Screening for Anxiety in Children and Adolescents: Evidence Report and Systematic Review for the US Preventive Services Task Force

• Published in: JAMA : the journal of the American Medical Association 2022-10, Vol.328 (14), p.1445-1455
• Main Authors: Viswanathan, Meera, Wallace, Ina F, Cook Middleton, Jennifer, Kennedy, Sara M, McKeeman, Joni, Hudson, Kesha, Rains, Caroline, Vander Schaaf, Emily B, Kahwati, Leila
• Format: Article
• Language: English
• Subjects: Adolescents; Anxiety; Children; Clinical trials; Cognitive ability; Cognitive behavioral therapy; Diagnosis; Drug therapy; Literature reviews; Mental disorders; Mental health; Pediatrics; Pharmacology; Remission; Remission (Medicine); Screening; Sertraline; Statistical analysis; Suicide; Systematic review; Task forces; Teenagers
• ISSN: 0098-7484; 1538-3598
• DOI: 10.1001/jama.2022.16303

IMPORTANCE: Anxiety in children and adolescents is associated with impaired functioning, educational underachievement, and future mental health conditions. OBJECTIVE: To review the evidence on screening for anxiety in children and adolescents to inform the US Preventive Services Task Force. DATA SOURCES: PubMed, Cochrane Library, PsycINFO, CINAHL, and trial registries through July 19, 2021; references, experts, and surveillance through June 1, 2022. STUDY SELECTION: English-language, randomized clinical trials (RCTs) of screening; diagnostic test accuracy studies; RCTs of cognitive behavioral therapy (CBT) or US Food and Drug Administration–approved pharmacotherapy; RCTs, observational studies, and systematic reviews reporting harms. DATA EXTRACTION AND SYNTHESIS: Two reviewers assessed titles/abstracts, full-text articles, and study quality and extracted data; when at least 3 similar studies were available, meta-analyses were conducted. MAIN OUTCOMES AND MEASURES: Test accuracy, symptoms, response, remission, loss of diagnosis, all-cause mortality, functioning, suicide-related symptoms or events, adverse events. RESULTS: Thirty-nine studies (N = 6065) were included. No study reported on the direct benefits or harms of screening on health outcomes. Ten studies (n = 3260) reported the sensitivity of screening instruments, ranging from 0.34 to 1.00, with specificity ranging from 0.47 to 0.99. Twenty-nine RCTs (n = 2805) reported on treatment: 22 on CBT, 6 on pharmacotherapy, and 1 on CBT, sertraline, and CBT plus sertraline. CBT was associated with gains on several pooled measures of symptom improvement (magnitude of change varied by outcome measure), response (pooled relative risk [RR], 1.89 [95% CI, 1.17 to 3.05]; n = 606; 6 studies), remission (RR, 2.68 [95% CI, 1.48 to 4.88]; n = 321; 4 studies), and loss of diagnosis (RR range, 3.02-3.09) when compared with usual care or wait-list controls. The evidence on functioning for CBT was mixed. Pharmacotherapy, when compared with placebo, was associated with gains on 2 pooled measures of symptom improvement—mean difference (Pediatric Anxiety Rating Scale mean difference, −4.0 [95% CI, −5.5 to −2.5]; n = 726; 5 studies; and Clinical Global Impression–Severity scale mean difference, −0.84 [95% CI, −1.13 to −0.55]; n = 550; 4 studies) and response (RR, 2.11 [95% CI, 1.58 to 2.98]; n = 370; 5 studies)—but was mixed on measures of functioning. Eleven RCTs (n = 1293) reported harms of anxiety treatments. Suicide-rela