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Child Psychiatry & HumanDevelopment ISSN 0009-398X Child Psychiatry Hum DevDOI 10.1007/s10578-012-0297-y
Evidence Based Clinical Assessment ofChild and Adolescent Social Phobia: ACritical Review of Rating Scales
Bogdan T. Tulbure, Aurora Szentagotai,Anca Dobrean & Daniel David
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REVIEW PAPER
Evidence Based Clinical Assessment of Childand Adolescent Social Phobia: A Critical Reviewof Rating Scales
Bogdan T. Tulbure • Aurora Szentagotai • Anca Dobrean •
Daniel David
� Springer Science+Business Media, LLC 2012
Abstract Investigating the empirical support of various assessment instruments, the
evidence based assessment approach expands the scientific basis of psychotherapy. Starting
from Hunsley and Mash’s evaluative framework, we critically reviewed the rating scales
designed to measure social anxiety or phobia in youth. Thirteen of the most researched
social anxiety scales for children and adolescents were identified. An overview about the
scientific support accumulated by these scales is offered. Our main results are consistent
with recent reviews that consider the Social Phobia and Anxiety Scale for Children (SPAI-C) and the Social Anxiety Scale for Adolescents (SAS-A) among the most pertinent and
empirically supported measures of social anxiety for youngsters. However, after consid-
ering the existing evidence, we highly recommend another couple of scales that proved to
be empirically supported (i.e., the Social Phobia Inventory—SPIN, and the LiebowitzSocial Anxiety Scale for Children and Adolescents—LSAS-CA).
Keywords Social anxiety disorder/social phobia � Evidence-based assessment �Children and adolescents � Rating-scale � Questionnaire
Introduction
Anxiety disorders represent a common and impairing condition affecting an important
number of children and adolescents. Among anxiety disorders, social phobia (SP), also
B. T. Tulbure (&) � A. Dobrean � D. DavidDepartment of Clinical Psychology and Psychotherapy, Babes-Bolyai University, Cluj-Napoca,Romaniae-mail: bogdan.tulbure@ubbcluj.ro
A. Dobreane-mail: AncaDobrean@psychology.ro
D. Davide-mail: danieldavid@psychology.ro
A. SzentagotaiDepartment of Psychology, Babes-Bolyai University, Cluj-Napoca, Romaniae-mail: auraszentagotai@psychology.ro
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Child Psychiatry Hum DevDOI 10.1007/s10578-012-0297-y
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known as social anxiety disorder (SAD) is ‘‘a persistent fear of one or more social or
performance situations in which the person is exposed to unfamiliar people or to possible
scrutiny by others’’ accompanied by a tendency to avoid feared stimuli [1].1 It is the third
most common psychiatric disorder, with a lifetime prevalence of about 13 % in the general
population [2]. The onset of SAD is early/middle adolescence, but the disorder was
identified in younger children [3]. Once developed, SAD tends to become chronic, and
does not remit without treatment [4]. If left untreated, beyond its own symptoms, SAD
renders the suffering youngsters with vulnerabilities for the development of other disorders
later in life [5].
In this review, we examine the empirical support accumulated by child and adolescent
social phobia rating scales used as screening and treatment outcome measures. Starting
from the framework proposed by Hunsley and Mash [6], we critically evaluated 13 of the
most researched SP youth scales in terms of norms, internal consistency, reliability, content
and construct validity, treatment sensitivity and clinical utility. An extensive summary on
the scientific support of youth SP rating scales, reasons for legitimately using them in both
research and practice, and encouragement for the international availability of validated
scales are provided.
What is and Why do We Need Evidence-Based Assessment for Youngsters?
One of the most influential paradigms in the clinical psychology domain is the evidence-
based approach. Within this paradigm, there are two asymmetric branches: the evidence
based treatment (EBT) approach (the best-represented one), and the evidence based
assessment (EBA) approach (the least-represented one). Mash and Hunsley [7] use the
term EBA to describe ‘‘assessment methods and processes that are based on empirical
evidence in terms of both their reliability and validity as well as their clinical useful-
ness…’’ (p. 364). Despite the fact that a limited number of researchers spared no effort to
promote the EBA approach, scientific evidence to support the usefulness of assessment
offered to both children and adults is still scarce. Considering the developments in the
evidence-based treatment domain, it is surprising that until recently [6–10] few efforts have
been made to develop the EBA approach.
Referring to the development of new and sound assessment methods, some authors
praise the progress of the field considering it a sign of flourishing [11]. In this view, having
a wide range of measures with good psychometric proprieties is an important asset for both
research and practice. On the other hand, Kazdin [12] rightfully notice the proliferation of
child functioning measures and wonders whether there are differences among them in
terms of validity and utility. The endless expanding of different measures was ironically
called the big bang of assessment [12]. In the same manner, Balon [13] considers that
psychiatry has been ‘‘plagued by the everlasting and, at times, seemingly purposeless
development of new scales.’’ (p. 1). Given the growing number of new or revised
instruments available, the task of selecting the optimal assessment tool for a specific
purpose can be daunting. In this context, EBA has the potential of providing the empirical
arguments for both selecting and promoting the measures that present the highest support.
This approach was designed both to investigate what makes measures reliable and valid,
and to catalog their evidence. Overall, the EBA approach aims to fill the gap in the
1 We used the terms Social Phobia (SP) and Social Anxiety Disorder (SAD) to refer to the diagnosticcategory and the term social anxiety to refer to levels along the normally distributed continuum.
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evidence-based literature, enlarging the empirical support of psychological services in
general, and of psychotherapy in particular.
Summarizing, the evidence-based assessment (EBA) represents an integral part of the
evidence-based paradigm, providing a meaningful way to filter a large number of mea-
sures, facilitating the selection of the most appropriate instruments for a specific purpose.
Moreover, the EBA expands the scientific basis of psychotherapy, by investigating the
empirical support of the assessment instruments available on the scientific market.
Criteria for Evaluating Psychological Measures
One of the main questions within the EBA approach refers to what constitutes the nec-
essary and sufficient evidence for an assessment instrument to be empirically supported. In
their systematic review of assessment strategies, Clark et al. [14] proposed a set of criteria
for interpreting psychometric data. Building on previous research, the authors specified
under what conditions a certain psychometric propriety is considered acceptable or good. A
few years later, Brooks and Kutcher [15] critically assessed 15 youth anxiety measures,
offering a detailed index of their psychometric proprieties. Although both rating systems
are important, neither of them seems to be comprehensive and articulate enough to
incorporate a large variety of assessment purposes, populations, and clinical situations.
Other efforts directed at promoting EBA [7–10, 16, 17] present helpful overviews of the
filed, discuss common themes that cut across different problems, and elaborate on the need
for EBA guidelines, but none of them actually presents such guidelines. At the time, all
authors seem to agree that psychologists should use measures supported by strong evi-
dence. But exactly how to proceed in determining the scientific support of an instrument
was unclear.
The Rating System Proposed by Hunsley and Mash [6]
In an effort to determine the minimal evidence needed for assessment instruments Mash
and Hunsley [7] provided a first set of guidelines. A few years later, they furthered their
work by presenting a rating system to be used when investigating the empirical support of
an instrument [6]. After delving into the voluminous assessment literature, the authors
managed to crystallize a minimal set of criteria against which to judge a specific measure.
Nine psychometric proprieties (i.e., norms, internal consistency, inter-rater reliability, test–
retest reliability, content and construct validity, validity generalization, sensitivity to
treatment, and clinical utility) are to be rated for a specific disorder (e.g., social phobia,
depression etc.), in relation to a specific assessment purpose (i.e., screening, diagnostic,
treatment monitoring etc.). For each category, a rating of: (a) less that adequate, (b) ade-quate, (c) good, (d) excellent, (e) unavailable, or (f) not applicable is to be used. In
Hunsley and Mash’s [6] words: ‘‘a rating of adequate indicates that the instrument meets a
minimum level of scientific rigor, good indicates that the instrument would generally be
seen as possessing solid scientific support, and excellent indicates there was extensive, high
quality supporting evidence. Accordingly, a rating of less than adequate indicates that the
instrument did not meet the minimum level set out in the criteria. A rating of unavailableindicates that research on the psychometric propriety under consideration had not yet been
conducted or published.’’ (p. 7). Scientists using this rating system should survey the
literature to gather the relevant data about a particular measure. This approach is in line
with Antony and Rowa’s [9] argument that quantitative reviews of specific instruments are
useful in evaluating their scientific support. Further details about the meaning of adequate,
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good, and excellent, and how these criteria were used to rate the psychometric proprieties
are provided in ‘‘Appendix’’.
The rating system advanced by Hunsley and Mash appears to be a coherent and general
evaluative framework for a variety of instruments and assessment situations. It was
designed to take into account the specificity of each disorder, sample, context, and
assessment purpose. This rating system was previously used to provide indicators of sci-
entifically strong measures for a wide range of situations and problems (i.e., attention-
deficit and disruptive behavior disorder, mood disorder and self-injury, anxiety disorders,
substance use and gambling, schizophrenia and personality disorders, couple distress and
sexual problems, and health-related problems [6, 18, 19]). This is why we decided to utilize
Hunsley and Mash’s evaluative framework in the current review. Since our goal was not to
develop a new rating system, we observed the authors’ original suggestions in applying
their evaluative framework.
Method
Data Collection
We collected the published studies relevant to our review. First, the databases PsychInfo,
Medline, Ebsco, Science Direct and Google Scholar were searched with the following key
words: social anxiety disorder, social phobia, children and adolescents, youth social fear(s),withdrawal, measure, rating-scale, self-report, questionnaire. In addition, we checked the
references of numerous articles to identify possible missing papers. The studies included in
our review had been published up to March 2011 (when we closed our search).
In total, we collected 60 articles that met our inclusion criteria. In these studies 56,346
participants were examined, and 3,399 of them received some form of treatment for their
social anxiety condition. The participants were between 7 and 18 years of age, with few
exceptions. Most of the studies were conducted with children and adolescents from the US
(24) and Spain (14). We also identified articles conducted in Finland (3), Norway (3),
Brazil (2), Canada (2), China (2), Germany (2), Slovenia (2), Chile (1), Portugal (1),
Sweden (1), Taiwan (1), Turkey (1), and the UK (1).
Criteria for Selecting Articles
The EBA approach was designed to redress the relative inattention to the assessment instru-
ments and their existing support [7]. With this in mind, we critically reviewed rating scales that
meet the following criteria: (a) were empirically developed to measure social anxiety or phobia,
(b) were used with children and adolescents samples, and (c) were presented in at least one
published paper (in the English language). We focused only on social phobia rating scales,
because a different set of youth anxiety measures (i.e., diagnostic interviews, omnibus anxiety
scales, social skill measures) were critically analyzed elsewhere [19, 20].
The Rating System Used
Any instrument is useful as long as it allows us to reach a certain purpose. Hunsley and
Mash [6] offered a conceptual framework that enable researchers to evaluate the scientific
support accumulated by any measure. More precisely, the instrument’s psychometrics
(e.g., internal consistency, reliability, validity etc.) are evaluated in the context of a specific
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disorder (e.g., social phobia), according to a specific assessment purpose (e.g., screening,
treatment outcome etc.). A subset of the criteria proposed by Hunsley and Mash (used in
this critical review), together with details on how they were used are presented in
‘‘Appendix’’. Interested readers could consult Hunsley and Mash’s work for a detailed
description of the rating system [6].
Results
Social Anxiety Rating Scales for Children and Adolescents
To provide a comprehensive overview of social anxiety rating scales, we briefly describe
their general characteristics. As stated earlier, we restricted our review to social anxiety
scales for children and adolescents. Even with such restrictions, our review incorporates 13
rating scales that meet our criteria (see Table 1). While it is possible that we have missed
some scales, the most researched ones are certainly included.
All the reviewed youth social anxiety scales, their number of items, the theory behind the test
or how the items were developed, and the factor analysis results, if conducted, are summarized
in Table 1. Most of the scales used a Likert, forced-choice format. The scales length ranged
between 17 and 45 items, requiring 10–30 min to be completed. A five-point Likert scale for
each item was the most common, although variations between 3 and 7 points were found.
Regarding the rating approach, self-report, parent report, and clinician report were used for all
social anxiety scales, with some scales having more than one rating approach. A numeric
description for a subset of the analyzed psychometric proprieties is presented in Table 2.
Regarding the origin of the measures, most scales were developed in the US. The scales
were frequently translated into other languages, and one or more studies established the
psychometrics with participants in that particular country. Moreover, some countries have
developed their own scales.
All of the scales were developed following one or more of the classical steps presented
in the test construction literature. Thus, researchers first generated a large item pool based
on a particular theory, from former scales, through interviews with experts or members of
the population of interest, from the DSM criteria, or from definitions of social anxiety
found in the literature. Being developed on such solid bases, the content validity of most
reviewed scales was ensured from the very beginning.
The Empirical Support of Social Anxiety Rating Scales as a Function of Assessment
Purposes
For clarity reasons, we focused only on a subset of assessment purposes, namely screeningand treatment outcome. These purposes are relevant for rating scales, as most articles report
extensive data on these issues, covering the main aspects of both research and practice. If
designed for more than one purpose, the same scale was rated twice, and different ratings were
used for the same measure, as the empirical support varied from context to context.
Assessment for Screening
Screening youngsters who are at risk of developing SAD is important for at least two
reasons. First, social anxiety is a highly underreported disorder, with less that 23 %
diagnosed youth seeking treatment [21]. Second, SAD symptoms generally appear during
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7]
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from
scie
nti
fic
lite
ratu
re,
clin
ical
exper
ience
,
oth
erm
easu
res,
and
stru
cture
din
terv
iew
s
Beh
avio
ral
Anxie
tyan
d
Avoid
ance
subsc
ale
wit
h
6fa
ctors
each
Dis
tres
s34
S12–18
Port
ugues
eC
unha
etal
.[5
8]
1
Subje
ctiv
eA
void
ance
5pt.
Lik
ert
Tota
l
SP
SQ
-CG
ren-
Lan
del
l
etal
.[5
9]
DS
M-I
Vcr
iter
iafo
rS
PB
ehav
iora
l–
Tota
l17
S15–18
Sw
edis
hG
ren-L
andel
let
al.
[59]
1
Item
sder
ived
from
oth
er
mea
sure
s(S
PS
Qfo
r
adult
s)
Subje
ctiv
e3
pt.
Lik
ert
SP
AI
Soci
alP
hobia
and
Anxie
tyIn
ven
tory
[20
],SP
AI-
CS
oci
alP
hobia
and
Anxie
tyIn
ven
tory
for
Chil
dre
n[2
4],
SA
SC
-RS
oci
alA
nxie
tyS
cale
for
Chil
dre
n–R
evis
ed[3
0],
(FN
EF
ear
of
Neg
ativ
e
Eval
uat
ion,
SA
D-N
ew/G
en.
Soci
alA
void
ance
and
Dis
tres
sfo
rN
ew/G
ener
alsi
tuat
ions)
,SA
S-A
Soci
alA
nxie
tyS
cale
for
Adole
scen
ts[3
3],
SP
INS
oci
alP
hobia
Inven
tory
[37],
LSA
S-C
AL
iebow
itz
Soci
alA
nxie
tyS
cale
for
Chil
dre
nan
dA
dole
scen
ts[4
3],
SIA
SS
oci
alIn
tera
ctio
nA
nxie
tyS
cale
[45],
SA
SA
Soci
alA
nxie
tyS
cale
for
Adole
scen
ts[4
7],
SoP
hI
Soci
alP
hobia
Inven
tory
[48
],K
GSA
DS
-
AK
utc
her
Gen
eral
ized
Soci
alA
nxie
tyD
isord
erS
cale
for
Adole
scen
ts[5
0],
QID
AQ
ues
tionnai
reab
out
Inte
rper
sonal
Dif
ficu
ltie
sfo
rA
dole
scen
ts[5
2],
SA
ASA
Soci
alA
nxie
tyan
dA
void
ance
Sca
lefo
r
Adole
scen
ts[5
5],
SP
SQ
-CS
oci
alP
hobia
Scr
eenin
gQ
ues
tionnai
refo
rC
hil
dre
n[5
6],
Form
sS
self
-rep
ort
,P
par
ent
report
,C
clin
icia
nre
port
*L
SA
S-C
Asc
ore
s:so
cial
inte
ract
ion
anxie
ty,
per
form
ance
anxie
ty,
tota
lan
xie
ty,
avoid
ance
of
soci
alin
tera
ctio
n,
avoid
ance
of
per
form
ance
situ
atio
ns,
tota
lav
oid
ance
,to
tal
LS
AS
-CA
score
Child Psychiatry Hum Dev
123
Author's personal copy
Ta
ble
2N
um
eric
dat
afo
rra
tin
g-s
cale
sp
sych
om
etri
cp
rop
riet
ies
Inst
rum
ent
acro
nym
Inst
rum
ents
subsc
ales
/
tota
lsc
ore
Norm
sIn
tern
alco
nsi
sten
cyr
Tes
t–re
test
reli
abil
ity
Val
idit
y
Rec
om
men
ded
cut
off
score
or
inte
rval
/
most
freq
uen
tsc
ore
Sen
siti
vit
y/
spec
ifici
ty
Alf
a
Cro
nbac
h
No.
of
aC
.90/
no
studie
s
Tim
e
bet
wee
n
asse
ssm
ents
No.
of
rC
.70/
no.
studie
s
Conver
gen
t
[corr
elat
ion
wit
h
oth
erS
Psc
ales
]
Dis
crim
inan
t
[corr
elat
ion
wit
h
non
SP
scal
es]
SP
AI
Soci
alphobia
70/1
970
88
%/9
7%
[.95;
.97]
5a/
5–
––
––
Agora
phobia
––
[.83;
.95]
2a/
5–
––
––
Tota
lS
PA
I(D
iff)
60/1
960
88
%/9
3%
[.92;
.97]
3a/
3[.
60;
.86]
2w
eeks–
6m
onth
s2
r/3
[.73;
.88]
[ns;
.36]
SP
AI-
CT
ota
lS
PA
I-C
18/8
918
[70–91
%]/
[80–82
%]
[.90;
.95]
11
a/11
[.47;
.86]
2w
eeks–
12
month
s3
r/7
[.31;
.79]
[-.3
3;
.37]
SA
SC
-RF
NE
––
[.86;
.96]
2a/
3–
––
––
SA
D-N
ew–
–[.
78;
.95]
1a/
3–
––
––
SA
D-G
en–
–[.
60;
.90]
1a/
3–
––
––
Tota
lS
AS
C-R
––
––
––
–[.
12;
.75]
[ns;
-.2
4]
SA
S-A
FN
E–
–[.
83;
.94]
4a/
7[.
55;
.84]
2w
eeks–
12
month
s3
r/4
––
SA
D-N
ew–
–[.
67;
.86]
–[.
58;
.78]
2w
eeks–
12
month
s1
r/4
––
SA
D-G
en–
–[.
41;
.80]
–[.
54;
.75]
2w
eeks–
12
month
s1
r/4
––
Tota
lS
AS
-A[4
4–
54]/
49
50
[43–89
%]/
[82–94
%]
[.85;
.93]
4a/
7[.
60;
.86]
2w
eeks–
12
month
s2
r/3
[.24;
.79]
[ns;
.36]
SP
INT
ota
lS
PIN
[19–
25]/
39
19
[71–80
%]/
[77–85
%]
[.82;
.95]
6a/
11
[.32;
.89]
2w
eeks–
5w
eeks
5r/
6[.
55;
.92]
[.23;
.58]
LS
AS
-CA
Tota
lL
SA
S-C
A[2
2–
29]/
–[9
0–95
%]/
[52–96
%]
[.73;
.97]
6a/
8[.
78;
.94]
1–2
wee
ks
2r/
2[.
33;
.80]
–
SIA
ST
ota
lS
IAS
[38–
40]/
––
[.85;
.94]
1a/
3r
=.9
24
wee
ks–
3m
onth
s1
r/1
[.48;
.74]
[.45;
.58]
SA
SA
Tota
lS
AS
A–
–[.
87;
.90]
1a/
3–
––
[.13;
.68]
–
SoP
hI
Tota
lS
oP
hI
48/1
948
82
%/7
7%
[.92;
.93]
2a/
2r
=.7
06
month
s1
r/1
[.61;
.89]
–
KG
SA
DS
-AT
ot.
KG
SA
DS
-A–
–a
=.9
61
a/1
[.52;
.74]
4w
eeks
1r/
1[.
56;
.89]
.10
Child Psychiatry Hum Dev
123
Author's personal copy
Ta
ble
2co
nti
nu
ed
Inst
rum
ent
acro
nym
Inst
rum
ents
subsc
ales
/
tota
lsc
ore
Norm
sIn
tern
alco
nsi
sten
cyr
Tes
t–re
test
reli
abil
ity
Val
idit
y
Rec
om
men
ded
cut
off
score
or
inte
rval
/
most
freq
uen
tsc
ore
Sen
siti
vit
y/
spec
ifici
ty
Alf
a
Cro
nbac
h
No.
of
aC
.90/
no
studie
s
Tim
e
bet
wee
n
asse
ssm
ents
No.
of
rC
.70/
no.
studie
s
Conver
gen
t
[corr
elat
ion
wit
h
oth
erS
Psc
ales
]
Dis
crim
inan
t
[corr
elat
ion
wit
h
non
SP
scal
es]
QID
AT
ota
lQ
UID
A–
–[.
89;
.93]
4a/
5[.
78;
.88]
2w
eeks
3r/
3[.
34;
.62]
[-.3
8;
.34]
SA
AS
AD
istr
ess
––
[.91;
.96]
1a/
1r
=.7
45
wee
ks
1r/
1[.
40;
.53]
.30
Avoid
ance
––
[.80;
.87]
1a/
1r
=.7
15
wee
ks
1r/
1[.
40;
.52]
.33
Tota
lS
AA
SA
71/1
971
75
%/8
0%
––
––
––
–
SP
SQ
-CT
ota
lS
PS
Q-C
–71
%/8
6%
a=
.77
–r
=.6
02
wee
ks
––
–
We
incl
uded
num
eric
des
crip
tions
for
those
psy
chom
etri
cpro
pri
etie
sfo
rw
hic
hsu
chsu
mm
ary
was
appro
pri
ate.
The
rem
ainin
gpsy
chom
etri
cpro
pri
etie
sw
ere
rate
din
Tab
les
3an
d4
,as
no
com
monly
acce
pte
dsu
mm
ary
stat
isti
csar
eav
aila
ble
inth
eli
tera
ture
SP
AI
Soci
alP
hobia
and
Anxie
tyIn
ven
tory
[20],
SP
AI-
CS
oci
alP
hobia
and
Anxie
tyIn
ven
tory
for
Chil
dre
n[2
4],
SA
SC
-RS
oci
alA
nxie
tyS
cale
for
Chil
dre
n–R
evis
ed[3
0],
(FN
Efe
arof
neg
ativ
e
eval
uat
ion,
SA
D-N
ew/G
en.
Soci
alA
void
ance
and
Dis
tres
sfo
rN
ew/G
ener
alsi
tuat
ions)
,SA
S-A
Soci
alA
nxie
tyS
cale
for
Adole
scen
ts[3
3],
SP
INS
oci
alP
hobia
Inven
tory
[37],
LSA
S-C
AL
iebow
itz
Soci
alA
nxie
tyS
cale
for
Chil
dre
nan
dA
dole
scen
ts[4
3],
SIA
SS
oci
alIn
tera
ctio
nA
nxie
tyS
cale
[45],
SA
SA
Soci
alA
nxie
tyS
cale
for
Adole
scen
ts[4
7],
SoP
hI
Soci
alP
hobia
Inven
tory
[48],
KG
SA
DS
-
AK
utc
her
Gen
eral
ized
Soci
alA
nxie
tyD
isord
erS
cale
for
Adole
scen
ts[5
0],
QID
AQ
ues
tionnai
reab
out
Inte
rper
sonal
Dif
ficu
ltie
sfo
rA
dole
scen
ts[5
2],
SA
ASA
Soci
alA
nxie
tyan
dA
void
ance
Sca
lefo
r
Adole
scen
ts[5
5],
SP
SQ
-CS
oci
alP
hobia
Scr
eenin
gQ
ues
tionnai
refo
rC
hil
dre
n[5
6]
Child Psychiatry Hum Dev
123
Author's personal copy
childhood or adolescence, and sufferers can stay untreated for a long time [22]. Therefore,
screening for SAD during early years seems a worthwhile enterprise. We summarized the
psychometric proprieties, and the empirical support accumulated by rating scales designed
for screening in Table 3. The final column indicates the best screening scales available
according to our analysis, and thus highly recommended for both clinical and research use.
The Social Phobia and Anxiety Inventory (SPAI)
Although the SPAI [23] was initially designed for adults, it was used to assess adolescents’
social fears [25, 26, 37, 60–62]. SPAI is a 45-item self-report measure, containing a Social
Phobia and an Agoraphobia scale.
In the initial paper, the SPAI scores of socially anxious and non-socially anxious college
students were compared, and significant difference emerged [23]. In a later study, it was
demonstrated that both SPAI subscales and the total score are significantly different in a
clinical and community sample of youngsters [60]. Examining the psychometrics of sev-
eral social anxiety measures in Spain, differences between SP and non-SP adolescents also
emerged [37].
The Social Phobia and Anxiety Scale for Children (SPAI-C)
Starting from the initial SPAI, Beidel, Turner and Morris [27] subsequently developed the
SPAI-C. This is an empirically derived self-report measure design to assess the somatic,
cognitive and behavioral symptoms of child social phobia. The 26 items that assess young-
sters’ responses require a third-grade reading level. Socially anxious children displayed
higher total SPAI-C scores compared to normal controls [27]. In a similar study, Epkins [63]
found that SP diagnosed children scored higher than community children on the SPAI-C.
Subsequently, it was demonstrated that children with three anxiety diagnoses were signifi-
cantly more likely then children with two diagnoses, and children with SP only to display
more social anxiety symptoms [64]. High correlations between SPAI-C and other measures of
SP were found [27, 29–31, 64–66]. Finally, normative data based on several large and
representative samples (including clinical and nonclinical youth) are available [26–30, 66],
with a sensitivity between 70 and 91 % for the cut-off score of 18. Consequently, we consider
the SPAI-C a sensitive screening measure for youngsters’ SP symptoms.
The Social Anxiety Scale for Children–Revised (SASC-R)
The SASC-R [33] was designed to measure children’s subjective experience of social
anxiety in situations involving contact with their peers. The discriminative accuracy of the
SASC-R was investigated in two different studies [35, 67]. In both studies children in the
socially anxious group reported higher SASC-R scores compared with children in non-
socially anxious group. These two independent studies (conducted in the US and in
Norway) support the effectiveness of the SASC-R as a screening instrument.
The Social Anxiety Scale for Adolescents (SAS-A)
The SAS-A [36] is a modified version of the SASC-R for the use of adolescents. It was
demonstrated that the scale discriminates between socially anxious and non-anxious
Spanish adolescents [37]. In another study, significant differences were observed across
levels of symptom endorsement (i.e., social anxiety) for both the original SAS-A scale (18
Child Psychiatry Hum Dev
123
Author's personal copy
Tab
le3
Rat
ing
of
inst
rum
ents
use
dfo
rsc
reen
ing
Inst
rum
ent
nam
eN
orm
sR
elia
bil
ity
Val
idit
yV
alid
ity
gen
eral
izat
ion
Tre
atm
ent
sensi
tivit
yC
linic
alu
tili
tyH
ighly
reco
mm
ended
Inte
rnal
con
sist
ency
Tes
t–re
test
reli
abil
ity
Co
nte
nt
val
idit
yC
on
stru
ctv
alid
ity
SP
AI
GE
AE
GG
GG
4
SP
AI-
CE
EG
EG
EE
E4
SA
SC
-RG
GU
GG
GG
G
SA
S-A
EE
AA
GE
EE
4
SP
INE
EA
GG
EG
G4
LS
AS
-CA
GE
AE
GE
GG
So
Ph
IA
EA
GG
AU
A
QID
AG
EA
GG
GU
A
SP
SQ
-CL
AA
LA
GA
LA
UA
Th
efi
rst
auth
or
and
acl
inic
alp
sych
olo
gis
tex
per
ience
din
chil
dan
dad
ole
scen
tas
sess
men
tra
ted
all
inst
rum
ents
.F
or
the
scre
enin
gin
stru
men
tsp
rese
nte
din
Tab
le3
we
fou
nd
a9
0.3
8%
con
cord
ance
bet
wee
nth
etw
ora
ters
SP
AI
So
cial
Ph
ob
iaan
dA
nx
iety
Inv
ento
ry[2
0],
SP
AI-
CS
oci
alP
ho
bia
and
An
xie
tyIn
ven
tory
for
Ch
ild
ren
[24],
SA
SC
-RS
oci
alA
nx
iety
Sca
lefo
rC
hil
dre
n–
Rev
ised
[30],
SA
S-A
So
cial
An
xie
tyS
cale
for
Ad
ole
scen
ts[3
3],
SP
INS
oci
alP
hob
iaIn
ven
tory
[37
],L
SA
S-C
AL
iebo
wit
zS
oci
alA
nx
iety
Sca
lefo
rC
hil
dre
nan
dA
do
lesc
ents
[43],
So
PhI
So
cial
Ph
ob
iaIn
ven
tory
[48],
QID
AQ
ues
tionnai
reab
out
Inte
rper
sonal
Dif
ficu
ltie
sfo
rA
dole
scen
ts[5
2],
SP
SQ
-CS
oci
alP
hobia
Scr
eenin
gQ
ues
tionnai
refo
rC
hil
dre
n[5
6]
Ra
tin
gs:
Eex
cell
ent,
Gg
oo
d,
Aad
equat
e,L
Ale
ssth
anad
equ
ate,
Uunav
aila
ble
Child Psychiatry Hum Dev
123
Author's personal copy
items) as well as for a shorter version (with only 13 items; [68]). After using the ADIS-
IV-SP to evaluate the clinical condition of Spanish adolescents, the SAS-A predictive
proprieties were investigated. Results demonstrated that the scale is a significant predictor
of the SP diagnostic status [69]. Convergent validity data indicate high correlations
between SAS-A and SPAI-C [63, 66]; SPAI [37]; SAS-A [38, 68]. Finally, normative data
based on large samples were provided [37, 39, 69], with a recommended cut-off score
between 50 and 54 [36]. These data support the use of SAS-A as a social anxiety screening
instrument in adolescence.
The Social Phobia Inventory (SPIN)
The SPIN [40] is a 17-item self-report measuring fear in social situations, avoidance of
performance/social events, and physiological discomfort in social situations. Although the
SPIN was developed for adults, it was frequently used with adolescents [42, 44, 45, 70, 71].
In Connor’s [40] initial study the SPIN scores of SP individuals were compared with the
scores of non-psychiatric controls and a significant difference emerged. A score of 19 was the
recommended as a cut-off value that distinguished participants with and without SP, dis-
playing a diagnostic accuracy of 79 % [40]. The scale’s power to distinguish between SP
diagnosed adolescents (assessed with the ADIS-IV) and controls received further empirical
support [70]. The SPIN was used as a screening instrument for adolescents in Finland [42, 71];
China/Taiwan [44]; and Spain [45]. Discriminative validity was established in all three
cultures, as the SPIN scores differentiated adolescents with SP from controls/other anxiety
disorders. Excellent normative data are available [40, 42–45]. SPIN also demonstrated high
correlation with other SP measures (i.e., LSAS-CA [40]; SPAI [45]; SPAI-C [45, 66]; SAS-A
[70]). Taken together, these results are important in that they support both the convergent and
discriminant validity of the SPIN in more than one culture, favoring its diagnostic utility.
The Liebowitz Social Anxiety Scale for Children and Adolescents (LSAS-CA)
The LSAS-CA [46] was downwardly developed from its adult version. The resulting
clinician-rating scale measures both anxiety and avoidance. Although the LSAS-CA was
not designed as a diagnostic instrument, two studies—conducted by the same research
team—report both discriminant validity and normative data [46, 65]. Convergent validity
data demonstrate high correlations between LSAS-CA and SPAI/SPAI-C [46, 65], and
SIAS [47]. Up-to-date, only one study reports normative data based on a large, nonclinical
sample [47]. For an instrument to be evidence based, the EBA requires proven scientific
support obtained by more than one research team and in more than one context. As a result,
based on the existing evidence no firm conclusion can be drawn now regarding the
empirical support of LSAS-CA as a valid screening instrument.
Because of the limited number of available studies, we will not further detail the
discriminant validity data for the other youth social anxiety scales included in this review.
Overall Evaluation and Recommendations
Investigating the empirical support of youth screening rating scales for SP, we identified a
number of measures that accumulated a solid scientific support. While reviewing the
evidence, we noticed three studies that directly compared the screening power of the SPAI-
C and SAS-A/SASC-R [30, 66, 69]. In all studies, the SPAI-C has proven a better
screening tool, being able to accurately identify youngsters with SP. It would have been
Child Psychiatry Hum Dev
123
Author's personal copy
Tab
le4
Rat
ing
of
inst
rum
ents
use
dfo
rtr
eatm
ent
ou
tco
me
Inst
rum
ent
nam
eN
orm
sR
elia
bil
ity
Val
idit
yV
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Child Psychiatry Hum Dev
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useful to have more such studies, with two or more instruments directly compared and
analyzed in the same context.
Summarizing, the SPAI-C and the SPIN were the two measures that accumulated the
strongest support as screening instruments for youth SP. That is why we highly recommend
them as empirically proven tools for identifying social anxiety and social phobia symptoms
in children and adolescents. The SAS-A/SASC-R have also been proven reliable screeners,
with SAS-A having a wider empirical support. However, according to our evaluation, they
are only the third choice when it comes to identifying SP symptoms. We should note that
these scales were designed to detect fear of negative evaluations, and social avoidance and
distress. If researchers and practitioners intend to screen youngsters for these specific
components, then SAS-A is the instrument of choice. If the purpose of assessment is to
identify undetected or unreported SP or to detect youth at risk, then the SPAI-C (for
children) and the SPAI/SPIN (for adolescents) are recommended. Finally, the scientific
data for the new generation of scales like SPSQ-C and SoPhI (which use items derived
from the DSM-IV) are still in their infancy, and future studies might prove their efficacy.
Assessment for Treatment Outcome
When clinicians evaluate the impact of a given treatment procedure, they can monitor the
outcome (i.e., the patients’ symptoms), and/or the therapeutic process (i.e., the mechanisms
of change, the therapeutic relationship; [18]. When it comes to SP interventions for
youngsters, most studies compare anxiety levels at the beginning and at the end of the
treatment. Consequently, we will examine the long-term outcome evidenced by the various
SP rating scales for youth. We only selected the scales that were specifically designed to
assess treatment outcome. If designed for more than one purpose, the same scale was rated
twice, explaining the partial overlap in our analysis. We summarized the psychometric
proprieties, and the empirical support accumulated by the treatment outcome rating scales
in Table 4. According to our analysis, the final column indicates the best treatment out-
come scales now available in the literature (i.e., highly recommended).
The Social Phobia and Anxiety for children (SPAI-C)
One of the first studies where the SPAI-C was selected as an outcome measure compared
Social Effectiveness Therapy for Children (SET-C) with a test-taking strategy program
(i.e., Testbusters) [72]. The SPAI-C yielded a large effect sizes (d = 1.24) for the SET-C
group, while a low effect size (d = 0.22) was observed for the Testbusters. The majority of
SET-C positive changes as measured by the SPAI-C were maintained three [73] and
5 years later [74]. The SPAI-C was used in another intervention study examining the
efficacy of the Skills for Academic and Social Success (SASS) program delivered in
schools. Compared to wait-list participants, the intervention group reported fewer social
phobia symptoms [75]. The SPAI-C also captured the changes in children’s social anxiety
levels occasioned by a different, but similar intervention [76]. Moreover, the SPAI-C was
one of the primary outcome measures in a prevention program in Norway [77] and a new
CBT intervention in Germany [32]. Compared to children in the wait-list group, children
who benefited from either the prevention or the treatment program showed a greater
decrease of SP symptoms on the SPAI-C. Similarly, the SPAI-C was proven sensitive to
the treatment changes in other studies [53, 54, 78–82].
Taken together, the above-mentioned empirical data strongly support the use of the
SPAI-C as a reliable and sensitive treatment outcome measure. Not only that we identified
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an impressive number of studies, but these studies were conducted by different research
teams. Moreover, children from various cultures who benefited of diverse interventions
showed significant changes in their SPAI-C scores.
The Social Anxiety Scale for Children Revised (SASC-R) and the Social Anxiety Scalefor Adolescents (SAS-A)
Because of the highly similar wording and identical structure, the treatment sensitivity data
pertaining to the SASC-R and SAS-A will be reviewed together. The SAS-A proved sensitive
to the changes occasioned by three treatment programs [81]. When the effect sizes were
computed, all three interventions yielded high coefficients [83]. Moreover, in a follow up
study conducted 5 years latter the effect size remained high [61]. In another study, self-
reported social anxiety (SAS-A) was significantly lower for the intervention group when
compared to the control group [76]. Similarly, Herbert et al., [80] found that his CBT group
displayed a significant decline in the social anxiety symptoms for both self-report (d = 1.14)
and parent-report (d = 0.76) versions of the SASC-R. Finally, when the SASC-R scores were
followed after two similar interventions, notable improvements were observed [82].
As a whole, these empirical data suggest that both the SASC-R and the SAS-A represent
good outcome measures of social anxiety symptoms. The two scales could be implemented
especially when clinicians or researchers intend to capture the evolution of the cognitive
and behavioral components of social anxiety as a function of various interventions.
The Social Phobia Inventory (SPIN)
Using more than one sample of socially phobic adults, Connor [40] reported preliminary
data about the SPIN’s treatment sensitivity. In another study, involving socially phobic
youth, the SPIN was administered both before and after a CBT intervention [45]. The total
SPIN score was significantly lower at post-test when compared to the pretest. However,
this was the only youth study providing treatment sensitivity data for the SPIN. Although
SPIN’s treatment sensitivity was already demonstrated with adult population [84], we still
need more studies to firmly support the treatment sensitivity with adolescents.
The Leibowitz Social Anxiety Scale for Children and Adolescents (LSAS-CA)
Wagner et al. [54] conducted one of the first multicenter, pharmacological trials for
socially anxious youth. Results showed that children in the paroxetine group displayed
grater reduction in LSAS-CA total score, revealing a statistically significant benefit of
paroxetine over placebo [54]. The LSAS-CA was also selected as the main outcome
measure by Masia-Warner et al. [75]. Likewise, the LSAS-CA total scores decreased
significantly as a function of this intervention (d = 0.77) [75]. Although a limited number
of studies selected the LSAS-CA as a treatment outcome measure, the obtained data
support the use of this scale as a treatment outcome instrument.
The Kutcher Generalized Social Anxiety Disorder Scale for Adolescents (K-GSADS-A)
This scale is a clinician rated instrument for assessing SP in youth [53]. It is divided in
three sections, containing 29 statements and 3-filler items. The KGSADS-A was used to
estimate the treatment outcome in two similar trials [53, 54]. In both studies, the
K-GSADS-A proved to be sensitive to the treatment changes, as statistically significant
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benefits of paroxetine over placebo were reported. However, the evident similarities
between the two articles does not yet allow us to consider the K-GSADS-A as an evidence
based instrument for measuring treatment outcome, as a greater number of diverse studies
are needed for this purpose.
Because of the limited number of available studies, we will not detail further the
treatment outcome data for the other youth social anxiety scales included in this review.
Overall Evaluation and Recommendations
When it comes to evaluating the treatment outcome of SAD interventions for youth, the
strongest support was accumulated by the SPAI-C, whose sensitivity to therapy changes
was repeatedly demonstrated. That is why we highly recommend it, as most intervention
studies conducted until now reported positive results. A substantial empirical support was
accumulated by the SAS-A, with the self-report version being more sensitive to treatment
changes than the parent-report version. Among the clinician rating scales, the LSAS-CA is
one of the best options for estimating treatment outcome. The emerging K-GSADS-A
seems a promising instrument, but more research is needed until this—and other instru-
ments (e.g. SPIN)—will be considered evidence based for SP youth.
Discussions and Recommendations
The psychometric characteristics of the most widely used social anxiety rating scales for
children and adolescents were extensively investigated. Overall, our intention was to
advance the state of EBA by: (a) drawing researchers attention to the rating scales that
could legitimately be considered for a specific assessment purpose, (b) offering practi-
tioners the opportunity to select the most relevant instruments in a specific context,
(c) informing test developers about the present state of their scales, (d) encouraging the
international availability and use of validated scales, and (e) suggesting a reliable way for
the development of future evidence based measures. Specifically, we offered an overview
about the scientific support accumulated by the rating scales used with socially anxious or
socially phobic youth. We also provided an extensive summary of both well established
and new rating scales in an effort to advance the field of clinical child psychology. Since a
considerable number of rating scales are available on the scientific market, and little
consensus regarding their efficacy is to be found, we intended to cover that gap. Our main
results are consistent with recent reviews that considered the SPAI-C and the SAS-A
among the most pertinent and empirically supported measures of social anxiety for
youngsters [19, 22, 85]. However, after considering the existing evidence, we highly
recommended another couple of scales that proved to be empirically supported (i.e., SPIN,
LSAS-CA).
All of the recommended SP youth rating scales demonstrated excellent internal con-
sistency, with a C 0.90 in most of the studies (see Table 2). Regarding the test–retest
reliability, the evidence indicated preponderance of correlations above .70 over a period of
2 weeks for the highly recommended scales, which we evaluated as only adequate. When it
comes to content validity, we found independently replicated evidence for both criterion
and construct validity. The empirical data suggest that the SPAI-C, SAS-A and SPIN
reliably differentiate between youth with and without an SP diagnosis (i.e., with a sensi-
tivity of 70–91 % for SPAI-C, 43–89 % for SAS-A, and 71–80 % for SPIN). Finally, the
empirical data support the recommended scales’ sensitivity to track treatment outcome
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(i.e., pre- to posttest d = [0.68; 2.75] for SPAI-C, d = [0.79; 2.26] for SAS-A, and
d = 0.77 for LSAS-CA), with SPAI-C and SAS-A demonstrating treatment sensitivity
across different types of interventions.
Although we reviewed both self- and clinician-rated SP scales for youth, we did not
focus on omnibus anxiety measures, behavioral avoidance tests, social skills instruments,
or diagnostic interviews. In this respect, our review serves just a partial role, offering
information only about the empirical support accumulated by social anxiety rating scales
for youth. Other sources provide valuable information about the empirical support of
different anxiety measures for youngsters, including clinical interviews, omnibus anxiety
measures [19], or social skill measures [20]. Moreover, we have not emphasized the
assessment process (i.e., how various measures are used), but rather our discussion focused
on evidence-based methods per-se. We chose this approach in part because measures are
more easily identified and the assessment literature emphasizes their psychometric
proprieties.
In this context, a wider perspective, in which not only separate instruments, but also
assessment protocols are examined for their empirical support might be useful. An
assessment protocol is a coherent strategy that incorporates a wide range of instruments
designed for the same assessment purpose [84]. It is true that assessment protocols are
based on individually sound measures, but they could offer more than partial data, as the
emphasis is on multimodal assessment. However, up-to-date it is unknown whether
assessment protocols significantly increase our potential to make informed judgments, and
it is unclear how individual assessment techniques should be combined in order to provide
useful and valid data (i.e., to our best knowledge no study examining the empirical support
of assessment protocols for SP youth was published). Consequently, we join other
researchers [84] who advocate the need of further research in this area, as assessment
protocols might be potentially useful in the future.
One more comment regarding the names of the scales is still needed. Researchers
should propose different names for their new measures, otherwise unnecessary confusion
could be created. We identified different scales with the same name, as the same label was
used for two dissimilar scales. For example, the name Social Anxiety Scale for Adolescentscorresponds to both La Greca and Lopez’s scale [36] and to Puklek and Vidmar’s scale
[50]. Likewise, the name Social Phobia Inventory was used by both Connors et al. [40],
and Moore and Gee [51]. The authors who published their papers at a latter time should
have adopted a different name for their scale, in order to avoid confusions. Furthermore,
before accepting an original paper proposing a new instrument, reviewers should check to
see whether the exact same name was already used in the literature.
Finally, despite the consistent efforts to promote the EBA, a wide gap between theory
and practice remains. How assessment instruments are utilized by clinical child psychol-
ogists in their daily practice is largely unknown. Because of their previous training or the
endorsed theoretical models, clinicians could frequently adopt measures with little or no
empirical support, while evidence-based measures are underutilized. Moreover, selecting
the most appropriate scale for achieving a specific purpose is just one part of the assess-
ment process, but definitely not enough to ensure an evidence-based result. The respon-
sibility and professionalism involved in the other aspects of assessment (i.e., the
assessment process, integrating multiple sources and perspectives) are crucial when it
comes to the evidence based assessment. Therefore, as Hunsley and Mash [6] noted, the
major challenge faced by both researchers and practitioners is to adopt an evidence-based
framework when both the interventions and assessments are implemented.
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Summary
As an integral part of the evidence based paradigm, the evidence based assessment (EBA)
approach investigates the empirical support of various psychological measures. It was
designed to investigate what makes assessment instruments reliable, and also to classify
their evidence. Its aim is to provide a scientifically grounded modality to determine the best
instruments to be used in specific contexts. As a result, the EBA offers the empirical
arguments for selecting and promoting the assessment instruments that present the highest
support. In their attempt to specify the minimal evidence needed for assessment instruments
Hunsley and Mash [6] were among the first scientists to provide a general set of criteria
against which to evaluate specific measures. This rating system takes into account the
specificity of each disorder, sample, and assessment purpose. It was previously employed to
provide indicators of scientifically strong measures in a wide range of situations [6, 18, 19].
Utilizing this evaluative framework, in the current article we critically reviewed the rating
scales designed to measure social anxiety or phobia in youth. The psychometric charac-
teristics of 13 social phobia rating scales were extensively investigated. After carefully
analyzing the evidence, we rendered the SPAI-C and the SAS-A as the most empirically
supported measures of youngsters’ social anxiety. Our results are consistent with previously
obtained data [19, 22, 85]. However, the existing evidence suggests that another couple of
scales (i.e., SPIN, LSAS-CA) recently gained a solid empirical support. In the future,
scientists should continue to investigate the empirical support that rapidly becomes avail-
able in the literature, as the data regarding different measurement instruments keeps
growing. This approach not only allows the new generation of sound measures to gain an
empirically based status, but also helps researchers and practitioners alike to make informed
decisions when selecting the optimal assessment tool for their specific purposes.
Acknowledgments This work was possible with the financial support of the Sectoral Operational Pro-gramme for Human Resources Development 2007–2013, co-financed by the European Social Fund, underthe project number POSDRU 89/1.5/S/60189 with the title ‘‘Postdoctoral Programs for SustainableDevelopment in a Knowledge Based Society’’. We would also like to express our gratitude for the valuableinput offered by [Ramona Moldovan] in rating all the assessment instruments presented in Tables 3 and 4.
Appendix
See Table 5.
Table 5 Rating criteria proposed by Hunsley and Mash ([6], p. 8, 9)
Norms
Adequate = Measures of central tendency and distribution for the total score (and subscores) based on alarge, relevant clinical sample are available
Good = Measures of central tendency and distribution for the total score (and subscores) based onseveral large, relevant samples (must include data from both clinical and nonclinical samples) areavailable
Excellent = Measures of central tendency and distribution for the total score (and subscores) based onone or mere large, representative samples (must include data from both clinical and nonclinicalsamples) are available
Internal consistency
Adequate = Preponderance of evidence indicates a values of .70–79
Good = Preponderance of evidence indicates a values of .80–89
Excellent = Preponderance of evidence indicates a values greater than .90
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Table 5 continued
Test–retest reliability
Adequate = Preponderance of evidence indicates test–retest correlations of at least .70 over a period ofseveral days or weeks
Good = Preponderance of evidence indicates test–retest correlations of at least .70 over several month
Excellent = Preponderance of evidence indicates test–retest correlations of at least .70 over a year orlonger
Content validity
Adequate = The test developers clearly defined the domain of the construct being assessed and ensuredthat selected items were representative of the entire set of facets included in the domain
Good = In addition to the criteria used for adequate rating, all elements of the instrument (e.g.instruction, items) were evaluated by judges (e.g. by experts, by pilot research participants)
Excellent = In addition to the criteria used for good rating, multiple groups of judges were employedand quantitative ratings were used by the judges
Construct validity
Adequate = Some independently replicated evidence of construct validity (e.g. predictive validity,concurrent validity, and convergent and discriminant validity)
Good = Preponderance of independently replicated evidence, across multiple types of validity (e.g.predictive validity, concurrent validity, and convergent and discriminant validity) is indicative ofconstruct validity
Excellent = In addition to the criteria used for good rating, evidence of incremental validity with respectto other clinical data
Validity generalization
Adequate = Some evidence support the use of the instrument with either (a) more than one specificgroup (based on sociodemographic characteristics such as age, gender, ethnicity), or (b) in multiplecontexts (e.g. home, school, primary care settings, impatient settings)
Good = Preponderance of evidence support the use of the instrument with either (a) more than onespecific group (based on sociodemographic characteristics such as age, gender, ethnicity), or (b) inmultiple contexts (e.g. home, school, primary care settings, impatient settings)
Excellent = Preponderance of evidence support the use of the instrument with more than one specificgroup (based on sociodemographic characteristics such as age, gender, ethnicity), and in multiplecontexts (e.g. home, school, primary care settings, impatient settings)
Treatment sensitivity
Adequate = Some evidence of sensitivity to change over the course of treatment
Good = Preponderance of independently replicated evidence indicates sensitivity to change over thecourse of treatment
Excellent = In addition to the criteria used for good rating, evidence of sensitivity to change acrossdifferent types of treatment
Clinical utility
Adequate = Taking into account practical considerations (e.g. cost, ease of administration, availabilityof administration and scoring instruction, duration of assessment, availability of cut-off points,acceptability to patient) the resulting assessment data are likely to be clinically useful
Good = In addition to the criteria used for adequate rating, there is some published evidence that the useof the resulting assessment data confers a demonstrable clinical benefit (e.g. better outcome, lowerattrition rate, greater patient satisfaction)
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References
Note: References marked with an asterisk indicate studies included in this literature-review.
1. American Psychiatric Association (2000) Diagnostic and statistical manual of mental disorders, 4th edn.DSM-IV, Bucuresti
2. Rao PA, Beidel DC, Turner SM, Ammerman RT, Crosby LR, Sallee FR (2007) Social anxiety disorderin childhood and adolescence: Descriptive psychopathology. Behav Res Ther 45:1181–1191. doi:101016/jbrat200607015
3. Beidel DC, Turner SM, Morris T (1999) Psychopathology of childhood social phobia. J Am Acad ChildAdolesc Psychiatr 38:643–650
4. Khalid-Khan S, Santibanez M, McMicken C, Rynn M (2007) Social anxiety disorder in children andadolescents: epidemiology diagnosis and treatment. Paediatr Drugs 9:227–237 doi:1174-5878/07/0004-0227 Retrieved from http://wwwadolescenciasemaorg/ficheros/26345886pdf
5. Beidel DC, Turner SM (2007) Shy children, phobic adults—nature and treatment of social anxietydisorder, 2nd edn. American Psychological Association, Washington DC
6. Hunsley J, Mash EJ (2008) A guide to assessments that work. Oxford Univ Press, NY7. Mash EJ, Hunsley J (2005) Evidence-based assessment of child and adolescent disorders: Issues and
challenges. J Clin Child Adolesc Psychol 34:362–3798. Achenbach ThM (2005) Advancing assessment of children and adolescents: commentary on evidence-
based assessment of child and adolescent disorders. J Clin Child Adolesc Psychol 34:541–5479. Antony MM, Rowa K (2005) Evidence-based assessment of anxiety disorders in adults. Psychol Assess
17:256–266. doi:101037/1040-359017325610. Barlow D (2005) What’s new about evidence-based assessment? Psychol Assess 17:308–311. doi:
101037/1040-359017330811. Velting O, Setzer N, Albano A (2004) Update on the advances in assessment and Cognitive-Behavioral
Treatment of anxiety disorders in children and adolescents. Prof Psychol Res Pract 35:42–54. doi:101037/0735-702835142
12. Kazdin A (2005) Evidence-based assessment for children and adolescents: issues in measurementdevelopment and clinical application. J Clin Child Adolesc Psychol 34:548–558
13. Balon R (2005) Measuring anxiety: are we getting what we need? Depress Anxiety 22:1–1014. Clark DB, Feske U, Masia C, Spaulding S, Brown C, Mammen O, Shear K (1997) Systematic
assessment of social phobia in clinical practice. Depress Anxiety 6:47–6115. Brooks S, Kutcher S (2003) Diagnosis and measurement of anxiety disorder in adolescents: A review of
commonly used instruments. J Child Adolesc Psychopharmacol 13:351–400
Table 5 continued
Excellent = In addition to the criteria used for good rating, there is independently replicated publishedevidence that the use of the resulting assessment data confers a demonstrable clinical benefit
When applying Hunsley and Mash’s evaluative framework, we observed the authors’ original suggestions.For each psychometric propriety, a rating of adequate, good or excellent was applied if the specifiedconditions were met. For example, if most published studies report an a greater that .90 for a certain scale,then we rated that scale as excellent on internal consistency. The psychometric propriety ratings achieved bythe analyzed scales are displayed in the first 8 columns of Tables 3 and 4 in our review. Additionally, weexamined the empirical data that recommends a specific scale as a screener and/or treatment outcomemeasure. In this additional investigation, we also followed Hunsley and Mash’s suggestion to analyze theevidence presented in the literature. For example, when we reviewed the scales designed as screeners, weexamined their power to discriminate between clinical and nonclinical samples; and when we reviewed thescales design as treatment outcome measures, we examined their power to detect treatment effects. If wefound a preponderance of evidence in the expected direction, then we considered the recommendation ofthat specific scale. Finally, a scale was highly recommended if: (a) we found at least two studies (conductedby different research teams) where the scale was considered a reliable screener/treatment outcome measure,and (b) the scale achieved ratings of good or excellent in the majority of its rated psychometric proprieties.These data are summarized in the last, Highly recommended column of Tables 3 and 4
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16. Klein DN, Dougherty LR, Olino ThM (2005) Toward guidelines for evidence-based assessment ofdepression in children and adolescents. J Clin Child Adolesc Psychol 34:412–432
17. Silverman WK, Ollendick ThH (2005) Evidence-based assessment of anxiety and its disorder in chil-dren and adolescents. J Clin Child Adolesc Psychol 34:380–411
18. Person JB, Fresco DM (2008) Adult depression. In: Hunsley J, Mash EJ (eds) A guide to assessmentsthat work. Oxford Univ Press, NY, pp 96–120
19. Silverman WK, Ollendick ThH (2008) Child and adolescent anxiety disorders. In: Hunsley J, Mash EJ(eds) A guide to assessments that work. Oxford Univ Press, NY, pp 181–206
20. Matson JL, Wilkins J (2009) Psychometric testing methods for children’s social skills. Res Dev Disabil30:249–274. doi:101016/jridd200804002
21. Essau CA, Conradt J, Petermann F (1999) Frequency and comorbidity of social phobia and social fearsin adolescents. Behav Res Ther 37:831–843
22. Kearney CA (2005) Social anxiety and social phobia in youth Characteristics assessment and psy-chological treatment. Springer, New York
23. *Turner SM, Beidel DC, Dancu CV, Stamley MA (1989) An empirically derived inventory to measuresocial fears and anxiety: the Social Phobia and Anxiety Inventory. Psychol Assess J Consult ClinPsychol 1:35–40
24. Goldfried MR, D’Zurilla TJ (1969) A behavioral analytic model for assessing competence in CDSpilberger (Ed.). Current topics in clinical psychology (pp 151-196) NY Academic Press
25. *Olivares J, Garcia-Lopez LJ, Hidalgo MD, Turner SM, Beidel DC (1999) The Social Phobia andAnxiety Inventory: reliability and validity in an adolescent spanish population. J Psychopathol BehavAssess 21:67–78
26. *Olivares J, Vera-Villarroel P, Rosa-Alcazar AI, Kuhne W, Montesinos L, Lopez-Pina JA (2010) TheSocial Phobia and Anxiety Inventory: first results of the reliability and structural validity in chileanadolescents. Universitas Psychologica 9:149–160
27. *Beidel DC, Turner SM, Morris T (1995) A new inventory to assess childhood social anxiety andphobia—the Social Phobia and Anxiety Inventory for children. Psychol Assess 7:73–79
28. *Gauer GJC, Picon P, Vasconcellos SJL, Turner SM, Beidel DC (2005) Validation of the Social Phobiaand Anxiety Inventory (SPAI-C) in a sample of Brazilian children. Bras J Med Biol Res 38:795–800Retreived from http://www.scielobr/pdf/bjmbr/v38n5/5446pdf
29. *Aune T, Stiles T, Svarva K (2008) Psychometric properties of the Social Phobia and Anxiety Inventoryfor Children using a non-American population-based sample. J Anxiety Disord 22:1075–1086. doi:101016/jjanxdis200711006
30. *Kuusikko S, Pollock-Wurman R, Ebeling H, Hurting T, Joskitt L, Mattila M-L, Jussila K, Moilanen I(2009) Psychometric evaluation of the Social Phobia and Anxiety Inventory for children (SPAI-C) andsocial anxiety scale for children revised (SASC-R). Eur Child Adolesc Psychiatr 18:116–124. doi:101007/s00787-008-0712-x
31. *Olivares J, Sanchez-Garcia R, Lopez-Pina JA, Rosa-Alcazar AI (2010a) Psychometric proprieties ofthe Social Phobia and Anxiety Inventory for Children in a Spanish sample. Span J Psychol 13:961–969Retrieved from http://www ucmes/info/psi/docs/journal/v13_n2_2010/art961pdf
32. *Melfsen S, Kuhnemund M, Schwieger J, Warnke A, Stadler C, Poustka F, Stangier U (2011) Cognitivebehavioral therapy of socially phobic children focusing on cognition: a randomized wait-list controlstudy. Child Adolesc Psychiatr Ment Health 5:5 Retrieved from http://www.capmhcom/content/pdf/1753-2000-5-5pdf
33. *La Greca AM, Stone WL (1993) Social anxiety scale for children-revised: factor structure and con-current validity. J Clin Child Psychol 22:17–27
34. Watson D, Friend R (1969) Measurement of social-evaluative anxiety. J Consult Clin Psychol 33:448–457
35. *Kristensen H, Torgensen S (2006) Social anxiety disorder in 11–12-year-old children—the efficacy ofscreening and issues in parent-child agreement. Eur Child Adolesc Psychiatr 15:163–171. doi:101007/s00787-005-0519-y
36. *La Greca AM, Lopez N (1998) Social anxiety among adolescents: linkages with peer relations andfriendships. J Abnorm Child Psychol 26:83–94
37. *Garcia-Lopez LJ, Olivares J, Hidalgo MD, Beidel DC, Turner SM (2001) Psychometric properties ofthe Social Phobia and Anxiety Inventory the social anxiety scale for adolescents the fear of negativeevaluation scale and the social avoidance and distress scale in an adolescent spanish-speaking sample.J Psychopathol Behav Assess 23:51–59 Retrieved from http://www.4ujaenes/* ljgarcia/investig_archivos/Psycpropertpdf
Child Psychiatry Hum Dev
123
Author's personal copy
38. *Zhou X, Xu Q, Ingles CJ, Hidalgo MD, La Greca AM (2008) Reliability and validity of the Chineseversion of the social anxiety scale for adolescents. Child Psychiatr Hum Dev 39:185–200. doi:101007/s10578-007-0079-0
39. *Memik NK, Sismanlar SG, Yildiz O, Karakaya I, Isik C, Agaoglu B (2010) Social anxiety level inTurkish adolescents. Eur Child Adolesc Psychiatr 19:765–772. doi:101007/s00787-010-0119-3
40. *Connor K, Davidson J, Chirchill E, Sherwood A, Foa E, Weisler R (2000) Psychometric proprieties ofthe Social Phobia Inventory (SPIN)-a new self rating scale. Br J Psychiatr 176:379–386
41. *Vilete L, Figueira I, Coutinho E (2006) Portuguese-language cross-cultural adaptation of the SocialPhobia Inventory (SPIN) to be used with adolescent students. Revista de Psiquiatria do Rio Grande doSul 28:40–48. doi:101590/S0101-81082006000100006
42. *Ranta K, Kaltiala-Heino R, Koivisto AM, Tuomisto MT, Polkonen M, Marttunen M (2007) Age andgender differences in social anxiety symptoms during adolescence: the Social Phobia Inventory (SPIN)as a measure. Psychiatry Res 153:261–270. doi:101016/jpsychres200612006
43. *Sosic Z, Gieler U, Stangier U (2008) Screening for social phobia in medical in- and outpatients withthe German version of the Social Phobia Inventory (SPIN). J Anxiety Disord 22:849–859. doi:101016/jjanxdis200708001
44. *Tsai CF, Wang SJ, Juang KD, Fuh JL (2009) Use of the Chinese (Taiwan) version of the Social PhobiaInventory (SPIN) among early adolescents in rural areas: reliability and validity study. J Chin MedAssoc 72:422–429
45. *Garcia-Lopez LJ, Bermejo RM, Hidalgo MD (2010) The Social Phobia Inventory: screening andcross-cultural validation in spanish adolescents. Span J Psychol 13:970–980
46. *Masia-Warner C, Storch E, Pincus D, Klein R, Heinberg R, Leibowitz MR (2003) The Leibowitzsocial anxiety scale for children and adolescents: an initial psychometric investigation. J Am AcadChild Adolesc Psychiatr 42:1076–1084. doi:101097/01CHI00000702492412589
47. *Zubeidat I, Salinas JM, Sierra JC (2008) Exploration of the psychometric characteristics of theLiebowitz social anxiety scale in a Spanish adolescent sample. Depress Anxiety 25:977–987. doi:101002/da20404
48. *Mattick RP, Clarke C (1998) Development and validation of measures of social phobia scrutiny fearand social interaction anxiety. Behav Res Ther 36:455–470
49. *Zubeidat I, Salinas JM, Sierra JC, Fernandez-Parra C (2007) Psychometric proprieties of socialinteraction anxiety scale and separation criterion between Spanish youth with and without subtypes ofsocial anxiety. J Anxiety Disord 21:603–624
50. *Puklek-Levpuscek M, Vidmar G (2000) Social anxiety in Slovene adolescents: psychometric pro-prieties of a new measure age differences and relation with self-consciousness and perceived incom-petence. Eur Rev Appl Psychol 50:249–258
51. *Moore KA, Gee DL (2003) The reliability validity discriminant and predictive proprieties of the SocialPhobia Inventory (SoPhI). Anxiety Stress Coping 16:109–117. doi:101080/1061580021000057068
52. *Bermejo R, Garcia-Lopez LJ, Hidalgo M, Moore K (2011) The Social Phobia Inventory (SoPhI):validity and reliability in adolescent population. Anales de Psicologia 27:333–341 Retrieved fromhttp://www.revistasumes/analesps/article/view/122961/115591
53. Brooks S, Kutcher S (2004) The kutcher generalized social anxiety disorder scale for adolescents:assessment of its evaluative properties over the course of a 16-week pediatric psychopharmacotherapytrial. J Child Adolesc Psychopharmacol 14:273–286. doi:101089/1044546041649002
54. *Wagner K, Berard R, Stein M, Wetherhold E, Carpenter D, Perera P, Gee M, Davy K, Machin A(2004) A multicenter randomized double-blind placebo-controlled trial of paroxetine in children andadolescents with social anxiety disorder. Arch General Psychiatr 61:1153–1162 Retrieved from wwwarchgenpsychiatrycom
55. *Ingles C, Hidalgo M, Mendez F (2005) Interpersonal difficulties in adolescence: a new self-reportmeasure. Eur J Psychol Assess 21:11–22. doi:101027//1015-575921111
56. *Ingles C, Marzo JC, Hidalgo M, Zhou X, Garcıa-Fernandez J (2008) Factorial invariance of thequestionnaire about interpersonal difficulties for adolescents across Spanish and Chinese adolescentsamples. Meas Eval Couns Dev 41:89–103
57. *Zupancic M, Ingles CS, Bajec B, Levpuscek MP (2011) Reliability and validity evidence of scores onthe Slovene version of the questionnaire about interpersonal difficulties for adolescents. Child PsychiatrHum Dev. doi:101007/s10578-011-0218-5
58. *Cunha M, Gouveia J, Salvador M (2008) Social fears in adolescence: The Social Anxiety andAvoidance Scale for Adolescennce. Eur Psychol 13:197–213. doi:101027/1016-9040133197
59. *Gren-Landell M, Bjorklind A, Tillfors M, Furmark T, Svedin CG, Andersson G (2009) Evaluation ofthe psychometric proprieties of a modified version of the social phobia screening questionnaire for usein adolescents. Child Adolesc Psychiatr Mental Health 3:36. doi:1011861753-2000-3-36
Child Psychiatry Hum Dev
123
Author's personal copy
60. *Clark DB, Turner SM, Beidel DC, Donovan JE, Kirisci L, Jacob RG (1994) Reliability and validity ofthe Social Phobia Inventory for adolescents. Psychol Assess 6:135–140
61. *Garcia-Lopez LJ, Olivares J, Beidel DC, Albano AM, Turner SM, Rosa AI (2006) Efficacy of threetreatment protocols for adolescents with social anxiety disorder: a 5-year follow-up assessment.J Anxiety Disord 20:175–191. doi:101016/jjanxdis200711006
62. *Olivares J, Garcıa-Lopez LJ, Hidalgo MD, La Greca AM, Turner SM, Beidel DC (2002) A pilot studyon normative data for two social anxiety measures: the Social Phobia and Anxiety Inventory and thesocial anxiety scale for adolescents. Int J Clin Health Psychol 2:467–476
63. *Epkins CC (2002) A comparison of two self-report measures of children’s social anxiety in clinic andcommunity samples. J Clin Child Adolesc Psychol 31:69–79
64. *Viana A, Rabian B, Beidel DC (2008) Self-report measures in the study of comorbidity in children andadolescents with social phobia: Research and clinical utility. J Anxiety Disord 22:781–792. doi:101016/jjanxdis200708005
65. *Storch EA, Masia-Warner C, Heidgerken AD, Fisher PH, Pincus DB, Liebowitz MR (2006) Factorstructure of the liebowitz social anxiety scale for children and adolescents. Child Psychiatr Hum Dev37:25–37. doi:101007/s10578-006-0017-6
66. *Inderbitzen-Nolan HM, Davies CA, McKeon ND (2004) Investigating the construct validity of theSPAI-C: comparing the sensitivity and specificity of the SPAI-C and the SAS-A. J Anxiety Disord18:547–560. doi:101016/S0877(03)00042-2
67. *Ginsburg GS, La Greca AM, Silverman W (1998) Social anxiety in children with anxiety disorders:Relation with social and emotional functioning. J Abnorm Child Psychol 26:175–185
68. *Myers MG, Stein MB, Aarons GA (2002) Cross validation of the social anxiety scale for adolescents ina high school sample. J Anxiety Disord 16:221–232
69. *Olivares J, Garcıa-Lopez LJ, Hidalgo MD, Caballo V (2004) Relationship among social anxietymeasures and their invariance: a confirmatory factor analysis. Eur J Psychol Assess 20:172–179. doi:101027/1015-5759203172
70. *Johnson HS, Inderbitzen-Nolan HM, Anderson ER (2006) The Social Phobia Inventory: validity andreliability in an adolescent community sample. Psychol Assess 18:269–277. doi:101037/1040-3590183269
71. *Ranta K, Kaltiala-Heino R, Rantanen P, Tuomisto MT, Marttunen M (2007) Screening social phobia inadolescents from general population: the validity of the Social Phobia Inventory (SPIN) against aclinical interview. Eur Psychiatr 22:244–251. doi:101016/jeurpsy200612002
72. *Beidel DC, Turner SM, Morris T (2000) Behavioral treatment of childhood social phobia. J ConsultClin Psychol 68:1072–1080. doi:101037/0022-006X6861072
73. *Beidel DC, Turner SM, Young B, Paulson A (2005) Social effectiveness therapy for children: three-year follow-up. J Consult Clin Psychol 73:721–725. doi:101037/0022-006X734721
74. *Beidel DC, Turner SM, Young B (2006) Social effectiveness therapy for children: five years latter.Behav Ther 37:416–425
75. *Masia-Warner C, Klein RG, Dent HC, Ficher PH, Alvir J, Albano AM, Guardino M (2005) School-based intervention for adolescents with social anxiety disorder: results of a controlled study. J AbnormChild Psychol 33(6):707–722
76. *Masia-Warner C, Ficher PH, Shrout PE, Rathor S, Klein RG (2007) Treating adolescents with socialanxiety disorder in school: an attention control trial. J Child Psychol Psychiatr 48:676–686. doi:101111/j1469-7610200701737x
77. *Aune T, Stiles T (2009) Universal-based prevention of syndromal and subsybdromal social anxiety: arandomized controlled study. J Consult Clin Psychol 77:867–879. doi:101037/a0015813
78. *Ferrell CB, Beidel DC, Turner SM (2004) Assessment and treatment of socially phobic children-across cultural comparison. J Clin Child Adolesc Psychol 33:260–268
79. *Gallagher HM, Rabian BA, McCloskey MS (2004) A brief group cognitive-behavioral intervention forsocial phobia in childhood. J Anxiety Disord 18:459–479. doi:101016/S0887-6185(03)00027-6
80. *Herbert JD, Gaudiano BA, Reingold AA, Moitra E, Myers VH, Dalrymple KL, Brandsma LL (2009)Cognitive behavior therapy for generalized social anxiety disorder in adolescents: a randomized con-trolled trial. J Anxiety Disord 23:167–177. doi:101016/jjanxdis200806004
81. *Olivares J, Beidel DC, Turner SM, Albano AM, Hidalgo MD (2002b) Results at long term amongthree psychological treatments for adolescents with generalized social phobia (I): statistical significance.Psicologia Conductal 10:147–164 Retrieved from http://www 4ujaenes/*ljgarcia/investig_archivos/tesis1pdf
82. *Sanchez-Garcia R, Olivares J (2009) Effectiveness of a program for early detection/intervention inchildren/adolescents with generalized social phobia. Anales de Psicologia 25:241–249 Retreived fromhttp://www.revistasumes/analesps/article/view/87521/84281
Child Psychiatry Hum Dev
123
Author's personal copy
83. *Garcia-Lopez LJ, Olivares J, Turner SM, Beidel DC, Albano AM, Sanchez-Meca J (2002) Results atlong-term among three psychological treatments for adolescents with generalized social phobia (II):clinical significance and effect size. Psicologia Conductal 10:371–385 Retrieved from http://www.4ujaenes/*ljgarcia/investig_archivos/tesis2pdf
84. Rowa K, McCabe RE, Antony M (2008) Specific phobia and social phobia. In: Hunsley J, Mash EJ(eds) A guide to assessments that work. Oxford Univ Press, NY, pp 207–228
85. *Ingles C, La Greca AM, Marzo J, Garcia-Lopez LJ (2010) Social anxiety scale for adolescents:factorial invariance and latent mean differences across gender and age in spanish adolescents. J AnxietyDisord 24:847–855. doi:101016/jjanxdis201006007
Child Psychiatry Hum Dev
123
Author's personal copy