The Intersection of Physical and Mental Health

Our mind and our body are not just connected — they are inextricably linked. Two common complaints frequently heard by pediatric providers highlighting this connection include: 

1. The interplay between sleep and mental health.
2. Complaints of physical symptoms when no other illness or injury can be identified.

Sleep and mental health

Mental health prevention efforts certainly should include attention to the domains of sleep, hydration, nutrition and exercise. Though sleep problems are generally considered a physical concern, lack of sleep or too much sleep can have a negative impact on mental health. Currently, the Centers for Disease Control (CDC) recommends that kids between 6 to 12 years of age get 9 to 12 hours of sleep, and that teens from 13 to 18 years of age get between 8 to 10 hours of sleep. Based on this data, the CDC points out that the majority of both middle schoolers and high schoolers do not get enough sleep. 

Sleep is important for facilitating healthy digestion, reducing inflammation, encoding memories and improving emotion regulation abilities. In longitudinal studies, sleep problems in childhood have been linked with adolescent and adult internalizing (depression and anxiety) concerns. Further, sleep disturbances in healthy children have been associated with behavior problems, decreased cognitive performance, academic problems and impairment in daily living. 

Sleep is often impacted by mental health concerns (e.g., fear of the dark makes it harder to go to sleep at night), but maintaining a regular sleep schedule and healthy sleep hygiene is recommended to both prevent mental health concerns and as an intervention when mental health concerns and sleep problems are present simultaneously.

Early screening for sleep problems

Asking specific questions about sleep leads to access to easy sleep quality information. Screening tools validated in children and youth can be useful for assessing sleep concerns. Freely available and empirically validated screening tools include:

• The Child Sleep Habits Questionnaire 
• Patient-Reported Outcomes Measurement Information System (PROMIS) Sleep Disturbance Measure
• The Brief Infant Sleep Questionnaire (BISQ)
• Epworth Sleepiness Scale for Children and Adolescents (ESS-CHAD)

When screening tools are not immediately available, the following questions may be useful for determining if additional sleep intervention is warranted:

• What time does your child get into bed?
• How long does it take them to fall asleep?
• Do they wake up at night? If so, how long does it take them to fall back to sleep?
• Where does your child sleep each night?
• Approximately how many hours of sleep do  they get each night? 

Families who report their children receive less than the recommended amount of sleep or whose children regularly take more than 30 minutes to fall asleep could benefit from additional behavioral sleep intervention. Further, for children who have bedtime resistance or increased behavioral problems in the evening, behavioral sleep intervention is also recommended. 

Behavioral sleep interventions

• Encourage good sleep hygiene, including allotting at least eight hours for sleep at night, both during the week and on the weekend.
• Use a sleep log to monitor sleep over a longer period of time. Families who notice patterns in their child’s sleep difficulties may be able to prevent issues from arising.
• Use behavioral reinforcement systems targeting compliance with getting up on time. A consistent waketime is the most important factor in creating a new sleep schedule for school aged children and teens. 
• Encourage families to treat other mental health symptoms that may be interfering with bedtime and sleep (e.g., fear of the dark, fear of someone breaking into the home). Working with a therapist specifically for sleep is recommended for families who continue to struggle after establishing good sleep hygiene and consistent bedtime routines.

Physical (somatic) symptoms

For many individuals, stress is often experienced in the body. For example, kids who struggle with attending school may have stomach aches prior to leaving home each morning. Changes in appetite are a common symptom of depression, and physiologic symptoms (e.g., headaches, muscle aches, stomach aches) are a frequent occurrence for children with generalized anxiety disorder. However, not all children experience an underlying mental health concern linked with their physical symptoms.

When children start to experience any symptoms, families first turn to their primary care providers, wondering if there is a cold, virus or other illness causing these symptoms. Of course, resting when a child has a virus is important for recovery, but when physical symptoms occur that are not consistent with a medical condition (e.g., stomach distress without any inflammatory markers associated with inflammatory bowel disease), somatic symptoms should be considered and normalized in conversations with families. Families may often struggle with the concept of somatic symptoms due to the stigma that this is “all in [their child]’s head.”  It is important to highlight that somatic symptoms are real experiences in our bodies. For example, the pain signals from our nerves during a stress headache are being interpreted by our brain, which spurs us to take ibuprofen. Your brain is playing the same role in this experience of pain as it does when you react to stubbing your toe. 

Somatic symptoms are common and can be experienced on a wide spectrum, ranging from butterflies in your stomach to events that present like an epileptic seizure. Please see Dr. Kozlowska’s figure below, which demonstrates the wide range of potential functional/somatic symptoms. 

The wide-ranging functional diagnoses that fall under the umbrella term functional somatic symptoms (© Kasia Kozlowska 2019) from “Functional Somatic Symptoms in Children and Adolescents A Stress-System Approach to Assessment and Treatment”

While mild somatic symptoms are quite common, a gradually growing number of children have been documented to suffer with the more severe somatic symptoms over the course of the COVID-19 pandemic, known as functional neurological disorder (FND).  A diagnosis of FND will be given when neurological symptoms are present and significantly interfere with day-to-day functioning, the presence of an underlying medical condition has been ruled out and a neurologist has identified symptoms incompatible with organic disease. Though having a diagnosis may feel reassuring for providers, families will sometimes continue to struggle with absorbing this information. This is especially true when a child’s symptoms change over time.

Factors that may increase risk for FND or functional symptoms include:

• Trauma/psychiatric symptoms
• Comorbid chronic pain
• Parental reinforcement of physical symptoms
• Illness exposure
• Symptom monitoring
• Decreased sense of agency over actions
• Hypervigilance related to affected body areas 
• Catastrophizing of symptoms

Treatment

To date, there is only one randomized control trial examining treatment of FND in children, which looked specifically at non-epileptic seizures (NES). Youth received a cognitive behavioral therapy-based (CBT) intervention with additional emphasis on developing an internal locus of control (e.g., “taking control of their symptoms”). In this study, 100% of participants reported remission of NES episodes, and 82% remained NES free at the 6 month follow up.

Based on the limited available data, CBT with emphasis on gradually developing insight and control of FND warning signs and FND symptoms is highly recommended. Further, significant research in adults has demonstrated the chronicity of illness is associated with worse outcomes; thus, the sooner children with somatic symptoms can engage in treatment, the better their prognosis.

Consistent messaging across providers on a patient’s team and minimizing excessive medical referrals (e.g., discouraging specialist shopping) are also important when treating children and families with somatic symptoms. As pediatric providers often serve as the gatekeepers for additional referrals, communication with other specialist-treating providers is essential.

If providers are concerned about a patient and would like to make a referral for psychiatric evaluation and treatment, they can refer families to the following:

• Children’s Hospital Colorado Pediatric Mental Health Institute provides evidence-based, family-focused comprehensive mental health services. For more information, providers can call 720-777-6200 or visit the website.

Additional resources for somatic symptoms

• NeuroSymptoms.org
• Functional Neurological Disorder Society
• FND Hope