J Dev Phys Disabil (2008) 20:573–580

DOI 10.1007/s10882-008-9120-x
O R I G I N A L A RT I C L E

Psychometric Properties of the Zung Self-Rating

Anxiety Scale for Adults with Intellectual Disabilities
(SAS-ID)

Sylvia Z. Ramirez & James Lukenbill

Published online: 17 September 2008

# Springer Science + Business Media, LLC 2008

Abstract The study reports preliminary evidence of the psychometric properties of

the Zung Self-Rating Anxiety Scale (SAS) as adapted for individuals with
intellectual disabilities (ID) by Lindsay and Michie (Journal of Mental Deficiency
Research, 32, 485–490, 1988). The SAS-ID was administered individually and
orally to 137 adults with intellectual disabilities and 96 caregivers. An internal
consistency reliability coefficient of.80 was obtained. The SAS-ID’s convergent
validity was demonstrated by significant correlations ranging from.21 to.60 between
the SAS-ID and related self-report measures (Fear Survey for Adults with Mental
Retardation [FSAMR]); and Psychopathology Instrument for Mentally Retarded
Adults [PIMRA] Total scale, Anxiety subscale, and Affective (Depression) subscale.
In particular, SAS-ID correlated.40 with the FSAMR, and.44 with the PIMRA
Anxiety subscale. Implications of the study are discussed.

Keywords Intellectual disability . Mental retardation . Anxiety . Scale . Adult

High levels of anxiety in individuals with intellectual disabilities (ID) have been
consistently reported in the literature (Emerson 2003; Esbensen et al. 2003;
Stavrakaki and Lunsky 2007). Anxiety is defined as a diffuse reaction to non-
specific stimuli that is out of proportion to the actual danger level of the fear stimuli
in terms of subjective distress, avoidance, and/or duration (Albano et al. 2001;

We are very grateful to the Hogg Foundation for Mental Health, Ford Foundation, Texas Department of
Mental Health and Mental Retardation, and Faculty Research Council of the University of Texas–Pan
American for their support; the research assistants and data collectors; and especially the respondents
and participating facilities.
S. Z. Ramirez (*)
University of Texas-Pan American; College of Education; Dean’s Office, 1201 W. University Dr.,
Edinburg, TX 78539, USA
e-mail: ramirezs@utpa.edu

J. Lukenbill
Ingenix, Austin, TX, USA
574 J Dev Phys Disabil (2008) 20:573–580

Sweeney and Pine 2004). For persons with ID, anxiety has been related to
challenging behaviors (e.g., self-injury, hyperactivity, and irritability), and it can
have particularly detrimental effects on their exposure to new learning and
community integration (King et al. 1990; Masi et al. 2000). Biological, environ-
mental, and psychological mechanisms have been posited for the reported high
anxiety levels. They include a relationship between anxiety and the underlying
pathology responsible for ID (e.g., Prader Willi and Fragile X); cognitive and
communication difficulties that limit expression of feelings and understanding of
feared stimuli; learned dependence and avoidance of such stimuli due to caregivers’
overprotection; and increased likelihood of environmental effects (e.g., trauma,
abuse, and limited social support, stimulation, and control of their environments)
(Ranzon 2001; Stavrakaki and Lunsky 2007).
Although the cognitive and communication limitations of persons with ID
contribute to the difficulty of self-reporting, it is a critical component of anxiety
assessment (Lindsay and Michie 1988; Masi et al. 2000; Morris and Kratochwill
1998; Stavrakaki and Lunsky 2007). While general psychopathology measures, such
as the Psychopathology Instrument for Mentally Retarded Adults (PIMRA)
(Senatore et al. 1985), have anxiety subscales, there is a paucity of more
comprehensive self-rating anxiety scales that are psychometrically supported and
appropriate for use with adults with ID (Charlot et al. 2007). Relatively recently,
preliminary psychometric evidence has been reported for two self-rating anxiety
scales that were adapted/developed for individuals with ID. They are the Beck
Anxiety Inventory (Glenn et al. 2003; Lindsay and Skene 2007) and Glasgow
Anxiety Scale for People with an Intellectual Disability (GAS-ID) (Mindham and
Espie 2003).
A more widely used and researched scale of generalized anxiety is an adaptation of
the Self-Rating Anxiety Scale (SAS) (Zung 1971) for adults with ID. Lindsay and
Michie (1988) adapted the SAS (hereafter referred to as the SAS-ID) with modified
items and response choices to improve understanding by the respondents.
Additionally, several response types were evaluated for reliability with 29 adults with
ID (ages 19–57 years, mean age=35.6 years). Results indicated that the yes–no response
format was more reliable (r=.69) than the original, standard response presentation
(4-point scale) (r=.12). No validity information for the scale was reported. The SAS-ID
items and supplementary questions are provided in the Appendix.
Lindsay et al. (1994) conducted a study using the SAS that “was revised for use
with people with intellectual disability according to the principles outlined by”
Lindsay and Michie (1988) and Helsel and Matson (1988) (p. 62). However, no
description of the specific modifications was provided. The participants consisted of
77 adults with ID (ages 22–56 years; mean IQ=56.6, range=40–69). In the study,
convergent validity was demonstrated with correlations between this SAS adaptation
and the Zung Depression Inventory (.59), as well as the following General Health
Questionnaire (GHQ) factors: Anxiety (.59), Depression (.72), and Neuroticism
(.73). Subsequently, Morrison and Lindsay (1997) used non-specified “simplified”
versions of the items of the original SAS and a 3-point Likert-scale with 30 Scottish
adults with ID (mean age=37 years, range=28–53 years; IQ range=48–59).
Although the authors indicated that this scale had been previously validated, there
is no published research to support this assertion.
J Dev Phys Disabil (2008) 20:573–580 575

In the most recent SAS adaptation, Masi et al. (2002) reported validity data for 50
Italian adolescents (ages 11.8–18 years) (mean IQ=56.7, SD=4.4). The authors
indicated “the questions were rephrased by the interviewer until the patient had
understood what was being asked” (p. 229). Without justification, they replaced the
original 4-point scale with a 5-point scale. This is problematic because it increases
the difficulty of rating the severity of anxiety. Additionally, there was no discussion
regarding whether forward–backward translation procedures were used to ensure
item equivalence across cultures. Although no reliability data were provided,
convergent validity was documented with correlations ranging from.33 to.60
between this SAS adaptation and other general psychopathology, anxiety, and
depression measures (Child Behavior Checklist; PIMRA Total scale, Anxiety
subscale, and Affective [Depression] subscale; and Zung Depression Scale).
The purpose of the present study was to evaluate the psychometric properties of
the SAS-ID (Lindsay and Michie 1988). Of the available SAS adaptations, this
version was used because the yes–no response format was shown to be more reliable
than the original 4-point format. Moreover, standardized “supplementary” items
were provided that are absent in other SAS adaptations. Potentially, there is evidence of
the measure’s convergent validity (assuming that the SAS-ID and the version used
by Lindsay et al. [1994] are the same). The present study evaluates the SAS-ID’s
reliability and convergent validity with related measures of fear, anxiety, depression,
and general psychopathology. Measurement of depression was included because of
the high rates of co-morbidity of anxiety and depression in both individuals with and
without ID (Lindsay et al. 1994; Masi et al. 2000).

Method

Participants

The sample was comprised of 137 adults with intellectual disabilities and
primary caregivers for 96 of the participants. Participation was voluntary for both
the adults with ID and their caregivers. Of the participants, 54% were from large
institutional settings, and 46% from community settings. The participants were
recruited through state institutions, community group homes, and community day
centers in small to large Texas cities. Participant selection criteria included being
able to meet the study’s task demands and having met the criteria for diagnosis
of intellectual disabilities (mental retardation) (American Association on Mental
Retardation 2002).
The gender breakdown was 36% females and 64% males (mean age=39.33 years,
SD=12.91, range=18–73 years). The ethnic/racial composition was 53% European-
American/White (not Hispanic origin), 34% Hispanic, 11% African-American/
Black, and 2% “other.” Individually administered intelligence test IQ scores were
available for 77% of the participants (mean=50.51, SD=11.94). Levels of IQ (mild,
moderate, and severe) were ascertained from the IQ scores or the primary caregivers’
estimation when the scores were unavailable. The following levels were represented:
54% mild, 37% moderate, and 8% severe. Psychiatric diagnoses were reported for
51% of the participants, with 3% identified as having anxiety disorders.
576 J Dev Phys Disabil (2008) 20:573–580

Measurement and Procedure

The SAS-ID is a 20-item scale with a yes–no response format. Five of the items (5,
9, 13, 17, and 19) are reverse scored. (See the Appendix for the items, and the
preceding discussion for more information about the SAS-ID.) The evaluators orally
presented the items to the participants on an individual basis. The evaluators were
instructed to rephrase or reword the questions if the respondents appeared to lack
understanding, and, if necessary, the supplementary questions were to be used (in the
local dialect, if needed) (Lindsay and Michie 1988).
In addition to the SAS-ID, the following were administered individually and
orally: the self-report Fear Survey for Adults with Mental Retardation (FSAMR)
(Ramirez and Lukenbill 2007) and self-report and informant-report versions of the
Psychopathology Instrument for Mentally Retarded Adults (PIMRA) (Senatore et
al. 1985). Both the FSAMR and PIMRA have yes–no formats. The FSAMR is
comprised of 73 distinct fear stimuli, and the PIMRA has 56 items with eight
psychopathology subscales, including Anxiety and Affective (Depression).
Evidence of adequate reliability and validity of the FSAMR and PIMRA has been
documented (Ramirez and Lukenbill 2007; Matson et al. 1984; Senatore et al.
1985).

Results and Discussion

An alpha coefficient of r=.80 was obtained for the SAS-ID that supports its internal
consistency. Evidence of the convergent validity of the measure was provided by
moderately high, statistically significant Pearson correlations between the SAS-ID
and criterion-related measures (see Table 1). As expected, correlations were higher
with client self-reports than informant reports, and correlations with the fear and
anxiety scales were higher than those with the depression scale. The relatively high
correlation of.60 with the PIMRA Total score suggests that high anxiety levels are
associated with general psychopathology.
Validity coefficients of the current study are consistent with those reported by
Masi et al. (2002):.60 with the PIMRA Total scale,.48 with the PIMRA Anxiety

Table 1 Pearson correlations

between the SAS-ID and related r value Number
scales/subscales
Client
FSAMR 0.40**** 136
PIMRA
Total scale 0.60**** 123
Anxiety subscale 0.44**** 123
Affective (depression) subscale 0.31*** 123
FSAMR Fear survey for adults Caregiver
with mental retardation, PIMRA PIMRA
Psychopathology instrument for Total scale 0.36*** 96
mentally retarded adults Anxiety subscale 0.32** 96
*p<0.05; **p<0. 01; Affective (depression) subscale 0.21* 96
***p<0.001; ****p<0.0001
J Dev Phys Disabil (2008) 20:573–580 577

subscale, and .38 with the PIMRA Affective (Depression) subscale. The Lindsay et
al. (1994) study offered generally stronger support for the convergent validity of
their SAS adaptation that correlated.59 with the General Health Questionnaire
(GHQ) Anxiety factor,.72 with the GHQ Depression factor, and.59 with the Zung
Depression Scale. Unfortunately, it is unclear if the Lindsay et al. SAS version was
the same as the one used in the present study due to the lack of specificity of the
exact scale adaptations they made.
On the other hand, Lindsay and Michie (1988) clearly described three main
modifications of the original SAS that include a yes–no response format, rewording
of the items, and addition of supplementary items. Although various response types
have both strengths and weaknesses when used with people with ID (Sigelman et al.
1981), the yes–no response format was selected for the SAS-ID because of evidence
that it was more reliable than the original 4-point format. Categorization and grading
of anxiety by maintaining in memory the severity levels in a Likert-scale may be too
complex (especially for people with lower cognitive abilities) (Glenn et al. 2003;
Sigelman et al. 1981). Three-point scales have been used with reported success in
similar measures with individuals with ID (e.g., Levine 1985; Mindham and Espie
2003). To lessen the cognitive demands, while still obtaining a severity rating,
another alternative is recommended (Ramirez and Kratochwill 1990; Ramirez and
Lukenbill 2007). It involves a two-part presentation of the items to measure the
symptoms’ severity. The first part asks a yes–no question about the presence or
absence of the symptom, and the second part addresses its severity (e.g., by asking
whether the symptom occurs “a little” or “a lot”).
Since understanding the items is of prime importance, especially with people
with ID, rewording the items in the local dialect for a particular respondent may be
needed, despite the loss of strict standardization (Lindsay and Michie 1988). As with
a few other measures (e.g., FSAMR), the SAS-ID includes supplementary items that
offer a degree of standardization, and their inclusion is a necessary compromise
between strict standardization and lack of understanding. To improve accuracy,
future SAS-ID revisions should allow the evaluator the option of scoring specific
items as “don’t know” when respondents indicate verbally or nonverbally that they
do not know the answer or understand the items even with attempts at clarifications
(Finlay and Lyons 2002; Ramirez and Lukenbill 2007).
Some changes in the wording of the original items should be considered since
those made by Lindsay and Michie (1988) were minimal (i.e., were limited to
rewording the items as questions rather than statements), and some of the concepts/
language may be too difficult (e.g., “panicky” and “usually”). Additionally, other
items can be misinterpreted, for example, when several participants responded
affirmatively to item 6 and added that their “arms and legs shake and tremble” when
they are cold.
In conclusion, although the present study provides preliminary evidence of the
SAS-ID’s acceptable psychometric properties, more research is needed to substan-
tiate the findings, especially with samples representative of other geographical areas,
as well as socio-economic and ethnic groups. Evidence of test–retest reliability and
discriminant validity is particularly needed. Nonetheless, the SAS-ID is potentially
useful for research and clinical purposes, including for the longitudinal assessment
of treatment effectiveness.
578 J Dev Phys Disabil (2008) 20:573–580

Appendix

Table 2 SAS-ID Items

1. Do you feel more nervous and anxious than usual?

It was often necessary to explain the word ‘anxious’ with the following supplementary questions:
Do you feel more jumpy or shaky than usual, do you feel your tummy nervous and upset?
2. Do you feel afraid for no reason at all?
3. Do you get upset easily or feel panicky?
4. Do you feel you are falling apart and going to pieces?
Supplementary questions:
Do you feel that everything is going wrong and there is nothing you can do about it?
Do you feel you can’t cope/carry on with things any more?
5. Do you feel that everything is alright and nothing bad will happen?
Supplementary questions:
Do you worry in case anything terrible might happen, do you feel everything is going to be fine?
6. Do your arms and legs shake and tremble?
7. Are you bothered by headaches, neck and back pains?
Supplementary question:
Are you bothered by a sore head, a sore neck or a sore back?
8. Do you feel weak and get tired easily?
9. Do you feel calm and can you sit still easily?
10. Can you feel your heart beating fast?
11. Are you bothered by dizzy spells?
12. Do you have fainting spells or feel like it?
Supplementary question:
Do you feel you are going to fall down because you are weak or dizzy?
13. Can you breathe in and out easily?
14. Do you get feelings of numbness and tingling in your fingers and toes?
Supplementary question:
Do you ever get pins and needles in your fingers and toes; do you ever get any funny feelings in
your fingers and toes?
15. Are you bothered by stomach aches or indigestion?
Supplementary question:
Are you bothered by a sore stomach, do you ever get a burning feeling in the middle of your chest?
16. Do you have to empty your bladder often?
Supplementary question:
Do you have to go to the toilet to pee a lot?
17. Are your hands usually dry and warm?
18. Does your face get hot and go red?
19. Do you fall asleep easily and get a good nights rest?
20. Do you have nightmares?
Supplementary question:
Do you have bad/frightening dreams?

Source: Lindsay and Michie (1988) (pp. 486–487). Items 5, 9, 13, 17, and 19 are reverse scored. Reprinted
with permission from the journal

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