Comparison of DSM-III Separation Anxiety and Overanxious Disorders: Demographic Characteristics and Patterns of Comorbidity

Comparison of DSM-III Separation Anxiety and Overanxious Disorders: Demographic Characteristics and Patterns of Comorbidity CYNTHIA G. LAST, PH.D., MICHEL HERSEN, PH.D., ALAN E. KAZDIN, PH.D., RICHARD FINKELSTEIN, PH.D., AND CYD C. STRAUSS, PH.D. Abstract. In an initial empirical evaluation of the DSM-III diagnostic categories of separation anxiety disorder (SAD) and overanxious disorder (OAD), the demographic characteristics and patterns of comorbidity associated with the two anxiety diagnoses were examined and compared in a clinical sample of 69 children and adolescents. The two anxiety disorders differed on several dimensions: age, social class, and presence of a coexisting anxiety disorder. Children with SAD were younger and from families of lower socioeconomic status than children with OAD. Children with OAD were much more likely than children with SAD to present with an additional concurrent anxiety disorder, usually simple phobia or panic disorder. Results from this study support the DSMIII distinction between SAD and OAD. J. Amer. Acad. Child Adol. Psychiat., 1987,26,4:527-531. Key Words: separation anxiety disorder, overanxious disorder.

Separation anxiety disorder (SAD) and overanxious disorder (OAD) are two childhood anxiety disorders that have received very little research attention. Over the years, the clinical literature in this area has supported the existence of SAD (Bowlby, 1973; Eisenberg, 1968; Johnson et al., 1941; Kanner, 1957) and OAD (Hewitt and Jenkins, 1946; Jenkins, 1964, 1969; Suh and Carlson, 1977) as distinct syndromes. As a result, both disorders have been included in the most recent version of the DSM. However, both before and after the publication of DSM-I1I, virtually no empirical investigations have been published on the characteristics of children with these disorders. Before DSM-I1I, numerous studies had examined the clinical features and correlates of "school phobia." Indeed, several of these investigations included fairly large samples of children who were assessed on multiple dimensions (Baker and Wills, 1978; Berg, 1980; Berg et al., 1969; Hersov, 1960). However, as investigators in this area previously have noted, not all children with school phobia show separation anxiety problems, nor do all children with SAD exhibit school refusal (Gittelman, 1983;Ollendick and Mayer, 1985).Thus, findings from studies of school phobic children cannot be generalized a priori to the population of youngsters with SAD. Since the publication of DSM-I1I, only two studies have reported any information on children with SAD or OAD (Bernstein and Garfinkel, 1986; Hershberg et al., 1982). Both of these studies addressed the specific question of overlap between anxiety and depressive disorders in children and thus limited their assessment to the presence or absence of depressive symptomatology. Moreover, very small numbers of anxious children (N -s 16) were included in each of these investigations. Although the current DSM-I1I conceptualization of SAD and OAD is consistent with the clinical literature, empirical evaluation of the diagnostic categories has yet to appear. In light of this gap in the empirical literature, we have been conducting a large scale investigation of the two childhood

anxiety disorders in order to determine their characteristics, correlates, and discriminative validity. In this first report, the demographic characteristics and patterns of comorbidity associated with SAD and OAD were examined and compared in a clinical sample of 69 children and adolescents. The report addresses three main questions: (I) What are the demographic features of SAD and OAD? (2) What other DSM-I1I disorders are associated with SAD and OAD? (3) Can SAD and OAD be distinguished by their demographic features and/or associated disorders? Method

Sample

During an 18-month period (September 1984 through February 1986), 91 children were evaluated in the Child and Adolescent Anxiety Disorder Clinic at Western Psychiatric Institute and Clinic. The clinic sees children and adolescents, ages 5 to 18, who are referred for anxiety problems. Patients were interviewed by one of the investigators (c. G. L., R. F., or C. C. S.) using the Interview Schedule for Children (lSC) (Kovacs, 1978, 1983a), which is a semistructured, symptomoriented psychiatric interview based on DSM-I1Icriteria. This particular diagnostic instrument was selected based on previous research that had shown high levels of interrater agreement for anxiety symptoms (Kovacs, 1983b). Based on the interviews, a total of 69 children (76%) met DSM-I1I criteria for either SAD (N = 22), OAD (N = 26), or both SAD + OAD(N= 21).

Diagnostic Reliability

During the first 12 months of the study period, we evaluated the reliability of diagnosing the two DSM-I1Ianxiety disorders using the ISC. Interviews were conducted using a counterbalanced short-term test-retest reliability paradigm (Grove et al., 1981). The test-retest method (i.e., two different interviewers conducting separate evaluations) was selected because it is considered to be the most stringent test of reliability. A short time interval between interviews (i.e., morning-afternoon) was chosen in order to minimize the likelihood of patient change over time. Children and adolescents were interviewed and diagnosed separately by two of the investigators (C. G. L. and R. F.). Kappa coefficients and percentage of agreement were computed for each of the two anxiety diagnoses: SAD (N = 28) -

Received April 15. 1986: revised July 21. 1986: accepted September 3.1986. From the Department of Psychiatry. Western Psychiatric Institute and Clinic. University of Pittsburgh School of Medicine. Pittsburgh. Pennsylvania. Reprint requests to Dr. Last. Western Psychiatric Institute and Clinic. 38/l O'Hara si. Pittsburgh. PA 152/3. 0890-8567/87/2604-O527$02.00/0© 1987 by the American Academy of Child and Adolescent Psychiatry. 527

528 K

LAST ET AL.

= 0.81 (S.E. = 0.12), percentage of agreement = 91; OAD = 32) - K = 0.82 (S.E. = 0.12), percentage of agreement

(N

= 91. Reliability also was calculated for subjects who had only one versus both anxiety disorders: SAD only (N = 12) - K = 0.77 (S.E. = 0.10), percentage of agreement = 91; OAD only (N = 16) - K = 0.96 (S.E. = 0.12), percentage of agreement = 99, both SAD + OAD (N = 16) - K = 0.72 (S.E. = 0.12), percentage of agreement = 94. Reliability also was calculated for all other DSM-III disorders that were observed during the reliability trial. Kappa coefficients for these disorders ranged from 0.64 to 1.00.

Data Collection and Analysis

At the time of the diagnostic interview, information was collected on the following demographic variables: age, sex, race, and socioeconomic strata of the child's family. Social class ratings were determined using the Hollingshead (1975) Four-factor index of social status. Comorbidity was examined by observing concurrent DSMIII diagnoses assigned by the interviewers based on the ISC. In order to obtain a detailed and comprehensive picture of comorbidity for the two anxiety disorders, children were assigned all the DSM-III anxiety and affective diagnoses for which they qualified; that is, the DSM-III hierarchical system and diagnostic exclusionary rules were not adhered to, as they pertain to the diagnosis of anxiety and affective disorders. However, as suggested by Barlow and colleagues (Barlow, 1985; DiNardo et aI., 1983), we did impose one guideline: if one disorder could be subsumed under another (i.e., the subsumed disorder did not cause additional adjustment problems), then the subsumed disorder was not diagnosed. Because nearly one third of the sample consisted ofchildren who received diagnoses of both SAD + OAD, data were analyzed by comparing three groups of children: (I) those who had SAD but not OAD, (2) those who had OAD but not SAD, and (3) those who had both SAD + OAD. Data first were observed separately for each group (within-group analysis) and then compared across groups (between-group analysis). Categorical data were analyzed with x 2 tests, first for three (SAD versus OAD versus SAD + OAD) and then for two (SAD versus OAD, SAD versus SAD + OAD, and OAD versus SAD + OAD) group comparisons. Between-group differences on continuous variables first were examined with one-way analyses of variance; orthogonal comparisons be-

TABLE

IV

Results Demographic Characteristics

Demographic characteristics for the three anxiety groups: SAD, OAD, and SAD + OAD, are presented in Table I. Age at intake. The three groups were significantly different with respect to age at intake (F = 12.73, df = 2, p < 0.001). Children with SAD and SAD + OAD were significantly younger than children with OAD (both p < 0.00 I). Age at intake was not significantly different for SAD and SAD + OAD. The percentage of children (age < 13 years) and adolescents (age ~ 13 years) also was observed for each of the anxiety groups. The SAD group had the highest percentage ofchildren under the age of 13 (91 %), followed by the SAD + OAD group (71%), and then the OAD group (31%)( X 2 = 19.42, df = 2, p < 0.00 I). The SAD and SAD + OAD groups had significantly higher percentages of children than the OAD group(x 2= 15.34,df= l,p<0.001;x 2 = 6 . 1 4 , d f = I,p= 0.01, respectively). There were no differences between the SAD and SAD + OAD groups. Sex. Both SAD and SAD + OAD groups had more girls than boys (% female = 64 and 76, respectively), while there was an equal number of girls and boys in the OAD group. There were no significant differences, however, in the sex distribution of the three groups. Race. Almost all of the children in each of the three groups were white, with OAD showing the highest percentage of such children (SAD = 86%, SAD + OAD = 95%, OAD = 100%). There were no significant differences among the groups. Social class (Hollingshead index). The three groups differed significantly with respect to social strata ratings (x 2 = 16.23, df = 8, p < 0.05). Families of SAD children received significantly lower social strata ratings than families of OAD children (x ' = 13.27, df= 4, p = 0.01). Although the SAD + OAD group also received lower ratings than the OAD group, differences were not statistically significant. There were no significant differences between the SAD and SAD + OAD groups. Data were reanalyzed by combining social class ratings into

I. Demographic Characteristics a/Children With SAD. OAD, or SAD + OAD

Characteristics Mean age(yr) Sex (% female) Race (% white) Headof household's social class (Hollingshead index) (%) I (highest) II III

tween specific groups (SAD versus OAD, SAD versus SAD + OAD, and OAD versus SAD + OAD) subsequently were conducted with Tukey tests.

SAD, N

= 22

OAD, N

= 26

SAD

+ OAD,

9.1 M 86

13.4 ID 100

9.6 M 95

0 13 13 19 56

32

19 6 13 31 31

11 37 II

N

= 21

pa <0.001

NS NS

<0.05

V (lowest) II 2 a Probabilities refer to comparisons across three groups and are based on F (age) or x (sex, race, and social class) tests. NS indicates not significant.

SEPARATION ANXIETY AND OVERANXIOUS DISORDERS

two groups: (I) middle/upper socioeconomic level (I, II. and III); and (2) lower socioeconomic level (IV and V). In viewing the data in this manner, the difference between the SAD and OAD groups is even more striking, with the majority of the SAD group (75%) receiving ratings of IV and V and the majority of the OAD group (80%) receiving ratings of I, II, and III (Xl = 8.13, df= I, p < 0.005). The SAD + OAD group showed a similar pattern of findings when compared with the OAD group (Xl = 4.61, df= I, p < 0.05). SAD and SAD + OAD , again, did not differ for social class.

Coexisting Disorders Additional DSM-III diagnoses received by SAD, OAD, and SAD + OAD children are summarized in Table 2. Anxiety disorders. The three groups differed significantly with respect to having an additional anxiety disorder (Xl = 14.99, df= 2, p < 0.001). More than half of the OAD group met criteria for at least one additional anxiety diagnosis, compared with only one child in the SAD group (Xl = 12.85, df = I, P < 0.00 I). Comparisons between SAD and SAD + OAD, and OAD and SAD + OAD, did not yield significant differences. For specific anxiety disorders, the three groups showed significant differences for simple phobia and panic disorder (Xl = 6.97, df = 2, P < 0.05; Xl = 7.02, df = 2, p < 0.05, respectively). The OAD group was significantly more likely to have an additional diagnosis of simple phobia than the SAD group, which had no cases of the disorder (Xl = 4.94, df = I, P < 0.05). Differences between SAD and SAD + OAD, and OAD and SAD + OAD, were not significant. For panic disorder, pairwise comparisons did not yield any significant differences, although the OAD group was the only group that received this diagnosis. Affective disorders. Approximately one third of the cases in each of the three anxiety groups met DSM-III criteria for TABLE

2. Additional DSM-Ill Diagnoses for Children With SAD (N = 22), OAD (N = 26), or SAD + OAD (N = 2/) SAD

OAD

Additional Diagnoses N Anxiety disorders Avoidant disorder Simple phobia Social phobia Agoraphobia Panic disorder Obsessive-compulsive disorder Affective disorders Major depression Dysthymic disorder Bipolar disorder Cyclothymic disorder Other disorders Attention deficit disorder Conduct disorder Oppositional disorder No additional disorders

%

N

%

SAD+ OAD

N

pO

%

I 4.5 IS 57.7 8 38.1 I 4.5 3 11.5 4 19.0 726.9 3 14.3 0 0 0 0 2 7.7 I 4.8 0 0 2 7.7 0 0 4 15.4 0 0 0 0 0 0 2 7.7 I 4.8 7 31.8 II 42.3 9 42.8

<0.001 NS <0.05 NS NS <0.05 NS NS

7 31.8

9 34.6 7 33.3 NS

0 0 0

2 7.7 2 0 0 0 0 0 0

0 0 0

5 22.7 0 0 6 27.2 4 18.2

4 0 4 4

15.4 0 15.4 15.4

9.5 NS 0 NS 0 NS

5 23.8 NS 2 9.5 NS 3 14.3 NS 1 4.8 NS

o Probabilities refer to comparisons across three groups and are based on x 2 tests. NS indicates not significant.

529

major depression. None of the children in the SAD group, and very few of the children in the OAD (7.7%) and SAD + OAD (9.5%) groups, received the diagnosis of dysthymic disorder. None of the children in the study met criteria for either bipolar or cyclothymic disorders. There were no significant differences among the groups for any of the affective disorders. Other disorders. Between 15 and 24% of each of the three groups presented with a concurrent attention deficit disorder. Only two children received the diagnosis of conduct disorder, both of whom were in the SAD + OAD group. Between 14 and 27% of each of the three groups presented with a concurrent oppositional disorder. There were no significant differences among the groups for any of these disorders. No additional disorders. Almost all of the children in the SAD, OAD, and SAD + OAD groups received at least one additional diagnosis. The SAD + OAD group had the lowest percentage (4.8%, N = I) of children who did not receive an additional diagnosis. Differences among the groups were not statistically significant. Discussion The vast majority (76%) of children referred to our outpatient anxiety clinic received the DSM-III diagnosis of SAD or OAD or both. Interestingly, of these youngsters, nearly one third met criteria for both SAD and OAD. These findings correspond to those previously obtained for anxious adults, who often present with two or more concurrent anxiety disorders (Barlow et aI., 1985; Barlow et aI., 1986). Moreover, in that SAD and OAD can be viewed as the childhood equivalents of agoraphobia and generalized anxiety disorder, our results are similar to those obtained for the adult disorders in terms of both the prevalence of and association between the two conditions (Barlow et aI., 1986; DiNardo et aI., 1983). The extremely high reliability obtained for the DSM-III SAD and OAD diagnoses in this study differs from previous findings (Chambers et aI., 1985; Mezzich et aI., 1985; Williams and Spitzer, 1980). It seems likely that our high rates of agreement were influenced by at least three major factors: (I) the training of the interviewers in the evaluation and diagnosis of childhood anxiety disorders using the ISC before the onset of the reliability trial, (2) the use of a semistructured interview schedule, and (3) the particular interview schedule used, which was very comprehensive in its coverage of anxiety symptoms/ disorders. Moreover, it should be noted that children were referred to us, and participated in the reliability trial, only if their initial complaints included anxiety symptoms. In this sense, our sample essentially was biased in our favor (i.e., the sample only included children suspected of having anxiety problems). However, our aim primarily was to determine whether we could reliably distinguish among the various anxiety disorders. Consequently, the procedure used to establish reliability was appropriate to this goal. The age differences among the SAD, OAD, and SAD + OAD groups raises an important hypothesis concerning the development of the two anxiety disorders. Almost all SAD children were prepubertal (91 %), while OAD was most likely to occur at or after puberty (69%). SAD + OAD children were slightly older than SAD children but younger than OAD children. This pattern of findings raises the possibility that

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LAST ET AL.

SAD may be a risk factor for the later development of OAD. That is, as SAD children grow older and approach or enter puberty, the onset of OAD may be likely. Prospective, longitudinal investigations of SAD children are necessary to adequately test this hypothesis. It was interesting to observe the large differences in socioeconomic levels for the SAD and OAD groups, especially with regard to children with OAD. DSM-III suggests that OAD may be more common in upper socioeconomic groups. Our investigation confirms this hypothesis and also underscores a major difference in the demographic features of SAD and OAD children. Alternatively, we did not support DSMIII statements regarding the sex distribution of either SAD or OAD. The SAD group contained more girls than boys (rather than an equal number of each), while the OAD group contained an equal number of boys and girls (rather than more boys than girls). Although our findings need replication with a larger sample, at this point in time they are the only data available on the sex distribution of the two disorders. The vast majority of children in each of the three anxiety groups were white. Although interpretation of this finding is hampered by lack of a psychopathological control group, we wish to point out that a large percentage (35%) of black children are referred to and evaluated within our institution. Therefore, it appears that although black children often are seen for psychiatric problems at our institution, their presenting complaints very rarely consist of anxiety symptoms, and thus they are not referred to our anxiety clinic. Patterns of comorbidity observed for the SAD, OAD, and SAD + OAD groups yielded several interesting findings. OAD children were significantly more likely to receivean additional anxiety diagnosis than SAD children. In fact, over half of the OAD group received such a diagnosis as compared with only one child in the SAD group. Although differences between the SAD + OAD and SAD groups were not statistically significant, it should be emphasized that SAD + OAD children were categorized a priori based on their coexisting anxiety diagnoses (i.e., concurrent diagnoses of SAD and OAD). Thus, one can conclude that when a child has OAD, he or she is more likely than not to have an additional anxiety disorder, whether SAD or another particular anxiety disorder. OAD children were more likely than SAD children to receive the diagnosis of simple phobia or panic disorder. The association between OAD and simple phobia is noteworthy, in that our experience with OAD children suggests that they have a great number of fears and phobias, only some of which are diagnosable as full-blown phobic disorders. The coexistence of OAD and panic disorder highlights yet another similarity between childhood and adult anxiety disorders in that approximately one third of adult patients with generalized anxiety disorder also meet DSM-III criteria for a panic disorder (Barlow et aI., 1986). A number of investigations have indicated that adults with anxiety disorders often present with a concurrent major depression (Barlow, 1985; Clancy et aI., 1979; Gurney et aI., 1972; Roth et aI., 1972; Schapira et aI., 1972; Woodruff et aI., 1972). Our findings correspond to those obtained for anxious adults in that approximately one third of the children in our study met DSM-III criteria for major depression. Two studies previously have been published that investigated the

presence of depression in children with DSM-III anxiety disorders (Bernstein and Garfinkel, 1986; Hershberg et aI., 1982). Hershberg et al. found that none of 10 children diagnosed as having SAD or OAD met DSM-III criteria for major depression. By contrast, Bernstein and Garfinkel reported that the majority of their sample of 16 adolescents with SAD or OAD showed major depression. The differences in findings among our study and the two studies cited above may be caused, at least in part, by differences in the ages of the study groups. Overall, we found that anxious children who presented with a concurrent major depression tended to be older than those who did not exhibit major depression. In the Hershberg et al. (1982) study, they reported that their anxiety group tended to be young (although specific ages were not reported), which may have accounted for the absence of depression. Alternatively, Bernstein and Garfinkel's sample consisted exclusively of adolescents, which may have increased the rates of depression observed. However, the very small numbers of anxious patients included in both of these studies restricts the interpretation, and generalizability, of their findings. Approximately one third (32%) of our sample of anxious children presented with attention deficit disorder (13 %), oppositional disorder (12%), or both of these disorders (7%). Although there has been some controversy concerning the coexistence of "internalizing" and "externalizing" disorders, evidence accrued to date suggeststhat at least one internalizing disorder, major depression, frequently coincides with one externalizing disorder, conduct disorder, in children (PuigAntich, 1982). Similarly, it may be that certain behavior disorders (i.e., attention deficit disorder, oppositional disorder) are, in some cases, associated with anxiety disorders in children. However, in light of the fact that attention deficit disorder and oppositional disorder can vary widely in severity, it will be informative to evaluate the severity of coexisting behavior disorders in future investigations. Finally, we wish to emphasize that our findings for demographic characteristics and patterns of comorbidity are based on clinical referrals to an outpatient anxiety clinic and thus are not generalizable to the general population of anxious children, many of whom are untreated and unreferred. Epidemiological studies of community samples of children will be necessary to determine how clinically referred anxious children differ from those who are not referred. Overall, results from our investigation lend preliminary support for the DSM-III childhood diagnoses of SAD and OAD. In future reports, we will examine the validity of the diagnostic categories in more detail through presentation of results from family and follow-up studies. References Baker, H. & Wills, U. (1978), School phobia: classification and treatment. Brit. J. Psychiat., 132:492-499. Barlow, D. H. (1985), The dimensions of anxiety disorders. In: Anxiety and the Anxiety Disorders, ed. A. H. Tuma & J. D. Maser. Hillsdale, N.J.: Lawrence Erlbaum Associates. - - Blanchard, E. B., Vermilyea, J. A., Vermilyea, B. B. & DiNardo, P. A. (1986), Generalized anxiety and generalized anxiety disorder: description and reconceptualization. Amer. J. Psychiat., 143:4044. - - Vermilyea, J., Blanchard, E. 8., Vermilyea, B. B., DiNardo,

SEPARATION ANXIETY AND OVERANXIOUS DISORDERS

P. A. & Cerny. J. A. ( 1985). Th e phenomenon of panic. J . Ahnorm . Psychol. 94 :320-328 . Berg. I. ( 1980). School refusal in earl y ado lescence. In: Out ofSchool. ed . L. Herso v & I. Berg. New York: Wiley. - - Nichol s. K. & Pritchard. C ( 1969). School phobia-its classification and relationship to dependenc y. J . Child Psychol. Psychiat.• 10:123-141. Bernstein. G . A. & Garfinkel. B. D. ( 1986). School phobia: the overlap of affective and anxiety disord ers. This Journ al. 2:235-24 1. Bowlby. J. (1973 ). Attachment and Loss. Vol. II S epa ration: Anxiety and A nger. New York : Basic Books. Chambers. W. J.. Pu ig-Antich, J.• Hirsch. M.. et al. ( 1985). The assessment of affecti ve disord ers in children and adolesc ent s by semi structured interviews : test-retest reliability of the K-SADS-P . Arch. Gen. Psychiat.• 42 :696-702 . Clan cy. J., Noyes, R. J . & Hoenk, P. J .. ( (979). Secondary depression in anx iety neurosis. J. Nc rv. Me nt. Dis.. 166:846-850. DiNardo, P. A.. O'Brien, G . T .. Barl ow, D. H.. Waddell. M. T . & Blanchard, E. B. (1983), Reliab ility of DSM-III anxiety disord er categories using a new structured interview. Arch. Gen. Psychiat.• 40: 1070-1074. Eisenberg, L. (1968). School phobia: a study in the communication of anxiety. Amer. J . Psychiat .• 114:712-718. Gittelman, R. (1983. September). Th e relationsh ip between childhood separatio n anxiety and adult ago raphobia. Paper presented at Anxiet y and the Anxiety Disorders. NIMH-spon sored conference. New York . Grove, W. M., Andreasen. N. C , McDonald-Scott, P.. Keller. M. B. & Shapiro. R. W. ( 1981), Reliability stud ies of psychiatric diagnosis. A rch. Gen. Psychiat.• 38 :408-4 13. Gurney. C , Roth , M. & Garside. R. F. ( 1972). Studies in the classification of affective disorders: the relationship between an xiety states and depressi ve illness-II . Brit. J. Psychiat.• 121:162-166. Hershberg, S. G .. Carlson. G . A.. Cantwell. D. P. & Strober. M. ( 1982). Anxiety and depressive disorders in psychiatricall y disturbed children. J. Clin. Psvchiat.• 43:358-361. Herso v, L. A. (1960) . Refusal to go to school. Child Psych ol. Psych iat.• 1:137-145 . Hewitt C E. & Jenkins. R. L. ( 1946). Fundamental Patt erns of Maladjustment : Th e Dynamics of Their Origin. Springfield: Stat e of Illino is.

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Hollingshead. A. B. ( 1975), Four-factor index of socia l status. Unpubl ished manuscript. Jenkins, R. L. (1964 ). Diagnos is. d ynamics, and treatments in ch ild psychiatry . Psych iat . Res. Rep.• 18:91-1 20 . - - ( 1969). Classifica tion of behavior problems of children . Amer. 1. Psych iat .• 125:1032-1039. Johnson. A. M.. Falstein . E. I.. Szur ek, S. A. & Svendson, M. ( 194 1). School phobia. A m er. J. Orthopsych iat.. 11:702-711. Kanner. L. (1957 ). Child Psychiatry. Springfield. Ill.: Charles C Thomas. Kovacs. M. (1978). The interview sche dule fo r children (ISC) : form C. and the fo llow-up fo rm . Unpublished manuscript, University of Pittsburgh, Pittsburgh. Pennsylvan ia. - - ( 1983a), Th e inte rview schedule fo r children (ISC) :fo rm C. and the fo llow-up fo rm . Unpublished manuscript. Un iversity of Pittsburgh . Pittsburgh, Pennsylvan ia. - - (l983b), The interview schedule fo r children (IS C): lnt errater and parent-child agreement . Unpublished manuscript, Uni versit y of Pittsburgh, Pittsburgh, Pennsyl vania. Mezzich, A. C. Mezzich, J. E. & Coffman. G. A. (1985), Reliabil ity of DSM-III vs. DSM-II in child psychopathology. Thi s Journ al, 24:273-280. Ollendick, T. H. & Mayer. J. A. (1985), School phobia. In: Beha vioral Treatm ent of Anxiety Disorders. ed. S. M. Turner. New York : Plenum Publishing. Pu ig-Ant ich , J. (1982 ). Major depression and conduct disord er in prepuberty. This Journal, 2 1: 118-128. Roth , M.• Gurney, C & Garside. R. F. ( 1972). Studies in the classificat ion of affective disorders: the relationship between anx iet y stat es and depressi ve illness-I. Brit. J . Psychiat., 121:147 -161. Schap ira, K., Roth. M.. Kerr . T . A. & Gurney. C (19 72), Th e prognosis of affective disorders: the differentiation of anx iety state s from depressive illnesses. Brit. J. Psychiat., 121:175-181. Suh , M. & Carlson, R. (1977) . Childhood beha vior disorder-a famil y typology. Psychiat . J. Univ. Ottawa. 2:84-88. Williams, J. B. W. & Spitzer . R. L. ( 1980). Appendix F. In : Dia gnostic and Statistical Manual of Me ntal Disorders: Th ird Edition . Washington, D.C: American Psychiatric Association. Woodruff. R. A.• Guze, S. B. & Clayton . P. J. ( 1972). An xiety neurosis among psych iatric outpatients . Com pr. Psychiatry , 13: 165-170.