IACAPAP Textbook of Child and Adolescent Mental Health

CHILD PSYCHIATRY & PEDIATRICS

Chapter

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SOMATIC SYMPTOM, BODILYDISTRESS AND RELATED DISORDERS
IN CHILDREN AND ADOLESCENTS
2019 edition
Olivia Fiertag, Sharon Taylor, Amina Tareen & Elena Garralda
Olivia Fiertag MBChB,
MRCPsych, PGDip CBTConsultant Child andAdolescent Psychiatrist.
Honorary Clinical Researcher,
HPFT NHS Trust &collaboration with Imperial
College London, UK
Conflict of interest: none
declared

Sharon Taylor BSc, MBBS,
MRCP, MRCPsych,
CASLAT, PGDip
Consultant Child andAdolescent Psychiatrist
CNWL Foundation NHS Trust& Honorary Senior ClinicalLecturer Imperial College
London, UK. Joint Program
Director, St Mary’s Child
Psychiatry Training Scheme

Sick Girl.
Christian Krogh,(1880/1881) National
Gallery of Norway

Conflict of interest: none
declaredThis publication is intended for professionals training or practicing in mental health and not for the general public. The opinions
expressed are those of the authors and do not necessarily represent the views of the Editor or IACAPAP. This publication seeks todescribe the best treatments and practices based on the scientific evidence available at the time of writing as evaluated by the authorsand may change as a result of new research. Readers need to apply this knowledge to patients in accordance with the guidelines andlaws of their country of practice. Some medications may not be available in some countries and readers should consult the specific drug
information since not all dosages and unwanted effects are mentioned. Organizations, publications and websites are cited or linked toillustrate issues or as a source of further information. This does not mean that authors, the Editor or IACAPAP endorse their content or
recommendations, which should be critically assessed by the reader. Websites may also change or cease to exist.
©IACAPAP 2019. This is an open-access publication under the Creative Commons Attribution Non-commercial License. Use,
distribution and reproduction in any medium are allowed without prior permission provided the original work is properly cited andthe use is non-commercial.
Suggested citation: Fiertag O, Taylor S, Tareen A, Garralda E. Somatic symptom, bodily distress and related disorders in children
and adolescents. In Rey JM, Martin A (eds), IACAPAP e-Textbook of Child and Adolescent Mental Health. Geneva: International
Association for Child and Adolescent Psychiatry and Allied Professions 2019.

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IACAPAP Textbook of Child and Adolescent Mental HealthPhysical (somatic) symptoms are extremely common in children andadolescents. Children and adolescents often find it difficult to express their
feelings and emotions through language. Because of this, expression of
psychological distress can manifest as physical (somatic) symptoms.
Parents are usually aware that their children may sometimes experiencesomatic symptoms if they are worried about something or trying to avoid something.
Most parents will naturally minimise the importance of these symptoms and try
and find out the cause. This tactic usually aids the child to learn to cope witheveryday stresses. However, despite this, sometimes the symptoms persist.
It is thought that about 2-10% of children in the general population complainof bothersome aches and pains (e.g. stomach aches, joint pains, headaches) thatare likely to be medically unexplained. The term medically unexplained symptoms
refer to all bothersome or recurrent bodily symptoms that do not have a recognized
medical illness explanation. Unexplained physical symptoms may lead to distress,
impairment in functioning and health care seeking behavior, as in somatizing
conditions, such as DSM-5 somatic symptom disorder (American Psychiatric
Association, 2013) and ICD-11 (World Health Organisation, 2018) bodily distressand related disorders. These were previously known as “somatoform disorders.”

Amina Tareen MBBS,
MRCPsychConsultant Child andAdolescent Psychiatrist at
Barnet, Enfield and Haringey
Mental Health NHS Trust,
Honorary Teaching Fellow,
Imperial College London, UK
Conflict of interest: none
declared

Elena Garralda MD, MPhil,
FRCPsych, FRCPCH
Emeritus Professor of Childand Adolescent Psychiatry,
Imperial College London,
Honorary Consultant in Childand Adolescent Psychiatry
CNWL Foundation NHS Trust,
London, UK
Conflict of interest: none
declaredFunctional impairment can occur in children with medically unexplained
somatic symptoms at any age and at various levels of symptom severity, and thesymptoms, especially when multiple, tend to be associated with psychologicalproblems. There is evidence that even in very young children who are nurseryschool aged, those that present with frequent somatic symptoms are significantly
more likely than children without symptoms to have associated behavioural andemotional problems, to miss nursery and to attend clinics. (Domenech-Llaberia
et al, 2004). These children may also be at increased risk of experiencing further
physical symptoms and psychological difficulties later in childhood or adolescence.
There are many ways in which physical and psychological symptoms interact
and, really, no illness is purely one or the other, after all one cannot separate thebody from the mind. In patients who present repeatedly with physical symptoms
especially, but not exclusively, if these are medically unexplained, it is vital toconsider underlying psychological distress. This chapter focuses on psychiatricdisorders that present with physical symptoms. Table I.1.1 summarises thedifferent ways in which physical and psychological aspects may be linked.

WHAT IS SOMATIZATION?
This term describes a constellation of clinical and behavioral featuresindicating the experience and communication of psychological distress throughphysical (somatic) symptoms unaccounted for by pathological findings, and forthese symptoms to be attributed to a physical illness, thus leading the patient toseek medical help. The production of symptoms is usually not under conscious
control; however, in children and adolescents it is often particularly difficult toestablish the level of conscious control. Table I.1.1 below summarises the broader
different ways in which physical and psychological aspects may be linked.

Somatic symptom disorders

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Children with somatic
symptom disorder areoften distressed by their
symptoms but not much byhaving an actual illness,whereas their parents often
are concerned about themhaving an illness.

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Table I.1.1

Ways in which physical and psychological aspects ofillness are linked

Nature of Association

ExamplePsychological distress / Psychiatric disorders
can present with physical symptoms

Child presenting with recurrent
abdominal pain of non-organic origin

Physical complications of psychiatricproblems

Child presenting with liver failure after
self- harming with a paracetamol
overdose

Psychiatric consequences of physical illness
and treatment

Child with sickle cell diseasedeveloping depression due todeteriorating physical health

Effects of psychiatric disorder on physicalillness

Child with diabetes and needle phobia
refusing treatment leading to diseaseprogression

DIAGNOSTIC CRITERIA
DSM-5 describes somatic symptom and related disorders as encompassing
disorders which have prominent somatic symptoms associated with significant
distress and impairment. The diagnosis of somatic symptom disorder emphasizes
the presence of positive symptoms and signs (i.e., distressing somatic symptoms
plus abnormal thoughts, feelings and behaviors in response to these symptoms)
rather than the absence of a medical explanation of the symptoms. A distinctive
feature is not the somatic symptom per se, but rather the way the individual
presents and interprets it. It is important to note that somatic symptom disordercan exist alongside a diagnosed medical disorder. Medically unexplained symptoms
remain a key feature of the related conversion disorder (dissociative disorder) andpseudocyesis (false or phantom pregnancy) where the somatic symptoms are
explicitly not consistent with medical pathophysiology. In DSM-5, conversion
disorder (now also called functional neurological symptom disorder) is categorized
together with somatic symptom and related disorders, as are illness anxiety disorderand factitious disorders.
In somatic symptom and related disorders, there are physical symptoms
suggesting a medical condition; however, no medical disease, substance misuseor other mental disorder can be found to account for the level and impact ofthe physical (somatic) symptoms. The symptoms cause significant distress or
impairment in social, occupational or other areas of functioning. The physicalsymptoms are usually not intentional, with the exception of factitious disorderwhere there is deliberate falsification of physical or psychological symptoms.
ICD-11 categorizes somatizing under the heading of disorders of bodily
distress or bodily experience. This is described as having bodily symptoms which
the individual finds distressing and to which excessive attention is directed.
Unlike DSM-5, ICD-11 disorders of bodily distress do not include conversion
disorder, which is integrated within a separate category of dissociative neurologicalSomatic symptom disorders

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Table I.1.2 Characteristics of various somatization disorders according to ICD-11 and DSM-5

•

•
•
•
•
•
•

ICD-11

DSM-5

Disorders of Bodily Distress

Somatic Symptom Disorder

Bodily symptoms that are distressing to the individual.
Typically, there are multiple symptoms that may varyover time; however, a single symptom may be present(e.g., fatigue or pain)
Excessive attention directed towards the symptoms
Most patients have repeated contact with primaryand specialist medical services during which many
negative investigations may have been carried out
If another condition is causing or contributing to thesymptom, then the degree of attention is excessive in
relation to its nature and progression
Excessive attention is not alleviated by appropriate
examination, investigation and reassurance
Bodily symptoms are persistent, present most days
for several months
Often associated with disruption of social,interpersonal, and family functioning

Dissociative Neurological Symptom Disorder•

One or more somatic symptoms cause significant
distress or impairment
Excessive thoughts, feelings, or behaviours related tothese symptoms
The physical symptoms are not caused intentionaly
No diagnosable medical condition can fully accountfor the symptoms. However, they can coexist withphysical illness
Symptoms may be specific (e.g., localised pain) or
relatively nonspecific (e.g., fatigue).

•
•
•
•

Conversion Disorder(Functional Neurologic Symptom Disorder)
•

•
•

•

Motor, sensory, or cognitive symptoms that imply an
involuntary discontinuity in the normal integration of
motor, sensory or cognitive functions.
Symptoms are not consistent with a recognizeddisease of the nervous system, other mental healthor other health condition or due to effects frommedication use or substance misuse. Medical
examination and investigation do not reveal thepresence of any known physical or neurologicaldisorder.
The possibility of the later appearance of serious
physical or psychiatric disorders should always be
kept in mind.

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•
•
•

One or more symptoms or deficits affecting voluntary
motor or sensory function that suggest a neurologicalor other general medical condition
Stressful life events are often, but not always present.
There may be a history of maladaptive personality
traits and childhood abuse/neglect.
The symptom /deficit is not intentionally produced or
feignedThe symptom /deficit:»» Cannot, after investigation, be explained bya medical condition, substance abuse or aculturally sanctioned behaviour or experience»» Causes clinically significant distress or
impairment in social, occupational, or otherimportant areas of functioning or warrants
medical attention»» Is not limited to pain, and is not betteraccounted for by another medical disorder4

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Table I.1.2 (continuation)

•
•

•
•
•

ICD-11

DSM-5

Factitious Disorder

Factitious Disorder

Intentionally feigning medical, psychological or
behavioral signs and symptoms
Pre-existing disorder/disease may be present;
however, the individual intentionally aggravates
existing symptoms or falsifies or induces additional
symptoms.
Individuals seek treatment or present themselves toanother person as ill, injured or impaired based onthese symptoms
Deceptive behavior not solely motivated by obvious
external rewards (in contrast to malingering whereclear external incentives motivate the behavior).
Symptoms can be imposed on others*

•
•
•
•
•

Falsification of physical/psychological symptoms/signs
or inducing injury, with associated identified deception
Individuals presents themselves as unwell, impaired
or injured
Deceptive behaviour is evident even in the absence ofobvious external rewards
Behaviour is not better explained by another mental
disorder (e.g., delusional disorder).
When symptoms are imposed on another person it is
known as “factitious disorder imposed on another” **Also known as Munchausen syndrome by proxy.

symptom disorders (in which there is a disruption of and/or discontinuity in thenormal integration of consciousness, memory, identity, emotion, perception, body
representation, motor control and behavior). The full ICD-11 is not yet available;
however, we present the most recent information, provided in the December 2018
version.
In both, DSM-5 and ICD-11, the somatizing disorders most commonly
seen in children and adolescents are:
• Somatic symptom disorder• Disorder of bodily distress• Dissociative disorders• Conversion disorder and• Chronic fatigue syndrome.
Conditions categorized in previous classifications as somatoform disorder orsomatization disorder would now be included under the categories of disorders ofbodily distress/somatic symptom disorder. Chronic fatigue syndrome shares key featureswith somatic symptom disorder but is not included in DSM-5 as a separate category.
It is classified in ICD-11 under “other disorders of the nervous system” as “postviral fatigue syndrome.” This category includes the illnesses termed benign myalgic
enecephalitis and chronic fatigue syndrome. If the fatigue is not associated with avirus it is recommended to consider coding it within disorders of bodily distress,
which can present with a single symptom (e.g., fatigue) or multiple symptoms(e.g., fatigue, pain, aches). A summary of the specific criteria for some of these
disorders is outlined in Table I.2.2.

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Chronic Fatigue Syndrome
This condition, earlier described as “neurasthenia” and “post viral fatigue” in ICD-10, was not included in DSM-IV
nor DSM-5. It is classified in ICD-11 under “other disorders of the nervous system” as “post viral fatigue syndrome.” This
category includes the illnesses termed “benign myalgic encephalitis” and “chronic fatigue syndrome.” If the fatigue is not
associated with a virus, it is recommended to consider coding it within “disorders of bodily distress,” which can present witha single symptom (e.g., fatigue) or multiple symptoms (e.g., fatigue, pain, aches). Criteria for diagnosis for post viral fatigue
include:•Presence of a viral infection pre-dating the illness onset•

Either persistent and distressing complaints of increased fatigue after mental effort, or persistent and distressing
complaints of bodily weakness and exhaustion after minimal effort•

May have associated feelings of muscular aches/pains, dizziness, headaches, sleep disturbance, inability to relax,
irritability, dyspepsia•

Autonomic or depressive symptoms present are not sufficiently persistent and severe to fulfil the criteria for any
other disorder

Patient groups with his condition often object to the psychological approach to its understanding and management(Cohen, 2015), as has been the case in the past for patients with somatoform disorders. In addition there are different views
as to how it should be named. As for other disorders in this chapter, disease mechanisms are likely to be complex, with bothbiological (infectious, immunological, genetic) and psychosocial factors contributing to the development and maintenance ofsymptoms (Brurberg et al, 2014).

All of these conditions encompass:• Repeated presentations of physical symptoms with• Persistent requests for medical investigations despite negative findings
and medical reassurance and• The patient often resists attempts to discuss the possibility of a
psychological causation.
For completeness, we will also describe the criteria for factitious disorders,which have similarities in presentation and management. In factitious disorder,
individuals may deliberately injure themselves to simulate illnesses and describe
symptoms they are not experiencing in order to seek medical care, prolong medical
treatment, and receive attention. For example, in a case report, a12-year-old girlwas thought to suffer from a mysterious fever until she was 17; she was foundto be faking thermometer readings. In other cases, children and adolescents
have inflicted serious harm upon themselves or deceived doctors into prolonged
hospital stays and repeated surgical procedures (DeNoon, 2000). It is often hardin clinical practice to make a distinction between what is a conscious manipulationin factitious disorder and what is a psychosomatic presentation, particularly inchildren.
A special instance of factitious disorder is when it is imposed on another,
typically a parent on a child. This condition, previously known as Munchausen
syndrome by proxy, occurs when a caregiver elicits healthcare on a child’s behalf
without justification. It can involve actions to actually produce symptoms or
falsely reporting concerns about both the physical and mental health of a child(McNicholas et al, 2000; Bass & Glaser, 2014); for example, a mother bruises her
child leading physicians to suspect and investigate a rare hematological disorder,
a caregiver starves her child because she suspects multiple food allergies, a parent
smears their child’s wounds with dirt causing infection and preventing healing.
In factitious disorder and factitious disorder imposed on another, diagnosis
is often difficult and may take years. This problem is not restricted to a particular
culture; Feldman and Brown (2002) identified 122 cases in 24 countries speaking
nine different languages. In factitious disorder, there may be a history of attachment

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IACAPAP Textbook of Child and Adolescent Mental Healthdifficulties and abuse but this is not always the case. In some circumstances there
is a lack of personal resources in the child and a predicament (e.g., major school
failure or abuse outside the family) that is resolved by attention to the fabricatedproblems (Fiertag & Eminson, 2014). Factitious disorder imposed on anotheris a serious form of child abuse that has physical implications for the child (e.g.,
repeated procedures, school absences, serious illness or injury) and psychologicaleffects (e.g., the child may develop a distorted view of their health and may become
anxious about it).

BURDEN
Somatic symptom and related disorders tend to present repeatedly to
primary care practitioners and pediatricians rather than psychiatrists due to thepresenting symptoms being physical and the families tending to attribute thesymptoms to organic, not psychological causes. The medical-seeking behavior thatusually accompanies somatic symptoms often leads to numerous—potentiallypainful or even harmful—medical investigations and treatments before a diagnosis
is made and appropriate management initiated.
Families can be skeptical about the usefulness of a psychiatric or mental
health assessment and may continue to pursue investigation of an organic
pathology. Over-investigation reinforces the belief in the patients and their families
that there is an underlying physical cause. All of this can result in a huge burden
on the patients, families as well as on medical services. Children will miss school toattend multiple appointments and parents may need to take time off work to carefor their child and take them to appointments.

EPIDEMIOLOGY
Little is known about the incidence or prevalence of the different
somatizing conditions. However, the epidemiology of somatic complaints ingeneral, psychosomatic factors, and medically unexplained symptoms is better
documented.

Somatic Complaints, Medically Unexplained Symptoms andPsychosomatic Factors
About 10% of children attending general practitioners or pediatricclinics are reported as having medically unexplained symptoms. However, when
considering all children attending with any kind of physical presentation, where
doctors identify associated or contributing psychological factors, these are seen in
25-50% of cases.
Surveys from different countries have found that approximately one in fourchildren complain of at least one set of somatic symptoms weekly or fortnightly.
The most common are abdominal pain, headaches, and muscular or joint pains.
Recurrent and troublesome somatic symptoms occur in under 10% of children
and adolescents (Garralda, 2005; Rask et al, 2018).

Somatoform and Pain Disorders
Note that these two conditions are now subsumed under the diagnostic
categories of “somatic symptom disorder” and “disorder of bodily distress.”

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The German Early Developmental Stages of Psychopathology Project
documented somatoform disorders in adolescence and young adulthood amongst
a large sample of 14-24-year-olds. It found that 12% suffered during their lifetime
from at least one somatoform disorder. Having a somatoform disorder was linked
to low socioeconomic status except in the case of pain disorder, which was more
likely in those with higher education (Lieb et al, 2000).

Chronic Fatigue Syndrome
In the US the population rate of chronic fatigue syndrome-like symptoms
in children and young people was estimated to be 2%, but the full syndrome ismuch rarer (0.19 % in the UK) (Chalder et al, 2003; Garralda & Chalder, 2005).
There appears to be an uneven distribution of chronic fatigue syndrome acrosscountries with more cases described in Northern and Western countries.

Conversion Disorder
Prevalence rates of conversion disorder across the world is unknown. A
study of Australian children under 16 years of age seen by pediatric specialists witha diagnosis of conversion disorder indicates that it was rare (incidence of 2.3-4.2
per 100,000 children) (Kozlowska et al, 2007). This is supported by a national
surveillance study in the UK that found a 12-month incidence of 1.3 per 100,000
children under 16 (Ani et al, 2013).

Functional Abdominal Pain
In his classical study, Apley (1975) found that 10 % (12% female, 9% male)of children in the general population had at least three episodes of functional
abdominal pain severe enough to affect activity and function over a 3-month
period, though only some of these children were severely affected to the degree
expected in clinical somatoform disorders. Comparable rates have since beenreported in the UK (Vila et al, 2012).

AGE OF ONSET AND GENDER RATIO
Most pain and somatic symptom disorders start in childhood and earlyadolescence. However, conversion disorder tends to arise later, at a median age of
16 years (Lieb et al, 2000). Abdominal symptoms increase in frequency from three
to nine years of age and then steadily increase up to adolescence. Headaches areless common in preschool than in older children or in adolescents. In females, pain
disorder has an age of onset 11 to 19 years, but under 13 years for males.
Somatic symptoms occur more commonly in females than males. Girls
report more symptoms as puberty and adolescence progresses (LeResche et al,2005). In the majority of studies, girls have been found to report symptoms atincreasing rates during adolescence, whereas reporting levels by boys of somesomatic symptoms (e.g., abdominal pain) fall during this time (LeResche et al,2005).
Although this is the general age and gender pattern, there are variations
across types of somatizing. Puberty has also been found to be a more important
marker than age alone. Karin et al (2011) found that pubertal status was associatedwith some, but not all, functional somatic symptoms, suggesting that biologicalfactors are differentially involved in the etiology of somatizing.

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ETIOLOGY
A variety of individual, family, biological, and environmental factors havebeen proposed as predisposing, precipitating, or perpetuating in somatizing
disorders. However, which factors are relevant will vary in each individual case,and none of these factors are on their own necessary or sufficient to trigger sucha presentation. Each individual will have their unique vulnerability factors;
understanding this is vital when tailoring individual management plans (Rask etal, 2018).

Individual Factors
Individuals with a sensitive, conscientious, anxious temperament are more
vulnerable to developing somatizing symptoms. Those with a history of anxiety
and emotional lability are also at increased risk. Precipitating factors may include
social stressors, such as harsh comments on school work or relationships, and may
be evidenced by a temporal link between these stressors and the developmentof symptoms. Stressors on the child may not objectively be particularly severe;
however, in combination with a sensitive and anxious temperament, they may
be perceived in a more extreme way and be sufficient to precipitate an episodeof illness. Even common life events may play a role. For example, preschoolers
with frequent somatic symptoms have been found to experience an excess ofordinary life events (e.g., birth of a sibling) in comparison to children without
somatic symptoms. Careful consideration should also be given to whether there isindication of other stressors, such as abuse or school stress, impacting on the child.
Previous abuse may also predispose or precipitate an episode of illness, although
this seems to be more of a risk factor for adults than for young people.
Maintenance of somatizing symptoms may be mediated by personal traits
in the child (e.g., hypersensitivity, anxiety) and the child having subsequentdifficulties adjusting to everyday issues due to these emotional and temperamental
factors.
Table I.1.3

Individual

FamilyEnvironment

Risk factors for somatization in children andadolescents*
•
•
•
•
•

Personal experience of physical illness
Enhanced focus on physical sensations
Conscientious, vulnerable, sensitive, anxious personalities
Particular concerns about peer relationships
High achievement orientation

•
•
•
•
•

Physical health problems
Mental health problems
Parental somatization
Emotional over-involvement
Limitations in the ability to communicate about emotional
issues••Life stresses e.g. school, teasing or bullying,
Academic pressure.

* Adapted from Gledhill & Garralda (2009)

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9IACAPAP Textbook of Child and Adolescent Mental HealthFamily Factors
Families with prominent anxiety, over-protectiveness, emotional overinvolvement, and high levels of maternal distress may predispose a child todevelop somatizing symptoms. In families where there are health problems, thechild’s unexplained medical symptoms may mirror other family member’s illnesses(e.g., loss of mobility in a child may occur in a family where a parent has sufferedparalysis through an accidental injury). In addition to this, if there are physicalhealth problems or somatizing illness in family members, or frequent medical
health-seeking behavior within the family, this may contribute to the child’s
symptoms through attention being given to this type of behavior and through the
behavioral learning mechanism of modelling.
Parental ill health (physical, somatizing, or other psychiatric symptoms),
chronically stressful situations (e.g., marital disharmony, ongoing schooldifficulties) may be associated with the maintenance of unexplained or recurrent
symptoms in the child. Parental distress about the child’s symptoms and frequent
reporting of these symptoms are likely to increase attention to them, reduce theuse of alternative coping strategies, such as distraction, and reinforce the child’s
behavior in experiencing and reporting the somatizing symptoms. Parents ofchildren with somatizing illness tend to be less punitive, disappointed and angry
in their responses to their child’s complaints, compared to the parents of children
who do not experience recurrent somatizing symptoms. This type of parenting
style may contribute to perpetuating the illness. Family beliefs may be dominatedby thinking there is an underlying organic cause and, if the families do not consider
psychological explanations, they may be resistant to psychosocial treatment,
increasing the likelihood of the persistence of somatizing symptoms.
The effect of somatisation in a child is likely to impact on the dailyfunctioning of the wider family unit as well as the child. For example, it may
result in parents having less leisure time or having to take time off work with thesubsequent financial implications. Families may need to reorganize themselves intheir activities of daily living to accommodate caring for the sick child, which may
increase overall family tension.

Biological Factors
In some cases, somatizing disorders may appear to follow a recent physicalillness (e.g., gastroenteritis being followed by severe functional abdominal pain;
glandular fever being followed by chronic fatigue syndrome; physical injury
preceding loss of function of a limb in conversion disorder; fainting episodeoccurring prior to developing pseudo-seizures).
Genetics have been found to play a role in sensitivity to pain and otherbodily sensations. Diatchenko et al (2005) found that the experience of pain is
influenced by the heritable polymorphism in the catechol-O-methyltransferase(COMT) gene. A genetic basis has been suggested for the relationship between
depression and life adversity (Caspi et al, 2003) and functional somatic symptoms(Yeo et al, 2004; Campo 2012).

Environmental Factors
Concerns about school in terms of academic pressure, peer problems,
relationship with teachers and, in particular, bullying are common in children

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IACAPAP Textbook of Child and Adolescent Mental Healthwith somatizing symptoms and may be predisposing or precipitating risk factors.
Children with somatizing symptoms often are particularly sensitive to social
interactions and may have high educational expectations. They may express theirconcern as an inability to perform educationally because of their symptoms, school
absence making them worse. They often feel embarrassed, angry and misunderstood
as well as sensitive about assumptions from others that they are trying to missschool. These concerns often lead to non-attendance and once they have stopped
attending the child may become very anxious at restarting, which may maintainthe problem (see Table I.1.2).

ASSESSMENT
Consider somatic symptom and related disorders when the following arepresent:• There is a time relationship between psychosocial stressor and physicalsymptoms• The nature and severity or handicap from the symptom are out of
keeping with the pathophysiology• There is a concurrent psychiatric disorder.
The primary care doctor is likely to be the first port of call for most children.
Usual assessment, investigations, and reassurance that there is no treatable medical
condition by the family doctor will often relieve enough concerns for the child to

The Sick Child. Edvard Munch (1885), the Munch Museum, Oslo.

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IACAPAP Textbook of Child and Adolescent Mental Healthimprove and to ensure an adequate level of functioning, without need for further
intervention. However, sometimes symptoms persist.
Children and families with frequent, persistent symptoms and high anxiety
levels about them may be referred to a specialist pediatric or medical service.
Because of the nature of these problems, assessment at this stage needs to takeparticular note of both physical and psychosocial contributory and maintaining
factors. The best approach is to use a bio-psycho-social framework, whereby
the relative contribution of biological, psychological, family and social factors is
considered. However, if the symptoms persist even after this level of assessment
and intervention, which includes targeting the identified biopsychosocial factors,
or if the symptoms are particularly severe, or if there is diagnostic uncertainty, thechild should be referred to a mental health service.
Referral to mental health services needs to be done in a sensitive mannerwith acknowledgement of the symptoms, as many children and families fear thatthey are not being taken seriously, and that referral to mental health services means
their symptoms are not believed to be real. During the mental health assessment,
ascertaining the child and parental views of the illness is extremely important. Many
parents may still be pursuing organic causes; therefore, it is important to address all
the physical symptoms, find out what medical disorders have been excluded, explore
possible physiological explanations, and be aware that physical and psychologicalcauses can coexist. Psychiatric assessment should include developmental andpsychiatric history, mental state and family functioning. Psychometric assessments
may be helpful especially in determining if there is a disparity between the child’s
educational expectations and actual abilities. A detailed school history is needed
including days missed off school because of the symptoms.
Parents’ Perspective of a Child Presenting With Co-Existing Somatising and Physical Illness
Sarah had a sudden and complete loss of movement in her arms and legs and headaches. She was diagnosed withconversion disorder despite the presence of an operable brain tumor. All her symptoms resolved following a joint medical
and mental health intervention prior to surgery – the surgeons were not prepared to operate until all symptoms had resolved,
which fortunately they did, and fully. Below is a quote from her parents:“Our daughter was approaching her 15th birthday and seemed to be enjoying life. She had plenty of friends, was doing
well at school and displayed a wide-ranging and vivid enthusiasm for learning and playing. After a family holiday in a foreigncountry came complaints of severe back pain. This developed into intermittent headaches and an inability to move her arms
and legs. Upon admission to hospital it was clear that some of her symptoms did not have a physical origin. This did notmean that the problem was less real, only more problematic.
We were at a loss as to what may have triggered this behavior. There were none of the obvious causes; a grandparent
had died but some years previously and of reasonably old age, and there was no evidence of abuse or trauma. All we wereleft with were the concerns that are peculiar to puberty and adolescence, which are not part of the open discourse between
parents and children. So, we were standing on the edge of a half forgotten sea, half remembered from our own adolescencebut unknown with this individual and at a loss as to how it could relate to these symptoms.
It ought to be stressed that there was huge support from the medical team. Our daughter had physiotherapy, frequent
reviews from the pediatric team and numerous interviews with the child psychiatrist. Her life was explored from a
psychological, family and social perspective. Eventually a physical event was found: a brain tumor. This diagnosis led to a
rapid mitigation of symptoms. It is possible − or probable − that the diagnosis of a physical illness gave her a face-saving
way to retreat from her symptoms. What is sure is that her symptoms served a purpose. Certainly, we started the processwith symptoms and no physical cause and we ended with a physical cause but no symptoms; a strange sequence.”
This example illustrates the complexities of many of these disorders and the fact that a diagnosis such as conversion
disorder can coexist with a physical illness, where the physical illness is not congruent with the symptoms, and psychosocial
contributory factors are identified on the psychiatric assessment.

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IACAPAP Textbook of Child and Adolescent Mental Health

Even after mental health assessment and intervention has been commenced,
many families of children with somatic symptom and related disorders may beunreceptive to psychological explanations and may want to continue seeking
further investigation of organic pathology. Engaging the family early on in theassessment process and working with them to achieve a common view is vital
before effective treatment can be instituted. Prompt accurate identification andnaming of somatization can improve prognosis, whereas misdiagnosis or delay canlead to negative impacts on the individual’s prognosis, family and societal burden.

CLINICAL FEATURES
The most common somatic symptoms are recurrent abdominal pain,
musculoskeletal pains and headaches, however different symptoms can coexist.

Persistent Pain
Abdominal pain, headaches, joint pains and other aches and pains, mayconstitute somatic symptom disorder with predominant pain when the pain ispersistent, severe, distressing, and occurs in association with psychosocial stressorsthat are sufficient to have etiological significance.
Characteristically, functional abdominal pain presents as a diffuse or periumbilical, intense pain. The pain tends to be worse during the day, is likely not
to occur at night or during school holidays. There may be also altered bowel
habit, vomiting, fever, headache, lethargy, and the child may look pale, which canreinforce family beliefs of an organic pathology.
Headaches are more likely than not to be characterized as tension
headaches (frequent, bilateral, typically frontal, pain like a band) but these cansometimes coexist with migraine attacks (a periodic, severe, unilateral pain with anaccompanying aura, nausea, and family history).

Click on the picture tohear 15 year old Sophie
describe her chronic fatigue
syndrome.

Chronic Fatigue
It is classified in ICD-11 under “disorders of bodily distress” or “post viralfatigue” if it develops following a viral infection. This syndrome commonly starts
with an acute flu-like illness or glandular fever. It can have an insidious onset
and fluctuating course. Chronic fatigue is characterized by physical and mental
fatigue and exhaustion after comparatively minor mental or physical effort. The
fatigue is not relieved by rest and is associated with a decline in the ability tocope with, and withdrawal from daily activities. The child is likely to complainof headaches, sleeping problems, aches and pains, poor concentration, dizziness,
physical weakness, moodiness and worry about decreasing physical and mental
health. The fatigue is chronic and is not related to an ongoing medical illness.
There is often comorbid psychopathology particularly anxiety and depression. The
child’s family may have sought numerous medical opinions and the child may havereceived multiple diagnoses by the time of assessment. The functional impairment
is often prolonged, with marked school absence and lengthy periods of bed rest
(Garralda, 1996, Garralda & Chalder, 2005; Roma et al, 2019).

Conversion Disorder
Also called in DSM-5 “functional neurological symptom disorder,” thiscondition involves partial or complete loss of bodily sensations or movements

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IACAPAP Textbook of Child and Adolescent Mental Healthnot explained by a neurological or medical disease. When this disorder occurs inchildren, loss or disturbance of motor function is the most common presentation.
Psychogenic nonepileptic seizures may also be the presenting symptom. Less
commonly in children, it may present with loss of sight, hearing, touch,consciousness, fugue or mutism. To make a diagnosis, there must be clinicalfindings showing that symptoms are incompatible with neurological illness andtake into consideration the overall clinical picture, not just the symptoms. The
traditional phenomenon of belle indifference, which refers to lack of concern about
the symptoms, is not particularly helpful in diagnosis in children. Symptoms areoften brought on by a traumatic trigger and usually remit after a few weeks ormonths.

Psychogenic Nonepileptic Seizures
These tend to be seen in Western countries and may be more common incertain cultures. Psychogenic nonepileptic seizures are seizures with movements or
convulsions inconsistent with the features of a real epileptic seizure and without
an abnormal EEG. In a review of 883 patients in one pediatric epilepsy clinic,
15% had paroxysmal nonepileptic events. Of these, the rates with pseudo-seizures
were 3% in preschoolers, 43% in the 5-12-year-olds, and 87% in the 12-18 age
group (Kotagal et al, 2002). Psychogenic nonepileptic seizures and epilepsy cancoexist but those with both conditions form a small proportion of the children
with true epilepsy—1.5% of those with true epilepsy according to Kotagal (2002).
The presenting symptoms may be similar to epileptic seizures, leading to delays indiagnosis. Psychogenic nonepileptic seizures can occasionally be part of complex
clinical presentations (e.g., Chandra et al, 2017). Children with psychogenic
nonepileptic seizures are at high risk for psychopathology, particularly depression
and anxiety (Reilly et al, 2013).

DIFFERENTIAL DIAGNOSIS
Symptoms found in somatizing conditions such as physical complaints andschool non-attendance could be an indicator of various underlying psychiatricdisorders. Therefore, it is important to bear in mind the following differential
diagnoses:
•
•
•
•
•
•

School phobia and refusal
Anorexia nervosa
Depressive disorderAnxiety disorders and separation anxiety
Elective mutism
Factitious illness

COMORBIDITY
Comorbid psychiatric disorders may precede the development of somatic
symptoms but often also develop over the course of the somatic symptom disorder.
Among children presenting to services, one third to one half may have a psychiatriccomorbidity. This may be intermittent and, in severe chronic fatigue syndrome,over the course of a year as many as three quarters may experience a depressive or
anxiety disorder.

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IACAPAP Textbook of Child and Adolescent Mental HealthIn school age children, anxiety and depression are the most common
comorbidities. Comorbid ADHD and oppositional defiant disorder may also
be present, especially in boys. In preschoolers, ADHD adjustment disorders,separation anxiety, feeding and elimination disorders may coexist.
The Early Developmental Stages of Psychopathology Study (Lieb et al,2000) showed that, in older adolescents and young people, conversion disorders
were associated with eating disorders and pain disorders were associated withdepression, panic disorder, and post-traumatic stress. Degree of impairment was
shown to increase with increasing comorbidities.
Research diagnostic criteria for conditions such as chronic fatigue syndrome
make the presence of primary mental disorders (e.g., anorexia nervosa) exclusion
criteria. However, somatic symptom disorders and somatizing conditions cancoexist with other psychiatric diagnoses. Somatic symptom disorder is the primary
diagnosis when the following occurs:•

The physical symptoms are more prominent than the emotional or
behavioral ones•

The physical symptoms are the main cause of functional impairment•

There are unwarranted beliefs about the presence of a medical disorderand repeated medical help-seeking behavior.

Somatic symptom disorders can also coexist with organic disorders. If
there is a medical illness, it is important to establish what physical symptoms arecongruent with the organic illness and what are more likely to be attributed to
identified psychosocial stressors.
Differentiating between various potential diagnoses, establishingcomorbidities, and initiating management can be complex, especially in cases
where biological and psychological symptoms coexist. For example, in a child who
has coexisting psychogenic nonepileptic seizures and epileptic seizures.

RATING SCALES AND DIAGNOSTIC INSTRUMENTS
Instruments to measure physical symptoms and functional impairment
can be useful both for assessment purposes and to monitor ongoing progress.
Table I.1.4 Rating scales*
Rating Scale

What does it measure?

Comments

Child Somatization Inventory

35 symptoms and their severity in thetwo weeks prior to assessment

Identifies somatization disorderrelated symptoms and theirseverity

Functional disability in walking, travelling,daily chores, social and leisure activities,
sleeping and eating

Rates the presence and severity ofrelated impairment

Features of physical and mental fatigue

Rates fatigue symptoms

Functional Disability Index

Chalder Fatigue Self-Report
Scale*Click on the name of the scale to access it

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IACAPAP Textbook of Child and Adolescent Mental HealthSymptom diaries tailored to the individual presentation can also be helpful. By
using a symptom diary to document severity and frequency of symptoms overtime, a visual improvement may be noticeable to the patient prior to the subjective
experience of getting better. Visualization may help to maintain therapeutic
optimism and motivation. In addition, the use of scales may help facilitate further
engagement with treatment and rehabilitation. Specific rating scales that may be
helpful include the Children’s Somatic Symptom Inventory, Functional Disability
Index—Fatigue Scale, and the Chalder Fatigue Self-Report Scale (Chalder et al,1993) (see Table E.1.3). It may also be helpful to measure changes in anxiety
and depressive symptoms through appropriate scales, when these symptoms arepresent.

TREATMENT
General Strategies
Following on from assessment, and once physical and psychiatric disorders
have been addressed or excluded, treatment for the somatic symptom disordershould be planned. The first step is to engage the family. The following strategies
may be helpful to facilitate engagement during treatment (many of these strategies
will also be helpful in the assessment stage):• Make an effort to understand the family’s beliefs about the illness, levelof conviction about physical causes, satisfaction with investigations,and views about the mental health referral and treatment• Do not question the reality of the symptoms• Acknowledge that patients have a real illness disrupting their life andimpacting on the family• Investigate alternative explanations for the symptoms• Fully discuss any physical concerns preoccupying the family and theresults of the physical investigations carried out• Discuss fully the physiological mechanisms contributing to symptoms(e.g., contractures secondary to immobilization)• Make families aware of the high prevalence of medically unexplained
symptoms (2-10%). This may reassure parents about the absence of anorganic cause• Do not convey a sense of embarrassment when communicating adiagnosis of somatic symptom and related disorder or other psychiatricdiagnosis• Emphasize that it may take time to recover but the majority of young
people do very well
• Help the family and child develop ways of coping with the symptoms
and reduce functional impairment.

Management Setting
As already mentioned, assessment and initial treatment is typically initiatedby the primary care/general practitioner or pediatrician, and use of the bio-psychosocial framework is encouraged from an early stage. When the symptoms do notrespond to this assessment and intervention, a psychiatric referral should be made. A
psychiatric referral may be particularly helpful when there is diagnostic uncertainty,
if there is a comorbid psychiatric disorder, and when major family problems are

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IACAPAP Textbook of Child and Adolescent Mental Healthaffecting resolution of symptoms. If a psychiatric referral is recommended, theclinician should establish the family’s attitudes towards a psychiatric assessment
and discuss this with the family, addressing their concerns prior to the referral.

Specific Management Strategies
Specific treatments may involve individual psychological work, family
work, liaison with school and with social services. Coordination of all therapists
and professionals involved is vital to ensure everyone is working towards similargoals. Treatment should aim to develop partnerships with the child, family andall professionals involved, including teachers, especially where school attendanceis an issue. Specific strategies will vary depending on the exact nature of thesomatoform disorder (see box on the side for information about specific treatmentin psychogenic nonepileptic seizures).

Click on the picture toview a short presentation
about pseudo-seizures or
psychogenic nonepileptic
seizures (3:53)

The management of factitious disorders is similar to that for somatic
symptom and related disorders. Emphasis on engaging the parents is crucial toreduce the risk of becoming punitive or disengaging when the factitious nature of
the presentation becomes known. Young people with severe factitious symptoms
often live in a family with interpersonal problems, communication difficulties,
and substance misuse, which make family work challenging (Fiertag & Eminson,2014).

Psychological Interventions
The specific psychological treatments and frequency of contact will varydepending on the nature of the disorder. However, certain features will becommon to, and can be effective for all somatic symptoms disorder and somatizing
conditions (Bonvanie et al, 2017). The interventions may be provided by a variety
of professionals such as primary care clinicians, pediatricians, psychiatrists or othermental health workers. Most treatment strategies will involve the following:
•
•
•
•
•

•
•

•
•
•
•
•

Work at a pace the family can tolerate
Emphasize reducing impairment
Use motivational techniques tailored to encourage ambivalent children
Collaboratively find a way to get better that is acceptable to the childUse diaries to monitor variations in symptoms, impairment andprogress. This may motivate the patient and family to engage further
with treatment
Acknowledge that rehabilitation may temporarily worsen symptoms andaddress concerns around thisDevelop techniques to deal with specific symptoms and impairments(e.g., distraction, muscular relaxation for headaches, graded physicalexercise for muscular problems and fatigue, practical management ofpseudo-seizures)
Develop active, problem focused coping strategies and attitudes
Create a goal-based, gradual rehabilitation program with achievable,consistent, and agreed aims
Explore expectations on ultimate goals as they may be unrealisticallyhigh
Encourage sleep hygiene and give dietary advice
Use psychological interventions such as CBT and mindfulness

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IACAPAP Textbook of Child and Adolescent Mental Health•

Use family work to deal with family factors that may be contributing to
the symptoms or interfering with their resolution.

The effectiveness of family-based CBT has been demonstrated for recurrent
abdominal pain. Randomized controlled studies have shown that this helps toachieve greater pain reduction, lower interference with daily activities, fewer relapses,
and increased parental satisfaction (Sanders et al, 1994; Robins et al, 2005). In
chronic fatigue, several adult trials suggest that CBT and graded exercise programs
are beneficial (Whiting et al, 2001) and modifying this CBT approach for children
via involving the family is recommended. There are suggestions also that internet
delivered CBT is effective with adolescents (Crawley, 2018). Examples of specific
CBT techniques are mentioned in the list above and include symptom diaries,
limiting attention to the symptoms, graded exposure to activities, relaxation, andpsychoeducation around the links between physical and psychological pain.

Family Work
It is vital to engage families to facilitate the implementation of an effective
management; therefore, throughout the management process, families need tohave their concerns addressed. Families play a key role in helping the child learn
new coping strategies and in reducing family behaviors that may be reinforcing
the symptoms. Parental psychopathology, family dysfunction, and family stressthat might be contributing to maintaining the child’s difficulties can be dealt within family work. Some family issues may not be apparent in the initial phase oftreatment so regular assessment and adding appropriate intervention as needed isrequired.

Medication
Medication can be considered although no psychotropic drug is licensed
specifically for somatic symptom and related disorders and the available evidence
is limited. Selective serotonin reuptake inhibitors may be helpful if there is anassociated major depression—the majority of children suffering from somatizing
conditions are low in mood or in a state of anxiety at some time in their illness.
Medication can in some children make the rehabilitation process easier toimplement. Occasionally benzodiazepines (keeping in mind their shortcomings)
may be helpful for short term use in treating associated anxiety, for example whilst
waiting for selective serotonin reuptake inhibitors to take effect (Campo, 2008).

School Liaison
Close liaison with school to reduce school related stress and to address
conflicting expectations between the child, family and teachers is important.
Tailoring a school program and setting up strategies to help the child cope withsymptoms within the school (e.g., a reduced timetable) is an important part oftreatment. If psychogenic nonepileptic seizures are a symptom, a clear management
plan that includes ways of reducing their dramatic impact within the school, needs
to be instituted. In severe cases where children have been absent from school, agradual reintegration should be arranged, with consideration of admission to apediatric or psychiatric unit with educational facilities if available.

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Table I.1.5 Elements of Cognitive Behavioral Family Intervention
•
•
•
•
•
•
•
•

Discuss investigations and rationale for pain management
Encourage self-monitoring of pain
Reinforce well behavior
Develop healthy coping skills: relaxation, positive self-talk, distraction, positive
imagery
Teach problem solving skills
Encourage participation in everyday activities
Reduce attention from parents in relation to physical symptoms
Increase attention when symptom free by instituting pleasant joint activities

Hospitalization
Consider hospital admission if:• The child is severely impaired• Observation is needed (e.g., in the case of seizures)• There is significant associated psychopathology• Outpatient treatment has not been successful.
Hospitalization may help break the excessive anxiety and dependence ofthe child on parents and focus on rehabilitation. Specific inpatient interventions
through a multidisciplinary approach may include physiotherapy, diet advice,occupational therapy, family intervention, and more intensive psychological andpsychiatric work.
Young people are usually admitted to a pediatric or psychiatric ward as
joint pediatric and psychiatric wards are rare. Families may be reluctant to allow
psychiatric admission; thus, it is important to discuss their concerns and attitudes
to enable the best possible package of care to be instituted.

Liaison with Social Services
Always consider child abuse and safety issues—the safety of the child must
be the uppermost consideration. In rare instances the somatoform disorder willbe the expression of severe family dysfunction or child abuse. Close cooperationand communication between all the professionals involved are essential to avoid
differing opinions being relayed to the patient and family. If families are unwillingto engage in any type of treatment for the child, clinicians should consider whether
it would be in the best interests of the child to be treated away from the family. Thisis a difficult issue to assess and would require close collaboration between clinicians
and child protection personnel.

Patient Support Groups
These can be helpful sources of support to families. However, some groups
may hold views contrary to the management team recommendations, which may
be unhelpful if they undermine the treatment.

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IACAPAP Textbook of Child and Adolescent Mental Health

Saira
Saira was a 12 year old girl of Pakistani background who had been diagnosed as suffering from epilepsy at the age offive. She had been treated with anti-epileptic medication and had been seizure free for four years. Saira presented to the
local outpatient clinic with a recurrence of her fits. Her earlier convulsions had been grand-mal seizures, mostly occurring
during the night, accompanied by incontinence. Her current episodes were not consistent with epilepsy, were occurring
during the day and were prolonged, lasting half an hour at a time.
A stressor was identified; the family had decided that as Saira had completed her primary school education there wasno need for her to continue with her schooling, she would stay at home to look after her youngest sibling so that her mother
could return to attend to the family’s livestock. A poor harvest meant that the family was under financial stress.
Treatment consisted of psychoeducation for Saira and her family, highlighting the close relationship of the body and themind, and the co-occurrence of physical symptoms with psychological stresses. In individual meetings and later in family
meetings, Saira was able to talk about her distress at the proposed plan, which would result in the loss of her friendships
at school as well as the positive relationships she had with her teachers. Although financial considerations meant that no
immediate change could be made to the planned arrangements, the family agreed amongst themselves to try and support
her in continuing her education once the financial pressures had eased. They were happy to support her in continuing tomeet with her friends. Saira’s seizures subsided soon after.

Effectiveness of Treatment
Although there is some evidence of the efficacy of psychological treatments
for children with somatic symptom and related disorders (Bonvanie et al, 2017;
Rask et al, 2018), there is limited evidence of the effectiveness of treatment in
the more severe somatic symptom disorders. However clinical reports frompediatricians and child psychiatrists support the beneficial effects of the approaches
described in this chapter even for severely affected children.
When pain is an issue, helping patients and families understand the links
between psychological and physical pain tends to be greatly appreciated by themand is thought to be crucial in reducing pain and in helping patients manage
it. The best evidence of effectiveness for unexplained abdominal pain is from
cognitive behavioral family interventions (Robins et al, 2005; Bonvanie et al,2017), which lead to a larger reduction in the level of pain, lower relapse rates, andlessens interference with daily activities as well as increased parental satisfaction.
In chronic fatigue syndrome, there are promising results from the use ofcognitive family interventions and internet delivered CBT (Crawley, 2018). In
adults with this condition, a number of controlled trials have shown CBT and
graded exercise to be beneficial (Whiting et al 2001; Prins et al 2001; Larun et al,2017).
In factitious disorder, particularly when imposed on another, the mainpriority is to make sure the child is safe, now and in the future. Local childprotection procedures need to be adhered to, and cooperative work between
healthcare, social services and police is vital. The therapeutic needs of the child,caregiver and family, including siblings, have to be assessed and addressed (Bass &Glaser, 2014). Treatment should take place in the least restrictive setting possible.
The case of Janine highlights many of the features of assessment andmanagement described in this chapter. In addition, this case illustrates that, when
considering psychiatric referral, it is important to keep in mind that the family
may feel “sent” and not “customers” of therapy (De Shazer, 1985; Iveson, 2002).
Family may attend because they are asked to do so by their pediatrician rather thanSomatic symptom disorders

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IACAPAP Textbook of Child and Adolescent Mental HealthJanineJanine, a 10 year old girl, was referred because of a oneyear history of weekly presentations to casualty for multiple
pains in all joints. Despite extensive investigations, including
X-rays and MRI scans, no organic pathology had been
identified. Janine had been in a plaster cast and wheel chairbound on five occasions despite no fractures being identified;
as a result she had missed a lot of school. At the initial
psychiatric appointment Janine was extremely distressed by:− Severe aches and pains throughout her body (giving thepain a score of nine out of 10)− One year history of bullying (mentioned for the first timeat the assessment)− Weight gain
− Deep sadness at the death of grandfather three years
earlier (“It is as if it has happened yesterday”).
As a result of her aches and pains Janine had missed
a lot of school. Her mother’s believed that Janine hada physical illness yet to be identified and was unhappy
about being “sent” to see a psychiatrist. Both Janineand her mother described not communicating much as“talking makes things worse”. Hence, Janine had remained
silent about the bullying and about her feelings about her
grandfather’s death. Her mother dealt with stress by “burying
her head in the sand” and used alcohol on occasions(following the example of some of her relatives).
The child psychiatrist knew that many people contributed
to Janine’s care, and all needed to be kept in mind. In
addition to the family doctor who had referred her, schoolstaff, emergency room staff and the physiotherapist, allneeded to work together with Janine and her family. In spiteof the family believing that Janine was suffering from a yet
to be discovered physical illness, the child psychiatrist andthe others involved in Janine’s care, worked with Janine andher family in a model that incorporated the psychological,
biological, family and social factors. Janine was offeredindividual therapy sessions using cognitive behavioral
techniques, as well as facilitating emotional expression(including writing a letter to her deceased grandfather),positive self-talk, exploring alternative explanations for her
pain, anger management, problem solving skills, relaxation
exercise, and distraction when in pain. Alongside this, family
sessions were arranged to encourage Janine’s mother toreinforce well-behavior, to spend time helping Janine copewith stress, to problem solve with Janine, to have non-pain
based talk with Janine, and to learn how to assess theseriousness of symptoms.
Soon after the first session, the previous weekly
attendance to the emergency department stopped.
Therefore, unnecessary use of medicines and procedures
ended. When Janine was asked what had changed since
starting treatment, she described that she had acquired anemotional language. She felt safe to speak to people about
her fears about bullying and said she knew that talking was
helpful as her aches and pains had got “half better”. Writing
a letter to her late grandfather as if he were still alive, about
how much he had meant to her, helped her grief. She said
that her aches and pains got better because “I had done
activities more often”. She was able to keep going “despite
the pain” and she started to enjoy physical activities again,
helped by using the distraction and relaxation techniques
she had learnt. She said she was accepting “a bit of pain”,
which went away after a day following exercise. Janine’s
mother added that exercise had kept her joints working eventhough it hurt her. She spoke about how they had turned theTV off, started talking and playing together.

believing this is the right thing to do, potentially resulting in feelings of rejection
and anger towards the doctor for being asked to see a mental health professional. In
relation to management, this case illustrates that treatment not only helps children
and their parents manage the symptoms better, but also to communicate more
effectively about psychological matters.

PROGNOSIS
Reassuringly, the majority of children with somatic symptom and relateddisorders seen in specialist services recover in the short term. However, symptoms
can persist and some patients develop psychiatric disorders subsequently (e.g.,eating disorders or anxiety disorders). Symptoms may continue into adulthood.
In chronic fatigue syndrome, the majority of even those markedly affected
eventually make either a complete recovery or improve sufficiently to lead nearnormal lives (Rangel et al, 2000). Nevertheless, school absence may last longer
than a year and it may take more than three years for full recovery. Additionally,

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IACAPAP Textbook of Child and Adolescent Mental Healththere are indications that, after recovery, sufferers have a greater likelihood ofdeveloping further psychiatric disorders (Garralda & Chalder, 2005).
Similarly, a study of childhood conversion disorder showed that, eventhough 85% had recovered, a third had a mood or anxiety disorder at four years
follow-up (Pehlivanturk & Unal, 2002).
Indicators of favorable outcome include:• Specific medical precipitants• Good premorbid personality• Good parental psychiatric adjustment• Favorable social circumstances.

PREVENTION
Childhood somatic symptom disorders are associated with a history ofsomatic symptoms in the family and with school non-attendance in the child. A
tendency to somatize can be observed in children as young as preschoolers andthroughout childhood, adolescence and adulthood. Therefore, identifying families
with high levels of somatic symptoms in the parents as well as the children, andidentifying those with frequent school absences, may provide an opportunity forearly intervention. This could be done via (i) primary care practitioners identifying
parents who regularly attend with somatic complaints and providing guidance
regarding strategies for coping with their own and their children’s somatic
symptoms (e.g., distraction techniques) and (ii) teachers and medical professionals
identifying children who miss a lot of school because of physical symptoms andsupporting them in developing coping strategies and feel in control of situations
they find difficult. In children with established symptoms, addressing personality
vulnerabilities and excessive academic and behavioral expectations may help
prevent relapse.

CROSS CULTURAL PERSPECTIVES
Traditionally it was thought that somatic symptom disorders occurred mainly
in non-Western countries. However, more recent research has identified them asa universal phenomenon. A WHO study looked at somatization presentations inprimary care in 14 countries (Turkey, Greece, Germany, The Netherlands, Italy,
India, Nigeria, China, Japan, France, Brazil, Chile, the UK and USA) and foundthat somatization symptoms were common across all these countries and frequently
associated with comorbid depressive and anxiety disorders (Gureje et al, 1997).
A cross cultural perspective is particularly important in the evaluation ofsomatic symptom disorders in terms of how symptoms are understood by thefamily in the context of their cultural beliefs:•

Although headaches, musculoskeletal pains and abdominal pains are
the most common symptoms in somatic symptom disorders overall,there are culture- or geographic area-specific symptoms. For example,“numbness” and “feelings of heat” in Africa, “burning hands and feet”
in India, and “fatigue” in Western countries•

Awareness of the cultural influence on how symptoms are understoodor described is important because certain symptoms may be an

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Kofi
Kofi is an 8 year old boy from a Nigerian family who presented with abnormal movements
affecting all his limbs. At the same time he would suddenly stop responding to questions fromothers, make scary noises, sometimes stare at his family in a frightening way and he evenattacked his family occasionally. The abnormal movements and associated behaviors lasted
about 20 minutes at a time. His maternal grandmother suffered from generalized tonic-clonicseizures.
The family were concerned that he may be suffering from epilepsy but were equallyconcerned that Kofi’s disturbed behavior resulted from being possessed by evil spirits. The
family described Kofi as being cursed after an elderly man in their community had looked at
him with an evil eye. They were keen to consult with a priest to perform an exorcism.
Psycho-social stressors included financial difficulties, housing problems, parental
separation, peer relationship difficulties at school, poor school attendance and Kofi
experiencing symptoms of anxiety.
Kofi’s difficulties resolved with interventions involving the family, medical consultation to
exclude seizures (including EEG), help with housing and financial support, liaison with thepriest to ensure religious rituals did not harm the child and, finally, meetings with the school tosupport Kofi’s attendance and reintegration with peers.

accepted mode of expression of cultural or religious activities in somesocieties; thus, they may be interpreted as a sign of spiritual or othernon-medical process. This may result in families seeking help fromalternative medicine practitioners or healers instead of, or in addition
to medical practitioners. In cases where medical help has been sought,these patients are more likely to disengage from a traditional medical
approach.
It is important to address family attitudes and beliefs about the symptoms
within the appropriate cultural context, find out what interventions have alreadybeen tried, including culture-specific interventions, and spend time with them
discussing alternative explanations and engaging them in the treatment process.
The case of Kofi (see case vignette) is an example of this. However, the culturaldifferences in the interpretation of symptoms, the broad types of etiological stressors(e.g., everyday school stressors such as bullying, or everyday family stressors such as
financial problems) are comparable across cultures (see the case of Saira).

Barriers to Implementation of Evidence-Based Medicine in Low
Income Countries
A number of barriers to the implementation of evidence-based practice forchild and adolescent mental health problems have been described in the context of
low-income countries (Knapp et al, 2006; Keiling et al, 2011) and are of relevancefor the management of somatic symptom disorders. Low-income countries
allocate a proportion of their gross domestic product to health but, as this is low,
the allocated resources are considerably fewer than the need. There is, moreover,little government funding available for professional regulation, allowing healthcare
providers to offer treatments with limited or no evidence, without fear of challenge
or withdrawal of their registration. In the absence of comprehensive governmental
provision of care, patients and families need to self-fund their treatment. Poverty
and lack of knowledge makes them vulnerable to unregulated providers.

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The medical and nursing brain drain from low- to high-income countries has
meant that there are insufficient human resources to meet the local needs for healthprofessionals. Those remaining are often not trained in using audit to improve careor in critically evaluating available evidence. In addition, low-income countries
often do not have a well-developed and comprehensive primary healthcare system,and there is poor integration of mental healthcare within primary healthcare,leading to fragmentation of care.
Of direct relevance to somatic symptom disorders, there is a paucity of
trained professionals to meet the mental health needs of children and adolescents,
and barriers to care include poor identification and lack of specialized personnel.
Hence attention needs to be focused on the training and supervision of professionals
who are usually the first port of call for families, such as primary care physicians
and pediatricians.

••

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CONCLUSION
Recurrent, unexplained physical symptoms are common in children andadolescents. When severe, impairing, related to psychological factors, and if they
result in frequent medical help-seeking behavior, they form the basis of somatic
symptom disorders. In these cases, families tend to attribute the somatic symptoms
to underlying physical pathology despite absence of medical evidence for this. In
some cultures, families may explain the physical symptoms in religious or culturally
specific ways.
Psychiatric comorbidity commonly occurs and this, together with thechild’s personality traits, family health problems, family response to the symptoms,
and problems in communicating effectively about emotionally-laden issues, may
contribute to the maintenance of the disorder.
Medical examination and investigations, recognition of parental and childattitudes to the symptoms and strategies to help reduce impairment, are central tosuccessful management. Psychiatric treatment of comorbidities and instituting achild and family rehabilitation program are required.
The best evidence of efficacy comes from the use of family CBT. However,helping families communicate about, and manage stressors for the child is often
clinically efficacious. Engaging families during every step of assessment andtreatment is important and will aid recovery.
The lack of pediatric mental health facilities may impede this work indeveloping countries with low levels of investment in child mental healthcare,but psychoeducation by primary healthcare workers and educators may still bean effective means of preventing and managing these disorders across different
countries and cultures.

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