Psychometric properties of the Screen for Child Anxiety Related Emotional Disorders (SCARED) in Brazilian children and adolescents

Abstract

The aim of this study was to evaluate the psychometric properties of the Brazilian-Portuguese version of the Screen for Child Anxiety Related Emotional Disorders (SCARED) in a large community sample of Brazilian children and adolescents. A total of 2410 students completed the 41-item Brazilian-Portuguese version of the SCARED. The one-factor and the five-factor structure of the SCARED fit this sample well. However, the five-factor model had a significantly better fit than the one-factor model and an adequate fit for age and gender subgroups. Anxiety symptoms in Brazilian youth were reported at a moderate-high level as compared to other studies. Females were found to score significantly higher on the total score and on all of the subscales as compared to the males. The total score and each of the five factors for both children and adolescents showed good internal consistency, test–retest and construct validity. According to our findings the Brazilian-Portuguese version of the SCARED is a reliable and valid instrument to assess anxiety in Brazilian children and adolescents.

Introduction

Anxiety disorders are one of the most common psychiatric disorders in children and adolescents. Epidemiological studies describe prevalence rates ranging from 2 to 4% for current or 3-month pediatric anxiety disorders, respectively. Six-month and 12-month prevalence rates vary between 10 and 20%, whereas lifetime rates are slightly higher (Costello, Egger, & Angold, 2005). These disorders are frequently comorbid with each other, as well as with other psychiatric disorders, mainly with major depression (Essau et al., 2000, Ginsburg and Silverman, 1996, Kendall et al., 2010). Childhood anxiety disorders are associated with impairments in academic, social, and family functioning (Essau et al., 2000, Messer and Beidel, 1994). Moreover, anxiety disorders in youths are strong predictors of other anxiety disorders, major depression, substance abuse and educational underachievement in adulthood (Buckner et al., 2008, Woodward and Fergusson, 2001). In addition, these disorders tend to be stable over time (Keller et al., 1992, Roza et al., 2003). These observations highlight the importance of understanding and screening pediatric anxiety.

Despite high prevalence and morbidity, anxiety disorders in youth are often unrecognized and underdiagnosed. This may happen because they are frequently comorbid with other psychiatric disorders and because anxious children cause fewer problems as compared to children with externalization disorders (Conolly & Bernstein, 2007). In addition, children may be more aware of their inner distress while parents or teachers may underestimate the severity or impact of anxiety symptoms in the child (Conolly & Bernstein, 2007). For these reasons, it is important to have reliable instruments that can screen and diagnose children who suffer from anxiety symptoms.

Structured and semistructured interviews have been used to evaluate anxiety disorders in youth, but they are highly time-consuming and require trained interviewers to be administered (Pavuluri and Birmaher, 2004, Silverman and Ollendick, 2005). On the other hand, self-report instruments are efficient, less expensive, and can initially be deployed as screening instruments to determine whether more detailed interviews should be subsequently employed to diagnose anxiety disorders in children and adolescents (Pavuluri and Birmaher, 2004, Silverman and Ollendick, 2005). With respect to the determination of anxiety disorder symptoms, many anxiety questionnaires are used, however, there is no consensus as to which self-report anxiety questionnaire is the best for screening anxiety disorder symptoms in youth. An extensive review of rating scales for internalizing disorders, suggested that the Screen for Child Anxiety Related Emotional Disorders (SCARED) is a very good self-report instrument to evaluate anxiety symptoms (Myers & Winters, 2002).

The SCARED was originally developed by Birmaher et al. (1997) as a screening tool for DSM-IV childhood anxiety disorders. It comprises 38-items that can be grouped into five anxiety symptoms subscales, specifically: panic disorder (PD), generalized anxiety disorder (GAD), separation anxiety disorder (SAD), social phobia (SP), and school anxiety (SA). Although the fifth subscale (SA) of the SCARED represents a common anxiety problem in children and adolescents, it is not a DSM-IV anxiety disorder. Due to difficulties in discriminating between the social phobia factor and other anxiety disorders, Birmaher et al. (1999) added three new items for social phobia, thus developing the final 41-item version of the SCARED. This new version also demonstrated that the five-factor structure was the best fit for the data (Birmaher et al., 1999).

The psychometric properties of versions of the SCARED have been consistently evaluated in clinical and community samples and in several countries such as the USA (Birmaher et al., 1997, Birmaher et al., 1999, Boyd et al., 2003, Haley et al., 2011, Monga et al., 1998, Wren et al., 2004, Wren et al., 2007), Belgium (Muris, Merckelbach, Ollendick, King, & Bogie, 2002), Germany (Essau, Muris, & Ederer, 2002), Spain (Vigil-Colet et al., 2009), Italy (Crocetti et al., 2009, Ogliari et al., 2006), the Netherlands (Hale et al., 2005, Muris et al., 1998, Muris et al., 1999b, Muris et al., 2004), South Africa (Muris et al., 2002b, Muris et al., 2006) and China (Su, Wang, Fan, Su, & Gao, 2008). Meanwhile, data had demonstrated that the SCARED presented good internal consistency as well as good test–retest reliability (Birmaher et al., 1997, Birmaher et al., 1999, Boyd et al., 2003, Essau et al., 2002, Haley et al., 2011, Muris et al., 1999b, Su et al., 2008), parent–child correlation (Birmaher et al., 1997, Muris et al., 1999b, Su et al., 2008, Wren et al., 2004), convergent validity (Boyd et al., 2003, Essau et al., 2002, Muris et al., 1998, Muris et al., 2002a, Monga et al., 1998, Su et al., 2008) and discriminant validity (Birmaher et al., 1997, Birmaher et al., 1999, Monga et al., 1998, Su et al., 2008). In general, these studies have suggested that the SCARED is a reliable and valid screening instrument to rate anxiety symptoms in children and adolescents. A recent meta-analysis (Hale, Crocetti, Raaijmakers, & Meeus, 2011) evaluating the cross-cultural psychometrics of SCARED suggested that this scale has robust psychometric properties and can be utilized as a screening instrument for the DSM-IV-TR's AD, PD, SAD, SP symptoms, and, to a lesser extent, for SA symptoms. This meta-analysis also suggested that the SCARED can be utilized in different countries as a cross-cultural screening instrument for DSM-IV-TR anxiety disorder symptom dimensions.

It is important to examine applicability and the psychometric properties of the SCARED in different cultures and countries. While North America and Europe have been well represented, there are only two African studies (both from South Africa), only one study from China and neither South America nor Brazilian studies concerning the psychometrics of the SCARED (Hale et al., 2011). Brazil is the largest and most populous country in South America and anxiety disorders are prevalent conditions in this population (Alselmi et al., 2010, Fleitlich-Bilyk and Goodman, 2004, Goodman et al., 2005). A study in the Southeast region, comprising 1251 Brazilian schoolchildren aged 7–14 years-old described a total prevalence rate of 12.7% for any psychiatric disorder and 5.2% for any anxiety disorder using the DSM-IV criteria (Fleitlich-Bilyk & Goodman, 2004). Despite the high prevalence of anxiety disorders, there is a lack of specific validated instruments to assess anxiety symptoms in Brazilian children and adolescents (Silva & Figueiredo, 2005). It is also important to evaluate the applicability of the SCARED for different gender (males and females) and age (child and adolescent) groups, since there is evidence that anxiety symptoms varies significantly between these groups (Hale et al., 2011).

Taking these findings into account, the main purpose of the present study was to assess the psychometric properties of the Brazilian-Portuguese SCARED in a large sample of Brazilian children and adolescents. Specifically, the aims of this study were: (1) to examine the factor structure of the Brazilian-Portuguese SCARED by means of Confirmatory Factor Analysis (CFA) and to compare a one-factor model to the theoretic five-factor model of the SCARED (Birmaher et al., 1997, Birmaher et al., 1999); (2) after determining which models have the best fit to the data for the subgroups, we then examine gender (males and females) and age (children and adolescents) differences on anxiety scores; finally (3) to examine the internal consistency, test–retest reliability, and the construct validity of the Brazilian-Portuguese SCARED.