ARTICLE IN PRESS

Journal of Adolescent Health 000 (2018) 1 6

www.jahonline.org

Original article

Somatic Symptom Disorders in Adolescent Inpatients

Xue Gao, M.P.H., Ph.D.a, Phillipa McSwiney, M.B.B.S.a, Andrew Court, M.B.B.S.b,
Aaron Wiggins, M.B.B.S.b, and Susan M. Sawyer, M.B.B.S., M.D.a,c,d,*
a
Centre for Adolescent Health, Royal Children’s Hospital, Parkville, Victoria, Australia
b
Department of Mental Health, Royal Children’s Hospital, Parkville, Victoria, Australia
c
Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia
d
Murdoch Children’s Research Institute, Parkville, Victoria, Australia

Article History: Received January 14, 2018; Accepted June 18, 2018
Keywords: Somatic symptom disorder; Conversion disorder; Functional illness; Parents; Healthcare utilization; Recovery

A B S T R A C T
IMPLICATIONS AND
CONTRIBUTION
Purpose: There are only a few reports of adolescents with somatic disorders (SDs) whose symptoms are
sufficiently severe to require hospital admission. The aim of this study was to describe the symptom pro-
Somatic disorders are a
file, health service utilization, and outcome of adolescents with SDs admitted to a tertiary children’s
relatively common cause of
hospital.
admission in adolescents
Methods: A retrospective cohort study of all adolescents admitted to the Adolescent Medicine Unit of a
and utilize significant
tertiary children’s hospital was undertaken from July 2013 to June 2014. In a two-stage process, medical
healthcare resources.
records were examined to identify patients who met the diagnostic criteria for SD. Evidence of functional
While the majority recov-
recovery was obtained for the period from 18 to 30 months after discharge and rated as completely
ers, the influence of parent
recovered, partially recovered, or functionally disabled.
acceptance on functional
Results: A total of 60 admissions (53 patients, 79% female) were identified with SD, accounting for 12% of
recovery suggests that
the unit’s admissions and 2% of hospital admissions over 12 years old. Nearly half (45%) the presenting
multidisciplinary teams
symptoms were neurological and 39% involved pain. In total, 20% of admissions were for complex symp-
focus on parent engage-
toms involving multiple body systems. The majority (81%) of adolescents with follow-up documentation
ment as well as adolescent
(n = 37) demonstrated complete or partial recovery. Patients whose families fully accepted the diagnosis
concerns.
were more likely to accept counseling following discharge (p < .001) and were almost 20 times more
likely to have completely recovered compared to adolescents whose families partially accepted or
rejected the diagnosis (odds ratio 17.36, p = .003).
Conclusions: Hospitalized adolescents with SD utilize substantial resources due to the requirement for
comprehensive assessment, including multidisciplinary communication. Recovery can be anticipated for
the majority, especially if supported by parents.
© 2018 Society for Adolescent Health and Medicine. All rights reserved.

Somatic symptoms are highly prevalent. A prospective school-
based study of common somatic complaints found that two-thirds
of 12 year olds reported at least one somatic symptom each week
[1]. Headache and abdominal pain are most frequently reported,
but adolescents commonly experience more than one symptom
[1 3]. For example, a population survey of 12 16 year old
*Address correspondence to: Susan M. Sawyer, Centre for Adolescent Health, Royal
Children’s Hospital, 50 Flemington Rd, Parkville 3052, Victoria, Australia.
E-mail address: susan.sawyer@rch.org.au (S.M. Sawyer).
Canadians reported that the prevalence of multiple, distressing
recurrent somatic symptoms was 10.7% in girls and 4.5% in boys
[3]. Studies using detailed psychiatric interviews similarly affirm
the frequency of somatic disorders (SDs). A population study of
German 14 24 year olds reported that 12.6% met criteria for clini-
cally significant somatoform syndromes, with a 2.7% lifetime prev-
alence of DSM-IV SD [4]. Often comorbid with other mental
disorders [4,5], SDs typically present to medical rather than mental
health professionals [6], where they substantially contribute to

1054-139X/© 2018 Society for Adolescent Health and Medicine. All rights reserved.
https://doi.org/10.1016/j.jadohealth.2018.06.026

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 ARTICLE IN PRESS
2 X. Gao et al. / Journal of Adolescent Health 00 (2018) 1 6
clinical workloads in primary care and specialist pediatric settings
[2,7 10]. SDs can be challenging to diagnose and manage, at least
in part because both parents and adolescents can find it difficult to
accept the contribution of psychosocial stressors to the experience
of physical symptoms [6,10]. Medical investigations can be fueled
by parent anxiety about missing organic diagnoses [6,10]. SDs are
also a source of anxiety for treating clinicians who in the face of
unremitting symptoms and distressed parents can worry about
missing rare disorders [10]. Many children end up undergoing
extensive, sometimes invasive, investigations [10 12], with SD only
diagnosed following the exclusion of all other potential conditions.
Hospitalized adolescents with SD utilize substantial healthcare
resources. In an Australian study of childhood conversion disorder,
the average length of stay was 11 days [13]. In the United King-
dom, 53 children with medically unexplained neurological symp-
toms constituted 12.5% of neurology admissions [12]. A cohort of
60 Danish pediatric patients with SD constituted 1% of hospital
admissions, and nearly one in five was admitted >2 weeks [8]. A
US study of psychiatry referrals of 3 18 year olds admitted to a
tertiary children’s hospital with SD showed that one in seven
required readmission [9]. Despite this, only a few studies have
documented the symptom profile of adolescents whose symptoms
are so severe, complex, or disabling that hospital admission is
required [9,12,14]. Even fewer studies have attempted to docu-
ment recovery or identify factors associated with recovery, not-
withstanding the extent of functional impairment that can be
experienced, particularly school absence [12,15].
We undertook a retrospective cohort study of all adolescents with
SD admitted to the Adolescent Medicine unit (AMU) of a tertiary
children’s hospital over 12 months to describe the clinical profile and
pattern of healthcare utilization. In the context of clinical experience
suggesting that recovery was influenced by parent understanding,
we also assessed parent acceptance of the diagnosis of SD and ana-
lyzed its effect on functional recovery. For the purpose of this study,
SD refers to Diagnostic and Statistical Manual (Fifth Edition) DSM-5
Somatic Symptom Disorder and Conversion Disorder [16].
Methods
Setting
Ethical approval was obtained from the Royal Children’s Hospital
(RCH) Research Ethics Committee. The RCH is a tertiary children’s
hospital in Melbourne, Australia. At the time of the study, the AMU
admitted 12 19 year old adolescents with general medical prob-
lems, complex chronic illnesses requiring multidisciplinary care, and
mental health conditions with physical comorbidities (e.g., eating
disorders and SDs). The AMU has a close working relationship with
the Consultation Liaison Mental Health (CL) service, which includes
an adolescent psychiatrist and mental health nurse. A separate inpa-
tient mental health unit manages adolescents with life-threatening
mental health conditions without medical co-morbidities.
Approach to somatic disorders
The AMU and CL service view SDs as complex conditions where
the symptoms function to assist the adolescent avoid emotional
distress, in the context of the family system. Pediatricians within
the AMU have a low threshold for referral to the CL service soon
after admission once SD is considered. Rather than “diagnosis by
exclusion,” we prefer to intentionally diagnose SD when symp-
toms do not correspond to an organic syndrome, fail to follow a
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normal recovery pattern, or fluctuate depending on who is pres-
ent, in the absence of a better alternative. Once the diagnosis is
made, typically following detailed communication between medi-
cal and mental health providers, it is discussed in a straightfor-
ward, nonjudgmental manner with the adolescent and family,
usually at a multidisciplinary team meeting with both medical and
mental health clinicians. For follow-up, medical care and mental
health counseling are prioritized with community providers if pre-
viously involved; ambulatory care at the hospital is reserved for
families who are less accepting of the diagnosis or for adolescents
who are more severely impaired.
Study procedure
A retrospective cohort study was conducted of all patients with
SD admitted to the AMU between July 1, 2013 and June 30, 2014.
This cohort was identified using a two-stage process. Due to con-
cerns that discharge diagnoses would not capture all cases, an expe-
rienced clinician (PMS) carefully reviewed the entire medical record
of every admission over the study period including admission docu-
mentation, daily progress notes, referrals to other units, and the dis-
charge summary, to consider whether the clinical presentation was
consistent with an SD. Uncertain cases were discussed with the
senior author (SMS). At the time of the study, the hospital used an
Electronic Scanned Medical Record (EMR) system. In the second
stage, two authors (SMS and XG) independently reviewed each
EMR to ensure patients met DSM criteria for an SD, to ascertain
parental acceptance of the diagnosis and assess functional recovery
status. Any differences were resolved by discussion with a third cli-
nician available if consensus was unable to be reached. For patients
admitted more than once to the AMU during the 12-month study
period, data were extracted for each admission.
Extracted data included demographic details, prior medical
comorbidities, previous medical and mental healthcare, and health
service utilization during each admission. All presenting symptoms
were identified. If possible, a predominant symptom was identified
and categorized by system (e.g., neurological), influenced by physi-
ological plausibility. For example, a patient who presented with
prominent abdominal pain with occasional mild nausea would be
classified within the “pain” category. In contrast, a patient whose
major presenting symptoms were nausea and vomiting with mild
abdominal pain would be categorized within the “gastroenterolog-
ical” category. Some patients were unable to be grouped into a pre-
dominant symptom category. Thus, an adolescent who presented
with fatigue, dizziness, palpitations, nausea, and abdominal pain
would be categorized within the “complex” category.
Parent acceptance of the diagnosis of SD was retrospectively
categorized at discharge into one of four categories (fully accepted,
partially accepted, not accepted, or unknown) according to docu-
mentation from multidisciplinary meetings with the patient and
parent/s and any other clinical notes (e.g., nursing and CL team).
The category of “fully accepted” was applied when parents
appeared to have understood and accepted the team’s explanatory
model about the role of physical symptoms as a way the body
avoids distressing emotional stressors, and could appreciate the
importance of returning to function despite symptoms. The “not
accepted” category was used for parents who appeared to reject
this explanation and who solely attributed symptoms to organic
disease. The “partially accepted” category was used when docu-
mentation suggested the parents did not neatly fit into either of
these categories. While generally apparent from the case notes,
 ARTICLE IN PRESS
X. Gao et al. / Journal of Adolescent Health 00 (2018) 1 6
“unknown” was used if a decision could not be made, which
mostly reflected insufficient documentation.
Readmission to any unit at the RCH within 12 months following
discharge from the initial admission for SD was recorded. This
included subsequent admissions with somatoform features and
other mental disorders (e.g., anorexia nervosa and self-harm). We
did not include admissions for unrelated causes, such as road
trauma, or admissions for diagnostic procedures.
Functional recovery was defined as completely recovered, par-
tially recovered, functionally disabled, or unknown, and assessed
until December 31, 2015; a follow-up period that, given the study
period, ranged from 18 to 30 months. For patients with more than
one AMU admission during the 12-month study period, informa-
tion following the most recent admission was used to ascertain
functional recovery. Any subsequent documentation in the EMR
was used to inform the assessment of functional recovery, includ-
ing appointment notes and medical letters for unrelated appoint-
ments. Complete recovery was defined as full resolution of
symptoms. Adolescents with residual symptoms that had signifi-
cantly improved following discharge were categorized as partially
recovered. Those whose symptoms were relatively unchanged fol-
lowing discharge were categorized as functionally disabled (the
reason for admission).
Analysis
Data were de-identified and abstracted into a Microsoft Excel
Spreadsheet. Stata 13 (Stata Statistical Software: Release 13, Stata
Corp LP, College Station, TX) was used for data analysis. Descriptive
statistics were used to report adolescent demographic variables,
symptoms, parent acceptance, and functional recovery. Fisher’s
exact test was used to test the association between parental accep-
tance of the diagnosis of SD and of mental health counseling in the
follow-up plan, and between parental acceptance of the diagnosis
of SD and the readmission to the RCH within the 12 months fol-
lowing discharge from the initial admission for SD. Exact logistic
regression was used to assess the relationship between functional
recovery outcome and parent acceptance of the diagnosis of SD,
adjusting for gender, symptom complexity, and previous medical
and mental health service engagement. The outcome variable was
coded as 1 for “completely recovered” and 0 for “partially or not
recovered.”
Results
Demographic and admission characteristics
During the 12 months, 405 adolescents were admitted to
the AMU on 510 occasions. A total of 53 (13%) patients were
identified to have an SD, which accounted for 60 (12%) of unit
admissions (Table 1). Four patients had repeated admissions in
the 12 months. SD admissions constituted 2% of the hospital’s
adolescent multiday medical and surgical admissions. In 30% of
admissions, the diagnosis of SD was made following review of
the medical record rather than by discharge diagnosis. The
majority of patients (79%) were female, with a mean age of
14.6 years. For most admissions (63%), patients presented with
one symptom, but the number of presenting symptoms ranged
up to six. The majority of admissions (90%) followed presenta-
tion to the emergency department. The median admission
length was 3 days, although 23% of admissions were longer
than 6 days.
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3
Table 1
Demographic and admission characteristics
Demographic information N (%) or mean (SD)
Patients, number 53
Gender, female 42 (79.3%)
Mean age at admission, years (SD) 14.6 (1.5)
Admission characteristics N (%)
Admissions, number N = 60
Admission type
Emergency 55 (91.7%)
Elective 5 (8.3%)
Number of presenting symptoms at each admission
1 38 (63.3%)
2 10 (16.7%)
3 8 (13.3%)
4 3 (5.0%)
6 1 (1.7%)
Length of stay, days
1 16 (26.7%)
2 5 30 (50.0%)
6 10 10 (16.7%)
11 15 3 (5.0%)
>15 1 (1.7%)
Two-thirds (66%) of patients had consulted at least one medical
specialist before admission, and 60% had at least one medical
comorbidity at that time. More than half (53%) of the medical
comorbidities had features that overlapped with the presenting
symptom (e.g., severely disabling chronic hip pain in the context
of a pre-existing orthopedic diagnosis of mild hip dysplasia). In
total, 30% of adolescents had seen a mental health specialist in the
community prior to admission.
Pattern of somatic symptoms
The variety of presenting symptoms is shown in Table 2. Nearly
half (45%) the presenting symptoms were neurological and 39%
involved pain at various sites. The three most prevalent individual
symptoms were abdominal pain, headache, and seizures. The
majority of admissions had a predominant symptom group (Table
3), most commonly pain (42%), followed by neurological symp-
toms (30%). Among the 25 admissions with predominantly pain,
abdominal pain and headache were the most common pain sites.
Among the 18 admissions with predominantly neurological symp-
toms, seizure and consciousness-related symptoms (e.g., acute
confusional state) were the most common symptoms.
In total, 65% of adolescents were referred to another medical
specialist during the admission for an opinion (45% involved one
other specialist and 20% involved 2). In addition, nearly half
(48%) the admissions involved at least one allied health team (e.g.,
physiotherapy and occupational therapy) for assessment or man-
agement (17% involved 2 teams). Over three-quarters (78%) of
admissions were referred to the CL service (all were discussed
with the CL service at weekly team meetings).
Acceptance of diagnosis and follow-up plans
In 51 (85%) admissions, the parent response to the diagnosis
was able to be categorized (Table 4). While generally straightfor-
ward, nine admissions had insufficient documentation to make an
assessment. In 30 admissions (59% of those with documentation of
parent acceptance), parents were deemed to have fully accepted
the diagnosis. In a further 13 admissions (25% of those with
 ARTICLE IN PRESS
4 X. Gao et al. / Journal of Adolescent Health 00 (2018) 1 6

Table 2 Table 4
Variety of presenting symptoms at admission (N = 60) Level of parental acceptance, admissions, and evidence of recovery

Individual symptoms Number of admissions in which Outcomes N (%)

each symptom was present
Parental acceptance of SSD diagnosis (n = 60a)
Abdominal pain 16 Fully accepted 30 (50.0%)
Headache 9 Partially accepted 13 (21.7%)
Seizure 8 Not accepted 8 (13.3%)
Weakness 7 Unknown 9 (15.0%)
Limb pain 7 Number of related admissionsb to the RCH in the 12 months after discharge from
Confusion 5 first admission (n = 53c)
Difficulty walking 4 0 40 (75.5%)
Unresponsiveness 4 1 3 (5.7%)
Altered sensation 4 2 5 (9.4%)
Visual problems 4 3 2 (3.8%)
Chest pain 3 4 1 (1.9%)
Difficulty speaking 3 11 1 (1.9%)
Fatigue 2 14 1 (1.9%)
Vomiting 2 Evidence of functional recovery (n = 53c)
Memory loss 2 Full recovery 18 (34.0%)
Palpitations 2 Partial recovery 12 (22.6%)
Dizziness 2 Still functionally disabled 7 (13.2%)
Nausea 2 Unknown 16 (30.2%)
Diarrhea 1 a
Number of admissions.
Cough 1 b
Related admissions included those to the AMU, mental health unit and other
Shortness of breath 1
RCH units for any heath issue where SD was the most likely explanation.
Loss of weight 1 c
Number of individual patients.
Hearing loss 1
Difficulty swallowing 1
Unusual eye movements 1
Urinary retention 1 whether the parents accepted the diagnosis of SD (p< .001, Fisher’s
Back pain 1
Facial pain 1
exact test). Among the patients for whom mental health counsel-
Pelvic pain 1 ing was recommended, parents who fully or partially accepted the
Scrotal pain 1 diagnosis of SD all accepted the recommendation; more than half
Multiple pains 1 of those who did not accept the diagnosis chose to not further
Full body pain 1
engage with mental health care following discharge.
Total 100

Outcome

In total, 25% were readmitted to the RCH in the 12 months after

documentation of parental acceptance), parents partially accepted the first admission, including two patients with extremely numer-
the diagnosis. The diagnosis of SD was categorized as not accepted ous readmissions (Table 4). The majority of these patients were
by the parental in eight admissions (16% of those with documenta- readmitted with different symptoms. In 8 of the 13 (62%) readmit-
tion of parental acceptance). ted adolescents, other mental disorders became apparent over the
At discharge, beyond arranging medical follow-up, mental follow-up period including personality disorder, self-harm,
health counseling was offered to 80% of admissions. In total, 10% anorexia nervosa, and anxiety. Parent psychopathology also
did not accept this recommendation. Acceptance of the unit’s rec- became more apparent in a minority, including one case that
ommendation for counseling was significantly associated with required protective services. Patients whose parents fully (n = 30)
accepted the diagnosis of SD were significantly less likely to be
readmitted compared to those whose parents partially accepted
Table 3 (n = 13) or did not (n = 4) accept the diagnosis (odds ratio .083,
Predominant presenting symptom category at admission (N = 60) p = .018, Fisher’s exact test).
Predominant presenting symptom category Number of admissions (%) Table 4 reports functional recovery as a proportion of the 53
adolescents. Among the 37 whose recovery status could be deter-
Pain
Abdominal pain 10 mined, 18 (49%) had evidence of complete functional recovery,
Headache 4 such as complete absence of pain and return to daily schooling.
Other single-site pain 10 Twelve (32%) had evidence of partial recovery and seven (19%)
Multisite pain 1
continued to be significantly functionally impaired. The outcome
Subtotal 25 (41.7%)
Neurological of the remaining 16 was uncertain; their follow-up was elsewhere,
Seizure 6 and there was no further documentation in the EMR.
Consciousness-related (e.g., confusion) 5 Readmitted patients had an eightfold odds of less than com-
Multiple neurological symptoms 7 plete recovery (OR 8.89, p= .007); only 2 of the 13 readmitted ado-
Subtotal 18 (30%)
lescents were categorized as completely recovered. No patient had
Complexa 12 (20%)
Gastroenterological 4 (6.7%) any new organic diagnoses made during the follow-up period.
Urinary 1 (1.7%) Table 5 reports on the 33 cases in which both parental accep-
Total 60 tance of the diagnosis and functional recovery were known. The
a
Multiple symptoms involving different body systems. relationship between variables was examined using exact logistic

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 ARTICLE IN PRESS
X. Gao et al. / Journal of Adolescent Health 00 (2018) 1 6
Table 5
Likelihood of full recovery based on parental acceptance of SD diagnosis, after con-
trolling for complexity of main presenting symptoms, previous medical and mental
health service engagement, and gender (n = 33).
Odds ratio (95% CI)
Parental acceptance
Partially or not accepted Reference
Fully accepted 17.36 (2.10, 816.15)
Symptom complexity
Simple Reference
Complex .62 (.02, 10.86)
Previous medical service engagement
No Reference
Yes .26 (.004, 4.57)
Previous mental health service engagement
No Reference
Yes 2.01 (.13, 130.25)
Gender
Male Reference
Female 1.00 (.05, 22.56)
*p value is based on the probability of observed sufficient statistic.
regression, controlling for symptom complexity, previous medical
and mental health service engagement, and gender. Patients
whose parents fully accepted the diagnosis (n = 17) were nearly 20
times more likely to have made a complete recovery compared to
those patients whose parents only partially accepted (n = 13) or
rejected (n = 3) the diagnosis (OR 17.36, p = .003).
Discussion
In addition to the prevalence of SD in population cohorts and
ambulatory clinics [1,17], this study shows that adolescents with
SD constitute a significant workload within tertiary pediatric serv-
ices. Our cohort represented 2% of multiday hospital admissions of
adolescents. Around three-quarters were referred to CL mental
health services, two-thirds had involvement of another medical
specialist, half were engaged with allied health teams, a quarter
were admitted for longer than 6 days, and a quarter required read-
mission. While factors associated with the persistence of SD in
adolescents have been previously described such as female gender,
common mental disorder (e.g., depression and anxiety), pain
symptoms, frequent negative life events, and parent psychiatric ill-
ness [17 19], there is limited information on positive prognostic
factors. A striking feature of this study was the significance of par-
ent acceptance of the diagnosis on readmission and recovery; ado-
lescents whose parents fully accepted the diagnosis were nearly
20 times more likely to have functionally recovered than those
whose parents only partially accepted or rejected the diagnosis,
independent of gender, prior medical and mental health service
usage, and level of symptom complexity.
Physical symptoms can reflect either organic or functional eti-
ologies or a combination of both, as in this study where just over
half the adolescents had a medical comorbidity with clinical fea-
tures that overlapped with their presenting symptoms. This adds
significant complexity to diagnosing and managing SD, especially
for conditions that investigations cannot exclude such as pain syn-
dromes. This affirms the suggestion of Bujoreanu et al. [9] that doc-
tors consider “ruling in” a diagnosis of SD rather than the more
usual “ruling out” approach. Consistent with this, our medical and
mental health services seek somatization “red flags” (such as
symptoms that fluctuate depending on who is present), which sug-
gest the possible contribution of SD to the experience of symp-
toms, regardless of the presence of an organic disease.
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5
Although parent acceptance of the diagnosis of SD appears an
important aspect of adolescent recovery, engaging patients and
families in the possibility of SD can be challenging [11]. Even in pri-
mary care, a recent survey of American pediatric providers found
p valuea that almost half reported often having difficulty getting patients
and parents to accept the diagnosis [10]. For the complex cases in
our study, parents who were able to accept the diagnosis of SD
.003 may have been reassured by the process of the admission, during
which “fresh eyes” carefully reviewed the patient’s symptoms,
1.000 examination findings and investigations in the context of adoles-
cent development and family functioning. This may have been
helped by our clinical approach which, consistent with best prac-
.608
tice for SD [9,19], has a low threshold to engage other specialists,
uses the expertise of a multidisciplinary team to explore the psy-
1.000 chosocial context of symptoms, is clear about the diagnosis,
strongly promotes the benefits of return to function and encour-
ages both medical and mental health review [9,19].
1.000
A particular challenge for parents is understanding how emo-
tional stressors can be physically experienced in the body. We pro-
vide parents with an explanatory model that describes the
psychologically protective benefit for adolescents in avoiding anxi-
ety associated with stressors (so called “primary gain”) and the
complex role of the autonomic nervous system in amplifying phys-
ical symptoms. We reinforce that return to function, despite symp-
toms, is part of the recovery process. Contextualizing the problem
and the solution in this manner may of itself have led to changes
in some of these adolescents and their families. However, it seems
highly likely that recovery also reflected engagement with mental
health care, as families who accepted the diagnosis of SD also
accepted the recommendation for mental health follow-up.
In this study, we did not attempt to assess the extent of diagnos-
tic acceptance by adolescents as our experience is that they mostly
reject the diagnosis, at least initially. Prospective studies that com-
pare adolescent and parent acceptance of the diagnosis on recovery
would be valuable, as well as studies that explore the consistency of
acceptance (or not) between parents (and other family members)
on recovery. The importance of addressing somatic symptoms in
childhood and adolescence is that longitudinal population studies
show that firstly, many children do not “grow out” of somatic com-
plaints and that secondly, they can “grow into” other mental disor-
ders [20,21]. Even within our 12-month study period, readmission
was typically for different symptoms.
A few clinical studies have attempted to document functional or
psychological recovery in hospitalized cohorts. In total, 76% of 21 US
children with pseudoseizures had functionally recovered when
assessed 6 66 months after diagnosis [22]. In this context, a normal
EEG is highly reassuring for doctors and may facilitate clarity of the
diagnosis, which is anticipated would reduce parent anxiety and pro-
mote acceptance. However, chronicity is also a feature of SDs, even in
the young. An English study of 25 children admitted to a quaternary
children’s hospital with medically unexplained neurological symp-
toms diagnosed through a complex multidisciplinary assessment
was more sobering; 2 years later, only 36% had any improvement in
neurological symptoms although 44% had better school attendance
[12]. Notwithstanding that our cohort required admission due to
major functional disturbance, the majority (81% of those with recov-
ery documented) showed evidence of some functional recovery, and
close to half (49%) were deemed to have fully recovered at a mini-
mum of 18 months following discharge.
This study has various limitations. As data were retrospectively
collected from a chart review, they depend on the quality of the
original history taking and documentation. While efforts were
 ARTICLE IN PRESS
6 X. Gao et al. / Journal of Adolescent Health 00 (2018) 1 6
made to carefully define outcomes, interpretation of individual
case notes remains subjective especially in relation to parent
acceptance. While three cases had been previously diagnosed with
SD following prolonged hospital admission elsewhere, we did not
have consistent knowledge of whether other clinicians had previ-
ously diagnosed SD and how this might have influenced outcomes.
Finally, the sample size is small, with wide confidence intervals
around secondary analyses.
The reliability of the findings is promoted by undertaking the
study within a single medical unit with relatively consistent practi-
ces around the diagnosis and management of SD, and by careful
review of the entire EMR. A strength of the study is that all AMU
admissions were reviewed in a two-stage process to identify possi-
ble cases and ensure each admission met DSM-5 criteria; a third of
cases would otherwise have been missed. Rather than a definitive
study, however, we suggest these findings are viewed as hypothe-
sis generating, to be advanced by prospective studies.
In conclusion, the relatively high functional recovery rate in a
cohort with SD severe enough to warrant admission suggests the
value of an experienced specialist multidisciplinary inpatient ser-
vice. Despite this, functional impact continued to be experienced
in many, which highlights the potential significance of this disor-
der. To our knowledge this is the first study to suggest that parent
acceptance of the diagnosis of SD has a significant effect on adoles-
cent functional recovery. Further research is needed to understand
the effect of parent life experiences, mental illness and personality
on their preparedness to accept the diagnosis of SD in their chil-
dren, as it may be anticipated that beyond parental anxiety, more
complex parent psychopathologies will hinder adolescent recov-
ery. In the meantime, these results suggest potential targets for
clinical interventions, of relevance for primary care as well as spe-
cialist settings.
Funding Sources
The work of Dr. Xue Gao was supported by the Endeavour Aus-
tralia Cheung Kong Research Fellowship.
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