Draft Recommendation Statement
Screening for Anxiety in Children and Adolescents
April 12, 2022
Recommendations made by the USPSTF are independent of the U.S. government. They should not be construed as an official position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.
|Children and adolescents ages 8 to 18 years||The USPSTF recommends screening for anxiety in children and adolescents ages 8 to 18 years.||B|
|Children age 7 years or younger||The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for anxiety in children age 7 years or younger.||I|
Recommendations made by the USPSTF are independent of the U.S. government. They should not be construed as an official position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.
Anxiety disorder, a common mental health condition in the United States, is comprised of a group of related conditions characterized by excessive fear or worry that present as emotional and physical symptoms.1,2 The 2018–2019 National Survey of Children’s Health found that 7.8% of children and adolescents ages 3 to 17 years had a current anxiety disorder.3 Anxiety disorders in childhood and adolescence are associated with an increased likelihood of a future anxiety disorder or depression.1
The U.S. Preventive Services Task Force (USPSTF) concludes with moderate certainty that screening for anxiety in children and adolescents ages 8 to 18 years has a moderate net benefit.
The USPSTF concludes that the evidence is insufficient on screening for anxiety in children age 7 years or younger. Evidence on the accuracy of screening tools and the effects of screening and treatment in this younger age group is lacking, and the balance of benefits and harms cannot be determined.
Go to the Table for more information on the USPSTF recommendation rationale and assessment. For more details on the methods the USPSTF uses to determine the net benefit, see the USPSTF Procedure Manual.4
Patient Population Under Consideration
This recommendation applies to children and adolescents age 18 years or younger who have no signs or symptoms of anxiety.
Anxiety disorders are characterized by greater duration or intensity of impairment of a stress response. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, recognizes seven different types of anxiety disorders in children and adolescents: generalized anxiety disorder GAD, social anxiety disorder, panic disorder, agoraphobia, specific phobias, separation anxiety disorder, and selective mutism.2
Assessment of Risk
Risk factors for anxiety disorders include genetic, personality, and environmental factors, such as attachment difficulties, interparental conflict, parental overprotection, early parental separation, and child maltreatment. Demographic factors such as poverty and low socioeconomic status are also associated with higher rates of anxiety disorders. Females are also at higher risk for anxiety disorders.1,5-12 The National Survey on LGBTQ Youth Mental Health reported that 72% of lesbian, gay, bisexual, transgender, and queer youth and 77% of transgender and nonbinary youth described GAD symptoms.13 According to the 2016 National Survey of Children’s Health, anxiety conditions were most common in older children and adolescents (ages 12 to 17 years) compared with younger children (age 11 years or younger) and in non-Hispanic White children compared with children of other racial or ethnic backgrounds.13
The prevalence of anxiety in Black youth may be evolving. Previous studies suggested that Black youth may have had lower rates of mental health disorders compared with White youth. However, recent cohorts of Black children or adolescents have reported a higher prevalence of anxiety disorders than in the past.1,14,15 Reasons for this increase may be because of multiple factors such as socioeconomic status, family structure, neighborhood effects, and childhood adversity. Adverse childhood experiences influence the likelihood of suffering from mental health conditions such as anxiety. Adverse childhood experiences may result from a complex interaction of familial, peer, or societal factors, including racial discrimination. These adverse childhood experiences may be blatant or subtle (e.g., microaggressions) but are potentially traumatic events that, in the context of historic trauma, structural racism, and biopsychological vulnerability, can worsen mental health outcomes.1,16 Combined with lower engagement with mental health services, adverse childhood experiences can result in high levels of unmet mental health needs in Black youth.1,17-21 Similar patterns of historic trauma, adverse childhood experiences, and substance abuse may also explain higher rates of mental health disorders in American Indian/Alaska Native youth.1
Anxiety screening instruments that have been assessed by the USPSTF are heterogenous. Some screening instruments are designed to assess for a specific anxiety disorder (e.g., social anxiety disorder), while others are designed to assess several anxiety disorders. Broader screening instruments used to identify children with several different anxiety disorders were the Screen for Child Anxiety Related Disorders (SCARED) (global anxiety and any anxiety disorder) and the Patient Health Questionnaire-Adolescent (GAD and panic disorder).
Many instruments that are used for screening for anxiety were initially developed for epidemiologic studies for surveillance or to evaluate response to treatment. Not all of the screening instruments are feasible for use in primary care settings because of length.1 Currently, only two screening instruments are widely used in clinical practice for detecting anxiety: SCARED and Social Phobia Inventory. Anxiety screening tools alone are not sufficient to diagnose anxiety. If the screening test is positive for anxiety, a confirmatory diagnostic assessment and followup is required.
The USPSTF found no evidence on appropriate or recommended screening intervals, and the optimal interval is unknown. Repeated screening may be most productive in adolescents with risk factors for anxiety. Opportunistic screening may be appropriate for adolescents, who may have infrequent health care visits.
Treatment or Interventions
Treatment for anxiety disorders can include psychotherapy, pharmacotherapy, a combination of both, or collaborative care.14 Several psychotherapy approaches have been used to treat anxiety; however, cognitive behavioral therapy is the most commonly used approach.14-17 Duloxetine, a serotonin–norepinephrine reuptake inhibitor, is the only medication approved by the U.S. Food and Drug Administration for treatment of GAD in children age 7 years or older. Other medications have also been reported as being prescribed off-label for treatment of anxiety in youth.1
Additional Tools and Resources
The Community Preventive Services Task force recommends targeted school-based cognitive behavioral therapy programs to reduce depression and anxiety symptoms (available at https://www.thecommunityguide.org/findings/mental-health-targeted-school-based-cognitive-behavioral-therapy-programs-reduce-depression-anxiety-symptoms).
The Centers for Disease Control and Prevention also has additional information on anxiety in childhood (available at https://www.cdc.gov/childrensmentalhealth/depression.html).
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 (available at https://www.thecommunityguide.org/findings/violence-psychological-harm-traumatic-events-among-children-and-adolescents-cognitive-individual).
The Community Preventive Services Task Force recommends group cognitive behavioral therapy for symptomatic youth who have been exposed to traumatic events based on strong evidence of effectiveness in reducing psychological harm (available at https://www.thecommunityguide.org/findings/violence-psychological-harm-traumatic-events-among-children-and-adolescents-cognitive-group).
Various questionnaires have been evaluated as screening tools for anxiety in children and adolescents. Some may target specific anxiety disorders, while others may screen for various disorders. The length of questionnaires can also vary. Clinicians are encouraged to consider which anxiety disorders may be most common in their practice and which screening tools may be most feasible to use in their practice settings. For patients to benefit from screening, positive screening results should be confirmed by diagnostic assessment and patients should be linked with appropriate care.
Suggestions for Practice Regarding the I Statement
Potential Preventable Burden
Developing an anxiety disorder during childhood or adolescence increases the likelihood of a future anxiety disorder (the same disorder or another anxiety disorder) or secondary depression.18,19-21 These mental health conditions have long-term effects that may include chronic mental and physical or somatic health conditions, psychosocial functional impairment, increased risk for substance abuse, and premature mortality.22-25 Anxiety problems are more common in older (ages 12 to 17 years) compared with younger children (ages 3 to 5 years and ages 6 to 11 years) Separation anxiety, selective mutism, and GAD tend to appear earlier in childhood (preschool and early school years), whereas social anxiety and specific phobias generally appear in later school years.1 Limited evidence was available on accuracy of screening questionnaires and effectiveness of anxiety treatments in younger children.
Potential harms of screening questionnaires include false-positive screening results that lead to unnecessary referrals (and associated time and economic burden), treatment, labeling, anxiety, and stigma. Pharmacologic interventions may result in adverse events, while psychological interventions are likely to have minimal harms1. Evidence on harms of screening and treatment in younger age groups is limited.
Evidence is limited on the implementation of routine mental health screening in the United States. A survey of primary care physicians found that 76% believe in the importance of talking to adolescent patients about their mental health; however, only 46% said that they always asked their patients about their mental health.26 Information on screening for anxiety in younger children is lacking.
Other Related USPSTF Recommendations
Scope of Review
The USPSTF commissioned a systematic review1 to evaluate the benefits and harms of screening for anxiety disorders in asymptomatic children and adolescents. The USPSTF has not previously made a recommendation on this topic. Conditions that are no longer included as part of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, anxiety disorders (such as obsessive-compulsive disorder, acute stress disorder, and posttraumatic stress disorder) were not a focus of this review.
Accuracy of Screening Tests
Ten fair-quality studies (n=3,260) evaluated accuracy of screening instruments. Most studies included primarily adolescents (ages 12 to 18 years; mean age, 14.8 years). Four studies also included children as young as age 7 years, but the mean age in those studies was 10.5 years, reflecting that the majority of participants were older children or adolescents. There were no studies in younger children and there is limited evidence available on screening accuracy for the anxiety conditions that are more common in younger children. One study of children and adolescents with social anxiety disorder provided data separately for children ages 8 to 12 years and adolescents ages 13 to 17 years, with similar results in both age groups.1
The studies used 12 screening instruments to screen for six anxiety conditions (global anxiety, GAD, panic disorder, separation anxiety, social anxiety disorder, and any anxiety disorder). Some screening instruments with subscales screened for more than one anxiety disorder. Only one or two studies used each screening instrument for a given disorder. Although a variety of different screeners were assessed, only two are widely used in practice for detecting anxiety: SCARED and Social Phobia Inventory. The reference standard was a structured clinical interview for anxiety diagnosis.1
Screening accuracy varied by condition screened for and specific screening test and threshold used. For example, sensitivity for detection of GAD ranged from 0.50 to 0.88 and specificity ranged from 0.63 to 0.98 (based on three studies); for social anxiety disorder, the ranges were narrower, with a sensitivity of 0.67 to 0.93 and specificity of 0.69 to 0.94. Across all of the screening instruments and subscales and thresholds for a positive test evaluated, sensitivity ranged between 0.34 and 1.00; specificity ranged between 0.47 and 0.98. Confidence intervals were wide and imprecise. The number of false-positive results also varied. For example, false-positive results per 1,000 persons screened ranged from 17 to 361 for GAD and from 104 to 254 for social anxiety disorder.1 No additional analyses were available on populations by age, sex, or race or ethnicity.1
Benefits of Early Detection and Treatment
The USPSTF found no studies that directly evaluated the benefits of screening for anxiety disorders. The evidence on screening for anxiety in children and adolescents relies on linking indirect evidence on the accuracy of screening and the benefits of treatment. There were 29 good- or fair-quality randomized, controlled trials (RCTs) on anxiety treatment (n=2,970): 22 trials assessed cognitive behavioral therapy, six trials assessed pharmacotherapy (sertraline and fluoxetine were most commonly studied but other medications studied included fluvoxamine, escitalopram, and duloxetine), and one trial evaluated both cognitive behavioral therapy and pharmacotherapy and combinations of cognitive behavioral therapy and pharmacotherapy. Three studies included young children with ages ranging from 3 to 7 years, four studies included adolescents with ages ranging from 13 to 20 years, and 22 studies focused on older children (ages 5 to 14 years [12 studies]) or children and adolescents (ages 7 to 18 years [10 studies]).1 Most trials enrolled children and adolescents with any anxiety disorder, but a small number of trials focused on a specific anxiety diagnosis. The most common primary diagnoses in these trials were social anxiety disorder and GAD. Anxiety trials recruited using referrals from specialist mental health settings (10 trials) or from the community and schools (28 trials) using a wide range of recruitment methods. The USPSTF concluded that the community settings in which most participants were recruited from were similar to patients followed in primary care settings and determined that the treatment benefits would be applicable to screen-detected asymptomatic patients.1
Cognitive behavioral therapy was associated with improvement in anxiety outcomes across several pooled measures: treatment response (pooled relative risk [RR], 1.89 [95% CI, 1.17 to 3.05]; N=606; 6 trials; I2=64%), disease remission (RR, 2.68 [95% CI, 1.48 to 4.88]; N=321; 4 trials; I2=48%), and loss of diagnosis (RR range, 3.02 to 3.09) compared with usual care or wait-list. The evidence on improved functioning with cognitive behavioral therapy in participants with any anxiety was inconsistent.
The evidence on pharmacotherapy compared with placebo was associated with an increased improvement in symptoms and response on the Clinical Global Impressions-Improvement scale (scores of 1 or 2; RR, 2.11 [95% CI, 1.58 to 2.98]; N=370; 5 trials; I2=18%) but was inconsistent on measures of functioning.1
Harms of Screening and Treatment
The USPSTF found no studies that directly evaluated the evidence on the harms of screening for anxiety disorders. The evidence on harms of screening for anxiety in children and adolescents relies on linking indirect evidence on the harms of inaccurate screening test results and the harms of treatment.
Eleven RCTs (n=1,293) on treatment of anxiety in children and adolescents addressed harms. The evidence from cognitive behavioral therapy trials demonstrated inconsistent results on suicide-related events. These trials also showed lower rates of withdrawal due to adverse events and serious adverse events in the cognitive behavioral therapy arms. One study evaluated homicidal ideation but showed no pattern with cognitive behavioral therapy.
Pharmacotherapy studies reported some harms such as more suicide-related events, psychiatric adverse events, and withdrawals due to adverse events; however, these events were rare and not statistically significant. No pattern for homicidal ideation was seen in a single study of pharmacotherapy.1
There are several critical evidence gaps. Studies are needed that provide more information on the following.
- More RCTs are needed on the direct benefits and harms of screening for anxiety among children and adolescents in primary care settings (or similar settings) compared with no screening or usual care.
- Multiple types of anxiety disorders exist, so future research could clarify trade-offs between screening instruments designed to identify any anxiety disorder and instruments designed for specific anxiety disorders.
- More research is needed on accuracy of screening tools and anxiety treatment in younger children across all types of therapies. In addition, evidence is lacking in populations defined by sex, race and ethnicity, sexual orientation, and gender identity.
The American Academy of Child and Adolescent Psychiatry acknowledges the lack of empirically-based guidelines on screening but offers resources for screening.31 The American Academy of Pediatrics and Bright Futures recommends annual screening for emotional and behavioral problems in adolescent patients age 12 years or older.32 The American College of Obstetricians and Gynecologists recommends that all adolescents should be screened for any mental health disorder in a confidential setting during preventive care visits.33
- Viswanathan M, Wallace I, Middleton JC, et al. Screening for Depression, Anxiety, and Suicide Risk in Children and Adolescents: An Evidence Review for the U.S. Preventive Services Task Force. Evidence Synthesis No. 221. Rockville, MD: Agency for Healthcare Research and Quality; 2022. AHRQ Publication No. 22-05293-EF-1.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA: American Psychiatric Association; 2013.
- U.S. Department of Commerce. 2020 National Survey of Children’s Health: Topical Frequencies. Washington, DC: U.S. Census Bureau; 2021.
- U.S. Preventive Services Task Force. U.S. Preventive Services Task Force Procedure Manual. Accessed March 29, 2022. https://uspreventiveservicestaskforce.org/uspstf/procedure-manual
- Tandon M, Cardeli E, Luby J. Internalizing disorders in early childhood: a review of depressive and anxiety disorders. Child Adolesc Psychiatr Clin N Am. 2009;18(3):593-610.
- Ehrenreich JT, Santucci LC, Weiner CL. Separation anxiety disorder in youth: phenomenology, assessment, and treatment. Psicol Conductual. 2008;16(3):389-412.
- Beesdo K, Pine DS, Lieb R, et al. Incidence and risk patterns of anxiety and depressive disorders and categorization of generalized anxiety disorder. Arch Gen Psychiatry. 2010;67(1):47-57.
- Yap MB, Jorm AF. Parental factors associated with childhood anxiety, depression, and internalizing problems: a systematic review and meta-analysis. J Affect Disord. 2015;175:424-40.
- Bogels SM, Brechman-Toussaint ML. Family issues in child anxiety: attachment, family functioning, parental rearing and beliefs. Clin Psychol Rev. 2006;26(7):834-856.
- Lemstra M, Neudorf C, D’Arcy C, et al. A systematic review of depressed mood and anxiety by SES in youth aged 10–15 years. Can J Public Health. 2008;99(2):125-129.
- Beesdo-Baum K, Hofler M, Gloster AT, et al. The structure of common mental disorders: a replication study in a community sample of adolescents and young adults. Int J Methods Psychiatr Res. 2009;18(4):204-220.
- Costello EJ, Mustillo S, Erkanli A, et al. Prevalence and development of psychiatric disorders in childhood and adolescence. Arch Gen Psychiatry. 2003;60(8):837-844.
- The Trevor Project. 2021 National Survey on LGBTQ Youth Mental Health. West Hollywood, CA: The Trevor Project; 2021.
- Ghandour RM, Sherman LJ, Vladutiu CJ, et al. Prevalence and treatment of depression, anxiety, and conduct problems in US children. J Pediatr. 2019;206:256-267.e3.
- Louie P, Wheaton B. Prevalence and patterning of mental disorders through adolescence in 3 cohorts of Black and White Americans. Am J Epidemiol. 2018;187(11):2332-2338.
- Bernard DL, Calhoun CD, Banks DE, Halliday CA, Hughes-Halbert C, Danielson CK. Making the "C-ACE" for a culturally-informed adverse childhood experiences framework to understand the pervasive mental health impact of racism on Black youth. J Child Adolesc Trauma. 2021;14(2):233-247.
- Lu W. Treatment for adolescent depression: national patterns, temporal trends, and factors related to service use across settings. J Adolesc Health. 2020;67(3):401-408.
- Lu W. Child and adolescent mental disorders and health care disparities: results from the National Survey of Children's Health, 2011-2012. J Health Care Poor Underserved. 2017;28(3):988-1011.
- Merikangas KR, He JP, Burstein M, et al. Service utilization for lifetime mental disorders in U.S. adolescents: results of the National Comorbidity Survey-Adolescent Supplement (NCS-A). J Am Acad Child Adolesc Psychiatry. 2011;50(1):32-45.
- Howell E, McFeeters J. Children's mental health care: differences by race/ethnicity in urban/rural areas. J Health Care Poor Underserved. 2008;19(1):237-247.
- Emergency Task Force on Black Youth Suicide and Mental Health. Ring the Alarm: The Crisis of Black Youth Suicide in America. Accessed March 29, 2022. https://watsoncoleman.house.gov/uploadedfiles/full_taskforce_report.pdf
- Wang Z, Whiteside S, Sim L, et al. Anxiety in Children. Comparative Effectiveness Review No. 192. Rockville, MD: Agency for Healthcare Research and Quality; 2017. AHRQ Publication No. 17-EHC023-EF.
- Wehry AM, Beesdo-Baum K, Hennelly MM, et al. Assessment and treatment of anxiety disorders in children and adolescents. Curr Psychiatry Rep. 2015;17(7):52.
- Connolly SD, Suarez L, Sylvester C. Assessment and treatment of anxiety disorders in children and adolescents. Curr Psychiatry Rep. 2011;13(2):99-110.
- Comer JS, Hong N, Poznanski B, et al. Evidence base update on the treatment of early childhood anxiety and related problems. J Clin Child Adolesc Psychol. 2019;48(1):1-15.
- Higa-McMillan CK, Francis SE, Rith-Najarian L, et al. Evidence base update: 50 years of research on treatment for child and adolescent anxiety. J Clin Child Adolesc Psychol. 2016;45(2):91-113.
- Siu AL; U.S. Preventive Services Task Force. Screening for depression in children and adolescents: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2016;164(5):360-366.
- Michael L LeFevre, U.S. Preventive Services Task Force. Screening for suicide risk in adolescents, adults, and older adults in primary care: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2014;160(10):719-726.
- US Preventive Services Task Force. Primary care-based interventions to prevent illicit drug use in children, adolescents, and young adults: US Preventive Services Task Force recommendation statement. JAMA. 2020;323(20):2060-2066.
- US Preventive Services Task Force. Screening and behavioral counseling interventions to reduce unhealthy alcohol use in adolescents and adults: US Preventive Services Task Force recommendation statement. JAMA. 2018;320(18):1899-1909.
- Walter HJ, Bukstein OG, Abright AR, et al. Clinical practice guideline for the assessment and treatment of children and adolescents with anxiety disorders. J Am Acad Child Adolesc Psychiatry. 2020;59(10):1107-1124.
- Weitzman C, Wegner L. Promoting optimal development: screening for behavioral and emotional problems. Pediatrics. 2015;135(2):384-395.
- Committee Opinion No 705 summary: mental health disorders in adolescents. Obstet Gynecol. 2017;130(1):247-248.
|Rationale||Children (age ≤7 years)||Children and adolescents ages 8 to 18 years|
|Detection||Inadequate evidence on screening instruments for anxiety in children age 7 years or younger in primary care.||Adequate evidence that accurate screening instruments are available to identify anxiety in children and adolescents ages 8 to 18 years.|
|Benefits of early detection and intervention and treatment||
|Harms of early detection and intervention and treatment||Inadequate evidence on the harms of screening for or treatment of anxiety in children age 7 years or younger||
|The benefits and harms of screening for anxiety in children age 7 years or younger is uncertain, and the balance of benefits and harms cannot be determined.||Moderate certainty that screening for anxiety in children and adolescents ages 8 to 18 years has a moderate net benefit in improving outcomes such as treatment response and disease remission.|