Teodora C. ZOLOG*¹, Ma Claustre JANE-BALLABRIGA¹, Albert BONILLO- MARTIN¹, Josefa CANALS-SANS², Carmen HERNANDEZ-MARTINEZ², Kelly ROMERO-ACOSTA¹, Eldemira DOMENECH-LLABERIA¹

¹Universitat Autònoma de Barcelona, Barcelona, Spain ²Universitat 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 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 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 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 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 4^th to 6^th 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.  

 

 

 

 

 

 

Table 1. Socio-demographic characteristics

 

	CATEGORY	N	(%)
GENDER	Male Female	690 760	47.6 52.4
AGE	8 9 10 11 12 13	8 335 474 490 137 6 10.29 0.95	0.6 23.2 32.9 34.0 8.9 0.4
	MEAN SD
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 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 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 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)

 

 

 

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

 

	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)

 

Note: OR = Odds Ratio; CI. = Confidence Interval; p = significance value

* p < 0.05; ** p < 0.01; ***p < 0.001

 

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 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 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 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 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.

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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