Anxious Stomachaches and Headaches

All kids get an occasional headache or stomachache — think not enough sleep or too much Halloween candy. But when children get them often, they may be signs of anxiety.

Stomachaches in the morning before school. Headaches when there’s a math test on the schedule. Butterflies before a birthday party. Throwing up before a soccer game. These physical symptoms may be the first evidence a parent has that a child is anxious. In fact, the child may not even know they are anxious.

“Especially with kids who may not be able to verbalize what they’re feeling anxious about, the way their anxiety manifests can be through physical symptoms,” explains Amanda Greenspan, LCSW, a clinical social worker at the Child Mind Institute.

In fact anxiety is associated with a host of physical symptoms, including headaches, nausea, vomiting and diarrhea, along with a racing heart, shakiness or sweating — symptoms older people experience when they’re having a panic attack.

All these physical symptoms are related to the fight-or-flight response triggered when the brain detects danger. All of them have a purpose, notes Janine Domingues, PhD, a clinical psychologist at the Child Mind Institute. When she talks to kids about anxious headaches or stomachaches, she explains the role of each. For instance, she says, “your stomach hurts because your digestive system is shutting down to send blood to other areas of your body. You don’t want to be digesting food at that moment because you’re trying to either flee danger or fight danger.”

Dr. Domingues assures children that these symptoms are not harmful — they’re just their emergency system responding to a false alarm. But it’s important to understand that kids aren’t necessarily inventing their symptoms, and the danger may feel very real to them. Don’t assume a child who spends a lot of time in the nurse’s office at school is doing it intentionally to get out of class. Their acute anxiety may be causing them pain.

“Headaches and stomachaches related to anxiety are still real feelings, and we want to take them seriously,” says Ms. Greenspan.

When a child develops a pattern of physical symptoms before school, or other potentially stressful moments, experts recommend that you visit your doctor to rule out medical concerns. But if the child gets a clean bill of health, the next step is to help the child make the connection between their worries and their physical symptoms.

“We help them understand in a very child-friendly way that sometimes our body can actually give us clues into what we’re feeling,” explains Ms. Greenspan.

Parents can start by validating their child’s experience and reframing it in a more helpful way. Instead of telling kids there’s nothing wrong with them, the goal is to tell them that what they’re feeling is worry.

“We give it a name,” adds Dr. Domingues. “We help them connect it to an emotion and label it. And after some practice kids are able to identify it,” she adds. “‘Yes, my stomach hurts and, oh yeah, I remember that’s because I’m feeling worried.’ And after learning some skills to help them calm down, I think they feel a sense of control. And that helps.”

The first thing our experts suggest is something parents should not do, or at least try not to do: Let kids avoid things they are afraid of. It can be very tempting when children are complaining of a headache or stomachache to let them stay home from school, or skip the party or the game they’re worried about. But avoidance actually reinforces the anxiety.

“If we’re allowing them to avoid it,” says Ms. Greenspan, “then they’re not able to learn that they can tolerate it.” The message needs to be: “I know it hurts, I know it’s uncomfortable, but I know you can do it.”

Another things parents should not do is ask children leading questions like “Are you worried about the math test?” Questions should be open ended, to avoid suggesting that you expect them to be anxious: “How are you feeling about the math test?”

If the problems your child is having are disrupting their ability to go to school consistently — or concentrate at school, participate in activities, socialize with peers — they might have developed an anxiety disorder that should be treated by a mental health professional. The treatment favored by most clinicians for anxiety disorders is cognitive behavioral therapy (CBT). CBT helps kids — as young as 5 years old — identify their anxiety and learn skills to reduce it.

The techniques clinicians teach children to calm down body and mind can also be deployed by parents, for children with less impairing symptoms.

Here are some of the techniques clinicians teach anxious children, adapted from CBT and mindfulness training:

Deep breathing: Drawing in air by expanding the belly, sometimes called belly breathing, helps kids relax by slowing breathing, and reducing the heart rate, blood pressure and stress hormones. It can also help relax tense stomach muscles.
Mindfulness exercises: Techniques such as focusing on what’s around them, what they see and hear, can help pull children away from the anxiety and ground them in the moment.
Coping statements: Children are taught to “talk back to their worries,” Ms. Greenspan explains. “They can say, ‘I’m feeling scared and I can handle it.’ Or something along the lines of, ‘I’m bigger than my anxiety.’”
Coping ahead: Children are taught that when you have to do something that makes you nervous, it helps to anticipate that you might have some discomfort, and plan what you can do to counteract it, knowing that if you can push through it, it will get easier.
Acceptance: This involves acknowledging the discomfort without fighting it. “Instead of trying to push the feeling away and get rid of it,” Dr. Domingues explains, “we ask you to hold onto it and tolerate it and get through it.”

It’s only natural that parents don’t want to see their kids in distress or make them go to school when they’re worried that they’ll throw up. That puts parents in a difficult spot. “What we hear from parents is, ‘We just let them stay home one day — and one day led to three months,’ ” says Dr. Domingues. It’s a slippery slope — the child may ask to stay home more and more.

“So we work with parents a lot around how to find that balance between enabling anxiety and meeting a child where they are,” she adds. “And we also give them statements that they can use to be empathic and encouraging at the same time. For instance: ‘I know that this is really hard and you feel like you’re sick. But we also know that this is anxiety, and you can get through it.’ ”

Sometimes setting up a reward system can help by giving a lot of positive reinforcement for kids pushing through their anxiety.

Parents also face the challenge of tolerating their own anxiety about pushing a child who says they are ill or worried about vomiting. “If your kid is in distress and talking about not wanting to go to school or feeling sick or thinking they might throw up,” says Dr. Domingues, “then you’re, as a parent, also anxious that that might happen.”

The school plays an important role when kids develop physical symptoms of anxiety. Clinicians work with the school nurse — and sometimes the psychologist or school counselor — to set up a protocol for keeping the child’s absences from class as short as possible. For instance, the recommended amount of time to wait before encouraging the child to go back to class might be as short as five minutes.

“As much as we can, we urge them not to contact the parent or send the child home if they’re saying that they’re nauseous,” adds Dr. Domingues, “if we know that they are feeling this way because they’re anxious.” The shorter the break can be, the better it is, because the longer they’re out of the thing that’s making them feel anxious, she says, the harder it will be to get them back in.

This sort of symptoms can appear in a wide-range of children, but they’re most common in the grade-school years, notes Ms. Greenspan. “As kids get older and transition into adolescence and adulthood, they are more likely to manifest their anxiety symptoms in other ways.”