Background
Somatic symptom disorders (SSD) describe a heterogeneous entity, though the terminology has changed over the years [
1,
2]. In the present article they include somatoform disorders, dissociative (or conversion) disorders and somatic disorders with psychiatric comorbidity. Somatic symptom disorders lead to significant functional and emotional impairments e.g., school absence, high socioeconomic costs and frequent use of healthcare services [
3,
4]. Recently, increased numbers of children and adolescents suffering from somatic symptom complaints with functional impairments have been reported by van Geelen and colleagues [
5]: between 1988 and 2011 the percentage of boys with psychosomatic problems larger than 90th percentile increased from 5.0 to 9.1% and in girls from 16.7 to 24.5% (2619 adolescents included). In particular, factors related to treatment outcomes are poorly understood, and there is a need for further research in this field [
3].
In the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), a new category was introduced known as “somatic symptom and related disorders”. The DSM-5 emphasizes a significant functional impairment, as well as excessive thoughts, feelings and behaviors related to somatic symptoms, while the absence of a medical explanation for the symptoms is no longer necessary [
6].
In contrast to the DSM-5, the International Statistical Classification of Diseases and Related Health Problems ICD-10 defines SSD in different categories e.g., somatoform disorder (F45.x) and dissociative and conversion disorder (F44.x) [
7].
The most common symptoms reported by children and adolescents with SSD include pain, fatigue, faintness and nausea [
8‐
10]. Specifically, chronic somatic pain (headache, recurrent abdominal and musculoskeletal pain) appears to be very frequent, with up to 25% of children and adolescents being affected in general population samples, including the “German Health Interview and Examination Survey for Children and Adolescents” (KiGGS) [
8,
11‐
13]. Conversion disorders are less frequent, with a prevalence varying between 1–4% and up to 10%, as measured in a pediatric neurological unit [
14,
15]. Moreover, data from the KiGGS-survey showed that up to 10.8% of children and adolescents suffer from a chronic somatic disorder and show a threefold increased risk of developing psychiatric comorbidities compared to healthy controls [
13]. Likewise, children and adolescents with an SSD show an increased risk of developing psychiatric comorbidity, especially anxious or depressive symptoms [
11,
16]. Moreover, adolescents with affective, anxiety and behavior disorders are at risk of developing somatic symptoms such as chronic pain; on the other hand depression and anxiety disorders can be a consequence of chronic pain [
17,
18]. Up to 50% of children and adolescents with SSD suffer from psychiatric comorbidity [
2]. In addition, affected children and adolescents often face functional long-term impairments resulting in poor academic achievements, an increased risk for later medical treatment and vocational impairment [
8,
16,
19]. The emotional burden seems to have an important influence on the long-term treatment outcome [
20]. This highlights the importance of consideration and treatment of psychiatric comorbidities during the inpatient multidisciplinary treatment.
Treatment often appears to be unsatisfactory to patients, families and healthcare professionals due to a low acceptance of the concepts of, and interventions for, somatic symptom disorders [
1,
8,
11]. For subjects with severe impairments, inpatient multidisciplinary treatment in specialized healthcare units based on a cognitive behavioral approach has been recommended [
11,
21]. Notably, a close cooperation among multiple disciplines is warranted, as biological and environmental/social aspects have to be considered [
4,
22]. However, a systematic evaluation of treatment approaches is lacking, and specialized healthcare units are rare in Germany and many other developed countries [
20]. More specialized multidisciplinary units are needed as unimodal treatment appears to be insufficient for the complexity of the SSD [
20]. Compared to sole pediatric and psychiatric treatment, a multidisciplinary treatment approach facilitates a highly specialized treatment and ensures a close collaboration between pediatricians and psychiatrists. Previous studies predominantly focused on chronic somatic pain, while studies investigating SSD, including dissociative (or conversion) disorders and somatic disorders with psychological factors, are scarce [
21].
Research of chronic somatic pain in children and adolescents has demonstrated that inpatient multidisciplinary treatment is effective for improving pain intensity, school absence and further pain-related disabilities (e.g., social activities, sports, sleep) [
23]. Improvement of pain coping appears to have a strong effect on pain-related treatment outcomes e.g., pain intensity [
24‐
26]. A recently published meta-analysis by Bonvanie and colleagues [
21] demonstrated the effectiveness of psychological treatment in improving symptom severity, disability and school attendance at posttreatment and follow-up in children and adolescents with functional somatic symptoms. The type of symptoms did not seem to influence the outcomes [
21]. Despite these promising results, research on multidisciplinary treatment of children and adolescents with SSD is scarce, and the mediators of these treatment processes are still not well understood. In addition, an interpretation of the existing studies is limited due to the heterogeneity of the measures used and a lack of data concerning the long-term treatment effects regarding psychosocial functioning (e.g., school attendance) and psychiatric comorbidity [
4,
12,
21,
27].
Thus, our study focused on the evaluation of inpatient multidisciplinary treatment of SSD covering all disorders enumerated in DSM-5, with a particular evaluation of distress and impairment (i.e., school absence). In detail, the aims of our study were twofold: first, we aimed to evaluate the effectiveness of an inpatient interdisciplinary treatment for children and adolescents with somatic symptom disorders. The multidisciplinary team consisted of child & adolescent psychiatrists, pediatricians, clinical psychologists, physiotherapists, occupational therapists and nurses. The outcome parameters were a reduction in somatic complaints and psychiatric comorbidity (anxiety, depression) at discharge and upon a 6-month follow-up after treatment completion. At this assessment, school attendance was also evaluated. Second, we aimed to assess the impact of coping strategies and comorbid psychiatric symptoms (depression, anxiety) on changes in functional impairment (i.e., school attendance) and the level of discomfort.
Discussion
The key finding of this study was that, in children and adolescents with SSD, an inpatient interdisciplinary treatment program is highly effective in reducing somatic complaints, increasing school attendance, developing adaptive coping strategies and improving psychiatric comorbidity (depression, anxiety). Furthermore, our findings highlighted the importance of developing adaptive coping strategies that are associated with improved school attendance.
Our findings were consistent with those of previous studies, which demonstrated that children who were highly affected by chronic pain improved in response to inpatient treatment in regard to functional impairment, pain intensity and quality of life [
4,
11,
37,
38]. Although there exists strong evidence for the short-term effectiveness of inpatient treatment, research concerning the long-term outcome is rare, and tools for measuring treatment outcomes need to be standardized for better comparability [
38]. A meta-analysis by Hechler and colleagues demonstrated that intensive interdisciplinary pain treatment has positive treatment effects on pain intensity, disability and depressive symptoms, though school functioning and anxiety were excluded due to the heterogeneity in the treatment outcome measures [
4]. A recent meta-analysis [
21] demonstrated the effectiveness of psychological treatment on functional somatic symptoms. Notably, the
type of symptom was not associated with the effectiveness of treatment. This may be interpreted in support of the findings of this study that included all somatic symptom disorders and pediatric disorders being complicated by psychological factors.
Second, our results support previous findings that inpatient interdisciplinary treatment can substantially reduce school absence [
23]. In accordance with prior research showing that 80–90% of patients with chronic pain show a significant improvement in school attendance, our findings suggest similar results, with only 13.3% maintaining high levels of school absence at 6 months after discharge (i.e., 6–20 school days missed over 4 weeks) [
23,
39]. As school attendance is highly important for the development of children and adolescents, factors explaining the persistent school absence rates must urgently be identified [
23].
Moreover, previous studies have suggested that adaptive coping strategies play an important role in the treatment of recurrent and chronic pain [
40,
41]. While associations of pain coping and improvement in affective symptoms have been inconsistent [
42,
43], improvements in functional disability and quality of life have been previously reported [
43]. Further, our findings regarding the changes in coping are consistent with former research conducted by Hechler and colleagues [
41], who reported identical findings, i.e., reduced passive pain coping and seeking of social support after a multimodal inpatient treatment, with positive self-instruction being maintained. Thus, associations of improved behavioral coping strategies (more active coping, less seeking of social support) with improved school attendance implies that one promising treatment approach could involve focusing on helping patients become more active in reducing passive coping. One element of our multidisciplinary treatment that helped patients become active were the several treatments of physiotherapy per week, in both group and individual settings. Moreover, this treatment fostered positive social experiences and skills within the patient group, both due to the inpatient setting and specifically in social competence trainings and in supervised group activities. Future research should further investigate which specific treatment strategies are most beneficial in improving behavioral coping. While the importance of coping has been demonstrated in adolescents with chronic somatic pain, our results suggested that improvements in coping strategies are an important treatment target in children and adolescents with SSD as well.
Concerning associations of gender and pain coping, one study demonstrated that reduced seeking of social support was associated with reduced pain intensity in girls but not in boys [
41]. In our study, boys showed larger improvements in pain coping strategies compared to girls; however, due to the sample size, we did not explore gender-specific associations of pain coping and the level of discomfort. More research is needed to investigate the role of gender in pain coping, as gender-specific coping strategies may improve the treatment outcomes [
32].
Lastly, concerning comorbid affective disorders, our findings support previous data showing that over the course of the inpatient treatment, anxiety and depression improved significantly [
4,
11,
37]. However, previous research has been heterogeneous and has not always included specific psychiatric treatments of comorbidities, as conducted in this study. In some cases, treatment of psychiatric comorbidity involved the use of medication that was not previously administered to the patients. This must be considered when interpreting the results of our study. Of note, the improvements in psychiatric comorbidity were not significantly related to changes in school attendance or the level of discomfort. While this finding has been reported previously [
44], it should be interpreted with caution due to the sample size this non-finding is based on.
The strengths of this study include the use of the standardized assessment of treatment effects and the inclusion of a 6-month follow up. The limitations apply to the study design, as it evaluates a “natural” clinical treatment program lacking randomization, a control group, a standardized therapeutic manual and structured measures of treatment adherence. Future studies with larger sample sizes are needed to assess which specific treatment strategies add to the effectiveness of an inpatient interdisciplinary treatment and also to investigate the role of coping strategies in more detail.
Authors’ contributions
BH and JB conceptualised the study. JB supervised data collection, PH, AD and GGP analysed and interpreted the data and drafted the manuscript. BH, NW, and CS revised the manuscript critically. All authors read and approved the final manuscript.