The multifaceted consequences and economic costs of child anxiety problems: A systematic review and meta-analysis

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Video abstract from Mara Violato and Jack Pollard on their JCPP Advances Special Issue paper ‘The multifaceted consequences and economic costs of child anxiety problems: A systematic review and meta-analysis’.

The multifaceted consequences and economic costs of child anxiety problems: A systematic review and meta-analysis
Jack Pollard, Tessa Reardon, Chloe Williams, Cathy Creswell, Tamsin Ford, Alastair Gray, Nia Roberts, Paul Stallard, Obioha C. Ukoumunne, Mara Violato

First published: 21 April 2023

Open Access paper

Mara Violato

Mara Violato is an Associate Professor who joined HERC in September 2006. Mara graduated in Economics at Ca’ Foscari University of Venice (Italy) in 1998. She obtained her MSc in Economics from the University of Glasgow in 2000, her PhD in Economics from the University of Dundee in 2006, and her Doctorate in Economics from the University of Milano Bicocca (Italy) in 2007. Her research interests include (child) health inequalities, health econometrics, economic evaluations in various disease areas, economic aspects of perinatal and paediatric care, health care utilisation and costs, ethnicity and health, (child) mental health, respiratory health, coeliac disease and gastrointestinal infections.

Mara is currently working on a number of NIHR and MRC funded economic evaluations alongside randomised controlled trials in the area of treatments of child anxiety (OVERCOMING, MACH, T-CAP),  and ophthalmology (ECHoES). She is the PI of a Coeliac UK-funded projected aimed to further explore what it is like to live with coeliac disease in the United Kingdom, both before and after the condition has been diagnosed.  She also leads the health economics component of the NIHR Health Protection Research Unit in Gastrointestinal Infections, a 5-year interdisciplinary research programme in collaboration with the Universities of Liverpool and East Anglia and Public Health England to generate new strategies for control of diarrheal diseases. Prior to this appointment, Mara worked as research assistant and teaching fellow in economics at the University of Dundee. (image and bio via Oxford University)

Jack Pollard

Jack Pollard is a researcher at the Health Economics Research Centre (HERC). Jack’s current research involves a programme of work aimed at modelling the mental health outcomes and economic impact of elevated child anxiety, as part of a wider multidisciplinary NIHR-funded 5-year research programme – identifying Child Anxiety Through Schools (iCATS). Prior to his current position, Jack worked as a health economist and analyst at RAND Europe on a variety of projects. His research included investigating the impact of poor indoor climate on child health and examining the associated economic burden, as well as investigating the economic burden of physical inactivity. He also worked on the outcome and economic evaluation of the national Liaison and Diversion scheme, and the economic modelling of the future cancer workforce in England. Jack was awarded a studentship from the NIHR to study for an MSc in Economics and Health Economics at the University of Sheffield, where he graduated with distinction. His master’s dissertation examined the association between well-being and the existence of a partner who is problem drinker. He also holds an undergraduate degree in Economics from the University of Sheffield. (image and bio via Oxford University)

Other resources

  • Featured paper ‘Research Review: The multifaceted consequences and economic costs of child anxiety problems: A systematic review and meta-analysis’, (2023). Jack Pollard, Tessa Reardon, Chloe Williams, Cathy Creswell, Tamsin Ford, Alastair Gray, Nia Roberts, Paul Stallard, Obioha C. Ukoumunne, Mara Violato
  • Full list of papers published in the JCPP Advances 2023 Special Issue ‘Evidence-based Synthesis Studies for Child and Adolescent Mental Health Conditions’


[00:00:16.980] Mara Violato: Hi, my name is Mara Violato, and I am a Health Economist at the University of Oxford.  My colleague, Jack Pollard, and I, are going to talk about a systematic review and meta-analysis on the “Consequences of Child Anxiety Problems,” which we have recently completed and published.  This was a collaborative research with other colleagues at the University of Oxford and other UK universities, and it was funded by the UK National Institute for Health and Care Research.

To give you a bit of background, anxiety problems are very common.  For example, over a quarter of people experience an anxiety disorder at some time in their life, and very often, difficulties emerge during childhood and adolescence.  Despite being such a common mental health disorders, a gap still exist in the current evidence base of the multiple consequences of child anxiety problems and their costs.  For example, existing literature reviews have explored the relationship between child anxiety problems and specific outcomes, and they have focused mainly on consequences for the child.

We, instead, produce a holistic overview of the impact of child anxiety problems at the child, family, soci – and societal level and their associated costs.  And we do this because we believe that this approach is very important for informing multidisciplinary policies and intervention to tackle anxiety problems and their multifaceted consequences.  So, now Jack will explain the methods that we used and the results that we obtained.

[00:02:45.180] Jack Pollard: Thanks for the introduction, Mara.  I’m Jack Pollard, another Health Economist at the University of Oxford.  So, with respect to the methods, we searched four databases to identify longitudinal and economic studies reporting on the association between childhood anxiety problems and at least one individual family or societal level outcome or cost.  After the title abstract and full text screening and reviewing the reference lists of included studies, 83 papers were included in the narrative synthesis.

For longitudinal studies, effect direction was used as a common metric, where each association was categorised as an improvement, worsening or no clear change in the outcome of interest.  13 studies were included in 13 separate meta-analyses, which required two or more studies to have a similar exposure and outcome, as well as other similar study characteristics.

Of the 83 studies included in our systematic review, 71 were longitudinal studies, including 788 separate analyses that were extracted and grouped into 15 mutually exclusive outcome domains.  12 studies were economic based, six of which were costing studies, five trial-based economic evaluations and one burden of disease study.  41 studies were of strong quality and 31 were of moderate quality, with quality assessed using the Effective Public Health Practice Project quality assessment tool for quantitative studies.

In summary, anxiety problems were associated with worse outcomes in each of the 15 outcome domains.  However, the strength and quality of evidence varied.  Figure one shows the 15 outcome domains.  The colour shows the quality of evidence in a traffic light system, while the arrows show the strength of evidence.  The results of the meta-analysis, shown with the bold solid line, show that anxiety problems were associated with anxiety, mood, behaviour and substance use problems.  The unbolded solid line shows the results of the sign test, where we tested whether there were significantly more worse outcomes than improved outcomes in the domain of interest.  There were worse outcomes in anxiety, mood, substance use and physical health.

Finally, the dashed line shows evidence that exposure to anxiety problems in pre-teenage years was associated with worse outcomes in the narrative review, while the dash and dotted line shows evidence of worse outcomes associated with teenage anxiety problems.

With respect to economic costs, they varied among the costing studies.  Direct costs, such as healthcare costs, varied from £965 to £3,610 per year per child, with societal costs up to £4,040 annually per child, which were mostly made up of non-healthcare costs.

I’ll now pass you back to Mara to summarise our conclusions.

[00:05:45.270] Mara Violato: Thank you, Jack.  So, to conclude, our findings suggest that the child anxiety problems persist in later childhood, teenage years and early adulthood, and they are also associated with the various long-lasting adverse outcomes that cover several domains of everyday life.  Furthermore, our holistic overview of the consequences of child anxiety problems provide very important evidence that can be used for modelling the long-term clinical and economic outcomes of child anxiety problems.  And finally, the finding that child anxiety disorders are associated with substantial child, family and societal level economic costs also highlights the urgent need for cost effective, preventative and interventional policies to address this very common mental health disorder.

We’d like to thank our funder, the UK NIHR and to remind that the views expressed are ours and not those of the funders.  And finally, we hope that you find reading our article both useful and interesting.  So, thank you very much for listening to us.

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