Clinical Practice Guidelines for the

Management of Paediatric Somatoform disorders

VIVEK AGARWAL,CHHITIJ SRIVASTAVA, PRABHAT SITHOLEY

INTRODUCTION
Somatoform disorders are characterized by the repeated subjective experience of physical
symptoms (hereafter somatoform symptoms) which are not explained by any physical
disease. The types of somatoform disorders in ICD-10 are listed in Table 1. All the
disorder subtypes share one common feature, that is, predominance and persistence of
somatic symptoms associated with significant distress and impairment. There are
repeated requests by the child or adolescent (hereafter child unless specified) or family
for medical investigations in spite of consistent negative findings and reassurances from
medical professionals. Even if a physical disorder is present, it does not explain the
nature and extent of the somatoform symptoms. These affected children often have a
degree of attention seeking behaviour. They are usually diagnosed by excluding organic
causes for the somatoform symptoms. Despite absence of any physiological abnormality
these children show considerable distress and impairment.
These guidelines are an update of the previous IPS guidelines on management of
paediatric somatoform disorders (2008). These guidelines are broad and are expected to
help in systematic assessment and management of a child with somatoform disorders.

Table 1: ICD-10 categories of Somatoform Disorders

1 Somatization disorder
2 Undifferentiated somatoform disorder
3 Hypochondriacal disorder
4 Somatoform autonomic dysfunction
5 Persistent somatoform pain disorder
6 Other somatoform disorders
7 Somatoform disorder, unspecified

ASSESSMENT
Difficulties in assessment (Table 2)
The assessment of these disorders is not straightforward, partly because of the nature of
these disorders and partly because of the nature of medical training of physicians. Mind
body dualism has traditionally existed in the way doctors understand medical problems.
Therefore, when presented with disorders that are not properly understood because they
do not conform to this dualism, physicians feel that it must be something to do with the
mind (functional / psychogenic) and hence refer the patient to a psychiatrist. The
message often perceived by the family is that their child is making up the symptoms.
Poor liaison between the treating physician and the psychiatrist results in the family
seeking multiple medical opinions. Even when the family sees a psychiatrist, they don’t
feel confident enough as the treating physician is not seen as competent in assessing the
physical symptoms.
Table2: Difficulties in assessment
  Mind body dualism inherent in medical training
 Poor understanding of these disorders
 Miscommunication to family about the problem
 Lack of liaison and joint work between different professionals
 Family and child perceive treating physicians and psychiatrists as incompetent
in management of the child’s somatic symptoms.

Initial assessment (table 3)

Once, somatoform disorders are suspected, the assessment requires a comprehensive,
multidisciplinary approach with close monitoring of symptom evolution. The assessment
should include thorough history taking, physical examination and diagnostic tests to rule
out both serious and benign medical factors that may be contributing to the child’s
symptoms. Relevant investigations should be done wherever indicated. The possibility of
a somatoform disorder superimposed on neurological or medical disorders, or other
psychiatric disorders should always be considered.
Somatoform disorders shouldnot be primarily diagnosed by exclusion of an organic
cause. It is much more effective to pursue a positive diagnosis of somatoform disorder
when the child presents with typical features of somatoform disorders. Multiple
symptoms, often occurring in different organ systems, symptoms that are vague or that
exceed in number or intensity or donot conform to the objective findings are suggestive
of somatoform disorders. A chronic course, prior history of unexplained physical
symptoms, presence of a psychiatric disorder, history of extensive diagnostic testing,
rejection of previous physicians, responsiveness of the symptoms to placebo or
suggestion are some important pointers to the diagnosis somatoform disorders. The
treating psychiatrist should always consider seeking appropriate consultations if there are
new symptoms or there is a possibility of a somatoform disorder superimposed on
neurological or medical disorders. There must be an ongoing liaison between the treating
psychiatrist and the pediatrician and any new symptom should be assessed by the
paediatrician.
Table 3: Assessment

 Thorough medical assessment to rule out any serious medical disorder

 Initial joint assessment with psychiatrist and physician (if possible)
 Pursuing a positive diagnosis of somatoform disorders

Psychosocial Assessment (table 4)

Psychiatric assessment should take a systemic perspective looking into all relevant bio-
psycho-social factors. These can be divided into individual factors, family related factors
and other environmental factors.
Individual factors
Assessment of the child’s temperament (anxious, behavioural inhibition, harm
avoidance) helps to understand how he copes with stress. The child’s coping skills are
often modelled on the family’s coping skills, which also need to be understood.
Assessment of intelligence to rule out borderline or low intellectual functioning can help
to understand the child’s coping skills in the face of stress. Low intelligence is also a risk
factor for a number of psychiatric disorders. A detailed psychiatric assessmentis needed
to assess psychiatric conditions, such as depression and anxiety disorders, which may
present with nonspecific physical symptoms to paediatricians or physicians. Separation
fears in the child can be associated with the somatic symptoms and therefore should be
properly assessed. Presence of a psychiatric condition gives a valuable clue that the child
may be suffering from a somatoform disorder.
Family related factors

Obtaining examples of how the family members deal with stressful situations can be very
helpful. Sometimes, maladaptive ways of dealing with stressors are evident in family
members, which serves as a model for the child. Exploring the family’s understanding of
and response to the child’s symptoms is crucial to understanding the perpetuating and
maintaining factors. Both lack of communication and over involvementwith the child can
maintain the symptoms of a somatoform disorder. Any secondary gain because of
somatic symptoms should be carefully elicited.The style of parenting, intra-family
relationships and family functioning need to be assessed comprehensively, focussing not
only on difficulties but also on the strengths. These strengths can be used later in therapy.
It is particularly relevant to comprehensively assess for recent or ongoing stressors which
interact with the individual factors (as discussed above) to shape the course of child’s
problems. Studies in children have shown that stressors are generally present in their day-
to-day life and are known to the child and their family members. It is important for the
clinician to evaluate for stressors from a developmental perspective and to try and assess
for any temporal relationship between the stressor and onset of symptoms. It may not be
possible to find out stressor in the initial interviews; however, by repeated, careful and
sensitive interviewing stressors can be elicited. Mental illness, substance abuse, physical
illness, conflictual relationships in parents and other key family members can present as
both acute and ongoing stressors and, therefore, need to be properly assessed. History of
chronic physical illness, somatoform symptoms and disability in close family members,
together with their coping mechanisms, serve as a model for the child to emulate. They
can contribute to the child’s problems in multiple ways.
Environmental factors
Environmental factors can also present as both acute and ongoing stressors in the life of
the child and need to be assessed comprehensively. Stressors in school can arise from
poor peer relationships, bullying, academic stress, and teaching style (harsh or critical).
Acute and ongoing frightening experiences that include physical and sexual abuse also
need to be assessed. Information should be obtained both from the family and school to
understand the nature and extent of stressors. At times, stressors may not be obvious or
severe enough to be noticed by the family members. In such cases, stressors should be
assessed systematically and their severity and temporal correlation with the onset of
somatoform symptoms should be clearly delineated. One may use WHO interview
schedule for assessment of psychosocial situations(ICD-10 Axis V) for systematic
assessment of stressors in children.
Table 4: Psychosocial Assessment

1. Individual factors
a. Temperament (anxious, behavioural inhibition, harm avoidance)
b. Poor coping skills
c. Borderline intellectual functioning
d. Underlying Psychiatric illness (anxiety, depression)
2. Family related factors
a. Coping skills of family members
b. Response of family members towards the child’s problems
c. Poor communication with child
d. Parenting style
e. Intra-familial relationships
f. Physical and psychiatric problems in family members
g. Substance abuse in family members
3. Environmental factors
a. Peer relationships
b. Bullying
c. Academic stress
d. Teaching style
e. Frightening experiences (physical or sexual abuse)

TREATMENT

It is imperative to treat these disorders promptly to prevent habituation and future

disability. The longer the symptoms remain, the more aggressive the treatment should be.
It may be helpful to consider treatment in stages with having immediate, short-term, and
long-term goals(table 5). Immediate goals can be cessation of inappropriate medical
interventions, ensuring the safety of the child, engaging the family in treatment, and
arranging ongoing care. Short-term goals can be preventing further unnecessary medical
interventions, maintaining reasonable medical monitoring, symptom reduction, and steps
to initiate age appropriate activities. Long-term goals can be appropriate use (not
overuse) of medical care, resolution/minimization of symptoms and psychosocial
stressors, development of appropriate coping skills to deal with psychological and
environmental stressors, and resumption of age-appropriate activities. In severe cases,
symptoms are unlikely to resolve completely and even if they do, they are likely to keep
relapsing. Therefore, the goals may have to be revised regularly and kept realistic.
Unrealistic goals often lead to symptom substitution by the child to stay in the sick role.
A better goal is to help the child and family in coping with the symptoms, keeping the
child engaged in school, extra-curricular activities and away from hospital admission.

Table 5: Treatment Goals

Immediate goals
 cessation of inappropriate medical interventions
 ensuring the safety of the child
 engaging the family in treatment
Short-term goals
 preventing further unnecessary medical interventions
 maintaining reasonable medical monitoring
 symptom reduction
 initiating age appropriate activities
Long-term goals
 appropriate use (not overuse) of medical care
 resolution/minimization of symptoms and psychosocial stressors
 development of appropriate coping skills to deal with psychological and
environmental stressors
 resumption of age-appropriate activities
 aim for realistic goals in severe, long standing cases

Rapport and Therapeutic Alliance

Once a diagnosis of one of the somatoform disorders is made, the most difficult process
is engaging the child and family in the treatment plan. The cornerstones of successful
therapy include establishment of rapport and therapeutic alliance with them. Resistance
to seeing a psychiatrist because of various misconceptions and stigma is prevalent. The
initial sessions, even while the assessment is ongoing, should aim to come to a shared
formulation of symptoms that the child and family agree with. We recommend using a
Cognitive Behaviour Therapy (CBT) framework (figure 1).Family influences are
particularly relevant especially in young children and these need to be built in to the
formulation.
Psychoeducation (Table 6)
The family and the child should be educated that physical symptoms in the absence of
known physical disorder are common and representative of how the body responds to
stress. Communicating that there is nothing seriously wrong with the child from a
medical point of view is not always straightforward.The family and the child may
disagree with the view that there could be anything psychologically wrong with their
child, their parenting styles or the family functioning. Any suggestion of this possibility
can be met with resentment, anger and sometimes, open hostility. It is, therefore,
important to not get into an argument with the family over this. Common examples of
physical symptoms in stressful situations e.g., becoming sweaty, experiencing
palpitations, feeling “butterflies in the stomach” etc. can be quite helpful in driving home
the point that physical symptoms can be present in the absence of physical disease. The
best approach is to get these examples from the history narrated by the family. However,
when the diagnosis is presumptive, it’s best to acknowledge that rather than pretending to
be certain. A better stand would be that although there is no evidence of a serious life-
threatening medical illness, the child does have an impairing illness that is not properly
understood. If a confident diagnosis of somatoform disorder has been made then
unnecessary medical workup should be avoided unless there are new symptoms that are
not consistent with the diagnosis.However if the diagnosis is presumptive, then the
family should be reassured that the paediatrician will continue to monitor symptoms from
a medical point of view.At the same time it should be communicated that practical
psychological approach can alleviate the symptoms even if the family thinks that these
are due to a medical cause (that the physician havenot found). An alternative formulation
of symptoms is presented using the CBT framework. The child and family is educated
about that while the child’s symptoms may be physiological, it is their interpretation and
the subsequent behaviour of the child that exacerbates them. The CBT formulationshould
be collaborative and prepared involving the child and family. A shared formulation helps
to shift the beliefs away from a purely medical model of the child’s problems.Subsequent
treatment approach using the CBT model should be explained early on and its
collaborative nature needs to be stressed upon properly. It’s important to arrive at shared
treatment goals that are explicitly communicated between the treating clinician, the child
and family so that the members of the treating team should adopt the same approach
towards the disorder and the child and family.
Table 6: Psychoeducation- key points

 Reassure that the symptoms are not due to any serious medical illness
 Use examples to communicate the link between stress and physical symptoms
 Try and arrive at a shared formulation with the family and child using a CBT
model
 Communicate that psychological approaches can help even if the family don’t
agree with the diagnosis
 Clear communication about the working formulation and management to
family and everyone involved in the management plan

Solving the Psychosocial Problems

It’s important to understand the psychosocial problems that may be contributing to the
child’s condition. Once these are known, then attempts should be made to resolve or
minimise them. The problem should be discussed with the child and the family. In case
of adolescents, if the problem has been revealed to doctor or the ward staff in confidence,
then consent of the adolescent should be taken to discuss it with the family. The
physician should not force his opinion on the child or the family. Problems of family
relationships should be discussed and family should be told that the child is being
adversely affected by the family problems and their resolution will improve the child. It
is important to open up the channels of communication between the child and his family.
Through out the treatment, attention should be focused on the child rather than on the
symptoms to ensure a speedy recovery.
Psychological Treatment (table 7)
CBT based approaches have been shown to be helpful in reducing the intensity of
symptoms and help the child in coping with them and improve his general
functioning.CBT formulation is useful in understanding the symptoms regardless
whether formal CBT is used in treatment or not. In mild cases, the formulation itself may
be therapeutic. However, where symptoms are chronic, recurring and disabling, formal
CBT is recommended. Following are the key points-

a) 8-16 weekly sessions following general CBT framework

b) A shared formulation to understand the child’s problems
c) Using active CBT techniques, the dysfunctional beliefs are gently challenged and
replaced by adaptive ones
d) Gradually replace illness behaviour with more healthy behaviours.
e) Negotiate a phased return to school and other extra-curricular activities that the
child was pursuing before. Incorporating some physical activity can be especially
useful. It helps the child to improve fitness, build self-esteem, and replace the
time spent on illness behaviours. It can also serves as a behaviour experiment that
proves that the child is not too physically unwell.
a) Combine relaxation training, Yoga, problem solving, social skill training and
mindfulness to the child.
Family therapy can be useful if there is evidence that dysfunctional family dynamics are
contributing to the child’s difficulties. It can also be helpful if there are strengths in the
family set-up that can be used therapeutically.
Secondary Gains
Reduction in secondary gains is not advisable very early in the treatment and without
adequate explanations to the family because of three reasons. First, the physician himself
may not be certain about the origin of the symptoms. Secondly, the family may perceive
reduction in secondary gain as neglect of the child. Also, initially the family may not
have full confidence in the hospital’s ability to take total care of their child.
Later on, the family should be offered adequate explanations regarding secondary gains.
Reduction in secondary gains in a child should be accompanied by providing the child
with an alternative, healthy, socially acceptable and age appropriate role in which he or
she can be rewarded for doing something positive.
Table 7: Non pharamacological Management – key points

 Use the CBT model to communicate how checking, seeking reassurance,

seeking multiple consultations and avoiding normal daily activities
accentuates the problems
 Try and solve any relevant psychosocial problems
  Encourage the child to gradually resume normal daily activities
 Encourage the child to engage in daily, regular physical activity and other age
appropriate activities of interest like drawing, painting, story book reading etc.
 Advise the parents to give attention to the child when he engages in positive
activities as advised.
 Encourage joint activities with parents.
 Advise the family to stop seeking consultations unless advised by the treating
psychiatrist. If they do then get them to discuss their understanding of the
problem with the psychiatrist or paediatrician.
 Advise the child and family to not seek information about symptoms on the
internet.
 Use relaxation training (e.g., breathing exercises), mindfulness to cope with
symptoms
 Gradually cut down maladaptive secondary gains that the child may be getting
because of his/her symptoms.
 Consider Family therapy where indicated
 Combine problem solving, social skill training as needed
 Formal CBT especially where symptoms are chronic, recurring and disabling.

Pharmacological Treatment
There is no good quality evidence to recommend any particular medication for
somatoform disorders in the paediatric population. A recent cochrane review
(Kleinstäuber et. al.) concluded that there is low or very low quality evidence for the
efficacy of pharmacological interventionsfor somatoform disorders in adults which
makes it difficult to extrapolate those findingsto the paediatric population. Medications
including SSRIs and SNRIs have been used and reported to be helpful in somatoform
disorders especially when symptoms are particularly severe, resistant to psychological
approaches and when other psychiatric comorbidity is present. Anxiety and depressive
disorders may be associated with somatoform disorders and these respond well to
antidepressants. However, it is advised that only those antidepressants which are
approved in paediatric age group for other indications, should be used if required. The
clinician should pay particular importance to side effects while choosing medication, as
this patient group is more sensitive to them. One should start with low doses and increase
them progressively to avoid side-effects that may mimic the symptoms present before the
treatment.
Dealing with negative emotions
These patients and the families often arouse negative responses in medical professionals
and hospital staff. The staff can feel frustrated and angry. There can be beliefs that these
patients and families are abusing health care resources, wasting the professionals’ time,
and that no intervention will help. The psychiatrist needs to both deal with these negative
emotions himself and help other treating team members including the paediatrician, in
coping with them.
 Management Scheme Symptoms suggestive for paediatric Somatoform
Disorders of somatoform disorder

Assess for comorbid psychiatric

illness
Thorough medical
assessment and Child related factors espcially.
investigations if required temperament

Rule out any serious Family factors esp. parenting

medical disorder and Environmental factors
assess for comorbidDiagnosis of Somatoform
medical disorder Presence of psychiatric/physical
Disorder
illness in family member
Rapport
Therapeutic alliance
Psycho-education using
CBT framework
Set-
Immediate goals
Treatment
Short-term goals
Management
Long term of psychosocial
goals
factor
FURTHER Behavioral management of child READING
Relaxation training, mindfulness
Formal CBT for chronic,
1. Campo JV. resistant symptoms Annual research
review: Consider family therapy functional somatic
symptoms and Medication for concomitant associated anxiety and
depression - anxiety or depression in suitable developmental
cases psychopathology in
pediatric practice. J Child Psychol Psychiatry 2012; 53(5): 575-92.
2. Karkhanis DG, Winsler A. Somatization in Children and Adolescents: practical
 implications. Journal of Indian Association of Child and Adolescent Mental
Health 2016; 12(1):79-115.
3. Escobar JI, Dimsdale JE. Somatic symptom and related disorders. In the
Comprehensive Textbook of Psychiatry 10th edition. Ed. Saddock BJ, Saddock
VA, Ruiz P. Wolters Kluwer 2017.
4. Garralda ME, Rask CU. Somatoform and related disorders. In Rutter’s Child and
Adolescent Psychiatry 6th edition. Ed. Thapar A, Pine DS, Leckman JF, Scott S,
Snowling MJ, Taylor E. Wiley Blackwell 2015.
5. Kleinstäuber M, Witthöft M, Steffanowski A, van Marwijk H, Hiller W, Lambert
MJ. Pharmacological interventions for somatoformdisorders in adults. Cochrane
Database of Systematic Reviews 2014, Issue 11. Art. No.: CD010628. DOI:
10.1002/14651858.CD010628.pub2.
6. Kroenke K, Swindle R. Cognitive behaviour therapy for somatization and
symptom syndromes: a critical trials. Psychother Psychosom 2000; 69;205-215.
7. Malas N, Ortiz-Aguayo R, Giles L, Ibeziako P. Paediatric Somatic Symptom
Disorders. Curr Psychiatry Rep 2017; 19: 11.
8. Schaefert R, Hausteiner-Wiehle C, Häuser W, Ronel J, Herrmann M, Henningsen
P. Non-Specific, Functional, and Somatoform Bodily Complaints. Dtsch Arztebl
Int 2012; 109(47): 803−13.
9. Sitholey P, Agarwal V. Management of Pediatric Somatoform Disorders. In Child
and Adolescent Psychiatry: Clinical Practice Guidelines for Psychiatrists in India.
Gautam S, Avasthi A & Malhotra S, editors. Indian Psychiatric Society 2008; pp
154-158.

Authors-
1. Dr. Vivek Agarwal
Professor
Department of Psychiatry
King George’s Medical University
Lucknow

2. Dr. Chhitij Srivastava

Assistant Professor, Psychiatry unit, Moti Lal Nehru Medical College, Allahabad,
India
Research Affiliate, Institute of Psychiatry, King’s College London, London,
United Kingdom
Associate Faculty, Centre for Behaviour & Cognitive Sciences, University of
Allahabad, Allahabad, India
3. Dr. Prabhat Sitholey
Ex Professor and Head
Department of Psychiatry
King George’s Medical University
Lucknow