Walking into the exam room, it was clear that our 10-year-old patient and her mother had been having a  heated discussion.  Asked what brought  young "Danielle" into the office, her  mother began to tell the story, her frustration apparent.

Danielle was having off-and-on stomach pain for several weeks and had missed school on a several days, prompting a visit to another physician in our office two weeks prior.  She had been diagnosed with constipation and had started a stool softener at that time.

Since then, Danielle's mother said that her complaints had worsened.  Each morning, Danielle complained of stomach pains and nausea.  Her mother reported getting three calls in the past two weeks from a school nurse asking her to come pick up Danielle from school because of abdominal pain.  In addition, her mother expressed that Danielle was beginning to push back on wearing her hijab (the head covering some Muslim women wear) to school, which she had done without concern in the past.

Danielle's abdominal exam was normal two weeks ago, and it was normal at this second visit. She had no fever, and appeared very comfortable.  So serious issues such as appendicitis, ovarian torsion, and/or bowel obstruction were no concerns. As for  diagnostic imaging, given her normal exam and non-distressed appearance, we would not have known what to look for.

One interesting symptom: Danielle looked at the floor, avoiding eye contact, as her mother describe what had been going on.

Asked what she eats for breakfast, the girl replied,  "milk and cereal."  When asked about lunch, Danielle replied "I don't really eat that much for lunch."  Danielle's mother appeared surprised by this.  Danielle's response to the next question was the last clue to solving this medical mystery.


Asked why she wasn't eating lunch, Danielle began to cry.  She then began to tell us about a small group of girls who have been making fun of her during the school day since the New Year.  It became clear to everyone that Danielle was likely having real stomach pains but that they were unlikely due to any gastrointestinal illness or constipation.  Danielle's abdominal pains were a manifestation of being bullied.

Childhood bullying is an epidemic that is largely overlooked and frequently normalized.  Bullying has demonstrable effects on physical, psychological, and emotional health, but parents and caregivers may not aware of their children's negative experiences at school. If they are, they may not know of possible health consequences or where to turn for help.  Parents, teachers, and school staff may represent the first line for detecting and intervening in cases of bullying.  Primary care providers also play an important role in screening for bullying and helping to connect parents with resources, yet often have little or no training in how to approach this issue or where to turn for help.

Connecting patterns of complaints, behaviors, and medical issues related to bullying may help identify patients in need of help.  We recently published a guide for providers to raise awareness,  to serve as a template for screening, and to introduce available resources for patients.  Identifying patients at risk for bullying and using simple screening questions and conversation starters are first steps for providers and caregivers.  The US Department of Health & Human Services hosts a website called stopbullying.gov that provides advice and handouts, as well as links to resources. The "Get Help Now" tab, for instance, offers help for adolescents and parents with acute needs.   Providers may also help foster open communication between children and parents about the topic.

In Danielle's case, we assured her she deserves a safe place to learn and express herself.  We discussed referral her to a mental health specialist and counseling, which she felt would be a welcome intervention.  We also discussed how her mother should contact her school and report the bullying.

Robert J. McClowry, M.D. is chief resident, and Geoffrey D. Mills, M.D., Ph.D, is an assistant professor, in the Department of Family and Community Medicine, Thomas Jefferson University.