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Screening for Anxiety in Children and AdolescentsEvidence Report and Systematic Review for the US Preventive Services Task Force

To identify the key insights or developments described in this article
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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-related harms were rare, and the differences were not statistically significantly different.

Conclusions and Relevance  Indirect evidence suggested that some screening instruments were reasonably accurate. CBT and pharmacotherapy were associated with benefits; no statistically significant association with harms was reported.

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Article Information

Corresponding Author: Meera Viswanathan, PhD, RTI International, 3040 E Cornwallis Rd, Research Triangle Park, NC 27709 (viswanathan@rti.org).

Accepted for Publication: August 25, 2022.

Author Contributions: Dr Viswanathan had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Viswanathan, Kahwati.

Acquisition, analysis, or interpretation of data: Viswanathan, Wallace, Cook Middleton, Kennedy, McKeeman, Hudson, Rains, Vander Schaaf, Kahwati.

Drafting of the manuscript: Viswanathan, Kennedy, Rains.

Critical revision of the manuscript for important intellectual content: Viswanathan, Wallace, Cook Middleton, Kennedy, McKeeman, Hudson, Rains, Vander Schaaf, Kahwati.

Statistical analysis: Viswanathan, Wallace, Kahwati.

Obtained funding: Viswanathan, Kahwati.

Administrative, technical, or material support: Viswanathan, Kennedy, Rains.

Supervision: Viswanathan.

Conflict of Interest Disclosures: Dr Vander Schaaf reported that she is a Fellow of the American Academy of Pediatrics and member of American Academy of Pediatrics CATCH Committee. No other disclosures were reported.

Funding/Support: This study was funded under contract HHSA-290-2015-00011-I, Task Order 15, and Contract 75Q80120D00007, Task Order 05, from the Agency for Healthcare Research and Quality (AHRQ), US Department of Health and Human Services (HHS), under a contract to support the US Preventive Services Task Force (USPSTF).

Role of the Funder/Sponsor: Investigators worked with USPSTF members and AHRQ staff to develop the scope, analytic framework, and key questions for this review. AHRQ had no role in study selection, quality assessment, or synthesis. AHRQ staff provided project oversight, reviewed the report to ensure that the analysis met methodological standards, and distributed the draft for peer review. Otherwise, AHRQ had no role in the conduct of the study; collection, management, analysis, or interpretation of the data; or preparation, review, or approval of the manuscript findings. The opinions expressed in this document are those of the authors and do not represent the official position of AHRQ or HHS.

Additional Contributions: We acknowledge the following individuals for their contributions to this project: AHRQ staff Iris Mabry-Hernandez, MD, MPH, and Tracy Wolf, MD, MPH; current and former members of the USPSTF who contributed to topic deliberations; and RTI International–University of North Carolina Evidence-based Practice Center staff Christiane Voisin, MSLS, Candi Wines, MPH, Nila A. Sathe, MA, MLIS, Carol Woodell, BSPH, Sharon Barrell, MA, Staci Rachman, BA, Sarah Barringer, Michelle Bogus, Teyonna Downing, and Loraine Monroe. USPSTF members, peer reviewers, and federal partner reviewers did not receive financial compensation for their contributions.

Additional Information: A draft version of the full evidence report underwent external peer review from 4 content experts (Gregory Simon, MD, MPH, University of Washington; Joan Asarnow, PhD, University of California, Los Angeles; Natalie Cort, PhD, William James College; and Raquel Halfond, PhD, American Psychological Association) and 1 federal partner reviewer (Erin Abramsohn, DrPH, Centers for Disease Control and Prevention). Comments from reviewers were presented to the USPSTF during its deliberation of the evidence and were considered by the authors in preparing the final evidence review.

Editorial Disclaimer: This evidence report is presented as a document in support of the accompanying USPSTF recommendation statement. It did not undergo additional peer review after submission to JAMA.

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AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

  • 1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
  • 1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
  • 1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
  • 1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
  • 1.00 credit toward the CME [and Self-Assessment requirements] of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.

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