The relationship between separation anxiety and impairment

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Abstract

The goal of this study was to characterize the contemporaneous and prognostic relationship between symptoms of separation anxiety disorder (SAD) and associated functional impairment. The sample comprised n = 2067 8–16-year-old twins from a community-based registry. Juvenile subjects and their parents completed a personal interview on two occasions, separated by an average follow-up period of 18 months, about the subject's current history of SAD and associated functional impairment. Results showed that SAD symptoms typically caused very little impairment but demonstrated significant continuity over time. Older youth had significantly more persistent symptoms than younger children. Prior symptom level independently predicted future symptom level and diagnostic symptom threshold, with and without impairment. Neither diagnostic threshold nor severity of impairment independently predicted outcomes after taking account of prior symptom levels. The results indicate that impairment may index current treatment need but symptom levels provide the best information about severity and prognosis.

Introduction

Clinically significant impairment or distress was added to the diagnostic criteria for many psychiatric disorders in the DSM-IV (American Psychiatric Association, 1994). This criterion was introduced to help “establish the threshold for the diagnosis of a disorder in those situations in which the symptomatic presentation by itself (particularly in its milder forms) is not inherently pathological and may be encountered in individuals for whom a diagnosis of “mental disorder” would be inappropriate” (American Psychiatric Association, 1994, p. 7 Use of the Manual).

Despite the widespread adoption of these criteria, especially the impairment criterion, rather little is known about the relationship between impairment and juvenile anxiety disorders in community settings. There is a substantial reduction in the estimated rate of individual or aggregate juvenile anxiety disorders when impairment is required for a diagnosis (Canino et al., 2004; Costello, Egger, & Angold, 2004; Essau, Conradt, & Peterman, 2000; Romano, Tremblay, Viaro, Zoccolillo, & Pagani, 2001; Simonoff et al., 1997), consistent with expectations (Wakefield & Spitzer, 2002). The utility of diagnostic thresholds for identifying impaired youth in need of services cannot, however, be inferred from these data. Youth with sub-threshold symptoms or NOS disorders may also be significantly impaired (Angold, Costello, Farmer, Burns, & Erkanli, 1999).

The severity of impairing childhood emotional disorder (anxiety or depression) was prognostic for adolescent disorder (Costello, Angold, & Keeler, 1999) but does not clarify whether impairment ratings capture prognostic information independent of symptom or syndrome severity or if there is any heterogeneity in the symptom-impairment relationship within the emotional disorders. Pickles et al. (2001) found that juvenile depression and oppositional-defiant disorder symptoms were highly impairing whereas conduct disorder symptoms were not. Impairment related to conduct and oppositional symptoms predicted future symptoms and impairment independent of symptom load but impairment related to depression did not. This led to the suggestion (Pickles et al., 2001) that impairment may be an epiphenomenon of depression symptoms. Do results for juvenile depression generalize to all juvenile emotional disorders or do anxiety disorders have a distinct symptom-impairment relationship?

The aim of this study was to characterize the relationship between a common juvenile anxiety disorder, separation anxiety disorder, and associated functional impairment in a large community based sample of youth aged between 8 and 16 years. We report the temporal and prognostic relationship between separation anxiety disorder symptom levels, diagnostic symptom threshold, and functional impairment, by age and sex.

Section snippets

Method

Subjects were participants in The Virginia Twin Study for Adolescent Behavioral Development (VTSABD) (Eaves et al., 1997, Hewitt et al., 1997, Simonoff et al., 1997), a longitudinal community-based family study of Caucasian twins born between 1974 and 1983. Twins were recruited through the public and private school systems in the state of Virginia and through state-wide publicity. From a target population of 1892 families, 1412 families (75%) agreed to participate in the study at time 1 (Meyer,

Contemporaneous relationship between separation anxiety and impairment

Nineteen percent (53/281) of children who met the (3+) diagnostic symptom threshold and 5% (13/248) of children with (2) sub-threshold symptoms had clinically significant impairment.

The distribution of subjects by the number of separation anxiety symptoms and associated impairment scores is given in Fig. 1. Data points are randomly perturbed to distinguish otherwise coincident points and subdivided into the four categories defined by the diagnostic symptom and impairment thresholds. The

Discussion

Symptoms of separation anxiety disorder were typically associated with relatively low levels of functional impairment but symptoms appeared to be more impairing among youth with higher symptom levels. There was little evidence that the diagnostic symptom threshold identified any critical point on the symptom scale with respect to expected impairment, consistent with findings for other, more impairing, juvenile psychiatric syndromes (Pickles et al., 2001). Using impairment as one of the criteria

Acknowledgments

This research was supported by grants MH-60324 (Debra Foley, PI) and MH-65322 (Michael Neale, PI) from the U.S. National Institute of Mental Health, Bethesda, MD.

The Virginia Twin Study for Adolescent Behavioral Development, now part of the Mid-Atlantic Twin Registry (MATR), ascertained subjects for this study and was supported by grant MH-45268 (Lindon Eaves, PI), the Carman Trust for Scientific Research, Richmond, VA (Judy Silberg, PI) and by a MacArthur Junior Faculty Award (Judy Silberg).

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