ANSWER
Background
This naturalistic study examines the role of pain coping strategies and psychiatric comorbidity in the effectiveness of inpatient multidisciplinary treatment of children and adolescents with somatic symptom disorders (SSD) (anxiety, depression).
Methods
Sixty children and adolescents with SSD (mean age 14.4 years) who received inpatient multidisciplinary treatment were evaluated for school attendance, levels of discomfort, coping strategies, and psychiatric comorbidity (depression, anxiety) at pretreatment, discharge, and 6 months after treatment.
Results
With medium to large effect sizes, the children and adolescents reported improvements in their level of discomfort, psychiatric comorbidities (anxiety, depression), and pain coping strategies at discharge. Six months after treatment, the improvements remained consistent, with significantly higher school attendance rates (d = 1.6; p 0.01). Improvement in pain coping was associated with increased school attendance.
Conclusion
Inpatient multidisciplinary treatment is effective in reducing levels of discomfort, psychiatric comorbidity (anxiety, depression), and school absence and in improving coping strategies.
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Keywords: Somatic symptom disorder, Multidisciplinary treatment, School attendance, Pain coping strategies, Comorbidity
Go to: \sBackground
Somatic symptom disorders (SSD) describe a heterogeneous entity, though the terminology has changed over the years [1, 2]. In the present article they include somatoform disorders, dissociative (or conversion) disorders and somatic disorders with psychiatric comorbidity. Somatic symptom disorders lead to significant functional and emotional impairments e.g., school absence, high socioeconomic costs and frequent use of healthcare services [3, 4]. Recently, increased numbers of children and adolescents suffering from somatic symptom complaints with functional impairments have been reported by van Geelen and colleagues [5]: between 1988 and 2011 the percentage of boys with psychosomatic problems larger than 90th percentile increased from 5.0 to 9.1% and in girls from 16.7 to 24.5% (2619 adolescents included) (2619 adolescents included). In particular, factors related to treatment outcomes are poorly understood, and there is a need for further research in this field [3].
In the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), a new category was introduced known as “somatic symptom and related disorders”. The DSM-5 emphasizes a significant functional impairment, as well as excessive thoughts, feelings and behaviors related to somatic symptoms, while the absence of a medical explanation for the symptoms is no longer necessary [6].
In contrast to the DSM-5, the International Statistical Classification of Diseases and Related Health Problems ICD-10 defines SSD in different categories e.g., somatoform disorder (F45.x) and dissociative and conversion disorder (F44.x) [7].
The most common symptoms reported by children and adolescents with SSD include pain, fatigue, faintness and nausea [8–10]. Specifically, chronic somatic pain (headache, recurrent abdominal and musculoskeletal pain) appears to be very frequent, with up to 25% of children and adolescents being affected in general population samples, including the “German Health Interview and Examination Survey for Children and Adolescents” (KiGGS) [8, 11–13]. Conversion disorders are less frequent, with a prevalence varying between 1–4% and up to 10%, as measured in a pediatric neurological unit [14, 15]. Moreover, data from the KiGGS-survey showed that up to 10.8% of children and adolescents suffer from a chronic somatic disorder and show a threefold increased risk of developing psychiatric comorbidities compared to healthy controls [13]. Likewise, children and adolescents with an SSD show an increased risk of developing psychiatric comorbidity, especially anxious or depressive symptoms [11, 16]. Moreover, adolescents with affective, anxiety and behavior disorders are at risk of developing somatic symptoms such as chronic pain; on the other hand depression and anxiety disorders can be a consequence of chronic pain [17, 18]. Up to 50% of children and adolescents with SSD suffer from psychiatric comorbidity [2]. In addition, affected children and adolescents often face functional long-term impairments resulting in poor academic achievements, an increased risk for later medical treatment and vocational impairment [8, 16, 19]. The emotional burden seems to have an important influence on the long-term treatment outcome [20]. This highlights the importance of consideration and treatment of psychiatric comorbidities during the inpatient multidisciplinary treatment.
Treatment often appears to be unsatisfactory to patients, families and healthcare professionals due to a low acceptance of the concepts of, and interventions for, somatic symptom disorders [1, 8, 11]. For subjects with severe impairments, inpatient multidisciplinary treatment in specialized healthcare units based on a cognitive behavioral approach has been recommended [11, 21]. Notably, a close cooperation among multiple disciplines is warranted, as biological and environmental/social aspects have to be considered [4, 22]. However, a systematic evaluation of treatment approaches is lacking, and specialized healthcare units are rare in Germany and many other developed countries [20]. More specialized multidisciplinary units are needed as unimodal treatment appears to be insufficient for the complexity of the SSD [20]. Compared to sole pediatric and psychiatric treatment, a multidisciplinary treatment approach facilitates a highly specialized treatment and ensures a close collaboration between pediatricians and psychiatrists. Previous studies predominantly focused on chronic somatic pain, while studies investigating SSD, including dissociative (or conversion) disorders and somatic disorders with psychological factors, are scarce [21].
Research of chronic somatic pain in children and adolescents has demonstrated that inpatient multidisciplinary treatment is effective for improving pain intensity, school absence and further pain-related disabilities (e.g., social activities, sports, sleep) [23]. Improvement of pain coping appears to have a strong effect on pain-related treatment outcomes e.g., pain intensity [24–26]. A recently published meta-analysis by Bonvanie and colleagues [21] demonstrated the effectiveness of psychological treatment in improving symptom severity, disability and school attendance at posttreatment and follow-up in children and adolescents with functional somatic symptoms. The type of symptoms did not seem to influence the outcomes [21]. Despite these promising results, research on multidisciplinary treatment of children and adolescents with SSD is scarce, and the mediators of these treatment processes are still not well understood. In addition, an interpretation of the existing studies is limited due to the heterogeneity of the measures used and a lack of data concerning the long-term treatment effects regarding psychosocial functioning (e.g., school attendance) and psychiatric comorbidity [4, 12, 21, 27].
Thus, our study focused on the evaluation of inpatient multidisciplinary treatment of SSD covering all disorders enumerated in DSM-5, with a particular evaluation of distress and impairment (i.e., school absence) (i.e., school absence). In detail, the aims of our study were twofold: first, we aimed to evaluate the effectiveness of an inpatient interdisciplinary treatment for children and adolescents with somatic symptom disorders. The multidisciplinary team consisted of child & adolescent psychiatrists, pediatricians, clinical psychologists, physiotherapists, occupational therapists and nurses. The outcome parameters were a reduction in somatic complaints and psychiatric comorbidity (anxiety, depression) at discharge and upon a 6-month follow-up after treatment completion. At this assessment, school attendance was also evaluated. Second, we aimed to assess the impact of coping strategies and comorbid psychiatric symptoms (depression, anxiety) on changes in functional impairment (i.e., school attendance) and the level of discomfort.
Go to: \sMethods
Patients aged 8–18 years with somatoform disorders, dissociative disorders or chronic somatic disorders with psychiatric comorbidity who were referred to our somatic symptom unit were eligible for inclusion. The requirements for admission included a complete pediatric diagnostic evaluation and an appointment with a member of the treatment team to discuss the indication of inpatient treatment and treatment goals. The exclusion criteria included insufficient knowledge of the German language, duration of treatment of less than 14 days and severe psychiatric comorbidity, such as acute suicidal ideation or psychosis. Regular treatment attendance at individual and group therapies was a precondition for admission and continued participation in the treatment program. Patient assessments were conducted upon admission (T1), discharge (T2) and 6 months following treatment (T3) (T3). The local ethics committee approved the study in accordance with the Declaration of Helsinki.
Sample \sSeventy-three individuals were screened over a 16-month period, and 60 patients were eligible for inclusion. Eight patients cancelled treatment prematurely, and five patients had to be transferred to the child and adolescent psychiatric unit due to severe psychiatric disorders. Forty-five (75%) of all included patients participated in the follow-up assessment. Study completers did not differ from non-completers in terms of age, sex, distribution of disorders or missed school days upon admission (T1) (T1). The details are presented in Table 1.
Table 1 \sDemographic and clinical data
Mean [SD]
Sample size (n) (n)
60
Female (%)
56.7 \sAge 14.43 [2.0] .0]
Duration of treatment (days) (days)
48.15 [19.7] .7]
Diagnostic distribution N [%]
A primary diagnosis
Somatoform disorder (F45.x) (F45.x)
47 [78.3] .3]
Dissociative (conversion) disorder (F44.x) (F44.x)
4 [6.7] .7]
Other pediatric diagnosisa
9 [15]
B comorbidities
Depressive episode (F32.x) (F32.x)
27 [45]
Phobic/other anxiety disorder (F40.x/F41.x)
24 [40]
Attention deficit hyperactivity disorder (F90.x) (F90.x)
22 [36.7] .7]
Other Fb—diagnoses
23 [38.3] .3]
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a Rheumatic diseases (n = 2), migraine (n = 1), obesity (n = 5), chronic inflammatory bowel syndrome (n = 1)
b Obsessive–compulsive disorder (F42.x, n = 2), reaction to severe stress and adjustment disorder (F43.x, n = 6), specific developmental disorders of scholastic skills (F81.x, n = 4), mixed disorders of conduct and emotions (F92.x, n = 1), emotional disorders with onsets specific to childhood (F93.x, n = 1), tic disorders (F95.x, n = 1), somatoform disorder (F45.x, n = 1)
Measures \sSchool attendance
School attendance was assessed in accordance with a scheme proposed by Hechler et al. (2014) over the 4 weeks prior to admission and over the 4 weeks prior to the 6-month follow-up [37]. School absence was categorized by the amount of missed school days: none (0–1 days), moderate (2–5 days) and high (6–20 days) (6–20 days). School attendance was assessed via self-and parental reports.
PPCI
The German version of the revised Pediatric Pain Coping Inventory (PPCI-R), a validated self-report questionnaire, was used to assess pain coping strategies in the children and adolescents [25, 28]. The PPCI-R considers the following subscales: cognitive self-instruction, seeking of social support and passive coping strategies. Passive coping strategies and seeking of social support are defined as behavior-related strategies, while positive self-instruction is defined as a cognitive strategy. The summed scores were used for statistical analyses. Lower numbers indicated more adaptive coping strategies [25].
Level of discomfort
The German “Giessen physical complaints inventory for children and adolescents” (GBB-SB) is a self-report questionnaire designed to assess subjective somatic complaints [29]. The GBB-SB includes fatigue, gastric and cardiovascular complaints, rheumatic pain, and cold symptoms that altogether provide a total score of the complaints [30]. The subjective perception of somatic complaints often differs from the clinical findings, especially in somatoform disorders. T levels, in accordance with the German norms referred to in the manual, were used for statistical analyses.
Anxiety
The German version of the Spence Children’s Anxiety Scale (SCAS), a self-report questionnaire, was used to measure overall anxiety and includes the following six subscales: generalized anxiety, panic/agoraphobia, social phobia, separation anxiety, obsessive–compulsive disorder and physical injury fears [31, 32]. The total SCAS sum scores were used for statistical analyses.
Depression
The German Children’s Depression Inventory (DIKJ), a self-assessment questionnaire, was used to measure the severity of depressive symptoms [33]. T levels, in accordance to the norms reported in the manual, were used for statistical analyses.
Treatment
For highly affected children and adolescents with SSD, an interdisciplinary inpatient treatment (Monday until Friday) based on cognitive behavioral treatment strategies was recommended [21, 34]. The primary goal of the treatment was to develop adaptive pain coping strategies and to facilitate a return to everyday adolescent life (e.g., regular school attendance, sports, and social activities) (e.g., regular school attendance, sports, and social activities). The treatment comprised psychotherapy and complimentary therapies such as physiotherapy and social competence training, as well as parental psychoeducation. One important strategy was the supervised gradual exposition to situations in which somatic symptoms frequently occur with the goal to help patients reappraise associated thoughts and feelings increasing somatic symptoms. The parents were invited to participate in the coaching sessions to learn about the individual pathogenesis of SSD and to understand how to reduce overprotective or perpetuate behavior. At the beginning of the treatment, all patients attended a special school at the hospital, with most returning to their classes at their original schools at the end of the treatment. Pharmacological treatment was recommended as an auxiliary intervention in some cases. Of all the patients, 50% (n = 30) received no medication, and 21.7% (n = 13) were treated with a selective serotonin reuptake inhibitor (SSRI) because of comorbid depression (n = 9) and/or anxiety (n = 6). Of all the patients 21.7% (n = 13) were treated with extended-release methylphenidate, and 1.7% (n = 1) were treated with atomoxetine due to comorbid attention deficit hyperactivity disorder. In 5% (n = 3) of all patients, a combination of SSRIs and extended-release methylphenidate because of comorbid depression (n = 2) or anxiety (n = 1) and attention deficit hyperactivity disorder was administered. All patients were drug-naïve at pretreatment. The treatment included regular team meetings to discuss the individual progress of the patients, as well as regular supervisions. The treatment team had prior experience in the therapy of patients with somatic symptom disorders. Before discharge, caregivers were supported in setting up continued care including psychotherapy and child- and adolescent care including medication in some patients. At discharge, all patients had first appointments set for continued ambulant care.
The interdisciplinary inpatient unit in Aachen provides nine treatment units for highly affected children and adolescents. In Germany, inpatient treatment is more widespread compared to similar health care systems in other Western countries with over 6000 psychiatric inpatient treatment units [35]. However, units for children with SSD are scarce in Germany and mostly cared by only one discipline, either child and adolescent psychiatry or pediatrics. The interdisciplinary model presented here is one of the very few in Germany.
Statistical analyses
IBM SPSS version 23 was used to perform all statistical analyses (IBM Corp., Armonk, N.Y.) (IBM Corp., Armonk, N.Y.). Sample characteristics were summarized using descriptive statistics. Descriptive statistics were employed for the categorical variables and also for the means and standard deviations (SDs) for the continuous variables. Three time-points were assessed: admission, discharge and the follow-up (6 months after discharge) (6 months after discharge). A test of the distribution of normality revealed that the values of the DIKJ, SCAS and the number of missing school days were not normally distributed. Wilcoxon signed-rank tests (DIKJ, SCAS, and missing school days) and paired T-tests (GBB; PPCI) were conducted to assess changes from pre- to posttreatment (T1–T2) and from pretreatment to 6 months after discharge (T1–T3) (T1–T3). Due to the use of multiple tests of the same dataset, we adjusted the alpha level using the Bonferroni–Holm procedure [36], which specified a p value of 0.0033 for a test to be considered significant. The resulting output of the group comparisons was used to calculate the effect sizes (Cohen’s d). Additionally, exploratory post hoc analyses were conducted to investigate the influence of (a) age and sex, or (b) baseline levels of depression or discomfort on the changes in coping strategies, levels of discomfort, depression and anxiety. A repeated measures model with sex as between subject factor and time (T1, T3) as within subject factor was used for (a), while linear regression models were used for (b) (b). Finally, using Pearson correlations, we investigated whether changes in school attendance (T1 to T3) were related to changes (T1 to T3) in pain coping (PPCI), discomfort or comorbidity.
QUESTION
1. What are the common somatic conditions in the pediatric population? How are pediatric somatic conditions diagnosed and treated? Cite two sources to support your reasoning
2. How does the presentation of depression in children differ from adults? What is the recommended treatment of depression in children? What are some safety issues for pediatric treatments (include any medications/treatments that are contraindicated in pediatric populations or have warnings)? Cite two sources to support your reasoning,
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