Research ArticleParent-Child Agreement Using the SpenceChildren’s Anxiety Scale and a Thermometer inChildren with Autism Spectrum Disorder
T. May,1 K. Cornish,2 and N. J. Rinehart3
1Deakin Child Study Centre, Deakin University, Melbourne Burwood Campus, 221 Burwood Highway,Burwood, VIC 3125, Australia2School of Psychological Sciences and Monash Institute for Brain Development & Repair, Monash University,Clayton Campus, Building 17, Wellington Road, Clayton, VIC 3800, Australia3Deakin Child Study Centre, School of Psychology, Deakin University, Melbourne Burwood Campus,221 Burwood Highway, Burwood, VIC 3125, Australia
Children with Autism Spectrum Disorder (ASD) experience high anxiety which often prompts clinical referral and requiresintervention. This study aimed to compare parent and child reports on the Spence Children’s Anxiety Scale (SCAS) and a child-reported “worry thermometer” in 88 children aged 8–13 years, 44 with ASD and 44 age, gender, and perceptual IQ matchedtypically developing children. There were no gender differences in child report on the SCAS and worry thermometers. Resultsindicated generally good correlations between parent and child self-reported SCAS symptoms for typically developing childrenbut poor agreement in parent-child ASD dyads. The worry thermometer child-report did not reflect child or parent reports on theSCAS. Findings suggest 8–13-year-old children with ASDmay have difficulties accurately reporting their anxiety levels.The clinicalimplications were discussed.
1. Introduction
Childrenwith Autism SpectrumDisorder (ASD) consistentlyshow high levels of anxiety. Around 40% of children andadolescents with ASD have clinically elevated anxiety levelsor experience at least one anxiety disorder [1–4]. A recentmeta-analysis of anxiety in ASD found that specific phobiawas the most common subtype (30%), followed by ObsessiveCompulsive Disorder (OCD; 17%), social anxiety disorderand agoraphobia (17%), generalized anxiety disorder (15%),separation anxiety disorder (9%), and panic disorder (2%)[3]. Anxiety related issues may prompt clinical referral andalso require clinical intervention in this population. AschildrenwithASDmay quickly escalate their emotional statesduring “meltdowns,” assessing anxiety symptoms in a timelyand valid manner is important for management at home,at school, and in clinical setting [5, 6]. A rapid assessment
measure of anxiety in ASD would be useful in these contexts.This would allow parents, teachers, and clinicians to easilydetermine the level of anxiety in a child with ASD and,if elevated, employ an appropriate intervention. However,whether self-reported anxiety symptoms in children withASD are valid is somewhat unclear.
A number of researchers have questioned the ability ofchildren with ASD to self-report internal emotional states[7–10]. In empirical studies of ASD, there are mixed find-ings. Many have used the parent and child version of theSpence Children’s Anxiety Scale (SCAS) in children withASD. Russell and Sofronoff [11] investigated 10–13-year-oldchildren with Asperger’s Disorder compared to a clinicallyanxious normed group and found that parents of childrenwith ASD rated their children as having higher levels ofoverall anxiety, obsessive compulsive symptoms, and specificphobias than parents of clinically anxious children. Children
Hindawi Publishing CorporationAutism Research and TreatmentVolume 2015, Article ID 315495, 9 pageshttp://dx.doi.org/10.1155/2015/315495
2 Autism Research and Treatment
with ASD rated themselves as having similar levels of anxietyto clinically anxious children. Parents rated their childrenas having higher levels of separation anxiety, social phobia,and generalized anxiety than did their child, with childratings significantly higher than parent ratings for obsessivecompulsive symptoms. Magiati and colleagues [12] examineda nonreferred sample of children with ASD aged over 8 years(mean age 12 y 10m) and found moderately good parent-child agreement for only three subscales (Physical Injuries,Generalised Anxiety Disorder, and separation anxiety). Far-rugia and Hudson [13] found generally good parent-childcorrelations (𝑟 = .697) in 12–16-year-olds with Asperger’sDisorder. Ozsivadjian et al. [14] also found good parent-childagreement on the total SCAS score in 10–16-year-old maleswith ASD. Potentially, the older child age may account for thebetter consistency between parent-child reports comparedwith younger children examined byRussell and Sofronoff andMagiati et al.
Othermeasures of anxiety have also been used to examineparent-child agreement on anxiety symptoms. Lopata andcolleagues [15] found parents reported higher levels of anx-iety than their 7–13-year-old children with ASD using theBehavior Assessment System for Children Second Edition.However, children with ASD self-reported similar levels ofanxiety to comparison children. Parent and child anxietysymptoms showed poor correlations in theASDgroup.Whiteand colleagues [16] used the Multidimensional Anxiety Scalefor Children, child and parent version in 12–17-year-olds withASD. They also found child and parent reports were notsignificantly correlated. The validity of self-report measuresin adolescents with ASD was questioned given only 23%self-reported clinically elevated anxiety scores despite allbeing diagnosed with an anxiety disorder. They noted thatadolescentswithASDmay underreport their anxiety, perhapsdue to a lack of insight, because they have a differentperspective about their own anxiety, or an unwillingnessto truthfully report their difficulties. Using the Screen forChildAnxiety Related EmotionalDisorders [17] in 8–14-year-olds with ASD, Blakeley-Smith et al. [18] found moderateinterclass correlations between parent-child reports withparents reporting higher levels of anxiety than their children,except for separation anxiety. van Steensel and colleagues [19]compared child and parent reports also using the SCARED in7–17-year-old children with ASD and an anxiety disorderedgroup. Parent-child agreement on this instrument was poorerin the ASD group than in the anxiety disordered group.
Overall, there are equivocal findings, with some studiesshowing parents generally report higher levels of anxietyin their child with ASD compared with the child’s ownreport [11, 15, 19], whereas other studies have found relativelygood parent-child agreement [12–14, 16, 18]. These discrep-ancies may relate to different methodologies employed givenvarious ages, diagnoses, gender proportions, measurementinstruments, and child IQ levels used across studies. Forexample, a meta-analytic review of anxiety in ASD found agewas associated positively with levels of Generalised AnxietyDisorder and negatively with Obsessive Compulsive Disor-der (OCD) and separation anxiety [3]. The meta-analysisalso found a complex relationship between type of ASD
(Asperger’s Disorder, PDD-NOS, or Autistic Disorder) andtype of anxiety, including higher rates of Generalised AnxietyDisorder in Asperger’s Disorder, higher OCD, and specificphobia in Autistic Disorder and lower rates of OCD in PDD-NOS.
The studies reviewed so far have examined parent-childagreement usingmultiple item questionnaires (such as on theSCAS). Given the cognitive and verbal deficits in this popu-lation, high levels of alexithymia, and difficulties answeringopen ended questions, more simple ways of assessing internalstates are indicated [20]. Visual cues such as Visual AnalogueScales, for example, “emotional thermometers,” can be usedto measure the strength of feelings [20]. Thermometer scalesare frequently used in mood and anxiety interventions forindividuals with ASD [21–23] and have the advantage ofbeing a largely visual tool which is important in ASD wherelanguage delays and deviance are commonplace with relativestrengths in visual skills.
Thermometer scales have long been used and validatedin paediatric pain management to assess the level of pain[24–26] and emotional distress in hospital [27, 28] andnonhospital settings [29–31]. Generally, visual analogue painscales show reasonably sound psychometrics [32]; however,there are somemixedfindings. Some studies have shownpooragreement between parent and child ratings, with parentsreporting generally lower levels of pain than their child[33]. Research suggests that children generally need to havenormal IQ and be 7 years of age and older to use thermometerscales reliably [34].
The validity of these types of visual scales is largelyunexamined in ASD. Lopata and colleagues [35] used athermometer scale to examine stress in children aged 6–13years with ASD. They found mild to moderate correlationsbetween a stress thermometer scale and cortisol levels whichwas unexpected given the fact that child self-reports often donot correlate well with physiological measures [35, 36]. Thisindicated that children with ASD may have some capacityto rate their internal states accurately using a thermometerscale. No studies examining the validity of anxiety specificthermometers for ASD were found in the literature.
It is also noteworthy that studies in this area of ASD havegenerally failed to examine gender differences in parent-childagreement on anxiety symptoms. There are many more boysthan girls diagnosed with ASD, yet how gender interacts withanxiety in ASD is not well explored. Girls from adolescenceonwards are reported to experience higher levels of anxietythan boys [37], which may also be the case in ASD [38].Younger girls with ASDmay also show higher levels of socialanxiety relative to boys with ASD, with this difference alsoreflected in typically developing children [39]. It is possiblethat girls and boys may also self-report different levels ofanxiety, with this yet to be explored by gender in ASD.
The major aim of this study was to determine how wellchild and parent reports on the SCAS correlated in childrenwith ASD. Secondly, the study aimed to determine if a “worrythermometer” correlated with the SCAS. We also soughtto examine whether there were any gender differences inchild reports on the SCAS and the “worry thermometer.” Weinvestigated the following research questions. (1) Howwell do
Autism Research and Treatment 3
typically developing (TYP) and ASD children’s self-reportscorrelate with their parent report on the SCAS? (2) How welldo anxiety thermometer child-report ratings correlate withparent and child report on the SCAS and does this differ ifa child has ASD? (3) Do boys and girls with ASD self-reportsimilar levels of anxiety symptoms on the SCAS and a worrythermometer?
2. Method
2.1. Participants. In total, 88 children participated in thisstudy. Participants with ASD were 44 children, 21 male and23 female, with Autistic Disorder or Asperger’s Disorderand aged between 8 and 13 years. This sample was takenfrom our larger study of gender differences in children withASD, and hence females were oversampled compared to thenormalmale prevalence found inASD [39]. Participants wererecruited prior to the release of DSM-5. All clinical childrenwere diagnosed using DSM-IV-TR criteria by registeredpsychologists and pediatricians prior to taking part in thestudy. The DSM-IV-TR criteria for Autistic Disorder orAsperger’s Disorder were confirmed for ASD participantsusing our standard process involving reviewing diagnosticreports completed by pediatricians/psychologists and inter-viewing parents using a symptom checklist to ensure DSM-IV-TR criteria were fulfilled. In addition, all ASD participantswere screened and confirmed to be within the clinical rangeon the Social Responsiveness Scale (SRS) parent report [40]which has demonstrated validity with the Autism DiagnosticInterviewRevised [41]. To increase the diagnostic validity andhomogeneity of the ASD sample, children with PDD-NOSwere excluded given the fact that this condition is diagnosedonly when there are subclinical autism symptoms or atypicalpresentation [42]. All participants were recruited throughtheMonashUniversity Centre forDevelopmental Psychologyand Psychiatry, the Autism Victoria “Get Involved” volunteerregister, and private clinics in the Melbourne metropolitanarea. Only children with a full-scale IQ of 70 and above wereincluded in the study.
Forty-four typically developing children, 25 male and 19female, who were matched based on gender, age, and per-ceptual IQ, were recruited from a Melbourne metropolitanprimary school. These children were also aged between 8and 13 years. None of these children had any prior historyof parent or teacher reported developmental disability orpsychopathology. Further, possible ASD symptoms in thispopulation were screened with these children scoring withinthe typical range on the SRS parent report [40]. Childrenacross both groups were excluded if they had a history ofbrain injury or any genetic disorders (such as Fragile Xsyndrome).
2.2. Measures
2.2.1. Intellectual Functioning. For all children with ASD,intellectual ability was assessed using the Wechsler Intelli-gence Scale for Children IV (WISC-IV, [43]), Australian ver-sion.This yields a full-scale IQ,Verbal Comprehension Index,
and a Perceptual Reasoning Index.TheWechsler AbbreviatedScale of Intelligence (WASI, [44]), which yields a full-scaleIQ, a Verbal IQ, and a Performance IQ, was completed forall typically developing children. The typically developingchildren completed the WASI as it was a shorter assessmentwhich reduced the time burden of their participation in thestudy. The WASI full-scale IQ is comparable to the WISC-IV full-scale IQ, the Verbal IQ comparable to the VerbalComprehension Index of theWISC-IV, and the PerformanceIQ comparable to the Perceptual Reasoning Index from theWISC-IV [44].
2.2.2. Parent- and Child-Reported Anxiety. The Spence Chil-dren’s Anxiety Scale [45] parent report is a 38-item question-naire based on DSM-IV-TR criteria for anxiety disorders inchildren. The child-report is a 45-item questionnaire whichincludes six positive filler items (i.e., “I am happy”) andone general item which are not scored in either the total orsubscale scores. Hence, the child report has 38 items whichare scored and correspond directly with the parent version.The scale assesses six domains of anxiety including gener-alized anxiety, panic/agoraphobia, social phobia, separationanxiety, Obsessive Compulsive Disorder, and Physical InjuryFears. Parents and children report how often each of theitems happens to their child using a four-point scale: “never,”“sometimes,” “often,” and “always.” Validity and reliabilityhave been established [45–47].The SCAS has previously beenemployed and shown to be a valid measure of anxiety levelsin individuals with ASD [11, 13].Thismeasure does not have aunitary cutoff point but employs age and gender based normsto place children in clinically significant or the normal rangeof anxiety.
This study also used a 100-point Visual Analogue Scale(VAS) for the assessment of self-reported anxiety (worrythermometer adapted from [48]). Higher scores on thisscale reflected higher levels of anxiety. The thermometerwas presented on an A4 sized page with the thermometerpresented vertically in the middle of the page marked from0 (bottom) to 100 (top) with marks at 1-point intervals. Ascore of 0 indicated “Not at all worried,” 50 “worried,” and100 “very very worried,” with these words placed next to theircorresponding point on the scale.Three worry thermometerswere utilised which referred to current worry, the worstworries in the last 2 weeks, and the worst worries in the child’slifetime. Children are asked for the two-week thermometer,“Including the last twoweeks, what’s themost worried/scaredyou’ve ever felt?”; for the ever thermometer, “What is themostworried/scared you’ve ever felt?”; and the now thermometer,“How worried/scared do you feel now?”
2.3. Procedure. The study was approved by Human ResearchEthics Committees of Monash University and the VictorianGovernment Department of Education and Early Childhood.Parents received an explanatory statement and providedwritten informed consent. Children provided assent. Partic-ipation was voluntary and participants did not receive anymonetary reward for participation other than reimbursementfor travel costs.
4 Autism Research and Treatment
Table 1: Demographic characteristics of the Autism SpectrumDisorder and typically developing groups.
Variable ASD group(𝑁 = 44)
TYP group(𝑁 = 44)
Age in months M (SD) 124.7 (19.3) 122.9 (19.5)Boys : girls 21 : 23 25 : 19Verbal IQ M (SD) 100.7 (13.2) 107.1 (9.6)Performance IQ M (SD) 100.7 (15.3) 105.2 (13.9)ASD: Autism Spectrum Disorder; TYP: typically developing.
Parents of participants were invited to participate viaemail or letter and follow-up telephone call. Participants weretested at a home visit, at the Monash University campus,or at their primary school. The WASI and WISC-IV wereadministered according to standardized instructions.
Parents filled out the questionnaires as per their standardinstructions. Age-based standardized scores were utilized forthe WISC-IV and WASI. Raw scores were used in analysesunless otherwise stated. Children completed the SCAS andworry thermometers in the presence of the examiner (TM)who explained and clarified any questions about themeasuresand read the questions from the SCAS for all children.All data were entered into statistical package for the socialsciences (SPSS) version 22.0 for statistical analyses.
3. Results
3.1. Preliminary Analyses. Analyses utilised included 𝑡-teststo compare demographic variables between groups andmixed model analysis of variance (ANOVA) to comparegroup differences in anxiety measures across raters andgender. Pearson correlations were used to determine theassociations between variables. Bonferroni corrections wereemployed for post hoc tests.
Independent 𝑡-tests showed no difference in age 𝑡(86) =−.440, 𝑃 = .661 and perceptual IQ 𝑡(86) = 1.436, 𝑃 = .155,between the ASD and TYP groups, Table 1. Children withASD had lower Verbal IQs than TYP children, 𝑡(86) = 2.573,𝑃 = .012. The group was matched on gender according to aChi square test, 𝜒2(88) = .729, 𝑃 = .393.
3.2. Group and Gender Differences on the SCAS. The meansof the SCAS total score and subscales by parent, child, andgroup are found in Figure 1, with group differences describedin the following analyses. For the SCAS total score, a RepeatedMeasures ANOVA with group (ASD or TYP) and gender(male or female child) as the between-subject factors andSCAS rater (parent or child) as the repeated measure wasconducted. This showed a significant main effect of group,𝐹(1, 84) = 11.978, 𝑃 = .001, 𝜂
To explore the interaction, independent 𝑡-tests were usedwith Bonferroni corrections (.05/4 = .0125). These found nodifference between TYP and ASD child self-reports, 𝑡(86) =−.569, 𝑃 = .517, but parents of children with ASD reported
0
5
10
15
20
25
30
PTCT
PACA
Tota
l
Sepa
ratio
n an
xiet
y
Soci
al p
hobi
a
OCD
Pani
c/ag
orap
hobi
a
Phys
ical
In
jury
Fea
rs
Gen
eral
ised
Anx
iety
PA > PTPA > PT
PA > PTPA > PT
PA > PTCT > PT
PA > PTCT > PT
PG > PBCA > PACT > PT CT > PT
CT > PT
Figure 1: Means of the SCAS total and subscales for parents andchildren by group. Significant group differences are coded as follows:PA, parents of childrenwithASD; PT, parents of typically developingchildren; CA, children with ASD; CT, typically developing children;PG, parents of girls; PB, parents of boys.
higher levels of anxiety than parents of TYP children, 𝑡(86) =−7.023, 𝑃 < .001. Paired samples 𝑡-test showed there was nodifference between parent and child reporting total anxietyfor children with ASD, 𝑡(43) = −.654, 𝑃 < .517, but there wasa difference for the TYP group with TYP children reportinghigher levels of anxiety than their parents, 𝑡(43) = −6.252,𝑃 < .001.
The six subscales were then explored using a RepeatedMeasures ANOVA to compare rater (parent versus child),group (TYP versus ASD), and gender (male versus femalechild). There was a significant main effect of subscale,𝐹(1, 84) = 24.573, 𝑃 < .001, 𝜂
𝑃
2= .226, rater 𝐹(1, 84) =
19.132, 𝑃 < .001, 𝜂𝑃
2= .186, and group, 𝐹(1, 84) = 11.978,
𝑃 < .001, 𝜂𝑃
2= .125. There was a significant interaction
between rater and group, 𝐹(1, 84) = 11.653, 𝑃 = .001, 𝜂𝑃
2=
.122, and subscale and rater 𝐹(1, 84) = 21.811, 𝑃 < .001,𝜂𝑃
2= .206. These were explored using post hoc ANOVAs
with Bonferroni corrections for each subscale (.05/4 = .0125)and the differences are summarised in Figure 1. For PhysicalInjury Fears, there were no significant differences betweenparent-child reports.
For separation anxiety, there was a significant differencein parent reports (𝑃 < .001) for TYP and ASD children. TYPparents reported lower levels of separation anxiety than theirchildren (𝑃 < .001) whereas in ASD parent-child dyads levelswere similar.
For social phobia, parent-child dyads reported similarlevels regardless of diagnosis. There was a significant dif-ference between TYP and ASD parent reports (𝑃 = .007)with ASD parents reporting higher levels, but no differencebetween child reports.
Similarly, for Obsessive Compulsive Disorder, parents ofchildrenwithASD reported higher levels than parents of TYP
Autism Research and Treatment 5
Table 2: Agreement between parent and child SCAS subscales and total score for the ASD and TYP groups.
Child SA Child SP Child OCD Child PA Child PIF Child GA Child totalTypically developing
children (𝑃 < .001) but there was no difference in childreport. Both parents of children with ASD (𝑃 < .001) andparents of TYP children (𝑃 < .001) reported lower levels ofOCD than their children.
Parents of TYP children reported significantly lowerlevels of panic/agoraphobia than their children (𝑃 <.001), with no difference between ASD parent-child reports.Parents of children with ASD reported higher levels ofpanic/agoraphobia than parents of TYP children (𝑃 < .001),with children reporting similar levels.
For Generalised Anxiety, parents of TYP childrenreported lower levels than their children (𝑃 < .001), withno difference between ASD parent-child dyads. Parents ofchildren with ASD reported higher levels than parents ofTYP children, with no difference in self-reportedGeneralisedAnxiety in children with or without ASD.
For gender there was only one subscale by gender interac-tion, 𝐹(1, 84) = 2.391, 𝑃 = .037, 𝜂
𝑃
2= .028, with a significant
difference for parent-reported social phobia (𝑃 < .001), withinspection of means revealing that girls were reported toexperience higher levels (𝑀 = 6.26, SD = 3.22) than boys(𝑀 = 4.02, SD= 2.41).Therewere no other gender differencesin any other analyses, including the thermometer scales.
3.3. ChildThermometer Scales. Pearson correlations betweenthe now, ever, and two-week scales were calculated for theTYP and ASD groups. For the TYP group, the ever and two-week scales were correlated, 𝑟 = .459, 𝑃 = .002, but thenow and ever (𝑟 = .151, 𝑃 = .328) and now and two-weekscales (𝑟 = .280, 𝑃 = .065) were not. For the ASD group, thesame pattern was present.The ever and two-week scales werecorrelated, 𝑟 = .304,𝑃 = .045, but the now and ever (𝑟 = .144,𝑃 = .352) and now and two-week scales (𝑟 = .199, 𝑃 = .196)were not.
An ANOVA showed no group differences in the child-reported anxiety thermometer scales (now, two weeks, ever)in regard to ASD (two weeks𝑀 = 35, SD = 33; now𝑀 = 11,SD = 21; ever 𝑀 = 79, SD = 76) versus TYP children (twoweeks𝑀 = 29, SD = 21; now𝑀 = 5, SD = 10; ever𝑀 = 72,SD= 26).Given the fact thatVerbal IQwas correlatedwith the2-week thermometer, an ANCOVA was conducted and sim-ilarly found no difference between TYP and ASD children.
3.4. SCAS Parent and Child Correlations. Correlationsbetween the SCAS parent and child reports for both groupsare shown in Table 2. In children with ASD, there was asignificant correlation between parent- and child-reportedseparation anxiety. In TYP children, there were significantcorrelations between parent- and child-reported separationanxiety, social phobia, panic/agoraphobia, Physical InjuryFears, and the SCAS total score.
3.5. Child Thermometer Correlations with Parent and ChildSCAS Scores. Pearson correlations between the child ther-mometers and parent and child SCAS scores were calculated.For child reports on the SCAS and thermometer, in the ASDgroup, separation anxiety (𝑟 = .380, 𝑃 < .05), social phobia(𝑟 = .441, 𝑃 < .01), and the SCAS total score (𝑟 = .305,𝑃 < .05) correlated with the ever thermometer; PhysicalInjury Fears (𝑟 = .373, 𝑃 < .05) with the now thermometer;and social phobia (𝑟 = .304, 𝑃 < .05), panic/agoraphobia(𝑟 = .357, 𝑃 < .05), and Generalised Anxiety (𝑟 = .319,𝑃 < .05) with the two-week thermometer. In TYP children,there was only one correlation which was between separationanxiety and the now thermometer (𝑟 = .350, 𝑃 < .05).
In regard to parent-child agreement, in the TYP group,the two-week thermometer was unexpectedly negatively cor-related with parent-reported separation anxiety (𝑟 = −.327,
6 Autism Research and Treatment
𝑃 < .05). For children with ASD, the now thermometerwas correlated with parent-reported OCD (𝑟 = .309, 𝑃 <.05) and Generalised Anxiety (𝑟 = .352, 𝑃 < .05). Thelack of associations indicated that the thermometer was notmeasuring the same anxiety construct as the SCAS.
4. Discussion
In the present study, we sought to compare parent and childreports of child anxiety using the SCAS in children with ASDand typically developing children aged 8–13 years. We foundthat typically developing parent-child reports on the SCASshowed good correlations, whereas ASD parent-child reportswere generally poorly correlated.We also examinedwhether a“worry thermometer” was able to measure anxiety and foundpoor construct validity with the SCAS.
4.1. TYP versus ASD on the SCAS. Children with ASD ratedthemselves as having similar levels of anxiety to typicallydeveloping children across all subscales and for the totalscore, which was in contrast to some past studies [11] butconsistent with others [15]. This was despite ASD parentsreporting significantly higher levels of anxiety in regard tototal anxiety, social phobia, separation anxiety, OCD, andGeneralised Anxiety than did TYP parents, a finding consis-tent with some past studies [15, 18]. Hence, even though chil-drenwithASDhave high levels of anxiety according to parentreport, they self-report similar levels to typically developingchildren. This may relate to poorer emotion recognitionin children with ASD who may have difficulty recognizingand expressing their anxiety, despite them being cognitivelyhigh-functioning in the present study. For example, althoughchildrenwithAsperger’s Disorder generally have superficiallynormal language development, their comprehension may beparticularly poor [49] which may impact on their ability tounderstand and express complex constructs such as their ownanxiety. Research in adults with ASD suggests up to 50% havealexithymia which impacts on the ability to recognize andexpress emotional states [50, 51].
Parents of TYP children reported lower levels of anxietythan did their children with the exception of Physical InjuryFears and social phobia. These types of anxiety may be morereadily observed by parents in child behavior, potentiallyresulting in better concordance on these two measures.ASD parents reported lower levels of OCD than their chil-dren, with otherwise similar mean scores for the other fivesubscales and total SCAS score. Russell and Sofronoff [11]similarly found that children with ASD rated themselves ashaving higher levels of OCD than their parents indicated.Overall, ASD parents and children actually reported moresimilar mean levels of anxiety, with TYP parents generallyreporting lower mean levels of anxiety than their children.It may be that TYP children overreport their levels of anxietyand children with ASD underreport theirs, resulting in thispattern of similar child-reported anxiety levels.
4.2. Correlations between Parent and Child SCAS. Althoughat the group level there was general consistency between
mean parent- and child-reported levels of anxiety, the parent-child correlations suggested poor agreement in ASD parent-child dyads compared with better agreement in TYP parent-child dyads. These findings are in contrast to some paststudies [12–14], which found generally good child-parentcorrelations on the total SCAS score in youth with ASD, butconsistent with White and colleagues [16] who found poorparent-child correlations (12–17 years).These differencesmaybe due to the older children in these three aforementionedstudies (10–16 years) compared to the current study (8–13years). The SCAS may be better able to accurately captureself-reported anxiety in older children with ASD. Consistentwith the current study, Lopata and colleagues [15] and vanSteensel and colleagues [19] also found poor correlationsbetween parent-child-reported anxieties in children withASD using other anxiety measures. Their age ranges alsoincluded younger participants (7–17) further supporting thenotion that age may be a factor in the accurate self-reportingof anxiety in ASD.
4.3. Thermometer Scale. This is the first study to our knowl-edge to compare a Visual Analogue Scale to the SCAS inchildren with ASD.The child-rated worry thermometer usedin the study showed poor construct validity with parent andchild reports on the SCAS for both TYP and ASD groups.There have been some studies which have not found VisualAnalogue Scales to be well correlated with parent reports, atleast in the paediatric pain literature [33]. Parent-child agree-ment is good for severe difficulties (such as severe injuriesand things complained of daily), but less for more infrequentor less severe difficulties [52]. The thermometer scale used inthe current study asked children to report on how “worried”or “scared” they were, which can be considered two separateconstructs; hence, this could explain the lack of validity of thethermometer. Future workmay benefit from separating theseconstructs into separate thermometers.
4.4. Gender. Finally, this was the first study to compare self-reported anxiety in girls and boys with ASD. There were nogender differences found in boys and girls ratings of their ownanxiety in the ASD or TYP groups, on both the SCAS andworry thermometers. Potentially, as girls reach puberty, theymay experience greater levels of anxiety than boys and showdifferences in anxiety self-report from this period onwards.
4.5. Clinical Implications. The present findings contribute toa growing body of research showing that children with ASDprior to puberty may have difficulties accurately reportingtheir anxiety. This is not the case for typically developingchildrenwhichmay relate to their better verbal and emotionalunderstanding. Parent report, at least using the SCAS, is likelyto be a more accurate measure of anxiety than children withASD’s self-report. Hence, clinicians and those who work withchildren with ASD within the 8–13-year age range may needto primarily rely on parent reports of anxiety. Additionally,the use of thermometer scales to measure internal states inchildren with ASD is commonplace in a number of ASDspecific interventions [20, 22, 23]. Clinicians should interpret
Autism Research and Treatment 7
these child self-reported thermometer scales cautiously untilvalidity is demonstrated.
4.6. Limitations. An important extension of this study will befor clinicians to rate anxiety in the children using structuredparent and child interviews. In the present study, the childratings were compared to their parents and not to a clinicalassessment of anxiety symptoms. This will then allow clin-ician reports to be correlated with child and parent reportsof anxiety to further examine the validity of a thermometerscale. The lack of a clinician report is a major limitationof the study. However, it is noteworthy that past studiesthat have compared parent, child, and clinician structuredinterviews in youth with ASD have found good to excellentcorrespondence between clinician consensus diagnosis andparent reports of anxiety [53]. Comparing a group of childrenwith anxiety disorders without ASD to those with ASDon the thermometer scale may have also been informativeto determine whether the poor correspondence betweenparent-child reports is associated with anxiety per se or ASD.
Only children with full-scale IQs greater than 70 wereincluded, and hence these findings may not generalize tochildrenwithASD and intellectual disability. Of note, none ofthe studies examining self-reported anxiety in ASD discussedhave included children with intellectual disability as partic-ipants. Given the fact that most individuals with ASD haveintellectual disability, examining whether similar self-reportmeasures of anxiety are valid in this population is needed.
5. Conclusion
Overall, children with ASD aged between 8 and 13 yearsshow difficulty in accurately reporting their anxiety relativeto parent reports. In contrast, typically developing children ofthis age range self-report anxiety levels similar to their parentratings.The use of a visual analogue “worry thermometer” togauge anxiety levels in children with ASD was not supportedby the present studies findings. Given the extensive useof these types of scales in interventions for children withASD, further research into the validity of these measures iswarranted.
Conflict of Interests
The authors declare that there is no conflict of interestsregarding the publication of this paper.
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