2022+USPSTF建议声明：儿童和青少年焦虑的筛查.pdf

ScreeningforAnxietyinChildrenandAdolescentsUSPreventiveServicesTaskForceRecommendationStatementUSPreventiveServicesTaskForceSummaryofRecommendationsSeetheSummaryofRecommendationsfigure.ImportanceAnxietydisorder,acommonmentalhealthconditionintheUS,com-prisesagroupofrelatedconditionscharacterizedbyexcessivefearor worry that present as emotional and physical symptoms.1-3The2018-2019NationalSurveyofChildrensHealth(NSCH)foundthat7.8%of children and adolescents aged 3 to 17 years had a currentanxietydisorder.4Anxietydisordersinchildhoodandadolescenceare associated with an increased likelihood of a future anxiety dis-orderordepression.1,3USPSTFAssessmentofMagnitudeofNetBenefitThe US Preventive Services Task Force(USPSTF)concludes withmoderate certainty that screening for anxiety in children and ado-lescentsaged8to18yearshasamoderatenetbenefit.IMPORTANCEAnxietydisorder,acommonmentalhealthconditionintheUS,comprisesagroupofrelatedconditionscharacterizedbyexcessivefearorworrythatpresentasemotionalandphysicalsymptoms.The2018-2019NationalSurveyofChildrensHealthfoundthat7.8%ofchildrenandadolescentsaged3to17yearshadacurrentanxietydisorder.Anxietydisordersinchildhoodandadolescenceareassociatedwithanincreasedlikelihoodofafutureanxietydisorderordepression.OBJECTIVETheUSPreventiveServicesTaskForce(USPSTF)commissionedasystematicreviewtoevaluatethebenefitsandharmsofscreeningforanxietydisordersinchildrenandadolescents.Thisisanewrecommendation.POPULATIONChildrenandadolescents18yearsoryoungerwhodonothaveadiagnosedanxietydisorderorarenotshowingrecognizedsignsorsymptomsofanxiety.EVIDENCE ASSESSMENTTheUSPSTFconcludeswithmoderatecertaintythatscreeningforanxietyinchildrenandadolescentsaged8to18yearshasamoderatenetbenefit.TheUSPSTFconcludesthattheevidenceisinsufficientonscreeningforanxietyinchildren7yearsoryounger.RECOMMENDATIONTheUSPSTFrecommendsscreeningforanxietyinchildrenandadolescentsaged8to18years.(Brecommendation)TheUSPSTFconcludesthatthecurrentevidenceisinsufficienttoassessthebalanceofbenefitsandharmsofscreeningforanxietyinchildren7yearsoryounger.(Istatement)JAMA.2022;328(14):1438-1444.doi:10.1001/jama.2022.16936Editorialpage1399MultimediaRelatedarticlepage1445andJAMAPatientPagepage1469SupplementalcontentGroupInformation:AcompletelistofthemembersoftheUSPreventiveServicesTaskForceappearsattheendofthisarticle.CorrespondingAuthor:CarolM.Mangione,MD,MSPH,DavidGeffenSchoolofMedicine,UniversityofCalifornia,LosAngeles,10940WilshireBlvd,Ste700,LosAngeles,CA90024().Children and adolescents aged 8 to 18 yearsBThe USPSTF recommends screening for anxiety in children and adolescents aged 8 to18 years.Children 7 years or youngerIThe USPSTF concludes that the current evidence is insufficient to assess the balance ofbenefits and harms of screening for anxiety in children 7 years or younger.PopulationRecommendationGradeSeethePracticeConsiderationssectionforadditionalinformationregardingtheIstatement.USPSTFindicatesUSPreventiveServicesTaskForce.ClinicalReview&EducationJAMA|USPreventiveServicesTaskForce|RECOMMENDATIONSTATEMENT1438JAMAOctober11,2022Volume328,Number14(Reprinted) 2022 American Medical Association.All rights reserved.Downloaded From:https:/ Traffic(NHT)by li li on 10/11/2022The USPSTF concludes that the evidence is insufficient onscreeningforanxietyinchildren7yearsoryounger.Evidenceontheaccuracyofscreeningtoolsandtheeffectsofscreeningandtreat-ment in this younger age group is lacking,and the balance of ben-efitsandharmscannotbedetermined.SeetheTableformoreinformationontheUSPSTFrecommen-dationrationaleandassessmentandtheeFigureintheSupplementfor information on the recommendation grade.See the Figure fora summary of the recommendation for clinicians.For more detailson the methods the USPSTF uses to determine the net benefit,seetheUSPSTFProcedureManual.5PracticeConsiderationsPatientPopulationUnderConsiderationThisrecommendationappliestochildrenandadolescents18yearsoryoungerwhodonothaveadiagnosedanxietydisorderorarenotshowingrecognizedsignsorsymptomsofanxiety.ConditionDefinitionsAnxiety disorders are characterized by greater duration or inten-sity of impairment of a stress response.The Diagnostic and Statis-tical Manual of Mental Disorders(Fifth Edition)recognizes 7 dif-ferent types of anxiety disorders in children and adolescents:generalized anxiety disorder(GAD),social anxiety disorder,panicdisorder,agoraphobia,specific phobias,separation anxiety disor-der,and selective mutism.2AssessmentofRiskRisk factors for anxiety disorders include genetic,personality,andenvironmental factors,such as attachment difficulties,interpa-rental conflict,parental overprotection,early parental separation,and child maltreatment.Demographic factors such as povertyand low socioeconomic status are also associated with higherrates of anxiety disorders.1,3,6-13The National Survey on LGBTQYouth Mental Health reported that 72%of lesbian,gay,bisexual,transgender,and queer youth and 77%of transgender and nonbi-nary youth described GAD symptoms.14According to the 2016NSCH,anxiety conditions were most common in older childrenand adolescents(aged 12 to 17 years)compared with youngerchildren(11 years or younger).15Previous studies suggested that Black youth may have lowerrates of mental health disorders compared with White youth.The2016 NSCH also found that anxiety conditions were more com-mon in non-Hispanic White children compared with children ofother racial or ethnic backgrounds.15However,recent cohorts ofBlack children or adolescents have reported a higher prevalenceof anxiety disorders than in the past.16Multiple factors,rangingfrom socioeconomic status,childhood adversity,family structure,and neighborhood effects,may influence patterns of prevalenceby race or ethnicity.1,3Adverse childhood experiences influencethe likelihood of experiencing mental health conditions such asanxiety.Adverse childhood experiences may result from a com-plex interaction of familial,peer,or societal factors,includingracial discrimination.These adverse childhood experiences maybe blatant or subtle(eg,microaggressions)but are potentiallytraumatic events that,in the context of historic trauma,structuralracism,and biopsychological vulnerability,can worsen mentalhealth outcomes.1,3,17Combined with lower engagement withmental health services,adverse childhood experiences can resultin high levels of unmet mental health needs in Black youth.1,3,18-22Similar patterns of historic trauma,adverse childhood experi-ences,and substance abuse may also explain higher rates of men-tal health disorders in Native American/Alaska Native youth.1,3ScreeningTestsAnxiety screening instruments that have been assessed by theUSPSTF are heterogeneous.Some screening instruments aredesigned to assess for a specific anxiety disorder(eg,the SocialPhobia and Anxiety Inventory for Children,which screens forsocial phobia and anxiety disorder),while others are designed toTable.SummaryofUSPSTFRationaleRationaleChildren(7 y or younger)Children and adolescents(aged 8 to 18 y)DetectionInadequateevidenceonscreeninginstrumentsforanxietyinchildren7yoryoungerinprimarycareAdequateevidencethataccuratescreeninginstrumentsareavailabletoidentifyanxietyinchildrenandadolescentsaged8to18yBenefitsofearlydetectionandintervention No direct evidence on benefits ofscreening for anxiety on healthoutcomes owing to a lack of studiesin children 7 years or younger Inadequate evidence on the benefitsof treatment in children 7 yearsor younger with anxiety No direct evidence on benefits of screening for anxiety on health outcomesowing to a lack of studies Adequate evidence that treatment of anxiety with psychotherapy is associatedwith a moderate magnitude of benefit(eg,treatment response,diseaseremission,or resolution)Adequate evidence to link screening and early treatment of anxiety to amoderate benefit in improving health outcomes such as treatment responseand disease remissionHarmsofearlydetectionandinterventionInadequateevidenceontheharmsofscreeningforortreatmentofanxietyinchildren7yoryounger No direct evidence on the harms of screening for anxiety owing to a lackof studies Adequate evidence to bound the magnitude of harms of screening andpsychotherapy as no greater than small,based on the likely minimal harms ofusing screening tools,limited evidence of treatment harms,and the natureof the intervention.(When direct evidence is limited,absent,or restricted toselect populations or clinical scenarios,the USPSTF may place conceptualupper or lower bounds on the magnitude of benefit or harms.)USPSTFassessmentThebenefitsandharmsofscreeningforanxietyinchildren7yoryoungerisuncertain,andthebalanceofbenefitsandharmscannotbedeterminedModeratecertaintythatscreeningforanxietyinchildrenandadolescentsaged8to18yhasamoderatenetbenefitinimprovingoutcomessuchastreatmentresponseanddiseaseremissionAbbreviation:USPSTF,USPreventiveServicesTaskForce.USPSTFRecommendation:ScreeningforAnxietyinChildrenandAdolescentsUSPreventiveServicesTaskForce ClinicalReview&E(Reprinted)JAMAOctober11,2022Volume328,Number141439 2022 American Medical Association.All rights reserved.Downloaded From:https:/ Traffic(NHT)by li li on 10/11/2022assess several anxiety disorders.Broader screening instrumentsused to identify children with several different anxiety disordersinclude the Screen for Child Anxiety Related Disorders(SCARED)(global anxiety and any anxiety disorder)and the Patient HealthQuestionnaireAdolescent(GAD and panic disorder).Many instruments that screen for anxiety were initially devel-oped for epidemiologic studies for surveillance or to evaluate re-sponse to treatment.Not all of the screening instruments are fea-sibleforuseinprimarycaresettingsbecauseoflength.1,3Currently,only2screeninginstrumentsarewidelyusedinclinicalpracticefordetectinganxiety:SCAREDandSocialPhobiaInventory.Anxietyscreeningtoolsalonearenotsufficienttodiagnoseanxi-ety.Ifthescreeningtestispositiveforanxiety,aconfirmatorydiag-nosticassessmentandfollow-upisrequired.ScreeningIntervalsThe USPSTF found no evidence on appropriate or recommendedscreening intervals,and the optimal interval is unknown.RepeatedFigure.ClinicianSummary:ScreeningforAnxietyinChildrenandAdolescentsWhat does the USPSTFrecommend?To whom does thisrecommendation apply?Whats new?How to implement thisrecommendation?The USPSTF recognizes that clinical decisions involve more considerations than evidence alone.Clinicians should understand the evidence but individualizedecisionmaking to the specific patient or situation.This recommendation applies to children and adolescents 18 years or younger who do not have a diagnosed anxiety disorderand who are not showing recognized signs or symptoms of anxiety.This is a new USPSTF recommendation.What additionalinformation shouldclinicians know aboutthis recommendation?Why is thisrecommendationand topic important?What are otherrelevant USPSTFrecommendations?What are additionaltools and resources?Anxiety disorder is a common mental health condition in the US.According to the 20182019 National Survey of Children s Health,7.8%of children and adolescents aged 3 to 17 years had a current anxiety disorder.Anxiety disorders in childhood and adolescenceare associated with an increased likelihood of a future anxiety disorder or depression.Screening for depression and suicide risk in children and adolescents Primary carebased interventions for illicit drug use in children,adolescents,and young adults Information on additional mental health recommendations in children and adolescents from the USPSTF are available at https:/www.uspreventiveservicestaskforce.org/.The Community Preventive Services Task Force recommends:Targeted schoolbased cognitive behavioral therapy programs to reduce depression and anxiety symptoms (https:/www.thecommunityguide.org/findings/mentalhealthtargetedschoolbasedcognitivebehavioral therapy-programsreducedepressionanxietysymptoms)Individual cognitive behavioral therapy for symptomatic youth who have been exposed to traumatic events (https:/www.thecommunityguide.org/findings/violencepsychologicalharmtraumaticeventsamongchildrenand-adolescentscognitiveindividual)Group cognitive behavioral therapy for symptomatic youth who have been exposed to traumatic events (https:/www.thecommunityguide.org/findings/violencepsychologicalharmtraumaticeventsamongchildren and-adolescentscognitivegroup)The Centers for Disease Control and Prevention has information on anxiety in childhood(https:/www.cdc.gov/childrensmentalhealth/depression.html)There are multiple treatment options available,including medications,counseling,a combination of these approaches,and collaborative care,which is a team approach where the primary care clinician works with a behavioral health care manager and psychiatrist to ensure patients receive the best care.Clinicians should be aware of the risk factors,signs,and symptoms of anxiety,listen to any patient concerns,and make sure that persons who need help get it.Youth diagnosed with anxiety and their health care professional should decide together with the parents or guardians what treatment is right for them.Although all youth aged 8 to 18 years are at risk for anxiety and should be screened,there are factors that increase the risk.Risk factors for anxiety disorders include genetic,personality,and environmental factors,such as attachment difficulties,conflict between parents,parental overprotection,early parental separation,and child mistreatment.Certain groups are also at increased risk,including LGBTQ youth,transgender youth,and older adolescents aged 12 to 17 years.In the absence of evidence,health care professionals should use their judgment based on individual patient circumstances when determining whether to screen for anxiety in youth 7 years or younger.Where to read the fullrecommendationstatement?Visit the USPSTF website(https:/www.uspreventiveservicestaskforce.org/)or the JAMA website(https:/ read the full recommendationstatement.This includes more details on the rationale of the recommendation,including benefits and harms;supporting evidence;and recommendations of others.Children and adolescents aged 8 to 18 years:Screen for anxiety.Grade:BChildren 7 years or younger:The evidence is insufficient to assess the balance of benefits and harms of screening for anxiety.I statementLGBTQindicateslesbian,gay,bisexual,transgender,queer;USPSTF,USPreventiveServicesTaskForce.ClinicalReview&Education USPreventiveServicesTaskForceUSPSTFRecommendation:ScreeningforAnxietyinChildrenandAdolescents1440JAMAOctober11,2022Volume328,Number14(Reprinted) 2022 American Medical Association.All rights reserved.Downloaded From:https:/ Traffic(NHT)by li li on 10/11/2022screening may be most productive in adolescents with risk factorsforanxiety.Opportunisticscreeningmaybeappropriateforadoles-cents,whomayhaveinfrequenthealthcarevisits.TreatmentorInterventionsTreatment for anxiety disorders can include psychotherapy,phar-macotherapy,a combination of both,or collaborative care.15Sev-eral psychotherapy approaches have been us