According to the National Institute of Mental Health, approximately 25% of adolescents between the ages of 13 and 18 will experience an anxiety disorder, with nearly 6% experiencing severe anxiety.

So, if you believe your teen may be struggling with this disorder, they're certainly not alone.

That’s why I’m dedicating several episodes to the topic of teen anxiety. It can be really confusing and scary for both teens and parents and it’s important that you know what to look for, how it’s diagnosed and treated and how to help them the best you can.

Last week I kicked off this series in episode 215 by explaining how anxiety manifests in teens and sharing some common signs and symptoms that may indicate a disorder. It’s critical that you understand that teen anxiety doesn’t always look the way you’d imagine so please go back and listen to that episode if you haven’t already.

Today I want to talk to you about getting a proper diagnosis for your teen and, if they are diagnosed with an anxiety disorder, I want you to be aware of the treatment options. Stay right there—let’s dig deeper.

PODCAST INTRO

As I explained last week, there’s a difference between being anxious or nervous and having an anxiety disorder.

The American Academy of Child & Adolescent Psychiatry (or AACAP) says, “Anxiety disorders are different from regular or typical anxiety, just like depression is different from everyday sadness…”

Of course, this is where it can be so confusing for us as parents. How do you know when your teen is just experiencing normal anxiety and when does it cross over into an actual disorder that requires professional intervention?

According to AACAP, the  symptoms of anxiety disorders differ from those of normal anxiety in several different ways.

 

1. Normal anxiety occurs throughout one’s lifetime, but anxiety disorders often start in the years just before puberty and they can start or intensify seemingly out of the blue.

 

2. An anxiety disorder can make regular activities completely unmanageable for a teen. The intensity of their nervousness is disproportionate. Your teen might have an intense reaction to routine activities that most kids their age handle without issue. We're talking about everyday things like going to school, sleeping over at a friend's house, or making new friends at a party.

 

3. Unexplained physical symptoms can occur—like we discussed last week. They may be throwing up in the mornings before school or have a bought of diarrhea right before a recital or notice and obsess over the smallest things about their body (like a lump or a spot on their skin) and may even want to go to the doctor or see the school nurse more often.

 

4. Anxiety disorders also tend to persist over time and are pretty consistent (but they can also suddenly worsen) We're not talking about a few weeks of worry during finals. Clinical anxiety shows up consistently, in the same patterns.

 

5. Normal life tends to be interrupted by avoiding the things they’re anxious about—avoidance becomes the primary coping strategy. Instead of facing challenging situations, anxious teens systematically avoid anything that triggers their anxiety. When these triggering experiences are normal developmental tasks, this avoidance significantly disrupts their life. This results in what they call “functional impairment”.

 

When you combine this functional impairment with the psychological impairment of the constant physical and emotional distress of the anxiety—that’s the definition of an anxiety disorder.

Now, there isn’t just one type of anxiety disorder—there are 6 that commonly occur in teens. Most of the behavioral issues I’ve discussed here and in the last episode are going to show up no matter the specific type of disorder. But just so you’re aware, let me briefly describe the most common anxiety disorders that affect teenagers and some of the features of each that you would notice:

1. Specific Phobias

This involves extreme, irrational fear of specific objects or situations like throwing up, a dark room, heights, injections…whatever. The fear is so intense that teens will go to great lengths to avoid these triggers, even when it disrupts normal activities.

2. Separation Anxiety

This goes beyond normal homesickness. Teens with separation anxiety have specific worries that something terrible will happen to them or you when you’re apart. They might struggle with sleeping alone, going to school, or even being in a different room from you.

3. Generalized Anxiety Disorder

These are the chronic worriers who anticipate disasters occurring around every corner. They worry about their health, money, their relationships, school, and may even obsess about death. These kids are often described as tense, uptight, or perfectionistic.

4. Social Anxiety Disorder

This involves intense fear of being judged or humiliated in social situations. It might be limited to specific situations like public speaking, or it can be so pervasive that your teen struggles with one-on-one interactions like ordering food or asking a teacher a question.

5. Panic Disorder

This is when they experience sudden, intense panic attacks that peak within just minutes but include physical symptoms like shortness of breath, chest pain, rapid heartbeat, and feelings of losing control. And the fear of having another attack can be as debilitating as the attacks themselves. And panic disorder can show up along with the other anxiety disorders as well.

6. Obsessive-Compulsive Disorder

This involves unwanted, intrusive thoughts (obsessions) that drive your teen to repeat certain behaviors over and over (compulsions). They’re commonly obsessed over fears about contamination or some sort of harm coming to them or someone else so the compulsions might include stuff like washing their hands over and over or checking that they’ve done something they were supposed to.

Now let's talk about getting right diagnosis for your child so they can receive the best treatment.

Your first stop may be your pediatrician, and pediatricians can certainly screen for anxiety in children in teens with assessments made specifically for that reason. If the screening indicated a kid may have an anxiety disorder, the next step is for that pediatrician to refer the child to the proper mental health professional to conduct a thorough evaluation.

Pediatricians don’t normally have the training or the experience to diagnose an anxiety disorder or any other mental health disorder. But there are plenty out there who will not admit that and will happily diagnose and prescribe medication so please be careful here.

Now, if your teen is really struggling and you can’t get in to see a mental health professional, your pediatrician could be a stop-gap measure to help until you can. And they can also simply be the first person you reach out to for a recommendation for a mental health professional.

If not your pediatrician, a therapist or counselor can also be a good place to start. They can spot an anxiety disorder better than a pediatrician, but they also do not conduct the same type of thorough evaluations that a psychiatrist or psychologist (we’ll talk about that in a minute). However, after your evaluation, you may be coming back to a therapist anyway, so it may not hurt to establish a relationship and find someone who primarily works with children and adolescents with anxiety.

But to receive a complete psychological evaluation you will need to get your teen to either a child and adolescent psychologist or psychiatrist. Both can provide psychological evaluations, both can provide therapy, however neither all psychologists or all psychiatrists do both. And the biggest difference between these providers is that a psychologist has a PhD (a Doctor of Philosophy) and is not a medical doctor and therefore cannot prescribe medications but a psychiatrist is an MD and can prescribe medication if necessary.

The other big logistical difference is that child and adolescent psychiatrists are much more rare and getting in to see one can take months and months.

So, what I would recommend is getting on a waiting list for a psychiatrist (because the likelihood is that if your teen is diagnosed with an anxiety disorder, they are going to need to be on medication at least for a time). But in the meantime, find a child and adolescent psychologist who can conduct the evaluation. Better still, find a psychologist who can both conduct the evaluation and provide therapy. About that—as I said, both psychologist and psychiatrists can provide therapy as well as conduct evaluations. But many psychologists choose only to conduct evaluations, and many psychiatrists choose only to provide medication. So, it’s up to you to do your research on the various  providers in your area to coordinate care for your kid.

For example, if you find a psychologist who’ll provide an evaluation and it’s going to take a few weeks to get in for the appointment and another couple of weeks to get the results of the evaluation, and they do not provide therapy, then go ahead and get your child in with a therapist while you wait. And get on that waitlist for a psychiatrist for medication (which you can always cancel if it turns out you don’t need it).

Let’s talk about the evaluation process too. It can feel overwhelming. And at this point I think it’s important to distinguish between the various evaluations you may have either heard about or already been involved with. Anxiety disorders often occur in kids who have ADHD and learning issues so your child may have already undergone a neuropsychological evaluation or a psychoeducational evaluation. These are different types of tests, but both are geared toward learning and academic performance and do not test for psychiatric disorders like anxiety.[1]

Psychological testing, however, includes different types of cognitive, personality, behavioral and other assessments depending on the reason for the testing (what issues someone is presenting with). This is just one of the tools used by a psychiatrist or psychologist to diagnose anxiety in your teen. They’ll also conduct interviews with both you and your teen and will use ratings scales and standardized questions to help them measure the severity of symptoms and track changes over time.

They use these various assessments to look for specific patterns of anxiety symptoms, levels of avoidance, and how these impact your teen's daily functioning. In fact, it would be extremely beneficial for you to start a journal right now about your teen’s behavior, so you’ll be able to answer their questions in detail.

The provider will also likely collect records, questionnaires, and ratings scales from teachers, other family members, their pediatrician, school counselor, therapist, or anyone else with information that may them help understand your teen’s worries and fears as well as their outward behaviors (like avoidance, meltdowns, and physical complaints).

A thorough evaluation should also include a Family assessment where the provider is looking to see if there are certain environmental factors that are reinforcing your teen’s anxiety. Your parenting style (being too controlling, authoritarian, anxious—all those things can contribute to your child’s anxiety).

Something else the evaluation should always include is a differential diagnosis. This just means the provider will work to rule out other mental health conditions that could be mimicking anxiety, such as ADHD, OCD, autism spectrum disorder, depression, bipolar disorder or even learning disorders.

They should also rule out medical conditions that may be causing the anxiety or the symptoms of anxiety. There’s a long list of these conditions in the Diagnostic and Statistical Manual (their reference guide for diagnosing anxiety) so these potential issues should be addressed.

They should also look at the medications your teen takes that can cause anxiety; things like asthma medications, decongestants, antihistamines, antidepressants…and even withdrawal from certain medications. There’s a long list of medications that can cause anxiety symptoms.

They should also talk to your teen about whether they’re using any substances like nicotine, alcohol, caffeine, marijuana, cocaine, steroids, and so many more…all of which can cause anxiety or make the symptoms worse.

Anxiety disorders also commonly occur at the same time as other disorders – they call this comorbidities or co-occurring disorders. ADHD, depression, OCD, learning issues and substance related disorders and more, can be happening right alongside the anxiety.

So, it takes a very thorough evaluation conducted by a very knowledgeable and experienced psychologist or psychiatrist to determine exactly what’s going on with your teen—and just as important—what’s not going on with your teen. You can’t insure they’re receiving the right treatment until you know exactly what’s going on.

As you might imagine, these evaluations are not cheap. They can cost anywhere from $1,500 to several thousand dollars depending on where you live, the provider’s experience, and how much they dig into co-occurring issues and making a differential diagnosis. Insurance can cover some of it and you may be able to use FSA/HAS accounts to pay for medically necessary services.

When it comes to treating teen anxiety, the good news is that there are several evidence-based approaches that work well, either alone or in combination. The gold standard therapy modality for anxiety (no matter your age), is cognitive-behavioral therapy (CBT). And I’m going to refer to this therapy being conducted by a “provider” because it could be a therapist, a psychologist or even a psychiatrist working with your teen so I didn’t want to just say therapist.

So, in general the way CBT works is sort of a 3-pronged approach.

First, is psychoeducation, which basically just means your teen and the rest of the family learn about anxiety and how it works, why avoidance makes it worse, and how the treatment process will help.

Then the core component of CBT for both anxiety and OCD is called Exposure and Response Prevention or ERP.

This part of the process is where the provider helps your teen gradually face their fears in a controlled and supportive way. Your teen learns that what they’ve feared isn't actually dangerous and that their anxiety will decrease over time by pushing through and doing the thing that makes them nervous.

For example, let’s say your teen is anxious about being judged or embarrassed in social situations. They avoid speaking up in class, eating lunch with peers, and going out with friends. The provider will create an exposure hierarchy with your teen ranking social situations by how anxiety-provoking they are.

For instance low anxiety might be making eye contact with a cashier while buying something, medium-high might be ordering food at a restaurant and asking for a modification, and very high might be attending a school social event.

Then your teen and the provider will make a plan to start with the lowest anxiety exercise, building up gradually to the highest, and to engage in those activities without avoidance strategies. The goal isn't to eliminate the anxiety altogether, but to learn they can manage it without allowing it to control their daily life.

The third prong of CBT for anxiety is skill building, which is helping your teen learn coping strategies, relaxation techniques, how to challenge anxious thoughts—tools they can use anytime they need them.

Now, in a perfect world, the treatment provider will collaborate with the family and even school personnel to round out support for your teen. But this depends on the provider, their experience and their willingness to go the extra mile.

As I said in the last episode, anxiety is a combination of thoughts, emotions and behavior which is influenced by environment—mainly family and school.

So, helping you improve your communication and problem-solving skills and the relationship with your teen should be high on the provider’s list of priorities.

Additionally, helping you decrease your anxiety, and teaching you to help your teen reduce their anxiety would be a great supplement to your teen’s treatment. Sadly, most providers do not extend very far beyond the therapy with your child so you may need to seek this help elsewhere. This podcast is a great start.

Again, in a perfect world, the provider could reach out to your teen’s teachers and explain their anxiety and teach them how to help your teen with problem-solving, coping, and anxiety management strategies at school. These plans could even be added to your teen’s 504 or IEP if they have one.

The general rule of thumb is that within 12 to 20 sessions of CBT, your teen should start seeing improvement in their anxiety symptoms and in their actual functioning.

Unfortunately, I think this is very highly dependent on the provider, how well your teen likes and trusts them, how skilled the provider is, and their willingness to involve and educate you and the school.

What about the medication issue? Medication isn't always necessary, but it can be incredibly helpful, especially for higher levels of anxiety and when combined with therapy. The psychiatrist will consider a variety of factors when it comes to prescribing a specific medication including their age, severity of their symptoms, other medications they’re taking and so forth.

The main medications used to treat anxiety are antidepressants, specifically SSRIs (Selective Serotonin Reuptake Inhibitors) and SNRIs (Serotonin-Norepinephrine Reuptake Inhibitors)

SSRIs like sertraline (Zoloft), fluoxetine (Prozac), and fluvoxamine (Luvox) increase serotonin levels in the brain, which helps regulate anxiety and mood.

SNRIs like duloxetine (Cymbalta) and venlafaxine (Effexor), work on both serotonin and norepinephrine systems in the brain.

However, both SSRIs and SNRIs come with a warning label for suicidal thinking and behavior in kids up through age 24.

Suicidality isn’t the only side effect though – all SSRIs and SNRIs come with a long list. The real problem is that most prescribers (at least the ones I’ve encountered) never mention these side effects before writing the prescription and they’re even less likely to talk to you about the issues with stopping these medications or switching to different one – both of which can cause physical and psychological issues called discontinuation syndrome.

So, it’s vital that you’re aware of these things so you can ask the right questions, do your own research, and closely monitor your kid for side effects and to make sure they are taking this medication as prescribed.

I kept a medication journal for my son and noted anytime he was prescribed a new medication. I wrote down everything about his behavior from his appetite to his sleep and mood. It was vital at least a couple of times in catching major side effects.

Depending on the medication, your teen could start feeling better in about 2 to 4 weeks of starting the meds. But it can take 8 to 12 weeks to feel a lot better and they can continue improving even up to 6 or 9 months of when they started.

Now, some psychiatrists may prescribe a medication for your teen to take for short-term relief when they become extremely anxious—when they’re just so dysregulated they can’t function properly. That could be a benzodiazepine, like lorazepam (Ativan). which works fast but shouldn’t be used long-term because of the risk for dependance.

They may prescribe a beta-blocker like propranolol for performance anxiety, like giving a speech or test anxiety and even an antihistamine like hydroxyzine can provide a little bit of short-term anxiety relief.

The research clearly shows that teens who receive both medication and therapy tend to do better than those who receive either treatment alone. And of course, the goal of treatment is complete remission of their anxiety symptoms, not just helping them feel "a little less anxious." Again, in a perfect world, when they receive the proper treatment from skilled clinicians, their anxiety symptoms would all but disappear so they can live their life.

Of course, we don’t live in a perfect world, and you have to actually find the money for all of this, get your kid to cooperate in the evaluation, with therapy, and taking medication. There can be some big hurdles to get over to see the finish line.

Just take it one step at a time. Do your research, find the right people, make the appointments and do what you have to do to make it work. If you can’t afford an evaluation, start with a therapist and your pediatrician. Where there’s a will there’s a way.

Alright, thank you for making it through another episode of Speaking of Teens with me. Stick around for the remaining episode or episodes of this anxiety series because next week I want to focus on what you can do to help your teen with their anxiety and avoid making their symptoms worse.

If you’re new here, please jump into our over 200 previous episodes that will help you parent your teen with less conflict and more connection. And if you’re an SOT OG – thank you for your continued support. I’m so glad you’re still here!

I would appreciate you sharing the show with a friend if you found today’s episode helpful. We have to support each other on this bumpy road of parenting teenagers.

Okay, until next week, remember to connect with your teen in at least some small way, each and every day.

 

[1] Psychoeducational evaluations primarily assess intellectual abilities or IQ and compare that to a kid’s academic performance to identify possible learning disabilities. It’s the testing you have done when you’re trying to determine eligibility for special education services. But it doesn’t look at executive function or emotional issues like anxiety.

Neuropsychological evaluations look more at brain-behavior relationships by focusing on cognitive processes like memory, attention, language and executive functions. This type of evaluation also looks at IQ and includes academic testing, but goes further to assess things like information processing and emotional functioning so you get a much broader understanding of how all of this can affect learning. Often these evaluations can lead to referrals to determine whether the child has ADHD, anxiety or other disorders.