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Anxiety symptoms in Japanese and in German children
Behaviour Research and Therapy 42 (2004) 601–612 www.elsevier.com/locate/brat
Anxiety symptoms in Japanese and in German children C.A. Essau a,, Y. Sakano b, S. Ishikawa b, S. Sasagawa b a
Westfa¨lische Wilhelms-Universita¨t Mu¨nster, Psychologisches Institut I, Fliednerstraße 21, 48149 Mu¨nster, Germany b School of Human Sciences, Waseda University, 2-579-15, Mikajima, Tokorozawa, Saitama 359-1192, Japan Received 15 November 2002; received in revised form 28 May 2003; accepted 5 June 2003
Abstract The purpose of this study was to compare the frequency of anxiety symptoms and their association with gender and age in Japanese and German children using the Spence Children’s Anxiety Scale (SCAS). A total of 1837 children (862 from Germany and 975 from Japan) between the age of 8 and 12 years were investigated. Results revealed that German children reported significantly higher symptoms of separation anxiety, social phobia, obsessive compulsive disorder, and generalized anxiety disorder than Japanese children. Conversely, Japanese children reported significantly higher scores on symptoms related to physical injury fear. In both countries, girls scored higher than boys on all the scales of the SCAS. Symptoms of separation anxiety and panic decreased with age, whereas social phobia increased with age. The findings underscore the impact of culture on children’s anxiety. # 2003 Elsevier Ltd. All rights reserved. Keywords: Anxiety symptoms; Spence Children’s Anxiety Scale; Cross-cultural; Children
1. Introduction Research on the etiology, diagnosis, assessment, and treatment of anxiety disorders in children has been increasingly accumulated in the last 20 years (Essau & Petermann, 2001). This growing interest can be attributed to the high prevalence of anxiety disorders and anxietyrelated problems in this age group (Essau, Conradt, & Petermann, 2000; Lewinsohn, Hops, Roberts, Seeley and Andrews, 1993; McGee et al., 1990). Another factor that contributes to the interest and research in this area is the chronicity of anxiety (Cohen et al., 1993; Feehan, McGee, & Williams, 1993; Keller et al., 1992), and the fact that the presence of anxiety
Corresponding author. Tel.: +49-251-83-34152. E-mail address: [email protected] (C.A. Essau).
0005-7967/$ - see front matter # 2003 Elsevier Ltd. All rights reserved. doi:10.1016/S0005-7967(03)00164-5
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symptoms may act as a risk factor for the development of various types of psychiatric disorders in adulthood (Wittchen & Essau, 1994). With few exception (e.g. Dong, Yang, & Ollendick, 1994), studies exploring anxiety in children have been limited to Western countries with similar cultural values (e.g. Australia, Germany, USA). Cross-cultural research on children’s anxiety symptoms has been relatively neglected (Essau & Petermann, 2001). A study of cross-cultural differences and similarities in the nature and prevalence of anxiety may enrich our information regarding anxiety. Empirical research conducted in various cultures should enable us to test the universality of anxiety, and situations or stimuli which elicit anxiety. Since children’s anxiety may reflect social values and a cognitive and social awareness within the family context, knowledge of anxiety in children from different cultural backgrounds may enhance our understanding of children’s anxiety needed for theory building and may provide cues for clinical practice. An important prerequisite for cross-cultural studies is the presence of reliable and valid instruments. The most commonly used instrument for the assessment of children’s fear in crosscultural studies is the Revised Fear Survey Schedule (FFSC-R). Results from Australian (King, Gullone, & Ollendick, 1990; King et al., 1989) and British studies (Ollendick, Yule, & Ollier, 1991) are consistent with those found with white North American samples. In these studies, five factors were found: ‘‘fear of danger and death’’, ‘‘fear of failure and criticism’’, ‘‘fear of unkown’’, ‘‘fear of injury and small animals’’, and ‘‘medical fear’’. In a study that compared fears in children in the US, Australia, China and Nigeria using the FSSC-R (Ollendick, 1983), Nigerian children reported higher levels of fear than Chinese children, who in turn reported higher fear scores than Australian and American children. Children from Australia and America did not differ significantly from each other. It has been suggested that China and Nigeria stress more obedience, self-control, emotional restraint and compliance to social rules, which may account for the elevated social-evaluative and safety fears (Ollendick, Yang, King, Dong, & Akande, 1996). Among Turkish children, fears related to death and separation, as well as religious fears (i.e. going to hell) were highly prevalent in children (Erol & Sahin, 1995). Thus, although similarities in age and gender findings may be consistent across cultures, some differences also existed. The authors argued that these findings may be related to parent’s socialization practice. In order to achieve control and discipline over their children’s behavior, parents often utilize the threat of religious punishment. Another method used by parents to foster dependency and obedience to authority figures is to talk of the dangerous world outside the family. A study by Dong, Yang and Ollendick (1994) showed that Chinese children and adolescents report higher levels of social-evaluative fears than children in Western countries such as Australia, England and the US. According to Dong, Yang and Ollendick (1994), this result can be attributed to the Chinese child-rearing and educational practices that are generally restrictive, overprotective and emotionally unexpressive, placing considerable emphasis on other peoples’ opinions and high achievement in school. While studies using the FSSC-R have enhanced our understanding of fears in various cultures, the FSSC cannot be used to measure the symptoms of DSM-IV anxiety disorders. An ideal questionnaire that can be used for this purpose is the Spence Children’s Anxiety Scale (SCAS; Spence, 1998). Having been translated into various languages (German, Dutch, Japanese) and tested for its reliability and validity in each version, the SCAS is an appropriate ques-
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tionnaire for studying anxiety symptoms in different cultures. Therefore, the main aim of the present study is to compare anxiety symptoms in German and Japanese children using the SCAS. Age and gender differences, and interactions of these variables with culture will also be examined. The special interest is due to marked cultural differences in child-rearing. As discussed by Weisz, Rothbaum, and Blackburn (1984, pp. 965), ‘‘Japanese patterns of child-rearing and socialization seem to foster self-discipline, politeness, attentiveness to others, a strong sense of personal and group identity’’. It has furthermore been argued that Japanese intense ability for accommodation makes them overly sensitive to disapproval. As shown by Friedlmeier and Trommsdorff (1998), Japanese mothers generally teach their children to accommodate to social expectations. Given these child-rearing practices and cultural values (Friedlmeier & Trommsdorff, 1998; Weisz, Rothbaum & Blackburn, 1984), Japanese children, in comparison to German children, were predicted to display a higher number of anxiety symptoms, in particular for social phobia. In line with gender and age findings in Western countries, girls are expected to show higher levels of anxiety than boys, and some anxiety symptoms (those related to separation anxiety, physical injury fears) were expected to decrease with age while others increase with age (e.g. social phobia, obsessive compulsive disorder, panic/agoraphobia, generalized anxiety disorder).
2. Method The sample included 1837 children—862 from Germany and 975 from Japan. Nine hundred and thirty-three (N ¼ 933) of these children were boys (50.8%) and 904 (49.2%) were girls, all in grades 2–7. Children’s age ranged from 8 to 12 years (mean ¼ 10:44, SD ¼ 1:2). The German participants were recruited from two urban and one rural primary schools in Mu¨nster, Germany. The vast majority of the children (92%) were Caucasian, the rest come mostly from Turkey and the former Russia. The socioeconomic status of the subjects varied greatly, ranging from parents with low-skill jobs to physicians. The major objectives and method of this study were explained to the principals and teachers of the participating schools, children, and their parents. School approval and parental written informed consent were obtained before participation in the study; children’s participation was voluntary. About 85% of the children who were invited to participate in the study eventually did so. The Japanese sample was randomly selected from four public schools in the suburban area of Tokyo (residential area). As with the German sample, the socioeconomic status of subjects varied greatly, ranging from parents with low-skill jobs to physicians. The main aims and method of the present study were explained to the school principals, children, and their parents. School approval and informed consent were obtained before participation in the study. Response rate for the Japanese data is 94%. Years 8–9, 10, 11, and 12 were combined to form four age groups. This resulted in a 2 ðgenderÞ 2 ðcultureÞ 4 ðage groupÞ design. The German cells consisted of 90 boys aged 8– 9 years, 119 boys aged 10, 115 boys aged 11, and 101 aged 12. For girls, the respective cell sizes were 57, 113, 137, and 90. The Japanese sample included 169 boys aged 8–9 years, 147 boys aged 10, 145 boys aged 11, and 47 aged 12. For girls, the respective cell sizes were 148, 125, 139, and 55.
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2.1. Instrument The Spence Children’s Anxiety Scale (SCAS; Spence, 1997, 1998) is a 38-item measure of anxiety symptoms in children aged 8–12 years. The SCAS items reflect symptoms of the main DSM-IV anxiety disorders that may occur in children including separation anxiety (six items; e.g. ‘‘I would feel afraid of being on my own at home’’), social phobia (six items; e.g. ‘‘I worry what other people think of me’’), obsessive compulsive disorder (six items; e.g. ‘‘I can’t seem to get bad or silly thoughts out of my head’’), panic/agoraphobia (nine items; e.g. ‘‘I suddenly feel as if I can’t breathe when there is no reason for this’’), physical injury fears (five items; e.g. ‘‘I am scared of dogs’’), and generalized anxiety disorder (six items; e.g. ‘‘When I have a problem, I get a funny feeling in my stomach’’). Each item is rated on a 4-point scale in terms of its frequency from ‘‘never’’ (0) to ‘‘always’’ (3). The 0–3 ratings of the 38 anxiety items are summed to yield a total score, with higher scores reflecting higher levels of anxiety symptoms. Internal consistency and test–retest reliability of the SCAS have been reported as satisfactory, with alphas generally well above 0.70 and a test– retest correlation coefficient of 0.60. The scale also demonstrated acceptable convergent validity as demonstrated by a significant correlation with the Revised Children’s Manifest Anxiety Scale (RCMAS; Reynolds & Richmond, 1985) (r ¼ 0:71). Furthermore, clinically anxious children had significantly higher SCAS scores and marked particularly high scores on the subscales that reflected the anxiety disorders they suffered from (i.e. social phobia and separate anxiety disorder). The English version of SCAS was adapted and translated to German and Japanese languages according to the guidelines that are widely accepted for the successful translation of instruments in cross-cultural research (Brislin, 1970). One bilingual translator who was also a native speaker or culturally informed individual blindly translated the SCAS from the original language (English) to the second language (German or Japanese), and another bilingual translated it back to the original language (German back to English; Japanese back to English). Differences in the original and the back-translated versions were discussed and resolved by joint agreement of both translators. The reliability and the validity of the German SCAS (SCAS-G) has been examined in a sample of German primary school children (Essau, Muris, & Ederer, 2002). The SCAS-G was demonstrated to have high internal consistency, with Cronbach’s alpha being 0.92 and GuttmanSplit-half being 0.90. The validity of the SCAS-G was supported by the following findings. First, in agreement with previous studies, girls displayed significantly higher levels of anxiety symptoms than boys. Second, SCAS scores were substantially interrelated with another measure of anxiety symptoms (the SCARED; r ¼ 0:85; p < 0:001Þ. Finally, significant correlations were found between the SCAS and the Youth Self-Report (Achenbach, 1991) (r ¼ 0:67; p < 0:001) and the Columbia Impairment Scale (Bird et al., 1996) (r ¼ 0:41; p < 0:001). The reliability and validity of the Japanese version of the SCAS (SCAS-J) has been examined in a group of 934 primary school children (Ishikawa, Oota, & Sakano, 2001). It has high internal consistency, with an alpha of 0.88 for the total scores of the SCAS. High correlation was demonstrated with the Children’s Form of Manifest Anxiety Scale (Castenada, McCandless, & Plermo, 1956) (r ¼ 0:73, p < 0:01).
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3. Results Group differences were tested with respect to the scores for total SCAS and each subscale. Given the high statistical power afforded by the large sample sizes, only differences reaching p < 0:01 were accepted as significant. 3.1. Total SCAS scores The first step in our analysis was to perform a 2 2 4 (gender culture age) ANOVA on the total SCAS score. The means and standard deviations for the total SCAS scores, as well as their subscales are presented in Table 1. Although no significant differences were found in the total SCAS scores, significant group differences were found in five of the six subscales. Specifically, a 2 2 4 (gender culture age) ANOVA on the SCAS subscales revealed significant main effect of culture for separation anxiety (Fð1; 1836Þ ¼ 7:29, p < 0:01), social phobia (F ð1; 1836Þ ¼ 22:28, p < 0:001), obsessive compulsive disorder (Fð1; 1836Þ ¼ 83:66, p < 0:001), physical injury fear (F ð1; 1836Þ ¼ 101:03, p < 0:001), and generalized anxiety disorder (F ð1; 1836Þ ¼ 89:26, p < 0:001). The only subscale which did not reveal any significant main effect was panic disorder. These results revealed that German children reported significantly higher scores on separation anxiety, social phobia, obsessive compulsive disorder, and generalized anxiety disorder than the Japanese children. By contrast, the Japanese children reported significantly higher scores on physical injury fear. A significant main effect of gender was found for all the subscales of SCAS, indicating that girls reported higher scores than boys. The mean total SCAS scores for girls was 27.21 (SD ¼ 15:6) and for boys was 18.20 (SD ¼ 11:7). None of the interactions was significant. A main effect of age was found for separation anxiety, panic, and social phobia; the first two showed a decrease with age, whereas the latter (social phobia) displayed an increase with age. Given the unexpected findings on the relationship between panic and age, an extra analysis was conducted. This analysis showed that panic symptoms had no significant main effect in the Japanese children (F ð3; 974Þ ¼ 1:22, p ¼ 0:30), but a significant main effect of age was found in German children (Fð3; 861Þ ¼ 4:52, p ¼ 0:004). 3.2. Most common anxiety symptoms To explore the most common anxiety symptoms, the ten anxiety symptoms rated with high frequency (i.e. rated with either ‘‘often’’ or ‘‘always’’) were tabulated for the total sample and separately by gender, age and culture (Table 2). Inspection of Table 2 reveals that two of the ten most common anxiety were symptoms of separation anxiety disorder, two were symptoms of social phobia, three obsessive compulsive disorder, two generalized anxiety disorder, and only one symptom for physical injury fear. Seven of the ten most common anxiety symptoms reported by boys and girls were the same symptoms. It should, however, be noted that a higher percentages of these symptoms were reported by girls than by boys. Six of ten anxiety symptoms were the same across the different age groups. The two separation anxiety disorder symptoms were most frequently reported in the younger (8–9, 10 and 11 year olds) than in the older (12 year olds) age groups. For culture, six
4.64 (3.4) 3.70 (2.8) 5.55 (3.6) 3.96 (3.3) 4.78 (3.4) 4.90 (3.3) 4.77 (2.9)
4.23 (2.9) 3.75 (2.6) 4.69 (3.2) 4.26 (3.0) 4.54 (2.8) 4.23 (3.1) 3.81 (2.9)
4.18 (3.4) 3.09 (2.8) 5.29 (3.6) 3.73 (3.4) 4.19 (3.4) 4.39 (3.4) 4.52 (3.3)
Social phobia Total Boys Girls 8–9 Years 10 Years 11 Years 12 Years
Obsessive compulsive disorder Total 3.59 (2.7) Boys 3.23 (2.4) Girls 3.96 (2.9) 8–9 Years 3.52 (2.7) 10 Years 3.70 (2.6) 11 Years 3.62 (2.7) 12 Years 3.48 (2.6)
3.75 (2.8) 3.05 (2.2) 4.44 (3.1) 4.56 (2.9) 3.88 (2.9) 3.54 (2.8) 3.08 (2.5)
3.61 (3.0) 2.78 (2.5) 4.47 (3.3) 4.21 (3.2) 3.73 (3.1) 3.30 (3.0) 2.94 (2.5)
Separation anxiety Total Boys Girls 8–9 Years 10 Years 11 Years 12 Years
22.86 (14.2) 18.39 (11.0) 27.20 (15.5) 22.89 (14.0) 23.86 (14.6) 23.33 (15.0) 20.96 (12.6)
Germany mean (SD)
22.63 (14.5) 18.20 (11.7) 27.21 (15.7) 23.05 (15.1) 23.11 (14.6) 22.64 (14.8) 21.07 (12.4)
Total mean (SD)
Total anxiety score Total Boys Girls 8–9 Years 10 Years 11 Years 12 Years
SCAS-subscales
3.03 (2.3) 2.80 (2.2) 3.28 (2.4) 3.08 (2.5) 2.99 (2.2) 3.07 (2.3) 2.87 (1.9)
3.77 (3.4) 2.59 (2.8) 3.28 (2.4) 3.60 (3.5) 3.68 (3.3) 3.95 (3.3) 4.04 (3.1)
3.49 (3.2) 2.55 (2.6) 4.50 (3.5) 4.01 (3.4) 3.60 (3.2) 3.09 (3.1) 2.66 (2.6)
22.44 (14.9) 18.04 (12.4) 27.21 (15.8) 23.14 (15.7) 22.47 (14.7) 22.03 (14.7) 21.27 (12.4)
Japan mean (SD)
Table 1 Mean scores and standard deviations on the SCAS in Japanese and German school children
Country: Fð1; 1836Þ ¼ 83:66, p < 0:001 Gender: Fð1; 1836Þ ¼ 28:22, p < 0:001 Age: Fð3; 1836Þ ¼ 1:52, p ¼ 0:21
Country: Fð1; 1836Þ ¼ 22:28, p < 0:001 Gender: Fð1; 1836Þ ¼ 179:85, p < 0:001 Age: Fð3; 1836Þ ¼ 3:42, p ¼ 0:017
Country: Fð1; 1836Þ ¼ 7:29, p < 0:01 Gender: Fð1; 1836Þ ¼ 133:76, p < 0:001 Age: Fð3; 1836Þ ¼ 17:64, p < 0:001
Country: Fð1; 1836Þ ¼ 0:29, p ¼ 0:59 Gender: Fð1; 1836Þ ¼ 168:98, p < 0:001 Age: Fð3; 1836Þ ¼ 1:83, p ¼ 0:14
Effects
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3.41 2.81 4.03 3.49 3.39 3.45 3.23
4.06 3.41 4.73 3.87 4.17 4.10 4.14
Physical injury fears Total Boys Girls 8–9 Years 10 Years 11 Years 12 Years
Generalized anxiety Total Boys Girls 8–9 Years 10 Years 11 Years 12 Years (3.0) (2.6) (3.2) (2.9) (3.0) (3.1) (2.7)
(2.8) (2.6) (2.7) (2.8) (2.7) (2.7) (2.5)
(3.4) (2.6) (3.8) (3.5) (3.4) (3.5) (2.7)
Note: SCAS, Spence Children’s Anxiety Scale.
2.86 2.03 3.71 3.15 3.02 2.79 2.19
Total mean (SD)
Panic disorder Total Boys Girls 8–9 Years 10 Years 11 Years 12 Years
SCAS-subscales
Table 1 (continued )
4.79 3.99 5.56 4.39 5.06 4.97 4.60
2.75 2.08 3.40 2.62 2.74 2.89 2.71
2.70 1.81 3.56 3.10 2.87 2.80 1.98
(2.9) (2.4) (3.0) (2.7) (3.0) (3.0) (2.5)
(2.4) (1.9) (2.5) (2.4) (2.2) (2.2) (2.4)
(3.2) (2.2) (3.7) (3.1) (3.4) (3.5) (2.3)
Germany mean (SD)
3.42 (3.4) 2.93 (2.7) 3.96 (3.1) 3.56 (3.0) 3.41 (2.9) 3.33 (3.1) 3.27 (2.1)
3.99 (2.9) 3.42 (2.9) 4.62 (2.9) 4.00 (3.0) 3.95 (3.0) 3.95 (2.9) 4.19 (2.6)
2.99 (3.5) 2.21 (2.8) 3.85 (4.0) 3.18 (3.7) 3.15 (3.5) 2.78 (3.4) 2.59 (3.3)
Japan mean (SD)
Country: Fð1; 1836Þ ¼ 89: 26, p < 0:001 Gender: Fð1; 1836Þ ¼ 86:58, p < 0:001 Age: Fð3; 1836Þ ¼ 1:4, p ¼ 0:33
Country: Fð1; 1836Þ ¼ 101:03, p < 0:001 Gender: Fð1; 1836Þ ¼ 86:49, p < 0:001 Age: Fð3; 1836Þ ¼ 0:15, p ¼ 0:93
Country: Fð1; 1836Þ ¼ 2:82, p ¼ 0:09 Gender: Fð1; 1836Þ ¼ 105:46, p < 0:001 Age: Fð3; 1836Þ ¼ 4:82, p < 0:01
Effects
C.A. Essau et al. / Behaviour Research and Therapy 42 (2004) 601–612 607
16.4f 19.6
22.7 27.4 21.7h
18.6 26.8
16.9 17.1 17.2 12.4e 17.0 14.5 14.8
23.9 21.8 19.9 19.8 19.3 19.0 17.8
21.4
21.0j
16.8k
21.5
18.7
19.0
21.7
20.6
23.8
27.6 29.4
37.1
10
17.1l
19.4
20.5
23.3
20.0
14.0n
18.1
13.7i 14.7m
20.7
21.2
19.9
18.2
23.5
28.7
10.0d 15.5g
15.6c
24.7
38.9 39.9
32.7
Japan
28.7
23.1
21.2 16.6a
40.0
Germany
17.7
20.5
16.9
16.7
26.6
16.3b 17.6
33.5 20.9
31.0
12
31.8 30.0
34.9
11
Culture
Superscript indicates that this anxiety symptom was not one of the top 10 for this sub-sample, even though it was one of the 10 most common for the sample as a whole. 0 a When I have a problem, I get a funny feeling in my stomach (20.0%). b I get bothered by bad or silly thoughts or pictures in my mind (19.2%). c I am scared of dogs (21.0%). d I have to do some things over and over again (like washing my hands, cleaning or putting things in a certain order) (19.4%). e I have to do some things over and over again (like washing my hands, cleaning or putting things in a certain order) (14.7%). f I am scared of the dark (19.3%). g I feel scared when I have to take a test (19.1%). h I feel afraid that I will make a fool of myself in front of people (23.5%). i I feel afraid that I will make a fool of myself in front of people (20.2%). j I am scared of the dark (22.2%). k I am afraid of being in crowded places (like shopping centers, the movies, buses, busy playgrounds) (18.5%). l I feel afraid that I will make a fool of myself in front of people (17.9%). m I feel scared when I have to take a test (17.7%). n I feel afraid that I will make a fool of myself in front of people (18.6%).
19.4
20.0
30.4
20.0
30.7 32.2
23.9
26.6
31.3
43.0 31.2
39.2
30.6 28.9
42.7
29.7
36.1
11. I worry that something awful will happen to someone in my family 29. I am scared of insects or spiders 13. I have to keep checking that I have done things right (like the switch is off, or the door is locked) 10. I worry that I will do badly at my school work 8. I worry about being away from my parents 37. I have to do some things in just the right way to stop bad things happening 26. I worry what other people think of me 17. I can’t seem to get bad or silly thoughts out of my head 20. I worry that something bad will happen to me 18. When I have a problem, my heart beats really fast
8/9
Boys
Girls
Age (years)
Gender
Total
Items
Table 2 Ten most common anxiety symptoms by gender, age and culture (percent children endorsed; rated as ‘‘often’’ or ‘‘always’’) 608 C.A. Essau et al. / Behaviour Research and Therapy 42 (2004) 601–612
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of the ten most commonly reported anxiety symptoms were the same as those reported by the whole sample, and among the Japanese children, it was nine of ten. For Japanese children ‘‘I worry about being away from my parents’’ was replaced by ‘‘I am scared of dogs’’. For the German children, ‘‘I have to keep checking that I have done things right (like the switch is off, or the door is locked)’’, ‘‘I have to do some things in just the right way to stop bad things happening’’, ‘‘I worry what other people think of me’’, and ‘‘When I have a problem, my heart beats really fast’’ were replaced by ‘‘I feel scared when I have to take a test’’, ‘‘I feel afraid that I will make a fool of myself in front of people’’, ‘‘When I have a problem, I get a funny feeling in my stomach’’, and ‘‘I have to do some things over and over again (like washing my hands, cleaning or putting things in a certain order).’’ 3.3. Factor structure Confirmatory factor analyses were carried out on the SCAS, separately for the German and the Japanese samples. For this purpose, EQS, the structural equations modeling approach (Bentler, 1995) was used. A 5-correlated-factor model in the German sample provided a good fit for the data: comparative fit index ðCFIÞ ¼ 0:94, normed fit index ðNFIÞ ¼ 0:89, non-normed fit index ðNNFIÞ ¼ 0:92; RMR ¼ 0:03, and RMSEA ¼ 0:04. A good fit was also found in the Japanese sample: CFI ¼ 0:92; NFI ¼ 0:87; NNFI ¼ 0:89; RMR ¼ 0:03, and RMSEA ¼ 0:04. Overall, the factor structure of the SCAS showed more similarities than differences in Germany and in Japan. In both countries, generalized anxiety and obsessive compulsive disorder could not be extracted as a single factor. However, it should be noted that all items in the obsessive compulsive disorder factor (of the original Australian SCAS; Spence, 1997, 1998) loaded onto a single factor. Separation anxiety disorder loaded onto two factors, and the items in these two factors were very similar in the two countries. In Germany, obsessive compulsive disorder, generalized anxiety, and social phobia all loaded onto a single factor. In Japan, panic disorder was divided into two factors, and loaded on generalized anxiety and obsessive compulsive disorder.
4. Discussion The main purpose of this article was to compare the frequency of anxiety symptoms and their association with age and gender in German and Japanese children using the SCAS. Before interpreting our findings, some limitations should be discussed. First, only 8–12-year-old school children were included in our study, so it is not clear whether our findings can be generalized to other populations (e.g. clinical setting) and age groups (e.g. adolescents). Second, the data was solely based on child self-report. Although it is widely acknowledged that the best method to assess children’s psychopathology in children is via multiple informants (Essau & Barrett, 2001), studies have found parents and teachers less satisfactory as informants of internalizing problems in comparison to externalizing problems (Klein, 1991; Loeber, Green, & Lahey, 1990). Given the low agreement among informants, the use of child self-report seemed justifiable given the fact that anxiousness is an internally-derived experience. Third, our study did not include any measures of social desirability effects. It could be that the Japanese children were more
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influenced by social desirability effects than by the German children. This could have explained for our finding of the lower than expected scores of anxiety symptoms among Japanese children. In order to examine the possible effects of social desirability, future cross-cultural studies should include the Revised Children’s Manifest Anxiety Scale—lie scale (Reynolds & Richmond, 1985). Fourth, our findings may be limited by issues which plague all cross-cultural research. Specifically, difference in response styles may have affected our findings. However, we are not aware of research that supports differences in response styles across these cultures. The mean anxiety scores for Japanese children was 22.44 and for German children was 22.86. These findings fall in the middle range of what has been reported previously. For example, in a large sample of Dutch children, the mean SCAS score was 18.11 (Muris, Schmidt, & Merckelbach, 2000), whereas in Australian children, scores of 28.59 and 25.28 have been reported (Spence, 1998), and in our earlier study, the mean score was 22.24 (Essau, Muris & Ederer, 2002). The overall levels of anxiety symptoms were equivalent across the two cultures, with significant differences in the subtypes of anxiety. That is, German children compared to Japanese children had significantly higher scores on separation anxiety, social phobia, obsessive compulsive disorder, and generalized anxiety disorder, and the opposite was true for physical injury fear. Future studies need to explore if child-rearing and educational practices ascribed to the Japanese culture are related to the lower levels of separation anxiety, social phobia, obsessive compulsive disorder, and generalized anxiety disorder symptoms. In contrast to our expectation, Japanese child-rearing practices do not seem to have detrimental effects. Instead, they appear to be associated with reduced levels of anxiety in some domains. Why Japanese children retained higher scores on physical injury fear (i.e. higher fear of dark, dogs, insects or spiders, and being in high places) is unclear. Similar result has been found by Davey et al. (1998). In that study, Japanese students were reported to be significantly more fearful of spiders than students in India, UK, USA, Korea, and Hong Kong. Compared to boys, girls had significantly higher scores on all subscales of SCAS. The gender difference in the frequency of anxiety symptoms replicated previous studies showing that more girls than boys were affected by anxiety symptoms (Essau, Conradt & Petermann, 2000; Lewinsohn, Hops, Roberts, Seeley & Andrews, 1993; Reinherz, Giaconia, Lefkowitz, Pakiz, & Frost, 1993). The exact meaning of this gender difference is, however, unclear. Some authors (e.g. Morris & Kratchowill, 1991) argued that girls compared to boys are socialized to be more fearful and are reinforced when reporting their inner worries and fears. If true, such socialization practices seem to be present in Germany and Japan. Our findings also demonstrated age differences in the number of anxiety symptoms. While separation anxiety and panic/agoraphobia decreased with age, generalized anxiety tended to increase as children became older. In the study by Spence (1997), the mean scores for separation anxiety, obsessive compulsive symptoms, and panic/agoraphobic problems declined with age, whereas no significant age effects were found for physical injury fears or generalized anxiety symptoms. Our finding that panic/agoraphobia symptoms decreased with age was surprising given the debate that children can experience panic attack only at a certain age. In fact, our results indicated that younger children reported having experienced symptoms related to panic such as ‘‘I suddenly feel as if I can’t breathe when there is no reason for this’’, and ‘‘All of sudden I feel really scared for no reason at all’’; only one symptom was related to agoraphobia,
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‘‘I am afraid of being in crowded places (like shopping centers, the movies, buses, busy playgrounds)’’. In summary, most of our knowledge on anxiety in children has come from studies in Western countries. The present study has attempted to compare the frequency of anxiety symptoms and their association with age and gender in Japanese and German children. Generally, the pattern of age and gender differences found in our study replicated previous findings. However, in contrast to our hypothesis, German children had significantly higher scores on symptoms related to various types of DSM-IV anxiety disorders than their Japanese counterparts. More studies are needed to explore cultural context and environmental experiences that account for the higher rates of anxiety in German than Japanese children.
References Achenbach, T. M. (1991). Manual for the youth self-report and 1991 profile. Burlington: University of Vermont. Bentler, P. M. (1995). EQS structural equations program manual. Encino, CA: Multivariate Software. Bird, H. R., Andrews, H., Schwab-Stone, M., Goodman, S., Dulcan, M., Richters, J., Rubio-Stipec, M., Moore, R. , Chians, P.-H., Hoven, C., Canino, G., Fisher, P., & Gould, M. S. (1996). Global measures of impairment for epidemiologic and clinical use with children and adolescents. International Journal of Methods in Psychiatric Research, 6, 295–307. Brislin, R. W. (1970). Back translation for cross-cultural research. Journal of Cross-Cultural Psychology, 1, 185–216. Castenada, A., McCandless, B., & Plermo, D. (1956). The children’s form of the Manifest Anxiety Scale. Child Development, 27, 317–326. Cohen, P., Cohen, J., Kasen, S., Velez, C. N., Hartmark, C., Johnson, J., Rojas, M., Brook, J., & Streuning, E. L. (1993). An epidemiological study of disorders in late childhood and adolescence—I. Age- and gender-specific prevalence. Journal Child Psychology and Psychiatry, 34, 851–866. Davey, G. C. L., McDonald, A. S., Hirisave, U., Prabhu, G. G., Iwawaki, S., Jim, C. I., Merckelbach, H., de Jong, P. J., Leung, P. W. L., & Reimann, B. C. (1998). A cross-cultural study of animal fears. Behaviour Research and Therapy, 36, 735–750. Dong, Q., Yang, B., & Ollendick, T. H. (1994). Fears in Chinese children and adolescents and their relations to anxiety and depression. Journal of Child Psychology and Psychiatry, 35, 351–363. Essau, C. A., & Barrett, P. (2001). Developmental issues in the assessment of anxiety. In C. A. Essau, & F. Peterman (Eds.), Anxiety disorders in children and adolescents: Epidemiology, risk factors, and treatment. London: Harwood Academic Publishers. Essau, C. A., & Petermann, F. (Eds.) (2001), Anxiety disorders in children and adolescents: Epidemiology, risk factors, and treatment. London: Harwood Academic Publishers. Essau, C. A., Conradt, J., & Petermann, F. (2000). Frequency, comorbidity, and psychosocial impairment of anxiety disorders in adolescents. Journal of Anxiety Disorders, 14, 263–279. Essau, C. A., Muris, P., & Ederer, E. M. (2002). Reliability and validity of the ‘‘Spence Children’s Anxiety Scale’’ and the ‘‘Screen for Child Anxiety Related Emotional Disorders’’ in German children. Journal of Behavior Therapy and Experimental Psychiatry, 33, 1–18. Erol, N., & Sahin, N. (1995). Fears of children and the cultural context: the Turkish norms. European Child and Adolescent Psychiatry, 4, 85–93. Feehan, M., McGee, R., & Williams, S. M. (1993). Mental health disorders from age 15 to age 18 years. Journal of the American Academy of Child and Adolescent Psychiatry, 32, 1118–1126. Friedlmeier, W., & Trommsdorff, G. (1998). Japanese and German mother–child interactions in early childhood. In Friedlmeier, W. Friedlmeier, & H. -J. Kornadt (Eds.), Japan in transition—a comparative view on social and psychological aspects. (pp. 217–230). Lengerich: Pabst Science Publishers.
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Ishikawa, S., Oota, R., & Sakano, Y. (2001). Development of the Japanese version of Spence Children’s Anxiety Scale. Waseda Journal of Clinical Psychology, 1, 75 (84). Keller, M. B., Lavori, P. W., Wunder, J., Beardslee, W. R., Schwartz, C. E., & Roth, J. (1992). Chronic course of anxiety disorders in children and adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 31, 595–599. King, N. J., Gullone, E., & Ollendick, T. H. (1990). Childhood anxiety disorders and depression: phenomenology, comorbidity, and intervention issues. Scandinavian Journal of Behaviour Therapy, 19, 59–70. King, N. J., Ollier, K., Iacuone, R., Schuster, S., Bays, K., Gullone, E., & Ollendick, T. H. (1989). Child and adolescent fears: an Australian cross-sectional study using the Fear Survey Schedule for children. Journal of Child Psychology and Psychiatry, 30, 775–784. Klein, R. G. (1991). Parent–child agreement in clinical assessment of anxiety and other psychopathology: a review. Journal of Anxiety Disorders, 5, 187–198. Lewinsohn, P. M., Hops, H., Roberts, R. E., Seeley, J. R., & Andrews, J. A. (1993). Adolescent psychopathology: I. Prevalence and incidence of depression and other DSM-III-R disorders in high school students. Journal of Abnormal Psychology, 102, 133–144. Loeber, R., Green, S. M., & Lahey, B. B. (1990). Mental health professionals’ perceptions of the utility of children, mothers, and teachers as informants on childhood pathology. Journal of Clinical Child Psychology, 19, 136–143. McGee, R., Feehan, M., Williams, S., Partridge, F., Silva, P. A., & Kelly, J. (1990). DSM-III disorders in a large sample of adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 29, 611–619. Morris, R., & Kratchowill, T. (1991). Childhood fears and phobias. In T. Kratchowill, & R. Morris (Eds.), The practice of child therapy. (2nd ed.). New York: Pergamon. Muris, P., Schmidt, H., & Merckelbach, H. (2000). Correlations among two self-report questionnaires for measuring DSM-defined anxiety disorder symptoms in children. The Screen for Child Anxiety Related Emotional Disorders and the Spence Children’s Anxiety Scale. Personality and Individual Differences, 28, 333–346. Ollendick, T. H. (1983). Reliability and validity of the revised Fear Survey Schedule for Children (FSSC-R). Behaviour Research and Therapy, 21, 395–399. Ollendick, T. H., Yang, B., King, N. J., Dong, Q., & Akande, A. (1996). Fears in American, Australian, Chinese and Nigerian children and adolescents: a cross-cultural study. Journal of Child Psychology and Psychiatry, 37, 213–220. Ollendick, T. H., Yule, W., & Ollier, K. (1991). Fears in British children and their relationship to manifest anxiety and depression. Journal of Child Psychology and Psychiatry, 32, 321–331. Reinherz, H. Z., Giaconia, R. M., Lefkowitz, E. S., Pakiz, B., & Frost, A. K. (1993). Prevalence of psychiatric disorders in a community population of older adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 32, 369–377. Reynolds, C. R., & Richmond, B. O. (1985). Revised Children’s Manifest Anxiety Scale. Los Angeles: Western Psychological Services. Spence, S. H. (1997). Structure of anxiety symptoms among children: a confirmatory factor—analytic study. Journal of Abnormal Psychology, 106, 280–297. Spence, S. H. (1998). A measure of anxiety symptoms among children. Behavior Research and Therapy, 36, 545–566. Weisz, J. R., Rothbaum, F. M., & Blackburn, T. M. (1984). Standing out and standing in. The psychology of control in America and Japan. American Psychologist, 39, 955–969. Wittchen, H.-U., & Essau, C. A. (1994). Epidemiology of anxiety disorders. In P. J. Wilner (Ed.), Psychiatry. (pp. 1– Philadelphia: J.B. Lippincott Company.
Anxiety symptoms in Japanese and in German children C.A. Essau a,, Y. Sakano b, S. Ishikawa b, S. Sasagawa b a
Westfa¨lische Wilhelms-Universita¨t Mu¨nster, Psychologisches Institut I, Fliednerstraße 21, 48149 Mu¨nster, Germany b School of Human Sciences, Waseda University, 2-579-15, Mikajima, Tokorozawa, Saitama 359-1192, Japan Received 15 November 2002; received in revised form 28 May 2003; accepted 5 June 2003
Abstract The purpose of this study was to compare the frequency of anxiety symptoms and their association with gender and age in Japanese and German children using the Spence Children’s Anxiety Scale (SCAS). A total of 1837 children (862 from Germany and 975 from Japan) between the age of 8 and 12 years were investigated. Results revealed that German children reported significantly higher symptoms of separation anxiety, social phobia, obsessive compulsive disorder, and generalized anxiety disorder than Japanese children. Conversely, Japanese children reported significantly higher scores on symptoms related to physical injury fear. In both countries, girls scored higher than boys on all the scales of the SCAS. Symptoms of separation anxiety and panic decreased with age, whereas social phobia increased with age. The findings underscore the impact of culture on children’s anxiety. # 2003 Elsevier Ltd. All rights reserved. Keywords: Anxiety symptoms; Spence Children’s Anxiety Scale; Cross-cultural; Children
1. Introduction Research on the etiology, diagnosis, assessment, and treatment of anxiety disorders in children has been increasingly accumulated in the last 20 years (Essau & Petermann, 2001). This growing interest can be attributed to the high prevalence of anxiety disorders and anxietyrelated problems in this age group (Essau, Conradt, & Petermann, 2000; Lewinsohn, Hops, Roberts, Seeley and Andrews, 1993; McGee et al., 1990). Another factor that contributes to the interest and research in this area is the chronicity of anxiety (Cohen et al., 1993; Feehan, McGee, & Williams, 1993; Keller et al., 1992), and the fact that the presence of anxiety
Corresponding author. Tel.: +49-251-83-34152. E-mail address: [email protected] (C.A. Essau).
0005-7967/$ - see front matter # 2003 Elsevier Ltd. All rights reserved. doi:10.1016/S0005-7967(03)00164-5
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symptoms may act as a risk factor for the development of various types of psychiatric disorders in adulthood (Wittchen & Essau, 1994). With few exception (e.g. Dong, Yang, & Ollendick, 1994), studies exploring anxiety in children have been limited to Western countries with similar cultural values (e.g. Australia, Germany, USA). Cross-cultural research on children’s anxiety symptoms has been relatively neglected (Essau & Petermann, 2001). A study of cross-cultural differences and similarities in the nature and prevalence of anxiety may enrich our information regarding anxiety. Empirical research conducted in various cultures should enable us to test the universality of anxiety, and situations or stimuli which elicit anxiety. Since children’s anxiety may reflect social values and a cognitive and social awareness within the family context, knowledge of anxiety in children from different cultural backgrounds may enhance our understanding of children’s anxiety needed for theory building and may provide cues for clinical practice. An important prerequisite for cross-cultural studies is the presence of reliable and valid instruments. The most commonly used instrument for the assessment of children’s fear in crosscultural studies is the Revised Fear Survey Schedule (FFSC-R). Results from Australian (King, Gullone, & Ollendick, 1990; King et al., 1989) and British studies (Ollendick, Yule, & Ollier, 1991) are consistent with those found with white North American samples. In these studies, five factors were found: ‘‘fear of danger and death’’, ‘‘fear of failure and criticism’’, ‘‘fear of unkown’’, ‘‘fear of injury and small animals’’, and ‘‘medical fear’’. In a study that compared fears in children in the US, Australia, China and Nigeria using the FSSC-R (Ollendick, 1983), Nigerian children reported higher levels of fear than Chinese children, who in turn reported higher fear scores than Australian and American children. Children from Australia and America did not differ significantly from each other. It has been suggested that China and Nigeria stress more obedience, self-control, emotional restraint and compliance to social rules, which may account for the elevated social-evaluative and safety fears (Ollendick, Yang, King, Dong, & Akande, 1996). Among Turkish children, fears related to death and separation, as well as religious fears (i.e. going to hell) were highly prevalent in children (Erol & Sahin, 1995). Thus, although similarities in age and gender findings may be consistent across cultures, some differences also existed. The authors argued that these findings may be related to parent’s socialization practice. In order to achieve control and discipline over their children’s behavior, parents often utilize the threat of religious punishment. Another method used by parents to foster dependency and obedience to authority figures is to talk of the dangerous world outside the family. A study by Dong, Yang and Ollendick (1994) showed that Chinese children and adolescents report higher levels of social-evaluative fears than children in Western countries such as Australia, England and the US. According to Dong, Yang and Ollendick (1994), this result can be attributed to the Chinese child-rearing and educational practices that are generally restrictive, overprotective and emotionally unexpressive, placing considerable emphasis on other peoples’ opinions and high achievement in school. While studies using the FSSC-R have enhanced our understanding of fears in various cultures, the FSSC cannot be used to measure the symptoms of DSM-IV anxiety disorders. An ideal questionnaire that can be used for this purpose is the Spence Children’s Anxiety Scale (SCAS; Spence, 1998). Having been translated into various languages (German, Dutch, Japanese) and tested for its reliability and validity in each version, the SCAS is an appropriate ques-
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tionnaire for studying anxiety symptoms in different cultures. Therefore, the main aim of the present study is to compare anxiety symptoms in German and Japanese children using the SCAS. Age and gender differences, and interactions of these variables with culture will also be examined. The special interest is due to marked cultural differences in child-rearing. As discussed by Weisz, Rothbaum, and Blackburn (1984, pp. 965), ‘‘Japanese patterns of child-rearing and socialization seem to foster self-discipline, politeness, attentiveness to others, a strong sense of personal and group identity’’. It has furthermore been argued that Japanese intense ability for accommodation makes them overly sensitive to disapproval. As shown by Friedlmeier and Trommsdorff (1998), Japanese mothers generally teach their children to accommodate to social expectations. Given these child-rearing practices and cultural values (Friedlmeier & Trommsdorff, 1998; Weisz, Rothbaum & Blackburn, 1984), Japanese children, in comparison to German children, were predicted to display a higher number of anxiety symptoms, in particular for social phobia. In line with gender and age findings in Western countries, girls are expected to show higher levels of anxiety than boys, and some anxiety symptoms (those related to separation anxiety, physical injury fears) were expected to decrease with age while others increase with age (e.g. social phobia, obsessive compulsive disorder, panic/agoraphobia, generalized anxiety disorder).
2. Method The sample included 1837 children—862 from Germany and 975 from Japan. Nine hundred and thirty-three (N ¼ 933) of these children were boys (50.8%) and 904 (49.2%) were girls, all in grades 2–7. Children’s age ranged from 8 to 12 years (mean ¼ 10:44, SD ¼ 1:2). The German participants were recruited from two urban and one rural primary schools in Mu¨nster, Germany. The vast majority of the children (92%) were Caucasian, the rest come mostly from Turkey and the former Russia. The socioeconomic status of the subjects varied greatly, ranging from parents with low-skill jobs to physicians. The major objectives and method of this study were explained to the principals and teachers of the participating schools, children, and their parents. School approval and parental written informed consent were obtained before participation in the study; children’s participation was voluntary. About 85% of the children who were invited to participate in the study eventually did so. The Japanese sample was randomly selected from four public schools in the suburban area of Tokyo (residential area). As with the German sample, the socioeconomic status of subjects varied greatly, ranging from parents with low-skill jobs to physicians. The main aims and method of the present study were explained to the school principals, children, and their parents. School approval and informed consent were obtained before participation in the study. Response rate for the Japanese data is 94%. Years 8–9, 10, 11, and 12 were combined to form four age groups. This resulted in a 2 ðgenderÞ 2 ðcultureÞ 4 ðage groupÞ design. The German cells consisted of 90 boys aged 8– 9 years, 119 boys aged 10, 115 boys aged 11, and 101 aged 12. For girls, the respective cell sizes were 57, 113, 137, and 90. The Japanese sample included 169 boys aged 8–9 years, 147 boys aged 10, 145 boys aged 11, and 47 aged 12. For girls, the respective cell sizes were 148, 125, 139, and 55.
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2.1. Instrument The Spence Children’s Anxiety Scale (SCAS; Spence, 1997, 1998) is a 38-item measure of anxiety symptoms in children aged 8–12 years. The SCAS items reflect symptoms of the main DSM-IV anxiety disorders that may occur in children including separation anxiety (six items; e.g. ‘‘I would feel afraid of being on my own at home’’), social phobia (six items; e.g. ‘‘I worry what other people think of me’’), obsessive compulsive disorder (six items; e.g. ‘‘I can’t seem to get bad or silly thoughts out of my head’’), panic/agoraphobia (nine items; e.g. ‘‘I suddenly feel as if I can’t breathe when there is no reason for this’’), physical injury fears (five items; e.g. ‘‘I am scared of dogs’’), and generalized anxiety disorder (six items; e.g. ‘‘When I have a problem, I get a funny feeling in my stomach’’). Each item is rated on a 4-point scale in terms of its frequency from ‘‘never’’ (0) to ‘‘always’’ (3). The 0–3 ratings of the 38 anxiety items are summed to yield a total score, with higher scores reflecting higher levels of anxiety symptoms. Internal consistency and test–retest reliability of the SCAS have been reported as satisfactory, with alphas generally well above 0.70 and a test– retest correlation coefficient of 0.60. The scale also demonstrated acceptable convergent validity as demonstrated by a significant correlation with the Revised Children’s Manifest Anxiety Scale (RCMAS; Reynolds & Richmond, 1985) (r ¼ 0:71). Furthermore, clinically anxious children had significantly higher SCAS scores and marked particularly high scores on the subscales that reflected the anxiety disorders they suffered from (i.e. social phobia and separate anxiety disorder). The English version of SCAS was adapted and translated to German and Japanese languages according to the guidelines that are widely accepted for the successful translation of instruments in cross-cultural research (Brislin, 1970). One bilingual translator who was also a native speaker or culturally informed individual blindly translated the SCAS from the original language (English) to the second language (German or Japanese), and another bilingual translated it back to the original language (German back to English; Japanese back to English). Differences in the original and the back-translated versions were discussed and resolved by joint agreement of both translators. The reliability and the validity of the German SCAS (SCAS-G) has been examined in a sample of German primary school children (Essau, Muris, & Ederer, 2002). The SCAS-G was demonstrated to have high internal consistency, with Cronbach’s alpha being 0.92 and GuttmanSplit-half being 0.90. The validity of the SCAS-G was supported by the following findings. First, in agreement with previous studies, girls displayed significantly higher levels of anxiety symptoms than boys. Second, SCAS scores were substantially interrelated with another measure of anxiety symptoms (the SCARED; r ¼ 0:85; p < 0:001Þ. Finally, significant correlations were found between the SCAS and the Youth Self-Report (Achenbach, 1991) (r ¼ 0:67; p < 0:001) and the Columbia Impairment Scale (Bird et al., 1996) (r ¼ 0:41; p < 0:001). The reliability and validity of the Japanese version of the SCAS (SCAS-J) has been examined in a group of 934 primary school children (Ishikawa, Oota, & Sakano, 2001). It has high internal consistency, with an alpha of 0.88 for the total scores of the SCAS. High correlation was demonstrated with the Children’s Form of Manifest Anxiety Scale (Castenada, McCandless, & Plermo, 1956) (r ¼ 0:73, p < 0:01).
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3. Results Group differences were tested with respect to the scores for total SCAS and each subscale. Given the high statistical power afforded by the large sample sizes, only differences reaching p < 0:01 were accepted as significant. 3.1. Total SCAS scores The first step in our analysis was to perform a 2 2 4 (gender culture age) ANOVA on the total SCAS score. The means and standard deviations for the total SCAS scores, as well as their subscales are presented in Table 1. Although no significant differences were found in the total SCAS scores, significant group differences were found in five of the six subscales. Specifically, a 2 2 4 (gender culture age) ANOVA on the SCAS subscales revealed significant main effect of culture for separation anxiety (Fð1; 1836Þ ¼ 7:29, p < 0:01), social phobia (F ð1; 1836Þ ¼ 22:28, p < 0:001), obsessive compulsive disorder (Fð1; 1836Þ ¼ 83:66, p < 0:001), physical injury fear (F ð1; 1836Þ ¼ 101:03, p < 0:001), and generalized anxiety disorder (F ð1; 1836Þ ¼ 89:26, p < 0:001). The only subscale which did not reveal any significant main effect was panic disorder. These results revealed that German children reported significantly higher scores on separation anxiety, social phobia, obsessive compulsive disorder, and generalized anxiety disorder than the Japanese children. By contrast, the Japanese children reported significantly higher scores on physical injury fear. A significant main effect of gender was found for all the subscales of SCAS, indicating that girls reported higher scores than boys. The mean total SCAS scores for girls was 27.21 (SD ¼ 15:6) and for boys was 18.20 (SD ¼ 11:7). None of the interactions was significant. A main effect of age was found for separation anxiety, panic, and social phobia; the first two showed a decrease with age, whereas the latter (social phobia) displayed an increase with age. Given the unexpected findings on the relationship between panic and age, an extra analysis was conducted. This analysis showed that panic symptoms had no significant main effect in the Japanese children (F ð3; 974Þ ¼ 1:22, p ¼ 0:30), but a significant main effect of age was found in German children (Fð3; 861Þ ¼ 4:52, p ¼ 0:004). 3.2. Most common anxiety symptoms To explore the most common anxiety symptoms, the ten anxiety symptoms rated with high frequency (i.e. rated with either ‘‘often’’ or ‘‘always’’) were tabulated for the total sample and separately by gender, age and culture (Table 2). Inspection of Table 2 reveals that two of the ten most common anxiety were symptoms of separation anxiety disorder, two were symptoms of social phobia, three obsessive compulsive disorder, two generalized anxiety disorder, and only one symptom for physical injury fear. Seven of the ten most common anxiety symptoms reported by boys and girls were the same symptoms. It should, however, be noted that a higher percentages of these symptoms were reported by girls than by boys. Six of ten anxiety symptoms were the same across the different age groups. The two separation anxiety disorder symptoms were most frequently reported in the younger (8–9, 10 and 11 year olds) than in the older (12 year olds) age groups. For culture, six
4.64 (3.4) 3.70 (2.8) 5.55 (3.6) 3.96 (3.3) 4.78 (3.4) 4.90 (3.3) 4.77 (2.9)
4.23 (2.9) 3.75 (2.6) 4.69 (3.2) 4.26 (3.0) 4.54 (2.8) 4.23 (3.1) 3.81 (2.9)
4.18 (3.4) 3.09 (2.8) 5.29 (3.6) 3.73 (3.4) 4.19 (3.4) 4.39 (3.4) 4.52 (3.3)
Social phobia Total Boys Girls 8–9 Years 10 Years 11 Years 12 Years
Obsessive compulsive disorder Total 3.59 (2.7) Boys 3.23 (2.4) Girls 3.96 (2.9) 8–9 Years 3.52 (2.7) 10 Years 3.70 (2.6) 11 Years 3.62 (2.7) 12 Years 3.48 (2.6)
3.75 (2.8) 3.05 (2.2) 4.44 (3.1) 4.56 (2.9) 3.88 (2.9) 3.54 (2.8) 3.08 (2.5)
3.61 (3.0) 2.78 (2.5) 4.47 (3.3) 4.21 (3.2) 3.73 (3.1) 3.30 (3.0) 2.94 (2.5)
Separation anxiety Total Boys Girls 8–9 Years 10 Years 11 Years 12 Years
22.86 (14.2) 18.39 (11.0) 27.20 (15.5) 22.89 (14.0) 23.86 (14.6) 23.33 (15.0) 20.96 (12.6)
Germany mean (SD)
22.63 (14.5) 18.20 (11.7) 27.21 (15.7) 23.05 (15.1) 23.11 (14.6) 22.64 (14.8) 21.07 (12.4)
Total mean (SD)
Total anxiety score Total Boys Girls 8–9 Years 10 Years 11 Years 12 Years
SCAS-subscales
3.03 (2.3) 2.80 (2.2) 3.28 (2.4) 3.08 (2.5) 2.99 (2.2) 3.07 (2.3) 2.87 (1.9)
3.77 (3.4) 2.59 (2.8) 3.28 (2.4) 3.60 (3.5) 3.68 (3.3) 3.95 (3.3) 4.04 (3.1)
3.49 (3.2) 2.55 (2.6) 4.50 (3.5) 4.01 (3.4) 3.60 (3.2) 3.09 (3.1) 2.66 (2.6)
22.44 (14.9) 18.04 (12.4) 27.21 (15.8) 23.14 (15.7) 22.47 (14.7) 22.03 (14.7) 21.27 (12.4)
Japan mean (SD)
Table 1 Mean scores and standard deviations on the SCAS in Japanese and German school children
Country: Fð1; 1836Þ ¼ 83:66, p < 0:001 Gender: Fð1; 1836Þ ¼ 28:22, p < 0:001 Age: Fð3; 1836Þ ¼ 1:52, p ¼ 0:21
Country: Fð1; 1836Þ ¼ 22:28, p < 0:001 Gender: Fð1; 1836Þ ¼ 179:85, p < 0:001 Age: Fð3; 1836Þ ¼ 3:42, p ¼ 0:017
Country: Fð1; 1836Þ ¼ 7:29, p < 0:01 Gender: Fð1; 1836Þ ¼ 133:76, p < 0:001 Age: Fð3; 1836Þ ¼ 17:64, p < 0:001
Country: Fð1; 1836Þ ¼ 0:29, p ¼ 0:59 Gender: Fð1; 1836Þ ¼ 168:98, p < 0:001 Age: Fð3; 1836Þ ¼ 1:83, p ¼ 0:14
Effects
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3.41 2.81 4.03 3.49 3.39 3.45 3.23
4.06 3.41 4.73 3.87 4.17 4.10 4.14
Physical injury fears Total Boys Girls 8–9 Years 10 Years 11 Years 12 Years
Generalized anxiety Total Boys Girls 8–9 Years 10 Years 11 Years 12 Years (3.0) (2.6) (3.2) (2.9) (3.0) (3.1) (2.7)
(2.8) (2.6) (2.7) (2.8) (2.7) (2.7) (2.5)
(3.4) (2.6) (3.8) (3.5) (3.4) (3.5) (2.7)
Note: SCAS, Spence Children’s Anxiety Scale.
2.86 2.03 3.71 3.15 3.02 2.79 2.19
Total mean (SD)
Panic disorder Total Boys Girls 8–9 Years 10 Years 11 Years 12 Years
SCAS-subscales
Table 1 (continued )
4.79 3.99 5.56 4.39 5.06 4.97 4.60
2.75 2.08 3.40 2.62 2.74 2.89 2.71
2.70 1.81 3.56 3.10 2.87 2.80 1.98
(2.9) (2.4) (3.0) (2.7) (3.0) (3.0) (2.5)
(2.4) (1.9) (2.5) (2.4) (2.2) (2.2) (2.4)
(3.2) (2.2) (3.7) (3.1) (3.4) (3.5) (2.3)
Germany mean (SD)
3.42 (3.4) 2.93 (2.7) 3.96 (3.1) 3.56 (3.0) 3.41 (2.9) 3.33 (3.1) 3.27 (2.1)
3.99 (2.9) 3.42 (2.9) 4.62 (2.9) 4.00 (3.0) 3.95 (3.0) 3.95 (2.9) 4.19 (2.6)
2.99 (3.5) 2.21 (2.8) 3.85 (4.0) 3.18 (3.7) 3.15 (3.5) 2.78 (3.4) 2.59 (3.3)
Japan mean (SD)
Country: Fð1; 1836Þ ¼ 89: 26, p < 0:001 Gender: Fð1; 1836Þ ¼ 86:58, p < 0:001 Age: Fð3; 1836Þ ¼ 1:4, p ¼ 0:33
Country: Fð1; 1836Þ ¼ 101:03, p < 0:001 Gender: Fð1; 1836Þ ¼ 86:49, p < 0:001 Age: Fð3; 1836Þ ¼ 0:15, p ¼ 0:93
Country: Fð1; 1836Þ ¼ 2:82, p ¼ 0:09 Gender: Fð1; 1836Þ ¼ 105:46, p < 0:001 Age: Fð3; 1836Þ ¼ 4:82, p < 0:01
Effects
C.A. Essau et al. / Behaviour Research and Therapy 42 (2004) 601–612 607
16.4f 19.6
22.7 27.4 21.7h
18.6 26.8
16.9 17.1 17.2 12.4e 17.0 14.5 14.8
23.9 21.8 19.9 19.8 19.3 19.0 17.8
21.4
21.0j
16.8k
21.5
18.7
19.0
21.7
20.6
23.8
27.6 29.4
37.1
10
17.1l
19.4
20.5
23.3
20.0
14.0n
18.1
13.7i 14.7m
20.7
21.2
19.9
18.2
23.5
28.7
10.0d 15.5g
15.6c
24.7
38.9 39.9
32.7
Japan
28.7
23.1
21.2 16.6a
40.0
Germany
17.7
20.5
16.9
16.7
26.6
16.3b 17.6
33.5 20.9
31.0
12
31.8 30.0
34.9
11
Culture
Superscript indicates that this anxiety symptom was not one of the top 10 for this sub-sample, even though it was one of the 10 most common for the sample as a whole. 0 a When I have a problem, I get a funny feeling in my stomach (20.0%). b I get bothered by bad or silly thoughts or pictures in my mind (19.2%). c I am scared of dogs (21.0%). d I have to do some things over and over again (like washing my hands, cleaning or putting things in a certain order) (19.4%). e I have to do some things over and over again (like washing my hands, cleaning or putting things in a certain order) (14.7%). f I am scared of the dark (19.3%). g I feel scared when I have to take a test (19.1%). h I feel afraid that I will make a fool of myself in front of people (23.5%). i I feel afraid that I will make a fool of myself in front of people (20.2%). j I am scared of the dark (22.2%). k I am afraid of being in crowded places (like shopping centers, the movies, buses, busy playgrounds) (18.5%). l I feel afraid that I will make a fool of myself in front of people (17.9%). m I feel scared when I have to take a test (17.7%). n I feel afraid that I will make a fool of myself in front of people (18.6%).
19.4
20.0
30.4
20.0
30.7 32.2
23.9
26.6
31.3
43.0 31.2
39.2
30.6 28.9
42.7
29.7
36.1
11. I worry that something awful will happen to someone in my family 29. I am scared of insects or spiders 13. I have to keep checking that I have done things right (like the switch is off, or the door is locked) 10. I worry that I will do badly at my school work 8. I worry about being away from my parents 37. I have to do some things in just the right way to stop bad things happening 26. I worry what other people think of me 17. I can’t seem to get bad or silly thoughts out of my head 20. I worry that something bad will happen to me 18. When I have a problem, my heart beats really fast
8/9
Boys
Girls
Age (years)
Gender
Total
Items
Table 2 Ten most common anxiety symptoms by gender, age and culture (percent children endorsed; rated as ‘‘often’’ or ‘‘always’’) 608 C.A. Essau et al. / Behaviour Research and Therapy 42 (2004) 601–612
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of the ten most commonly reported anxiety symptoms were the same as those reported by the whole sample, and among the Japanese children, it was nine of ten. For Japanese children ‘‘I worry about being away from my parents’’ was replaced by ‘‘I am scared of dogs’’. For the German children, ‘‘I have to keep checking that I have done things right (like the switch is off, or the door is locked)’’, ‘‘I have to do some things in just the right way to stop bad things happening’’, ‘‘I worry what other people think of me’’, and ‘‘When I have a problem, my heart beats really fast’’ were replaced by ‘‘I feel scared when I have to take a test’’, ‘‘I feel afraid that I will make a fool of myself in front of people’’, ‘‘When I have a problem, I get a funny feeling in my stomach’’, and ‘‘I have to do some things over and over again (like washing my hands, cleaning or putting things in a certain order).’’ 3.3. Factor structure Confirmatory factor analyses were carried out on the SCAS, separately for the German and the Japanese samples. For this purpose, EQS, the structural equations modeling approach (Bentler, 1995) was used. A 5-correlated-factor model in the German sample provided a good fit for the data: comparative fit index ðCFIÞ ¼ 0:94, normed fit index ðNFIÞ ¼ 0:89, non-normed fit index ðNNFIÞ ¼ 0:92; RMR ¼ 0:03, and RMSEA ¼ 0:04. A good fit was also found in the Japanese sample: CFI ¼ 0:92; NFI ¼ 0:87; NNFI ¼ 0:89; RMR ¼ 0:03, and RMSEA ¼ 0:04. Overall, the factor structure of the SCAS showed more similarities than differences in Germany and in Japan. In both countries, generalized anxiety and obsessive compulsive disorder could not be extracted as a single factor. However, it should be noted that all items in the obsessive compulsive disorder factor (of the original Australian SCAS; Spence, 1997, 1998) loaded onto a single factor. Separation anxiety disorder loaded onto two factors, and the items in these two factors were very similar in the two countries. In Germany, obsessive compulsive disorder, generalized anxiety, and social phobia all loaded onto a single factor. In Japan, panic disorder was divided into two factors, and loaded on generalized anxiety and obsessive compulsive disorder.
4. Discussion The main purpose of this article was to compare the frequency of anxiety symptoms and their association with age and gender in German and Japanese children using the SCAS. Before interpreting our findings, some limitations should be discussed. First, only 8–12-year-old school children were included in our study, so it is not clear whether our findings can be generalized to other populations (e.g. clinical setting) and age groups (e.g. adolescents). Second, the data was solely based on child self-report. Although it is widely acknowledged that the best method to assess children’s psychopathology in children is via multiple informants (Essau & Barrett, 2001), studies have found parents and teachers less satisfactory as informants of internalizing problems in comparison to externalizing problems (Klein, 1991; Loeber, Green, & Lahey, 1990). Given the low agreement among informants, the use of child self-report seemed justifiable given the fact that anxiousness is an internally-derived experience. Third, our study did not include any measures of social desirability effects. It could be that the Japanese children were more
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influenced by social desirability effects than by the German children. This could have explained for our finding of the lower than expected scores of anxiety symptoms among Japanese children. In order to examine the possible effects of social desirability, future cross-cultural studies should include the Revised Children’s Manifest Anxiety Scale—lie scale (Reynolds & Richmond, 1985). Fourth, our findings may be limited by issues which plague all cross-cultural research. Specifically, difference in response styles may have affected our findings. However, we are not aware of research that supports differences in response styles across these cultures. The mean anxiety scores for Japanese children was 22.44 and for German children was 22.86. These findings fall in the middle range of what has been reported previously. For example, in a large sample of Dutch children, the mean SCAS score was 18.11 (Muris, Schmidt, & Merckelbach, 2000), whereas in Australian children, scores of 28.59 and 25.28 have been reported (Spence, 1998), and in our earlier study, the mean score was 22.24 (Essau, Muris & Ederer, 2002). The overall levels of anxiety symptoms were equivalent across the two cultures, with significant differences in the subtypes of anxiety. That is, German children compared to Japanese children had significantly higher scores on separation anxiety, social phobia, obsessive compulsive disorder, and generalized anxiety disorder, and the opposite was true for physical injury fear. Future studies need to explore if child-rearing and educational practices ascribed to the Japanese culture are related to the lower levels of separation anxiety, social phobia, obsessive compulsive disorder, and generalized anxiety disorder symptoms. In contrast to our expectation, Japanese child-rearing practices do not seem to have detrimental effects. Instead, they appear to be associated with reduced levels of anxiety in some domains. Why Japanese children retained higher scores on physical injury fear (i.e. higher fear of dark, dogs, insects or spiders, and being in high places) is unclear. Similar result has been found by Davey et al. (1998). In that study, Japanese students were reported to be significantly more fearful of spiders than students in India, UK, USA, Korea, and Hong Kong. Compared to boys, girls had significantly higher scores on all subscales of SCAS. The gender difference in the frequency of anxiety symptoms replicated previous studies showing that more girls than boys were affected by anxiety symptoms (Essau, Conradt & Petermann, 2000; Lewinsohn, Hops, Roberts, Seeley & Andrews, 1993; Reinherz, Giaconia, Lefkowitz, Pakiz, & Frost, 1993). The exact meaning of this gender difference is, however, unclear. Some authors (e.g. Morris & Kratchowill, 1991) argued that girls compared to boys are socialized to be more fearful and are reinforced when reporting their inner worries and fears. If true, such socialization practices seem to be present in Germany and Japan. Our findings also demonstrated age differences in the number of anxiety symptoms. While separation anxiety and panic/agoraphobia decreased with age, generalized anxiety tended to increase as children became older. In the study by Spence (1997), the mean scores for separation anxiety, obsessive compulsive symptoms, and panic/agoraphobic problems declined with age, whereas no significant age effects were found for physical injury fears or generalized anxiety symptoms. Our finding that panic/agoraphobia symptoms decreased with age was surprising given the debate that children can experience panic attack only at a certain age. In fact, our results indicated that younger children reported having experienced symptoms related to panic such as ‘‘I suddenly feel as if I can’t breathe when there is no reason for this’’, and ‘‘All of sudden I feel really scared for no reason at all’’; only one symptom was related to agoraphobia,
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‘‘I am afraid of being in crowded places (like shopping centers, the movies, buses, busy playgrounds)’’. In summary, most of our knowledge on anxiety in children has come from studies in Western countries. The present study has attempted to compare the frequency of anxiety symptoms and their association with age and gender in Japanese and German children. Generally, the pattern of age and gender differences found in our study replicated previous findings. However, in contrast to our hypothesis, German children had significantly higher scores on symptoms related to various types of DSM-IV anxiety disorders than their Japanese counterparts. More studies are needed to explore cultural context and environmental experiences that account for the higher rates of anxiety in German than Japanese children.
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