Somatic Symptoms in Anxious-Depressed School Refusers

Somatic Symptoms in Anxious-Depressed School Refusers GAIL A. BERNSTEIN, M.D., ELISE D. MASSIE, A.B., PAUL D. THURAS, PH.D., AMY R. PERWIEN, B.A., CARRIE M. BORCHARDT, M.D., AND ROSS D. CROSBY, PH.D.

ABSTRACT ObJective: To identify the most common physical complaints in a sample of adolescent school refusers with comorbid anxiety and depressive disorders. Whether somatic symptoms are more likely to be associated with high levels of anxiety or high levels of depression was also explored. Method: Forty-four adolescents in a treatment study were evaluated at baseline with structured psychiatric interviews and measures of anxiety, depression, and somatization. Results: The most common somatic complaints were in the autonomic and gastrointestinal categories. In simple regression analyses, anxiety level as measured with the Revised Children's Manifest Anxiety Scale and depression level as measured with the Beck Depression Inventory each significantly predicted the severity of somatic symptoms. The correlation between percentage of days absent from school and severity of somatic symptoms approached significance (r= .27, p = .074). Conclusions: Knowledge that somatic complaints are commonly an expression of underlying anxiety and depression may facilitate more rapid referral for psychiatric assessment and treatment and thereby help avoid unnecessary medical workups and sequelae from school refusal. J. Am. Acad. Child Ado/esc. Psychiatry, 1997, 36(5):661-668. Key Words: anxiety, depression, school refusal, somatization.

Only since the late 1980s have somatic complaints become a topic of research and discussion in the child and adolescent psychiatric literature. It appears that somatic complaints are frequently endorsed by children and adolescents with psychiatric disorders. Last (1991) examined somatic complaints in outpatient children with anxiety disorders (N = 158) and found that somatic symptoms were common. In a study by Livingston et al. (1988), somatic complaints in child psychiatric inpatients were associated with anxiety disorders, major

Acaptrd Novrmba 7, 1996. Dr. Brrnsuin is Associau Proftssor and Dirator, Ms. Massir is Projrct Coordinator, and Dr. Borchardt is Associau Proftssor, Division of Child and Adoksant Psychiatry, and Dr. Thuras is Assistant Proftssor, Drpartmmt of Psychiatry, Univmiry ofMinnrsota Mrdical School, Minnrapolis. Ms. Prrwim is a graduau stuMnt in thr Drpartmmt of Clinical and Hralth Psychology, Univmiry ofFlorida, Gainrsvilk. Dr. Crosby is Dirretor ofBiomrdical Statistics and Mrthodology, Nruropsychiatric Rmarch Instituu, Fargo, ND. This study was pmmud as a posta at Nrw Rrsrarch Smion II ofthr 42nd Annual Muting ofthr Amrrican AcaMmy ofChild and Adokscmt Psychiatry. Nrw Orkans, 1995. This mrarch was jimMd by NIMH grant R29 MH46534 to Dr. Brrnstrin. Thr authors acknowlrdgr Lois Laitinm. M.B.A., M.M., for manuscript prrpararion. Rrprint rrqursts to Dr. Brrnsuin. Division ofChild andAdolrsant Psychiatry, Box 95 UMHC, 420 Drlawarr Strut S.£., Minnrapolis. MN 55455. 0890-8567/97/3605-0661$03.00/0©1997 by the American Academy of Child and Adolescent Psychiatry.

depression, and psychosis. Severity of depression was positively correlated with frequency of somatic complaints in a study by McCauley and colleagues (1991). Some investigations that have attempted to determine whether anxiety or depression plays a significant role in somatic complaints have had divergent findings (Jolly et al., 1994; Last, 1991; McCauley et aI., 1991). Few studies have evaluated the relationship between specific anxiety disorders and associated somatic symptoms. Both separation anxiety disorder and panic disorder, for which physical symptoms are a part of the DSM-IV diagnostic criteria (American Psychiatric Association, 1994), are associated with increased somatic complaints (Last, 1991; Livingston et al., 1988). A study of outpatient children and adolescents with anxiety disorders found that those who reported more somatic complaints were more likely to be older and to demonstrate school refusal (Last, 1991). Although no known studies of school refusal have looked at school attendance and its relationship to somatic complaints and psychiatric illness (i.e., anxiety and depressive disorders), the idea that the rate of absences may be related to the severity of somatization, anxiety, and depression, and possibly to specific diagnoses, is compelling. This is important to delineate because missing school is associated with substantial sequelae

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for the adolescent, including loss of peer relationships and academic difficulties. This invesrigation was conducred as part of a rreatment study of school refusal in anxious and depressed adolescents. The first goal was ro explore rhe mosr common somatic symproms in an outparient adolescent sample of anxious and depressed school refusers using several types of assessment measures. Another goal was to determine whether somatic symptoms are more likely ro be associated wirh high levels of anxiety or high levels of depression. An additional purpose was to explore whether the pattern of somatic complaints would predier specific anxiety disorders. Furthermore, the role of gender and age in somatic complaints and the relarionship of somatization in parents and their children were investigared. Finally, school artendance parrern was invesrigared for its possible associarion with somatic complaints, anxiety, and depression. METHOD

SUBJECTS Subjects consisted of 44 adolescents (17 males and 27 females) 12 to 18 years of age in an 8-week ongoing National Institute of Mental Health (NIMH}-funded treatment study of school refusal. Racial composition included 89% (11 = 39) Caucasian, 9% (n = 4) African-American, and 2% (n = I) Hispanic. Socioeconomic status based on the Hollingshead Two-Factor Index (Hollingshead, 1957) for this sample was 2.3% (n = I) class I, 13.6% (n = 6) class II, 43.2% (n = 19) class Ill, 38.6% (n = 17) class IV, and 2.3% (n = I) class V. Inclusion criteria for the study included the following: (I) minimum of 20% absences from school in the 4 weeks prior to evaluation for the study; (2) diagnosis of at least one anxiery disorder from Diagnostic Interview for Children and Adolescents-Revised-Adolescent Version (DICA-R-A) and/or Diagnostic Interview for Children and Adolescents-Revised-Parent Version (DICA-R-P) (Reich and Weiner, 1990) or the NIMH Diagnostic Interview Schedule for Children, child (DISC-C) and/ or parent (DISC-P) forms (Shaffer et aI., 1996); (3) diagnosis of major depression based on DICA-R-A and/or DICA-R-P; and (4) postpubertal status (Tanner stages 3 to 5) (Marshall and Tanner, 1969, I970) based on physical examination. Exclusion criteria were as follows: (I) major medical diagnosis that could preclude safe administration of a tricyclic antidepressant (e.g., cardiovascular disease or seizure disorder); (2) drug or alcohol abuse, mental retardation, attention-deficit/hyperactiviry disorder, bipolar disorder, eating disorder, or conduct disorder; (3) history of bipolar disorder in first-degree relatives; and (4) current psychotropic medication. All subjects had received the diagnoses of major depression and one or more anxiery disorders (Table I).

TABLE 1 Characteristics, Severity Scores, and Diagnoses of 44 School Refusers

Age (in months) Absences~ at baseline (%) DICA-R-A Somatization items (No. endorsed) Anxiety scales ARC-R total ARC-R Physiological subscale RCMAS Depression scales CDRS-R BDI Diagnoses/' Avoidant disorder Overanxious disorder Separation anxiery disorder Agoraphobia c Panic disorderc Social phobiaC

Mean

SO

176.6 71.8 2.9

17.8 27.6 3.0

12.8 5.5 13.6

5.0 3.4 5.4

49.6 13.5 No.

9.5 10.8

22 41 13 14

50.0 93.2 29.5 40.0 8.6 68.6

3 24

%

Nou: DICA-R-A = Diagnostic Interview for Children and Adolescents-Revised-Adolescent Version; ARC-R = Anxiery Rating for Children-Revised; CDRS-R = Children's Depression Rating ScaleRevised; RCMAS = Revised Children's Manifest Anxiery Scale; BDI = Beck Depression Inventory. ~ Includes full and partial days missed. b Diagnoses based on DICA-R-A and/or DICA-R-P (Parent Version) or Diagnostic Interview Schedule for Children, Child and Parent forms.} 'n = 35.

Subjects were recruited through biannual mailings sent to middle, junior high, and high schools in the seven-counry metropolitan

area surrounding Minneapolis and St. Paul. Referrals were made by school personnel, physicians, mental health workers, and family members. Each potential subject was evaluated for e1igibiliry at an initial assessment, which consisted of two main parts: First, a child and adolescent psychiatrist conducted two clinician rating scales, the Children's Depression Rating Scale-Revised (CDRS-R) (Poznanski et aI., 1985) and the Anxiery Rating for Children-Revised (ARC-R) (Bernstein et aI., 1996b). Scores of at least 35 on the CDRS-R and a minimum of 5 on the ARC-R Anxiety subscale were required. Second, the DICA-R-A and DICA-R-P were administered to the subject and a parent, respectively, by two different research assistants. The sections for social phobia, agoraphobia, and panic disorder from the DISC-C and DISC-P were added in the second year of the study. All eligible subjects received a I-week single-blind placebo washout followed by 8 weeks of imipramine or placebo in combination with a cognitive-behavioral school reentry program. After the I-week placebo washout, subjects returned for the CDRS-R, ARC-R, and self-report measures. Self-report measures included the Revised Children's Manifest Anxiety Scale (RCMAS) (Reynolds and Richmond, 1978) and the Beck Depression Inventory (BDI) (Beck et aI., 1979). In addition, mothers completed the Symptom Checklist-90-Revised (SCL-90-RiIl» (Derogatis, 1994), a self-report measure, and the Child Behavior Checklist (CBCL) (Achenbach, 1991). Scores following the I -week placebo washout are reported in this investigation.

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ATTENDANCE The number of days absent in the 4 weeks preceding initial assessment were evaluated to determine baseline attendance pattern. These data were obtained from the subjects' school attendance records and corroborated by the subjects' parents. Several subjects fulfilled the required 20% absence rate (i.e., 4 days) in the first 2 to 3 weeks of the academic year. For the purpose of data analysis, attendance data included number of full days missed and number of partial days missed. A partial day was defined as missing greater than 50% of the school day. Both types of absences were summed together for a total number of days absent. Rate of absencc was dctermined by ratio of absences to total baseline school days. It should be noted that two subjects who were considered to have fulfilled the 20% absence rate for entrance into the study had an attendance rate of 15% based on the definition of absences used for data analysis as outlined above.

Symptom Checklist-90-Revised. The SCL-90-R® is a self-report symptom inventory composed of90 items (Derogatis, 1994). There are nine main symptom dimensions (Somatization, ObsessiveCompulsive, Interpersonal Sensitivity, Depression, Anxiety, Hostility, Phobic Anxiety, Paranoid Ideation, and Psychoticism). Tscores greater than 60 may signifY possible psychopathology. The nine primaty symptom constructs have a high degree of convergent validity (Derogatis et aI., 1976). This scale was completed by mothers about their own symptoms.

Parent Report Child Behavior Checklist. The CBCL is a report measure that the parent completes about the child (Achenbach, 1991). There are eight scales of thc CBCL (Withdrawn, Somatic Complaints, Anxious/Depressed, Social Problems, Thought Problems, Attention Problems, Delinquent Behavior, and Aggressive Behavior). T scores of70 (98th percentile) or greater are considered clinically significant.

PSYCHOMETRIC INSTRUMENTS Structured Interviews Diagnostic Interview for Children and Adolescents-Revised-Adolescent Version and Parent Version. The DICA-R-A and DICA-R-P are diagnostic structured interviews that cover symptom criteria from the DSM-III-R (Reich and Weiner. 1990). Boyle et al. (1993) demonstrated that the DICA-R has good measurement potential for use as a diagnostic interview in general population samples. NIMH Diagnostic Interview Schedule for Children Version 2.3 Child Form and Parent Form. The DISC-C and DISC-P are highly structured interviews that evaluate DSM-III-R diagnoses. The 2.3 version is a reliable instrument for evaluating child psychiatric disorders (Shaffer et aI., 1996).

Clinician Rating Scales Children j- Depression Rating Scale-Revised. The CDRS-R is a clinician rating scale that comprises 14 symptom items relatcd to depression and 3 items related to nonverbal depressive behavior (Poznanski et aI., 1985). This instrument has demonstrated good reliability and differentiates between depressed and nondepressed children (Poznanski et aI., 1984). Anxiety Rating for Children-Revised. The ARC-R is a clinician rating scale for anxiety (Bernstein et aI., 1996b). The instrument is composed of two subscales: the Anxiety subscale and the Physiological subscale. In a study that examined the psychometric properties of this instrument (Bernstein et aI.• 1996b), test-retest reliability was found to be high and the instrument discriminated bctween children with and without an anxiety disorder.

Measures of Somatic Symptoms The DICA-R-A somatization disorder section is made up of 30 physical complaints from the following areas: gastrointestinal, pain, cardiopulmonary, conversion or pseudoneurological, sexual, and female reproductive. Headaches or symptoms of depression are not included. Complaints are scored as present only if they are not medically related and are not associated with drug or alcohol use and panic attacks. The ARC-R Physiological subscale consists ofsix items: muscular, sensoty. cardiovascular. respiratory. gastrointestinal, and autonomic. Each item is made up of several questions or symptom clusters related to anxiety symptoms indicative of a specific type of physiological response. An item is rated on a Likert scale from 0 (nor present) to 4 (vety severe), and scores on the six items are summed to attain the Physiological subscale score. The following three severity groups were established from scores on individual ARC-R Physiological items: not present (score of 0), mild (score of 1), and moderate or severe (scores of 2 or 3). The CBCL Somatic Complaints scale consists of nine items that are rated on a Likert scale of 0 to 2. These items include feels dizzy, overtired, aches or pains, headaches, nausea, problems with eyes, rashes or skin problems. stomachaches or cramps. and vomiting.

STATISTICAL ANALYSIS

Revised Children j- Manifest Anxiety Scale. The RCMAS is a selfreport measure of anxiety symptoms (Reynolds and Richmond, 1978). There are three anxiety subscales: Physiological, Worry/ Oversensitivity. and Social Concerns/Concentration. There is also a Lie subscale. The RCMAS is a valid measure of anxiety in adolescents (Lee et aI., 1988). Beck Depression Inventory. The BDI is a self-report measure of symptoms of depression (Beck et aI., 1979). Ambrosini et aI. (I991) found that the BDI discriminated between depressed and nondepressed adolescents in an outpatient setting, has good internal consistency, and has high test-retest reliability.

The distributions of somatic symptoms by age and by gender were computed using analyses of variance for continuous variables and X' tests for categorical comparisons with Bonferroni corrections for multiple paitwise comparisons. Pearson correlation coefficients were used to examine associations between baseline school attendance, somatic symptoms, and scores on anxiety and depression rating scales and to identifY variables for further investigation through standard multiple linear regressions and logistic regression analyses. Multiple regressions were used with forced entty of variables to examine the association of RCMAS and BDI with ARC-R Physiological subscale scores. Logistic regression analyses were used to determine whether patterns of ARC-R Physiological items were predictive of specific anxiety disorders with those reporting no physiological symptoms serving as the reference category. All analyses were conducted with SPSS for Windows, version 6.12. All tests were two-tailed.

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TABLE 3 Frequency of hems Endorsed on the DICA-R-A Somatization Section

RESULTS Descriptive Analyses

On the basis of the ARC-R, the three most common types of somatic symptoms were autonomic (includes headaches, sweatiness, and dizziness), gastrointestinal, and muscular. These were rated by the clinician at a moderate or severe level in 45.4%, 34.1 %, and 27.3% of the sample, respectively (Table 2). On the somatization disorder section of the DICA-R-A, the mean number of symptoms endorsed was 2.9 ± 3.0 (Table 1). Approximately one third (31.8%) of the adolescents endorsed five or more somatic symptoms on the DICAR-A. The most common complaints on the DICAR-A were faint/light-headed/dizzy, sick to stomach, and back pain, which were each endorsed by 20.5% of the sample (Table 3). The next most common symptoms were stomach pains and throws up a lot, each endorsed by 18.2% of the sample. Irregular menstrual periods and severe menstrual cramps were each reported by 22.2% of the females. In reporting their adolescent's symptoms on the CBCL, mothers endorsed the Somatic Complaints scale as having the highest group mean score (T = 72.5 ± 11.4) (Table 4). The next highest group mean scores were on the Anxious/Depressed scale (T = 70.4 ± 10.7) and the Withdrawn scale (T = 69.8 ± 10.6). None of the mothers' SCL-90-R® mean symptom dimension T scores were clinically significant (range = 48.4 to 58.9, with Somatization mean T score = 54.2). The mean CBCL Somatic Complaints scale score, the adolescent's ARC-R Physiological subscale score, and the mother's own Somatization score on the SCL90-R were not significantly correlated with one another.

Moderate or Severe

Mild

Items

No.

%

No.

%

No.

%

Autonomic Gastrointestinal Muscular Sensoty Cardiovascular Respiratoty

8 15 15 24 24 32

18.2 34.1 34.1 54.5 54.5 72.7

16 14 17 12 13 9

36.4 31.8 38.6 27.3 29.5 20.5

20 15 12 8 7

45.4 34.1 27.3 18.2 16.0 6.8

3

Nou: N =44 anxious-depressed school refusers. ARC-R =Anxiety Rating for Children-Revised.

664

No.

%

9

20.5 20.5 20.5 18.2 18.2 15.9 15.9 13.6

Faintllight-headed/dizzy Sick to stomach Back pain Pains in stomach Throws up a lor Chest pain Palpitations Blurred vision Trouble walking Short of breath Loss of voice Pain in joints Difficulty swallowing Stomach fills with gas

7 7 6 6

Menstruation symptoms~ Irregular periods Severe cramps Excessive bleeding

6 6

9 9 8 8

13.6 11.4 11.4 11.4 9.1 9.1

5 5 5 4 4

22.2 22.2 7.4

2

Note: N = 44 anxious-depressed school refusers. DICA-R-A = Diagnostic Interview for Children and Adolescents-Revised-Adolescent Version. • In 27 females.

An examination of the somatic complaints as they related to age and gender revealed few significant differences. Neither the ARC-R Physiological subscale score nor the number of DICA-R-A somatic symptoms showed any significant association by age. However, adolescents with moderate or severe muscular symptoms were significantly older than those with mild or no muscular symptoms (F = 6.32, df = 2,41, P = .004). TABLE 4 CBCL Scores Reported by Mothers T Scores

TABLE 2 Frequency of Severity Ratings on the ARC-R Psychological hems Not Present

Items

Scales

Mean

SD

Withdrawn Somatic Complaints Anxious/Depressed Social Problems Thought Problems Attention Problems Delinquent Behavior Aggressive Behavior

69.8 72.5 70.4 62.6 60.0 64.1 63.1 61.0

10.6 11.4 10.7 11.8 8.7 7.9 7.3 9.2

Total Problem score Internalizing score Externalizing score

69.0 72.9 61.3

7.0 8.8 9.1

Nou: CBCL

J.

=

Child Behavior Checklist.

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There were no significant mean differences by gender on the ARC-R Physiological subscale score nor on the number of OICA-R-A somatic complaints. There were no significant gender differences on any of the ARC-R Physiological items. We also examined the association between age, gender, and diagnoses. Subjects with separation anxiety disorder were significantly younger (14.0 ± 1.0 years) than those without separation anxiety disorder (15.0 ± 1.6 years) (F=4.55,df= 1,42, P = .039). No other significant associations were found. Role of Anxiety and Depression in Somatic Symptoms

Using regression analysis, we tested the RCMAS for its ability to predict the severity of somatic symptoms as measured on the ARC-R Physiological subscale. The RCMAS significantly predicted somatic symptoms (R 2 = .16, F = 7.84, df = 1,42, P = .008). After we controlled for RCMAS score, the BOI added no additional predictive information (R 2 change = .024, F = 1.21, df = 2,41, not significant). Using a separate regression analysis, the BOI was tested for its ability to predict the severity of somatic symptoms on the ARC-R Physiological subscale. The BOI also significantly predicted the ARC-R Physiological subscale score (R 2 = .14, F = 6.87, df = 1,42, P = .012). After we controlled for BOI score, the RCMAS provided no additional contribution to the model (R 2 change = .04, F = 2.04, df = 2,41, not significant). There was a moderate to high correlation (r = .65, P = .001) between scores on the RCMAS and the BOI indicating high rates of both anxiety and depressive symptoms in this sample. Pattern of Somatic Symptoms and Specific Diagnoses

df = 6, P = .034). For each incremental increase in muscular symptoms, the diagnosis of avoidant disorder was 3.4 times less likely. Somatic Complaints and School Attendance

Correlation analyses examined baseline school attendance and measures of somatic symptoms, depression, and anxiety. The mean percentage of days absent at baseline was 71.8 ± 27.6% (range of 15% to 100%) (Table 1). One fourth of the subjects were missing 100% of school days in the 4 weeks prior to entering the study. Trends were found between the percentage of school days missed at baseline and the ARC-R Physiological subscale score (r = .27, P = .074) and between percentage of days absent and the ARC-R total score (r = .27, P = .079). Of the ARC-R Physiological items, the autonomic item was significantly correlated with poor attendance (r = .37, P = .013) and the correlations between poor attendance and respiratory and cardiovascular items also approached significance (r= .29,p = .06; and r= .27,p = .08, respectively). The mean RCMAS, BO!, and CORS-R scores were not significantly correlated with baseline attendance. School attendance was also examined in relation to specific anxiety diagnoses. Only separation anxiety disorder was significantly related to school attendance. Adolescents with separation anxiety disorder compared with those without the diagnosis showed significantly better attendance (42% versus 22% attendance) (F = 4.67, df = 1,42, P = .036). DISCUSSION

Logistic regression analyses were used to determine whether the reporting of symptoms on the ARC-R Physiological items were predictive of specific anxiety disorders. Separation anxiety was predicted by both the presence of gastrointestinal symptoms and the absence of cardiovascular symptoms (X 2 = 12.76, df = 6, P = .047). For each incremental increase in gastrointestinal symptoms (e.g., mild to moderate or moderate to severe), the likelihood of having a diagnosis of separation anxiety was 2.8 times greater; for each incremental increase in cardiovascular symptoms, a diagnosis of separation anxiety was 7.2 times less likely. We also found that avoidant disorder was predicted by the absence of muscular symptoms (X 2 = 13.67,

The most commonly endorsed somatic symptoms in this outpatient adolescent sample of school refusers were autonomic and gastrointestinal items. These findings were consistent across the ARC-R and OICAR-A instruments. Furthermore, these results are in agreement with those of Beidel and colleagues (1991), who investigated the most frequently reported physical symptoms in a group of children with anxiety disorders (N = 24). The most common symptoms endorsed in their study fell predominantly into the autonomic category (shakinessltrembling, flushes/chills, sweating). The other two most commonly reported symptoms were nausea and palpitations, which are in the gastrointestinal and cardiovascular categories, respectively. In an inpatient adolescent sample (N = 96), including a

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subgroup with comorbid anxiety and depressive disorders (n = 64), Jolly and colleagues (1994) reported that the most common somatic complaint was nausea. The other most frequently identified symptoms were palpitations, chest pains, and feeling faint, all considered by the authors to be autonomic symptoms. Simple regressions demonstrated that the RCMAS and BDI each significantly predicted somatic complaints on the ARC-R Physiological subscale. Therefore, both anxiety and depression playa significant role in physical complaints. However, the strong correlation between the RCMAS and BDI in this sample makes direct comparisons of the relative influence of anxiety versus depression on somatic complaints difficult. It is possible that these findings may be influenced by characteristics of the sample being studied (i.e., all subjects in this study had comorbid anxiety and depressive disorders). Last (1991) evaluated children with anxiety disorders and found their somatic complaints to be related more to anxiety disorders than to depression. Moreover, McCauley et al. (1991) studied depressed and nondepressed controls and concluded that their somatic complaints increased with the severity of depression, regardless of anxiety levels. Among the anxiety disorders, separation anxiety disorder and avoidant disorder were associated with specific patterns ofsomatic complaints. Separation anxiety disorder was predicted by the presence of gastrointestinal symptoms and the absence of cardiovascular symptoms. Teenagers endorsing severe gastrointestinal symptoms compared with those reporting no gastrointestinal symptoms were 8.4 times more likely to have separation anxiety disorder. In the study conducted by Livingston et al. (1988), abdominal pain and palpitations were significantly more common in children with separation anxiety disorder. Thus, it is less clear why adolescents with separation anxiety disorder report significantly fewer cardiovascular symptoms. One possibility is that subjects may focus their attention on a particular kind of symptom (e.g., gastrointestinal) and then pay less attention to other symptoms (e.g., cardiovascular). Thus, the subjects with separation anxiety may not have attended to cardiovascular symptoms and, therefore, did not report them. Another possibility is that subjects with separation anxiety disorder represent a younger, more immature subset of adolescent school refusers. As such, their symptoms may be less severe, which is reflected by the

significantly better school attendance pattern found in adolescents with separation anxiety disorder. Furthermore, somatic symptoms may turn out to be influenced by physiological development. We already know that vulnerability to panic attacks and panic disorder is associated with increasing pubertal development in adolescence (Bernstein et al., 1996a; Hayward et al., 1992). It is possible that cardiovascular symptoms, commonly found in panic disorder, are also associated with physiological development, becoming more prominent in older subjects. Avoidant disorder was negatively associated with muscular symptoms. This finding is somewhat difficult to interpret. However, it may be that avoidant adolescents are less social and also less physically active, and thus experience fewer muscle aches, which were commonly reported by our subjects in relation to physical activity. Further investigation with a larger sample size will help determine whether these preliminary findings regarding the association between specific somatic symptoms and specific anxiety disorders are valid. No gender differences in the reporting of somatic complaints were found. The only significant finding by age was that muscular symptoms were more common in older adolescents. This may reflect differences in physical conditioning by age, i.e., older subjects experience more muscle aches after exercise. There was no significant association between the level of somatization in the mothers on the SCL90-R® and the level of somatization in their children on the ARC-R or on the CBCL. This may partially be explained by the lack of clinically significant elevation on the mother's SCL-90-R Somatization symptom dimension. Nonetheless, the CBCL scores demonstrate that the mothers identified somatic complaints as the most prominent type of symptom in their teenage children. The positive correlation (r = .27, P = .074) between severiry of somatic symptoms as measured on the ARC-R Physiological subscale and school absentee rate suggests that physical symptoms may impede school attendance. Specifically, the presence of autonomic symptoms was significantly associated with greater absence from school. Thus, headaches, dizziness, and other autonomic symptoms are among the most common symptoms teenagers report as reasons for nonattendance at school.

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The findings presented in this report have important clinical implications for the medical and psychiatric care of adolescents. Somatization is associated with increased health care use (Campo and Fritsch, 1994). Therefore, understanding somatization as associated with underlying anxiety and depressive disorders will help avoid unnecessary organic workups and facilitate referral for psychiatric evaluation and treatment. A high absentee rate and somatic complaints should serve as a "red flag" to parents, school administrators, and physicians that an adolescent might be experiencing anxiety and/or depression. Parents who view these physical complaints as indicative of a justifiable or even unexplainable medical condition should be educated that somatic symptoms commonly reflect underlying anxiety and/or depression, so that their children can receive psychiatric treatment before the school refusal problem becomes chronic. In addition, collaboration with physicians may assist in this process by alerting the physicians to the psychological nature of the somatic symptoms and the impact on school attendance. A study with adults found that when patients' physicians received a psychiatric consultation letter about management of somatization in their patients, physical functioning improved in the patients and there was a decrease in medical care charges (Smith et aI., 1995). An examination of the somatic complaints in children and adolescents presenting with anxiety and/or depression may assist in treatment planning. A study conducted by Sanders et aI. (I989) examined a cognitive-behavioral treatment package versus waitlist control for recurrent abdominal pain in children. The cognitive-behavioral therapy was more effective than waiting list in improving symptomatology quickly, producing generalized benefits across settings, and allowing subjects to be pain-free at 3-month follow-up. However, the treatment approach included multiple components (e.g., differential reinforcement of well behavior, cognitive coping strategies, generalized enhancement procedures) and the study was not designed to determine which parts were the most effective. In describing the cognitive-behavioral treatment of four children with overanxious disorder, Eisen and Silverman (I993) suggested that treatment should be matched to the type of anxiety response experienced (cognitive or somatic). The effectiveness of treatments theoretically targeted

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at somatic symptoms, (e.g., education about the expression ofanxiety through somatic complaints and progressive muscle relaxation) should be determined through treatment studies. As suggested in the present study, school attendance pattern appears to be an important outcome measure. A strength of this investigation is the comprehensive evaluation of somatic symptoms from multiple perspectives including the adolescent's report on the DICA-R interview, parental report on the CBCL, and clinician assessment with the ARC-R. Another strength is the daily attendance data which were meticulously collected. Shortcomings of the present study include a relatively small sample size and a lack of control groups with which to compare our results. Future studies should examine the possible links between school attendance, somatic complaints, and psychiatric symptoms with clinical and normal samples of adolescents. The trend that higher levels of somatic symptoms was related to greater school absenteeism deserves to be further addressed. In particular, it would be of clinical interest to identifY possible school triggers that relate to the expression and/or exacerbation of somatic complaints. Addressing the role of somatic complaints in school attendance is of particular importance because poor attendance has the potential to significantly affect academic achievement and the development of peer relationships. The results reported here are baseline data from an 8-week treatment study and therefore will allow these relationships to be examined over the duration of the study period and at I-year follow-up.

REFERENCES Achenbach TM (1991). Manual for thr Child &havior Chrcltlist/4-18 and 199/ Profilr. Burlington: University of Vermont Department of Psychiatty Ambrosini PJ, Men C. Bianchi MD. Rabinovich H. Undie A (1991). Concurrent validity and psychomerric properties of the Beck Depression Inventory in outpatient adolescents. JAm Acad Child Adoksc Psychiatry 30:51-57 American Psychiatric Association (1994). Diagnostic and Statistical Manual ofMmtal DisorMrs. 4th rdition (DSM-IV). Washington. DC: American Psychiatric Association Beck AT. Rush AJ. Shaw BF. Emery G (1979), Cognitivr Thrrapy for Drpmsion. New York: Guilford Beidel DC. Christ MG. Long PJ (1991), Somatic complaints in anxious children. J Abnorm Child Psychol 19:659-670 Bernstein GA. Borchardt CM. Perwien AR (l996a). Anxiety disorders in children and adolescents: review of the past 10 years. JAm Acad Child Adoksc Psychiatry 35:1110-1119

667

BERNSTEIN ET AL.

Bernslein GA. Crosby RD. Perwien AR. Borchardl CM (l996b). Anxiery Raling for Children-Revised: reliabiliry and validiry. J Anxirty Disord 10:97-114 Boyle MH. Offord DR, Racine Y el al. (1993), Evalualion of rhe DiagnoSlic Inrerview for Children and Adolescenrs for use in general populalion samples. J Abnonn Child Psychol 21 :663-681 Campo JV. Frilsch SL (1994). Somaliulion in children and adolescenrs. JAm Acad Child Adouse Psychiatry 33:1223-1235 Derogalis LR (1994). SCL-90-R": Adminisrration. Scoring and Procrduw Manual. Minneapolis: Nalional Compuler Syslems Derogalis LR. Rickels K. Rock AF (1976), The SCL-90 and lhe MMPI: a srep in lhe validalion of a new self.repon scale. Br J Psychiatry 128:280-289 Eisen AR. Silverman WK (1993), Should I relax or change my lhoughts? A preliminary examinalion of cognilive lherapy. relaxalion !raining. and lheir combinalion wilh overanxious children. J Cognit Psychothrr 1m Q 7:265-279 Hayward C, Killen JD. Hammer LD et al. (1992). Puberral slage and panic atlack hislory in sixlh- and sevenrh-grade girls. Am J Psychiatry 149:1239-1243 Hollingshead AB (1957), Two FaclOr Index of Social Posilion. Available from PO Box 1965. Yale Slalion, New Haven. CT 06520 Jolly JB. Wherry IN. Wiesner DC, Reed DH, Rule JC, Jolly JM (1994), The medialing role of anxiery in self-reponed somatic complainrs of depressed adolescenrs. J Abnonn Child Ptychol 22:691-702 Lasl CG (1991). Somalic complainlS in anxiery disordered children. J Anxirty Disord 5:125-138 Lee SW, Piersel WC. Friedlander R. Collamer W (1988), Concurrenr vatidiry of lhe Revised Children's Manifesl Anxiery Scale (RCMAS) for adolescenrs. Educ Psychol Mra! 48:429-433 LivingslOn R, Taylor JL. Crawford SL (1988), A study of somatic complainrs and psychia!ric diagnosis in children. J Am Acad Child Adolrsc Psychiatry 27:185-187

Marshall WA. Tanner JM (1969). Varialions in pmern of pubmal changes in girls. Arch Dis Child 44:291-303 Marshall WA. Tanner JM (1970), Varialions in lhe pmern of pubenal changes in boys. Arch Dis Child 45: 13-23 McCauley E. Carlson GA. Calderon R (1991). The role of somalic complaints in lhe diagnosis of depression in children and adolescenrs. JAm Acad Child Adouse Ptychiatry 30:631-635 Poznanski EO, Freeman LN, Mokros HB (1985), Children's Depression Raling Scale-Revised. Ptychophannacol Bull 4:979-989 Poznanski EO, Grossman JA. Buchsbaum Y, Banegas M. Freeman L. Gibbons R (I 984). Preliminary sludies of lhe reliabiliry and validiry of lhe Children's Depression Raling Scale. JAm Acad Child Ado!LJc Ptychiatry 23:191-197 Reich W. Weiner Z (1990). Diagnostic lmrrvirwfor Childrm andAdousemtJRrviud-Child Vmion and Diagnostic Intrrvirw for Childrm and Adouscrms-Rrviud-Parrm Vmion. Sl Louis: WashinglOn Universiry Division of Child Psychialry Reynolds CR. Richmond BO (I978), Whal I Think and Feel: a revised measure of children's manifesl anxiely. J Abnorm Child Psychol 6:271-280 Sanders MR. Rebgelz M. Morrison M el al. (I989). Cognitive-behavioral rrealment of recurrent nonspecific abdominal pain in children: an analysis of generaliulion. maintenance, and side effects. J Comult Clin Psychol 57:294-300 Shaffer D. Fisher P. Dulcan MK el al. (1996). The NIMH Diagnoslic Inrerview Schedule for Children Version 2.3 (DISC 2.3): descriplion. acceplabiliry. prevalence rales. and performance in lhe MECA sludy. JAm Acad Child Adousc Ptychiatry 35:865-877 Smilh GR. ROSI K. Kashner M (I 995). A !rial of lhe effecl of a slandardized psychiarric consullalion on lhe heallh oulcomes and COSlS in somalizing palients. Arch Gm Psychiatry 52:238-243

668

J.

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