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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 conﬁrmed 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: firstname.lastname@example.org (M.A. Rynn). 0887-6185/$ – see front matter # 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.janxdis.2005.01.004
. 1997). These two forms have demonstrated satisfactory test-retest reliability (March. / Anxiety Disorders 20 (2006) 139–157 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. Social Anxiety (humiliation/performance fears) and Separation Anxiety/Panic. 1997). Langley. while March. Birmaher et al. developed the Screen for Child Anxiety Related Disorders (SCARED. Parker. In a large sample of normal adolescents. 1993. 1973). 1999. Feehan. The MASC includes items at the factor. Dierker et al.g. a number of scales have been developed in the last decade. Reynolds & Richmond. The MASC contains 39 items that approximate the DSM-IV anxiety diagnoses and contains four factors: Physical Symptoms (tense/somatic). (2001) screened their participants. and Connor. (1997) developed the Multidimensional Anxiety Scale for Children (MASC). Roberts. and Bogie (2002) found that the MASC was highly correlated with other older (RCMAS and STAIC) and more recent (e. Seligman. In the current paper. Stallings. Given the overlap of many features of anxiety and depression (e. McGee. Stallings.. Sullivan. the State-Trait Anxiety Scale for Children (STAIC. Among others. 2004). Harm Avoidance (perfectionism/anxious coping). The full MASC has shown good internal consistency and test-retest reliability. and physical symptoms).140 M. Rynn et al.A. subfactor and item level that assess clinically relevant anxiety symptoms and reﬂect overlap among the factors (March. problems with concentration. & Connor. and Baldacci (2004) showed that the Revised Children’s Manifest Anxiety Scale (RCMAS. Williams. see Section 1). Langley. King. Chorpita. and the Child Behavior Checklist (CBCL. one of the important clinical issues for clinicians and researchers is to develop measures that will discriminate between anxiety and depressive disorders.’s adaptation of the Children Anxiety Scale were not available at the time the studies included in this paper were initiated.. Achenbach. To address these and other issues. Mofﬁt.g. Merckelbach. & Andrews. In a recent meta-analysis of three important measures. & Partridge. Birmaher et al. Lewinsohn. Ollendick. Muris. Parker. for the most part were signiﬁcantly less correlated with a self-report of depression (CDI). fatigue. Ollendick. who were recruited from a school setting. we examined the psychometric properties of the MASC because the SCARED and the Chorpita et al. Umemoto. Sullivan. 1999.g. Ollendick. for the presence of psychiatric disorders. Spielberger. two shorter forms designed for screening anxiety disorders. Yim. the MASC-10 and the Anxiety Disorder Index can be derived from the MASC. 1991) could discriminate between youth with an anxiety disorder and youth without a psychiatric disorder. They were able to show . and Francis (2000) also recently improved the Spence’s (1998) Children Anxiety Scale. Hops. & Parker. these scales were not very good at distinguishing between youth with an anxiety disorder and youth with an affective disorder (Seligman. Sullivan. Also. 1978). SCARED) anxiety measures and. In the last decades many such measures have been developed. & Baldacci. Seeley. However. 1990).
Merckelbach. 6) To predict the presence of anxiety disorders in this sample. reliability and validity of the MASC in this clinical sample. 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 hypothesized that the MASC would be more closely associated with other measures of anxiety than with measures of depression. than among different methods of assessing the same symptoms. we examined the following questions: 1) To examine whether the factor structure of the MASC uncovered by March et al.A. / Anxiety Disorders 20 (2006) 139–157 141 that in the sample of these diagnosable participants who had not requested treatment.. 1997).. Rynn et al.. More speciﬁcally. 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. Ollendick. 2001). 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. the MASC was a moderately accurate predictor of Generalized Anxiety Disorder (GAD) in females (AUC = . That is.82) (Dierker et al. 3) To examine the reliability of the MASC and its different subscales in our sample of anxious and depressed children. all of these studies with the MASC have used either non-clinical populations (Muris. 5) To examine the criterion validity of the MASC. 4) To examine the concurrent validity of the MASC and its subscales with other measures of anxiety and depression both self-report and clinicianrated. Furthermore. 2001). . (1997) in a sample of school children was conﬁrmed in our sample of anxious and depressed patients using a conﬁrmatory factor analysis (CFA). in contrast to the RCMAS and CES-D. 2001). More speciﬁcally. We attempted to ﬁnd a small number of MASC items that could help us differentiate patients with anxiety disorders from patients with depressive disorders. 2002) or children who had not sought treatment (Dierker et al. 1998) and of the MASC-10 to differentiate these two groups of patients. 2) To examine whether the factorial structure of the MASC was equivalent across sex and age groups. Those items could be used in the future for clinicians to quickly discriminate between these two disorders. & Bogie. 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. We assessed the factor structure. Furthermore. However. King. we expected that the correlations would be higher among same method measures of same symptoms.M.
an outpatient clinic focused on childhood anxiety and depressive disorders. or major depression (MDD). 1996 or The Schedule for Affective Disorders and Schizophrenia for School-Age Children. Silverman & Albano. Therefore. patients with the following psychiatric disorders or symptoms were excluded: attention deﬁcit disorder. no current cognitive behavioral therapy. at the University of Pennsylvania Medical Center. The studies these patients were being recruited for participation were medication trials to assess the efﬁcacy of an SSRI for a speciﬁc diagnostic entity. In this paper. a patient recruited for the GAD study could not have a current diagnosis of MDD or vice versa). One hundred and thirty-eight (71%) patients were White.A. bipolar affective disorder. schizophrenia. panic disorder. post-traumatic stress disorder. hospitalization within past 6–12 months. 34 (18%) were African American. Two hundred and eighty-seven pediatric patients were found inappropriate for those trials.1. developmental disorders. and no exposure to the study medication within the last year. 1978) with an experienced child and adolescent psychiatrist speciﬁcally trained in the use of these diagnostic interviews. patients with disorders that could beneﬁt from a different medication are usually excluded.g.142 M. ADIS-R. / Anxiety Disorders 20 (2006) 139–157 1. . 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. 8 (4%) were either ‘‘Other’’ or unknown. Method 1. or MDD and not have diagnostic level symptomatology of other Axis I diagnoses (e. 13%). In such trials. Social Anxiety Disorder (N = 25. Children and adolescents were recruited. agencies. Puig-Antich & Chambers. K-SADS. attention deﬁcit/hyperactive disorder. The patients included in this study met diagnostic criteria based on the structured interview (Anxiety Disorders Interview Schedule for Children— Revised. obsessive-compulsive disorder.. substance abuse/dependence. resulting in 193 patients who had been randomized and had ﬁlled out the MASC questionnaire. 47%). family physicians. Patients needed to have a clear primary diagnosis of GAD. The patients and their parents agreed to begin one of a total of eight different consecutive placebo controlled pharmacological studies during years 1999–2003. SAD. social anxiety. acute suicidality. no acute or serious unstable medical problems. and previously treated patients. 40%). Rynn et al. 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 GAD which could be comorbid with separation anxiety disorder (SAD) at the Child and Adolescent Research Service (CAReS). and MDD (N = 77. Seventy percent of patients were direct referrals from pediatricians. The 193 patients received the following diagnoses: GAD/SAD (N = 91. 3 (2%) were Asian American and 10 (5%) were Hispanic.
March et al. & Brown.. 1981. The scale was developed by taking the 4 highest loading items on each MASC subscale. 1997 manual). 1999). The State-Trait Anxiety Inventory for Children—Trait version (STAIC.1. and a still respectable rate of 71% when classifying anxious versus ADHD children. The Revised Children’s Manifest Anxiety Scale (RCMAS. (2) A 10-item Anxiety Disorder Index (ADI) combining the 10 best items at discriminating between anxious and non anxious children (March. Reynolds & Richmond. for a review).90.89 indicating adequate stability over time as well as satisfactory internal consistency (Cronbach alpha = . Measures 2. on a 4point severity scale. It has been widely used in studies of psychosocial treatments for anxiety (see Fydrich. and (4) Separation Anxiety (9 items). In a previous factor analysis. / Anxiety Disorders 20 (2006) 139–157 143 2. then these 16 items were factor analyzed in the normative sample. March et al. and the items with the lowest loading was removed. 1973) is a 20-item measure of trait anxiety (enduring tendencies to experience anxiety). Epstein. Beck.. 1979. Patient self-report measures of anxiety The Multidimensional Anxiety Scale for Children (MASC. 2. and also March et al. The MASC-10 has been shown to be a coherent measure of anxiety (March.M. which measures long-standing and relatively stable components of a child’s personal characteristics in the area of anxiety. Beck Anxiety Inventory (BAI. (2) Harm Avoidance (9 items such as anxious coping and perfectionism).A. 1978) consists of 37 true/false items (28 Anxiety and 9 Lie scale items) that assess a variety of anxiety symptoms. Adequate reliability. We are using the total score of the RCMAS in this paper.2. with a focus on cognition. This process was repeated until 10 items remained. Kovacs.. The MASC also includes two embedded subscales: (1) a 10-item short form (MASC-10) intended to be a short and efﬁcient global measure of anxiety symptoms. March (1997) reported an overall classiﬁcation rate of 95% when classifying anxious and normal children. 1997). Adequate reliability. 1997. 1999) is a 39-item 4-point Likert self-report questionnaire recently developed to assess anxiety symptoms. Spielberger. Rynn et al. March et al. 1978). (1997) found four factors: (1) Physical Symptoms (12 items such as tense/restless and somatic/ autonomic). (3) Social Anxiety (9 items such as humiliation/rejection and public performance fears). Reynolds & Richmond. 1997 also reported mean intraclass correlation for those scales ranging from . 1992. to . Patient self-report measures of depression The Child Depression Inventory (CDI. Dowdall. 1981) is a 27-item scale that allows the child to select among alternatives on a 3-point scale reﬂecting degree .64. & Chambless. validity and normative data have been reported (Reynolds & Pagetc. 1988a) is a 21-item scale that assesses common features of anxiety. validity and normative data have been reported by Spielberger (1973).
& Garbin. This measure is used for children under age 12. 1994. 1992. according to the 0– 8 distress/impairment severity scale.3. 1996) is a clinical structured interview used to identify the principal diagnosis. & Erbaugh. Silverman & Nelles. & Evans. Parent report measures on child The State-Trait Anxiety Inventory for Children—Modiﬁcation of trait version for parents (STAIC-P): Strauss (1987) modiﬁed the trait version of STAIC to be used as a complementary parent rating of child anxiety especially relevant in a middle childhood population. 1984). 1988b. Hamilton Rating Scale for Depression (HAM-D. Adequate reliability and validity have been reported (Kazdin. This scale has been the standard depression scale against . The Beck Depression Inventory (BDI. Evidence for its reliability and validity with a clinical sample are provided by Kendall (1994) and Kendall et al. This is operationally deﬁned as the disorder associated with the most severe current impairment and/or distress. was chosen because it contains an expanded anxiety section not found in other available instruments. 2. and also allows the assessor to screen for other disorders. 1981. 1988). 1959): The HAM-A is a widely used 14-item inventory that assesses the severity of common anxiety symptoms. Spirito. The HAM-A is intended for use with adults. Dadds. Mock. The form was ﬁlled out by the primary care taker. It is a revision of the original ADIS for DSM-IIIR (Silverman & Nelles. The K-SAD was used to assess the primary diagnosis of major depression if the patient endorsed symptoms of depression. This structured interview (which is based on the Diagnostic and Statistical Manual of Mental Disorders. 1988). Ward. (1997).4. Hamilton. and thus required the research psychiatrists or psychologist to describe the symptoms in a more child appropriate manner. Silverman & Rabian. The ADIS has satisfactory test-retest reliability (Silverman & Eisen. The Schedule for Affective Disorders and Schizophrenia for School-Age Children (K-SADS) Present Episode (Puig-Antich & Chambers. It is a widely used. 1995) and moderate to high inter-rater reliability (Rapee. reliable measure of depressive symptoms (see Beck.144 M. Barrett. Hamilton. for a review). The BDI was used for children 12 and older. / Anxiety Disorders 20 (2006) 139–157 of particular depressive symptoms (total scores range from 0 to 54) over the past 2 weeks. Saylor. Clinician-rated measures Anxiety Disorders Interview Schedule for Children—Revised (ADIS-R. Beck. 1960): The 17item version was used. 1978): This is a semi-structured interview for children and adolescents based on the adult version of the instrument (SADS). Rynn et al. Steer. & Bennet. 1961) is a 21-item self-report measure of depression. 2. Mendelson. who was primarily the mother. Finch.A. 4th edition). Hamilton Anxiety Rating Scale (HAM-A. Silverman & Albano.
Data analytic strategy T-tests. 1978). which assesses the discrepancy between the model and the data per degree of . If the patient met study criteria. Steiger. 2.6. Rynn et al. either the ADIS-R to conﬁrm an anxiety diagnosis (Silverman & Albano. Finch. All forms were ﬁlled out in one setting. At the intake interview. If a child had difﬁculties reading or understanding any questionnaire. 1996) or the Kiddie-SADs to conﬁrm the diagnosis of major depression (Puig-Antich & Chambers. while the CDI was given only to children younger than 12 years old.A. CDRS. a research assistant or psychiatrist assisted them in completing the forms.. 1999) as in this instance.M. The BDI and BAI were given only to adolescents. Children Depression Rating Scale (CDRS. Analysis of Variance (ANOVA) models. The MASC. to all children or adolescents. A better measure of ﬁt and one of the most reliable (Hu & Bentler. 1990). Therefore. and if they appeared to meet preliminary inclusion criteria were invited in for an intake interview. 1984): A clinician rated instrument designed to assess the presence and severity of depression symptoms. The STAIC-P was given to the primary caretaker of the children.5. Because x2-sampling distributions are inﬂuenced by the number of observations. and in larger samples the distribution begins not to conform to a x2distribution. the mother in the majority of case. there are no similar instruments for childhood anxiety disorders. 1999) is the root mean square error of approximation (RMSEA. x2-measures are likely to reject models that ﬁt approximately in the population more often when the sample size is large (Hu & Bentler. Spirito. CGIS and ADIS were given to all patients. 1984). Conﬁrmatory factor analysis was used to validate the factorial structure of the MASC. Analysis of Covariance (ANCOVA) models and chi-square tests were used to detect differences between the diagnostic groups. Poznanski et al. they were invited to be part of the clinical research trial and written informed consent was obtained. Adequate reliability and validity have been reported (Kazdin. The HAM-D was given. Procedure All patients ﬁrst participated in an extensive phone screen. / Anxiety Disorders 20 (2006) 139–157 145 which all other depression scales are compared. all children and their parents were interviewed by experienced research psychiatrists and psychologists who used a structured interview. The HAM-A was given only to anxious children or adolescents. to rate the parent’s view of the child anxiety. Although this is an adult instrument. The STAIC was given to a part of the sample at the beginning of the study. however. 2. the clinician described the symptoms in child language. & Bennet. 1981. It is a 27-item scale that allows the child to select among alternatives on a 3-point scale reﬂecting degree of particular depressive symptoms (total scores range from 0 to 54) over the past 2 weeks. Saylor. RCMAS.
ROC curves have since been applied to problems in experimental psychology and medicine (Zweig & Campbell. were used to identify the items prognostic of a diagnosis of anxiety disorder versus depressive disorder in this sample. the test is not much better than a coin ﬂip in discriminating between true positives and true negatives. 1999). 1994). sensitivity) yields a bow-shaped receiver operating characteristic (ROC) curve. 1989. Positive scores on this equation classify individuals as having an anxiety disorder. 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.146 M. Originally developed more than 40 years ago for the study of electronic signal detection and evaluation of radar signals. If the ROC curve lies close to the 458 line. Each cutpoint yields an estimated sensitivity and speciﬁcity. 1988). This results in a curve that rises quickly and is close to the upper left corner of the graph. Stepwise regression enters predictors one at a time. This optimal threshold is called the optimal operating point. Similar to the ROC curve’s graphical description of the performance of an instrument. 1996.50. negative scores classify individuals as having a depressive disorder. RMSEA values of . respectively. Somoza & Mossman. Halpern.1 PROC LOGISTIC. Metz. 2003. Krieger. as implemented in SAS 8. 1993). Crits-Christoph. signiﬁcant predictors were then entered simultaneously in a stepwise model. Hanley. Muenz. & Smith. 1993). whereas.08 or less suggest an adequate ﬁt (Browne & Cudeck. & Tu. 1992. This optimal operating point will be of clinical use in guidelines for decision-making. Schafer. random discrimination to a high of 1. Logistic regression models. 1993. where sensitivity and speciﬁcity are. Albert.A. Rynn et al. which displays the performance of all possible decision rules. a standard approach to summarize the test’s performance is to examine all possible cutpoints for the best linear combination. 1990). 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. / Anxiety Disorders 20 (2006) 139–157 freedom (Browne & Cudeck. perfect discrimination (Kufera & Mitchell. Recent attention has also been given to determining the optimal threshold cutpoint from the ROC curve (Gallop. & Maidment.00. The optimal operating point produces a mathematical equation based on a linear combination of the included predictors. Steiger.05 was required for a variable to stay in the model. the locus of (1: speciﬁcity. A quantiﬁer of the performance of a diagnostic test is the area under the curve (AUC). 1993). An individual’s classiﬁcation is based . To determine the best linear combination of items. 1991. the chance that a true positive and a true negative will be identiﬁed as such (Fisher & Van Belle. The AUC ranges from a low of . Phelps & Mushlin.05 or less suggest a good ﬁt of the model to the data and values of . As the cutpoint varies. Sainfort. Since the test outcome is quantitative. 1995). where a signiﬁcance level of . the optimal operating point provides a geometrical tool for the classiﬁcation of the predicted outcome at the corresponding sensitivity and speciﬁcity levels of the optimal operating point.
g. P < . Conﬁrmatory factor analysis (CFA) of the MASC The four-factor solution obtained by March et al. S.3.2. df = 191. The RMSEA was equal to . 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).1) were older than the anxious ones (mean age = 12.073. age is included as a covariate in all comparisons between the primarily depressed and anxious children and in all the correlations presented below. age differences between the two groups: the depressed children (mean age = 13.007). because we are more concerned in the classiﬁcation of the presence of an anxiety disorder as compared to a depressive disorder. The CFA indicated a reasonable ﬁt between the a priori factorial structure and our data (x2 = 1427.D.74. There were. Therefore. = 3.75.19. / Anxiety Disorders 20 (2006) 139–157 147 on estimation of this equation using an individual’s observed values.D. (1997) did ﬁt the current data. similar factor loadings) and population homogeneity (e. the degree of measure invariance (e. 1999). We will maximize speciﬁcity over the set of cutoff points meeting this restriction. In determining the optimal operating point. we used the RMSEA (Hu & Bentler. df = 4. 3.0001).g.3.. we have set a minimum value of 80% for which we do not want sensitivity to fall below. n.2. equal means) were examined in boys and girls using multiple groups CFAs (n = 104 for boys and n = 89 for girls). therefore 80% of children with anxiety disorder are accurately classiﬁed. = 3. As explained above instead of using the x2 values as a way of evaluating the degree of ﬁt between the model and data.A. .). 3.1. t = 2. indicating that we were able to replicate the factorial structure of the MASC in this sample of pediatric patients.M.1.) 3.. P = . n. df = 702. After separate CFAs were conducted to ensure adequate ﬁt in the boys and girls samples. This high cutoff allows for good identiﬁcation of children with anxiety disorder.5.s. df = 1. a two group CFA was conducted to evaluate simultaneously the MASC between sexes.s. 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. Rynn et al. Results 3. however. No signiﬁcant difference between diagnostic categories and races were found (x2 = 4. S. There were no signiﬁcant differences in gender distribution between the two disorders (x2 = 1.
0 (7.5) (4. like the BAI was available only for a subsample of older children. Cronbach alphas were used as a measure of internal consistency. 3.9) (6.72 .9 (4. which.4 41 75 56 100 66 20 30 15.67 Percent of items with item total correlations >.78 . P < .148 M.001).077).5. the BAI was available only for a subsample of older children. RMSEA = .8 (17. Rynn et al.3) 15.4) Note.87 . we tested whether the MASC correlated signiﬁcantly higher with the BAI than with the . which were made of relatively heterogeneous items. The other self-report measure of anxiety. P < .2 15.69.14. RMSEA = . / Anxiety Disorders 20 (2006) 139–157 Table 1 Subscale statistics and internal consistency Number of items MASC—Total 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. The Anxiety Disorder Index and the MASC-10 scales.0001). MASC: Multidimensional Anxiety Scale for Children. The reliability of the MASC and its subscales Means and standard deviations for all subscales are presented in Table 1.D. P < .62 .86 .84 .70. They were computed for all subscales and for the entire scale (see Table 1). Because of the importance of these scales.2) Cronbach alpha . 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).6 17.9) 15.9) (6.0001. 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) = 2281.078). As hypothesized the MASC correlated highly with other self-report measures of anxiety (such as the STAIC and the RCMAS). The only self-report measure of depression was the BDI. n = 104. 3. This model ﬁt the data appropriately (x2(1443) = 2252.A.4. we needed to show that the MASC correlated more highly with measures of anxiety than with measures of depression. but it correlated very highly with the MASC (pr = .6 (5. suggesting relatively weak internal consistency. Further.) 57. had internal consistency below .8 10.
07 .Table 2 Partial correlations between the MASC.09 .42**** .46**** .17* .16 . its subscales and other measures of anxiety and depression corrected for age Self-report anxiety measures RCMAS n MASC—Total MASC—Physical Symptoms MASC—Harm Avoidance MASC—Social Scale MASC—Separation Anxiety Scale MASC-ADI MASC-10 167 . 149 . / Anxiety Disorders 20 (2006) 139–157 Depression CDRS 149 General CGI-S 147 .05 .65**** .34**** All correlations are corrected for age. HARS: Hamilton Anxiety Rating Scale.02 À24*** À.27 .12 .45**** .60**** .22** .16* STAIC 38 .66**** .46*** . ** P < .54**** .09 .56**** . RCMAS: Revised Children’s Manifest Anxiety Scale.22* .03 . STAIC: State-Trait Anxiety Inventory—Children.15 . CDRS: Child Depression Rating Scale.04 À.09 .03 .19* .13 À.13 .35** .22** .27 . CDI: Child Depression Inventory.61**** .08 . HDRS: Hamilton Depression Rating Scale.41**** . * P < .17 .11 .07 .31*** .005 (two-tailed).20 . *** P < .58**** .58**** .41**** . Rynn et al.61 **** Self-report depression measures BAI 104 **** Structured clinical ratings M.34 **** Depression H HAM-D 83 .47 .05 (two-tailed). BAI: Beck Anxiety Inventory.00 .04 À. STAIC-P: State-Trait Anxiety Inventory—Children ﬁlled out by Parent.47**** .60 BDI 103 CDI 64 **** Anxiety HAM-A 85 .57**** .76**** .49**** .51**** .09 À.26* .12 .001 (two-tailed).19 .14 .01 (two-tailed).22 ** STAIC-P 158 .60**** . **** P < .A.23* .44*** . BDI: Beck Depression Inventory.69 **** . MASC: Multidimensional Anxiety Scale for Children.13 À.42**** À.47 **** À.05 . CGI-S: Clinical Global Impression—Severity.
As reported above. the MASC and almost all the MASC subscales. P < .A. we calculate the correlation between the STAIC ﬁlled out by the child and the STAIC-P ﬁlled out for the child for those few children we have both data. and Rubin (1992) that. Finally.20 (n = 38. we also compared these scores without correcting for age. Similarly.001). however.001 (correcting for age did not alter the correlation).19. Other self-report measures of anxiety did not correlate signiﬁcantly with the HAM-A (RCMAS.001). the STAIC was highly correlated with the MASC. P < . The correlation. Because the Physical Symptoms subscale was almost equivalent in the two diagnostic groups. the MASC scores did not correlate well with the STAIC-P (ﬁlled out by the parents on behalf of their children). corrected for age. but less with the CDRS (. the CDRS and the HAM-D. P < . However. P < . the self-report MASC did not correlate with the clinician based depression scales. n = 39. the correlation was non-signiﬁcant . indicating some disparity between the child’s view of their anxiety and the parents’ view.29.). n = 81.150 M. the ADI scale and the MASC-10 subscales differentiated between the two groups as predicted despite their relatively low internal . n. To examine this question further. As predicted. which did not change the results. most likely due to the small sample size (z = 1. Rosenthal. the HAM-A and the HAM-D.05) also correlated moderately with the HAM-A. as expected the MASC correlated signiﬁcantly higher with the BAI than it correlated with the BDI (z = 3. and STAIC-P. As expected. a clinician rating measure of anxiety. n = 37. / Anxiety Disorders 20 (2006) 139–157 BDI.).61. Similarly. 3. Table 2 also presented the correlations between the MASC scores and the clinician rated measures. n. n = 58. P < . not signiﬁcantly higher than the correlation between the MASC and the HAMD. 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. pr = . clinician report) are not highly correlated. Taking into consideration that the correlation between the BDI and BAI in that sample was pr = .) suggesting again that measures of the same symptom or trait (depression) using different methods (self-report vs. The STAIC (pr = .05). we found using the methodology presented by Meng. the correlations between measures of depression such as the BDI correlated moderately with the HAM-D (pr = . n = 47.39. P = .45.s. n. the CDRS. n = 85.36.s. n.10). pr = . As expected. Rynn et al.s.32. the correlation between the MASC and the BAI was larger than the correlation between the MASC and the HAM-A.s). P < . except for the Physical Symptoms subscale differentiated the two diagnostic groups. The correlation between the MASC and the HAM-A was. n = 85.20. n = 58. but only at the trend level (z = 1.06. the MASC did correlate moderately with the HAM-A. P < .6. n = 40. between the HAM-A and the HAM-D for the patients who had both measures was pr = .56.17.63 (n = 100.05) and the BAI (pr = .
The global test of signiﬁcance for the multivariate model is highly signiﬁcant (x2 = 24.369 Â MASC33 À .E.8 . * P < . 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’’. the MASC Physical Symptoms subscale does not distinguish between depressed and anxious pediatric patients.M. ‘‘I have trouble asking kids to play with me’’.6 .4 . the model included patients’ age.50* 4.3653. Items 2 (‘‘I usually ask permission’’).8 .2a 15. ‘‘I try hard to obey my parents and teachers’’.A.9a 14. which is in the fair to good range.27* Even when not corrected with age.6a 18.6 F 151 7.E. ‘‘I get scared when my parents go away’’. 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.7a 10. ‘‘I stay away from things that upset me’’. then the patient is not likely to have a GAD diagnosis.7. / Anxiety Disorders 20 (2006) 139–157 Table 3 Differences on the MASC between anxious and depressed children corrected for age Anxious Mean MASC—Total score MASC subscales MASC—Physical Symptoms MASC—Harm Avoidance MASC—Social Anxiety MASC—Separation Anxiety MASC-ADI MASC-10 61.5 .699 Â MASC02 + .0 .3a S. **** P < .7a 16. we acquire an optimal operating point corresponding to the following equation: F (AGE. The AUC for this ﬁnal model is . 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.82* 4. Setting Sensitivity at 80%.6 . ‘‘I get nervous if I have to perform in public’’.6 .5 Depressed Mean 54. then the patient is likely to have a GAD diagnosis.6 . With sensitivity at 80% we have maximum speciﬁcity of 55%. a Covariates appearing in the model are evaluated at the following values: age = 12.001.7a 14. MASC33) = À.4a 16. P < .7 . Rynn et al. As in other analyses.33** 0 20.5 .5a 16. MASC02. If the right side of the equation results in a positive score.03**** 4.0001). consistency. ‘‘I am afraid other kids will make fun of me’’. ** P < . ‘‘I check things out’’. ‘‘I check to make sure things are safe’’. which corresponds to having at least a 55% .7215.6a S.05.3a 14. 2.3a 15. df = 3.73* 5.6a 15. if the right equation results in a negative score. supporting their utility in distinguishing between these two subgroups of patients. 3.5 .1.5a 8.742.126 Â AGE + .01. 1.
In terms of concurrent validity. Interestingly. Although it is known that children with depression have somatic complaints it may be of the same magnitude seen by anxiety-disordered youth. we found. Although the total score was statistically signiﬁcant (Wald x2(1) = 6. depressed children and adolescents scored lower than their anxious counterparts.67.. (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 ﬁlled out by the child. P = . which corresponds to having at least a 34% chance of correctly identifying a nonGAD child among the non-GAD group. provided us less discrimination in our sample. In fact. signiﬁcantly larger than the ones between the MASC and the BDI (see also Muris et al. if the MASC—Total score is larger than 46. 2002).014. Clearly the MASC correlated signiﬁcantly with these other self-report measures of anxiety and depression. as expected. When we examined the correlations between the MASC and the clinician-rated scales for depression. The overall factorial structure uncovered by March et al. / Anxiety Disorders 20 (2006) 139–157 chance of correctly identifying a non-GAD child among the true non-GAD children. Odds ratio = 1. 4.41. (1997) was replicated in this patient sample across age and across gender. we found as expected no . the Harm Avoidance Subscale was the best subscale to discriminate between anxious and depressed children in this clinical sample. Discussion To our knowledge this is the ﬁrst report of the validation of the MASC in a relatively large clinical sample of anxious and depressed pediatric patients. Thus. the four subscales of the MASC represent an adequate model of the sample data and are consistent with March’s (1997) prior work. The ROC analysis estimates an optimal cutpoint on the MASC—Total score of 46. With sensitivity set at 80% we have a maximum speciﬁcity of 34%.005. 1.623 which is in the poor to fair range. Support for the importance of these subscales was provided in this sample by the fact that the MASC—Total Scale score. the psychometric properties of the MASC received good support in this application to a patient sample. the Physical Symptoms subscale did not distinguish between anxious and depressed pediatric patients. Overall. Thus. The magnitude of the correlations between the MASC and the BAI was. Because the BDI and BAI were given only to the older children. 95% CI = (1. The MASC and its subscales were reliable as assessed by Cronbach Alpha.A. we were able to examine the relation between the MASC and those measures only in the subsample of these older children (!12).043)). Running a parallel analysis using the MASC—Total score. In all these scales.67 then the child is likely to have a GAD diagnosis. three of the four subscales and the two MASC embedded subscales (ADI and MASC-10) distinguished between anxious and depressed children.152 M.024. Rynn et al. the AUC is . as did Muris et al. even when correcting for age. These subscales are likely to be helpful.
the MASC. the HAM-A was given only to anxious children. 2003). Second. 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 child’s anxiety as viewed by the child. however. / Anxiety Disorders 20 (2006) 139–157 153 correlation between those measures. as expected we found small to moderate correlations between the MASC and its subscales with the clinicianrated HAM-A. We should remain careful in our conclusion since we had only 36 child–parent pairs in which both ﬁlled out the STAIC. To explain this phenomenon. In fact. however. 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). whereas.g.. coupled with Age provided a higher accuracy rate of classifying non-GAD children as compared to using the MASC— Total.A. In the present study. we will present results from two hypothetical children with the same total MASC score by focusing on responses on the two . Silverman & Eisen. a self-report measure of anxiety and a clinician-rated scale of anxiety share only trait variance (Kazdin. Nevertheless. This is an interesting ﬁnding suggesting that parents’ ratings and child ratings are not consistent. 1992). In other words.M. Finally. This lack of concordance between parent and child reports has been found for internalizing disorders in general and anxiety disorders speciﬁcally (e. when we examined the correlation between the STAIC ﬁlled out by the child and the STAIC-P ﬁlled out by the parents. we used logistic regression to ﬁnd the MASC items that would best distinguish between anxiety and depressive disorders. we found a non-signiﬁcant relation between the two. These two reasons together with the smaller sample in which both Hamilton scales and the MASC were given. therefore narrowing the range of scores on the HAM-A. We were able to ﬁnd that in addition to age. in our sample. with the consequent results of potentially lowering the correlation between the HAM-A and the MASC in our sample. two self-report measures of anxiety share both method variance and trait variance. As previously mentioned. We recommend that future studies look at the impact of parent’s own anxieties or more general psychopathology on how they score the STAIC for their children. Unfortunately. did not correlate with the STAIC-P (ﬁlled out by the parent). The signiﬁcant individual items of the MASC (‘‘I usually ask permission’’ and ‘‘I get nervous if I need to perform in public’’). Rynn et al. 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. lead to the lack of a signiﬁcant difference between the correlation of the HAM-A and MASC and between the correlation of the HAM-D and MASC. 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. 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. two items seemed to predict whether a child was anxious or depressed.
including pediatricians. 0. may differ on unknown dimensions from the general treatment seeking population at large. 3. while another child gave a 3 to the ﬁrst item and 0 to the second item. this methodology could be used to distinguish anxious and ‘‘normal’’ children in order to provide clinicians. with the full MASC providing ratings . however. Using the equation derived at the optimal operating point yields a score À.1. Rynn et al. the ﬁrst child would be classiﬁed as Non-GAD. For example.699 Â 0 + . / Anxiety Disorders 20 (2006) 139–157 signiﬁcant individual items. therefore. The fact that this small difference in age was signiﬁcant was partly due to the fact that we have a relatively large sample.7703 (F (12.126 Â 12 + . whereas the second child would be classiﬁed as GAD.154 M.3653) for the ﬁrst child and .369 Â 3 À . supportive of the use of these scales to discriminate between pediatric patients who are anxious and depressed. Furthermore. The results obtained with the MASC ADI and the MASC-10 subscales are. our sample was diverse. Given the exclusion criteria of these psychopharmacological clinical trials the sample may also had lower comorbidities than other samples. Those patients. Both the MASC-10 and the full MASC can be used for these purposes. two 12-year-old children may have equal MASC—Total 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’’. these results need to be replicated in other clinical samples. 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. however. Nevertheless. 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.2197 (F (12. Our ﬁndings need to be replicated before recommending them in pediatric care practices. Another limitation was that the depressed patients were on average older than the anxious pediatric patients.369 Â 0 À . including a 30% participation of minority pediatric patients. 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.3653) for the second child.0) = À. The magnitude of the difference. 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. This would be especially useful for pediatricians given that many anxious children ﬁrst present in the primary care setting with their physical symptoms. Therefore.699 Â 3 + . was not large.A.3) = À. with a series of key questions that could help them distinguish anxious and normal children.126 Â 12 + . Therefore. These scales have been used in similar roles in prior studies and our conﬁrmation of their ability to distinguish between anxious and depressed young clients support their use in clinical care. 4.
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