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

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

Relations of tripartite dimensions of emotion to childhood anxiety and mood disorders.

This study examined preliminary higher-order models relating tripartite dimensions of emotion to severity of anxiety and depressive disorders in 100 clinically referred children and adolescents. In light of the accumulating support for multifactor models of vulnerability and negative emotion in children, the present investigation was designed to establish preliminary estimates of the structure and magnitude of the relations of three emotion factors with dimensions of social anxiety, depression, panic, generalized anxiety, obsessions/compulsions, and separation anxiety. Results were consistent with structures that minimally specified two higher-order emotion factors, yet only some parameter estimates were consistent with theory regarding the tripartite model. Problems with the measurement of tripartite factors and possibilities for further research are outlined.

Factors affecting the reliability of clinical judgments about the function of children's school-refusal behavior.

Conducted two studies to examine the interrater reliability, test-retest stability, and the effect of various clinician variables, such as years of clinical experience, theoretical orientation, and prior experience with children, on clinical judgments about the reinforcement functions of children's school-refusal behavior. Results indicated that the judgments by individual clinicians were of questionable reliability. Judgments aggregated across 3 clinicians yielded acceptable interrater and test-retest reliability in Study 1, but a greater number of clinicians were necessary to achieve acceptable reliability in Study 2. Years of clinical experience and training were the only clinician variables related to the reliability of judgments about reinforcement functions. Several recommendations for the clinical assessment of the function of children's school-refusal behavior are discussed.

Subtypes of social phobia in adolescents.

Thirty-three social phobic adolescents were asked to name their ten most feared social situations. Two independent judges classified each situation reported by the participants into one of four situational domains: formal speaking/interactions, informal speaking/interactions, observation by others, and assertion. Fifteen participants (45.5%) were assigned a generalized subtype of social phobia because they endorsed at least moderate anxiety in all four situational domains. This subgroup scored higher on self-report measures of anxiety and depression than the rest of the sample. These results provide empirical support for the existence of subtypes of social phobia in adolescents.

Diagnostic reliability of the DSM-III-R anxiety disorders. Mediating effects of patient and diagnostician characteristics.

Factors influencing diagnostic reliability were examined using a sample of 267 patients who underwent two independent administrations of the Anxiety Disorders Interview Schedule--Revised (ADIS-R). Several potential mediators were examined in terms of their association with interrater agreement as measured by kappa coefficients. These included comorbidity, disorder severity, diagnostician training, patient education, presence of behavioral feature, and time separating interviews. Results suggest that several factors appear to have an important effect on diagnostic agreement, most notably, the presence or absence of comorbidity and the presence or absence of overt behavioral symptoms. Details of these influences and the impact of other selected mediators on the diagnosis of anxiety disorders are presented.

The development of anxiety: the role of control in the early environment.

Current developments in cognitive and emotion theory suggest that anxiety plays a rather central role in negative emotions. This article reviews findings in the area of anxiety and depression, helplessness, locus of control, explanatory style, animal learning, biology, parenting, attachment theory, and childhood stress and resilience to articulate a model of the environmental influences on the development of anxiety. Evidence from a variety of sources suggests that early experience with diminished control may foster a cognitive style characterized by an increased probability of interpreting or processing subsequent events as out of one's control, which may represent a psychological vulnerability for anxiety. Implications for research are discussed.

Structural relationships among dimensions of the DSM-IV anxiety and mood disorders and dimensions of negative affect, positive affect, and autonomic arousal.

Using outpatients with anxiety and mood disorders (N = 350), the authors tested several models of the structural relationships of dimensions of key features of selected emotional disorders and dimensions of the tripartite model of anxiety and depression. Results supported the discriminant validity of the 5 symptom domains examined (mood disorders: generalized anxiety disorder, GAD; panic disorder; obsessive-compulsive disorder; social phobia). Of various structural models evaluated, the best fitting involved a structure consistent with the tripartite model (e.g., the higher order factors, negative affect and positive affect, influenced emotional disorder factors in the expected manner). The latent factor, GAD, influenced the latent factor, autonomic arousal, in a direction consistent with recent laboratory findings (autonomic suppression). Findings are discussed in the context of the growing literature on higher order trait dimensions (e.g., negative affect) that may be of considerable importance to the understanding of the pathogenesis, course, and co-occurrence of emotional disorders.

Methodological strategies in child clinical trials: advancing the efficacy and effectiveness of psychosocial treatments.

The present paper reviews issues of treatment efficacy (i.e., potency) and effectiveness (i.e., clinical utility) in applied clinical child research. Threats to treatment evaluation are reviewed in the context of these two dimensions. It is proposed that treatment outcome research faces new challenges stemming from the ever increasing emphasis on generalization of gains and dissemination of interventions outside of clinical research settings. Issues and approaches proposed as warranting further development and attention include development, flexibility, acceptability, and disseminability of psychosocial assessment and treatment methods. A research emphasis is promoted that balances experimental control with the need for treatment generalization and delivery outside of the research setting, in order to maximize the utility of clinical research.

The structure of negative emotions in a clinical sample of children and adolescents.

The authors sought to define the latent factors associated with childhood anxiety and depression, using a structural equations/confirmatory factor-analytic approach involving multiple informants (i.e., parent and child report) of symptoms. A sample of 216 children and adolescents with diagnoses of an anxiety disorder or comorbid anxiety and mood disorders and their parents were administered measures of childhood fear, anxiety, and depression. Results of comparative modeling best supported 3-factor solutions (fear, anxiety, and depression) that were consistent with recent conceptual models of anxiety and depression (e.g., tripartite model). Results also suggested that 3 widely used measures of childhood negative emotion are conceptually heterogeneous (containing item sets that loaded on different latent factors). Implications for the assessment of childhood negative emotions are discussed.

Assessment of worry in children and adolescents: an adaptation of the Penn State Worry Questionnaire.

An adaptation of the Penn State Worry Questionnaire (Meyer, Miller, Metzger & Borkovec, 1990, Behaviour Research and Therapy, 28, 487-495) for use with children and adolescents was evaluated in two studies (Penn State Worry Questionnaire for Children: PSWQ-C). Study I involved the examination of factor structure, internal consistency, and convergent and discriminant validity in a school sample (N = 199). The measure was found to be unifactorial and to possess favorable reliability and validity. Study 2 evaluated the PSWQ-C in a clinical sample and found significantly higher scores in children with generalized anxiety disorder (n = 14) than children with other anxiety disorders (n = 10) and normal controls (n = 10). The PSWQ-C also demonstrated good convergent and discriminant validity and excellent reliability in the clinical sample.

Psychometric properties of the Depression Anxiety Stress Scales (DASS) in clinical samples.

The psychometric properties of the Depression Anxiety Stress Scales (DASS) were evaluated in two studies using large clinical samples (N = 437 and N = 241). In Study 1, the three scales comprising the DASS were shown to have excellent internal consistency and temporal stability. An exploratory factor analysis (principal components extraction with varimax rotation) yielded a solution that was highly consistent with the factor structure previously found in nonclinical samples. Between-groups comparisons indicated that the DASS distinguished various anxiety and mood disorder groups in the predicted direction. In Study 2, the conceptual and empirical latent structure of the DASS was upheld by findings from confirmatory factor analysis. Correlations between the DASS and other questionnaire and clinical rating measures of anxiety, depression, and negative affect demonstrated the convergent and discriminant validity of the scales. In addition to supporting the psychometric properties of the DASS in clinical anxiety and mood disorders samples, the results are discussed in the context of current conceptualizations of the distinctive and overlapping features of anxiety and depression.

Empirical evaluation of DSM-IV generalized anxiety disorder criteria in children and adolescents.

Evaluated the Diagnostic and Statistical Manual of Mental Disorders (4th ed. [DSM-IV], American Psychiatric Association, 1994) generalized anxiety disorder (GAD) criteria in children and adolescents. Clinic-referred children meeting criteria for DSM-IV GAD, those meeting criteria for another DSM-IV anxiety disorder, and normal children participated in a structured interview and completed self-report questionnaires. Groups were compared in terms of interview and self-report measures to examine convergent and discriminant validity. In addition, developmental differences, cross-informant symptom and syndrome agreement, and validity of parent and child report were determined. Finally, the symptoms comprising the GAD associated symptom criterion (Criterion C) were examined in terms of rate of endorsement and predictive power. Results showed that parameters of worry differentiated children with GAD from those with other anxiety disorders and controls. Developmental differences in the sample did not appear to necessitate a separate criteria set for the classification of generalized anxiety in children of this age. Symptoms from GAD Criterion C evidenced moderately high rates of endorsement and acceptable predictive power. Overall, the DSM-IV GAD criteria for children and adolescents are supported, but further evaluation is necessary before firm conclusions can be drawn.

Unearthing the nonassociative origins of fears and phobias: a rejoinder.

In recent years numerous disagreements and controversies have ensued over the place of Pavlovian or associative conditioning in the etiology of specific phobias and other fear-related clinical syndromes. A major source of disagreement emerged from clinical observations suggesting that environmental aversive conditioning events could not be identified for many specific phobias. Part of the controversy can also be traced to disagreements over what constitutes a direct conditioning event and over what exactly is being conditioned in phobic acquisition. More fundamental, however, is confusion over the critical process variables involved in the conditioning etiology of human phobias and fear-related clinical syndromes. We address some of the recent controversies surrounding associative conditioning accounts of phobic onset in light of recent proposals that nonassociative factors account for the etiology of many specific phobias. The viability of the nonassociative position is questioned and alternatives are suggested that emphasize the complex and multifaceted processes involved in the etiology of specific phobias.

Behavioral treatment of choking phobia in an adolescent: an experimental analysis.

A multiple baseline approach across foods was used to evaluate an exposure-based treatment for choking phobia in a 13-year-old girl. Following 14 sessions, the patient demonstrated substantially reduced self-reported, observer-rated, and parent-reported anxiety, increased eating rate and bite size, and increased variety of food intake. Clinical diagnoses present at pretreatment were not present at posttreatment at a clinical level. These gains were maintained at a 9-month follow-up assessment.

A systematic replication of the prescriptive treatment of school refusal behavior in a single subject.

We employed a multiple-baseline design to test the efficacy of a recently developed approach for reducing school refusal behavior. This approach uses a systematic method for conducting a functional analysis for the target behaviors and suggests specific intervention strategies based upon this analysis. To maximize external validity, the intervention was tested using a systematic replication strategy, whereby only the major conceptual elements of the intervention were retained from previous applications. The subject was a 10 year old girl who attended school with great difficulty and resistance and who was assigned DSM-III-R diagnoses of separation anxiety disorder and social phobia prior to treatment. Following 8 weeks of treatment, she showed marked reductions in problem behavior and no longer met criteria for any anxiety disorder diagnoses. The results highlight the importance of the use of functional analytic strategies to effect behavior change.

Treatment of anxiety disorders of childhood.

The development of empirically derived, efficacious treatment methods for the range of anxiety disorders in children and adolescents lags far behind the field of adult anxiety treatment research. Controlled trials of both psychosocial and pharmacologic methods are warranted, and several trials are currently underway. Although the literature in this field is growing, many questions remain regarding the application and long-term benefit of interventions with youth. Specifically, although the field of adult psychosocial treatment research has advanced such that empirically derived treatment protocols are readily available, such methodologies are lacking for anxious youth. Serious attention must turn toward the empirical testing and validation of developmentally appropriate psychosocial treatment protocols. Fortunately, work in this area is currently under way in several centers (e.g., for social phobia, OCD, and generalized anxiety). Moreover, the role of parents in the psychosocial treatment process remains largely unexplored. Investigations are underway examining the effectiveness of training parents in the delivery of particular psychosocial procedures and evaluating the optimal "degree" of parental involvement. Attention also must turn to the systematic study of variables hypothesized to affect negatively the successful integration of parents (e.g., age of child, severity of disorder, parental psychopathology). And lastly, combined trials of pharmacologic compounds and psychosocial interventions are needed to examine the prescriptive treatment approach of matching patients to treatments.