Parents’ Reflective Functioning, Emotion Regulation, and Health: Associations with Children’s Functional Somatic Symptoms

Abstract

Functional somatic symptoms (FSSs) in children—such as headaches, stomachaches, and muscle pain without clear medical explanations—pose a significant clinical challenge, often leading to repeated healthcare visits and impairments in daily functioning. While the role of parental psychological factors in shaping children’s FSSs has been suggested, empirical evidence remains limited and fragmented. This study addresses this gap by systematically examining the associations between parents’ reflective functioning, emotion regulation, alexithymia, and physical and mental health, and the frequency and severity of children’s FSSs. A total of 339 parents of children aged 6–12 completed surveys assessing their capacity to understand mental states, regulate emotions, and identify or describe feelings, as well as their self-reported physical and mental health. They also indicated whether their child experienced FSSs (e.g., headaches, stomachaches) more than once per week. Results revealed that parents of children with FSSs reported significantly lower levels of reflective functioning (lower certainty, higher uncertainty), higher alexithymic traits, and greater emotion regulation difficulties, alongside poorer physical and mental health indices. Logistic regression analyses demonstrated that emotion regulation difficulties and poorer mental health significantly increased the likelihood of a child exhibiting FSSs, while lower reflective functioning also emerged as a significant predictor. Furthermore, multiple linear regression indicated that emotion regulation challenges and poor mental health predicted greater severity of FSSs. These findings offer novel insights into how parents’ psychological and health characteristics can shape children’s somatic symptom expression, highlighting the need for family-focused interventions. By identifying and addressing parental emotional and cognitive difficulties, clinicians may be able to mitigate the intergenerational transmission of maladaptive stress responses, ultimately reducing the burden of FSSs in children.

1. Introduction

Functional somatic symptoms (FSSs) in childhood and adolescence represent a complex intersection of physical complaints and psychosocial factors, capturing the attention of pediatricians, psychologists, and psychiatrists alike (Jungmann et al., 2022; Kolaitis et al., 2022; Münker et al., 2024). These symptoms—encompassing a wide range of presentations such as abdominal pain, headaches, muscle aches, fatigue, and other medically unexplained ailments—have been broadly documented in clinical and population studies, with prevalence estimates ranging from 10% up to 30% in school-aged youth (Sally & Gillian, 2024). While some children experience occasional, short-lived episodes of FSSs without any pronounced impact on quality of life, others endure persistent or recurrent somatic complaints severe enough to interfere with daily functioning, school attendance, extracurricular activities, and social interactions (Jungmann et al., 2022; Münker et al., 2024).

Although a significant number of pediatric patients presenting with FSSs undergo extensive medical evaluations, many do not receive a clear physiological explanation for their symptoms. Terms such as “somatization”, “persistent somatic symptoms”, or “functional somatic disorders” have been used in the literature to capture instances of physical distress poorly accounted for by biomedical factors (Cathébras, 2021; Hüsing et al., 2023; Lamm et al., 2025; Münker et al., 2022). Contemporary frameworks underscore that FSSs often arise from intricate interplays among biological predispositions, emotional and cognitive processes, and social and family influences. This multifactorial nature presents a unique challenge: the clinician must balance ruling out organic pathology with recognizing that the child’s symptoms reflect difficulties with stress regulation, emotional processing, or interpersonal dynamics.

Over recent decades, there has been growing recognition that FSSs tend to cluster within families. It is not uncommon to find a parent and child reporting similar pains or somatic complaints, prompting questions regarding genetic, environmental, and sociocultural contributors to pediatric FSSs (France et al., 2023). Indeed, parental experiences of chronic pain, persistent fatigue, or anxiety about health can influence how children learn to interpret and cope with their own bodily sensations (Corey et al., 2021; Rask et al., 2024). Children typically observe and internalize parents’ reactions to pain or discomfort—especially if the parents themselves have longstanding somatic complaints. Notably, parents may inadvertently reinforce maladaptive responses to pain or magnify the child’s inclination to see benign bodily experiences as threatening (Beeckman et al., 2019). The result can be a vicious cycle wherein each episode of a child’s headache or stomachache is amplified by worry and heightened medical service use.

In addition to parental modeling, the broader emotional climate of the family and parental psychological well-being appears to shape children’s vulnerability to FSSs (Qian et al., 2024). For instance, parents with their own mental health difficulties—such as depression, anxiety, or a history of unresolved trauma—can struggle to support a child’s emotional needs in moments of distress (Diamond et al., 2021). When combined with a child’s inherent temperament or heightened reactivity, these family stressors may create an environment in which somatic expressions of emotional strain become increasingly likely (Allen et al., 2023; Lin & Guo, 2024). Consequently, variables such as parental emotion regulation skills, reflective functioning, and alexithymia (i.e., difficulties identifying and describing one’s emotions) have emerged as particularly relevant to understanding the etiology of pediatric FSSs (Medrea & Benga, 2021; Pisani et al., 2021).

Reflective functioning, also known as mentalization, offers a promising framework for unraveling the association between parental characteristics and FSSs in childhood (Chevalier et al., 2021). At its core, reflective functioning refers to a person’s ability to interpret behavior—both one’s own and others’—as driven by internal mental states such as beliefs, desires, intentions, and emotions (Luyten et al., 2024). In practical terms, a parent who demonstrates high reflective functioning tends to be more attuned to a child’s internal world, noticing when a child’s irritability or physical complaint may reflect emotional distress or unspoken worry (Stuhrmann et al., 2022). This attunement helps the parent provide more targeted, empathic responses, which in turn foster the child’s capacity for self-regulation and self-reflection (Wesarg-Menzel et al., 2023). Children gradually internalize the sense that their physical sensations and emotions are both meaningful and manageable (Wesarg-Menzel et al., 2023). By contrast, parents with limited reflective functioning skills may struggle to connect the child’s somatic complaints with underlying emotional processes—leading either to under-response or over-concern, both of which may reinforce maladaptive patterns (Bennett et al., 2023). While reflective functioning has been increasingly studied in relation to parenting sensitivity and attachment security, its potential influence on how parents interpret and respond to children’s somatic symptoms remains relatively unexplored. This study aims to extend the reflective functioning framework by examining its relevance in the context of functional somatic symptoms, a domain where parental attunement may be especially crucial.

Similar mechanisms underlie the roles of emotion regulation and alexithymia in pediatric FSSs (Hamel et al., 2024; Petzke & Witthöft, 2024; Renzi et al., 2022; Schnabel et al., 2022). Emotions such as fear, anger, and sadness commonly manifest in physical ways, and children who have difficulty processing or articulating them may turn more readily to bodily expressions of distress (Paulus et al., 2021). Parents who also find it difficult to name, differentiate, or regulate their own emotional states can unintentionally pass on these limitations to their children, both through modeling and via limited emotional scaffolding (De Palma et al., 2023; Hay et al., 2021; Myruski & Dennis-Tiwary, 2022). For example, a parent who is prone to shutting down emotionally may have trouble guiding a child through anxious feelings related to stressful situations. Faced with an unrecognized or unsupported emotional challenge, the child’s body may become the default channel for expressing distress—manifesting, for instance, as recurrent stomachaches or headaches with no easily discernible medical cause (Ayonrinde et al., 2020).

Research likewise indicates that parental alexithymia is an important consideration. Individuals high in alexithymia tend to experience emotions in a diffuse or confusing manner, struggle to label their feelings accurately, and often somaticize psychological stress (Hogeveen & Grafman, 2021). Since children rely on parents to interpret and validate inner experiences, a parent’s alexithymic tendencies can compromise the capacity to help a child separate benign bodily sensations from true illness signals or to contextualize physical discomfort in emotional terms (Renzi et al., 2022; Scarzello, 2023). Over time, children who see their parents handling vague physical sensations with high anxiety or confusion may adopt a similar hypervigilance to body signals. In turn, such heightened attentional focus can lower the threshold for perceiving typical fluctuations in bodily states as symptomatic of illness, thus increasing the child’s susceptibility to FSSs (Lee et al., 2024; Maulina et al., 2022; Wolters et al., 2022).

Adding to this, the broader domain of stress physiology implicates the hypothalamic–pituitary–adrenal (HPA) axis and autonomic nervous system (ANS) in the pathogenesis of FSSs (Sic et al., 2025). Chronic stress or poor emotional regulation can increase sympathetic reactivity and disrupt the delicate balance of cortisol responses, leading to heightened vulnerability to functional gastrointestinal, musculoskeletal, and other systemic complaints (Bonanno et al., 2024; Sic et al., 2024). Parental difficulties in managing stress, along with tension in the home environment, can amplify these physiological pathways in their children. Repeated exposure to high family stress may sensitize children to internal cues, strengthening the perceived link between emotional upset and bodily discomfort (Bosmans et al., 2022).

The growing body of literature examining how parental psychological factors intersect with children’s FSSs sheds light on critical clinical implications. For decades, the tendency was to focus on children’s personality traits, coping styles, or specific life stressors as primary drivers of FSSs, but it is now evident that parental characteristics and family dynamics substantially shape symptom trajectories (Berg et al., 2022; Senger-Carpenter et al., 2025). However, many existing studies have significant methodological limitations. These include reliance on small or clinical-only samples, narrow focus on singular parental variables (such as maternal depression or health anxiety), and an overrepresentation of maternal respondents. In addition, most available research employs cross-sectional designs, which limit inferences about directionality or causality. Few studies have adopted an integrative approach examining multiple parental psychological domains—such as reflective functioning, alexithymia, and emotion regulation—in relation to child somatic symptoms. The present study addresses these gaps by examining how a combination of parental emotional and cognitive traits, along with self-reported health, are associated with both the presence and severity of children’s FSSs in a community-based sample.

Emerging interventions that incorporate parental psychoeducation, family therapy, or mentalization-based approaches suggest that bolstering parental reflective functioning can help parents interpret children’s physical complaints through a more empathic and psychologically oriented lens (Adkins et al., 2022; De Palma et al., 2023; Stuhrmann et al., 2022). Parents can learn to explore their child’s perspective rather than solely focusing on the complaint’s possible medical significance. In parallel, helping parents gain comfort with discussing and labeling emotions—both their own and the child’s—supports a healthier, more adaptive way of relating to bodily distress. Intervention efforts are further supported by the notion that, once parents become aware of their own emotional blind spots or difficulties tolerating distress, they can more effectively model positive coping strategies and reinforce a child’s sense that physical sensations are manageable and open to interpretation.

In the Greek cultural context, family bonds are typically strong, and child-rearing practices are often rooted in close-knit intergenerational networks, where emotional and physical well-being are highly valued but sometimes primarily expressed through somatic language (Georgas et al., 2006). Traditional values often place a strong emphasis on physical health and academic success, while emotional challenges may be less openly discussed (Antoniadou et al., 2024; Trikoilis, 2024). This may contribute to a tendency to interpret psychological distress in children through a physical lens, particularly in families where parents face emotional regulation difficulties themselves. Furthermore, while Greece has made notable strides in expanding mental health services in recent years, public mental health literacy remains relatively limited, especially regarding psychosomatic connections and childhood emotional well-being (Anastasopoulou et al., 2024; Galanou, 2025; Liargovas, 2024). Mental health education is not yet systematically integrated into parenting programs or school curricula, and access to child mental health services varies widely depending on geographic location and socioeconomic status (Leontopoulos et al., 2024). Against this backdrop, understanding how parental psychological functioning relates to children’s somatic symptoms may provide critical insight into both prevention and early intervention efforts within the Greek healthcare system.

The present study builds on these insights to investigate the associations between specific parental psychological factors and the frequency of FSSs in school-aged children (6–12 years). Understanding these associations is not only important for informing targeted interventions but also essential for advancing theoretical models of somatic symptom development. By identifying which parental characteristics are most closely linked to FSSs, researchers can better delineate the pathways through which parental emotional and cognitive processes influence children’s symptomatology. This knowledge is vital for developing comprehensive frameworks that account for both biological and psychosocial influences, ultimately contributing to a more nuanced understanding of how family dynamics shape somatic symptom presentations.

More precisely, we focus on parental reflective functioning (i.e., mentalization capacity), emotional dysregulation, alexithymia, and overall physical and mental health status. By delineating whether and how these parental characteristics correlate with children’s recurring somatic complaints, we hope to inform more targeted, family-centered approaches to prevention and treatment. Our underlying hypothesis is that parents who struggle with mentalization have difficulties regulating their own emotions or demonstrate elevated alexithymia are more likely to report FSSs in their children. Likewise, we anticipate that diminished parental physical or mental health may further intensify FSSs in youth, highlighting the interconnectedness of well-being across family members.

Ultimately, elucidating these pathways lays the groundwork for interventions that recognize both children’s individual vulnerabilities and the potential role of parental emotional and cognitive processes. Establishing robust evidence for these links paves the way for clinicians, educators, and families to approach childhood FSSs in a more holistic manner—one that acknowledges not only the child’s biology and behavior but also how the home environment and parental functioning can either mitigate or exacerbate somatic distress. As research in this field continues to grow, integrating findings on parental reflective functioning, emotional dysregulation, and alexithymia holds promise for designing nuanced, effective strategies that foster resilience in children and cultivate healthier parent–child relationships.

Based on the existing literature, we hypothesized that parents of children with recurrent somatic symptoms would demonstrate (1) lower reflective functioning (i.e., lower certainty and higher uncertainty scores), (2) higher levels of alexithymia and emotional dysregulation, and (3) poorer self-reported physical and mental health. We further expected that these parental variables would correlate with each other and significantly predict the presence and severity of children’s functional somatic symptoms. The analyses were structured to test these associations in a stepwise manner.

2. Materials and Methods

2.1. Research Design

This study was a non-interventional, cross-sectional investigation targeting parents of children aged 6 to 12 years. The study took place between May and December 2022. Participants were invited to complete a series of assessments concerning their own health status, their capacity for mentalization (reflective functioning), their ability to regulate emotions, and their alexithymic traits. In parallel, parents were asked to report on their child’s somatic complaints over the preceding six months. Following established criteria from past research involving pediatric populations, the presence of at least two somatic complaints more than once per week can be indicative of psychosocial adjustment problems (Kerekes et al., 2021; Löwe et al., 2024). Hence, children who had at least two somatic complaints occurring more than once weekly were placed in the FSSs group, while children with fewer or less frequent somatic complaints were assigned to the comparison group. The study was conducted entirely in Greek, utilizing previously validated Greek versions of all questionnaires. These instruments have been shown to have satisfactory psychometric properties in Greek-speaking populations, as documented in prior research. This ensured that the data collected were both linguistically and culturally appropriate.

2.2. Sample and Participants

Participants were parents who had at least one child between 6 and 12 years of age. In the event that a parent had two or more children in the qualifying age bracket, instructions specified completing the questionnaire for the eldest of these children. Each child could be represented by only one parent. Proficiency in Greek sufficient for understanding and completing the surveys was an inclusion criterion for participation. Exclusion criteria included parents who did not have sufficient proficiency in Greek to complete the survey, parents who did not consent to participate, and any respondents who failed to complete all mandatory sections of the questionnaire. All questionnaires used in the study were validated Greek versions, which had been previously translated and standardized in Greek population studies. The psychometric properties, including validity and reliability, of these Greek versions have been documented in the corresponding validation studies, ensuring accurate and consistent measurement across the sample.

Based on the goals and analytic plan of the study, the target sample size was estimated to be at least 200 participants. This number was primarily determined by practical and logistical considerations, including financial constraints and the feasibility of recruitment. While the target sample size of 200 was not strictly required from a statistical power perspective, it was considered adequate for preliminary statistical analysis given the available resources. The confidence level was set at 95%.

It is important to note that while the target sample size of 200 participants was chosen based on practical and logistical considerations, it may not fully meet the commonly recommended guideline of having at least 100 participants per predictor in regression analysis. As the number of predictors in our models exceeds two, the statistical power may be limited, and results should be interpreted with caution. Future studies with larger sample sizes are needed to validate these findings and increase generalizability.

2.3. Procedure

Participants were recruited via two main channels. The first involved collaboration with primary schools in the Attica region, selected by convenience sampling. Following an initial telephone contact with school principals, an official letter of collaboration was sent via email. This email included a brief invitation for parents/guardians to participate in the study and a link to the online questionnaire. School principals were free to distribute the study by forwarding it to the Parent–Teacher Association’s social media platforms or by sending it directly by email, WhatsApp, or Viber to the parents/guardians.

Participation was entirely voluntary, and therefore it was not feasible to compute a response rate for each individual school. In total, 10 primary schools in Attica took part. In addition to recruitment through schools, the questionnaire link was also shared on relevant social media platforms to reach a broader audience of parents.

The online survey was conducted using the Google Forms platform, which allowed for secure and anonymous data collection. Responses to all survey items were mandatory (forced-response format) to minimize missing data. The average time to complete the survey was approximately 20 min.

2.4. Ethical Considerations

This study was based on a master’s thesis that received approval as a non-interventional, minimal risk study from the Scientific Committee of the MSc Program in Child and Adolescent Mental Health and Psychiatry of the School of Medicine of the National and Kapodistrian University of Athens (Approval: Session 2/25-02-2022). All questionnaires were completed electronically and in anonymity. Participants were informed of their right to withdraw at any point, and no identifying personal information was collected.

2.5. Measures

2.5.1. Demographic Data

Participants provided information on gender, profession, employment status, marital status, and general family/financial circumstances. Income level was assessed by asking participants to self-report their perceived economic status, using a three-category scale: low, medium, and high. This classification reflects the participants’ subjective evaluation of their financial situation rather than objective income measurements, which aligns with prior research methodologies in similar contexts (Cialani & Mortazavi, 2020). While objective income data might offer additional insights, this subjective approach is commonly used in psychological and health research to capture participants’ perceived socioeconomic standing.

2.5.2. Parental Health Status

Parents’ health was assessed using the 12-item Short-Form Health Survey (SF-12; Ware et al., 1996), a widely used self-report instrument that measures health-related quality of life across two main domains: Physical Component Summary (PCS) and Mental Component Summary (MCS). The SF-12 includes items related to physical functioning, role limitations due to physical and emotional problems, bodily pain, general health, vitality, social functioning, and mental health. Responses are coded and weighted to produce two composite scores: PCS and MCS. The SF-12 has been validated extensively in various populations, including the Greek general population, where it demonstrated satisfactory internal consistency with Cronbach’s alpha values of 0.82 for PCS and 0.83 for MCS (Kontodimopoulos et al., 2007). In the present study, we utilized the Greek version of the SF-12 to ensure cultural and linguistic relevance. Given that the SF-12 calculates composite scores rather than providing separate item-level reliability metrics, Cronbach’s alpha values are not directly calculated from our data. Instead, we rely on previously established validation studies to support the instrument’s reliability.

2.5.3. Functional Somatic Symptoms in Children

Children’s FSSs were captured using parent reports of the Health Behaviour in School-Aged Children Symptom Checklist (Currie et al., 2009). The HBSC-SCL is a self-reported checklist that evaluates the frequency of eight common somatic symptoms over the past six months: headache, stomachache, back pain, feeling low, irritability, nervousness, sleeping difficulties, and dizziness. Each symptom is rated on a five-point Likert scale ranging from “almost daily” (4) to “rarely/never” (0). In the present study, the HBSC-SCL total score was calculated by summing the scores of the eight items, resulting in a continuous variable that reflects the overall severity of somatic symptoms, with higher scores indicating greater symptom burden. This total score was used in multiple linear regression analyses to examine predictors of symptom severity. To classify children into FSSs and comparison groups, we applied a criterion based on the frequency and number of somatic complaints. Children who experienced at least two different somatic complaints more than once per week were categorized into the FSSs group. Children with fewer or less frequent complaints were assigned to the comparison group. This binary categorization was used in logistic regression analyses to examine factors predicting the presence of recurrent somatic complaints.

Internal consistency for the HBSC-SCL in the present sample was acceptable (α = 0.62), in line with previous findings in a Greek population (Petanidou et al., 2014).

2.5.4. Reflective Functioning

The Reflective Functioning Questionnaire (RFQ; Fonagy et al., 2016) was used to assess the capacity for mentalization (i.e., understanding and interpreting behaviors—one’s own and others’—based on underlying thoughts, feelings, and motives). The RFQ is an eight-item, self-report questionnaire rated on a Likert scale from 1 (strongly disagree) to 7 (strongly agree). It yields two factors, Certainty and Uncertainty, with extreme scores in either subscale reflecting mentalizing difficulties. In Greece, the RFQ has been validated in both community and clinical samples, supporting the two-factor structure and reporting satisfactory internal consistency for both subscales (Cronbach’s alpha = 0.80 for Certainty, 0.79 for Uncertainty) (Griva et al., 2020). Internal consistency for the RFQ in the present sample was satisfactory, with Cronbach’s alpha values of 0.80 for Certainty and 0.70 for Uncertainty.

2.5.5. Emotion Regulation

Parents’ abilities to regulate emotions were measured with the Difficulties in Emotion Regulation Scale-Short Form (DERS-SF; Kaufman et al., 2016). The DERS-SF includes 18 items tapping six dimensions of emotion regulation—divided into six dimensions: (1) Non-acceptance of emotional responses (Non-Acceptance) shows a proclivity for negative secondary reactions to emotion and/or denial of distress; (2) The difficulties engaging in goal-directed behavior subscale (Goals) captures the difficulties with concentrating and completing tasks while experiencing negative emotion; (3) The impulse control difficulties subscale (Impulse) reflects difficulties controlling behavior when upset; (4) The lack of emotional awareness (Awareness) subscale measures inattention to emotional responses; (5) The limited access to emotion regulation strategies (Strategies) subscale assesses beliefs that an individual is restricted in effectively regulating emotion after becoming upset; and (6) The lack of emotional clarity (Clarity) subscale reflects the degree to which individuals are unsure about their emotions. However, it is often treated as a unidimensional measure in research (Danasasmita et al., 2024). The original 36-item version of the DERS has shown adequate psychometric properties in a Greek community sample (Mitsopoulou et al., 2013). The DERS-SF demonstrated good internal consistency in the present sample with a Cronbach’s alpha of 0.87.

2.5.6. Alexithymia

Parental alexithymia was evaluated with the Toronto Alexithymia Scale-20 (TAS-20; Bagby et al., 1994). This 20-item Likert-type scale (1 = strongly disagree to 5 = strongly agree) comprises three factors: Difficulty Identifying Feelings, Difficulty Describing Feelings, and Externally Oriented Thinking. The Difficulty Identifying Feelings factor assesses the degree to which respondents find it hard to distinguish emotional arousal from physical sensations, while the Difficulty Describing Feelings factor pertains to difficulties describing feelings to others, and the Externally Oriented Thinking factor captures a preference for externally oriented thought processes. The TAS-20-G has been shown to be a valid and reliable measure of alexithymia in Greek-speaking samples (Tsaousis et al., 2010). The TAS-20 exhibited variable internal consistency in the present sample (α = 0.86 for Difficulty Identifying Feelings, 0.34 for Difficulty Describing Feelings, and 0.19 for Externally Oriented Thinking), which may reflect the scale’s psychometric limitations when used in non-clinical populations or translated forms.

2.6. Statistical Analysis

Descriptive statistics for quantitative variables included mean and standard deviation (SD), as well as median and interquartile range where appropriate. Qualitative variables were summarized in absolute (N) and relative (%) frequencies. To detect potential group differences on categorical variables (e.g., demographic characteristics), Pearson’s χ² test was used. For continuous variables, between-group comparisons (FSSs versus comparison group) were carried out with the independent-samples t-test.

Correlations between two continuous variables were assessed using Pearson’s correlation coefficient (r). A coefficient between 0.1 and 0.3 was considered low correlation, 0.31 to 0.5 moderate correlation, and above 0.5 high correlation (Cohen, 1988). Simple or multiple logistic regression models were employed to assess how one or more independent variables predicted a binary dependent variable. Simple or multiple linear regression analyses were carried out to investigate whether changes in one or more independent variables explained variations in a continuous dependent variable. All significance levels (p-values) were two-tailed, with statistical significance set at 0.05. SPSS version 29.0 was used for all analyses.

3. Results

The results are presented in four main parts: (1) group comparisons of demographic and psychological variables between parents of children with and without recurrent somatic symptoms; (2) bivariate correlations among the main study variables; (3) logistic regression analyses examining predictors of symptom presence; and (4) a multiple linear regression model predicting symptom severity.

We begin by comparing demographic and psychological characteristics between the two groups of parents—those whose children exhibit recurrent FSSs and those whose children do not.

Table 1. Descriptive statistics of demographic variables.

Variables	Total Sample (N = 339)	FSSs Group (N = 64)	Comparison Group (N = 275)	χ2/t-Test (p-Value)
Parent’s Gender				χ2 = 0.32 (p = 0.57)
Male	27 (8%)	4 (6.3%)	23 (8.4%)
Female	312 (92%)	60 (93.6%)	252 (91.6%)
Child’s Gender				χ2 = 0.34 (p = 0.56)
Boy	179 (53%)	36 (56.3%)	143 (52.2%)
Girl	159 (47%)	28 (43.8%)	131 (47.8%)
Marital Status				χ2 = 7.15 (p = 0.07)
Single	11 (3.2%)	2 (3.1%)	9 (3.3%)
Married/Civil Union	282 (83.2%)	47 (73.4%)	235 (85.5%)
Divorced	41 (12.1%)	14 (21.9%)	27 (9.8%)
Other	5 (1.5%)	1 (1.6%)	4 (1.5%)
Employment Status				χ2 = 12.59 (p = 0.002)
Employed	269 (79.4%)	42 (65.6%)	227 (82.5%)
Unemployed (seeking work)	38 (11.2%)	15 (23.4%)	23 (8.4%)
Economically Inactive	32 (9.4%)	7 (10.9%)	25 (9.1%)
Economic Level				χ2 = 3.27 (p = 0.20)
Low	48 (14.2%)	11 (17.2%)	37 (13.5%)
Medium	270 (79.6%)	52 (81.3%)	218 (79.3%)
High	21 (6.2%)	1 (1.6%)	20 (7.3%)
Educational Level				χ2 = 6.59 (p = 0.04)
Primary (Elementary)	1 (0.3%)	1 (1.6%)	0 (0%)
Secondary (High School)	102 (30.1%)	24 (37.5%)	78 (28.4%)
Tertiary (University)	236 (69.6%)	39 (60.9%)	197 (71.6%)
Parent Age (years)	M = 41.22 (SD = 5.45)	M = 39.67 (SD = 5.35)	M = 41.59 (SD = 5.43)	t = 2.89, p = 0.004
Child Age (years)	M = 9.07 (SD = 1.90)	M = 9.00 (SD = 1.92)	M = 9.08 (SD = 1.83)	t = 1.73, p = 0.75
Number of Children	M = 1.91 (SD = 0.77)	M = 1.95 (SD = 0.74)	M = 1.90 (SD = 0.78)	t = 0.14, p = 0.61

presents the descriptive statistics for the demographic characteristics of the sample, both overall and stratified by group (FSSs group versus comparison group). Participants were assigned to one of these groups based on whether the child had more than one somatic complaint occurring more than once a week.

Regarding the parent’s gender, 92% of the total sample were mothers, and 8% were fathers. Within the FSSs group, 93.6% were mothers, and 6.3% were fathers, compared to 91.6% mothers and 8.4% fathers in the comparison group. This difference was not statistically significant (χ² = 0.32, p = 0.57).

The average age of the parents was 41.22 years (SD = 5.45, range: 22–58). The mean age of parents in the FSSs group (M = 39.67, SD = 5.35) was significantly lower than that of the comparison group (M = 41.59, SD = 5.43), t(337) = 2.89, p = 0.004.

Regarding marital status, the majority of participants (83.2%) were either married or in a civil union. Additionally, 12.1% of participants were divorced, 3.2% were single, and 1.5% reported being in another form of marital status (e.g., separated or widowed). There were no statistically significant differences in marital status distribution between the two groups (χ² = 7.15, p = 0.07).

In terms of socioeconomic level, 14.2% rated their economic status as low, 79.6% as medium, and 6.2% as high; no significant differences were found between the FSSs and comparison groups (χ² = 3.27, p = 0.20). Regarding employment, 79.4% reported being employed, 11.2% were unemployed (actively seeking work), and 9.4% were economically inactive. The distribution of these employment categories differed significantly between the FSSs and comparison groups (χ² = 12.59, p = 0.002).

Concerning educational level, 69.6% had completed tertiary education, 30.1% had completed secondary, and 0.3% primary education. The distribution across these levels differed significantly between the FSSs and comparison groups (χ² = 6.59, p = 0.04).

The average number of children per family was 1.91 (SD = 0.77), with no significant difference between groups (t(337) = 0.14, p = 0.61). As for the child’s gender, 53% of the children were boys and 47% girls, again with no statistical difference between groups (χ² = 0.34, p = 0.56). The mean age of the children was 9.07 years (SD = 1.90), and there was no significant difference between the FSSs group and the comparison group (t(337) = 1.73, p = 0.75).

Having described demographic differences, we next examined whether parents of children with FSSs differed significantly in psychological traits and health indicators compared to parents of children without recurrent symptoms.

Table 2. Descriptive statistics of clinical measures.

Measure/Subscale	Total Sample (Mean ± SD)	FSSs Group (Mean ± SD)	Comparison Group (Mean ± SD)	t-Test/χ2
RFQ
Certainty	1.15 (0.80)	0.90 (0.75)	1.20 (0.80)	t = 2.89, p = 0.004
Uncertainty	0.53 (0.56)	0.77 (0.69)	0.47 (0.52)	t = −3.88, p < 0.001
TAS-20 (Total)	49.00 (11.19)	49.00 (11.19)	45.31 (9.80)	t = 2.46, p = 0.014
Difficulty Describing Feelings	11.71 (3.65)	12.48 (4.56)	11.53 (3.39)	t = 1.75, p = 0.081
Difficulty Identifying Feelings	15.81 (2.23)	17.25 (6.01)	15.47 (4.99)	t = 2.28, p = 0.023
Externally Oriented Thinking	18.48 (3.72)	19.27 (3.38)	18.30 (3.78)	t = 1.90, p = 0.058
TAS-20 Categories
No Alexithymia (≤51)	—	45 (70.3%)	210 (76.4%)	χ2 = 4.06, p = 0.13
Possible Alexithymia (52–60)	—	8 (12.5%)	41 (14.9%)
Alexithymia (≥61)	—	11 (17.2%)	24 (8.7%)
DERS-SF (Total)	31.20 (9.69)	37.52 (11.69)	29.73 (8.54)	t = 6.95, p < 0.001
Strategies	2.19 (0.85)	2.72 (1.07)	2.07 (0.74)	t = 5.35, p < 0.001
Non-Acceptance	1.93 (0.85)	2.28 (0.98)	1.85 (0.80)	t = 3.49, p = 0.001
Impulse	2.20 (0.80)	2.73 (1.06)	2.08 (0.67)	t = 5.19, p < 0.001
Goals	2.52 (0.90)	2.96 (0.97)	2.41 (0.85)	t = 4.15, p < 0.001
Clarity	1.56 (0.67)	1.81 (0.80)	1.50 (0.63)	t = 3.01, p = 0.003
SF-12
PCS	50.67 (7.08)	48.25 (8.48)	51.23 (6.61)	t = −2.45, p = 0.015
MCS	44.23 (11.12)	37.71 (11.27)	45.75 (10.54)	t = −6.69, p < 0.001

Abbreviations: RFQ—Reflective Functioning Questionnaire, TAS-20—Toronto Alexithymia Scale-20, DERS-SF—Difficulties in Emotion Regulation Scale-Short Form, SF-12—12-item Short-Form Health Survey, PCS—Physical Component Summary, MCS—Mental Component Summary.

summarizes the scores on the study’s main psychological and health measures. For the Reflective Functioning Questionnaire (RFQ), the overall mean for the Certainty subscale was 1.15 (SD = 0.80), with the FSSs group scoring significantly lower (M = 0.90, SD = 0.75) than the comparison group (M = 1.20, SD = 0.80), t(337) = 0.53, p = 0.006. Conversely, for the Uncertainty subscale (overall M = 0.53, SD = 0.56), the FSSs group scored significantly higher (M = 0.68, SD = 0.62) compared to the comparison group (M = 0.43, SD = 0.50), t(337) = −3.88, p < 0.001.

On the TAS-20, the overall mean was 49.00 (SD = 11.19). There were no statistically significant differences between the two groups on the three TAS-20 subscales (Difficulty Describing Feelings, Difficulty Identifying Feelings, Externally Oriented Thinking). However, the FSSs group had a higher overall TAS-20 score (M = 49.00, SD = 11.19) than the comparison group (M = 45.31, SD = 9.80), a difference that reached statistical significance (t(337) = 2.46, p = 0.009).

On the DERS-SF, the FSSs group scored significantly higher on the total score (M = 37.52, SD = 11.69) than the comparison group (M = 29.73, SD = 8.54), t(337) = 17.95, p < 0.001. The FSSs group also registered higher mean scores for each of the DERS-SF subscales (Strategies, Non-Acceptance, Impulse, Goals, Clarity).

Finally, on the SF-12, the total sample’s mean PCS was 50.67 (SD = 7.08). The FSSs group reported a significantly lower mean (M = 48.25, SD = 8.48) than the comparison group (M = 51.23, SD = 6.61), t(337) = 7.59, p = 0.010. In parallel, the FSSs group’s MCS was lower (M = 37.71, SD = 11.27) than that of the comparison group (M = 45.75, SD = 10.54), t(337) = 2.33, p < 0.001.

Beyond group-level comparisons, we explored how key parental variables interrelate, to better understand the psychological profile associated with children’s somatic symptomatology.

Table 3. Correlations among clinical variables and parent age (Pearson’s r).

	(1) Parent Age	(2) RFQ Certainty	(3) RFQ Uncertainty	(4) TAS-20 Total	(5) DERS-SF Total	(6) SF-12 PCS	(7) SF-12 MCS
(1) Parent Age	1	0.007	−0.21 ***	−0.11 *	−0.09	−0.003	0.17 **
(2) RFQ Certainty	0.94	1	−0.64 ***	−0.50 ***	−0.51 ***	0.17 **	0.30 ***
(3) RFQ Uncertainty	<0.001	<0.001	1	0.46 ***	0.59 ***	−0.12 *	−0.37 ***
(4) TAS-20 Total	0.032	<0.001	<0.001	1	0.61 ***	−0.35 ***	−0.41 ***
(5) DERS-SF Total	0.067	<0.001	<0.001	<0.001	1	−0.30 ***	−0.56 ***
(6) SF-12 PCS	0.97	0.008	0.031	<0.001	<0.001	1	0.18 **
(7) SF-12 MCS	0.003	<0.001	<0.001	< 0.001	<0.001	0.002	1

* p < 0.05, ** p < 0.01, *** p < 0.001. Abbreviations: RFQ—Reflective Functioning Questionnaire, TAS-20—Toronto Alexithymia Scale-20, DERS-SF—Difficulties in Emotion Regulation Scale-Short Form, SF-12—12-item Short-Form Health Survey, PCS—Physical Component Summary, MCS—Mental Component Summary.

shows the correlations (Pearson’s r) among the main clinical variables and parent age. The RFQ Certainty subscale had a moderate negative correlation with the RFQ Uncertainty subscale (r = −0.64), with overall TAS-20 (r = −0.50) and with overall DERS-SF (r = −0.51). RFQ Uncertainty showed a moderate positive correlation with DERS-SF (r = 0.59). In addition, DERS-SF was moderately positively correlated with TAS-20 Total (r = 0.61). Finally, the SF-12 MCS was moderately negatively correlated with DERS-SF (r = −0.56).

The RFQ Uncertainty subscale had a low positive correlation with TAS-20 Total (r = 0.46) and a low negative correlation with the SF-12 MCS (r = −0.37). Additionally, TAS-20 Total showed a low negative correlation with both the SF-12 MCS (r = −0.35) and PCS (r = −0.41).

Next, to assess which parental characteristics independently predict the likelihood of a child having recurrent FSSs, we conducted hierarchical logistic regression analyses.

Table 4. Logistic regression with dependent variable: presence or absence of functional somatic symptoms.

		Model 1					Model 2
		b (S.E.)	Exp (B)	CI 95%		R2 *	b (S.E.)	Exp (B)	CI 95%		R2 *
				Lower	Upper				Lower	Upper
RFQ	Certainty	−0.502 (0.186)	0.605 p = 0.007	0.42	0.87	0.036	−0.578 (0.197)	0.561 p = 0.003	0.38	0.83	0.153
	Uncertainty	0.83 (0.227)	2.294 p < 0.001	1.47	3.58	0.062	0.853 (0.257)	2.346 p = 0.001	1.42	3.89	0.162
TAS-20	Total	0.035 (0.013)	1.035 p = 0.010	1.01	1.06	0.031	0.029 (0.014)	1.029 p = 0.046	1.00	1.06	0.130
DERS-SF	Total	0.074 (0.014)	1.077 p < 0.001	1.05	1.11	0.138	0.075 (0.015)	1.078 p < 0.001	1.05	1.11	0.229
SF-12	PCS	−0.055 (0.018)	0.947 p = 0.003	0.91	0.98	0.041	−0.053 (0.020)	0.949 p = 0.009	0.91	0.99	0.142
	MCS	−0.062 (0.012)	0.94 p < 0.001	0.92	0.96	0.118	−0.064 (0.014)	0.938	0.91	0.96	0.215

* R² Nagelkerke. Note: Model 2 includes adjustment for additional confounders (parent gender, age, educational/economic level, employment status, as well as child gender and age). Abbreviations: RFQ—Reflective Functioning Questionnaire, TAS-20—Toronto Alexithymia Scale-20, DERS-SF—Difficulties in Emotion Regulation Scale-Short Form, SF-12—12-item Short-Form Health Survey, PCS—Physical Component Summary, MCS—Mental Component Summary.

displays the hierarchical logistic regression results, with the dependent variable being the presence (or absence) of recurrent somatic complaints and independent variables being the scores from each main measure. Model 1 presents the simple association, whereas Model 2 includes potential confounders (gender, age, educational/economic level, employment status of the parent, as well as child gender and age).

The Odds Ratios (OR) suggest that the RFQ Certainty subscale (OR = 0.561, 95% CI: 0.38–0.83), RFQ Uncertainty (OR = 2.346, 95% CI: 1.42–3.89), TAS-20 Total (OR = 1.029, 95% CI: 1.00–1.06), DERS-SF Total (OR = 1.078, 95% CI: 1.05–1.11), and the SF-12 PCS (OR = 0.949, 95% CI: 0.91–0.99) and MCS (OR = 0.938, 95% CI: 0.91–0.96) all exhibit significant relationships with the likelihood of having recurrent somatic complaints.

While the previous analysis addressed predictors of FSS presence, we also sought to determine which parental factors are associated with the severity of children’s somatic symptoms. This was examined using multiple linear regression. To further investigate how parental psychological characteristics predict the severity of children’s functional somatic symptoms (measured by HBSC week sum), a multiple linear regression analysis was conducted. The model accounted for approximately 15.0% of the variance in FSS severity (R² = 0.150, F(6, 332) = 9.739, p < 0.001).

The analysis revealed that emotion regulation difficulties (DERS-SF Total) significantly predicted greater severity of FSSs (β = 0.022, p = 0.035), indicating that higher emotion regulation challenges are associated with more severe symptoms. Furthermore, mental health status (SF-12 MCS) negatively predicted symptom severity (β = −0.030, p < 0.001), suggesting that poorer mental health is linked to increased somatic symptom severity.

In contrast, reflective functioning (RFQ Certainty and Uncertainty), alexithymia (TAS-20 Total), and physical health (SF-12 PCS) did not significantly predict the severity of symptoms (p > 0.05). The detailed results of the multiple linear regression analysis are presented in

Table 5. Multiple linear regression analysis predicting the severity of functional somatic symptoms (FSSs) based on parental psychological factors.

Predictor	Coefficient (β)	SE	t	p-Value
Intercept	−0.188	0.444	−0.424	0.672
RFQ Certainty	0.114	0.112	1.015	0.311
RFQ Uncertainty	0.039	0.167	0.234	0.815
TAS-20 Total	−0.002	0.009	−0.180	0.857
DERS-SF Total Score	0.022	0.011	2.115	0.035
SF-12 PCS	−0.019	0.010	−1.895	0.059
SF-12 MCS	−0.030	0.007	−4.120	<0.001

Abbreviations: RFQ—Reflective Functioning Questionnaire, TAS-20—Toronto Alexithymia Scale-20, DERS-SF—Difficulties in Emotion Regulation Scale-Short Form, SF-12—12-item Short-Form Health Survey, PCS—Physical Component Summary, MCS—Mental Component Summary.

.

4. Discussion

The principal aim of this study was to assess whether distinct parental psychological characteristics—including reflective functioning (mentalization), emotion regulation skills, alexithymia, and self-reported physical and mental health—predict the presence of FSSs in their school-aged children (6–12 years). The finding that parents of children with FSSs reported lower Certainty and higher Uncertainty about mental states is noteworthy. Such parents seem less confident in attributing underlying emotions or thoughts to themselves and others, which may mean they are less able to interpret their child’s nonverbal or physical signals in an emotionally attuned way. These results align with theoretical models suggesting that a parent’s reflective functioning underpins a child’s capacity to transform “raw” somatic experiences into mental representations (Schwarzer et al., 2021). In households where parents struggle with mentalization, a child’s bodily symptoms may remain unlinked to psychological states, thus recurring or intensifying over time (Nieto-Retuerto et al., 2024).

This study is unique in that it systematically combines multiple parental psychological dimensions, such as reflective functioning, emotion regulation, alexithymia, and parental health, to explore their collective impact on children’s FSSs. Building on previous studies that often focus on singular aspects of parental characteristics, our research adopted an integrative approach to identify the complex interplay between these factors. This holistic perspective allows for a more comprehensive understanding of how parental psychological profiles influence children’s functional somatic symptomatology.

Our results further indicate that FSSs group parents had higher levels of alexithymia and reported significantly greater emotion regulation difficulties. These two constructs—alexithymia and poor affective regulation—can intertwine, influencing how parents experience and respond to both their own and their children’s distress (Salazar Kämpf et al., 2023). Parents with higher alexithymic traits often lack the ability to recognize or describe their emotional states, and this limitation may inhibit them from accurately mirroring a child’s discomfort as having psychological roots rather than purely physical ones (Scarzello, 2023). Consequently, children may learn to present stress or negative affect through physical complaints (Davis & Soistmann, 2022; Lynch et al., 2022). Compounding this pattern, mothers or fathers who have more difficulty regulating their own negative affect may display inconsistent or excessively anxious responses to the child’s minor pains, reinforcing the child’s belief that such somatic signals are severe or threatening (Jungmann et al., 2022).

A notable aspect of our findings is the connection between parents’ lower self-reported mental and physical health and the frequency of children’s somatic symptoms. A parent who feels chronically unwell—physically or psychologically—might inadvertently model heightened vigilance toward bodily sensations or might lack the emotional energy to discern stress-based symptoms from organically driven ones (Thomas et al., 2024). This finding contributes to the existing literature by highlighting the interplay between parental health perceptions and children’s somatic symptom development, which has received limited attention in prior research. While previous studies have shown that parental stress and emotion regulation deficits are associated with negative child outcomes (De Palma et al., 2023; Hay et al., 2021; Myruski & Dennis-Tiwary, 2022), our results extend this knowledge by demonstrating that parental health perceptions themselves may constitute a distinct and meaningful predictor of functional somatic symptoms in children. Furthermore, the fact that both mental and physical components of parental health are implicated underscores the need to consider comprehensive parental well-being as part of prevention and intervention strategies for FSSs. By identifying parental health as a key factor, our study not only aligns with but also advances existing theoretical models that emphasize the psychosocial context of FSSs (France et al., 2023). Thus, addressing parental physical and mental health may be crucial in developing holistic and effective therapeutic approaches for children at risk of FSSs.

Past longitudinal and cross-sectional research has similarly shown that parental health status, including subclinical or mild distress, can place children at increased risk for recurring somatic complaints (Elliott et al., 2020). Although serious psychiatric diagnoses (e.g., bipolar disorder, schizophrenia) are often most strongly tied to children’s health problems (Can et al., 2024), our data align with the broader perspective that even moderate deficits in the parent’s well-being can affect a child’s vulnerability to functional somatic issues. It is possible that parents who struggle with daily pain or persistent fatigue have reduced emotional and cognitive resources for responsive parenting. This might heighten a child’s uncertainty about whether certain bodily sensations should be taken as routine or as cause for alarm, feeding into a cycle of FSSs.

Despite these compelling patterns, several limitations must be underscored. Foremost among them, our reliance on a cross-sectional, convenience-sampled dataset constrains any inferences about causality or the direction of effects. Future longitudinal studies examining both parents’ and children’s psychological and somatic functioning over multiple time points would be vital in clarifying whether parental reflective functioning or alexithymia truly precede (and potentially trigger) child somatic complaints. Additionally, children’s FSSs were reported by parents rather than self-reported by children. Parental biases—arising from their own health anxieties or difficulties in mentalization—could skew or inflate the association between parental characteristics and child complaints (Jungmann et al., 2022). Although it would be ideal to gather direct reports from children, as well as clinical evaluations by pediatricians or psychologists, our findings remain meaningful in highlighting the possibility that parents’ interpretations and emotional states may critically shape how child somatic symptoms are recognized and addressed in day-to-day family life.

A further methodological consideration relates to our use of a general reflective functioning questionnaire (RFQ). While informative, it is not specifically designed for measuring “parental” mentalization. An instrument focusing on how well parents mentalize a child’s emotions (rather than just adult mentalization in general) could reveal more precise associations, especially given the importance of interpreting a child’s distress cues. Similarly, emotion regulation and alexithymia might manifest differently in caregivers than in non-caregiving contexts, so future research could aim for multi-informant, context-specific measures that tap into how parents regulate emotions specifically in the parent–child dynamic.

Another limitation relates to the inherent complexity of categorizing somatic complaints. Functional somatic symptoms represent a diverse set of physical complaints—such as headaches, abdominal pain, and dizziness—that may vary greatly in severity, duration, and underlying mechanisms. Despite using a standardized checklist (HBSC-SCL), the broad and often overlapping nature of these symptoms makes it challenging to definitively classify them as either functional or medically unexplained. This ambiguity may affect both parental interpretation and reporting accuracy, as well as our ability to fully disentangle psychosocial from potential physiological contributors. Future studies might benefit from incorporating more nuanced diagnostic tools or clinical assessments to strengthen the precision of symptom categorization.

Though preliminary, these findings point to a few key directions for future studies and clinical practice. Future studies should employ longitudinal designs to track changes in both parental psychological functioning and children’s somatic symptoms over time. This approach would help clarify the directionality and causality of the observed associations, determining whether improvements in parental reflective functioning or emotion regulation precede reductions in children’s FSSs. In addition, adopting a multi-informant methodology would enrich the data by incorporating reports from children, independent clinical assessments, and observations from teachers or caregivers. Such diverse data sources would mitigate potential biases inherent in single-informant studies and provide a more holistic understanding of the parent–child dynamic in the context of somatic symptomatology. Incorporating objective physiological measures, such as biomarkers of stress, could further enhance the validity of the findings, offering insights into the underlying mechanisms linking parental and child health outcomes. Investigations might also identify whether attachment style or family climate moderate these processes—such that, for instance, the child’s sense of security buffers or magnifies the influence of parental mentalization deficits. Moreover, exploring potential interventions is crucial. Randomized controlled trials testing multidisciplinary treatment approaches could provide essential evidence. Such interventions have shown promise in alleviating adult somatization, and adapting them to parent–child contexts may prove beneficial (Patel & Chalder, 2025).

On a practical level, these results encourage a shift away from focusing solely on the child’s bodily complaints. Instead, clinicians might consider broad family assessments that examine how parents process emotions—particularly if they display alexithymic traits—and how effectively they differentiate emotional distress from physical discomfort. Psychoeducation could be offered to parents to help them reframe episodes of a child’s abdominal pain or headache as potential signals of worry, sadness, or frustration. Such approaches might lessen the degree to which children default to somatic expressions of psychological challenges. Additionally, identifying parents with chronic health conditions or mental health difficulties early on could allow for preventative strategies, ensuring they receive the support needed to respond sensitively to a child’s distress rather than escalating it.

Overall, the current study underscores how parental reflective functioning, emotion regulation, and health status intersect with children’s somatic symptom development. While replication and expansion in larger, more diverse samples are imperative—particularly including longer-term follow-up and direct child self-reports—our findings suggest that these variables play a non-trivial role in whether a child’s physical discomfort becomes entrenched as recurrent FSSs. Ultimately, fostering parents’ mentalization capacities and emotional awareness, as well as supporting parental well-being, may be key to reducing functional somatic symptomatology in children. In taking a family-centered approach, healthcare professionals can help parents recognize and guide their children’s emotional expression, thereby minimizing the need for children to resort to recurring somatic complaints when faced with stress or adversity.

5. Conclusions

This study highlights the complex interplay of psychological factors in parents—specifically their reflective functioning (mentalization), emotion regulation, alexithymia, and overall physical and mental health—and how these factors may shape the emergence and persistence of FSSs in school-aged children. Our findings indicate that children’s FSSs were more frequent when parents showed higher alexithymic traits, struggled with regulating their emotions, and demonstrated lower reflective functioning. We also noted a significant link between parents’ poorer self-reported health status (both physical and mental) and children’s increased somatic complaints.

Collectively, these results point to the importance of gathering information on child somatic symptoms not solely from the children themselves but also from their parents, who can substantially influence how physical signs of distress are perceived and interpreted. In practical terms, any comprehensive intervention that targets FSSs in childhood should account for both child- and parent-level variables. Treatment goals might center on reducing the child’s symptoms and improving day-to-day functioning, while simultaneously addressing the parental risk factors—such as difficulty mentalizing or regulating emotions—that may contribute to or perpetuate those symptoms.

A proactive focus on identifying and supporting psychosocially vulnerable families could preempt the long-term entrenchment of FSSs. Interventions that enhance parents’ capacities for self-awareness, emotional expression, and empathic responsiveness to a child’s distress have the potential to limit how often children resort to, or remain fixed in, physical expressions of psychological or emotional challenges. By bringing parents’ perspectives and well-being into the therapeutic frame, clinicians may help families develop healthier models of communication, ultimately preventing FSSs from becoming a persistent barrier to children’s overall development and quality of life.