The US Preventive Services Task Force, an independent panel of experts in primary care and prevention, issued a final recommendation on October 11, 2022, published in JAMA, stating that all children and adolescents between the ages of 8 and 18 should be screened for anxiety, whether or not they have symptoms. The recommendation follows a systematic review that evaluated the potential harms and benefits of screening.
The Conversation asked Elana Bernstein, a school psychologist who researches anxiety in children and adolescents, to explain the task force’s recommendations and what they might mean for children, parents and providers.
1. Why is the task force recommending that young children be screened?
Nearly 80% of chronic mental health conditions begin in childhood, and when help is sought, it is often years after the onset of the problem. In general, recommendations for screening for mental health disorders are based on research demonstrating that young people typically do not independently seek help and that parents and teachers are not always qualified to correctly identify problems or know how to respond.
Anxiety is the most common mental health problem affecting children and teenagers. Epidemiological studies indicate that 7.1% of children are diagnosed with anxiety disorders. However, studies also estimate that more than 10% to 21% of children and teens struggle with an anxiety disorder, and up to 30% of children experience moderate anxiety that interferes with their daily functioning at some point in their life.
This tells us that many children experience anxiety at a level that interferes with their daily functioning, even if they are never formally diagnosed. In addition, there is a well-established evidence base for the treatment of childhood anxiety.
The task force evaluated the best available research and concluded that, although there are gaps in the evidence base, the benefits of screening are clear. Untreated anxiety disorders in children result in additional burdens for the public health system. Therefore, from a cost-benefit perspective, the cost-effectiveness of screening for anxiety and providing preventive treatment is favorable, while, as the task force pointed out, the harms are negligible.
The task force’s recommendation to screen children as young as 8 years old is driven by the research literature. Anxiety disorders are most likely to first appear during the elementary school years. And typical age of onset of anxiety is among the earliest childhood mental health diagnoses. The panel also pointed to the lack of accurate screening tools available to detect anxiety among younger children; as a result, it concluded that there is insufficient evidence to recommend screening children aged 7 years and younger.
Anxiety disorders can persist into adulthood, particularly those with early onset and those left untreated. Individuals who experience anxiety in childhood are also more likely to deal with it in adulthood, along with other mental health disorders such as depression and an overall diminished quality of life. The task force considered these long-term impacts when making its recommendations, noting that screening children as young as 8 years old can ease an avoidable burden on families.
2. How can caregivers identify anxiety in young children?
In general, it is easier to accurately identify anxiety when the child’s symptoms are behavioral in nature, such as refusing to go to school or avoiding social situations. While the task force recommended that screening take place in primary care settings – such as a pediatrician’s office – the research literature also supports school-based screening for mental health issues, including anxiety.
Fortunately, over the last three decades, considerable advances have been made in mental health screening tools, including for anxiety. Evidence-based strategies for identifying anxiety in children and adolescents are centered on collecting observations from multiple perspectives, including the child, parents, and teachers, to provide a complete picture of the child’s functioning at school, at home, and in the community.
Anxiety is what we call an internalizing trait, which means that the symptoms may not be observable to people around the person. This makes accurate identification more challenging, although certainly possible. Therefore, psychologists recommend including the child in the screening process as much as possible based on age and development.
Among youth who are actually treated for mental health issues, nearly two-thirds receive these services at school, making school screening a logical practice.
3. How would the triage be carried out?
Universal screening for all children, including those without symptoms or diagnoses, is a preventive approach to identifying young people who are at risk. This includes those who may need further diagnostic evaluation or those who would benefit from early intervention.
In both cases, the goal is to reduce symptoms and prevent lifelong chronic mental health problems. But it’s important to note that a screening does not equate to a diagnosis, something the task force highlighted in its recommendation statement.
Diagnostic evaluation is more in-depth and costs more, while triage is intended to be brief, efficient, and cost-effective. Screening for anxiety in a primary care setting may involve the completion of short questionnaires by the child and/or parents, similar to how pediatricians often screen children for attention-deficit/hyperactivity disorder or ADHD.
The task force did not recommend a single method or tool, nor a specific time frame, for screening. Instead, caregivers were advised to consider the evidence in the task force recommendation and apply it to the specific child or situation. The task force pointed to several available screening tools, such as the Screen for Child Anxiety Related Emotional Disorders and the Patient Health Questionnaire Screeners for Generalized Anxiety Disorder, which accurately identify anxiety. These assess overall emotional and behavioral health, including questions specific to anxiety. Both are available at no cost.
4. What do healthcare professionals look for when screening for anxiety?
A child’s symptoms can vary depending on the type of anxiety they have. For example, social anxiety disorder involves fear and anxiety in social situations, while specific phobias involve fear of a specific stimulus, such as vomiting or thunderstorms. However, many anxiety disorders share symptoms, and children often don’t fit neatly into one category.
But psychologists typically notice some common patterns when it comes to anxiety. This includes negative self-talk such as “I’m going to fail my math test” or “Everyone is going to laugh at me” and emotion regulation difficulties such as increased tantrums, rage or sensitivity to criticism. Other typical patterns include behavioral avoidance, such as reluctance or refusal to participate in activities or interact with other people.
Anxiety can also appear as physical symptoms that lack a physiological root cause. For example, a child may complain of stomachaches or headaches or general malaise. Indeed, studies suggest that identifying young people with anxiety in pediatric settings may simply be through identifying children with unexplained physical symptoms.
The distinction we seek in triage is to identify the magnitude of symptoms and their impact. In other words, how much do the symptoms interfere with the child’s daily functioning? Some anxiety is normal and, in fact, necessary and useful.
5. What are the recommendations for supporting children with anxiety?
The key to an effective screening process is that it is connected to evidence-based care.
The good news is that we now have decades of high-quality research demonstrating how to effectively intervene to reduce symptoms and help anxious young people cope and function better. This includes medications or therapeutic approaches such as cognitive behavioral therapy, which studies have shown to be safe and effective.
This is an updated version of an article originally published on May 13, 2022.
Elana Bernstein, assistant professor of school psychology, University of Dayton
This article is republished from The Conversation under a Creative Commons license. Read the original article.