Emotional distress in children and young people

How to recognise emotional distress in children and young people and when to refer to mental health services.

Around 20% of children and young people have a mental health problem in any given year, and about 10% at any one time.1

It can be a challenge for GPs to determine the correct care pathway for these patients. Getting this right is essential to speeding up referrals and improving patients’ recovery times.

Identifying mental health issues

Emotional distress is present in more than one-quarter of children who attend general paediatric clinics.2 Children and young people are likely to present with comorbid anxious and depressed symptoms, termed ‘emotional distress’ for the purpose of this activity.

Although symptoms such as abdominal pain, dizziness, and lethargy are associated with many physical ailments, they can also be somatic signs that a child or young person is experiencing emotional distress. When a child or young person also has a chronic health condition, it can be hard to separate somatic symptoms from the symptoms of physical illness.

This overlap between emotional and physical symptoms can make it difficult for GPs to know whether to direct referrals for children and young people who present with somatic symptoms into mental or physical health pathways, and this can be a barrier to such children/young people receiving appropriate care.

It is essential from the first consultation that GPs have the tools they need to differentiate between symptoms of physical illness and those of emotional distress in children and young people. This can be difficult to achieve within a 10-minute consultation, particularly when the patient presents with additional physical health conditions.

Assessment tools

Young patients with chronic medical conditions, such as diabetes and cystic fibrosis, are at a higher risk of developing mental health difficulties. Indeed, SIGN Guideline 1163 suggests that children and young people who are diagnosed with diabetes mellitus should be routinely screened for emotional distress, and that the screening tool used should exclude somatic symptoms.

The hospital anxiety and depression scale (HADS) excludes somatic symptoms and is widely used by clinical practitioners to identify anxiety and depression in adults, but no similar measure has previously been available for use with paediatric patients.

Fortunately, a paediatric screening tool is now available - the paediatric index of emotional distress (PI-ED). The tool is based on the HADS but uses language and concepts that are appropriate for young patients.

The PI-ED is a brief, robust self-report measure which does not ask about somatic symptoms. It makes it easier for GPs to identify clinically significant symptoms of emotional distress in eight-16 year olds.

Although the PI-ED is not the only measure of emotional distress in children and young people, it is the only measure that excludes somatic symptoms. As such, it can be used with children or young people who have a physical illness because it will not confound physical symptoms of distress, such as abdominal pain or dizziness, with those of a physical condition.

The measure has been psychometrically evaluated in research trials (school- and clinic-based) with more than 1200 children and young people by a team of clinical and health psychologists from NHS Ayrshire & Arran, and the Universities of Glasgow and Nottingham.4

Boosting the effectiveness of care

The PI-ED is quick to complete and score during a consultation. It can be administered and scored by a GP in minutes, and provides gender-specific cut-off scores to indicate where support from a paediatric mental health specialist may be required.

This will help clinicians to identify a child's issues early on in the treatment planning process and enable them to put appropriate interventions in place in a more targeted and cost-efficient way.

Further advice

Advice can be sought from child and adolescent mental health services (CAMHS) teams about whether a referral for further assessment of emotional distress is warranted. Children and young people who have long-term health conditions can often have access to paediatric clinical psychologists who usually work in hospital settings and are affiliated to physical health care teams.

Most children and adolescent mental health services (CAMHS) teams offer a triage service and can give advice by phone. CAMHS clinicians can also signpost to alternative sources of support – for example, third sector agencies - for children, young people, and their families.


Jack was diagnosed with cystic fibrosis aged 8 months and was then referred to a multidisciplinary cystic fibrosis team. Jack was given a comprehensive treatment plan, which included intensive physiotherapy. Jack and his family adjusted to the diagnosis and were coping well with the treatment.

By the time Jack was 11 he had learned to manage his condition effectively. He had good lung function, was growing well and had a good appetite. However, during a routine check-up, Jack's GP noted his general health had deteriorated. He had lost weight and was lethargic. Jack was asked to complete the PI-ED and the results revealed that he had developed significant levels of emotional distress. Further discussion revealed that Jack's distress was about his condition, its impact on his school life and his future prognosis. This allowed Jack's GP to refer him for appropriate intervention from a paediatric clinical psychologist.

The symptoms that Jack was experiencing could have been attributed purely to his physical condition. The PI-ED screen allowed Jack’s emotional distress to come to light, and he received the mental health support he needed.

  • Dr Suzy O'Connor is principal clinical psychologist, University of Glasgow;Dr Emma House is consultant clinical psychologist, NHS Ayrshire and Arran; Dr Terri Carneyis consultant clinical psychologist, Child and Adolescent Mental Health Services, Jersey 

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  1. The Mental Health Foundation. Lifetime impacts: childhood and adolescent mental health, understanding the lifetime impacts. 2005.
  2. Glazebrook C, Hollis C, Heussler H et al. Detecting emotional and behavioural problems in paediatric clinics. Child Care Health Dev (2003); 29: 141-9.
  3. Scottish Intercollegiate Guidelines Network. Management of diabetes: a national clinical guideline. 2010. 116. www.sign.ac.uk/pdf/sign116.pdf
  4. O’Connor S, Fergusson E, Carney T et al (2015). The development and evaluation of the paediatric index of emotional distress (PI-ED). Soc Psychiatry Psychiatr Epidemiol (2016); 51:15–26. www.springermedizin.de/the-development-and-evaluation-of-the-paediatric-index-of-emotional-distress-pi-ed/6094110.html

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