The Screen for Child Anxiety Related Emotional Disorders(SCARED): Scale Construction and Psychometric

Characteristics

BORIS BIRMAHER. M.D.. SUNEETA KHETARPAL. M.D.. DAVID BRENT. M.D., MARLANE CULLY. M.En.,

LISA BALACH, M.A.. JOAN KAUFMAN. PH.D., AND SANDRA McKENZIE NEER, PH.D.

ABSTRACT

Objective: To develop a reliable and valid child and parent self- report instrument to screen children with anxiety

disorders. Method: An 85-item questionnaire was administered to 341 outpatient children and adolescents and 300

parents. Utilizing item analyses and factor analyses, the original scale was reduced to 38 items. A subsample of children

(n = 88) and parents (n = 86) was retested an average of 5 weeks (4 days to 15 weeks) after the initial screening.

Results: The child and parent Screen for Child Anxiety Related Emotional Disorders (SCARED) both yielded five

factors: somatic/panic, general anxiety, separation anxiety, social phobia, and school phobia. For the total score and

each of the five factors, both the child and parent SCARED demonstrated good internal consistency (a = .74 to .93),

test-retest reliability (intraclass correlation coefficients = .70 to .90), discriminative validity (both between anxiety and

other disorders and within anxiety disorders), and moderate parent-ehild agreement (r = .20 to .47, P < .001, all

correlations). Conclusions: The SCARED shows promise as a screening instrument for anxiety disorders. Future

studies using the SCARED in community samples are indicated. J. Am. Acad. Child Ado/esc. Psychiatry, 1997,

36(4):545-553. Key Words: children, adolescents, anxiety disorder, rating scales.

Anxiety disorders in children and adolescents are oneof the most prevalent forms of psychopathology, affect­ing as many as 10% of youth (Anderson, 1994; Bell­Dollan and Brazeal, 1993; Bernstein and Borchardt,1991; Kashani and Orvashel, 1990). These disorders areoften associated with psychosocial difficulties, schoolproblems. low self-esteem, and increased risk for otherserious conditions including depression. suicide, andsubstance abuse (e.g., Breslau et al., 1995; Keller et al.,1992; Klein, 1994; Lipsitz et al., 1994; Reinherz etal., 1993; Strauss et al., 1988).

Anxiety disorders are often unrecognized and under­diagnosed, despite their prevalence and associated mor-

Accepffd Ortobrr 3. I 'J'J6.From the Child Psychiiltry Department, Western Psychiatric lnstitute and

Clinic, Pittsburgh. Dr. Khrtarpal is nOli' u-ith the Department 01' Psychiatry,Uniuersity ofAlberta. Canada.

The 1II111",rs thank Therese Deisrroth jor her assistance in prepilring thismanuscript,

Reprint reqllests to Dr. Birmahrr, Western Psvchiatric lnstitute 'lIld Clinic.Department oj' Child Psychiatry, 311 II 0 'Hara Street, Pittsbllrgh, PA 15213.

08,)O-8'i67/,)7/J('04-0'i4'i$O.H)O/O~,) 1')')7 by the American Academy

of Child and Adolescent Psychiatry.

J. AM. A<.AIl. c.nn.n ADOlFSC. PSYCHIATRY..\6:4, APRil I'J'J7

bidiry, This may be due both to their frequent co­occurrence with other disorders, in particular depres­sion. as well as the covert nature of anxiety symptom­atology (Curry and Murphy, 1995; Kendall et al.,1992; Kovacs et aI., 1989).

Structured interviews have been used to reliablydiagnose anxiety disorders in children, but they aretime-consuming, they require trained interviewers, andtheir validity with regard to anxiety disorders still needsfurther research (for a review, see Costello et al., 1994;Klein. 1994; Silverman, 1994). Alternatively, one canuse rating scales to assess anxiety symptomatology.Three rating scales have been used to measure varioussymptoms of anxiety in children and adolescents: theRevised Children's Manifest Anxiety Scale (Reynoldsand Richmond, 1978), the Revised Fear Survey Sched­ule for Children (Ollendick, 1983), and the Cognitiveand Somatic State and Trait Anxiety Scale (CSSTAS)(Spielberger, 1973). In addition, the Social AnxietyScale for Children has been used to evaluate socialanxiety and fear of negative evaluation (LaGreca andStone, 1993). Overall, these self-reports possess moder­ate to high internal consistency and moderate test-

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retest reliability. While in som e studies the CSSTAShas been shown ro discriminate anxious from otherpsychiatrically disordered and normal children (Bell­Dollan et al., 1990; Hodges, 1990; Last, 1991), otherstud ies have questioned the discriminant validity ofthe above-noted scales (Hoehn-Saric et al., 1987; Matti ­son and Babn ato, 1987; Perrin and Last, 1992; Strausset al., 1988). Furthermore, while the currently usedrating scales are useful to assess general anxiety symp­tornatology, they do not diffe rentiate individual anxietydisorders (e.g., panic versus separation anxiety disor­ders) (Brad y and Kendall , 1992; Klein, 1994; Sil­verman , 1994; Stallings and March, 1995 ).

Thus, there appears to be a need for a practicalinstrument that would serve as a reliable and validscreening tool for anxiety disorders and also providediagnostic information about the rypets) of an xietyd isorder of the responder. For th is purpose, a self­report instrument, the Screen for C hild Anx iety RelatedEmotional Disorders (SCARED), for children and theirparents was developed ro screen for the followinganxiety disorders: general anxiety disorder (GAD), sepa­rat ion an xiety d isorder (SAD) , pan ic disorder, socialphobia, and school phobia. This article present s thescale construction along with internal con sistency, relia­bility, and discriminant validity stu d ies of theSCARED . A subsequent art icle will present the concur­rent and con vergent valid ity of the SCARED withother self-report instruments.

METHOD

First. a list of items with clinically relevant questions based onthe DSM -IV(A merica n Psychiatr ic Association. 1994) classificatio nof anxiety disord ers was generated. Thi s questionn aire was thenadministered to a small sample of children of various ages todetermine basic comprehension. Comments and criricisms fromthese children were used to mod ify questions with age-appropriateword ing and sentence constructi on . Eighty-five questions ident i­fying symptoms of SAD. GAD. pan ic disorder. social phobia . andschoo l phobia were included . in random order. th roughout thequestionnaire. Several of these 8S questions were similar in contentbur different in wording so as to provide an op portunity todetermine the best wording and sentenc e constructio n for children.Severity of symptoms was rated for the past .3 mon ths using a 0­to 2-point ratin g scale. with 0 mean ing not true or hardly evertrue. I meaning sometimes true. and 2 meanin g true or often true.

Patient s' psychiatri c diagno ses were made by interviewing bothchildren and parent s using one of two methods: a clin ical interviewwhich includes a comprehensive sympto m list for all DSM -I Vdiagnostic categories (Birrna her and Poling . unpubl ished) or theSchedule for Affect ive Disorders and Schizophrenia for School­Age C hildren-Present Episode (K-SADS-P) (Chambers cr al., 1985).

546

which was mod ified for anxiety disorders (Last, unpublished). Noone subject received both K-SADS and the clinical interview.

T o examine the test-retest reliability of the SCARED. a groupof children (n = 88) and parent s (n =86 ) were retested an averageof 5 weeks after the initial screening (range = 4 days to 15 weeks).

Sample

Three hund red forty-one consecut ive referrals to a mood/anxietydisorders clinic completed the SCARED. The children's ages rangedfrom 9 to 18 years (mean age 14.5 :t 2.3 years), 59% (n = 203)were female, 82% (n = 278 ) were Caucasian. and 18% (n = 63)were African-Ameri can . Of these child ren, 180 were interviewedwith the clinical interview and 16 1 with the K-SADS-P. Of the34 1 parents requested to fill out the SCARED parent version, 300parents completed the entire form .

Similar to other studies (e.g.• Angold and Costello. 1993 ; Kashan iand Orvashel, 1990; Last et al., 1987; Strau ss et al., 1988). themajori ty of the anxious child ren included in th is study had twoor more anxiety disorders and there was substantia l cornorbidirywith the depressive and disruptive disorders. O ne hundred sixty­nine children had an anxiety disorder (47 SAD . 89 GAD, 27social phobi a, 26 school phobi a. and 22 pan ic disorde r); 236 hada depressive diso rder (166 major depressive disorder, 54 dysthymia,4.3 depressive disorder not oth erwise specified); and 125 had adisruptive disorder (52 attention-deficit hyperactivi ty disorder, 97conduct/oppositional disorders) . Of the 341 children , 70 had pureanxiety disorders (defined as anxious children with out depressionand disrupt ive disord ers) (21 SAD. 25 GAD, 14 social phobia.19 schoo l phob ia, and 10 panic d isorder); 138 had pure depression(no anxiety and disruptive disorde rs) (92 major depress ive disorder ,26 dysthymia, 3 1 depressive disorder not otherwise specified);and 35 had pure disruptive disorders (no anxiety and depressivedisorders) ( )9 artent ion-deficir hyperactivity disorder . 26 conduct/oppositional d isorder).

Data Analysis

Data distributions were examined for normality using the Shapiroand Wilk Wstat istic (Shapiro and Wilk , 1965). Where significantlyno nnormal distributions were found, transformat ions were per­form ed to normalize the distr ibut ions before using parametrictests. In cases in which no transformation nor malized the data .non parametric statistics (e.g., Kruskal-Walli s) were used. Samplecharacteristics were compared using t tests, X. 2 tests, and Fisher 'sexact tests as appro priate.

Data from both the parent and child samples were analyzedusing item analysis and prin cipal-components factor analysis withvarimax rotation (Spector, 1992). Several facto r solutions wereanalyzed. Only those solutions with factors with eigenvalues greaterthan 1 and which were clinically sound were chosen. Internalconsistency was measured by means of coefficient a and parent­child correlati ons through Pearson correlations (r) .

Tes t-retest correlations were measured through inrraclass correla­tion coefficient s (ICCs) . In addition. because of the variability inthe test-retest intervals. part ial correlation analyses controll ing fordifferent time intervals were performed (SPSS, 1994). Analyses ofcovariance were used to test effects of age, sex, and race onall variables analyzed. Discrim inant validity was examined usingparametric and nonp arametric statistics (e.g.• ana lysis of variance)and receiver operating character istic (RO C) analysis (Mossman andSornoza. 1991 ; Somoza er al., 198 9; Somoza and Mossman , 1991).This method is a standard way of assessing multiple pairs of test

J. AM . ACAD . CII ILO ADOI.ES C. PSYC H IAT RY. .16 :4. AP R IL 19 9 7

sensitivities (rates of true positives) and specificities (rate of falseposit ives) at numerous cutoff scores.

For the most part, data from all the above-noted analyses showedsimilar results for both children and parents. Therefore. with fewexceptions. results will be presented using only the SCAREDchild form.

The K-SADS generated DSM-f1I-R (American Psychiatr ic Associ­ation. 1987) anxiety diagnoses, and the clinical interview generatedDSM-IV anxiet y diagnoses. Howe ver, analysis of the data frompatients interviewed with the K-SADS yielded results similar tothose obtained from analysis of data from patients interviewedwith the clin ical interview. Therefore, the data obta ined with thesetwo int erview methods were combined.

All values are reported as means :t SO . All P values are basedon two-tailed tests. Corrections for multiple comparisons wereperformed using the Bonferroni correction method.

. RESULTS

Scale Reduction and Internal Consistency

An item analysis was conducted with the purposeof reducing the original 85-item scale and to ensurethat items formed an internally consistent scale. Item­remainder correlation coefficients were derived for bothparent and child samples, and final scale reduction wasconducted by identifYing items with item-remaindercorrelation coefficients greater then .40. Items thatoverlapped with symptoms ofdepression were excluded(e.g., sleep problems, tiredness , irritability) . Four itemswith item-remainder correlation coefficients berween.30 and .39 were retained on the final 38-item scalebecause of their clinical relevance and included thefollowing items: "I get scared if I sleep away fromhome" (.32) ; "I worry about sleeping alone" (.39); " Ifollow my mother or father wherever they go" (.30);and "I don't like to be away from my family" (.38).The other 34 items had item-remainder coefficientsin the range of .40 to .69.

The original 85-item scale, and final 38-item scale,had coefficient ex values of .96 and .93, respectively,for the total score.

Factor Structure

Principal-components factor analyses with varim axrotation were conducted on the 85- and 38-item parentand child scales (Table 1). Both scales yielded identicalfive-factor solutions, with all factors having eigenvaluesgreater than 1. The factors were (1) somatic/panic, (2)generalized anxiety, (3) separation anxiety, (4) socialphobia, and (5) school phobia. The factor solutionshowed good internal consistency, with coefficient ex

j , AM . ACA D . C H I l. D ADO l. ESC. PSYCHI AT RY. j6:4. APRI l. 19 '>7

SCREEN FOR ANXI ETY D ISO RD E RS

values ranging from .74 to .89. The factor scoreswere relatively independent, however, with correl ationsamong individual factors ranging from .17 to .30.Children's scores on a given factor accounted for lessthan 10% of the variance in any of remaining factorscores.

Age, Sex, and Race Differences

T here were vety few age, sex, or race differences inboth parents' and children's responses to the items onthe SCARED. In the child report, younger children(aged 9 to 12 years, n = 61) had significantly higherseparation anxiety scores than older children (> 12years old, n = 280) (4.9 ± 3.8 versus 2.1 ± 2.5, l UI'! =5.36, P < .00 1). However, no age differences werefound on the parent report.

The child and parent total anxiety scores, gener alizedanxiety, separation anxiety, panic, and school phobiafactors were significantly high er in females th an inmales (all noted comparisons p < .05).

There were no race differences in the child SCARED.In the parent SCARED, African-American childrenhad significantly higher scores on the separation anxietyfactor (3.8 ± 3.3 versus 2.6 ± 3.1, tl.!'J7 = 2.0 , P = .05,after Bonferroni correction) than Caucasian children.

Parent-Ghild Correlations

Parent-ehild correlation for the tot al anxiety scorewas r = .33, and for specific factors, correlations rangedfrom a low of .20 for social phobia to a high of .47for SAD and school phobia (all noted comparisons p< .00 1). There were no age, sex, and age or sex bydiagnosis effects on the parent-child correlations.

Test-Retest Reliability

A total of 88 children and 86 parents completedthe SCARED on rwo different occasions ranging from4 days to 15 weeks apart (median time: 5 weeks), with79% of these children completing the SCARED within8 weeks of the original dat e of completion. ICCs were.86 for the total score, .70 to .90 for the individualfactors , and not significantly different if calculatedseparately for children who completed retest before orafter 5 weeks. When ICCs were recalculated controllingfor retest time intervals, they were somewhat lower,but not significantly different.

There were no age, sex, or age or diagnosis by ageor sex effects on the test-retest correlations.

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Table 1. Factor Analysis (38-ltem SCARED)*

'Factor 1: Items 1,6,9,12,15,18,19,22,24,27,30,34,38; Factor2: Items 5,7,14,21,23,28,33,35,37;

Factor3: Items 4, 8, 13, 16, 20, 25, 29, 31; Factor 4: Items 3, 10, 26, 32; Factor5: Items 2, 11, 17, 36

548 J. AM . ACAD . C H I l. D AD O l.E SC. PSYCH IATRY . ,\6 :4 . AP RI l. 1'19 7

SC REEN FO R ANX IETY DISOR DERS

TABLE 2Co mparison of Anxiery Disorders With O ther Nonanxiery Psychiatric Disorders (Child Form)

Anxiery Cases Nonanxiery CasesChild Form (n = 169) (n = 172) t Value p Value

T otal score 26 .76 + 14.68 17.24 :!:: 12.06 6.54 <.000 1Facto r I (panic/somatic) 6.86 :!:: 6.09 3.87 :!:: 4.22 5.28 <.000 1Facto r 2

(general anxiety) 9. 14 :!:: 4.92 6.58 :!:: 4.77 4.87 <.000 1Facto r 3

(separation anxiery) 3.45 + 3.36 1.84 + 2.30 5.14 <.000 1Factor 4

(social phobia) 3.69 :!:: 2.54 2.73 :!:: 2.43 3.56 .0004Factor 5

(school phobia) 2.58 :!:: 2.05 1.43 :!:: 1.56 5.84 <.000 1

N ote: Values represent mean rr SD.

Discriminant Validity

1. Comparison ofAnxiety Disorders as a Group WithNonanxiety Psychiatric Disorders. As depicted in Table2, the total score and the total scores for each of thefive factors from the child SCARED form significantlyd ifferentiated children with anx iety disord ers (n = 169 )from those with nonanxiety psychia tr ic disorders(n = 172).

2. Comparison ofChildren With PureAnxiety. Depres­sion. and Disruptive Disorders. Table 3 compares chil­dren with pure anxiety (n = 70), depressive disorders(n = 138), and disruptive disorders (n = 35) .

Children With Pure Anxiety Versus Pure Disrupti veDisorders. The total anxiety and each of the five factorssignificantly differentiated children with anxiety disor­ders from tho se with d isruptive disorders ( p values <.05) (Table 3).

Children With Pure Anxiety Versus Pure DepressiveDisorders. The separati on anxiety and school phobiafacto rs from both ch ild and parent form s, and thesoma tic/panic anxiety factor from the parent form,significantly discriminated betw een anxious and de­pressed child ren (p values < .05 ) (Table 3) .

3 . Comparisons Within Individual Anxiety Disorders.C hild ren with panic disorder (n = 22 ) showed signifi­cantl y higher scores on the soma tic/panic factor thanchildren with other anx iety disorders (n = 151) (I3.0± 6.1 versus 6.0 ± 5.6, tW I = 5.39, P = .000 1,respectively). Child ren with GAD (n = 90) showedsignificant ly higher sco res on the GAD facto r thanchildren with other anxiety disorders (n = 83 ) (11.0± 4.4 versus 7.2 ± 4.9, t l,) 71 = 5.39, P = .0001 ,respectively), and child ren with SAD (n = 48) showedsignificantly high er scores on the SAD factor than

TABLE 3Comparison of Children Wit h Pure Anxiety, Depression, and Disrupt ive Disorders (Child Form)

Anxiety Depression Disruptive Stat istics

Child Form ( n = 70) ( n = 138) in = 35) F P Value

Total score 22.89 :!:: 13.16" 18.80 :!:: 11.81" 11.09 ::!: 1l.1 5b 11.05 .00 1Factor I (panic/somatic) 5.47 :!:: 4.70" 4.27 :!:: 4.34" 2.26 :!:: 3.33" 6.48 .00 1Factor 2

(general anxiery) 7.37 :!:: 4.50 " 7.23 :!:: 4.68" 4.03 :!:: 4.031, 7.59 .00 1Factor 3

separatio n anxiery) 3.5 1 :!:: 3.53" 1.96 :!:: 2.36" 1.37 :!:: 2.02 1, 10.16 .00 1Factor 4

(social phob ia) 3.33 :!:: 2.44" 2.94 :!:: 2.50"" 1.91 ::!: 1.981,·, 4.04 .0 1Factor 5

(school phobia) 2.39 ::!: 1.99" 1.56 :!:: 1.581, 0.89 ::!: 1.37'" 10.41 .00 1

No te: Values represent mean :!:: SD . Means not shar ing a superscrip t letter are significant ly different . All analyses were protected formult iple comparisons using Bonferron i correction meth od.

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children with other anxie ty disord ers ( n = 126) (5.92: 4 . 1 versus 2.5 2: 2.4, t i n = 5.45, P = .0001,respectively) . For children with social ph obia or schoolphobia, onl y the parent report was significantly d iffer­ent , with social-phobic children ( n = 28) and scho ol­phobic children ( n = 25) having higher scores on thesocial phobia (4.8 2: 2.5 versus 3.3 2: 2.6, t l,l (,7 =2.72, P = .007) and school phobia facto rs (6.0 2: 2.0versus 4.5 2: 2.8, t l, l ('(' = 3. 13, P = .003) , respectively,than children with other anx iety d isorders.

4. Receiver Operating Characteristic Analysis: Sensitiv­ity and Specificity. RO C analyses were carried out usingthe SCARED total anxiety and indi vidual factor scores.T o assess whether any specific cuto ff scores sign ificantl ydiscriminates between anxious and non anxious chil­dren , the ROC method was used (e.g., Somoz.a et al.,1989). The optimal cutoff point is det ermined byplotting sensitivity versus 1 - specificity and examin ingthe point of max imum deviation from chance.

Fo r illustration , Figure 1 shows the child total anxie tyscore ROC cu rve comparing pure anxiety (n = 70)versus pure nonanxiety psychiatric disorders (n = 173),pure anxiety versus pure depression (n = 138), andpure anxiety versus pure disruptive disord ers ( n = 35).

Table 4 shows the optimal cutoff scores with theirrespective sensitivity and specific ity values derived fromthe ROC obtained for the comparison among pureanxi ety, depression, and disruptive disorders.

Pure Anxiety Versus Non anxiety Psychiatric Disorders.The area under the curve (AUC ) for the total anxietysco re was .70 ( p = .0001) . The AUCs for each individ­ual facto r ranged between .86 for the som atic/pani cfactor to .66 for the social phob ia factor. All weresignificantly different from the random AUC (p valuesbetween .05 and .000 1).

Pure A nxiety Versus Pure Disruptive Disorders. TheAUCs for the comparison of anxiety with disruptivedisorder for the total anxiety score and each individual

0.8

anxiety vsdepression

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(AUC= .5 6, p=O .02 )

0.80 .7

anxiety vsdisruptive

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anxiety vs all othernon anxietypsychiatric disorders(AUC= .70 , p <O.OOOI) (AUC= .76 , p <O.OOOI)

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1 - False Positive Rate (Specificity)Fig. 1 C h ild to ta l anx iety sco re: estimat ed binormal RO C co m paring pure anxiety ( n = 70) versus pu re nona nxiety psychiat ric disorders ( n = 173), pure

anxiety versus pure disrup tive d iso rde rs ( n = 35) , and pure anx iety versus pure d epression (n = I3R). ROC = receiver operat ing character ist ic cu rve; AVe =

aH.'3 under th e cu rve .

550 J. AM . AC A D . C H I I. O AD O I. ES C . PSYC H IAT RY, .H>:4 . AP R Il. 19 9 7

SCREEN FOR ANXIETY DISORDERS

TABLE 4Pure Anxiety, Depression, and Disruptive Disorder ROC Analysis: Cutoff Scores;

Sensitivity and Specificity (Child Form)

Maximum OptimalScore Cutoff

Sensitivity(%)

Specificity(%)

Total anxiety score 76 15 70Factor I (panic/somatic) 26 9 80Factor 2 (general anxiety) 18 8 72Factor 3 (separation anxiety) 16 4 76Factor 4 (social phobia) 8 4 7 1Factor 5 (school phobia) 8 3 67

508464805958

Note: Anxiety: n = 70; depression: n = 138; disrupt ive disorder : n = 35. ROC = receiver operat ing character istic curve.

factor ranged between .68 and .78. All were significantlydifferent from the random AVC (all Pvalues < .000 1).

PureAnxiety Versus PureDepression. The comparisonwith depression yielded AVCs for the total anxiety,somatic/panic, separation anxiety, and school phobiafactors of approximately .60. All were significantlydifferent from the random AVC (all p values < .02) .AVCs for GAD and social phobia were nonsignificant.

DISCUSSION

The purpose of this study was to develop an empiri­cally derived self-report instrument for use in clinicalsettings that would screen for DSM-IVchildhood anxi­ety disorders.

The child and parent SCARED each produced fiverobust factors: somatic/panic anxiety, general anxiety,separation anxiety , social phobia, and school phobia.The first four factors correspond to their DSM-IVcounterparts. School phobia is not a DSM-IVdiagnosticcategory, but it is a common clinical entity that isseen both comorbidly and independently from otheranxiety disorders (Berg, 1993) .

The SCARED demonstrated good reliability as mea­sured by internal consistency and test-retest reliability.

. Comparable with the parent--ehild correlations for psy­chiatric symptoms reported in the literature (e.g., Her­janic and Reich, 1982; Kashani et al., 1985; Klein,1994; Rapee et al., 1994; Weissman et al., 1987), theSCARED showed moderate parent--ehild correlationswith a correlation of .33 (p = .001) for the totalanxiety score. Aswould be expected, lower parent-childcorrelations were seen with more covert behaviors aswas found in adolescents with social phobia (r = .20,P = .001), and higher parent-child correlations inchildren with more overt behaviors, such as in children

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with separation anxiety or school phobia (r = .45,P = .001).

The SCARED showed good discriminant validity,both between children with anxiety versus nonanxietydisorders and among individual anxiety disorders. TheSCARED did particularly well differentiating anxietydisorders from disruptive disorders. The SCARED alsodiscriminated children with anxiety and depression onthe child's total score, somatic/panic, separation anxi­ety, and school phobia factors. Despite the fact thatitems with symptoms that correspond to depressionwere excluded from the SCARED, there was significantoverlap between the anxiety and depressive disorders.Similar results have been reported in adult studies (fora review see Clark and Watson, 1991; Somoza et al.,1994). It is not surprising that anxiety and depressionmeasures in general do not discriminate well betweenanxious and depressed patients (e.g., Eason et al., 1985;Norvell et al., 1985; Ollendick and Yule, 1990; Sornozaet al., 1994; Wolfe er al., 1987) . First, genetic, familyaggregation, epidemiological, nosological, and biologi­cal studies have shown a strong relationship betweenanxiety and depression in adult and youth populations(e.g., Angold and Costello, 1993; Biederman et al.,1995; Birmaher et al., 1996; Kendler et al., 1994;Kovacs et al., 1989; Kutcher and Marton, 1991; Rohdeet al., 1991; Warner et al., 1995; Weissman et al.,1993; Williamson et al., 1995) . Second, anxiety anddepression rating scales frequently include similar itemswhich are endorsed by both depressed and anxiouspatients, which accounts, in part, for the high intercor­relation between anxiety and depression scales (for areview, see Brady and Kendall, 1992) . In this study,however, some items that potentially could be endorsedby both depressed and anxious children, such as tired­ness and sleep problems, were excluded from the finalversion of the SCARED.

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The results of this study need to be considered inlight of the following limitations. First, the SCAREDwas constructed using a clinical sample of children;therefore, results cannot be generalized to communitysamples. In the future, we plan to use the SCAREDin a community sample to determine its utility innonreferred samples. Second, the SCARED is basedon the DSM-IVcategorization of anxiety disorders andwe do not know how well the DSM-IV reflects thestructure of anxiety disorders in clinical or communitysamples. Subsequent studies will compare the SCAREDwith anxiety scales not tied to the DSM classification,e.g ., CSSTAS. Third, with some exceptions, theSCARED significantly differentiated depression fromanxiety, but still there were substantial overlaps betweenthese two disorders. However, the differentiation be­tween anxiety and depression may not be practical orecologically valid because of the frequent cornorbidiryand shared symptomatology between these two sets ofdisorders. Fourth, the social phobia factor did notdiscriminate as well as other factors between anxiouschildren and children with other disorders. This findingmay account for the small number of children withsocial phobia included in the study, or it may be theresult of the SCARED items for social phobia failingto tap this disorder. Future studies will include largersamples of social-phobic children and will focus onpotentially modifying this section to improve itsperformance.

In summary, the SCARED is a promising scale toidentify children aged 9 to 18 years with anxietydisorders in clinical samples; however, the use of theSCARED in nonreferred samples needs to be evaluated.The SCARED is recommended as a screening tool foranxiety disorders in clinical samples of children aged9 to 18 years, but it should not replace the formalclinical interview. Further investigation will determineits utility in epidemiological and other research studies(e.g., pharmacological, biological).

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