Emotions like anxiety can manifest as unexplained symptoms in children.
Pediatricians know firsthand that anxiety is a universal experience. Children naturally feel vulnerable and crave protection. We also know that children have feelings in abundance, but often lack the cognitive skills to express them. So it is not surprising to us when we find that kids, with their limited ability to navigate emotional storms, start experiencing their scary emotions not as feelings but rather through their bodies. According to pre-pandemic data from the US school-related anxiety presenting as unexplained medical symptoms accounted for five to 12 percent of outpatient pediatric visits. That’s a lot of frightened kids missing a lot of school.

School attendance is one of the most significant markers for how well a child is functioning, and recurrent absenteeism due to unexplained medical symptoms is a red flag for any pediatric provider.

The neuroscience of brain mapping that links physical symptoms to the emotional brain has been rapidly advancing in recent decades. Treatment approaches, however, have been slow to make it out of academic centers to professionals in the community. Most pediatricians have been treating minor versions of these emotional illnesses without understanding their full nature.

Pediatricians are pretty good at recognising emotionally driven symptoms in children. Sure, they include a careful history and physical exam, but when all that is reassuring, and the timing of the pain seems directly related to the anticipation of a school day, then school-related anxiety moves to the top of the diagnostic list. They don’t close the door on other possibilities. But trying to rule out every possible cause of a physical complaint before diagnosing an emotional source is for amateurs.

Many parents, on the other hand, are understandably frightened by these symptoms. They know their child is not a liar. They might take offense that you thought the problem was “all in their head,” or feel that their concerns are being dismiss. My recommendation to get the child back in school would often sound counterintuitive. There were a few that even left my practice out of fear and frustration that I was unable to quell. A simple, solid MedPsych toolkit that provided me with a clearer understanding of the dynamics of the illness and honed the language I used would have helped me provide clear psychoeducation and align better with many of these worried parents. It would have improved my effectiveness.

Pain is pain, whether it is caused by the inflammatory mediators that rush to a very sprained ankle, or by misleading signals across the emotional matrix of the brain, sending messages of pain out to a specific body part. In short, the child may have had the healthiest belly, but he could still be experiencing pain. He truly has no understanding that it was related to school.

Simply put, your child might not be faking it. Their anxiety at the thought of walking into that giant brick building would be overwhelming his fledgling coping mechanisms. His emotional brain, in a frantic display of strength, was using a host of neurotransmitters and specialized proteins to send out false but compelling messages of physical symptoms.

Pediatric providers need to look these young patients in the eye and tell them, not as an attempt at diplomacy but with conviction, that we believe them. We understand they are experiencing the symptoms they say they are experiencing. And we follow that with basic psychoeducation about the role of the emotional brain in producing these very real symptoms. That is where trust and healing begin. That is how we align with the child and their family. Only then can we help them better understand and connect with their feelings. Sometimes they will need to continue this work with a therapist. Sometimes not.

The next critical step is to restore function. Your child’s pediatric provider, his parents, and his teachers must be able to expect and tolerate the inevitable distress, both on the child’s and our own, as the doctor avoids excusing absences and helps the distraught child back into the classroom in a compassionate way.