Overt and Relational Victimization Among Children with Frequent Abdominal Pain: Links to Social Skills, Academic Functioning, and Health Service Use Laurie A. Greco,1 PHD, Kari E. Freeman,2 MS, and Lynette Dufton,2 MS 1

University of Missouri at St. Louis and 2Vanderbilt University

Key words

abdominal pain; overt victimization; peer relationships; relational victimization.

Abdominal pain is the single most common chronic pain complaint in childhood, with an estimated 8–20% of school-aged youth experiencing symptoms severe enough to interfere with daily functioning (Goodman & McGrath, 1991; Perquin et al., 2003). Frequent abdominal pain is associated with elevated school and social problems such as school absenteeism, academic difficulties, withdrawal from activities, and low perceived social competence (Scharff, 1997). Other behavioral and emotional correlates reported in community and clinical samples include anxiety, depression, somatization, excessive healthcare utilization, and functional disability (Garber, Zeman, & Walker, 1990; Hyams, Burke, Davis, Rzepski, & Andrulonis, 1996). Among children who seek treatment for abdominal pain, physical discomfort,

emotional symptoms, and associated psychosocial impairment may persist well into adolescence and adulthood (Campo et al., 2001; Walker, Garber, Van Slyke, & Greene, 1995). Frequent abdominal pain often occurs in the absence of identifiable medical diagnosis, and, as such, it is essential to identify psychosocial factors which may contribute to children’s subjective experience of pain and related disability (Bursch, Walco, & Zeltzer, 1998; Zeltzer, Bursch, & Walco, 1997). Consistent with a biopsychosocial approach to pain, clinical and empirical research suggests that frequent abdominal pain may be, at least in part, a reaction to chronic or daily stressors. For example, family-related stress predicted somatic symptoms above and beyond initial pain levels 1 year

All correspondence concerning this article should be addressed to Laurie A. Greco. University of Missouri-St. Louis Psychology, 325 Stadler Hall, One University Boulevard, Saint Louis, Missouri, 63121. E-mail: [email protected]. Journal of Pediatric Psychology 32(3) pp. 319–329, 2007 doi:10.1093/jpepsy/jsl016 Advance Access publication July 13, 2006 Journal of Pediatric Psychology vol. 32 no. 3 © The Author 2006. Published by Oxford University Press on behalf of the Society of Pediatric Psychology. All rights reserved. For permissions, please e-mail: [email protected]

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Objectives Chronic abdominal pain is linked with school absenteeism and diminished social competence; yet, little is know about the extent to which negative peer encounters contribute to symptoms and functioning in youth with abdominal pain. This study compared children with frequent abdominal pain with a pain-free control group on measures of overt and relational victimization and examined the link between abdominal pain and school-related functioning. Methods Participants were 60 children with frequent abdominal pain and 60 gender- and age-matched peers. Child, peer, and teacher reports were used to assess abdominal pain, peer victimization, use of school medical services, social skills, and academic competence. Results Children with frequent abdominal pain experienced higher levels of victimization than their pain-free peers, with boys in the pain group rated highest in overt victimization. For children in the pain group, overt and relational victimization made incremental contributions to outcomes and moderated the link between pain- and school-related functioning. Conclusions Overt and relational victimization may increase risk of concurrent adjustment problems among youth with frequent abdominal pain; thus, it may be useful to assess peer relationships when working with this population.

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victimization experienced by boys and girls, similar processes have been reported such that overt and relational victimization are expected to be emotionally damaging for both sexes (Nishina et al., 2005). In fact, boys and girls who fall prey to overt and relational aggression appear to be uniformly at risk of a host of adjustment problems, including loneliness, anxiety, depression, peer rejection, and nonspecific physical symptoms such as nausea, abdominal pain, headaches, and sore throats (Crick & Bigbee, 1998; Nishina et al., 2005; Olweus, 1995; Rigby, 1999; Schwartz, 2000; Swearer & Doll, 2001; Williams, Chambers, Logan, & Robinson, 1996). Very little is known about the link between peer relationships and abdominal pain in community or clinic samples, and there are currently no studies on peer victimization in this population. Published accounts of psychosocial adjustment in clinic and community samples suggest that children with chronic abdominal pain may be at risk of peer relationship problems. Children with abdominal pain, for instance, often experience co-occurring anxiety and depression and may demonstrate corresponding avoidance-withdrawal behavior that isolates them from their peer group (Campo et al., 2004; Campo, Comer, Jansen-McWilliams, Gardner, & Kelleher, 2002; Compas & Thomsen, 1999; Hyams et al., 1996). Furthermore, results from clinicbased studies suggest that young people with abdominal pain describe themselves as behaviorally submissive and low in social competence (Claar et al., 1999; Merlijn et al., 2003; Thomsen et al., 2002). Central to hypotheses of this study, children who exhibit such behaviors may be violating important “social etiquette norms” in ways that make them likely targets of peer harassment. Importantly, prior research on peer relationships and physical symptoms does not consider the ways in which peer difficulties contribute to relevant school and social outcomes. In addition, these studies do not consider various types of peer harassment such as overt and relational victimization and rely exclusively on selfreport despite the availability of many psychometrically sound peer nomination procedures (Nishina et al., 2005; Rigby, 1999). Peer report is particularly important during middle childhood and adolescence, as parental and teacher knowledge of social activities and peer functioning declines during this time. Furthermore, obtaining peer reports in classroom settings yields highly stable and accurate sets of judgments because children have the opportunity to become acquainted with their classmates over time and across a range of situations (Seeman, 1983). To address these conceptual and methodological limitations, this study employs a well-established peer

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following children’s initial medical evaluation (Walker, Garber, & Greene, 1993). More recently, Walker and colleagues (2001) used consecutive daily telephone interviews to assess daily stressors and symptoms among pediatric patients with and without medically unexplained pain. Results indicated that children with abdominal pain experience more frequent daily stressors at home and school than their peers. Moreover, the occurrence of school-based stressors was more strongly associated with somatic symptoms in children with recurrent abdominal pain (Walker et al., 2001). The authors concluded that, compared with their pain-free counterparts, pediatric patients with frequent abdominal pain may experience heightened visceral and somatic discomfort in response to stress. Published research documents the link between symptoms and stress among children who seek treatment for frequent abdominal pain in tertiary care settings (Walker et al., 2001). Notably, however, existing studies focus broadly on negative life events or wideranging stressors at home and school. Much less is known about the specific types of stressors contributing to symptoms and impairment, and few studies have examined the link between abdominal pain and peerrelated stress. This omission is significant given the importance of peer relationships in childhood as well as strong prospective evidence demonstrating that disruptions in peer functioning predict adverse outcomes in adolescence and adulthood (Boivin, Hymel, & Bukowski, 1995; Olweus, 1995; Parker & Asher, 1987). This study sought to extend the existing research by examining whether children with frequent abdominal pain experience more overt and/or relational victimization than their pain-free peers. Peer victimization is a frequent and emotionally salient stressor involving the degree to which children are targeted by peers for physical, verbal, and/or relational acts of aggression (Olweus, 1978). Boys have been found to experience more overt types of aggression such as physical attacks and verbal humiliation compared with girls. Research on relational victimization has yielded mixed results. In one study, girls appear to be more frequent targets of relational aggression involving subtle and manipulative acts such as gossiping, spreading rumors, and giving the silent treatment (Grotpeter & Crick, 1996). More recently, research suggests that boys and girls experience similar levels of relational victimization (Storch, Crisp, Roberti, Bagner, & Masia-Warner, 2005) or that boys are more frequent targets of both overt and relational victimization compared with girls (Nishina, Juvonen, & Witkow, 2005). Despite inconsistent findings on the frequency of

Abdominal Pain and Victimization

Method Children and teachers were recruited from four public schools in middle Tennessee to participate in a project on children’s health and friendships. Following requirements specified by the Vanderbilt University Institutional Review Board, written consent was obtained from children, parents, and teachers before participation in this project. Child-and peer-report measures were administered by class in the school cafeteria, library, or an empty classroom. Trained undergraduate and graduate research assistants read out instructions for each questionnaire and verbally administered all items on the

peer nomination procedure. Teachers completed a measure of social skills and academic functioning for participating students. An undergraduate or graduate research assistant met with teachers on an individual basis to provide verbal instructions and to schedule a day and time to pick up the completed measures. Children received a keychain for participating in this study, and teachers were compensated with $2.00 for each questionnaire they completed. Classrooms with a minimum of 80% consent return rates were given money for a pizza party, regardless of whether they agreed to participate.

Participants Participants were 120 children in grades 5–10 who participated in a larger project on children’s health and friendship. This larger project was composed of 520 school-aged youth, with an overall consent rate of 78%. This study included 60 children with abdominal pain (pain) and 60 pain-free children (control). Participant selection and group assignment were determined by children’s responses on the Abdominal Pain Index, a widely used measure of abdominal pain frequency, duration, and intensity. Consistent with research criteria proposed by Von Baeyer and Walker (1999), children in the pain group reported (a) a minimum of 3–4 episodes of abdominal pain over the past 2 weeks; (b) pain episodes lasting at least 30 min; and (c) pain rated as moderate to severe in intensity. Similar to prevalence rates reported in school-based samples (Hyams et al., 1996), 11.5% of children from our larger project met these criteria. Also consistent with published reports, 68% of children in the pain group were girls (n = 41). The pain group had a mean age of 12.22 years (SD = 1.19) and was 85% Caucasian, 8.3% African American, and 3.3% Latino American. Children in the pain-free control group reported zero episodes of abdominal pain over the past 2 weeks. Of the 178 children who were pain-free, 41 girls and 19 boys were selected for participation using a case-by-case matching procedure such that children in the pain group were paired with a classroom peer who was the same gender and had the closest date of birth. The control group had a mean age of 12.30 years (SD = 1.35) and was 84.2% Caucasian, 11.7% African American, 2.5% Hispanic, and 0.8% Asian. Ethnic characteristics of the pain and control samples were representative of the larger school-based population. However, girls were overrepresented in the pain group relative to the population at large. This finding is consistent with evidence that chronic or recurrent episodes of abdominal pain are more common among schoolaged girls than boys (Perquin et al., 2003; Scharff, 1997).

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nomination procedure to assess overt and relational victimization among children with and without frequent abdominal pain. The purpose of our study was to add to the existing literature by using child, peer, and teacher reports to examine whether children with frequent abdominal pain experience more overt and/or relational victimization compared with their pain-free classmates. For children in the pain group, secondary hypotheses examined (a) the association between levels of abdominal pain and school and social functioning; (b) the extent to which overt and relational victimization made an incremental contribution to school and social functioning after controlling for relevant covariates and levels of abdominal pain; and (c) the degree to which overt and relational victimization moderated the link between abdominal pain and functioning. Children with frequent abdominal pain were expected to experience significantly higher levels of overt and relational victimization relative to their pain-free peers. For children in the pain group, higher levels of abdominal pain were expected to correlate with poorer social skills, academic difficulties, and more frequent use of school medical services. Furthermore, it was predicted that overt and relational victimization would contribute significantly to school and social functioning after accounting for covariates and abdominal pain frequency, duration, and intensity. Finally, in light of research documenting the adverse correlates of peer difficulties, both types of victimization were expected to moderate the link between abdominal symptoms and school and social functioning (i.e., social skills in peer and classroom settings, academic competence, and use of school medical services). Specifically, children with high abdominal pain and high victimization scores were hypothesized to be at greatest risk of concurrent adjustment problems.

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Child-Report Measures

Use of School Medical Services Children were asked to estimate the number of times they used school medical services or visited the school nurse since the beginning of school. A research assistant specified the month children should refer to when answering this question. Mean levels of school medical services use were 2.40 (SD = 2.98) in the pain group and 1.08 (SD = 2.03) in the control group. In the pain group, reported medical service use ranged from 0 to 15 times; in the control group, reports ranged from 0 to 12 uses since the beginning of school.

Peer-Report Measure Children’s Social Experiences Questionnaire-Peer Report The Children’s Social Experiences Questionnaire-Peer Report (CSEQ-PR; Crick & Bigbee, 1998) is a measure of overt and relational victimization that has been well validated by prior research (Crick & Bigbee, 1998). Items on the CSEQ-PR ask children to identify classmates who are the targets of overt victimization (e.g.,

Teacher-Report Measure Social Skills Rating Scale Homeroom teachers completed the Social Skills Rating Scale (SSRS; Gresham & Elliot, 1990) for elementary school students, and English teachers completed the SSRS for middle- and high-school students. The SSRS is a teacher-report measure that includes 30 items assessing Social Skills and 9 items assessing Academic Competence. Items on the Social Skills Scale measure cooperation, assertion, and self-control in peer and classroom settings, with a possible range in scores from 0 to 60. Scales on the SSRS have been found to have good internal consistency, test–retest reliability, and concurrent validity (Gresham & Elliot, 1990). In this study, social skills scores ranged from 16 to 60 in the pain group (M = 43.36, SD = 13.70) and from 18 to 60 in the control group (M = 48.03, SD = 9.93). Items on the Academic Competence Scale assess children’s academic performance across multiple domains with a possible range in scores from 7 to 35. Academic competence

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Abdominal Pain Index The Abdominal Pain Index (API; Walker, Smith, Garber, & Van Slyke, 1997) is a five-item scale used to assess the frequency, duration, and intensity of abdominal pain episodes occurring over the previous 2 weeks. As described above, responses on the API were used to create the pain and control groups. In addition, mean standardized API scores were used in regression analyses investigating the incremental and moderating role of overt and relational victimization in predicting school and social functioning in the pain group. Standardized API scores have been used effectively in past research to differentiate children with chronic abdominal pain from their pain-free peers (Walker et al., 1997), and standardized scoring reveals relative placement of individuals’ pain reports in the context of the larger sample. Assuming a normal distribution of scores, >99% of z scores will fall between −3 and 3. Cronbach’s alpha in this sample was 0.93, with scores ranging from 0.51 to 3.14 in the pain group (M = 1.56, SD = 0.70) and −0.92 to 0.61 in the control group (M = −0.91, SD = 0.06). In the pain group, standardized mean scores were, on average, 1.5 SD above the mean for the entire sample (n = 520), whereas standardized mean scores in the control group were, on average, nearly 1 SD below the total sample mean. The API has good concurrent and predictive validity as well as acceptable internal consistency and test–retest reliability.

gets beat up, is picked on by bullies) and relational victimization (e.g., is left out, has lies and rumors told about him/her). Using a class roster and number identification procedure, children nominated up to three classmates who fit each of nine descriptors. Overt and relational victimization scores were then computed for each child by summing the items within each category and standardizing scores by gender within each classroom. [Middle- and high-school youth who switched classes completed the CSEQ-PR for peers in their English class. English was selected for students in older grades because all students are required to take English and are commonly assigned to this class based on ability and level of interest, resulting in a greater probability that children’s friends will be in the class (Noll, Bukowski, Davies, Koontz, & Kulkarni, 1993).] Cronbach’s alphas in our sample were .84 for overt victimization and .81 for relational victimization. For children in the pain group, overt victimization scores ranged from −0.65 to 4.26 (M = 0.16, SD = 1.27), and relational victimization scores ranged from −0.91 to 3.46 (M = 0.16, SD = 1.07). For children in the control group, overt victimization scores ranged from −0.91 to 3.46 (M = −0.27, SD = 0.51) and mean relational victimization scores ranged from −0.91 to 1.70 (M = −0.27, SD = 0.68). Youth in the pain group scored approximately one fourth of a standard deviation above the mean in the larger sample (N = 520), whereas youth in the control group scored approximately one sixth of a standard deviation below the mean.

Abdominal Pain and Victimization

Data Preparation Outlying scores were identified separately in the pain and control groups. Scores greater than 3 SD above or below the group mean were windsorized before examination of descriptive data and hypothesis tests (Tabachnick & Fidell, 2001). There were no more than two outlying scores on any variable included in subsequent analyses. Because of the relatively small sample size and limited empirical findings regarding peer victimization among youth with abdominal pain, analyses were approached as preliminary in nature, and an alpha level of .05 was used as the cutoff for statistical significance of two-tailed

tests. Following data analyses addressing our hypotheses, power analyses were conducted using Cohen’s criteria (1992), which classify effect sizes as small (0.20), medium (0.50), and large (0.80), as detected at an alpha level of .05. These analyses were conducted to determine whether statistical tests were sufficiently powered to detect medium-sized effects in our sample. Adequate power was indicated when there was an 80% probability of detecting actual group differences.

Results Differences in Overt and Relational Victimization A 2 (group) × 2 (sex) multivariate analysis of variance was conducted to examine whether boys and girls with frequent abdominal pain experience higher levels of overt and/or relational victimization compared with children without pain (Table I). Results were significant for Group, F(2, 115) = 7.84, p = .001, and Sex, F(2, 115) = 28.45, p = .000, and there was a significant Group–Sex interaction, F(2, 115) = 6.50, p = .002. Follow-up univariate analyses and pair-wise comparisons were used to examine the nature of these effects. A Group–Sex interaction was found for overt victimization (F = 10.65, p = .001), with boys in the pain group experiencing the highest levels of overt victimization. For relational victimization, main effects were found for Group (F = 8.81, p = .004) and Sex (F = 9.07, p = .003) such that children in the pain group scored higher than pain-free children, and boys scored higher than girls. According to power analysis of a 2 × 2 analysis of variance (ANOVA) (Hintz, 2005), these analyses were adequately powered to detect an effect size of 0.52 SD difference between the group means.

Associations Among Abdominal Pain, Demographic Variables, and Functioning Pearson product moment correlations were conducted to examine the interrelations among demographic variables, levels of abdominal pain, overt and relational Table I. Results of Multivariate Analysis of Variance (MANOVA) Examining Peer Victimization as a Function of Pain Group and Child Sex Boy

Girl

Total

Pain

1.26**

−0.35

0.16

Control

0.14

−0.46

−0.27

Total

0.70

−0.40

−0.05

Overt victimization

Relational victimization Pain Control Total *p < .05; **p < .01.

0.64

0.06

−0.05

−0.38

−0.27

−0.22

−0.56

0.29**

0.16*

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scores for the pain and control groups ranged from 7 to 35 (M = 22.22, SD = 8.47) and 9 to 35 (M = 25.07, SD = 8.07), respectively. Scores in our sample were consistent with normative data reported for the Social Skills and Academic Competence Scales reported by Gresham & Elliot (1990). Cronbach’s alphas for our sample were .95 for the Social Skills and .94 for the Academic Competence Scales. Academic competence was conceptualized as a relevant outcome, as youth with abdominal pain have been shown to demonstrate higher rates of school absenteeism compared with pain-free children (Campo et al., 2002; Goodman & Pantell, 1984; Robinson, Alzarez, & Dodge, 1990). Level of social skill was of interest given evidence that social competence is an important moderator between negative life events and future adjustment. For instance, Claar et al. (1999) found that children with abdominal pain experience more symptoms and disability when they rate themselves low in social competence. Furthermore, if youth with frequent abdominal pain are at risk of peer victimization as hypothesized, then co-occurring academic and social skill difficulties are plausible for myriad reasons. One possibility is that children with frequent abdominal pain may experience elevated physical and emotional symptoms at school, where peer maltreatment is most likely. These symptoms may interfere with concentration during class time and/or motivate youth to skip school or use school medical services to avoid the possibility of negative peer encounters. In this way, youth may fall behind on class assignments and miss out on social activities that provide the basis for normative peer interactions. It is also possible for abdominal pain to impede the development of age-appropriate social skills either directly or because of reduced engagement in school and social activities. Although these specific hypotheses were not tested, they provide a basis for examining academic competence and social skills among youth with frequent abdominal pain.

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Table II. Correlations Among Demographic, Abdominal Pain, Peer Victimization, and School Functioning Variables Variables

1

2

1. Sex

−

0.16

2. Age 3. Race

−

3

−0.06

4

−0.02

6

7

8

9

−0.52**

−0.26**

0.21

0.08

−0.01

0.00

−0.09

−0.11

−0.08

−0.03

−0.19*

−0.04

−0.11

−0.07

0.03

−0.05

−0.07

0.22** −

5

4. Abdominal pain

–

5. Overt victimization

0.25** –

0.23*

−0.29**

−0.29**

0.71***

−0.52**

−0.38**

0.40**

–

−0.40**

−0.30**

0.35**

–

0.58**

−0.38**

–

−0.28*

6. Relational victimization 7. Social skills 8. Academic competence 9. Medical services

0.36**

–

victimization, and school and social functioning. As summarized in Table II, a significant positive correlation was found between abdominal pain symptoms and overt and relational victimization and use of school medical services. Conversely, a significant negative correlation was found between levels of abdominal pain and social skills and academic competence. Age correlated positively with medical service use and was accounted for in relevant analyses. In addition, child sex correlated significantly with overt and relational victimization and was therefore entered as a covariate in all subsequent regression equations. Separate analyses were not conducted for boys and girls, as victimization was expected to function similarly for both sexes. The decision to conduct combined analyses is consistent with evidence suggesting that overt and relational victimization do not have differential effects for boys versus girls (Nishina et al., 2005).

Overt and Relational Victimization Among Youth with Abdominal Pain Next, six hierarchical regression analyses were conducted with social skills, academic functioning, and health service use as the dependent variables. These analyses tested the incremental contribution of peer victimization after accounting for relevant control variables and levels of abdominal pain frequency, duration, and intensity. In addition, analyses examined whether overt and relational victimization moderated the association between abdominal pain and school and social functioning. Before analyses, scores for abdominal pain and victimization were centered within the pain group to allow meaningful interpretation of effects (Aiken & West, 1991). In each regression, child sex was entered as a control variable in step 1, and the API total was entered in step 2. Peer-reported overt or relational victimization was entered in step 3, and the API–victimization interaction term was entered in step 4. Using Cohen’s criteria

(1992), we adequately powered these analyses to detect large effects. Effects of Overt Victimization After entering covariates and abdominal pain, overt victimization made a significant incremental contribution to teacher-reported social skills (ΔR2 = .17, p = .004), academic competence (ΔR2 = .08, p = .042), and selfreported use of school medical services (ΔR2 = .19, p = .000) (Table III). In addition, overt victimization moderated the relation between children’s abdominal pain and (a) academic competence (t = 3.43, p = .001) and (b) use of school medical services (t = 3.05, p = .004). Post hoc probing strategies recommended by Aiken and West (1991) were used to examine the nature of these effects, Table III. Regression Analyses Examining Effects of Overt Victimization on School Functioning R2

B (SE)

Beta

t

Child sex

−4.17 (4.97)

−.14

−0.84

Abdominal pain

−2.75 (3.06)

−.15

−0.90

Overt victimization

−8.73 (3.08)

−.60

−2.83**

Pain × victimization

2.36 (3.67)

.12

0.64

Child sex

−2.86 (2.71)

−.15

−1.05

Abdominal pain

−1.26 (1.67)

−.11

−0.75

Overt victimization

−6.67 (1.68)

−.74

−3.96***

Pain × victimization

6.89 (2.01)

.56

3.43*

Social skills Step 4 (df = 4, 41)

.31

Academic competence Step 4 (df = 4, 41)

.46**

School medical service use Step 4 (df = 5, 56)

.43**

Child sex

1.55 (0.79)

.26

1.97

Child age

−0.25 (0.22)

−.13

−1.13

Abdominal pain

1.10 (0.44)

.29

Overt victimization

0.88 (0.34)

.38

2.59*

Pain × victimization

1.39 (0.46)

.38

3.05**

*p < .05; **p < .01; ***p < .001.

2.52*

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*p < .05; **p < .01; ***p < .001.

Abdominal Pain and Victimization

and regression lines were plotted for high (+1 SD) and low (−1 SD) levels of overt victimization. Among children experiencing low rates of overt victimization, academic competence was higher and appeared to be influenced by level of abdominal pain (t = −4.51, p = .000; Fig. 1). Finally, as shown in Fig. 2, high abdominal pain was associated with more frequent use of school medical services when overt victimization was also high (t = 3.84, p = .000). In contrast, when overt victimization was low, abdominal pain was not associated with health service use.

Table IV. Regression Analyses Examining Effects of Relational Victimization on School Functioning R2

Step 4 (df = 4, 41)

HIGH overt vict

40

Beta

t

.25

Child sex

0.69 (4.54)

.02

0.15

Abdominal pain

−6.00 (2.72)

−.32

−2.20*

Relational victimization

−4.11 (2.04)

−.31

−2.01

Pain × victimization

−3.78 (3.04)

−.18

−1.25

Academic competence Step 4 (df = 4, 41)

.29

Child sex

0.40 (2.74)

.02

0.15

Abdominal pain

−4.38 (1.64)

−.38

−2.67*

Relational victimization

−2.34 (1.23)

−.28

−1.90

1.99 (1.83)

.16

1.09

Pain × victimization School medical service use Step 4 (df = 5, 56)

LOW overt vict

45

B (SE)

Social skills

.29*

Child sex

0.32 (0.74)

.06

0.44

Child age

−0.25 (0.25)

−.13

−1.02

Abdominal pain

1.16 (0.47)

.30

2.49*

Relational victimization

0.71 (0.34)

.26

2.09*

Pain × Victimization

1.32 (0.53)

.31

2.50*

*p < .05.

30

LOW relational victimization

25

HIGH relational victimization 8

20 15

7

10

6

5 0 low pain

high pain

Figure 1. Estimated regression lines showing predicted academic competence for subjects with low (−1 SD) and high (+1 SD) levels of overt victimization.

school medical use

academic competence

35

5 4 3 2 1

LOW overt vict 7

HIGH overt vict

0 low pain

high pain

6

Figure 3. Estimated regression lines showing predicted school medical use for subjects with low (−1 SD) and high (+1 SD) levels of relational victimization.

medical service use

5 4 3 2 1 0 low pain

high pain

Figure 2. Estimated regression lines showing predicted school medical use for subjects with low (−1 SD) and high (+1 SD) levels of overt victimization.

addition, relational victimization moderated the association between abdominal pain and use of school medical services (t = 2.50, p = .016). As shown in Fig. 3, there was a significant positive association between pain and school medical service utilization for children experiencing high levels of relational victimization (t = 3.82, p = .000). The slight negative relationship between pain and school medical service use for children experiencing

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Effects of Relational Victimization Relational victimization made a significant incremental contribution to teacher-reported social skills (ΔR2 = .09, p = .040) and self-reported use of school medical services (ΔR2 = .08, p = .031), beyond the effects of child abdominal pain and control variables (Table IV). In

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low levels of relational victimization is not statistically significant (t = −0.74, p = .46).

Discussion

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Although complaints of abdominal pain are common and have been associated with psychosocial factors that might impact peer functioning (e.g., anxiety, depression, and social competence), very little is known about the peer relationships of young people with frequent abdominal pain. The few studies in this area are limited by their reliance on self-report measures as well as their broad focus on social stress without considering the role of specific types of peer experiences. This study marked an important extension of this literature as it was the first to examine the occurrence and role of peer victimization among youth with frequent abdominal pain. Strengths of our article include detailed assessments of peer relations, social skills, and academic functioning as well as the use of psychometrically sound child, teacher, and peer report measures and the inclusion of a painfree comparison group matched on gender and age. This investigation compared children with and without frequent abdominal pain on measures of overt and relational victimization and examined the role of victimization among youth with abdominal pain. As predicted, children in the pain group experienced significantly higher levels of overt and relational victimization, with this effect especially pronounced for boys with abdominal pain. Furthermore, results supported the hypothesis that overt and relational victimization contributed significantly to school and social outcomes even after accounting for the effects of relevant demographic variables and abdominal pain frequency, duration, and intensity. Finally, modest support was found for the hypothesis that peer victimization moderates the relation between pain and school functioning. Specifically, abdominal pain and victimization interacted meaningfully to predict academic competence and medical service use, such that children with the highest levels of both pain and victimization demonstrated the worst outcomes. Overall, findings suggest that overt and relational victimization may be important in understanding the social context of abdominal pain. Results corresponded with study hypotheses, although future research is needed to examine whether boys with abdominal pain are indeed at elevated risk of peer relationship difficulties. It is possible that boys may respond to harassment with physical symptoms to avoid expressing themselves in ways that are less “acceptable” such as through sadness or fear. Another possibility is

that children (especially boys) with frequent abdominal pain may behave in ways that are viewed as “sickly,” “timid,” or “weak,” thereby making them relatively easy targets for bullying (Nishina et al., 2005). Although speculative, the lack of significant effects for girls may be attributed in part to social norms and gender roles which suggest that it is more acceptable for girls to exhibit vulnerabilities such as internalizing symptoms and pain complaints. Boys, in contrast, may be judged more harshly and subsequently mistreated by their peers for demonstrating similar types of behavior. Studies investigating these and other gender issues will assist in our understanding of why boys and girls with abdominal pain come to be overtly and relationally victimized by members of their peer group. There are undoubtedly multiple pathways leading to chronic abdominal pain, peer victimization, and adjustment difficulties among youth. The cross-sectional design of this study precludes conclusions regarding direction of effects. Poor social skills, for example, may increase risk of peer victimization, which in turn gives rise to heightened anxiety and co-occurring physical symptoms such as abdominal pain. Alternatively, youth with abdominal pain may develop academic and peer-related problems due to missing out on important school and social activities. Such missed opportunities may isolate children from their peer group and thereby increase risk of maltreatment. Multiwave longitudinal studies are needed to identify antecedents and consequences of overt and relational victimization and to elucidate the ways in which peer harassment and abdominal pain interface over time. Another area for further exploration involves studying the additive and interactive nature of different types of peer relationships (e.g., peer acceptance–rejection, victimization, and friendship quality). It may be, for example, that some aspects of peer relationships such as friendship quality protect against the negative outcomes associated with both abdominal pain and peer victimization. Future research might also investigate how peer experiences interact with individual characteristics and family functioning to predict children’s subjective experience of pain and associated functioning. It will also be important to replicate this study with children who present in tertiary care clinics to see whether treatment seekers experience even higher levels of social difficulties and are perhaps more affected by negativity within peer relationships. Several shortcomings of this article are deserving of attention. First, this sample was composed primarily of Caucasian children who live in rural areas, thus leaving a clear need for research targeting more ethnically and

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disability (Greco & Morris, 2001). Future research is needed to document the potential utility of assessing and targeting peer relationships among young people who experience recurrent episodes of abdominal pain.

Acknowledgments The authors thank Dr. Lynn Walker for providing helpful feedback on earlier drafts of this manuscript and Dr. Warren Lambert for his statistical guidance and contributions to this work. Received August 21, 2005; revisions received February 3, 2006 and June 1, 2006; accepted June 1, 2006

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