May 9, 2022
National Center for Health Research’s Comments on U.S. Preventive Services Task Force’s Draft Recommendation on Screening for Anxiety in Children and Adolescents
We are writing to express our views on the U.S. Preventive Services Task Force’s (USPSTF) draft recommendation for screening for anxiety in children and adolescents.
The National Center for Health Research (NCHR) is a nonprofit think tank that conducts, analyzes, and scrutinizes research on a range of health issues, with particular focus on which prevention strategies and treatments are most effective for which patients and consumers. We do not accept funding from companies that make products that are the subject of our work, so we have no conflicts of interest.
We agree with USPSTF’s “I” grade recommendation regarding anxiety screening for children 7 years or younger, since there is not sufficient evidence on the benefits and harms of screening for this age group, or to determine the impact of treatments for anxiety in children in this age group.
However, regarding screening for anxiety in asymptomatic children between the ages of 8 and 18, we do not agree with USPSTF’s “B” grade recommendation, because of the lack of direct evidence to support USPSTF’s recommendation. Instead, the review “relies on linking indirect evidence” on the accuracy of screening, the harms of inaccurate tests, as well as the potential benefits and harms of treatments. While USPSTF states that there is “adequate evidence” that accurate screening instruments are available, the review also acknowledges that the evidence relied on a range of different screening tools, which differed in length and were developed to screen for different conditions. And unfortunately, there is no evidence on appropriate screening intervals. We are particularly concerned that the screening accuracy and number of false-positive results varied among the different anxiety conditions studied. Moreover, since several of the assessed screening instruments are too lengthy to be used in primary care, we do not have adequate evidence on the accuracy of instruments that would be used in the primary care setting. More research is needed to identify accurate screening tools, especially for those patient groups that USPSTF has identified to be at higher risks, based for example on sexual orientation, gender identity, sex, and race.
These shortcomings are of particular concern, as false-positive screening can lead to serious harm. For example, although USPSTF stated that psychological interventions are assumed to pose minimal harms, screening can result in harm from unnecessary treatments, labeling, and stigma. USPSTF should be especially concerned that pharmacotherapy interventions can lead to serious psychiatric adverse events. We therefore disagree with the conclusion that such harms were “rare and not statistically relevant.” We concur with the USPSTF that more research is needed to assess the direct benefits as well as harms of screening in children of all ages.
Anxiety in childhood and adolescence can be debilitating, and accurate screening instruments to help identify children in need are necessary, particularly since anxiety in childhood also increases the likelihood of developing anxiety or depression later in life. However, the available data on screening and the potential benefits and harms are currently too limited to recommend screening in asymptomatic children of any age. We thus urge USPSTF to provide adequate guidance for health care providers which screening tools are appropriate for the primary care setting and how to identify patients who would benefit the most from screening.
The National Center for Health Research can be reached at info@center4research.org or at (202) 223-4000.