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A GP’s perspective on managing childhood anxiety

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Your next patient is a six-year-old girl, Lucy, booked in for a 15-minute appointment.
 
You walk out and notice her curled up on her mum’s lap.
 
‘Lucy’, you call out to her. She starts whispering to her mum. ‘No, come on Lucy, you’ll be fine,’ her mum says.
 
‘Hi Lucy, I’m the doctor seeing you today.’
 
Lucy doesn’t really respond; she gives you a half smile.

‘Hi doctor, I’m Sharon, Lucy’s mum.’
 
You take them both into your consultation room.

‘Lucy, I noticed you’re cuddling a really special toy. Who is it?’

No answer.

‘That’s piggy, Lucy takes him everywhere,’ Sharon answers for her.
 
You ask what brings them in.

Sharon responds: ‘Lucy has had some terrible eczema, it has been there for a while now.’

You go through the usual questions about skin irritants and develop a management plan. But is that all there is to it?
 
General practice is never just ‘one thing’. You know there’s more going on – you saw it when you first met Lucy in the waiting room.
 
You ask how things are going for Lucy in general. Sharon asks, ‘What do you mean?’

‘How is Lucy’s development going? Her mental health? Her emotions?’
 
Sharon answers with a big sigh.
 
‘Well to be honest, not great. Lucy has been so difficult lately. She is always screaming at me, and then hitting her little sister,’ she says.
 
‘At school drop off, she’s clinging onto me, it’s such a process. It takes about an hour to get her into the classroom. I feel like I’m walking on eggshells with her. One little thing and there’s an explosion.
 
‘Her father and I have run out of ideas on how to handle it. We’ve tried time outs, we’ve tried rewards, we’ve tried talking to her, nothing works.’
 
Suddenly you realise this is not going to be a simple consultation – it is far bigger than just a conversation about skin problems.
 
Fortunately, GPs are perfectly positioned to discuss the ‘whole child’. That is, we have the unique opportunity to be inquisitive and interested in what is going on in a child’s life.
 
The problem is we are busy, consultations can be short, and it is challenging work. It would be far easier to give a steroid cream for the eczema and let them go.
 
I often hear the phrase ‘early intervention’. This works well for almost any condition, but none better than in the setting of paediatric mental and developmental health. The earlier we get onto issues that arise, the better the outcomes – short and long term.
 
How can we deal with all this, as well as the presenting complaint when we are already so busy?
 
The answer is in the ability to connect and get to know families over time. For Lucy, it would mean listening to her mum’s initial concerns, acknowledging that they are facing a difficult period, and if needed, arrange a follow-up consultation that is longer.
 
In between sessions, I would ask Sharon to complete a strengths and difficulties questionnaire. While I don’t find questionnaires particularly helpful per se, I do find that it helps parents feel like they are being listened to, because a lot of the questions will relate to what they are going through at home.
 
Just acknowledging someone is having a hard time is so therapeutic, even if we don’t have the answers on what to do next.
 
The second consultation for Lucy requires a review of four key areas:

• Sleep
• Diet
• Relationships (school, family)
• Parenting style

I like to focus on these because they are the easiest to work with first.

Let’s go back to the consult with Lucy and Sharon.
 
GP: ‘How’s Lucy’s sleep going?’

Sharon: ‘Oh, it’s terrible. I have to lie with her for two hours while she falls asleep. Then every night, without fail, she’ll run into our room and come and wake us up for a cuddle. She complains of nightmares. But I don’t know. She’s probably just wanting us there all the time.’
 
GP: ‘What about food? Does she have a good breakfast?’

Sharon: ‘She eats breakfast. But the rest of the day is a battle. She is incredibly fussy.’ 
 
GP: ‘Lucy, who are your best friends at school?’

Lucy: ‘Lilly and Tom’. 

Sharon: ‘Lucy’s teacher told me she’s having a rough time with the other kids and that she usually just sits in the library at lunchtime’.
 
At this point, we have some useful information to help us start to manage a six-year-old with anxiety.

We have observed Lucy being a sensitive, shy child, who is difficult to build rapport with. We have heard from mum that she has big emotions and behaviours at home and school, that she struggles to sleep at night and that she is a fussy eater.
 
None of this is unusual for six-year-olds. In fact, we might even consider this to be quite a normal range of experiences and developmentally appropriate.
 
I often point this out to parents, that six-year-old children can be challenging in how they react to things, such as not getting their way at home, or being tired after a week of school. It is also very common to find they have particular tastes in foods, and struggle to make friends.
 
One of the aspects of mental health in children I find the hardest, is figuring out the abnormal from the normal. What is a normal range of emotions?
 
If all of this is impacting their learning, relationships with others and appears to be affecting their wellbeing, I’d prefer to intervene now and offer suggestions, then let it brew and build into a bigger problem.
 
Anxiety in children can present in this way, as a heightened range of emotions including stress, anger, physical symptoms and behavioural difficulties, that impacts learning and development. It is crucial that in primary care we detect and manage these issues.
 
Lucy might not need a lot of intervention at this stage. But we have just connected with this family in a way that was not anticipated. They now know they can return if this does become harder to handle.
 
In terms of what might help:
 
Sleep – reduction in screen time before bed. Stopping all screens after dinner is hugely helpful in creating a calmer environment before bed.
 
So are dimming the lights around the house, and encouraging reading, drawing and colouring, or family card games like Uno or a short meditation from the smiling minds app. As for the difficulty falling asleep, use of melatonin can be hugely helpful if all else has failed.
 
Diet – structuring mealtimes such as breakfast, lunch, dinner, morning tea and afternoon tea can avoid those hunger meltdowns. Advise aiming for more wholesome foods and less junk, packaged food, but also work within the child’s range of likes and pick your battles with them so it does not become a stress for the parent as well.
 
Relationships and friendships – encouraging children to join a social, sporting, spiritual/church or after school group can go a long way to providing social skills and connection. Work with their strengths and not against them – find out what they truly like.
 
Parenting styles – we know that positive parenting styles tend to work better for children with anxiety. Working towards the child’s strengths rather than their weaknesses. Suggest that parents reward better behaviours rather than punish the bad ones and keep their own mental health in check.
 
We often forget that while the patient might be the child, they are influenced and raised by a parent or caregiver. One that may also be struggling in their own way. It is very hard to manage a child’s emotional wellbeing if that person is also suffering from an anxiety disorder, and this is not an uncommon scenario.
 
Set up a separate consult with the caregiver of that child.
 
Discussing the idea of modelling calmer reactions to stress and reducing worry in the household is immensely powerful. During COVID I remember telling almost every parent to turn off the news as I was seeing weekly increases in children presenting with anxiety around becoming ill.  
 
If in doubt, a patient like Lucy could benefit from a mental health occupational therapist or a psychologist, but it may not come to that. Time and support might just be enough.
 
Finally, when talking to children, it is always important to help them understand that worry, fear, anger, stress and anxiety are all normal emotions. Remind them that there is ‘nothing wrong with them’ as such, rather their busy brain has found it hard to turn them down.
 
As a result, we are here to help and want to give them tools to reduce these feelings when they are too strong to handle.
 
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Anxiety children GP–patient relationship mental health patient-centred care

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