By Caitlin Connolly, LCSW, CAADC
Are there specific diagnoses associated with teen avoidance behaviors?
Teen avoidance behaviors are strongly associated with many mental health diagnoses, especially major depressive disorder, generalized anxiety disorder, and other anxiety disorders. When we are looking at teen avoidance behaviors, we need to consider the role of illnesses like depression and anxiety as well as child and adolescent development.
During this phase of development, teens are already handling a lot, physically and emotionally. They are going through puberty, starting to form an identity separate from their parents, and test-driving independence. The adults in their lives often are expecting them to take on more responsibility, and they are making choices that could influence their adult lives significantly. No pressure, right? When you add symptoms of depression or anxiety into the mix, it makes everything harder.
For a teen struggling with this storm of feelings and changes, avoidant behaviors may come naturally. “I can’t control any of this, so I will just avoid it.” “I don’t feel comfortable anywhere, so I will just stay home.” For some teens, avoidance may feel like the only option they have to feel “better.”
How do avoidant behaviors contribute to depression and anxiety?
Unfortunately, avoidant behaviors—even if they are driven by depression or anxiety—make many mental health problems worse. There can be a “snowball effect.” Avoiding one situation leads to avoiding another, and another, until the teen effectively shuts down.
We see that snowball effect in many scenarios and especially with isolation. If an adolescent with anxiety is uncomfortable in social situations or if an adolescent with depression has low self-worth, they may isolate and avoid their family and friends. Being alone with your negative thoughts can certainly exacerbate the feelings of sadness and worthlessness associated with depression as well as the worries and fears associated with anxiety.
For a teen who has low mood and decreased energy associated with depression, taking care of daily hygiene and personal grooming (sometimes referred to as “activities of daily living”) may feel like an insurmountable challenge. Avoiding these activities then contributes to feelings of low self-esteem and the impulse to avoid people and activities.
Fear of failure is a common symptom of anxiety for many adolescents. Some teens may try to address those fears by avoiding school, sports, and other activities associated with that fear. The lack of any opportunity to demonstrate competency or build confidence can feed depression and anxiety.
Once an adolescent engages in mental health treatment, they can start to identify those “snowball scenarios.” Then they can identify the situations that start the ball rolling as “triggers.” Instead of avoiding those triggers, through effective mental health treatment, teens can learn coping skills and strategies to manage their discomfort in healthy ways. Avoidance can be a response to feeling powerless. Learning healthy coping skills can give teens a sense of power and control over their feelings, thoughts, and behaviors.
Are avoidant behaviors dangerous?
The most concerning avoidant behaviors are self-harming behaviors like cutting as well as suicidal or parasuicidal behaviors. These maladaptive behaviors may be used by teens to avoid painful feelings when they don’t have the skills to ask for help or address their feelings in more healthy ways. A sense of shame or secret-keeping related to these behaviors can contribute to isolation. These behaviors can have very serious outcomes.
Teens may use alcohol, marijuana, or other substances to avoid their fears, especially teens experiencing social anxiety. Using these substances, particularly in this context, can impair judgment and lead to impulsive behaviors. Substance use is especially dangerous for adolescents experiencing self-harming or suicidal thoughts.
What is the difference between developmentally appropriate teen behavior and maladaptive avoidant behavior?
Making this distinction can be challenging because there are so many layers to adolescent behavior. Mental health clinicians examine to what extent the behaviors impact how the adolescent functions in school, in their families, or in their social networks.
Do we have a teen who is exploring how it feels to be rebellious or go against the grain? Or are we seeing a teen whose school grades are dropping, who is desperately seeking excuses not to go to school, or who is spending all of their time alone? Looking globally, are these isolated incidents, or is the adolescent continually having challenges in a number of different areas?
Mental health clinicians also apply the idea of ecological systems theory. If you think of starting with the teen as an individual and then move outward in circles, are their problems at the individual, family, school, and community levels?
Some teens may internalize their anxiety and depression. They could be the “over-achiever” at school with top academic performance. They could be a people pleaser who seems to be socially connected and involved with several clubs and activities. Their avoidant behaviors may be less outwardly obvious. In fact, their focus on achievement could be the behavior they are using to avoid confronting feelings of low self-esteem or fear of failure. To maintain the façade of perfection, these individuals may hide self-harming behaviors and be very guarded about sharing negative thoughts, including thoughts about self-harm or suicide.
For all adolescents, physical symptoms like gastrointestinal problems or vomiting can be indicators of underlying anxiety. Changes in sleep, appetite, and energy levels should also be considered as potential symptoms of mood and anxiety disorders.
What should a parent, educator, or caregiver do to help teens who are exhibiting avoidant behaviors?
Start with your relationship with the young person. Whether you are a teacher or parent, let the adolescent know that you care about them and are concerned that they may be struggling. Give them a safe space to talk about what is going on in their life. You might say, “Hey, I’m seeing that you are having trouble with your grades at school. Is that something you have noticed or have concerns about?” or, “I notice you aren’t spending as much time with your friends. Has something changed with your relationships? How are you feeling about that?”
As a caring adult in their lives, validating their struggles and getting their input on what they are experiencing can be very meaningful. Instead of explaining why their behaviors are “bad” or disappointing, demonstrate with your approach and choice of words that you see them as a person, you see that they might be hurting, and you would like to help.
As they open up to you about their struggles, you can have more specific conversations about what they would like to see change at school or at home and if they would be open to getting help from a professional mental health provider, individually or as a family.
Let the teen know that, while you can’t wave a magic wand to fix everything instantly, there are many options to help them make positive changes and feel better. A next step could be exploring resources available at school. Most schools have mental health services available, from guidance counseling to support groups to special accommodations.
If an adolescent seems open to the idea of counseling or mental health treatment but hesitant to commit to participating, talk to them about their concerns. Encourage them to participate in the search for a provider or program and give them opportunities to directly ask questions about what the treatment experience may look or feel like.
While adults ultimately need to make decisions to protect the health of their adolescents, communicating openly with adolescents and including them in the process can help teens be invested in treatment and open to engaging in therapy in productive ways.
What mental health treatment modalities are effective in changing teen avoidance behaviors?
Cognitive behavioral therapy (CBT) and dialectical behavior therapy (DBT) are really strong foundations for managing avoidant behaviors and mental health in general. Both CBT and DBT help teens understand the connection between their thoughts, feelings, and behaviors.
Through therapy, adolescents are encouraged to define their own values and goals for themselves. Then, instead of looking at how their avoidant behavior creates problems for other people, they can explore how avoidant behaviors may be creating barriers for them in pursuing their goals or may be preventing them from living a life that feels authentic to their values and identity.
More therapeutic work focused on building insight then helps teens connect those avoidant behaviors with some of the thoughts and feelings that drive them. Finally, skill-building therapeutic work helps adolescents learn strategies to make different choices when they experience those same thoughts or feelings in the future.
CBT is focused on helping individuals understand and challenge unhealthy thinking patterns and negative core beliefs and reframe thinking to improve mood and behaviors. DBT is more skill-based. DBT helps individuals learn strategies for distress tolerance and emotion regulation so that they can change patterns of impulsive behavior. Foundational DBT helps young people get to a place where they can productively work with a therapist, participate in a support group, or engage in self-guided skills practice.
Radically open DBT (RO-DBT) is a newer therapeutic modality that is particularly effective for “over-controlled” young people who are driven by external pressures to succeed and excel. With the omnipresence of social media and increasing pressures for young people to demonstrate achievement at younger and younger ages, mental health treatment programs are seeing an increase in teens struggling with unhealthy perfectionism and a fear of failure. RO-DBT helps these teens be less-guarded and more open to sharing thoughts and feelings.
Ecological Systems Theory can help adolescents learn to apply CBT and DBT concepts and skills in the different aspects of their life, starting with the individual and moving out to their interactions and connections with family, friends, sports teams and clubs, schools, faith communities, larger communities, etc. Adults and caregivers can use ecological systems theory to ensure that supports are in place in all of the “systems” connected to an adolescent. This ensures that the progress the teen is making in a mental health treatment setting can be reinforced at home, at school, and in other settings.
Adolescent residential treatment may be an appropriate treatment option for teens whose avoidance behaviors are significantly affecting their ability to function across a number of areas, including school, peers, and families. Residential treatment gives adolescents time and space away from their “triggers” to gain insight and practice new skills in a safe and supportive environment.
What role does family therapy play in addressing teen avoidant behaviors?
As part of that “systems” work, family therapy is one of the most important components in a young person’s progress. Family therapy helps parents and caregivers see and understand the drivers of an adolescent’s avoidant behaviors. Through family therapy, parents may learn that behaviors that were previously assumed to be driven by willfulness or laziness were actually a maladaptive response to an intense fear of rejection. That new understanding can help parents respond more effectively to avoidant behavior moving forward.
Family therapy also can reveal how the family has helped shape that teen’s perspective and how they could be instrumental in helping the young person develop more healthy behaviors. Young people are like sponges. They learn so much from their environment, including cues about how to respond to and deal with challenges and adversity. Through family therapy, parents and caregivers may discover that they also use avoidance behaviors in certain situations and can work toward developing new coping skills as well.
Family therapy ensures that families advance alongside teens throughout their therapeutic work and are equipped to help their loved one continue to move forward over time. Consistency is important. Behaviors are learned and adopted over years, and it is easy to fall back into old patterns. If family members help reinforce the skills teens are learning in therapy, the teen has a better chance of solidifying healthier behavior patterns for the future. And family communication and relationships between family members can improve when everyone is on the same page.
Family therapy also helps families learn how to have hard conversations. Families learn a common language to talk about difficult topics like self-harm or thoughts of suicide. Conversations that the whole family was routinely avoiding can be normalized. Teens and parents can build safe spaces to ask for support.
Teen avoidance behaviors may be part of a developmentally appropriate “phase,” or they could be indications that an adolescent is experiencing symptoms of a mental illness like depression or anxiety. Many effective therapeutic approaches can help teens and adults replace avoidant behaviors with healthy coping skills. Adolescent residential treatment may be the best option for teens whose avoidant behaviors are affecting their ability to function globally. Caregivers and educators can best support teens by validating their feelings and connecting them to mental health services and treatment when appropriate. Teens may be more receptive to help and interventions if they are given the opportunity to express their needs and concerns and be included in the treatment planning process. Family members and other supportive adults can help teens change unhealthy behavior patterns by engaging in therapy together and learning skills with teens in a parallel process. While we all may take the dog for a walk to avoid cleaning the kitchen, with connections to appropriate mental health care, we all can learn skills to face our fears and discomfort without withdrawing from the people who love us and the world we can enjoy.
Caitlin Connolly, LCSW, CAADC, is the Director of Clinical Services for the Skyland Trail Adolescent Program. In her role, she manages and provides support and consultation for the adolescent clinical team and provides therapy to adolescent clients in the residential program.