The U.S. Preventive Services Task Force released a draft statement in April 2022 recommending screening for anxiety in children and adolescents ages 8 to 18. This recommendation – which remains open for public comment – is timely, given the impact of the COVID-19 pandemic on children’s mental health. The Conversation asked Elana Bernstein, a school psychologist who researches child and adolescent anxiety, to explain the task force’s new draft recommendations and what they might mean for children, parents and providers.
1. Why does the staff recommend screening for young children?
Nearly 80% of chronic mental health conditions appear in childhood, and when help is eventually sought, it is often years after the problem has appeared. In general, recommendations for screening for mental health disorders are based on research showing that young people do not usually seek help independently, and that parents and teachers are not always skilled at correctly identifying problems or knowing how to respond.
Anxiety is the most common mental health problem affecting children and teens. Epidemiological studies indicate that 7.1% of children suffer from anxiety disorders. However, studies also estimate that up to 10% to 21% of children and adolescents have an anxiety disorder and up to 30% of children experience moderate anxiety that interferes with their daily functioning at some point in their lives.
This tells us that many children experience anxiety at a level that interferes with their daily functioning, even if they have not been formally diagnosed. In addition, there is an established evidence base for treating childhood anxiety.
The opportunity to prevent lifelong potential chronic mental health conditions through a combination of early identification and evidence-based treatment certainly served the task force’s recommendation. Untreated anxiety disorders in children place additional burdens on the public health system. So from a cost-benefit perspective, the cost-effectiveness of screening anxiety and providing preventive treatment is favourable, while, as pointed out by the task force, the harms are negligible.
The task force’s recommendation to screen children under eight years of age is driven by the research literature. Anxiety disorders are most likely to first appear during the elementary school years. The typical age of onset of anxiety is among the oldest of all childhood mental health diagnoses.
Anxiety disorders can persist into adulthood, especially those that appear in the early stages and those that are left untreated. Individuals who experience anxiety in childhood are more likely to deal with it in adulthood, along with other mental health disorders such as depression and a general decline in quality of life.
2. How can caregivers identify anxiety in young children?
Fortunately, in the past three decades, great advances have been made in mental health screening tools, including anxiety. Evidence-based strategies for identifying anxiety in children and adolescents focus on collecting observations from multiple perspectives, including the child, parent, and teacher, to provide a complete picture of a child’s performance in school, home, and society.
Anxiety is a so-called intrinsic trait, which means that the symptoms may not be visible to those around the person. This makes precise identification more difficult, although it is certainly possible. Therefore, psychologists recommend that the child be involved in the examination process as often as possible based on age and development.
In general, it is easier to accurately identify anxiety when a child’s symptoms are behavioral in nature, such as refusing to go to school or avoiding social situations. While the staff recommended screening in primary care settings, the research literature also supports in-school screening for mental health problems, including anxiety.
Among young people who have already been treated for mental health issues, nearly two-thirds receive these services at school, which makes screening at school a logical practice.
3. How will the examination be carried out?
Universal screening of all children is a preventive approach to identifying young people at risk. This includes those who may need further diagnostic evaluation or those who may benefit from early intervention.
In either case, the goal is to reduce symptoms and prevent lifelong chronic mental health problems. But it is important to note that screening does not imply a diagnosis. Diagnostic evaluation is more in-depth and costs more, while examination is intended to be brief, efficient and cost-effective. Screening for anxiety in a primary care setting may include completion of short questionnaires by the child and/or parent, similar to how pediatricians frequently screen children for attention-deficit/hyperactivity disorder, or ADHD.
The staff did not recommend a single method or tool, nor a specific time period, for screening. Instead, she referred to multiple tools such as the Children’s Anxiety Affective Disorders Screen and the Children’s Symptom Checklist. These assess general emotional and behavioral health, including questions specific to anxiety. Both are available at no cost.
4. What do caregivers look for when examining anxiety?
A child’s symptoms can vary depending on the type of anxiety he or she has. 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 usually do not fit into one category.
But psychologists usually notice some common patterns when it comes to anxiety. These include negative self-talk such as “I’m going to fail my math test” or “Everyone is going to laugh at me,” and difficulties regulating emotions, such as increased outbursts of anger or sensitivity to criticism. Other typical patterns include behavioral avoidance, such as reluctance or refusal to participate in activities or interact with others.
Anxiety can also manifest as a physical symptom that lacks a root physiological cause. For example, a child may complain of stomach pain, headache, or general malaise. In fact, studies suggest that detecting anxious young adults in pediatric settings may occur simply by identifying children with medically unexplained physical symptoms.
The distinction we aim at in screening is to determine the magnitude and effect of symptoms. In other words, how much does it affect a child’s daily performance? Some anxiety is normal and, in fact, necessary and beneficial.
5. What are the recommendations to support children with anxiety?
The key to an effective screening process is to be linked to evidence-based care. One strategy that research clearly supports is for schools to establish a continuum of care that includes comprehensive screening, school-wide prevention programs and evidence-based treatment options.
The good news is that we have decades of high-quality research showing how to effectively intervene to reduce symptoms and help anxious young people cope and function better. These include medical and non-medical interventions such as cognitive behavioral therapy, which studies show are safe and effective.
The USPSTF recommends screening for anxiety and depression in children
Introduction of the conversation
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