Pmwl.
PII: S0191-8869(97)00190-6
k/ilk/.
Dl/f. Vol. 24, No. 4, pp. 575-578, 1998
(: 1998 Elsevier Science Ltd. All rights reserved
Printed in Great Britain
0191-8869198
$19.00+0.00
Common fears and their relationship to anxiety disorders symptomatology
in normal children
Peter Muris,*’ Harald Merckelbach,’ Birgit Mayer2 and Cor Meesters’
‘Department
of Psychology, Cie. Psychology, and ‘Department of Experimental Abnormal Psycho1og.v.
Maastricht Uniuersitv. P.O. Bo.u 616. 6200 MD Maastricht. The Netherlands
(Receioed 19 June 1997)
Summary-The
current study examined the relationship
between the revised Fear Survey Schedule for
Children (FSSC-R) and anxiety disorders symptomatology
in normal children. First, professionals
were
asked to relate the IO most common FSSC-R items to separate childhood anxiety disorders. Then, primary
school children (N = 178) completed a short version of the FSSC-R and the Screen for Child Anxiety
Related Emotional Disorders (SCARED).
The SCARED is a questionnaire
that consists of 9 subscales
each measuring the symptoms of a separate, DSM-IV defined anxiety disorder in children (e.g. separation
anxiety disorder, panic disorder, etc.). Professionals’
anxiety disorder classification
of the FSSC-R items
were validated against SCARED data. Results revealed that professionals
related most FSSC-R items to
specific phobia and generalized anxiety disorder. These relationships
were supported
by the SCARED
data. However, FSSC-R items were also found to be connected to less obvious SCARED subscales. Thus,
FSSC-R items do not point in the direction of one particular anxiety disorder. The implications
of this
finding for the use of the FSSC-R are briefly discussed. C 1998 Elsevier Science Ltd. All rights reserved
INTRODUCTION
Anxiety disorders are one of the most prevalent forms of child psychopathology,
affecting about 10% of children and
adolescents (Bernstein & Borchardt,
1991). The latest edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-IV; American Psychiatric Association,
1994) recognizes the following anxiety disorders in children and adolescents:
panic disorder, separation anxiety disorder, social phobia, specific phobia, generalized anxiety disorder, obsessive-compulsive
disorder and post-traumatic
or acute stress disorder. Research has shown that anxiety disorders symptoms are also common
in normal children. For example, Bell-Dolan et al. (1990) found that overanxious disorder symptoms and subclinical phobias
were present in 20-30% of their sample of never-psychiatrically-ill
children.
Structured interviews such as the Anxiety Disorders Interview Schedule (ADIS; Silverman & Nelles, 1988) and questionnaires such as the Screen for Child Anxiety Related Emotional
Disorders (SCARED;
Birmaher et al.. 1997) have been
construed to reliably determine anxiety disorders and related symptomatology
in youths. Furthermore,
self-report rating
scales have been developed to assess global anxiety symptoms. These scales are important because they can be employed as
therapy outcome measures or epidemiological
instruments.
One widely used scale is the revised version of the Fear Survey
Schedule for Children (FSSC-R; Ollendick,
1983). The FSSC-R lists a wide range of potentially
fear-evoking
stimuli.
Children are asked to indicate on a 3-point scale how much they fear these stimuli (“none”. “some”, “a lot”). While the
FSSC-R has been proven to be a valuable index of general fearfulness in treatment outcome studies (Kendall, 1994; Barrett
et al., 1996) little is known about the relationship between specific FSSC-R items and anxiety disorders in children. Although
some items clearly refer to a specific phobia (e.g. “spiders”, “snakes”, ” germs or getting a serious disease”) or social phobia
connection to certain anxiety disorders (e.g.
(e.g. “being criticized”, ” being teased”), other items have a less straightforward
“being hit by a car or truck”, “bombing attacks”, ” burglar breaking into the house”). This has led some authors to question
the validity of the FSSC-R. For example, McCathie and Spence (1991) argue that the FSSC-R does not measure actual fear,
but rather reflects children’s negative affective response to the thought ofoccurrence of specific events. If this line of reasoning
is correct, one would expect that items such as “being hit by a car or truck”. “bombing attacks”, and so on. are related to
children’s tendency to worry, which is, of course, a core symptom of generalized anxiety disorder.
So far. there has been only one study that examined the relationship between the FSSC-R and childhood anxiety disorders.
In that study, Last er al. (1989) compared the FSSC-R scores of children with different anxiety disorder diagnoses, i.e.
separation
anxiety disorder, generalized anxiety disorder and phobic disorder (either social or simple phobia) of school.
Results showed that the diagnostic groups could not be discriminated
on the basis of their FSSC-R total score. However,
significant differences among the groups were found with regard to fear of specific FSSC-R items. As expected, children with
separation anxiety disorder more often reported fear of “getting lost in a strange place”. whereas children with generalized
anxiety disorders more frequently had fears focusing on social evaluative and performance
concerns. In addition, some
unexpected connections
between FSSC-R items and anxiety disorders were found. For example, children with separation
anxiety disorder more frequently reported fear of “bee stings” and “germs, or getting a serious disease” than children with
generalized anxiety disorder or school phobia. Taken together, the findings of Last and colleagues suggest that there is a
connection between childhood fears as determined by the FSSC-R and anxiety disorders in children. but that this connection
is not very specific.
The present study further investigated
the connection
between the FSSC-R and childhood
anxiety disorders symp-
*To whom all correspondence
Box 616. 6200 MD Maastricht,
should be addressed:
The Netherlands,
Dr P Muris.
575
Maastricht
University,
Department
of Psychology,
PO
576
Notes
and Shorter Communications
tomatology
in a sample of normal children. This was done in two steps. First of all, professionals
were asked to relate the
10 most common FSSC-R items to separate DSM-IV defined anxiety disorders. Secondly, a pool of children recruited from
regular school classes completed a short version of the FSSC-R and the SCARED. The SCARED is a questionnaire
that
consists of 9 subscales each measuring the symptoms of a DSM-IV defined anxiety disorder in children (e.g. panic disorder,
separation anxiety disorder, etc.). Professionals’ anxiety disorder classification of the separate FSSC-R items were validated
against SCARED data.
METHOD
Three professionals
(a child psychologist,
a mental health scientist and a research psychologist)
were given a list with the
top-10 FSSC-R fears (Ollendick et al.. 1989. 1991; Ollendick & King, 1994; Muris et al., 1997a,b): death or dead people,
getting lost in a strange place, bombing attacks-being
invaded, spiders, a burglar breaking into our house, fire-getting
burned, falling from high places, being hit by a car or truck, germs or getting a serious illness and not being able to breathe.
They were then asked to indicate for each separate item what DSM-IV defined anxiety disorder(s) they expected to be present
in a child who scored high on that particular item. The professionals
were familiar with the classification of mental disorders
and were allowed to consult the specific criteria of DSM-IV (childhood) anxiety disorders.
Next. 178 children (86 boys and 92 girls; M = 10.3 years, SD = 1.2, r = 8813 years) of two regular primary schools in
Maastricht,
The Netherlands
were recruited and asked to complete a short version of the FSSC-R and the SCARED. This
was done in their classroom in the presence of a research assistant and their teacher.
The short version of the FSSC-R lists the 10 top intense childhood fears (see above). Children indicated their level of fear
of these items on a 3-point scale: “none”, “some”, or “a lot”. These were scored 1.2, and 3, respectively and then combined
to yield a total fear score ranging from 10-30.
The SCARED is a 66-item self-report questionnaire
measuring anxiety disorders symptomatology
(Birmaher et al., 1997).
The SCARED consists of 9 DSM-IV linked subscales: panic disorder symptoms (13 items; e.g. “When frightened, my heart
beats fast”), generalized anxiety disorder symptoms (9 items; e.g. “I worry about things working out for me”), social phobia
symptoms (4 items; e.g. “I don’t like to be with people I don’t know”), separation anxiety disorder symptoms (I 2 items; e.g.
“I don’t like being away from my family”), obsessive-compulsive
disorder symptoms (9 items; e.g. “I have thoughts that
frighten me”). traumatic stress disorder symptoms (4 items; e.g. “I have frightening dreams about a very aversive experience
I once had”), specific phobia-animal
type symptoms (3 items: e.g. “I am afraid of an animal that is not really dangerous”).
specific phobia-blood-injection-injury
type symptoms (7 items; e.g. “I am afraid to go to the dentist”) and specific phobiaenvironmental-situational
type symptoms (5 items; e.g. “I am scared to fly in an airplane”).
Children have to rate how
frequently they have each symptom using a 3-point scale: “almost never”. “sometimes”,
or “often”. These are scored 0. 1,
and 2, respectively. SCARED total score and subscale scores can be obtained by summing relevant items, Previous research
(Birmaher et al.. 1997) has shown that the SCARED is a reliable questionnaire
in terms of internal consistency and test&
retest stability. Furthermore,
that research obtained evidence for the validity of the SCARED. That is, the scale was found
to differentiate
between anxiety disordered
children, children with depression,
and children with disruptive disorders.
Furthermore.
children suffering from a specific anxiety disorder (e.g. generalized
anxiety disorder, separation
anxiety
disorder. and panic disorder) exhibited the to-be-expected
profile of SCARED scores.
RESULTS AND DISCUSSION
Table 1 lists the anxiety disorders that professionals related to the separate FSSC-R items. As can be seen, the professionals
were rather unanimous in their judgments.
As anticipated,
specific phobia and generalized anxiety disorder were the most
frequently mentioned anxiety disorders in relation to these IO FSSC-R items.
Before addressing the main question of the present investigation,
some remarks about the general statistics of the FSSCR and the SCARED are in order (Table 2). First, all questionnaires
had satisfactory internal consistency: Cronbach’s r were
0.80 for the short version of the FSSC-R, 0.92 for the total SCARED, and between 0.60 (social phobia; specific phobiaenvironmental-situational
type) and 0.81 (traumatic stress disorder) for the separate SCARED subscales. Second, significant
sex differences were found on FSSC-R [r(176) = 4.8, P < O.OOl]. SCARED total score [r(176) = 3.2, P < 0.005], SCARED
panic disorder [r(l76) = 2.3, P < 0.05], SCARED separation
anxiety disorder [f(176) = 2.8, P < O.Ol],
SCARED specific
phobia-animal
type [/( 176) = 3.1, P < O.OOS]. SCARED
specific phobia-blood-injection-injury
type [t(176) = 4.2,
I.
Table
1.Judgements
Death
or dead people
of the three professmnals
of what anxiety
disorder(s)
they expected to be related to the separate FSSC-R
Generalized
anxiety
disorder
(2)
Specific phobia-blood-injection-injury
Getting
lost in a strange
Bombmg
place
attacks-bang
Separation
mvaded
Generalized
Spiders
breakmg
Fire--getting
Into our house
Generalized
burned
anxiety
from
high places
Specific
8. Bemg hit by a car or truck
disorder
(3)
type (3)
anxiety disorder
(3)
stress disorder
Germ5
or getting a serious
phobia--environmental-situational
Generalized
illness
anxiety
disorder
Obsessive-compulsive
Generalized
bemg able to breathe
Speafic
anxiety
disorder
The
number
of professionals
relating
the FSSC-R
item to a particular
anxiety
disorder
type (3)
(3)
type (3)
(I)
phobia-blood-injection-injury
Panic disorder
Now.
disorder
type (3)
(3)
Specific phobia-blood-injection-injury
10. Not
type (3)
(I)
Specific phobia-blood-injection-inJury
9
type (3)
(3)
Specific phobta-blood-injectIon-injury
Traumatic
Falling
disorder
Specific phobia-animal
A burglar
7
anxiety
type (2)
(2)
IS shown
Items
between parentheses
577
Notes and Shorter Communications
Table 2. Some general stat!stIcs (mean scores. Cronbach’s
5(. sex dtfferences.
scales
and relationship
M (SD)
21.6 (4.2)
20.1 (4.0)
SCARED
Total score
Panic disorder
Generalized anxiety disorder
Social phobia
Separation anxiety disorder
Obsessive-compulsive
disorder
Traumatic stress disorder
Specific phobia--animal
type
Specific phobia-blood-injection-injury
Specific phobia-situational-environmental
36.1
4.6
4.6
3.1
6.5
5.7
2.8
I.1
4.5
3.2
32.0
3.9
4.1
2.9
5.8
5.6
2.5
0.7
3.6
2.7
Note.
‘P
<
type
type
(I 5.5)
(3 I)
(2.9)
(1.9)
(3.3)
(3.2)
(2.2)
(1.0)
(2.5)
(2.2)
and the SCARED
Girls
z
r with age
22.9 (3.8)
0.80
- 0.20;
39.9 (17.2)
5.2 (4.1)
5.0 (3.6)
3.3 (1.7)
7.2 (3.4)
5.8 (2.9)
3.1 (2.5)
l.4(1.6)
5.3 (2.7)
3.6 (2.3)
0.92
0.78
0.77
0.60
0.64
0.61
0.81
0.71
0.62
0.60
-0.17;
- 0.08
-0.06
-0.32*
-0.19*
-0.13
-0.15’
0.13
-0.08
-0.14
Boys
Fear Survey Schedule for Children-Revised
(16.8)
(3.7)
(3.3)
(1.8)
(3.4)
(3.0)
(2.4)
(1.4)
(2.8)
(2.3)
wtth age) of the FSSC-R
0.05
3. Mean SCARED
subscale scores (SD) of children who reported “none”, ” some”. or “a lot” of fear to the separate FSSC-R items and
the results of the analyses of variance with sex and age as covariates. Only data of subscales that professionals linked to the FSSC-R items
are shown
Table
Rating
“none”
“some”
“a lot”
F?,,,1
P
Par-hoc comparisons
3.2 (2.7)
3.5 (2.8~
5.4 (3.1)
5.0 (2.3)
6.3 (4. I)
5.9 (3.3)
13.8
6.5
<O.OOl
< 0.005
I <2,3
I <2.3
2. Getting lost in a strange place
Separation anxiety disorder
5.3 (2.9)
6.2 (3.1)
8.4 (3.9)
6.1
<0.005
I.213
3. Bombing attacks-being
invaded
Generdhzed anxiety disorder
3.2 (3.5)
4.7 (3.5)
4.9 (3.0)
2.2
NS
4. Spiders
Specific phobta-animal
0.6 (0.8)
1.2 (1.4)
2.4 (1.8)
15.7
<O.OOl
l<2<3
3.2 (2.4)
4.8 (3.5)
5.1 (3.1)
3.0
<0.05
I <2.3
3.4 (2.8)
1.9 (2.1)
3.9 (2.4)
2.7 (2.1)
5.9 (2.7)
3.6 (2.5)
10.7
5.5
<O.OOl
< 0.005
1.2<3
1.2<3
I .4 (I .4)
2.9 (2.2)
3.9 (2.2)
13.1
<O.OOl
l<2<3
2.8 (2.9)
2.9 (2.8)
3.9 (2.6)
3.9 (2.9)
5.4 (3.4)
5.1 (2.5)
6.8
5.8
<O.OOl
<0.005
l.2<3
l,2<3
3.7 (2.8)
4.3 (2.3)
3.8 (3.7)
3.8 (2.6)
5.1 (3.0)
3.9 (3.0)
5.6 (2.5)
6.8 (2.9)
5.6 (3.2)
I I.2
10.5
5.5
<O.OOl
<O.OOl
<0.005
l,2<3
1,213
l.2<3
2.0 (2.5)
2.7 (3.1)
3.7 (2.8)
3.6 (3.1)
5.1 (2.5)
5.2 (3.8)
8.4
4.1
<O.OOl
co.05
l<2<3
1.2<3
FSSC-R
I.
item
Death or dead people
Generalized anxiety disorder
Specific phobia-blood-injection-injury
type
type
5. A burglar breaking into our house
Generalized anxiety disorder
6. Fire-getting
burned
Specific phobia-blood-mjectiott-Injury
Traumatic stress disorder
type
7. Falling from high places
Specific phobia-environmental-situational
8. Being hit by a car or truck
Generalized anxiety disorder
Specific phobia-blood-Injection-injury
9. Germs or getting a serious illness
Specific phobia-blood-injection-inJury
Obsessive-compulsive
disorder
Generalized anxiety disorder
IO. Not being able to breathe
Specific phobia-blood-mjection-injury
Panic disorder
P < O.OOl] and
type
type
type
type
SCARED
environmental-situational
type [/(I761
= 2.5. P < 0.051. In line with previous
research (e.g.
Bernstein and Borchardt,
1991). girls exhibited higher levels of fearfulness and anxiety disorders symptomatology
than boys.
Third, significant negative correlations
emerged between age, on the one hand, and FSSC-R [r(l78) = -0.20, P < O.Ol].
SCARED
total score [r( 178) = -0.17,
P < 0.05], SCARED
social phobia
[r(178) = -0.32,
P < O.OOl] and SCARED
separation
anxiety
disorder
[r(178) = -0.19,
P < 0.051, on the other hand. Again, this is in line with previous studies that
showed that fearfulness and anxiety disorders symptomatology
appear to decline with age (Ollendick et al., 1989. 1994;
Birmaher et al., 1997).
To examine the connection between FSSC-R items and anxiety disorders symptomatology,
analyses of variance with age
and sex as covariates (ANCOVAs) were carried out. With these ANCOVAs, the SCARED subscales scores of children who
reported “none”, “some” or “a lot” of fear on the separate FSSC-R items were compared. Table 3 shows the results of the
ANCOVAs that were carried out on those SCARED subscales that professionals
linked to the separate FSSC-R items. As
can be seen, for all FSSC-R items (except for “bombing
attacks-being
invaded”), the predicted pattern of SCARED
578
Notes and Shorter Communications
subscale scores emerged. For example, children who scored “a lot” on FSSC-R item “spiders” exhibited significantly higher
scores on SCARED specific phobia-animal
type subscale than children who scored “none”, whereas children who scored
“some” fell in between.
So far, the data suggest the existence of straightforward
connections between FSSC-R items and DSM-IV linked anxiety
disorders symptomatology
as tapped by the SCARED. Thus, professionals
associated most FSSC-R fears with specific
phobia and generalized anxiety disorder and this, in turn, was borne out by the SCARED data. However, it is important to
note that the ANCOVAs
also yielded a considerable
number of unexpected, less obvious results. For instance, children’s
scores on the FSSC-R item “not being able to breathe” appeared to be related to SCARED obsessivecompulsive
disorder.
Thus. children who scored “a lot” on this item had significantly higher SCARED obsessivecompulsive
disorder scores than
children who scored “none”. while children who scored “some” fell in between. Even when applying a Bonferroni correction
(setting the P-value of the ANCOVA on P < 0.05/75. i.e. the number of tests on non-expected
SCARED subscales), a total
number of 19 ANCOVAs on unexpected SCARED subscales remained significant. Thus, although the FSSC-R items were
generally found to be connected with the to-be-expected
anxiety disorders symptomatology,
they were also associated with
less obvious SCARED scales. Taken together, the pattern of anxiety disorders symptomatology
associated with the separate
FSSC-R items appears to be not very specific. A limitation of the present study is that it relied on a sample of non-clinical
children. Note. however, that the current finding accords well with-the results of the clinical study of Last ct al. (1989).
Given the asoecific relationshio between FSSC-R and SCARED, it is not surprising to find that the short version of FSSCR correlated only moderately with the SCARED. The correlation
of FSSC-R with-SCARED
was 0.58. P < 0.001 for the
SCARED total score, and varied between 0.26, P < 0.001 (specific phobia-animal
type) and 0.51, P < 0.001 (specific
phobias-situational-environmental
type) for the various subscales. Yet, unexpectedly.
the FSSC-R total score was also
associated with SCARED social phobia [r(178) = 0.44. P < O.OOl], although none of the IO items had any relevance to social
phobia. Interestingly,
a similar finding was reported by Goetsch e/al. (1987). In their study among undergraduate
students,
these authors found that the Fear Survey Schedule (FSS) subscale “fear of social interaction”
best predicted self-reports of
general anxiety. Goetsch et al. (1987) propose that this relationship is probably due to the fact that social contact is a more
frequently encountered stimulus situation than other categories of fear stimuli. Alternatively.
the association between general
fearfulness and social anxiety may be carried by a third, underlying variable. For example. the social phobia items of the
SCARED may tap a temperamental
category such as behavioral inhibition (i.e. the tendency to react with withdrawal to
unfamiliar situations or people), which is known to be a predictor of anxiety proneness (Biederman rr ul.. 1990).
In sum, then, the current study found meaningful and significant connections between FSSC-R items and anxiety disorders
symptomatology
in normal children. In addition, a considerable number of less straightforward
relationships between FSSCR and anxiety disorders symptomatology
emerged. Thus, FSSC-R items do not point out unambiguously
in the direction of
one particular anxiety disorder. The practical implications of this finding are obvious: although the FSSC-R has proven to
be a valuable instrument for assessing general fearfulness in children and can be readily used as a general outcome measure
for evaluating treatment efficacy. it seems to be less useful in the diagnostic process of differentiating
among various anxiety
disorder subtypes in children.
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and
32. 321-331.
Interview
27. 772-778.
for Children
Journal
of the