Should we be screening every 8-year-old for anxiety?
This is the April 25, 2022, edition of the 8 to 3 newsletter about school, kids and parenting. Like what you’re reading? Sign up to get it in your inbox every Monday.
Earlier this month, an influential group of experts recommended that every child age 8 and older be screened for anxiety.
Behind the advice is the U.S. Preventive Services Task Force, an independent volunteer panel of national experts in disease prevention and evidence-based medicine. Although the group has no regulatory authority, its draft guidance has made national headlines and carries a lot of weight with pediatricians. And it’s the first time the task force has advocated for including anxiety screenings in annual wellness checks for kids and teens. The panel didn’t change its previous recommendation to screen adolescents 12 and older for depression.
There’s no question that anxiety is on the rise among teens and younger kids. Symptoms of depression and anxiety have doubled during the pandemic, with 25% of youth experiencing symptoms of depression and 20% experiencing anxiety symptoms, according to a public health advisory from U.S. Surgeon General Vivek H. Murthy.
Public health experts say universal mental health screenings are an integral part of a rapid response to the youth mental health crisis. But most kids aren’t getting them. A national survey conducted by the University of Michigan in fall 2021 found that only a third of parents said their teen had completed a mental health screening questionnaire at their primary care doctor’s office.
Advocates for screenings argue that they are a critical step in identifying and treating anxiety early. Left unaddressed, anxiety can lead to depression, substance use and full-blown anxiety disorders later in life.
“We know that one of the first mental health challenges children face is anxiety,” said Jonathan Goldfinger, CEO of L.A.-based Didi Hirsch Mental Health Services. Screenings also provide an “on-ramp” for primary care providers to talk with parents about childhood mental health and stress — an essential step to normalizing and destigmatizing those conversations, Goldfinger told me.
There’s plenty of evidence that cognitive behavioral therapy and other interventions can effectively treat anxiety disorders in kids, said Janine Domingues, a clinical psychologist with the Child Mind Institute’s Anxiety Disorders Center in New York. “We also know that intervention is most effective when symptoms are mild to moderate,” she added. “If we’re able to recognize symptoms early through screening, we’re reaching children before more harmful behavioral patterns are more ingrained.”
Eight years old is around the age when most kids are able to read and reliably report anxiety symptoms, which explains the task force’s age cutoff, said Bruce Chorpita, professor of psychology and psychiatry at UCLA, who studies mental health service systems and treatment design for children.
There are several different questionnaires that can be used to screen anxiety in primary care, experts told me. A popular one is the GAD-7, and you can see the full list of questions here. A screener asks patients to rate their symptoms on a scale. For example, how often over the past two weeks have you been unable to control worrying? How often have you felt nervous? Anxious? On edge? Kids usually fill out the surveys themselves.
Another is the 41-question SCARED (Screen for Child Anxiety Related Disorders) survey. The assessment lists sentences that describe how people feel. Children mark whether the statement is not true, hardly every true, sometimes true or very often true.
The surveys are designed to flag children who are experiencing anxiety symptoms, which exist along a spectrum from mild to severe and may be situational or more generalized. In other words, screenings aren’t a diagnosis.
“All screenings are intended to be the beginning of a conversation,” Goldfinger said.
Additional assessments (which tend to be more costly) provide specific information on the extent of the anxiety and the level of support a kid needs — if any at all, Chorpita said.
Herein lies the main concern that clinicians have shared with me. Many children will never receive that second assessment or the treatment they might need, in large part because of the massive shortage of behavioral and mental health care workers nationwide, to say nothing of larger issues of equity and access.
“Screening recommendations,” Chorpita said, “need to be part of a more comprehensive and coordinated set of endeavors for children to lead better lives, which is the goal here.”
He used the analogy of a three-legged stool, with screenings being one of those legs. A well-functioning mental health system is able to provide those in-depth assessments and treat children for anxiety, the second leg of the stool. But it should also engage and educate families as to why mental health care is vital to the well-being of their children, the third leg. Stigma is a potent force in preventing young people from completing a full course of treatment, even when it’s available to them, Chorpita said.
There is some concern that the inability to provide kids with therapeutic interventions — which tend to be more time- and resource-intensive — will lead to an over-reliance on psychiatric medications. This has been the case for children with attention deficit and hyperactivity disorder, said Allen Frances, chairman emeritus of the Department of Psychiatry and Behavioral Sciences at Duke University. The rise of ADHD diagnoses and prescriptions for stimulants coincided with a two-decade campaign by pharmaceutical companies to publicize the syndrome and promote the pills to doctors. The American Academy of Pediatrics recommends that psychological services like therapy should be tried first before medications are prescribed.
Chorpita sees overprescribing as the consequence of a fragmented healthcare system, and one that could emerge as a result of increasing anxiety disorder diagnoses among youth. “Medication is a lot easier to scale” than therapy sessions, he said. “Producing a workforce that can serve children at that scale is extremely challenging.”
These concerns don’t mean we should eschew screening, experts told me.
“Not identifying a problem because there isn’t an immediate resolution is at odds with addressing stigma,” Goldfinger said, “which is the root cause of there not being any services in the first place.”
The hope is that, at the very least, universal screenings will provide a clearer picture of how bad the problem is — so that people in power might be motivated to address it.
Teacher shortages prompt last-ditch K-12 plan, and more
With less than two months left in the school year, many of Los Angeles Unified’s highest-needs campuses remain significantly understaffed, impeding academic recovery and prompting Supt. Alberto M. Carvalho to redeploy personnel who hold teaching credentials back into the classroom. The district’s teacher shortage — a deepening problem in California and nationwide — has hit hardest at schools in parts of South L.A. and several other low-income neighborhoods. My colleague Melissa Gomez explains what’s behind the shortage and what educators think about the plan.
We also reported on aid for college students. The Los Angeles Community College District will fund a $1.5-million pilot program to provide housing for more than 100 students who are homeless or housing insecure. As the pandemic continues to exacerbate students’ basic food and housing needs, many have prioritized jobs over education, prompting a green light for the effort.
Here is what you need to know if you are weighed down by federal student-loan debt. First, the Biden administration extended a moratorium on federal student loan payments and interest charges through August. Then on Tuesday the Education Department announced that it was reviewing payment records to give borrowers more credit for the progress they’ve been making toward loan forgiveness.
And the troubles at Sonoma State University continue. President Judy Sakaki, who is facing growing criticism of her handling of sexual harassment allegations involving her husband, announced Monday that she is separating from her spouse.
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