This research was part of a cross-sectional observational study conducted in May 2020 at the tertiary level, university teaching, children’s hospital, Institute for Maternal and Child Health of Trieste, Italy. Eligible participants were adolescents aged between 13 and 18 years, experiencing the Covid-19 pandemic restrictive measures.
The inclusion criteria were: (1) adolescents who received a diagnosis of SSD at the Institute, within the previous one year, confirmed by a neuro-psychiatric specialist according to the DSM-V, (2) youths who previously accessed the Institute for an acute injury or an acute organic disease in the same period, matched for age and sex. The exclusion criteria were considered the inability to understand the Italian language, the presence of cognitive impairment, a chronic disease, a neuropsychiatric disorder, or any history of non-investigated chronic pain.
All the adolescents of the SSD groups were clinically evaluated jointly by a trained paediatrician and a pediatric psychiatrist.
Adolescents in the control group were consecutively enrolled if admitted for acute trauma (fractures) or illnesses (appendicitis, testicle torsion, pneumonia) without any referred previous history of chronic illness or psychological problem.
The SSD diagnosis was based on a clinical interview conducted by a child neuropsychiatrist and symptom ratings according to the DSM-V criteria [5]. The electronic medical records of all patients admitted between May 2019 and May 2020 were reviewed to collect information about age, gender, symptoms, symptoms complained at admission, diagnostic test, specialist consult, previous hospitalizations, and final diagnosis, including SSD, at discharge.
Based on the defined criteria, we identified two groups:
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SSD group: adolescents with SSD diagnosis;
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Control group: adolescents admitted to the hospital for an acute problem.
A letter explaining the purpose of the study was sent to parents of adolescents who met the inclusion/exclusion criteria. Written informed consent was signed before participation. An anonymous semi-structured SurveyMonkey questionnaire was offered (see online Supplementary file 1) to both adolescents’ groups. It included a general demographic survey, a modified version of the Health Questionnaire Physical Symptoms 15 (PHQ15), the MASC-2-SR and the CDI-2-SF questionnaires. Data regarding the MASC-2-SR and the CDI-2-SF have already been published in another study analyzing depression and anxiety tendencies [9].
The general demographic survey included 18 questions with binary, multiple choices, and the possibility of providing open answers. For each enrolled patient, the following demographic variables were collected: age, gender, information on coping strategies during adolescents’ free-time, including the following main domains: ‘purpose of internet usage,’ ‘pattern of social media, videogames and other leisure usages,’ ‘relationships with peers and parents.’ We also added two questions about general worries and any perceived positive aspect about the ongoing pandemic period to describe adolescents’ general coping strategies during the quarantine period. The PHQ15 questionnaire was administered with the intended goal of quantifying the somatic symptom burden perceived by this cohort of patients [10]. This questionnaire, which investigated somatic symptoms or symptom clusters that accounted for over 90% of the physical complaints reported in the outpatient setting [11], was initially composed of 15 items scoring 0–2 for each. In this study it was administrated with 14 items, excluding the one strictly related to the sexual sphere. According to previous studies with the PHQ-15 [12], missing values were replaced with the mean value of the remaining items if the number of absent items was less than 20%. If the number of missing items in the scale exceeded 20%, the sum score was not computed and counted as missing. The overall results over 14 items were then weighted to 15 items, to compare the result of this study to other previous studies and reference ranges (see Supplementary file 2). The total PHQ-15 score ranges from 0 to 30, and scores of ≥ 5, ≥ 10, ≥ 15 represent mild, moderate, and severe levels of somatization [10]. To assess the anxiety tendency we used the MASC 2-SR which quantifies adolescents’ anxiety across ten domains: separation panic (SP), generalized anxiety disease (GAD), humiliation and refusal (HR), performance fear (PF), social anxiety (SA:T), obsessive compulsive (OC), panic (P), tension and restlessness (TR), physical symptoms (PS:T) and harms avoidance (HA). It investigates 50 items with a score from 0 to 3 for each item. T-scores are categorized into six classifications: Very Elevated (score 70 +), Elevated (score 65–69), Quite Elevated (score 60–64), High Average (score 55–59), Average (score 40–54), and Low (score < 40) [13].
The primary study outcome was to detect differences in attitudes and behaviors during the COVID-19 lockdown, including coping strategies and relationships with parents and peers, between SSD group and their healthy peers. Ethics Committee and approval number: IRB, RC 10/20.
The sample size of 94 (47 for each group) was predetermined to carry out the study, assuming a between groups minimum clinically significant difference of 5 in the mean MASC 2-SR total score.
G* power software, two sided Wilcoxon-Mann Whitney test, 2 groups).
Categorical data were presented as number and percentage, continuous data as median and interquartile range (IQR). Differences between groups (i.e., male vs female or healthy vs SSD) were evaluated with the chi-squared test for categorical data and with the non-parametric Mann–Whitney test for continuous data. The use of nonparametric tests is justified by the non-normal distribution of data, evaluated both visually and with the Kolmogorov–Smirnov test. Differences with p-value < 0.05 were considered statistically significant. Analysis was performed using SPSS version 23 (IBM, New York, USA).