U n e x p l a i n e d Ph y s i c a l

Complaints
M. Elena Garralda, MD, MPhil, FRCPsych, FRCPCH, DPM

KEYWORDS
 Physical complaints  Somatization  Somatoform disorders

Physical complaints tend not to feature prominently in the everyday work of child and
adolescent psychiatrists or child and youth mental health clinics. These problems are
more likely to be referred to the local pediatric clinic. As a result, expertise in the assess-
ment and management of the psychiatric aspects of such problems varies considerably
and can be limited. An exception are psychiatric pediatric liaison teams as they deal
primarily with problems at the interface between physical and mental health problems,
which include medically unexplained symptoms. Nevertheless, family engagement in
assessment and treatment can be problematic even for specialist liaison teams.
Whether children and families engage with and benefit from psychiatric services
depends to a large extent on whether families appreciate the link between physical
and psychiatric symptoms, and wish to work on the comorbid psychopathology such
as anxiety disorders or on the contributing psychosocial problems such as family disrup-
tion or school difficulties. Benefit may also depend on the joint expertise of pediatric and
child and adolescent mental health teams in attending to these types of problems.

DEFINITIONS AND GENERAL CLINICAL ISSUES

Physical complaints or somatic symptoms are common in children and adolescents,

and the majority will have a physiologic explanation rather than one deriving from
a diagnosable medical illness. Nevertheless, they often lead to pediatric visits. General
population surveys show that young people report a mean of 2 somatic symptoms
being present ‘‘a lot’’ in the 2 weeks before assessment; the most common being
headaches, low energy, sore muscles, nausea and upset stomach, back pains, and
stomach pains.1 Many of these symptoms will be mild but for a minority they will be
recurrent and impairing. About 1 in 10 children report recurrent impairing aches and
pains, and a comparable number have distressing somatic symptoms or are regarded
by their parents as ‘‘sickly.’’
The way complaints are managed relies on how they are understood; if parents or
young people see them as a likely expression of medical illness, they will either visit

Academic Unit of Child and Adolescent Psychiatry, Imperial College London St Mary’s Campus,
Norfolk Place, London W2 1PG, UK
E-mail address: e.garralda@imperial.ac.uk

Child Adolesc Psychiatric Clin N Am 19 (2010) 199–209

doi:10.1016/j.chc.2010.01.002 childpsych.theclinics.com
1056-4993/10/$ – see front matter ª 2010 Elsevier Inc. All rights reserved.
200 Garralda

their doctor or handle the problem themselves using their personal medical knowledge
and experience. On the other hand, they may be of the opinion that the symptoms are
temporary and unlikely to indicate illness, such as when a child’s abdominal symp-
toms are linked to certain foods ‘‘not agreeing’’ with them. Alternatively, they can
have a psychological or social explanation, for example, symptoms exacerbated by
stress such as worries about school, the child complaining in order to be comforted
and to avoid going to school, or a particularly feared lesson. Common and effective
parental reactions to dealing with symptoms thought to be psychosocially influenced
are to ‘‘play down’’ the importance of the symptom so that the child learns to cope, or
to comfort the child and try to find the cause of the distress.
There are times, however, when symptoms become marked and persistent, remain
unexplained after pediatric examination, and cause considerable distress and impair-
ment. There may also be indications of ongoing stress or associated psychiatric
symptoms; however, these are not always obvious and parents and doctors may be
at a loss to explain the severity and impairment. A psychiatric opinion is helpful to
assist with differential diagnosis and confirm or exclude the presence of somatization,
or of a somatoform disorder or another primary or comorbid psychiatric disorder
amenable to psychiatric intervention. It is also helpful to identify psychosocial factors
likely to be playing a part in symptom maintenance even when a definite psychiatric
disorder is not present, and in medically informed psychosocial rehabilitation.

Somatization and Somatoform Disorders

For many children coming into contact with medical services with unexplained phys-
ical complaints, there will be evidence of somatization. This term describes a constel-
lation of clinical and behavioral features indicating a tendency to experience and
communicate distress through somatic symptoms unaccounted for by pathologic
findings, and for these symptoms nevertheless to be attributed to physical illness,
thus leading the patient to seek medical help. Somatization is a crucial feature of
several ICD-10 (International Classification of Diseases, tenth revision) and DSM-IV
(Diagnostic and Statistical Manual of Mental Disorders, fourth edition) somatoform
disorders of which the most commonly seen in children and adolescents are persistent
somatoform pain disorder, dissociative/conversion disorder, and—even though not
part of DSM-IV and referred to as ‘‘neurasthenia’’ in ICD-10—chronic fatigue
syndrome (CFS). Mental factors are assumed to have major significance as either
precipitating or maintenance influences in these disorders.
Unexplained physical complaints become a clinical problem when, in addition to
severe, recurrent, and impairing, they lead to repeated medical contacts with expec-
tations of medical treatment. It is common by that stage for parents and children to
hold the belief that there is some medical problem their doctor may be missing; this
leads on the one hand to excessive special investigations determined more by the
principle of not leaving any stone unturned than by sound clinical indication, and on
the other to a reluctance to seek or accept a referral for psychiatric evaluation. Rejec-
tion of psychiatric assessment by children and parents can be intense to the extent
that it seems unreasonable to others.

Psychological ‘‘Mindedness’’ and Related Dilemmas

The intensity is partly related to the fear that a physical illness will be missed, but prob-
ably also to a lack of psychological ‘‘mindedness,’’ with difficulty acknowledging that
psychological and physical symptoms may be closely interconnected, and a concom-
itant reluctance to consider that the child and family may be able to gain control over
them. This reluctance is sometimes a result of frustrated efforts to manage the
 Unexplained Physical Complaints 201

complaints at early stages in their presentation, and is also likely to be connected to

impairment being a central feature of severe functional somatic symptoms.
Impairment often involves withdrawal and avoidance of everyday responsibilities
and stresses. Many children severely affected with unexplained medical complaints
and somatoform disorders are in stressful situations they find difficult to manage or
seek support for on a day-to-day basis. In this context illness represents a double-
edged sword; while it is an unpleasant distressing physical experience it is also an
escape or way out of these stresses. The withdrawal is, however, only legitimate
and acceptable if the negative experience of illness and its physical nature are
acknowledged by others, thus assuming that the child is at the mercy of a ‘‘force
majeure,’’ and therefore unable to resist. A markedly affected child will often seemingly
‘‘hold on’’ to the illness and oppose expectations from others that he or she may have
some control over the impairment. Children might challenge families and doctors
when asked to contribute actively to the rehabilitation process, or simply display
passive noncooperation. These children might feel too weak to resist the symptoms,
or be too frightened to face the prospect of returning to everyday life and those very
stressors the symptoms are helping to avoid. It is not uncommon, therefore, for some
children to angrily state that the doctor or rehabilitation staff do not ‘‘believe’’ the
symptoms because otherwise they would not be expected to do anything strenuous
or demanding.
Assessment and Management
Because of the nature of these problems, assessment and treatment need to take due
note of both the physical and psychosocial contributory and maintaining factors. The
best approach is one using a biopsychosocial framework whereby problems are not
regarded as either physical or mental, but rather whereby the relative contribution of
biologic, psychological, and social factors is considered. The view that physical symp-
toms are wholly medically explained and therefore within the exclusive domain of the
pediatrician, or alternatively are wholly medically unexplained and by implication are
not within the pediatrician’s domain but rather within the domain of psychiatric teams,
does not correspond to clinical experience. A medical disorder may trigger or underlie
medical symptoms which then become unexplained not in themselves but rather in
terms of their severity or the impairment caused. For example, excessive lower limb
weakness may follow a bone fracture and subsequent immobilization, or pseudosei-
zures may manifest in a child with epilepsy. In practice, pediatricians often recognize
that psychosocial issues can influence pediatric problems, whether with or without an
organic substrate, as demonstrated in other articles in this issue. Understanding unex-
plained medical problems and their management at the pediatric clinic therefore
needs to take into account the triggering of physical problems or other stressors, as
well as psychosocial problems that may play a part in their maintenance. A particular
complicating, and not uncommon, factor in clinical practice is when the attending
clinician suspects psychological issues are playing a part, as in somatization or soma-
toform disorders, but this is at odds with the child’s and parental attitudes and views
about the nature of the problem and who is the best professional to help. Engaging
and working with the family to achieve a common view will thus be a requirement
before effective treatment can be undertaken.

PREVIOUS REVIEWS

Several reports have reviewed the literature on unexplained physical complaints, and
somatization and somatoform disorders as they manifest in children and young
202 Garralda

people. This article reviews first the main conclusions from these reviews and then
considers new findings that have helped illuminate their nature and management.
The clinical picture, frequency and epidemiology, etiologic factors, and treatment of
unexplained physical complaints have been reviewed comprehensively.2–5 An early
review of child psychiatric symptoms with somatic presentations4 highlighted that
the nosologic validity and boundaries of somatoform disorders, as described in
DSM-IV and ICD-10 classification systems, were still comparatively untested in chil-
dren. Nevertheless, there was converging evidence that functional or likely medically
unexplained physical complaints were common and present in about 1 in 10 children
in the general population. These symptoms often involved recurrent abdominal pains
or headaches, and there was a female predominance. Concurrent psychopathology
was present in excess in affected children (between one-third to one-half) and usually
consisted of emotional (anxiety of depressive) disorders, disruptive problems being
a considerably less common association.
Specific child personality features were noted with several affected children who
were described in clinical reports as conscientious or obsessional, sensitive, insecure,
and anxious; high academic expectations were also noted. An excess of stressful
events commonly involving school activity but also sometimes physical illness were
reported, as was illness triggering symptom onset. Family influences were thought
to be important; more specifically, family health problems, preoccupation with illness,
and in some cases parents appearing anxiously sensitized to the experience of phys-
ical symptoms and seeking reassurance from medical services. For a small number of
families profound family disorganization and sexual abuse were relevant. Clinicians
described high levels of enmeshment between family members and parental overpro-
tection. The emerging picture was one of children with vulnerable personality features
who developed functional somatic symptoms following traumatic (physical or psycho-
social) events.
The review of the topic by Campo and Fritsch2 was generally in line with these
observations and conclusions. This review addressed a variety of unexplained phys-
ical symptoms, not just abdominal pains and headaches but also limb pains and
aching muscles (‘‘growing pains’’), although they noted that pseudoneurologic symp-
toms are comparatively rare in community samples. Campo and Fritsch highlighted
that presentations are often multi-symptomatic and that—in contrast with the
frequency of functional symptoms—somatoform disorder presentations are rare in
childhood. The excess of unnecessary and potentially dangerous and costly medical
investigations and treatments to which these children are exposed, alongside the
excessive use of health care services, was emphasized.
A further summary review5 considered tentative findings about possible biologic
substrates for unexplained physical complaints; for example, altered colonic motility,
enhanced gastrointestinal sensitivity, and possible inflammatory changes in children
with functional gastrointestinal symptoms. Evidence was starting to emerge that
parental reinforcement of symptoms and discouragement of coping were likely to
be factors contributing to symptom maintenance, and that the effect of external
stressors on the emergence of physical symptoms might be mediated by low levels
of social competence.
A recent article3 has outlined some of the reasons for studying unexplained medical
symptoms in children separately from adults, including the observation that the pre-
senting symptoms tend to be specific to childhood and therefore questionnaires
designed for adults are not appropriate, and the importance of gathering parental
reports especially for preadolescents. Recent research has confirmed the presence
of unexplained medical symptoms in young preschool children, and their association
 Unexplained Physical Complaints 203

with anxiety symptoms in the child and distress in the parents. More unexplained
somatic symptoms are reported by older than younger girls, and there is congruence
generally between symptom reporting, illness attitudes conducive to somatization,
and low academic attainment.
This review mentioned an unusual syndrome linked to somatization in children
called ‘‘pervasive refusal’’ whereby children and adolescents present with profound
and pervasive withdrawal, including refusal to eat, drink, talk, walk, and engage in
any form of self-care. Although the nosology of this syndrome has not been estab-
lished, it appears to be an extreme and serious manifestation of somatoform and other
stress disorders. The review also noted factitious presentations in childhood, whereby
parents fabricate childhood illness or children themselves cause damage to wounds
or scratch corneas, as problems related to childhood somatization, although the
active part played by young people or their parents in symptom production is at vari-
ance with the traditional assumption that in somatization and somatoform disorders
unconscious mechanisms determine symptom production.

UPDATE ON MORE RECENT FINDINGS

In recent years several studies have taken these issues forward, and are reviewed here
briefly. These studies address the development of instruments to assist the investiga-
tion of unexplained physical symptoms in children, the contribution of symptoms to
pediatric practice, and further work on associations with psychopathology, biologic
and psychological vulnerabilities, sensibility to stress in the child, and familial influ-
ences, as well as on treatment and outcome. Because much of this work has
addressed recurrent abdominal pains and CFS, these conditions feature most prom-
inently and are used as models for understanding general somatization principles.
The Use of Fit for Purpose Questionnaires and Epidemiologic Findings
An important methodological advance has been the development of questionnaires to
assess physical symptoms and clusters likely to be related to somatization in children.
The Children Somatization Inventory (CSI) created by Garber and colleagues1 in 1991
is a well-standardized self-rated scale for adolescents detailing 36 common physical
symptoms experienced over the previous 2-week period. The CSI has been used
across different countries with results comparable to those from the original North
American adolescent school sample. The most recent survey was carried out in the
United Kingdom and found a median CSI symptom/severity score of 12 (5,23), with
headaches, feeling low in energy, sore muscles, faintness, and nausea being the
most frequent, and girls scoring higher than boys.6 A quarter of respondents thought
that their somatic symptoms were made worse by stress, and 10% reported marked
impairment; a higher number of symptoms was linked to greater impairment of
everyday life as well as to more emotional symptoms. This result indicates that
multiple somatic symptoms in children in the general population are often likely to
be an expression of somatization. The authors of the CSI have since developed
a shorter 24-item version with one factor made up of multiple symptoms explaining
almost 30% of the total variance.
Eminson and colleagues7 adapted the Illness Attitudes Scales for use with young
people, and demonstrated links between high symptom scores and distress about
illness in a general population sample of young people. These scales have been
used in young people with CFS, and have shown that these children and their parents
display an enhanced general tendency to believe in the presence of a disease despite
contrary medical evidence and reassurance to the contrary, a tendency that persists
204 Garralda

after the child’s recovery, therefore suggesting enduring—not just illness-related—

health beliefs.8
More recently Rask and colleagues9 have developed, and satisfactorily validated,
a parental interview to assess functional somatic symptoms in children, the Soma
Assessment Interview, which may be used in clinical settings as well as in research.
The instrument was used to establish rates of impairing functional symptoms in 4%
of young 5- to 7-year-olds in a general population.
In contrast to unexplained physical complaints, severe somatoform disorders are
rare. Kozlowska and colleagues,10 using the Australian Pediatric Surveillance Unit,
a research resource to establish rates of new rare disorders seen by pediatricians,
found rates of childhood conversion disorder of 0.02 to 0.04 per 1000 total child pop-
ulation. The most common symptoms in this survey were loss of movement and
sensation. CFS appears to be more common (0.19% in a general population survey)
and partial or CFS-like syndromes even more so (about 2%).8
Functional Somatic Symptoms, Primary Health Care Help Seeking,
and Psychiatric Comorbidity
Work by Campo and colleagues11 has documented primary health care pediatric
consultations of children with medically unexplained recurrent abdominal pain
(RAP). This study found frequent complaints to be present in 2% of consulters, less
frequent complaints in 11%, and a clear predominance of girls over boys (2 to 1). In
about half the children parents and doctors thought there were concurrent psychoso-
cial problems, with fears of novelty and separation and worries being the most
common psychological features reported by parents. About half the children with
frequent complaints were thought to be impaired in some way because of their symp-
toms, about a third were regarded as comparatively frequent users of medical
services, and some 1 in 10 were missing substantial schooling. These data confirm
that somatization expressed through RAP is a regular feature of pediatric primary
care consultations.
In a further study Campo and colleagues12 investigated psychiatric comorbidity
among young people with RAP attending primary care services, and found anxiety
disorders to be present in over three-quarters (depressive disorders in about half),
making it highly appropriate to systematically screen for these disorders in pediatric
clinics.
High levels of psychiatric comorbidity are also being recognized in other somato-
form disorders. Thus, Pehlivanturk and Unal13 identified psychiatric disorders in
more than half their sample of children admitted to hospital with conversion disorders,
and about three-quarters of young people with CFS have had psychiatric—mainly
emotional—disorders documented in the year prior to interview.8 Moreover, further
indications of close links between anxiety and somatoform disorders are findings
that anxiety disorders tend to both precede the emergence of and follow the recovery
from somatoform disorders.
Biologic and Psychological Vulnerabilities
New evidence is emerging to support biologic vulnerabilities in unexplained physical
complaints and somatoform disorders. Thus, in response to a water load challenge,
children with RAP report significantly greater symptom increase than controls, sug-
gesting an enhanced gastrointestinal sensitivity.14 Campo and colleagues15 have dis-
cussed the possibility that dysregulation of serotonergic neurotransmission is
implicated in both gastrointestinal and emotional symptoms, on the basis that sero-
tonin is an important neurotransmitter in the gastrointestinal tract and enteric nervous
 Unexplained Physical Complaints 205

system, that it influences gut peristaltic activity and symptoms of nausea, and that it is
also implicated in mood disorders.
The influence of biologic mechanisms on CFS is still debated; certain infections
such as mononucleosis infectiosa appear particularly likely to precipitate CFS in chil-
dren, and reports (most recently Lombardi and colleagues16; not replicated by Erlwein
and colleagues17) continue to highlight a possible contribution of other viral agents.
However, very few individuals develop CFS following viral illnesses, and the signifi-
cance of viral infections needs to be clarified further.
Stress Sensitivity, Personality, and Coping
Research reports confirm psychological vulnerabilities in young people with unex-
plained physical symptoms and somatoform disorders, through heightened stress
sensitivity, sometimes related to personality difficulty. Stressful events as illness
precipitants are reported in the majority of children with conversion disorder or
CFS8,13: mainly relationship problems and family illness in conversion, and infections
and school events in CFS. Children with RAP and frequent somatic symptoms tend to
report an excess of life events. Walker and colleagues18 compared diaries on daily
stressors and somatic/emotional symptoms in children with RAP and controls; more
daily stressors at home and school, and strong associations between daily stressors
and somatic symptoms were reported in the pain sample, especially in those reporting
negative affect traits. The same research group studied stress, appraisal, and coping
with pain in children with RAP,19 also using diaries, and in line with their previous
results patients with pain were less confident in their ability to change or adapt to
stress, and less likely to use accommodative coping strategies.
Personality Features
These stress-management deficits might well be related to temperament or person-
ality difficulty. Earlier evidence is being supported by findings that child temperament
(eg, irregular feeding and sleeping) in the first year of life already predicts future RAP.20
Personality anomalies (eg, prominent vulnerability, anxiousness and conscientious-
ness, as well as worthlessness and emotional lability) have now been documented
in young people with CFS and have shown them unlikely to be merely consequences
of having a chronic physical disorder.8
A Clinical Formulation
Kozlowska21 has expanded David Taylor’s formulation of conversion disorder reflect-
ing children being in ‘‘intolerable predicaments.’’ The basic concept is one of good,
compliant children from families with high expectations, inarticulate family relation-
ships, and hostility to psychological expectations. Children in intolerable situations
they cannot escape or communicate about without threatening their feeling of safety
will manage their fears of parental rejection, hostility, anger, or displeasure through
compulsive compliance and sometimes through conversion symptoms. Compulsive
compliance would minimize hostility in attachment relationships and allow for
maximum physical and psychological closeness and safety. However, when compul-
sive compliance breaks down it leads to anxiety, fear, and anger in the child; physical
illness then serves to elicit parental care and protection as well as safeguard the child
from parental expectations, anger, displeasure, or rejection in the face of failure to
perform.
Work on children and young people with CFS has further emphasized the crucial
role of impairment as a defining feature of severe unexplained physical complaints
and somatoform disorders, and as a factor contributing to its maintenance. Research
206 Garralda

has also demonstrated inefficient coping strategies, such as low use of problem
solving, in children with these disorders specifically when dealing with symptoms
and impairment.8
Parental Influences
The influence of parental and family factors is becoming increasingly documented.
Mothers of children with RAP have been found to have increased histories of anxiety
and depression,22 and parental anxiety during the child’s first year of life predicts RAP
in the child 6 years later.20 Parental somatization is also relevant, as children of parents
with current somatization display an excess of somatic symptoms and school
absence.23
Work on young people with CFS has demonstrated high levels of parental emotional
overinvolvement with the child’s illness, when compared with parents of children with
other severe pediatric disorders.8 In children with RAP detailed assessments of
parental behaviors have shown that giving attention to symptoms results in doubling
of symptom complaints, especially in girls, whereas distraction reduces the symptoms
by half.24 Of note, whereas children report that distraction makes the symptoms better,
parents rate distraction as being more likely to have a negative impact on symptoms
than attention. Understanding these attitudes is highly relevant for treatment.

Treatment and Outcome

The cornerstone of treatment is for pediatric clinicians to be interested in the child and
his background, to carry out the necessary investigations, to discuss with parents
tactfully that organic disease has been excluded as well as to discuss any harmful
aspects in the child’s environment, such as excessive academic and emotional
demands (often self-imposed by the child), and to help the family modify them.
More specific cognitive-behavioral techniques involve self-monitoring of the main
symptoms through diaries, limiting the attention given to the symptom by others,
relaxation techniques if appropriate, encouraging participation in routine activities
through gradual exposure, confirming that the child is not ‘‘putting the symptom
on,’’ explaining the links between physical and psychological pain, and addressing
parental anxieties and the child’s reluctance to engage in a rehabilitative approach.
Relaxation can be helpful for circumscribed problems such as headaches, and treat-
ment of comorbid psychiatric disorders is also called for.
The best evidence for treatment efficacy in RAP is for family behavioral programs
using techniques along the aforementioned lines (graded evidence rating A). The
earlier randomized controlled trial by Sanders and colleagues25 showed that this tech-
nique was better than treatment as usual, and has been largely replicated by Robins
and colleagues.26 Graded activity programs with cognitive-behavioral features deliv-
ered within a family treatment context have been shown to be promising and effica-
cious for the treatment of CFS.27,28 For the treatment of the more severe case, the
term ‘‘restrained rehabilitation’’ has been used to describe a coordinated multidisci-
plinary rehabilitation package that ensures consistency and collaboration between
different professionals and families.29 Selective serotonin reuptake inhibitors such
as citaprolam have been piloted successfully for the treatment of RAP.12
Outcome will vary according to severity, impairment, and possibly also risk factors
such as the degree of personality difficulty and family support. Mulvaney and
colleagues30 categorized children with RAP attending pediatric services into (1) low
risk (70%) with low levels of symptoms and impairment expected to improve within 2
months; (2) short-term risk (16%) for those who, despite high levels of symptoms and
impairment, improve greatly over several months and maintain their improvement;
 Unexplained Physical Complaints 207

and (3) long-term risk (14%) when symptoms and impairment persist and there are high
initial levels of anxiety and depression, low self worth, and negative life events. The
longer term adult outcome of childhood RAP has documented high levels of anxiety
disorder, poor social outcome, perceived susceptibility to physical impairment, and
hypochondriacal beliefs.31 The majority (about two-thirds) of children with severe
CFS have been shown to recover. Nevertheless, recovery can be slow, taking years,
and one-third remain affected, with indications that poor prognosis may be linked to
more disordered personalities and to maternal beliefs about psychological factors
being irrelevant to the disorder.

SUMMARY

Unexplained physical complaints are frequent in the general population. These

complaints are commonly associated with somatization (the tendency to express
psychological distress through somatic symptoms and to request medical help) the
phenomenon at the root of the somatoform disorders, of which pain and conversion
in addition to CFS are seen in children. There is evidence that psychiatric comorbidity
is common, particularly anxiety and to a lesser extent depressive disorders and that
children with severe somatoform disorders are stress sensitive, which is probably
related to personality difficulty. There are also indications of biologic vulnerability
contributing to the development of physical symptoms in response to physical or other
stressors. Family clustering, parental emotional overinvolvement and overattention to
the child’s symptoms are thought to play a part in symptom maintenance. Manage-
ment needs to take into account the physical health focus of some children and their
parents, alongside skepticism, and sometimes even hostility, to the possibility of
a psychological contribution; this can make the initial pediatric assessment and
psychiatric intervention challenging. Psychiatric pediatric liaison teams have devel-
oped techniques for dealing with these attitudes and for engaging families in the
assessment and management process. Unfortunately liaison teams are not well devel-
oped.32 Effective attention to impairing somatoform disorders is likely to require
further development of specialist services of this kind. Nevertheless, for families in
which a psychological contribution to symptoms is acknowledged, generic child
and adolescent mental health services have much to offer in helping reduce concur-
rent physical symptoms and psychiatric comorbidity and possibly also help improve
adult health outcomes.

REFERENCES

1. Garber J, Walker LS, Zeman J. Somatization symptoms in a community sample of

children and adolescents: further validation of the Children’s Somatization Inven-
tory. Psychol Assess 1991;3:588–95.
2. Campo JV, Fritsch SL. Somatization in children and adolescents. J Am Acad
Child Adolesc Psychiatry 1994;33(9):1223–35.
3. Eminson M. Medically unexplained symptoms in children and adolescents. Clin
Psychol Rev 2007;27:855–71.
4. Garralda ME. A selective review of child psychiatric syndromes with a somatic
presentation. Br J Psychiatry 1992;161:759–73.
5. Garralda ME. Somatization in children. J Child Psychol Psychiatry 1996;37:
13–33.
6. Vila M, Kramer T, Hickey N, et al. Assessment of somatic symptoms in British
secondary school children using the Children’s Somatization Inventory (CSI).
J Pediatr Psychol 2009;34:989–98.
208 Garralda

7. Eminson M, Bejamin S, Shortall A, et al. Physical symptoms and illness attitudes

in adolescents: an epidemiological study. J Child Psychol Psychiatry 1996;37:
519–28.
8. Garralda ME, Chalder T. Practitioner review: chronic fatigue syndrome in child-
hood. J Child Psychol Psychiatry 2005;46(11):1143–51.
9. Rask CU, Christensen MF, Borg C, et al. The SOMA assessment interview: new
parent interview on functional somatic symptoms in children. J Psychosom Res
2009;66(5):456–64.
10. Kozlowska K, Nunn KP, Rose D, et al. Conversion disorder in Australian pediatric
practice. J Am Acad Child Adolesc Psychiatry 2007;46(1):68–75.
11. Campo JV, Jansen-McWilliams L, Comer DM, et al. Somatization in pediatric
primary care: association with psychopathology, functional impairment and use
of services. J Am Acad Child Adolesc Psychiatry 1999;38(9):1093–101.
12. Campo JV, Perel JM, Lucas A, et al. Citalopram treatment of pediatric recurrent
abdominal pain and comorbid internalizing disorders: an exploratory study.
J Am Acad Child Adolesc Psychiatry 2004;43(10):1234–42.
13. Pehlivanturk B, Unal F. Conversion disorder in children and adolescents: clinical
features and comorbidity with depressive and anxiety disorders. Turk J Pediatr
2000;42:132–7.
14. Walker LS, Williams SE, Smith CA, et al. Validation of a symptom provocation test
for laboratory studies of abdominal pain and discomfort in children and adoles-
cents. J Pediatr Psychol 2006;31(7):703–13.
15. Campo JV, Dahl RE, Williamson DE, et al. Gastrointestinal distress to serotonergic
challenge: a risk marker for emotional disorder? J Am Acad Child Adolesc
Psychiatry 2003;42(10):1221–6.
16. Lombardi VC, Ruscetti FW, Das Gupta J, et al. Detection of an infectious retro-
virus, XMRV, in blood cells of patients with chronic fatigue syndrome. Science
2009;326(5952):585–9.
17. Erlwein O, Kaye S, McClure MO, et al. Failure to detect the novel retrovirus XMRV
in chronic fatigue syndrome. PLoS ONE 2010;5:e8519.
18. Walker LS, Garber J, Smith CA, et al. The relation of daily stressors to somatic and
emotional symptoms in children with and without recurrent abdominal pain.
J Consult Clin Psychol 2001;69(1):85–91.
19. Walker LS, Smith CA, Garber J, et al. Appraisal and coping with daily stressors by
pediatric patients with chronic abdominal pain. J Pediatr Psychol 2007;32(2):
206–16.
20. Ramchandani PG, Stein A, Hotopf M, et al. Early parental and child predictors of
recurrent abdominal pain at school age: results of a large population-based
study. J Am Acad Child Adolesc Psychiatry 2006;45(6):729–36.
21. Kozlowska K. Good children presenting with conversion disorder. Clinical Child
Psychol Psychiatry 2001;6(4):575–91.
22. Campo JV, Bridge J, Lucas A, et al. Physical and emotional health of mothers of
youth with functional abdominal pain. Arch Pediatr Adolesc Med 2007;161:131–7.
23. Craig TK, Cox AD, Klein K. Intergenerational transmission of somatization behav-
iour: a study of chronic somatizers and their children. Psychol Med 2002;32:
805–16.
24. Walker LS, Williams SE, Smith CA, et al. Parent attention versus distraction:
impact on symptom complaints by children with and without chronic functional
abdominal pain. Pain 2006;122(1-2):43–52.
25. Sanders MR, Shepherd RW, Cleghorn G, et al. The treatment of recurrent abdom-
inal pain in children: a controlled comparison of cognitive-behavioural family
 Unexplained Physical Complaints 209

intervention and standard pediatric care. J Consult Clin Psychol 1994;62(2):

306–14.
26. Robins PM, Smith SM, Glutting JJ, et al. A randomized controlled trial of a cogni-
tive-behavioural family intervention for pediatric recurrent abdominal pain. J Pe-
diatr Psychol 2005;30(5):397–408.
27. Stulemeijer M, de Jong LW, Fiselier TJ, et al. Cognitive behaviour therapy for
adolescents with chronic fatigue syndrome: randomised controlled trial. Br Med
J 2005;330(7481):14.
28. Wright B, Ashby B, Beverley DW, et al. A feasibility study comparing two treat-
ment approaches for chronic fatigue syndrome in adolescents. Arch Dis Child
2005;90:369–72.
29. Calvert P, Jureidini J. Restrained rehabilitation: an approach to children and
adolescents with unexplained signs and symptoms. Arch Dis Child 2003;88:
399–402.
30. Mulvaney S, Warren LE, Garber J, et al. Trajectories of symptoms and impairment
for pediatric patients with functional abdominal pain: a 5-year longitudinal study.
J Am Acad Child Adolesc Psychiatry 2006;45(6):737–44.
31. Campo JV, Di Lorenzo C, Chiappetta L, et al. Adult outcomes of pediatric recur-
rent abdominal pain: do they just grow out of it? Pediatrics 2001;108(1):E1.
32. Woodgate M, Garralda ME. Pediatric liaison work by child and adolescent mental
health services. Child Adolesc Ment Health 2006;11:19–24.