MB, 14-year-old female patient, presents to her pediatric NP with a report of severe anxiety that is interfering with school performance, sleep, and social interactions. The patient's mother states that therapy and/or psychiatry is “too expensive and is not covered by our insurance” and that she is opposed to psychiatric medications. Considering the family's particular attitude toward mental health care, how might a pediatric primary care NP approach treatment for this child?
The interplay between concerns about adverse reactions of antidepressants and the increasing costs of mental health care provides new ways for NPs to treat anxious adolescents with low-cost, alternative treatment methods. This article explores the value of mind and body practices in adolescents suffering from anxiety.
Anxiety is the anticipation of a threat, whereas fear is the physical and emotional reaction to a potential threat.1 The phrase “anxiety disorder” is an umbrella term for a variety of disorders that are characterized by excessive and perpetual anxiety and fear that severely impact daily life.1 Anxiety disorders tend to be comorbid with one another, and the specific fears or triggers that produce pathologic anxiety differentiate them from each other.
Common anxiety disorders in adolescents include specific phobias, generalized anxiety disorder, social anxiety disorder, panic disorder, and agoraphobia.2 Due to their comorbid nature, this article does not differentiate between specific anxiety disorders, but will rather address adolescent pathologic anxiety as a whole.
Prevalence and demographics. Anxiety disorders are the most common adolescent mental health conditions in the United States, with approximately one-third (31.9%) of 13- to 18-year-old children suffering from clinical anxiety.3 In addition, 8.3% of adolescents with anxiety disorders experience severe impairment in their daily functioning.3 Females are more commonly affected than males, with lifetime prevalence rates of 38% and 26%, respectively.3 A 2017 New York Times Magazine article highlighted the increasing problems of anxiety disorders in adolescents.4 The article cites academic pressures, physical and intellectual insecurities, cyber-bullying, and peer judgment on social media sites as factors contributing to the increasing rates of intense juvenile anxiety.
Several signs and symptoms help NPs differentiate between adolescents suffering from normative fear and anxiety versus clinical anxiety. Whereas anxiety and fear are typical reactions to the academic, social, and developmental challenges common during the adolescent years, clinical or pathologic anxiety is excessive, persistent, and disruptive.1 Furthermore, while normative anxiety is often transient and situational, clinical anxiety disorders are typically chronic and usually last 6 months or more.1
Clinical anxiety also deviates from normative anxiety through an overestimation of risk or danger.2 While adolescents typically experience anxiety with regard to developmentally appropriate fears and concerns, adolescents with clinical anxiety have an intense interpretation of everyday events.2 Clinical anxiety may manifest as a fear response called a panic attack, which is a sudden burst of intense fear accompanied by physical manifestations, such as heart palpitations, accelerated heart rate, sweating, shaking, shortness of breath, chest pain, dizziness, paresthesia, and nausea.1
Screening. Due to the high prevalence of anxiety disorders among children and adolescents, the American Academy of Child and Adolescent Psychiatry (AACAP) recommends that clinicians practice developmentally appropriate anxiety screening during routine mental health assessments.5 The American Academy of Pediatrics and the AACAP recommend several self-report tools.5-7 These tools are available at no cost and include the Screen for Child Anxiety Related Emotional Disorders in children and adolescents for children over 8 years and the Spence Children's Anxiety Scale, which has been shown to be a reliable and valid measure of anxiety in adolescent populations.
Current treatment practices
The most common practices in the treatment of adolescent anxiety include cognitive behavioral therapy (CBT), pharmacotherapy with antidepressants, or a combination of the two therapies.5 Although CBT therapy has been shown to be useful in the treatment of anxiety, hindrances to the use of CBT include limited affordable mental health services, long waiting lists for treatment, and demanding parental time commitments to care.2
The pharmacologic treatment of choice is the use of selective serotonin reuptake inhibitors (SSRIs), which can be worrisome to parents due to an FDA black box warning for increased risk of suicidal ideation. Furthermore, the risk of SSRIs to the developing brain remains unclear and underresearched.
While adolescents are less likely to obtain mental health services, they are more likely to use complementary therapies than any other pediatric subgroup.8 In addition, children with anxiety disorders are more likely to use complementary therapies for the treatment of symptoms. Mind and body practices encompass self-regulation and positive thinking, including techniques such as biofeedback, mindfulness, yoga, and hypnosis to help promote self-control, physical health, and emotional well-being.9
Review of literature
A search of PubMed, Columbia Libraries Catalog, and Google Scholar was performed to find articles related to the reduction of adolescent anxiety through mind and body practices. The research yielded four subcategories of interest: biofeedback, mindfulness, yoga, and hypnosis. Studies published between 2010 and 2016 were selected based on the quality of the research, application to anxiety control, incorporation of mind and body practices, and relevance to the adolescent population. Key search words included adolescents, teens, pediatrics, high school, anxiety, anxiety disorder, worrying, mind and body practices, complementary and alternative medicine, yoga, hypnosis, biofeedback, and mindfulness.
Biofeedback. Biofeedback is a tool that enables individuals to increase self-awareness and physical control through physiologic feedback. (See Biofeedback therapies in the treatment of adolescent anxiety.) This feedback can include heart rate monitoring, neurofeedback, skin conductance levels, skin temperature measurements, or electromyography for muscle tension awareness.9 The two methods of biofeedback studied in anxious adolescents include heart rate variability (HRV) and video game–based biofeedback. HRV is a low-cost, portable, and commercially available method of reducing anxiety through the measurement of an adolescent's pulse in diverse situations.10,12
Game-based biofeedback mechanisms apply relaxation techniques in a video game scenario where adolescents complete tasks through controlling heart rate, skin conductance, and/or emotion regulation techniques.11,13 In the adolescent population, both HRV biofeedback and video game-based biofeedback demonstrated progress in combating anxiety and stress.10-13
Mindfulness. Mindfulness training involves the refinement of consciousness, which provides individuals with skills to focus their attention on the present moment and to separate from negative thoughts or feelings. (See Mindfulness in the treatment of adolescent anxiety.) Mindfulness programs use components of Buddhist Vipassana meditation, which emphasizes sensory detachment through reducing bias, remaining nonjudgmental, and focusing on a separation from negative outlooks.9,11 Mindfulness programs often incorporate aspects of thought meditation, body scanning, and mindful breathing to promote anxiety reduction.10,11,14
Randomized controlled trials (RCTs) have demonstrated the benefits of mindfulness training in adolescents.10,12,14-17 Several of these studies found that mindfulness programs implemented in secondary school settings were effective in alleviating anxiety and stress in students.12,14-17 While adolescence itself can be a tumultuous period of emotional, physical, and cognitive development, several predisposing factors can put this population at even higher risk for symptoms of anxiety.15-17 Three high-risk populations that demonstrated positive effects from mindfulness therapy included minority children, inner-city youths, and teens with social anxiety.15-17
Yoga is a mind and body practice that incorporates physical postures (asanas), breathing control (pranayama), and mindful meditation to elicit relaxation, improve flexibility, regulate emotions, and reduce stress and anxiety.9,18 As one of the most popular mind and body practice therapies in the United States, yoga has numerous anxiolytic effects. Focusing specifically on the adolescent population, researchers recently demonstrated the benefits of yoga.18-21
Low in cost, easy to implement, and accessible to individuals of all physical fitness levels, yoga has become an increasingly popular anxiety management tool. The recent implementation of yoga in high school and summer program curriculums has been shown to improve anxiety and reduce stress.20,29 Practicing yoga for 30 minutes 3 to 4 days per week over a semester improved students' primary coping skills and emotional regulation (see Yoga in the treatment of adolescent anxiety).18
Hypnosis. Clinical hypnosis is a form of mind-body therapy that strives to reduce the sympathetic stress response through the activation of the parasympathetic nervous system.9 Through guided relaxation techniques, the parasympathetic nervous system activates and creates an altered state of consciousness that aids in forming a mind-body connection and control over one's stress response.9,21 Hypnosis is a low-cost therapy that incorporates imagery and relaxation techniques. These relaxation techniques can be easily taught to adolescents to reduce the sympathetic stress response.22-24
Ericksonian hypnosis, which provides patients with indirect suggestions for relaxation, has been shown to significantly reduce anxiety in preprocedural adolescent patients.23 Additionally, telehypnosis has been shown to be an effective tool in the management of anxiety-related absenteeism in high school students.22 Biofeedback, mindfulness, and yoga each incorporate components of hypnosis and may even be considered subtypes of the hypnotic state (see Hypnosis in the treatment of adolescent anxiety).21
Summary of literature findings. A growing body of evidence supports the implementation of mind-body practices as a low-risk and cost-effective strategy in the management of adolescents with anxiety. Biofeedback, mindfullness, yoga, and hypnosis are all promising forms of mind and body practices in the battle against rising rates of adolescent anxiety. The literature supports the use of mind and body practices in the home, the classroom, and in clinical settings. A lack of randomized studies, appropriate sample sizes, and longitudinal data emphasize the need for future research to refine the benefits of mind and body practices for adolescents with anxiety.
Role of the pediatric NP
Clinical. In the field of pediatric primary care, there is a dire need for affordable and accessible mental health care strategies. As of 2014, 55% of adolescents with mental health disorders did not receive any form of professional mental health care.25 Of this 55%, the least likely adolescents to receive psychiatric healthcare were teens with underlying anxiety disorders.
The NP should provide competent anxiety screening at every annual health visit.5 Ensuring that the child is getting adequate sleep is an integral part of the history, as recent data point to a lack of sleep being a risk factor for mental health disorders.26 The use of screening tools enables NPs to identify the signs and symptoms of anxiety and subsequently form the appropriate plan of care. Low-cost, low-barrier, and effective mind and body practices can be explained in the primary care setting to create a personalized plan to combat anxiety.
Recognizing barriers to mind and body practices in primary care. Financial and structural barriers hinder the integration of these practices into primary care. By acknowledging and overcoming these obstacles, patients can benefit from the full potential of mind and body practices. Three significant challenges to mind and body practices in primary care include time restrictions, financial constraints, and a lack of administrative support.
Two recent studies analyzing clinician perceptions of mind and body practices in primary care found that time restraints are the primary barriers to the using these therapies.27,28 Similarly, reimbursement and billing constraints hinder the time clinicians can spend using complementary therapies in the office setting.28 A lack of administrative support and financial backing was also a significant hindrance to using complementary therapies.28 Without the help of the clinic administration and leadership, continuing-education resources and opportunities for providers were limited.
Education. Research has demonstrated a severe deficit in NP education regarding complementary therapies. Although 81% of NPs believe that complementary therapies have a place in primary care medicine, only 32% of NPs feel that they have adequate knowledge of mind and body practices.27 Education regarding the benefits and methods of integrating mind and body practices into patient care should be initiated in nursing school, supported in NP master's programs, and reinforced the primary care workplace (see Mind and body educational resources for NPs).
Need for further research. Future studies tailoring mind and body practices to primary care mental health management should include large and diverse population samples that highlight the benefits and disadvantages of mind and body practices among various cultural groups. Finally, an understanding of the short-term versus long-term benefits, feasibility, and adherence should be appreciated to determine the effectiveness of these treatments over time.
In response to the intense need for adolescent mental health care in the United States, the pediatric NP's role must expand to integrate screening and treatment for anxiety among adolescents. Increased interest in complementary therapies, high rates of childhood anxiety, the controversy surrounding SSRI use in adolescents, and the climbing costs of mental health care point to the need for mind and body therapeutic approaches to anxiety management. Despite the many barriers to mind and body practices, current research focusing on biofeedback, mindfulness, yoga, and hypnosis demonstrates that these methods show promise to reduce anxiety among adolescent populations.
Mind and body educational resources for NPs
National Center for Complementary and Integrative Health
Center Institute for Research and Education in Integrative Medicine
The Center for Mind-Body Medicine
Massachusetts General Hospital
Applied Psychophysiology and Biofeedback
The University of Minnesota
1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders
. 5th ed. Washington, DC: American Psychiatric Association; 2013.
2. Creswell C, Waite P, Cooper PJ. Assessment and management of anxiety disorders in children and adolescents. Arch Dis Child
3. Merikangas KR, He JP, Burstein M, et al. Lifetime prevalence of mental disorders in U.S. adolescents: results from the National Comorbidity Survey Replication—Adolescent Supplement (NCS-A). J Am Acad Child Adolesc Psychiatry
4. Denizet-Lewis B. Why are more American teenagers than ever suffering from severe anxiety. New York Times Magazine
. 2017. www.nytimes.com/2017/10/11/magazine/why-are-more-american-teenagers-than-ever-suffering-from-severe-anxiety.html
5. Connolly SD, Bernstein GA; Work Group on Quality Issues. Practice parameter for the assessment and treatment of children and adolescents with anxiety disorders. J Am Acad Child Adolesc Psychiatry
6. Spence SH, Barrett PM, Turner CM. Psychometric properties of the Spence Children's Anxiety Scale with young adolescents. J Anxiety Disord
7. Wehry AM, Beesdo-Baum K, Hennelly MM, Connolly SD, Strawn JR. Assessment and treatment of anxiety disorders in children and adolescents. Curr Psychiatry Rep
8. Birdee GS, Phillips RS, Davis RB, Gardiner P. Factors associated with pediatric use of complementary and alternative medicine. Pediatrics
9. McClafferty H. Complementary, holistic, and integrative medicine: mind-body medicine. Pediatr Rev
10. de Bruin EI, van der Zwan JE, Bögels SM. A RCT comparing daily mindfulness meditations, biofeedback exercises, and daily physical exercise on attention control, executive functioning, mindful awareness, self-compassion, and worrying in stressed young adults. Mindfulness
11. Knox M, Lentini J, Cummings TS, McGrady A, Whearty K, Sancrant L. Game-based biofeedback for paediatric anxiety and depression. Ment Health Fam Med
12. Ratanasiripong P, Park JF, Ratanasiripong N, Kathalae D. Stress and anxiety management in nursing students: biofeedback and mindfulness meditation. J Nurs Educ
13. Scholten H, Malmberg M, Lobel A, Engels RC, Granic I. A randomized controlled trial to test the effectiveness of an immersive 3D video game for anxiety prevention among adolescents. PLoS One
14. Anila MM, Dhanalakshmi D. Mindfulness based stress reduction for reducing anxiety, enhancing self-control and improving academic performance among adolescent students. Indian J Positive Psychol
15. Ebrahiminejad S, Poursharifi H, Bakhshiour Roodsari A, Zeinodini Z, Noorbakhsh S. The effectiveness of mindfulness-based cognitive therapy on Iranian female adolescents suffering from social anxiety. Iran Red Crescent Med J
16. Liehr P, Diaz N. A pilot study examining the effect of mindfulness on depression and anxiety for minority children. Arch Psychiatr Nurs
17. Semple RJ, Lee J, Rosa D, Miller LF. A randomized trial of mindfulness-based cognitive therapy for children: promoting mindful attention to enhance social-emotional resiliency in children. J Child Family Studies
18. Frank JL, Kohler K, Peal A, Bose B. Effectiveness of a school-based yoga program on adolescent mental health and school performance: findings from a randomized controlled trial. Mindfulness
19. Daly LA, Haden SC, Hagins M, Papouchis N, Ramirez PM. Yoga and emotion regulation in high school students: a randomized controlled trial. Altern Ther Health Med
20. Khalsa SB, Butzer B, Shorter SM, Reinhardt KM, Cope S. Yoga reduces performance anxiety in adolescent musicians. Altern Ther Health Med
21. Sawni A, Breuner CC. Clinical hypnosis, an effective mind-body modality for adolescents with behavioral and physical complaints. Children (Basel)
22. Aviv A. Tele-hypnosis in the treatment of adolescent school refusal. Am J Clin Hypn
23. Huet A, Lucas-Polomeni MM, Robert JC, Sixou JL, Wodey E. Hypnosis and dental anesthesia in children: a prospective controlled study. Int J Clin Exp Hypn
24. Goldbeck L, Schmid K. Effectiveness of autogenic relaxation training on children and adolescents with behavioral and emotional problems. J Am Acad Child Adolesc Psychiatry
25. Costello EJ, He JP, Sampson NA, Kessler RC, Merikangas KR. Services for adolescent psychiatric disorders: 12-month data from the national comorbidity survey–adolescent. Psychiatr Serv
26. Zhang J, Paksarian D, Lamers F, Hickie IB, He J, Merikangas KR. Sleep patterns and mental health correlates in US adolescents. J Pediatr
27. Geisler C, Cheung C, Johnson Steinhagen S, Neubeck P, Brueggeman AD. Nurse practitioner knowledge, use, and referral of complementary/alternative therapies. J Am Assoc Nurse Pract
28. McGuire C, Gabison J, Kligler B. Facilitators and barriers to the integration of mind-body medicine into primary care. J Altern Complement Med
29. Noggle JJ, Steiner NJ, Minami T, Khalsa SB. Benefits of yoga for psychosocial well-being in a US high school curriculum: a preliminary randomized controlled trial. J Dev Behav Pediatr
30. Carei TR, Fyfe-Johnson AL, Breuner CC, Brown MA. Randomized controlled clinical trial of yoga in the treatment of eating disorders. J Adolesc Health