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The Assessment of Anxiety Symptoms in Preschool-

Aged Children: The Revised Preschool Anxiety Scale
a a a b
Susan L. Edwards , Ronald M. Rapee , Susan J. Kennedy & Susan H. Spence
a
Centre for Emotional Health, Department of Psychology, Macquarie University,
b
Griffith Institute of Health and Medical Research, Griffith University,
Version of record first published: 23 Apr 2010.

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Anxiety Symptoms in Preschool-Aged Children: The Revised Preschool Anxiety Scale, Journal of Clinical Child & Adolescent
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 Journal of Clinical Child & Adolescent Psychology, 39(3), 400409, 2010
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ISSN: 1537-4416 print=1537-4424 online
DOI: 10.1080/15374411003691701

The Assessment of Anxiety Symptoms in Preschool-Aged

Children: The Revised Preschool Anxiety Scale
Susan L. Edwards, Ronald M. Rapee, and Susan J. Kennedy
Centre for Emotional Health, Department of Psychology, Macquarie University

Susan H. Spence
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Grifth Institute of Health and Medical Research, Grifth University

The purpose of this study was to test the validity and factorial structure of a modied
version of the Preschool Anxiety Scale (Spence, Rapee, McDonald, & Ingram, 2001).
The measure was completed by 764 mothers and 418 fathers of children aged 3 to 5
years. After removing, two items tapping obsessive compulsive symptoms, conrmatory
factor analysis showed that a four-factor model (social anxiety, generalized anxiety, sep-
aration anxiety, specic fears) all loading on a higher order anxiety factor, provided
an optimal t for the data. The total scale and 4 subscales showed strong internal con-
sistency (alphas .72.92), 12-month stability y (rs .60.75) and maternal=paternal
agreement (rs .60.75). Scores on the scale also showed expected correlations with a
measure of emotional distress, diagnosed anxiety disorders, and behavioral indicators
of anxiety.

Anxiety disorders are the most common class of
childhood psychopathology, with point-prevalence
estimates averaging around 2.5 to 5% in community
samples (Rapee, Schniering, & Hudson, 2009). Across
the lifespan, anxiety disorders demonstrate some of the
strongest stability of any disorders, have an early age
of onset, and are associated with moderate to marked
life impairment (Rapee et al., 2009). Although research
efforts over the past 20 years have greatly increased
our understanding of the prevalence, impact, and treat-
ment of anxiety in older children, we know little about
the nature of anxiety in the preschool age group
(Campbell, 1995; Egger & Angold, 2006; Eley et al.,
2003). In a review of the limited research on psycho-
pathology in very young children, Egger and Angold
reported that anxiety problems in very young children
are comparable to those reported for older children in
terms of prevalence, stability, and impairment (e.g.,
Furniss, Beyer, & Guggenmos, 2006; Gadow, Sprafkin,
Correspondence should be addressed to Ronald M. Rapee, Centre
for Emotional Health, Department of Psychology, Macquarie
University, Sydney, NSW, 2109 Australia. E-mail: Ron.Rapee@
psy.mq.edu.au
& Nolan, 2001; Lavigne et al., 1998). Yet although early
onset anxiety disorders have been shown to lead to
greater impairment and chronicity (Weissman et al.,
1999), it is rare that preschool-aged children are referred
for treatment (Egger & Angold, 2006; Furniss et al.,
2006).
The lack of research on anxiety problems in younger
children is disappointing given the potential for early
intervention and for the prevention of anxiety across
the developmental spectrum. Research into the under-
standing and management of anxiety in this age group
is not without its difculties. For example the reduced
ability to rely on self report of emotions raises particular
challenges for assessment of internal states such as
anxiousness (Warren, Umylny, Aron, & Simmens,
2006). Perhaps foremost among the difculties is the
controversy surrounding the use of diagnostic constructs
in the preschool period and questions about the
relevance of criteria taken from older groups for use
at this early age (e.g., Egger & Angold, 2006; Roberts,
Attkisson, & Rosenblatt, 1998). Some evidence is
beginning to emerge indicating that standard diagnos-
tic constructs can be reliably identied in preschool

populations (Egger et al., 2006; Scheeringa, Zeanah,
Myers, & Putnam, 2003; Task Force on Research
Diagnostic Criteria: Infancy and Preschool [RDC-IP],
2003; Warren et al., 2006). This research includes at least
one structured instrument specically designed to assess
mental health problems among preschool-aged children,
the Preschool Age Psychiatric Assessment (PAPA;
Egger et al., 2006). Although this argument is still far
from resolved, the importance of identifying symptoms
linked with impairment at the preschool age has been
strongly supported by several authors (e.g., Carter,
Briggs-Gowan, Jones, & Little, 2003; Egger & Angold,
2006; RDC-IP, 2003). These authors point to the
importance of providing appropriate health services
for this population and the potential for prevention
of later difculties with early intervention. Hence this
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issue has been identied as a priority research area (Eley
et al., 2003; RDC-IP, 2003).
Despite the importance of identifying anxiety symp-
tomatology in young children, few psychometrically
established measures exist that specically assess a range
of symptoms of anxiety, fear, and worry among very
young children. The most utilized measures address
broader constructs, such as internalizing, which com-
bine symptoms of depression, anxiety, and withdrawal
(e.g., Child Behavior Checklist [CBCL], Achenbach,
1991; Childrens Moods, Fears & Worries Question-
naire, Bayer, Sanson, & Hemphill, 2006; Strengths and
Difculties Questionnaire [SDQ]; Goodman, 1997), or
focus specically on phobic fears (e.g., The Fear Survey
Schedule for ChildrenIIP (preschool), Bouldin & Pratt,
1998; Koala Fear Questionnaire, Muris et al., 2003).
Measures of withdrawal, shyness, or inhibition also
tap related but distinct constructs (see Rapee & Coplan,
in press).
To our knowledge, the Preschool Anxiety Scale
(PAS; Spence et al., 2001) is the only measure that
specically assesses a wide range of anxiety symptoms
in preschool-aged children. Consistent with most ques-
tionnaires designed for very young children, the PAS
utilizes parent report. This may raise some questions
of its validity given the vast literature with older children
indicating lack of agreement in reporting symptoms of
anxiety between parents and children (e.g., Choudhury,
Pimentel, & Kendall, 2003; Rapee, Barrett, Dadds, &
Evans, 1994). Designed to be consistent with Diagnosis
and Statistical Manual of Mental Disorders (4th ed.
[DSMIV]; American Psychiatric Association, 1994) anxi-
ety categories, items were selected based on an extensive
review of the literature, existing measures, international
diagnostic criteria, and psychiatric interviews. In a large
community sample of 3- to 5-year-old children, con-
rmatory factor analysis revealed a good t for the ve
DSMIV consistent anxiety factors: generalized anxiety
disorder (GAD), social phobia, separation anxiety
REVISED PRESCHOOL ANXIETY SCALE 401
disorder (SAD), obsessive-compulsive disorder, and
physical injury fears. A higher order anxiety factor
explained the covariance between these rst-order
factors. Posttraumatic stress and panic items were not
included based on the lower frequency of such symp-
toms in this age group (Nelles & Barlow, 1988;
Scheeringa et al., 2003). Intercorrelations between
factors were in the moderate-to-high range. Construct
validity was also established, with all PAS scales
correlating signicantly and moderately with internal-
ising symptoms reported on the CBCL (Achenbach,
1991) and low correlations with CBCL externalizing
symptoms.
One of the limitations of this measure was that several
items on the PAS were endorsed relatively infrequently
by parents (Spence et al., 2001, p. 1309). The authors
also highlighted that, although the ve-factor model
provided a good t for the data, there appeared to be
considerable overlap between the generalized anxiety
(GA) and separation anxiety (SEP) factors. Thus, the
aim of the current study was to slightly modify the
measure in an attempt to better reect the spectrum of
common anxiety symptoms in this age group and to pro-
vide a clearer distinction between the SEP and GA
scales. The factor structure and psychometric properties
of the revised version of the PAS (PASR) were tested in
a community sample. The validity of the measure was
assessed by comparing scores on the PASR with a
measure of internalising and externalising symptoms
and, in a smaller sample, with a semistructured diagnos-
tic interview and observer ratings of child anxiety. Cross-
informant reliability and the stability of symptoms over
12 months were also assessed.
METHOD
Participants
Parents of children aged 3 to 5 years were recruited via
preschools (48.6%), magazines (47.4%), or health care
services (4.0%) through the distribution of letters and
yers. Two forms of recruitment were used. The largest
proportion responded to information that described
research into anxiety but specically stated that children
did not need to be anxious to participate. A smaller pro-
portion responded to information specically asking for
shy or condent children. Children were excluded if they
had a diagnosed developmental disorder (e.g., Mental
Retardation, Autistic Disorder), a language disorder,
or if their parents could not read English. In families with
twins, one twin was randomly included in the study.
The sample consisted of 380 boys (49.7%) and 384
(50.3%) girls. Children ranged in age from 36 to 67
months (M 47.39, SD 6.37). Most children lived in
two-parent households (93.1%), with their biological
 402 EDWARDS, RAPEE, KENNEDY, SPENCE
parents (86.8%), and were born in Australia (95.7%).
Parent-identied child ethnic groups were Caucasian
(85.5%), East Asian (1.5%), Arabic (0.1%), Mixed or
Other (12.9%). Mothers and fathers average ages were
35.81 (SD 4.47) and 38.09 (SD 5.19) years, respect-
ively. The sample was predominantly from middle- to
high-income households (58.2% earned above $80,000).
Approximately half of mothers (55.2%) and fathers
(54.7%) had completed a university degree. Most chil-
dren were attending preschool or day care (95.1%).
Measures
The preschool anxiety scalerevised. The modi-
cations made to the original PAS for the revised version
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consisted of seven items being removed based on very
low response rates in the original study, three items were
adapted to provide a clearer meaning, and nine items
were added to further the breadth of symptom coverage
(see Table 1 for details). In particular, items added to the
GA scale were designed to reect behavioral manifesta-
tions of worry. This construct is difcult to assess in
young children, with their limited vocabularies for
describing inner states (Warren et al., 2006). For exam-
ple, for two items on the original measure, tension and
irritability due to worrying and trouble sleeping due
to worrying, it would be difcult for parents to ascer-
tain whether such symptoms were a direct result of
worrying. Also, as worry is essentially an internal cogni-
tive experience, it was expected that parents would have
difculty estimating how much of the day their child
spent worrying. Thus, these items were excluded and
four new items were added with a more behavioral focus
(e.g., gets upset if something unexpected happens). It
was anticipated that these changes would result in a
clearer distinction between the GA and SEP scales.
The revised version consisted of 30 items rated from 0
(not at all true) to 4 (very often true), intended to assess
List of Changes From Original PAS to PASR
Removed Items
Is tense, restless or irritable due to worrying Becomes distressed by thoughts or images
Has trouble sleeping due to worrying in his=her head
Spends a large part of each day worrying about Has nightmares
various things Would be upset at sleeping away from
Washes his=her hands over and over many home
times each day
Has to have things in exactly the right order or
position to stop bad things from happening
Has to keep thinking special thoughts (e.g.,
numbers or words) to stop bad things from
happening
Is afraid of crowded or closed-in places
Note. PAS Preschool Anxiety Scale.
the same ve factors as the original PAS (Spence et al.,
2001): social anxiety (SOC), SEP, GA, specic fears
(SPC), and obsessive-compulsive symptoms (O-C). The
questionnaire was designed to be completed by parents,
as very young children are generally not considered
reliable informants of their own anxiety symptoms
(Edelbrock, Costello, Dulcan, Kalas, & Conover,
1985; although see Muris et al., 2003).
Other questionnaires. Parents also completed the
Short Temperament Scale for Children (STSC;
Approach subscale; Prior, Smart, Sanson, & Oberklaid,
2000) and the emotional symptoms (ES), hyperactivity-
inattention (HI), and conduct problems (CP) subscales
of the SDQ (parent version; Goodman, 1997). Cron-
bachs alpha for the STSC Approach subscale was
0.90 and for the SDQ: ES .70 (.70), HI .75 (.77),
and CP .47 (.53; father data in parentheses).
Anxiety disorders interview schedule for DSMIV,
parent version (ADISP). The ADISP (Silverman &
Albano, 1996) is a semistructured interview designed
to assess anxiety, mood, and externalizing disorders in
children and adolescents based on DSMIV diagnostic
criteria. Although it was designed for use in children
aged 6 and older, acceptable interrater agreement has
previously been reported in this age group (Kappas of
.77 to .86; Rapee, Kennedy, Ingram, Edwards, &
Sweeney, 2005). Although the PAPA (Egger et al.,
2006) would have provided a more age-appropriate
instrument, it was not widely available or clearly
evaluated at the time the current research began. The
ADISP based on interviews with mothers was used to
assess the concurrent validity of the PASR for the
major DSMIV anxiety diagnoses. Clinical severity rat-
ings were assigned on a 9-point scale, from 0 (none) to 8
(very severely disturbing=disabling) based on the number,
TABLE 1
Modied Items Additional Items
Is afraid of loud noises
Is wary of large animals
Becomes distressed if separated from parents
Gets upset if something unexpected happens
Is afraid of doctors and=or dentists
Worries about doing the right thing
Acts shy and quiet around new people
Seems nervous in new or unusual situations
Gets upset if he=she makes a mistake

frequency, and severity of symptoms and life impair-
ment. Impairment ratings took account of the impact
of symptoms relative to normal developmental expecta-
tions in this age group, such as peer interactions, family
life, and preschool attendance.
The rst author, a postgraduate student in clinical
psychology, administered all ADISP interviews. She
had prior training and 6 years experience using the
ADISC=P, assessing child anxiety disorders at the
Centre for Emotional Health. The interviewer was blind
to PASR and STSC scores. A second clinician rated
30% of the videotaped ADISP interviews. Interrater
kappas for the main diagnoses were separation anxiety
(.69), generalized anxiety (.56), social phobia (.89), and
specic phobia (.77).
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Laboratory Assessment
The laboratory assessment was based on that used in
previous research into preschool inhibition (e.g., Rapee
et al., 2005). A full description of the assessment
procedures is available from the rst author. The tasks
relevant to the current study were a 3-min play interac-
tion with a costumed stranger (wearing a white coat
and character mask), presentation of a short story,
and completing an obstacle course consisting of a
wooden ladder, a trestle, a beam, a trampoline, six step-
ping stones, and climbing onto a rope ladder attached to
the ceiling. The child was then asked to remain with the
assessor while the mother completed the ADISP in
another room. During this time the child was also asked
to sing a nursery rhyme into a microphone. Laboratory
assessments were conducted by the rst and third
authors, both with considerable experience in conduct-
ing assessments with children in this age group.
Observer ratings of child anxiety symptoms. Imme-
diately after each task, an observer rated the childs
apparent anxiety level on a 5-point scale from 0 (not
at all anxious) to 4 (very anxious) from behind a one-way
screen. An average anxiety score was also calculated
across the four tasks. A second observer, blind to all
other information regarding the child, rated 30% of
the videotaped child assessments. The observers were
postgraduate students in clinical psychology and the
main observer had several years prior experience in rat-
ing anxiety in preschool-aged children. A manual was
developed describing criteria and the reliability observer
was trained to criterion based on videotapes. The obser-
vers were blind to childrens questionnaire and interview
data. Child anxiety for the singing task was coded later
from a videotape. Intraclass correlation coefcients
(ICC) for observer-rated child anxiety for each task were
as follows: costumed character .91 (95% CI .82.96), values indicating better t (
.08; Hu & Bentler, 1999).
REVISED PRESCHOOL ANXIETY SCALE 403
speech presentation .84 (CI .69.92), physical
task .70 (CI .44.84), and karaoke .91 (CI .79
.96). The ICC for the average anxiety rating was .88
(CI .76.94).
Procedure
The Macquarie University Human Ethics Committee
granted approval for the study. Parents received a
packet containing a consent form, the STSC, and a
reply-paid envelope. When the STSC and signed consent
were returned (completed by mothers in most cases),
parents were sent the PASR, the SDQ, a demographic
form, and measures for another study. Separate book-
lets were sent for mothers and fathers along with
instructions to complete the measures independently.
Of the 944 families returning screening questionnaires,
764 mothers (80.9%) and 418 fathers (44.3%) returned
the complete set of questionnaires. The demographic
information for households where only mothers
returned questionnaires closely matched that of house-
holds where both parents had returned questionnaires.
Families were resent the PASR 12 months later. A
subset of the sample attended an assessment at the
university (only mothers attended with their child). A
high-risk group (n 79) was being assessed for an
intervention study (Kennedy, Rapee, & Edwards,
2009), having been identied on the basis of their high
scores on the STSC (at least 1 standard deviation above
the mean). A smaller group, scoring at or below the
mean, were also invited to attend as a comparison low
risk sample (n 31).
Statistical Analysis
To examine the factor structure of the PASR, con-
rmatory factor analysis (CFA) was performed using
AMOS 5.0 (Arbuckle, 2003). CFA was chosen over
exploratory factor analysis as the aim was to test the
ultimate model demonstrated by Spence et al. (2001).
Given that some variables were positively skewed,
unweighted least squares was selected as the estimation
method as it takes into account deviations from nor-
mality (Anderson & Gerbing, 1988) and it has been
shown to outperform other estimation methods, such
as maximum likelihood, in such cases (Briggs &
MacCallum, 2003). CFA was used to test whether the
proposed models adequately t the data and to compare
models. The goodness of t index (GFI), the adjusted
goodness of t index (AGFI), and the normed t index
(NFI), with possible ranges from 0 to 1, were used in the
current study. Values greater than .95 indicate good t
(Hu & Bentler, 1999). The standardised root mean
square residual (SRMR) is also reported, with smaller
 404 EDWARDS, RAPEE, KENNEDY, SPENCE

RESULTS TABLE 2
Factor Loadings of Items Reported by Mothers and Fathers
(in Parentheses)
Obsessive-Compulsive Subscale
Standardized Regression
Following removal of items showing low endorsement
Questionnaire Item Weights
from the original measure, only two items remained in
the OC subscale. These items loaded onto a distinct factor Social Anxiety
in CFA. However, all other psychometric measures 2. Worries that he=she will do something to .58 (.56)
look stupid in front of other people
indicated quite poor results for this two-item subscale
5. Is scared to ask an adult for help (e.g., a .69 (.61)
(mother=father report: a .46= .41; 12-month reliability preschool or school teacher)
.57=.51; correlations with total PASR score .62=.59; 9. Is afraid of meeting or talking to .80 (.71)
SDQ ES scale .43=.32; observed anxiety .22). There- unfamiliar people
fore, the two OC items were removed from the PASR 12. Is afraid of talking in front of the class .72 (.69)
(preschool group) e.g., show & tell
and all analyses were re-run with these items removed.
15. Worries that he=she will do something .59 (.66)
The following results describe the properties of the PASR embarrassing in front of other people
without the OC items. 18. Is afraid to go up to a group of children to .80 (.77)
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join their activities

CFA 25. Acts shy and quiet around new people .77 (.70)

Spence and colleagues (2001) compared three models of Generalized Anxiety

1. Has difculty stopping him=herself from .59 (.62)
the factor structure of the original PAS. Their results worrying
indicated that the nal model, which consisted of ve fac- 20. Has nightmares .32 (.26)
tors loading onto a single higher order factor, provided 21. Worries about doing the right thing .51 (.53)
the best t for the data. Therefore, we tested the good- 23. Asks for reassurance when it doesnt seem .67 (.63)
ness of t of a similar, four-factor model where the four necessary
26. Seems nervous in new or unusual .87 (.79)
factors loaded onto a single, higher order factor.1 The situations
four factors constituted the factors demonstrated by 27. Gets upset if s=he makes a mistake .58 (.58)
Spence et al. and consistent with DSM conceptions: 29. Gets upset if something unexpected .73 (.74)
GA, SOC, SEP, and SPC. As described earlier, the two happens
OC items demonstrated good t in a model that con- Separation Anxiety
tained a separate fth factor but these items were 7. Would be upset at sleeping away from .69 (.67)
removed due to poor psychometric properties. home
The model provided a good t for the data, based on 10. Worries that something bad will happen .52 (.52)
to his=her parents
both mothers reports (GFI .98, AGFI .97, NFI
13. Worries that something bad might happen .50 (.52)
.97, SRMR .08) and fathers reports (GFI .96, to him=her (e.g., getting lost or
AGFI .95, NFI .94, SRMR .08). All of the lower kidnapped), so he=she wont be able to see
order factors loaded strongly on the higher order factor you again
according to both mother=father data: (standardized 17. Becomes distressed about your leaving .72 (.65)
him=her at preschool or with a babysitter
regression weights) GA (1.00=1.00), SOC (.87=.84),
28. Becomes distressed if separated from .82 (.74)
SEP (.83=.86), SPC (.77=.82). Standardized regression parents
weights indicating the relationship between each item
and its relevant factor are shown in Table 2. Specic Fears
4. Is afraid of doctors and=or dentists .60 (.43)
Each subscale correlated strongly with the total score 8. Is scared of heights (high places) .39 (.41)
according to both mothers and fathers (in parentheses) 11. Is scared of thunderstorms .44 (.44)
reports: GA r .88 (0.87), SOC r .86 (0.86), SEP r 14. Is nervous of going swimming .39 (.47)
.79 (0.78), SPC r .78 (0.80). The subscales also correlated 16. Is afraid of insects and=or spiders .36 (.52)
moderately to strongly with each other (all rs .47.70). 19. Is frightened of dogs .35 (.37)
22. Is afraid of the dark .39 (.57)
24. Is wary of large animals .53 (.51)
1 30. Is afraid of loud noises .64 (.62)
To fully compare with the previous research by Spence et al.
(2001), we also tested two additional modelsa single factor model
and a simple four correlated factors model. The four-factor model
showed a signicantly better t to the data than the single factor
model for both mothers (v2D 1996.18, dfD 10, p < .001) and fathers Age and Gender Differences
(v2D 380.93, dfD 10, p < .001). The t of the correlated four-factor
model and the four-factor model loading on a single higher order fac-
Table 3 shows the mean scale scores for the total sample
tor were almost identical. Therefore the higher order model appeared and for boys and girls. The only signicant gender
to provide the best description of the data. difference was for specic fears, based on mother report,
 REVISED PRESCHOOL ANXIETY SCALE 405

TABLE 3
Reliability and Distribution of PASR Scores

Mother Report Father Report

a b c d
Scale (No. of Items) a Total Sample Boys Girls F(1, 762) a Total Sample Boyse Girlsf F(1, 416)

Total Scale (28) .92 38.4 (19.0) 38.2 (19.2) 38.4 (18.8) 0.01 .92 37.5 (17.6) 37.7 (17.6) 37.4 (17.6) 0.07
Generalized (7) .83 10.5 (5.6) 10.8 (5.6) 10.3 (5.7) 1.06 .82 10.1 (5.1) 10.1 (5.1) 10.0 (5.1) 0.01
Social (7) .89 9.6 (6.6) 9.7 (6.5) 9.4 (6.7) 0.42 .89 9.7 (6.2) 9.7 (6.0) 9.7 (6.3) 0.00
Separation (5) .79 5.9 (4.4) 6.2 (4.4) 5.6 (4.3) 2.91 .75 5.4 (3.8) 5.6 (3.9) 5.3 (3.7) 0.99
Specic (9) .72 12.3 (6.3) 11.7 (6.3) 13.0 (6.3) 8.77 .74 12.3 (6.1) 12.2 (6.1) 12.4 (6.1) 0.17

Note. Analysis of variance F values indicate differences between boys and girls on each scale. Generalized Generalized anxiety scale;
Social Social anxiety scale; Separation Separation anxiety scale; Specic Specic fears scale.
a
n 764.
b
n 380.
c
n 384.
d
n 418.
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e
n 203.
f
n 215.

p < .05.  p < .01.  p < .001.

with girls scoring higher than boys. Based on an
adjusted alpha value of .01 for the ve comparisons
for each informant, the only signicant correlation with
age was found on the fathers report on the GA subscale
(r .17, p < .001).
two time points, were total score (r .74=.73), GA
(r .71=.76), SOC (r .73=.70), SEP (r .62=.60), and
SPC (r .71=.70). All correlations were signicant
(p < .001).

Construct Validity
Internal Consistency and Cross-Informant Reliability
To assess the construct validity of the PASR, scores
Table 3 also displays the internal consistency (a) of were correlated with subscales of the SDQ. Results are
PASR scale scores. Internal consistency was acceptable presented in Table 4. As expected the PASR and its
for all scales (as > .70). subscales were found to correlate in the moderate to
Cross-informant correlations between mothers and high range with the measure of ES and in the low range
fathers for PASR scores were in the moderate range, with measures of conduct problems and hyperactivity.
being lowest for the SEP subscale (r .60) and highest All PASR subscales correlated signicantly more
for SOC (r .75). All correlations were signicant strongly with the ES subscale than with the other two
(p < .001). Paired t tests were also conducted on SDQ subscales for both informants (all zs > 5).
PASR scores where both parents returned question-
naires. Controlling for the multiple comparisons
(a .01), mothers reported higher anxiety symptoms in TABLE 4
their children compared to fathers for the total scale Correlations Between PASR Scores and SDQ Subscale
(p .003), and the GA (p .001) and SEP scales
Mother Reporta Father Reportb
(p < .001).
PASR Scales ES CP HI ES CP HI

Stability of PASR Scores Over 12 Months Total .70 .14 .07 .62 .15 .04
GA .67 .13 .03 .60 .14 .06
Eighty-six percent of mothers (n 655) and 64% of SOC .62 .08 .17 .57 .08 .11
fathers (n 266) returned the PASR at Time 2. The SEP .56 .14 .02 .52 .12 .01
SPC .47 .12 .02 .39 .15 .06
demographic information for families returning the
PASR at Time 2 was almost identical to that reported Note. SDQ Strengths and Difculties Questionnaire; ES
at Time 1. The mean number of days between Time 1 Emotional Symptoms subscale; CP Conduct Problems subscale;
and Time 2 was 391.05 (SD 68.08). Participants who HI Hyperactivity-Inattention subscale; PASR Revised Preschool
had taken part in an intervention program (n 20) were Anxiety scale; GA Generalized Anxiety scale; SOC Social Anxiety
scale; SEP Separation Anxiety scale; SPC Specic Fears scale.
excluded from the analysis. Based on mother=father a
n 764.
report, partial correlations between Time 1 and Time 2 b
n 418.
scores, controlling for the number of days between the 
p < .05.  p < .01.  p < .001.
 406 EDWARDS, RAPEE, KENNEDY, SPENCE

TABLE 5
Results of Logistic Regression Analyses Predicting Anxiety Diagnoses (Mother Report)

Anxiety Disorder Best PASR Predictor b Wald v2 p 95% CI (ADISP) for O=R

GAD Generalized anxiety .25 9.51 .002 1.28 (1.091.50)

Social Phobia Social anxiety .53 9.84 .002 1.69 (1.222.35)
SAD Separation anxiety .26 9.01 .003 1.30 (1.101.54)
Specic Phobia Specic fears .21 16.45 <.001 1.23 (1.111.35)

Note. PASR Revised Preschool Anxiety Scale; ADISP Anxiety Disorders Interview ScheduleParent Version; GAD Generalized Anxiety
Disorder; SAD Separation Anxiety Disorder; O=R odds ratio; CI condence interval.

Based on the ADISP interview, 28 children met
DSMIV diagnostic criteria for GAD, 76 for social pho-
bia, 28 for SAD, 44 for specic phobia, and 4 for
obsessive-compulsive disorder. There were no post-
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Table 5. Anxiety diagnoses of GAD, SAD, social
phobia, and specic phobia were best predicted by the
corresponding PASR subscale. All condence intervals
for the odds ratios were higher than 1.00, indicating that

traumatic stress disorder diagnoses. The high prevalence
of diagnoses, particularly social phobia, reects that the
majority of the children attending assessments were
recruited specically as being at risk for anxiety pro-
blems. Twenty-ve percent did not meet criteria for
any anxiety disorder, 21% met criteria for one diagnosis,
25% for two diagnoses, 19% for three diagnoses, and
10% for four anxiety diagnoses. The PASR total scale
correlated highly with number of diagnoses (r .73,
p < .001). Mean PASR scores were 61.22 (SD 15.11)
for children with an anxiety diagnosis and 23.33
(SD 8.52) for children with no diagnosis. Therefore,
the PASR differentiated children with and without
anxiety diagnoses, t(66) 15.72, p < .001.
To examine the utility of PASR subscale scores for
predicting specic anxiety diagnoses, a series of logistic
regressions were conducted separately for each anxiety
diagnostic category. The GA, SOC, SEP, and SPC
subscales of the PASR were entered as predictors,
with diagnostic status as the dependent variable
(0 diagnosis absent, 1 diagnosis present) for each
anxiety diagnosis. This method for assessing the utility
of questionnaires in predicting diagnostic status has
been used previously (e.g., Muris, Dreessen, Bogels,
Weckx, & van Melick, 2004). Results are presented in
higher scores on the appropriate PASR subscale
increased the likelihood of meeting criteria for the
corresponding anxiety diagnosis. For GAD, SAD, and
specic phobia, the corresponding scale was the only
signicant predictor of diagnostic status. For social
phobia diagnoses, the PASR SEP scale was also a
signicant predictor (O=R 1.28, p .04).
PASR scores were also correlated with observer rat-
ings of child anxiety on the assessment tasks. Mean
(standard deviation) observer ratings for child anxiety
during each segment were as follows: costumed stranger
1.52 (1.08), speech presentation 1.28 (0.97), play
equipment 0.65 (0.77), singing task 1.34 (0.66). The
mean anxiety rating across tasks was 1.16 (0.69). PAS
R total, GA, SOC, and SEP scores correlated signi-
cantly and moderately with all observer ratings of child
anxiety (Table 6). Correlations between observer-rated
anxiety and the SPC scale were lower although mostly
signicant. Given that most tasks involved social threat,
it makes sense that the SOC scale had generally higher
correlations with observed anxiety.
During the assessment tasks, 10 children refused to
separate from their mothers while the ADISP was com-
pleted in a nearby room. As an additional validation for
the SEP scale, a logistic regression was performed with

TABLE 6
Correlations Between PASR Scales and Observer Ratings of Child Anxiety

Observer Ratings of Child Anxiety on Assessment Tasks

PASR Scale Stranger Speech Present Physical Task Singing Average Anxiety

Total Score .46 .44 .35 .46 .60

Generalised anxiety .30 .38 .27 .35 .44
Social anxiety .56 .51 .37 .56 .70
Separation anxiety .35 .44 .29 .32 .50
Specic fears .28 .14 .28 .21 .30

Note. PASR Revised Preschool Anxiety Scale; Speech present speech presentation; Average anxiety average observer rating of child
anxiety across tasks (n 110).

p < .05.  p < .01.  p < .001.

each of the subscales entered as predictors and child
separation as the dependent variable (0 did not separate,
1 separated). With a Bonferroni adjustment for the
four comparisons, the SEP scale was the only signicant
predictor of child separation from their mother, Wald
v2(1) 11.08, p < .001. The corresponding values for the
other scales were: GAD, Wald v2(1) 5.06, p .03;
SOC, Wald v2(1) 0.13, p .72; SPC, Wald v2(1)
0.14, p .71.
DISCUSSION
The study examined the psychometric properties of a
revised version of the PAS (Spence et al., 2001). Of the
three models tested by CFA, the four-factor solution
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provided the best t for the data, with a higher order
anxiety factor accounting for the covariance between it is possible that assessment of separation anxiety in this
rst-order factors. Differentiating the items of the PASR
into generalized anxiety, social anxiety, separation
anxiety, and specic fears provided a better t than a
model where all items loaded on a single anxiety dimen-
sion. Factors were moderately to strongly interrelated
and each factor loaded strongly on the higher order fac-
tor. Acceptable internal consistency was demonstrated
across scales. These results provide further evidence
for the validity of DSMIV-based anxiety categories in
young children. However, it should be noted that differ-
ences in the size of t indices for the three models tested
were small therefore further investigation is warranted
regarding the most optimal factor structure for anxiety
symptoms in this age group. A model where all items
loaded onto a single anxiety factor also provided a
reasonably good t for the data, suggesting that in this
age group, anxiety symptoms are highly interrelated.
It is notable that the two remaining items relevant to
obsessive-compulsive phenomena had to be removed
from the scale due to poor psychometric properties. This
follows removal of several similar items from the orig-
inal measure based on their particularly low endorse-
ment. Although further development may identify
more commonly rated obsessive-compulsive items that
have better psychometric properties, these results are
consistent with the low prevalence of obsessive compul-
sive disorder in younger childhood populations (Broeren
& Muris, 2008; Rapee et al., 2009). In turn the lack of
items reecting obsessive-compulsive concerns should
not compromise the validity of the scale to assess anxi-
ety in young children.
Stability of parent-reported anxiety symptoms across
12 months was high for such a long period according to
both mothers and fathers. This result not only demon-
strates the reliability of the measure but also reects
the stability of symptoms of anxiety, even at such a
young age (Rapee et al., 2009). Mothers were more
REVISED PRESCHOOL ANXIETY SCALE 407
likely to report higher anxiety symptoms in their child
than fathers, which is a fairly consistent nding in child
anxiety research (e.g., March, Parker, Sullivan,
Stallings, & Connors, 1997; Spence et al., 2001). Low
concordance between informants is a common aspect
of research into child psychopathology (de Los Reyes
& Kazdin, 2005), so the moderate to good agreement
between parents on the current subscales appears to be
a strength of the measure (.57 for separation anxiety
to .75 for social anxiety). The slightly lower interrater
agreement for separation anxiety may reect that, in this
age group, mothers are likely to be witnessing such
symptoms more frequently than fathers (e.g., when leav-
ing their children at preschool). Children may also be
more distressed when separating from one parent com-
pared to the other. Future research would need to deter-
mine the accuracy of mothers and fathers reports, but
age group would be reported better by mothers.
The only gender difference across PASR scales was
that girls scored higher than boys on specic fears only
according to mothers reports. These data are consistent
with other studies that have failed to demonstrate gen-
der differences in anxiety symptoms at the pre-school
age (Egger & Angold, 2006; Furniss et al., 2006; Spence
et al., 2001). Of interest, they stand in contrast to the
higher anxiety reported by girls among older children
(March et al., 1997; Muris et al., 2004; Rapee et al.,
2009). Gender differences in symptoms of anxiety
appear to emerge from around 4 to 5 years of age (Roza,
Hofstra, van der Ende, & Verhulst, 2003). Similarly,
there were no signicant relationships demonstrated
between scores on the PASR subscales and age aside
from a single signicant correlation based on fathers
reports on the GA scale. It would be surprising to nd
marked age changes over such a relatively brief range
for a stable disorder such as anxiety. Indeed the lack
of age effects is consistent with minimal developmental
changes in the prevalence of anxiety disorders shown
in epidemiological studies (Rapee et al., 2009).
There was considerable evidence supporting the con-
struct validity of the PASR, with all scales showing
moderate to high correlations with the ES scale of the
SDQ. The PASR also discriminated anxiety symptoms
from child behavioral problems, with low correlations
(
.17) between PASR scale scores and the HI and
CP scales of the SDQ. Although most of the correlations
between PASR and CP scores reached signicance
(partly due to the strong power of the study), this
reects the well-documented comorbidity between child
anxiety symptoms and externalizing problems (Egger &
Angold, 2006; Last, Perrin, Hersen, & Kazdin, 1996).
The current study extended the results of Spence et al.
(2001), in that the PASR SOC, GA, SEP, and total
scales were found to correlate moderately with observer
 408 EDWARDS, RAPEE, KENNEDY, SPENCE
ratings of child anxiety. Subscale scores were also
predictive of corresponding DSMIV anxiety diagno-
ses assessed by semistructured interview, considered
the gold standard for assessing psychopathology
(Costello, Egger, & Angold, 2005). Overall, the results
support the validity of the PASR in assessing a broad
range of anxiety symptoms in preschool-aged children.
One caveat raised by Spence et al. (2001) in their dis-
cussion of the original scale was the lack of distinction
between the SEP and GA subscales. In the original
version these factors were highly correlated and both
loaded strongly on the higher order factor. There were
a number of changes made to the GA scale for this rea-
son in the revised version, and this appears to have
resulted in a clearer distinction between these scales on
the PASR. The correlation between the two scales
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was lower than that reported for the original measure
(.67=.63 compared to .87=.83 for mothers=fathers).
The revised GA factor was found to have a very high
loading on the higher order anxiety factor, evidence
that generalized anxiety may well be analogous to an
underlying anxiety trait (e.g., Nauta et al., 2004; Rapee
& Coplan, in press). The loading of the SEP factor on
the higher-order factor (.83=.86) was lower than that
found by Spence et al. in the original measure (.94).
Thus, it appears that the changes to the separation
anxiety items in the PASR also contributed to a better
discrimination between the SEP factor and the higher
order factor.
The sample was not representative of the wider popu-
lation of Australian preschoolers. Although this limits
the extent to which the results can be generalized to
other samples, having a larger group of high-risk
children allowed an assessment of the utility of the
PASR in distinguishing children with more severe
anxiety symptoms from children with no identied
anxiety problems. The results supported the validity of
the PASR in this regard. However, further testing in
a representative community sample is required to
establish acceptable PASR norms and to replicate the
current ndings.
This study used the ADISP to diagnose DSMIV
anxiety disorders; however, this instrument was not
designed for this age group and, despite showing good
interrater reliability, few studies have utilized it with
preschool-aged children. Therefore it would be prema-
ture to conclude that the PASR identies actual anxi-
ety diagnoses and further examination of validity using
diagnostic interviews designed for this age group is war-
ranted. Recent efforts have been made to adapt current
diagnostic criteria to the preschool age group (e.g., Luby
et al., 2003; RDC-IP, 2003; Warren et al., 2006) and
replication of the current results using age-specic diag-
nostic instruments such as the PAPA (Egger et al., 2006)
is needed.
Implications for Research, Policy, and Practice
The identication of psychopathology among preschool-
aged children remains a controversial topic but has
been identied as a priority area for future psychiatric
research (Eley et al., 2003; RDC-IP, 2003). Researchers
have pointed to the importance to public health of
identifying disorders early and providing early inter-
vention (e.g., Egger & Angold, 2006). Given the early
onset and chronic course of anxiety, early identica-
tion and intervention may be especially important for
these disorders. Some research has begun to demon-
strate the efcacy of interventions for preschool-aged
children who score high on anxious symptomatology
(Hirshfeld-Becker et al., 2008; Kennedy et al., 2009;
Pincus, Eyberg, & Choate, 2005; Rapee et al., 2005).
Therefore, the development of valid and reliable
instruments to identify and assess anxiety in early child-
hood is particularly important. The current data suggest
that the PASR provides one such instrument. The
PASR appears to be a reliable and valid measure for
assessing a broad range of commonly reported anxiety
symptoms in this age group, with potential utility in
clinical and research settings.
REFERENCES
Achenbach, T. M. (1991). Manual for the Child Behavior Checklist=418
and 1991 prole. Burlington: University of Vermont, Department
of Psychiatry.
American Psychiatric Association. (1994). Diagnostic and statistical
manual of mental disorders (4th ed.). Washington, DC: Author.
Anderson, J. C., & Gerbing, D. W. (1988). Structural equation model-
ling in practice: A review and recommended two-step approach.
Psychological Bulletin, 103, 411423.
Arbuckle, J. L. (2003). Amos 5.0 [Computer software]. Chicago: SPSS=
SmallWaters Corp.
Bayer, J. K., Sanson, A. V., & Hemphill, S. A. (2006). Childrens
moods, fears, and worries: Development of an early childhod parent
questionnaire. Journal of Emotional and Behavioral Disorders, 14(1),
4149.
Bouldin, P., & Pratt, C. (1998). Utilizing parent report to investigate
young childrens fears: A modication of the Fear Survey Schedule
for Children-II: A research note. Journal of Child Psychology and
Psychiatry, 39, 271277.
Briggs, N. E., & MacCallum, R. C. (2003). Recovery of weak common
factors by maximum likelihood and ordinary least squares esti-
mation. Multivariate Behavioral Research, 38, 2556.
Broeren, S., & Muris, P. (2008). Psychometric evaluation of two new
parent-rating scales for measuring anxiety symptoms in young
Dutch children. Journal of Anxiety Disorders, 22, 949958.
Campbell, S. B. (1995). Behavioural problems in preschool children: A
review of recent research. Journal of Child Psychology and
Psychiatry, 36, 113150.
Carter, A. S., Briggs-Gowan, M. J., Jones, S. M., & Little, T. D.
(2003). The Infant Toddler Social and Emotional Assessment
(ITSEA): Factor structure, reliability, and validity. Journal of
Abnormal Child Psychology, 31, 495514.
Choudhury, M. S., Pimentel, S. S., & Kendall, P. C. (2003). Childhood
anxiety disorders: Parent-child (dis)agreement using a structured

interview for the DSMIV. Journal of the American Academy of
Child and Adolescent Psychiatry, 42, 957964.
Costello, E. J., Egger, H., & Angold, A. (2005). 10-year research
update review: The epidemiology of child and adolescent psychiatric
disorders: I. Methods and public health burden. Journal of the Amer-
ican Academy of Child and Adolescent Psychiatry, 44, 972986.
De Los Reyes, A., & Kazdin, A. E. (2005). Informant discrepancies in
the assessment of childhood psychopathology: A critical review,
theoretical framework, and recommendations for further study.
Psychological Bulletin, 131, 483509.
Edelbrock, C., Costello, A. J., Dulcan, M. K., Kalas, R., & Conover,
N. C. (1985). Age differences in the reliability of the psychiatric
interview of the child. Child Development, 56, 265275.
Egger, H. L., & Angold, A. (2006). Common emotional and behavioral
disorders in preschool children: Presentation, nosology, and epi-
demiology. Journal of Child Psychology and Psychiatry, 47, 313337.
Egger, H. L., Erkanli, A., Keeler, G., Potts, E., Walter, B. K., &
Angold, A. (2006). Test-retest reliability of the preschool age psychi-
atric assessment (PAPA). Journal of the American Academy of Child
Downloaded by [University of Hong Kong Libraries] at 00:47 03 April 2013
& Adolescent Psychiatry, 45, 538549.
Eley, T. C., Bolton, D., OConnor, T. G., Perrin, S., Smith, P., &
Plomin, R. (2003). A twin study of anxiety-related behaviours in
pre-school children. Journal of Child Psychology and Psychiatry,
44, 945960.
Furniss, T., Beyer, T., & Guggenmos, J. (2006). Prevalence of
behavioural and emotional problems among six-years-old preschool
children. Social Psychiatry and Psychiatric Epidemiology, 41,
394399.
Gadow, K. D., Sprafkin, J., & Nolan, E. E. (2001). DSMIV
symptoms in community and clinic preschool children. Journal of
the American Academy of Child and Adolescent Psychiatry, 40,
13831392.
Goodman, R. (1997). The Strengths and Difculties Questionnaire: A
research note. Journal of Child Psychology and Psychiatry, 38,
581586.
Hirshfeld-Becker, D. R., Masek, B., Henin, A., Blakely, L. R., Rettew,
D. C., Dufton, L., et al (2008). Cognitive-behavioral intervention
with young anxious children. Harvard Review of Psychiatry, 16,
113125.
Hu, L., & Bentler, P. M. (1999). Cutoff criteria for t indexes in
covariance structure analysis: Conventional criteria versus new
alternatives. Structural Equation Modeling, 6, 155.
Kennedy, S. J., Rapee, R. M., & Edwards, S. L. (2009). A selective
intervention program for inhibited preschool-aged children of
parents with an anxiety disorder: Effects on current anxiety disor-
ders and temperament. Journal of the American Academy of Child
& Adolescent Psychiatry, 48, 602609.
Last, C. G., Perrin, S., Hersen, M., & Kazdin, A. E. (1996). A prospec-
tive study of childhood anxiety disorders. Journal of the American
Academy of Child and Adolescent Psychiatry, 35, 15021510.
Lavigne, J. V., Arend, R., Rosenbaum, D., Binns, H. J., Christoffel,
K., & Gibbons, R. D. (1998). Stability of diagnosis: Psychiatric
disorders with onset in the preschool years, Part 1. Journal of the
American Academy of Child and Adolescent Psychiatry, 37,
12461254.
Luby, J. L., Mrakotsky, C., Heffelnger, A., Brown, K., Hessler, M.,
& Spitznagel, E. (2003). Modication of DSM-IV criteria for
depressed preschool children. American Journal of Psychiatry, 160,
11691172.
March, J. S., Parker, J. D., Sullivan, K., Stallings, P., & Connors, C.
K. (1997). The Multidimensional Anxiety Scale for Children
(MASC): Factor structure, reliability, and validity. Journal of the
American Academy of Child and Adolescent Psychiatry, 36, 554565.
Muris, P., Dreessen, L., Bogels, S., Weckx, M., & van Melick, M.
(2004). A questionnaire for screening a broad range of DSM-
REVISED PRESCHOOL ANXIETY SCALE 409
dened anxiety disorder symptoms in clinically referred children
and adolescents. Journal of Child Psychology and Psychiatry, 45,
813820.
Muris, P., Meesters, C., Mayer, B., Bogie, N., Luijten, M., Geebelen,
E., et al. (2003). The Koala Fear Questionnaire: A standardized
self-report scale for assessing fears and fearfulness in pre-school
and primary school children. Behaviour Research and Therapy, 41,
597617.
Nauta, M. H., Scholing, A., Rapee, R. M., Abbott, M., Spence, S. H.,
& Waters, A. (2004). A parent-report measure of childrens anxiety:
Psychometric properties and comparison with child-report in a clinic
and normal sample. Behaviour Research and Therapy, 42, 813839.
Nelles, W. B., & Barlow, D. H. (1988). Do children panic? Clinical
Psychology Review, 8, 359372.
Pincus, D. B., Eyberg, S. M., & Choate, M. L. (2005). Adapting
Parent-Child Interaction Therapy for Young Children with Separation
Anxiety Disorder. Education & Treatment of Children, 28, 163181.
Prior, M., Smart, D., Sanson, A., & Oberklaid, F. (2000). Does
shy-inhibited temperament in childhood lead to anxiety problems
in adolescence? Journal of the American Academy of Child and
Adolescent Psychiatry, 39, 461468.
Rapee, R. M., Barrett, P. M., Dadds, M. R., & Evans, L. (1994).
Reliability of the DSM-III-R childhood anxiety disorders using struc-
tured interview: Inter-rater and parent-child agreement. Journal of the
American Academy of Child and Adolescent Psychiatry, 33, 984992.
Rapee, R. M., & Coplan, R. J. (in press). Conceptual relations between
anxiety disorder and fearful temperament. In H. Gazelle & K. H.
Rubin (Eds.), Social anxiety in childhood: Bridging developmental
and clinical perspectives. San Francisco, CA: Jossey-Bass.
Rapee, R. M., Kennedy, S., Ingram, M., Edwards, S., & Sweeney, L.
(2005). Prevention and early intervention of anxiety disorders in
inhibited preschool children. Journal of Consulting and Clinical
Psychology, 73, 488497.
Rapee, R. M., Schniering, C. A., & Hudson, J. L. (2009). Anxiety dis-
orders during childhood and adolescence: Origins and treatment.
Annual Review of Clinical Psychology, 5, 311341.
Roberts, R. E., Attkisson, C. C., & Rosenblatt, A. (1998). Prevalence
of psychopathology among children and adolescents. American
Journal of Psychiatry, 155, 715725.
Roza, S. J., Hofstra, M. B., van der Ende, J., & Verhulst, F. C. (2003).
Stable prediction of mood and anxiety disorders based on beha-
vioral and emotional problems in childhood: A 14-year follow-up
during childhood, adolescence, and young adulthood. American
Journal of Psychiatry, 160, 21162121.
Scheeringa, M. S., Zeanah, C. H., Myers, L., & Putnam, F. W. (2003).
New ndings on alternative criteria for PTSD in preschool children.
Journal of the American Academy of Child & Adolescent Psychiatry,
42, 561570.
Silverman, W. K., & Albano, A. M. (1996). The Anxiety Disorders
Interview Schedule for Children for DSMIV: Child and Parent
Versions. San Antonio, TX: Psychological Corporation.
Spence, S. H., Rapee, R., McDonald, C., & Ingram, M. (2001). The
structure of anxiety symptoms among preschoolers. Behaviour
Research and Therapy, 39, 12931316.
Task Force on Research Diagnostic Criteria: Infancy, & Preschool.
(2003). Research diagnostic criteria for infants and preschool chil-
dren: The process and empirical support. Journal of the American
Academy of Child and Adolescent Psychiatry, 42, 15041512.
Warren, S. L., Umylny, P., Aron, E., & Simmens, S. J. (2006). Toddler
anxiety disorders: A pilot study. Journal of the American Academy of
Child and Adolescent Psychiatry, 45, 859866.
Weissman, M. M., Wolk, S., Wickramaratne, P., Goldstein, R. B.,
Adams, P., Greenwald, S., et al (1999). Children with prepubertal-
onset major depressive disorder and anxiety grown up. Archives of
General Psychiatry, 56, 794801.