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

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.