Introduction 

Paediatric somatic symptom disorders refer to a collection of physical symptoms lacking a medical explanation which are experienced by children. Often, such symptoms include: 

• Pain 
• Fatigue
• Gastrointestinal issues 
• Muscle pain 
• Shortness of breath
• Headaches 

These symptoms can have a psychological impact. They are also likely to cause significant distress and impair the ability to carry out day-to-day activities.

Oftentimes, such symptoms are also accompanied by mood disorders such as depression. Manifested through changes in sleep and appetite levels, children often present with 

• Persistent sadness 
• Irritability
• Lack of interest in daily activities

This article provides an overview of the various symptoms and the diagnostic criteria for somatic disorders and associated depression in children. It also includes potential treatment opportunities. Understanding its manifestation in the paediatric population is crucial to providing comprehensive instrumental, psychological, and financial support. This will improve patient outcomes, and reduce the caregiver burden on families and healthcare systems alike. 

Overview of somatic symptom disorders 

Somatic symptom disorders (SSDs) are characterized by physical symptoms lacking an identifiable medical explanation. Patients diagnosed with SSDs can experience 

• Pain 
• Nausea 
• Fatigue
• Headaches 

Patients with SSDs also often display psychological symptoms such as excessive levels of thoughts, feelings, and behaviours related to their physical symptoms. Such excessive levels of concern exhibited by patients about the origin and lack of explanation about their symptoms severely impair their daily functioning and quality of life.¹ 

The Diagnostic & Statistical Manual of Disorders has identified such functional impairments due to psychological responses as a diagnosis. The manual explains that the experienced dysfunction is not because of any pre-existing medical or psychiatric conditions. The manual also considers the severity, duration, and contextual factors of these impairments.²

SSDs in children are quite severe to assess, diagnose and treat. This is due to unique factors concerning their 

• Developmental processes 
• Psychological resilience 
• Communication skills
• Environmental dynamics 

All of these factors will be discussed in detail in the upcoming sections.

Some of the most common physical symptoms experienced are:

• Headaches
• Abdominal pain
• Muscle pain
• Nausea
• Fatigue
• Chest pain
• Shortness of breath

The Diagnostic & Statistical Manual for Disorders states that a key aspect of somatic disorders is the preoccupation and excessive worry that accompanies such physical symptoms. Some examples of psychological and behavioural manifestations of the same include:

• Health-related anxiety
• Preoccupation and excessive worrying about symptoms
• Withdrawal and avoidance from social and academic interactions
• Emotional distress
• Low self-esteem
• Frequent mood changes
• Irritability
• Loss of interest in activities of daily living

The intersection of somatic symptom disorder and depression in paediatric populations 

Often, children suffering from somatic symptom disorders are also diagnosed with mood disorders such as depression. Large-scale studies have shown somatic symptom disorders are often accompanied by major depressive disorder. However, there is a lack of agreement and adequate research into the overlapping pathophysiology of both disorders.³ It affects about 10 to 30% of children and youths in the United States. There is a growing interest in discovering mind-body relations and manifestations of psychological experiences as physical symptoms. Listed below are some of the major contributing factors that can cause the simultaneous appearance of depression and somatic symptom disorder. These factors are specific to the paediatric population.

Gender differences 

Co-existing SSD and depression affect both children assigned male at birth (AMAB) and children assigned female at birth (AFAB) across all ages, with varied rates of prevalence. A study found differences not only in prevalence rates but also in the symptoms exhibited by children of different ages and sexes. For instance, children with AFAB exhibited higher prevalence rates of somatic symptoms as compared to children with AMAB. This is due to differences in psychological traits, family and contextual dynamics and environmental factors.⁴ For example, alexithymia is a condition characterized by difficulty in recognizing and describing emotions. This condition manifested as somatic symptoms in children with AFAB. In contrast, pressures of perfectionism result in a rise in physical stress and symptoms in people with AMAB. Differences in physical symptoms were observed. People with AMAB were more likely to report musculoskeletal pains, whereas people with AFAB reported gastrointestinal issues and headaches.

Environmental and familial factors 

The ways in which depression and SSD manifest in children are greatly influenced by various environmental and familial factors. Factors such as stressful life events, daily stressors and social support greatly affect the way symptoms are reported and dealt with. Studies have linked negative life events such as:

• Death of family members 
• Conflicts 
• Academic pressures 

to an increased report of physical symptoms.⁵ When such events are not carefully dealt with, they are more likely to hamper a child’s sense of social competence and esteem. This can lead to depression and have other negative effects. Similarly, a lack of social, financial, instrumental and operational support to disadvantaged children is likely to result in greater levels of physical stress and psychological burden.

Developmental and contextual influences

Contextual and developmental trajectories significantly shape the manifestation and expression of somatic symptoms and depression in children. Families which emphasize overprotectiveness cause a higher exposure to adversity and daily stressors. This contributes to the rising severity of symptoms. Moreover, adolescents have limited emotional vocabulary and often express the need for independence. Therefore, the effects of parental accommodation and coping methods also contribute to the multifaceted nature of the disorder.⁶ Such complex and nuanced presentations of the disorder therefore call for greater attention to detail in assessment and treatment formulation.

Diagnosis of somatic symptom disorders

Somatic symptom disorders require a thorough 

• Medical history
• Physical evaluation
• Psychological evaluation 
• Cognitive evaluation

to successfully diagnose the condition in paediatric patients. Such methodological evaluations paint a comprehensive picture of the circumstances surrounding the patient’s medical, psychosocial and environmental condition at the time of diagnosis. This assists in formulating effective treatment plans to successfully help manage and alleviate the symptoms.

Diagnostic tools and questionnaires such as the Somatic Symptom Disorder-B Criteria Scale and the Child Depression Inventory (CDI) are crucial to assessing the severity of disorders and the possible existence of comorbidities related to the condition. Such diagnostic tools can also reveal associated obsessions and health concerns. All of this information is vital to reach an accurate diagnosis.

Accurate diagnosis and assessments carried out by trained mental health professionals are crucial to early intervention and to formulate detection strategies. This also prevents further development or severity of symptoms and allows for a timely intervention. Building effective coping skills and educating parents and caregivers about appropriate treatment regimens is paramount. It allows a successful assessment and diagnosis that can be instrumental in improving the prognosis of these conditions. This ensures the establishment of strong social support and successful adherence to treatment plans addressing the health, personal and psychological well-being and educational growth of children.⁷ 

Treatment of somatic symptom disorder

Effective treatment and therapeutic regimens address the improvement of 

• Symptoms 
• Health conditions 
• The overall physical and psychological well-being of clients 

Treatment also reduces the burden and improves the resilience of caregivers. Various forms of therapy such as 

• Cognitive behavioural therapy 
• Family therapy 
• Mindfulness therapy 
• Stress reduction techniques 
• Lifestyle changes 

are available. Coupled with medications and physical activity, they play a great role in reducing the symptoms of anxiety, depression, and preoccupied thoughts. At the same time, it alleviates somatic symptoms and helps children regain control of their lives. A successful treatment regimen calls for a close collaboration between all “stakeholders of treatment”. These are

• The child
• The parents
• The education providers 
• The healthcare providers 

This ensures adjustment in all aspects of life.⁸

Challenges and barriers of somatic symptomatic disorder treatment 

The very nature of mental disorders poses significant barriers to treatment in that symptoms are not readily visible and explicable to the naked eye. In cases such as somatic symptom disorders where physical pains arise with no attributable cause, challenges in treatment may persist. These challenges are due to stigma and misconceptions surrounding somatic symptoms, societal attitudes and misperceptions. This invariably affects access to care and adherence to treatment regimens.

In children, SSDs may be more severe, with serious implications on well-being and holistic physical and psychological development. Some of the factors that may hinder access to effective treatment include:

• Limited coping mechanisms in children, added to the inability to understand and manage their stress factors independently
• The very nature of the illness leads to misunderstandings about the causes of their illness, resulting in heightened anxiety surrounding their health
• Challenges in communicating with caregivers and healthcare providers where children cannot successfully and effectively articulate their experiences and symptoms
• Heightened sensitivity and emotional reactivity and response to their disease severity
• Fear of medical procedures owing to less research and information about their disorder 
• Fear of failing treatments if symptoms continue to persist
• Parental influence: heightened anxiety or neglect of the parents towards the child’s report of medical symptoms, which reinforces the level of care and preoccupation children may have with the disorder
• Effect on social and academic activities: heightened anxiety, absenteeism, withdrawal from social situations, perceived lower self-esteem and difficulty forming healthy social relationships 

Summary 

• Somatic symptom disorders refer to the experience of physical symptoms without any linked medical condition 
• In children, somatic Symptom Disorders are often accompanied by mood disorders such as major depressive disorder, due to the complex interplay of physical, psychological, social, and developmental aspects of childhood growth 
• Commonly known as depression, this condition is characterized by heightened anxiety, poor social and emotional development, poor communication skills, miscommunication in symptom reporting, and impact on academic achievement
• The severity and complexity of the accompanying depression call for more effective interventions to address the multifaceted nature of the disorder 
• Early and comprehensive intervention backed by close collaboration with patients and families is necessary to help support symptoms and improve adjustment in day-to-day life and successful psychosocial growth of a child