Kids age 8 and up may soon be asked to answer questions about their anxiety symptoms when they visit their primary care doctor. In October 2022, the U.S. Preventive Services Task Force (USPTF) recommended that primary care doctors screen all children between the ages of 8 and 18 for anxiety as a routine part of their annual wellness visit. An evidence report of 39 supporting studies was compiled and published in JAMA. The report says that evidence suggests that some screening instruments were reasonably accurate, leading to "low-to-moderate strength of evidence" and that Cognitive Behavioral Therapy (CBT) and pharmacotherapy were associated with benefits for those diagnosed with anxiety. The recommendation is to routinely screen children who don't have any apparent symptoms; children with symptoms should not wait to see a doctor for mental health treatment.
Additionally:
- The task force reaffirmed its 2018 recommendation for routine screening of all 12 to 18 year-olds for depression.
- The task force recommended routine screening for anxiety at primary care visits for all adults under age 65, but the specifics of the recommendation are still being finalized.
Two items that were considered but NOT recommended:
- The task force did NOT recommend that children under 8 receive routine screening for anxiety or depression.
- The task for did NOT recommend routine screening for suicide risks.
Reaction from some U.S. pediatricians: An editorial by doctors from the Ann and Robert H. Lurie Children’s Hospital, Weill Cornell Medicine and the University of Cincinnati was published alongside the Task Force's recommendations in JAMA. It said that an evidence report provided with the recommendations doesn’t give specific or actionable guidance for how screening should happen in primary care settings, and that there are outstanding questions around screening. However, “While future research efforts are needed to address the gaps in the evidence base, the available evidence appears to support moving forward with implementing screening and treatment for anxiety disorders in pediatric primary care settings,” they wrote.
Canada's Approach to Anxiety Screening in Children
In Canada, pediatricians will take a different approach. They do not recommend routine screening of children for anxiety. Instead, a tip sheet will help parents and caregivers recognize signs worth mentioning to a doctor.
The lead author of two recent papers says this is the first time the Canadian Paediatric Society (CPS) has formalized its position, in part to address a “great demand for comprehensive guidance.” Dr. Benjamin Klein, on commenting on the new recommendations in the U.S., says there's a "big downside" to general screening if it finds false positives and further strains the health-care system's already limited capacity to assess and treat more severe cases. "Screening is something that is kind of pretty fiercely debated," he says."The usual problems with screening is identifying a lot of false positives that now you're taking through more assessment and possible treatment that may be harmful."
It is normal to have fears during childhood and adolescence, the guidelines note. "However, symptoms of anxiety disorders go well beyond typical behaviour and can include persistent, disproportionate, or distorted responses that hinder everyday life. "
https://www.timescolonist.com/the-mix/pediatric-group-releases-guidelines-for-detecting-anxiety-in-kids-and-youth-5980931
Anxiety Screening Instruments
A questionnaire or survey is filled out and scored to determine if the patient needs a referral for further assessment and possible treatment. The report did not make any recommendations on which screening instrument is preferred, but two examples were mentioned in the evidence report:
1. Screen for Child Anxiety Related Emotional Disorders (SCARED) This is a child and parent self-report instrument used to screen for childhood anxiety disorders including general anxiety disorder, separation anxiety disorder, panic disorder, and social phobia. In addition, it assesses symptoms related to school phobias" https://www.pediatricbipolar.pitt.edu/ (for age 8 – 18; for age 8 to 11, a survey can be administered to the parent or the child or both. For age 11 and up, usually only the patient completes the survey.)
2. Patient Health Questionnaire Screeners (PHQS) Pfizer (also maker of antidepressants and anxiety drugs) has developed a variety of mental illness screening tools, including one that screens for generalized anxiety disorder (GAD-7) and a depression screener for teens (PHQ-9) which is already being used at many pediatricians' offices at annual wellness visits. https://www.phqscreeners.com/
Here is a sample screening instrument, called the "GAD-7" for
seven questions for Generalized Anxiety Disorder:
Scoring is as follows for the questionnaire above ("GAD-7"): Assign a score of 0, 1, 2, and 3, to the response categories of ―not at all,‖ ―several days,‖ ―more than half the days,‖ and ―nearly every day,‖ respectively. GAD-7 total score for the seven items ranges from 0 to 21. Scores of 5, 10, and 15 represent cutpoints for mild, moderate, and severe anxiety, respectively.
Anxiety Treatments for Children
Cognitive Behavioral Therapy (CBT)
The USTF does not recommend any particular therapy for treating anxiety in children, but the report cites many examples among its 39 cited studies that provide evidence of effectiveness of Cognitive Behavioral Therapy (CBT) in treating anxiety in adolescents. For example,
The Community Preventive Services Task Force recommends targeted school-based cognitive behavioral therapy programs to reduce depression and anxiety symptoms (https://www.thecommunityguide.org/findings/mental-health-targeted-school-based-cognitive-behavioral-therapy-programs-reduce-depression-anxiety-symptoms).
The Community Preventive Services Task Force recommends individual cognitive behavioral therapy for symptomatic youth who have been exposed to traumatic events, based on strong evidence of effectiveness in reducing psychological harm (https://www.thecommunityguide.org/findings/violence-psychological-harm-traumatic-events-among-children-and-adolescents-cognitive-individual).
Drug Treatments
The USTF also cites some examples among its 39 cited
studies that provide evidence of effectiveness of
pharmacotherapy (drug treatments) for anxiety in children.
However, drug treatment options are more limited in children
than in adults.
Some antidepressants are also approved to treat GAD, but only for adults. Lexapro, for example, is approved only to treat depression in adolescents age 12 and up. Cymbalta is one of the few treatments that has been specifically approved to treat generalized anxiety disorders in children age 7 and older. However, parents may be wary of this treatment due to the boxed warning: "Antidepressants increased the risk of suicidal thoughts and behavior in children, adolescents, and young adults in short-term studies."
Other Anxiety Treatments Research
- In a recent study by a researcher at Georgetown University's Anxiety Disorders Research Program, meditation worked just as well as Lexapro (ESCITALOPRAM OXALATE). The study was published in JAMA Psychiatry. https://ondemand.kansaspublicradio.org/npr-news/meditation-works-well-popular-drug-reduce-anxiety-study-finds
- Newsweek Magazine's Dan Hurley interviewed experts for an extensive article on anxiety treatments. Here are some of the highlights from his report:
- National Institute of Mental Health's Dr. Daniel Pine says that drugs like Prozac, Zoloft, or Cymbalta are now considered first-line drug treatments for anxiety disorders.
Ironically, many antidepressants have been shown to work better
for anxiety than they do for depression, and many work better at
reducing anxiety than the benzodiazepines like Valium or Xanax
that are specifically approved to treat anxiety.
- Studies have found that two-thirds of adolescents treated with Cognitive Behavioral Therapy (CBT) will be free of an anxiety disorder after three to four months.
- One of the most surprising new findings about the treatment of anxiety is that marijuana doesn't appear to help and might make things worse. "There are no good studies of cannabis as a treatment for anxiety," says Dr. Jodi M. Gilman, an associate professor at Harvard Medical School and director of neuroscience at Massachusetts General Hospital's Center for Addiction Medicine.
Source:
https://www.newsweek.com/2022/10/21/forget-weed-wine-xanax-science-has-better-ways-treat-anxiety-1750921.html
Sources and
Additional Reading:
USPTF report in JAMA on screening all adolescents
for anxiety:
https://jamanetwork.com/journals/jama/fullarticle/2797219
For the first time, an influential panel recommends that U.S.
doctors should regularly screen all adults under 65 for anxiety.
https://apnews.com/article/science-health-covid-mental-b6bdfec54c16ff04ca18bba18000bbf9
https://uspreventiveservicestaskforce.org/uspstf/draft-update-summary/anxiety-adults-screening
The USPTF identified Anxiety disorder as a topic of importance: "It is a common mental health condition in the US, comprises a group of related conditions characterized by excessive fear or worry that present as emotional and physical symptoms. The 2018-2019 National Survey of Children’s Health found that 7.8% of children and adolescents aged 3 to 17 years had a current anxiety disorder. Anxiety disorders in childhood and adolescence are associated with an increased likelihood of a future anxiety disorder or depression."
UPSPTF Objective: "to evaluate the benefits and harms of
screening for anxiety disorders in children and adolescents."