days of school in the
last six months due to recurrent abdominal pain. In the same study, children not
only missed school, but parents missed work too, to care for children with
abdominal pain. An average of 1.9 days of work was missed, resulting in $313 of
forgone earnings. Families that hired a babysitter to care for a child with
abdominal pain required such services for an average of 3.6 days during the 6-
month study period (Saps et al., 2009). Bernstein et al. (1997) reported that
children with higher levels of somatic complaints have poorer school attendance
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Teodora C. Zolog et al.
204
and Last (1991) found a higher rate of anxious children with somatic complaints
who were more likely to refuse school than those without somatic complaints.
Few studies evaluated functional impairment in children and adolescents with
somatic complaints and, generally, only school absence was used as measure of
disability. Indeed, studies found complaining children and adolescents missed
school (e.g., Bernstein et al., 1997; Domenech-Llaberia et al., 2004; Rothner,
1993; Saps et al., 2009; Walker et al., 2001), but few studies reported the number
of days absent from school and neither of these studies reported such high rates of
non-attendance as the subjects of our study. We consider that the elevated number
of days off from school due to the somatic complaints in the two weeks prior to
evaluation might be a sign of marked impairment, raising serious questions
regarding prevention and treatment.
The difference regarding the school attendance rates between frequently
complaining children and children who reported less than four symptoms is
statistically significant (M= 0.63). This shows that children with four or more
complaints are significantly more affected in their school attendance rates
compared to their counterparts. However, although statistically significant, it
could be that this difference is not clinically significant. Studies are needed to
establish cut- off points in order to maximize the correct identification of cases
that suffer from clinically significant impairment (school adjustment and
academic achievements) associated with absences from school due to somatic
complaints.
In our study, it was found that frequently complaining children had more
functional impairment compared to children who reported three or less somatic
complaints in the last two weeks. This finding was expressed in terms of
restrictions in activities at school, home, and in relationships with peers. Also, the
risk of being affected due to somatic complaints is greater for frequently
complaining children. These findings fit in well with studies on functional
impairment in children and adolescents with somatic complaints in which
frequency of somatic complaints is positively associated with restrictions at
school, home and in relationships with peers (see Beck, 2008).
There are some limitations that lead us to interpret the results cautiously:
the limitation associated with cross-sectional data that did not permit us to explore
the causal relationship between anxiety and somatization. Another shortcoming is
that no diagnostic interview was used; the symptoms identify the various types of
anxiety. Finally, the somatic symptoms rely on the children’s recall only and we
have doubts with regard to the accuracy of the evaluation. As a future direction, it
is essential to study a larger age range including other populations (middle and
older adolescents) in order to provide complete evidences about somatization
across ages.
The findings presented here draw attention to several points with regard
to implications in the accurate diagnosis and intervention of children with somatic
complaints.
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Somatic complaints, anxiety and depression in children and adolescents 20
5
Because medically unexplained physical symptoms may be an important
aspect of emotional disorders, professionals should carefully examine somatizers,
as emotional disorders are harder to recognize. Furthermore, there is a need for
intervention not only for the physical complaints, but also the associated
psychopathology.
In addition, some evidence from the school refusal literature highlights
the idea that many complaining children that are absent from school are not
receiving adequate treatment, because their problems are wrongly perceived to be
delinquency and referred to a social worker rather than to a
psychologist/psychiatrist (e.g., Bernstein et al., 1997; Honjo et al., 2001; Last,
1991).
Regarding intervention, an intervention that addresses both the somatic
complaints and the emotional disturbance associated with somatization seems
ideal. Research has shown that cognitive-behavioral therapy in children with
anxiety disorders leads to reductions in somatic complaints through strategies that
teach children to identify the somatic complaints related to anxiety, and relaxation
techniques (e.g., Kendall, 1994; Kendall & Pimentel, 2003). More research is
needed with regard to the effectiveness of various behavioral and cognitive
strategies for somatic complaints.
An important aspect to underline here is the importance of therapy with
parents who have complaining children. Parental attitudes regarding somatization
in their children often have undesirable effects: positive or solicitous attention
from parents can reinforce somatic complaints. From a social learning theory
perspective, relief from responsibility in the form of restricting activity as a
consequence of illness may be more rewarding for children, especially for
children who perceive themselves as inadequate or have not developed a sense of
competence (Walker, Claar & Garber, 2002). From this point of view, it is
beneficial to help parents and children to view the somatic complaints as less
threatening and, at the same time, to change the high level of irrational beliefs in
somatizers with emotional disturbances, based on research that has reported links
between somatization and irrational beliefs (see for details David, Szentagotai,
Kallya, & Macavei, 2005).
Acknowledgments: This research was supported by grants from the Instituto de Salud
Carlos III, Ministerio de Sanidad y Consumo (PI 07/0839 and PI 04/0978).
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... Further, the presence of elevated somatic symptoms may indicate negative social, emotional, and academic consequences for children. Somatic symptoms are associated with greater impairment in activities at home and in relationships with peers (Zolog et al., 2011). Such functional impairment has been observed among those with high levels of persistent distressing somatic symptoms and psychological concerns (van Geelen et al., 2015). ...
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... Bajo un modelo tridimensional-interactivo, la ansiedad escolar queda definida como un grupo de respuestas cognitivas, psicofisiológicas y motoras presentadas por un sujeto ante situaciones escolares que son percibidas como una amenaza (Méndez et al., 2003). Las investigaciones indican que los trastornos de ansiedad están presentes de forma común en la infancia y en la adolescencia (García-Fernández, Inglés, Martínez-Monteagudo y Redondo, 2008;Zolog et al., 2011) y son los más prevalentes en estas etapas del desarrollo (Kashani y Orvaschel, 1990;Valiente, Sandín, Chorot y Tabar, 2003). En este sentido, resulta de vital importancia analizar las dimensiones cognitivas, psicofisiológicas y motoras implicadas en la respuesta de ansiedad, así como las situaciones específicas que generan la ansiedad escolar en los estudiantes. ...
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