Evidence based clinical assessment of child and adolescent social phobia: A critical review of...

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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: [email protected]

A. Dobreane-mail: [email protected]

D. Davide-mail: [email protected]

A. SzentagotaiDepartment of Psychology, Babes-Bolyai University, Cluj-Napoca, Romaniae-mail: [email protected]

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Child Psychiatry Hum DevDOI 10.1007/s10578-012-0297-y

Author's personal copy

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.

Child Psychiatry Hum Dev

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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


123


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


123


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123


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123


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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


123


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


123


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]


123


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


123


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


123


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


123


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

alid

ity

gen

eral

izat

ion

Tre

atm

ent

sensi

tivit

yC

linic

alu

tili

tyH

ighly

reco

mm

ended

Inte

rnal

consi

sten

cyT

est–

rete

stre

liab

ilit

yC

onte

nt

val

idit

yC

onst

ruct

val

idit

y

SP

AI

GE

AE

GG

GG

SP

AI-

CE

EG

EG

EE

E4

SA

SC

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123


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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Evidence based clinical assessment of child and adolescent social phobia: A critical review of...

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