Chronic physical complaints represent significant morbidity in children, with frequent doctor visits, school absence, and social disability. The most common complaints reported by children include headaches, stomachaches, musculoskeletal pains, dizziness, and fatigue. Teenage girls tend to report more somatic symptoms than boys. '
Pain should be viewed as a signal that a child may be under stress, anxious, or depressed. It is the job of parents and pediatricians to decipher that message and go beyond simple reassurance. Emotional issues often go unrecognized, and a recent study showed approximately 7.5% of an adolescent sample reported significant depressive symptoms, but only 11% to 15% of diese children sought help.2 Many of these children and adolescents end up in the pediatrician's office with vague physical complaints. They have risks of greater future problems including substance abuse, recurrent physical symptoms, academic and behavioral problems, and even suicide.
Working with children is complicated by the fact that children and teenagers may not talk about emotional issues directly. However, parents can learn to better decipher nonverbal signals,3 and programs such as the Columbia University Teen Screen Program (www.teenscreen.org) can help identify psychiatric illness in youth.
It can be a challenging task for the pediatrician to evaluate these symptoms since it often is unclear if a child is "truly ill," but nevertheless, the effects of stress can be subtle and insidious and often not apparent to the child or parents. In assessing such symptoms, it is essential for pediatricians to view the physical symptoms, even if they seem to be occurring in the context of stress or psychiatric illness, to be real. Such symptoms are as real to a child as physical symptoms from a medical illness, and these children are generally not faking or malingering. In fact, common biological pathways may predispose a child to having both physical and emotional symptoms, mediated by neurotransmitter systems such as those using serotonin, and influenced by stress in the environment
STRESS IN CHILDREN ANDADOLESCENTS
Children today are under greater stress, including threats of terrorism, violence in schools and the community, drugs, sexual issues, human immunodeficiency virus, and the Internet, that previous generations did not have. Academic pressures, extracurricular activities, an emphasis on achievement, competitiveness, and pressure from parents and family can further lead to a heavily loaded emotional environment for children.
The effects of stress on children can manifest as disturbances in physiological functioning including sleep and appetite, alterations in mood including moodiness, anxiety, and withdrawal, and recurrent physical symptoms including headaches, stomachaches, musculoskeletal pain, and rashes. Recent research has linked immune function, stress, and emotional disorders, which suggests common biological pathways may affect all of these areas simultaneously. In the field of psychoneuroimmunology, links among behavior, the central nervous system, the peripheral nervous system, hormones, and the immune system have been identified.
Stress has been related to immune response.4 In animal models, the effects of stress have been shown to correlate with the dose and time response of the stressor. Lymphocyte responses, T-cell suppression, delayed hypersensitivity, graft versus host response, and natural killer cell activity have all been shown to be related to stress; fear has been shown to determine the level of immunosuppression in certain contexts. In addition, aversive stressors have been related to disease susceptibility with respect to viral, paracytic, and neoplastic agents; the effects seem to depend on the virulence of the illness and the psychosocial stressors.4
A greater incidence of asthma and allergic rhinitis occurs more frequently in stressed children with limited coping strategies.58 Streptococcal throat infections and elevated Antistreptolysin O titers have been found in family members with high stress levels.9 Recurrent colds, increased incidence of flu, and decreased salivary IgA levels have been found to be related to stress.10
Depression has been related to immunity in children, with the severity of depression linked to lower natural killer cell activity in hospitalized adolescents." In addition, increased B cells and lower natural killer cell activity have been found in patients with conduct disorder compared to adolescent patients with major depressive disorder and normal patients aged 11 to 18.12 Depressed prepubertal children have lower natural killer cell activity compared with healthy children.13
Finally, stress has been connected with the neuroendocrine axis,14 with increased maternal prenatal stress correlated with temperament changes in infants at 8 months; this is theorized to be mediated by an altered hypothalamic-pituitary-adrenal axis.15 Such prenatal stress may increase the risk of future anxiety, mood, and behavioral disorders.
PAIN SYNDROMES IN CHILDREN AND ADOLESCENTS
In a large community-based sample, at least one physical symptom was present in 13.3% of girls, with 10% having headaches, 2.8% having abdominal pain, and 2.2% having joint pain.1 The physical complaints were defined as being present at least 1 hour per day, three times per week for 3 months.
One or more physical complaints were reported by 60% of girls with an anxiety disorder, and 69% of girls with stomachaches and headaches also had anxiety disorders. Girls with headaches and stomachaches had higher rates of generalized anxiety. Musculoskeletal pains alone and with stomachaches were associated with separation anxiety in girls. The diagnoses in boys with stomachaches included oppositional behavior and attentiondeficit/hyperactivity disorder.
Overall, girls with anxiety disorders had 100 times the risk of having both stomachaches and headaches together, and headaches were linked with depression and anxiety disorders, with a 4 times higher prevalence in depressed girls. The authors concluded chronic pain is often associated with psychiatric syndromes.1
Other studies have found associations between recurrent abdominal pain and anxiety in children.16 Psychopamology in children and adolescents with recurrent abdominal pain and tension headaches has been related to psychopamology and expressed emotion in their mothers and family functioning17; a relationship between negative life events and recurrent abdominal pain and headaches also was found.
In another study, 81.6% of children with recurrent abdominal pain and 83.9% of children with headaches, respectively, had a psychiatric diagnosis, primarily anxiety or depressive disorders. Similar diagnoses were found in only 15% of healthy children.18
Children with physical complaints tend to miss more school, do more poorly in school, and use health care services to a greater degree.19 These children also have more internalizing emotional symptoms. Children with recurrent abdominal pain are predisposed to anxiety disorders in adultiiood.20
Exposure to an ill parent during childhood may be a risk factor for somatizing disorders in adults.21 Somatizing mothers had a greater incidence of a history of childhood neglect and physical illness in a parent, and children of these somatizing mothers were more likely to have health problems than children of healthy motiiers or momers with true medical illness. Children of somatizing mothers also were found to have had more contact witir family doctors.
A physical examination and routine laboratory work often can quickly determine whether symptoms are related to a medical illness. It also is important to look at the pattern of symptom occurrence. For example, physical symptoms related to anxiety over school might be seen on weekday mornings just before me child leaves for school. Nonspecific or more centralized stomach pain typically is less likely to be related to pathology in the abdomen than localized pain. However, it also should be remembered that even genuine medical syndromes such as hypertension, asthma, or diabetes can be worsened by stress and that emotional factors should not be discounted if a medical condition is present.
Approaches to clinical management of suspected psychiatric disorders include such diagnostic issues. If there is a comorbid medical condition, the direct effects of illness and decreased sleep on mood, anxiety and behavior must be considered. In addition, medication side effects and the effects of hospitalization can influence a child's emotional status.
Neurovegetative symptoms affecting sleep, appetite, and energy level are often not specific indicators for psychiatric illness. Cognitive symptoms of depression such as hopelessness, diminished self-worth, and suicidal ideation tend to be more specific for depression in the medically ill population.
Untreated pain, comorbid psychiatric syndromes, neuropsychiatrie syndromes, unexplained syndromes, and somatoform disorders should be considered. Psychiatric referral should be made if a comorbid or a primary psychiatric diagnosis is suspected of contributing to physical symptoms.
Treatment for chronic pain syndromes must focus on adaptation and rehabilitation, not convalescence, with an effort to increase functionality. Children with pain syndromes must learn to function normally despite the chronic symptoms and be given coping strategies to deal with pain.
When working with families to treat chronic physical complaints, it is important not to view the symptoms as a disability, which may represent more of a psychological construct than actual physical disease. Part of the treatment must be psychosocial and familial in nature, with areas of stress in social, academic, and home areas identified and addressed. This approach emphasizes that the child must learn to function normally despite the chronic symptom, such as headaches or abdominal pain. Children should be taught coping strategies, such as relaxation exercises and hypnosis, that help reduce pain and discomfort.
In a study examining the efficacy of treatment for recurrent abdominal pain, therapies that used famotidine, pizotifen, cognitive behavioral therapy, biofeedback, and peppermint oil entericcoated capsules were effective.22 The effects of dietary fiber were less conclusive, and the use of a lactose-free diet was not associated with improvement. There was greater improvement when these therapies were specifically used to treat functional gastrointestinal disorders including dyspepsia, abdominal migraine, and irritable bowel syndrome. The behavioral interventions had a greater positive effect on children with nonspecific recurrent abdominal pain.
Specific psychopharmacologic treatments for pain complaints are beyond the scope of this article but may include antineuropathic agents such as tricyclic antidepressants, antiepileptic agents, clonidine, antihistamines, steroids, and antiserotonin agents. Acute pain can be treated with acetaminophen, nonsteroidal antiinflammatory drugs, COX-2 inhibitors, or when severe, opioids. Comorbid psychiatric syndromes often can be treated with antidepressants, eg, selective serotonin reuptake inhibitors used in the treatment of anxiety and depression.
It is important to underscore that psychopharmacologic agents may not work specifically by treating psychiatric syndromes, but may have generalized effects on the central nervous system, such as medications that affect serotonin, the predominant neurotransmitter in the gut. The psychopharmacologic treatment of medically ill children and adolescents has recently been reviewed.23
With respect to principles of intervention, these should be evidenced-based if possible. Symptoms that cause significant distress and impairment should be targeted with objective criteria to judge improvement, and a collaborative approach used. Pediatricians should use an integrative model in understanding physical symptoms and try to "de-pathologize" the intervention, noting negative effects of stress on pain if psychiatric symptoms are being treated. The psychiatric diagnosis, however, is one of exclusion, and the underlying medical condition must be diagnosed and treated first.
The goals of medication if used must be to improve comfort, reduce distress, reduce impairment, and treat symptoms negatively impacting on any medical treatment. Symptoms should be targeted, a manner of assessing response be instituted, and a review of potential side effects discussed with the patient and family.
With respect to treatment of pain, pediatricians should discuss the potential side effects both of the specific agents used as well as the potential morbidity of not treating pain. Chronic pain carries significant morbidity including disability as well as iatrogenic insult by the use of invasive test procedures and medication, and empirical treatment may be warranted in some situations.
When using medication to treat pain, an alliance with the family and all physicians involved is essential. A discussion of when medications can be removed or reduced should be part of the initial plan. The child's mental status should be monitored for adverse effects, and medications with lower risk should be chosen first.
Comorbid psychiatric syndromes or symptoms may improve with psychoactive medication, and pain syndromes without clearly defined medical illness also may benefit from psychoactive medication at times. It is important to remember that psychotropic medications can have effects independent of their "psychiatric effects." It is also essential to take into consideration that pharmacokinetics and pharmacodynamics are altered medical syndromes and this influences how medications are dosed. It is essential that a team approach is used.
Parents must realize that pain may indicate more than just a physical ailment, and pediatricians can teach parents how to evaluate physical symptoms and "mind/body interactions." Pediatricians can teach parents how physical symptoms may mask emotional difficulties, and then instruct parents on ways to reduce stressrelated illnesses, understand the warning signs, and then take action even before a child gets sick. In addition, pediatricians can help parents be more receptive toward psychological intervention.
Parents should be educated on evaluating physical symptoms in their children and deciding when to visit the pediatrician or keep their child home from school. If a child is depressed or anxious, and it is causing distress or affecting the child's life in a significant way, a psychologist or psychiatrist should evaluate the child. In addition, contacting the child's teacher or school psychologist to see how the child is doing in school, emotionally, socially, and academically may be warranted.
Once the underlying factors are identified, a plan that addresses the causes can be formulated. Such a plan might include measures to reduce stress, treat an emotional condition, or teach coping strategies. In addition, parents should examine their own stress levels, emotional wellbeing, and relationships with their partners and with their children since these factors may affect a child's well-being.
Parents should not cultivate a philosophy of disability or allow symptoms to be a child's excuse to avoid important areas of his or her life, whether it be social or academic. Parents need to become savvy to the potential "secondary gain" a child might get from a physical symptom, if the symptom removes the child from a stressful situation.
On the other hand, children should not be forced into an overwhelmingly stressful situation. Children should be exposed to stress in a gradual way, and this should be combined with teaching them ways to cope with and process stress.
Parents need to promote stress-reducing activities within the family, such as spending unstructured time together, taking family vacations, and eating dinner together. Parents also should be encouraged to find things their children enjoy, such as art, music, and sports, that will reduce stress.
Parents need to examine their family lifestyle, which includes sleep, diet, exercise, and "down time." They need to promote healthier eating habits and regular physical activity, and look carefully at who is teaching, coaching, and mentoring their children. When children are thought to be under stress as evidenced by a change in behavior or the appearance of physical symptoms, parents should try to identify where the stress is coming from, find ways to reduce the stress if it is in specific areas such as social or academic, and help their children learn better ways to deal with stress.
Children should be taught strategies for coping with stress in a proactive manner including self-talk, deep breathing, distraction, and muscle relaxation. They should be encouraged to diffuse stress with activities such as sports and art. Children should be given outlets for reducing stress both inside and outside of the family.
It is helpful when parents communicate in an optimal fashion with their children. Children are often indirect when tiiey communicate ideas, but they may be overly concrete at the same time. They may not want adults to know what they are thinking about and may actually conceal feelings. Children can misread things they see and hear, and draw conclusions about life based on these misconceptions.
Finally, parents should pay close attention to their child's social connections and help their child take greater responsibility for improving his or her diet, fitness level, self-image, and satisfaction, as well as trying to set a good example. Parents should try to teach their children to deal with things by looking at the "big picture," how they feel, eat, sleep, play, and exercise both meir minds and bodies.
SEEKING PSYCHIATRIC CONSULTATION
Parents should be encouraged to see a mental health professional when there are symptoms in two or more domains of functioning (home, friends, school, and self-perception), when there is significant distress or impairment in functioning, or when the course of a medical illness is adversely affected by emotional symptoms. Parents, with the help of pediatricians, can be taught to hone their skills when observing an ill child and become more sensitive about what to look and listen for, become better at recognizing and deciphering distress signals, and keeping open lines of communication.
Pain syndromes in children are common and can often be associated with stress, which can have biological as well as psychiatric concomitants. After a comprehensive evaluation is performed, an overall intervention plan should be presented to the child and family.
Pediatricians need to be sensitive to the negative stigma attached to treatment directed at mood and behavior, and nonpharmacologic interventions should be considered before any psychopharmacologic intervention is instituted. Finally, pediatricians should always regard pain as "real," and the child psychiatrist can play an important role in integrating care of patients with chronic physical complaints.
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