The Journal for Nurse Practitioners xxx (xxxx) xxx

Contents lists available at ScienceDirect

The Journal for Nurse Practitioners

journal homepage: www.npjournal.org

Anxiety in Adolescents
Iliana Garcia, Jean O’Neil

a b s t r a c t
Keywords: Anxiety is a highly prevalent mental disorder in today’s adolescent population. It can sometimes lead to
adolescents severe physical and mental impairment. Several adolescent population-specific factors make this age group
anxiety disorders
particularly vulnerable to the development of anxiety. Providers and the medical team must be diligent in
assessment
treatment
recognizing subtle signs of adolescent anxiety and implement prompt treatment of this disorder. Untreated
primary care providers anxiety can have detrimental consequences later in life.
© 2020 Elsevier Inc. All rights reserved.

Anxiety is a highly prevalent mental disorder in today’s
adolescent population. It can sometimes lead to severe physical and
mental impairment and disability. Adolescence is a time of explo-
ration and for the development of a sense of self.1 It is a critical
transition period from childhood to adulthood. Undiagnosed and
untreated anxiety can interfere with normal psychological devel-
opment and cause a significant burden on an individual’s quality of
life and well-being. It is predicted that nearly 1 in 3 adolescents
aged 13 to 18 years will experience an anxiety disorder.2 Between
2007 and 2012, anxiety disorders in children and teens increased
by 20%.2 The 2016 National Survey of Children’s Health reported
that among US children between the ages of 3 and 17 years, 7.1%
(4.4 million) had current anxiety problems, 7.4% (4.5 million) had a
concurrent behavioral problem, and 3.2% (1.9 million) had a con-
current problem with depression.3 Treatment of anxiety costs
approximately $42 billion a year.4
DSM-5 Definition of Adolescent Anxiety
The Diagnostic and Statistical Manual of Mental Disorders (5th
edition; DSM-5) includes 7 anxiety disorders seen in children:
generalized anxiety, social anxiety, separation anxiety, panic dis-
order, agoraphobia, specific phobia, and selective mutism.5 Gener-
alized anxiety disorder (GAD), separation anxiety, and social
anxiety disorder (SAD) are the 3 most common adolescent anxiety
disorders seen by primary care providers (PCPs).5 These disorders
can have overlapping symptoms and sometimes occur simulta-
neously, as well as with other psychiatric disorders, such as
depression, eating disorders, and attention-deficit/hyperactivity
disorders.6
Generalized anxiety involves constant and excessive worrying
that interferes with daily activities and lasts more than 6 months. It
can be accompanied by physical signs, such as restlessness,
insomnia, difficulty concentrating, and muscle tension. In the
adolescent population, it usually includes feeling inadequate in
school and constant worry about their family, their own health, or
minor matters such as appointments or chores.7
Separation anxiety occurs when an adolescent is excessively
fearful or anxious about separating from those to whom they feel
attached, usually lasting for 4 weeks or more. They may always feel
anxious about going on sleepovers, outings, to school, or on any
travel that would take them away from those they love.7
Social phobia, present for 6 months or more, is when an
adolescent becomes anxious and uncomfortable about being
embarrassed, rejected, or humiliated during social interactions.7
They fear social gatherings but also worry when they are not
included, due to “fear of missing out.”7 Public speaking, meeting
new people, and even eating or drinking in public are great sources
of anxiety for them. Social anxiety, in particular, has specific
detrimental effects. Social learning theory stresses the importance
of acquiring new knowledge and adaptive capabilities that are
imperative to the psychosocial development for adolescents.8 So-
cial learning is defined as a change in understanding, attitudes, or
new knowledge acquisition that takes place through social inter-
action.8 Adolescents with social anxiety tend to avoid social events
and therefore miss out on this type of learning. This type of anxiety
often begins in childhood and can persist into adulthood.7
Prevalence and Pathophysiology of Anxiety
The median age of onset for anxiety disorders is 11 years, with
75% of all anxiety disorders having developed by age 21 years.9 In
the United States, there are almost 42 million adolescents between
the ages of 10 and 19, and they make up 12.9% of the population.10
The National Institute of Mental Health estimates that 31.9% of
adolescents have some sort of anxiety disorder, with 8.3% having

https://doi.org/10.1016/j.nurpra.2020.08.021
1555-4155/© 2020 Elsevier Inc. All rights reserved.
2 I. Garcia, J. O’Neil / The Journal for Nurse Practitioners xxx (xxxx) xxx
severe mental impairment related to their anxiety. The prevalence
of such disorders was higher for adolescent females (38.0%) than
males (26.1%).11,12 However, many cases of unreported adolescent
anxiety are often underrecognized and undertreated in primary
care.12
Anxiety is defined as the response of an individual to real or
potential threats that can endanger their homeostasis.13 This
response may include both physiological and behavioral symptoms.
Our brain regulates our physiological response to situations that
cause fear or anxiety by stimulating the sympathetic nervous sys-
tem, which in turn releases epinephrine and norepinephrine.14
These hormones trigger the “fight-or-flight” mechanism in
response to stressors. In addition to epinephrine and norepineph-
rine, serotonin and dopamine, also found in the brain, are the pri-
mary monoamine neurotransmitters responsible for mood
regulation. A reduced level of dopamine is often linked to depres-
sion and low motivation, whereas serotonin is involved in how
people process their emotions. Depression, mania, and anxiety
have been linked to the dysfunction of these neurotransmitters. For
example, medications that block the process of serotonin reab-
sorption in the brain, such as selective serotonin reuptake in-
hibitors (SSRIs), are used to treat depression and anxiety as well as
other psychiatric disorders.15
The behavioral component of anxiety involves actions such as
inhibition of ongoing behaviors, heightened awareness of one’s
surroundings, and avoidance of the source of danger.13 The anxiety
response is normal in healthy individuals, serving as a protective
mechanism by causing temporary worry or fear due to certain life
stressors or events. It becomes pathological when the feelings of
anxiety are persistent and impair a person’s ability to perform their
activities. Many forms of adolescent anxiety are associated with
other psychiatric conditions, such as depression, that can persist
into adulthood.16
Biopsychosocial and Environmental Factors
The development of anxiety appears to be determined by in-
teractions among biological, developmental, psychological, and
social/environmental factors.16 Biological factors refer to the ge-
netic vulnerability that is seen in anxiety disorders. Anxiety tends
to run in families, and there is a genetic component associated with
this disorder.17 Children of parents with anxiety disorders (44%)
were 7 times more likely to be diagnosed with an anxiety disorder
compared with children of parents with no anxiety disorder (8%).17
Developmental factors refer to the link between the anxiety
disorders and a child’s development of temperament and behavior.
The most significant developmental risk factors for anxiety are
temperament, parent psychopathology, and parentechild rela-
tionship.9 Temperament, in this case, refers to behavioral inhibi-
tion, which is a style of reacting with extreme withdrawal and
avoidance from unfamiliar situations.9 Research has shown a strong
link between behavioral inhibition in infants and toddlers and the
development of anxiety in adolescence.9
Dysfunctional psychosocial interactions with parents or care-
takers can place the adolescent at a higher risk of developing
anxiety. These behaviors can result from negative parenting be-
haviors, including overprotective parenting, parental rejection and
criticism, and patterns of adverse familial interactions, such as
marital conflict and hostile sibling relationships.17,18 The link be-
tween parenting styles and the development of anxiety tends to be
more pronounced in the female population.18
Attempting to conform to social norms and pressures can also
lead to adolescent anxiety. The most commonly identified stressors
include issues regarding sexual development, uncertainty
regarding self-identity, fear of not being accepted by those they find
attractive, lack of self-confidence with social interactions, and
poorly self-perceived general psychological well-being.19 Later in
adolescence, excessive worries may arise from the pressure of
choosing a college or career path or finding a job.19
Environmental factors can play a role in the development of
anxiety. A child or adolescent can develop anxiety from unpleasant
life experiences. Anxiety and depression can be the result of
physical or emotional trauma, such as being abused or bullied or
experiencing losses due to natural disasters. Familial economic
insecurity and community or school situations that have exposed
children to violence, including the recent rash of school shootings
and terrorist attacks, can also lead to the development of
anxiety.2,16
Studies have demonstrated a link between the increased
popularity of social media and the rise in psychological disorders,
such as anxiety in the adolescent population.20 Loneliness is a
significant risk factor for some mental disorders, particularly social
anxiety.21 The rise in adolescent use of social media can lead to
social discomfort and isolation, which can lead to adolescent anx-
iety, depression, or something more emergent, such as suicide.
Excessive use of social media leads to physical inactivity, feeling
envious of others, and poor self-esteem related to the feelings of
inadequacy related to what they see online, whether or not it is a
real depiction of society.2
Poor sleep habits have also been found to cause anxiety. How-
ever, anxiety can also be the cause of insomnia. The National Sleep
Foundation recommends 8e10 hours of sleep per night for ado-
lescents, yet only 15% of adolescents report an average of 8 hours or
more of sleep on school nights.22 Potential causes of poor sleep in
adolescents can include busy schedules and the use of electronics
such as video games, television, and social media. Use of substances
such as caffeine, nicotine, drugs, and alcohol can also increase stress
and anxiety.23
Assessment and Diagnosis
One of the challenges of assessing anxiety disorders is that the
clinical features of one disorder can closely resemble those of
another behavioral or physical problem.24 Young patients with
anxiety disorders may not recognize that their fears or excessive
worrying are inappropriate.16 In other situations, certain symptoms
or outward expressions of anxiety, such as irritability, crying, and
angry outbursts, may be mistaken for rebellious and disobedient
behavior. Routine screening for anxiety and other mental health
symptoms should be done during the annual physical exam.2 The
majority of patients with anxiety present with somatic complaints,
like fatigue, headaches, stomach aches, palpitations, muscle pain,
while only a minority present with psychiatric complaints.16
Physical exams are imperative to make sure there are no underlying
medical problems causing their symptoms. For example, hormonal
imbalance, cardiac issues, infections, nutritional problems, brain
tumors, hematologic disorders and issues with drugs and alcohol
can produce symptoms that may mimic anxiety. On the basis of
exam findings and somatic complaints, the provider may need to
order laboratory and other diagnostic testing, as well as consult
with specialists if there is a suspected physiological cause for these
symptoms.
The diagnosis of anxiety disorder implies that the fear or anxiety
must be out of proportion to the situation, or are age-inappropriate,
and hinder one’s ability to function normally. A diagnosis of anxiety
should be made utilizing the diagnostic criteria listed in the DSM-5
and a structured diagnostic interview with the use of validated
assessment tools.16 Assessment and patient self-reporting in-
struments are available for providers and can be useful for
screening and monitoring the severity of symptoms. Examples of
 I. Garcia, J. O’Neil / The Journal for Nurse Practitioners xxx (xxxx) xxx
such instruments include the Generalized Anxiety Disorder (GAD-
7) survey and the Youth Anxiety Measure for DSM-5 (YAM-5).24,25
Simple self-reporting tools for assessing child and adolescent
anxiety, such as Screen for Child and Anxiety Related Disorders
(SCARED), can be found on the Anxiety and Depression Association
of America website.26 These adolescents are encouraged to share
their results with their provider.26 The PCP can then intervene as
needed. In some cases, it helps to include the input of multiple
sources, such as parents/caregivers, social workers, and teachers.27
Treatment of Anxiety
Anxiety can require lifelong treatment. Long-term effects and
rates of successful remission must be considered as part of the goals
of treatment. Referral for psychotherapy and/or the use of medi-
cation should be individualized to the patient’s symptoms and level
of dysfunction. The Child/Adolescent Anxiety Multimodal Study
(CAMS) randomized children and adolescents with diagnosed
anxiety disorders into 1 of 4 treatment groups: cognitive behavioral
therapy (CBT), sertraline (SRT), combination of SRT and CBT, or
placebo pills. The average participant age was 17.5 years old. The
results of the study suggested that both CBT and SRT alone reduced
the severity of anxious symptoms in children and adolescents;
however, the combination of the 2 therapies showed the most
benefit.28
The Child/Adolescent Anxiety Multimodal Extended Long-Term
Study (CAMELS), which examined the long-term outcomes of the
CAMS study, revealed remission rates of the children in this initial
study, and identified predictors of remission.29 Surprisingly, less
than half of the subjects were found to be in stable remission,
which revealed the chronicity and progressive nature of anxiety
disorders, particularly in the pediatric and adolescent years. The
data also highlights the importance of follow-up care for patients
with anxiety. Another significant finding of the CAMELS study was
that the participants who received treatment at a younger age were
more likely to respond positively for the long term. The study found
that the predictors of long-term remission included those who
were male gender, successful at initial treatment response, younger
aged, youth without the diagnosis of social phobia, who had higher
global functioning, fewer interim negative life events, and better
family functioning.29
Psychotherapy
Before prescribing antianxiety medication, psychotherapy is
usually recommended as the first choice treatment for adolescent
anxiety.12 One type of psychotherapy is CBT, or “talk” therapy,
which helps identify and clarify why a person is feeling anxious.16
CBT can also help change a person’s reactions to stressors or trig-
gers by modifying thought processes. Particularly aimed at teens
suffering from anxiety and depression, the Creating Opportunities
for Personal Empowerment (COPE) program was created using the
principles of CBT but with more options for accessibility and is
more age-appropriate for adolescents.30 The COPE program pro-
motes active self-management of their problems through 7 to 15,
20e30-minute sessions. There is also an option for them to do the
lessons online and connect with providers through telehealth. In
addition to promoting self-control, positive thoughts and out-
comes, self-empowerment to manage feelings of anxiety are
emphasized.30 Interpersonal psychotherapy (IPT) posits that some
people have risk factors, such as poorly adapted interpersonal be-
haviors, that cause negative emotions, thereby making social situ-
ations or relationships anxiety provoking. These behaviors can lead
to anxiety and depression. IPT focuses on modifying these personal
interactions so that they are less stressful.31 Studies have found that
3
the combination of psychotherapy and pharmacotherapy have the
best outcome for adolescent anxiety reduction.2,32
Psychopharmacotherapy
In 2004, the US Food and Drug Administration (FDA) issued a
black box warning (BBW) on antidepressants as the result of a
meta-analyses of 372 randomized clinical trials that involved
examining the rate of suicidal ideations in 100,000 subjects on an
antidepressant versus placebo.33 Suicidal ideations occurred
among 4% taking antidepressants versus 2% on placebos.33 A sub-
sequent age-stratified analysis showed that suicidal ideations were
significant among patients under age 18 years but not for those 24
years and older.33 This BBW warning led to a decrease in antide-
pressant prescriptions for adolescents.34 Some studies also linked
suicidal ideations in adolescents to increases in energy or mania
from antidepressant use while they were still dealing with the
unresolved issues that were causing depression or anxiety.35,36 In
2007, the FDA added to the BBW that depression is also the cause of
suicide.35 Currently, providers have learned that antidepressants
can be useful in treating adolescents with depression and anxiety
provided they are started at low doses and are closely monitored,
especially in the first few weeks of use.35,36
Antidepressants are often used as treatment for various forms of
adolescent anxiety, especially in cases where the patient is not
improving with just psychotherapy. Currently, duloxetine, a sero-
tonin norepinephrine reuptake inhibitor (SNRI), is the only FDA-
approved medication for treating GAD in adolescents.37 However,
randomized controlled trials have found certain SSRIs, as well as
other SNRIs, can also be effective as first- and second-line drugs,
respectively (Table).38-41 Utilizing antidepressants to treat GAD,
except for duloxetine, is considered off-label use. Although pro-
viders have used citalopram or escitalopram as a second-line
treatment for anxiety, some studies have shown a slightly higher
rate of side effects when used in children and adolescents.42,43
If the PCP is comfortable prescribing these drugs and patient
and family education regarding their use have been provided, an
adolescent can begin an SSRI at its lowest dose. Using fluoxetine or
sertraline as first-line off-label treatments for adolescent anxiety
have had favorable results.39,40
It will take most antidepressants about 4e6 weeks to work.39
Patients just beginning these medications should be brought back
in a week to assess for side or adverse effects. If the patient is feeling
less anxious, the provider can keep the adolescent at the lower
dose. However, if they are still suffering from anxiety, then the
provider may titrate the dose to the next appropriate level in
approximately 1e2 weeks (Table). Titration of the drug should be
done on an individual basis based on its effectiveness.
Other medications, such as buspirone and antihistamines, have
also been found to be helpful in controlling anxiety (Table). Bus-
pirone alone is not more effective than a placebo when treating
adolescent anxiety. However, sometimes buspirone and/or anti-
histamines have been used in addition to an SSRI or SNRI, as a
second drug to help with anxiety.39
While benzodiazepines have been used for short-term anxiety
disorders in adolescents, they are for emergent or severe psychi-
atric symptomology. They are not recommended for ongoing
treatment due to their highly addictive nature and adverse or lethal
side effects related to overdosing.39
Tricyclic antidepressants (TCA) are considered third-line drugs
for the treatment of anxiety and are rarely used in adolescents due
to the higher risk of a cardiac event and adverse effects.39
If the adolescent has been anxiety free for at least a year, then
the provider could begin to wean the patient off of the medica-
tion.39 Initially, the dose could be cut by 25% for 1e2 weeks,
4 I. Garcia, J. O’Neil / The Journal for Nurse Practitioners xxx (xxxx) xxx
Table
Medication Used for Treatment of Generalized Adolescent Anxiety Disorder
Medication Dose
SSRIs
Fluoxetine (Prozac)a Start at 10 mg po QD; may increase to 20mg po
QD after 12 weeks
Sertraline (Zoloft)a Start at 12.5e25 mg po QD; may increase to 25e50 mg PO
QD after 1e2 weeks
a
Paroxetine (Paxil) Start at 10 mg PO QD; may increase to 20 mg PO
QD after 1e2 weeks
Fluvoxamine (Luvox)a Start at 25e50 mg HS; may increase to 50 mg in 1e2 weeks,
given in divided doses
SNRIs
Venlafaxine (Effexor)a Start at 37.5 PO QD; may increase to 75 mg in 1e2 weeks
Duloxetine (Cymbalta)b Start at 30 mg PO QD; may increase to 60 mg in 2 weeks
Otherc
Diphenhydramine Start at 25 mg PO QD; may increase to 50 mg if needed
(Benadryl)a
Hydroxyzine (Vistaril)a Start at 25 mg PO QD; may increase 50e100 mg QD in
divided doses
Buspirone (BuSpar)a Start at 7.5 mg BID; may increase to 15 mg BID in
1e2 weeks
BID ¼ twice a day; GAD ¼ generalized anxiety disorder; HS ¼ at bedtime; PO ¼ by mouth; QD ¼ daily; SNRIs ¼ serotonin norepinephrine reuptake inhibitors; SSRIs ¼ selective
serotonin reuptake inhibitors.
a
Off-label use for GAD. References 38e40 were used for the development of this table.
b
The only US Food and Drug administration-approved medication for treatment of generalized anxiety disorder in children and adolescents.
c
Sometimes used in conjunction with an SSRI or SNRI.
followed by 50% for the 1e2 weeks, until the patient is off
completely. During this time, the provider should be monitoring
the patient for symptoms of withdrawal or the relapse of anxiety.44
Provider Implications
The increasing prevalence of adolescent anxiety disorders is a
serious issue. Allowing adolescents to speak to their provider pri-
vately could also help uncover problems that patients may not feel
comfortable sharing in front of parents or caregivers. In addition to
discussing the importance of healthy lifestyle choices, such as stress
reduction, exercise, good nutrition, avoidance of drugs and alcohol,
and proper sleep hygiene, providers can refer their patients to
websites such as https://www.adolescenthealth.org/About-SAHM/
Health-Info-for-Parents-Teens.aspx and http://teenmentalhealth.
org/our-vision/ for more information regarding mental health is-
sues geared to this population.
Knowing when to refer out for therapy or start antianxiety
medication must be done on a case-by-case basis. Sometimes a
combination of psychotherapy and medications will deliver the
best outcome for the patient. Unfortunately, there is an inadequate
amount of research regarding the best pharmacotherapeutic
treatment options for adolescents suffering from anxiety disorders.
The decision to prescribe medication needs to be thoughtfully
considered by the PCP, patient, and parents or caregivers because
most medications being prescribed are not FDA approved but used
as off-label treatment for adolescent anxiety.
References
1. Erikson EH. Childhood and society. London, UK: Vintage; 1995.
2. McCarthy C. Anxiety in teens is rising: what’s going on? 2019. https://www.
healthychildren.org/English/health-issues/conditions/emotional-problems/Pages/
Anxiety-Disorders.aspx. Accessed November 27, 2019.
3. Ghandour RM, Sherman LJ, Vladutiu CJ, et al. Prevalence and treatment of
depression, anxiety, and conduct problems in US children. J Pediatr. 2019;206:
256-267. https://doi.org/10.1016/j.jpeds.2018.09.021.
4. Anxiety and Depression Association of America. Facts & statistics. 2018.
https://adaa.org/about-adaa/press-room/facts-statistics. Accessed November
27, 2019.
Common Side Effects
Hives, restlessness, anorexia, headache, somnolence, tremor, dizziness
Diarrhea, nausea, dizziness, fatigue, drowsiness
Anxiety, insomnia, irritability, hostility, hypomania, mania, nausea, anorexia,
weight gain, anticholinergic effects
Constipation, headache, insomnia, fatigue, nausea, dyspepsia, girls require
less than boys
Hypertension, hyperlipidemia, weight loss, prolonged QT interval
Nausea, diarrhea, weight loss, dizziness, headache, palpitations
Sleepiness, excitation, hallucinations, seizures, dyspepsia, thickening of
bronchial secretions
Sleepiness, depression, headache, syncope, constipation, diarrhea,
arrhythmias, urinary retention
Dizziness, nausea, nervousness, lightheadedness
5. Regier DA, Kuhl EA, Kupfer DJ. The DSM-5: classification and criteria changes.
World Psychiatry. 2013;12(2):92-98. https://doi.org/10.1002/wps.20050.
6. Cummings C, Caporino N, Kendall P. Comorbidity of anxiety and depression in
children and adolescents: 20 years after. Psychol Bull. 2014;140:816-845.
https://www.ncbi.nlm.nih.gov/pubmed/24219155. Accessed November 27,
2019.
7. American Psychiatric Association. What are anxiety disorders? 2017. https://
www.psychiatry.org/patients-families/anxiety-disorders/what-are-anxiety-
disorders. Accessed November 27, 2019.
8. Reed MS, Evely AC, Cundill G, et al. What is social learning? Ecol Soc. 2010;15:
257-268. https://doi.org/10.5751/es-03564-1504r01.
9. Rapee RM. Preschool environment and temperament as predictors of social
and nonsocial anxiety disorders in middle adolescence. J Am Acad Child Adolesc
Psychiatry. 2014;53(3):320-328. https://doi.org/10.1016/j.jaac.2013.11.014.
10. US Department of Health and Human Services Office of Population
Affairs. The changing face of America’s adolescents. 2019. https://www.
hhs.gov/ash/oah/facts-and-stats/changing-face-of-americas-adolescents/index.
html. Accessed November 27, 2019.
11. National Institute of Mental Health. Mental health information. Any Anxiety
Disorder. 2017. https://www.nimh.nih.gov/health/statistics/any-anxiety-
disorder.shtml. Accessed November 27, 2019.
12. Bandelow B. Long term treatment of anxiety disorders. Eur Psychiatry. 2007;22:
S73. https://doi.org/10.1016/j.eurpsy.2007.01.282; Accessed November 27, 2019.
13. Belzung C, Griebel G. Measuring normal and pathological anxiety-like
behaviour in mice: a review. Behav Brain Res. 2001;125:141-149. https://
doi.org/10.1016/s0166-4328(01)00291-1.
14. Rajmohan V, Mohandas E. The limbic system. Indian J Psychiatry. 2007;49:132.
https://doi.org/10.4103/0019-5545.33264.
15. Hensler JG. Serotonergic modulation of the limbic system. Neurosci Biobehav
Rev. 2006;30:203-214. https://doi.org/10.1016/j.neubiorev.2005.06.007.
16. Bennett S, Walkup J. Anxiety disorders in children and adolescents; UptoDate.
2019, https://www.uptodate.com/contents/anxiety-disorders-in-children-
and-adolescents-epidemiology-pathogenesis-clinical-manifestations-and-
course#!.
17. Drake KL, Ginsburg GS. Family factors in the development, treatment, and
prevention of childhood anxiety disorders. Clin Child Fam Psychol Rev. 2012;15:
144-162. https://doi.org/10.1007/s10567-011-0109-0.
18. Rapee RM. Early adolescents’ perceptions of their mother’s anxious parenting
as a predictor of anxiety symptoms 12 months later. J Abnorm Child Psychol.
2009;37:1103-1112. https://doi.org/10.1007/s10802-009-9340-2.
19. Yearwood EL, Pearson GS, Newland JA, Kenney-Riley K, Pearson G. Anxiety
disorders. In: Child and Adolescent Behavioral Health: A Resource for Advanced
Practice Psychiatric and Primary Care Practitioners in Nursing. Ames, IA: Wiley-
Blackwell; 2012:153-164.
20. Keles B, Mccrae N, Grealish A. A systematic review: the influence of social media
on depression, anxiety and psychological distress in adolescents. Int J Adolesc
Youth. 2019;25:79-93. https://doi.org/10.1080/02673843.2019.1590851.
21. Zhu X, Huebner ES, Tian L. A person-centered longitudinal analysis of ado-
lescents’ loneliness and social anxiety: clusters, predictors, and outcomes.
School Psychol. 2019;34:576-589. https://doi.org/10.1037/spq0000328.
 I. Garcia, J. O’Neil / The Journal for Nurse Practitioners xxx (xxxx) xxx
22. National Sleep Foundation. Do student athletes need extra sleep? 2019.
https://www.sleepfoundation.org/articles/do-student-athletes-need-extra-
sleep. Accessed November 27, 2019.
23. Barata B, Ribeiro B, Gamito A. Influence of legal drugs (alcohol, nicotine and
caffeine) on the sleep of individuals with and without mental disorders. Sleep
Med. 2017;40:e24. https://doi.org/10.1016/j.sleep.2017.11.063.
24. Farinde A. Diagnosing anxiety disorders in primary care. Clinical Advisor. 2015.
https://www.clinicaladvisor.com/home/features/diagnosing-anxiety-%E2%80%
A8disorders-in-primary-care/. Accessed November 27, 2019.
25. Muris P, Simon E, Lijphart H, Bos A, Hale W, Schmeitz K. The Youth Anxiety
Measure for DSM-5 (YAM-5): Development and first psychometric evidence of
a new scale for assessing anxiety disorders symptoms of children and ado-
lescents. Child Psychiatry Hum Dev. 2016;48:1-17. https://doi.org/10.1007/
s10578-016-0648-1.
26. Anxiety and Depression Association of America. Screening tools. n.d. adaa.org/
living-with-anxiety/ask-and-learn/screenings. Accessed November 27, 2019.
27. Connolly SD, Bernstein GA. Practice parameter for the assessment and
treatment of children and adolescents with anxiety disorders. J Am Acad
Child Adolesc Psychiatry. 2007;46:267-283. https://doi.org/10.1097/
01.chi.0000246070.23695.06.
28. Compton SN, Walkup JT, Albano AM, et al. Child/Adolescent Anxiety Multi-
modal Study (CAMS): rationale, design, and methods. Child Adolesc Psychiatry
Mental Health. 2010;4. https://doi.org/10.1186/1753-2000-4-1.
29. Ginsburg GS, Becker-Haimes EM, Keeton C, et al. Results from the Child/
Adolescent Anxiety Multimodal Extended Long-Term Study (CAMELS): pri-
mary anxiety outcomes. J Am Acad Child Adolesc Psychiatry. 2018;57:471-480.
https://doi.org/10.1016/j.jaac.2018.03.017.
30. Lusk P, Melnyk BM. COPE for depressed and anxious teens: a brief cognitive-
behavioral skills building intervention to increase access to timely, evidence-
based treatment. J Child Adolesc Psychiatr Nurs. 2012;26:23-31. https://
doi.org/10.1111/jcap.12017.
31. Young JF, Benas JS, Schueler CM, Gallop R, Gillham JE, Mufson L. A randomized
depression prevention trial comparing interpersonal psychother-
apydadolescent skills training to group counseling in schools. Prev Sci.
2015;17:314-324. https://doi.org/10.1007/s11121-015-0620-5.
32. Avarez E, Puliafico A, Leonte K, Albano A. Psychotherapy for anxiety disorders
in children and adults; UptoDate. December 2018, https://www.uptodate.com/
contents/psychotherapy-for-anxiety-disorders-in-children-and-adolescents.
Accessed June 15, 2020.
33. Friedman RA. Antidepressants’ black-box warningd10 years later. New Engl J
Med. 2014;371(18):1666-1668. https://doi.org/10.1056/nejmp1408480.
34. Carson NJ, Progovac AM, Wang Y, Cook BL. A decline in depression treatment following
FDA antidepressant warnings largely explains racial/ethnic disparities in prescription
fills. Depress Anxiety. 2017;34:1147-1156. https://doi.org/10.1002/da.22681.
5
35. Cuffe S. Do antidepressants increase the risk of suicide in children and ado-
lescents? American Academy of Child and Adolescent Psychiatry. n.d. https://
www.aacap.org/AACAP/Medical_Students_and_Residents/Mentorship_Matters/
DevelopMentor/Do_Antidepressants_Increase_the_Risk_of_Suicide_in_Children_
and_Adolescents.aspx. Accessed June 15, 2020.
36. Perroud N. Suicidal ideation during antidepressant treatment. CNS Drugs.
2011;25:459-471. https://doi.org/10.2165/11589420-000000000-00000.
37. Antidepressants for Children and Teens. Mayo Foundation for Medical
Education and Research. http://www.mayoclinic.org/diseases-conditions/
teen-depression/in-depth/antidepressants/art-20047502. Accessed June
15, 2020.
38. Prescription Drug Information. Interactions & side effects; Drugs.com. 2020,
https://www.drugs.com/. Accessed June 15, 2020.
39. Leonte K, Puiafico A, Na P, Rynn M. Pharmacotherapy for anxiety disorders
in children and adolescents; UptoDate. March 2019, https://www.
uptodaste.com/contents/pharmacotherapy-for-anxiety-disorders-in-children-
and-adolescents. Accessed June 15, 2020.
40. Bushnell GA, Compton SN, Dusetzina SB, et al. Treating pediatric anxiety. J Clin
Psychiatry. 2018;79:16m11415. https://doi.org/10.4088/jcp.16m11415.
41. Garland JE, Kutcher S, Virani A, Elbe D. Update on the use of SSRIs and SNRIs
with children and adolescents in clinical practice. J Can Acad Child Adolesc
Psychiatry. 2016:1719-8429. http://www.ncbi.nlm.nih.gov/pubmed/27047551.
Accessed June 15, 2020.
42. Aldrich SL, Poweleit EA, Prows CA, Martin LJ, Strawn JR, Ramsey LB. Influence
of CYP2C19 metabolizer status on escitalopram/citalopram tolerability and
response in youth with anxiety and depressive disorders. Front Pharmacol.
February 19, 2019. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6389830/.
Accessed July 16, 2020.
43. Carandang C, Jabbal R, Macbride A, Elbe D. A review of escitalopram and cit-
alopram in child and adolescent depression. J Can Acad Child Adolesc Psychi-
atry. November 2011. http://www.ncbi.nlm.nih.gov/pubmed/22114615.
Accessed July 16, 2020.
44. Horowitz MA, Taylor D. Tapering of SSRI treatment to mitigate withdrawal
symptomsdauthors’ reply. Lancet Psychiatry. 2019;6:562-563. https://doi.org/
10.1016/s2215-0366(19)30219-6.
Iliana Garcia, MSN, FNP-C, is a former graduate student at the Patricia A. Chin School of
Nursing, California State University, Los Angeles, CA. She can be contacted at
Lillygg123@yahoo.com. Jean O’Neil, DNP, FNP-BC, is an Assistant Professor at the Patri-
cia A. Chin School of Nursing, California State University, Los Angeles, CA.
In compliance with national ethical guidelines, the authors report no relationships
with business or industry that would pose a conflict of interest.