Anxiety

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Use the links below to access the key information about recognising and treating anxiety issues in young people. Jump to:

 

Assessment

  1. Consider anxiety issues if the young person reports somatic symptoms (e.g. abdominal pain, shortness of breath) or avoidance of situations (e.g. school refusal, not wanting to leave the house or participate in activities)
  2. If school refusal is prominent, consider the potential contribution of bullying in addition to the need for specific assessment and support targeting school refusal. It is important to address school refusal issues early to work toward preventing longer term decline in a young person’s functioning.
  3. Assess intake of caffeine and other stimulants (e.g. energy drinks, coffee) as these can contribute to anxiety symptoms.
  4. Always assess risk to self and others.
  5. Depression and anxiety are highly co-morbid and symptoms of both can be screened using the DASS (for 18+) or the RCADS (for 13 to 18 years).  RCADS scoring programs (downloadable xls format) are available (scoring is in the second tab).
    1. The longer version has 47 items and is validated to screen for separation anxiety, generalized anxiety, panic, social phobia and obsessive compulsiveness in addition to ‘total’ anxiety and depression scores.
    2. RCADS-25  is a short version that is validated to screen for anxiety and depression.
  6. The PHQ-9 can then be used to further assess depression if indicated by the above screeners
  7. If post-traumatic stress disorder or other trauma-related difficulties (e.g. complex trauma) are suspected, focus on providing trauma-informed care with an emphasis on supporting the young person’s sense of safety in your relationship with them. Reassure them that they can get support to deal with their difficulties, and support them to feel in control of treatment decisions. Further assessment and provision of trauma-informed care (including psychoeducation) is recommended if this is appropriate within the service setting. If not, providing a supported referral to a mental health professional is recommended. GPs should continue to follow-up with the young person following referral, and being involved in their care as needed. Note that discussing past traumatic events can itself be traumatising. Watch Dr Sandra Radovini speaking about taking a clinical history where trauma is suspected. Following comprehensive assessment, if the young person’s symptoms suggest a trauma-focused therapy is indicated and the young person is ready to engage in trauma-focused work, a supported referral to a clinician with trauma-focused training may be needed. Many young people benefit from provision of trauma-informed care prior to being ready to commence with trauma-focused therapies.

 

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Management 

Accurate and specific diagnosis is required, followed by staged care:

  1. Provide psychoeducation, self-help (e.g. tips for a healthy headspace, lifestyle advice - sleep, diet, exercise, relationship breakups) and monitoring
  2. It is important to understand what the young person is anxious about and if there are real threats in the young person’s environment that need to be assessed and addressed (e.g. exposure to family violence, bullying) rather than assuming their anxiety is excessive to the situation..
  3. It is important to help the young person understand how avoidance of anxiety provoking situations maintains anxiety. Consider provision of psychoeducation and use of appropriate exposure techniques to assist in reducing safety behaviours
  4. If a young person has a suspected anxiety disorder, provide assessment and offer CBT first with regular monitoring (refer on if necessary)
  5. OCD in young people warrants careful assessment and treatment. The first-line treatment for OCD is exposure and response prevention, medication may be considered in some circumstances. Families and/or significant others should be involved in treatment wherever possible.
  6. PTSD require specialist treatment and inappropriate care in the case of trauma can cause harm. Treating clinicians can support young people to understand their trauma symptoms (which may not meet criteria for PTSD, complex trauma and other trauma-related presentations are common) by providing trauma-informed care including psychoeducation about trauma and its treatments and when trauma-focused treatment may be indicated – always refer to a specialist for trauma-focused treatments.
  7. If CBT is unsuccessful, there may be a role for medication. There are considerable risks related to the use of medication in young people and we recommend discussion with a specialist GP and Psychiatrist in these cases (be aware of the potential risks in young people). Medication should only be used if symptoms remain severe after a trial of CBT, and medication should always be used in conjunction with psychological therapy
  8. Young people (and their caregivers where relevant) should be informed about the potential side effects of medication, including the risk of increased suicidality and the importance of keeping in touch (including formal monitoring)
  9. If a young person is prescribed medication, you should monitor their mood, suicidal ideation, and behaviours and side effects 
  • Unless it seems antidepressants need to be started immediately, symptoms that might be subsequently interpreted as side effects should be monitored for 7 days before prescribing.
  • Monitor within one week of first prescribing, and weekly for the first month
  • Arrange weekly appointments for people assessed to be at risk of suicide until there is no indication of increased suicide risk, then every 2-4 weeks during the first 3 months of treatment and every month thereafter
  • The young person and their family/caregivers (if involved) to monitor for adverse effects relating to deterioration in mood, emergence or exacerbation of self-harm, suicidality, or hostility and seek urgent follow-up if they have any concerns
  • If you are unable to monitor this regularly, make sure that monitoring is discussed with other staff involved (e.g. psychologist), caregivers, and the young person themselves.

 

 

Continuing Care 

  1. Learn about anxiety and the effective use of treatments from headspace (What is anxiety and the effects on mental health - for young people) or Reach Out (Anxiety).
  2. Support the young person to learn anxiety management techniques (controlled breathing, relaxation techniques and exercise) and provide a strong rationale for why these are important in managing anxiety
  3. For young people experiencing panic symptoms, support in learning grounding strategies and understanding how panic attacks happen is important.
  4. Identify activities that have a positive impact on the young person’s mood (e.g. listening to music, visiting friends) and include as routine activities. Be especially aware of safety behaviours (including avoidance) as these can perpetuate or maintain the anxiety and should be addressed.
  5. Ensure that the young person follows the management plan, even when symptoms start to improve – for example ensure that medication is taken for the period advised, psychological therapy sessions are completed as guided in your reviews and they have a relapse prevention plan).
  6. Encourage a healthy lifestyle, including exercise, proper nutrition and good sleep habits.
  7. Suggest a range of strategies for coping with stress and support in considering if a reliance on safety behaviours to manage anxiety may be re-emerging
  8. Encourage contact with friends and family and avoiding spending too much time alone, particularly if symptoms of depression are also present.

 

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