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Factor Structure of the Urdu Version of the Spence Children's Anxiety Scale in
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Factor Structure of the Urdu Version of the Spence

Children's Anxiety Scale in Pakistan

Farah Qadir, Aneela Maqsood, Najam us-Sahar, Nadia Bukhtawer, Amna

Khalid, Regina Pauli, Catherine Gilvarry, Girmay Medhin & Cecilia A. Essau

To cite this article: Farah Qadir, Aneela Maqsood, Najam us-Sahar, Nadia Bukhtawer, Amna
Khalid, Regina Pauli, Catherine Gilvarry, Girmay Medhin & Cecilia A. Essau (2017): Factor
Structure of the Urdu Version of the Spence Children's Anxiety Scale in Pakistan, Behavioral
Medicine

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BEHAVIORAL MEDICINE
2017, VOL. 0, NO. 0, 1–8
http://dx.doi.org/10.1080/08964289.2016.1276427

Factor Structure of the Urdu Version of the Spence Children’s Anxiety Scale
in Pakistan
Farah Qadira, Aneela Maqsooda, Najam us-Sahara, Nadia Bukhtawera, Amna Khalida, Regina Paulib,
Catherine Gilvarryb, Girmay Medhinc, and Cecilia A. Essaub
a
Fatima Jinnah Women’s University; bUniversity of Roehampton; cAddis Ababa University

ABSTRACT KEYWORDS
Spence Children’s Anxiety Scale (SCAS) is one of the most commonly used self-report questionnaires Adolescents; anxiety
to measure symptoms of anxiety disorders in adolescents. Despite its common use, studies that symptoms; cultural sensitive
examine the psychometric properties of SCAS in Pakistan is lacking. Therefore, the purpose of this manifestation of anxiety;
study was to examine the psychometric properties of the Urdu translated version of the SCAS factorial validation
among adolescents in Pakistan. A total of 1277 students (708 boys and 569 girls), aged 13
to17 years, who had been recruited from 13 schools in Rawalpindi, Pakistan participated in the
study. The mean overall anxiety score was significantly higher in girls than males on all the SCAS
subscales except for obsessive compulsive disorder. The internal consistency of the Urdu SCAS was
good. Confirmatory factor analyses supported six separate factor structures. Results of the study are
discussed with reference to the sociocultural milieu of Pakistan and culture sensitive
conceptualization of anxiety and its subtypes.

Introduction
Anxiety disorders are common among children and ado-
lescents in the West, causing severe distress and
impairment in their broader existence,1 and, if left
untreated may act as a risk factor for mental disorders in
adulthood2 emphasizing early intervention. Compared to
developed countries, the prevalence estimates of anxiety
disorders are generally higher in developing countries.3
Despite the enormous burden of mental health prob-
lems, particularly anxiety, this is still a seriously neglected
area in developing countries.4 Pakistan is a developing
country, with about 41% of the population younger than
18 years.5 To our knowledge, no large-scale community
surveys are available on prevalence of anxiety disorders
among Pakistani children and adolescents population.
However, according to community reports, Pakistani
adults showed alarmingly high rates of psychological dis-
tress, with rates ranging from 29% to 66% among females
and from 10% to 33% among males.6 These high rates sig-
nify the need for proper screening and early diagnosis of
anxiety among Pakistani population. Hence, availability
of appropriate screening and diagnostic instruments with
sound psychometric foundation is essential.
Research shows that there is an inconsistency in the expe-
rience, expression, and description of anxiety symptoms
across different cultural7; therefore, special consideration
must be given to the cultural factors when assessing anxiety.1
This should also be reflected in the instruments and criteri-
ons used to assess anxiety. Moreover, anxiety disorders are
particularly difficult to diagnose in children and adolescents
because of symptom overlap with other disorders, common-
ality with general fears and worries of childhood, variations
at different stages of development, and incomplete set of
symptoms.8 Combining these diagnostic questions with cul-
tural influence makes the estimation of rates of anxiety dis-
orders complex in children and adolescents. Therefore a
careful selection of instruments is necessary when assessing
anxiety.
The existing diagnostic interviews for anxiety disorders
with sound reliability and validity have been criticized for
being lengthy and taking time to complete, and for being
complicated to administer and requiring a level of skilled
training.9 Comparatively, self-report measures seem less
complicated, inexpensive, and easy to administer. Several
screening tools such as Fear Survey Schedule for Chil-
dren,10 Multidimensional Anxiety Scale for Children,11
Revised Children’s Manifest Anxiety Scale,12 and State
Trait Anxiety Inventory for Children13 are not based on
Diagnostics and Statistical Manual.14 Spence Children’s
Anxiety Scale (SCAS)15 is an exception because it was

CONTACT Dr. Aneela Maqsood dr_aneelamaqsood@fjwu.edu.pk Head Department of Behavioral Sciences, Fatima Jinnah Women’s University, the Mall,
Rawalpindi, Pakistan.
© 2017 Taylor & Francis Group, LLC
2 F. QADIR ET AL.
primarily developed to assess the Diagnostic and Statisti-
cal Manual of Mental Disorders (DSM)-IV symptoms of
anxiety disorders in children and adolescents, including
generalized anxiety disorder, separation anxiety disorder,
social phobia, panic disorder and agoraphobia, obsessive-
compulsive disorder, and fears of physical injury.
The original validation studies have provided strong
support for the psychometric properties of the SCAS.15–
16
Similarly, several recent studies reported high alpha
coefficients for subscales of SCAS.17–22 Spence in her
original study suggested a correlated six factor structure
for the scale.15–16 Other studies19 also provided strong
support for a six-correlated factor model. However, as
reported in a recent meta-analysis by Orgil
es and col-
leagues54 these factor structures were not consistently
replicated in studies that have used various translated
versions of the SCAS. A five-factor model best accounted
for the German,17 Chinese,18 and Japanese translations
of the scale21; whereas data from South Africa23 showed
a four-factor structure. Possible reasons for these varia-
tions may include sample size variation, differences in
age of study participants, methodological approaches,
type of sample (clinical versus. community), and cultural
factors. Although SCAS has been used to differentiate
Pakistani children in clinical and nonclinical settings24
that study did not explore the psychometric properties of
SCAS. As more studies are likely to use the SCAS in
Pakistan, it is important to examine the psychometric
properties of the Urdu translation of the SCAS among
adolescents in Pakistan.
Methods
Participants
A total of 1277 students (708 boys and 569 girls) were
recruited from 13 secondary and higher secondary
schools in Rawalpindi city. It is the fourth largest city of
Pakistan. The city has a population of about 3.36 mil-
lion.25 A complete list of schools was acquired from the
Directorate of Federal Government Educational Institu-
tions (Cantt/Garrison). “Active data” software was used
to randomly select the schools and the classes with in the
schools from the list of total schools.
Instruments
26
Strengths and Difficulties Questionnaire (SDQ) was used
to measure emotional and behavioral problems. It consists
of 25 items pertaining to five subscales: Hyperactivity,
Emotional Symptoms, Conduct Problems, Peer Problems,
and Pro social behavior.27 The items are scored 0 for Not
True, 1 for Somewhat True, and 2 for Certainly True.
The subscale scores are generated by summing up all the
items pertaining to the specific subscale score ranging
from 0 to 10. A total difficulty score (ranging from 0 to
40) can be generated by summing up the scores on all
subscales of SDQ except for prosocial behavior.26 SDQ
has been reported to have adequate psychometric proper-
ties 27 including the Urdu version of SDQ.28–29
The Sociodemographic Questionnaire was used to
gather adolescent’s sociodemographic information such
as gender, age, living arrangement, and parent’s employ-
ment status.
SCAS was used to measure symptoms of DSM anxiety
disorders among children and adolescents.15–16 The
SCAS has 44 items, of which 38 are used to measure
symptoms of social phobia, separation anxiety, panic
attack/agoraphobia, obsessive-compulsive disorder, gen-
eralized anxiety, and physical injury fears. These 38 items
can be summed up to obtain a total anxiety score.15
These six items are called “filler items” and are used to
reduce response bias. All these items can be rated on a
four-point Likert scale, ranging from never (0) to always
(3).
Translation and face validity of SCAS
Although SCAS has been translated previously by
another research group,24 it was not available for use in
the present study. Therefore, the SCAS was translated
into Urdu by four bilinguals (research team members)
with special focus on content equivalence with the origi-
nal version. The translated items were evaluated by a
committee of five experts. This process helped to select
most suitable Urdu translation of the items. The refined
Urdu version was then given to another group of five
bilinguals for back translation. For evaluation, a follow-
up committee approach was adopted to critically evalu-
ate the appropriateness of the Urdu version. Since diffu-
sion in Urdu language is quite high, certain words from
English language were retained, examples are Dentist
(item 23), train (item 28), shopping centers (item 30),
switch (item 14), and toilet (item 7). Five bilingual
experts in psychology examined the face validity of the
translated version. All the experts and committee mem-
bers were senior faculty members in a Pakistani Univer-
sity and had extensive knowledge of the subject.
Ethical consideration
Ethical approval was obtained from a research commit-
tee in Rawalpindi, Pakistan. Written permission was also
sorted form the Directorate, Federal Government Educa-
tional Institutions (Cantt/Garrison), Rawalpindi Cantt,
to access adolescents within schools/colleges premises.
All the students present in the selected classes at that
 BEHAVIORAL MEDICINE 3

Table 1. Demographics Characteristics of Participants (n D 1277). seemed congruent to Pakistani setup with majority of
Characteristic Number (%) the mothers being housewives and the fathers were
employed outside of home (Table 1).
Gender Girl 569 (44.6)
Boy 708 (55.4) Table 2 shows the mean and standard deviation of the
Education Grades 7–8 594 (46.5) SCAS subscales for the total sample and separately for
Grades 9–10 609 (47.7)
Grades 11–12 74 (5.8) boys and girls. The average score on SCAS was 41.38
Mother’s occupation Not working/Homemakers 1134 (90.2) (SD D 16.38). Girls compared to boys have significantly
Working 120 (9.5)
Deceased 3 (0.2)
higher mean scores on panic/agoraphobia, separation
Father’s occupation Not working 49 (3.83) disorder, and have more physical injury fears (p <
Working 1196 (94.8) 0.001). No significant gender difference was found for
Deceased 16 (1.3)
Mother’s education 0–5 years 324 (27.2) symptoms of social phobia and generalized anxiety dis-
6–10 years 410 (34.5) order, whereas obsessive compulsive disorder was higher
11–16 years 345 (29)
Don’t know 111 (9.3) among boys than girls (t D –2.67(1208), p < 0.05).
Father’s education 0–5 years 111 (9.3) Table 2 also shows mean comparison on SCAS in present
6–10 years 448 (37.6)
11–16 years 526 (44.2) sample compared to previous studies.
Don’t know 106 (8.9) The SCAS subscales correlated significantly with the
Religion Islam 1262 (99.6)
Christianity 5 (0.4)
emotional symptoms subscale of SDQ (Table 3). Significant
Ethnicity Punjabi 935 (76.3) correlations were observed between all the SCAS subscales
Pathan 138 (11.3) and the SDQ total score, with the exception of obsessive-
Sindhi 6 (0.5)
Balochi 2 (0.2) compulsive disorder. SDQ pro-social behavior did not sig-
Others 145 (11.8) nificantly correlated with any of the SCAS subscales.
The internal consistency for the total SCAS score was
good (Cronbach alpha D 0.87); however, the internal
time of data collection were invited to take part in this consistency for the SCAS subscales was moderate
research. Participants were given the right to consent. (Cronbach alpha < 0.7) (Figure 1). Of all the SCAS sub-
scales, separation anxiety had the lowest alpha coefficient
(Cronbach alpha D 0.54).
Results
Fit indices of various alternative factor structures of
Slightly more than half (55.4%) of the participants were SCAS are summarized in Table 4. Individually the six
male, with most of them (94.2%) studying in between subscales of SCAS have good overall fit (CFI > 0.95,
seventh and tenth grade. The familial arrangement TFI > 0.90, RMSEA < 0.053). However, the overall fit

Table 2. Means (and Standard Deviations), Gender Differences on SCAS in Comparison to Previous Research.
Present Study Spence, Barrett, & Turner30 Essau et al.31 Amaya & Campbell32
Gender Mean (SD) Mean (SD) Mean (SD) Mean (SD)

TAS Girls 47.04 (16.46) 25.08 (13.37) 35.61 (17.78) 40.07 (17.72)
Boys 36.83 (14.84) 18.85 (13.07) 30.62 (16.71) 33.41 (15.4)
Combined 41.38 (16.38) 21.72 (13.56) 33.15 (17.43) 36.65
PAA Girls 36.83 (14.84) 2.95 (3.35) 4.32 (4.65) 6.17 (5.34)
Boys 41.38 (16.38) 1.95 (3.20) 3.91 (4.56) 4.43 (3.94)
Combined 5.10 (4.22) 2.41 (3.25) 4.12 (4.61) 5.28
SAD Girls 8.15(3.76) 2.77 (2.29) 6.52 (3.62) 6.68 (3.61)
Boys 6.10 (3.35) 1.83 (2.29) 5.64 (3.44) 5.48 (2.94)
Combined 7.02 (3.67) 2.26 (2.34) 6.09 (3.56) 6.06
SP Girls 7.84 (3.80 6.63 (3.29) 6.40 (3.76) 7.98 (3.77)
Boys 6.04 (3.59 5.27 (3.07) 5.58 (3.37) 7.10 (3.41)
Combined 6.84 (3.79) 5.90 (3.24) 5.99 (3.60) 7.53
PIF Girls 6.64 (3.41) 3.05 (2.31) 4.94 (3.21) 3.46 (2.40)
Boys 3.28 (2.92) 1.86 (2.22) 3.48 (3.07) 2.54 (2.32)
Combined 4.78 (3.56) 2.41 (2.34) 4.22 (3.22) 2.98
OCD Girls 9.96 (3.78) 3.59 (3.01) 5.42 (3.72) 7.66 (3.94)
Boys 10.53 (3.72) 3.22 (2.86) 5.19 (3.62) 7.08 (3.61)
Combined 10.28 (3.75) 3.39 (2.93) 5.31 (3.68) 7.36
GAD Girls 8.38 (3.36) 6.07 (3.07) 8.09 (3.78) 8.12 (3.56)
Boys 6.55 (3.15) 4.70 (2.69) 6.86 (6.44) 6.79 (3.32)
Combined 7.37 (3.37) 5.33 (2.95) 7.48 (3.77) 7.44

Note. TAS, Total Anxiety score; PAA, subscale of SCAS panic and agoraphobia; SAD, separation anxiety disorder; SP, subscale of SCAS Social phobia; PIF, subscale of
SCAS Physical injury fear; OCD, subscale of SCAS obsessive compulsive disorder; GAD, subscale of SCAS, generalized anxiety disorder.
4 F. QADIR ET AL.

Table 3. Inter-correlations between spence children’s anxiety scale (SCAS) and strength & difficulty questionnaire (SDQ).
ES CP HI PR PSB SDQT

PAA 0.49

0.21

0.22

0.18

¡0.00 0.42

SAD 0.34

0.04 0.11

0.05 0.00 0.22


SP 0.41

0.19

0.25

0.17

¡0.05 0.38


PIF 0.33

0.05 0.12

0.04 ¡0.00 0.21


OCD 0.24

0.10

0.11

0.08

0.07
0.20


GAD 0.47

0.16

0.24

0.14

0.00 0.38


TAS 0.52

0.18

0.24

0.15

0.00 0.42




Correlation is significant at 0.05 level (2-tailed).

Correlation is significant at 0.01 level (2-tailed).
GAD, Generalized Anxiety subscale; PIF, Physical Injury Fear; OCD, obsessive-compulsive disorder; SAD, separation anxiety disorder; SP, social phobia; PAA, panic
attack and agoraphobia; TAS, Total Anxiety score; EP, emotional symptoms; CP, conduct problems; HI, hyperactivity/inattention; PR, peer problems; PSB, pro-
social behavior.

of other factor structures, which take all subscales into
consideration in various forms, have poor fit to the
data. Unstandardized coefficients of SCAS with corre-
sponding confidence intervals for the six correlated fac-
tors and six separate factors are summarized in Table 5.
In both models, individual items significantly load on
their respective subscales and all loadings have expected
sign. The magnitude of loadings of items on respective
factors is reasonably large, except for few items that
load weakly on separation anxiety disorder.
Discussion
The aim of the present study was to establish the levels of
anxiety among Pakistani adolescents. The overall mean
anxiety score in this sample was relatively high
(M D 41.38) compared to studies conducted elsewhere
including Belgium (M D 16.9),23 Germany (M D 22.24; M
D 22.86),17,33 Netherlands (M D 18.11),14 Colombia (M D
36.65),32 Australia (M D 34.1),15 and Iran (M D 33.16).20 It
is also higher than the mean reported among normal con-
trol group children recruited from a Pakistani school
(25.3). However, the mean is similar to that of pediatric
controls (39.4) and cases with medically unexplained symp-
toms (43.2). The reason for these differences could be
because the school sample in Imran’s study was from a sig-
nificantly higher socioeconomic status.24 The total anxiety
scores among South African sample of children belonging
to low-middle socioeconomic status was also reported to be
much higher (46.4) than those belonging to middle-high
socioeconomic status (25.2).23 The current study sample
was drawn from government schools, which have low-mid-
dle socioeconomic status, which could explain for the high
anxiety in this sample. Low socioeconomic status was sug-
gested as a reason for similar rates (42.3) of anxiety among
Hellenic community sample as well.22 However, this needs
to be assessed in future specifically with reference to Pakis-
tani cultural context.
In agreement with numerous previous studies, anxiety
symptoms as measured using the SCAS were signifi-
cantly higher in girls than boys.9,31,35–39 This finding also
replicated previous study among adults in Pakistan in
that higher prevalence for depression and anxiety was
reported for women in Pakistan compared to men.40 The
finding showed that only obsessive-compulsive symp-
toms were higher in boys as compared to girls, which is
also consistent with previous literature.41
To our knowledge, the present study was the first to
have examined the psychometric properties of the Urdu
version of SCAS among Pakistani youth. The results of

Figure 1. Alpha reliability coefficients of Spence Child Anxiety Scale (N D 1277).

 BEHAVIORAL MEDICINE 5

Table 4. SCAS Fit Indices for Tested Models in the Present Study.
Model Chi-square(df) p-value CFI TLI RMSEA (90%CI)

Separately for each sub-scale:

GAD 15.99 (9) 0.068 0.99 0.97 0.025 (0.000, 0.044)
FEARS 8.45 (4) 0.076 0.99 0.98 0.030 (0.000, 0.058)
PANIC 89.13 (20) < 0.001 0.96 0.91 0.052 (0.041, 0.063)
OCD 5.42 (6) 0.491 1.00 1.00 0.000 (0.000, 0.034)
SOCPH 8.77 (7) 0.269 0.99 0.99 0.014 (0.000, 0.039)
SAD 8.20 (6) 0.224 0.99 0.99 0.017 (0.000, 0.043)
Overall models:
As a single factor 3811.38 (655) 0.000 0.67 0.63 0.061 (0.060, 0.063)
Second-order factor model 2831.20 (643) 0.000 0.77 0.74 0.052 (0.050, 0.054)
Correlated 6-factor model 2794.48 (638) 0.000 0.77 0.74 0.05 (0.050, 0.053)
5-factor model (with GAD and SP as one factor) 2860.747 (644) 0.000 0.77 0.73 0.052 (0.050, 0.054)
4-factor model (with PIF and SAD as one factor 3106.344 (648) 0.000 0.74 0.71 0.055 (0.053, 0.056)
and GAD and OCD as one factor)
4-factor model (with PAA and GAD as one 3043.038 (647) 0.000 0.75 0.71 0.054 (0.052, 0.056)
factor and PIF and SAD as a single factor)

this study provide little support to the previously
reported correlated six-factor structure of the scale.
However, if the six subscales of SCAS are considered sep-
arately, they show acceptable fit (CFI > 0.95, TFI > 0.90,
RMSEA < 0.053). This implies that the six subscales of
the Urdu version of SCAS can be administered separately
to measure the subtypes of anxiety. Although most stud-
ies supported the six-correlated factor model as per
DSM-IV structuring,30,42 inconsistencies in the factorial
structure have emerged when examined in different cul-
tures.17–18,21,23,54. Some of the reasons for this finding
could be as follows. First, the SCAS is based on DSM-IV
criteria of anxiety disorders, and although DSM-IV has
identified anxiety disorders as universally occurring, they
have also shown cultural variation in prevalence and
manifestation of symptoms.43 Second, when the DSM
system is employed, many individuals are found to have
more than one disorder, which need to be accounted for
when measuring anxiety. Thus, as highlighted by Hinton
and Lewis-Fernandez,44 there is a need for developing a
culturally determined explanatory model for anxiety, so
that anxiety disorders can be better understood in terms
of their rates, chronicity, presentation, and treatment.19
Third, young people experience worries and fears as a
part of their normal development. Thus, many young
people experience anxiety symptoms but do not fulfil the
diagnostic criteria for the anxiety disorder.45 In the pres-
ent study the support for six separate scales might be
partially explained by the cultural differences.
What is of most relevance to the current sample is
the proposal that in a country where terrorism is rec-
ognized as a norm it seems reasonable to ascribe
intense worry and stress as a consequence of exposure
to terrorism. Even if there has not been a direct expo-
sure to trauma the awareness of knowing that they or
their loved ones might be injured or killed might be a
dire source of fear and/or worry. This concern could
perpetuate a vicious cycle of anxiety symptoms that
may manifest in any or all forms of anxiety. This
argument is well supported by previous researches
conducted in Pakistan.46–47 The unpredictable nature
of attacks instills more fear when the whereabouts of
family and friends after attacks remain un-established.
Being unsure of one’s own safety and that of the fam-
ily members particularly parents can lead to substan-
tial stress. The circumstances in Pakistan have
changed over the past few years to a point where
ordinary citizens including children and adolescents
live in constant fear. This could have resulted into
items cross-loadings when all the subscales are mod-
eled together.
It can also be debated that the difference in factor
structure is an artifact of problematic translation.
Because of cultural and linguistic differences, the ques-
tions or items can have quite different meaning in the
translated instruments, thus threatening the validity of
measurement.
Overall the Urdu version of SCAS showed high
internal consistency in the present study, while the
subscales did not show good reliability estimates. The
SCAS subscale with the lower internal consistency was
of separation anxiety disorder (SAD)20,23 and highest
Cronbach Alpha was for panic attack/agoraphobia
which is consistent with previous reports.16,20,33 The
essential feature of SAD is excessive worry about sepa-
ration from attachment figures. It is very common
among pre-pubertal children.48 However, given the
socio-political scenario and its probable impact on the
well-being of the general population, it is plausible
that these worries continues into late adolescence.
There is a need to further examine the manifestation
of SAD among adolescent’s sample to better under-
stand the symptomatology of this disorder.
The correlation between SCAS and SDQ emotion
symptoms subscale, which includes anxiety and depres-
sive symptoms, was significant, which corroborates
6 F. QADIR ET AL.

Table 5. Unstandardized Coefficients of SCAS with Corresponding Confidence Intervals for the Six Correlated Factors and Six Deparate
Factors.
Six Correlated Factors Six Separate Factors

Items Unstandardized coefficients (CI) Standardized Coefficients Unstandardized Coefficients (CI) Standardized Coefficients

Generalized Anxiety Subscale

SCAS1 1 0.317 1 0.337
SCAS3 1.06 (0.79,1.33) 0.327 1.12 (0.81, 1.42) 0.367
SCAS4 1.63 (1.30,1.95) 0.551 1.419 (1.08, 1.76) 0.511
SCAS20 1.68 (1.34,2.03) 0.510 1.618 (1.24, 2.00) 0.522
SCAS22 1.71 (1.36,2.06) 0.524 1.474 (1.12, 1.83) 0.480
SCAS24 1.65 (1.32,1.99) 0.529 1.662 (1.28, 2.04) 0.566
Physical Injury Fear
SCAS2 1 0.631 1 0.518
SCAS18 1.04 (0.91,1.17) 0.566 1.45 (1.22, 1.68) 0.646
SCAS23 0.64 (0.54,0.75) 0.418 0.79 (0.63, 0.94) 0.418
SCAS25 0.65 (0.55,0.76) 0.403 0.69 (0.53, 0.84) 0.347
SCAS33 0.92 (0.80,1.03) 0.533 1.31(1.10, 1.52) 0.624
Panic Attack and Agoraphobia
SCAS13 1 0.415 1 0.412
SCAS21 1.23 (1.02,1.44) 0.532 1.25 (1.03, 1.47) 0.538
SCAS28 0.59 (0.45,0.73) 0.301 0.54 (0.40, 0.68) 0.273
SCAS30 0.89 (0.69,1.09) 0.330 0.72 (0.52, 0.92) 0.264
SCAS32 1.52 (1.28,1.75) 0.657 1.53 (1.28, 1.78) 0.658
SCAS34 0.66 (0.53,0.79) 0.374 0.73 (0.59, 0.87) 0.410
SCAS36 1.57 (1.32,1.82) 0.641 1.69 (1.42, 1.97) 0.687
SCAS37 1.42 (1.20,1.63) 0.666 1.47 (1.24, 1.70) 0.683
SCAS39 1.54 (1.26,1.82) 0.483 1.23 (0.95, 1.50) 0.381
Separation Anxiety Disorder
SCAS5 1 0.651 1 0.761
SCAS8 0.33 (0.21,0.45) 0.181 0.18 (0.06, 0.29) 0.112
SCAS12 0.32 (0.22,0.42) 0.205 0.15 (0.06, 0.24) 0.115
SCAS15 1.01 (0.90,1.12) 0.663 0.83 (0.69, 0.97) 0.637
SCAS16 0.33 (0.26,0.40) 0.292 0.17 (0.10, 0.24) 0.180
SCAS44 0.92 (0.79,1.05) 0.502 0.75 (0.62, 0.88) 0.477
Social Phobia
SCAS6 1 0.495 1 0.435
SCAS7 0.80 (0.64,0.95) 0.363 0.73 (0.55, 0.92) 0.292
SCAS9 1.19 (1.00,1.38) 0.539 1.66 (1.33, 1.99) 0.659
SCAS10 0.73 (0.57,0.87) 0.352 0.86 (0.66, 1.05) 0.364
SCAS29 1.23 (1.05,1.42) 0.579 1.34 (1.09, 1.59) 0.553
SCAS35 0.81 (0.67,0.95) 0.464 0.95 (0.73, 1.17) 0.476
Obsessive Compulsive Disorder
SCAS14 1 0.330 1 0.404
SCAS19 1.27 (0.97,1.57) 0.462 0.37 (0.19, 0.56) 0.165
SCAS27 1.53 (1.19,1.86) 0.556 0.89 (0.66, 1.11) 0.395
SCAS40 1.14 (0.85,1.43) 0.378 1.33 (1.04, 1.63) 0.541
SCAS41 1.83 (1.44,2.22) 0.611 1.13 (0.86, 1.39) 0.460
SCAS42 1.26 (0.96,1.55) 0.437 1.34 (1.05, 1.63) 0.569

Correlations Among the Factors in the Six Correlated Factors Structure

FEARS $ PANIC 0.567
GAD $ PANIC 0.807
GAD $ FEARS 0.789
SAD $ SOCPH 0.524
OCD $ SOCPH 0.656
OCD $ SAD 0.305
OCD $ PANIC 0.493
GAD $ SAD 0.724
GAD $ SOCPH 0.875
OCD $ GAD 0.717
FEARS $ SAD 0.906
FEARS $ SOCPH 0.581
OCD $ FEARS 0.280
PANIC $ SOCPH 0.637
PANIC $ SAD 0.581

support for the convergent validity of SCAS.31,49–50 Our that anxious adolescents have more friendship related
findings also showed a significant positive correlation issues.20,51 Further, as expected and similar to the find-
between SCAS and the peer relationships subscale of ings of Essau and colleagues20 weak associations were
SDQ, which has been supported previously, indicating obtained between SCAS and two subscales of SDQ

(conduct and hyperactivity) providing further support to
its validity.
Among the limitations of this study is that our sample
did not include a clinical assessment or a clinical diagno-
sis. The results therefore might not be applicable to the
clinical population. Second, a diverse socioeconomic
group should be included in future studies as other studies
have shown that children/adolescents from the upper-
socioeconomic strata perceive fears and threatening situa-
tions differently from those belonging to lower socioeco-
nomic background.52 Preferably, several methods of
assessment should be used to collect information from
multiple sources such as parents, teachers, and peers.53
Conclusions
The URDU version of SCAS is a valid and reliable instru-
ment for measuring anxiety symptoms among Pakistani
adolescent population. This study also brings light to a
huge health concern for school adolescents who are at
high risk of anxiety. However, keeping in view the poor
fit of the scale’s original factor structure, these overall
rates of anxiety might be misleading. Further research is
therefore recommended, and culturally appropriate and
multi-pronged prevention and interventions programs
for this population must be designed.
Funding
This project was funded under Higher Education Commission,
Pakistan and British Council’s project “International Strategic
Partnerships in Research and Education” for joint research
between Fatima Jinnah Women University, Pakistan and
Roehampton University, London.
References
[1] Albano AM, Chorpita BF, Barlow DH. Childhood anxiety
disorders. In Mash EJ, Barkley RA (Eds.), Child psychopa-
thology. 2nd ed. New York: Guildford Press;2003:279–329.
[2] Essau CA, Lewinsohn PM, Olaya B, Seeley JR. Anxiety
disorders in adolescents and psychosocial outcomes at
age 30. J Affect Disord. 2014;163:125–32.
[3] Kessler RC, Aguilar-Gaxiola S, Alonso J, Chatterji S, Lee
S, Ormel J, Ust€ un TB, Wang PS. The global burden of
mental disorders: an update from the WHO World Men-
tal Health (WMH) surveys. Epidemiol Psichiatr Soc.
2009;18:23–33.
[4] Lopez AD, Mathers CD, Ezzati M, Jamison DT, Murray
CJ. Global and regional burden of disease and risk fac-
tors, 2001: systematic analysis of population health data.
Lancet. 2006;367:1747–57.
[5] United Nations International Children’s Emergency
Fund. Pakistan: Statistics. 2013. http://www.unicef.org/
infobycountry/pakistan_pakistan_statistics.html
(accessed May 19, 2015).
BEHAVIORAL MEDICINE 7
[6] Mirza I, Jenkins R. Risk factors, prevalence, and treat-
ment of anxiety and depressive disorders in Pakistan: sys-
tematic review. BMJ. 2004;328(7443): 794–797.
[7] Friedman S. Cultural issues in the assessment of anxiety
disorders. In Antony M, Orsillo S, Roemer L (Eds.), Prac-
titioner’s guide to empirically based measures of anxiety.
Dordrecht, Netherlands: Kluwer Academic Publish-
ers;2001:37–41.
[8] Beesdo K, Knappe S, Pine DS. Anxiety and anxiety disor-
ders in children and adolescents: developmental issues
and implications for DSM-V. Psychiatr Clin North Am.
2009;32:483–524.
[9] Essau CA, Barrett P. Developmental issues in the assess-
ment of anxiety. In: Essau CA, Petermann F (Eds.), Anxi-
ety disorders in children and adolescents: epidemiology
risk factors, and treatment. London: Harwood; 2001.
[10] Scherer MW, Nakamura CY. A fear survey schedule for
children (FSS-FC): a factor analytic comparison with
manifest anxiety (CMAS). Behav Res Ther. 1968;6:173–
82.
[11] March JS, Parker, JD, Sullivan K, Stallings P, Conners
CK. The Multidimensional Anxiety Scale for Children
(MASC): factor structure, reliability, and validity. J Am
Acad Child Adolesc Psych. 1997;36:554–65.
[12] Reynolds CR, Richmond BO. What I think and feel: a
revised measure of children’s manifest anxiety. J Abnorm
Child Psychol. 1978;6:271–80.
[13] Spielberger CD. Manual for the State–Trait Anxiety
Inventory for Children. Palo Alto, CA: Consulting Psy-
chologists Press;1973.
[14] American Psychiatric Association. Diagnostic and statisti-
cal manual of mental disorders (DSM-IV). 4th ed.
Washington, DC: American Psychiatric Association;1994.
[15] Spence SH. The structure of anxiety symptoms among
children: a confirmatory factor analytic study. J Abnorm
Psychol. 1997;106:280–97.
[16] Spence SH. A measure of anxiety symptoms among chil-
dren. Behav Res Ther. 1998;36:545–66.
[17] Essau CA, Sakano Y, Ishikawa S, Sasagawa S. Anxiety
symptoms in Japanese and in German children. Behav
Res Ther. 2004;42:601–12.
[18] Essau CA, Leung PW, Conradt J, Cheng H, Wong T.
Anxiety symptoms in Chinese and German adolescents:
their relationship with early learning experiences, perfec-
tionism, and learning motivation. Depress Anxiety.
2008;25:801–810.
[19] Essau CA, Sasagawa S, Anastassiou-Hadjicharalambous X,
Guzm
an BO, Ollendick, T. H. Psychometric properties of
the Spence Child Anxiety Scale with adolescents from five
European countries. J Anxiety Disord. 2011;25:19–27.
[20] Essau CA, Leung PW, Koydemir S, Sasagawa S, O’
Callaghan J, Bray D. The impact of self-construals and
perceived social norms on social anxiety in young adults:
a cross-cultural comparison. Int J Cult Ment Health.
2012;5:109–20.
[21] Ishikawa SI, Sato H, Sasagawa S. Anxiety disorder symp-
toms in Japanese children and adolescents. J Anxiety Dis-
ord. 2009;23:104–111.
[22] Mellon RC, Moutavelis AG. Structure, developmental
course, and correlates of children’s anxiety disorder-
related behaviour in a Hellenic community sample. J
Anxiety Disord. 2007;21:1–21.
 8 F. QADIR ET AL.
[23] Muris P, Schmidt H, Engelbrecht P, Perold M. DSM-
IV-defined anxiety disorder symptoms in South
African children. J Am Acad Child Adolesc Psychia-
try. 2002;41:1360–8.
[24] Imran N, Ani C, Mahmood Z, Hassan K A, Bhatti, MR.
Anxiety and depression predicted by medically unex-
plained symptoms in Pakistani children: a case-control
study. J Psychosom Res. 2014;76:105–112.
[25] Bureau of Statistics. Punjab Development Statistics. Gov-
ernment of The Punjab. 2012. http://bos.gop.pk/
?qDsystem/files/Development-Statistics-2012.pdf
(accessed May 14, 2013).
[26] Goodman R. The Strengths and Difficulties Questionnaire:
a research note. J Child Psychol Psych. 1997;38:581–6.
[27] Goodman R, Meltzer H, Bailey V. The Strengths and Diffi-
culties Questionnaire: a pilot study on the validity of the self-
report version. Eur Child Adolesc Psych. 1998;7:125–30.
[28] Samad L, Hollis C, Prince M, Goodman R. Child and
adolescent psychopathology in a developing country:
testing the validity of the Strength and Difficulty Ques-
tionnaire (Urdu Version). Int J Methods Psychiatr Res.
2005;14:158–66.
[29] Syed EU, Hussein SA, Azam S I, Khan AG. Comparison
of Urdu version of Strengths and Difficulties Question-
naire (SDQ) and the Child Behaviour Check List (CBCL)
amongst primary school children in Karachi. J Coll
Physicians Surg Pak. 2009;19:375.
[30] Spence SH, Barrett PM, Turner CM. Psychometric prop-
erties of the Spence Children’s Anxiety Scale with young
adolescents. J Anxiety Disord. 2003;17:605–25.
[31] Essau CA, Olaya B, Pasha G, O’Callaghan J, Bray D. The
structure of anxiety symptoms among adolescents in
Iran: a confirmatory factor analytic study of the Spence
Children’s Anxiety Scale. J Anxiety Disord. 2012;26:871–
8.
[32] Amaya A, Campbell C. Cross-cultural comparison of
anxiety symptoms in Colombian and Australian children.
Electronic Journal of Research in Educational Psychol-
ogy. 2010;8:497–516.
[33] Essau CA, Muris P, Ederer EM. Reliability and validity of
the Spence Children’s Anxiety Scale and the screen for
child anxiety related emotional disorders in German chil-
dren. J Behav Ther Exp Psychiatry. 2002;33:1–18.
[34] Muris P, Merckelbach H, Mayer B, Prins E. How serious
are common childhood fears? Behav Res Ther.
2000;38:217–28.
[35] Lewinsohn PM, Hops H, Roberts RE, Seeley JR, Andrews
JA. Adolescent psychopathology: I. Prevalence and inci-
dence of depression and other DSM-III—R disorders in
high school students. J Abnorm Psychol. 1993;102:133.
[36] Muris P, Merckelbach H, Ollendick T, King N, Bogie N.
Three traditional and three new childhood anxiety ques-
tionnaires: their reliability and validity in a normal ado-
lescent sample. Behav Res Ther. 2002;40:753–72.
[37] Reinherz HZ, Giaconia RM, Lefkowitz ES, Pakiz B, Frost
AK. Prevalence of psychiatric disorders in a community
population of older adolescents. J Am Acad Child Ado-
lesc Psychiatry. 1993;32:369–77.
[38] Su L, Wang K, Fan F, Su Y, Gao X. Reliability and validity
of the screen for child anxiety related emotional disorders
View publication stats
(SCARED) in Chinese children. J Anxiety Disord.
2008;22:612–21.
[39] Wren FJ, Berg EA, Heiden LA, Kinnamon CJ, Ohlson
LA, Bridge JA, Bernal MP. Childhood anxiety in a diverse
primary care population: parent-child reports, ethnicity
and SCARED factor structure. J Am Acad Child Adolesc
Psychiatry. 2007;46:332–40.
[40] Qadir F, Khan MM, Medhin G, Prince M. Male gender
preference, female gender disadvantage as risk factors for
psychological morbidity in Pakistani women of child-
bearing age-a life course perspective. BMC Public Health.
2011;11:745.
[41] March JS, Leonard HL, Swedo SE. Obsessive-compulsive
disorder. In March JS (Ed.), Anxiety disorders in children
and adolescents. New York: Guilford;1995:251–75.
[42] Essau CA, Sasagawa S, Anastassiou-Hadjicharalambous X,
OlayaGuzm
an B, Ollendick TM. Psychometric properties
of the Spence Child Anxiety Scale with adolescents from
five European countries. J Anxiety Disord. 2011;25:19–27.
[43] Ahmer S, Faruqui RA, Aijaz A. Psychiatric rating scales
in Urdu: a systematic review. BMC Psychiatry. 2007;7:59.
[44] Hinton DE, Lewis-Fern
andez R. “Idioms of distress” (cul-
turally salient indicators of distress) and anxiety disor-
ders. In Simpson HB, Neria Y, Lewis-Fern
andez R,
Schneier FS (Eds.), Anxiety disorders: theory, research,
and clinical perspectives. Cambridge: Cambridge Univer-
sity Press; 2010:127–38.
[45] Bell-Dolan, DJ, Last CG, Strauss CC. Symptoms of anxi-
ety disorders in normal children. J Am Acad Child Ado-
lesc Psychiatry. 1990;29:759–65.
[46] Khalily TM, Fooley S, Hussain I, Bano M. Violence, psy-
chological trauma and possible acute post-traumatic
interventions in Pakistani society. Australasian J Disaster
Trauma Stud. 2011;1:1–9.
[47] Khalily MT, Gul S, Mushtaq R, Jahangir SF. To examine
delayed PTSD symptomatology over time among trauma
survivors in Pakistan. The Online Journal of Counselling
and Education. 2012;1–11.
[48] Donnelly CL, McQuade DV. Anxiety disorders in childhood
and adolescence. Clin Child Psychiatry. 2005; 235–262.
[49] Essau CA, Ishikawa S, Sasagawa S, Sato H, Okajima I,
Otsui K, Georgiou GA, O’Callaghan J, Michie F. Anxiety
symptoms among adolescents in Japan and England:
their relationship with self-construals and social support.
Depress Anxiety. 2011;28:509–18.
[50] Muris P, Meesters C, van den Berg F. The strengths and
difficulties questionnaire (SDQ). Eur Child Adolesc Psy-
chiatry. 2003;12:1–8.
[51] Morgan J, Banerjee R. Social anxiety and self-evaluation
of social performance in a non-clinical sample of chil-
dren. J Clin Child Adolesc Psychol. 2006;35:292–301.
[52] Spielberger CD, D
ıaz-Guerrero R, Strelau J (Eds.). Cross-
cultural anxiety. Washington, US: Taylor & Francis;1990:4.
[53] Greco LA, Morris TL. Assessment. In Morris TL, March
JS (Eds.), Anxiety disorders in children and adolescents.
2nd ed. New York: Guilford Press; 2004:98–121.
[54] Orgil
es M, Fern
andez-Mart
ınez I, Guill
en-Riquelme A,
Espada JP, Essau C. A systematic review of the factor
structure and reliability of the Spence Children’s Anxiety
Scale (SCAS). J Affect Disord. 2016;190:333–40.