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Why a US task force is recommending anxiety screening in kids 8 and older

Up to 20% of US children have an anxiety disorder, and many suffer in silence.

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Anxiety is the most common mental health problem affecting U.S. children. Brian A. Jackson/iStock via Getty Images

The U.S. Preventive Services Task Force issued a draft statement in April 2022 recommending screening for anxiety in children and adolescents between the ages of 8 and 18. This recommendation – which is still open for public comment – is timely, given the impact of the COVID-19 pandemic on children’s mental health. The Conversation asked Elana Bernstein, a school psychologist who researches child and adolescent anxiety, to explain the task force’s new draft recommendations and what they might mean for kids, parents and providers.

1. Why is the task force recommending young kids be screened?

Nearly 80% of chronic mental health conditions emerge in childhood, and when help is eventually sought, it is often years after the problem’s onset. In general, recommendations to screen for mental health disorders are based on research demonstrating that youths do not typically seek help independently, and that parents and teachers are not always skilled at correctly identifying problems or knowing how to respond.

Anxiety is the most common mental health problem affecting children and adolescents. Epidemiological studies indicate that 7.1% of children are diagnosed with anxiety disorders. However, studies also estimate that upwards of 10% to 21% of children and adolescents struggle with an anxiety disorder and as many as 30% of children experience moderate anxiety that interferes with their daily functioning at some time in their life.

This tells us that many kids experience anxiety at a level that interferes with their daily functioning, even if they are never formally diagnosed. Additionally, there is an established evidence base for treating childhood anxiety.

The opportunity to prevent potentially chronic lifelong mental health conditions through a combination of early identification and evidence-based treatment certainly informed the task force’s recommendation. Untreated anxiety disorders in children result in added burdens to the public health system. So from a cost-benefit perspective, the cost-effectiveness of screening for anxiety and providing preventive treatment is favorable, while, as the task force pointed out, the harms are negligible.

The task force recommendation to screen kids as young as age 8 is driven by the research literature. Anxiety disorders are most likely to first show up during the elementary school years. And the typical age of onset for anxiety is among the earliest of all childhood mental health diagnoses.

Anxiety disorders can persist into adulthood, particularly those disorders with early onsets and those that are left untreated. Individuals who experience anxiety in childhood are more likely to deal with it in adulthood, too, along with other mental health disorders like depression and an overall diminished quality of life.

A discussion of the differences between normal worry and anxiety.

2. How can care providers identify anxiety in young kids?

Fortunately, in the past three decades, considerable advances have been made in mental health screening tools, including for anxiety. The evidence-based strategies for identifying anxiety in children and adolescents are centered on collecting observations from multiple perspectives, including child, parent and teacher, to provide a complete picture of the child’s functioning in school, at home and in the community.

Anxiety is what’s called an internalizing trait, meaning that the symptoms may not be observable to those around the person. This makes accurate identification more challenging, though certainly possible. Therefore, psychologists recommend including the child in the screening process to the degree possible based on age and development.

In general, it is easier to accurately identify anxiety when the child’s symptoms are behavioral in nature, such as refusing to go to school or avoiding social situations. While the task force recommended that screening take place in primary care settings, the research literature also supports in-school screening for mental health problems, including anxiety.

Among the youths who are actually treated for mental health problems, nearly two-thirds receive those services at school, making school-based screening a logical practice.

3. How would the screening be carried out?

Universal screening for all children is a preventive approach to identifying youths who are at risk. This includes those who may need further diagnostic evaluation or those would benefit from early intervention.

In both cases, the aim is to reduce symptoms and to prevent lifelong chronic mental health problems. But it is important to note that a screening does not equal a diagnosis. Diagnostic assessment is more in-depth and costs more, while screening is intended to be brief, efficient and cost-effective. Screening for anxiety in a primary care setting may involve completion of short questionnaires by the child and/or parent, similar to how pediatricians frequently screen kids for attention-deficit/hyperactivity disorder, or ADHD.

The task force did not recommend a single method or tool, nor a particular time interval, for screening. Instead, it pointed to multiple tools such as The Screen for Child Anxiety Related Emotional Disorders and the Pediatric Symptom Checklist. These assess general emotional and behavioral health, including questions specific to anxiety. Both are available at no cost.

A youth anxiety psychologist who experienced severe anxiety as a child talks about how to raise kids who can overcome anxiety.

4. What are care providers looking for when screening for anxiety?

A child’s symptoms can vary depending on the type of anxiety they have. For instance, social anxiety disorder involves fear and anxiety in social situations, while specific phobias involve fear of a particular stimulus, such as vomiting or thunderstorms. However, many anxiety disorders share symptoms, and children typically do not fit neatly into one category.

But psychologists typically observe some common patterns when it comes to anxiety. These include negative self-talk such as “I’m going to fail my math test” or “Everyone will laugh at me,” and emotion regulation difficulties, like increased tantrums, anger or sensitivity to criticism. Other typical patterns include behavioral avoidance, such as reluctance or refusal to participate in activities or interact with others.

Anxiety can also show up as physical symptoms that lack a root physiological cause. For example, a child may complain of stomachaches or headaches or general malaise. In fact, studies suggest that spotting youths with anxiety in pediatric settings may simply occur through identification of children with medically unexplained physical symptoms.

The distinction we are aiming for in screening is identifying the magnitude of symptoms and their impact. In other words, how much do they interfere with the child’s daily functioning? Some anxiety is normal and, in fact, necessary and helpful.

5. What are the recommendations for supporting kids with anxiety?

The key to an effective screening process is that it be connected to evidence-based care. One strategy that is clearly supported by research is for schools to establish a continuum of care that involves universal screening, schoolwide prevention programming and evidence-based treatment options.

The good news is that we have decades of high-quality research demonstrating how to effectively intervene to reduce symptoms and to help anxious youth cope and function better. These include both medical and nonmedical interventions like cognitive behavioral therapy, which studies show to be safe and effective.

Elana Bernstein has received funding from her organization to examine school-based practices for youth with anxiety. She is currently working collaboratively on a federally funded (HRSA) grant aimed at improving behavioral health workforce education and training. Additionally, as part of a national research team focused on improving mental health screening practices, she is collaborating to develop a screening tool for emotional well-being in teens. This project was recently funded through the Institute for Collaboration on Health, Intervention, and Policy at the University of Connecticut via their Mechanisms Underlying Mind-Body Interventions & Measurement of Emotional Well-Being (M3EWB) Network, which is funded through the NIH (Grant #: NIH U24AT011281).

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Spread & Containment

Ontario election gives voters the chance to choose people over profits in long-term care

Ontario voters can bring about change by prioritizing people over profits and casting our ballots for those committed to transforming long-term care into…

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Flowers sit on a bench in front of a for-profit long-term care home in Pickering, Ont., where dozen of seniors died of COVID-19, in April 2020. THE CANADIAN PRESS/Frank Gunn

In the wake of the COVID-19 pandemic, there’s a once-in-a-generation opportunity to correct how public funds will be allocated for long-term care in Ontario. The choice is between more profits for shareholders or reinvestment in care for seniors and improved working conditions for employees.

Ownership in Ontario’s publicly funded long-term care is currently split between two types of providers.

First, there are for-profit facilities, owned largely by real estate companies that hold and/or manage licences to provide care. My research has found that currently, 60.1 per cent of the beds are owned or managed by for-profits. This group is a mixture of public corporate chains, real estate investment trusts and private equity firms. Six in 10 people who live in long-term care in this province do so under a profit-taking model.

The second group are care homes that happen to own real estate and reinvest surplus back into the home. Nearly four of 10 bed licences (39.9 per cent) are owned by this group. The latter are typically called not-for-profit, although they may also be publicly owned.

Even before the pandemic, for-profit facilities were associated with significantly higher rates of mortality and hospital admission, suggesting there’s significantly worse quality of care overall in for-profit than in non-profit and public homes.

In addition, the devastation in long-term care during the height of the pandemic’s first and second waves happened mostly in for-profits, where a higher proportion of residents died. There was a 25 per cent higher risk of death from COVID-19 in for-profit facilities.

A row of white crosses on a green lawn. A small Canadian flag is attached to one of the crosses.
Crosses are displayed in memory of elderly people who died from COVID-19 at a for-profit long-term care facility in Mississauga, Ont., in November 2020. THE CANADIAN PRESS/Nathan Denette

Renegotiating licences

The Ontario government is currently approving licences with operators for up to 30 years. About one-third of the existing bed licences (26,531 beds) in 257 long-term care homes will expire by June 30, 2025. These licenses are in various stages of being renegotiated for the next 30 years.

The current government also announced there will be 30,000 new beds and 28,000 upgraded beds in place by 2028, also at various stages of approval. With the renewals, renovations and construction, what happens to long-term care licences in the next calendar year will shape the course of long-term care for the next 30 years.

A vote in this election therefore represents a choice between more for-profits or a move towards non-profit long-term care.


Read more: Canadians want home care, not long-term care facilities, after COVID-19


Long-term care licences can be very lucrative. Each new bed built is eligible for a construction funding subsidy, known as a CFS, calculated per day. The CFS ranges from $20.53 to $23.78 per day depending on where the home is located; large urban settings have higher subsidies. This is in addition to the funding an operator receives from government to provide care and food.

If a home has 160 beds, an additional 75 cents per bed per day is added to the subsidy. In the most expensive urban market with 160 beds (five units of 32 people), tax dollars will fund that organization $3,924.80 per day in capital costs to a maximum of $51,376 per bed — or a subsidy for the building of $8,220,160.

These subsidies are meant to cover between 10 to 17 per cent of capital costs. Rural beds are capped at a maximum subsidy of $29,246 per bed annually, while large urban centres cap at $51,376 per bed.

There are no upper limits on bed numbers, so it’s difficult to calculate the maximum subsidy. There are few homes in the province exceeding 160 beds, but that could change. The public doesn’t have a stake in the ownership of a home due to the subsidies.

Accommodation fees

Facilities also collect and retain rental accommodation fees from residents. For semi-private, shared nursing home rooms, a resident will pay $2,280.61 monthly at current rates, and for a private room, residents are charged up to $2,701.61 per month. Those living in for-profit retirement homes, many of whom are on waiting lists for a long-term care bed, are not included in this model.

If 60 per cent of the rooms are private and not shared, and assuming current accommodation rates, my calculations show the home will collect and retain $116,719,810 in accommodation fees over the 30-year licence, or nearly $4 million per year.

These funds collected for accommodation rental are completely separate from the funds publicly paid to support care, currently set at $187.73 per day for a home operating at 100 per cent based on the complexity of the needs of its residents.

If the current government or any successive government replicates past decisions, more than 65,000 Ontarians a year will live in a for-profit facility — many run by corporations focused on their real estate investments — in the next decade. If we follow a different path, these subsidies could fund operators that are primarily care organizations and where real estate holdings support the care, not the other way around.

A man pushes his walker as he strolls outside a long-term care home.
A man takes a walk outside the not-for-profit Seven Oaks Long-Term Care Home in Toronto in June 2020. THE CANADIAN PRESS/Frank Gunn

No one should assume they or their loved ones won’t need long-term care. All modern and caring societies have long-term care. The difference is that in countries like Norway, the focus is on high-quality, publicly delivered care, not on favouring for-profit real estate models.

Certainly not everyone will need long-term care. Not everyone needs open-heart surgery. But we do need high-quality public health care so that no one has to contemplate losing their life savings to survive. Those who need long-term care are among society’s most vulnerable members, and they deserve the very best quality of care and for every dollar to be invested in ensuring their care is top-notch.

No further study of this issue is required. Those living in for-profit facilities fare worse than those in non-profits and public homes.

In Ontario, we can prioritize people over profits by casting our ballots for those committed to transforming long-term care into a non-profit model focused on high-quality care. Know which party supports non-profit, long-term care and vote accordingly.

Tamara Daly receives funding from the Canadian Institutes of Health Research and Social Sciences and Humanities Research Council

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Economics

Hotels: Occupancy Rate Down 3.5% Compared to Same Week in 2019

From CoStar: STR: Weekly US Hotel Revenue per Available Room Reaches Highest Level Since July 2019U.S. hotel performance increased from the previous week, according to STR‘s latest data through May 21.May 15-21, 2022 (percentage change from comparable …

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U.S. hotel performance increased from the previous week, according to STR‘s latest data through May 21.

May 15-21, 2022 (percentage change from comparable week in 2019*):

Occupancy: 68.6% (-3.5%)
• Average daily rate (ADR): $151.75 (+13.4%)
• Revenue per available room (RevPAR): $104.06 (+9.5%)

*Due to the pandemic impact, STR is measuring recovery against comparable time periods from 2019.
emphasis added
The following graph shows the seasonal pattern for the hotel occupancy rate using the four-week average.

Click on graph for larger image.

The red line is for 2022, black is 2020, blue is the median, and dashed light blue is for 2021.  Dashed purple is 2019 (STR is comparing to a strong year for hotels).

The 4-week average of the occupancy rate above the median rate for the previous 20 years (Blue).

Note: Y-axis doesn't start at zero to better show the seasonal change.

The 4-week average of the occupancy rate will mostly move sideways seasonally until the summer travel season.

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Economics

“This Is A Crucible Moment” – Sequoia’s Ominous Warning To Companies On How To “Avoid The Death Spiral”

"This Is A Crucible Moment" – Sequoia’s Ominous Warning To Companies On How To "Avoid The Death Spiral"

"This is not a time to panic. It is…

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"This Is A Crucible Moment" - Sequoia's Ominous Warning To Companies On How To "Avoid The Death Spiral"

"This is not a time to panic. It is a time to pause and reassess," begins the thought-provoking presentation from veteran venture capital firm Sequoia Capital.

But that's about as 'positive' as they get as the founders of the firm warn of a prolonged market downturn and urges the startups in its portfolio to preserve cash and brace for worse to come.

"We believe this is a Crucible Moment, one that will present challenges and opportunities for many of you. First and foremost, we must recognize the changing environment and shift our mindset to respond with intention rather than regret."

And in its somewhat ubiquitous historically grim outlooks (its "R.I.P Good Times" in 2008 and "Black Swan" memo in March 2020 have become legendary) don't expect a quick rescue and recovery this time.

"Sustained inflation, and geopolitical conflicts further limit the ability for a quick-fix policy solution. As such, we do not believe that this is going to be another steep correction followed by an equally swift V-shaped recovery, like we saw at the outset of the pandemic," the note said.

They argue that it will be "Survival of the Quickest"...

In particular, Sequoia urged companies to look at cutting projects, R&D, marketing, and other expenses, noting that companies should be ready to cut in the next 30 days.

"We expect the market downturn to impact consumer behaviour, labour markets, supply chains and more. It will be a longer recovery and while we can't predict how long, we can advise you on ways to prepare and get through to the other side," it said.

The founders/CEOs who face reality, adapt fast, have discipline rather than regret will not just survive, but win, noting that "It is easier to preserve cash when you have more than six months left. Recruiting is about to get easier. All the FANG have hiring freezes."

They conclude their presenttation by noting that:

"At Sequoia, we believe that the one who wins is the one most prepared."

In other words America, brace for capex cuts, hiring freezes to accelerate, and growth to evaporate.

*  *  *

Read the full presentation below:

Tyler Durden Thu, 05/26/2022 - 15:45

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