Child Psychiatry Hum Dev (2012) 43:661–673
DOI 10.1007/s10578-012-0289-y
ORIGINAL ARTICLE
Somatic Symptoms in Traumatized Children
and Adolescents
Brittany B. Kugler • Marlene Bloom • Lauren B. Kaercher
Tatyana V. Truax • Eric A. Storch
•
Published online: 7 March 2012
Ó Springer Science+Business Media, LLC 2012
Abstract Childhood exposure to trauma has been associated with increased rates of
somatic symptoms (SS), which may contribute to diminished daily functioning. One
hundred and sixty-one children residing at a residential treatment home who had experienced neglect and/or abuse were administered the Trauma Symptom Checklist for Children
(TSCC), the Multidimensional Anxiety Scale for Children, and the Children’s Depression
Inventory (CDI). Primary caregivers completed the Child Behavior Checklist. Two composite measures of SS were formed to represent both child- and caregiver-rated SS. Over
95% of children endorsed at least one SS on the child-rated measure. Children who had
experienced sexual abuse had higher rates of SS relative to children who had not. Childrated SS were highly correlated with the CDI total score and the TSCC subscales of
anxiety, depression, posttraumatic stress, dissociation, and anger. The TSCC anxiety
subscale mediated the relationship between sexual abuse and child-rated SS.
Keywords Trauma Children Anxiety Somatic symptoms
Posttraumatic stress disorder
The contributions of Samantha Nagy, B.A. are greatly appreciated.
B. B. Kugler E. A. Storch
Department of Psychology, University of South Florida, Tampa, FL, USA
B. B. Kugler L. B. Kaercher T. V. Truax E. A. Storch (&)
Department of Pediatrics, University of South Florida, 800 6th Street South, Box 7523,
St. Petersburg, FL 33701, USA
e-mail: estorch@health.usf.edu
M. Bloom
The Children’s Home, Inc., Tampa, FL, USA
E. A. Storch
Department of Psychiatry and Behavioral Neuroscience, University of South Florida, Tampa, FL, USA
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Introduction
Somatic symptoms (SS) represent an array of physical complaints that encompass a range
of severities. Although the experience of SS per se is not atypical among non-clinical
pediatric populations, exposure to trauma has been associated with increased rates of SS
such as stomachaches, headaches, and muscle tension [1–3]. Following childhood trauma,
SS may cause significant interference in daily functioning and may negatively affect social,
academic and emotional well-being due to impairment in memory and learning, missed
school days, and decreased sleep [4–6]. Additionally, due to the chronicity and severity of
many SS, children may undergo unnecessary and stressful medical evaluations, procedures
and treatments to rule out organic conditions, oftentimes accruing large medical costs [7].
In general, studies have examined correlates of adulthood SS, finding connections with
retrospective recall of childhood traumas [8, 9]. Although informative, the extant research
does not touch upon the experience of SS in childhood following exposure to varied
traumatic events. However, several studies have highlighted the relationship between
exposure to natural disasters and SS in children and adolescents [1, 10]. Trait anxiety,
severity of exposure, family psychopathology and severity of loss uniquely predicted both
posttraumatic stress disorder (PTSD) and SS following a natural disaster-related trauma in
childhood [1, 10].
Few data exist on SS in children experiencing abuse and neglect despite its clinical
importance. Children in the child welfare system are a unique population that may shed
light on the experience of SS following trauma. These children have often been exposed to
multiple traumatic events including physical, emotional and sexual abuse, neglect, abandonment, and witnessing of domestic violence, in addition to being removed from their
homes [11]. Symptomatically, children may present with typical Diagnostic and Statistical
Manual of Mental Disorders, 4th edition text revision (DSM-IV-TR) PTSD symptom
clusters including re-experiencing of symptoms (e.g., nightmares, play enacting the
trauma), avoidance of trauma reminders (e.g., forgetting aspects of the trauma, anhedonia)
and hyperarousal (e.g., hypervigilance, irritability, sleep problems) [12]. However, children’s reactions to trauma may often look quite different than the framework for PTSD
highlighted by the DSM-IV-TR [13]. For instance, children may respond to trauma by
exhibiting SS, depressive and anxiety symptoms [10], inattention/hyperactivity, and/or
disruptiveness [14].
Several theories have been proposed to explain the presence of SS following childhood
trauma. One such theory posits that both SS and negative reactions to trauma, such as
PTSD, share a similar psychological vulnerability [15]. This theory has been expanded to
elucidate that the shared vulnerability is dependent on trait anxiety sensitivity (i.e., the fear
of anxiety related sensations) [1]. It is also suspected that anxiety may relate to the increase
in arousal symptoms following trauma. Following childhood trauma, the arousal symptom
cluster of PTSD, as described in the DSM-IV [12], may be heightened while other
symptom clusters (e.g., avoidance or re-experiencing) may be suppressed. This may lead to
an over-expression of hyperarousal and may be displayed as an increase in SS [2]. Children
who exhibit high rates of trait anxiety sensitivity may fear the negative sensations associated with anxiety and therefore be more highly attuned to arousal symptoms. This theory
explains both the experience of increased anxiety and posttraumatic arousal symptoms
with the presence of SS. Additionally, studies addressing the prevalence of SS in children
with anxiety disorders have shown that up to 95% of children with an anxiety disorder
report at least one SS and on average report six SS [16]. It is therefore suspected that the
mechanism driving the relationship between childhood trauma and SS is the presence of
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anxiety. Specifically, this theory posits that childhood exposure to trauma yields anxiety
which is experienced as an increase in hyperarousal symptoms and expressed in part as SS.
Studies that have addressed demographic and clinical characteristics of SS among
clinically anxious children have yielded mixed findings. Evidence regarding gender differences in the expression of SS has varied with studies showing either no gender differences [16] or a higher rate of SS in females [1, 17]. Similarly, evidence regarding age
differences in SS has also been mixed with some studies finding no age differences [1, 17]
or higher rates of SS in older children [16]. The question of whether varying abuse types
influence the experience of SS in childhood has seldom been explored. However, childhood sexual abuse is a unique predictor of SS in childhood and adolescence [18] as well as
young adulthood [3]. There is evidence to support the direct association between posttraumatic stress reactions following other types of trauma (e.g., natural disasters, witnessing community violence) and SS in children [1, 19].
The purpose of this study is to determine the extent to which SS are associated with
sociodemographic (i.e., gender, age at assessment) and clinical variables (i.e., type of
abuse, anxiety, posttraumatic stress symptoms, anger, dissociation and depression). There
are several reasons why it is important to study SS in traumatized youth. First, significant
associations between trauma and SS may indicate the need to include measures of SS in the
routine psychological and physical assessment of children following traumatic events. In
order to avoid unnecessary and costly medical testing, it is important that healthcare
providers are cognizant of the fact that traumatized children may present with SS unrelated
to any underlying medical cause. Second, treatments for posttraumatic symptoms and other
adverse outcomes of trauma may need to include additional interventions that target SS.
For example, addressing underlying anxiety with either cognitive-behavioral therapy or
psychopharmacology may reduce SS [16, 17]. Finally, it is important to examine the
physiological correlates of trauma yielding a better understanding of the phenomenology
of posttraumatic reactions in children. We predicted that: (a) Consistent with previous
research [17], there will be gender and age differences, with females and older children
exhibiting higher rates of SS relative to males and younger children. (b) Consistent with
others [3, 18], children who have experienced sexual abuse will have higher rates of SS
relative to those children who have not experienced sexual abuse. (c) Duration in time
since removal from home will be negatively associated with presence of SS. This prediction was based on literature indicating that psychosocial stressors such as loss, injury
and trauma are associated with increased SS [10]. (d) Somatic symptoms in traumatized
children will be directly related to anxiety, posttraumatic stress, and depressive symptoms.
(e) In accordance with previous research that posits that health anxiety may increase
awareness to arousal symptoms, thereby increasing the experiencing of SS [9], we predict
that anxiety will mediate the relationship between trauma and SS. Additionally, the
mediational analysis will focus on sexual abuse as previous research has noted the strong
connection between sexual abuse, health anxiety, and SS [3, 9, 18].
Method
Participants
Archival data were reviewed for 161 children residing in a residential setting for foster
children necessitating a higher level of care than can be provided in a traditional foster
home. All records were reviewed for children living in the home between 1996 and 2011.
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On average, the residential setting admits four new children per month. For study purposes,
all children who met the following inclusion criteria were included in analyses: (a) at least
8 years of age (3 excluded), (b) had completed the Multidimensional Anxiety Scale for
Children (MASC; [20]) (217 excluded), the Trauma Symptom Checklist for Children
(TSCC; [21]) (10 excluded), and the Children’s Depression Inventory (CDI; [22]) (2
excluded), (c) Primary caregivers (i.e., house-parents in the children’s units) had completed
the Child Behavior Checklist (CBCL) (7 excluded), and (d) background information
regarding the child’s psychosocial history was available in the file (2 excluded). Twohundred and forty-one children were excluded based on the above mentioned criteria.
There were no significant differences on clinical (e.g. abuse type) or demographic variables
(e.g., ethnicity) for the children included versus the children excluded from this study. The
sample consisted of 44.7% females, with an ethnic breakdown of 54.7% Caucasian, 24.5%
African American, 6.3% Hispanic and 14.5% Biracial/Other and an age range of 8–17 with
a mean age of 10.89 years (SD = 2.23 years). Measures were administered by a trained
clinician between 3 and 6 months after the child was admitted. For children that had been
admitted, released, and readmitted, data were used from their initial assessment battery.
Measures
Childhood Background Information
Childhood background information was obtained through psychosocial write-ups found in
each child’s file. The psychosocial reports were comprised of comprehensive accounts of
the children’s history and background based on a multi-informant collaboration of individuals and service providers involved with the child. Assessments were taken within
30 days after admission to the residential facility and recorded by trained clinicians.
Information provided in the psychosocial reports included the child’s demographic
information (age, sex, gender, ethnicity), number of placements, documented trauma
history and perpetrator, educational background and status, as well as significant medical
and/or psychiatric histories of the child, his/her biological mother, father, and sibling(s).
Child Behavior Checklist (CBCL; [23])
The CBCL is a 118-item parent or primary caregiver report of their child’s behavior.
Parents/primary caregivers respond to each question utilizing a 3-point Likert scale
(0 = not true, 1 = somewhat or sometimes true, 2 = very or often true). Eight subscales
are derived from the 118 questions and include anxiety/depression, withdrawn behaviors,
somatic complaints, social problems, attention problems, thought problems, delinquent
behaviors and aggressive behaviors. Internalizing, externalizing and total scores are generated. The CBCL is a widely used behavior scale with good psychometric properties [23]
including strong discriminant and predictive validity [24, 25].
Children’s Depression Inventory (CDI; [22])
The CDI is a child-report measure that asks children to rate the presence and severity of 27
symptoms of depression. The child is presented with three statements and asked to circle
the statement that best expresses how they have felt over the last 2 weeks (i.e. ‘‘I am sad
once in a while’’ ‘‘I am sad many times’’ ‘‘I am sad all the time’’). Individual items range in
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score from 0 to 2 ultimately producing a total summed score of 0–54. Additionally, the
CDI produces scores for five subscales including negative mood, interpersonal problems,
ineffectiveness, anhedonia and negative self-esteem. The CDI has sound psychometric
properties including good test–retest reliability, predictive validity, internal consistency
and construct validity [22, 26, 27].
Multidimensional Anxiety Scale for Children (MASC; [20])
The MASC is a child-report measure that consists of 39-items addressing various symptoms of anxiety. Scores are rated on a 4-point Likert scale (0 = never, 1 = sometimes,
2 = often, 3 = always). The MASC yields a total score derived from the sum of all items
as well as four subscale scores, three of which are further divided into two sections each:
physical symptoms (somatic symptoms and tense symptoms), social anxiety (humiliation
fears and performance fears), harm avoidance (perfectionism and anxious coping) and
separation/panic. The MASC has good psychometric properties including test–retest reliability, convergent and divergent validity [20, 28, 29].
Trauma Symptom Checklist for Children (TSCC; [21])
The TSCC is 54-item child-report measure of trauma-related symptoms in children. Items
are answered using a 4-point Likert scale (where 0 = never, 1 = sometimes, 2 = lots of
times, and 3 = almost all of the time). Symptomatology is measured in 10 domains:
Anxiety, Depression, Anger, Overt-Dissociation, Dissociation, Dissociation-Fantasy,
Posttraumatic Stress Symptoms, Sexual Concerns, Sexual Distress, Sexual Preoccupation
and Validity of responses (both Underresponse and Hyperresponse). The TSCC has strong
psychometric properties including convergent and discriminant validity [30], internal
consistency and predictive validity [31, 32].
Somatic Symptoms Measures
Similar to Ginsburg et al. [16] and Storch et al. [17], two composite measures of SS were
formed to represent both child- and caregiver-rated SS. The child-rated measure was
derived by summing the 12 items on the MASC that assessed SS. The primary caregiverrated measure was compiled by summing the 9 items of the CBCL that addressed SS.
Similar to Storch et al. [17], we believed that creating separate composite measures for
child- and caregiver-rated SS would provide valuable information regarding the consistencies and differences in multi-informant reporting of SS. Cronbach’s alpha for child- and
primary caregiver-rated SS were 0.82 and 0.62, respectively.
Procedure
Children living in the residential facility were administered the above measures and other
instruments not germane to this investigation 3–6 months after they were admitted. For the
purposes of this study, all files collected between 1996 and 2011 in the archives of the
residential facility were examined. The CBCL was completed utilizing a primary caregiver
model in which the child’s ‘‘house parent’’ filled out the measure.
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Analytic Plan
Independent samples t-tests were used to examine group differences on child-rated and
caregiver-rated SS as a function of gender and type of trauma (presence/absence of
physical abuse, emotional abuse, sexual abuse, neglect, abandonment, and witnessing of
domestic violence was used because children may have experienced multiple abuse types).
Pearson correlations were used to examine associations between child- and caregiver-rated
SS, as well as relationships between SS and age at assessment, time in years since removal
from home, TSCC anxiety, depression, posttraumatic stress, anger and dissociation subscales, and CDI total score.
Mediational analyses addressed whether anxiety as measured by the TSCC mediated the
relationship between abuse type and SS. This analysis was first completed with the childrated composite measure of SS as the outcome and second with the caregiver-rated
measure of SS as the outcome. Using the bootstrapping mediation method, the provided
sample was resampled k = 5,000 times generating a 95% confidence interval. Bootstrapping involves the repeated random resampling from the data with replacement, which
yields an estimation of the indirect effect of the mediator. Replacement allows for a new
sample of size n to be determined by sampling cases from the original sample. The
criterion for mediation was the exclusion of zero between the lower and upper bound of the
confidence interval. If zero was not present it indicated that the indirect effect of the
mediator on the outcome was not zero with 95% confidence [33].
Results
Clinical Characteristics
Rates of SS were high with 95.2% of children endorsing at least one SS on the child-rated
measure and 80.7% experiencing at least one SS as indicated by the caregiver-rated
measure. Independent samples t-tests revealed a significant group difference on child-rated
SS between children who had experienced sexual abuse as compared to those who had not
(t(159) = 2.69, p \ 0.01). No group difference was noted for presence/absence of sexual
abuse on caregiver-rated SS. No group differences were found for children with the
presence/absence of physical abuse, emotional abuse, neglect, abandonment or witnessing
of domestic violence.
Independent samples t-tests revealed gender differences on total scores for the childrated measure of SS (t(159) = 2.20, p \ 0.05; d = 0.35), but not for the caregiver-rated
measure of SS (t(159) = 0.67, p = 0.50; d = 0.10). Additionally, on the child-rated
measure of SS, gender differences were found for individual items including dizziness
(t(159) = 2.67, p \ 0.01; d = 0.41) and feeling sick to the stomach (t(159) = 2.38,
p \ 0.05; d = 0.38), with females endorsing higher rates of both symptoms as compared to
males (Table 1). On the caregiver-rated measure of SS, gender differences were noted for
individual items including restlessness (t(159) = - 2.48, p \ 0.05; d = 0.40), dizziness
(t(159) = 2.05, p \ 0.05; d = 0.31), nausea (t(159) = 2.05, p \ 0.05; d = 0.30), stomachaches (t(159) = 2.50, p \ 0.05; d = 0.38), and vomiting (t(159) = 2.28, p \ 0.05;
d = 0.34), with males experiencing higher rates of restlessness and females exhibiting
higher rates of dizziness and gastrointestinal symptoms (Table 2).
Pearson correlations revealed that age at assessment was negatively correlated with
child-rated SS (r = - 0.21, p \ 0.01) but positively correlated with caregiver-rated SS
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Table 1 Child-rated means (standard deviations) for individual SSs by gender
Somatic symptom
Female (n = 72)
Male (n = 89)
Total (N = 161)
Cohen’s d
Tense
0.97 (1.06)
0.87 (.88)
0.92 (0.97)
0.10
Short of breath
1.03 (1.14)
0.75 (1.06)
0.88 (1.09)
0.25
Shaky
1.15 (1.15)
0.91 (1.04)
1.01 (1.08)
0.22
Dizzy
1.26 (1.21)**
0.79 (1.06)**
0.98 (1.14)
0.41
Jumpy
1.63 (1.20)
1.35 (1.30)
1.46 (1.25)
0.22
Chest pains
0.88 (1.06)
0.88 (1.08)
0.86 (1.06)
0.00
Feel strange
0.72 (1.04)
0.61 (0.92)
0.65 (0.97)
0.11
Heart racing
0.97 (1.15)
0.75 (1.07)
0.85 (1.11)
0.20
Restless
1.24 (1.13)
0.97 (1.14)
1.08 (1.15)
0.24
Sick to stomach
1.25 (1.12)*
0.85 (0.98)*
1.02 (1.06)
0.38
Hands shake
1.10 (1.18)
0.88 (1.16)
0.95 (1.16)
0.19
Sweaty
1.08 (1.15)
1.05 (1.08)
1.06 (1.10)
0.03
13.28 (8.00)*
10.65 (7.16)*
11.72 (7.60)
0.35
Index
Child reported somatic symptoms are from the MASC (response scale = 0, 1, 2, or 3). Differences based on
gender were tested with independent samples t tests
* p \ 0.05; ** p \ 0.01
Table 2 Primary caregiver-rated means (standard deviations) by child gender
Somatic symptom
Female (n = 72)
Male (n = 89)
Total (N = 161)
Cohen’s d
Restless
0.76 (.76)*
1.07 (0.78)*
0.93 (0.79)
0.40
Dizzy
0.10 (0.34)*
0.02 (0.12)*
0.05 (0.24)
0.31
Overtired
0.31 (0.66)
0.16 (0.42)
0.22 (0.55)
0.27
Aches and pains
0.14 (0.39)
0.09 (0.29)
0.11 (0.33)
0.15
Headaches
0.17 (0.41)
0.17 (0.38)
0.17 (0.39)
0.00
Nausea
0.15 (0.36)*
0.06 (0.23)*
0.10 (0.30)
0.30
Stomachaches
0.22 (0.45)*
0.08 (0.27)*
0.14 (0.37)
0.38
Vomiting
0.11 (0.40)*
0.01 (0.11)*
0.06 (0.28)
0.34
Underactive
0.28 (0.59)
0.26 (0.51)
0.26 (0.53)
0.04
Index
1.93 (2.17)
1.75 (1.21)
1.83 (1.70)
0.10
Primary caregiver-reported somatic symptoms are from the CBCL (response scale = 0, 1, or 2). Differences
based on gender were tested with independent samples t tests
* p \ 0.05
(r = 0.17, p \ 0.05). Child-rated SS were positively correlated with CDI total score
(r = 0.50, p \ 0.01) and the TSCC subscales of anxiety (r = 0.57, p \ 0.01), depression
(r = 0.62, p \ 0.01), posttraumatic stress (r = 0.56, p \ 0.01), dissociation (r = 0.59,
p \ 0.01) and anger (r = 0.40, p \ 0.01). No further significant correlations with the CDI
total score or TSCC subscales were found with the caregiver-rated SS measure (Table 3).
Mediational Analyses
Two mediational analyses were conducted in which the independent variable was sexual
abuse (presence/absence), the mediating variable was the TSCC anxiety subscale, and the
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Table 3 Correlations for somatic symptoms, demographic and clinical characteristics
1
1. Child-rated SS
–
2. Caregiver-rated SS
2
0.05
–
3. Time since removal
3
4
0.03
-0.06
–
4. Age
5
0.17*
-0.21**
6
7
8
9
10
0.06
0.06
0.07
0.09
0.12
0.50**
0.57**
0.62**
0.56**
0.59**
-0.15
-0.21**
-0.21**
-0.16*
-0.09
-0.06
–
-0.23**
-0.18*
-0.22**
-0.09
-0.15
-0.10
–
6. TSCC anxiety
0.47**
0.65**
0.49**
0.58**
0.50**
–
0.74**
0.82**
0.75**
0.52**
–
0.67**
0.73**
0.64**
–
0.72**
0.54**
–
0.62**
7. TSCC depression
8. TSCC PTS
9. TSCC dissociation
–
11.82
1.83
6.36
10.89
10.07
51.64
49.80
52.14
53.23
50.23
7.64
1.71
4.03
2.23
7.00
14.14
11.69
11.92
12.99
11.17
Child-rated SS somatic items from the Multidimensional Anxiety Scale for Children, Caregiver-rated SS somatic items from the Child Behavior Checklist, CDI total score
Children’s Depression Inventory total raw score, TSCC anxiety Trauma Symptom Checklist for Children anxiety subscale, TSCC depression Trauma Symptom Checklist for
Children depression subscale, TSCC PTS Trauma Symptom Checklist for Children posttraumatic stress subscale, TSCC dissociation Trauma Symptom Checklist for Children
dissociation subscale, TSCC anger Trauma Symptom Checklist for Children anger subscale
* p \ 0.05; ** p \ 0.01
Child Psychiatry Hum Dev (2012) 43:661–673
10. TSCC anger
SD
0.40**
0.38**
5. CDI total score
Mean
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dependent variable was either child- or caregiver-rated SS. Bootstrapping confidence
intervals revealed that the TSCC anxiety subscale mediated the relationship between
sexual abuse and child-rated SS (-1.81; 95% CI -3.64 to -0.37) but did not for caregiverrated SS (-0.03; 95% CI -0.24 to 0.06). The mediation model accounted for 33% of the
variance in child-reported SS, but only 0.96% of the variance in caregiver-reported SS.
Discussion
Overall, the present findings reflect on the frequency and characteristics of SS in traumatized children. Specifically, most youth in this sample (95.2%) self-reported at least one
SS and over 80% of caregivers reported that children experienced at least one SS. Over
55% of youth endorsed feeling tense/uptight, jumpy, sick to their stomach, and/or having
sweaty hands. These findings must be interpreted with caution as no measure of lie
detection was utilized to ensure that children and caregivers were accurately reporting the
presence of SS. Clinical characteristics of SS revealed significant gender differences on
child-reported total SS. Of note, dizziness and gastrointestinal symptoms were reported
more often in females relative to males on both child-reported and caregiver-reported
measures of SS. This difference may be indicative of a physiological sensitivity of anxious
females over males to experience and express dizziness and gastrointestinal distress, which
has been found by others [17]. It is also possible that girls are more willing to express,
whether through child-report or to caregivers, that they are experiencing SS [34]. Caregiver-reports of SS indicated that males experienced higher rates of restlessness as compared to females. This specific SS may reflect on males’ trauma-related coping techniques
as well as males’ tendency towards heightened externalizing symptoms after trauma
exposure [35]. Interestingly, no significant gender difference was noted for total caregiverrated SS, highlighting a possible and essential difference between self- and caregiverreported measures for SS. This finding may be reflective of a shared posttraumatic experience across genders, indicating that males and females may appear quite similar in terms
of physiological responses to traumatic events. Additionally, this finding—and the modest
difference in rates of SS reported between children and non-parent caregivers—may be due
to children not reporting SS to caregivers, adult respondents not being aware of such
symptoms, and/or that children are more accurate reporters of internalizing symptoms
relative to caregivers [36].
Consistent with findings of high prevalence of SS in youth following sexual abuse [18],
differences were noted when comparing child-reported SS in children who had or had not
experienced sexual abuse. One explanation for the high rates of SS in children who have
experienced sexual abuse involves the experience of a heightened sense of health anxiety
[9]. This concept reflects on trait anxiety sensitivity theory in that the fear of negative
sensations associated with anxiety result in a heightened awareness of arousal symptoms.
In turn, health anxiety related to these arousal symptoms may increase stress-related
physiological reactions, yielding even more SS. No differences were noted when comparing the presence/absence of physical abuse, emotional abuse, neglect, abandonment or
witnessing of domestic violence on child-reported or caregiver-reported SS; additionally,
no group differences were noted for sexual abuse presence/absence and caregiver-reported
SS. These findings may reflect on a variation in symptom cluster experiencing for children
following various types of trauma. Specifically, children who have experienced neglect and
non-sexual abuse may experience high rates of re-experiencing and avoidance symptoms
and lower rates of hyperarousal symptoms, thereby not relating to an increase in SS.
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Correlational findings highlight other factors related to SS in traumatized children.
Interestingly, opposite effects, albeit both modest in magnitude, were noted for age at
assessment and child-reported versus caregiver-reported SS. On the child-reported measure
of SS, age was negatively correlated with rates of SS, yet on the caregiver-report measure
of SS age was positively correlated with rates of SS. Younger children may be more likely
to honestly report symptoms that may be embarrassing or private, such as having gastrointestinal distress. Alternatively, caregivers may be better attuned to older children’s SS
as older youth may refrain from activities due to the experience of SS.
The discrepancy between child- and non-parent caregiver-reported SS as indicated by
many study findings may be explained in several ways. First, caregivers may not be
accurate reporters of internalizing symptoms in children and adolescents relative to the
youngster him/herself [36]. Second, children may be reluctant to express complaints of SS
to caregivers, especially in a sample of abused children who may not have trusting relationships with adults and who may not have formed close relationships with their relatively
new and temporary caregivers [37]. Third, the limited findings for caregiver-rated SS may
reflect the low internal consistency of the caregiver-rated measure. Finally, caregivers may
be attuned to behaviors and symptoms such as aggression that warrant immediate interventions to keep children safe in their residential settings. This in turn, may interfere with
caregivers’ ability to recognize or attend to symptomatic expressions of trauma (e.g., SS,
anxiety, sadness) that do not cause significant disruption to the home environment.
Large direct associations were noted between child-rated SS and the CDI total score, the
TSCC anxiety subscale, the TSCC depression subscale, the TSCC posttraumatic stress
subscale, the TSCC dissociation subscale and the TSCC anger subscale. These relationships may be understood in several ways. First, anxiety and depressive symptoms in
traumatized youth may also manifest themselves as SS. Indeed, diagnostic criteria for
anxiety and depressive disorders include robust somatic domains such as symptoms related
to sleep, appetite, restlessness, and muscle tension. Therefore, children who are experiencing significant anxiety and depression posttrauma may exhibit high rates of SS. These
findings raise the question of whether SS change as a function of treatment for anxiety,
depression and posttraumatic stress with some evidence for reductions in SS with psychopharmacological (i.e., selective serotonin reuptake inhibitors; SSRIs) or psychotherapeutic (i.e., cognitive-behavioral therapy; CBT) interventions [16, 17]. Second, consistent
with previous research, symptoms of dissociation following trauma are highly associated
with SS [38–41]. Third, it is possible that relations are a product of shared method or
source variance. No significant correlations were noted between clinical characteristics and
caregiver-rated SS. This finding may highlight children’s ability to report more accurately
on internalizing symptoms relative to caregivers [36] and/or that children may not be
reporting SS or anxiety and depression to their non-parent caregivers.
Mediation analyses found that child reported anxiety mediated the relationship between
sexual abuse and child-rated SS, but not caregiver-rated SS. Of note, this finding highlights
the role of anxiety in the presence of SS and provides further evidence for the concept of
trait anxiety sensitivity as an essential aspect in the experience of SS following trauma.
This mediational model may suggest that the experience of sexual abuse relates to
heightened health-anxiety (or the fear of consequences related to SS) as children become
more attuned to symptoms of hyperarousal; this in turn predisposes the child to higher rates
of SS. It is important to fully understand the route of expression of SS in children to tailor
interventions to address these symptoms. Treatments aimed at the amelioration of posttraumatic symptomology must factor in the essential role of anxiety in the expression of
SS. For example, cognitive-behavioral therapeutic approaches that focus on addressing
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671
traumatic anxiety may also work to reduce SS. Additionally, healthcare providers should
be aware of the potential presence of SS following traumatic events in childhood. An
awareness and attention to SS in traumatized children may: 1), allow for the proper
treatment of posttraumatic physiological sequelae and 2), prevent children from undergoing invasive and unnecessary medical testing. Additionally, implications regarding
discrepancies presented in health care settings must be considered by health care professionals. It is evident that differences between self- and caregiver- reports are prevalent,
pointing to the importance of utilizing a multi-modal and multi-informant approach to
understanding somatic symptoms in traumatized youth. Additionally, a multi-informant
assessment of somatic symptoms may yield a more accurate clinical picture and allow for
the application of appropriate interventions. Ultimately, SS are highly prevalent in children
following traumatic events and reflect a need for tailored treatments aimed at the attenuation of SS.
Limitations
This study is not without limitations. First, we utilized unstandardized child- and caregiverreport measures of SS derived from standardized measures of behavior and anxiety in
children. Second, it was not possible to ascertain whether children had organic physical
problems that may cause rates of SS to occur. Third, certain SS were not measured by both
child- and caregiver-reported measures of SS. Forth, no measure of lie detection was
utilized and therefore complete validation of self- and caregiver- reported somatic
symptoms is not possible. Findings must therefore be interpreted with caution. Finally,
children’s history of abuse was based on documented cases only. In the child welfare
system, children are exposed to myriad of traumatic events, and it is therefore impossible
to determine additional undocumented traumas. Within these limitations, this study contributes to the literature by examining SS in a large, diverse sample of children who had
been exposed to varied traumas.
Summary
Childhood exposure to trauma has been associated with increased rates SS, which may
contribute to diminished daily functioning. Trait anxiety theory posits that children who
exhibit high anxiety sensitivity may fear the negative sensations associated with anxiety
and therefore be more highly attuned to arousal symptoms. One hundred and sixty-one
children residing at a residential treatment group home who had experienced neglect,
abandonment, physical, emotional, and/or sexual abuse were administered the TSCC, the
MASC, and the CDI shortly after their admission. Primary caregivers (i.e., direct care staff
in the children’s cottages) completed the CBCL. Two composite measures of SS were
formed to represent both child- and caregiver-rated SS. The child-rated measure was
derived by summing the 12 MASC items that assessed SS, and the primary caregiver-rated
measure was compiled by summing the 9 CBCL items that addressed SS. Over 95% of
children endorsed at least one SS on the child-rated measure. Children who had experienced sexual abuse had higher rates of SS relative to children who had not. Gender
differences were found for overall child-rated SS, as well as for individual SS on both the
child- and caregiver-rated measures. Child-rated SS were highly correlated with the CDI
total score and the TSCC subscales of anxiety, depression, posttraumatic stress,
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dissociation, and anger. The TSCC anxiety subscale mediated the relationship between
sexual abuse and child-rated SS. These findings highlight the prevalence of SS following
childhood trauma, as well as demographic and clinical characteristics related to SS.
Identifying SS following childhood trauma is essential to understanding a complete clinical
picture of posttraumatic reactions. Additionally, treatments previously focused on solely
psychological outcomes of trauma should take into account the distress and impairment
related to SS.
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