Keywords

Introduction: Somatic Syndromes in Youth

Health complaints and somatic symptoms such as headaches, abdominal pain, non-cardiac chest palpitations, musculoskeletal pain, nausea, vomiting, dizziness, and fatigue are common in children and adolescents. Up to one-third of children and adolescents experience recurring and/or chronic functional somatic symptoms (FSS), for which no well-defined physical disorder is identified to explain the symptoms (Campo, 2012; Korterink et al., 2015). Four to 10% of these children will experience persistent symptoms and these can have serious psychosocial implications in the medium to longer-term (Rask et al., 2018). When these symptoms are recurring and increase in intensity, a growing and evolving body of literature has shown that they are related to functional impairment, as well as psychosocial problems, and a reduction in overall quality of life (Kangas et al., 2020). However, the assessment and treatment of debilitating and recurring somatic symptoms in children and adolescents has been hampered by a lack of consensus in definitions and terminology, which has further been impacted by changes across the diagnostic nomenclature for somatic syndromes including the change in focus of somatic criteria stipulated between the fourth and current, fifth editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV/TR (1994; 2001); DSM-5/TR; American Psychological Association, 1994, 2001, 2013, 2022) and the criteria for somatization disorder and bodily distress disorder in the International Classifications of Diseases and Related Health Problems codes (ICD-10 and ICD-11; World Health Organization).

The objective of this chapter is to provide an overview of the prevalence and characteristics of somatic syndromes in children and adolescents, and diagnostic and assessment methods used to screen for somatic syndromes in youth, as well as evaluating the current evidence base for psychological interventions for managing somatic symptoms in children and adolescents. First, an overview of common definitions used in this field will be presented, followed by an overview of features characterizing somatic syndromes in children and adolescents. A summary of key components of biopsychosocial conceptual models in this field will also be presented as a heuristic framework to facilitate assessment and treatment evaluations. A review of current, relevant diagnostic frameworks and assessment methods including validated measures used to screen and assess children and adolescents for recurring somatic symptoms is then presented. This is followed by a review of the evidence base for the psychological treatment of somatic syndromes in children and adolescents presenting for therapy. The chapter concludes with clinical implications for practitioners working with children and adolescents with somatic syndromes as well as highlighting gaps that need to be addressed in future research to further advance the assessment and treatment evidence-base for somatic syndromes in youth. For the purpose of this chapter, the term “youth” will refer to both children and adolescents.

Prevalence of Somatic Syndromes in Youth

A variety of terms have been used to refer to recurring somatic complaints in youth related to pain and/or discomfort and which have no clear pathophysiology (Campo, 2012; Walker, 2019). These terms include functional somatic syndromes (FSS) (Kangas et al., 2020), medically unexplained symptoms, physically unexplained symptoms, bodily distress syndrome, persistent physical symptoms, and persistent somatic symptoms. More specialized terms have also been used focusing on specific sites (or clusters) of symptoms including functional abdominal pain (FAP); recurrent abdominal pain (RAP); functional gastrointestinal disorders (FGIDs), chronic fatigue syndrome (CFS), and functional intestinal bowel syndrome (functional IBS). The term “functional” in this body of literature is typically used (e.g., FSS, FGIDs, and functional IBS) to denote that no clear pathophysiological cause has been detected to explain the onset and maintenance of symptoms and/or clusters of symptoms.

The DSM-5 (American Psychiatric Association, 2013) introduced the category somatic symptom and related disorders (SSRDs) to capture somatic-related psychological disturbances in individuals across the life span. The DSM-5/TR (2013; 2022) category comprises seven specific types of disorders including somatic symptom disorder (SSD), illness anxiety disorder (formerly known as health anxiety or hypochondriasis), functional neurological symptom disorder (conversion disorder), psychological factors affecting other medical conditions, factitious disorder, other specified somatic symptom and related disorder, and unspecified somatic symptom and related disorder. A common feature across these disorders is the recurrence of somatic symptoms and/or illness anxiety which is associated with heightened, significant distress and impairment in functioning (American Psychological Association, 2013; 2022). Whereas the previous DSM-IV/TR criteria for somatoform disorders (1994; 2001) placed a heavy focus on the centrality of symptoms being unexplained by recognized pathophysiological processes, the DSM-5/TR (2013; 2022) criteria have shifted from an absence of symptoms to the presence of somatic symptoms, notably distressing somatic symptoms associated with maladaptive thoughts, feelings, and behaviors in response to these symptoms. With the introduction of the SSRD category in DSM-5, the term SSRDs has also been used in the literature focusing on youth experiencing recurring somatic syndromes (e.g., Ibeziako et al., 2017; Winarizal et al., 2020). Additionally, the introduction of the Bodily Distress Disorder (BDD) in the International Classification of Diseases (ICD-11; World Health Organization, 2018) further captures a constellation of physical/somatic symptom presentations categorized into one of four groups including cardiopulmonary, gastrointestinal, musculoskeletal, and general symptoms group. Importantly, the interchangeable use of somatic symptom terminologies such as FSS, medically unexplained symptoms, and persistent physical symptoms with diagnostic conditions such as somatic symptom disorder (SSD) and BDD is problematic when assessing children presenting with somatic health complaints (Blake et al., 2018). Due to developmental considerations, some children and adolescents may not necessarily meet all the criteria for any of the DSM or ICD somatic-related disorder codes, although they may still present for treatment due to recurring and distressing somatic symptoms which are causing functional impairment (Kangas et al., 2020). Hence, for the purposes of this chapter the term “somatic syndromes” will be used to refer to children and adolescents with recurring somatic symptoms (either singular and/or multiple symptoms) which cause significant functional impairment. In line with other researchers (e.g., Brostrom, 2019, Kangas et al., 2020; Walker, 2019), the use of term “somatic syndromes” refers to a dimensional phenomenon, without assumptions referring to any specific organic cause.

Prevalence and Characteristics of Somatic Syndromes in Youth

The prevalence of somatic syndromes in youth is highly variable contingent on the range of terminology and diagnostic frameworks that are used within this field, including the presence of chronic pain (e.g., Rief et al., 2017). The estimated prevalence of FSS has been reported to be between 4% and 30% (Elliott et al., 2020; Geist et al., 2008; Rask et al., 2018), with prevalence rates being lower (between 4% and 10%) for youth whose symptoms contribute to substantial adverse impacts on functionality (Rask et al., 2018). Similarly, using diagnostic frameworks, research has indicated that between 10% and 15% of children and adolescents meet the criteria for SSRDs (Ibeziako et al., 2019; Winarizol et al., 2020). In children, the most common somatic complaints include recurring headaches, abdominal pain, fatigue, and nausea (American Psychiatric Association, 2022; Ng et al., 2016; O’Connell et al., 2020).

Moreover, due to the heterogeneity in symptom presentations, some children may present with only singular site symptoms of pain and/or discomfort (e.g., RAP or headaches), while others may present with multiple symptoms. It is noteworthy that the actual presence of any somatic symptoms is high in childhood. It is therefore important to differentiate between symptom presence per se relative to the recurring, chronicity of symptom presence and intensity, and the impact this has on functioning. The latter denotes the ability to perform activities of daily living expected commensurate with a child’s developmental milestones (Winarizol et al., 2020).

There is an increasing body of literature demonstrating that recurring somatic syndromes in youth have a significant impact on functioning. Recurring somatic symptoms are a predictor of school absenteeism (Korterink et al., 2015), decline in academic performance (Janssens et al., 2014), and poor peer and social interactions (Mackner et al., 2012). Repeated school absenteeism and withdrawal from social activities also hinder social maturation including connectedness with same-aged peers (Mackner et al., 2012). It is therefore not surprising that recurring somatic syndromes in youth are associated with a range of emotional problems and have been documented to have a chronic course well into adulthood (Horst et al., 2014). For example, in a 15-year follow-up study, Bohman et al. (2012) found that adolescents with somatic syndromes, particularly abdominal pain were at greater risk of developing depression in adulthood. Moreover, four or more somatic symptoms during childhood predicted more severe mental illness in adulthood including recurrent, chronic depression, and suicidal behaviors.

Understandably, the ambiguity pertaining to the underlying cause of the somatic symptoms, inclusive of the recurring pain, is often highly distressing for both children/adolescents and their parents (Neville et al., 2019) and has been referred to as a “diagnostic vacuum” (Eccleston et al., 2003). These children and adolescents are prone to undergo numerous medical investigations including repeated (and costly) medical consultations to rule out the presence of organic disease with the risk of iatrogenic harm (Kangas et al., 2020; Malas et al., 2017; Neville et al., 2019; Rask et al., 2018). Indeed, in a recent Canadian population-based sample of children and young people with somatic syndromes, Saunders et al. (2020) found this cohort of youth to have a high-frequency use of the health-care system associated with substantial health-care system costs. Importantly, these researchers found that the identification and care for comorbid mental health problems in youth with somatic syndromes were poor.

In particular, studies have shown that 50–80% of children and adolescents with recurring somatic syndromes experience clinically elevated anxiety and/or depression symptomatology (Campo, 2012; Deshplande et al., 2015; Heimann et al., 2018; Winarizol et al., 2020). Unfortunately, the psychological impact of somatic syndromes in youth, for the most part, goes undetected or is minimized (Sood et al., 2016), as the immediate focus for parents/carers is typically to find a “medical” solution for their child’s somatic symptoms. Although the causal link between somatic syndromes and psychological problems is not definitively known, it is most likely bi-directional and even multidimensional. Converging neurobiological and psychological research in adult populations with somatic syndromes suggests that anxiety reactions which enhance the central stress regulation system may provide a specific mechanism for elevated visceral sensitivity toward pain and other bodily sensations arising from somatic health complaints (Craske et al., 2011). Research indicates that somatic symptom-specific anxiety is a critical variable contributing to pain sensitivity, hypervigilance of bodily sensations, and poor coping responses (Craske et al., 2011). In one of the first studies investigating fear and avoidance in children with chronic abdominal pain, Flack et al. (2017) found that provocation of proximal (vs. distal) interoceptive sensations elicited greater fear and avoidance responses. These results indicate that children with recurring somatic syndromes have heightened pain perception due to biases in their pain expectations which contributes to exacerbating comorbid anxiety and mood disturbances (and/or vice versa). Moreover, the bi-directional effects of somatic and psychological symptom presentations further attest to shifting from a dualistic explanation of somatic syndromes to a more holistic, biopsychosocial explanation of symptom onset and maintenance.

Biopsychosocial Conceptual Framework for Somatic Syndromes in Youth

Over the past four decades, the child and adolescent literature for somatic syndromes have paralleled the adult literature in terms of moving from biomedical, dualistic explanations to more holistic biopsychosocial models (Chalder & Willis, 2017; Walker, 2019). To this end, recent biopsychosocial models incorporate specific individual theoretical frameworks (including social learning theory, attachment and family system theories), to conceptualize biological/genetic, child, parent/carer, family, and environmental variables related to predisposing, precipitating, and perpetuating mechanisms for the manifestation of somatic syndromes in children and adolescents (e.g., see Beck, 2008 and Kangas et al., 2020 for reviews). In particular, social learning theory (SLT) is a common conceptual framework within this field highlighting the role of parental/carer modeling behaviors.

In accord with SLT, studies have shown that parental factors including parental styles, appraisals and behaviors toward their child’s somatic responses, parental emotion regulatory strategies, and emotional well-being can have a negative reinforcing effect on their child’s coping repertoire and contribute to maintaining somatic syndrome responses and functional impairment. Specifically, research has shown that parental maladaptive modeling of somatic behavior is related to somatic syndromes in youth (Elliott et al., 2020; Rousseau et al., 2014). Parents’ own catastrophizing of their child’s somatic symptoms has been associated with elevated pain symptoms in their child (Wilson et al., 2014). Parental responses including over-protectiveness, reassurance seeking, and reduced child autonomy and decreases in participation in somatic-inducing activities have also been related to an increased functional disability including distress in children with somatic syndromes (Caes et al., 2011; Palermo et al., 2014). Poor emotional regulatory skills among parents have also been associated with heightened somatic complaints in children (Horwitz et al., 2015). Furthermore, maternal communication and modeling of pain management strategies have been found to influence adolescents’ pain management choices (Elliott et al., 2020; Hatchette et al., 2008). In fact, a growing body of research has demonstrated the intergenerational transmission of pain (Stone et al., 2018), illness-beliefs (Ramchandani et al., 2011), and sick-role behaviors (e.g., Elliott et al., 2020). Parents’ own health including chronic pain experiences and associated emotional distress have also been linked with somatic syndromes including chronic pain in youth (Cordts et al., 2019; Elliott et al., 2020).

Collectively, these findings support the proposition that parental modeling of their own health-related behaviors and emotion-regulatory strategies influence the maintenance and potential exacerbation of somatic reactions and associated dysfunction in children and adolescents with recurring somatic syndromes. This attests to the importance of actively involving parents in psychological interventions for youth with somatic syndromes.

Research has further shown that a child’s intrapersonal vulnerability factors as well as environmental/contextual variables may also predispose and precipitate the development and maintenance of chronic somatic syndromes in youth (Kangas et al., 2020). For example, early childhood trauma and adversity have been associated with somatic syndromes in children including SSRDs (American Psychiatric Association, 2022). As aforementioned, iatrogenic factors may also play a pivotal role in perpetuating maladaptive somatic reactions in youth by way of parents/carers seeking repeated medical consultations for reassurance as well as in the hope of finding an underlying organic, “medical” cause for their child’s symptoms (Kangas et al., 2020; Neville et al., 2019; Sood et al., 2016). Unfortunately, repeated medical tests can lead to false-positive diagnosis and/or inappropriate interventions that do not necessarily alleviate the somatic responses including pain (Rask et al., 2018). Explicit focus on finding underlying medical causes is increasingly being recognized as a hindrance in identifying in a timely manner comorbid mental health problems in youth with somatic syndromes (Saunders et al., 2020).

In terms of intrapersonal vulnerability factors, a child’s interoceptive and stress sensitivity may also play a role. A child’s temperament including less adaptive coping styles (e.g., Walker et al., 2007) and emotion-regulatory behaviors (e.g., Jungmann et al., 2022) may further exacerbate their heightened interoceptive and stress sensitivity (e.g., Cappucci & Simons, 2015) and lower thresholds of pain (e.g., Bruehl et al., 2010). To this end, a child’s appraisals of their somatic symptoms may also facilitate the chronicity of their symptoms. Research has shown that both child and maternal pain catastrophizing is associated with greater somatic symptoms even in pain-free children (Van Lierde et al., 2020).

In summation, this body of literature attests to the role of biopsychosocial mechanisms in the onset and maintenance of somatic syndromes in youth. This conceptual framework, therefore, has utility in informing assessment and treatment interventions for children and adolescents referred to psychological clinics in hospital, community, and private practice settings.

Screening and Assessing Youth with Somatic Syndromes

Given the various terminology and nomenclature used in the pediatric field for referring to and classifying somatic syndromes, this has resulted in a lack of universal consensus of international guidelines for assessment instruments and diagnostic frameworks to use when screening youth who present to clinical settings with somatic complaints (Ibeziako et al., 2019; Kangas et al., 2020; Walker, 2019). This lack of consensus is further reflected in the recent findings of a scoping review conducted by Winarizal et al. (2020) to identify outcome measures used to index functional recovery in youth (0–24 years) with SSRDs presenting to clinical/health services. Based on 16 studies, Winarizal et al. (2020) found that only six of these studies used validated measures, a further three of the studies used a combination of measures and clinical notes, while the remaining seven trials relied solely on clinical notes to monitor and index functional recovery.

Winarizal et al. (2020) identified a total of eight validated measures used to assess functional recovery (defined as the ability to perform activities of daily living concordant with an individual’s developmental age), in youth presenting with SSRDs. The majority of measures included multidimensional elements of functioning (overlapping with domains from multidimensional quality-of-life, or QoL, scales), which included the Strengths and Difficulties Questionnaire (SDQ: Goodman et al., 2003) (measuring physical, emotional, social cognition, behavioral, academic, leisure/social activities, and impact on family functioning), Child Health Questionnaire (CHQ; Raat et al., 2002) (measures physical, mobility, emotional, social cognition, behavioral, academic, leisure/social activities, and impact on family functioning), and Columbia Impairment Scale (CIS; Attell et al., 2020) (measures emotional, social cognition, behavioral, academic, leisure/social activities). A further common measure identified in this review is the Functional Disability Inventory (Claar & Walker, 2006; Walker & Greene, 1991). However, the FDI was a unitary measure, and in contrast to the SDQ, CHQ, and CIS, it does not include items on emotional well-being. A noteworthy outcome from Winarizal et al.’s (2020) scoping review is that none of the scales identified were specifically designed to measure functional recovery in youth recovering from SSRDs. Yet as these scholars acknowledge, this in part could reflect the relative infancy of the SSRD category in DSM5/TR (American Psychiatric Association, 2013, 2022).

Despite the lack of consensus of assessment instruments in this field, there is increasing recognition for the need to conduct a comprehensive and multifaceted assessment when screening and assessing children and adolescents presenting with somatic health complaints. To aid assessment, adapting a biopsychosocial framework has utility to ensure that both the child’s psychological and physical functioning is considered and that specific disorders are ruled out through applications of differential diagnostic considerations (Blake et al., 2018; Kangas et al., 2020).

In psychological settings, it is recommended that a case formulation approach is adopted. The clinical interview is recommended to be supplemented by using relevant modules from validated structured diagnostic interviews (where appropriate), and to also consider potential comorbid affective and mood disorders, particularly given the high rates of comorbidity in this cohort of youth which tend to be minimized or go unrecognized (e.g., Campo, 2012; Heimann et al., 2018; Korterink et al., 2015; Saunders et al., 2020). It is further recommended that validated self-report measures are also administered to index the severity of somatic symptom presentations including presence and frequency of pain, and the impact these symptoms have on functioning, illness appraisals, parenting behaviors, and comorbid anxiety and/or depressive symptoms. In Table 33.1, a summary of commonly used measures to assess these multidimensional domains of symptoms and functioning including parenting responses in the pediatric somatic syndrome literature is outlined. In particular, the CSSI and FDI are two of the most frequent measures utilized in clinical trials to monitor somatic symptom presence, intensity, and impact on functioning. Moreover, parallel versions are used to index both the child’s response and their parent/guardians’ perception of the child’s symptoms. As further outlined in Table 33.1, pain symptoms should also be considered when screening youth with somatic presentations, including pain scales to measure intensity and severity of pain, as well as coping styles, especially if the pain is a primary and/or chronic complaint. This latter recommendation aligns with the Initiative on Methods Measurement and Pain Assessment in Clinician Trials (IMPACCT: McGrath et al., 2008).

Table 33.1 Summary of clinician interviews and common self-report measures for assessing somatic syndromes and psychological comorbidities in youth
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Psychological Clinical Assessment: Case Formulation

Table 33.2 presents a framework to aid clinicians in assessing children who present with somatic health complaints in clinical settings. A comprehensive case formulation is recommended including establishing reasons for the referral and whether the child and their parents/carers elicit any reluctance to seeking professional support from psychological services. In line with pediatric psychological assessments, it is also recommended that both the child and parent should be assessed in relation to the child’s symptom presentation. In particular, the child’s onset and duration of somatic health complaints need to be determined, as well as whether any triggers precipitate the onset of ongoing symptoms. It is also useful to determine whether the child reports primarily one somatic complaint (e.g., recurring headaches) or multiple symptoms (e.g., combined headaches and nausea, dizziness). Using a dimensional (continuum) perspective for evaluating presence, severity, and diagnostic status of symptom presentation, given that a proportion of children may not necessarily meet full diagnostic criteria for somatic syndromes (Rask et al., 2018), it is important to determine symptom frequency and duration, and whether the constellation of symptoms actually meet criteria for SSRDs in line with DSM-5/TR (American Psychiatric Association, 2013, 2022), particularly Somatic Symptom Disorder (SSD). Illness Anxiety Disorder (IAD), formerly known as health anxiety needs to also be considered and ruled out. A summary of the core criteria for SSD relative to IAD is summarized in Table 33.3. Although both conditions include heightened levels of anxiety about one’s health and are also associated with health/illness-related behaviors, they differ primarily in relation to the presence and recurrence of somatic symptoms. Notably, a core, essential criterion for SSD is the presence and persistence of at least one or more somatic symptoms resulting in distress and significant impairment in functioning for a 6-month duration (American Psychiatric Association, 2022). In contrast, somatic symptoms are not a core feature of IAD; and even if present, they are only mild in intensity. Indeed, given the central feature of IAD is the fear of illness, there is ongoing debate as to whether IAD would have been better classified under the anxiety category of disorders in DSM-5. It is also noteworthy that children with chronic medical conditions (e.g., asthma and diabetes) can meet the criteria for SSD. The latter needs to be considered if the somatic symptoms are disproportionate and excessive to common symptoms associated with the child’s chronic health condition

Table 33.2 Summary of topics when conducting an assessment case formulation for youth with somatic syndromes
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Table 33.3 Differentiating between somatic symptom disorder and illness anxiety disorder in children and adolescents presenting with recurring somatic complaints
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When assessing children for the presence and impact of somatic syndromes, it is important to identify what type of medical and allied health consultations and tests the child has received prior to seeking psychological assistance and whether the child has been recommended any interventions including pharmacological treatments by other providers for managing the symptoms. It is also useful to gage what the child and their parent/carer attributes the symptoms to as this will also facilitate determining whether the child meets criteria for an SSRD, particularly SSD as well as helping incorporate misappraisals of typical physiological sensations into the treatment formulation.

As discussed, given the high psychological comorbidity with somatic syndromes, it is also important for clinicians to assess for comorbid anxiety and mood disorders, including psychiatric history. The impact of both somatic symptoms and any comorbid psychological problems need to be determined in the context of academic, social, and general functioning. For example, is school absenteeism a problem since the onset of somatic problems? And/or what impact has this had on the child’s academic performance? Related to this, it is useful to establish if the family reinforces and/or even models sick-role behaviors as this can inadvertently perpetuate symptoms and would need to be factored into the treatment formulation. The assessment should also be supplemented with relevant diagnostic and/or validated self-report instruments (e.g., measures outlined in Table 33.1). These measures also have utility in monitoring treatment progress and determining treatment outcomes if the child is recommended to receive psychotherapy to facilitate the managing of their somatic symptoms.

Treatment Interventions for Somatic Syndromes in Children and Adolescents

Given the lack of consensus on terminology and diagnostic screening frameworks for somatic syndromes in youth, the evidence-base has to date been informed by trials investigating the effects of psychological treatments targeting children and adolescents with a specific constellation of symptoms (e.g., recurrent abdominal pain), to more heterogeneous somatic clusters including recurring pain. Over the past two decades there has been a consistently, growing body of psychological-based treatment trials testing predominantly cognitive-behavioral therapy (CBT) approaches in managing somatic syndromes in youth samples. This has culminated in an increasing number of systematic reviews and meta-analyses in this field. In this section, synthesis and evaluation of the most up-to-date systematic and meta-analytic reviews will be presented which have focused on testing the efficacy of psychological treatments for managing somatic syndromes (including recurrent pain) in youth and which have been published in peer-reviewed journals.

Evaluation of Psychotherapy Interventions for Somatic Syndromes in Youth

A total of six published reviews were identified as summarized in Table 33.4. There were two systematic reviews (SR) (Holsting et al., 2021; O’Connell et al., 2020), and four meta-analytic (MA) reviews (Abbott et al., 2017; Bonvanie et al., 2017; Fisher et al., 2018, 2019). Whereas one of the MA reviews focused explicitly on samples experiencing recurrent abdominal pain (RAP; Abbott et al., 2017), the other five reviews focused on samples with a mixed array of somatic presentations using the terms, FSS (Bonvanie et al., 2017); chronic and recurrent pain (Fisher et al., 2018, 2019); persistent physical symptoms (Holsting et al., 2021); and medically unexplained symptoms (O’Connell et al., 2020). Three of the MA reviews are based on the most recently updated Cochrane review focusing on testing the efficacy of RAP (Abbott et al., 2017) and chronic and persistent pain (Fisher et al., 2018, 2019). The latter are companion Cochrane reviews, given that the Fisher et al. (2018) review focuses on testing the efficacy of psychological treatments conducted in-person or via the telephone (excluding the Internet and smartphone) for chronic pain in youth, whereas the Fisher et al. (2019) review focuses on testing the efficacy of psychotherapy trials delivered remotely via technology which they defined as the Internet, computer programs, and smartphone applications.

Table 33.4 Summary of methods from the systematic and meta-analytic reviews evaluating psychological treatments for somatic-related syndromes including chronic pain for children and adolescents
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In the Cochrane MA review focusing on children and adolescents (aged 5–18 years) with RAP (defined as experiencing three pain episodes over a 3-month interval), Abbott et al. (2017) identified 18 randomized controlled trials (RCTs) with a pooled sample of 928 youth, with a mean age range between 9.4 and 14.9 years. Four types of therapies were evaluated. A majority of trials were based on CBT interventions (K = 10, 55%) which included components such as relaxation, coping and distraction strategies, cognitive reappraisal, as well as modifying responses to illness and wellness behaviors. The other three types of interventions tested comprised hypnotherapy (K = 4) which included relaxation and imagery techniques, yoga (K = 4) and one trial focused on written self-disclosure. A summary of the key findings for this review is outlined in Table 33.5.

Table 33.5 Summary of key findings from the systematic and meta-analytic reviews evaluating psychological treatments for somatic-related syndromes including chronic pain for children and adolescents
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Overall, Abbott et al. (2017) found some short-term significant effects in relation to CBT-based “therapy success” (defined as pain-free or reduction in pain symptoms). However, these effects were not maintained at medium or longer-term follow-up. Similarly, no significant, robust effects were found for pain intensity, pain-related functioning, school performance, or overall quality-of-life (QoL). For the hypnotherapy trial, the findings revealed significant effects for therapy success, reduction in pain intensity and frequency, although mixed effects were found for QoL, while no significant effects were documented for school performance/absences. Similar results emerged for the yoga trials. Specifically, one of the studies reported therapy success up to one-year follow-up, while all three studies reported a significant decline in pain intensity post-therapy. However, no significant effects were reported for improvement in pain frequency, school performance, or overall QoL. Finally, Abbott et al. (2017) identified one trial testing the effects of written disclosure, although no significant effects were reported for pain outcomes including QoL.

It is noteworthy that the trials included in the Abbott et al. (2017) Cochrane MA review were evaluated to be of low-grade quality, including very small sample sizes. Overall, the evidence for the effects of non-pharmacotherapy interventions for managing RAP in youth is weak. There is some preliminary support for CBT and hypnotherapy interventions in reducing pain symptoms in the shorter-term, although there is a paucity of evidence for longer-term maintenance. In terms of the CBT studies identified in Abbott et al.’s review, there was high variability in specific therapy components as well as format (see Table 33.4), thus making comparisons between CBT studies difficult in order to determine which components and types of format(s) are more conducive to better outcomes for youth with RAP.

In a separate review, Bonvanie et al. (2017) extended their criteria to evaluate the effectiveness of psychological interventions on symptom load and disability in youth aged 6–18 years with FSS (defined as “physical symptoms not fully explained by a well-defined medical psychiatric or somatic illness”; p. 273). Bonvanie et al. (2017) identified 27 studies of which 22 trials were included in their MA review. Comparable to Abbott et al.’s (2017) MA, a majority of trials identified (K = 15/27; 56%) were CBT-based interventions. Bonvanie et al. (2017) reported pooled moderate to small significant effects for the psychotherapy trials in reducing symptom load (g = −.61) and disability (g = −.42) post-therapy, with significant, yet smaller effect sizes reported at follow-up for both symptom load (g = −.38) and disability (g = −.31). Notably, these researchers found pooled significant moderate effect for reducing school absence at post-therapy (g = .51). Given the heterogeneity of trial therapy components, it is not clear which therapy components contributed to better outcomes, as moderator analyses were not conducted due to methodological variability. However, Bonvanie et al. (2017) reported that neither therapy dosage nor age significantly influenced outcomes; although they did report that stronger effects were found for samples that included youth with fatigue symptoms.

In the third review, Fisher et al. (2018) conducted an updated Cochrane review to evaluate the efficacy of psychotherapy interventions (excluding Internet or smartphone therapies) for youth (less than 18 years of age) experiencing chronic and recurrent pain (with a minimum of 3 months duration). A secondary aim was to also test the efficacy of these trials in reducing comorbid anxiety and/or depressive symptoms. Fisher et al. (2018) identified 47 trials with a pooled sample of 2884 youth. They categorized pain samples into two groups of studies: (1) headache conditions and (2) mixed-pain (predominantly non-headache) conditions including RAP, FAP, and musculoskeletal pain. A majority of trials comprised cognitive and/or behavioral-based therapy components including coping skills, problem-solving, and relaxation training.

For the headache trials, Fisher et al. (2018) found that the psychotherapy interventions contributed to a significant reduction in headache frequency post-therapy and at follow-up. However, no significant improvement in disability post-therapy was found. Similarly, no significant reductions in depression or anxiety symptoms were found post-therapy or at follow-up (see Table 33.5). For the mixed-pain conditions, moderate beneficial effects were found in reducing pain intensity symptoms post-treatment, but these effects were not maintained at follow-up. Significant small effects in reducing disability were however found both post-therapy and at follow-up. Additionally, small significant effects were also found in reducing anxiety post-therapy, although no significant effects were found at follow-up. Moreover, no significant effects in a decline in depressive symptoms were found at post-therapy or follow-up.

Comparable to the Abbott et al. (2017) Cochrane MA review, the overall quality of studies was evaluated to be low or very low in the Fisher et al. (2018) Cochrane review. Moreover, most of the trials included youth samples with recurring headaches and the therapeutic approaches were predominantly CBT-based. Overall, the findings from the Fisher et al. (2018) review indicate that in the short-term, CBT-based interventions may have utility in facilitating the reduction of pain intensity, disability, and potential comorbid anxiety symptoms. However, further research is warranted to determine what therapy components are instrumental for facilitating the maintenance of effects in the medium to longer term for youth with recurring somatic pain.

As aforementioned, Fisher et al. (2019) conducted a companion Cochrane MA review to examine the efficacy of psychotherapy interventions delivered remotely via technology for youth experiencing chronic and recurring pain with a minimum of 3 months duration. Comparable to the Fisher et al. (2018) review, Fisher et al. (2019) evaluated the studies according to two categories: (1) headache samples and (2) mixed pain (predominantly non-headache) samples. A total of 10 trials were evaluated which comprised CBT-based approaches. Specific details of results according to pain severity, intensity, and disability and concurrent anxiety and depressive symptom outcomes are outlined in Table 33.5. The findings showed that CBT-based therapies delivered remotely using e-health and smartphone approaches may help reduce headache pain severity post-therapy but these effects are not necessarily maintained at follow-up. Moreover, this field in terms of remote technology interventions is very much in its infancy, as reflected by the small number of RCTs included in this review (K = 10). Notably, there is a current lack of evidence for the remote delivery of CBT in reducing pain intensity and disability due to pain symptoms as well as concurrent anxiety and depressive symptoms in youth with recurrent pain presentations. Importantly, comparable to the other MA reviews (Abbott et al., 2017; Fisher et al., 2018), the Fisher et al. (2019) review also accentuates the need to improve the quality of trial methodology in this field.

O’Connell et al. (2020) conducted the first systematic review (SR) to evaluate the efficacy of psychological therapies for mental health problems in youth (7–18 years) with medically unexplained symptoms (which they defined as “any physical symptom causing distress or impeding function which was not accounted for through medical examination” (p. 275)). They included 18 RCTs which were predominantly CBT-based (K = 14, 78%; see Table 33.4). Once again, comparable to the previous reviews in this field, O’Connell et al. (2020) also noted that the quality of the studies was low. Moreover, given the heterogeneity of methodology including treatment types, dosage, and measurement variability, they did not conduct a MA, but rather provided a qualitative (descriptive) evaluation of pooled findings, with key results summarized in Table 33.5. In summary, none of the three child-only therapist-delivered CBT programs found improvements in anxiety or depressive symptoms. For the CBT trials which were both child and parent-directed approaches (K = 7), all four trials that included anxiety outcomes reported significant reductions post-therapy, although only two of these four trials found these effects were maintained at follow-up relative to the control conditions. Similarly, three of the five CBT, child- and parent-directed approaches found a significant reduction in depressive symptoms post-therapy, although these effects were only maintained for one of these trials at follow-up. For the most part, non-significant effects were found for improvements in mental health outcomes for CBT self-directed approaches. Only one of these four trials reported a significant decline in depression and pain-related anxiety but not for general anxiety post-therapy.

O’Connell et al. (2020) also identified three biofeedback trials, although all three studies did not find significant differences in mental health outcomes. These researchers also identified one trial, referred to as the “Lightening Process Therapy” which combined psychotherapy with medical care for youth with CFS (n = 100). For this latter trial, significant reductions were found for both anxiety and depression symptoms post-therapy and which were maintained at 12 months follow-up.

Overall, the findings from the O’Connell et al. (2014) review indicate some provisional evidence for in-person CBT-based approaches which include both child and parent components in reducing comorbid anxiety and/or depressive symptoms in the short-term for youth with somatic syndromes. However, a noteworthy outcome from this review was that the overall improvement in mental health functioning was not necessarily related to the concurrent improvement in physical symptoms including pain intensity. This outcome further attests to the need for a more integrative biopsychosocial therapeutic approach for youth with somatic syndromes experiencing comorbid anxiety and/or depressive symptoms, particularly given that until recently, mental health symptoms have for the most part been overlooked or at most considered as secondary outcomes in this population (Kangas et al., 2020; Saunders et al., 2020).

In the final, the most recent review identified, Holsting et al. (2021) evaluated the efficacy of self-help psychological-based interventions for youth (6–18 years) with persistent physical symptoms which they defined on a continuum perspective (ranging from non-diagnostic FSS to SSRDs; see Table 33.4). Holsting et al. (2021) identified 11 trials comprising five self-help CBT-based interventions, two relaxation trials, two self-help hypnotherapy trials, and two written self-help disclosure trials. Comparable to O’Connell et al.’s (2020) review, Holsting et al. (2021) did not conduct a MA due to the heterogeneity in methods including measures used, intervention frameworks, and content and duration of therapy. Overall, mixed effects were found across the four broad categories of interventions identified in Holsting et al.’s (2021) review in terms of pain symptom frequency and intensity, as summarized in Table 33.5. Again, comparable to the other reviews, Holsting et al. (2021) also found the quality of self-help interventions to be low; hence, there is only provisional evidence at best in using self-help psychotherapy interventions to assist youth in managing their somatic syndromes. Importantly, most of the self-help interventions involved some level of therapist/professional guidance either in-person, by phone or via email, with a paucity of trials identified using solely Internet media.

Clinical and Research Implications

The findings from the recent treatment outcome reviews indicate that the majority of trials are predominantly CBT-based interventions, with a smaller proportion of studies testing other forms of interventions including hypnotherapy, yoga, biofeedback methods, and written disclosure. The evidence indicates that CBT-based approaches should be considered as part of a multidisciplinary care plan to facilitate children and adolescents presenting with distressing somatic complaints to mental health services. Specifically, there is evidence to show that CBT approaches can help reduce pain intensity and disability in the short term, as well as facilitate the management of comorbid anxiety symptoms. However, there is mixed evidence for the co-management of depressive symptoms for youth with somatic syndromes. Moreover, the medium- to longer-term effects of CBT-based approaches is lacking for managing both primary somatic symptoms, as well as comorbid anxiety and/or mood problems in youth, and the impact this has on broader functioning including academic performance and peer relations. These latter outcomes are likely due to several reasons. First, psychological interventions have not conventionally been the first line of treatment for this population. In line with recent stepped-care approaches proposed to manage somatic syndromes in youth (e.g., Rask et al., 2018), the first step has typically involved children and adolescents being referred to primary care/medical settings. Management of somatic syndromes is also managed in pediatric specialist settings, while mental health referrals are not typically activated unless children and adolescents present with more severe and chronic levels of somatic symptoms and are typically comorbid with anxiety and/or depression. Hence, it is not unusual for some children and their parents to have some initial reservations when being referred to mental health settings (Kangas et al., 2020) including fear of stigmatization (e.g., Hulgaard et al., 2020), and considering the problem from a biomedical perspective (Neville et al., 2019).

A further reason for the lack of medium to long-term effects for the utility of CBT-based approaches is that there has been a lack of consensus on what the core therapy components comprise for managing somatic syndromes in youth presenting with various symptom profiles (inclusive of single-site versus multi-site health complaints). This is further reflected in the diversity of specific cognitive and/or behavioral strategies used across CBT trials in the reviews summarized in this chapter (see Table 33.4). To this end, common components have included relaxation training, distraction strategies, coping and problem-solving training, cognitive reappraisal techniques, as well as targeting modification of illness and sick-role behaviors in children and their parents through behavioral (including exposure) methods. However, given the heterogeneity in methods including primary and secondary outcome measures, no meta-analytic review to date has been able to conduct analyses to determine which specific components are deemed most essential in reducing pain and somatic discomfort. Indeed, there is also a paucity of programs to date that have been specifically designed for youth with somatic syndromes to also target comorbid anxiety and/or depressive symptoms (Kangas et al., 2020). Hence, there is a vital need for future trials to conceptually design and test transdiagnostic frameworks in the concurrent management of both somatic and comorbid mental health problems in youth experiencing distressing chronic somatic syndromes.

The evidence further shows the importance of including parents/carers in therapy, as the O’Connell et al. (2020) review revealed that combined child and parent-directed CBT approaches were more effective in reducing pain intensity and disability than child-only-directed approaches. This latter outcome further supports the biopsychosocial framework for somatic syndromes (e.g., Kangas et al., 2020), where parents and family members may inadvertently influence the perpetuation of symptoms through negative reinforcement and/or overprotective behaviors. Hence, the inclusion of a parent-focused module may be a crucial factor in enhancing the efficacy of psychological interventions for managing somatic syndromes in youth. Although there are a few studies that have included parental-specific modules, the focus has primarily been on operant techniques to facilitate parents to encourage the use of more proactive and less illness-related behaviors in their children (Palermo et al., 2014).

For parental interventions to make an additive contribution to the efficacy of psychological interventions, these interventions need to clearly target mechanisms associated with somatic syndromes in youth. To this end, recently, Stone et al. (2018) tested an integrative conceptual model based on social learning theory for the intergenerational transmission of chronic pain between parents and adolescents aged 11–17 years using baseline parent-adolescent dyadic measures followed by a 7-day diary assessment. This is one of the first studies to simultaneously evaluate adolescent perceptions of parental pain behaviors and parental reinforcement as prospective predictors of adolescent daily pain severity and functional impairment. Parental modeling of pain-related behaviors was found to have the strongest relation to adolescent daily pain severity and functional impairment, while adolescents were found to be cognizant of parental pain behaviors. These findings accentuate the importance of children’s appraisal of parental health-related behaviors (Stone et al., 2018). Notably, these results attest to the important role parents have in hindering versus facilitating their child’s management and recovery from recurring somatic complaints contingent on their own health-related behaviors, illness perceptions, and emotion-regulatory strategies. This further highlights that parental interventions need to target the modeling of adaptive parental health-related behaviors and emotion-regulatory strategies. Yet there is a notable paucity of such interventions in this field (inclusive of pediatric chronic pain) (Stone et al., 2018).

The findings from the treatment reviews further revealed that interventions delivered with minimal therapist guidance and/or remotely using e-health technology are very much in their infancy. For adolescents, online therapies may be a fruitful avenue to test future research given adolescents may be more adept and likely to engage with e-technological-based interventions. Additionally, future research is warranted in testing interventions beyond traditional CBT-based approaches including third-wave, mindfulness-based interventions.

A consistent outcome from the treatment reviews is that for the most part, the quality of the trials was deemed low grade. This attests to the importance of improving the methodological rigor of trials in this field, including using larger scale studies, including longer-term follow-up periods to monitor maintenance effects, as well as clearly differentiating between primary and secondary outcome measures, and using appropriate measures to test symptom and functional recovery.

Concluding Comments

Over the past decade, there is a continuing growth of research which has focused on the symptom profile, course, and management of recurring somatic complaints in youth. However, the lack of consensus and consistency in terminology, assessment tools, and diagnostic nomenclature has contributed to a notable absence of international clinical guidelines for clinicians working with this population. Yet there is increasing acknowledgment that a collaborative multidisciplinary health-care approach is needed for health-care professionals including psychologists working with children and adolescents with recurring somatic syndromes (e.g., Ibeziako et al., 2019; Rask et al., 2018). This body of literature highlights the importance of clinicians to regularly screen for comorbid mental health problems given that a considerable proportion of youth with somatic syndromes is also experiencing undetected elevated anxiety and/or depressive symptoms. A case-formulation approach using the proposed biopsychosocial framework is also recommended, along with using a CBT-based intervention approach which includes both children and parented-directed components. Early interventions may also have utility given untreated somatic syndromes in youth increase the probability of experiencing a more chronic course of comorbid psychopathology well into adulthood. This necessitates a shift from medicalizing the presence of recurring somatic health complaints in youth to acknowledging the mid-body connections. To this end, psychologists have an instrumental role in the multidisciplinary care of somatic syndromes in children and adolescents.