Research reportAnxiety disorders in adolescents and psychosocial outcomes at age 30
Introduction
Anxiety disorders are among the most common disorders affecting adolescents (Costello et al., 2005). Recent epidemiological studies estimated that the prevalence of anxiety disorders in adolescents ranges between 10% and 31.9% (Merikangas et al., 2010). The high frequency of anxiety disorders in adolescents means that these disorders tend to have an early onset. Some anxiety disorders (e.g., separation anxiety disorder, specific phobias) tend to have an onset in childhood, while others (e.g., social anxiety) tend to have an onset in adolescence (Beesdo et al., 2009). In addition to being prevalent, anxiety disorders co-occur highly among themselves and with numerous other psychiatric disorders (Essau, 2003, Essau et al., 2000, Feehan et al., 1993, Lewinsohn et al., 1997, Wittchen et al., 1998). The most common comorbid pattern was that of anxiety and depressive disorders (Essau et al., 2000, Lewinsohn et al., 1997), with comorbidity rates ranging from 50% to 72%. Among those with both disorders, up to 75% reported the first onset of anxiety before that of depression (Essau et al., 2000). Adolescents with anxiety and comorbid disorders tend to have more severe symptoms of their disorders (Essau, 2005), higher mental health utilization (Essau, 2005, Lewinsohn et al., 1995), and higher rates of suicidal behaviour (Rohde et al., 2001). Most anxiety disorders have an early onset, generally in childhood or early adolescence (Kessler et al., 1994, Mathew et al., 2011). Thus, the question of what happens to children and adolescents with an anxiety disorder after they become adults is of great concern.
According to several follow-up studies, anxiety disorders that begin early in life can become chronic (Feehan et al., 1993, Ferdinand and Verhulst, 1995, Keller et al., 1992, Letcher et al., 2012, Pine et al., 1998) and are associated with a high probability of recurrence (Bruce et al., 2005). The presence of anxiety disorders during adolescence also predicted a two- to- three-fold increased risk for anxiety in adulthood (Pine et al., 1998). Mathew et al. (2011) showed anxiety disorders in adolescence significantly predict the onset of MDD in adulthood. Adolescents who had more than three anxiety disorders had a rate of MDD 3.5 times higher and a rate of illicit drug dependence 4 times higher than peers without any anxiety disorders (Woodward and Fergusson, 2001).
Adolescents with anxiety disorders have been reported to show significant impairment in multiple domains of psychosocial functioning (e.g., educational underachievement; Woodward and Fergusson, 2001), as well as general health, physical and cognitive functioning in adulthood (Essau et al., 2000, Feehan et al., 1993, Ferdinand and Verhulst, 1995, Keller et al., 1992, Lewinsohn et al., 1998, Pine et al., 1998, Reinherz et al., 1993). However, the mechanisms through which anxiety disorders impact psychosocial outcomes are unknown. Recent studies have documented similarity in psychosocial impairments experienced by adolescents with anxiety, MDD, and SUD (Angold et al., 1999, Essau, 2003, 2008; Karlsson et al., 2006, Nottelmann and Jensen, 1999). Studies have also identified significant overlap in the risk factors for anxiety and MDD such as being female and stressful life events (Essau et al., 2000, Lewinsohn et al., 1995). Additionally, Mathew et al. (2011) found that poor interpersonal functioning in adolescents conferred risk for both anxiety and depression; these factors included loneliness, emotional reliance, and impaired relations with family and peers.
Due to the high comorbidity between anxiety, MDD and SUD, it remains unknown whether psychosocial impairments are specific to anxiety or to these comorbid disorders. The association between adolescent anxiety and psychosocial impairments in adulthood could be related to the fact that many adolescents with anxiety disorders experience another psychiatric disorder as adults (Keller et al., 1992, Pine et al., 1998). It is possible that having other disorders or recurrent anxiety disorder accounts for psychosocial impairments in adulthood (Keller et al., 1992). Furthermore, psychosocial impairment observed in adulthood could have been present in adolescence. As reported in several studies, adolescents with anxiety disorders are significantly impaired in various life domains, especially in social and academic performances (Essau, 2003). In this case, adult psychosocial impairments observed in anxious adolescents may reflect continuities in psychosocial, some of which may have preceded, and may even have contributed to, adolescent anxiety.
On the basis of this general background, the present study reports the result of a 16-year longitudinal study on the association between an early onset of anxiety (i.e., childhood and adolescent anxiety) and psychosocial functioning in adulthood. Because most anxiety disorders tend to have an onset either in childhood or during adolescence, the present study will categorize the age of onset of anxiety into childhood and adolescence. The more specific aims are to address the following questions: (a) What is the association between childhood and adolescent anxiety and psychosocial outcomes at age 30? The psychosocial outcomes that were explored included highest education level completed, recent unemployment, annual household income, poor physical health, and family and friends support – as these are the most common outcomes being identified in similar longitudinal studies (Mathew et al., 2011, Woodward and Fergusson, 2001). (b) What are the associations between childhood and adolescent anxiety and psychopathology after age 19? The types of psychopathology examined were anxiety, MDD, SUD, AUD. (c) Did other forms of psychopathology in adulthood mediate the relationship between childhood or adolescent anxiety and psychosocial outcome at age 30? (d) What are the associations between psychopathology after age 19 and psychosocial outcomes at age 30?
The hypotheses to be tested in this study were as follows: First, based on previous studies (Mathew et al., 2011), early onset anxiety (i.e., childhood or adolescent anxiety) is hypothesized to be associated with psychosocial impairment in academic, employment, health, and social/family domains. Specifically, individuals with a childhood-onset anxiety, compared to those with an adolescent-onset anxiety are hypothesized to have low education achievement, recent unemployment, low annual household income, poor physical health, and lack of family and friends support. Second, childhood and adolescent anxiety is associated with the presence of MDD, AUD, and SUD after age 19. Third, the presence of adult psychopathology is expected to mediate the relationship between childhood or adolescent anxiety and psychosocial outcomes at age 30. Finally, there will be a strong association between psychopathology after age 19 and psychosocial outcomes at age 30.
To our knowledge, this is the first study that has differentiated between anxiety disorders that begin early in life by their age of onset in childhood and in adolescence. This is surprising given differences among anxious children and adolescents in duration, severity, comorbidity patterns and correlates of anxiety disorders (Essau, 2005; Orgiles et al., 2012). Therefore, what is needed is a study that examines the association between childhood and adolescent anxiety and psychosocial functioning at adulthood. Another novel aspect of this research is to examine the extent to which other psychopathology in adulthood mediate the association between childhood and adolescent onset anxiety.
Section snippets
Participants
The present study used data from the Oregon Adolescent Depression Project (OADP) (Lewinsohn et al., 1993), a longitudinal study of a large cohort of high school students who were randomly selected from nine high schools in western Oregon as previously described (Rohde et al., 2007) (Fig. 1). A total of 1709 adolescents (ages 14–18; mean age 16.6, SD=1.2) completed the initial (T1) assessments. About a year later, all T1 participants were invited to participate in the second assessment. However,
Results
At T4, 207 participants (25.4% of the sample) met criteria for one or more lifetime anxiety disorders: 18 (8.7%) had a lifetime prevalence of at least one generalized anxiety disorder, 12 (5.8%) met criteria for a lifetime obsessive compulsive disorder, 44 (21.3%) for separation anxiety disorder, 38 (18.4%) for specific phobia, 36 (17.4%) for social phobia, 20 (9.7%) for panic disorder with agoraphobia, and 39 (18.8%) for panic disorder without agoraphobia. Of the 207 participants with a
Discussion
To our knowledge, the present study is the first to systematically (a) examine the associations between childhood and adolescent anxiety and psychosocial outcomes at age 30, and (b) address the extent to which psychopathology after age 19 mediated these relations. The results contribute to our understanding of the long-term psychosocial outcomes of childhood and adolescent anxiety in several ways. First, because of the large representative sample size, the problems associated with poor
Limitations
The study has some limitations which should be considered. First, although the OADP sample is representative of youth in Oregon, the extent to which our findings are generalizable to other populations is unknown. Second, as the OADP is a 16-year longitudinal study, changes in the diagnostic criteria and assessment approaches used are inevitable. Specifically, at T1 and T2, the K-SADS and DSM-III-R criteria were used, and at T3 and T4, the SCID and DSM-IV criteria were used. Third, there have
Conclusions
Adolescent anxiety is more important than childhood anxiety in predicting psychosocial outcomes and psychopathology at age 30 years. Adolescent anxiety affects deleterious outcomes in adults both directly and through others forms of psychopathology such as AUD, anxiety, and SUD. Thus, prevention and intervention efforts that target adult, AUD, SUD and anxiety may be useful for targeting the negative outcomes of adolescent anxiety. A challenge for future research is to develop a better
Role of funding source
This research was supported in part by National Institute of Mental Health awards MH40501 and MH50522 (Dr. Lewinsohn). The NIMH had no further role in study design; in collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the paper for publication.
Conflict of interest
The authors have no conflict of interest to report in relation to the research presented in this manuscript.
Acknowledgement
The authors are grateful to all those who participated in the study. Dr Olaya is grateful to the Sara Borrell postdoctoral program (reference CD12/00429) supported by the Instituto de Salud Carlos III, Spain.
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