Likewise, anxiety and depression represent the most prevalent problems facing young adults attending college, with these two conditions being ranked first and third, respectively, among college students seeking counseling services (Mccarthy, Fouladi, Juncker & Matheny, 2006).
According to Armstrong and her associates (2003), adolescence and young adulthood is a period in life when most people engage in explorative behaviors and test their limits in ways that may contribute to their propensity to develop anxiety disorders. In this regard, Armstrong and her associates note that, "From their late teens to their early twenties, young adults experience dramatic changes across all realms of development. . . . During this stage of development, young adults are more likely to engage in substance abuse, drive while intoxicated, and have unprotected sex" (p. 66). Likewise, D'Amico, Ellickson, Collins, Martino and Klein (2005) report that, "Although the majority of people have reduced their substance use by the mid-20s, many young adults continue to use substances at significant levels and may go on to develop substance-use disorders (SUDs) in adulthood" (p. 766). Although anxiety disorders can contribute to depression and may produce similar or even identical symptoms, most authorities seem to agree that these are distinct disorders and should be diagnosed and treated as such. Indeed, Lerner, Safren, Henin, Warman, Heimberg and Kendall (1999) point out that, "Although some have argued that anxiety and depression are variants of the same disorder in children and adolescents, others have posited that anxiety and depression are distinct syndromes with unique characteristics" (p. 82).
According to Mcloone et al. (2006), the types of anxieties that people tend to experience change as they grow older, shifting from the specific to the more abstract with age. In addition, Mcloone and her associates note that, "The prevalence of anxiety disorders also differs by gender, with epidemiological surveys showing that females are around one and a half to two times more likely to have an anxiety disorder than males" (2006, p. 219). The consequences of an untreated anxiety disorder in adolescents or young adults can be severe, persistent and even life-threatening. In this regard, Stanard emphasizes that, "The presence of other psychiatric disorders in the adolescent increase the risk factor for the development of depression and associated suicidal risk. Adolescents diagnosed with a personality disorder are 10 times more likely to commit suicide than those who are not" (p. 204). In fact, anxiety disorders among adolescents in particular are one of the warning signs for suicide that clinicians are advised to monitor in this population (Muehlenkamp, Ertelt & Azure, 2008). According to Muehlenkamp and her associates, "Suicide remains a significant cause of death in the United States, particularly among youth. Suicide is the third leading cause of death among 15 to 19-year-olds" (2008, p. 105).
Identifying such behaviors and disorders among young people in order to diagnose an anxiety disorder, though, can be especially difficult among adolescents because of a powerful reluctance to share and reveal their problems with others. In this regard, Lerner et al. point out that, "Self-report assessment of anxiety and depression in adolescents has limitations. It may be difficult to determine the extent to which adolescents are able or willing to report anxious or depressive symptoms. Older children with anxiety disorders may be inhibited by concerns about self-presentation and negative evaluation by others" (1999, p. 92). Such inhibitions about revealing one's inner-most thoughts and fears are certainly not unique to younger people, but they do appear to be more pronounced in this segment of the population, making the use of appropriate diagnostic tools and techniques all the more important.
In some cases, though, adolescents and young adults who suffer from an intellectual disability may not have developed the cognitive abilities needed to adequately communicate the requisite diagnostic criteria to clinicians that can aid in the diagnosis of an anxiety disorder. In this regard, Hurley (2007) emphasizes that, "Because it is necessary for the patient to report internal complex perceptions, it is difficult to anxiety disorders in people with intellectual disability. The diagnosis of three anxiety disorders requires that the patient be able to verbalize his or her feelings and perceptions of worry, apprehension, or impending doom" (p. 26). While it may be a simple matter for some adolescents and young adults to verbalize such apprehensions in a clinical setting, others may be reluctant for the reasons noted above or they may be unable to do so by virtue of an intellectual disability. For example, Hurley adds that, "These perceptions require a moderate level of awareness wherein one can reflect upon his or her reflections, a higher cognitive capacity that typically arises in puberty with increasing development of the frontal lobe and executive control systems" (p. 26). It is reasonable to suggest that young people with an intellectual disability may be particularly susceptible to anxiety disorders because of their inability to process events that confront them in a healthy fashion, and these constraints may also contribute to the existence of an anxiety disorder remaining undiagnosed in this population. In this regard, Hurley advises that, "People with intellectual disability suffer from psychiatric illness at a rate that is thought to be much higher than the general population. Yet, anxiety disorders have only rarely been reported" (p. 26). Because the accurate and timely diagnosis of anxiety disorders requires significant feedback from the sufferer, young people with anxiety disorders who are intellectually disabled are clearly at a disadvantage. For example, according to Hurley:
It is unclear to what extent most people with intellectual disability achieve this level of cognitive capacity. Thus, it is possible that individuals with intellectual disability and great anxiety cannot communicate their symptoms or understand them sufficiently so that the anxiety is recognized by others and/or interpreted correctly by diagnosticians. It is for these reasons that much of the field of psychiatric illness and intellectual disability uses behavioral equivalents of diagnostic criteria. (p. 27)
Behavioral equivalents of the diagnostic criteria described above can be identified using a variety of diagnostic tools, but existing instruments vary in their ability to capture this critical information in a viable fashion. For instance, a study by Turchik and her associates (2007) determined that one of the common tools used for diagnostic purposes, the Child Behavior Checklist, is not particularly effective at predicting anxiety disorders; however, this instrument has been found to be useful in ruling out anxiety disorders among adolescents. Likewise, the Ohio Youth Problems, Functioning, and Satisfaction Scales (commonly referred to as the Ohio Scales) are intended to identify changes in behavior over time in adolescents by distinguishing between internalizing and externalizing problems; Turchik and her colleagues report that in the Ohio Scales, externalized behaviors indicate conditions such as hyperactivity, oppositionality, and aggression while internalized disorders are characterized by depression, anxiety, and physical symptoms. The results of an analysis of the efficacy of the Ohio Scales in various diagnostic settings conducted by Turchik and her associates found that, "Youth with mood and anxiety disorders had higher Internalizing scores than youth with other diagnoses" (Turchik et al., 2007, p. 120).
Despite the availability of these diagnostic tools, Lerner and her colleagues (1999) suggest that there is a growing consensus among practitioners that both parents and the patient should be consulted in order to confirm or rule out a diagnosis of anxiety disorder. For instance, Turchik et al. report, "Parents may be more reliable informants than children when queried about children's overt behavior and its interference with functioning. It is now preferred practice to rely on both parent and child report in making diagnostic decisions" (p. 84). While a number of diagnostic tools exist that can be used to identify anxiety disorders in adolescents and young adults, it is important for the treating clinician to recognize some of the causes of this disorder that are particularly prevalent among younger people, and these issues are discussed further below.
Causes of Anxiety in Adolescents and Young Adults
As noted above, adolescence and young adulthood are periods in life when people tend to "sow their oats" by experimenting with different things and testing their limits. While such experimentation can result in risky behaviors, most people manage to endure the rigors of adolescence with few scars to show for their efforts. There are some other issues that are particularly relevant to this period in young people's lives that are not shared by their older counterparts, though, that can contribute to the incidence of anxiety disorders. For instance, according to Stanard (2000), "Research suggests that persistent or escalating stressful events (e.g., disagreements with parents) increase the risk for development of adolescent depression or anxiety" (p. 204). Furthermore, extending the adage that "there is no problem so large that drinking cannot make it worse," the tendency of young people to experiment with various drugs and alcohol during this formative period in their lives can result in substance abusive behaviors that will further exacerbate any anxiety disorders that may already exist (Stanard, 2000). This assertion is highly congruent with the…