Paediatrician identification of psychological factors associated with general paediatric consultations

Joumul o/Ps.vchosomaric Printed in Great Bntam.

Research.

Vol.

34, No.

3, pp.

303-312.

1990. 0

0022.-3999:90 33.00 + .oO 1990 Pergamon Press plc

PAEDIATRICIAN IDENTIFICATION OF PSYCHOLOGICAL FACTORS ASSOCIATED WITH GENERAL PAEDIATRIC CONSULTATIONS M. ELENA GARRALDA and DOROTHY BAILEY (Received 20 June 1989; accepted in revisedform

31 October 1989)

Abstract-In a study of children 7712yr of age referred to general paediatric clinics, paediatricians reported psychological factors associated to somatic presentations in 47% of the children. These cases presented with a variety of somatic symptoms, but abdominal/chest/joint pains and soiling were particularly common. From research interviews with the parents we found increased rates of psychiatric disorder (abnormalities of emotions, behaviour or relationships) amongst them. The most common psychiatric symptoms were depressive mood changes and relationship problems. We also identified an excess of certain personality features in the children and of family health problems in this group. Paediatricians commonly identify psychosomatic issues in children attending general paediatric clinics and independent evidence supports the validity of their assessments.

INTRODUCTION

recognized that paediatricians spend considerable time dealing with the psychosocial needs of children, and that child psychiatric skills should be taught to paediatricians in training [l]. There is, however, lack of an agreed approach to the conceptualization of the psychosocial issues relevant to paediatric work. Existing research--mostly carried out in primary care settings-tends implicitly to adhere to one of three main models, each of them with varying clinical assumptions and implications. The first model considers psychosocial issues at their most obvious, namely children presenting with emotional or behavioural symptoms as primary complaints. Surveys have reported rates of between 2% and 10% in children’s consultations [2-81. A paediatric-psychiatric approach to these cases is clearly indicated. But primary mental health consultations do not describe the range of relevant psychosocial issues. These may be important as associated or background factors to somatic consultations. The second model concerns itself with the presence of psychiatric disorder-or handicapping abnormalities of emotions, behaviour or relationships-as a background phenomenon to somatic presentations, the assumption being that the somatic complaints will often be an expression of the psychiatric disturbance. The preferred research strategy has been the use of parental questionnaires or interviews and these have estimated psychiatric disorders to be present in a quarter to a third of children attending general practice or paediatric clinics [8-l 11. A link between psychiatric and somatic symptoms is nevertheless not always easy to ascertain in these cases and a paediatric-psychiatric approach not necessarily called for. IT IS GENERALLY

Corresponding author: Dr E. Garralda, University Charlestown Road, Manchester M9 2AA. U.K. 303

of Manchester.

Booth

Hall Children’s

Hospital,

304

M.

ELENA

GARRALDA

and DOROTHY

BAILEY

The third and broadest approach takes the paediatrician’s clinical perspective as its starting point. In this model, the relevant psychological issues are those judged by the paediatrician to be contributory in children’s somatic presentations, by for example maintaining or aggravating physical symptoms. As with the concept of adult somatization [I 21 the psychological factors in this model may or they may not overlap with psychiatric disorders. A child’s asthma can be aggravated or his abdominal pains maintained by family stress in the absence of child behavioural or emotional symptoms. This approach is potentially most relevant to paediatric practice, but it has been least documented. Two surveys have applied it to the study of general practice consultations of children, the strategy being one of asking paediatricians to document any presentations with associated psychological factors. Rates of about 20% have been reported [3, 131. In our previous study in general practice we carried out detailed psychological interviews in order to establish the precise nature of the associated psychological factors identified by general practitioners in these children. They were largely in the area of family health problems and educational difficulties [ 131. In addition, we found that children with associated psychological factors had high rates of referral to medical specialist services, and this suggested that psychological issues would be particularly common at the hospital paediatric clinic. This is the issue addressed in the present study, the specific aims of which were: 1. To document the frequency with which paediatricians judge psychological factors to contribute to children’s somatic presentations in secondary or hospital paediatric out-patient clinics; 2. To use detailed research interviews with the parents in order to explore in some detail the nature of the associated psychological factors and to provide a measure of validity for the doctors’s assessments. We used a controlled design where children judged by paediatricians to have associated psychological factors were compared with children not so identified. More specifically, we examined the extent to which the presence of associated psychological factors was linked to psychiatric disorder and symptoms in the children, to personality features and to family characteristics generally assumed to contribute to somatic symptoms in childhood [14-181.

METHOD Consecutive new referrals of children aged 7-12 yr to general paediatric clinics were selected for study. The children attended clinics run during 19861987 by six consultant paediatricians with clinical responsibilities in four health districts in Greater Manchester and Cheshire covering a mixed population: two districts were in city urban/suburban areas and the other two covered medium-sized industrial towns and the surrounding rural areas. Only routine referrals entered the study: casualty referrals and those attending special interest clinics were not included and, to avoid language difficulties in completing questionnaires and interviews, children of immigrant families were also excluded. Paediatricians completed questionnaires on every child noting the reasons for consultation (classified according to the International Classification of health problems in primary care [19] which generally correspond with ICD-9 scores [?O]), their diagnoses following assessment, and details of psychological factors related to the referral: they were asked to note whether there were psychological factors associated with somatic presentations; to indicate the nature of any existing psychological factors from a list of pre-determined items (e.g. depression or antisocial symptoms in the child, parental illness or anxiety), and to specify whether these factors were aggravating the somatic symptoms or were a result of them. Parents (mostly mothers) of eligible children were approached at the time of their first visit to the paediatric clinic and their permission obtained to be interviewed at home. The inverviews inquired about general demographic factors, social conditions, the children’s early development and recent health and psychiatric status (modified Child Health Questionnaire and Psychiatric Interview with Parents: [21]).

Paediatrician

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Parents were asked about recent family health problems, about social stresses and supports in a number of social and interpersonal areas, about recent stresses in the child’s life, and they completed questionnaires on their own mental health (Social Stress and Supports Interview [22, 231; Child Life Events Inventory [24-261; General Health Questionnaire or GHQ28 [27]). The presence of psychiatric symptoms and disorder in the child was assessed with an up-dated version of the Psychiatric Interview with Parents [21] and information from school was obtained using the Teacher Behavioural Questionnaire [21]. The Psychiatric Interview with Parents has been found to be a valid and reliable method for gathering evidence in order to make a diagnosis of psychiatric disorder. This was defined as a handicapping abnormality of behaviour, emotions or relationships. On the basis of the interview, the child psychiatrist author (EMG) who was blind to the paediatricians’ assessments scored individual symptoms and the overall presence of psychiatric disorder. The reliability of these assessments was tested in our previous study of psychiatric disorder amongst children attending general practice [S]. Twenty schedules were scored independently and blindly as to psychiatric status by another child psychiatrist. The overall agreement for the presence of absence of disorder was SO%, a similar rate to previous reports [21], with an acceptable kappa coefficient of 0.6. In the analysis of data, children identified by paediatricians as having psychological factors associated with the presentations were compared with the rest of the children on paediatrician and on detailed parental information. Tests of statistical significance were used as appropriate (chi-square with Yates correction in fourfold tables and non-parametric tests for continuous variables).

RESULTS

The parents of 137 children aged 7-12 yr were approached for the study; 128 (93%) agreed to take part and completed questionnaires. Subsequently two parents declined to be interviewed and full parental information was available for 126 subjects. Eight paediatricians (the six consultants and two senior registrars) completed questionnaires for 127 subjects but since one of the doctors requested a revised shorter version, full paediatrician information was vailable for 96 subjects. Of the 128 entering the study there were 66 boys and 62 girls, and the mean age was 9.1 yr. The majority (81%) of children were taken to the hospital by their mothers. Most (93%) had been referred by their general practitioners and few had been seen by a medical specialist previously (15%). The main paediatric diagnoses, accounting for half the presentations were: migraine, asthma, abdominal pains, urinary tract infections, growth failure, bedwetting, blackouts, headaches and soiling. The rest of the children were given one of other 34 diagnoses. Mental health problems (e.g. behaviour disorders, anxiety, nightmares) were the main referring reason in 3%. Most complaints were longstanding and episodic. Paediatrician

information

on psychosomatic

presentations

Paediatricians reported psychological factors associated to somatic presentations in 55 cases (47%): these were thought to be definitely present in 20 (17%) and possibly present in 35 (30%). The rate of identification of psychological factors ranged from 33% to 55% for seven of the participating paediatricians; for one this was higher (SO’/,). Details on the nature of the psychological factors were available for 44 subjects. The most common ones are outlined in Table I. It can be seen that depression in the child, parental illness and over involvement featured most prominently as aggravating factors. Parental anxiety was as likely to be an aggravating as a resulting factor whereas the opposite was true of problems with peers in school. Other factors named in the questionnaires of at least three subjects as potentially relevant were problems with peers in school, inadequate parental care/control and marital prob-

M. ELENAGARRALDA

306 TABLE

and DOROTHYBAILEY

I.-PAEDIATRICIAN ASSESSMENTS, MAIN PSYCHOLOGICAL FACTORSASSOClATEDTOSOMATlC CONSULTATIONS Result of

Aggravates

somatic

somatic Child symptoms Depression Antisocial School Problems with peers Family Parental anxiety Illness Over involvement Inadequate care/control Marital problems

10 3

3 3

2

4

4 5 4 3 3

4

I

n = 44 subjects.

lems. Problems with work, teachers or behaviour in school, and family difficulties such as single parents, negative attitudes towards the child or high parental expectations were rarely mentioned. In order to examine whether certain somatic symptoms were more likely to be associated with psychological factors than others, we compared the present complaints reported by the paediatricians for the 55 children in the psychological factors group with those for the 61 children with somatic presentations but without associated psychological factors. Table II shows that abdominal pains, chest, joint and ‘functional’ pains. and soiling were present in about one-third of presentations with associated psychological factors but in only 4% of the rest, whereas urinary tract infections and asthma were less common in the psychological factors group. There were few differences between the group for migraine and headaches, bedwetting. blackouts/convulsions, or in children with no diagnoses.

TABLE II.----PRESENTING COMPLAINTS

Psychosomatic* (n = 55) O/b I. Conditions more common in the group with psychosomatic factors ‘Functional’ chest or joint pains Abdominal pain Soiling 2. Conditions less common Urinary tract infection Asthma 3. Conditions present similarly frequently in both groups Migraine Bedwetting Blackouts/convulsions Headache No pathology 4. Infreauentlv named conditions *Group

with associated

psychological

Others (II = 61) “‘0

6 I 4

(11) (13) (7)

0 2

(3)

I

(2)

1 4

(2) (7)

8 8

(13) (13)

6 3 3 3 3 15

(11) (5) (5) (5) (5)

6 3 3 2 4 24

(10) (5) (5) (3) (7)

factors.

Paediatrician

identification

of associated

psychological

factors

Detailed exploration of the nature of the associatedpsychologicalfactors parental information

307

using research

We used the detailed information from our research home interviews with the parents to explore in more depth the nature of the associated psychological factors. We compared children with and without these factors on aspects of child and family psychosocial functioning. As the parents of two children with associated psychological factors had not been fully interviewed, parental information was available for 53 subjects in this group and for 61 subjects with other somatic presentations. (a). Child factors. Psychiatric disorder as assessed from information from the Psychiatric Interview with Parents was present significantly more commonly in the psychological factors group (one-third vs 14%). These children had significantly more symptoms of chronic unhappiness and more relationship problems including defiance to parents, problems with siblings, bullying by other children, and problems with teachers (Table III). The presence of antisocial symptoms on the parental interviews and of behavioural problems on the teachers questionnaires failed to differentiate between the two groups. Previous studies of ‘functional or psychosomatic’ symptoms in children--or symptoms for which psychological factors are thought to be specially relevant, for example abdominal pains-have described unusual habitual anxiety, timidity, apprehension of new people and situations, and fearfulness; children are also described as TABLEIII.-PSYC~IIATRICINTERVIEWWITHTHEPARENT:PSYCHIATRICDISORDERANDSYMPTOMS

Pschosomatic* (?I = 53) % Psychiatric

disorder

Psychiatriac symptoms 1. Chronic unhappiness Episodes usually lasting:
with associated

psychological

Other (n = 61) %

Statistics

19 (36)

9 (15)

xz = 5.7 Idf p < 0.02

10 (19) 6 (11)

6 (10) 1 (2)

x2 = 7.2 2df p = 0.02

12 (23) 11 (21)

13 (21) 2 (3)

9 (17) 4 (8)

1 (2) 0

x2 = 13.9 2df

8 (15) 5 (9)

3

x2 = 7.3 2df p = 0.03

12 (23) 6 (11)

1 (2) 13 (25)

1 (2) 15 (28) factors.

(5)

1 (2) 30 (49) 3 (5) 0

6 (10) 6 (to) 5 (8)

x2=9.12df p = 0.02

p = 0.001

x’ = 9.7 3df p = 0.02

x2 = 6.7 2df p = 0.03 x2 = 6.5 ldf p < 0.02

M. ELENAGARKALDA and DOROTHYBAILEY

30s

fussy and sensitive [l4]. These features are taken as likely to reflect personality characteristics which may render children vulnerable to somatization under stress. Our Psychiatric Interview with Parents enquired about enduring traits in these areas of functioning but neither worrying, fearfulness nor timidity differentiated the psychological factors children from the rest. However. children in the group with associated psychological factors were more commonly described as unusually tidy, and when asked about the child’s habitual mood more parents in this group spontaneously described the children as ‘sensitive’ (i.e. easily hurt) (Table III). Details about the children’s early development, chronic physical illness, recent medical contacts or school absences did not differentiate between the two groups. The only difference was that children with asthma in the psychological factors group had had significantly more episodes of wheezing in the three months prior to interview (means of 13.5 (SD 24.4) vs 3.4 (SD 5.7); p = 0.02). (b). Family factors. There were no significant differences between the groups in broad indicators of psychosocial functioning such as socioeconomic status or broken homes. But fewer mothers of children with associated psychological factors were at work (40% vs 67%; x 2 = 7.9; 1 df; p < 0.01); more children in this group were middle (32% vs 11%) and fewer were youngest in the sibship (25% vs 44%; 3 df; p = 0.02). There were indications that the group with associated psychological factors had been under more stress because of family health problems. Although when we asked parents to specify whether they had had any major stresses during the year prior to interview a comparable two-thirds of the parents in each group reported at least one major stress, there were differences in the types of stresses reported: these were significantly more commonly in the area of family health in the psychological factors group and in social areas in the rest. Moreover, if there had been any health problems in the three months prior to interview. these were more often major in the former (Table IV). At the time of assessment mothers in the group with associated psychological factors felt under more general psychosocial stress as measured by the Social Stress and Supports Interview (total stress mean scores of 5.49 (3.91) vs 4.18 (SD 3.18): TABLE IV.--FAMILY STRESSIY (XILI)REN

1. Stressful events reported previous year Types of events reported Death/illness of family

-__ in the

member

WITH PSYCHOSOMA’TIC* PIWSNT’ATIONS

Psychosomatic* (II = 53) “1” 49

51

27/49 (55)

17151 (33)

X/49 (16)

23/51 (45)

9149 (18) 5:49 (10)

3/51 (6) g/51 (16)

20

14

7/20 (3s) 13’20 (65)

11; 14 (79) 3jl4 (21)

Housing/finance/occupation Arguments Other 2. Family health problems in the past three months Types of illness (somatic): Minor Major *Group

with associated

psychological

Other (II = 61) %

factors.

Statistics --

x2 = 3.9 ldf p < 0.05 x2 = 8.3 ldf p < 0.01 NS NS

$ = 4.6 ldf p < 0.05

Paediatrician

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p = 0.07 on the Wilcoxon test). This stress was global and not focused differentially on any one of the psychosocial areas explored (e.g. housing, work, marriage, children, social life). There were no significant differences in maternal GHQ scores or ‘nerve’ problems, but only mothers in the psychological factors group (six mothers) were on psychotropic medication. Two further findings related to family relationships differentiated the two groups. Firstly, when mothers identified one of their children as particularly supportive to them, this tended to be the index child in the psychological factors group (54% vs 35%, x 2 = 3.3; 1 df; p = 0.06). Secondly, although the number of parents reporting temporary marital separations was similar in both groups (14% and 12%), the mean number of years since the last separation was higher in the psychological factors group (6.1 SD 3.1; vs 1.7 SD 1.1 yr, p = 0.005).

DISCUSSION

In this survey paediatricians identified associated psychological factors in nearly half of new referrals of children aged 7-12 yr. The rate was twice that reported amongst children attending primary care in previous surveys [3, 131. This indicates a high level of vigilance by many paediatricians towards psychological issues and suggests that these are more relevant to specialized paediatric than to primary care. It also highlights the need for routine exploration of psychosocial issues in new referrals within this age group. It was clear from our findings that paediatricians were noting psychological factors in association with a wide variety of physical presentations. Although certain types of complaints (e.g. abdominal, chest and joint pains) were more common in this group, not all children presenting with these symptoms had identifiable associated psychological problems and a number of symptoms presumed to be psychosomatic in previous surveys such as asthma and headaches [5] were not in excess in our psychological factors group. It would appear that ascribing a ‘psychosomatic’ status exclusively to some conditions is too narrow an approach and one not in accordance with clinical paediatric experience. It might be argued that our results were based on clinical judgements of doctors who may not be representative. Moreover there was variation in their rate of identification. The work clearly needs replication in other populations. However, from our independent research interviews with parents we found characteristic associations with child somatic and psychiatric symptomatology as well as with family stress factors in children for whom paediatricians had identified psychological factors and this provides a measure of validity for their assessments. Child psychiatric disturbance was increased in the psychological factors group. The most common psychiatric symptoms were chronic though episodic depressive symptoms and problems in relationships with other family members, with peers and teachers, suggesting a special affinity between emotional and relationship symptoms-as opposed to for example antisocial features--and somatic complaints. The pattern was one of defiance at home but of being bullied by peers and raises the issue whether--over and above the identification of psychiatric disturbance and attention to the depressive features-appropriate assertiveness training might be indicated for

310

M. ELENA GARRALDA and DOROTHY BAILEY

the significant minority of children with psychiatric symptoms and paediatrician identified psychological factors. It must, however, be emphasized that the majority of children with associated psychological factors did not have psychiatric disorder. This supports the view that the presence of handicapping behavioural and emotional relationship problems is not sufficient to describe the frequency and nature of associated psychological factors in paediatric clinics. Our findings lend some support to the notion that certain personality traits (being ‘fussy’ and sensitive) may be at the basis of somato-psychological relationships in some children. Similar features have been highlighted in work on children with recurrent abdominal pains, a condition traditionally regarded as likely to have important psychological components [14, 151. The excess of middle children in our psychological factors group could also reflect personality characteristics in this group. There is some evidence to suggest that second borns show more dependency behaviour than either first or later borns [28], and a dependent personality is said to influence people’s responses to physical symptoms as illness permits the gratification of dependency needs [29]. Unlike the present study, work on children with recurrent abdominal pains has emphasized additional traits (anxiety, timidity, apprehension of new people and situations, fearfulness and an irregular temperamental style) and symptoms of anxiety as relevant [14, 16, 171. It is possible that these are specific to abdominal pain symptoms whereas the features identified by us may represent a more general feature in somato-psychological relationships. Future work using temperamental scales could help clarify the issue. The family factors most commonly noted by doctors as aggravating the children’s somatic symptoms were family illness, and parental anxiety and over involvement. The findings from our research interviews with the parents whilst in line with these. allowed us a more precise description of these factors. Thus it was not only the presence of more family health problems in the previous year but also of recent major family health problems. and that of psychological symptoms in the mothers which were marked enough to require psychotropic medication, which differentiated the group with associated psychological factors. It seems likely that the presence of family health problems would have sensitized mothers to their children’s health and increased their likelihood of seeking medical help, particularly in those mothers whose general ability to cope was decreased as evidenced by the need for psychotropic medication. They could also have served as a model and focus for anxieties in the children themselves and contributed to the continuation of the symptoms. In keeping with this finding, Wasserman et al. [17] have described high rates of physical ill health in the families of children with recurrent abdominal pains referred to specialist clinics. The excess of physical illness in the psychological factors families may have led to misconceptions about the children’s symptoms and further fuelled parental and child anxieties. Bass and Cohen [30] questionned parents taking their children to paediatric clinics about their concerns: about a third of parents interviewed entertained some covert fears that something much more serious was wrong with the child than could be anticipated from the overt reason for seeking assistance.

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There was a trend for mothers in the group with associated psychological factors to regard the index children as being specially supportive and doctors noted parental over involvement as a relevant factor in a number of children in this group. These tentative findings indicate the need for a detailed investigation of parenting styles, particularly as they are in line with previous work highlighting links between over-involved parenting and psychosomatic complaints in children [ 181. Fewer mothers in the psychological factors group were in outside employment. The design of the study does not allow for a full exploration of whether this was related to the previously discussed findings but certain links suggest themselves. Thus, it could have been related: (1) to the recent family health problems; (2) to handicapping maternal psychological symptoms; or (3) to a high emphasis on mothering and a tendency to mother-child over involvement in this group.

CONCLUSIONS

Our study shows that paediatricians identify psychological factors associated with somatic presentations in a high number of children aged 7-12 yr referred to general paediatric clinics, and specific associations with: (1) certain somatic and psychological symptoms in the child; (2) personality features of obsessionality and ‘sensitiveness’; (3) severe health problems in the family, mothers on psychotropic medication and/or not in outside employment; and (4) suggestions of a specially close mother-child relationship. Further investigation into the precise way in which these factors affect somatic symptoms appears warranted. Acknowled~ements~The authors wish to thank Drs Adler, Bradbury, Couriel, Owens, Roberts and Robinson and their staff for their co-operation and assistance in this stuhy. They are also grateful to Prof. R. Boyd for his comments. The research was funded by a grant from the North West Regional Health Authority.

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