School-Related Anxiety: It's Not All in Your Head

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 school-related anxiety presenting as unexplained medical symptoms accounted for 5-12 percent of outpatient pediatric visits¹. That’s a lot of frightened kids missing a lot of school.

Jason, 7 years old, flanked by two unhappy parents, was waiting for me when I arrived at my pediatric office early one Monday morning. Jason had been experiencing frequent unexplained belly pain over the past month and the symptoms had flared again the previous night. By this morning the mid-abdominal pain was sharper, and Jason cried and pleaded that he could not go to school, again. His parents had a list of diagnoses they felt should be ruled out. The school was asking for a “doctor’s note” so he could be allowed to make up the work at home. Then came an important diagnostic clue: “He’s missed five days of school in the past two weeks because of this.”

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. In my work as medical director of the Inpatient Med/Psych program at Hasbro Children’s Hospital, I learned a great deal about the mechanisms of these emotionally based illnesses from the remarkable psychiatrists and psychologists I worked with. I also began to look back on my previous outpatient pediatric practice with dismay. I came to realize that I, like most pediatricians, had been treating minor versions of these emotional illnesses without understanding their full nature.

Jason was perched on the edge of the exam table as if preparing for flight. He stared down at his toes with an alertness that made it clear he was listening closely to every word that was spoken. When I attempted to engage him in the conversation, he looked to his parents to answer for him. His lips trembled as I gently pushed my hands around his soft belly. Diagnostic clue number two: Jason seemed more worried about this visit than he was about his belly pain.

Pediatricians are pretty good at recognizing emotionally driven symptoms in children. Sure, we 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 our diagnostic list. We 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 I thought the problem was “all in his head,” or feel that I was being dismissive of their concerns. 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.

What did my MedPsych experience teach me? For one thing, “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, Jason may have had the healthiest belly in southern New England, but as I now realize, he was actually experiencing pain. He truly had no understanding that it was related to school. In a pediatric Catch-22, if he was able to recognize how anxious he actually was about school, his emotional brain wouldn’t have produced these decoy abdominal symptoms to begin with.

Simply put, Jason was not faking. His anxiety at the thought of walking into that giant brick building was 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.

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

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