Anxiety is considered the fastest growing childhood mental health issue in Australia. Dr Andrew Leech explains. 

GPs are the most used service provider when it comes to mental health of children. We are often the first point of contact for families, yet understandably do not feel confident in how best to manage this. Feeling anxious, stressed, angry or scared are normal parts of growing up and learning about the world. It can be challenging to figure out the exact moment in time where a child shifts from being anxious, to developing an anxiety disorder.

Dr Andrew Leech

For example, pre-school 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 to recognise the ranges of ‘normal feelings’ so that as health professionals we don’t over-label 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 on 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.
  • The COVID-19 pandemic has increased anxiety through the media and constant reminders of the threats related to the virus through lockdowns and changes at school.
  • 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 impact of devices and computer games. 
  • The pressure to be ‘perfect’ on social media. The longer periods of time spent playing with technology. 
  • Less sleep, less good food, 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?

Children present quite differently to adults when it comes to mental health. 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
  • Difficulty sleeping

Clarify with parents the degree 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 extent of its impact on the whole ecology of the child. 

Discussing anxiety? 

Be aware that the child is sitting in front of you in the consultation room and overhearing a lot of this adult conversation. Start with positive questions to build rapport. Ask the child first about what is going well for them, what are their favourite hobbies or friends? Who do they play with at school? What are their hopes and dreams for the future? 

If this is ineffective, colouring-in and drawing also works well enabling the child to express themselves differently. Questions related to anxiety require child-friendly language that is easy to understand. Instead of the word anxiety, use words like, being scared, having a tummy ache or butterflies, or labelling the anxiety as something else like ‘the worry monster’.

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. 

Normalising can be immensely powerful. ‘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. 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. 

Practical tips for parents
  • Start by slowing down
  • Make time to worry
  • Climb that ladder
  • Encourage positive thinking
  • Have a go
  • Model helpful coping
  • Help your child take charge
  • Be upfront about scary stuff
  • Be brave, allowing children to take risks and learn from their mistakes
  • And finally, check your own behaviour

Refer parents to the BRAVE program

Start with the basics
  • Sleep – discuss sleep hygiene and no screens after dinner. Melatonin can be useful for the difficult sleepers. 
  • Diet – water should be the predominant drink. Avoid packaged foods. A diet lower in added sugars and colours. Build around fresher foods, fruit and vegetables.
  • Physical symptoms – tummy aches, headaches, anxious feelings – daily mindfulness to slow down using the Smiling Mind app or bedtime explorer’s podcast. Encourage children to label their emotion using an emotion chart, drawing and colouring.
  • School – encourage parents to talk to the teacher and let them know what is going on. 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, exercise is great for helping release serotonin. 

Follow up with the family and if 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 concerned about developmental conditions or autism, refer early to a developmental paediatrician as there are currently extended wait times. 

ED: Dr Andrew Leech is a GP with special interest in paediatric health and mental health.