‘I’m petrified. I can’t eat.’ Ireland’s teenage anxiety problem

It’s hard to say when or why it began, says Amy. Anxiety always seemed to hover in the background of her life, even during primary school. Her mother recalls how she would be curled up in a ball in bed some mornings not wanting to go to school. But at second level it began to take over her life.

In Amy’s first year at secondary school, she obsessed over class timetables, trying to memorise her subjects and classrooms off by heart. Then there were school tests, where anything less than 100 per cent felt like a failure.

By second year, the panics attacks started. Amy’s chest would tighten. It felt like she couldn’t breathe. She was sent for medical tests, which came back clear.

In third year, with State exams looming, her anxiety levels were sky-high. School felt impossible. Amy felt terrified of going to school – and terrified of not going to school and falling behind. The more anxious she felt, the more hopeless and depressed she became.

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“I am absolutely petrified,” she wrote in her diary, at the time.

“I can’t eat because I am so worried about the exams. I can hardly sleep; all I seem to do is toss and turn. I can’t study or concentrate. I have been staring at the same bloody page for the last 90 minutes and I still have absolutely no recollection of what is written. My stupid brain just won’t work! I can’t take anything in…”

The panic attacks, when they came, took days to recover from. She tried to hide what she was feeling and used every possible excuse not to go to school.

“‘I had a ‘headache’, or ‘I fell out of bed and hit my hip’ or ‘my stomach is upset’.. You name it, I had it,” says Amy.

“I didn’t tell my mum, and no one around me knew what was going on in my head. My mum knew about my anxiety. But I was feeling fear. I was terrified of going in, and terrified of not going in.”

Amy was given permission to sit her exams in a special exam centre on her own. It helped, she says. But afterwards, Amy “crashed” and felt burnt out. When transition year came around, she was barely sleeping and missing school again.

Soon,it felt like depression had crept in with anxiety. Suicidal thoughts began to enter her head, which she kept to her self. Her mother, consumed with worry, decided enough was enough: mainstream school simply wasn’t working.

Clinical issue

The education system is struggling to cope with an upsurge in the numbers of young people presenting with anxiety and related disorders.

The number of third-level students with mental health problems, including anxiety and related disorders, has surged by about 270 per cent since 2010, up from 473 to 1,750.

This, however, significantly underestimates the scale of issues among young people as it only includes those with diagnosed conditions.

Counselling services at third level report major increases in students with anxiety disorders who have not been formally diagnosed.

More than 10,000 students sought counselling in 2016/17 , with anxiety the biggest clinical issue. The system, say counsellors, is creaking under the weight of demand.

Many of those who work with young people suspect that what they're seeing can't easily be explained away

Statistics for young people at primary and second level are more difficult to come by. However, a 2015 national study of more than 6,000 adolescents found one in three had experienced elevated levels of depression and anxiety.

These numbers come as little surprise to those involved in supporting young people with mental health problems.

“It is the number one, most pressing issue that young people identify themselves,” says Dr Gillian O’Brien, director of clinical governance for Jigsaw, the national youth mental health service.

Many experts say there is little doubt that greater awareness and openness about mental health is driving these increases.

While it’s difficult to tease apart how much of this apparent spike in anxiety is related to an increase in awareness and diagnosis of the disorder, many of those who work with young people suspect that what they’re seeing can’t easily be explained away.

Dr Colman Noctor, a child and adolescent psychotherapist with St Patrick's mental health services with 20 years' experience, is alarmed by the increases he is seeing on a daily basis.

“In the last five to 10 years, I would say anxiety has become the epidemic of this generation,” he says. “I have never met more anxious children than I do now. I have never met so many anxious parents as well.

Educational pressure

Amy says she didn’t feel pressure to succeed from her parents. Her father died when she was nine; her mother, she says, advised her to simply do her best.

"I feel in my case it was societal and educational pressure," says Amy, now 20 years old. "At second level, in particular, all you heard was 'the Junior Cert is the most important thing'.

“And after that, it was: ‘If you don’t have a good Leaving Cert, you’re not going anywhere. You’ll be stuck in a dead-end job’. That pressure fuelled the anxiety enormously.”

Amy was also battling with low self-esteem; she felt the problems in her life were her own burden to carry, she didn’t want to heap them on others. There was also guilt that she was responsible for her own struggles.

“No-one else need know how messed-up I am,” she wrote in her diary at the time. “I won’t be anyone’s problem, anyone’s burden. I’ll sort my own issues out. I shouldn’t even have them in the first place! I have had a good life, much better than many others. My anxiety and my problems are proof that I am a weak and pathetic person.”

By this stage, Amy was self-harming but passing injuries off as a result of her diagnosis of dyspraxia, a disorder which affects co-ordination and sensory perception.

Amy had resisted most offers of help, or found they went nowhere, until her mother brought her to the Cork Life Centre.

It’s a voluntary organisation which offers an alternative learning environment to young people who have fallen through the cracks of the mainstream education system.

The centre – staffed mainly by volunteers – offers students support in small classes in Junior and Leaving Cert subjects.

“In the public mind, people think of young people who fall out of education as being troublemakers or in the care system, but we don’t see many of them,” says Don O’Leary, the centre’s director.

“We see far young people with anxiety, mental health issues from all kinds of social classes . . . Leaving school for them isn’t an event, it’s a process.”

Amy met O’Leary along with her mother. Afterwards she felt anxious, but relieved.

“The one thing he said that really hit home was that unless something changed soon I was going to burn out and have a nervous breakdown before I reached my twenties,” Amy wrote after wards. “I could get 600 points in my Leaving Cert but they would be of no use to me because I would have already run myself into the ground.”

Key milestones

Anxiety is the most common mental health disorder among young people and adults in Ireland – though, unlike depression, it is often seen as a less serious issue.

That, perhaps, is because we all experience anxiety to a greater or lesser degree. It has an evolutionary purpose; it helps us detect and avoid potentially dangerous situations. Highly anxious people, though, have an overactive fight-or-flight response that perceives threats where there often are none.

But what’s driving the apparent increase in problematic anxiety? And who is most at risk?

Research shows anxiety rates are typically higher among young people who have been abused or who live in homes where there is poverty, substance abuse or where there have been stressful events such as bullying, bereavement or assaults.

On the face of it, teenagers raised in more affluent communities might have less to feel anxious about – but privileged young people are often among the most emotionally distressed.

Dr Colman Noctor says he sees young people who feel under huge pressure to compete and who have a sense that they are not measuring up.

He says an “expectations-driven comparative culture” means young people are under an increasing burden of expectation to hit key milestones, even though  children’s abilities vary widely.

“We like to think we live in a world that is very inclusive of diversity, but I’m not so sure we are,” he says. “Now, the normative is so narrow . . . and we’re in a culture that values outcomes over effort.”

It’s easy to blame helicopter parents for much of this pressure. And many experts do. But some health professionals say they have seen an important shift with a growth in internalised anxiety.

These are young people who are anxious about school and how friends or teachers perceive them. They fret about body image, or what food they should eat or whether they exercised enough.

“We see a lot of young people who put that pressure on themselves; it not necessarily all driven by the parents or school,” says Dr Gillian O’Brien. “It’s the young person themselves who wants to perform . . . and this may have its roots in wider social and cultural norms.”

Social media

Ask experts about the common sources of worry among highly anxious young people, and most give a single answer: social media.

Anxious young people, of course, existed long before Snapchat and Instagram. But many worry that young people's digital lifestyles – around-the-clock texts, constant posting to social media, obsessively following the filtered exploits of peers – are partly to blame for children's struggles.

"There is undoubtedly a role played by social media," says Brendan Kelly, professor of psychiatry at Trinity College Dublin, who says the problem is not an "epidemic" but is a corrosive, serious and extensive problem – albeit a soluble one.

“The various platforms facilitate comparisons and competition at a much faster, more intense rate than previously. Gossip and unfounded rumours can also now be spread more quickly, further increasing anxiety in children.”

The good news, at least, is that anxiety is amenable to treatment – the earlier the better

Dr Gillian O’Brien says the fact that this is happening during a critical developmental stage in young people’s lives – when they form their identity – tends to magnify this pressure.

“There is a constant externalisation of self-worth happening online. . . If we’re always looking to others to say, ‘do I look good?’, then you’re putting yourself at mercy of strangers or peers to say if you’re okay or not okay . . . That’s risky.”

Those who struggle, says Dr Noctor, often tend to be high achievers, but have a poor sense of self.

“We tend to value self-confidence over self-esteem. I see kids with buckets of self confidence – captain of hockey team, hundreds of friends – but they don’t believe in their own value. Often they’ll say being good at something – say, swimming – ruined it for them, because it puts them in this pressure-cooker world.”

The good news, at least, is that anxiety is amenable to treatment – the earlier the better.

Many therapeutic interventions involve analysing – and learning to talk back to – anxious thoughts.

Some focus on identifying the physical symptoms of anxiety – racing heart, shortness of breath, panic attacks – so sufferers understand what is happening.

Others incorporate mindfulness techniques or exposure therapy, a treatment that incrementally exposes people to what they fear.

“For a lot of people, you can really learn to live with it,” says Dr O’Brien. “Anxiety is a normal response. Its just when it becomes exaggerated or takes over that it becomes a real problem.

“Don’t ignore it or hope it goes away. It is very manageable if you catch it early and support that young person. It’s important to encourage a young person to not let it fester, and get bigger and bigger and bigger.”

Burnt out

It took Amy a long time to adjust to being in a small classroom setting; staff were dressed casually and called by their first names. The emphasis was on relationships, rather than academic performance.

“The classes were so small that you couldn’t hide,” she says. “I had tried to be invisible in my old school. But you couldn’t be invisible in the centre if you tried.”

She still had difficulty communicating or opening up about what was going through her head; most offers of help were politely declined.

“Amy would come in quite early,” recalls Don O’Leary. “She’d sit on the carpet, her back against the wall. That’s when we’d get a chance to chat, or not . . . she would deflect the whole time. If you asked her how she was, she’s say ‘I’m fine, thank you. How are you?’.”

She still felt burnt out and exhausted – and the anxiety hadn’t gone away. By her second year, she says, it was harder to keep up the mask.

On one particularly bleak day, one of the volunteer staff mentioned that she was a counsellor and asked Amy if she wanted to try it. Without thinking, she said yes.

It proved to be a turning point. Amy practised talk therapy and breathing exercises to manage her anxiety.

She later opened up about her self-harm for the first time. Having a trusting relationship with someone she knew, she says, was crucial.

“I was starting to talk more about what was going in my head. I was finding a way to express myself that I felt safe with,” she says.

It wasn’t all plain sailing , but she completed her Leaving Cert exams. She even performed better than she expected in a few subjects, and secured enough points to study arts at UCC.

Today, she is continuing to break new ground. She has completed her first year in college; she is making friends in a campus with thousands of students; she had documented her experiences in a book, and has even spoken at public events about anxiety.

The condition hasn’t disappeared but Amy has learned to live with it.

“The reality is everyone has anxiety,” Amy says. “Mine just happens to be over the top, so I’ve adapted to live with it. I’ve been gradually exposing myself to more and more situations. It’s give and take. Some days are better than others.”

Right balance

For parents, trying to strike the right balance, between supporting their child and letting them figure their own way in the world, it can seem like a fiendishly tricky balancing act.

Dr Noctor uses a light-hearted slide in his presentations on “how to be a parent in 2018”.

“Just make sure your child’s academic, social, psychological, spiritual and nutritional needs are met, ensuring you don’t over-stimulate, under-stimulate or helicopter them . . . Provide a screen-free, processed food-free, negative energy-free, body positive, socially-conscious environment that nurtures but fosters independence, is gentle but not overpermissive . . . In a two-storey home, with a back garden and 1.5 siblings, spaced evenly apart . . .. Not forgetting the coconut oil.”

He feels for parents, faced with an array of parenting books from the moment their children are born – inevitably with blissfully happy mother and child on the cover.

“We all get caught-up in that expectations arms race,” he says.

For all the increases in mental health issues, Prof Brendan Kelly says it is important to also remember the majority of Irish young people have low levels of difficulties.

“Most children and adolescents are mentally well, psychologically balanced, and resilient,” he says.

“All that most children and adolescents require for good mental health is a stable, loving family, good relationships at school and with friends, and a sense of belonging. Stability and the absence of conflict in the home are key.”

Many schools have introduced mindfulness programmes and are exploring ways to help students

For the minority of children and adolescents who develop psychological problems – even despite these advantages – he says it is critical that services are appropriate, accessible, sensible and effective.

Schools are in a unique position to promote mental health and wellbeing and to identify young people experiencing emotional distress.

The Department of Education says it is aware of the challenges and the importance of the development of resilience skills and wellbeing in our schools.

It says promoting student mental health is a key part of its action plan on education, which includes the implementation of a new wellbeing programme at junior cycle, along with the reversal of austerity-era cuts to guidance counsellors and the recruitment of additional psychologists.

Mindfulness programmes

Many schools have introduced mindfulness programmes and are exploring ways to help students boost their resilience.

Many teachers, though, feel ill-equipped to deal with more serious issues. There are long waiting lists for young people with anxiety in the child and adolescent mental health services in some parts of the country; while counsellors at third level also say they are under-resourced to deal with the rising demands for support.

There are also a very small number of alternative education providers like the Cork Life Centre. It says it cannot keep up with demand. It is currently full with just over 50 students and was forced to turn away a further 160 last year.

“There is a huge need for alternative settings,” says Don O’Leary, the centre’s director. It has about 70 staff – the majority are volunteers.

The most important work they do, he says, is building relationships with young people who may have had many labels attached to them over the years.

“We work one-on-one with the students. It reduces the feeling of competition. We create our curriculum around what the young people need and want.”

Amy, for her part, says she benefited from these trusting relationships, even if it took time to forge them. She is reluctant to give simple advice to other students at risk of sounding trite.

“Part of me wants to say ‘it will be alright’, or ‘find someone you trust’. But, my story is my own. I don’t claim to know anyone else’s feelings.

“I only know what I’ve gone through. I think it’s a matter of just looking for the light that shines here and now.

“I always had the motto, “Stars can’t shine without the darkness”... There are tough times, but it is possible to get through it.”

Advice panel for parents

DO:

Listen: It may sound obvious, but being a good listener is a skill and takes effort. Give your child time and your full attention. If you are not in a position to listen attentively to a young person, it is better to tell them and try to find a better time.

Look for windows of opportunity: Choose you moment. Try to find a quiet moment, or a time when you are both engaged in an activity.

Ask direct questions: Don't be afraid to ask a direct question, such as, 'are you feeling okay?' Sometimes, parents may be concerned about the answer they might receive, so avoid asking the question.

Comment on what you see: Such as , 'I notice you haven't been yourself lately, is everything okay?' or 'I've heard you up in the middle of the night a few times this week, are having trouble sleeping?

Ask how you can be of help: Young people will want support at different times in different ways, so ask them how you might help rather than assuming you know what's best.

DON’T:

Judge: Try to be non-judgmental as fear of being judged is one of the main reasons why young people don't share worries/concerns with others.

Overreact: No matter what a young person tells us, we need to try not to overreact but just listen, stay calm and then decide how to respond

Avoid/ignore the issue: If a young person opens us to us, we shouldn't brush it off or assume someone else will pick up on it.

Dismiss their concerns: As adults, we can very easily forget what it's like to be a teenager. From our perspective, it might not seem like a big deal but it's the young person's perspective that matters.

Talk just about problems: Explore strengths too – what is going well, how are they coping, what else is going on in their life? Keep in mind that feeling anxious is just one part of the person. Just spending time with the person lets them know we care.

Rush to solve the problem: The first step is to listen and try to understand what is going on for the young person. Helping/trying to solve the problem comes next. Be guided by the young person.

Tell them they're wrong to feel a certain way: There are no "wrong" feelings. Accept how the young person is feeling. Rushing to try to encourage them to 'change' how they feel can be unhelpful.

Use clichés: "Pull yourself together"; "there's always someone worse off than you" or "you'll soon snap out of it.' Cliches are unhelpful and can communicate that we don't really understand what the young person is telling us.

Source: Advice courtesy of Jigsaw, an early intervention support service for young people’s mental health(www.jigsaw.ie).

If you, or someone you are concerned about, is in need of support, contact your local doctor, hospital or the HSE’s child and adolescent mental health services (www.hse.ie)