Assessment of anxiety in children and adolescents with autism spectrum disorders

Research in Autism Spectrum Disorders 6 (2012) 1345–1365

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Research in Autism Spectrum Disorders Journal homepage: http://ees.elsevier.com/RASD/default.asp

Review

Assessment of anxiety in children and adolescents with autism spectrum disorders Sabrina N. Grondhuis, Michael G. Aman * The Ohio State University, United States

A R T I C L E I N F O

A B S T R A C T

Article history: Received 26 April 2012 Accepted 27 April 2012

Anxiety disorders are among the most common comorbid conditions in children and adolescents with autism spectrum disorders (ASDs), although assessment presents unique challenges. Many symptoms of anxiety appear to overlap with common presentations of autism. Furthermore, deficits in language and cognitive functioning make it difficult for such children to convey their emotional states accurately. A comprehensive review of the recent literature was conducted to assay the types and rates of use of tools for evaluating anxiety symptoms in children and adolescents with ASDs. We identified strengths and weaknesses in existing scales, identified instruments that (although imperfect) seem to have a good coverage for youngsters with ASDs, recommended strategies for studying anxiety in these youth, and offered suggestions for future scale development. ß 2012 Elsevier Ltd. All rights reserved.

Keywords: Anxiety Autism Assessment

Contents 1. 2.

3. 4.

5.

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Measurement problems. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Overlap of symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.1. Restrictions due to language and cognitive functioning. . . . . . . . . . . . . . . . . . . . . . . . 2.2. Current prevalence of anxiety disorders in children with ASDs . . . . . . . . . . . . . . . . . . . . . . . Review of anxiety assessment measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Autism Comorbidity Interview–Present and Lifetime Version (ACI-PL) . . . . . . . . . . . . 4.1. Anxiety Disorders Interview Schedule for DSM-IV–Child and Parent Versions (ADIS) 4.2. 4.3. Autism Spectrum Disorders–Comorbid for Children (ASD-CC). . . . . . . . . . . . . . . . . . . Baby and Infant Scale for Children with Autistic Traits (BISCUIT) . . . . . . . . . . . . . . . . 4.4. 4.5. Behavioral Assessment System for Children-2 (BASC-2) . . . . . . . . . . . . . . . . . . . . . . . Child Behavior Checklist (CBCL). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.6. 4.7. Child Symptom Inventory (CSI) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Multidimentional Anxiety Scale for Children (MASC). . . . . . . . . . . . . . . . . . . . . . . . . . 4.8. 4.9. Social Anxiety Scale for Children-Revised (SASC-R) . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.10. Spence Children’s Anxiety Scale (SCAS). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Summary and conclusions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

* Corresponding author. Tel.: +1 614 688 4196. E-mail addresses: [email protected] (S.N. Grondhuis), [email protected] (M.G. Aman). 1750-9467/$ – see front matter ß 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.rasd.2012.04.006

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1. Introduction Autism spectrum disorders (ASDs) are a category of pediatric neurodevelopmental conditions that include autistic disorder (AD), Asperger syndrome (AS), Rett’s disorder, childhood disintegrative disorder, and pervasive developmental disorder–not otherwise specified (PDD-NOS; American Psychiatric Association [APA], 2000). AD, AS, and PDD-NOS occur relatively frequently in the population (estimates vary considerably, but the United States Center for Disease Control [2012] has suggested that 1 out of 88 children is diagnosed with an ASD). However, Rett’s disorder and childhood disintegrative disorder are quite rare in comparison and usually are not included under the ASD classification unless specifically designated (Fombonne et al., 2004). One topic that has recently become a common focus of investigation in children with ASDs is comorbid psychopathology and its associated treatments (Bradley, Summers, Wood, & Bryson, 2004; de Bruin, Ferdinand, Meester, de Nijs, & Verheij, 2007; Lainhart, 1999; Lecavalier, 2006). This is at least partially because ASDs are such heterogeneous categories and consequently have diversity in symptom severity, presentation, and etiology (Piven et al., 1991). Anxiety disorders are quite common in children and adolescents with ASDs, and anxiety has a history of exacerbating the level of impairment experienced by persons with ASDs (e.g., Green & Ben-Sasson, 2010; Leyfer et al., 2006; Moree & Davis, 2010; White, Oswald, Ollendick, & Scahill, 2009). Even though the relationship between anxiety and ASD has only recently become a focus of research (Fodstad, Rojahn, & Matson, 2010), there has been a known association between the two conditions since the original account of autism (Kanner, 1943). In this paper we shall discuss challenges that clinicians and researchers face when evaluating anxiety in children with ASDs. We conducted a review of the recent literature using anxiety-assessment instruments published since 2000 to assess the scope of comorbid anxiety and to determine which measures are being used by researchers. The most common instruments were then examined to determine whether they are appropriate for children with ASD and if they have sound psychometric properties. Recommendations for future researchers and clinicians wishing to explore this area follow. 2. Measurement problems 2.1. Overlap of symptoms Diagnosing anxiety in children who have ASDs can be problematic because many of the conditions’ features (avoidance, irritability, fears, abnormal sleep habits, etc.) are found in both groups of conditions (Kim, Szatmari, Bryson, Streiner, & Wilson, 2000; Mayes, Calhoun, Murray, Ahuja, & Smith, 2011; Tsai, 1996). When this happens frequently (as in the case of Attention-Deficit Hyperactivity Disorder [ADHD] and ASDs) clinicians are encouraged not to diagnose the comorbid condition formally since the problems could be attributed entirely to the core symptoms of the ASD. However, some investigators question whether that is true or if anxiety conditions are ‘‘separate, but co-occurring problem(s)’’ (White, Oswald, et al., 2009; Mason & Scior, 2004). When this situation occurs, professionals can be subject to a ‘‘diagnostic overshadowing bias,’’ or the attribution of the symptoms to the previously diagnosed condition rather than an additional mental health problem (Mason & Scior, 2004). Proper assessment (both through questionnaires and observation) of the current cluster of symptoms experienced by the patient would allow skilled clinicians to determine whether impairments displayed are a product of the ASD or co-occurring conditions (Leyfer et al., 2006; Matson & Nebel-Schwalm, 2007; Wood et al., 2009). The current version of the DSM (DSM-IV-TR) does not permit persons with an ASD to be diagnosed with additional diagnoses of generalized anxiety disorder (GAD), separation anxiety disorder, or social phobia (APA, 2000). Although these guidelines are the official recommendation of the APA, it does not mean that a youngster with ASD cannot experience clinically significant anxiety, but rather that he or she would not receive an official diagnosis of anxiety in addition to his or her ASD. The DSM’s guidelines do not preclude additional symptoms (i.e., anxiety) unrelated to ASD core features from intensifying symptoms that are connected with ASDs or further affecting functioning (Weisbrot, Gadow, DeVincent, & Pomeroy, 2005). 2.2. Restrictions due to language and cognitive functioning Communication deficits are one of the three core domains of ASDs, and up to 50% of people diagnosed with AD are functionally nonverbal (Leyfer et al., 2006). In addition to affecting the way people interact with the world, communication may influence the way people with ASDs experience comorbid conditions such as anxiety. There appears to be an inverse relationship between language ability and anxiety symptoms in children and adolescents on the spectrum. The greater the communication deficit, the less anxiety appears to be a problem for those with ASDs (Davis, Moree, et al., 2011). The expression of anxiety symptoms seems greatest for individuals who are higher functioning (i.e., without severe language or cognitive delays; Chalfant, Rapee, & Carroll, 2007), which typically include either people with AS or those with an ASD but without intellectual disability (ID; APA, 2000). While it is important to note that higher-functioning children with better language skills and greater cognitive functioning are reported as being more prone to anxiety symptoms, it is possible that this linkage is a fallacy. Lowerfunctioning children may not have the insight or level of intelligence required to understand and/or express the emotions

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that they are feeling (Russell & Safronoff, 2005). This self-disclosed experience of unease is the most common way for others to identify anxiety as a problem (Myrbakk & von Tetzchner, 2008; Wood et al., 2009). This suggests that the children themselves might be poor self-raters of their symptoms and also that lack of communication may be a barrier to parents’ or caregivers’ awareness of such symptoms. Either situation could lead to a perception of lower prevalence rates because of reporting impediments that prevent recognition (Hagopian & Jennett, 2008). It is also interesting to note that, in one study, early language skills did not predict anxiety later in life for children with ASDs (Kim et al., 2000). However, others have reported that children with ASDs and intellectual disability have higher rates of anxiety than children with similar intellectual functioning but without ASDs (Bradley et al., 2004; Sukhodolsky et al., 2008). 3. Current prevalence of anxiety disorders in children with ASDs Although anxiety disorders are only found in around 5% of the typically developing population (King & Ollendick, 1997), Ghaziuddin (2002) noted that anxiety concerns are more common for both children and adolescents with an ASD, particularly in those with AS. It stands to reason that AS might be at the highest risk for anxiety symptoms, because those with AS usually possess average or above levels of intelligence and consequently have the language capacity to interact with peers. In one study (Russell & Safronoff, 2005) ratings on the Spence Children’s Anxiety Scale (Spence, 1997) indicated that children with AS had significantly more anxiety than a comparison group of clinically anxious children. There is a variety of measures that can be used to assess anxiety in children with ASDs. Indeed, some assessments were specifically designed for persons with ASDs. Variation in assessment tools can produce differing prevalence estimates. White, Oswald, et al. (2009) completed a comprehensive review of the literature and reported that the epidemiological studies they evaluated had prevalence rates of anxiety ranging from 11% to 84% in children with ASDs (including all three subtypes). However, for most cases the prevalence appeared to be closer to 40–50% rather than the more extreme prevalence estimates cited (Moree & Davis, 2010). Research has demonstrated that the type of anxiety disorders experienced by those with an ASD diagnosis may be somewhat unusual (Farrugia & Hudson, 2006). Muris, Steernemen, Merckelbach, Holdrinet, and Meesters (1998) found that, in their sample of 15 children with AD and 29 with PDD-NOS, simple (or specific) phobia was the most common anxiety condition (63.3%) and panic disorder was the least frequent (9.1%). The remaining diagnoses ranged from 11.4% (obsessivecompulsive disorder) to 45.5% (agoraphobia). There were no statistically significant differences between males and females with ASDs in the total number or type of symptoms experienced (Worley & Matson, 2011). 4. Review of anxiety assessment measures There are quite a few measures available to assess anxiety in both children and adolescents, but that does not necessarily mean that they are appropriate for all individuals. Rarely have measures been designed specifically to address anxiety in children with ASDs (MacNeil, Lopes, & Minnes, 2009; Reaven et al., 2009). This makes assessment of comorbid conditions particularly challenging, because of the special cluster of symptoms that youngsters with ASDs possess. Presenting characteristics may be attributed primarily to either the ASD or may be interpreted as a comorbid condition. Because it can be difficult to disentangle anxiety symptoms from ASD symptoms, it is important to use assessments that take the unique profile of ASDs into account in determining whether comorbid anxiety constitutes a separate condition. An accurate diagnosis could guide clinicians and researchers to recommend the additional management for the presenting symptomatology (White, Ollendick, Scahill, Oswald, & Albano, 2009) and could alert caregivers that there are other symptoms that need to be addressed. In order to determine the rate of anxiety scales being used with children with ASDs, we conducted a comprehensive literature search for articles published since 2000 in journals with a disability- or autism-specific focus. The turn of the century was chosen as an appropriate cutoff time since it would provide an impression of the popularity of measures for more than the past decade. The attractiveness of research topics waxes and wanes with the progress made in the field, and new instruments are typically developed to reflect what is considered to be a construct of interest at the time. It seemed imprudent then, to go back further, because the assessments used may be out of date and subsequently no longer used. Conversely, if the assessments used from pre-2000 articles are not out of date, they would still be captured in this review. This search was conducted using PsycInfo, Medline, and Google Scholar with various combinations of the terms ‘‘anxiety,’’ ‘‘anxious,’’ ‘‘children,’’ ‘‘adolescents,’’ ‘‘comorbidity,’’ ‘‘autism,’’ ‘‘Asperger,’’ or ‘‘pervasive.’’ Then, a manual search was done using an online journal database by looking through all abstracts from the most popular journals in the IDD field. These searches produced 60 articles that met the desired criteria of evaluating psychopathology or anxiety symptoms as the primary focus in children or adolescents with ASDs that were published no earlier than 2000. We imposed a ‘‘primary focus’’ rule that required that children were being assessed or selected by some tool. This is because many researchers published information about anxiety because it was included in a measure already in place, rather than employing an instrument that they thought was suited for measuring anxiety. We made every attempt to ensure thoroughness, but there is always the chance that we inadvertently missed relevant studies. The identified articles used a total of 36 different measures to assess symptoms of anxiety, although with varying definitions about what anxiety encompasses (worry, fears, avoidance, etc.). Two of the articles (Johnson & Hollander, 2003; O’Connor, 2009) did not report using any measures, and instead evaluated improvement using subjective observations. The

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majority of the instruments were only used in a single study, and it did not seem prudent to evaluate measures that were used sparingly. Instead, measures were critiqued here if they were used by more than 5.0% (three articles) of those found. This review includes 10 out of the original 36 scales (28%). For short article summaries, please refer to Table 1, and for a complete list of measures used and their frequency in the recent literature, please refer to Table 2. 4.1. Autism Comorbidity Interview–Present and Lifetime Version (ACI-PL) The ACI-PL (Leyfer et al., 2006) is a structured psychiatric parent interview that was used in three articles (Leyfer et al., 2006; Mazefsky, Conner, & Oswald, 2010; Mazefsky, Kao, & Oswald, 2011). All three studies focused on the prevalence rates of anxiety subtypes [e.g., specific phobias (SP), separation anxiety disorder (SAD)] and other common disorders, such as depression, in children and adolescents with ASDs (see Table 1). The tool was developed by modifying the Kiddie Schedule for Affective Disorders and Schizophrenia (K-SADS; Ambrosini, 2000) to address the presentation of various disorders in children with ASDs and by adjusting the coding procedures. All disorders included in the original measure were evaluated in an attempt to differentiate whether impairment was due to core features of ASDs or from a comorbid disorder. Inter-rater reliability was established for three disorders using existing literature norms established by Fleiss (1981). Inter-rater agreement for obsessive-compulsive disorder (OCD) and ADHD was good (both had kappa = .70) and for major depressive disorder kappa was excellent (.80). Criterion validity was investigated with ADHD and major depression diagnoses, and for both disorders sensitivity was 100% and specificity was 93%. Anxiety was not evaluated for either construct, although the authors did suggest that SPs were the most common lifetime diagnosis, with 44% of the children evaluated meeting criteria (Leyfer et al., 2006). Other prevalence estimates suggested that 12% of children with ASDs qualified for SAD, 7.4% qualified for social phobia (SoP), and almost none satisfied criteria for generalized anxiety disorder. However, that could be a reflection of poor evaluation criteria rather than an indication of low prevalence for GAD. Concurrent validity was established by comparing OCD diagnosis on the ACI-PL (Leyfer et al., 2006) with questions related to compulsions on the Autism Diagnostic Interview–Revised (Lord, Rutter, & Le Couteur, 1994), and a Spearman’s correlation between the two subscales indicated a degree of correspondence (rho = .57; Leyfer et al., 2006). The ACI-PL is a potentially promising measure for evaluating psychiatric disorders in persons with ASDs since it was designed specifically for that purpose. Unfortunately, its utility for assessing anxiety disorders is largely unestablished, as no psychometric characteristics were reported for anxiety disorders (only OCD and major depressive disorder). Another drawback to this tool is that it is confined to parent informants and does not allow for self report in verbal children. Multiple responders usually result in multiple perspectives with internalizing disorders, and it is entirely possible that clinicians could miss valuable information that could be provided by the children concerned. Additionally, the interview assumes similar presentation of anxiety disorders in children with and without ASDs. 4.2. Anxiety Disorders Interview Schedule for DSM-IV–Child and Parent Versions (ADIS) The ADIS (Silverman & Albano, 1996) was used in six of the articles reviewed (Chalfant et al., 2007; Drahota, Wood, Sze, & Van Dyke, 2011; Sze & Wood, 2007, 2008; White, Ollendick, et al., 2009; Wood et al., 2009), and all used the tool as an outcome measure for cognitive behavioral therapy (see Table 1). It is a semi-structured interview designed for children and adolescents aged 6–17 years. There is both a parent and a youth version, which are almost identical with the exception that the parent version includes questions related to externalizing disorders, and the child version uses child-appropriate language and picture prompts for clarity. The assessment uses an ‘‘interviewer–observer’’ format and relies on diagnostic criteria provided by the current version of the DSM. Although the title suggests that this measure is only for anxiety disorders, it also screens for other psychological conditions common in childhood. There is a separate interference rating to determine how much any symptoms impact daily activities, and when taken together with the endorsed severity ratings, it produces a composite diagnosis. The interview takes between 60 and 90 min to administer. Wood, Piacentini, Bergman, McCracken, and Barrios (2002) found that the ADIS anxiety disorders section demonstrated a robust correspondence with the Multidimentional Anxiety Scale for Children (MASC; March, 1997) in the areas of SoP, SAD, and panic disorder in a sample of typically developing, clinically anxious children. However, there was no significant convergence between the two scales on the GAD domain. Kappa coefficients for both the child and parent reports ranged from good to excellent (.63–.80 and .65–.88 respectively; Silverman, Saavedra, & Pina, 2001). This article also reported intraclass correlation coefficients (ICCs) for test-retest reliability. The child sample demonstrated excellent reliability, with ICCs ranging from .78 to .95 for the SAD, SoP, SP, and GAD symptom scales. The parent sample had similar reliability levels, extending from .81 to .96 for GAD, SAD, SP, and SoP. Pearson correlation coefficients were used as an alternate type of testretest reliability, as correlations were calculated to compare multiple time points on the subscales. Correlations for parent ratings of SAD, SoP, SP, and GAD were .56, .81, .78, and .84, respectively. The child correlations were .10 for SoP, .60 for SAD, .72 for GAD and .84 for SP. Both versions of the measure had acceptable test-retest reliability except for child rating of SoP and SAD (Silverman et al., 2001). The ADIS is well respected in the anxiety literature, but the scale has not been psychometrically evaluated with a sample of children with ASDs. Without further investigation, it is unknown whether the measure can distinguish between core symptoms of ASDs and anxiety, and whether altered expression of anxiety is captured. The parent version should give a reasonable profile of the child’s anxiety presentation, but would require cautious evaluation to determine whether

Table 1 Summary of descriptive characteristics and findings from anxiety articles reviewed. Diagnosis (n)

Age in years

Functional level (IQ)

Anxiety type(s) investigated

Measures used

Findings (anxiety-specific italicized)

Bellini (2004)

HF ASD (n = 19) AS (n = 16) PDD-NOS (n = 6)

12–18

M = 99.94

SoP

MASC, BASC, SAS-A

Bellini (2006)

AD (n = 19) AS (n = 16) PDD-NOS (n = 6) AS (n = 1)

12–18

M = 99.94

SoP

SAS-A, MASC

11

IQ = 90

SAD

K-SADS

AD (n = 12) TD (n = 12)

12–20

IQ < 75

Not specified

DASH-II

Brereton, Tonge, and Einfeld (2006)

AD (n = 381) ID (n = 581)

4–18

AD: 13.2% severe, 33.3% moderate, 27.8% mild, 12.1% borderline, 13.1% normal ID: IQ breakdowns or mean not specified

Not specified

Developmental Behaviour ChecklistParent version

Burnette et al. (2005)

HF ASD (n = 31) TD (n = 33)

8–13

HF ASD M =109.74 TD = matched

Not specified

SASC-R, BASC

Chalfant et al. (2007).

ASD (n = 47)

8–13

No data

SAD, GAD, SP, SoP, PD

RCMAS, SCAS, ADIS– Child/Parent Versions

Couturier and Nicolson (2002)

AD (n = 14) AS (n = 3)

4–15

No data

Not specified

CGI

Davis et al. (2010)

AD (n = 159) PDD-NOS (n = 154) TD (n = 200)

17–37 months

No data

Not specified

BISCUIT-Part 2

MASC – subjects with ASD were rated significantly higher than TD norms on subscales for physical symptoms, SoP, and SAD plus total score. BASC-ASD scores were significantly higher than TD norms for internalizing problems, anx and depression. Social skills level and physiological arousal, assessed on SAS-A, were predictors for SoP in ASDs. SAD was diagnosed (as per DSM criteria) due to symptoms separate from AS core features. 42% of AD reached clinically significant levels on anx subscale compared to 0% of TD without AD. Significantly more AD also reached clinically significant levels compared to TD on subscales for PDD/AD, mania, depression, schizophrenia, stereotypies, self-injury, eating disorders, sleep disorders, sexual disorders, impulse control, organic syndromes, and elimination disorders. AD sample reported significantly higher levels compared to ID sample on subscales for disruptive behavior, self-absorbed, communication disturbance, ADHD, depression, and anx plus total behavior problem score. No difference on subscales for social relating and antisocial. ASD self-reported significantly higher rates than TD on SCAS general social avoidance and distress and total score, and on BASC interpersonal relations. No difference on SCAS feelings of negativity, specific social avoidance and distress, or BASC anx, depression, or social stress. 71.4% of subjects no longer met anx criteria on any instrument after CBT vs. 0% of waitlist group. 10/17 patients reduced symptoms (including anx, aggression and self-injury) with citalopram. Subjects with AD had sig more anx than PDDNOS or TD and PDD-NOS had sig more anx than TD on anx/repetitive behavior and avoidance behavior subscales. No other subscales reported.

Bhardwaj, Argarwal, and Sitholey (2005) Bradley et al. (2004)

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Study

1349

Diagnosis (n)

Age in years

Functional level (IQ)

Anxiety type(s) investigated

Measures used

Findings (anxiety-specific italicized)

Davis et al. (2011a)

AD (n = 131) Broken into toddler (18–36 months), child (3–16 years), adult (20–65 years) AD (n = 33) PDD-NOS (n = 33) TD (n = 33)

18 months to 65 years

No data

Not specified

BISCUIT-Part 2, ASDCC

Anx rose from toddlerhood to childhood, decreased to young adulthood, rose from young adulthood to older adulthood. All were self-report if able, except BISCUIT.

2–14

No data

Not specified

ASD-CC

For AD: Anx decreased with more comm. deficits. For PDD-NOS: Anx increased with more comm. deficits compared to TD on combined worry/depression and avoidant behavior subscales. 55.3% met criteria for an anx disorder. More social comm. deficits if there was comorbid condition. Other endorsed disorders included disruptive behavior disorder (61.7%) and a mood disorder (13.8%). Children in CBT treatment improved daily living skills more than waitlist. Fewer deficits in adaptive behavior correlated with reduced anx severity based on ADIS severity score of primary anx condition. No additional info on anx. For ASD, the following were significantly corr with one another: fears of situations and harm and, conduct subscale, fears of strangers and learning disorder subscale, animal, environmental, and social fears and somatic subscale. Environmental and medical fears and impulsivity subscale. Anxiety subscale and situational, harm, social, and stranger fears. Hyperactivity subscale and medical, environmental, and stranger fears. Group differences on all subscales and total score on SCAS, CATS; higher anx levels for AS and Anx over TD except fear of physical injury subscale. AS scored highest on obsessivecompulsive, SoP, and GAD subscales. ASD group significnatly more anx. Effect size = .204. 32–39 mo group had significantly higher anx subscale scores than 12–18 mo and 19–24 mo groups. ASD also had significantly higher scores on subscales for tantrum/ conduct, inattention/impulsivity, avoidance, and eating/sleeping problems. 25.2% of males and 19.5% of females with ASD screened positively for GAD, but only 6.2% of males and 7.1% of females did for SAD. No prevalence rates for SoP or SP.

Davis et al. (2011b)

de Bruin et al. (2007)

PDD-NOS (n = 94)

6–12

No data

SP, PD, SAD, GAD

DISC-IV

Drahota et al. (2011)

ASD (n = 40)

7–11

IQ > 70

Not specified

ADIS

Evans, Canavera, Kleinpeter, Maccubbin, and Taga (2005)

ASD (n = 25) Down (n = 43) Matched mental age (n = 45) Chronological age (n = 37)

M = 9.2

ASD M = 59.6

SP

Conners’ Parent Rating Scale

Farrugia and Hudson (2006)

AS (n = 29) Anx (n = 34) TD (n = 30)

12–16

No data

AGP, GAD, SoP, SP, SAD

Children’s Automatic Thoughts Scale, SCAS

Fodstad et al. (2010)

ASD (n = 109) Non-ASD (n = 160)

12–39 months

No data

Not specified

BISCUIT–Part 2

Gadow et al. (2005)

AD (n = 103), AS (n = 80) PDD-NOS (n = 118) Non-ASD (n = 181) Regular ed (n = 404) Special ed (n = 60)

6–12

No data

GAD, SAD, SP, SoP

CSI-4

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Study

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Table 1 (Continued )

ASD (n = 67)

4–14

M = 79.2, SD = 23.2

GAD, SAD, SoP

CSI-4

Gillott, Furniss, and Walter (2001)

HF ASD (n = 15) Specific language impairment (n = 15) TD (n = 15) AS (n = 20) CD (n = 20)

8–12

No data

Not specified

SCAS, Social Worries Questionnaire

11–19

IQ > 70

Not specified

Isle of Wight Interview

Green, Gilchrist, Burton, and Cox (2000) Greenaway and Howlin (2010)

ASD (n = 41) TD (n = 42)

11–14

IQ = 80–125 (M = 100)

A, SoP, SAD, GAD

SCAS

Greig and MacKay (2005)

AS (n = 1)

12

IQ = 118

Not specified

Briere Trauma Scales

Hartley and Sikora (2009)

HF ASD (n = 55) ADHD (n = 27) Anx (n = 23)

6–15

HF ASD M = 102.67

Not specified

CBCL

Hess et al. (2010)

ASD (n = 65) TD (n = 72)

14–16

No data

Not specified

ASD-CC

Johnson and Hollander (2003)

AD (n = 1)

11

No data

Not specified

None

Juranek et al. (2006)

AD (n = 42)

3–14

19–107, M = 60.5

Not specified

CBCL

Kanai et al. (2004)

HF atypical AD (n = 53) HF ASD (n = 21)

2–23

IQ > 70

Not specified

CARS–Tokyo version

Kauffmann, Vance, Pumariega, and Miller (2001)

PDD-NOS (n = 1)

7

No data

Not specified

CARS

Mother ratings significantly elevated for SAD, not GAD. No SoP in parent report. Teachers reported significantly elevated GAD, not SoP. No SAD in teacher report. Children homozygous with C allele had more anx than those with T allele. HF ASD showed more anx and social worries than other two groups. For SCAS, subscales for SAD and obsessive/compulsive behaviors had the highest endorsement rates for ASD. Significantly more GAD, SP, P, and rumination in AS sample. Other anx disorders were not included. Both parent and child reported SCAS indicated more anx for ASD group. Anx total and subscales on SCAS (P, SoP, SAD, GAD) were not significantly corr with dysfunctional attitudes or perfectionism. After the ‘‘Homunculi’’ type of CBT, subject’s scores were no longer elevated and were within normal limits for age. Compared core ASD symptom criteria. Communication and social relatedness domains were largely able to discriminate between ADHD or Anx and ASD diagnosis. The restricted/repetitive patterns of behavior domain did not discriminate between the three disorders. All subscales (tantrum behavior, repetitive behavior, worry/depressed, avoidant behavior, under-eating, conduct, over-eating) were endorsed significantly more for the ASD sample compared to TD. Fish oil added to existing pharmacological and behavior treatment helped to reduce anx levels significantly after one week according to parents and clinicians. Significantly correlation between amygdala volume and parent-reported dep/anx subscale. No other CBCL subscales were included. HF atypical AD scored significantly higher on only anx reaction items than HF ASD. HF ASD scored significantly higher on relationship with people, affect, and general impressions when compared with HF atypical AD. Fluvoxamine significantly decreased anx, stereotypies, repetitive behaviors, and aggression. The drug increased prelinguistic and social behaviors. Composite CARS score was significantly reduced after treatment.

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Gadow et al. (2010)

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Diagnosis (n)

Age in years

Functional level (IQ)

Anxiety type(s) investigated

Measures used

Findings (anxiety-specific italicized)

Kim et al. (2000)

HF ASD (n = 40) AS (n = 19) Community sample (1751)

9–14

IQ > 70

Not specified

Revised Ontario Child Health Study

Kuusikko et al. (2008)

HF ASD (n = 54) TD (n = 305)

8–15

HF ASD IQ > 80

SoP

SPAI-C, SASC-R, CBCL

Lecavalier (2006)

ASD (n = 487)

3–12

66% had IQ <60

Not specified

NCBRF

Lehmkuhl, Storch, Bodfish, and Geffken (2008)

AD (n = 1)

12

IQ = 92

OCD

CY-BOCS

Leyfer et al. (2006)

AD (n = 109)

5–17

IQ = 42–141

Not specified

ACI-PL

Lopata et al. (2010)

ASD (n = 40) TD (n = 40)

M = 9.8

ASD M = 110 TD M = 113

Not specified

BASC-2-PRS, BASC-2SRP

Lopata, Volker, Putnam, Thomeer, and Nida (2008)

ASD (n = 33)

6–13

M = 101.66

Not specified

Subjective Units of Distress Survey

HF ASD children had significantly more clinically relevant scores (>2 standard deviations) on subscales of internalizing, overanxious behavior, depression, SAD, externalizing, ADHD, and oppositional behavior when compared to mean scores. No difference between HF ASD and AS on depression and overanxious behavior categories. HF ASD subjects scored higher on all three measures and their anx increased with age. Ratings that were significantly higher include SPAI-C: total, subscales of social assertiveness, fear of general conversation, behavioral avoidance, fear of public performance. SASC-R: total, subscales of fear of negative evaluation, new social avoidance, generalized social avoidance. CBCL: subscales of internalizing, withdrawn, somatic, anx/depressed. 22% of parent ratings and 11% of teacher ratings score above one standard deviation on Insecure-Anxious cluster. This group had higher adaptive behavior scores than all other clusters for parents and higher than those in the problem free, ritualistic, hyperactive, and undifferentiated behavioral disturbance with stereotypy clusters on teaching ratings. Teacher reports also indicated that those in the anxious cluster were older than those in the problem free, hyperactive, and conduct disorder clusters. CBT caused OCD severity rating to decrease from 18 to 3. Results maintained at threemonth follow-up. 44% of sample met criteria for SP, 37% for OCD, 12% for SAD, 8% for SoP, and 2% for GAD. Other categories of note that were endorsed included depression (10%) and ADHD (31%). Significant elevation on anx subscale in ASD parent report, not significant for child report. The depression subscale was significantly elevated for both parent and child report. High levels of subjective distress in both familiar or unfamiliar social situation were associated with high cortisol levels.

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Table 1 (Continued )

AD (n = 126) PDD-NOS (n = 126) TD (n = 126)

17–36 months

No data

Not specified

BISCUIT–Part 2

Mayes et al. (2011)

HF ASD (n = 233) LF ASD (n = 117) TD (n = 187) Other disorder (n = 853)

6–16

HF ASD IQ M = 103 LF ASD IQ M = 59

Not specified

Pediatric Behavior Scale

Mazefsky et al. (2010)

ASD (n = 31)

10–17

IQ = 71–144 (M = 104.85)

GAD, SoP, SP, transition related

ACI-PL

Mazefsky et al. (2011)

ASD (n = 38), divided into those who endorsed anx (n = 11) and those who did not (n = 21)

10–17

IQ = 71–144 (M = 105)

GAD, SAD, SoP, SP

RCMAS ACI-PL

Melfsen, Walitza, and Warnke (2006)

AS (n = 7) clinical group of other disorders (n = 341) AS (n = 31) TD (n = 33)

7–18

No data

SoP

SPAI–German version

7–13

No data

Not specified

BASC, SASC

Meyer et al. (2006)

Namerow, Thomas, Bostic, Prince, and Monuteaux (2003)

AS (n = 6) AD (n = 2) PDD-NOS (n = 7)

6–16

No data

Not specified

CGI

O’Connor (2009)

ASD (n = 1)

No data

No data

SoP, SP

None

Pfeiffer, Kinnealey, Reed, and Helzberg (2005)

AS (n = 50)

6–17

No data

Not specified

RCMAS

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AD was rated significantly higher from other groups on all factors (tantrum/conduct behavior, inattention/impulsivity, avoidance, anxiety/repetitive behavior, eating/sleep problems). PDD-NOS and TD were only significantly different from each other on tantrum/conduct behavior, inattention/ impulsivity, and eating/sleep problems. Maternal ratings of anx higher for HF ASD than LF ASD, and frequency of anx symptoms was similar between HFASD and children with anx disorder. Anx was most severe for children with anx disorder. Anx was found in 44% of TD, 67% of LF ASD, 79% of HF ASD, and 94% of anx disorder. Parent report of HF ASD also indicated depression in 54% of subjects and irritable/angry in 88%. Parent report of LF ASD reported depression in 42% of subjects and irritable/angry in 84%. GAD = 9.7%, SoP = 12.9%, SP = 12.9%, Transition related anx = 32.3%, Major depression = 19.4%, Any depression = 32.3% Nearly significant difference (p = .58) on total RCMAS scores between those who endorsed anx symptoms and those who did not. Means for both groups below threshold for concern. Disorders of subjects who met full DSM criteria according to the ACI-PL included major depression (16%), any depression (18%), GAD (8%), SAD (8%), SoP (13%), SP (13%), ADHD (37%). AS mean score for SoP was above clinical cutoff. The only other clinical group who had this was those with selective mutism. AS had significantly impaired prosocial behavior and social initiative from a social competence measure. AS were more likely than TD to have social difficulties (BASC) and social anxiety (SASC). For AS, both parent and child report resulted in higher t-score means than TD for anxiety, social stress, and depression subscales (BASC). 11/15 patients with citalopram had improvement of anx, PDD, or mood scores. Anx associated with PDD improved in 66% of subjects. Social story reduced anx according to subjective observations. Significant corr between sensory defensiveness and anx, no significant corr between overall adaptive functioning and either anx or depression. Functional academics were inversely related to anx.

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Matson et al. (2010)

Diagnosis (n)

Age in years

Functional level (IQ)

Anxiety type(s) investigated

Measures used

Findings (anxiety-specific italicized)

Reaven et al. (2009)

AD (n = 15) PDD-NOS (n = 4) AS (n = 14)

8–14

IQ = 75–144

Not specified

SCARED, K-SADS

Reaven and Hepburn (2003)

AS (n = 1)

7

IQ in ‘‘high gifted’’ range

OCD

CY-BOCS

Russell and Safronoff (2005)

AS (n = 65)

10–13

No data

Not specified

SCAS, Social Worries Questionnaire

Simonoff et al. (2008)

AD (n = 62) PDD-NOS (n = 50)

10–14

No data

Not specified

Sofronoff, Attwood, and Hinton (2005)

AS (n = 71)

10–12

No data

PD/AGP, SoP, SAD, GAD, SP

Child and Adolescent Psychiatric Assessment SCAS, Social Worries Questionnaire

Solomon et al. (2008)

ASD (n = 17) TD (n = 22)

8–18

ASD IQ (76–142) TD IQ (99–134)

Not specified

BASC, Stress Survey Schedule

Sukhodolsky et al. (2008)

PDD-NOS (n = 171)

5–17

GAD, SP, PD, SAD, SoP

CASI-20 item modified scale

Sze and Wood (2007)

HFASD (n = 1)

11

13% average, 15% borderline, 23% mild ID, 14% moderate ID, 25% severe/profound ID No data

Parent report after group treatment showed significant decrease in anx symptoms compared to no treatment group. Child report did not show this. Modified CBT reduced severity of OCD symptoms after six months of treatment. Severity score of 23 was reduced to 8. On SCAS, both parent and child reported more anx than normative sample. Also AS had more OCD symptoms, physical injury fears, and total anx than clinical sample. On Social Worries Questionnaire, parents reported more social worry for AS than for TD. 42% of sample met criteria for at least one anx disorder, 13% for GAD, 1% for SAD, 10% for PS, 8% for AGP, 29% for SoP, 9% for SP. AS had similar anx as an Anx sample. Significant decrease in anx symptoms for all types of anx disorders for AS after CBT intervention. Significant correlations between ‘‘loose associations’’ and ‘‘anticipating changes’’ and BASC scores. ‘‘Loose associations’’ also related to communication symptoms and parent reports of stress and anx. Anx was common in PDD-NOS, overlap between SP/SoP and core symptoms of ASD. Higher IQ significantly more likely to have GAD, SAD, or any anx disorder in general.

SAD, GAD

ADIS

Sze and Wood (2008)

AS (n = 1)

10

No data

GAD, SAD, SoP

ADIS, MASC, CBCL

Thede and Coolidge (2006)

AS (n = 16) HF ASD (n = 15) TD (n = 31)

5–17

IQ > 69

GAD

Weisbrot et al. (2005)

PDD-NOS: 3–5 years: n = 182 6–12 years: n = 301 Non-PDD-NOS: 3–5 years: n = 135 6–12 years: n = 191

3–12

PDD-NOS: 3–5 years M = 79 6–12 years M = 87 Non-PDD-NOS: 3–5 years M = 92 6–12 years M = 98

GAD, SAD, SP, SoP

Coolidge Personality and Neuropsychological Inventory Early Childhood Inventory, CSI

After 16 sessions of modified CBT the subject no longer met criteria for SAD or GAD. After CBT the subject no longer met criteria for GAD or SoP on ADIS. Significant reduction of anx symptoms on MASC and all scores within normal limits for CBCL. Maintained at threemonth follow-up. AS had more anx than HF ASD. 10/16 with AS had elevated GAD scores, but no difference from HF ASD on ADHD subscale (although both higher than TD). Teachers gave higher anx ratings to PDD-NOS subjects, while parents gave higher rating to non-PDD-NOS subjects. Children with PDDNOS had positive correlation between IQ and anx. AS had more anx than PDD-NOS which had more anx than AD.

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Table 1 (Continued )

AS (n = 3) PDD-NOS (n = 1)

12–14

IQ = 105–135

GAD, SoP, SP

ADIS, CASI-20, MASC

White and Roberson-Nay (2009)

ASD (n = 20)

7–14

M = 92

Not specified

MASC, CBCL

Witwer & Lecavalier (2010)

AD (n = 17) AS (n = 16) PDD-NOS (n = 26)

6-17

M = 68.4

SoP, SAD, SP, GAD

P-ChIpS, NCBRF

Wood et al. (2009)

ASD (n = 40)

7–11

No data

SoP, SAD, GAD

ADIS, MASC,

Worley and Matson (2011)

ASD: Male: n = 44 Female: n = 26 TD: Male: n = 27 Female: n = 32

4–16

No data

Worry

ASD-CC

CBT reduced anx in 3 out of 4 subjects. On ADIS, all subjects stopped meeting anx criteria. On CASI modified 20 item, 3 subjects’ total anx scores declined significantly. On MASC, 1 subject’s total anx score significantly declined. Youth reported anx on MASC correlated to greater social loneliness. Parent-reported anxious/depressed scale on CBCL not significantly corr with social deficits. Those with ID less likely to meet full criteria for GAD and reported fewer symptoms across disorders. 67% of sample had SP regardless of IQ. 78.5% of children receiving CBT had reduction of anx compared to 8.7% of waitlist group. Total ADIS scores and parent total MASC posttreatment scores differed significantly from the two treatment groups. Post-treatment there were no significant differences seen from child MASC total scores. No ASD gender differences, ASD significantly elevated relative to TD on all subscales and total scores except ‘‘under-eating,’’ where there was no difference. Males with ASD scored significantly higher than TD females.

AGP: agoraphobia; ACI-PL: Autism Comorbidity Interview–Present and Lifetime; AD: Autistic Disorder; ADIS: Anxiety Disorders Interview Schedule for Children; Anx: anxiety; AS: Asperger syndrome; ASD: autism spectrum disorder; ASD-CC: Autism Spectrum Disorders-Comorbid for Children; BASC: Behavioral Assessment System for Children, Parent Rating Scale (PRS) or Self-Report of Personality (SRP); BISCUIT: Baby and Infant Scale for Children with aUtIsm Traits; CARS: Childhood Autism Rating Scale; CASI: Child and Adolescent Symptom Inventory; CBCL: Child Behavior Checklist; CBT: cognitive behavioral therapy; CD: conduct disorder; CGI: Clinical Global Impression; Comm: communication; Corr: correlation/correlated; CSI: Child Symptom Inventory; CY-BOCS: Children’s Yale-Brown Obsessive Compulsive Scale; DASH: Diagnostic Assessment for the Severely Handicapped; DISC: Diagnostic Interview Schedule for Children; Ed: education; GAD: generalized anxiety disorder; HF: high functioning; ID: intellectual disability; K-SADS: KiddieSchedule for Affective Disorders and Schizophrenia; LF: low functioning; MASC: Multidimentional Anxiety Scale for Children; NCBRF: Nisonger Child Behavior Rating Form; OCD: obsessive-compulsive disorder; PDD-NOS: pervasive developmental disorder not otherwise specified; RCMAS: Revised Children’s Manifest Anxiety Scale; PD: panic disorder; P-ChIPS: Children’s Interview for Psychiatric Symptoms–Parent Version; SoP: social phobia; SP: specific phobia; SAD: separation anxiety disorder; SAS-A: Social Anxiety Scale for Adolescents; SASC-R: Social Anxiety Scale for Children–Revised; SCARED: Screen for Child Anxiety and Related Emotional Disorders; SCAS: Spence Children’s Anxiety Scale; SPAI-C: Social Phobia and Anxiety Inventory for Children; TD: typically developing.

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White, Ollendick, et al., 2009

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Table 2 Alphabetical list of assessment instruments. Assessment (frequency) Anxiety Disorders Interview Schedule for Children, ADIS (6) Autism Comorbidity Interview–Present and Lifetime, ACI-PL (3) Autism Spectrum Disorders-Comorbid for Children, ASD-CC (4) Baby and Infant Scale for Children with aUtIsm Traits, BISCUIT (4) Behavioral Assessment System for Children, BASC (5) Brier Trauma Scales (1) Child and Adolescent Psychiatric Assessment (1) Child and Adolescent Symptom Inventory, CASI (2) Child Behavior Checklist, CBCL (5) Child Symptom Inventory, CSI (3) Childhood Autism Rating Scale, CARS (1) Children’s Automatic Thoughts Scale (1) Children’s Interview for Psychiatric Symptoms–Parent Version, P-CHIPS (1) Children’s Yale-Brown Obsessive Compulsive Scale, CY-BOCS (2) Clinical Global Impression, CGI (1) Conners Parent Rating Scale (1) Coolidge Personality and Neuropsychological Inventory (1) Developmental Behavior Checklist (1) Diagnostic Assessment for the Severely Handicapped, DASH (1) Diagnostic Interview Schedule for Children, DISC (1) Early Childhood Inventory (1) Isle of Wight Interview (1) Kiddie-Schedule for Affective Disorders and Schizophrenia, K-SADS (2) Multidimentional Anxiety Scale for Children, MASC (6) Nisonger Child Behavior Rating Form, NCBRF (2) No Formal Measure (2) Ontario Child Health Study (1) Pediatric Behavior Scale (1) Revised Children’s Manifest Anxiety Scale, RCMAS (2) Social Anxiety Scale for Adolescents, SAS-A (2) Social Anxiety Scale for Children–Revised, SASC-R (4) Social Worries Questionnaire (2) Screen for Child Anxiety and Related Emotional Disorders, SCARED (1) Social Phobia and Anxiety Inventory for Children, SPAI-C (2) Spence Children’s Anxiety Scale, SCAS (6) Stress Survey Schedule (1) Subjective Units of Distress Survey (1)

adaptations are needed to identify any differences in the expression of anxiety. Whether the child version provides an appropriate assessment appears dependent on the child’s intellectual functioning and language abilities. If youngsters are higher functioning, they would likely be able to answer the questions validly. 4.3. Autism Spectrum Disorders–Comorbid for Children (ASD-CC) The ASD-CC (Matson & Gonzalez, 2007) was used in four studies that we evaluated (Davis, Hess, et al., 2011; Davis, Moree, et al., 2011; Hess, Matson, & Dixon, 2010; Worley & Matson, 2011). These articles focused on levels of anxiety (a) across the lifespan for those with ASDs (Davis, Hess, et al., 2011), (b) in relation to ASD communication deficits (Davis, Moree, et al., 2011), (c) for children with ASDs compared to typically developing children (Hess et al., 2010), and (d) across genders (Worley & Matson, 2011; see Table 1). This rating scale, which can be completed by either parent or child, is intended for children 3–16 years of age to evaluate symptoms of comorbid psychological disorders, particularly eating problems, ADHD, conduct disorder, tic disorder, OCD, and specific phobia (Matson, Fodstad, Mahan, & Sevin, 2009). These disorders are known for being common in individuals with ASDs (Bradley et al., 2004). There are 49 items on a 3-point Likert scale (0 = not different or no impairment, 1 = somewhat different or mild impairment, 2 = very different or severe impairment). The assessment can be administered and scored in under 20 min. Results of a factor analysis identified a seven-factor model as providing the best fit, and the derived factors were named (1) Tantrum Behavior (alpha = .86), (2) Repetitive Behavior (alpha = .75), (3) Worry/Depressed (alpha = .74), (4) Avoidant Behavior (alpha = .77), (5) Under-Eating (alpha = .78), (6) Conduct (alpha = .74), and (7) Over-Eating (alpha = .70). The full instrument possessed good internal consistency (.91), mediocre test-retest reliability (.51), and mild to acceptable interrater reliability (.46; Matson & Wilkins, 2008). The subscale alpha values ranged from adequate (.70) to good (.86). Matson, LoVullo, Rivet, and Boisjoli (2009) compared full-scale versions of the ASD-CC to the Behavioral Assessment System for Children (BASC; Reynolds & Kamphaus, 2004). Based on a moderate correlation of .66 between the two instruments, they concluded that the measure is an appropriate and valid instrument to assess emotional problems in

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children with ASD. Intercorrelations between the ASD-CC, on the one hand, and the BASC subscales on the other, were variable. Significant correlations at the p < .001 level (ASD-CC and BASC, respectively) were as follows: Tantrum subscale and Hyperactivity (.57), Tantrum and Aggression (.54), Tantrum and Atypicality (.49), and Tantrum and Attention Problems (.36). There were also significant correlations between the Repetitive Behavior subscale and Atypicality (.48), between the Worry/ Depressed subscale and Anxiety (.68), Worry/Depressed and Depression (.66), and Worry/Depressed and Somatization (.52). Significant correlations were additionally found between the Conduct subscale and Hyperactivity (.40), Conduct and Aggression (.43), Conduct and Conduct Problems (.44), Conduct and Anxiety (.48), Conduct and Depression (.56), and Conduct and Somatization (.39), and finally, between Over-Eating and Conduct Problems (.46) and Over-Eating and Atypicality (.42). There were no significant correlations at this level for the Under-Eating or Avoidant Behavior subscales, although the Avoidant Behavior subscale was significantly correlated for Atypicality (.27; p < .05) and Withdrawal (.32; p < .05). Although significant correlations between subscales on the two measures suggested convergent validity to the constructs they were measuring, the ASD-CC Conduct subscale was more highly correlated with BASC Depression subscale than BASC Conduct Problems subscale, which indicates poor divergent validity. The ASD-CC may well be the first rating scale the field designed to assess comorbid emotional disturbance in children with ASD (Matson & Wilkins, 2008). The available work with it corroborates the observation that children with ASDs experience a higher number of psychiatric symptoms compared to typically developing peers (Hess et al., 2010). While this is a good first step towards accurate evaluation of children with ASDs and comorbid psychopathology, the ASDCC may not be ideal for those interested in investigating anxiety problems. The factor model and resulting subscales include only worry, even though it was initially designed to address SP. Worry and SP comprise relatively few aspects of possible anxiety expression. Either way, it is indicative that there are both restricted types of anxiety disorders included in the ASD-CC and a limited number of questions to assess them. 4.4. Baby and Infant Scale for Children with Autistic Traits (BISCUIT) The BISCUIT (Matson, Boisjoli, & Wilkins, 2007) was used in four of the studies that assessed anxiety symptoms in young children with ASDs (Davis et al., 2010; Davis, Hess, et al., 2011; Fodstad et al., 2010; Matson, Hess, & Boisjoli, 2010), and these articles explored prevalence rates across the lifespan or frequency in subtypes (see Table 1). This recently developed measure was designed to be a screen for socio-emotional problems in very young children between 17 and 37 months of age. Although this is a very young age bracket, typically developing toddlers are also occasionally evaluated for anxiety (Warren & Dadson, 2001). Early diagnosis of anxiety in children with normative development is increasing in frequency, although it is still relatively uncommon. The BISCUIT is divided into three sections. Part 1 evaluates the symptoms of ASDs. Part 2 assesses comorbid psychopathology and is the module that is used by the studies reviewed here. Part 3 was designed to look at externalizing behaviors. Part 2 of the assessment includes 57 items that are rated on a 3-point scale (0 = not a problem or impairment/not at all, 1 = mild problem or impairment, 2 = severe problem or impairment). Factor analysis was used and indicated that five factors provided the most appropriate fit. Those factors are Tantrum/Conduct Problems, Inattention/Impulsivity, Avoidance Behavior, Anxiety/Repetitive Behavior, and Eating Problems/Sleeping. Part 2 of the overall measure appears to be sound from the limited psychometric data available and includes an internal consistency coefficient of .96 (Matson, LoVullo, et al., 2009). Subscale alphas appeared to be in the mediocre to good range, as Tantrum/Conduct had an alpha of .92, Inattention/ Impulsivity was .88, Avoidance Behavior was .67, Anxiety/Repetitive Behavior was .81, and Eating Problems/Sleeping was .76 (Matson, Wilkins, et al., 2009). This scale has quite a few strengths. It was designed specifically for children with ASDs and has the ability to evaluate younger children than any other measure evaluated here. It is also the instrument with the smallest age range (20 months), but is considered invalid after the child passes 37 months of age. Conversely, this instrument is quite new and, to date, limited psychometric data are available. A last consideration is that anxiety items were combined with repetitive behaviors rather than being presented separately. While many researchers believe that there is considerable symptom overlap between anxiety and repetitive behavior (Davis, Hess, et al., 2011; Steingard, Zimnitzky, DeMaso, Bauman, & Bucci, 1997; Tantam, 2000), it would be more compelling if the scale had a way of differentiating between them. The factor analytic finding of the two elements sharing a factor could indicate that the elements belong together. If so, then this would be among the first empirical demonstrations that the two are clinically related. The Anxiety/Repetitive Behavior subscale had the lowest endorsement rating of any of the BISCUIT subscales (only 6.3% of parents indicated their child had moderate or severe impairment; Matson, Fodstad, et al., 2009; Matson, LoVullo, et al., 2009; Matson, Wilkins, et al., 2009). This is not in accord with other findings that anxiety is one of the most common comorbid conditions for children with ASDs (e.g., Green & BenSasson, 2010), although the age range covered may be responsible. There are two other possible explanations as to why anxiety and repetitive behaviors are clustered together. First, it is possible that the questions are not specific enough to differentiate between the constructs of anxiety and repetitive behavior. Second, the questions appear to assume that anxiety is only related to repetitive behaviors in this young sample. All eleven items except one (‘‘Trembles or shakes in the presence of specific objects or stimulations’’) on the subscale are related to repetitive mental acts, movements, or vocalizations. Further, only three repetitive items specifically mention that the actions may be performed to reduce stress (‘‘Engages in repetitive behaviors for no apparent reason or to reduce stress’’). Reducing stress should not necessarily be construed as reducing anxiety. Moreover, even if it is a good indicator of anxiety symptoms,

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there is no way of knowing whether the parent is endorsing the ‘‘stress reduction’’ component, or the ‘‘for no apparent reason’’ part of the question. 4.5. Behavioral Assessment System for Children-2 (BASC-2) The BASC-2 (Reynolds & Kamphaus, 2004) was employed in five of the articles reviewed for this manuscript (Bellini, 2004; Burnette et al., 2005; Lopata et al., 2010; Meyer, Mundy, van Hecke, & Durocher, 2006; Solomon, Ozonoff, Carter, & Caplan, 2008). These studies emphasized differences between parent report and child report, and also made comparisons to stress and other symptoms that could be related to anxiety (see Table 1). The BASC-2 is a broad-band assessment that includes norms and cognitive profiles for both children with ASDs and other disorders. It evaluates young people between 2 and 21 years from both an adaptive and clinical perspective. There are three parent-rating forms that are age dependant: for preschoolers (ages 2–5 years, inclusive), children (ages 6–11 years, inclusive), and adolescents (ages 12–21 years, inclusive). Informants use a 4-point Likert scale (1 = never to 4 = always) to rate a host of 16 dimensions including Attention Problems, Aggression, Anxiety, Conduct Problems, Hyperactivity, Depression, Somatization, Withdrawal, Learning Problems, Atypicality, Adaptability, Activities of Daily Living, Functional Communication, Leadership, Social Skills, and Study Skills. Both the Anxiety and Somatization subscales are related to anxiety constructs; the Anxiety subscale assessment emotional symptoms of fear, while the Somatization subscale taps into physiological features such as shortness of breath or nausea (Campbell, 2006). There is a child self-report version of this instrument that can be administered either in interview form (with true/false responses) or in questionnaire format (with response options the same as in the caregiver version). There is also a teacherreport form. Ideally, all three versions would be completed for comprehensiveness. Concurrent validity of the full-scale assessment was high with the Child Behavior Checklist (CBCL; Achenbach, Rescorla, & Maruish, 2004), and high internal consistency (.85–.95) was obtained across subscales together with high inter-rater reliability (.70–.88). The authors reported reliabilities for each individual scale. For the Anxiety subscale, coefficient alpha was .84, and test-retest reliability was .79. Alpha for the Somatization subscale was .85, and test-retest reliability was between .65 and .84, depending on the sample (general vs. clinical; Campbell, 2006). This measure has similar problems as the ASD-CC. On the positive side, the authors provided norms and profiles for youth with ASDs. However, it may tap into too many behavioral constructs to make this an ideal anxiety assessment. One study (Lopata et al., 2010) specifically mentioned that the instrument should be used in combination with other evaluations in order to obtain a comprehensive assessment of child behavioral health. It produces a printout that ultimately looks like the more popular CBCL, and as such provides a considerable amount of breadth but lacks depth for any individual construct in the sense that the BASC anxiety subscales have relatively few items. 4.6. Child Behavior Checklist (CBCL) The CBCL (Achenbach & Rescorla, 2001) was used in five of the reviewed articles (Hartley & Sikora, 2009; Juranek et al., 2005; Kuusikko et al., 2008; Sze & Wood, 2008; White & Roberson-Nay, 2009). These articles covered a variety of topics, not limited to anxiety alone (see Table 1). The CBCL is a behavioral rating scale for assessing children 1.5–18 years (in two age categories: 1.5–5 years and 6–18 years) of age, inclusive. There are parent, teacher, and child versions (using different names but similar content) that take between 15 and 20 min for the informant to complete. The informant answers 118 questions about the child’s behavior in the past six months. The behavioral symptoms are divided into (a) Problem Subscales (Internalizing, Externalizing, and Total Problems), (b) Syndrome Subscales (Anxious/Depressed, Withdrawn/Depressed, Somatic Complaints, Social Problems, Thought Problems, Attention Problems, Rule-Breaking Behavior, Aggressive Behavior), and (c) DSM-Oriented Subscales (Affective Problems, Anxiety Problems, Somatic Problems, Attention Deficit/Hyperactivity Problems, Oppositional Defiant Problems, and Conduct Problem). Of note is the fact that the CBCL includes two different subscales that address anxiety: the Anxiety/Depressed Syndrome Subscale and the Anxiety Problems DSM-Oriented Subscale. Items were empirically derived. They were chosen based on their ability to distinguish between healthy children and children who needed further psychological evaluation, unspecified. Alphas for the subscales using the typically developing sample on the 1.5–5-year-old form and their values for an ASD sample, respectively, were (Pandolfi, Magyar, & Dill, 2009): (a) Emotionally Reactive = .73 (.67 for ASD), (b) Anxious/Depressed = .66 (.63 for ASD), (c) Somatic Complaints = .80 (.49 for ASD), (d) Withdrawn = .75 (.73 for ASD), (e) Sleep Problems = .78 (.83 for ASD), (f) Attention Problems = .68 for both typical and ASD samples, (g) Aggressive Behaviors = .92 (.89 for ASD), (h) Internalizing = .89 (.80 for ASD), and (i) Externalizing = .92 (.90 for ASD). The n’s for the subscales ranged from 5 to 19 items depending on the specific form used. The alpha coefficients had a wide range and were generally comparable for typically developing children and children with ASDs (but not always; alpha only .49 for the Somatic Complaints subscale for children with ASDs). Embregts (2000) reran the reliability and validity figures using a sample of children diagnosed with mild intellectual disability. He found that the psychometric characteristics were not as robust with his sample, with mean ICCs for inter-rater reliability of .49 for the full-scale measure (the ICC for Anxious/Depressed Syndrome Subscale was .55). The test-retest reliability was .78 for the full instrument (the ICC for Anxious/Depressed Syndrome Subscale was .81). Thus, Embregts’ (2000) findings indicated that results for the full CBCL may not always be as reliable for children with developmental and intellectual disabilities. This is potentially a concern, since so many children with ASDs also have intellectual disability.

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The CBCL is frequently used by both researchers and clinicians. It has very good psychometric characteristics for typically developing children and adequate values for those with an intellectual disability, but subscale alpha values were smaller on average for ASD children than for the original sample used for norming. It appears to be a helpful tool for capturing a broad picture of functioning in a given child. However, validity of CBCL items across all three autism conditions is unknown, and there remains the possibility that anxiety transmogrifies within the ASDs. 4.7. Child Symptom Inventory (CSI) The CSI (or CSI-4 Gadow & Sprafkin, 1994, 2002) is an updated version of the original CSI-3, which was created with the DSM-III diagnostic criteria in mind. The current version of the CSI uses DSM-IV diagnostic criteria. There is a parent checklist with 97 items and a teacher checklist with 87 items. Both use a Likert-type rating scale with four options: (no numeric equivalents) never, sometimes, often, and very often. The scale is organized into 13 ‘‘categories,’’ with each corresponding to disorder-specific diagnostic criteria. The scale makes a distinction between GAD, SoP, and SAD, and gave each its own category. However, SP, compulsions, and obsessions, only have one question apiece. It was designed for youngsters, ages 5–12 years old, and was used in three of the reviewed studies (Gadow, Devincent, Pomeroy, & Azizian, 2005; Gadow, Roohi, DeVincent, Kirsch, & Hatchwell, 2010; Weisbrot et al., 2005). The psychometric characteristics of the CSI have been extensively researched and published. According to Gadow and Sprafkin (2002), Cronbach’s alpha for internal consistency on the parent checklist was .74 for GAD and .85 for SAD; alpha was not provided for SoP, and cannot be computed for the one-item subscales. Test-retest reliability was good: .67 for GAD, .87 for SoP, and .74 for SAD. The scale’s disorder categories each had statistically significant discriminant validity for both genders at the p < .001 level between a clinical sample and normative sample, with the exception of SAD (for boys), the only category that was not significant. Although not identical, the CSI has a version for younger children between the ages of 3 and 6 called the Early Childhood Inventory (Sprafkin & Gadow, 1996) and another version for adolescents between the ages of 12 and 18 called the Adolescent Symptom Inventory-4 (Gadow & Sprafkin, 1995). The Adolescent Symptom Inventory and the CSI were combined together to create the Child and Adolescent Symptom Inventory-4 (CASI; Gadow & Sprafkin, 2000) which includes all items from the child and adolescent versions (from ages 5 through 18 years). However, scoring and norms are based on previously published manuals of the separate scales. The Early Childhood Inventory was used in one study reviewed (Weisbrot et al., 2005), the CASI (with 20 items culled to reflect anxiety) was used in two articles (Sukhodolsky et al., 2008; White, Ollendick, et al., 2009), and the Adolescent Symptom Inventory-4 was not used in any of the studies reviewed. All of the scales are similar in content and have many overlapping questions, with adjustments made for developmental level and relative disorder frequency (e.g., there is no Schizophrenia subscale in the Early Childhood Inventory). There are certain advantages in using the CSI and related scales. First, this is the only measure evaluated here that truly allows a clinician to track a patient from toddlerhood through young adulthood without significantly changing the evaluating criteria. The psychometric characteristics indicate that the scale is reliable over time and has acceptable internal consistency. The exception to this is SoP, which has only one item and which, therefore, is unlikely to be very reliable. Another drawback is that the measure was not specifically designed for children with ASDs, as demonstrated by the fact that some, but not all versions of the measure have a set of PDD ‘‘screener’’ questions. Finally, although it is good to have multiple viewpoints from both the parent and teacher, it may also be advantageous to have a child self-report version that could be used with children who are higher functioning. 4.8. Multidimentional Anxiety Scale for Children (MASC) The MASC (March, 1997) is a brief self-report measure with 39 items, and it can typically be completed by the child in under 15 min. All questions are rated on a 4-point scale ranging from 0 (never true about me) to 3 (often true about me). This measure was used in six of the studies evaluated, suggesting relative popularity among researchers (Bellini, 2004, 2006; Sze & Wood, 2008; White & Roberson-Nay, 2009; White, Ollendick, et al., 2009; Wood et al., 2009). It assesses four major dimensions of anxiety, including Physical Symptoms, Harm Avoidance, Separation/Panic, and Social Anxiety. The studies in this review that used the MASC did so primarily as an outcome measure for cognitive behavioral therapy or to make comparisons to social functioning (see Table 1). Cronbach’s alpha for these four subscales ranged from .74 to .85 (adequate to good; March, Parker, Sullivan, Stallings, & Conners, 1997). These subscales were derived by ‘‘principal-components factor analysis’’ (sic, see below; March et al., 1997), and the scores from all items are taken into account to produce an index of total anxiety to indicate whether the child should undergo further clinical assessment. With typically developing children, the total score (across subscales) had good interrater reliability (.88), test-retest reliability (.93), and ICCs for multiple time points (.64 at three weeks and .93 at three months). ICCs for the subscales were as follows: (a) .61 at three weeks and .83 at three months for Physical Symptoms, (b) .21 at three weeks and .72 at three months for Harm Avoidance, (c) .65 at three weeks and .83 at three months for Social Anxiety, and (d) .81 at three weeks and .93 at three months for Separation Anxiety (March et al., 1997). All subscales had better consistency at the three months follow-up than at three weeks, which is contrary to expectation. The total score (r = .63) and all subscale scores (r = .43–.71), with the exception of Harm Avoidance (r = .13), were significantly correlated with the Revised Children’s Manifest Anxiety Scale (RCMAS; Reynolds & Richmond, 1985), another self-rating scale. There is also a parent-report version of this instrument

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(MASC-P), although there are no published parent norms available. Cronbach’s alpha values for the four subscales on the parent version were as follows: .68 (mediocre) for Harm Avoidance, .72 (adequate) for Separation Anxiety, .81 (good) for Physical Symptoms, and .85 (good) for Social Anxiety (Wood et al., 2002). The authors reported a significant amount of concordance between the scores of children and mothers, but not between the children and fathers (March et al., 1997). Unfortunately, the MASC has not been psychometrically evaluated for children with ASDs. Children and adolescents with a diagnosis of ASDs may experience symptoms at different frequencies (e.g., more tantrums) than those who are neurotypical, which could make interpretation of scores difficult. Also, it appears as though March et al. (1997) made the common error of assuming that principal-components analysis and factor analysis are the same statistical procedure, whereas exploratory factor analysis is designed to identify latent variables and principle-components analysis is used to determine which variables best account for all variance in the model (Norris & Lecavalier, 2001). Once again, whether a child can complete this measure will depend on adequate language and cognitive ability. On the other hand, the breakdown of anxiety into four subscales touching on the main issues children with anxiety disorders experience is a strength. Given that the scale has satisfactory psychometric properties generally, the MASC may well provide an adequate index of anxiety for children with ASDs who are higher functioning. Psychometric assessments of the MASC with children having ASDs are badly needed. 4.9. Social Anxiety Scale for Children-Revised (SASC-R) The SASC-R (La Greca & Stone, 1993) was used in four of the reviewed articles (Burnette et al., 2005; Chalfant et al., 2007; Kuusikko et al., 2008; Meyer et al., 2006): as an outcome for cognitive behavior therapy treatment, to investigate prevalence rates, and to compare those rates to typically developing children (see Table 1). This instrument is the revised version of the original SASC (La Greca, Dandes, Wick, & Shaw, 1988) and is a child self-report measure comprising of 22 items, 10 of which were in the original version. The items were rated on a 5-point scale from 1 (not at all) to 5 (all the time). A principal-factors procedure identified three factors: (1) Social Avoidance and Distress Specific to New Situations, (2) Fear of Negative Evaluation from Peers, and (3) Generalized Social Avoidance and Distress. These were later substantiated by a confirmatory factor analysis (La Greca & Stone, 1993). The internal consistency for the scale was mediocre to good, as Cronbach’s alpha was .69 for Generalized Social Avoidance and Distress, .78 for Social Avoidance and Distress to New Situations, and .86 for Fear of Negative Evaluation from Peers. Other researchers examined the psychometric properties of the SASC-R with typically developing children and found that the total scale produced an excellent alpha at .92 (Kuusikko et al., 2009), although importantly they did not provide alphas for the subscales. The same study found that the total score for the scale was significantly correlated (r = .78) with the Social Phobia and Anxiety Inventory for Children (SPAI-C; Beidel, Turner, & Morris, 1998). The SPAI-C (Beidel et al., 1998) is another scale used with children with autism in this review but not used in enough articles to warrant detailed evaluation. There is a parent version of both the SASC-R and an adolescent counterpart, the Social Anxiety Scale for Adolescents (SAS-A; La Greca & Lopez, 1998). The SAS-A, which was used in two of the articles reviewed, contains essentially the same items as the SASC-R, but the language was altered to make the questions more developmentally appropriate. A confirmatory factor analysis suggested that a three-factor model was also the best fit for this scale for older children. The psychometric investigation of this version revealed that the SAS-A had better internal consistencies at the subscale level (alpha between .76 and .91) than did the SASC-R (alpha between .69 and .86). Both of these scales were evaluated together since they possess the same content but with language adjusted for developmental level. Strengths of these two instruments are their adequate psychometric features (albeit, with typically developing children), separate versions based on age (or language ability), and a complimentary parent version. The measure was never intended to assess all aspects of anxiety and, although social anxiety is important, it is not the only type of anxiety that youngsters with ASDs face. One might argue that since social deficits are a core symptom of ASDs, evaluating social anxiety is extremely problematic in this diagnostic group. The scale has some of the other associated problems previously mentioned, including the inherent difficulty for some children and adolescents to complete selfreport questionnaires and lack of psychometric evaluation with persons who have ASDs. For high-functioning individuals this could be a good measure for evaluating social anxiety, but it fails to address several other anxiety conditions. 4.10. Spence Children’s Anxiety Scale (SCAS) The SCAS (Spence, 1997) was used in five of the studies that were reviewed for this manuscript as either an outcome measure for cognitive behavioral therapy intervention or to compare parent and child report directly (see Table 1). This selfreport measure was designed for children between 8 and 12 years, inclusive, and it encompasses 44 items rated on a 4-point scale (0 = never to 3 = always). Only 38 of the items are related to anxiety, while the remaining six are positive filler questions to increase test-taker ‘‘morale.’’ It is acceptable to read the questions to children if their reading abilities are questionable. A confirmatory factor analysis, using ratings on typically developing children, produced a six-factor solution that corresponds to anxiety disorders listed in the DSM-IV. Those subscales (and their corresponding coefficient alphas) include Panic Attack/ Agoraphobia (.61), Separation Anxiety Disorder (.74), Social Phobia (.74), Physical Injury Fears (.58), Obsessive-Compulsive Disorder (.74), and Generalized Anxiety Disorder-Overanxious Disorder (.67; i.e., generally poor to just adequate; Spence,

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1997; Nauta et al., 2004). The initial study (Spence, 1997) found an alpha of .93 for the full scale, which was corroborated by a later study (alpha of .92) (Essau, Muris, & Ederer, 2002). In 2003 Spence, Barrett and Turner published psychometric characteristics using the scale for adolescents who were 13 or 14 years of age to determine whether it was prudent to administer the instrument beyond its intended younger age range. A confirmatory factor analysis indicated that the same six-factor model was still the most appropriate factor structure, despite including only older children within the sample. Internal consistency was still high (alpha = .92) for the total score, whereas alpha ranged from poor to acceptable (between .60 and .80) for the six subscales. The test-retest reliability was mediocre (.63) for the total score after 12 weeks. The full scale and the subscales demonstrated fair-to-good psychometric properties with multiple community-based samples. All major DSM anxiety diagnoses were included in the subscales. This measure was limited by its restricted fouryear age range (or six-year age range if one is guided by the extension study; Spence, Barrett, & Turner, 2003) and child-only response format, which continues to raise practical issues for persons with ASDs. The lack of psychometric characteristics for this scale with children who have ASDs is problematic, as it is for so may other instruments. This is another measure that would likely be useful for children who are higher functioning and who have moderate language and cognitive abilities. 5. Summary and conclusions As noted, the prevalence estimates of anxiety conditions among people with ASD have ranged from 11% to 84%. Of course, when reliability drops to an unacceptably low level, this challenges the very validity of the diagnostic process. This suggests a lack of reliability, at least historically, when diagnosing anxiety in the ASD population. Hence it appears that at least some of the historic diagnostic reports were invalid. Undoubtedly, more validation work is needed to evaluate anxiety disorders among children and adolescents with ASDs and to estimate prevalence rates. However, we believe that work grounded with better assessments, such as those summarized below, will lead to more accurate diagnoses and estimates of prevalence. In Table 3, we have summarized the instrument characteristics on the ten most commonly used anxiety tools for assessing children with ASDs. For simplicity, they are indexed here by the numbers assigned in Table 3. Almost all instruments allow for self-report, with #1, 4, and 7 being exceptions. Given the intended age range to be assessed, this can hardly be held against the BISCUIT (#4). Most instruments allow for caregiver report, exceptions being SASC-R (#9) and the SCAS (#10). Only three instruments, namely 1, 3, and 4, were empirically derived with ASD samples. Four instruments (1, 3, 4, and 5) have some psychometric data derived from young people with ASD. Six instruments (1, 3, 4, 5, 6, and 7) were ‘‘broad band’’ and intended to capture both internalizing and externalizing domains, whereas the remainder focused on anxiety alone. The last column of Table 3 describes the types of anxiety conditions that are captured by these scales. Only four of the instruments reviewed (1, 2, 8, and 10) captured four or more dimensions of anxiety. Of course, it may well be unrealistic to Table 3 Summary of assessment characteristics. Instrument name

Self report?

Caregiver report?

Empirically derived or validated for ASD?

Psychometric characteristics for ASD?

Age group

Broadband evaluation?

Number of anxiety types assessed?

1. Autism Comorbidity Interview – Present and Lifetime Version 2. Anxiety Disorders Interview Schedule for Children 3. Autism Spectrum Disorders– Comorbidity for Children 4. Baby and Infant Scale for Children with Autistic Traits 5. Behavioral Assessment System for Children – 2 6. Child Behavior Checklist

No

Yes

Yes

Yes

Yes

Yes

Yes

No

No

Child/ adolesc Child

No

7: GAD, SAD, PD, SoP, SP, OCD, Any DSM Anxiety 4: GAD, SAD, SP, SoP

Yes

Yes

Yes

Yes

Child

Yes

1: Worry/depressed

No

Yes

Yes

Yes

Toddler

Yes

Yes

Yes

No

Yes

Child

Yes

1: Anxiety/repetitive behavior 1: Anxiety

Yes

Yes

No

No

Yes

7. Child Symptom Inventory

No

Yes

No

No

8. Multidimentional Anxiety Scale for Children 9. Social Anxiety Scale for Children – Revised

Yes

Yes

No

No

Child/ adolesc Child/ Adolesc Child

Yes

No

No

No

Child

No

Yes

No

No

No

Child

No

10. Spence Children’s Anxiety Scale

Note: Child = suitable for children; Adolesc = suitable for adolescents; Toddler = suitable for toddler.

Yes No

2: Anxious/depressed, anxiety problems 3: GAD, SAD, SoP 4: Harm avoidance, SAD, physical symptoms, SoP 3: Social avoidance and distress specific to new situations, fear of negative evaluation from peers, generalized social avoidance and distress 6: PD/AGP, SAD, SoP, OCD, GAD, physical injury fears

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hope for such discrimination from the BUSCUIT (4), as one would not expect great elaboration in expression of anxiety among children three years and under. All in all, this is a good start, but we cannot conclude yet that any of these instruments does an adequate job of assessing anxiety in youth with ASDs. At this stage, the ADIS (clinical interview format), coupled with the ACI-PL or CSI (for caregiver report) and MASC or SCAS (for child report) may be the best current options for clinical and research applications. One issue for consideration is the appropriate use of anxiety diagnoses in the presence of ASDs. Currently, according to proposed DSM-V guidelines provided on the internet (www.dsm5.org), diagnoses of panic disorder, agoraphobia, and SP will be permitted in presence of an ASD. However, diagnoses of SAD, SoP, GAD, and OCD will not be permitted in the presence of an ASD. Such restrictions would make sense if all children with ASDs have such anxiety disorders or if no children with ASDs have these conditions. However, we can be reasonably confident that some young people with ASDs will and will not have these conditions. If true, this (a) will reduce communication about such comorbid conditions, (b) may impair relevant research on the comorbidities and (c) may undermine clinical care in presence of such co-recurrences. This seems to be a potentially adverse nosological development, and we urge researchers in this field to keep careful track of relevant anxiety symptoms for children with ASDs, even when the symptoms involve anxiety conditions that are not ‘‘allowed’’ to co-occur with ASDs. In doing so, such investigators and clinicians may be providing a genuine service to children with such cooccurrences when diagnostic structures are considered in the future. There are two possible options for a solution to the lack of validated and reliable anxiety instruments for ASDs, and both require additional research. One immediate option is that an existing scale could be modified to make it more appropriate for the intended informant (by revising the language, adding a parent report version, and so forth). It could then be studied with samples of children and adolescents on the autism spectrum. A decent choice for this type of modification would be the CSI family of measures, as symptom presentation can be tracked from early childhood through adolescence due to significant overlap of diagnostic questions on these scales. A more distant option is that new scales could be created—or new items could be added to existing scales—to address the concerns (e.g., over-sensitivity to typical stimuli) for evaluating anxiety in children and adolescents with ASDs. If possible, such new tools or extensions to old ones would be created with input from parent focus groups and expert clinicians in the ASD field. Experimental instruments could then be analyzed by exploratory factor analysis to examine construct validity, followed by psychometric assessment. It would also be advantageous to investigate measures of anxiety related to physical indicators of anxiety, such as heart rate, skin conductance, muscle tension, or brain activation. Another strategy that could be used to validate such instruments would be to compare children with ASDs from families with strong pedigrees of specific anxiety syndromes. Such children, presumably with a strong genetic predisposition for the disorders, could then be compared to others from families whose members are relatively free of anxiety conditions. In conclusion, researchers are currently investigating comorbid anxiety disorders with a substantially greater frequency than in the past. 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Historical development and present status of the schedule for affective disorders and schizophrenia for school-age children (K-SADS). Journal of the American Academy of Child and Adolescent Psychiatry, 39, 49–58. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders, fourth edition text revision. Washington, DC: APA. *Bellini, S. (2004). Social skill deficits and anxiety in high-functioning adolescents with autism spectrum disorders. Focus on Autism and Other Developmental Disabilities, 19(2), 78–86. *Bellini, S. (2006). The development of social anxiety in adolescents with autism spectrum disorders. Focus on Autism and Other Developmental Disorders, 21(3), 138–145. Beidel, D. C., Turner, S. M., & Morris, T. L. (1998). Social Phobia and Anxiety Inventory for Children (SPAI-C): Users manual. North Tonawanda: Multi-Health Systems Inc. *Bhardwaj, A., Argarwal, V., & Sitholey, P. (2005). 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