Anxiety disorders are the most common mental health condition in children and adolescents. Prevalence estimates suggest that 6.5% of young people
1 worldwide meet diagnostic criteria for an anxiety disorder in comparison with 2.6% for depressive disorders, 3.4% for attention deficit hyperactivity disorder, and 5.7% for disruptive disorders (Polanczyk et al.,
2015). Pediatric anxiety disorders are associated with substantial economic burden, including both direct (e.g., treatment) and indirect (e.g., informal care) costs including adverse effects on the functioning of children (e.g., missed days of school), caregivers (e.g., time off work) and broader society (e.g., loss of productivity; Pollard et al.,
2023). Indeed, the costs to society of pediatric clinical anxiety have been estimated to be 21 times greater than having no disorder (Bodden et al.,
2008), with a recent meta-analysis suggesting that the total annual societal cost per anxious child is up to £4040 (2021 GPD) (Pollard et al.,
2023). In addition to their high prevalence and cost, anxiety disorders are associated with substantial impairment in young people’s day-to-day functioning and a poorer quality of life.
Impairment
Impairment refers to the degree to which a young person’s symptoms interfere with their ability to perform important aspects of their daily life (Rapee et al.,
2012). Anxiety symptoms can result in difficulties across multiple areas of child functioning including their family, academic, and social life. For example, anxiety symptoms may impact young people’s relationships with caregivers and siblings, the completion of family routines (e.g., bedtime), and activities (e.g., parties, holidays, visiting friends or relatives) (Langley et al.,
2014; Lyneham et al.,
2013). In school settings, anxious young people show poorer academic performance, greater absenteeism, and are less likely to enter higher education following their secondary schooling than their non-anxious counterparts (de Lijster et al.,
2018; Goodsell et al.,
2017; Lawrence et al.,
2015; Lee et al.,
2009). Anxiety disorders are also negatively associated with peer relationships, with anxious young people reporting fewer friendships, greater loneliness and victimization, and poorer social competence (de Lijster et al.,
2018). Impairment is a central feature of diagnostic criteria for most anxiety disorders and is one of the strongest drivers for seeking treatment (Becker et al.,
2011). Changes in levels of impairment are also an indicator of treatment progress and success (see Dickson et al.,
2022; Kreuze et al.,
2018 for reviews). Despite the critical role impairment plays in the diagnosis and treatment of anxiety disorders, it is a surprisingly under researched area in children and adolescents (Langley et al.,
2014).
In the extant literature, several measures of impairment have been developed for children and adolescents. These include both general functional impairment measures not specific to any disorder (e.g., Children's Global Assessment Scale (CGAS); Shaffer et al.,
1983) and disorder-specific scales designed to assess the particular impact of anxiety disorders (e.g., Child Anxiety Impact Scale (CAIS) and Child Anxiety life interference Scale (CALIS; Langley et al.,
2014; Lyneham et al.,
2013). A number of widely used structured and semi-structured diagnostic interviews, such as the Anxiety Disorders Interview Schedule (ADIS; Albano & Silverman,
2016), also measure the impairment to inform diagnostic decision making. However, these clinician-rated interviews typically combine the ratings of symptom presence, severity, and impairment. While independent ratings of impairment can potentially be disentangled, this information is rarely reported (Rapee et al.,
2012). Additionally, when impairment ratings from diagnostic interviews have been reported, they have shown relatively poor psychometric properties (Bird et al.,
2000). A range of multi-informant (e.g., clinician, children, and caregiver) impairment measures have been developed, including the CGAS (Shaffer et al.,
1983), which is clinician-administered, and the CALIS (Lyneham et al.,
2013), the CAIS (Langley et al.,
2014), and the Sheehan Disability Scale (SDS; Sheehan et al.,
1996) which offer both caregiver and child self-report versions. Consistent with informant discrepancies reported in the broader child anxiety literature, relatively modest agreement has been observed between young person and caregiver ratings of impairment, with clinician ratings often aligning most closely with caregivers (De Los Reyes et al.,
2011; Dickson et al.,
2022; Lyneham et al.,
2013).
Mixed findings have been documented between studies that have examined the correlation between impairment and demographic and psychological variables, including age, gender, ethnicity, socioeconomic status, type of anxiety diagnosis, and medication status. While some pediatric studies have found greater overall impairment and interference in academic and social functioning among older children (Langley et al.,
2014; Whiteside,
2009), other studies have found no age differences (Langley et al.,
2014; Lyneham et al.,
2013). Mixed gender effects have also been observed. For example, Lyneham et al. (
2013) found that female young people with anxiety reported greater impairment than their male counterparts. However, other studies have not found gender differences in impairment (Langley et al.,
2004,
2014; Whiteside,
2009). Mixed effects have also been documented for ethnicity. While some studies have not found differences in the levels of impairment based on ethnicity (Langley et al.,
2004), others (e.g., Langley et al.,
2014) have found that Hispanic children and adolescents with anxiety experienced greater overall and social impairment than other ethnic groups.
Quality of Life
Quality of life (QoL) is a multidimensional construct reflecting the positivity with which a young person views his/her life circumstances and state (Olatunji et al.,
2007). It extends beyond anxiety symptoms to include an overall sense of well-being and life satisfaction and encompasses physical, psychological, and social functioning. While it is commonly used interchangeably with the term impairment, these two constructs are conceptually distinct (Rapee et al.,
2012). A substantive body of research has investigated the relationship between anxiety and QoL in adults; however, to date, QoL in anxious young people has been largely neglected. The first and only meta-analysis to compare QoL in adults between anxious and non-clinical controls identified 23 studies (
N = 2892) and, as expected, yielded large effect sizes suggesting poorer QoL among anxious adults (Olatunji et al.,
2007). Not surprisingly, among the few studies conducted in young people, overall QoL has also been found to be inversely associated with anxiety in young people (Öztürk et al.,
2018; Raknes et al.,
2017). In cross-sectional studies, and in comparison with non-anxious children and adolescents, anxious young people have been found to report poorer QoL across multiple dimensions (e.g., physical well-being, psychological well-being, autonomy and parent child relations, social support and peers and school environment (Raknes et al.,
2017; Telman et al.,
2017). A systematic review and/or meta-analysis that synthesizes these disparate findings is needed.
Several child and caregiver QoL measures are available, which assess both global QoL and specific dimensions. These measures are designed to be used across a broad range of physical (e.g., cancer, diabetes, kidney disease) and mental health problems (e.g., Autism) such as the Pediatric Quality of Life Scale (PedsQL; Varni et al.,
2001) and the Pediatric Quality of Life Enjoyment and Satisfaction Questionnaire (PQ-LES-Q; Endicott et al.,
2006). The three dimensions, physical, psychological, and social functioning are commonly included in the majority of QOL measures in this field. Reflecting the healthcare shift toward considering young people’s priorities and preferences alongside their symptoms, recent mental health-specific QoL measures like the Self-Report Quality of Life—Child and Youth Mental Health Instrument (QoL-ChYMH; Celebre et al.,
2021; Stewart et al.,
2020) have been developed.
Only a small number of studies have explored the factors associated with QoL in anxious young people with mixed effects reported. One such study, conducted by Ramsawh and Chavira (
2016), found that greater comorbidity, anxiety severity, and specific type of anxiety symptomatology (e.g., physical and social anxiety symptoms) were correlated with poorer QoL, while age, gender, and ethnicity were not significantly associated with QoL. In contrast, Raknes et al. (
2017) found that older age, female sex, lower socioeconomic status, and negative life events were associated with poorer QoL. Given the growing volume of studies assessing QoL, and sociodemographic moderators of QoL, in anxious youth, a comprehensive review of this literature provides an opportunity to clarify these relationships.
While individual studies have documented that anxious young people experience significant impairment in their functioning at home with their family, at school, and with peers (de Lijster et al.,
2018; Goodsell et al.,
2017; Langley et al.,
2014; Lawrence et al.,
2015), no comprehensive synthesis has been conducted to aggregate these findings and quantify the overall extent of impairment associated with anxiety disorders in young people. Similarly, the degree to which anxiety disorders affect the QoL of young people in comparison with healthy peers remains unclear. A systematic review and quantitative analysis of these relationships is important to understand the impact of anxiety disorders on child and adolescent functioning and overall QoL. In addition, this synthesis of the literature may allow a more comprehensive analysis of potential sociodemographic moderators of impairment and QoL, including age, gender, reporter (e.g., child, caregiver or clinician), anxiety disorder subtype, comorbidity, and type of assessment measure used (e.g., global versus anxiety disorder-specific). Hence, the primary objective of this study was to conduct a systematic review and meta-analysis of impairment and QoL in young people with clinical anxiety disorders compared to unaffected healthy control groups.
Discussion
Over the past decade, the association between anxiety disorders and poor functioning and overall QoL among pediatric samples has received increasing attention. However, given the dearth of quantitative reviews in this field, we conducted the first systematic and meta-analytic review to synthesize the findings from this growing body of literature, and to determine the extent of impairment in functioning and QoL that young people with anxiety disorders experience relative to their healthy peers. A total of 12 studies met criteria for this review. A majority of studies (K = 9) focused on impairment as the outcome measure in which the results were available for both anxious and non-anxious pediatric samples (i.e., studies which included both anxious and control/comparison conditions), while only three studies were identified which met review criteria and assessed QoL.
Children and adolescents with anxiety disorders reported significantly greater impairment in functioning relative to non-anxious youth, with an overall large effect size (
g = 3.23), and with considerable heterogeneity between studies. Preliminary findings further revealed that although calculated effect sizes were large across each type of reporter, clinician reports evidenced the strongest effects (
g = 5.00) followed by caregiver (
g = 2.15) and child (
g = 1.58) reports. This outcome is compatible with the findings from the broader pediatric anxiety literature which has shown that clinician and caregiver reports tend to show larger discrimination between samples or across treatment relative to child reports (Reardon et al.,
2018; Spence,
2018). However, as noted, the effect sizes even for self-reports from the young person remained large in the current review, demonstrating that even anxious young people, themselves, perceive high levels of life impairment. Although the comparison between raters needs to be interpreted cautiously due to the small number of studies, it is interesting to note that the group differences reported by clinicians appear to be considerably larger than other reporters. Assuming that clinicians are often not blind to group membership, it is possible that they are affected by an a-priori assumption that anxious young people are heavily impacted by their anxiety. Overall, the quality of studies was found to be very good which provides further confidence in the current findings. These findings attest to the importance of targeting improvements in functioning in addition to a reduction in symptom severity in treatment interventions for children and adolescents with anxiety disorders (Dickson et al.,
2022; Rapee et al.,
2012; Wu et al.,
2016).
Given the large heterogeneity identified across studies, it is likely that these effects are underpinned by several moderators. Unfortunately, the small number of quantitative studies conducted to date meant that we were unable to evaluate the impacts of potential moderators. It is noteworthy that a majority of the studies (
K = 7 of the 9 studies) which reported impairment outcomes included samples with a range of anxiety disorders, while one study was based on a sample diagnosed specifically with generalized anxiety disorder (GAD; Alfano,
2012), and another study was based on a pediatric sample with social anxiety (Beidel et al.,
2007). Collectively, these findings indicate that child and adolescent samples experiencing a range of different anxiety disorders likely report significant impairments in functioning relative to non-anxious pediatric samples. However, at this stage, differences in impairment between specific anxiety disorders remain unclear. Impairment in functioning is probably common across all pediatric anxiety disorders, although this conclusion needs to await a larger research base.
Given the increasing importance of factors such as peer relationships, self-concept, and test results as young people move into later adolescence (Rapee et al.,
2019), it might be predicted that the impact of anxiety disorder would increase with age. Similarly, the fact that a greater proportion of boys than girls with anxiety disorders seem to be brought for treatment might indicate a larger perceived impairment associated with anxiety among males (Rapee et al.,
2023). Perhaps surprisingly at least some individual studies have failed to show differences in the impact of anxiety based on age (Langley et al.,
2014; Lyneham et al.,
2013) or sex (e.g., Langley et al.,
2014; Whiteside,
2009). Unfortunately, the number of studies in our review was insufficient to be able to analyze the influence of these moderators. Further, age ranges in most studies are relatively limited and few studies break down their means by age or sex. Considerably more research evaluating the relationship between pediatric anxiety disorders and life impairment is needed to address the influence of demographic moderators and this question may also be better addressed using different analyses such as individual participant data meta-analysis.
The current findings should also be interpreted in relation to the measures used to assess impairment. Most research which has assessed impairment in children and adolescents relied on administering general (i.e., not disorder-specific) and global measures such as the CGAS. Use of consistent measures across a field is valuable to allow between study and potentially between disorder comparisons. However, this consistency comes at the cost of specificity. Hence, critical information may be missed that could enhance anxiety treatment planning and evaluation of progress (Etkin et al.,
2023b). Broad overarching measures of functioning (such as CGAS) also risk missing the nuances of measures that break down functioning into specific domains. For example, anxiety may facilitate greater functional impairment within a school setting relative to home, whereas a disorder such as depression might involve more consistent impact across domains. Such profile differences might even extend to the level of specific types of anxiety disorders. However, this has yet to be empirically evaluated within the pediatric field. Future research should aim to implement consistent measures across studies that, nonetheless, encompass detailed assessment of functional impairment across a range of separate domains.
Interestingly, in the current review, no study was identified that measured both impairment in functioning and QoL. This may further reflect the nuanced approach researchers have adopted in this field. That is, whereas some scholars may be using more global scales of impairment, others may be relaying on multidimensional QoL scales to index functioning across specific domains (e.g., Öztürk et al.,
2018). To this end, in the current review, only three studies compared children and/or adolescents with anxiety disorders to healthy controls on QoL (Öztürk et al.,
2018; Raknes et al.,
2017; Telman et al.,
2017). The three studies evaluated QoL using different scales but converging on key dimensions including physical, emotional, social, and school. Across these dimensions, each study reported moderate to large effect size differences, indicative of poorer QoL in the group with anxiety (
d = 0.46 to 2.2). The single study offering both child self- and caregiver reports on QoL revealed a potential discrepancy, with children reporting somewhat larger effects than caregivers across every dimension and in the overall QoL (child
d = 1.59 vs parent
d = 1.38) (Öztürk et al.,
2018). Although only one study, it is interesting to note the difference of this pattern from reports on functional impairment, where caregivers show stronger discrimination between anxious and non-anxious groups. If this pattern was demonstrated in other studies, it might underscore an important difference in the two constructs and the role of caregivers in assessing them. While impairment involves disruptions in daily functioning that are often observable, allowing caregivers to serve as direct raters, QoL is definitionally internal and subjective (Olatunji et al.,
2007). When caregivers assess their child’s QoL, they do so only as ‘proxy raters’ (e.g., Telman et al.,
2017), thereby potentially relying more directly on their child’s descriptions (Öztürk et al.,
2018). On the other hand, functional impairment is generally assessed as a negative characteristic and may therefore maximize the tendency to “fake good” (De Los Reyes et al.,
2015; Kendall & Chansky,
1991; Schniering & Lyneham,
2007) from anxious young people.
This is the first review to synthesize the findings from studies that included outcome data on both functional impairment and QoL from young people with anxiety disorders and healthy control group comparisons. The quality of the included studies was strong, thus supporting confidence in the findings. The explicit focus on anxiety disorders in line with current diagnostic frameworks allows meaningful clinical conclusions to be drawn, but does mean that related conditions including PTSD and OCD had to be excluded.
We acknowledge several limitations associated with this review. The relatively small number of studies which include healthy comparison conditions in the anxiety pediatric literature attests to the shortcomings of this field. Almost twice as many studies (
K = 22) were excluded than included at the full-text phase of this review because no healthy control group data were included. There is a current inherent assumption that non-anxious (healthy) young people have uniformly better levels of functioning across multiple domains. Yet as aforementioned, there is a paucity of studies that have empirically compared anxious against non-anxious young people across multiple domains of functioning. There is a potential confound in the recruitment of healthy control groups in three studies, which specifically sought ‘confident’ or ‘friendly’ young people. Such criteria may not represent the normative range of the broader non-clinically anxious population, particularly in early teenage years, where self-conscious feelings and emotions are heightened (Rapee et al.,
2023; Westenberg et al.,
2007). The review was restricted to papers published in the English language in peer review journals. Hence, it is possible we may have missed some existing research. Finally, studies that included dimensional assessment of the relationship between anxiety severity and impairment and/or QoL within anxious samples were excluded due to the different conceptual focus of this research. Again, this limited the number of suitable studies.
Notwithstanding these limitations, the findings from this review accentuate the negative relationship between anxiety disorders and overall life functioning in pediatric populations. At a clinical level, it is often the impact on functioning that motivates people to seek treatment for anxiety, and reduced life impairment is often the primary outcome goal for families (Creswell et al.,
2021; Rapee et al.,
2023). Given this motivation from end-user stakeholders, it was slightly disappointing to note in our review how few studies address the relationship between impairment and QoL and anxiety disorders, relative to the vast literature exploring presenting symptomatology. The natural implications from this review and our related review on the impact of treatment on life impairment (Dickson et al.,
2022) are that mental health researchers need to begin routinely including measures of impairment and QoL into both basic research and clinical trials for pediatric anxiety. Particular advances are likely to come from not only self-reported impairment, but also the inclusion of objective measures (such as school attendance) and independent raters (such as teachers or sports coaches). Even greater value would come from longitudinal studies that evaluate the cascading impact of specific impairments on cognitive and social development. By extending the evidence base on the many and varied ways in which anxiety disorders can impact a child or adolescent’s life, treatment and prevention programs can begin to be more finely tailored.
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