Screening and Intervention for Pediatric Anxiety Disorders

Anxiety disorders are among the most common psychiatric concerns experienced by children and adolescents. In fact, a recent meta-analysis indicated that rates of severe anxiety have doubled among youth during the ongoing COVID-19 pandemic, with more than one in five now meeting diagnostic criteria. Anxiety disorders typically emerge earlier in development than other forms of mental illness, but frequently take a lifelong, chronic course and impart vulnerability to other problems including depression and substance use. Anxious youth can present as excessively fearful of a broad range of situations (e.g., separating from caregivers, novelty, social interactions, uncertainty, insects, storms, potential failure), however one unifying factor is the desire to avoid situations associated with their fears. This avoidance largely underlies the significant impairment experienced by youth with untreated anxiety disorders.

Screening for anxiety disorders

Effective screening for anxiety disorders in the primary care setting is a critical need, as childhood and adolescent anxiety often go undetected. The 2018 report of the Child Mind Institute reported that only 1% of youth with anxiety seek treatment in the year their symptoms begin, and 80% of youth with anxiety never receive any care for their anxiety. Primary care providers must take care to screen for problems that youth and their parents may not volunteer during routine clinical interactions. The use of validated screening instruments drastically improves the detection of mental health complaints among youth. Two excellent, brief, validated anxiety measures with clinical cutoffs are:

• The Screen for Child Anxiety Related Emotional Disorders (SCARED), a child- and parent-report measure for children ages 8 to 18, with translations into numerous languages.
• The Spence anxiety scales include child-report and parent-report screens, and a parent-report Preschool Anxiety Scale, with translations into more than 30 languages.

In addition to the use of such measures at clinical visits, health care providers can improve screening by asking direct questions about a child’s anxiety and mood. Effective screening can then facilitate conversations with children and parents that help destigmatize anxiety symptoms, and promote the benefits of pursuing treatment.

Intervention for pediatric anxiety disorders

The most well-established intervention for pediatric anxiety is cognitive behavioral therapy (CBT). CBT, which can be delivered in either individual- or group-format, is typically goal-directed, short-term therapy featuring components such as psychoeducation about anxiety, relaxation training, challenging of anxious thinking patterns, and exposure with response prevention. Of these components, exposure appears to be the most critical. Exposure with response prevention involves carefully and collaboratively working with patients to approach the situations or objects that provoke fear. Research has repeatedly shown that exposures are the key driver of anxiety reduction, that the more exposures conducted the greater the clinical improvement, and that the faster that exposures are introduced into therapy, the more rapid a patient's improvement. Despite these compelling findings, surveys of community mental health providers indicate that a small minority who treat anxiety among youth actually practice exposure therapy.

Selective serotonin reuptake inhibitors (SSRIs) are commonly prescribed medications used for treating anxiety disorders among youth. These medications, particularly when combined with CBT, have been shown to effectively reduce symptoms of anxiety. The landmark study of treatment for pediatric anxiety disorders found that between 46-68% of youth treated with combined CBT and SSRI medication achieved remission of anxiety after only 12 weeks.

Intervention for pediatric anxiety within primary care

There are numerous barriers to pursuing effective treatment for pediatric anxiety in the community, including stigma and a scarcity of qualified providers. Integrating behavioral health intervention into primary care settings is a potentially appealing strategy. One 2017 study compared outcomes among anxious youth receiving brief (8 to 12 weekly sessions) behavioral therapy provided in their pediatrician's office to an assisted referral condition, in which youth were given personalized referrals to mental health care along with check-in calls to support access. The youth receiving therapy in their pediatrician's office had significantly higher rates of clinical improvement, greater reduction in anxiety symptoms, and better functioning than the referred group, even when both groups received the same amount of care.

Resources for pediatric anxiety

Children's Hospital Colorado (CHCO) is one of the largest provider's of mental health services for youth in the Rocky Mountain region. CHCO has recently launched a specialty clinic, the Colorado OCD and Anxiety Program (COAP) to serve youth with moderate to severe anxiety or obsessive-compulsive disorder. Providers who would like to refer families for evaluation and treatment can call 720-777-6200 or visit the website.

The Anxiety and Depression Association of America website provides a wealth of useful resources for learning about stress, anxiety, depression, and how to locate qualified therapists.

The Society of Clinical Child and Adolescent Psychology maintains a webpage providing information for families and clinicians about evidence-based interventions for child mental health problems, including anxiety disorders.

Recommended books for parents

• “Breaking Free of Child Anxiety and OCD” Eli Lebowitz
• “You and Your Anxious Child” Anne Marie Albano
• “Helping Your Anxious Child: A Step-by-Step Guide for Parents” Ronald Rapee