The deteriorating mental health of children has prompted an influential group of experts to recommend for the first time that all children ages 8 to 18 should be screened for anxiety, one of the most common childhood mental disorders.
A draft of the new guidelines, open to public comment, is likely to be finalized later this year. It was released Tuesday by the US Preventive Services Task Force, a panel of volunteer experts appointed by a federal government agency to make recommendations to health care providers about clinical preventive care.
The task force, which was created by Congress in 1984, has no regulatory authority; however, their recommendations weigh heavily among clinicians.
Screening more children for anxiety is “very important,” says Stephen PH Whiteside, a child psychologist and director of the pediatric anxiety disorder clinic at the Mayo Clinic in Rochester, Minnesota, who is not part of the task force. “Most kids who need mental health care don’t get it.”
That may be especially true for those with anxiety, he added.
Children with behavioral problems are more likely to be identified as needy, but if children with anxiety disorders don’t cause problems at school or at home, they can easily “slip through the cracks,” he said.
The pandemic has only exacerbated the problems children are experiencing.
Why is early detection important?
The US task force recommended screening for anxiety regardless of whether a doctor has fallen into a loop of signs or symptoms.
“It’s critical to be able to intervene before a life is disrupted,” said Martha Kubik, a task force member who is also a professor in the School of Nursing at George Mason University in Fairfax, Virginia.
Childhood anxiety disorders have been linked to an increased risk of later depression, anxiety, behavioral problems and substance abuse, according to a report from the Child Mind Institute, a nonprofit organization that provides therapy and other services to children and families with mental and learning disabilities.
The task force said it didn’t yet have enough evidence to recommend for or against screening children under 8 for anxiety. The panel of experts continues to recommend depression screening for children 12 years and older.
How would the screening proceed?
There are several studies and questionnaires that can be used to screen for anxiety in primary care, said Dr. cubik.
Some of these tools can target specific anxiety disorders, while others can screen for a variety of disorders — and the length of each screening can vary. “What our review found is that these screening tools are effective at picking up anxiety in young people before they can show overt signs and symptoms,” she said.
Children should ideally be screened during their annual checkups from their source, said Dr. Kubik, but clinicians should also be open to screening opportunities during other visits.
If a screener indicates that a child needs additional support, that’s not a diagnosis, the experts said, but rather a starting point for a larger conversation for further follow-up, including a referral to a mental health service.
“Psychotherapy is the first-line treatment,” said Tami D. Benton, chief psychiatrist of child and adolescent psychiatry and behavioral sciences at Children’s Hospital in Philadelphia. Medication may also be needed if the anxiety is impairing a child’s ability to function normally or if psychotherapy alone has not been effective, she added.
Finding a health care provider isn’t necessarily a quick or easy task, but screening is no less important, the experts said.
As more youth are identified who need help, “it’s starting to put pressure on many of the decision-makers and people in charge,” including insurers, said Dr. Carol Weitzman, the co-director of the Autism Spectrum Center at Boston Children’s Hospital and a spokeswoman for the American Academy of Pediatrics. “We need to shine a bright light on the mental health needs of children, youth and adolescents in this country, and advocate for better access to mental health care.”
Other organizations have their own processes for making recommendations separate from those of the US task force.
dr. Weitzman said the AAP is developing more tools and resources to support pediatricians in screening for anxiety.
What about the suicide risk?
The task force emphasized the need for additional research, but said it had insufficient evidence to recommend automated suicide risk screening in children and adolescents who are asymptomatic.
However, the AAP does recommend regular screening for suicide risk in children 12 years and older. Suicide is the second leading cause of death among children aged 10 to 19 years.
“A lot of kids will keep suicidal thoughts to themselves — won’t bring up the topic unless asked — so if you screen all kids 12 and older, it helps create a sense of safety net, it’s OK to talk about it,” said Dr. Weitzman, who is also a developmental behavioral pediatrician.
How common is anxiety in children?
According to the Centers for Disease Control and Prevention, more than 7 percent of children ages 3 to 17 have been diagnosed with anxiety. But “many kids who struggle with anxiety don’t necessarily need to be diagnosed,” said Dr. benton. For example, a nationally representative household survey found that nearly one in three adolescents, or about 30 percent, meet the criteria for an anxiety disorder.
And a study published in JAMA Pediatrics found that between 2016 and 2020, there was a significant increase in diagnosed anxiety and depression in children, as well as decreases in the emotional well-being of caregivers.
How do you know if your child needs help?
If you’re concerned that your child may be struggling with anxiety, the experts recommend talking with your child’s pediatrician or other primary care physician, who can help differentiate between typical anxiety and the type that indicates an emerging problem or disorder.
Some degree of anxiety is perfectly normal, the experts said, and anxiety can even provide benefits by keeping us safe and conscientious. In addition, there may be periods in our lives when fear can become stronger; these are also normal, and regardless of the circumstances, some children are more likely to worry than others.
But persistent anxiety affecting a child’s daily life could indicate an anxiety disorder. The experts said they were looking for the following signs, especially if they reflect changes from previous behavior:
Eating too much or too little
Sleeping more or less than usual
Sensitivity to criticism
A loss of interest in activities
Physical symptoms, such as headache or stomachache
Difficulty separating from caregivers and resistance to going to school or sleeping alone