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Anxiety can lead to challenging and dangerous behaviors (e.g., throwing objects, destroying property, self-injury, assault, suicide). Unresolved anxiety, as well as ineffective coping with anxiety, can lead to depression. Regularly occurring anxiety in an adolescent patient may be a sign of depression or another underlying mental health issue.
Anxiety disorders in children and adolescents are often precursors to psychiatric disorders in later adolescence and adulthood. These disorders may include additional subsequent anxiety disorders, major depression, substance abuse, self-injurious behaviors, and suicide attempts.undefined#ref5">5
Anxiety is different than fear. The two conditions share some similarities but have many differences. Fear is typically a healthy, natural emotional reaction to an impending threat; it has a direct cause and promotes safety. Anxiety is the expectation of an imagined or potential threat; it tends to be vague and unfocused. Fear is commonly combined with an acute arousal of the autonomic system needed for fight or flight and thoughts and behaviors associated with immediate danger and escape. Anxiety can affect emotions, thought processes, bodily sensations, and behaviors. With anxiety, vigilance, preparation for future threats, caution, and avoidant behaviors are more common.1
A patient’s memories, experiences, and social situations play intricate roles in the experience of stress and the development of anxiety. The patient may experience vague anxiety stemming from past pain and suffering or fear. Because these experiences are unique to each person, understanding or relating to the patient’s stress and anxiety may be difficult.
Anxiety is characterized by the following:1,2
An anxiety disorder often occurs concomitantly with physical, emotional, or mental illnesses or substance abuse. These other issues can also hide or aggravate anxiety symptoms. Assessment for an anxiety disorder must be part of a comprehensive examination that includes a detailed history, physical assessment, a review of symptoms, and assessments of associated functional impairments, current psychosocial issues, and other contributing factors.7
Adolescents may experience anxiety differently than adults. Adolescents typically have more anxiety regarding social relationships and may avoid social activities, such as talking in groups or school.1,2 Adolescents with an anxiety disorder are more likely to demonstrate irritability and difficulty coping and functioning than adolescents who do not have an anxiety disorder.3 Agitation may develop more quickly and result in aberrant behaviors. Interactions that may increase the patient’s anxiety, such as confrontation, should be avoided.
A constant state of panic or feeling of restlessness, anxiousness, and irritability is not a typical aspect of adolescence. Anxiety can cause significant impairments in functioning and the patient’s sense of well-being. In the most debilitating forms of anxiety disorders, psychiatric treatment is indicated.
Important goals for caring for adolescent patients who are experiencing anxiety include:1,2
Recent research, such as the Child/Adolescent Anxiety Multimodal Study (CAMS), and a review of evidence-based practice, have found that adolescents with anxiety who were treated with cognitive behavioral therapy or medication, such as a selective serotonin reuptake inhibitor (SSRI) (sertraline), experienced favorable outcomes.7,10
Currently, certain SSRIs are approved by the U.S. Food and Drug Administration (FDA) only for obsessive-compulsive disorder or depression in children and adolescents. The risks and benefits of using medications to treat anxiety need to be considered, and informed consent must be obtained from parents and, if possible, the patient. SSRIs carry a black box warning for increased suicidality in children, adolescents, and young adults. If SSRIs are prescribed, the patient should be routinely assessed for suicidal thoughts and worsening of mood. The therapeutic effect of these medications may not be experienced immediately; however, studies indicate that the benefits of treatment outweigh the risks.4
Health care team members should consistently follow the patient’s care plan, which should be individualized for the patient’s specific issues, both medical and psychological. Patients should be included in the development of their care plans, and goals must delineate the actions necessary to achieve them.
Rationale: Establishing a rapport is a priority when working with adolescents. It facilitates assessment of the anxiety level, provides the patient with reassurance, engages the patient in a cooperative manner, and facilitates anxiety reduction.
Rationale: Appearing confident is reassuring, lends support, and helps establish boundaries for the patient. Adolescents are particularly sensitive to any communication or intervention that indicates disrespect, power, or control.
Rationale: Anxiety levels can change quickly, which may put the patient at risk for aberrant behaviors. The use of force or unreasonable consequences may be viewed as punitive or vindictive and can lead to increased agitation or aggression.
Rationale: Moving to a quiet or private area provides increased confidentiality, removes observers, reduces the likelihood of shame or embarrassment for the patient, and decreases environmental stimulation.
Rationale: The use of observational statements is less judgmental and more likely to be perceived as an attempt to understand the patient rather than as a negative view of the patient or an accusation. Identifying the source of distress allows statements of validation and empathy.
Rationale: Reliable assessment scales are accepted as a quantifier for patients to communicate pain and anxiety. When patients are reassured that their distress is temporary, they are more likely to help themselves and be receptive to interventions.
Be aware that an adolescent experiencing extreme anxiety may be unable to rate distress and may become angry if pressured.
Rationale: Techniques that encourage the patient to demonstrate self-expression without fear of reprisals, consequences, or judgments should be used. A nonjudgmental attitude encourages the patient to share personal information that may be the cause of the increasing anxiety.
Rationale: Medical complaints should never be assumed to be solely related to anxiety without proper investigation. Anxiety can be a symptom of some medical conditions (e.g., arrhythmias, low blood sugar, thyroid disorders). Anxiety can also produce physical symptoms (e.g., nausea, shaking, sweating).
Rationale: Involving patients in their own care empowers them and helps them gain knowledge and insight when they make healthy, successful decisions.
Rationale: Identifying coping skills and encouraging their use empowers patients to regain control over their anxiety. The patient must be allowed to determine what is most helpful; for instance, he or she may prefer listening to music that would not be soothing to an adult.
Rationale: Caring for one’s self is empowering for the patient.
Rationale: Taking sides with the parent or patient may increase anxiety and interfere with problem-solving.
Rationale: Having an established plan optimizes the likelihood that the patient will succeed at managing his or her anxiety. This strategy also strengthens the working relationship with the patient.
Rationale: Reviewing the plan after implementation and making necessary changes before discharge is beneficial to the patient while he or she manages the anxiety. Commending the patient’s success keeps him or her motivated and positive when adhering to the plan.
Rationale: Acknowledging the patient’s developmental needs shows respect and understanding.
Nelson, H.D. and others. (2020). Screening for anxiety in adolescent and adult women: A systematic review for the Women's Preventive Services Initiative. Annals of Internal Medicine, 173(1), 29-41. doi:10.7326/M20-0579
*In these skills, a “classic” reference is a widely cited, standard work of established excellence that significantly affects current practice and may also represent the foundational research for practice.
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