A PSYCHOMETRIC ANALYSIS OF THE PARENT VERSION OF THE REVISED CHILD ANXIETY AND DEPRESSION SCALE IN A CLINICAL SAMPLE

Transcription

1 A PSYCHOMETRIC ANALYSIS OF THE PARENT VERSION OF THE REVISED CHILD ANXIETY AND DEPRESSION SCALE IN A CLINICAL SAMPLE A THESIS SUBMITfED TO THE GRADUATE DIVISION OF THE UNIVERSITY OF HAW AI'I IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS IN PSYCHOLOGY MAY 2008 By Chad K. Ebesutani Thesis Committee: Bruce F. Chorpita, Chairperson Jason Schiffman Charles Mueller

2 ii We certify that we have read this thesis and that, in our opinion, it is satisfactory in scope and quality as a thesis for the degree of Master of Arts in Psychology. THESIS COMMfITEE C on

3 ill Abstract The parent version of the Revised Child Anxiety and Depression Scale (ReADS-p) is a 47-item parent-report questionnaire of youth anxiety and depression, with scales corresponding to separation anxiety disorder (SAD), social phobia (SOC), generalized anxiety disorder (GAD), panic disorder (PD), obsessive compulsive disorder (OeD), and major depressive disorder (MDD). As the RCADS-P is currently the only parent-report questionnaire that concurrently assesses child and adolescent symptomatology of depression and specific anxiety disorders in accordance with the DSM-N diagnostic criteria, the present study examined the psychometric properties of the RCADS-P in a large (N=119), clinic-referred sample of children and adolescents. The RCADS-P demonstrated favorable psychometric properties in this sample, including high internal consistency, test-retest reliability, and adequate convergent and divergent validity with selected validity criteria.

4 iv TABLE OF CONTENTS Introduction: Assessment of Childhood Anxiety and Depression... 1 Youth Self Report Questionnaires... 2 Additional Informants....3 Parent Report... 4 DSM Oriented Questionnaires... 6 Limitations to Existing DSM-Oriented Questionnaires... 9 Concurrent Assessment of Depression and Anxiety Current Study Methods Participants Measures Procedures Results Data Integrity Missing Data Assumptions of Data Reliability... 20

5 v Scale Consistency Convergent Validity Parent -Child Agreement Divergent Validity Discussion References Tables Appendix... 60

6 vi LIST OF TABLES 1. Diagnostic Frequency Descriptive Statistics of Each Scale Normality of Each Scale Test-Retest Coefficients for the RCADS-P Scales Correlations of RCADS-P and CBCL DSM Subscales with Convergent Validity Criteria Correlations of RCADS-P with RCADS Subscales Correlations of RCADS-P with Divergent Validity Criteria Correlations of RCADS with Divergent Validity Criteria Correlations of RCADS-P with Externalizing Divergent Validity Criteria Correlations of RCADS-P Subscales and Divergent Validity Criterion Correlations of RCADS-P Subscales with Convergent and Divergent Validity Criterion, with Fisher's z-tests... 59

7 1 A Psychometric Analysis of the Parent Version of the Revised Child Anxiety and Depression Scale in a Clinical Sample Anxiety and depression are highly prevalent psychological disorders that encumber the lives of children and adolescents (Compas, 1997; Kashani & Orvaschel, 1990), afflicting the lives of up to 10 to 20% of children and adolescents at some point in their development (Costello & Angold, 1995). These disorders often lead to significant psychosocial impairment, as well as a range of moderate to severe disruptions in their childhood and/or adolescent development, including, though not limited to withdrawal, isolation, and suicidal ideation (Bernstein et al., 1996; Reinherz et al., 1993; Silverman & Ginsburg, 1998); thus, their accurate diagnostic assessment is an important issue in mental health. Accurate diagnostic identification can not only help youth and families better understand and account for the youths' symptomatology and related challenges but also help lead to the appropriate allocation of treatment and services often needed for children and adolescents to overcome their afflictions and improve their overall mental health. To acquire information regarding youth anxiety and depression related symptoms and experiences, mental health care providers often obtain infonnation directly from youths themselves. Assessment tools have therefore been created to gather infonnation from youths in a systematic way. One such method has been through the development and utilization of structured and semi-structured interviews, conducted with the youth by an administrator (e.g., clinician, psychiatrist). In these interviews, an administrator asks the youth in-depth sets of questions, designed to provide a thorough account of the youth's symptoms and experiences across a wide range of disorders and contexts. The

8 2 Children's Interview for Psychiatric Syndromes (ChIPS; Weller, B., Weller, A., Fristad, Rooney, & Schecter, 1999), the Diagnostic Interview Schedule for Children (DISC; Shaffer, Fisher, Dulcan, Davies, Piacentini, Schwab-Stone et ai., 1996), the Child Assessment Schedule (CAS; Hodges, 1982), and the Anxiety Interview Schedule for Children (ADIS; Silverman and Nelles, 1988) are among the structured and semistructured interviews commonly used to obtain youth reports of depression and anxietyrelated symptomatology. The Introduction o/youth Self-Report Anxiety and Depression Questionnaires Although both structured and semi-structured interviews have been demonstrated to be reliable, systematic and thorough assessment tools in the assessment of anxiety and other related disorders (Di Nardo, Moras, Barlow, Rapee, & Brown, 1993; Weller, Weller, Fristad, Rooney, & Schecter, 2000), these types of interviews have been criticized for being too labor and time intensive, and also often requiring trained interviewers to either administer, score or interpret results (Silverman, 1994). To that end, youth self-report questionnaires have also been developed, offering the field a relatively inexpensive, more time efficient way to obtain information from children and adolescents regarding their depression and anxiety related symptomatology. As self-report questionnaires have demonstrated remarkable clinical utility since their inception, they have become heavily utilized in the field of mental health (Schniering et ai., 2000). Among the well-validated and widely used anxiety and depression-related youth self-report questionnaires are the Revised Children's Manifest Anxiety Scale (RCMAS; Reynolds & Richmond, 1978), the Fear Survey Schedule for Children-Revised (FSSC-R; Ollendick, 1983), the Spielberger State-Trait Anxiety Inventory for Children (STAlC, Spielberger, 1973), the Children's

9 3 Depression Inventory (COl. Kovacs. 1980), the Youth Self-Report (YSR; Achenbach. 1991), and the Revised Child Anxiety and Depression Scale (RCADS; Chorpita, Yim, Moffitt, Umemoto & Francis, 2000). With the validity of these measures supported in psychometric investigations (e.g., Chorpita et ai., 2005; Ollendick, 1983; Reynolds & Paget, 1983; Saylor, Finch, Spirito, & Bennett, 1984), these measures are available to inform mental health providers about youths' problem areas (e.g., anxiety, depression), as well as lead to advancements in research related to youth anxiety and depression. The Utility of Additional Informants Despite the utility of anxiety and depression-related youth self-report questionnaires (La Greca,1990), the vast literature on psychological measurement highlights the vaiue of additional informants (Barbosa, Tannock, & Manassis, 2002), particularly given that the accuracy of children's reports may be limited in certain contexts. For example, Edelbrock, Costello, Dulcan, Kala and Conover (1985) posited that children below the age of 10 appear to not be fully cognizant of subtle feeling states such as worry, anxiety, and depression. Similarly, it has been shown that some children demonstrate difficulties recalling past events accurately and answering questions that require insight regarding cognitive states and processes, such as recalling, reflecting and commenting on internal feeling (Perez, Ascaso, Massons, & Chaparro, 1998). More recently, Schniering et ai. (2000) asserted that children appear to have difficulty conjuring and thus reporting on complex details such as the duration and onset of symptoms. Findings related to the inconsistency of youth reports have been demonstrated in other studies (Harris, 1993; Silverman & Eisen, 1992), suggesting the need for the inclusion of additional informants. Although additional informants relevant

10 4 to the assessment of child and adolescent depression and anxiety disorders may include teachers, athletic coaches, siblings, and group affiliates such as church members and ministers, parents (e.g., biological parents, foster parents, guardians) are co=only used and recommended as additional informants. The Role of Parent Report in Youth Mental Health Assessments Youths' parents may be able to provide information to aid in the assessment of their children's mental health for several reasons. Parents typically know their children well, interact with them often, engage in dialogue and have several opportunities with which to observe their children's behavior over an extended period of time. Empirical studies have also substantiated the clinical utility of parent reports in the assessment of youths' internal states related to anxiety. For example, Manassis et al. (1997) found that children with anxiety disorders who employed a distraction coping strategy often underreported their symptoms, while parents tended to provide more accurate accounts of their children's anxiety features. Similarly, research on separation anxiety disorder among children further substantiates the point at hand. Separation anxiety disorder is characterized by overt, observable behaviors such as clinging or crying when the youth is away from his/hercaregiver. These types of behaviors have been noted to be often readily reported by parents, though less so by children, who appear to be less cognizant or aware of these types of behaviors (Jenson et ai., 1999). Given poor concordance that has been found between parent and child reports on various anxiety measures (Engel, Rodrigue, & Geffken, 1994; Kenny & Faust, 1997), parent-child agreement has been studied systematically through examining crossinformant correlations. Within youth anxiety problems, low cross-informant correlations

11 5 coefficients have been found (DiBartolo, Albano, Barlow, & Heimberg, 1998; Frick, Silverthorn, & Evans, 1994; Klein, 1991). There findings were consistent with a previous meta-analytic investigation (Achenbach et al., 1987), revealing that the correlation between parent and child reports of children's behavioral-emotional problems averaged.22. Far below perfect agreement, these findings not only make apparent the divergent nature of youth and parent reports of youth symptomatology, but also the extent of the disagreement. Although some have interpreted these low correlations as evidence that parents (or even children) may be unreliable andlor invalid informants (Garrison & Earls, 1985; Orvaschel, Puig-Antich, Chambers, Tabrizi, & Johnson, 1982), other researchers have suggested that the disagreement between parent and child report should be viewed instead as different yet equally valid perceptions of youths' problems (Kazdin, French, & Unis, 1983). Namely, several studies have shown that children appear to report accurately on their anxiety and distress in certain cases (e.g., Edelbrock, Costello, Dulcan, Conover, & Kala, 1986; Jensen, Traylor, Xenakis, & Davis, 1988), whereas parents offer accurate accounts of their children's anxiety and distress in other situations (DiBartolo et al., 1998; Rapee, Barrett, Dadds, & Evans, 1994; Schniering, Hudson, & Rapee, 2(00). Additionally, several youth self- and parent- report questionnaires have demonstrated relatively good reliability and validity, supporting the utility of both parent and child reports within particular contexts (Achenbach & Edelbrock, 1989; Kazdin & Petti, 1982; Kendall, Cantwell, & Kazdin, 1989; Nauta, Scholing, Rapee, Abbott, Spence, & Waters, 2004).

12 6 Recognizing the importance of incorporating information from additional informants (e.g., parents) in the mental health assessment of children and adolescent, Achenbach et al. (1987) and Kazdin et ai. (1998) recommended the use of a multiaxial, multi-informant assessment system that capitalizes on the diversity of viewpoints represented by different informants, including parent report. Through such an approach, more comprehensive, representative profiles of youths emerge, with which to better understand, screen for, as well as aid in the diagnoses of anxiety and depression, compared to using youth self-report alone (Barbosa, Taonock, & Manassis, 2(02). Given this need for a parent-inclusive, multi-informant approach toward youth assessment, parent-report versions of anxiety and depression questionnaires have been developed, validated and applied in clinical and research settings. Among the first of these parent-report questionnaires were the Child Behavior Checklist (CBCL; Achenbach, 1991), the State-Trait Anxiety Inventory for Children-Parent Report-Trait Version (STAIC-P-T; Straus, 1987), parent version of the Revised Children's Manifest Anxiety Scale (RCMAS-P; Reynolds & Richmond, 1978), the parent version of the Fear Survey Schedule for Children-II (FSSC-IIP; Bouldin & Pratt, 1998), and the Multidimensional Anxiety Scale for Children (MASC; March, Parker, Sullivan, Stallings, & Conners, 1997). Anxiety and Depression Parent Report Questionnaires and DSM Diagnostic Criteria Although existing parent-report measures gather information regarding a range of anxiety-related problem areas, the utility of these measures in clinical and research settings may be limited due to their scale development preceding the establishment of the current diagnostic criteria (DSM-N-TR; APA, 2000; Stark & Laurent, 2(01). As a result, the various subscale scores of these measures do not map well onto the DSM nosology

13 7 (perrin & Last, 1992), making it difficult to interpret these scores in relation to specific DSM disorders and symptomatology. As these measures were not designed to yield DSM oriented results, it may be difficult to thus use these questionnaires in systematic DSMoriented diagnostic determinations of children and adolescents (Muris et al., 1999), which may at times be of interest during the assessment of children and adolescents. Relatedly, although the RCMAS-P, CBCL and STAlC-P-T have shown to be able to adequately discriminate between youth with and without anxiety disorders, these measures have shown to be relatively insensitive with respect to being able to discriminate between the various anxiety disorders, as well as discriminating between anxiety and affective disorders (e.g., Major Depressive Disorder; Seligman et al., 2004). Although several factors may account for this, the fact that scale development of these measures was not constructed along DSM nosology may be one contributing factor. Further, it has also been noted that these questionnaires define "anxiety" in different ways from each other. As a result, the various subscale scores of these questionnaires represent potentially different aspects, or conceptualizations of "anxiety." For example, some parent-report child anxiety questionnaires focus on specific fears (e.g., FSSC-RlP), whereas others focus on a multidimensional concept, assessing many general dimensions of anxiety at the same time (e.g., hyperarousal, fearfulness, worry; RCMAS-P, MASC). Furthermore, other questionnaires, such as the STAlC-p-r, focus on the assessment of both trait (e.g., long-tenn) and state (e.g., situational) components of anxiety, capturing reports of "anxiety" in an entirely different way. Although these different conceptualizations of anxiety may offer valuable information in certain assessment contexts, the lack of agreement makes it unclear as to which

14 8 conceptualization of "anxiety" is most appropriate for understanding a particular youth's presenting anxiety-related problem areas. Considering the dearth of existing parent-report questionnaires of youth anxiety (Southam-Gerow, Flanner-Schroeder, & Kendall, 2003) and the importance of having measurement scales constructed in accordance with specific DSM symptoms to aid in the diagnostic process, there has recently been a push towards developing more focused. symptom-specific parent report questionnaires that correspond to the constructs underlying DSM diagnostic criteria of youth anxiety. The parent version of the Spence Children's Anxiety Scale (SCAS-P; Spence, 1999) and the parent version of the Screen for Child Anxiety Related Emotional Disorders-Revised (SCARED-R; Muris, Mayer, Bartelds. Tierney, & Bogie, 2001) are among the few. The SCAS-P is a 38-item parent-report questionnaire, intended to measure youth DSM anxiety disorders symptoms pertaining to panic disorder/agoraphobia (PD/A). generalized anxiety disorder (GAD), social phobia (SOC), separation anxiety disorder (SAD), obsessive-compulsive disorder (OCD), as well as various specific phobias (SP), such as fear of physical injury and animals. The parent version of the SCARED-R, similarly, consists of 66 items, designed to measure the DSM-N anxiety disorders symptoms pertaining to panic disorder (PD). generalized anxiety disorder (GAD), social phobia (SOC), separation anxiety disorder (SAD). obsessive compulsive disorder (OeD), specific phobia (SP), traumatic stress disorder (TSD). plus an additional scale for "school phobia." which is not in the DSM. Gaining prevalence in the field of youth anxiety assessment, these measures represent progress towards a more developed and clinically useful parent-report measure,

15 9 allowing for more systematic diagnostic identification of youth anxiety disorders in accordance with the DSM nosology. In support of this are findings that youth anxiety symptoms assessed for by these measures appear to have a structure consistent with the DSM anxiety disorders (Spence, 1997). Several of their scales have also demonstrated the ability to discriminate between certain anxiety disorders (e.g., the parent version of the SCARED-R's SAD, PD, OCD, TSD and SOC subscales), strengthening their clinical utility beyond that of the RCMAS-P, CBCL and STAIC-P-T. Limitations to Existing DSM-Oriented Questionnaires Despite such merit, the SCAS-P and the parent version of SCARED-R are but the first steps towards creating parent report measures of specific youth anxiety disorders. Specifically, the psychometric evaluation of the SCAS-P (as well as its corresponding SCAS-child version) revealed that modifications could be made to their scales to increase their diagnostic utility. That is, although exploratory factor analysis on the SCAS-P showed that its scales factored consistently with respect to several of the DSM-IIl-R anxiety disorders, the SCAS-P failed to produce factors corresponding to Generalized Anxiety (GA; Spence, 1994; Spence, 1998). Further examination of the SCAS-P scales revealed that the SCAS items for the GA Scale do not appear to correspond with the DSM-JV criteria, but rather more with the DSM-IIl-R criteria for overanxious disorder (Chorpita et al., 2000). Instead of representing excessive worry, which is the defining feature of the DSM-JV's Generalized Anxiety Disorder (GAD), it was noted that the SCAS-P Scale items appear to focus more on various central nervous system and autonomic arousal symptoms, such as stomachaches and shakiness. As somatic features, relevant to the classification of the DSM-IlI-R's overanxious disorder, have been found to

16 10 be less relevant to the DSM-lV's conceptualization of generalized anxiety disorder (Tracey, Chorpita, Douban, & Barlow, 1997), this scale could be modified to increase its utility along the current DSM nosology. Examination of the Fear of Physical Injury (FPI) Scale of the SCAS also suggested that this scale, designed to measure a type of specific phobia, ought to be removed from future versions of this measure. Not only did its items load on mnltiple factors in an exploratory factor analysis (Chorpita et al., 2000), but it has also been suggested that the assessment of specific phobia may not be attainable by a single scale (Spence, 1997). That is, feared stimuli pertinent to the diagnosis of specific phobia for a given individual may vary greatly, thereby rendering the development of a valid, representative single scale of specific phobia improbable. With respect to the parent version of the SCARED-R, several needed improvements were also noted. For example, although its SAD, PD, OCD, TSD and SOC subscales have demonstrated the ability to discriminate between other anxiety subscales, the GAD and SP subscale did not. The stability (test-retest reliability) of the parent version of the SCARED-R is also currently unknown among a clinical population, as an investigation has not yet been conducted to assess these properties. A factor structure analysis of the parent version of the SCARED-R has also yet to be afforded by its researchers. Because a less than satisfactory factor structure was found for the child version of the SCARED-R among a normal child population (Muris et al., 1999), the factor structure of the parent report measure also stands in question. Giving these fmdings, there appears to be a need for additional anxiety measures to be constructed that map closer to the current DSM nosology of anxiety disorders.

17 11 The Concurrent Assessment of Depression and Anxiety Disorders Given the high degree of comorbidity between anxiety and depression among child and adolescent populations (Curry and Murphy, 1995), as well as the co=onalities between anxiety and depression (e.g., high negative affect; Barlow, Chorpita & Turovsky, 1996; Brady & Kendall, 1992; Clark & Watson, 1991), concurrently assessing for anxiety and depression among youth may also offer increased clinical utility for such measures. The SCAS, as well as the SCAS-P, were thus revised not only by omitting the FPI Scale and including items that represent DSM-/V criteria for generalized anxiety disorder (GAD), but also by including an additional scale corresponding to the DSM-/V nosology for major depression disorder (Chorpita et al., 2000). This revision led to the development of the child and parent version of the Revised Child Anxiety and Depression Scale, known as the RCADS (Chorpita et al., 2000), and RCADS-P, respectively. Favorable psychometric properties of the RCADS have been demonstrated in previous studies (Chorpita, Moffitt, & Gray, 2005; Chorpita, et al., 2000; de Ross, Gullone & Chorpita, 2002), specifically indicating that its depression and various anxiety scales appear to be better indicators of depression and anxiety in a diagnostic context than the Children's Depression Inventory and the Revised Children's Manifest Anxiety Scale (Chorpita, Moffitt, & Gray, 2005). Further, a confirmatory factor analysis of the RCADS supported its 6 factor development (i.e., Separation Anxiety Disorder, Social Phobia, GeneraIized Anxiety Disorder, Obsessive-Compulsive Disorder, Panic Disorder, and Major Depressive Disorder), suggesting that its scale development maps well onto the current DSM nosology.

18 12 Despite strong psychometric support for the RCADS, the psychometric properties of the RCADS-P (parent-version) have not yet been evaluated. Given the potential clinical utility of the RCADS-P with respect to offering a parent-report measure that concurrently assesses youth depression and anxiety-related symptomatology along the DSM-N nosology, the purpose of the present study was to examine the psychometric properties of the RCADS-P in a large, clinic-referred sample of children and adolescents. Methods Participants Participants were 119 children and adolescents and their primary caretakers referred to the Child and Adolescent Stress and Anxiety Program (CASAP) at the Center for Cognitive Behavior Therapy, at the University of Hawaii at Manoa, for mental health assessments related to emotional andlor behavioral concerns. Referrals were obtained through contracts with the State of Hawaii Department of Education (DOE), State of Hawaii Department of Health (DOH), and directly from parents or guardians. Youth in the sample consisted of 84 males (71 %) and 35 females (29%). Age ranged from 5.07 to years (M = 13.69, SD = 2.99). Major ethnic groups of the youth included Multiethnic (n = 61; 51 %), White (n =14; 12%), Asian American (n = 17; 14%), HawaiianlPacific Islander (n=16; 13%), and Puerto RicalHispanic (n = 11; 9%). All children spoke English at school. Information about the principal diagnoses of participants and total frequency count of diagnoses appears in Table 1. Primary caretakers in the current study were mostly biological mothers (n = 57; 48%). Marital status among all primary caretakers was 36.3% married, 13.7% single, 11.3% divorced, 4% separated and 1.6% widowed.

19 13 A subset of the participants in this study (n = 31) participated in a re-test of the RCADS-P to evaluate the reliability of the RCADS-P. This subset of participants consisted of 25 (81%) boys and 6 (19%) girls, with a mean age of (SD = 3.45, range = ). Ethnicity for the 31 retest participants was representative of that found in the entire sample of 119. For information on the retest procedures, see Procedure sections, below. Measures Child Behavior Checklist for Ages 6-18 (CBCU6-18; Achenbach, 2001). The CBCU6-18 is a 113-item parent questionnaire that measures both child competencies and needs related to a variety of childhood problems over the past 6 months. Items are rated as Not True (0), Somewhat or Sometimes True (1), or Very True or Often True (2); higher scores reflect greater endorsement of each item. Items from the CBCL can be summed to yield (a) Competence and Adaptive Scale scores, (b) Syndrome Scale scores, (c) DSM Oriented Scale scores, and (d) Total Problems Scale scores (including Internalizing and Externalizing Scale scores). The CBCU6-18 Syndrome scales include withdrawn/depressed, somatic complaints, social problems, anxious/depressed, aggressive behavior and rule-breaking behavior subscales. The CBCL has been shown in numerous studies to have strong psychometric properties, demonstrating good internal consistency, test-retest reliability (r >.87 over 1 week, r>.62 over 1 year), and the ability to discriminate between youth with an anxiety disorder and youth without a psychiatric disorder (Connor-Smith & Cornpas, 2003; Edelbrock & Costello, 1988; Gould, Bird, & Jaramillo, 1993; Kasius, Ferdinand, van den Berg, & Verhulst, 1997;

20 14 Lengua, Sadowski, Friedrich, & Fisher, 2001). Extensive normative data are also available for children ranging from 6 to 18 (Achenbach, 2001). The CBCL also yields six rationally-derived DSM-Oriented Scales (Le., Affective Problems, Anxiety Problems, AttentionlDeficitIHyperactivity Problems, Conduct Problems, Oppositional Defiant Problems, and Somatic Problems; Achenbach, Dumenci, & Rescoria, 2001). The DSM-Oriented scales were constructed from new national samples (Achenbach et ai., 2001) in response to Lengua et ai.'s (2001) comment that the CBCL should be scored in accordance with "current conceptualizations of child symptomatology" (Le., DSM nosology). Each scale was thus constructed through clinician agreement among 22 highly experienced child psychiatrists and psychologists (from 16 cultures) on the extent to which the CBCU6-18 items represented each of these DSM-oriented problem areas (Achenbach, 2001). The Anxiety Problems DSM-Oriented Scale, for instance, consists of six items, and is based on expert clinician agreement for those CBCU6-1S items characteristic of Generalized Anxiety Disorder (GAD), Separation Anxiety Disorder (SAD), and Specific Phobia (SP). Although psychometric data on the DSM-Oriented scales are limited, recent efforts have begun to support the Validity of these rationally-derived subscales (e.g., Achenbach & Dumenci, 2003). In particular, van Lang et a1. (2005) demonstrated support for the concurrent validity of the YSR DSM-Oriented Affective Problems subscale (child version of the CBCL DSM-Oriented Affective Problems subscale), whereby the YSR DSM-Oriented Affective Problems subscale had a stronger association with symptoms of DSM-IV Major Depressive Disorder than the YSR WithdrawnlDepressed and AnxiouslDepressed Syndrome scales. In addition, psychometric analyses of the parent

21 15 DSM Anxiety scores (raw scores from the CBCU6-18 Anxiety Problems DSM-Oriented Scale) among a clinical sample of736 children revealed acceptable internal consistency and discriminative validity (Nakamura, Stumpf, Becker, & Chorpita, 2005). Children's Interview for Psychiatric Syndromes (ChIPS; Weller, B., Weller, A., Fristad, Rooney, & Schecter, 1999). The ChIPS is a highly structured interview designed to be administered to children aged 6-18 years by trained interviewers. It screens for 20 different Axis I disorders as well as psychosocial stressors. Questions use simple language and short sentence structure to enhance subject comprehension and cooperation. The interview is based on the DSM-/V classification criteria. Children's Interview for Psychiatric Syndromes -Parent Version (P-ChIPS; Weller, B., Weller, A., Fristad, Rooney, & Schecter, 1999). The P-ChIPS is a highly structured interview designed to be administered to the parents of children aged 6-18 years by trained interviewers. It screens for the same 20 Axis I disorders as well as psychosocial stressors. As with the ChIPS, the P-ChIPS interview is based on the DSM IV classification criteria. Content and concurrent validity, interrater reliability, and testretest of both the ChIPS and P-ChIPS have been demonstrated in previous studies in both clinical and community samples (Fristad et ai., 1998a-c; Teare et ai., 1998a,b), evidencing the strong psychometric properties of these structured interviews. Dimensional Ratings (Chorpita, Plummer, & Moffitt, 2000). Following the administration of the ChIPS and P-ChIPS, clinicians are asked to complete a separate measure in which they provide ratings indicating their assessment of the degree to which dimensions of various disorders are present in the child or adolescent, regardless of whether the child or adolescent met DSM diagnostic criteria for that particular disorder.

22 16 Dimensional Ratings are completed on a scale from 0 to 8, in which zero represents the complete absence of dimensions of the disorder, and greater scores represent greater clinical severity. Dimensional Ratings are given to the dimensions pertaining to: Separation Anxiety, Social Anxiety, Specific FearlPhobia, Generalized Anxiety, Panic, Agoraphobia, Posttraumatic Stress, Obsessions/Compulsions, DepressionlDysthymic Disorder, Inattentive, Hyperactive, Oppositional, and Delinquent (Le., Conduct) Behaviors. In this process, clinicians were asked to make three different sets of Dimensional Ratings according to three separate clinical impressions: (1) their impression from the child/adolescent interview, (2) their impression from the parent/guardian interview, and (3) their consensus clinical impression based off of both child and parent report (Chorpita, Plummer et al., 2000). Revised Child Anxiety and Depression Scales (ReADS; Chorpita. Yim, Moffitt. Umemoto. & Francis. 2000). The RCADS is a 47 -item youth self-report questionnaire designed to assess for DSM-N depression and anxiety disorders in children and adolescents. The RCADS is composed of six subscales: Separation Anxiety Disorder, Social Phobia, Generalized Anxiety Disorder, Obsessive-Compulsive Disorder. Panic Disorder, and Major Depressive Disorder, as well as an Anxiety Total Score and RCADS-P Total Score. Children and adolescents are asked to rate items according to how often each applies to them. Choices range from 0-3, corresponding to "never," "sometimes," "often," and "always," and summed to create a total raw score. The RCADS has been shown to have good internal consistency, high convergent and discriminant validity, and an adequate factorial structure in both community and clinical

23 17 samples of children and adolescents aged seven to seventeen (Chorpita et al., 2000; Chorpita et al., 200S; de Ross et al., 2002). Revised Child Anxiety and Depression Scales - Parent Version (RCADS-P). The RCADS-P is a 47-item parent report measure of youth anxiety and depression. Its items were adapted from the RCADS, with wording slightly modified to have it asking parents about their child. It assesses for the same DSM-N depression and anxiety disorders in children and adolescents as the RCADS: Separation Anxiety Disorder, Social Phobia, Generalized Anxiety Disorder, Obsessive-Compulsive Disorder, Panic Disorder, and Ml\ior Depressive Disorder. Parents of children and adolescents are asked to rate items according to how often each applies to their child. Choices range from 0-3, corresponding to ''never,'' "sometimes," "often," and "always," and summed to create a total raw score. Psychometric data are current! y not available for this measure. Procedure Following initial referrals, graduate student clinicians contacted the child or adolescent's parent or legal guardian via telephone for a brief screening interview. Prospective assessments were not accepted only if there were previous diagnoses of Autism or Mental Retardation. If prospective assessments were not accepted, more appropriate referrals were made. Interviews were scheduled with the remaining children and adolescents and their parents or legal guardians. At the time of the interview, the parent or guardian signed a consent form for assessment, while the child or adolescent signed an assent for assessment. The ChIPS and P-ChIPS interviews were then administered consecutively, in this order. The parent or guardian filled out parent-report questionnaires regarding their child (e.g., RCADS-P, CBCL) during the child interview,

24 18 while the child filled out several self-report questionnaires (e.g., RCADS) during the parent interview. Undergraduate assistants were available to provide help to children or parents who had difficulty reading the questionnaires. After the ChIPS and P-ChIPS interviews, the youths' teachers, previous andlor current mental health providers, and other relevant informants (e.g., another parent living with the child or adolescent, probation officers) were contacted for brief, unstructured telephone interviews. Assessors reviewed and integrated information from all assessment materials (e.g., child and parent questionnaires, ChIPS, P-ChlPS and unstructured telephone interviews), except for the RCADS-P, when formulating diagnoses. To help ensure that assessors were blind to the RCADS-P, assessors were specifically instructed not to look at the RCADS-P during any part of the assessment process. Cover sheets were also used to blind assessors from RCADS-P responses. Assessors also completed child, parent and consensus Dimensional Ratings, based on the ChIPS interview, P-ChIPS interview and overall clinical impression based on all available information from the assessment (except from the RCADS-P), respectively. In order to obtain test-retest data on the RCADS-P, the primary caretakers (e.g., parents, guardians, foster parents) of the participating children of the study were asked via mailed consent packets to fill out the RCADS-P for a second time approximately two weeks following their initial administration of the RCADS-P. Upon receiving and reading through the mailed consent forms, primary caretakers who agreed to participate in the test-retest portion of the study indicated their consent by datiog and filling out the included RCADS-P for a second time and returning the RCADS-P in a provided stamped, addressed envelope to the first author. The retests of the RCADS-P occurred prior to the

25 19 diagnostic feedback session with the parent or guardian so as to prevent reporting biases due to receiving information regarding the diagnoses of their children. Consent packets were mailed to all caretakers until at least thirty RCADS-P retests were obtained. Consent packets were mailed to fifty-five caretakers. Thirty-one caretakers agreed to participate in the test-retest portion of the study, and completed and returned their retest of the RCADS-P to the first author. Results Analysis of Measures Data integrity. Prior to data analysis, the data set was checked for impossible values (Le., values outside the possible range for each measure/scale) that could have occurred due to data entry errors. No impossible values were found for any items or scales. This was expected as data entry within the employed database (Microsoft Access) was linked to response tables specific to each measure; accordingly only the values comprising each measure's scale were enterable. Missing data. RCADS and RCADS-P subscale scores were considered missing data and thus excluded from analyses if more than one item comprising a given subscale was missing. If only one item was missing, then scores on that subscale were corrected by summing the remaining items and multiplying that score by the total number of items divided by the total number of items minus 1 (Le., within-scale, within subject mean substitution). A relatively large number of missing scale scores were found in the current data set among all measures. Specifically, 35.23% of all RCADS scales scores, 36.98% of all RCADS-P scales scores, 33.60% of all CBCL scale scores, 44.0% of all Child

26 20 Dimensional Ratings scales, 47.08% of all Parent Dimensional Ratings scales, and 36.07% of all Consensus Dimensional Ratings scales were missing. These missing data were likely due to several factors, including youths and parents not filling out measures, youths and parents leaving certain items blank, and data not completely entered at the time of analysis. Due to the high number of missing values, correlations employed in the current study were calculated via pair-wise analyses, whereby cases were excluded from analyses if one or both values were missing. Assumptions. Descriptive statistics (i.e., minimum values, maximum values, mean and standard deviations) of all scales were examined (see Table 2). Further, the data were reviewed for assumptions of normality. Specifically, skewness and kurtosis of each scale was examined, appearing in Table 3. Skewness and kurtosis values outside the range of - 2 to +2 were corrected for and transformed using the square root function. Although the majority of scales demonstrated acceptable skewness and kurtosis patterns, select scales required transformations (see Table 3). Following square root function transformations, normality of all scales were improved, with the exception of the DR-Panic-Consensus, DR-Panic-Parent, DR-Panic-Child, and the DR-OCD-Child scales. Reliability The reliability of the RCADS-P was estimated using a test-retest paradigm, over an average of 2.7 weeks (SD = 1.07; range = 7 to 47 days) after the initial screening. These reliability coefficients for 31 participants are reported in Table 4. All reliability coefficients were favorable, ranging from.79 (PD) to.93 (Total Score, Anxiety Total Score).

27 21 Scale Consistency To provide an additional index ofreliability, Cronbach's alpha coefficients were evaluated to estimate internal consistency of each of the six RCADS-P subscales using the total sample. All scales were found to have good internal consistency (a MDD =.88; a. SAD =.83; a. soc =.89; a GAD =.90; a. PD =.79; a. OCD =.90; a Anxiety Total =.95; a. Total Soore=.96). Convergent Validity In order to examine the convergent validity of the RCADS-P as an overall measure of anxiety and depression, the correlation of the RCADS-P Total Score Scale (i.e., MDD plus the five anxiety subscales) with the CBCL's Anxious/Depressed Syndrome Scale was evaluated. Given that both subscales are presumed to measure anxiety and depression, it was predicted that this correlation would be significant. Consistent with prediction, this correlation was significant, r =.77, P <.0 I, two-tailed. To test whether the RCADS-P Total Score Scale was significantly more correlated with the CBCL's Anxious/Depressed Syndrome Scale than with the CBCL's Social Problems, WithdrawnJDepressed and Somatic Complaints Syndrome scales, correlations of the RCADS-P Total Score with the CBCL's Social Problems, WithdrawnJDepressed, and the Somatic Complaints Syndrome scales were calculated. Differences between each of these correlations with the correlation between the RCADS-P Total score and the CBCL's AnxiouslDepressed Syndrome Scale Score were then evaluated using Fisher's z tests for correlated correlations (Meng, Rosenthal & Rubin, 1992). As predicted, the RCADS-P Total score was significantly more correlated with the CBCL's Anxious/Depressed Syndrome Scale than with the CBCL's Social Problems Syndrome

28 22 Scale, z (76) = 2.49, p <.05, the CBCL Somatic Complaints Syndrome Scale, z (76) = 2.50,p <.05, and the CBCL's WithdrawnlDepressed Syndrome Scale, z (76) = 2.31,p <.05. These fmdings support the notion that the RCADS-P Total is a measure of anxiety and depression. With respect to the RCADS-P subscales, it was predicted that the RCADS-P MDD and individual anxiety subscales would correlate positively and significantly with all convergent child, parent and consensus Dimensional Ratings for their target syndromes. It was also predicted that the RCADS-P subscales would be correlated highest with their corresponding parent Dimensional Ratings, and less so with the consensus and child Dimensional Ratings, given that the parent Dimensional Ratings are based on reports from the same informant as the RCADS-P (i.e., youths' parents). Correlations of the RCADS-P MDD Scale with the child, parent and consensus depression Dimensional Ratings, as well as the correlations of the RCADS-P anxiety subscales with corresponding child, parent and consensus anxiety Dimensional Ratings (i.e., obsessive-compulsive, general anxiety, separation anxiety, social phobia and panic scales), were evaluated. These correlations appear in Table 5 (columns 1,2 and 3, top of table). As predicted, correlations with all parent Dimensional Ratings were greater than with child or consensus Dimensional Ratings. Further, correlations of all RCADS-P subscales with corresponding parent Dimensional Ratings were significant, with the exception of the RCADS-P PD subscale. The RCADS-P sub scales were also expected to correlate with other parent-report measures of anxiety and depression. Correlations of the RCADS-P MDD Scale with the CBCL Affective Problems DSM Oriented Subscale, as well as the correlations of the

29 23 RCADS-P anxiety subscales with the CBCL Anxiety Problems Subscale, were thus evaluated. These correlations appear in Table 5 (column 4, top of table). As predicted, the RCADS-P MDD Scale correlated positively and significantly with the CBCL Affective Problems DSM Oriented Subscale, and the RCADS-P anxiety scales each correlated positively and significantly with the CBCL Anxiety Problems DSM Oriented Subscale. For comparison purposes, the CBCL Affective Problems and CBCL Anxiety Problems DSM Oriented Subscales were also correlated with the same child, parent and consensus Dimensional Ratings. These correlations also appear in Table 5 (columns I, 2 and 3, bottom of table). These correlations were significant for the CBCL Affective Problems DSM Oriented Subscale, and variably significant for the CBCL Anxiety Problems DSM Oriented Subscale, but lower for nearly all convergent validity coefficients than those demonstrated by the RCADS-P subscales. In addition, correlations with parent Dimensional Ratings were larger than correlations with child or consensus Dimensional Ratings of each target syndrome. Parent-Child Agreement To examine the parent-child agreement of the RCADS/RCADS-P Total Score and subscales (Le., MDD, SAD, SOC, GAD, OCD, PD, and Anxiety Total), correlations among corresponding RCADS-P and RCADS scales were evaluated. It was expected that these scales would be only moderately correlated given previous findings that parentchild agreement on youth internalizing symptomatology tends to range from low to moderate (Edelbrock, Costello, DuIcan, Kala & Conover, 1985; Rey, Schrader, & Morris-Yates, 1992). These correlations appear in Table 6. Results were consistent with

30 24 predictions. with low but non-zero parent-child agreement evidenced for all subscales, ranging from.1o (GAD) to.27 (SAD). Divergent Validity As divergent validity of the RCADS (child version) was tested and supported through correlations with child and parent interview ratings (i.e., Dimensional Ratings) of oppositional problems (Chorpita et al., 2005), the divergent Validity of the RCADS-P in the present study was also evaluated through correlations between the RCADS-P scales and the child, parent and consensus Dimensional Ratings of oppositional and delinquent problems. It was predicted that correlations would not be positive and significant. These correlations appear in Table 7 (columns 1,2 and 3, top two sections of table). Consistent with prediction, no correlations were significant and positive, and all correlations were either near zero or were significant in the negative direction, with the exception of the correlation of the RCADS-P MDD scale with the parent Dimensional Ratings of oppositional problems, which was positively correlated. For comparison purposes, additional parent measures of problem areas related to anxiety and depression (Le., the CBCL Internalizing Total Score, CBCL AnxiouslDepressed Syndrome Scale, CBCL Withdrawn/Depressed Syndrome Scale, CBCL Affective Problems DSM Oriented Scale, and CBCL Anxiety Problems DSM Oriented Scale) were correlated with the same child, parent and consensus Dimensional Ratings of oppositional and delinquent problems. These correlations also appear in Table 7 (columns 1,2 and 3, bottom two sections of table). Consistent with the fmdings of the RCADS-P scales, only one of these correlations was significant and positive (the

31 25 correlation of the CBCL Affective Problems scale with the parent Dimensional Ratings of oppositional problems). Given that the only significant positive correlations were specifically between the parent Dimensional Ratings of oppositional problems and parent-measures of affective problems (i.e., CBCL Affective Problems DSM Oriented Scale, RCADS-P MDD Scale; see Table 7), for comparative purposes, correlations of the Dimensional Ratings of oppositional and delinquent problems with a youth self-report measure of internalizing problems (i.e., RCADS), were examined. These correlations appear in Table 8. Similarly, none of the correlations was significant and positive. The divergent validity of the RCADS-P scales was further tested through correlations among the RCADS-P scales and other parent report measures/scales of externalizing problem areas (i.e., the CBCL Externalizing Total Score Scale, CBCL Rule Breaking Syndrome Scale, CBCL Aggressive Behaviors Scale, CBCL Oppositional Defiant Problem DSM Oriented Scale, CBCL Conduct Problems DSM Oriented Scale). Again, it was predicted that none of these correlations would be significant and positive. These correlations appear in Table 9 (top of the table). Contrary to predictions, however, several significant correlations were found between the various RCADS-P scales and the criterion measures of externalizing behaviors. Although these correlations were variably significant for the RCADS-P anxiety scales, it is notable that the RCADS-P MDD scale was significantly correlated with all divergent validity criterion measures of externalizing behaviors. Oi ven that these fmdings were contrary to predictions, for comparative purposes, the correlations between additional parent measures/scales of internaiizing problems (i.e.,

32 26 the CBCL Internalizing Total Score Scale, CBCL AnxiouslDepressed Syndrome Scale, CBCL Withdrawn/Depressed Syndrome Scale, CBCL Affective Problems DSM Oriented Scale, CBCL Anxiety Problems DSM Oriented Scale) and the same parent measures/scales of externalizing behaviors were evaluated. These correlations also appear in Table 9 (bottom of the table). Results indicated that (with the exception of two correlations) all correlations were significant. These results support the notion that significant correlations between the RCADS-P scales and measures of externalizing behaviors may in fact be expected. Although the RCADS-P Total Score, GAD and MDD scales were significantly correlated with the CBCL Externalizing Total Score, it is notable that these RCADS-P scales were significantly more correlated with the CBCL Internalizing Total Score (also appearing in Table 9) than with the CBCL Externalizing Total Score. Specifically, the RCADS-P Total Score was significantly more correlated with the CBCL Internalizing Total Score than the CBCL Externalizing Total Score, Z (76) = 5.31, p <.001; the RCADS-P GAD scale was significantly more correlated with the CBCL Internalizing Total Score than the CBCL Externalizing Total Score,,Z (81) = 4.13, p <.001; and the RCADS-P MDD scale was significantly more correlated with the CBCL Internalizing Total Score than the CBCL Externalizing Total Score,,Z (83) = 3.37, p <.001. As the clinical utility of the RCADS-P rests somewhat on its ability to discriminate between anxiety and depression, the correlation between the RCADS-P MDD subscale and RCADS Anxiety Total Score Scale, as well as correlations between each of the RCADS-P anxiety subscales (Le., GAD, SOC, OCD, PO, SAD) and the RCADS MDD subscale, were evaluated. Although a relationship and high degree of

33 27 comorbidity has been found between anxiety and depression (Curry and Murphy, 1995), it was predicted that all correlations would be low and non-significant, particularly given that these correlations were based on cross-informant (i.e., parent-child) reports. These correlations appear in Table 10. As predicted, all correlations between the RCADS-P anxiety subscales (i.e., GAD, SOC, oeo, PO, SAD) and the RCADS MDD subscale were low and not significant. Contrary to prediction, however, the RCADS-P MDD subscale was significantly correlated with the RCADS Anxiety Total score. This correlation, however, was in the low to moderate range (r =.24). To offer a more stringent test of divergent Validity of the RCADS-P subscales, the correlation of the RCADS-P MDD subscale scores with another parent-report measure of anxiety (i.e., CBCLAnxiety Problems DSM Oriented Scale) was evaluated. Similarly, the correlations of each of the RCADS-P anxiety subscale scores (i.e., GAD, SOC, oed, PO, SAD) with another parent-report measure of depression (i.e., the CBCL Affective Problems DSM Oriented Scale) were evaluated. Given the relationship between anxiety and depression, and that these correlations were based on the same informant (i.e., youths' parents), it was predicted that these correlations would be somewhat correlated. These correlations appear Table 11, and as predicted, all correlations were significant. However, to investigate further the divergent validity of the RCADS-P subscales along these lines, a test was performed to determine whether the RCADS-P anxiety subscales would be significantly more correlated with the CBCL Anxiety Problems DSM Oriented Scale than with the CBCLAffective Problems DSM Oriented Scale; and whether the RCADS-P MDD scale would be significantly more correlated with the CBCL Affective Problems DSM Oriented Scale than with the CBCL Anxiety Problem

34 28 DSM Oriented scale. It was predicted that the RCADS-P MDD sub scale would be significantly more correlated with the CBCL Affective Problems DSM-Oriented Scale than with the CBCLAnxiety Problems DSM-Oriented Scale, and that the RCADS-P anxiety subscales would be significantly more correlated with the CBCLAnxiety Problems DSM Oriented Scale than the CBCL Affective Problems DSM-Oriented Scale. These correlations and accompanying Fisher's z-tests appear in Table 11. As predicted, the results indicate that the RCADS-P MDD subscale was significantly more correlated with the CBCL Affective Problems DSM-Oriented Scale than with the CBCL Anxiety Problems DSM-Oriented Scale, z (83) = 2.33, P <.05. In addition, as predicted, the RCADS-P SAD subscale was significantly more correlated with the CBCL Anxiety Problems DSM Oriented Scale than the CBCL Affective Problems DSM-Oriented Scale, z (83) = 2.75, p <.01, and the RCADS-P GAD subscale was significantly more correlated with the CBCL Anxiety Problems DSM Oriented Scale than the CBCL Affective Problems DSM-Oriented Scale, z (81) = 2.29, p <.05. Contrary to predictions, however, no other differences between correlations were significant, as indicated in Table 11. Discussion The results of the current study suggest that RCADS-P possesses favorable psychometric properties in this sample of clinic-referred children and adolescents. In particular, results indicated high internal consistency and test-retest coefficients for all subscales, supporting the reliability of the RCADS-P. The RCADS-P test-retest reliability coefficients in the present study were comparable to the retest reliability estimates of other parent report measures of anxiety (e.g., ST AIC-P-T: mean maternal report ICC =.77, Southam-Gerow et al., 2003; SCARED-Parent Version: ICC =.70 to.90, Birmaber

35 29 et al., 1997). High convergent and divergent validity with interview, youth-report, parentreport and clinician-rated measures of related constructs were also demonstrated, supporting the validity of the RCADS-P as a parent-report measure of youth DSM anxiety and depression. Although parent-child agreement of the RCADS-P subscales was adequate (ranging from.10 to.27) and in the range consistent with that found in Achenbach et al.'s (1987) meta analysis, studies evaluating other parent-report questionnaires of youth anxiety found somewhat higher parent-child agreement (Le., r SCARJID.R-P all scales =.20 to.47, Birmaher et al.,1997; rscared-r-ptota1 score =.69, Muris et al., 2004; rscasptotalscore =.51, Nauta et al., 2003). Interestingly, previous studies have also concluded that parentchild agreement in the field of anxiety disorders tends to be lower for older children (Achenbach et al., 1987; Rapee, Barrett, Dadds, & Evans, 1994); although it is unknown whether the ages of the participants in the present sample contributed to the lower parentchild agreement compared to those found by Muris et al. (2004) and Nauta et al. (2003), it is notable that the participants of the present sample were older (M =14.03, SD = 2.84) than the participants in Muris et al.( M = 12.0, SD = 2.9) and Nauta at al.'s (M = 10.4, SD = 2.5) samples. Despite relatively lower parent-child agreement in the present study, consistent with findings by Nauta et al. (2004), parent-child agreement of the RCADS-P was highest for the subscales that consisted of items with observable behaviors (e.g., SAD). Results also revealed that although there was near complete divergence (Le., lack of any significant positive correlations) of the RCADS-P and CBCL internalizing scales with Dimensional Ratings of externalizing behaviors (Le., oppositional and delinquent

36 30 behaviors), the only two significant positive correlations which occurred were between the parent reports of affective problems (Le., RCADS-P MDD, CBCL Affective Problem DSM Oriented Scale) and the parent-based measure of oppositional behaviors (i.e., parent Dimensional Rating of oppositional behavior). The RCADS-P MDD subscale, specifically, was also significantly correlated with all externalizing subscales of the CBCL. Taken together with previous fmdings, these results suggest that there may be a linkage between youth affective problems and externalizing (e.g., oppositional) behaviors. In addition to the present findings, Loeber, Russo, and Stouthamer-Loeber (1994) found that boys in early adolescence who were reported to exhibit high levels of externaiizing behaviors also exhibited depressive mood. Goodman and Scott (1999) also reported correlations between the CBCL Externalizing and Internalizing Total Score scales of.63, and correlations between the Strengths and Difficulties Questionnaire Externalizing and InternaIizing scales of.37, suggesting a relationship between internaiizing (e.g., depression) and externalizing behaviors. Contributing at least in part to these fmdings may be the general fmdings that depressed mood in children may often be characterized by irritable mood (DSM-IV-TR: APA, 2000). Despite this potential association between affective problems and oppositionality, interestingly, child reports of affective problems (i.e., RCADS-MDD scores) were not significantly correlated to child-based measures of oppositional behaviors (Le., child Dimensional Ratings of oppositional behavior), as seen with parent reports of youth affective problems and oppositional behaviors, as indicated above These fmdings suggest that, while parents tend to report on oppositionality in addition to affective problems, children themselves do not. That is, children may be less aware of the

37 31 oppositional behaviors they may exhibit in addition to their affective problems, while their parents may be more aware of both behavioral and mood states exhibited by their children. Certainly, more research is needed to determine the exact relationship between internalizing (e.g., anxiety and depression) and externalizing disorders (e.g., oppositionality). However, given the strong psychometric properties of the RCADS-P demonstrated in the present investigation, futore studies involving the RCADS-P may help answer these and other questions related to anxiety and depression among youth. Although the current study offers preliminary support for the validity of the RCADS-P as a parent-report measure of youth anxiety and depression, the study has certain limitations. One such limitation was that the factor analytic results of Chorpita et al.'s (2000) investigation on the RCADS was extended to the ReADS-p, whereby it was assumed that the same items of the RCADS subscales comprised the RCADS-P subscales. Neither an exploratory nor confirmatory factor analysis was performed in the present study to determine whether this assumed factor structure of the RCADS-P was appropriate. In particular, RCADS-P item #36 ("My child thinks about death often") may need to be subject to factor analytic scrutiny. Although this item was initially rationally determined to comprise the RCADS MDD subscale given its theoretical relationship with depression, results from Chorpita et al.' s (2000) factor analytic investigation determined this item to load on the RCADS GAD subscale. This item was therefore deemed an item of the RCADS GAD subscale, and thus assumed to be an item of the RCADS-P GAD subscale in the present study. An exploratory andlor conrmnatory factor analysis may be needed to determine whether this item indeed loads on the RCADS-P GAD subscale.

38 32 Another limitation of the current study was the weakness of the Dimensional Ratings Panic Scale as a criterion measure for the convergent validity analyses of the RCADS-P PD Scale. Although the Dimensional Ratings Panic Scale was designed to theoretical I y provide ratings indicating the clinician's assessment of the degree to which Panic was present in the child or adolescent, the ChIPS and P-ChIPS from which the Dimensional Ratings are derived do not include questions pertaining to Panic Disorder. As a result, parents whose children experience known difficulties related to Panic may report these symptoms on the RCADS-P Panic scale, though may not have to opportunity to report such information during the P-ChIPS interview. Therefore, the lack of convergence between the RCADS-P PD subscale and the child, parent and consensus Dimensional Ratings Panic Scale is likely, at least in part, due to this weakness of the Dimensional Ratings Panic Scale as a criterion measure, rather than the RCADS-P PD subscale not being a measure of Panic Disorder symptomatology. However, because there were no other measures in the present study specifically designed to measure Panic Disorder, the psychometric support offered for the RCADS-P PD scale may be relatively weaker than for the other RCADS-P scales. (Analyses were attempted on all cases whereby Dimensional Ratings Panic Scale ratings were provided - for cases when Panic Disorder was a known problem area and thus screened in addition to the ChIPS and P ChIPS protocol- sample size, however, was not adequate to perform any substantive analyses). An additional limitation of the current study is that although it uses a multiinformant, multi-method approach, there is a considerable amount of shared method variance between the various measures, resulting in an increased chance for Type I error.

39 33 The CBCL and RCADS-P. in particular. are both parent-report measures. and thus correlations between them (e.g. correlations between the RCADS-P Subscales and corresponding CBCL DSM-Oriented Anxiety/Affective Problems Subscales) could be due, at least in part, to the fact that they share the same informant (Le., youths' parents), instead of resulting from a correlation between the actual constructs of interest. Another limitation is the relatively small number of youth in the sample who had diagnoses of anxiety and depression. Given that a large proportion of youth in the present sample did not have diagnoses of anxiety andlor depression, the convergent validity of the RCADS-P demonstrated in the present study may thus extend primarily to youths without anxiety or depressibn diagnoses. Resultantly, generalizability of these findings may be limited to similar service populations and may apply less to mental health clinics that target specific clinical populations (e.g., specialty anxiety clinics). Lastly, given that results from convergent and divergent Validity analyses are only as informative as the Validity of the criterion measures themselves, another weakness of the present study is the employment of the CBCL DSM Oriented scales (Le., CBCL Anxiety and Affective Problems DSM Oriented Scales) as convergent and divergent criterion measures despite a lack of research investigating and substantiating their psychometric properties. For example, although the RCADS-P MDD subscale converged in the present study with the CBCL Affective Problems DSM Oriented subscale, without psychometric evidence supporting the CBCL Affective Problems DSM Oriented subscale as indeed a measure of affective problems (e.g., depression), it is less clear whether this finding suggests that the RCADS-P MDD subscale also measures depression, or in fact some other construct which the CBCL Affective Problems DSM Oriented subscale may

40 34 be tapping. Nonetheless, studies evaluating the psychometric properties of the CBCL DSM Oriented scales have commenced, with recent studies finding preliminary support for its psychometric properties (Nakamura, Stumpf, Becker, & Chorpita, 2OOS). Despite the mentioned limitations, the collective results of the current study suggest that the RCADS-P possesses favorable psychometric properties in this large sample of clinic-referred children and adolescents. The strengths demonstrated by the RCADS-P include high internal consistency and high convergent and discriminant validity with youth-report, parent-report and clinician-rated measures of related constructs. Given that this is the first psychometric investigation of the RCADS-P, future research may be needed to strengthen its psychometric properties. Future research might evaluate the degree to which the RCADS-P subscales converge with youth diagnoses as determined by the PIC-ChIPS interviews. Further, as indicated above, exploratory and/or confirmatory factor analyses may be needed to confirm the assumed factor structure of the RCADS-P subscales. Additionally, the clinical utility of the RCADS-P may be strengthened through the collection and generation of norm data from children and adolescents in clinical and community settings. Whatever its future applications, the RCADS-P demonstrated favorable psychometric properties in this large sample of clinicreferred youth, showing promise as a parent report measure of youth anxiety and depression.

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53 47 Table 1 Diagnostic Frequency Diagnosis PrinciEal Diagnosis Diagnosis Anywhere Total Conduct disorder Oppositional defiant disorder Disruptive behavior disorder nos 7 11 AJ)fU),combinedtype 3 24 AJ)fU), predominantly inattentive type 2 10 AJ)fU), predominantly hyperactiveimpulsive type 1 3 AJ)fU)NOS 2 3 Major depressive disorder 9 13 Dysthymic disorder 3 7 Depressive disorder NOS 3 4 Posttraumatic stress disorder 6 15 Generalized anxiety disorder 5 10 Social phobia 3 8 Separation anxiety disorder 2 4 Obsessive-compulsive disorder 3 4 Panic disorder without agoraphobia 0 1 Anxiety disorder NOS 3 0 Alcohol abuse/dependence 0 4 Cannabis abuse/dependence 0 10 Otherlunknown substance abuse 0 1 Bulimia nervosa 1 I Schizophrenia 4 4 Selective Mutism 0 1 Rett's, Asperger's, or Pervasive developmental disorders NOS 7 8 No Diagnosis 0 0 Note. Totals sum to more than the sample size for the second column because many youth had more than one diagnosis.

54 48 Table 2 Descriptive Statistics of Each Scale Scale N Minimum Maximum Mean Std. Deviation RCADSP SAD GAD MDD PD SOC OCD Total Anxiety Total RCADS SAD GAD MDD PD 85 0 II SOC OCD Total Anxiety Total Score DR ChUd SAD GAD SOC OCD Panic Depression Oppositional Delinquent DR Parent SAD GAD SOC OCD Panic Depression Oppositional Delinquent DR Consensus SAD GAD SOC OCD Panic Depression Oppositional Delinguent

55 49 Table 2 (Continued) Descriptive Statistics of Each Scale Scale N Minimum Maximum M SD CBCLScales Anxious/Depressed WithdrawnlDepressed Somatic Complaints Social Problems Rule Breaking Behavior Aggressive Behavior Affective Problems -DSM Oriented Anxiety Problems -DSM Oriented Oppositional Defiant Problems - DSM Oriented Conduct Problems -DSM Oriented Internalizing Total Externalizing Total Note. RCADS-P = Revised Child Anxiety and Depression Scale - Parent Version; MDD = major depressive disorder; SAD = separation anxiety disorder; SOC = social phobia; GAD = generalized anxiety disorder; PD = panic disorder; OCD = obsessive compulsive disorder; RCADS = Revised Child Anxiety and Depression Scale; DR = Dimensional Ratings; CBCL = Child Behavior Checklist.

56 50 Table 3 Normality of. Each Scale Scale Original Transformed Skewness Kurtosis Transformation Skewness Kurtosis RCADSP SAD GAD MDD PD Sq root SOC OeD Total Anxiety Total RCADS SAD GAD MDD PD SOC OCD Sq root Total Anxiety Total Score DR-Child SAD Sqroot GAD SOC Sqroot oeo Sq root Panic Sq root Depression Oppositional Delinquent DR-Parent SAD Sq root GAD SOC OCD Sq root Panic Sqroot Depression Oppositional Delinquent DR Consensns SAD Sq root GAD SOC OeD Sq root Panic Sq root Depression Oppositional Delinquent

57 51 Table 3 (Continued) Normality of Each Scale Scale CBCLScales Anxious/Depressed WithdrawnlDepressed Somatic Complaints Social Problems Rule Breaking Behavior Aggressive Behavior Affective Problems - DSM Oriented Anxiety Problems - DSM Oriented Oppositional Defiant Problems -DSM Original Skewness Kurtosis Oriented Conduct Problems - DSM Oriented Internalizing Total Externalizing Total Transformed Transformation Skewness Kurtosis Note. RCADS-P = Revised Child Anxiety and Depression Scale - Parent Version; MDD = major depressive disorder; SAD = separation anxiety disorder; SOC = social phobia; GAD = generalized anxiety disorder; PD = panic disorder; OCD = obsessive compulsive disorder; RCADS = Revised Child Anxiety and Depression Scale; DR = Dimensional Ratings; CBCL = Child Behavior Checklist.

58 52 Table 4 Test-Retest Coefficients for the RCADS-P Scales Scale MDD SAD SOC GAD PD OCD Anxiety Total Score Total Score Retest Coefficients (n).88 (30).80 (30).90 (31).87 (29).79 (28).87 (30).93 (26).93 (26) Note. RCADS-P = Revised Child Anxiety and Depression Scale - Parent Version; MDD = major depressive disorder; SAD = separation anxiety disorder; SOC = social phobia; GAD = generalized anxiety disorder; PD = panic disorder; OCD = obsessive compulsive disorder; All correlations are significant at the p <.01 level (two-tailed).

59 53 Table 5 Correlations of RCADS-P and CBCL Affective Problems and Anxiety ProblelWi DSM Oriented Subscales with Convergent Validity Criteria Dimensional Ratings Parent Re~rt Consensus Scale Construct Child (n) Parent (n) (n) CBCL RCADS-P DSMScale MDD Depression.31" (75).56"(79).38"(79) Affective.78" (83) OCD Obsessive-Compulsive.24' (73).44'(76).35'(78) Anxiety.49"(81) GAD General Anxiety.22 (73).47"(77).31"(79) Anxiety.73" (81) SAD Separation Anxiety.34" (76).63"(77).54**(81) Anxiety.66" (83) SOC Social Phobia.16 (73).42"(76).26 (78) Anxiety.65" (81) PO Panic.rn (29).18 (29).02 (31) Anxiety.65" (78) CBC\. Affective Depression.39" (80).60" (83).44"(83) Anxiety Obsessive-Compulsive.11 (79).28' (82).24' (84) Anxiety Geneml Anxiety.15 (79).43" (82).25' (84) Anxiety Separation Anxiety.18(80).43"(80).35"(84) Anxiety Social Phobia.13 (80).30" (82).20 (84) Anxie!X Panic -.01 (36) -.05 (36) -.04 (36) Note. RCADS-P = Revised Child Anxiety and Depression Scale - Parent Version; MDD = major depressive disorder; SAD = separation anxiety disorder; SOC = social phobia; GAD = generalized anxiety disorder; PD = panic disorder; OCD = obsessive compulsive disorder; CBCL = Child Behavior Checklist. * Correlation is significant at the p <.05 level (two-tailed). ** Correlation is significant at the p <.01 level (two-tailed).

60 54 Table 6 Correlations of RCADS-P with RCADS Subscales (Parent-Child Agreement) Scale SAD SOC MDD PD OCD GAD Anxiety Total Score Total Score Correlation (n).27* (77).26* (75).24* (76).23 (71).19 (74).10 (75).20 (69).21 (69) Note. RCADS-P = Revised Child Anxiety and Depression Scale - Parent Version; RCADS = Revised Child Anxiety and Depression Scale; MDD = major depressive disorder; SAD = separation anxiety disorder; SOC = social phobia; GAD = generalized anxiety disorder; PD = panic disorder; OCD = obsessive compulsive disorder. * Correlation is significant at the p <.05 level (two-tailed).

61 55 Table 7 Correlations of RCADS-P with Divergent Validity Criteria Externalizing Dimensional Ratings Scale Constmct Child (n) Parent (n) Consensus (n) RCADS-P MDD Oppositional.11 (76).29* (7S).16 (SO) SOC Oppositional -.04 (75).1S (77).05 (79) GAD Oppositional -.10(75).10 (77) -.03 (79) SAD Oppositional -.25* (77) -.00 (79) -.13 (Sl) OCD Oppositional -.02 (74).01 (76) -.10 (7S) PD Oppositional -.10 (71) -.04 (73) -.16(75) Anxiety Total Oppositional -.14 (69).06 (71) -.OS (73) Total Score Oppositional -.11 (69).11 (71) -.03 (73) MDD Delinquent -.09 (75).16 (SO) -.02 (SO) SOC Delinquent -.20 (74).01 (79) -.14 (79) GAD Delinquent -.32** (74) -.14 (79) -.27* (79) SAD Delinquent -.46** (76) -.26* (SI) -.39** (SI) OCD Delinquent -.16 (74) -.OS (7S) -.17 (7S) PD Delinquent -.26* (70) -.06 (75) -.22 (75) Anxiety Total Delinquent -.33** (69) -.13 (73) -.29* (73) Total Score Delinquent -.29* (69) -.06 (73) -.23* (73) CBCL Internalizing Total Oppositional -.02 (S1).21 (S2).04 (84) AnxiouslDepressed Oppositional -.02 (Sl).19 (S2).06 (84) Withdrawn/Depressed Oppositional -.07 (Sl).15 (S3).04 (85) Affective Problems Oppositional.03 (Sl).23* (S2).10 (S4) Anxiety Problems Oppositional -.13 (Sl).09 (S2) -.05 (84) Internalizing Total Delinquent -.22* (79).00 (84) -.17 (84) AnxiouslDepressed Delinquent -.26 (79) -.02 (84) -.IS (84) Withdrawn/Depressed Delinquent -.12 (79).02 (85) -.07 (S5) Affective Problems Delinquent -.06 (79).12 (84) -.04 (84) Anxiety Problems Delinguent -.36** (79) -.16 (84) -.32** (84) Note. RCADS-P = Revised Child Anxiety and Depression Scale - Parent Version; MDD = major depressive disorder; SOC = social phobia; GAD = generalized anxiety disorder; SAD = separation anxiety disorder; OCD = obsessive compulsive disorder; PD = panic disorder. * Correlation is significant at the p <.05 level (2-tailed). ** Correlation is significant at the p <.01 level (two-tailed).

62 56 TableS Correlations of RCADS with Divergent Validity Criteria Externalizing Dimensional Ratings Scale Construct Child (n) Parent (n) Consensus (n) RCADS MDD SOC GAD SAD OCD PD Anxiety Total Total Score Oppositional Oppositional Oppositional Oppositional Oppositional Oppositional Oppositional Oppositional.22 (80).09 (SO).1S(SO) -.03 (SO).OS (SO).13 (SO).12 (SO).15 (80).10 (73).16 (80) -.03 (73) -.04 (80) -.01 (73) -.02 (SO) -.10 (73) -.14 (SO) -.08 (73) -.06 (SO).13 (73).07 (SO) -.02 (73) -.04 (SO).01 (73).01 (SO) MDD SOC GAD SAD OCD PD Anxiety Total Total Score Delinquent Delinquent Delinquent Delinquent Delinquent Delinquent Delinquent Delinquent.15 (79) -.17 (79) -.02 (79) -.22* (79) -.OS (79).05 (79) -.11 (79) -.05 (79).07 (75).OS (80) -.10 (75) -.19 (80) -.02 (75) -.03 (80) -.16 (75) -.28* (SO) -.03 (75) -.10 (SO).05 (75) -.01 (80) -.07 (75) -.15 (SO) -.04 (75) -.10 (SO) Note. RCADS = Revised Child Anxiety and Depression Scale; MDD = major depressive disorder; SOC = social phobia; GAD = generalized anxiety disorder; SAD = separation anxiety disorder; OCD = obsessive compulsive disorder; PD = panic disorder. * Correlation is significant at the p <.05 level (2-tailed). ** Correlation is significant at the p <.01 level (two-tailed).

63 57 Table 9 Correlations ofrcads-p with Externalizing Problems Divergent Validity Criteria CBCLScale Oppositional IntemaIizing Externalizing Rule Aggressive Defiant Conduct Scale Total (n) Total (n) Breaking (n) Behaviors (n) Problems (n) Problems (n) RCADS-P MDD.73" (81).43'* (83).36" (83).50" (83).40" (83).39" (83) SOC GAD SAD.65" (81).11 (81).03 (81).18 (81).14 (81).02 (81).67" (81).25* (81).11 (81).31'(81).17 (81).11 (81).58" (83).10 (83) -.02 (83).20 (83).05 (83).03 (83) OCD.51"(81).18 (81).09 (81).24' (81).11 (81).09 (81) PD.63" (78).10 (78).03 (78).24* (78).07 (78).04 (78) Anxiety Total.73" (76).16 (76).04 (76).26" (76).13 (76).04 (76) Total Score.77" (81).23' (76).11 (76).33" (76).20 (76).12 (76) CBCL Internalizing Total.41" (89).30" (89).50" (89).36" (89).34" (89) Anxious! Depressed.40" (89).28" (89).51'* (89).36" (89).35" (89) Withdrawn! Depressed.33" (89).28" (89).40*' (89).30" (89).32" (89) Affective Problems.52* (89).43" (89).56" (89).43*' (89).46** (89) Anxiety Problems.23' (89).06 (89).37" (89).24" (89).13 (89) Note. RCADS-P = Revised Child Anxiety and Depression Scale - Parent Version; RCADS = Revised Child Anxiety and Depression Scale; MDD = major depressive disorder; SOC = social phobia; GAD = generalized anxiety disorder; SAD = separation anxiety disorder; OCD = obsessive compulsive disorder; PD = panic disorder. Correlation is significant at the p <.05 level (2-tailed).,. Correlation is significant at the p <.01 level (two-tailed).

64 58 Table 10 Correlations of RCADS-P Subscales and Divergent Validity Criterion Scale Scale Correlation (n) RCADS-P RCADS SAD MDD.10 (77) SOC MDD.11 (75) GAD MDD.08 (75) PD MDD.18 (71) OCD MDD.01 (74) MDD Anxiety Total Score.24* (76) Note. RCADS-P = Revised Cbild Anxiety and Depression Scale - Parent Version; RCADS = Revised Child Anxiety and Depression Scale; * Correlation is significant at the p <.05 level (two-tailed).

65 59 Table 11 Correlations of RCADS-P Suhscales with Convergent and Divergent Validity Criterion, with Fisher's z-tests Correlatioos with RCADS-P Subscales Convergent Correlatio Divergeot Scale Scale n (0) Scale Correlation (0) Fisher's z-test RCADS-P CBCL CBCL MDD Affective Problems 78 (83) Anxiety Problems.64 (83) z (83) = 2.35, p <.05. SAD Anxiety Problems.66 (83) Affective Problems.46 (83) z (83) = 2.775, P <.05 GAD Anxiety Problems.73 (81) Affective Problems.58 (81) z (81) = 2.291,p <.05 SOC Anxiety Problems.65 (81) Affective Problems.51 (81) z (81)= 1.869,p=.06; NS OCD Anxiety Problems.49 (81) Affective Problems.43 (89) z (81) = 0.696,p=.47; NS PD Anxiety Problems.65 (78) Affective Problems.52 (78) z (78) = 1.835, p =.07; NS Note. RCADS-P = Revised Child Anxiety and Depression Scale - Parent Version; MDD = major depressive disorder; SAD = separation anxiety disorder; SOC = social phobia; GAD = generalized anxiety disorder; PD = panic disorder; OCD = obsessive compulsive disorder. All correlations are significant at the p <.01 level (two-tailed).

66 60 Appendix A Agreement to Participate Test-Retest Reliability of the Parent Version of the Revised Child Anxiety and Depression Scale Bruce F. Chorpita Department of Psychology University of Hawai'i at Miinoa (808) The purpose of this aspect of the present investigation is to evaluate the test-retest psychometric properties of the parent fonn of the Revised Child Anxiety and Depression Scale (RCADS-P) Participation will entail completing the RCADS-P prior to the face-ta-face feedback session, approximately twa-weeks from the completion of the initial administration of the RCADS-P. It should take approximately 5 minutes to complete the RCADS-P. Participating in this aspect of the project may benefit the field of childhood and adolescence anxiety and depression research by aiding in the validation of an instroment that may be used to assess children and adolescents with depression and various anxiety disorders. There should be little or no risk to participating in this research project. However, there may be a small risk that participants may experience slight distress from thinking about these topics. Research data will be confidential to the extent allowed by law. Every participant will be assigned a number that will be used to track all of the data that is collected. No personal identifying infonnation will be included with the research results. Agencies with research oversight, such as the UH Committee on Human Studies, have the authority to review research data. All research records will be stored in a locked file in the primary investigators office for the duration of the research project and will be destroyed upon completion of the project. Participation in this research project is completely voluntary. You are free to withdraw from participation at any time during the duration of the project with no penalty, or loss of benefit to which you would otherwise be entitled. If you have any questions regarding this research project, please contact the researcher, Chad Ebesutani at (808) Participant: I have read and understand the above information, and agree to participate in this research project. Name (printed) Signature Date If you have any questions regarding your rights as a research participant, please contact the UH Committee on Human Studies at (808)

67 61 AppendixB RCADS P Please put a circle around the word that shows how often each of these things happens for your child. 1. My child worries about things Never Sometimes Often Always 2. My child feels sad or empty Never Sometimes Often Always 3. When my child bas a problem, he/she gets a funn~ feeling in hislher stomach 4. My child worries when he/she thinks he/she bas done poorl~ at something 5. My child feels afraid of being alone at home Never Sometimes Often Always Never Sometimes Often Always Never Sometimes Often Always 6. Nothing is much fun for my child anymore Never Sometimes Often Always 7. My child feels scared when taking a test Never Sometimes Often Always 8. My child worries when helshe thinks someone is anl!!i with himlher. 9. My child worries about being away from me 10. My child is bothered by bad or silly thoughts or I!ictures in his!her mind Never Sometimes Often Always Never Sometimes Often Always Never Sometimes Often Always 11. My child has trouble sleeping Never Sometimes Often Always 12. My child worries about doing badly at school work Never Sometimes Often Always 13. My child worries that something awful will hae~n to someone in the famil~ Never Sometimes Often Always 14. My child suddenly feels as if he/she can't breathe when there is no reason for this. Never Sometimes Often Always 15. My child bas problems with hislher ae~tite Never Sometimes Often Always 16. My child bas to keep checking that he/she has done things right (like the switch is off, or Never Sometimes Often Always the door is locked) 17. My child feels scared to sleep on his!her own Never Sometimes Often Always 18. My child bas trouble going to school in the mornings because of feeling nervous or afraid. Never Sometimes Often Always 19. My child bas no energy for things Never Sometimes Often Always 20. My child worries about looking foolish Never Sometimes Often Always 21. My child is tired a lot Never Sometimes Often Always 22. My child worries that bad things will happen to him!her 23. My child can't seem to get bad or silly thoughts out of hislher head. Never Sometimes Often Always Never Sometimes Often Always