Screening Children for Anxiety at an Earlier Age May Lower Risk of Future Mental Health Disorders

Anxiety is one of the most common mental health disorders in children, affecting about 1 in 11 kids ages 3 to 17 in the United States. To address this issue, the U.S. Preventive Services Task Force recently issued new recommendations, calling for anxiety screening to begin at age 8.

“We’ve seen an upward trend in anxiety in U.S. children in the last several years,” says Dr. Shira Ritholtz, an assistant attending psychologist at NewYork-Presbyterian Westchester Behavioral Health Center. “The COVID-19 pandemic along with the rise of social media and technology usage has likely exacerbated things.”

Health Matters spoke with Dr. Ritholtz, an assistant professor of psychology in clinical psychiatry at Weill Cornell Medicine, to understand what these recommendations mean and what screening entails for children and parents.

Why is early screening for anxiety so important?

Dr. Ritholtz: One of the major benefits of screening kids earlier is that it provides the opportunity for early intervention when necessary. An untreated anxiety disorder is associated with a higher chance of anxiety, depression, substance abuse, and suicidal ideation later in life. If we can catch it early, we can not only provide immediate relief to the child who may be suffering but also hopefully prevent a lot of future suffering.

What does this screening entail?

The screening would take place during annual well-child checkups with a pediatrician, who likely would use a validated measure designed to screen for childhood anxiety. These screeners involve a set of questions for the child, the parent, or both, like:

• Do you worry about other people liking you? How often?
• Do you get stomachaches at school?
• Do you worry about the future?

Based on the responses, a clinician makes recommendations on the next steps to take, if any. This screening is not intended to diagnose. It’s intended to raise a flag that an assessment with a mental health provider may be needed.

How does anxiety manifest in young kids? How is it different from depression?

Kids experiencing anxiety and depression may present as irritable, oppositional, or tearful at times. Typically, kids who primarily have anxiety will try to avoid difficult situations and become upset when asked to face a situation they deem scary. In contrast, depression primarily manifests as low energy, irritability, or the feeling that things just don’t seem fun anymore.

The tricky thing about anxiety is that the symptom of avoidance can make the anxiety worse in the long term. Let’s imagine there is a child who is socially anxious: They’re going to avoid social situations. While this may feel better for them in the moment, it reinforces the idea in their brain that social situations are dangerous. So they never get the chance to learn that they can tolerate hard things.

When is it just normal anxiety that is natural to experience vs. an anxiety disorder?

Everybody experiences the emotion of anxiety, which is not a bad thing. A healthy level of anxiety can keep us safe from harm. If a child is feeling anxious but still able, with encouragement, to do what they need to do, that’s a typical part of development. It becomes an anxiety disorder when anxiety interferes with the child’s ability to function in the world.

For example, it’s age-appropriate for young children to be scared of the dark. But if it’s preventing your child from getting a good night’s sleep, that’s when it becomes functionally impairing. Or if your child is so anxious about separating from you that they’re unable to attend school, go to a play date, or stay with a babysitter, assessing for an anxiety disorder may be recommended.

Why is age 8 the recommended age to begin screening?

The typical age of onset for anxiety disorders is in the younger elementary school years. This is younger than the typical age of onset for depression, which is in adolescence or young adulthood.

Separation anxiety often shows up in the early preschool years. Social anxiety has an average age of onset of 13 years, with 75% of cases diagnosed between 8 and 15 years of age. Age 8 captures kids who may be on the lower end of that range before anxiety has a chance to progress.

The tricky thing about anxiety is that these kids, especially when younger, are typically not the squeaky wheels in class. Kids with anxiety are often quiet and don’t disturb the class. The result? Their challenges may be missed, as well as their opportunity for a diagnosis or treatment until much later.

What does this screening mean for caregivers?

Early detection of anxiety gives parents an opportunity to work with providers to learn how to gently encourage their child to do things even if they’re feeling anxious. A good clinician will be able to give a child skills to cope with that uncomfortable feeling they may initially experience, and also coach the parents on how to support their child.

While your clinician may be the expert on childhood anxiety, you are the expert on your child. As a parent, you should speak up if the screening results come back positive or negative and that doesn’t fit with what you’re seeing.

How is anxiety treated in children?

The first line of treatment for young kids with anxiety is therapy. Cognitive behavioral therapy (CBT) has been shown to reduce anxiety in a clinically meaningful way. CBT involves a child therapist working with a child to help them notice their thoughts and behaviors that may be making their anxiety worse. They can help children learn different patterns of thinking and acting to feel better. For some types of anxiety, this involves Exposure and Response Prevention, a type of CBT, which gradually exposes a child to the thing they fear so they can learn that they can handle it.

How can we be allies for children living with anxiety?

It’s natural to want to protect your child from everything that makes them anxious. But I encourage parents to work with a mental health provider to learn how they can create opportunities for their child to engage with the world, make mistakes, and experience small levels of anxiety so that they learn that they can tolerate it, while you cheer them on along the way.

As teachers, allies, friends, and family, check in with those parents and kids and ask how you can help. Noticing those emotions and demonstrating that you’re there to support them can make a world of difference in how they develop coping skills.

Learn more about children’s health and NewYork-Presbyterian’s Youth Anxiety Center.

Shira Ritholtz, Ph.D., is an assistant attending psychologist at NewYork-Presbyterian Westchester Behavioral Health Center and an assistant professor of psychology in clinical psychiatry at Weill Cornell Medicine. Dr. Ritholtz is a licensed clinical psychologist who specializes in cognitive behavioral therapy (CBT) for children, adolescents, and young adults with anxiety, mood, and traumatic stress disorders. She provides a variety of clinical services in both outpatient and inpatient settings, including diagnostic evaluation, consultation, and psychotherapy. She serves as a clinical supervisor for psychology and psychiatry fellows in the child outpatient and inpatient departments.