Journal of Behavior Therapy and Experimental Psychiatry 33 (2002) 118

Reliability and validity of the Spence Childrens Anxiety Scale and the Screen for Child Anxiety Related Emotional Disorders in German children
Cecilia A. Essaua,*, Peter Murisb, Elfriede M. Edererc
a

Psychologisches Institut I, Westfalische Wilhelms-Universitat Fliednerstrae 21, 48149 Munster, . . Munster, . . Germany b Department of Medical, Clinical, and Experimental Psychology, Maastricht University, P.O. Box 616, 6200 MD Maastricht, The Netherlands c Institut fur . Erziehungs- und Bildungswissenschaften, Karl-FranzensUniversitat . Graz, Merangasse 70/2, A8010 Graz, Austria Received 20 November 2000; received in revised form 5 December 2001; accepted 11 January 2002

Abstract The reliability and validity of the Spence Childrens Anxiety Scale (SCAS) and the Screen for Child Anxiety Related Emotional Disorders (SCARED) were evaluated in a sample of 556 German primary school children. Both the SCAS (alpha=0.92) and the SCARED (alpha=0.91) were demonstrated to have high internal consistency. The validity of the SCAS and the SCARED was supported by a number of ndings. First, in agreement with previous studies, girls displayed signicantly higher levels of anxiety symptoms than boys. Furthermore, SCAS and SCARED scores were substantially interrelated. Finally, signicant correlations were found between these two measures of anxiety symptoms and the Youth SelfReport and the Columbia Impairment Scale. The utility of the SCAS and the SCARED as screening instruments for anxiety symptoms in children is briey discussed. r 2002 Elsevier Science Ltd. All rights reserved.
Keywords: Spence Childrens Anxiety Scale; Screen for Child Anxiety Related Emotional Disorders; Anxiety symptoms

*Corresponding author. Tel.: +49-251-83-341-52. E-mail address: essau@uni-muenster.de (C.A. Essau). 0005-7916/02/$ - see front matter r 2002 Elsevier Science Ltd. All rights reserved. PII: S 0 0 0 5 - 7 9 1 6 ( 0 2 ) 0 0 0 0 5 - 8

C.A. Essau et al. / J. Behav. Ther. & Exp. Psychiat. 33 (2002) 118

1. Introduction Anxiety disorders represent one of the most common psychiatric disorders in children and adolescents. Findings from epidemiological studies have shown that as many as 10% of the children and adolescents are affected by these disorders (Essau, Conradt, & Petermann, 2000; Essau & Petermann, 2001; Lewinsohn, Hops, Roberts, Seeley, & Andrews, 1993; McGee et al., 1990). Although some fears and anxieties are part of normal development, for some proportions of the children these problems, if left untreated, may persist through adolescence and adulthood (Cohen et al., 1993; Feehan, McGee, & Williams, 1993; Keller et al., 1992). Anxiety is associated with impairment in various life domains such as in school, leisure-time activities, and peer-interaction (Bowen, Offord, & Boyle, 1990; Essau et al., 2000; Kashani & Orvaschel, 1990; Ginsburg, La Greca, & Silverman, 1998). Studies have also indicated that the presence of anxiety symptoms may act as a risk factor for the development of various types of psychiatric disorders in adulthood, including depression and substance use disorders (Wittchen & Essau, 1994). These ndings stress the importance to identify clinically anxious children at an early stage so that appropriate intervention can be provided. The realization of this aim, however, depends on the availability of instruments with sound psychometric properties. Structured diagnostic interviews are not practical as a screening instrument because they are too time consuming to administer, and usually require that the interviewers are well-trained in using the instrument (Essau & Barrett, 2001). By contrast, selfreport questionnaires are more convenient, less expensive, and are easy to standardize. Given these advantages, numerous self-report questionnaires for the assessment of anxiety symptoms in children and adolescents have been developed and examined in the literature. The most commonly used scales are the Fear Survey Schedule for Children-Revised (FSSC-R; Ollendick, 1983), the Revised Childrens Manifest Anxiety Scale (RCMAS; Reynolds & Richmond, 1985), and the State-Trait Anxiety Inventory for Children (STAIC; Spielberger, Gorsuch, & Luchene, 1976). Other instruments have been tailored to specic types of anxiety, including social anxiety and fear of negative evaluation (e.g., the Social Anxiety Scale for Children; LaGreca & Stone, 1993), and posttraumatic stress disorder (e.g., the PTSD Reaction Index; Frederick, 1985). While these questionnaires have sound psychometric properties, they cannot be used to measure symptoms of DSM-IV anxiety disorders. Two noteworthy exceptions in this respect are the Spence Childrens Anxiety Scale (SCAS; Spence, 1997, 1998) and the Screen for Child Anxiety Related Emotional Disorders (SCARED; Birmaher et al., 1997, 1999). Unlike other existing questionnaires (e.g., RCMAS or STAIC), the SCAS and the SCARED tap anxiety symptoms that can be specically linked to DSM-IV anxiety disorders. The SCARED was developed within the context of samples in clinical settings (Birmaher et al., 1997), however, it has been used in non-referred school children (Muris, Schmidt, & Merckelbach, 2000). Although the development of the SCAS was based on community samples, this scale has also norms for clinically referred children (Spence, 1997, 1998). Recent studies have provided strong support for the

C.A. Essau et al. / J. Behav. Ther. & Exp. Psychiat. 33 (2002) 118

psychometric properties of the SCAS and the SCARED (Birmaher et al., 1997; Muris, Merckelbach, van Brakel, Mayer, & van Dongen, 1998a; Muris et al., 2000; Spence, 1997, 1998). Strong correlations have also been reported between the SCAS and the SCARED with traditional measures of anxiety symptoms such as the RCMAS, STAIC, and the FSSC-R (Muris et al., 1998b; Spence, 1998). The main purpose of the present study was to examine the reliability and the validity of the German translation of the SCAS and SCARED in primary school children. Such psychometric evaluation would indicate whether these two self-report questionnaires are useful for screening anxiety symptoms in normal population. Another purpose is to examine age and gender patterns of anxiety symptoms, and the relationship of anxiety symptoms with psychosocial functioning.

2. Methods 2.1. Participants The sample consisted of 556 children (275 boys and 281 girls) who were enrolled in grades 36. Childrens age ranged from 8 to 12 years (mean=10.6, SD=1.2). The participants were recruited from urban and rural primary schools in Niedersachen, Germany. Most of the children came from small families and were rstborn children. The vast majority of them came from intact families; about 80% of the children were living with both parents. The socioeconomic status of subjects varied greatly, ranging from parents with low-skill jobs to physicians. School approval and parental written informed consent were obtained before participation in the study; childrens participation was voluntary. About 75% of the children who were invited to participate in the study eventually did so. 2.2. Procedure In addition to the SCAS and the SCARED, the children also completed a brief questionnaire to obtain demographic characteristics such as age, gender, and parental occupation. In order to further test the convergent validity of the SCAS and the SCARED, subjects were also administered the Columbia Impairment Scale (CIS) and the Youth Self-Report (YSR). These instruments were administered in counterbalanced order to children across classes. Two research assistants were present to provide assistance to the children if necessary. For children 8 and 9 years, questionnaire items were read aloud by one of the research assistants, whereas the older children completed the questionnaires independently. 2.3. Instruments The SCAS is a 38-item measure of anxiety symptoms in children aged 812 years (Spence, 1997, 1998). The SCAS items reect symptoms of the main DSM-IV anxiety

C.A. Essau et al. / J. Behav. Ther. & Exp. Psychiat. 33 (2002) 118

disorders that may occur in children including separation anxiety (6 items; e.g., I would feel afraid of being on my own at home), social phobia (6 items; e.g., I feel afraid if I have to use public toilets or bathrooms), obsessivecompulsive disorder (6 items; e.g., I cant seem to get bad or silly thoughts out of my head), panic/ agoraphobia (9 items; e.g., I suddenly feel as if I cant breathe when there is no reason for this), physical injury fears (5 items; e.g., I am scared of dogs), and generalized anxiety disorder (6 items; e.g., When I have a problem, I get a funny feeling in my stomach). Each item is rated on a 4-point scale in terms of its frequency from never (0) to always (3). The 03 ratings of the 38 anxiety items are summed to yield a total score, with higher scores reecting higher levels of anxiety symptoms. Internal consistency and testretest reliability of the SCAS have been reported as satisfactory, with alphas generally well above 0.70 and a testretest correlation coefcient of 0.60. The scale also demonstrated acceptable convergent validity as demonstrated by a signicant correlation with the RCMAS (r 0:71). Furthermore, clinically anxious had signicantly higher SCAS scores and in particular on subscales that reected the anxiety disorder they suffered from (i.e., social phobia and separate anxiety disorder) than control children. The SCARED was developed to screen symptoms for some anxiety disorders, namely, generalized anxiety disorder, separation anxiety disorder, panic disorder, social and school phobia. There are several versions of the SCARED. The original version contained 85 questions identifying symptoms of DSM-IV anxiety disorders (see above) which have been generated by experienced clinicians (Birmaher et al., 1997). A factor analysis and a deletion of items which overlapped with depressive symptoms led to the derivation of the 38-item version. However, since social factor failed to discriminate patients with social phobia and other anxiety disorders, three items were added, thus, resulting in the 41-item version. For the present study, the 41-item version was used (Birmaher et al., 1999). Factor analysis yielded ve factors/ subscales: somatic/panic (13 items; e.g., When I feel frightened, it is hard to breathe), generalized anxiety (9 items; e.g., I worry about other people liking me), separation anxiety (8 items; e.g., I get scared if I sleep away from home), social phobia (7 items; e.g., I dont like to be with people I dont know well), and school phobia (4 items; e.g., I get headaches when I am at school). Children are to indicate the frequency in which each symptom is experienced on a 3-point scale: 0 (almost never), 1 (sometimes), and 2 (often). The SCARED total anxiety and subscale scores can be obtained by summing across relevant items. Each factor/ subscale had good internal consistency, with Cronbachs alphas ranging from 0.74 to 0.89. Testretest reliability has found to be good, with intraclass correlation coefcients for the total score being 0.86, and between 0.70 and 0.90 for the individual factors/subscales. The SCARED also has good discriminant validity, that is, the scale differentiated between children with anxiety disorders and children suffering from other disorders, as well as among children with different subtypes of anxiety disorders. The CIS is a 13-item scale that can be used to measure four major domains of functioning or impairment: interpersonal relations, broad areas of psychopathology, functioning at school or work, and use of leisure time. Items of the CIS are rated on

C.A. Essau et al. / J. Behav. Ther. & Exp. Psychiat. 33 (2002) 118

a Likert scale ranging from 0 (no problem) to 4 (a very big problem). The CIS total score and their subscales scores can be obtained by summing scores on relevant items. The CIS has been found to show excellent psychometric properties when applied to children ranging in age from 9 to 17 years (Bird & Gould, 1995). Both the internal consistency and testretest reliability of the scale are high. As for its validity, the CIS correlated signicantly with clinicians ratings based on the Childrens Global Assessment Scale (Bird et al., 1996). The reliability and validity of the German version of the CIS has been examined in a large epidemiological study of adolescents aged 1217 years (Essau, 2000). The results generally showed good reliability as measured by the internal consistency; the alpha for the total CIS score was 0.77 and the Guttman split-half was 0.76. Furthermore, adolescents who met the diagnosis of any anxiety and depressive disorders had signicantly higher CIS scores than adolescents without any disorders. Adolescents with a high score on the CIS signicantly used more mental health services than those with low CIS score. In the present study, the Cronbachs alpha for the CIS total score was 0.76 and a Guttman split-half was 0.75. The alphas for the subscales functioning at school or work and psychopathology were moderate, being 0.69 and 0.68, respectively. The internal consistency for the subscales interpersonal relations (alpha=0.44) and the use of leisure time (alpha=0.32) was less satisfying. The YSR contains a list of 118 specic problems in children and adolescents (Achenbach, 1991). The YSR consists of the following subscales: withdrawal, somatic complaints, anxious/depressed, social problems, thought problems, attention problems, delinquent behavior, and aggressive behavior. Based on these scales, two second-order scales that reect externalizing and internalizing syndromes can be calculated (Achenbach, 1991). The anxious/depressed, somatic complaints, and withdrawn syndromes are assigned to the internalizing syndrome. The aggressive behavior and delinquent behavior syndromes are assigned to the externalizing syndrome. Some syndromes which do not fall within one of the two broad-band categories are dened as the mixed syndromes. Children have to respond on 3point scales whether each behavior is not true, somewhat or sometimes true or very true or often true of their behavior now or in the past 6 months. Findings on the internal consistency and validity of the YSR reported in various studies (e.g., Achenbach, 1991) have been replicated in a number of German studies of children and adolescents in clinical and epidemiological settings . . (Dopfner, Schmeck, Berner, Lehmkuhl, & Poustka, 1994; Dopfner, Berner, & Lehmkuhl, 1995). In the present study, the internal consistency of the YSR was high. The alpha for the total score was 0.94, and the Guttman split-half was 0.83. The alpha for the internalizing syndromes was 0.89, for externalizing syndromes 0.85, and for the mixed syndromes 0.86. The intercorrelations among these subscales were all highly signicant (po0:001). That is, the correlation between externalizing and internalizing syndromes was 0.66 (po0:001), externalizing and mixed syndromes was 0.76 (po0:001), and internalizing and mixed syndromes was 0.83 (po0:001). Signicant correlations were also found between the YSR and the CIS (r 0:53; po0:001).

C.A. Essau et al. / J. Behav. Ther. & Exp. Psychiat. 33 (2002) 118

2.3.1. Translation of instruments The English version of the SCAS and the SCARED were adapted and translated according to guidelines that are widely accepted for the successful translation of instruments in cross-cultural research (Brislin, 1970). One bilingual translator who was also a native speaker or culturally informed individual blindly translated the questionnaires from the original language (English) to the second language (German), and another bilingual translated it back to the original language (German back to English). Differences in the original and the back-translated versions were discussed and resolved by joint agreement of both translators.

3. Results The means and standard deviations for the SCAS and the SCARED,1 as well as their subscales are presented in Table 1. The most frequently reported symptoms in the SCAS were related to generalized anxiety disorder and social phobia. In the SCARED, the most common symptoms were related to social phobia. The least common symptoms were related to panic disorder (as measured using the SCAS), school phobia and panic disorder (based on the SCARED). 3.1. Reliability The internal consistency was computed for the SCAS and SCARED total anxiety scores and for each of their subscales. The results showed that the SCAS and the SCARED possess high internal consistency. Cronbachs alpha for the SCAS total score was 0.92 and a Guttman split-half was 0.90. The internal consistency of the various subscales was also acceptable. Cronbachs alphas were 0.70 for separation anxiety, 0.72 for social phobia, 0.71 for Obsessivecompulsive, 0.82 for panic/ agoraphobia, 0.57 for physical injury fears, and 0.74 for generalized anxiety.
The factor structure of the SCAS and SCARED was examined by means of exploratory factor analysis. A principal components extraction method with oblimin rotation was performed as the various anxiety factors were substantially intercorrelated. Initial factor analysis of the SCAS revealed problems with the physical injury fears items: these items failed to load on one separate factor (see also Chorpita, Yim, Moftt, Umemoto, & Francis, 2000). After removing these items, a second factor analysis yielded 7 factors with eigenvalues >1.0 (9.9, 1.8, 1.7, 1.6, 1.3, 1.1, 1.0) with the screen test suggesting either 4 or 5 factors. Inspection of the solutions indicated that the 5-factor structure, which accounted for 43.8% of the variance, was most satisfactory. Items loaded principally on hypothesized factors. This was particularly true for the panic/agoraphobia and social phobia factors. Separation anxiety was divided into two separate factors, that is, separation fear (i.e., feeling insecure when being alone) and worry about harm to self or signicant others. Items of obsessivecompulsive disorder (in particular those referring to intrusive thinking) and generalized anxiety disorder generally clustered together on one factor, while other items of these disorders spread across multiple factors. For the SCARED, a 6-factor structure was found (eigenvalues: 9.4, 2.4, 1.8, 1.5, 1.4, 1.4; percentage of explained variance: 43.7%). Four factors emerged that corresponded with intended subscales: generalized anxiety, social phobia, school phobia, and somatic/ panic. Again, separation anxiety splitted into two factors: separation fear and worry about harm.
1

C.A. Essau et al. / J. Behav. Ther. & Exp. Psychiat. 33 (2002) 118

Table 1 Mean scores and standard deviations on the SCAS and the SCARED in sample of normal German school children Number of items Raw total score Mean SCAS Total anxiety score Separation anxiety disorder Social phobia Obsessivecompulsive disorder Panic disorder Physical injury fears Generalized anxiety disorder SCARED Total anxiety score Separation anxiety disorder Social phobia Panic disorder Generalized anxiety disorder School phobia 38 6 6 6 9 5 6 22.24 3.72 4.58 4.05 2.47 2.79 4.60 (SD) (14.5) (2.9) (3.6) (2.9) (3.3) (2.4) (2.9) Total/number of items Mean 0.59 0.62 0.76 0.67 0.27 0.56 0.77 (SD) (0.4) (0.5) (0.6) (0.5) (0.4) (0.5) (0.5)

41 8 7 13 9 4

18.85 4.54 4.57 3.69 4.95 1.10

(11.6) (3.0) (3.1) (3.8) (3.6) (1.4)

0.46 0.57 0.65 0.28 0.55 0.27

(0.3) (0.4) (0.4) (0.3) (0.4) (0.4)

Note: SCAS=Spence Childrens Anxiety Scale; SCARED=Screen for Child Anxiety Related Emotional Disorders.

Similar results were obtained for the SCARED. Cronbachs alpha for the SCARED total anxiety score was 0.91 and a Guttman split-half 0.90. The internal consistency for the SCARED subscales were also good, with alphas being 0.66 for school phobia, 0.81 for panic and generalized anxiety, 0.71 for separation anxiety, and 0.75 for social phobia. Further analyses showed substantial intercorrelations among SCAS as well as SCARED subscales. All correlations were highly signicant (po0:001). The strongest correlations were found between panic and generalized anxiety, and between social phobia and generalized anxiety (Table 2). 3.2. Validity The validity of the SCAS and the SCARED was tested in three ways. First, because previous studies generally have found that girls report higher levels of anxiety symptoms or anxiety disorders than do boys (e.g., Essau et al., 2000), gender differences were tested. A nding that girls reported signicantly more anxiety symptoms than boys would support the validity of the SCAS and the SCARED. As shown in Table 3, signicant gender differences emerged for the SCAS, F (1, 554)=28.31, po0:001) and SCARED total scores, F (1, 554)=45.44, po0:001) as well as for all subscales. That is, girls displayed signicantly higher levels of anxiety symptoms than boys.

C.A. Essau et al. / J. Behav. Ther. & Exp. Psychiat. 33 (2002) 118

Table 2 Intercorrelations of the SCAS and SCARED subscales SCAS subscales Separation anxiety Separation anxiety Social phobia Obsessive compulsive Panic disorder Physical injury fears Generalized anxiety 1.00 0.55 0.50 0.62 0.49 0.59 Social phobia 1.00 0.61 0.59 0.57 0.68 Obsessive Panic disorder Physical injury fears

1.00 0.57 0.41 0.66 1.00 0.51 0.69

1.00 0.47

SCARED subscales Separation anxiety Separation anxiety Social phobia Panic disorder Generalized anxiety School phobia 1.00 0.51 0.51 0.48 0.35 Social phobia 1.00 0.48 0.58 0.27 Panic disorder Generalized anxiety School phobia

1.00 0.66 0.43

1.00 0.41

1.00

Note: SCAS=Spence Childrens Anxiety Scale; SCARED=Screen for Child Anxiety Related Emotional Disorders.

The next step of our analysis was to examine the association between age and anxiety symptoms. In the SCAS, signicant age effects were found in three of the six subscales: separation anxiety, F (4, 551)=6.51, po0:001; panic/agoraphobia, F (4, 551)=2.5, po0:05; and generalized anxiety, F (4, 551)=3.02, po0:05: That is, separation anxiety and panic/agoraphobia decreased with increasing age, whereas the reverse was true for generalized anxiety. For the SCARED, a signicant age effect was found for separation anxiety, F (4, 551)=7.06, po0:001 and generalized anxiety, F (4, 551)=3.16, po0:01: Again, separation anxiety declined with age, whereas generalized anxiety showed a uctuating pattern, but tended to increase slightly. In general, no substantial interaction effects of age and gender emerged. Second, the convergent validity was tested by computing correlations between SCAS and SCARED. Signicant positive correlations between these two anxiety measures would support their convergent validity. The Pearson product-moment correlation between the total scores of the SCAS and the SCARED was 0.85 (po0:001). As shown in Table 4, there was a substantial correlation between most of the SCAS subscales and their corresponding SCARED subscales. That is, SCAS separation anxiety correlated strongly with SCARED separation anxiety, SCAS panic with SCARED panic, and so forth. In some cases, correlations between the corresponding SCARED and SCAS subscales were stronger than between noncorresponding subscales.

Table 3 Mean and standard deviations by gender and age for SCAS and SCARED subscales Age (years) ANOVA 8 M SCAS Total score (SD) 9 M (SD) 10 M (SD) 11 M (SD) 12 C.A. Essau et al. / J. Behav. Ther. & Exp. Psychiat. 33 (2002) 118 M (SD) Effects

Boys 16.06 (10.4) 16.94 (12.9) 19.67 (9.8) 17.84 (10.4) 16.43 (10.2) Gender: F (1, 554)=60.02, po0:001 Girls 25.75 (14.3) 24.10 (13.3) 28.24 (18.9) 27.41 (17.5) 26.00 (14.6) Age: F (4, 551)=1.10, p 0:35 Total 22.09 (13.7) 20.19 (13.4) 23.81 (15.5) 23.00 (15.4) 20.92 (13.3) Gender age: F (4, 555)=0.12, p 0:98 Boys Girls Total Boys Girls Total 3.88 6.00 5.20 3.00 4.00 3.62 3.12 3.57 3.40 1.94 3.96 3.20 2.17 3.00 2.69 1.94 5.21 3.98 (2.1) (2.3) (2.5) (3.3) (3.9) (3.7) (1.9) (2.4) (2.2) (2.1) (4.0) (3.5) (2.9) (2.2) (2.5) (1.6) (2.9) (2.9) 3.61 5.37 4.41 3.33 4.57 3.89 3.67 3.53 3.61 1.72 2.97 2.29 1.53 3.30 2.33 3.08 4.37 3.67 (2.4) (3.4) (2.9) (3.4) (3.5) (3.4) (3.1) (2.9) (3.0) (2.5) (2.7) (2.6) (1.8) (2.6) (2.4) (2.8) (2.0) (2.6) 3.52 4.31 3.90 3.69 5.86 4.75 4.38 4.73 4.55 1.65 3.88 2.73 2.05 3.73 2.86 4.37 5.73 5.02 (2.4) (3.5) (3.5) (2.5) (4.1) (3.5) (2.4) (3.3) (2.9) (2.2) (4.5) (3.7) (1.5) (2.9) (2.4) (2.5) (3.7) (3.2) 2.84 4.10 3.52 3.71 5.70 4.78 3.49 4.80 4.20 1.54 3.71 2.71 2.23 3.59 2.96 4.02 5.51 4.82 (2.1) (3.3) (2.9) (2.7) (3.8) (3.4) (2.4) (3.4) (3.0) (2.0) (4.5) (3.7) (2.1) (2.6) (2.4) (2.3) (3.5) (3.1) 2.57 3.59 3.05 3.74 6.04 4.82 3.14 4.67 3.86 1.11 2.59 1.80 2.17 3.49 2.69 3.71 5.59 4.59 (2.0) Gender: F (1, 554)=28.31, po0:001 (2.9) Age: F (4, 551)=6.51, po0:001 (2.5) Gender age: F (4, 555)=0.68, p 0:61 (2.9) Gender: F (1, 554)=43.77, po0:001 (3.8) Age: F (4, 551)=1.85, p 0:61 (3.6) Gender age: F (4, 555)=0.52, p 0:72 (2.6) Gender: F (1, 554)=12.75, po0:001 (3.6) Age: F (4, 551)=2.01, p 0:09 (3.2) Gender age: F (4, 555) =1.45, p 0:22 (1.4) Gender: F (1, 554)=52.69, po0:001 (2.9) Age: F (4, 551)=2.54, p 0:04 (2.3) Gender age: F (4, 555)=0.51, p 0:74 (2.2) Gender: F (1, 554)=51.73, po0:001 (2.6) Age: F (4, 551)=0.84, p 0:50 (2.5) Gender age: F (4, 555)=0.38, p 0:82 (2.5) Gender: F (1, 554)=46.60, po0:001 (2.7) Age: F (4, 551)=3.02, p 0:02 (2.7) Gender age: F (4, 555)=1.11, p 0:35

Separation anxiety disorders

Social phobia

Obsessivecompulsive disorder Boys Girls Total Panic disorder Boys Girls Total Boys Girls Total Boys Girls Total

Physical injury fears

Generalized anxiety disorder

10

Table 3 (continued) Age (years) ANOVA 8 M SCARED Total score (SD) 9 M (SD) 10 M (SD) 11 M (SD) 12 M (SD) Effects

C.A. Essau et al. / J. Behav. Ther. & Exp. Psychiat. 33 (2002) 118

Boys 13.76 Girls 21.21 Total 18.40 Boys Girls Total Boys Girls Total Boys Girls Total Boys Girls Total Boys Girls Total 4.00 6.68 5.76 4.00 5.75 5.09 2.06 3.96 3.24 2.59 3.89 3.40 1.18 0.93 1.00

(8.2) 16.28 (9.8) 18.27 (11.9) 14.17 (10.8) 15.05 (8.7) Gender: F (1, 554)=45.69, po0:001 (8.9) 20.80 (9.9) 22.44 (13.8) 22.31 (13.1) 22.10 (10.8) Age: F (4, 551)=0.61, p 0:66 (9.3) 18.33 (10.0) 20.29 (12.9) 18.56 (12.7) 18.36 (10.3) Gender age: F (4, 555)=0.74, p 0:57 (2.7) (2.3) (2.8) (2.7) (3.3) (3.2) (2.4) (3.4) (3.1) (2.5) (3.5) (3.2) (1.1) (0.9) (1.0) 4.78 6.93 5.76 3.47 4.77 4.06 2.92 3.03 2.97 4.19 5.00 4.56 0.92 1.07 0.98 (2.7) (2.7) (2.9) (2.1) (3.5) (2.9) (4.2) (3.1) (3.7) (2.8) (2.9) (2.9) (1.1) (1.4) (1.2) 4.27 5.10 4.67 4.30 5.61 4.93 3.79 5.08 4.42 5.21 5.31 5.25 0.69 1.34 1.01 (3.1) (2.9) (3.0) (2.8) (3.2) (3.0) (3.7) (5.0) (4.4) (3.8) (3.9) (3.8) (1.2) (1.5) (1.4) 3.53 5.00 4.32 3.60 5.26 4.49 2.63 4.40 3.58 3.75 5.89 4.90 0.66 1.76 1.26 (2.7) (3.2) (3.1) (2.8) (3.4) (3.2) (3.2) (3.9) (3.7) (3.4) (3.8) (3.8) (1.3) (1.8) (1.7) 3.03 4.64 3.78 3.62 5.34 4.43 2.91 4.52 3.67 4.67 6.28 5.43 0.83 1.31 1.06 (2.2) Gender: F (1, 554)=39.38, po0:001 (3.1) Age: F (4, 551)=7.06, po0:01 (2.8) Gender age: F (4, 555)=1.09, p 0:36 (2.6) Gender: F (1, 554)=39.54, po0:001 (2.8) Age: F (4, 551)=1.33, p 0:26 (2.8) Gender age: F (4, 555)=0.14, p 0:97 (3.1) Gender: F (1, 554)=20.19, po0:001 (3.5) Age: F (4, 551)=1.96, p 0:10 (3.4) Gender age: F (4, 555)=0.69, p 0:59 (3.4) Gender: F (1, 554)=16.93, po0:001 (3.5) Age: F (4, 551)=3.16, p 0:01 (3.5) Gender age: F (4, 555)=1.68, p 0:15 (1.2) Gender: F (1, 554)=27.99, po0:001 (1.5) Age: F (4, 551)=0.84, p 0:50 (1.4) Gender age: F (4, 555)=2.75, p 0:03

Separation anxiety disorder

Social phobia

Panic disorder

Generalized anxiety disorder

School phobia

Note: SCAS=Spence Childrens Anxiety Scale; SCARED=Screen for Child Anxiety Related Emotional Disorders.

C.A. Essau et al. / J. Behav. Ther. & Exp. Psychiat. 33 (2002) 118

Table 4 Correlations between the SCAS and SCARED SCAS Total anxiety score SCARED Total anxiety score Separation anxiety disorder Social phobia Panic disorder Generalized anxiety School phobia Separation anxiety disorder 0.68 0.72 0.49 0.52 0.48 0.39 Social phobia Obsessive compulsive disorder 0.66 0.40 0.51 0.56 0.66 0.32 Panic disorder Physical injury fears Generalized anxiety disorder 0.76 0.51 0.54 0.71 0.67 0.43

0.85 0.62 0.65 0.72 0.73 0.50

0.73 0.45 0.59 0.56 0.71 0.48

0.71 0.51 0.53 0.68 0.52 0.46

0.53 0.38 0.47 0.41 0.45 0.27

Note: SCAS=Spence Childrens Anxiety Scale; SCARED=Screen for Child Anxiety Related Emotional Disorders; The numbers in bold represent correlations between the SCAS and the SCARED scales that are supposed to measure symptoms of the same anxiety disorder; All correlations are signicant at the po0:001:

11

12

C.A. Essau et al. / J. Behav. Ther. & Exp. Psychiat. 33 (2002) 118

Further analyses were done to test the signicance between some of these correlations. The correlation between SCAS social phobia and SCARED social phobia was signicantly higher than the correlation between SCAS social phobia and SCARED separation anxiety (z 4:1; po0:001). The correlation of SCAS social phobia and SCARED social phobia, and the correlation of SCAS social phobia and SCARED generalized anxiety (z 0:4; p 0:69) failed to reach a signicant level. No statistical signicant level could also be found between the correlation of SCAS social phobia and SCARED social phobia, and between SCAS social phobia and SCARED panic (z 0:9; p 0:36). Third, the validity of the SCAS and the SCARED was further examined by correlating them with the CIS and the YSR. The SCAS (r 0:41; po0:001) and SCARED (r 0:46; po0:001) total anxiety scores correlated signicantly with total CIS scores (Table 5). That is, a higher frequency of anxiety symptoms was associated with a higher level of impairment. When considering the subscales of these instruments, the most substantial correlations were found between generalized anxiety and psychopathology (SCAS: r 0:44; po0:001; SCARED: r 0:49; po0:001).

Table 5 Correlations between SCAS, SCARED, and CIS Total score SCAS Total anxiety score Separation anxiety disorder Social phobia Obsessive compulsive disorder Panic disorder Physical injury fears Generalized anxiety disorder SCARED Total anxiety score Separation anxiety disorder Social phobia Panic disorder Generalized anxiety disorder School phobia Interpersonal relation 0.19 0.13 0.18 0.18 0.13 0.15 0.15 Psychopath. At school/ work 0.24 0.15 0.30 0.18 0.14 0.22 0.13 Use of leisure time 0.31 0.17 0.30 0.25 0.29 0.22 0.26

0.41 0.27 0.41 0.34 0.30 0.30 0.35

0.46 0.30 0.43 0.37 0.33 0.29 0.44

0.46 0.27 0.33 0.36 0.43 0.38

0.23 0.13 0.19 0.16 0.18 0.26

0.49 0.29 0.32 0.43 0.49 0.33

0.29 0.18 0.20 0.21 0.27 0.29

0.30 0.16 0.26 0.21 0.32 0.21

Note: SCAS=Spence Childrens Anxiety Scale; SCARED=Screen for Child Anxiety Related Emotional Disorders; CIS=Columbia Impairment Scale; All correlations are signicant at the po0:001; except for the correlation between SCARED separation anxiety disorder and interpersonal.

Table 6 Correlations between YSR, SCAS, and SCARED C.A. Essau et al. / J. Behav. Ther. & Exp. Psychiat. 33 (2002) 118 Total YSR Total internalizing Internalizing Anx. SCAS Total anxiety score Separation anxiety Social phobia Obsessivecompulsive Panic disorder Physical injury fears Generalized anxiety SCARED Total anxiety score Separation anxiety Social phobia Panic disorder Generalized anxiety School phobia 0.67 0.87 0.71 0.57 0.55 0.42 0.59 0.92 0.50 0.62 0.59 0.61 0.43 0.66 0.71 0.49 0.64 0.59 0.57 0.44 0.64 Som. 0.54 0.38 0.41 0.45 0.52 0.31 0.51 With. 0.50 0.34 0.45 0.40 0.43 0.31 0.47 0.86 0.26 0.40 0.37 0.32 0.22 0.36 Total externalizing Externalizing Aggr. 0.43 0.26 0.43 0.39 0.34 0.24 0.38 Delin. 0.26 0.19 0.25 0.23 0.19 0.13 0.24 0.67 0.47 0.60 0.57 0.55 0.47 0.55 Total mixed Mixed Soz. 0.54 0.39 0.49 0.44 0.46 0.37 0.44 Thoug. 0.43 0.35 0.33 0.42 0.37 0.27 0.33 Atten. 0.56 0.33 0.52 0.51 0.44 0.37 0.48 Other 0.59 0.44 0.54 0.47 0.49 0.44 0.48

0.70 0.44 0.55 0.57 0.64 0.47

0.75 0.48 0.59 0.60 0.68 0.52

0.73 0.47 0.54 0.59 0.69 0.51

0.56 0.36 0.41 0.49 0.48 0.42

0.56 0.35 0.55 0.41 0.49 0.36

0.46 0.23 0.35 0.41 0.45 0.31

0.49 0.25 0.37 0.42 0.47 0.31

0.29 0.13 0.22 0.28 0.28 0.23

0.67 0.45 0.53 0.53 0.61 0.45

0.56 0.42 0.51 0.39 0.48 0.36

0.39 0.28 0.29 0.31 0.37 0.19

0.58 0.33 0.47 0.49 0.55 0.36

0.59 0.42 0.43 0.47 0.53 0.44

Note: YSR=Youth Self-Report; SCAS=Spence Childrens Anxiety Scale; SCARED=Screen for Child Anxiety Related Emotional Disorders; Anx.=Anxious/depressed; Som.=Somatic complaints; With.=Withdrawal; Aggr.=Aggressive behavior; Delin.=Delinquent behavior; Soz.=Social problems; Thoug.=Thought problems; Atten.=Attention problems; Other=Other problems; All correlations were signicant at po0:001; except for the correlation between SCAS physical injury fears and delinquent behavior (po0:01), and between SCARED separation anxiety disorder and delinquent behavior (po0:01).

13

14

C.A. Essau et al. / J. Behav. Ther. & Exp. Psychiat. 33 (2002) 118

Table 6 shows the correlation between SCAS, SCARED, and YSR. The total scores of the anxiety scales correlated strongly with the YSR total scores. Although the SCAS and the SCARED total anxiety scores also correlated signicantly with the YSR externalizing subscales (aggressive behavior and delinquent behavior), these correlations were less convincing than those between SCAS/SCARED and YSR internalizing subscales (anxious/depressed, somatic complaints, and withdrawn syndromes). As expected, SCARED and SCAS were most substantially connected to the YSR subscale anxious/depression.

4. Discussion The main purpose of this article was to examine the reliability and validity of the SCAS and the SCARED in German children. Unlike other instruments that measure anxiety in youths, the SCAS and the SCARED contain items that can be linked to symptoms of DSM-IV anxiety disorders. Before discussing our ndings, some limitations should be discussed. First, only 812 year olds were included in our study, so it is not clear whether our ndings can be generalized to other populations (e.g., adolescents). Second, the subjects were not recruited from a clinical sample and no diagnostic interview was used. Hence, the clinical and diagnostic utility of the German version of the SCAS and the SCARED has not yet been established. Third, only one aspect of reliability (i.e., internal consistency) and a few aspects of its validity were examined. Further studies need to examine other psychometric properties of the SCAS and the SCARED such as their testretest reliability as well as their predictive and discriminant validity. Fourth, the data were solely based on child self-report. Although it is widely acknowledged that the best method of assessing psychopathology in children is via multiple informants (Essau & Barrett, 2001), studies have found parents and teachers less satisfactory as informants of internalizing problems compared to externalizing problems (Klein, 1991; Loeber, Green, & Lahey, 1990). Given the low agreement among informants, the use of child self-report seemed justied given the fact that anxiousness is an internally derived experience. Finally, the YSR was used as one of the validity standards. Although the YSR was originally developed for children 11 years of age and older, it was proven to be psychometrically sound in our sample of 812 year olds. That is, a high internal consistency has been found, with alpha of 0.94, and a Guttman half-split of 0.83. These limitations should be taken into account when interpreting our ndings. Overall, the results of the present study support both the reliability and validity of the SCAS and the SCARED. The internal consistency of the SCAS total score was high, with a Cronbachs alpha of 0.92. The SCAS subscales also showed acceptable levels of internal consistency, with alphas ranging from 0.57 for physical injury fears to 0.82 for panic/agoraphobia. Similar results have been reported by Spence (1997). In her study (1997), the alpha for the total score was 0.92, and the alphas for each of the subscales were 0.82 for panic-agoraphobic symptoms, 0.70 for separation anxiety, 0.70 for social phobia, 0.60 for physical injury fears, 0.73 for obsessive compulsive, and 0.73 for generalized anxiety. Our result also showed high internal

C.A. Essau et al. / J. Behav. Ther. & Exp. Psychiat. 33 (2002) 118

15

consistency of the SCARED total score (alpha=0.91), with subscales indicating acceptable levels of internal consistency. In a recent study by Muris et al. (2000), the Cronbachs alpha for the total anxiety score was 0.94. The alphas for the SCARED subscales ranged from 0.66 (for situationalenvironmental phobia and Obsessive compulsive disorder) to 0.82 (for animal phobia). The convergent validity of the SCAS and the SCARED was supported by strong correlations between these two measures of anxiety symptoms. The two scales seemed to measure highly similar constructs, namely, anxiety symptoms as categorized under the DSM-IV anxiety disorders. Another important nding was a stronger correlation between the corresponding SCARED and SCAS subscales than between non-corresponding subscales. Similar to the nding of Muris et al. (2000), only a modest correlation could be found among social phobia subscales of SCAS and SCARED (r 0:59). Examination of these two scales seem to indicate that the SCARED items are more related to fear of meeting unfamiliar people, whereas the SCAS items are more closely linked to DSM-IV criteria such as fear of social or performance situation and fear of negative evaluation. Our results also showed a strong correlation between symptoms of generalized anxiety and symptoms of most other anxiety. There is no clear explanation for this nding, although it is tempting to speculate that it is the unspecic nature (i.e., when I have problem, y) of a number of generalized anxiety items that cause its relatively strong overlap with other anxiety scales. The SCAS and the SCARED also correlated signicantly with the CIS and the YSR, suggesting that a high level of anxiety symptoms is associated with impairment in various life domains and a high frequency of behavior problems. As reported by numerous authors, the presence of anxiety has negative impact on various areas of childrens life including academic performance and social functioning (Essau et al., 2000; Strauss, Lease, Last, & Francis, 1988; Turner, Beidel, & Costello, 1987). Within the YSR scales, it was interesting to note that the total anxiety scores of the SCAS and the SCARED were most strongly associated with anxious/depressed scale. The strong magnitude of these correlation coefcients suggest that the measures assess identical characteristics. Indeed, most studies have shown a high comorbidity rate between anxiety and depression (see review by Nottelmann & Jensen, 1999), and that they are difcult to differentiate from one another (e.g., Essau, 2000). The mean anxiety scores based on the SCAS was 22.24, with symptoms of generalized anxiety and social phobia being most common. This nding is in the middle range of what has been reported previously. That is, in a large sample of Dutch children, the mean SCAS score was 18.11 (Muris et al., 2000), whereas, in Australian children scores of 28.59 and 25.28 have been reported (Spence, 1998). Compared to boys, girls had signicantly higher scores on all the SCAS and SCARED subscales. This gender difference in the frequency of anxiety symptoms replicated previous studies showing that more girls than boys were affected by anxiety symptoms (Essau et al., 2000; Lewinsohn et al., 1993; Reinherz, Giaconia, Lefkowitz, Pakiz, & Frost, 1993). Our nding also showed age differences in the number of anxiety symptoms. While separation anxiety and panic/agoraphobia

16

C.A. Essau et al. / J. Behav. Ther. & Exp. Psychiat. 33 (2002) 118

decreased with age, generalized anxiety tended to increase as children became older. In the Spence study (1997), the mean scores for separation anxiety, Obsessive compulsive symptoms, and panic/agoraphobic problems declined with age, whereas no signicant age effects were found for physical injury fears or generalized anxiety symptoms. The age difference was less clear for social phobia, but symptoms appeared to increase between ages 9 and 11. In summary, the SCAS and the SCARED have proven to be reliable (as shown by its high internal consistency) and valid when used in community children, although their use in clinical settings should be tested in future studies. Because of their ease of administration, SCAS and SCARED seem to be ideal instruments for screening anxiety in large-scale studies in clinical and epidemiological settings.

References
Achenbach, T. M. (1991). Manual for the Youth Self-Report and 1991 prole. Burlington: University of Vermont. Bird, H. R., Andrews, H., Schwab-Stone, M., Goodman, S., Dulcan, M., Richters, J., Rubio-Stipec, M., Moore, R. E., Chians, P-H., Hoven, C., Canino, G., Fisher, P., & Gould, M. S. (1996). Global measures of impairment for epidemiologic and clinical use with children and adolescents. International Journal of Methods in Psychiatric Research, 6, 295307. Bird, H. R., & Gould, M. S. (1995). The use of diagnostic instruments and global measures of functioning in child psychiatry epidemiological studies. In F. C. Verhulst, & H. M. Koot (Eds.), The epidemiology of child and adolescent psychopathology (pp. 86103). Oxford: Oxford University Press. Birmaher, B., Brent, D., Chiappetta, L., Bridge, J., Monga, S., & Baugher, M. (1999). Psychometric properties of the Screen for Child Anxiety Related Emotional Disorders (SCARED): A replication study. Journal of the American Academy of Child and Adolescent Psychiatry, 38, 12301236. Birmaher, B., Khetarpal, S., Brent, D., Cully, M., Balach, L., Kaufman, J., & McKenzie Neers, S. (1997). The Screen for Child Anxiety Related Emotional Disorders (SCARED): Scale construction and psychometric characteristics. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 545553. Bowen, R. C., Offord, D. R., & Boyle, M. H. (1990). The prevalence of overanxious disorder and separation anxiety disorder: Results from the Ontario Child Health Study. Journal of the American Academy of Child and Adolescent Psychiatry, 29, 753758. Brislin, R. W. (1970). Back translation for cross-cultural research. Journal of Cross-Cultural Psychology, 1, 185216. Chorpita, B. F., Yim, L., Moftt, C., Umemoto, L. A., & Francis, S. E. (2000). Assessment of symptoms of DSM-IV anxiety and depression in children: A revised child anxiety and depression scale. Behaviour Research and Therapy, 38, 835855. Cohen, P., Cohen, J., Kasen, S., Velez, C. N., Hartmark, C., Johnson, J., Rojas, M., Brook, J., & Streuning, E. L. (1993). An epidemiological study of disorders in late childhood and adolescenceFI: Age- and gender-specic prevalence. Journal Child Psychology and Psychiatry, 34, 851866. . . t und faktorielle Validita . t der Youth SelfDopfner, M., Berner, W., & Lehmkuhl, G. (1995). Reliabilita Report Form der Child Behavior Checklist bei einer klinischen Stichprobe. Diagnostica, 41, 221244. . . t und Dopfner, M., Schmeck, K., Berner, W., Lehmkuhl, G., & Poustka, F. (1994). Zur Reliabilita . t der Child Behavior ChecklistFeine Analyse in einer klinischen und einer faktorielle Validita Feldstichprobe. Zeitschrift fur . Kinder- und Jugendpsychiatrie, 22, 189205. Essau, C. A. (2000). Angst und Depression bei Jugendlichen [anxiety and depression in adolescents]. Habilitationschrift. Bremen: University of Bremen.

C.A. Essau et al. / J. Behav. Ther. & Exp. Psychiat. 33 (2002) 118

17

Essau, C. A., & Barrett, P. (2001). Developmental issues in the assessment of anxiety. In C. A. Essau, & F. Petermann (Eds.), Anxiety disorders in children and adolescents: Epidemiology, risk factors, and treatment. London: Harwood Academic Publishers. Essau, C. A., Conradt, J., & Petermann, F. (2000). Frequency, comorbidity, and psychosocial impairment of anxiety disorders in adolescents. Journal of Anxiety Disorders, 14, 263279. Essau, C.A., & Petermann, F. (Eds.) (2001). Anxiety disorders in children and adolescents: Epidemiology, risk factors, and treatment. London: Harwood Academic Publishers. Feehan, M., McGee, R., & Williams, S. M. (1993). Mental health disorders from age 15 to age 18 years. Journal of the American Academy of Child and Adolescent Psychiatry, 32, 11181126. Frederick, C. (1985). Selected foci in the spectrum of PTSD. In J. Laube, & S. A. Murphy (Eds.), Perspectives on disaster recovery. New York: Appleton. Ginsburg, G. S., La Greca, A. M., & Silverman, W. K. (1998). Social anxiety in children with anxiety disorders: Relation with social and emotional functioning. Journal of Abnormal Child Psychology, 26, 175185. Kashani, J. H., & Orvaschel, H. (1990). A community study of anxiety in children and adolescents. American Journal of Psychiatry, 147, 313318. Keller, M. B., Lavori, P. W., Wunder, J., Beardslee, W. R., Schwartz, C. E., & Roth, J. (1992). Chronic course of anxiety disorders in children and adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 31, 595599. Klein, R. G. (1991). Parent-child agreement in clinical assessment of anxiety and other psychopathology: A review. Journal of Anxiety Disorders, 5, 187198. LaGreca, A. M., & Stone, W. L. (1993). Social anxiety scale for childrenFrevised: Factor structure and concurrent validity. Journal of Clinical Child Psychology, 22, 1727. Loeber, R., Green, S. M., & Lahey, B. B. (1990). Mental health professionals perceptions of the utility of children, mothers, and teachers as informants on childhood pathology. Journal of Clinical Child Psychology, 19, 136143. Lewinsohn, P. M., Hops, H., Roberts, R. E., Seeley, J. R., & Andrews, J. A. (1993). Adolescent psychopathology: I. Prevalence and incidence of depression and other DSM-III-R disorders in high school students. Journal of Abnormal Psychology, 102, 133144. McGee, R., Feehan, M., Williams, S., Partridge, F., Silva, P. A., & Kelly, J. (1990). DSM-III disorders in a large sample of adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 29, 611619. Muris, P., Merckelbach, H., van Brakel, A., Mayer, B., & van Dongen, L. (1998a). The Screen For Child Anxiety Related Emotional Disorders (SCARED): Relationship with anxiety and depression in normal children. Personality and Individual Differences, 24, 451456. Muris, P., Merckelbach, H., Mayer, B., Van Brakel, A., Thissen, S., Moulaert, V., & Gadet, B. (1998b). The Screen for Child Anxiety Related Emotional Disorders and its relationship to traditional childhood anxiety. Journal of Behavior Therapy and Experimental Psychiatry, 29, 327339. Muris, P., Schmidt, H., & Merckelbach, H. (2000). Correlations among two self-report questionnaires for measuring DSM-dened anxiety disorder symptoms in children: The Screen For Child Anxiety Related Emotional Disorders and the Spence Childrens Anxiety Scale. Personality and Individual Differences, 28, 333346. Nottelmann, E. D., & Jensen, P. S. (1999). Comorbidity of depressive disorders in children and adolescents: Rates, temporal sequencing, course and outcome. In C. A. Essau, & &F. Petermann (Eds.), Depressive disorders in children and adolescents: Epidemiology, risk factors, and treatment (p. 0). Northvale, NJ: Jason Aronson. Ollendick, T. H. (1983). Reliability and validity of the revised Fear Survey Schedule For Children (FSSCR). Behaviour research and Therapy, 21, 395399. Reinherz, H. Z., Giaconia, R. M., Lefkowitz, E. S., Pakiz, B., & Frost, A. K. (1993). Prevalence of psychiatric disorders in a community population of older adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 32, 369377. Reynolds, C. R., & Richmond, B. O. (1985). Revised childrens manifest anxiety scale. Los Angeles: Western Psychological Services.

18

C.A. Essau et al. / J. Behav. Ther. & Exp. Psychiat. 33 (2002) 118

Strauss, C. C., Lease, C. A., Last, C. G., & Francis, G. (1988). Overanxious disorder: An examination of developmental differences. Journal of Abnormal Psychology, 16, 433443. Spence, S. H. (1997). Structure of anxiety symptoms among children: A conrmatory factor-analytic study. Journal of Abnormal Psychology, 106, 280297. Spence, S. H. (1998). A measure of anxiety symptoms among children. Behavior Research and Therapy, 36, 545566. Spielberger, C., Gorsuch, R., & Luchene, R. (1976). Manual for the state-trait anxiety inventoryFchild version. Palo Alto, CA: Consulting Psychologists Press. Turner, S. M., Beidel, D. C., & Costello, A. (1987). Psychopathology in the offspring of anxiety disorders patients. Journal of Consulting and Clinical Psychology, 55, 229235. Wittchen, H.-U., & Essau, C. A. (1994). Epidemiology of anxiety disorders. In P. J. Wilner (Ed.), Psychiatry (pp. 125). Philadelphia: J.B. Lippincott Company.