Adolescence

The developmental period of adolescence is characterised by many cognitive, behavioural, social and environmental transformations simultaneously occurring (Geldard et al., 2019).  Puberty, and the biological changes that ensue, typically initiate the onset of adolescence.  Such radical hormonal and physical changes can be challenging as each individual matures differently. These changes are often coupled with greater introspection and may lead to heightened sensitivity regarding self image.  At the same time, sexual maturation is occurring, causing increased interest in sexual identity, orientation and behaviour.

As the body, mind and identity of each adolescent transforms, so to do the social structures that they interact with and which surrounds them. Changes in friendship groups, the desire to individualise outside of the family, independent participation of interests, and identity exploration all contribute to new and challenging situations that require resilience, emotional strength, help seeking skills and adaptive coping behaviours from the adolescent.

During adolescence, the young person’s brain undergoes a transformation, resulting in many new thinking skills. During this transformation, brain plasticity may result in heightened impulsivity, risky behaviour, emotional turbulence, increased responsiveness to rewards / stress and a rise in perceived ‘boredom’ (Geldard et al., 2019; Romeo, 2013). Dangerous driving, drinking, smoking, substance experimentation, and sexual exploration all become significant challenges that may face adolescents during this stage.

Major social challenges also arise at this developmental point. Power struggles between parents and adolescents can occur as young people seek to individualise. Peer pressure becomes a strong factor in decision making and egocentric thinking tends to make adolescents overly aware of their self image and the perceptions of others.  These challenges are exacerbated by conflicting environmental attitudes between their parents, themselves and the new environments they exist within.

Anxiety

Anxiety is a growing problem among Australian adolescents. In 2015, the prevalence rate for anxiety disorders in adolescents aged 12 to 17 was 7% (Lawrence et al., 2015).  There are however, a wide range of disorders that fit under the ‘anxiety’ umbrella. The Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; APA, 2013b) recently created 3 anxiety categories: anxiety disorders, obsessive compulsive disorders, and trauma and stressor related disorders (APA, 2013b). The first category alone includes seven distinct disorders. Each anxiety disorder may have differing observable behaviours, symptoms, triggers, impacts, risk factors, protective factors, interventions and/or support strategies (APA, 2013b). The following report is focussed on social phobia in adolescence, otherwise known as social anxiety disorder (SAD).

For a diagnosis of SAD, the DSM-5 requires key symptoms to be present and ongoing. Symptoms must significantly alter either the adolescent’s normal routine functioning, academic functioning or social functioning. In children and adolescents, the anxiety must also occur in peer settings.

Box 1

Diagnosing Criteria for Social Anxiety Disorder  (APA, 2013b)

Barlow (2002) describes anxiety as an emotion orientated toward the future, where the attention is focused on potentially aversive events, or one’s response to such events. Such thoughts and feelings are normal, however if this thinking/feeling disrupts functioning it becomes problematic (Wicks-Nelson & Israel, 2015). In the case of adolescents, this fear may result in avoidance of settings that involve social interactions such as those at school, in public, or social events. Home settings tend to be more predictable and less of an issue (Aderka et al., 2012).  Weeks et al. (2014) describe common physiological symptoms such as: stomach aches, blushing, breathlessness, nausea, elevated hearth rate and restlessness are also common.  Feigned illness may also start to appear in response to potential social interactions.

Evidence of Symptoms

There are a range of factors that contribute to SAD manifestation in adolescence. Many determining anxiety-related traits have biological aetiology, however environmental influences also play a large role in the development of SAD (Wicks-Nelson & Israel, 2015).  Insecure attachments in infancy, authoritarian/over demanding parenting styles, victimization, cyberbullying, significant adverse social interactions/experiences and childhood trauma are all significant risk factors for SAD (Ruscio et al., 2008; Shapira et al., 2003).  Peer or romantic rejection, cyberbullying, teasing and victimisation by peers can all trigger the development of SAD, and all are significant challenges during the adolescent period (Kashdan & Herbert, 2001).

Adolescence is typically a period dominated by social interactions with peers (Geldard et al., 2019). Young people with SAD however, tend to resist such interactions. Feelings of anticipated confrontation / negative evaluation can effect their ability to make and maintain friendships (Wicks-Nelson & Israel, 2015). They may have few friends and are at risk of developing low quality friendships. This may be noticeable in their behaviour at school, preferring to find spaces where they are ‘isolated’ from others, choose to eat / use public toilets when areas are empty. Adolescents with SAD can appear ‘invisible’ to school staff and peers (Kashdan & Herbert, 2001). They may suffer emotional distress, loneliness, sadness, have low self-confidence and often hold distorted cognitions about their impression on others. They may experience and disclose feelings of rejection or anticipated rejection, of failure and have a fear of making mistakes. This lack of social self-esteem can lead to a reliance on internet based identities/activities as compensation (Steinfield et al., 2008). SAD has a high comorbidity with other anxiety diagnoses: generalised anxiety disorder and separation anxiety disorder (Wicks-Nelson & Israel, 2015). Other aspects of life can be affected by SAD, which can reinforce SAD symptoms. Reduced participation in physical activity, poor diet and unhealthy sleeping patterns are examples of this. In such instances, adolescents are at high risk of developing comorbidities such as depression, alcohol related problems, substance use, and suicide (Ruscio et al., 2008).

Recent findings have documented significantly increased SAD prevalence among gender and sexual minorities relative to peers. Targeted screening of these groups would be beneficial as self reporting of SAD is commonly very low (Parodi et al., 2022; Wehry et al., 2015)

Schools are well placed to identify and contribute to the assessment process. Education professionals spend significant amounts of time observing student interactions with their peers and other adults, where symptoms may become apparent (Masia-Warner et al., 2005). Data collection, observations and anecdotal records regarding behaviours can add to the identification of youth at risk. Screening tools from multiple sources, the adolescent, parents and teachers, is an effective initial assessment process (Wehry et al., 2015). An example is The Adaptive Behaviour Assessment System, Third Edition, (Harrison & Oakland, 2015).  This should be followed up by interviews of the child and parent by the relevant professional who is trained in such processes (psychologist, paediatrician, or guidance counsellor).

Impact on the the Individual and Interactions

The individual may experience rapid and unexpected mood swings in anticipation of potential social situations (Wicks-Nelson & Israel, 2015). In the family setting, somatic complaints and/or panic attacks may occur at the thought of attending a certain social experience, and attendance in any such activities tends to drop or stop completely. On a school level, academic achievement/output may drop as adolescents with social anxiety disorder may try to avoid scrutiny and negative evaluations of themselves and their work in speaking, reading, performing or even writing. They tend to avoid any adult confrontations and may withdraw from recreational events and friendship groups. If left untreated this can lead to impaired educational attainment and/or employment attainment. Individuals with SAD are less likely to complete senior schooling (Nagata et al., 2015).

Suggested Intervention

Common intervention programs for SAD often include psychotherapy and/or pharmacological intervention (Wehry et al., 2015). Approximately 50-60% of youth with SAD are diagnosed with a comorbid disorder. Cognitive  Behaviour Therapy (CBT) for adolescents has been found to remain effective in treating anxiety alongside comorbid disorders (Seligman & Ollendick, 2011). Further evidence suggests CBT alongside serotonin reuptake inhibitors results in the greatest improvements of SAD in adolescents (Wehry et al., 2015).

Within the school context, a Guidance Counsellor who has relevant training could undertake a form of CBT such as Cognitive Behaviour Group Therapy for Adolescents (CBGT-A: Masia-Warner et al., 2005).  Ellis (2008) recommends that younger clients benefit from group therapy as well as individual therapy. Individual CBT would also need to occur simultaneously if time constraints allow. The CBGT-A program utilises cognitive restructuring to identify and challenge anxiety-provoking thoughts. Parents and adolescent are educated on SAD and its dimensions. Specific triggers and physiological indicators are identified and training in management skills in response to such occasions is undertaken. Throughout the sixteen 90 minute sessions, the adolescent is given opportunities to practice problem solving and coping strategies in response to anticipated anxiety-provoking challenges with like peers. Gradual exposure to feared social stimuli and/or situations is done systematically alongside the counsellor (simulated, imaginal and real life situations), with the goal of eventual independent exposure and desensitisation to social fears (Masia-Warner et al., 2005; Wehry et al., 2015). Creating a realistic personal growth plan with the individual regarding this progress and possible relapse would allow for independent and visual monitoring of progress.  Aspects of this plan could be incorporated on Individual Support Plans that are shared with the adolescent’s teachers and family.