*Keywords:* children’s anxiety, attention deficit hyperactivity disorder, screening, SCARED scale, parent-child dyads

‘victor-martinelli’

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Volume 1 6 , No. 2 ., 195 210

Faculty of Education©, UM, 202 2

Parent-child Congruency on the Screen for Child Anxiety

Related Emotional Disorders

Victor Martinelli

University of Malta

victor.martinelli@um.edu.mt

Abstract Anxiety is a frequently experienced mental health issue among children and youth, particularly among children with attention deficit hyperactivity disorder (ADHD) due to their adverse experiences in social and school settings. Child anxiety often remains unnoticed or misinterpreted, and this leads to delayed diagnosis and treatment of children’s anxiety issues. Educators and professionals also face difficulties in diagnosing the anxiety of children due to the lack of valid and reliable instruments for screening and diagnostics of children’s anxiety. This study applied the SCARED scale for children and parents, which is a proven screening instrument for the identification of children’s anxiety to examine parents’ perception and awareness of the anxiety experienced by their children diagnosed with ADHD. The scale was translated and administered to 11 to 13-year-old children and their parents. Based on responses from 65 parent-child dyads, this study found that the translated and modified scoring procedure of the SCARED scale used in this study effectively identified higher anxiety levels in children with clinically diagnosed ADHD compared to children with no such condition. This was so for both the child and the parent versions of the SCARED. The study also identified high levels of correlation between the children’s selfratings and their parents’ ratings of these same children, but children’s self-reported scores were significantly higher than the level of anxiety perceived by their parents. Overall, the study found that the translated and modified SCARED scale could be used to screen children’s anxiety. However, a large-scale analysis is necessary to precisely confirm the metric characteristics of the SCARED scale. Keywords : children’s anxiety, attention deficit hyperactivity disorder, screening, SCARED scale, parent-child dyads.

1. Introduction

Anxiety as a subjective sensation of a real or perceived threat (Joshi et al., 2013)

is highly prevalent in children, ranging between 5.7% and 12.8% (Ramsawh et

al., 2011). Although research shows that mild anxiety can be beneficial

(Brahmbhatt et al., 2021), when anxiety increases above an optimal level of

intensity, it prevents students from fulfilling their usual daily and school

activities (Monga & Benoit, 2018). Research shows that anxiety disorders

negatively impact students’ educational achievement, social adaptation, and

development and often extend into adulthood (Costello et al., 2003; Kitchener

et al., 2018; Rapee et al., 2009). Anxiety disorders include a variety of forms,

such as phobias, separation anxiety, social anxiety, generalised anxiety, panic

disorders, and agoraphobia (Kaajalaakso et al., 2020). The DSM5 TR

(American Psychiatric Association, 2022) classification of anxiety disorders

recognises 11 anxiety disorders, including generalised anxiety disorder, panic

disorder, selective mutism, separation anxiety disorder, social anxiety

disorder, and specific phobia. Anxiety disorders are among the most common

mental health issues affecting secondary school students (Allen et al., 2020;

Tramonte & Willms, 2010; Putwain & Daly, 2014; Tang et al., 2019), and female

students tend to experience anxiety disorders more frequently than their male

counterparts (Hill et al., 2016; OECD, 2017; Putwain & Daly, 2014; Tang et al.,

2019; Tramonte & Willms, 2010).

In addition to anxiety disorders, attention deficit hyperactivity disorder

(ADHD) is also a highly prevalent and clinically heterogeneous disorder

(Biederman, 2005; Gokce et al., 2015). It is one of the most common

neurobehavioral disorders with psychiatric comorbidity and impairments in

adaptive functioning (Barkley, 2002). According to self-report measures of

symptoms (Willcutt, 2012), about 6% to 7% of children and adolescents have

ADHD. ADHD increases individuals’ and their families’ proneness to stress,

usually resulting in adverse academic and vocational outcomes (Biederman,

2005). Children with ADHD and their families are at risk of several comorbid

clinical conditions, including anxiety disorders (Pliszka, 2007; Souza et al.,

2005; Koyuncu et al., 2015).

Research also shows (Hartman et al., 2004) that children with ADHD who have

sluggish cognitive tempo experience more anxiety and depression than

children with the combined subtype of ADHD. Children with comorbid

ADHD and anxiety disorders also have severe anxiety symptoms, sometimes

combined with additional psychiatric conditions (Katzman et al., 2017).

According to Bowen et al. (2008), about half of children with ADHD are likely

to have an anxiety disorder. Despite the high prevalence of ADHD comorbidity

with anxiety disorders, the number of studies in this field is surprisingly low,

and this area of inquiry would benefit from some studies about the association

between these two conditions (Gokce et al., 2015).

Research shows that anxiety among secondary school students often remains

undiagnosed (Tomb & Hunter, 2004) or misunderstood, leading to severe

individual and social consequences (La Vonne et al., 2012). Therefore, the early

identification and treatment of anxiety disorders in youth are crucial for timely

intervention and students’ well-being (Mychailyszyn et al., 2011). However,

prevention and screening of anxiety among adolescents are rarely practised.

Clinical diagnostic procedures are reliable but costly and difficult to use for

larg-scale assesements. When there is concern about a child’s emotional well

being, one way of efficiently addressing this need is to use supervised or self

administered rating scales. These scales can contribute to the identification of

children at risk of anxiety disorders (Vasey & Lonigan, 2000; Kendall &

Flannery-Schroeder, 1998; Chisholm et al., 2016) that, if needed, can be

followed by a full professional assessment required for proper diagnosis and

the development of a treatment plan (Bruhn et al., 2014). Such reliable clinical

diagnostic procedures will eliminate false-positive cases at minimal cost

(Kendall & Flannery-Schroeder, 1998; Phillips et al., 2002; Vasey & Lonigan,

2000).

There are well-established, valid and reliable diagnostic tests (Freidl et al.,

2017), but, as described above, screening for adolescent anxiety using clinical

procedures is time-consuming and costly. On the other hand, using self

completing scales is the feasible and economical procedure for identifying

psychopathology, while the confirmatory clinical diagnosis will identify the

treatment approach (Weitcamp et al., 2010). One such questionnaire developed

on the basis of the DSM-IV classification of anxiety disorders (Runyon,

Chesnut, & Burley, 2018) is the Screen for Child Anxiety-Related Emotional

Disorders (SCARED) (Birmaher et al., 1997), which is an instrument that

examines child anxiety and parent’s perceptions of their children’s anxiety

(Weitkamp et al., 2010). Although the SCARED scale was initially developed

as a screening tool for use in clinical settings, this scale is often used in

community settings (Rapaport et al., 2017). At the time of the publication of the

SCARED instrument, the DSM-IV (American Psychiatric Association, 1994)

classification of anxiety disorders recognised the following constructs in

children’s and adolescents’ anxiety disorders: separation anxiety disorder,

generalized anxiety disorder, panic disorder, social phobia, specific phobia,

obsessive-compulsive disorder, and posttraumatic stress disorder (Muris et al.

2002). SCARED was developed by Birmaher et al. (1997), reflecting the

following five specific anxiety disorders: somatic/panic, generalized anxiety,

separation anxiety, social phobia, and school phobia. Four of these subscales

measure anxiety disorder symptoms as conceptualised in the DSM-IV-TR

(American Psychiatric Association, 1994) and the fifth subscale, school anxiety,

represents a common anxiety problem in childhood and adolescence.

2. Methods

2.1 Measure and indicator of anxiety

The SCARED scale is one of the most commonly used self-report scales for

assessing anxiety in young people (Birmaher et al., 1997). The entire scale has

high internal consistency, as do most of the five constituent subscales. The 41

item SCARED version (Birmaher et al., 1999) has excellent internal consistency

(.90) and test-retest reliability (Runyon et al., 2018). Subsequent evaluations of

the SCARED scale also reported good validity, reliability, and sensitivity to

change (Behrens et al., 2019; Early Intervention Foundation, 2020) and the 41

item version (Birmaher et al., 1999) is the widely recommended version for use

in research (Hale et al., 2011). This scale has been used widely in at least

fourteen countries. The scale was translated and used in the following

countries South Africa/Netherlands (Muris et al., 2002), Saudi Arabia and

Lebanon (Arab et al., 2016; Hariz et al., 2013), Brazil (Desousa et al., 2013; Isolan

et al., 2011), Canada (Martin & Gosselin, 2012), Cyprus (Essau et al., 2013),

Finland (Kaajalaakso et al., 2020), Iceland (Olason et al., 2004), Italy (Crocetti et

al., 2009), Malaysia (Ang, 2020), Iran (Dehghani et al., 2013), Spain (Hale et al.,

2013), and Sweden (Ivarsson et al., 2018) among others.

The SCARED sub-scales measure the five anxiety disorder as follows;

Generalized Anxiety Disorder (9 items), Panic Disorder (13 items), Separation

Anxiety Disorder (8 items), Social Anxiety Disorder (7 items), and Significant

School Avoidance (4 items). In this self-rated scale, children are asked to rate

the frequency with which they experience each symptom using a three-point

Likert scale (0=almost never, 1=sometimes, and 2=often) (Russell et al., 2013).

The parents’ version uses the same items and type of Likert scale and parents

were required to estimate the level of anxiety of their children.

SCARED has been designed for and validated with children experiencing

anxiety. However, there is little information on how anxiety presents in

individuals with other disorders relative to the typical population (Carruthers,

2020). There is also an evident lack of research in Malta about children’s mental

health (Rampazzo et al., 2016) and even less about children with ADHD. Some

exploratory work on school climate in Malta (Martinelli & Raykov, 2021)

provides some results about students’ school connectedness in the local setting,

but there is still an evident need for research in this domain.

The current study used the SCARED scale to assess children’s anxiety and

parents’ perception of anxiety symptoms in their children. Data were collected

for children and parents in dyads to address Carruther et al.’s (2020) and Gokce

et al.’s (2015) concerns about the limited studies on anxiety and ADHD. This

study compared the results of parent and child reports of the SCARED scale of

children diagnosed with ADHD with those who did not report having the

condition. The first aim of this study was to evaluate how children with and

without ADHD rated themselves for anxiety. The second aim of this study was

to evaluate how parents of children with and without ADHD rated their

children for anxiety. Finally, the third objective of this study was to explore the

congruency between the matched children’s self-reported anxiety and parent

perception of children’s anxiety.

To reduce possible over-reporting of anxiety symptoms through the use of a

trichotomous scale indicator and to accurately reflect participants’ perceptions

(Krosnick & Presser, 2010), this study used a 5-point Likert scale. As Cummins

and Gullone (2000) and Lozano et al. (2008) suggested, this modification

increases the sensitivity and validity of the SCARED scale and improves the

consistency and reliability of participants’ responses (Cummins & Gullone,

2000; Lozano et al., 2008). This study applied a back-translated version of the

1999 English version of the SCARED 41-item questionnaire (Birmaher et al.,

1999). Some minor modifications were necessary to mitigate linguistic

differences between the original and Maltese versions of the scale. A Maltese

language expert translated the English version of SCARED to Maltese, and a

second expert back-translated the Maltese version to English. The author

examined the content of the final translated version to ensure that the meaning

of the questions was consistent with the original English version.

2.2 Participants

The study applied an online form of the SCARED scale to examine the

incidence of anxiety in secondary school children attending state, church, and

independent schools in Malta. According to the latest available data, of the

21,064 secondary school children in compulsory education in Malta, 11,275

attend state schools, 7,450 attend church schools, and 2,339 attend independent

schools (National Statistics Office, 2021). Ethical approval for this study was

obtained from the institutional research ethics committee. The school

administrators granted permission for this study, and consent was sought from

each participant’s parent/s or guardian/s. Children in Years 8 to 10, who were

between 12 and 14 years old, were invited to participate in this voluntary study

to complete the online SCARED scale. About 3000 children were invited to

participate, and only 362 parents and children completed the questionnaire.

Sixty-five pairs of matched parent-child data sets were collected. Most

participants were from state schools (N=36), while a smaller number were from

the church (N=15) and independent schools (N=13).

2.3 Data analysis

Exploratory techniques (means and standard deviations) were used to examine

the distribution of responses and describe the level of anxiety among children

with and without ADHD. The same exploratory analysis was applied to

examine the parents’ rating of the anxiety level of their children (Field, 2018).

The study used the Mann-Whitney U test to explore the relationship between

the self-rating for anxiety of children with ADHD and children without the

condition. The same tests were used to examine how parents of children with

ADHD rated their children for anxiety compared to parents of children with

no such condition. The Wilcoxon signed-rank test was used to compare the

ratings within each child-parent dyad and to explore differences between the

scores. The statistical analyses were conducted using the SPSS package (IBM

SPSS Statistics, IBM Corp., USA). Spearman’s rank correlation was used to

examine relationships between the children’s and their parents’ scores for the

children with and without ADHD.

3. Results and discussion

The initial screening of the collected data identified no outliers among the

responses of the parents or their children. In the parents’ responses, skewness

(-.074) and kurtosis (-.919) coefficients were in the range which is considered

acceptable and indicated a normal univariate distribution of anxiety scores

(Hair et al., 2019). The inspection of the quantile-quantile (Q-Q) plots and the

histograms also showed the normality of the distribution of parents’ SCARED

scores. The assumption of multivariate normality was confirmed by the

Shapiro-Wilk test, which indicated no differences in the normality of the

distribution of the overall score ( W = .972, p = .134). On the other hand, in the

children’s responses, skewness (-.304) and kurtosis (-.854) coefficients differed

somewhat from those of their parents. Inspecting the quantile-quantile (Q-Q)

plots and the histograms indicated some minor departure from a normal

distribution of SCARED scores. The assumption of multivariate normality was

also not confirmed by the Shapiro-Wilk test, which indicated some deviation

from a normal distribution of the score (W = .962, p = .041). This and the limited

number of participants necessitated the use of nonparametric analysis. Basic

descriptive results of children’s self-reported anxiety levels and parents’

perceptions of their children’s anxiety on the SCARED scales are presented in

Table 1.

Table 1 SCARED subscales and total score means and standard deviations

Panic Disorder Generalized Anxiety Disorder Separation Anxiety Social Anxiety Disorder Significant School Avoidance Total All parents (n=65)

26.22

(10.361)

24.52

(8.537)

18.77

(7.280)

19.43

(6.636)

7.97

(3.046)

96.89

(29.825)

All children (n=65)

29.40

(11.678)

26.78 (9.54)

19.71

(7.707)

21.72

(7.705)

8.97 (3.8)

106.58

(33.677)

Parents of children with ADHD (n=16)

32.69

(12.349

27.75

(5.434)

22.88

(7.830)

20

(6.208)

9.94

(3.151)

113.25

(30.396)

Parents of children without ADHD (n=49)

24.10

(8.773)

23.45

(9.127)

17.43

(6.636)

19.24

(6.821)

7.33

(2.74936)

91.55

(27.911)

Children with ADHD (n=16)

36

(10.758

29.38

(6.771)

24.38

(8.861)

23

(6.055)

10.63

(6.3.243)

123.38

(28.182)

Children without ADHD (n=49)

27.24

(11.243)

25.94

(10.201)

18.18

(6.710)

21.31

(8.183)

8.43

(3.841)

101.10

(33.754)

(Bracketed values are standard deviations)

The first aim of this study was to compare how children with and without

diagnosed ADHD rate themselves for anxiety. The study found statistically

significant differences between median SCARED scores of children with and

without ADHD (126.5 and 107, respectively). Mann–Whitney ( U = 238, n 1 = n 2

= 65, p < 0.019 two-tailed) confirmed that children diagnosed with ADHD

experience significantly greater anxiety than their counterparts without

ADHD.

Considering the SCARED subscales and the significant difference between the

participants with and without ADHD, children with ADHD reported

significantly higher scores in three of the five subscales. Median Panic Disorder

scores of the ADHD and non-ADHD groups were 40.5 and 26, respectively; the

distributions in the two groups differed significantly (Mann–Whitney U =

206.5, n 1 = n 2 = 65, p < 0.005 two-tailed). Median Separation Anxiety scores of

the ADHD and non-ADHD groups were 25.5 and 18, respectively; the

distributions in the two groups differed significantly (Mann–Whitney U =

221.55, n 1 = n 2 = 65, p < 0.009 two-tailed). Finally, the median Significant School

Avoidance scores of the ADHD and non-ADHD groups were 11 and 8,

respectively; the distributions in the two groups differed significantly (Mann–

Whitney U = 237, n 1 = n 2 = 65, p < 0.18 two-tailed).

The second aim of this study was to compare how parents of children with

ADHD rated their children for anxiety compared to parents of children with

no such condition. Parents of children with ADHD rated the anxiety of their

children (with ADHD) on the SCARED scale significantly higher than other

parents. Median SCARED-P scores in the two groups were 122.5 and 93,

respectively; the distributions in the two groups differed significantly (Mann–

Whitney U = 230, n 1 = n 2 = 65, p < 0.014 two-tailed).

The comparisons of parents’ estimated anxiety levels of their children on the

SCARED subscales have also found significant differences between the parents

of children with and without ADHD in three of the five subscales. Median

Panic Disorder scores of the parents of the ADHD and the non-ADHD groups

were 38.5 and 22, respectively; the distributions in the two groups differed

significantly (Mann–Whitney U = 218, n 1 = n 2 = 65, p < 0.008 two-tailed).

Median Separation Anxiety Disorder scores of the parents of the ADHD and

non-ADHD groups were 23.5 and 17, respectively; the distributions in the two

groups differed significantly (Mann–Whitney U = 225, n 1 = n 2 = 65, p < 0.011

two-tailed). Median Significant School Avoidance scores of the ADHD and the

non-ADHD groups were 10.5 and 7, respectively; the distributions in the two

groups differed significantly (Mann–Whitney U = 209, n 1 = n 2 = 65, p < 0.005

two-tailed).

The third aim of this study was to explore differences between the dyads and

examine the match between children’s self-reported anxiety and parents’ rating

of the anxiety level of their children. As shown in Table 1, children ranked their

anxiety levels ( Mdn = 111) higher than their parents ( Mdn = 95). A Wilcoxon

signed-rank test indicated that this difference was statistically significant, Z =

• 3.563, z= p <.001. The scores of the child-parent dyads correlated at .822, p <.001.

The scores of the ADHD dyads correlated at .903 p <.001, and those of the non

ADHD dyads were less at .775 p <.001, but nevertheless high.

This study was intended to explore possible issues stemming from

administering this screening instrument to child-parent dyads where the

children were clinically diagnosed with ADHD and other dyads where the

children did not have such a diagnosis. It was intended to examine whether

this translated version is sensitive to the differences in anxiety that other

studies claim children with ADHD experience (Biederman, 2005; Bowen et al.,

(2008); Hartman et al., 2004; Koyuncu et al., 2015). The study also intended to

compare the self-reported anxiety of children and parents’ ratings of their

children’s level of anxiety. The scale was changed from a 3-point to a 5-point

Likert scale to increase the sensitivity of the translated instruments.

Overall, in the SCARED subscales and the composite SCARED score, as shown

in Table 1, children with ADHD consistently ranked themselves as having

higher levels of generalised anxiety, panic disorder, separation anxiety, social

anxiety and school avoidance than their peers without ADHD. The same was

true for the parents’ ranking of their ADHD children in each subscale and the

composite score compared to the other parents. This is consistent with several

studies conducted by Bowen et al. (2008), Hartman et al. (2004), Koyuncu et al.

(2015), Pliszka (2007), and Souza et al. (2005), who showed a significant

association between the intensity of anxiety and ADHD. The higher scores of

the ADHD children self-reported scores and their parents’ perception of their

children’s levels of anxiety in comparison to their non-ADHD peers was

statistically significant for the total SCARED score and subscales that measure

Panic Disorder, Separation Anxiety, and Significant School Avoidance. There

were no statistically significant differences between the compared groups on

Generalized Anxiety and Social Anxiety Disorders. It is likely that generalised

anxiety and social anxiety may be less evident in children’s and parents’

perceptions than the other three types of anxiety because they are less

situationally embedded. Panic, separation, and school avoidance are easier to

identify because they cause significantly more distress to the affected children

and their parents than general feelings of anxiety and social anxiety.

Generalized Anxiety and Social Anxiety Disorders may be perceived as aspects

of children’s personalities rather than anxiety.

In sum, the adapted SCARED scale appears to retain its validity and effectively

screen for anxiety symptoms in school children. The translated measure

effectively identified anxiety symptoms in children who are typically expected

to be more anxious than others because of their ADHD conditions (Bowen et

al., 2008). The results also show that the SCARED scale is efficient for

identifying children’s anxiety and parent perception of the level of anxiety their

children experience. The modification of the Likert scale from three to five

points did not appear to reduce the scale’s metric characteristics. Like other

studies on very specific groups of children in small populations, this study

suffers from a low number of participants because the data needed to be

collected in intact child-parent pairs. It is expected that the future use of the

modified SCARED scale will provide a larger dataset for a more

comprehensive validation of the scared scale.

Nevertheless, given the encouraging results of this study and the simplicity of

the screening procedure, the adapted version of the Maltese SCARED scale can

be considered an appropriate instrument for use in education settings once a

norming process has been completed for the entire population of 11 to 13-year

old children. Furthermore, given the lack of studies using SCARED with

populations of children with ADHD (Carruthers et al., 2020; Gokce et al., 2015),

this study provides new evidence about links between the two conditions and

provides some initial evidence that the SCARED scale is a useful instrument

for the population of 11 to 13-year-old children.

Acknowledgement

The author wishes to acknowledge the invaluable contribution of Jeanelle

Barabara, Aleinad Nappa Licari, and Julia Pavia, who collected the data for this

article.

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