Headache, Stomachache, Backache, and Morning Fatigue Among

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ARTICLE Headache, Stomachache, Backache, and Morning Fatigue Among Adolescent Girls in the United States Associations With Behavioral, Sociodemographic, and Environmental Factors

Reem M. Ghandour, MPA; Mary D. Overpeck, DrPH; Zhihuan J. Huang, MB, PhD, MPH; Michael D. Kogan, PhD; Peter C. Scheidt, MD, MPH

Background: Data on the prevalence and co- headaches, 20.7% report stomachaches, 23.6% experi- occurrence of multiple somatic symptoms among US ado- ence back pain, and 30.6% report morning fatigue at lescent females as they are influenced by sociodemo- the rate of more than once a week. Co-occurrence of graphic, behavioral, and environmental factors is limited. somatic complaints is common. Among girls who experienced headaches more than once a week, 3.2 million Objectives: To describe the health status of adoles- (53.3%) also reported stomach pain more than once a cent US females measured by the prevalence, frequency, week and 4.1 million (74.3%) reported morning fatigue and co-occurrence of headache, stomachache, back- more than once a week. Heavy alcohol use, high caf- ache, and morning fatigue and to investigate associa- feine intake, and smoking cigarettes every day were tions between selected risk and protective factors. strongly associated with all symptoms, while parent and teacher support served as protective factors. Design, Setting, and Participants: School-based, cross-sectional, nationally representative survey of ado- Conclusions: Somatic complaints of headache, stom- lescents in the 6th through 10th grades in the US. Data achache, backache, and morning fatigue are common collected between 1997 and 1998. among US adolescent girls and co-occur often. Effective clinical treatment of this population requires compre- Main Outcome Measures: Prevalence of headache, hensive assessment of all female adolescents presenting stomachache, backache, and morning fatigue. with seemingly isolated somatic complaints.

Results: Among US adolescent girls, 29.1% experience Arch Pediatr Adolesc Med. 2004;158:797-803

EADACHE, STOMACH- iors.2,3,17-21 Social and institutional support ache, backache, and measures may capture the protective role morning fatigue are fre- of peer, teacher, and parental support as quently reported so- well as risks associated with being bul- matic complaints among lied.3,19,20,22 Research has also shown po- childrenH and adolescents.1-7 Studies of this tential biological links between some population in the United States, Israel, and health behaviors and the 4 symptoms in Scandinavia show that, compared with question. For example, the relationships boys, girls report higher prevalence of these between headache, stomachache, and back symptoms.2-9 Furthermore, at least 1 non- pain and health behaviors such as caf- representative US study and 1 Icelandic feine consumption, heavy alcohol use, and survey indicate that girls are at greater risk smoking have been documented, but as- From the Offices of Women’s for experiencing symptoms concur- sociations with other symptoms and be- Health (Ms Ghandour) and rently.4,6 For all adolescents, the experi- haviors need further investigation.3,19,23,24 Data and Information ence of chronic pain may have long-term The disproportionate rates of symp- Management, Maternal and effects and contribute to functional limi- toms experienced by adolescent girls, in con- Child Health Bureau tations, adversely affecting school atten- junction with the potentially detrimental (Drs Overpeck, Huang, and dance, development of healthy social re- effects of these symptoms on social devel- Kogan), Health Resources and lationships, and participation in a variety opment, including social phobia, separa- Services Administration, 10-16 25 14 Rockville, Md; and National of developmental experiences. tion anxiety, and social withdrawal sug- Institute of Child Health and Factors associated with somatic gests the need for a better understanding of Human Development, National symptoms include the following: socio- the nature, extent, and possible causes for Institutes of Health, Bethesda, demographic characteristics, social and in- frequent somatic symptoms among this Md (Dr Scheidt). stitutional support, and health behav- population. This investigation describes the

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©2004 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/25/2021 health status of US adolescent females as measured by the plaints and the predictors were tested using the ␹2 test. The in- prevalence, frequency, and co-occurrence of 4 somatic dependent variables in the logistic regression models were ex- symptoms and explores associations with psychosocial and amined for evidence of multicollinearity and interactions with environmental factors. grade, race/ethnicity, and mother’s educational attainment. All final analyses were weighted to be nationally representative. METHODS RESULTS SAMPLE Table 1 presents the overall prevalence of headache, stom- Between 1997 and 1998, the National Institutes of Health, Na- achache, backache, and morning fatigue among US girls tional Institute of Child Health and Human Development con- in grades 6 through 10. Within this population, about one ducted a school-based, cross-sectional, nationally representa- third experienced headaches or morning fatigue more than tive survey of adolescents in grades 6 through 10 as part of the once a week, one fifth reported stomachache more than multicountry Health Behavior of School-aged Children study. 26 once a week, and almost one quarter experienced back- Study design and protocols are discussed elsewhere. Schools ache more than once a week. Almost 40% of the girls re- were selected to ensure nationally representative estimates for each grade and classes were selected from the target grade using ported stomachache about once a month, while more than simple random sampling. All students in a selected class were one third reported morning fatigue about once a week. Only asked to participate with active parental and student consent. one fifth of the respondents reported rarely or never ex- Seventeen thousand students responded, resulting in a partici- periencing headaches or stomachaches and only 7% re- pation rate of 83%. If records were missing for key variables (eg, ported rarely or never experiencing morning fatigue. age or sex) or had more than 75% missing responses, the re- Race and ethnicity was not significantly associated cords were dropped according to the study protocol require- with the prevalence of reported symptoms, with one ex- ments (n=835). Records were excluded if the participant’s grade ception. Non-Hispanic black girls were significantly more was out of the target range, if the participant’s age was outside likely than other girls to report stomachaches more than of the 99th percentile for the grade (n=440 students), or if either once a week. Girls whose mothers had not graduated from the participant’s grade or age was unknown (n=39). The resulting analytic sample was 15686 students in grades 6 through 10, high school were also at higher risk for frequent head- including 8370 girls. For the 4 dependent variables, headache, aches (34.5%; 95% CI, 31.5-37.5) and stomachaches stomachache, backache, and morning fatigue, a range of 13 to (27.6%; 95% CI, 25.6-29.6) compared with those whose 120 records were excluded for each variable owing to missing mothers had at least completed high school (Table 2). data resulting in a final analytic sample of 8250 girls, represent- There was a consistent and significant relationship being 10360601 US girls in grades 6 through 10. tween grade and symptom prevalence. Morning fatigue 4 times or more a week increased from 26.9% among sixth VARIABLES graders (95% CI, 24.5-28.3) to 36.5% among 10th graders The 4 dependent variables were measured by asking how of- (95% CI, 34.3-38.6). More girls also reported experienc- ten a student experienced any of the symptoms in the last 6 ing backache and stomachache once a month with each in- months: rarely or never, about once every month, about once creasing grade level, with the exception of the 10th grade. every week, more than once a week, or about every day. The 5 The prevalence of stomachache reported once a month in- categories were compressed to 4 levels for this analysis with creased from 30.5% (95% CI, 29.0-32.0) in sixth grade to the responses for more than once a week and about every day 40.8% (95% CI, 39.1-42.4) in 10th grade (Table 2). being combined; the resulting composite category was labeled Co-occurring symptoms were common. About one “more than once a week.” Social and institutional support was third of the girls who reported experiencing headaches more assessed using 3 composite variables: parent support, teacher support, and student support, and frequency of bullying ex- than once a week also reported experiencing at least 1 of perienced during the past school term. Health behavior mea- the other 3 symptoms at least once a week or more. Among sures included the frequency of alcohol use in the past 30 days, girls reporting stomachaches more than once a week, about particularly binge drinking defined as 5 drinks or more con- 40% also reported experiencing backaches or morning fa- sumed consecutively on more than 3 days in the past month; tigue once a week or more while more than 40% of those smoking; caffeine intake (including both coffee and soda); and with backaches more than once a week reported either head- physical activity as measured by participation in nonorga- aches or morning fatigue once a week or more (Table 3). nized sports. Sociodemographic characteristics included grade, Multivariate analyses in Table 4 indicated that very race/ethnicity, and mother’s educational attainment. low levels of support, particularly from parents and teach- ers, were associated with higher risk for the 4 symptoms STATISTICAL METHODS studied. Students who reported very low levels of paren- Statistical analyses were performed using SUDAAN and SPSS tal support were 1.4 times (95% CI, 1.0-2.0) more likely software.27,28 Principal components analysis and correlation ma- to experience headaches and 1.5 times (95% CI, 1.1- trices (including varimax rotations29 and scree plots30) were used 2.0) more likely to report stomachaches once a week or to determine the selection of variables for inclusion in the com- more while students reporting very low teacher support posite parent, teacher, and student support variables. SUDAAN were 1.9 times (95% CI, 1.3-2.9) and 1.8 times (95% CI, was used in all statistical analyses to obtain standard errors and 1.3-2.5) more likely to experience stomach and back pain, 95% confidence intervals (CIs) that account for the complex multistage design. Methods of analysis included univariate de- respectively, compared with students with high sup- scriptive analyses, bivariate comparisons, and multiple logis- port. Prevalence data support these findings, with higher tic regression controlling for all predictors and grade level, race/ levels of perceived support from peers, parents, and teach- ethnicity, and mother’s educational attainment. The significance ers generally associated with reduced incidence of fre- of the bivariate relationships between the 4 somatic com- quent symptoms, particularly for stomachaches and back-

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No. of Participants No. of Participants Weighted Symptoms Sampled Weighted Frequency, % SE Headache More than once a week 2383 2998916 29.1 0.71 About once every week 1956 2473908 24.0 0.80 About once every month 2277 2833849 27.5 0.62 Rarely or never 1706 2007881 19.5 0.63 Stomachache More than once a week 1697 2129369 20.7 0.77 About once every week 1688 2230386 21.7 0.79 About once every month 3179 3893235 37.9 0.72 Rarely or never 1736 2026843 19.7 0.54 Backache More than once a week 1915 2421378 23.6 0.53 About once every week 1097 1326528 12.9 0.62 About once every month 1916 2375989 23.2 0.76 Rarely or never 3361 4139541 40.3 0.81 Morning fatigue More than once a week 2529 3165374 30.6 0.85 About once every week 2959 3733891 36.1 0.68 About once every month 2217 2709084 26.2 0.75 Rarely or never 652 742603 7.2 0.46

*Weighted percentage based on sample design for estimates.

aches. The proportion of girls reporting a backache once larly high risk for headache, stomachache, backache, and a week or more decreased from more than 50% with very morning fatigue. While other studies have documented the low levels of teacher or parent support to fewer than one high prevalence of these symptoms among adolescents and third with high levels of perceived support (data avail- girls in particular, few have pursued a gender-specific analy- able on request). Girls who drank alcohol were more likely sis of multiple co-occurring symptoms.1-7,31 Adolescent fe- to experience stomachaches (adjusted odds ratio, 1.2; 95% males who report experiencing one symptom more than CI, 1.0-1.5) than nondrinkers, while girls who reported once a week often experience at least one other symptom high caffeine consumption were 1.4 times more likely to at the same frequency rate. Among girls who experienced report headaches, stomachaches, and backaches com- headaches more than once a week, 3.2 million (53.3%) also pared with those who consumed lower levels. Teens who reported stomachaches more than once a week and 4.1 mil- smoked were about 1.5 times more likely to report all lion (74.3%) reported morning fatigue more than once a symptoms compared with nonsmokers. A dose- week. The high prevalence of these somatic symptoms ex- response was also observed between the prevalence of perienced alone and concurrently could have important im- frequent symptoms and the increasing levels of sub- plications for this population’s daily functional status and stance use and caffeine consumption. For example, the clinical treatment. prevalence of stomachache once a week or more in- This investigation found a generally positive asso- creased from one third among nondrinkers to almost two ciation between grade level and symptom frequency or thirds among binge drinkers. Caffeine intake demon- intensity. Age effects reported for the prevalence of so- strated a similar pattern with the proportion of frequent matic symptoms vary by complaint and symptom fre- headache sufferers increasing 30 percentage points be- quency in previous studies. Other studies found a strong tween low- and high-caffeine consumers (data available association between increased age and the prevalence of on request). Bullying experienced at least once a week backache,19,32 while Egger et al4 found no age effects for increased the risk for all symptoms. Bullied girls were 1.4 headaches, stomachaches, or musculoskeletal pains. In times (95% CI, 1.1-1.8) more likely to report headaches this study, significant grade-level effects were observed and 1.3 times (95% CI, 1.1-1.6) more likely to experi- primarily for symptoms occurring at least weekly and in ence backaches once a week or more compared with girls some cases monthly, possibly capturing the onset of men- who were not bullied. Prevalence estimates supported struation and associated symptoms.33-36 The variance in these findings with three quarters of the girls who expe- age effects observed in previous studies may be attrib- rienced bullying at this rate also reporting morning fa- uted to different sample sizes, age groupings, and study tigue (data available on request). No evidence of either designs. Further research is needed to determine the ex- multicollinearity or interactions were found in the mul- tent to which somatic complaints can be explained by tivariate models. pubertal developments such as menstruation. Future research on the relationship between age and COMMENT somatic complaints may need to consider the degree to which observed age effects are potentially a reflection of This first national study to report on multiple somatic com- girls’ increasing participation in risky health behaviors and plaints indicates that US adolescent females are at particu- reduced involvement in protective activities. A study

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©2004 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/25/2021 Table 2. Weighted Proportions of US Girls Reporting Symptoms: Demographic Characteristics*

Race/Ethnicity Grade Non- Non- All Hispanic Hispanic Native Girls 6th 7th 8th 9th 10th White Black Hispanic Asian American Symptoms (N = 8370) (n = 1500) (n = 1445) (n = 1817) (n = 1929) (n = 1679) (n = 4714) (n = 1501) (n = 1690) (n = 351) (n = 114) Headache† About once 27.5 (0.6) 27.6 (1.8) 28.1 (1.6) 27.7 (1.3) 27.8 (1.5) 26.2 (1.1) 27.0 (0.9) 29.6 (1.6) 26.0 (1.2) 31.4 (3.3) 30.5 (5.0) a month About once 24.0 (0.8) 21.2 (2.2) 24.4 (2.1) 24.5 (1.7) 23.9 (1.2) 25.9 (1.3) 26.1 (1.0) 19.8 (1.4) 20.5 (1.2) 18.1 (2.2) 24.3 (5.9) a week More than once 29.1 (0.7) 28.3 (2.0) 24.7 (1.6) 29.3 (2.0) 32.0 (1.2) 30.7 (1.4) 29.3 (0.9) 27.9 (1.7) 30.2 (1.4) 25.1 (2.8) 32.5 (6.3) a week Stomachache About once 37.9 (0.7) 30.5 (1.5) 36.8 (1.6) 39.8 (1.5) 41.0 (1.3) 40.8 (1.7) 38.5 (0.9) 38.3 (1.5) 34.1 (1.3) 40.8 (4.3) 35.0 (5.5) a month About once 21.7 (0.8) 21.9 (1.8) 22.0 (1.7) 22.5 (1.2) 21.7 (1.3) 20.5 (1.2) 22.9 (0.9) 18.6 (1.6) 20.0 (1.2) 19.6 (3.6) 27.6 (5.6) a week More than once 20.2 (0.8) 23.9 (2.4) 21.1 (1.4) 18.4 (1.6) 20.7 (1.7) 19.5 (1.3) 18.9 (0.8) 26.4 (2.0) 23.6 (1.4) 16.1 (2.5) 20.6 (4.8) a week Backache About once 23.2 (0.8) 16.5 (1.5) 23.0 (1.6) 25.9 (1.3) 25.6 (1.3) 24.30 (1.5) 24.7 (1.0) 20.0 (1.5) 20.9 (1.6) 28.7 (3.4) 23.5 (5.4) a month About once 12.9 (0.6) 10.8 (1.9) 9.4 (0.7) 12.3 (1.7) 15.3 (1.3) 16.5 (1.0) 13.7 (0.8) 10.0 (1.0) 12.9 (1.0) 11.8 (2.4) 19.2 (5.2) a week More than once 23.6 (0.5) 21.5 (1.5) 21.2 (1.9) 22.7 (1.4) 26.0 (1.4) 26.3 (1.5) 23.3 (0.8) 24.8 (1.6) 24.9 (1.1) 17.8 (2.6) 20.8 (4.9) a week Morning fatigue Less than once 26.2 (0.8) 28.2 (2.2) 28.2 (1.8) 27.7 (1.5) 25.7 (1.7) 21.3 (1.7) 24.6 (1.0) 29.6 (1.7) 28.1 (1.7) 29.5 (3.7) 31.2 (6.5) a week 1-3 Times a week 36.1 (0.7) 32.1 (1.6) 38.5 (1.9) 34.7 (1.1) 37.1 (1.7) 37.7 (2.1) 38.3 (0.9) 30.8 (1.9) 34.2 (2.2) 31.2 (3.6) 26.5 (5.4) Ն4 Times a week 30.6 (0.9) 26.9 (1.9) 26.5 (1.8) 30.1 (2.1) 32.6 (1.6) 36.5 (2.1) 31.5 (1.2) 29.7 (1.4) 27.5 (1.9) 29.1 (3.9) 31.4 (5.2)

*Weighted percentage based on sample design for estimates. Data are given as the percentage (SE). †Proportions for each symptom add to 100%, but classifications for “rarely” or “never” are not shown.

Table 3. Proportion of US Girls Experiencing Frequent Multiple Symptoms*

Symptoms Experienced Once a Week or More, Weighted % (95% Confidence Interval)†

Symptoms Headache Stomachache Backache Morning Fatigue Headache More than once a week NA 31.9 (30.6-33.2) 33.5 (32.6-34.4) 36.7 (35.6-37.9) Stomachache More than once a week 46.5 (45.3-47.6) NA 38.4 (37.1-39.8) 40.0 (38.6-41.3) Backache More than once a week 45.0 (43.8-46.1) 36.6 (35.0-38.1) NA 40.9 (39.6-42.1) Morning fatigue Ն4 Times a week 32.9 (32.0-33.8) 24.1 (23.3-25.0) 27.8 (27.1-28.6) NA

Abbreviation: NA, not applicable. *Weighted percentage based on sample design for estimates. †Weighted percentages represent the proportion of students who report experiencing both symptoms once a week or more.

Table 4. Adjusted Odds Ratios for Symptoms Reported by Psychosocial and Behavioral Factors*

Headache Stomachache Backache Morning Fatigue Very low parent support (compared with high support) 1.4 (1.0-2.0) 1.5 (1.1-2.0) 1.6 (1.2-2.1) 1.1 (0.8-1.6) Very low student support (compared with high support) 1.3 (1.0-1.7) 1.1 (0.9-1.5) 1.2 (0.9-1.5) 1.2 (0.9-1.6) Very low teacher support (compared with high support) 1.0 (0.7-1.3) 1.9 (1.3-2.9) 1.8 (1.3-2.5) 1.6 (1.2-2.2) Have experienced bullying at least once a week (compared with no bully experience) 1.4 (1.1-1.8) 1.2 (1.0-1.4) 1.3 (1.1-1.6) 1.3 (1.0-1.6) Alcohol use (any; compared with never drinking) 1.1 (0.9-1.4) 1.2 (1.0-1.5) 1.0 (0.8-1.2) 1.1 (0.9-1.3) Caffeine intake (high; compared with none) 1.4 (1.0-1.8) 1.4 (1.0-1.8) 1.4 (1.0-1.8) 1.2 (0.9-1.5) Tobacco smoking (ever; compared with no smoking) 1.4 (1.1-1.8) 1.4 (1.1-1.8) 1.4 (1.1-1.9) 1.6 (1.2-2.2) Physical activity (nonorganized sports; compared with rarely or never) 1.2 (1.0-1.5) 1.0 (0.8-1.3) 0.8 (0.6-1.0) 1.0 (0.8-1.2)

*Model adjusted for all predictors and grade level, race/ethnicity, and mother’s educational attainment. Data are given as adjusted odds ratio (95% confidence interval).

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©2004 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/25/2021 family connectedness was protective against several risk factors for somatic symptoms including substance abuse, violence, and emotional distress. These findings were ech- Mother’s Educational Attainment oed in studies of 2 high-risk populations: overweight ado- Less lescents and African American girls. Among overweight Than High Some College 41 High School School College Degree adolescents, Mellin et al reported that high levels of fam- (n = 913) (n = 1690) (n = 1760) (n = 2850) ily connectedness were positively associated with better school performance and lower levels of emotional dis- 25.9 (2.1) 26.7 (1.5) 28.8 (1.5) 28.1 (1.4) tress. Among African American girls, Aronowitz and Mor- 19.6 (1.7) 27.1 (1.5) 23.1 (1.5) 24.2 (1.5) rison-Beedy40 found that connectedness with mothers was 34.5 (3.0) 30.0 (1.7) 28.8 (1.6) 27.6 (1.4) associated with fewer risky health behaviors and more positive future aspirations. Similar protective effects have been observed for teacher support.20 These findings sug- 34.5 (2.3) 35.0 (2.1) 42.0 (1.8) 39.4 (1.6) gest that increased parent and teacher support may act 21.5 (2.0) 24.7 (1.3) 18.9 (1.7) 22.0 (1.2) to help reduce risk behaviors shown to be related to health 27.6 (2.0) 21.2 (1.3) 19.7 (1.3) 17.8 (1.2) symptoms among adolescent girls. Additional research is needed to identify effective methods for fostering parent- and school- connectedness within familial and com- 22.6 (1.9) 23.1 (1.8) 24.4 (1.7) 25.0 (1.2) munity structures that may already be overburdened. 12.4 (1.3) 13.3 (1.1) 13.8 (1.2) 12.7 (1.1) Although peer support appeared to play a less pro- 19.3 (2.0) 25.7 (1.6) 23.0 (1.7) 20.9 (1.2) tective role than parental or teacher support in this study, the proportion of girls reporting somatic complaints once a week or more in this study decreased by almost 10% for 24.8 (1.8) 25.3 (1.5) 25.1 (1.6) 27.2 (1.4) all 4 symptoms between those reporting very low levels 33.6 (1.9) 38.5 (1.9) 38.9 (1.5) 35.0 (1.0) and those reporting high levels of peer support. These find- 33.7 (1.8) 30.5 (1.6) 29.2 (1.5) 30.7 (1.6) ings are consistent with those of Natvig et al20 who reported that increasing support from fellow students was associated with decreased risk for somatic symptoms. In particular, Natvig et al observed a protective effect be- reported significant increases in the proportion of girls us- tween student support and depression, a symptom com- ing alcohol and tobacco products between the 8th and 10th monly linked to a range of somatic symptoms in other stud- grades.37 Increased participation in these risky behaviors ies.4,7,18 Additional research is needed to determine whether may be occurring in conjunction with decreased involve- some risk factors for somatic symptoms can be effectively ment in potentially protective behaviors like physical ac- addressed through positive peer networks, and if so, what tivity and activities that foster family connectedness. A re- mechanisms can be used to mitigate the negative effects cent US study found that levels of physical activity decline of poor peer relations associated with bullying. sharply among adolescent girls, with the median activity In this study, girls who experienced bullying at least score decreasing by 83% between the ages of 9 and 10 years once a week were more likely to experience headaches, and 18 and 19 years.38 Physical activity among young people backaches, and morning fatigue compared with girls who has been linked to higher-quality relationships with par- had not been bullied during that term. Previous studies ents, improved academic performance, and a lower preva- have documented the association between bullying and lence of depression.39 This study did not find physical ac- both health behaviors and symptoms.21,43,44 These stud- tivity to be a protective factor for somatic symptoms except ies indicate that while being bullied is associated with backache. This may be owing to the inability to measure difficulty making friends and lower use of alcohol,21 per- total physical activity in the survey. In addition to re- petration of bullying is associated with more time spent duced physical activity, as adolescents age, less leisure time with friends44 and increased use of alcohol and ciga- may be spent engaged in family-related activities. Several rettes.21 This suggests that although adolescents who are studies have found parent-child connectedness to be pro- bullied may be at less risk for adverse health outcomes tective against a range of risk behaviors and conditions as- associated with substance use, they may be at increased sociated with somatic symptoms including emotional dis- risk for somatic complaints associated with poor peer re- tress, suicidal thoughts, violence, and substance abuse, even lationships.3,18 New initiatives such as the US Depart- among high-risk groups.22,40-42 ment of Health and Human Services, Health Resources Social and institutional support from peers and in- and Services Administration’s Stop Bullying Now cam- structors may also have a significant effect on the health paign45 should be evaluated for their efficacy in raising of adolescent girls.19,20,22 In this study, both parent and public awareness and reducing the prevalence of bul- teacher support measures had a more notable association lying. with somatic symptoms than peer support. For both fac- Binge drinking and frequent smoking were signifi- tors, a protective association was observed for most symp- cantly associated with all symptoms. Of note was the simi- toms even at the low and moderate levels of perceived sup- larity in prevalence of frequent headaches, stomach- port (compared with very low). Previous studies have aches, and morning fatigue between girls reporting at least documented the protective effects of parental support in weekly smoking and those reporting less than weekly particular.22,40-42 Resnick et al22 reported that parent- smoking. This suggests that even sporadic smoking may

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©2004 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/25/2021 What This Study Adds to somatic symptoms and, in particular, how stress and depression, may impact health behaviors and outcomes. Several limitations should be noted. The school- Headache, stomachache, backache, and morning fa- based study population excludes high-risk teens not at- tigue are frequently reported somatic complaints among tending school. Students in special education classes were children and adolescents. Studies have shown that girls also less likely to be interviewed. Students with language report a higher prevalence of these symptoms and are at greater risk for experiencing these symptoms concur- difficulties or learning disabilities may have been less likely rently. The disproportionate rates of symptoms experi- to complete the questionnaires. Students who were ab- enced by adolescent girls, in conjunction with the det- sent on the day of the survey may be more likely to have rimental effects of these symptoms on social development, chronic illnesses or have higher risks associated with tru- suggest the need for a better understanding of the na- ancy or other related factors assessed here. Assessment of ture, extent, and possible causes for frequent somatic effects of absenteeism on adolescent reports of health be- symptoms among adolescent girls in the United States. haviors has shown it may be a problem.55 Students in al- This first national study to report on multiple so- ternative schools are excluded from the sample and have matic complaints among US adolescent females indi- been shown to have higher levels of health-related risk be- cates that this population is at particularly high risk for haviors than high school students surveyed in the Centers headaches, stomachaches, backaches, and morning fa- for Disease Control and Prevention’s Youth Risk Behavior tigue and frequently experiences symptoms in tandem 56 with other conditions. Among girls who experienced Survey. Thus, the levels of risk reported here may be lower headaches more than once a week, 3.2 million (53.3%) than those of the adolescent population as a whole. also reported stomachaches more than once a week, and Assessment of the association between food intake 4.1 million (74.3%) reported morning fatigue more than and restriction practices and somatic symptoms was omit- once a week. Analysis of selected social, environmental, ted because of concerns about the reliability of self- and behavioral factors found protective associations for report data for these measures. Self-reported data on risk parent and teacher support, while cigarette smoking and behaviors among adolescents have been found to be lower heavy caffeine and alcohol consumption were strongly for dietary behaviors compared with other health behav- associated with symptom prevalence. iors,57 while comparisons of self-reported energy intake and expenditure have shown adolescents to underesti- mate energy intake.58 Food restriction practices were also omitted because data were unavailable on the intensity be associated with somatic symptoms. Smoking among or frequency of dieting behaviors. adolescent girls has been associated with somatic symp- The association between stressful life events, such toms,3 lower parent-family connectedness, and weight as familial illness and violence, on somatic symptoms ex- control efforts.46 The reported relationship between weight perienced by adolescent girls was not addressed in this control and smoking is particularly salient to the health study.54 Given the prevalence of sexual assault59 and part- status of adolescent girls. As they age, girls report in- ner violence60 experienced by adolescent girls, subse- creased dissatisfaction with their bodies,47 participation quent studies of multiple co-occurring symptoms among in dieting behaviors,48 and cigarette smoking.49 It is pos- this population would benefit from inclusion of these mea- sible that some of the symptoms associated with adoles- sures. cent female smoking may also reflect negative health ef- Finally, a similar study of somatic symptoms among fects associated with the psychological pressure to fit social adolescent boys would be valuable. Male adolescents do body norms and the physical effects of food restriction not report suffering from somatic symptoms as fre- and disordered eating. quently as female adolescents, with the exception of morn- Alcohol consumption was modestly associated with ing fatigue26; however, further research is needed to de- increased risk for headaches, stomachaches, and morn- termine how social and environmental factors influence ing fatigue in this study. The association between alcohol the frequency and prevalence of this condition and oth- abuse and lifetime negative health effects has been docu- ers among boys. mented.50,51 Adolescent alcohol use has been associated with frequent physical symptoms ranging from headaches to CONCLUSIONS abdominal pain, risky health habits including poor diet, smoking, low levels of regular physical activity, and de- Somatic complaints of headache, stomachache, back- layed puberty.23,52 At least 1 study has suggested that de- ache, and morning fatigue are common among US ado- pression and anxiety among this population may be more lescent girls. These health conditions are reported fre- significantly associated with reported symptoms than the quently and often in tandem with other conditions physical effects of alcohol.53 Another study has reported affecting daily functional levels. These findings suggest a strong association between somatic symptoms and “re- that effective clinical treatment may require comprehen- lief” substance abuse among adolescent girls, a practice sive assessment of all female adolescents presenting with characterized by substance use during stressful events.54 seemingly isolated somatic complaints to accurately iden- These findings suggest that the physical symptoms asso- tify and treat both the presenting symptom and any re- ciated with substance use may also be reflecting the so- lated conditions. While linkages may be drawn between matization of concurrent emotional distress. Further re- selected complaints and other biological functions such search is necessary to determine to what extent students as menstruation, most of these complaints seem to be as- who report risky health behaviors may be otherwise prone sociated more strongly with social, environmental, and

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©2004 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/25/2021 behavioral risk factors such as perceived social support 30. Kleinbaum DG, Kupper LL, Muller KE. Applied Regression Analysis and Other Multivariable Methods. Boston, Mass: PWS-KENT Publishing Co; 1988. and alcohol and caffeine consumption. 31. Goodman JE, McGrath PJ. The epidemiology of pain in children and adolescents: a review. Pain. 1991;46:247-264. 32. Taimela S, Kujala UM, Salminen JJ, ViljanenT. The prevalence of low back pain Accepted for publication March 29, 2004. among children and adolescents: a nationwide, cohort-based questionnaire sur- Correspondence: Reem M. Ghandour, MPA, Office of vey in Finland. Spine. 1997;22:1132-1136. Women’s Health, Health Resources and Services Adminis- 33. Campbell MA, McGrath PJ. Use of medication by adolescents for the management of menstrual discomfort. Arch Pediatr Adolesc Med. 1997;151:905-913. tration, Parklawn Bldg, Room 10C-09, 5600 Fishers Lane, 34. Klein JR, Litt IF. Epidemiology of adolescent dysmenorrhea. Pediatrics. 1981; Rockville, MD 20857 ([email protected]). 68:661-664. 35. Shye D, Jaffe B. Prevalence and correlates of premenstrual symptoms: a study of Israeli girls. J Adolesc Health. 1991;12:217-224. REFERENCES 36. Teperi J, Rimpela¨ M. Menstrual pain, health and behavior in girls. Soc Sci Med. 1989;29:163-169. 37. US Department of Health and Human Services, Centers for Disease Control and 1. Alfven G. The covariation of common psychosomatic symptoms among chil- Prevention, National Center for Health Statistics. Table 63: Use of selected sub- dren from socio-economically differing residential areas: an epidemiological study. stances by high school seniors, eighth-, and tenth-graders, according to sex and Acta Paediatr. 1993;82:484-487. race: United States, selected years 1980-2002. Health, United States, 2003. Avail- 2. Belmaker E. Non-specific somatic symptoms in early adolescent girls. J Ado- able at: http://www.cdc.gov/nchs/data/hus/tables/2003/03hus063.pdf. Ac- lesc Health Care. 1984;5:30-33. cessed March 24, 2004. 3. Brattberg G. The incidence of back pain and headache among Swedish school 38. Kimm SYS, Glynn NW, Kriska AM, et al. Decline in physical activity in black and children. Qual Life Res. 1994;3(suppl 1):S27-S31. white girls during adolescence. N Engl J Med. 2002;347:709-715. 4. Egger HL, Costello EJ, Erkanli A, Angold A. Somatic complaints and psychopa- 39. Field T, Diego M, Sanders CE. Exercise is positively related to adolescent’s re- thology in children and adolescents: stomachaches, musculoskeletal pains and lationships and academics. Adolescence. 2001;36:105-110. headaches. J Am Acad Child Adolesc Psychiatry. 1999;38:852-860. 40. Aronowitz T, Morrison-Beedy D. Resilience to risk-taking behaviors in impover- 5. Ha¨rma¨ A, Kaltiala-Heino R, Rimpela M, Rantanen P. Are adolescents with frequent ished African American girls: the role of mother-daughter connectedness. Res pain symptoms more depressed? Scand J Prim Health Care. 2002;20:92-96. Nurs Health. 2004;27:29-39. 6. Kristja´nsdo´ttir G. Prevalence of pain combinations and overall pain: a study of 41. Mellin AE, Neumark-Sztainer D, Story M, Ireland M, Resnick MD. Unhealthy be- headache, stomach pain and back pain among school-children. Scand J Soc Med. haviors and psychosocial difficulties among overweight adolescents: The po- 1997;25:58-63. tential impact of familial factors. J Adolesc Health. 2002;31:145-153. 7. Larsson BS. Somatic complaints and their relationship to depressive symptoms 42. Field T, Diego M, Sanders C. Adolescents’ parent and peer relationships. Ado- in Swedish adolescents. J Child Psychol Psychiatry. 1991;32:821-832. lescence. 2002;37:121-130. 8. Nolen-Hoeksema S, Girgus JS. The emergence of gender differences in depres- 43. Fekkes M, Pijpers FI, Verloove-Vanhorick SP. Bullying behavior and associa- sion during adolescence. Psychol Bull. 1994;115:424-443. tions with psychosomatic complaints and depression in victims. J Pediatr. 2004; 9. Schoenbach VJ, Garrison CZ, Kaplan BH. Epidemiology of adolescent depres- 144:17-22. sion. Public Health Rev. 1984;12:159-189. 44. Forero R, McLellan L, Rissel C, Bauman A. Bullying behaviour and psychosocial 10. Pine DS, Cohen P, Brook J. The association between major depression and head- health among school students in New South Wales, Australia: cross-sectional ache: results of a longitudinal epidemiologic study in youth. J Child Adolesc Psy- survey. BMJ. 1999;319:344-348. chopharmacol. 1996;6:153-164. 45. US Department of Health and Human Services, Health Resources and Services 11. Linet MS, Stewart WF, Celentano DD, Ziegler D, Sprecher M. An epidemiologic study Administration. Stop Bullying Now. Available at: http://www.stopbullyingnow of headache among adolescents and young adults. JAMA. 1989;261:2211-2216. .hrsa.gov/index.asp. Accessed March 24, 2004. 12. Mannix LK, Diamond M, Loder E. Women and headache: a treatment approach 46. US Department of Health and Human Services, US Public Health Service, Office based on life stages. Cleve Clin J Med. 2002;69:488-500. of the Surgeon General. Women and Smoking: A Report of the Surgeon Gen- 13. Rhee H. Risk factors for and sequelae of headaches in schoolchildren with clinical eral. Washington, DC: US Government Printing Office; 2001. implications from a psychosocial perspective. J Pediatr Nurs. 2001;16:392-401. 47. McCabe MP, Ricciardelli L. Parent, peer, and media influences on body image 14. Eccleston C, Malleson P. Managing chronic pain in children and adolescents: we and strategies to both increase and decrease body size among adolescent boys need to address the embarrassing lack of data for this common problem. BMJ. and girls. Adolescence. 2001;36:225-240. 2003;326:1408-1409. 48. Field AE, Camargo CA Jr, Taylor CB, Berkey CS, Roberts SB, Colditz GA. Peer, 15. Weydert JA, Ball TM, Davis MF. Systematic review of treatments for recurrent parent, and media influences on the development of weight concerns and fre- abdominal pain. Pediatrics [serial online]. 2003;111:e1. quent dieting among preadolescent and adolescent girls and boys. Pediatrics. 16. Howard RF. Current status of pain management in children. JAMA. 2003;290: 2001;107:54-60. 2464-2469. 49. US Department of Health and Human Services, Centers for Disease Control and 17. Marcus DA. Reducing headache disability in children and adolescents. Am Fam Prevention. Tobacco use among middle and high school students–United States, Physician. 2002;65:554-557. 2002. MMWR Morbid Mortal Wkly Rep. 2003;52:1096-1098. 18. Rhee H. Prevalence and predictors of headaches in US adolescents. Headache. 50. Hingson RW, Heeren T, Jamanka A, Howland J. Age of drinking onset and un- 2000;40:528-538. intentional injury involvement after drinking. JAMA. 2000;284:1527-1533. 19. Kristja´nsdo´ttir G, Rhee H. Risk factors of back pain frequency in schoolchildren: 51. National Institute on Alcohol and Alcoholism, National Institutes of Health, US a search for explanations to a public health problem. Acta Paediatr. 2002;91: Department of Health and Human Services. Medical consequences of alcohol 849-854. abuse. Alcohol Res Health. 2000;24:27-31. 20. Natvig GK, Albrektsen G, Anderssen N, Qvarnstrøm U. School-related stress and 52. Dees WL, Srivastava VK, Hiney JK. Alcohol and female puberty: the role of in- psychosomatic symptoms among school adolescents. J Sch Health. 1999;69: traovarian systems. Alcohol Res Health. 2001;25:271-274. 362-368. 53. Clark DB, Lynch KG, Donovan JE, Block GD. Health problems in adolescents with 21. Nansel TR, Overpeck M, Pilla RS, Ruan WJ, Simons-Morton B, Scheidt P. Bul- alcohol use disorders: self-report, liver injury, and physical examination find- lying behaviors among US youth: prevalence and association with psychologi- ings and correlates. Alcohol Clin Exp Res. 2001;25:1350-1359. cal adjustment. JAMA. 2001;285:2094-2100. 54. Poikolainen K, Kanerva R, Lonnqvist J. Life events and other risk factors for so- 22. Resnick MD, Bearman PS, Blum RW. Protecting adolescents from harm: find- matic symptoms in adolescence. Pediatrics. 1995;96(pt 1):59-63. ings from the National Longitudinal Study on Adolescent Health. JAMA. 1997; 55. Guttmacher S, Weitzman BC, Kapadia F, Weinberg SL. Classroom-based sur- 278:823-832. veys of adolescent risk-taking behaviors: reducing the bias of absenteeism. Am 23. Arria AM, Dohey MA, Mezzich AC, Bukstein OG, Van Thiel DH. Self-reported health J Public Health. 2002;92:235-237. problems and physical symptomatology in adolescent alcohol users. J Adolesc 56. Grunbaum JA, Kann L, Kinchen SA, et al. Youth risk behavior surveillance: na- Health. 1995;16:226-231. tional alternative high school youth risk behavior survey, United States, 1998. 24. El-Mallakh RS, Kranzler HR, Kamanitz JR. Headaches and psychoactive sub- J School Health. 2000;70:5-17. stance use. Headache. 1991;31:584-587. 57. Brener ND, Kann L, McManus T, Kinchen SA, Sundberg EC, Ross JG. Reliability 25. Rasquin-Weber A, Hyman PE, Cucchiara S, et al. Childhood functional gastro- of the 1999 Youth Risk Behavior Survey Questionnaire. J Adolesc Health. 2002; intestinal disorders. Gut. 1999;45(suppl 2):II60-II68. 31:336-342. 26. Currie C, Hurrelmann K, Settertobulte W, Smith R, Todd J, eds. Health and health 58. Schoeller DA. Limitations in the assessment of dietary energy intake by self- behaviour among young people. In: WHO Policy Series: Health Policy for Chil- report. Metabolism. 1995;44(suppl 2):18-22. dren and Adolescents Issue 1. Copenhagen, Denmark: World Health Organiza- 59. Tjaden P, Thoennes N. Full Report of the Prevalence, Incidence, and Conse- tion Regional Office for Europe; 2000. quences of Violence Against Women: Findings From the National Violence Against 27. Shah BV, Barnwell BG Bieler GS. SUDAAN User’s Manual, Release 8.0. Re- Women Survey. Washington, DC: Institute of Justice and the Centers for Dis- search Triangle Park, NC: Research Triangle Institute; 2001. ease Control and Prevention; 2000. 28. SPSS Inc. SPSS Base 10.0 User’s Guide. Chicago, Ill: SPSS Inc;1999. 60. Ackard DM, Neumark-Sztainer D, Hannan P. Dating violence among a nationally 29. StatSoft Inc. Principal components and factor analysis, 1984-2003. Available at: representative sample of adolescent girls and boys: associations with behav- http://www.statsoftinc.com/textbook/stfacan.html. Accessed March 24, 2004. ioral and mental health. J Gend Specif Med. 2003;6:39-48.

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