Recent world events are causing a lot of anxiety – particularly with children and young adults. Screenagers posted an informative article, featured below, about how to determine what action should be taken in regards to anxiety.
If you have a loved one struggling with anxiety, please contact Tamara Ancona, MA, LPC at (678) 297-0708 for an evaluation, and to discuss the best treatment options available.
Anxious feelings are understandably very high right now in youth given COVID-19. My daughter is a senior in high school and gets waves of many emotions right now–such as anxious feelings related to deciding on a college or sad feelings thinking about all the things she will miss from not being able to go back to her school. All kids have stories right now of things they are fearing, regretting, missing out on, obsessing over, and much more.
As a physician, I thought it would be helpful to give insight into the difference between anxious feelings vs. clinical anxiety, and then to provide examples of skills and resources.
I have been talking with psychiatrists and psychologists who are finding that many teens who were experiencing a lot of anxious feelings related to things at school are doing overall emotionally better with school out. Yet they do talk about how this can change for them at any time, particularly as the days like this continue.
Traditionally schools in our country do not teach about mental health challenges and skills. Fortunately, that is changing, as seen in Screenagers NEXT CHAPTER.
No matter what has been taught at school, there is still so much that can be discussed with our kids now that will help them when they face anxious feelings and will help them in helping their friends and others. In surveys, teens report that they are more likely to tell a peer about hard emotions than adults. I say this only to point out that helping our youth gain skills can be a real asset to be able to help others in their lives, be it now or be it years from now.
We often use the word “stressed” in our society, which can mean many different things to the person saying it, such as feeling that something in their life is out of control, or they feel overburdened, or irritated, or many other things.
In the same way, when a person says they are feeling “anxious”, it can mean many different things—similar to the word “stressed.” This is where the skill of stopping to think about the core emotions behind these words is a great one to hone. Understanding leads to the most effective interventions.
It can be helpful when thinking about anxious feelings to know that often the anxious feelings are actually fear. Fear of an uncertain future, fear that you did the wrong thing (regret is a type of anxiousness), fear of what will happen if you ask someone if they want to video chat, and then the fear of how that person will perceive you.
In Washington State, there is a survey of high schoolers every two years. Here are the 2018 results regarding anxious feelings for teens in King County– where the city I live, Seattle, is located:
58% reported that they at least sometimes “felt nervous or anxious in the past two weeks.”
46% reported that at least sometimes, they were “unable to stop or control worrying in the past two weeks.”
69% felt nervous at least sometimes
59% were unable to stop or control worrying at least sometimes
Unfortunately, they only started asking these questions in 2018, so I cannot provide you with any data from past years.
There is an incredible dearth of data in this country to be able to effectively compare data about anxious feelings of youth over past years. Often people cite two surveys of college students.
For example, the American College Health Association surveys students from many colleges over many years. They have been asking if students “ever felt overwhelming anxiety in the past 12 months.” In 2011, roughly 50% reported yes, and in 2016 approximately 58% reported yes.
The other study of U.S. freshmen asked if they ever “felt overwhelmed.”
The numbers here come from the main comprehensive study on youth mental health, called the National Comorbidity study-Adolescent Supplement. When any book or scientific paper references rates of adolescent clinical anxiety, this is the paper to which they are referring.
(*Of note the numbers here were rounded to the nearest tenth.)
- By age 18, 32% of youth will have met criteria for some type of clinical anxiety, ranging from very mild to very serious.
- By age 18, 19 % of youth will have met the criteria for severe clinical anxiety — meaning it caused severe impairment and/or distress.
The prevalence of the main specific types of clinical anxiety
By Age 18…
…19% of youth will have met criteria for having had a specific anxiety phobia (such as towards spiders). These were ranked from mild to severe, and the majority met criteria for “mild.”)
….9% met criteria for social anxiety (the majority met criteria for “mild.”)
….5% will have met criteria for PTSD.
….8% will have met criteria for separation anxiety.
….2% will have met criteria for generalized anxiety (the majority met criteria for “severe.”)
…2% will have met criteria for a panic disorder (the majority met criteria for “severe.”)
…2% will have met criteria for agoraphobia (the majority met criteria for “severe.”)
Unfortunately, the data collected for this study was done in the early 2000s and published in 2010, and there has not been a follow-up study. I know this is shocking. I have spoken with the researchers, and they told me it had to do a lot with a lack of funding.
Diagnosing Clinical Anxiety
Some anxious feelings are to be expected and are even helpful. For example, anxiousness in anticipation of a test in a few days can help a person to study for a test.
When anxious feelings are often out of proportion for the situation, and the feeling does not fit the fact, this may indicate the possibility of clinical anxiety.
For example, these two scenarios would be cause for concern:
1. A teen worries all the time about tests. Long before it is even going to happen the student is so consumed by the fear. The teen loses sleep and has lots of intrusive thoughts about failing.
2. A youth experiences significant anxious feelings when they imagine talking to other people or raising their hands in class. This has resulted in them being extremely behind in school and not have any friends. While the student desperately wants to change, they can’t move past their anxious feelings.
As a physician, I assess anxiety in teens and adults in my clinic. I ask everyone who comes into the clinic at some point in the visit, “Are you experiencing any anxiety or depression?” The incidence of anxiety and depression is significantly higher in a medical setting than in the general population, so it is important that I ask about these things. And, so often, I see how relieved they are that I asked. When I see people in my clinic, and I have identified a concern about anxiety, the number one question I then ask is, “Are you avoiding things?” Their eyes light up and often respond, “How did you guess that?
The main questionnaire used in health settings to help diagnose clinical anxiety is called the GAD 7. I really recommend going over these questions with your kids or teens.
It starts with these questions:
- Over the last two weeks, how often have you been bothered by the following problems?
- Feeling nervous, anxious, or on edge
- Not being able to stop or control worrying
2. If the teen answers yes to either, then the following questions are asked if they have these symptoms:
- Worrying too much about different things?
- Trouble relaxing?
- So restless that it’s hard to sit still?
- Become easily annoyed or irritable?
- Felt afraid as if something awful might happen?
3. Then the third part assesses how distressing and/or debilitating the symptoms are and asks:
If you checked off any problems:
How difficult have these made it for you to do your work?
Take care of things at home, or get along with other people?
(Options are from “Not difficult at all” to “Extremely difficult”)
When symptoms are ongoing, there can be real suffering and can lead to avoidance of certain situations. So, while it is common for teens to feel a bit nervous about going up to talk with a peer, a more intense nervousness, would indicate a more severe problem. This might present by them starting to avoid most social interactions and becoming more isolated.
When anxious feelings lead to a lot of suffering, via constant worrying, and a lot of negative consequences, such as avoiding situations often, these are signs that anxiety is a clinical problem and should be addressed with professional help such as counselors or therapists.
Skills to Help with Anxiety
These skills can be helpful even for youth who do not have clinical anxiety but for whom anxious feelings are getting in the way of doing things they would like doing, such as having more friends, worrying less often, and so on.
Let’s start with a skill that can help with all types of anxious feelings—not just clinical anxiety.
In Screenagers NEXT CHAPTER psychologist and author Lynn Lyons describes a skill she calls the 3 Ex’s:
- “The 1st X is you will expect worry to show up. You would say something to yourself like, “Oh, there it is. So I’m about to take a test. I hear somebody else got into this school. You have to recognize that. That’s your worry.
- The 2nd X is you are going to externalize it. You pull it out, you give it a name, and say something like ‘Hi, Pete, nice to see you.”
- The 3rd ex is that you are going to experiment, so you do the opposite of what the worry is demanding. The worry demands attention. You decide not to get in a discussion with it and, instead, you are going to pivot. You pivot into getting started on your homework. Or if you’re falling asleep, pivot into thinking about something that is sort of mundane enough that doesn’t really matter to you.”
Exposure therapy (also referred to as exposure response prevention)
The goal of this therapy is to work towards no longer avoiding things that a person wishes they were not avoiding. It is about eventually doing the things the person is avoiding over and over, so they get used to the uncomfortable feelings and learn how to do actions despite anxious feelings. Meanwhile, the more the action is done, over time, the anxious feelings will go down to some degree.
This technique is done in graded steps. For example, a teen is too anxious to participate in class. They might not even be able to verbalize what they are afraid of, but they might be able to verbalize reasons, such as they are afraid people will judge them poorly, laugh at them and not want to associate with them.
Graded steps that might work for the student — and perhaps working with the teacher in the class to go through this:
1. Start by making time with a supportive teacher to practice outside of class to ask questions and to offer answers.
2. Making plans with a teacher before a class to have an answer ready, so when the teacher asks the question, the student will raise their hand and propose the answer.
3. Doing the same prep work to think of, and together, think of a question the student could ask in class. Then, the student is reassured that the teacher thinks this is a “good” question that is valid, reasonable.
4. Creating a goal of how many times in the class they will raise their hand regarding answering a question or asking a question. For instance, picking four times a week and having an accountability plan with a reward/ treat when they accomplish the goal.
5. Finally, starting to raise their hand and participate more in another class where the student has not been working with the teacher.
This is challenging to do, but the good news is it has a high success rate. As the teen does these exposures, as they step into the discomfort of getting scaffolding and support, you can actually see changes in the brain scans of the amygdala. It is no longer as hyperactive as it was before to that stimuli.
In Screenagers NEXT CHAPTER, Olivia, who is 15, had clinical social anxiety, and her therapeutic exposure task was to go to a shopping mall and ask for sushi at a pizza place. She needed to practice being embarrassed. When you do something like this, it makes real-life situations that much more tolerable. I’m not saying we have to do that for everyone, but sometimes it’s just calling that friend you don’t like to call, you practice doing that. You just do baby steps.
Parents and teens need support to do this. Asking youth to face the fear and feel anxiety is so hard as a parent and, of course, for the youth to do—if it were not hard, they would have been able to stop.
For parents, finding other parents who are going through the same situation or have gone through it can be such a help–not only as a source of support but also as a way to find resources.
Getting counseling for one’s child or teen is key, and for parents to be a part of that counseling at times, it is also important when appropriate. In addition, parents usually benefit from things like their own counseling, support groups or parent coaching.
Building Brain Attention Skills with Mindfulness
In Screenagers NEXT CHAPTER, we learn that my college-age son, Chase uses the App, 10% Happier to learn mindfulness skills from George Mumford, an expert who has taught these skills to many athletes, including Michael Jordan.
In the film, I say:
“My son, Chase, also found an online tool that has really helped him. He’s had chronic pain from an accident years ago and lots of stress because of it. From his favorite online teacher he’s been learning mindfulness. It’s all about getting more insight into one’s patterns of thinking and learning to direct attention to more helpful thoughts.”
In the film, Chase talks about it in this way:
“There’s the sensation of pain, but then I add the stress of being in pain and the emotional baggage of the history of the pain and the uncertainty of the future of the pain. And I recognize that I actually have a lot more control over this than I thought. So in my day-to-day when I’m in physical or emotional pain, I can be mindful of the negative layers that are building up on top of it and intervene before they themselves cause unnecessary suffering.”
Here are some popular Apps that teach mindfulness
(Myself, my husband and my teens have used all of these at different times)
Dialectical Behavioral Therapy (DBT) has many useful skills for overcoming intense feelings, including anxiety. There are many websites with many skills.
The TIPP skill is one such example. If a person is suddenly overcome by anxiety or other strong emotions, doing one of these things changes a person’s physiology, which helps stop or lower the intense emotions.
T – Temperature–the person applies ice in a bag to their face for a minute or two. Many teens also talk about how useful it is to put their faces into an ice bath of water for a few seconds. I have known many teens who find this temperature skill very helpful.
I– Intense exercise–the person takes the energy of the emotions and does some quick jumping jacks or other quick exercises.
P-Paced breathing–the person slows their breathing-such as breathing in for breathing for 5 seconds in and then 7 seconds out.
P-Paired muscle relaxation-the person breaths in and tenses a body part at the same time, such as the arms–they pay attention to the feeling of the contractions and then when they breathe out they release the contraction.
Mental Health Organizations – Resources for Teens and Parents
The following are examples of mental health organizations
Anxiety and Depression Association of America
This organization has information on stress and many types of anxiety conditions as well as links to find help for children, teens, and adults.
The National Alliance on Mental Illness has local branches across the country and offers support groups, online resources, programs in schools, and more.
The site has many written materials and links to awareness campaigns. My Younger Self, for example, is 30 short interviews with actors, athletes, and other celebrities who discuss their past mental health challenges.
These are free day-long courses designed to help parents learn how to understand youth mental health issues better and as a parent, things to do. On the website, you can find if there are classes near you.
This organization has affiliates across the country. The website has links to information, and they also do important work in working to increase mental health access, locally and nationally. This page on their website is helpful for the nuts and bolts of finding mental health support.
The international emotional intelligence network researches and shares tools, methods, and training to create a kinder, more positive world.
Born This Way Foundation – Started by Lady Gaga and her mother, the organization works to build a “braver, kinder world” for youth by creating safe-spaces and promoting self-care skills.
Psychology Today (link to https://www.psychologytoday.com/)
This site is very well respected as a way to find a therapist, psychiatrist, or support group in one’s area. One puts in their zip code, and any indicators, such as “adolescent” and it will list many possible providers. Then the provider can be contacted, and a short call can be set up to see if there will be a good fit.
Phone and Text Lines for Mental health
Crisis Text Line is free, 24/7 support for those in crisis. Text 741741 from anywhere in the US to text with a trained Crisis Counselor. Crisis Text Line trains volunteers to support people in crisis. This organization is a resource that many youth and adults report using and feeling helped. People who volunteer for CT receive 30 hours of training before they start, and they volunteer several hours a month.
My good friend is a volunteer, and we spent an afternoon together, where she showed me how their training works and examples of the work she does with people. It was powerful. A person can text about anything they are struggling with, and the volunteers are there and provide supportive interactions. Even though it is called Crisis Text, the texter does not have to have an imminent crisis; they get all sorts of people seeking support for things like eating issues, problems with peers, and just people dealing with hard emotions.
National Suicide Prevention Lifeline Call 1-800-273-8255
7 Cups – Connects you to caring listeners for free emotional support
Better Help – This is a fee-based service that provides online therapy via Skype and text
Boys Town National Hotline 1-800-448-3000. 24-hour, free, confidential hotline staffed by trained counselors for boys and girls to receive help with bullying, anger, abuse, depression, school issues, and more.
211.org is a free and confidential national hotline that connects callers with resources and support in their area.
Ideas for conversation starters with youth in your life:
- Clearly, there is a need for more research done around both anxious feelings and clinical anxiety of youth in this country. What type of research could you imagine doing?
- If you were to study anxious feelings as they relate to screen time, what would be some interesting questions that you could see researching?
- What strategies do you find helpful when you are feeling anxious?
- What skills mentioned here could you see ever using or telling a friend about?