Ronald E. Dahl, MD, is professor of Community Health Science at the School of Public Health, University of California, Berkeley. He has published numerous studies on the behavioral and emotional health and development of children and adolescents. Here he discusses the common problem of anxiety during the adolescent years.
Does puberty make adolescents particularly vulnerable to anxiety?
At puberty, kids tend to become more self-conscious and to have stronger feelings related to self-conscious emotions. They also become more sensitive to social feedback—especially to peer rejection or disapproval. In addition, there’s a greater tendency to ruminate and worry. Some of these changes are part of the normal psychological and social experiences of adolescent development. However, there also is a growing understanding of the biological underpinnings—hormones, the nervous system, and the interactions between them—to these increased social and emotional sensitivities during pubertal maturation and how, for some, these changes may increase vulnerability for clinical problems with anxiety.
From a health perspective this is not just about feelings of anxiety, but also how anxiety interferes with functioning. I think people tend to assume that the impairment comes when the intensity or duration of the anxiety is disabling. But there's not a lot of strong evidence for that. The real impairment is related to avoiding situations that make you anxious, such as a child who is socially anxious and avoids going to school, or a child afraid of bugs who refuses to go outside. One of the ways that anxious kids become impaired is through patterns of behavior, avoiding the things that make them anxious. At first, avoidance is rewarding: You feel better when you avoid the thing that creates anxious feelings. But that's a short-term strategy; over time this can spiral into patterns of avoidance that begin to interfere with one’s life.
This is an important set of issues because it creates both vulnerabilities and opportunities during this window of adolescent development. On one hand, there are increased feelings of anxiety, self-conscious emotions, and tendencies to worry. On the other hand, the onset of puberty and adolescence is a time when most kids tend to become more risk-taking and sensation seeking, and to be really good at approaching things that they're afraid of. This may be an ideal time for behavioral interventions that help teach anxious kids to learn new patterns of response, through gradual exposure—learning to master their fears through small gradual steps. There is growing evidence that successful treatment of clinical anxiety may not require getting rid of the anxiety or extinguishing the fear, but rather learning to get beyond the comfort zone, gradually learning to approach the things that make one anxious. Adolescence may be an ideal time for learning to approach and master feelings of anxiety or discomfort, in the same way that many adolescents seem to be naturally drawn to explore, discover, and try new things.
Can rejection on social media and mobile technologies increase anxiety in young people who are vulnerable to it?
Social media and all of its complexities and technologies can be powerful amplifiers of these vulnerabilities. For many young people, there is a strong tendency to think that one is constantly being evaluated and being judged. In some cases, this can involve thousands of people liking or disliking something someone posts or says online. And this is all occurring at a time when young people are figuring out the most basic aspects of their identity and they’re going through dramatic changes in all aspects of their physical, social, and mental development. Social media can give young people the sense of a thousand mirrors being held up, and it can intensify a negative spiral of increasing self-consciousness and social sensitivity to rejection. Even if 20 people like you, you can ruminate and worry about the one person who says something really mean.
But rather than paint some dystopian vision that this is a horrible thing for all youth, it is also important to recognize that social media and mobile technologies can also create opportunities for kids to find connections, other young people like themselves, to find a niche, to feel valued and admired. These are complex but important issues. Social media can create increased vulnerabilities but also opportunities. Ideally, the goal is to help scaffold the experiences—to help young people find the positive opportunities for communication and connection, without getting overwhelmed by the negative.
Does anxiety as a child lead to anxiety disorders or depression in adolescence?
Not necessarily.Some longitudinal studies have followed groups of young kids who were shy and anxious and have found that these kids do have a higher rate of developing anxiety disorders. And there is evidence that youth with anxiety disorders have elevated rates of becoming depressed. However, only a small percentage of kids develop clinical disorders. The majority of these kids turn out fine.
There is a fascinating set of issues regarding the developmental changes during this transition from childhood to adolescence. This is a time when most kids become a little bolder, a little more sensation seeking, a little more exploratory. Many people focus on the negative risk-taking that emerges during adolescence, but these same tendencies also contribute to healthy versions of risk-taking and exploration. Raising your hand in class, going out for the class play, trying a new sport, asking someone out on a date all feel like very risky things to do when you’re that age. But these are part of healthy, normal development.
The transition from childhood to adolescence is a key window for that kind of learning. This is a period of opportunity for social and emotional learning. And, for shy and anxious kids who are prone to avoid, it can be a time of learning to explore and take some healthy risks.
What determines whether anxiety leads to depression?
The relationship between anxiety and depression is complicated. We know from the epidemiology that anxiety and depression are associated. Also, anxiety can cause kids to not only avoid things that could be threatening, but also to avoid the social situations that can create opportunities for positive development. We believe it’s the diminishment of the positive emotional experiences that may be more important to the development of depression, rather than the presence of negative emotions. This is consistent with the idea that treating anxiety should focus on the impairments related to avoidance. Activating good feelings and social success—even if these create uncomfortable feelings in the short run—may have a positive effect.
What factors might make an adolescent vulnerable to anxiety?
There are a variety of factors. Clearly there is some genetic component, and some types of early experience as well as interactions between genetics and experience. For example, some personality types seem to strongly prefer comfort and predictability and tend to become very uncomfortable in situations that are novel or uncertain. Some kids seem very sensitive to low levels of physical or emotional distress. For example, even a minor stomachache or headache strongly interferes with their ability to do things. However, this sensitivity to any kind of distress may be learned and may change during adolescent development. And I think it's important when we talk about kids with these tendencies to not think of this as a fixed trait. Rather, it can be a mental or emotional habit that’s quite changeable. We should think of the capacities of these kids to effectively learn to overcome these tendencies, as well as the capacity for interventions, such as cognitive behavioral therapy, to help children and adolescents develop these skills.
Do anxious adolescents have difficulty bonding with peers and having fun?
We found in our studies that there seems to be a wide range of experiences among youth with anxiety. Some of these kids are sensitive in ways that help them to be socially skilled and popular. Yet even when their peers described them in positive ways, some of those kids didn’t see themselves as popular—they focused on negative worries about themselves and feelings of social awkwardness. And in some cases the anxious kids were rated by their peers more negatively; their degree of self-consciousness and being withdrawn and socially awkward interfered with their ability to develop friendships. There’s a wide range.Even if kids are moderately socially successfully, since they often don’t perceive themselves that way, they may avoid social groups because they are not comfortable in those situations. All these things need to be better studied. They are part of the spiral. These are things that kids can learn how to improve and be better at. We shouldn’t think that these kids can’t bond, but rather, work to find ways to improve their ability to enjoy social situations.
How can parents encourage their child or adolescent to better deal with anxiety and stressful situations?
The principles are easy, but the details of exactly how to apply the principles can be quite challenging. One of the things we know about this period when children are moving toward adolescence is that it’s a time when having positive mastery experiences is really important. What I mean by mastery experiences is doing something challenging that you get better at. Whether it’s a sport, school, music, or reading poetry, the key process is a balance of effort and rewarding success in a way that is enjoyable and also builds confidence. During this window of identity development, mastering something—especially when this feels meaningful to the individual—can have a powerful influence on how they feel about themselves.
Mastering one’s fears by gradually learning to approach things that are uncomfortable is a mastery experience as well. A core aspect of cognitive behavior therapy—which has been proven to help kids with anxiety disorders—is the graded exposure, in other words, gradually moving beyond one’s comfort zone to overcome a bit more anxiety each time. It’s like how a yoga teacher would have you breathe through a stretch. Gradually getting comfortable and overcoming fear occurs not by eliminating the feeling but by being able to approach and tolerate the feeling. If you work with kids who are making great progress using cognitive behavioral therapy, they become comfortable with a fair amount of anxiety to get to a mastery experience. It can actually become a bit thrilling to overcome that feeling.
What parents can do is help their kids have mastery experiences, encouraging them and helping them to celebrate their successes. If parents try to do this in a way that is too directive, however—by telling their kids to toughen up or by pushing them in a directive way about what they should do—this can backfire and be quite counterproductive. The key principle is to encourage kids to try things and, if there’s traction, then supporting them. That’s especially important in the social domain. But it can be difficult since parents may also be struggling with their own anxiety and negative thinking. So, when parents are anxious and they're worried about the child, they're sending off anxious signals; they're criticizing the child and trying to push him or her to do things. That becomes an amplifier of negative things. It’s tricky. Even when parents are trying to help their child become less anxious, they may make them more anxious. In some cases, kids can benefit from working with a behavioral therapist and then the parent’s role can be more supportive than directive.
Can an adolescent’s closeness with his or her parents be a modifier of anxiety?
Yes. But this requires a balance of loving support and promoting autonomy—that is, being caring but not overprotective and controlling. Again the principle is simple, but what that means to a particular family can be complicated. When kids are becoming more sensitive to their peers and they want their peers’ admiration and acceptance, a lot of parents can think that they don't matter anymore. That’s just not true. Adolescents still care about their parents’ feelings, and they still want to be close to their parents. But they also want independence and autonomy. And they will push back against their parents’ efforts to protect and control them.
Helping kids feel loved and cared about, rather than being controlled, is an important dimension. Many parents are worried about what the kids are doing and they try to control them. Anxious parents may try to express their feelings of love and caring in a well-motivated desire to help keep their child safe, but in ways that feel intrusive to the adolescent. Alternatively, some parents pull away completely. Ideally the goal is encouraging kids to explore and try things and giving them freedom, but also really caring about them, being warm, and making them feel loved. That’s the combination that seems to be really helpful.
Can the amount of sleep an adolescent gets have an effect on negative emotions and anxiety, and vice versa?
We know that feeling anxious and vigilant can interfere with sleep. And that not getting enough sleep can interfere with emotion regulation and can increase negative emotions. It's important to understand that sleep is more than rest; it’s a restorative state that requires disconnecting one’s awareness of the world for periods of time. Since sleeping individuals lose vigilance and responsiveness, sleep is naturally restricted to safe times and places. Animals tend to sleep in safe burrows, nests, or times of the day or night when they are safe from predators. For most of human history, our ancestors did not have physically safe sleep sites, but found safety in social groups.
We are still wired in ways that reflect that evolutionary heritage. Our threat and vigilance systems are powerfully influenced by our feelings of social connection. Young children don’t need vigilance around sleep because adults create safety.But as kids get older, there’s a greater capacity for social anxiety and feeling unsafe can disrupt sleep. When kids hit puberty and become very anxious about whether they belong and are accepted and are socially safe, this increases their vigilance. This can create a negative spiral of sleep deprivation, vigilance, and anxiety.So a number of research groups have been looking at how promoting healthy sleep could actually be a protective factor against anxiety and depression. But it’s not simply telling kids to get more sleep. One key factor in becoming a good sleeper is related to emotions at bedtime. Positive emotion and feelings of social connection signal safety in ways that promote sleep. In contrast, bedtime tendencies to worry and ruminate about negative events can interfere with falling asleep.
Other sources of sleep deprivation—such as being up really late at night, having electronic devices in the bedroom, and late-night social activities on weekends and holidays—also interfere with sleep and sleep-wake schedules. Once sleep unravels, adolescents often do maladaptive things to cope with the sleep deprivation, such as taking long naps at the wrong time of day, or using stimulants to stay awake. We think that promoting good sleep habits early in adolescence is particularly important in kids with anxiety. Having a good sleep schedule and good sleep habits may help protect against developing this negative spiral during later adolescence.
Also see Teens and Mental Health.