Anxiety in children is on the rise. At last check, approximately 278,000 Australian children had an anxiety disorder, according to 2017-2018 AIHW data. That equates to 8% of those aged 4-17. However, this figure likely underrepresents the true prevalence, as only about 50% of children with mental health concerns present to their GP.

Separation anxiety is the most common anxiety disorder seen in children, closely followed by social anxiety (or social phobia) and generalised anxiety disorder. However, it’s important to recognise that there is often considerable overlap between these conditions, and many children may experience features of more than one type of anxiety at different stages of their development.

Rather than focusing too heavily on diagnosing the specific type, what matters most is identifying when anxiety is starting to interfere with a child’s wellbeing by impacting their home life, school engagement, or relationships. Early recognition allows for timely support, regardless of the label.

Why are children developing anxiety?

Multiple factors contribute to children developing anxiety. Genetic predisposition plays a significant role. It’s not so much that children are born with anxiety, but rather that they have a genetic vulnerability that can be triggered by early trauma or stress in their life.

Stressful situations might include school challenges, bullying, grief or loss, even moving house or changing a routine. The risk of anxiety is heightened by factors such as personality traits (some children being naturally more sensitive), and environmental factors such as home experiences or challenges, screen time, diet, and sleep patterns.

Clinical Presentation

Anxiety presents differently in children compared to adults. It may not be immediately obvious to a family that their child is struggling with anxiety. Children are good at ‘masking,’ meaning they can hide their struggles just to fit in. This is why some children seem to be perfect at school, but highly emotional at home. Other symptoms of anxiety in children can include:

• Persistent emotional outbursts lasting beyond typical developmental stages
• Physical symptoms like “butterflies,” stomach aches, or headaches
• Difficulty concentrating in school
• Trouble with school drop-offs
• Diminished self-esteem

Distinguishing between normal childhood fears and anxiety as a disorder

GPs play an important role in distinguishing between normal fears and worries in children and adolescents, and what might be becoming an anxiety disorder. GPs have a unique perspective as they see families over a long period of time, and can often see changes through observation, history taking, parental feedback or speaking with the child themself.

Anxiety is a normal biological response. Children can have anxious feelings around separation from parents at school drop off, fear of the dark, worry about school performance, an upcoming test, or making friends and fitting in. These feelings might come and go and sometimes it is helpful to monitor over time with some simple suggestions around supporting them with these feelings. Children don’t always know the words to express an emotion though so parents may indicate other signs such as a change in their behaviour, physical symptoms such as tummy aches or avoidance of things they used to enjoy.

An anxiety disorder typically persists for at least two weeks, significantly impacts daily functioning, and manifests throughout the day, rather than just during specific triggering events.

Assessment

Begin by building rapport with the child, asking about what’s going well (for example questions about friends, pets, teachers, and interests). Then explore challenges, including what they find difficult and what might have changed in their life recently.

A comprehensive biopsychosocial approach is essential when assessing childhood anxiety as there may be multiple contributing factors.

Start with basic areas such as sleep, diet and nutrition, screen time versus outdoor play, social and emotional wellbeing, learning and school and family factors such as parental separation or recent changes in the child’s home or school environment.

It may be important to also screen for neurodevelopmental conditions such as ADHD or Autism as both conditions have a strong overlap with anxiety.

Perform a physical health check of the child, including their growth, blood pressure, checking ears and throat (rule out ear effusions or large tonsils), chest and heart, abdominal examination and overall appearance.

It can be helpful to perform a general blood test for vitamin deficiencies such as iron, vitamin d, b12 and folate, zinc and magnesium, along with thyroid, full blood picture and kidneys and liver tests. This is a comprehensive way of excluding secondary causes of the anxiety.

Management Strategies

Simple strategies can be suggested to families to help them navigate anxiety.

An easy starting point is to suggest that families practice ‘mindfulness’ by slowing down. Wherever possible, cut back activities to allow more time to pause and ‘be bored’. Spending time outdoors has been proven to help children reduce anxiety.

Mindfulness might be simple, or more formal such as using the Smiling Mind App to do a daily 5-minute family meditation.

The BRAVE program online is a useful online resource for both children and parents.

Nutrition and Diet

Ask what the child eats and drinks throughout the day. Many anxious children may have sensory issues affecting their eating habits. For fussy eaters, suggest offering various food options without pressure. Manage any nutritional deficiencies using a calorie supplement and/or supplements to address specific deficits found on blood testing (e.g. an iron supplement). Some parents spend a lot of time and energy battling meal-time stress, advise parents to “pick their battles” around food while still introducing new options regularly with a lower expectation. Children with anxiety take longer to build the confidence to try new foods.

Sleep hygiene

Ensure children receive adequate sleep (9-12 hours depending on age). Screen for potential sleep disturbances, including restlessness or signs of sleep apnoea, which can manifest with symptoms similar to anxiety. Recommend consistent bedtime routines and appropriate wind-down periods.

Screen time management

While the recommendation is two hours of no screen time before bed, this can be challenging for families to implement. Starting with more modest goals (30-60 minutes screen-free before bed) may be more practical. The type of content may be significant too. Limit fast-paced shows, stimulating games and on-demand apps to short blocks of time. Encourage parents to be firm with screens and to develop a system that fits in with their family schedule. This could include turning off the WiFi, locking away the devices, or setting controls on individual devices to time the use of their screen.

Parenting Support

GPs are good at understanding the family as a whole. It is reasonable to suggest to parents that they also see their own GP and seek out support for their mental health. Normalise the fact that ‘parenting is hard’ and that they too need to look after themselves.

Simple tips include parents ‘tag teaming’ so each parent can take an hour or two a week off for themselves to do something they enjoy. Regular date nights using local babysitting support is effective for maintaining a strong relationship. If parents find they get caught up in their child’s anxiety and emotional outbursts, a family ‘time out’ can allow each member to separate within the house for a few moments to catch their breath.

Family mental health

Ensure parents have their own support systems, whether it is through their own family, or friends. Social connection helps reduce the isolated feeling that can come with mental illness. Parental anxiety can develop alongside or precede the child’s anxiety. Siblings may also require attention and support as they navigate family dynamics affected by an anxious child.

Psychologists are a good point of reference for parents, who can each access a mental health plan. Some psychologists may suggest family therapy so that each member can voice their concerns and work through possible solutions.

School factors

Assess the child’s relationships at school, both with peers and teachers. Screen for bullying, which is a significant risk factor for anxiety.

Build a collaborative team

For children requiring additional support, build a collaborative team. Refer to psychologists or occupational therapists through Medicare mental health care plans. For significant anxiety that affects learning, development, or school attendance, consider referral to a paediatrician or psychiatrist for medication assessment.

If there is difficulty accessing a psychiatrist, refer to therapeutic guidelines, or the Royal Children’s Hospital guidelines, to understand the role of medication in managing moderate to severe anxiety.

Fostering resilience

A crucial component of anxiety treatment involves facing fears progressively. Encourage children to be brave and not avoid anxiety-provoking situations. Implement gradual exposure techniques to help desensitise the fight-or-flight response. For example, if a child struggles with independent sleeping, suggest a stepwise approach from parent co-sleeping to eventual independent sleeping. For performance anxiety such as a running race at school, the parents might inform the school of the child’s anxiety but still provide encouragement, even just having a go is a success and each time gets easier.

In summary

As GPs, we are often the first point of contact for many families dealing with childhood anxiety. It’s important to build rapport with children and this takes time (sometimes multiple consultations), provide ongoing support for the entire family, and connect with schools, specialists or allied health professionals when needed. By taking a comprehensive approach that addresses multiple factors contributing to anxiety, we can significantly improve outcomes for these children and their families.

Key points:

• Anxiety rarely presents in isolation; think holistically and broadly about what might be going on in the child’s life.
• Take a bio-psycho-social approach.
• Be aware that anxiety presents differently in children compared to adults.
• Normal developmental fears and worries come and go.
• Consider early referral to a psychologist, occupational therapist or family support if concerns are ongoing.
• Follow up regularly, monitor progress and adjust management strategies as needed.
• Early intervention can make a substantial difference in a child’s developmental trajectory and long-term mental health.

For more information: Dr Andrew Leech is the author of Calm Kids, Happy Hearts: Practical Strategies for Raising Emotionally Resilient and Joyful Children which explores this topic further.