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J. Indian Assoc. Child Adolesc. Ment. Health 2016; 12(1):79-115
Review Article
Somatization in Children and Adolescents: practical implications
Deepti Gupta Karkhanis, Adam Winsler
Address for correspondence: Deepti Karkhanis, Department of Psychology Social
Sciences Division, D 110 3000 Landerholm Cr. SE Bellevue College WA 98007
Email:[email protected]
Abstract
Somatization is the propensity to experience and report psychological and/or emotional suffering through physical symptoms that cannot be explained by known medical causes.
Somatic complaints are often a result of an impaired ability to verbalize emotional distress, and are commonly encountered in children and adolescents. Children report a diversity of somatic problems, including headache, stomachache, dizziness, and lethargy.
Several factors contribute to the display of somatic complaints, such as a family history of health problems, parental modeling and reinforcement of illness behavior, temperament, psychological processes, gender, and cultural emotion socialization influences. In this review, we define somatic symptom clusters, and report the frequency of somatic problems in children and adolescents. Second, we discuss biological and environmental influences that contribute to somatization in children and youth. Third, we 80 discuss gender differences and cultural factors related to somatic complaints in childhood. Finally, possible cognitive interventions (such as guided imagery, mindfulness training, and relaxation), and recommendations for practitioners dealing with children with somatic complaints in schools are discussed.
Keywords: somatic complaints, anxiety, children, school
Introduction
Children and teenagers often express health concerns that seem to have no medical basis.
School personnel (including teachers, nurses) and parents are often concerned about children who constantly report feeling unwell, and who frequently ask to visit the school clinic [1]. These children regularly spend considerable time out of the classroom and are frequently skipping school [2]. Somatization, which is defined as a tendency to report distress via physical ailments that cannot be explained by medical reasons and to seek medical help [3], is commonly encountered in children and teenagers. In clinical populations, it is an anxiety disorder characterized by an impaired ability to verbalize one’s emotional distress, with emotional suffering being central to the somatic symptoms.
Somatizers (individuals who report somatic complaints) often express psychological pain through physical illness and may seek medical help [4]. Children lack certain cognitive and verbal skills, and possess limited vocabulary for emotional expression [5]; hence, somatization is common in childhood. Children tend to experience a variety of somatic problems, including headache, dizziness, stomachache, and fatigue [6] [7]. Somatic symptoms may be related to disordered physiological processes [8], and/or be manifested due to psychosocial stress (in school and/or the family) [1]. In most cases, children 81
reporting physical problems get the attention of caregivers, and receive secondary gains as well. For instance, parents can reinforce illness behavior by giving toys or special privileges (i.e., taking leave from school, watching TV to distract from pain etc.) to the child who is ill [2].
While somatic symptoms may sometimes be associated with clinical conditions, there is need for practitioners to be aware of and concerned about children’s sub-clinical somatic presentations of distress because if they are identified and acted upon early with intervention, the long-term impact of somatization can be reduced. The goal of this review is to raise awareness about somatization as a prevalent sub-clinical condition that is present in children and youth, and to provide accessible information about non-medical interventions that may help reduce somatic complaints and emotional distress in the school-going population. We will first explain somatic symptom clusters and the prevalence of somatic complaints in children. Second, we will review biological and non- biological factors associated with somatization in children and teenagers. Third, we will shed light on gender differences and cultural factors as potential contributors to somatic problems in children and adolescents. Finally, we discuss possible interventions and practical solutions for parents and practitioners when dealing with young somatizers.
Somatic Symptoms: Clusters, Comorbidity, and Prevalence in Childhood
Somatic complaints are physical health problems such as headache, backache, stomach pain that have no medical basis. A factor analysis of responses to the Children's
Somatization Inventory (CSI) [9] has reported four clusters of somatic complaints in youth, wherein the first cluster of somatic symptoms has neurological associations, such 82
as seizures, fainting, etc. The second includes cardiovascular and respiratory symptoms, including palpitations, chest pain, breathlessness, etc. The third consists of gastrointestinal symptoms such as stomachache, and nausea. The fourth cluster involves problems like chronic pain [10] and fatigue [11]. Research has shown that clusters one and two, with neurological and respiratory symptoms, are more common in individuals with generalized anxiety disorder (GAD) [12] or post-traumatic stress disorder (PTSD)
[13] than in psychologically healthy individuals.
In terms of frequency, headache, stomachache, pain in joints, followed by muscle fever and vomiting or upset stomach are the most regularly occurring symptoms in children [14]. Others agree that gastrointestinal and autonomic ailments (such as headaches, stomachaches, sweatiness, and lightheadedness) are the most common somatic complaints reported by children [2]. In addition, there is substantial co-morbidity among somatic symptoms. For instance, headache often co-occurs with reported abdominal pain. Both headache and abdominal pain are also associated with nausea/vomiting. Child report of somatic symptoms is also associated with conduct disorder as well as symptoms of hyperactivity, and depression [15]. Importantly, somatic symptoms are often multiple, persistent, and disabling in nature [16], and a somatizer tends to use numerous symptoms to express distress across situations [17].
The incidence of somatic experiences among children and adolescents is comparable across various countries. According to Australia’s Department of Health and
Ageing (1998), 14% of young participants aged 4-17 years reported an experience of a mental health problem, with the most frequently identified being somatic complaints 83
(chronic bodily complaints without a known cause; including headache and stomachache) with reports from 7% of the child and teen population [18]. Similarly,
Haugland, et al., analyzed data from a cross-national survey conducted by the World
Health Organization (WHO) on 11-15 year old adolescents indicating that headache was the most frequent somatic symptom, followed by abdominal pain, backache, dizziness, low energy, irritability, nervousness, and sleep difficulties [19]. In Germany, Roth-
Isigkeit and colleagues found that pediatric pain is a common public health problem, and
30 to 40% of school-going children with pain reported increased use of health services and claimed that their pain adversely affected their school attendance, involvement in hobbies, quality of peer interactions, appetite, and sleep [20]. A longitudinal study in
Finland found that the occurrence of frequent headaches and stomachaches has increased from 1989 to 1999 [15]. Overall, the occurrence rates as well as the types of somatic complaints appear similar across countries. Thus, somatic complaints are common in childhood, have high comorbidity with other health problems, and are found to be more frequent with age. Moreover, in terms of long-term effects, there is a temporal link between childhood somatization and adult psychopathology such that high levels of somatic problems during adolescence are a significant risk factor for depression [21, 22], and anxiety in adulthood [23, 24], suggesting a need for early intervention [25].
Stress and Somatization in School-Age Children
Shannon et al. proposed a model of somatization in school-going children that depicts the complex cyclic interactions between life factors and health-related outcomes, driven by basic personal attributes. Specifically, the model indicates one comprehensive 84
predisposing factor for somatization in school-age children: stress. The factors that make children vulnerable to somatic behavior are environmental stressors and poor coping skills. The factors associated with high prevalence of somatization include parental neglect, poor neighborhood quality, parental anxiety, family history of depression, and school-related stress (including peer victimization and perceived loneliness). For example, a recent study reported that a fearful temperament, maternal somatic distress, anxiety during pregnancy, and parenting stress each individually increase the likelihood of children’s somatic complaints [26]. Based on the model, we will be discussing child characteristics (such as temperament, gender), psychological comorbidity, family history, and school stress (i.e., low peer and teacher support, classroom noise, perceived loneliness, and bullying) as potential factors associated with somatic problems in children.
Biological and Psychological Factors in Somatization
By definition, somatic complaints have no known medical or biological basis, so when children complain frequently about physical pain, it is of course critical for the child first to be referred to a health care provider to rule out biological causes for the child’s symptoms. There are some recognized medical conditions, however, such as recurrent abdominal pain (RAP), irritable bowel syndrome (IBS) and chronic fatigue syndrome (CFS) that involve increased sensitivity to experiencing bodily sensations and that are associated with increased susceptibility to emotional distress, and increased risk of a wide variety of somatic concerns that go beyond the original condition [23]. So certain biological conditions can place individuals at risk for somatic problems. 85
A common somatic problem in children is migraine and tension headaches. While biological systems are believed to explain migraines, psychological factors are found to play a major role in headaches [27]. Several mental processes appear to be related to somatization. First, alexithymia is a psychological mechanism found to underlie the tendency to somatize [28]. It is a psychological condition with the underlying affective and cognitive characteristics: (a) difficulty in verbalizing one’s feelings, (b) difficulty in discriminating between affect and bodily sensations from emotional arousal, (c) limited imaginative processes (e.g., paucity of dreams), and (d) a cognitive style that is concrete and reality-driven [29]. Past research shows that alexithymia is closely associated with somatization wherein individuals amplify somatic sensations associated with emotional arousal and misinterpret these sensations as symptoms of illness [28]. Second, thought suppression [30] could be an underlying phenomenon associated with somatic behavior.
Thought suppression helps to psychologically escape from negative thoughts and stressors [30]. Somatizers often show an enhanced tendency to focus on bodily states, wherein they underevaluate their thoughts and overemphasize both emotions and physical sensations.
Temperamental Traits and Somatization
Emotion regulation and personality traits are found to be central in influencing somatic symptoms [31]. A number of emotion-related concepts that have been linked to psychosomatic behavior include (a) negative affectivity (NA) [32, 33], (b) ‘socio- affective vigilance’ (SAV) [17], (c) social withdrawal and inhibition [34], and a (d)
‘behavioral/ avoidant coping style’ [35]. NA refers to one’s proneness to experience 86
feelings of anger and discomfort [32]. SAV is a multidimensional construct that brings together the core constructs thought to contribute to somatic behavior. Neuroticism is SAV’s affective component, which is defined as the feeling of worry, anxiety, suspicion, and uncertainty. Social avoidance is the behavioral component, reflecting an individual’s active avoidance of people, places, and unfamiliar situations. And, thought distortion is the cognitive characteristic, wherein there are disturbing thoughts and negative evaluation of situations and people around the self [17]. Social withdrawal is the steady (across situations and over time) pattern of various forms of unsociable behavior
(such as shyness and solitary, passive play) [34]. Last, persons with an avoidant coping style usually deny experiencing elevated levels of anxiety, and overlook their behavioral and physiological responses to stress, making themselves prone to somatic complaints
[35]. In general, children reporting somatic problems are likely in need of attention in the area of emotional understanding and expression [36]. Also, it is helpful for parents and school staff to be aware of these temperamental characteristics in children that make them more prone to somatic complaints. In any case, it is crucial to teach young children effective coping strategies and emotion regulation in order to prepare them to deal with emotionally stressful life events.
Familial and Environmental Factors in Somatization
There are several theories on environmental factors that propose to explain the genesis of somatization. One of them claims that unfavorable childhood experiences contribute to the development of somatic behaviors. A theory states that somatic behavior is a result of maladaptive daily family life that develops due to environmental stress [20]. 87
For example, an insecure attachment with a parent leads to poor interpersonal interaction and often produces persistent care-seeking behavior, manifested in the form of somatic complaints [37]. Violon invented the term “conditional caretaking” that refers to the selective attention parents pay to their children’s physical complaints while denying their emotional needs [38]. It leads to the development of a working model, wherein parents’ careful attention to a child’s illness needs, and negligence toward care-based behaviors during childhood makes the child believe that care will be provided only for physical suffering [37]. Such parental response may reinforce somatic behavior in children.
From a behavioral perspective, positive familial reactions to illness behavior can increase the display of somatic complaints by young children, especially in cases of parental solicitousness (that is, parents giving their children extra treats or privileges to relieve them of their distress) and in turn, reinforce children’s somatic complaints. For instance, parental attentive behaviors are linked with greater somatic symptoms, such as chronic pain [39]. Specifically, for children with more psychological distress, parental solicitous behaviors were associated with greater pain behaviors and child functional disability [40]. There is a need to understand the social mechanisms of parental solicitous behaviors and/or modeling of poor coping styles in order to reduce the intergenerational transmission of illness behavior by appropriate education of parents, and to provide them with effective cognitive behavioral treatments designed to deal with children’s somatic symptoms.
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Role of Stressful Family Life on Somatic Symptoms in Children
In addition to parental response to child’s somatic complaints, both family history and stress may also have an effect on illness behaviors in children. Stressful life conditions are often related to an increase in somatic complaints [41, 42]. Family-related stress or negative life events include a parent losing a job or a history of poverty [6].
Moreover, teenagers who perceive their family life as disorganized, chaotic, and less cohesive report more somatic complaints [43]. Exposure to negative affect and stress in the family environment may put youth at high risk for developing somatic problems.
Hence, several familial factors are associated with somatic behavior [42], and a possible outcome of a stressful life includes the continuity of somatic symptoms [1]. Somatic complaints in children may be indicative of stress at home, and teachers could be educated to make a referral to the school counselor or school psychologist who could entertain options for assessing the extent to which there is home-based discord and stress for the student, and perhaps discuss this issue along with potential interventions with parents.
School-Related Stress and Somatization in Children
Apart from familial factors, common somatic complaints in school-age children, such as headache and stomachache, are also found to be associated with school stress [1,
44]. Perceived loneliness and peer alienation are associated with increased headaches, stomachaches, anxiety, and sadness in children [44]. School bullying is defined as a repeated aggressive behavior perpetrated by one or more bully(s) toward a weaker peer
[45]. Children who experience bullying, peer victimization, disruptive, noisy classrooms, 89
and poor teacher support tend to report more somatic complaints when at school as compared to ‘popular’ children who experience higher peer acceptance [44, 46, 47].
For instance, child victims of bullying are at significantly higher risk for psychosomatic complaints and maladjustment in the school setting, compared to children who are never bullied [48]. Furthermore, school children that are bullied tend to be vulnerable to a wide variety of psychosocial and psychosomatic problems, including anxiety, headaches, depression, sleep problems, and stomachaches [46, 49].
Moreover, undergoing high-stakes standardized testing has also been found to produce stress, and subsequent somatic behavior in school children. Rudowitz noted that student intelligence and achievement testing, as well as teacher experience and classroom stress are significant predictors of school stress, making children prone to somatic problems [50]. Similarly, a study conducted in India on middle-school children found that high-stakes examinations were positively related to somatization symptoms such as headaches, vomiting, and fever [51]. In terms of academic performance, high-somatizing children are significantly more likely to have academic difficulty, poor grades [52], and higher absenteeism [2, 53] than low-somatizing children. Reducing school stress by improving teacher and peer support, lowering class noise, decreasing stress related to high-stakes testing, and preventing bullying may reduce somatic complaints among children [48, 54]. School personnel should, thus, determine if children who are frequently presenting with somatic complaints are being bullied at school or if they are particularly anxious about school-based testing practices.
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The Role of Cultural Socialization in Somatization
Although somatic behavior in school-age children is influenced by child temperament (e.g., inhibition, NA), psychological processes (e.g., dissociation, thought suppression), and/or parental reaction to child’s illness behavior, it all occurs in the larger context of a family, school, and culture. While individual parenting variables (e.g., parenting style, parental reinforcement) exist within a larger context of dyadic factors
(e.g., quality of parent–child interaction, and family dynamics), it is crucial to note that a family is further embedded within their culture. Culture includes the patterns of behavior within an identified group of people that are acquired and transmitted through symbols and artifacts across generations. A family environment driven by the collectivistic ideology (where, the focus is on the group rather than the individual), for example, discourages a child’s negative emotional expression, and (implicitly) encourages the child to rely on affect-suppression methods of managing with one’s emotions, and thus may encourage somatization [55].
Culture influences how people experience symptoms, the communication patterns about physical/health problems, the idioms they use to report them, and the way they understand psychological “illnesses” [56]. In Asian societies, the body is holistically integrated with emotions. Emotion display rules and expressions of distress through the body is the cultural norm within many Asian cultures. For example, Japanese individuals report more somatic complaints than Americans [57]. Similarly, Lu et al., found that the
Hong Kong Chinese made a distinction between the affective/interpersonal and somatic
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items on a depression scale, while Americans fused such items. Specifically, the
Chinese attribute their mental distress as a source of somatic complaints [58].
Cultures also differ in beliefs concerning expression of psychopathology, attitudes toward mental health, and subjective experiences of illness [59]. Cross-cultural work suggests that in Eastern societies, psychological symptoms are typically considered less socially tolerable than physical symptoms as Asian cultural values stress the development of interpersonal relationships, family closeness, and social harmony [94]. Weisz etal., found that Thai children exhibit more somatic behavior, while Caucasian American children exhibit more externalizing behavior [60], suggesting that cultural factors influence children’s displays of emotional and behavioral problems. Within the United
States, research indicates that somatization is a particularly common expression of psychological distress among African Americans and Latinos [56]. Social modeling tends to define culturally appropriate psychological distress, and somatization appears to be a particularly accepted manifestation of distress in specific cultural groups [59].
Somatic expression of psychological problems among people of Asian societies has been reported in several studies [61, 55]. In India, Raval and Martini found that
Indian Gujarati mothers considered their children's expressions of anger and sadness to be less acceptable than physical pain, and they were more likely to convey to the child that the angry or sad expression was socially inappropriate [62]. The author also noted that in comparison to physical pain, Indian children were less likely to report expressing anger and sadness through direct facial or verbal means [55]. In the school context, particularly with regard to test anxiety, Sovani et al., noted that Indian children and youth 92
endorsed bodily symptoms more than cognitive symptoms [61]. Similarly, depressed Chinese individuals are found to rely relatively more on their somatic symptoms rather than their sad feelings to express depression, even though they are aware of their psychological disturbance [58]. Hence, Asian (e.g., Chinese, Indian),
African American, and Latino children are more likely than Caucasian children to internalize rather than externalize their psychological distress. Specifically, help-seeking behavior in these cultures is organized around the presentation of physical complaints rather than explicit display of emotional distress [59].
Gender Differences in Somatization
Somatic complaints are often more prevalent in women than in men [22, 44]. In the Health Behavior in School-aged Children (HSBC) study by the World Health
Organization, girls reported several subjective psychosomatic complaints more often than boys and the levels increased with age, while those for boys showed little change [63].
There could be several reasons why girls show higher vulnerability to psychosomatic problems. One reason for female proneness to somatic complaints could be that females tend to be more health-focused, and are found to perceive their health and body image through a distorted lens of their socio-emotional needs [64]. A second reason could be that during the transition from childhood to adolescence, girls are increasingly found to channel their early problem behaviors into internalizing problems such as anxiety and somatization as a result of socialization [65]. Gender differences may be at least partly related to different gender role expectations in society. By adulthood, women are twice as likely as men to suffer from affective and anxiety problems [66]. Also, gender differences 93
in somatization may be due to earlier female pubertal onset [7, 67] and differences in symptom perception [20]. Female somatizers tend to have a lower threshold for environmental stressors [17], and they use situational clues such as pain more in appraising bodily sensations compared to males [20].
PRACTICAL IMPLICATIONS FOR SCHOOL MENTAL HEALTH
Implications for Practitioners and Parents of Young Somatizers
The short-term outcomes of somatic complaints in school children are poor academic performance, family difficulties, and poor peer relationships. The long-term consequences for somatizers are increased risk for academic underachievement, unemployment, criminal offences, and adult psychopathology [68]. Children with somatic complaints must be taken to a physician for a thorough health check-up to rule out a physical reason for the symptoms, and they must be given due attention regarding their physical needs. However, once it is evident that there is nothing “medically” wrong, then the child must be provided with care and emotional support, but not be exempted from his/her usual responsibilities. Often care providers, focus exclusively on the physical symptoms of a somatizer, while ignoring the child having unexpressed emotional needs. It is important that clinical practitioners and parents dealing with somatic behavior in children provide them with a platform to express their feelings, and assure them that they can communicate without the fear for being scolded or left unheard.
And, children must be encouraged by their teachers in classrooms to seek the nurse or school counselor/psychologist when feeling anxious, and to talk about stress and emotions. Additionally, Campo and Fritz have suggested that it is important to explore 94
the timing (what time in the day) and context (in what situations such as at meal time, day care pickup or drop off) in which children display somatic behaviors, as well as the characteristics of children’s health complaints. Also, it is essential to solicit information about the child from multiple sources, such as family members, school nurses, teachers, primary care professionals, and other school personnel [69], because young children are dependent on adults not only for care and attention but also to make important decisions for them [70]. It would be important to begin with the process of early identification of somatizers in school, detect situations that relieve and/or worsen the symptoms [69], and then build on possible long- and short-term interventions; such as stress management classes, parent-child emotion education programs, and teacher training in anxiety-reduction techniques.
School-based Anxiety-reduction Interventions
Numerous school-based interventions have been explored and found to be helpful in reducing somatic behavior in children. Some of these directly address somatic behavior [71, 72] and other address broader anxiety-reduction interventions [73-75] given the close association between childhood anxiety and somatization [76, 77]. Introducing cognitive-behavioral techniques (CBT) in the school setting, such as guided imagery
[72], relaxation training (e.g., Progressive Muscle Relaxation) [78], and social skills training [68] may help reduce distress in young somatizers, and could help improve their peer relations and academic performance. For instance, Warner and colleagues (2009) conducted a pilot study on seven boys and girls (ages 8-15) with medically unexplained gastrointestinal ailments and anxiety symptoms. The participants underwent a 12-session 95
CBT intervention that targeted their anxiety and somatic symptoms. The CBT program used was Treatment for Anxiety and Physical Symptoms (TAPS) that addresses anxiety and physical symptoms by identifying social settings in which symptoms occur, and uses relaxation, cognitive restructuring, and exposure exercises to target fears linked to physical pain (e.g., RAP) and anxiety-inducing situations. Results found that children’s physical discomfort decreased from a moderate to minimal level based on self and parent-reports [79]. Although some forms of CBT are clinical interventions that require extensive training and intense supervision [80]; group CBT for school children (ages 7-
11) [74] is doable within a school setting. Moreover, when parent training is combined with child group CBT, it significantly decreases child anxiety symptoms and associated impairment [74]. Studies in Australia have revealed the feasibility of using classroom teachers to administer universal CBT interventions to children [81].
Progressive muscle relaxation (PMR). Relaxation is an emotion-focused strategy that decreases emotional and somatic reactions to stressful events. Specifically,
Progressive Muscle Relaxation (PMR) is especially helpful for individuals whose anxiety is associated with muscle tension. Guided imagery, on the other hand, is a form of self- regulation therapy. During the therapeutic process, a state of deep relaxation is induced using PMR, which allows the child to then be guided in actively creating images that facilitate resolution of certain anxiety problems [72]. There is evidence for the effectiveness of the use of guided imagery and deep relaxation via PMR in reduction of anxiety levels in school-age children [75]. Importantly, the response to guided imagery is rapid, easily sustained, clinically effective, and not associated with any apparent side 96 effects [72]. School nurses and school psychologists could be trained in guided imagery and PMR, so they could promote self relaxation in children with anxiety and somatic problems, and parents can be referred to places that offer such services.
Mindfulness training. Next, similar to CBT is mindfulness training, which can also be employed to treat anxiety and stress in children [82, 83, 84]. The primary mechanism of mindfulness is self-management of attention. Repeatedly returning one’s attention to a single neutral stimulus (e.g., breathing pattern and heart rate), those that are normal in one’s physical functioning, produces a stable psychological mind frame.
Mindfulness training with children teaches them attention focusing on body sensations, and includes breathing, walking, and simple sensory exercises. Semple and associates
(2005) conducted an open clinical 6-week trial with anxious children (ages 7-8 years), and found that enhancing self-management of attention via mindfulness training leads to reduction in anxiety and number of somatic complaints, as well as improvements in academic performance [84]. Similarly, Kuyken and colleagues tested the efficacy of a school-based universal mindfulness intervention with 522 students (aged 12-16), and found that the Mindfulness in Schools Programme (MiSP) helped reduce stress and enhance well-being in a school population [85]. It is important to keep in mind that child- reported somatic symptoms are associated with depression and anxiety [15, 86]. Anxiety- reducing techniques may help lessen associated impairment and psychosomatic complaints in children.
Friends for children program. In a similar vein, another preventive intervention for anxiety symptoms in children is the Friends for Children program [87], which is a 97
brief cognitive-behavioral intervention that assists children in learning important skills and techniques to help them cope with and manage anxiety. The training includes relaxation; cognitive restructuring of inner thoughts and exploration of plans of action; attention training; and family and peer support [87]. Barrett and Turner provided evidence for the effectiveness of both psychologist-led and teacher-led intervention provided to clinically anxious school children (aged 10-12 years). Results indicated that both psychologists and teachers are efficient group leaders, and the intervention is generalizable and sustainable within a school setting [73]. The Friends for Children program can be effectively delivered in schools by integrating it into the classroom curriculum, and there is evidence that teacher-led intervention helps move the ‘at-risk’ anxious children to better health [73, 81].
School Teachers as Awareness Creators
Apart from imparting instruction, teachers often have more information on the child's personality and reaction to stressors [88]. Teachers can often be helpful in solving children's emotional problems, but one needs to be respectful of their limitations because they have to deal with so many children. Teachers often have a good view of the child's emotional health. Teachers could be informed that the presence of anxiety and depression should be carefully considered, and referral to school psychologists or counselors should be made when appropriate. Teachers must be sensitized toward cultural differences in socialization of emotions, and be made aware that Asian Indian [62] and Hispanic [89] children may be more vulnerable to somatic problems. Simple questions from the teacher to the student can help the teacher assess whether the somatizing student is particularly 98
stressed at home or at school, or being bullied, and appropriate referrals could then be made. Teachers, with the support of parents, must discourage absenteeism, and with the assistance of the school counselor or school psychologist, help children vent out their feelings when experiencing distress during school hours. Finally, teachers should be firm with somatizers, and not accept their excuses and reward students for not meeting performance expectations [68].
Early identification and treatment of problems with peer victimization and aggression may have important health implications for children [90]. Teachers, with the help of school psychologists and clinical practitioners, could advocate to the school authorities for increase awareness, conduct prevention programs (to deal with problems of bullying and peer rejection), and improve access to mental health services for children and families [1]. Schools could provide hard-to-reach parents with skills training, such as by using a telephone-based parent education program, and distributing newsletters and emails to generate awareness. Based on emotional-support therapy, children could be asked to keep a diary, wherein they describe their fears, thoughts, coping strategies, and feeling associated with their fears [68]. Also, children who attribute their health problems to school stress are at increased risk to experience school disconnectedness [1]. This could also have a negative impact on academic outcomes. Hence, the Centers for Disease
Control and Prevention [91] published a guide with evidence-based interventions that teachers could use to improve school climate, and increase children’s connectedness with school.
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Parent Activities and Home-based Interventions
On the other hand, it is very important for parents to attend school conferences regularly, and ask specific questions about their child's performance [88]. It is the role of parents to enhance emotional awareness by communicating with the children about how they feel, what they want, and teach them effective emotion display rules. Often parents underestimate the significance of somatic complaints, and they may either not understand or not be willing to acknowledge emotional or behavioral problems in their child [1].
Parents should be made aware if they are engaging in “conditional caretaking” and rewarding children’s somatic behavior [38], and be taught to be more available for their child and avoid selective attention to child’s physical needs.
Some of the behavioral management strategies that could be employed by parents include escorting the child to school, providing positive reinforcement for attending school, and discouraging staying home. Research suggests that family assessments and family cognitive-behavioral interventions hold promise for reducing chronic pain and somatic disability in children [71]. For instance, Allen and Shriver (1998) compared the use of parent-mediated pain behavior management strategies to biofeedback treatment of children with tension headaches. They found that the group of children receiving parent- mediated pain management showed significantly greater reductions in headache frequency, were more likely to experience clinically significant improvements, and were more likely to be headache-free both during treatment and at 3-month follow-up [71].
Hence, parents can influence how their children cope with and manage experiences of tension headaches and chronic pain. Additionally, parents could train their child to set 100
aside a worry period for each day, ask the child to monitor their worrisome thoughts and postpone them until that period, and redirect their focus on present moment experience [92]. This method has been found to significantly reduce children’s self- reported rumination about bodily distress [93].
Future Directions and Conclusion
Somatization is a major health problem in school-age children that tends to go unnoticed by teachers, school psychologists, and parents. Somatization involves a) psychological mechanisms that give rise to somatic/physical symptoms, b) cognitive attributional processes that characterize symptoms as belonging to body or mind, and c) social processes (family stress, cultural socialization etc.) that encourage or sanction particular styles of expressing distress [59]. School staff, clinicians, and parents should view recurrent somatic complaints as indicators of potentially serious emotional problems worthy of attention. Information and awareness through research and practice is needed to advance the understanding of somatization, and improve the ability of parents, school personnel, and teachers to care for emotionally distressed children, who display somatic problems and are at risk for psychopathology. Untreated somatic behavior in children is unacceptable, and psychologists and psychiatrists need to make an effort to inform teachers and educate parents about how children’s emotional needs may need to be met, and children and families can be taught effective coping skills. It is important to first identify the children who are prone to somatic behavior, and help them cope with socio- emotional needs early in life. However, those children who already have had an experience with poor psychosomatic health must be given due attention and relevant 101
intervention to reduce their risk for adulthood psychiatric diagnoses. The problem of somatic complaints in young children and teenagers needs to move away from the realm of medicine, pediatrics, and school nursing to gain more attention from teachers, developmental, and school psychologists, and counselors, as well as parents who closely deal with children and teens on a daily basis.
Acknowledgements-Nil
Conflicts of Interest- Nil
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Deepti Gupta Karkhanis, Ph.D. Instructor, Department of Psychology Social
Sciences Division Bellevue College WA; Adam Winsler, Ph.D. George Mason
University, Fairfax, VA USA.
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