When things get complicated: At-risk attachment in children and adolescents with chronic pain

["Somatic symptom disorders" in adolescence. A systematic review of the recent literature]

OBJECTIVES

Body expression of mental disorders is common in adolescence. Only two literature reviews over the last five years have been identified about somatoform disorders in children., The present article provides a systematic review of articles in English, which concern "Somatic Symptom and Related Disorders" according to the DSM-5 (Diagnostic and Statistical Manual - 5th Edition) among adolescents.

METHODS

The article search was made on Medline, Psychinfo, Google Scholar, BiomedCentral, Central and tripdatabase (for grey literature) according to PRISMA criteria and with the items "somatoform disorders" or "somatic symptom disorders". An age filter was applied for "adolescents", and a selection was done from the last five years. All articles concerning adolescents (often associated with children) were initially included, except for articles concerning eating disorders, dysmorphic disorders or adult population. Comments, editorials, opinion or descriptive articles were also excluded. The authors then carried out an analysis of the main topics, themes and questions covered in the selected publications and presented a descriptive synthesis.

RESULTS

A total of seventy-seven publications were included in the analysis, from three hundred and seventy-two publications. First, the terms used to refer to these "somatic symptom disorders" were varied, such as "somatization", "somatic complaints/symptoms", "functional disorder", "unexplained symptoms" and "somatoform disorders". Then, studies related just to adolescents were limited: most of studies included children and adolescents in their methodologies; and some of them questioned somatic symptoms from a developmental perspective. Case reports were the most represented articles among all medical specialties, with clinical descriptions about "functional neurological symptom disorder", "factitious disorder" and "somatic symptom disorder" with a medical disease, among children and adolescents. We sometimes observed a controversial borderline between psychological and somatic disorders. Various explanatory models appeared, especially the trauma path; familial and social environment was also pointed out, with a possible peer group effect; neurocognitive theories were finally described. The literature highlights the effectiveness of psychosocial therapies (especially the cognitive-behavioral therapy) and the importance of multidisciplinary management. Finally, a few studies with a qualitative methodology are represented.

CONCLUSIONS

Only nine articles included "somatic symptom disorder" in their titles, despite a terminology valued by many authors (compared to "somatoform disorders" from the DSM-IV). The heterogeneity of terminologies, case reports and explanatory models witness a lack of connexions between medical specialties. This could explain in part the wandering of adolescents and their families in the health care system. It could also contribute to the delay before diagnosis, especially when neurological symptoms exist, and a late referral for psychiatric consultation. Further studies are needed to understand difficulties to use a clinical pathway among medical specialties, when the benefit of amultidisciplinary approach seems to be unanimous.

Alexithymia and Somatization in Chronic Pain Patients: A Sequential Mediation Model

OBJECTIVE

To investigate whether chronic pain (CP) patients with somatization reported higher alexithymic traits than those without somatization and to study the different relationships between psychological characteristics, pain, health-related quality of life (HRQL), and somatization.

METHOD

A consecutive sample of 134 CP treatment-seeking outpatients were evaluated for alexithymia (TAS-20), somatization (PHQ-15), distress (HADS), HRQL (SF-12), and pain (BPI).

RESULTS

Patients with somatization (37.04%) reported significantly higher TAS-20 total scores (p < 0.001) and difficulty in identifying feelings (DIF) (p < 0.001) than those without somatization. The somatizer group had also a significantly higher disease duration, severity and interference of pain, distress, and lower HRQL than the non-somatizer group. Hierarchical regression analysis showed that although distress, pain interference and the mental HRQL component are closely related to somatization (R 2 = 0.55), DIF was the strongest predictor of severity of somatization (β = 0.31). A sequential indirect effect from DIF to somatization via distress symptoms and pain interference turned out to be significant [95% CI (0.01, 0.09)]. Support was also found for sequential mediation paths from DIF to somatization via distress and mental HRQL [95% CI (0.01, 0.11)].

CONCLUSIONS

Our results pointed-out that alexithymia, particularly DIF, may be major factor for somatization risk in CP patients. Longitudinal observations are needed for evaluating the role of alexithymia in clinical outcomes.

Family history of pain and risk of musculoskeletal pain in children and adolescents: a systematic review and meta-analysis

Emerging evidence suggests that musculoskeletal (MSK) pain should be viewed from a biopsychosocial perspective and consider the influence of family factors. We conducted a review with meta-analysis to provide summary estimates of effect of family history of pain on childhood MSK pain and explore whether specific family pain factors influence the strength of the association (PROSPERO CRD42018090130). Included studies reported associations between family history of pain and nonspecific MSK pain in children (age <19 years). The outcome of interest was MSK pain in children. We assessed the methodological quality using a modified version of the Quality in Prognosis Studies instrument and quality of evidence for the main analyses using the GRADE criteria. After screening of 7281 titles, 6 longitudinal and 23 cross-sectional studies were included. Moderate quality evidence from 5 longitudinal studies (n = 42,131) showed that children with a family history of MSK pain had 58% increased odds of experiencing MSK pain themselves (odds ratio [OR] 1.58, 95% confidence interval 1.20-2.09). Moderate quality evidence from 18 cross-sectional studies (n = 17,274) supported this finding (OR 2.02, 95% 1.69-2.42). Subgroup analyses showed that the relationship was robust regardless of whether a child's mother, father, or sibling experienced pain. Odds were higher when both parents reported pain compared with one ([mother OR = 1.61; father OR = 1.59]; both parents OR = 2.0). Our findings show moderate quality evidence that children with a family history of pain are at higher risk of experiencing MSK pain. Understanding the mechanism by which this occurs would inform prevention and treatment efforts.

Pediatric Persistent Pain: Associations Among Sensory Modulation, Attachment, Functional Disability, and Quality of Life

IMPORTANCE

Although attachment is associated with sensory modulation among children and adolescents and insecure attachment is associated with pain severity among adolescents, relationships among sensory modulation, attachment, and function have not previously been demonstrated in a clinical sample of children and adolescents with complex persistent pain.

OBJECTIVE

To investigate relationships among sensory modulation, attachment, function, and quality of life (QOL) in a pediatric population with persistent pain.

DESIGN

Cross-sectional quantitative design. From October 2015 to July 2017, all children, adolescents, and parents attending a clinic for assessment completed questionnaires and were provided information and consent forms. Those who consented completed sensory modulation and attachment questionnaires.

SETTING

Tertiary pain management clinic.

PARTICIPANTS

Children (ages 8-12 yr) and adolescents (ages 13-18 yr) with persistent pain (pain of >3 mo duration or a specific pain disorder) and the capacity to answer questionnaires independently.

MEASURES

Standardized sensory modulation, attachment, pain intensity, functional disability, and QOL questionnaires. Hypotheses were generated before data collection.

RESULTS

Of 152 children and adolescents, 114 children (30 girls, 9 boys) and adolescents (68 girls, 7 boys) met study criteria and consented to participate. Hierarchical multiple regression analyses revealed that sensory sensitivity predicted disability for children and adolescents, and attachment anxiety mediated the relationship between low registration and poorer school-related QOL.

CONCLUSION AND RELEVANCE

Behaviors related to insecure attachment patterns provide a mediating pathway from sensory modulation to functional disability; addressing such behaviors clinically may facilitate engagement in daily activities for children and adolescents with persistent pain.

WHAT THIS ARTICLE ADDS

Results support the need to consider the interactions between sensory modulation and attachment when addressing functional abilities with occupational therapy treatment.

Making Sense of "Somatization": A Systematic Review of its Relationship to Pediatric Pain

OBJECTIVES

Pain and other physical symptoms commonly co-occur in childhood. There is debate about the relevance of somatization in understanding pain. The present review critically appraised and synthesized the extant literature on the relationship between pediatric pain and somatization.

METHODS

A systematic review (PROSPERO registration #95956) was conducted in Medline, PsycINFO, EMBASE, and CINAHL using search terms related to pain and somatization in children and adolescents. A total of 156 articles were eligible for inclusion in the review. For studies that measured somatization using a symptom questionnaire, descriptions of "somatization" were extracted. Data regarding the relationship between pain and somatization were extracted for studies measuring somatization using a diagnostic category (e.g., Somatic Symptom and Related Disorders [SSRDs]).

RESULTS

While many studies using somatic symptom questionnaires described somatization as having a psychological component, this was not always captured in measurement tools. Pain was reported as a common symptom in patients with an SSRD diagnosis, though rates varied depending on the specific diagnosis and pain location. Rates of SSRD diagnoses among pain patients were less frequent than rates of pain amongst SSRD patients.

CONCLUSIONS

SSRDs and pain commonly co-occur, though rates differ depending on diagnosis and pain location. Understanding the relationship between pain and somatization is complicated by the discrepancy between how somatization is defined and measured in questionnaire studies. A comprehensive and measurable definition of somatization is needed so researchers can better identify the shared and unique contributions of pain and somatization in pediatric populations.

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.

Associations between attachment and pain: From infant to adolescent

Pain experience is a negative complex phenomenon influenced by several mechanisms. Attachment processes may affect the way in which individuals experience and signal pain. Hence, in the last two decades, the role of attachment quality has drawn attention in pain research and practice. However, previous reviews on this topic focused on adulthood and/or specific types or pain. We conducted a narrative review examining the association between attachment and different pain conditions from infancy to adolescence. Two independent researchers searched scientific databases for relevant papers. A total of 17 articles were included. Results highlight the following: (a) children and adolescents with chronic idiopathic pain showed low rates of attachment security compared to control groups; (b) pain conditions are consistently associated with elevated rates of at-risk pattern of attachment and information processing; and (c) the presence of unresolved trauma or loss is higher in children and adolescent who experienced pain compared to healthy controls. Despite the significance of these empirical evidences, the impact of caregiving environment and interpersonal context on pain experience in infancy and preschool age is poorly investigated compared to adulthood. Research on pain and attachment needs to be extended since the majority of the studies are limited to specific pain conditions. Future research should investigate the role of anxious attachment on procedural pain and transition from acute to chronic pain, testing new conceptual models. These findings shed light on the importance of relational factors and psychosocial vulnerabilities in pain clinical practice. An attachment-informed approach to pain will help health professionals to offer adequate support during procedures and to increase effectiveness of interventions. A developmental perspective is needed to integrate familial and relational contribution into a multimodal assessment and treatment of pain. Longitudinal studies are recommended.

Ghosts, tigers and landmines in the nursery: Attachment narratives of loss in Tamil refugee children with dead or missing fathers

OBJECTIVE

To build an account of how bereaved Tamil refugee and asylum seeker children, resettled in Australia, had processed the loss of their dead or missing fathers.

METHOD

Phenomenological and discourse analysis was applied to attachment narratives of nine children (aged 11-17 years) and their surviving mothers in families that lost fathers in war-related circumstances. The narratives were analysed through the lens of Crittenden's Dynamic-Maturational Model of Attachment and Adaptation (DMM) and Klass' cross-cultural model of grief.

RESULTS

Two divergent pathways - 'burying the past' and 'reifying the past' - emerged, encompassing the children's contrasting patterns of information processing regarding loss and trauma (dismissing or preoccupying) and representation of the past (distant-buried or rich-reconstructed). Each pathway reflected a strategic compromise between the constraints and resources presented to the child by the circumstances of the loss (ambiguous or confirmed), the response of their surviving parent (stricken or stoic) and the collective narrative surrounding the loss (silenced or valorised).

CONCLUSION

The DMM's conceptualisation of attachment as self-protective strategies for navigating danger was helpful in explaining the contrasting adaptations of refugee children to loss and trauma. However, to understand the multivalent meanings of these adaptations, there was a need to situate child-parent attachment relationships within the wider sociocultural reconfigurations arising from contexts of political violence.

Grey matter abnormalities in children and adolescents with functional neurological symptom disorder

Objective

Functional neurological symptom disorder refers to the presence of neurological symptoms not explained by neurological disease. Although this disorder is presumed to reflect abnormal function of the brain, recent studies in adults show neuroanatomical abnormalities in brain structure. These structural brain abnormalities have been presumed to reflect long-term adaptations to the disorder, and it is unknown whether child and adolescent patients, with illness that is typically of shorter duration, show similar deficits or have normal brain structure.

Method

High-resolution, three-dimensional T1-weighted magnetic resonance images (MRIs) were acquired in 25 patients (aged 10–18 years) and 24 healthy controls. Structure was quantified in terms of grey matter volume using voxel-based morphometry. Post hoc, we examined whether regions of structural difference related to a measure of motor readiness to emotional signals and to clinical measures of illness duration, illness severity, and anxiety/depression.

Results

Patients showed greater volumes in the left supplementary motor area (SMA) and right superior temporal gyrus (STG) and dorsomedial prefrontal cortex (DMPFC) (corrected p < 0.05). Previous studies of adult patients have also reported alterations of the SMA. Greater SMA volumes correlated with faster reaction times in identifying emotions but not with clinical measures.

Conclusions

The SMA, STG, and DMPFC are known to be involved in the perception of emotion and the modulation of motor responses. These larger volumes may reflect the early expression of an experience-dependent plasticity process associated with increased vigilance to others' emotional states and enhanced motor readiness to organize self-protectively in the context of the long-standing relational stress that is characteristic of this disorder.

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We used high-resolution MRI to investigate brain structure in children presenting with acute functional neurological symptom disorder (FND).

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Patients had multiple antecedent stressors, a long-standing history of relational stress and at-risk attachment strategies.

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Patients had greater volumes in the SMA—where motor-, cognitive-, and emotion-processing signals interact to influence motor function.

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FND may involve experience-dependent changes in brain structure alongside experience-dependent changes in brain function.