How Anxiety Affects Teenagers

There is substantial evidence that the pandemic has increased the number of adolescents (and even some pre-adolescents) who are anxious. It’s no wonder, given that Covid lockdowns and distancing robbed teenagers of many of the activities they care about most, disrupted their education, and isolated them from their friends.

We’re all hoping that over time, adolescents will rebound. But anxiety in adolescents was already on the rise before the pandemic. Why? Experts cite increased pressure to succeed in school, a world that feels scarier and the toll social media can take on self-esteem. But nobody really understands it. It’s important to recognize the signs of anxiety, and get kids who are struggling help.

Anxious teenagers are different from anxious children. At each stage of development, kids have different worries and vulnerabilities.

Younger children are prone to be anxious about external things — like animals or insects, the dark, monsters under the bed, or something bad happening to mom and dad. But teenagers are more likely to be worried about themselves — their performance in school or sports, how they are perceived by others, the changes in their bodies.

Some anxious teenagers have been anxious for many years by the time they reach adolescence. Maybe parents have been aware of it, but the child functioned well despite their distress, so nothing was done about it. Or the child was treated, and things got better. But as more is expected of them, in middle and high school, and as they develop more focus on their peers, the anxiety can resurface and become more severe. And some teens who weren’t anxious children develop adolescent-onset kinds of anxiety, including social anxiety and panic attacks.

Their performance. “We see a lot of fear of not doing well,” explains Jerry Bubrick, PhD, a clinical psychologist at the Child Mind Institute who specializes in anxiety and OCD. “A lot of anxiety is geared towards perfectionism, or needing to do their absolute best in school, beyond an intense work ethic.” Even when parents report that they urge kids not to stress over college admissions, teenagers say they feel intense pressure to get those straight A’s.

How they’re perceived. “Every teenager is going to have an awareness of and a certain vigilance about how they’re being perceived,” Dr. Bubrick notes. “That’s just part of the adolescent process, but some kids have that on steroids.” The result can be debilitating social anxiety. “They’re going to be really excessively worrying about whether they might be seen as incompetent or stupid, or they’re really worried about doing something embarrassing.”

Their bodies. Physical changes of adolescence are a cause of discomfort for many teenagers. Developing either before most of your peers, or after them, can make kids feel different and out of step.  “For girls if you’re on the early side in development, it’s going to affect you more negatively than if you were on time with development or even late,” notes Dr. Bubrick. Boys, he adds, are especially sensitive to height. “So if a 15-year-old hasn’t gone through puberty yet, and they’re looking like they’re 12 and their peers are looking like they’re 19, that can have a pretty profound impact on self-esteem and confidence.” Some kids develop a form of extreme anxiety called body dysmorphic disorder, becoming so obsessed with a perceived physical flaw (real or imagined) that it causes great distress and interferes with their functioning.

Symptoms of anxiety vary widely, from withdrawal and avoidance to irritability and lashing out. Anxiety is often overlooked because teenagers are good at hiding their thoughts and feelings. But these are some of the behaviors that might be a sign that a teenager is anxious.

• Recurring fears and worries about routine parts of everyday life
• Irritability
• Trouble concentrating
• Extreme self-consciousness or sensitivity to criticism
• Withdrawal from social activity
• Avoidance of difficult or new situations
• Chronic complaints about stomachaches or headaches
• Drop in grades or school refusal
• Repeated reassurance-seeking
• Sleep problems
• Substance use

Since so much of what adolescents are focused on is connected with school — think academics, sports, other activities and social life — school can be the setting of a lot of things a teenager might be anxious about. Hence when kids resist going to school, it’s not necessarily about school itself.

Dr. Bubrick notes that what we call school refusal used to be called school phobia, but that implied that school is the source of their anxiety. Instead, in dealing with kids who find frequent excuses to stay home, or flat-out refuse to go, the focus isn’t on that decision to not go to school. “We’re more focused on why they’re making that decision to not go to school.”

The problem could be worry about being called on randomly by a teacher and making a mistake. Or having a panic attack in class. Or worry that they look wrong, and people will make fun of them. “You could interview a hundred kids refusing to go to school,” adds Dr. Bubrick, “and get a hundred different reasons why.”

Teenagers who are anxious (not unlike adults who are anxious) may use recreational drugs, especially marijuana, as a way of coping with their discomfort. It’s self-medication, notes Dr. Bubrick, and the reality is, in the short term, it works. “It does alleviate anxiety and stress. It numbs it. It does shut off the worry part of your brain.” But it’s a poor coping mechanism in the longer term, because the anxiety persists and the teenager becomes dependent on the substance.

Dr. Bubrick says what he hears about most from teenagers is that marijuana is healthier than alcohol. And now that marijuana is legal in many places (for those over 21) and vaping is an option, it’s easier than ever to smoke — on the street, at home or at school — without adults being aware of it.

But he notes that neither is a healthy way to manage anxiety, and he urges kids not to use recreational drugs as medicine. “If you have a joint in your pocket all the time and you’re smoking during the day, to get through your day at school, that’s no different from having a bottle of vodka in your desk drawer at work.” You’re still relying on a substance to get through the day — and the more you use it, the more dependent on it you’ll be.

It’s common in teenagers to find that they are depressed as well as anxious. That is in part because an anxious lifestyle can be so distressing, or so limiting, that it leads to depression.

Dr. Bubrick recalls treating a young woman whose move to a new high school triggered intense social anxiety. She was so worried about failing in a more competitive atmosphere that she began to withdraw from activities. Then she had a panic attack, and began to withdraw from friends because she was afraid of having another panic attack in front of them. Eventually she was so isolated she became severely depressed.

This kind of layering of anxiety and depression is both common and commonly missed, Dr. Bubrick notes. If a clinician just treats the presenting symptoms of depression, and misses the anxiety, the result won’t be effective.

But it’s also possible that anxiety and depression are two separate co-occurring disorders.

Dr. Bubrick explains: “The question I ask kids is ‘If I was able to go into your brain and just remove your anxiety, would you still be depressed?’ If they say ‘Yes, I would still be depressed,’ that would suggest it might be a co-occurring depression. If the answer is, ‘No, I would feel amazing if you took the anxiety away,’ then I would think the anxiety is causing the depression.”

Dr. Bubrick notes that among the various kinds of anxiety, generalized anxiety disorder, commonly called GAD, is particularly linked to depression later in life — so much so that it’s also thought of as a precursor for depression. GAD is anxiety that’s not triggered by a particular thing (that’s called specific phobia) but by persistent and excessive worry about a variety of everyday things.

What’s the link between anxiety and depression? Dr. Bubrick thinks anxiety undermines well-being. If you can’t trust yourself and you can’t trust that you’re going to make good decisions and you live defensively, then you’re especially at risk for depression.

“If you’re walking around always worrying and always doubting, and everything in life is ‘what if?’ that’s going to start to have a pretty profound effect on how you see yourself and your confidence and your self-esteem,” he explains. It’s not surprising, he adds, that if you’ve been living defensively, with a steady diet of fear, it could lead to depression.

The most effective treatment for anxiety in teenagers is cognitive behavioral therapy (CBT), combined, if needed, with antidepressant medication. And the good news is that it’s very effective.

CBT teaches anxious kids strategies for thinking differently about anxiety and responding to it differently when it occurs. By tolerating anxiety rather than avoiding things that trigger it, they learn that it diminishes over time. And by gradually increasing exposure to feared objects or activities (a type of CBT called exposure therapy), the anxious response itself is reduced or eliminated.

Antidepressants called SSRIs (selective serotonin reuptake inhibitors) ― are the medications recommended for treating anxiety disorders in children. They are combined with CBT in kids whose anxiety is too great to enable them to participate in CBT alone.