Improving Anxiety Detection in Pediatrics Using Health Information Technology

Physicians face numerous challenges when evaluating children with inattentive symptoms. Mental health and behavioral (MHB) disorders are complex, and there is no specific test to confirm diagnosis. Similar behaviors are also observed among children with anxiety, which is even more common than attention deficit hyperactivity disorder (ADHD), but is under-diagnosed and can coexist with ADHD. Over time, children with unrecognized anxiety may be prescribed ADHD medications or even multiple psychotropic medications for persistent inattentive symptoms.

The project team revised their Child Health Improvement through Computer Automation (CHICA) clinical decision support (CDS) system, which supports implementation of guidelines for preventive and chronic care management in pediatric primary care. The ADHD module in CHICA was enhanced to include an anxiety-specific validated screening tool, the 41-item Screen for Childhood Anxiety Related Emotional Disorders (SCARED). CHICA automatically scores the SCARED screening tool and generates a report with interpretations. In addition, a one-page handout about pediatric anxiety was developed for families.

The specific aims of the project were as follows:

• Expand and modify the CHICA CDS to improve the diagnostic processes for screening children with inattention, including screening in the waiting room, physician prompts, and tailored diagnostic and brief counseling tools. 
• Improve physician awareness of identification and referral patterns for children presenting with inattentive symptoms by providing run charts for each physician of their screening, referral, and medication-prescribing patterns, paired with facilitated discussion to share strategies to improve diagnostic process and obtain preliminary feedback for future development of a comprehensive anxiety module. 
• Examine the effect of the CHICA anxiety module on the diagnostic processes of physicians when screening children with inattentive symptoms. 

The project was completed in two phases: the first to develop the anxiety module and the second to pilot the tool with a randomized controlled feasibility study. In the first phase, CHICA user group meetings were convened at two intervention clinics to obtain input into needs of the module, workflow concerns, and feedback on existing educational tools and resources. Revised algorithms for the anxiety module and patient handouts for ADHD and anxiety were presented and reviewed. During the pilot phase, the two intervention clinics had access to CHICA and the revised ADHD anxiety module, while the two control clinics had access to CHICA and the usual ADHD module. During the 12-month feasibility study, more than 3,000 children were eligible for the SCARED tool; however, use of the tool was low and there was no significant difference between the intervention and control groups with regard to detecting anxiety.

The project team conducted interviews with caregivers and providers to understand their experience with using the module. While one caregiver described the tool as helpful for understanding anxiety, several others indicated it was too long and difficult to understand. Providers also voiced concern about the length of the SCARED tool, but said it was a useful reminder to consider anxiety in addition to ADHD. The project team concluded that, despite inconsistent use of the tool, the revised module and interactions with the study team have been enough to prompt providers to think about anxiety as a possibility and distinguish ADHD from anxiety.