Identifying somatic and social concerns that may suggest an underlying mental health condition in pediatric primary care

Clinical summary

Several patterns of symptoms have been identified as potential signals that a child may have an underlying mental health condition that requires attention. General symptoms that may suggest a mental health condition include changes in sleep, eating, weight, or physical pain with no clear medical cause, as well as trouble in school or not wanting to go to school [4]. Studies suggest that because common somatic and emotional concerns such as these can precede a diagnosis of anxiety or depression, screening of children with these complaints is recommended [5].

Signs and symptoms associated with anxiety disorders include school refusal, somatic complaints [6], reported stress, anger, trouble sleeping, and a positive substance use screen. Children with anxiety can present with social concerns such as difficulty making and keeping friends, academic issues, and general withdrawal. Children with anxiety can also present with physical symptoms including musculoskeletal pain, abdominal pain [7], headaches, or fatigue (Table 1) [8].

Symptoms associated with depressive disorders include sadness or irritability, increase in physical symptoms, and positive screen for depression including substance, stress, anger, and worries about family alcohol and drug use [9]. Younger children with depressive disorders may present with physical complaints such as frequent headaches or functional abdominal pain, whereas adolescents with depressive disorders often present with co-occurring substance use [9].

Eating disorders can be associated with a wide variety of signs and symptoms depending on the type of eating disorder behaviors. In general, children with disordered eating may report weight-based stigma and changes to their eating or exercise patterns. Symptoms of oligomenorrhea or amenorrhea suggests a possible energy deficiency. Other signs that may suggest behavior include abnormal vitals such as low heart rate, low blood pressure, orthostatic hypotension, or hypothermia. Additionally, children may have carotenemia, lanugo, thin scalp hair, or a delay or interruption in pubertal development. Symptoms possibly linked to an excess in energy intake include deviation from previous growth trajectory, elevated blood pressure, acanthosis nigricans, acne, hirsutism, and/or premature puberty [10].

Somatic symptom disorder can be associated with impaired coordination or balance, weakness, paralysis or loss of sensation, seizures, blindness, double vision, deafness, or one severe symptom, typically pain. Studies have shown that somatic symptom disorder is rare in children less than 11 years old; however, in children 12–16 years old, approximately 11 % of girls and 5 % of boys meet the criteria for a diagnosis [10]. An important aspect of this disorder is that the presence of maladaptive thoughts, feelings, and behaviors about their physical symptoms, meaning that if a child presents with a list of medically unexplained symptoms, it is important to identify whether these symptoms cause significant distress for the child [11].

Disruptive behavior disorders have been linked, although not exclusively, to severe outbursts [12]. Outbursts may vary by age, with younger children often screaming, crying, throwing oneself on the ground, or breath holding. In toddlers, these outbursts may be age appropriate, although the increased frequency and severity of outbursts may suggest a clinical concern.

Other disorders, categorized as externalizing disorders, which include diagnoses such as oppositional defiant disorder (ODD, attention-deficit/hyperactivity disorder (ADHD), intermittent explosive disorder, and conduct disorder, show a gender-dependent pattern in symptoms [2]. Females with parental depression and substance use at age three uniquely predicted adolescent tonic irritability. Meanwhile, for males, less parental education, greater ODD symptoms, higher irritability, and no parental substance use history at age three uniquely predicted adolescent phasic irritability [13].

Discussion

Several themes were identified for common physical symptoms and social concerns associated with mental health conditions in pediatric patients. These include physiologic symptoms including severe and/or frequent headaches or stomachaches, as well as social concerns such as school avoidance, or a decline in social functioning, as possible signs that a child or adolescent may be experiencing a psychiatric disorder. Beyond personal clinical experience, a PubMed search was conducted to augment the discussion. The search utilized was conducted between February 5, 2025, and February 25, 2025, utilizing the following key terms: “mental disorders,” “mental health,” “psychiatry,” “psychology,” “primary care,” “child,” “children,” “pediatrics,” “adolescent,” “young people,” “risk factors,” “pain,” “affective symptoms,” “depression,” “anxiety,” “eating disorders,” “trauma,” “physical symptoms,” “somatic symptoms,” and “early intervention,” with the filters “English language” and the time limitation of 2000–2025. The American Academy of Child and Adolescent Psychiatry (AACAP) search was conducted utilizing the terms “disruptive” and “disorder.” For the purposes of this review, “children” were defined as birth to age 18. A review of the Merck Manual Professional Version, National Institutes of Health (NIH) Mental Health, and several parenting websites were also utilized.

When a child presents to the primary care clinic with generalized symptoms or concerns, such as fatigue, school refusal, or social withdrawal, it is important not to discount possible physiologic reasons. The initial workup would ideally include both physiologic and psychiatric causes, which may include checking vitamin D levels, thyroid function, hemoglobin levels, as well as screening for possible depression, anxiety, or other psychiatric causes.

If a child has a constellation of the previously mentioned symptoms and if a psychiatric condition is also suspected, there are many validated screening tools available. Please see Table 2 for a list of the validated screening and monitoring tools for children and adolescents. Early identification and treatment are crucial to ensure the best possible outcome in terms of mental health for a patient. This period of childhood and adolescence is when the highest onset of major mental disorders of adulthood occurs, making it a critical period for early intervention to alter the trajectory of mental illness [1].

Limitations of the current review include limited data regarding the strength of associations between specific somatic symptoms and psychiatric disorders, and the fact that no articles or reviews addressed any complex presentations involving patients with both psychiatric and somatic conditions. Although the connection between mind and body is clear, the specific role of osteopathic manipulative medicine (OMM) as it relates to somatic symptoms related to psychiatric disorders is not yet fully developed. Future studies to better understand the role of OMM in treating the previously mentioned somatic symptoms in the setting of psychiatric disorders may reveal further treatment strategies.

Conclusions

There are many significant clusters of symptoms that children may present to primary care clinicians that point to potential psychiatric conditions. When clinicians are aware of these key symptoms, they can play an integral role in reducing the delay between the onset of symptoms and diagnosis for a child, ultimately leading to earlier treatment and improved long-term outcomes.