Somatization symptoms in pediatric abdominal pain patients: Relation to chronicity of abdominal pain...

Journal of Abnormal ChiM Psychology, Vol. 19, No. 4, 1991

Somatization Symptoms in Pediatric Abdominal Pain Patients: Relation to Chronicity of Abdominal Pain and Parent Somatization

Lynn S. Walker, 1,3 Judy Garber, 2 and John W. Greene 1

Symptoms of somatization were investigated in pediatric patients with recurrent abdominal pain (RAP) and comparison groups of patients with organic etiology for abdominal pain and well patients. Somatization scores were higher in RAP patients than well patients at the clinic visit, and higher than in either well patients or organic patients at a 3-month followup. Higher somatization scores in mothers and fathers were associated with higher somatization scores in RAP patients, but not in organic or well patients. Contrary to the findings of Ernst, Routh, and Harper (1984), chpvnicity of abdominal pain in RAP patients was not significantly associated with their level of somatization symptoms. Psychometric information about the Children's Somatization In- ventory is presented.

In a recent review of the literature, Shapiro and Rosenfeld (1987) con- cluded that symptoms of somatization disorder are common in children, although it is rare for children to have symptom clusters that meet explicit

Manuscript received in final form February 4, 1991. This research was supported by grants from the Vanderbilt University Research Council and from the National Institute of Child Health and Human Development (HD2364). Garber was supported in part by the W. T. Grant Foundation Faculty Scholar program during completion of this work. The authors are grateful for the assistance of Fayez K. Ghishan, Harry L. Greene, and Patty Vieira of the Vanderhilt Division of Pediatric Gastroenterology.

1Department of Pediatrics, Vanderbilt University, Nashville, Tennessee 37232. 2Department of Psychology and Human Development, Vanderbilt University, Nashville, Tennessee 37232.

3Address all correspondence to Lynn S. Walker, Division of Adolescent Medicine, 436 Medical Center South, Vanderbilt University School of Medicine, Nashville, Tennessee 37232-3571.

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0091-0627/91/0800-0379506.50 �9 1991 PIenum Publishing Corporation

380 Walker, Garber, and Greene

diagnostic criteria. Indeed, in an epidemiological sample of over 2000 children, somatization disorder was so uncommon among children 4 to 11 years of age that prevalence rates could not be estimated (Offord et al., 1987). Livingston and Martin-Cannici (1985) have argued that the initial tasks for research in this area are (a) to determine whether there are children who present a clinical picture compatible with the existing diagnostic criteria for somatization disorder and (b) to demonstrate that these children can be discriminated from children with other disorders. They described five children in an inpatient psychiatric unit with clinical histories and symptoms compatible with a diagnosis of somatization disorder. These children had significantly more DSM-III somatization disorder symptoms than did children with other psychiatric diagnoses.

Ernst, Routh, and Harper hypothesized that in some children recurrent abdominal pain without identifiable organic etiology (RAP) may be a childhood precursor of later somatization disorder (Ernst, Routh, & Harper, 1984; Routh, Ernst, & Harper, 1988). They reasoned that children with recurrent abdominal pain who will eventually have a diagnosis of somatization disorder should complain of an increasing number of other symptoms as their condition becomes more chronic. In contrast, for children with organically based abdominal pain there would be no reason to expect a relation between chronicity of abdominal pain and number of other somatic complaints. Results of a medical chart review supported their hypothesis: In pediatric patients with recurrent abdominal pain without organic findings, but not in those with organically based abdominal pain, the number of symptoms of somatization disorder increased significantly with increasing chronicity of the child's abdominal pain (Ernst et al., 1984). In a subsequent study of a subset of the original sample, Routh and Ernst (1984) found that, in comparison to children with organically based abdominal pain, children with recurrent abdominal pain had significantly higher scores on the somatic complaints scale of the Child Behavior Checklist and also were significantly more likely to have relatives with somatization disorder (Routh & Ernst, 1984). Results of these studies were interpreted as evidence that pediatric recurrent abdominal pain may be a precursor of somatization disorder.

The purpose of the present study was to replicate and extend this work on the presence of somatization symptoms in RAP patients and their family members. Because Ernst et al. (1984) obtained data on the children's symptoms by retrospective chart review, they were unable to inquire specifi- cally about symptoms associated with somatization. In this study pediatric patients with abdominal pain were interviewed at the clinic visit in order to assess the number and severity of somatization symptoms. Based on the work of Ernst et al. (1984), it was hypothesized that there would be a significant relation between chronicity of abdominal pain and the level of

Somatization Symptoms 381

somatization symptoms in RAP patients but not in patients with an organic etiology for abdominal pain.

The DSM-III-R lists 35 possible symptoms of somatization disorder and requires 13 for a diagnosis (American Psychiatric Association, 1987). There is not a separate set of criteria for defining the disorder in children, despite the fact that prepubertal children would be unlikely to manifest several of the symptoms (e.g., pain during intercourse, severe vomiting throughout pregnancy). Thus, there is some question as to whether the disorder, as currently defined, can be diagnosed in children (Livingston & Martin-Cannici, 1985; Offord et al., 1987). Ernst et al. (1984) reported group means for somatization symptoms but did not indicate the number of children in their RAP and organic groups whose medical charts indicated 13 or more somatization symptoms. Furthermore, without a healthy control group it was not possible to know whether the study subjects had more somatization symptoms than would be found in a normal population. In the current study, in addition to examining the relation between chronicity of abdominal pain and level of somatization in abdominal pain patients, we included a comparison group of well patients and assessed the number of patients in each group (RAP, organic, well) who reported 13 or more symptoms of somatization disorder at the clinic visit and again at a 3-month followup.

An additional focus of this study concerned the relation between somatization symptoms in children and their parents. In a review of the literature on somatization and hypochondriasis, Kellner (1986) reported that patients with functional somatic complaints have more relatives with similar complaints than would be expected by chance (see Kellner, 1986, for a review). In the case of recurrent abdominal pain, Routh and Ernst (1984) found evidence of a high frequency of relatives, especially female relatives, who met the criteria for a diagnosis of somatization disorder. In this study we examined the data for evidence of an association between the severity of somatization symptoms in children and severity of similar symptoms in their mothers and fathers.

METHOD

Sample

Subjects were recruited from patients at the pediatric outpatient clinics of a university medical center. Their participation was part of a larger study which has been described elsewhere (Walker & Greene, 1989; Walker & Greene, 1991). The patients' mothers and fathers also were in-

382 Walker, Gather, and Greene

vited to participate. Consecutive new patients, ages 8 to 17, who presented for evaluation of abdominal pain of at least 1-month duration were eligible for the study. As in the Ernst et al. (1984) study, patients were excluded if they had a chronic medical condition other than abdominal pain. One month was set as the minimum pain duration for subject participation 4 in order for the initial subject pool to include not only RAP patients but also comparison patients with organic diagnoses who were expected to have a shorter pain duration than is typical for RAP patients. This subject recruit- ment procedure allowed researchers to be blind to patient diagnostic status during data collection, which occurred prior to the medical evaluation.

Most abdominal pain patients had been evaluated or treated pre- viously by primary care practitioners in the region, and one-third of the patients had a prior hospitalization for abdominal pain. They were referred to our tertiary care clinic because of continued symptomatology. The nature of the medical evaluation at the current clinic visit is described elsewhere (Walker & Greene, 1989).

Patients were classified into two groups on the basis of results of their medical evaluation. The recurrent abdominal pain (RAP) group (n = 41) consisted of patients for whom there was no identifiable organic etiology to explain abdominal pain. The organic group (n = 28) consisted of patients who were found to have an organic cause for abdominal pain. In the present study, organic causes were defined as those reflecting tissue pathol- ogy (damage, inflammation, structural change, abnormal growth). Most of the patients in the organic group had ulcer or ulcer-related disorders; diagnoses included gastritis (n = 9), esophagitis (n = 5), peptic ulcer disease (n = 4), duodenitis (n = 3), reflux esophagitis with antral gastritis (n = 1), gastritis and duodenal ulceration (n = 1), reflux esophagitis vs. peptic ulcer disease (n = 1), reflux vs, lactose intolerance (n = 1), constipation with megacolon (n = 1), nodular lymphoid hyperplasia (n = 1), and sal- pingitis (n = 1).

A comparison group of well patients (n = 41) consisted of individuals who had presented to the pediatric clinics for routine examinations, such as a school or sports physical, or for an acute minor illness that was resolved at the time of the research interview. Subjects were recruited such that this group would have the same ratio of boys to girls and children to adolescents as the RAP group.

The sample was primarily white, with one black patient in the RAP group, three black patients in the organic group, and three black patients in

4Minimum pain duration for RAP subjects in previous investigations has a broad range, e.g., 5 days (Astrada, Licamele, Walsh, & Kessler, 1981), less than 1 month (Ernst et al., 1984; Stone & Barbero, 1970), 1 month (Stickler & Murphy, 1979), 2 months (Berger, Honig, & Liebman, 1977) and 3 months (Apley, 1975; Hodges, Kline, Barbero, & Woodruff, 1985).


the well group. Analysis of variance indicated no significant difference among the diagnostic groups on the Hollingshead Index of Social Status (Hol- lingshead, 1975). The majority of participating families were in the middle class. Fathers (or father figures) were present in approximately 80% of the homes in each diagnostic group. Father questionnaire data were received for 74 of the 90 children (82%) who had fathers (or father figures) in the home.

Procedure

Parents of patients scheduled for evaluation of abdominal pain were contacted by telephone prior to their children's clinic appointments and invited to participate in the study. Informed consent was obtained from both parent and child at the clinic. The research protocol was administered to the child and parents separately at the clinic, prior to completion of the medical evaluation and diagnosis. Parents self-administered the question- naires after a brief explanation. An interviewer administered the question- naires orally to the children, who responded by selecting items on printed cards that gave the response format for each questionnaire. When the father was not present at the clinic, his questionnaire was sent home and returned by mail.

The comparison group of well patients was obtained by contacting parents of children who had been seen in the clinic for a well child visit or an acute minor illness. The majority of these patient families were administered the research protocols in their homes, allowing sufficient time from the clinic visit so that children who had presented for acute minor illnesses would have recovered.

Permission was obtained to contact the children's schools for information regarding school attendance. Followup interviews were conducted by telephone 3 months following the initial interview. Followup data were not available for five RAP subjects, two organic subjects, and six well subjects. This was due to inability to contact families who lacked a telephone or had moved without leaving a forwarding address.

Measures

Only those measures relevant to the current study are presented. Several measures described here were included in order to evaluate the construct validity of the Children's Somatization Inventory (CSI).

Chronicity of Abdominal Pain. At the initial interview mothers were asked to report how long the child had been complaining of abdominal pain. Chronicity was coded into three categories similar to those used by Ernst et


al. (1984). 5 Levels of chronicity were (a) three months or less, (b) more than three months but not more than one year, and (c) more than one year.

Child Behavior Checklist (CBCL). T h e C B C L ( A c h e n b a c h & Edelbrock, 1983) provides a standardized description of children's problem behaviors during the previous 6 months, as reported by their parents. It consists of 118 behavior problems, each scored on a 3-point scale. There are two broad-band subscales: The Internalizing Behavior Problems scale reflects fearful, inhibited, overcontrolled behavior; the Externalizing Be- havior Problems scale reflects aggressive, antisocial, undercontrolled behavior. Several narrow-band subscales also can be calculated. One of these, the Somatic Complaints scale, was used in this study. Originally derived by factor analysis (Achenbach & Edelbrock, 1983), it includes items referring both to somatic symptoms (e.g., nausea, headaches) and to other child behaviors (e.g., fear of school, worrying). Normalized T scores for the scales are standardized for child age and sex. These T scores were used in the present data analysis.

State-TraitAnxietylnventoryfor Children (STAIC). The trait anxiety form of the STAIC (Spielberger, 1973) was used to assess children's general level of anxiety. The instrument consists of 20 self-report items that are rated on a 3-point scale ranging from hardly ever to often and are summed to obtain a total score. Total scores can range from 20 to 60. Evidence supporting the instrument's reliability and validity is provided by Spielberger (1973).

Children's Depression Inventory (CDI). The CDI (Kovacs, 1980/1981; Kovacs & Beck, 1977) is a downward extension of the Beck Depression Inventory for adults (Beck, Ward, Mendelson, Mock, & Erbaugh, 1961). It is a child self-report instrument with 27 items scored on a 3-point scale. Each item represents a depressive symptom and is scored 0 for absence of the symptom to 2 for the most severe form of the symptom. Total scores range from 0 to 54. Mild depression is indicated by scores of approximately 9 or above, and moderate depression by scores of 16 or above. Studies of the psychometric properties of the CDI indicate good internal consistency, but test-retest reliability varies across populations and test-retest intervals (Saylor, Finch, Spirito, & Bennett, 1984). Validity studies demonstrate that the CDI has a high correlation with self-report measures of self-concept and can distinguish children with emotional distress from normal school children (Saylor et al., 1984).

5Ernst et al. (1984) coded chronicity in four categories: (a) 1 month or less, (b) longer than 1 month but not more than 1 year, (c) duration for a period more than 1 year following the child's sixth birthday, and (d) duration longer than 1 year with onset prior to the child's sixth birthday. Categories used in the present study differed somewhat because of the absence of children younger than 8 years or with pain of less than 1 month's duration.


Table I. Pearson Correlation Coefficients for the Children's Somatization Inventory with Other Measures (n = 110) a

CSI CBCL-I CBCL-E CBCL-S STAIC CDI

CSI CBCL-I .22 b - CBCL-E .01 .67 c CBCL-S .42 c .74 c STAIC .53 c .30 c CDI .43 c .24 b Age -.05 .01

.24 b

.17 a .25 a _

.18 d .20 a .69': .00 .10 .08

m

.02

aNote: CSI = Children's Somatization Inventory; CBCL-I = Child Behavior Checklist, internalizing scale; CBCL-E = Child Behavior Checklist, Externalizing scale; CBCL-S = Child Behavior Checklist, Somatic Complaints scale; STAIC = State-Trait Anxiety Inventory for Children, Trait form; CDI = Children's Depression Inventory.

bp < .01.

~p < .001. < .05.

School Absence. Schools were contacted and asked to provide the dates of children's absences during the school year. These da ta were used to calcu- late the number of school absences in the 3 months be tween the initial and followup interviews.

Socioeconomic Status (SES). Fami ly SES was m e a s u r e d by the Ho l - l ingshead F o u r - F a c t o r Index of Social Sta tus (Hol l ingshead , 1975). Scores range f rom 8 ( lowest SES) to 66 (highest SES).

Children's Somatization Inventory (CSI). The Children 's Somatizat ion In- ventory was constructed by the authors to include (a) symptoms from the DSM-I I I criteria for somatizat ion disorder (Amer ican Psychiatric Associat ion,

1980) and (b) symptoms from the Hopkins Symptom Checklist (Derogatis , Lipman, Rickels, Uhlenhuth , & Covi, 1974) that have a pr imary factor loading on the somatizat ion subscale of that instrument. 6 (Four symptoms that are

included both in the Hopkins Symptom Checklist and the D SM -I I I cri teria are listed only once on the CSI.) Symptoms from the following four D S M - I I I categories are included: (a) conversion or pseudoneurological (e.g., fainting, difficulty swallowing), (b) gastrointest inal (e.g., abdominal pain, nausea) , (c) pain (e.g., back pain), and (d) card iopulmonary (e.g., dizziness, shortness of breath) . Psychosexual symptoms and female reproduct ive symptoms were not included as they are not relevant for most children. 7 The list of symptoms is read to the child. The child rates the extent to which he or she experiences each of the 36 symptoms on a 4-point scale ranging from not at all to a whole

6An additional somatic symptom from the HSCL, i.e., constipation, was included on the CSI although it did not have a primary factor assignment on any of the HSCL factors.

7These symptoms also were omitted in the work of Ernst et al. (1984).


lot. A total score is obtained by summing the ratings and can range from 0 to 108.

Coefficient alpha for the CSI was .88. The 3-month test-retest reliability coefficient using Pearson correlations was .50 (p < .001) for the well group, and .66 (p < .001) for the RAP group. As expected, the test-retest reliability coefficient was not significant for the group of organic patients (r = .13, n.s.), the majority of whom had received medical treatment for their condition.

The correlation of the CSI with several measures of distress known to be associated with somatic complaints (e.g., Lipscomb & Katon, 1987; Orenstein, 1989) provided evidence regarding the instrument's construct validity (see Table I). The CSI correlated significantly with the CBCL internalizing scale and the CBCL somatic complaints scale. The CSI also showed discriminant validity in that it did not correlate significantly with the CBCL externalizing scale, which reflects behavioral acting out rather than a child's experience of distress. There were significant positive correlations between the CSI and anxiety and depression on the STAIC and CDI, respectively, reflecting the association between symptoms of emotional and somatic distress. These correlations were lower, but still significant, when the items referring to somatic distress were removed from the STAIC and the CDI (r's = .41 and .28, p < .001, respectively). There also was a significant positive correlation between the CSI and frequency of school absences in the 3 months following the initial interview (r = .44,p < .001). Finally, there was a low but significant inverse correlation between CSI scores and family SES (r = -.26, p < .01), indicating that children from lower social classes tended to score higher on the CSI. Additional psychometric information about the CSI is available in a recent paper by Garber, Walker, and Zeman (in press).

Adult Somatization Inventory (ASI). Developed by the authors to assess somatization in parents, the ASI lists the same 36 somatic symptoms as the CSI and was used to assess symptoms of somatization in the child's mother and father. Parents rate the extent to which they experience each symptom on a 4-point scale, and a total score ranging from 0 to 108 is obtained by summing the ratings. Internal consistency of the scale was adequate, with alpha reliability coefficients of .89 for mothers and .93 for fathers.

RESULTS

Relation Between Chronicity of Abdominal Pain and Somatization Symptoms

The relation of chronicity of abdominal pain to severity of somatization symptoms reported at the time of the clinic visit was examined in a


Diagnostic Group x Abdominal Pain Chronicity repeated-measures analysis of variance (ANOVA) with CSI score as the dependent variable. Contrary to the results reported by Ernst et al. (1984), there were no main or interaction effects involving abdominal pain chronicity. The interaction of Diagnostic Group with Time of Administration was significant, F(1, 54) = 4.16, p < .05. A univariate A N O V A for Diagnostic Group with post hoc analysis using Duncan 's Multiple Range Test indicated significantly higher CSI scores at the initial administration in the RAP and organic groups in comparison to the well group, F(2, 107) = 18.59, p < .001 (for RAP, M = 20.34, SD = 12.10; for organic, M = 23.39, SD = 12.76; for well, M = 7.93, SD = 9.98). At the 3-month followup there was a significant difference among the diagnostic groups, with RAP patients scoring significantly higher on the CSI than either organic or well patients, F(2, 94) = 5.94, p < .01 (for RAP, M = 10.83, SD = 9.41; for organic, M 5.81, SD = 5.37; for well, M = 5.64, SD = 5.64). 8

Endorsement of 13 or More DSM-III-R Somatization Disorder Symptoms

A score was calculated for each subject representing the number of DSM-I I I -R somatization disorder symptoms that were endorsed on the CSI, regardless of intensity. In the initial interview, nine RAP patients (22%), six organic patients (21%), and two well patients (5%), X2(2) = 55.44, p < .001, reported 13 or more of the symptoms listed in the DSM- I I I -R criteria for somatization disorder. At the 3-month followup, six RAP patients (17%) reported 13 or more symptoms of somatization disorder, whereas no patients in the organic group and only one patient in the well group met this criterion, Z2(2) = 73.12, p < .001.

We further examined the data for reports of 13 or more symptoms at both the initial and 3-month interviews to examine maintenance of somatization symptoms. Three subjects in the RAP group (8%), and none in the other groups, maintained this number of symptoms. It is noteworthy that each of these three identified subjects reported symptoms from all four symptom domains in the DSM-III -R criteria for somatization disorder.

SAs an additional comparison of our symptom data with those reported by Ernst et al. (1984), who counted the number of symptoms noted in children's medical charts, we calculated the number of DSM-III somatization disorder symptoms that each subject endorsed on the CSI, regardless of intensity. Results of the Diagnostic Group x Abdominal Pain Chronicity repeated-measures analysis of variance yielded a pattern of results similar to what had been found for CSI total scores.


Relation Between Child and Parent Somatization

As a first step in examining the relation between somatization in children and in their mothers and fathers we examined the data for evidence that the slope between child and parent somatization scores did not differ significantly for the RAP, organic, and well groups. This was done by conducting an analysis of covariance comparing CSI scores of children in the three groups, with parent ASI scores as the covariate, and testing the assumption of homogeneous regression coefficients. Separate analyses were done with mothers' and fathers' ASI scores as covariates. Significant interactions between Diagnostic Group and maternal ASI score, F(2, 102) = 4.71, p < .01, and between Diagnostic Group and paternal ASI score, F(2, 68) = 6.44, p < .01, indicated that the relation between child and mother somatization scores and between child and father somatization scores differed for the three groups. Therefore, the relation between child and parent somatization scores was examined in separate regression analyses for each diagnostic group. For the RAP group, the regression equation predicting child CSI scores from maternal ASI scores was significant, F(1, 38) = 9.51, p < .01, R 2 = .20, beta = .45, as was the equation predicting child CSI scores from paternal ASI scores, F(1, 30) = 7.55, p < .01, R; = .20, beta = .45. Higher CSI scores in RAP patients were associated with both higher mother and father ASI scores. Similar regression analyses for the organic and well groups were not significant. Thus, for RAP patients but not for organic or well patients, higher parent somatization scores were associated with higher child somatization scores.

DISCUSSION

Results indicate that pediatric patients with recurrent abdominal pain report high levels of somatization symptoms at the clinic visit and are significantly more likely than well patients and patients with organically based abdominal pain to maintain these symptoms 3 months following the clinic visit. Followup investigations of RAP patients rarely have reported subsequent organic findings that would explain the patient's original complaints (Apley, 1975; Christensen & Mortensen, 1975; Stickler & Murphy, 1979). Nevertheless, it is possible that in some RAP patients continuing abdominal pain and other symptoms reflect an as yet undiagnosed organic disease or physiological processes (e.g., aberrations in intestinal motility) that create physical discomfort but are not associated with organic pathol- ogy (cf. Barr & Feuerstein, 1983). If this is the case, then the symptomatology of RAP patients may one day be understood as a consequence of


limitations in medical diagnosis and available treatment. On the other hand, several psychological explanations for the etiology

and maintenance of symptoms associated with somatization disorder have been proposed (see Kellner, 1986, and Kirmayer, 1986, for reviews) and may be relevant to RAP. In addition to the view that more severe somatic symptomatology may represent a distinct psychiatric clinical entity, somatic complaints that are disproportionate to objective findings have been ex- plained as the manifestation of underlying anxiety or depression (e.g., Katon, 1982; Lesse, 1967), as the result of a cognitive style of heightened awareness of bodily sensations (e.g., Barsky, 1979; Barsky & Klerman, 1983), as an expression of family system distress (Minuchin, Rosman, & Baker, 1978), and as responses learned through family modeling and reinforcement (e.g., Edwards, Zeichner, Kuczmierczyk, & Boczkowski, 1985).

In this study, higher levels of somatization symptoms in both mothers and fathers were associated with higher levels of somatization symptoms in RAP patients. Although genetic explanations should be considered (e.g., Sigvardsson, Van Knoving, Bohman, & Cloninger, 1984), this link between parents' and children's levels of symptomatology is also consistent with the notion that exposure to persons with health concerns increases somatic preoccupation and symptom reporting even in the absence of disease (Pen- nebaker, 1982; Rodin, 1978). When children from families for which illness is salient experience negative emotional states that make them "feel bad," they may direct their attention to the somatic components of their distress. In such families, illness may be the most readily available explanation of the cause of a child's discomfort.

Modeling and reinforcement of illness behavior by family members also may influence the development or maintenance of symptoms in RAP patients. Results of recent investigations suggest that parent modeling of illness behavior contributes to the development of symptom complaints in otherwise healthy children (Osborne, Hatcher, & Richtsmeier, 1989; Rick- ard, 1988). Moreover, Whitehead and colleagues have argued that both hypochondriacal complaints (e.g., chronic pain syndromes) and symptoms related to physiological processes about which people have good subjective percept ion (e.g., irritable bowel) are influenced by social learning (Whitehead, Fedoravicius, Blackwell, & Wooley, 1979). Recurrent abdominal pain may be a heterogeneous category that includes patients whose symptoms are hypochondriacal and others whose symptoms reflect actual underlying disease or physiological dysfunction. The possibility that for some RAP patients these symptoms are due to social learning processes described by Whitehead is consistent with our finding that higher levels of somatization symptoms in mothers or fathers were associated with higher levels of somatization in RAP patients. The fact that this was not the case


for organic patients also would have been predicted by Whitehead, who suggested that because there is little subjective awareness of gastric acid secretion, the symptoms of ulcer-related conditions (such as those in our organic group) are less likely to be learned responses.

Although it is not uncommon for children and adolescents to report symptoms associated with somatization disorder, they rarely report the number of symptoms required for a diagnosis of somatization disorder (Shapiro & Rosenfeld, 1986). The criteria for a DSM-III-R diagnosis of somatization disorder include a history of many physical complaints for several years and 13 specific symptoms that are not due to physical disease but have resulted in alteration of activities or use of medication or health services. Thus, endorsement of 13 somatization symptoms is not by itself sufficient for a diagnosis of somatization disorder, although failure to en- dorse 13 symptoms would indicate that the child did not meet one of the essential criteria for this diagnosis. In our study, three RAP patients maintained 13 or more somatic symptoms over three months. Information about extent of disability, health service utilization, and potential physical disease associated with each of these symptoms was not available and it was not known whether the patients also had a history of physical complaints for several years; thus, we cannot determine whether these three patients would have been diagnosed as having somatization disorder. Nevertheless, the majority of children with recurrent abdominal pain in this study would not have qualified for a diagnosis of somatization disorder.

Ernst et al. (1984) suggested that RAP is a precursor of somatization disorder on the basis of their finding that in RAP patients, but not in organic patients, the number of symptoms of somatization disorder increased with the chronicity of abdominal pain. Given this trend, Ernst et al. (1984) speculated that by the time they reached adulthood, some RAP patients would meet the criteria for somatization disorder. In our data, however, chronicity of abdominal pain was not related to severity of somatization scores on the Children's Somatization Inventory or to the number of symptoms of somatization disorder endorsed on the CSI. Differences in the methodology of the two studies may help to explain these conflicting findings. Ernst et al. (1984) obtained information about somatization symptoms from medical charts. The recording of somatization symptoms in the medical chart depended on the attending physician, who might have biased the data in a systematic manner; e.g., because patients with chronic abdominal pain of unknown etiology presented a more puzzling clinical picture, the physician may have been more thorough in documenting their concurrent symptoms than those of other patients, resulting in an association between RAP chronicity and number of somatization symptoms. The fact that subjects in this study were recruited from a tertiary care setting


while subjects for the Ernst et al. (1984) study came from a primary care setting also may have contributed to differences in results obtained by the two studies. Interpretation of findings is further complicated by potential problems with the measure of abdominal pain chronicity, which was defined in Ernst et al. (1984) and our study as time since initial onset of abdominal pain. Some children with RAP are free of abdominal pain for several months at a time, whereas others rarely experience more than a few days without pain. Thus, it would be appropriate in future research to use a measure of abdominal pain chronicity that includes both duration (time since initial onset) and frequency of pain episodes. Finally, a prospective study spanning several years really is necessary in order to examine the relation between childhood abdominal pain and somatization disorder during adulthood, as well as to identify factors that can be used to predict which RAP children, if any, go on to reach the criteria for somatization disorder.

Shapiro and Rosenfeld (1986) noted in their review of the literature on somatization symptoms in children that differences in the methods of assessing symptoms may account for inconsistencies in estimates of the in- cidence of these symptoms. Somatization symptoms have been assessed in a variety of ways including medical chart review, parent report, and child self-report. Given that definit ions of somatization (e.g., APA, 1987; Lipowski, 1988) emphasize the subjective perception of symptoms, child self-report measures should be included in research and clinical work in this area. The Children's Somatization Inventory may be a useful tool for assessing children's subjective reports of somatization symptoms. The CSI had good test-retest reliability for well patients and for patients with recurrent abdominal pain. The concurrent validity of the instrument was supported by the correlation of CSI scores with the somatic complaints scale of the CBCL. Evidence of discriminant validity was apparent by the lack of correlation between CSI scores and externalizing symptoms as assessed on the CBCL. Construct validity of the CSI was supported by its correlation with number of days of school absence and with measures of emotional distress that typically are associated with somatic complaints (cf. Kellner, 1986; Orenstein, 1989). It should be noted, however, that at the time of the clinic visit the CSI did not discriminate between patients with and without an identifiable organic etiology for abdominal pain. This finding underscores that, as with all such self-report inventories, the presence of physical disease must be ruled out before it can be assumed that the CSI is a measure of somatization symptoms (cf. Kellner, 1986).

Assessment of somatization in children presents unique difficulties. First, because there are limitations in children's ability to remember and to report symptoms (Kovacs, 1986), symptom persistence over time may


need to be assessed by parental report. The difficulty with this method, however, is that there typically is poor concordance between parents' and children's reports of children's subjective symptoms (cf. Kashani, Orvaschel, Burk, & Reid, 1985; Kazdin, French, Unis, & Esveldt-Dawson, 1983), thus bringing into question the validity of parental report of these symptoms. Second, decisions to limit a child's activities and obtain health services are likely to be made by the mother and may reflect her own characteristic illness behavior rather than the child's level of somatization (cf. Newacheck & Halfon, 1986). Thus, because child illness behavior is typically influenced by parents, the relation between subjective and objective health is even more complex in children than adults. Despite these difficulties, further research on the determinants of children's symptom reporting and associated illness behavior is important as styles of under- and overreporting of symptoms become highly stable by adulthood (Costa & McCrae, 1985) and contribute to the appropriateness of health service utilization.

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