by Dessy Tzoneva
According to the South African Stress and Health Study, anxiety disorders are the most prevalent mental health concern in our country, and children are far from immune to this… But without being able to recognise what they feel as anxiety and possibly even struggling to find the words to describe this very personal experience, children often go untreated for quite some time. What can you, as a medical professional, do to identify childhood anxiety and how do you guide the family in finding the best possible treatment?
Meryl’s daughter, Gizella developed an intense anxiety around the concept of death, which resulted in panic attacks, and peaked around the age of 5: “Every time she came across anything to do with death – whether it was in conversation or even in a cartoon or movie, she would stop dead in her tracks and not respond. She’d become pale, say she feels very cold, then she’d build up a lot of saliva in her mouth that would lead to her vomitting. Sometimes, she’d also lose control of her bowels.”
Anxiety is linked to our fight-or-flight response, which contributes to our survival. But when this response is disproportionate or triggered without a threat present, it becomes unhealthy. Although it may seem that childhood should be largely stress-free, international data shows that 1 in 8 children are affected by anxiety, to which girls are more vulnerable than boys. If left untreated, an anxiety disorder can become chronic and can interfere with a child’s school work, family relations and their ability to form social relationships, resulting in long-standing problems. The onset of many anxiety disorders is in childhood or adolescence.
“A lot of adult patients with anxiety report frequent visits to the doctor when they were younger, with diffuse or unexplained symptoms,” says clincial psychologist Lee-Ann Hartman. “The consequences of leaving this condition untreated in childhood include school underperformance and later career difficulties, social isolation, decreased self-esteem and sense of self-worth, and substance abuse, which people tend to use to control the feelings of anxiousness and to make socialising easier.”
Identify at-risk children
When dealing with a young patient, always be sensitive to symptoms that may be more psychological in nature. This is especially relevant with anxiety disorders and even more so when it comes to anxious children, who tend to experience more somatic complaints.
Psychiatrist Dr Kedi Motingoe says: “Childhood anxiety disorders are very common, but frequently missed. Children present mostly with vague physical symptoms – abdominal pains, headaches, nausea and breathlessness. The most common tend to be gastrointestinal problems.”
Other physical symptoms commonly associated with anxiety are tiredness, vomitting, dizziness, sweating and heart palpitations. These can vary in intensity and/or may have a tendency to come and go. Other signs include fear, nervousness, irritability, worry, poor concentration and avoidance of social situations or other activities.
“Some children even call it ‘this thing in my tummy’, describing a kind of movement in their stomachs, others say it feels like their heart wants to get out of their chest,” explains Dr Motingoe. She says that children most often present to a doctor during transitions – when starting preschool, at the beginning of Grade 0, when moving from primary to high school or when there’s a change in family circumstances. “During these times, any existing anxiety seems to become more prominent.”
Because of the largely physical nature of these complaints, parents often seek help from their primary healthcare provider, like their GP, and may themselves be unaware of the psychological nature of the illness. It is for therefore vital for all medical professionals to be aware of the symptoms to look out for.
Making a diagnosis
There are a number of illnesses that fall under the umbrella of anxiety disorders.
- Separation anxiety disorder: a child fears that something may happen to them or their parents/caregiver when they are apart and therefore experiences distress when being away from them. Separation anxiety is expected during early development, but should not continue beyond that.
- Social anxiety disorder: extreme anxiety is experienced in social situations, which may then be avoided because the child fears drawing attention to themsleves or being embarassed in front of others.
- Phobia: an intense fear of an object or a situation, a fear that is disproportionate to the danger posed.
- Generalised anxiety disorder (GAD): children worry in excess about everyday responsibilities and events.
- Panic disorder: children experience attacks of acute anxiety out of the blue and marked mainly by intense physical symptoms like heart palpitations, sweating, breathlessness and dizzyness.
- Obsessive compulsive disorder (OCD): a child experiences unwanted obsessions (anxiety-provoking intrusive thoughts and/or images) and compulsions (repetitive behaviours used to relieve the anxiety).
Dr Motingoe says: “With children, a mixed presentation is more common – you may, for example, find that a child has a specific phobia, as well as OCD features.” She further points out that GPs usually get to know families well and are in a better position to pick up on signs of anxiety in children. “An anxiety disorder may be present if you see a child often, they have uncommon presentations, their symptoms don’t seem to respond to typical treatments and there’s a family history of anxiety disorders.”
Hartman comments that children as young as 4 and even below can have severe OCD. “Never overlook the possibility of an anxiety disorder because a patient seems too young,” she says. “Look out for changes in eating habits, fear of/difficulty in going to sleep, school refusal, withdrawal from friends and/or parents, tantrums/irritability, insistence on certain things, repetitive or rigid behaviours, and even conflict with siblings.”
“Gizella was only 3 when she had her first attack and I felt to blame for bringing up the subject,” says Meryl. “She couldn’t understand what was happening to her and was so scared. The more I tried to talk to her to calm her down, the worse her symptoms got. I felt helpless… It was horrible for me to watch her go through that.”
The Screen for Child Anxiety Related Disorders (SCARED) is a self-report instrument (with both parent and child versions) that can be helpful in diagnosing anxiety disorders. A score of 25 or higher suggests such a disorder may be present and further investigation is necessary.
Motingoe and Hartman agree that it’s vital to spend some time during a consultation simply speaking with a child. “There are a lot of assumptions that children can’t explain their sympotms, but they can surprise you and at times describe what they’re feeling even better than adults,” says Dr Motingoe. Hartman’s advice is: “Chat with children about what is happening in their world, beyond their physical symptoms. Especially, if you’re seeing them often! They may reveal information they haven’t shared with their parents.”
Medication and psychotherapy, especially cognitive behavioural therapy (CBT), are usually central components of treating anxiety. Supportive treatments include improving a child’s nutrition and sleep patterns, ensuring they exercise daily, reducing uncertainty through an adhered to routine, and encouraging social interactions weekly with friends and family. When treating children, it’s always important to alert the school to any diagnoses so that necessary adjustments can be made and their treatment can be montiored. Continuously evaluating treatment efficacy and a child’s level of functioning is very important, as is assessing suicide risk, in an age-appropriate manner.
In speaking about what she would have appreciated in finding help for her daughter, Meryl says: “It’s important to understand that dealing with children is not like any other panic patient. They’re so little, and most don’t understand at all what’s happening to them. As a mom, I felt incapable of helping my own daughter, and finding guidance and practical advice proved challenging.”
Cassey Chambers, Operations Director of the SA Depression and Anxiety Group (SADAG) says: “We often receive calls from parents and loved ones looking for advice on how to help a child with anxiety. This can be very overwhelming for the child and for their family, who may feel responsible for their comfort and recovery. We have a lot of brochures, articles and videos available on our website – www.sadag.org. Anyone looking for help can also call our toll-free helpline 7 days a week from 8am to 8pm on 0800 21 22 23 to speak to a counsellor.” In addition, SADAG can refer those affected to mental health support groups in their area, which can really help a family adjust to a diagnosis.