Adolescence

The World Health Organisation (2022a) defines adolescence as a developmental period that extends from the age of 10 through to 19 years. Other researchers consider that adolescence lasts much longer, until approximately 25 years, at which time the body and the brain have completed their structural development (Siegel, 2014). Regardless of the varying specifications of exact ages, what remains undisputed is that adolescence is a transitional stage defined by significant cognitive, physical and socioemotional development with a view to achieving independence into adulthood (Chulani & Gordon, 2014).

As a result of the rapid changes that occur throughout adolescence, developmental challenges are commonplace across cognitive, social, behavioural and environmental domains. For example, as the adolescent brain develops, their reward circuitry becomes hypersensitive and the limbic system oversensitive. This is further exacerbated by an underdeveloped executive functioning region (Casey & Caudle, 2013; Galván, 2013). This results in an adolescent brain that emotively seeks out rewards without the balance of executive functions such as logic and reason (Sandor & Gürvit, 2019). This can lead to disrupted moods and risky behaviours, such as shoplifting; experimentation with drugs and alcohol; vandalism; unsafe use of vehicles and unsafe sex (Ahmed et al., 2020). These behavioural challenges are further impacted by the adolescent drive for social connection with peers and an elevation of peer opinion above that of caregivers (Blakemore, 2018). Throughout this period of connection-seeking and experimentation, adolescents are simultaneously developing their personal and social identity within the changing landscape of transitioning from primary to high school and for some, making their way into the workforce for the first time (Crocetti et al., 2018). All this occurs while physical changes are taking place, which for adolescents who enter puberty either early or late, can cause additional distress (Seligman & Gahr, 2013). The combination of these ongoing stressors throughout this lengthy developmental stage can lead adolescents to experience feelings of psychological distress which, for some adolescents, can develop into psychopathology.

Anxiety Disorder 

Anxiety Disorder (AD) is one of the most commonly reported mental health issues in adolescence (Australian Institute of Health and Welfare, 2021b). AD is an internalising disorder characterised by holding a future-oriented outlook that provokes feelings of unpredictability and uncontrollability that results in maladaptive responses to perceived dangers that negatively impact an individual’s life (Wicks-Nelson & Israel, 2015). According to the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association [APA], 2013a), AD includes Separation Anxiety Disorder, Social Anxiety Disorder, Panic Disorder, Specific Phobia, Selective Mutism, Agoraphobia and Generalised Anxiety Disorder. While recognising that there are nuanced and specific variations within the AD umbrella depending upon the focus of the adolescent’s anxiety, this report considers AD in general. AD can be present from childhood through to adulthood (APA, 2013). It has a median onset age of 11 years, prevalence rates estimated between five and 18 per cent and a relapse rate of approximately 30 per cent when shifting from adolescence into adulthood (Seligman & Gahr, 2013; Zavos et al., 2013).

AD can have deleterious impacts on everyday functioning resulting from its characteristic social withdrawal, which hinders the development of important adolescent social connections (Allen et al., 2018). Avoidance behaviours that originate in AD can impact on school attendance and involvement in extracurricular activities, such as sports. In turn, this can reduce the amount of physical activity an adolescent undertakes, which diminishes the protective factor that physical activity offers for mental wellbeing to combat mental ill-health, such as depression (Biddle et al., 2019). This is noteworthy as there is significant comorbidity between anxiety and depression (Zavos et al., 2013). Additionally, reduced physical activity can result in undesired changes to the adolescent’s physical development, impacting upon their body image. This is problematic because impaired self-image is commonly associated with adolescent AD (Di Blasi et al., 2015). Self-image not only incorporates body image, but includes social emotional aspects of perception of educational goals and relationships with friends and family (Di Blasi et al., 2015). In the presence of AD, these factors combine to have negative flow-on effects that become evident across life domains.

Evidence of Symptoms

The symptomatic evidence of AD can be seen across behavioural, cognitive and social contexts. Observed behaviours of anxiety include physiological symptoms such as headache, stomach ache, sweating, heart palpitations and shortness of breath (Beesdo et al., 2009). Sleep disturbance is also common (Zavos et al., 2013), which exacerbates the distractibility, irritability and excessive worrying that is characteristic of AD (Wicks-Nelson & Israel, 2015). Social withdrawal is often observed in adolescent AD (Ollendick & Ishikawa, 2013). This is further complicated by the incongruence of social withdrawal with the innate adolescent desire for social connection with peers. The implications become more far-reaching if school refusal or school dropout ensues (Aqeel & Rehna, 2020). Withdrawal, combined with avoidance behaviours leave ample scope for rumination, which can lead to further maladaptive responses such as self-harm (Stanford et al., 2017) and in some instances, suicidal ideation (Teismann & Forkmann, 2017).

As anxiety is an internalising disorder that originates in maladaptive client perceptions, it is recommended that data collection techniques used to assist in identifying AD should include informants from multiple domains, including the adolescent, their primary caregivers, teachers and clinicians (Creswell et al., 2021). Discrepancies are often found between reporters, in particular variances between the adolescent and primary caregiver report (Clementi & Alfano, 2013). Dillon-Naftolin (2016) attributes this to the varying emphases reporters have; such as adolescents more commonly reporting somatic symptoms and parents reporting behavioural symptoms. The Adaptive Behaviour Assessment System, Third Edition (ABAS-3) (Achenbach, 2013) is an assessment instrument that allows for multi-informant data gathering and is well-accepted as a comprehensive instrument that is aligned with DSM-5. While it is not within the parameters of a school Guidance Officer’s (GO) role to diagnose, the ABAS-3 is nominated as an approved psychoeducational test for Queensland Education GO administration under appropriate supervision (Department of Education, 2021a).

Impact on the Individual and Interactions

AD can have negative impacts on an individual that diminish their connection with peers, family and the broader community; may lead to reduced academic engagement; and, result in ongoing psychopathology into adulthood. The social withdrawal that is characteristic of AD can have significant consequences because adolescence is a key phase for building lifelong social competence, in tandem with the broadening of adolescent cognitive skills (de Lijster et al., 2018). Adolescents with AD report higher levels of interpersonal issues across life domains, including friendships, romantic partners, caregivers and teachers (Brumariu et al., 2012). While Neal et al. (2016) find that the transition from primary to high school can be a trigger for social withdrawal, Barzeva et al. (2020) find that for some adolescents with AD, this key transition can present as an opportunity for social reinvention. Therefore, transitions are a critical time of impact for adolescents with AD.

As children transition into adolescence, it becomes more common for adolescents to experiment with substances (Berge et al., 2016). However, male adolescents with AD are at a higher risk of substance misuse (Alfano, 2012). Interestingly, Rieselbach et al. (2022) find that AD in adolescent females is evidenced to serve as a protective factor for substance misuse; however, upon entering adulthood, AD increases the risk of substance misuse in adult females. An emerging field of research around other areas of misuse in adolescence investigates the links between mobile phone addiction and anxiety (Soni et al., 2017). While Akhther and Sopory (2022) find that technology can positively assist socially withdrawn adolescents to remain connected to peers, Yang et al. (2019) find a positive correlation between mobile phone addiction and anxiety. Overuse of technology can also result in insufficient sleep (Lemola et al., 2014). Roberts and Duong (2016) find that insufficient sleep during adolescence significantly increases the risk of AD onset. Therefore it is apparent that overuse of mobile phones may trigger AD.

While Jarrett et al. (2015) report that adolescent AD is associated with lower academic performance, de Lijster et al. (2018) find that academic results are not impacted. This discrepancy may be mediated by the perfectionistic tendencies of some adolescents with AD (Lyman & Luthar, 2014). Thus, in spite of increased school absenteeism that often results from somatic complaints of headache and stomach ache, adolescents with AD strive to achieve academically (Allen et al., 2018). Regardless of the debate around the immediate impact on academic results, Seligman and Gahr (2013) report links between increased prevalence of AD in mid-adolescence with a significantly reduced likelihood of entering tertiary education. In turn, this can impact on important life domains into adulthood, such as employability (Creswell et al., 2021). Thus it is evident that if left untreated, AD can cause negative impacts on immediate daily functioning as well as having long-term implications on mental health and employability.

Suggested Interventions

Given the far-reaching implications of untreated anxiety, the development of an Individual Support Plan (ISP) that promotes an integrated support approach across the various domains of an adolescent’s life is beneficial. An ISP may include strategies for parents, such as encouraging healthy sleep hygiene in the home (McMakin et al., 2019); teachers, such as celebrating effort over achievement to alleviate perfectionistic tendencies (Schleider & Weisz, 2018); and strategies for the adolescent, which could include active participation in anxiety-focused Cognitive Behaviour Therapy (CBT). Anxiety-focused CBT is well-established as an effective evidenced-based intervention for AD (Bennett et al., 2016; Sburlati, 2014). CBT addresses the maladaptive thought patterns characteristic of AD through cognitive restructuring, recognising affect, relaxation techniques and psychoeducation (Baourda et al., 2021; Silfvernagel et al., 2015). By targeting these key areas, the impacts of AD, including social withdrawal, poor social development, disturbed sleep, perfectionism and substance abuse can be mediated. Recognising and treating adolescent AD is critical to help adolescents build a toolkit of strategies that they can draw on to maintain mental health throughout their significant transition into adulthood.