Spanish Validation of the Spence Children’s Anxiety Scale

ORI GIN AL ARTICLE

Spanish Validation of the Spence Children’s AnxietyScale

Mireia Orgiles • Xavier Mendez • Susan H. Spence •

Tania B. Huedo-Medina • Jose P. Espada

Published online: 16 November 2011� Springer Science+Business Media, LLC 2011

Abstract The purpose of this study was to investigate the factorial structure and psy-

chometric properties of the Spence Children’s Anxiety Scale (SCAS) in a sample of 1,708

Spanish children aged between 8 and 12 years. The SCAS was demonstrated to have

satisfactory internal consistency with the Spanish sample, and factor analysis confirmed the

six-factor original model. Convergent validity was supported by correlations with the

State-Trait Anxiety Inventory for Children and the welfare dimension of the Child Health

and Illness Profile-Children Edition. Low correlations between the SCAS and the Chil-

dren’s Depression Inventory supported the divergent validity. Analysis suggested that

anxiety scores decrease with age, and girls reported higher scores than boys. Overall, the

SCAS was shown to have good psychometric properties for use with Spanish children by

clinicians and researchers.

Keywords Spence Children’s Anxiety Scale � Anxiety disorders �Children � Assessment

M. Orgiles (&) � J. P. EspadaDepartment of Health Psychology, Miguel Hernandez University,Avda. de la Universidad s/n, 03202 Elche, Alicante, Spaine-mail: [email protected]

X. MendezFaculty of Psychology, University of Murcia, Campus Universitario de Espinardo,30100 Murcia, Spain

S. H. SpenceGriffith University, Nathan Campus, Nathan, QLD 4111, Australia

T. B. Huedo-MedinaCenter for Health, Intervention, and Prevention, University of Connecticut,2006 Hillside Road, Unit 1248, Storrs, CT 06269-1248, USA

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Child Psychiatry Hum Dev (2012) 43:271–281DOI 10.1007/s10578-011-0265-y

Introduction

Anxiety disorders are one of the most common disorders in childhood and adolescence

[1, 2] and reported among the most frequently diagnosed in the services of Child and

Adolescent Mental Health of Spain, accounting for more than 20% of the caseload [3].

Prevalence rates vary according to each disorder, estimating that between 5 and 18% of

children and adolescents meet the criteria for an anxiety disorder [4–7]. Although some

anxiety problems, such as separation anxiety or specific phobias, tend to disappear with

age, in some children they persist and adversely affect the child’s life becoming a risk

factor for the development of other anxiety disorders in adolescence and adulthood [8].

Early detection and intervention are therefore of great significance, as unfortunately only

30% of children with anxiety problems receive treatment [9].

Despite the diversity of instruments assessing anxiety in children, most of them present

two main limitations: many are adaptations of anxiety measures developed for adult

population and adapted for children, so they do not consider the variation of symptoms

among children versus adolescents, and most assess general anxiety symptoms but do not

measure symptoms related to specific anxiety disorders that may guide the clinician to the

content of the treatment [10]. In response to this issue, the Spence Children’s Anxiety

Scale (SCAS) [11] was developed to assess symptoms of the most common anxiety dis-

orders in childhood and adolescence in accordance with the diagnostic categories of the

DSM-IV. The SCAS was initially created for use with an Australian community sample,

and it constitutes a self-report instrument consisting of 45 items administrable to children

and adolescents aged between 8 and 17 years. Unlike other scales, the SCAS is not an

adaptation of an instrument for adult population, as it was designed specifically to measure

anxiety symptoms in children considering the existence of developmental differences in

anxiety symptoms. The factorial analysis of the scale revealed that anxiety symptoms were

grouped into six subscales that correspond to the classification of anxiety disorders in line

with the DSM-IV [11].

The SCAS has been widely used in a significant number of research studies to examine

the structure of anxiety symptoms across different cultures and as an indicator of anxiety in

children [12, 13]. Clinically the SCAS is of particular value in identifying children’s

elevated anxiety symptoms and for whom further assessment and treatment should be

considered. Along with the Screen for Child Anxiety Related Emotional Disorders

(SCARED) [14], the SCAS is now used extensively in clinical practice [13], but unlike the

SCARED, the SCAS has the following advantages [10, 15–17]: (a) includes all the anxiety

disorders recognized by the DSM-IV as the most common in children, including a social

phobia subscale, (b) provides more information on anxiety disorders despite a lower

number of items, facilitating a more rapid administration, (c) was developed with a

community sample rather than a clinical sample, highlighting their utility to assess anxiety

symptoms in the general population, and (d) has a greater range of response options

allowing for a broader range of symptom severity. The SCAS has been adapted and

validated among Dutch [15], German [13], South-African [18], Japanese [12, 19], North-

American [17], Catalan [20], Hellenic [21], Mexican [22], Chinese [23], Colombian [24],

Cypriot [25], and English, Italian, Swedish and Cypriot Greek samples [26]. The internal

consistency of the scale is high and ranges for the overall measure from 0.80 with Japanese

children [12] to 0.93 with Australian population [11]. Although a South American Spanish-

language version of the SCAS was validated with a Mexican sample [22], that translation is

not applicable to a European Spanish speaking sample due to differences in grammar and

vocabulary between both dialects. Furthermore, cultural differences between Spain and

272 Child Psychiatry Hum Dev (2012) 43:271–281

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Mexico make difficult to generalize psychometric properties from the Mexican sample to

the European Spanish sample.

The present study extends the literature by examining in a large community sample of

Spanish children aged 8–12: (a) the internal consistency, the convergent validity and the

discriminant validity of the Spanish version of the SCAS, (b) the factor structure in the

Spanish population, (c) the most common anxiety symptoms reported by Spanish children,

and age and gender patterns. The hypotheses to be tested were as follows: The internal

consistency and validity of the Spanish version of the SCAS was expected to be adequate.

Specifically, it was predicted, as in previous studies, a significant correlation between the

SCAS and two measures of anxiety symptoms [20, 27] and perceived welfare [28]. Due to

the comorbidity between anxiety and depression symptoms in children, a significant

positive correlation between the SCAS and a measure of depression was expected [10, 20],

but lower than the correlation between the SCAS and the measures of anxiety and welfare

symptoms. It was also expected a good fit of the Spanish data to the six-factor model found

in the original version of the SCAS representing the most common anxiety disorders in

children as defined in the DSM-IV. If the reliability and validity of the SCAS are satis-

factory within a large Spanish community sample, this would justify its use in clinical

practice in Spain, and would add to the international empirical support for the measure.

Methods

Participants

This cross-sectional study included 1,708 children aged between 8 and 12 (Mage = 9.43;

SD = 1.15); 865 boys (50.6%) and 843 girls (49.4%). The age distribution was as follows:

19.9% of 8 years; 19.7% of 9 years; 20.7% of 10 years; 20.9% of 11 years; 18.8% of

12 years. Data were collected from fifteen schools, selected based on their availability and

to represent the socioeconomic structure of Spanish population. Most children were born in

Spain, with an 11% foreign-born. The socioeconomic status was varied, but most children

were from middle-class families. School approval was obtained and information was

provided to parents and principals. Parents’ written informed consent was obtained for

each child. Approximately the 99% of parents gave consent to their children participate in

the study.

Instruments

SCAS

The children were administered the SCAS, a 44-item scale; 38 items provided information

about the six more common anxiety disorders in childhood and adolescence: generalized

anxiety disorder, panic attack/agoraphobia, social phobia, separation anxiety disorder,

obsessive–compulsive disorder, and physical injury fears. The remaining six items were

positive filler items, included to reduce negative response bias. Children indicated the

frequency of occurrence of each symptom on a 4-point scale: never (0), sometimes (1),

often (2), or always (3). A final additional open-ended question permitted children to

indicate other fears they may have. This item was included at the end of the scale, to

provide more clinical information, but was not included in the scoring of the SCAS. The

SCAS was translated from English into Spanish, with the permission of the author, using

Child Psychiatry Hum Dev (2012) 43:271–281 273

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the back-translation method described by Hambleton [29] to translate assessment instru-

ments in transcultural research. Although there is a Mexican Spanish version of the SCAS

[22], initial investigation revealed that the language differences between Spain and Mexico

required modification of 25 of the 38 anxiety items. Thus, a bilingual psychologist

(American-born) translated these 25 items from the original English language version to

Spanish. Another bilingual psychologist translated them back into English and the new

version was compared to the original scale, resolving minor differences found in three

items (items 32, 35, and 36). The remaining items were retained from the Spanish-Mexican

translation. The final Spanish version may be downloaded from the SCAS website (http://

www.scaswebsite.com) and used free of charge by researchers and clinicians.

State-Trait Anxiety Inventory for Children [30] (STAI-C)

The STAI-C is made up of two subscales, with 20 items, that evaluate the state and trait

anxiety. It can be used individually or collectively with 9–15 year old children or with

smaller children with the ability of reading and comprehension. The Spanish version has a

high reliability (0.85–0.89) and a concurrent validity coefficient with other scales of

anxiety (0.75) [31]. Participants were administered the trait-anxiety scale, to assess the

construct validity of the SCAS. Response options are rarely, sometimes and often, with

higher scores indicating greater anxiety.

Child Health and Illness Profile-Children Edition (CHIP-CE) [32]

The CHIP-CE is a generic instrument to assess perceived health of children aged 6–12,

defined as the ability to participate in physical, psychological and social activities age

appropriate. The CHIP-CE consists of 44 items grouped into five dimensions: satisfaction,

welfare, resistance, risks, and functions. Response options are never, rarely, sometimes,

often or always; higher scores reflect a better perceived health. Each item includes two

illustrative pictures at each end of the response categories to facilitate the child’s under-

standing of the content. The internal consistency of the questionnaire is acceptable, with

Cronbach’s alpha ranking from 0.60 to 0.70 depending on dimension. Participants com-

pleted the welfare dimension, which refers to physical and emotional symptoms. An

example item on the welfare dimension is ‘‘In the past 4 weeks, how often did you feel

afraid?’’

Children’s Depression Inventory (CDI) [33]

The CDI is the most commonly used self-report of depressive symptoms for children and

adolescents. The instrument has 27 items to evaluate a wide group of symptoms regarding

depression. For each item children choose the response that best reflect their feelings in the

last 2 weeks. There are three alternative responses scoring 0, 1 or 2 depending on the

severity; higher scores reflect more severe symptoms.

Procedure

Instruments were anonymous and completed collectively in groups of approximately 20

children and three researchers remained in each classroom to deal with any problems.


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http://www.scaswebsite.com

http://www.scaswebsite.com

Questionnaires were counterbalanced in classrooms in order to control the order effects.

Instructions were read aloud and the questions were resolved, emphasizing the importance

of completing all the items. The study was reviewed and approved by the ethics boards of

the institution.

Statistical Analysis

Analyses were carried out using the statistical program SPSS 19 that incorporates AMOS.

The internal consistency of the SCAS and the subscales was calculated with Cronbach’s

alpha coefficient, and correlations between the subscales were computed. Pearson corre-

lations were calculated to obtain convergent and divergent validity. Confirmatory factor

analysis was conducted to determine whether the factor structure of the Spanish version

reflected the six dimensions of anxiety disorder of the original version, using a structural

equation modeling approach [34, 35].

Results

Descriptive Data for the SCAS

The means and standard deviations for the total scores and subscales of the SCAS in boys

and girls are shown in Table 1. Results showed significant age effects for the total score

(r = -.13), indicating that anxiety decreases with increasing age. Significant effects were

also found for gender (p \ .001), with higher scores for anxiety in girls than in boys.

Anxiety symptoms were ranked based on the frequency with which children gave

responses of either ‘‘often’’ or ‘‘always’’. The most commonly reported anxiety symptom

was related to separation anxiety (item 12: I worry that something awful will happen to

someone in my family), with a high prevalence of 70.1% in the sample. The next most

frequently reported symptom was item 22: I worry that something bad will happen to me,

with 33.5% of children reporting that they often or always experienced this symptom. Item

28 (‘‘I feel scared if I have to travel in the car, or on a bus or a train’’) was the low-

frequency symptom reported by children (2.1%).

Table 1 Mean and standard deviation by gender

Total Male Female Male vs. female

Mean SD Mean SD Mean SD t test

Separation anxiety disorder 4.53 3.077 4.22 2.98 4.84 3.14 -4.15***

Social phobia 4.24 3.33 3.90 3.19 4.59 3.44 -4.26***

Obsessive/compulsive disorder 4.47 3.67 4.31 3.61 4.62 3.73 -1.74

Panic/agoraphobia 2.39 3.41 2.084 3.21 2.70 3.58 -3.70***

Physical injury fears 2.23 2.48 1.86 2.26 2.62 2.64 -6.31***

Generalized anxiety disorder 4.80 3.59 4.50 3.53 5.11 3.63 -3.53***

Total score 33.94 15.44 32.29 14.49 35.64 16.18 -4.32***

*** p \ .001


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Reliability and Validity

The internal consistency was measured for the SCAS total score and for each subscale,

using Cronbach’s alpha coefficient. Results showed that the SCAS has a high internal

consistency, with a Cronbach’s alpha of 0.89 for the total score, confirming that the items

collectively measure the same construct. The reliability for the subscales was poor to

adequate ranging from 0.52 to 0.76. Table 2 shows significant intercorrelation among

SCAS subscales. The strongest correlations were found between generalized anxiety and

social phobia, and between generalized anxiety and obsessive/compulsive.

Correlation analyses were computed to examine convergent and divergent validity

(Table 3). As hypothesized, the correlations between the SCAS and the STAI-C and CHIP-

CE were higher than the correlation between the SCAS and the CDI. Results show moderate,

but significant, correlations between the trait-anxiety scale and the total score of the SCAS

(r = 0.41) and its subscales, all higher than 0.30. Similar results were found between the

SCAS and the welfare dimension of the CHIP-CE (r = -.65) with a negative correlation

indicating that anxiety tended to increase as emotional wellbeing decreased. The SCAS and

the CDI were weakly correlated (r = -.004), supporting discriminant validity of the SCAS.

Confirmatory Factor Analysis

Confirmatory factor analysis was conducted to determine if the six-factor original model

provided a good fit of the data for the Spanish sample using maximum likelihood.

Table 2 Consistency and correlations among subscales of SCAS

SAD SP OCD PA PIF GAD

Separation anxiety disorder (SAD) 0.59

Social phobia (SP) 0.52 0.62

Obsessive/compulsive disorder (OCD) 0.47 0.49 0.65

Panic/agoraphobia (PA) 0.49 0.46 0.55 0.76

Physical injury fears (PIF) 0.48 0.39 0.35 0.46 0.52

Generalized anxiety disorder (GAD) 0.53 0.56 0.56 0.53 0.45 0.69

Correlations significant at p \ .001

Table 3 Correlation between the SCAS and the STAIC-trait, the welfare dimension of the CHIP-CE andthe CDI

SCAS STAIC-trait CHIP-CE CDI

Separation anxiety disorder .36 -.45 -.047

Social phobia .45 -.44 -.017

Obsessive compulsive disorder .44 -.47 -.051

Panic/Agoraphobia .37 -.63 -.051

Physical injury fears .33 -.44 -.025

Generalized anxiety disorder .50 -.53 -.022

Total score .41 -.65 -.004

STAIC-trait state-trait anxiety inventory for children, CHIP-CE child health and illness profile-childrenedition, CDI children’s depression inventory


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Structural equation modeling suggested an adequate fit for the six factor, correlated model

(GFI = 0.92, CFI = 0.87, RMSR = 0.03, and RMSEA = 0.04, v2 = 2,425.752 df = 643).

Table 4 provides the factor loadings, all statistically significant with standardized values

exceeding 0.30, except items 16 and 18.

The modification indices suggested that a better fit could be obtained if items 40, 16 and

18 were removed, and item 28 was moved from Panic/agoraphobia to the specific phobia

subscale (named physical injury fears in the English version of the SCAS). This model

showed a slightly better model fit, (GFI = 0.94, CFI = 0.902, RMSR = 0.03, and

RMSEA = 0.04, v2 = 1,786.199 df = 529). The factor loadings were higher than 0.35

except for one item (item 12). The internal consistency for this new structure was slightly

lower when these items were removed, with a Cronbach’s alpha of 0.87 for the total scale,

and 0.54–.75 for the subscales.

Discussion

The main purpose of the current study was to examine the psychometric properties and the

factorial structure of the SCAS in a Spanish sample. The overall mean score (33.94)

suggests that the level of anxiety symptoms in Spanish children is similar to Australian

children (31.28) [10], but higher than scores found in studies involving some other

nationalities, such as Japanese (23.48) [19], Dutch (20.51) [15], Japanese and German

children (22.44 and 22.86) [12]. Results also demonstrated a significantly lower level of

separation anxiety symptoms with increasing age, as reported previously [11, 12]. Not

surprisingly gender differences were found for the total score, given that anxiety symptoms

have been reported to be higher among girls than boys in some studies [10, 15].

In terms of the most frequently reported anxiety symptoms, analysis revealed that an

item related to separation anxiety (‘‘I worry that something awful will happen to someone

in my family’’) was reported among 70.1% of Spanish children. Although this item was

also reported as the most frequently reported symptom in Japanese and Germany children

[12], the percent of children reporting to experience this symptom among Spanish children

is considerably higher than in other samples. There is no clear explanation for this finding,

but it is possible that Spanish children are more affected by anxiety symptoms related to

separation from affective figures than children from other countries. This could perhaps

reflect the Spanish child-rearing style characterized by parental overprotection [36]. It is of

interest to note that 3.9% of a sample of 1,407 Spanish children from 8 to 12 met the

criteria to separation anxiety, using a specific assessment measure based on the DSM-IV-

TR [37]. Furthermore one of the most feared situations reported by children was, as the

present study, being worried about something bad happening to mum or dad. Low-fre-

quency symptom reported by Spanish children assessed by the SCAS (‘‘I feel scared if I

have to travel in the car, or on a bus or a train’’) was similar to previous studies, as found in

Japanese research.

The results of this study support the reliability and validity of the SCAS in Spanish

children. Internal consistency was high (a = 0.89), replicating previous studies involving

Australian (a = 0.92) [10], German (a = 0.92) [13], Japanese (a = 0.88) [19], South

African (a = 0.92) [18], Hellenic (a = 0.90) [21], North-American (a = 0.94) [17], and

Mexican samples (a = 0.88) [22]. The reliability for some subscales was not as robust as

expected. The physical injury fears subscale showed the lower coefficient, consistent with

previous studies reflecting that this subscale is composed of a number of specific fears that

do not necessarily co-occur [17]. To examine the convergent validity, correlations between


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Table 4 Results of confirmatory factor analysis

Factor loading

F1 F2 F3 F4 F5 F6

Separation anxiety disorder

5. I would feel afraid of being on my own at home .52 – – – – –

8. I worry about being away from my parents .64 – – – – –

12. I worry that something awful will happen to someone in my family .31 – – – – –

15. I feel scared if I have to sleep on my own .39 – – – – –

16. I have trouble going to school in the mornings because I feelnervous or afraid

.24 – – – – –

44. I would feel scared if I had to stay away from home overnight .50 – – – – –

Social phobia

6. I feel scared when I have to take a test – .39 – – – –

7. I feel afraid if I have to use public toilets or bathrooms – .37 – – – –

9. I feel afraid that I will make a fool of myself in front of people – .54 – – – –

10. I worry that I will do badly at my school work – .50 – – – –

29. I worry what other people think of me – .59 – – – –

35. I feel afraid if I have to talk in front of my class – .40 – – – –

Obsessive compulsive disorder

14. I have to keep checking that I have done things right – – .42 – – –

19. I can’t seem to get bad or silly thoughts out of my head – – .50 – – –

27. I have to think of special thoughts to stop bad things fromhappening (like numbers or words)

– – .50 – – –

40. I have to do some things over and over again – – .33 – – –

41. I get bothered by bad or silly thoughts or pictures in my mind – – .62 – – –

42. I have to do some things in just the right way to stop bad thingshappening

– – .55 – – –

Panic/agoraphobia

13. I suddenly feel as if I can’t breathe when there is no reason for this – – – .53 – –

21. I suddenly start to tremble or shake when there is no reason for this – – – .58 – –

28. I feel scared if I have to travel in the car, or on a bus or a train – – – .34 – –

30. I am afraid of being in crowded places – – – .41 – –

32. All of a sudden I feel really scared for no reason at all – – – .60 – –

34. I suddenly become dizzy or faint when there is no reason for this – – – .56 – –

36. My heart suddenly starts to beat too quickly for no reason – – – .64 – –

37. I worry that I will suddenly get a scared feeling when there isnothing to be afraid of

– – – .49 – –

39. I am afraid of being in small closed places, like tunnels or smallsrooms

– – – .46 – –

Physical injury fears

2. I am scared of the dark – – – – .46 –

18. I am scared of dogs – – – – .23 –

23. I am scared of going to the doctor or dentists – – – – .43 –

25. I am scared of being in high places or lifts (elevators) – – – – .47 –

33. I am scared of insects or spiders – – – – .45 –


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the SCAS and two other measures, the STAIC- trait and the welfare dimension of the

CHIP-CE were examined. Results showed moderate correlations, consistent with previous

research and supporting the convergent validity of the SCAS. In contrast, correlations

between SCAS and CDI revealed low coefficients, supporting the discriminant validity of

the scale, consistent with previous research involving samples from other countries

[11, 22]. It should be noted, however, that the correlation between anxiety and depression

found in the Spanish sample is lower than in other studies in which low, but significant

correlations have been found. It is not clear why this should be the case and would be a

useful area for future research. Together these findings are consistent with the proposition

that the SCAS is evaluating anxious rather than depressive symptoms, and is not merely

reflecting a tendency to report negative affectivity.

The original factor structure of the SCAS was supported in this study, with confirmatory

factor analysis supporting the six hypothesized factors, consistent with specific anxiety

disorders outlined in DSM-IV. Although a slightly better fit could be obtained through a

small number of changes to the loading of items upon factors, this produced minimal

impact on the psychometric properties of the scale. For example, a better fit could be

obtained if item 28 (‘‘I feel scared if I have to travel in the car, or on a bus or a train’’) was

moved from Panic/agoraphobia factor to the Specific phobia factor (named Physical injury

fear in the original version of the SCAS). This is perhaps not surprising given that fear of

traveling by car, bus or train in children could reflect a fear of being injured (and a specific

situational phobia) rather than a symptom of agoraphobia. The fit could also be improved

further if three items were dropped from the scale, but this then resulted in a reduction in

internal consistency. Given the overall good fit of the original model, and the minimal

benefit to the psychometric properties of the scale to be gained by changing the items or

factor structure, it is suggested that the SCAS in its original form can be supported for use

in practice.

There are some limitations in the present research. The main limitation derived from

the recruitment of the sample. Children were assessed in schools and from a normal

community sample, so it is not clear whether the finding would generalize to clinical

samples. Second, when interpreting findings should be taken into account that children

included in the sample were 8–12 years old and is unclear whether results can be

generalized to adolescents. Third, test–retest data was not obtained as this was beyond

the scope and resources of the present study, and this should be a focus for future

research.

Table 4 continued

Factor loading

F1 F2 F3 F4 F5 F6

Generalized anxiety disorder

1. I worry about things – – – – – .51

3. When I have a problem, I get a funny feeling in my stomach – – – – – .46

4. I feel afraid – – – – – .51

20. When I have a problem, I get a funny feeling in my stomach – – – – – .57

22. I worry that something bad will happen to me – – – – – .44

24. When I have a problem, I feel shaky – – – – – .61


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Summary

The study examines the psychometric properties and the factorial structure of the SCAS in

a large Spanish sample of children. The SCAS is one of the most widely used instruments

to assess anxiety symptoms in children, with abundant research in sixteen countries. This

study adds evidence to the international empirical support for the measure. The reliability,

validity and factor structure of the SCAS are supported in the Spanish sample, justifying

the use of the SCAS by clinicians and researchers in the assessment of anxiety in Spanish

children.

Acknowledgments This research was supported by BANCAJA-UMH Grant (2007–2009) awarded toMireia Orgiles and National Plan for Research, Development and Technological Innovation Grant(EDU2008-05060) awarded to Xavier Mendez.

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Spanish Validation of the Spence Children’s Anxiety Scale