Adolescence

Adolescence is described by Geldard et al. (2019) as the development period between childhood and adulthood. During adolescence individuals are faced with multiple challenges including biological, cognitive, psychological and social which can contribute to increasing feelings of anxiety.

Anxiety

Anxiety is a basic human emotion, however when it becomes prolonged, with heightened levels of discomfort and impacts normal daily functioning it becomes a mental health concern (APA, 2015; Wicks-Nelson & Israel, 2015). While anxiety can occur over the lifespan of an individual, it is the most commonly reported disorder experienced by adolescents (Wicks-Nelson & Israel, 2015) with the median age of onset being teens to twenties. The Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; APA, 2013a) lists 11 anxiety disorders:

• Separation anxiety disorder,
• Selective mutism,
• Specific phobia,
• Social anxiety disorder (social phobia),
• Panic disorder,
• Agoraphobia,
• Generalized anxiety disorder,
• Substance/medication-induced anxiety disorder,
• Anxiety disorder due to another medical condition,
• Other specified anxiety disorder, Unspecified anxiety disorder.

Each of the 11 anxiety disorders has specific diagnostic criteria. However, commonly observed behaviours are avoidance, distress, physiological indicators such as blushing, sweating, shaking. The degree to which the behaviours are demonstrated impact the severity on how the individual can function. For example, in the school setting, social anxiety may present as a student avoiding eye contact in a group setting and remaining on the periphery with limited verbal engagement, or it may present as panic attacks at the school gate, creating severe distress, somatic pains such as stomach ache and school refusal impacting their own education and family routines. In the home situation, separation anxiety disorder may range from a child who seeks constant proximal closeness or frequent eye contact with a parent, to a child who cannot sleep in their own room and frequently has nightmares about being separated, lost or searching for their parent disturbing their own and the families sleep patterns. Each anxiety disorder has unique criteria, however, comorbidity is common (APA, 2013a).

Internationally, anxiety is the most prevalent psychiatric condition with 10 to15% of patients diagnosed with an anxiety disorder and 40% of new clinical referrals related to anxiety (APA, 2015). In Australia, between 2017 and 2018 a reported 3.2 million individuals had an anxiety related condition representing 13.1% of the population (Australian Bureau of Statistics, 2018). Concerningly, individuals diagnosed with one of more anxiety disorders have a heightened risk of suicide attempt or suicide ideation (APA, 2015). Many anxiety disorders developed in childhood persist into adolescence and beyond if not treated (APA, 2015).

Evidence of Symptoms 

Adolescence has already been outlined as a period of development where behavioural changes, thought processes and social challenges can be observed in individuals. The delimitation between what may be considered atypical ‘storm and stress’ responses and indicators of anxiety disorders requires observation and data collection over an extended period of time and multiple settings.

Thought processes include, but are not limited to, a pre-occupation of excessive worry, trouble concentrating, feelings of impending danger, worrying excessively or irrationally about key people in their lives, mind going blank or worry about catastrophic events such as nuclear war, earthquake (APA, 2015).

Observable indicators include appearing nervous, restless or tense, irritable and distressed, potentially sweating, shaking, and breathing rapidly. Somatic stomach-aches, dizziness and headaches may also present. Seeking perfectionism in tasks or becoming increasingly withdrawn may become evident in observations (APA, 2015; Wicks-Nelson & Israel, 2012).

Avoidance of people or situations that trigger feelings of anxiety (American Academy of Child and Adolescent Psychiatry, 2022). This may present as being absent from school during assessment periods, or eating alone in the library to avoid peer group conversations. In the home setting it may look like the adolescent withdrawing from everyone, refusing to engage with peers, hobbies or even family.

Data collection will support case conceptualisation and begin to differentiate between anxiety symptomology and typical adolescent challenges. Collecting pre-existing data from Queensland schools system, OneSchool, can give background information and potentially identify an overall pattern of behaviour, attendance and academic achievement. Previous reports or records of social emotional interventions can provide valuable information and a timeline for consideration. Reviewing records of contact may provide an indicator of the mesosystem relationship and any potential life changes in family settings.  Interviews with the adolescent and/or close significant family members can provide information on the level of impact across various contexts and, importantly, how long feelings of anxiety have been present (essential for anxiety diagnosis). Potentially the use of a norm-referenced test for anxiety screening, such as the Spence Children’s Anxiety Scale (Spence, 1998), suitable for adolescents up to the age of 16. Caution must be taken using anxiety screeners as most assess frequency of symptomology and neglect to assess the functional impact on life over an extended period of time (Krygsman & Vaillancourt, 2022).

Impact on the Individual and Interactions

Feelings of anxiety, particularly social anxiety which is the most prevalent anxiety disorder diagnosed during the adolescence (Krygsman & Vaillancourt, 2022) impact the extent to which the individual socialises and integrates with peers, family and society.  Avoidance and withdrawal is a common symptom of social anxiety and can be pervasive impacting all aspects of the adolescent life, the impact of which is discussed next.

Withdrawing from social interactions may result in feelings of isolation, loneliness and exacerbate cognitive egocentric thinking beliefs that no one understands what they are going through (Geldard et al., 2019).  Social anxiety is linked to lowering of self-esteem, poor self-concept and future depressive episodes (American Academy of Child and Adolescent Psychiatry, 2022; Krygsman & Vaillancourt, 2022). Complete withdrawal may include school refusal impacting academic performance. Social media comparison may act as a trigger for the adolescent who is becoming more self-reflective and awareness of physical changes. Physiological symptoms, or the thought of displaying symptoms such as sweating or blushing may also trigger anxiety.

Avoidance of social settings and peers, including school and extra-curricular activities may result in a diminished circle of friends. Worry around what peers think of how they look, how they behave may become all-consuming and lead to further withdrawal. Alternatively, risk taking behaviour in the form of substance abuse, to lower inhibitions and become more relaxed to interact with peers may occur where the adolescent becomes boisterous or adopting clowning behaviour to cover anxiety (Krygsman & Vaillancourt, 2022).  Triggers for anxiety may include situations where attention may be on the individual such as group assessments at school where they as required to contribute or social parties where the egocentric thinking natural in this development period leads them to believe everyone’s attention is on them.

The family unit may become temporarily dysfunctional as parents and caregivers adapt to the adolescent’s behaviours, emotions, and moods. A permissive parenting style may perpetuate or heighten feelings of anxiety. Caregivers may need to adapt practises such as speaking on behalf of the child, providing special meals away from the family and facilitating school refusal which have been shown to prolong social anxiety (Norman et al., 2015).

Complete withdrawal may lead to agoraphobia, or fear of open spaces limiting the individual’s opportunities to engage in the wider community. This may limit exposure to social norms, experiences and adolescent adaptation.

Suggested Interventions

An initial treatment phase of Rational Emotional Behaviour Therapy (REBT) may be recommended for the adolescent experiencing anxiety disorders. This therapy centres around the presupposition that thoughts, perceptions and beliefs create the emotional state rather than external stimulus (Corey, 2016). To effect change therefore, REBT relies on challenging, disputing and thinking differently around perspectives. The timing of this approach for adolescents is particularly relevant as their cognitive development shifts to a more abstract level of thinking allowing them to explore other people’s perspectives.

The Guidance Officer and adolescent adopt a collaborative approach exploring self-defeating beliefs, irrational thinking and self-constructed truths. Collaboration is imperative for the adolescent whose egocentric thinking may make them feel unique and like no-one understands them (Geldard et al., 2019). REBT promotes the power of choice over emotional response therefore facilitating autonomy as part of the individuation process (Dobson, 2009).

REBT may require several sessions and typically involve homework such as listing self-defeating thoughts, identifying frequency of anxiety, duration and self-rating levels of anxiety providing a further degree of autonomy. Self-identification of antecedents to feelings of anxiety across multiple systems – home, peer and school may also provide distinguishing factors for specific anxiety disorders (Dobson, 2009).