Introduction

Fatigue, headache, stomach ache, and backache are common. Large international surveys show that about 8% of adolescents report daily headaches, 10% daily backache, and 16% daily sleepiness in the mornings. Fatigue is even more common—about a third of both boys and girls have substantial fatigue four or more times a week.

Competing demands in adolescence

Most adolescents with these symptoms do not seek help from their doctor. They can present diagnostic dilemmas when they do, however. In most cases, the symptoms reflect not an organic disorder but an imbalance between the increasing educational, social, and sports demands on young people and physiological “debts” owed to rapid growth and sexual development. Adolescents, for example, need more sleep than children and adults, yet social and educational demands often mean that they sleep less. Adolescents may also have a physical hypersensitivity to changes in the growing body. For a minority, these symptoms may represent a functional or somatoform disorder, where psychological problems are expressed through physical symptoms rather than through language. Unexplained abdominal pain is a common example of this in early adolescents, with older adolescents more likely to have headaches or fatigue.

Somatic symptoms

Signs or symptoms suggestive of more serious somatoform disorder include the co-occurrence of multiple symptoms (such as headaches with fatigue and muscle aches), chronicity (symptoms lasting more than three months), diminishing school attendance, and social isolation, together with a history of recent family, school, or psychological problems.

When pain or symptoms remain unexplained, they should …