Abstract

The Diagnostic and Statistical Manual (DSM-5, fifth edition, text revision) defines Generalized Anxiety as “excessive worry, apprehensive expectations, occurring more days than not for at least 6 months, and associated with symptoms like restlessness, difficulty concentrating, irritability, muscle tension, and sleep disturbance; essentially, a persistent feeling of unease or dread about future events, often with no clear trigger, that significantly impacts daily life” (300.02). Moderate to severe anxiety amongst adolescents is a growing concern. Mental health counselors must be equipped with information and tools to assist parents and teens when they seek help to manage the effects of anxiety. This commentary will explore common interventions for anxiety, preferred medications, and how certain risk factors may predispose youths to developing anxiety disorders. The collaboration of adolescents, parents (guardians), teachers, and mental health practitioners will allow for increased awareness of the effects of anxiety and successful management of it.

Keywords: Anxiety, Youths, and Anxiety, Parenting Youths with Anxiety, Anxiety Medications, Anxiety Interventions

Anxiety Treatment Interventions

Some of the most common interventions for anxiety are psychoeducation, relaxation techniques, cognitive behavioral therapy (CBT), and other forms of psychotherapy [1]. The goal of psychoeducation is to provide information about anxiety and how it may impact the adolescent in various life domains. Relaxation techniques such as deep breathing and progressive muscle relaxation can be taught by and practiced with practitioners and utilized outside of therapy as needed. CBT is an effective intervention that focuses on interactions between thoughts, feelings, and behaviors. The goal of utilizing CBT is to change thoughts and behaviors that perpetuate symptoms of an anxiety disorder [2]. Another form of psychotherapy that has been utilized with the adolescent population is psychodynamic psychotherapy. This form of therapy involves the therapist assisting the adolescent to explore the conscious and unconscious mental forces that contribute to anxiety [3]. Additionally, acceptance and commitment therapy has been used by some mental health practitioners to assist the adolescent in accepting uncomfortable realities such as the lack of control, imperfections, and uncertainties. Family and group therapy have proven to be valuable interventions [4]. In addition to individual and group talk therapies, medications may be used as a tool to alleviate the symptoms of anxiety. The class of medications most commonly utilized in the treatment of adolescents with anxiety disorders is selective serotonin reuptake inhibitors and benzodiazepines [5]. When CBT and serotonin reuptake inhibitors are utilized together, they are highly effective at reducing symptoms of anxiety [5]. Research suggests that anxiety can be a lifelong issue. Thus, the goal of adolescent treatment should be to facilitate long term impact by increasing the time in remission from symptoms [6]. Symptoms of an anxiety disorder may manifest in different ways in different individuals and are seen more often in girls than boys [7].

Diagnoses, Symptomatology, and Etiology

Anxiety disorders are commonly diagnosed in childhood and adolescence. Common diagnoses include generalized anxiety disorder, agoraphobia, social anxiety disorder, selective mutism, panic disorder, and specific phobias [8]. Anxiety disorders continuing into adulthood are often linked to depression, substance use disorders, suicidal behavior, and reduced productivity in the workplace [9,10]. Symptoms of adolescent anxiety may be somatic in nature and include stomach discomfort, headaches, and queasiness which may affect school attendance and performance when at school [1]. The modern-day contextual framework for understanding anxiety includes understanding that “clinical expertise is required to differentiate anxiety disorders from normal psychological processes common to human experiences” [11]. Without appropriate intervention, anxiety can persist into adulthood. The U.S. Preventive Services Task Force [12] recommends screening children for anxiety who are ages 8 to 18 regardless of symptomatology. Researchers cannot accurately determine all causes of anxiety. However, a combination of factors such as chemical imbalances, brain changes, genetics, and environmental factors may play a role [8].

Prevalence and Risk Factors

Between 2016 and 2019, there were significant increases in anxiety among children (27%, n = 174,551). These numbers continued to increase in 2020 with 5.6 million children being diagnosed with anxiety. Post-pandemic research findings indicate that the prevalence of anxiety in children was exacerbated by the COVID-19 pandemic [13,14]. Additionally, the Healthy People 2030 (2022) study revealed that between 2016 and 2019 there were notable decreases in the percentage of parents or caregivers with “very good or excellent mental health”. There was also a decrease in the number of parents responding “very well” to questions about coping with parental demands. While there is no solitary risk factor that can be attributed to the development of anxiety in youths, overprotective, anxious parenting is one example of an environmental risk factor within the family system [1]. The impact of social media and access to abundant information via the internet (at the adolescent’s fingertips) can lead to symptoms of anxiety [15]. The stress of fitting in, performing well in the classroom, and excelling in sports and extra-curricular activities can also produce anxiety. While social media is a proven platform for connecting with others, there are also anxiety-provoking aspects of social media and online exposure [15]. Other risks factors pertaining to the development of anxiety disorders in adolescents may include parental/family history of mental illness or suicide, chronic illness or disability, high number and intensity of family stressors, poor access to mental health services, lower socioeconomic status, parental non-acceptance of child, authoritarian parenting style, lack of autonomy granted by parents, and structural constraints and barriers associated with parents’ perception of mental health needs and services [7,16-18].

The Role of Schools

The Guide to Community Preventive Services, U.S. Department of Health and Human Services [19] highlighted an evidence-based initiative that could possibly help in decreasing the number of youths experiencing anxiety: The Targeted School-Based Cognitive Behavioral Therapy Programs to Reduce Depression and Anxiety Symptoms (TSCBT). These programs teach (individually or in group settings) problem-solving behaviors, emotional regulation, and helpful patterns of thought and behavior. Since schools and teachers are a large part of life for the average youth, schools can be a catalyst for positive outcomes when mental health resources are provided for students with anxiety and related disorders [20]. The responsibility of diagnosing a student with anxiety is not that of teachers, however, they play a key role in recognizing signs and symptoms of student anxiety [21]. Upon witnessing signs and symptoms of anxiety teachers can become advocates for treatment and in-school accommodations [1]. Teacher initiated interventions are becoming increasingly essential because school and school work have been identified as two major triggers for adolescent anxiety [20].

Pharmacotherapy for Anxiety Disorders in Children and Adolescents

In severe cases where cognitive and other talk therapies do not render desired results, the use of selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRI), tricyclic antidepressants (TCA), and benzodiazepines may be necessary. Regarding the use of SNRIs, it is important to note that only Duloxetine has been approved by the Food and Drug Administration (FDA) for the treatment of anxiety in children age seven to seventeen. The concern pertains to the increased risk of suicidality. Extensive examination of clinical trials showed that antidepressants may cause or worsen suicidal thinking or behavior in some children and adolescents. Moreover, the FDA issued a strong public health (Black Box) advisory warning to pharmaceutical companies and requires them to inform the public of the propensity to suicidal thinking in individuals under the age of 25. Not all researchers and clinicians agree with the precautions, emphasizing that the benefits of using antidepressants outweigh the risks. Adolescents being treated with anti-depressions should be closely monitored by prescribing physicians, therapists, school officials, and family members [22]. In regard to the use of pharmacotherapy with adolescents, special consideration should be given to establishing therapeutic dosages, titration rates, medication trials, monitoring for side effects, medication holidays, and termination of use [23].

The Influence of Parents and Family

A parent’s participation in anxiety treatment can help decrease anxiety levels. Anxious adolescents can benefit from parental encouragement, comfort, and protection. The challenge for parents is to refrain from over-accommodating (attempting to remove all stimuli) or preventing the adolescent from developing age-appropriate coping skills and learning how to cope with stressors. The Yale Child Study Center tested a program called Supportive Parenting for Anxious Childhood Emotions (SPACE). SPACE helps parents of anxious children recognize which accommodating behaviors can be reduced, and teaches parents alternative ways of responding and problem solving. Parents are taught methods for responding to anxiety and communicating confidence in their children’s ability to cope with their thoughts and feelings and with change. Study outcomes revealed that SPACE was equally effective as cognitive behavioral therapy in reducing levels of anxiety and anxiety-related emotional disorders [24]. Only half of the children and adolescents involved in SPACE responded to medication and cognitive behavioral therapy, thus; there is a dire need for alternate treatments such as SPACE. According to Ghandour, et al. [16], anxiety is more prevalent in children from low-income families and in families where there is parental mental illness. Children experiencing anxiety in low-income families also have low access to mental health services. Wolfradt et al.’s [17] study on anxiety in adolescents found that parental psychological pressure and authoritarian parenting styles positively correlated with anxiety. Parental warmth negatively correlated with trait anxiety. Yaffee’s [18] study revealed a positive association between a lack of autonomy granting parents and high anxiety and with particular types of anxiety. There was a negative correction between a father’s acceptance and children’s overall anxiety. A mother’s low acceptance of a child and a father’s low acceptance revealed different findings, both negatively correlating with overall anxiety or specific types of anxiety. Yaffee [25] also found a positive association between authoritarian parenting styles and anxiety in children.

Treatment Interventions Best Practices

The Adolescent Psychotherapy Treatment Planner renders over 40 therapeutic interventions for the mental health practitioner. The partial listing that follows provides a best practice assessment and intervention framework for working with adolescents with anxiety disorders: (1) assess the focus, excessiveness, and uncontrollability of the fears and worries, and the type, frequency, intensity, and duration of the anxiety; (2) administer an adolescent and/or parent report measure to help assess the nature and degree of fears, worries, and anxiety symptoms; (3) assess for issues of age, gender, or culture that could help the currently defined “problem behavior” and factors that could offer a better understanding of the behavior; (4) assess the home, school, and community for pathogenic care; (5) monitor psychotropic medication compliance, side effects, and effectiveness; (6) teach the adolescent calming skills and how to discriminate (daily) between relaxation and tension; (7) assign parents and adolescents relevant readings; (8) use biofeedback techniques to facilitate calming; (9) assist adolescent in challenging fear or worry by examining the actual probability of the negative expectation occurring, the real consequences of it occurring, and the ability to manage the likely outcome and the worst possible outcome; and (10) explore the influence of past experiences with loss, abandonment, and other anxiety-related developmental themes on current fears or worries [4].

Conclusion

Anxiety is one of the more common mental health disorders affecting our youths. Thus, there must be ongoing endeavors to improve how anxiety is identified, addressed, and managed with consideration being given to the most favorable short- and long- term outcomes. This commentary informs the readership of the basic elements of adolescent anxiety management. It emphasizes the importance of stakeholders working together to support and promote successful anxiety management at home, school, and in the community. Parents (guardians), mental health practitioners, and school officials must continue to effectively advocate and intervene on behalf of this population in order to increase awareness of the effects of anxiety and to support and promote successful management. The extant literature provides evidence-based justifications for using psychotherapeutic interventions, home-based and school-based interventions, and pharmacological interventions, when needed, to help adolescents successfully manage their anxiety.

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