Normal and Abnormal Fear and Anxiety in Children and Adolescents

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NORMAL AND ABNORMAL FEAR AND ANXIETY IN CHILDREN AND ADOLESCENTS

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NORMAL AND ABNORMAL FEAR AND ANXIETY IN CHILDREN AND ADOLESCENTS

PETER MURIS

AMSTERDAM • BOSTON • HEIDELBERG • LONDON NEW YORK • OXFORD • PARIS • SAN DIEGO SAN FRANCISCO • SINGAPORE • SYDNEY • TOKYO

Elsevier 30 Corporate Drive, Suite 400, Burlington, MA 01803, USA 525 B Street, Suite 1900, San Diego, California 92101-4495, USA 84 Theobald’s Road, London WC1X 8RR, UK This book is printed on acid-free paper. Copyright © 2007, Elsevier Inc. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without permission in writing from the publisher. Permissions may be sought directly from Elsevier’s Science & Technology Rights Department in Oxford, UK: phone: (+44) 1865 843830, fax: (+44) 1865 853333, E-mail: [email protected]. You may also complete your request on-line via the Elsevier homepage (http://elsevier.com), by selecting “Support & Contact” then “Copyright and Permission” and then “Obtaining Permissions.” Library of Congress Cataloging-in-Publication Data Muris, Peter. Normal and abnormal fear and anxiety in children and adolescents/ Peter Muris. p. ; cm.—(BRAT series in clinical psychology) Includes index. ISBN-13: 978-0-08-045073-5 (alk. paper) ISBN-10: 0-08-045073-3 (alk. paper) 1. Anxiety in children. 2. Anxiety in adolescence. 3. Fear in children. I. Title. II. Series. [DNLM: 1. Anxiety Disorders—etiology. 2. Adolescent. 3. Anxiety—psychology. 4. Anxiety Disorders. 5. Child. 6. Fear—psychology. WM 172 M977n 2007] RJ506.A58M87 2007 618.92'8522—dc22 2007006299 British Library Cataloguing-in-Publication Data A catalogue record for this book is available from the British Library. ISBN 978-0-08-045073-5 For information on all Elsevier publications visit our Web site at www.books.elsevier.com Printed in the United States of America 07 08 09 10 9 8 7 6 5 4 3

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Working together to grow libraries in developing countries www.elsevier.com | www.bookaid.org | www.sabre.org

To my beautiful daughters, Jip and Kiki, who so far have developed without serious anxiety problems


Table of Contents

Preface

ix

Introduction

xi

1.

Normal and Abnormal Fear and Anxiety in Children and Adolescents

1

2.

Genetically Based Vulnerability

31

3.

Environmental Influences

61

4.

Protective Factors

99

5.

Maintaining Factors

129

6.

The Aetiology of Childhood Phobias and Anxiety Disorders: A Dynamic Multifactorial Model

163

7.

Assessment of Fear and Anxiety in Children and Adolescents

193

8.

Treatment and Prevention of Childhood Anxiety

225

Appendix

Questionnaires

267

References

299

Index

373


Preface

In the Behaviour Research and Therapy (BRAT) Series in Clinical Psychology, Craske (2003) wrote her monograph “Origins of phobias and anxiety disorders: Why more women than men?” in which she provided an excellent overview of current theories on the aetiology of phobias and anxiety disorders. Although the emphasis of Craske’s book is mainly on adults, it is also clear that she assumes that the foundation of these problems is already laid during childhood. In the past decades, the research domain of childhood phobias and anxiety disorders has made an enormous progress, as evidenced by a massive amount of empirical articles in scientific journals. This book provides an overview of the accumulating knowledge on the pathogenesis of fear and anxiety in youths. The main target will be to give the reader an idea of the factors that are thought to be involved in the development of abnormal fear and anxiety in children and adolescents, and to integrate this knowledge in a comprehensive model. An additional purpose will be to provide an update of current assessment methods as well as empirically supported intervention strategies for fear and anxiety problems in young people. In the Appendix, the reader will find a number of instruments that can be employed for research (and eventually clinical) purposes. Admittedly, many good books have been published that deal with the domain of childhood fear and anxiety (see Weems, 2005). Most books are more predominantly concerned with the phenomenology and treatment of various phobias and anxiety disorders in children and adolescents (e.g., Essau & Petermann, 2001; Morris & March, 2004; Ollendick & March, 2004) and only partially cover the aetiology of this type of child psychopathology. Exceptions are the volumes edited by Vasey and Dadds (2001; “The developmental psychopathology of anxiety”) and Silverman and Treffers (2001; “Anxiety disorders in children and adolescents”), which both give an in-depth coverage of the multiple factors involved in the origins of phobias and anxiety disorders in youths. However, having appeared more than five years ago, the field seems ready for a new update of this rapidly expanding and intriguing research area. Peter Muris


Introduction

“My dear professor, I am sending you a little more about Hans—but this time, I am sorry to say, material for a case history. As you will see, during the last few days he has developed a nervous disorder, which has made my wife and me most uneasy, because we have not been able to find a means of dissipating it. I shall venture to call upon you tomorrow, . . . but in the meantime . . . I enclose a written record of the material available. “No doubt the ground was prepared by sexual overexcitation due to his mother’s tenderness, but I am not able to specify the actual exciting cause. He is afraid a horse will bite him in the street, and this fear seems somehow to be connected with his having been frightened by a large penis. As you know from a former report, he had noticed at a very early age what large penises horses have, and at that time he inferred that as his mother was so large she must have a widdler like a horse. “I cannot see what to make of it. Has he seen an exhibitionist somewhere? Or is the whole thing simply connected with his mother? It is not very pleasant for us that he should begin setting us problems so early. Apart from his being afraid of going into the street and from his being in low spirits in the evening, he is in other respects the same Hans, as bright and cheerful as ever.” (Freud, 1909/1955; p.22) The preceding quotation was taken from a letter written to Sigmund Freud by the father of a five-year-old boy at the beginning of the 20th century. It is clear that the boy, also known as Little Hans, was troubled by fear and anxiety, and apparently these negative emotions were so intense that his parents decided to seek help from a psychiatrist. Freud was of course interested in the case, carefully documented it as the “Analysis of a phobia in a five-year-old boy,” and he used this case history to further illustrate his theoretical notions on the genesis of neurotic behavior. Due to Freud, Little Hans became the subject of one of the most famous case studies in psychological history. However, the symptoms displayed by the boy are certainly not exceptional, as it is a well-known fact that many children and adolescents suffer from fear and anxiety complaints at some point of time during their development to adulthood. In such a way, fear and anxiety have long been considered as normal developmental phenomena, and as a result little research effort was made to properly understand these emotions in youths. Since the early 1980s, this situation has gradually changed. Clinicians, and in their wake researchers, gradually came to the conclusion that although fear and anxiety are transitory in most children, in some of the youths these symptoms may become so severe that they do significantly interfere with daily functioning and clearly warrant the diagnosis of an anxiety disorder. This insight has resulted in a host of empirical studies examining the phenomenology, prevalence, aetiology, persistence, assessment, and treatment of anxiety symptoms and disorders in youths.

xii

Introduction

This book is titled Normal and Abnormal Fear and Anxiety in Children and Adolescents, and as such it covers many aspects of these internalizing symptoms in youths. However, another focus of the book is What Was Really Wrong with Little Hans? That is, many of the sections in this book discuss why some children develop serious fear and anxiety problems. In Freud’s (1909/1955) opinion, Little Hans was afraid of horses because he suffered from a so-called Oedipus complex. That is, Hans wanted to have sex with his mother and therefore expected to be punished by his father. As a result, Hans became afraid of his father. However, this was considered as unacceptable by his Ego, and therefore the fear was displaced to another object, resulting in a phobia of horses. From a scientific point of view, Freud’s analysis of the case is of course unacceptable, as the main concepts of his account (i.e., Oedipus complex, Ego) cannot be validated empirically (Eysenck, 1985). Moreover, after a reanalysis of the case, Wolpe and Rachman (1960) rightly indicated that there was no convincing connection between Little Hans’s sexual behavior and his phobia of horses. Further, these authors pointed at a number of negative learning experiences (e.g., Hans witnessed a horse crashing on the street), which likely played a more plausible role in the aetiology of Hans’s phobic symptoms. This book makes no attempt to reconstruct the aetiology of the phobia of Little Hans’s in detail. Instead, a general theoretical framework will be described that may help clinicians and researchers to understand the pathogenesis of excessive anxiety in youths. It has become clear that an “understanding of the pathways by which childhood anxiety disorders develop, persist, and remit is likely to require consideration of a wide range of influences and, most importantly, their potential for complex, dynamic, transformational interactions (i.e., transactions) across development” (Vasey & Dadds, 2001; p.3). Clearly, this notion fits nicely with the major tenets of the developmental psychopathology perspective (Cicchetti & Cohen, 1995), which imply that (1) most forms of psychopathology are the result of multiple causal influences, (2) both successful and unsuccessful adaptation are important for understanding the origins of psychopathology, and (3) psychopathology occurs in a developing organism, which is of course particularly relevant in childhood and adolescence, when developmental changes are most pronounced. As such, the framework that is explicated in this book emphasizes multicausality, includes vulnerability as well as protective factors, and stresses the importance of developmental transitions. The main perspective of the book is psychological, although in some chapters biological processes (genetics, brain processes) are also discussed. After an introductory chapter, in which the basic phenomena of normal and abnormal fear and anxiety in children and adolescents are described, following chapters of the book will extensively discuss various vulnerability (Chapters 2 and 3), protective (Chapter 4), and maintaining (Chapter 5) variables that are involved in the pathogenesis of phobias and other anxiety disorders. In Chapter 6, this information will be integrated and a dynamic, multifactorial model for the aetiology of pathological fear and anxiety will be presented. In this chapter, an attempt will be made to analyze the case of Little Hans in terms of this model and to provide an answer to the question that was posed in the case of Little Hans. Chapter 7 will give an overview of empirically validated assessment instruments that can be used for measuring normal and abnormal fear and anxiety in youths. Finally, Chapter 8 describes psychological and pharmacological interventions that are employed for children and adolescents with anxiety problems, and summarizes the research that has demonstrated their effectiveness.

Chapter 1


Introduction Fear and anxiety are common in childhood, but in most cases short-lived and dissipating within a brief period of time (see Craske, 1997). Initially, this has led many child psychologists to the faulty conclusion that childhood fear and anxiety should not be taken too seriously, and as a result these phenomena received little research attention (Cartwright-Hatton, McNicol, & Doubleday, 2006). During the past decade, this opinion has changed as researchers have increasingly demonstrated that a substantial minority of children do suffer from such high fear and anxiety levels that a diagnosis of an anxiety disorder is clearly warranted. In fact, epidemiological studies have shown that anxiety disorders are among the most prevalent forms of psychopathology among youths (Costello, Mustillo, Erkanli, Keeler, & Angold, 2003; Ford, Goodman, & Meltzer, 2003; Verhulst, Van der Ende, Ferdinand, & Kasius, 1997). Moreover, there is evidence indicating that a significant proportion of the childhood anxiety disorders have a chronic course and, although they may change form, even last into adulthood (Biederman, Petty, Faraone et al., 2005; Goodwin, Fergusson, & Horwood, 2004; Keller, Lavori, Wunder, Beardslee, Schwartz, & Roth, 1992; Last, Perrin, Hersen, & Kazdin, 1996; Roza, Hofstra, Van der Ende, & Verhulst, 2003). The main purpose of the present chapter is to provide a description of the basic phenomena under study. To begin with, definitions of fear and anxiety will be given, and evidence will be catalogued showing that fear and anxiety are common experiences to most children and adolescents. It is argued that these normal manifestations of fear and anxiety follow a predictable developmental course that is strongly guided by children’s level of development. This does not mean, however, that fear and anxiety sometimes interfere significantly with youths’ daily functioning, and ultimately may take the form of a phobia or an anxiety disorder. The remainder of the chapter will focus on abnormal fear and anxiety in children and adolescents, and will discuss their phenomenology, epidemiology, severity, persistence, and comorbidity with other forms of psychopathology.

Definitions of Fear and Anxiety Although the terms fear and anxiety are frequently employed interchangeably, a close examination of the literature indicates that both concepts are quite different in terms of their

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manifestation, function, and biological underpinnings (e.g., Barlow, 2002; Craske, 2003). To begin with, factor analytic studies of the symptomatology in anxious youths have clearly identified two separate factors (Chorpita, Albano, & Barlow, 1998). The first factor is characterized by autonomic arousal, and at a behavioral level fight-flight reactions, and can be labelled as fear. The second factor is typified by tension, apprehension, and worry, and can best be defined as anxiety. Fear typically occurs when threat is proximate and imminent. Its function is clear: The organism must be alert, and the body is quickly prepared for immediate action, either fight or flight. This is achieved by an activation of the sympathetic nervous system, which shows itself in a pupil dilatation and increases in heart rate, respiration, and muscle tension. Because fear pertains to a fast response that is universal and innate and clearly serves survival purposes, theorists have since long assumed that the more primitive subcortical brain systems are involved in this type of emotion (LeDoux, 1996). Research has indeed provided evidence for this notion and has shown that in particular the amygdala seems to play a key role in the formation of fear. Briefly, this relatively small subcortical brain structure detects and organizes responses to natural dangers (like predators) and learns about novel threats and stimuli that predict their occurrence (LeDoux, 1998). Incoming information about (potentially threatening) stimuli is quickly scanned in the amygdala, and once threat is detected, various types of defensive responses (e.g., activation of the sympathetic nervous system) are immediately activated. Whereas fear arises when threat is certain and/or detected, anxiety may become manifest without the presence of actual danger. Worry is the prototypical example of anxiety—that is, when worrying, a person engages in thinking about negative things that might happen. In a way, worry also has adaptive features as it prepares for unexpected aversive events. However, there is increasing evidence demonstrating that worry functions as a cognitive avoidance strategy, which inhibits emotional processing (Borkovec, Ray, & Stöber, 1998). Worry predominantly is a cognitive-verbal activity and as such primarily involves left cortical activation and ongoing inhibition of autonomic activation in order to facilitate cognitive processing and planning to deal with impending danger. Craske (2003) described the threat imminence model, which assumes that anxiety/worry and fear are related but functionally different defensive systems that are determined by varying levels of proximity to threat. Confrontation with distal threat (i.e., threat related to the possible occurrence of negative, future events) will elicit anxiety/worry. Once threat is actually detected, anxious worry will shift to fear. The fear response itself may vary from anticipatory arousal when confronted with stimuli closely associated with the threat, to intense fear or even panic when fully exposed to the threatening stimulus or situation. Although the threat imminence model nicely illustrates the functionality and biological basis of fear and anxiety, this account is not used as the guiding principle for describing these negative emotions in the present book. The main reason for this is that it is largely unknown how the defensive systems of fear and anxiety/worry vary with the anxiety disorders as defined in contemporary classification systems such as the Diagnostic and Statistical Manual of Mental Disorders (DSM; American Psychiatric Association [APA], 2000). Therefore, fear and anxiety will be defined in terms of the nosologic descriptions employed by most current researchers and clinicians. Thus, fear explicitly refers to phobic disorders that are all characterized by a negative emotional response in relation to a certain stimulus


3

or situation that is out of proportion to its actual danger, whereas anxiety refers to the anxiety disorders that are typified by tension, apprehension, worry, and general distress that arise without any objective source of danger (see Pavuluri, Henry, & Allen, 2002). A factor analytic study by Muris, Schmidt, Merckelbach, and Schouten (2001b) demonstrated that this division of fear and anxiety is empirically justifiable. In their study, a large sample of nonclinical youths (N = 968) completed self-report questionnaires for measuring symptoms of anxiety disorders, phobias, and depression. Structural equations modeling was employed to test the following models for the structure of these negative emotions: (1) a one-factor model with all symptoms loading on a single factor; (2) a two-factor model with symptoms of anxiety disorders and phobias loading on one factor and depression symptoms loading on the other factor; (3) a two-factor model with symptoms of anxiety disorders and depression loading on one factor and symptoms of phobias loading on the other factor; (4) a three-factor model in which symptoms of anxiety disorders, phobias, and depression load on three separate factors; and (5) a correlated three-factor model with symptoms of anxiety disorder, phobias, and depression loading on three correlated factors. Results indicated that the fifth model provided the best fit for the data, (see Figure 1.1) which implies that anxiety disorders, phobias, and depression are reasonably distinct but correlated components of negative emotions. Most pertinent for the present discussion is that fear (phobias) and anxiety (anxiety disorders) were distinguishable types of negative emotion. The fact that fear and anxiety are discernible and related to, respectively, phobias and anxiety disorders, does not imply that it is easy to separate these phenomena. This point was nicely illustrated in a study by Muris, Merckelbach, Mayer, and Meesters (1998), who examined the relationship between common fears and anxiety disorders symptoms in nonclinical children. The results of this investigation clearly showed that childhood fears are not merely connected to symptoms of phobias, but also frequently reflect other anxiety disorders. For example, fear of getting a serious illness may represent a blood-injectioninjury phobia, but may also point in the direction of an obsessive-compulsive disorder or a generalized anxiety disorder.

.72 .55

.38

Anxiety

.83

A1

A2

.82

.73

A3

Fear

.71

.71

A4

A5

.72

F1

.71

F2

Depression

.62

F3

.87

D1

D2

.62

.61

D3

.59

D4

.56

.49

D5

D6

Figure 1.1: Correlated three-factor model of negative emotions in youths. Based on: Muris, Schmidt, Merckelbach, & Schouten (2001b).

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Normal Fear and Anxiety Studies of normal childhood fears have predominantly relied on surveys that list a broad range of potentially fear-provoking stimuli and situations. A widely used instrument for this purpose is the Revised version of the Fear Survey Schedule for Children (FSSC-R; Ollendick, 1983). The FSSC-R asks children to indicate on three-point scales (“none,” “some,” “a lot”) how much they fear specific stimuli and situations. FSSC-R surveys indicate that nonclinical children and adolescents report a surprisingly large number of fears. For example, Ollendick, King, and Frary (1989) found an average of 14 fears reported by American and Australian youths aged 7 to 17 years. A cross-cultural study by Ollendick, Yang, King, Dong, and Akande (1996) has demonstrated that this high prevalence of fears is quite similar across Western and non-Western countries. Typically, most of the common fears as obtained with the FSSC-R pertain to dangerous situations and physical harm. Thus, according to various FSSC-R studies, the 10 most common fears among nonclinical youths are (1) not being able to breathe, (2) being hit by a car or truck, (3) bombing attacks/being invaded, (4) getting burned by fire, (5) falling from a high place, (6) burglar breaking into the house, (7) earthquake, (8) death/dead people, (9) illness, and (10) snakes (e.g., Gullone & King, 1992; King, Ollier, Iacuone et al., 1989; Mellon, Koliadis, & Paraskevopoulos, 2004; Ollendick & King, 1994; Ollendick et al., 1989, 1996; Ollendick, Yule, & Ollier, 1991). Since the development of the FSSC-R in the early 1980s, society has changed, and youths are increasingly confronted with “new” threatening stimuli and situations: School violence, sexual assaults, domestic violence, parental divorce, abuse, and neglect are real-life threats for a growing number of children and adolescents (e.g., Fishkin, Rohrbach, & AndersonJohnson, 1997). In addition, television makes youths increasingly aware of diseases (e.g., AIDS), disasters (e.g., floods), and other threatening events (e.g., drugs, terrorist attacks) that may occur (e.g., Cole & Cole, 1996; Hicks & Holden, 1994). Research with updated versions of the FSSC-R, which include more of these contemporary fear stimuli and situations, has indicated that although most prevalent fears are still concerned with the theme of danger and harm, a number of the new fear items list high in the top 10 of most common fears (e.g., Burnham & Gullone, 1997; Shore & Rapport, 1998; Muris & Ollendick, 2002). While a questionnaire like the FSSC-R certainly yields important information on childhood fears, it is also clear that this type of assessment is determined by the items that are included in this scale. This point was nicely illustrated by Muris and colleagues (Muris, Merckelbach, & Collaris, 1997; Muris, Merckelbach, Meesters, & Van Lier, 1997), who examined the prevalence of common childhood fears by employing two different methods. That is, in these studies, fear rank orders were not only obtained by means of the FSSC-R, but also by asking children what they feared most without specifying items a priori (i.e., “free option” method). Results indicated that the fear rank order based on the free option method substantially deviated from that produced by the FSSC-R survey. More precisely, whereas the FSSC-R ranking again suggested that top intense fears have to do with danger and death, the free option method consistently showed that top intense fears pertain to animals (in particular, spiders). Further, as can be seen in Table 1.1, a number of prevalent


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Table 1.1 Fear rank order in 9- to 13-year-old children (N = 129) based on the question “What do you fear most?”

1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

Number of subjects

Percentage of sample

Number in FSSC-Rbased rank order

24 10 8 8 7 6 5 5 5 4

18.6 7.8 6.2 6.2 5.4 4.7 3.9 3.9 3.9 3.1

10 — 21 15 23 11 4 28 — 6

Spiders Being kidnapped Predators The dark Frightening movies Snakes Being hit by a car Being teased Parents dying Burglar breaking into the house

From: Muris, Merckelbach, & Collaris (1997).

free option fears ranked relatively low in the FSSC-R-based ranking (i.e., predators, scary movies, and being teased). The preceding studies merely focused on childhood fears, but there are also studies that investigated the prevalence of anxiety symptoms among youths. One example is a study by Bell-Dolan, Last, and Strauss (1990), who examined the prevalence of symptoms of DSMIII-R anxiety disorders in a sample of 62 nonclinical children and adolescents aged between 5 and 18 years. Youths and parents were administered a semistructured interview in order to check present and past psychiatric problems, including a variety of anxiety disorders. Although it was found that these children and adolescents had never displayed any serious psychiatric problems, the results also indicated that subclinical anxiety disorders symptoms were relatively common among these youths. More precisely, not only phobic symptoms were highly prevalent, but also symptoms of generalized anxiety disorder, separation anxiety disorder, and social phobia (see Table 1.2). Similar results were obtained in a more recent study by Spence (1997), who examined the frequency of self-reported anxiety disorders symptoms in large community sample of 8- to 12-year-old children. Results showed that especially symptoms of social phobia and generalized anxiety were most prevalent. Symptoms of obsessive-compulsive disorder, separation anxiety disorder, and specific phobias were less common, whereas symptoms of panic disorder and agoraphobia appeared the least frequent. These results were largely replicated in a follow-up study by Spence, Rapee, McDonald, and Ingram (2001), who examined the prevalence of DSM-defined anxiety symptoms in preschoolers aged 2 to 6 years by means of parent ratings. Thus, even in very young children, anxiety disorders symptoms are highly prevalent. Separate studies have investigated the prevalence of more specific anxiety phenomena in youths. These studies have shown that worry (Muris, Meesters, Merckelbach, Sermon, &

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Table 1.2 Most common anxiety disorders symptoms in a sample of never psychiatrically ill youths aged 5 to 18 years (N = 62) Symptom

Anxiety disorder

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.

GAD GAD SP SOP SP SAD GAD GAD SOP GAD SOP

Overconcern about competence Excessive need for reassurance Fear of heights Fear of public speaking Fear of the dark Fear of harm of attachment figure Excessive worry about past behavior Self-consciousness Fear of dressing in front of others Somatic complaints Shrinks from contact with others

Percentage of sample with subclinical symptoms 30.6 22.6 22.6 21.7 19.4 16.1 16.1 16.1 14.5 14.5 14.5

Note. GAD = Generalized Anxiety Disorder, SP = Specific Phobia, SOP = Social Phobia, SAD = Separation Anxiety Disorder (current diagnostic terms are used). Based on: Bell-Dolan, Last, & Strauss (1990).

Zwakhalen, 1998; Orton, 1982; Silverman, LaGreca, & Wasserstein, 1995), nighttime fears (Mooney, 1985; Mooney, Graziano, & Katz, 1985; Muris, Merckelbach, Ollendick, King, & Bogie, 2001), scary dreams and nightmares (Mindell & Barrett, 2002), anxietyrelated physiological symptoms (Weems, Zakem, Costa, Cannon, & Watts, 2005), panic attacks (Hayward, Killen, & Taylor, 1989; King, Gullone, Tonge, & Ollendick, 1993; King, Ollendick, Mattis, Yang, & Tonge, 1997), and OCD-related rituals (Leonard, Goldberger, Rapoport, Cheslow, & Swedo, 1990) are commonly observed in youths. All these findings further justify the conclusion that fear and anxiety seem to be part and parcel of children’s normal development (Craske, 1997; Gullone, 2000).

Developmental Patterns in Fear and Anxiety If it is true that fear and anxiety in youths are intimately linked to development, one would expect to find a clear developmental pattern in the manifestation of these negative emotions. This topic was first addressed in an older study by Bauer (1976) who asked 4- to 12-yearold children to specify what they feared most. Results showed that 74% of the 4- to 6-yearolds but 53% of the 6- to 8-year-olds but only 5% of the 10- to 12-year-olds reported fear of ghosts and monsters. In contrast, only 11% of the 4- to 6-year-olds but 53% of the 6- to 8-year-olds and 55% of the 10- to 12-year-olds reported fears of bodily injury and physical danger. A more recent study by Muris, Merckelbach, Gadet, and Moulaert (2000) investigated the prevalence of fears, worries, and scary dreams among 4- to 12-year-old children by means of a semistructured interview, which included pictures to explain these anxiety

Normal and Abnormal Fear and Anxiety in Children and Adolescents 100 90 80 70 60 50 40 30 20 10 0

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Fears Worries Scary dreams

4 to 6

7 to 9

10 to 12

Figure 1.2: Prevalence rates (percentages) of various anxiety phenomena in three age groups of children. Based on: Muris, Merckelbach, Gadet, & Moulaert (2000).

phenomena to the (younger) children. Inspection of the general developmental pattern of these phenomena revealed that fears and scary dreams were common among 4- to 6-yearolds, became even more prominent in 7- to 9-year-olds, and then decreased in frequency in 10- to 12-year-olds. The developmental pattern of worry deviated from this pattern. This phenomenon was clearly more prevalent in older children (i.e., 7- to 12-year-olds) than in younger children (see Figure 1.2). As to the frequency of specific types of fears, some developmental patterns emerged that were comparable to those obtained by Bauer (1976). For example, the prevalence of fears and scary dreams pertaining to imaginary creatures decreased with age, whereas worry about performance at school increased as children became older. Weems and Costa (2005) recently carried out a study to examine developmental differences in the expression of childhood anxiety symptoms. Symptoms of separation anxiety disorder, generalized anxiety disorder, and social phobia were assessed using child- and parent-report questionnaires. Three age groups of youths were compared: children aged 6 to 9 years, preteens aged 10 to 13 years, and adolescents aged 14 to 17 years. The results indicated that there were systematic age differences in the expression of childhood anxiety symptoms. More precisely, separation anxiety was predominant in 6- to 9-year-olds, but steadily decreased as children were older. The opposite pattern was observed for symptoms of generalized anxiety and social phobia, which were relatively infrequent among the youngest group but prevalent during adolescence (see Figure 1.3). This pattern was most clearly visible in the child report data. Although the parent data were largely comparable, the increase of generalized anxiety symptoms across the three age groups was not found, which makes sense because these types of symptoms are not readily observable. An investigation by Westenberg, Drewes, Goedhart, Siebelink, and Treffers (2004) also performed a developmental analysis of fears in 8- to 18-year-old youths. Based on Campbell and Rapee’s (1994) observation that childhood fears can be divided in two broad categories of physical harm and social problems, these researchers focused their analysis on the developmental pattern of fears concerning physical danger and fears concerning social evaluation. For this purpose, children in three age groups (i.e., 8- to 11-year-olds, 12- to 14-year-olds,

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Normal and Abnormal Fear and Anxiety in Children and Adolescents 0,5 0,4 0,3 0,2 0,1 0 –0,1 –0,2 –0,3 –0,4 –0,5

Separation anxiety Generalized anxiety Social anxiety

6 to 9

10 to 13

14 to 17

Figure 1.3: Standardized scores of self-reported anxiety symptoms in youths across three age groups. Based on: Weems & Costa (2005).

and 15- to 18-year-olds) completed the FSSC-R. Results indicated that scores on FSSC-R subscales pertaining to physical fears clearly decreased across the three age groups. A differential pattern was observed within the category of social fears. That is, whereas fears of social evaluation (e.g., “Being criticized by others”) and achievement evaluation (e.g., “Failing a test”) clearly increased when children were older, fear of punishment (e.g., “Getting punished by mother”) significantly decreased with age. Research on the development of rituals (which can be seen as the normal expression of compulsions as seen in obsessive-compulsive disorder [OCD]) has also yielded a meaningful pattern. That is, Evans, Leckman, Carter et al. (1997) examined the prevalence of rituals in a large sample of 1488 children aged between 1 and 6 years by means of a parent-report questionnaire. The results indicated that rituals were not very frequent among 1-year-old children, became more prevalent among 2-, 3-, and 4-year-olds, and then decreased after the age of 4. Further research by Zohar and Bruno (1997) has demonstrated that ritualistic behaviors continue to decline during the remainder of childhood. Interestingly, it has also been observed that rituals, which tend to persist as children grow older, are more clearly related to anxiety and gradually acquire OCD-like properties (see also Evans, Gray, & Leckman, 1999; Leonard, Goldberg, Rapoport, Cheslow, & Swedo, 1999). Altogether, research has shown that normal fear and anxiety follow a predictable course, a phenomenon that has been termed “the ontogenetic parade” (Marks, 1987; p.109). It is generally assumed that children’s cognitive capacities are an important determinant of this ontogenetic parade of fear and anxiety. This is not surprising given the fact that fear and anxiety originate from threat, and threat must be conceptualized. Conceptualization, in turn, critically depends on cognitive abilities (e.g., Vasey, 1993). Thus, at very young ages, fear and anxiety are primarily directed at immediate, concrete threats (e.g., loud noises, loss of physical support). As cognitive abilities reach a certain maturational stage, fear and anxiety become more sophisticated. For example, at 9 months, children learn to differentiate between familiar and unfamiliar faces, and, consequently, separation anxiety and fear of strangers become manifest. Following this, fears of imaginary creatures occur, and it is believed that these are closely linked to the magical thinking of toddlers (e.g., Bauer, 1976). Fears of


9

Table 1.3 Important developmental issues and related normal fear and anxiety in children and adolescents Age

Developmental issues

Fear and anxiety

0–6 months

Biological regulation

6–18 months

Object permanence Formation of attachment relationship Exploration of external world Magical thinking Autonomy Self-control

Fear of loud noises Fear of loss of support Fear of strangers Separation anxiety Fear of animals Fear of imaginary creatures Fear of the dark Fear of storms Fear of loss of caregivers Fear of school Worry Concerns about bodily injury and physical danger Social concerns

2–3 years 3–6 years

6–10 years

10–12 years 13–18 years

School adjustment Concrete operations: inference of cause-effect relations and anticipation of dangerous events Social understanding Friendship Identity Formal operations: catastrophizing about physical symptoms Sexual relationships Physical changes

Social anxiety Panic

Partly based on: Warren & Sroufe (2004). In Ollendick & March (2004), pp.92–115.

animals also develop during this phase. These fears are believed to be functionally related to the increased mobility of the child and its exploration of the external world. Some authors assume that fears of animals have survival value, as they would protect the mobile child from predators and other dangerous animal species (e.g., spiders, snakes; Öhman, Dimberg, & Öst, 1985). From age 7 onwards, children are increasingly able to infer physical causeeffect relationships and to anticipate potential negative consequences. These cognitive changes broaden the range of fear-provoking stimuli and enhance the more cognitive features of anxiety (e.g., worry). Taken together, in the course of their life, children are confronted with various developmental issues that have to be resolved and that largely determine the content of their fears and anxiety (see Table 1.3).

Fear, Anxiety, and Cognitive Development Indirect support for the notion that cognitive abilities and, in its wake, conceptualization have an influence on manifestations of fear and anxiety in youths comes from studies of children with autism or related disorders for which it is well known that they exhibit various

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cognitive aberrations (e.g., Frith, 1989). For example, Evans, Canavera, Kleinpeter, Maccubin, and Taga (2005) compared the fears of children with an autism spectrum disorder (ASD), children with Down syndrome, and chronologically age-matched children (with average ages ranging between 9 and 12 years), using parent ratings of a standardized fear questionnaire. Results indicated that children with ASD more frequently reported situational, social, and medical fears but less often fears of harm and injury as compared to the other two groups. In another study, Weisbrot, Gadow, DeVincent, and Pomeroy (2005) obtained parent and teacher ratings of anxiety symptoms in a large sample of 3- to 12-yearold clinically referred children with and without a pervasive developmental disorder (PDD). These researchers noted that both informants rated children with PDD as significantly more anxious than non-PDD children, which led them to the conclusion that “anxiety appears to be a clinically important concern in many children with PDD” (p.477). Finally, Muris, Steerneman, Merckelbach, Holdrinet, and Meesters (1998) found that children with PDD (i.e., autistic disorder and pervasive developmental disorder—not otherwise specified; N = 44) frequently displayed clinically relevant fear and anxiety symptoms. In particular, severe symptoms of specific phobia (63.6%) and agoraphobia (45.5%) were highly prevalent within this group, whereas symptoms of panic disorder, social phobia, and generalized anxiety disorder were relatively less common. With respect to these results, Muris et al. (1998; p.392) note that “it is conceivable that a serious cognitive dysfunction rules out those types of anxiety phenomena that presuppose sophisticated cognitive processes (e.g., worrying, fearful anticipation) . . . fear and anxiety symptoms of these children originate from their weak integration capacity. That is, PDD children have extreme difficulties in relating diverse sources of information. As a result, PDD children would experience many everyday situations as chaotic, obscure, and thus frightening,” which of course clearly link the manifestation of fear and anxiety to the cognitive abilities of children with this type of developmental disorder. While it is a widely accepted notion that the developmental pattern of fear and anxiety reflects everyday experiences and to an important extent is mediated by children’s cognitive capacities (Marks, 1987), it should also be acknowledged that direct empirical evidence for this idea is extremely sparse. One exception is a study by Muris, Merckelbach, Meesters, and Van den Brand (2002), who examined the connection between cognitive development and worry. Children were interviewed about the presence and content of a personal worry. Furthermore, a worry elaboration score was obtained by encouraging children to think up potential negative outcomes associated with a series of worry topics. Finally, a number of Piaget’s (1970) conservation tasks were administered in order to assess children’s level of cognitive maturation. Results revealed a mediation model in which increased age and, in its wake, cognitive development lead to enhanced worry elaboration, which in turn increases the possibility of a personal worry to emerge (see Figure 1.4). Thus, it can be concluded that worry becomes increasingly manifest in middle childhood when children reach a certain level of cognitive maturation (see also Vasey, Crnic, & Carter, 1994). Another example involves the aforementioned investigation by Westenberg et al. (2004). These researchers examined developmental patterns in fears concerning both physical danger and social evaluation in a large sample of children and adolescents. Interestingly, participants’ level of sociocognitive maturation was also assessed. Results demonstrated that fears of physical danger decreased with age, whereas fears concerning social evaluation increased as children got older. Most important, however, it was found that the age effect


11

.08

Age .23*

Cognitive development

.30*

Worry elaboration

.18*

Personal worry

–.04

Figure 1.4: Model showing the mediational effects of worry elaboration on the relationship between cognitive development and age, on the one hand, and the emergence of a personal worry, on the other hand. *Significant path at p < .05. From: Muris, Merckelbach, Meesters, & Van den Brand (2002).

in social-evaluative fears was entirely explained on the basis of developmental differences in sociocognitive maturity. This led the authors to the conclusion that the social fear and anxiety, which frequently arise during adolescence, are a corollary of sociocognitive development. A final example that illustrates the developmental course of fear and anxiety among youths pertains to the phenomenon of panic. Several researchers have argued that real panic symptoms usually do not occur before adolescence because younger children are less capable of experiencing the cognitive symptoms that accompany panic, such as “fear of going crazy” and “fear of dying” (e.g., Nelles & Barlow, 1988). A recent investigation by Muris, Vermeer, and Horselenberg (in press) indeed provided some evidence to suggest that cognitive development is associated with children’s ability to consider physical symptoms as a sign of anxiety. In that study, children aged between 4 and 13 years were presented with a number of vignettes in which the presence and absence of physical symptoms (e.g., “difficulties with breathing,” “heart beating fast,” “feeling dizzy”) was systematically varied. Results revealed a clear developmental pattern for anxiety-related interpretations of physical symptoms. More precisely, from age 7, children were increasingly capable of linking physical symptoms to the emotion of anxiety. Moreover, cognitive development as measured by Piagetian conservation tasks also appeared to influence children’s anxiety-related interpretations of physical symptoms. That is, children who had reached a more advanced stage of cognitive development (e.g., concrete operations) were better in linking physical symptoms to the emotion of anxiety. Unfortunately, this study did not examine to what extent these children were capable of making catastrophic, panic-like interpretations of the physical symptoms. This issue was addressed in a study by Mattis and Ollendick (1997), who reported that even children as young as 9 years were able to attribute physical symptoms to internal, threat-related cognitions, although less to catastrophic ones. Further, these researchers assume that such cognitions more frequently occur in adolescence when children’s cognitive abilities have further matured. All these studies seem to indicate that cognitive development in particular plays a prominent role in the occurrence of various “normal” anxiety phenomena and may herald periods in which vulnerable children are prone to develop high levels of fear and anxiety or even anxiety disorders.

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Gender Differences in Fear and Anxiety It is well established that girls display higher levels of fear and anxiety than boys (Bernstein, Borchardt, & Perwien, 1996; Ollendick, King, & Muris, 2002). For example, it is a consistent finding that girls exhibit significantly higher scores on standard self-report questionnaires for measuring fear and anxiety as compared to boys. To illustrate this point, Figure 1.5 shows mean standardized fear and anxiety scores for nonclinical boys and girls, using data of studies that either employed the FSSC-R or the Screen for Child Anxiety Related Emotional Disorders (SCARED; Birmaher, Khetarpal, Brent et al., 1997) for measuring these types of symptoms in youths. As can be seen, girls clearly reported higher fear (FSSC-R) and anxiety (SCARED) levels than boys (see also Craske, 2003). Although there is abundant evidence for gender differences in self-reported fear and anxiety, it should be noted that these differences are less clear-cut when using parents as raters of children’s symptoms. For example, a recent study by Muris, Meesters, and Knoops (2005) demonstrated that when employing children’s self-report data, substantial gender differences in fear and anxiety were observed. However, when using parent report data, the effects of gender were only present for fear and not for anxiety. This probably has to do with the fact that anxiety is not as easy to observe as fear (e.g., Stallings & March, 1995). More precisely, whereas children’s fear is, at least to some extent, visible to parents (and other caregivers), anxiety symptoms such as worry and somatic sensations may remain largely hidden when the child does not communicate them (see Layne, Bernstein, & March, 2006). Support for this idea was obtained in a recent study by Comer and Kendall (2004), who demonstrated better parent-child agreement for observable, school-based fear and anxiety symptoms (e.g., “There are places the child won’t go because he/she is afraid to be away from his/her parents,” “Child gets more nervous or scared than other children of his/ her age when answering questions in class”) than for unobservable, non-school-based

0,8 0,6 0,4 0,2

Boys

0

Girls

–0,2 –0,4 –0,6 –0,8 FSSC-R

SCARED

Figure 1.5: Mean standardized fear (FSSC-R) and anxiety (SCARED) scores for nonclinical boys and girls using self-report data of 20 studies published between 1983 and 2005. FSSC-R = Revised Fear Survey Schedule for Children, SCARED = Screen for Child Anxiety Related Emotional Disorders. Both gender differences are significant at p < .01.


13

symptoms (e.g., “Child worries a lot about that something bad might happen to him/her,” “Child has bad dreams about being away from his/her parents”).

Severity of Childhood Fear and Anxiety As mentioned before, fear and anxiety are normal phenomena that occur in many children and adolescents. Still, it is largely unknown how serious fear and anxiety actually are. In other words, to what extent do children and adolescents engage in worry about feared stimuli and situations at a frequent or regular basis? Do they engage in avoidance behavior to prevent their occurrence? Do these fear and anxiety symptoms interfere with youths’ daily functioning? (see Ollendick & King, 1994). Few studies have addressed these questions in a systematic fashion. In a survey by McCathie and Spence (1991), 7- to 13-year-old children (N = 376) were asked to complete the FSSC-R and the Fear Frequency and Avoidance Survey Schedule for Children (FFASSC). The FFASSC measures the frequency with which children respond with fearful thoughts and avoidance behavior to fear items as listed by the FSSC-R. McCathie and Spence noted that there were robust connections between the most commonly reported fears on the FSSC-R and the frequency of fearful thoughts and avoidance behaviors. Thus, not only did children report having FSSC-R defined fears, they also said that these fears were accompanied by aversive thoughts and avoidance behavior. Similarly, Ollendick and King (1994) found that a large majority of children (i.e., more than 60%) reported that their fears interfered substantially with daily activities. These findings emphasize the point that symptoms of childhood fear and anxiety are often seriously disturbing and distressing. This point can also be illustrated by a study of Strauss, Frame, and Forehand (1987), who compared the general functioning of anxious children with that of nonanxious controls. Peer, teacher, and self-reports clearly indicated that the anxious youths showed impairments in social, emotional, and school functioning as compared to their nonanxious counterparts. Similar results were obtained by Muris and Meesters (2002a), who examined the relation between children’s self-reported anxiety symptoms and teacher ratings of school functioning in a sample of 317 primary school children. Results indicated that higher levels of anxiety symptoms were accompanied by less optimal school functioning. More specifically, anxiety symptoms were associated with lower levels of selfesteem and school performance. Finally, it should be mentioned that fear and anxiety symptoms in nonclinical youths are accompanied by heightened levels of depression, difficulties in establishing social and romantic relationships, and in some cases alcohol abuse (Cole, Peeke, Martin, Truglio, & Seroczynski, 1998; Glickman & La Greca, 2004; Kaplow, Curran, Angold, & Costello, 2001; Strauss, Lease, Kazdin, Dulcan, & Last, 1989). Research has also indicated that children and adolescents who display high levels of fear and anxiety symptoms at one point in time are at increased risk for exhibiting high levels of such symptoms on a later occasion. For example, prospective studies employing the FSSC-R, in which children and adolescents were followed for longer time periods (i.e., 2 to 3 years), have demonstrated that youths’ fear levels generally decreased from the initial to the follow-up assessment (Gullone & King, 1997; Spence & McCathie, 1993). However, the data also showed that initial fear scores were good predictors of follow-up fear scores, suggesting that such symptoms were relatively stable over time. Similar results have been

14


obtained by Ialongo, Edelsohn, Werthamer-Larsson, Crockett, & Kellam (1995), who longitudinally followed a group of 356 school children over a four-year period. In grade 1, selfreported anxiety symptoms appeared inversely related to adaptive functioning (see also Ialongo, Edelsohn, Werthamer-Larsson, Crockett, & Kellam, 1994). Most importantly, firstgrade anxious symptoms were found to have significant prognostic value in terms of children’s levels of anxious symptoms and adaptive functioning in grade 5. Taken together, high levels of fear and anxiety symptoms tend to be stable over longer time periods (see also Gullone, King, & Ollendick, 2001), thereby causing youths to experience long-lasting difficulties. In order to get a better picture of the clinical significance of “normal” fear and anxiety symptoms among youths, their connection to DSM-defined phobias and anxiety disorders should be considered. A study by Muris, Merckelbach, Mayer, and Prins (2000) explored this issue. In that study, fears of 290 children aged 8 to 13 years were assessed, and then their severity was evaluated by means of a structured diagnostic interview measuring anxiety disorders in terms of DSM criteria. Results showed that in a sizable minority of the children (22.8%), fears reflected significant anxiety disorders, notably specific phobias. Similar findings were reported in a follow-up study that investigated the connection between childhood fears and specific phobias by interviewing children’s parents (Muris & Merckelbach, 2000). Other studies that examined the severity of normal children’s nighttime fears and worries through their links with DSM classifications (Muris et al., 1998, 2001) also revealed that such fear and anxiety phenomena reflect serious problems in a fair proportion of the youths (see Table 1.4). Thus, while there has been a strong tendency in the literature to portray childhood fear and anxiety as mild and nonpathological (e.g., Rutter, Tizard, & Whitmore, 1968), the studies summarized in this section make clear that at least a subgroup of children evidence significant phobias and anxiety disorders that not only hinder current functioning but also may have a negative impact on future life (see, e.g., Vignoli, Croity-Belz, Chapeland, De Fillipis, & Garcia, 2005).

Abnormal Fear and Anxiety in Children and Adolescents Abnormal fear and anxiety in children and adolescents are typically expressed in terms of the phobias and anxiety disorders as defined in the DSM. The latest edition of the DSM (i.e., the DSM-IV-TR; APA, 2000) for the most part employs the same diagnostic criteria and entities for classifying “anxiety disorders” in youths as in adults. The only exception is separation anxiety disorder, which is subsumed under the section “disorders usually first diagnosed in infancy, childhood, or adolescence.” Table 1.5 lists the various phobias and anxiety disorders that, according to the DSM, can be classified in children and adolescents, as well as a brief description of the essential features of each disorder. It is good to keep in mind that during the past decades, the classification of anxiety disorders in youths has been somewhat changed. For example, previous editions of the DSM (e.g., DSM-III-R; APA, 1987) included anxiety disorders that were specifically diagnosed in youths. That is, avoidant disorder and overanxious disorder were the child and adolescent counterparts of the adult classifications of respectively social phobia and generalized anxiety disorder. In later editions, this distinction was no longer made (APA, 1994, 2000), and now similar criteria are used for defining these disorders in youths and adults (although some differences


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Table 1.4 The severity of common childhood fear and anxiety phenomena as expressed by their relations to DSM anxiety disorder diagnoses Fear and anxiety phenomenon (study) Worry (Muris et al., 1998)

Childhood fears (Muris et al., 2000)

Childhood fears (Muris & Merckelbach, 2000) Nighttime fears (Muris et al., 2001)

Informant/sample Child report 193 children aged 8 to 13 years Child report 290 children aged 8 to 13 years

Parent report 160 children aged 4 to 12 years Parent report 176 children aged 4 to 12 years

DSM anxiety disorder GAD

Percentage of total sample 6.2

SP Situational-environmental SP Blood-injection-injury SP Animals GAD SAD PD At least 1 anxiety disorder SP Situational-environmental SP Blood-injection-injury SP Animals

4.5 7.9 7.2 5.5 4.8 1.7 22.8 6.3 1.3 10.0

SP Situational-environmental SP Animals GAD

1.3 1.9 4.4

Note. SP = Specific Phobia, GAD = Generalized Anxiety Disorder, SAD = Separation Anxiety Disorder, PD = Panic Disorder (current diagnostic terms are used).

in the precise symptomatology of various anxiety disorders may still be observed; see Geller, Biederman, Faraone et al., 2001; Kendall & Pimentel, 2003). For reasons of clarity, the current nosologic terms are consistently employed throughout this book, even when describing older studies that used diagnoses based on somewhat different diagnostic criteria (Kendall & Warman, 1996). Nevertheless, this procedure seems defendable because the core features of the anxiety disorders in youths (see Table 1.5) have remained unchanged throughout the years. It should be noted that the current edition of the DSM also includes two other types of anxiety disorders: “substance-induced anxiety disorder” and “anxiety disorder—not otherwise specified.” The first type refers to a variety of serious anxiety symptoms that occur after substance intoxication or withdrawal, whereas the second type pertains to disorders with prominent anxiety and phobic avoidance that do not meet the criteria for any specific anxiety disorder (APA, 2000). However, these two types of anxiety disorders are not listed in Table 1.5 because they are not characterized by a specific set of symptoms but rather “borrow” symptoms from various other anxiety disorders. Further, there are a number of

16


Table 1.5 DSM-IV-TR defined phobias and anxiety disorders in children and adolescents Anxiety disorder

Essential features

Specific phobia

Marked and persistent fear of clearly discernible, circumscribed objects or situations. Five types: animal, situational, blood-injection-injury, natural environment, and other. The presence of recurrent, unexpected panic attacks, i.e. discrete periods of intense fear that are accompanied by somatic and cognitive symptoms. There is also persistent concern about having another panic attack, worry about the implications or consequences of the panic attacks, or a significant behavioral change related to the attacks. Anxiety about being in places or situations from which escape might be difficult or in which help may not be available in the event of having a panic attack or panic-like symptoms. Marked and persistent fear of social or performance situations in which embarrassment may occur. Recurrent obsessions and/or compulsions. Obsessions are persistent ideas, thoughts, impulses, or images that are experienced as intrusive and inappropriate and that cause marked anxiety or distress. Compulsions are repetitive behaviors or mental acts, the goal of which is to prevent or reduce anxiety or distress. Following exposure to an extreme traumatic stressor, which elicited intense fear, helplessness, or horror, the person develops a characteristic pattern of symptoms including reexperiencing the traumatic event, persistent avoidance of stimuli associated with the trauma, and increased arousal. Enduring and excessive anxiety and worry (apprehensive expectation) about a number of events and activities. Excessive anxiety concerning separation from the home or from those to whom the person is attached.

Panic disorder

Agoraphobia

Social phobia (previously known as avoidant disorder) Obsessive-compulsive disorder

Posttraumatic or acute stress disorder

Generalized anxiety disorder (previously known as overanxious disorder) Separation anxiety disorder

Based on: American Psychiatric Association (2000).


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other mental disorders that occur in youths in which fear and/or anxiety seem to play an important role. For instance, selective mutism, which can be defined as the refusal or withholding of speech in some situations while displaying normal speech in other settings, may reflect high levels of social anxiety (e.g., Vecchio & Kearney, 2005; Yeganeh, Beidel, Turner, Pina, & Silverman, 2003). As another example, some adolescents come to suffer from the somatoform disorder of hypochondriasis, which refers to the preoccupation with having a serious disease, which is accompanied by high levels of fear and worry (Fritz, Fritsch, & Hagino, 1997). Epidemiological surveys have yielded prevalence rates of childhood phobias and anxiety disorders that vary between 2% and 27% (see, for a recent review, Costello, Egger, & Angold, 2004). This range is rather broad, but it should be kept in mind that rates are largely dependent on the type of prevalence that is studied. More precisely, three-month estimates ranged from 2.2% to 8.6%, six-month estimates from 5.5% to 17.7%, 12-month estimates from 8.6% to 20.9%, whereas lifetime prevalence estimates varied between 8.3% and 27.0%. A comparison with the prevalence rates of other psychiatric disorders in youths reveals that anxiety disorders are among the most common psychological problems in children and adolescents. For example, in a sample of 10,438 5- to 15-year-old children and adolescents, Ford et al. (2003) found a three-month prevalence rate of 3.7% for anxiety disorders, which means that this type of problem ranks high among the psychiatric disorders that occur in youths. Only disruptive behavior disorders (including oppositional-defiant disorder, conduct disorder, and attention-deficit and hyperactivity disorder) were more prevalent (Figure 1.6). On the basis of a large cohort study carried out in the Great Smoky Mountains in the United States, Costello et al. (2003) report a cumulative prevalence rate of 9.9% for anxiety disorders by the age of 16 years. This implies that 1 out of 10 children in this study had suffered from an anxiety disorder at some point during their youth. Figure 1.7 displays the prevalence rates for various types of anxiety disorders in youths using the data of 14 epidemiological studies that included children and adolescents of

6 5 4 3 2 1 0 Disruptive behavior disorders

Anxiety disorders

Depressive disorders

PDDs

Eating disorders

Tic disorders

Figure 1.6: Percentage of youths with DSM-IV defined anxiety disorders as compared to other psychiatric disorders. PDDs = Pervasive Developmental Disorders. Based on: Ford, Goodman, & Meltzer (2003).

18

Normal and Abnormal Fear and Anxiety in Children and Adolescents 4 3 2 1 0 SP

SOP

GAD

SAD

AGO

PTSD

PD

OCD

Figure 1.7: Mean prevalence rates of various anxiety disorders in youths, using the data of 14 epidemiological studies. SP = Specific Phobia, SOP = Social Phobia, GAD = Generalized Anxiety Disorder, SAD = Separation Anxiety Disorder, AGO = Agoraphobia, PTSD = Posttraumatic Stress Disorder, PD = Panic Disorder, OCD = Obsessive-Compulsive Disorder. Based on: Costello, Egger, & Angold (2004). In Ollendick & March (2004), pp.61–91.

various ages. As can be seen, specific phobia, social phobia, generalized anxiety disorder, and separation anxiety disorder are most common, with mean prevalence rates between 2.2% and 3.6%. Agoraphobia (1.5%) and posttraumatic stress disorder (1.5%) are less prevalent, whereas panic disorder and obsessive-compulsive disorder are relatively rare (i.e., P: vulnerability clearly predominates protection, and this results in pathological anxiety.

The Aetiology of Childhood Phobias and Anxiety Disorders

187

present: (1) normal and abnormal fear and anxiety are part of one and the same continuum, (2) although not visually depicted in the figure, it is clear that vulnerability and protective factors are continuously in dynamic interaction with each other to determine the anxiety level at each point in time, and (3) development has an important influence: This is illustrated by the fact that the balance between vulnerability and protection continuously changes during the course of development. Furthermore, in this vulnerable child, normal developmental challenges (such as going to primary school) seem to herald a difficult period in which related anxiety symptoms (e.g., separation anxiety/school phobia) become more intense. Two additional remarks regarding the analysis as shown in Figure 6.14 are in order. To begin with, time frames of one year were used in order to keep the figure orderly. However, it is clear that this approach allows a more detailed and refined analysis of the origins of anxiety problems as long as the exact points in time for certain life events are known. Further, the model is of course far from complete. That is, no information was available for other vulnerability and protective factors that play a role in the aetiology of childhood phobias and anxiety disorders. This points out that in order to fully understand the origins of the anxiety problems of a specific child, it is important for clinicians to have a good overview of all the factors that may be involved.

What Was Really Wrong with Little Hans? Little Hans was an almost 5-year-old boy who was so afraid of horses that he did not dare to go out on the street anymore. Freud (1909/1955) postulated that these complaints originated from a so-called Oedipus complex: Hans wanted sex with his mother and therefore expected to be punished by his father. As a result, Hans came to fear his father. However, this was considered as unacceptable by his Ego, and therefore his fear was shifted to another object: horses. As a result of his fear of horses, Hans no longer went out of the house. According to Freud, these agoraphobic complaints helped him to achieve his main goal: staying at home with his beloved mother. As already pointed out by Wolpe and Rachman (1960), there is absolutely no empirical evidence for the Freudian interpretation of Little Hans’s case. However, Wolpe and Rachman identified various factors in Freud’s description of the case that may have been relevant for understanding the aetiology of the phobia in this 5year-old boy. Briefly, these authors assume that negative learning experiences with horses have played an important role in the origins of Hans’s horse phobia. First of all, they note a number of events that may have enhanced the boy’s susceptibility to become fearful of horses. In Wolpe and Rachman’s (1960) words, Hans had gone through “two unpleasant incidents with horses prior to the onset of the phobia. It is likely that these experiences had sensitized Hans to horses, or in other words, he had already been partially conditioned to fear horses. These incidents occurred at Gmunden [a small village in Austria where Hans and his family went for the summer holidays]. The first was the warning given by the father of Hans’s friend to avoid the horse lest it bite, and the second when another of Hans’s friends injured himself (and bled) while they were playing horses” (p.146). Obviously, the first incident involves negative information transmission, while the second event can be qualified as a vicarious learning experience. Second, the onset of Hans’s phobia probably

188


occurred when the boy witnessed a horse in front of a carriage falling on the street. Hans himself pointed at this incident when his father asked him about where his fear of horses came from: “I only got it [the phobia] then. When the horse in the bus fell down, it gave me such a fright, really! That was when I got the nonsense [father and Hans use this word to refer to Hans’s horse phobia]” (Freud, 1909/1955; p.192). This incident can be viewed as a classical conditioning experience, and although the event from an adult’s point of view can be regarded as rather mild, it was severe enough for Hans to display intense fear of horses immediately afterward. Besides these negative learning experiences, a number of other variables can be identified in the case history of Little Hans that may also be relevant in the context of the origins of his phobic complaints. To begin with, questions can be posed concerning the rearing behaviors of Hans’s parents. Father impresses as a real adept of Freud’s theoretical notions of psychopathology, and obviously had a clear view of what was wrong with his son. He really seemed to make a lot of fuss about Hans’s problem and talked a lot with him about the presupposed (sexual) origins but actually did little to help the boy to cope with his fears. Little is known about Hans’s mother. We only know that she was a former patient of Freud, and that she threatened Hans when she found him with his hand to his penis when he was 3 years old: “If you do that, I shall send for Dr. A. to cut off your widdler!,” which gives us the impression that she may have not been particularly suitable for dealing with the intense fears of her son. Further, a number of stressful life experiences occurred in the year before the onset of his phobia, which may have enhanced Hans’s vulnerability to develop anxiety complaints. First of all, his sister was born, and as in many young children, Hans initially was rather jealous about the new arrival in the family. Further, the boy got influenza and even underwent an operation during which his tonsils were removed. Clearly, these experiences introduced stress in Hans’s life and as a consequence he may have felt less secure. Admittedly, the information about Hans’s parents and these negative life events is rather meager, and hence one could argue that the role of all these factors in the aetiology of Hans’s fears is rather speculative. However, even psychoanalysts themselves have noted these factors and tried to incorporate them in a reformulation of the case. For example, Ornstein (1993) offered a self-psychological perspective on the origins of Hans’s horse phobia, and concluded that the problem probably emerged because of the child’s separation anxiety and an increasingly insecure attachment to his mother. However, there is no need for new psychoanalytic speculations, because Little Hans’s case can be perfectly analyzed in terms of a developmental psychopathology account (see Figure 6.15). While we know little about protective variables, it can be assumed that several factors enhanced Hans’s vulnerability to develop an anxiety problem, including the stressful life events, the way his parents dealt with his fear, and the negative learning experiences with horses (of which the mild conditioning event of the horse falling on the street probably caused his fear to gain phobic properties). Important in this account is the fact that Hans is only 5 years old. At this age, fantasy is a significant aspect in children’s perception and thinking. From the description of Freud’s case, it becomes clear that Hans indeed tended to magnify the danger of horses. For example, he viewed the halter as a muzzle, which prevented the horse from biting. In his perception, horses were quite large animals and from his point of view, the incidents with horses were rather impressive and really frightening


189

5-year-old boy

Pathological anxiety

Protection

?

Vulnerability

Normal anxiety

Anxiety-promoting rearing behaviors of parents Stressful life events: newborn sister, tonsillectomy Negative learning experiences with horses

Figure 6.15: Analysis of Little Hans’s case in terms of a developmental psychopathology perspective.

for him. It seems doubtful, however, that these events would have exerted a similar impact if Hans had been 10 years of age. Finally, Little Hans’s case is also a nice illustration of the fact that normal and abnormal fears are part of one and the same dimension. More precisely, at its climax, Hans’s fear of horses certainly exhibited phobic characteristics. In terms of the current diagnostic criteria of a specific phobia (American Psychiatric Association, 2000), there was a marked fear of a clearly discernable and circumscribed object (i.e., horses), exposure to this stimulus invariably provoked an anxiety response, and the stimulus was avoided to such an extent that it interfered with Hans’s daily functioning (i.e., he did not dare to go out on the street anymore). However, there is one important DSM-criterion that Hans’s “phobia” did not fulfill: in youths, the duration of the phobic complaints should at least be six months, and this was obviously not the case. According to the original case description, the phobia broke out in January 1908, whereas Freud’s (one-session) therapy ended in May of that year (Freud, 1909/1955). In other words, it seems most plausible to view the “phobia” of Little Hans as a significant but short-lasting increase of fear in a 5-year-old boy in which the vulnerability factors briefly exceeded the protective potential. The weight of these vulnerability factors seemed to be partly determined by the developmental level of Hans: His restricted experience with and knowledge about horses as well as his rich fantasy may have created a good soil for developing a fear of these animals.

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Conclusion This chapter conceptualized the aetiology of phobias and anxiety disorders in youths in terms of a dynamic multifactorial model. The model incorporates a wide range of vulnerability, maintaining, and protective variables that have been identified as relevant for the origins of anxiety problems in youths. The basic idea is that normal and abnormal fear and anxiety are situated on a continuum and that at each point in time, while taking into account the developmental level of the individual child or adolescent, vulnerability and protective factors operate in dynamic interaction with each other to produce a certain level of fear or anxiety. If protection is greater or equal to vulnerability, fear and anxiety levels will remain within acceptable limits. However, when vulnerability clearly exceeds protection, fear and anxiety may become so frequent and intense that the young person experiences significant interference in his daily routine and functioning. In the latter case, fear and anxiety are no longer normal but acquire the status of a phobia or an anxiety disorder. Development is considered as an important moderating variable in the model; for example, the child’s developmental level may determine the type of fear (phobia) or anxiety (disorder) from which the child comes to suffer or may have an impact on the precise symptomatology of the disorder. Admittedly, the hypothesized model does not have all the qualities of a scientific model. Clearly, many issues need to be investigated. To begin with, this account implies that the aetiology of the anxiety problem may be totally different for each individual child. This does not mean, however, that it is an important issue for researchers to examine whether there are common pathways to pathological anxiety in youths. Researchers have begun to identify such trajectories for various types of child psychopathology (e.g., Broidy, Nagin, Tremblay et al., 2003; Kim & Cicchetti, 2006; Mulvaney, Lambert, Garber, & Walker, 2006; Shaw, Lacourse, & Nagin, 2005), and it seems important to examine this issue for childhood phobias and anxiety disorders. Further, the precise dynamics and interactions among various vulnerability and protective factors that figure in the model are far from clear. The recent past has seen the emergence of studies that examine the contributions of multiple factors to childhood fear and anxiety, but it is clear that more research is required to establish the overlap among these variables and to study interactive effects, in particular between vulnerability and protective factors. Finally, the role of development needs careful consideration. So far, in most studies, development (in most studies: age) has been predominantly treated as a confounding variable, and as a consequence most researchers have simply partialled out its influence in their statistical analyses. It seems important to thoroughly examine the influence of development on the emergence of normal and abnormal fear and anxiety. In this research, age might be employed as a proxy of development. However, it would certainly be an improvement to employ more direct indices of social, cognitive, and emotional development. Obviously, all these issues preferably require longitudinal prospective studies that include various parameters. Of course, such complex prospective studies are not easy to conduct, precisely because they are time consuming and difficult to get funded. However, only in this way we can further expand our knowledge on the aetiology of this highly prevalent type of psychopathology, which is a burden to many of our youths and inherently a silent threat to the future adult generation.


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Although the focus of this book is on the aetiology of phobias and anxiety disorders in youths, the following two chapters are concerned with assessment and treatment. More precisely, Chapter 7 provides a thorough overview of various types of empirically validated measures that can be employed to assess normal and abnormal manifestations of fear and anxiety in children and adolescents. Finally, in Chapter 8 various interventions methods that are used for treating pathological fear and anxiety in youths will be described. Again, science will be our guide, which means that only those intervention methods will be discussed that have demonstrated efficacy in controlled outcome research.


Chapter 7


Introduction Freud made little effort to assess the fears and anxiety of Little Hans in a systematic way. Instead, he mainly relied on observations of the boy’s father to gather information about the case (Freud, 1909/1955). In current psychological setting, it is common practice to employ some kind of psychological test to quantify and qualify children’s fear and anxiety complaints. While it is true that projective tests like the Columbus (Langeveld, 1981) and the Children’s Apperception Test (Bellak, 1993) are still frequently used and certainly may provide interesting information on children’s fear and anxiety, various other instruments can be employed to measure these negative emotions in a more standardized manner. This chapter provides an overview of empirically validated assessment instruments that may be helpful for assessing fear and anxiety in youths. First, a wide range of general and specific self-report questionnaires of childhood fear and anxiety will be reviewed. Next, a number of clinician rating scales will be discussed. Then, various interview instruments will be described that can be employed to classify childhood anxiety disorders in terms of current nosologic constructs as described in the DSM. Finally, a number of assessment methods will be described that rely on the direct observation of fearful and anxious behaviors in children and adolescents.

Self-Report Questionnaires In both research and clinical practice, self-report instruments for measuring childhood anxiety symptoms are frequently used. This type of measure is easy to administer, requires a minimum of time, and captures information about anxiety symptoms from the child’s point of view (Strauss, 1993). The latter is particularly important as fear and anxiety belong to the so-called internalizing problems, which are frequently less observable, even to people in youths’ direct environment. Although self-report instruments appear to assess children’s anxiety directly, these measures are not without limitations. As Stallings and March (1995) rightly remarked, social factors may influence the veracity of reporting. That is, some children tend to underreport fear and anxiety symptoms, simply because they want to present a more favorable evaluation of themselves or to avoid treatment. Further, when a questionnaire is used, one has to take into account the child’s ability to read and to understand the

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items, which of course determine the validity of responses. In spite of these limitations, self-reports represent an important source of information on fear and anxiety symptoms in youths. A wide range of instruments are available, of which the most important will be discussed in the following sections of the chapter.

Traditional Fear and Anxiety Scales The three most widely used self-report scales for measuring childhood anxiety are the StateTrait Anxiety Inventory for Children (STAIC; Spielberger, 1973), the Revised Children’s Manifest Anxiety Scale (RCMAS; Reynolds & Richmond, 1978), and the Revised Fear Survey Schedule for Children (FSSC-R; Ollendick, 1983). All these instruments are agedownward versions of adult questionnaires and were been developed more than 20 years ago. As such, it is not surprising that these scales do not use the current diagnostic constructs that are employed by many contemporary researchers and clinicians, which has led some authors to label them as “traditional” childhood anxiety questionnaires (Muris, Merckelbach, Ollendick, King, & Bogie, 2002). The STAIC is a widely used questionnaire, which consists of a state scale (20 items) that measures present-state and situation-linked anxiety, and a trait scale (20 items) that addresses temporally stable anxiety across situations. From a clinical perspective, the trait anxiety version of the STAIC (STAIC-T; item examples are “I am scared,” “I feel troubled,” and “I get a funny feeling in my stomach”) is more relevant than the state anxiety version because in most cases the assessor will be interested in assessing more chronic anxiety symptoms in children. The RCMAS resembles the STAIC-T in that this scale also attempts to assess more general anxiety levels in youths. Briefly, the RCMAS is a 37-item self-report rating scale that contains three anxiety-related subscales: physiological manifestations of anxiety (e.g., “Often I have trouble getting my breath”), worry and oversensitivity (e.g., “I worry a lot of the time”), and problems with fear and concentration (e.g., “Others seem to do things easier than I can”; Reynolds & Paget, 1983). Research has indicated that the STAIC-T and the RCMAS are reliable instruments (e.g., Varela & Biggs, 2006). However, there are questions about the validity of both instruments. As both questionnaires include items referring to mood rather than anxiety problems (see Szabó & Lovibond, 2006), several authors have argued that the STAIC-T and the RCMAS can best be considered as measures of “general distress, with the accent on anxiety” (Greco & Morris, 2004; Stallings & March, 1995, p.134). The FSSC-R primarily focuses on fears and phobic symptoms, and simply asks children and adolescents to rate how much fear they experience in response to specific stimuli or situations. In this way, information can be obtained on the number, severity, and types of fears. Factor analysis has consistently demonstrated that the FSSC-R contains five factors: fear of danger and death (e.g., “being hit by a car or truck”), fear of failure and criticism (e.g., “looking foolish”), fear of the unknown (e.g., “going to bed in the dark”), fear of small animals (e.g., “snakes”), and medical fears (e.g., “getting an injection from the nurse or doctor”; Ollendick, 1983; Ollendick, King, & Frary, 1989; Ollendick, Yule, & Ollier, 1991; see also Schaefer, Watkins, & Burnham, 2003). Interestingly, over the years, several authors have made an attempt to update the scale in such a way that it includes the new threats of


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contemporary society (e.g., “school violence,” “terrorists,” “AIDS,” “sexual assaults”; Fisher, Schaefer, Watkins, Worrell, & Hall, 2006; Gullone & King, 1992; Muris & Ollendick, 2002; Shore & Rapport, 1998). The psychometric properties of the FSSC-R are generally satisfactory, although Perrin and Last (1992) noted that the scale failed to discriminate between youths with either anxiety disorders, ADHD, or no psychiatric diagnosis. However, a more recent study by Weems, Silverman, Saavedra, Pina, and Lumpkin (1999) found evidence to suggest that the FSSC-R may be useful in differentiating among children with various types of phobias. Although the FSSC-R clearly seems to have its niche for assessing fears and fearfulness in youths (Myers & Winters, 2002), it should be mentioned that several authors have questioned the validity of this scale. For example, based on the observation that fears of danger and death (e.g., “not being able to breathe,” “bombing attacks or being invaded,” “being hit by a car or truck”) in FSSC-R studies typically belong to the most prevalent fears reported by children, McCathie and Spence (1991; p.495–496) noted: “Whereas it is perhaps sensible to suggest that these events would be extremely fear-producing if they were to occur, they are not highly probable events. Given such a low probability of occurrence, it seems unlikely that children frequently worry about these events or engage in avoidance behavior in order to prevent their occurrence.” A diary study of children’s fears indeed seemed to confirm this notion (Muris, Merckelbach, Ollendick et al., 2002). In that study, it was found that frequent FSSC-R danger and death fears have a low prevalence rate in daily life and, even when they do occur, elicit fairly low levels of fear. On the basis of these findings, it can be concluded that various FSSC-R items do not assess the frequency of actual fearful behavior, but rather the negative affective responding to the thought of occurrence of these specific events. In spite of their obvious limitations, it can be concluded that traditional scales such as the STAIC-T, RCMAS, and FSSC-R provide useful information on childhood fear and anxiety. Greco and Morris (2004) rightly remarked that these scales are good measures of global, anxiety-related distress. Some authors note this as a shortcoming of these questionnaires and have argued that these scales are more suitable for measuring general psychopathology-related distress rather than specific anxiety problems (Perrin & Last, 1992). Further, as these measures are not closely linked to the most recent diagnostic taxonomy of childhood anxiety, it can be concluded that their clinical utility is restricted. Fortunately, recent times have seen the emergence of modern self-report instruments, which intend to assess anxiety symptoms in youths in terms of current classification systems such as the DSM.

Modern, Multidimensional Questionnaires Over the past few years, a number of new questionnaires have been developed in an attempt to measure the various aspects of childhood anxiety in terms of the nosologic constructs that are currently employed by researchers and clinicians. In this context, three scales should be mentioned, namely the Multidimensional Anxiety Scale for Children (MASC; March, Parker, Sullivan, Stallings, & Conners, 1997), the Spence Children’s Anxiety Scale (SCAS; Spence, 1998), and the Screen for Child Anxiety Related Emotional Disorders (SCARED; Birmaher, Khetarpal, Brent et al., 1997).

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The MASC was constructed to assess four theoretically meaningful domains of childhood anxiety symptoms: affective, physical, cognitive, and behavioral. Items selected to represent these domains were subjected to factor analysis. Results, indeed, revealed four factors, yet the content of these factors deviated somewhat from the hypothesized anxiety domains. More precisely, the MASC seems to tap the following four dimensions of childhood anxiety: physical symptoms (e.g., “I feel tense”), social anxiety (e.g., “I am worried about others laughing at me”), separation anxiety (e.g., “I am scared when my parents go out”), and harm avoidance (e.g., “I avoid things that upset me”). These psychometrically derived dimensions have been found consistently in normal and clinical samples (March et al., 1997; March, Sullivan, & Parker, 1999; March, Conners, Arnold et al., 1999; Olason, Sighvatsson, & Smami, 2004). The psychometric properties of the MASC appear to be adequate with good internal consistency and test-retest stability (March et al., 1997; March et al., 1999). Furthermore, there is evidence for the concurrent and discriminant validity of this scale. For example, the MASC correlates significantly with traditional and other modern anxiety scales (Muris et al., 2002), and most MASC dimensions show specific convergence with their corresponding anxiety disorder as measured with a diagnostic interview (Wood, Piacentini, Bergman, McCracken, & Barrios, 2002). Finally, the scale differentiates reasonably well between anxious children, normal children, and children with other types of psychopathology (see March et al., 1999; Rynn, Barber, Khalid-Khan et al., 2006). The SCAS is a DSM-based questionnaire that measures youths’ perceptions of the frequency with which they experience symptoms related to generalized anxiety disorder (e.g., “I worry about things”), separation anxiety disorder (e.g., “I would feel afraid of being on my own at home”), social phobia (e.g., “I feel afraid that I will make a fool of myself in front of people”), panic and agoraphobia (e.g., “I suddenly feel as if I can’t breathe when there is no reason for this”), physical injury fears (which replace specific phobias—e.g., “I am scared of dogs”), and obsessive-compulsive disorder (e.g., “I can’t seem to get bad or silly thoughts or pictures out of my head”). The psychometric properties of the SCAS are strong. That is, the scale possesses good internal consistency, sufficient test-retest reliability (Spence, 1998; Spence, Barrett, & Turner, 2003), and satisfactory validity as evidenced by its correlations with concurrent anxiety scales (Essau, Muris, & Ederer, 2002; Mellon & Moutavelis, 2007; Muris, Schmidt, & Merckelbach, 2000). Further, the SCAS discriminates between youths with and without anxiety disorders, and within youths suffering from different anxiety disorders (Spence, 1998). It should be mentioned that Chorpita, Yim, Moffitt, Umemoto, and Francis (2000) undertook a revision of the SCAS. Physical fear items were removed, generalized anxiety disorder items were changed (focusing more on excessive worry, which seems to be the key feature of DSM-IV-defined generalized anxiety disorder), and depression items were added, resulting in the Revised Child Anxiety and Depression Scale (RCADS). Available evidence indicates that the psychometric qualities of the RCADS are good (Chorpita, Moffitt, & Gray, 2005; Chorpita et al., 2000; De Ross, Gullone, & Chorpita, 2002; Muris, Meesters, & Schouten, 2002). Just like the SCAS, the SCARED is a questionnaire for measuring anxiety symptoms in terms of DSM-classifications. The original SCARED (Birmaher, Ketharpal, Brent et al., 1997) consists of 38 items that can be allocated to five anxiety subscales. Four of these subscales represent anxiety disorders as described in the DSM—namely, separation


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anxiety disorder, generalized anxiety disorder, panic disorder, and social phobia. The fifth subscale is school phobia, which according to some authors can best be considered as a separate childhood anxiety disorder (see Blagg & Yule, 1994). The original SCARED has good internal consistency, test-retest reliability, and discriminant validity, both between anxiety and other psychiatric disorders and within anxiety disorders (Birmaher et al., 1997). In a follow-up study, Birmaher, Brent, Chiapetta et al. (1999) modified the SCARED by adding three items in order to strengthen the social phobia scale. This 41-item version of the SCARED displayed similar satisfactory psychometrics as the original version. The MASC, SCAS, and SCARED are modern measures of childhood anxiety that are closely related to current nosologic constructs as described in the DSM. The researchers that developed these scales were well aware of the problems with traditional scales, and have succeeded in constructing more anxiety-specific questionnaires. This becomes particularly evident in the discriminant validity of these scales. That is, even within clinical samples, MASC, SCAS, and SCARED scores are able to distinguish between anxiety and other disorders (Birmaher et al., 1997; Spence, 1998; Wood et al., 2002).

Screen for a Broad Range of Anxiety Symptoms The MASC, SCAS, and SCARED are certainly an improvement as compared to the more traditional scales. However, from a clinical point of view, it may be a disadvantage that each of these questionnaires is limited to assess symptoms of a restricted number of anxiety problems. With this issue in mind, Muris, Merckelbach, Schmidt, and Mayer (1999) revised the SCARED in three ways. First of all, school phobia items were joined to the separation anxiety disorder subscale. This was done because the DSM (see especially the DSM-III-R; APA, 1987) views school phobia as a symptom of separation anxiety disorder. Second, 15 new items were added in an attempt to index symptoms of specific phobia. The latest editions of the DSM (APA, 1994, 2000) distinguish three main subtypes—namely, animal phobia, situational-environmental phobia, and blood-injection-injury phobia (see Frederikson, Annas, Fischer, & Wik, 1996; Muris, Schmidt, & Merckelbach, 1999). Because specific fears and phobias are highly prevalent among children (e.g., Ollendick, King, & Muris, 2002), items of all three subtypes were included in the revised version of the SCARED. Third, although obsessive-compulsive disorder (OCD) and posttraumatic stress disorder (PTSD) are relatively rare, an extra 13 items were added so that it is also possible to tap symptoms of these disorders with the revised SCARED. Thus, the final 66-item revised version of the SCARED (i.e., SCARED-R; see Appendix) purports to measure symptoms of the entire anxiety disorders spectrum that, according to the DSM, may occur in children and adolescents. Previous studies have shown that the SCARED-R possesses adequate internal consistency (e.g., Muris et al., 1999), test-retest stability (Muris, Merckelbach, Van Brakel, & Mayer, 1999), and good validity—that is, the scale correlates substantially with other childhood anxiety measures (Muris, Merckelbach, Mayer et al., 1998; Muris et al., 2000) and discriminates between children with and without subclinical anxiety disorders (Muris, Merckelbach,

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Kindt et al., 2001; Muris, Merckelbach, Mayer, & Prins, 2000). A recent study by Muris, Dreessen, Bögels, Weckx, and Van Melick (2004) underlined the clinical utility of the SCARED-R. In a large sample of 242 clinically referred youths, SCARED-R scores were found to be significantly correlated with internalizing problems (as indexed by the Child Behavior Checklist; Achenbach, 1991) but not with externalizing problems. Further, within the group of children and adolescents who suffered from anxiety disorders, SCARED-R scores were negatively associated with children’s daily functioning on the Global Assessment of Functioning (GAF) scale (APA, 1994). In other words, higher levels of anxiety symptoms were accompanied by greater dysfunction in daily life. Finally, SCARED-R scores had satisfactory discriminant validity (both between anxiety disorders and other problems and within anxiety disorders) and, most importantly, had reasonable value for predicting specific anxiety disorders. Research has also evaluated the utility of specific SCARED-R subscales. For example, Muris, Merckelbach, Körver, and Meesters (2000) examined the validity of the SCARED-R PTSD subscale. Children who scored high on this subscale (i.e., the trauma group) and control children (matched for gender, age, and educational level) were interviewed about their most aversive life event. Results showed that children in the trauma group more frequently reported life events that independent judges considered as “potentially traumatic” than did control children. Further, children in the trauma group also reported to have experienced more traumatic incidents and displayed higher scores on PTSD-related questionnaires as compared to control children. All in all, these findings seem to support the validity of PTSD subscale of the SCARED-R. The SCARED-R possesses good psychometric qualities that are similar to those documented for other DSM-based questionnaires such as the MASC, SCAS, and original SCARED. The main advantage of this scale, however, is that it taps the full range of anxiety disorders symptoms in youths.

Choosing an Anxiety Self-Report When selecting a self-report questionnaire for measuring anxiety symptoms in youths, one should of course take the purpose of the assessment into consideration. For example, if one is interested in measuring children’s global level of anxiety-related distress, the researcher or clinician may choose the STAIC-T or the RCMAS, although the total scores of the MASC, SCAS, and SCARED(-R) are also suitable for this purpose. When one wants to evaluate frequency of various anxiety disorders symptoms—for example, in the process of a clinical evaluation—modern multidimensional questionnaires like the MASC, SCAS, and SCARED(-R) are preferable. In their comprehensive review of childhood anxiety measures, Stallings and March (1995; p.127) noted, “Ideally, instruments to assess anxiety in young persons should (1) provide reliable and valid ascertainment of symptoms across multiple symptom domains; (2) discriminate symptom clusters; (3) evaluate severity; (4) incorporate and reconcile multiple observations, such as parent and child ratings; and (5) be sensitive to treatment-induced change in symptoms.” Table 7.1 summarizes how various child anxiety questionnaires score on these parameters.


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As Table 7.1 shows, childhood anxiety scales generally perform satisfactorily on these parameters. That is, all questionnaires appear to possess good reliability and seem to be appropriate for measuring the severity of anxiety-related complaints. For most scales, a parent version is available, of which the psychometric properties have been investigated in at least one empirical study (e.g., Birmaher et al., 1997; Cole, Hoffman, Tram, & Maxwell, 2000; Muris et al., 2004; Nauta, Scholing, Rapee et al., 2004; Southam-Gerow, Flannery-Schroeder, & Kendall, 2003). Traditional scales like the STAIC-T, RCMAS, and FSSC-R are less suitable for assessing clinically relevant symptom clusters—that is, these questionnaires are unidimensional (STAIC-T) or assess symptom clusters that are less clearly linked to the anxiety disorders as described in the DSM. Relatedly, traditional scales often lack discriminative power, which means that they do not distinguish very well between children with anxiety disorders and children suffering from other psychiatric disorders, in particular mood disorders, and among children with different types of anxiety disorders (Perrin & Last, 1992; see Seligman, Ollendick, Langley, & Bechtoldt Baldacci, 2004). Available research has demonstrated that modern, multidimensional scales like the MASC, SCAS, and SCARED(-R) perform much better on this important aspect (e.g., Birmaher et al., 1997, 1999; Muris et al., 2004; Muris & Steerneman, 2001; Spence, 1998). On the other hand, the STAIC-T, RCMAS, and FSSC-R are found to possess good treatment sensitivity, which means that they are able to tap reductions in anxiety or anxietyrelated distress following successful psychological and pharmacological treatment (see for a review, Silverman & Ollendick, 2005). This aspect is less established for the modern, multidimensional scales, although such evidence is rapidly emerging (Barrington, Prior, Richardson, & Allen, 2005; Muris, Merckelbach, Gadet, Moulaert, & Tierney, 1999; Muris, Meesters, & Van Melick, 2002; Walkup, Labellarte, Riddle et al., 2002). There are some indications that the new questionnaires are even better in tapping treatment effects than the traditional scales. For example, in a study by Muris, Mayer, Bartelds, Tierney, and Bogie (2001), 36 anxiety disordered children were treated with cognitive-behavioral therapy. Treatment effects were documented with a traditional scale, the STAIC-T, and a modern questionnaire, the SCARED-R. On both scales, anxiety scores were significantly reduced after the intervention. Results further showed that the treatment effect as measured by the SCARED-R remained significant while controlling for STAIC prepost-treatment change scores. In contrast, when covarying SCARED-R change scores, the STAIC no longer tapped a significant treatment effect. This finding indicates that the SCARED-R explained variance in treatment effects over and above the STAIC-T. Altogether, for the assessment of general, anxiety-related distress, the STAIC-T and RCMAS can be used. However, if one likes to select a more specific anxiety scale for measuring symptoms in terms of the nosologic constructs as defined in the DSM, the MASC, SCAS, and SCARED(-R) are better options (Brooks & Kutcher, 2003). The MASC, SCAS, and original SCARED are relatively short and hence economic, and as such may be the instruments of choice in research. The SCARED-R is longer as it taps symptoms of the full range of anxiety problems that occur in youths and therefore may be the most useful selfreport instrument in clinical settings. In spite of its shortcomings, the FSSC-R remains the tool of choice for assessing fears and phobic tendencies, although the specific phobia scales of the SCARED-R can also be used for this purpose (Muris et al., 1999).

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Questionnaire STAIC-T (Spielberger, 1973)

Goal, description, other features Temporally stable anxiety 20 items 3-point scale 10 minutes 8- to 18-year-olds

RCMAS (Reynolds & Richmond, 1978)

Manifest anxiety 37 items 2-point scale 15 minutes 7- to 18-year-olds

FSSC-R (Ollendick, 1983)

Fears and fearfulness 80 items 3-point scale 20 minutes 7- to 18-year-olds

MASC (March, 1997)

Multiple domains of anxiety symptoms 39 items 4-point scale 20 minutes 8- to 18-year-olds

Psychometrics General evaluation: ± Internal consistency: + Test-retest reliability: + Convergent and divergent validity: ± Discriminant validity: ± General evaluation: ± Internal consistency: + Test-retest reliability: + Convergent and divergent validity: ± Discriminant validity: ± General evaluation: ± Internal consistency: + Test-retest reliability: + Convergent and divergent validity: + Discriminant validity: ± General evaluation: + Internal consistency: + Test-retest reliability: + Convergent and divergent validity: + Discriminant validity: +

Symptom clusters

Evaluate severity

Multiple observations

Treatment sensitivity

−

+

+ Parent version

+

± 3 empirically derived factors: Physiological worryoversensitivity, fear-concentration

+

+ Parent version

+

± 5 empirically derived factors: Danger and death, unknown, small animals, failure and criticism, medical fears

+

+? Parent version

+

+ 4 empirically derived factors, partly related to the DSM: Physical symptoms, social anxiety, separation anxiety, harm avoidance

+

+ Parent version

+?

Unidimensional


Table 7.1 Summary of the practical parameters and psychometric properties of the most important self-report anxiety questionnaires for children and adolescents

DSM-defined anxiety symptoms 38 items 4-point scale 20 minutes 8- to 18-year-olds

General evaluation: + Internal consistency: + Test-retest reliability: + Convergent and divergent validity: + Discriminant validity: +

SCARED (Birmaher et al., 1997, 1999)

DSM-defined anxiety symptoms 38–41 items 3-point scale 20 minutes 8- to 18-year-olds DSM-defined anxiety symptoms 66 items 3-point scale 30 minutes 8- to 18-year-olds

General evaluation: + Internal consistency: + Test-retest reliability: + Convergent and divergent validity: + Discriminant validity: + General evaluation: + Internal consistency: + Test-retest reliability: + Convergent and divergent validity: + Discriminant validity: +

SCARED-R (Muris et al., 1999)

+ 6 DSM-defined anxiety clusters: Separation anxiety disorder, generalized anxiety disorder, social phobia, panic and agoraphobia, obsessivecompulsive disorder, physical injury fears + 4 DSM-defined anxiety clusters and school phobia: Separation anxiety disorder, generalized anxiety disorder, social phobia, panic + 9 DSM-defined anxiety clusters: Separation anxiety disorder, generalized anxiety disorder, social phobia, panic disorder, obsessive-compulsive disorder, posttraumatic stress disorder, 3 types of specific phobia

+

+ Parent version

+?

+

+ Parent version

+?

+

+ Parent version

+?

Note. STAIC-T = Trait version of the State-Trait Anxiety Inventory for Children, RCMAS = Revised Children’s Manifest Anxiety Scale, FSSC-R = Revised Fear Survey Schedule for Children, MASC = Multidimensional Anxiety Scale for Children, SCAS = Spence Children’s Anxiety Scale, SCARED = Screen for Child Anxiety Related Emotional Disorders, SCARED-R = Revised version of the Screen for Child Anxiety Related Emotional Disorders. − Not satisfactory, ± Moderately satisfactory, + Satisfactory and well established in research, +? Probably satisfactory, but more empirical evidence is needed.


SCAS (Spence, 1998)

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Specific Fear and Anxiety Measures Traditional scales like the RCMAS, STAIC-T, and FSSC-R tap more general levels of fear and anxiety symptoms, whereas modern, multidimensional scales such as the MASC, SCAS, and SCARED(-R) tap symptoms of a variety of anxiety disorders. There are also scales that specifically measure the symptoms of one type of anxiety problem. Examples of such instruments can be found for all childhood anxiety disorders. Social Phobia. There are a number of questionnaires specifically developed for measuring symptoms of social phobia in youths. The Social Anxiety Scale for Children–Revised (SASC-R; La Greca & Stone, 1993) is a self-report measure that has been developed to assess social anxiety symptoms in children aged 8 to 13 years. The scale consists of 18 items that can be allocated to three subscales: fear of negative evaluation from peers (e.g., “I worry about what other kids say about me”), social avoidance and distress specific to new situations (e.g., “I get nervous when I talk to new kids”), and generalized social avoidance and distress (e.g., “I feel shy even with kids I know very well”). The psychometric properties of the SASC-R are satisfactory: Internal consistency and test-retest reliability are sufficient to good (La Greca, Dandes, Wick, Shaw, & Stone, 1988; La Greca & Stone, 1993). Furthermore, support has been found for the discriminant validity of the scale: In a sample of children with anxiety disorders, scores on the SASC-R differentiated children with and without a social-based anxiety disorder (Ginsburg, La Greca, & Silverman, 1998). La Greca and Lopez (1998) modified the language of the SASC-R to make the scale appropriate for adolescents. The resulting Social Anxiety Scale for Adolescents (SAS-A) has highly similar psychometric qualities as compared to the SASC-R: The original threefactor structure of the scale was retained, internal consistency and test-retest reliability are found to be good, and the validity is also satisfactory (Inderbitzen-Nolan & Walters, 2000; La Greca & Lopez, 1998; Myers, Stein, & Aarons, 2002). An alternative questionnaire for measuring social anxiety in youths is the Social Phobia and Anxiety Inventory for Children (SPAI-C; Beidel, Turner, & Morris, 1995), which can be employed in young people from age 8. The SPAI-C was empirically developed to assess cognitive (e.g., “When with others, I think scary thoughts”), physiological (e.g., “In a social situation, I feel [physical symptoms]”), and behavioral symptoms (e.g., “I avoid social situations”) of social phobia in children and adolescents as defined in the DSM. Items were generated on the basis of clinical interviews of children with social phobia and their mothers, daily diaries of stressful situations, and an adult questionnaire, the Social Phobia and Anxiety Inventory (Turner, Beidel, Dancu, & Stanley, 1989). The SPAI-C has excellent internal consistency and sufficient test-retest stability (Beidel et al., 1995), good convergent validity, and satisfactory discriminant validity with nonclinical controls and disruptive behavior disorders (Beidel, Turner, & Fink, 1996). Finally, a study by Beidel, Turner, Hamlin, and Morris (2000) demonstrated that the SPAI-C successfully distinguishes between socially phobic children and children with other anxiety disorders. Recent studies that directly compared the psychometrics of the SASC-R/SAS-A and the SPAI-C have demonstrated that both instruments seem to tap related but relatively independent constructs of social phobia and anxiety, and so both provide valuable information on this


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anxiety disorder (Storch, Masia-Warner, Dent, Roberti, & Fisher, 2004). When predicting social phobia in terms of the DSM, it was found that the SPAI-C was somewhat more sensitive than the SAS-A (Inderbitzen-Nolan, Davies, & McKeon, 2004). Separation Anxiety Disorder. Separation anxiety disorder is a relatively prevalent childhood anxiety disorder, and according to the latest edition of the DSM (DSM-IV-TR; APA, 2000) the only anxiety disorder that specifically occurs in youths. As such, it is somewhat surprising to note that questionnaires for specifically measuring symptoms of separation anxiety in youths are extremely sparse. Most of these instruments are grounded in the attachment theory, which is plausible as Bowlby (1973) described separation anxiety in older children as one of the signs indicating insecure attachment relationships. An example is the Separation Anxiety Test (SAT; see Richard, Fonagy, Smith, Wright, & Binney, 1998; Wright, Binney, & Smith, 1995), which assesses children’s responses to photographs depicting separations from parents (e.g., “Mum is going to the hospital to have a serious operation,” “Dad is leaving home after an argument,” and “This young person is going on a school trip for two weeks. He/she is saying good-bye to mum and dad”). For each separation situation, children and adolescents are asked how they would feel in that situation, why they would feel so, and what they would do in the pertinent situation. Responses are coded to yield one of three attachment classifications: secure, avoidant, and ambivalent. The ambivalent classification is most relevant for those interested in anxiety, as this category is indicative for children’s anxious responding to separation situations (Scott Brown & Wright, 2001, 2003). Generalized Anxiety Disorder. The key feature of generalized anxiety disorder is excessive worry (APA, 2000). The Penn State Worry Questionnaire (Meyer, Miller, Metzger, & Borkovec, 1990) is the most widely used scale for measuring worry in adults (see also Brown, Anthony, & Barlow, 1992). The age-downward version of the scale, the Penn State Worry Questionnaire for Children (PSWQ-C; Chorpita, Tracey, Brown, Collica, & Barlow, 1997; see Appendix) consists of 14 items that measure the tendency of youths to engage in generalized and uncontrollable worry (e.g., “I worry all the time,” “Once I start worrying, I can’t stop”). Research has demonstrated the PSWQ-C to be unifactorial and to possess good reliability in terms of internal consistency and test-retest reliability. Furthermore, evidence was found for the convergent and divergent validity of the scale. That is, in both samples of normal and clinically referred children, PSWQ-C scores correlated in a theoretically meaningful way with scores on measures of anxiety and depression. Finally, PSWQ-C scores of children with generalized anxiety disorder were found to be significantly higher than those of children with other anxiety disorders and nonclinical controls, thus yielding support for the discriminant validity of the scale (Chorpita et al., 1997). Similar favorable psychometric properties have been reported by Muris, Meesters, and Gobel (2001), although these authors advise that it is preferable to discard the three reversely scored items from the PSWQ-C when using the measure in younger (i.e., 8- to 12-year-old) children. Panic Disorder. Anxiety sensitivity refers to the fear of anxiety-related bodily sensations (e.g., Taylor, 1995) and has been proposed to play an important role in the aetiology and

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maintenance of panic disorder (e.g., Rachman, 1998). In children and adolescents, anxiety sensitivity is measured by means of the Childhood Anxiety Sensitivity Index (CASI; Silverman, Fleisig, Rabian, & Peterson, 1991; see Appendix), which is an age-downward modification of the Anxiety Sensitivity Index (Reiss, Peterson, Gursky, & McNally, 1986), the most frequently employed instrument for assessing anxiety sensitivity in adults. The CASI consists of 18 items such as “It scares me when I feel shaky,” “It scares me when my heart beats fast,” and “It scares me when I feel nervous.” Previous studies have consistently shown that the CASI is a reliable and valid questionnaire for measuring anxiety sensitivity in both clinical and nonclinical samples of children and adolescents (e.g., Chorpita, Albano, & Barlow; 1996a; Lambert, Cooley, Campbell, Benoit, & Stansbury, 2004; Muris, Schmidt, Merckelbach, & Schouten, 2001a; Rabian, Embry, & MacIntyre, 1999; Silverman et al., 1991; Silverman, Ginsburg, & Goedhart, 1998a; Van Widenfelt, Siebelink, Goedhart, & Treffers, 2002; Weems, Hammond-Laurence, Silverman, & Ginsburg, 1998). In an attempt to tap the underlying factor structure of anxiety sensitivity in a more adequate way, Muris (2002a) developed a revised version of the CASI (i.e., CASI-R). The CASI-R is lengthier than the original version and contains 31 items that can be allocated to four factors—namely, fear of cardiovascular symptoms (e.g., “When my heart is skipping a beat, I worry that something might be seriously wrong”), fear of publicly observable anxiety symptoms (e.g., “When I tremble in the presence of others, I fear what people think of me”), fear of cognitive dyscontrol (e.g., “When I feel strange, I worry that I might go crazy”), and fear of respiratory symptoms (e.g., “When my chest feels tight, I am scared that I cannot breathe properly”). The CASI-R has been shown to be a reliable scale in terms of internal consistency. Furthermore, CASI-R scores were substantially related to levels of anxiety sensitivity as measured by the CASI, and to symptoms of anxiety disorders—in particular, panic disorder. Finally, some evidence was found for the divergent validity of the CASI-R factor scores. That is, all factors convincingly loaded on symptoms of panic disorder, whereas the factor “fear of publicly observable anxiety reactions” was also strongly associated with symptoms of social phobia. Although these results with the CASI-R are encouraging, the original CASI remains the instrument of choice for measuring this panicrelated anxiety construct. More research with the expanded scale is necessary to demonstrate its incremental value as compared to the original index. Obsessive-Compulsive Disorder. The only currently available self-report scale for measuring symptoms of obsessive-compulsive disorder in youths is the Leyton Obsessional Inventory for Children (LOI-C; Berg, Whitaker, Davies, Flament, & Rapoport, 1988). This brief 20-item scale taps symptoms of OCD in children and adolescents aged 8 to 18 years. Examples of items are “Do you have to check things several times?,” “Are you fussy about keeping your hands clean?,” and “Do you move or talk in just a special way to avoid bad luck?” Research on the psychometric properties has indicated that the LOI-C is reliable in terms of internal consistency (Berg et al., 1988). Furthermore, Flament and colleagues (1988) have found that the scale has acceptable sensitivity for identifying adolescents with OCD, although its specificity was rather poor (i.e., high false-positive rate). March and Mulle (1998) advise that the LOI-C can best be used as a screening tool for initial evaluation.


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Posttraumatic Stress Disorder. Several scales can be employed for obtaining information in children who have (possibly) been traumatized. The Childhood Trauma Questionnaire (Bernstein, Ahluvalia, Pogge, & Handelsman, 1997) and the Self-Reported Post-Traumatic Symptomatology (March, Amaya-Jackson, Terry, & Costanzo, 1997) are two scales that may be particularly helpful for identifying the traumatic events that children have experienced. Both questionnaires ask children to indicate whether they ever have experienced frightening events such as violence, accidents, sexual abuse, severe illness and death, war, and natural disasters. A number of scales can be used for measuring the presence and severity of posttraumatic stress symptoms in children and adolescents. For example, the Child version of the PostTraumatic Stress Disorder Reaction Index (CPTSD-RI; Frederick, Pynoos, & Nader, 1992) measures trauma-related symptoms in three domains: reexperiencing (e.g., “When I think back on this event, I get scared”), avoidance and numbing of general responsiveness (e.g., “It seems that I am less in contact with other people since the event”), and hyperarousal (e.g., “I am nervous and jumpy”). Support has been obtained for the psychometric qualities of the CPTSD-RI. That is, the instrument has good internal consistency, interrater and testretest reliability, and correlates in a meaningful way with other measures of posttraumatic stress (Muris et al., 2000; Nader, Pynoos, Fairbanks, & Frederick, 1990; Pynoos & Nader, 1989; Shannon, Lonigan, Finch, & Taylor, 1994). The Impact of Event Scale (IES; Horowitz, Wilner, & Alvarez, 1979) is a 15-item scale that measures two important aspects of posttraumatic symptomatology—namely, intrusive thinking (e.g., “I think about it when I don’t mean to”) and cognitive avoidance of traumatic intrusions (e.g., “I try to remove it from memory”). The IES is currently the most widely used instrument in research on PTSD in adults. Yule and colleagues (1990, 1991) have used the scale with children aged 8 to 16 years. These authors concluded that children who had survived a sea disaster found the IES questions meaningful and reported scores as high as those of traumatized adults. Dyregrov, Kuterovac, and Barath (1996) found the IES to possess good psychometric properties in children exposed to warfare. Further evidence on the reliability and validity of the IES in children and adolescents has been provided in a recent study by Perrin, Meiser-Stedman, and Smith (2005), who demonstrated that the scale can be effectively used to identify youths with or without PTSD. Although scores on the CPTSD-RI and IES provide useful information of PTSD-related symptoms in youths, both scales do not fully cover the criteria as listed in the DSM. The Child PTSD Symptom Scale (CPSS; Foa, Johnson, Feeny, & Treadwell, 2001) certainly is an improvement in this respect. This measure is designed to assess PTSD diagnosis and symptom severity in children and adolescents aged 8 to 18 years, and consists of 24 items referring to symptoms of reexperiencing (e.g., “Upsetting thoughts about the event”), avoidance (e.g., “Trying not to talk about the event”), and hyperarousal (e.g., “Being irritable since the event”), as well as trauma-related functional impairment across various domains of daily functioning (e.g., relationships with friends, schoolwork). Preliminary support has been found for the reliability and validity of the CPSS. That is, internal consistency, testretest reliability, and concurrent validity with other PTSD scales are satisfactory. Moreover, the scale has been demonstrated to possess excellent discriminant validity (Foa et al., 2001). Although more research with the CPSS is certainly required, the good psychometrics and

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the full coverage of PTSD symptoms as defined in the DSM seem to make this instrument most suitable for assessing PTSD symptomatology in youths. Specific Phobias and Other Anxiety(-Related) Problems. Specific phobias refer to a wide variety of distinct fears, and perhaps for this reason few attempts have been made to develop specific scales for assessing this type of childhood anxiety disorder. In most cases, assessment is confined to the aforementioned FSSC-R, which includes most stimuli and situations for which youths may typically develop a specific phobia (King, Muris, & Ollendick, 2005). Spider phobia certainly is one of the most prevalent phobias in youths (e.g., Muris, Merckelbach, & Collaris, 1997), and because this phobia has been used as an exemplary model to study the aetiology, maintenance, and treatment of pathological anxiety (De Jong, 1993), it is not surprising that researchers have developed a self-report scale for measuring this type of fear in children and adolescents. The Spider Phobia Questionnaire for Children (SPQ-C; Kindt, Brosschot, & Muris, 1996; see Appendix) consists of 29 items for assessing fear of spiders (e.g., “I avoid being in gardens or parks because spiders might be there,” “Even a toy spider in my hand scares me a bit,” and “If I see a spider, I feel tense”). The internal consistency and test-retest reliability of the SPQ-C are very good. Further, SPQ-C scores predict performance on a behavioral approach test, during which children engaged in a stepwise procedure to approach a real spider in a closed jar, some three meters in front of them. Finally, a shortened version of the SPQ-C has been demonstrated to possess excellent treatment sensitivity (Muris, Merckelbach, Van Haaften, & Mayer, 1997; Muris, Merckelbach, Holdrinet, & Sijsenaar, 1998). Given the increased emphasis on children’s school performance in most Western countries, it makes sense that various instruments have been developed to measure school-related fear and test anxiety. For example, the School Refusal Assessment Scale (SRAS; Kearney, 2002; Kearney & Silverman, 1993) is a rating scale that can be completed by children and/or their parents to identify the primary function of a child’s school refusal behavior. Of course, avoidance of stimuli and situations that provoke fear, anxiety, or sadness is one of the main reasons why children refuse to go to school, which is therefore included in the SRAS as a subscale with items such as “How often do you have bad feelings about going to school because you are afraid of something related to school (e.g., tests, school bus, teacher, fire alarm)?” and “How often do you feel worse at school (e.g., scared, nervous, sad) compared to how you feel at home with friends?” Escape from aversive social and evaluative situations may be a second important reason for school refusal and as such also incorporated in the SRAS (e.g., “How often do you stay away from school because it is hard to speak with the other kids at school” and “How often do you stay away from school because you do not have many friends there?”). The psychometric qualities of the SRAS are satisfactory (Higa, Daleiden, & Chorpita, 2002; Kearney, 2006), and although the questionnaire taps various other reasons of school refusal (such as the pursuit of attention and tangible rewards), the scale can also be employed for measuring school-related fear and anxiety. Another school phobia-related scale, the Visual Analogue Scale for Anxiety-Revised (VAA-R), was developed by Bernstein and Garfinkel (1992). Interestingly, this scale uses pictorial visual analogues scales to help the children to rate the degree of anxiety elicited by school-related situations such as “Starting school in the fall” and “Thinking about going


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to school on Monday morning.” While internal consistency reliability is good and correlations with other anxiety scales support its convergent validity, the measure has not been extensively used in research. The Test Anxiety Inventory (TAI; Spielberger, 1980) is a brief 20-item scale for measuring specific symptoms of anxiety before, during, and after examinations. Two major components of test anxiety are addressed in the TAI: worry, which refers to cognitive concerns about consequences of failure (e.g., “Thoughts of doing poorly interfere with my concentration on tests”), and emotionality, which pertains to reactions of the autonomic nervous system that are evoked by evaluative stress (e.g., “I feel my heart beating very fast during important tests”). Although originally developed to measure test anxiety in adolescent and adult students, the TAI has also proved to be a reliable and useful instrument for assessing this type of anxiety in children (Peleg-Popko, 2004; Zeidner & Nevo, 1992).

Scales for Measuring Anxious Cognition With the rise of the cognitive-behavioral theory of psychopathology and its application to the treatment of children (see Chapter 8), a number of instruments have been constructed that intend to measure the negative thought content of disordered youths. In the context of anxiety, three instruments are particularly worthy of note. The first instrument is the Negative Affect Self-Statement Questionnaire (NASSQ; Ronan, Kendall, & Rowe, 1994), which asks for the occurrence of anxious and depressive thoughts in children aged between 7 and 15 years. Research with the NASSQ has demonstrated that there are indeed specific selfstatements related to either anxiety or depression and this is even the case in pre-adolescent youths (7- to 10-year-olds; Ronan et al., 1994). Further, the NASSQ is reliable in terms of internal consistency and test-retest reliability, correlates in a theoretically meaningful way with concurrent measures of anxiety and depression (see also Lerner, Safren, Henin et al., 1999; Muris, Merckelbach, Mayer, & Snieder, 1998), and discriminates between anxious and nonanxious youths (Rietveld, Prins, & Van Beest, 2002; Ronan et al., 1994). Finally, it has been found that the reduction in distress after successful treatment of anxietydisordered children, was predominantly mediated by the decline in negative self-statements (Treadwell & Kendall, 1996). The latter finding not only demonstrates that the NASSQ possesses treatment sensitivity but also seems to support the main premise of cognitive therapy—namely, that a diminution of faulty cognition yields an improvement of mental health. The second instrument is the Children’s Automatic Thoughts Scale (CATS; Schniering & Rapee, 2002), which purports to measure negative self-statements in four domains: physical threat, social threat, personal failure, and hostility. The first two domains would refer to the automatic negative thoughts of anxious children, whereas the third and fourth domains would pertain to the negative thinking of children with, respectively, mood and disruptive behavior disorders. So far, only one study has examined the reliability and validity of the CATS (Schniering & Rapee, 2002). In that study, this scale was demonstrated to possess excellent reliability in terms of both internal consistency and test-retest stability. Most important, CATS domains effectively discriminated between control children and adolescents and clinically referred youths, and showed reasonable discriminant validity across

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various clinical groups. More precisely, clinically referred youths clearly displayed higher levels of negative automatic thoughts as compared to their nonclinical counterparts. Moreover, the pattern of scores on the CATS subscales was largely as predicted—that is, anxious youths displayed the highest scores on the domains of physical and social threat, depressed youths exhibited the highest scores on the personal failure domain, whereas youths with behavior disorders clearly showed the highest scores on the hostility domain. The third and final scale is the Children’s Thought Questionnaire (CTQ; Marien & Bell, 2004). Briefly, the CTQ consists of 10 vignettes, each followed by a series of corresponding negative and positive thought and mood rating items. Half of the vignettes pertain to anxious themes and are concerned with potential threat to the physical or psychological well-being of the child (e.g., trouble breathing in gym class), whereas the other half refer to depressive themes of loss and social rejection (e.g., not being invited to a party). Preliminary evaluation of the CTQ has yielded promising results. More precisely, higher levels of anxious thoughts uniquely predicted anxiety symptoms, while higher levels of depressive thoughts were most convincingly linked to symptoms of depression. Finally, positive thoughts were only negatively related to depression and unrelated to anxiety. Altogether, there seem to be reliable and valid self-report instruments for measuring negative thought processes in youths, it seems to be the case that relatively few researchers and clinicians are employing such measures in spite of the fact that anxious cognition is generally viewed as an important concomitant of childhood anxiety disorders and is thought to play a role in the continuation of such problems.

An “Anxiety Control” Scale All of the preceding interviews and questionnaires intend to measure the frequency, intensity, and severity of fear and anxiety symptoms and anxiety-related cognitions, and as such these instruments focus on the negative, problematic side of these phenomena. Interestingly, Weems, Silverman, Rapee, and Pina (2003) developed a scale that takes a more positive perspective, as it measures children’s perception of control over anxiety-related feelings and events. This Anxiety Control Questionnaire for Children (ACQ-C) can be completed by children aged 8 years and over, and consists of 14 items designed to assess perceived control over “external” threats (e.g., “When something scares me, there is always something I can do,” “I would be able to get away from a scary or frightening place,” and “I am good at getting along with people who bug me”) and 16 items for assessing control over negative “internal” emotional and bodily reactions associated with anxiety (e.g., “When I am in a place that gets me nervous or afraid, I can take charge over and control my feelings,” “If I begin to shake or tremble, I can stop myself,” and “When I am anxious or nervous, I can still think about things other than my feelings of anxiety”). Research has provided some preliminary support for the reliability and validity of the scale. That is, Weems et al. (2003) found that the ACQ-C had good internal consistency, correlated negatively with selfreported anxiety levels, and differentiated between children with and without an anxiety disorder. Furthermore, it was found that even when controlling for self-reported anxiety levels, ACQ-C scores were still predictive of anxiety disorder status. The latter finding is


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particularly important as it demonstrates that the ACQ-C is not just the inverse of an anxiety scale but indeed seems to tap a unique anxiety-related characteristic of children and adolescents.

Instruments for Assessing Fear and Anxiety in Young Children Some self-report questionnaires (e.g., RCMAS, FSSC-R) can be reliably used in children aged 7 years and over (see Stallings & March, 1995). For younger children, this type of instrument does not seem suitable because the questionnaire items and response format are too abstract. For this reason, the assessment of fear and anxiety in preschool children has been confined to interviews in which children are simply asked to report the stimuli and situations that they fear or worry about (e.g., Lentz, 1985; Muris, Merckelbach, Gadet, & Moulaert, 2000; Stevenson-Hinde & Shouldice, 1995). While this method has yielded interesting information regarding the content of young children’s fear and anxiety, such an approach is less precise with regard to the frequency and intensity of these negative emotions. In her review on a century of research on normal childhood fears, Gullone (2000) concludes that the lack of standardized self-report questionnaires has hindered systematic research of fears and fearfulness in young children (i.e., children aged 6 years or under). Nevertheless, it is worthy of note that there have been a few attempts to develop measures of anxiety that can be used with children in the preschool age. For example, Ialongo and colleagues (1994, 1995) used an interview version of the RCMAS employing symbols (i.e., pictures of shapes and objects) to help children to find the correct place on the answer sheet. The authors concluded that in this way “a reliable and valid assessment of anxiety in children as young as five or six is quite possible” (Ialongo et al., 1995; p.436). A further interesting line of research was instigated by Valla, Bergeron, Berube, Gaudet, and St-Georges (1994), who developed the Dominic questionnaire. The Dominic is a pictorial interviewbased scale to assess mental disorders in childhood, designed with the cognitive immaturity of young children in mind. The Dominic depicts a child named “Dominic” facing various situations in the daily life. In fact, the pictures illustrate the emotional and behavioral content of various childhood disorders including a number of anxiety disorders (i.e., specific phobias, separation anxiety, and generalized anxiety). So far, the Dominic has been psychometrically tested in children as young as six (see for a review, Valla, Bergeron, & Smolla, 2000), but given its content, the questionnaire might also be applicable to younger children. The Koala Fear Questionnaire (KFQ; Muris, Meesters, Mayer et al., 2003; see Appendix) is a standardized self-report instrument for assessing fears and fearfulness in children below the age of 7 years. This scale consists of 31 potentially fear-provoking stimuli and situations that are all illustrated with pictures. Children rate the intensity of their fear of these stimuli by using a visual scale that depicts koala bears expressing various degrees of fear (no fear, some fear, a lot of fear). The use of pictures and the visual fear scale makes the KFQ suitable for younger children. Muris et al. (2003) have reported on a series of studies examining the psychometric properties of the KFQ in pre- and primary school children. The results of this research can be summarized as follows. To begin with, it was demonstrated that the visual

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fear scales of koala bears as employed in the KFQ are highly comparable to the standard Likert scales that are used in other childhood fear measures such as the FSSC-R. Further, the KFQ was found to posses good internal consistency and test-retest stability, and this appeared also true for children aged 4 to 6 years. Additional studies provided support for the concurrent validity of the KFQ in schoolchildren. That is, the scale correlated significantly with alternative measures of childhood fear and anxiety, such as the FSSC-R, STAICT, and SCAS (older children), and a picture-based fear and anxiety interview (young children). Finally, in a study carried out on Sint-Maarten (Saint Martin), the Netherlands Antilles, which is a small island in the Carribean (Muris, 2002b), KFQ scores were substantially correlated among children with a high relevant of fear—namely, fear of storms and hurricanes. Altogether, available evidence indicates that the KFQ might be a reliable and valid scale for assessing fears and fearfulness in children aged 4 years and over, although it is clear that further research is necessary to investigate the psychometrics (e.g., reliability, discriminant validity, treatment sensitivity) of the KFQ in clinically referred children.

General Behavior Rating Scales Besides specific anxiety instruments, researchers and clinicians also use general behavior rating scales to measure symptoms of anxiety in youths. The Achenbach (1991) scale is without doubt the most widely employed instrument for this purpose. The scale consists of 118 items addressing two broad domains of psychopathology: One is externalizing, which reflects behavioral problems, and the other is internalizing, which refers to emotional problems. The latter domain is of particular importance in the case of anxiety, because it contains an anxious-depressed subscale, which refers to anxiety and mood problems. A further strong point of this measure is that there are versions for multiple informants (i.e., child, parent, and teacher), which makes it possible to evaluate children’s (anxiety) problems from various perspectives. However, although the psychometric properties of the scales are well established, it has been noted that neither the internalizing nor the anxious-depressed scales of this instrument are suitable for specifically measuring anxiety symptoms (e.g., Aschenbrand, Angelosante, & Kendall, 2005; Kasius, Ferdinand, Van den Berg, & Verhulst, 1997; Seligman et al., 2004). Even a reconstruction of the Achenbach scale in terms of DSM categories could not improve its correspondence with anxiety disorders symptoms (Van Lang, Ferdinand, Oldehinkel, Ormel, & Verhulst, 2005). The recently developed Strengths and Difficulties Questionnaire (SDQ; Goodman, 1997) is also a rating scale that can be employed to assess children’s emotional and behavioral problems. The SDQ is a reliable and valid scale that can be completed by youths, parents, and teachers (Goodman, 2001; Muris, Meesters, & Van den Berg, 2003). The measure consists of 25 items that cover the most important domains of child psychopathology— namely, emotional symptoms, conduct problems, hyperactivity-inattention, and peer problems, as well as personal strengths (i.e., prosocial behavior). In particular, the emotional symptoms subscale is relevant in the context of anxiety, as it includes items such as “I worry a lot” and “I have many fears. I am easily scared.” However, just like the Achenbach scales, the SDQ emotional symptoms scale lacks specificity as it also taps symptoms of mood problems.


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A behavior rating scale that seems to be an improvement in this regard is the Child Symptom Inventory-4 (CSI-4; Gadow & Sprafkin, 1994). This parent- and teachercompleted instrument assesses symptoms of childhood disorders in terms of the DSM-IV. Besides various disruptive behavior disorders, mood disorders, schizophrenia, and pervasive developmental disorders, the CSI-4 also includes scales for measuring the main symptoms of various types of anxiety disorders, such as generalized anxiety disorder, separation anxiety disorder, social phobia, specific phobia, and obsessive-compulsive disorder. Each CSI-4 item closely resembles a symptom/criterion as listed in the DSM. For each disorder, symptoms are summed, and if this score is equal to the number of symptoms specified in the DSM as being necessary for a diagnosis, the child or adolescent receives a “screening” (i.e., probability) diagnosis. Of course, this diagnosis does not signify a clinical diagnosis because the CSI-4 does not include additional diagnostic criteria (e.g., impairment of functioning). Nevertheless, research has indicated that CSI-4 ratings as obtained from parents can successfully discriminate youths with and without various DSM-IV disorders (Sprafkin, Gadow, Salisbury, Schneider, & Loney, 2002). Unfortunately, in the case of anxiety symptoms, such discriminant validity was only established for generalized anxiety disorder, and so it remains to be seen whether these positive validity findings can also be found for the other anxiety disorders tapped by the CSI-4.

Clinician Rating Scales Besides self-report questionnaires and their parent-rated equivalents, there are also clinician rating scales for evaluating anxiety symptoms in youths. The Hamilton Anxiety Rating Scale (HARS; Hamilton, 1959) is an example of such an instrument. Originally, the HARS was developed for assessing the severity of anxiety disorders in adults, but the scale also has been frequently employed with adolescents. Unfortunately, there is only one study evaluating the psychometric properties of the HARS in a youth sample, and so overall one has to conclude that “the HARS’s suitability, utility, and appropriateness for teenagers remain unclear” (Myers & Winters, 2002). The Pediatric Anxiety Rating Scale (PARS; Research Units of Pediatric Psychopharmacology Anxiety Study Group, 2002) is another clinician rating scale that does not have this problem because this instrument has been specifically developed for children and adolescents aged 6 to 18 years. Briefly, the PARS consists of a checklist of 50 items that can be grouped into the following categories: social phobia, separation anxiety, generalized anxiety, specific phobia, physical anxiety signs and symptoms, and other symptoms (e.g., “Temper tantrums when in anxiety-provoking situations”). On the basis of an interview with the child and the parent, the clinician rates each of the symptoms as being absent or present during the previous week. Next, additional information about the symptoms is gathered from interviews with both the child and the parents. Endorsed symptoms are then collectively rated on seven dimensions of severity: (1) number of symptoms, (2) frequency, (3) severity of distress associated with anxiety symptoms, (4) severity of physical symptoms, (5) avoidance, (6) interference at home, and (7) interference out of home. A 5-point rating scale is used for this purpose, with 1 = minimal severity and 5 = maximal severity. A score on each of these scales would indicate a clinically significant level of frequency, severity, and

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interference. The psychometric qualities of the PARS have been examined in a sample of 128 children, aged 6 to 17 years, with a current diagnosis of social phobia, separation anxiety disorder, and/or generalized anxiety disorder, based on a semistructured diagnostic interview of the child and his/her parent (Research Units of Pediatric Psychopharmacology Anxiety Study Group, 2002). Results demonstrated that the PARS was a reliable instrument in terms of internal consistency, test-retest reliability, and interrater agreement. Further, the scale showed good convergent and divergent validity as established through correlations with, respectively, measures of internalizing and externalizing problems. Finally, PARS scores appeared to be sensitive to treatment and paralleled change on other anxiety measures. These results are certainly encouraging, but further data are needed to establish whether this clinician-rated scale can successfully discriminate between nonclinical, clinical nonanxious, and anxious youths. Whereas the HARS and PARS can be used to evaluate a broad range of anxiety symptoms in youths, there are also clinician rating scales for assessing specific childhood anxiety problems. A good example is the Children’s Yale-Brown Obsessive-Compulsive Scale (CY-BOCS; Goodman, Price, Rasmussen et al., 1989b), which is considered as the primary instrument for assessing OCD symptomatology in youths aged 6 to 17 years (March & Mulle, 1998). The CY-BOCS basically is a semistructured interview with child and parent(s), during which the clinician first identifies the most severe obsessions and compulsions of the child and then rates their severity in terms of (1) time occupied by obsessive thoughts and spent on performing compulsive behaviors, (2) level of interference, (3) level of distress, (4) degree of resistance against the obsessions and compulsions, and (5) degree of control over such thoughts and behaviors. In this way, the CY-BOCS yields three scores: the obsessions severity score, the compulsions severity score, and a total score, which provides a general index of the severity of obsessive-compulsive symptoms. Research has demonstrated that the scale has good internal consistency and interrater reliability, and fair convergent and dicriminant validity (Goodman, Price, Rasmussen et al., 1989a; McKay, Piacentini, Greisberg et al., 2003; Scahill, Riddle, McSwiggin-Hardin et al., 1997; Storch, Murphy, Geffken et al., 2005) and even possesses satisfactory psychometrics when completed by children and adolescents and their parents (Storch, Murphy, Adkins et al., in press). Other clinician-rated scales can be found in the domain of social anxiety. The Liebowitz Social Anxiety Scale for Children and Adolescents (LSAS-CA; Masia-Warner, Storch, Pincus et al., 2003) and the Kutcher Generalized Social Anxiety Disorder Scale for Adolescents (K-GSADS-A; Brooks & Kutcher, 2004) are recently developed scales for measuring social phobia symptoms and their associated severity and impairment. Psychometric evaluations of these scales have yielded promising results (e.g., Storch, Masia-Warner, Heidgerken et al., 2006), but clearly more research is required to further establish their clinical usefulness. The recently developed Child Stress Disorders Checklist (CSDC; Saxe, Chawla, Stoddard et al., 2003) is an observer-report measure of PTSD (that can be completed by clinicians and parents) which is particularly useful for the assessment of anxiety-related stress responses in acutely traumatized youths (i.e., acute stress disorder). This checklist measures symptoms in four domains: reexperiencing (e.g., “Child reports uncomfortable memories of the event”),


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increased arousal (e.g., “Child startles easily. For example, he/she jumps when hearing sudden or loud noises”), avoidance (e.g., “Child avoids doing things that remind him/her of the event”), and numbing/dissociation (e.g., “Child seems ‘spaced out’ or in a daze”), as well as impairment in functioning. Preliminary evidence has indicated that the CSDC seems to possess reliable and valid psychometric properties. In sum, clinician rating scales represent an informative source of information and seem particularly relevant for assessing anxiety symptoms in clinical settings and treatment outcome research.

Diagnostic Interviews With the rise of the medical, disease-oriented model in psychology and psychiatry, the classification of child psychopathology in terms of the DSM has become common practice in many clinical settings. Clearly, the DSM is a categorical system and thus neglects the fact that there is still debate whether psychopathology can best be defined in terms of a categorical, dimensional, or mixed model (with categories for some disorders—e.g., schizophrenia—and dimensions for others—e.g., anxiety disorders). Nevertheless, a big advantage of the categorical DSM-system is that, compared to previous practice, both clinicians and researchers can communicate more easily about diagnostic entities with at least some expectation that the disorders are the same, or at least similar, across various settings (McClellan & Werry, 2000). The clinical interview still remains the main assessment tool for clinicians and researchers to reach a DSM-diagnosis. Nevertheless, Angold and Fisher (1999) have rightly remarked that diagnoses based on a standard clinical interview are liable to various biases, such as (1) the tendency to determine diagnoses before all relevant information is collected, (2) the tendency to collect information selectively when confirming a diagnosis and/or to ignore information that rules out a diagnosis, (3) the lack of a systematic approach for combining various types of information, and (4) the tendency to make diagnoses or judgments based on what is most familiar to the clinician. Even when clinicians employ the same diagnostic criteria, disagreement may occur for several reasons: There may be differences in wording and questions asked by the clinicians, in how clinicians interpret the responses, and in responses that respondents make to different interviewers or at different times. With these problems of the clinical interview in mind, semistructured and structured interviews have been developed, which enable clinicians to gather information concerning various mental disorders in a more systematic way, thereby reducing the variability in how interviews are conducted and improving the reliability and validity of the collected information (McClellan & Werry, 2000). In the field of childhood anxiety, several diagnostic interviews can be employed to classify the anxiety problems of youths in terms of the DSM. Briefly, these instruments can be divided into two broad categories: highly structured interviews during which the interviewer asks a fixed set of questions using specified wording, and semistructured interviews, which allow interviewers to use their own questions and to incorporate other sources of information to reach a classification of the disorder.

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Highly Structured Interviews The Children’s Interview of Psychiatric Syndromes (ChIPS; Weller, Weller, Teare, & Fristad, 1999) is a highly structured diagnostic interview, which is suitable for children and adolescents aged 6 to 18 years. The instrument can be administered to youths, but there is also a version for interviewing children’s parents. The ChIPS is based on DSM-IV criteria and screens for various Axis I disorders, including the following anxiety disorders: specific phobia, social phobia, separation anxiety disorder, generalized anxiety disorder, obsessive-compulsive disorder, acute stress disorder, and posttraumatic stress disorder. The instrument also contains two sections addressing the psychosocial stressors of abuse and neglect. During the interview, for each disorder, the most essential DSM features are checked. If these key symptoms are not applicable to the child, the interviewer proceeds to the next section, which covers another disorder. The ChIPS was originally developed for children aged 6 to 12 years, and this has resulted in a number of strong points— namely, its brief duration (120 minutes (parent).

PICA (Ernst et al., 1994)

Semistructured DSM-III-R-based interview for youths (6–16 years). Trained clinical interviewer;

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