How digital devices and special considerations can create a crutch for children with anxiety…

In the past two weeks, almost four in 10 GPs have been asked to provide a special consideration or exemption letter for a child under 16 having difficulties at school due to anxiety, a national Healthed poll of 1300 GPs found this month.

With over half a million Australian youngsters experiencing a mental health disorder each year, GPs sometimes feel pressured to provide these letters, says Dr Danielle Einstein, a clinical psychologist and co-author of the book Raising Anxiety, and Adjunct Fellow at Macquarie University’s School of Psychological Sciences.

But can these exemptions do more harm than good?

While exemptions of a few days or so are fine, they do not help anxiety if they go on for too long, Dr Einstein says.

Any accommodations put in place should be in the context of a treatment plan for anxiety, and should be removed “fairly quickly” to encourage the child to face their fears, she explains.

“Treatment of anxiety first involves psychoeducation around what is going on — what the anxiety looks like and what we know about anxiety—then moving very quickly into treatment, which involves facing fears steadily, and usually doing more rather than less,” Dr Einstein says.

While 37% of GPs in Healthed’s survey have been asked to provide at least one exemption or special consideration letter in the last fortnight, Dr Lilijana Gorringe — a GP and senior lecturer in the University of Sydney’s Medical School — thinks they are “just seeing the tip of an iceberg.”

“When we get asked for letters, we’re probably seeing families in more distress, and maybe a bit more extreme examples,” she says.

Encouraging children to face their fears

Dr Einstein says regular or lengthy exemptions or special considerations can create an environment where anxiety persists.

For example, she’s heard of students getting special permission to wear false eyelashes or make-up to give them confidence during their exams – but that can then become a crutch they feel they need in order to focus.

“We want them to learn that they don’t need the false eyelashes, that they don’t need to be excused from the room… they need to learn to face the challenge.”

Digital devices are a powerful crutch

Devices are becoming crutches too, she says, providing a distraction that can prevent children from pushing past their fears.

“It’s no longer the case that a student will be at home bored,” Dr Einstein says. “Now time passes quite quickly because we have this intense distraction.”

In Healthed’s survey, 98% of GPs say overuse of devices and social media are contributing to adolescent mental health issues — with 43% saying they’re a major contributor, and 44% a moderate contributor. Only 1% said they are not a contributor.

However, while GPs almost universally agree about the impact of social media and device overuse, there’s wider variability in their confidence in supporting patients to reduce their use of these.

Just 5% said they were very confident they could help patients with this issue, 30% were moderately confident, while 45% were only slightly confident — and 21% were not at all confident.

Strategies to reduce device use

So, what exactly can GPs do?

Dr Einstein suggests screening for device use as part of an initial mental health assessment, thinking of it like a third ‘S’ in the HEADSS Assessment.

“It needs to be part of the conversation from the very beginning,” she says.

You can also include it specifically in a Mental Health Treatment Plan and review it during a plan review, she adds, noting this could “actually change our whole approach to device use and how it is undermining mental health.”

Encouraging families to implement some changes is also important.

If you want a teenager who has an anxiety disorder to spend more time out of their bedroom, for example, you “can’t have strong distractions sitting in their bedroom.”

“It’s not that every single family has this issue, but many, many families do now.”

Dr Einstein recommends acknowledging the addictive pull of devices and social media, without labelling them as an addiction.

“Once we’ve recognised it, we can build up that muscle of putting device discipline in place,” she says. For example, you can encourage patients to keep devices out of bedrooms, or away from the table at family dinner time.

It’s important to have empathy about the difficulty of dealing with devices, she says. But “instead of saying it’s all too hard and having that sense of we’ll just give up, it’s important to convey the fact that it is manageable.”

When relevant, explain that parents need to be involved with the psychologist before the child goes to see them, she adds, stressing therapy is more likely to be effective when the family situation is conducive to cognitive behavioural treatment.

Problematic versus non-problematic use

Dr Gorringe notes GPs need to work out whether device use is problematic or not.

While there’s not a hard and fast rule, symptoms such as sleep issues, disordered eating, musculoskeletal problems, eye issues, mood changes, and self-harm can point to problematic use, she says.

She agrees with including another ‘S’ when you’re doing a HEADSS Assessment, adding that the Smartphone Addition Scale—Short Version is a helpful screening tool.

“I swing my monitor around and bring it up, and it’s a great because it gives the person a visual indication, a bit like anything else—smoking and alcohol and cardiovascular risk—a traffic light system to start that discussion,” Dr Gorringe says.

Useful resources

Dr Gorringe recommends the following resources to help families manage social media and device use:

• Smartphone Free Childhood – “They’ve got great videos that I sometimes show people in my room,” she says.

• Health Professionals for Safer Screens – “They have excellent, evidence-based resources, broken down for different ages. They’ve got flyers that I’ve printed out, and I pick the age and then talk it through with the parent.”

There are also Australian grassroots collectives for parents who want to delay letting their kids use smartphones, like Wait Mate and The Heads Up Alliance, she says.

If you suspect problematic use, consider referring the child to a psychologist, she adds.

Dr Einstein and clinical psychologist and parenting expert Dr Judith Locke have also co-authored a book with additional information: Raising Anxiety: Why our good intentions are backfiring on children & how to fix it.