A GP’s guide to anxiety in children

General practitioners (GPs) are the most-used service provider when it comes to the mental health of children. We are often the first point of contact for families, yet understandably do not feel confident in managing anxiety in children.

Anxiety is considered the fastest-growing childhood mental health issue in Australia. Feeling anxious, stressed, angry or scared are normal parts of growing up and learning about the world, and it can be challenging to figure out the exact moment a child shifts from being anxious, to developing an anxiety disorder.

For example, preschool-aged children may be anxious about changes in their routine, separating from parents and spending time with unfamiliar people, all normal. In the early school years, children can worry about the dark, monsters and ghosts. It is important GPs feel confident in recognising the ranges of ‘normal feelings’ in children, so that they can intervene early at signs of paediatric anxiety, without over-labelling conditions.

Is anxiety increasing?

Anxiety in children is a complex process. Infants and children, more than any other age group, are shaped and influenced by a range of social, biological and environmental factors, all of which go into making them who they are. Anxiety remains both environmental and genetic and there is often a strong family link.

There are multiple theories as to why paediatric anxiety might be increasing:

• Anxiety is increasing in adults. Children learn their own coping mechanisms through watching how their parents deal with stress.
• Living with worry and anxiety amidst the global uncertainty of the COVID-19 pandemic has become a ‘new normal’ for many families. Increased anxiety through the media updates and constant reminders of the threats related to the virus through lockdowns and changes at school may be impacting on children.
• Children are given less opportunity to take risks. Resilience is affected by this, and they are more sensitive to change and stress.
• On the flipside, children are now rewarded for anything and everything. Children can be ‘over rewarded’ to the point they feel they have failed if they don’t get praise.
• Children’s diets are deteriorating. There is more fast food and sweet food on offer and less awareness of good food choices.
• The use of devices and computer games is increasing, particularly during lockdowns when children are unable to leave the house to play with friends.
• The pressure to be ‘perfect’ on social media.
• Less sleep, less good food and less physical activity, due to all the above factors.

What is an anxiety disorder?

The DSM classifies anxiety for children in the same way it does for adults. The exception of this is PTSD and ADHD where children have their own criteria.

Social anxiety disorder, obsessive compulsive disorder and phobias remain the most common childhood anxiety disorders. Anxiety disorders rarely exist alone, however, and can be linked to other neurodevelopmental conditions such as Autism Spectrum Disorder and ADHD. For this reason, it is important to take time when considering the diagnosis and follow families up over a few consultations. Enquire about that child’s overall development. When in doubt involve a developmental paediatrician.

What are the symptoms of anxiety in children?

Children present quite differently to adults when it comes to mental health difficulties. The breadth of symptoms can be wide and often warrant consideration of medical and psychological causes. Think about anxiety whenever a child presents with:

• increased irritability and behavioural outbursts
• butterflies or a sore tummy
• headaches and dizziness
• reports of being able to feel their heart beating
• difficulty concentrating at school, avoidance of a particular place, person or experience
• resistance when separating from primary carers; or
• difficulty sleeping.

Clarify with parents the degree to which each of these symptoms is occurring by asking, ‘is the emotion pervasive, severe and persistent?’ A child mental health condition can be distinguished from a vulnerability by its intensity, duration and the extent of its impact on the whole ecology of the child.

Discussing anxiety with parents and kids

Be aware that the child is sitting in front of you in the consultation room and overhearing a lot of this adult conversation. Start by asking them positive questions to build rapport:

• ‘What is going well for you at the moment?’
• ‘What are your favourite hobbies?’
• ‘Who do you play with at school?’
• ‘What are your hopes and dreams for the future?’

Colouring-in and drawing are also great ways for the child to express themselves. For younger children, it can help to draw a human body shape and then ask the child to tell you where they feel these worries in their body.

Questions related to anxiety require child-friendly language that is easy to understand. Instead of ‘anxiety’, use words like ‘being scared’, ‘having a tummy ache or butterflies’, or label the anxiety as something else like ‘the worry monster’.

Normalising anxiety can be immensely powerful for children. You could say something like, ‘I’ve talked to other children before who get a bit scared at night when Mum and Dad put them to bed. Does this happen to you?’

I will often leave parents with a screening tool to take home and email back to me. There are two useful tools when it comes to anxiety: the Strengths and Difficulties Questionnaire (SDQ) and the Spence Anxiety Score.

Medical screening

Consider secondary medical causes of the anxiety. Perform a physical examination checking their height and weight. Examine their ears and throat, chest, and heart sounds. If there are bowel changes, consider constipation and examine their abdomen.

Assess the need for blood screening, in particular iron, thyroid, a full blood panel, vitamins, and coeliac serology. When it comes to sleep, consider sleep disorders and ask if the child is snoring. A snoring child is never normal and warrants further review with an ENT or sleep specialist.

Teaching self-regulation

The goal for most kids is not to eliminate anxiety completely. It is about giving them the skills to manage anxiety, so it does not get in the way of enjoying life.

Discuss with parents their own coping strategies and encourage them to be consistent with how they help kids regulate; to acknowledge the difficult feeling they are experiencing and help them through that.

Talk to parents about slowing down. A suitable time to do this is in the school holidays. Allowing the child time to calm down, going for a walk with them, sitting with them, holding them, hugging them when they are angry or stressed, stating clearly and firmly that they are okay and that you are with them now.

Treating paediatric anxiety: Start with the basics

As well as improving self-regulation skills, you can help to manage anxiety in children by offering parents the following advice:

• Sleep – discuss sleep hygiene and limit screen use after dinner. Melatonin supplements can be useful for difficult sleepers.
• Diet – water should be the predominant drink. Avoid packaged foods, added sugars and colours; and increase the number of fresher foods, fruit and vegetables in the child’s diet.
• Physical symptoms (e.g. tummy aches, headaches, anxious feelings) – practice daily mindfulness to slow down, using the Smiling Mind app or Bedtime Explorers podcast. Encourage children to label their emotions using an emotion chart, drawing and colouring.
• School – encourage parents to talk to the child’s teacher about what is going on, and to ask them to allow the child to take more regular breaks in the classroom if this helps.
• Social – find a positive activity for the child to engage with on a regular basis. For example, exercise is great for helping to release serotonin.

It is important to follow up with the family regularly. If the child’s anxiety is not improving, it can be helpful to refer to a child psychologist or occupational therapist with training in mental health, using the mental health treatment plan item numbers. If you’re concerned about developmental conditions or autism, refer early to a developmental paediatrician as there are currently extended wait times.