Skip to main content
PMC home page
Canadian Family Physician logoLink to Canadian Family Physician
. 2001 May;47:1023–1030.

Rages and refusals. Managing the many faces of adolescent anxiety.

E J Garland 1
PMCID: PMC2018505  PMID: 11398717

Abstract

OBJECTIVE: To provide family physicians with a practical approach to recognition, assessment, and treatment of adolescent anxiety disorders complicated by avoidance or oppositional behaviour. QUALITY OF EVIDENCE: Current literature was searched via MEDLINE using the MeSH headings Anxiety and Anxiety Disorders, focusing on epidemiology, clinical presentations in adolescence, and both pharmacologic and nonpharmacologic treatment. In addition, internationally accepted diagnostic criteria, current practice guidelines, and recent textbooks by recognized experts were reviewed. Research evidence and consensus recommendations were integrated with a practical approach developed in a provincial mood and anxiety disorders clinic. MAIN FINDINGS: Anxiety disorders are common in adolescents, with estimated prevalence of at least 10%. Substance abuse and avoiding school are common complications, and irritability with behavioural and rage problems can interfere with effective management. Current controlled research is examining the effectiveness of serotonergic medications known to benefit panic disorder, social phobia, and generalized anxiety in adults. While cognitive and behavioural treatments are effective for some child and adolescent anxiety disorders, they can be difficult to administer, and a supportive and psychoeducational approach could be as effective for those who refuse to go to school. CONCLUSION: Family physicians' awareness of the role of anxiety in adolescent school avoidance and in intense, oppositional emotional reactions at home can lead to more specific assessment and therapeutic intervention. Practical management strategies are recommended.

Full Text

The Full Text of this article is available as a PDF (59.2 KB).

Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. Albano A. M., Marten P. A., Holt C. S., Heimberg R. G., Barlow D. H. Cognitive-behavioral group treatment for social phobia in adolescents. A preliminary study. J Nerv Ment Dis. 1995 Oct;183(10):649–656. doi: 10.1097/00005053-199510000-00006. [DOI] [PubMed] [Google Scholar]
  2. Ambrosini P. J., Bianchi M. D., Rabinovich H., Elia J. Antidepressant treatments in children and adolescents: II. Anxiety, physical, and behavioral disorders. J Am Acad Child Adolesc Psychiatry. 1993 May;32(3):483–493. doi: 10.1097/00004583-199305000-00001. [DOI] [PubMed] [Google Scholar]
  3. Bernstein G. A., Borchardt C. M., Perwien A. R. Anxiety disorders in children and adolescents: a review of the past 10 years. J Am Acad Child Adolesc Psychiatry. 1996 Sep;35(9):1110–1119. doi: 10.1097/00004583-199609000-00008. [DOI] [PubMed] [Google Scholar]
  4. Bernstein G. A., Borchardt C. M., Perwien A. R., Crosby R. D., Kushner M. G., Thuras P. D., Last C. G. Imipramine plus cognitive-behavioral therapy in the treatment of school refusal. J Am Acad Child Adolesc Psychiatry. 2000 Mar;39(3):276–283. doi: 10.1097/00004583-200003000-00008. [DOI] [PubMed] [Google Scholar]
  5. Bernstein G. A., Shaw K. Practice parameters for the assessment and treatment of children and adolescents with anxiety disorders. American Academy of Child and Adolescent Psychiatry. J Am Acad Child Adolesc Psychiatry. 1997 Oct;36(10 Suppl):69S–84S. doi: 10.1097/00004583-199710001-00006. [DOI] [PubMed] [Google Scholar]
  6. Birmaher B., Waterman G. S., Ryan N., Cully M., Balach L., Ingram J., Brodsky M. Fluoxetine for childhood anxiety disorders. J Am Acad Child Adolesc Psychiatry. 1994 Sep;33(7):993–999. doi: 10.1097/00004583-199409000-00009. [DOI] [PubMed] [Google Scholar]
  7. Black B., Uhde T. W. Treatment of elective mutism with fluoxetine: a double-blind, placebo-controlled study. J Am Acad Child Adolesc Psychiatry. 1994 Sep;33(7):1000–1006. doi: 10.1097/00004583-199409000-00010. [DOI] [PubMed] [Google Scholar]
  8. Brion N., Kollenbach K., Marion M. H., Grégoire A., Advenier C., Pays M. Effect of a macrolide (spiramycin) on the pharmacokinetics of L-dopa and carbidopa in healthy volunteers. Clin Neuropharmacol. 1992 Jun;15(3):229–235. doi: 10.1097/00002826-199206000-00003. [DOI] [PubMed] [Google Scholar]
  9. Court J. M. Cannabis and brain function. J Paediatr Child Health. 1998 Feb;34(1):1–5. doi: 10.1046/j.1440-1754.1998.00142.x. [DOI] [PubMed] [Google Scholar]
  10. Crowley T. J., Macdonald M. J., Whitmore E. A., Mikulich S. K. Cannabis dependence, withdrawal, and reinforcing effects among adolescents with conduct symptoms and substance use disorders. Drug Alcohol Depend. 1998 Mar 1;50(1):27–37. doi: 10.1016/s0376-8716(98)00003-9. [DOI] [PubMed] [Google Scholar]
  11. Frick P. J., Lilienfeld S. O., Ellis M., Loney B., Silverthorn P. The association between anxiety and psychopathy dimensions in children. J Abnorm Child Psychol. 1999 Oct;27(5):383–392. doi: 10.1023/a:1021928018403. [DOI] [PubMed] [Google Scholar]
  12. Haney M., Ward A. S., Comer S. D., Foltin R. W., Fischman M. W. Abstinence symptoms following smoked marijuana in humans. Psychopharmacology (Berl) 1999 Feb;141(4):395–404. doi: 10.1007/s002130050849. [DOI] [PubMed] [Google Scholar]
  13. Keller M. B., Lavori P. W., Wunder J., Beardslee W. R., Schwartz C. E., Roth J. Chronic course of anxiety disorders in children and adolescents. J Am Acad Child Adolesc Psychiatry. 1992 Jul;31(4):595–599. doi: 10.1097/00004583-199207000-00003. [DOI] [PubMed] [Google Scholar]
  14. King N. J., Tonge B. J., Heyne D., Pritchard M., Rollings S., Young D., Myerson N., Ollendick T. H. Cognitive-behavioral treatment of school-refusing children: a controlled evaluation. J Am Acad Child Adolesc Psychiatry. 1998 Apr;37(4):395–403. doi: 10.1097/00004583-199804000-00017. [DOI] [PubMed] [Google Scholar]
  15. Kushner M. G., Sher K. J., Erickson D. J. Prospective analysis of the relation between DSM-III anxiety disorders and alcohol use disorders. Am J Psychiatry. 1999 May;156(5):723–732. doi: 10.1176/ajp.156.5.723. [DOI] [PubMed] [Google Scholar]
  16. Kutcher S. P., MacKenzie S. Successful clonazepam treatment of adolescents with panic disorder. J Clin Psychopharmacol. 1988 Aug;8(4):299–301. [PubMed] [Google Scholar]
  17. Last C. G., Hansen C., Franco N. Cognitive-behavioral treatment of school phobia. J Am Acad Child Adolesc Psychiatry. 1998 Apr;37(4):404–411. doi: 10.1097/00004583-199804000-00018. [DOI] [PubMed] [Google Scholar]
  18. March J. S. Cognitive-behavioral psychotherapy for children and adolescents with OCD: a review and recommendations for treatment. J Am Acad Child Adolesc Psychiatry. 1995 Jan;34(1):7–18. doi: 10.1097/00004583-199501000-00008. [DOI] [PubMed] [Google Scholar]
  19. Otto M. W., Whittal M. L. Cognitive-behavior therapy and the longitudinal course of panic disorder. Psychiatr Clin North Am. 1995 Dec;18(4):803–820. [PubMed] [Google Scholar]
  20. Pope H. G., Jr, Gruber A. J., Yurgelun-Todd D. The residual neuropsychological effects of cannabis: the current status of research. Drug Alcohol Depend. 1995 Apr;38(1):25–34. doi: 10.1016/0376-8716(95)01097-i. [DOI] [PubMed] [Google Scholar]
  21. Reiter S., Kutcher S. P. Disinhibition and anger outbursts in adolescents treated with clonazepam. J Clin Psychopharmacol. 1991 Aug;11(4):268–268. doi: 10.1097/00004714-199108000-00016. [DOI] [PubMed] [Google Scholar]
  22. Rocca P., Fonzo V., Scotta M., Zanalda E., Ravizza L. Paroxetine efficacy in the treatment of generalized anxiety disorder. Acta Psychiatr Scand. 1997 May;95(5):444–450. doi: 10.1111/j.1600-0447.1997.tb09660.x. [DOI] [PubMed] [Google Scholar]
  23. Solowij N., Michie P. T., Fox A. M. Differential impairments of selective attention due to frequency and duration of cannabis use. Biol Psychiatry. 1995 May 15;37(10):731–739. doi: 10.1016/0006-3223(94)00178-6. [DOI] [PubMed] [Google Scholar]
  24. Stein D. J., Bouwer C. A neuro-evolutionary approach to the anxiety disorders. J Anxiety Disord. 1997 Jul-Aug;11(4):409–429. doi: 10.1016/s0887-6185(97)00019-4. [DOI] [PubMed] [Google Scholar]
  25. Valleni-Basile L. A., Garrison C. Z., Jackson K. L., Waller J. L., McKeown R. E., Addy C. L., Cuffe S. P. Frequency of obsessive-compulsive disorder in a community sample of young adolescents. J Am Acad Child Adolesc Psychiatry. 1994 Jul-Aug;33(6):782–791. doi: 10.1097/00004583-199407000-00002. [DOI] [PubMed] [Google Scholar]
  26. Wiesbeck G. A., Schuckit M. A., Kalmijn J. A., Tipp J. E., Bucholz K. K., Smith T. L. An evaluation of the history of a marijuana withdrawal syndrome in a large population. Addiction. 1996 Oct;91(10):1469–1478. [PubMed] [Google Scholar]
  27. Zoccolillo M., Vitaro F., Tremblay R. E. Problem drug and alcohol use in a community sample of adolescents. J Am Acad Child Adolesc Psychiatry. 1999 Jul;38(7):900–907. doi: 10.1097/00004583-199907000-00021. [DOI] [PubMed] [Google Scholar]

Articles from Canadian Family Physician are provided here courtesy of College of Family Physicians of Canada

RESOURCES