The impact of anxiety disorders on educational achievement

Abstract

Anxiety disorders typically have an age of onset in childhood and adolescence, resulting in significant disability in social and occupational functioning. Epidemiological evidence suggests that persons with psychiatric disorders and perhaps especially social phobia are at increased risk for premature withdrawal from school [Am. J. Psychiatry 157 (2000) 1606]. In order to further determine the impact of anxiety disorders on school functioning and/or premature withdrawal from school, 201 patients meeting DSM-IV criteria for a primary anxiety disorder completed a school leaving questionnaire as well as self-report measures of anxiety, depression, and social adjustment.

About 49% (n=98) reported leaving school prematurely and 24% of those indicated that anxiety was the primary reason for this decision. Patients who had left school prematurely were significantly more likely to have a lifetime diagnosis of generalized social phobia, a past history of alcohol abuse/dependence and a greater number of lifetime diagnoses than those who completed their desired level of education.

This study suggests that anxiety disorders, and perhaps especially generalized social phobia, are associated with premature withdrawal from school. Further studies are required to determine methods for early identification and treatment of anxiety disorders in school aged children to enable these students to reach their full potential.

Introduction

Anxiety disorders are among the most common psychiatric disorders (Kessler et al., 1994). Anxiety disorders have high rates of comorbidity with other psychiatric disorders and result in significant disability and quality of life (Lesser et al., 1989; Massion, Warshaw, & Keller, 1993; Mogotsi, Kaminer, & Stein, 2000; Schneier, Johnson, Horning, Liebowitz, & Weissman, 1992).

Anxiety disorders typically onset in childhood and adolescence and run a chronic course well into adulthood (Albano, Chorpita, & Barlow, 1998). In the United States, prevalence studies of childhood and adolescent anxiety disorders in the general population have yielded overall rates of between 17 and 21% (Anderson, Williams, McGee, & Silva, 1987; Kashani & Orvaschel, 1988, Kashani & Orvaschel, 1990). In Canada, a 1994 survey revealed 1-year prevalence rates of anxiety disorders of 20% for females and 11% for males in youth 15–24 years of age (Offord et al., 1994). The peak age of onset for panic attacks is between 15 and 19 (Von Korff, Eaton, & Keyl, 1985). One-third of patients with obsessive–compulsive disorder (OCD) develop the disorder before the age of 15 and 50% report onset in childhood and adolescence (Rapoport, Swedo, & Leonard, 1992). The average age of onset for social phobia is in midadolescence but others have argued that the disorder has a much earlier onset (Ballenger et al., 1998). Over half of adult patients with generalized anxiety disorder report onset in childhood or adolescence (American Psychiatric Association, 1994). In our own anxiety disorders clinic, data from a recent sample of 559 patients revealed retrospective reports of age of onset of 10.30 (S.D.=5.63) years for social phobia (n=157), 25.63 (S.D.=9.89) years for panic disorder (n=295), and 14.35 years (S.D.=6.47) for OCD (n=107).

As for adults, anxiety disorders of childhood and adolescence have high rates of comorbidity with other psychiatric disorders including other anxiety disorders, depression, substance abuse/dependence, and attention-deficit hyperactivity disorder (ADHD, Albano et al., 1998, Anderson et al., 1987; Biederman, Newcorn, & Sprich, 1991; Kashani & Orvaschel, 1990; Mancini, Van Ameringen, Oakman, & Figueiredo, 1999; Massion et al., 1993; Strauss, Last, Hersen, & Kazdin, 1988; Strauss & Last, 1993). Research has consistently demonstrated the negative impact of childhood and adolescent anxiety on a broad range of psychosocial variables, including academic performance and social functioning (e.g., Davidson, Hughes, George, & Blazer, 1993; Kessler et al., 1994; Last, Perrin, Hersen, & Kazdin, 1992). In younger children, anxiety disorders are likely to result in chronic school refusal, resulting in significant social and academic difficulties (Berg, 1992, Last & Strauss, 1990). Older children and adolescents with anxiety disorders are at increased risk for underachieving in school and/or leaving school prematurely as compared to the general population (Kessler, Foster, Saunders, & Stang, 1995).

Students dropping out of school prematurely is a phenomenon with major social and economic implications (Kessler et al., 1995). In the United States over the past decade, 300,000–500,000 students per year leave high school without completing a high school program, and approximately 15% of young adults aged 18–24 years of age have not completed a high school program (National Center for Education Statistics, 1997). The Canadian statistics are quite similar. Gilbert, Barr, Clark, Blue, and Sunter (1993) have reported that approximately 18% of 20-year-old Canadians have not completed high school.

While there are many factors that determine whether or not a high school student will drop out, anxiety disorders may be an important determinant of dropping out of school and academic underachievement. Kessler et al. (1995) have reported that in the United States, persons with psychiatric disorders account for 14.2% of high school dropouts and 4.7% of college dropouts. According to Kessler et al. (1995) conduct disorders were the most important psychiatric determinant of dropping out for males, while anxiety disorders were the most important psychiatric determinant of dropping out for females.

Horowitz (1992) found that dropouts from vocational school, who tended to be “low achievers,” scored higher than “persistent” students on Anderson’s Alienation Scales of Meaninglessness, Misfeasance (or normalness) and Self-Estrangement. The only difference identified between dropouts and persistent students, who tended to be high achievers, was school-related anxiety as measured by the School Anxiety Scale developed by the author.

There is some evidence to suggest that people with social phobia are especially likely to drop out of high school prematurely. According to the DSM-IV (American Psychiatric Association, 1994), social phobia is defined as a “marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. The individual fears that he or she will act in a way that will be humiliating or embarrassing.” Situations typically avoided by social phobics include public speaking; speaking at meetings or in small groups; giving a presentation; meeting strangers; attending social gatherings; eating, writing or working in front of others; and, dealing with authority figures. Individuals who experience social anxiety in only one or a few social situations such as public speaking and giving presentations are described as having social phobia of the nongeneralized subtype, whereas, social phobia is described as generalized (GSP) if the fears include most social situations.

Estimates of the 1-year prevalence of social phobia range from 5–8%, making it one of the most common psychiatric disorders (Magee, Eaton, Wittchen, McGonagle, & Kessler, 1996; Offord et al., 1994; Wittchen, Nelson, & Lachner, 1996). The mean age of onset of social phobia is 15.5 years with peaks at the interval 0–5 years and at age 13 (Robins et al., 1984).

Communication apprehension has been described as an internal cognitive state generated by the fear of communicating with others (Monroe, Borzi, & Burrell, 1992). Monroe et al. (1992) studied communication apprehension in 1426 students over 4 years starting in the 9th grade using the Personal Report of Communication Apprehension Scale and found that students who are highly apprehensive regarding communication with others are more likely to terminate their high school education prior to graduation. In fact, Monroe et al. (1992) reported that 25% of students cited communication apprehension as the primary reason for dropping out of high school. In addition, Monroe and colleagues found that many other students avoid postsecondary education in order to eliminate their need to cope with associated communication demands. In summary, not only is communication apprehension an important determinant of high school drop out, it also an important determinant of whether or not those who graduate from high school will go on to postsecondary education. It is important to note that students with “communication apprehension” as described by Monroe et al. (1992), would likely at the very least, meet DSM-IV criteria for social phobia of the nongeneralized subtype.

According to data from the Durham site of Epidemiological Catchment Area Study survey, persons with social phobia reported poor employment performance, reduced social interaction, and more difficulties in school during adolescence as compared to other respondents (Davidson et al., 1993). In more recent study of the range and breadth of disability and quality of life associated with social phobia Stein and Kean (2000) analyzed data from the Mental Health Supplement to the Ontario Health Survey, which included a detailed assessment of disability associated with psychiatric disorders in the community. Stein and Kean (2000) calculated odds ratios and confidence intervals for a variety of disability measures for three groups including: (1) all persons with social phobia; (2) only nondepressed persons with social phobia; and (3) all persons with major depressive disorder. Stein and Kean (2000) argued that by including people with depression, a disorder that has been clearly demonstrated to have serious deleterious effects on health and quality of life (Hays, Wells, Sherbourne, Rogers, & Spritzer, 1995; Wells & Sherbourne, 1999) as the control group, they could best demonstrate relative “potency” of the effects of social phobia on quality of life.

Stein and Kean (2000) reported that after adjusting for demographic variables a lifetime diagnosis of social phobia was associated with a significantly greater likelihood of having failed a grade and that this association was significantly stronger among those with social phobia of the generalized subtype. After adjusting for demographic variables a lifetime diagnosis was also associated with a significantly greater likelihood of leaving school early, with no significant differences between people with social phobia of the generalized versus nongeneralized subtype. Interestingly, presence or absence of comorbid lifetime major depression did not have a significant impact on these outcomes.

In summary, children and adolescents with anxiety disorders, and perhaps especially those with social phobia, may be especially at risk for underachieving in school and dropping out. The current study was conducted in order to determine if data from a clinical sample of patients with anxiety disorders would support the epidemiological evidence. Patients in a large anxiety disorders clinic were asked to retrospectively report on their school experience. It was hypothesized that patients with anxiety disorders would have a higher high school drop out rate than the community rate (Canadian average) and that they would report that their anxiety had a major contribution in their decision to drop out of school. We also predicted that patients with anxiety disorders would tend to report a history of academic underachievement (leaving school prematurely) whether or not they finished high school. “Leaving school prematurely” was selected as a measure of academic underachievement because it has been our clinical experience that many patients with anxiety disorders who finish high school are either reluctant to enter college and university or begin but do not complete their intended program of study. Finally, it was hypothesized that people with social phobia are especially at risk.