Screening for Anxiety in Children and Adolescents

Abstract

ImportanceAnxiety in children and adolescents is associated with impaired functioning, educational underachievement, and future mental health conditions.ObjectiveTo review the evidence on screening for anxiety in children and adolescents to inform the US Preventive Services Task Force.Data SourcesPubMed, Cochrane Library, PsycINFO, CINAHL, and trial registries through July 19, 2021; references, experts, and surveillance through June 1, 2022.Study SelectionEnglish-language, randomized clinical trials (RCTs) of screening; diagnostic test accuracy studies; RCTs of cognitive behavioral therapy (CBT) or US Food and Drug Administration–approved pharmacotherapy; RCTs, observational studies, and systematic reviews reporting harms.Data Extraction and SynthesisTwo reviewers assessed titles/abstracts, full-text articles, and study quality and extracted data; when at least 3 similar studies were available, meta-analyses were conducted.Main Outcomes and MeasuresTest accuracy, symptoms, response, remission, loss of diagnosis, all-cause mortality, functioning, suicide-related symptoms or events, adverse events.ResultsThirty-nine studies (N = 6065) were included. No study reported on the direct benefits or harms of screening on health outcomes. Ten studies (n = 3260) reported the sensitivity of screening instruments, ranging from 0.34 to 1.00, with specificity ranging from 0.47 to 0.99. Twenty-nine RCTs (n = 2805) reported on treatment: 22 on CBT, 6 on pharmacotherapy, and 1 on CBT, sertraline, and CBT plus sertraline. CBT was associated with gains on several pooled measures of symptom improvement (magnitude of change varied by outcome measure), response (pooled relative risk [RR], 1.89 [95% CI, 1.17 to 3.05]; n = 606; 6 studies), remission (RR, 2.68 [95% CI, 1.48 to 4.88]; n = 321; 4 studies), and loss of diagnosis (RR range, 3.02-3.09) when compared with usual care or wait-list controls. The evidence on functioning for CBT was mixed. Pharmacotherapy, when compared with placebo, was associated with gains on 2 pooled measures of symptom improvement—mean difference (Pediatric Anxiety Rating Scale mean difference, −4.0 [95% CI, −5.5 to −2.5]; n = 726; 5 studies; and Clinical Global Impression–Severity scale mean difference, −0.84 [95% CI, −1.13 to −0.55]; n = 550; 4 studies) and response (RR, 2.11 [95% CI, 1.58 to 2.98]; n = 370; 5 studies)—but was mixed on measures of functioning. Eleven RCTs (n = 1293) reported harms of anxiety treatments. Suicide-related harms were rare, and the differences were not statistically significantly different.Conclusions and RelevanceIndirect evidence suggested that some screening instruments were reasonably accurate. CBT and pharmacotherapy were associated with benefits; no statistically significant association with harms was reported.

Screening for Depression and Suicide Risk in Children and Adolescents

“… a Combined searches were conducted on anxiety, depression, and suicide risk. Results for anxiety are presented in a separate publication …”

Screening for Pediatric Anxiety Disorders

“…In this issue of JAMA , the US Preventive Services Task Force (USPSTF) presents a Recommendation Statement on screening for anxiety in children and adolescents, based on an Evidence Report and Systematic Review by Viswanathan et al that summarized the evidence for screening and treatment. In its current report, the USPSTF “recommends screening for anxiety in children and adolescents aged 8 to 18 years (B recommendation)” and “concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for anxiety in children 7 years or younger (I statement).”…”

“…The success of a screening initiative depends on the availability of a sensitive and specific screening process for detecting a disorder and safe and effective treatments for persons identified. On both counts, the Evidence Report supports both screening for anxiety disorders in children and adolescents 8 years or older and, importantly, the efficacy and the safety of cognitive behavioral therapy (CBT) and antidepressant medications (eg, selective serotonin reuptake inhibitors) . As a high-quality, up-to-date review, it is encouraging that the available evidence supports identifying and treating children with anxiety disorders.…”

“…The Evidence Report by Viswanathan et al focused on the benefit of screening and the evidence base for treatment but did not provide specific, actionable guidance for how anxiety screening should occur in primary care. There are also several outstanding questions, such as what measure is best for screening and whether screening has benefits.…”

“…Importantly, the discussion of treatment in the Evidence Report by Viswanathan et al indicates that “consistent, precise, statistically significant differences for most anxiety outcomes for CBT and pharmacotherapy led to strength-of-evidence ratings of moderate for benefit for nearly all outcomes.” However, context is important with regard to the 2 evidence-based treatments for pediatric anxiety. CBT is considered the most effective psychotherapeutic intervention but regrettably has not yet become standard practice in the community.…”