Anxiety Disorders in Adolescents: Assessment and Treatment

Assessment

Anxiety disorders are very common in adolescents and are associated with considerable distress and impairment in adaptive function. Unexplained physical complaints, problems with school attendance, and parental concerns about isolation or irritability suggest the possibility of an anxiety disorder (Connolly & Bernstein, 2007). A clinical interview, ideally with a behavioral health professional, is the most important diagnostic tool in the assessment of anxiety. Multiple sources of information for the assessment are ideal; parents may provide more reliable information about how their child is functioning at home and at school, but the teenager is likely to have the best sense of his or her own internal experience (Connolly & Bernstein, 2007).

Here are some important guidelines to follow during the assessment process:

• Adolescents should be given the opportunity to meet with the provider alone for at least part of the assessment.
• It is best if the limits of confidentiality are explained upfront, e.g., safety issues will need to be shared with a caregiver.
• Collateral information from the school often provides a useful perspective.
• It is best to start with open-ended questions about how things are going in general at home, at school or with friends. From there, inquiry should get more specific.
• Determine whether the adolescent or parents think there are problems with worries, stress, nervousness, or anxiety? This should be followed by more targeted questions regarding specific features of anxiety disorders commonly seen in adolescents (American Psychiatric Association, 2004).
• Explore when symptoms first started, whether they have occurred before, and what effect they are having on the adolescent's ability to function in the various environments of his or her life.
• A prior treatment history including therapy, medications, and complementary or alternative treatments, should be obtained.
• Inquire about family history of anxiety and other mental health disorders, including depression and substance use disorders.
• Inquire about current and past thoughts of suicide or parasuicidal behavior, e.g., self-injurious behavior, and whether he or she has ever engaged in self-harm.

Many psychiatric disorders share key features with anxiety and should therefore be considered in the differential diagnosis (Connolly & Bernstein, 2007; Bernstein & Victor, 2011; American Psychiatric Association, 2004; Krain et al., 2007; Cohen et al., 2010; Kodish et al, 2011). For example, difficulty concentrating, irritability, and sleep disturbance are diagnostic criteria for pediatric major depression and generalized anxiety disorder (GAD) (American Psychiatric Association, 2004). Hyperarousal and irritability occur in some anxiety disorders such as posttraumatic stress disorder (PTSD) or may be caused by disruptive behavior disorder such as attention deficit/hyperactivity disorder (ADHD) or oppositional defiant disorder (ODD) (Cohen et al., 2010).

Adolescents with autism spectrum disorders (ASDs), especially those who are "higher functioning" can be misdiagnosed as having social phobia (SP) (American Psychiatric Association, 2004). To attempt to distinguish these diagnoses one can ask whether the adolescent has been able to make age-appropriate relationships with familiar people. Additionally, the restrictive, repetitive behaviors of ASDs can be confused with obsessive-compulsive disorder (OCD) (Cohen et al., 2010).

Treatment

Treatment of anxiety in an adolescent typically consists of some combination of individual therapy, family therapy, group therapy, medication, and education about anxiety. (Connolly & Bernstein, 2007). Which treatment components are chosen as part of the initial treatment plan is determined by the type, severity, and functional effects of the anxiety, the availability of treatment options in the community, and patient and family preference (Connolly & Bernstein, 2007). The plan may continue to evolve depending on how the adolescent responds. When anxiety is mild, treatment should start with psychotherapy (Connolly & Bernstein, 2007; Cohen et al., 2004).

Types of Treatment:

• There is substantial evidence from controlled trials that cognitive-behavioral therapy (CBT) works for a variety of anxiety disorders (Connolly & Bernstein, 2007; Bernstein & Victor, 2011; Krain et al., 2007; Cohen et al., 2010; Kodish et al., 2011; Cohen et al., 2004; Kendall et al., 2008; Hudson et al., 2009), although other types of therapy such as psychodynamic psychotherapy are used and can be effective.
• Long term follow up studies suggest that there continues to be effect even after CBT is completed (Bernstein & Victor, 2011; Kodish et al., 2011; Kendall et al., 2011; Deblinger et al., 2006).
• CBT is based on the relationship among thoughts, feelings, and behaviors (Cohen et al., 2010; Kendall, 2010).
• A CBT therapist teaches an adolescent coping skills and strategies to develop mastery over anxiety and its effect on his or her life (Connolly & Bernstein, 2007; Kendall et al., 2008).
• The main strategies used are cognitive restructuring, problem solving skills, relaxation exercises, and exposure to feared stimuli or situations (Kendall et al., 2008).
• Cognitive restructuring involves challenging the negative, unhelpful thoughts that tend to occur automatically in anxious children and replacing them with more balanced, helpful thoughts (Connolly & Bernstein, 2007; Bernstein & Victor, 2011).
• In problem solving, the adolescent and therapist identify a problem, brainstorm possible solutions, anticipate possible outcomes, and choose an option to try (Kendall et al., 2008).
• Relaxation strategies decrease physiological arousal. Examples include progressive muscle relaxation, guided imagery, and breathing exercises (Hudson et al., 2009).
• Exposure is a key component of CBT and it is done by either placing the adolescent in real-life situations that trigger anxiety or by leading the adolescent to imagine himself or herself in the feared situation (Hudson et al., 2009). This is done carefully, and the therapist must continuously monitor the adolescent's level of distress to assure successful management of the anxiety.
• A "hierarchy" of feared stimuli is used, allowing the adolescent to progressively gain mastery over increasingly distressing situations (Hudson et al., 2009). Because motivation to exposure may be low, a system of rewards is typically used (Birmaher et al., 1999).
• In CBT, therapy homework is typical, so that the client can practice his or her new skills between sessions in the real world (Kendall et al., 2008).

Although CBT traditionally involves the client and therapist only, CBT can also be provided in group, school, and family settings (Cohen et al., 2010). Some parents of anxious children have developed a pattern of inadvertently reinforcing anxious behaviors or rituals over time (Hudson et al., 2009). Work with parents may be necessary so that they can change this pattern, and develop and reinforce anxiety-management skills for use with their child or teenager (Hudson et al., 2009). In conclusion, while the adolescent may be exhibiting the anxiety symptoms, work with the family as a whole in family therapy may be needed to address problems with overall family patterns of interaction (Connolly & Bernstein, 2007).

References

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorder, (4th ed.)., Washington, DC.
2. Bernstein, G. A., Victor, A. M., (2011). Pediatric anxiety disorders. In: Cheng K, Myers KM, eds. Child and Adolescent Psychiatry: The essentials. (2nd ed.). Philadelphia, PA: Wolters Kluwer Health, Lippincott Williams & Wilkins, 2011: 103-120.
3. Birmaher, B., Brent, D.A., Chippetta, L., Bridge, J., Monga, S., Baugher, M. (1999). Psychometric properties of the Screen for Child Anxiety Related Emotional Disorders (SCARED): a replication study. Journal of American Academy of Child Adolescent Psychiatry, 38(10), 1230-1236.
4. Cohen, J.A., Bukstein, O., Walter, H., et al; AACP Work Group on Quality Issues., (2010). Practice parameter for the assessment and treatment of children and adolescents with posttraumatic stress disorder. Journal of American Academy of Child Adolescent Psychiatry, 49(4), 414-430.
5. Cohen, J.A., Deblinger, E., Mannarino, A. P., Steer, R. A. (2004). A multisite, randomized Controlled trial for children with sexual abuse-related PTSD symptoms. Journal of American Academy of Child Adolescent Psychiatry, 43(4), 393-402.
6. Connolly, S. D., Bernstein, G.A. (2007). Work Group on Quality Issues. Practice Paradigm for the assessment and treatment of children and adolescents with anxiety disorders. Journal of American Academy of Child Adolescent Psychiatry, 46(2), 267-283.
7. Deblinger, E., Mannarino, A. P., Cohen, J.A., Steer, R. A. (2006). A follow-up study of a multisite, randomized, controlled trial for children with sexual abuse-related PTSD the symptoms. Journal of American Academy of Child Adolescent Psychiatry, 45(12), 1474-1484.
8. Hudson, J. L., Rapee, R. M., Deveney, C., Schniering, C. A., Lyneham, H. J., Bovopoulos, N. (2009). Cognitive-behavioral treatment versus an active control for children and adolescents with anxiety disorders: A randomized trial. Journal of American Academy of Child Adolescent Psychiatry, 48(5), 533-544.
9. Kendall, P. C., Gosch, E., Furr, J. M., Sood., E. (2008). Flexibility within fidelity. Journal of American Academy of Child Adolescent Psychiatry, 47(9), 987-993.
10. Kodish, I, Rockhill, C., Ryan, S., Varley, C. (2011). Pharmacotherapy for anxiety disorders in children and adolescents. (2011). Pediatric Clinics of America, 58(1). 55-72.
11. Krain, A. L., Ghaffari, M., Freeman, J., Garcia, A., Leonard, H., Pine, D. S. Anxiety disorders. (2007). In: Martin A., Volkmar F.R., eds. Lewis's Child and Adolescent Psychiatry: A Comprehensive Textbook. (4th Ed.). Philadelphia, PA: Wolters Kluwer Health, Lippincott Williams & Wilkins.

Lee Phillips is a Licensed Clinical Social Worker and a Certified Substance Abuse Counselor in the state of Virginia. Lee holds a Bachelor of Arts degree in Communication from Old Dominion University and a Master of Social Work degree from Norfolk State University. Lee is currently pursuing his Doctor of Education degree in Organizational Leadership with an Emphasis in Behavioral Health from Grand Canyon University in Phoenix, Arizona. Lee is employed full time as a Licensed Therapist with Central Access at Colonial Behavioral Health. Lee has over eight years of experience in treating mood, anxiety, and substance use disorders using a client-centered, strength based, and cognitive behavioral therapy approach.