Psychosomatics 40:404-413, October 1999
© 1999 The Academy of Psychosomatic Medine
Assessment of Anxiety Disorders in Asthmatic Children
Gilbert Vila, M.D.,
Chantal Nollet-Clémençon, Ph.,
Jacques de Blic, M.D.,
Bruno Falissard, M.D.,
Marie-Christine Mouren-Simeoni, M.D., and
Pierre Scheinmann, M.D.
Received October 5, 1998; revised January 4, 1999; accepted March 22, 1999. From the Service d'Allergologie et de Pneumologie Pédiatriques, Hôpital Necker-Enfants Malades, 149 rue de Sévres, 75015 Paris, France; and the Service de Psychopathologie de l'Enfant et de l'Adolescent, Hôpital Necker-Enfants Malades, 149 rue de Sévres, 75015 Paris, France. Address correspondence and reprint requests to Dr. Vila, Service de Psychopathologie de l'Enfant et de l'Adolescent, Hôpital Necker-Enfants Malades, 149 rue de Sévres, 75015 Paris, France.
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ABSTRACT
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The study's objective was to determine whether the State Trait Anxiety Inventory for Children, Trait version (STAIC), is suitable for the assessment of DSM-IV anxiety disorders in asthmatic children and adolescents. Ninety-two outpatients were given a semistructured diagnostic interview. They completed STAIC; another questionnaire about anxiety, the Echelle Comportementale d'Anxiété et de Peurs (ECAP); and the Child Depression Inventory. The parents filled in the Child Behavior Check-List (CBCL) and the Conners Parent Rating Scale (CPRS). A group of healthy children was assessed with STAIC. Thirty asthmatic children had anxiety disorders. They had significantly higher STAIC scores than the nonanxious asthmatic and the nonasthmatic children. STAIC scores were independent of age and sex and were correlated with ECAP, CPRS anxiety subscore, CBCL total score, internalizing score, and CBCL anxiety-depression subscore. Internal consistency was 0.75. With a threshold value of 34 for anxiety disorders, this method had a sensitivity of 73% and a specificity of 70%. STAIC was thus a useful method for anxiety disorder screening in a pediatric population.
Key Words: Asthma • Anxiety • Children and Adolescents
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INTRODUCTION
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Mental disorders, particularly anxiety and depression, frequently affect children and adolescents with a chronic somatic illness like asthma. Although several studies1–3 found no difference in emotional disorders between people with asthma and the general population, in a large epidemiological study on the Isle of Wight, Graham et al.4 found a higher incidence of psychiatric problems among severely asthmatic children. Kashani et al.5 report evidence for a higher incidence of psychiatric disorders in a group of 56 people with asthma than 56 control children. McNichol et al.6 report similar findings in Australia, as do Strunk et al.7 Mrazek et al.8 studied 26 asthmatic children and 22 control subjects and reported that the asthmatic children had psychological disturbances more often than the control children. Bussing et al.,9 in a study comparing 37 children with asthma, 23 children with hemophilia, and 31 healthy children, found that the group with asthma had a significantly greater prevalence of anxiety disorders than did the healthy control group. Up to 43% of asthmatic children could have anxiety disorders, according to the DSM–III-R criteria.5,9 This particular comorbidity is linked with the fact that changes in respiratory function produce a great deal of anxiety in the patient.10 However, it has been suggested that the central chemical receptors monitoring the partial pressure of carbon dioxide may lead to an anxiety or panic attack and that this mechanism has evolved in humans as an asphyxia alarm signal. There may be a higher genetic risk of anxiety disorders in children with severe asthma.11 These disorders are an extra handicap and may reduce the effectiveness of treatment by affecting compliance or because the emotional state of the patient has a direct effect on autonomic reactions and pulmonary function.12 Some studies have demonstrated that treatment of anxiety by relaxation, for example, can reduce asthma in children, whose attacks may be triggered by emotional factors.13 Thus, it is important to screen for these anxiety disorders so that they can be treated. To achieve this goal, every asthmatic child should be examined systematically by a mental health specialist; however, this is, in practice, difficult in most pediatric departments.14 Simple screening methods are particularly important for children at risk of anxiety disorders. Self-administered questionnaires about anxiety are effective because they are simple to complete, and the children, who are more aware of their inner states than their parents or teachers, provide the information.15
Moreover, observers' characteristics, such as experience and attitude, may affect observation, and a diagnostic interview may confuse psychiatric symptoms of anxiety or depression and somatic symptoms like pain or dyspnea.16,17 According to some researchers, children are able to think conceptually about the differences between pain and anxiety and can understand and use a rating scale,17,18 but it is important to assess the validity of such instruments in pediatrics. Various questionnaires are used to measure anxiety in children, including the Revised-Children Manifest Anxiety Scale (R-CMAS)19 and the State-Trait Anxiety Inventory for Children (STAIC),20 which are the most frequently used. The STAIC is a self-administered questionnaire that consists of two separate 20-question rating scales, one for "state" anxiety (acute, transitory) and the other for "trait" anxiety (chronic, pervasive anxiety—the general tendency of the child to be anxious).20 The STAIC is potentially valuable for screening of anxiety disorders because its trait version assesses chronic anxiety and can be quickly completed. We felt that it could be used not only for children age 8 to 12 years, but also for adolescents.21,22 The STAIC distinguishes anxious and nonanxious subjects in general populations.20 We wanted to assess its value for a pediatric population. We studied asthmatic children, because anxiety disorders have a high prevalence in patients with asthma, particularly in severe cases, in which the occurrence of psychiatric problems can have a major effect.4–7,11,23
The aims of this study, conducted in 1995, were to evaluate the value of STAIC-trait for assessing DSM-IV24 anxiety disorders in a population of asthmatic children and adolescents. We identified those children within this population diagnosed with DSM-IV24 anxiety disorders by using a standard diagnostic technique. We calculated STAIC mean scores for the anxious and nonanxious children in our study population. We then compared these scores with those obtained for a control population of nonasthmatic children to determine whether the STAIC could distinguish the anxious and nonanxious children and adolescents. We set a threshold score for screening a pediatric population for anxiety disorders by using the STAIC-trait, and we calculated its sensitivity and specificity. We assessed 1) the concurrent validity of STAIC against another self-administered anxiety questionnaire and two questionnaires completed by parents that yield internalization and anxiety scores and 2) the internal consistency of STAIC-trait for this pediatric population. The overall aim of the work was to test whether STAIC-trait is an effective clinical tool for systematic screening for anxiety disorders in a pediatric department.
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METHODS
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Instruments
State Trait Anxiety Inventory for Children.
The STAIC is a self-administered questionnaire that is widely used to measure anxiety in children. It consists of two separate 20-question rating scales, one for "state" anxiety (acute, transitory) and the other for "trait" anxiety (chronic, pervasive).20 Only the trait subscale, which measures a durable form of anxiety, was used. Items are answered "hardly ever," "sometimes," or "often" and are given a score of 1 to 3. Internal consistency has been estimated at 0.78 to 0.87,20 and split-half reliabilities of 0.88 have been reported.25 Test–retest reliability coefficients vary from 0.44 to 0.94 for anxiety trait, according to the time interval between the two tests.26 The STAIC has been shown to have a good concurrent validity against other measures of anxiety (R-CMAS, Generalized Anxiety Scale for Children [GASC], and the State-Trait Anxiety Inventory [STAI]), but the STAIC's discriminatory power is not clear.26,27 Like the R-CMAS and the Revised Fear Survey Schedule for Children, the STAIC is an overall anxiety evaluation because it cannot distinguish between the various types of anxiety, such as separation anxiety disorder and school phobia.19,20,28 The STAIC is positively correlated with the R-CMAS (0.75), GASC (0.63), and Children's Anxiety Evaluation Form scores.29 The French version has been used in recent studies.21,22,30 In a prior study of child and adolescent outpatients at a French child psychiatry unit, we identified 97 subjects presenting with DSM-III-R anxiety disorders, with mean±standard deviation (SD) scores of 13.2±7.2 for the Child Depression Inventory and 36.9±7.3 for STAIC-trait.30,31
Anxiety and Fear Behavioral Scale ("Echelle Comportementale d'Anxiété et de Peurs" [ECAP]).32
The ECAP is a 78-item self-report form for assessing the fears of children and adolescents (8–16 years old) and the symptoms of DSM-IV anxiety disorders. The ECAP has been used in various French studies,21,22,33 and we have demonstrated that this questionnaire discriminates DSM-III-R anxiety disorders and other mental disorders in clinical populations (unpublished data). Factor analysis has shown three factors: "self-image," "interaction with pairs," and "fears of a danger." Test–retest validity (n=91) was 0.74, with an interval between passations of 8–14 days. Correlation between ECAP and STAIC-trait was 0.77 (n=239 nondepressed children), with an ECAP mean±SD score=124±24 and a STAIC mean±SD score= 37.6±8.3 in children with DSM-III-R anxiety disorders and a mean STAIC-trait=33.0 in normal children.32
Child Depression Inventory (CDI).
The CDI is a 27-question self-report that measures symptoms of depression.31 Although the CDI was originally tested on 8- to 13-year-old children, the current version of the CDI has been validated for a large population of 10- to 17-year-old children, with a threshold score for depression of 17.34 The CDI was translated into French35 and is widely used in France.
Child Behavior Check-List (CBCL).
The CBCL is a 138-item questionnaire completed by parents.36,37 The CBCL provides a standardized description of the competences and emotional and behavioral problems of children age 4 to 16 years. The first part deals with social skills, participation in organizations, contact with friends, participation and skills in sports, and ratings for academic performance. The second part assesses internalized and externalized emotional and behavioral problems. Internalized problems affect the child's emotional state and view of him- or herself and include being anxious/depressed or withdrawn and schizoid and somatic complaints. Externalized problems affect the way the child interacts with others and include delinquent, cruel, and aggressive types of behavior. The French version of the CBCL has been shown to be valid and reliable in its use in a community sample of 2,480 children.38
Conners Parent Rating Scale (CPRS).
The 48-item version of the CPRS was used. It was completed by the parents. This rating scale was designed to identify hyperactive children, but other symptoms are also assessed: conduct problems, learning difficulties, psychosomatic problems, impulsiveness, and anxiety.39 In preliminary work, we showed that the French version could discriminate DSM–III-R attention-deficit disorders, hyperactivity, and other disruptive behavior disorders from other mental disorders in psychiatric outpatients (unpublished data).
Schedule for Affective Disorders and Schizophrenia for School-Age Children, Present Episode Version, Revised (K–SADS-R).
The K-SADS-Present Episode was a semistructured interview designed by Puig-Antich and Chambers40 to record information about the mental state of children and to determine whether they had any psychiatric disorders, as assessed by DSM-III. A French version has been used for psychiatric populations.41 The K-SADS had several limitations and so was revised in the lifetime version (K-SADS-L: R. Klein et al., 1993, New York State Psychiatric Institute, unpublished). The K-SADS meets the DSM-IV criteria and assesses current and past psychopathology. However, most affective symptoms are only rated for the current episode and past 2 weeks. Psychometric properties are not recorded. It has been translated into French (K-SADS-R), in collaboration with R. Klein, at Necker-Enfants Malades Hospital (Paris), where it is currently used in evaluations. We considered only the current episodes of mental disorders in the children evaluated for this study. In a preliminary validation study, we found that the French version performed satisfactorily and had a good concurrent validity for diagnosis of DSM-IV anxiety disorders and depression (major depressive disorder, dysthymic disorder), compared with standard self-report scales (STAIC-trait, ECAP, CDI, CBCL). Compared with the normal subjects (n=72, Mann-Whitney U-test), K–SADS–R anxiety disorders (n=52) had significantly higher STAIC-trait (37.0 vs. 29.1), ECAP (127.1 vs. 103.4), CBCL-Internalizing (65.6 vs. 50.8), and CBCL-anxiety/depression (66.3 vs. 53.4) mean scores; K–SADS–R affective disorders (n=18) had significantly higher CDI (17.7 vs. 8.1), CBCL-Internalizing (67.8 vs. 54.3), and CBCL-anxiety/depression (69.7 vs. 56.2) mean scores; and disruptive behavior disorders (n=8) had significantly higher CBCL-Externalizing (66.0 vs. 48.4) mean scores (unpublished data).
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SUBJECT SAMPLES
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The study population consisted of 92 asthmatic children (63 boys and 29 girls), consecutive outpatients at the Department of Pediatric Allergology and Pneumology at Necker-Enfants Malades Hospital in Paris. They were age 8 to 17 years, with a mean±SD age of 11.7±2.5. Twenty subjects had a low socioeconomic status (SES), 41 a middle SES, and 31 a high SES. The mean±SD duration of asthma was 8.8±7 years. The children were assessed on a day on which they did not suffer an asthma attack. They were classed as having mild-to-severe asthma based on clinical feature pretreatment and the type and frequency of prescribed medication.42 Four levels of severity were defined: intermittent, mild-persistent, moderate-persistent, and severe-persistent. Intermittent asthma was defined as intermittent symptoms less than once a week, brief exacerbations, nighttime asthma symptoms less than twice a month, asymptomatic and normal lung function between exacerbations, peak expiratory flow (PEF) or forced expiratory volume in 1 second (FEV1)  80% predicted with variability <20%, and intermittent reliever medication taken as needed only. Mild-persistent asthma was defined as clinical feature pretreatment with symptoms more than once a week but less than once per day, exacerbations possibily affecting activity and sleep, nocturnal asthma symptoms more than twice a month, and PEF or FEV1 80% predicted with variability of 20% to 30%; mild-persistent asthma was also defined according to therapy with one daily controller medication (long-acting bronchodilator and anti-inflammatory medication). Moderate-persistent asthma was defined according to clinical features pretreatment with daily symptoms, exacerbations affecting activity and sleep, nocturnal asthma symptoms more than once a week, daily use of short-acting inhaled beta2-agonist, and PEF or FEV1 <60% and <80% predicted with variability >30%. Moderate-persistent asthma was also defined as therapy with daily controller medication (inhaled corticosteroid and long-acting bronchodilator). Severe-persistent asthma was defined as clinical features pretreatment: continuous symptoms, frequent exacerbations, physical activity being limited by asthma symptoms, frequent nocturnal asthma symptoms, daily use of short-acting inhaled beta2-agonist, and PEF or FEV1 > 60% predicted with variability >30%. Severe-persistent asthma also involved therapy several times daily with controller medications (high doses of inhaled corticosteroid, long-acting bronchodilator, and long-term oral corticosteroid). Twelve of the 92 children had mild-persistent asthma, 29 had moderate-persistent asthma, and 51 had severe-persistent asthma. None of the patients were treated continuously with oral corticosteroids.
A comparison group of normal children was recruited from a school near Paris. Ninety-four children were included, paired with the asthmatic children matched for age, gender, and SES. There were 64 boys and 30 girls, age 8 to 17 years (mean±SD: 11.6±2.7 years). The exclusion criterion was a diagnosis of asthma or another chronic illness (Table 1).
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DESIGN
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For 1 year, all asthmatic children over 7 years old were serially recruited from the Department of Pediatric Allergology and Pneumology of Necker-Enfants Malades Hospital in Paris. A letter was sent to parents informing them of the objectives and procedure of the study and requesting their consent. One hundred and twelve families were asked to participate, and only seven refused. One boy and one girl were excluded because they were mentally retarded. Eleven interviews were incomplete because the parents did not have enough available time and could not return during the study. The CBCL and the CPRS were administered to the parents. The children were assessed by using three self-reports: the STAIC, ECAP, and CDI. The children were also assessed with a semistructured interview, the K–SADS-R, modified for DSM-IV diagnoses. Investigations were performed by an experienced child psychologist trained in the use of these techniques and blind to the medical treatment and severity of asthma.
The children in the comparison group who gave their informed consent were assessed by self-administered anxiety questionnaires (STAIC-trait) only, because the aim was to obtain reference scores for a normal French population so that we could interpret the scores of asthmatic children with and without DSM-IV anxiety disorders.
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DATA ANALYSIS
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The Statistical Package for the Social Sciences PC program was used for statistical analysis. Results are expressed as frequencies (%) and means with SDs. Groups of children were compared by using Student's t-test, the chi-square test, and Fisher's exact test. Relationships between the scores for the various questionnaires were assessed by calculating the Pearson coefficient of correlation (2-tailed significance). Significance was calculated with a risk alpha=0.05.
The evaluation of the STAIC-trait as a screening instrument has been done by using the Receiver Operating Characteristic (ROC) analysis.43 This methodology isolates a test's capacity to discriminate between a given disorder and its absence from the confounding influence of the cutting score. In a second time, its sensitivity (true-positive fraction) and specificity (complement of the false-positive fraction) have been estimated for the cutting score clinically and is statistically pertinent.
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RESULTS
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DSM-IV Diagnoses and Asthma
Diagnostic interviews with K-SADS-R identified 32 asthmatic children with at least one psychiatric disorder. Thirty had at least one DSM-IV anxiety disorder (23 generalized anxiety disorders, 13 separation anxiety disorders, 9 social phobias, and 1 panic disorder with agoraphobia; some children had more than 1 disorder). Five children had an affective disorder (dysthymic disorder, no major depressive disorder). Five children had disruptive behavior disorders (2 conduct and opposition disorders, 3 attention-deficit disorders/hyperactivity). The demographic characteristics and questionnaire scores of the children, both with and without DSM-IV anxiety disorders, are presented in Table 2. Gender ratio and age were similar for the children with and without anxiety disorders. Questionnaires to assess anxiety made it possible to distinguish those asthmatic children with an anxiety disorder from those without anxiety, unlike CBCL externalizing scores, which instead assess behavior disorders. STAIC-trait mean±SD score was 36.5±5.6 in the anxious asthmatic children and 30.5±4.9 in the asthmatic children without DSM-IV anxiety disorders, a highly significant difference (P=0.0005).
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TABLE 2. Gender ratio, age, and questionnaire scores of asthmatic children with and without DSM-IV anxiety disorders (diagnosed by the Kiddie SADS-R)
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The STAIC-trait items that distinguished the anxious asthmatic children from the asthmatic children without DSM-IV anxiety disorders by a significantly higher item mean score were Items 1 ("I worry about making mistakes"), 4 ("I have trouble making up my mind"), 20 ("I worry about what others think of me") (P=0.02) and Items 2 ("I feel like crying"), 6 ("I worry too much"), 9 ("I feel troubled"), and 18 (" It is hard for me to fall asleep at night") (P=0.0005).
STAIC-Trait, Demographic Factors, and Asthma Severity
STAIC-trait scores were not significantly different for the asthmatic boys (mean±SD: 32.4±5.8) and girls (mean±SD: 33.0±6.0). There was no correlation between STAIC score and age in the asthmatic children (R: 0.15, NS). STAIC mean scores were similar for children under 9 years of age (n=6, mean±SD STAIC: 32.5±7.4); 9 to 12 years old (n=50, mean±SD STAIC: 33.3±5.7); and over 12 years of age (n= 36, mean±SD: 31.6±5.8). STAIC-trait sores were not significantly different between mild-persistent asthma (mean±SD: 30.2±4.6), moderate-persistent asthma (mean±SD: 32.2±6.3), and severe-persistent asthma (mean±SD: 33.0±5.7) (ANOVA P=0.416).
External and Discriminant Validity of STAIC-Trait
There is a highly significant difference in the STAIC-trait scores of the asthmatic children with DSM-IV anxiety disorders (mean±SD:36.5±5.6), compared either with the nonasthmatic control subjects (mean±SD: 32.9±5.7, P=0.0005) or with the asthmatic subjects without anxiety disorders (mean±SD: 30.5±4.9, P=0.0005). The asthmatic children without anxiety disorders had scores similar to those of the nonasthmatic control subjects (mean±SD: 30.5±4.9 vs. 32.9±5.7).
The STAIC-trait scores of the asthmatic children were strongly correlated with the scores for the other self-administered anxiety questionnaire completed by the children (ECAP) and with the scores for questionnaires completed by the parents (CPRS, CBCL) to assess the anxiety of their children (CPRS anxiety subscore, internalization, and anxiety-depression CBCL subscores). CBCL total scores were correlated with STAIC-trait scores, but not with externalization scores, which are more effective for assessment of behavior problems (Table 3).
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TABLE 3. Correlations between STAIC-trait, scores, age, and scores of other questionnaires filled in by the asthmatic children and their parents
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STAIC-trait scores were significantly correlated (r=0.58, P=0.0005) with CDI depression scores for the asthmatic children (Table 3).
Internal Consistency of STAIC-Trait in Asthmatic Children
The 20-item scale was internally consistent, with a Cronbach alpha coefficient of 0.75. The value of this coefficient was 0.58 for the 7 items that discriminated the anxious and nonanxious children (Items 1, 2, 4, 6, 9, 18, 20).
STAIC-Trait, Clinical Cutoff for DSM-IV Anxiety Disorders, Specificity, and Sensitivity in Asthmatic Children
A ROC curve was generated to determine the cutoff score for STAIC-traits, leading to a diagnosis of a DSM–IV anxiety disorder (Figure 1). A score of 34 was selected because it is clinically relevant and corresponds to the maximum of the sum of sensitivity and specificity.
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FIGURE 1. Receiver operating characteristic curve for diagnosis of DSM-IV anxiety disorders by STAIC score
Note: STAIC=State Trait Anxiety Inventory for Children, Trait version. A score greater than or equal to 34 maximizes the sum of specificity and sensitivity.
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Thus, in asthmatic children age 8 to 17 years, a score of 34 or over for STAIC-trait was used to identify 40 anxiety-positive subjects; 22 true-positives, diagnosed with DSM-IV anxiety disorders by K-SADS-R; and 18 false-positives without anxiety disorders, according to K–SADS–R. We also identified 43 true-negatives without anxiety disorders, according to K-SADS-R, and 8 false-negatives with DSM-IV anxiety disorders, according to K–SADS-R.
The sensitivity of STAIC-trait with 34 as the cutoff point was 0.73 (95% confidence interval: 0.58 to 0.89), and specificity was 0.70 (95% confidence interval: 0.59 to 0.82).
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DISCUSSION
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We tested whether STAIC-trait could accurately detect anxiety disorders in a population of asthmatic children and adolescents. The asthmatic subjects with DSM-IV anxiety disorders, diagnosed by the K-SADS-R, were significantly distinguished from other nonanxious asthmatic children and from the nonasthmatic children by STAIC-trait scores. This validity, in relation to clinical diagnosis, was supported by a good correlation with another self-administered questionnaire to assess anxiety (ECAP) and scores from questionnaires completed by the child's parents (CPRS, CBCL). The STAIC scores were correlated with CBCL internalizing and anxiety-depression subscores, but not with externalizing subscores, suggesting that the STAIC has some degree of specificity, in contrast with the results of other studies.15,20
The mean score for the anxious asthmatic children was 36.5, whereas the mean score for the nonanxious asthmatic children was 30.5 and that for the nonasthmatic control subjects was 32.9. The mean score for the anxious asthmatic subjects (36.5) is similar to that obtained for the nonasthmatic Child Psychiatry Department outpatients with DSM-III-R anxiety disorders (36.9).30 Although significantly different, these scores for the children with and without anxiety disorders are actually quite similar, considering that this scale extends from 20 to 60. These data illustrate the difficulty in finding relevant items for diagnosis of anxiety disorders. Anxiety, in all its forms, is ubiquitous, and the definition of pathological anxiety is based on the intensity and effects of anxiety on the patient's life rather than on its presence alone. To our knowledge, there is no other study using STAIC-trait with asthmatic anxious children, but the scores obtained in our study are similar to those obtained in other studies for nonpediatric, general, or psychiatric populations including both anxious and nonanxious subjects.44,45
Seven items distinguished the anxious from the nonanxious asthmatic subjects. None of the items of somatization were effective discriminators (13="I notice my heart beats fast"; 16="my hands get sweaty"; 19="I get a funny feeling in my stomach"). This finding is consistent with the conclusions of other authors who found that it is difficult for a child with a chronic illness to discriminate between true somatic symptoms and the neurovegetative symptoms of anxiety, particularly in cases of pain or respiratory disease (panic attacks mimic the symptoms of hypercapnia and respiratory distress).16 In contrast, difficulties with falling asleep (Item 18), which are more specific to anxiety disorders, were discriminant, even though asthma often disturbs sleep because attacks occur at night. The other discriminating items are mostly cognitive in nature.
"I feel unhappy" (Item 3) did not distinguish between the anxious and the nonanxious subjects (diagnosis by K–SADS-R), although the STAIC-trait score was significantly correlated with the CDI depression score. However, no child presented with major depressive disorder, and there were no more affective disorders among the children with anxiety disorders than among the nonanxious children. The total STAIC-trait score probably cannot discriminate between anxiety disorders and depressive disorders, because several STAIC items are common to the semiology of anxiety and depression (Item 2: "I feel like crying," Item 3: "I feel unhappy," Item 7: "I get upset at home," and Item 9: "I feel troubled"). This lack of specificity was reported by Strauss et al.,46 who found that STAIC-trait could not distinguish the children with DSM-III anxiety disorders without depression from the psychiatric control subjects with a DSM-III disorder other than anxiety or depression. The Multidimensional Anxiety Scale for Children seems to discriminate effectively anxiety and depression from other disorders.47 STAIC, like other self-administered questionnaires, is more an indicator of distress recognized by the subject than a specific diagnostic technique. However, we found a low prevalence of depressive illness in our asthmatic subjects (5% dysthymic disorder and no major depressive episodes) in contrast to other studies showing a higher risk of depression than of other chronic illnesses in asthmatic subjects.48–50 Nevertheless, our results are consistent with those of other authors (DSM-III-R depression: 15%, composed of 8% major depressive disorder and 3% dysthymia; anxiety disorders: 28%, composed of 24% overanxious disorder; and 8% behavior disorders).5 One limitation of this work seems to be the lack of sensitivity of K-SADS-R for diagnosis of affective disorders in persons with asthma. The strong correlation between the STAIC and CDI scores may be due not only to a lack of specificity of the STAIC but also to an underestimation of the comorbidity of anxiety and affective disorders in our asthmatic subjects, although the CDI is specific (84% and 91% specific against the K-SADS-P and the Children Assessment Scale).51,52 A study should be performed to test whether the K-SADS-R is more reliable in general than the K-SADS-P (DSM-III anxiety disorders: Kappa=0.37; depression: 0.52; behavior disorders: 0.36–0.50), as suggested by our preliminary validation study for the French version of the K-SADS-R.53 Moreover, several items of major depressive disorder and dysthymia in K-SADS-R (anorexia, loss of weight, insomnia, attention-deficit) may be attributed to physical symptoms of asthma rather than depression, and the K-SADS-R does not allow diagnosis if symptoms can be attributed to a somatic illness.
We found a low prevalence of behavior disorders in the asthmatic children, consistent with other studies,4,5,49 and the STAIC-trait clearly distinguished between the internalized and externalized symptoms.
The STAIC scores were similar for the boys and girls in the anxious and nonanxious asthmatic groups, as shown before.4,10 Even if girls find it easier to speak about what they feel, as suggested by some authors, this difference was not evident in the asthmatic patients who completed this questionnaire.
The STAIC was initially validated with children between 9 and 12 years of age. Our results show that STAIC-trait can be used for children over the age of 12. It is appropriate for use in children between ages 8 and 16, like the RCMAS, so long as the children can describe their inner states and assess them by using a quantitative scale (i.e., over 7 years of age). Anxiety scores were independent of age, as for other studies.10
We chose 34 as the cutoff point for detection of DSM–IV anxiety disorders, with 73% sensitivity and 70% specificity. It would be of interest to investigate whether this cutoff point is also appropriate for other pediatric illnesses. Standardized tools like the K-SADS-R give a lower level of subjective bias in psychiatric diagnosis than simple clinical diagnosis. Self-administered questionnaires are generally believed to be very sensitive, but they are not very specific for a particular type of disorder. The CDI is, however, very specific (84% to 91%) but not very sensitive (54% for diagnosis of depression).51 Although the questionnaires completed by the parents, like the CPRS, and particularly the CBCL, can be used to explore all types of mental disorders, they are less sensitive for the screening of internalized than for externalized disorders39,54 and are not very effective for screening for emotional disorders (35.3% for the CBCL, according to Fombonne55). A self-report such as the STAIC, with a sensitivity of 73%, may be the best—or the worst—way to detect anxiety and anxiodepressive disorders. Diagnosis should then be confirmed by a clinical interview, because the STAIC may generate as many as 45% false-positives, a major drawback of this mesure. Diagnosis is the first stage of psychiatric treatment, even if the initial level of the anxiety trait does not predict the effect of the response to anxiety treatment of the patient's asthma.13 It would be interesting to compare STAIC-trait scores for anxiety with those for other mental disorders, such as depression or behavior disorders, in French psychiatric populations. In work with a French population (unpublished), we compared 97 children presenting with DSM-III-R anxiety problems with 90 age- and gender-matched subjects treated in the Child Psychiatry Department for other mental disorders. We found that mean STAIC-trait scores did not discriminate between the two populations (mean±SD: 36.9±7.3 for the anxious subjects and 35.4±7.2 for the nonanxious psychiatric patients, unpublished data). The cutoff point selected is proportionally higher than that previously used for an adolescent and adult version of STAI in a French population.56
We used only the trait form of STAIC, although the full questionnaire also contains a state form. These two scales are correlated, even in asthmatic persons,10 and our aim was to validate an easy-to-use screening method. This objective was achieved by using only 20 items of STAIC-trait, which reduces assessment time, increasing the likelihood that the child will cooperate. We did not aim to assess state changes, which is the goal of the STAIC-state questionnaire.
The STAIC-trait was internally consistent in the asthmatic children, with a Cronbach alpha coefficient of 0.75. This coefficient is similar to those obtained for studies with the English version of the questionnaire, in which this coefficient was between 0.78 and 0.87.15,20
The STAIC-trait is an effective screening method, detecting 73% of the cases of anxiety disorders in cases of childhood and adolescent asthma, in which this problem is common and often serious. Thirty-two percent of our population of asthmatic children had anxiety disorders. This figure is clearly higher than that for the prevalence of anxiety disorders in the general population, estimated at 5.9% for all emotional disorders in French children.55 A simple, systematic screening technique for anxiety disorders in asthmatic children, particularly in cases of severe asthma in which these disorders have a major impact on everyday life, enables us to treat the mental problems, reducing their effects on compliance and the patient's quality of life and possibly having a positive effect on the patient's asthma. However, this questionnaire is not very specific, which limits its use as a research tool in studies of anxiety disorders. The ease of the STAIC-trait assessment is a major advantage and already makes it possible to avoid underestimation of a major additional handicap in asthmatic children. In clinical use, however, STAIC screening results should always be checked in consultation with a specialist.
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ABSTRACT
INTRODUCTION
