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Case Example
A 16-year-old female presents for outpatient evaluation due to intractable migraine. Over the course of the last 5 months, she has had 12 emergency room visits for management of her headache, 6 of which have resulted in inpatient admission. Extensive neurological work up, including imaging and lum- bar puncture have been negative. She is on topiramate, aten- olol, and amitriptyline for headache prophylaxis and sumatrip- tan for abortive treatment. The patient endorses decreased en- ergy and difficulty falling asleep. She reports she frequently feels irritable and anxious at home, at school, or when visiting friends. Parents report she is often irritable and can become highly argumentative and verbally aggressive when trying to get her to school or setting limits. Past medical history is significant for history of recurrent abdominal pain between ages 8 and 12 years old and chronic daily headache. Birth and developmental history is unremarkable.
She was previously diagnosed with oppositional defiant disorder and school avoidance several years ago. Family underwent two courses of parent management training and family therapy with some reported success. The patient has been resistant to attending psychotherapy as she reports wors- ening headaches and not wanting to leave the house. Family history is significant for generalized anxiety and post- traumatic stress disorder in mother, who is currently physical- ly disabled. Father recently suffered a stroke and was forced to

retire after a 30-year successful career as a surgeon. An older brother has a history of oppositional defiant disorder and pos- tural orthostatic tachycardia syndrome. The patient currently lives with her biological mother and father in a suburban com- munity. She denies a history of physical or sexual abuse. She attends the 10th grade and denies bullying. She has missed considerable school due to headaches and school refusal. As a result, her academic performance is declining.
The patients headaches have progressed to the point where she is requesting to participate in cyber school. There is often high expressed emotion in the home related to argumentation between the patient and parents about her headache. The par- ents are frustrated and state no one has been able to give us any answers about our daughters headache, we feel like we are losing her....
Introduction
The case presentation above highlights some of the common themes seen in pediatric somatization and somatic symptom disorder (SSD). Somatization is common and occurs when a patients subjective report of a physical symptom or symp- toms is inconsistent with clear physical illness or etiology and results in functional impairment [1, 2]. Somatization lies along a spectrum of severity and can manifest in different ways depending on patient development [2]. Often, somatic symptoms are transient and resolve with minimal intervention [3]. However, somatization can persist, particularly when predisposing or perpetuating factors influence continued symptom presentation. Somatization can occur in the setting of physical illness, mental illness, or independently [1]. The prevalence of somatization in primary care pediatric settings has been estimated to be 2550% of visits, although data on prevalence is limited, particularly in non-primary care settings [6, 1921]. Abdominal pain and headache are the most com- mon presenting symptoms, followed by back pain, limb pain, other neurologic symptoms, and fatigue [2, 6, 7, 18, 21].
Somatization frequently results in a change in lifestyle, increased physician visits and/or increased medication use [1, 3, 46, 7, 8]. Presentations are similar across settings although medically hospitalized patients often have increased symptom quantity and severity [7, 8]. Somatization accounts for 1520% of yearly healthcare expenditures in the United States [5, 9]. This includes frequent emergency room visits, hospitalizations, excess diagnostic evaluation, and invasive procedures [2, 9, 10]. Somatization itself results in significant disability even when accounting for comorbid psychopathol- ogy, individual health factors, and demographics [11]. Similar frequencies of somatization exist regardless of region, coun- try, or culture [6].
Somatization can be a normative part of development and coping. Somatization becomes a disorder when it is impairing
and meets specific criteria outlined by the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (Table 1) [12]. By definition, SSD develops as a result of somatization that is either disproportionate to or incongruent with clinical findings. The diagnosis of SSD does not require identification of additional comorbid psychopathology, or the identification of a particular stressor or triggering event [12, 13]. SSD can also occur in the presence of a known physical health condition
Individual, family, cultural, and environmental factors can significantly influence symptom presentation. Patients and their families are often frustrated by a lack of a conceptual framework to understand symptomatology. Caregivers may be heavily invested in identifying something serious or something being missed [14]. Caregiver anxiety about their childs decline in function can significantly influence care and management including increased demands for testing and in- tervention. Patients and families can feel dismissed, unheard, and devalued. Furthermore, patients may receive implicit or explicit messages that their symptoms are all in my head, which can disrupt the patient-clinician relationship so crucial to managing SSD [2].
Patients with SSD tend to present to medical rather than mental healthcare settings. Primary care providers (PCPs) are at the frontline of the assessment and management of SSD. Barriers to collaboration between PCPs and mental health clinicians, as well as inadequate training in SSD, often results in poor recognition, and missed opportunities for early inter- vention and standardization of care, and at times unnecessary invasive interventions [3, 7, 10, 14]. Often it is only after repeated emergency room visits, hospitalizations, consulta- tions, and investigations that SSD is considered [3, 7].
Currently, there is a significant mismatch between patient needs and the systems of care servicing patients with SSD [2]. PCPs and mental health clinicians are frequently frustrated due to a lack of knowledge and skills to address SSD [9, 10, 15]. Providers can become dismissive, avoidant, or anxious about missing something or alienating the patient and fam- ily. This can foster the unintended perception of the patient or family as being needy and not really sick [2, 7, 10, 14, 1517]. Without a clear roadmap for evaluation and manage- ment, conflict occurs with either care strategies that may per- petuate the cycle of disability, mistrust, frustration, and soma- tization or the dissolution of the therapeutic relationship [2].
Risk Factors
Youth with SSD have been shown to have a variety of biopsychosocial risk factors that are key for successful identi- fication, evaluation, and management. Below we review sev- eral risk factors that are important in the assessment and care of youth with SSD.

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Childhood Temperament and Coping Style
There is evidence suggesting that a childs temperament in the first year of life predicts somatization later in life [20]. Coping behaviors affect emotional regulation and adjustment to stress. Children with heightened somatic complaints use fewer and lesser effective coping strategies [6, 10]. Youth with SSD have been described as insecure, internalizing, perfectionistic, and conscientious [1, 6, 10]. Patients with an internalizing coping
styles struggle with expressing emotion and often channel their emotional distress through physical symptoms. [7] This can occur either due to an acute event or stressor or a learned pattern of coping with chronic stress or life events. Patients often avoid negative effect due to internal discomfort or other familial, cultural, or societal pressures to dampen expression of negative effect [21].
Children who are high achieving or have perfectionistic traits may find subconscious relief from assuming the sick role [21]. In this way, the patient may be able to receive respite from the high demands of the home and academics without resulting in distressing effect, behavioral disturbance, or con- flict [21]. Other patients may exhibit a shy temperament, pes- simistic worry, or passive/avoidant coping style with in- creased risk of developing SSD and associated disability [14, 22].
Sex and Age
Younger children and females tend to be at higher risk for somatization [2, 7]. Rates are equal between genders until puberty, when girls appear to have increased rates of somati- zation [23, 24]. Girls may be at higher risk due to more inter- nalizing or ruminative coping styles compared with boys, who tend to utilize more externalizing behaviors [25]. There is little existing data on the role of sexuality on SSD, and this is an area of needed future research.
Cognitive and Learning Difficulties
Children who lack the intellectual ability, social capacity, or emotional language to process severe or ongoing stress are at increased risk of SSD. Cognitive impairments and low aca- demic performance are associated with a higher predisposition for SSD in adolescents, particularly in those who perceive high parental expectations [26]. Recent studies suggest that youth with functional neurological disorders scored lower on full scale IQ, vocabulary, and mathematics testing and had more learning difficulties compared with their siblings [27, 28]. They also performed poorly on attention, executive func- tion, and memory domains than healthy controls [27, 28].
Childhood Physical Illness
A childs past history of physical illness and treatment, togeth- er with current, fearful misinterpretation of physical sensa- tions are related to an increased risk of developing SSD [14]. An illness trigger may set off a cascade of symptoms and lead to prolonged recovery or symptom recurrence after illness resolves. This may be partly due to a conditioned phys- iologic response to past physical disease. Parental catastrophizing and/or overprotection in response to a childs physical symptoms can reinforce somatization and perpetuate

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SSD [3, 29, 30]. Past healthcare use is also a strong predictor of future healthcare use due to SSD, including utilization re- lated to other non-SSD-related physical conditions [3]. As the number and severity of somatic symptoms increase, the like- lihood of developing SSD, seeking care, being hospitalized, and having persistent symptoms also increases [3].
Family Medical and Psychiatric History
Higher rates of physical disease have been demonstrated in the families of children with SSD [31]. In particular, children who are living with a mother with chronic illness or functional symptoms are at greater risk of developing SSD [32]. This can be partly due to genetic predisposition [32]. In addition, social learning theories propose that vulnerable youth may respond to a family model of illness, particularly in the context of certain family health beliefs and practices, familial coping styles, difficulty managing symptoms, and/or sick role behav- iors [30].
Studies also show familial links between SSD and familial psychopathology. Specifically, rates of anxiety and depression are higher in family members of youth with SSD [31]. Parental substance use disorders have been identified as a predictor of somatization in their offspring, with SSD cluster- ing in families with alcoholism [33, 34].
Childhood Psychiatric Disorders
Emotions such as worry, sadness, or fear can significantly influence the processing of physical symptoms and contribute to the development of SSD. Studies comparing youth with SSD to healthy controls demonstrated significantly higher rates of anxiety and depressive disorders in youth with SSD [7, 24, 35, 36]. Growing literature suggests that this is not solely a consequence of having SSD, but that the relationship is bidirectional.
Other Biological Factors
Biological vulnerabilities described in patients with SSD in- clude an overactive sympathetic nervous system, hypersensi- tivity to pain, abnormal modulation of sensory transmissions, altered cortical perceptions, smaller amygdala volumes, and white matter deficiencies [4, 37]. Impairments in brain struc- tures involved in pain registration, perception, and modula- tion, such as the cingulum, have been demonstrated [4, 38]. Individuals who exhibit hypersensitivity to sensory stimuli are more likely to exhibit somatization,and show increased acti- vation of the prefrontal, anterior cingulate gyrus, insula, and somatosensory cortices [39]. Additionally, reduced glycemic metabolism in the basal ganglia has been associated with se- vere somatization [40]. Our emerging understanding of the neurobiology of SSD shows that certain patients are more
susceptible to somatization and that somatization may influ- ence neurobiology in tangible ways. For example, patients with underlying anxiety, chronic stress, or trauma may be biologically primed to be hypersensitive to somatic stimuli related to the physiologic response to stressors. This primed or conditioned response may then strengthen these underlying neurophysiologic processes that result in somatization.
Life Adversities
Environmental factors play a significant role in the develop- ment of pediatric SSD. Negative life events have been shown to predict SSD in older adolescents [41]. Youth with somati- zation report significantly more life adversities than their sib- lings [30]. Common school stressors include beginning of the school year, transitioning to a new grade, and declining grades [42]. High familial expectations and its effects on patient per- ceptions of academic, athletic, and extracurricular perfor- mance can significantly impact vulnerability to somatization [7]. Bullying has been identified as a major risk factor for the development of SSD in youth [42, 43]. In the home setting, experiences can include frequent family conflicts, family en- meshment, and major life events such as loss or parental di- vorce. Children are highly attuned to the physical and emo- tional well being of those close to them, and the emotional distress of a family member can contribute to the somatization.
Childhood trauma (e.g., sexual abuse, physical abuse, emo- tional abuse, neglect) has long been considered important in the development of SSD. In addition to interpersonal trauma, other environmental events like earthquakes and terrorist at- tacks have been associated with an increased somatization in youth [44, 45]. Compared to the adult literature, however, trauma is not as frequently endorsed in pediatric SSD [1]. Rates of traumatic experiences in youth with SSD are nearly 30% and similar to the general population [1]. Nevertheless, when trauma is present in pediatric patients with SSD it sig- nificantly modulates the patients clinical course with poorer outcomes. Specifically, youth with trauma and SSD tend to have more psychiatric comorbidity, more extensive psychiat- ric treatment history, greater familial mental health history, and increased familial conflict [1]. Youth with trauma and SSD who are medically hospitalized due to their symptoms have higher rates of inpatient psychiatric hospitalization fol- lowing medical discharge, at times at a rate of three times higher than SSD patients without a trauma history [1] Several considerations may influence the greater impairment seen in pediatric patients with SSD and trauma. Trauma in- duces a state of hyperarousal and heightened awareness of bodily function, which can result in dissociation [46]. Dissociation results in poor insight into physical experiences making it more challenging to engage patients in their treat- ment [1, 5]. Trauma can fracture development of trusting

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attachments resulting in increased healthcare seeking behavior [47]. Trauma impacts the hypothalamic-pituitary-adrenal axis, neuronal circuits, and hemodynamics in response to stress, making the patient more vulnerable to future stressors [46]. Repeated trauma reinforces this conditioned response, making the response (i.e., somatization) more severe and entrenched. Therefore, given the impact of trauma in patients with SSD, it is important to routinely screen for trauma as part of the as- sessment of these patients and, if it exists, address it through evidence-based treatment methods to reduce the effect trauma may have on the patients SSD course.
Evaluation
The evaluation of SSD requires a comprehensive, mul- tidisciplinary approach with close monitoring of symp- tom evolution and engagement of the patients family, school, and PCP [2, 7] (Fig. 1). Evaluation involves close assessment of pathophysiology and biological fac- tors, including exclusion of organic disease based on judicious diagnostic evaluation. It also involves assess- ment of psychiatric, psychological, social, environmen- tal, and familial factors that may predispose, precipitate, or perpetuate a given patients presentation.
Medical Evaluation
With SSD physical symptoms and the degree of functional impairment are inconsistent with the historical presentation, physical examination, and diagnostic testing. While SSD is not a diagnosis of exclusion, the evaluation of the patients physical health must be thorough to rule out both serious and benign factors that may be contributing to the patients somat- ic symptoms. [7, 36] Having a coexisting physical health condition in addition to underlying SSD is common and can make the evaluation process both challenging and nuanced [7]. A balance must exist between providing needed diagnos- tic evaluation, while being cautious to not cause undue harm by conducting unnecessary or invasive evaluation. Evaluation should be guided by careful historical information, including collateral information from school, family, and other settings. The PCP should be vigilant of how the patient and familys perceptions of the physical symptoms impact decision- making and avoid being overly influenced by this during the evaluation process. It is important that a broad diagnostic as- sessment be considered, while attempting to limit reinforce- ment of further patient disability or familial anxieties.
Psychosocial Evaluation
As part of the evaluation, there should be an ongoing simul- taneous assessment of psychosocial factors influencing or
exacerbating the patients presentation. This includes a thor- ough assessment of patient and family perception of illness, level of disability, past psychiatric history, past history of physical illness, family history, developmental history, and psychosocial history [7]. Particular attention should be paid to individual and family characteristics that could influence symptom presentation, as well as reviewing examples of how the patient and family typically cope with strong emotion or stress [7, 14, 36]. During this process, it is important to also highlight patient and family strengths, past successes, resilien- cy, and areas of functionality [7].
Early mental health consultation should be sought and conducted concurrently with ongoing medical eval- uation [48]. Early mental health consultation is impor- tant for multiple reasons. Firstly, it normalizes the psy- chological and social factors influencing somatization. Secondly, it identifies the mental health clinician as part of a multidisciplinary team and reduces the perception that the primary medical team is handing off the pa- tient to mental health [7, 48]. Thirdly, it allows ample time for engagement and enhanced communication with the patient and family. Mental health clinicians can be- gin early psychoeducation and psychotherapeutic inter- vention to reduce symptom severity until diagnostic evaluation is complete. Mental health consultants can also address comorbid psychopathology, patient coping, and familial factors impacting care. Mental health con- sultation can result in significant reductions in hospital length of stay and cost. [49] Despite early involvement of mental health services, repeat consultation is common in a small proportion of patients [7].
Screening
There is no universally utilized screening tool for pediatric SSD. However, several validated rating scales exist (Table 2). Subscales of widely used comprehensive screening tools, such as the Somatic Complaint Subscale of the Child Behavior Checklist and the Somatisation Subscale of the Survey Diagnostic Instrument, can be used to screen youth for risk of SSD [3]. Several standardized interviews also exist including the Munich Composite International Diagnostic Interview (M-CIDI), the Child and Adolescent Psychiatry Assessment (CAPA), and the Soma Assessment Interview (SAI) [50]. Poor correlation sometimes exists between paren- tal and youth reports of somatic symptoms when assessing SSD [6]. Therefore, it is critical to obtain patient, family, and other collateral assessments of symptom presentation and se- verity to gain a fuller picture of the patients symptomatology [42]. Clinicians can also use screening tools for mood disor- ders, anxiety disorders, behavioral difficulties, or broader as- sessments of emotional and behavioral disturbance.

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Fig.1 FrameworkforApproachingPediatricSomaticSymptomDisorder
Patient and Family Engagement
Throughout the process of evaluation and subsequent management, communication is critical. Close communi- cation should occur between all members of the care team to provide consistent messaging and emphasize the multifactorial nature of SSD [7]. Engaging patients and their families throughout the evaluation process aids in validating emotions, addressing concerns, and balancing ongoing evaluation with communication that reinforces improved functionality.
Physicians may find themselves easily frustrated in communicating with patients and families during the eval- uation process. Patients and families are quick to detect providers unease and less likely to accept a diagnosis and treatment recommendations [51]. Physicians may be tempted to focus on the exclusionary diagnoses, negative diagnostic tests, and what is not causing the symptoms. Physicians may state we dont know what is causing this to avoid attempts to describe the complex physiolog- ical and psychological processes at play. However, this approach tends to increase family anxiety and sends a message that additional diagnostic searching is needed [52]. Physicians may also oversimplify the explanation of symptoms and make direct statements of psychological causality. Making a direct link between physical symp- toms and psychological causes is not readily acceptable
to many patients [52]. Utilizing empathic statements, ex- plicitly acknowledging the difficulty of having a sick loved one, legitimizing patients suffering, avoiding blame, promoting enhanced patient functionality, and em- pathizing with the familys efforts to seek treatment for their child can be instrumental in facilitating family satis- faction and receptiveness to the biopsychosocial formula- tion [53]. Staying focused on the body and the symptoms themselves throughout the process can help align commu- nications with where the patient and family are at in their understanding [27].
Once the diagnostic evaluation is complete, findings should be presented as a multidisciplinary team. The PCP, school, close family members, and other important figures in the patients life may be invited to participate in a multidisciplinary care meeting to discuss the find- ings of the evaluation. The diagnosis should be clearly communicated in a non-judgmental fashion with an ex- planatory model describing how the patients symptoms evolved. The use of simple analogies, visual diagrams, written materials, and concrete examples can be effec- tive in delivering this message. At times, the patient and family may have very strong emotions about the diag- nostic findings and may assume an incomplete evalua- tion has been conducted. Presenting a conceptual frame- work for how the symptoms emerged is helpful in strengthening patient and family understanding.

Identifies common somatic complaints in the past 2 weeks that occur without clear underlying physical disease. Used in multiple settings and adapted in multiple countries.
Broad evaluation of somatic symptoms across nine primary symptom dimensions and three global scores for distress. Items are rated on a 5-point Likert scale, and the tool also has a specific somatization subscale.
Reviews fears, beliefs, and attitudes regarding physical symptoms, and the caregivers role in addressing these physical symptoms. Each item is rated along a 3-point Likert scale.
Psychosocial screening tool that evaluates patients along 12 symptoms with each item being rated on a 04 Likert scale on both frequency and severity. This tool was modified from the Adult Psychosomatic Symptom Checklist.
Based on DSM criteria, this tool identifies symptoms on a 2-point Likert scale and evaluates the lifetime prevalence of somatic symptoms rather than acute symptom presentation.
Explores the frequency of somatic symptoms in the past month on a 5-point Likert scale from never (1) to quite often (5).
Often used in pain disorder assessment, monitoring outcomes, or as an adjunctive tool with other somatization screens, such as the CSI. This tool evaluates the presence and severity of functional disability on a 5-point Likert scale over the past 2 weeks. The scale ranges from no trouble (0) to impossible (4). Scores range from 0 to
60 and are divided into minimal, mild, moderate, and severe categories of functional disability.
Behavioral interventions can help reinforce health- focused behaviors instead of the sick role. The treatment team works with patients and their families to minimize secondary gains from illness behaviors [2, 14]. CBT with pediatric SSD is most effective if parents are also involved [54]. Although other therapeutic interventions have not been as systematically studied, multiple case examples suggest the value of psychodynamic psycho- therapy in understanding the intrapsychic and systemic functions of somatic symptoms. [54] Family therapy has been shown to provide improvements in somatization with a higher rate of symptom elimination, lower levels of relapse, and overall improved functioning [2, 14]. Rehabilitative therapies, such as physical therapy, also play a valuable role in restoring functioning and ad- dressing deconditioning.
Role of PCP
The PCP plays a crucial role in ongoing recovery. Families need continued education and reassurance. Scheduled and frequent follow-up visits with a PCP are important to maintain alliance and investment in treatment, address fears of abandonment, and prevent
Family and patient engagement is crucial to the success- ful management of pediatric SSD. Treatment begins with the initial assessment, emphasizing the importance of creating an alliance with patient and family. Treatment is centered on shifting patient and familys mindset from searching for the cause of symptoms to focusing on overall functioning. When families and pa- tients understand their diagnosis and are engaged with their physician, they have an easier time making this shift.
Psychotherapy
Cognitive behavioral therapy (CBT) is the hallmark of treatment for SSD. Current evidence regarding somati- zation, functional disorders, and pain disorders suggests CBT is effective with moderate effect sizes [10, 54, 55]. CBT can provide active coping strategies while working with thoughts and feelings directly related to the illness experience. Behavioral approaches often included in CBT, such as biofeedback, hypnosis, and relaxation, are effective in reducing somatization [14, 54].

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doctor shopping and over medicalization. These fre- quent visits can include ongoing exams to address new symptoms, continued empathetic support, addressing factors perpetuating symptoms, follow-up on functional progress, and continuing avoidance of any unnecessary testing or subspecialty referral [53].
Collaboration Between Mental Health and Primary Care
Early, frequent, and close communication between the patients PCP, subspecialty providers, and mental health providers is necessary to provide consistent communica- tion and care. This partnership allows for key exchange of information regarding prior assessment and treatment experience, so as to obviate unneeded evaluation and treatment, as well as to ensure patient and families are heard by their providers [56]. Collaboration reduces stigma regarding engagement in mental health services and keeps each member of the care team alert for un- recognized physical, social, or psychological factors impacting care [56]. Mental health providers can assist primary care and subspecialty providers in framing their message to families. A psychiatric consultation letter to the primary care physician containing strategies for managing somatization can significantly improve patient outcomes and primary care-patient relationship [55]. Along the way, functional outcomes can be monitored and shared across disciplines.
Role of School
Many patients miss school because of SSD, and symp- toms may be reinforced by school avoidance. Therefore, having a clear functional plan to return to school is important. Strong channels of communication are need- ed between clinicians and schools with concrete guid- ance on how to manage symptoms in the school setting [2]. Patients may need additional accommodations to be successful at school and a plan for gradual re- integration to return. Every attempt should be made to partner with schools to facilitate continued involvement in school with limited disruptions and avoidance of resorting to homebound or online schooling that can perpetuate symptom manifestation.
Medications
There is a very limited role for psychopharmacology in the direct management of SSD. A systematic Cochrane review in adults found a lack of data supporting the use of any pharmacologic agent specifically for SSD [57]. No such review exists in pediatrics. However, the man- agement of comorbid depression, anxiety, or other
associated psychopathology using psychotropic medica- tions can be helpful as adjunctive treatment in the over- all management of SSD [57].
Higher Levels of Care
Children with more profound and pervasive functional impair- ment may need more intensive treatment. Studies looking at various tertiary multidisciplinary approaches, either with ad- mission to medical-psychiatric units, physical rehabilitation units, or structured day treatment programs, have generally shown symptom reduction, improved quality of life, and de- creased healthcare utilization [2, 5].
Future Directions
Although there has been tremendous growth in clinical interest and research in pediatric SSD over the past 5 years, there is still much that needs to be explored going forward. Greater exploration of the epidemiology of SSD is needed. Given the prevalence of somatization, its varied presentations, and its presentation along a spectrum from normal to pathologic, it is challenging to obtain accurate estimates of the true prevalence of SSD, and further work is needed to elucidate the true extent of SSD in inpatient and outpatient settings. It is unclear to what extent race, sexual orientation, ethnicity, cultural background, and religion may impact manifes- tations of pediatric SSD. Specific populations, such as youth with developmental delay or intellectual disability, warrant further attention to identify the unique experi- ences and challenges that exist in identifying and man- aging SSD in these populations. Greater understanding of the neuroanatomic and neurophysiologic underpin- nings of SSD to better identify at-risk populations, en- hance diagnostic evaluation, and potentially provide fur- ther therapeutic tools to address SSD. Although many screening tools exist, there is a lack of standardized screening in SSD. Furthermore, there is a lack of pri- mary and secondary preventative resources to address high-risk populations to stem progression of somatiza- tion and emergence of SSD. Education is lacking among primary care clinicians and mental health professionals. Innovative approaches to education are needed to heighten awareness, enhance collaboration, and increase self-efficacy among clinicians at the front lines of ad- dressing SSD. This includes exploring telemedicine and interactive web-based resources as modalities of dissem- inating education, outreach, and potentially psychother- apeutic intervention. The mainstay of treatment is psy- chotherapy and more study is needed to continue to explore the necessary ingredients of successful

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psychotherapy and enhance existing psychotherapeutic techniques.
Conclusion
Pediatric SSD is common and places a significant bur- den on healthcare utilization. Primary care is at the forefront of assessing and managing youth with SSD. There is little standardization or training in practice to address the prevention, communication strategies, evalu- ation, and management of SSD. Patients and families are often frustrated with inconsistencies in care, lack of an understandable conceptual framework for symp- tom presentation, feelings of marginalization, and con- cerns about serious missed pathology. Providers are sim- ilarly frustrated by the lack of a consistent assessment and management strategy, unclear etiologic understand- ing, communication breakdowns, and negative percep- tions of patients and families. As a result, there are multiple missed opportunities for partnership between PCPs, patients, families, mental health clinicians, and community supports to address SSD.
A growing literature base exists for the evaluation and management of pediatric SSD. Current data sup- ports enhanced training for PCPs and mental health pro- viders, proactive assessment of both physical and psy- chological etiologies for SSD, a multidisciplinary ap- proach with early mental health involvement, and a communication strategy that stresses the multifactorial nature of SSD. Treatment should include a focus on enhancing functionality, addressing factors sustaining disability, and collaboration with community supports with the overarching goal of rehabilitation of the phys- iologic and psychological factors influencing symptom presentation. As this approach continues to gain a great- er foundation and adoption into pediatric care settings, the elusive, perplexing, and often frustrating place that SSD holds in pediatric medicine can be ameliorated resulting in improved patient outcomes and greater pa- tient, family, and clinician satisfaction.
Key Clinical Perspectives
Somatization is common and normative in the pediatric population, but can become a disorder when symptoms are impairing and persistent.
Currently, SSDs are poorly recognized and frequently mismanaged. This results in disproportionate healthcare utilization, increased risk of unnecessary invasive evaluation and intervention, as well as patient, family, and clinician dissatisfaction.
There are multiple biological, interpersonal, familial, and environmental risk factors for SSD.
Multiple risk factors do not necessarily equate to a diagnosis of SSD, but should increase suspicion for SSD and be accounted for in the management of SSD.
Trauma is not a pre-requisite for SSD and is less frequently associated with pediatric SSD compared to adults. However, it significantly modulates the SSD experience when present and can be a target for intervention.
Early detection, collaborative communication, and an integrated multidisciplinary approach are important to promoting enhanced patient functionality.
Diagnostic evaluation should involve a multidisciplinary approach with early and close collaboration with mental health providers.
Evaluation should include a thorough work up of physical health causes appropriate for the presenting complaints, while avoiding invasive diagnostic testing or intervention.
Close assessment of psychosocial factors including individual, familial, school, and environmental factors is important to reaching a biopsychosocial formulation of the patients presentation.
Communication of the diagnostic evaluation should be completed in a multidisciplinary fashion with involvement of the primary care provider, while providing the patient and family with a conceptual framework to understand symptom presentation.
Management requires a proactive, multidisciplinary approach focused on improving function.
Close collaboration between mental health clinicians, primary care providers, schools, and families is a requisite component of comprehensive management of SSD.
Therapy, especially cognitive behavioral therapy, is the hallmark of treatment for SSD.
Targeted and conservative pharmacologic management can be helpful in some cases, yet there is little evidence for the role of psychotropics in SSD.
The editors would like to thank Dr. Tami D. Benton for taking the time to review this manuscript.
Compliance with Ethical Standards
Conflict of Interest Nasuh Malas, Roberto Ortiz-Aguayo, Lisa Giles,
and Patricia Ibeziako declare that they have no conflict of interest.
Human and Animal Rights and Informed Consent This article does not contain any studies with human or animal subjects performed by any of the authors.
. De oefenexamen moet geschreven zijn in de Nederlandse taal. Onderin staan de antwoorden. Het aantal vragen dat het oefenexamen moet bevatten is 10.

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