Somatic complaints (SCs) are body-related perceptions with subjectively experienced unpleasant qualities.1,2 Twenty-five percent of children seen at the paediatrician's office have physical symptoms that are better explained as psychosomatic manifestations rather than medical conditions.3 Epidemiology studies show an increase in the prevalence of SCs, with 5–30% of children 8–16 years of age affected by them.3,6,7 Some studies identify stomachache as the most common SC, with a prevalence that ranges between 8% and 25% of schoolchildren,8 while others reported fatigue (12.1%)1 or headache (58.5%) as the most prevalent.9,10 When we consider sex and age, the prevalence of SCs is higher in girls than in boys,1,8,10,11 and in early childhood and early adolescence.12

In the absence of identifiable organic causes, there is growing interest in the processes at play in psychosocial factors.2,5,10–14 This study analysed two possible factors: emotional functioning as manifested by emotion awareness, and the maladjustment of the child in various settings.

The association between emotional functioning and SCs2,15,16 suggests that alexithymia, a limited ability to identify and express emotions, is the main characteristic of individuals with SCs.17,18 There is evidence of this association in the paediatric population,13,19 as it has been observed that an inability to differentiate emotions and a strong bodily awareness in the course of experiencing emotion are predictors for SCs.13,20 Van der Veek et al2 noted that children with poor emotional awareness have difficulty recognising the emotions they experience and coping effectively with them. The use of maladaptive coping strategies leads to an increase in somatisation in response to the unresolved emotional conflict.21

Recurrent SCs can lead to psychosocial impairment and have a negative impact on the child's family life, ability to concentrate, cognitive development and academic achievement.4,9,16,21,22 Furthermore, children with SCs have poorer school attendance, participate less in extracurricular activities, and have poorer interpersonal relationships.4,5,9,10,22 Vila et al22 observed that 47% of children with SCs had difficulty concentrating, 30% missed school, and 24% spent time with friends less frequently. The presence of SCs as a result of personal maladjustment and social problems has also been studied. In this regard, conflict with peers or in the family environment leads to negative moods that in turn increase the likelihood of SCs.6,15,23,24

In conclusion, SCs are common in childhood, yet there is little research on the subject.25 There is evidence that the aetiology of SCs involves psychosocial factors in addition to medical factors. This underscores the importance of knowing the variables that may influence SCs in order to develop effective interventions.

In this context, we established three objectives: (1) to analyse the prevalence of SCs; (2) to explore the relationship between the variables under study; and (3) to identify predictor for SCs. Based on the findings of previous studies, we formulated the following hypotheses: (1) the prevalence of SCs is between 5% and 30%, and the most prevalent complaints are headache and stomachache; (2) SCs correlates negatively to emotional awareness variables and positively to maladjustment variables; and (3) the variables that can predict SCs are differentiating emotions, verbal sharing of emotions, bodily awareness and social maladjustment.

This study was approved by the ethics committee of the Conselleria d’Educació de la Comunitat Valenciana (Education Department of the Autonomous Community of Valencia), adhering to the principles of the Declaration of Helsinki and the current law. Self-administered questionnaires were given out by teachers to entire classes of students during school hours in two sessions of 45min each.

Our objectives were to analyse the prevalence of SCs, explore their relationship with emotional awareness and maladjustment, and identify predictor variables. The results showed differences between sexes and age groups, but these variables were not included in subsequent analyses due to their small effect size. The results we obtained were not consistent with the existing literature,9,10 as girls only scored higher than boys in having a headache and feeling nauseated. When it came to age, we observed an inverse correlation with SCs, rather than the increase in frequency described in the previous literature,1,9,12 and we also did not find a greater prevalence of headache in older children.

Based on our initial hypotheses, we expected the prevalence of SCs to be between 5% and 30%.3,6 Only 9.8% of participants reported being free from SCs, which means that 90.2% had experienced some type of pain in the past few weeks. And while 22.3% of participants reported a single SC, this was not the usual pattern, as 67.9% of participants reported having two or more. In this sense, our results showed a greater prevalence of SCs in childhood,4,5 and were alarming due to the high rates reported and the sample not being a clinical but a community sample. The data showed similar prevalences of headache and stomachache (45.7% and 43.7%, respectively), which were the most prevalent SCs in the literature we reviewed.8,9 However, the most prevalent SC was tiredness (81.3%), similar to the fatigue reported by Barkmann et al.1 When we consider the pace of life in current society, it makes sense for children to feel tired, as it is difficult to balance work and family life. The daily routine includes the school day and coordinating the parents’ work schedules with homework and extracurricular activities (foreign language study, music, sports). This situation results in longer days, delayed bedtimes, and a reduction in the hours of sleep. The high prevalence we observed may also be due to characteristics of our sample or to the self-reporting nature of the instruments used in our assessment. However, the fact that these self-reporting tools have been used in the past and that the observed results are consistent with the literature supports this hypothesis.

Our second hypothesis stated that SCs would be negatively correlated with emotional awareness variables and positively correlated to maladjustment variables. On this point, as expected, SCs were negatively correlated to the differentiating emotions, verbal sharing of emotions, not hiding emotions, and attending to others’ emotional variables.2,15,21 We would like to underscore the positive correlation between SCs and bodily awareness. Similar to previous studies that used the EAQ2,21 and with the purpose of making a homogeneous interpretation of the analyses of every aspect of emotional awareness, we computed the score of the bodily awareness subscale without reversing the items. The results seem confusing, as being aware of the physical sensations that accompany emotions should be a good thing, but it is associated to SCs. However, they are similar to results obtained in previous studies,13,14 in which children that were more aware of the relationship between bodily sensations and emotions reported more somatic symptoms. One possible explanation is that these children are very aware of their sensations and are therefore more nervous, manifesting anxiety through SCs. On the other hand, the correlation between SCs and personal, social, family and school maladjustment was positive.4–6,9,10,16,21 We ought to note that the positive correlation between SCs and personal maladjustment was the highest we found in our results. This is relevant given how little evidence is available on the association of these variables, although there are studies that analyse the association of SCs with maladjustment and social, school, and family problems.4,6,9,16,23,24 Previous studies may have underestimated the importance of intrapersonal variables in favour of interpersonal variables due to the difficulties inherent in evaluating the former.

Our third hypothesis stated that aspects of emotion awareness associated with alexithymia would contribute most to explaining SCs 2,13 along with social maladjustment.4,16,23 Yet, the variable that explained the greatest amount of variance was personal maladjustment; while the other variables contributed less to it. As we noted above, few studies have analysed the association between SCs and personal maladjustment, although SCs have been associated with variables like self-esteem, quality of life, wellbeing, mood, and adjustment.2,4–6,9,15 The personal maladjustment scale of the TAMAI refers to the adjustment and balance of the individual with him or herself; it is a complex construct, but it can be used to observe the relevance of the child's inner life in his or her physical wellbeing. Considering our results, the study of personal aspects is important to understand what is happening to the child, how it is affecting him or her, and the ensuing consequences. From an early age, children have personal feelings and thoughts about what is happening in their environment, and it is important that we understand how they function at a personal level and how they face everyday conflicts. Thus, the more effective their coping mechanisms, the better their adjustment is, and the lesser their health and social problems.

One of the main limitations of our study is the exclusive use of self-reporting tools, although from 8 years of age children start having direct knowledge of their thoughts and feelings, and their answers can be reliable.29 It is also worth noting that the effect size was small in every case; however, we did observe significant differences, so we must consider what these results are pointing at, and explore it more thoroughly in future research. Lastly, it would be interesting to include different informants, like parents, paediatricians and teachers, to gain a broader understanding of the issue and its scope.

To conclude, the prevalence of SCs in children 10–12 years of age (community sample) was high, as 90.2% of participants reported having at least one SC. Furthermore, emotional awareness was important in explaining SCs, although the variable that contributed most to the presence of SCs was personal maladjustment. Thus, focusing exclusively on the association between emotional awareness and SCs is an oversimplified approach to the issue, as SCs are not only the result of poor emotional regulation through the day, but a physical response of the body to personal problems and conflicts.

Our study is relevant in that it contributes a new perspective to the understanding of SCs. Childhood is a developmental stage in which there is considerable physical pain requiring more attention.10,27 Collective interventions implemented in schools27 for the development of emotional skills and coping strategies may contribute to wellbeing, reducing the prevalence of SCs, the use of primary care healthcare services, and parental absences from work.

This study has been funded by:

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  The Ministerio de Ciencia e Innovación (Ministry of Science and Innovation, project PSI2010-18742).

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  The Consellería d’Educació de la Generalitat Valenciana (Department of Education of the Autonomous Community of Valencia, PROMETEO/2011/009).

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  The Universitat de València (Atracció de Talent fellowship for predoctoral researchers).

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  Departamento de Educación, Política Lingüística y Cultura (Department of Education, Political Linguistics and Culture) of the Autonomous Community of the Basque Country (IT638-13).

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  The Unidad de Formación e Investigación (Department of Training and Investigation) of the Universidad del País Vasco (UFIPSIXXI-11/04).

The authors have no conflicts of interest to declare.