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2 Journal of Anxiety Disorders 23 (2009) Contents lists available at ScienceDirect Journal of Anxiety Disorders Anxiety disorder symptoms in Japanese children and adolescents Shin-ichi Ishikawa a, *, Hiroshi Sato a, Satoko Sasagawa b a Faculty of Education and Culture, University of Miyazaki, 1-1 Gakuen-Kibanadai-Nishi, Miyazaki, , Japan b Faculty of Human Sciences, Mejiro University, Naka-Ochiai, Shinjuku-ku, Tokyo, , Japan ARTICLE INFO ABSTRACT Article history: Received 19 October 2007 Received in revised form 21 April 2008 Accepted 21 April 2008 Keywords: Spence Children s Anxiety Scale Anxiety Children Adolescents This study investigated anxiety symptoms in Japanese children and adolescents. Students 9 15 years old (N = 2275) completed the Spence Children s Anxiety Scale (SCAS). The internal consistency and test retest reliability of the SCAS were satisfactory. Scores for overall anxiety symptoms and each subscale were similar between Japan and other countries. Girls reported more anxiety symptoms than boys, and adolescents presented with fewer anxiety symptoms than younger children, as in previous studies. The items most frequently endorsed by Japanese students were different from those endorsed by Western students, although lower frequency symptoms were almost the same. Factor analyses using multi-group analysis supported a common model of anxiety for children and adolescents. Clinical applicability and research implications are discussed. ß 2008 Elsevier Ltd. All rights reserved. In the past decade, research interest in childhood and adolescent anxiety disorder symptoms has increased. Costello, Mustillo, Erkanli, Keeler, and Angold (2003) conducted a longitudinal community study of a 9 16-year-old multi-cohort sample. The 3-month prevalence of any anxiety disorder was 2.4% and the cumulative prevalence by age 16 was 9.9%. Anxiety disorder is one of the most common psychiatric disorders in children and adolescents (Albano, Chorpita, & Barlow, 2003). Most studies exploring anxiety in children have been conducted in Western countries with similar cultural values (Essau, Sakano, Ishikawa, & Sasagawa, 2004). Previous studies of adults with anxiety disorders have suggested that manifestations and patterns of anxiety disorders are different in different races and cultures (e.g. Horwath & Weissman, 1997; Ritsher, Struening, Hellman, & Guardino, 2002). Thus, there are some empirical questions as to quantitative and qualitative commonalities and differences in anxiety symptoms in children and adolescents cross-culturally. However, cross-cultural studies on children s anxiety symptoms have been relatively neglected (Essau & Petermann, 2001). In order to identify cultural influences on anxiety symptoms in children and adolescents, assessment data from different cultures that have confirmed reliability and validity are requires. The Spence Children s Anxiety Scale (SCAS; Spence, 1998) is a 38-item self-report questionnaire that assesses multiple symptoms of childhood anxiety disorders based on current diagnostic criteria. The subscales of the SCAS correspond with the diagnostic * Corresponding author. Tel.: ; fax: address: ishinn@cc.miyazaki-u.ac.jp (Shin-ichi Ishikawa). classification system of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV; American Psychiatric Association, 1994). Reliability and validity were confirmed in a survey involving 2052 Australian children aged 8 12 years (Spence, 1998). Researchers and clinicians can use the SCAS to assess overall anxiety levels as well as anxiety symptoms related to obsessive-compulsive disorder, separation anxiety disorder, social phobia, panic/agoraphobia, generalized anxiety/overanxious disorder, and fears of physical injury. The SCAS has been translated into various languages and used in several cultures. For example, Muris, Schmidt, and Merckelbach (2000) translated the SCAS into Dutch and conducted a survey with Dutch children and adolescents aged 7 19 years. Muris, Merckelbach, Ollendick, King, and Bogie (2002) administered the SCAS to 521 Belgian adolescents aged years. In Germany, Essau and colleagues used a German translation of the SCAS with children and demonstrated its psychometric properties (Essau, Muris, & Ederer, 2002). All these studies were conducted in Western societies. Muris, Schmidt, Engelbrecht, and Perold (2002) indicated that SCAS was applicable to South African youth in a research study of 591 children (mean age = 10.7). Thus, previous studies suggest that the SCAS can be used to assess anxiety disorder symptoms in different countries, including a few non-western and non-english speaking countries. It is important to examine whether the construct of DSM-IV childhood anxiety disorder symptoms is applicable to other societies (Muris, Schmidt, et al., 2002). The original factor structure of the SCAS has not always fit the data collected using the translated versions. Through exploratory and confirmatory factor analyses, the DSM-IV anxiety disorder symptoms model was /$ see front matter ß 2008 Elsevier Ltd. All rights reserved. doi: /j.janxdis

3 Shin-ichi Ishikawa et al. / Journal of Anxiety Disorders 23 (2009) validated with the original instrument (Spence, 1997, 1998). Confirmatory factor analysis comparing four models (i.e., singlefactor, six uncorrelated factors, six correlated factors, and six factors loading onto a single higher-order factor) suggested that the six-factor, hierarchical factor model fit better than the other models. However, Essau et al. (2004) found that a different fivefactor model best accounted for the data of 556 German children aged 8 12 years (CFI =.94, NFI =.89, NNFI =.89, RMSEA =.04). Data from South African youth in Muris, Schmidt, et al. (2002) showed a four-factor structure in a confirmatory factor analysis which was different from any other country. There have been only a few studies of anxiety symptoms in Asian children and adolescents (Essau et al., 2004). Moreover, investigations have failed to confirm a concordant factor structure between the original and translated versions (Ishikawa, Ota, & Sakano, 2001; Ishikawa, Sato, & Sakano, 2005) of the instruments. The Japanese model included five factors: separation anxiety disorder, panic (panic/generalized anxiety disorder), worry (generalized anxiety disorder/social phobia/separation anxiety disorder), specific phobia (fears of physical injury), obsessivecompulsive disorder, and one higher-order factor. Furthermore, there are no data on Asian adolescents, since previous studies have only targeted children below the age of 13. There is a particular need to examine social phobia and social anxiety disorder in Asian adolescents. Some studies have suggested that lifetime rates of social phobia in Asian samples are lower than those in North America (Horwath & Weissman, 1997). In addition, in Japan, there is a culture specific interpersonal phobic disorder known as taijin kyofusho, and several studies have discussed similarities and differences between social phobia and taijin kyofusho. Thus, we used a Japanese sample and confirmatory factor analysis to investigate the empirical question of whether social phobia should be included in the same anxiety factor model. We used the Japanese SCAS with both children and adolescents, and examined whether the original six factor higher-order model fit the data by using multi-group analysis. The purpose of this study is (1) to examine the psychometric properties of the SCAS in a large sample including children (9 12 years) and adolescents (13 15 years) as part of the process of developing a standardized data set for Japan, (2) to examine the factor structure of the SCAS in an Asian culture, and (3) to examine the internal consistency, test retest reliability, and concurrent validity of the Japanese version of the SCAS. 1. Methods 1.1. Participants The Japanese sample was selected from five public elementary schools and five public middle schools in the suburban area of Saitama, Ibaraki, and Miyazaki (residential area). Most participants (99% or more) attending the schools were Japanese and all of them could read/write Japanese. The remaining 1% consisted of Korean or Chinese students, or those who were of mixed descent. Since these students have resided extensively in Japan, no significant differences in cultural background emerged. Although the socioeconomic status of the participants varied, most were from middle-class families, and there were very few children with low socioeconomic status. The main aims and method of the present study were explained to the school principals, children, and their parents. School approval and informed consent were obtained before participation in the study. All participants (N = 2275) were aged 9 15 years; 1046 children (9 12 years) and 1182 adolescents (13 15 years) completed all items of the questionnaire (mean age = 12.01, S.D. = 1.81). The overall response rate was 98% Measures The Spence Children s Anxiety Scale (SCAS; Spence, 1998) 1 The SCAS is a 38-item measure of anxiety symptoms for children and adolescents. We translated the English version into Japanese. One bilingual translator who was a native English speaker translated the SCAS from English to Japanese, and another bilingual individual translated it back from Japanese to English (Ishikawa et al., 2001; Ishikawa et al., 2005). The original version of the SCAS has six factors: separation anxiety disorder, social phobia, obsessive-compulsive disorder, panic attack and agoraphobia, physical injury fear, and generalized anxiety disorder. Each item is rated on a 4-point scale in terms of its frequency from never = 0 to always = Depression Self-Rating Scale (DSRS; Birleson, 1981) The DSRS is an 18-item measure of depressive symptoms for children. Murata, Shimizu, Mori, and Oushima (1996) translated the English scale into Japanese. The DSRS has a single factor structure and each item is rated on a 3-point scale in terms of its frequency from never = 0 to always = Procedure Children were asked to complete the SCAS in their classroom after their regular class. In order to ensure that the same procedure was used throughout the study, the teachers were asked to read and follow the research guideline manual, which contained research objectives, instruction and collection procedures, and contact information. Instructions for the SCAS and DSRS were as follows: (1) this survey does not count for or against grades, (2) you should not imitate or consult with friends because there are no correct or wrong answers to this questionnaire, and (3) your teachers, parents, friends, or anyone else who knows you will never see your questionnaire, so please respond honestly. The same procedure was used in each school. After the study, feedback was given to the participating schools, explaining the general findings from the results. On this occasion, we informed the school principal of the students who scored well above the cutoff or responded to suicidal items. Mental health services were introduced as necessary Statistical analysis Confirmatory factor analysis is useful method to conduct whether the same model fit to another cultural sample (Ritsher et al., 2002). Thus, a structural equation modeling approach was used for the confirmatory factor analyses. In this study, multigroup analysis was adopted for confirmatory factor analyses, because the data set had two populations: children in elementary school and adolescents in middle school. Although previous studies suggested that a common factor structure for anxiety symptoms existed for both children and adolescents (Muris et al., 2000; Spence, 1997, 1998; Spence, Barrett, & Turner, 2003), the two groups were analyzed separately. Multigroup analysis was used in this study to examine whether the same factor structure fit data for both children and adolescents while retaining the two separate groups. For fit indices, the goodness of fit index (GFI), adjusted goodness of fit index (AGFI), root mean square residual (RMR), and the normed fit index (NFI) were calculated. 1 The SCAS has 44 items including 6 lie scale items. In this study, the six lie scale items were not used. Consequently, the item numbers in the tables do not correspond with the original version.

4 106 Shin-ichi Ishikawa et al. / Journal of Anxiety Disorders 23 (2009) Table 1 Mean and standard deviations by gender and age Children (boys = 520, girls = 525) Adolescents (boys = 604, girls = 576) F (d.f.) p M (S.D.) M (S.D.) Total score Boys (16.47) (12.06) Gender (1,2221).001 Girls (19.82) (16.68) Age (1,2221).001 Total (18.75) (15.38) Gender age 1.04 (1,2221).31 Separation anxiety disorder Boys 2.82 (3.16) 1.40 (1.86) Gender (1,2221).001 Girls 4.66 (4.12) 3.08 (2.93) Age (1,2221).001 Total 3.74 (3.78) 2.22 (2.58) Gender age 0.41 (1,2221).52 Social phobia Boys 3.07 (3.14) 3.09 (2.94) Gender (1,2221).001 Girls 5.36 (4.27) 5.11 (3.69) Age 0.53 (1,2221).47 Total 4.22 (3.92) 4.08 (3.47) Gender age 0.82 (1,2221).36 Obsessive-compulsive disorder Boys 4.17 (3.45) 3.70 (3.01) Gender (1,2221).001 Girls 4.73 (3.50) 4.48 (3.40) Age 6.38 (1,2221).05 Total 4.45 (3.48) 4.08 (3.23) Gender age 0.62 (1,2221).43 Panic attack and agoraphobia Boys 2.61 (3.96) 1.83 (2.53) Gender (1,2221).001 Girls 4.07 (4.95) 3.74 (4.25) Age (1,2221).001 Total 3.34 (4.54) 2.76 (3.61) Gender age 1.74 (1,2221).19 Physical injury fear Boys 2.93 (2.93) 2.82 (2.68) Gender (1,2221).001 Girls 4.39 (3.21) 4.69 (3.09) Age 0.57 (1,2221).45 Total 3.66 (3.16) 3.73 (3.04) Gender age 2.71 (1,2221).10 Generalized anxiety disorder Boys 3.47 (3.54) 3.26 (3.16) Gender (1,2221).001 Girls 4.69 (3.90) 4.89 (3.73) Age 0.00 (1,2221).97 Total 4.08 (3.77) 4.07 (3.55) Gender age 6.96 (1,2221) Results 2.1. Psychometric characteristics of the SCAS in Japan The mean score on the SCAS was (S.D. = 18.75) for children, and (S.D. = 15.38) for adolescents. A MANOVA on the total scores and subscales was conducted to examine gender and age differences; Wilks s lambda was significant (lambda =.99, F(6,2216) = 4.47, p <.001). The means and standard deviations for the total scores and subscales of the SCAS are shown in Table 1. Results of the ANOVA indicated that gender differences were significant for the total score and all subscales. Girls reported higher anxiety scores than boys (SCAS total scores; girls: M = 26.99, S.D. = 18.26; boys: M = 17.38, S.D. = 14.35). In addition, age effects were found for the total score, separation anxiety disorder, obsessive-compulsive disorder, panic attack, and agoraphobia suggesting that children showed more anxiety symptoms. A significant interaction was found for generalized anxiety disorder. Results of simple effects analyses indicated that girls had more anxiety symptoms than boys for both children and adolescent age groups (p <.001), and younger boys showed a significantly higher score than adolescents (p <.05), but there was no significant difference for girls. Table 2 shows the most frequently endorsed anxiety symptoms reported by Japanese children and adolescents. The item to which most children responded was an obsessive item. Two items representing specific phobias were also frequently observed in Japan. Least frequently reported by Japanese children and adolescents were items corresponding to panic attacks and agoraphobia and separation anxiety disorder. Results of correlation analyses are shown in Table 3. In general, correlation coefficients among subscales were relatively high Factor analysis Previous studies suggested that a common factor structure fit both children and adolescents (Spence, 1997; Spence et al., 2003). We conducted a multi-group confirmatory factor analysis using data of children in elementary schools and adolescents in middle school. First, based on the original model (Spence, 1997; Spence et al., 2003), a six-factor model with a single higher-order factor was examined (Model 1). Variances of each error variable and the coefficients from the first-order factors for each observed variable were assumed to be equivalent between the two populations of children and adolescents. The unweighted least squares method was utilized for parameter estimation. Estimation terminated appropriately and goodness of fit indices were satisfactory (GFI =.97, AGFI =.96, RMR =.045, and NFI =.95). Standardized path coefficients from the higher-order factor to each first-order factor (for children and adolescents, respectively) were.92 and.91 for separation anxiety disorder,.93 and.94 for social phobia,.89 and.85 for obsessive-compulsive disorder,.88 and.86 for panic attack and agoraphobia,.82 and.75 for physical injury fears, and 1.00 and.99 for generalized anxiety disorder. Table 4 depicts the factor loadings from the first-order factor to each item. Results of an explanatory factor analysis suggested a five-factor structure, similar to the model with 26 items in Essau et al. (2004; Model 2). The constraints for Model 2 were identical to those introduced in Model 1. When the five-factor model with one higher-order factor in Essau et al. (2004) was examined, the goodness of fit indices were GFI =.98, AGFI =.97, RMR =.039, and NFI =.96 indicating that this model had a better fit for the Japanese data. The overall factor loadings were higher than.40 in children and adolescents, except for two items (16 and 37). In addition, the standardized path coefficients from the higher-order factor to each

5 Shin-ichi Ishikawa et al. / Journal of Anxiety Disorders 23 (2009) Table 2 Most common anxiety symptoms in Japanese children and adolescents (rated as often or always ) Total % Children % Adolescents % 13. I have to keep checking that I have done things right (like the switch is off, or the door is locked) I am scared of insects or spiders I worry about things I worry what other people think of me I am scared of the dark I worry that something awful will happen to someone in my family I feel afraid that I will make a fool of myself in front of people I have to do some things in just the right way to stop bad things happening When I have a problem, my heart beats really fast I worry that something bad will happen to me I can t seem to get bad or silly thoughts or pictures out of my mind I am scared of being in high places or lifts (elevators) I suddenly become dizzy or faint when there is no reason for this I worry that I will do badly at my school work I would feel afraid of being on my own at home I feel afraid if I have to use public toilets or bathrooms I get bothered by bad or silly thoughts or pictures in my mind When I have a problem, I get a funny feeing in my stomach I worry about being away from my parents I am scared of dogs I feel afraid if I have to talk in front of my class I suddenly start to tremble or shake when there is no reason for this I feel afraid I have to do some things over and over again (like washing my hands, cleaning or putting things in a certain order) 33. I worry that I will suddenly get a scared feeling when there is nothing to be afraid of I am afraid of being in small closed places, like tunnels or small rooms I feel scared when I have to take a test I am scared of going to the doctors or dentists I feel scared if I have to sleep on my own When I have a problem, I feel shaky I suddenly feel as if I can t breathe when there is no reason for this I have trouble going to school in the mornings because I feel nervous or afraid My heart suddenly starts to beat too quickly for no reason I have to think special thoughts to stop bad things from happening (like numbers or words) All of a sudden I feel really scared for no reason at all I am afraid of being in crowded places (like shopping centers, the movies, buses, busy playgrounds) I would feel scared if I had to stay away from home overnight I feel scared if I have to travel in the car, or on a bus or a train factor ranged from.77 to.91 in children and.78 to.88 in adolescents Reliability and validity 2 Reliability and validity of the Japanese SCAS were examined using several methods (Table 5). First, to examine internal consistency of the scale, we calculated Cronbach s alphas for total score and the six subscales according to the original model with 38 2 The Japanese five-factor model also fit the data as well as the original six-factor structure. The reliability and validity of the factor structure based on the Japanese data, which had 26 items, were confirmed as well. Reliability coefficients were.91 and.88 for the total score,.85 and.78 for separation anxiety disorder,.85 and.78 for panic/agoraphobia,.80 and.76 for worry,.50 and.49 for specific phobia, and.48 and.45 for obsessive-compulsive disorder (children and adolescents, respectively). Since the number of items for some subscales was small, the alpha coefficients and overall alpha values were high enough.test retest reliability coefficients for the total score of 26 items were.75 in children and.80 in adolescents (p <.01). In addition, the coefficients were.75 and.80 for separation anxiety disorder,.72 and.80 for panic/agoraphobia,.70 and.79 for worry,.68 and.79 for specific phobia, and.46 and.83 for obsessive-compulsive disorder subscales in children and adolescents respectively (p <.01).The 26 item SCAS correlated positively with the DSRS scores (r =.42 for children and r =.47 for adolescents, ps <.01). Similarly, the correlations between each subscale of the SCAS and the DSRS were also significant (separation anxiety disorder: r =.27 for children and r =.25 for adolescents; panic/agoraphobia: r =.51 for children and r =.52 for adolescents; worry: r =.38 for children and r =.42 for adolescents; specific phobia: r =.18 for children and r =.28 for adolescents; and obsessive-compulsive disorder: r =.15 for children and r =.19 for adolescents, p <.05). items. Reliability coefficients were.94 and.92 for the total score (children and adolescents, respectively). In addition, alpha values of the six subscales were generally well above.70 and acceptable for both children and adolescents, except for the physical injury fear subscale. To examine test retest reliability of the Japanese SCAS, 308 children (mean age = 10.54, S.D. =.94, 149 boys, 159 girls) and 283 adolescents (mean age = 12.98, S.D. =.78, 144 boys, 139 girls) were reassessed 2 4 weeks later. Results show that the test retest reliability coefficients of the SCAS total score were.76 in children and.86 in adolescents. As Table 5 shows, most values were high enough and sufficient temporal stability was demonstrated. Previous studies found a high rate of comorbidity between anxiety and depression in children and adolescents (e.g., Kendall, Kortlander, Chansky, & Brady, 1992). Based on the original studies of the SCAS (Spence, 1998; Spence et al., 2003), moderate positive correlations were expected between anxiety and depression. We examined convergent validity by using a depression questionnaire, the Depression Self-Rating Scale (DSRS) Japanese version. Complete data for the SCAS and DSRS were available for 200 children (mean age = 10.48, S.D. =.90, 102 boys, 98 girls) and 221 adolescents (mean age = 13.54, S.D. =.98, 118 boys, 103 girls). Correlation analyses showed moderate correlations between the SCAS scores and DSRS scores (r =.47 in children and r =.51 in adolescents, p <.01). As indicated in Table 5, each subscale of SCAS was correlated positively with the DSRS score.

6 108 Shin-ichi Ishikawa et al. / Journal of Anxiety Disorders 23 (2009) Table 3 Correlations among subscales of SCAS Total score Entire sample Children Adolescents Separation anxiety disorder (SAD) Entire sample.82 Children.85 Adolescents.80 Total SAD SP OCD PAA PIJ GAD Social phobia (SP) Entire sample Children Adolescents Obsessive-compulsive disorder (OCD) Entire sample Children Adolescents Panic attack and agoraphobia (PAA) Entire sample Children Adolescents Physical injury fear (PIF) Entire sample Children Adolescents Generalized anxiety disorder (GAD) Entire sample Children Adolescents Note: All correlations were significant at p < Discussion The current study investigated DSM-IV anxiety symptoms in Japanese children and adolescents as assessed by the SCAS, and examined the anxiety symptoms model in children and adolescents. Internal consistency of the Japanese SCAS was mostly high, and moderate correlations were found between test and retest scores, replicating the original studies (Spence, 1998; Spence et al., 2003). Internal consistency for physical injury fear was relatively low, but at the same level as the original study (Spence, 1998). This subscale includes a variety of objects which can arouse children s fear, but items for other anxiety symptoms also refer to similar content. Thus, consistency of physical injury fear was lower than other subscales. To examine the convergent validity of the SCAS, correlation coefficients were calculated. Results showed weak to moderate correlations between depression and anxiety symptoms, except for physical injury fears, which also were consistent with previous research (Muris, Merckelbach, et al., 2002; Spence, 1998; Spence et al., 2003). Consequently, the present study confirmed that reliability and validity of the Japanese SCAS were satisfactory. Mean score on the SCAS of Japanese children was in this study. This score is similar to means for Japanese and German children in previous studies (22.44 and 22.86, respectively; Essau et al., 2004), much lower than for Australian children (31.28; Spence, 1998) and South African youth (e.g., 46.4, 45.1, and 43.4; Muris, Merckelbach, et al., 2002; Muris, Schmidt, et al., 2002), and slightly above the Dutch mean (20.51; Muris et al., 2000) and the Belgian (16.9; Muris, Merckelbach, et al., 2002) score. The mean SCAS score of Japanese adolescents (20.91) was higher than Dutch adolescents (16.56; Muris et al., 2000) and at the same level as Australian adolescents (21.72; Spence et al., 2003). This suggests that anxiety symptoms in Japanese children and adolescents were reported at a moderate level. Consistent with previous studies (Spence, 1998; Spence et al., 2003), the current study indicated that girls report more anxiety symptoms than boys, adolescents have lower SCAS total scores, and less reported symptoms of separation anxiety disorder, obsessive-compulsive disorder, panic attack and agoraphobia. No significant age differences in physical injury fear and generalized anxiety disorder were found. Therefore, the overall anxiety symptoms level and gender/age differences in Japanese children and adolescents seem similar to those in Western countries. Item analysis showed that anxiety symptoms that most Japanese students reported were different from those of Western students. In both Japan and Germany separation anxiety disorder items were commonly endorsed (I worry that something awful will happen to someone in my family). However, the most frequently endorsed item in Japanese children was that of obsessivecompulsive disorder (I have to keep checking that I have done things right, like the switch is off, or the door is locked); this item was not ranked within the top ten for German children (Essau et al., 2004). This item was also the most commonly endorsed item among adolescents in Japan, which was not found with Australian adolescents (Spence et al., 2003). In Japanese children and adolescents, another item representing obsessive-compulsive symptom (I have to do some things in just the right way to stop bad things from happening), which was rare in other countries, was also endorsed frequently. Thus, more Japanese children and adolescents responded often or always to inquiries about obsessions. It is possible that this response tendency is influenced by the Japanese instructional style in school. In Western cultures, expectations of parents and teachers of young people may change

7 Shin-ichi Ishikawa et al. / Journal of Anxiety Disorders 23 (2009) Table 4 Results of confirmatory factor analysis using multi-group analysis in Japanese children and adolescents Factor loading F1 F2 F3 F4 F5 F6 Separation anxiety disorder 5. I would feel afraid of being on my own at home I worry about being away from my parents I worry that something awful will happen to someone in my family I feel scared if I have to sleep on my own I have trouble going to school in the mornings because I feel nervous or afraid I would feel scared if I had to stay away from home overnight Social phobia 6. I feel scared when I have to take a test I feel afraid if I have to use public toilets or bathrooms I feel afraid that I will make a fool of myself in front of people I worry that I will do badly at my school work I worry what other people think of me I feel afraid if I have to talk in front of my class Obsessive-compulsive disorder 13. I have to keep checking that I have done things right (like the switch is off, or the door is locked) 17. I can t seem to get bad or silly thoughts or pictures out of my mind I have to think special thoughts to stop bad things from happening (like numbers or words) 35. I have to do some things over and over again (like washing my hands, cleaning or putting things in a certain order) 36. I get bothered by bad or silly thoughts or pictures in my mind I have to do some things in just the right way to stop bad things happening Panic attack and agoraphobia 12. I suddenly feel as if I can t breathe when there is no reason for this I suddenly start to tremble or shake when there is no reason for this I feel scared if I have to travel in the car, or on a bus or a train I am afraid of being in crowded places (like shopping centers, the movies buses, busy playgrounds) 28. All of a sudden I feel really scared for no reason at all I suddenly become dizzy or faint when there is no reason for this My heart suddenly starts to beat too quickly for no reason I worry that I will suddenly get a scared feeling when there is nothing to be afraid of 34. I am afraid of being in small closed places, like tunnels or small Physical injury fears 2. I am scared of the dark I am scared of dogs I am scared of going to the doctors or dentists I am scared of being in high places or lifts (elevators) I am scared of insects or spiders Generalized anxiety disorder 1. I worry about things When I have a problem, I get a funny feeling in my stomach I feel afraid When I have a problem, my heart beats really fast I worry that something bad will happen to me When I have a problem, I feel shaky Note: The factor to which each item loaded on originally is indicated in parentheses. Factor loadings for adolescents are printed in boldface type. from heteronomy to autonomy, as they grow older. On the contrary, in the Japanese instructional system, teachers expect disciplines from students until early adolescence: school uniforms are adopted, well-disciplined club activities take place, and school rules become more rigorous and more detailed from most public middle schools. Likewise, instructions of ascertainment (e.g. Check if the door is closed or Turn off the light if you turn it on ) are commonly given in Japanese elementary and middle schools. Thus, students who check themselves may be regarded as well-behaved. However, a student who obeys and responds positively to these rules cannot necessary be considered to have clinical symptoms of obsessions. Of course, excessive ascertainment and checking can cause disturbances in daily life, and students who suffer from serious obsessions and compulsions are at risk for the onset of obsessive-compulsive disorders. Thus, it is important to know the extent to which obsessions contribute to maladjustment through referring to standard or other methods of assessment. Item analyses also showed high response rates for spider or dark phobias in the Japanese children and adolescents, which were not found in other countries. These phobic symptoms are common in Japan, although the reason why is unclear (Essau et al., 2004). One extensive cross-cultural study found that the fear of spiders as well as other fear-evoking animals was most frequent in Japanese children compared to Hong Kong, Indian, Korean, Dutch, American, and English children (Davey et al., 1998). Also, a cross-cultural study of adults found that Japanese people reported the highest score on animal or bodily injury illness death phobias (Arrindell

8 110 Shin-ichi Ishikawa et al. / Journal of Anxiety Disorders 23 (2009) Table 5 Internal consistency, test retest reliability, and convergent validity of SCAS Alpha Test retest Correlation with DSRS Total score Children ***.47 *** Adolescents ***.51 *** Separation anxiety disorder Children ***.28 *** Adolescents ***.31 *** Social phobia Children ***.47 *** Adolescents ***.43 *** Obsessive-compulsive disorder Children ***.35 *** Adolescents ***.44 *** Panic attack and agoraphobia Children ***.50 *** Adolescents ***.43 *** Physical injury fear Children ***.17 * Adolescents ***.46 *** Generalized anxiety disorder Children ***.49 *** Adolescents ***.46 *** Note: DSRS: Depression Self-Rating Scale. * p <.05. *** p <.001. et al., 2004). Thus, these specific fears occur frequently in Japan irrespective of age. Although the reason cannot be identified based solely on these findings, multiple trajectories in the onset of anxiety disorders have been identified (Vasey & Dadds, 2001). Parental rearing practices and modeling can play a major role in transmitting anxiety from parents to children (e.g., Hudson & Rapee, 2004), Therefore, it is possible that children learn these specific phobias from their parents, and from other adults. Low-frequency symptoms (i.e., to travel in the car, to stay away from home overnight, or to be in crowded places) were similar in incidence in Japan compared to Western countries. Although the comparison can be made only with Australian adolescents, some cultural differences were found regarding high-frequency anxiety symptoms, while low-frequency items were consistent among Western and Eastern countries. Thus, high-frequency anxiety symptom may be relatively more affected by cultural and social differences, in spite of there being some rare anxiety symptoms that depend on common developmental differences. The six-correlated-factors structure, similar to the original factors of the English SCAS, was confirmed by multi-group analysis using childhood and adolescent data. The analysis also showed that the five-factor structure found by Essau et al. (2004) fit the current data. These are not surprising results, given that some studies using translated versions of SCAS had their own structure, even though these structures correspond to the original one (Essau et al., 2002; Essau et al., 2004; Muris, Schmidt, et al., 2002; Muris et al., 2000). Before clinical applications could be considered, it is important to replicate the factor structure obtained in this study in other societies, based on DSM defined anxiety symptoms. However, fit indices in this study were not identical to the original index. Therefore, accumulated findings of multiple studies must be analyzed before deciding whether results can be expanded to other non-western countries, and to non-english speakers; or if the findings are only applicable to Japanese data. The major difference of the Japanese factor structure is that the items representing social phobia did not comprise an independent factor. However, the social phobia items I worry what other people think of me and I feel afraid that I will make a fool of myself in front of people are ranked among the top ten endorsed items. Thus, incidence of social phobic symptoms reported by children in Japan may be similar to children in other countries, but many of the Japanese children reporting social phobic symptoms may also report other concurrent anxiety symptoms. However, the possibility that symptoms of social anxiety in Japanese people are different from Western countries cannot be ignored. Social anxiety items most frequently selected in the present study were those pertaining to concerns over negative evaluation from others. In contrast, the frequency of items pertaining to test or speech phobia was lower than in an Australian sample (Spence et al., 2003). Whether a student feels anxious or not depends on the prospective standard of performance and the frequency of opportunities in the society. If standards of performance and the frequency of opportunities are different between Japanese and Western cultures, students in Japan may not feel as maladjusted as students in Western cultures, given equal levels of skills, or anxiety. If not too excessive, non-assertive, humble and inhibited behaviors are viewed as favorable in the Japanese culture. Such behaviors are likely to be left untreated until they become serious problems, or begin to co-occur with other problems. Thus, it was considered that the expression of social anxiety is affected by cultural and contextual influence to a great extent. There are some limitations in the present study. First, all students in this study are derived from a nonclinical sample, so whether these results can be generalized to clinical samples is unclear. Second, this study has a limitation in regard to the measurement of validity. Previous studies examined convergent validity using additional scales, such as the Revised Children s Manifest Anxiety Scale (RCMAS; Reynolds & Richmond, 1978) or the Fear Survey Schedule for Children-Revised (FSSC-R; Ollendick, 1983) as a standard measurement. However as there are no translated and validated versions of other anxiety scales in Japanese, we could not examine the SCAS s validity in the same way as previous studies. In addition, discriminant validity of the SCAS in Japan is still unclear. 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