Prevalence of generalized joint hypermobility in children with anxiety disorders
Open accessPublished version of a preprint
Abstract
Background: Concerning the high prevalence of anxiety disorders and joint hypermobility in children and the lack of related studies in this age group, we aimed to assess the association of hypermobility with anxiety disorders in children. Methods: In this case-control study, 93 children ages 8–15 years with anxiety disorders referring to the Child and Adolescent Psychiatry Clinic of Mofid Children’s Hospital, Tehran, Iran, during 2018, were enrolled. The control group consisted of 100 age and sex-matched children without anxiety disorders. Anxiety was evaluated using the Spence Children Anxiety Scale (SCAS). The diagnosis of generalized joint hypermobility was done based on Beighton and Shiari-Javadi criteria. Results: Based on Beighton’s diagnostic criteria 52.7% of the children in the case group and 16% of the children in the control group had generalized joint hypermobility. Moreover, based on Shiari-Javadi criteria, 49.5 and 13% of the children in the case and control groups had generalized joint hypermobility, respectively. Moreover, the internal correlation between the two criteria was 0.91 showing almost complete compatibility between the two ( P < 0.001). Age was a risk factor that could predict hypermobility in these children. Other variables such as sex, severity, and type of anxiety disorders, and ADHD, were not predictors of hypermobility syndrome. Conclusion: The prevalence of hypermobility was three times higher in children with anxiety disorders and only age was a predictor for the possibility to suffer from generalized joint hypermobility in these children.
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TL;DR
In this case-control study of children aged 8–15 in Tehran, generalized joint hypermobility was about three times more prevalent in children with anxiety disorders than in controls (52.7% vs 16% by Beighton criteria; 49.5% vs 13% by Shiari-Javadi criteria). Younger age predicted hypermobility, while sex, anxiety severity/type, and ADHD did not.
Key findings
- Based on Beighton criteria, 52.7% (49/93) of children with anxiety disorders had generalized joint hypermobility versus 16% (16/100) of controls; based on Shiari-Javadi criteria, 49.5% (46/93) versus 13% (13/100), both P < 0.001.
- The two diagnostic criteria showed almost complete compatibility: internal correlation 0.91 (95% CI 0.88–0.93, P < 0.001), Kappa = 0.834, and ROC area under curve 0.907.
- Younger age predicted hypermobility in children with anxiety disorders: Beighton OR = 0.75 (95% CI 0.59–0.95, P = 0.02); Shiari-Javadi OR = 0.72 (95% CI 0.56–0.92, P = 0.01).
- Sex, anxiety severity, anxiety type, and ADHD were not significant predictors of generalized joint hypermobility in this sample.
Methods
- Case-control study: 93 children ages 8–15 with anxiety disorders referred to the Child and Adolescent Psychiatry Clinic of Mofid Children’s Hospital, Tehran, Iran, during 2018, and 100 age- and sex-matched controls without anxiety disorders from emergency and surgery clinics without chronic or underlying diseases.
- Anxiety was assessed with the Spence Children Anxiety Scale (SCAS; Iranian validity Cronbach’s alpha 0.86); generalized joint hypermobility was diagnosed by a pediatric rheumatologist using Beighton and Shiari-Javadi criteria, with cut-off > 6 for both.
- Analysis used SPSS version 16 with chi-square and t-tests, ROC curve analysis comparing Shiari-Javadi with Beighton criteria, and binary logistic regression for risk factors including age, gender, anxiety severity, anxiety type, and ADHD; P < 0.05 was significant.
Limitations
- Stated in the paper: Beighton criteria are not specific for children and have pediatric limitations, including difficulty performing forward bending in young children, ignoring cervical/total spinal hypermobility, and underconsidering large joints such as shoulders and hips.
- Evident from the text: this is a single-center case-control study, so temporality and causality cannot be established; controls were drawn from emergency and surgery clinics, which may not be fully representative.
- Evident from the text: the authors state that environmental or genetic factors were not in the study aims, and ADHD was assessed alongside anxiety disorders rather than as the primary disorder, limiting comparison with ADHD-hypermobility studies.
Model-written summary. Check it against the paper before relying on it.
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Cites
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Claims the paper makes
2 of 6 cited sources checked · 0 supported · 0 flagged · accuracy not yet measured
- Findingown data
Based on Beighton's diagnostic criteria, 52.7% of children with anxiety disorders had generalized joint hypermobility.
“Based on Beighton’s diagnostic criteria 52.7% of the children in the case group and 16% of the children in the control group had generalized joint hypermobility.”
Quote in the paperSubstantial claim - Findingown data
Age was a risk factor that could predict generalized joint hypermobility in children with anxiety disorders.
“Age was a risk factor that could predict hypermobility in these children.”
- Also stated in: § Discussion · hedged
“Age could significantly predict hypermobility in children with anxiety disorders in our study (OR = 0.75 CI 95% = 0.59–0.95 based on Beighton’s criteria and OR = 0.72 CI 95% = 0.56–0.9 based on Shiari-Javadi’s criteria)”
Quote in the paperSubstantial claim - Also stated in: § Discussion · hedged
- Findingown data
ADHD was not a predictor of generalized joint hypermobility in children with anxiety disorders.
“Other variables such as sex, severity, and type of anxiety disorders, and ADHD, were not predictors of hypermobility syndrome.”
Quote in the paperNot a substantial claim - Findingown data
Based on Beighton's diagnostic criteria, 16% of children without anxiety disorders had generalized joint hypermobility.
“Based on Beighton’s diagnostic criteria 52.7% of the children in the case group and 16% of the children in the control group had generalized joint hypermobility.”
Quote in the paperSubstantial claim - Findingown data
Severity of anxiety disorders was not a predictor of generalized joint hypermobility in children with anxiety disorders.
“Other variables such as sex, severity, and type of anxiety disorders, and ADHD, were not predictors of hypermobility syndrome.”
Quote in the paperNot a substantial claim
- Findingown data
Based on Shiari-Javadi criteria, 49.5% of children with anxiety disorders had generalized joint hypermobility.
“Moreover, based on Shiari-Javadi criteria, 49.5 and 13% of the children in the case and control groups had generalized joint hypermobility, respectively.”
Quote in the paperSubstantial claim - Findingown data
Sex was not a predictor of generalized joint hypermobility in children with anxiety disorders.
“Other variables such as sex, severity, and type of anxiety disorders, and ADHD, were not predictors of hypermobility syndrome.”
- Also stated in: § Discussion · plain
“This is while based on regression analysis in our study sex was not a predicting factor for hypermobility in children with anxiety disorders.”
Quote in the paperNot a substantial claim - Also stated in: § Discussion · plain
- Findingown data
Type of anxiety disorder was not a predictor of generalized joint hypermobility in children with anxiety disorders.
“Other variables such as sex, severity, and type of anxiety disorders, and ADHD, were not predictors of hypermobility syndrome.”
Quote in the paperNot a substantial claim - Findingown data
The results using Shiari-Javadi criteria were similar to those using Beighton criteria for risk factors of generalized joint hypermobility in children with anxiety disorders.
“Repeating the evaluations using the Shiari-Javadi criteria yielded similar results to those of Beighton’s criteria (Table 4).”
Quote in the paperNot a substantial claim - Findingown data
Based on Shiari-Javadi criteria, 13% of children without anxiety disorders had generalized joint hypermobility.
“Moreover, based on Shiari-Javadi criteria, 49.5 and 13% of the children in the case and control groups had generalized joint hypermobility, respectively.”
Quote in the paperSubstantial claim - Findingown data
The internal correlation between the Beighton and Shiari-Javadi criteria was 0.91, indicating almost complete compatibility (95% CI 0.88-0.93, P < 0.001).
“Moreover, the internal correlation between the two criteria was 0.91 showing almost complete compatibility between the two (95%CI: 0.88–0.93, P < 0.001).”
Quote in the paperNot a substantial claim - Findingown data
The mean age of children with anxiety disorders and generalized joint hypermobility was significantly lower than those without hypermobility (9.69 vs 10.89 years by Beighton criteria; 9.55 vs 10.95 years by Shiari-Javadi criteria).
“Age evaluations in children with anxiety disorders showed that the mean age in children with generalized joint hypermobility was significantly lower than those without hypermobility (9.69 vs 10.89 years based on Beighton’s criteria and 9.55 vs 10.95 based on Shiari-Javadi’s criteria).”
Quote in the paperSubstantial claim - Findingown data
More than half of the children with anxiety disorders and hypermobility were boys.
“We found that more than half the children with anxiety disorders along with hypermobility were boys, which is inconsistent with other studies [26, 27].”
Quote in the paperNot a substantial claim - Interpretationown data
The prevalence of generalized joint hypermobility was three times higher in children with anxiety disorders than in children without anxiety disorders.
“The prevalence of hypermobility was three times higher in children with anxiety disorders and only age was a predictor for the possibility to suffer from generalized joint hypermobility in these children.”
- Also stated in: § Discussion · plain
“Moreover, we found a significant association between generalized joint hypermobility and anxiety disorders in children, so that this phenotype was three times more prevalent in children with anxiety disorders.”
Quote in the paperSubstantial claim - Also stated in: § Discussion · plain
- Study design and conductcitation
The validity of the Spence Children Anxiety Scale for the Iranian population has been previously confirmed with a Cronbach's alpha of 0.86.
“The validity of the scale for the Iranian population has been previously confirmed with a Cronbach’s alpha of 0.86 [17].”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [17] Beighton P, Solomon L, Soskolne CL. Articular mobility in an African population. Ann Rheum Dis. 1973;32:413–8. source
- Study design and conductown data
There was no statistically significant difference between the case and control groups concerning age and sex.
“There was no statistically significant difference between both groups concerning age and sex (Table 2).”
Quote in the paperNot a substantial claim - Interpretationown data
There is a significant association between generalized joint hypermobility and anxiety disorders in children.
“Moreover, we found a significant association between generalized joint hypermobility and anxiety disorders in children, so that this phenotype was three times more prevalent in children with anxiety disorders.”
Quote in the paperSubstantial claim
- Classified as probably not a substantial claim. 4
- May combine two claims. 6
- The quote only partly states this claim. 1
Classified as probably not a substantial claim. May combine two claims.
PremisecitationBeighton criteria are the standard criteria with acceptable inter-rater reliability in clinical practice.
“On the basis of the international consensus statement on the Beighton score 2017, Beighton criteria are the standard criteria with acceptable inter-rater reliability in clinical practice [18].”
Quote in the paperSubstantial claim1 of 1 sources checked- cites [18] Juul-Kristensen B, Schmedling K, Rombaut L, Lund H, Engelbert RHH.2017. Measurement properties of clinical assessment methods for classifying generalized joint hypermobility-A systematic review. Am J Med Genet C Semin Med Genet 175C:116–147. source
The review says the Beighton Score was the most frequently used assessment method (p. 2) and recommends it for clinical use in adults. But the Discussion (p. 10) describes inter-rater reliability evidence as limited positive to conflicting and says it *may* be acceptable, particularly with uniform testing procedures. The sentence presents that qualified finding as an unqualified standard and describes this systematic review as an international consensus statement. (LLM, conf=0.86)
Experimental — accuracy not yet measured
Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.
PremisecitationThe prevalence of mental disorders in children and adolescents that moderately interferes with their performance is around 20%, and anxiety disorder is the most prevalent (13%).
“The prevalence of mental disorders in children and adolescents that moderately interferes with their performance has been reported to be around 20%, among which anxiety disorder is the most prevalent (13%) [14].”
Quote in the paperNot a substantial claim1 of 1 sources checked- cites [14] Pitcher DA, Grahame RO. Mitral valve prolapse and joint hypermobility: evidence for a systemic connective tissue abnormality? Ann Rheum Dis. 1982;41(4):352–4. source
The Patients and methods section (p. 352) describes adults recruited from a cardiology clinic for a study of mitral valve prolapse. The Discussion addresses joint mobility and rheumatic complaints. Searches for mental disorders, children and adolescents, anxiety, and the stated prevalence figures found no passage addressing the claim. (LLM, conf=0.79)
Experimental — accuracy not yet measured
The quote only partly states this claim.
Findingown dataThe Shiari-Javadi criteria had high diagnostic performance compared with Beighton criteria (sensitivity 96.9%, specificity 84.6%, PPV 92.5%, NPV 93.2%, effectiveness 92.7%, AUC 0.907%).
“Sensitivity, specificity, positive and negative predictive values, effectiveness, and area under ROC curve were 96.9, 84.6, 92.5, 93.2, 92.7, and 0.907%, respectively.”
Quote in the paperNot a substantial claimMay combine two claims.
Findingown dataThe most prevalent anxiety disorders were generalized anxiety (61.4%), specific phobia (73.1%), and separation anxiety (67.7%).
“The most prevalent anxiety disorders were generalized anxiety (61.4%), specific phobia (73.1%), and separation anxiety (67.7%), respectively.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.
PremisereasoningBeighton criteria have limitations in the pediatric group, including difficulty performing the forward bending maneuver, ignoring cervical and total spinal column hypermobility, and not considering or underscoring large joints such as shoulders and hips.
“Furthermore, it has some limitations in pediatric group such as: a) performing the forward bending maneuver in young children is difficult and challenging, b) hypermobility of cervical and total spinal column has been ignored, while this is important in children with hypermobility, c) large joints such as shoulders and hips have not been considered or underscored.”
Quote in the paperNot a substantial claimMay combine two claims.
PremisecitationIn a systematic review of 35 studies on psychological manifestations of joint hypermobility, 17 articles showed a statistically significant association between anxiety disorders and joint hypermobility, while 4 did not.
“In a systematic review of 35 studies on the psychological manifestations of joint hypermobility, joint hypermobility syndrome, and Ehlers-Danlos syndrome, of which 21 assessed the association between anxiety disorder and joint hypermobility. Seventeen articles showed a statistically significant association between anxiety disorders and joint hypermobility, while 4 did not find such a relationship.”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [11] Tung JS, Eccles JA, Harrison NA, Critchley HD. Brain structure and joint hypermobility: relevance to clinical anxiety disorder. J Natl Stud Assoc Med Res. 2018;1(1):33.
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
Probably not a substantial claim: may not pass S3 (load-bearing).
PremisecitationHypermobility syndrome has been identified as a risk factor predicting anxiety disorders in adults over 60 years.
“Consistently, hypermobility syndrome has been identified as a risk factor predicting anxiety disorders in adults over 60 years [13].”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [13] Leonte KG, Puliafico A, Na P, Rynn MA. Pharmacotherapy for anxiety disorders in children and adolescents. Waltham, MA. (Accessed on March 21, 2018: UpToDate; 2018.
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
May combine two claims.
PremisecitationAll 21 studies assessing the association between anxiety disorders and joint hypermobility were done on the adult population, and no related study had been done on children.
“It should be stated that all these 21 studies were done on the adult population and to the best of our knowledge no related study has been so far done on children [11].”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [11] Tung JS, Eccles JA, Harrison NA, Critchley HD. Brain structure and joint hypermobility: relevance to clinical anxiety disorder. J Natl Stud Assoc Med Res. 2018;1(1):33.
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
The paper relies on this without support.
The control group of children visiting emergency and surgery clinics without chronic or underlying diseases is representative of children without anxiety disorders with respect to joint hypermobility.
“The control group consisted of 100 age and sex-matched children who visited in emergency and surgery clinics without any chronic or underlying diseases and without anxiety disorders.”
The paper relies on this without support.
The SCAS cutoff scores used to define anxiety disorders correctly identify children with anxiety disorders in this population.
“The criteria for confirming anxiety are as follows: total score of > 40 in boys and > 50 in girls aged 8–11 years, and total score of > 33 in boys and > 40 in girls aged 12–15 years.”
Claims other papers make about this one
Each is checked against this paper’s own text: does it say what the citing paper says it does?
In 93 children aged 8-15 years, with anxiety the prevalence of GJH (Beighton score ≥ 6) was three times higher than controls.
“In 93 children aged 8–15 years, with anxiety the prevalence of GJH (Beighton score ≥ 6) was three times higher than controls [54].”
From Pediatric joint hypermobility: a diagnostic framework and narrative review (2023) · cites this paper as [54]
The Methods report 93 children aged 8–15 with anxiety disorders. The Results report GJH in 52.7% of those children versus 16% of controls—about three times as prevalent. However, the Methods define hypermobility as a Beighton score higher than six, not ≥6. (LLM, conf=0.90)
Experimental — accuracy not yet measuredIn that cross-sectional case-control study, 16% of children in the comparison group had GJH.
“In contrast, 16% of children in the comparison group had GJH, and age was found to be a risk factor, whereas sex, severity and type of anxiety disorder and attention deficit hyperactivity disorder (ADHD) were not predictive of GJH.”
From Variant connective tissue (joint hypermobility) and its relevance to depression and anxiety in adolescents: a cohort-based case–control study (2022) · cites this paper as [29]
A recent cross-sectional case-control study compared 93 children aged 8 to 15 years with anxiety disorders with 100 age- and sex-matched children without anxiety disorders, and found that according to Beighton criteria, 52.7% of children with anxiety disorders had GJH.
“However, a recent cross-sectional case–control study compared 93 children between the ages of 8 and 15 years with anxiety disorders with 100 age-matched and sex-matched children without anxiety disorders, and found that according to Beighton criteria, 52.7% of children with anxiety disorders had GJH.29”
From Variant connective tissue (joint hypermobility) and its relevance to depression and anxiety in adolescents: a cohort-based case–control study (2022) · cites this paper as [29]
In that cross-sectional case-control study, sex, severity and type of anxiety disorder and ADHD were not predictive of GJH.
“In contrast, 16% of children in the comparison group had GJH, and age was found to be a risk factor, whereas sex, severity and type of anxiety disorder and attention deficit hyperactivity disorder (ADHD) were not predictive of GJH.”
From Variant connective tissue (joint hypermobility) and its relevance to depression and anxiety in adolescents: a cohort-based case–control study (2022) · cites this paper as [29]
In that cross-sectional case-control study, age was found to be a risk factor for GJH.
“In contrast, 16% of children in the comparison group had GJH, and age was found to be a risk factor, whereas sex, severity and type of anxiety disorder and attention deficit hyperactivity disorder (ADHD) were not predictive of GJH.”
From Variant connective tissue (joint hypermobility) and its relevance to depression and anxiety in adolescents: a cohort-based case–control study (2022) · cites this paper as [29]
There are varying levels of evidence for a link between joint hypermobility and ASD, DCD and anxiety disorders in child cohorts.
“Additionally, there are varying levels of evidence for a link with ASD, 20,22,23 DCD 24–28 and anxiety disorders. 29,30”
From No association between joint hypermobility, musculoskeletal pain and neurodevelopmental problems in a school-based sample of 11-year-old children (2025) · cites this paper as [23]
Self-check
Percentages, sums and reported differences re-computed from the paper’s own numbers.
Each contradiction between two passages listed here was confirmed by an independent check.
Reported diagnostic sensitivity exceeds what the case counts allow
MajorTable 2 gives 65 Beighton-positive children but only 59 Shiari-Javadi-positive children across both groups. With Beighton as the stated reference, sensitivity therefore cannot exceed 59/65, or 90.8%, yet the results report 96.9%.
“Sensitivity, specificity, positive and negative predictive values, effectiveness, and area under ROC curve were 96.9, 84.6, 92.5, 93.2, 92.7, and 0.907%, respectively.”
“| Beightona | 49 (52.7) | 16 (16) | < 0.001 | | Shiari-Javadia | 46 (49.5) | 13 (13) | < 0.001 |”
Generalized anxiety prevalence is misstated in the discussion
MinorThe results report 85 children with generalized anxiety among 93 cases, which is 91.4%, not 61.4%.
Reported 61.4 · recomputed 91.397849
“The most prevalent anxiety disorders were generalized anxiety (61.4%), specific phobia (73.1%), and separation anxiety (67.7%), respectively.”
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Pediatric joint hypermobility: a diagnostic framework and narrative review
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“In 93 children aged 8–15 years, with anxiety the prevalence of GJH (Beighton score ≥ 6) was three times higher than controls [54].”
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Blajwajs, L., Williams, J., Timmons, W., & Sproule, J. (2023) · Rheumatology International · doi:10.1007/s00296-023-05338-x · Cited by 35 · see citing works
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“Furthermore, an increased incidenceof other psychiatric disorders, including panic disorders [58, 69] and anxiety disorders [67, 68, 70] were found to be associatedwithG-HSD/hEDS.”
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What is the role of ultrasonography in the early diagnosis of scaphoid fractures?
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“29,30 In adults, anxiety disorders and ADHD have shown robust associations, with emerging evidence for ASD, mood disorders depression and eating disorders.”
Does it take the joints to stretch a mind? The ADHD and General Joint Hypermobility connection
Kacperczyk, J., Czyż, W., Wójcikiewicz, M., Arczewski, F., Dziedzic, K., Kulbacka, J., Wojszczyk, M., Zys, D., Pasek, P., & Ryniecka, J. (2025) · Quality in Sport · doi:10.12775/qs.2025.37.57296
- Authors
- Javadi Parvaneh, V., Modaress, S., Zahed, G., Rahmani, K., & Shiari, R.
- Affiliations
- Shahid Beheshti University (IR)
- Corresponding author
- Zahed, Ghazal
- Venue
- BMC Musculoskeletal Disorders
- Published
- 2020-06-02
- Volume
- 21
- Issue
- 1
- Pages
- 337-337
- ISSN
- 1471-2474 (ISSN-L)
- PMC
- PMC7265217
- OpenAlex
- W3031174253
- Semantic Scholar
- 791331d2d8bf9adc9cf150f0a26d7e1aeb04bf01
- Cited by
- 9
- References
- 34
- Citations by year
- 2025: 2 · 2023: 3 · 2022: 1 · 2021: 2 · 2020: 1
- FWCI
- 0.91
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Locations
- BMC Musculoskeletal Disorders (publishedVersion, cc-by)
- Research Square (acceptedVersion, cc-by)
- PubMed (publishedVersion)
- PubMed Central (submittedVersion, cc-by)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- Topics
- Life Sciences › Biochemistry, Genetics and Molecular Biology › Genetics › Connective tissue disorders research
- Social Sciences › Psychology › Clinical Psychology › Child and Adolescent Psychosocial and Emotional Development
- Health Sciences › Health Professions › Pharmacy › Oral and gingival health research
- Keywords
- generalized joint hypermobility, hypermobility syndrome, childhood anxiety disorders, prevalence, Beighton criteria, age as risk factor
- MeSH terms
- Adolescent, Anxiety Disorders, Child, Female, Humans, Iran, Joint Instability, Male, Risk Factors, Severity of Illness Index, Prevalence, Logistic Models, Case-Control Studies
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