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It is a common enough experience for pediatricians to note, around the beginning of the school year, a peak in the visits by parents with school-aged children complaining of abdominal pain or related symptoms. In some cases, the symptoms are worrisome, because they are unusual, debilitating or lasting so long as to concern the pediatrician who might refer for more tests or specialist opinion.
Children with abdominal pain that lasts several days, or sometimes weeks, and interferes with their daily activities are not likely to be pretending
Even experienced pediatricians will admit, from time to time, that they cannot make up their minds on whether something is truly wrong with a child, so it is little wonder that parents often find themselves scratching their heads or disagreeing on what to do.
A common misconception is that most of the time the child is making it up or otherwise exagerrating the complaint – some parents might adopt an attitude of benign neglect (‘ignore it till it goes away’). Although the lay public has, in general, grasped the effect of stress on abdominal symptoms in adults, parents may not make the connection between certain complaints with school-related stress or even that school may be stressful for an otherwise happy-go-lucky child.
Interestingly, the other extreme includes parents who themselves experience significant stress-related pain or who perhaps have been diagnosed with Irritable Bowel Syndrome – these parents may overreact to what objectively are minimal, overall insignificant symptoms in the child. These parents usually fear a serious illness – this fear, in turn, increases the family’s stress around the subject and, to some extent, drive it on.
It is important up front to realise that the majority of children complaining of abdominal pain around the beginning of school are unlikely to have anything serious. On the other hand it is equally true that children with abdominal pain that lasts several days, or sometimes weeks, and interferes with their daily activities are not likely to be pretending.
Just as in adults, the effect of stress on children can be difficult to define. Indeed, stress itself may not be obvious – children who are high achievers and overtly enjoy going to school may in fact have internalised significant anxiety from anticipation and to some degree fear of the changes they experience at the start of the scholastic year. More insidiously, some children may be victims of bullying – this is a stressor that they will be very reluctant to share with their parents, fearing reprisals if the parent follows it up with the school.
Unfortunately – and adding to the complexity of the subject – stress is hard to define and the child may not appreciate how distressing the changes taking place around them are. This means that their experience of pain may be, in itself, inexplicable and leads to a vicious circle of more uncertainty, anxiety and therefore stress.
Stress in children can be related to pain which is very similar to what in adults is called Irritable Bowel Syndrome or IBS. However, stress can also increase the symptoms of pain from certain intestinal diseases like stomach ulcers and heartburn as well as other more complex diseases like Inflammatory Bowel Disease or IBD. In the latter instance, it is well known that stress plays a part in increasing inflammation and therefore a child or adolescent may have a first attack of IBD around the time of starting school (or around exams) or may have what is called a flare-up of their illness around the time of stress.
Given the various possibilities, some of which need specific medical attention, parents should always take their child complaining of abdominal pain for several days seriously, even if around the start of a new scholastic year – in fact, perhaps more so at that time. Certainly pain that comes with other symptoms such as weight loss, change in bowel habit, vomiting or bleeding requires the more urgent attention of the family doctor who might opt to refer for specialist care depending, in turn, on his impression or to reassure the parents that, in fact, there is no reason for concern. It is often then that the role of the Pediatric Gastroenterologist is to investigate the symptoms and, in some cases advise on more detailed tests. A common scenario is to treat the symptoms and wait to see if they resolve or if new symptoms develop, signalling the need to look more closely.
One cause for chronic abdominal pain that gets worse with school and may surprise parents is constipation as children tend to procrastinate (sometimes with good reasons) from using the school toilets – coupled with less fluid intake and more sedentary behaviour, this may worsen a child’s bowel habit. Sometimes constipation can be difficult to diagnose as the child can’t appreciate that their stooling pattern is abnormal as it is, in fact, what is ‘normal’ for them, having gotten used to it.
It can sometimes be difficult to pick up what stressors may be present at school and it is common enough for parents to be told to work with a psychologist to understand how to help the child while at the same time, medical problems are being investigated. Parents appreciate that a lot of time is spent going back and forth to school in buses and they have to make an effort to understand if bullying is rearing its ugly head there – outside the school but not quite at home. It is sometimes possible to get a sense on what other children say about the trip in the bus by discussing concerns with other parents and the matter may need to be raised with the school directly if there is enough cause for concern.
Time can be an ally or an enemy depending on the willingness of the family to wait and see if things change with reassurance or symptom-directed tratment. Time can be of the essence if the pain is interfering with school attendance and academic performance, in which case it is not uncommon for the child to have tests ordered seeking an elusive ‘quick fix’.
In the case where a psychosocial component is the overriding factor driving the pain, it is important to state it as such rather than pursue endless tests that will only reinforce the family’s anxiety that there is ‘something wrong’ but ‘nobody can understand what it is.’ It is vital for the family to work hand-in-hand with the school and the support staff available to the student, including counselors and, of course, teachers.
Prof. Thomas Attard MD FAAP FACG is a Consultant Pediatric Gastroenterologist.