A Parents’ Guide to Pediatric Anxiety Screening

This year the US Preventive Service Task Force recommended that all children between the ages of 6 and 18 be screened in primary care settings for anxiety. The guidance was based on the fact that clinical levels of anxiety are common in youth but often quite treatable, and that screening for them is not overly burdensome.

Primary-care clinicians like pediatricians are not required to do this, but many will likely try to work this into their practice if they don’t do it already. This brief post was written to help parents think through some of the issues involved in this screening, if it happens in their clinician's office—and if it doesn’t, it is certainly reasonable to ask, particularly if you have some concerns about anxiety in your child. Some pediatricians might not be aware of the recommendations, while others may be holding back for a variety of reasons including not having enough time (primary-care clinicians are supposed to screen for lots of things) or a concern about what they can do if a child screens positive. The recommendations don’t specify when, exactly, a child should be screened or how often, so it’s also possible that the plan is to screen at another visit.

When it does happen, the screen is likely to occur via a parent filling out a short questionnaire that could range from 2 items to over 100. This could happen in the waiting room, online, or the questionnaire might be administered by staff. These questionnaires are then scored and those who score above some determined cutoff are deemed a positive screen. Like pretty much everything in mental health, anxiety is dimensional (like height or IQ) and the boundary between what is considered “clinical” and what isn’t is somewhat murky and open to interpretation. What’s important is the degree to which the anxiety is leading to significant impairment and/or distress. If a child is deathly afraid of snakes and you live somewhere where there aren’t any, then no big deal. But if your child is consumed by anxious thoughts that can’t be turned off and lead to them not being able to do things they want or need to do, then getting some treatment might really help.

Since a positive screen is not an official diagnosis, further investigation is necessary either by the primary-care clinician or someone else like a mental-health professional. This workup can help confirm the screen and determine if your child meets the criteria for one of the many different anxiety disorders such as Generalized Anxiety Disorder, Social Anxiety Disorder, or Separation Anxiety Disorder. It can also help rule out other potential causes of anxiety such as substance use or medical conditions like heart arrhythmias.

Very often, youth will present with challenges that span multiple different anxiety disorders with the “final” diagnosis being something like Unspecified Anxiety Disorder. This can sound pretty vague and unhelpful, but it’s common and usually enough to get effective treatment which generally doesn’t change that much from one anxiety disorder to the next.

When a diagnosis is given, I believe that most children should be aware of it and have the diagnosis explained to them in a way that doesn’t make them feel defective or damaged. One analogy I use often is our immune system, which most kids understand to some degree. Both our anxiety network and our immune system are normal and critical in keeping us alive, and both help us detect and respond to different kinds of threats. However, when our threat response kicks in when it doesn’t need to do, or activates in a manner that is out of proportion to the level of threat, it can cause problems. Thinking about anxiety this way helps kids understand that it is nothing to be ashamed of but may need some attention so that their anxiety is working for them rather than against them. This message can be particularly important for youth who have experienced trauma as there likely was a time in the past when it was quite adaptive for them to have a very sensitive threat detection system.

If your child is being recommended for treatment, there are a few things to consider. When these recommendations were first released, there was some concern that they might lead to excessive medication use. This is a valid concern, and it is important to know that medications are almost never recommended as the only type of treatment. Psychotherapy can be very effective, particularly a modality called cognitive-behavioral therapy. Having someone work with you, the parent, can also be helpful. This should not be interpreted to mean that your parenting skills are poor, but rather that anxious kids have a way of evoking overprotective responses which can sometimes unintentionally reinforce anxious behavior. With these complex and difficult interactions, it can be helpful to have someone to talk through your options and expand your toolbox as much as possible.

Relatedly, a critical ingredient to most effective therapy approaches to anxiety is exposure, which means facing and confronting the anxiety with some extra support and skills even when still feeling somewhat uncomfortable about it. Why this works with anxiety isn’t obvious, and so it can be useful to mention this process specifically as it isn’t the typical way in which things get “fixed.” If your car won’t go up a hill, for example, a good mechanic is not going to recommend that you try to drive up the hill anyway as part of the repair process, but this is actually how many people truly overcome their anxiety over the long-term.

Medications can have a role in treatment, and your primary care clinician may prescribe something, particularly if the anxiety is severe or other treatments have not been successful. A referral to a psychiatrist or nurse practitioner may also occur, although more pediatric providers are comfortable with first-line medications such as SSRIs (selective serotonin reuptake inhibitors). Of note, anxiety medications that are classified as benzodiazepines (like Valium, Klonipin, Xanax, etc.) are sometimes used for adults but tend to be avoided in youth for a lot of good reasons.

Anxiety Essential Reads

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Overall, the hopeful message here is that the impairing aspects of anxiety in children and adolescents can often be effectively addressed with various types of treatment. Identifying these problems early can reduce years of suffering and distress that might otherwise occur. Screening and addressing anxiety problems, when done well and based on best-practice recommendations, can lead to positive outcomes, and parents have a major role in this process.