Adolescence

Different life stages present differing personal challenges and the adolescent stage is no exception. Adolescence is the multi-dimensional and culturally influenced stage of life when an individual moves from childhood into adulthood, typically taking place from the age of 11 until 18 years of age (Geldard et al., 2019). It is often characterised by emotional reactivity, a decreased ability to tolerate change and disruptive emotions (Geldard et al., 2019). It is a transitional period, biologically, psychologically, socially and economically with remarkable changes happening cognitively and sexually with the individual becoming more self-aware, independent and future-oriented (Steinberg, 2014). An adolescent can experience a decrease in their level of self-control and an increase in their sensitivity. The World Health Organisation (2021a) highlights that mental health conditions, emotional disorders, behavioural disorders, eating disorders, psychosis, suicide and self-harm and risk-taking behaviours begin in the adolescent years due to physical, emotional and social changes and challenges.

Anxiety

Anxiety is an internalising disorder. Barlow (2002) characterises anxiety as a future-oriented emotion with feelings that events are potentially uncontrollable, unpredictable, dangerous or adverse and the response is unknown. Often the terms fear (a reaction to a threat) and worry (intrusive negative outcome thoughts) are used synonymously with anxiety, and it is only when these common emotions become persistent, intense, inappropriate and interfere with functioning that intervention is required (Geldard et al., 2019).

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (5th ed; DSM-5; APA, 2013) includes separation anxiety disorder, specific phobia, social anxiety disorder, selective mutism, panic disorder, agoraphobia and generalised anxiety disorder under the anxiety disorders diagnosis. Related disorders such as obsessive-compulsive disorder, posttraumatic stress disorder, acute stress disorder, reactive attachment disorder and disinhibited social engagement disorder are included in a separate section, however, it is suggested that adolescents can display various symptoms occurring together and are likely to meet the criteria for more than one disorder (Geldard et al., 2019). Miller (2022b) explains that some adolescents who present with anxiety struggle with anxiety-related problems for years prior, others develop symptoms in their teenage years citing social anxiety and panic attacks as the main disorders experienced. Geldard et al. (2019) state generalised anxiety disorder, social phobia, specific phobia and obsessive-compulsive disorder as common types young people experience.

Experiencing anxiety is typical when it is consistent with the requirements of a situation and may help increase awareness and performance, however, if the anxiety level is too high and the situation does not require such a level, anxiety can be debilitating (Geldard et al., 2019). Observed behaviours include agitation, insomnia, panic attacks, obsessions, compulsions, excessive worry and rumination (Mansberg & Lamble, 2021). The impact on daily functioning can include school refusal due to attempting to avoid anxious feelings which can result in reduced academic performance and involvement in extracurricular activities and self-esteem issues (American Academy of Adolescent Child and Psychiatry [AACAP], 2022). The individual may be reluctant to leave home and struggle to attend activities, sports, social or family events; may seek excessive reassurance about identity and ability; possibly engage in self-destructive behaviours like turning to alcohol and drugs to self-medicate or develop rituals in an effort to reduce or prevent anxiety (AACAP, 2022).

Evidence of Symptoms 

Behaviourally, symptoms such as nervousness, restlessness, sleep problems, irritable and depressed mood, muscular tension and fatigue could be observed especially if generalised anxiety disorder is present (Geldard et al., 2019). Cognitively, poor concentration, unpleasant and intrusive thoughts and irrational and persistent fear could be observed in adolescents suffering from obsessive-compulsive disorder and specific phobia, with avoidance behaviours in social or performance situations evident in social phobia cases (Geldard et al., 2019). Physical behaviours that may be observed include breathing difficulties, chest pains, perspiration, accelerated heart rate and feeling separated from reality during panic attacks and repetitive actions and compulsions in individuals with obsessive-compulsive disorder (Mansberg & Lamble, 2021). Sleep problems may be observed due to melatonin, the hormone that induces sleep, being released up to two hours later than it is in children and adults, which delays sleepiness in adolescents and with early morning rises for school, sleep deprivation can cause anxiety and exacerbate the condition if it already exists (Young, 2022). School refusal is often a symptom as trying to avoid negative thoughts and feelings is sometimes the anxiety-related reason (Mansberg & Lamble, 2021). Being unable to relax, feeling annoyed or irritated by others or events, avoiding people or places and withdrawing from family and friends are symptoms visible in social contexts (Headspace, 2021b).

There is a wide variety of self-tests or self-report questionnaires available for the individual or parent to complete, many are on-line and freely available from websites such as Black Dog Institute (www.blackdoginstitute.org.au), Mind Spot (www.mindspot.org.au), Beyond Blue (www.beyondblue.org.au) and Headspace (headspace.org.au). Screening and assessment tools such as the Beck’s Anxiety Inventory (Beck et al., 1988), the Depression Anxiety Stress Scales (Lovibond & Lovibond, 1995), the Hamilton Anxiety Scale (Hamilton, 1959), and the Yale-Brown Obsessive Compulsive Scale (Goodman et al., 1989; Heninger et al., 1989) assist with identifying when a more detailed assessment is necessary (Headspace, n.d.). A doctor is required for a formal diagnosis of the type of anxiety disorder based on recognised criteria such as those listed in the DSM-5 (Healthdirect, 2020a).

Impact on the Individual and Interactions

The impact on an adolescent with anxiety can be debilitating. Dealing with physical responses such as a racing heart, breathlessness, tense feelings with aches and pains especially in the neck, shoulders and back, perspiring and feeling dizzy, shaky and nauseous can cause an individual to become withdrawn and isolated trying to avoid these symptoms (Headspace, 2021b). Isolating and withdrawing limits family, social and educational interaction. An adolescent with a mental health problem can pose challenges for parents, siblings, relatives and family friends. It can breed resentment as they can be seen as being manipulative and attention seeking, particularly to siblings, if the adolescent is receiving more consideration than others (Mansberg & Lamble, 2021). Family relationships can become strained and may affect the family’s connection with relatives and their social network, isolating the family from potential support sources (Youth.gov, n.d.). Alternatively, it could bring the family closer as they work together to support their child and seek interventions and help.

Throughout adolescence, greater importance is placed on peer and social interaction and with a still developing brain comes increased vulnerability to misinterpreting social cues, emotions or intentions of others, and poses the potential for conflict, exclusion, or broken friendships fuelling anxiety (Young, 2022). The fear of missing out (FOMO) and fear of being left out (FOBLO) are modern day worries and triggers derived from social media use. Comparing attractiveness, lifestyles, materialistic possessions and friends can leave many adolescents with low self-esteem. Recent studies have shown the longer the amount of time spent on social media connects with a higher risk of anxiety and depression including social anxiety, issues with eating and sleep problems (Mansberg & Lamble, 2021). Anxiety is also more common in adolescents who identify as LGBTQIA+, pansexual or asexual and appear to be worse for those from rural or suburban areas (Mansberg & Lamble, 2021).

Suggested Interventions

Anxiety interventions and support depends on individual circumstances and the type of anxiety disorder present. Lifestyle changes such as regular physical exercise and adequate sleep and nutrition may help mild anxiety sufferers, whereas more severe cases may require medication, intensive therapy or both (Healthdirect, 2020a). A Guidance Officer in a school setting can develop an Individual Support Plan for an adolescent with anxiety and details will depend on the severity of symptoms, available health services, other presenting health issues, the support network including family, friends and school supports and the individual’s preference for a particular treatment approach (Headspace, n.d.).

The support plan could include the guidance officer offering counselling sessions that promote a therapeutic alliance and collaboration on the approach, skill development, stress management and the use of cognitive behavioural therapy (CBT). CBT is the most researched treatment for anxiety in young people and has been found to reduce symptoms of anxiety, post-traumatic stress disorder and obsessive-compulsive disorder in adolescents (Headspace, n.d.). In CBT, patterns of thinking and behaviour that are prone to cause anxiety are recognised and changes are devised to replace the patterns with ones that help reduce feelings of anxiousness and enhance coping (Reavley et al., 2019).

The therapy involves helping individuals to recognise anxious feelings and somatic reactions, clarify thoughts in triggering situations, develop coping skills and evaluate outcomes (James et al., 2015). Modelling, reality exposure, role playing and relaxation training can be offered as behavioural strategies and are based on the premise that fear and anxiety are learnt responses and can be reversed (James et al., 2015). Cognitive strategies such as self-control approaches can be taught and include a step by step process such as first identifying when anxious feelings occur, identify associated thoughts, modify or restructure feelings by creating alternative coping thoughts or behaviours and finally, rewarding and praising for confronting fears (James et al., 2015). CBT can be adapted to include parents and family and can involve identifying ways to assist and respond to their child’s behaviours and even help parents to manage their own anxiety (James et al., 2015).

As in all cases, if attempts at the school and home level do not succeed then further help is required. Referrals to medical and psychological professionals should occur with relevant authorities, such as child safety, being alerted if the family are not responding with the help and support required and the adolescent is suffering.