Assessment of symptoms of DSM-IV anxiety and depression in children: a revised child anxiety and depression scale

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Abstract

The practical significance of assessing disorders of emotion in children is well documented, yet few scales exist that possess conceptual if not empirical relevance to dimensions of DSM anxiety or depressive disorders. The current study evaluated an adaptation of a recently developed anxiety measure (Spence Children's Anxiety Scale; [Spence, S. H. (1997). Structure of anxiety symptoms among children: a confirmatory factor-analytic study. Journal of Abnormal Psychology, 106, 280–297; Spence, S. H. (1998). A measure of anxiety symptoms among children. Behaviour Research and Therapy, 36, 545–566]), revised to correspond to dimensions of several DSM-IV anxiety disorders as well as major depression. This investigation involved initial evaluation of the factorial validity of the revised measure in a school sample of 1641 children and adolescents and reliability and validity in an independent sample of 246 children and adolescents. Results yielded an item set and factor definitions that demonstrated structure consistent with DSM-IV anxiety disorders and depression. The revised factor structure and definitions were further supported by the reliability and validity analyses. Some implications for assessment of childhood anxiety and depressive disorders are discussed.

Introduction

Self-report measures play an important role in the assessment of childhood anxiety and depressive disorders because such measures provide information about subjective experiences of the child that might not be obtainable from other sources (Strauss, 1990). In the past two decades, such measures as the Spielberger State-Trait Inventory for Children (STAIC; Spielberger, 1973), the Fear Survey Schedule for Children-Revised (FSSC-R; Ollendick, 1983) and the Revised Manifest Anxiety Scale for Children (RCMAS; Reynolds & Richmond, 1978), and the Children's Depression Inventory (CDI; Kovacs, 1980/1981) have each played a major role in the assessment of childhood anxiety and depressive disorders in clinical and research settings, and are among the most widely used instruments for the assessment of these disorders.

Measures such as the STAIC, FSSC-R, RCMAS and CDI have a substantial accumulation of empirical support (e.g. Carey et al., 1987, Lonigan et al., 1994, McCathie and Spence, 1991, Papay et al., 1975, Reynolds and Richmond, 1978, Saylor et al., 1984). However, because they were developed prior to the establishment of current diagnostic criteria (DSM-IV; APA, 1994) and thus were not designed to provide information about symptoms specific to particular clinical syndromes, these measures have sometimes been less promising with respect to their clinical utility (e.g. Perrin & Last, 1992).

This lack of a ‘gold standard’ for assisting with diagnosis in child populations has consistently served as an obstacle to the systematic identification of disorders in children (Hodges, 1990) and has directed the attention of researchers and clinicians alike to the development of more focused, symptom-specific instruments that correspond to the constructs underlying DSM-IV diagnostic criteria for these disorders.

The Spence Children's Anxiety Scale (SCAS; Spence, 1994) was created with this goal in mind. The SCAS is a 45-item scale with 38 items designed to assess children's report of anxiety symptoms corresponding to DSM anxiety disorders and seven items designed to assess social desirability. The six anxiety factors of the SCAS are: Panic/Agoraphobia (P/A), Social Anxiety (SOC), Separation Anxiety (SA), Generalized Anxiety (GA), Obsessions/Compulsions (OC) and Fear of Physical Injury (FPI). Initial evaluation of the SCAS suggested adequate internal consistency and preliminary support for convergent and discriminant validity (Spence, 1994, Spence, 1997). Exploratory factor analysis on the SCAS yielded factors consistent with several of the DSM-III-R anxiety disorders, but failed to produce a factor corresponding to GA in one investigation (Spence, 1994) and a relatively weak GA factor in another investigation (e.g. the GA factor accounted for lowest variance and failed to contain the item “I worry that something bad will happen to me”, Spence, 1998). Confirmatory factor analysis (CFA) of the SCAS supported a 6-factor structure consistent with DSM anxiety disorders relative to a one-factor comparison model (Spence, 1997, Spence, 1998).

For its total score, the SCAS has demonstrated good internal consistency (r=0.92) and adequate test–retest reliability over a six-month interval (r=0.60) in a sample of Australian children between the ages of 8 and 12. In this same sample, the SCAS also showed good convergent validity, as it was strongly correlated with the RCMAS Total Anxiety score (r=0.71). Additionally, each subscale of the SCAS was significantly positively correlated with the RCMAS total score, with correlation coefficients ranging from 0.50 for the Fear of Physical Injury subscale to 0.61 for the Generalized Anxiety subscale (Spence, 1998). As might be expected, the SCAS also demonstrated a positive correlation with the CDI (r=0.48) and subscales of the SCAS were significantly positively correlated with CDI scores, with correlation coefficients ranging from 0.32 for the Generalized Anxiety subscale to 0.44 for the Panic–Agoraphobia subscale (Spence, 1998). Although these findings appear to represent problems with discriminant validity, these findings are perhaps more attributable to the limited discriminant validity of the CDI, which has occasionally been described as a general measure of negative emotionality rather than a specific depression measure (Chorpita et al., 1998, Lonigan et al., 1994, Wolfe et al., 1987). The initial findings regarding the SCAS supported its use as a clinical assessment measure both for symptoms of anxiety and for dimensions of specific anxiety disorders in children. These developments were especially noteworthy, given the lack of brief, syndrome specific measures available for anxiety and depressive disorders in children (Chorpita et al., 1998).

Nevertheless, Spence (1997) reported a number of concerns with the SCAS. First, it was difficult to design a suitable scale to correspond to the diagnosis specific phobia, because its criteria focus on a single stimulus, and Spence (1997, p. 282) concluded, “it is not meaningful to search for a specific phobia factor”. In subsequent analyses, Spence (1998) found that one of the FPI items failed to load on any factor, and that the FPI scale demonstrated the lowest internal consistency (α=0.60). Therefore, one goal of the present study was to evaluate the structural validity of the FPI scale through another examination of its internal consistency and its discriminant validity from the other anxiety and depression factors (i.e. factorial validity; Cronbach & Meehl, 1955).

Second, SCAS items for the GA scale did not appear to represent the DSM-IV criteria, but rather were more consistent with the DSM-III-R criteria for overanxious disorder. Thus, rather than representing excessive worry, the key feature of DSM-IV GAD, these items focused more on a diversity of central nervous system and autonomic arousal symptoms (e.g. stomachaches, shakiness). Recent evidence regarding the DSM-IV GAD and DSM-III-R overanxious disorder criteria has demonstrated that the somatic features of overanxious disorder and GAD are less relevant to classification of generalized anxiety in children (Tracey, Chorpita, Douban & Barlow, 1997). In addition, accumulating evidence on GAD in adults suggests that autonomic symptoms in particular are not strongly associated with GAD (e.g.Borkovec et al., 1991, Brown et al., 1998, Brown et al., 1995).

Finally, the SCAS did not include items tapping symptoms of depression, despite the conceptually and clinically important relation between depression and anxiety (e.g.Barlow et al., 1996, Brady and Kendall, 1992, Clark and Watson, 1991). Our proposed revision of the SCAS (i.e. Revised Child Anxiety and Depression Scale; RCADS) therefore involved the addition of items corresponding to DSM-IV major depression, in light of this significant relation (e.g.Brady and Kendall, 1992, Lonigan et al., 1994, Tanenbaum et al., 1992) and the addition of items to represent the DSM-IV criteria for generalized anxiety disorder (GAD). The current study further extended the important work of Spence, 1994, Spence, 1997, Spence, 1998 by administering this revised scale to a US sample with a wider age range, and by performing an evaluation of the revised scale's factor structure, reliability, and validity with an ethnically diverse US sample.

Section snippets

Participants

Participants were 1641 children and adolescents recruited from 13 public and private schools in grades 3–12 on O'ahu, Hawaii (median grade=7). The mean age of the sample was 12.87 years (S.D.=2.82; range=6.17–18.92) and the group consisted of 893 girls (54.4%) and 748 boys (45.6%). Over 20 different ethnicities were identified, including Japanese American (n=463; 28.2%), Filipino (n=217; 13.2%), Hawaiian (n=204; 12.4%), Chinese American (n=138; 8.4%), Caucasian (n=133; 8.1%) or multi-ethnic (n

Participants

Participants were 246 children and adolescents recruited from public and private schools on O'ahu, Hawaii. The sample consisted of 109 males (44.3%) and 137 females (55.7%). The mean age was 12.20 years (S.D.=2.89; range=8.33–18.33). Major ethnic groups represented included Filipino (n=67; 29.9%), Japanese American (n=28; 12.5%), Caucasian (n=21; 9.4%), Hawaiian (n=20; 8.9%) and multi-ethnic (n=45; 20.1%). A subset of participants in this study (n=125) attended schools that provided

Discussion

Results of the current investigation provide strong initial support for the structural validity, reliability and convergent and discriminant validity of the RCADS, which was modified from the SCAS (Spence, 1994, Spence, 1997) and designed to measure child self-report of DSM childhood anxiety disorders and depression. The RCADS reflects four major changes to the SCAS: (a) removal of the FPI scale because its items loaded on multiple scales; (b) narrowing of the PA scale to PD to reflect removal

Acknowledgements

The authors wish to thank O'ahu public schools and the St. Louis School for their cooperation and participation. We also gratefully acknowledge Milani Plummer, Gayle Shore, Charmaine Higa, I Han Lam, Sandra Scarbrough, Dana Rho, Asako Shinagawa, Jennifer Vanslyke, Ann Huynh, Susan Chon, Kristi Nakada, Tisha Taba, Jesse Reiff, Jodi Ninomiya, Ayada Azeez and Jamela Santos for their assistance with data collection and entry.

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