All Children 8 and Older Should Be Screened for Anxiety, U.S. Task Force Says

The worsening state of mental health among children has prompted an influential group of experts to recommend for the first time screening all children ages 8 to 18 for anxiety, one of the most common mental health disorders of childhood.

A draft of the new guidelines, which is open to public comment, will most likely be finalized later this year. It was issued on Tuesday by the U.S. 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, created in 1984 by Congress, has no regulatory authority; however, their recommendations carry weight among clinicians.

Screening more children for anxiety is “really important,” said Stephen P. H. Whiteside, a child psychologist and director of the Pediatric Anxiety Disorders Clinic at the Mayo Clinic in Rochester, Minn., who is not on the task force. “Most kids in need of mental health care don’t get it.”

That may be especially true of those with anxiety, he added.

Kids with behavioral problems are more likely to be identified as needing help, but if children with anxiety disorders aren’t causing problems at school or at home, they could easily “slip through the cracks,” he said.

The pandemic has only continued to exacerbate the problems children have been experiencing.

The U.S. task force recommended screening for anxiety regardless of whether a clinician has been looped into any signs or symptoms.

“It’s critical to be able to intervene before a life is disrupted,” said Martha Kubik, a member of the task force who is also a professor in the School of Nursing at George Mason University in Fairfax, Va.

Childhood anxiety disorders have been linked to an increased risk for later depression, anxiety, behavior problems and substance abuse, according to a report from the Child Mind Institute, a nonprofit that provides therapy and other services to children and families with mental health and learning disorders.

The task force said it did not yet have enough evidence to recommend for or against screening children younger than 8 for anxiety. The panel of experts continue to recommend depression screenings for children 12 and older.

There are several different surveys and questionnaires that can be used to screen anxiety in primary care, Dr. Kubik said.

Some of these tools may target specific anxiety disorders, while others may screen for a variety of disorders — and the length of each screener can vary. “What our review found is that these screening tools are effective in picking up anxiety in young people before they can present with overt signs and symptoms,” she said.

Children would ideally be screened during their annual well child checkups, Dr. Kubik said, but clinicians should also remain open to opportunities to screen during other visits.

If a screener indicates that a child needs additional support, it is not a diagnosis, the experts said, but rather a starting point for a larger conversation for further follow-up that may include a referral to a mental health provider.

“Psychotherapy is the first-line treatment,” said Tami D. Benton, psychiatrist-in-chief of child and adolescent psychiatry and behavioral sciences at Children’s Hospital of Philadelphia. Medication may also be needed if the anxiety is hurting a child’s ability to function as normal or if psychotherapy alone has not been effective, she added.

Finding a mental health provider isn’t necessarily a quick or easy task, but screening is no less important, the experts said.

As more youths in need of help are identified, “it does start to put pressure on many of the decision makers and people who hold the purse strings,” 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 the light brightly on the mental health needs of children, youth and adolescents in this country, and we need to be advocating for better access to mental health care.”

Other organizations have their own processes to make recommendations that are separate from those of the U.S. task force.

Dr. Weitzman said the A.A.P. is in the process of developing more tools and resources to support pediatricians in screening for anxiety.

The task force, while stressing the need for additional research, said it had insufficient evidence to recommend automatic screening for suicide risk in children and adolescents who are asymptomatic.

The A.A.P. does, however, recommend regular screening for suicide risk in children 12 and older. Suicide is the second leading cause of death among children ages 10 to 19.

“A lot of kids will keep suicidal thoughts to themselves — won’t bring up the topic unless they’re asked — so when you screen all kids 12 and over, it does help to create a sense of a safety net, that’s it’s OK to talk about,” said Dr. Weitzman, who is also a developmental-behavioral pediatrician.

According to the Centers for Disease Control and Prevention, more than 7 percent of children ages 3 to 17 have diagnosed anxiety. But “many kids struggling with anxiety may not necessarily be diagnosed,” Dr. Benton said. A nationally representative household survey, for example, 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 were significant increases in diagnosed anxiety and depression among children as well as decreases in the emotional well-being of caregivers.

If you are concerned that your child might be struggling with anxiety, the experts recommended speaking with your child’s pediatrician or another primary care clinician, who may be able to help distinguish between typical anxiety and the type indicative of an emerging problem or disorder.

Some degree of anxiety is perfectly normal, the experts said, and anxiety can even offer benefits by helping to keep us safe and conscientious. In addition, there may be periods in our lives when anxiety might become stronger; those are also normal, and regardless of the circumstances, some children are more prone to worrying than others.

But persistent anxiety that is affecting a child’s everyday life can be indicative of an anxiety disorder. The experts said to be on the lookout for the following signs, especially if these reflect changes from previous behavior:

  • Eating too much or too little

  • Sleeping more or less than usual

  • Falling grades

  • Relationship changes

  • Irritability

  • Anger

  • Sensitivity to criticism

  • A loss of interest in activities

  • Physical symptoms, like headache or stomachaches

  • Problems separating from caregivers and resistance to going to school or sleeping alone

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