Bill Klaproth (Host): Understanding the signals of anxiety in young people can be difficult. So, let's explore adolescent anxiety as we cover the spectrum from childhood through teenage years. And here to discuss is Dr. Mohamed Awais Aftab, a psychiatrist at Southwest General Health Center.

This is Southwest General Health Talk. I'm Bill Klaproth. Dr. Aftab, thank you for being here.

Dr. Awais Aftab: Thanks, Bill. I'm glad to be talking to you.

Host: This is really an important topic. I'm glad we're covering this, because I know there's a lot of questions out there. So hopefully, we can clear some of the confusion. So, let's start with this: what does anxiety actually look like in kids or teens, and how is that different than what we usually see in adults?

Dr. Awais Aftab: Yeah. I think that's a great question for us to start the discussion. An important thing for us to note is that anxiety as a term is used both for the kind of everyday normal worries, fears, anxieties that individuals have that are not disorders, that don't require clinical treatment. But the term is also used for more severe conditions that do require treatment or that accompany varying forms of distress and impairment.

So, sometimes when we are talking about adolescent anxiety or anxiety as such, people can get confused on those points whether we are just talking about everyday anxiety or clinical anxiety. So, it's important to keep in mind that anxiety occurs on a spectrum, on a range. It kind of goes from everyday concerns to more severe ones and serious ones. A lot of people when they think about anxiety, they are thinking of two kinds of things. One is excessive worry. They're just constantly worried about things, fearful about things, they're nervous about things. And then, there's a second element that they feel restless, they feel on edge, they feel unsettled, and that feeling is there all the time, sometimes with bodily sensations like heart beating fast or muscle tension. That's how anxiety is usually described and how it usually presents in adults.

The difference in teenagers and children is that children can be less expressive about these emotions. They may not verbalize, "i'm feeling very nervous." They might not say, "I'm worried about something all the time," or "I'm restless." Rather, they may express that anxiety through their behaviors. So, they may avoid things that make them anxious. So, they may start avoiding school. They may start kind of skipping school. They may stop kind of hanging out with their friends. They may stop spending time with their family. So, it may manifest as avoidance, it may manifest as social isolation. In some cases, it can manifest as irritability. They seem irritable for reasons that cannot be determined. So, it's important to look out for those behavioral signs and use them as an opportunity to talk to the child and talk to the teenager about what's driving them.

Host: So, every kid worries now and then, right? I mean, that's just normal. So for a parent-- and I know you've given us a little bit of information on-- this for a parent, how do they know when it's something more serious than normal stress or normal worry that a teen would have?

Dr. Awais Aftab: And distinguishing that can be a tricky thing, sometimes even for professionals. And the reason this distinction is tricky is, as I mentioned earlier, anxiety exists on a spectrum and on a continuum. There is no firm bright line where "normal anxiety" ends and "abnormal anxiety" begins. Rather, what we have is that we are looking at anxiety through a number of different perspectives.

One is that kind of persistence. How persistent is anxiety? Is it time-limited? Just kind of if a person is anxious for a few days, and then they go back to their normal usual self that doesn't indicate something that warrants clinical concerns. But if it has been six months or a year, that's a different story. So, we're looking at persistence or chronicity, then we are looking at severity. Is the severity enough that it is affecting the person's day-to-day life in a negative manner? Is it affecting their schoolwork? Is it affecting their family interactions, their socialization?

And then, professionals also talk about kind of anxiety being adaptive or maladaptive. Normal anxiety is adaptive. It forces us to be vigilant. It forces us to pay attention. It motivates us. If we are somewhat nervous about, let's say, an upcoming test or a task, we are likely to expend effort towards that. Versus anxiety, when it becomes a disorder, it becomes maladaptive instead of enhancing functioning. It starts negatively affecting that functioning.

So, those are some of those features and clues that I think parents and family members can look for as well. Persistence of anxiety, severity of anxiety, and its functional impact and the impact on day-to-day life.

Host: Okay. So, those are really good tips. And you said kids will exhibit avoidance of anxiety through their actions or behavior. So, look for persistent change in behavior, as you said, severity, functional things that are happening that the child just isn't doing anymore, those types of things. So, that's really good advice. So, being the parent of two, when kids hit the teen years, Dr. Aftab, things can really shift emotionally. How does anxiety typically change as kids get older?

Dr. Awais Aftab: Yeah. Teenage years and adolescence, it's a period of rapid change. Children are experiencing and confronting new challenges that they were not experiencing during earlier periods of childhood. In particular, issues of identity become pretty salient. It's one of the first times in the life the child is beginning to wonder, "Who am I and how do I differentiate myself from other people? And how do I differentiate myself from other members of my family? So, we start seeing these struggles and experimentations around what kind of style, clothing style, or what forms of expression.

But that process of exploring identity can be uncomfortable too. And children and adolescents can express discomfort through various ways. Sometimes through anxiety and nervousness, sometimes through other rebellious means. So, it's important to keep that larger context of adolescence in mind and the challenges. And in contemporary world, there are tremendous social demands on adolescents too. They have to navigate a complex school environment, where there's social hierarchies and social rules and interpersonal interactions. They have to navigate friendships and relationships with other teenagers and kids. And that social work can be messy and sometimes there can be elements of harassment and bullying. And sometimes with social media, there are some of these interpersonal interactions that can take on other dimensions. So, there is a complex social world that teenagers are navigating. And it is normal to experience a certain degree of anxiety associated with that too.

The key thing here is that we get a normal anxiety, a kind of everyday anxiety, it is best addressed by confronting that challenge head on, by confronting that task head on. Anxiety thrives on avoidance. If you are anxious of a task, if you're fearful of something and you avoid it, you will remain fearful of that. But if you step outside your comfort zone and you confront what needs to be done, the anxiety will dissipate. This is what happens with kind of everyday ordinary anxiety. And so, we should be encouraging kids usually to step outside the comfort zone and try to confront their anxiety as much as possible.

Now, when it comes to clinical anxiety, kind of, you know, disordered states that are severe, persistent, maladaptive, their ability to confront that anxiety on their own can be undermined because the anxiety is just so overwhelming. In those situations, they can require clinical treatment to help them confront that anxiety in a careful manner.

Host: So, help them address their challenges and their anxiety by confronting any challenge or stressor head on. It sounds like that's your advice on that. And you're right, kids, when they become teenagers, they've got to deal with identity and social demands, school demands, and those types of things. What about social media? Is that one of the biggest things that seem to trigger anxiety in teens today? Is social media really as big of a factor as we hear?

Dr. Awais Aftab: It can be, it really depends. I think there's a certain moral panic around social media use as well, and there are exaggerated fears. What social media does is that it simply provides another domain in which people are interacting with each other. And then, those interactions can go well. And when they go well, they can be transformative. For example, teenagers who may otherwise be isolated, they can sometimes find really valuable friendships online and they can connect with people who share interests. So, people can have meaningful, productive relationships through social media that they would not have in real life.

At the same time, social media can also facilitate negative social interactions. It can facilitate harassment in other forms. It can facilitate insecurities in other forms. It can supercharge this comparison that, "Oh, my classmate is doing such and such and has been posting on Instagram" versus "I'm falling short in comparison." So, it can supercharge those social comparisons, it can supercharge social hierarchies. And in some cases, there can also be targeted harassment. So, it's difficult to generalize. Social media by itself is neither good nor bad, but it presents certain risks. And it's important to be mindful of them and be vigilant of them.

Host: So then, the big question that I would think is for parents who are wondering when is it time to seek help, how do they know when it's time to reach out to a professional?

Dr. Awais Aftab: Usually, I think what professionals such as myself recommend is that when anxiety begins to exceed the demands and kind of the needs that family and friends can provide. So, if the anxiety, for example, is mild that If the child is able to talk to parents about it and kind of is able to process their fears and nervousness through that. Or if the child, let's say, has a group of friends. And then the child is able to manage their anxiety, fears or their nervousness by spending time with their friends and talking about it, and their functioning is not affected, their grades are not dropping as much, their family functioning is okay, socialization is okay, that's fine.

But if the functioning starts getting affected and everyday means of reassurance and family support and those things are not doing the job, or if there are more concerning, behavioral signs, so if for example, if the person is so anxious that they are expressing suicidal thoughts or they're expressing thoughts of wanting to die or they are exhibiting, for example, other concerning behaviors like self-cutting. Sometimes for some teenagers, anxiety can get so overwhelming that they can resort to things like cutting themselves or harming themselves without suicidal intent behind it. If those kinds of concerning things are there, immediately seek clinical help. And if the anxiety is so disabling or overwhelming that the child is having a difficult time functioning at school or interacting with family, that would be another side.

Host: Yeah. So when anxiety exceeds support of friends and family, that is a good clue that it's time to seek professional help. And you said earlier, watch out for persistent severity, functional things like that. Very important. So if a parent does decide to seek help, what does that process actually look like? How do doctors or therapists diagnose anxiety in kids or teens?

Dr. Awais Aftab: Yeah. It really depends a great deal on who one sees for the first time for that complaint of anxiety. I would say the usual thing that happens in America and, certainly, in this part of the country as well, is that people usually go to their pediatrician, because that tends to be the point of contact for healthcare issues. And pediatricians can do an assessment and try to kind of assess the degree of severity of anxiety and its impairment. And if they feel that a diagnosis is warranted, they'll discuss that and make recommendations.

But some people can also bypass the pediatrician, for example, and they might end up meeting with a counselor first. Let's say, so often schools can have counselor, so it might be that the school counselor first recognizes that there's some kind of an anxiety problem happening, or if the family is aware, has resources, they might meet with an independent mental health counselor or a psychotherapist, or they might even go see a child psychiatrist. So, there are a number of different options available to families and patients. The pediatrician is the most common route, but counselor and child psychiatrist are also a thing.

And then, with regards to treatment, I'll jump into that part of it, the recommendation kind of right now, and these are recommendations that are supported by kind of like the clinical psychology associations and American psychiatric and kind of, you know, other psychiatric associations, is that in adolescence and children, psychotherapy is the preferred first line strategy. We first try addressing the problem through means of counseling and talk therapy to see kind of how well it can be handled.

However, if the problem is not responding adequately to talk therapy or if the problem is very severe, so, if there's concerning suicidal thoughts, or there's a lot of depression, or there are other aspects that complicate the fixture. So if the problem is severe and there are complicating factors, then medications can be considered as a first-line treatment too from the beginning. And we have a number of anxiety medications that have been studied and approved and that are backed by medical research.

Host: And then, how would a family decide between therapy or medication, or maybe even both?

Dr. Awais Aftab: So ideally, this is the conversation that whoever the clinician is making the diagnosis would have, so if the pediatrician is making the diagnosis, they would discuss that anxiety can be treated with psychotherapy, and there are also medication options. And same thing if a counselor is making a diagnosis, they'll have that.

Unfortunately, access can be a limiting factor. For a lot of people, it is not easy to access psychotherapy. It may not be covered by insurance, for example, or there may be a long wait time for psychotherapy. So for some of those structural reasons, you know, due to reasons about kind of accessibility of psychotherapy, in practice, many pediatricians and other professionals sometimes end up starting with medications, just because it is easier for the patient to access them.

So we have to keep these broader factors in mind. But as I mentioned, the general recommendation is that for mild to moderate levels of clinical anxiety, psychotherapy is the preferred. So, it is better if you can access it. If you have access to a psychotherapist or a counselor, and the anxiety is mild to moderate, start with psychotherapy. See how well the child does. And if needed, then medication can be added. But if the anxiety is severe or there are many complicating factors, then a medication can be started from the beginning, or a combination of medication and psychotherapy can be used.

Host: So for anybody watching this listening to this, they might say to themselves, what is psychotherapy? So, can you just briefly explain what psychotherapy is?

Dr. Awais Aftab: yeah. So, psychotherapy is a general term we use for a form of psychological treatment in which a person is sitting down with a trained mental health professional. These are often kind of licensed social workers with mental health training, or these are psychologists, clinical psychologists with PsyD or PhD level of training, and they talk with a patient. And there are different schools of thought and different kind of ways in which counselors approach that. And so, the focus can be different. But that's the basic idea, is that a non-judgmental, supportive person is sitting down with the patient and talking about and exploring their distress with a certain degree of regularity. Usually, especially in the beginning, it tends to be weekly. So, that every week for about 40 minutes or 50 minutes, they're sitting and talking about these things.

But depending on the school of psychotherapy, there are further differences. So, for example, some psychotherapists might be more supportive, they might focus on various kinds of psychological skills and other kind of techniques that a person can use to control their anxiety. So, some psychotherapists can focus on learning skills and kind of teaching skills. Others can focus more on kind of unconscious conflicts on relationship issues. So, the psychodynamic therapist might try to focus on what is happening in this person's learning environment and what kind of fears might be happening beneath their conscious mind that are contributing to this. And interpersonal therapist might look at what kind of Relationship issues are driving this. And then, other therapists might focus on the ways in which our mind distorts things and distorts our experiences. So, our anxieties have a way of exaggerating our perception, negative perception of the world for instance. So, there's a term called cognitive distortions in the psychotherapy world. So, another therapist might focus on those.

So, there are different styles and schools available. But they all share the basic idea that a supportive, caring, non-judgmental person is devoting their time and effort to talking with the patient.

Host: So if medication is called for, if psychotherapy doesn't work necessarily or they're going to be used in combination, there seems to be a lot of hesitation around medications. What should parents know about anti-anxiety meds for children or teens? Are they generally safe?

Dr. Awais Aftab: Yeah. So, by standards that we consider across all of medicine, the anti-anxiety medication that are available are considered safe and effective. That does not mean that there are no side effects or no risks involved. All medications come with certain risks, certain side effects, but, those side effects offer a nature that their use is still considered reasonable and legitimate as long as a person is aware of what those side effects are.

The most common form of anti-anxiety medications are a group of antidepressants that act through the serotonin system. These are called SSRIs or selective serotonin reuptake inhibitors. These are common medications with names such as Prozac and Zoloft and Lexapro. So, they tend to be the mainstream, the first line treatment for anxiety disorders, for medications. And some important risks with those to keep in mind is that in the beginning some people can have stomach issues with that. With long-term use, some people can have sexual functioning issues, which present some distinctive challenges among teenagers and adolescents. And there are kind of rare cases in which, in children with antidepressant use, suicidal thoughts can worsen. So, these are not benign medicines. They should be used under the supervision of a clinician with close monitoring. But there are other anxiety medication options available as well. in addition to the SSRIs that can be utilized depending on the situation and the preferences of the person.

Host: So, does treatment look different depending on the child's age? Like, say, a 7-year-old versus a 17-year-old?

Dr. Awais Aftab: In general, the younger the child is, the more it would make sense for psychotherapy to be the guiding treatment. So, it would be kind of much more important for, let's say, a 7-year-old to kind of start with psychotherapy, as the starting treatment point. So, that's one consideration.

And then, the second thing is that if medications are used in a 7-year-old, we might use lower doses than what we would use in a 17-year-old. So, dose considerations also come into play. And then, because our brain is developing and maturing over the years, so there are certain brain pathways that are not fully developed in a 7-year-old compared to a 17-year-old. And that affects the choice of the medication. So, a certain medication that may work well in a 17-year-old may not work as well in a 7-year-old, because the relevant neurotransmitter pathway is not very well developed. So there are some differences that come up, but the broad principles remain the same.

Host: So then, outside of therapy, what are some real life things parents can do at home to help their child manage anxiety day to day?

Dr. Awais Aftab: what I would say is that families have to pull off a delicate balance because they have to provide enough kind of a support and, accommodation for the child that they're not overwhelmed. So, they might need some flexibility, for example, around schoolwork, or they might need some flexibility around social interactions. But parents should also not facilitate the process of anxiety avoidance. They should not take away all obligations or responsibilities away from the child just because they have a clinical anxiety problem, because then that would just feed the avoidance. So, it's delicate. You know, so we have to provide a supportive space without kind of reinforcing the avoidance that comes with anxiety. And then, generally, kind of encouraging. the child to maintain healthy social interaction, so to continue to socialize with friends in a healthy manner.

And lifestyle changes can be helpful too. Exercise is a very useful tool. So, either, if the child, it can be physically active, it's sports. Or for teenagers, they might, you know, benefit from going to gym or going for runs. So, facilitating kind of physical activity. There's a strong link between physical activity and kind of mental health. So, that's important.

And then, there's emerging kind of evidence and emerging clues that the quality of the diet can also have an impact on kind of depression and anxiety symptoms. And there seems to be this kind of relationship that the more refined and processed the diet is, so the more highly processed food there are, the more refined sugars there are, the more vulnerable the individual seems to be to developing depression and anxiety. So, a healthier diet can also be an important tool in addition to the clinical treatments.

Host: Yeah. All of that makes sense. I like how you said all of that. Exercise always lifts the mood, pay attention to diet, other things as well. And for the parent then who's feeling overwhelmed or doesn't know where to start, is there one thing that that parent can do to support the child?

Dr. Awais Aftab: Yeah, I would say reach out to the professionals, reach out to the pediatrician or if you have school counselor, reach out to the school. And so, if you're overwhelmed, reach out for professional help and see what the professionals can offer.

Host: So then, do anxiety and depression tend to go hand in hand in kids? And if anxiety is treated, does that also help with symptoms of depression?

Dr. Awais Aftab: They are related for a lot of people. They are distinct diagnosis, because the characteristic symptoms are different. Some people can present just with depression. Some people can present just with anxiety . But there's a large number of people that can have both at the same time. Because kind of stress response and kind of elevated stress situations can feed into that. And if both anxiety and depression are present, it is important for the clinical treatment to target both at the same time.

Now, the good thing is that oftentimes many of the same medications work for both. So for example, SSRIs like Prozac address both anxiety and depression. And many psychotherapies also work for anxiety and depression at the same time. But there are further differences. There are some medications that help only with anxiety, and there are some medications that'll help only with depression. And correspondingly, there can be differences in psychotherapy too. So, keeping that in mind. But the general thing is that when they are present together, they tend to go hand in hand. And as the anxiety improves, the depression tends to improve as well.

Host: Well, this has really been a great discussion, Dr. Aftab. Thank you so much for your time. Really important discussion and good information for parents and children to know. Is there anything else you want to add? Anything we didn't cover that you'd like to say?

Dr. Awais Aftab: I'll just say that, you know, Southwest General has a lot of mental health kind of resources and we have dedicated mental health programs and, in particular, we also have an intensive outpatient program designed for adolescence who are having mental health challenges. So, as you are looking for professional help for your struggling adolescent and teens, think of Southwest General as an option too.

Host: Well, thank you so much for your time. This has really been informative. We appreciate it.

Dr. Awais Aftab: I enjoyed it as well.

Host: Thank you so much. And once again, that is Dr. Mohamed Awais Aftab, a physician with Southwest General Medical Group. For more information and to book an appointment with Dr. ftab, visit swgeneral.com. That's swgeneral.com. And if you found this episode to be helpful, please share it on your social channels and check out the full podcast library for topics of interest to you, this is Southwest General Health Talk. Thanks for listening.