Download Evidence-Based Assessment of Anxiety and Its Disorders in

Journal of Clinical Child and Adolescent Psychology
2005, Vol. 34, No. 3, 380–411
Copyright © 2005 by
Lawrence Erlbaum Associates, Inc.
Evidence-Based Assessment of Anxiety and Its Disorders
in Children and Adolescents
Wendy K. Silverman
Florida International University
Thomas H. Ollendick
Virginia Polytechnic Institute and State University
We provide an overview of where the field currently stands when it comes to having
evidence-based methods and instruments available for use in assessing anxiety and
its disorders in children and adolescents. Methods covered include diagnostic interview schedules, rating scales, observations, and self-monitoring forms. We also discuss the main purposes or goals of assessment and indicate which methods and instruments have the most evidence for accomplishing these goals. We also focus on
several specific issues that need continued research attention for the field to move
forward toward an evidence-based assessment approach. Finally, tentative recommendations are made for conducting an evidence-based assessment for anxiety and
its disorders in children and adolescents. Directions for future research also are
discussed.
The field of child psychology has made significant
strides in the past decade in having as part of its armamentarium evidence-based methods and instruments
for use in assessing anxiety and its disorders in children and adolescents. Specifically, systematic empirical testing and evaluation of certain assessment
methods and instruments have been undertaken. In addition, increased attention has been paid to conducting research that will help in deriving evidence-based
guidelines about how to proceed with the assessment
of anxiety and its disorders in youths. Examples of evidence-based guidelines or recommendations suggest
that the field is beginning to have answers to questions
such as the following: If I can give only one rating scale
as an anxiety screen, which one should I give? How
should I handle discrepant parent–child anxiety assessment data? Can I use a particular instrument to help
differentiate between anxiety and other disorders, such
as depression? Which measure or set of measures
should I include in a treatment outcome study?
In this article, our aim is to provide a summary of
where the field currently stands when it comes to having evidence-based methods and instruments available
for assessing anxiety and its disorders in children and
adolescents. This summary serves to highlight the
methods and instruments (e.g., interview schedules)
that have been most heavily evaluated relative to others
(e.g., direct observations), as well as how certain properties of these methods and instruments (e.g., retest reliability) have been more heavily evaluated than others
(e.g., clinical significance). The summary also serves
to highlight how certain purposes or goals of assessment (e.g., screening) can be better attained with certain methods and instruments (e.g., rating scales) than
others (e.g., self-monitoring forms). Our other aim is to
summarize where the field stands when it comes to
having evidence-based guidelines to questions such as
those just mentioned. By so doing, our hope is that the
reader will come away with an improved sense of how
to proceed in assessing anxiety and its disorders in
children and adolescents in a manner that is as evidence based as possible. In addition, our hope is that
the article highlights gaps in the current knowledge
base regarding evidence-based assessment methods for
anxiety and its disorders and stimulates further research to help fill these gaps.
Because a special section titled “Assessing Anxiety
and Anxiety Disorders in Ethnic Minority Youth” recently appeared in the pages of this journal, we refer
the reader directly to this special section (2004, Vol.
33), rather than attempt to summarize the topic here.
Similarly, in a special section titled “Laboratory and
Performance-Based Measures of Childhood Disorders” (2000, Vol. 29), Vasey and Lonigan (2000) contributed an article on using such measures (e.g., Stroop
This study was funded by National Institute of Mental Health
Grant R0163997 to Wendy Silverman and R0151308 to Thomas
Ollendick. The authors also would like to thank Ximena Franco,
Armando Pina, and Yazmin Rey, for their help in the preparation of
this article.
Requests for reprints should be sent to Wendy K. Silverman, Child
and Family Psychosocial Research Center, Child Anxiety and Phobia
Program, Department of Psychology, University Park, Florida International University, Miami, FL 33199. E-mail: [email protected]
380
EVIDENCE-BASED ASSESSMENT OF ANXIETY
tasks) for assessing child and adolescent anxiety. We
refer the reader directly to this article as well. Also,
projective methods and related approaches are not covered. Although they are frequently used in practice,
their empirical underpinnings have been thoroughly
and critically evaluated in past writings (see Lilienfeld,
Wood, & Garb, 2000) and have been found to be severely deficient. Ignoring the importance of using evidence-based assessment procedures lead to several
limitations, including a failure to advance the assessment technology, a less complete understanding of disorders of youth, and an inability to compare diagnostic
and outcome findings across studies (Ollendick, 1999,
2003). We hope this article is helpful in informing the
reader about evidence-based assessment procedures
for children and adolescents who experience anxiety
and its disorders and, even more important, lead the
reader to use these procedures in his or her clinical
work.
We begin with a discussion of definitional and developmental considerations, followed by a brief discussion of a framework for approaching the assessment process and an indication of the main purposes or
goals of assessment. We then present the most widely
used methods and instruments for use in assessing anxiety and its disorders in children and adolescents and
the evidence for each for accomplishing certain goals.
The methods covered include diagnostic interview
schedules, rating scales, direct observations, and selfmonitoring forms.
Definitional Considerations
In defining anxiety, we find Barlow’s (2002; Barlow, Allen, & Choate, 2004) recent formulations particularly insightful and useful. According to Barlow,
anxiety seems best characterized as a future-oriented
emotion, characterized by perceptions of uncontrollability and unpredictability over potentially aversive
events and a rapid shift in attention to the focus of potentially dangerous events or one’s own affective response to these events. (p. 104)
Along these lines, Barlow noted two main consequences when anxiety becomes a chronic or clinical
condition: avoidance and worry. Both avoidance and
worry—when they become pervasive, intense, or uncontrollable—represent maladaptive ways that individuals attempt to cope with their aversive anxious
states. Barlow further discussed the evidence showing
that as individuals are faced with their anxiety-eliciting
situations, elevated physiological arousal occurs. As
such, Barlow endorsed the three-response system to
anxiety first articulated by Lang (1968).
Our definition thus far has centered on anxiety and
on how clinical manifestations of anxiety are characterized primarily by avoidance, worry, and physiological arousal; where then does “fear” fit in? Again, we
find Barlow’s (2002) formulations helpful. Barlow
viewed the clinical manifestation of fear as “panic” or
“the unadulterated, ancient, possibly innate alarm system” (p. 104). He noted the striking similarities between a specific fear response and a panic attack,
namely, both are characterized by strong behavioral
urges to avoid or escape as well as similar underlying
neurobiological and neurophysiological processes. At
a response level, it can be seen that anxiety and fear are
quite similar: They both are characterized by cognitive,
behavioral, and physiological indexes.
Anxiety and fear typically have three common referents in the clinical literature, as symptoms, syndromes or disorders, and nosological entities (Beck,
1967). At the symptom level, these terms usually refer
to the layperson’s denotation (e.g., anxiety is a subjective feeling of tension; fear is a sense of dread or impending doom). As a syndrome or disorder, anxiety
and fear refer to a group of symptoms that cluster together (discussed further later). The symptoms that
cluster together to comprise anxiety or fear map onto
Lang’s (1968) triple response conceptualization, as
noted earlier, in which the response is displayed across
(a) the behavior or motor response system (e.g., behavioral avoidance), (b) the somatic or physiological response system (e.g., increased heart rate), and (c) the
cognitive or verbal response system (e.g., reports of
danger or apprehension). Finally, as a nosological entity, anxiety and fear usually refer not only to syndromal
specificity but also to a set of symptoms that should
display a certain time-course, prognosis, and probable
treatment response (Kazdin, 1990). In this article, we
use the term anxiety and its disorders because we oftentimes are referring to anxiety and fear as symptoms
as well as syndromes or disorders and nosological entities, with no distinctions made between the latter two
referents and, unless otherwise indicated, no distinction
made between fear and anxiety at the response level.
There are methods and instruments available for assessing each of the three response systems of anxiety
and fear at the symptom level as well as at the syndrome or disorder and nosological entity level. Although a tripartite assessment approach to anxiety has
long been espoused (Rachman & Hodgson, 1974), it is
unclear whether the multiple measures across the three
response systems offer incrementally meaningful information to assessment (Johnston & Murray, 2003)
or treatment planning (Davis & Ollendick, 2005) relative to the assessment of a single response system in
isolation. In addition, as Davis and Ollendick noted,
concordance among the three systems is oftentimes
wanting, and most researchers have not shown that efficacious treatments address and reduce the three re381
SILVERMAN AND OLLENDICK
sponse modes even when they are present. Still, at this
time, it appears best to attempt to assess each of these
response modes whenever possible and until more firm
findings are made available to us.
It continues to be more common in research and
clinic settings to assess the three response systems using
self-reports. For example, although exceptions exist
(e.g., Beidel, Turner, & Morris, 1999), it has been more
common to ask a child to rate how much “My heart beats
fast when I feel anxious” or “I worry about making mistakes” and to evaluate the psychometrics of such reports
than to use heart-rate monitors or laboratory-based measures to elicit various cognitive processes. Because research support for the direct clinical utility of psychophysiological and laboratory-based measures is less
clear and because both require a level of technology and
expertise that is quite specialized, they are not summarized in this article (see King, 1994, and, as noted earlier,
Vasey & Lonigan, 2000, for summaries).
Developmental Considerations
Much of the anxiety and fear experienced by children
and adolescents develops at particular junctures in development based on normative age-related experiences
(e.g., anxiety about separation as children begin prekindergarten or kindergarten, anxiety about social evaluation as adolescents become more involved with peers
or attempt romantic attachments, fear following an embarrassing event at school or in the community). When
such normative experiences lead children and adolescents to avoid these experiences (e.g., school, parties) or
to have uncontrollable worry and heightened physiological arousal about them, it is likely that the anxiety has
become a nonnormative or “clinical” problem.
In addition to the importance of assessing clinical
child and adolescent anxiety problems in a manner that
is consistent with the evidence base, it is equally important that the assessment procedures be developmentally sensitive (Ollendick & King, 1991; Silverman &
Ollendick, 1999). Probably the most distinguishing
characteristic of young people is change. Change has
implications for the selection of specific assessment
strategies, in their value in understanding the different
anxiety disorders, and in evaluating treatment outcome. To illustrate briefly, diagnostic interviews are
difficult to conduct, and self-reports may be less reliable with young anxious children, whereas self-monitoring and behavioral observation may be more reactive with older anxious children and adolescents
(Ollendick, Grills, & King, 2001; Ollendick & Vasey,
1999). Unfortunately, though, how development should
precisely dictate the assessment process with anxious
children has not been systematically studied.
In addition, as will become apparent, many anxiety
assessment methods and instruments for children have
382
been extended downward from those used with adults
with insufficient attention paid to whether adaptations
or changes are needed. Furthermore, in most instances,
the underlying assumptions about these methods and
the underlying constructs they are said to measure are
the same. Further, measures designed specifically for
children may be problematic, inasmuch as a 4-yearold’s world and his or her interpretations of it may be
quite different from that of an 8-, 12-, or 16-year-old’s
(Ollendick et al., 2001; Ollendick & Vasey, 1999; Silverman & Ollendick, 1999). Kendall (1984) referred to
the practice of treating all children alike as the “developmental uniformity myth.” Just as children differ
from adults, so too do young children differ from older
ones, and older ones, in turn, differ from adolescents.
Moreover, the expectations we have for children
and adolescents vary with age, as do the norms associated with certain behaviors. Several studies have described “normal age trends” associated with certain behavioral problems (cf. Edelbrock, 1984). In the context
of child and adolescent fears, the interaction between
emerging cognitive abilities and specific situational
events are believed to occasion the presence and intensity of specific fears and phobias that have been shown
to occur with regularity during the course of development (Muris, Merckelbach, Mayer, & Prins, 2000;
Ollendick, King, & Frary, 1989). Awareness of developmental trends such as these can serve as a guide in
the selection of meaningful target fear and anxious behaviors and the interpretation of their significance for
the growing child.
Ollendick and Hersen (1984) earlier suggested that
the developmental point of view can best be incorporated into our research and clinical practice by invoking “normative-developmental” principles. Implicit in
this approach is the notion that current behavior can be
viewed as a function of the context in which it occurs,
including consideration of antecedent and consequent
events. That is, whereas the developmental principle
calls attention to the importance of accounting for
quantitative and qualitative changes that occur with development, the normative principle points to the need
for evaluation of youths’ behaviors with respect to appropriate reference groups. Most generally, the appropriate reference group involves youths of the same age.
Obviously, age is a crude index of developmental level,
and there are additional limits to the use of norms, as
discussed later, yet age can yield important comparative information along a number of dimensions, including the youth’s emotional, cognitive, behavioral, and
social functioning. Bongers, Koot, van der Ende, and
Verhulst (2003) conducted an excellent example of the
type of research that we are advocating for here, in that
normative information on common childhood problems across age ranges was gathered. Ideally, normative information related to gender, socioeconomic
status, race, culture, and nationality also would be
EVIDENCE-BASED ASSESSMENT OF ANXIETY
gathered. In this way we can be assured that the comparison group is truly a representative one. Given base
rates for normal changes in the reference group, we
could then identify those behaviors in the targeted
child and his or her family that are outside the normal
range. The importance of contextual aspects of behavior must also be noted, such that behaviors viewed as
problematic in one setting (e.g., school) may not be
viewed as such in a different setting (e.g., community).
In sum, incorporating developmental theory into
child and adolescent evidence-based assessment is of
considerable importance. From our standpoint, developmentally informed assessment is made possible by
(a) attention to cognitive and socioemotional developmental processes in the selection of assessment measures, (b) use of normative guidelines in interpreting
adaptive and maladaptive behavioral outcomes, (c)
examination of age differences in the patterning of behaviors and syndromes, and (d) awareness of the stability and change in behavior over time. These developmental features are important not only for our initial
assessment practices with youths and their families but
also for outcome assessment. As noted by Weisz and
Weersing (1999), clinical child and adolescent psychologists are, in a sense, “chasing the normal developmental curve” (p. 460) when they undertake outcome
assessment with children and adolescents. In most instances, the goal of treatment is to “return children to
healthy developmental pathways” (Shirk, 1999, p. 68).
1996, 1997) is to be guided by what works with the
particular problem that we are trying to solve or the
particular goal we are trying to accomplish. We resort
on this pragmatic criterion because it helps us to accomplish our ultimate goal, namely, to help the children and families with whom we work.
Thus, in the subsequent sections we describe the
most widely used methods and instruments for assessing anxiety and its disorders in children and adolescents, with an eye on highlighting which of them works
best for in terms of satisfying particular purposes or attaining certain goals. We also acknowledge the limits
of these methods and instruments in accomplishing
these purposes or goals. With respect to the purposes or
goals of assessment, we draw on B. J. Jensen and
Haynes (1986), as we believe the purposes or goals
they delineated continue to be highly relevant in working with clinical child and adolescent populations;
these are (a) screening, (b) diagnosing, (c) identifying
and quantifying symptoms and behaviors, (d) identifying and quantifying controlling variables or assessing
contextual variables, and (e) evaluating and monitoring
treatment outcome and mediators or moderators.
Assessment Methods and Instruments
for Anxiety and Its Disorders in Youth
Semistructured and Structured
Diagnostic Interview Schedules
A Framework for Approaching
the Assessment Process and the
Purposes and Goals of Assessment
Silverman and Kurtines (1996, 1997) noted the utility of having a pragmatic framework or attitude when
approaching the assessment process. A pragmatic
framework or attitude dictates that researchers and clinicians alike suspend judgment with respect to what
will work and what will not work. That is, researchers
and clinicians ought not to simply “fall back” on their
favorite assessment method, whatever it happens to be
(e.g., projectives, clinical interviews). It may be the
eventual choice (and it may work fine), but it is not a
good idea to resort to it without considering the available alternatives. A pragmatic attitude further suggests
that in deciding on what assessment method to use, the
method chosen should be the one that is most useful in
a particular setting. Part of what it means to be useful is
that the method is clinically feasible in a particular setting. It also means choosing the method that ultimately
works best in accomplishing the specific goal. We recognize that best is a normative concept that derives its
meaning and significance from the context in which it
is used. The criterion that we advocate and recommend
in this article and elsewhere (Silverman & Kurtines,
The clinical interview is the most prominent method of assessment in clinical child and adolescent psychology (Ollendick & Hersen, 1993; Silverman, 1994).
Despite the prominence of the clinical interview, it produces considerable error or variance attributed to interviewers, usage in diagnostic criteria, or both (Silverman, 1994). In addition, it can be daunting to fully
ascertain the wide range of problems that a youth may
experience in light of the high rates of comorbid (cooccurring) disorders in youth. Partly in response to the
limits in using unstructured clinical interviews, semistructured and structured diagnostic interview schedules were developed for use with youths, including
those with anxiety problems. Their most frequent use
has been in the diagnosis process, including the identification and quantification of youths’ symptoms and
behaviors, by using the module of an interview schedule as a “mini” subscale. They also have been frequently used in the treatment evaluation research process by determining diagnostic recovery rates of the
sample from pre- to posttreatment. So, for example, of
100% of the youths who meet diagnostic criteria at pretreatment, at posttreatment perhaps 80% are recovered
or are no longer meeting diagnostic criteria. We discuss this in more detail later.
383
SILVERMAN AND OLLENDICK
Interview schedules have been developed to cover
the different types of anxiety disorders specified in the
Diagnostic and Statistical Manual of Mental Disorders (4th ed. [DSM–IV]; American Psychiatric Association, 1994). Table 1 summarizes the key clinical features of the most prevalent anxiety disorders displayed
by children and adolescents that are covered in interview schedules. The table highlights that most anxiety
disorders share similar processes. For example, most
are characterized by apprehension of situations or objects as well as anxiety-reducing actions such as avoidance (Barlow, 2002; Silverman & Kurtines, 1996).
How they differ is in terms of the content or the focus
of apprehension (e.g., worries about embarrassment in
social phobia [SOP], worry about harm befalling parents in separation anxiety disorder [SAD]; Barlow,
2000; Silverman & Kurtines, 1996).
This difference among the anxiety disorders constitutes the key reason why we believe using structured or
semistructured interview schedules is necessary from
an evidence-based perspective. Namely, the current
treatment approach that has the strongest and most
consistent research support for reducing any anxiety
disorder in young people is the cognitive behavioral
treatments (CBT), which involve exposure-based exercises both in session and out of session (situational,
imaginal, and interoceptive; Ollendick & King, 1998;
Silverman & Berman, 2001). Indeed, Westen, Novotny, and Thompson-Brenner (2004), in their critical re-
view of the “empirical status of empirically supported
psychotherapies” (p. 631), similarly acknowledged
that the phobic and anxiety disorders “are the disorders
that and treatments that have generated the clearest empirical support using RCT [randomized clinical trial]
methodology: exposure-based treatments” (p. 658).
Although Westen et al. were not referring directly to
the child and adolescent treatment research literature
when they made this statement, the fact is that this
statement is true whether one is working with child, adolescent, or adult populations. Hence, although Westen
et al. and others (e.g., Goldfried & Wolfe, 1998) have
criticized the strong linkage between diagnosis and
treatments in the evidenced-based treatment movement, even among these critics, this concern appears
minimized in the context of phobia and anxiety treatment because of the strong research evidence showing
support for exposure CBT approaches.
Consequently, if one wishes to use the treatment
that possesses the most research evidence, it is important to first have confidence (i.e., have reliable and
valid information) that the youth or groups of youths
with whom one is working are in fact suffering primarily from clinical levels of anxiety, rather than some
other clinical disorder, such as attention deficit hyperactivity disorder (ADHD). Second, it is important to
have confidence about the specific type(s) of anxiety
disorder from which the youth is suffering so that the
appropriate exposure tasks can be assigned in and out
Table 1. DSM–IV Anxiety Disorders
Disorder
Separation Anxiety Disorder
Specific Phobia
Social Phobia
Generalized Anxiety Disorder
Panic Disorder
Posttraumatic Stress Disorder
Obsessive–Compulsive Disorder
Clinical Features
Excessive and developmentally inappropriate anxiety concerning separation from home or attachment
figures that begins prior to 18 years old, has been present for at least 4 weeks, and causes clinically
significant distress or impairment in important areas of functioning (e.g., social, academic).
Marked, excessive, and persistent fear in either presence or anticipation of a circumscribed object or
event that is developmentally inappropriate, leads to avoidance or attempts at avoidance of object or
event, not due to a recent stressor, present for at least 6 months, and causes clinically significant
distress or impairment.
Marked and persistent fear circumscribed (e.g., school) or pervasive (e.g., school, family, and friends) of
situations in which there is likelihood of social evaluation for at least 6 months leads to avoidance or
attempts at avoidance of situation and causes clinically significant distress or impairment.
Excessive anxiety and worry that is difficult to control, not focused on a specific situation or object,
unrelated to a recent stressor, occurs more days than not, at least one physical symptom (e.g.,
restlessness, stomach, and muscle aches), present for at least 6 months, and causes clinically significant
distress or impairment.
Sudden occurrence of a cluster of symptoms that peaks within 10 min (e.g., palpitations, sweating,
trembling, feelings of shortness of breath, chest pain, nausea, dizziness). Reoccurs unexpectedly,
associated with at least 1 month of chronic worry or fear about future attacks and consequences
regarding attacks, and leads to avoidance or attempts at avoidance. Can occur either independently or
with agoraphobia.
Exposure to a traumatic event leads to persistent reexperiencing (e.g., intrusive thoughts or images),
persistent avoidance of situations or persons associated with event or lack of responsiveness (e. g.,
avoid thoughts, feelings, conversations associated with or a reminder of event), and increased arousal
(e. g., hypervigilance, sleep disturbance). Present for at least 1 month and causes clinically significant
distress or impairment.
Obsessive thoughts, impulses, or images, compulsions, or both that lead to marked distress, last over 1 hr
a day, and causes clinically significant distress or impairment. Attempts are made to ignore obsessions;
relieve distress by performing compulsions.
Note: DSM–IV = Diagnostic and Statistical Manual of Mental Disorders (4th ed., American Psychiatric Association, 1994).
384
EVIDENCE-BASED ASSESSMENT OF ANXIETY
disorder was identified in sufficient numbers in the
study’s samples, usually at least five cases. That is why
some disorders have reliability information and others
do not. This raises an important issue about base rates
that is worthy of a few additional comments (see Johnston & Murray, 2003, for further discussion).
As Table 2 shows, current knowledge about the reliability of diagnoses is limited to those anxiety disorder
subtypes that possess relatively high base rates in
youth. Consequently, little is known about the diagnostic reliability using interview schedules of the disorder
subtypes with relatively low base rates in youth (i.e.,
panic disorder [PD], agoraphobia, posttraumatic stress
disorder, and obsessive–compulsive disorder). In addition, most of the diagnostic reliability research work
has been conducted in child anxiety disorder specialty
clinics (e.g., Rapee, Barrett, Dadds, & Evans, 1994;
Silverman, Saavedra, & Pina, 2001) in which the base
rates of the anxiety disorders are undoubtedly higher
than in other clinics or settings. Consequently, it is important that additional research be conducted on the reliability of anxiety disorder diagnoses in settings in
which base rates of specific anxiety disorders are lower
and in which other childhood disorders are observed
(e.g., Grills & Ollendick, 2003). From an evidencebased assessment perspective, researchers and clinicians who use structured or semistructured interviews
should not assume that simply using these more datastructured interviewing procedures guarantees that all
anxiety diagnoses obtained are reliable. They may or
may not be. More research is needed before we can say
for sure.
of the treatment sessions (e.g., expose the child to social evaluative situations if the child has social anxiety
disorder and to separation situations if the child has
SAD). Nevertheless, as Nelson-Gray (2003) astutely
pointed out, a full empirical test of the preceding statement has yet to be undertaken. That is, it has not been
empirically tested whether children who have had their
diagnoses assigned with a diagnostic interview schedule and receive CBT versus a group of children who
have not been given a diagnostic interview schedule
and receive CBT experience different outcomes. Put
another way, the “treatment utility” of conducting interview schedules has not yet been demonstrated, so all
the field really has now is “pseudotreatment utility”
(Nelson-Gray, 2003). Although a demonstration test of
treatment utility has not been done, it is difficult for us
to understand how CBT could be exactly (or correctly,
or appropriately) implemented and exposure tasks assigned within a CBT protocol unless a clinician knows
that the youth has an anxiety disorder, in the first place,
and what type of disorder it is, in the second place. It
seems to us that starting CBT without this information
would be like starting a fishing trip without bringing the
fishing rod and bait. One may eventually catch a fish,
but it would seem a lot easier with a rod and some bait.
Table 2 presents a brief description of the most
widely used semistructured and structured youth diagnostic interview schedules that contain sections for diagnosing anxiety disorders as well as the reliability coefficients that were obtained when the schedules were
used to diagnose some of the disorders. Studies only
calculate and report reliability information if a specific
Table 2. Structured and Semistructured Interview Schedules for Diagnosing DSM–IV Anxiety Disorders in Youth
Diagnostic Interview Schedule
Ages (Years)
Versions
Structured or
Semistructured
Reliability of Anxiety Diagnoses
(κ coefficients)
Anxiety Disorders Interview Schedule for
DSM–IV: Child and Parent Versions
(Silverman & Albano, 1996; Silverman,
Saavedra, & Pina, 2001)
6 to 18
C/P
SS
Child: SAD = .78; SOP = .71; SP = .80;
GAD = .63. Parent: SAD = .88; SOP
= .86; SP = .65; GAD = .72.
Combined: SAD = .84; SOP = .92; SP
= .81; GAD = .80.
Child and Adolescent Psychiatric
Assessment (Angold & Costello, 2000)
9 to 13
C
S
Child: OAD = .74; GAD = .79.
Diagnostic Interview for Children and
Adolescents (Herjanic & Reich, 1982;
Reich, 2000)
6 to 17
C/P/A
SS
Child: OAD = .55; SAD = .60; SP = .65.
Adolescent: OAD = .72; SAD = .75
(past)
NIMH Diagnostic Interview Schedule for
Children Version IV (Shaffer, Fisher,
Lucas, Dulcan, & Schwab-Stone, 2000)
9 to 17
C/P
S
Child: SP = .68; SOP = .25; SAD = .46.
Parent: SP = .96; SOP = .54; SAD =
.58; GAD = .65. Combined: SP = .86;
SOP = .48; SAD = .51; GAD = .58.
Schedule for Affective Disorders and
Schizophrenia for School-Age Children
(Ambrosini, 2000)
6 to 18
C/P
SS
Combined: OAD = .78; SP = .80.
Note: DSM–IV= Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994); C = child; P = parent;
A = adolescent; S = structured; SS = semistructured. SAD = separation anxiety disorder; SOP = social phobia; SP = specific phobia; GAD = generalized anxiety disorder; OAD = overanxious disorder; NIMH = National Institute of Mental Health.
385
SILVERMAN AND OLLENDICK
Further, different assessment strategies would likely be needed as a function of the disorder’s base rate in
that particular setting (Johnston & Murray, 2003). For
example, given the relatively high base rates for SOP
diagnoses in most clinic settings, particularly in anxiety disorder specialty clinics, it is reasonable to proceed with a full diagnostic interview when trying to
identify youth with this disorder. However, for selective mutism—a possible variant of SOP with a low
base rate—it would seem more cost and time efficient
to use a multistage sampling design (Kendall, Cantwell, & Kazdin, 1989) in which “screener” questions
might be administered first. This would be followed by
a fuller diagnostic interview for those youths who are
“caught in the net” of the screen (Costello & Angold,
1988). Due to the absence of specific base rate information about each anxiety disorder in diverse clinical,
school, and community settings, details of how this
type of multistage sampling strategies might be conducted across settings and across the different subtypes
of disorders (e.g., which screen for which disorder in
which setting?) remain sketchy.
Table 2 also summarizes studies in which evaluating reliability was the primary objective. Thus, although it is fairly standard practice for research articles
to report diagnostic reliability, the table does not summarize the reliability data that were reported in every
study in which an interview schedule was used. In addition, although all the schedules listed in Table 2 contain sections on the DSM–IV anxiety disorders, the
Anxiety Disorders Interview Schedule for Children for
DSM–IV: Child and Parent Versions (ADIS: C/P;
Silverman & Albano, 1996; Silverman et al., 2001),
similar to the adult version, the Anxiety Disorders Interview Schedule for DSM–IV (Brown, Di Nardo, &
Barlow, 1994) is more detailed in its coverage. Probably for this reason, the ADIS: C/P and its previous versions (3rd ed. and 3rd ed., rev.; Silverman, 1991) have
been used most frequently in the youth anxiety disorders research literature, including the randomized clinical trials (see Table 7 and Silverman & Berman,
2001).
The ADIS: C/P contains not only questions that allow for diagnoses of anxiety disorders but also contains questions that allow interviewers to assign ratings
from 0 to 8 on the youths’ fear and avoidance of diverse
situations in each of the diagnostic categories in which
fear or avoidance occurs (e.g., SOP, specific phobia),
allowing for an identification and quantification of
symptoms. It also contains questions that allow for obtaining information about the history of the problem
and situational and cognitive factors influencing anxiety, as well as sections that cover the most prevalent conditions of childhood and adolescence (e.g.,
ADHD, conduct disorder, depressive disorder) and
screening questions for most others (e.g., eating disorders, enuresis).
386
Given the importance of knowing which anxiety
disorder should be targeted in an exposure-based CBT,
the ADIS: C/P further assists with this by providing
clinician severity rating scales. Based on the information obtained during the course of the interview, interviewers assign the degree of distress and interference in functioning associated with each disorder,
ranging from 0 (none) to 8 (very severely disturbing/impairing). Similar to the adult ADIS, clinician severity ratings of 4 (definitely disturbing/impairing) or
higher are considered “clinical” diagnoses, and those
of less than 4 are viewed as “subclinical” or subthreshold. Principal status, and the disorder that would
then be targeted using CBT, would be the disorder that
is determined to be relatively most severe and interfering. Although the ADIS: C/P has been used most for
assisting in the subsequent assignment of youths to an
evidence-based CBT program in the way just described (i.e., target the disorder with the highest severity rating scores), as discussed further later, research is
needed on exactly what the scores on the clinician severity rating scale truly mean in terms of real-world
impairment.
Studies have confirmed, however, the reliability and
validity of diagnoses using the ADIS: C/P, with several
studies confirming its interrater (Grills & Ollendick,
2003; Rapee et al., 1994; Silverman & Nelles, 1988)
and test–retest reliability for specific diagnoses (Silverman & Eisen, 1992) as well as symptom patterns
(Silverman & Rabian, 1995). These studies were all
conducted in university-based research clinics. In a recent study in which the characteristics of youths with
anxiety disorders at research-based clinics versus community-based clinics were compared, reliability of the
diagnoses was not reported in the community clinic using the Diagnostic Interview Schedule for Children
(Southam-Gerow, Weisz, & Kendall, 2003). The lack
of data on the reliability and validity of anxiety diagnoses when diagnoses are obtained in community clinics
likely reflects, in part, the general difficulties in gathering “effectiveness” data (assessment or treatment) in
nonresearch settings (e.g., clinicians are burdened with
large case loads, reduced incentives for gathering data
in applied settings, and so on; Weisz, 2000). Gathering
such data is important to move the field forward with
respect to having interviewing assessment procedures
that are fully evidence based.
With regard to validity, in Wood, Piacentini, Bergman, McCracken, and Barrios (2002), the concurrent
validity of ADIS: C/P diagnoses of SOP, SAD, generalized anxiety disorder (GAD), and PD was examined
in children and adolescents referred to an outpatient
anxiety disorders clinic (N = 186; ages 8 to 17 years).
Youths and parents were administered the ADIS interviews as well as the Multidimensional Anxiety
Scale for Children (MASC; March, Parker, Sullivan,
Stallings, & Conners, 1997). There was strong corre-
EVIDENCE-BASED ASSESSMENT OF ANXIETY
spondence between the ADIS: C/P diagnoses and empirically derived MASC factor scores corresponding to
these disorders, with the exception of GAD. In addition, there was an absence of convergent or presence of
divergent validity as would be predicted (e.g., MASC
social anxiety factor scores but no other factor scores
were significantly elevated for children meeting DSM–
IV SOP on the ADIS: C/P).
As noted, the child and parent ADIS interviews have
been used in almost all the randomized clinical trials that
have been conducted to evaluate the efficacy of CBT to
reduce anxiety disorders in treated youths (see Table 7).
In all of these studies, significant improvements in diagnostic recovery rates were observed in the majority of
the treated youths at posttreatment and follow-up.
In sum, relative to the other interview schedules
listed in Table 2, the ADIS: C/P has been studied the
most in the youth anxiety disorders treatment research
area and has the strongest evidence when it comes to
providing reliable and valid diagnoses and sensitivity to
clinical change in treatment outcome research. In addition, as noted, it is our view that interview schedules are
important from a treatment utility perspective, though
this view needs to be further established empirically.
Rating Scales
Table 3 presents the most widely used youth selfrating scales that have been used for assessing anxiety
and related symptoms such as fear. The table does not
emphasize scales designed to assess anxiety disorders
that have lower base rates in youths, such as posttraumatic stress disorder. See the recent review by
Ohan, Myers, and Collett (2002), for a summary of
scales assessing trauma and its effects. Table 4 presents
the most widely used parent and teacher rating scales,
and Table 5 presents recently developed clinician rating scales. Table 6 presents a sampling of rating scales
that can be used to assess contextual aspects of anxiety
and its disorders in youth.
Generally speaking, the rating scales listed have
been well tested in terms of internal consistency and
test–retest reliability and thereby possess sufficient
and adequate evidence when it comes to the criterion
of reliability. Consequently, the reliability information
of the rating scales is summarized in the tables. With
regard to validity, most of the rating scales have research evidence when it comes to concurrent validity
in that they show positive convergence with related
constructs and divergent validity in that they do not
converge with unrelated constructs. This is particularly
true when it comes to the scales’ total scores, with findings regarding particular subscales of the rating scale
varying. Due to space constraints, it is not possible to
summarize all of the studies that have been conducted
to establish each scale’s concurrent and discriminant
validity. Later in the article we summarize this line of
research with the most widely used and widely researched youth self-rating anxiety scale, the Revised
Children’ Manifest Anxiety Scale (RCMAS). Interestingly, however, the psychometric properties of most of
these scales, including the RCMAS, have been empirically established mainly for community samples of
youths. There are some notable exceptions, such as the
Pediatric Anxiety Rating Scale (PARS), described
later. With this scale, for example, the data reported
were based only on a clinically anxious sample (Research Units on Pediatric Psychopharmacology Anxiety Study Group, 2002). This too has limits with regard
to generalizability of the findings to other clinical samples or community samples.
Returning to the purposes and goals of assessment,
all of the rating scales listed in the tables have been
used in the research literature for identifying and quantifying symptoms or behaviors. Many of them also
have been used for evaluating treatment outcome (see
Table 7). With regard to screening, only a small number of the rating scales have begun to be evaluated for
this purpose (e.g., the RCMAS, MASC, Social Anxiety Scale for Children–Revised [SASC–R], and Social
Phobia and Anxiety Inventory for Children [SPAI–C]).
Finally, the scales listed on the tables, particularly Table 6, have the potential to be used for identifying and
quantifying maintaining or controlling variables of
anxiety and evaluating mediators or moderators in
treatment outcome research, though they have not been
used as much for this purpose. A few additional comments now follow about using rating scales for each of
these purposes, except for screening, which is discussed in a separate section of the article.
The use of any of these rating scales to quantify a
youth’s level of anxiety is accomplished by administering the scale to the informant and obtaining a score,
which serves to quantify the youth’s standing on the
anxiety construct in terms of amount, degree, or magnitude. The term metric refers to the range of numbers
that the observed measures take on when describing
youths’ standings on the construct of interest and the
way that those numbers map onto the underlying dimension (Blanton & Jaccard, in press). As Blanton and
Jaccard pointed out, however, metrics in psychological
research often are arbitrary. This is the case with all the
rating scales presented in the tables. Let’s illustrate
with the most widely used scale, the RCMAS. When
the RCMAS is administered to youths, a Total Anxiety
score is obtained based on summing 28 of the scale’s
37 items (with the other 9 items comprising the Lie
scale). If a youth obtains a score of 13, this number and
where it falls on the metric does not give us a “real-life”
picture of how anxious the youth is. Indeed, that same
score can occur with youths who meet DSM–IV diagnoses of anxiety as well as youths who also meet other
diagnoses (e.g., Perrin & Last, 1992). To render the
score less arbitrary and thereby more evidence based, it
387
388
Table 3. Youth Self Rating Scales for Assessing Anxiety and Its Disorders
Instrument
Ages (Years)
Brief Description
Affect and Arousal Scale (Chorpita, Daleiden, Moffitt, Yim, &
Umemoto, 2000; Daleiden, Chorpita, & Lu, 2000)
8 to 19
Anxiety Control Questionnaire for Children (Weems,
Silverman, Rapee, & Pina, 2003)
9 to 17
Children’s Automatic Thoughts Scale (Schniering & Rapee,
2002)
7 to 16
Child Anxiety Sensitivity Index (Silverman, Fleisig, Rabian, &
Peterson, 1991)
6 to 17
Fear Survey Schedule for Children–Revised (Ollendick, 1983)
7 to 18
Multidimensional Anxiety Scale for Children (March, Parker,
Sullivan, Stallings, & Conners, 1997; March, Sullivan, &
James, 1999)
8 to 19
Negative Affect Self-Statement Questionnaire (Ronan,
Kendall, & Rowe, 1994)
7 to 15
Penn State Worry Questionnaire for Children (Chorpita,
Tracey, Brown, Collica, & Barlow, 1997)
6 to 18
Physiological Hyperarousal Scale for Children (Laurent,
Catanzaro, & Joiner, 2004)
12 to 17
27 items. Assesses affective dimensions related to anxiety and
depression. Yields three subscales: NA (Negative Affect),
PA (Positive Affect), and PH (Physiological Hyperarousal).
Respondents rate how true each item is with respect to their
usual feelings.
30 items (14-item external subscale, 16-item internal reactions
subscale). Assesses perceived lack of control over
anxiety-related external threats and negative emotional and
bodily reactions associated with anxiety. Respondents rate
their agreement with each question (i.e., “I can take charge
and control my feelings”).
40 items. Assesses automatic thoughts about physical threat,
personal failure, and hostility. Respondents rate the
frequency with which they have experienced each thought
over the past week.
18 items. Assesses aversiveness of experiencing anxiety
symptoms. Yields four subscales: Disease Concerns,
Unsteady Concerns, Mental Incapacitation Concerns, and
Social Concerns. Respondents rate how aversively they view
anxiety symptoms.
80 items. Assesses subjective levels of fear. Yields a total
score and five subscales: Fear of Failure and Criticism, Fear
of the Unknown, Fear of Danger and Death, Medical Fears,
and Small Animals. Respondents rate amount of fear
elicited by each object or situation listed.
39 items. Assesses anxiety in four domains: Physical
Symptoms, Social Anxiety, Harm Avoidance, and
Separation/Panic. Respondents rate how true each item is
for them.
11–31 Items (depending on age group). Assesses
self-statements related to negative affect (i.e., “I was afraid I
would make a fool of myself”). Anxious self-statements are
different for 7- to 10-year-olds. Respondents rate the
frequency with which they experience a range of automatic
thoughts.
14 items. Assesses frequency and controllability of worry.
Respondents rate how much they agree with each statement
(i.e. “Many things make me worry”).
18 items. Assesses physiological hyperarousal, defined as
bodily manifestations of autonomic arousal. Respondents
rate how often they have experienced symptoms (i.e.,
“sweaty hands/palms”) during the past 2 weeks.
Reliability
Internal consistency: NA subscale = .80; PA subscale = .77;
PH subscale = .81. Test–retest reliability: NA subscale =
.68; PA subscale = .68; PH subscale = .72.
Internal consistency: External subscale = .86; Internal subscale
= .89; Total scale = .93. Test–retest reliability: Not reported.
Internal consistency: Total scale = .94. Test–retest reliability:
Total scale = .79.
Internal consistency: Total scale = .87. Test–retest reliability:
Total scale = .76.
Internal consistency: Total scale ranges from .92 to .95.
Test–retest reliability: Total scale = .82.
Internal consistency: Total scale and subscales range from .74
to .90. Test–retest reliability: Total scale and subscales range
from .34 to .93.
Internal consistency: Total scale ranges from .89 to .96.
Test–retest reliability: Total scale ranges from .78 to .96.
Internal consistency: Total scale = .89. Test–retest reliability:
Total scale = .92.
Internal consistency: Total scale = .87. Test–retest reliability:
Not reported.
Positive and Negative Affect Schedule for Children (Laurent et
al., 1999)
8 to 14
Revised Child Anxiety and Depression Scales (Chorpita, Yim,
Moffitt, Umemoto, & Francis, 2000)
6 to 19
Revised Children’s Manifest Anxiety Scale (Reynolds &
Richmond, 1985)
6 to 19
Screen for Child Anxiety Related Emotional Disorders
(Birmaher et al., 1999; Birmaher et al., 1997)
9 to 18
Social Anxiety Scale for Children (La Greca, Dandes, Wick,
Shaw, & Stone), Revised Version (La Greca & Stone, 1993),
and Adolescent Version (La Greca & Lopez, 1998)
8 to 18
Social Phobia and Anxiety Inventory for Children (Beidel,
Turner, & Morris, 1995, 1999)
8 to 17
Spence Children’s Anxiety Scale (Spence, 1998)
7 to 14
State–Trait Anxiety Inventory for Children (Spielberger, 1973)
8 to 15
Test Anxiety Scale for Children (Sarason, Davidson, Lighthall,
& Waite, 1958)
8 to 17
27 items (15 items for NA subscale and 12 items for PA
subscale). Assesses children’s sensitivity to positive and
negative stimuli. Respondents rate adjectives (i.e., “sad,”
“interested”) based on the frequency they felt that way
during the past few weeks.
47 items. Assesses SAD, SOP, GAD, PD, OCD, and MDD.
Respondents rate how true and frequent each anxiety
symptom is for them.
37 items. Assesses anxiety symptoms. Yields Total Anxiety
and Lie scores and three subscales: Physiological Anxiety,
Worry/Oversensitivity, and Social Concerns/Concentration.
Respondents endorse either yes or no to each item.
38 items. Assesses symptoms of SAD, GAD, SOP, and school
phobia. Respondents rate severity of symptoms for the past
3 months
26 items (C) and 22 items (A). Assesses the subjective
experience of social anxiety. Yields three subscales: Fear of
Negative Evaluation, Social Avoidance and Distress in New
Situations, and General Social Avoidance and Distress.
Respondents rate how much each item is true for them.
26 items. Assesses the range of situations known to be
distressful to youth with social phobia. Yields three
subscales: Assertiveness/General Conversation, Traditional
Social Encounters, and Public Performance. Respondents
rate the degree to which they experience distress in each
situation.
44 items. Assesses symptoms of SAD, SOP, OCD,
PD-Agoraphobia, GAD, and Fears of Physical Injury.
Respondents rate the frequency with which they experience
each symptom.
20 items. Assesses chronic symptoms of anxiety. Yields two
subscales: Anxiety-Trait assesses chronic cross situational
anxiety; A-State assesses acute, transitory anxiety.
Respondents rate the frequency with which they experience
anxiety symptoms (e.g., “I am scared”).
30 items. Assesses anxiety in test-taking situations.
Respondents rate whether they experience anxiety with
respect to each test-taking situation.
Internal consistency: NA subscale = .92; PA subscale = .87.
Test–retest reliability: Not reported.
Internal consistency: SAD = .72; SOP = .71; GAD = .83; PD =
.79; OCD = .73; MDD = .78. Test–retest reliability: SAD =
.75; SOP = .80; GAD = .79; PD = .76; OCD = .65; MDD =
.77.
Internal consistency: Total scale and subscales > .80.
Test–retest reliability: Total scale and subscales range from
.64 to .76.
Internal consistency: Total scale = .93. Test–retest reliability:
Total scale = .86; Subscales range from .70 to .90.
Internal consistency: For child version, subscales range from
.69 to .86. For adolescent version, subscales range from .76
to .91.Test–retest reliability: Subscales range from .69 to
.86.
Internal consistency: Total scale = .95. Test–retest reliability:
Total scale = .86.
Internal consistency: Total scale and subscales range from .60
to .92. Test–retest reliability: Total scale and subscales range
from .45 to .60.
Internal consistency: Subscales range from .80 to .90.
Test–retest reliability: Subscales range from .31 to .71.
Internal consistency: Total scale ranges from .82 to .90.
Test–retest reliability: Total scale ranges from .44 to .82.
Note: SAD = separation anxiety disorder; SOP = social phobia; GAD = generalized anxiety disorder; PD = panic disorder; OCD = obsessive–compulsive disorder; MDD = major depressive disorder; C = child;
A = adolescent.
389
Table 4. Selected Parent and Teacher Rating Scales for Assessing Anxiety and Its Disorders in Youth
Instrument
Brief Description
Reliability
Behavior Assessment System for
Children (Reynolds & Kamphaus,
1992)
126 to 148 items. Assesses behavior problems. Yields
20 scales and subscales (e.g., Internalizing, Anxiety).
Child Behavior Checklist
(Achenbach, 1991a), Teacher
Report Form (Achenbach, 1991b)
118 items (P) and 120 items (T). Assesses positive and
problem behaviors. Includes broadband subscales
(Externalizing, Internalizing), and narrowband
subscales (Withdrawn, Somatic Complaints,
Anxious/Depressed, Social Problems, Thought
Problems, Attention Problems, Delinquent Behavior,
and Aggressive Behavior).
48 items (P) and 59 items (T). Assesses behavior
problems and includes five subscales: Conduct
Problems, Learning Problems, Psychosomatic,
Impulsive–Hyperactive, and Anxiety.
40 items. Assesses behavior problems. Includes four
subscales: Interpersonal Problems, Inappropriate
Behaviors/Feelings, Depression, Physical Symptoms
and Fears.
26 items. Assesses parents’ perceptions of the child’s
trait anxiety.
Internal consistency: Total scale and
subscales range from .70s to .90s.
Test–retest reliability: Total scale
and subscales range from .70s to
.90s.
Internal consistency: Subscales range
from .54 to .96. Test–retest
reliability: Subscales range from
.86 to .89.
Conner’s Rating Scales–Revised P/T
(Conners, 1990)
Devereux Behavior Rating Scale–T
School Form (Naglieri, LeBuffe,
& Pfeiffer, 1993)
State–Trait Anxiety Inventory for
Children- Parent Report–Trait
Version (Southam-Gerow,
Flannery-Schroeder, & Kendall,
2002; Spielberger, 1973; Strauss,
1987).
Internal consistency: Subscales range
from .73 to.96. Test–retest
reliability: Subscales range from
.47 to .86.
Internal consistency: Subscales range
from .92 to .97. Test–retest
reliability: Subscales range from
.69 to .85.
Internal consistency: Total scale for
maternal and paternal reports
range from .84 to .91. Test–retest
reliability: Total scale for maternal
and paternal reports range from
.68 to .76.
Note: P = parent; T = teacher.
Table 5. Clinician Rating Scales for Assessing Anxiety and Its Disorders in Youth
Instrument
Children’s Yale–Brown Obsessive
Compulsive Scale (Goodman et al.,
1989; Scahill et al., 1997)
Pediatric Anxiety Rating Scale
(Research Units on Pediatric
Psychopharmacology Anxiety Study
Group, 2002)
Clinician Severity Rating Scale for the
Anxiety Disorders Interview Schedule
for Children: Child and Parent
Versions (ADIS: C/P; Silverman &
Nelles, 1988; ADIS–IV: C/P;
Silverman & Albano, 1996).
Brief Description
10 items. Semistructured clinical interview administered
to parent or child. Assesses obsessive–compulsive
disorder severity. Two sections (obsessions,
compulsion) yielding separate scores. Clinicians rate
severity of symptoms based on frequency or duration,
interference, distress, resistance, and control on a
5-point scale. Score > 15 indicates clinically significant
obsessive–compulsive disorder.
50 items. Semistructured interview administered to parent
and child. Assesses anxiety symptoms in six areas
(Separation, Social Interactions or Performance
Situations, Generalized, Specific Phobia, Physical
Signs and Symptoms, and Other). Clinicians rate
severity in each of seven dimensions (number of
symptoms, frequency, severity of distress associated
with anxiety symptoms, interference at home, severity
of physical symptoms, and avoidance) on a 6-point
scale. Score greater than 2 indicates clinically
significant interference.
Assesses level of severity/interference associated with
each DSM-IV anxiety disorder assessed via the
ADIS–IV: C/P. Clinicians rate (based on child and
parent report) severity of symptoms based on
interference in school, peer relationships, family life,
and internal distress on a 9-point scale.
Reliability
Internal consistency: Total
scale = .87. Inter-rater
reliability: Total scale and
subscales range from .66 to
.91. Test–retest reliability:
Not reported.
Internal consistency: Total
scale = .64. Inter-rater
reliability: Total scale = .97;
Severity dimensions range
from .78 to .97. Test–retest
reliability: Total scale = .55;
Severity dimensions range
from .37 to .59.
Interrater reliability: .74.
Test–retest reliability:
ADIS–C = .89; ADIS–P =
.87; Composite = .88.
Note: DSM–IV = Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994).
390
Table 6. Selected Rating Scales Used to Assess Variables Maintaining Anxiety in Youth
Variable
Parent–Child Relationship
Parent–Child Relationship
Rating Scale
Parenting Behavior Inventory Child
Report/Parent Report (Schludermann &
Schludermann, 1970).
Conflict Behavior Scale (Prinz, Foster, Kent, &
O’Leary, 1979).
Peer Relationships and Social Skills
Friendship Questionnaire (Bierman & McCauley,
1987).
Social Skills
Social Skills Rating System Child & Parent
Version (Gresham & Elliot, 1990).
School Refusal Behavior
School Refusal Assessment Scale (Kearney &
Silverman, 1993); Revised Version (Kearney,
2002).
Note: C = child; P = parent.
Description
Reliability
30 items. Assesses perceptions of parents’ behaviors toward child
from child and parent report. Includes three subscales:
Psychological Control, Acceptance, and Firm Control
20 items. Assesses problem areas (i.e., conflict) and positive and
negative parent–child communications from child and parent
report.
40 items (8 open-ended). Assesses peer interactions from child
report. Includes three subscales: Positive Interactions, Negative
Interactions, and Extensiveness of Peer Network.
44 items (C); 38 items (P). Assesses social skills. Includes 5
subscales: Empathy, Cooperation, Assertion, Responsibility, and
Self-control.
16 items; revision 24 items. Assesses factors maintaining school
refusal behavior from parent and child report. Includes four
subscales: Avoidance of Fear-Provoking Situations, Escape from
Aversive Social Evaluation Situations, Attention-Getting
Behavior, and Positive Tangible Reinforcement.
Internal consistency: Subscales range from .65
to .74. Test–retest reliability: Subscales range
from .66 to .93.
Internal consistency: Total scale ranges from .88
to .95. Test–retest reliability: Not reported.
Internal consistency: Subscales range from .72
to .82. Test–retest reliability: Not reported.
Internal consistency: Subscales range from .83
to .87. Test–retest reliability: Subscales range
from .68 to .87.
Internal consistency: Not reported. Test–retest
reliability: Subscales range from .44 to .87.
391
392
Table 7. Interview Schedules and Rating Scales Used to Assess Youth Anxiety Treatment Outcome
Study
Barrett, Dadds, & Rapee (1996)
Barrett (1998)
Beidel, Turner, & Morris (2000)
Cobham, Dadds, & Spence (1998)
Cornwall, Spence, & Schotte (1996)
Flannery-Schroeder & Kendall (2000)
Gallagher, Rabian, & McCloskey (2004)
Ginsburg & Drake (2002)
Hayward et al. (2000)
Heyne et al. (2002)
Kendall (1994)
Kendall et al. (1997)
King et al. (1998)
Last, Hansen, & Franco (1998)
Manassis et al. (2002)
Masia, Klein, Storch, & Corda (2001)
Mendlowitz et al. (1999)
Muris, Merckelbach, Holdrinet, & Sijsenaar (1998)
Muris, Meesters, & van Melick (2002)
Nauta, Scholing, Emmelkamp, & Minderaa (2003)
Shortt, Barrett, & Fox (2001)
Silverman, Kurtines, Ginsburg, Weems, Lumpkin,
et al. (1999)
Silverman, Kurtines, Ginsburg, Weems, Rabian, et
al. (1999)
Spence, Donovan, & Brechman-Toussaint (2000)
ADIS–C/P
DICA
DISC
K–SADS
RCMAS
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
STAIC
FSSC-R
CDI
yes
yes
yes
SPAIC
yes
yes
yes
yes
yes
yes
yes
yes
CBCL
TRF
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
Note: ADIS–C/P = Anxiety Disorders Interview Schedule: Child and Parent Version; DICA = Diagnostic Interview Schedule for Children; K–SADS = Schedule for Affective Disorders and Schizophrenia for
School-Age Children; RCMAS = Revised Children’s Manifext Anxiety Scale; STAIC = State–Trait Anxiety Inventory for Children; FSSC–R = Fear Survey Schedule for Children–Revised; CDI = Children’s Depression Inventory; SPAIC = Social Phobia and Anxiety Inventory for Children; CBCL = Child Behavior Checklist; TRF = Teacher Report Form; Yes = Scale showed significant and positive changes from pre- to
posttreatment. The following rating scales were also used in three or fewer studies: Children’s Coping Strategies Checklist (Sandler & Ayers, 1990), Children’s Negative Cognitive Error Questionnaire (Leitenberg, Yost,
& Carroll-Wilson, 1986), Coping Questionnaire for Children (Kendall, 1994), Global Assessment of Functioning Scale (Jones, Thornicraft, & Coffey, 1995), Multidimensional Anxiety Scale (March et al., 1997;
March, Sullivan, & James, 1999), Negative Affect Self-Statement Questionnaire (Ronan, Kendall, & Rowe, 1994), Revised Children’s Anxiety and Depression Scale (Chorpita, Yim, Moffitt, Umemoto, & Francis,
2000), Screen for Anxiety Related Emotional Disorders (Birmaher et al., 1997, 1999), Social Skills Questionnaire-Parent Version (Spence, 1995a), Social Worry Questionnaire Pupil Version (Spence, 1995b), Spence
Children’s Anxiety Scale (Spence, 1998), and State Trait Anxiety Inventory for Children–Parent Version (Strauss, 1987).
EVIDENCE-BASED ASSESSMENT OF ANXIETY
is important to conduct empirical tests that link specific RCMAS scores to meaningful events and that define cutoff or threshold values that imply significantly
heightened risks or benefits (Blanton & Jaccard, in
press; Sechrest, McKnight, & McKnight, 1996). This
also would require not just linking RCMAS scores to
events that render the metric meaningful, but conducting the necessary generalizability studies to different
populations, contexts, and so on.
A similar set of concerns can be expressed about using the rating scales to assess treatment outcome. Table
7 shows the rating scales that have been used in the
published youth anxiety treatment outcome studies.
With some of the scales, such as the Child Behavior
Checklist (CBCL), norms are used. However, norming
mainly indicates a youth’s relative standing; it does not
indicate a youth’s absolute standing on anxiety (Blanton & Jaccard, in press). More specifically, when the
CBCL is used to assess treatment outcome, “clinically
significant improvement” is defined as meeting a minimum criterion T score on the CBCL Internalizing scale
of less than 70 (adjusted according to age norms;
Kendall, 1994; Silverman, Kurtines, Ginsburg, Weems,
Lumpkin, et al., 1999). In other words, cases that shift
from being above this cutoff value to being below the
cutoff value are said to have shown clinically significant improvement following treatment (see Kazdin,
1999; Kendall & Grove, 1988). There is no evidence,
however, that youths with a score below 70 have fewer
worries or display fewer avoidant behaviors than
youths with a score above 70. That is, this shift on the
CBCL, or the declining scores on the RCMAS, or any
rating scale listed on the tables, from pre- to
posttreatment does not truly inform whether the CBT
had meaningful impact on the day-to-day functioning
of the treated youth (see Kazdin, 1999).
Blanton and Jaccard (in press) further pointed out
that using Cohen’s d, a standardized index of effect
size, does not serve to yield a more meaningful metric—all it does is rescale the unstandardized difference
onto another arbitrary metric. What is necessary, therefore, when these scales are used in youth anxiety treatment outcome research is to have empirically established information about what different effect sizes, as
indexed by Cohen’s d, mean in terms of “real” concrete
changes. Kazdin (1999) provided examples such as
meeting role demands, functioning in everyday life,
and improvement in the quality of one’s life.
With regard to using the rating scales to identify and
quantify controlling or maintaining variables of anxiety, work in this area has only just begun. Prins (2001)
and Boer and Lindout (2001), for example, summarized the research that has examined cognitive and
family processes, respectively, that maintain anxiety as
well the measures that have been used to assess these
processes. With regard to potential mediators of changes, studies conducted to date have been post hoc in na-
ture rather than designed from the onset as “mediational studies” (Kazdin & Nock, 2003; Weersing &
Weisz, 2000), though research in this area is in progress (Silverman, 2003). One of the few studies that has
evaluated a potential mediator of CBT in the youth
anxiety area (i.e., Treadwell & Kendall, 1996) found
that children’s negative self-statements, assessed using the Negative Affect Self-Statement Questionnaire
(Ronan, Kendall, & Rowe, 1994) mediated improvement following individual CBT in child self-reported
anxiety severity and a specific state-of-mind ratio but
not in parent or teacher reports of externalizing or internalizing symptoms. Although the study by Treadwell and Kendall represents an important initial step in
the youth anxiety research on evaluating mediators or
mechanisms of positive treatment response, it does not
meet the criteria of establishing the time line between
the mechanism and behavior changes (Kazdin & Nock,
2003; Weersing & Weisz, 2002), or the additional requirements delineated by Kazdin and Nock (2003).
More research is sorely needed in this area. Certainly,
however, the majority of the rating scales listed in the
tables have the potential to be used in the assessment of
contextual variables that influence the maintenance of
anxiety and its disorders in youths as well as in the assessment of therapy mediators and moderators. It is
now up to the investigators in the field to take these
measures and use them accordingly for these purposes.
Some additional comments specific to the youth,
teacher, and clinician rating scales are in order. Regarding youth self-rating scales, despite their apparent
advantages (e.g., quick, efficient, inexpensive), it is
reasonable to presume that some anxious youths would
be reluctant to self-disclose about their personal anxious reactions. Research findings back this up. The
RCMAS offers an advantage that sets it apart from the
other anxiety rating scales in that it contains not only a
Total Anxiety scale but also a Lie scale. The RCMAS
Lie scale, a downward extension of the Lie scale on the
adult version of the Manifest Anxiety Scale, was derived from the Social Desirability/Lie scale of the Minnesota Multiphasic Personality Inventory. Containing
items such as “I never get angry,” “I like everyone I
know,” and “I am always kind,” the Lie scale has been
used as an indicator of social desirability (Dadds, Perrin, & Yule, 1998; Reynolds & Richmond, 1985) or defensiveness (e.g., Joiner, 1996), reflecting a tendency
to present oneself in a favorable light or deny flaws and
weaknesses that others are usually willing to admit.
Research using the RCMAS Lie scale in unselected
school samples (Dadds et al., 1998) and clinic-referred
anxious samples (Pina, Silverman, Saavedra, & Weems,
2001) reveals that younger children score significantly
higher on the Lie scale than older children (Dadds et al.,
1998; Pina et al., 2001); African American youths score
significantly higher than European American youths
(Dadds et al., 1998), and Hispanic American youths
393
SILVERMAN AND OLLENDICK
score significantly higher than European American
youths (Pina et al., 2001). No significant gender differences have been observed in Lie scale scores (Hagborg,
1991; Pina et al., 2001; Reynolds & Richmond, 1985).
These findings underscore the need for clinicians
and researchers to recognize that certain groups of anxious children and adolescents are more likely to evidence social desirability when using anxiety rating
scales than are other groups. For example, when assessing a young anxious child, if the child endorses
four Lie scale items (the younger children’s mean Lie
score in Pina et al., 2001) or more, it may be worthwhile to question the validity or accuracy of the child’s
self-reports of anxiety and consider alternative sources. It further underscores the need to emphasize to anxious youth that there are no right or wrong answers during the assessment process. Similar pressure to please
and to be seen in a favorable light may be placed on
children and adolescents with anxiety disorders during
other assessment strategies such as behavioral observations, though the issue has not been studied.
Teacher ratings, like parent and child ratings, generally show poor correspondence to other informants’
ratings (Achenbach, McConaughy, & Howell, 1987).
There also is general consensus in the field that teachers are less helpful for assessing internalizing problems, such as anxiety, than they are for externalizing
problems (Loeber, Green, & Lahey, 1990). This makes
sense in light of the overt versus covert nature of
externalizing and internalizing behavior problems, respectively. That is, teachers can more readily tell when
a child is out of the chair or is calling out of turn (an
externalizing problem). It is not as obvious when a
child is experiencing severe internal distress because
he or she is about to be called on (an internalizing problem). Obtaining teacher ratings also poses methodological difficulties in that as children enter the middle
school and high school years, they have multiple teachers; so determining which teacher to ask to complete
the forms is not readily apparent. The time of the year
when the assessment occurs poses additional difficulties (e.g., the summer months, early in the school year).
Perhaps partly for these reasons, teacher ratings have
been infrequently used in the youth anxiety research
area and therefore have a thin evidence base.
The clinician rating scales presented in Table 5 are
all relatively new to the field, and their evidence base
also is therefore thin. In light of the response biases
that may occur with child and parent rating scales (e.g.,
social desirability), however, clinician rating scales
can serve to supplement other informants’ reports in
potentially useful ways. For example, the recently developed PARS (Research Units on Pediatric Psychopharmacology Anxiety Study Group, 2002) was designed to assess the frequency, severity, and associated
impairment across SAD, SOP, and GAD symptoms in
children and adolescents (ages 6 to 17 years), rather
394
than assessing impairment of each individual anxiety
disorder as does the clinician severity rating scale of
the ADIS: C/P (Silverman & Albano, 1996). The developers of the PARS note that in light of the high rates
of comorbidity observed among the anxiety disorders,
this type of global rating of impairment, similar to the
Children’s Global Assessment Scale (Bird, Canino,
Rubio-Stipec, & Ribera, 1987), could be useful.
As Table 5 shows, although the internal consistency
of the PARS was found to be satisfactory, its retest reliability needs further examination (e.g., retest reliability = .55 for the total scale score using a retest interval
of a mean of 24.7 +/– 14.7 days; though this likely reflects in part the changing nature of children’s display
of anxiety over time). Also needing further examination is the scale’s convergent and divergent validity.
With regard to the latter, although the observed correlations were in the expected directions (in terms of
being positively correlated with ratings of internalizing
symptoms and negatively correlated with externalizing
symptoms), this was more true when the PARS’s ratings were correlated with other clinician ratings rather
than with other sources’ ratings, such as children’s ratings on the MASC. This was true for both pretreatment
as well as posttreatment rating scores, suggesting some
potential, though limited, utility of the PARS to assess
treatment responsiveness.
In summary, rating scales have been frequently used
in child and adolescent anxiety research. They have
been studied frequently with regard to reliability (interrater, internal consistency), and many of them have
been studied for concurrent and divergent validity.
Less psychometric information (reliability, validity) is
available on all of these ratings scales’ psychometrics
with clinically anxious samples of youths. Youth and
parent rating scales, especially the RCMAS for youth
and the CBCL for parents, are the most widely used
and evaluated. Their most frequent usage has been to
identify and quantify symptoms and for evaluating
treatment outcome. Despite their wide usage and the
fact that in most treatment outcome studies the scales
show sensitivity to change, the scores obtained on
these rating scales are on an arbitrary metric. Considerably more research is needed to determine the meaning
or practical value of a youth’s score on these scales, as
well as the meaning or practical value of observed
changes on these scales during the course of a treatment outcome study. Finally, although rating scales
have considerable potential to inform the field about
maintaining or controlling variables of anxiety as well
as mediators and moderators of therapy outcome, research in this area has only just begun.
Direct Observations
Direct observation procedures have been used extensively in the pediatric psychology area, such as in
EVIDENCE-BASED ASSESSMENT OF ANXIETY
the filmed modeling research where it has been found
that children’s observed distress prior to surgical procedures can be significantly reduced by watching films
(e.g., Melamed & Siegel, 1975). Direct observations
also have been used to assess anxiety in young, preschool-age children (e.g., Glennon & Weisz, 1978)
given the potential limits (e.g., social desirability) noted previously when it comes to obtaining self-reports
from younger populations. Direct observations also
were used in the early days of behavior therapy when
the technology of behavioral assessment procedures,
particularly behavioral avoidance tasks, were being designed and evaluated for use primarily with individuals
with phobias, though not necessarily clinic-referred
phobia cases (e.g., Kornhaber & Schroeder, 1975;
Murphy & Bootzin, 1973). In some studies, temporal
stability was evaluated over minutes (e.g., Kornhaber
& Schroeder, 1975). When assessed over minutes, stability was acceptable. When assessed over days, stability or reliability deteriorated (e.g., Murphy & Bootzin,
1973). Also, in some of these studies (e.g., Kornhaber
& Schroeder, 1975; Murphy & Bootzin, 1973), how
the child behaved during the observation task was evaluated in relation to the child’s self-report, with reasonable convergence usually found.
Direct observational procedures have been far less
used with DSM cases of clinical child and adolescent
anxiety. Table 8 provides a summary of studies that we
could locate that have employed and evaluated the
psychometrics of direct observation tasks, with mainly
clinic-referred anxious youths. The observations were
conducted in clinic or experimental settings in all the
studies listed in the table.
Further examination of Table 8 reveals that although direct observations are designed particularly
well for the purposes of identifying and quantifying
specific fear and anxiety symptoms and behaviors,
such as avoidance, few youth anxiety studies have actually used them for this purpose. An example of a
study that did is Ost, Svensson, Hellstrom, and
Lindwall (2001), in which, inasmuch as the behavioral
avoidance tasks consisted of a series of graduated
steps, the percentage of steps the youth accomplished
was recorded. Direct observations have been used
more frequently in youth anxiety research for evoking
fear and anxiety reactions in youths (i.e., in an in vivo
exposure) and then having youths subjectively rate
their levels of fear or anxiety, having trained observers
subjectively rate the youths’ levels of fear or anxiety, or
both. In some studies, observers’ subjective ratings
were obtained not only by providing the observers with
global rating scales (e.g., a Likert rating scale from 1 to
5), but also by providing the observers with behavioral
dimensions to help assist them in making their subjective ratings (Kendall, 1994).
Direct observation procedures also have been used
in a small number of clinical trials (e.g., Barrett,
Dadds, & Rapee, 1996; Beidel, Turner, & Morris,
2000; Kendall, 1994) to evaluate treatment outcome,
with uneven results (e.g., Beidel et al., 2000, and Kendall, 1994, reported improvements, but Barrett et al.,
1996, did not find significant differences in family observation tasks depending on whether youths received
individual CBT or a parent involvement CBT). In addition, direct observation procedures have been used to
assess the controlling or maintaining variables of anxiety, most typically family interaction patterns.
Table 8 shows the three main types of tasks that
have been used in the youth anxiety area: (a) social
evaluative tasks, (b) behavioral avoidance tasks, and
(c) parent–youth interaction tasks. With regard to social evaluative tasks (Beidel et al., 2000; Kendall, 1994),
participants are informed of the evaluative nature of the
task and are given standard behavioral assertiveness instructions. For example, Beidel et al. invited children
and adolescents to read aloud a story in front of a small
group and were told to “Respond as if the scene were
really happening.” With regard to behavioral avoidance tasks, Ost et al. (2001) exposed children and adolescents to their feared stimuli under relatively controlled and replicable conditions in the clinic setting.
For example, for fear of snakes, youths were asked to
enter a room where a live snake was enclosed in a glass
container and to remove the lid from the container and
pick up the snake and hold it for 10 sec.
With regard to the parent–youth interaction tasks
(e.g., Hudson & Rapee, 2002), parents and youths are
observed while engaging in problem-solving situations. For example, Hudson and Rapee conducted observations of “normal” and anxious youths and their
siblings while separately completing a set of tangram/
puzzle tasks designed to be slightly too difficult to
complete in 5 min. Of interest was the degree of parental involvement during the task (e.g., degree of unsolicited help, degree to which the parent physically
touched the tangram piece).
Another point worth noting about the studies listed
in Table 8 is that experimenter instructions vary with
respect to how much demand is placed on the youth,
with some instructions exerting high demand (e.g.,
“Make this talk as interesting as possible; we will be
listening”) and with some exerting less demand (e.g.,
“Tell us about yourself”). The explicit instructional set
is not given in all of the studies, and how this instructional set influences studies’ findings has not been
studied with child and adolescent anxious participants.
It is possible that the types of significant group differences found with the RCMAS Lie scale (or social desirability) may play a role in how different groups of
children react to high versus low instructional sets.
Relatedly, although these procedures have been used
with a wide range of age groups, the equivalence of
the tasks across age groups has not been established
(Vasey & Lonigan, 2000).
395
Table 8. Sample of Observation Tasks Conducted With Anxious Youth
Study
N
Sample
Age
Observation Tasks
Instructions
Rater
Reliability
Social Evaluative Tasks
Ferrell, Beidel, & Turner
(2004)
58
SOP
7 to 12 years
(1) role play with peer
(2) read aloud task for 10 min
“Respond as if the scene were really happening”
“Read aloud the story of Jack and the Beanstalk”
Youth and Observer
Youth and Observer
Interrater reliability: .89 (skills)
Interrater reliability: .87 (anxiety)
Beidel, Turner, & Morris
(2000)
67
SOP
8 to 12 years
(1) role play with peer
(2) read aloud task for 10 min
“Respond as if the scene were really happening”
“Read aloud the story of Jack and the Beanstalk”
Youth and Observer
Interrater reliability: .89 (skills)
Kendall (1994)
47
SAD, OAD, AVD
9 to 13 years
5-min talk
“Tell us about yourself”
Observer
Interrater reliability: .82
Hamilton & King (1991)
14
SP
2 to 11 years
in vivo exposure
“Close interaction with dogs”
Observer
Test–retest reliability: .97
Ost, Svensson, Hellstrom,
& Lindwall (2001)
60
SP
7 to 17 years
in vivo exposure
“Do your very best, you can terminate the test at
any point”
Youth
No reliability reported
68
OCD, SAD, GAD,
SOP, SP, PD, AG
7 to 15 years
(1) 5-min warm-up
parent–youth dyad
(2) 5-min conflict conversation
“Come to a consensus decision about characteristics
of an ideal person”
“Talk about something you argue about and attempt
to reach an agreement or solve the problem”
“Talk about something that made the child anxious
or worried”
Observer
Interrater reliability: Values
range from .88 to .94.
Behavioral Avoidance Tasks
Parent–Child Interaction Tasks
Moore, Whaley, & Sigman
(2004)
(3) 5-min anxiety conversation
Hudson & Rapee (2002)
37
20
Woodruff-Borden,
Morrow, Bourland, &
Cambron (2002)
Cobham, Dadds, &
Spence (1999)
57
73
GAD, SP, SOP,
SAD, PD, OCD
nonclinic
7 to 16 years
5-min parent–youth dyad
while working on puzzle
“The puzzle is a test of the child’s cognitive ability;
you can help if you think it’s needed”
Observer
Interrater reliability: .83
PD, SP, PD with
AG, OCD,
GAD, PTSD
6 to 12 years
(1) 10-min parent–youth
dyad working on
unsolvable anagrams
“Do the best you can with the list of word puzzles;
we will be back in 10-min to see how many you
have correct”
Observer
Interrater reliability: Values
range from .80 to 1.00
(2) 10-min parent–youth dyad
talking about themselves
“Give a speech about yourselves in front of the
camera”
(1) 3-min talk
Youth and Parent
(2) three 5-min talk youth–
parent
(3) 3-min talk (optional)
“Make this talk as interesting as possible; we will be
listening”
“How he or she felt, prepare for talk, discussion for
second talk”
“Talk about your fear"
Interrater reliability: .93
(skills); Interrater reliability:
.70 (anxiety)
SAD, SP, OAD,
GAD, SOP, AG
7 to 14 years
Dadds, Barrett, Rapee, &
Ryan (1996)
66
SAD, SP, OAD,
SOP
7 to 14 years
5-min parent–youth dyad to
generate problem-solving
solutions
Youth was asked to interpret and respond to a
physical and social situation first alone and then
with parents
Observer
Interrater reliability: Values
range from .72 to .99
Barrett, Dadds, & Rapee
(1996)
79
SAD, OAD, SOP
7 to 14 years
5-min parent–youth dyad to
generate problem-solving
solutions
Youth was asked to interpret and respond to a
physical and social situation first alone and then
with parents
Observer
Interrater reliability: 1.00
Siqueland, Kendall, &
Steinberg (1996)
17
27
OAD, SAD,
nonclinic
9 to 12 years
4- to 6-min talk youth–parent
“Read the topic printed on a card and discuss the
topic”
Observer
Interrater reliability: Values
range from .85 to .91
Note: SOP = social phobia; GAD = generalized anxiety disorder; SP = simple phobia disorder; SAD = separation anxiety disorder; PD = panic disorder; OCD = obsessive–compulsive disorder; OAD = overanxious disorder;
AVD = avoidant disorder; AG = agoraphobia; PD with AG = panic disorder with agoraphobia; PTSD= posttraumatic stress disorder.
EVIDENCE-BASED ASSESSMENT OF ANXIETY
Finally, in almost all of the studies, reliability was
assessed in terms of interrater agreement using percentage agreement, Pearson correlations, kappa coefficients, internal consistency, or intraclass correlation
coefficient. Each of these reliability statistics has
strengths and weaknesses (see Mitchell, 1979), and
conclusions obtained from a given study need to be
drawn judiciously depending on the reliability statistic
used. Research on observational procedures’ retest reliability is particularly scarce.
In summary, direct observations have been most
frequently used to obtain subjective ratings of youths
and observers when the youth is either in a fear-provoking situation or in a family interaction task. When
used in family tasks, the observations are used to assess
contextual (family) variables that may serve to maintain anxiety. Surprisingly, direct observations have
been less frequently used to identify and quantify specific anxious symptoms and behaviors and also less
used to assess treatment outcome. In addition, there
currently is an absence of a standardized task and coding procedure, which makes it difficult to generalize
across studies (Barrios & Hartmann, 1997).
Critical for further study is whether the time and
cost involved in the use of direct observations have a
knowledge development “payoff.” That is, do direct
observation procedures possess incremental validity
over simply using self-reports or self-monitoring (discussed later)? Despite the important questions that
need to be answered, we do believe that direct observational procedures have clinical utility. For example,
they are likely to yield helpful conceptual information
about the nature of family interactions among anxious
children or just “how far children can go” when it
comes to interacting with a feared object or event.
Given the potentially useful conceptual information
that can be gained from these procedures, we encourage their continued use and evaluation.
Self-Monitoring
Self-monitoring procedures have often been viewed
as a more efficient and easier way to accomplish the
same goals as direct observations—that is, to identify
and quantify symptoms and behaviors, to identify and
quantify controlling variables, and to evaluate and
monitor treatment outcome. In the youth anxiety area,
self-monitoring procedures have been used for these
purposes (see Silverman & Kurtines, 1996). With regard to treatment outcome evaluation, self-monitoring
data have been used in a number of single case study
designs as a baseline that is later used to document behavior change during the treatment phase (e.g., Eisen
& Silverman, 1998; Ollendick, 1995). They have not
been used as outcome measures in the clinical trials.
Although self-monitoring is relatively common in
practice among behaviorally oriented clinicians, little
has been done in the child and adolescent anxiety research area to evaluate its feasibility and psychometric
properties. An exception is Beidel, Neal, and Lederer
(1991), who devised and evaluated the feasibility (i.e.,
child compliance), reliability, and validity of a daily diary for use in assessing the range and frequency of social-evaluative anxious events in elementary school
children (N = 57; n = 32, test anxious; n = 25, nontest
anxious) during a 2-week assessment phase. Relatively
structured in nature, the daily diary listed events such
as “I had a test” and “The teacher called on me to answer a question,” as well as a list of potential responses
to the occurrence of the events, including positive (e.g.,
“I practiced extra hard, told myself not to be nervous, it
would be okay”), negative (e.g., “I cried, got a headache or stomachache”), and neutral (e.g., “I did what I
was told”) behaviors. The children also rated the degree of distress they experienced using the Self-Assessment Manikin (Lang & Cuthbert, 1984), which is a
pictorial 5-point rating scale that depicts increasing degrees of anxious arousal.
With regard to feasibility or compliance, with no incentives offered, the mean number of days the diary
was completed ranged from 7.9 to 11.5 days, though
only 31% to 39% of the children complied for the full 2
weeks. Retest reliability was found to be modest, but
that is probably because the events listed on the diary
likely show true fluctuations. Evidence for validity was
demonstrated in that the test-anxious children reported
significantly more emotional distress and more negative behaviors such as crying or behavioral avoidance.
Despite Beidel et al.’s (1991) limitation of not having an outside validity check for the children’s daily recordings (e.g., parent ratings or independent observer),
the study is an important one in providing some basic
psychometric data of self-monitoring forms for use in
assessing childhood anxiety. The authors suggested
that diverse diaries be developed that are tailored to
other, specific anxiety concerns of children (e.g., separation situations for children with SAD). This suggestion has not been followed up by other investigators,
though it would seem a potentially useful way to improve self-monitoring procedures even further with
child anxious populations. In the meantime, it appears
that a relatively structured self-monitoring form possesses some degree of evidence, though whether this
type of structure is necessary for older children and adolescents is unknown.
As with direct observation procedures, additional
research is needed on self-monitoring procedures (i.e.,
feasibility, reliability, validity). In addition, although
the data obtained from self-monitoring have been
found to be sensitive to change in single case study designs, whether treatment sensitivity would be found in
a large-scale randomized trial is uncertain. Indeed,
given the extensive encouragement and enhanced motivational efforts that need to be exerted to get young
397
SILVERMAN AND OLLENDICK
people to comply with filling out self-monitoring
forms, it is possible that exerting such efforts is more
difficult in large randomized trials; and so the treatment sensitivity of self-monitoring data observed in
the single case studies may not emerge in the clinical
trials. This is an empirical question that would be
worth answering. Nevertheless, self-monitoring procedures have clinical utility in terms of yielding helpful
conceptual information (e.g., the specific situations
that elicit anxiety in a child, the child’s cognitions
when faced with a specific object or event), so we encourage their continued use and evaluation.
Summary
The overview provided in this section presents the
most frequently used assessment methods and instruments for use with youths with anxiety disorders. The
overview also indicates the main purposes or goals of
assessment for each of these methods and instruments
and where the evidence is most abundant when it
comes to how well these methods and instruments can
successfully accomplish these goals. To briefly summarize, interview schedules have been used most frequently for diagnosing, identifying, and quantifying
symptoms and for assessing for diagnostic recovery in
treatment outcome research. Among the interview
schedules available, the ADIS: C/P (Silverman & Albano, 1996) has been used in most of the youth anxiety
research studies, and it also has been evaluated with respect to both reliability and validity of DSM–IV anxiety diagnoses. Interview schedules also would appear
to have treatment utility, though this requires further
empirical verification.
Rating scales have been used most for identifying
and quantifying symptoms and behaviors and for evaluating treatment outcome. They also may be useful for
screening purposes, as summarized in the next section.
The RCMAS has been most frequently used for these
purposes, with the CBCL being used primarily for
evaluating treatment outcome. The psychometric properties of many of these measures have been evaluated
mainly for nonclinic referred anxious children and adolescents, with less evaluative work done on clinic-referred anxious youths. Teacher- and clinician-completed rating scales of child anxiety have been less used
in clinical child and adolescent anxiety assessment research. New clinician rating scales, such as the PARS,
suggest that such scales may be useful supplements to
parent and child reports. The metrics of all of the rating
scales need to be further tested and tied to real-life
practical events. Although the use of ratings scales is
the most efficient way to assess for mediators and moderators of treatment and to assess the contextual aspects of anxiety and its disorders, work in this arena is
limited.
398
Direct observational procedures have been used in
several studies, and they are likely to have clinical utility, especially in terms of yielding conceptually useful
information. Interestingly, when they have been used,
subjective ratings from the youth, observers, or both
are most frequently obtained. Using direct observation
to actually quantify specific symptoms or behaviors of
anxiety has been less frequently done. There is a lack
of information about their retest reliability and incremental validity, with the latter seeming particularly important to determine in light of the investigator and participant burden that observational procedures impose.
Self-monitoring procedures also would seem to yield
conceptually useful information. To date, however, only one assessment study (Beidel et al., 1991) has evaluated the feasibility, reliability, and validity of self-monitoring procedures with anxious children.
Some Additional Issues
In this section, we discuss what more might be done
to move toward an evidence-based assessment approach
by focusing on several additional assessment issues
that have begun to be tackled empirically by investigators in the youth anxiety area and where a body of
research studies has begun to accumulate. This has
been done mostly within the context of self-report assessment methods (diagnostic interviews and rating
scales) and within the context of the assessment goals
of screening and diagnosing. More specifically, we
focus on discriminating between anxiety and other
constructs, screening for anxiety disorders, and the
handling of discrepant information from multiple
informants.
Discriminating Between Anxiety
and Other Constructs
With the exception of interview schedules, which
were developed specifically for assessing differential
diagnosis, only the rating scales have been examined
with regard to how well they can discriminate between
youths with anxiety and other constructs (and other
disorders). Having assessment instruments that can accurately discriminate is of particular importance given
the common observation that multiple disorders tend to
co-occur within the same child and at the same time
(i.e., comorbidity). Estimated rates of comorbidity
among youths with clinical disorders, in general, run as
high as 91% in clinic samples (e.g., Angold & Costello, 1999) and up to 71% in community samples (e.g.,
Woodward & Fergusson, 2001). Although some of the
observed high rates of comorbidity reflect assessment
artifacts (or other artifacts, such as referral bias), there
is considerable evidence to the observed comorbidity
(e.g., Beiderman, Faraone, Mick, & Lelon, 1995; Selig-
EVIDENCE-BASED ASSESSMENT OF ANXIETY
man & Ollendick, 1998). This underscores the need to
carefully assess for different disorders.
Within the anxiety disorders, the particular comorbid patterns most critical to assess for are the following
(arranged from most observable and predictable): primary anxiety disorder diagnoses co-occurring first
with other anxiety disorders, second with depression,
and third with the externalizing disorders (ADHD,
oppositional defiant disorder, conduct disorder; Kovacs
& Devlin, 1998). Although the many reasons for
comorbidity are not fully understood (Angold &
Costello, 1999), anxious youths who are comorbid
with another disorder, especially an affective disorder,
are more severely impaired than youths with either disorder alone, their problems are more likely to persist
over time, and they are more likely to be refractory to
behavior change (see Saavedra & Silverman, 2002;
Seligman & Ollendick, 1998). Thus, it is important that
assessment measures be able to discriminate among
the various comorbid disorders, particularly between
anxiety and depression.
The issue has not been studied with most of the
measures listed in the tables. It has been studied most
extensively with the RCMAS. In an early study, using a
multitrait–multimethod design (Campbell & Fiske,
1959), which allows for the simultaneous evaluation of
convergent and divergent validity, Wolfe et al. (1987)
correlated inpatient children’s RCMAS total scores (N
= 102; ages 6 to 16 years) with their scores from another scale, the State–Trait Anxiety Inventory for
Children (STAIC) and with depression (Children’s Depression Inventory), as well as with scores from a
teacher rating scale.
The convergent validity of the RCMAS was supported by a significant and positive correlation between the RCMAS total scores and the STAIC trait
scores, but the correlation between the RCMAS total
scores and the teacher-rated anxiety scores was not significant. However, the total scores on the RCMAS, the
STAIC–Trait, and the Children’s Depression Inventory
were all intercorrelated. Wolfe et al. (1987) noted that
these findings are due in part to the overlap of many of
the items contained on each rating scale; however, they
also discuss the findings in terms of the negative
affectivity construct. This construct has received increased attention over the years, and more is said about
it shortly.
Several studies have examined the ability of the
RCMAS to discriminate between youths with anxiety
disorders and youths with no disorders or youths with
other disorders. Mattison, Bagnato, and Brubaker
(1988) reported that in a sample of 8- to 12-year-old
outpatient boys, those diagnosed with overanxious disorder according to the DSM–III (American Psychiatric
Association, 1980) scored significantly higher than
boys with dysthymia or attention deficit disorder on the
Worry/Oversensitivity and Physiological factor scales
of the RCMAS. On the other hand, Hodges (1990) in
her examination of several child self-rating scales, including the RCMAS, in anxious, depressed, and conduct-disordered psychiatric inpatients (ages 6 to 13
years), reported that the RCMAS could not differentiate among these three groups. Perrin and Last (1992),
using a sample of 213 outpatient boys (ages 5 to 17
years), showed that the total score on the RCMAS,
along with each of its three subscale scores, differentiated boys with anxiety disorders from boys with no
disorders. However, the scales did not differentiate
between boys with an anxiety disorder and boys with
ADHD. Overall, these findings indicate that the ability of the RCMAS to discriminate among groups is
questionable.
A recent meta-analysis of 43 published studies by
Seligman, Ollendick, Langley, and Baldacci (2004)
supported this conclusion. A large effect size was found
when the RCMAS was used to compare youth with an
anxiety disorder to youth with no disorder, as was initially shown by others (e.g., Perrin & Last, 1992).
However, when comparing youths with anxiety disorders to those with other disorders, the picture was more
mixed. The RCMAS was found to be useful when discriminating between youths with anxiety disorders and
youths with oppositional and conduct problems but not
between youths with an affective disorder. Thus, its
discriminant validity was only partially supported.
In the interview section, we reported how diagnoses
obtained using the ADIS: C/P converged and diverged
as expected with ratings on the MASC (Wood et al.,
2002). Similar encouraging findings have appeared
with the Screen for Anxiety and Related Emotional
Disorders (SCARED; Birmaher et al., 1997, 1999). In
a sample of 341 consecutively referred children (M age
= 14.5 years old), Birmaher et al. (1997) found that
based on the items endorsed, children with anxiety disorders could be differentiated from children with nonanxiety psychiatric disorders, and children with pure
anxiety disorders could be differentiated from children
with depression and disruptive behavior problems.
Moreover, based on symptom reports on the SCARED,
children with different types of anxiety disorders could
be differentiated. Specifically, children with PD, GAD,
and SAD, respectively, could be differentiated from
children with other anxiety disorders.
Using a revised version of the SCARED, Birmaher
et al. (1999) conducted a replication of Birmaher et al.
(1997) using a sample of 190 outpatient children and
adolescents (ages 9 to 18 years) and 166 parents.
Youths with anxiety disorders could be differentiated
from youths with nonanxious psychiatric disorders
based on their self-ratings on this scale. Youths’ selfratings on the SCARED also differentiated youths with
anxiety disorders from youths with pure depression as
well as youths with disruptive behavior disorders.
Self-ratings on each of the SCARED’s subscales also
399
SILVERMAN AND OLLENDICK
were found to differentiate among several of the anxiety disorders based on the corresponding subscale.
That is, self-ratings on the Panic/Somatic subscale differentiated youths with PD from youths with other
anxiety disorders; self-ratings on the GAD and SOP
subscales differentiated youths with these respective
disorders from youths with other anxiety disorders.
Parent ratings on the Separation Anxiety subscale differentiated youths with SAD from youths with other
anxiety disorders.
The discriminant validity of youths’ and parents’
ratings of youths’ fears on the Revised Fear Survey
Schedule for Children (FSSC–R; Ollendick, 1983) was
evaluated by Weems, Silverman, Saavedra, Pina, and
Lumpkin (1999) using 120 children and adolescents
(ages 6 to 17 years) who met for a primary diagnosis of
SOP, simple or specific phobia of the dark or sleeping
alone, animals, or shots or doctors. Results indicated
that both the youth and parent completing the fear inventory were similarly useful in differentiating among
the specific types of phobias. Moreover, item analyses
indicated that youth-completed FSSC–R items could
discriminate among the different simple and specific
phobias but not SOP, and that parent-completed FSSC–R
items could discriminate not only the different simple
and specific phobias but also SOP. These findings build
on a previous study conducted by Last, Francis, and
Strauss (1989) who found that when using the FSSC–R,
clinically referred children with SAD, overanxious disorder, and school phobia could be discriminated qualitatively using an item analysis based on the most commonly reported fears.
A few studies have suggested that a scale’s discriminant validity varies depending on whether the
scale’s total score is used versus its subscale scores.
Lonigan, Carey, and Finch (1994), for example, found
the Worry/Oversensitivity subscale of the RCMAS to
distinguish between hospitalized youths with anxiety
disorders and youths with a major affective disorder;
the RCMAS Total score and the Fear/Concentration
and Physiological Anxiety subscales did not differentiate between the two groups. Similarly, whether Total
scale scores or subscale scores of the Childhood Anxiety Sensitivity Index (Silverman, Fleisig, Rabian, &
Peterson, 1991) are used influence the extent to which
anxiety and depression can be differentiated in youths
(e.g., Joiner et al., 2002; Weems, Hammond-Laurence,
Silverman, & Ferguson, 1997) as well as youths with
SOP versus other phobic and anxiety problems (Silverman, Goedhart, Barrett, & Turner, 2003).
In summary, the FSSC–R (completed by both child
and parent) appears to have preliminary support for
discriminating among different types of phobias. In addition, although the RCMAS may be used to differentiate youth with anxiety disorders from youth with no
disorders, caution is warranted in using the RCMAS to
400
differentiate youth with other disorders. There is some
evidence that the Worry/Oversensitivity subscale might
do a better job than the Total RCMAS scale or the other
two subscales in differentiating anxiety from other
constructs, particularly depression, but further research is needed to establish this point. The SCARED
and MASC have somewhat more positive supportive
evidence with regard to their ability to differentiate
anxiety from other disorders as well as to differentiate
among some of the anxiety disorders, though the
amount of research conducted is quite scant. Similar
concerns about differentiating between anxiety and depression have been raised as well with the CBCL’s Internalizing broadband scale and the Anxious/Depressed narrowband subscale in that recent research
has shown that both subscales appear to measure a
more global construct (i.e., negative affect) common to
both mood and anxiety disorders (Chorpita, Albano, &
Barlow, 1998; Chorpita & Daleiden, 2002).
In light of the mixed findings in rating scales’ abilities to discriminate anxiety disorders from other disorders, particularly depression, investigators have recently drawn on the tripartite model (e.g., Clark &
Watson, 1991) in developing scales that might perform
better with regard to discriminating between these two
constructs. According to the tripartite model, anxiety
and depression share a significant but nonspecific
component of generalized distress referred to as “negative affect.” Examples of negative affective symptoms
include anxious or depressed mood, poor concentration, sleep difficulties, and irritability. “Positive affect”
also needs to be considered, in that depression is characterized by low positive affect (e.g., not being able to
experience pleasure, cognitive and motor slowing).
Low positive affect is generally not a component of
anxiety; however, research with adult patients has
found an equally strong association between low positive affect and SOP (Watson, Clark, & Carey, 1988).
Finally, there is physiological hyperarousal, which was
originally hypothesized as a factor specific to anxiety
(Clark & Watson, 1991), but recent findings with youth
(Chorpita & Daleiden, 2002) have mirrored findings
with adults (Brown, Chorpita, & Barlow, 1998).
Namely, physiological hyperarousal shows the strongest relation with PD symptoms, followed by depression and then GAD symptoms.
Thus, youth self-rating scales, summarized in Table
3, drawn from the tripartite model (e.g., Clark & Watson, 1991) have been developed. These include the Revised Child Anxiety and Depression Scale (Chorpita,
Yim, Moffitt, Umemoto, & Francis, 2000), an adaptation of the Spence Children’s Anxiety Scale (Spence,
1997), the Positive and Negative Affect Scale for
Children (Laurent et al., 1999), the Physiological
Hyperarousal Scale for Children (Laurent, Catanzaro,
& Joiner, 2004), and the Affect and Arousal Scale
EVIDENCE-BASED ASSESSMENT OF ANXIETY
(Chorpita, Daleiden, Moffitt, Yim, & Umemoto, 2000;
Daleiden, Chorpita, & Lu, 2000). Findings obtained
thus far with each of these scales suggest that each of
them do a better job than the anxiety (or depression)
rating scales in discriminating between anxiety and depression. However, each of them also appears to be
able to accomplish certain tasks relative to others. As
Chorpita and Daleiden (2002) explained, the Affect
and Arousal Scale may be preferred for assessing youths’
general sensitivity to negative emotions and the experience of arousal. For assessing youths’ experience of
negative and positive emotions in a group of children
and adolescents, the Positive and Negative Affect
Scale for Children may be preferred. It appears then
that the complexities and divergent findings that exist
with the anxiety rating scales exist as well with the tripartite-based rating scales. Further research using multiple criterion variables assessed from multiple informants is needed to help clarify the tripartite model, and
the instruments designed to assess this model, in children and adolescents (Chorpita & Daleiden, 2002). In
addition, although these scales hold theoretical interest, it is important in the future for researchers to focus
greater attention on demonstrating the clinical relevance of this area of study, as Barlow et al. (2004) have
begun to demonstrate in their work with anxiety-disordered adults.
Screening and Diagnostic Accuracy
of Anxiety Assessment Measures
Related to the issue of discriminating between anxiety and other constructs and disorders is the issue of the
diagnostic accuracy of anxiety assessment measures
for screening purposes. Data on the sensitivity (the percentage of individuals who receive the diagnosis who
have been positively identified by the rating scale, or
true positives) and specificity (the percentage of individuals who do not receive the diagnosis and who are
not identified by the rating scale as anxious, or true
negatives) of the various rating scales are scarce, particularly so in non-White child and adolescent samples. Also scarce are the converse probabilities. Specifically, positive predictive power means that an
individual has the disorder given that he or she obtained a positive test result. Negative predictive power
reflects the probability of the individual not having the
disorder given a negative test result. Other than rating
scales, how well any of the other assessment methods
screen for youth anxiety has not been examined.
The little work that has been conducted with rating
scales suggests that scales designed to assess similar
anxiety constructs may yield different sensitivity and
specificity findings. A case in point is research using
the SASC–R (La Greca & Stone, 1993) and its adolescent version (Social Anxiety Schedule for Adolescents
[SAS–A]; La Greca & Lopez, 1998), and the SPAI–C
(Beidel, Turner, & Morris, 1995). The former is based
on the theoretical conceptualizations of social anxiety
of Watson and Friend (1969); the latter is based on the
specific symptomatology of SOP as described in
DSM–IV. Perhaps it is not surprising then that they
yield different findings, as they were not designed to
assess identical aspects of the social anxiety construct.
Thus, differences in the two measures’ classification correspondence have been observed (Epkins,
2002; Morris & Masia, 1998). Morris and Masia found
that only 54% of children (fourth through sixth grade)
identified by one measure as being above the cutoff
were so identified by both measures. Epkins similarly
found in her community sample that only 43% of those
identified as high on the SPAI–C were also high on the
SASC–R, but 80% of those identified as high on the
SASC–R were also high on the SPAI–C. InderbitzenNolan, Davies, and McKeon (2004) obtained similar
results using an older adolescent (13 to 17 years)
school sample in that 63% of those who scored high on
the SPAI–C also scored high on the SAS–A; 77% of
those scoring high on the SAS–A also scored high on
the SPAI–C.
Taken together, these studies’ findings indicate that
the two scales do not assess the identical construct of
social anxiety. Thus, if the purpose for using a self-rating scale of social anxiety is for identifying those adolescents who most likely meet DSM–IV diagnostic criteria for SOP, the current research evidence suggests
that the SPAI–C is likely to be a better selection instrument than the SAS–A. Given that these studies’ findings also show that some adolescents who meet for
SOP would be missed if only the SPAI–C was used, an
evidence-based assessment approach would suggest
the need to rely on another assessment method (e.g., an
interview schedule; Inderbitzen-Nolan et al., 2004).
On the other hand, if one was more interested in learning about adolescents’ fears of negative evaluation, the
SAS–A is the better choice.
Another avenue that needs to be pursued in the
screening area relates to determining the symptoms
that are most essential to a given anxiety diagnosis and
thus should be assessed first (as screeners) prior to assessing all the symptoms that comprise a given anxiety
disorder diagnosis. A couple of such studies have been
conducted in the GAD area. Tracey, Chorpita, Douban,
and Barlow (1997), for example, found that the symptom of restlessness/keyed up, when endorsed by youths
(ages 7 to 17 years), was predictive of youths receiving
a DSM–IV GAD diagnosis. The symptom of irritability, when endorsed by parents, also was predictive of
youths receiving a DSM–IV GAD diagnosis. The extent that these symptoms have specificity for GAD,
however, was not investigated (e.g., is irritability similarly predictive of major depressive disorder?).
401
SILVERMAN AND OLLENDICK
In a subsequent study, Pina, Silverman, Alfano,
and Saavedra (2002) evaluated not only the symptoms
comprising the uncontrollable excessive worry criteria
of DSM–IV GAD, but also the physiological symptoms
criteria, with separate evaluations conducted for children (N = 57; ages 6 to 11 years) and adolescents ages
(N = 54; ages 12 to 17 years). More specifically, the
diagnostic value of each symptom, operationalized
by the odds ratio—an index that takes into account
the symptom’s sensitivity, specificity, positive predictive power, and negative predictive power—was
determined.
Results indicated that uncontrollable excessive
worry in the area of “health of self” (as reported by
children and adolescents and parents of adolescents)
had the highest diagnostic value (i.e., the highest
odds ratio) relative to the average of all the other
symptoms comprising the uncontrollable excessive
worry criteria of DSM–IV GAD. In other words, this
symptom came up as highly specific or descriptive of
GAD; thus when endorsed as Yes, youths ended up
with a GAD diagnosis most of the time, and when endorsed No, youths did not end up with the diagnosis
most of the time. Similarly, uncontrollable excessive
worry in the area of “health of others” (as reported by
parents of children) had the highest diagnostic value
for GAD relative to the average value of the other
areas of uncontrollable excessive worry. The physiological symptoms associated with uncontrollable
excessive worry with the highest diagnostic value
were irritability, trouble sleeping (as reported by children), can’t sit still and relax, can’t concentrate (as
reported by adolescents), can’t concentrate (as reported by parents of children), and can’t sit still and
relax and trouble sleeping (as reported by parents of
adolescents).
If the findings of Tracey et al. (1997) and Pina et al.
(2002) are replicated, they would suggest a sequence
for inquiring about GAD symptoms (i.e., start with the
symptoms indicated previously as having highest diagnostic value, followed by those with average, and then
those with lower than average value). Diagnostic efficiency research has not been conducted for other anxiety disorders, except for posttraumatic stress (Lonigan,
Anthony, & Shannon, 1998).
In terms of screening for anxiety disorders in children and adolescents, the available self-rating scales
are likely to select more false positives than true positives (Costello & Angold, 1988). In other words,
youths identified as anxious at an initial screening are
likely not to be so identified the next time. In the study
cited previously by Mattison et al. (1988) using the
RCMAS, the sensitivity rates were found to be 41%,
36%, and 48%, depending on the cutoff technique employed. Using the STAIC, Hodges (1990) found the
scale to have a sensitivity of 42% and a specificity of
79% in inpatient children.
402
A potentially useful approach for developing empirically based screening methods is to use receiver operator characteristic curves. Studies that rely on receiver
operator characteristic curves focus on the area under
the curve (AUC) to estimate diagnostic accuracy
across the range of scores on individual scales. This approach is not dependent on prevalence (as is positive
predictive value) or on the cutoff scores (as are sensitivity and specificity; Rey, Morris-Yates, & Stanislaw,
1992). In general, AUC may be evaluated according to
the guidelines of Swets and Pickett (1982): .50 to .70
(low accuracy), .70 to .90 (moderate accuracy), and
greater than .90 (high accuracy).
The only study we could locate that used receiver
operator characteristic curves in the youth anxiety area
is Dierker et al. (2001). In this study, two anxiety
self-rating scales (RCMAS and MASC) and one depression self-rating scale (Center for Epidemiologic
Studies Depression Scale) were evaluated with respect
to each of their respective levels of diagnostic and
discriminative accuracy for detecting anxiety and depressive disorders in a school-based survey of ninthgrade children. Youths scoring at or above the 80th percentile on one or more of the three rating scales and a
random sample scoring below this threshold participated in follow-up ADIS–C interviews within 2
months of the screening sessions.
Results indicated that MASC scores were partially
successful in identifying certain anxiety disorders, but
only among girls. Specifically, among girls, only GAD
was significantly associated with the MASC composite scale; thus neither SOP nor specific phobia was significantly associated with the MASC composite scale.
Interestingly, among boys, the externalizing disorders
were found to show a marginally significant association with the MASC composite scale. The RCMAS
was found to be the least successful in identifying anxiety and depression. Moreover, only the MASC scale
was found to have moderate predictive power for anxiety comorbidities. Specifically, the MASC composite
scale had moderate predictive power for both boys and
girls with social or specific phobia (AUC boys = .73,
girls = .73) and for girls with SOP or GAD (AUC =
.80). Interestingly, both the RCMAS and the Center for
Epidemiologic Studies Depression Scale showed moderate accuracy only for predicting an externalizing disorder among boys.
Thus, the Dierker et al. (2001) findings suggest that
the MASC holds more promise than the RCMAS as a
screen, but this is only in terms of screening for GAD
in girls and anxiety comorbidities. That the MASC
composite scale was marginally associated with screening boys with externalizing disorders also requires further study. Nevertheless, the Dierker et al. study does,
in our view, represent a good launching pad for continued evaluative work on the MASC as a potential screen
for anxiety disorders.
EVIDENCE-BASED ASSESSMENT OF ANXIETY
Handling Multiple Informants’
Reports in the Assessment of Anxiety
Paralleling the general findings in the parent–youth
(dis)agreement research literature (e.g., Achenbach et
al., 1987), research findings in the anxiety area show
high parent–youth discordance. An earlier review by
Klein (1991) revealed high discordance in the dimensional assessment of a youth’s level of anxiety in that
parents and youths display low correspondence in their
scores on rating scales. High parent–youth discordance
also has been found in the categorical assessment of
youth anxiety using interview schedules. Here we
briefly summarize the categorical assessment research
findings given that this work is relatively recent. In a
four-community epidemiology survey of 9- to 17year-old youths and their parents (1,285 pairs; 247 of
the dyads were interviewed) using the Diagnostic Interview Schedule for Children (Version 2.3), P. S.
Jensen (1999) examined parent–youth agreement
along a variety of disorders, including anxiety. Of interest was the finding that although parents and youths
rarely agreed on the presence of diagnostic conditions,
regardless of diagnostic types, for ADHD, oppositional defiant disorder, and depressive disorder,
parents and youths were similar in that they excessively identified these disorders. In contrast, within the
overall category of anxiety disorders, differences were
found between parents and youths regarding which
disorders they were most likely to identify, with some
disorders (and symptoms) being excessively reported
by one source but not necessarily by the other source,
and vice versa. SAD, for example, has many overt
signs (e.g., clinging, refusal to attend school) that were
reported as highly distressing to some mothers but not
necessarily distressing to these mothers’ children. Conversely, mothers who suffered from their own feelings
of separation distress when separated from their children did not acknowledge the SAD as part of their
child’s clinical picture, but the children did.
Evidence for discrepant reports between parents
and youths has been reported recently using the ADIS:
C/P (Choudhury, Pimentel, & Kendall, 2003; Grills &
Ollendick, 2003; Rapee et al., 1994). Choudhury et al.,
for example, reported that in 45 children (ages 7 to 14
years) and parents who presented to a child anxiety disorders specialty clinic, levels of agreement were low
for all the major anxiety disorders. This was true for
both the primary or principal diagnosis as well as for
whether the anxiety diagnosis was determined to be
present anywhere in the child’s clinical picture. Grills
and Ollendick reported similar findings in a nonspecialty research clinic. Specifically, 165 children and
adolescents (ages 7 to 16 years) and their parents were
separately interviewed with the ADIS: C/P. Parent–youth agreement was low and fell below chance
occurrence (50%) for all disorders, but especially so
for the anxiety (range between 24% and 32%) and depressive disorders (8%). Youth characteristics such as
age, gender, and social desirability were not related
systematically to these disagreements, nor were family
variables such as conflict in the family or parental
psychopathology. Clinicians tended to agree more with
the reports of parents. Using 98 children and young adolescents (ages 7 to 14 years) referred to a childhood
anxiety specialty clinic and who met diagnostic criteria
for SAD, SOP, or GAD, Comer and Kendall (2004)
found that although there was high parent–youth discordance at the diagnostic level, it was not as high (i.e.,
there was stronger agreement) at the symptom level.
Parent–youth agreement was stronger for observable
than unobservable symptoms and weaker for schoolbased than nonschool-based symptoms.
Krain and Kendall (2000) examined the influence
of mother and father anxiety and mother and father depression on each of their respective ratings of their
child’s anxiety levels. Agreement between mother and
father ratings of child anxiety also was examined. Participants consisted of 239 youths (ages 7.5 to 15 years
old) and their parents (193 fathers, 238 mothers) from a
childhood anxiety specialty clinic. Results indicated
that both mothers and fathers rated their children as
significantly more anxious than the children rated
themselves, but mothers rated their children as more
anxious than did fathers. Both mother and father ratings of child anxiety were higher for older than for
younger children. In addition, although significant correlations were found between mother and child ratings
of anxiety for the total sample, younger children, boys,
and girls, significant correlations only were found between fathers’ and boys’ ratings. In terms of parents’
self-ratings of anxiety and depression, mothers’ selfratings of depression predicted mothers’ ratings of
child anxiety for the total sample, older children,
and girls. Fathers’ self-ratings of depression predicted fathers’ ratings of child anxiety only for girls. Overall, the Krain and Kendall study is an important first
step in examining agreement between mothers’ and
fathers’ ratings of their child’s anxiety. Further research is needed on the factors that influence the different patterns of findings obtained with mothers and
fathers.
Research findings are mixed on the influence of age
in parent–youth (dis)agreement as well as on the reliability of parent and youth reports about youth anxiety.
Rapee et al. (1994) found no difference in parent–youth agreement based on age, but there was significantly greater agreement between parents and
youths for diagnoses of SOP based on increasing age.
Choudhury et al. (2003) and Grills and Ollendick
(2003) similarly found no difference in parent–youth
agreement based on age. With regard to reliability,
Edelbrock (1985) found parent reports of internalizing
symptoms were more reliable than younger children’s
403
SILVERMAN AND OLLENDICK
(ages 6 to 9 years) self-reports. For older children (10
years and above), Edelbrock found children’s self-reports of their own internalizing symptoms were more
reliable than parents’ reports. Silverman and Eisen
(1992) did not find age differences in parent and youth
reliability reports about youth anxiety. Foley et al.
(2005) recently noted reasons for low parent–youth
anxiety agreement in community-based interview
studies, including (a) a “hierarchy of informant knowledge” in that the sources may agree that a child is anxious but may disagree on number of symptoms or on
whether the anxiety was best attributed to a generalized
source of worries or to specific phobic triggers; (b)
misinterpretation of diagnostic status in that symptoms
of anxiety are taken as symptoms of another disorder,
such as depression; (c) differential thresholds, standards, or time frames for identifying a deviation from
normal functioning; and (d) variable maternal rating
bias or maternal sensitivity.
In summary, mothers, fathers, and youths provide
useful and complementary information that relates to
meaningful, clinically credible diagnosis. However,
high disagreement, particularly at the diagnostic
level, for nonobservable symptoms and for schoolbased symptoms exists. Generally, both parent-only
and youth-only derived diagnoses are accompanied
by substantial specific impairment as well as overall
impairment. The influence of youth’s age on parent–(dis)agreement is uncertain as well. The influence that parental psychopathology, including anxiety
and depression, plays in leading to discrepancies also
is uncertain and may be different for mothers and
fathers.
In light of these findings, the general consensus in
the youth assessment area (P. S. Jensen, 1999), including anxiety (Comer & Kendall, 2004), is that mothers
and children—and fathers if possible—should be considered in assessing youth symptoms and diagnoses.
One is not necessarily more right or wrong than the
other(s). By carefully considering each source’s information, there is increased likelihood that no child or
adolescent is denied services (Comer & Kendall, 2004;
Foley et al., 2005). De Los Reyes and Kazdin (in
press), in a comprehensive review of the informant discrepancy literature in clinical child and adolescent psychology, further proposed that in addition to obtaining
information of youths’ problems from multiple informants, efforts should be made to collect information
from these informants about their perceptions of why
the youth is exhibiting these problems, as well as their
perceptions of the youth’s treatment. De Los Reyes and
Kazdin further discussed how gathering this type of information can serve as the basis for an assessment
model that can guide research and clinical practice to
help understand informant discrepancies in clinical
child and adolescent research.
404
Conclusions and Recommendations
Based on our review of the literature, it is obvious
that much has been accomplished on the journey to establish evidence-based assessments for anxiety and its
disorders in childhood and adolescence. Promising
structured and semistructured diagnostic interviews,
self-rating scales, direct behavioral observation systems, and self-monitoring forms have all been pioneered in recent years. Yet, it is equally obvious that
much remains to be accomplished in the years ahead.
We believe the review of the literature does allow us
to make tentative evidence-based recommendations
for use in assessing anxiety and its disorders in children and adolescents. Our recommendations are
framed around the main purposes and goals of assessment as well as around the additional issues we covered in this article. We emphasize that the recommendations are tentative, as considerable more research is
needed in all of these areas before we can truly say we
have an “evidence-built house.” Indeed, we wrestled
with whether we even should attempt to provide recommendations. The reason for our uncertainty was because we were unsure how much evidence is needed to
declare that a given assessment method is evidence
based for attaining a specific assessment goal. At this
point, a set of criteria or guidelines for what is an evidence-based assessment is simply not there. For example, how many studies, done by how many different investigators, using how many different types of samples
does one need to declare: This is an evidence-based
method for accomplishing Goal X? We hope this special section will serve as a catalyst toward developing
guidelines for an evidence-based assessment. We also
hope that researchers and clinicians will have a pragmatic attitude toward the assessment process of clinical child and adolescent problems, including anxiety,
in terms of being open to new methods, new instruments, and new ways of doing things, as further research evidence becomes available regarding what
works best. In the meantime, we delineate a tentative
set of evidence-based recommendations for assessing
anxiety and its disorders in children and adolescents.
Tentative Evidence-Based
Recommendations
1. To screen for anxiety disorders, rating scales
have been most frequently used. In comparing the use
of the RCMAS or the MASC, the MASC has stronger
evidence and so we therefore recommend this measure. The evidence is limited, however, to screening for
GAD in girls and anxiety comorbidities in girls and
boys (i.e., specific phobia and SOP). Until more evidence becomes available, we recommend that screening for anxiety disorders not rely simply on the MASC
EVIDENCE-BASED ASSESSMENT OF ANXIETY
but be accompanied by another assessment method,
such as a diagnostic interview schedule.
2. To screen for SOP, the evidence suggests using
the SPAI–C. However, as with the MASC, we recommend not relying simply on the SPAI–C but to use another assessment method as well. To assess youths’
fears of negative evaluation, the SAS–A is the better
choice. Overall, we recommend that one does not assume that scales designed to assess similar constructs
will identify the same group of youths.
3. There is some preliminary evidence of potential
screening items for GAD. However, this work requires
further replication and extension with other disorders
and samples.
4. To discriminate among youths with anxiety disorders and other disorders, the SCARED and MASC
currently have the most support. The FSSC–R, both
parent and child versions, has evidence of being able to
discriminate between cases of SOP, simple or specific
phobia of the dark or sleeping alone, animals, or shots
or doctors. In general, we recommend that scales’ factor scale scores be examined, not just total scores,
when trying to discriminate youths with anxiety disorders and other disorders. This is because different findings have emerged depending on whether total or factor scale scores are used (e.g., RCMAS and CASI).
The Worry/Oversensitivity factor scale appears able to
discriminate best relative to the Total scale and the
other two RCMAS factor scales.
5. To discriminate between anxiety and depression,
we recommend using scales specifically designed for
this purpose, such as the Revised Child Anxiety and
Depression Scale. Be aware that the different tripartite-based self-rating scales are not equivalent, and
each appears to capture differential aspects of the tripartite model.
6. To diagnose anxiety disorders in children and
adolescents, structured or semistructured clinical interviews lead to more reliable anxiety diagnoses than unstructured clinical interviews. The interview schedule
that has been used most frequently in the youth anxiety
area has been the ADIS: C/P. In research-based clinics,
the reliability and validity of anxiety diagnoses have
been documented using the ADIS: C/P. Further information about reliability when the interview is used in
community clinics and when diagnosing disorders of
varying base rates is needed. Also needed is a test of
the interview schedule’s treatment utility. On a clinical
level, however, it appears to us that having reliable and
valid anxiety diagnoses pave the way for successful
implementation of exposure-based CBT.
7. To identify and quantify anxious symptoms and
behaviors, interview schedules and rating scales have
been used most frequently in research, and we recommend these assessment methods for this purpose. Caution is needed in interpreting scores using these assessment methods, however, because scores obtained on
them are on an arbitrary metric, and their linkage to
meaningful or real-life events is lacking. Although one
might expect direct behavior observations would be
particularly useful in identifying and quantifying anxious symptoms or behaviors, there is actually only limited research, and basic psychometric information such
as retest reliability is lacking. For now, we primarily
recommend direct behavioral observations for clinical
formulation purposes (e.g., to obtain conceptually interesting information that might help in better understanding how the child or adolescent reacts when faced
with the feared object of event, how the parents interact
with their child in certain situations).
8. To identify and quantify controlling or maintaining variables of anxiety, we recommend the use of rating scales, direct observations, and self-monitoring
procedures. The limits noted under Number 6, however, regarding the arbitrary metrics of rating scales,
hold here as well. In addition, although direct observations and self-monitoring methods likely have clinical
utility, concerns exist regarding their feasibility, retest
reliability, and incremental validity.
9. To evaluate treatment outcome, diagnostic recovery rates using the ADIS interviews, the RCMAS,
and the CBCL have been the most widely used, and
they all have been found to be sensitive to change. If investigators opt to include some of the newer measures
(e.g., the MASC) or a specific anxiety measure (e.g.,
the SPAI–C) or a measure of a related construct (e.g.,
the FSSC–R), we still recommend the continued use of
the previously mentioned three measures. In this way,
the field can begin to have a set of standard measures
that will allow for improved cross-study comparisons.
It also will be a way to begin investigating what clinically significant change truly means on each of these
scales as the data accumulate across different studies.
10. Any of the assessment methods can be used to
evaluate moderators and mediators of treatment, but
ratings scales would appear to be the easiest and most
efficient way to do so. Research in this area is scarce,
and we recommend that more be done in this area following the guidelines of Kazdin and Nock (2003) and
Weersing and Weisz (2002).
11. We recommend careful consideration of multiple sources of information, particularly mother, father,
and child. Do not assume there is a gold standard, as
different perspectives likely reflect biases and varying
perceptions of what is in the best interest of the child or
adolescent. Further work on understanding the meaning of these discrepancies is needed.
12. We recommend not only multi-informant assessment but also multiresponse assessment, given that
research findings in the anxiety disorders area show
high discordance among the tripartite features of anxiety. More work is needed in understanding the discordance and in incorporating this understanding into the
existing assessment armamentarium and treatment de405
SILVERMAN AND OLLENDICK
cisions. Discordance among systems might suggest,
for example, behavioral versus cognitive interventions
(see, e.g., Eisen & Silverman, 1998). Evidence regarding the incremental validity of using multi-informant
assessment and multiresponse assessment procedures
also is needed.
References
Achenbach, T. M. (1991a). Manual for the Child Behavior Checklist
14–18 and 1991 profile. Burlington: University of Vermont,
Department of Psychiatry.
Achenbach, T. M. (1991b). Manual for the Teachers Report Form
and 1991 profile. Burlington: University of Vermont, Department of Psychiatry.
Achenbach, T. M., McConaughy, S. H., & Howell, C. T. (1987).
Child/adolescent behavioral and emotional problems: Implications of cross-informant correlations for situational specificity.
Psychological Bulletin, 101, 213–232.
Ambrosini, P. J. (2000). Historical development and present status of
the Schedule for Affective Disorders and Schizophrenia for
School-Age Children (K–SADS). Journal of the American
Academy of Child & Adolescent Psychiatry, 39, 49–58.
American Psychiatric Association. (1980). Diagnostic and statistical
manual of mental disorders (3rd ed.). Washington, DC: Author.
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC:
Author.
Angold, A., & Costello, J. E. (1999). Comorbidity. Journal of Child
Psychology and Psychiatry & Allied Disciplines, 40, 57–87.
Angold, A., & Costello, E. J. (2000). The Child and Adolescent Psychiatric Assessment (CAPA). Journal of the American Academy of Child & Adolescent Psychiatry, 39, 39–48.
Barlow, D. H. (2002). Anxiety and its disorders: The nature and
treatment of anxiety and panic (2nd ed.). New York: Guilford.
Barlow, D. H., Allen, L. B., & Choate, M. L. (2004). Towards a unified treatment for emotional disorders. Behavior Therapy, 35,
205–230.
Barrett, P. M. (1998). Evaluation of cognitive–behavioral group
treatments for childhood anxiety disorders. Journal of Clinical
Child Psychology, 27, 459–468.
Barrett, P. M., Dadds, M. R., & Rapee, R. M. (1996). Family treatment of childhood anxiety: A controlled trial. Journal of Consulting and Clinical Psychology, 64, 333–342.
Barrios, B. A., & Hartmann, D. P. (1997). Fears and anxieties. In E. J.
Mash & L. G. Terdal (Eds.), Assessment of childhood disorders
(3rd ed., pp. 230–327). New York: Guilford.
Beck, A. T. (1967). Depression: Clinical, experimental, and theoretical aspects. New York: Harper & Row.
Beidel, D. C., Neal, A. M., & Lederer, A. S. (1991). The feasibility
and validity of a daily diary for the assessment of anxiety in
children. Behavior Therapy, 22, 505–517.
Beidel, D. C., Turner, S. M., & Morris, T. L. (1995). A new inventory
to assess childhood social anxiety and phobia: The Social Phobia and Anxiety Inventory for Children. Psychological Assessment, 7, 73–79.
Beidel, D. C., Turner, S. M., & Morris, T. L. (1999). Psychopathology of childhood social phobia. Journal of the American
Academy of Child & Adolescent Psychiatry, 38, 643–650.
Beidel, D. C., Turner, S. M., & Morris, T. L. (2000). Behavioral treatment of childhood social phobia. Journal of Consulting and
Clinical Psychology, 68, 1072–1080.
Biederman, J., Faraone, S., Mick, E., & Lelon, E. (1995). Psychiatric
comorbidity among referred juveniles with major depression:
Fact or artifact? Journal of the American Academy of Child &
Adolescent Psychiatry, 34, 579–590.
406
Bierman, K. L., & McCauley, E. (1987). Children’s descriptions of
their peer interactions: Useful information for clinical child assessment. Journal of Clinical Child Psychology, 16, 9–18.
Bird, H. R., Canino, G., Rubio-Stipec, M., & Ribera, J. C. (1987).
Further measures of the psychometric properties of the Children’s Global Assessment Scale. Archives of General Psychiatry, 44, 821–824.
Birmaher, B., Brent, D. A., Chiappetta, L., Bridge, J., Monga, S., &
Baugher, M. (1999). Psychometric properties of the Screen for
Child Anxiety Related Emotional Disorders (SCARED): A
replication study. Journal of the American Academy of Child &
Adolescent Psychiatry, 38, 1230–1236.
Birmaher, B., Khetarpal, S., Brent, D. A., Cully, M., Balach, L.,
Kaufman, J., et al. (1997). The Screen for Child Anxiety Related Emotional Disorders (SCARED): Scale construction and
psychometric characteristics. Journal of the American Academy of Child & Adolescent Psychiatry, 36, 545–553.
Blanton, H., & Jaccard, J. (in press). Arbitrary metrics in psychology. American Psychologist.
Boer, F., & Lindhout, I. (2001). Family and genetic influences: Is
anxiety “all in the family”? In W. K. Silverman & P. D. A.
Treffers (Eds.), Anxiety disorders in children and adolescents:
Research, assessment, and intervention (pp. 235–254). Cambridge, England: Cambridge University Press.
Bongers, I. L., Koot, H. M., van der Ende, J., & Verhulst, F. C.
(2003). The normative development of child and adolescent
problem behavior. Journal of Abnormal Psychology, 112,
179–192.
Brown, T. A., Chorpita, B. F., & Barlow, D. H. (1998). Structural relationships among dimensions of the DSM-IV anxiety and
mood disorders and dimensions of negative affect, positive affect, and autonomic arousal. Journal of Abnormal Psychology,
107, 179–192.
Brown, T. A., Di Nardo, P. A., & Barlow, D. H. (1994). Anxiety Disorders Interview Schedule for DSM–IV (ADIS–IV). San Antonio, TX: Psychological Corporation/Graywind.
Campbell D. T., & Fiske, D. W. (1959). Convergent and discriminant
validation by the multitrait–multimethod matrix. Psychological
Bulletin, 56, 81–105.
Chorpita, B. F., Albano, A. M., & Barlow, D. H. (1998). The structure of negative emotions in a clinical sample of children and
adolescents. Journal of Abnormal Psychology, 107, 74–85.
Chorpita, B. F., & Daleiden, E. L. (2002). Tripartite dimensions of
emotion in a child clinical sample of children and adolescents.
Journal of Consulting and Clinical Psychology, 107, 74–85.
Chorpita, B. F., Daleiden, E. L., Moffitt, C., Yim, L., & Umemoto,
L. A. (2000). Assessment of tripartite factors of emotion in children and adolescents: I. Structural validity and normative data
of an affect and arousal scale. Journal of Psychopathology and
Behavioral Assessment, 22, 141–160.
Chorpita, B. F., Tracey, S. A., Brown, T. A., Collica, T. J., & Barlow,
D. H. (1997). Assessment of worry in children and adolescents:
An adaptation of the Penn State Worry Questionnaire. Behaviour Research and Therapy, 35, 569–581.
Chorpita, B. F., Yim, L., Moffitt, C., Umemoto, L. A., & Francis, S.
E. (2000). Assessment of symptoms of DSM–IV anxiety and
depression in children: A revised child anxiety and depression
scale. Behaviour Research and Therapy, 38, 835–855.
Choudhury, M. S., Pimentel, S. S., & Kendall, P. C. (2003). Childhood anxiety disorders: Parent–child (dis)agreement using a
structured interview for the DSM–IV. Journal of the American
Academy of Child & Adolescent Psychiatry, 42, 957–964.
Clark, L. A., & Watson, D. (1991). Tripartite model of anxiety and
depression: Psychometric evidence and taxonomic implications. Journal of Abnormal Psychology, 100, 316–336.
Cobham, V. E., Dadds, M. R., & Spence, S. H. (1998). The role of parental anxiety in the treatment of childhood anxiety. Journal of
Consulting and Clinical Psychology, 66, 893–905.
EVIDENCE-BASED ASSESSMENT OF ANXIETY
Cobham, V., Dadds, M., & Spence, S. (1999). Anxious children and
their parents: What do they expect? Journal of Clinical Child
Psychology, 28, 220–231.
Comer, J. S., & Kendall, P. C. (2004). A symptom-level examination
of parent–child agreement in the diagnosis of anxious youth.
Journal of the American Academy of Child & Adolescent Psychiatry, 43, 878–886.
Connors, C. K. (1990). Manual for Connor’s Rating Scales. Toronto,
Ontario, Canada: Multi-Health Systems.
Cornwall, E., Spence, S. H., & Schotte, D. (1996). The effectiveness
of emotive imagery in the treatment of darkness phobia in children. Behaviour Change, 13, 223–229.
Costello, E. J., & Angold, A. (1988). Scales to assess child and adolescent depression: Checklists, screens, and nets. Journal of
the American Academy of Child & Adolescent Psychiatry, 27,
726–737.
Dadds, M., Barrett, P., Rapee, R., & Ryan, S. (1996). Family process
and child anxiety and aggression: An observational analysis.
Journal of Abnormal Child Psychology, 24, 715–734.
Dadds, M. R., Perrin, S., & Yule, W. (1998). Social desirability and
self-reported anxiety in children: An analysis of the RCMAS
Lie scale. Journal of Abnormal Child Psychology, 26, 311–317.
Daleiden, E., Chorpita, B. F., & Lu, W. (2000). Assessment of tripartite factors of emotion in children and adolescents: II. Concurrent
validity of the affect and arousal scales for children. Journal of
Psychopathology and Behavioral Assessment, 22, 161–182.
Davis, T. E., III., & Ollendick, T. H. (2005). A critical review of empirically supported treatments for specific phobia in children:
Do efficacious treatments address the components of a phobic
response? Clinical Psychology: Science and Practice, 12,
144–160.
De Los Reyes, A., & Kazdin, A. E. (in press). Informant discrepancies in the assessment of childhood psychopathology: A critical
review, theoretical framework, and recommendations for further study. Psychological Bulletin.
Dierker, L. C., Albano, A. M., Clarke, G. N., Heimberg, R. G., Kendall, P. C., Merikangas, K. R., et al. (2001). Screening for anxiety
and depression in early adolescence. Journal of the American
Academy of Child & Adolescent Psychiatry, 40, 929–936.
Edelbrock, C. S. (1984). Developmental considerations. In T. H. Ollendick & M. Hersen (Eds.), Child behavioral assessment: Principles and procedures (pp. 20–37). Elmsford, NY: Pergamon.
Edelbrock, C. (1985). Age differences in the reliability of the psychiatric interview of the child. Child Development, 56, 265–275.
Eisen, A. R., & Silverman, W. K. (1998). Prescriptive treatment for
generalized anxiety disorder in children. Behavior Therapy, 29,
105–121.
Epkins, C. C. (2002). A comparison of two self-report measures of
children’s social anxiety in clinical and community samples.
Journal of Clinical Child and Adolescent Psychology, 31,
69–79.
Ferrell, C., Beidel, D., & Turner, S. (2004). Assessment and treatment of socially phobic children: A cross-cultural comparison.
Journal of Clinical Child and Adolescent Psychology, 33,
260–268.
Flannery-Schroeder, E. C., & Kendall, P. C. (2000). Group and individual cognitive–behavioral treatments for youth with anxiety
disorders: A randomized clinical trial. Cognitive Therapy and
Research, 24, 251–278.
Foley, D. L., Rutter, M., Angold, A., Pickles, A., Maes, H. M.,
Silberg, J. L., et al. (2005). Making sense of informant disagreement for overanxious disorder. Journal of Anxiety Disorders,
19, 193–210.
Gallagher, H. M., Rabian, B. A., & McCloskey, M. S. (2004). A brief
group cognitive–behavioral intervention for social phobia in
childhood. Journal of Anxiety Disorders, 18, 459–479.
Ginsburg, G. S., & Drake, K. L. (2002). School-based treatment for
anxious African-American adolescents: A controlled pilot
study. Journal of the American Academy of Child & Adolescent
Psychiatry, 41, 768–775.
Glennon, B., & Weisz, J. R. (1978). An observational approach to the
assessment of anxiety in young children. Journal of Consulting
and Clinical Psychology, 46, 1246–1257.
Goldfried, M. R., & Wolfe, B. E. (1998). Toward a more clinically
valid approach to therapy research. Journal of Consulting and
Clinical Psychology, 66, 143–150.
Goodman, W. K., Price, L. H., Rasmussen, S. A., Mazure, C.,
Fleischmann, R. L., Hill, C. L., et al. (1989). The Yale–Brown
Obsessive–Compulsive Scale: I. Development, use, and reliability. Archives of General Psychiatry, 46, 1006–1011.
Gresham, F. M., & Elliott, S. N. (1990). Social Skill Rating System.
Circle Pines, MN: American Guidance Service.
Grills, A. E., & Ollendick, T. H. (2003). Multiple informant agreement and the Anxiety Disorders Interview Schedule for Parents
and Children. Journal of the American Academy of Child & Adolescent Psychiatry, 42, 30–40.
Hagborg, W. J. (1991). The Revised Children’s Manifest Anxiety
Scale and social desirability. Educational and Psychological
Measurement, 51, 423–427.
Hamilton, D. I., & King, N. J. (1991). Reliability of a behavioral
avoidance test for the assessment of dog phobic children. Psychological Reports, 69, 18.
Hayward, C., Varady, S., Albano, A. M., Thienemann, M., Henderson, L., & Schatzberg, A. F. (2000). Cognitive–behavioral
group therapy for social phobia in female adolescents: Results
of a pilot study. Journal of the American Academy of Child &
Adolescent Psychiatry, 39, 721–726.
Herjanic, B., & Reich, W. (1982). Development of a structured psychiatric interview: Agreement between child and parent on individual
symptoms. Journal of Abnormal Child Psychology, 10, 307–324.
Heyne, D., King, N. J., Tonge, B. J., Rollings, S., Young, D., Pritchard,
M., et al. (2002). Evaluation of child therapy and caregiver training in the treatment of school refusal. Journal of the American
Academy of Child & Adolescent Psychiatry, 41, 687–695.
Hodges, K. (1990). Depression and anxiety in children: A comparison of self-report questionnaires to clinical interview. Psychological Assessment: A Journal of Consulting and Clinical Psychology, 2, 376–381.
Hudson. J. L., & Rapee, R. M. (2002). Parent–child interactions in
clinically anxious children and their siblings. Journal of Clinical Child and Adolescent Psychology, 31, 548–555.
Inderbitzen-Nolan, H., Davies, C. A., & McKeon, N. D. (2004). Investigating the construct validity of the SPAI–C: Comparing the
sensitivity and specificity of the SPAI–C and the SAS–A. Journal of Anxiety Disorders, 18, 547–560.
Jensen, B. J., & Haynes, S. N. (1986). Self-report questionnaires and
inventories. In A. R. Ciminero, K. S. Calhoun, & H. E. Adams
(Eds.), Handbook of behavioral assessment (pp. 150–175).
New York: Wiley.
Jensen, P. S. (1999). Parent and child contributions to diagnosis of
mental disorders: Are both informants always necessary? Journal of the American Academy of Child & Adolescent Psychiatry, 38, 1569–1579.
Johnston, C., & Murray, C. (2003). Incremental validity in the psychological assessment of children and adolescents. Psychological Assessment, 15, 496–507.
Joiner, T. E. (1996). The relations of thematic and nonthematic childhood depression measures to defensiveness and gender. Journal
of Abnormal Child Psychology, 24, 803–813.
Joiner, T. E., Jr., Schmidt, N. B., Schmidt, K. L., Laurent, J., Catanzaro, S. J., Perez, M., et al. (2002). Anxiety sensitivity as a
specific and unique marker of anxious symptoms in youth psychiatric inpatients. Journal of Abnormal Child Psychology, 30,
167–175.
Jones, S. H., Thornicroft, G., & Coffey, M. (1995). A brief mental
health outcome scale–Reliability and validity of the Global As-
407
SILVERMAN AND OLLENDICK
sessment of Functioning (GAF). British Journal of Psychiatry,
166, 654–659.
Kazdin, A. E. (1990). Assessment of childhood depression. In A. M.
La Greca (Ed.), Through the eyes of the child (pp. 189–233).
Needham Heights, MA: Allyn & Bacon.
Kazdin, A. E. (1999). The meanings and measurement of clinical
significance. Journal of Consulting and Clinical Psychology,
67, 332–339.
Kazdin, A. E., & Nock, M. K. (2003). Delineating mechanisms of
change in child and adolescent therapy: Methodological issues
and research recommendations. Journal of Child Psychology
and Psychiatry, 44, 1116–1129.
Kearney, C. A. (2002). Identifying the function of school refusal behavior: A revision of the School Refusal Assessment Scale.
Journal of Psychopathology and Behavioral Assessment, 24,
235–245.
Kearney, C. A., & Silverman, W. K. (1993). Measuring the function
of school refusal behavior: The School Refusal Assessment
Scale. Journal of Clinical Child Psychology, 22, 85–96.
Kendall, P. C. (1984). Social cognition and problem solving: A developmental and child–clinical interface. In B. Gholson & T. L.
Rosenthal (Eds.), Applications of cognitive–developmental theory (pp. 115–148). New York: Academic.
Kendall, P. C. (1994). Treating anxiety disorders in youth: Results of
a randomized clinical trial. Journal of Consulting and Clinical
Psychology, 62, 100–110.
Kendall, P. C., Cantwell, D. P., & Kazdin, A. E. (1989). Depression
in children and adolescents: Assessment issues and recommendations. Cognitive Therapy and Research, 13, 109–146.
Kendall, P. C., Flannery-Schroeder, E., Panichelli-Mindel, S., Southam-Gerow, M., Henin, A., & Warman, M. (1997). Therapy for
youth with anxiety disorders: A second randomized clinical
trial. Journal of Consulting and Clinical Psychology, 65,
366–380.
Kendall, P. C., & Grove, W. M. (1988). Normative comparisons in
therapy outcome. Behavioral Assessment, 10, 147–158.
King, N. J. (1994). Physiological assessment. In T. H. Ollendick, N.
J. King, & W. Yule (Eds.), International handbook of phobic
and anxiety disorders in children (pp. 365–380). New York:
Plenum.
King, N. J., Tonge, B. J., Heyne, D., Pritchard, M., Rollings, S.,
Young, D., et al. (1998). Cognitive–behavioral treatment of
school-refusing children: A controlled evaluation. Journal of
the American Academy of Child & Adolescent Psychiatry, 37,
395–403.
Klein, R. G. (1991). Parent–child agreement in clinical assessment
of anxiety and other psychopathology: A review. Journal of
Anxiety Disorders, 5, 187–198.
Kornhaber, R. C., & Schroeder, H. E. (1975). Importance of model
similarity on extinction of avoidance behavior in children. Journal of Consulting and Clinical Psychology, 43, 601–607.
Kovacs, M., & Devlin, B. (1998). Internalizing disorders. Journal
of Child Psychology, Psychiatry & Allied Disciplines, 39,
47–63.
Krain, A. L., & Kendall, P. C. (2000). The role of parental emotional
distress in parent report of child anxiety. Journal of Clinical
Child Psychology, 29, 328–335.
La Greca, A. M., Dandes, S. K., Wick, P., Shaw, K., & Stone, W. L.
(1988). Development of the Social Anxiety Scale for Children:
Reliability and concurrent validity. Journal of Clinical Child
Psychology, 17, 84–91.
La Greca, A. M., & Lopez, N. (1998). Social anxiety among adolescents: Linkages with peer relations and friendships. Journal of
Abnormal Child Psychology, 26, 83–94.
La Greca, A. M., & Stone, W. L. (1993). Social Anxiety Scale for
Children–Revised: Factor structure and concurrent validity.
Journal of Clinical Child Psychology, 22, 7–27.
408
Lang, P. J. (1968). Fear reduction and fear behavior. In J. Schlein
(Ed.), Research in psychotherapy (pp. 85–103). Washington,
DC: American Psychological Association.
Lang, P. J., & Cuthbert, B. N. (1984). Affective information processing and the assessment of anxiety. Journal of Behavioral Assessment, 6, 369–395.
Last, C. G., Francis, G., & Strauss, C. C. (1989). Assessing fears in
anxiety-disordered children with the Revised Fear Survey
Schedule for Children (FSSC–R). Journal of Clinical Child
Psychology, 18, 137–141.
Last, C. G., Hansen, C., & Franco, N. (1998). Cognitive–behavioral
treatment of school phobia. Journal of American Academy of
Child & Adolescent Psychiatry, 37, 404–411.
Laurent, J., Catanzaro, S. J., & Joiner, T. E., Jr. (2004). Development
and preliminary validation of the Physiological Hyperarousal
Scale for Children. Psychological Assessment, 16, 373–380.
Laurent, J., Catanzaro, S., Joiner, T. E., Jr., Rudolph, K. D., Potter, K.
I., Lambert, S., et al. (1999). A measure of positive and negative
affect for children: Scale development and preliminary validation. Psychological Assessment, 11, 326–338.
Leitenberg, H., Yost, L. W., & Carroll-Wilson, M. (1986). Negative
cognitive errors in children: Questionnaire development, normative data, and comparisons between children with and without self-reported symptoms of depression, low self-esteem, and
evaluation anxiety. Journal of Consulting and Clinical Psychology, 54, 528–536.
Lilienfeld, S. O., Wood, J. M., & Garb, H. N. (2000). The scientific
status of projective techniques. Psychological Science in the
Public Interest, 1, 27–66.
Loeber, R., Green, S. M., & Lahey, B. B. (1990). Mental health professionals’ perception of the utility of children, mothers, and
teachers as informant on child psychopathology. Journal of
Clinical Child Psychology, 19, 136–143.
Lonigan, C. J., Anthony, J. L., & Shannon, M. P. (1998). Diagnostic
efficacy of posttraumatic symptoms in children exposed to disaster. Journal of Clinical Child Psychology, 27, 255–267.
Lonigan, C. J., Carey, M. P., & Finch, A. J., Jr. (1994). Anxiety and
depression in children and adolescents: Negative affectivity and
the utility of self-reports. Journal of Consulting and Clinical
Psychology, 62, 1000–1008.
Manassis, K., Mendlowitz, S. L., Scapillato, D., Avery, D., Fiksenbaum, L., Freire, M., et al. (2002). Group and individual cognitive–behavioral therapy for childhood anxiety disorders. A randomized trial. Journal of the American Academy of Child &
Adolescent Psychiatry, 41, 1423–1430.
March, J. S., Parker, J. D. A., Sullivan, K., Stallings, P., & Conners,
K. (1997). The Multidimensional Anxiety Scale for Children
(MASC): Factor, structure, reliability, and validity. Journal of
the American Academy of Child & Adolescent Psychiatry, 36,
554–565.
March, J. S., Sullivan, K., & James, P. (1999). Test–retest reliability
of the multidimensional anxiety scale for children. Journal of
Anxiety Disorders, 13, 349–358.
Masia, C. L., Klein, R. G., Storch, E. A., & Corda, B. (2001).
School-based behavioral treatment for social anxiety disorder
in adolescents: Results of a pilot study. Journal of the American
Academy of Child & Adolescent Psychiatry, 40, 780–786.
Mattison, R. E., Bagnato, S. J., & Brubaker, B. M. (1988). Diagnostic utility of the Revised Children’s Manifest Anxiety Scale in
children with DSM–III anxiety disorders. Journal of Anxiety
Disorders, 2, 147–155.
Melamed B. G., & Siegel, L. J. (1975). Reduction of anxiety in children facing hospitalization and surgery by use of filmed modeling. Journal of Counseling and Clinical Psychology, 43,
511–521.
Mendlowitz, S. L., Manassis, K., Bradley, S., Scapillato, D.,
Miezitis, S., & Shaw, B. F. (1999). Cognitive–behavioral group
EVIDENCE-BASED ASSESSMENT OF ANXIETY
treatments in childhood anxiety disorders: The role of parental
involvement. Journal of the American Academy of Child & Adolescent Psychiatry, 38, 1223–1229.
Mitchell, S. K. (1979). Interobserver agreement, reliability, and
generalizability of data collected in observational studies. Psychological Bulletin, 86, 376–390.
Moore, P. S., Whaley, S. E., & Sigman, M. (2004). Interactions between mothers and children: Impacts of maternal and child anxiety. Journal of Abnormal Psychology, 113, 471–476.
Morris, T. L., & Masia, C. L. (1998). Psychometric evaluation of the
Social Phobia and Anxiety Inventory for Children: Concurrent
validity and normative data. Journal of Clinical Child Psychology, 27, 452–458.
Muris, P., Meesters, C., & van Melick, M. (2002). Treatment of
childhood anxiety disorders: A preliminary comparison between cognitive–behavioral group therapy and a psychological
placebo intervention. Journal of Behavior Therapy and Experimental Psychiatry, 33, 143–158.
Muris, P., Merckelbach, H., Holdrinet, I., & Sijsenaar, M. (1998).
Treating phobic children: Effects of EMDR versus exposure. Journal of Consulting and Clinical Psychology, 66,
193–198.
Muris, P., Merckelbach, H., Mayer, B., & Prins, E. (2000). How serious are common childhood fears? Behaviour Research and
Therapy, 38, 217–228.
Murphy, C. M., & Bootzin, R. R. (1973). Active and passive participation in the contact desensitization of snake fear in children.
Behavior Therapy, 4, 203–211.
Naglieri, J. A., LeBuffe, P. A., & Pfeiffer, S. I. (1993). The Devereux
Behavior Rating Scale–School Form. San Antonio, TX: Psychological Corporation.
Nauta, M. H., Scholing, A., Emmelkamp, P. M. G., & Minderaa, R.
B. (2003). Cognitive–behavioral therapy for children with anxiety disorders in a clinical setting: No additional effect of a cognitive parent training. Journal of the American Academy of
Child & Adolescent Psychiatry, 42, 1270–1278.
Nelson-Gray, R. O. (2003). Treatment utility of psychological assessment. Psychological Assessment, 15, 521–531.
Ohan, J. L., Myers, K., & Collett, B. R. (2002). Ten-year review of
rating scales: IV. Scales affecting trauma and its effects. Journal
of the American Academy of Child & Adolescent Psychiatry,
12, 1401–1422.
Ollendick, T. H. (1983). Reliability and validity of the Revised Fear
Survey Schedule for Children (FSSC–R). Behaviour Research
and Therapy, 21, 395–399.
Ollendick, T. H. (1995). Cognitive behavioral treatment of panic disorder with agoraphobia in adolescents: A multiple baseline design analysis. Behavior Therapy, 26, 517–531.
Ollendick, T. H. (1999). Empirically supported assessment for clinical practice: Is it possible? Is it desirable? The Clinical Psychologist, 52, 1–2.
Ollendick, T. H. (2003). The role of assessment in evidence-based
practice. Clinical Child and Adolescent Psychology Newsletter,
18, 1–2.
Ollendick, T. H., Grills, A. E., & King, N. J. (2001). Applying developmental theory to the assessment and treatment of childhood
disorders: Does it make a difference? Clinical Psychology and
Psychotherapy, 8, 304–314.
Ollendick, T. H., & Hersen, M. (1984). An overview of child behavioral assessment. In T. H. Ollendick & M. Hersen (Eds.), Child
behavioral assessment: Principles and procedures (pp. 3–19).
New York: Pergamon.
Ollendick, T. H., & Hersen, M. (1993). Child and adolescent behavioral
assessment. In T. H. Ollendick & M. Hersen (Eds.), Handbook of
childandadolescentassessment(pp.3–14).NewYork:Pergamon.
Ollendick, T. H., & King, N. J. (1991). Developmental factors in
child behavioral assessment. In P. R. Martin (Ed.), Handbook of
behavior therapy and psychological science: An integrative approach (pp. 57–72). New York: Pergamon.
Ollendick, T. H., & King, N. J. (1998). Empirically supported treatments for children with phobic and anxiety disorders. Journal
of Clinical Child Psychology, 27, 156–167.
Ollendick, T. H., King, N. J., & Frary, R. B. (1989). Fears in children
and adolescents: Reliability and generalizability across gender,
age, and nationality. Behaviour Research and Therapy, 27,
19–26.
Ollendick, T. H., & Vasey, M. W. (1999). Developmental theory and
the practice of clinical child psychology. Journal of Clinical
Child Psychology, 28, 457–466.
Ost, L. G., Svensson, L., Hellstrom, K., & Lindwall, R. (2001).
One-session treatment of specific phobias in youths: A randomized clinical trial. Journal of Consulting and Clinical Psychology, 69, 814–824.
Perrin, S., & Last, C. G. (1992). Do childhood anxiety measures
measure anxiety? Journal of Abnormal Child Psychology, 20,
567–578.
Pina, A. A., Silverman, W. K., Alfano, C. A., & Saavedra, L. M.
(2002). Diagnostic efficiency of symptoms in the diagnosis of
DSM–IV: Generalized anxiety disorder in youth. Journal of
Child Psychology and Psychiatry, 43, 959–967.
Pina, A. A., Silverman, W. K., Saavedra, L. M., & Weems, C. F.
(2001). An analysis of the RCMAS Lie scale in a clinic sample of anxious children. Journal of Anxiety Disorders, 15,
443–457.
Prins, P. J. M. (2001). Affective and cognitive processes and the development and maintenance of anxiety and its disorders. In W.
K. Silverman & P. D. A. Treffers (Eds.), Anxiety disorders in
children and adolescents: Research, assessment, and intervention (pp. 23–44). Cambridge, England: Cambridge University
Press.
Prinz, R. J., Foster, S., Kent, R. N., & O’Leary, K. D. (1979).
Multivariate assessment of conflict in distressed and nondistressed mother–adolescent dyads. Journal of Applied Behavior
Analysis, 12, 691–700.
Rachman, S. J., & Hodgson, R. I. (1974). Synchrony and desynchrony in fear and avoidance. Behaviour Research and Therapy, 12, 311–318.
Rapee, R. M., Barrett, P. M., Dadds, M. R., & Evans, L. (1994). Reliability of the DSM–III–R childhood anxiety disorders using
structured interview: Interrater and parent–child agreement.
Journal of the American Academy of Child & Adolescent Psychiatry, 33, 984–992.
Reich, W. (2000). Diagnostic Interview for Children and Adolescents (DICA). Journal of the American Academy of Child &
Adolescent Psychiatry, 39, 59–66.
Research Units on Pediatric Psychopharmacology Anxiety Study
Group. (2002). The Pediatric Anxiety Rating Scale (PARS):
Development and psychometric properties. Journal of the
American Academy of Child & Adolescent Psychiatry, 41,
1061–1069.
Rey, J. M., Morris-Yates, A., & Stanislaw, H. (1992). Measuring the
accuracy of diagnostic tests using receiver operating characteristics (ROC) analysis. International Journal of Methods in Psychiatric Research, 2, 39–50.
Reynolds, C. R., & Kamphus, R. W. (1992). Behavioral Assessment
Scale for Children. Circle Pines, MN: American Guidance Service.
Reynolds, C. R., & Richmond, B. O. (1985). Revised Children’s
Manifest Anxiety Scale: Manual. Los Angeles: Western Psychological Services.
Ronan, K. R., Kendall, P. C., & Rowe, M. (1994). Negative affectivity in children: Development and validation of a selfstatement questionnaire. Cognitive Therapy and Research, 18,
509–528.
409
SILVERMAN AND OLLENDICK
Saavedra, L. M., & Silverman, W. K. (2002). Classification of anxiety disorders in children: What a difference two decades make.
International Review of Psychiatry, 14, 87–100.
Sandler, I., & Ayers, T. (1990, August). The Children’s Coping Strategies Checklist. Symposium conducted at the meeting of the
American Psychological Association, Boston.
Sarason, S., Davidson, K., Lighthall, F., & Waite, R. (1958). A test
anxiety scale for children. Child Development, 29, 105–113.
Scahill, L., Riddle, M. A., McSwiggin-Hardin, M., Ort, S. I., King,
R. A., Goodman, W. et al. (1997). Children’s Yale–Brown Obsessive Compulsive Scale: reliability and validity. Journal of
the American Academy of Child & Adolescent Psychiatry, 36,
844–852.
Schludermann, E., & Schludermann, S. (1970). Replicability of factors in children’s report of parent behavior (CRPBI). Journal of
Psychology: Interdisciplinary and Applied, 76, 239–249.
Schniering, C. A., & Rapee, R. M. (2002). Development and validation of a measure of children’s automatic thoughts: The Children’s Automatic Thoughts Scale. Behaviour Research and
Therapy, 40, 1091–1109.
Sechrest, L., McKnight, P., & McKnight, K. (1996). Calibration of
measures for psychotherapy outcome studies. American Psychologist, 51, 1065–1071.
Seligman, L. D., & Ollendick, T. H. (1998). Comorbidity of anxiety
and depression in children and adolescents: An integrative review. Clinical Child and Family Psychology Review, 1,
125–144.
Seligman, L. D., Ollendick, T. H., Langley, A. K., & Baldacci, H. B.
(2004). The utility of measures of child and adolescent anxiety:
A meta-analytic review of the RCMAS, STAIC, and CBCL.
Journal of Clinical Child and Adolescent Psychology, 33,
557–565.
Shaffer, D., Fisher, P., Lucas, C., Dulcan, M. K., & Schwab-Stone,
M. E. (2000). NIMH Diagnostic Interview Schedule for
Children Version IV (NIMH DISC–IV): Description, differences from previous versions, and reliability of some common
diagnoses. Journal of the American Academy of Child & Adolescent Psychiatry, 39, 28–38.
Shirk, S. R. (1999). Developmental therapy. In S. W. Russ & T. H.
Ollendick (Eds.), Developmental issues in the clinical treatment of children (pp. 60–73). Needham Heights, MA: Allyn &
Bacon.
Shortt, A. L., Barrett, P. M., & Fox, T. L. (2001). Evaluating the
FRIENDS Program: A cognitive–behavioral group treatment
for anxious children and their parents. Journal of Clinical Child
Psychology, 30, 525–535.
Silverman, W. K. (1991). Anxiety disorders interview schedule for
children. Albany, NY: Graywind.
Silverman, W. K. (1994). Structured diagnostic interviews. In T. H.
Ollendick, N. J. King, & W. Yule (Eds.), International handbook of phobic and anxiety disorders in children and adolescents (pp. 293–315). New York: Plenum.
Silverman, W. K. (2003, August). Treatments of anxiety disorders in
children: Why do they work? In T. H. Ollendick (Chair), Treatments of childhood disorders: Why do they work? Symposium
conducted at the annual convention of the American Psychological Association, Toronto, Ontario, Canada.
Silverman, W. K., & Albano, A. M. (1996). Anxiety Disorders Interview Schedule for Children for DSM–IV: (Child and Parent Versions). San Antonio, TX: Psychological Corporation/ Graywind.
Silverman, W. K., & Berman, S. L. (2001). Psychosocial interventions for anxiety disorders in children: Status and future directions. In W. K. Silverman & P. D. A. Treffers (Eds.), Anxiety
disorders in children and adolescents: Research, assessment
and intervention (pp. 313–334). Cambridge, England: Cambridge University Press.
Silverman, W. K., & Eisen, A. R. (1992). Age differences in the reliability of parent and child reports of child anxious symp-
410
tomatology using a structured interview. Journal of the
American Academy of Child & Adolescent Psychiatry, 31,
117–124.
Silverman, W. K., Fleisig, W., Rabian, B., & Peterson, R. A. (1991).
Childhood Anxiety Sensitivity Index. Journal of Clinical Child
Psychology, 20, 162–168.
Silverman, W. K., Goedhart, A. W., Barrett, P., & Turner, C. (2003).
The facets of anxiety sensitivity represented in the childhood
anxiety sensitivity index: Confirmatory analyses of factor models from past studies. Journal of Abnormal Psychology, 112,
364–374.
Silverman, W. K., & Kurtines, W. M. (1996). Anxiety and phobic disorders: A pragmatic approach. New York: Plenum.
Silverman, W. K., & Kurtines, W. M. (1997). Theory in child psychosocial treatment research: Have it or had it? A pragmatic alternative. Journal of Abnormal Child Psychology, 25, 359–367.
Silverman, W. K., Kurtines, W. M., Ginsburg, G. S., Weems, C. F.,
Lumpkin, P. W., & Carmichael, D. H. (1999). Treating anxiety
disorders in children with group cognitive–behavioral therapy:
A randomized clinical trial. Journal of Consulting and Clinical
Psychology, 67, 995–1003.
Silverman, W. K., Kurtines, W. M., Ginsburg, G. S., Weems, C. F.,
Rabian, B., & Serafini, L. T. (1999). Contingency management,
self-control, and education support in the treatment of childhood phobic disorders: A randomized clinical trial. Journal of
Consulting and Clinical Psychology, 67, 675–687.
Silverman, W. K., & Nelles, W. B. (1988). The Anxiety Disorders Interview Schedule for Children. Journal of the American Academy of Child & Adolescent Psychiatry, 27, 772–778.
Silverman, W. K., & Ollendick, T. H. (Eds.). (1999). Developmental
issues in the clinical treatment of children. Needham Heights,
MA: Allyn & Bacon.
Silverman, W. K., & Rabian, B. (1995). Test–retest reliability of the
DSM–III–R childhood anxiety disorders symptoms using the
Anxiety Disorders Interview Schedule for Children. Journal of
Anxiety Disorders, 9, 1–12.
Silverman, W. K., Saavedra, L. M., & Pina, A. A. (2001). Test–retest reliability of anxiety symptoms and diagnoses using the
Anxiety Disorders Interview Schedule for DSM–IV: Child and
Parent Versions (ADIS for DSM–IV: C/P). Journal of the
American Academy of Child & Adolescent Psychiatry, 40,
937–944.
Siqueland, L., Kendall, P. C., & Steinberg, L. (1996). Anxiety in
children: Perceived family environments and observed family interaction. Journal of Clinical Child Psychology, 25,
225–237.
Southam-Gerow, M. A., Flannery-Schroeder, E. C., & Kendall, P. C.
(2002). A psychometric evaluation of the parent report form of
the State–Trait Anxiety Inventory for Children–Trait Version.
Journal of Anxiety Disorders, 17, 427–446.
Southam-Gerow, M. A., Weisz, J. R., & Kendall, P. C. (2003) Youth
with anxiety disorder in research and service clinics: Examining client differences and similarities. Journal of Clinical
Child and Adolescent Psychology, 32, 375–385.
Spence, S. H. (1995a). The Social Skills Questionnaire. Social skills
training: Enhancing social competence with children and adolescents. Windsor, England: NFER–Nelson.
Spence, S. H. (1995b). The Social Worries Questionnaire. Social
skills training: Enhancing social competence with children and
adolescents. Windsor, England: NFER–Nelson.
Spence, S. H. (1997). The structure of anxiety symptoms among
children: A confirmatory factor analytic study. Journal of Abnormal Psychology, 106, 280–297.
Spence, S. H. (1998). A measure of anxiety symptoms among children. Behaviour Research and Therapy, 36, 545–566.
Spence, S. H., Donovan, C., & Brechman-Toussaint, M. (2000). The
treatment of childhood social phobia: The effectiveness of a social skills training-based, cognitive–behavioural intervention,
EVIDENCE-BASED ASSESSMENT OF ANXIETY
with and without parental involvement. Journal of Child Psychology and Psychiatry, 41, 713–726.
Spielberger, C. D. (1973). Manual for the State–Trait Anxiety Inventory for Children. Palo Alto, CA: Consulting Psychologists
Press.
Strauss, C. (1987). Modification of trait portion of State–Trait Anxiety
Inventory for Children–Parent Form. (Available from author,
University of Florida, Gainesville, [email protected])
Swets, J. A., & Pickett, R. M. (1982). Evaluation of diagnostic systems. Orlando, Fl: Academic.
Tracey, S. A., Chorpita, B. F., Douban, J., & Barlow, D. H. (1997).
Empirical evaluation of DSM–IV generalized anxiety disorder
criteria in children and adolescents. Journal of Clinical Child
Psychology, 26, 404–414.
Treadwell, K. R. H., & Kendall, P.C. (1996). Self-talk in youth with
anxiety disorders: States of mind, content specificity, and treatment outcome. Journal of Consulting and Clinical Psychology,
64, 941–950.
Vasey, M. W., & Lonigan, C. (2000). Considering the clinical utility
of performance-based measures of childhood anxiety. Journal
of Clinical Child Psychology, 29, 493–508.
Watson, D., Clark, L. A., & Carey, G. (1988). Positive and negative
affectivity and their relation to anxiety and depressive disorders. Journal of Abnormal Psychology, 97, 346–353.
Watson, D., & Friend, R. (1969). Measurement of social-evaluative
anxiety. Journal of Consulting and Clinical Psychology, 33,
448–457.
Weems, C. F., Hammond-Laurence, K., Silverman, W. K., & Ferguson, C. (1997). The relation between anxiety sensitivity and depression in children and adolescents referred for anxiety. Behaviour Research and Therapy, 35, 961–966.
Weems, C. F., Silverman, W. K., Rapee, R. R., & Pina, A. A. (2003).
The role of control in childhood anxiety disorders. Cognitive
Therapy and Research, 27, 557–568.
Weems, C. F., Silverman, W. K., Saavedra, L. M., Pina, A. A., &
Lumpkin, P. W. (1999). The discrimination of children’s pho-
bias using the Revised Fear Survey Schedule for Children.
Journal of Child Psychology and Psychiatry, 40, 941–952.
Weersing, V. R., & Weisz, J. R. (2002). Mechanisms of action in
youth psychotherapy. Journal of Child Psychology and Psychiatry, 43, 3–29.
Weisz, J. R. (2000). Lab–clinic differences and what we can do about
them: I. The Clinic-Based Treatment Development Model.
Clinical Child Psychology Newsletter, 15, 1–3, 10.
Weisz, J. R., & Weersing, V. R. (1999). Developmental outcome research. In S. W. Russ & T. H. Ollendick (Eds.), Developmental
issues in the clinical treatment of children (pp. 457–469). Needham Heights, MA: Allyn & Bacon.
Westen, D., Novotny, C. M., & Thompson-Brenner, H. (2004) The
empirical status of empirically supported psychotherapies: Assumptions, findings, and reporting in controlled clinical trials.
Psychological Bulletin, 130, 631–663.
Wolfe, V. V., Finch, A. J., Saylor, C. F., Blount, R. L., Pallmeyer, T.
P., & Carek, D. J. (1987). Negative affectivity in children: A
multitrait–multimethod investigation. Journal of Consulting
and Clinical Psychology, 55, 245–250.
Wood, J., Piacentini, J. C., Bergman, R. L., McCracken, J., & Barrios, V. (2002). Concurrent validity of the anxiety disorders section of the anxiety disorders interview schedule for DSM–IV:
Child and parent versions. Journal of Clinical Child and Adolescent Psychology, 31, 335–342.
Woodruff-Borden, J., Morrow, C., Bourland, S., & Cambron, S.
(2002). The behavior of anxious parents: Examining mechanisms of transmission of anxiety from parent to child. Journal
of Clinical Child and Adolescent Psychology, 31, 364–374.
Woodward, L. J., & Fergusson, D. M. (2001). Life course outcomes
of young people with anxiety disorders in adolescence. Journal
of the American Academy of Child and Adolescent Psychiatry,
40, 1086–1093.
Received June 15, 2004
Accepted March 25, 2005
411