Returning to school after the summer break can be a source of mixed feelings. Children and adolescents know the shift means more than getting the brand-new backpack or colourful binders they asked for. While they could be going back to the same school, they might have new teachers and classmates; be exposed to more complex knowledge; and have to adjust to a more rigid schedule, compared to their vacation days filled with sleep-ins and no homework.
“One of the main stressors is the uncertainty about whether they will be liked by others and belong in that environment,” says Dr. Amrit Dhariwal, an investigator at BC Children’s Hospital Research Institute (BCCHR) and clinical assistant professor in the Department of Psychiatry at the University of British Columbia. These students may also struggle with academic pressure. “Depending on their age, they might be trying to figure out their identities, future goals, and the kind of adults they want to become.”
Summer provides students with a break from those stressors. To some degree. “A complete break from the social scene is impossible because they keep seeing on social media what everybody else is doing and they might feel left out,” says Dr. Dhariwal.
“As a psychologist, I’ve seen children’s physical experiences of stress increase during the school period, disappear during the summer break, and come back once school starts again.”
The peak in referrals usually happens in October, after the new school year starts and social or academic pressure begins to build.
From a human development perspective, adolescence is an important stage for social connection and peer-to-peer development. Individuals stop turning only to their families for fun, support, and emotional regulation and start forming other strong bonds. “It makes sense that their bodies would be stressed if they’re uncertain about these relationships,” says Dr. Dhariwal. “Evolutionarily speaking, we feel safe when we’re part of a group, so it’s essential to find ours.”
Experts in the field state that psychological and emotional stress can show up in the form of physical symptoms, which is known as somatization. For example, crying when feeling sad, getting an upset stomach when nervous, or tensing the muscles when angry. Somatization becomes a concern when physical symptoms worsen, persist, or interfere with the individual’s daily life. “In these cases, both medical and mental health clinicians need to become involved to provide coordinated care,” says Dr. Dhariwal.
Western medicine has traditionally treated mind and body separately, so Dr. Dhariwal considers it natural to visit a physician when physical symptoms appear. “It’s easier to accept what we can see, such as an X-ray or a blood test result,” she says. However, when underlying heavy emotions are repeatedly suppressed, the stress response can remain activated, leading to persisting and deteriorating symptoms that can include fatigue, pain, digestive problems, altered sensory and perceptual experiences, and changes in motor function.
Somatization can be caused by a variety of factors, from genetic predisposition to adverse experiences. It can happen at any age, but most patients referred to BC Children’s Hospital (BCCH) to treat this condition are teen girls. “Depending on the severity, these kids may stop doing their regular activities, including going to school, but our goal is to prevent that from happening,” says Dr. Dhariwal. “It’s hard to help kids go back to school once they’ve been away for a period of time, so we recommend very short re-entries to start, such as walking to school and coming back home.”
Even if somatization has been triggered in the school environment, unless there are special circumstances, changing schools is not recommended. The problem seems to follow the students to the next setting. Learning how to navigate social relationships, study for tests, manage extracurricular activities, and handle any related hardships can help adolescents later in life. “Many of these patients are involved in high-level activities, so they pressure themselves to excel and don’t handle setbacks well,” says Dr. Dhariwal.
Parents can support children displaying stress-related physical symptoms by encouraging them to explore their emotions through words. Her advice is to establish a connection between the event and what they’re feeling in their body. “Parents can say, ‘You might be worried about what happened, so it would make sense if your tummy hurts,’ or ‘What do you think your tummy is telling you?’” says Dr. Dhariwal. When adults are comfortable talking about emotions and kids learn from them at an early age, they may grow up as adults who are good at identifying signals from their body.
For some adults, this may be a difficult approach. If no one paid attention to their emotions when they were children and they aren’t good at understanding what they’re feeling, they might in turn have challenges attending to their child’s emotions. “Part of the work is making emotions safe again and finding the right kind of help, which could be a counsellor or a friend who can be a sounding board for you to safely talk about your experiences and support your kids,” says Dr. Dhariwal. An important recommendation is to not only validate the child’s emotions, but also refrain from fixing the problems on their behalf. “Giving them back some responsibility, like considering options before making a decision, is helpful to prepare them for adulthood.”
To move forward with therapeutic assessment and treatment, it’s critical for clinicians to pay attention to the patient’s concerns. If their symptoms persist and they’re not getting answers, it becomes hard for them to trust their medical team, so they end up moving too often from doctor to doctor. “We have to do a better job in the health-care industry to validate patients’ concerns because trust starts once they feel heard and understood,” says Dr. Dhariwal.
A pivotal initiative at BCCH to support pediatric patients and families impacted by somatization is the multifamily group intervention, which was discussed in a qualitative study published recently in the Clinical Practice in Pediatric Psychology journal. Initially held in person, it runs three times a year remotely, a shift that happened during the COVID-19 pandemic.
“We kept the group intervention online because it’s more accessible, allowing us to connect with patients all over BC,” says Dr. Dhariwal.
“Everyone can hear from each other, notice the similar patterns in their stories, and realize theirs is not an isolated case.” Parents join the same virtual room, but patients aged 13 and older have an additional youth group.
The experts in the group intervention act as facilitators, presenting ideas and raising questions to help participants understand the value of mental health care and recognizing emotions felt in the body. This initiative was piloted by BCCH in 2014 and adopted by other pediatric hospitals across Canada. “It’s key to normalize somatization and pay attention to emotions felt in the body because understanding what these signals are telling us is crucial to improved overall health,” says Dr. Dhariwal.
