The day after her school closed its doors for social distancing, a canker sore developed in my daughter’s mouth.
A few days later, two more popped up. When a fourth arrived a week after we settled into isolation, I phoned the doctor.
Since my 8-year-old daughter lacked a fever and other signs of illness, the doctor had a simple diagnosis: stress.
Kids may not understand Covid-19, and they might not fully comprehend its effects on our health and the economy. But children notice when their parents are stressed, and they react to their parents’ emotional state, said Dr. Scott Goldstein, M.D., a pediatrician with Northwestern Children’s Practice in Chicago.
Instead of being able to explain how they’re feeling, however, kids are experiencing their own physical effects of stress, leading to an increase in frantic phone calls to pediatricians during the pandemic.
“Toddlers and young school-age children are not capable of expressing their feelings as well as an older child can,” said Dr. Goldstein, M.D. “They often show their emotional stress in a physical way.”
When under stress, bodies make chemicals that have physical effects — just like a medicine would, Dr. Goldstein said. In children who are emotionally stressed, these chemicals make their stomachs feel funny.
“And to them, it really does hurt — they aren’t making it up,” Dr. Goldstein said. “There is just nothing that is physically wrong.”
So how do you tell if your child is exhibiting physical signs of stress? And if they are, what should you do? Doctors share their recommendations for managing common types of stress in young children.
While tantrums may be an obvious sign of stress, withdrawal is common as well, said Dr. Christina Johns, M.D., a pediatrician, pediatric emergency physician and senior medical adviser for PM Pediatrics in Annapolis, Md.
Dr. Johns said a total lack of emotion is often a behavioral change spotted in very young children under stress. “While the biological mechanism isn’t exactly clear, stress and anxiety can cause a change in hormones and body chemicals that are ultimately expressed as physical symptoms,” Dr. Johns said.
Even if your child is shutting down emotionally, you should continue to reassure them that they are safe. Keeping to a familiar routine can help, as does regular physical exercise, she said.
Nope, this time it may not be a typical sleep regression.
“Sleep problems such as difficulty falling asleep or waking up in the middle of the night can signal stress,” said Dr. Florencia Segura, M.D., a pediatrician with Einstein Pediatrics in Vienna, Va. A variation on this may include an excessive need for reassurance prompted by activities such as bedtime, Dr. Segura said. Translation: Your child’s bedtime routine may now go on for hours.
If this occurs daily without other associated symptoms — and the child has had a normal physical exam — it’s most likely a somatic sign of stress.
Try engaging your child in a constructive activity, since bored or frustrated kids are more likely to focus on their stress, especially in the evenings, she suggested. Even something as simple as playing with measuring cups and spoons in the bathtub before bed would be entertaining.
This is a common manifestation of stress in young children, said Dr. Sylvia Owusu-Ansah, M.D., a pediatric emergency medicine physician at the UPMC Children’s Hospital of Pittsburgh. The stomach and intestine have their own nervous system called the enteric nervous system.
Stress and fatigue also decrease pain thresholds. So while a rested, happy child may not notice the subtleties in their GI tract, an anxious, tired child with functional abdominal pain may have a hypersensitive nervous system.
“The gut reports pain to the spine, which relays the pain signals to the brain when a child experiences stressors,” Dr. Owusu-Ansah said.
A major study examining children ages 4 and older found that in 90 percent of the kids, there was no diagnosable disease tied to their stomach pain. These children are still growing normally, they have a normal appetite, are able to sleep through the night and appear to be healthy apart from their abdominal pain.
Signs that there’s more to the pain than anxiety: vomiting, diarrhea, fevers, chills, unrelenting abdominal pain or weight loss.
In addition to lessening the stressful situation, Dr. Owusu-Ansah suggested adding natural fibers to the diet to help maintain a regular bowel regimen. This would prevent constipation, which can also result in abdominal pain, and can be worsened during stressful times.
The overall cause of canker sores is unknown, but they can be stress-related, and stress can exacerbate the problem, said Denise Daniels, a child development expert.
One study of college students found that canker sores were often triggered during exam times.
If the canker sore is unaccompanied by a fever or other signs of illness, then it will usually go away on its own. But parents can take this cue to assess their child’s emotional state, Daniels said.
Younger children may display regressive behavior such as thumb sucking, clinginess, eating or sleep disturbances, she said. If you notice this happening, try being extra comforting and reassuring with your child.
“The pandemic may have life-changing effects on children’s well-being,” she said. “Past experience has taught us that caring grown-ups in children’s lives can make a significant difference by providing safety, empathy, predictability, age-appropriate information, comforting reassurance and loving guidance.”
Stress can manifest in different ways in young children, and for some, this means needing to use the bathroom more frequently or having a potty regression, said Dr. Abigail Schlesinger, M.D., chief of the behavioral science division at UPMC Children’s Hospital of Pittsburgh.
Children may need more attention right now, they may develop a fear of the toilet or they may be more in tune with their body when they’re anxious — making them feel like they have to use the toilet more often.
There’s no cookie-cutter approach to knowing whether your child is anxious or has a real physical disorder, Dr. Schlesinger said. But if they’re eating normally and don’t have a fever, then most likely they’re stressed.
Still, if you believe that anxiety or worry is causing a physical complaint or making it worse, then first understand the physical problem better and talk with your child about how to help it, Dr. Schlesinger said.
Often referred to as functional pain, this occurs because the body is a complex machine driven by many pathways of nerves — and stress triggers some of these pathways and presents as true physical pain, said Dr. Jay Lovenheim, D.O., a pediatrician with Lovenheim Pediatrics in West Orange, N.J.
If your child complains about bone or muscle pain, notice whether they are still engaged in sports or playtime without difficulty. If so, this is a pain probably brought on by stress rather than a physical issue. Don’t dismiss the pain, but instead use positive reinforcement and remind your child that they can fight through it, Dr. Lovenheim said.