Pediatric Mental Health Screening: How to Spot Early Anxiety and Depression

Kids with anxiety frequently present with physical complaints before they ever dOne of the things I love most about primary care is the opportunity to build relationships with kids and their families. If you earn a child’s trust, they’ll often tell you things they haven’t shared with anyone else, sometimes not even their parents or caregivers. But not every child comes right out and says, “I’m feeling anxious.” Or “I think I’m depressed.” More often, they come in with headaches, stomach aches, trouble sleeping, slipping grades, or a parent who says, “They’re just not acting like themself anymore.”

That’s where we come in. Pediatricians and primary care clinicians are usually the first to see these kids, often at routine well-child visits, which makes early identification part of our job whether we signed up for it or not.

Anxiety is the most common mental health disorder in childhood, affecting approximately 1 in 12 children and 1 in 4 adolescents¹ at some point. Depression and other mood disorders are also increasingly common and often go unrecognized, particularly in teenagers whose symptoms can masquerade as irritability, anger, aggression, conduct problems, or withdrawal. Catching these conditions early can change the trajectory of a child’s life.

Looking for Anxiety Beneath the Surface

Sometimes anxiety is easy to recognize: a child who worries constantly, avoids school, or refuses to separate from a parent. But often, it’s much more subtle.

Describe feeling anxious. Recurrent headaches, abdominal pain, nausea, fatigue, sleep difficulties, perfectionism, irritability, or frequent visits to the school nurse can all be clues. Some children become overly compliant while others appear oppositional or have frequent emotional outbursts.

Keep the differential broad, too. Inattention and restlessness can look like attention-deficit/hyperactivity disorder (ADHD), school avoidance can follow bullying, and anxiety is especially common in children with autism spectrum disorder.

Of course, not every child with stomachaches has anxiety. But when symptoms are persistent, interfere with daily functioning, and seem disproportionate to the situation, it’s worth digging deeper. Fortunately, you don’t have to rely on clinical judgment alone. In my practice, I often use the SCARED screening questionnaire (Screen for Child Anxiety Related Emotional Disorders), which is validated for children ages 8-18 years, or the GAD-7 (Generalized Anxiety Disorder-7 item) for older adolescents. The Pediatric Symptom Checklist is another good option when you want a broad psychosocial screen at well-child visits rather than an anxiety-specific tool. These tools don’t make the diagnosis, but they can help identify children who need a more comprehensive evaluation.

Depression Doesn’t Always Look Like Sadness

Depression in children and adolescents can be surprisingly easy to miss. Adults often picture depression as persistent sadness, but many kids (especially teenagers) present with irritability instead. Others simply stop doing the things they used to enjoy.

Early signs may include:

• Persistent sadness or irritability

• Loss of interest in previous enjoyable activities

• Sleep or appetite changes

• Fatigue or low energy

• Difficulty concentrating

• Declining academic performance

• Social withdrawal

• Feelings of worthlessness or excessive guilt

The PHQ-9 and PHQ-A are validated, widely available screening tools that fit easily into a primary care visit and can help identify adolescents who need additional assessment. Some behavioral changes should always prompt a deeper conversation:

• Loss of interest in friends or favorite activities

• Significant decline in school performance

• Marked changes in eating or sleeping (and remember that eating disorders and depression often travel together)

• Giving away valued possessions

• Talking about death or wishing they weren’t alive

• Increasing isolation from family or peers

• Expressions of hopelessness or feeling like a burden

Screening Recommendations: Don’t Wait for Symptoms

One of the biggest shifts in pediatric mental health is that we no longer wait until concerns are obvious.

The USPSTF recommends annual screening for anxiety disorders² in all children aged 8 years and older, regardless of whether symptoms are present. Annual depression screening³ is recommended beginning at age 12.

The American Academy of Pediatrics also recommends annual suicide risk screening⁴ for all youth aged 12 and older, with screening whenever clinically indicated for younger children. The Ask Suicide-Screening Questions (ASQ) tool is a validated, free, four-question screen that takes less than a minute and fits into nearly any visit.

It’s important to remember that screening tools are just that: screening tools. A positive screen should always be followed by a diagnostic assessment⁵ that includes clinical interview, caregiver input, psychosocial history (including bullying, food insecurity, and other social determinants of health), screening for trauma exposure, substance use assessment when appropriate, and evaluation for suicide risk.

What if a Child Screens Positive for Suicidal Thoughts?

This is the moment that makes many clinicians nervous, but having a plan helps. If a child endorses suicidal ideation on a screening tool like the ASQ or during your interview, don’t panic, and don’t avoid asking more questions.

Instead, assess:

• Are they having passive thoughts (“I wish I wouldn’t wake up”) or active suicidal thoughts?

• Do they have a plan?

• Do they have the means to carry out the plan (for example, access to a firearm)?

• Have they attempted suicide before?

• What protective factors exist, such as supportive caregivers, future goals, or trusted adults?

Current suicidal intent, a specific plan, access to lethal means, inability to maintain safety, psychosis, or severe intoxication all warrant immediate psychiatric evaluation — often through the emergency department or a crisis service.

Not every child who reports suicidal thoughts requires hospitalization. Many adolescents experience passive suicidal ideation without imminent intent. That’s where a thoughtful risk assessment is so important.

When Should You Create a Safety Plan?

A safety plan is appropriate for patients who have suicidal thoughts but are considered safe for outpatient management after a comprehensive assessment. Unlike a no-harm or no-suicide contract, which has not been shown to reduce suicide risk, a collaborative safety plan⁴ gives patients concrete steps to follow during a crisis.

A good safety plan includes:

• Personal warning signs that a crisis is developing

• Coping strategies that the child can try independently

• Trusted adults they can contact

• Crisis resources, including the 988 Suicide and Crisis Lifeline

• Restricting access to lethal means, including firearms and medications

• A clear plan for follow-up

Just as importantly, involve caregivers whenever it is safe to do so. Parents should understand the safety plan, know what warning signs to watch for, and help make the home environment safer by limiting access to medications, firearms, and other potentially lethal means. Means restriction is one of the most effective suicide prevention tools we have.

Primary Care Clinicians Make a Difference

When you’re on the front lines caring for kids, it’s worth taking a few extra minutes to explore changes in mood, behavior, or functioning that don’t quite fit the rest of the clinical picture. We may not be child psychiatrists, but we are often the first clinicians families trust with these conversations. Identifying anxiety, depression, or suicide risk early can open the door to treatment, support, and hope long before a child reaches a crisis. Sometimes that means cognitive behavioral therapy (CBT). Sometimes it means a referral to a mental health specialist. Sometimes it starts with one honest conversation in your exam room.

Caring for mental health isn’t separate from caring for the whole child; it’s an essential part of it.

References:

1. Kowalchuk A, Gonzalez SJ, Zoorob RJ. Anxiety disorders in children and adolescents. Am Fam Physician. 2022;106(6):657-664.

2. US Preventive Services Task Force. Screening for anxiety in children and adolescents: US Preventive Services Task Force recommendation statement. JAMA. 2022;328(14):1438-1444. doi:10.1001/jama.2022.16936

3. US Preventive Services Task Force. Screening for depression and suicide risk in children and adolescents: US Preventive Services Task Force recommendation statement. JAMA. 2022;328(15):1534-1542. doi:10.1001/jama.2022.16946

4. Hua LL, Lee J, Rahmandar MH, Sigel EJ; Committee on Adolescence; Council on Injury, Violence, and Poison Prevention. Suicide and suicide risk in adolescents. Pediatrics. 2024;153(1):e2023064800. doi:10.1542/peds.2023-064800

5. Weitzman C, Guevara J, Curtin M, Macias M; AAP Section on Developmental and Behavioral Pediatrics; AAP Council on Early Childhood; AAP Committee on Psychosocial Aspects of Child and Family Health; Society for Developmental and Behavioral Pediatrics. Promoting optimal development: screening for mental health, emotional, and behavioral problems: clinical report. Pediatrics. 2025;156(3):e2025073172. doi:10.1542/peds.2025-073172