Episode 117: Anxiety Screening. 

Adriana and Ikleel explain the new recommendation given by the USPSTF in October 2022 regarding screening for anxiety in children and adolescents 8-18 years old. Dr. Arreaza discusses the SCARED tool to screen for anxiety in pediatric patients. 

By Adriana Rodriguez, MS3, and Ikleel Moshref, MS3. Ross University School of Medicine. Moderated by Hector Arreaza, MD. 

You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.

Recommendation.

• The USPSTF recommends screening for anxiety in children and adolescents aged 8 to 18 years. Grade of recommendation: B (offer this service to your patients)
• The USPSTF 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. Grade of recommendation: I (insufficient evidence, unknown benefits vs. harms)

USPSTF concludes this new screening guideline for anxiety in this population has a moderate net benefit. For children 7 and younger, evidence is insufficient to determine screening tools accuracy and its effects, and benefit-to-risk balance. 

Anxiety. 

Anxiety disorder is characterized by excessive, persistent worry and or fear that is difficult to control, resulting in significant distress or impairment. Anxiety disorder manifests in psychological/emotional and physical/somatic symptoms. DSMV recognizes 7 types of anxiety disorders: GAD, social anxiety disorder, panic disorder, agoraphobia, specific phobias, separation anxiety disorder, and selective mutism. 

Comment: Anxiety is not your patient’s fault. In some cultures, anxiety is seen as a weakness. America seems to be a highly stressful society.

Epidemiology.

Anxiety disorder is a common mental health condition in the United States. According to the National Survey of Children’s Health in 2018-2019, 7.8% of people aged 3-17 yrs. old had an anxiety disorder that was current. In the adult population, past studies have shown ~3% past-year prevalence and ~5-12% lifetime prevalence of anxiety disorder in adults. 

Topic Importance.

Anxiety disorders are the most common childhood-onset mental health condition. Childhood and adolescent anxiety disorder is associated with an increased likelihood of poor academic performance and co-occurring psychiatric conditions. It is also associated with future anxiety disorder, secondary depression, substance abuse, psychosocial functional impairment, chronic mental/somatic health conditions, and/or suicide. Screening anxiety disorder in youth may serve to improve potential prevent burdens in the future. 

Assessment of Risk. 

Although this new screening guideline is meant for children and adolescents aged 8-18 who have not been diagnosed with an anxiety disorder and without signs and symptoms, it is important to note what factors would increase their chances of developing any of the aforementioned anxiety disorders: 

• Genetic, personality, and environmental factors: biopsychological vulnerability, attachment difficulties, child maltreatment, adverse childhood experience 
• Demographic factors: poverty, low socioeconomic status
• Racial and ethnic factors: racial discrimination, historic trauma, structural racism
• Other factors: LGBTQ youth, older adolescents 12-17

Screening Tools.

Although there are many screening tests for anxiety, two are widely utilized in clinical practice for screening purposes: (1) SCARED (Screen for Child Anxiety Related Disorders), and (2) Social Phobia Inventory. These screening instruments are insufficient for the actual diagnosis of any particular anxiety disorder listed earlier; if positive, however, a confirmatory assessment and follow-up is required to establish diagnosis using DSM V criteria for any of the recognized anxiety disorders (GAD, social anxiety disorder, panic disorder, agoraphobia, specific phobias, separation anxiety disorder, and selective mutism).

SCARED (Screen for Children Anxiety Related Disorders): It is a 41-Item questionnaire, each question can be answered from 0-2 (0=not true or hardly true, 1=somewhat true or sometimes true, 2=very true or often true). A score greater than or equal to 25 is highly associated with anxiety disorder; panic disorder, significant somatic symptoms, generalized anxiety disorder, separation anxiety disorder, social anxiety disorder, and significant school avoidance. SCARED is available online (here). There is a child version and a parent version. The only difference between the two is the different pronouns, for example, question 17 is “My child worries about going to school” vs “I worry about going to school”. 

Although the USPSTF could not find optimal screening intervals, these screenings may be best used in older adolescents aged 12-17 yrs. old with risk factors for anxiety disorder. 

Other anxiety screening tools have been assessed by the USPSTF but were insufficient for the purposes of this guideline because they were too specific to a specific anxiety disorder (for example, the Social Phobia and Anxiety Inventory for Children), were for a particular set of disorders, or were too long to use for screening in a primary care setting. 

In studies found by the USPSTF, social anxiety disorder and GAD were the most common detected anxiety disorder in children and adolescents. 

Fun fact: What is the most common phobia in the US? Public speaking, AKA glossophobia.

Treatment. 

Anxiety disorders can be treated with medications, psychotherapy, a combination of both, or multidisciplinary care. Of the variety of psychotherapies available, cognitive behavioral therapy (CBT) is the most used. As for pharmacotherapy, US FDA has only approved duloxetine, an SNRI, for the treatment of GAD in children 7 yrs. and older. Off-label prescriptions of other drugs have been reported to treat anxiety in youth. 

Potential Harms.

False-positive screening results may lead to an unnecessary burden on the patient and family from avoidable referrals, monetary costs, anxiety, the stigma of illness, and adverse effects of pharmacotherapy (weight loss, cholesterol, etc.)

Bottom line: Anxiety is a treatable mental condition and detection in childhood is now recommended by the USPSTF. Screen if you have a way to treat (refer or treat yourself).

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Conclusion: Now we conclude episode number 117 “Anxiety Screening.” Adriana and Ikleel explained that screening for anxiety disorders in children between 8-18 is now a grade B recommendation by the United States Preventive Services Task Force. During this episode, you heard about “SCARED”, a useful screening tool to help in the diagnosis of anxiety disorders in children. Once diagnosed, anxiety is treated with psychotherapy, medications, or a combination of both. This week we thank Hector Arreaza, Adriana Rodriguez, and Ikleel Moshref. Audio edition by Adrianne Silva.

Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week! 

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Links:

1. Final Recommendation Statement, Anxiety in Children and Adolescents: Screening, United States Preventive Services Task Force, https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/screening-anxiety-children-adolescents#fullrecommendationstart, accessed on Oct 11, 2022. 
2. Screen for Child Anxiety Related Disorders (SCARED), available online, for example: Oregon Health & Science University: https://www.ohsu.edu/sites/default/files/2019-06/SCARED-form-Parent-and-Child-version.pdf
3. Bennett, Shannon, et al. Anxiety disorders in children and adolescents: assessment and diagnosis, UpToDate, last updated: Aug 19, 2022. https://www.uptodate.com/contents/anxiety-disorders-in-children-and-adolescents-assessment-and-diagnosis.
4. Baldwin, David, et al. Generalized anxiety disorder in adults: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis, UpToDate, last updated: Apr 18, 2022. https://www.uptodate.com/contents/generalized-anxiety-disorder-in-adults-epidemiology-pathogenesis-clinical-manifestations-course-assessment-and-diagnosis.
5. Craske, Michelle, et al. Generalized anxiety disorder in adults: Management, Up to Date, last updated Nov 12, 2021. https://www.uptodate.com/contents/generalized-anxiety-disorder-in-adults-management.
6. Royalty-free music used for this episode: Real Live by Gushito, downloaded on October 1, 2022, from https://www.videvo.net/. 

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