Research on psychosomatic complaints by senior high school students in Tokyo and their related factors

Authors


Correspondence address: YurikoTakata MC Master of Counseling, Doctoral Program in Medical Science, University of Tsukuba, 1-19-17-3 Matsuba-Cho, Kashiwa-City, Chiba 277-0827, Japan. Email: takatayuri@aol.com

Abstract

Abstract The purpose of this study was to clarify the relationships between psychosomatic complaints of senior high school students in Tokyo and the cognition they receive from their fathers, mothers, friends, teachers, and schoolwork and between their complaints and lifestyle habits. The subjects were 168 first-grade students (58 males and 110 females) at a Tokyo Metropolitan senior high school. In June 1996, a collective survey was carried out, using questionnaires. Moreover, I conducted a longitudinal study to investigate the variation of their complaints over the 3 years at the school. The females had more psychosomatic complaints than the males. There was the relationship between their psychosomatic complaints and the cognition they receive from their fathers, mothers and teachers, the relationship between their psychosomatic complaints and their schoolwork, the relationship between their psychosomatic complaints and their ingestion conditions at meals, or sleeping hours. As for the their complaints, they had more complaints at admission than at the completion of their first grade and at graduation.

INTRODUCTION

The rate of secondary school attendance is 96% in Japan, 90% in the USA, 82% in the UK, and 86% in France.1 The figure for Japan is substantially higher than that for other nations in Europe and America, and it can be said that most Japanese senior high school students attend school. Brown2 and Angelino et al.3 point out that the place where children feel most stressed is at school.

The author has been working as a nurse teacher at a senior high school and considers the number of adolescent boys and girls complaining of physical problems has increased. Hence, I have conducted studies to investigate the present state of children's health.4–6

Considering school health issues overall, I have noticed that the most serious health problems encountered by students are emotional problems and psychosomatic problems, which are commonly observed by both Japanese and American school nurses.7 However, the background of schoolchildren's health-care problems differs between Japan and the USA. In Japan, children's health-care problems are attributable to stress arising from academic competition, interpersonal relations with classmates or teachers, a psychologically rooted refusal to attend school, or other problems peculiar to Japanese society.7 In contrast, in the USA, poverty and family problems produced by social structure are more important causes of schoolchildren's health-care problems than academic competition.8.9American school health-care research has focused mostly on issues related to AIDS, alcohol, smoking, violence, drug abuse etc.10–14

In the Japanese situation, a phenomenon called ‘spending time in the school infirmary’ has become notable, in which students go to school, but spend their time in the school infirmary instead of in class. The number of students with physical symptoms caused by mental problems who come to school infirmaries has increased. About 30% of senior high school students complain of fatigue or of being easily fatigued.

From a review of previous studies on the health of senior high school students in Japan, there have been some studies on the relationship to healthy habits or psychosocial factors, focusing on symptoms of depression.15,16 However, those studies were not as extensive as the epidemiological studies on symptoms of depression in pubertal subjects in Europe and the USA.17–19 Moreover, there have been only a few studies on the overall health of senior high school students.

High school students are in a transitional stage in terms of development of human relations with their parents, friends etc. Thus, for the students to achieve successful development and enhance their health, it is necessary for people who support them, including families, friends, and teachers, to understand the factors affecting their health and to consider the problems related to their health, and their countermeasures, together with the students themselves. Thus, there is a need to accumulate basic data on the health of senior high school students.

In this study I conducted two surveys. With survey 1, the aim was to establish an understanding of the actual situation with respect to the health of first-grade students soon after they entered senior high school and to clarify the relationship between their psychosomatic complaints and the recognition they received from their fathers, mothers, friends, and teachers, the relationship between their complaints and their schoolwork and the relationship between their complaints and their lifestyle habits. With survey 2, I conducted a longitudinal study to elucidate the variation of their psychosomatic complaints over a 3-year period at the school.

SURVEY 1

Subjects and methods

Subjects

A questionnaire survey was conducted in June 1996 on 168 first-grade students [males: 58 (34.5%); females: 110 (65.5%)] enrolled in April 1996 at the Tokyo Municipal Vocational High School A.

The reasons for using the first-grade students as the subjects were because: their health education and instruction should be started soon after their admission from the viewpoint of primary prevention; the first-grade students are likely to have more subjective symptoms than the second- or third-grade students; and understanding the factors is necessary to help them effectively.20

Data collection

The survey conducted in June 1996 was in the form of group surveys using questionnaires filled in by the students themselves with the cooperation of the home-room teacher. The students were asked to enter their names on the questionnaires for the purpose of data matching.

Instrument

The survey contents consisted of the following items: (i) 30 items about psychosomatic complaints; (ii) 6 items each about their cognition to fathers, mothers, friends, teachers and friends; (iii) 5 items about their cognition to the schoolwork; and (iv) items about their lifestyle habits (ingestion conditions, sleeping hours etc.). Although Minnesota Multiphasic Personality Inventory (MMPI),21 the Cornell Medical Index (CMI)22 and so forth are used for questionnaires relating to psychosomatic complaints, both of these have many questions. Moreover, they are not used that frequently for Japanese high school students. It was therefore decided to use 30 items pertaining to somatic and psychological complaints currently mentioned most frequently by students with reference to Nippon Hoso Kyokai (NHK) public opinion surveys23 and surveys of the Tokyo Metropolitan Board of Education24 that are used nationwide in Japan for junior high school and senior high school students (Table 1).

Table 1.  Mean and factor analysis of psychosomatic complaint items
Psychosomatic complaint itemsMean (SD)IIIIIIIVV
  1. Extraction method, principal factor analysis; rotation method, Varimax with Kaiser normalization; cumulative factor contribution rate, 51.8%.

Depressive symptoms (α = 0.91)
Lack tenacity1.36 (1.06)0.780.120.020.130.21
Get distracted1.39 (1.05)0.760.210.140.140.11
Irritated without any reasons1.27 (1.18)0.750.040.180.140.08
Somehow feel sick1.06 (1.02)0.730.28− 0.020.100.02
Tired of talking with other people1.29 (1.12)0.720.160.130.070.06
Get in no mood to do anything1.78 (1.16)0.680.280.210.17− 0.09
Feel gloomy1.48 (1.06)0.640.330.07− 0.05− 0.07
Difficulty in putting my thoughts together1.46 (1.10)0.630.350.18− 0.02− 0.01
Relationship between me and my friends gets bad0.99 (0.94)0.630.090.19− 0.200.12
Like shouting1.54 (1.17)0.600.180.070.080.07
Physical symptoms (α = 0.83)
Catch a cold0.93 (1.00)0.080.67− 0.09− 0.040.20
Tired easily1.57 (0.99)0.370.65− 0.06− 0.040.05
Headache0.83 (0.90)0.170.630.300.07− 0.01
Stiffness in the shoulder1.29 (1.15)0.210.580.110.18− 0.01
Dizziness when I stand up1.48 (1.09)0.130.570.230.230.14
Heavy in the head1.05 (0.98)0.310.560.350.04− 0.08
Heavy in the stomach or nausea0.72 (0.95)0.040.550.190.21− 0.09
Pain in the chest0.62 (0.86)0.180.470.34− 0.160.33
Like lying1.79 (1.12)0.280.460.150.13− 0.06
Sleep badly1.04 (1.08)0.280.41− 0.010.12− 0.05
Neurotic symptoms (α = 0.65)
Palpitation without any reasons0.55 (0.87)0.060.280.710.020.04
Numbness or trembles in the arms or legs0.33 (0.65)0.140.050.620.250.09
Tic0.86 (0.97)0.130.170.52− 0.02− 0.05
Suddenly feel difficulty in breathing0.44 (0.78)0.190.440.51− 0.190.37
Eat too much when I have some uneasiness0.39 (0.77)0.44− 0.130.490.08− 0.12
Digestive symptoms (α = 0.69)
Diarrhoea0.39 (0.72)0.170.20.010.730.05
Stomach ache0.75 (0.88)0.190.360.160.71− 0.02
Allergic symptoms (α = 0.32)
Allergic rhinitis0.73 (1.14)0.060.01− 0.11− 0.010.76
Atopic dermatitis0.27 (0.72)0.01− 0.090.230.340.63
Asthma attack0.26 (0.67)0.210.15− 0.01− 0.210.33
Factor contribution rate 29.607.605.205.004.40

The items about their cognition to their friends and teachers, and schoolwork were decided with reference to the study by Okayasu et al.25 Okayasu's survey targets junior high school students. This report covers students in the first grade of senior high school. Most of the students are 15 years old at the time of the first survey (June). As teachers, we know that the development of children is being arrested year by year. Therefore, I consider junior high school students, especially those who are in the third grade in Okayasu's research, are on the equivalent level of development as the first-grade senior high school students targeted in this report. For the current study I have referenced the items used from the report by Okayasu.

The items about their cognition to their fathers and mothers were cited from the survey carried out by Tokyo Metropolitan Living Culture Bureau.26 Each item has four scale levels, and the respondents were asked to select the most appropriate frequency.

Data analysis

Assessment of each item was scored from 0 to 3 points for replies consisting of ‘never’, ‘rarely’, ‘sometimes’, and ‘frequently’. The score with respect to psychosomatic complaints was shown as the higher the score, the more their complaints. The scale in 30 items about psychosomatic complaints was based on a principal factor analysis with varimax rotation. In order to analyse the relationships between extracted factors and cognition to their fathers, mothers, friends, teachers and awareness of schoolwork, I conducted Pearson's product moment correlation by the sexes. The cognition score showed that the higher the score, the more their cognition was positive.

With respect to the relationship between extracted factors and the items about lifestyle habits, I conducted Pearson's product moment correlation by the sexes. For analyses, the statistical package SPSS was used (SPSS 9.05 for Windows, SPSS Co., Chicago, USA).

Results

The number of valid answers was 168 (100% of the collection rate, 58 males and 110 females).

(1) Scale for 30 items of psychosomatic complaints.

The content validity of the 30 psychosomatic complaints was confirmed by specialists (one doctor and one psychologist). As for the surface validity, I asked five non-target students to respond to the questions to get their opinions on difficulty of expression of questions and the length of the time for responding, and they did not indicate any problems.

I studied the construct validity by principal factor analysis. The communality estimation was established by squared multiple correlation. The rotation was performed on factors with eigenvalues ≥1.0. Consequently, five factors were extracted. The five factors, Factors 1, 2, 3, 4, and 5, were named factors of depressive symptoms, physical symptoms, neurotic symptoms, digestive symptoms, and allergic symptoms, respectively. The Cronbach's alpha coefficient indicating internal consistency in each factor was 0.32–0.91. The alpha coefficient was 0.91 for 30 psychosomatic complaints (Table 1).

Because the alpha coefficient for factors of allergic symptoms was low, the three items belonging to the factors were excluded and the analyses of factors were conducted with 27 items again. Four factors were extracted as was the case for 30 items. Moreover, as for the correlation coefficients of 30 items, the three items classified into those of allergic symptoms have such small correlation with the other items that its relation was not found. Thus, the factors of allergic symptoms were excluded in the analyses, and their psychosomatic complaints were analysed with the four factors. The alpha coefficient was 0.91 for 27 items.

In the items about their cognition to their fathers, mothers, friends, and teachers, and schoolwork, the alpha coefficient was 0.69, 0.70, 0.87, 0.79, and 0.51, respectively.

(2) Comparison of psychosomatic complaints between the males and females.

The female students had significantly higher scores for depressive symptoms, physical symptoms, and neurotic symptoms, as shown in Table 2.

Table 2.  Mean of the scores for the factors of psychosomatic complaints
 Males (n = 58)Females (n = 110)
Factor of complaints (range)Mean (SD)Mean (SD)t-value
  • * 

    P < 0.05;

  • ** 

    P < 0.01;

  • *** 

    P < 0.001; n.s., not significant.

Depressive symptoms (0–30)11.28 (7.65)15.66 (7.84)3.48***
Physical symptoms (0–30)9.48 (6.29)12.27 (6.21)2.76**
Neurotic symptoms (0–15)1.84 (2.32)2.95 (2.71)2.63*
Digestive symptoms (0–6)1.03 (1.68)1.20 (1.24)0.73 n.s.

(3) The relationship between their psychosomatic complaints and their cognition to their fathers, mothers, friends, teachers, and schoolwork.

It is concluded that male and female students who negatively recognize their fathers, mothers, teachers and schoolwork often have psychosomatic complaints (Table 3).

Table 3.  Correlation between psychosomatic complaints scale score and students' cognition
 Cognition to
their fathers
Cognition to
their mothers
Cognition to
their friends
Cognition to
their teachers
Cognition to
schoolwork
  • * 

    P < 0.05;

  • ** 

    P < 0.01;

  • *** 

    P < 0.001.

Male
Depressive symptoms− 0.36**− 0.11− 0.20− 0.33**− 0.47***
Physical symptoms− 0.22− 0.14− 0.01− 0.27*− 0.29*
Neurotic symptoms− 0.18− 0.30*− 0.13− 0.14− 0.30*
Digestive symptoms− 0.04− 0.16− 0.09− 0.36**− 0.41***
Female
Depressive symptoms− 0.18− 0.31**− 0.120.07− 0.28**
Physical symptoms− 0.25*− 0.20− 0.01− 0.13− 0.06
Neurotic symptoms− 0.10− 0.17− 0.05− 0.22*− 0.02
Digestive symptoms− 0.05− 0.07− 0.20− 0.16− 0.05

(4) The relationship between psychosomatic complaints and ingestion or sleep.

For the males, the correlation between the scores for various neurotic symptoms and those of meals is shown in Table 4. For the females, the correlation between the scores for various depressive symptoms and sleeping hours is shown in Table 4.

Table 4.  Correlation between psychosomatic complaints scale score and students' lifestyle habits
 Ingestion at breakfastIngestion at evening mealIngestion form at
evening meal
Sleeping hours
  • ** 

    P < 0.01.

Male
Depressive symptoms0.050.32− 0.15− 0.26
Physical symptoms0.090.22− 0.17− 0.18
Neurotic symptoms− 0.260.38**0.01− 0.12
Digestive symptoms0.010.04− 0.08− 0.22
Female
Depressive symptoms0.020.08− 0.04− 0.28**
Physical symptoms0.050.23− 0.04− 0.22
Neurotic symptoms− 0.07− 0.010.10− 0.01
Digestive symptoms0.17− 0.010.10− 0.19

SURVEY 2

Subjects and methods

A questionnaire survey was conducted on 168 first-grade students enrolled in April 1996 at the same Tokyo Municipal Vocational High School as in the first survey. Analysis was performed on 142 students from whom survey forms were able to be collected all four times.

Data collection

With the cooperation of teachers in charge of classes, I conducted the collective survey with questionnaires in which the subjects themselves entered their names at the following stages: in June 1996 (at admission) when survey 1 was conducted; March 1997 at the completion of the first grade; March 1998 at the completion of the second grade; and January 1999 at graduation.

The reason for the student's names being indicated on the questionnaires was to trace year-by-year changes of the group of the same respondents, with the exception of those who dropped out of school or failed to pass on to the next grade.

Instrument

The survey contents consisted of the same items in the first survey.

Data analysis

The four factors for psychosomatic complaints, which were extracted in survey 1, were analysed. Using the scores of the four factors as criterion variables, I conducted replications of two-way analysis of variance for sex difference and time (at admission, the completion of the first grade, the completion of the second grade, or graduation). The F-test and Tukey's test for multiple comparisons as subordinate testing of analysis of variance were conducted. For the analyses, the statistical package SPSS was used.

Results

The number of valid answers was 142 (84.5% of the collection rate; 50 males and 92 females). In the multivariate analysis of variance with replications, the results for depressive symptoms showed significant differences in the main effect for the sexual group (males and females) (F = 11.05, P < 0.001) and the main effect for the time group (F = 11.10, P < 0.001). That is, the females had a significantly higher score for depressive symptoms than the males (P < 0.001). In the multiple comparisons of times, the score for depressive symptoms at admission was significantly higher than that at the completion of the first grade (P < 0.05). The score for depressive symptoms at admission was significantly higher than that at graduation (P < 0.05). The score for depressive symptoms at the completion of the second grade was significantly higher than that at graduation (P < 0.05).

Physical symptoms showed significant differences in sexual main effect (F = 10.08, P < 0.01) and time main effect (F = 4.08, P < 0.01). That is, the females had a significantly higher score for physical symptoms than the males (P < 0.001). In the multiple comparisons of times, the score for physical symptoms at admission was significantly higher than that at the graduation (P < 0.05).

For neurotic symptoms, significant differences were found due to sexual main effect (F = 12.39, P < 0.001). The females had significantly higher scores for neurotic symptoms than the males (P < 0.001). As for digestive symptoms, no significant difference was seen in both main effect and interaction. Table 5 shows the results of their complaints.

Table 5.  Mean of the scores for the factors of psychosomatic complaints in different sex and time
Factor of
complaints (range)
Males
(n = 50)
Females
(n = 92)
 Mean (SD)Mean (SD)
Depressive symptoms (0–30)
At admission10.80 (7.56)15.56 (7.67)
Completion of the first grade9.32 (6.60)12.17 (6.53)
Completion of the second
grade
10.40 (6.71)13.64 (7.30)
Graduation8.72 (7.05)10.86 (6.94)
Physical symptoms (0–30)
At admission9.16 (6.14)11.88 (6.09)
Completion of the first grade8.04 (5.54)10.70 (6.13)
Completion of the second
grade
9.18 (5.18)11.38 (5.37)
Graduation7.70 (5.89)10.19 (5.41)
Neurotic symptoms (0–15)
At admission1.78 (2.38)2.95 (2.73)
Completion of the first grade1.60 (1.90)2.89 (2.47)
Completion of the second
grade
2.00 (2.04)3.30 (2.70)
Graduation1.70 (1.91)0.95 (1.17)
Digestive symptoms (0–6)
At admission1.06 (1.67)1.19 (1.28)
Completion of the first grade1.14 (1.11)1.12 (1.27)
Completion of the second
grade
1.00 (1.23)1.17 (1.44)
Graduation1.04 (1.32)0.95 (1.17)

DISCUSSION

Validity and reliability of scale

Content validity and surface validity are considered to be supported without any concerns. As for construct validity, I conducted the principal factor analysis for 30 items and 27 items. As a result, the subscale of the same factor was extracted as shown in Table 1.

The alpha coefficient of Cronbach, an indicator of internal consistency of the reliance, ranged between 0.69 and 0.91, which is rather high. Therefore, it can be considered that each factor is at the level of satisfying the reliability of subscale. From this I considered that the 27 items in Table 1 are effective as the research items of this study concerning high school students’ psychosomatic health conditions.

Psychosomatic complaints in males and females

In females, rapid physical changes occur with initiation of menstruation in the secondary sex characteristics, accompanied by various symptoms. The effect of the secondary sex characteristics is assumed to be one of the factors causing many complaints by the first-grade female students. My results that the females had more psychosomatic complaints than the males corresponded to the survey results in other reports.6,15,24 In other countries, Craig and Van Ntta.27 reported that females had a higher depressive level than males and were likely to express more temporally depressive emotion. Hirschfeld and Cross.28 stated that females had a higher level of depressive symptoms within the normal range. Results from the present study support these results.

The relationship between their psychosomatic complaints and their cognition to their fathers, mothers, friends, teachers, and schoolwork

When male and female high school students recognize their fathers and mothers negatively, they often complain of psychosomatic symptoms. The results show that for high school students who are at a turning point in their development of psychological weaning for mental independence, how they recognize their parents as a safety base affects their psychosomatic complaints.

Surveys in the past clearly show that teachers' attitudes affects children's stress to no small extent.29–31 Because students must be educated by teachers, if they recognize their teachers negatively, it is inferred that considerable mental conflict will occur. Alexander32 clarified that there were close relations between repressing the desire of attack or dependency and physical symptoms. The results of this survey show that male students who recognize teachers negatively have more psychosomatic symptoms, thus it is understood that male students repress their desire toward their teachers.

The negative cognition to schoolwork, saying ‘Studying does not interest me’ or ‘School is not an enjoyable place’, leads to vicious cycle, with a loss of their desire to study and then being behind in regular schoolwork. Students who have bad marks at school along with related unpleasant experiences feel more stress, and such students complain of physical symptoms often.

The relationship between psychosomatic complaints and ingestion or sleep

In the males, regarding evening meals, the sometimes non-ingestion students showed significantly higher scores for neurotic symptoms than the daily ingestion students.

Toyokawa33 pointed out that to skip breakfast was not good for health because to keep a nutritive balance by taking a variety of foods is prevented by skipping breakfasts. Similarly, missing their evening meal is associated with unbalanced nutrition. This fact was assumed to be related to their psychosomatic complaints.

As for the relationship between their psychosomatic complaints and sleeping hours, the female students with short sleeping hours had a higher score for depressive symptoms than the students with long sleeping hours.

With respect to the relationship between sleeping hours and subjective symptoms, there is a report stating that sleep is related to depressive symptoms.15 This study was applied to first-grade senior high school students who are free from physical or mental diseases. Therefore, those who suffer from depression are not contained herein, and thus no relation between insomnia and depression can be established. Wolfson and Carskadon.34 pointed out that adolescents' sleep loss interfered with daytime functioning. In this study, I considered that appropriate sleeping hours would reduce depressive symptoms in the females, as did the study by Breslow and Enstrom.35

The variation of psychosomatic complaints over the 3 years

Erikson36 listed the establishment of identity as a developmental task from the age of 13–19 years. There are many conflicts and various symptoms appear in the formation of their identity. They are in the midst of identity formation both at admission and at the completion of the second grade. In addition, unstable situations in the first grade were assumed because of stress resulting from an unfamiliar new environment in the first grade and also at the completion of the second grade because of anxiety for their direction in the future when only a year remained at the completion of the second grade.

At graduation, the age of 18, stress decrease because the course of identity formation advances more than at the first and second grade. In the subject school where this study was conducted, most of the third-grade students have decided what to do after graduation by the end of January. It can be considered that those third-grade students who have decided what to do after graduation feel relieved and suffer less from depression, waiting for graduation only.

This study was a survey of students at one senior high school, which limits the ability to generalize from the results obtained. The ratio of Japanese children who go to senior high school is about 97%. The students who enter the subject school of this study have average grades. Given the ratio of students who go to high school and their scholastic ability, those respondents hereof can be considered as typical and average high school students in Japan. However, it is necessary that data on adolescent health problems is gathered to promote people's health. Further survey studies need to be conducted in the future to establish a general understanding of the actual situation.

CONCLUSION

I investigated the relationship between the psychosomatic complaints and cognition to fathers, mothers, friends, teachers, and schoolwork, or lifestyle habits of the first-grade senior high school students, and the variation of their psychosomatic complaints over the 3 years at the senior high school. The results showed that the female students had more complaints than the male students. Their psychosomatic complaints were apparently associated with their ingestion conditions at evening meals, sleeping hours, cognition to their fathers, mothers, teachers, and schoolwork. It was also clarified that the degree of the complaints differed according to the school grade.

ACKNOWLEDGMENTS

The author would like to thank Prof. Y. Nakatani and his team at the Institute of Community Medicine, University of Tsukuba, for their thoughtful comments regarding the manuscript. I would like to thank senior high school students for their cooperation.

Appendix

Appendix 1 Questionnaire

I. Lifestyle habits:

1. Do you eat breakfast every morning?

2. What do you eat for lunch?

3. Do you eat an evening meal everyday?

4. Who do you eat an evening meal with?

5. How many hours in average do you sleep on weekdays (in a day they go to school)?

II. For the last few months, have you experienced or felt the following matters?

1. My father/mother is kind to me.

2. My father/mother is trying to understand me.

3. My father/mother is strict to me.

4. My father/mother always warns me against my behavior.

5. My father/mother always tries to make me follow his opinion.

6. I am satisfied with my father/mother, given my father's/mother's view on me and how he/she treats me.

7. I have friend/s to whom I can talk frankly.

8. I have friend/s who understand me well.

9. I like playing or studying with my friend/s.

10. I have friend/s who help me when I am in trouble.

11. I have many friends.

12. I am satisfied with my friends, given my friends' view on me and how they treat me.

13. I can talk to teacher frankly.

14. I cannot listen to teacher obediently when they advise me.

15. I don't like teacher because they are fastidious.

16. Teacher understands me.

17. I like teacher.

18. I am satisfied with teacher, given teacher's view on me and how he/she treats me.

19. I study voluntarily without being advised by others.

20. I am often absentminded in the class.

21. Classes are boring, not interesting.

22. I sometimes think study is not important.

23. I am satisfied with my grades in the school.

Ancillary