Introduction
The Diagnostic and Statistical Manual for Mental Disorders (DSM-5; [
5]) identifies several anxiety disorders that can develop in childhood or adolescence (e.g., separation anxiety disorder, specific phobia and social anxiety disorder). Anxiety can have a significant negative impact on daily life for young people and is associated with low quality peer relationships [
18], lowered attendance in school [
32,
41,
46] and academic underachievement [
26,
40]. Moreover, it can follow a chronic pathway from childhood through to adulthood, placing children and adolescents at risk for further mental and physical health difficulties [
18,
42]. Researchers have highlighted that anxiety symptoms can be less visible in development compared with other disorders (review by [
17]); emphasizing the importance of self-report measurements that are reliable and valid [
20,
25].
One widely used DSM based anxiety questionnaire for children and adolescents aged 8–18 years is the Screen for Child Anxiety Disorders (SCARED; [
7]). The 41 items in this measure were developed in English and based on anxiety symptoms in clinical populations. The questionnaire measures total anxiety and includes five factors or subscales (separation anxiety disorder, generalized anxiety, social phobia (now social anxiety disorder), school phobia and panic/somatic symptoms). In addition, it provides a cut-off to identify young people who are experiencing clinically significant symptom levels. Several papers have reported good reliability (e.g., test–re-test and internal consistency; [
6,
7,
9,
20,
31,
43]). In addition, the questionnaire has been found to have good convergent [
9,
20,
36,
39,
43] and discriminant validity [
6,
7,
36,
43]. Since its development, the SCARED has been translated into several languages and has used as an anxiety screening tool in Europe, (e.g. [
16,
19,
29]) and worldwide (e.g. [
11,
33]). In addition, several studies have found support for its five factor structure (e.g. [
9,
19,
28,
31,
38,
43]).
In Western cultures, anxiety represents one of the most prevalent disorders in development, with up to 15 % of children and adolescents meeting the diagnostic criteria [
45]. Studies typically report that while negative affect is similar in boys and girls in childhood [
8,
21,
42], gender differences start to emerge in adolescence; with females showing elevated and more stable symptoms compared with males [
8,
30]. Few studies have, however, explored the prevalence of anxiety in Arab countries in child and adolescent populations. In one recent study, Al-Sughayr and Ferwana [
2] measured mental health difficulties in adolescents and young adults in Saudi Arabia (including somatic symptoms, anxiety, depression and social dysfunction). This paper highlighted that 48 % of individuals reported symptoms consistent with a psychiatric disorder and that symptom severity was higher in females compared with males. Other studies have found similar levels (49 %) of anxiety in adolescent boys in Saudi Arabia [
1]. A review paper considering anxiety disorders in adults in Saudi Arabia also highlighted gender differences, although prevalence rates in some studies were lower (from 7 to 33 %; [
44]). Consideration of previous research highlights a need to understand more clearly child and adolescent anxiety symptoms in Arabic cultures to develop a better understanding of prevalence rates across development and between gender and with a view to addressing causal factors and prevention and intervention strategies in the longer term.
Previous studies generally support the use of SCARED as a reliable and valid screening tool to measure anxiety symptoms. Only one study to-date has explored the psychometric properties of SCARED in an Arabic speaking population. Hariz et al. [
31] demonstrated satisfactory psychometric properties (related to internal consistency and good discriminant, convergent and divergent validity) for total anxiety scores in a clinical population aged 9–17 years in Lebanon. The aim of the current study was to extend this research to explore the psychometric properties of this questionnaire in a community sample of children and adolescents in Saudi Arabia. It measured anxiety symptoms in two age groups (pre-adolescent and adolescent) and between gender. Following previous research (e.g. [
42]), it was anticipated that anxiety symptoms would increase with age and that gender differences would be most evident in adolescence. In addition, the study measured the reliability (internal consistency and test–re-test reliability) and convergent validity of the SCARED. Following Hariz et al. [
31], it considered the association between self-report anxiety symptoms with a parent measure of emotional symptoms and behavioural difficulties. It also extended previous research to explore the factor structure of this measure in an Arabic population. The study has implications for understanding symptoms of anxiety in a developing population in Saudi Arabia and the use of the SCARED as an effective screening tool in this culture.
Methods
Participants
Children and adolescents living in Jeddah in the west of Saudi Arabia (n = 1100) aged between 9 and 15 years were randomly selected to take part from nine basic and elementary schools. All schools were from metropolitan regions, had single gender populations and represented diverse socio-economic backgrounds (as measured using postcodes). Of the initial 1100 students, 161 were excluded due to incomplete questionnaires. The final sample consisted of 939 participants (mean age = 11.70 years, SD = 1.82, 562 females); 609 children from basic (mean age = 10.59, SD = 1.14 years old, range = 9–12 years old) and 330 adolescents from elementary schools (mean age = 13.76 years, SD = .74 years old, range = 13–15 years old). Participation was dependent on gaining appropriate permissions from the School Boards and parents. Students completed the SCARED during regular classroom hours. In addition, a subgroup of children and adolescents (n = 223, mean age = 11.76, SD = 1.84) completed the SCARED again 2 weeks later to measure test–re-test reliability. In order to ensure data collection was administered in the same way between schools, research assistants read and followed manual guidelines.
Measures
The Screen for Child Anxiety Related Disorders (SCARED)
We used the 41 item child self-report version of the SCARED to measure anxiety symptoms in children and adolescents [
6,
7]. Thirteen items relate to panic/somatic symptoms (PN), 8 each to generalized anxiety (GD) and separation anxiety (SP), 7 to social phobia (SOC) and 4 to school phobia (SCH). It asks young people to judge for each item how true it is of them from never (0) to often (2). The possible score range is from 0 to 82 and evidence suggests that scores equal to or greater than 33 effectively discriminate between anxious and non-anxious youth [
6].
The Strengths and Difficulties of the Questionnaire (SDQ; [23])
We used the parent version SDQ questionnaire (for ages 4–16 years; [
24]). This measure includes 25 items across 5 subscales (5 items in each) linked to emotional symptoms, conduct problems, hyperactivity/inattention, peer problems, and pro-social behavior. Items are measured on a 3 point Likert scale reflecting how true the parent feels the statement is for their child (where 0 = not true, 1 = to some extent is true, and 2 = definitely true; score range = 0–10). The SDQ generates a total behavior difficulty score (from 0 to 40) based on items from all subscales (except the prosocial scale which is scored separately). The SDQ shows good reliability and validity [
24]. It has been translated into 74 languages and validated in Arabic [
3,
4].
The English versions of the SCARED and the SDQ were adapted and translated using the back-translation method. The two scales were translated into Arabic and then back-translated to English. The content of the final translated versions were checked to make sure that they were similar to the original English versions.
Discussion
The current study examined the psychometric properties and factor structure of the Arabic version of the SCARED (total anxiety and subscales reflecting symptoms of panic (PN), generalised anxiety (GD), separation anxiety (SA), social phobia (SC) and school avoidance (SH) in a non-clinical large school sample of children and adolescents in Saudi Arabia. The study explored the pattern of anxiety symptoms between age and gender, and it considered the proportion of young people who reported anxiety symptoms that were greater than the indicated clinical cut-offs. The study also measured the reliability and validity of this screening questionnaire. In addition, it looked at whether the proposed construct measurements (i.e., the five factor model of anxiety) represented a good model fit for this population. The study highlighted some important differences in SCARED scores and factor structure in this Arabic population compared to previous research.
The results indicate that the SCARED is a useful tool to measure anxiety symptoms in an Arabic population. Consideration of the psychometric properties showed that the scale had moderate to good internal consistency for total anxiety and four of the five subscales. In addition test–retest correlations were moderate or good for total anxiety and all subscales. The study therefore supported previous findings of the internal consistency and moderate test–retest reliability in the SCARED [
6,
7,
9]. The current study also considered associations between child self-report of anxiety symptoms and parent report of behavioural symptoms more broadly in a subset of the sample. The findings showed positive associations between these two measurements and provided good evidence for convergent validity of the SCARED total score and its five subscales in this population. The results fit well with previous research which has considered links between the SCARED and the SDQ (e.g. [
6,
7,
31,
36]).
The study further aimed to examine the suitability of the hypothesized structural model by considering the goodness of fit of the current data to the proposed factor structure reflecting five subscale measurements of panic/somatic symptoms, generalized and separation anxiety, as well as social phobia and school avoidance. The original hypothesized model did not show a good fit to the data. However, the systematic elimination of questionnaire items did generate a five factor model that showed a good fit to the data, indicating that the questionnaire and its subscale measurements could be applied to this population. These findings are consistent with previous studies that supported the SCARED five factor structure [
16,
28,
39,
43]. The reduction of items within each scale indicates that a narrower set of items reflects anxiety in children and adolescents in Saudi Arabia (e.g., symptoms associated with shyness for social anxiety or being alone or away from home/family for separation anxiety). Further research should aim to replicate this result in a further sample of children and adolescents in this country and Arabic cultures more widely.
Considering patterns of age and gender, the study is consistent with most studies (e.g. [
13‐
15,
28]) demonstrating elevated anxiety symptoms in girls compared to boys (where this difference was evident for total anxiety symptoms and subscales measuring panic and separation anxiety). In addition, the data showed reporting of anxiety symptoms diminished with age for total anxiety and each subscale, and where this reduction was significant for all variables except generalized anxiety disorder) and only evident for boys with respect to total anxiety, panic and separation symptoms (with girls showing stable symptoms over time). The results support previous research showing that in adolescence girls report increased emotional symptoms (including anxiety and depression) compared with boys (e.g. [
42]). One notable feature of the current data was that gender interacted with age, reflecting reduced total anxiety symptoms in boys from childhood to adolescence and a stable pattern of (comparatively) elevated symptoms across time in girls. The results highlight that girls in Saudi Arabia are at increased risk of experiencing elevated and chronic anxiety symptoms. Further longitudinal research is needed to explore these developmental and gender differences and specifically the different pathways between gender (i.e., the stable symptom pathway in girls and the high decreasing pattern seen in boys in this sample).
Considering clinical cut-offs on this measurement, the results found that a large proportion of children and adolescents (<50 %) endorsed anxiety symptoms and met the clinical cutoff for the SCARED. The results showed that around half of children (males and females) showed elevated symptoms using this screen, and that this percentage was also true for female adolescents (scores for adolescent males were typically reduced relative to the child scores). Other studies have found that this screening measure has identified around one-third of African American adolescents showing elevated symptoms [
9] and similar scores were found in a population of children from South Africa [
37,
39]. In addition, subscale scores in this sample were largely equivalent to other samples including Dutch children and adolescents [
28], but were greater than a Chinese school sample of adolescents [
43]. It is possible that cultural differences might account for elevated scores in children and adolescents in Saudi Arabia and further research should aim to understand the elevated endorsement of symptoms in this population. One alternative explanation of these results is that the use of a three point Likert scale can potentially lead to an over reporting of anxiety symptoms in some populations. For example, Krosnick and Presser [
34] noted that “moderate attitudes” (p. 269; those that do not sit in the neutral midpoint of a scale) can be difficult to endorse on a three point scale. They suggest that the inclusion of a Likert scale with five response options allows for a response that reflects some endorsement of a symptom (e.g., little or somewhat) and that does not require responding to either extreme point of a response scale. Modification of the response scale could potentially lead to a different score profile for children and adolescents in Saudi Arabia.
Summary
This study explored anxiety symptoms in a population of children and adolescents in Saudi Arabia using the SCARED. The results showed that this questionnaire was a reliable and valid tool for use in this population. In addition, the five factor structure represented a good fit to the data. The emergence of anxiety in this population and the different symptom profile for girls and boys (though somewhat elevated) was similar to the pattern of anxiety symptoms in other countries. They highlight that while boys showed a reduction of anxiety symptoms with age, girls showed stable and elevated anxiety symptoms over time, suggesting that they would benefit from a universal intervention at an early age to address the development of further mental health difficulties and adverse developmental outcome. The results are important for understanding cross cultural differences in disorders that can emerge early in childhood and that have a significant negative impact on development.
Acknowledgments
This project was funded by the Deanship of Scientific Research (DSR), King Abdulaziz University, Jeddah (Grant No: 125/011/PHRP 1434). The authors, therefore, acknowledge with thanks DSR technical and financial support.