Understanding Anxiety & OCD in Teens: Symptoms, Causes, and Impact

Tiffany: What are some of the signs and symptoms of anxiety in teens?

Mark: Oh, there are so many. At WayPoint, one of the most common signs we see is school refusal. I’ve worked with students who haven’t gone to school in over two years because they’re anxious about performing well. It’s interesting because many of these students are brilliant—they’re the kind of kids you wouldn’t want to play chess with because they’d likely win every time. But they often have this perfectionistic attitude toward school. If they get an A-minus, it can be devastating.

Other signs include social withdrawal. These teens may have friends, but when invited to go out—to a movie, the park, or the skate park—they often make excuses, saying, “No, I’m busy.” Parents can see through this, knowing their teen isn’t actually busy but is just avoiding social situations. Often, these teens think, “They’re just inviting me to be polite; they don’t want me there.”

Then there’s the tendency to isolate. With technology, it’s easy to retreat into a world where they have everything they need—phone, computer, and access to everything online. It’s often more comfortable for them to interact socially online rather than in person. I joke with my students that managing relationships online is easier because, if there’s conflict, they can just click “unfollow” and avoid any difficult conversations.

Tiffany: Yes, it’s so much easier.

Mark: They don’t have to deal with face-to-face conversations, like explaining hurt feelings or navigating annoyances. It’s simple to just walk away. And because of that, we’re seeing more and more of these behaviors.

Tiffany: Absolutely. And online, they don’t have to read social cues, body language, or subtleties. I imagine you also see a lot of difficulty with completing assignments and daily activities, and even living through social media rather than real life. What other things do you notice?

Mark: When it comes to struggling with assignments, it’s often not an inability to complete them. At WayPoint, we say we don’t treat anxiety; we treat avoidance. One of the core lessons I want my students to leave WayPoint with is understanding that there’s nothing inherently wrong with anxiety. Anxiety is simply an emotion, just like happiness or joy. I often reference the Pixar movie Inside Out to explain this concept, though my kids are probably tired of hearing about it.

Tiffany: I love that movie!

Mark: Me too! It illustrates emotions well. I explain to students that anxiety has always served a purpose. I ask them to imagine a caveman in the forest who hears a twig snap—his heart rate spikes, adrenaline surges, and he’s ready to outrun his buddy to avoid the saber-tooth tiger. While we’re no longer facing those physical dangers, anxiety still shows up in situations like public speaking or taking tests, which helps us prepare and stay alert.

Once students start seeing anxiety as a tool rather than something to fear, it becomes easier for them to complete tasks. They stop worrying that not performing perfectly will “end their world.” For example, if a student takes the ACT and doesn’t get the score they hoped for, they can shift from panicking to thinking, “This just means I need to study more.” They can then work with a tutor or their parents to improve.

We’ve seen students who haven’t attended school for two years begin showing up at WayPoint’s school. They go from sitting at the back of the class to moving to the front, from listening to music in class to finally engaging in assignments. Eventually, they realize, “School isn’t a danger; it’s something I can take pride in.” And even if they earn a B, they feel proud of their hard work. 

Tiffany: That’s interesting. It sounds like their nervous system is stuck in a “fight, flight, or freeze” state, which might feed into perfectionism and shame, leading them to avoid things due to their fear of failure. Helping them work through that—like with ERP, which we’ll touch on shortly—makes a lot of sense. What other signs and symptoms do you commonly see in adolescents? I imagine they struggle with coping skills and executive functioning at times.

Mark: One of the intriguing aspects of anxiety is that we often see students who are the perfect models at school, but they come home as completely different people. I’ve had so many parents describe going to parent-teacher conferences hoping to discuss their child’s struggles—like schoolwork issues or tantrums at home—only to hear the teacher say, “Oh, we just love Jimmy! He’s so kind, attentive, and responsible.” The parents then ask me, “Does my kid just not like me?” But the reality is, it’s quite the opposite.

When kids are at school, they’re “white-knuckling” it—they’re holding everything in, following instructions, and keeping their anxieties tightly controlled. Then, when they get home and see those taillights of the school bus fade, they finally feel they can relax. And that’s when all the pent-up frustration, anxiety, and stress come out.

Tiffany: Because they feel safe there.

Mark: It’s this ironic dynamic where parents feel like their child hates them, but in truth, the child feels safe enough to be vulnerable around them. Our goal is to help them feel safe enough at school, too—around teachers, school counselors, and support staff—so they can release some of that tension there. This way, when they come home, they’re still in a safe place, but it’s less about managing pent-up frustration and more about actually being able to connect without that buildup of emotion.

Tiffany: Yeah, that makes a lot of sense.

Mark: Another thing we see is tantrums, especially at home. Some students will throw a tantrum over not getting the newest game or not being allowed to hang out with friends. What’s happening here is that they were relying on those activities—like playing a game or socializing—as a way to cope with their anxiety. When you say “No,” they perceive that as you taking away their coping mechanism. So, it’s not about them being out of control or rebellious; it’s about them feeling like the world is out of control, and those activities were one of the few things they could use to manage that anxiety.

Tiffany: I’ve seen that with clients dealing with anxiety—they feel like they can’t control what’s going on inside, so they try to control what’s going on outside. That leads to overreactions to seemingly minor issues.

Mark: This is especially true for students with OCD. One common symptom is parental accommodation. For example, we had a student a while ago who had contamination-related OCD. He made his parents buy him dozens of toothbrushes because he believed each one was contaminated. The parents thought they were helping by buying these new toothbrushes, but it only reinforced the behavior. Similarly, some kids with anxiety convince their parents to call the school and say they’re sick, even when they’re not, to avoid school. The parents, feeling bad about the anxiety, try to cover for their child, which ends up accommodating the anxiety, making it worse.

Tiffany: That makes sense. It’s like the parents are trying to make up for the distress their child is feeling.

Mark: Another symptom we often see is somatic complaints, like stomach aches, GI issues, headaches, or even fevers. These are ways the anxiety manifests physically or is used as an excuse to avoid difficult situations. The brain is signaling that there’s danger, even though the danger isn’t real. Physical complaints can sometimes be a way for the child to maintain some sense of control over their external world.

These kids—especially the ones we work with at WayPoint—are often very bright. They’ll go to great lengths to “keep themselves safe,” even if that means creating elaborate ways to avoid situations that cause them anxiety. It’s fascinating to see how creative they can get in finding ways to manage their emotions, even if those ways aren’t healthy.

Tiffany: That makes total sense when you understand the nervous system. If someone’s in a constant state of fight, flight, or freeze, they’re not in a “rest and digest” state. Their body is on alert, and parents don’t always realize how interconnected everything is. When someone is struggling emotionally, it can show up physically. That’s when we start clenching our teeth, getting migraines, or holding tension in our necks, which causes more headaches or stomachaches. Their system is stuck in a constant state of alarm, so it can’t function properly. It’s all connected—even if a parent takes their child to the doctor, and the doctor can’t find a physical reason for their symptoms. Helping parents understand that is key.

Mark: And that brings us to what anxious teens have in common. The biggest thing they share is maladaptive coping strategies.

Tiffany: Yeah.

Mark: They tend to isolate or hide. They might lie, but it’s not the kind of lying to hurt someone—it’s more like lying to protect themselves. So, instead of just maladaptive coping strategies, I’d also say there’s a lack or misuse of effective coping strategies. For example, I work with students and teach them coping strategies like distraction. But the first question I usually get is, “Well, Mark, you told me not to avoid.”

Tiffany: Right.

Mark: They often ask, “Why are you teaching me to distract?” They don’t understand that distraction is very effective—until it turns into avoidance. So I’ll ask them, “What are some things you enjoy doing?” For example, if a student likes reading, I’ll say, “Great, let’s pick out a book, put it in your binder, and carry it with you. When you start to feel anxious, let’s measure it on a 1 to 10 scale of distress. 1 is calm and collected, and 10 is feeling like your head is on fire.” When their distress hits a 5, I tell them to pull out the book, read for 5 or 10 minutes to let their system cool down, and then re-engage with the anxiety-causing activity.

What usually happens is they get into the book and end up reading the entire class period. Then, I’ll get a call from the teacher saying, “Why is he reading the whole class time?” So, it’s not just about teaching coping strategies—it’s about using them correctly. Recently, a student told me he’d used all his coping strategies “30 times over” but still wasn’t feeling better. So I asked him, “Have you tried sitting with the anxiety, inviting it in, and befriending it?” He asked, “Why would I do that?”

The issue was, he was trying to get rid of the anxiety. But the main approach to treating anxiety is not to eliminate it—it’s to accept it, to make it part of who you are. The more you try to push it away, the more it clings on. But when you sit with it, let it be, it will eventually lose its power. So I told him, “Why don’t you go outside, sit in one of our chairs for 20 or 30 minutes, and just be with the anxiety?” He reluctantly agreed. After about 10 minutes, he came back and said, “Yeah, I feel better. What the heck?”

Tiffany: It’s not as scary as they think it is.

Mark: They might not feel great, but that’s okay. We talk about getting comfortable with discomfort. It’s something we address over multiple sessions.

Tiffany: A lot of times, the emotions teens experience are trying to tell them something. It’s like a little alert saying, “Hey, something’s off.” The more they try to avoid, ignore, or bury those feelings, the louder they get. It’s like the emotions are saying, “You’re not paying attention to me. Something needs to change.”

Mark: That’s a great example. For this particular student, we processed his emotions and discovered he was worried about whether he’d make enough progress before going home. And I had to be honest with him: “You may not, and that’s okay.” It’s a reality we had to address. So we talked about the fear of failure—what happens if he goes home and starts experiencing anxiety and panic attacks again? By addressing that fear now, he has a plan. He’s gaining skills and knowledge so if the worst happens, he’s ready. And if it doesn’t happen, he can feel good knowing he did the prep work, even if it wasn’t needed.

Tiffany: That makes sense. Going back to the book example, I have a daughter who teeters on that line of avoidance versus coping. She loves reading, but sometimes I have to take the books away because she gets lost in them for hours, and it becomes avoidance. That’s a great example, and I’m sure many parents can relate to that with their teens.