Our 6-year-old son complains of stomach pain only when going to school - and refuses to go

Question

Our 6-year-old son is crying almost every day when we try to leave him at school. He will start to cry and complain of stomach pain. This stomach pain only shows up in the morning when we are about to go to school or on the way to school. He does not have stomach pain at home, nor during after-school activities nor on week-ends.

To be sure, we have been to the doctors to have him checked. They could not find anything. He has some intolerance to gluten, and he had a period last year when he complained about stomach pain but then it wasn't "only when going to school".

He is very social and has generally had an easy time to make friends and adapt to new environments. We moved to a new country 1.5 years ago, and the first week he cried when we left him at kindergarten - but he picked up the new language and made friends and it took about a month and he was genuinely happy to go to kindergarten. This year he was looking forward to start at a new school.

The first weeks went fine. Unfortunately, there were three (maybe four) incidents between him and some older children at the playground where he had been hit by them. All these incidents occurred at the time when several grades are waiting to enter the canteen. We have of course taken this up with the school and the director. We believe this has been resolved and there hasn't been any more incidents since then. He is now eating at home instead of at school (as do many other kids).

We have met with his teacher and we have seen him during a break at school. I trust his teacher and he seems to get along fine with his classmates. On the way to school and home from school several kids want to talk to him - he seems to do well socially. The teacher says that she can see those mornings when he has been crying, but that he is happy in class and does well in school.

However, he is crying and is complaining of stomach pain in the mornings, often just at the time when one says "OK now it is time to put on the shoes and go". We have asked for a meeting with the school psychologist.

We are not sure exactly how to handle this. Initially, when we were not sure what was going on, we would have him stay home instead of going to school. He would play with his toys as normal at home (but no screen time!).

Once it was clear it was not a physical health issue and after meeting with the teacher and it felt that school should be safe - we said he has to go to school - even if he feels he has stomach pain.

We have tried to ask him about his stomach pain but I'm not sure he knows himself what exactly he feels or why he feels he has pain.

He has complained that school feels long. He might be bored. It may not be what he expected school to be like (it is different from kindergarten). He might also not feel safe (yet) due to the incidents.

To complicate matters, where we live (Barcelona), the school is in Catalan, while most social interactions on playgrounds etc., are in Spanish. In kindergarten it was more relaxed (teachers would speak English/Spanish and Catalan), while at school all teaching is in Catalan (although his teacher is fine if he replies in any language he wants). And the teacher does not think he needs support in Catalan as of now - (he has less of a vocabulary than some other kids, but there are also many kids like him who know only Spanish. Our son also speaks English and Italian well).

How can we help him with this?

Should we bring him to school even if he breaks down and starts to cry on the way complaining about stomach pain?

I'm not sure, but I think his sense of pain is real, but I think it may be due a lot of factors that he is not himself aware of. I think he is not as aware of his feelings as she is. I think one of the factors is that he simply thinks school is not fun and he prefers to be home - but I also think that this is not the only factor.

Today, my wife brought him to school and it ended up with him laying down on the street refusing to go. So she took him home. I spoke with him and told him that he has to go to school - even if he has some stomach pain - that he will do fine and that school is important. I said eventually that he will go to school even if that means I will carry him to school. And so I did, I carried him to school. He cried for most of the way but once he had accepted it he stopped crying. Just when leaving him at school he wanted to hug a lot and he was sad but he did go to his classroom.

I think I did the right thing, but I'm not sure. Thoughts and suggestions are very welcome.

Answer 1

I think I did the right thing, but I'm not sure.

I believe there is only one safe answer to give here (unless the user is a child psychologist, which I am not): I don't know either.

But consider that children with nonorganic recurrant abdominal pain often continue to have problems into adulthood:

The long-term outcome of this condition has not been determined, but preliminary data indicate that young adults with a history of recurrent abdominal pain that began in childhood who are treated by a subspecialist are significantly more likely than their peers without recurrent abdominal pain to have lifelong psychiatric problems and migraine headaches.

This might mean that the treating subspecialist is causing harm (as a physician myself, I'm kinda but not totally joking here.) The effect of repeatedly seeing a specialist for a nonorganic disorder may have a psychological effect, but that study hasn't been done.

Under point #7 (What is the Effectiveness of Cognitive-Behavioral Therapy?) there is evidence that seeing a therapist can be helpful:

...the treated group improved more quickly, the effects generalized to the school setting, and a larger proportion of subjects were completely pain-free by 3-month follow-up. In the second study, the children and mothers who were taught coping skills had a higher rate of complete elimination of pain, lower levels of relapse at 6 and 12 months' follow-up and lower levels of interference with their activities as a result of pain, and parents reported a higher level of satisfaction with the treatment.

I don't have wisdom about how to handle this except to recommend talking to your pediatrician (nonorganic/functional abdominal pain is a relatively common problem which they see) or a good therapist about it. It sounds extreme enough to warrant intervention.

Edited to Add:

I didn't really address your question, I'm sorry. I think you probably did the right thing.

As you already did, I would explain that while looking for a way to treat it, a child must still go to school (unless there were bullying or some other specific source of anxiety that would warrant a school absence.)

That said, functional abdominal pain is painful, though.

You say,

We have tried to ask him about his stomach pain but I'm not sure he knows himself what exactly he feels or why he feels he has pain.

I mentioned that I'm a physician, and probably every other day that I saw patients, there was someone with abdominal pain. I can tell you from experience that kids his age generally can't describe their pain, let alone why. First, their understanding is limited. Maybe more importantly, their vocabulary is limited. They don't think in terms of 'sharp'/'dull'/'constant'/'crampy'/etc. It just hurts sometimes.

Similarly, to discuss his feelings about school, he needs a rich emotional vocabulary. I would start building one whilst awaiting seeing a therapist to help.

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_{Source: Chronic Abdominal Pain In Children: A Technical Report of the American Academy of Pediatrics and the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition: AAP Subcommittee and NASPGHAN Committee on Chronic Abdominal Pain, Pediatrics 2005}

Answer 2

This sounds like a very tough situation. I agree that it seems like the pain is likely coming from anxiety, and not from a physical source, although there could always be something specific about your morning routines that isn't being triggered at other times such as the weekends.

I'm not sure exactly what you've tried to isolate the cause, but if you haven't already, it would likely be worth trying to keep your exact school morning routine on a day when he doesn't have to go to school. You could do this on a weekend day by planning an outing to a zoo/cinema/beach/etc. that would require waking up early and getting ready in the same way. You might also try getting him up on a school day, starting the morning routine, and telling him that he doesn't have to go to school that day, and instead, you're taking a "field trip" to someplace more exciting. Obviously, you should talk to his teacher and make sure to get any work that he would miss. If the pain still shows up even in this case, then that would be illuminating.

But assuming that the causes seem to be mostly psychological, I think that seeing the school psychologist is a very good idea. You may even look into finding a separate child psychologist for him to meet with regularly.

He is young, so you may not have much luck with this, but I am always of the opinion that children should be told the truth. Talk to him about different kinds of stomach pain (nausea, heartburn, sharp or thudding, placement, etc.) and what can cause them. Make sure to say that sometimes emotions like sadness or being afraid can make your body hurt as well as your brain. You can talk about the painful feeling that happens in the back of your throat before you start crying as another example of that. Ask him to describe his pain when he feels it (a or b questions are good for this: "is it high, up here?" Lightly touch his upper stomach, "or low, down here?" and his lower stomach. "Is it in the middle? or to one side?") and help walk him through your thought process of possible causes. If he understands the idea that emotional pain can cause physical pain, ask him if he thinks that could be part of it. Ask him if he is scared or sad to go to school and why. You can talk about why you think it's emotional, that it only happens on school days, right before leaving the house, etc. and why, if that's true, then it's important to still go. Because not going will only make it worse in the long run.

Best of luck!

Answer 3

My initial thoughts lean toward an anxiety issue, but in consideration of all the GI Tract issues that have been identified over the last decade or so... the pain may be real. So, my suggestion is that you get a composition (or journal) book and start by recording his day to day "life". Things that would be important to track:

what he eats (breakfast, lunch, dinner, snacks)
how he feels (when he wakes up, in the afternoon, at bedtime)
activities (outdoor play, quiet play, alone, with friends)
general attitude emoji's (happy, whiny, uncooperative, helpful)
out of the ordinary (special events, field trips, play dates)

Granted, keeping a journal full of notes is going to make a dent in your day, but the volumes of information you compile will help you figure out if this is food related, activity related, or (hopefully not) a complete mystery. If he says he's sick, take his temperature. Record it in the journal. Along with how long it lasts.

Eventually, you will should be able to see a pattern forming. Highlight or bookmark days that he's not doing so well, or spikes in unusual behavior. Take the journal to your pediatrician (and any other doctors) and share your concerns. It will make a huge difference in the actual diagnosis.