Anxiety in Children
An anxiety disorder in childhood and adolescence can result in serious psychological suffering. It can harm the development of security friendships and family relationships, as well as interfere with a youth's education. Anxiety disorders also can result in an increased risk of developing a major depressive disorder, other secondary anxiety disorders and even suicidal thoughts (Strawn, J.R., 2018), as well as physical symptoms.
There is also a strong relationship between elevated levels of anxiety symptoms and poor health related quality of life in adolescents which demonstrate the importance of mental health interventions targeting anxious adolescents (Raknes, S., 2017).
Fortunately, anxiety disorders frequently respond to a number of treatment modalities.
This chapter is meant to help parents come to a deeper understanding of how they can protect the emotional lives of their children from anxiety, fears and insecurities.. A number of virtues will be presented which can help children and teenagers grow in their ability to deal with their anxiety, insecurity and anger. A separate chapter on this website addresses the anxiety and anger in obsessive-compulsive disorders in children. Case studies from the child chapter of Forgiveness Therapy: An Empirical Guide for Resolving Anger and Restoring Hope (American Psychological Association Books, 2014) will be presented.
In a major research update on child and adolescent psychiatric disorders the authors stated that there is mounting evidence that many, if not most, lifetime psychiatric disorders will first appear in childhood or adolescence and that methods are now available to monitor young people and to make early intervention feasible.
A national comorbidity face-to-face survey of 10,123 adolescents aged 13 to 18 revealed that anxiety disorders were the most common condition (31.9%), followed by behavioral disorders , such as oppositional defiant disorder, (19.1%), mood disorders (14.3%), and substance use disorders (11.4). The median age of onset for disorder classes was earliest for anxiety (6 years), followed by 11 years for behavioral, 13 years for mood, and 15 years for substance use disorders, (Merikangas, K.R.,et al., 2010.)
Dr. Bob Enright, University of Wisconsin, has demonstrated in his research that the use of forgiveness in children can diminish their anxiety, anger and sadness, as well as improve their school performance. His forgiveness education programs have taught youth and their parents a proven method for reducing excessive anger that is associated with anxiety disorders in many countries.
Anxiety and Anger
The first diagram below demonstrates the relationship between unjust hurts and the development of sadness, anxiety and weakness in confidence and its relationship to anger. The second diagram shows how anger can encapsulate in a sense emotional pain and can interfere with its resolution.
A 2005 national study of psychiatric disorders revealed that the median age of onset is
11 years for anxiety disorders
11 years for impulse-control disorders
20 years substance use
30 years mood disorders
Half of all lifetime cases start by age 14 years and three fourths by age 24 years (Kessler RC, 2005).
Longitudinal studies have shown that anxiety disorders during childhood are moderately stable and predictive of other mental health disorders, especially depression, later (Rapee R, 2009).
Due to the strong relationship between anxiety and anger it is important to evaluate the degree of anger in anxious children. As the diagram above tries to demonstrate, anger can encapsulate anxiety and interfere with its resolution. Please complete the anger checklist on your child and identify the number of active and passive aggressive angry behaviors.
Children who experience separation anxiety disorders, divorce and separation stress, bullying victimization or adoption usually have sustained damage to their basic ability to trust and feel safe in or outside the home. Their difficulty in trusting is often not identified adequately. The checklist below has helped many parents and youth to understand the various origins of anxiety/mistrust.
Parental anger or selfishness
Loss of a parent, sibling or close friend
Serious illness in a parent, sibling, or oneself
Weakness in confidence
An addicted parent
A fearful, mistrustful or overly controlling parent
Legacy of mistrust and fear in the family
Betrayal by loved ones
Parental separation or divorce
Rejection by peers
Victimization by the excessive anger of others
Excessive time in day care
Same causes as in childhood
Poor body image
Rejection by peers
Difficulty in playing sports
Used as a sexual object
Parental separation or divorce
Behavioral Inhibition in children
The first clinically described conflict with anxiety in children is behavioral inhibition. Approximately 15 to 20% of children can be classified as behaviorally inhibited during early childhood. This temperamental style involves the tendency to show signs of fear, reticence, or wariness in response to unfamiliar situations and to withdraw from unfamiliar peers.
Approximately half of all children categorized as extremely behaviorally inhibited continue to show signs of wariness across childhood. Early reported behavioral inhibition was associated 3.79 times increased odds of lifetime separation anxiety disorder diagnosis, (Chronis-Tuscano, A., 2009).
Separation Anxiety Disorder
Separation anxiety disorder is common among children and teenagers. It is often seen in children who fear that the conflicts between their parents could result in separation or divorce. Symptoms of separation anxiety disorder are:
recurrent excessive distress when separation from home or a parent occurs
excessive worry about losing or harm befalling a parent
excessive worry that an untoward event will lead to separation from a parent
persistent reluctance or refusal to go to school or elsewhere because of fear of separation
fearful of being alone without a parent at home
persistent fears of going to sleep without a parent in the home
persistent nightmares involving the theme of separation
repeated complaints of physical symptoms.
Studies of co morbidity in SAD reveal depression in one third and other anxiety disorders in one half (Klein, 1989; Last, et al., 1987). Studies of depressed pre pubertal children and adolescents have found concurrent SAD in 30 to 60% of subjects (Biederman, et al., 1989; Ryan, et al, 1987).
Children often develop separation anxiety disorder after some major life stress or traumatic experience which can include: a mothers serious illness, prolonged separation from the mother, excessive fighting between parents, marital separation or divorce, a serious illness in the child, change in school, move to a new neighborhood, or the death of a sibling.
Children whose family histories are positive for depression, panic disorder, and alcoholism appear to be at increased risk. Clinically we find that ridicule and the experience of being a scapegoat by other children may lead to intense fears of betrayal outside the home and separation anxiety. Also, one study found that 83% of mothers of children with SAD had a lifetime diagnosis of anxiety disorder, 53% had a lifetime diagnosis of major depression, and 57% had a current anxiety disorder diagnosis (Last, et al., 1987)
While these youngsters are aware of their intense fears of separation from their mothers or fathers, most are unaware of the cause of their fears and they are not conscious of the anger they have toward those who have hurt or disappointed them. The identification of the origin of their fears and the resolution of the anger associated with the traumatic experience through forgiveness therapy facilitates the treatment of their separation anxiety symptoms. Therapists can relate to these youngsters how their fears are tied into anger from various hurts and will diminish if they can learn to resolve their anger.
This case study from Forgiveness Therapy demonstrates the value of forgiveness in resolving symptoms of separation anxiety disorder.
Marty developed separation anxiety symptoms at the beginning of second grade. He had great difficulty leaving his mother and begged her to ride on the school bus with him. When she did not join him, he would fly into a rage and 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 that could produce such intense fears. His parents, however, had been separated for a period of six months and his father had only recently moved back home. For two years Marty had witnessed such intense fighting between his parents that, at times, it subsided only with police intervention.
After several therapy sessions Marty was able to identify that he was angry with his parents and that he had strong fear of another separation. "Don't you love each other anymore?", he asked perceptively. His parents were no longer fighting, but they had great difficulty trusting each other and, subsequently, they were not particularly affectionate.
In family sessions, Marty's parents apologized to him for their behavior and insisted that they were motivated to improve their marital relationship. They specified, "You don't have to be afraid. We're not going to separate again because we love each other and were going to work this out ." Although these words comforted Marty, he did not trust them fully.
When it was explained to Marty that the resolution of his own anger would help his fears diminish, he decided to work on thinking of forgiving his par 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 Marty worked at forgiving his parents, he became aware that he had much more anger than he realized with each of them. 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, Marty experienced a much greater degree of comfort and sense of safety in going to school and found himself feeling much less angry with his parents.
At the same time, the therapist was seeing Marty's parents and attempting to strengthen the trust in their relationship and work on forgiveness between them. Consequently, the improvement in the marital relationship helped to diminish Marty's separation anxiety disorder symptoms in a significant way.
Separation anxiety disorder symptoms are found frequently in the children of divorce and marital separation. Children respond to absence of a parent in the home and the collapse of their parents marriage as a major traumatic emotional event. They regularly develop the catastrophic fear that they may then lose their mother.
In Catholic families when the absence the father is absent from the home, mothers have helped their children with their fears by reminding them that they have another loving father who is with them, St. Joseph, and by placing images of this saint in the bedrooms of the children. Fearful children are also helped by meditating during the day, "Lord, you are with me as a friend. Help me to feel safe and protected."
Children of Divorce and Anxiety/Mistrust
Conflicts with excessive anxiety and mistrust, anger and sadness in children from divorce families have been reported in many studies and books (The Unexpected Legacy of Divorce, Wallerstein, 1991; Between two worlds; The inner lives of children of divorce by E. Marquadt, 2006 and The effects of divorce on America, The Backgrounder, Executive Summary by P. Fagan and R. Recto, 2000, the Heritage Foundation) and are observed regularly by mental health professionals.
Children from divorced families can have great difficulty controlling their strong feelings of mistrust, anxiety, and anger, particularly toward a parent whom they viewed as being selfish. Such is regularly misdirected at the other parent, a sibling, peers, teachers or a stepparent. Often, they deny their anger, but this powerful emotion can emerge in times of stress. Stepparents can also 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 step-children 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 enormous 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.
It was particularly difficult for Rachel's stepson, Brad, to let go of his anger with his mothers physically abusive boyfriend. Brad viewed that this man as being emotionally sick 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 to let go of their resentment with their mother by forgiving her. They were helped in the process by trying to recall that much of their mothers behavior was the result of her illness of alcoholism. 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.
Some children from divorced families harbor rage and some have violent impulses against a parent. Often these young people are unable to use the word forgiveness because they sincerely believe that the parent, stepparent or parents 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.
Finally, in merged families a stepparent should have the freedom and the spousal support to correct the anxiety/ mistrust, anger or selfishness in a stepchild by encouraging growth in trust, forgiveness, generosity and other virtues.
Parental Actions to Build Trust and Confidence in Children
Parents can take a number of steps to try to protect their children from anxiety. First, they should work to master their own anxiety and fears by growing in trust so that they model calm behaviors for their children. Then, they should their best to assure that children can feel safe and protected in their homes and as much as possible in their friendships. This necessitates the parental mastery over anger because excessive anger in parents is a major source of anxiety in children. Also, they should also protect their children from excessive anger in siblings or peers.
Siblings should be taught to love and forgive one another for the numerous daily bumps in life. Since selfishness is a major cause of excessive anger in the home, siblings should be taught about its dangers to psychological and spiritual health and encouraged to grow in the virtues that diminish it. These include a commitment to be generous, kind, respectful and loving.
Children also should be taught that friends should also treat them with the same virtues.
The marital anger chapter can be helpful in the parental understanding and mastery of anger, www.maritalhealing.com/conflicts/angryspouse.php.
Other steps parents can take include:
avoid arguing in front of the children
correcting children with gentleness and not in anger
working to resolve marital conflicts peacefully
attempting to be a responsible parent and not a permissive or controlling parent
protecting the child as much as possible so that they can have trustworthy friendships
building the child's confidence in his/her God-given gifts
giving cheerfully to one's spouse as one's best friend
maintaining loyalty to one's spouse by focusing on his/her goodness
teaching children how to deal with controlling individuals.
The Role of Faith in Diminishing Anxiety
A number of studies have demonstrated the benefits of faith in addressing anxiety disorders in adults. They include the following:
In a survey of 37,000 men and women those who attend church, synagogue or other religious services, the higher the worship frequency, the lower the prevalence of depression, mania and panic disorder. Baetz, M., et al. (2006) How spiritual values and worship attendance relate to psychiatric disorders in the Canadian population. Can J Psychiatry 51:654-61. Researcher Marilyn Baetz, MD, of the University of Saskatchewan in Canada, stated, "The higher the worship frequency, the lower the odds of depression, panic disorders and mania."
The importance of religion was a predictor of improvement in panic disorder after one year. Over time, the improvement was seen for the religion was very important. Bowen, R, et al. (2006) Self-rated importance of religion predicts one year outcome of patients with panic disorder. Depress Anxiety 23:266-73.
In a systematic review of 850 studies the majority of well-conducted studies found that higher levels of religious involvement are positively associated with indicators of psychological well-being, life satisfaction, happiness, positive affect, and with less depression, suicidal thoughts and behavior, drug/alcohol abuse. (Moreira-Almeida, A., Neto, F., Koenig, H.G. (2006) Religiousness and mental health:a review.Rev Bras Psiquiatr.28:242-50.)
As stated in other sections of this web site, faith can play a beneficial role in the healing of emotional pain and conflicts. (See Healing and Faith at the National Library of Medicine web site, www.ncbi.nlm.nih.gov/pubmed/.) A number of spiritual interventions help in resolving anxiety and in building trust. These include employing daily modification of the first two steps of Alcoholics Anonymous and thinking, "I am powerless over my anxieties, mistrust, anger or my tendency to control and want to turn them over to God." Also, a daily meditation upon God as one's protector can decrease anxiety in youth.
In June 2008 Pope Benedict commented on the role of faith in addressing anxiety when he stated, " In the face of the ample and diversified panorama of human fears, the word of God is clear: He who 'fears' the Lord is 'not afraid.' The fear of God, which the Scriptures define as the 'beginning of true wisdom,' coincides with faith in God, with the sacred respect for his authority over life and the world. Being 'without the fear of God' is equivalent to putting ourselves in his place, feeling ourselves to be masters of good and evil, of life and death."
"But he who fears God feels interiorly the security of a child in the arms of his mother: He who fears God is calm even in the midst of storms, because God, as Jesus has revealed to us, is a Father who is full of mercy and goodness. He who loves God is not afraid," 6/22/2008.
In families with strong faith, parents also report the benefit of praying with anxious children at bedtime on giving all their fears to the Lord. Also, they coach their children to make acts of trust in God with their fears each time they feel anxious or insecure.
In an important study of children and adolescents with generalized, separation and social anxiety disorders, treatment with Selective Serotonin Reuptake Inhibitors (SSRIs) was associated with more rapid and greater improvement compared with SNRIs (Strawn, R. 2018). Our clinical experience is consistent with this research.
Positive psychology or the role of virtues in the treatment of childhood disorders is a newer area in the mental health field. However, growth in virtues has been viewed historically in western civilization as being essential to the development of a healthy personality.
Youth with anxiety disorders need to be protected from the excessive anger that damages trust and unwaranted criticism or abuse that harms the development of confidence in one's gifts and abilities. Responsible parenting involves understanding the needs of children for close, comforting and secure attachment relationships with both the father and the mother, siblings and same sex peers in particular.
Youth need to learn how to recover from emotional hurts and to work to grow in trust with those who are, indeed, trustworthy. They also need to learn how to work on forgiving those who have damaged their confidence and their trust, so that they do not become emotional prisoners of their past.