Paediatric medicine - Identifying emotional distress in children

Children with chronic conditions are at higher risk of anxiety. By Dr Suzy O'Connor, Dr Emma House and Dr Terri Carney

Abdominal pain can be a sign of emotional distress or anxiety (Photograph: SPL)
Abdominal pain can be a sign of emotional distress or anxiety (Photograph: SPL)

Research suggests that 20 per cent of children have a mental health problem in any given year, and about 10 per cent at any one time.1

One of the most challenging issues GPs face is determining the correct treatment path for these patients. Getting this right is key to speeding up referrals and improving patient recovery times.

Identifying mental health issues
Emotional disorders are common in more than a quarter of children who attend general paediatric clinics.2

Although symptoms such as abdominal pain, dizziness and lethargy can be linked to many physical ailments, they can also be signs that a child is experiencing anxiety or emotional distress.

In some cases it may be appropriate to channel referrals for young patients presenting with these symptoms into mental rather than physical health pathways.

Signs and symptoms to look out for include crying and worried thoughts; developmental regression, such as in toilet training; reduced pleasure or participation in activities; sleep or appetite disturbance; concentration difficulties; irritability and abdominal pain or headaches with no organic cause.

All these factors should be considered within a developmental framework; worries about separation from caregivers are common in small children but unusual and concerning in older children.

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

Assessing children and young people
Young patients with chronic medical conditions, such as diabetes and cystic fibrosis, are at a higher risk of developing mental health problems. In fact, a report on managing diabetes published by SIGN3 suggests that children diagnosed with the condition should be routinely screened for emotional distress and that the screening tool used should exclude somatic symptoms.

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

However, a new paediatric screening tool has now been launched. The tool is based on HADS but uses language and concepts that are appropriate for use with young patients.

The paediatric index of emotional distress (PI-ED) is a single, robust measure with predictive validity that will make it easier for practitioners to identify clinically significant symptoms of emotional distress in eight to 16-year-olds. It is designed to differentiate between symptoms of emotional distress and those of physical illness.

While the PI-ED is not the only measure of emotional distress in children, it is the only measure that excludes somatic symptoms. As such, it can be used with children 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 tested extensively in trials including more than 1,100 children by a team of psychologists from NHS Ayrshire & Arran and the universities of Stirling and Nottingham.

Boosting the effectiveness of care
One of the key advantages of using a screening tool, such as the PI-ED, within a practice setting is that it is simple for patients to complete during a consultation. The measure can be administered and scored by a GP in minutes and it provides gender-specific cut-off scores to indicate where support from a paediatric mental health specialist may be required.

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

If a young person wishes to complete the form in the absence of a parent or carer, this should be facilitated. However, it is good practice to explain the limits of confidentiality, in terms of risk management, to children and young patients before they complete the form.

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.

Most CAMHS teams offer a triage service and can give advice by phone. CAMHS teams are also good at signposting referrers to alternative sources of support for children, young patients and their families.

Case Study

Jack was diagnosed with cystic fibrosis at eight months and 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 mental health specialist.

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

  • Dr O'Connor, Dr House and Dr Carney are registered clinical psychologists and three of the authors of the PI-ED. For further details visit

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.

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