Penn State Worry Questionnaire for Adults (PSWQ-A)

Developed in America in 1990, the Penn State Worry Questionnaire for Adults (PSWQ) is the measure most frequently used to assess trait pathological worry in adults (Meyer, Miller, Metzger, & Borcovec, 1990). The PSWQ is a 16-item self-report questionnaire, derived from a factor analysis of 161 items believed to be related to worry. It is intended to measure an individual’s disposition to worry, as well as the frequency, intensity, and tendency for worry to be generalised (Meyer et al., 1990). Respondents are asked to rate each item on a 5-point Likert scale ranging from 1 (“not at all typical of me”) to 5 (“very typical of me”). Eleven of the items are positively scored in the direction of pathological worry (e.g. “my worries overwhelm me”), while the remaining five items require reverse scoring and indicate worry is not a problem (e.g. “I never worry about anything”). The scores from each item are added together to yield a total score that ranges from 16-80, with higher scores representing higher levels of pathological worry (Meyer et al., 1990).

The PSWQ is not a diagnostic tool; however, it is useful as a screening tool to detect pathological worry, and to evaluate therapeutic changes on worry (Meyer et al., 1990). It also successfully distinguishes GAD from other anxiety disorder groups, such as Post Traumatic Stress Disorder (Brown, Antony, & Barlow, 1992). Most GAD patients tend to show higher PSWQ scores (above 50), although some people with other diagnoses may sometimes report PSWQ levels similar to those with GAD (e.g. depression in Starcevic, 1995). This may be the result of high levels of comorbid GAD, or possibly because the DSM-IV does not allow a diagnosis of GAD if symptoms occur during episodes of other disorders (Chelminski & Zimmerman, 2003).

The PSWQ has been shown to have good internal reliability in samples consisting of older adults with GAD (Generalised Anxiety Disorder), community samples, and undergraduates, with cronbach alphas ranging from .88 to .95 (Startup & Erickson, 2006). It has also demonstrated favourable test-retest reliability over 8-10 weeks in a sample of college students (r= 0.92) (Meyer et al., 1990). In both clinical and community samples, the PSWQ has shown high convergent validity with other worry questionnaire measures, such as The Worry Domains Questionnaire (r=.67) (Tallis, Eysenck, & Mathews, 1992), and the student worry scale (r=.59) (Davey, Hampton, Farrell, & Davidson, 1992), and has shown high discriminant validity as it correlates significantly with anxiety and depression as measured by the State Trait Anxiety Inventory (trait r= .64-.79, state r = .49) (Meyer et al., 1990; Spielberger, Gorsuch, Lushene, Vagg, & Jacobs, 1983) and the Beck Depression Inventory (r= .36-.62) (Beck, Ward, Mendelson, Mock, & Erbaugh, 1961; Meyer et al., 1990).

It is also important to consider whether scores remain stable across demographic groups, or if any individual factors impact the PSWQ’s psychometric properties. With the regard to gender, no differences have been found (Meyer et al., 1990). In addition, the PSWQ has demonstrated to be valid in cross cultural populations, yielding good psychometric properties in samples in Korea (Lim Kim, Lee & Kwon, 2008), India (Parikh & Chhibber, 2016), and Germany (Stöber, 1995). In contrast to ethnicity, age is a factor that may influence PSWQ scores. Older adults have reported significantly lower scores than younger adults in both community (Gillis et al., 1995) and clinical samples (Hopko et al., 2003). Furthermore, older age may also impact the psychometric properties, as the PSWQ has demonstrated reasonable internal reliability and validity for this age group, but poor test-retest reliability (Davey & Wells, 2006). When a test has poor test-retest reliability, it makes it unclear whether the data is an accurate representation of a participant’s performance or whether extraneous variables interfered.

A major limitation of the PSWQ is that it does not capture worry changes over short periods of time. In some situations, a more frequent assessment of pathological worry is needed. To meet the need for a more frequent worry assessment, Stober and Bittencourt (1998) developed the PSQW- Past Week for weekly assessments of worry which also has good psychometric properties. Overall, the PSWQ appears to have sound psychometric properties and sensitivity to treatment change. It is a good choice for research and clinical studies to assess the intensity of pathological worry and to discriminate GAD from other disorders (Turk, Heimberg, & Mennin, 2004).

References

Beck, A.T., Ward, C. H., Mendelson, M., Mock, J., & Erbaugh, J. (1961). An inventory for measuring depression. Archives of General Psychiatry, 4, 561-571.

Brown, T. A., Antony, M. M., & Barlow, D. H. (1992). Psychometric properties of the Penn State Worry Questionnaire in a clinical anxiety disorders sample. Behaviour Research and Therapy, 30(1), 33-37.

Chelminski, I., & Zimmerman, M. (2003). Pathological worry in depressed and anxious patients. Journal of Anxiety Disorders, 17(5), 533-546

Davey, G. C., Hampton, J., Farrell, J., & Davidson, S. (1992). Some characteristics of worrying: Evidence for worrying and anxiety as separate constructs. Personality and Individual Differences, 13(2), 133-147.

Davey, G., & Wells, A. (2006). Worry and its psychological disorders. Chichester, England: Wiley. Gillis, M. M., Haaga, D. A., & Ford, G. T. (1995). Normative values for the Beck Anxiety Inventory, Fear Questionnaire, Penn State Worry Questionnaire, and Social Phobia and Anxiety Inventory. Psychological Assessment, 7(4), 450.

Hopko, D.R., Stanley, M.A., Reas, D.L., Wetherell, J.L., Beck, J.G., Novy, M.D., Averill, P. M. (2003). Assessing worry in older adults: confirmatory factor analysis of the Penn State Worry Questionnaire and psychometric properties of an abbreviated model. Psychological Assessment, 15, 173–183.

Lim, Y. J., Kim, Y. H., Lee, E. H., & Kwon, S. M. (2008). The Penn State Worry Questionnaire: Psychometric properties of the Korean version. Depression and Anxiety, 25(10).

Meyer, T. J., Miller, M. L., Metzger, R. L., & Borkovec, T. D. (1990). Development and validation of the Penn State Worry Questionnaire. Behaviour Research and Therapy, 28(6), 487-495.

Parikh, S., & Chhibber, K. (2016). Use of the Penn State Worry Questionnaire to identify individuals with GAD: An Indian perspective. Journal Psychology and Clinical Psychiatry, 6(5).

Spielberger, C. D., Gorsuch, R. L., Lushene, R., Vagg, P. R., & Jacobs, G. A. (1983). Manual for the State-Trait Anxiety Inventory. Palo Alto, CA: Consulting Psychologists Press.

Startup, H. M., & Erickson, T. M. (2006). The Penn State Worry Questionnaire (PSWQ). In G. C. L. Davey, & A. Wells (Eds.), Worry and Its Psychological Disorders: Theory, Assessment and Treatment, 101-119. Chichester: Wiley.

Starcevic, V. (1995). Pathological worry in major depression: A preliminary report. Behaviour Research and Therapy, 33(1), 55-56.

Stöber, J. (1995). Worrying: A comparison of three questionnaires concerning everyday worries. Zeitschrift fuer Differentielle und Diagnostische Psychologie, 16, 50-63.

Stoeber, J., & Bittencourt, J. (1998). Weekly assessment of worry: an adaptation of the Penn State Worry Questionnaire for monitoring changes during treatment. Behaviour Research and Therapy, 36(6), 645-656.

Tallis, F., Eysenck, M., & Mathews, A. (1992). A questionnaire for the measurement of nonpathological worry. Personality and Individual Differences, 13(2), 161-168.

Turk, C. L., Heimberg, R. G., & Mennin, D. S. (2004). Assessment of worry and generalized anxiety disorder. In R. G. Heimberg, C. L. Turk, and D. S. Mennin (Eds.), Generalized anxiety disorder: Advances in research and practice, 219–247. New York: Guilford.

Child Anxiety Life Interference Scale (CALIS)

Commonly, clinical measures of children’s anxiety focus on the assessment of disorder symptoms to support formal diagnoses. This has led to assessments of anxiety symptom impact or “anxiety life interference” becoming less common, despite reductions in these impairments contributing to clients’ treatment satisfaction (Lyneham, et. al., 2013). Consequently, the Child Anxiety Life Interference Scale (CALIS; Lyneham, et. al., 2013) was developed to provide a psychometrically supported method of evaluating the impact that children’s anxiety has on their life, as well as on the life of their parents.

Developed at the Centre for Emotional Health at Macquarie University in Sydney, Australia, the CALIS consists of one 10-item scale administered to children, and two 9-item scales administered to parents. The scale administered to children evaluates self-reported anxiety life interference; the scales administered to parents evaluate child anxiety life interference relative to the child’s life, and child anxiety life interference relative to the parents’ life. All items, which relate to common activities (e.g. “being with friends outside of school” or “your career choice”), are rated on a five-point Likert scale (0 = not at all, 4 = a great deal), with higher scores indicating higher anxiety life interference.

Psychometric Properties

Currently, psychometric data for the CALIS is based exclusively on one evaluative study (Lyneham, et. al., 2013); this study administered the scale to 622 Australian or American children with anxiety disorders, aged between 6 and 17 years.

According to this study, the CALIS demonstrates moderate internal consistency, with Cronbach’s Alphas ranging from .84 for children to .90 for mothers. The CALIS also demonstrates moderate inter-rater reliability between parents and children, which is consistent with previous studies that have identified differences in children and parents’ perceptions of anxiety (Niditch & Varela, 2011). Lastly, the CALIS demonstrates strong test-retest reliability; pre- and post-waitlist administrations of the CALIS produced significant correlations.

Clinical Utility

The use of the CALIS in clinical settings is supported by psychometric data that indicates that it is a significant, valid and reliable measure of anxiety life interference. The CALIS contributes to the development of a comprehensive understanding of a child’s experience of anxiety by using multiple raters to evaluate its impact across multiple activities. Additionally, the CALIS can be used to inform treatment decisions by indicating the domains in which a child is most significantly impaired, as well as provide an indication of overall treatment efficacy. However, due to limited evaluations of the scale’s psychometric properties, the CALIS should be used and interpreted with caution; limited data relating to the impact that cultural differences may have on psychometric properties. Furthermore, Lyneham et. al. (2013) advise that the CALIS be used in conjunction with symptom-specific scales, as it cannot independently support a diagnosis of anxiety.

CALIS freely available from: http://www.mq.edu.au/

References

Lyneham, H., Sburlati, E., Abbott, M., Rapee, R., Hudson, J., Tolin, D., & Carlson, S. (2013). Psychometric properties of the Child Anxiety Life Interference Scale (CALIS). Journal of Anxiety Disorders, 27(7), 711-9.  doi: 10.1016/j.janxdis.2013.09.008

Niditch, L., & Varela, R. (2011). Mother-child disagreement in reports of child anxiety: Effects of child age and maternal anxiety. Journal of Anxiety Disorders, 25(3), 450-5. doi: 10.1016/j.janxdis.2010.11.009

Kutcher Generalised Social Anxiety Disorder Scale for Adolescents (K-GSADS-A)

The Kutcher Generalised Social Anxiety Scale for Adolescents (K-GSAD-A) is an instrument developed to monitor the symptom severity of social anxiety problems in children or adolescents (11-17 years of age) over time (Brooks & Kutcher, 2004). It was developed by Professor Stanley Kutcher (an expert in child and adolescent mental health) in conjunction with input from doctors and nurses with many years’ experience in treating and monitoring the symptoms of adolescents with social anxiety. When it was developed in 1999, no such clinician-rated scales existed. Psychometric properties of this scale were evaluated in a later drug trial study using adolescent subjects from the USA, South Africa, Canada and Belgium (Brooks & Kutcher, 2004).

Psychometric Properties

Items

The K-GSAD-A has three sections. In section A there are 18 items relating to fear and avoidance (of social situations). Each item is rated on two scales, the first being discomfort/anxiety/distress experienced, and the second being avoidance. Items are rated using a four-point scale of strength of fear/avoidance, ranging from 0= ‘never’, 1= ‘mild’, 2= ‘moderate’, and 3= ‘severe’. In section B, the respondent is asked for three of their most feared social situations which are also rated on the above four-point scales. Section C consists of 11 items relating to affective and somatic distress measured on the same scale.

Reliability

Cronbach’s alphas of the instrument (subscales and total) averaged between .74 and .96 across the 5 assessments times of the 16 week trial. Thus the internal consistency was at least acceptable (in most social science research), and is in the majority of cases excellent.

Test-retest reliability was found to be on the lower end of adequate, as adolescents in the placebo condition had a test-retest intraclass correlation of .64 across a 4-week interval. This means that the adolescents that did not receive the drug had a somewhat similar score at baseline and at 4 weeks, meaning that there was a minimal level of consistency and reproducibility.

Validity

There were moderate correlations between the K-GSADS-A Total Score (see below) and two illness-nonspecific clinician rated measures in the expected direction (see Brooks & Kutcher, 2004). There was also a very strong correlation between the K-GSADS-A and another clinician rated measure of paediatric social anxiety (the LSAS-CA) which was new and recently validated when this paper was written. The K-GSADS-A additionally strongly correlated with a scale designed very similarly to itself, however was self-reported (the SPAI; Brooks & Kutcher, 2004). All the above correlations therefore demonstrated convergent validity. On the other hand, a depression measure was shown to correlate weakly indicating divergent validity.

Sensitivity to change

Changes between the 5 assessment occasions mirrored corresponding changes in other instruments (see Brooks & Kutcher, 2004)

Subscale scores

The Fear and Anxiety Score is made of Items A 1-18, using the anxiety column. The Avoidance Score is made of Items A 1-18, using the avoidance column. The Affective Distress Score is made of Items C 1-5, while the Somatic Distress Score is made of Items C 6 – 11. The Total K-GSADS-A Score is made of the addition of the four subscale scores.

Interpretation of scores

Diagnostic categories are not associated with particular score ranges. Rather, scores should be assessed in relation to the young person’s baseline score to see if there is a worsening of social anxiety (increase in scores) or a possible improvement (reduction in score).

Access and uses

K-GSADS-A is available at no cost at http://teenmentalhealth.org/product/kutcher-generalized-social-anxiety-scale-adolescents-kgsads/ under ‘toolbox’. Suitable administrators include mental health specialists, as well as doctors, nurses and social workers who have experience working with socially anxious adolescents. More recently, the test has been use in a normative sample in Pakistan to show that female adolescents have an increased level of social anxiety compared to males (Inam, Khalil, Tahir, & Abioudullah, 2014). A negative correlation with social anxiety and emotional intelligence was also found (Inam et al., 2014.

References

Brooks, S. J., & Kutcher, S. (2004). The Kutcher Generalized Social Anxiety Disorder Scale for Adolescents: Assessment of its evaluative properties over the course of a 16-week pediatric psychopharmacotherapy trial. Journal of Child and Adolescent Psychopharmacology, 14(2), 273-286. doi: 10.1089/1044546041649002

Inam, A., Khalil, H., Tahir, W. B., & Abiodullah, M. (2014). Relationship of emotional intelligence with social anxiety and social competence of adolescents. Nurture, 8(1), 20-29. Retrieved from https://search-proquest-com.ezproxy.lib.monash.edu.au/docview/1807744503?accountid=12528

Depression Anxiety Stress Scale (DASS)

Initially introduced as the DASS – 42, a self-report questionnaire measured on 4 Likert ratings assessing the levels of severity of depression, anxiety and stress. The DASS takes a dimensional approach rather than a categorical (P.F. Lovibond, & S.H. Lovibond,1995; Psychology Foundation of Australia, 2014).
Originally developed at the university of New South Wales, Australia. First developed by using a sample of 1st year psychology students. Shortly after, the revised version of the DASS-21 was developed to reduce administration and test-taker time. The DASS-21 has 7 items designated to each subscale of depression, anxiety and stress.

The DASS has been widely used in both clinical and non- clinical samples and showed excellent reliability and validity across both the clinical and non-clinical samples. Many studies, using factor analysis have confirmed that the items all load accurately making up each subscale of depression, anxiety and stress.  The DASS shouldn’t be used to simply diagnose a person with depression as it’s important to for the clinician to use their clinical judgement and expertise as well.

The tool has been translated in different cultures such as variety of Asian cultures. However, due to it being standardised and developed within a westernised framework, it has been suggested that it’s validity may be comprised when employed in collectivist cultures. This is because collectivist cultures perception of depression, stress and anxiety is somewhat different.

References
Lovibond, P.F, & Lovibond, S, H. (1995). The structure of negative emotional states: comparison of the depression anxiety stress scales (DASS) with the Beck depression and anxiety inventories. Journal of Behaviour Research and Therapy, 33 (3).
Psychology Foundation of Australia. (2014). Depression anxiety stress scales (DASS). Retrieved from http://www2.psy.unsw.edu.au/dass/

Children’s Somatization Inventory (CSI-24)

Background
The Children’s Somatization Inventory (CSI-24; Walker, Garber, & Greene., 1991) is a revised version from the original Children’s Somatization Inventory conceptualized by Walker and Colleagues in 1991. The original version of the CSI consisted of 35 items corresponding with symptoms consistent with the DSM-III-R criteria for Somatization Disorder. In 2009 the CSI was reviewed and a shorter version, consisting of 24 items, was created. The revised version was the result of eliminating 11 items that were rarely endorsed and had low item-total correlations.
There has been some controversy over the factorial structure of the instrument. Factorial Analysis of the CSI-24 found it not to be considered a strictly uni-dimentional instrument as although its items load onto one factor, with positive standardized factor loadings, the fit was found to be poor (Walker, Garber, & Greene., 1991). Further research has suggested that a 6-item one factor instrument demonstrates a better fit and adequate psychometric properties (Orgiles & Espada, 2013).
Validation
The inventory was conceptualized using a predominantly Caucasian clinical sample with a primary complaint of chronic abdominal pain, but this instrument has since been found a valid measure in community populations (Lavigne, Saps, & Bryant., 2012) and other cultures (Orgiles & Espada, 2013)
Psychometric properties
The CSI-24 has been found to correlate highly with the CSI-35 (– r=.99, p<.001; Walker et al., 2009) and hence has been considered a refined version of the original measure. The CSI-35 has been examined in numerous studies and has evidence of high concurrent and convergent validity (r>.4) with other measures of somatization, and good support from a number of studies for it’s construct validity.

  • Internal Consistency alpha .84-.92 (Cerutti et al., 2017; Lavigne, Saps, & Bryant., 2012)
  • Validity for the CSI-24 has been demonstrated in its correlation as expected with measures of anxiety, depression, functional impairment and quality of life (Lavigne, Saps, & Bryant., 2012)
  • Scores for older children and females tend to be higher with a low to medium effect size (d=0.52) (Walker et al., 2009).
  • Parent report has been shown to be lower in school samples and higher in clinical samples than the associated child report (Cerutti et al., 2017).

References

Cerutti R., Spensieri V., Valastro C., Presaghi F., & Guidetti V. (2017). A comprehensive approach to understand somatic symptoms and their Impact on emotional and psychosocial functioning in children. PLoS ONE, 12(2). doi.org/10.1371/journal.pone.0171867

Laird K., Sherman A., Smith C., & Walker L. (2015). Validation of the abdominal pain index using a revised scoring method. Journal Pediatric Psychology, 40(5). Doi:10.1093/jpepsy/jsu118

Lavigne, S.L., Saps, M., & Bryant, F.B. (2012). Reexamining the factor structure of somatization using the children’s somatization inventory (CSI-24) in a community sample. Journal of Pediatric Psychology, 37, 914-924. Doi:10.1093/jpepsy/jss060

Orgiles, M. & Espada, J. P. (2014). Spanish version of the children’s somatization inventory: factorial structure and psychometric properties in a community sample. International Journal of Behavioural Medicine, 21, 556-560. Doi:10.1007/s12529-013-9335-9

Walker, L. S., Beck, J. E., Garber, J., & Lambert, W. (2009). Children’s somatization inventory: Properties of the revised form (CSI-24). Journal of Pediatric Psychology, 34, 430-440.

Clinically Useful Anxiety Outcome Scale (CUXOS)

The Clinically Useful Anxiety Outcome Scale (CUXOS) is a brief 20-item self-report measure designed to assess the severity of anxiety symptoms in adults with a diagnosed anxiety disorder or depression (D’Avanzato et al., 2013; Zimmerman, Chelminski, Young, & Dalrymple, 2010). The CUXOS can be used as a screening tool or to monitor and evaluate symptom changes over the course of treatment, as it is sensitive to change (Beidas et al., 2015).

Developed in 2010, the CUXOS item content is based on the DSM-III-R and DSM-IV descriptions of Generalised Anxiety Disorder and Panic Disorder (Zimmerman et al., 2010). The items are derived from the Hamilton Rating Scale for Anxiety (1959), whilst the structure of the measure is based on the Clinically Useful Depression Outcome Scale (2008). The CUXOS is compromised of two subscales; the psychic anxiety subscale consisting of 6-items (“I felt scared”), and the somatic anxiety subscale containing 14-items (“I was sweating”). Each item is rated on a Likert-type scale from zero (“not at all true”) to four (“almost always true”), with total scores ranging from zero to 80 (<10 non-anxious; 11-20 minimal anxiety; 21-30 mild anxiety; 31-40 moderate anxiety; 41+ severe anxiety). On average, clients completed the measure within two minutes and clinicians scored the scale within 15 seconds (Zimmerman et al., 2010). The efficient nature of this measure is an advantage when considering using it as a screening tool or to monitor symptom change over time.

The CUXOS’ solid psychometric properties are also an advantage. The initial validity study included 963 patients, 556 with a diagnosed non-comorbid anxiety disorder and 407 with no current anxiety disorder (Zimmerman et al., 2010). The study demonstrated strong internal consistency for the total scale (Cronbach α = 0.95) and each subscale (α = 0.90 for the psychic anxiety subscale, and α = 0.93 for the somatic anxiety subscale). The test re-test reliability of the total scale was also strong (r=0.90).

In terms of convergent and divergent validity, the CUXOS correlated more highly with other measures of anxiety (median r=0.54) than with scales measuring other symptom domains (median r=0.32). The CUXOS’ ability to discriminate between severity levels was also investigated via an analysis of variance conducted with the Social Avoidance and Distress Scale (SADS) severity ratings in relation to the CUXOS’ ratings. Higher SADS severity ratings correlated significantly with higher CUXOS ratings of severity.

Whilst the psychometric properties reported in the Zimmerman et al. (2010) study are promising, little research has been conducted on different demographic features and varied clinical populations. At this stage there is only one other validity study concerning the CUXOS. Jeon et al. (2017) conducted a study with 838 psychiatric outpatients during intake, using a Korean adaptation of the CUXOS. The study found similar psychometric properties as reported by the original study, with a high internal consistency (Cronbach α = 0.90) and a test re-test reliability of r=0.74. Jeon et al. also found that the CUXOS was more highly correlated with other measures of anxiety (mean r= 0.74) than with measures of the other symptom domains (mean r= 0.53).

Based on the current literature, the CUXOS is a valid and reliable brief assessment tool. The CUXOS can be readily incorporated into clinical practice given the efficiency and ease of administering and scoring. However, there are limitations. The scale is not extensively researched and the impact of individual difference factors has not been explored rigorously. Additionally, clinicians should be mindful that item content is based on the DSM-III-R and DSM-IV definitions of anxiety disorders and some symptoms of distress may be underreported if triggers are being avoided by client e.g. phobic objects may have not been encountered that week.

References

Beidas, R. S., Stewart, R. E., Walsh, L., Lucas, S., Downey, M. M., Jackson, K., . . .Mandell, D. S. (2015). Free, brief, and validated: Standardized instruments for low-resource mental health settings. Cognitive and Behavioral Practice, 22, 5–19.

D’Avanzato, C., Martinez, J., Attiullah, N., Friedman, M., Toba, C., Boerescu, D. A., Zimmerman, M. (2013). Anxiety symptoms among remitted depressed outpatients: Prevalence and association with quality of life and psychosocial functioning. Journal of Affective Disorders, 151(1), 401-404. http://dx.doi.org/10.1016/j.jad.2013.06.040

Hamilton, M. (1959). The assessment of anxiety states by rating. British Journal of Medical Psychology, 32, 50-55.

Jeon, S. W., Han, C., Ko, Y.-H., Yoon, S., Pae, C.-U., Choi, J., . . . Zimmerman, M. (2017). A Korean validation study of the Clinically Useful Anxiety Outcome Scale: Comorbidity and differentiation of anxiety and depressive disorders. PLoS ONE, 12(6), e0179247. doi:10.1371/journal.pone.0179247

Zimmerman, M., Chelminski, I., McGlinchey, J. B., & Posternak, M. A. (2008). A clinically useful depression outcome scale. Comprehensive Psychiatry, 49(2), 131-140. http://dx.doi.org/10.1016/j.comppsych.2007.10.006

Zimmerman, M., Chelminski, I., Young, D., & Dalrymple, K. (2010). A Clinically Useful Anxiety Outcome Scale. The Journal of Clinical Psychiatry, 71, 534– 542.

Vanderbilt Assessment Scales (VAS)

The Vanderbilt Assessment Scales (parent/teacher) were created in 2002 by the American Academy of Pediatrics (AAP) and the National Initiative for Children’s Healthcare Quality (NICHQ) at the completion of a project aimed to create and implement a model of care for children with ADHD. The VAS is a brief scale completed by parents and teachers that assesses ADHD symptoms of inattention and hyperactivity along with conduct disorder, oppositional defiance disorder, anxiety, depression and academic performance (Fields & Hale, 2011).
Psychometric Properties
The scale has good internal reliability with Cronbach’s alpha coefficient of > .90 (parent) and >.89 (teacher) (Wolraich et al., 2002; Wolraich et al., 2013). Test-retest reliabilities were assessed as adequate (r >.80) (Bard et al., 2013). Interrater reliability, between the two scales is very low (r=.27 – .34) (Wolraich et al., 2002).
The four factor structure of the scale confirms it is a valid measure of inattention, hyperactivity, conduct disorder/oppositional defiance disorder, anxiety/depression. Convergent validity is evidenced by the moderate to high correlations with the Diagnostic Interview Schedule for Children-IV Parent Version (Bard et al., 2013; Collett et al., 2003).
The parent scale produced sensitivity measure (true positives) of 80% and specificity (true negatives) of 75% when predicting a diagnosis of ADHD. However when the parent and teacher scales were combined positive predictive value fell to 19% and the negative predictive value increased to 98% suggesting that the combined scale is very good for identifying children who do not have ADHD (Bard et al., 2013).
The VAS has been used with clinical and community samples of American, African American, Hispanic, Spanish and German children in rural, urban and suburban areas; with those at high and low risk of ADHD. Only small differences were found for gender, age, school grade or severity of ADHD symptoms (Wolraich et al., 2002).
Strengths:
The scale is: easy to complete and score, psychometrically sound, useful for collecting data from multiple sources and assessing academic and behaviour performance (Collett et al., 2003; Kratochvil et al., 2009). It can be used to establish baselines to measure treatment effectiveness (Kratochvil et al., 2009) and has utility to screen for comorbid disorders (Becker et al., 2012; Langberg et al., 2010). The teacher scale correlates highly with a diagnosis of ADHD (Austerman, 2015).
Weaknesses:
There is no evidence found for discriminant validity. Items are more relevant for school aged children than younger. Very low inter-rater reliability between scales and is to be used as a screening tool only.
Clinical utility:
The VAS provides a psychometrically sound method of data collection from both parents and teachers that can be used in the diagnostic process for children with ADHD.  It useful and acceptable to clinicians, readily available and provides assessment of performance and comorbid disorders (Bard et al., 2013).  It is so simple to use, a line can be drawn down the page to delineate meeting or not meeting diagnostic criteria (Molina, 2017).
Link to scale: https://www.nichq.org/resource/nichq-vanderbilt-assessment-scales

References
American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Washington, DC: Author.
Austerman, J. (2015). ADHD and behavioral disorders: Assessment, management, and an update from DSM-5. Cleveland Clinic Journal of Medicine, 82, S2-S7.
Bard, D.E., Wolraich, M.L., Neas, B., Doffing, M., & Beck, L. (2013). The psychometric properties of the Vanderbilt attention-deficit hyperactivity disorder diagnostic parent rating scale in a community population. Journal of Developmental and Behavioral Pediatrics, 34, 72-82.
Becker, S.P., Langberg, J.M., Vaughn, A.J., & Epstein, J.N. (2012). Clinical utility of the Vanderbilt ADHD diagnostic parent rating scale comorbidity screening scales. Journal of Development and Behavioral Pediatrics, 33, 221-228.
Collett, B.R., Ohan, J.L., & Myers, K.M. (2003). Ten-year review of rating scales. V: Scales assessing attention-deficit/hyperactivity disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 42, 1015-1037.
Fields, S.A., & Hale, L.R. (2011). Psychoeducational groups for youth attention-deficit hyperactivity disorder: a family medicine pilot project. Mental Health in Family Medicine, 8, 157-165.
Kratochvil, C.J., Vaughan, B.S., Barker, A.M.., Corr, L., Wheeler, A., & Madaan, V. (2009). Review of pediatric attention deficit/hyperactivity disorder for the general psychiatrist. Psychiatric Clinics of North America, 32, 39-56.
Molina Healthcare (2017). Behavioral health provider toolkit. Retrieved from: http://www.molinahealthcare.com/providers/common/PDF/Behavioral-Health-Toolkit-for-Specialists.pdf
National Initiative for Children’s Healthcare Quality (2017). Attention Deficit Hyperactivity Disorder (ADHD) Learning Collaborative. Retrieved from: https://www.nichq.org/project/attention-deficit-hyperactivity-disorder-adhd-learning-collaborative
National Initiative for Children’s Healthcare Quality (2017). NICHQ Vanderbilt assessment scales. Retrieved from: https://www.nichq.org/project/attention-deficit-hyperactivity-disorder-adhd-learning-collaborative
Wolraich, M.L., Bard, D.E., Neas, B., Doffing, M., & Beck, L. (2013). The psychometric properties of the Vanderbilt attention-deficit hyperactivity disorder diagnostic teacher rating scale in a community population. Journal of Developmental and Behavioral Pediatrics, 34, 83-93.
Wolraich, M.L., Lambert, W., Doffing, M.A., Bickman, L.B., Simmons, T., & Worley, K. (2003). Psychometric properties of the Vanderbilt ADHD diagnostic parent rating scale in a referred population. Journal of Pediatric Psychology, 28. 559-568.

Revised Children’s Anxiety and Depression Scale (RCADS)

Description
The Revised Children’s Anxiety and Depression Scale (RCADS; Chorpita, Yim, Moffitt, Umemoto & Francis, 2000) is a 47-item self report measure which assesses the frequency of anxiety and depression symptoms in youth aged 8-18 years.  The RCADS was developed in Hawaii, United States and is partly a revision of Spence’s Children’s Anxiety Scale (SCAS; 1997).  The measure has a parent-version form as well as a short-form (RCADS-25; Ebesutani et al., 2012). The RCADS is composed of 6 scales, 5 of which are related to anxiety (separation anxiety disorder, social phobia, generalized anxiety disorder, panic disorder, obsessive compulsive disorder) and another one related to major depressive disorder. The scales are aligned with anxiety and depression diagnosis criteria in the DSM-IV. Individuals rate their answers on a 4-point likert scale ranging from “never” to “always”.  The results can be scored manually or via the scoring software created by the authors. In terms of results, T-scores greater than 65 are borderline clinically significant whereas those above 75 are clinically significant. These T-scores indicate that the individual’s responses reflect anxiety and depression-related symptoms very similar to those of individuals who meet diagnostic criteria for that particular disorder or syndrome.

Psychometrics
The RCADS has good internal consistency with Cronbach alpha values ranging from .78 for social anxiety disorder to .88 for panic disorder in a clinical population (Chorpita, Moffitt & Gray, 2005) as well as acceptable internal consistency in the general population (Chorpita et al.,2000).  Furthermore, the measure has good convergent validity with similar measures such as the Revised Children’s Manifest Anxiety Scale (RCMAS; Reynolds & Richmond, 1978), the Children’s Depression Inventory (CDI) and interview dimensional ratings (Chorpita et al., 2005).  The RCADS also has favourable test-retest reliability for most scales with the social phobia scale being most reliable (0.80) and the obsessive compulsive disorder scale generally being the least reliable (0.65) when tested in a community sample of school children and adolescents (Chorpita et al., 2000). In terms of model fit, a study by Chorpita et al. (2005) using confirmatory factor analysis indicated an adequate model fit for a 6-factor model when compared to a 1 factor and a 2 factor model. The RCADS has been successfully validated in several countries including Australia (de Ross, Gullone & Chorpita,2002), Denmark (Esbjorn, Somhovd, Turnstedt & Reinholdt-Dunne, 2010), the Netherlands (Kosters, Chinapaw, Zwaanswijk, van der Wal & Koot, 2015) and Spain (Sandin, Valiente & Chorot, 2009) in clinical and school-based samples.

Use
The RCADS is available publicly and free of cost from www.childfirst.ucla.edu/resources.html. It can be used for both educational and professional purposes. However, if you want to use this tool for research purposes, permission is required from the authors. It’s a valuable tool for use with youth suspected of having an anxiety disorder or major depressive disorder as its scales reflect DSM-IV criteria and it’s one of the only anxiety measures that also measures depressive symptoms separately.  Furthermore, the RCADS has been translated into several languages including Spanish, Chinese and French and due to its cross-cultural validations, it can be used with youth from different cultures. It should be noted that the RCADS is only standardized for grades 3 and above as T-Score conversions have not been developed for children younger than grade three. Therefore, the authors recommend using clinical judgement for interpreting raw scores for these children.

 

References

Chorpita, B. F., Moffitt, C. E., & Gray, J. (2005). Psychometric properties of the Revised Child Anxiety and Depression Scale in a clinical sample. Behaviour research and therapy43(3), 309-322.

Chorpita, B. F., Yim, L., Moffitt, C., Umemoto, L. A., & Francis, S. E. (2000). Assessment of symptoms of DSM-IV anxiety and depression in children: A revised child anxiety and depression scale. Behaviour research and therapy38(8), 835-855.

de Ross, R. L., Gullone, E., & Chorpita, B. F. (2002). The revised child anxiety and depression scale: a psychometric investigation with Australian youth. Behaviour Change19(02), 90-101.

Ebesutani, C., Reise, S. P., Chorpita, B. F., Ale, C., Regan, J., Young, J., … & Weisz, J. R. (2012). The Revised Child Anxiety and Depression Scale-Short Version: Scale reduction via exploratory bifactor modeling of the broad anxiety factor. Psychological Assessment24(4), 833.

Esbjørn, B. H., Sømhovd, M. J., Turnstedt, C., & Reinholdt-Dunne, M. L. (2012). Assessing the Revised Child Anxiety and Depression Scale (RCADS) in a national sample of Danish youth aged 8–16 years. PLoS One7(5), e37339.

Kösters, M. P., Chinapaw, M. J., Zwaanswijk, M., van der Wal, M. F., & Koot, H. M. (2015). Structure, reliability, and validity of the revised child anxiety and depression scale (RCADS) in a multi-ethnic urban sample of Dutch children. BMC psychiatry15(1), 132.

Reynolds, C. R., & Richmond, B. O. (1978). What I think and feel: A revised measure of children’s manifest anxiety. Journal of abnormal child psychology6(2), 271-280.

Sandín, B., Valiente, R. M., & Chorot, P. (2009). RCADS: evaluación de los síntomas de los trastornos de ansiedad y depresión en niñosy adolescentes. Revista de Psicopatología y Psicología Clínica14(3), 193-206.

Spence, S. H. (1998). A measure of anxiety symptoms among children. Behaviour research and therapy36(5), 545-566.

Generalized Anxiety Disorder Screener-7 (GAD-7)

The Generalized Anxiety Disorder Screener (GAD-7; Spitzer, Kroenke, Williams, & Lowe, 2006) is a brief, 7-item self-report measure for anxiety symptoms in adolescents (Daig, Herschbach, Lehmann, Knoll, & Decker, 2009; Farrand & Woodford, 2013; Johnson, Harris, Spitzer, & Williams, 2002) and adults (Spitzer et al., 2006). Although developed primarily as a screening tool for GAD, it can also be used as: a) a diagnostic tool (Spitzer et al., 2006), b) to monitor changes in symptoms over time (Kertz, Bigda-Peyton, & Bjorgvinsson, 2013), and as a screener for social anxiety, panic disorder, and post-traumatic stress disorder (Kroenke, Spitzer, Williams, Monahan, & Lowe, 2007).

The development of the GAD-7 began with the development the Primary Care Evaluation of Mental Disorders (PRIME-MD) at Columbia University, USA. The PRIME-MD was an instrument developed and validated in the early 1990s to diagnose five of the most common mental disorders presenting in clinical populations, including anxiety (Spitzer et al., 1994). It comprised a 2-stage process including self-report and clinically administered items for screen positive individuals. However, the length of time this process took (up to 12 minutes in clinical populations) proved a barrier to universal screening in primary practice, and was thus modified, developed, and validated into the Patient Health Questionnaire (PHQ; Spitzer, Kroenke, & Williams, 1999; Spitzer, Williams, Kroenke, Hornyak, & McMurray, 2000). The GAD-7 is one of the key questionnaires in the PHQ, and has been validated in 2740 primary care patients (Spitzer et al., 2006). Example items include “Feeling nervous, anxious or on edge”, “Not being able to stop or control worrying”, and “Worrying too much about different things”. Each item is rated on a likert-type scale from zero (“not at all”) to three (“nearly every day”), with total scores ranging from 0 to 21 (< 5 mild anxiety; 10-15 moderate anxiety; 15+ severe anxiety). Individuals with scores of 10+ are recommend for further assessment (Spitzer et al, 2006).

The GAD-7 demonstrates good convergent validity with the Beck Anxiety Inventory (r = 0.72) (BAI; Beck, Epstein, Brown, & Steer, 1988) and the anxiety subscale of the Symptom Checklist-90 (r = 0.74) (SCL-90; Derogatis, Lipman, Rickels, Uhlenhuth, & Covi, 1974). It also has excellent internal consistency (α = .92) and test-retest reliability (r = .83; Spitzer et al., 2006). A recent systematic review and diagnostic meta-analysis of 11 studies by Plummer, Manea, Trepel, and McMillan (2016) revealed the GAD-7 had acceptable properties for identifying GAD at cut off scores between 7-10, with optimal sensitivity/ specificity at a cut-off of 8 [sensitivity: 0.83 (95% CI 0.71–0.91), specificity: 0.84 (95% CI 0.70–0.92)].

The GAD-7 is available in over 20 languages, including English, Spanish, French, and Mandarin. Cultural adaptations of the Spanish (Garcia-Campayo et al., 2010) and Portuguese (Sousa et al., 2015) versions demonstrates good to excellent internal consistency, reliability, and validity (.71+). Criteria validity (using Receiver Operator Characteristic (ROC) curve analysis for the Spanish version also showed excellent specificity, sensitivity, positive, and negative predictive values (86%+) (Mills et al., 2014). The GAD-7, including manual, instructions and all translations, are available free online (http://www.phqscreeners.com), with no permissions required to reproduce, translate, display or distribute them.

Based on the available literature reviewed, it is recommended that the GAD-7 is useful both as a clinical instrument and in research; however, there is a caveat to be aware of – the PHQ (of which GAD-7 is part of), was developed with the support of an educational grant from Pfizer Inc, a pharmaceutical company, and it is not clear if the authors receive any royalties from Pfizer. However, it is beneficial to see good convergent validity with other well-known anxiety instruments, report in peer reviewed journals (including from teams not associated with the authors and Pfizer), and declaration of funding from Pfizer.

 

References

Beck, A. T., Epstein, N., Brown, G., & Steer, R. A. (1988). An inventory for measuring clinical anxiety: psychometric properties. Journal of Consulting and Clinical Psychology, 56(6), 893-897.

Daig, I., Herschbach, P., Lehmann, A., Knoll, N., & Decker, O. (2009). Gender and age differences in domain-specific life satisfaction and the impact of depressive and anxiety symptoms: a general population survey from Germany. Quality of Life Research, 18(6), 669-678. doi:10.1007/s11136-009-9481-3

Derogatis, L. R., Lipman, R. S., Rickels, K., Uhlenhuth, E. H., & Covi, L. (1974). The Hopkins Symptom Checklist (HSCL): A self-report symptom inventory. Behavioral Science, 19(1), 1-15. doi:10.1002/bs.3830190102

Farrand, P., & Woodford, J. (2013). Measurement of individualised quality of life amongst young people with indicated personality disorder during emerging adulthood using the SEIQoL-DW. Quality of Life Research, 22(4), 829-838. doi:10.1007/s11136-012-0210-y

Garcia-Campayo, J., Zamorano, E., Ruiz, M. A., Pardo, A., Perez-Paramo, M., Lopez-Gomez, V., . . . Rejas, J. (2010). Cultural adaptation into Spanish of the generalized anxiety disorder-7 (GAD-7) scale as a screening tool. Health and Quality of Life Outcomes, 8, 8. doi:10.1186/1477-7525-8-8

Johnson, J. G., Harris, E. S., Spitzer, R. L., & Williams, J. B. (2002). The patient health questionnaire for adolescents: validation of an instrument for the assessment of mental disorders among adolescent primary care patients. Journal of Adolescent Health, 30(3), 196-204.

Kertz, S., Bigda-Peyton, J., & Bjorgvinsson, T. (2013). Validity of the Generalized Anxiety Disorder-7 scale in an acute psychiatric sample. Clin Psychol Psychother, 20(5), 456-464. doi:10.1002/cpp.1802

Kroenke, K., Spitzer, R. L., Williams, J. B., Monahan, P. O., & Lowe, B. (2007). Anxiety disorders in primary care: prevalence, impairment, comorbidity, and detection. Annals of Internal Medicine, 146(5), 317-325.

Mills, S. D., Fox, R. S., Malcarne, V. L., Roesch, S. C., Champagne, B. R., & Sadler, G. R. (2014). The Psychometric Properties of the Generalized Anxiety Disorder-7 scale in Hispanic Americans with English or Spanish Language Preference. Cultural Diversity and Ethnic Minority Psychology, 20(3), 463-468. doi:10.1037/a0036523

Plummer, F., Manea, L., Trepel, D., & McMillan, D. (2016). Screening for anxiety disorders with the GAD-7 and GAD-2: a systematic review and diagnostic metaanalysis. General Hospital Psychiatry, 39, 24-31. doi:10.1016/j.genhosppsych.2015.11.005

Sousa, T. V., Viveiros, V., Chai, M. V., Vicente, F. L., Jesus, G., Carnot, M. J., . . . Ferreira, P. L. (2015). Reliability and validity of the Portuguese version of the Generalized Anxiety Disorder (GAD-7) scale. Health and Quality of Life Outcomes, 13(1), 50. doi:10.1186/s12955-015-0244-2

Spitzer, R. L., Kroenke, K., & Williams, J. B. (1999). Validation and utility of a self-report version of PRIME-MD: the PHQ primary care study. Primary Care Evaluation of Mental Disorders. Patient Health Questionnaire. JAMA, 282(18), 1737-1744.

Spitzer, R. L., Kroenke, K., Williams, J. B., & Lowe, B. (2006). A brief measure for assessing generalized anxiety disorder: the GAD-7. Archives of Internal Medicine, 166(10), 1092-1097. doi:10.1001/archinte.166.10.1092

Spitzer, R. L., Williams, J. B., Kroenke, K., Hornyak, R., & McMurray, J. (2000). Validity and utility of the PRIME-MD patient health questionnaire in assessment of 3000 obstetric-gynecologic patients: the PRIME-MD Patient Health Questionnaire Obstetrics-Gynecology Study. American Journal of Obstetrics and Gynecology, 183(3), 759-769.

Spitzer, R. L., Williams, J. B., Kroenke, K., Linzer, M., deGruy, F. V., 3rd, Hahn, S. R., . . .Johnson, J. G. (1994). Utility of a new procedure for diagnosing mental disorders in primary care. The PRIME-MD 1000 study. JAMA, 272(22), 1749-1756.

Brief Problem Checklist (BPC)

The Brief Problem Checklist (BPC) is a measure designed by Chorpita et al. (2010) to periodically assess the clinical progress of a child over the course of psychological treatment. The scale measures internalising and externalising problems found in children aged 7-13, and such feedback can be used by a clinician to track outcomes and to adjust treatment. The scale is presented in an interview format which contains twelve items, and there is both a child and caregiver version. The BPC is intended to be conducted via an over-the-phone interview at weekly intervals during treatment. The burden for families partaking in such frequent interviews is believed to be minimal, as Chorpita et al. (2010) found that on average the administration time takes less than one minute.

The measure was developed in the USA, and the normed sample was composed of American children (aged 7 -13 years old) who were offered treatment due to a range of problems that could be subsumed under the broad categories of anxiety, depression, or disruptive behaviour (Chorpita et al., 2010). The BPC interviews yield three scales; a Total Problems scale, and Internalising scale, and an Externalising scale. When answering the questions, children and care-givers are required to rate how true the 12 items are in reference to the previous week, using a 3-point Likert scale. Example items include: “I disobey my parents or people at school” (caregiver version: “disobedient at home or school”) and “I threaten to hurt people” (caregiver version: “threatens people”).

To create items for the BPC, Chorpita et al. (2010) applied factor analysis to both the Child Behaviour Checklist (CBCL) and the Youth Self-Report (YSR); two instruments which are widely used and established as evidence-based measures. Items with high factor loadings across both the CBCL and YSR were chosen, leading to the identification of 14 internalising items and 20 externalising items. Items were then selected based on their ability to maximise information pertaining to the clinical change of the client. The resultant 12 items were subjected to exploratory factor analysis using maximum likelihood estimation. A two-factor solution was drawn from the following scree plot, and the factors were extracted and subjected to promax rotation. The resultant factors corresponded to the Externalising and Internalising scales of the BPC.

To determine convergent validity the scales of the BPC were correlated with corresponding scales from the CBCL and YSR (Chorpita et al., 2010). Each BPC scale (Internalising, Externalising, and Total Problems) was highly significantly correlated to scales on both the YSR (coefficients at .61 or above) and the CBCL (coefficients at .56 or above). A longitudinal examination of BPC interview data across 6 months of treatment demonstrated that the BPC is capable of significantly predicting change in related measurements of symptomology (ie. the CBCL and YSR), providing strong evidence for its clinical utility. Test-retest coefficients across an average period of 8-9 days ranged from .72 to .79 for each of the BPC subscales. The agreement of the child and caregiver versions of the scale were examined and produced correlations ranging from .19 to .31; findings which are comparable to the literature comparing parent-child symptom agreement (Chorpita et al., 2010).

The BPC can be readily accessed online and is available for both commercial and research purposes. Due to the relatively new construction of the measure and its potential to quickly and efficiently monitor clinical change in children, the BPC holds both great practical relevance and would benefit from further psychometric testing and cross-cultural validation. No major revisions of the BPC have occurred to the author’s knowledge.

References

Chorpita, B. F., Reise, S., Weisz, J. R., Grubbs, K., Becker, K. D., Krull, J. L., & The Research Network on Youth Mental Health. (2010). Evaluation of the Brief Problem Cheklist: Child and caregiver interviews to measure clinical progress. Journal of Consulting and Clinical Psychology, 78(4), 526-536. doi: 10.1037/a0019602

BPC Links:

Child version: http://www.childfirst.ucla.edu/Brief%20Problem%20Checklist%20-%20Child.pdf Parent Version: http://www.childfirst.ucla.edu/Brief%20Problem%20Checklist%20-%20Parent.pdf