Anxiety Disorders in Youth

In Forgiveness Therapy:
An Empirical Guide for Resolving Anger and Restoring Hope,
APA Books, 2014.

 

Anxiety disorders are the most common class of disorders in youth, followed by behavior, mood, and substance disorders (Kessler, Avenivoli, Costello, Georgiades & Green, 2012a; Costello, Egger, & Angold, 2005). In the study of the lifetime prevalence of mental disorders in U.S. adolescents, nearly one in three adolescents (31.9%) met criteria for an anxiety disorder, with rates for individual disorders ranging from 2.2% for GAD to 19.3% for specific phobia. All anxiety disorder subtypes were more frequent in females (the greatest sex difference being observed for PTSD). The aggregate category of any anxiety disorder was stable across age groups, but considerable variance was observed by disorder subtype. In particular,the prevalence of PTSD, panic disorder, social phobia, and GAD showed modest but consistent increases with age (Merikangas, et al.).

Youth with anxiety disorders exhibit significantly more irritability and associated impairment than healthy adolescents; self-reported irritability in youths with anxiety disorders is comparable to that observed in youths with severe mood disorders (Stoddard, Stringaris, Brotman, Montville & Pine, et al., 2013). Anxiety disorders in childhood are predictors of a range of psychiatric disorders in adolescence. Over Anxious Disorder (OAD) was associated with later OAD, panic attacks, depression, and conduct disorder (CD). Generalized Anxiety Disorder was related only to Conduct Disorder. Social phobia in childhood was associated with adolescent OAD, social phobia, and attention-deficit/hyperactivity disorder (Bittner, Egger, Erkanli, Costello & Foley, et al., 2007).

Peer reviewed research studies have demonstrated that forgiveness therapy decreases anxiety although none have been done to date with children that measure anxiety. Clinical experience with forgiveness therapy also indicates its benefits in the treatment of youth with anxiety disorders. Its use will now be presented.

Social Anxiety Disorder

Social Anxiety Disorder (SAD) is a marked and persistent fear of social situations characterized by pervasive social inhibition and timidity and is one of the most common anxiety disorders. It has an early age of onset--by age 11 years in about 50% and by age 20 years in about 80% of individuals--and it is a risk factor for subsequent depressive illness and substance abuse (Stein & Stein, 2008). It is associated with significant role impairment and treatment-seeking, all of which have a dose-response relationship with a number of social fears (Ruscio, Brown, Chiu, Sareen, Stein & Kessler, 2008). In one study of adolescents, those with generalized social phobia reported an earlier age of onset, higher symptom persistence, more comorbidity, more severe impairments, higher treatment rates, and indicated more frequently a parental history of mental disorders than respondents with non-generalized social phobia (Wittchen, Stein & Kessler, 1999). Excessive anger has been found to be co-morbid with social anxiety (Barrett, Mills & Teeson, 2013).

In children, social anxiety must occur in peer settings and not just during interaction with adults (DSM-5, p.202). The fear or anxiety may be expressed by crying, tantrums, freezing, clinging, shrinking, or failing to speak in social situations. These intense fears often emerge in youth during times when they are scrutinized by others, such as in reading in front of a classroom. The average age of onset is early to middle adolescence, but social phobia has been documented in children as young as eight.

The most common distressing events were reading aloud in front of the class, musical or athletic performance, joining in on a conversation, speaking to adults and starting a conversation (Beidel, Morris, & Turner, 2004). These fears can contribute to social avoidance. In socially distressful situations, children with social phobia report a number of physical symptoms including heart palpitations, shakiness, sweating, nausea and flushes or chills. Among adolescents with social phobia, 41.2% were reported to have a somatoform disorder, 29.4% had a depressive disorder, and 23.5% had a substance abuse disorder (Essau, Conradt, & Peterman, 1999).

Various risk factors and pathways for the acquisition and maintenance of SAD have been identified (Epkins & Heckler, 2011 & Natsuaki, Leve, L.D., Neiderhiser, Shaw, Scarmella, Ge & Reiss, 2013). Festa and Ginsberg (2011) found that in youth with social anxiety there were higher levels of parental anxiety, rejection, and over-control. Not surprisingly, higher levels of social support, acceptance, and validation were associated with lower levels social anxiety. The strongest predictors of social anxiety symptoms (as rated by an independent evaluator) were parental anxiety and friendship quality (i.e., validation from a peer). The strongest predictors of child-rated social anxiety symptoms were parental over-control and perceived social acceptance. In addition, parenting practices that are characterized as disengaged, less warm, and withdrawn have been linked to anxiety in children (McLeod, Wood, & Weisz, 2007; Woodruff-Borden, Morrow, Bourland, & Cambron, 2002).

It has been estimated that the odds of children of anxious parents developing social phobia are 4.7 times greater than the odds for children of non-affected parents (Lieb, Wittchen, Hofler, Fuetsch, Stein & Merikangas, 2000). In our clinical work the loss of self-esteem and trust in youth as the result of traumatic experiences with parents, siblings or peers results in the development of both significant anxiety and anger. Also, children often are unconsciously angry with parents who are not warm, withdrawn, controlling, or critical. Also, in our clinical experience exposure in childhood to excessive parental, sibling, or peer anger contributes to social anxiety.

Behavioral and CBT therapies for childhood anxiety disorders are effective (Silverman, Pina & Viswesvaran, 2008), however, as many as half of anxious youth do not benefit from these interventions (Alfano, Pina, Villalta, Beidel, Ammerman, et al., 2009). The identification of the origin of the fears in youth with SAD and the resolution of the anger associated with them through forgiveness therapy can enhance the use of CBT for the treatment of SAD. Often, therapists fail to uncover and treat the comorbid anger in these anxious youth that limits recovery. Also, the role of loneliness as an important mechanism of change during treatment for social anxiety has been identified with decreases in loneliness specifically mediating improvements in social anxiety (Alfano, et al., 2009).

Chad was nine-year-old who was shy for most of his childhood. His SAD symptoms of fearing to socialize with peers and his growing timidity became more apparent in the third grade. He then tried to avoid going to school and when his mother rejected his request to stay home from school, he would fly into a rage. He would tell her that he would not talk to her when he returned from school. In the evenings he became increasingly fearful and anxious. The history revealed that there had been no traumatic experiences with his peers at school that could explain such intense fears.

The family history revealed conflicts in each parent that contributed to his SAD symptoms. His mother, Renata, was a warm, loving mother, but she had struggled with chronic anxiety from her youth due to her parents’ divorce when she was ten. When anxious, she would often overreact in irritability. Also, his father, Bill, who was a hard-working man, expressed his love for Chad through his financial support for the family but not through the affection or praise that Chad desired. Both his mother and Chad described Bill as being emotionally distant and not particularly warm or affirming of his son or of her. In the family sessions Bill recognized that he had modeled after an emotionally distant father and failed to recognize the importance of communicating affection and affirmation to his son to build his confidence. Chad’s mother’s anxiety was also influenced to a degree by loneliness and stress in her martial relationship.

After several therapy sessions, Chad was able to recognize that he was angry with his mother for being so anxious and with his father for contributing to his insecurity and anxiety by being so emotionally distant and difficult to please. He stated, “I want my mother to be less upset about everything and my father to be more loving and closer to me. Also, I want them to get along better.”

In family sessions, Chad’s parents apologized to him for their behaviors and insisted that they were motivated to work on their own conflicts. His mother began a course of CBT for her anxiety and started on an SSRI also. His father uncovered anger with his father for being so distant and worked in forgiveness therapy to try to break the negative paternal legacy. These issues also were addressed in marital therapy. His father told Chad, “I am sorry that I was not a warmer, more positive father, but I am committed to change and to help you to feel better about yourself and less anxious.”

When it was explained to Chad that the resolution of his own anger would help his fears diminish, he decided to work on thinking of forgiving his parents for the hurts and disappointments of the past. His work on forgiving was aided by the fact that his parents regularly requested forgiveness from him for all the stress they had caused him.

As Chad worked at forgiving his parents, he became aware that he had much more anger with each of them than he realized. The therapist made the recommendation that he should not feel guilty because the anger was justified and if he worked regularly at forgiving, he would experience his anger diminishing in time. Over the course of several months, each of his parents became more sensitive to him and he experienced less anxiety and more confidence with his peers. He began to isolate himself less and to enjoy more his peer relationships.

At the same time, the marital therapy with Chad’s parents strengthened their marital friendships and decreased the stress in the home. Consequently, the improvement in the marital relationship helped to diminish Chad’s social anxiety in a significant way.

Obsessive-Compulsive Disorder

Early-onset obsessive-compulsive disorder (OCD) is one of the more common mental illnesses of children and adolescents, with prevalence of 1% to 3%. In the United States the mean age of onset is 19.5 years and 25% of cases start before age 14 years with nearly 25% of males having an onset before age 10 years (DSM-5, p.239). Its manifestations often lead to severe impairment and to serious conflicts in the family. Comorbid mental disturbances are present in as many as 70% of patients.

While CBT is the treatment of first choice (March & Mulle, 1998) , followed by CBT with an SSRI, the disease takes a chronic course in more than 40% of patients (Walitza, Melfsen, Jans, Zellman & Wewetzer, et al., 2011). Forgiveness therapy can be effective in treating the excessive anger and disruptive behaviors that are highly comorbid with OCD.

A 2012 study demonstrated that rage attacks are relatively common in youth with OCD, have a negative impact on illness presentation, and contribute to functional impairment above and beyond obsessive-compulsive symptom severity (Storch, Jones, Ale, Sulkowski & Lewin, et al., 2012). This intense anger can contribute to family accommodation of symptoms, which may further affect obsessive-compulsive symptom severity and impairment.

In a 2008 study of 236 children (149 boys and 87 girls) with OCD (Mataix-Cols, Nakatani, Micali & Heyman, 2008), the most common obsessions were aggressive (81%), contamination (79%), symmetry (41.9%) and religious (40.7%). Girls had significantly more aggressive obsessions, while boys had significantly more religious and sexual obsessions. The most common compulsions were checking (80%), cleaning (79%), repeating (75%), ordering (59%) and counting (49%). The high prevalence of aggressive thoughts indicates the need to evaluate anger and to develop a treatment protocol for it in children and youth with OCD.

In a study of adolescents with OCD there was a high comorbidity with disruptive disorders and tic, mood, and anxiety disorders (Geller, Biederman, Griffin, Jones & Lefkowitz, 1996). The most frequently reported obsessions were those of violent and/or catastrophic events, often involving a loved one (60%). In this study 53% of the participants had at least one disruptive disorder, 43% had oppositional defiant disorder, 73% had major depression, and 33% ADHD. Also, when present, the disruptive behavior disorders developed years before the onset of OCD. A research study of 2,057 youth who developed OCD before the age of 18 has demonstrated solid evidence for the high family aggregation of OCD (Steinhausen, Bisgaard, Munk-Jorgensen & Helenius, 2013).

Most children and adolescents with OCD initially do not identify excessive anger as a serious difficulty in their lives. However, significant anger is regularly uncovered that is meant for parents, siblings, or peers. Obsessive-compulsive symptoms are often a defense against strong feelings of intense anger that the child is unable to face due to fear. Forgiveness helps to resolve the anger and associated aggressive obsessions in these youngsters and thereby assists in their recovery from OCD.

Van, a seven-year-old first grader, developed a severe germ phobia and extremely compulsive behaviors. After going to the bathroom, he would regularly spend twenty minutes to a half an hour cleaning himself. At school, he would not open or close any doors without first covering his hand with his sweater to protect himself from germs. He limited his play with his friends because of his fear of being contaminated by germs. His compulsive behaviors increased and required larger amounts of time. The only anger Van manifested was when his parents tried to shorten the time he spent in compulsive behaviors. His intense anger led to a family accommodation to his symptoms.

Initially, Van had no awareness of any difficulties that preceded the development of his symptoms. However, when his parents were seen alone, they related numerous stresses in their relationship. His mother had been sick over the previous two years with severe chronic fatigue and numerous vague health problems that had resulted in prolonged bed rest. As a child, she had a very stressful relationship with her mother and in adulthood she had difficulty trusting her husband. Also, even though Van’s parents rarely quarreled, there was very little affection in the marital relationship. Although each was dissatisfied with the marriage, they were not considering separation or divorce, neither were they working to improve their marital relationship.

Van denied having any fear that his parents might separate or divorce although he had been informed by them that there was considerable stress in the marriage. He, in fact, called their relationship good. When asked about his mother who had been in bed for almost two years, he insisted, “I’m not worried about her. She’ll be fine.” It was suggested to Van that he might have developed a fear of something bad happening to him due to his mother’s illness and of the stress in his parents’ marriage. It was explained to him that these fears might have been too frightening to face, so instead of addressing them, he acquired the fear that he might contract a serious illness from germs.

Van’s parents made a commitment to working on a resolution of their difficulties so that their relationship would improve. The therapist then told Van that he thought he had denied angry feelings toward his parents and validated those feelings as being normal. Then, after forgiveness was explained to him, he was asked to think daily that he wanted to forgive his parents. He reluctantly agreed to think of forgiving them for those times when they were not kind or loving to one another even though he was not consciously aware of being angry with them. After several months of therapy Van was able to admit having angry feelings toward his parents. Also, Van was encouraged to trust that his parents’ marriage could become a happier one. Working on forgiveness and growth in trust over a period of six months, in addition to antidepressant medication for his mother and participation in marital therapy by the parents, resulted in a significant improvement of Van’s obsessive-compulsive symptoms.

Anxiety due to Bullying

Bullying has been at the center of some highly tragic news stories over the past decade and is a serious public health problem. The types of bullying include verbal attacks, physical attacks, social attacks, and online attacks or cyberbullying which is the newest and perhaps most prevalent form of bullying in some communities. Bullying is a distressing experience that is often continuous over years and predicts both concurrent and future psychiatric symptoms and disorders, even into adulthood (Kumpulainen, 2008).

Poor gross motor skills constitute a strong and independent risk factor for peer victimization in childhood, regardless of sex, childhood psychiatric care, and diagnosis (Bejerot & Humble, 2013). These children are seen as clumsy and have difficulty participating in athletic activities. Children who were bullied tend to like school and to feel alone (Forero, McLellan, Rissel & Bauman, 1999). Furthermore, children with depressive symptoms and anxiety are at increased risk of being victimized (Fekkes, Pilpers, Fredriks, Vogels & Verloove-Vanhorick, (2006). Social problems increase the risk of becoming a victim or a victim-perpetrator (Kim, Leventhal, Yoh, Hubbard, & Boyce (2006). Compared to non-involved children, victims of bullying are more submissive, have fewer leadership skills, are more withdrawn, more isolated, less cooperative, less sociable, and frequently have no playmates (Perren & Alsaker, 2006) Also, their peers regularly side with the bullies against them, do not support them, and even develop strong anger toward them (Rigby & Slee, 1991).

Children who are bullied by their peers often develop a number of psychological difficulties. This trauma increases the risk of self-harm in late adolescence (Lereya, Winsper, Heron, Lewis, Gunnell, Fisher & Wolke, 2013); increases the risk for suicide ideation and suicidal/self-injurious behavior in preadolescence (Winsper, Lereya, Zanarini & Wolke (2012); is a precursor or marker on the trajectory toward the development of Borderline Personality Disorder symptoms in childhood (Wolke, Schreier, Zanarini & Winsper, (2012); increases risk of in psychotic symptoms in early adolescence which nearly doubles among children who were victims of bullying at age 8 or 10 years (Schreier, Wolke, Thomas, Horwood, & Hollis, et al., 2009) and can result in social isolation and loneliness (Boulton & Underwood, 1992), psychosomatic symptoms (Kumpulainen, 1998), social phobia (Gilmartin, 1987), school phobia, low self-esteem, and intense anger with impulses for revenge.

In our clinical experience, severe bullying damages a child's ability to feel safe in the world and in adolescence can progress into paranoid thinking that can be associated with severe rage and violent impulses for revenge. Some of these victims become obsessed with violent video games and have acted out their violent impulses against bullies or innocent victims in American schools with tragic consequences. Self-mastery over anger in bullies and in the victims is essential to address this major public health problem.

Forgiveness therapy has been demonstrated to be effective in females victimized by those who bully by diminishing anger and hostile attribution, by reducing aggression and delinquency and by improving academic performance (Park, J.H., Enright, R.D., Essex, M.J., Zahn-Waxler, C., & Klatt, J.S., 2013). The following clinical case demonstrates it effectiveness. Manuel, a ten-year-old boy, told his parents whenever other children made fun of him at school or in sports. Although he was one of smartest student in his class, he became increasingly anxious and angry as a result of the constant ridicule by peers. The apparent reason for the abuse was his clumsiness that interfered with his ability to join other boys in sporting activities, especially soccer and basketball at recess. He preferred engaging in artistic and musical activities. Manuel related feeling that he never felt that he fit in with his male peers, making him feel insecure and lonely. When he explained his peer conflicts to his father, he was understanding and supportive. He suggested that Manuel think that perhaps his peers were jealous of his intelligence and that they work on developing friendships with boys with similar interests. To his credit, even when he was outnumbered, Manuel was emotionally strong and had no difficulty responding in an assertive way to his tormentors. However, he developed symptoms of anxiety and anger as a result of ongoing peer rejection.

Manuel’s anger with his peers regularly spilled over into his relationships with his younger sister and his mother. He knew that he was overreacting in anger and that they did not deserve it. He related in a session, “I am furious with the kids at school and don’t know how to deal with my anger. I wish someone would teach me to control it without hurting those I love.” In the therapy sessions, he denied impulses for revenge or violent fantasies against his peers. He was asked daily to try to view his peers as being jealous of his intelligence, as his father had suggested, and then think of wanting to try to forgive them. He was helped in this process with his father’s encouragement. His father would suggest, “Manuel don’t let them control you. Let go of your anger.” Manuel’s dad told him that he also had been subjected to similar treatment as a boy. Slowly, Manuel actually came to feel compassion for his peers and viewed many of them as being weak males who could not face him individually, but needed to hide in a group.

In the deepening phase, Manuel was pleased that both his anxiety and his anger were decreasing and that he had learned of a way to control his temper and that he was able to help his younger sister to work at controlling her anger by talking with her about forgiving others.

Our clinical experience from treating bully-victims for over three decades is that bullying has increased significantly in our schools and communities. This public health problem needs to be addressed with new programs in our homes and schools to help children to master their anger and to encourage peers to understand bullies and to support victims.

Teachers can educate children in how to address and reduce their anger by using forgiveness (Fitzgibbons, Enright & O’Brien, 2004.) Research studies have demonstrated the effectiveness of forgiveness education in the classroom in diminishing anger in youth with the angriest children showing the most improvement (Enright, et al., 2007; Holter, Magnuson, Knutson, Knutson Enright & Enright, 2008; Gambaro, Enright, Baskin, & Klatt, 2008). Teaching forgiveness in the classroom and in the family has the potential to diminish the serious public health problem of bullying in youth. An anti-bullying curriculum guide for middle school and early high school is described in Forgiveness Therapy.

Anxiety and Anger in Children of Divorce and Stepchildren

Conflicts with anxiety, sadness, and excessive anger in children and young adults from divorced families have been reported in a number of studies (Fuller-Thomson & Dalton, 2011; Kessler, Davis, & Kendler,1997 & Nomura, Wickramaratne, Warner, Mufson & Weissman, 2002). Children whose parents divorce will exhibit more anxiety and depression than children from intact families (Strohschein,2005). Youth whose parents are going through divorce or have divorced can manifest a number of anxiety disorders, including an obsessive-compulsive disorder.

The primary effect of divorce and of the parental conflict that precedes the divorce is a decline in the relationship between parent and child. (Amato & Afifi, 2006). The stress of divorce damages the parent-child relationship for as many as 40 percent of divorced mothers (Wallerstein & Kelly, 1996). Parental divorce makes it more difficult for children to trust their parents while a “decline in the closeness of the parent-child relationship mediates much of the association between parental divorce, marital discord, and offspring’s psychological wellbeing in adulthood,”(Amato & Sobolewski, 2001, p.912).

Divorce leads to a decline in the frequency and quality of parent-child contact and relationships (Booth & Amato, 2001) and it becomes difficult for nonresidential parents, 90 percent of whom are fathers, to maintain close ties with their children (Peters & Ehrenberg, 2008). By adolescence, fewer than half of children living with separated, divorced, or remarried mothers had seen their fathers at all in more than a year, and only one in six saw their fathers once a week (Popenoe, 1996).

Also, some stepchildren often harbor serious resentment toward a biological parent that is often unconscious and difficult to control. They often deny this anger, but it can emerge in times of stress. Stepparents also can have difficulties with their anger as a result of a number of factors including residual resentment from their previous marriage.

Rachel was a thirty-five year old married woman who, in addition to her own two children, had two stepchildren in her home. The stepchildren had been deeply hurt by their alcoholic mother and her abusive boyfriend before they had come to live with Rachel. The children’s anger that was meant for the adults with whom they had formerly lived was frequently misdirected toward Rachel and the other children. Their angry behaviors created severe tension in the home. Rachel became so exhausted and overwhelmed that she even considered separating from her husband, Aaron. She began therapy and quickly after the first session took steps to become assertive with her stepchildren. She identified the origin of their anger and encouraged them to try to let go of their resentment by forgiving their mother and her boyfriend rather than by misdirecting their anger at her and her children.

It was particularly difficult for Rachel’s stepson, Brad, to let go of his anger with his mother’s physically abusive boyfriend. Brad viewed him as being emotionally unwell and his opinion was validated by the therapist. The treatment of his anger was facilitated by punching a pillow and then by thinking he wanted to let go of his impulses to strike back.

This work of forgiveness was a lengthy and difficult process for the children and, at times, they continued to overreact in anger toward Rachel. When that would happen, she would remind them that she did not deserve their anger and would encourage them to try letting go of their resentment with their mother by forgiving her. They were helped in the process by trying to recall that much of their mother’s behaviors were the result of her illness of alcoholism and an untrustworthy boyfriend. Finally, Rachel modeled forgiveness in the home by asking for forgiveness for any ways in which she may have disappointed the children and by granting it to others who hurt her, including their father who had abandoned them.

Some children from divorced families harbor intense rage and may have violent fantasies or impulses against a parent. Often these young people are unable to use the word “forgiveness” because they sincerely believe that the parent, stepparent, or parent’s friend should not be forgiven. In lieu of using the word “forgiveness,” when these children choose the spiritual form of forgiveness, they are asked to think that they are powerless over their anger and want to turn it over to God. It is important for such strong anger to be addressed because the failure to do so can result in hostile impulses becoming misdirected at oneself or outwardly toward the family, school, or community. Also, the failure to face and resolve the anger predisposes these youth to difficulties in trusting, along with anxiety and depressive episodes, with males being particularly vulnerable to severe depression with suicidal ideation (Fuller-Thomson & Dalton, 2011).

Adopted Children

In the United States, about 120,000 children are adopted annually, with adopted youth constituting 1.5 million (or at least 2% of) children younger than age 18 years (Nickman, Rosenfeld, Fine, MacIntyre, Pilowsky, et al., 2005). We must be with sensitive adoptive parents and adopted children. Not all adopted children have psychological disorders and our discussion here is not meant to leave the impression that they do. When we cite studies of international adoptees, we are not meaning to generalize this discussion to all who have been adopted. With these cautions in mind, we will discuss adoptive children and forgiveness.

Some adopted youth experience early life emotional trauma as a result of separation from the birth mother or from prolonged time in care without a secure maternal attachment. A study of 1,364 international adoptees on the impact of early childhood adversities on adult psychiatric disorders revealed that severe early adversities increase the risk of adult psychopathology, even when children are taken out of their problematic environments. These children have an increased risk of anxiety disorders, mood disorders, or substance abuse disorders into adulthood.

The results suggest that psychiatric disorders in international adoptions may arise de novo after childhood due to early experiences (van der Vegt, Tieman,, van der Ende, Ferdianand, Verhulst, & Tiemeier, 2009.) The experience of early childhood adversity prior to adoption has been shown to increase substantially the level of psychiatric problems, especially when maltreatment was severe. Moreover, the impact of early adversities on psychiatric problems remained markedly stable. This suggests that vulnerability of early-maltreated children persists even if they are raised in enriched circumstances (van der Vegt, van der Ende, Ferdianand, Verhulst, & Tiemeier, 2009).

In one study, adoptees from Eastern Europe had more attentional problems, poor adaptive abilities, and poorer interpersonal relationships than the other adoptees and adopted boys had higher scores on externalizing behaviors and depression than girls (Barcons-Castel, N., Fornieles-Deu, A. & Costas-Moragas, C., 2011). A study of 1,484 young adult inter-country adoptees in the Netherlands demonstrated that the adopted young adults were 1.52 times as likely to meet the criteria for an anxiety disorder as the non-adopted young adults. The adoptees were also 2.05 times as likely to meet the criteria for substance abuse or dependence.

The adopted men were 3.76 times as likely to have a mood disorder as non-adopted men (Tieman, van der Ende, & Verhulst, 2005). Also, adoptees, compared to non-adoptees, were less likely to have intimate relationships, to live with a partner, and to be married. Adopted males showed somewhat less favorable outcomes than adopted females (Tieman, van der Ende, & Verhulst, 2006). The experience of being adopted approximately doubled the odds of having contact with a mental health professional and of having a disruptive behavior disorder.

Relative to international adoptees, domestic adoptees had higher odds of having an externalizing disorder (Keyes, Sharma, Elkins, Iacono, & McGue, 2008). Also, late age at adoption, neglect, and institutionalization have been shown to be risk factors for the psychological and behavioral problems in adoptees and families (Fensbo, 2004). Adoptees placed after infancy may have developmental delays, attachment disturbances, and posttraumatic stress disorder (Nickman, Rosenfeld, Fine, MacIntyre & Piolowsky, 2005).

Forgiveness therapy can be effective in addressing the serious early-life emotional conflicts in some adopted children, which can continue into adulthood. In our experience, the anxiety, insecurity, and anger in some adopted children originates from a number of sources, including traumatic memories with their birth parents or other caregivers, shame, a profound difficulty in trusting or other experiences of rejection. These youngsters can exhibit angry behavior and usually lack an understanding of the origin of their resentment. Their anger can diminish by discussing the early-life, unconscious betrayal anger that may develop after separation from a biological parent or from lack of nurturance. The youngster should be encouraged to consider making a decision to work at forgiving rather than venting anger in an excessive and misdirected manner, particularly at adoptive parents. In some cases forgiveness exercises are given to them in which the young people are asked to think of forgiving one or both biological parents for abandoning them.

The hostile feelings in such children are a defense against their feelings of vulnerability and fear of further betrayal. These youngsters often will only work at changing their angry behaviors after they have worked on trusting their adoptive parents to a much greater degree and after they have given up the need to try to control others.

Amber was an intelligent nine-year-old girl who was adopted from Russia at the age of five with her two-year-old brother. After being taken away from her drug addicted mother who was a prostitute, Amber was placed in a strict orphanage and later related being treated in a harsh manner there. Her adjustment to her family and community was quite difficult. She distanced her adoptive parents, children in the neighborhood, and anyone who tried to befriend her. She became increasingly angry and later engaged in violent behaviors toward her mother.

The therapist told Amber, “You have every reason to feel very angry about what happened to you in Russia with your mother and at the orphanage. However, that anger has never left you and now you are misdirecting at your mother and others. Why not try to think that you want to understand and try to forgive your birth mother rather than take that resentment out on your mother now? I have seen forgiveness diminish strong anger in other adopted children.” Amber initially denied this anger for months. At home her mother was told to tell her that she did not deserve her hostile aggressive treatment and that if she could forgive her birth mother her anger would diminish and they might have a good relationship.

Amber slowly acknowledged that she had felt a great deal of resentment toward her birth mother for her addictive behavior and for failing to protect both her and her brother. She also expressed anger toward the caretakers of the orphanage in Russia. Painful memories emerged in which she recalled hitting her birth mother in Russia when she was drunk. It was suggested to Amber that at the present time she was misdirecting intense hostile feelings that she had for her birth mother toward her adoptive mother and was using her anger as a defense to keep everyone at a distance.

Amber was given handwritten forgiveness notes to take home and work on between sessions. These notes stated: a) I want to stop misdirecting my anger at those who don’t deserve it; b) I want to try to understand that my birth mother was sick with a drug addiction and I want to try to forgive her; c) I want to let go of the anger from Russia so that I can be free and not controlled by the past. She also was challenged to trust people more than her birth mother had ever been able to trust. It was stated that unless she took these steps, she might be as lonely, unhappy, and fearful as her birth mother.

As she worked both on trusting her adoptive mother more and on forgiving people for her past hurts, Amber became aware that some good could come from her pain. She expressed the desire to become a health professional and someday go back to Russia to help children who had suffered in the same manner as she. This new meaning and purpose in her life was emotionally healing for her. As her resentment diminished and her trust grew, she became much less defensive and more loving toward her mother and her peers.

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