Familial risk factors for the development of somatoform symptoms and disorders in children and adolescents: a systematic review

A matter of balance. Positioning of parents' selves through negotiations of symptoms' meaning at a pain clinic for children/young people

This paper traces how the meaning of symptoms and the positioning of selves are entangled and discursively constructed in therapeutic conversations between parents and therapists at a pain clinic for children and young people (age 8 to 18) with recurrent or chronic pain or other somatic symptoms with no established biophysical pathology. Based on data material from an ethnographic fieldwork it is examined how the selves of respectively children/young people and their parents are discursively positioned in conversational encounters and the role positioning of selves play in the context of establishing and negotiating the symptoms' meaning. The bearer of medically unexplained symptoms is oftentimes subjected to moral assessments. In this paper it will be shown that parents, in the institutional setting of the pain clinic, enter the negotiation of moral assessments assigned to their children, and that these moral assessments not only concern the sufferers' selves but also the selves of the parents. The overall argument is that dialogues between parents and therapists concerning the meaning and source of their children's symptoms are simultaneously negotiations in which not only the sufferers'  but also their parents' moral positions are at stake.

Exploring the course of functional somatic symptoms (FSS) from pre- to late adolescence and associated internalizing psychopathology - an observational cohort-study

BACKGROUND

Functional somatic symptoms (FSS), which commonly cannot be attributed to well-defined organic pathology, often co-occur with internalizing psychopathology and fluctuate throughout different life stages. We examined FSS courses throughout adolescence, and the association between preadolescent FSS, FSS severity and internalizing psychopathology at late adolescence.

METHODS

Data from the Copenhagen Child Cohort (CCC2000) were utilized from assessments at ages 11-12 years (preadolescence; T0) and 16-17 years (late adolescence; T1). Self-report questionnaire and interview data on FSS, internalizing psychopathology, chronic medical conditions, and sociodemographic data from Danish national registers were available for 1285 youths. FSS courses were categorized into persistent (high FSS at T0 & T1), remission (high FSS only at T0), incident (high FSS only at T1) or no FSS (no FSS at T0 & T1). Multiple linear and multinomial logistic regressions were conducted to investigate the FSS/psychopathology association.

RESULTS

1.8% of adolescents fell into the persistent FSS course group throughout adolescence. Higher preadolescent FSS predicted FSS (b = 0.07, p < .001), anxiety (b = 0.05, p < .001) and depression (b = 0.06, p < .001) at age 16/17, even after controlling for sex, parental education, a chronic medical condition and internalizing psychopathology in preadolescence. Persistent, incident, and remittent FSS courses were associated with significantly higher mean levels of anxiety and depression compared to the reference group (no FSS).

CONCLUSIONS

FSS during pre- and late adolescence might increase and co-occur with anxiety and depression throughout adolescence, potentially due to shared underlying risk factors and processes.

Annual Research Review: Health anxiety in children and adolescents-developmental aspects and cross-generational influences

Health anxiety involves excessive worries about one's health along with beliefs one has an illness or may contract a serious disease. Concerning evidence suggests that health anxiety is on the rise in society, possibly further fueled by the COVID-19 pandemic. Recent classification systems acknowledge that impairing health-related worries and beliefs can emerge in early childhood with significant levels of symptoms persisting throughout childhood, and possibly continuous with diagnostic considerations in adulthood. This narrative review summarizes recent research advances in health anxiety in children and adolescents, focusing on various developmental aspects of health anxiety and related concepts in youths. Findings suggest that health anxiety symptoms in young age groups are associated with impairment, distress, and increased healthcare use, as well as substantial comorbidity with mainly other emotional problems and disorders. Furthermore, longitudinal studies suggest that childhood health anxiety can persist across adolescence, perhaps with links to chronic courses in adulthood. The growing literature was further reviewed, thus extending our understanding of early risk factors, including the potential role of exposure to serious illness and transgenerational transmission of health anxiety. Learning more about developmental trajectories will be highly relevant to inform strategies for early detection and prevention. While modified cognitive behavioral therapies in adults are successful in treating health anxiety, specific interventions have not yet been tested in youths. Given substantial overlaps with other psychopathology, it could be important to develop and explore more transdiagnostic and scalable approaches that take advantage of common factors in psychotherapy, while also including a wider perspective on potential familiar maladaptive illness cognitions and behaviors.

A cross-sectional study of the association between family conflicts and children's health: Lolland-Falster Health Study

BACKGROUND

Few family interaction processes are more detrimental to children's health than family conflicts. Conflictual relationships in childhood predict a host of adverse health outcomes across the life course. The current study examines associations between household conflicts and the health of children aged 6-12 years and explores to which extent this may vary by socioeconomic status (SES) and multimorbidity (MM) in the household.

METHODS

Cross-sectional study using questionnaire data gathered between 2016 and 2020 as part of the Lolland-Falster Health Study (LOFUS) combined with routine register data on health care use and socio-demography from the Danish nationwide administrative databases. The study sample consisted of 1065 children 6-12 years old, who answered LOFUS4 or LOFUS11, from 777 households for which at least one adult answered LOFUS18. Main outcome was children's health complaints, defined as headache, abdominal pain, back pain, and sleep difficulties. Covariates included MM, SES, and conflicts, all three measured at household level. Multivariable logistic regression models were used.

RESULTS

Conflicts were negatively associated with children's health. This was most pronounced for general conflicts in the household, with increased complaints of abdominal pain, back pain, and sleep difficulties. The associations varied when we stratified the households according to MM and SES. Significant associations were found within households without MM for abdominal pain, and within households with MM and low SES, and without MM and with high SES for sleep difficulties. While the higher level of abdominal pain for the above indicated households were found for both internal and external conflicts in the household, the higher level in sleep difficulties was mostly driven by internal conflicts.

CONCLUSION

Children reporting frequent health complaints have a higher future health care use compared with children without such complaints. Our results indicate that growing up in a household with a high conflict level might be a predisposing factor.

The Contribution of Bullying Involvement and Alexithymia to Somatic Complaints in Preadolescents

Somatic complaints during preadolescence are connected to individual and contextual factors, and extant research highlights the relevance of alexithymia and bullying involvement. In this cross-sectional study, we explored the joint and unique influence of bullying involvement-as perpetrators, victims, or outsiders-and alexithymia on somatic complaints in a sample of 179 Italian middle-school students (aged 11-15). Findings revealed an indirect association between bullying perpetration and victimization complaints through alexithymia. We also found a significant direct association between victimization and somatic complaints. No significant association between outsider behavior and somatization was found. Our results revealed that bullying perpetration and victimization could increase youths' risk for somatic complaints and clarify one of the processes underlying this association. The current findings further emphasize the relevance of emotional awareness for youths' well-being and propose that implementing social-emotional skills might prevent some of the adverse consequences of being involved in bullying episodes.

Impact of COVID-19 pandemic on families living with autism: An online survey

BACKGROUND

The current SARS-CoV-2 global pandemic presents a great challenge for governments, health care professionals and the general population. Individuals with autism spectrum disorder (ASD) might be especially vulnerable to restrictions imposed by the crisis.

AIM

The objective of the study was to examine the impact of the SARSCoV- 2 pandemic on children with ASD and their families.

METHODS AND PROCEDURES

We conducted an online survey two months after the beginning of lock-down (18th of May to 5th of July 2020) in Germany and Austria. We investigated behavioral and emotional changes of children related to the lock-down alongside parental stress and intrafamilial burden OUTCOME AND RESULTS: Of the 216 participating families with an autistic child (mean age: 12.23 years), nearly 50% reported aggravation of autistic symptoms and heightened parental stress. Families reported discontinuation of therapy, more intrafamilial conflicts and increase of psychopharmacological medication of the child.

CONCLUSIONS AND IMPLICATIONS

Our report on short-term detrimental effects of the pandemic calls for thorough investigation of long-term sequalae for children and families.

Families With Violence Exposure and the Intergenerational Transmission of Somatization

INTRODUCTION

Adults who have histories of childhood trauma have been noted to display greater somatization, dissociative symptoms and affect dysregulation. What happens in the parent-child relationship when those traumatized children become parents? A potential link to somatization in the child has been suggested by several prior studies. Children who have early attachment disturbances had more physical complaints if their mothers displayed less maternal sensitivity during observed parent-child interactions. Yet, the intergenerational link between maternal and child somatization has not been sufficiently explored in a longitudinal study in order to understand the potential impact of maternal trauma history and related psychopathology on subsequent child somatization and psychopathology.

METHODS

This paper examined prospective, longitudinal data of 64 mother-toddler dyads (mean age = 2.4 years, SD = 0.7) who were later studied when children had a mean age of 7 years. Mothers with and without histories of interpersonal violence (IPV; physical/sexual abuse and/or family violence exposure) were included. Mothers with IPV histories were oversampled. Linear and Poisson regression models were used to test the associations between maternal IPV-related post-traumatic stress disorder (PTSD) with maternal somatization severity when children were toddlers, and between maternal somatization and maternal interactive behaviors with child somatization by maternal report and clinician-rated assessment at school-age.

RESULTS

Maternal PTSD severity was significantly associated with increased maternal somatization severity (p = 0.031). Maternal somatization severity during the child's early childhood predicted both maternal report of child somatization (p = 0.011) as well as child thought problems (p = 0.007) when children were school-aged. No association was found between maternal somatization and child-reported psychopathology. The study did not find that maternal alexithymia, caregiving behaviors or child exposure to violence contributed significantly to the model examining the association between maternal and child somatization.

CONCLUSION

The results are in line with the hypothesis of intergenerational transmission of somatization in the context of IPV and related maternal PTSD during formative early development. We interpret this as an expression of psychological distress from mother to child, as maternal trauma and pathology affect the caregiving environment and, thus, the parent-child relationship. The authors conclude with a discussion of implications for parent-infant and early childhood intervention.

"My Body Hates Me": A Qualitative Analysis of the Experience of Functional Nausea in Adolescent Girls and Their Mothers

Nausea is a somatic sensation typically associated with the need to vomit in order to remove a toxin from the body. When nausea occurs in the absence of a specific structural cause or toxin, it is classified as a functional gastrointestinal disorder (FGID). Functional nausea was newly recognized in 2016 as a FGID in children and little is known about its prevalence, course or patient experiences. Nausea co-occurring with functional abdominal pain in childhood has been associated with long-term risk for anxiety and ongoing somatic symptoms into young adulthood. However, few studies have focused uniquely on the experience and impact of nausea on youth. The present study aimed to qualitatively understand the experiences of adolescent girls with functional nausea and their parents. Five mother-daughter dyads were recruited from a specialized pediatric gastroenterology clinic focused on nausea and completed semi-structured interviews. Interviews were transcribed and coded using interpretive phenomenological analysis (IPA). Four main themes emerged: nausea interference, body frustration, misunderstanding of symptoms, and maternal helplessness and guilt. These themes were similar to prior studies on the experiences of youth with chronic pain but also indicated unique challenges due to nausea, such as significant food restriction and subsequent weight loss.

The relationship between attachment and somatoform symptoms in children and adolescents: A systematic review and meta-analysis

OBJECTIVE

Problems in childhood and adolescence are often present with recurring physical signs of illness, called somatoform symptoms. These symptoms are a common reason for consultation at both paediatric care and psychotherapeutic/psychiatric praxis. We propose that attachment is a possible predictive factor. This article provides a systematic overview of the existing research literature concerning the relationship between attachment and somatoform symptoms in children and adolescents.

METHODS

A systematic search for empirical articles from 1990 up to August 2018 focusing on this association was conducted. Out of six databases, 4994 studies were detected by using defined keywords. One study was added identified by checking reference lists. Finally, 15 studies were selected, which were the bases for the narrative review. Ten studies were included in meta-analysis.

RESULTS

Combining study results, we found that attachment cannot solely predict somatoform symptoms. Mixed results are shown. The quantitative analysis substantiated these narrative results, revealing a small but significant combined effect size of Δ ≈ .12 (95% CI .04 - .19).

CONCLUSIONS

The findings suggest that a relationship exists, but further investigations need to demonstrate that these are not only superficial. There are many developmental factors that affect the relationship between attachment and somatoform symptoms in children and adolescents. Further research should explore this interplay in order to gain a holistic and comprehensive understanding of the underlying mechanisms that lead to these correlations and to discover possible predicting factors.

Illness perceptions of youths with functional disorders and their parents: An interpretative phenomenological analysis study

BACKGROUND

Functional disorders, defined as disorders with no clear medical explanation, are common and impose a significant burden on youths, their families, healthcare services and society as a whole. Currently, the literature describes resistance among patients and their families towards psychological symptom explanations and treatments. More knowledge about the thoughts and understandings of youths with functional disorders and their parents is needed. The aim of this study was to explore the illness perceptions of youths with severe functional disorders and their parents.

METHODS

A qualitative interview study using interpretative phenomenological analyses. The study included 11 youths aged 11-15 years with functional disorders and their parents, where interviews were performed at the point of referral from a somatic to a psychiatric treatment setting.

RESULTS

Analyses identified three main themes. Themes 1(Ascribing identity to the disorder) and 2 (Monocausal explanations) explore key elements of the participants' illness perceptions, and theme 3 (Mutable illness perceptions) explores how illness perceptions are influenced by experiences from healthcare encounters.

CONCLUSIONS

The label 'functional disorder' was poorly integrated in the illness perceptions of the youths and their parents. Participants used a monocausal and typically physical explanation rather than a multicausal biopsychosocial explanation for their symptoms.

Childhood Maltreatment, Limbic Dysfunction, Resilience, and Psychiatric Symptoms

Previous research has indicated that childhood maltreatment is predictive of psychiatric symptoms in adulthood. Among the potential intervening factors in this relationship are affective reactions in the victims, neurodevelopmental problems, and resilience. The purpose of this study was to test, in a nonclinical low-risk sample, an integrative developmentally based psychoneurological model of the roles of limbic system dysfunction, shame and guilt, and resiliency as potential intervening variables between childhood maltreatment and adult psychiatric symptoms. Also of interest was whether there were gender-specific pathways from maltreatment to symptoms. Based on the results of preliminary analyses, several regressions were conducted separately by gender, entering the different forms of parental aggression at Step 1, resilience at Step 2, the resilience by parental aggression interaction term at Step 3, shame and guilt at Step 4, and limbic dysfunction at Step 5, as predictors of psychiatric symptoms. Analyses indicated that both maternal psychological maltreatment and paternal physical maltreatment were predictive of total psychiatric symptomatology in adulthood, with shame mediating the relationship in women and guilt mediating it in men, limbic system symptoms mediating the relationship in both genders, and trait resilience moderating the relationship in both genders.

Early maladaptive schemas in patients with somatoform disorders and somatization

Maladaptive schemas are stable relational patterns that develop through harmful childhood experiences with primary caregivers. Schemas within somatoform disorders are rarely explored even though these disorders are clinically important due to high prevalence, co-morbidity, and cost for the health care system. This study investigates schemas according to Young's schema theory in patients with somatoform disorders in comparison with healthy controls and patients with depressive or anxiety disorders. Further associations between schemas and somatization were explored. We included 134 patients with a somatoform disorder and 39 age-matched healthy controls, 83 patients with a unipolar depression, and 34 patients with an anxiety disorder. The clinical sample consists of day care patients, diagnosed with the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, but without a personality disorder. Primary measures were the Young Schema Questionnaire (YSQ-S2), the Screening for Somatoform Disorders (SOMS-7T), the Beck Depression Inventory, Second Edition, and the Childhood Trauma Questionnaire. Analyses of variance indicated that somatoform patients scored higher on almost all schemas than do healthy controls (p < 0.001, η²  = 0.148). The highest mean scores were reached for the schemas "self-sacrifice" and "unrelenting standards," with significant higher values in the patient sample. However, when compared with patients with depressive or anxiety disorders, somatoform patients scored equally or even lower. High somatization was associated with generally higher schema activation. This effect was to a great extent mediated by depressive symptoms. Only the schema "vulnerability to harm or illness" was exclusively related to somatization. These findings suggest that schemas should be systematically assessed within psychotherapy of somatoform patients.

Do negative childhood conditions increase the risk of somatic symptoms in adolescence? - a prospective cohort study

Background

In order to prevent health and social problems later in life, it is important to identify childhood conditions related to the development of somatic symptoms. This prospective study expands on previous research by investigating whether negative childhood conditions are related to somatization later in life, taking other risk factors into account.

This study aims to investigate whether somatic symptoms of the participants’ parents, poor family functioning, or negative life events during childhood result in somatic symptoms in early or late adolescence.

Methods

The study population includes participants from the West Jutland Cohort Study who responded to the survey on their somatic symptoms at age 15 (n = 2963) and/or age 18 (n = 2341). The study also includes additional questionnaire information about the participants’ poor family functioning, number of negative life events, and parental reports of somatic symptoms as well as register information about parental socioeconomic background. Generalized linear models for the binomial family were used and the results were presented as relative risks (RR) and risk differences (RD) with 95% confidence intervals (95%-CI).

Results

Experiencing poor family functioning at age 15 showed associations with somatic symptoms at age 15 (RR 1.75, 95%-CI, 1.43–2.14 and RD 18, 95%-CI, 11–25%) and 18 (RR 1.32, 95%-CI, 1.00–1.75 and RD 7, 95%-CI, 0.2–14%). The relative risks between poor family functioning and somatic symptoms were 2.5 for the boys at age 15 and 1.71 for the girls at age 18. Having experienced two or more negative life events up to the age of 15 was associated with reporting somatic symptoms at age 15 (RR 1.73, 95%-CI, 1.31–2.28 and RD 24, 95%-CI, 11–37%). No relative risks above 1.35 were found between parents reporting somatic symptoms and participants reporting somatic symptoms at ages 15 or 18.

Conclusions

An increased awareness of the association between a poor social climate in the family and somatic symptoms may help professionals in health and educational systems prevent the development of such symptoms among adolescents.

Somatic symptoms in children who have a parent with cancer: A systematic review

BACKGROUND

This systematic review explored the occurrence and types of somatic symptoms in children (0-20 years) who have experienced parental cancer.

METHODS

We complemented a systematic literature search from PubMed and PsycInfo with a reference search. We identified 1,694 articles, which were independently screened by two authors; they further evaluated potentially relevant papers for quality and extracted the data. We found nine relevant studies (10 publications) on altogether 672 children with a parent who had cancer; four studies included a control group.

RESULTS

The studies typically focused on children's psychosocial reactions on parental cancer rather than somatic complaints, so symptom prevalence cannot be reliably summarized. Several studies were small, and the types of somatic symptoms were only specified in five studies. Somatic symptoms were reported as a measure of emotional reactions in the remaining four studies. Three studies provided longitudinal data. The main types of specific symptoms reported were eating problems, pain, sleeping troubles, and bed-wetting. Children of cancer patients tended to show an increase of unspecified somatic symptoms and pain, but evidence was inconsistent. There was a tendency that somatic complaints were associated with increased emotional distress in the children. The material did not allow for separate analysis by age group or bereavement status.

CONCLUSIONS

Children in families with parental cancer may present with somatic complaints, but the prevalence and significance is not possible to estimate due to very sparse research in this area. Health professionals or counselling providers should not overlook this possible sign of distress. Qualitative studies report significant health anxiety in these children; this may represent a specific topic for counselling in this population. Targeted studies are needed to evaluate the prevalence and significance of somatic symptoms, and especially vulnerable groups need to be identified.

Prevalence and environmental impact factors of somatization tendencies in eastern Chinese adolescents: a multicenter observational study

The aim of this study is at examining the prevalence and impact factors of adolescent somatization tendencies (ST) across three eastern Chinese provinces. A multicenter school-based cross-sectional study was conducted in these provinces from 2015 to 2016. The sample included 11,153 middle-school students aged 13-18 years, who were randomly selected using a multi-phase stratified cluster sampling technique. We also designed a multicenter school-based case-control study to evaluate the potential environmental impact of ST factors on this population. The overall positive rate of ST among the eastern Chinese adolescents was 12.1%. Somatic symptoms score (SSS) and positive ST rate were higher in females than males. Additionally, the SSS and positive ST rate for the 18-year-old group were significantly higher than in other age groups. In comparison to those in urban areas, adolescents in rural areas had significantly higher SSS and positive ST rate. Multiple conditional regression analyses revealed that family medical history, anxiety and depression scores; superstitious beliefs; left-behind adolescents; teacher-student support; family conflict; and family independence and achievement orientation were significantly linked to ST in adolescents. The models also indicated family medical history was the strongest impact factor to adolescent ST, even though ST were prevalent in the three studied eastern Chinese provinces. Gender, age, and dwelling differences were very significant in the SSS and positive ST rate in adolescents. This study concludes that adolescent ST are influenced by multiple environments.

Parent Attributions of Ambiguous Symptoms in Their Children: A Preliminary Measure Validation in Parents of Children with Chronic Pain

How parents attribute cause to their child’s physical symptoms is likely important in understanding how the parent responds to the child, as well as the child’s health outcomes, especially within the context of chronic illness. Here, we adapt the Symptom Interpretation Questionnaire for parent report (SIQ-PR) and provide preliminary validation in a sample of parents of children with chronic pain (N = 311). Confirmatory factor analysis revealed that the SIQ-PR structure is consistent with the original measure, with three distinct attribution types: psychological (emotional/affective), somatic (illness/disease), and environmental (situational/transient) causes. All three subscales demonstrated satisfactory to good internal consistency, and temporal stability. Parents typically endorsed more than one attribution for each symptom, indicating that parents of children with chronic pain have a multidimensional interpretation of physical symptoms in their children. Further, parent psychological and somatic attributions, but not environmental attributions, were significantly associated with (i) parent protective responses towards their child, and (ii) the child’s self-reported somatic and psychological symptoms, indicating convergent and divergent validity. The SIQ-PR may be a useful measure for future studies investigating intergenerational and interpersonal models of pediatric chronic pain, and more broadly, to examine parent attributions of children’s ambiguous symptoms within the context of childhood chronic illness.

Assessing physical symptoms during the postpartum period: reliability and validity of the primary health questionnaire somatic symptom subscale (PHQ-15)

INTRODUCTION

This study aimed at establishing the reliability and validity of the primary health questionnaire (PHQ-15) somatic symptom severity subscale for postpartum women.

METHODS

Women (N = 495) completed the PHQ-15 approximately 6 weeks postpartum during the baseline phase of a randomized controlled trial evaluating a writing intervention for postnatal health in England. Reliability was assessed using internal consistency statistics and convergent validity by comparing differences in self-reported physical health, health-related quality of life (QoL) and primary care usage by PHQ-15 symptom severity category.

RESULTS

Cronbach's α for the PHQ-15 was 0.73 and item-total statistics met recommended guidelines. Validity analyzes showed 6% of women reported severe symptoms, 17% medium, 50% low and 27% minimal symptoms. Women with severe symptoms reported poorer overall physical health, poorer physical health-related QoL and greater use of primary care. Women with severe symptoms also rated their baby's health as worse and used primary care more for their baby.

DISCUSSION

This study suggests the PHQ-15 has the potential to be a useful and valid measure of physical symptoms in postpartum women in high-income countries.

Morality in clinical space: treatment of youngsters with functional somatic symptoms in a Western clinical context

This paper explores the moral implications of treatment of young people with functional somatic symptoms. Based on an ethnographic field study at a Danish pain clinic for youngsters (age 8 to 18), the paper seeks to unearth the cultural, moral values that clinical practice steers by and upholds, and the implications this has for the assessment and management of ill body-selves. Through an exposition of the general practice of the clinic and an investigation of two specific cases of youngsters, it is found that the assessment of symptoms and selves and the goals of treatment are informed by cultural ideals of 'the good self' and 'the good life' in which agency and work ethic - both pertaining to the notion of individual responsibility - figure as prevalent virtues. The study underpins the findings of other researchers who have found that ideals of individual autonomy and responsibility for own life and health permeate the Western health care system and the discourses of ill individuals. The contribution of this article is to portray in ethnographic detail how such a cultural ethics manifests in practice and what implications this have for the treatment of young people with functional symptoms at a specific location and in specific cases. The two cases illustrate that the underlying norms and values can give rise to very different moral assessments of symptoms and selves within the same diagnostic category.

Systematic review of childhood and adolescent risk and prognostic factors for persistent abdominal pain

This review aimed to identify childhood and adolescence risk and prognostic factors associated with onset and persistence of persistent abdominal pain and related disability and assess quality of the evidence. While findings suggest a possible role for negative emotional symptoms and parental mental health as risk and prognostic factors for onset and persistence of persistent abdominal pain, the evidence is of poor quality overall and nonexistent when it comes to prognostic factors associated with disability.

CONCLUSION

Further research is needed to increase confidence in existing evidence and to explore new factors. This research will inform prevention.

Medically Hospitalized Patients With Eating Disorders and Somatoform Disorders in Pediatrics: What Are Their Similarities and Differences and How Can We Improve Their Care?

OBJECTIVES

The purpose of the current study is to describe the demographic and clinical characteristics and health care use of medically hospitalized patients with eating disorders (ED) and somatoform disorders (SFD) in a pediatric setting and to use the findings to explore opportunities for improved care.

METHODS

Retrospective chart reviews of 125 patients with SFD and 125 patients with ED (N = 250) seen at a tertiary pediatric facility over a 12- and 19-month period, respectively.

RESULTS

Patients in both groups were predominantly girls, white, came from households with above average incomes, and had academic pressures, internalizing coping styles, and high rates of anxiety disorders. Compared with SFD patients, ED patients had longer medical admissions (P < .001), more depressive disorders (P < .01), higher lifetime rates of suicidal ideation and self-injurious behaviors (P < .05), and were more frequently discharged to intensive psychiatric treatment programs (P < .001). SFD patients were referred later to psychiatry (P < .001), had more emergency department visits (P < .001) and more visits to other hospitals (P < .05) and also had higher rates of learning difficulties (P < .001), bullying (P < .05), and trauma (P < .01) compared with ED patients.

CONCLUSIONS

Identifying overlapping features and key differences in the clinical characteristics and health care use of patients with primary psychiatric disorders like ED and SFD, who are frequent users of medical services, is the first step toward developing innovative, integrated hospital-based care approaches and clinical pathways that can reduce service utilization and improve patient outcomes.

Attachment and Chronic Pain in Children and Adolescents

Although attachment theory is not new, its theoretical implications for the pediatric chronic pain context have not been thoroughly considered, and the empirical implications and potential clinical applications are worth exploring. The attachment framework broadly focuses on interactions between a child’s developing self-regulatory systems and their caregiver’s responses. These interactions are believed to create a template for how individuals will relate to others in the future, and may help account for normative and pathological patterns of emotions and behavior throughout life. This review outlines relevant aspects of the attachment framework to the pediatric chronic pain context. The theoretical and empirical literature is reviewed regarding the potential role of attachment-based constructs such as vulnerability and maintaining factors of pediatric chronic pain. The nature and targets of attachment-based pediatric interventions are considered, with particular focus on relevance for the pediatric chronic pain context. The potential role of attachment style in the transition from acute to chronic pain is considered, with further research directions outlined.

Clinical features of functional somatic symptoms in children and referral patterns to child and adolescent mental health services

AIM

Functional somatic symptoms (FSS) are common in paediatric patients who are referred to Child and Adolescent Mental Health Service (CAMHS), but little is known about current referral practices. The aim of this study was to systematically investigate clinical features of paediatric inpatients with FSS referred to CAMHS and to describe why paediatricians referred them.

METHODS

The study population comprised 60 children with FSS admitted to a large Danish paediatric department during 2012. We compared medical record data on the clinical characteristics and paediatric management of 16 children who had been referred and 44 children who had not.

RESULTS

Most paediatric records lacked information on psychosocial factors and symptoms. Referred children were significantly more multisymptomatic of FSS (p < 0.01) than the controls, had longer symptom duration, underwent more clinical investigations, had longer paediatric admissions of at least two weeks and received more treatment elements before referral. The most frequently stated referral reason was inadequate treatment response.

CONCLUSION

Paediatric inpatients with more severe FSS were more likely to be referred to CAMHS, but referral reasons were generally vague and psychosocial information was frequently missing. Clinical guidelines are needed to improve and systematise mental health referrals for children with FSS.

Families' and healthcare professionals' perceptions of healthcare services for children and young people with medically unexplained symptoms: a narrative review of the literature

Children and young people frequently report physical complaints that have no observable physical pathology known as medically unexplained symptoms (MUS). Research suggests that MUS are associated with substantial physical and psychological impairments and may have a negative impact on children's and young people's functional status and well-being in the long term. Due to the potentially complex needs of this group, children and young people with MUS may require timely access to suitable health and social care services to effectively manage symptoms and achieve their academic, social and personal potential. Families and professionals can offer important insights into the availability and appropriateness of current community and specialist health and social care services. This review is the first critical evaluation and synthesis of research that has examined families' and healthcare professionals' (HCP) perceptions of healthcare services for children and young people with MUS. A systematic search of electronic databases and manual searches of key journals and reference lists identified 17 papers from 15 studies for inclusion in the review. The review highlights the paucity of rigorously conducted research on this topic. Studies have been narrowly focused on the views of a homogeneous group of mothers and young people attending single centres. There has been some attempt to examine doctors' views, but the perceptions of children, fathers and health and social care professionals are absent or under-represented, and multi-site and longitudinal studies are lacking. Thematic analysis of the results from the included studies suggests that knowledge, communication, health beliefs and healthcare settings are factors that influence families' and HCPs' perceptions of services. Families report dissatisfaction with some HCPs' approach to managing MUS. The findings suggest that children and young people with MUS are at risk of receiving suboptimal care and support because there is insufficient research to inform high-quality, evidence-based practice.

Searching for existential security: a prospective qualitative study on the influence of mindfulness therapy on experienced stress and coping strategies among patients with somatoform disorders

OBJECTIVE

The aim was to explore how mindfulness group therapy for somatoform disorders influenced the patients' stress experiences, coping strategies and contextual psychosocial processes.

METHODS

A longitudinal pre- and post-treatment design, using 22 semi-structured individual pre- and post-treatment interviews. Data-analysis was based on a thematic methodology.

RESULTS

Pre-treatment patients were struggling in an existential crisis, feeling existentially insecure about their social identity, the causes, consequences and management of their illness; experiencing difficulties identifying and expressing stress-related cognitions, emotions and feelings, and low bodily and emotional self-contact; often leading to avoidant coping, making these individuals highly stress-vulnerable. Post-treatment, the overall change was conceptualized as increased existential security, defined by patients being more self-confident; more clarified with their social identity, the nature, management and future prospects of their illness; generally using more flexible coping strategies to reduce their daily stress experiences. Four related subthemes were identified contributing to increased existential security: 1) more secure illness perceptions - feeling existentially recognized as "really" ill, 2) enhanced relaxation ability - using mindfulness techniques, 3) increased awareness - connecting differently to mind and body 4) improved ability to identify and express needs and feelings of distress - more active communicating. Patients suggested that mindfulness therapy could be expanded with more time for group-discussions followed by additional individual therapy.

CONCLUSION

Generally, treatment positively influenced the patients' illness perceptions, stress-experiences, body- and self-awareness, coping strategies, self-image, social identity and social functioning. However, patients identified potentials for treatment improvements, and they needed further treatment to fully recover.

The influence of unsupervised time on elementary school children at high risk for inattention and problem behaviors

In the last few decades, changing socioeconomic and family structures have increasingly left children alone without adult supervision. Carefully prepared and limited periods of unsupervised time are not harmful for children. However, long unsupervised periods have harmful effects, particularly for those children at high risk for inattention and problem behaviors. In this study, we examined the influence of unsupervised time on behavior problems by studying a sample of elementary school children at high risk for inattention and problem behaviors. The study analyzed data from the Children's Mental Health Promotion Project, which was conducted in collaboration with education, government, and mental health professionals. The child behavior checklist (CBCL) was administered to assess problem behaviors among first- and fourth-grade children. Multivariate logistic regression analysis was used to evaluate the influence of unsupervised time on children's behavior. A total of 3,270 elementary school children (1,340 first-graders and 1,930 fourth-graders) were available for this study; 1,876 of the 3,270 children (57.4%) reportedly spent a significant amount of time unsupervised during the day. Unsupervised time that exceeded more than 2h per day increased the risk of delinquency, aggressive behaviors, and somatic complaints, as well as externalizing and internalizing problems. Carefully planned afterschool programming and care should be provided to children at high risk for inattention and problem behaviors. Also, a more comprehensive approach is needed to identify the possible mechanisms by which unsupervised time aggravates behavior problems in children predisposed for these behaviors.

[Critical Approach to Somatomorphic Disorders in Children]

Somatomorphic disorders have common somatic manifestations without medical explanation, that can affect daily life. There are evaluation difficulties regarding symptom report or observation in children due to their age, parental influence and associated factors. The aim of this work is to acknowledge diagnosis difficulties and clinic tools to approach somatomorphic disorders in children. A systematic search in the information published for the last ten years was carried out. Historical evolution of the concept of somatization has generated difficulties to approach this issue. Some signs could indicate a somatomorphic disorder; however, there are very little evaluating tools for children. Currently, said tools are only based on lists of symptoms without fully answering to all questions. Somatomorphic disorders or somatic symptoms in children are still a gap to be closed.

Interethnische Analysen der Verteilungen psychischer Störungen bei Kindern und Jugendlichen in einer Inanspruchnahmepopulation

Interethnic Analyses of Distributions in Children and Adolescents Mental Disorders in a Health Care Utilization The study examines ethnic differences in mental disorders in a child and adolescent psychiatry population in a major German city from 2007 to 2011 (N = 5,680). Risks of developing specific mental disorders were calculated. African migrant children and adolescents showed higher risk in traumatic stress and adjustment disorders (F 43 in ICD-10), the Asiatic group in dissociative disorders (F 44-45). Compared to other European migrants the German children and adolescents without migration background had a higher risk of affective disorders (F 3). Adolescents (N = 3,556) with Russian and Polish background had a higher risk of disorders induced by psychotropic substances (F 1). Turkish and Arabic adolescents had a 4- to 5-times increasing risk in schizophrenia as well as schizotypal or delusional disorders (F 2). In addition, mental disorders were influenced by gender and nationality. These study results suggest that a different vulnerability to specific mental disorders is associated to ethnicity.

Struggling in an emotional avoidance culture: a qualitative study of stress as a predisposing factor for somatoform disorders

OBJECTIVE

To explore patterns of experienced stress and stress reactions before the onset of illness in the life history of patients with severe somatoform disorders to identify predisposing stress-mechanisms.

METHODS

A systematic, thematic analysis was conducted on data collected from 24 semi-structured individual life history interviews.

RESULTS

Generally, patients had experienced high psychosocial stress during childhood/youth. However, there was considerable variability. Characteristic of all patients were narrations of how communication with significant adults about problems, concerns, and emotions related to stress were experienced to be difficult. The patients described how this involved conflicts stemming from perceived absent, insufficient, or dismissive communication during interactions with significant adults. We conceptualized this empirically based core theme as "emotional avoidance culture." Further, three related subthemes were identified: Generally, patients 1.) experienced difficulties communicating problems, concerns, and related complex feelings in close social relations; 2.) adapted their emotional reactions and communication to an emotional avoidance culture, suppressing their needs, vulnerability and feelings of sadness and anger that were not recognized by significant adults; and 3.) disconnected their stress reaction awareness from stressful bodily sensations by using avoidant behaviors e.g. by being highly active.

CONCLUSION

Patients adapted to an emotional avoidance culture characterized by difficult and conflicting communication of concerns and related emotions in social interactions with significant adults. Patients experienced low ability to identify and express stress-related cognitions, emotions and feelings, and low bodily and emotional self-contact, which made them vulnerable to stressors. Generally, patients resolved stress by avoidant behaviors, prolonging their stress experience.

Prevalence and comorbidities of adolescent depression in Germany. An analysis of Health Insurance Data

OBJECTIVE

Data on the prevalence of depressive disorders in adolescents are scarce. We aimed to examine the administrative prevalence of depressive disorders and related comorbidities in German adolescents. A second objective of was to assess potential regional (East vs. West Germany) differences in depression prevalence.

METHOD

Data of a statutory health insurance company were analysed and outpatients from 12 to 18 years of age with diagnosed depression during a one-year-period (2009) were identified.

RESULTS

The population at risk consisted of 140,563 adolescents. Of these, 4,295 (41.2% male; mean age: 15.5 years) had a diagnosis of depression. This equates to a prevalence of 3.1% (females: 3.7%, males: 2.5%). There were no significant differences between East and West Germany. Of all adolescents with depression, 62.5% had at least one comorbid psychiatric diagnosis, with anxiety and emotional disorders (23.7%), somatoform disorders (16.8%), hyperkinetic disorders (16.2%) and posttraumatic stress disorder (10.0%) being most frequently diagnosed.

CONCLUSIONS

The depression prevalence in this sample was lower than that in studies of clinical samples. There was a marked prevalence of psychiatric comorbidities, especially of internalizing disorders. In adolescents, the risk of depression seems to be comparable in both East and West Germany.