Journal of Adolescent Health 49 (2011) 199 205

www.jahonline.org
Original article

Relationship Between Life Events and Psychosomatic Complaints During

Adolescence/Youth: A Structural Equation Model Approach
Ester Villalonga-Olives, M.Sc.a,b, Carlos G. Forero, Ph.D.a,b, Michael Erhart, Ph.D.c,
Jorge A. Palacio-Vieira, M.P.H.d, Jos M. Valderas, M.D., M.P.H., Ph.D.a,b,e, Michael Herdman, M.Sc.a,b,
Montserrat Ferrer, M.D., Ph.D.a,b,f, Lus Rajmil, M.D., M.P.H., Ph.D.a,b,d, Ulrike Ravens-Sieberer, Ph.D.c,
and Jordi Alonso, M.D., Ph.D.a,b,g,*
a

CIBER en Epidemiologa y Salud Pblica (CIBERESP), Barcelona, Spain

Health Services Research Unit, Institut Municipal dInvestigaci Mdica (IMIM-Hospital del Mar), Barcelona, Spain
Department of Psychosomatics in Children and Adolescents, University Clinic Hamburg-Eppendorf, Hamburg, Germany
d
Catalan Agency for Health Information, Assessment and Quality (CAHIAQ), Barcelona, Spain
e
Division of Primary Care and Public Health, Department of Primary Care, NIHR School for Primary Care Research, University of Oxford, Oxford, UK
f
Associate professor of Faculty of Medicine, Universitat Autnoma de Barcelona (UAB), Barcelona, Spain
g
Director of Master in Public Health, Universitat Pompeu Fabra (UPF), Barcelona, Spain
b
c

Article history: Received May 4, 2010; Accepted November 28, 2010

Keywords: Psychosomatic complaints; Life events; Socioeconomic factors; Structural equation modeling; Adolescents; Youths;
Home life

A B S T R A C T

Purpose: To assess the contribution of life events (LEs) on psychosomatic complaints in adolescents/youths
taking into account a set of socioeconomic variables.
Methods: We tested a conceptual model implemented with structural equation modeling on longitudinal data
from a representative sample of adolescents/youths and parents. Psychosomatic complaints were measured by
the Health Behaviour in School-aged Children scale and hypothesized to be affected by: (a) contextual factors at
distal level: nancial resources, home life and social support (KIDSCREEN), and parent baseline mental health
(SF-12); (b) triggering factors: LEs (Coddington Life Events Scales, with two typologies: desirability and familiarity); (c) intermediate factors: same as distal level but measured at follow-up; (d) immediate cause: mental health
at proximal level (Strengths and Difculties Questionnaire at baseline and follow-up); and (e) gender.
Results: The structural model yielded a good t (Comparative Fit Index .95, TuckerLewis Index .93, Root
Mean Square Error .04). Boys showed more psychosomatic complaints than girls ( .40, p .05). Girls
reported experiencing more LEs (p .05). Only undesirable LEs showed a signicant direct negative effect on
psychosomatic complaints, which became nonsignicant when mediated by home life and mental health.
Undesirable LEs had a remaining indirect effects on psychosomatic complaints (indirect .10, p .05) via
Home Life and Mental health, which were protective factors ( .41 and .15, p .05).
Conclusions: The experience of undesirable LEs increases the probability of psychosomatic complaints, but
the nal effect would be determined by previous levels of home life and mental health stability.
2011 Society for Adolescent Health and Medicine. All rights reserved.

* Address correspondence to: Jordi Alonso, M.D., Ph.D., Health Services Research Unit, IMIM-Hospital Del Mar, Barcelona Biomedical Research Park, Doctor
Aiguader, 88 08003 Barcelona, Spain.
E-mail address: jalonso@imim.es (J. Alonso).
The authors declare they have no conicts of interest.

Stress is a demand for adaptation and coping [1]. Its negative

effects, such as somatic symptoms (e.g., headache or backache)
and low mood, emerge when demands imposed by change exceed individual capacities and resources [2]. In adolescence and
youth, stress has been associated with life changes, particularly
with negative situations at school or work [3,4]. Positive life
changes can also cause stress.

1054-139X/$ - see front matter 2011 Society for Adolescent Health and Medicine. All rights reserved.
doi:10.1016/j.jadohealth.2010.11.260

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E. Villalonga-Olives et al. / Journal of Adolescent Health 49 (2011) 199 205

Table 1
Summary of the time sequence of contextual variables for Berntsson model of psychosomatic complaints
Distal level

Intermediate level

Proximal level

Economic factors: international and national political systems, social, and cultural systems
Socioeconomic level of the family: education, profession, family structure, and employment
Familys economic resources

Family activities
Parents sense of coherence
Support from society and relatives
Health status of parents

School satisfaction
Contacts with peers
Mental stability
Social competence

Personal resources (such as self-esteem, performance at

school) and social resources (such as the quality of home life and
the support of the family structure) are known to have an inuence on the association between stress and psychosomatic complaints [3,5]. For instance, an unstable family structure is hypothesized to reect an unpredictable family environment, which in
the end negatively inuences health [6,7]. However, relatively
few studies have examined contextual and mediating factors
between life events (LEs) and psychosomatic complaints in adolescents. Moreover, those that have been performed did not study in
detail the role of the LE typologies, nor their severity [3,8].
A framework for such study is provided by Berntsson et al [9],
who studied the effect of LEs on psychosomatic complaints from
a multidisciplinary perspective based on research in pediatrics,
epidemiology, psychology, and sociology. They assigned an important role to socioeconomic factors and time sequence (distal,
intermediate, and proximal) to reinforce causal hypothesis. In
their model, some factors, such as child and family characteristics or social context are considered at different moments in time
[9]. Berntssons framework placed the child within the family
and the social structure. At the distal level, contextual variables
that could act as protective factors were included (e.g., economic
and socioeconomic factors), whereas intermediate variables
were potential mediators in a persons response to stress (e.g.,
support from society and relatives). Finally, immediate causes of
psychosomatic complaints at a proximal level were included (e.g.,
mental stability) (Table 1). The authors hypothesized that somatization is the result of LEs in combination with high levels of physical
symptomatology and psychological distress in families [9].
However, the joint relationship of LEs, symptoms, and stress
was not tested in their study. Moreover, several researchers have
maintained that it is inappropriate to assume that health risk or
protective factors in adults can be directly transferred into childrens health [10]. These caveats advise for further assessment of
the determinants of psychosomatic complaints in early ages including LEs.
The objective of the present study was to assess the strength
of the association between LEs and psychosomatic complaints in
adolescents/youths and to examine the role of a range of socioeconomic variables as potential mediators of the relationship.
The study was performed taking into account the previous results on psychosomatic complaints in school-age children by
Berntsson et al and tested in a general population sample of
adolescents and youths included in the Spanish KIDSCREEN
follow-up study.
Methods
Design and sample
The Spanish KIDSCREEN baseline sample was recruited as
part of the European KIDSCREEN eldwork [11]. The target population was children and adolescents aged 8 18 years represen-

tative of general population. Telephone sampling was performed

in 2003 using a Computer Assisted Telephone Interview with
random-digital dialing. Whenever contacted households agreed
to participate, the questionnaire and other study materials were
mailed, with two reminders in cases of nonresponse. In total, 840
families participated in Spain.
Follow-up data were collected 3 years after baseline, an interval which was considered large enough to observe substantive
changes in participants health status. The eldwork followed
the same methodology applied at baseline, but in this instance, a
third reminder was sent after 20 weeks and any remaining nonrespondents were contacted by phone. In total, 454 follow-up
questionnaires were received, 75% of them had paired parent
child information necessary for the analysis of the present work.
More details are provided elsewhere [11,12].
Measures
Adolescents/youths psychosomatic complaints. These were measured using the Health Behaviour in School-aged Children
(HBSC) symptom checklist, which measures the frequency of
occurrence of eight common health complaints over the past 6
months (headache, stomachache, backache, feeling low, irritable
or bad-tempered, feeling nervous, sleeping difculties, and dizziness). Response options are: rarely or never, about every
month, about every week, more than once a week, and
about every day. The items are summed to provide an index
score of psychosomatic complaints ranging from 1 to 40. Higher
values indicate fewer and less severe health complaints. The
scale has demonstrated acceptable validity and reliability [13].
Life events. LEs experienced by adolescents/youths were measured using the Coddington Life Events Scales (CLES) [14 16].
CLES assess the occurrence of 53 events, each item describing a
specic LE. Respondents were asked to indicate the number of
times the event has occurred from 6 months until 3 years before
the follow-up. LEs were classied into two typologies of two
categories each: desirable (e.g., Graduating from high school)
versus undesirable events (e.g., Divorce of parents) and family
(e.g., Loss of a job of your father or mother) versus extra-family
events (e.g., Going on the rst date) [14 16]. Each event has a
value in Life Change Units (LCUs) ranging from 5 to 216 depending on its frequency, the amount of stress associated, and the
time since occurrence (LCUs). Finally, each respondent is assigned a weighted total score in LCUs. The Spanish version of
CLES has been found valid and psychometrically equivalent to
the original [17].
Financial and social capital. Three dimensions of the KIDSCREEN
questionnaire measured nancial resources and social relations
[18]. These dimensions were Financial resources, Social support and peers, and Home life. Scores were computed for each
dimension using a Rasch scoring model and transforming scores

E. Villalonga-Olives et al. / Journal of Adolescent Health 49 (2011) 199 205

into t-values with a mean of 50 and standard deviation (SD) of 10.

The t-scores are based on the mean values and SDs from a representative sample of the European general population [19].
Higher scores indicated better resources. Spanish version of the
KIDSCREEN-52 has demonstrated acceptable reliability and validity [20].
Adolescents/youths mental health. Mental health was assessed
with the Strengths and Difculties Questionnaire (SDQ). This
instrument assesses the psychological adjustment of adolescents and youths using 25 items in the following ve scales:
Conduct, Emotional, Hyperactivity, Prosocial, and Problems
with peers. The SDQ has been shown to be valid and reliable
both in the original English and the adapted Spanish version
[21]. Respondents are classied as Unlikely, Possible, or
Probable cases of specic disorders (conduct, emotional, or
hyperactivity) or any type of mental disorder. Adolescents
and parents responses were used to calculate scores. By comparing baseline and follow-up data, changes in mental heath
were categorized, as follows: (1) Stayed healthy (no mental
health problems at baseline or follow-up unlikely cases), (2)
Improved mental health between assessments, (3) Remained
poor mental health at both assessments; and (4) Worsened
mental health at follow-up.
Parents mental health. We used the Spanish version of the SF-12
questionnaire to assess parents mental health status [22,23].
Scores for the Mental Health Component Summary (MCS-12)
were calculated using a standardizing procedure to obtain a
mean of 50 and a SD of 10 on the basis of the general population
data of the United States.
All variables were collected both at baseline and at follow-up,
except for the LEs, which were retrospectively collected at
follow-up. Table 2 illustrates how the concepts under study were
made operational and includes item examples for these
variables.

201

Development of the model

We adapted Berntssons model by including LEs as a trigger
for the onset of psychosomatic complaints while taking into
account possible mediators (Figure 1). We hypothesized that
nancial resources, home life, social support, and peers and parents mental health status measured at baseline would operate at
a distal level (Figure 1a), whereas the same variables measured at
the follow-up (excluding nancial resources, because of its stability) would operate at an intermediate level. Distal variables
collected at baseline were hypothesized to have a protective
effect because good levels would positively affect the same variables at intermediate level and reinforce their potentially protective effect as mediators.
On the basis of the work done by Greene and Walker [2] and
the work presented by Berntsson et al [9], LEs were considered as
triggering factors (Figure 1b) for psychosomatic complaints. The
relation between LEs and psychosomatic complaints was hypothesized to be indirect, as several mediators may act between
the two. Model mediators (intermediate variables) were home
life, and social support and peers (Figure 1c). A direct effect from
parents mental health to psychosomatic complaints was also
hypothesized. Parents mental health was considered to be a
mediator despite not having a direct relation with LEs because of
its potential protective effect for psychosomatic complaints. Adolescents/youths mental health stability was included at a proximal level (Figure 1d) because the lack of mental health stability
was hypothesized to be an immediate cause of psychosomatic
complaints. All variables were selected following Berntssons
model, although some intermediate and proximal variables were
lacking in KIDSCREEN (family activities, parents sense of coherence, parents global health status, school satisfaction, and social
competence). Other factor included in the model was gender. It
was expected that girls would suffer more psychosomatic complaints and LEs. We hypothesized that undesirable and family LEs
would have a greater effect on psychosomatic complaints than
desirable or nonfamily events.

Table 2
Variables and assessment instruments used from the KIDSCREEN follow-up study
Observed variables

Instruments

Time data collected

Recall period

Respondent

Item example

Psychosomatic
complaints

HBSC

Follow-up

Previous 6
months

Adolescents/youths

Life events

Coddington Life Events Follow-up

Scales
retrospectively

Financial resources

KIDSCREEN dimension Baseline and follow-up Previous week

Adolescents/youths

Social support and

peers
Home life

KIDSCREEN dimension Baseline and follow-up Previous week

Adolescents/youths

KIDSCREEN dimension Baseline and follow-up Previous week

Adolescents/youths

Headache, stomach ache, backache, feeling

low, irritable or bad tempered, feeling
nervous, sleeping difculties, dizziness
Becoming involved with drugs (undesirable
and extra-family)
Major increase in your parents income
(desirable and family)
Have you had enough money to do the
same things as your friends
Have you and your friends helped each
other?
Have your parent(s) had enough time for
you?
Have you felt downhearted and depressed?

Parents mental heath SF-12 v2

status
Mental health
SDQ
stability

From 6 months to Adolescents/youths

3 years before
assessment

Baseline and follow-up Previous week

Parents/proxy

Baseline and follow-up Previous 6

months

Parents/proxy and
adolescents/youths

I try to be nice with other people. I care

about their feelings.
Conduct: lies, ghts, temper, steals
Emotional: fears, worries, clingy, unhappy,
somatic
Hyperactivity: distractible, persistent,
restless, dgety, reective

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E. Villalonga-Olives et al. / Journal of Adolescent Health 49 (2011) 199 205

Figure 1. Etiological model of relationships among risk factors that might affect psychosomatic complaints in the KIDSCREEN follow-up study.

Statistical analysis
The nal dependent outcome was psychosomatic complaints
in adolescents/youths as measured at follow-up (in 2006). A
structural equation modeling was used to: (a) test whether intermediate variables acted as partial or full mediators for the
inuence of LEs on psychosomatic complaints; (b) establish the
magnitude of the relationship among variables; and (c) jointly
assess which factors most strongly inuenced psychosomatic
complaints in adolescents/youths [24].
One structural model for each LE category was constructed to
predict the direct and indirect effect of variables in the model. All
models took into account the time sequence of the different
variables: distal, triggering, intermediate, and proximal. As both
continuous and ordinal variables were included, the estimator of
choice was Unweighted Least Squares Estimation with mean and
variance corrections (ULSMV), to provide robust p-values and
standard errors [25]. Model t was assessed using Comparative
Fit Index (CFI), TuckerLewis Index (TLI), and Root Mean Square
Error (RMSEA) [26]. Conventional cut-off criteria indicating good
t are CFI and TLI greater than .90, whereas RMSEA typically used
a cut-off value of .05. The model was implemented and estimated using Mplus 5.2 [27].
Final parameters for continuous variables are parameterized as
standardized regression coefcients [28]. Mental health stability
was treated as ordered categorical, with four ordered categories
assuming a proportional odds logistic model [29]. To simplify interpretation, mental health stability parameter estimates were reparameterized to reect changes in odds ratios [29].
There were marginally signicant differences between baseline and follow-up samples regarding mean age and socioeconomic level, which is a common result in longitudinal studies of
this type [30]. Additionally, attrition was compatible with a missing completely at random (MCAR) data pattern. Littles test [31]
for MCAR was nonsignicant (p .26), indicating that results

would be equal to those that would be obtained if no data were

missing. This result and the small variable differences led to the
decision of complete data patterns analysis, without using any
imputation method.
Results
There were marginally signicant differences between baseline
and follow-up samples regarding mean age and socioeconomic
level, which is a common result in this type of longitudinal studies
[30]. The 331 paired parent children data array did not differ from
the total 454 questionnaire sample and was compatible with a
MCAR pattern (Littles MCAR test p .26), and thus the complete
patterns sample were deemed adequate for analysis.
In all, 52% of adolescents/youths and 77% of responding parents
were females (Table 3). No signicant differences in parental report
were evident depending on parents gender. Boys reported more
psychosomatic complaints than girls (HBSC sum-scores of 35.6 for
boys and 33.6 for girls, t 3.025, df 329, p .002). For both boys
and girls, the most prevalent psychosomatic complaint was dizziness and the least prevalent was feeling nervous. Girls reported
experiencing more LEs, with higher LCUs than boys both in terms of
overall LEs and across all the categories. Extra-family LEs were
associated with the highest LCU scores.
Figure 2 shows the model factors that affect the presence of
psychosomatic complaints. Although we tested the model with
the four LEs categories, only undesirable events were found to be
a signicant triggering factor for psychosomatic complaints.
Model absolute t was excellent (2 22.87, df 15, p .09). The
model also showed good indices for approximate (RMSEA .04)
and incremental t (CFI .95, TLI .93) and it explained 28% of
the variance in overall psychosomatic complaints.
To test the effect of LEs on psychosomatic complaints, we
compared the model to assess the signicance of the direct and
mediator effects. The direct effect from LEs on psychosomatic

E. Villalonga-Olives et al. / Journal of Adolescent Health 49 (2011) 199 205

Table 3
Sample descriptives on baseline and follow-up. KIDSCREEN follow-up study
Observed variables

Total (n 331)
Mean/percentage

Baseline
Adolescents and youths
Financial resources
Social support and peers
Home life
Any mental health disorder: possible
and probable cases
Parents
Age
Mother responding
Parents mental health status
Follow-up
Adolescents and youths
Age
Psychosomatic complaints
Headache
Stomach ache
Backache
Feeling low
Irritable or bad-tempered
Feeling nervous
Sleeping difculties
Dizziness
LCUs global life events
LCUs undesirable life events
LCUs desirable life events
LCUs family life events
LCUs extrafamily life events
Social support and peers
Home life
Any mental health disorder: possible
and probable cases
Mental health stability
Worsened
Remained poor mental health
Improved
Stayed healthy
Parents
Parents mental health status
a

SD

52
54.5
52.22
17%

8.7
9.7
9.7
.4

42.22
77.5%
52.4

6.8
8

15.4
34.6
4.3
4.5
4.2
4.4
4.1
3.8
4.4
4.6
48.8
22.8
22.2
14.4
33
51.4
49.6
18.9%

2.8
5.2
.9
.8
1.1
.9
1
1.2
1
.8
53.5
36.3
25.2
22.9
42.2
8.8
9.1
.5

12.7%a
6.9%
9.4%
71%
48.3

10.3

SD are not given because percentages pertain to group of respondents.

complaints was signicant ( .12, p .007), and did not show

acceptable t (2 44.45, df 15, p .001; RMSEA .08; CFI
.80; TLI .72). When mediators were included, the direct relationship failed to reach statistical signicance ( .03, p
.344) but the indirect relationships in Figure 2 (via home life and
mental health stability) became signicant ( .09, p .004).
Results indicate that the direct effects of the LEs become nonsignicant when intermediate variables are taken into account (i.e.,
they act as full mediators) [32].
Total indirect effect of undesirable LEs on psychosomatic
complaints was .10 (p .011). This result implies that the most
undesirable LE (i.e., the death of a close family member, achieving 108 LCUs) would lead to a decrease (worsening) in psychosomatic HBSC scores equivalent to .25 SDs. The experience of an
undesirable LE that weighs 108 LCUs was associated with a
reduction (worsening) of .21 SDs on the home life domain which
would lead to a decrease in home life scores equivalent to one SD.
Variables at distal level signicantly affected those included
at the intermediate level. All the coefcients were positive, indicating a protective effect from distal to intermediate level variables. Social support and peers showed protective effect on home
life ( .25, p .05) and it was directly related with psychoso-

203

matic complaints ( .41, p .05). Additionally, home life

showed an indirect protective effect on psychosomatic complaints as it increased mental health stability ( .44, p .05).
Home life total effects (the sum of direct and indirect effects) was
.47 (p .05), indicating that better home life is signicantly
associated with lower levels of psychosomatic complaints. In
mental health stability, all category intercepts were signicant,
indicating correct ordering of severity in the classication. The
estimated odds ratio was .64, which means that increasing home
life in one SD reduces the odds of being in a poorer mental health
category (reduction of .64 SDs in mental health score). The effect
of mental health stability on psychosomatic complaints was negative ( .15, p .05), indicating also a protective effect.
Although the effect of parents mental health status on psychosomatic complaints was not statistically signicant ( .09,
p .08), it was retained in the model on theoretical grounds.
Finally, males were more prone to suffer psychosomatic complaints, compared with girls ( .40, p .05).
Discussion
The ndings of the present study indicate that inuences on
psychosomatic symptoms in adolescents and youths can be attributed to a complex causal model with several indirect causes
and mediating factors. In accordance with Berntsson et al [9], our
results show that common undesirable LEs are associated with
psychosomatic complaints through their effect on home life
problems. Importantly, the reinforcement of socioeconomic factors could act as mitigating part of this relationship as long as
they improve the measures that are negatively affected by undesirable LEs. The strong relationship between stressors and psychosomatic complaints has been widely investigated in adults.
However, the testing of a theoretical model assessing mediating
effects and different types and magnitudes of LEs in children and
adolescents was lacking in the published data.
Our model explained 28% of the variance in psychosomatic
complaints, in the same range than previous research, such as
Berntsson et al (24%) [9]. But our model included fewer factors,
which might indicate that adding LEs as triggering factors and
considering an etiological sequence of variables renders a thorough causal hypothesis of psychosomatic complaints.
Concerning this etiological sequence, we found that those
factors hypothesized to be at a distal or intermediate level had an
important protective effect. Financial resources protected home
life and social relations [3335]. Good levels of family relations
are associated with higher levels of stable mental health, and it
protects against undesirable events. In our study, family context
variables seem more important protecting against the effects of
undesirable LEs than social support and peers. This is consistent
with the previously published data [36], showing that the lack of
nurturance and family related problems contribute to maladjustment and, as a consequence, in health related problems [37].
Regarding the triggering factor, and consistent with previous
research, our results show that a relationship exists between
stressors and psychosomatic complaints [2]. But only undesirable LEs were associated with psychosomatic complaints. This
association yielded a total effect of .24 in Cohens d units (effect
sizes). More noticeably, from this total, the partial value for
indirect effect reached .20 in Cohens d units. Pure direct effects
had a partial effect value of just .04 an effect value that did not
even reach signicance. In our model, results indicate that such
association is completely mediated by the relation between LEs

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E. Villalonga-Olives et al. / Journal of Adolescent Health 49 (2011) 199 205

a) Financial
resources
0.32 (0.04)

0.21(0.05)
0.87

0.60
0.20 (0.05)

a) Parents
mental health
status at
baseline

0.34
0.48 (0.05)

(0.04)

a) Home life
at baseline

Distal
level

a) Social
support and
peers at
baseline

0.37 (0.05)

b)Undesirable life
events

0.39 (0.05)

Triggering
factor

-0.21 (0.05)
0.83
0.82

0.67

c) Parents
mental health
status at
follow-up

c) Home life at
follow-up
0.25 (0.05)

c) Social
support and
peers at
follow-up

Intermediate
level

-0.44 (0.08)
1.54 OR increase for better pronostic.
0.83

0.09 (0.05)*
0.41 (0.05)

Proximal
level

d) Mental
health
stability

-0.15 (0.06)

0.73

Psychosomatic
complaints

e) Gender
0.40 (0.10)
for boys

Figure 2. Structural parameters for the model of undesirable life events. KIDSCREEN follow-up study. Note: Dashed lines represent nonsignicant paths. Double headed
arrows represent the residual variance of the endogenous variables. Only signicant standardized parameters and their standard errors are shown (p .05), * except (p
.08). Categorical variable parameter interpretation as odds ratios is shown in italics. Fit indexes: 2 22.87, df 15, p .09; Comparative Fit Index .95; TuckerLewis
Index .93; Root Mean Square Error: .04.

and home life. Consequently, one LE implying 45 LCUs (e.g., the

loss of a job by the father/mother or tutor) conveys a change in
home life scores equivalent to .5 SD. Such value can be considered a clinically important difference [38].
Our previous hypothesis on gender differences was that girls
would display higher risk of psychosomatic complaints than
boys. In fact, the results were quite the contrary. Most of the
previous reports indicate that girls have a higher risk than boys of
suffering psychosomatic complaints [5,8,34], whereas we found
that boys, as a group, were more prone to suffer from such
complaints than girls. Girls, on average, showed somewhat better home life, higher mental health stability, and more social
support and peers. This combined values, altogether protective,
could partially explain these results [39]. Other factors not con-

sidered in this study such as different social roles, coping mechanisms, and lifestyles could also explain the greater frequency of
complaints among boys [34]. However, this result should be
considered in future research.
One limitation of our study was a somewhat low response
rate at the follow-up (54%). Although this level of response is
typical in postal surveys [40], it is important to indicate that
despite attrition, the sample was representative of the Spanish
population in terms of age and gender when compared to census
data [12]. In addition, individuals lost in the follow-up sample
were shown to be compatible with the assumption of missing at
random data, which also points at good external validity of our
results. Second, the CLES questionnaire was used to collect LEs
which had occurred up to 3 years before the assessment date.

E. Villalonga-Olives et al. / Journal of Adolescent Health 49 (2011) 199 205

Likewise, the SDQ was originally developed for children aged 16,
whereas our sample included adolescents/youths aged up to 21.
However, a pilot test performed before the follow-up study
showed that using these questionnaires outside their original
age range was adequate [12]. Finally, some factors which were
signicant mediators in the Bertssons model, were not included
in our study, and could have had an effect on the results [9]. They
should be considered for inclusion in future studies.
Despite these limitations, the present study is one of the few
based on a general population sample of adolescents and youths.
Most research into LEs and psychosomatic complaints has been
carried out in adults, in clinical settings or in convenience samples of students. Our results add population representative information on ages that has been seldom studied in the published
data. We also found support for an etiological sequence and
simplied previous models in terms of number of variables studied while explaining a high degree of the variance.
One straightforward implication of the present study is that
intervention programs should aim to increase family support as
well as to improve the nancial and social resources available to
families. These factors have been shown to be nuclear in the
etiological process from undesirable LEs to psychosomatic complaints. Future research should assess whether other factors can
inuence the frequency of psychosomatic complaints, and to
conrm the increased vulnerability of boys.
Acknowledgments
The authors are grateful to CIBER-ESP and the Ministerio de
Educacin for providing a grant for E. Villalonga-Olives to prepare the present manuscript at the University Clinic HamburgEppendorf. This research was supported by FIS Expte PI042315,
DURSI-GENCAT (2005-SGR-00491), and Ministerio de Ciencia e
Innovacin FSE (JCI-2009-05486).
JMV, LR, and JA participated in the conception and design of
the study. EVO, CGF, ME, and JAP analyzed the data. EVO, JMV,
MH, MF, URS, LR, and JA participated in the drafting of the article.
All authors contributed to a critical revision of the manuscript
and made a substantial contribution to its content, and read and
approved the nal manuscript.

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