Anxiety disorders are among the most common mental health disorders of childhood. The impact of anxiety can be wide reaching, with social relationships, education, family life and health all potentially disrupted.

Three quarters of anxiety disorders have their origins in childhood, with presentation often chronic in nature.¹ Children with an anxiety disorder are 3.5 times more likely to experience depression or anxiety in adulthood,² highlighting the importance of early diagnosis and appropriate treatment. Primary care can play a key role in the recognition and early treatment of these disorders. 

Across all global studies of mental illness in children and adolescents, the pooled prevalence of any anxiety disorder is 6.5% (95% CI: 4.7- 9.1).³  However, making a diagnosis can often prove difficult. Fear and anxiety have important developmental roles and are of major evolutionary significance; therefore it is important for clinicians to distinguish between normal anxiety and anxiety disorders.4 In the latter, symptoms may impair function and/or cause marked avoidance behaviour and significant distress.

 Furthermore, presentation in children is complicated by the high comorbidity with depression, and symptoms can present as somatic in nature. For example, one third of children presenting with medically unexplained symptoms also experience anxiety or depression.⁵

There are a number of different anxiety disorders that affect children and young people and despite their high prevalence, there is a relative lack of guidance for GPs on their diagnosis and treatment. Although NICE provides guidance for common mental health problems, and some specific anxiety disorders in children, (e.g. social anxiety disorder, see Useful information box), guidance for many of the anxiety disorders presenting in children and young people is lacking. Despite this paucity of specific guidance, it should be noted that many of the general principles of treatment set out can be applied to all anxiety disorders.⁶

Presentation

Some cases of anxiety will be relatively straightforward to detect, while others are well masked. Children, young people and parents do not always recognise symptoms as anxiety, and may be reluctant to identify symptoms as such.

The presenting symptoms of anxiety may vary according to the child’s developmental stage. Younger children, who are less able to verbalise their anxiety, may show symptoms of regression of physical abilities (e.g. toileting, requiring carrying); increased attachment seeking  behaviours (e.g. becoming more clingy); or increased physical symptoms (e.g. stomach aches, headaches). Older children and teenagers may be able to verbalise their concerns better, although the stigma of anxiety may prevent them from opening up.

Older children, aged 11 to 16, are more likely to present with anxiety disorders, with girls in this age group at greatest risk with a prevalence of 6.5%.² Increased cognitive sophistication in older children may enable them to imagine a whole world of possibilities and outcomes, both good and bad. This, coupled with increased responsibility and pressure (social and personal expectations around tests and exams may be an additional stressor), means that anxiety often manifests at this age.

Other key factors to be aware of include a history of parental depression7 and bullying,⁸ both of which have been associated with anxiety disorders in children and young people.

ICD-10 and DSM-5 criteria for anxiety disorders ICD-10 and DSM-5 both have a series of subdivisions for anxiety disorders; but all have a number of common features, such as anticipatory fear of, or worry about, a specified stimulus or situation; physical symptoms of anxiety; significant levels of distress over a period of time and functional impairment. Common anxiety disorders in children are listed in table 1, below.

Assessment

NICE quality standards recommend the need for an accurate assessment of which specific anxiety disorder the individual is experiencing, its severity, and the impact on functioning.¹

GPs are an important first point of contact in identifying those with anxiety disorders.

However, given the range of anxiety disorders and the patchy guidance, it can be difficult to assess accurately which disorder is present. NICE guidance for assessment of social anxiety disorder⁹ may be helpfully extrapolated to the assessment of other anxiety disorders: e.g. giving the child the opportunity to provide information on their own, and conducting a risk assessment.

Causal and maintaining factors should be assessed; GPs should be alert to a past history of anxiety, presence of somatic symptoms, any historic or recent traumatic events (including bullying), parental mental health problems which may indicate increased risk of an anxiety disorder. 

NICE recommends referral to a specialist if needed.

The severity and impact of the suspected anxiety disorder can be assessed by asking questions such as: 

• How long have you noticed these worries have been going on for?

• Do you notice any changes in your/your child’s body (e.g. sweating, racing heart, breathing, going red/blotchy)?

• Do you/does your child ever feel that you/he/she can't do thingsor try/tries to get out of them? (As recommended for social anxiety disorder by NICE)⁹

• Do these anxieties/worries stop you/your child doing things you/he/she would like to do?

• How easy is it for you/your child to be distracted from anxiety/worries?

Confirming diagnosis

NICE¹⁰ recommends that thorough assessment of the anxiety disorder should include consideration of the following factors:

• History of any mental health disorder

• History of a chronic physical health problem

• Past experience of, and response to, treatments

• Quality of interpersonal relationships

• Living conditions and social isolation

• Family history of mental illness

• History of domestic violence or sexual abuse

There are some questionnaires that can be used to assist in the diagnosis and in determining severity, for example the RCADS (revised children’s anxiety and depression scale) is freely available but quite lengthy with 47 questions. Alternatively, the SDQ (strengths and difficulties questionnaire) has 25 questions and is also freely available online. It is a good general screening instrument and can identify some anxiety disorders that will contribute to a higher emotional symptom score (www.sdqinfo.com), although specific phobias and separation anxiety are less easily identified with the SDQ.¹¹  

Referral

Early intervention at an appropriate level can help prevent anxiety disorders taking hold. This might be provided through local voluntary or council-led services, or via the child’s school.

Where the child is experiencing significant distress or functional impairment (e.g. missing school, not participating in age-appropriate activity), then specialist input is likely to be needed.

There are a number of options for children with a suspected anxiety disorder, and treatment pathways may well increase and/or change with forthcoming changes to mental health services. Currently, the child and adolescent mental health team or local equivalent would be the most appropriate place to refer to.

The Children and Young People’s Mental Health and Wellbeing Taskforce was established in September 2014 to consider ways to make it easier for children, young people, parents and carers to access help and support when needed and to improve how children and young people’s mental health services are organised, commissioned and provided.

Children and Young People’s Improving Access to Psychological Therapies (CYP-IAPT) continues to expand, with 100% coverage for England expected by 2018.

Both of these initiatives may see changes to the provision of treatment for anxiety disorders with more community therapeutic provision made available.

If the anxiety disorder relates to a health condition (e.g. social anxiety stemming from looking different because of a medical condition or intervention) or interferes with medical treatment (e.g. needle phobia), it may be worth looking into local paediatric psychology or psychological medicine services. These are often linked to a children’s hospital or district general hospital and can provide specialist support for anxiety in the context of physical health. The Paediatric Psychology Network UK is useful to find out what services are available locally.

Evidence-based treatment

Early detection and treatment of childhood anxiety disorders can prevent significant impairment. Existing studies support a number of psychotherapeutic and pharmacological interventions. Family interventions to reduce reinforcement of anxiety and avoidance behaviour are also important.

Psychological therapy

In younger children, intervention focuses on behavioural components and family psychoeducation, whereas in older children, cognitive work provides an additional complementary strategy.

CBT is the most widely researched and evidence-based treatment for anxiety disorders in children and young people. Randomised controlled trials of CBT have shown benefit for generalised anxiety disorder, social anxiety disorder and panic disorder.³

Young people with mild-moderate functional impairment benefit from psychological therapy such as CBT or psychoeducation.¹² Examples of low-intensity interventions based on CBT or psychoeducation that may be offered in mild-moderate cases include bibliotherapy and e-therapy. Bibliotherapy (such as parent-led workbooks) have shown promising results, with recovery increased when combined with therapist support.

E-therapy research to date has also been encouraging, with some studies showing that 68-75% of children and young people were free of their primary diagnosis at follow-up.

See Cresswell and colleagues for a full review of the evidence base.³

For young people with moderate to severe impairment, multimodal treatment  using medication and psychological therapy may be more appropriate.¹³ Psychological therapy is more likely to require face to face support from an appropriately trained professional. Medication can be initiated before psychological therapy to reduce symptoms to allow therapy to commence; it can also be initiated following the commencement of therapy if symptom relief is not satisfactory.¹²

CBT includes many core components which form part of the treatment of a range of anxiety disorders. Many of the interventions involve graded exposure to the anxiety-provoking stimuli, while using pre-practised coping strategies, until anxiety is extinguished at each level, see box 1.

Pharmacological therapy

Medication should not be used as a first-line treatment and is usually only started in secondary care. SSRIs are first-line therapy for pharmacological management of anxiety disorders in young people.¹⁴ Medication has been shown in trials to be more effective than placebo in reducing symptom severity across anxiety disorders.¹⁵

Treatment for anxiety disorders in children and young people may not fully eradicate symptoms, but the goal would be to improve functional impairment and reduce distress.¹⁴  The strongest evidence supports use of SSRIs and CBT. Combination treatment with SSRIs and CBT has been found to be more effective than either treatment alone.^16,17

GP support

GPs have an important role to play and provide a less stigmatising environment for children and young people to turn to with anxiety problems. Resources such as MindEd (see Useful information box) have been launched, to help families and healthcare professionals understand the problems facing children and young people with mental health needs, and is a useful resource.¹⁸