Issued by the US Preventive Services Task Force a draft statement in April 2022 the recommendation of an anxiety screening for children and adolescents between the ages of 8 and 18 years. This recommendation – which is open to 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 studies anxiety in children and adolescents, to explain the task force’s new draft recommendations and what they might mean for children, parents and providers.
Why does the task force recommend screening young children?
Nearly 80 percent of chronic mental illness occurs in childhood, and when help is sought, it often takes years for the problem to emerge. In general, recommendations for screening for mental health disorders are based on research showing that adolescents do not typically seek help on their own and that parents and teachers are not always able to properly identify problems or know how to respond.
Anxiety is the most common mental health problem in children and adolescents. Epidemiological studies show that 7.1 percent of children are diagnosed with anxiety disorders. However, studies also estimate that more than 10 to 21 percent of children and teens struggle with an anxiety disorder, and up to 30 percent of children experience moderate anxiety that will affect them at some point in their lives.
This tells us that many children experience anxiety at levels that interfere with their daily functioning, even if they are never formally diagnosed. In addition, there is an established evidence base for treating anxiety in children.
The ability to prevent potentially chronic lifelong mental illness through a combination of early detection and evidence-based treatment certainly justified the task force’s recommendation. Untreated anxiety disorders in children place additional burdens on the public health system. From a cost-benefit perspective, the cost-effectiveness of screening for anxiety and providing preventative treatment is favorable, while the task force emphasized the harms are negligible.
The task force’s recommendation to screen children as young as 8 years of age is based on the research literature. Anxiety disorders are most likely to appear in elementary school. And the typical age at which anxiety occurs is among the earliest of any childhood mental health diagnosis.
Anxiety disorders can persist into adulthood, especially those that start early and go untreated. Individuals who experience anxiety in childhood are more likely to continue to struggle with it in adulthood, along with other mental health disorders such as depression and an overall reduced quality of life.
How can caregivers identify anxiety in young children?
Fortunately, there have been significant advances in mental health screening tools, including for anxiety, over the last three decades. The evidence-based strategies for identifying anxiety in children and adolescents focus on collecting observations from multiple perspectives, including the child, parents, and teachers, to provide a complete picture of how the child is functioning at school, at home, and in the community.
Anxiety is what is known as an internalizing trait, meaning the symptoms may not be observable to those around the person. This makes accurate identification more difficult, although certainly possible. Therefore, psychologists recommend involving the child in the screening process as much as possible, depending on their age and development.
In general, it is easier to accurately identify anxiety when the child’s symptoms are behavioral, such as: B. refusing to go to school or avoiding social situations. While the task force recommended screening in primary care, the research literature also supports school-based screening for mental health problems, including anxiety.
Among adolescents who are actually being treated for mental health problems, nearly two-thirds receive these services at school, making school-based screening a logical practice.
How would the screening be done?
Universal screening for all children is a preventive approach to identify at-risk youth. This includes those who may need further diagnostic work-up or would benefit from early intervention.
In both cases, the goal is to reduce symptoms and prevent lifelong chronic mental health problems. However, it is important to note that screening is not the same as diagnosis. Diagnostic assessment is more thorough and costs more, while screening aims to be brief, efficient, and inexpensive. Screening for anxiety in primary care may involve 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, instrument, or time interval for screening. Instead, it referenced several tools such as The Screen for Child Anxiety Related Emotional Disorders and the Pediatric Symptom Checklist. These assess overall emotional and behavioral health, including anxiety-specific issues. Both are available for free.
What do healthcare providers look for when screening for anxiety?
A child’s symptoms can vary depending on the type of anxiety. 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 common symptoms, and children don’t usually fit neatly into one category.
But psychologists typically observe some common patterns when it comes to anxiety. These include negative self-talk, such as “I’m not going to pass my math test” or “everybody’s going to laugh at me,” and difficulties with emotion regulation, such as increased temper tantrums, anger, or sensitivity to criticism. Other typical patterns include behavior avoidance, such as reluctance or refusal to participate in activities or interact with others.
Anxiety can also present itself as a physical symptom that has no physiological cause. For example, a child may complain of stomach pains, headaches, or general malaise. In fact, studies suggest that identifying adolescents with anxiety in pediatric settings can be done simply by identifying children with medically unexplained physical symptoms.
The distinction we strive for in screening is to identify the extent of the symptoms and their impact. In other words, how much do they interfere with the child’s daily functioning? Some anxiety is normal and indeed necessary and helpful.
What are the recommendations for supporting children with anxiety?
The key to an effective screening process is that it is coupled with evidence-based care. One strategy that is clearly supported by research is for schools to establish a continuum of care that includes universal screening, school-wide prevention programs, and evidence-based treatment options.
The good news is that we have decades of quality research showing how effective intervention can be to reduce symptoms and help anxious adolescents cope and function better. This includes both medical and non-medical interventions such as cognitive behavioral therapy, which studies have shown to be safe and effective.
Elana Bernstein is an Assistant Professor of School Psychology at the University of Dayton
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