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Anxiety and Quality of Life: Clinically AnxiousChildren With and Without Autism Spectrum DisordersComparedFrancisca J. A. van Steensel a , Susan M. Bögels a & Carmen D. Dirksen ba Research Institute of Child Development and Education , University of Amsterdamb Department of Clinical Epidemiology and Medical Technology Assessment , MaastrichtUniversity Medical CentrePublished online: 09 Jul 2012.

To cite this article: Francisca J. A. van Steensel , Susan M. Bögels & Carmen D. Dirksen (2012) Anxiety and Quality of Life:Clinically Anxious Children With and Without Autism Spectrum Disorders Compared, Journal of Clinical Child & AdolescentPsychology, 41:6, 731-738, DOI: 10.1080/15374416.2012.698725

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Anxiety and Quality of Life: Clinically Anxious Children Withand Without Autism Spectrum Disorders Compared

Francisca J. A. van Steensel and Susan M. Bogels

Research Institute of Child Development and Education, University of Amsterdam

Carmen D. Dirksen

Department of Clinical Epidemiology and Medical Technology Assessment,Maastricht University Medical Centre

Comorbid anxiety disorders are common in children with autism spectrum disorders(ASD). However, studies comparing children with ASD to clinically anxious childrenare rare. This study investigated anxiety problems and health-related quality of life inchildren with high-functioning ASD and comorbid anxiety disorders (referred to asthe ASD group), compared with children with anxiety disorders (referred to as theAD group). In total, 237 families participated; 115 children were in the ASD group(90 boys and 25 girls, M age¼ 11.37 years), and 122 children were in the AD group(62 boys and 60 girls, M age¼ 12.79 years). Anxiety disorders, anxiety symptoms,ASD-like symptoms, and health-related quality of life were assessed with theADIS-C=P, SCARED-71, CSBQ, and EuroQol-5D, respectively. The number and typesof anxiety disorders, as well as their severity, were similar in the ASD and AD groups;however, specific phobias were more common in the ASD group than in the AD group.As compared to the AD group, parents from the ASD group reported their children tohave higher scores for total anxiety, social anxiety disorder, and panic disorder. MoreASD-like behaviors and higher anxiety severity predicted a lower quality of life, irres-pective of group. The results of this study support a highly similar phenotype of anxietydisorders in children with ASD; however, additional research is needed to examine theetiology and treatment effectiveness of anxiety disorders in children with ASD.

INTRODUCTION

Autism spectrum disorders (ASD) are characterized bya number of impairments and abnormalities in thedomains of communication; social interaction; andrestricted, repetitive, and stereotyped patterns of beha-viors (American Psychiatric Association, 2000). Fur-thermore, many children with ASD display features ofother psychiatric disorders, such as anxiety disorders(e.g., Lecavalier, 2006; Sukhodolsky et al., 2008). Ameta-analysis estimated that anxiety disorders occur in

approximately 40% of youth with ASD (van Steensel,Bogels, & Perrin, 2011). As anxiety disorders are highlyprevalent among children with ASD, it is important toexamine the similarities and differences between childrenwith (high-functioning) ASD and clinically anxiouschildren. However, studies comparing children withASD to clinically anxious children are rare. There aretwo studies that have examined this issue in more detail(Farrugia & Hudson, 2006; Russell & Sofronoff, 2005).Both studies used questionnaires instead of interviewsand therefore did not assess anxiety disorders. Russelland Sofronoff (2005) examined a sample of 65 children,aged 10 to 13, with Asperger’s Syndrome and comparedthem to clinically anxious and nonclinical children.Analyses based on parent reports showed that the chil-dren with Asperger’s Syndrome had higher levels of

Correspondence should be addressed to Francisca J. A. van

Steensel, Research Institute of Child Development and Education,

University of Amsterdam, Nieuwe Prinsengracht 130, 1018 VZ

Amsterdam, The Netherlands. E-mail: f.j.a.vansteensel@uva.nl

Journal of Clinical Child & Adolescent Psychology, 41(6), 731–738, 2012

Copyright # Taylor & Francis Group, LLC

ISSN: 1537-4416 print=1537-4424 online

DOI: 10.1080/15374416.2012.698725

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total anxiety, obsessive-compulsive disorder, and fear ofphysical injury compared to clinically anxious children.In a study by Farrugia and Hudson (2006), 29 adoles-cents with Asperger’s Syndrome were compared to 34adolescents with anxiety disorders and 30 nonclinicaladolescents. No differences in anxiety levels (parentand child reports were aggregated) were found betweenthe subjects with Asperger’s Syndrome and those whowere clinically anxious. However, adolescents withAsperger’s Syndrome showed significantly higher levelsof global life interference compared to the clinicallyanxious and nonclinical groups.

Although age and gender effects have been found interms of anxiety disorders in typically developing children(e.g., Costello, Egger, & Angold, 2005), these variableshave rarely been examined in the ASD population. Ageeffects on anxiety symptoms in the ASD population aremixed; some studies report higher anxiety symptoms inolder children compared to younger children (e.g., Leca-valier, 2006), whereas others have not found relationshipsbetween age and anxiety symptoms in children with ASD(e.g., Meyer, Mundy, Hecke, & Durocher, 2006). Inaddition, no gender differences in anxiety symptom-sever-ity in children withASDwere found by Sukhodolsky et al.(2008), and only one gender difference was found byGadow, DeVincent, Pomeroy, and Azizian (2005).

Quality of life refers to an individual’s subjective per-ception of their personal well-being and encompassesmultiple domains, generally representing physical,psychological, and social functioning (e.g., Leidy,Revicki, & Geneste, 1999). Children with anxiety dis-orders have been found to have a poorer quality of lifein the domain of emotional functioning compared tochildren with other disorders (Bastiaansen, Koot,Ferdinand, & Verhulst, 2004). There are also indicationsthat quality of life in children with ASD is poorercompared to children with chronic health conditionsor children with other psychiatric disorders (Bastiaansenet al., 2004; Kuhltau et al., 2010).

The aim of the current study was to compare childrenwith high-functioning ASD and comorbid anxiety disor-ders to children with only anxiety disorders; the types ofanxiety disorders, number of anxiety disorders, anxietyseverity, and quality of life were investigated. The effectsof gender and age, including how these effects mightdiffer between groups, were also examined.

METHOD

Participants

Children aged 7 to 18 years who were referred to mentalhealth care centers for anxiety problems and=or ASD-related problems were eligible for this study. In total,

237 children, 229 mothers, and 180 fathers participated.Based on the Diagnostic and Statistical Manual ofMental Disorders (4th ed., text rev.) clinical diagnoses,the children were divided into two groups: (a) 115 chil-dren with high-functioning ASD and comorbid anxietydisorders (23 children with Autistic Disorder, 33 withAsperger’s Syndrome, and 59 with PDD-NOS, referredto as the ASD group), and (b) 122 children with anxietydisorders (referred to as the AD group). The DSM–IV–TR clinical diagnoses of ASD (and ASD subtypes) andanxiety disorders were established by a multidisciplinaryteam of psychologists, therapists, social workers, andpsychiatrists at the mental health care centers. No stan-dardized protocol was used to establish DSM–IV–TRdiagnoses; however, diagnoses were based on clinicalevaluations, including interviews with the parent(s)and child, observations of child–parent interactionsand=or school observations, diagnostic assessments,and psychiatric consults. As part of the research mea-surements, the presence of at least one anxiety disorderwas confirmed with the Anxiety Disorder InterviewSchedule–Child and Parent version (ADIS-C=P) for allchildren. In addition, the Autism Diagnostic Inter-view–Revised (ADI–R; Lord, Rutter, & Le Couteur,1994) was completed by the parents of 90 of the childrenin the ASD group (Table 1). Children with and withoutan ADI–R report did not differ with respect to gender,v2(1)¼ 0.62, p¼ .432. However, children without anADI–R report had a higher mean age, F(1,113)¼ 5.45, p¼ .021 (M¼ 12.44, SD¼ 2.69 vs.M¼ 11.08, SD¼ 2.55), and had more ASD-like behaviors(i.e., higher Children’s Social Behavioral Questionnaire[CSBQ] total scores), F(1, 101)¼ 5.08, p¼ .026, d¼ 0.58(M¼ 40.30, SD¼ 16.82 vs.M¼ 50.22, SD¼ 17.67).

The demographics of both groups are displayed inTable 1. Compared to the AD group, the ASD groupcontained more boys, v2(1)¼ 19.38, p< .001; had alower mean age, F(1, 235)¼ 16.40, p< .001; and containedmore children attending special education, v2(1)¼ 22.41,p< .001, and primary school, v2(1)¼ 14.63, p< .001.However, the relative distribution of educational level(low, moderate, high) was similar, v2(1)¼ 2.64, p¼ .267.

Measurements

ADIS-C=P. Anxiety disorders were assessed withthe ADIS-C=P (Silverman & Albano, 1996). This inter-view is based on DSM–IV criteria and is developed forchildren aged 7 to 17 years. The ADIS-C=P has goodpsychometric properties (Silverman, Saavedra, & Pina,2001). A severity score is obtained from ratings givenby the respondent for each disorder separately, rangingfrom 0 to 8. A sum of the severity scores of all anxietydisorders was used as the total anxiety severity score.This approach, which combines the number and severity

732 VAN STEENSEL, BOGELS, DIRKSEN

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of anxiety disorders, has been used to measureimprovement in total anxiety severity following inter-vention in clinical as well as preventive contexts (e.g.,Hudson et al., 2009; Simon, Bogels, & Voncken, 2011).Child–parent agreement for the ADIS was substantial;kappa coefficients ranged from .52 (separation anxietydisorder) to .85 (agoraphobia) for the ASD group andfrom .55 (generalized anxiety disorder) to .75 (agora-phobia) for the AD group. A combined ADIS-C=P diag-nosis was used for further analyses (Silverman et al.,2001); all diagnoses with severity scores at or greaterthan 4 (according to children or parents) were includedalong with their corresponding parent- or child-reportedseverity scores. When child and parent reports agreed ona diagnosis, the highest severity rating was used.

Screen for Child Anxiety Related EmotionalDisorders. Children and parents completed the Dutchversion of the Screen for Child Anxiety Related

Emotional Disorders (SCARED-71; Bodden, Bogels,& Muris, 2009). This questionnaire contains 71 items(e.g., ‘‘I am afraid of heights’’) and has a 3-point ratingscale (0 ¼almost never; 1 ¼sometimes; 2 ¼often). A totalanxiety score can be calculated, as well as subscalescores for symptoms of separation anxiety disorder,social anxiety disorder, specific phobia, generalizedanxiety disorder, obsessive–compulsive disorder, panicdisorder and posttraumatic stress disorder. Psycho-metric properties of the SCARED-71 are good (Boddenet al., 2009). In this study, Cronbach’s alpha for theSCARED-71 was excellent (.92 [child], .94 [mother],and .95 [father] for the ASD group; .94 [child], .93[mother], and .94 [father] for the AD group).

EuroQol-5D. Both children and parents were askedto complete the EuroQol-5D (EQ-5D), a standardizedinstrument used to assess health-related quality of life(EuroQol group, 1990). The descriptive component ofthe EQ-5D was used; this component contains fivedimensions (mobility, self-care, usual activities, pain=discomfort, and depression=anxiety), each with threelevels ([1] no problems, [2] some problems, and [3] severeproblems). A health state index was calculated using aformula that attaches preferences weights to each levelof the five dimensions. If a child is reported to haveno problems in any of the dimensions, a health stateindex of 1 is given. If some or severe problems in adimension are reported, then a particular score (prefer-ence weight) is subtracted from 1. Using Dutch prefer-ence weights (Lamers, McDonnell, Stalmeier, Krabbe,& Busschbach, 2006), the health state index can rangefrom �0.024 (i.e., severe problems in all dimensions)to 1 (i.e., no problems in any dimension). Psychometricproperties of the EQ-5D are good (Brooks, 1996). Inaddition, good psychometric properties were found forthe proxy (parent) report of the EQ-5D (Stolk,Busschbach, & Vogels, 2000; Willems et al., 2009).

Children’s Social Behavioral Questionnaire. TheChildren’s Social Behavioral Questionnaire (CSBQ;Luteijn, Minderaa, & Jackson, 2002) is a 49-item ques-tionnaire, developed to assess a range of problems inchildren with pervasive developmental disorders. Par-ents are asked whether a given description applies totheir child (e.g., ‘‘has little or no need for contact withothers’’), using a 3-point scale (0 ¼does not apply; 1¼sometimes or somewhat applies; 2 ¼clearly or oftenapplies). The psychometric properties were examinedin a large Dutch study, and the CSBQ was found tobe a valid and reliable instrument (Hartman, Luteijn,Serra, & Minderaa, 2006). In addition, various groupsof children could be differentiated based on total CSBQscores (high-functioning autism, PDD-NOS, ADHD,

TABLE 1

Demographics of the ASD and AD Groups

ASDa ADb

Gender

Boys (n, %) 90 78.3 62 50.8

Girls (n, %) 25 21.7 60 49.2

Age (M, SD) 11.37 2.63 12.79 2.73

Ethnicity

Caucasian (n, %) 114 99.1 115 94.3

Other (n, %) 1 0.9 7 5.8

Schoolc

Primary (Elementary) (n, %) 71 61.7 45 36.9

Special (n, %) 15 21.1 1 2.2

Regular (n, %) 56 78.9 44 97.8

Secondary (n, %) 43 37.4 70 57.4

Special (n, %) 9 20.9 1 1.4

Low Level (n, %) 8 18.6 20 28.6

Moderate Level (n, %) 9 20.9 24 34.3

High Level (n, %) 17 39.5 25 35.7

Vocational (n, %) 1 0.9 7 5.7

Low Level (n, %) 0 0.0 0 0.0

Moderate Level (n, %) 1 100.0 7 100.0

High Level (n, %) 0 0.0 0 0.0

ADI-R (n¼ 90)

Social (M, SD) 16.62 4.84 — —

Meeting Cutoff (n, %) 88 97.8 — —

Communication (M, SD) 11.45 3.95 — —

Meeting Cutoff (n, %) 81 90.0 — —

Repetitive (M, SD) 4.02 2.71 — —

Meeting Cutoff (n, %) 63 70.0 — —

Note: ASD¼ children with ASD and comorbid anxiety disorders;

AD¼ clinically anxious children.an¼ 115.bn¼ 122.cSchools in the Netherlands are divided into primary, secondary

and vocational schools. Secondary and vocational schools are split

into three educational levels: low, moderate and high. Special edu-

cation is viewed as a separate category; however, all levels (low, mod-

erate, and high) may be present.

ANXIETY IN CHILDREN WITH ASD 733

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clinical controls, nonclinical controls; Luteijn et al.,2002). Cronbach’s alpha for the CSBQ was excellent inthis study (.94 [mother] and .95 [father] in the ASDgroup; .95 [mother] and .94 [father] in the AD group).

Procedure

Children in both the ASD and AD groups were recruitedfrom the same general secondary care community centersnot specifically specializing in anxiety disorders or ASD.Following assessment, 82% (n¼ 94) of the ASD groupand 78% (n¼ 95) of the AD group received treatmentfor anxiety problems. Inclusion criteria for the study were(a) at least one anxiety disorder, (b) at least one parentwilling to participate, and (c) normal cognitive function-ing (in cases where IQ was not assessed, IQ must havebeen estimated to be above 70 based on school perfor-mance). Exclusion criteria were (a) untreated psychoticdisorder, (b) acute suicidal risk, and (c) current sexualor physical abuse. When the study criteria were met andthe families agreed to participate in a longitudinal study,the participants were contacted for initial assessments.Exact participation rates are not known; however, theparticipating therapists recalled that only a few familiesdeclined. The study was approved by a Medical EthicalCommittee, and written consent was obtained.

The assessments took place either at the mental healthcare centers or at the families’ homes. The children wereasked to fill out the questionnaires themselves; however,help was provided when necessary (e.g., verbal help withthe interpretation of the questions). Assessments werecarried out by psychologists=diagnosticians workingand conducting research at the mental health centers;these clinicians were independent of the staff who haddetermined the initial DSM–IV–TR clinical diagnoses.Interrater agreement on the diagnoses in the currentstudy was not assessed but is assumed to be high basedon having followed the general standards for ADIS-C=P training (see Bodden et al., 2009), and interrater agree-ment (kappa) within the research group was found torange from .73 to 1.00 (Bodden et al., 2009; Simonet al., 2011). Administrators of the ADI–R were trainedby the first author of the study (who is certified foradministering the interview) and had to achieve interra-ter reliability of at least 80%. In addition, throughoutthe course of the study, a 1-day meeting was organizedbiannually by the research staff, providing additionaltraining and round-table discussions regarding theadministration and coding of the interviews.

Analyses

Data were incomplete for 42 families; however, nodifferences were found between those with or withoutcomplete data with respect to the child’s gender,

v2(1)¼ 0.47, p¼ .492; age, F(1, 235)¼ 1.26, p¼ .263; orgroup (ASD vs. AD), v2(1)¼ 0.02, p¼ .897. BinaryLogistic Regression was used to explore group differ-ences in the relative distribution of anxiety disorders(ADIS-C=P). The variables gender (girls vs. boys) andage (<12 years vs.� 12 years) as well as their interac-tions with group (ASD vs. AD) were added. To examinegroup differences for anxiety symptoms (SCARED-71)and quality of life (EQ-5D), multilevel analyses wereconducted, using maximum likelihood estimation proce-dures. Parameters for predicting anxiety levels includedgroup, respondent (children versus parents), gender, andage, and interactions with group. To predict quality oflife, anxiety (ADIS-C=P) and ASD (CSBQ), as well astheir interactions with group, were also added to themodel. When a significant interaction effect ofGroup�Age or Group�Gender was found, additionalanalyses were conducted to examine the effects of age=gender within the AD and ASD group (i.e., separatemultilevel analyses were conducted for the AD andASD group). When the interaction effect of Group -�Respondent yielded significance, additional analyseswere conducted in two ways: (a) to examine the effectsof respondents within the AD and ASD groups (i.e.,by conducting separate multilevel analyses for the ADand ASD groups), and (b) to examine whether groupdifferences were found for child report (i.e., by conduct-ing multiple regression analyses using child reports only)and=or for parental report (i.e., by conducting multilevelanalyses for father and mother report). Multilevel analy-ses can be used when data are nested; in this study, therespondents (children, mothers, and fathers) are nestedwithin families. Multilevel analyses take into accountthe dependencies among respondents of the same familyand have the advantage of using all of the available data(including those from families with incomplete data). Allcontinuous variables were transformed into standardnormal scores (with an overall mean of 0 and a standarddeviation of 1). Using this approach, the parameter esti-mate can be interpreted as a measure of effect; that is,the effect that a particular parameter has on the out-come variable (while controlling for the effects of otherparameters) can be interpreted as Cohen’s d (dichot-omous variables), or as r (continuous variables).

RESULTS

Anxiety Disorders

The ASD and AD groups did not differ with respect tothe number of anxiety disorders, F(1, 235)¼ 2.14,p¼ .145, d¼ 0.19 (M¼ 5.06, SD¼ 3.12 vs. M¼ 4.45,SD¼ 3.37), or mean severity scores, F(1, 235)¼ 0.03,p¼ .856, d¼ 0.03 (M¼ 6.26, SD¼ 0.87 vs. M¼ 6.29,SD¼ 1.00). The ASD group displayed more specific

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phobias than the AD group (Table 2). Boys with ASDwere more likely to meet criteria for generalized anxietydisorder than girls with ASD. Children 12 years or olderwere more likely to have social anxiety disorder, general-ized anxiety disorder, and agoraphobia compared tochildren younger than 12 years (irrespective of group).

Anxiety Symptoms

The ASD group had higher scores for specific phobiathan the AD group (Table 3). According to parental

report, children in the ASD group had higher scoresthan children in the AD group for total anxiety(estimate¼ .51, p< .05), social anxiety disorder(estimate¼ .48, p< .05), and panic disorder (estimate¼.42, p¼ .05), but similar scores for separation anxietydisorder, generalized anxiety disorder, obsessive-compulsive disorder, and posttraumatic stress disorder(ps> .05). No differences between the ASD and ADgroup were found among child reports (ps> .05).

Children in both groups reported lower scores forseparation anxiety disorder compared to their parents

TABLE 2

Presence of Anxiety Disorders (ADIS-C=P) for the ASD and AD Groups

ASDa ADb Odds Ratio

n % n % Groupc Genderd Agee Gender�Group Age�Group

SAD 35 30.4 38 31.1 0.73 1.32 0.46 0.84 1.77

SOC 66 57.4 66 54.1 1.53 2.11 2.62� 0.64 1.89

SPH 99 86.1 85 69.7 4.58� 1.13 0.51 0.77 0.41

GAD 64 55.7 74 60.7 2.13 1.43 2.80� 0.25� 0.45

OCD 17 14.8 22 18.0 0.45 0.50 0.65 2.27 1.37

PAN 6 5.2 16 13.1 0.35 2.08 2.78 0.30 2.60

AGOR 8 7.0 26 21.3 0.19 1.18 3.68� 0.36 2.94

PTSD 8 7.0 13 10.7 1.29 2.93 3.69 0.39 1.16

Note: ADIS-C=P¼Anxiety Disorder Interview Schedule–Child and Parent version; ASD¼ children with ASD and comorbid anxiety disorders;

AD¼ clinically anxious children; SAD¼ separation anxiety disorder; SOC¼ social anxiety disorder; SPH¼ specific phobia; GAD¼ generalized

anxiety disorder; OCD¼ obsessive-compulsive disorder; PAN¼panic disorder; AGOR¼ agoraphobia; PTSD¼posttraumatic stress disorder.an¼ 115.bn¼ 122.cAD¼ 0=ASD¼ 1.dBoys¼ 0=Girls¼ 1.e< 12 years¼ 0=� 12 years¼ 1.�p< .05.

TABLE 3

Parameter Estimates of the Model Concerning the Effects of Group (ASD vs. AD), Respondent (Children vs. Parents), Gender (Girls vs. Boys),

and Age (<12 years vs.�12 Years), and Interactions With Group, on Anxiety Symptoms (SCARED-71)

SCARED-71 (Outcome=Dependent Variablesa)

Parametersb TOT SAD SOC SPH GAD OCD PAN PTSD

Groupc .60��

.24 .55��

.63��

.36 .26 .46�

.29

Respondentd .16 –.19�

.05 .12 –.05 .55���

.23�

.24�

Group�Respondent –.46���

–.29�

–.42��

–.21 –.38��

–.42��

–.36��

–.27�

Gendere .46��

.23 .21 .45��

.23 .19 .52��

.44��

Group�Gender –.24 –.03 .13 –.30 .00 –.12 –.59��

–.27

Agef .21 –.11 .47��

–.30 .52��

–.11 .47��

–.18

Group�Age –.08 –.11 –.07 .15 –.18 .08 –.15 .09

Note: ASD¼ children with ASD and comorbid anxiety disorders; AD¼ clinically anxious children; SCARED-71¼ Screen for Child Anxiety

Related Emotional Disorders; TOT¼ total anxiety symptoms; SAD¼ separation anxiety disorder; SOC¼ social anxiety disorder; SPH¼ specific

phobia; GAD¼ generalized anxiety disorder; OCD¼obsessive-compulsive disorder; PAN¼ panic disorder; PTSD¼posttraumatic stress disorder.aOutcome variables were transformed into standard normal scores (with an overall mean of 0 and a standard deviation of 1).bParameters were tested for significance with t tests provided by SPSS.cAD¼ 0=ASD¼ 1.dParents¼ 0=Child¼ 1.eBoys¼ 0=Girls¼ 1.f< 12 years¼ 0=� 12 years¼ 1.�p< .05.

��p< .01.

���p< .001.

ANXIETY IN CHILDREN WITH ASD 735

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(Table 3); however, this effect was stronger for the ASDgroup (estimate ¼� .48, p< .001) as compared to theAD group (estimate ¼� .18, p< .05). Children in theASD group reported lower scores than their parentsfor total anxiety (estimate ¼� .30, p< .01), social anxi-ety disorder (estimate ¼� .37, p< .001), and generalizedanxiety disorder (estimate ¼� .42, p< .001), but similarscores for specific phobia, obsessive–compulsive dis-order, panic disorder, and posttraumatic stress disorder(ps> .05). Compared to their parents, children in theAD group reported higher scores for obsessive-compulsive disorder (estimate¼ .56, p< .001), panic dis-order (estimate¼ .23, p< .05), and posttraumatic stressdisorder (estimate¼ .24, p< .01), but similar scores fortotal anxiety, social anxiety disorder, specific phobia,and generalized anxiety disorder (ps> .05).

Girls had higher scores than boys (irrespective ofgroup) for total anxiety, specific phobia, and posttrau-matic stress disorder (Table 3). In the AD group itwas found that girls had higher scores for panic disorder

compared to boys (estimate¼ .48, p< .01), but thiseffect was not found in the ASD group (estimate ¼� .02, p> .05). Children 12 years or older had higherscores for social anxiety disorder, generalized anxietydisorder, and panic disorder compared to childrenyounger than 12 years, irrespective of group (Table 3).

Quality of Life

No group differences in quality of life were found accord-ing to parental or child report (ps> .05). However, chil-dren with ASD reported a higher quality of life thantheir parents (estimate¼ .30, p< .01), whereas childrenin the AD group did not report differently from their par-ents (p> .05). Children 12 years or younger had a lowerquality of life than children older than 12 years in theAD group (estimate ¼� .51, p< .01), but this age effectwas not found in the ASD group (estimate ¼� .06,p> .05). Higher anxiety severity scores on the ADIS, aswell as higher scores on the CSBQ (ASD-like behaviors),were associated with a lower quality of life, irrespective ofgroup (Table 4). Of note, the children in the ASD grouphad significantly higher CSBQ scores than the children inthe AD group, F(1, 208)¼ 93.38, p< .001, d¼ 1.33(M¼ 42.03, SD¼ 17.30 vs. M¼ 20.07, SD¼ 15.61).

DISCUSSION

The types of anxiety disorders endorsed and their seve-rities were found to be highly similar among childrenwith ASD and clinically anxious children; however, spe-cific phobias were more common among children withASD. More ASD-like behaviors and higher anxietyseverity contributed to a lower quality of life, irrespec-tive of group. In addition, the results indicated highlysimilar age patterns and gender patterns among the chil-dren with ASD and clinically anxious children. Childrenin both groups reported lower scores for separationanxiety disorder compared to their parents. In addition,children with ASD reported lower anxiety scores thantheir parents for several scales. Two reasons are that(a) children with ASD may underreport anxiety symp-toms due to their difficulties with insight (e.g., Russell& Sofronoff, 2005), and (b) parents of children withASD overreport their children’s anxiety symptoms.One explanation for the latter reason is that the symp-toms of anxiety and ASD are difficult to differentiate.Moreover, they seem positively related (Wood &Gadow, 2010). Post hoc, we indeed found positivemoderate correlations between anxiety and ASD-likebehaviors in both groups (r¼ .26–.45, p< .01), indicat-ing that higher levels of anxiety are associated withhigher levels of ASD-like behaviors. However, whetheranxiety increases ASD (symptoms), ASD (symptoms)

TABLE 4

Parameter Estimates Concerning the Effects of Group (ASD vs. AD),

Respondent (Children vs. Parents), Gender (Girls vs. Boys), Age

(<12 Years vs.�12 Years), Anxiety (ADIS Total Severity Score) and

ASD (CSBQ Total Score), and Interactions With Group, on

Health-Related Quality of Life (EQ-5D)

Health-Related Quality of Lifea

Parametersb Estimate t p

Groupc –.11 –0.57 .568

Respondentd –.09 0.98 .330

Group�Respondent .39 2.92 .004��

Gendere .10 0.71 .480

Group�Gender –.23 –1.08 .280

Agef –.49 –3.37 .001��

Group�Age .46 2.24 .027�

Anxietyg –.18 –2.49 .014�

Group�Anxiety –.03 –0.25 .799

ASDh –.31 –3.47 .001��

Group�ASD –.04 –0.30 .761

Note: ASD¼ children with ASD and comorbid anxiety disorders;

AD¼ clinically anxious children. ADIS¼Anxiety Disorder Interview

Schedule; CSBQ¼Children’s Social Behavioral Questionnaire;

EQ-5D¼EuroQol-5D.aOutcome variables and continuous predictors (i.e., Anxiety and

ASD) were transformed into standard normal scores (with an overall

mean of 0 and a standard deviation of 1).bParameters were tested for significance with t tests provided by

SPSS.cAD¼ 0=ASD¼ 1.dParents¼ 0=Child¼ 1.eBoys¼ 0=Girls¼ 1.f< 12 years¼ 0=� 12 years¼ 1.gTotal anxiety severity score (sum of the severity scores of all

ADIS-C=P anxiety disorders; range¼ 4–115).hASD-like behaviors (CSBQ total score; range¼ 2–91).�p< .05.

��p< .01.

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cause anxiety, or both (symptoms exacerbating oneanother), is unclear.

The results of this study support a highly similarphenotype for anxiety disorders in children with ASD;however, it is questionable whether the anxiety disordersin both groups have a similar etiology and whethertreatment developed for anxiety in typically developingchildren is (equally) effective for children with ASD.Wood and Gadow (2010) proposed that many coreASD symptoms lead to stressful experiences that pro-mote anxiety. In line with this reasoning, children withASD may be more likely to endorse specific phobiasbecause of their ASD-related deficits. Children withASD may have more (a) disabilities in motor skills(e.g., developing a phobia of water due to problems withswimming, in combination with a traumatic experience;Rapp, Vollmer, & Hovanetz, 2005), (b) cognitive dis-abilities (e.g., developing a phobia of wind, resultingfrom a faulty perception of wind strength in relationto human weight), (c) orientation problems (e.g., devel-oping a situational phobia due to a fear of getting lost inpublic transportation), and=or (d) awareness of concretebodily sensations (e.g., greater response to sensory stim-uli and subsequent avoidance of sensory stimuli in theenvironment; Pfeiffer, Kinnealey, Reed, & Herzberg,2005). Concerning treatment options, cognitive beha-vioral therapy (CBT) is the treatment of choice fortypically developing children with anxiety disorders;however, children with ASD may require special adapta-tions for such treatments, as they may differ in ability orskill (Wood et al., 2009). In regards to adaptation, cog-nitive behavioral therapy intended for anxiety disorders(developed for typically developing children) has alsobeen found to be effective in high-functioning ASDpopulations (e.g., Wood et al., 2009).

One limitation of the study is that all of the childrenwere referred to mental health care centers and had atleast one anxiety disorder. Therefore, the findings maynot be representative of the general ASD population.Furthermore, only children with high-functioning ASDwere selected, which limits the generalization to theoverall ASD population. In this study, measurementswere used that were not specifically adapted to theASD population. However, the aim of the study wasto compare children with ASD to clinically anxious chil-dren, so the use of instruments developed for the typi-cally developing population was necessary to makevalid and reliable comparisons. Finally, children aged7 years and older reported their quality of life. It is ques-tionable whether children of this age can reliably ratetheir quality of life. However, prior to our analyses,we examined the parent–child correlation of quality oflife among children younger than 12 years and com-pared it to the parent–child correlation for children12 years and older; we found similar parent–child

correlations, supporting the use of quality of life reportsin children aged 7 years and older.

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