An influential national panel of preventive health experts on Tuesday recommended for the first time that children and adolescents between 8 and 18 should be screened for anxiety, but said there was insufficient evidence to say that children 7 and under should be screened.
The new recommendations, issued by the U.S. Preventive Services Task Force and published in JAMA, are for the screening of children and teens who are seen in primary care settings and have no symptoms. Task force members emphasized that any child with symptoms of anxiety, regardless of age, should be connected to care.
“If a child is presenting with symptoms, or a parent is concerned about symptoms, that is not a screening issue, that is a care issue,” Martha Kubik, a task force member and a professor of nursing at George Mason University, told STAT. She emphasized that screening tools were not diagnostic tests but merely a first step before more directed evaluation.
The recommendations follow findings from the 2018-19 National Survey of Children’s Health, which found that 7.8% of children and adolescents aged 3-17 had a current anxiety disorder — numbers that many researchers believe have worsened during the Covid-19 pandemic. The call for screening is bolstered by research showing that untreated anxiety can lead to suicidal behavior and substance abuse as children age and the fact that treatments now exist that can help curb anxiety in this age group. The final recommendations are consistent with a draft document released in April of this year.
“We feel the mental health of our kids is something we should prioritize, and one way is to make time for screening,” Kubik said.
The task force also renewed a previous recommendation for universal screening in primary care for major depressive disorder in adolescents 12 to 18 years, but found that there was insufficient evidence to recommend screening for the disorder in children 11 or younger. They also said, even though suicide is the leading cause of death in older children and teens, there was insufficient evidence to recommend screening for suicide in children of any age who do not have symptoms. (As with anxiety, the task force emphasized that children or adolescents at high risk of suicide should be screened.) These recommendations are similar to ones released in 2016.
Kubik said that suicide was “an incredible and worrisome health problem for our young people” but that evidence did not yet support universal screening. “It’s a call for more research in this area,” she said of the recommendations, which could change in future years.
The task force is an independent, volunteer panel of experts in evidence-based medicine that reports to Congress and identifies gaps in research supporting preventive care services.
A review of studies the task force commissioned pertaining to anxiety in children and adolescents found more research is needed to better understand the benefits and potential harms of screening and to understand which screening tools are most accurate and work best in primary care settings. The review found that current screening tools were “reasonably accurate” in the older age group and that treatment, both cognitive-behavioral therapy and drugs such as SSRIs and serotonin-norepinephrine reuptake inhibitors were beneficial in treating anxiety.
An accompanying editorial called the new recommendations “very good news” because the majority of psychiatric disorders first present in childhood and adolescence and noted that while one in five youth aged 18 and under will experience a mental health condition, many of these conditions go unidentified and untreated.
But the editorial urged that younger children also be screened for anxiety, particularly because in this age group, anxiety may present as something else, such as abdominal pain or difficulty concentrating, leading to unnecessary tests and medical evaluations or treatments like stimulant drugs. “These children are at risk to not be identified or have their anxiety symptoms misattributed to either a medical condition or a different psychiatric disorder,” the editorial authors wrote.
The new recommendations do not go as far as those from other organizations, such as the American Academy of Pediatrics, which recommends annual screening for behavioral, social, and emotional problems — including anxiety — from birth to 21 years. While the task force based its recommendations only on medical evidence, Kubik said members were mindful of the shortage of mental health services and the reality that primary care physicians may be overburdened. One study cited by the task force showed that 76% of primary care physicians feel it is important to talk to adolescent patients about mental health but only 46% said they always did so.
“We’re all aware, and have been aware for a long time that it’s challenging to get primary care and even more challenging to get mental health care if needed,” she said. “These workforce issues need to be addressed.”
Some take issue with what they describe as the country’s “piecemeal approach” to pediatric mental health screening, which hasn’t routinely included screening for childhood anxiety despite how common it is. John Walkup, chief of child and adolescent psychiatry at Northwestern University’s Feinberg School of Medicine, and co-authors wrote in their editorial that primary care workers should not just rely on screening tests that are often simple rating scales, but consider family history of mental health issues and any symptoms to put screening test results in context.
The USPSTF recommendations also noted that children and adolescents in some demographic groups were at higher risk for anxiety, including those experiencing poverty, and Black and Indigenous youth, who are more likely to experience adverse childhood experiences and less likely to have access to mental health services. The National Survey on LGBTQ Youth Mental Health found that more than 70% of LGBTQ+, transgender, and nonbinary youth reported experiencing symptoms of anxiety.