Anxiety Disorders 20 (2006) 139157

The psychometric properties of the MASC in a pediatric psychiatric sample

Moira A. Rynn *, Jacques P. Barber, Sarosh Khalid-Khan, Lynne Siqueland, Michelle Dembiski, Kevin S. McCarthy, Robert Gallop
Department of Psychiatry, Mood and Anxiety Disorders Program, Center for Psychotherapy Research, Suite 670, University of Pennsylvania School of Medicine, 3535 Market Street, Philadelphia, PA 19104-3309, USA Received 16 November 2004; received in revised form 14 December 2004; accepted 20 January 2005

Abstract The goals of this study were twofold: to examine the psychometric properties of the Multidimensional Anxiety Scale for Children (MASC) in a clinical sample of 193 children and adolescents who had received a diagnosis of major depressive or anxiety disorder, and to discriminate between these two groups of patients. Participants had volunteered in randomized psychopharmacological clinical trials. The MASC four-factor structure was conrmed and its subscales were found to be reliable. The MASC correlated well with other self-report measures of anxiety, and less so with measures of depressive symptoms. The MASC subscales and two MASC items as well as age differentiated between anxious and depressed pediatric patients. If these results are replicated in an independent study, those items could be used by clinicians to discriminate between these two disorders. The MASC is a clinically useful measure to discriminate between anxious and depressed pediatric patients. Limitations due to the highly selective sample are noted. # 2005 Elsevier Inc. All rights reserved.
Keywords: Anxiety disorder; Self-report measure; Depressive disorders; Validation; Children; Adolescents

* Corresponding author. Tel.: +1 215 746 6665; fax: +1 215 746 6551. E-mail address: mrynn2@mail.med.upenn.edu (M.A. Rynn). 0887-6185/$ see front matter # 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.janxdis.2005.01.004

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Reliable self-report assessment tools that identify the presence and severity of anxiety disorders in children and adolescents are clearly needed given the high prevalence of these disorders among children seeking treatment (e.g., Lewinsohn, Hops, Roberts, Seeley, & Andrews, 1993; McGee, Feehan, Williams, & Partridge, 1990). In the last decades many such measures have been developed. Given the overlap of many features of anxiety and depression (e.g. fatigue, problems with concentration, and physical symptoms), one of the important clinical issues for clinicians and researchers is to develop measures that will discriminate between anxiety and depressive disorders. In a recent meta-analysis of three important measures, Seligman, Ollendick, Langley, and Baldacci (2004) showed that the Revised Childrens Manifest Anxiety Scale (RCMAS, Reynolds & Richmond, 1978), the State-Trait Anxiety Scale for Children (STAIC, Spielberger, 1973), and the Child Behavior Checklist (CBCL, Achenbach, 1991) could discriminate between youth with an anxiety disorder and youth without a psychiatric disorder. However, these scales were not very good at distinguishing between youth with an anxiety disorder and youth with an affective disorder (Seligman, Ollendick, Langley, & Baldacci, 2004). To address these and other issues, a number of scales have been developed in the last decade. Among others, Birmaher et al. developed the Screen for Child Anxiety Related Disorders (SCARED, Birmaher et al., 1999, 1997), while March, Parker, Sullivan, Stallings, and Connor, (1997) developed the Multidimensional Anxiety Scale for Children (MASC). Chorpita, Yim, Moft, Umemoto, and Francis (2000) also recently improved the Spences (1998) Children Anxiety Scale. In the current paper, we examined the psychometric properties of the MASC because the SCARED and the Chorpita et al.s adaptation of the Children Anxiety Scale were not available at the time the studies included in this paper were initiated. The MASC contains 39 items that approximate the DSM-IV anxiety diagnoses and contains four factors: Physical Symptoms (tense/somatic); Harm Avoidance (perfectionism/anxious coping); Social Anxiety (humiliation/performance fears) and Separation Anxiety/Panic. The MASC includes items at the factor, subfactor and item level that assess clinically relevant anxiety symptoms and reect overlap among the factors (March, Parker, Sullivan, Stallings, & Connor, 1997). The full MASC has shown good internal consistency and test-retest reliability. Also, two shorter forms designed for screening anxiety disorders, the MASC-10 and the Anxiety Disorder Index can be derived from the MASC. These two forms have demonstrated satisfactory test-retest reliability (March, Sullivan, & Parker, 1999, see Section 1). In a large sample of normal adolescents, Muris, Merckelbach, Ollendick, King, and Bogie (2002) found that the MASC was highly correlated with other older (RCMAS and STAIC) and more recent (e.g., SCARED) anxiety measures and, for the most part were signicantly less correlated with a self-report of depression (CDI). Dierker et al. (2001) screened their participants, who were recruited from a school setting, for the presence of psychiatric disorders. They were able to show

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that in the sample of these diagnosable participants who had not requested treatment, the MASC was a moderately accurate predictor of Generalized Anxiety Disorder (GAD) in females (AUC = .82) (Dierker et al., 2001). Furthermore, in contrast to the RCMAS and CES-D, the MASC was found to have moderate predictive power for both males and females for anxiety comorbidity in those children with another primary psychiatric diagnosis (Dierker et al., 2001). However, all of these studies with the MASC have used either non-clinical populations (Muris, Merckelbach, Ollendick, King, & Bogie, 2002) or children who had not sought treatment (Dierker et al., 2001). The only exception is the one study with a small sample size of 24 children that showed that the MASC distinguished children with anxiety disorders from children with ADHD (March, 1997). The goals of this study were to examine the psychometric properties of the MASC in a group of children and adolescents presenting at a university mood and anxiety treatment research clinic focused on pharmacological interventions for those disorders. We assessed the factor structure, reliability and validity of the MASC in this clinical sample. More specically, we examined the following questions: 1) To examine whether the factor structure of the MASC uncovered by March et al. (1997) in a sample of school children was conrmed in our sample of anxious and depressed patients using a conrmatory factor analysis (CFA). 2) To examine whether the factorial structure of the MASC was equivalent across sex and age groups. 3) To examine the reliability of the MASC and its different subscales in our sample of anxious and depressed children. 4) To examine the concurrent validity of the MASC and its subscales with other measures of anxiety and depression both self-report and clinicianrated. More specically, we hypothesized that the MASC would be more closely associated with other measures of anxiety than with measures of depression. Furthermore, we expected that the correlations would be higher among same method measures of same symptoms, than among different methods of assessing the same symptoms. 5) To examine the criterion validity of the MASC. That is, do the MASC subscales differentiated between children and adolescents with anxiety disorders and those with depressive disorders? We especially focused on the ability of the empirically derived Anxiety Disorder Index (March, 1998) and of the MASC-10 to differentiate these two groups of patients. 6) To predict the presence of anxiety disorders in this sample. We attempted to nd a small number of MASC items that could help us differentiate patients with anxiety disorders from patients with depressive disorders. Those items could be used in the future for clinicians to quickly discriminate between these two disorders.

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1. Method 1.1. Patients Four hundred and eighty patients were screened for possible participation in double-blind placebo controlled psychopharmacological trials for the treatment of social anxiety disorder (Soc), or major depression (MDD), or GAD which could be comorbid with separation anxiety disorder (SAD) at the Child and Adolescent Research Service (CAReS), an outpatient clinic focused on childhood anxiety and depressive disorders, at the University of Pennsylvania Medical Center. Two hundred and eighty-seven pediatric patients were found inappropriate for those trials, resulting in 193 patients who had been randomized and had lled out the MASC questionnaire. One hundred and thirty-eight (71%) patients were White, 34 (18%) were African American, 3 (2%) were Asian American and 10 (5%) were Hispanic, 8 (4%) were either Other or unknown. Seventy percent of patients were direct referrals from pediatricians, family physicians, agencies, and previously treated patients. Children and adolescents were recruited. The patients included in this study met diagnostic criteria based on the structured interview (Anxiety Disorders Interview Schedule for Children Revised, ADIS-R; Silverman & Albano, 1996 or The Schedule for Affective Disorders and Schizophrenia for School-Age Children, K-SADS; Puig-Antich & Chambers, 1978) with an experienced child and adolescent psychiatrist specically trained in the use of these diagnostic interviews. The patients and their parents agreed to begin one of a total of eight different consecutive placebo controlled pharmacological studies during years 19992003. The 193 patients received the following diagnoses: GAD/SAD (N = 91, 47%), Social Anxiety Disorder (N = 25, 13%), and MDD (N = 77, 40%). Patients needed to have a clear primary diagnosis of GAD, SAD, social anxiety, or MDD and not have diagnostic level symptomatology of other Axis I diagnoses (e.g., a patient recruited for the GAD study could not have a current diagnosis of MDD or vice versa). In this paper, we combined the sample of children meeting the diagnoses of GAD/SAD and Social Anxiety into one group called children and adolescents with anxiety disorders. The studies these patients were being recruited for participation were medication trials to assess the efcacy of an SSRI for a specic diagnostic entity. In such trials, patients with disorders that could benet from a different medication are usually excluded. Therefore, patients with the following psychiatric disorders or symptoms were excluded: attention decit disorder, attention decit/hyperactive disorder, obsessive-compulsive disorder, panic disorder, schizophrenia, bipolar affective disorder, post-traumatic stress disorder, developmental disorders, substance abuse/dependence, acute suicidality, hospitalization within past 612 months, no acute or serious unstable medical problems, no current cognitive behavioral therapy, and no exposure to the study medication within the last year.

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2. Measures 2.1. Patient self-report measures of anxiety The Multidimensional Anxiety Scale for Children (MASC, March et al., 1997, 1999) is a 39-item 4-point Likert self-report questionnaire recently developed to assess anxiety symptoms. In a previous factor analysis, March et al. (1997) found four factors: (1) Physical Symptoms (12 items such as tense/restless and somatic/ autonomic); (2) Harm Avoidance (9 items such as anxious coping and perfectionism); (3) Social Anxiety (9 items such as humiliation/rejection and public performance fears); and (4) Separation Anxiety (9 items). The MASC also includes two embedded subscales: (1) a 10-item short form (MASC-10) intended to be a short and efcient global measure of anxiety symptoms. The scale was developed by taking the 4 highest loading items on each MASC subscale, then these 16 items were factor analyzed in the normative sample, and the items with the lowest loading was removed. This process was repeated until 10 items remained. The MASC-10 has been shown to be a coherent measure of anxiety (March, 1997 manual). (2) A 10-item Anxiety Disorder Index (ADI) combining the 10 best items at discriminating between anxious and non anxious children (March, 1997). March et al., 1997 also reported mean intraclass correlation for those scales ranging from .64. to .89 indicating adequate stability over time as well as satisfactory internal consistency (Cronbach alpha = .90, and also March et al., 1999). March (1997) reported an overall classication rate of 95% when classifying anxious and normal children, and a still respectable rate of 71% when classifying anxious versus ADHD children. The Revised Childrens Manifest Anxiety Scale (RCMAS; Reynolds & Richmond, 1978) consists of 37 true/false items (28 Anxiety and 9 Lie scale items) that assess a variety of anxiety symptoms. Adequate reliability, validity and normative data have been reported (Reynolds & Pagetc, 1981; Reynolds & Richmond, 1978). We are using the total score of the RCMAS in this paper. The State-Trait Anxiety Inventory for ChildrenTrait version (STAIC; Spielberger, 1973) is a 20-item measure of trait anxiety (enduring tendencies to experience anxiety), which measures long-standing and relatively stable components of a childs personal characteristics in the area of anxiety. Adequate reliability, validity and normative data have been reported by Spielberger (1973). Beck Anxiety Inventory (BAI, Beck, Epstein, & Brown, 1988a) is a 21-item scale that assesses common features of anxiety, with a focus on cognition, on a 4point severity scale. It has been widely used in studies of psychosocial treatments for anxiety (see Fydrich, Dowdall, & Chambless, 1992, for a review). 2.2. Patient self-report measures of depression The Child Depression Inventory (CDI; Kovacs, 1979, 1981) is a 27-item scale that allows the child to select among alternatives on a 3-point scale reecting degree

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of particular depressive symptoms (total scores range from 0 to 54) over the past 2 weeks. Adequate reliability and validity have been reported (Kazdin, 1981; Saylor, Finch, Spirito, & Bennet, 1984). This measure is used for children under age 12. The Beck Depression Inventory (BDI; Beck, Ward, Mendelson, Mock, & Erbaugh, 1961) is a 21-item self-report measure of depression. It is a widely used, reliable measure of depressive symptoms (see Beck, Steer, & Garbin, 1988b, for a review). The BDI was used for children 12 and older. 2.3. Parent report measures on child The State-Trait Anxiety Inventory for ChildrenModication of trait version for parents (STAIC-P): Strauss (1987) modied the trait version of STAIC to be used as a complementary parent rating of child anxiety especially relevant in a middle childhood population. The form was lled out by the primary care taker, who was primarily the mother. 2.4. Clinician-rated measures Anxiety Disorders Interview Schedule for ChildrenRevised (ADIS-R; Silverman & Albano, 1996) is a clinical structured interview used to identify the principal diagnosis. This is operationally dened as the disorder associated with the most severe current impairment and/or distress, according to the 0 8 distress/impairment severity scale. It is a revision of the original ADIS for DSM-IIIR (Silverman & Nelles, 1988). This structured interview (which is based on the Diagnostic and Statistical Manual of Mental Disorders, 4th edition), was chosen because it contains an expanded anxiety section not found in other available instruments, and also allows the assessor to screen for other disorders. Evidence for its reliability and validity with a clinical sample are provided by Kendall (1994) and Kendall et al. (1997). The ADIS has satisfactory test-retest reliability (Silverman & Eisen, 1992; Silverman & Rabian, 1995) and moderate to high inter-rater reliability (Rapee, Barrett, Dadds, & Evans, 1994; Silverman & Nelles, 1988). The Schedule for Affective Disorders and Schizophrenia for School-Age Children (K-SADS) Present Episode (Puig-Antich & Chambers, 1978): This is a semi-structured interview for children and adolescents based on the adult version of the instrument (SADS). The K-SAD was used to assess the primary diagnosis of major depression if the patient endorsed symptoms of depression. Hamilton Anxiety Rating Scale (HAM-A; Hamilton, 1959): The HAM-A is a widely used 14-item inventory that assesses the severity of common anxiety symptoms. The HAM-A is intended for use with adults, and thus required the research psychiatrists or psychologist to describe the symptoms in a more child appropriate manner. Hamilton Rating Scale for Depression (HAM-D; Hamilton, 1960): The 17item version was used. This scale has been the standard depression scale against

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which all other depression scales are compared. Although this is an adult instrument, there are no similar instruments for childhood anxiety disorders. Therefore, the clinician described the symptoms in child language. Children Depression Rating Scale (CDRS; Poznanski et al., 1984): A clinician rated instrument designed to assess the presence and severity of depression symptoms. It is a 27-item scale that allows the child to select among alternatives on a 3-point scale reecting degree of particular depressive symptoms (total scores range from 0 to 54) over the past 2 weeks. Adequate reliability and validity have been reported (Kazdin, 1981; Saylor, Finch, Spirito, & Bennet, 1984). 2.5. Procedure All patients rst participated in an extensive phone screen, and if they appeared to meet preliminary inclusion criteria were invited in for an intake interview. At the intake interview, all children and their parents were interviewed by experienced research psychiatrists and psychologists who used a structured interview, either the ADIS-R to conrm an anxiety diagnosis (Silverman & Albano, 1996) or the Kiddie-SADs to conrm the diagnosis of major depression (Puig-Antich & Chambers, 1978). If the patient met study criteria, they were invited to be part of the clinical research trial and written informed consent was obtained. The MASC, RCMAS, CDRS, CGIS and ADIS were given to all patients. The STAIC was given to a part of the sample at the beginning of the study. The STAIC-P was given to the primary caretaker of the children, the mother in the majority of case, to rate the parents view of the child anxiety. The BDI and BAI were given only to adolescents, while the CDI was given only to children younger than 12 years old. The HAM-A was given only to anxious children or adolescents. The HAM-D was given, however, to all children or adolescents. If a child had difculties reading or understanding any questionnaire, a research assistant or psychiatrist assisted them in completing the forms. All forms were lled out in one setting. 2.6. Data analytic strategy T-tests, Analysis of Variance (ANOVA) models, Analysis of Covariance (ANCOVA) models and chi-square tests were used to detect differences between the diagnostic groups. Conrmatory factor analysis was used to validate the factorial structure of the MASC. Because x2-sampling distributions are inuenced by the number of observations, and in larger samples the distribution begins not to conform to a x2distribution, x2-measures are likely to reject models that t approximately in the population more often when the sample size is large (Hu & Bentler, 1999) as in this instance. A better measure of t and one of the most reliable (Hu & Bentler, 1999) is the root mean square error of approximation (RMSEA; Steiger, 1990), which assesses the discrepancy between the model and the data per degree of

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freedom (Browne & Cudeck, 1993; Steiger, 1990). RMSEA values of .05 or less suggest a good t of the model to the data and values of .08 or less suggest an adequate t (Browne & Cudeck, 1993). Logistic regression models, as implemented in SAS 8.1 PROC LOGISTIC, were used to identify the items prognostic of a diagnosis of anxiety disorder versus depressive disorder in this sample. To determine the best linear combination of items, signicant predictors were then entered simultaneously in a stepwise model. Stepwise regression enters predictors one at a time, where a signicance level of .05 was required for a variable to stay in the model. Since the test outcome is quantitative, a standard approach to summarize the tests performance is to examine all possible cutpoints for the best linear combination. Each cutpoint yields an estimated sensitivity and specicity, where sensitivity and specicity are, respectively, the chance that a true positive and a true negative will be identied as such (Fisher & Van Belle, 1993). As the cutpoint varies, the locus of (1: specicity, sensitivity) yields a bow-shaped receiver operating characteristic (ROC) curve, which displays the performance of all possible decision rules. Originally developed more than 40 years ago for the study of electronic signal detection and evaluation of radar signals, ROC curves have since been applied to problems in experimental psychology and medicine (Zweig & Campbell, 1993). The utility of the ROC curve lies in its ability to graphically describe the performance of an instrument without the need for statistical expertise and without loss of information (Lett, Hanley, & Smith, 1995). A diagnostic test that performs well is characterized by high chance of identifying true positives and true negatives for any value of the quantitative screening test (Schulzer, 1994). This results in a curve that rises quickly and is close to the upper left corner of the graph. If the ROC curve lies close to the 458 line, the test is not much better than a coin ip in discriminating between true positives and true negatives. A quantier of the performance of a diagnostic test is the area under the curve (AUC). The AUC ranges from a low of .50, random discrimination to a high of 1.00, perfect discrimination (Kufera & Mitchell, 1999). Recent attention has also been given to determining the optimal threshold cutpoint from the ROC curve (Gallop, Crits-Christoph, Muenz, & Tu, 2003; Halpern, Albert, Krieger, Metz, & Maidment, 1996; Sainfort, 1991; Schafer, 1989; Somoza & Mossman, 1992; Phelps & Mushlin, 1988). This optimal threshold is called the optimal operating point. This optimal operating point will be of clinical use in guidelines for decision-making. Similar to the ROC curves graphical description of the performance of an instrument, the optimal operating point provides a geometrical tool for the classication of the predicted outcome at the corresponding sensitivity and specicity levels of the optimal operating point. The optimal operating point produces a mathematical equation based on a linear combination of the included predictors. Positive scores on this equation classify individuals as having an anxiety disorder, whereas, negative scores classify individuals as having a depressive disorder. An individuals classication is based

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on estimation of this equation using an individuals observed values. In determining the optimal operating point, we have set a minimum value of 80% for which we do not want sensitivity to fall below. This high cutoff allows for good identication of children with anxiety disorder; therefore 80% of children with anxiety disorder are accurately classied. We will maximize specicity over the set of cutoff points meeting this restriction, because we are more concerned in the classication of the presence of an anxiety disorder as compared to a depressive disorder.

3. Results 3.1. Demographics data between anxious and depressed pediatric patients There were 116 children and adolescent with a primary diagnosis of anxiety disorder (67 males and 49 females) and 77 children with a primary diagnosis of depression (37 males and 40 females). There were no signicant differences in gender distribution between the two disorders (x2 = 1.75, df = 1, n.s.). There were, however, age differences between the two groups: the depressed children (mean age = 13.5, S.D. = 3.1) were older than the anxious ones (mean age = 12.2, S.D. = 3.3, t = 2.74, df = 191, P = .007). Therefore, age is included as a covariate in all comparisons between the primarily depressed and anxious children and in all the correlations presented below. No signicant difference between diagnostic categories and races were found (x2 = 4.1, df = 4, n.s.) 3.2. Conrmatory factor analysis (CFA) of the MASC The four-factor solution obtained by March et al. (1997) did t the current data. The CFA indicated a reasonable t between the a priori factorial structure and our data (x2 = 1427.19, df = 702, P < .0001). As explained above instead of using the x2 values as a way of evaluating the degree of t between the model and data, we used the RMSEA (Hu & Bentler, 1999). The RMSEA was equal to .073, indicating that we were able to replicate the factorial structure of the MASC in this sample of pediatric patients. 3.3. Is the factorial structure equivalent across sex and age group? To further evaluate the stability and generalizability of the four-factor model for the MASC, the degree of measure invariance (e.g., similar factor loadings) and population homogeneity (e.g., equal means) were examined in boys and girls using multiple groups CFAs (n = 104 for boys and n = 89 for girls). After separate CFAs were conducted to ensure adequate t in the boys and girls samples, a two group CFA was conducted to evaluate simultaneously the MASC between sexes.

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Table 1 Subscale statistics and internal consistency Number of items MASCTotal Scale MASC subscales Physical Symptoms Harm Avoidance Social Anxiety Separation Anxiety Anxiety Disorder Index MASC-10 39 12 9 9 9 10 10 Mean (S.D.) 57.8 (17.3) 15.6 17.2 15.8 10.0 (7.5) (4.9) (6.9) (6.2) Cronbach alpha .87 .84 .72 .86 .78 .62 .67 Percent of items with item total correlations >.4 41 75 56 100 66 20 30

15.9 (4.9) 15.6 (5.4)

Note. MASC: Multidimensional Anxiety Scale for Children.

This model t the data appropriately (x2(1443) = 2252.14, P < .0001; RMSEA = .077). A similar analysis was conducted comparing the structure of the MASC for children whose age was below or equal to 12 and those who were older than 12. This two group CFA suggested that the structure of the MASC was invariant across the two age groups (x2(1443) = 2281, P < .0001), RMSEA = .078). 3.4. The reliability of the MASC and its subscales Means and standard deviations for all subscales are presented in Table 1. Cronbach alphas were used as a measure of internal consistency. They were computed for all subscales and for the entire scale (see Table 1). The Anxiety Disorder Index and the MASC-10 scales, which were made of relatively heterogeneous items, had internal consistency below .70, suggesting relatively weak internal consistency. 3.5. Concurrent validity Concurrent validity of the MASC was examined by comparing scores from the MASC and its subscales with other measures of anxiety and depression corrected for age (see Table 2). As hypothesized the MASC correlated highly with other self-report measures of anxiety (such as the STAIC and the RCMAS). The other self-report measure of anxiety, the BAI was available only for a subsample of older children, but it correlated very highly with the MASC (pr = .69, n = 104, P < .001). Further, we needed to show that the MASC correlated more highly with measures of anxiety than with measures of depression. The only self-report measure of depression was the BDI, which, like the BAI was available only for a subsample of older children. Because of the importance of these scales, we tested whether the MASC correlated signicantly higher with the BAI than with the

Table 2 Partial correlations between the MASC, its subscales and other measures of anxiety and depression corrected for age Self-report anxiety measures RCMAS n MASCTotal MASCPhysical Symptoms MASCHarm Avoidance MASCSocial Scale MASCSeparation Anxiety Scale MASC-ADI MASC-10 167 .61
****

Self-report depression measures BAI 104

****

Structured clinical ratings M.A. Rynn et al. / Anxiety Disorders 20 (2006) 139157 Depression CDRS 149 General CGI-S 147 .22
**

STAIC-P 158 .14 .15 .00 .09 .09 .03 .16*

STAIC 38 .60

BDI 103

CDI 64
****

Anxiety HAM-A 85 .34

****

Depression H HAM-D 83 .13 .23* .05 .04 .03 .16 .07

.69

****

.47

.47

****

.13 .02 24*** .13 .04 .09 .09

.57**** .22** .54**** .35** .60**** .58****

.44*** .27 .58**** .27 .46*** .60****

.76**** .31*** .41**** .51**** .61**** .66****

.65**** .05 .42**** .12 .49**** .47****

.42**** .20 .56**** .26* .45**** .46****

.22** .08 .17* .12 .11 .19*

.41**** .07 .17 .19 .22* .34****

All correlations are corrected for age. RCMAS: Revised Childrens Manifest Anxiety Scale, STAIC-P: State-Trait Anxiety InventoryChildren lled out by Parent, STAIC: State-Trait Anxiety InventoryChildren, BAI: Beck Anxiety Inventory, BDI: Beck Depression Inventory, CDI: Child Depression Inventory, CDRS: Child Depression Rating Scale, HARS: Hamilton Anxiety Rating Scale, CGI-S: Clinical Global ImpressionSeverity, HDRS: Hamilton Depression Rating Scale, MASC: Multidimensional Anxiety Scale for Children. * P < .05 (two-tailed). ** P < .01 (two-tailed). *** P < .005 (two-tailed). **** P < .001 (two-tailed).

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BDI. Taking into consideration that the correlation between the BDI and BAI in that sample was pr = .63 (n = 100, P < .001), we found using the methodology presented by Meng, Rosenthal, and Rubin (1992) that, as expected the MASC correlated signicantly higher with the BAI than it correlated with the BDI (z = 3.29, P < .001). Table 2 also presented the correlations between the MASC scores and the clinician rated measures, the CDRS, the HAM-A and the HAM-D. As expected, the self-report MASC did not correlate with the clinician based depression scales, the CDRS and the HAM-D. As expected, the MASC did correlate moderately with the HAM-A, a clinician rating measure of anxiety. The correlation, corrected for age, between the HAM-A and the HAM-D for the patients who had both measures was pr = .45, n = 58, P < .001 (correcting for age did not alter the correlation). The correlation between the MASC and the HAM-A was, however, not signicantly higher than the correlation between the MASC and the HAMD, most likely due to the small sample size (z = 1.56, n = 58, n.s.). Similarly, the correlation between the MASC and the BAI was larger than the correlation between the MASC and the HAM-A, but only at the trend level (z = 1.61, n = 40, P < .10). The STAIC (pr = .39, n = 39, P < .05) and the BAI (pr = .36, n = 37, P < .05) also correlated moderately with the HAM-A. Other self-report measures of anxiety did not correlate signicantly with the HAM-A (RCMAS, pr = .20, n = 85, P = .06, and STAIC-P, pr = .17, n = 81, n.s.). Similarly, the correlations between measures of depression such as the BDI correlated moderately with the HAM-D (pr = .32, n = 47, P < .05), but less with the CDRS (.19, n = 85, n.s.) suggesting again that measures of the same symptom or trait (depression) using different methods (self-report vs. clinician report) are not highly correlated. As reported above, the STAIC was highly correlated with the MASC. However, the MASC scores did not correlate well with the STAIC-P (lled out by the parents on behalf of their children), indicating some disparity between the childs view of their anxiety and the parents view. To examine this question further, we calculate the correlation between the STAIC lled out by the child and the STAIC-P lled out for the child for those few children we have both data, the correlation was non-signicant .20 (n = 38, n.s). 3.6. Criterion validity Table 3 presents the MASC scores (least square means and standard errors) for the anxious and depressed children and adolescents corrected for age. As predicted, the MASC and almost all the MASC subscales, except for the Physical Symptoms subscale differentiated the two diagnostic groups. Because the Physical Symptoms subscale was almost equivalent in the two diagnostic groups, we also compared these scores without correcting for age, which did not change the results. Finally, the ADI scale and the MASC-10 subscales differentiated between the two groups as predicted despite their relatively low internal

M.A. Rynn et al. / Anxiety Disorders 20 (2006) 139157 Table 3 Differences on the MASC between anxious and depressed children corrected for age Anxious Mean MASCTotal score MASC subscales MASCPhysical Symptoms MASCHarm Avoidance MASCSocial Anxiety MASCSeparation Anxiety MASC-ADI MASC-10 61.2a 15.6a 18.4a 16.7a 10.7a 16.5a 16.3a S.E. 1.6 .7 .4 .6 .5 .5 .5 Depressed Mean 54.3a 15.6a 15.3a 14.5a 8.9a 14.7a 14.6a S.E. 2.0 .8 .5 .8 .6 .6 .6 F

151

7.33** 0 20.03**** 4.50* 4.73* 5.82* 4.27*

Even when not corrected with age, the MASC Physical Symptoms subscale does not distinguish between depressed and anxious pediatric patients. a Covariates appearing in the model are evaluated at the following values: age = 12.7215. * P < .05. ** P < .01. **** P < .001.

consistency, supporting their utility in distinguishing between these two subgroups of patients. 3.7. Predicting the presence of anxiety disorders in this sample The following MASC items were the best predictors of the diagnosis of anxiety disorders (I usually ask permission, I get scared when my parents go away, I try hard to obey my parents and teachers, I am afraid other kids will make fun of me, I check things out, I stay away from things that upset me, I get nervous if I have to perform in public, I check to make sure things are safe, I have trouble asking kids to play with me, and I feel shy. We then used a stepwise selection in logistic regression to identify the best combination of MASC items to serve as prognostic factors for an anxiety disorder diagnosis. As in other analyses, the model included patients age. Items 2 (I usually ask permission), and item 33 (I get nervous if I need to perform in public) independently of each other and in addition to patients age were predictive of having an anxiety disorder. The global test of signicance for the multivariate model is highly signicant (x2 = 24.1, df = 3, P < .0001). The AUC for this nal model is .742, which is in the fair to good range. Setting Sensitivity at 80%, we acquire an optimal operating point corresponding to the following equation: F (AGE, MASC02, MASC33) = .126 AGE + .699 MASC02 + .369 MASC33 .3653. If the right side of the equation results in a positive score, then the patient is likely to have a GAD diagnosis; if the right equation results in a negative score, then the patient is not likely to have a GAD diagnosis. With sensitivity at 80% we have maximum specicity of 55%, which corresponds to having at least a 55%

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chance of correctly identifying a non-GAD child among the true non-GAD children. Running a parallel analysis using the MASCTotal score, provided us less discrimination in our sample. Although the total score was statistically signicant (Wald x2(1) = 6.41, P = .014, Odds ratio = 1.024, 95% CI = (1.005, 1.043)), the AUC is .623 which is in the poor to fair range. The ROC analysis estimates an optimal cutpoint on the MASCTotal score of 46.67. Thus, if the MASCTotal score is larger than 46.67 then the child is likely to have a GAD diagnosis. With sensitivity set at 80% we have a maximum specicity of 34%, which corresponds to having at least a 34% chance of correctly identifying a nonGAD child among the non-GAD group.

4. Discussion To our knowledge this is the rst report of the validation of the MASC in a relatively large clinical sample of anxious and depressed pediatric patients. Overall, the psychometric properties of the MASC received good support in this application to a patient sample. The MASC and its subscales were reliable as assessed by Cronbach Alpha. The overall factorial structure uncovered by March et al. (1997) was replicated in this patient sample across age and across gender. Thus, the four subscales of the MASC represent an adequate model of the sample data and are consistent with Marchs (1997) prior work. These subscales are likely to be helpful. Support for the importance of these subscales was provided in this sample by the fact that the MASCTotal Scale score, three of the four subscales and the two MASC embedded subscales (ADI and MASC-10) distinguished between anxious and depressed children. In all these scales, depressed children and adolescents scored lower than their anxious counterparts, even when correcting for age. In fact, the Harm Avoidance Subscale was the best subscale to discriminate between anxious and depressed children in this clinical sample. Interestingly, the Physical Symptoms subscale did not distinguish between anxious and depressed pediatric patients. Although it is known that children with depression have somatic complaints it may be of the same magnitude seen by anxiety-disordered youth. In terms of concurrent validity, we found, as did Muris et al. (2002) that the MASC subscales and total score correlated highly with other self-report measures of anxiety such as the RCMAS and the STAIC when lled out by the child. Because the BDI and BAI were given only to the older children, we were able to examine the relation between the MASC and those measures only in the subsample of these older children (!12). Clearly the MASC correlated signicantly with these other self-report measures of anxiety and depression. The magnitude of the correlations between the MASC and the BAI was, as expected, signicantly larger than the ones between the MASC and the BDI (see also Muris et al., 2002). When we examined the correlations between the MASC and the clinician-rated scales for depression, we found as expected no

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correlation between those measures. Finally, as expected we found small to moderate correlations between the MASC and its subscales with the clinicianrated HAM-A. There are two explanations for these lower correlations between the MASC and the HAM-A in comparison to the correlations between the MASC and other self-report measures of anxiety: First, measures of the same construct (anxiety) correlate more highly if measured using a similar method (self-report) than if measured using a different method (clinician rating). In other words, two self-report measures of anxiety share both method variance and trait variance, whereas, a self-report measure of anxiety and a clinician-rated scale of anxiety share only trait variance (Kazdin, 2003). Second, in our sample, the HAM-A was given only to anxious children, therefore narrowing the range of scores on the HAM-A, with the consequent results of potentially lowering the correlation between the HAM-A and the MASC in our sample. These two reasons together with the smaller sample in which both Hamilton scales and the MASC were given, lead to the lack of a signicant difference between the correlation of the HAM-A and MASC and between the correlation of the HAM-D and MASC. As previously mentioned, the MASC, however, did not correlate with the STAIC-P (lled out by the parent). This is an interesting nding suggesting that parents ratings and child ratings are not consistent. In fact, when we examined the correlation between the STAIC lled out by the child and the STAIC-P lled out by the parents, we found a non-signicant relation between the two. We should remain careful in our conclusion since we had only 36 childparent pairs in which both lled out the STAIC. Nevertheless, this data seems to indicate that the STAIC-P should be taken with an awareness that it may not be the most valid measurement of the childs anxiety as viewed by the child. This lack of concordance between parent and child reports has been found for internalizing disorders in general and anxiety disorders specically (e.g., Silverman & Eisen, 1992). We recommend that future studies look at the impact of parents own anxieties or more general psychopathology on how they score the STAIC for their children. In the present study, we used logistic regression to nd the MASC items that would best distinguish between anxiety and depressive disorders. We were able to nd that in addition to age, two items seemed to predict whether a child was anxious or depressed. Individuals who endorsed the item usually asked permission and who reported getting nervous when performing in public were more likely to be diagnosed as anxious with 80% sensitivity. Unfortunately, however, these children who were not actually depressed were only predicted to be not depressed in 55% of the cases using their age and these two items. The signicant individual items of the MASC (I usually ask permission and I get nervous if I need to perform in public), coupled with Age provided a higher accuracy rate of classifying non-GAD children as compared to using the MASC Total. To explain this phenomenon, we will present results from two hypothetical children with the same total MASC score by focusing on responses on the two

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signicant individual items. For example, two 12-year-old children may have equal MASCTotal scores but one gave a response of 0 for I usually ask permission and 3 for I get nervous if I need to perform in public, while another child gave a 3 to the rst item and 0 to the second item. Using the equation derived at the optimal operating point yields a score .7703 (F (12, 0.3) = .126 12 + .699 0 + .369 3 .3653) for the rst child and .2197 (F (12, 3.0) = .126 12 + .699 3 + .369 0 .3653) for the second child. Therefore, the rst child would be classied as Non-GAD, whereas the second child would be classied as GAD, despite the fact that their total scores on these two MASC items was identical. The importance of these items for clinical practice for distinguishing depressed and anxious children needs to be replicated in an independent sample using the present methodology. Furthermore, this methodology could be used to distinguish anxious and normal children in order to provide clinicians, including pediatricians, with a series of key questions that could help them distinguish anxious and normal children. This would be especially useful for pediatricians given that many anxious children rst present in the primary care setting with their physical symptoms. Our ndings need to be replicated before recommending them in pediatric care practices. The results obtained with the MASC ADI and the MASC-10 subscales are, however, supportive of the use of these scales to discriminate between pediatric patients who are anxious and depressed. The fact that these two short scales were able to distinguish between these two groups of patients despite their relatively low internal consistency is supportive of their validity. These scales have been used in similar roles in prior studies and our conrmation of their ability to distinguish between anxious and depressed young clients support their use in clinical care. One of the major limitations of the current sample was that it only included children and families who had agreed to participate in randomized psychopharmacological clinical trials. Those patients, therefore, may differ on unknown dimensions from the general treatment seeking population at large. Given the exclusion criteria of these psychopharmacological clinical trials the sample may also had lower comorbidities than other samples. Therefore, these results need to be replicated in other clinical samples. Nevertheless, our sample was diverse, including a 30% participation of minority pediatric patients. Another limitation was that the depressed patients were on average older than the anxious pediatric patients. The magnitude of the difference, however, was not large. The fact that this small difference in age was signicant was partly due to the fact that we have a relatively large sample. 4.1. Clinical and research implications The MASC is a reliable and valid screening tool used to identify children and adolescents with anxiety disorders in clinical samples. Both the MASC-10 and the full MASC can be used for these purposes, with the full MASC providing ratings

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on four factors that match DSM-IV diagnoses. Scores on these factors can be supplemented with a formal clinical interview. If the present results are replicated in other clinical samples, the two items identied as predictive of anxiety disorders could be used by mental health practitioners and pediatricians, as an easy rst step to quickly screen for children at risk for anxiety symptoms and to make referral recommendation. Further evidence is needed to show that the MASC is sensitive to change, although preliminary evidence suggested that the MASC changed with sertraline treatment for children with anxiety disorders (Rynn et al., 2001).

Acknowledgements We want to thank Dr. Karl Rickels for his help on the paper. We also thank Dr. March for providing us with an early version of his scale. Supported in part by the Mood and Anxiety Disorders Program, University of Pennsylvania, and by grants NIMH K23 MH 01819 and NIMH RO1 MH61410.

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