Do Emotional Stressors Contribute to Abdominal Pain in the School Setting?

[k1p1ssk, BSN, RN]

ledzep97 said:

There isn't a day that goes by that I don't see a child that states that she has abdominal pain.  As an elementary school nurse, this can pose quite the challenge at times.  Students come from a variety of backgrounds, educational and developmental stages, and health histories. It becomes increasingly more challenging when the student can't articulate the symptoms, remember onset, and when essentially, they are a poor medical historian.  The constant flow does provide job security but often makes me ponder, "Is there a connection between abdominal pain and emotional issues"?

Several children come to the clinic with abdominal pain or discomfort that, through nursing judgment, would be associated with illness. However, there are students that come in, either on a regular basis or during certain time periods, such as PE class. First, try to rule out any obvious illness or medical condition. It may be appropriate to then discuss potential emotional triggers. These may include family issues at home, friend or classmate relationship problems, or academic concerns.  Some children become anxious when they are separated from their caregivers or have social anxiety.  There are also children with generalized anxiety or certain fears, such as being afraid to speak in class.

Anxiety can be unique to the individual. It can be a worry or a fear. This can cause students to become angry, disruptive in the classroom, withdrawn, or self-isolating. The student may be finding ways to escape the feeling of anxiety with the most comfortable actions available or socially acceptable at the time.

This also raises the question as to whether students at the elementary school level understand what anxiety feels like. One of the most common chief complaints in the clinic involves a stomach issue. They will most likely point to the middle of their abdomen when asked where the pain is located. They may need to use the restroom. They may even express that they "just don't feel good."  Some students do not have the vocabulary to express their feelings. They may not connect that something that makes them anxious makes their stomach feel different. Some students may too embarrassed or uncomfortable to discuss what is truly bothering them. Nonetheless, how can we help?

1- Discuss Feelings

Students may not be aware of the different emotions we as humans might feel. This is also an opportunity to have dialogue about emotions are normal and how they are feeling is appropriate for them. Some children might benefit from have visual representations of different emotions, such as a poster displaying different facial expressions one might have when experiencing a certain emotion.

2- Explain what anxiety might feel like

It could feel like "butterflies" in the stomach, having to have a bowel movement urgently, headache or simply "just not feeling right".  It might also help to let students know that stomachaches don't always mean they are ill. However, the body is trying to tell them something and should be evaluated.

3- Find an appropriate outlet to express the emotion

This could be journaling, talking to a trusted adult, meditation, getting a drink, writing a note, asking to speak to a counselor, or having a signal with the teacher when a difficult emotion arises.

4- Talk to the adults in the student's life

This may include the teacher, guardians, social worker, behaviorist and administration. Work as a team to advocate for the student and find ways that student can be supported during the school day.   

Many students Spring back to class after water, rest, and even chatting for a bit. The clinic can serve as an oasis for students that just need to collect their thoughts and get a time out from whatever they interpret as stressful. Yes, there are always students that use this time to avoid doing work, but it is also important to keep in mind the root of the avoidance.

FACT: We can help students identify emotions, develop coping skills and navigate their unique health needs. There is so much more than meets the eye.

I use these techniques on the daily and I have found that I see my frequent tummy ache students less and less as the year goes on. It of course takes time and multiple visits with these chats, but as they learn to recognize their "worry tummy aches" from other illness symptoms, they become able to manage & cope with the symptoms better. I think a lot of psycho-somatic symptoms are troublesome for students who are anxious because on top of not feeling well from anxiety or other social-emotional troubles, they are now also worried that they will throw up. So reassurance is key. 

I have a couple of students who have special plans in place where all they have to do is tell their teacher they need a break, and they can come to my office, no questions asked (within reason) to spend some time coloring or to get a coveted warm pack. 

Thank you for sharing! This has reinforced my practice, for sure!

[NutmeggeRN, BSN]

OOOH oh yes!!  AND I would add headaches and shortness of breath!

The kids are NOT all right. Before and especially after the onset of C19, I am  framing  my assessments to include mental health....how is your day? any drama? any issues with kids?....it is amazing the number of somaticized complaints there are!

[beachynurse, ASN, BSN]

Sigh, it's much different in high school. Some students do come to us with real complaints of abdominal pain, and we work with them to not only assess the physical, but the emotional as well. Then there are the others.. A majority of our visits with abdominal pain sadly use the clinic as a vehicle to go home early. Another big complaint to go home is headaches. They call their parents and go home.. then cry because they need a waiver.. 

[NutmeggeRN, BSN]

The possibility of pregnancy, STI, ovarian cysts further complicate the assessment of older girls.

[beachynurse, ASN, BSN]

It does complicate things for girls.. And now we have the trans population and sometimes we aren't sure which biological sex they are in order to do the correct assessment. The kids and parents get offended when you ask, which I can understand in a way, but it makes assessing them harder. 

[NutmeggeRN, BSN]

beachynurse said:

It does complicate things for girls.. And now we have the trans population and sometimes we aren't sure which biological sex they are in order to do the correct assessment. The kids and parents get offended when you ask, which I can understand in a way, but it makes assessing them harder. 

Yep!! Damned if you do and damned if you don't some days. I guess the best way to ask is simply "Do you menstruate? If so, when did it start (or stop?)" and move on from there.