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Volume 101, Issue 3
March 2012
Pages 324329
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Multiple psychosomatic symptoms can indicate child physical abuse

results from a study of Swedish schoolchildren
Carolina Jernbro, Birgitta Svensson, Ylva Tindberg, Staffan Janson

First published:
22 November 2011 Full publication history

DOI:
10.1111/j.1651-2227.2011.02518.x View/save citation

Cited by (CrossRef):
9 articles Check for updates Citation tools

Carolina Jernbro, Division of Public Health Sciences, Department of Health and Environment, Karlstad University,
65188 Karlstad, Sweden.
Tel: +46-54-700-2503 |
Fax: +46-54-700-1460 |
Email: carolina.jernbro@kau.se

Abstract
Aim: To examine whether children with self-reported experiences of either physical abuse alone or
combined with intimate partner violence report more psychosomatic symptoms than other children and to
explore whether these possible associations are enhanced by school-related factors, chronic condition and
demographic factors.
Methods: A national cross-sectional study of 2771 pupils in grades 4, 6 and 9 from 44 schools in Sweden
was carried out in 2006 (91% response rate). Data were analysed with univariate tests (chi-square), multiple
logistic regression analyses and stratified logistic regression analyses, expressed as crude odds ratio (OR)
and adjusted odds ratio (AOR) with 95% confidence intervals.

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Results: There was a strong association between reported physical abuse and multiple (three or more)
psychosomatic symptoms among schoolchildren (AOR 2.12). Chronic condition was the only determinant that
had an obvious enhancing effect on the association between physical abuse and psychosomatic symptoms in
childhood.
Conclusion: This study shows that multiple psychosomatic symptoms are associated with child physical
abuse. Health professionals therefore need to pay special attention to schoolchildren who complain about the
co-occurrence of psychosomatic symptoms and pattern of symptoms, which could not be easily explained by
other causes.

Abbreviations
CPA,
Child physical abuse
IPV,
Intimate partner violence

Key notes
In this nationally representative study of Swedish schoolchildren, a strong association between
reported physical abuse [alone or combined with intimate partner violence (IPV)] and psychosomatic
symptoms was found. This association was, however, only valid for children who reported three or
more symptoms. Chronic condition had an enhancing effect on the association between physical
abuse and psychosomatic symptoms in childhood.

Introduction
The association between childhood abuse and poor social, psychological and physical health in adulthood has
been shown in a great number of studies. The associations with behaviour problems, post-traumatic stress
disorder, obesity and criminal behaviour are well established (1), but associations with long-term psychosomatic
illness and pain problems have also been shown (2). Results from a meta-analytic review in 2005 (3) showed
that adult patients with chronic pain more often reported childhood abuse or neglect than healthy controls.
Additionally, individuals who reported being abused or neglected in childhood also reported more pain symptoms
and other health-related conditions in adulthood than non-abused. If these conditions are initiated already in
childhood or adolescence, there are reasons to believe that there could be an association between abuse and
psychosomatic symptoms also among children and adolescents. Understanding such a relationship would be of
great value in the professional meeting with children and adolescents.
Previous studies have shown associations between different types of psychosocial factors, psychopathology and
psychosomatic symptoms among adolescents, where depression and anxiety are commonly examined factors
(47). However, none of these studies have included questions on abuse, and to our knowledge, there is no
research on the association between childhood abuse and psychosomatic symptoms among younger children.
Several studies on schoolchildren have shown that psychosomatic symptoms are more common among girls
(8,9) and that the symptoms increase by age, particularly for girls (9,10). A Nordic study has shown that
structural factors, such as the socioeconomic living conditions, account for only a small proportion of
psychosomatic health complaints within a representative population of children (11).

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Different types of victimization seem to be related to psychosomatic symptoms. Children who have witnessed
IPV report more psychosomatic symptoms (12). These children are also at greater risk for being abused
themselves (13,14). The relationship between school-related victimization, as involvement in bullying, and
psychosomatic symptoms has also been shown in several studies (1517). According to these studies, children
and adolescents that are victims of bullying or both victims and bullies seem to be more vulnerable than solely
bullies. At the same time, studies have shown that abused children are more involved in bullying in school than
non-abused children (18). Children with chronic conditions/disabilities are at greater risk for child abuse
compared with children without chronic conditions. According to a recently published study on the same data
set, children with chronic conditions had a significantly increased risk for physical abuse (19). To understand the
presence of psychosomatic symptoms among children and adolescents, it is valuable to examine all types of
victimizations. There is however an obvious lack of these types of studies.
This study wants to fill some gaps, by assessing the relationship between physical abuse, IPV, bullying and
psychosomatic symptoms among children at 10, 12 and 15 years of age, using data from a Swedish national
school survey on child abuse, carried out in 2006 (20). Our first aim is to explore whether children with self-
reported experiences of either physical abuse alone or physical abuse combined with IPV report more
psychosomatic symptoms than other children. Our second aim is to explore whether these possible associations
are enhanced by factors that according to previous studies are associated with an increased prevalence of
psychosomatic symptoms and/or with an increased risk of abuse. These factors are (i) the childrens chronic
health condition, (ii) school-related factors such as involvement in bullying and school performance and (iii)
demographic factors such as family situation, country of birth, economical status of the area, sex and age.

Method
Data collection
A Swedish national questionnaire study was carried out between November 2006 and February 2007. Statistics
Sweden (SCB) was responsible for the data collection. SCB has strict rules for data collection and recording,
and all staff are working according to the official Secrets Act. The study was also approved by the ethical
research committee at Uppsala University, Sweden (Dnr 2006/277).
The Geographical Information System (GIS) was used to create a sample selection of 44 schools in Sweden,
matched to a national school register. A GIS-map was created around each school corresponding to a normal
catchment area for Swedish secondary schools. The households within the area were matched with disposable
income, country of birth and education level. From this procedure, it was possible to divide the schools into three
strata: high-income area, middle-income area and low-income area.
An information letter was sent to the headmaster at each school. A couple of days later, an interviewer from SCB
called each headmaster to get an approval to accomplish the study. When the most suitable time for the study
was decided, an information letter was sent to the pupils homes for consent. The parents were informed about
the aim of the study, and that questions were centred around upbringing, parental abuse and bullying. They were
also informed that the childs participation was voluntary and that the child had the right to change their
responses or refrain from answering certain questions. The letter also included information about the parents
right to prevent the child from participating in the study. On the day for data collection, an interviewer from SCB
visited each class. The interviewer informed the pupils about the aim of the study, and that the participation was
voluntary and anonymous. The interviewer stayed in the classroom, while the pupils answered the
questionnaire, but the teachers were not allowed to attend. The interviewer collected the questionnaires when
the survey was completed.

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Study population
The population constituted of 2771 pupils in grades 4, 6 and 9 (corresponding to ages 10, 12 and 15 years) from
the 44 selected schools; 2510 pupils responded to the questionnaire, corresponding to a response rate of 91%.
The children are described in Table S1. The internal dropouts for important key questions were low, physical
abuse (5%), IPV (2%) and chronic conditions (5%).
The procedure for data collection and study population is described in more detail in a previous article (20).

Measures
Psychosomatic symptoms

To estimate the prevalence of psychosomatic symptoms, a list of 6 symptoms was used based on previous
Nordic studies (21). The psychosomatic symptoms are stomach ache, headache, sleeplessness, dizziness,
back pain and loss of appetite. The question asked was Do you usually have any of these symptoms at least
twice a month? The response alternatives were Yes or No. Even if these symptoms are commonly referred to
as psychosomatic in previous research of schoolchildren (22), it cannot be excluded that some of the complaints
may be of primary organic cause.

Physical abuse and exposure to IPV

Questions based on Conflict Tactic Scales (23) were used to measure mild and severe physical abuse. The
children were asked whether they ever had their ears boxed, were severely shaken, had their hair pulled (mild
physical abuse), were beaten severely by the hand or were beaten with a device (severe physical abuse). In this
study, we present results according to whether the children ever had been physically abused (mild and/or
severe) ever or not.
Two questions measured IPV and were phrased accordingly: Has it ever happened that the adults in your family
have hit each other? Did you witness the violence between the adults in your family? The response alternatives
for both questions were No, Yes, once or twice, Yes, several times. In this study, we only consider whether
the children ever had experienced IPV (yes/no).

Chronic conditions

Chronic condition was defined as chronic disease/disorder and/or long-term disability. To estimate the
prevalence of chronic conditions, a list of 13 diagnoses was used based on previous Nordic studies (21). The
diagnoses were visual impairment, hearing impairment, speech defect, diabetes, mental illness, epilepsy,
abdominal pain, asthma, allergic rhinitis, eczema, physical dysfunction, overweight and ADHD/ADD. The
question asked was whether the children had any chronic disease or disability, with duration of at least three
months within the last year. No further questions were used to identify how severe the condition was or in what
way it affected the childrens daily life.

Involvement in bullying

To estimate the prevalence of involvement in bullying, the following two questions were used; (i) Have you ever
bullied another child at school or anywhere else? (ii) Have you ever been a victim of bullying? Response
alternatives for both questions were Yes, many times, Yes, a few times, Yes, once or twice and No, never
happened. In this study, we only consider whether the children ever had been involved in bullying as bully
(yes/no) and/or as a victim (yes/no).

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School performance

To measure school performance, the following question was used: How do you think you manage your school
work? Response alternatives were I think I perform better than most of my classmates, I think I perform just as
good as my classmates, I think most of my classmates perform better than I do, I dont know how I perform
compared to my classmates. In this study, we consider response alternative 1 and 2 as positive outcome
(perform well in school = Yes), response alternative 3 as negative outcome (perform well in school = No) and
response alternative 4 as didnt know.

Analysis
In our analyses, we used univariate tests (chi-square), multiple logistic regression analyses and stratified logistic
regression analyses, expressed as crude odds ratio (OR) and adjusted odds ratio (AOR) with a 95% confidence
interval. Trends in number of reported psychosomatic symptoms according to experience of physical abuse and
IPV were tested by linear-by-linear association. All analyses were considered to be statistically significant when
the p-value was <0.05. Statistical analyses were carried out using SPSS for Windows (version 18.0, PASW
Statistics 18, SPSS Inc., Chicago, IL, USA).

Results
Two-thirds of the children (66%) reported at least one psychosomatic symptom. Of these children, one-third
(35%) reported three symptoms or more. As described in Table S1, headache, sleeplessness and stomach ache
were the most common symptoms.

Associations between physical abuse, IPV and psychosomatic symptoms

Children who reported experiences of physical abuse alone or combined with IPV reported significantly more
psychosomatic symptoms than non-abused children. Psychosomatic symptoms were most common among
children who reported both physical abuse and IPV, where the majority of children (86%) reported any
psychosomatic symptom. Almost half of these children (41%) reported three or more symptoms, compared to
19% of the non-abused children. Among children who reported physical abuse but not combined with IPV, 82%
reported any psychosomatic symptoms and 35% reported three symptoms or more. Children who reported IPV
alone did not report significantly more psychosomatic symptoms than the non-abused children.
As presented in Table 1, abused children report multiple psychosomatic symptoms to a greater extent than non-
abused, while reports of one or two symptoms are similar for both groups. The association between reports of
multiple psychosomatic symptoms and physical abuse (alone or combined with IPV) remained when adjusting
for chronic condition, school-related factors and demographic factors. To control for confounders, we analysed
which factors that were associated with both physical abuse and psychosomatic symptoms. Plausible
confounders that could be controlled for were family situation, chronic condition, involvement in bullying (bully
and/or victim) and school performance. Except for school performance, stratified analyses based on each of the
factors mentioned earlier showed that the significant association between physical abuse alone or combined
with IPV and psychosomatic symptoms still remained. (Data not shown).

Table 1. The association between child physical abuse (CPA), intimate partner violence (IPV)
and psychosomatic symptoms

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12 psychosomatic symptoms 3 or more psychosomatic symptoms

Abuse indicators
OR crude (95% OR adjusted (95% OR crude (95% OR adjusted (95%
CI) CI) CI) CI)

No abuse 1.00 1.00 1.00 1.00

CPA alone 1.16 (0.861.58) 1.13 (0.821.57) 2.09 (1.522.89)*** 1.72 (1.182.50)*

IPV alone 1.09 (0.701.70) 1.12 (0.711.77) 1.28 (0.782.11) 1.09 (0.631.90)

Both CPA and IPV 0.91 (0.541.53) 0.84 (0.481.45) 5.29 (3.168.85)*** 2.71 (1.465.02)**

CPA (alone or combined with 1.07 (0.821.40) 1.04 (0.771.39) 2.95 (2.243.89)*** 2.12 (1.522.95)***
IPV)

Association expressed as OR and adjusted OR and 95% CI.

Bold values are significant as follows: *p < 0.05, **p < 0.01, ***p < 0.001.

Adjustments made for chronic condition, involvement in bullying, school performance, sex, age, family situation, country of birth
and income area.

Crude analyses showed that abused children reported significantly more symptoms than non-abused children for
each type of symptom. An analysis of each symptom, adjusted for all the others, was not meaningful because of
relatively high correlations between symptoms.

Other factors associated with psychosomatic symptoms

The analysis also showed that girls reported significantly more psychosomatic symptoms than boys
(AOR = 1.75) and children in 9th grade reported more symptoms than children in 4th and 6th grade
(AOR = 1.89). There was a link between involvement in bullying and psychosomatic symptoms, where the
association was strongest for children who reported being both bullies and victims (AOR = 3.61). Children who
assessed their school performance inferior to their classmates reported significantly more psychosomatic
symptoms than children who found their school performance just as good or better than their classmates
(AOR = 2.40). Further, children with chronic conditions reported more symptoms than children with no chronic
conditions (AOR = 2.11).
Similar to the association between physical abuse and psychosomatic symptoms, all of these significant
associations were explained mainly by the group of children who reported three or more symptoms. (Data not
shown).

Enhancing factors
To find out whether chronic condition, school-related factors and demographic factors had an enhancing effect
on the association between physical abuse and psychosomatic symptoms, crude analyses were made based on
combinations of physical abuse and each factor, which is presented in Table 2. Chronic condition turned out to
be the only factor that had a significant enhancing effect on the association between physical abuse and
psychosomatic symptoms.

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Table 2. Enhancing factors on the association between physical abuse [alone or combined with
intimate partner violence] and psychosomatic symptoms

Abused and OR crude (95% CI)

Health condition

No chronic condition 1.00

Chronic condition 3.90 (1.908.03)***

Income area

Middlehigh-income area 1.00

Low-income area 0.73 (0.381.41)

Country of birth

Born in Sweden 1.00

Born in a foreign country 0.99 (0.432.28)

Family situation

Living with both biological parents 1.00

Not living with both biological parents 1.95 (0.944.07)

Grade

4th6th (ref) 1.00

9th 1.90 (0.963.76)

Gender

Boys 1.00

Girls 1.72 (0.863.44)

Involvement in bullying

No involvement 1.00

Involvement 1.96 (0.993.90)

School performance

Perform same/better 1.00

Perform not as good 2.08 (0.607.19)

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Abused and OR crude (95% CI)

Association expressed as OR and 95% CI.

Bold values are significant as follows: *p < 0.05, **p < 0.01, ***p < 0.001

Abused children with chronic condition reported significantly more psychosomatic symptoms than abused
children without chronic condition (OR 3.90). Family situation, involvement in bullying, gender and age tended to
affect the association between physical abuse and psychosomatic symptoms, but there were no statistically
significant associations.

Discussion
In this large and nationally representative study of Swedish schoolchildren, we found a strong association
between reported physical abuse (alone or combined with IPV) and psychosomatic symptoms. This association
was, however, only valid for children who reported three or more symptoms, probably indicating a stressful life
situation. We have also shown that having a chronic condition had an enhancing effect on the association
between physical abuse and psychosomatic symptoms in childhood.
We did not find any association between experience of IPV alone and psychosomatic symptoms. This result was
unexpected as it has been mentioned as a consequence of family violence in previous studies (24). On the other
hand, we found that children who experienced both physical abuse and IPV reported more psychosomatic
symptoms than children who experienced physical abuse alone. According to a previous study on the same data
set, these children also reported more severe abuse than children who reported physical abuse alone (19). The
overlap between IPV and CPA is therefore important to take into consideration in future research.
In line with previous studies, we found associations between psychosomatic symptoms and age, sex, bullying in
school and school performance (9,10,16). We also found that income area was not a significant demographic
factor for psychosomatic symptoms, which has been shown by a previous Nordic study (21). Another interesting
result is that the association between sex, age and psychosomatic symptoms was obvious among the non-
abused, but not among the abused. This result indicates that the appearance of psychosomatic symptoms
among abused children is less dependent on a regular psychosocial development than for non-abused children.
Further, we did not find a clear enhancing effect of demographic and individual factors. According to our results,
experience of physical abuse seems to be by itself enough to give rise to psychosomatic symptoms among
children and adolescents. Chronic condition turned out to be the only determinant that had an obvious
enhancing effect on the association between physical abuse and psychosomatic symptoms among the children.
In total, children with all different types of chronic conditions reported more psychosomatic symptoms than
children without chronic conditions. As several of the chronic conditions to a certain (but relatively low) extent are
intercorrelated with psychosomatic symptoms, the enhancing impact of chronic conditions may be somewhat
overestimated.
One explanation to the enhancing effect of chronic condition among the abused children could be that already
somatically vulnerable children are more sensitive to the stress caused by physical abuse and will therefore
easier get psychosomatic symptoms than healthy children. A recently published article on the same data set
also showed that children with chronic conditions are particularly exposed to abuse (19).

Limitations

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A major problem approaching this area is that there are no clear definitions of either psychosomatic symptoms or
chronic conditions. The process of dealing with the chronic condition data for the present study is dealt with
elsewhere (19). For psychosomatic symptoms, we asked for six common symptoms in psychosomatic research
and received similar prevalences. A significant shortcoming, however, would be if postpubertal girls reporting
stomach ache at least twice per month were referring to menstrual pain. All reported symptoms could have an
organic cause, especially if reported only one at the time. However, the observation that multiple symptoms were
associated with victimization at home indicates a strong psychosomatic component for these. Whether three or
more symptoms occurred simultaneously cannot be definitely known, as this was not explicitly asked for.
Another difficulty is that maltreatment and harassment in any form can be sensitive to deal with. Consequently,
there is a risk of recall biases, which could have resulted in an underrepresentation of reported abuse. This
would, however, lead to an underestimation of the associations. To reduce this risk, we used a questionnaire
based on Conflict Tactic Scales (23).

Implications for practice and policy

To be able to discover physical abuse among children and adolescents in general and among those with chronic
conditions particularly, the current study contributes by raising the need for more professional awareness of
psychosomatic symptoms among schoolchildren. An important result in this study is the indication that abused
children experienced multiple psychosomatic symptoms compared with the non-abused children. Health
professionals therefore need to pay special attention to schoolchildren who complain about co-occurrence of
psychosomatic symptoms and pattern of symptoms, which could not easily be explained by an organic cause.

Acknowledgements
The study was supported by grants from Childrens Welfare Foundation (Stiftelsen Allmnna Barnhuset),
Stockholm and County Council of Vrmland in Sweden.

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