An adult version of the Screen for Child Anxiety Related Emotional Disorders (SCARED-A)

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1 Netherlands Journal of Psychology / SCARED adult version 81 An adult version of the Screen for Child Anxiety Related Emotional Disorders (SCARED-A) Many questionnaires exist for measuring anxiety; however, most are developed for children or adults only, or do not capture symptoms of all anxiety disorders. The Screen for Child Anxiety Related Emotional Disorders (SCARED) is a well-validated questionnaire for children, measuring symptoms of most anxiety disorders, but has not been validated for adults. The aim of the current study was to investigate the applicability of the SCARED for adults (SCARED- A). Participants were 175 females and 152 males, who were all included in a study examining the relation between parental rearing and anxiety in children and parents. All participants filled in the SCARED-A and the STAI (State- Trait Anxiety Inventory), and the ADIS-IV-L (Anxiety Disorders Interview Schedule for DSM-IV Lifetime version) was administered. The internal consistency of the SCARED-A total scale was excellent, and acceptable-to-good internal consistencies were found for almost all subscales. The SCARED-A significantly correlated with the STAI and ADIS- VI-L, providing support for convergent validity. The SCARED-A was able to differentiate between participants with and without an anxiety disorder, and cut-offs for the total score were established. The SCARED-A may be a valuable instrument for future research to investigate intergenerational anxiety, and the course of anxiety development from childhood to adulthood. However, research is needed to replicate the findings in a more representative sample, to examine the test-retest reliability, and to establish cut-offs for the different subscales. Where: Netherlands Journal of Psychology, Volume 68, Received: 10 November 2013; Accepted: 10 February 2014 Keywords: Anxiety; Adult, SCARED; validity Authors: Francisca Johanna Arnoldina van Steensel and Susan Maria Bögels Research Institute of Child Development and Education, University of Amsterdam, Amsterdam, the Netherlands Correspondence to: Francisca van Steensel, Research Institute of Child Development and Education, University of Amsterdam, Nieuwe Prinsengracht 130, 1018 Amsterdam, the Netherlands f.j.a.vansteensel@uva.nl Anxiety disorders are among the most common psychopathologies in childhood and adulthood (e.g., Costello, Egger, & Angold, 2005; Kessler, Chiu, Demler, & Walters, 2005). Screening for anxiety disorders is frequently done with the help of questionnaires. Several questionnaires have been developed to assess anxiety symptoms in children and adults. One of the most frequently used questionnaires to measure anxiety in children is the Screen for Child Anxiety Related Emotional Disorders (SCARED). The original SCARED, consisting of 38 items captured in five subscales (somatic/panic, general anxiety, separation anxiety, social phobia and school phobia), was developed by Birhamer et al. (1997). Internal consistency, test-retest reliability, and discriminant validity were investigated and were found to be good in a sample of 341 children referred to a mood/anxiety disorders clinic. Muris, Merkelbach, Schmidt, and Mayer (1999) made a revised version of the SCARED, SCARED-R, by (1) integrating the items measuring school phobia with items measuring separation anxiety, (2) adding 15 items to measure specific phobia, (3) adding 13 items to capture symptoms of obsessivecompulsive disorder and traumatic stress disorder. The SCARED-R consisted of 66 items and aimed to measure symptoms of nine DSM-IV anxiety disorders: panic disorder, separation anxiety disorder (including school phobia), generalised anxiety disorder, social phobia, specific phobia (animal

2 Netherlands Journal of Psychology / SCARED adult version 82 phobia, situational-environmental phobia and bloodinjection-injury phobia), obsessive-compulsive disorder, and traumatic stress disorder (Muris et al., 1999). Evidence for internal consistency, convergent validity and discriminant validity of the SCARED-R was found in a sample consisting of children with anxiety disorders and child disruptive disorders (Muris & Steerneman, 2001). Bodden, Bögels, and Muris (2009) added another five items to the social phobia subscale of the SCARED-R leading to a SCARED version consisting of 71 items (SCARED-71). The authors focused on the diagnostic utility of the instrument by examining the internal consistency and discriminant validity, exploring gender and age effects, and by establishing cut-offs. Bögels and Van Melick (2004) adapted the SCARED-71 by reformulating the items into an adult perspective and used this new adult version (SCARED-A) in their study to examine the relation between parental rearing behaviours and anxiety. The internal consistency of the SCARED-A was found to be good (Bögels & Van Melick, 2004), but further psychometric properties or the (clinical) application of the SCARED-A were not investigated. The SCARED-A may be a useful questionnaire to measure anxiety symptoms in adulthood. An advantage of this questionnaire is that it captures symptoms of most DSM-IV-TR anxiety disorders. The DSM-IV-TR (APA, 2000) distinguishes a number of anxiety disorders (e.g., social anxiety disorder, generalised anxiety disorder, specific phobia) for which the symptom criteria are applicable to both children and adults. One exception is separation anxiety disorder which includes a criterion that the onset age is before 18 years (APA, 2000). However, separation anxiety is also commonly found in adults (Pini et al., 2010) and in the DSM-5 the age criterion is dropped allowing for a diagnosis of separation anxiety disorder in adulthood (APA, 2013). Because of the lack of distinction between child anxiety disorders and anxiety disorders in adulthood in the DSM-IV-TR (and DSM-5), it is very likely that the items of the SCARED-71 measuring symptoms of anxiety disorders in children will be transferable to adults. Moreover, a major advantage of having a similar questionnaire for child and adult anxiety symptoms is that it can help research into intergenerational overlap and transmission of anxiety, as the same anxiety subscales can be measured with the same number of items and the same rating scale in different generations. In addition, it may more precisely inform us if and how anxiety symptoms change during development and over time (e.g., from childhood into adolescence into adulthood). With these future directions in mind, it is first important to explore the internal consistency, convergent validity and (clinical) applicability (discriminant validity and cut-offs) of the SCARED-A, which was the aim of the current study. Method Participants Participants consisted of parents of clinically anxious children and parents of non-referred control children, recruited for a study on the relation between anxiety and parental rearing (Bögels, Bamelis, & Van der Bruggen, 2008). There were no inclusion or exclusion criteria for the parents; however, their children needed to be between 8-18 years and needed to have normal levels of cognitive functioning. The parents who completed the Anxiety Disorder Interview Schedule for DSM-IV: Lifetime Version (ADIS-IV-L), the SCARED-A, and the State-Trait Anxiety Inventory (STAI) were selected for the current study. The total sample consisted of 175 females (M age = 42.15; SD = 5.11) and 152 males (M age = 44.99; SD = 5.16). Level of education was measured on a scale from 1 (no education) to 9 Table 1. Presence of anxiety disorders for females and males, measured with the ADIS-IV-L Females (n = 175) Males (n = 152) N % n % Current anxiety disorder Social anxiety disorder Specific phobia Panic disorder Agoraphobia Generalised anxiety disorder Obsessive-compulsive disorder Post-traumatic stress disorder Life-time anxiety disorder

3 Netherlands Journal of Psychology / SCARED adult version 83 (university). The mean educational level was 5.34 (SD = 1.97) for females, and 5.81 (SD = 2.06) for males. Most participants (93%) were born in the Netherlands. Of the total sample, 50 females (28.6%) and 18 males (11.8%) were found to have a current anxiety disorder, as measured with the ADIS-IV-L (Table 1). Instruments The SCARED-A is an adapted version of the SCARED-71 (Bodden et al., 2009) and contains 71 items each rated on a three-point scale (0 = almost never; 1 = sometimes; 2 = often). The content of the SCARED-71 items stayed the same; however, items were reformulated based on an adult perspective (Bögels & Van Melick, 2004). The SCARED-A captures the same subscales as the SCARED-71: panic disorder (13 items), generalised anxiety disorder (9 items), social phobia (9 items), separation anxiety disorder (12 items), obsessivecompulsive disorder (9 items), post-traumatic stress disorder (4 items), (specific) phobia consisting of three types, namely animal phobia (3 items), bloodinjection-injury phobia (7 items), and situationalenvironmental phobia (5 items). Anxiety disorders were assessed with ADIS-IV-L (DiNardo, Brown, & Barlow, 1994) which is a structured interview that assesses DSM-IV disorders and has good psychometric properties (Brown, DiNardo, Lehman, & Campbell, 2001). Both current and life-time diagnoses were gathered from the interview. In the interview, symptoms of (anxiety) disorders are checked, and when criteria were met an impairment rating (on a scale 0-8) was given. A rating of 4 indicates a diagnosis. A total anxiety severity score for current anxiety diagnoses was calculated by summing the impairment ratings of all anxiety disorders. This severity score was used to explore the convergent validity of the SCARED-A. The inter-rater reliability of the interviewers in the current study was excellent: kappa =.94 for the diagnostic status ((Bögels et al., 2008). The STAI-trait version (Spielberger, 1985) was used in this study to explore the convergent validity of the SCARED-A. It contains twenty items each rated on a four-point scale (ranging from never to almost always). Overall, internal consistency and test-retest reliability of the STAI are found to be good (Barnes, Harp, & Jung, 2002). Cronbach s alpha of the STAI in this study was excellent:.92 for females and.93 for males. Procedure Medical-ethical approval and signed informed consent was obtained. Parents of the clinically anxious children were recruited from eight community health centres throughout the Netherlands to which their child was referred because of anxiety problems. Parents of the control children were recruited through advertisements. For further details, see Bögels et al. (2008). Results Internal consistency Cronbach s alpha of the SCARED-A was calculated for the total score as well as for the subscales (Table 2). Cronbach s alpha was excellent with respect to the SCARED-A total score (α >.90, Table 2). Cronbach s alpha for the subscales were acceptable ( ) to good ( ), except for bloodinjection injury phobia ( ) and situationalenvironmental phobia (.53), see Table 2. Convergent validity Correlations (Pearsons r) were calculated between the SCARED-A and the ADIS-IV-L current total anxiety severity score, and were found to be.58 (p <.001) for males and.49 (p <.001) for females. Table 2. Cronbach s alpha for the SCARED-A total score and subscales SCARED-A Total Females Males Clinical Non-clinical Total score Panic disorder Generalised anxiety disorder Social anxiety disorder Separation anxiety disorder Obsessive-compulsive disorder Post-traumatic stress disorder Specific phobia a. Animal phobia b. Blood-injection-injury phobia c. Situational-environmental phobia

4 Netherlands Journal of Psychology / SCARED adult version 84 In addition, the correlation between the SCARED-A and the STAI was.75 (p <.001) and.74 (p <.001) for males and females, respectively. The correlations between the SCARED-A total score and the SCARED-A subscales are displayed in Table 3. Correlations range from small to large (all p s <.01), indicating that the degree that the SCARED-A subscales are related to each other varies among subscales. For example, the three phobia subscales are less correlated to the other subscales (Table 3). Discriminant validity Multi-level analyses (controlling for dependencies among parents of the same family) were used to examine whether participants with an anxiety disorder differed from participants without an anxiety disorder. Results of the analyses are displayed in Table 4 and the means and standard deviations are displayed in Table 5. It was found that the SCARED-A total score, as well as each subscale, was able to discriminate participants with and without a current anxiety disorder, with parameter estimates (interpretable as Cohen s d) ranging between 0.45 and 1.19 (Table 4). Simultaneously, effects of Gender, Age and Education were examined. Results indicated that compared with males females had significantly higher levels of anxiety symptoms in general (SCARED-A total score) as well as higher scores on symptoms of generalised anxiety disorder, social anxiety disorder, and specific phobia (more specifically, females had higher scores for animal phobia and situationalenvironmental phobia), with estimates ranging between 0.25 and 0.49 (Table 4). Age was negatively related to symptoms of panic disorder (small effect) while it was positively related to symptoms of social Table 3. Correlations between the SCARED-A subscales a 7b 7c Total SCARED-A score Panic disorder Generalised anxiety disorder Social phobia Separation anxiety disorder Obsessive-compulsive disorder Post-traumatic stress disorder Specific phobia a. Animal phobia b. Blood-injection-injury phobia c. Situational-environmental phobia - All correlations were significant (p <.01) Table 4. Results of the multi-level analysis: effect of Group (yes/no anxiety disorder), Gender (females versus males), Age and Educational level on anxiety symptoms (measured by the SCARED-A total score and subscales) Group a Gender b Age Educational level Estimate c SE Estimate c SE Estimate c SE Estimate c SE SCARED-A total score 1.19*** ** Panic disorder 0.99*** * Generalised anxiety disorder 1.04*** * Social anxiety disorder 1.05*** * * Separation anxiety disorder 0.65*** Obsessive-compulsive disorder 0.89*** Post-traumatic stress disorder 0.58*** Specific phobia 0.92*** *** a. Animal phobia 0.45** ** b. Blood-injection-injury phobia 0.63*** c. Situational-environmental phobia 0.84*** *** * 0.05 * p <.05;** p <.01; *** p <.001; a = participants with a current anxiety disorder (= 1) versus participants without a current anxiety disorder (= 0); b = females (= 1) versus males (= 0); c = estimates interpretable as Cohen s d for dichotomous variables and as r for continuous variables

5 Netherlands Journal of Psychology / SCARED adult version 85 Table 5. Means (SD) for the SCARED-A total score and subscales SCARED-A Total Females Males Clinical Non-clinical Total score (range = 0-142) (16.68) (17.14) (14.88) (21.36) (12.27) 1. Panic disorder (0-26) 2.45 (3.22) 3.09 (3.39) 1.72 (2.84) 4.96 (4.43) 1.85 (2.53) 2. Generalised anxiety disorder (0-18) 4.35 (3.87) 5.05 (3.92) 3.54 (3.66) 7.57 (4.43) 3.53 (3.25) 3. Social anxiety disorder (0-18) 3.57 (3.64) 4.24 (3.75) 2.80 (3.36) 6.67 (4.65) 2.80 (2.88) 4. Separation anxiety disorder (0-24) 3.31 (3.19) 3.83 (3.85) 2.72 (2.90) 5.27 (4.39) 2.83 (2.56) 5. Obsessive-compulsive disorder (0-18) 3.05 (2.48) 3.36 (2.58) 2.70 (2.31) 4.70 (3.26) 2.62 (2.03) 6. Post-traumatic stress disorder (0-8) 0.77 (1.35) 0.95 (1.43) 0.58 (1.23) 1.42 (1.87) 0.60 (1.10) 7. Specific phobia ( 0-30) 4.33 (3.96) 5.36 (4.26) 3.14 (3.21) 7.62 (4.86) 3.52 (3.26) 7a. Animal phobia (0-6) 0.57 (1.31) 0.83 (1.56) 0.26 (0.86) 1.30 (1.86) 0.41 (1.10) 7b. Blood-injection-injury phobia 0-14) 1.94 (2.19) 2.13 (2.35) 1.71 (1.97) 3.03 (2.61) 1.67 (2.00) 7c. Situational-environmental phobia (0-10) 1.82 (1.82) 2.40 (1.86) 1.16 (1.54) 3.29 (2.06) 1.44 (1.51) Range is given between brackets anxiety disorder (small effect). Finally, educational level was negatively related to scores on situationalenvironmental phobia (small effect). Cut-offs The optimal sensitivity and specificity score of the SCARED-A for predicting a current anxiety disorder (as measured with the ADIS-IV-L) was established with ROC analyses. Analyses were conducted separately for males and females because previous analyses demonstrated a significant effect of Gender. For males, the optimal cut-off of the SCARED-A was found to be 20. Corresponding sensitivity and specificity rates were both.72 (i.e., 72% of the males with and without a current anxiety disorder were correctly classified as such, while 28% were identified as false negatives and false positives). For females, a cut-off of 30 was found to be indicative for clinical anxiety. The sensitivity rate was.66 and the specificity rate was found to be.78 (i.e., 66% of the females with a current anxiety disorder were correctly identified by their SCARED-A scores to have clinical anxiety, and 78% of the females without a current anxiety disorder were correctly identified by their SCARED-A scores to not have clinical anxiety). Because the sensitivity rate for females was relatively low, we examined the false negatives and false positives in more detail. Of the false negatives (n = 17, females who had a current anxiety disorder but who did not meet the SCARED-A cut-off) 10 (58.8%) had specific phobias only. Of the false positives (n = 28, females who did not have a current anxiety disorder but who did fulfil the SCARED-A cut-off) 17 (60.7%) had either had an anxiety disorder in the past (n = 14) and/or had a life-time (that is, current or past) mood disorder diagnosis (n = 8) based on the ADIS-IV-L. Females who had had an anxiety disorder in the past (but were not diagnosed with a current anxiety disorder, n = 39) were found to have higher SCARED-A scores compared with those who had never had an anxiety disorder (n = 86), F (1, 123) = 10.09; p =.002 (M = 26.31; SD = versus M = 18.93; SD = 10.52, d = 0.61). When excluding the females who had had an anxiety disorder in the past (n = 39) and excluding specific phobia as an anxiety disorder, a more optimal fit was found; using a cut-off of 21 for the SCARED-A (excluding the specific phobia items) resulted in sensitivity and specificity rates of.82 and.72, respectively. Discussion The results of this study suggest that the SCARED-A is a valid measure to assess anxiety symptoms of DSM-IV defined anxiety disorders in adults. Internal consistency of the SCARED-A total questionnaire was excellent, and acceptable-to-good internal consistencies were found for most subscales. However, for one subscale the internal consistency was not acceptable: the situational-environmental subscale. In line, the study by Bodden et al. (2009) and Muris & Steerneman (2001) also found a lower internal consistency for the latter scale and noted the variability between items (e.g., being afraid of thunder or darkness does not necessarily have to be related to being afraid of heights). Correlations between the SCARED-A and the ADIS-IV-L/STAI were found to be medium to large, indicating good convergent validity. In addition, the SCARED-A was found to discriminate between participants with and without anxiety disorders providing support for discriminant validity. Analyses further demonstrated that females reported higher anxiety levels compared with males. This finding is not surprising as it is generally known that anxiety disorders are more common in females than males, and anxiety symptoms differ in type and severity

6 Netherlands Journal of Psychology / SCARED adult version 86 between the two sexes (Bekker & Van Mens- Verhulst, 2007). Age was found to be negatively related to symptoms of panic disorder but positively related to symptoms of social anxiety disorder, suggesting that feelings of panic may decrease with age while social anxiety may increase with age. In addition, educational level was found to be negatively related to situational-environmental phobia, indicating that a higher educational level may be associated with less situationalenvironmental anxiety. However, results from studies that have examined the relation between anxiety and age in adults have been inconsistent (see review by Jorm, 2000), and little is known about the relation between anxiety and educational level. Moreover, the effect sizes for age and education found in this study were (very) small. Cut-offs were established for the SCARED-A total score, resulting in acceptable sensitivity and specificity rates for males (>.70 with cut-off = 20); however, for females, the sensitivity rate was slightly lower (.66 with cut-off = 30). It was found that the SCARED-A was less specific for those females who had had an anxiety disorder in the past and was less sensitive for specific phobias. With respect to the latter, it will be important to establish cut-offs for each SCARED-A subscale; i.e., individuals with a specific phobia may not meet the total cut-off-score, but may meet the cut-off for its subscale. Indeed, the fact that the SCARED captures symptoms of all anxiety disorders might prove to be a major advantage; however, more research is needed. For example, research is needed to investigate the predictive validity of the SCARED-A (subscales), the test-retest reliability, and it will be important to examine whether the instrument is sensitive to change (to determine its use in treatment studies). Another advantage of this instrument is that there is a validated child version (SCARED-71; Bodden et al., 2009); the combination of both versions may be particularly useful for research examining the associations between parents and offspring s anxiety and for studying anxiety over time. The present findings need to be interpreted in light of the study limitations. One obvious limitation is the selection of participants. That is, all participants were parents which limits generalisation to the total population of adult females/males. Further, the sample of males that were found to have an anxiety disorder was rather small (n = 18). In addition, the sample size of those with a particular anxiety disorder (panic disorder, obsessive-compulsive disorder, etc.) was too small to establish cut-offs for the SCARED-A subscales. To summarise, the results suggest that the SCARED-A may be a useful instrument for clinical research; however, additional research is needed to replicate the findings of the present study in a larger representative sample (i.e., not only including parents) and to establish cut-offs for the SCARED-A subscales. Author s note / acknowledgements Data were collected while the second author worked at Maastricht University, and were part of a larger study supported by ZonMW grant number 9450_20_52 and NWO-VIDI grant number 4520_53_45 which were assigned to the second author. References American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders 4 th edition text revision (DSM-IV- TR). Washington, DC: American Psychiatric Association. 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