Are Somatic Symptoms and Related Distress More Prevalentin Hispanic/Latino Youth? Some Methodological Considerations

Glorisa CaninoUniversity of Puerto Rico

This article comments on the current status of the anxiety literature involving Latinochildren and adolescents. As the 2 articles that focus on Hispanic/Latino youth in thisspecial section independently found somatic symptoms to be more prevalent in Latinoyouth than other racial/ethnic groups (Pina & Silverman, this issue; Varela et al., thisissue), this commentary discusses methodological considerations for guiding futureanxiety research and makes suggestions for clinicians who treat Latino children andadolescents.

Medically unexplained physical symptoms havelong been recognized as common and problematic inpediatric practice, but only since the late 1980s havesomatic complaints become a topic of research and dis-cussion in the child and adolescent psychiatric litera-ture (Apley & Meadow, 1978). This paucity of re-search may be due in part to the fact that the psychiatricdiagnostic criteria of somatization disorder was not de-veloped for children until the early 1990s (AmericanPsychiatric Association, 1994). It is therefore not sur-prising that the research literature on somatic manifes-tations of psychological distress in children is scarce,and almost nonexistent when referring to minority orHispanic/Latino children.

The studies by Varela and colleagues (this issue) byPina and Silverman (this issue) present important con-tributions to the field of child psychiatry and psychol-ogy, inasmuch as these studies report on the culturalsignificance of somatic and anxiety symptoms amongHispanic/Latino youth. The common outcome of thesestudies was that somatic symptoms and their relateddistress in Hispanic/Latino youth were more prevalentthan in children of European American background. Inaddition, the data showed differences by Hispanic/La-tino subgroups and by acculturation in the rates andcultural attributions of somatic symptoms. Pina andSilverman’ and Varela et al.’s findings are consistentwith a number of adult studies that have reported highprevalence rates of somatic symptoms in both clinicaland community samples among Hispanics/Latinos aswell as differences in rates by Hispanic/Latino sub-groups. For example, adult epidemiological populationstudies have shown that Puerto Ricans report higherrates of somatic symptoms as compared to European

Americans and Mexican Americans from Los An-geles, California, even after statistically controlling forsociodemographic factors (Canino, Escobar, Canino,& Rubio-Stipec, 1992; Escobar & Canino, 1989).

The studies by Pina and Silverman (this issue) andVarela and colleagues (this issue) were conducted in-dependently and yielded similar results, and the resultsare consistent with those of the adult somatic literature.There are methodological and substantive reasons thatshould encourage future research into whether His-panic/Latino children and adolescents have higherrates of somatization symptoms and related distressas compared to non-Hispanic/Latino children beforereaching a definitive conclusion. For example, Varelaand colleagues offer a very plausible cultural explana-tion for their observed results. They rightfully claimthat in Hispanic/Latino families, it is a common child-rearing practice for parents to exert overly controllingbehavior such as demanding child acceptance of theparents’ assertions and beliefs and foreclosing discus-sion when trouble arises. These parenting styles are as-sociated with increased anxiety in the child and may berelated to the higher rates of somatization in the child.Alternative explanations may be related to method-ological issues classified into socioeconomic status(SES), type and size of the sample studied, and comor-bidity as a possible confounder of results.

Disentangling Socioeconomic StatusFrom Cultural Factors

Somatic symptoms in children have been associatedwith lower parental education or SES (Bernstein et al.,1997; Taylor, Szatmari, Boyle, & Offord, 1996). Giventhat somatic symptoms are more prevalent in poor fam-ilies and that most Hispanic/Latino families living inthe United States are poor, it is crucial to be able to dis-entangle the effect of poverty from that of ethnicity.

Journal of Clinical Child and Adolescent Psychology2004, Vol. 33, No. 2, 272–275

Copyright © 2004 byLawrence Erlbaum Associates, Inc.

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Requests for reprints should be sent to Glorisa Canino, Behav-ioral Sciences Research Institute, Medical Sciences Campus, Uni-versity of Puerto Rico, P.O. Box 365067, San Juan, PR 00936–5067E-mail: gcanino@rcm.upr.edu

Pina and Silverman (this issue) examined family in-come in their diverse Hispanic/Latino sample and didnot find statistically significant differences. Future re-search would benefit from studies that disentangle fac-tors related to family income, such as parental educa-tion, migration status, acculturation experience, andother types of stresses to which children from differentethnic groups are subjected. When a cultural group isstudied in its country of origin, some of the foregoingchallenges are more easily addressed. For example,Mexicans residing in Mexico are not faced with stress-ors associated with migration or minority status. Simi-larly, cultural heterogeneity is usually not an issue inMexico. There is also greater heterogeneity of SES inthe culture of origin, in contrast to the range of SESfound in the United States among Mexican Americansand other Hispanics/Latinos who tend to be mostly oflower SES. The inclusion of Mexicans residing inMexico is one of the main advantages of the study re-ported by Varela and colleagues (this issue). As pre-dicted, the Mexican group showed the strongestsomatic effects expected to be associated with the His-panic/Latino culture.

The two studies discussed found that even after con-trolling for SES and family income, children of His-panic/Latino origin had higher levels of somatic symp-toms as compared to the non-Hispanic/Latino Whites.In another study, Canino, González, and Ramírez(1999) using data from the Methods for the Epidemiol-ogy of Child and Adolescent Mental Disorders Study(Lahey et al., 1996) compared the rates of somaticsymptoms in children from three ethnic groups:Hispanics/Latinos (mostly Puerto Rican), EuropeanAmericans, and African Americans. The results of thisstudy showed that Hispanic/Latino children had signif-icantly higher cardiovascular somatic symptoms thanthe other three groups, but these differences disap-peared when controlling for parental income in the re-gression analysis. The differential results may be duein part to differences in studies regarding the risk thatSES may exert on somatic symptoms of the differentsubethnic groups (i.e., Mexican Americans vs. PuertoRicans) or to differences in the type of samples studied.The Canino et al. study was based on a probabilitycommunity sample, whereas the samples of the Pinaand Silverman (this issue) and Varela et al. (this issue)studies were not epidemiologically derived (i.e., aschool and clinic sample, respectively).

Probability Community SamplesVersus Clinical or School-Based

Samples: Directionsfor Future Research

The literature has shown substantial diagnostic anddemographic differences between those children at-

tending clinics and their counterparts who do not attendclinics. Clinic children tend to have higher comorbidrates, higher numbers of symptoms, and specific demo-graphic and diagnostic characteristics that differentiatethem from comparable children in the community(Angold, Costello, & Erkanli, 1999; Goodman et al.,1998). Important differences may exist between clinic-and school-based samples and probability representa-tive samples of the community that can change the re-sults of epidemiologic studies. It is therefore importantthat future cross-cultural research in the area of anxietyand somatic symptoms in youth include studies con-ducted with community probability samples.

Future research in the area of youth’s somatic symp-toms should also include more than one Hispanic/La-tino subgroup. Both the Pina and Silverman (this issue)and Varela et al. (this issue) studies did so. This is im-portant because adult studies reveal evidence that His-panic/Latino subgroups may differ in important diag-nostic ways. For example, Rubio-Stipec, Shrout, Bird,Canino, and Bravo (1989) in analyzing the factor struc-ture of the Diagnostic Interview Schedule for adults intwo Hispanic/Latino groups (Island Puerto Ricans andnative and immigrant Mexicans) found a somatizationfactor among island adult Puerto Ricans but not amongeither native or immigrant Mexican Americans.

Hispanics/Latinos are a diverse cultural group. Thedimensions of difference among Hispanic/Latinogroups are grounded in national origin and history; inthe particular social formations within each His-panic/Latino country that shape age, gender, and classrelations; in the pressures within each country thathave led to migration and the differing waves of migra-tion; and the differing relations with the United Statesthrough time that have affected how those migrantswere received (Aguirre-Molina & Molina, 1994; Mel-ville, 1994). This has not only created marked differ-ences among the Hispanic/Latino groups but consider-able intracultural variation within Hispanic/Latinogroups as well. Developing methods to fully assess andwork with the cultural diversity among Hispanics/Lati-nos is a key task of conducting cross-cultural work inthe area of somatic and anxiety symptoms amongchildren.

The Need for Analyzing Comorbidityand Sex Differences

Somatic symptoms in children, as well as in adults,are known to be expressions of psychological distress.For example, abdominal pain and headaches may de-velop as a result of psychological stressors (e.g., on thefirst day of school or before a test) and yet not be con-sidered a pathological condition. These characteristicpatterns of response to stressors reflect both geneticpredisposition and learned illness behavior, as well as

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tendencies toward anxiety and depression (Bernstein etal., 1997).

Somatic symptoms in children can also be manifes-tations of a psychiatric syndrome, such as depressionand anxiety (Bernstein et al., 1997; Egger, Angold, &Costello, 1998; Taylor et al., 1996) or the psychologi-cal expression that emerges from a known pathophysi-ological condition, as in asthma, peptic disease, or mi-graine headache. Because different Hispanic/Latinosubgroups of children may differ significantly fromother non-Hispanics/Latinos in their rates of specificpsychiatric disorders or syndromes that are commonlycomorbid with somatic symptoms, it is important toanalyze the data controlling for comorbid conditions. Itis possible that somatic symptoms are found morecommonly among Mexican American children be-cause the high rates of depression found in this sub-group as compared to non-Hispanics/Latinos (Roberts& Chen, 1995; Swanson, Linskey, Quintero-Salinas,Pumariega, & Holzer, 1992) may predispose them tosomatic symptoms. There is a need to conduct futurecross-cultural studies that will analyze the effect ofcomorbid patterns in increasing the vulnerability andrates of somatic symptoms in children. However, forthis to be accomplished, we must have commu-nity-based samples with large numbers of children andadolescents, as well as assessment instruments thatmeasure not only somatic and anxiety disorders andsymptoms, but also depression and other psychiatricconditions.

Somatic symptoms vary with age, so that abdominalpain and headaches are more common in early child-hood, whereas pseudoneurological, menstrual, andgenitourinary and polysymptomatic symptoms aremore common in adolescence (Beidel, Christ, & Long,1991). In addition, although no significant differencesin the distribution of somatization among the sexes arefound in early childhood, somatic symptoms are moreprevalent in girls after the onset of pubertal develop-ment and menarche (Beidel et al., 1991; Eminson,Benjamin, Shortall, Woods, & Faragher, 1996). Futureresearch should also analyze the risk of somatic symp-toms by sex and age in different ethnic and culturalgroups.

Conclusions

Clearly we need to continue cross-cultural researchin the area of somatic and anxiety disorders amongchildren and adolescents, as Pina and Silverman (thisissue) and Varela and colleagues (this issue) have be-gun. Very few studies have addressed this important is-sue, which has been widely recognized and studied inthe adult literature. Future studies should assess so-matic symptoms comparing different ethnic groupswith large enough sample sizes that permit the analy-

ses of important variables that have been associatedwith somatic symptoms in children. For example, thereis a need to examine differences among ethnic groupsin exposure to stressful and traumatic events, parentalpsychopathology, familial history of somatization, andphysical illness or disability in a parent, which havebeen found to be important predictors of somaticsymptoms in children (Bernstein, Warren, Massie, &Thuras, 1999; Garralda, 1996; Jolly et al., 1994). Thereis also a need to examine sex and sex distributions andhow comorbidity affects the vulnerability of somaticsymptoms in different Hispanic/Latino subgroups.

It is imperative that further research is carried outwith representative community samples that can pro-vide generalizable results. Given the lack of research inthis area, the studies by Pina and Silverman (this issue)and Varela et al. (this issue) contribute to the His-panic/Latino youth anxiety literature. Future researchmay permit the conclusion that somatic and anxietysymptoms are related to a culturally appropriate way ofmanifesting distress among Hispanic/Latino children.However, no matter what the cause of somatic symp-toms among certain subgroups of Hispanics/Latinos,the Pina and Silverman and Varela and colleagues stud-ies document high rates of somatic symptoms and re-lated distress particularly among Hispanic/Latinoyouth. This should alert clinicians to the importance ofassessing somatic symptoms in Hispanic/Latino chil-dren so they can treat these children and adolescentsmore effectively.

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Received May 15, 2003Accepted December 30, 2003

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