Abdominal Pain and Headache in Children: Psychosomatic Symptoms

"Every morning before school his stomach hurts, but at the weekend there's nothing wrong." This is among the sentences heard most often in child psychiatry clinics, and most families say it hesitantly: is the child pretending?

The answer is no. The pain is real. The child genuinely hurts; the source of the pain is not disease in an organ but the body's response to emotional strain.

This article explains how psychosomatic symptoms arise, when they should be considered, how medical causes are excluded, and what families can do.

Key Points

• Psychosomatic pain is real pain; it is not invented, feigned or attention-seeking.
• When children cannot put emotional strain into words, they express it through the body; this is expected at this age.
• Diagnosis is not made by saying "nothing was found"; medical causes must be excluded and psychosocial factors demonstrated together.
• The timing of symptoms is a diagnostic clue: school mornings, before examinations, on visiting days.
• Saying "there's nothing wrong with you" does not help; accepting the pain is the first step of treatment.

What Is a Psychosomatic Symptom?

A psychosomatic symptom is emotional strain emerging as a bodily complaint. The connection between brain and body is not one-way: anxiety is not only a thought but also muscle tension, altered bowel activity, increased heart rate and a lowered pain threshold.

This mechanism works in adults too — the stomach tightening before a tense meeting, hands shaking before an exam, or neck pain appearing during an intensely stressful period.

Why Is It More Common in Children?

Young children do not have the vocabulary to describe their inner world. A child who cannot say "I'm anxious" or "I'm being excluded at school" notices what they feel in their body and says "my stomach hurts".

This is not deception but a developmental limit. As age advances and words for emotions are acquired, bodily expression decreases; though it never disappears entirely, even in adulthood.

The Most Common Symptoms

• Abdominal pain: The most common, usually described around the navel
• Headache: Tension type; a sense of pressure in the forehead and temples
• Nausea, loss of appetite
• Muscle and joint pain
• Palpitations, chest tightness
• Dizziness, lethargy
• Frequent need to use the toilet

When Is a Psychosomatic Cause Considered?

The Pattern of Timing

The strongest clue is when the symptom appears:

• Present on school mornings, absent at weekends and in the holidays
• Becoming pronounced before examinations
• Starting before seeing a particular person
• Intensifying when tension at home increases
• Resolving soon after returning home or once going to school is abandoned

This pattern does not establish a diagnosis on its own but indicates the direction.

Other Clues

• The site and nature of the pain are described inconsistently
• It does not wake the child at night
• Investigations repeatedly come back normal
• The pain is not mentioned during play or an engaging activity
• There is a family history of similar bodily complaints
• The symptom removes a situation the child wants to avoid

Red Flags: Medical Assessment Is Essential

In the following situations a psychosomatic assessment is not the priority; a medical cause must be investigated first:

• Pain that wakes the child from sleep
• Weight loss, faltering growth
• Fever, rash, joint swelling
• Blood in the stool, persistent vomiting
• Difficulty swallowing
• Pain that steadily worsens and does not move
• Neurological signs: visual change, unsteadiness, weakness
• Headache accompanied by morning vomiting

Saying "it's stress" while these findings are present is a serious error. Psychosomatic assessment is not a substitute for a medical cause but a step that follows its exclusion.

Underlying Causes

A psychosomatic symptom is not a diagnosis but a mode of expression. Beneath it usually lies one of the following:

Anxiety Disorders

The most frequent accompanying condition. Separation anxiety and generalised anxiety disorder in particular begin with bodily symptoms. In the early stage of school refusal there is almost always abdominal pain, and intervention at this stage is most effective before the picture becomes entrenched.

Difficulties Arising at School

• Peer bullying or exclusion
• Unrecognised learning disorder: the child does not want to go because they cannot follow the lessons
• A problem with a teacher
• Examination anxiety

Factors Within the Family

• Conflict between parents, divorce proceedings
• Illness of a family member
• Bereavement or a house move
• High expectations and performance pressure within the family

Depression

Childhood depression presents not with low mood as in adults but frequently with bodily complaints and irritability.

Trauma

A past traumatic experience can persist as bodily symptoms. This possibility should be considered particularly in unexplained and entrenched complaints.

Learned Pattern

In some families an arrangement has formed in which a bodily complaint becomes the route to attention or to exemption from responsibility. This is not deliberate teaching; it settles over time.

If an adult in the family foregrounds bodily complaints, the child may also model that mode of expression. Assessment therefore also addresses the meaning the family attaches to bodily symptoms and past experiences of illness.

How It Presents by Age

Preschool (3-6): The symptom is usually abdominal pain and relates to separation anxiety. The child cannot localise it clearly, gesturing to the whole abdomen.

Primary school (7-11): The period in which it is most common. Abdominal pain and headache becoming pronounced on school mornings are typical. At this age the child can describe the pain in more detail but still cannot see its emotional source.

Adolescence: Headache, palpitations, dizziness and fatigue come to the fore. An adolescent may grasp that the pain could be stress-related but may resist accepting it; "you don't believe me" is a common reaction at this age.

The Assessment Process

Medical Exclusion First

The process usually begins with a paediatrician. The nature of the pain, the presence of red flags and examination findings are assessed; investigations are requested where needed.

There is an important balance here: necessary investigations must be done, but repeating them unnecessarily is harmful. Each new test reinforces the belief, in both family and child, that "there must be something serious", and sustains the picture.

Psychiatric Assessment

In the assessment conducted at Assoc. Prof. Mehtap Eroglu's practice in Ankara, the pattern of the symptom is established first: when it begins, how long it lasts, what makes it stop, which situations it removes.

Possible sources are then screened: anxiety symptoms, school functioning, peer relationships, the situation at home, sleep and appetite, depressive symptoms. Learning disorder and attention difficulties are assessed where indicated.

The family's response to the symptom is also part of the process: what happens when there is pain, how the day is spent if the child does not go to school.

The Family's Own Anxiety

A component frequently overlooked. A parent's anxiety about the pain is transmitted directly to the child: constantly asking "how are you, has it gone?", going to the doctor at every episode, and an anxious facial expression all tell the child the situation is serious.

Where there has been serious illness or a bereavement in the family, this anxiety is higher and understandable. But it needs to be addressed as part of the treatment plan.

A parent's ability to manage their own anxiety emerges as a measurable factor in the reduction of a child's symptoms.

A Symptom Diary

A simple two-week record is the most useful tool in assessment: day, time, severity of pain, what was happening at the time and how it resolved. This record often makes visible a pattern the family had not noticed. It also clarifies whether the pain genuinely occurs every day or only on certain days; impressions based on memory are frequently misleading here.

How Should It Be Explained to the Child?

A child understanding why the pain occurs directly affects their engagement with treatment. But where the explanation is framed wrongly, the child feels blamed.

To avoid: "There's actually nothing wrong with you", "you're imagining it", "it's just stress". These tell a child that what they experience is not real.

A frame that works: Explaining the body-brain connection with a concrete example. "When you're frightened your heart beats faster, doesn't it? Not because there's something wrong with your heart, but because your brain has signalled to your body. Your stomach is the same: when things are hard, your brain sends a signal to your stomach and it really does hurt."

This frame does two things at once: it does not invalidate the pain and it shows its source. The child moves out of the position of "they don't believe me".

Using a pain scale with school-age children also helps: rating severity from one to ten makes expression easier and makes change over time visible.

Treatment

The Family's Approach: The Most Critical Component

Accept the pain, but do not grant it privileges. These two go together.

• Acceptance: "I know your stomach hurts; this is real pain." Disputing the child's credibility worsens the picture.
• No privileges: Pain must not become the route to missing school or being exempt from responsibilities.

Without this balance one swings to one extreme or the other: either the child is judged as "pretending" and becomes isolated, or the pain becomes a means of avoidance and is reinforced. Both extremes sustain the picture; the way out is the middle position that holds both together.

Continuing at School

The most frequent consequence of psychosomatic abdominal pain is school absence, and this is the principal reason the picture persists. The longer the child stays home, the more the pain has worked, and it returns more strongly the next day; this cycle establishes itself quickly.

The general approach, where there is no medical barrier, is to continue attending school. Working with the school, someone the child can go to when struggling is identified, so attendance continues while support is provided.

Psychotherapy

In Assoc. Prof. Mehtap Eroglu's approach, cognitive behavioural therapy is the principal method with demonstrated effectiveness for psychosomatic symptoms in children. The work proceeds in three areas:

• Naming the feeling: Learning to connect the bodily sensation with its emotional source
• Body awareness and relaxation: Breathing work, muscle relaxation
• Reducing avoidance: Graded return to the avoided situation

Treating the Underlying Condition

Where there is an anxiety disorder, depression or learning disorder, the real treatment is directed at that. Focusing on the symptom and skipping the source brings temporary relief, but the picture returns quickly — often as a different bodily complaint.

How Long Does It Take and How Is It Monitored?

Improvement in psychosomatic symptoms is gradual and does not follow a straight line. Examination periods, a change of school or tension at home can cause temporary increases.

What is monitored is not the complete disappearance of pain but change in functioning: is the child attending school, taking part in activities, how much is daily life restricted.

Continuing the symptom diary through treatment allows the family to see progress. In day-to-day observation the change may be too slow to notice; looking back at records from a month earlier makes the difference concrete.

Medication

Painkillers for the pain itself are generally not recommended; if use becomes continuous it can lead to medication overuse headache. Medication is considered where there is a distinct accompanying anxiety disorder or depression.

Working with School

In psychosomatic symptoms the school is a direct part of treatment, because the symptom usually arises there and the solution is built there.

What Needs to Be Agreed with School

• What happens when the child reports pain: not being sent home immediately, resting briefly in the medical room and returning to class
• A specific person they can approach when struggling
• In which circumstances the family will be contacted (the red flag list)
• Addressing academic difficulty where present

The most common mistake is sending the child home at every report of pain. This is the fastest way of reinforcing avoidance and makes each return to school harder.

Graduated Return

Where absence has been prolonged, returning to a full day at once may be unrealistic. A graduated plan works: half days first, then full days beginning with favoured lessons, then the usual routine.

Making this plan jointly between school, family and clinician, and putting it in writing in advance, markedly improves how workable it is.

Expert Opinion

According to Assoc. Prof. Mehtap Eroglu, where families get most stuck in psychosomatic referrals is the question of whether the pain is "real". The question is wrongly framed: the pain is real; what is at issue is its source.

Clinical experience from consultations in Ankara shows that the picture eases markedly once the family accepts the pain. When the child stops having to prove themselves, the symptom's function also diminishes.

Assoc. Prof. Mehtap Eroglu also emphasises that unnecessary repetition of investigations is among the most important factors sustaining the picture. Each new test reinforces the belief in "a serious illness not yet found", and the family's anxiety is transmitted to the child.

A further important point is ending school absence early. Every day spent at home reinforces avoidance and makes return harder. Where there is no medical barrier, attendance is part of treatment.

Assessment and Appointment Process in Ankara

Most referrals with psychosomatic complaints in Ankara occur after the family has been round paediatrics and the relevant specialties. That sequence is correct; but it often takes longer than necessary, and anxiety grows throughout. In these referrals in Ankara the average delay can be measured in months.

In the assessment conducted by Assoc. Prof. Mehtap Eroglu in Ankara, previous investigations are reviewed first; which medical causes have been excluded is clarified and unnecessary repetition prevented. The pattern of the symptom and possible psychosocial sources are then addressed.

The assessment aims less at telling the family something they have not heard than at bringing scattered information together and making the pattern visible. Most families have already noticed that the symptom increases on school mornings; what is missing is what that observation means and what to do about it.

What families in Ankara should bring: all previous test results and consultation reports, a two-week symptom diary, the school attendance record and the teacher's observations.

If you would like to arrange an assessment for your child's unexplained physical complaints in Ankara, you can review our child psychiatry service and request an appointment.

In Summary

Psychosomatic pain is real pain. When children cannot verbalise emotional strain, they express it bodily; this is a developmental limit, not deception.

The timing of the symptom is the strongest clue: occurring on school mornings but not at weekends is meaningful. But where there is pain that wakes the child, weight loss, fever or neurological signs, a medical cause must be investigated first.

The family's most effective contribution is to accept the pain but not grant it privileges. Where there is no medical barrier, attending school is part of treatment.

Without addressing an underlying anxiety disorder, depression or learning disorder, lasting improvement is difficult.

For the types, symptoms and treatment of childhood anxiety disorders, see our anxiety disorders guide.